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Multimodal Cognitive Behavioural Treatment
Historical Background
The chapter will describe the multimodal psychological treatment jointly developed over three decades by the Public Dental Service, Department of Psychology and the Institute of Odontology at the University of Gothenburg. The Clinic of Oral Diagnosis at the Dental School in Gothenburg was founded in 1968. One group of patients that was referred to the clinic included those that due to their dental fear could not manage conventional treatment and therefore requested treatment under general anaesthesia. However, it became clear fairly soon that the available resources for treatment of fearful dental patients with avoidant behaviour were not sufficient. In addition, the patients that were treated under general anaesthesia often received a more radical treatment where teeth were extracted than they would have through conventional treatment. Further, many patients came back with a new referral after a few years, with new treatment needs but with the same level of dental fear.
The First Treatment Method
In the early 1970s the head of the Clinic of Oral Diagnosis, Alf Öhman, contacted the Department of Psychology at Gothenburg University with a request for help with the treatment of patients’ dental fear. The focus shifted from primarily treating teeth in the fearful patient to treatment of fear in the dental patient. An assistant psychologist, Olav Bjercke, was assigned to work with dental phobics at the dental clinic. The treatment used was systematic desensitization according to the South African psychiatrist Joseph Wolpe’s method (Wolpe 1954, 1958). The patient was initially trained in progressive relaxation according to Jacobson (1970) and then when relaxation was achieved, a hierarchy of anxiety-triggering situations or objects was formed. Desensitization was established when the patient, in the relaxed state, envisioned each of the situations, from the ‘easiest’ to the most anxiety provoking. Each step in the anxiety hierarchy was repeated until relaxation replaced the anxiety reaction. The treatment was performed in a rest room at the dental clinic. The initial evaluation of the method is described in Bjercke and Plantén (1974).
The first progress of the psychological treatment was to move it into a room that was equipped as a dental treatment room, which facilitated exposure in vivo. At the same time the context was more consistent with the phobic situation, which was considered preferable in terms of generalization of desensitization. Although the early treatment results were encouraging, it was found that some patients had difficulty visualizing situations in the anxiety hierarchies. As a consequence, a variety of dental situations were recorded on video and exposure to the phobic situation could then be performed in vitro, via a monitor. The patient gave a sign to the therapist when anxiety and corresponding tension elevated and then exposure was stopped and the therapist gave a brief relaxation instruction before the video scene was repeated. To further enhance the exposure and make the scenes more realistic, the corresponding exposure scenes were also recorded in ‘first person’, with the camera in the position of the patient’s eyes.
However, after working with these scenes for some time it was noted that patients often did not signal the therapist when anxiety was elevated and thus exposure continued, despite arousal. Some patients stated that they did not comply with the instruction to signal, due to reluctance to bother the therapist. Since exposure during tension was inconsistent with the rationale of systematic desensitization, a remote control was introduced, which gave the patient the ability to stop exposure, without having to act through the therapist. It was assumed that this would lower the threshold for the patient. In this way, the procedure for exposure was automated to a large extent. When the patient discontinued the exposure, a short instruction to relax was automatically given, which in turn was followed by a repetition of the recently stopped scene. During the course of treatment, the patient was sometimes left to carry out the systematic desensitization on his/her own, during periods of 15–30 minutes.
Sven G. Carlsson, who had been Olaf Bjercke’s supervisor during the process of therapy development, succeeded Bjercke as clinical psychologist in 1976. Carlsson had previously treated dental patients suffering from temporomandibular disorder (TMD) with biofeedback training of the facial muscles. This technique was now combined with other parts of phobia treatment to not only insure that the patient was relaxed during exposure, but also as a pedagogical tool to teach relaxation (Carlsson, Linde and Öhman 1980). Furthermore, it was later discovered that for some patients, the use of biofeedback helped them to attribute the fear to something observable and controllable. Progressive relaxation in combination with EMG biofeedback was used successfully in other places at this time as a means for reduction of fear and muscle tension (Miller, Murphy and Miller 1978). Subsequent evaluations of psycho-physiological activation of dental phobic patients showed that the initial idea of a straightforward relationship between autonomic response and dental fear was simplistic (Carlsson et al. 1986). However, it was shown that positive changes in mood, combined with the gradual reduction of heart rate during therapy, predicted a good treatment effect (Harrison, Carlsson and Berggren 1985).
The Revised Treatment
The behavioural treatment, which in the 1970s had a focus on technology, broadened in the 1980s and the importance of a good relationship between therapist and patient was highlighted in parallel with a greater interest in the patient’s perceptions of self and the dental situation. Berggren and Carlsson (1984) showed that the dental fear treatment, which was now referred to as ‘a psycho-physiological treatment’, was effective and that 88 per cent of the patients who had undergone treatment could be treated by general dental practitioners. Besides these quantitative results, Berggren and Carlsson (1984) made four qualitative observations:
‘(1) Patients appeared to profit from an integrated therapy approach, where the psycho-physiological training was an obvious part of treatment. (2) The real-life experiences of treatment at the special clinic were important parts of the therapy. The patients almost invariably were very reluctant to initiate dental treatment and became amazed when they experienced how relaxed they were and how well they came through. (3) Patient responses to biofeedback training indicated that factors other than improvement in relaxation were in operation. The patients became aware of their tension and began to use the concept of tension in conceiving of their reactions to dentistry. Some were able to indicate this meant an orientation away from the irrational and negative picture they previously had of their problems with dentistry. (4) By continuously observing the tension level displayed by the biofeedback apparatus both patients and therapist received useful information about therapeutic change. Most patients indicated that the observation of decreases in tension while they repeated a scene had beneficial effects upon motivation and perceived competence’ (Berggren and Carlsson 1984: 491).
Berggren and Carlsson (1984) also made a post hoc analysis of the treatment process and concluded that treatment success is not accompanied by increased relaxation in all patients, in contrast to what was postulated by Wolpe (1954). They also discussed the reduction of fear in patients in terms of a cognitive reattribution of dental care, in accordance with Albert Ellis’s cognitive theories (Ellis 1962). Furthermore, Lazarus’s theories of appraisal and coping (Lazarus 1966) were used to understand the dental phobic patient’s sense of hopelessness before treatment and how exposure gradually led to an increased sense of competence. In other words, it is clear that cognitive factors were becoming an important part of the description of this behavioural therapy.
Following his doctorate in 1984, Ulf Berggren, together with his former mentor, Sven Carlsson, composed the hub of a clinically and scientifically successful cooperation that has lasted for over 25 years. Some studies have compared the relative effectiveness of behavioural and cognitive interventions (Berggren, Hakeberg and Carlsson 2000; Lundgren, Carlsson and Berggren 2006). Berggren and Linde (1984) showed that the clinic-based behavioural therapy (BT) is both more cost efficient and provides better treatment results than dental treatment under general anaesthesia, which was the option previously offered to dental phobic patients. Follow-up studies after 2 and 10 years respectively, showed that psychological treatment resulted in lower dental anxiety and higher dental attendance compared to a control treatment (general anaesthesia) (Berggren and Carlsson 1986; Hakeberg et al. 1993). Another essential result is that treatment of dental fear and deteriorated oral health gives significant positive side effects, such as less use of alcohol and reduced sick leave (Berggren and Carlsson 1986; Hakeberg et al. 1993). These results represent an important background to the fact that since 1999 the Swedish dental insurance has subsidized the treatment of dental phobia in those cases where it is carried out in collaboration between experienced dentists and psychologists (or the equivalent), in full accordance with ‘the Gothenburg model’. The treatment has also proved effective in comparison with other published treatments of dental phobia (Kvale, Berggren and Milgrom 2004).
The Current Treatment
Today, the dental phobia treatment is part of the Dental Fear Research and Treatment Clinic (DFRTC), a specialist unit associated with the Clinic of Oral Medicine in Gothenburg. The unit has three dentists, three dental nurses, one dental hygienist and two psychologists. At the DFRTC, patie/>
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