CASE HlST0RlF.

S AND SHORTER COMMUNICATlONS

213
Behav. Res. & Therapy. 197X. Vol 16. pp. 213-216.
0 Pergamon Press. Ltd. Prmled tn Great Bntam
Mo5-7Y67 7X~0601-WI 3502 (x1 0
Fading-A new technique in the treatment of phobias
(Received 26 September 1977)
Phobias have been subject to more research by behavior therapists than any other psychiatric disorder.
In 1975 Marks described more than 20 different techniques that have been developed for or used in the
treatment of phobias.
The technique to be described in this paper-fading-was first used by Barlow and Agras (1973) as an
alternative to aversive techniques for homosexuals. Originally the technique was designed to change the
stimulus control of sexual responsiveness by introducing or fading in heterosexual stimuli during periods
of sexual arousal elicted by homosexual stimuli.
One purpose of the single-case studies presented here was to explore the possibility of achieving a similar
result with phobic clients. In other words, the aim was to create a state of calmness and positive sensations
in the client and then to gradually fade in phobic stimuli. The hypothesis was that the stimulus control
of anxiety exerted by the phobic stimuli would decrease and finally be extinguished due to the antagonistic
effects of observing and imagining positive scenes.
A second purpose of this application of fading was to develop a technique for reducing phobic anxiety
which could give more control to the client than is the case in, for example, systematic desensitization.
METHOD
Apparatus
The apparatus for the fading procedure consisted of two Model S Kodak Carousel projectors and a variable
voltage transformer box. The fan and lamp circuits of the projectors were separated and the fan circuits
were connected to the transformer box so that the lamp of the first projector dimmed while the lamp of
the second projector simultaneously brightened as the control lever was pulled to either side. The projectors
were mounted above and behind the clients head and the slides were projected on the screen 2 m in front
of her, in such a way that they were superimposed on each other.
Procedure
The first step in applying fading procedure with phobics is to have the client produce 10 pictures that
are associated with pleasurable, positive feelings, and then to rank these pictures. Examples of such pictures
are photos of the clients wife or husband, children, pets, or whatever objects or settings are capable of
arousing a positive sensation iri the client. The second step of this method is to teach the client to imagine
the positive scenes depicted in the photos and at the same time experience a calm and positive feeling.
This is achieved by first letting the client look at a photo. The therapist then instructs her to close her
eyes and imagine that she really is in the situation in questios and to try to experience the positive feelings
associated with it. The client is also given home assignments to practice imagining these scenes with the
help of the photos.
In the third step the client ranks 10 slides of the phobic stimuli, for example snakes, spiders, rats, etc.
This is done by placing the slides on an illuminated slide sorting desk so that the client can look at all
slides at the same time.
The fading treatment per se starts by having the client sit in an armchair and look at the first positive
slide. The client is to imagine the situation projected on the screen and to try to achieve a positive sensation
while doing so. Instructions are then given to pull the lever to the right in order to increase the brightness
of the phobic slide, when the client feels ready to do so. The client has the control box accessible at all
times and thus can decide on both the brightness and the duration of the phobic slide presentation.
When the client feels too much anxiety while observing the phobic slide, the lever is pulled to the left,
thus brightening the positive slide again. While looking at the positive slide, the client imagines the situation
and tries to experience the calm and positive feelings associated with it. When ready to try again, the client
reverses the lever to the right again and brightens the phobic slide.
When the cleint has observed the phobic slide for 20sec or more, the degree of anxiety felt during the
trial is rated on a scale from 0 to 10. In order to proceed to the next slide in the hierarchy, two consecutive
trials of 20 set observation time with an anxiety rating of 3 or less, must occur. For the next phobic slide,
which is somewhat more anxiety-producing, we use the second positive slide. which is more attractive than
the first. In this way we reduce the risk of wearing out a particular positive slide.
Clients
The first client was a 23-year-old female who had been afraid of rats since she was 9. She could not
stay in places where there might be rats, and she had great difficulty reading books or newspapers, or
looking at pictures, films or television where rats might possibly appear.
214 CASE HI STORI ES AND SHORTER COMMUNI CATI ONS
Fadtng
II ?onforced R P +
practice
9
\
\ P
I
k
k
modeling
15
Sessions
Fig. 1. Clients A. Observation time 04, and selfrating of anxiety O----O on the film
test.
The second client was a 42-year-old female who had been confronted with a large rat at work in the
factory just prior to the start of therapy. She was so afraid that she had to leave work and was on sick-leave
until three weeks later when therapy was begun. Her phobia for rats dated back to her early teens.
Assessnrrnt
Both clients refused to be confronted with a live laboratory rat before treatment. In order to assess each
clientS degree of phobic behavior, the following tests were administered immediately after each session.
Picture test. IO slides of different rats and 10 slides of neutral animals were randomly ordered and presented
for 2Osec each. If the client felt too much anxiety she could press a button and the next slide would appear.
Film test. An 8mm film consisting of five different sequences with rats was presented. The film took
three minutes and ended with a sequence where a person handled a white rat and finally put it on his
head. In this test the client also had the opportunity to press a button and thereby end the presentation
of the film.
Dependent measures. After each test the client rated the degree of anxiety (from 0 to 10) experienced during
the test. The behavioral measures were the mean number of seconds she observed the phobic slides in the
picture test and the time elapsed until the button was pressed in the film test. Finally. the heart rate of
the second client was continuously monitored during both tests.
RFSULTS
Client A
In the film test client A (Fig. 1) stopped the film after approxtmately 1 min and felt very anxious
(mean = 9.0). During the fading treatment she observed the film for increasingly longer periods of time and
Baseltne Fadtng
5 10
Sessions
IF
telnforced R.P l
wactcce
o--9-9-9-9
15
r,
-5 6
_ F
- 5
5
- d
0 0 -0
-
!M IZH
Fig. 2. Client A. Mean observation time for the phobic slides 04 and selfrating of anxiety
O---O on the picture test.
CASE HI STORI ES AND SHORTER COMMUNI CATI ONS 215
could watch the entire film during the 10th session. However. there was only a minor decrease in her self-rating
during this phase (mean = 7.3) which is why reinforced practice (Leitenberg and Callahan. 1973) was applied
in the third phase and modelhng added in the fourth. This led to a decrease in her anxiety rating and
at the 18th session. she could watch the whole film without anxiety. Figure 2 shows the clients reactions
to the picture test. Her mean observation time during the baseline was 8.7sec and her rating of anxiety
averaged 6.0. During the treatment with fading. the observation time increased rapidly-the mean was
19.1 set-and the anxiety rating decreased to a mean of 2.6. In the third phase there was a further decrease
and in the fourth the client could look at all the pictures without anxiety.
At the end of treatment she was able to stay alone in a room with over 100 caged rats for three minutes
without undue discomfort. She could also be in places where she had earlier come in contact with rats
without experiencing anxiety. These gains were maintained at both the two-month and one year follow-ups.
Clienr B
In the film test (Fig. 3) client B observed one third of the film (mean = 64.7sec) during the baseline
phase.
Bascltnc Fadtnp
-IN
.
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6M
~~
.
1 2 3 L 5 6 7 e F-UP
6M
Sesstons
Fig. 3. Client B. Rating of anxiety (upper panel). observation time (middle). and heart-rate (lower)
on the film test.
She experienced maximum anxiety while doing this and her heart rate was 80.4 beats/min on the average.
compared to a resting pulse rate of 75 bpm. During the fading treatment she gradually increased the observa-
tion time and could watch the whole film at session 7. The mean for this phase was 150.2sec. At the same
time there was a sharp decrease in her self-rating and the mean for this period was 5.2. There was also
a slight decrease in her heart rate. giving a mean for the phase of 77.7 bpm.
The results for the picture test (Fig. 4) were much the same in regards to self-rating and observation
time. The means for the anxiety rating are 10.0 and 4.0 respectively, and for the observation time 11.6
and 18.9. The change in heart rate was very small. from 77.8 during baseline to 77.3 during the fading
period.
At a six-month follow-up this client could watch the whole film and all the phobic slides the maximum
time prescribed without any anxiety, and with a heart rate near her resting value (74 bpm). In an in t:iro
rest with a white laboratory rat in an open box she could put her hand on the inside of the box without
undue discomfort. This was done both after session 8 and at the follow-up.
DISCUSSION
The conclusion that can be drawn from these two single-case studies is that fading is a promising technique
in the treatment of animal phobias, and that the procedure is controlled by the client to a larger extent
216 CASE HISTORIES AND SHORTER COMMUNICATIONS
Baseline Fadi ng
.
I. 5 6 7 8 F-UP
6M
.
I 2 3 L 5 6 7 8 ,
0L -
; EO-
\

g 76
a3
Yk!!%I
.
72
1 2 3 4 5 6 7 8 F-UP
Sessions
6M
Fig. 4. Client B. Rating of anxiety (upper panel), mean observation time for the phobic slides
(middle), and heart-rate (lower) on the picture test.
in fading than in systematic desensitization. The advantages that we have found thus far with fading are
that the technique is not only simpler and but also permits more self-control. The disadvantage might be
that the specific phobic slides used restricts the degree of generalization more than is the case for systematic
desensitization. These predictions should be thoroughly investigated however before any definite conclusions
are drawn.
The fading technique is similar to systematic desensitization in that both start with a condition (relaxation
and positive scene observation respectively) that is supposed to be antagonistic to the anxiety response.
The phobic stimulus is then gradually inserted into that condition. At this stage it is premature to conclude
that observing and imagining positive scenes is a necessary part of fading. Perhaps it would work just as
well with only gradual exposure to the phobic slide which the client fades in. This in turn, would be similar
to other techniques for phobias, e.g. modelling and reinforced practice. This question is now being investigated
in our laboratory.
Much research needs to be done in order to ascertain if fading is a viable alternative to established behav-
ioral techniques for phobias. The most important question is whether fading can be effective for other kinds
of phobias, e.g. specific, social and agoraphobia. The technique will be of little use to the clinician if its
sole applicability is with animal phobics. a client category which according to Marks (1969) comprised only
37, of the phobics treated at Maudsley Hospital in London.
Acknowledgement-The help of Lars-Goran KIII and Anita Jerremalm who served as therapists is gratefully
acknowledged.
Psychiatric Research Center,
LARS-GBRAN &T
Uniuersiry of Uppsala.
Sweden
REFERENCES
BARLOW D. H. and AGRAS W. S. (1973) Fading to increase heterosexual responsiveness in homosexuals.
J. appl. Behaa. Anal. 6, 355-366.
LEITENBERG H. and CALLAHAN E. J. (1973) Reinforced practice and reduction of different kinds of fears
in adults and children. Behau. Res. Therap. 11, 19-30.
MARKS 1. M. (1969) Fears and Phobias. Heineman, London.
MARKS 1. M. (1975) Behavioral treatments of phobic and obsessive-compulsive disorders: A critical appraisal.
In Progress in Behavior Modification (Eds. M. HERSEN, R. M. EISLER and P. M. MILLER). Vol. 1. Academic
Press. New York.