Journal of Consulting and Clinical Psychology 197S, Vol. 43, No. 5, 740-745
Behavioral Treatment of Mucous Colitis Katherine J. Youell and James P. McCullough Psychological Services Center, Virginia Commonwealth University A 22-year-old female graduate student who suffered approximately one colitis attack per day at the onset of therapy was apparently successfully treated by a procedure in which the therapist labeled antecedent stress events that appeared to be precipitating the attacks. The client was then taught a behavioral coping strategy to counter the stress events. Subsequently there was a steady decline in attack frequency. No attacks were reported during a 43 week follow-up period. Three attacks were reported during Week 44. The client selfapplied the therapy coping strategy and reported no more attacks during Weeks 45-49. Few case studies have been reported in which psychosomatic disorders were treated with behavioral techniques. The following apparently successful single-case study is a time-series account of a mucous colitis condition in which a covert-overt behavioral technique was taught to a client to combat frequent colitis attacks. Lachman (1972) described two types of psychogenic colitis disorders generally seen in the clinical setting. The first type is chronic ulcerative colitis, a serious, long-standing ulcerative condition of the colon. The second type is known as mucous colitis. It is a less serious condition that affects the motor activity and mucous-secreting functions of the colon. Mucous colitis is also known as spastic colitis, irritable colon, nervous diarrhea, and irritable colon syndrome (Alexander, 1950; Misiewicz, 1969). There is no evidence to support the hypothesis that mucous colitis is a precursor of ulcerative colitis or vice versa. Both types are considered psychosomatic by Lachman since the lower section of the gastrointestinal tract is responsive to emotional reactions, particularly stress. Stress is defined by Lachman as a "reaction pattern . . . in which energy resources are mobilized and one that prepares the organism for sudden, extensive activity—for the violent expenditure of energy needed to fight or flee—activities of a defensive or protective sort." (p. 29) Colonic stress reactions may lead to an increase or decrease in bowel activity as well as a change in the physical quality of defecated material. Lachman briefly reviewed several studies that reported both heightened colonic activity and colonic congestion during stress
periods (Almy, Kern, & Tulin, 1949; Grace, Wolf, & Wolff, 1950). The present case was treated following an extensive medical examination and after a 4-week baseline period during which the client kept data of colitis attack frequency and also reported in writing and via cassette tape log events that occurred prior to the onset of a colitis attack. The client was examined during the follow-up period after the termination of therapy by the same physician who bad conducted the first examination.
Requests for reprints should be sent to James P. McCullough, Virginia Commonwealth University Psychological Services Center, 800 West Franklin Street, Richmond, Virginia 23284.
My symptoms are basically the same each time. First I feel the muscles in my abdomen tighten, then relax—then severe cramps occur in my abdomen. Next, my rectum feels like it is jumping up and down,
CASE HISTORY C was a 22 year-old female graduate student attending a state university in Virginia. She presented herself to the Psychological Services Center with a colitis condition and a long-standing problem of obesity. The client described her interpersonal style as a "tendency to tolerate people who always end up putting something over on me." C's colitis attacks had begun 3 years earlier during her junior year in college. She pinpointed the first attack as occurring several hours after two escaped convicts murdered a maternal aunt and uncle to whom she had felt very close. "Since that time," she remarked, "attacks have occurred whenever I get under pressure." C had been a psychology major as an undergraduate. She told of one type of pressure situation in college that involved taking psychology tests. C described her test-taking behavior as follows: "I would write awhile, then go to the bathroom to relieve myself, come back and write some more, then repeat the cycle." When asked to describe an attack subjectively, C gave the following account:
740
CASE STUDY and I usually go to the bathroom at this point. My symptoms are relieved for a brief while but not for long. The client had tried food deprivation schedules, diet manipulation, and pharmaceutical prescriptions. No treatment strategy had relieved her of almost one attack per day during the previous year. The client had not been on medication for colitis for several months prior to applying for psychological services. C received a medical examination shortly after presenting herself for treatment. Her physician diagnosed her condition at that time as "irritable colon with colitis" and recommended that the condition be viewed as a psychosomatic disorder. TREATMENT PROCEDURES AND OUTCOME Base-Rate Phase (Sessions 1-4) The therapist, a 25 year-old female clinical psychology graduate student, decided to focus on the colitis condition to the exclusion of the weight problem because the former problem presented so much physical discomfort to the client. The weight problem was monitored, however, with C weighing at the Student Health Services on the morning of every therapy session and reporting her weight to the therapist later that same day. The stability of the client's weight across weeks of therapy functioned as a multiple baseline for the target behavior being treated. The client's untreated weight baseline is shown below in Figure 1. C was seen once per week throughout the base-rate and treatment phases of therapy. During the initial therapy session, the client was instructed to keep a daily log to report the number of attacks she had over a 24-hour period. She was also asked to include environmental events that occurred prior to each attack. An attack was defined as a syndrome that included (a) abdominal tensing and relaxing, (b) abdominal cramps, '(c) spasticity of the rectum, and (d) resultant diarrhea. Sessions 2-4 were spent attempting to identify covert and overt antecedent events that might have precipitated the attack. Every reported attack during the baseline period was preceded by events that C described as "stressful" (Lachman, 1972). Stress for the client usually involved an interpersonal encounter that led her to conclude that she had been rejected and deliberately harmed by another individual. C drew this conclusion because of some behavior, usually verbal, that another person emitted toward her. Her self-report concerning these stressful interpersonal encounters focused on the theme
741
260 2M 2G2 248 244 240 236
FIGURE 1. Untreated weight baseline during therapy and systematic weight loss during therapy follow-up. that an individual had planned and carried out a personally directed vendetta against her. At this point she was not able to consider other hypotheses that might explain the other person's behavior more accurately. She would ruminate over the event and simultaneously feel hurt and damaged following these encounters. She remained in this state until the onset of a colitis attack 30 minutes to 1 hour after the stress event. C never reported a stressful test-taking incident throughout therapy. The absence of such reports may have been due in part to her being seen at the beginning of an academic year when test administration was infrequent. Since reported antecedent events prior to attacks involved interpersonal encounters, the therapist decided to direct treatment strategy toward such encounters to the exclusion of other possible stress situations the client might experience during the course of therapy. C's data recording was carried out in a manner described by the therapist as "conscientious." She was never delinquent in her record keeping, and we were satisfied that the selfreports were as reliable as possible under the existing circumstances. Session 4 The client was asked to change her self-recording procedure during the fourth session from a written log to a tape-recorded log. She was instructed to continue recording the frequency of attacks and to note antecedent events but to do it with a small cassette tape recorder. The selfreported material was played during the next therapy session and was the primary focus of therapy. C carried the recorder on her person and recorded material as soon as possible after an attack occurred. She was asked to record answers to four questions after each attack. They were the following: (a) What stressful interpersonal transaction occurred (if any) prior to the attack? (A transaction was denned as a chain of inter-
742
CASE STUDY
personal exchanges, verbal and motor, that occurred between C and another individual.) (b) What did you and the other person do and say? (c) What emotions did you experience during that transaction? and (d) What thoughts did you have during and immediately afterwards concerning what had happened between you and the other person? The client was told that further therapy sessions would be spent reviewing all of the reported preattack incidents that had occurred during the previous week. The following procedure was administered during the remainder of therapy (Sessions 5-18): 1. The client and the therapist listened to C's self-report on tape. 2. The therapist attempted to construct a "functional narrative" of the transaction by questioning C about various aspects of the encounter. The transaction was broken down into a chain of sequences (e.g., What did you do and say? What did the other person do and say?). The functional assessment was terminated when the entire transaction had been reviewed. 3. The client's emotional reactions and thoughts during and after the transaction were then reviewed. 4. The therapist asked C to consider whether she had actually and deliberately been rejected during the transaction or whether other situational cues might account more accurately for the other individual's behavior. 5. The client was instructed to contact the individual in question to verify or invalidate the alternate hypotheses regarding the other person's behavior. The initial goal of therapy was to train the client to carry out Steps 4 and 5 shortly after a stressful transaction had occurred, thereby avoiding the resultant stress reaction pattern that led to a colitis attack. Gradually, the client was encouraged to complete Steps 4 and 5 during stress transactions. Treatment Phase (Sessions 5-18) During the fifth interview C and the therapist completed a goal attainment scale (Kiresuk & Sherman, 1968) to facilitate the evaluation of therapy effectiveness. Several levels of possible therapy outcome were projected using the scale. Goal attainment scaling is useful in specifying target behaviors to both client and therapist; it also helps to anchor goals at realistic and attainable levels, and it is one means to measure therapy progress during the process stage as well as at the termination stage of therapy. Five possible levels of outcome were written into the
scale. Two targets were set for C, and the goal attainment scale constructed during Session 5 is presented in Table 1. The following self-reported material was reviewed during the seventh therapy interview. This information is presented to further clarify the treatment procedure. C verbally summarized a semester project in one of her graduate classes. She stood before the group to make the presentation. The professor intensely questioned various aspects of the presentation. The client engaged the professor in a debate at one point and stood her ground in the face of the instructor's differing opinion. C ruminated about the encounter after it ended, particularly those times in which she was questioned by the teacher and had overtly debated with him. She drew the following conclusions about the transaction: The professor hates me; the professor was picking on me; and he deliberately made me look dumb before my friends. She described the event as stressful and reported that a colitis attack occurred shortly thereafter. The client and therapist reviewed the incident by listening to the tape. The therapist called C's attention to the fact that whenever she reacted to the tape she smiled. C admitted she had enjoyed being able to differ openly with her instructor. Several peers had approached C after class and said that she "did a great job." These remarks were mentioned briefly on the tape, but the client did not appear to attend seriously to these comments. The therapist asked C to consider the meaning of her peers' compliments when she engendered alternate hypotheses concerning the professor's behavior. C hypothesized that the transaction might have been a function of the instructor's classroom style since he had always been very cordial to her outside class. C agreed to contact her teacher prior to the next therapy session to confirm or invalidate this hypothesis. The client saw the instructor, who promptly congratulated her on her classroom performance. He stated that the argumentative class role he played was his preferred style of teaching. C disclosed the conclusions she had drawn following the transaction. The professor stated that rejecting her personally was not his intention. His classroom behavior during the remainder of the semester further validated his comments. The client reported administering Steps 4 and 5 of the treatment program to herself following a stressful transaction during the 8th week of therapy and successfully avoided a colitis attack. During the 14th week of therapy, C reported that she had administered the fourth and fifth steps to herself during a stress transaction and
743
CASE STUDY TABLE 1 GOAL ATTAINMENT SCALE FOR CLIENT Colitis attack
Cognitive hypothesis testing
Most unfavorable One per outcome day thought likely
Every stress transaction per week seen as attack on self
Date: 10/24/73
One every One out of 4 times Less then exother per week considers pected success that a stress transwith treatment day action might not be attack on self Expected level of treatment success
One per week
Completes Treatment Steps 4 and 5 after every stress transaction
More than exOne every Completes Treatment pected success 2 weeks Steps 4 and S during, with treatment stress transactions some of the time Best anticipated success with treatment
None per month
Completes Treatment Steps 4 and 5 during stress transactions all of the time
avoided an attack. The acquisition of the behavior to counter stress reactions within ongoing transactions became the beginning of the end of therapy. The client had one attack during the 14th week, and this was the last attack she reported throughout the remaining 4 weeks of therapy.
Outcome of Treatment The frequency of C's colitis attacks across weeks and sessions of therapy is presented in Figure 2. A dramatic decrease in attack frequency occurred between the fourth and fifth week. We cannot pinpoint the responsible independent variables, but three changes were made during the latter part of the fourth interview that might have contributed to the change. The self-recording procedure was changed from a written log to a cassette log; second, stress transactions were labeled as the causative agent of the attacks; and third, a specific therapy program was outlined for C. No environmental or historical changes that might have contributed to the decrease in attack frequency were reported by the client at the fifth session. A consistent decrease in attack frequency occurred over the next 13 weeks of therapy.
C reported that she had had no attacks during a 43-week follow-up period after therapy termination (see Figure 2). The client's physician examined her during the interim period between the termination of therapy and the 5-week follow-up and stated that the colitis condition had cleared. The two therapy goals established by goal attainment scaling during Interview S were satisfactorially realized by the i8th session. The "best anticipated success with treatment" was achieved with the colitis attacks in that the client reported no attacks over a 1-month period (Weeks 15-18). C obtained a "more than expected success with treatment" level regarding cognitive hypothesis testing. At the 18th session she was completing Steps 4 and 5 during most of her reported stressful transactions. The client reported no major life changes (e.g., moving a place of residence, addition or loss of significant friends or boyfriends, etc.) during the course of therapy that might have further confounded an evaluation of the effects of treatment.
DISCUSSION The present case is best described as a quasiexperimental design (Campbell & Stanley, 1966) and is noteworthy in several respects. First, several possible treatment variables are suggested that might have produced the specific treatment effects. This point is strengthened because of the stability of a second target behavior (weight) that remained untreated throughout therapy but that decreased steadily once the client undertook a systematic weight loss program at the termination of therapy. The multiple baseline aspect of the case provided a control feature that suggests the decrease in colitis attack frequency was a function of treatment and not of extraneous variables (Baer, Wolf, & Risley, 1968). The assumption here is that the weight baseline is representative of what the treated target baseline
BASERATE
TREATMENT
6
1823283661626364656667
FIGURE 2. The frequency of colitis attacks across weeks of therapy.
CASE STUDY
744 TABLE 2 MAJOR VARIABLES INVOLVED IN Two PHASES os THERAPY Base-rate phase variable
Treatment phase variable"
1. Client maintains written 7. Alteration in self-relog cording from written 2. Weekly therapy session to cassette tape log 8. Labeling of anteced3. Client characteristics ent cues leading to 4. Therapist characteristics 5. Client X Therapist attack interaction 9. Coping strategy 6. Time ft Variables 2-6 carried over from base-rate to treatment phase.
might have looked like had not treatment been administered. Second, the case suggested to the authors further research areas that needed investigation to determine what specifically produced the decrease in attack frequency. Such answers would contribute to the treatment of mucous colitis among the general patient population. Also, further research in this area may have additional value in that it might suggest an effective treatment paradigm for other psychosomatic disorders. Specific treatment effects were evaluated in the following way: We first delineated the major therapy variables. Such variables are listed in Table 2. Colitis attack frequency remained stable during the baseline phase of treatment (see Figure 2). A rather dramatic reduction in attack frequency occurred during the fifth week of therapy, which was also the first week of treatment. As mentioned earlier, three additions to therapy that might have accounted for the fluctuation of the data were instituted at the end of the fourth session (see Table 2). In our opinion, one or a combination of these three variables (i.e., Variables 7, 8 and 9) produced the treatment effects. A colleague1 called our attention to the potential treatment effects of the cassette recorder that C used to self-record attack frequency and preattack information. If the act of tape recording stress material is conceptualized as "self-disclosing behavior being done for the therapist," then this behavior is a 1 Special thanks are extended to Donald J. Kiesler for calling the authors' attention to the potentially significant treatment effects of the cassette tape recorder particularly when the use of the recorder is conceptualized as "self-disclosing behavior which was done for the therapist."
potentially significant treatment variable. The logic of the assumption is understood when one realizes that the client actually disclosed to the therapist (via the recorder) highly personal information about anxiety-charged areas of her life. This procedure may have functioned as a sort of self-desensitization to the reported stress situations. Such an exercise may very well have contributed to a decrease in the stress reaction pattern of the client and played a role in decreasing the frequency of the attacks. Research investigating specific treatment variables suggested by the present case could be undertaken along two lines. A factorial design could be used that would enable the experimenter to make cause and effect statements concerning significant treatment variables. Another alternative is a series of partial replications of the above case using single subjects. If a researcher could demonstrate a predicted outcome with a randomly selected group of mucous colitis patients using the single-case design, the hypotheses concerning the effectiveness of a combination of treatment variables would be greatly strengthened. We propose the following factorial design as one means to employ the information obtained from the present case: Written
Labeling
Coping
Cassette tape
Nonlabeling
Noncoping
Used in this manner, the present case is conceptualized as a pilot study that suggests the need for more sophisticated research, and second, the case points out potentially relevant treatment variables. Colitis patient classification should follow the physical description of the two major forms of the disorder (i.e., ulcerative versus nonulcerative). The written self-recording treatment group and the cassette self-recording group could use the procedural format assigned to C when during the fourth session the recording task was changed from written to tape recorder. We defined labeling as the identification of antecedent behavioral cues that precipitated the colitis attack. The identification of the antecedent cues is a time-consuming enterprise and makes group research in the colitis area an arduous task. Coping was described as a "doing strategy," more specifically Steps 4 and S of the treatment plan. Nonlabeling would mean not making the stimulus-response association explicit to the client. However, the association would have to be clear to the experimenter since the construction of a
745
CASE STUDY coping strategy could only be completed if such information were known. Noncoping suggests withholding from the client the administration of a prescription for reducing the attack frequency. A no-treatment control group should be run to test for the potential reactivity effects of selfrecording information surrounding the attack event. There would be no way to control for the possible reactivity effects of self-recording attack frequency since there is no alternate means to obtain such dependent variable data. Daily or weekly frequency of colitis attacks offers the experimenter a practical dependent variable. A second possible direction for a program of research in the colitis area would be a series of single-case design studies. The task would be to assess the effectiveness of the systematic administration of a combination of the three treatment .variables that we assume produced the treatment effects. We suggest that labeling be made explicit to all subjects in such a program. This will enable the client and therapist to make maximum use of the base-rate phase in determining which antecedent cues are producing the colitis attacks.
CLIENT CRISIS AND SELF-RESOLUTION The therapist contacted C during the 1974 Christmas season for a follow-up report. The client replied that she had had no attacks through Week 61 but that she had had three attacks during Week 62 (see Figure 2). C attributed the attacks to her frustrating working conditions that she concluded were unalterable. However, the therapist contact apparently led the client to engage in renewed coping behavior, because she subsequently told her supervisor of her job dissatisfaction and began to investigate other work possibilities. C and the therapist met for a therapy session at the end of the following
week (Week 63). She reported no attacks during that week. C's conversation with the supervisor had led to her achieving better working conditions and a salary increase. Her supervisor was also quite complimentary of her work performance. The remainder of the session was spent reviewing the coping strategy. C agreed to submit a periodic follow-up report, and the therapist told the client to contact her in the future in the event that she could not resolve a conflict situation. The last follow-up contact was during Week 67 with no attacks being reported (see Figure 2). REFERENCES Alexander, F. Psychosomatic medicine. New York: Norton, 1950. Almy, T. P., Kern, F., & Tulin, M. Alterations in colonic function in man under stress. II: Experimental production of sigmoid spasm in healthy persons. Gastroenterology, 1949,12, 425-436. Baer, D. M., Wolf, M. M., & Risley, T. R. Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1968, 1, 9197. Campbell, D. T., & Stanley, J. C. Experimental and quasi-experimental designs for research. Chicago: Rand McNally, 1966. Grace, W. J., Wolf, S., & Wolff, H. G. Life situations, emotions and chronic ulcerative colitis, Journal of American Medical Association, 1950, 142, 1044-1048. Kiresuk, T. J., & Sherman, R. E. Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Community Mental Health Journal, 1968, 4, 443-453. Lachman, S. J. Psychosomatic disorders: A behavioristic interpretation. New York: Wiley, 1972. Misiewicz, J. J. The irritable colon syndrome. In B. C. Morson (Ed.), Diseases of the colon, rectum and anus. New York: Appleton-Century-Crofts, 1969. (Received December 10, 1974)
Behavioral Treatment of Mucous Colitis Katherine J. Youell and James P. McCullough Psychological Services Center, Virginia Commonwealth University A 22-year-old female graduate student who suffered approximately one colitis attack per day at the onset of therapy was apparently successfully treated by a procedure in which the therapist labeled antecedent stress events that appeared to be precipitating the attacks. The client was then taught a behavioral coping strategy to counter the stress events. Subsequently there was a steady decline in attack frequency. No attacks were reported during a 43 week follow-up period. Three attacks were reported during Week 44. The client selfapplied the therapy coping strategy and reported no more attacks during Weeks 45-49. Few case studies have been reported in which psychosomatic disorders were treated with behavioral techniques. The following apparently successful single-case study is a time-series account of a mucous colitis condition in which a covert-overt behavioral technique was taught to a client to combat frequent colitis attacks. Lachman (1972) described two types of psychogenic colitis disorders generally seen in the clinical setting. The first type is chronic ulcerative colitis, a serious, long-standing ulcerative condition of the colon. The second type is known as mucous colitis. It is a less serious condition that affects the motor activity and mucous-secreting functions of the colon. Mucous colitis is also known as spastic colitis, irritable colon, nervous diarrhea, and irritable colon syndrome (Alexander, 1950; Misiewicz, 1969). There is no evidence to support the hypothesis that mucous colitis is a precursor of ulcerative colitis or vice versa. Both types are considered psychosomatic by Lachman since the lower section of the gastrointestinal tract is responsive to emotional reactions, particularly stress. Stress is defined by Lachman as a "reaction pattern . . . in which energy resources are mobilized and one that prepares the organism for sudden, extensive activity—for the violent expenditure of energy needed to fight or flee—activities of a defensive or protective sort." (p. 29) Colonic stress reactions may lead to an increase or decrease in bowel activity as well as a change in the physical quality of defecated material. Lachman briefly reviewed several studies that reported both heightened colonic activity and colonic congestion during stress
periods (Almy, Kern, & Tulin, 1949; Grace, Wolf, & Wolff, 1950). The present case was treated following an extensive medical examination and after a 4-week baseline period during which the client kept data of colitis attack frequency and also reported in writing and via cassette tape log events that occurred prior to the onset of a colitis attack. The client was examined during the follow-up period after the termination of therapy by the same physician who bad conducted the first examination.
Requests for reprints should be sent to James P. McCullough, Virginia Commonwealth University Psychological Services Center, 800 West Franklin Street, Richmond, Virginia 23284.
My symptoms are basically the same each time. First I feel the muscles in my abdomen tighten, then relax—then severe cramps occur in my abdomen. Next, my rectum feels like it is jumping up and down,
CASE HISTORY C was a 22 year-old female graduate student attending a state university in Virginia. She presented herself to the Psychological Services Center with a colitis condition and a long-standing problem of obesity. The client described her interpersonal style as a "tendency to tolerate people who always end up putting something over on me." C's colitis attacks had begun 3 years earlier during her junior year in college. She pinpointed the first attack as occurring several hours after two escaped convicts murdered a maternal aunt and uncle to whom she had felt very close. "Since that time," she remarked, "attacks have occurred whenever I get under pressure." C had been a psychology major as an undergraduate. She told of one type of pressure situation in college that involved taking psychology tests. C described her test-taking behavior as follows: "I would write awhile, then go to the bathroom to relieve myself, come back and write some more, then repeat the cycle." When asked to describe an attack subjectively, C gave the following account:
740
CASE STUDY and I usually go to the bathroom at this point. My symptoms are relieved for a brief while but not for long. The client had tried food deprivation schedules, diet manipulation, and pharmaceutical prescriptions. No treatment strategy had relieved her of almost one attack per day during the previous year. The client had not been on medication for colitis for several months prior to applying for psychological services. C received a medical examination shortly after presenting herself for treatment. Her physician diagnosed her condition at that time as "irritable colon with colitis" and recommended that the condition be viewed as a psychosomatic disorder. TREATMENT PROCEDURES AND OUTCOME Base-Rate Phase (Sessions 1-4) The therapist, a 25 year-old female clinical psychology graduate student, decided to focus on the colitis condition to the exclusion of the weight problem because the former problem presented so much physical discomfort to the client. The weight problem was monitored, however, with C weighing at the Student Health Services on the morning of every therapy session and reporting her weight to the therapist later that same day. The stability of the client's weight across weeks of therapy functioned as a multiple baseline for the target behavior being treated. The client's untreated weight baseline is shown below in Figure 1. C was seen once per week throughout the base-rate and treatment phases of therapy. During the initial therapy session, the client was instructed to keep a daily log to report the number of attacks she had over a 24-hour period. She was also asked to include environmental events that occurred prior to each attack. An attack was defined as a syndrome that included (a) abdominal tensing and relaxing, (b) abdominal cramps, '(c) spasticity of the rectum, and (d) resultant diarrhea. Sessions 2-4 were spent attempting to identify covert and overt antecedent events that might have precipitated the attack. Every reported attack during the baseline period was preceded by events that C described as "stressful" (Lachman, 1972). Stress for the client usually involved an interpersonal encounter that led her to conclude that she had been rejected and deliberately harmed by another individual. C drew this conclusion because of some behavior, usually verbal, that another person emitted toward her. Her self-report concerning these stressful interpersonal encounters focused on the theme
741
260 2M 2G2 248 244 240 236
FIGURE 1. Untreated weight baseline during therapy and systematic weight loss during therapy follow-up. that an individual had planned and carried out a personally directed vendetta against her. At this point she was not able to consider other hypotheses that might explain the other person's behavior more accurately. She would ruminate over the event and simultaneously feel hurt and damaged following these encounters. She remained in this state until the onset of a colitis attack 30 minutes to 1 hour after the stress event. C never reported a stressful test-taking incident throughout therapy. The absence of such reports may have been due in part to her being seen at the beginning of an academic year when test administration was infrequent. Since reported antecedent events prior to attacks involved interpersonal encounters, the therapist decided to direct treatment strategy toward such encounters to the exclusion of other possible stress situations the client might experience during the course of therapy. C's data recording was carried out in a manner described by the therapist as "conscientious." She was never delinquent in her record keeping, and we were satisfied that the selfreports were as reliable as possible under the existing circumstances. Session 4 The client was asked to change her self-recording procedure during the fourth session from a written log to a tape-recorded log. She was instructed to continue recording the frequency of attacks and to note antecedent events but to do it with a small cassette tape recorder. The selfreported material was played during the next therapy session and was the primary focus of therapy. C carried the recorder on her person and recorded material as soon as possible after an attack occurred. She was asked to record answers to four questions after each attack. They were the following: (a) What stressful interpersonal transaction occurred (if any) prior to the attack? (A transaction was denned as a chain of inter-
742
CASE STUDY
personal exchanges, verbal and motor, that occurred between C and another individual.) (b) What did you and the other person do and say? (c) What emotions did you experience during that transaction? and (d) What thoughts did you have during and immediately afterwards concerning what had happened between you and the other person? The client was told that further therapy sessions would be spent reviewing all of the reported preattack incidents that had occurred during the previous week. The following procedure was administered during the remainder of therapy (Sessions 5-18): 1. The client and the therapist listened to C's self-report on tape. 2. The therapist attempted to construct a "functional narrative" of the transaction by questioning C about various aspects of the encounter. The transaction was broken down into a chain of sequences (e.g., What did you do and say? What did the other person do and say?). The functional assessment was terminated when the entire transaction had been reviewed. 3. The client's emotional reactions and thoughts during and after the transaction were then reviewed. 4. The therapist asked C to consider whether she had actually and deliberately been rejected during the transaction or whether other situational cues might account more accurately for the other individual's behavior. 5. The client was instructed to contact the individual in question to verify or invalidate the alternate hypotheses regarding the other person's behavior. The initial goal of therapy was to train the client to carry out Steps 4 and 5 shortly after a stressful transaction had occurred, thereby avoiding the resultant stress reaction pattern that led to a colitis attack. Gradually, the client was encouraged to complete Steps 4 and 5 during stress transactions. Treatment Phase (Sessions 5-18) During the fifth interview C and the therapist completed a goal attainment scale (Kiresuk & Sherman, 1968) to facilitate the evaluation of therapy effectiveness. Several levels of possible therapy outcome were projected using the scale. Goal attainment scaling is useful in specifying target behaviors to both client and therapist; it also helps to anchor goals at realistic and attainable levels, and it is one means to measure therapy progress during the process stage as well as at the termination stage of therapy. Five possible levels of outcome were written into the
scale. Two targets were set for C, and the goal attainment scale constructed during Session 5 is presented in Table 1. The following self-reported material was reviewed during the seventh therapy interview. This information is presented to further clarify the treatment procedure. C verbally summarized a semester project in one of her graduate classes. She stood before the group to make the presentation. The professor intensely questioned various aspects of the presentation. The client engaged the professor in a debate at one point and stood her ground in the face of the instructor's differing opinion. C ruminated about the encounter after it ended, particularly those times in which she was questioned by the teacher and had overtly debated with him. She drew the following conclusions about the transaction: The professor hates me; the professor was picking on me; and he deliberately made me look dumb before my friends. She described the event as stressful and reported that a colitis attack occurred shortly thereafter. The client and therapist reviewed the incident by listening to the tape. The therapist called C's attention to the fact that whenever she reacted to the tape she smiled. C admitted she had enjoyed being able to differ openly with her instructor. Several peers had approached C after class and said that she "did a great job." These remarks were mentioned briefly on the tape, but the client did not appear to attend seriously to these comments. The therapist asked C to consider the meaning of her peers' compliments when she engendered alternate hypotheses concerning the professor's behavior. C hypothesized that the transaction might have been a function of the instructor's classroom style since he had always been very cordial to her outside class. C agreed to contact her teacher prior to the next therapy session to confirm or invalidate this hypothesis. The client saw the instructor, who promptly congratulated her on her classroom performance. He stated that the argumentative class role he played was his preferred style of teaching. C disclosed the conclusions she had drawn following the transaction. The professor stated that rejecting her personally was not his intention. His classroom behavior during the remainder of the semester further validated his comments. The client reported administering Steps 4 and 5 of the treatment program to herself following a stressful transaction during the 8th week of therapy and successfully avoided a colitis attack. During the 14th week of therapy, C reported that she had administered the fourth and fifth steps to herself during a stress transaction and
743
CASE STUDY TABLE 1 GOAL ATTAINMENT SCALE FOR CLIENT Colitis attack
Cognitive hypothesis testing
Most unfavorable One per outcome day thought likely
Every stress transaction per week seen as attack on self
Date: 10/24/73
One every One out of 4 times Less then exother per week considers pected success that a stress transwith treatment day action might not be attack on self Expected level of treatment success
One per week
Completes Treatment Steps 4 and 5 after every stress transaction
More than exOne every Completes Treatment pected success 2 weeks Steps 4 and S during, with treatment stress transactions some of the time Best anticipated success with treatment
None per month
Completes Treatment Steps 4 and 5 during stress transactions all of the time
avoided an attack. The acquisition of the behavior to counter stress reactions within ongoing transactions became the beginning of the end of therapy. The client had one attack during the 14th week, and this was the last attack she reported throughout the remaining 4 weeks of therapy.
Outcome of Treatment The frequency of C's colitis attacks across weeks and sessions of therapy is presented in Figure 2. A dramatic decrease in attack frequency occurred between the fourth and fifth week. We cannot pinpoint the responsible independent variables, but three changes were made during the latter part of the fourth interview that might have contributed to the change. The self-recording procedure was changed from a written log to a cassette log; second, stress transactions were labeled as the causative agent of the attacks; and third, a specific therapy program was outlined for C. No environmental or historical changes that might have contributed to the decrease in attack frequency were reported by the client at the fifth session. A consistent decrease in attack frequency occurred over the next 13 weeks of therapy.
C reported that she had had no attacks during a 43-week follow-up period after therapy termination (see Figure 2). The client's physician examined her during the interim period between the termination of therapy and the 5-week follow-up and stated that the colitis condition had cleared. The two therapy goals established by goal attainment scaling during Interview S were satisfactorially realized by the i8th session. The "best anticipated success with treatment" was achieved with the colitis attacks in that the client reported no attacks over a 1-month period (Weeks 15-18). C obtained a "more than expected success with treatment" level regarding cognitive hypothesis testing. At the 18th session she was completing Steps 4 and 5 during most of her reported stressful transactions. The client reported no major life changes (e.g., moving a place of residence, addition or loss of significant friends or boyfriends, etc.) during the course of therapy that might have further confounded an evaluation of the effects of treatment.
DISCUSSION The present case is best described as a quasiexperimental design (Campbell & Stanley, 1966) and is noteworthy in several respects. First, several possible treatment variables are suggested that might have produced the specific treatment effects. This point is strengthened because of the stability of a second target behavior (weight) that remained untreated throughout therapy but that decreased steadily once the client undertook a systematic weight loss program at the termination of therapy. The multiple baseline aspect of the case provided a control feature that suggests the decrease in colitis attack frequency was a function of treatment and not of extraneous variables (Baer, Wolf, & Risley, 1968). The assumption here is that the weight baseline is representative of what the treated target baseline
BASERATE
TREATMENT
6
1823283661626364656667
FIGURE 2. The frequency of colitis attacks across weeks of therapy.
CASE STUDY
744 TABLE 2 MAJOR VARIABLES INVOLVED IN Two PHASES os THERAPY Base-rate phase variable
Treatment phase variable"
1. Client maintains written 7. Alteration in self-relog cording from written 2. Weekly therapy session to cassette tape log 8. Labeling of anteced3. Client characteristics ent cues leading to 4. Therapist characteristics 5. Client X Therapist attack interaction 9. Coping strategy 6. Time ft Variables 2-6 carried over from base-rate to treatment phase.
might have looked like had not treatment been administered. Second, the case suggested to the authors further research areas that needed investigation to determine what specifically produced the decrease in attack frequency. Such answers would contribute to the treatment of mucous colitis among the general patient population. Also, further research in this area may have additional value in that it might suggest an effective treatment paradigm for other psychosomatic disorders. Specific treatment effects were evaluated in the following way: We first delineated the major therapy variables. Such variables are listed in Table 2. Colitis attack frequency remained stable during the baseline phase of treatment (see Figure 2). A rather dramatic reduction in attack frequency occurred during the fifth week of therapy, which was also the first week of treatment. As mentioned earlier, three additions to therapy that might have accounted for the fluctuation of the data were instituted at the end of the fourth session (see Table 2). In our opinion, one or a combination of these three variables (i.e., Variables 7, 8 and 9) produced the treatment effects. A colleague1 called our attention to the potential treatment effects of the cassette recorder that C used to self-record attack frequency and preattack information. If the act of tape recording stress material is conceptualized as "self-disclosing behavior being done for the therapist," then this behavior is a 1 Special thanks are extended to Donald J. Kiesler for calling the authors' attention to the potentially significant treatment effects of the cassette tape recorder particularly when the use of the recorder is conceptualized as "self-disclosing behavior which was done for the therapist."
potentially significant treatment variable. The logic of the assumption is understood when one realizes that the client actually disclosed to the therapist (via the recorder) highly personal information about anxiety-charged areas of her life. This procedure may have functioned as a sort of self-desensitization to the reported stress situations. Such an exercise may very well have contributed to a decrease in the stress reaction pattern of the client and played a role in decreasing the frequency of the attacks. Research investigating specific treatment variables suggested by the present case could be undertaken along two lines. A factorial design could be used that would enable the experimenter to make cause and effect statements concerning significant treatment variables. Another alternative is a series of partial replications of the above case using single subjects. If a researcher could demonstrate a predicted outcome with a randomly selected group of mucous colitis patients using the single-case design, the hypotheses concerning the effectiveness of a combination of treatment variables would be greatly strengthened. We propose the following factorial design as one means to employ the information obtained from the present case: Written
Labeling
Coping
Cassette tape
Nonlabeling
Noncoping
Used in this manner, the present case is conceptualized as a pilot study that suggests the need for more sophisticated research, and second, the case points out potentially relevant treatment variables. Colitis patient classification should follow the physical description of the two major forms of the disorder (i.e., ulcerative versus nonulcerative). The written self-recording treatment group and the cassette self-recording group could use the procedural format assigned to C when during the fourth session the recording task was changed from written to tape recorder. We defined labeling as the identification of antecedent behavioral cues that precipitated the colitis attack. The identification of the antecedent cues is a time-consuming enterprise and makes group research in the colitis area an arduous task. Coping was described as a "doing strategy," more specifically Steps 4 and S of the treatment plan. Nonlabeling would mean not making the stimulus-response association explicit to the client. However, the association would have to be clear to the experimenter since the construction of a
745
CASE STUDY coping strategy could only be completed if such information were known. Noncoping suggests withholding from the client the administration of a prescription for reducing the attack frequency. A no-treatment control group should be run to test for the potential reactivity effects of selfrecording information surrounding the attack event. There would be no way to control for the possible reactivity effects of self-recording attack frequency since there is no alternate means to obtain such dependent variable data. Daily or weekly frequency of colitis attacks offers the experimenter a practical dependent variable. A second possible direction for a program of research in the colitis area would be a series of single-case design studies. The task would be to assess the effectiveness of the systematic administration of a combination of the three treatment .variables that we assume produced the treatment effects. We suggest that labeling be made explicit to all subjects in such a program. This will enable the client and therapist to make maximum use of the base-rate phase in determining which antecedent cues are producing the colitis attacks.
CLIENT CRISIS AND SELF-RESOLUTION The therapist contacted C during the 1974 Christmas season for a follow-up report. The client replied that she had had no attacks through Week 61 but that she had had three attacks during Week 62 (see Figure 2). C attributed the attacks to her frustrating working conditions that she concluded were unalterable. However, the therapist contact apparently led the client to engage in renewed coping behavior, because she subsequently told her supervisor of her job dissatisfaction and began to investigate other work possibilities. C and the therapist met for a therapy session at the end of the following
week (Week 63). She reported no attacks during that week. C's conversation with the supervisor had led to her achieving better working conditions and a salary increase. Her supervisor was also quite complimentary of her work performance. The remainder of the session was spent reviewing the coping strategy. C agreed to submit a periodic follow-up report, and the therapist told the client to contact her in the future in the event that she could not resolve a conflict situation. The last follow-up contact was during Week 67 with no attacks being reported (see Figure 2). REFERENCES Alexander, F. Psychosomatic medicine. New York: Norton, 1950. Almy, T. P., Kern, F., & Tulin, M. Alterations in colonic function in man under stress. II: Experimental production of sigmoid spasm in healthy persons. Gastroenterology, 1949,12, 425-436. Baer, D. M., Wolf, M. M., & Risley, T. R. Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1968, 1, 9197. Campbell, D. T., & Stanley, J. C. Experimental and quasi-experimental designs for research. Chicago: Rand McNally, 1966. Grace, W. J., Wolf, S., & Wolff, H. G. Life situations, emotions and chronic ulcerative colitis, Journal of American Medical Association, 1950, 142, 1044-1048. Kiresuk, T. J., & Sherman, R. E. Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Community Mental Health Journal, 1968, 4, 443-453. Lachman, S. J. Psychosomatic disorders: A behavioristic interpretation. New York: Wiley, 1972. Misiewicz, J. J. The irritable colon syndrome. In B. C. Morson (Ed.), Diseases of the colon, rectum and anus. New York: Appleton-Century-Crofts, 1969. (Received December 10, 1974)
