CASE HISTORIES AND SHORTER COMMUNICATIONS 441

$2.69. Many sports clubs and theatre box offices in the San Francisco Bay Area donated free or reduced price tickets. These donations made it possible to hold the price of reinforcers at a relatively low level.

University of Calijornia, San Francisco, U.S.A.

SHARON M. HALL and JAMES L. COOPER

Methadone Maintenance Treatment Program,

City and County of San Francisco, U.S.A.

SALLY BURMASTER and ANDY POLK

REFERENCES

BOUDIN H. M. and VALENTINE V. E. (1973) Behavioral techniques as an alternative to methadone maintenance. Paper presented, Association for Advancement of Behavior Therapy Conference.

BOUDIN H. M., REGAN E. J. and RUIZ M. R. (1976) Contingency contracting with drug abusers in the natural environment: Treatment evaluation. Paper presented, Association for Advancement of Behavior Therapy.

US. PUBLIC HEALTH SERVICE (1966) Obesity and Health. U.S. Department of Health, Education and Welfare. Arlington, VA.

Behav. Res. & Therapy, 1977, Vol. IS, pp. 44W44. Pergamon Press. Printed m Great Brltam

Obsessional ruminations: a comparison between thought-stopping and prolonged exposure in imagination

(Received 5 January 1977)

Controlled experiments concerning the effects of variants of exposure in uiuo and response prevention with patients with compulsive rituals have produced satisfactory results (Boersma et al., 1976; Emmelkamp and Kraanen, 1977; Marks, Rachman and Hodgson, 1975; Rabavilas, Boulougouris and Stefanis. 1976). Patients suffering from serious obsessional ruminations as well as compulsive rituals seem, however, to derive little benefit from this type of treatment.

Very little controlled experimental research has been carried out with regard to the treatment of obsessional ruminations. Such cases as have been reported in the literature usually concern uncontrolled case studies with inadequate measurements or no measurements at all. With patients suffering from obsessions, the pro- cedure of thought-stopping is often applied (Campbell, 1973; Stern, 1970; Yamagami, 1971; Wolpe, 1958, 1970). A controlled investigation (Stern, Lipsedge and Marks, 1973) showed that the control treatment (stop ping neutral thoughts) was as least as effective as the treatment of stopping obsessional thoughts. This experi- ment resulted in only a slight improvement. Hackmann and’ McLean (1975) showed that thought-stopping was practically as effective as flooding in uivo with patients who almost all suffered from compulsive rituals. It is not clear whether thought-stopping was effective in dealing with obsessional ruminations in this study.

According to Rachman (1971), obsessional ruminations should be regarded as noxious stimuli to which patients haye difficulty in habituating. According to this habituation hypothesis, patients should show an improvement as a result of habituation training such as prolonged exposure in imagination to their obsessional thoughts. Although this type of treatment has frequently been applied with phobic patients, it has not yet been tried with patients suffering from obsessions.

In the.present study, a comparison was made between the effects of thought-stopping and the effects of prolonged exposure in imagination with patients whose major problem was obsessional ruminations but who did not suffer from compulsive rituals.

METHOD

Design

As it is very difficult to find a large number of patients with obsessional ruminations unaccompanied by compulsive rituals, we decided to use a cross-over design. This design made comparisons between the effects of the two treatments possible both between and within subjects.

The first four sessions were used for preparations and for a pretest. One week’s baseline was carried out before and after the first treatment and again after the second treatment. Then the posttest was carried out. Each treatment consisted of five sessions of 60min each. The treatment sessions were given three times a week. Patients were allocated to treatment groups and therapists at random.

Treatment

Before the treatment was begun, four sessions were devoted to collecting information about the scenes to be used in the treatments of thought-stopping and prolonged exposure in imagination.

The clients were instructed not to take any anxiety reducing or anti-depressant drugs during the experimental trial.

Thought-stopping. This procedure was very similar to the thought-stopping treatment described by Hackman and McLean (1975). Instead of hitting the desk with a ruler, a loud hooter was used. If the “stop” stimulus was effective in blocking the thought, the patients were instructed to think pleasant or neutral thoughts

442 CASE HISTORIES AND SHORTER COMMUNICATIONS

(about e.g. baking a cake. playing chess, walking along the beach, etc.). The problem situations were not tackled in any systematic order. Usually the obsessions which had troubled the patient most in the preceding few days were dealt with.

Prohgrd c~.~poswr it? inmjnution. With this procedure. the patient was exposed uninterruptedly to his obsessions for 60min. He was instructed to sit in a relaxed way and to close his eyes. Next. the therapist asked the client to imagine as vividly as possible the situations described by the therapist and not to avoid imagining these scenes in any way. Again and again the obessions which aroused the most anxiety were described. If the tension aroused by imagining a certain scene had dropped considerably, this scene was no longer used. The scenes consisted solely of the obsessional material; no attempt was made to increase the feelings of anxiety. For example: seeing a child aroused in one patient the obsessional thought that he is hitting out in the child’s direction with his fist. He ‘sees’ himself making this movement and thinks he has actually hit this child, but the precise nature of the consequences is not clear. During the treatment. the imagining of the scene stopped at the same moment-the moment at which the patient hits the child--and no attempt was made to put the consequences of this act into the concrete form OF the child’s being wounded, dying. or being buried.

Tkcrupists

The therapists were clinical psychologists who had almost graduated and had received training in behavior therapy. Both therapists already had some clinical experience with behavior therapy. They were supervised by the senior author.

Five patients with obsessional ruminations as their major problem and with no ascertainable compulsive rituals took part in the experiment.

Parie~~f A. Male, 27 years-old. duration of the complaint: one year. The obsession concerned mainly harming others. Children. elderly people. axes, knives. etc. aroused the obsession.

Patierlt B. Female, 23 years-old, duration of the complaint: four years. The obsessions concerned harming herself and others. They were aroused by e.g. heights, traffic, gas, electricity, glass and heavy objects. The patient had not gone out alone into the streets for the last 2.5 years.

Putirnt C. Fcmdle 51 years-old. duration of the complaint: 25 years. She suffered from religious obsessions that she had committed a mortal sin. These obsessions were aroused by stimuli of all kinds in her environment, and these stimuli varied continually.

Paticwt D. Female 51 years-old, duration of the complaint: two years. The obsessions concerned death caused by cancer.

Prrtient E. Female, 23 years-old, duration of the complaint: one year The obsessions concerned dying and harm befalling her child. Stimuli which aroused these obsessions were e.g. films. ambulances, funeral processions. etc.

(1) Freyuryy. The patients kept count of the number of obsessions they had with the aid of- a counting machine. At a certain hour every day the patients had to make a note of the total number of obsessions they had had.

(2) Distress. This was assessed by indicating the amount of distress suffered on a O-8 scale. The patient rated himself daily on this measure.

Daily average scores were computed for both these measures for the week preceding the first treatment (pretest), the week following the first treatment (intermediate test), and the week following the second treatment (posttest).

At the pretests and posttests the following measurements were also carried out: (3) &~o,~ Ohsc~s,sional Incc~~tory (LOI-Cooper, 1970). This scale results in four scores: symptom, trait. wsist-

mcc and irltwfiwuw. (4) Su!fRtrt& Drprrssion Scale (SDS-Zung, 1965). Range 23-92.

RESULTS

Figure I gives the results of the frequency measurement. In three cases (patients A, D. and E) a considerable decrease took place in the number of obsessions, both after prolonged exposure in imagination and after thought-stopping. In one case (patient C), exposure produced a slight increase and thought-stopping a decrease in the number of obsessions, whereas in another case (patient B), both forms of treatment were unsuccessful and even led to a slight increase in the number of obsessions.

The effect of the treatment at the posttest as indicated by the distress rating. the LOI and the SDS was tested with one-tailed r-tests for dependent samples (see Table I). Almost all these measurements showed a slight improvement (p <O.lO). The trait score of the LO1 showed a significant improvement (I) ~0.025).

DlSCUbSlON

Both thought-stopping and prolonged exposure in imagination can be effective in dealing with obsessional ruminations, but the effect of the two procedures tends to differ from patient to patient.

No clear differences were found between the effect of thought-stopping and the effect of exposure in imagina- tion. Patients who responded favorably to the treatment usually derived equal benefit from both procedures. It is possible that the effect brought about by the two procedures is the result of one and the same process. Part of the cffcct could be ascribed to non-specific factors and the self-monitoring of obsessions. Another. probably even more important common component of both procedures is the imaginal exposure to the obsessions. The way in which this exposure is achieved differs, however, for the two procedures. In the case of prolonged exposure in imagination the exposure is continuous. in the case of thought-stopping there

CASE HISTORIES AND SHORTER COMMUNICATIONS 443

Pat. A Pat. El

PW Inter Post

Pat. D Pat. E

c Exp. T.S. 50 1 t

40

30

20

IO

0 kl_IIn PE Inter Post

Pot. c

Exp.= Exposure in lmaglnotion

T.S. = Thought stopplng

Fig. I. Mean daily frequency of obsessions at the pretest, intermediate test and posttest.

Table 1. Effect of thought stopping and prolonged exposure in imagination combined- total treatment effect

Varnbles Pretest POStteSt

M S D. A4 S.D. .\ I

DliIESS 3.5 1.6 2.8 2.4 5 I 69* Symptom 21.4 4.9 16.4 83 5 1.69*

LOI Trait 8.6 2.2 6.0 32 5 3 4w ReSlStXlCe 21.6 8.3 20.4 13.6 5 I.XY

I Interference 24.6 10.3 18.2 12.7 5 1.73* SDS 55.6 IO.0 53 2 14.9 5 0.52

*p <O.lO t p <0.025

are interruptions. This common component of exposure may be responsible for the very similar effect of the two procedures. A supposition such as this about the therapeutic process involved in thought-stopping would be more in keeping with a theoretical behavioral framework than is the case with the present vague background of this procedure. Rachman (1976) speaks of thought-stopping as an ad hoc technique that rests on its empirical strength. If this hypothesis is correct, the effect of both prolonged exposure in imagination and thought-stopping could be based on habituation.

The interpretation of the frequency measurement of obsessions involves certain problems. It is not always possible to make a straight-forward comparison between the frequency measurement of different patients because of the nature of their obsessions. Some patients can make a clear distinction between different obses- sional thoughts although these thoughts occur as a sequence, others score a sequence of this kind as one single obsession. In the case of a comparison within one subject, this will presumably not presebt much difficulty, but in the case of a comparison between subjects, it may lead to great problems. Apart from that, the duration of an obsession can differ markedly. Thus obsessions can become less protracted and less concrete in the course of the treatment, and this would not find expression in the frequency measurement, In a few cases, an obsession which had initially lasted for a number of minutes and had been very concrete changed after some time into a flash lasting only a few seconds: for example a knife or an axe with which a movement of striking or slashing at someone was clearly repeatedly made changed gradually into a more neutral object which glided through the air or just fell on the ground.

As an improvement on the frequency measurement does not always run quite parallel with a clinical improvement, a short description of the five cases will now be given.

Two of the patients (A and D) were almost symptom free as regards their obsessions at the posttest. Patient A’s remaining obsessions consisted only of brief, vague flashes which no longer aroused any tension. After the posttest. this patient underwent 17 sesssions of assertive training, which met with success. Patient C showed a fair degree of improvement at the posttest, in spite of her still rather high frequency measurement. Patient E showed a moderate improvement at the end of the experimental trial; further treatment (1 I sessions. including sessions of assertive training and marital treatment) was thought necessary. Patient B was strongly motivated. but her treatment was nevertheless unsuccessful. Nor did further treatment (24 sessions). which included several variants of thought-stopping, exposure in uiuo and anti-depressant drugs, lead to a decided improvement’as far as the obsessional ruminations were concerned. The exposure in ciao did, however, have the result that the patient felt able to go out into the streets alone again. After moving house the obsessions suddenly reduced, with the result that the patient decided to drop the treatment. It remains to be seen if her improvement endures.

444 CASE HISTORIES AND SHORTER COMMUNICATIONS

Tn conclusion it may be said that a method of treatment which has a positive effect in almost all types of obsessions is still a far-off goal. However, habituation training might prove a valuable alternative to thought-stopping and deserves further experimental validation.

Academic Hospital, Department of Clinical Ps~lehala~?.~, Groi~i~gen, The Netherlands

PAUL M. G. EMMELKAMP* K. GWAN KWE

*The authors are grateful to W. van Diik. S. van de Flier and T. Marinkelle (Assen) for their assistance and to K. Wiersma who served as therapist.

Requests for reprints can be addressed to Paul M. G. Emmelkamp, Academic Hospital, Department of Clinical Psychology, Oostersingel 59, Groningen, The Netherlands.

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CAMPBELL L. M. (1973) A variation of thought-stopping in a twelve-year-old boy: a case report. J. Behav. Ther. Exp. Psychiat. 4, 69-70.

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of obsessive-compulsive patients. B&at;. Res. and Ther. 14, 349-356. RACHMAN S. (1971) Obsessional ruminations. Behaa Res. and Ther. 9, 229-235. RACHMAN S. (1976) The modification of obsessions: a new formulation. Behav. Rex and Thu. 14, 437443. STERN R. (1970) Treatment of a case of obsessional neurosis using a thought-stopping technique. &it. J.

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135. ZUNG W. W. K. (1965) A self-rating depression scale. Arch. gen. Psychiat. 12, 63-70.