Clinical Social Work Journal, Vol. 34, No. 3, Fall 2006 (Ó 2005) DOI: 10.1007/s10615-005-0019-z

EXPERIENCES WITH IMPLOSIVE THERAPY James D. Troester, M.S.W., C.S.W.1,2

ABSTRACT: Implosive Therapy (IT), which was originated by Thomas Stampfl in the 1950s, is an imagery technique built on psychoanalytic theory and learning theory. IT can be an effective means of helping people who have phobias and aversions. Examples illustrate the rationale, application, and outcome of the procedure. KEY WORDS: Implosive therapy; exposure therapy; phobias; fears; anxiety.

INTRODUCTION A phobia is ‘‘a dread of something to such an extent that it interferes with our ability to work, socialize, and go about our daily routine’’ (Waters, 2004, p. 7). According to Freud, ‘‘the anxiety accompanying a phobia is positively indescribable!’’ (Freud, 1952a, p. 610). The National Institute of Mental Health (NIMH) estimates that as many as 12.5 percent of Americans have phobias. NIMH considers phobias the most common psychiatric illness among women of all ages and, among men over 25, the second most common illness (Waters, 2004). While the greatest number of fears and phobias is experienced during childhood, about 40 percent of these continue into adulthood, 1 I am a graduate of the University of Michigan School of Social Work and have extensive practice experience in family services, child guidance, and schools. I am now retired and do volunteer work with parent support groups, as well as independent evaluation of children and youth. 2 Correspondence should be directed to James D. Troester, M.S.W., C.S.W., 1704 10th Street, Bay City, MI 48708-6745, USA; e-mail: [email protected].

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with fears of snakes, storms, animals, heights, enclosed spaces, and social situations showing an increasing prevalence up to age 20 (Doctor & Kahn, 2000). ‘‘Phobias that persist into adulthood remit only infrequently’’ (American Psychiatric Association, 2000, p. 447). An NIMH epidemiological study concluded that ‘‘fewer than one in four with a phobia have received treatment’’ (Saul, 2001, p. 4). Agoraphobia, which is considered the most disabling of the phobias, is the most common phobia for which people seek therapy (Doctor & Kahn, 2000). For the most part, behavior is regulated by the brain in response to information received from within the body or from the environment. When this information is enveloped in emotion, our feelings determine the intensity of our response to it. If we perceive and interpret a situation as life threatening, our emotions cause us to react by a flight or fight response (Bruhn & Wolf, 2003). Freud explained that ...the essence and meaning of a danger-situation...consists in the subject’s estimate of his own strength compared to the magnitude of the danger and in his admission of helplessness in the face of it–– physical helplessness if the danger is objective and psychological helplessness if it is instinctual. In doing this he will be guided by the actual experiences he has had. (Whether he is wrong in his estimation or not is immaterial for the outcome) (Freud, 1952b, p. 751).

Amygdala, an ‘‘almond-shaped structure, which is located deep within the brain, ...picks up on scary stimuli and sends out powerful panic signals. These signals can quickly turn peoples’ attention to possible threats’’ (Helmuth, 2003, p. 568). Since ‘‘the amygdala, believed to be the warehouse for fear, is functional at birth (Inbinder, 2002, p. 350)....an interactive experience in infancy perceived as ‘danger’ could throughout life, in a stimulus/response coupling, motivate behavior’’ (p. 353). Freud pointed out: In the phobias...two stages in the neurotic process are clearly discernible. The first effects the repressions and the conversion of the libido into anxiety which is then attached to some external danger. The second consists in building up all those precautions and safeguards by which all contact with this externalized danger shall be avoided (Freud, 1952a, p. 614).

Unlike objective anxiety, neurotic anxiety is based upon internal danger and is unconscious (Freud, 1952c, p. 841). ‘‘The phobia is

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thrown up before the anxiety like a frontier fortress’’ (Freud, 1938, p. 521). The outer danger now represents the dreaded libido (Freud, 1952a, p. 615), and the symptom prevents a break out of the anxiety (Freud, 1938, p. 521). It seems ‘‘highly improbable that a neurosis could come into being merely because of the objective presence of danger, without any participation of the deeper levels of the mental apparatus’’ (Wollheim, 1981, p. 129). Extinguishing our fears and phobias requires ‘‘turning toward what we dread most. In dealing with fear, the way out is in’’ (Kopp, 1990, p. 28).

THE USE OF IMAGERY IN THERAPY Freud (1909/1959, p. 262) stated that his goal was ‘‘to enable the patient to obtain a conscious grasp of his unconscious wishes....presenting the unconscious complex to his consciousness in our own words.’’ Before he used free association and dream interpretation, however, Freud, around the 1890s, began using a technique wherein ...he would press on the patient’s head and instruct him or her to observe the images which appeared as he relaxed the pressure. Freud reported that the patients started to see, in rapid succession, various scenes related to the central conflict (Sheikh & Jordan, 1983, p. 398).

However, around 1900, Freud began to consider imagery a resistance to free association regarding unacceptable impulses, so he began to emphasize the secondary process––verbal content and logical thought––rather than the primitive primary-process functioning associated with imagery. ‘‘My therapy consists in wiping away these pictures’’, he stated (Kosbab, 1974, p. 284). ‘‘One cannot help but wonder how psychoanalysis would have evolved if Freud had continued to stress image association instead of shifting to the verbal procedures...’’ (Sheikh & Jordan, 1983, p. 408). ‘‘It has been demonstrated that ‘free imagery’, an analogue of free association, is extremely effective in circumventing even very stubborn defenses and uncovering repressed material’’ (Sheikh & Jordan, 1983, p. 394), and that, due to its primordial forms, imagery is the ‘‘direct voice of the unconscious’’ (Jellinek as cited in Sheikh & Jordan, 1983, p. 395). Images represent ‘‘dynamic relationships between elements of the personality or psyche. Figures in imagery representing actual persons

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and expressing the quality of the individual’s relationship with them still are considered to ultimately characterize projections of the individual’s own needs and motives’’ (Sheikh & Jordan, 1983, pp. 403–404). ‘‘European clinicians deserve the credit for keeping alive the use of images in psychotherapy in the wake of behaviorism in the early 1900s’’ (Sheikh & Jordan, 1983, p. 404).

IMPLOSIVE THERAPY ‘‘Implosive therapy was developed by Thomas Stampfl, an American psychologist, in the mid-1950s, as a treatment for anxiety-related disorders and other negative emotional responses’’ (Doctor & Kahn, 2000, p. 84). The therapist uses a ‘‘technique in which the individual is exposed to anxiety-producing stimuli by thoughts and imagery rather than the real situation’’ (Doctor & Kahn, 2000, p. 301). ‘‘The strategy of the implosive therapist is to reexpose to the patient conditioned stimuli he is presumed to be avoiding’’ (Stampfl & Levis, 1967, p. 25). As Fiske (2002, p. 74) noted, ‘‘simply showing subjects something they should be afraid of also triggers an amygdala response, so the fear doesn’t have to be experienced; it can be imagined.’’ ‘‘Implosion is based on principles of learning theory and psychoanalytic theory. The latter is used as a theoretical guide to develop fantasies or fantasy images about the phobia event that relate to conscious fears (such as castration, separation, etc.)’’ (Doctor & Kahn, 2000, p. 301). The therapist develops themes, which include descriptions of sensory stimuli ‘‘hypothesized to be linked to the original conditioning events’’ (Levis, 1985, p. 69) and derived from the therapist’s diagnostic understanding of the client’s history and symptoms. ‘‘The goal is to obtain an intense emotional reaction from the patient’’ (Stampfl, 1966, p. 18). The themes are vividly described to the client. The images are not inherently aversive and, as the real situation (unconditioned stimulus) is not present, the images and thoughts they provoke (conditioned stimuli) explode within. Anxiety mounts but cannot be maintained. It extinguishes. The anxiety (objective, instinctual, or superego), avoidance behavior, and any other obstacles (e.g., rituals) imposed by the phobia are removed if the stimuli described by the therapist are on target and adequately applied. Experimental studies have found implosive therapy to be effective (Levis, 1966, 1995 Levis & Carrera, 1967) and safe (Levis, 1995).

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In the early 1900s, Jung wrote to Freud and described techniques similar to implosive therapy that were being used by Demeng Bezzola and Ludwig Frank. Bezzola puts a mask on people and gets them to tell him the visual images they see. Many traumatic moments are brought out, which he makes them repeat over and over until these are exhausted. Good results, so far as I have been able to check them. (McGuire, 1974, p. 50).

‘‘Frank, using hypnotic suggestion, concentrates attention on the traumatic moment... and makes the patient go through it again and again until it is exhausted’’ (McGuire, 1974, p. 50).

THE THERAPEUTIC RELATIONSHIP ‘‘It is a central tenet in the practice of psychotherapy that the relationship between patient and therapist is the primary tool used for change’’ (Edwards & Bess, 1998, p. 89). In a study by Ribner and KneiPaz (2002), clients viewed a successful relationship with their therapist as one in which the therapist achieved the art of ‘being’ with the client, which included warmth, acceptance as equals, and the ability to listen and to create a sense of calm. Although this may appear to be stating the obvious, the lack of such positive contacts in their histories as clients underscores the gap between social work theory and actual practice. (p. 386)

When the relationship does not ‘‘feel hopeful to the client’’ (Meyer, 2001, p. 329) the client does not return. From the other side of the relationship, effective therapists ‘‘viewed theories and techniques as tools to be used tentatively to supplement a natural, collaborative, relationship-building, intuitive approach to helping’’ (Coady & Wolgien, 1996, p. 319). Techniques such as implosive therapy must be used judiciously, as supported by the diagnosis and the assessment of ego strengths. At the conclusion of one of my early uses of IT, my mid-30-year-old schizoid client soberly remarked, ‘‘That was interesting. Who was it about?’’ On the other hand, the practitioner must know and accept self in order to feel comfortable in using implosive therapy. As a psychiatrist colleague use to say, ‘‘There’s only room in the interview for one anxious person, and it had better not be the therapist!’’

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Even though the client must agree to the use of implosion, the therapist must nevertheless maintain a vigilant and sensitive awareness of the client’s responses to the fearful stimuli, and the client retains the right to terminate the technique. According to Levis (1985) Any attempt on the patient’s part to avoid the imagined aversive stimuli is matched by the therapist’s attempt to circumvent or discourage such behavior. The essence of the procedure is to repeatedly expose the aversive stimuli underlying the patient’s difficulties until an extinction effect is obtained and symptomatic behavior is markedly reduced or eliminated. (p. 69)

I have found, however, that without exception, since I began using implosion in the early 1960s, that by respecting the client’s resistance and momentarily stopping the procedure, clients shortly permitted it’s resumption. They realized, I believe, that their anxiety was disproportionate to any real danger, and they seemed to sense that by continuing they might rid themselves of a troublesome problem.

EXAMPLES 1. Alice, 7½-years-old, was accompanied by both parents, who said that since infancy, Alice has been unable to sleep unless her father is nearby. She panics when she senses imminent danger of any kind, and she is extremely fearful of darkness and storms. Alice has one sibling, a 3½-year-old brother. The parents had been married 7 years before they achieved the pregnancy for Alice. Alice had breathing problems at birth and was administered oxygen. She was examined by a pediatrician when 2-days-old, and he told the parents that although Alice was in good health, ‘‘You’ll have your hands full.’’ When walking away from them he chuckled, ‘‘Don’t have another one.’’ The parents learned that the nurses had to hold and rock Alice 24 h a day to keep her from crying. Her longest duration of sleep in the hospital was 20 min. Alice’s problems continued at home. Between 3 and 4 years old, Alice vomited every night as bedtime approached. The parents sought help from the pediatrician and from friends and others, who suggested remedies such as letting Alice lie in her vomit. ‘‘We gave up on these solutions as it was too painful for us,’’ Alice’s dad explained. Rather, the parents decided to have Dad sleep every night on the floor next to Alice’s bed. Alice, a second grade student, had no problems separating from home for school attendance, and she always received a superb report card. She could spend long hours visiting alone at her aunt’s home and sleeping overnight there with no difficulty. She seemed to have minimal, if any, interest in peer relationships and activities. The mother appeared to be the task-leader in the family; the father the emotional leader.

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Alice was very anxious and was clingy to her parents throughout the initial session. I explained to Alice and her parents that I would see Alice alone for part of the next session, and that I would tell her some ‘‘pretend stories’’ about her fear of being alone in her bedroom at night, and about storms and darkness. It appeared that Alice was enmeshed in a symbiotic tie to her parents, and that this was due to having been continuously held and rocked in the hospital because of her problems when a neonate, coupled with the parents’ continuation of over-closeness because of the anxiety about her health and their over-investment in this long-awaited first born. Alice’s obvious oedipal symptoms seemed secondary to the earlier fixation. Alice did not want her parents to return to the reception room after the beginning phase of our second session, so I said she could have them stay but that I was going tell the ‘‘pretend story’’, as planned. She then said that she would rather have them not stay with us. I asked Alice to try to think that what I was going to tell her was ‘‘real’’ even though it was pretend and nothing was really going to happen. She sat on a large, comfortable chair, and I told her that she could probably imagine the story better if she relaxed and closed her eyes. She complied. I asked Alice to think of being all alone at home. Her parents and brother were away. She exhibited considerable anxiety. This imaginary scene and her resulting anxiety were described to her for about 20 min. I then had her imagine her parents and brother returning, and I had her imagine that she liked being with them, but that she also liked having been alone too. Between now and the four days before our next session, I explained to Alice and her parents, Dad was not to be in––or in proximity to––Alice’s bedroom, and Alice could keep a light on all night and keep her door and drapes open should she want to. At the next session, the parents said Alice had ‘‘had a terrible few days–– the worse ever.’’ She had clung to her dad throughout that time, and on the first night following the ‘‘pretend story’’ he had to take her to the parents’ bed while mother went to Alice’s bed. However, they noted that there were indications of Alice’s first peer group interests. All weekend she played with age peers for the first time and even spent two overnights at other girls’ homes. I encouraged continuation of peer involvement. Again Alice did not want her parents to leave the room, but that was resolved the same way as in the previous session. For the second ‘‘pretend story’’ I had Alice imagine herself alone at night in her bed. She became aware of the rumblings and distant flashes of an approaching thunderstorm, and she became very frightened and is unable to move. She hears her parents and brother leave the house, get into the car, and drive away. She feels very alone and empty. Then she feels very angry at her parents for leaving her behind. Alice next hears the door to her room open and soon feels a hand on her shoulder. She plunges a butcher knife she had been gripping into the person’s heart. The last word the dying person whispers is ‘‘Alice.’’ Alice cried at the conclusion of this story and then left for the restroom. She soon returned to the office, was composed, and asked me, ‘‘Who was the person I stabbed?’’ I said I did not know.

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Ten days later at the next appointment, Alice’s parents said that Alice had slept alone and dad had not had to sleep in the hallway for the previous seven nights. Also, Alice now has a television in her bedroom. In our next session 1 week later, Alice’s parents said that Alice continued to do well. They felt it was helpful for Alice to have a television in her room, and they said she had built a ‘‘clubhouse’’ to use with her playmates. This latency-age interest was a promising sign. When seen individually, Alice volunteered that she had not been having upsetting dreams lately, which she explained she used to have. She also said, ‘‘I wouldn’t want my kid joining me and my husband.’’ This, of course, was a reference to her own past behavior. Over 2 weeks later, the parents met with me and said that Alice continued to sleep alone, including a recent evening when there was an extremely severe thunderstorm. They also said that Alice refers to me in very positive ways, unlike previously. I encouraged the parents to get a sitter for Alice and her brother and to go out occasionally. About 2 years later, the parents contacted me to relay that Alice still sleeps alone and well. She has been active with her peers and takes lessons with some of her friends at a dance studio.

2. Lynette, 40-years-old, was referred by her therapist, who stayed with us during a single-session effort to extinguish her snake phobia. Her therapist had told me that ‘‘Lynette’s fear is so extensive that she cannot enter the study in her home as it includes a set of encyclopedias, which she knows includes the letter ‘s’, and that book must include a picture of a snake.’’ I asked Lynette if she could swim, and learning that she could I asked her to try to relax and close her eyes while she sat aside her therapist and I described the following: You’re standing at the end of a swimming pool. You dive in and begin swimming toward the opposite end. You feel something slither across your right ankle. (Lynette sprang from the chair, with eyes widened, and exclaimed, ‘‘I know, it’s a snake!’’ ‘‘Yes,’’ I confirmed, ‘‘would you like to continue?’’ Lynette sat down, closed her eyes, and remained so through completion of the imagery story.) I said that the wall at the end of the pool she had dove from, as well as the walls by the sides of the pool, had moved flush to the pool, leaving her only exit a door ahead beyond the other end of the pool. Snakes of all sizes and colors slid across her body and into and out of all body openings. When she finally reached the end of the pool and got out of it, she found the exit door locked. Her only way out of the pool was to swim back to the other end, which now had an opening in the wall. I repeated the snake infested environment of the pool during her return swim. Lynette was spent and visibly shaken when the story was concluded, but several months later I received a note from her. She wrote that she had moved to attend college and was living in the rural outskirts of the campus. One recent day she walked down a lane from her mobile home to deposit garbage when she saw a snake slowly crossing the path ahead of her. ‘‘I didn’t want to pick it up, but I just walked around it. When I turned around to walk back, the snake was gone. I guess it had gone into the woods.’’

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3. I had a previous long-term therapeutic relationship due to an adjustment problem to his parents’ marital conflicts with now 12-year-old Bob, whose recently divorced mother re-referred him because of extreme anxiety attached to several situations. Bob thought a killer (man) was hiding under his bed, that his mother might die in an automobile accident (‘‘You can’t really replace your parents,’’ he sadly explained), and that he might smother. He also was afraid to go to the basement of the home. Bob’s fears appeared to result from the coincidence of his parents’ separation during the time of his reawakened Oedipus complex, with his father represented by the killer, the basement representing his incestuous desires, smothering denoting over-closeness to mother, and mother’s death fulfilling the retribution extracted by the superego. After a brief explanation of implosion, I told Bob a story wherein I accompanied him as we slowly climbed the staircase to his bedroom, where we searched for any hidden persons. Finding none, Bob got in bed and I left. The killer had concealed himself behind a curtain, undetected, and he lunged out, a knife in hand. Bob wrestled the knife away and killed the man by repeated stabs. I then had Bob turn on his bedroom light, at which point Bob spontaneously opened his eyes and said, ‘‘That guy looked like my dad!’’ The next day in a follow-up session, Bob said he slept soundly the previous night and had none of his previous fears. ‘‘I just went to bed. I didn’t have to look under the bed or behind the door. I really feel at ease.’’ Two weeks later, Bob said he was still sleeping well. He had experienced ‘‘a little fear of a man in the house, but I told myself the pretend story and it went away.’’ Three months later, Bob’s mom said he was ‘‘doing much better. He is able to go to the basement freely, and he only has a little momentary hesitation going upstairs.’’ I crossed paths with Bob a few years later and he mentioned the implosion and said, ‘‘It cured me of those fears I had.’’

4. When an aggressive Airedale terrier, always unleashed, moved into our neighborhood, I quit walking on his side of the street, only rode my bike in the opposite direction of his house, and maintained surveillance whenever outside. When I heard reports of the dog’s aggression toward others, my anxiety and resulting need to avoid dogs in general steadily increased. I gave up bike riding, and I walked a circuitous route to work. One evening as I reflected upon this, I became aware of the increase in my fear and the handicap this phobia was imposing on me. I asked myself what would be the most catastrophic consequence if I confronted my fear by gallantly walking my former direct course to work. ‘‘The dog would kill me!’’ I told myself. I was startled by awareness of the preconscious thought that I had apparently harbored and quickly realized that, although I’d probably be bitten, I could sufficiently ward off the dog and successfully escape into someone’s house. I certainly

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would not die. I vowed to no longer avoid the terrier and to reclaim my rights and freedom. There was no sign of the terrier’s presence when I walked by his house the next morning. However, when I reached the corner and turned in the direction of my work place, I saw a mid-size German shepherd standing sideways in the middle of the block ahead. Not breaking my stride and as I was almost to the dog, he merely moved slightly to let me pass. I felt his nose upon my right hand as I moved past him. That evening I recalled that an older brother, with whom I was his 10year-old helper, was bitten by a dog while we peddled newspapers. When the investigating policeman asked my brother if he had bothered the dog, he replied, ‘‘No, I thought he was just coming to sniff me.’’ Since that time, I now realized, I had misinterpreted a dog’s intent to gain my scent as an approach to bite me, with the dog’s reactive aggression at my retraction confirming my belief. My dog phobia was extinguished on that day 30 years ago.

5. Aversive feelings can also be excised by implosion. When I almost stepped on a steamy pile of yellow vomit deposited on the sidewalk by a fleeing neighborhood cat, I equated it to the scrambled eggs I was served a few moments later. The association was quickly broken by imagining myself kneeling before the vomit and injesting it by spoon. After the initial gag reflex the connection dissolved and breakfast was thoroughly enjoyed.

6. Aaron, a 50-year-old salesman, was paralyzed at the thought of crossing a bridge, several of which were in his sales zone. He was traveling over two hundred miles weekly for sessions with his psychoanalyst, from whom I had him get permission before agreeing to see him for help with his phobia. Aaron’s history revealed an oedipal-based fear of his father. In the implosion I had Aaron imagine driving his car up a high and steep single-lane bridge. At the apex he met head-on with a car traveling in the opposite direction. A burly man got out of the other car and ordered Aaron to back his car down to where he had left from. Aaron was terrified at the thought of doing that, but almost equally terrified to challenge his rival. He chose the latter and was thrown from the bridge during the ensuing battle. Aaron fell into deep water, emerged, and swam a short distance to a small island. Exhausted, he crawled onto the island and was comforted by a woman lying there. Eventually, the maternal affection turned intimate. During that involvement Aaron looked skyward and recognized the angry, piercing eyes of his bridge rival as those of his father, and his love partner as his mother. The father dove off the bridge, swam to the island and charged Aaron with a knife, castrating him and then leaving in a rowboat with Aaron’s mother. Aaron cried and moaned as he imagined the events in this story. The following week Aaron reported that he was able to cross bridges without experiencing anxiety. He was elated.

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CONCLUSION The diagnostic formulations we derive from the data we consider relevant, and the resulting treatment strategies we utilize, should have a logical connection with each other (Osmo & Rosen, 2002). Implosion is sometimes the logical choice of treatment. Although I estimate that I only used Implosive Therapy with about three clients per annum while carrying a large, general clinical caseload over a 37-year span, it was an invaluable tool to have at hand. Despite the fact that our primary instrument is the therapeutic relationship, ‘‘more of the professional literature has been dedicated to understanding the patient half of that relationship than the therapist half, particularly as regards the subject of the integration of the personal self into the style and technique of a psychotherapist’’ (Edwards & Bess, 1998, p. 89). The therapist who uses implosion must have the capacity to identify with and accept the universal elements of self in order to develop and deliver the necessary themes. Furthermore, since ‘‘the ability to think consciously about oneself is perhaps the cardinal psychological characteristic that distinguishes human beings from all other animals’’ (Leary & Buttermore, 2003, p. 365), we can use that unique ability to enhance our own well-being. For some of us that improvement might be gained through the self-application of implosion.

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James D. Troester, M.S.W., C.S.W. 1704 10th Street Bay City, MI 48708-6745, USA [email protected]