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PSYCHOTHERAPY: THEORY, RESEARCH AND PRACTICE VOLUME 15, # 1 , SPRING.

1978

IMPLOSIVE THERAPY WITH HYPNOSIS IN THE TREATMENT OF CANCER PHOBIA: A CASE REPORT
JOHN M. O'DONNELL 204 East Capitol Drive Milwaukee, Wisconsin 53212 ABSTRACT: Much attention has recently been given to the high incidence of breast cancer and the need for more effective detection strategies in our society. Correlated with this attention, however, have come reports of a significant increase in cancer-related hypochondriasis. The present paper describes the successful treatment of cancer phobia in a hypochondriacal female by means of implosive therapy with hypnosis. Implosive therapy is a psychodynamically oriented behavior therapy initially developed for the treatment of phobias. The procedure entails utilizing the patient's imagery and purposely exposing him to the most intense anxietyeliciting stimuli imaginable. The supposition is that continuous and inescapable exposure to the fearful stimuli without negative consequences or reinforcement will eventually weaken the anxiety-arousing power of the stimuli. A current emphasis in hypnotherapy is on treating a patient in hypnosis versus treating him by hypnosis. In the present case, the hypnotic induction was intended to heighten the patient's bodily awareness, to increase the vividness of and suggestibility to imagery, and to narrow the focus of attention in order to maximize responsiveness to implosion. The patient is a 29-year-old female whose anxiety about cancer had reached uncontrollable and continuous phobic proportions. Three 60-minute treatment sessions were conducted within a one-week period. Subjective and behavioral rating scales before, during, and up to eight months following the treatment week revealed a significant decrease in phobic anxiety and hypochondriacal behavior. The results were discussed relative to cognitive interpretations of the mechanisms possibly underlying implosive therapy.

Due to recent well-publicized reports of radical mastectomies in several prominent American women, much attention has been focused on the high incidence of breast cancer and the need for more effective detection strategies in our society. Active multi-media campaigns
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have been initiated, for example, in order to heighten the public's awareness of the problem and hopefully effect more early detection and treatment. Correlated with the extensive publicity, however, have come reports from physicians of a significant increase in cancer-related hypochondriasis. Irrespective of frequent appeals to logic and common sense, and regardless of disconfirmation by medical tests, hypochondriasis typically is quite persistent. In fact, disconfirmations and rational arguments will often entrench the patient more deeply than ever in his obsessive ruminations. Relatively few of these patients ever come to the psychotherapist's office because of their intense conviction that the problem is organic, and not psychological; and, even if these patients do make it to a therapist, hypochondriasis is reportedly very resistant to psychotherapy (Coleman, 1972). The present paper describes the successful treatment of cancer phobia in a hypochondriacal patient by means of implosive therapy with hypnosis. Implosive therapy is a psychodynamically oriented behavior therapy initially developed by Stampti (1961) for the treatment of phobias. The procedure typically is quite direct and straightforward. Based on the therapist's theoretical interpretation of the dynamics of the case, he will utilize the client's imagery and purposely expose him to the most intense anxiety-eliciting stimuli imaginable. The supposition is that continuous and inescapable exposure to the fearful stimuli without negative consequences or reinforcement will eventually weaken the anxiety-arousing power of the stimuli. Stampfl and Levis (1967) have indicated that the ability to visualize imagery is essential for

IMPLOSIVE THERAPY WITH HYPNOSIS

successful implosive therapy. On several occasions with cognitive behavior therapy of various sorts, the present writer has experienced moderate success in using hypnosis to overcome what Ayer (1972) has described as an "invisible shield" often erected by the client to prohibit intimate association with imagined scenes. A current emphasis in hypnotherapy is on treating a client in hypnosis versus treating him by hypnosis. In the present case, the hypnotic induction was intended to heighten the client's bodily awareness, to increase the vividness of and her suggestibility to suggested imagery, and to narrow the focus of her attention in order to maximize her responsiveness to implosion. As Bell (1972) and many others have emphasized, the individual under hypnosis is not asleep or unconscious but is in fact more aware and vigilant due to a selective inattention to irrelevant stimuli.
CASE REPORT

Background Mrs. T., the client about whom this report revolves, is a 29-year-old, attractive female whose anxiety about cancer had reached uncontrollable and continuous phobic proportions. Mrs. T. was "self-referred" for therapy through a community mental health centeraffiliated telephone hotline service. There was no previous history of counseling or psychotherapy despite multiple attempts on the part of several physicians over the past year to refer her for such services. In the year immediately prior to implosive treatment, she had seen ten different physicians within a 75-mile radius for a total of 45 outpatient and two inpatient medical examinations for cancer, in addition to another 25 estimated telephone consultations with these same physicians. These examinations included the following: a brain scan, two barium swallows, and approximately two dozen different occasions of X-rays. The patient paid most of her outpatient medical expenses herself which amounted to several thousands of dollars. These frequency data and related circumstances for this year were reportedly the same for the preceding one-and-a-half years as well. Of all her friends, family, and numerous physicians for the three years prior to implosive treatment, only her husband and her

primary (and initial) physician had any awareness of the extensive scope of her problem. With permission of the client, close contact was maintained with these two persons throughout both the preliminary assessment and implosive treatment phases of the case for purposes of objective third-party verification of the diagnostic and therapeutic outcome data provided by Mrs. T. At the time of the initial preliminary assessment, Mrs. T. was almost constantly obsessed and ruminative over the prospect of having cancer. Whenever alone, she would frantically examine herself for tumors in her underarm area, breasts, and throat so frequently each day that bruises and abrasions were occurring which, in a vicious circle fashion, all the more intensified her fears and seemingly confirmed her worst expectations. On a cognitive level, Mrs. T. was verbally able to recognize the irrationality of her behavior and give acknowledgment to the consistently negative medical findings. She could not, however, exercise emotional or behavioral control over her anxiety symptoms; and the more reasssurances or appeals to reason she received, the more intense her discomfort seemed to become. Relevant History Psychological test and clinical interview assessment revealed that the client had had firsthand familiarity with terminal cancer through the deaths of her grandmother (breast and pelvic cancer), uncle (lung cancer), and a close, fatherly friend (brain tumor). Her grandmother had reportedly insisted on having Mrs. T. (in her late adolescence at the time) feel the growth on her grandmother's hip shortly before her deathan experience which was described as quite upsetting. An unhappy childhood, fraught with familial instability, was also reported. Mrs. T.'s mother was married five different times to a series of men whom the client, as a child, perceived to be hostile and rejecting. Throughout her childhood, Mrs. T. was reportedly quite susceptible to infectious illnesses and malnutrition; and at age 17 she was hospitalized for "malnutrition." There were a number of indications that the client as a child may have received attention from her mother or stepfathers primarily or only when she was physically ill. Assessment data presented a

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JOHN M. O'DONNELL

picture of mixed neurotic symptomatology with primary phobic, obsessive-compulsive, and hypochondriacal features. The interview data strongly suggested that the current symptoms were being maintained at least in part by the reinforcing attention Mrs. T. was receiving from medical personnel and from her husband. It was decided that the effect of conventional "talk-therapy" might be to elicit more symptomatology and unconscious attention-getting effort. Based upon these data and Mrs. T.'s high level of current anxiety, a behavior therapy regime was recommended. Mrs. T. was briefed as to the various approaches which might be taken with special focus on the relative advantages and disadvantages of each approach. She elected to undergo implosive treatment in the hope of a short-term behavior therapy intervention. It was mutually understood that if gains from implosive treatment were not soon forthcoming, then a desensitization approach would be undertaken. Description of Techniques Three 60-minute treatment sessions were conducted within the span of one week. Homework in the form of imagery practice was not assigned to occur between sessions. In the first session, the client was initially given ten minutes of practice in neutral imagery followed by a 20-minute hypnotic induction wherein she was presented with highly pleasant suggestions of progressively deepening relaxation and heightened body awareness. Bodily sensations relative to the critical areas of her body about which she was most fearful were especially emphasized. A 30-minute implosive segment then began by suggesting the subjective sensations of tumor-like growths developing throughout the critical bodily areas of fearful concern. Each growth was graphically described and presented in terms of a loathsome appearance, smell, texture, and taste. A process of bodily deterioration and a gradual transformation from a person into one large, massive tumor was also vividly described. All throughout her miserable ordeal, the client was told to envision family, physicians, and friends, shrinking away in horror at her monstrous grotesqueness. Everyone refused to attend to her in her misery, and she was "abandoned by everyone for months-on-end to die a long, drawn-out, excruciatingly painful, and lonely

death." Even death itself brought no relief, however; and she was "forced to go through all eternity as a pulsating, writhing mass of detestable putrescence." The entire procedure, excepting the neutral imagery practice, was repeated in two different sessions separated by 48-hour intervals. Mrs. T. was highly responsive to the hypnotic induction and was observed to be maximally anxious throughout the implosive imagery. Her anxiety characteristically peaked after approximately 20 minutes of implosion, however, and then began to decline slightly. After an approximately five-minute debriefing at the conclusion of each session, she reported feelings of exhaustion accompanied by minimal anxiety. Following the second and third implosive session debriefings, she was able to laugh about the ridiculousness of her symptomatology. The client reported significant and progressive improvements after each of the three implosive treatment sessions, and treatment was terminated with the conclusion of the third implosive session. Outcome Evaluation In order to establish a baseline for posttreatment assessment, a five-point rating scale with a zero-to-four range was devised and defined along a continuum of subjective discomfort and behavioral disruption. (See Table 1.) Ratings were recorded for five different weeks over a ten-month period. During each week, Mrs. T. was instructed to make one rating every half-hour throughout her normal waking hours (typically between 8 a.m. and 11 p.m.). Figure 1 depicts the daily mean ratings over an initial baseline week, a second baseline
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I BASELINE I; BASELINE 111IMPLOSIVE \ POST' FOLLOW-UP '' \ i THERAPY i TREATMENTl


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Fig. 1. Daily mean ratings of subjective and behavioral disruption by cancer phobia for five weeks over a ten-month period.

IMPLOSIVE THERAPY WITH HYPNOSIS

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week (following the four preliminary assessment sessions and immediately prior to the implosive treatment), the week of treatment, and post-treatment weekly assessment both one month and eight months following treatment. During the two baseline periods, over 55% of the individual half-hour ratings were rated at a level of two or higher, with thirty-six threepoint ratings and twelve four-point ratings having been recorded. In marked contrast, however, less than 2% of the half-hour ratings for the two post-treatment periods were at the two-point level, and no ratings were recorded at either the three or four-point levels. Most importantly, one year after treatment, Mrs. T. reported that she had been to see a physician only once since the termination of implosive treatment for an annual physical.
DISCUSSION

Whereas recent reviews of implosive therapy (e.g., Morganstern, 1973) have been critical of the technique, it should be noted that the reviews are largely based upon analogue studies using college students with fears of rats, snakes, or insects. How truly analogous these studies are to studies of clients whose daily functioning is seriously disrupted by obsessive fear-elicited stimuli is very much open to question. It is suggested that implosive therapy and related flooding techniques can be of considerable assistance to select clients given their particular circumstances and individual suitability for implosion. Careful assessment and caution should precede the decision to employ implosive therapy, however, since a poorly designed or executed procedure could result in a heightened sensitization to the fear-arousing stimuli. Of special import in this regard is the determination of length of proper exposure time

to the implosive imagery (Rimm & Masters, 1974; Wolpe, 1969). It should be noted that there were no significant differences between the two baseline periods interspersed by a month of weekly diagnostic sessions. This would seem to suggest that the successful outcome effect cannot be attributed to the self-monitored ratings or to therapist attention alone. However, there are a variety of possible cognitive interpretation alternatives to Stampfl's psychodynamic/two-part learning theory formulations of implosive therapy. In the present case report, a number of contributing factors may have been operative: covert conditioning, alteration of covert selfinstructional statements, paradoxical intention, client and/or therapist expectancy factors, responsiveness to the therapist and/or hypnotic demands, and so on. This case study does not attempt to analyze the differential role of these cognitive components, and it remains to be determined to what extent classical extinction versus cognitive mediational processes are operative in effective implosive therapy. The use of implosive therapy with hypnosis in the present case was surprisingly dramatic and swift in effectiveness. Similar successful reports of flooding under hypnosis have also recently been cited (Astrup, 1974). Although clarification of the underlying mechanisms responsible for the effectiveness of implosive therapy and hypnosis is lacking, this combined approach appears to have many practical application possibilitiesespecially with neurotic symptomatology seemingly unresponsive to conventional treatment.
REFERENCES ASTRUP, C. Flooding therapy with hypnosis. Behavior Therapy, 1974, 5, 704-705. AYER, W. A. Implosive therapy: A review. Psychotherapy:

TABLE 1. Rating Scale of Subjective and Behavioral Disruption by Cancer Phobia. 0 No awareness of cancer concerns. No noticeable effect of any cancer concerns upon behavior or emotions. 1 Minimal periodic concerns with cancer. No noticeable interference with daily routine functioning. 2 Moderate episodic concerns with cancer. Some minor disruption of daily routine functioning in evidence. 3 Continual moderate discomfort about cancer. Minimal to moderate disruption of daily routine functioning is evidenced. 4 Continual intense discomfort due to cancer concern. Major disruption or interference with daily routine functioning.

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JOHN M. O'DONNELL STAMPFL, T. G. (1961) Implosive therapy: A learning theory derived psychodynamic therapeutic technique. In Lebarba and Dent (Eds.): Critical issues in clinical psychology. New York: Academic Press, 1967.
STAMPFL, T. G., & LEVIS, D. J. Essentials of implosive

Theory, Research and Practice, 1971, 9, 242-250. BELL, G. K. Clinical hypnosis: Warp and woof of psychotherapies. Psychotherapy: Theory, Research and Practice, 1972, 9, 276-280. COLEMAN, J. C. Abnormal psychology and modern life. Glenview, Illinois: Scott, Foresman, 1972. MORGANSTERN, K. P. Implosive therapy and flooding procedures: A critical review. Psychological Bulletin, 1972,79,318-334.
RIMM, D. C , & MASTERS, J. C. Behavior therapy:

therapy: A learning-theory-based psychodynamic behavioral therapy. Journal of Abnormal Psychology,

1967,72,496-503.

Techniques and empirical findings. New York: Academic Press, 1974.

WOLPE, J. The practice of behavior therapy. New York: Pergaman Press, 1969.

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