REGULAR ARTICLES
Double-Exposure Therapy: Videotape Homework as a Psychotherapeutic Adjunct DAVID H . GASMAN, M.D.* In a retrospective pilot study, 88 outpatients were videotaped during therapy and encouraged to watch the tape at home. Seventy-three (83%) reported video homework was helpful to the therapeutic process. Success of therapy according to video-group self-ratings was higher than that of a control group, (p < 0.0001) Patients reported increased objectivity, insight, and self-esteem. There were no serious adverse consequences.
Videotape in psychiatry is reported in the literature as early as the late 1950s. In 1970, Berger published Videotape Techniques in Psychiatric Training and Treatment, and in 1983 Heilveil wrote Video in Mental Health Practice. During the late 1960s and 1970s, many articles appeared regarding the use of video in training and treatment, especially with groups, families, and couples in therapy often with patients who had Borderline or psychotic diagnoses. During the last decade fewer articles appeared and in recent years the official journal of our profession, The American journal of Psychiatry, published no articles on video. In his book on videotape techniques, Berger alluded briefly to patients' viewing tapes after therapy sessions. Heilveil devoted one page to "Video Homework'' in Video in Mental Health Practice. In personal communications, both authors expressed to me caution about evoking negative reactions, including suicide, in unsupervised settings. In 1974, Alkire and Brunse noted the dearth of evaluative studies of videotape feedback. They devised a 1
2
3
4,5
6
* Private Practice. Mailing address: 1302 Oregon Street, Redding, CA 96001. AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. XLVI, No. 1, January 1992
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study of two marital groups in which group-selected conflicts were roleplayed and later viewed by the groups. In these two groups, each with three dyads, there were two suicides, three divorces, and one rehospitalization. One of the suicides was committed the day after playback of the video and the hospitalization occurred two days after viewing. Curiously, five of the six identified male patients assessed immediately after playback, saw themselves in a more positive light. Although these subjects were outpatients at the time of the study, all had been recently hospitalized and judged to be functioning in the "moderate to severe range of neurotic symptoms." Berger, Heilveil, and Watchel et al. reported increased insight and self-esteem in their patients. Watchers reports followed playback of limited portions of a previous or current session viewed jointly by the patient and therapist. In 1965, Geertsma and Reivich had one patient view the tape of her previous session for seven times just before the next session. They reported that the video overcame resistances and helped the patient see herself more realistically. Anxiety and depression were readily evoked along with increased demands for approval and support. Other contributions describe various adaptations of video to the psychiatric setting. In 1973 Resnick et al. reported videotaping emergency-room procedures in treatment of a patient's suicide attempt, including reactions of family members on the scene. These tapes were later shown to the patient in order to confront denial of despair and suicidal intent. Other authors made some analyses of the reluctance that patients, therapists, and supervisors have to video taping. Except as noted above, there is no mention of unsupervised video homework in any of the articles on treatment that I reviewed. In my informal inquiries of colleagues across the country, I have found that use of video homework in treatment is all but nonexistent. 2
3
7
8
9
10
METHOD
While using a camcorder for self-supervision in dynamically oriented psychotherapy with short-term techniques, I offered several patients the opportunity to take their tapes home for self-observation. The response was positive and enthusiastic. Most watched each tape two or more times. Because of this positive response I decided to offer new patients this adjunct to therapy. SELECTION OF SUBJECTS IN STUDY GROUP
The judgment to use video was made on the basis of our introductory encounter, either by telephone or in the waiting room when I first met new patients. With patients whose responses were coherent and socially appropri92
Double-Exposure Therapy
ate, I suggested video. Patients whose presenting complaint indicated a psychotic diagnosis, and those in crisis or severe distress were excluded on the supposition that a suggestion for video would complicate and disrupt the diagnostic interview. In addition to 49 new patients, 39 continuing patients were introduced to video homework or double-exposure therapy. This group of 88 patients included 42 males and 46 females with an age range from 22 to 74 years; the majority were between 40-50. Most were highly functioning, often active in community affairs, and occupationally successful. Diagnoses were adjustment, anxiety, mood, and personality disorders, and included major depressive and bipolar disorders. Thirty-six (40%) of these patients were seen ten times or less (8 were seen once). Eighteen (20%) were seen more than 50 times. Psychotropic medication was used with 33 (37%). PROCEDURE
The initial enthusiastic response of patients continued as they watched their sessions. Since it seemed to show therapeutic promise and was all but unmentioned in the literature, I decided to attempt some objective measure of my impressions of video homework. The following nine-item questionnaire was mailed to all 88 patients: 1.
Rate the success of your psychotherapy overall.
1 2 3 4 5 6 7 No Effect 2. Is your treatment with me completed? Yes No 3. Watching the videotape produced the following results
4.
5. 6. 7. 8. 9.
8
9 10 Complete Success
1 2 3 4 5 6 7 8 9 10 No Complete Effect Success Did you use the videotape: throughout therapy beginning of therapy middle of therapy toward end of therapy Approximately how many therapy sessions did you have in all? Approximately how many therapy sessions did you watch on tape? How many times did you watch each session? If you stopped using the tapes, why? If the video helped, please comment on how it benefited. 93
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Trying to establish if patients with no exposure to video homework had a different self rating of success in their psychotherapy, I sent a modified questionnaire to 47 patients seen prior to my use of videotape. These control patients were selected on the basis of chart review, using the same criteria as for use of video homework described above. This control questionnaire briefly explained my questions. It asked for the same self-rating of therapeutic success on a scale of 1-10, whether they received medication; it also provided an opportunity for either positive or negative feedback on their therapeutic experience. RESULTS
Eighty-four (94%) of the 88-member study group responded to the questionnaire; 55 (61%) by mail and 29 (33%) by phone. Twenty-eight (60%) of the control group responded, 7 (15%) responded by mail and 21 (45%) by phone. Tabulation of the 84 responses revealed the average study patient had 48 therapy sessions, watched tapes of 7 sessions, viewed each tape twice, rated the overall success of therapy "6.7" on a scale of 1-10, and the effectiveness of the video "6.4." (The average of 48 therapy sessions with 7 sessions watched on video is skewed by the fact that many of the 39 continuing patients had been seen many times before tapes were introduced. Thirty-two patients seen 30 or fewer times with video from the start had an average of 7 treatment sessions with 5.4 watched on video.) Forty-one (49%) of the 84 respondents made video homework a regular part of their therapy. Sixteen (19%) used the tapes sporadically. Four (5%) stopped because they had achieved sufficient benefit, and 6 (7%) stopped because they considered viewing too painful. Two found the tapes "boring," and of "no use," and 3 had confidentiality concerns regarding their spouses. Four (5%) did not watch at all (2 had no VCR, one lacked privacy and one patient, seen once, did not want to delve into the past). Two patients watched only moments of the tape, became frightened, and stopped. One of them, a long-term patient, later began using the tapes and found them helpful. Five patients seen only once, and one seen twice—none of whom fit into the above categories—rated the video higher than the psychotherapy. From analyzing the questionnaires, the self-rating of patients' success in psychotherapy increases the more sessions they view and also the more times they watch each tape. Fifty (57%) patients from the study group and 26 (55%) from the control group all of whom had 30 or fewer psychotherapy sessions were compared for their self-rated success of therapy. (Only patients with 30 or fewer 94
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sessions were compared to create matched groups. As noted, a full 20% of the study group were seen more than 50 times and several were seen many more than 100 times.) The comparison and control groups were similar in age, sex and diagnostic category. The control group rated its success in therapy as 5.04 and the comparison group 6.8 (t = 5.97, df = 76, p < 0.0001, two tailed). The most striking aspect of this study was the response to question #9 on the questionnaire. "If the video helped, please comment onhow it benefited." Patients reported that video homework gave objectivity (29 responses), refreshed their memories of the session (23) and helped them review (7). It increased self-esteem (10), provided insight (8), accelerated treatment (7), reinforcement (4), and revealed defenses (4). Twenty described the tapes as painful to watch and 4 stopped because of this. The other 15 continued, judging the benefit worth the pain. For instance, one patient reported that "hurtful topics became less traumatic with each viewing." A dysthymic, 40-year-old, married woman, treated successfully in 30 sessions, wrote that she could see and hear information and progress she really had not grasped, and that some sessions were not nearly as painful as anticipated. Several patients noted that reviewing tapes after termination of therapy averted a return of symptoms thereby eliminating the need for more therapy. One patient with adjustment disorder wrote, "It was an incredible experience, Ifinallyfelt free. At first I could only watch 10-15 minutes, but realized what I saw was a legitimate expression of the anger I was denying." Another patient, using the tapes after 10 sessions, wrote she could be a "therapist to myself. Discoveries were more intense and meaningful and psychotherapy proceeded at least twice as fast." A disabled veteran said it helped him "better his therapy by a factor of two." A young depressed man reported, "Certain tapes, especially toward the end, contained breakthrough moments, i.e., something Ifinallyrealized about myself that was the source or underpinning of most, if not all, my problems. When I felt depression coming on, I turned to a 'breakthrough' tape and without fail, it would avert the depression." A long-term dependent patient revealed, "The tapes helped me sort out reality. I used to go to bed, now I'm able to function in difficult situations." A highly functioning patient with an ego-syntonic character disorder, seen three times for depression, commented that after seeing himself on tape he believed my observations and comments, whereas during the sessions he tended to reject them. A patient with compulsive traits and panic disorder rated overall therapeutic success as a "5," but gave the tapes an "8." Because of initial resistance 95
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and her focus on medication, the tapes were not suggested until the 10th session. She wrote, "The tape reminds me of things discussed during the session which didn't stick in my mind. I can replay portions several times to get additional input and to concentrate, and I can stop the tape and have time to think about a specific statement." The only adverse response to video homework was from a 28-year-old impulsive, suicidal patient diagnosed as having a Borderline personality disorder. She gave her two sessions a "—3" on both success of treatment and videotaping, and commented she "felt as ugly on the outside as on the inside," after viewing the tape. There was, however, no resultant selfdestructive behavior. The three other patients in the study diagnosed as Borderline rated their success in psychotherapy as 'two,' 'five/ and 'seven.' The first, seen twice, commented that the tapes were "of no use." The second, seen five times in the midst of a marriage breakup, wanted to continue therapy but failed to do so. She reported "confusion," but also that the tapes "made me look at myself." The third, an extremely impulsive patient, had attended over 200 sessions and stated that she had found the tapes "very helpful" and that seeing herself on video made her feel "more real." In addition, Geertsma and Reivich's patient with seven playback sessions (see above), if diagnosed in 1992, would likely meet the criteria for Borderline personality disorder. At age 27 she had two illegitimate children and presented withfinancialdifficulties, inability to hold a job, and trouble with men. Although viewing her seven sessions produced increased anxiety and depression, no adverse consequences were noted. The patient began to relinquish her arrogance and become more "tender-minded." The general tone of the article indicates that the authors viewed the procedure as useful, and not harmful. The two patients in the study who were frightened by the tape and watched only a few moments, still rated themselves as a "9" and "10" on success of therapy, and, as mentioned, one of these began using the tapes at a later date with regularity and benefit. Two of the four patients who did not return questionnaires, had earlier reported not having any adverse response to the tape and one of these had indicated that watching the tape increased his confidence of coping with his problem to the extent he believed he had no further need of assistance. 8
DISCUSSION
Although viewing videotaped sessions at home has been referred to as video homework by Heilveil in 1983, it could also appropriately be called 96
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double-exposure therapy. If we believe that listening to patients and talking with them about their problems is worthwhile and therapeutic, it seems reasonable that reviewing the process would also be useful. Overall, my patients have continued to validate these impressions andfindingssince the study was completed. It is a time-honored saying that "repetition is the mother of studies." Certainly every therapist is well aware of the repetition of various themes and interpretations that are required to bring about change in a patient's attitude or behavior. In my experience, patients often are surprised by hearing something when they reviewed the tape that they did not recall at all from the session. I suspect most therapists assume that when they say something to the patient, it is remembered. The reports of patients using double exposure therapy make it clear that this cannot be assumed. At times patients have reported they had to watch the tape 3-4 times before the therapist's comments were fully comprehended. Often patients later see this reabsorbed material as important to the changes they seek. Had it not been for the double exposure to the session, they would have had to wait for some other time to gain that insight. Reviewing the session by use of the tape tends to hasten change and reduce the number of therapy sessions. With the need for cost effectiveness, this issue is of prime concern to all psychotherapists. Unfortunately for this study, the limitations of private practice in a small town made such things as additional therapists, independent evaluators, and psychometrics before, during, and after the study well-nigh impossible. Another weakness is the lack of a more in-depth questionnaire. The questionnaire return rate (61% by mail and 94% overall), however, is striking. Twice in the past 20 years I have sent out brief questionnaires about treatment, and the return rate has been 8-10%. In this study, the control group's return rate is only slightly better (15%). It seems a reasonable conclusion that the high return rate of the study group is a reflection of the enthusiasm of the patients for double-exposure therapy. Lack of availability of a VCR precludes use of this adjunct and hence it cannot be used with some populations. However, recent tabulations in the media indicate that 67 million households in this country do have VCR's, which makes it available to the majority of patients. In any case, should double-exposure therapy prove its effectiveness, it would be relatively easy to provide viewing facilities for those who lacked them. It needs to be pointed out that the study was entirely retrospective. I only undertook it because of my patients' repeated enthusiastic comments, and the encouragement of colleagues with whom I discussed the technique. I have been asked if objective and honest commentary can be counted on 97
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from the patients, especially since significant numbers (1/3 of the study and nearly 1/2 of the control) were canvassed by phone by myself. In reply, I can only state that in psychotherapy I routinely call for and receive negative feedback about a variety of issues. Patients understand that complete honesty in such matters is essential for a successful therapeutic outcome. The numbers derived from the questionnaire certainly are not conclusive and objective measurement of improvement is lacking. However if taken together with the patients' commentary both spontaneous and elicited during therapy the responses strongly support my positive impressions of this adjunct to psychotherapy. On the practical side, the video homework is usually readily accepted by patients, although frequently with some surprise. At times I mention video use in my first phone contact with them, which may last 5-10 minutes. More often I wait until I see them for the first time in the waiting room. I say nothing about the technique to patients whom, based on their appearance, manner on the telephone, or report by relatives, I judge to be disorganized, significantly frightened, or in acute crisis. I may introduce the technique later when they stabilize and if they show inclination toward psychotherapy. Concerns regarding confidentiality with spouses or family are acknowledged and the patients' wishes are respected. When I introduce myself in the waiting room, if I have not already mentioned video by phone, I ask, "Do you have a VCR?" I then proceed to state very simply that I send patients home with their tapes to watch and most tell me it helps them. Only occasionally do patients say no, in which case I merely suggest they may wish to consider it later. I then proceed with the interview. Since completion of the study, there have been several patients where it was clear from the initial interview that either resistances were so great or the integrative capacity so low, that watching the session might be disruptive, or there would be confidentiality problems with families. In these instances, I advised the patients not take the tapes home and they readily acquiesced. Incorporation of the video-homework experience into the ongoing psychotherapy occurs through questioning about the effect of the video just as one asks about effects of the psychotherapy session itself. In addition, patients make spontaneous remarks alluding to the video frequently, especially when the content of the session reminds them of what they noticed on the video. All of this material is processed in the same way as the remainder of the patients' productions. Patients introduced to video homework in the midst of their therapy are able to render a more objective and comparative opinion about the effectiveness of the video homework. The same is true of patients who had not used 98
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the technique during a previous course of therapy and did so on returning for additional treatment. Of the 15 study patients who were introduced to video in the midst of the therapy, 9 patients gave the therapy combined with video use higher scores than the psychotherapy alone. Only 5 of the 28 new patients whose only psychotherapeutic experience with me was the combined therapy throughout gave the video homework higher scores than the psychotherapy. In several instances the patient and myself gave video homework credit for breaking a veritable log jam or impasse in therapeutic progress so that it soon became possible to terminate with a successful outcome. Medications seem to create no influence on the perceived helpfulness of the procedure. Self-ratings of patients' overall therapeutic success were the same with and without medications. Introduction of video often seemed to create an immediate therapeutic alliance. When there is reluctance or objection to video, it creates negative feelings regarding being examined and looked at. Contrary to my usual practice of addressing transference immediately, I found that attempting to do this as regards the video created a misalliance. Therefore, I bypassed the transference issue until a therapeutic alliance was developed. I make it clear that the video decision is the patient's, and that even if we did tape the sessions, the tape did not have to be viewed. Overall the therapeutic potency of double-exposure therapy seems directly related to a patient's capacity and motivation for insight. The safety of the technique for most patients in the study is evident. Contraindications are based on assumption, intuition, and the emergence of several negative or disruptive results since the study. If there is evidence of significant depletion of ego-defensive resources with generalized cognitive disorganization, unremitting depression, and severe anxiety during the session, it seems reasonable that additional stimulation via the videotape might well overwhelm the ego defenses completely and exacerbate the patient's symptoms. Therefore, I consider these situations as absolute contraindications to video homework. This applies to schizophrenics and patients with an active bipolar disorder. However, when in remission, I find they report favorably on the videotape if motivated for insight. I recommend caution for the initial sessions in major depression and sometimes with panic disorder when dysfunction requires pharmacologic intervention. It is most important to heed the patient's decision about using video homework. Since the study, one suicide occurred three days after the initial interview in an elderly recently widowed woman. Whether this was the result of my intervention, the tape, or some other factor is unknown. I had one minor 99
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"flare-up" over a comment I made regarding a patient's spouse. (I had seen her alone and also with her husband previous to this session.) The only other incident regarding confidentiality occurred when a "significant other" viewed the patient's tape as he was talking about another girl friend. This hastened what I had considered to be an inevitable breakup of the relationship. Depending on a patient's situation, I offer suggestions of caution to keep the tapes confidential. For instance, when I tape a couple in conjoint therapy, especially if the relationship is at a conflicted stage, I suggest they watch it individually. Sometimes I tell them not to discuss it, other times I suggest they watch it only if both agree to do so. An interesting variation of double-exposure therapy was a case where the patient refused to be taped. I acquiesced to her request that I be the one on camera rather than she. Her report of benefit with this variation was decidedly positive. Since the study and after many confrontations regarding the resistance aspects of her refusal, she finally agreed to be taped. She noted criticizing herself for her actions on the tape but also found herself looking up at me more to see my expression. She had been avoiding making eye contact before and during the taping despite many transference and resistance confrontations. Another use of video in my practice has been positioning a TV monitor so a patient can easily see it. This has been helpful in pointing out interaction patterns with couples, and also in orienting alters to reality in my one patient with multiple personality disorder. She has been unable to watch the tape either in the office or at home without dissociating, so video has not been used as homework. Colleagues with whom I have discussed the technique are intrigued and curious. Some have malpractice concerns. I have yet to convince anyone to try double-exposure therapy. CONCLUSION
Videotape technology appears to be underutilized in psychiatry as evidenced by the relative paucity of literature on this subject. This is surprising considering the widespread use and popularity of video with the general public. Perhaps the relative unpopularity stems from the reluctance of therapists to expose their work to scrutiny. Based on my experience, video homework or double-exposure therapy is an effective, inexpensive, and simple adjunct that appears to assist the treatment process for many adult psychotherapy outpatients. When psychotic patients and others in severe distress or life crises are excluded, the technique is free of serious risk. If double-exposure therapy can benefit our patients, it deserves the attention 100
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and study of our profession. To establish the benefits of double-exposure therapy, further studies should include a concurrent control group, multiple therapists, independent evaluators, and statistically reliable psychometric assessment before, during and after treatment. SUMMARY
Despite widespread popularity of videotapes, it is little used in psychiatric treatment. Video is frequently used in training and supervision and it is in this context that I began to suggest that patients watch the tapes at home. The response was enthusiastic, but I discovered that very few clinicians use this technique, therefore, I decided to do a pilot study and present it to the professional community. A nine-item questionnaire about success in treatment and response to the tapes was mailed to 88 outpatients who had watched their tapes. Patients with psychosis, or those in acute crisis, were excluded from the study. As a control, a modified questionnaire was sent to 49 outpatients seen previous to the use of videotape. Ninety-four percent of the study group and 60 percent of the control group responded. The tape group self-rated "success in treatment" was significantly greater; 6.8 (scale 1-10) compared to 5.04 for the control. The most striking findings were comments relating to the use of video homework. Eighty-three percent of the patients found the tapes helpful; one thought it harmful. Objectivity, insight, and memory aid were frequently cited as advantages. Further study is warranted. REFERENCES 1. Deva, M. (1981). Use of video-tapes in psychological medicine. Medical journal of Malaysia, 36:4. 2. Berger, M. (1970). Videotape techniques in psychiatric training and treatment (pp. 119-160). New York: Brunner/Mazel. 3. Heilveil, I. (1983). Video in mental health practice, (pp. 26-27). New York: Springer. 4. Nadelson, C , Bussuk, E., & Hopps, C. (1977). The use of videotape in couples therapy. International journal of Group Psychotherapy, 27:241-253. 5. Gutheil, T., Mikkelsen, E., Peteet, J., et al. (1981). Patient viewing of videotaped psychotherapy. Part I: Impact on the therapeutic process; Part II: Aspects of the supervisory process. Psychiatric Quarterly, 53:219-234. 6. Alkire, A., & Brunse, T. (1974). Impact and possible casualty from videotape feedback in marital therapy. Journal of Consulting and Clinical Psychology, 43:2203-2210. 7. Wachtel, A., Stein, A., & Baldinger, M. (1979). Dynamic implications of videotape recording and playback in analytic group psychotherapy, paradoxical effect on transference resistance. International Journal of Group Psychotherapy, 29:67-85. 8. Geertsma, R., & Reivich, R. (1965). Repetitive self observation by video playback. Journal of Nervous and Mental Disease, 141:29-41. 9. Resnik, H., Davison, W., & Schuyler, D. (1973). Videotape confrontation after attempted suicide. American Journal of Psychiatry, 130:461-463. 10. Friedman, C , Yamamoto, J., & Wolkon, G., et al. (1978). Videotape recording of dynamic psychotherapy: supervisory tool or hindrance. American Journal of Psychiatry, 135:1388-1391.
101
Double-Exposure Therapy: Videotape Homework as a Psychotherapeutic Adjunct DAVID H . GASMAN, M.D.* In a retrospective pilot study, 88 outpatients were videotaped during therapy and encouraged to watch the tape at home. Seventy-three (83%) reported video homework was helpful to the therapeutic process. Success of therapy according to video-group self-ratings was higher than that of a control group, (p < 0.0001) Patients reported increased objectivity, insight, and self-esteem. There were no serious adverse consequences.
Videotape in psychiatry is reported in the literature as early as the late 1950s. In 1970, Berger published Videotape Techniques in Psychiatric Training and Treatment, and in 1983 Heilveil wrote Video in Mental Health Practice. During the late 1960s and 1970s, many articles appeared regarding the use of video in training and treatment, especially with groups, families, and couples in therapy often with patients who had Borderline or psychotic diagnoses. During the last decade fewer articles appeared and in recent years the official journal of our profession, The American journal of Psychiatry, published no articles on video. In his book on videotape techniques, Berger alluded briefly to patients' viewing tapes after therapy sessions. Heilveil devoted one page to "Video Homework'' in Video in Mental Health Practice. In personal communications, both authors expressed to me caution about evoking negative reactions, including suicide, in unsupervised settings. In 1974, Alkire and Brunse noted the dearth of evaluative studies of videotape feedback. They devised a 1
2
3
4,5
6
* Private Practice. Mailing address: 1302 Oregon Street, Redding, CA 96001. AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. XLVI, No. 1, January 1992
91
AMERICAN JOURNAL OF PSYCHOTHERAPY
study of two marital groups in which group-selected conflicts were roleplayed and later viewed by the groups. In these two groups, each with three dyads, there were two suicides, three divorces, and one rehospitalization. One of the suicides was committed the day after playback of the video and the hospitalization occurred two days after viewing. Curiously, five of the six identified male patients assessed immediately after playback, saw themselves in a more positive light. Although these subjects were outpatients at the time of the study, all had been recently hospitalized and judged to be functioning in the "moderate to severe range of neurotic symptoms." Berger, Heilveil, and Watchel et al. reported increased insight and self-esteem in their patients. Watchers reports followed playback of limited portions of a previous or current session viewed jointly by the patient and therapist. In 1965, Geertsma and Reivich had one patient view the tape of her previous session for seven times just before the next session. They reported that the video overcame resistances and helped the patient see herself more realistically. Anxiety and depression were readily evoked along with increased demands for approval and support. Other contributions describe various adaptations of video to the psychiatric setting. In 1973 Resnick et al. reported videotaping emergency-room procedures in treatment of a patient's suicide attempt, including reactions of family members on the scene. These tapes were later shown to the patient in order to confront denial of despair and suicidal intent. Other authors made some analyses of the reluctance that patients, therapists, and supervisors have to video taping. Except as noted above, there is no mention of unsupervised video homework in any of the articles on treatment that I reviewed. In my informal inquiries of colleagues across the country, I have found that use of video homework in treatment is all but nonexistent. 2
3
7
8
9
10
METHOD
While using a camcorder for self-supervision in dynamically oriented psychotherapy with short-term techniques, I offered several patients the opportunity to take their tapes home for self-observation. The response was positive and enthusiastic. Most watched each tape two or more times. Because of this positive response I decided to offer new patients this adjunct to therapy. SELECTION OF SUBJECTS IN STUDY GROUP
The judgment to use video was made on the basis of our introductory encounter, either by telephone or in the waiting room when I first met new patients. With patients whose responses were coherent and socially appropri92
Double-Exposure Therapy
ate, I suggested video. Patients whose presenting complaint indicated a psychotic diagnosis, and those in crisis or severe distress were excluded on the supposition that a suggestion for video would complicate and disrupt the diagnostic interview. In addition to 49 new patients, 39 continuing patients were introduced to video homework or double-exposure therapy. This group of 88 patients included 42 males and 46 females with an age range from 22 to 74 years; the majority were between 40-50. Most were highly functioning, often active in community affairs, and occupationally successful. Diagnoses were adjustment, anxiety, mood, and personality disorders, and included major depressive and bipolar disorders. Thirty-six (40%) of these patients were seen ten times or less (8 were seen once). Eighteen (20%) were seen more than 50 times. Psychotropic medication was used with 33 (37%). PROCEDURE
The initial enthusiastic response of patients continued as they watched their sessions. Since it seemed to show therapeutic promise and was all but unmentioned in the literature, I decided to attempt some objective measure of my impressions of video homework. The following nine-item questionnaire was mailed to all 88 patients: 1.
Rate the success of your psychotherapy overall.
1 2 3 4 5 6 7 No Effect 2. Is your treatment with me completed? Yes No 3. Watching the videotape produced the following results
4.
5. 6. 7. 8. 9.
8
9 10 Complete Success
1 2 3 4 5 6 7 8 9 10 No Complete Effect Success Did you use the videotape: throughout therapy beginning of therapy middle of therapy toward end of therapy Approximately how many therapy sessions did you have in all? Approximately how many therapy sessions did you watch on tape? How many times did you watch each session? If you stopped using the tapes, why? If the video helped, please comment on how it benefited. 93
AMERICAN JOURNAL OF PSYCHOTHERAPY
Trying to establish if patients with no exposure to video homework had a different self rating of success in their psychotherapy, I sent a modified questionnaire to 47 patients seen prior to my use of videotape. These control patients were selected on the basis of chart review, using the same criteria as for use of video homework described above. This control questionnaire briefly explained my questions. It asked for the same self-rating of therapeutic success on a scale of 1-10, whether they received medication; it also provided an opportunity for either positive or negative feedback on their therapeutic experience. RESULTS
Eighty-four (94%) of the 88-member study group responded to the questionnaire; 55 (61%) by mail and 29 (33%) by phone. Twenty-eight (60%) of the control group responded, 7 (15%) responded by mail and 21 (45%) by phone. Tabulation of the 84 responses revealed the average study patient had 48 therapy sessions, watched tapes of 7 sessions, viewed each tape twice, rated the overall success of therapy "6.7" on a scale of 1-10, and the effectiveness of the video "6.4." (The average of 48 therapy sessions with 7 sessions watched on video is skewed by the fact that many of the 39 continuing patients had been seen many times before tapes were introduced. Thirty-two patients seen 30 or fewer times with video from the start had an average of 7 treatment sessions with 5.4 watched on video.) Forty-one (49%) of the 84 respondents made video homework a regular part of their therapy. Sixteen (19%) used the tapes sporadically. Four (5%) stopped because they had achieved sufficient benefit, and 6 (7%) stopped because they considered viewing too painful. Two found the tapes "boring," and of "no use," and 3 had confidentiality concerns regarding their spouses. Four (5%) did not watch at all (2 had no VCR, one lacked privacy and one patient, seen once, did not want to delve into the past). Two patients watched only moments of the tape, became frightened, and stopped. One of them, a long-term patient, later began using the tapes and found them helpful. Five patients seen only once, and one seen twice—none of whom fit into the above categories—rated the video higher than the psychotherapy. From analyzing the questionnaires, the self-rating of patients' success in psychotherapy increases the more sessions they view and also the more times they watch each tape. Fifty (57%) patients from the study group and 26 (55%) from the control group all of whom had 30 or fewer psychotherapy sessions were compared for their self-rated success of therapy. (Only patients with 30 or fewer 94
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sessions were compared to create matched groups. As noted, a full 20% of the study group were seen more than 50 times and several were seen many more than 100 times.) The comparison and control groups were similar in age, sex and diagnostic category. The control group rated its success in therapy as 5.04 and the comparison group 6.8 (t = 5.97, df = 76, p < 0.0001, two tailed). The most striking aspect of this study was the response to question #9 on the questionnaire. "If the video helped, please comment onhow it benefited." Patients reported that video homework gave objectivity (29 responses), refreshed their memories of the session (23) and helped them review (7). It increased self-esteem (10), provided insight (8), accelerated treatment (7), reinforcement (4), and revealed defenses (4). Twenty described the tapes as painful to watch and 4 stopped because of this. The other 15 continued, judging the benefit worth the pain. For instance, one patient reported that "hurtful topics became less traumatic with each viewing." A dysthymic, 40-year-old, married woman, treated successfully in 30 sessions, wrote that she could see and hear information and progress she really had not grasped, and that some sessions were not nearly as painful as anticipated. Several patients noted that reviewing tapes after termination of therapy averted a return of symptoms thereby eliminating the need for more therapy. One patient with adjustment disorder wrote, "It was an incredible experience, Ifinallyfelt free. At first I could only watch 10-15 minutes, but realized what I saw was a legitimate expression of the anger I was denying." Another patient, using the tapes after 10 sessions, wrote she could be a "therapist to myself. Discoveries were more intense and meaningful and psychotherapy proceeded at least twice as fast." A disabled veteran said it helped him "better his therapy by a factor of two." A young depressed man reported, "Certain tapes, especially toward the end, contained breakthrough moments, i.e., something Ifinallyrealized about myself that was the source or underpinning of most, if not all, my problems. When I felt depression coming on, I turned to a 'breakthrough' tape and without fail, it would avert the depression." A long-term dependent patient revealed, "The tapes helped me sort out reality. I used to go to bed, now I'm able to function in difficult situations." A highly functioning patient with an ego-syntonic character disorder, seen three times for depression, commented that after seeing himself on tape he believed my observations and comments, whereas during the sessions he tended to reject them. A patient with compulsive traits and panic disorder rated overall therapeutic success as a "5," but gave the tapes an "8." Because of initial resistance 95
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and her focus on medication, the tapes were not suggested until the 10th session. She wrote, "The tape reminds me of things discussed during the session which didn't stick in my mind. I can replay portions several times to get additional input and to concentrate, and I can stop the tape and have time to think about a specific statement." The only adverse response to video homework was from a 28-year-old impulsive, suicidal patient diagnosed as having a Borderline personality disorder. She gave her two sessions a "—3" on both success of treatment and videotaping, and commented she "felt as ugly on the outside as on the inside," after viewing the tape. There was, however, no resultant selfdestructive behavior. The three other patients in the study diagnosed as Borderline rated their success in psychotherapy as 'two,' 'five/ and 'seven.' The first, seen twice, commented that the tapes were "of no use." The second, seen five times in the midst of a marriage breakup, wanted to continue therapy but failed to do so. She reported "confusion," but also that the tapes "made me look at myself." The third, an extremely impulsive patient, had attended over 200 sessions and stated that she had found the tapes "very helpful" and that seeing herself on video made her feel "more real." In addition, Geertsma and Reivich's patient with seven playback sessions (see above), if diagnosed in 1992, would likely meet the criteria for Borderline personality disorder. At age 27 she had two illegitimate children and presented withfinancialdifficulties, inability to hold a job, and trouble with men. Although viewing her seven sessions produced increased anxiety and depression, no adverse consequences were noted. The patient began to relinquish her arrogance and become more "tender-minded." The general tone of the article indicates that the authors viewed the procedure as useful, and not harmful. The two patients in the study who were frightened by the tape and watched only a few moments, still rated themselves as a "9" and "10" on success of therapy, and, as mentioned, one of these began using the tapes at a later date with regularity and benefit. Two of the four patients who did not return questionnaires, had earlier reported not having any adverse response to the tape and one of these had indicated that watching the tape increased his confidence of coping with his problem to the extent he believed he had no further need of assistance. 8
DISCUSSION
Although viewing videotaped sessions at home has been referred to as video homework by Heilveil in 1983, it could also appropriately be called 96
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double-exposure therapy. If we believe that listening to patients and talking with them about their problems is worthwhile and therapeutic, it seems reasonable that reviewing the process would also be useful. Overall, my patients have continued to validate these impressions andfindingssince the study was completed. It is a time-honored saying that "repetition is the mother of studies." Certainly every therapist is well aware of the repetition of various themes and interpretations that are required to bring about change in a patient's attitude or behavior. In my experience, patients often are surprised by hearing something when they reviewed the tape that they did not recall at all from the session. I suspect most therapists assume that when they say something to the patient, it is remembered. The reports of patients using double exposure therapy make it clear that this cannot be assumed. At times patients have reported they had to watch the tape 3-4 times before the therapist's comments were fully comprehended. Often patients later see this reabsorbed material as important to the changes they seek. Had it not been for the double exposure to the session, they would have had to wait for some other time to gain that insight. Reviewing the session by use of the tape tends to hasten change and reduce the number of therapy sessions. With the need for cost effectiveness, this issue is of prime concern to all psychotherapists. Unfortunately for this study, the limitations of private practice in a small town made such things as additional therapists, independent evaluators, and psychometrics before, during, and after the study well-nigh impossible. Another weakness is the lack of a more in-depth questionnaire. The questionnaire return rate (61% by mail and 94% overall), however, is striking. Twice in the past 20 years I have sent out brief questionnaires about treatment, and the return rate has been 8-10%. In this study, the control group's return rate is only slightly better (15%). It seems a reasonable conclusion that the high return rate of the study group is a reflection of the enthusiasm of the patients for double-exposure therapy. Lack of availability of a VCR precludes use of this adjunct and hence it cannot be used with some populations. However, recent tabulations in the media indicate that 67 million households in this country do have VCR's, which makes it available to the majority of patients. In any case, should double-exposure therapy prove its effectiveness, it would be relatively easy to provide viewing facilities for those who lacked them. It needs to be pointed out that the study was entirely retrospective. I only undertook it because of my patients' repeated enthusiastic comments, and the encouragement of colleagues with whom I discussed the technique. I have been asked if objective and honest commentary can be counted on 97
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from the patients, especially since significant numbers (1/3 of the study and nearly 1/2 of the control) were canvassed by phone by myself. In reply, I can only state that in psychotherapy I routinely call for and receive negative feedback about a variety of issues. Patients understand that complete honesty in such matters is essential for a successful therapeutic outcome. The numbers derived from the questionnaire certainly are not conclusive and objective measurement of improvement is lacking. However if taken together with the patients' commentary both spontaneous and elicited during therapy the responses strongly support my positive impressions of this adjunct to psychotherapy. On the practical side, the video homework is usually readily accepted by patients, although frequently with some surprise. At times I mention video use in my first phone contact with them, which may last 5-10 minutes. More often I wait until I see them for the first time in the waiting room. I say nothing about the technique to patients whom, based on their appearance, manner on the telephone, or report by relatives, I judge to be disorganized, significantly frightened, or in acute crisis. I may introduce the technique later when they stabilize and if they show inclination toward psychotherapy. Concerns regarding confidentiality with spouses or family are acknowledged and the patients' wishes are respected. When I introduce myself in the waiting room, if I have not already mentioned video by phone, I ask, "Do you have a VCR?" I then proceed to state very simply that I send patients home with their tapes to watch and most tell me it helps them. Only occasionally do patients say no, in which case I merely suggest they may wish to consider it later. I then proceed with the interview. Since completion of the study, there have been several patients where it was clear from the initial interview that either resistances were so great or the integrative capacity so low, that watching the session might be disruptive, or there would be confidentiality problems with families. In these instances, I advised the patients not take the tapes home and they readily acquiesced. Incorporation of the video-homework experience into the ongoing psychotherapy occurs through questioning about the effect of the video just as one asks about effects of the psychotherapy session itself. In addition, patients make spontaneous remarks alluding to the video frequently, especially when the content of the session reminds them of what they noticed on the video. All of this material is processed in the same way as the remainder of the patients' productions. Patients introduced to video homework in the midst of their therapy are able to render a more objective and comparative opinion about the effectiveness of the video homework. The same is true of patients who had not used 98
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the technique during a previous course of therapy and did so on returning for additional treatment. Of the 15 study patients who were introduced to video in the midst of the therapy, 9 patients gave the therapy combined with video use higher scores than the psychotherapy alone. Only 5 of the 28 new patients whose only psychotherapeutic experience with me was the combined therapy throughout gave the video homework higher scores than the psychotherapy. In several instances the patient and myself gave video homework credit for breaking a veritable log jam or impasse in therapeutic progress so that it soon became possible to terminate with a successful outcome. Medications seem to create no influence on the perceived helpfulness of the procedure. Self-ratings of patients' overall therapeutic success were the same with and without medications. Introduction of video often seemed to create an immediate therapeutic alliance. When there is reluctance or objection to video, it creates negative feelings regarding being examined and looked at. Contrary to my usual practice of addressing transference immediately, I found that attempting to do this as regards the video created a misalliance. Therefore, I bypassed the transference issue until a therapeutic alliance was developed. I make it clear that the video decision is the patient's, and that even if we did tape the sessions, the tape did not have to be viewed. Overall the therapeutic potency of double-exposure therapy seems directly related to a patient's capacity and motivation for insight. The safety of the technique for most patients in the study is evident. Contraindications are based on assumption, intuition, and the emergence of several negative or disruptive results since the study. If there is evidence of significant depletion of ego-defensive resources with generalized cognitive disorganization, unremitting depression, and severe anxiety during the session, it seems reasonable that additional stimulation via the videotape might well overwhelm the ego defenses completely and exacerbate the patient's symptoms. Therefore, I consider these situations as absolute contraindications to video homework. This applies to schizophrenics and patients with an active bipolar disorder. However, when in remission, I find they report favorably on the videotape if motivated for insight. I recommend caution for the initial sessions in major depression and sometimes with panic disorder when dysfunction requires pharmacologic intervention. It is most important to heed the patient's decision about using video homework. Since the study, one suicide occurred three days after the initial interview in an elderly recently widowed woman. Whether this was the result of my intervention, the tape, or some other factor is unknown. I had one minor 99
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"flare-up" over a comment I made regarding a patient's spouse. (I had seen her alone and also with her husband previous to this session.) The only other incident regarding confidentiality occurred when a "significant other" viewed the patient's tape as he was talking about another girl friend. This hastened what I had considered to be an inevitable breakup of the relationship. Depending on a patient's situation, I offer suggestions of caution to keep the tapes confidential. For instance, when I tape a couple in conjoint therapy, especially if the relationship is at a conflicted stage, I suggest they watch it individually. Sometimes I tell them not to discuss it, other times I suggest they watch it only if both agree to do so. An interesting variation of double-exposure therapy was a case where the patient refused to be taped. I acquiesced to her request that I be the one on camera rather than she. Her report of benefit with this variation was decidedly positive. Since the study and after many confrontations regarding the resistance aspects of her refusal, she finally agreed to be taped. She noted criticizing herself for her actions on the tape but also found herself looking up at me more to see my expression. She had been avoiding making eye contact before and during the taping despite many transference and resistance confrontations. Another use of video in my practice has been positioning a TV monitor so a patient can easily see it. This has been helpful in pointing out interaction patterns with couples, and also in orienting alters to reality in my one patient with multiple personality disorder. She has been unable to watch the tape either in the office or at home without dissociating, so video has not been used as homework. Colleagues with whom I have discussed the technique are intrigued and curious. Some have malpractice concerns. I have yet to convince anyone to try double-exposure therapy. CONCLUSION
Videotape technology appears to be underutilized in psychiatry as evidenced by the relative paucity of literature on this subject. This is surprising considering the widespread use and popularity of video with the general public. Perhaps the relative unpopularity stems from the reluctance of therapists to expose their work to scrutiny. Based on my experience, video homework or double-exposure therapy is an effective, inexpensive, and simple adjunct that appears to assist the treatment process for many adult psychotherapy outpatients. When psychotic patients and others in severe distress or life crises are excluded, the technique is free of serious risk. If double-exposure therapy can benefit our patients, it deserves the attention 100
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and study of our profession. To establish the benefits of double-exposure therapy, further studies should include a concurrent control group, multiple therapists, independent evaluators, and statistically reliable psychometric assessment before, during and after treatment. SUMMARY
Despite widespread popularity of videotapes, it is little used in psychiatric treatment. Video is frequently used in training and supervision and it is in this context that I began to suggest that patients watch the tapes at home. The response was enthusiastic, but I discovered that very few clinicians use this technique, therefore, I decided to do a pilot study and present it to the professional community. A nine-item questionnaire about success in treatment and response to the tapes was mailed to 88 outpatients who had watched their tapes. Patients with psychosis, or those in acute crisis, were excluded from the study. As a control, a modified questionnaire was sent to 49 outpatients seen previous to the use of videotape. Ninety-four percent of the study group and 60 percent of the control group responded. The tape group self-rated "success in treatment" was significantly greater; 6.8 (scale 1-10) compared to 5.04 for the control. The most striking findings were comments relating to the use of video homework. Eighty-three percent of the patients found the tapes helpful; one thought it harmful. Objectivity, insight, and memory aid were frequently cited as advantages. Further study is warranted. REFERENCES 1. Deva, M. (1981). Use of video-tapes in psychological medicine. Medical journal of Malaysia, 36:4. 2. Berger, M. (1970). Videotape techniques in psychiatric training and treatment (pp. 119-160). New York: Brunner/Mazel. 3. Heilveil, I. (1983). Video in mental health practice, (pp. 26-27). New York: Springer. 4. Nadelson, C , Bussuk, E., & Hopps, C. (1977). The use of videotape in couples therapy. International journal of Group Psychotherapy, 27:241-253. 5. Gutheil, T., Mikkelsen, E., Peteet, J., et al. (1981). Patient viewing of videotaped psychotherapy. Part I: Impact on the therapeutic process; Part II: Aspects of the supervisory process. Psychiatric Quarterly, 53:219-234. 6. Alkire, A., & Brunse, T. (1974). Impact and possible casualty from videotape feedback in marital therapy. Journal of Consulting and Clinical Psychology, 43:2203-2210. 7. Wachtel, A., Stein, A., & Baldinger, M. (1979). Dynamic implications of videotape recording and playback in analytic group psychotherapy, paradoxical effect on transference resistance. International Journal of Group Psychotherapy, 29:67-85. 8. Geertsma, R., & Reivich, R. (1965). Repetitive self observation by video playback. Journal of Nervous and Mental Disease, 141:29-41. 9. Resnik, H., Davison, W., & Schuyler, D. (1973). Videotape confrontation after attempted suicide. American Journal of Psychiatry, 130:461-463. 10. Friedman, C , Yamamoto, J., & Wolkon, G., et al. (1978). Videotape recording of dynamic psychotherapy: supervisory tool or hindrance. American Journal of Psychiatry, 135:1388-1391.
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