cancer phobia

8/13/2019 Cancer Phobia

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PSYCHOTHERAPY: THEORY, RESEARCH AND PRACTICEVOLUME 15, # 1 , SPRING. 1978

IMPLOSIVE THERAPY WITH HYPNOSISIN THE TREATMENT OFCANCER PHOBIA: A CASE REPORTJOHN M. O'DONNELL204 East C apitol DriveMilwaukee, Wisconsin 53212

ABSTRACT: Much attention has recently been givento the high incidence of breast cancer and the needfor more effective detection strategies in our society.Correlated with this attention, however, have comereports of a significant increase in cancer-relatedhypochondriasis. The present paper describes thesuccessful treatment of cancer phobia in ahypochondriacal female by means of implosivetherapy w ith hypnosis. Implosive therapy is apsychodynamically oriented behavior therapy ini-tially developed for the treatment of phobias. Theprocedure entails utilizing the patient s imagery andpurposely exposing him to the most intense anxiety-eliciting stimuli imaginable. The supposition is thatcontinuous and inescapable exposure to the fearfulstimuli without negative consequences or reinforce-ment will eventually weaken the anxiety-arousingpower of the stimuli. A current emphasis in hyp-notherapy is o n treating a patient in hypnosis versustreating him by hypnosis. In the present case, thehypnotic induction was intended to heighten thepatient s bodily awareness, to increase the vividnessof and suggestibility to imagery, and to narrow thefocus of attention in order to maximize responsive-ness to implosion. The patient is a 29-year-oldfemale whose anxiety about cancer had reacheduncontrollable and continuous phobic proportions.Three 60-minute treatment sessions were conductedwithin a one-weekperiod Subjective and behavioralrating scales before, during, and up to eight monthsfollowing the treatment week revealed a significantdecrease in phobic anxiety and hypochondriacalbehavior. The results were discussed relative tocognitive interpretations ofth mechanisms possiblyunderlying implosive therapy.

Due to recent well-publicized reports of radi-cal mastectomies in several prominent Ameri-can women, much attention has been focusedon the high incidence of breast cancer and theneed for more effective detection strategies inour society. Active multi-media campaigns

have been initiated, for example, in order toheighten the public's awareness of the problemand hopefully effect more early detection andtreatment. Correlated with the extensive publi-city, however, have come reports from physi-cians of a significant increase in cancer-relatedhypochondriasis.Irrespective of frequent appeals to logic andcommon sense, and regardless of disconfirma-tion by medical tests, hypochondriasis typicallyis quite persistent. In fact, disconfirmations andrational arguments will often entrench the pa-tient more deeply than ever in his obsessiveruminations. Relatively few of these patientsever come to the psychotherapist's office be-cause of their intense conviction that the prob-lem is organic, and not psychological; and,even if these patients do make it to a therapist,hypochondriasis is reportedly very resistant topsychotherapy (Coleman, 1972).The present paper describes the successfultreatment of cancer phobia in a hypochondriacalpatient by means of implosive therapy withhypnosis. Implosive therapy is a psychodynam-ically oriented behavior therapy initially de-veloped by Stampti (1961) for the treatment ofphobias. The procedure typically is quite directand straightforward. Based on the therapist'stheoretical interpretation of the dynamics of thecase, he will utilize the client's imagery andpurposely expose him to the most intenseanxiety-eliciting stimuli imaginable. The sup-position is that continuous and inescapableexposure to the fearful stimuli without negativeconsequences or reinforcement will eventuallyweaken the anxiety-arousing power of thestimuli.Stampfl and Levis (1967) have indicated thatthe ability to visualize imagery is essential for

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IMPLOSIVE THERAPY WITH HYPNOSIS

successful implosive therapy. On several occa-sions with cognitive behavior therapy of varioussorts, the present writer has experienced mod-erate success in using hypnosis to overcomewhat Ayer (1972) has described as an inv isi-ble sh iel d often erected by the client to pro-hibit intimate association with imagined scenes.A current emphasis in hypnotherapy is ontreating a client in hypnosis versus treating himby hypnosis. In the present case, the hypnoticinduction was intended to heighten the client'sbodily awareness, to increase the vividness ofand her suggestibility to suggested imagery,and to narrow the focus of her attention in orderto maximize her responsiveness to implosion.As Bell (1972) and many others have em-phasized, the individual under hypnosis is notasleep or unconscious but is in fact more awareand vigilant due to a selective inattention toirrelevant stimuli.

CASE REPORTBackground

Mrs. T., the client about whom this reportrevolves, is a 29-year-old, attractive femalewhose anxiety about cancer had reached un-controllable and continuous phobic propor-tions. M rs. T. was self-ref erred for therapythrough a community mental health center-affiliated telephone hotline service. There wasno previous his tory of counsel ing orpsychotherapy despite multiple attempts on thepart of several physicians over the past year torefer her for such services. In the year im-mediately prior to implosive treatment, she hadseen ten different physicians within a 75-mileradius for a total of 45 outpatient and twoinpatient medical examinations for cancer, inaddition to another 25 estimated telephone con-sultations with these same physicians. Theseexaminations included the following: a brainscan, two barium swallows, and approximatelytwo dozen different occasions of X-rays. Thepatient paid most of her outpatient medicalexpenses herself which amounted to severalthousands of dollars. These frequency data andrelated circumstances for this year were report-edly the same for the preceding one-and-a-halfyears as well. Of all her friends, family, andnumerous physicians for the three years prior toimplosive treatment, only her husband and her

primary (and initial) physician had any aware-ness of the extensive scope of her problem.With permission of the client, close contact wasmaintained with these two persons throughoutboth the preliminary assessment and implosivetreatment phases of the case for purposes ofobjective third-party verification of the diagnos-tic and therapeutic outcome data provided byMrs. T.At the time of the initial preliminary assess-ment, Mrs. T. was almost constantly obsessedand ruminative over the prospect of havingcancer. Whenever alone, she would franticallyexamine herself for tumors in her underarmarea, breasts, and throat so frequently each daythat bruises and abrasions were occurringwhich, in a vicious circle fashion, all the moreintensified her fears and seemingly confirmedher worst expectations. On a cognitive level,Mrs. T. was verbally able to recognize theirrationality of her behavior and give acknowl-edgment to the consistently negative medicalfindings. She could not, however, exerciseemotional or behavioral control over her anxi-ety symptoms; and the more reasssurances orappeals to reason she received, the more intenseher discomfort seemed to become.Relevant H istory

Psychological test and clinical interview as-sessment revealed that the client had had first-hand familiarity with terminal cancer throughthe deaths of her grandmother (breast and pelviccancer), uncle (lung cancer), and a close,fatherly friend (brain tumor). Her grandmotherhad reportedly insisted on having Mrs. T. (inher late adolescence at the time) feel the growthon her grandmother's hip shortly before herdeathan experience which was described asquite upsetting. An unhappy childhood, fraughtwith familial instability, was also reported.Mrs. T.'s mother was married five differenttimes to a series of men whom the client, as achild, perceived to be hostile and rejecting.Throughout her childhood, Mrs. T. was report-edly quite susceptible to infectious illnessesand malnutrition; and at age 17 she was hos-pitalized for m aln utritio n. There were anumber of indications that the client as a childmay have received attention from her mother orstepfathers primarily or only when she wasphysically ill. Assessment data presented a


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10 JOHN M. O ' D O N N E L Lpictureof mixed neurotic symptomatology withprimary phobic, obsessive-compulsive, andhypochondriacal features.The interview data strongly suggested thatthe current symptoms were being maintained atleast in part by the reinforcing attention Mrs.T.was receiving from medical personnel and fromher husband. It was decided that the effectofconventional talk-therapy mightbe toelicitmore symptomato logy and unconsciousattention-getting effort. Based upon these dataand Mrs. T. s high level of current anxiety,abehavior therapy regime was recommended.Mrs. T. was briefed as to the various ap-proaches which might be taken with specialfocuson the relative advantages and disadvan-tagesofeach approach. She elected to undergoimplosive treatment inthe hopeof ashort-termbehavior therapy intervention. It was mutuallyunderstood that if gains from implosive treat-ment were not soon forthcoming, then a desen-sitization approach would be undertaken.DescriptionofTechniques

Three 60-minute treatment sessions wereconducted within the span of one week.Homework inthe formofimagery practice wasnot assigned to occur between sessions. In thefirst session, the client was initially giventenminutesofpracticein neutral imagery followedby a 20-minute hypnotic induction whereinshewas presented with highly pleasant suggestionsof progressively deepening relaxation andheightened body awareness. Bodily sensationsrelative to thecritical areasof herbody aboutwhich she was most fearful were especiallyemphasized. A 30-minute implosive segmentthen began by suggesting the subjective sensa-t ions of tumor- l ike growths developingthroughout the critical bodily areas of fearfulconcern. Each growth was graphically de-scribed and presented interms of aloathsomeappearance , sm ell, texture, and taste. A processof bodily deterioration and a gradual transfor-mation from a person into one large, massivetumor was also vividly described. All through-ou ther miserable ordeal, the client was toldtoenvision family, physicians, and friends,shrinking away in horror at her monstrousgrotesqueness. Everyone refused to attend toherin herm isery, andshe was abandonedbyeveryone for months-on-end to die a long,drawn-out, excruciatingly painful, and lonely

de ath . Even death itself brought no relief,however; and she was forced to go throughalleternity as apulsating, writhing massofdetest-able putresce nce.The entire procedure, excepting theneutralimagery practice, was repeated in two differentsessions separated by 48-hour intervals.Mrs.T. was highly responsive tothe hypnotic induc-tion and was observed tobe maximally anxiousthroughout theimplosive imagery. Her anxietycharacteristically peaked after approximately20minutesof implosion, however, and then beganto decline slightly. After an approximatelyfive-minute debriefing atthe conclusionofeachsession, she reported feelings of exhaustion

accompanied by minimal anxiety. Followingthe second and third implosive session debrief-ings, she was able to laugh about the ridicu-lousness of her symptomatology. The clientreported significant and progressive improve-ments after each of the three implosive treat-ment sessions, and treatment was terminatedwith the conclusion of the third implosivesession.Outcome Evaluation

In order to establish a baseline for post-treatment assessment, a five-point rating scalewith a zero-to-four range was devised anddefined along a continuum of subjectivedis-comfort and behavioral disruption. (SeeTable1.) Ratings were recorded for five differentweeks over a ten-month period. During eachweek, Mrs. T. was instructed to make onerating every half-hour throughout her normalwaking hours (typically between 8a.m. and 11p.m.) . Figure 1depicts the daily mean ratingsoveraninitial baseline week ,asecond baseline

Fig. 1. Daily mean ratingsof subjective and behavioraldisruption by cancer phob ia for five week s over a ten-monthperiod.

I BASELINE I; BASELINE 111IMPLOSIVE \ P O S T - FOLLOW-UP4 \ i THERAPY iTREATMENTl

I i ; i

i

s I I I I I , I I I I I I I I I1 7 1 7 1 7 1 7 1 75/14/73 6/20 6/27 7/14 3/17/74

WEEKS


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IMPLOSIVE THERAPY WITH HYPNOSIS 11week (following the four preliminary assess-ment sessions and immediately prior to theimplosive treatment), the week of treatment,and post-treatment weekly assessment both onemonth and eight months following treatment.During the two baseline periods, over 55 ofthe individual half-hour ratings were rated at alevel of two or higher, with thirty-six three-point ratings and twelve four-point ratings hav-ing been recorded. In marked contrast, how-eve r, less than 2 of the half-hour ratings forthe two post-treatment periods were at thetwo-point level, and no ratings were recorded ateither the three or four-point levels. Most im-portantly, one year after treatment, Mrs. T.reported that she had been to see a physicianonly once since the termination of implosivetreatment for an annual physical.

DISCUSSIONWhereas recent reviews of implosive therapy(e.g., Morganstern, 1973) have been critical ofthe technique, it should be noted that thereviews are largely based upon analogue studiesusing college students with fears of rats,

snakes, or insects. How truly analogous thesestudies are to studies of clients whose dailyfunctioning is seriously disrupted by obsessivefear-elicited stimuli is very much open to ques-tion. It is suggested that implosive therapy andrelated flooding techniques can be of considera-ble assistance to select clients given their par-ticular circumstances and individual suitabilityfor implosion. Careful assessment and cautionshould precede the decision to employ implo-sive therapy, however, since a poorly designedor executed procedure could result in aheightened sensitization to the fear-arousingstimuli. Of special import in this regard is thedetermination of length of proper exposure time

to the implosive imagery (Rimm & Masters,1974; W olpe, 1969).It should be noted that there were no sig-nificant differences between the two baselineperiods interspersed by a month of weeklydiagnostic sessions. This would seem to suggestthat the successful outcome effect cannot beattributed to the self-monitored ratings or totherapist attention alone. However, there are avariety of possible cognitive interpretation al-ternatives to Stampfl's psychodynamic/two-partlearning theory formulations of implosivetherapy. In the present case report, a number ofcontributing factors may have been operative:covert conditioning, alteration of covert self-instructional statements, paradoxical intention,client and/or therapist expectancy factors, re-sponsiveness to the therapist and/or hypnoticdemands, and so on. This case study does notattempt to analyze the differential role of thesecognitive components, and it remains to bedetermined to what extent classical extinctionversus cognitive mediational processes areoperative in effective implosive therapy.

The use of implosive therapy with hypnosis inthe present case was surprisingly dramatic andswift in effectiveness. Similar successful re-ports of flooding under hypnosis have alsorecently been cited (Astrup, 1974). Althoughclarification of the underlying mechanisms re-sponsible for the effectiveness of implosivetherapy and hypnosis is lacking, this combinedapproach appears to have many practical appli-cation possibilitiesespecially with neuroticsymptomatology seemingly unresponsive toconventional treatment.

REFERENCESASTRUP, C. Flooding therapy with hypnosis. BehaviorTherapy 1974, 5, 704-705.AYER, W. A. Im plosive therapy: A review.Psychotherapy:

TABLE 1. Rating Scale of Subjective and Behavioral Disruption by Cancer Phobia.

No awareness of can-cer concerns. Nonoticeable effect ofany cancer concernsupon behavior oremotions.

Minimal periodicconcerns with can-cer. No noticeableinterference withdaily routinefunctioning.

Moderate episodicconcerns with cancer.Some minor disrup-tion of daily routinefunctioning in evi-dence.

Continual moderatediscomfort aboutcancer. Minimal tomoderate disruptionof daily routinefunctioning isevidenced.

Continual intensediscomfort due to can-cer concern. Majordisruption or inter-ference with dailyroutine functioning.

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12 JOHN M. O ' D O N N E L LTheory Research and Practice, 1971,9,242-250.

BELL, G. K. Clinical hypnosis: Warp and woof ofpsychotherapies. Psychotherapy: Theory ResearchandPractice 1972,9,276-280.COLEMAN, J. C. Abnormal psychology and modern life.Glenview, Illinois: Scott, Foresman,1972.MORGANSTERN, K. P. Implosive therapy and floodingprocedures: A critical review. Psychological Bulletin1972,79 ,318-334.

RIMM, D. C , MASTERS, J. C. Behavior therapyTechniques and em pirical findings.New York: AcademicPress,1974.

STAMPFL, T. G. (1961) Implosive therapy: A learningtheory derived psychodynamic therapeutic technique.InLebarba and Dent (Eds.): Critical issues in clinicalpsychology. New York: Academic Press,1967.STAMPFL, T. G., LEVIS, D. J. Essentials of implosive

therapy: A learning-theory-based psychodynamic be-havioral therapy. Journal of Abnormal Psychology1967,72,496-503.WOLPE, J.The practice of behavior therapy. New York:Pergaman Press,1969.

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