J. Behov. Ther. & Exp. Psychiaf. Vol. 14, No. 1, pp. 61-65, 1983. Printed in Great Britain.

OC05-7916/83/01006!-05 $03.00/O Pergamon Press Ltd.

THE TREATMENT OF CHILDHOOD-ROOTED SEPARATION

ANXIETY IN AN ADULT

PETER BUTCHER

Department of Psychology, The London Hospital, Whitechapel, London

Summary-This paper describes the behavioral treatment of a continuing separation anxiety experienced by a 31 yr old male with a long history of school phobia in childhood. The patient was successfully treated by using a wide variety of behavioral strategies. One novel therapeutic technique was used: the patient wore a bleeper which sounded as a regulzr reminder to prepare for a phobic situation and to relax in the face of anticipated fearful events.

INTRODUCTION

Explanations of school refusal are varied. They have been explained by psychoanalytic views (Johnson, 1957; Kahn and Norsten, 1962), by biochemical causes (Campbell, 1955; Agras, 1959) and by learning theory (Yates, 1970; Ross, 1972). Research by Berg (1971, 1974) indicated that, compared with controls, school phobic adolescents showed overdependence in their reliance on the mother for personal activities and household tasks as well as for travelling away from home. Hersov (1976) describes an increase in school refusal at the age of 11 when children change schools in England. Rodriguez, Rodriguez and Eisenberg (1959) found that com- pared with younger school avoiders this popu- lation has a poorer prognosis with only 36% successfully returning to school. The few follow- up studies of school refusers suggest that one in three develop neurotic problems in maturity (Tyrer and Tyrer, 1974; Berg, Butler and Hall, 1976) and may continue to cling to their families for emotional support and direction (Weiss and Burke, 1967).

CASE HISTORY

The patient, H.L., was a successful 31 yr old branch manager of one of Britain’s leading life

insurance groups. Psychiatric and psychological assessment indicated that apart from very mild obsessional tendencies and a tendency to seek reassurance, he was a pleasant, capable, confi- dent and hardworking individual. His presenting problem was anxiety attacks when staying away from home. These were particularly pronounced when he attempted to stay overnight at conferences.

Family setting H.L. was an only child and was still living at

home with his now elder!y mother who had become more and more dependent on him since his father’s death 11 yr previously. She had few friends and went out infrequently. Most outings were with H.L. She doted on him and through her disapproval had tended to play a major part in the break-up of serious relationships he formed with girlfriends.

History of phobia The separation anxiety had been present dur-

ing his earliest years at school. He recalls that from the age of 5 or 7 yr, children in his class were not allowed to go home after school when it rained. Because of this he always carried a rain- coat, even on sunny days, in order to avoid be- ing detained. The fear became acute at the age

Requests for reprints should be addressed to Peter Butcher, Department of Psychology, The London Hospital, Whitechapel, London, E.l., England.

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62 PETER BUTCHER

of 11 when he changed from Junior to Senior school. Junior school had been a 5 min walk from home and he had always returned at mid- day for lunch. At lunch break on the first day in the Secondary school he became very much aware that he would have to stay on until 4.00 p.m. He experienced sensations of panic associated with being trapped. Following this anxiety attack he refused to attend school for several weeks. Even when he settled into school the phobia would emerge periodically, particu- larly after summer holidays or any long break. The phobia continued developing in this way for 5% yr. For 2 yr he was seen every second week at a Child Guidance Centre. When this failed to reduce his school avoidance he received 3 yr of regular psychoanalytic treatment from a psychia- trist at a London teaching hospital. Only in his very last term was he able to go back to school on the first day. Even then it was only possible because his exams were over and the atmosphere was more relaxed.

At the age of 17 he made a surprisingly easy transition from school to work. He thought this was due to the fact that he started on the last day of the working week and was able to come home in the lunch hour.

At the age of 19, accompanied by a friend, he took his first holiday away from his parents. On the first night away he became so stricken with panic that he had to return home from the con- tinent. The panic was similar to the fear he had experienced at school and he associated both these situations with the fantasy that he would never return home. Since that time he had been able to take brief holidays in England-as far as 200 miles from home-but during the first few days he always suffered a great deal of anxiety. He felt compelled to telephone his mother every day.

The patient was particularly anxious at con- ferences. Although he managed to attend several at a venue 50 miles from his home, he could only do so when he returned home in the evening.

Behavioral analysis H.L.‘s answer to questions in the assessment

interviews suggest that his phobia was being maintained by the following: 1. A continued separation anxiety-he was

over-attached to his mother and to his home and the security which both of these represented.

2. The school-like setting of business con- ferences which reminded him of the ex- perience of feeling trapped.

3. Breaks in home-based routine which made

him feel insecure. 4. His mother’s over-dependent behaviour.

Treatment Initial treatment trained the patient in pro-

gressive muscular relaxation and imaginal desen- sitisation. A hierarchy was developed of the stages and activities associated with getting to and staying at a conference. The patient’s abili- ty to picture these scenes was helped by the fact that because of having attended one day courses, he was familiar with the journey and the con- ference centre. In six sessions he was able to im- agine leaving home, completing the 50 mile journey, booking into the hotel, going to his room and taking part in the conferences without experiencing high levels of anxiety. At the sixth session, 4 days prior to the conference, he felt confident about staying overnight and decided he would attend. However, on the morning of the conference he woke in a state of panic. Con- tinued efforts to relax himself during the morn- ing by using progressive muscular relaxation were unsuccessful. Although he managed to drive three quarters of the way to the conference centre, his nerve failed and he returned home.

Following this failure, alternative strategies were introduced to disrupt his phobic response and to develop his confidence. 1. It was contracted that H.L. would discuss

with his mother the importance of their building more independent lives. He was also instructed to tell his mother frequently that he was genuinely worried about her spending so much time on her own and to use this as a lever to get her to join social groups or even- ing classes. He was also asked to encourage

THE TREATMENT OF CHILDHOOD-ROOTED SEPARATION ANXIETY IN AN ADULT 63

his mother in any positive effort she made to change their relationship toward a healthier state.

2. H.L. was asked to invite his mother along to sessions in order to discuss their difficulties and to introduce her gradually to the aims of treatment.

3. The patient was instructed to begin regular overnight stays in hotels, cottages and friends’ houses to help him adapt to periods away from home. In addition to treating the separa- tion anxiety, the aim of this approach was to disrupt routine patterns of behaviour. It had the advantage of helping him adjust to the separation anxiety without the added strain of coping with a classroom-like setting of con- ferences in which he felt trapped. Regular trips from home began with one night stop- overs and these were gradually lengthened to whole week-ends.

4. The patient was asked to make a number of alterations to his after-work routines. He was to spend more evenings and longer periods of time away from his home and mother.

5. H. L. was encouraged to look for a house or apartment to buy as an investment and somewhere into which he could move gradually. Weekly targets were set for the number of telephone calls made to estate agents and places to be visited.

The patient co-operated fully with all five parts of the contract. His mother on the other hand made various excuses for not cominig along to the therapeutic session. It was several weeks before she attended. A few days after this first interview she became “unwell” and took to her bed. When this had happened in the past, the patient’s response had been to spend even more time at home. This time he was instructed not to “spoil” his mother but, having established that she had all she needed, to continue his new pattern of regularly going out in the evening. H.L. maintained his consistent stand and his mother’s “health” gradually improved. Without specific prompting from H.L. she began accep- ting invitations for social engagements as well as arranging meetings and outings with acquain- tances .

When H.L. was able to stay away from home for more than one night without feeling anxious, he felt prepared to attend another conference. Again, two sessions involving rehearsal in imagi- nation, including the morning of departure, the 50 mile journey and all the stages of the conference, produced little or no anxiety. However, on the morning of the conference, he woke in panic and this time could not leave the house.

BEHAVIOUR RE-ANALYSIS

A re-analysis of factors associated with his panic revealed the previously undisclosed fact that during the period leading up to the conference-except for therapy sessions-he had done everything he could to completely block out or suppress the thought that a conference was imminent. He did this mainly by busying himself with work and home routines which he found reassuring. The behaviour was particularly pro- nounced during the 5 days between the last therapy session and the day of the conference. On the morning of departure the reality could no longer be denied and the realization led to a panic attack.

To disrupt the pattern of denial and reduce the growing anxiety this produced as a conference approached, the patient was asked to carry a bleeper which sounded hourly to remind him that he should prepare for any coming conference, to imagine or visualise that a conference was im- minent, and finally, to counteract the presence of any anxiety by relaxing himself. As an adjunct to this procedure the author conducted a weekly series of half hour relaxation and imaginal ses- sions focussed on the 2 weeks prior to a con- ference, covering a count-down of days and hours up to and including the morning of departure.

After 5 weeks the patient reduced the bleeper to four times each day-early morning, prior to lunch, before the evening meal and late evening. After 7 weeks the patient attended a conference, stayed overnight, and experienced only mild anxiety with no sudden build up of anxiety feelings.

64 PETER BUTCHER

Earlier in the treatment-a few weeks after his second unsuccessful attempt to attend a conference-the patient found a house and began the process of taking out a mortgage. However, it became clear from his comments that buying the house was construed as an ir- revocable commitment to final separation from his mother. During the following 6 weeks he began having sleepless nights and prior to the ex- change of mortgage contracts he panicked and ended the purchase proceedings. Because of the failure it was decided that he would not continue with this aspect of treatment until he had suc- cessfully attended an overnight conference, After reaching this latter target he was asked to resume his search for a house or apartment. When he did find a property he liked-an apartment this time-it was decided to counteract his tendency to avoid facing realities by once again using the bleeper. The device was used in the following way: Every hour, at the sound of the bleeper, H.L. would focus his attention on these thoughts: (1) Even after I have taken out the mortgage, I can sell the apartment whenever I want. (2) Purchase of the apartment does not necessarily mean I will have to leave home im- mediately and it can be used for week-ends only. (3) The apartment can be viewed simply as a wise investment and nothing more. These statements, along with a fourth suggestion to relax himself, were originally written in the back of his pocket diary so that on hearing the bleeper he could take out the diary and learn them by heart. No other method of desensitization to the fear of purchase was employed. Within a week he felt it was necessary to use the bleeper only once in every 2 hr. He described mild anxiety only when thinking about the purchase and no sleepless nights. In the third week we set the timer to sound only during the evening. During the following weeks he was able to complete the various arrangements for purchase without panicking.

At 6 month follow-up after taking out his mortgage, H.L. was continuing to attend residential conferences and to remain overnight. He was maintaining a good relationship with his

mother while managing to live more in-

dependently by staying at his apartment-27 miles away-on most week-ends and occasional- ly on evenings during the week.

DISCUSSION

In the treatment of a longstanding separation anxiety, successful outcome was achieved

through ongoing behavioural analysis and by us- ing a numberof behaviour therapy approaches. These included imaginal and in vivo desensitiza- tion and the recognition of the cognitive strategies which the patient employed to defend himself against rising anxiety as conferences came nearer in time. In addition a cueing device was used which forced the patient to attend regularly to the situation he had habitually come to push from consciousness. The results suggest that for some people and some fears an additional form of desensitization which focuses on a period of awareness training prior to the encounter with the fear situation may be an important mode of

treatment. The final outcome in treating the fear of

attending overnight conferences was achieved by a combination of two treatment approaches. This included weekly sessions of imaginal desensitization and daily awareness training using a bleeper, It is difficult to assess which, if either, made the greatest contribution. How- ever, it is worth noting that an additional

fear, the patient’s fear of purchasing his own apartment, was treated solely by means of the cueing device. Overall, the positive results using the bleeper suggest that a simple cueing device of this sort may be a valuable aid in desensitiza- tion programmes. It can help individuals carry out desensitization in their own time and should increase the frequency of imaginal exposure to the feared situations.

REFERENCES

Agras, S. (1959) The relationship of school phobia to childhood depression, Am. J. Psychiat. 116, 533-536.

Berg I. and McGuire, R. (1971) Are school phobic adolescents over-dependent? Br. J. Psychiat. 119, 167-168.

THE TREATMENT OF CHILDHOOD-ROOTED SEPARATION ANXIETY IN AN ADULT 65

Berg I. (1974) A self-administered dependency questionnaire (S.A.D.Q.) for use with mothers of school children, Br. J. Psychiut. 124, l-9.

Berg I., Butler A. and Hall G. (1976) The outcome of adoles- cent school phobia, Br. J. Psychiat. 128, 80-85.

Campbell, J. D. (1955) Manic depressive disease in children, J. Am. Med. Ass. 158, 154-157.

Hersov L. A. (1976) School refusal. In Child Psychiatry: Modern Approaches (Ed. by Rutter M. and Hersov L. A.). Blackwell Scientific Publications, London.

Johnson A. M. (1957) School phobia: Discussion, Am. J. Orthopsychiat. 27, 307-309.

Kahn .I. H. and Norsten J. P. (1962) School refusal: A com- prehensive view of school phobia and other failures of

school attendance, Am. J. Orthopsychiat. 32, 707-718. Rodriguez A., Rodriguez M. and Eisenberg L. (1959) The

outcome of school phobia: A follow-up study based on 41 cases, Am. J. Psychiat. 116, 540-544.

Ross A. 0. (1972) Behavior therapy. In Psychopathological Disorders of Childhood. (Ed. by Quay H. C. and Werry J. S.). Wiley, New York.

Tyrer F. and Tyrer S. (1974) School refusal, truancy and adult neurotic illness, Psychol. Med. 4, 416-421.

Weiss M. and Burke G. B. (1967) A five-ten year follow-up of hospitalised school phobic children and adolescents, Am. J. Orthopsychiat. 37, 294-295.

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