Behav Res. & Therapy.
1975. Vol. 13. pp. 193-195. Pergamon Press. Pruned m Great Bntam
CASE HISTORIES
AND SHORTER
COMMUNICATIONS
Brief flooding treatment for a debilitating revulsion (Recrived
24 October
1974)
Anger, hostility and revulsion are strong negative emotions which are in many ways like fear and anxiety in that both can have debilitating effects on patients. These debilitating effects usually take two forms: behavioral inhibitions and subjective discomfort. In recent years, behavior therapists have developed several ways of dealing with the latter two emotions. especially as they are present in phobias and other neuroses. Chief among the techniques which have been shown effective are systematic desensitization (Wolpe, 1958) and flooding (Marks. 1972). By extrapolation. one might expect the latter two techniques to be useful in treating other negative emotions. In an analogue study. O’Donnel (1971) found ‘standard’ systematic desensitization based on deep relaxation more effective than control conditions. including variants of systematic desensitization in which relaxation training was omitted, in reducing anger and disgust felt by white students toward racial stimuli. In a second analogue study. however. Harding (1970) found on all of his dependent measures of anger and hostility towards academic situations no differences between subjects treated by systematic desensitization and other control conditions including a no-treatment control group. Finally. Rimm et al. (1971) in another analogue study showed systematic desensitization to be more effective than two control conditions in reducing anger felt in driving situations. Turning to actual clinical cases, one finds very few examples: Herrell (1971) reported the treatment of inappropriate anger responses by a soldier. The patient showed uncontrollable anger and overt acts of aggression at commands. Although no systematic data were collected, it was reported that after 18 sessions of systematic desensitization the patient no longer experienced the negative emotions and the therapeutic gain had transferred to his natural environment. Hogan (1969) mentions using implosive therapy for aggressive feelings of patients and relates some anecdotal data but presents no specific case of data on the topic. The present report concerns the treatment of a debilitating revulsion or anger through a brief course of flooding and as such is novel in two respects: (1) very few other clinical cases of the treatment of anger and revulsion have been reported in the behavior therapy literature and none with detailed dependent measures, (2) the analogue studies have used systematic desensitization rather than flooding. CASE
HISTORY
The patient was a 27-yr-old who was currently separated from her husband and was referred by a marriage counselor seeing the estranged couple for the patient’s debilitating revulsion toward pregnant women and infants. Her early history revealed that she had always been fairly passive and dependent. She married immediately after completing secondary school, had high expectations of married life and wanted very much to be a good wife and mother. After several unsuccessful years of trying, the patient finally became pregnant while her husband was in the Army. She describes herself as having been elated but apprehensive by her pregnancy. During her second trimester the fetus died. However, her obstetrician decided to wait for her to abort spontaneously rather than to induce an abortion or perform surgery. During the next 2 months the patient had to make weekly visits to the obstetrician’s office knowing that she was carrying only a dead fetus. The office was always filled with obviously pregnant women who, ignorant of the patient’s problem, usually asked about her pregnancy. These vrsits seem to have been a series of traumatic conditioning trials as the hatred and revulsion for pregnant women developed at this time. After the patient finally aborted. a mild depression followed and the patient described herself as feeling a great sense of failure. The symptoms of the revulsion also appeared: the patient began to feel very angry and hostile towards all pregnant women and even to infants and their mothers; she was hostile and verbally abusive to some pregnant friends: she began to refuse to go to social gatherings for fear of seeing a pregnant woman and loosing her temper. Moreover. when she received baby shower invitations or birth announcements. she would have angry outbursts and tear them to shreds. Her problem had seriously curtailed the couple’s social life. Also the patient avoided the infants’ section of stores. Shortly after the development of these symptoms. the patient began a series of extramarital affairs, apparently in an effort to gain attention and psychological nurture. Her husband had left the Army to attend a local university but the change in location led to no change in her behavior. Her marital infidelities continued and eventually led her to separate from her husband. Shortly after this. the couple began seeing a marriage counselor. METHOD
Dependent Card included hostess and to of eight
men~ure~
Sort. Six items relating to the patient’s interaction with pregnant women were constructed. They statements such as. “You are introduced to an obviously pregnant woman at a party by the and left to chat with her.” Items also included related to the patient’s possibly becoming pregnant her relationship with her husband. These items were sorted at intervals by the patient into one envelopes labeled from. *‘So extremely unpleasant I cannot imagine myself doing it” (-4). “Extremely 193
CASE
194
HISTORIES
AVD
SHORTER
COMMUNlCATlONS
Fig. 1. Attitudinal and behavioral measures towards pregnant women taken during all stages of treatment. Numbers and arrows on bottom axis represent therapy sessions.
unpleasant” (-3) to “Indifferent” (0) to “Extremely pleasant” (+ 3). The patient was instructed to sort the items to reflect the way she felt at that particular time. Behavior approach test. A hierarchy of approach tasks was constructed involving the patient’s approaching the waiting area of the Medical Center’s Obstetric Clinic. entering the waiting room and then sitting in it for progressively longer intervals for a total of 13 steps. The patient was asked to rate the degree of discomfort and anger she felt on a l-10 scale at several points in the hierarchy. This test was administered periodically by a research assistant who was unaware of the patient’s clinical treatment program. Treatment Baseline. The dependent variable measures were begun early in treatment. All stages of treatment prior to active intervention with the revulsion are termed baseline and continued for ten visits over a IO-week period. During this time, therapy centered around several topics: a detailed history was taken including the development of the revulsion; a therapeutic relationship was established, and the patient was given some assertive training through modeling and behavior rehearsal to enable her to deal more effectively with her friends, her husband and her supervisor. Much social reinforcement was given for reports of improved functioning in these areas and for an improved view of herself. During each session, a certain amount of time was spent discussing the revulsion and problems it caused. The patient and her husband continued in marital counseling and were reunited. ‘Baseline’ sessions continued for 3 weeks after the couple were reunited. This period served as a control phase for the non-specific effects of therapy and provided a fairly long Baseline period. Flooding. Next. two l-l ‘2 hr flooding sessions. conducted in the manner described by Marks (1972). were held. The patient was instructed repeatedly to imagine scenes of intense interaction with pregnant women and infants, some from her past, some hypothetical. No other anxiety-arousing themes were introduced. Some scenes in which the patient coped with her feelings were included. At the beginning of the third scheduled flooding session. the patient claimed that the scenes no longer aroused feelings of hostility or anger. so the flooding was discontinued. Follow-up. The patient contmued to be seen on a weekly basis for 3 more weeks and then every 2-3 weeks for 2 months. These sessions consisted of giving her continued psychological support for her demonstrated gains in handling the revulsion. her marital difficulties and other problems.
In Fig. 1 are presented dam on three different dependent vdriab)es as a function of treatment phases: approach scores on the Behavior Approach Test. card sort (attitudinal) scores related to interaction with pregnant women and attitudes toward her husband and her own possible future pregnancy. approach behavior remained more or less constant during As can be seen in Fig. 1. the patient‘s Baseline: the patient could get to the entrance of the OB Clinic waiting area and sometimes could turn to look at the waitmg patients (task 7). Immediately after the two Flooding sessions, she was able to perform all approach behavrors including sittmg in the midst of the waiting area for I5 min and conversing with a stranger who was a patient. Her subjective discomfort ratings which had been at 10 for tasks 6 and 7 went to zero for the terminal item. Her attitudes toward mteracting with pregnant women. the average of six items, showed a steady decline during early stages of Baseline and had stabilized betwen moderately (-2) and extremely (-3) unpleasant. After the Flooding treatment. the attitudinal items were rated 0 (indifferent). Her ratings about being pregnant herself and about making love with her husband showed an interesting pattern. They went from moderately unpleasant to extremely pleasant during Baseline and probably reflect the successful marriage counseling. They showed no change during Flooding or Follow-up.
CASE HlSTORlES AND
195
SHORTEK COMMUNICATIONS
During Baseline, the patient became more assertive and seemed to gain new confidence in herself in that she was willing to stand up to her husband and take on the challenge of a new Job. After Flooding. the patient showed further gains in self confidence and was able to identify a new strategy for herself in coping with problems: facing them rather than avoiding them. The patient made a new friend of a neighbor who was pregnant and delivered during Follow-up. Moreover, the patient began to accompany her husband to social affairs at which pregnant women were present. A telephone follow-up 3 months after the last session revealed that the patient was maintaining her gains and was no longer troubled by pregnant women. DISCUSSION
This case illustrates with a clinically debilitating revulsion or anger response how such a negative emotion can be treated behaviorally. Particularly impressive was the swiftness of the Flooding treatment. Moreover, because of the long series of baseline measures. one feels confident in attributing the therapeutic gains to the Flooding. This case also documents with objective data the anecdotal reports of Hogan (1969) of the effectiveness of a flooding approach to deal with anger responses in patients. Acknowledgemetlr-The author would like to acknowledge ing the Behavioral Approach Test. Unioersity ofMississippi Medical 2500 Nor01 State Street. Jackson, Mississippi. U.S.A.
the assistance
Center.
of Ms. Mary
R. Haynes
EDWARD
in conduct-
B.BLANCHARD
REFERENCES
desensitization, relaxation, cognitive rehearsal and desensitization of anxiety on the modification of anger-hostility responses. Dim. Ahstr. Iat. 30 (9-B). 4372. HERREL J. M. (1971) Use of systematic desensitization to eliminate inappropriate anger. hoc. 7Yth Amual Corwentiou. APA. pp. 431432. American Psychological Association. Washington. HOGAN R. A. (1969) Implosively oriented behavior modification: Therapy considerations. BP/KI~. Res. & Therapy 7, 177-l X3. MARKS I. M. (1972) Flooding (implosion) and allied treatment. In: Behaoior Modification Principles a,ld Clinical Applicatiom (Ed. AGRAS W. S.). Little. Brown. Boston. O’DONNELL C. R. (1971) Motor and cognitive components in the desensitization of a social relevant target behavior. Diss. Ahstr. Int. 32 (2-B). 1221. RIMM D. C., DEGRCOT J. C.. B~ORD P., HERMAN J. and DILLOW P. V. (1971) Systematic desensitization of an anger response. Brha~. Rrs. & Therap! 9, 173-280. WOLPE J. (1958) Psychotherapy by Reciprocal Irthihition. Stanford Univ. Press. Stanford, Cal. HARDING
J. H. (1970) The effect of systematic
1975. Vol. 13. pp. 193-195. Pergamon Press. Pruned m Great Bntam
CASE HISTORIES
AND SHORTER
COMMUNICATIONS
Brief flooding treatment for a debilitating revulsion (Recrived
24 October
1974)
Anger, hostility and revulsion are strong negative emotions which are in many ways like fear and anxiety in that both can have debilitating effects on patients. These debilitating effects usually take two forms: behavioral inhibitions and subjective discomfort. In recent years, behavior therapists have developed several ways of dealing with the latter two emotions. especially as they are present in phobias and other neuroses. Chief among the techniques which have been shown effective are systematic desensitization (Wolpe, 1958) and flooding (Marks. 1972). By extrapolation. one might expect the latter two techniques to be useful in treating other negative emotions. In an analogue study. O’Donnel (1971) found ‘standard’ systematic desensitization based on deep relaxation more effective than control conditions. including variants of systematic desensitization in which relaxation training was omitted, in reducing anger and disgust felt by white students toward racial stimuli. In a second analogue study. however. Harding (1970) found on all of his dependent measures of anger and hostility towards academic situations no differences between subjects treated by systematic desensitization and other control conditions including a no-treatment control group. Finally. Rimm et al. (1971) in another analogue study showed systematic desensitization to be more effective than two control conditions in reducing anger felt in driving situations. Turning to actual clinical cases, one finds very few examples: Herrell (1971) reported the treatment of inappropriate anger responses by a soldier. The patient showed uncontrollable anger and overt acts of aggression at commands. Although no systematic data were collected, it was reported that after 18 sessions of systematic desensitization the patient no longer experienced the negative emotions and the therapeutic gain had transferred to his natural environment. Hogan (1969) mentions using implosive therapy for aggressive feelings of patients and relates some anecdotal data but presents no specific case of data on the topic. The present report concerns the treatment of a debilitating revulsion or anger through a brief course of flooding and as such is novel in two respects: (1) very few other clinical cases of the treatment of anger and revulsion have been reported in the behavior therapy literature and none with detailed dependent measures, (2) the analogue studies have used systematic desensitization rather than flooding. CASE
HISTORY
The patient was a 27-yr-old who was currently separated from her husband and was referred by a marriage counselor seeing the estranged couple for the patient’s debilitating revulsion toward pregnant women and infants. Her early history revealed that she had always been fairly passive and dependent. She married immediately after completing secondary school, had high expectations of married life and wanted very much to be a good wife and mother. After several unsuccessful years of trying, the patient finally became pregnant while her husband was in the Army. She describes herself as having been elated but apprehensive by her pregnancy. During her second trimester the fetus died. However, her obstetrician decided to wait for her to abort spontaneously rather than to induce an abortion or perform surgery. During the next 2 months the patient had to make weekly visits to the obstetrician’s office knowing that she was carrying only a dead fetus. The office was always filled with obviously pregnant women who, ignorant of the patient’s problem, usually asked about her pregnancy. These vrsits seem to have been a series of traumatic conditioning trials as the hatred and revulsion for pregnant women developed at this time. After the patient finally aborted. a mild depression followed and the patient described herself as feeling a great sense of failure. The symptoms of the revulsion also appeared: the patient began to feel very angry and hostile towards all pregnant women and even to infants and their mothers; she was hostile and verbally abusive to some pregnant friends: she began to refuse to go to social gatherings for fear of seeing a pregnant woman and loosing her temper. Moreover. when she received baby shower invitations or birth announcements. she would have angry outbursts and tear them to shreds. Her problem had seriously curtailed the couple’s social life. Also the patient avoided the infants’ section of stores. Shortly after the development of these symptoms. the patient began a series of extramarital affairs, apparently in an effort to gain attention and psychological nurture. Her husband had left the Army to attend a local university but the change in location led to no change in her behavior. Her marital infidelities continued and eventually led her to separate from her husband. Shortly after this. the couple began seeing a marriage counselor. METHOD
Dependent Card included hostess and to of eight
men~ure~
Sort. Six items relating to the patient’s interaction with pregnant women were constructed. They statements such as. “You are introduced to an obviously pregnant woman at a party by the and left to chat with her.” Items also included related to the patient’s possibly becoming pregnant her relationship with her husband. These items were sorted at intervals by the patient into one envelopes labeled from. *‘So extremely unpleasant I cannot imagine myself doing it” (-4). “Extremely 193
CASE
194
HISTORIES
AVD
SHORTER
COMMUNlCATlONS
Fig. 1. Attitudinal and behavioral measures towards pregnant women taken during all stages of treatment. Numbers and arrows on bottom axis represent therapy sessions.
unpleasant” (-3) to “Indifferent” (0) to “Extremely pleasant” (+ 3). The patient was instructed to sort the items to reflect the way she felt at that particular time. Behavior approach test. A hierarchy of approach tasks was constructed involving the patient’s approaching the waiting area of the Medical Center’s Obstetric Clinic. entering the waiting room and then sitting in it for progressively longer intervals for a total of 13 steps. The patient was asked to rate the degree of discomfort and anger she felt on a l-10 scale at several points in the hierarchy. This test was administered periodically by a research assistant who was unaware of the patient’s clinical treatment program. Treatment Baseline. The dependent variable measures were begun early in treatment. All stages of treatment prior to active intervention with the revulsion are termed baseline and continued for ten visits over a IO-week period. During this time, therapy centered around several topics: a detailed history was taken including the development of the revulsion; a therapeutic relationship was established, and the patient was given some assertive training through modeling and behavior rehearsal to enable her to deal more effectively with her friends, her husband and her supervisor. Much social reinforcement was given for reports of improved functioning in these areas and for an improved view of herself. During each session, a certain amount of time was spent discussing the revulsion and problems it caused. The patient and her husband continued in marital counseling and were reunited. ‘Baseline’ sessions continued for 3 weeks after the couple were reunited. This period served as a control phase for the non-specific effects of therapy and provided a fairly long Baseline period. Flooding. Next. two l-l ‘2 hr flooding sessions. conducted in the manner described by Marks (1972). were held. The patient was instructed repeatedly to imagine scenes of intense interaction with pregnant women and infants, some from her past, some hypothetical. No other anxiety-arousing themes were introduced. Some scenes in which the patient coped with her feelings were included. At the beginning of the third scheduled flooding session. the patient claimed that the scenes no longer aroused feelings of hostility or anger. so the flooding was discontinued. Follow-up. The patient contmued to be seen on a weekly basis for 3 more weeks and then every 2-3 weeks for 2 months. These sessions consisted of giving her continued psychological support for her demonstrated gains in handling the revulsion. her marital difficulties and other problems.
In Fig. 1 are presented dam on three different dependent vdriab)es as a function of treatment phases: approach scores on the Behavior Approach Test. card sort (attitudinal) scores related to interaction with pregnant women and attitudes toward her husband and her own possible future pregnancy. approach behavior remained more or less constant during As can be seen in Fig. 1. the patient‘s Baseline: the patient could get to the entrance of the OB Clinic waiting area and sometimes could turn to look at the waitmg patients (task 7). Immediately after the two Flooding sessions, she was able to perform all approach behavrors including sittmg in the midst of the waiting area for I5 min and conversing with a stranger who was a patient. Her subjective discomfort ratings which had been at 10 for tasks 6 and 7 went to zero for the terminal item. Her attitudes toward mteracting with pregnant women. the average of six items, showed a steady decline during early stages of Baseline and had stabilized betwen moderately (-2) and extremely (-3) unpleasant. After the Flooding treatment. the attitudinal items were rated 0 (indifferent). Her ratings about being pregnant herself and about making love with her husband showed an interesting pattern. They went from moderately unpleasant to extremely pleasant during Baseline and probably reflect the successful marriage counseling. They showed no change during Flooding or Follow-up.
CASE HlSTORlES AND
195
SHORTEK COMMUNICATIONS
During Baseline, the patient became more assertive and seemed to gain new confidence in herself in that she was willing to stand up to her husband and take on the challenge of a new Job. After Flooding. the patient showed further gains in self confidence and was able to identify a new strategy for herself in coping with problems: facing them rather than avoiding them. The patient made a new friend of a neighbor who was pregnant and delivered during Follow-up. Moreover, the patient began to accompany her husband to social affairs at which pregnant women were present. A telephone follow-up 3 months after the last session revealed that the patient was maintaining her gains and was no longer troubled by pregnant women. DISCUSSION
This case illustrates with a clinically debilitating revulsion or anger response how such a negative emotion can be treated behaviorally. Particularly impressive was the swiftness of the Flooding treatment. Moreover, because of the long series of baseline measures. one feels confident in attributing the therapeutic gains to the Flooding. This case also documents with objective data the anecdotal reports of Hogan (1969) of the effectiveness of a flooding approach to deal with anger responses in patients. Acknowledgemetlr-The author would like to acknowledge ing the Behavioral Approach Test. Unioersity ofMississippi Medical 2500 Nor01 State Street. Jackson, Mississippi. U.S.A.
the assistance
Center.
of Ms. Mary
R. Haynes
EDWARD
in conduct-
B.BLANCHARD
REFERENCES
desensitization, relaxation, cognitive rehearsal and desensitization of anxiety on the modification of anger-hostility responses. Dim. Ahstr. Iat. 30 (9-B). 4372. HERREL J. M. (1971) Use of systematic desensitization to eliminate inappropriate anger. hoc. 7Yth Amual Corwentiou. APA. pp. 431432. American Psychological Association. Washington. HOGAN R. A. (1969) Implosively oriented behavior modification: Therapy considerations. BP/KI~. Res. & Therapy 7, 177-l X3. MARKS I. M. (1972) Flooding (implosion) and allied treatment. In: Behaoior Modification Principles a,ld Clinical Applicatiom (Ed. AGRAS W. S.). Little. Brown. Boston. O’DONNELL C. R. (1971) Motor and cognitive components in the desensitization of a social relevant target behavior. Diss. Ahstr. Int. 32 (2-B). 1221. RIMM D. C., DEGRCOT J. C.. B~ORD P., HERMAN J. and DILLOW P. V. (1971) Systematic desensitization of an anger response. Brha~. Rrs. & Therap! 9, 173-280. WOLPE J. (1958) Psychotherapy by Reciprocal Irthihition. Stanford Univ. Press. Stanford, Cal. HARDING
J. H. (1970) The effect of systematic
