Symptom Substitution: A Case Study

The debate continues over the relative merits of psychodynamic versus behavior therapy approaches for the treatment of specific behavior disorders. The psychodynamic tradition views maladaptive behavior as a sign of an underlying disorder and avers that even if a problem behavior is removed by a nondynamic intervention technique, another symptom will likely appear since the basic “cause” of the disorder remains unaffected. This symptom substitution hypothesis has been a strong theoretical argument against behavior therapy; however, a review of the literature reveals little empirical support for such a notion. The following report presents suggestive evidence for a case of symptom substitution.

Case Study. The subject was a 4 year, 5 month old female with an I.Q. of 119 identified as H. She was the only child of a middle-class family residing in a midwestern city of 60,000. The parents reported that H had been a habitual thumb sucker since birth, and they expressed a desire to reduce this behavior before she entered kindergarten. H appeared well adjusted to her social and physical environment, and no previous treatment had been attempted. The parents had taken a laissez-faire attitude hoping H would outgrow the habit.

Baseline data was recorded using a time sampling procedure over a one week period. During the second week, a behavior modification program was initiated, employing a graduated token system. H was given stars for not sucking her thumb for progressively longer time periods. Accumulated stars were rewarded with tangible reinforcers (candy) or special trips. Figure 1 shows the dramatic decline in thumb sucking behavior during the first treatment week. On the fifth day of that week, H had her first nocturnal enuretic episode. H had been toilet trained at 18 to 20 months of age and had not had any enuretic episodes since that time. During the second treatment week no thumb sucking behavior was noted (Fig. 1). There was, however, a marked increase in enuretic ep