136 CASE HISTORIES hSD SHORTER COM4tUNICATIONS

,a serious problem m a case study as the present is derrrmimng the ci%cts of an mter!sntlon without a rsksrsal of continprnci?s: there are, however, ethical objections to the reinstatement of illness behavior

through a reversal of contingencies, especially when the bchavlor is potentially life-threatening. In lieu of a reversal. it should be noted that Wright rr al. (1976) ha%-s approximated the lnterrrntion strategies of the present case study in the treatment of vomiting and acquired similar results on two occasions. The? emphasized the use of differential reinforcement (DRO) of specific behavior during periods of no vomitinu, the chkldrrn &ere praised and tactually stimulated for independent and co-operative play. self-feeding anpd related behavior.

Additionally. the clean-up procedures in Wright er af.‘s (1976) case studies were immediately following a Qomiting episode: a wet diaper was used to ‘aversively’ remove the remaming vomitis from the child’s

mouth: the child was firmly told, “No!“. then taken to a time out setting and left for two minutes. One of their case studies shows continued remission of vomiting at an 18 month follow-up and the other is still free of symptoms at an 8 month follow-up.

The results obtatned by Wright rr al. (1976) and in the present case study suggest that these procedures are a viable alternative to the shock avoidance and punishment frequently used in vomiting disorders. In determining whether to use the procedures of the present study and Wright YI al. (1976) or shock avoidance. the question, “How life-threatening is the vomiting?” should be asked. If the child is near death. the shock avoidance procedures will effect a more immediate remission of vomiting; however. if vomiting behavior is in the early secondary stages and the child’s life is not in immediate dan,- 0-r. the less aversive procedures

of ihis case study and Wright rt al. are preferable. These results further suggest that continued failure in the treatment of childhood ruminative vomiting

ma): result from inconsistency in social contingencies of the health care and home environment; rhe probability

of success will be enhanced if continued failure in medical interventton is analyzed in terms of possible environmental pathology concurrent with disease diagnosis.

Dxviv FERRELL WRIC;IIT

RICHARD A. BRUWN

IMARY E. ANDREWS

REFERENCES

HAMMOND J. (1973) The late sequelae of recurrent vomiting of childhood. Dec. Med. Child Neuroi. 16, 15-X KOHLENBEHG R. J. (1970) The punishment of persistent vomiting: A Case Study. J. App/. Brhoo. .3rtnl. 3.

23 I-24s. LA~C P. J. and ?I~ELA?~EI) B. G. (1969) Care report: Avoidance conditioning therapy of an infant with chronic

ruminative vomiting. J. Abnortmi Rsychof. 74. i-3.

RICHMOND J. B.. EDDY E. and GREEN M. (1958) Rumination: A psychosomatic syndrome of infancy. Pediarrics

22. 49-55. STEIX M. L., R~LSEN A. R. and BLAU A. (1959) Psychotherapy of an infant with rumination. J. .-lm. itfrd.

Ass. 17. 73-76. TOISTER R. P.. CONDRIN C. J.. WORMY I.. and ARTHUR D. (1975) Faradic therapy of chronic vomiting in

infancy: A case study. J. Brhac. Ther. rxp. Psyciriar. 6. 55-59. WRIGHT D, F., ECKER D.. AVIXEWS M. E. and FAC!LRS E. (1976) Unpublished data. WRIGHT D. F. (1977) Behavioral Medicine: Strategies for Health Behavior Change. (Film) Sasha Productions,

Department of Human Behavior, University of Southern California School of Medicine.

Treatment of an obsessivexompulsive checker

(Receir,& 1s July 1977)

Rachman (1976) and R&man, de Sitva and Roper (1976) have described compulsive checking rituals as having positive reinforcing value when requests for reassurance to ‘put matters right’ reduce temporarily the amount of discomfort associated with the obsession. Rachman (1976) proposed a treatment program in which the client is trained in response prevention, i.e. refraining from ‘putting right’ the effects of the rumination. In addition. he suggested that response prevention and satiation training are most effective when used in combination.

The following is a brief case report of the utilization of response prevention and satiation training with

CASE HISTORIES AND SHORTER COMMUNLCA-RONS 137

a compulsive checker. The use of these techniques varies from those described by Rachman (1976) only in that the cltent put the techniques into practice without prior rehearsal in the therapist‘s office. The client was a 37-year-old male skilled laborer whose chief complaint was his habitual seeking of reassurance from his supervIsor about his job performance. His supervisor reported that the client requested reassurance about ten times more often than most other employees. The client reported the frequency of requesting reassurance to have been l&I5 times per week. This pattern of behavior had been occurring since adolescence when the client recalled constantly asking his friends whether they liked him.

The treatment consisted of the client being mstructed to allow the concern about job performance to occur and to refrain from requesting reassurance from his supervisor. in an attempt to increase the client‘s ability co self-assess and self-reinforce his job performance, the client was assisted in developing a rattng scale from 1 CO 10 with 5 being average and 10 being perfect job performance. A one sentence description accompanied each number on the scale and this was based upon his evaluation of the job performance of others which he was able to assess realistically. After he set a goal for his work to average 6-7, he was instructed to race his work at the completion of each task. A third intervention involved satiation training in which the client was instructed to utilize a 30min period at the same time each evening as ‘worry tim; in which he was to worry about his job performance or any other matter of concern which had developed during the day. The client maintained a journal in which he recorded the events. frequency of desire to check, or actual checking behavior. and any feelings about the interventions.

On the first day of implementation of the program, he did report having an intense desire to seek reassurance about a particuiar job task. But he was able CO delay 1 f days before seeking the reassurance. After four months elapsed, there was no significant instance of his asking for reassurance although the desire occurred. but with decreasing frequency and tntensity. His relationship with his supervisor improved dramatically, and the supervisor no longer avoids talking with him, which has had reinforcing effect on response prevention. The performance self-rating was equally as effective. The client developed the ability over five weeks co rate his job performance with satisfaction and the ratings averaged 7-8 on the scale. Four months later he was able to assess his job performance without use of the scale. The satiation program led Che chent co report that he was free from obsessive worrying throughout the day for the first time m years. The worry time was gradually reduced so that, at termination. he was using about 10 min at night for ‘worry time‘ about one day per week.

A response prevention program in which the client was encouraged to allow concerns about job performance co occur without ‘putting matters right’ through reassurance was found to be effective. His ability to assess his job performance was developed and seemed to replace the frequent need for evaluation and reassurance from his supervisor. The satiation treatment was also effective in. first, concentrating the pervasive and obsess- ive worrying and eventually led to nearly complete extinction of the worrying behavior.

3255 Flora St.. San Luis Obispo. CA 93401. U.S.A.

ROBERT HAYXES

REFERENCES

RACHMAN S. (1976) The modification of obsessions: A new formulation. Behau. Res. Ther. 14, 437-443. RACHMAN S.. DE SILVA P. and ROPER G. (1976) The spontaneous decay of compulsive urges. Behur. Res.

Ther. 14, 445-453.