J. Behav. Thu. & Exp. Psychiot. Vol. IO, pp. 251-255 c,Pergamon Press Ltd., 1979. Printed in Great Britain.

ooo5.7908/79/0901-0251$02.00/0

THE USE OF PARTICIPANT

MODELING

FOR CLAUSTROPHOBIA

MATTHEW L. SPELTZ
University of Missouri, Columbia

and DOUGLAS A. BERNSTEIN
University of Illinois, Champaign-Urbana

Summary-The use is described of participant modeling procedures in the treatment of a longstanding and debilitating fear of closed places. Objective and subjective data collected immediately after treatment showed dramatic improvements which were maintained at 33 month follow-up.

Participant modeling is a treatment technique emphasizing therapist demonstration of approach to graded in vivo fear stimuli, guided rehearsal by the client of progressively more difficult approach responses, and independent responses client performance of those (Bandura, 1976), This treatment package (also termed “contact desensitization” (Ritter, 1%8) has been used to attenuate fear responses to Bandura, targets such as snakes (e.g., Blanchard and Ritter, 1969; Blanchard, 1970; Ritter, 1968; Thase and Moss, 1976), heights (e.g., Ritter, 1969), water (e.g., Lewis, 1972*), rats (e.g., Lick and Bootzin, 1970), and dogs (MacDonald, 1975; Richards and Siegel, 1978). Comparative research would indicate that participant modeling is superior to other techniques commonly employed to promote fear reduction (Bandura, 1976), but Leitenberg (1976) notes a limitation to that research, namely its near exclusive focus on non clinical populations and targets. There are few reports on the use of participant modeling with chronic, debilitating fears (e.g., MacDonald, 1975). This paper describes the extension and refinement of participant modeling techniques

as applied to a long-standing significant fear reaction.

and clinically

CASE HISTORY The client-j-, a 48-yr-old self-employed accountant, sought help for claustrophobia. Mr. V. reported an extreme fear of confining areas which had persisted for over 30 years and appeared to become increasingly debilitating. He believed that his fear had originated during a childhood incident in which he had a severe asthma attack while beneath the family home. Situations which currently provoked strong anxiety reactions included elevators, sleeping bags, boats, travel trailers, and shower stalls. Being under bed covers was similarly disturbing. The client also reported panic reactions to any form of oral or nasal restrictions, (e.g., having a scarf over his mouth, using nose plugs, wearing a mask) even in the absence of body confinement. Mr. V’s fear was producing frequent sleep disturbances, nightmares related to enclosure, avoidance of favored leisure activities (e.g., camping), and an inability to perform certain
Unpublished

*Lewis S. (1972) A comparison of behavior therapy techniques in the reduction of fearful avoidance behavior. doctoral dissertation, University of Cincinnati. TSeen by the first author under the supervision and direction of the second. Requests for reprints should be addressed to Matthew L. Speltz, Department of Psychology, University Columbia, MO 65201. 251

of Missouri,

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A. BERNSTEIN

domestic chores (e.g., working beneath his automobile or home). Two more immediate problems had prompted him to seek professional help: (a) the discomfort produced by wearing an oxygen mask had forced him to resign from a valued volunteer fire organization and (b) he believed his fear to be at least partially responsible for an elevated blood pressure condition for which he was receiving medication.

as a basis for graduated exposure during participant modeling. Mr. V rated these items in terms of the arousal (o-100) produced by each and then arranged in a hierarchy of least to most aversive (see Table 1).

PRE-TREATMENT ASSESSMENT The client’s description of his fear suggested that it could by dichotomized into two stimulus categories: body restriction and breathing restriction. Two assessment interviews revealed that the intensity of arousal produced by these restrictions was mediated by four contextual variables: (a) size of area in which restriction occurred, (b) amount of illumination available, (c) body position, and (d) extent to which the client had control over the source of restriction. Mr. V reported that his most intense fear reaction was associated with being in a passive, recumbent position in small, poorly illuminated enclosures. Before treatment was initiated, the client was given a Behavior Avoidance Test (BAT) (Bernstein, 1973) involving an enclosed 2 ‘/zft. x 4ft. x 5ft. darkened test chamber* in which he was instructed to sit until he became uncomfortablej-. He emerged from the test chamber after 31 seconds and appeared distressed and agitated with evidence of profuse sweating. After a short rest interval, Mr. V was asked to wear a standard fireman’s oxygen mask (which covered his mouth and nose) until he became uncomfortable. He removed the mask eight seconds after it was applied by the therapists. Using assessment information as a guide, the therapists constructed a 28-item list of fearprovoking situations which could be employed

TREATMENT Weekly treatment sessions were conducted over a period of 13 weeks. The first ten sessions involved the use of participant modeling to facilitate the client’s dealing with the 28 tasks listed in Table 1, and the assignment of practice at home on certain comfortably completed tasks. The structured session format included (a) a brief discussion of the rationale for the participant modeling approach, (b) a therapist and co-therapist demonstration of each task giving the specific response required, (c) the use of response induction aids (Bandura, Jeffery and Wright, 1974) and behavioral prompts to facilitate response acquisition (e.g., physical contact and assistance, instructions, and encouragement), (d) the gradual reduction of therapist assistance, and (e) the client’s independent repetition of the task. The beginning of each session was devoted to a discussion of previous homework assignments, the client’s feelings about his progress and the overall treatment plan, and abbreviated practice of tasks completed during the previous session. A systematic procedure was developed for use when Mr. V indicated he was unable to attempt a new step in the in vivo hierarchy (see Table 1). First, he was asked to repeat the last successfully completed step while taking deep, slow, and exaggerated breaths. Relaxed sensations associated with this breathing pattern were paired with a self-produced verbal cue (Russel and Sipich, 1973) selected by him (“cool it”). When he reported relaxation, the problematic step was reintroduced with its required terminal behavior broken down into but we were concerned that stress

* This apparatus is described in more detail by Miller and Bernstein (1972). 1973) would have been preferable, tHigh-demand instructions (e.g., Bernstein, associated with them might be dangerous due to the client’s hypertension.

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Table 1. Hierarchy 1. 2. 3. 4. 5. 6. I. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 21. 28.

Client (C) holding hand over mouth/nose in large, well-lighted room. C holding handkerchief over mouth/nose in large, well-lighted room. C tying handkerchief over mouth/nose in large, well-lighted room. Therapist (T) tying handkerchief over C’s mouth/nose in large, well-lighted room.* C, and then T, tying handkerchief over C’s mouth/nose in small (8ft. x loft.), well-lighted room (this room used in steps 6-14). Handkerchief tied over C’s mouth/nose, (by 7), lights dimmed. Handkerchief tied over C’s mouth/nose, lights off.* Handkerchief tied over C’s mouth/nose, Creclining, lights off. Handkerchief tied over C’s mouth/nose, C recumbent (face-up), lights off. Handkerchief tied over C’s mouth/nose, C recumbent (face-down), lights off.* Handkerchief tied over C’s mouth/nose, C recumbent (face-up), feet tied together. Handkerchief tied over C’s mouth/nose, C recumbent, feet tied, hands tied in front of body. Handkerchief tied over C’s mouth/nose, C recumbent, feet tied, hands tied behind back. Handkerchief tied over C’s mouth/nose, C lying beneath 3 small tables (20in. high, 30in. wide) placed in a step-wise fashion over body (beginning with feet, progressing toward head in 6in. increments). Surgical mask applied (unstrapped) to C’s mouth/nose, C recumbent. Surgical mask applied and strapped over C’s mouth/nose, C recumbent. Surgical mask applied, Creclining, lights dimmed. Surgical mask applied, Crecumbent, lights dimmed. Surgical mask applied, C recumbent, lights off. Surgical mask applied, C recumbent, legs wrapped in blanket, lights dimmed. Surgical mask applied, C recumbent, entire body (except head) wrapped in blanket, lights dimmed. Surgical mask applied, C recumbent, wrapped in blanket, hands/feet tied, lights dimmed. Surgical mask applied, C wrapped in blanket, sleeping bag (90in. x 50in.) placed over body (beginning with feet, eventually encompassing head).* Surgical mask applied, Clying inside unzipped sleeping bag (blanket removed). Surgical mask applied, Clying inside sleeping bag (gradually zipped up in 6in. intervals), lights dimmed. Surgical mask applied, C wrapped in blanket, lying inside sleeping bag, lights dimmed. Surgical mask applied, C wrapped in blanket, lying inside sleeping bag, lights off. Surgical mask applied, C enclosed in fully-zipped bag in an inverted body position (i.e., head at foot of bag), hands/feet tied. that he was unable to attempt this step.

*Client initially indicated

graded components. When he eventually performed all aspects of the terminal behavior, it was rehearsed several times before proceeding with the next task. Homework assignments were designed to provide independent rehearsal of new behaviors in an extra-therapy situation. The nature of these assignments was determined by Mr. V’s performance during therapy sessions and the availability of certain materials in his home. For example, in working on step 14 during the fourth treatment session, it was noted that he initially experienced difficulty when under a small table for periods longer than one or two minutes. Homework arrangements were made to have Mr. V lie for progressively longer time periods (from 1 to 10 minutes) beneath a 4ft. x 8ft. sheet of plywood supported by 24in. concrete blocks. He was given explicit

instructions for completing this assignment with particular emphasis on procedures to be used whenever discomfort was experienced (e.g., repetition of his verbal cue accompanied by deep breathing). In order to preclude reinforcement of avoidance responses, he was told to discontinue this exercise only when he felt completely relaxed. Other homework assignments required him to self-administer various breathing restrictions (a handkerchief, folded blanket, and surgical mask following the first, second, and sixth treatment sessions, respectively) and to spend two nights sleeping in a sleeping bag (following the tenth session). Several unanticipated problems emerged during the course of therapy which required the development of special procedures. At the end of the second treatment session, Mr. V informed the therapist that he had cancelled a

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and DOUGLAS

A. BERNSTEIN

dental appointment because he often panicked when the dentist placed a rubber dam in his mouth while he was reclining at a 225” angle (i.e., head below hips). The therapists obtained a rubber dam and support bracket and during the third treatment session, repeated steps 2, 3, 4, 8, and 9 of the in vivo hierarchy, substituting the rubber dam for the handkerchief. A final step was added in which Mr. V repeated step 9 while reclining at the 225” angle. On another occasion (following the 10th session) he announced that his fear reaction to breathing restrictions of the sort used in previous sessions (e.g., steps 15 and 16) was intensified dramatically if such restrictions occurred Desensitization to sudden, unexpectedly. restriction breathing was unexpected accomplished as follows: Mr. V first tied a handkerchief around his mouth, nose, and eyes. Then the therapist quickly placed a folded blanket over the client’s mouth and nose immediately after having warned him of this. The therapist then applied the blanket after informing the client that he would do so after increasing intervals of uncertainty (from 5 to 30 seconds). By the end of the thirteenth session, the client was able to withstand a full minute of continuous breathing restriction applied unexpectedly in this manner. At that time the client expressed satisfaction with the treatment and stated that he could now handle any claustrophic situation which confronted him. Self-directed rehearsal techniques for use after termination (identical to previously assigned homework exercises) were outline and discussed.

he was no longer dreaming about being enclosed in small areas. A post-treatment BAT was conducted using procedures identical to those employed in the pre-treatment assessment. In contrast to the first enclosure time of 31 set, the client remained in the test chamber for 10 min, at which time the therapists terminated that portion of the test. The oxygen mask was then applied and worn until the therapists removed it 10 min later. No visible signs of arousal or discomfort were observed and Mr. V reported “feeling fine”. Three months after treatment, he reported that he had experienced only minimal discomfort during a dental appointment which necessitated use of a rubber dam and that his blood pressure was now within normal limits. He also stated that his asthmatic condition had improved somewhat since the termination of therapy. Thirty-three months after treatment, avoidance tests with the enclosed chamber and oxygen mask were repeated. Again, the client remained in the chamber for 10 min and after a brief rest, wore the mask for 10 more minutes. He reported “no problem” and appeared to be completely relaxed after each test. Mr. V also reported continued comfort in all the day-today situations (including volunteer fire duty) which had been distressing prior to treatment.

OUTCOME AND FOLLOW-UP During the course of treatment, Mr. V reported several specific improvements in his daily living routine. After the third session he stated that taking a morning shower was becoming an unexpected pleasure. Later, he reported performing house and yard chores which he had formerly avoided and stated that

DISCUSSION Despite Ritter’s (1969) concern over the limited feasibility of in vivo exposure techniques, the outcome of the present case study suggests that participant modeling can be designed to attack multicomponent fears of the type most often encountered in clinical settings. In the present instance in vivo exposure to both obvious and subtle aspects of a client’s fears were easily and economically arranged. While this may not always be as easy with other fear targets, our clinical experience in this and other cases (e.g., Bernstein and Beaty, 1971; Bernstein, 1974) has MacDonald and

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encouraged us actively to seek out ways of programming in vivo exposures to anxiety stimuli which, at first glance, may appear presentable only through imaginal means. We have also found that inclusion in clinical post-assessment preand casework of procedures typically associated with outcome research is of great value. In addition to the empirical benefits derived from obtaining objective measures of treatment efficacy, bold performance in a post-treatment BAT provides the client with a salient reinforcing experience which may facilitate generalization of new responses to real-life situations (Bandura, 1976). REFERENCES
Bandura A. (1976) Effecting change through participant modeling. In Counseling Methods (Ed. by Krumboltz J. D. and Thoresen C. E.), pp. 245-248, Holt, Rinehart & Winston, New York. Bandura A., Blanchard E. and Ritter B. (1969) The relative efficacy of desensitization and modeling approaches for inducing behavioral, affective, and attitudinal changes, J. Person. Socl. Psychol. 13, 173-199. Bandura A., Jeffery R. W. and Wright C. L. (1974) Efficacy of participant modeling as a function of response induction aids, J. Abnorm. Psycho/. 83, 56-64. Bernstein D. A. (1973) Behavioral fear assessment: Anxiety or artifact? In Issues and Trend% in Behavior Therapy (Ed. by Adams H. and Unikel P.) C. C. Thomas, Springfield. Bernstein D. A. and Beaty W. (1971) The use of in vivo desensitization as part of a total therapeutic intervention,

Blanchard E. (1970) Relative contributions of modeling, informational influences, and physical contact in the extinction of phobic behavior, J. Abnorm. Psychol. 76,

55-61.
Leitenberg H. (1976) Behavioral approaches to the treatment of neuroses. In Handbook of Behavior Modification and Behavior Therapy (Ed. by Leitenberg H.), Appleton Century Crofts, New York. Lick J. R. and Bootzin R. R. (1970) Expectancy, demand characteristics, and contact desensitization in behavior change, Behav. Ther. 1,176-183. MacDonald M. L. (1975) Multiple impact behavior therapy in a child’s dog phobia, J. Behav. Ther. & Exp.

Psychiat. 6,317-322.
MacDonald M. L. and Bernstein D. A. (1974) Treatment of a spider phobia with in vivo and imaginal desensitization,

J. Behav. Ther. & Exp. Psychiat. 5,47-52.
Miller B. V. and Bernstein D. A. (1972) Instructional demand in a behavioral avoidance test for claustrophobic fears, J. Abnorm. Psychiat. 80, 206-210. Richards C. S. and Siegel L. J. (1978) Behavioral treatment of anxiety states and avoidance behaviors in children. In Child Behavior Therapy, (Ed by Marholin D. II), Gardner Press, New York. Ritter B. (1968) The group desensitization snake phobias using vicarious and contact procedures, Behav. Res. Ther. 6, l-6. of children’s desensitization

Ritter B. (1969) The use of contact desensitization, demonstration-plus-participation, and demonstrationalone in the treatment of acrophobia, Behav. Res. Ther.

7,157-164.
Russell R. relaxation K. and Sipich J. F. (1973) Cue-controlled in the treatment of test anxiety, J. Behav. Ther.

& Exp. Psychiat. 4,47-49.
Thase M. E. and Moss M. K. (1976) The relative efficacy of covert modeling procedures and guided participant modeling on the reduction of avoidance behavior,

J. Behav. Ther. & Exp. Psychiat. 2,259-265.

J. Behav. Ther. & Exp. Psychiat. 7,7-12.

Acknowledgements-The
D.M.D., for his assistance

authors wish to thank John in supplying the apparatus.

Bresko

for his assistance

as co-therapist

and Lieb D. Alexander,