William G, Johnson, James M, Ross, and Marie A. Mastria. University of Mississippi Medical Center, Jackson, Mississippi. An otherwise normally functioning ...
Journal of Abnormal Psychology 1977, Vol. 86, No. 4, 421-426
Case Report Delusional Behavior: An Attributional Analysis of Development and Modification William G, Johnson, James M, Ross, and Marie A. Mastria University of Mississippi Medical Center, Jackson, Mississippi An otherwise normally functioning patient with a delusional system was treated using a reattribution procedure. The case illustrates the utility of attribution theory as a model for understanding the development and maintenance of delusions in addition to providing a basis for their modification. It is argued that the proper focus of attribution therapy lies in changing cognitions and not overt behavior by veridical rather than deceptive manipulations. Delusions represent a form of deviant behavior that has been described as elaborate thoughts logically following an erroneous premise. They are incongruent with established beliefs and are frequently organized around persecutory, controlling, or otherwise negative features of the environment (Heilburn & Bronson, 1975). Because delusions deviate from commonly held conceptions of reality and often refer to aversive control by others, they frequently evolve into a highly persistent set of beliefs that resist efforts at modification (Cameron, 19S9). Delusions have been considered attempts at self-cure (Freud, 1959), evidence of disordered thinking (Sullivan, 1956), and even normal behavior resulting from misconceptions or attentional deficits (Maher, Note 1). Typically, theoretical accounts of deviant behavior are remiss in providing guidelines for therapeutic intervention and such appears to be the case for delusions. Recently, there has been a trend toward a reliance on general behavior principles applicable to all human behavior that contrasts with attempts at the construction of separate and distinct theories for each pathological state. Accordingly, the basic processes of how individuals construe their environment and behavior are relevant to the understanding and treatment of delusions. Particularly notable in this context is attribution theory, which is a loosely organized set of principles devoted to James M. Ross is now at the Regional Guidance Center in McAlester, Oklahoma. Requests for reprints should be sent to William G. Johnson, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.
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how and on what basis people infer relations between behavior and its causes. The general assumption of attribution theory is that individuals form causal impressions or explanations (attributions) for their behavior and that of others. These attributions consist of beliefs and expectations that may serve to influence other behaviors (Kelley, 1973). As Weiner and Sierad (197S) state, "causal beliefs precede and in part determine subsequent action" (p. 420). Extension of the attributional process to delusional behavior is relatively direct. Generally, explanations of behavior are responsive to a common set of sociocultural contingencies and, thus, are congruent with the beliefs of others. In fact, Kelley (1973) notes that consensus is a major determinant of confidence and support for an individual's judgment. There are situations, however, where unfamiliar events or behaviors are not readily explainable. Under these conditions, and particularly when the opportunity for social comparison is unavailable, people become pressed to explain their behavior and often misattribute it to fictional causes (Nisbett & Valins, 1972; Schachter & Singer, 1962). It is precisely this process that may account for the development and maintenance of delusional behavior. Directly relevant to the use of attribution theory in modifying delusions are the reports of Davison (1966) on paranoid thinking and Neale (cited in Valins & Nisbett, 1972) on fear of homosexuality. In both cases, the prime treatment regimen consisted of providing "normal" explanations of deviant behavior as an alternative to the patient's attributions of abnormality. The present case extends these previous reports by providing an account of both the develop-
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ment and treatment of delusional behavior in an otherwise normally functioning person. Case Study Presenting Problem The patient was a 37-year-old black male with no previous psychiatric history. He came to the emergency room at the University of Mississippi Medical Center with the complaint that he was having sexual intercourse with a "warm form." The first occurrence was 8 days prior to admission. While sitting naked on his bed watching television, his penis became erect, and he felt a "warm object" pressing against his genitals. Soon afterwards he ejaculated. The patient denied genital manipulation or masturbation. He experienced a similar occurrence during the following week. The sensation was primarily tactile and was experienced as a vagina. He realized that his story sounded very strange but insisted that his experience was real. Also, he denied being under the influence of alcohol or other drugs at these times.
episode motivated him to seek the counsel of a minister and his cousin. He related his encounters with the warm form and the other circumstances that he felt verified its presence. Neither minister nor cousin offered a satisfactory explanation for his difficulty. However, his cousin encouraged him to seek help at the medical center where there were experts who dealt with his type of difficulty. Upon presentation at the emergency room, his only psychiatric difficulty was the verbal report concerning experiences with the warm form and his accompanying anxiety over its presence. He described a pattern of heavy drinking over the past several years that he felt was now under control. He also reported a hallucinatory-type experience of being "kissed" by another man while in a bar but noted that he was intoxicated and could not remember the details. Because of the bizarre nature of the patient's symptom and its distressing effects, he was admitted with a tentative diagnosis of paranoid schizophrenia, and Thorazine was prescribed (200 mg taken as needed). Procedure
Relevant Background
Information
Mr. J. is an only child and has been married twice. His first wife died, and his second marriage ended in divorce. He lives alone, and most of his leisure time is spent either with women in romantic situations or visiting his children. He claims to have male acquaintances but no consistent or enduring friendships. Mr. J. began heterosexual activity at 12 years old and denies ever having masturbated, which he believes to be an inappropriate form of sexual release. He currently has sexual intercourse once or twice weekly, never being abstinent for more than 2 consecutive weeks. One month prior to admission, he contracted body lice from a partner and consequently refrained from sexual contact. This was approximately 3 weeks before he experienced the warm sensation. Even though the warm form was associated with penile erection, the ambiguity and uncertainty surrounding the episodes were frightening to him. He feared that the warm form could occur without notice; it might enter his room while he was sleeping or even appear while he was at work. Other unusual events at this time were also attributed to the presence of the warm form. For example, during a visit, his son replaced the regular bathroom light with a blue bulb. Mr. J. entered the bathroom at night and became terrified when he turned on the blue light. This
Upon admission the patient was assigned to the second author (Ross), then a psychology intern, who was supervised by the first author (Johnson). Following several days of observation and extensive interviews, no other problems were obvious. The patient was interpersonally competent and vocationally well-adjusted. Several contacts with his cousin verified this impression and other background information as well as the patient's reports of the warm form. The patient had difficulty sleeping the first two nights of hospitalization. On the third night, 200 mg of Thorazine was given at bedtime, and he slept well. This medication made him groggy the following day, and he refused to take it again. This was the only medication administered. The foregoing analysis of Mr. J.'s problem was logically consistent with a faulty attribution process, and an attempt at reattribution was instituted on the third day of hospitalization. Although the psychiatric staff believed that the patient was schizophrenic, the diagnostic impression was changed from paranoid schizophrenia to adjustment reaction of adult life. Every effort was made to treat Mr. J.'s experience as normal instead of abnormal. He was assured that his problem was "real" and told that it would be helpful to measure the presence of the warm form. He was instructed to inform
CASE REPORT a nurse whenever he experienced it. At that time, the nurse would give him a penile strain gauge attached to a voltmeter. He was informed that this device would verify the presence of the form by measuring its arousal effects. After attaching the strain gauge to his penis, he and a male assistant would monitor the voltage indicator for movement. It was explained that several trials might be required before a reading was obtained. Also, videotaping with a special filtered lens might be necessary in an attempt to picture the warm form. Shortly after this explanation, Mr. J. indicated the presence of the form. He attached the strain gauge for IS minutes with no electrical potential obvious. During this time, it was observed that he lay on his side and moved his legs in a manner sufficient for penile stimulation. In discussing this episode, Mr. J. was impressed with the fact that the form was not recorded. He was then informed of his leg movements, and again he denied any history of masturbation and claimed ignorance of the movements. The feelings he had experienced were then reattributed to a buildup of sexual tensions as a result of abstinence and inadvertant masturbation via his leg movements rather than a warm form. The patient was very receptive to this explanation and stated it was sufficient to explain his problem with the form, which was now relabeled as a feeling. It was further explained that the unusual features of the experience, including its shameful quality, coupled with limited contact with male peers caused him to devise an "abnormal" interpretation of an otherwise normal experience. Subsequent to this session Mr. J. was granted a weekend pass, and he inquired as to the advisability of sexual intercourse. The therapist suggested masturbation as an alternative if the opportunity for heterosexual experience was unavailable. He was then discharged and considered himself to be cured. Three follow-up visits and several telephone contacts were conducted over the next 6 months. With the exception of one visit, these follow-up contacts were conducted primarily by the third author (Mastria), who had no contact with Mr. J. during his hospitalization. In each case a semistructured interview was conducted that surveyed his presenting problem on admission, other areas of functioning, and his mental status (affect, mood, thought organization, appearance, and so on). The results on each occasion were well within normal limits. The patient reported a return to his usual routine of work and social contact. There were several occur-
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rences of spontaneous erections that would have previously indicated the presence of the form. Additionally, during this time members of his family suggested that his experiences indicated the presence of demons and other supernatural forces. He actively resisted these interpretations and maintained their normal character. This view was reaffirmed during our contacts with him. Discussion Several noteworthy features of the present case include the nature of the deviant behavior, its treatment, and attribution therapy in general. The patient's delusional behavior was of short duration and relatively circumscribed. He manifested no concomitant problems other than the fear surrounding the ambiguity of the warm form and the apprehension of its presence. It does appear, however, that Ms difficulties were becoming increasingly troublesome as he began to incorporate disparate experiences and events into the belief of the warm form. These changes include attributing to the "object" characteristics such as movement, intent, vital existence, and controlling qualities. It is highly likely that Mr. J. would have continued to elaborate the delusional system with untoward and more severe consequences for his personal adjustment. The development of this delusional system is strikingly similar to the "lifelike" descriptions of experimental and presumably normal subjects observing the movement of inanimate objects. In one such study, Heider and Simmel (1944) found that movements of inanimate, geometric objects were described in anthropomorphic terms and causal relations were perceived. Rather than simply reporting movement, the objects were described as attacking, fleeing, and chasing one another within an animated, interpersonal context. It is apparent that unusual experiences such as that reported in the present case are more frequent in otherwise normal functioning people than heretofore believed. Goldstein's (1976) account of hallucinatory experiences provides a vivid example of unusual behavior associated with the fear of impending surgery. These and similar episodes appear to be transient and more directly related to immediate environmental antecedents. In contrast, deviant behavior not attributable to external influences is more likely to be viewed as indicative of personal (internal) psychopathology (Valins & Nisbett, 1972; Weiner, 197S). Like Goldstein's description, Mr. J. was also
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aware of the strangeness of his experiences and the difficulty others would have believing it. He also found it hard to understand—the warm form was his abstraction for these experiences. Less sophisticated persons might have attributed the experiences to "voodoo," a religiouslike phenomenon, or to a pathological process. At first glance, the circumscribed symptom set against a background of normal life experiences would not appear to warrant either hospitalization or a schizophrenic diagnosis. However, given the bizarre notion of the warm-form experience, its distressing effects, and his presence in an emergency room, the decision to admit Mr. J. was clearly justified. In the present case, the diagnosis of schizophrenia made on admission was tentative and later changed to conform with a behavioral analysis based on observations gained from interviews, ward behavior, and discussion with relatives. This formulation of the patient was based on the evaluation of both behavioral deficiencies and assets (Kanfer & Saslow, 1969). Thus, unlike Rosenhan's (1973) pseudopatients, the initial diagnostic impression of Mr. J. did not hinder the accumulation and interpretation of later observations. Less fortunate individuals displaying the same behavior are often labeled psychotic, which precludes innovative treatments like the one presented here in favor of the more traditional approaches of medication and therapy, which are designed to have patients renounce or suppress their behavior. There are several aspects of the treatment deserving comment. First, "antipsychotic" medication was not prescribed on a routine basis because the delusion, within the context of Mr. J.'s total behavioral repertoire, was not considered a psychotic symptom. Notwithstanding the very bizarre nature of the patient's report, the warmform experience was not viewed as an indication of an overall "thinking disorder." Second, the patient's experience was accepted as real, and only his interpretation was questioned. There was no attempt to suppress or deny his descriptions. This procedure runs counter to the standard clinical folklore that confronts the patient with reality (e.g., saying that there is no vagina independent of a woman) or attempting to control the verbal expression of delusions. For example, Wincze, Leitenberg, and Agras (1970) noted that instructions to decrease delusional behavior actually increased its rate. Also, whereas reinforcement of nondelusional talk did reduce the expression of delusions during therapeutic sessions, the display of this behavior in other settings remained unaffected.
The rapid and sustained change noted in the present case appears to speak to the efficacy of the reattribution intervention. Beyond this, the efficacy of specific components is speculative. The status of the therapists as experts, the acceptance of the patient's experience, the gadgetry employed, and the actual relabeling all appear important. Reports of attribution therapy consist of analogue studies on insomnia (Storms & Nisbett, 1970), tolerance of pain (Ross, Rodin, & Zimbardo, 1969), and the performance of avoidance behavior (Valins & Ray, 1967). The majority of these studies have utilized nonveridical and otherwise deceptive misattributions to induce or maintain changes in overt performance. For example, Ross et al. (1969) led subjects to believe that arousal was the result of irrelevant noise; Valins and Ray (1967) provided false heart-rate feedback to snake phobics; and Davison, Tsujimoto, and Glarus (1973) manipulated the expectancies of insomniacs who were taking sleeping medication. These reports document overt behavior change as a result of experimenter-communicated counter beliefs. However, attempts to replicate these laboratory findings have been uniformly negative (Borkovec, Wall, & Stone, 1974; Gaupp, Stern, & Galbraith, 1972; Kent, Wilson, & Nelson, 1972; Singerrnan, Borkovec, & Baron, 1976), and questions regarding their clinical utility have been raised. Specifically, Bandura (1969, p. 448) suggests that changes in avoidance behavior as a result of deceptive feedback will not persist without actual learning experiences. Similarly, Mahoney (1974, pp. 217-222) argues that simply relabeling problem behavior is insufficient; and when taken against the client's experiential background, therapist or experimenter misattributions appear incongruous if not blatantly ridiculous. In contrast to these reports using nonveridical manipulations, Wein, Nelson, and Odom (197S) found a cognitive relabeling procedure to be effective in reducing avoidance behavior. However, this manipulation consisted of a rational alternative that challenged existing faulty beliefs in snake phobics. As such, it was much more credible than manipulations typically employed in attribution analogue studies. Attribution therapy, like its parent attribution theory, is more implicit than explicit. It does not consist of specific therapeutic procedures. Rather, clinicians and researchers have been guided by the general assumption that the perception of causality influences behavior. Winett (1970) reviewed the implications of attribution
CASE REPORT theory for behavior therapy, and more recently, Kopel and Arkowitz (1975) urged a broader conception of behavior therapy that incorporated attribution principles. While affirming the relevance of attribution theory for clinical practice, Kopel and Arkowitz caution against the direct transfer of misattribution (nonveridical) manipulations from the laboratory to the consulting room. Their advice is based on the doubtful effectiveness of misattributions and the potential undermining of the therapeutic relationship that deception entails. Like Kelly's (1955) fixed-role therapy and Ellis's (1962) rational-emotive therapy, attribution therapy attempts to effect cognitive change. However, fixed-role therapy seeks to engender cognitive changes as a by-product of overt role performance, whereas both attribution therapy and rational-emotive therapy target cognitions directly. So, rather than focusing on overt performance, the procedure described in the present case targeted the patient's explanations and beliefs. Reports of experiences were accepted, yet the patient's interpretation was challenged by providing a more realistic alternative. The foregoing analysis, coupled with the observations of Kopel and Arkowitz (1975), strongly imply that the proper focus of attribution therapy lies in changing cognitions and not overt behavior by presenting veridical as opposed to deceptive information. Reference Note 1. Maher, B. Delusional thinking and cognitive disorder. Paper presented at the meeting of the American Psychological Association, Miami, September 1972. References Eandura, A. Principles of behavior modification. New York: Holt, Rinehart & Winston, 1969. Borkovec, T. D., Wall, R. L., & Stone, N. M. False physiological feedback and the maintenance of speech anxiety. Journal of Abnormal Psychology, 1974, 83, 164-168. Cameron, W. Paranoid conditions and paranoia. In S. Arieti (Ed.), American handbook of psychiatry (Vol. 1). New York: Basic Books, 1959. Davison, G. C. Differential relation and cognitive restructuring in therapy with a "paranoid schizophrenic" or "paranoid state." Proceedings of the 74th Annual Convention of the American Psychological Association, 1966, 177-178. Davison, G. C., Tsujiinoto, R. N., & Glarus, A. G. Attribution and the maintenance of behavior
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