Monday, March 14, 2011

Exposure Therapy for Hungry Elevator Phobics

Fun With Behavior Therapy from the 70s, Part 1

In 1973, Bryntwick and Solyom published a paper on a new method of behavior therapy for elevator phobia, which involved depriving their clients of food and water for 24 hours. The rationale for their unorthodox approach was as follows:
Fear habits in the animal laboratory have been diminished by first depriving the subject of food and then rewarding him with it in the fear provoking situation (Masserman, 1943; Wolpe, 1958). To apply this technique to clinical subjects has generally been considered "unthinkable". The present report illustrates the clinical effectiveness in the treatment of two elevator phobic subjects.
Apparently, both of the patients voluntarily agreed to forgo eating and drinking for one day. Here is the background information on the two elevator phobic subjects, one of whom had good reason to be phobic (in my view):
Mr. B.M., a 32-yr-old businessman, had suffered from an elevator phobia for about 5 yr. He attributed his fear to two occasions within a 2-week period when he was trapped in an elevator for a few minutes. Since then he would climb 16 floors rather than take an elevator. Several times daily he climbed three flights of stairs to his office. On a 0-4 point scale, he rated his fear of elevators as 4, corresponding to "terrifying panic attacks if avoidance impossible". No other obvious psychopathology was apparent...

Mr. W.H., a 19-yr-old student, had suffered from travel and claustrophobia for approximately 3 yr. He was markedly obsessive, being very orderly, meticulous and hesitant, with a tendency to ruminate. One manifestation of his claustrophobia was avoidance of elevators. He also rated his elevator phobia at 4...
As for treatment, both patients had failed "aversion relief therapy" for elevator phobia, so the authors found it appropriate to use feeding as a counter-conditioner in vivo.
Each patient, after agreeing to the new procedure, was instructed not to eat or drink for 24 hr prior to the treatment session. After that deprivation the patient was led to an elevator where he found a table attractively arranged with his most preferred foods. For the next 35 rain he sat eating his dinner while the elevator moved up and down. At the end of the session, the patient was encouraged to take self-service elevators in as many different buildings as possible.

Both patients reported minimal anxiety and for the first time did not avoid taking elevators.

Possible scenario for the elevator exposure dining experience.

Unfortunately, Mr. W.H. had a relapse after being the victim of a cruel prank:
One week after the first session, however, Mr. W.H. was riding in an elevator when the building superintendent, also in the elevator, stopped it with the comment, "I wonder if it will start again". Although the elevator was stopped for only 5 sec, Mr. W.H.'s anxiety rose to its original intensity.
No matter, all was not lost. Two weeks later a booster session eliminated his elevator phobia once again. Both patients were reportedly "phobia free" two years later.

Not everyone in the behavior therapy community was pleased with this approach, however. Rosen and Orenstein (1974) were quite critical of the treatment, and nearly called the food deprivation aspect a farce:
...There appears to be no evidence to support the position that such deprivation significantly adds to the effectiveness of a treatment program based on in vivo exposure alone. The first author’s own experience with an “elevator phobic” suggests that avoidance of elevators can be eliminated in a single in vivo session without recourse to theoretical “counter-conditioners”. The client spent 45 min riding in the elevator of an eight story building sometimes accompanied by the therapist and sometimes on her own. During the session there were large reductions in her self-reported anxiety. Four days later the client rode in the same elevator on her own. She has since ridden in other elevators demonstrating what could be called a “generalization of treatment effects”.
This particular patient missed out on the elevator fine dining experience, though...


Bryntwick, S. & Solyom, L. (1973). A brief treatment of elevator phobia. Journal of Behavior Therapy and Experimental Psychiatry, 4 (4), 355-356 DOI: 10.1016/0005-7916(73)90008-6

Rosen, G. & Orenstein, H. (1974). A critical comment on the use of food deprivation in the “Brief treatment of elevator phobia”. Journal of Behavior Therapy and Experimental Psychiatry, 5 (3-4) DOI: 10.1016/0005-7916(74)90087-1

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At March 15, 2011 4:06 AM, Blogger Irvann said...

Fascinating case.

At March 15, 2011 12:05 PM, Anonymous Emmy said...

Nice. I wonder if this phobia is similar to that of flying, where (from what I understand) it is several phobias wrapped into one, e.g. claustrophobia, fear of heights and all that. The recent grim findings I've read say that the plane-phobia patient's only recourse is to take a mind-bending cocktail of drugs in order to get over it.

At March 15, 2011 6:11 PM, Blogger Michelle Dawson said...

Not phobias, but extreme food deprivation has been used as an early autism treatment, with very young children.

You can find a 1970s use of extreme food deprivation at UCLA reported in this book. Lovaas' reported recommendation was 36hrs of food and liquid deprivation for a 4yr old. The purpose was to make the child "hungry and desperate enough to do anything for food." Instead the child got very sick, threw up bile, and was too tired and listless to work for his food.

Another book reports in passing the use of routine food deprivation as autism treatment by Lovaas at UCLA, within the most famous autism study ever.

To my knowledge there has never been any criticism of this kind of practice published in any journal.

At March 16, 2011 1:41 AM, Blogger The Neurocritic said...

Emmy - Claustrophobia is probably the greatest factor in most cases of elevator phobia, because of the fear of getting trapped and being unable to escape.

Michelle - This quote is telling:

To apply this technique to clinical subjects [as opposed to animals] has generally been considered "unthinkable".

It's most unfortunate that children with autism weren't put on the same level as the "clinical subjects".


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