CASE HlST0RlF.S AND SHORTER COMMUNICATlONS 213

Behav. Res. & Therapy. 197X. Vol 16. pp. 213-216.

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Fading-A new technique in the treatment of phobias

(Received 26 September 1977)

Phobias have been subject to more research by behavior therapists than any other psychiatric disorder. In 1975 Marks described more than 20 different techniques that have been developed for or used in the treatment of phobias.

The technique to be described in this paper-fading-was first used by Barlow and Agras (1973) as an alternative to aversive techniques for homosexuals. Originally the technique was designed to change the stimulus control of sexual responsiveness by introducing or “fading in” heterosexual stimuli during periods of sexual arousal elicted by homosexual stimuli.

One purpose of the single-case studies presented here was to explore the possibility of achieving a similar result with phobic clients. In other words, the aim was to create a state of calmness and positive sensations in the client and then to gradually “fade in” phobic stimuli. The hypothesis was that the stimulus control of anxiety exerted by the phobic stimuli would decrease and finally be extinguished due to the antagonistic effects of observing and imagining positive scenes.

A second purpose of this application of fading was to develop a technique for reducing phobic anxiety which could give more control to the client than is the case in, for example, systematic desensitization.

METHOD

Apparatus

The apparatus for the fading procedure consisted of two Model S Kodak Carousel projectors and a variable voltage transformer box. The fan and lamp circuits of the projectors were separated and the fan circuits were connected to the transformer box so that the lamp of the first projector dimmed while the lamp of the second projector simultaneously brightened as the control lever was pulled to either side. The projectors were mounted above and behind the client’s head and the slides were projected on the screen 2 m in front of her, in such a way that they were superimposed on each other.

Procedure The first step in applying fading procedure with phobics is to have the client produce 10 pictures that

are associated with pleasurable, positive feelings, and then to rank these pictures. Examples of such pictures are photos of the client’s wife or husband, children, pets, or whatever objects or settings are capable of arousing a positive sensation iri the client. The second step of this method is to teach the client to imagine the positive scenes depicted in the photos and at the same time experience a calm and positive feeling. This is achieved by first letting the client look at a photo. The therapist then instructs her to close her eyes and imagine that she really is in the situation in questios and to try to experience the positive feelings associated with it. The client is also given home assignments to practice imagining these scenes with the help of the photos.

In the third step the client ranks 10 slides of the phobic stimuli, for example snakes, spiders, rats, etc. This is done by placing the slides on an illuminated slide sorting desk so that the client can look at all slides at the same time.

The fading treatment per se starts by having the client sit in an armchair and look at the first positive slide. The client is to imagine the situation projected on the screen and to try to achieve a positive sensation while doing so. Instructions are then given to pull the lever to the right in order to increase the brightness of the phobic slide, when the client feels ready to do so. The client has the control box accessible at all times and thus can decide on both the brightness and the duration of the phobic slide presentation.

When the client feels too much anxiety while observing the phobic slide, the lever is pulled to the left, thus brightening the positive slide again. While looking at the positive slide, the client imagines the situation and tries to experience the calm and positive feelings associated with it. When ready to try again, the client reverses the lever to the right again and brightens the phobic slide.

When the cleint has observed the phobic slide for 20sec or more, the degree of anxiety felt during the trial is rated on a scale from 0 to 10. In order to proceed to the next slide in the hierarchy, two consecutive trials of 20 set observation time with an anxiety rating of 3 or less, must occur. For the next phobic slide, which is somewhat more anxiety-producing, we use the second positive slide. which is more attractive than the first. In this way we reduce the risk of wearing out a particular positive slide.

Clients The first client was a 23-year-old female who had been afraid of rats since she was 9. She could not

stay in places where there might be rats, and she had great difficulty reading books or newspapers, or looking at pictures, films or television where rats might possibly appear.

214 CASE HISTORIES AND SHORTER COMMUNICATIONS

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The second client was a 42-year-old female who had been confronted with a large rat at work in the factory just prior to the start of therapy. She was so afraid that she had to leave work and was on sick-leave until three weeks later when therapy was begun. Her phobia for rats dated back to her early teens.

Assessnrrnt

Both clients refused to be confronted with a live laboratory rat before treatment. In order to assess each clientS degree of phobic behavior, the following tests were administered immediately after each session.

Picture test. IO slides of different rats and 10 slides of neutral animals were randomly ordered and presented for 2Osec each. If the client felt too much anxiety she could press a button and the next slide would appear.

Film test. An 8mm film consisting of five different sequences with rats was presented. The film took three minutes and ended with a sequence where a person handled a white rat and finally put it on his head. In this test the client also had the opportunity to press a button and thereby end the presentation of the film.

Dependent measures. After each test the client rated the degree of anxiety (from 0 to 10) experienced during the test. The behavioral measures were the mean number of seconds she observed the phobic slides in the picture test and the time elapsed until the button was pressed in the film test. Finally. the heart rate of the second client was continuously monitored during both tests.

RFSULTS

Client A

In the film test client A (Fig. 1) stopped the film after approxtmately 1 min and felt very anxious (mean = 9.0). During the fading treatment she observed the film for increasingly longer periods of time and

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CASE HISTORIES AND SHORTER COMMUNICATIONS 215

could watch the entire film during the 10th session. However. there was only a minor decrease in her self-rating during this phase (mean = 7.3) which is why reinforced practice (Leitenberg and Callahan. 1973) was applied in the third phase and modelhng added in the fourth. This led to a decrease in her anxiety rating and at the 18th session. she could watch the whole film without anxiety. Figure 2 shows the client’s reactions to the picture test. Her mean observation time during the baseline was 8.7sec and her rating of anxiety averaged 6.0. During the treatment with fading. the observation time increased rapidly-the mean was 19.1 set-and the anxiety rating decreased to a mean of 2.6. In the third phase there was a further decrease and in the fourth the client could look at all the pictures without anxiety.

At the end of treatment she was able to stay alone in a room with over 100 caged rats for three minutes without undue discomfort. She could also be in places where she had earlier come in contact with rats without experiencing anxiety. These gains were maintained at both the two-month and one year follow-ups.

Clienr B

In the film test (Fig. 3) client B observed one third of the film (mean = 64.7sec) during the baseline phase.

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She experienced maximum anxiety while doing this and her heart rate was 80.4 beats/min on the average. compared to a resting pulse rate of 75 bpm. During the fading treatment she gradually increased the observa- tion time and could watch the whole film at session 7. The mean for this phase was 150.2sec. At the same time there was a sharp decrease in her self-rating and the mean for this period was 5.2. There was also a slight decrease in her heart rate. giving a mean for the phase of 77.7 bpm.

The results for the picture test (Fig. 4) were much the same in regards to self-rating and observation time. The means for the anxiety rating are 10.0 and 4.0 respectively, and for the observation time 11.6 and 18.9. The change in heart rate was very small. from 77.8 during baseline to 77.3 during the fading period.

At a six-month follow-up this client could watch the whole film and all the phobic slides the maximum time prescribed without any anxiety, and with a heart rate near her resting value (74 bpm). In an in t:iro

rest with a white laboratory rat in an open box she could put her hand on the inside of the box without undue discomfort. This was done both after session 8 and at the follow-up.

DISCUSSION

The conclusion that can be drawn from these two single-case studies is that fading is a promising technique in the treatment of animal phobias, and that the procedure is controlled by the client to a larger extent

216 CASE HISTORIES AND SHORTER COMMUNICATIONS

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in fading than in systematic desensitization. The advantages that we have found thus far with fading are that the technique is not only simpler and but also permits more self-control. The disadvantage might be that the specific phobic slides used restricts the degree of generalization more than is the case for systematic desensitization. These predictions should be thoroughly investigated however before any definite conclusions are drawn.

The fading technique is similar to systematic desensitization in that both start with a condition (relaxation and positive scene observation respectively) that is supposed to be antagonistic to the anxiety response. The phobic stimulus is then gradually inserted into that condition. At this stage it is premature to conclude that observing and imagining positive scenes is a necessary part of fading. Perhaps it would work just as well with only gradual exposure to the phobic slide which the client fades in. This in turn, would be similar to other techniques for phobias, e.g. modelling and reinforced practice. This question is now being investigated in our laboratory.

Much research needs to be done in order to ascertain if fading is a viable alternative to established behav- ioral techniques for phobias. The most important question is whether fading can be effective for other kinds of phobias, e.g. specific, social and agoraphobia. The technique will be of little use to the clinician if its sole applicability is with animal phobics. a client category which according to Marks (1969) comprised only 37, of the phobics treated at Maudsley Hospital in London.

Acknowledgement-The help of Lars-Goran KIII and Anita Jerremalm who served as therapists is gratefully acknowledged.

Psychiatric Research Center, LARS-GBRAN &T

Uniuersiry of Uppsala. Sweden

REFERENCES

BARLOW D. H. and AGRAS W. S. (1973) Fading to increase heterosexual responsiveness in homosexuals. J. appl. Behaa. Anal. 6, 355-366.

LEITENBERG H. and CALLAHAN E. J. (1973) Reinforced practice and reduction of different kinds of fears in adults and children. Behau. Res. Therap. 11, 19-30.

MARKS 1. M. (1969) Fears and Phobias. Heineman, London. MARKS 1. M. (1975) Behavioral treatments of phobic and obsessive-compulsive disorders: A critical appraisal.

In Progress in Behavior Modification (Eds. M. HERSEN, R. M. EISLER and P. M. MILLER). Vol. 1. Academic Press. New York.