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Order Number 9414208

Agoraphobia: The syndrome and internal life changes which

occur throughout treatment

Intoccia, Marianne

Elizabeth, Ph.D.

New School

for

Social

Research, 1988

Copyright 1994 by Intoccia, Marianne Elizabeth.

All

rights reserved.

U M I

300 N.

Zeeb

Rd.

Ann Arbor

Ml

48106


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A G O R A P H O B I A :

T H E S Y N D R O M E A N D I N T E R N A L

L I F E C H A N G E S W H I C H O C C U R T H R O U G H O U T

T R E A T M E N T

b y

M a r i a n n e

Intoccia

April 2 9 , 1 9 8 8

S u b m i t t e d to

T h e

G r a d u a t e Faculty of Political

and Social S c i e n c e of the N e w S c h o o l for Social

R e s e a r c h in partial fulfillment of

the

r e q u i r e m e n t

for

the d e g r e e of D o c t o r of

Philosophy.

Dissertation C o m m i t t e e :

Dr. J e r o m e B r u n e r

Dr. Herbert Schlesinger

Dr. Arnold

W i l s o n


6/142

Abstract

O ne

of

the

m o s t

intriguing

avenues

of

s t u d y

in

the

field

of

p s y c h o l o g y is t h e o n g o i n g

exploration of

m a n ' s v i e w of

himself

within

his world, the manner in w h i c h h e s h a r e s

this self

v i e w

within

his

social

network,

the capacity of this v i e w

to c h a n g e ,

and the

manner

in

w h i c h

this

v i e w

c a n come

to b e

the driving

force

in his

life. T h e s e

i s s u e s

w e r e explored b y

focusing o n

the internal life c h a n g e s that o c c u r

in

an a g o r a p h o b i c

population,

t h r o u g h o u t

the

c o u r s e of s u c c e s s f u l p s y c h o t h e r a p y .

A total of 1 4 patients

participated in

the treatment

p r o g r a m .

T h r e e patients wer e selected for an

in-depth

analysis. Patients

u n d e r w e n t a 1 2 - w e e k

cognitive

behavioral treatment p r o g r a m for

a g o r a p h o b i a .

Dependent

variable

measur es included

linguistic

analysis of

the

following utterances both pre- and

post-

treatment:

positive

a n d

negative statements,

positive

and

negative self-statements, self-as-agent, self-as-recipient,

self-as-agent

of s u c c e s s , and

self-as-agent

of failure.

Additional

d e p e n d e n t variable m e a s u r e s , t a k e n pre-, mid- and

post-treatment

included the F e a r Questionnaire, B e h a v i o r a l

Testing,

T h e B e c k

D e p r e s s i o n Inventory, and

T h e D e p r e s s i v e

E x p e r i e n c e Questionnaire. By the end of treatment, patients

reported

a n increase

in

their

mobility, as

well a s a d e c r e a s e in

felt

sympt oms

of anxiety and depression. T h e s e c h a n g e s w e r e

n o t e d in

the

more

traditional objective measur es

m e n t i o n e d

a b o v e . In

addition,

the

following c h a n g e s wer e o b s e r v e d

in


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patients'

verbalizations

b y the end of

treatment:

a n increase

in

the a c c o u n t i n g

of the a g o r a p h o b i a as

s o m e t h i n g determined,

controlled

or at

least

u n d e r s t o o d ;

an

increase in agentive

power

within o n e ' s

world; a d e c r e a s e in p a s s i v e recipiency in t e r m s of

failure

experiences, along

with an increase

in

a g e n c y

in t e r m s

of s u c c e s s experiences; a

d e c r e a s e in negative s t a t e m e n t s

a n d

negative

self-statements; a n d a n

increase

in

positive s t a t e m e n t s

and

positive self-statements. T h e s e c h a n g e s o c c u r r e d

in

reference to the a g o r a p h o b i a as well

as

to other life areas.

Qualitative

c h a n g e s in

expression wer e

also

n o t e d and discussed.

It s s u g g e s t e d that

successful

p s y c h o t h e r a p y c a n facilitate

patient

reformulation of their world v i e w s .

T h e instrumental

u s e

of l a n g u a g e in

this p r o c e s s is discussed, a l o n g

with

a

p r o p o s e d

v i e w of the

relationship

b e t w e e n l a n g u a g e , behavior and

intrapsychic

p r o c e s s e s .


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T A B L E

of C O N T E N T S

C h a p t e r

1.

A n Introduction

to

the

W o r l d of

the

A g o r a p h o b i c 1

2.

T h e

R e s e a r c h

Investigation 22

3. T h e Patients

S peak

3 6

4.

A g e n c y

...52

5.

What

A b o u t

D e p r e s s i o n ?

7 4

6.

In Q u e s t

of a N e w W o r l d V i e w 1 0 5

7. R e f e r e n c e s

1 1 3

8.

A p p e n d i c e s :

A . T h e Initial

Interview

1 2 1

B . T h e P o s t - T r e a t m e n t

Interview

122

ii


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L I S T of T A B L E S

1.

F e a r

Q u e s t i o n n a i r e R e s u l t s

- Population

1 2 3

2. A g e n t and Recipient

S t a t e m e n t s

- Sample 124

3. A g o r a p h o b i c and N o n - A g o r a p h o b i c S t a t e m e n t s

-

Sample 125

4.

Beck D e p r e s s i o n Inventory R e s u l t s - Sample 126

5. D e p r e s s i v e E x p e r i e n c e

Q u e s t i o n n a i r e -

Sample 127

6.

D e p r e s s i v e E x p e r i e n c e

Q u e s t i o n n a i r e -

Population 1 2 8

7. Beck D e p r e s s i o n

Inventory R e s u l t s -

Population 1 3 0

8. Positive and

N e g a t i v e

S t a t e m e n t s

- Sample

1 3 1

i i i


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C h a p t e r

1: A n

Introduction to

the

W o r l d

of

the A g o r a p h o b i c

T h e

field

of

P s y c h o l o g y

is

dedicated

to

the

s e a r c h

for

a

mor e c o m p l e t e u n d e r s t a n d i n g of man, the m o s t c o m p l e x and

sophisticated

of all

beings.

O u r s e a r c h h a s b e e n intense, the

s c o p e of w h i c h r a n g e s

f r o m

an in-depth exploration and

measur ement of specific a s p e c t s or

e l e m e n t s

of m a n ' s being, to

mor e

e n c o m p a s s i n g

a n d integrating

h y p o t h e s e s

regarding

his v e r y

nature. O ne

of the

m o s t intriguing,

a s

well

a s

controversial

avenues of

s t u d y is

the

o n g o i n g

exploration

of m a n ' s v i e w

of

himself

within his

world,

the

manner in

w h i c h

h e

s h a r e s this

self

v i e w within his social network, the

capacity of this

v i e w

to c h a n g e ,

a n d the manner in w h i c h this v i e w c a n come

to

b e the

driving

force in

his

life.

T h e

p r e s e n t exposition

is

a n a t t e m p t

to contribute to

this a r e a

of exploration.

Let u s

b e g i n b y taking

a

look

at

some of the

w o r k w h i c h h a s

already b e e n

d o n e

in this area.

It

eems m o s t fitting

to

b e g i n

o u r discussion with the w o r k of Sigmund

F r e u d

( 1 8 5 6 - 1939), o n e

of

the greatest

contributors within

the

history of modern

psychological

thought. Freud's

early

v i e w of m a n was

deterministic

in nature. H e did not believe that

free

choice or

p e r s o n a l

volition

h a d

a n y

role to

play

in t e r m s

of human

behavior. Instead, h e believed

that

all human behavior,

feelings a n d t h o u g h t s w e r e

d e t e r m i n e d

b y

the p o w e r f u l instincts

of

sex

a n d a g g r e s s i o n . In

addition,

h e

n o t e d that o n e ' s early

1


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2

childhood family constellation a n d parental influence h a v e

a n

irreversible

a n d

significant

i m p a c t

o n

the

s h a p i n g

of

personality.

In

fact,

a c c o r d i n g to his

psychoanalytic

theory,

the

basis of

personality is d e t e r m i n e d b y the

age of five or

six.

In

t e r m s

of

Freud's v i e w of p s y c h o p a t h o l o g y , symptoms a r e

motivated b y u n c o n s c i o u s

factors,

w h i c h s t e m f r o m childhood

experiences. T h e task of the F r e u d i a n psychotherapist

is to

u n c o v e r

t h e s e early life

e v e n t s

along with u n c o n s c i o u s u r g e s and

d e f e n s e s . O n c e the u n c o n s c i o u s

is

made

conscious,

the

individual is believed

able

to d e a l

with

internal conflicts. At

the point

of

successful resolution the patient's symptoms will

p r e su m a b l y b e eliminated.

F r e u d did recognize that the memory for early childhood

e x p e r i e n c e s is not veridical, but rather that it s colored b y

distortions g e n e r a t e d b y e a c h

patient's

individual d e f e n s e

s y s t e m (e.g., displacement, condensation, etc.). It s important

to note

h o w e v e r

that his early thinking s u g g e s t e d that c o m p l e t e

and successful

analysis could

r emove

t h e

distortions,

enabling

the original

i m a g e

to

e m e r g e .

A l t h o u g h a number of Freud's

v i e w s

h a v e not b e e n c o n f i r m e d

b y

moder n

scientific

research,

his

contributions h a v e

h a d

a

far-

r e a c h i n g a n d p r o f o u n d i m p a c t within the

field

of p s y c h o l o g y .

H i s v i e w s p r o v o k e d

much

t h o u g h t within

the

field,

a n d h e

h a d

many

followers. Erik

Erikson ( 1 9 0 2 -

)

was

o n e

s u c h follower.


12/142

3

Erikson felt

that his own v i e w s w e r e a

mer e extension of

Freud's, although

it

s

quite clear

that some of his i d e a s

represent a

significant

departure f r o m

traditional

psychoanalytic thought.

o u l d

like

to

briefly

d i s c u s s

some

of

his ideas,

a s

e e t h e m a s h a v i n g

made

a

significant

i m p a c t

o n

o u r

current

u n d e r s t a n d i n g of the d e v e l o p m e n t of m a n ' s v i e w s of

himself

within

his world.

Erikson did a c c e p t

many

of the

tenets of

traditional

psychoanalytic

theory

(e.g., the u n c o n s c i o u s , biological

d e t e r m i n i s m ,

etc.). A c c o r d i n g to Erikson h o w e v e r , personality

is

not

d e t e r m i n e d

b y

a g e five or

six as

F r e u d believed, but

rather continues o n in t e r m s of its d e v e l o p m e n t t h r o u g h o u t o n e ' s

lifetime.

He described ( 1 9 6 3 ) "Eight S t a g e s of M a n " w h i c h span

f r o m birth

t h r o u g h to late

adulthood. In addition, Erikson

stressed

that

our parents are

not

t h e

only

p e o p l e

who

h a v e

a

significant effect o n our d e v e l o p m e n t , but

that we

a r e likewise

influenced b y a number of significant others, including

siblings

and peers,

individuals associated with

many

social institutions,

s u c h

as

s c h o o l s a n d colleges, a s well

a s professional,

social

and political organizations.

He

a g r e e d

with

F r e u d

that man h a s

many internal conflicts

to d e a l with.

H o w e v e r , h e

felt

that

t h e s e conflicts w e r e

psychosocial,

rather than

p s y c h o s e x u a l .

W h i l e Freud's f o c u s

was

o n t h e exploration of u n c o n s c i o u s

m ent a l life

a n d

the

retracing

of

early life e v e n t s as t h e y


13/142

contribute to the d e v e l o p m e n t

of

adult p s y c h o p a t h o l o g y (i.e., a

mor e

archeological

point

of

view),

Erikson's

f o c u s

was

o n

m a n ' s

potential to o v e r c o m e the p s y c h o s o c i a l crises h e e n c o u n t e r s

a l o n g

life's w a y .

Wh at w e

s e e

h e r e is the optimistic v i e w that

man

c a n a c h i e v e control o v e r his

life,

as

well

a s

over

t h o s e

things

that h e e x p e r i e n c e s t h r o u g h o u t his lifetime.

It s

interesting

to note that a close reading of Freud's

later

w o r k ( 1 9 3 7 )

s u g g e s t s

that

h e

too

was

m o v i n g

in

the

direction of believing that

man h a s some

f o r m of

influence

c o n c e r n i n g

who

h e is, or

who

h e becomes t h r o u g h o u t his

lifetime.

He seems

to s u g g e s t the i d e a that m a n

"constructs"

his

experiences.

T h a t is, h e s u g g e s t s

that man a d d s his own

perceptions to t h o s e things w h i c h a r e actually h a p p e n i n g

a r o u n d

h i m .

In this s e n s e then, we may

n e v e r

b e able to b e true

to

the

field of a r c h e o l o g y a n d

dig up past e v e n t s a s

t h e y h a v e

actually

occurred. What we c a n a c h i e v e is contact with w h a t t h e

memor ies of t h o s e e v e n t s

h a v e

come to

mean

to

us

within o u r

world.

T h e s e v e r y

i d e a s

h a v e been

the f o c u s

of much moder n

d a y

thinking within the field of psychoanalysis. T h r e e

individuals

who are

responsible

for a great d e a l

of this

w o r k are G e o r g e

Klein (1973), R o y S c h a f e r

( 1 9 8 3 )

and D o n a l d Spence (1982). Klein

s u g g e s t s

that the p s y c h o a n a l y s t is not engaged in a n

archeological venture, but rather

that

the

psychoanalyst's role


14/142

5

is to b e

mor e

active in facilitating the

construction

of a m o r e

consistent a n d

productive

a c c o u n t i n g

of the patient's

life

e x p e r i e n c e s .

Spence d i s c u s s e s

some of

t h e same ideas.

In doing so,

h e

differentiates

"historical

truth" f r o m "narrative truth."

"Historical truth"

is

defined (p.

3 1 ) as: "concrete

objects and

e v e n t s that happened at

some

earlier period and

that c a n b e

b r o u g h t f o r w a r d to

the

present."

"Narrative

truth" o n the other

h a n d is defined as: "the criterion w e u s e to d e c i d e when a

certain e x p e r i e n c e

h a s

b e e n c a p t u r e d to o u r satisfaction; it

depends on

continuity

and

closure a n d

t h e

extent

to w h i c h

the

fit of the p i e c e s t a k e s o n

an

aesthetic

finality.

Spence

d i s c u s s e s

the power of "narrative truth," noting that s u c h

constructions are

not

only responsible for giving

s h a p e

to the

past, but

in

addition,

h a v e

the

potential

for

actually

b e c o m i n g

the

past.

In

this s e n s e

then, historical

truth is inaccessible,

and it s narrative truth

w h i c h

becomes not only

accessible,

but

also

utilizable.

Spence

states:

O n c e

e x p r e s s e d in

a

particular

set of s e n t e n c e s , the memory

itself h a s

c h a n g e d ,

a n d the

patient

will probably n e v e r

again

h a v e

quite

the

same

v a g u e ,

non-specific

and

unspoiled

impression.

T h u s ,

the v e r y

act of talking

a b o u t the

past

t e n d s to

crystalize it

n

specific but somewhat arbitrary

l a n g u a g e , a n d this l a n g u a g e s e r v e s

in

turn to distort

the


15/142

early memory. M o r e precisely, the new description becomes

the early memory.

In

a v e r y real s e n s e , m e m o r i e s

are

b e i n g

created in the c o u r s e of analysis... (p. 92)

S c h a f e r ( 1 9 8 3 ) makes

a

similar

point, e m p h a s i z i n g that the

analyst a n d

the

a n a l y s a n d embark o n a joint effort, a s t h e y

retell the past, t h u s d e v e l o p i n g the

narrative

accounting

of

events. H e

states:

In

psychoanalysis, the versions

of

significant

e v e n t s

c h a n g e a s the

w o r k

progresses, a n d with t h e s e c h a n g e s g o

c h a n g e s in w h a t is called the e x p e r i e n c e of t h e s e events.

T h e

analyst n e v e r t a k e s

i m m e d i a t e l y available

or

e m p h a s i z e d

subjective e x p e r i e n c e s

as the final

or

definitive

version

of

anything,

for

the analyst v i e w s that e x p e r i e n c e a s

a l w a y s

b e i n g constructed

or reconstructed; it a n b e

e n c o u n t e r e d

only in explicit or

implicit narrative

a c c o u n t s . (p. 1 8 6 )

S c h a f e r

adds that

t h e s e

narratives usually

become f o c u s e d

o n the a n a l y s a n d as "agent" rather t h a n "victim." He states:

T h e great extent to

w h i c h

the a n a l y s a n d

is

u n c o n s c i o u s l y

the

a g e n t

or author

of

his/her

life

g e t s

established

b e y o n d

doubt. T h e a n a l y s a n d emerg es

a s

d e e p l y implicated in

his/her

suffering e v e n ifnot

a s

the only

a g e n t

or

s o u r c e

of

the

pain. O n this basis,

t h o u g h

not in a n y

strict


16/142

7

se q u e n c e ,

the

a n a l y s a n d is better

able

to envision a n d

p u r s u e

desirable alternatives

to

t h o s e

a s p e c t s

of

existence

that heretofore

a n d consciously wer e passively

suffered or

at

least

p e r p e t u a t e d in

a n unquestioning

m a n n e r , (p.

1 9 1 )

A n additional

point that is

worth noting

is that it

as

b e e n a r g u e d

(Ricoeur,

1 9 7 7 ; Schafer, 1 9 8 3 ;

and S p e n c e , 1 9 8 2 )

that it s

not

important

that

we

discover

patient e x p e r i e n c e s a s

t h e y

actually

occurred. Rather, the

f o c u s

of

therapy

s h o u l d

b e

o n

the m e a n i n g

or

interpretations

the individual

h a s

a s s i g n e d to

t h e s e experiences.

In

v i e w

of

all that

h a s b e e n t h u s far

stated,

m y f o c u s h a s

b e e n o n t w o m a j o r ideas.

T h e

first is

that

man d o e s not

m e r e l y

r e s p o n d

in

some deterministic manner to t h o s e things w h i c h h e

e n c o u n t e r s

in

his

life,

but

rather

that

h e a d d s

s o m e t h i n g

to

t h e s e experiences. This i d e a is not n e w , nor is it imited to

the

field

of psychoanalysis. T h e power of

m e n t a l

activity

h a s

b e e n discussed, among many others, b y P a v l o v ( 1 9 5 7 ) in

his

discussion of the " S e c o n d S i g n a l

S y s t e m "

and

" S e m a n t i c

Generalization;"

V y g o t s k y

( 1 9 6 2 )

in his

discussion

of the " Z o n e

of

P r o x i m a l D e v e l o p m e n t ; "

b y attribution theorists

including

B e r n

(1972), H e i d e r ( 1 9 4 4 , 1958),

Kelly (1972), S c h a c h t e r (1964),

S c h a c h t e r

a n d S i n g e r

(1962),

and S e l i g m a n

(1979);

b y B r u n e r

( 1 9 8 6 ) in his presentation o n

the "Narrative Mode

of T h o u g h t , "

and ( 1 9 8 7 )

in

his conceptualization of "autobiographical


17/142

8

narratives," b y Goodman

( 1 9 8 4 ) in his

discussion

of " W o r l d

M a k i n g ; "

a n d

b y cognitive learning therapists s u c h as Beck

(1976), Ellis (1971),

a n d

Meichenbaum ( 1 9 7 7 )

in

their v i e w s o n

c o n s c i o u s t h o u g h t

playing

a n important role

in

mediating both

instrumental a n d e m o t i o n a l behavior.

T h e s e c o n d i d e a that a v e b e e n focusing o n is

that

there

a r e

limits

to

how much we c a n

trust

the

a c c u r a c y of our

memor ies

of

the

past. It s important to note that this i d e a

is s u p p o r t e d b y

much

of

the w o r k

w h i c h h a s b e e n

c o n d u c t e d in

t e r m s of human memory. Let us review some of this w o r k .

R e s e a r c h

into

the field

of

human

memory

was

l a u n c h e d b y

E b b i n g h a u s in

1 8 8 5 .

He e m p h a s i z e d

that given

the

complexity of

memory (i.e.,

that

memory c a n

b e influenced

b y

s u c h things a s

interest,

m o o d s ,

expectations),

it s

important

to study

tractable a s p e c t s

u n d e r

tightly controlled conditions. It s

certainly to the

credit of E b b i n g h a u s

that 1 0 2 years later many

of his

findings still hold up

u n d e r scientific scrutiny.

Bartlett

( 1 9 3 2 )

c h o s e to

study

memory via a different route

(i.e., h e a t t e m p t e d

to

s t u d y memory

in

e v e r y d a y life). B e g i n n i n g

in

the 1960's, a n d e v e n

m o r e

strongly b y the mid-1970's,

his

e m p h a s i s o n

studying

the complexity

of

human memory

as

it

exists

h a s b e e n the

p r e d o m i n a n t

mode

of study

within the

field.

Bartlett and mor e recently N e i s s e r

(1967),

among others

(e.g., Bransford and Frank, 1 9 7 1 ;

Hunter,

1 9 5 7 ;

Loftus

and P a l m e r ,


18/142

9

1 9 7 4 )

h a v e e m p h a s i z e d

that memory

is

not a

p a s s i v e process, but

rather that it s an

active

constructive process. Wha t

h a s

b e e n

s u g g e s t e d

is

that

the

m e m o r i a l

p r o c e s s of retrieval is very

intimately

tied to the

p r o c e s s

of s u c h things as

c o m p r e h e n s i o n ,

rehearsal a n d

organization

during initial acquisition; updating

a n d

a c c o m m o d a t i v e distortions

of the original memor y; as well

as

confusion

and/or

blurring together of

m e m o r i e s . T h u s , it

a p p e a r s that w h a t o n e currently holds

in

memory is the world a s

personally

e x p e r i e n c e d

(i.e.,

interpretations

b a s e d

o n

expectations,

bias,

prejudices, etc.).

T h e s e

things

are

important

not

only in t e r m s

of the

way

information

is

stored

in

memory, but t h e y are also important in t e r m s

of information

retrieval.

A l t h o u g h w e are

not at a

point w h e r e

we c a n

comfortably

s a y

that

w e

h a v e

c o n c l u d e d

o u r

w o r k

in

this

area,

w e are

certainly

at a point w h e r e

we

c a n

dr aw

the interim conclusion that

there

are

definite

limits to

how much we

are able to rely o n

our

memory

as being a n accurate representation of o u r past. It s

certainly

clear

that memory is a v e r y significant

e l e m e n t in

t e r m s of

the

d e v e l o p m e n t of o n e ' s v i e w

of

self,

a s it s memory

w h i c h

allows us to e x p e r i e n c e a contiguity of o u r present with

o u r past. Certainly, a n y limitations

in

t e r m s

of

the

a c c u r a c y of memor y, t h e n

w o u l d

h a v e

serious

implications for

the

d e v e l o p m e n t

of

a v i e w of

self.


19/142

Wh at is

this

c o n c e p t

of

"self"

w h i c h

a v e t h u s

far

b e e n

alluding

to?

It

s

important

to

note

that

some

r e s e a r c h e r s

and

theoreticians reject

the

i d e a and/or label

of "self."

Hazel

M a r k u s

(1983), consistent

with the

v i e w s of others, s u c h

as

Kelly

( 1 9 5 5 )

a n d

Epstein (1973),

h a s

bravely provided us with a

definition

of

self

w h i c h is not only conceptually

helpful,

but

in addition

is amenabl e to

research.

M a r k u s

v i e w s

self

a s

a set

of cognitive

structures or

schemas that h a v e the

capacity

to

organize,

direct,

c h a n g e a s

well

as integrate one's

functioning. A c c o r d i n g to M a r k u s ,

" S e l f - s c h e m a s

d e v e l o p

f r o m

the

r e p e a t e d

similar

categorization a n d

evaluation of b e h a v i o r

b y oneself and others, and result

in

a clear i d e a

of the

kind of

p e r s o n

o n e

is in a

particular

a r e a of behavior." S h e n o t e s that

t h e s e

structures are not

static,

but

rather, they

are d y n a m i c

growing

and

c h a n g i n g

in

r e s p o n s e

to

b o t h

internal

and

external

experiences.

o u l d like to stress a fe w things w h i c h are

of

p a r a m o u n t

i m p o r t a n c e in t e r m s

of

this

view.

First of

all, M a r k u s e s p o u s e s

a constructivist

v i e w of the self. T h a t

is,

as individuals

we

are actively involved

in

the p r o c e s s

of the


of

self.

S e c o n d l y ,

other p e o p l e are

also

involved in this

d e v e l o p m e n t . Clearly, we r e s p o n d to the evaluations

and

fe e d b a c k others give u s

a b o u t ourselves. W h e n

self

and

other

evaluations c o n v e r g e ,

a consistently

fortified s e n s e of

self

e n s u e s . W h e n

self

and other evaluations

diverge,

it s the


20/142

responsibility of the

self to

effectively

d e a l with t h e s e

o p p o s i n g

v i e w s in

a

way

that

is

a c c e p t a b l e

to

the

self.

At

times, this will involve the mobilization of one's d e f e n s e s , s o

that the others'

evaluation

is denied, ignored, or v i e w e d as

unimportant.

At other times, t h e s e

evaluations c a n

lead

to

a

c h a n g e

in

one's

v i e w

of

self.

At

a n y rate, m a n ' s

participation

within

a

verbal,

transactional world is v i e w e d to play a large

role

in

t e r m s

of

the d e v e l o p m e n t

of

self. B r u n e r ( 1 9 8 2 ) w o u l d

a g r e e with this.

He

states:

...Iw o u l d

like

to

u r g e that

it

s

precisely

in

the

negotiation of intended m e a n i n g

that

the

self

is fo r m e d

in

s u c h a

way that

we

c a n

relate

o u r s e l v e s

not only

to the

others i m m e d i a t e l y a r o u n d

us...particularly

to

the family

( a n d

its m y t h s

a b o u t

social

reality)...but also to the

b r o a d e r culture into

w h i c h

w e m u s t eventually

move.

It s

in this p r o c e s s that we create the internal

scripts in

t e r m s

of w h i c h w e interpret the

transactional

world in

w h i c h w e move

a s

socialized

human

beings, (p. 5 )

'Talking things through,'

operating conversationally

in

the

context of real

events,

m a k i n g intentions

clear

and

learning to

assign

flexible interpretations to a m b i g u o u s l y

e x p r e s s e d intentions...these are the instruments for the

forming of the

Self,

not the only o n e s , but

indispensable


21/142

12

o n e s . T h e y provide

the

means for entering

a n d

m a s t e r i n g

the

s c e n a r i o s

that

o n e

m u s t

c o p e

with,

or

if

not,

avoid.

(p. 2 0 )

B r u n e r ( 1 9 8 2 ) g o e s o n to a r g u e

that

transactional

relationships are of p a r a m o u n t i m p o r t a n c e in

this

d e v e l o p m e n t .

A s s u c h , the m o r e effective families, marriages,

friendships and

other

significant

relationships in offering

a n opportunity for

the

" m a s t e r y

of

the

arts

of

e x c h a n g e , "

a s

well

as

in

providing

the

n e c e s s a r y medium

for s u c h an e xc h a n g e ,

the

less needed will

b e

psychologists and

psychiatrists for interventions at a

later

point

in time.

After reading Bruner,

o n e

is

left

with the i m p r e s s i o n that

although

a healthy v i e w of self relies

v e r y

strongly

u p o n

the

family

and

other

significant

relationships,

the

therapeutic

relationship

c a n become

the

correcting

medium

for t h o s e

important e l e m e n t s w h i c h

may h a v e

been missing within p r i m a r y

relationships. S uc h is a n uplifting view, as itoffers h o p e

for

the many

individuals with

a

history of i m p o v e r i s h e d

relating,

and a thwarted

v i e w of t h e m s e l v e s .

Clinical populations

a b o u n d

with s u c h individuals.

O ne specific

clinical

population in

w h i c h t h e s e i d e a s seem

very

strongly to

apply

is that of a g o r a p h o b i c s .

A l t h o u g h

the

t e r m " a g o r a p h o b i a " h a s

b e e n

a r o u n d

since its

initial

u s e b y

W e s t p h a l in

1 8 7 1 ,

it s only within

the

past decade or

s o

that


22/142

13

the

nature

a n d treatment of this psychiatric disorder is being

m o r e

fully

u n d e r s t o o d .

Presently,

a g o r a p h o b i a is

classified

as a s e p a r a t e category

in

the A m e r i c a n Psychiatric Association's

3rd Edition ( R e v i s e d )

of the

Diagnostic and Statistical Manual

of

M e n t a l Disorders

( D S M

III-R, 1 9 8 7 ) .

T h e term,

w h i c h

was derived f r o m the Gr eek

root

"agora," m e a n i n g a s s e m b l y ,

the

place of a s s e m b l y , and

m a r k e t place is

u s e d

d u e to

the

quite consistent clinical

features

of

this

very c o m m o n a n d highly distressing p h o b i c

disorder. Generally speaking, the disorder is characterized

b y

a fear of b e i n g alone, or g o i n g out

into

public p l a c e s ( o p e n a n d

c r o w d e d places), w h e r e e s c a p e might b e

difficult, or

assistance

not

available in the event of sudden helplessness.

T h e

individual

d e v e l o p s

a pattern of actual

a v o i d a n c e

of t h e s e

feared

situations.

T h e

fears

may

or

may

not

b e

a c c o m p a n i e d

b y

p a n i c

attacks, w h i c h according

to

the

D S M

III-R,

include at

least four of the

following

symptoms: dizziness, vertigo, or

u n s t e a d y feelings;

feelings of unreality, paresthesias; hot

or

cold flashes; sweating;

faintness;

trembling or

shaking;

fears

of

dying,

going

crazy, or d o i n g s o m e t h i n g uncontrolled during a n

attack.

V e r y often, anxiety attacks

are

e x p e r i e n c e d early in the


of the disorder. T h e

individual,

in

a n attempt

to

make s e n s e of the symptoms,

attributes t h e m

to

t h o s e

p l a c e s or


23/142

things w h i c h w e r e occurring

during

the time

of

the

attack.

T h e

individual d e v e l o p s

a n

anticipatory

fear

of

experiencing

t h e s e

attacks a n d will

thus

set u p a n a v o i d a n c e pattern

w h i c h

is

centered a r o u n d t h o s e places and

things

w h i c h h a v e b e e n

associated with the attacks.

Left untreated,

the attacks often

continue and the fears b e g i n to generalize,

resulting

in

increasing d e g r e e s

of incapacitation. T h e anxiety,

the fears

a n d

the a v o i d a n c e b e h a v i o r s

come

to d o m i n a t e the

individual's

life.

In

the

m o s t e x t r e m e

cases,

t h e s e

individuals

c a n

become

s o

p r e o c c u p i e d

with their illness that t h e y h a v e little time or

e n e r g y

left

to

f o c u s

o n anything

else.

In addition

to

all

of

this, there are many

n o n p h o b i c

symptoms w h i c h

h a v e

b e e n f o u n d to b e

associated with

a g o r a p h o b i a . O n e s u c h

sympt om

is that

of

d e p r e s s i o n (Bowen &

K o h o u t , 1 9 7 9 ; M a r k s ,

1970).

A g o r a p h o b i c s

frequently report

feeling d e p r e s s e d ,

irritable

and hopeless. Many of t h e m readily

note

that t h e y e x p e r i e n c e

frequent

crying spells,

a

lack of

interest

in

their w o r k

and

previously

e n j o y e d activities,

difficulty

with

sleep,

a s well as suicidal thoughts. T h e y often

present with feelings of helplessness, depletion and being

unloved. It s interesting to note that

in

1 9 7 7 , Buglass,

Clarke,

H e n d e r so n , K r e i t m a n

a n d Presley

f o u n d

d e p r e s s i o n

strongly e v i d e n c e d

in

3 0 % of their

s a m p l e ,

and minimally present

in

a n o t h e r

1 7 %

of their subjects.

In

addition, Bowen and K o h o u t

(1 9 79 ) f o u n d that the incidence rate

of

primary affective


24/142

15

disorders

was

a b o u t

9 1 % for the

5 5 a g o r a p h o b i c s in

their

study.

A n o t h e r

v e r y important

sympt om w h i c h

a p p e a r s

to b e related

to

a g o r a p h o b i a

is that

of

depersonalization

( M a r k s , 1 9 7 0 ;

M a t h e w s , G e l d e r

&

J o h n s o n , 1981). A g o r a p h o b i c s

frequently

report

a

t e m p o r a r y

feeling of strangeness,

unreality,

or

d i s e m b o d i m e n t . T h e

individual may

report the e x p e r i e n c e of

a p p a r e n t

perception of

himself f r o m a distance, as

t h o u g h h e

w e r e

cut off or

far

away

f r o m the reality

of

his e n v i r o n m e n t .

He

may feel

"mechanicaland/or

not in

c o m p l e t e

control

of

his

functions and/or actions. B u g a s s et

al.

( 1 9 7 7 ) report

a

3 7 %

incidence rate

of

this

sympt om

among

the

a g o r a p h o b i c s in their

study.

In w o r k i n g with a g o r a p h o b i c s

for

the past s e v e n

years,

h a v e become awar e of h o w distraught s u c h

individuals

really

are.

Initially,

t h e s e patients

a p p e a r

to

h a v e

a

lack

of

u n d e r s t a n d i n g a s to the

origin

of

their symptoms.

T h e only

thing they

are

s u r e of is that t h e y

e x p e r i e n c e

t h e s e intense

attacks of anxiety

o n

m o s t o c c a s i o n s

when

t h e y

are

a l o n e

and/or

away f r o m their h o m e s . Nothing

a p p e a r s

to

b e effective

in t e r m s

of

controlling

the anxiety.

Patients s p e a k invariably

of

their

essential

helplessness, d i s c o u r a g e m e n t , and fear of losing

control. "I'm afraid of g o i n g crazy," I fear I'm losing m y

mind,"

"I'm

afraid

I'm

going to faint," are

some of the

m o s t

c o m m o n s t a t e m e n t s

made

b y the patient. T h e

patient e x p e r i e n c e s


25/142

16

himself/herself a s being very fragile.

A l t h o u g h

h e / s h e may b e

relaxed

a n d

relatively

able

to

care

for

himself/herself

and

his/

h e r

needs at one moment, the

next

m i n u t e might

bring with

it

that feared uncontrollable panic.

W i t h

s u c h a

fragile

s e n s e of

himself/herself, the individual

b e g i n s

avoiding m o r e a n d m o r e of

the activities a n d situations

previously

e n j o y e d . H e / s h e b e g i n s

to feel

that it

s

only

the s u r r o u n d i n g

of

his/her

home w h i c h

potentially offers any type of protection. W h i l e

at

home, it

is a c o m m o n o c c u r r e n c e

that

the

felt

symptoms of d e p r e s s i o n

and

depersonalization intensify. In

many

c a s e s , the individual

b e g i n s to e x p e r i e n c e

anxiety e v e n

wh en s u r r o u n d e d b y

the

familiarity

of

his/her

own

h ome.

At this point, in a

state

of

depression, many individuals s e e k treatment.

W h o

is this p e r s o n

they h a v e

become? From w h a t

a v e


in a

clinical setting,

family members

often

lack

as

much u n d e r s t a n d i n g a s d o e s the patient. O f te n the p e r s o n

receives the messag e that h e / s h e is

b e i n g

silly, immature, or

p e r h a p s h e / s h e

really

is "crazy." T h e patient is often

involved

in a n infinite number

of

t h e s e transactions. S l o w l y his/her

v i e w

of

himself/herself

a p p e a r s to become e v e n further depleted.

At this point,

many

individuals

report h a v i n g

great

difficulty

c o m m u n i c a t i n g with

a n y o n e .

I feel s o inferior," are the w o r d s

s o often h e a r d o n a n initial interview

H o w d o e s this illness

d e v e l o p ?

Wh at differentiates t h o s e


26/142

17

who

d e v e l o p

the

disorder f r o m t h o s e

who

do

n o t ? T h e question of

etiology

h a s b e e n

explored

f r o m

a

great

number

of

a v e n u e s .

Constitutional, cognitive, and

e n v i r o n m e n t a l

factors h a v e all

been the f o c u s of investigation. O n e

a r e a

of r e s e a r c h h a s b e e n

the

patient's family

of

origin.

Goldstein

a n d

S t a i n b a c k ( 1 9 8 7 )

state that as

a

result of

all of their

w o r k

with

h u n d r e d s of

a g o r a p h o b i c s , they

h a v e

b e e n

able

to

identify

six

categories

within

w h i c h

m o s t

a g o r a p h o b i c s

are reared. T h e s e include:

1) Their

parents

over-protected

t h e m ;

2) T o o much

responsibility

was thrust

upon

t h e m

b e c a u s e they

h a d

to

take c a r e

of

a m o t h e r or father who

was

chronically ill,

alcoholic,

or

a g o r a p h o b i c ; 3 )

Their

parents' b e h a v i o r

was

unpredictable

b e c a u s e

t h e y

wer e

alcoholic,

a g o r a p h o b i c

or

psychotic; 4 )

Their

parents

w e r e

perceived to b e

overcritical, often

impossible

to

please;

5 )

T h e y o u n g s t e r s

either

felt threatened

b y or wer e

actually subjected

to

the

p r e m a t u r e loss of or separation

f r o m o n e

or both

parents;

6 ) T h e y o u n g s t e r s

w e r e

sexually a b u s e d ,

usually

b y an adult

m a l e in the family.

Often

the

a b u s e r

was

intoxicated.

(p. 1 3 )

In addition, t h e s e authors

h y p o t h e s i z e

that a g o r a p h o b i a

o c c u r s

m o s t

often

during

t h o s e

t i m e s of

i n c r e a s e d interpersonal conflict.


27/142

It s interesting to note that additional studies

c o n d u c t e d

in

this

a r e a

offer

some interesting

results.

F o r

e xa m p l e ,

W e b s t e r

( 1 9 5 3 )

reports

that the

fathers

of a

studied

population

of a g o r a p h o b i c s

w e r e

m o r e

frequently

a b s e n t f r o m the

family home than w e r e fathers of other

clinical

populations.

Snaith ( 1 9 6 8 ) f o u n d that the

family b a c k g r o u n d s of


w e r e m o r e unstable t h a n the

b a c k g r o u n d s of other phobics.

Similarly, B u g l a s s et al. ( 1 9 7 7 ) f o u n d

that

the families of

a g o r a p h o b i c s included a

significantly

greater number of a d o p t e d ,

or step-relatives. In addition,

some studies ( S o l y o m ,

B e c k ,

S o l y o m & H u g e ,

1 9 7 4 ; S o l y o m , Siberfeld

&

S o l y o m , 1 9 7 6 ;

W e b s t e r , 1 9 5 3 ) report that there a p p e a r s

to

b e a

t e n d e n c y

for

m o t h e r s of a g o r a p h o b i c s to b e m o r e

overprotective than t h o s e of

other g r o u p s , a n d for a g o r a p h o b i c s

to

display mor e dependency in

g e n e r a l

(Shafer,

1976).

A l t h o u g h the results of t h e s e studies are interesting a n d

w o u l d support

the

line

of

r e a s o n i n g t h u s far presented, it s

important

to

note that the findings are far f r o m conclusive.

T h e m o s t

notable

difficulties with the r e s e a r c h w o u l d include:

1)

the fact that

all

of

t h e s e

studies

w e r e

in some way d e p e n d e n t

upon the subjective

ratings

and/or s t a t e m e n t s of the patients

t h e m s e l v e s ,

without a n y

validity

measur es b e i n g t a k e n in

t e r m s

of other family member s, objective others,

etc,;

2) all of the


28/142

19

o b v i o u s difficulties involved in t e r m s

of collecting

retrospective ratings

after

the


of

a

psychiatric

disorder;

and 3 ) the correlational nature

of

the data.

T h e

limitations

of t h e s e

studies are s h a r e d

b y the majority

of

r e s e a r c h

w h i c h

h a s b e e n c o n d u c t e d in s e a r c h

of

the

c a u s e

of


Therefore,

the e v i d e n c e is

far

f r o m b e i n g

conclusive

in

v i e w of the etiology of

this

disorder.

R e s e a r c h e r s

h a v e

b e e n

somewh at

mor e

s u c c e s s f u l

in

discovering

a

promising treatment. R e c e n t r e s e a r c h ( M a r k s , 1 9 8 1 ; M a t h e w s ,

G e l d e r

&

J o h n s t o n ,

1 9 8 1 ;

Mavissakalian

&

Barlow,

1 9 8 1 ) points

to

the effectiveness of the behavioral

treatment of

e x p o s u r e .

E x p o s u r e

involves

the therapist assisting the patient to

enter

a n d r e m a i n within all feared situations

until

the anxiety

dissipates. T h e individual is e x p o s e d to t h e s e situations until

d o i n g s o

is a c c o m p a n i e d

b y a

lack of anxiety. A c c o r d i n g to

M a r k s (1975), i m p r o v e m e n t rates are

a b o u t

6 0 % with

the

u s e

of

this

treatment

modality.

It s interesting to note that

in

a recent s t u d y

(Emmelkamp &

M e r s c h , 1982),

itwas

f o u n d that e x p o s u r e led

not

only

to i m p r o v e m e n t

in

p h o b i c anxiety and a v o i d a n c e

m e a s u r e s ,

but

also

to

i m p r o v e m e n t s in

depression.

I m p r o v e m e n t s w e r e

also

f o u n d

for a cognitive restructuring p r o g r a m o n

the

same

m e a s u r e s .

In

addition,

at

a 1 - m o n t h follow-up, itwas the

cognitive

restructuring w h i c h s h o w e d significant

i m p r o v e m e n t in


29/142

20

t e r m s of depression, internal locus of control,

a n d

assertiveness.

S uc h

findings

a p p e a r

to

warrant

further

investigation

of cognitive treatment

modalities

for


In

reviewing

the

literature

a n d looking at

exactly w h a t

treatment entails, a v e been struck

b y

the

similarity

of

s u p p o s e d l y

divergent treatments.

It s

clear that

m o s t

cognitive

treatments

f o c u s

o n

the

individual's

belief

s y s t e m .

T h r o u g h intense transactions with the therapist,

irrational

beliefs are discovered

and

corrected. T h e scenarios

w h i c h

individuals m u s t enter

into and

d e a l with are f o c u s e d u p o n . T h e

m e a n i n g of

one's behaviors, sympt oms

a n d

intentions are

negotiated. If it s true that l a n g u a g e and transactions are

s o

p a r a m o u n t in

the d e v e l o p m e n t

of a healthy

v i e w

of

oneself,

t h e n

it s u n d e r s t a n d a b l e

ho w s u c h a

treatment w o u l d

lead

to a

d e c r e a s e in s y m p t o n s - to a n e n h a n c e d s e n s e of p e r s o n a l

competence and

control.

T h u s , o n e w o u l d

not

b e

surprised

to

r e a d of the findings of the Emmelkamp & M e r s c h ( 1 9 8 2 ) s t u d y in

v i e w

of

cognitive

treatment.

B u t w h a t

a b o u t e x p o s u r e treatments

w h e r e

action

vs. verbal

transaction seems

s o important? T h i s writer s u g g e s t s that the

difference is m o r e a p p a r e n t t h a n real. A closer look at

e x p o s u r e

treatments reveals

that therapist/patient

transaction

is

of

u t m o s t

importance.

T h r o u g h verbal interaction, the


30/142

21

patient

is

led to

a clearer u n d e r s t a n d i n g as

to the nature of

the

phobia.

H e / s h e is

i n f o r m e d

as

to

the uncomfortable,

but

h a r m l e s s nature

of

his/her s y m p t o m s . H e / s h e is i n f o r m e d that

r e m a i n i n g within the

feared

situation

will

lead

to

a

d e c r e a se

of anxiety. N e w

m e a n i n g

is a s s i g n e d to the

patient's

s y m p t o m s .

It s

this

verbal transaction, this first p h a s e

of

treatment,

w h i c h

a p p e a r s s o primary in motivating the

patient

to enter the

s e c o n d ,

action p h a s e

of

treatment.

In a

s e n s e ,

w h a t

we

are

looking

at

h e r e is the

patient's


of

a new

"narrative"

or

m o r e

specifically, a new way

of

construing

himself/herself and his/her

participation within

the

social

world

a s

h e / s h e p r o g r e s s e s

t h r o u g h p s y c h o t h e r a p y .

A l t h o u g h

others

(Klein, 1 9 7 3 ;

S p e n c e ,

1 9 8 2 ; &

Schafer,

1 9 8 3 )

h a v e

a r g u e d that

this is w h a t

o c c u r s

in successful psychoanalysis,

o u l d like to a r g u e

that there is

a similar p r o c e s s

at w o r k

e v e n

in

effective short-term p s y c h o t h e r a p y w h i c h is cognitive

behavioral in

nature.

F o c u s i n g

o n a n a g o r a p h o b i c

population,

the

construction

of a new narrative with a n e m p h a s i s o n the self

a s a

responsible

a g e n t s h o u l d b e

correlated

with an increase

in

one's

ability to

travel outside

of

one's home

without

experiencing uncontrollable anxiety;

a

d e c r e a s e

in


anxiety and

fear,

as

well

as

a

d e c r e a s e

in

a n y depressive

s y m p t o m a t o l o g y that resulted f r o m a s e n s e

of

loss o v e r

incapacitation

due

to the illness.


31/142

C h a p t e r

2:

T h e

R e s e a r c h

Investigation

M E T H O D

In

this

chapter o u l d like to d i s c u s s the

m e t h o d s

e m p l o y e d in

the

present

r e s e a r c h

investigation.

A

t h o r o u g h

u n d e r s t a n d i n g of the

m e t h o d s

will facilitate a n

appreciation

for

the obtained results.

T h e s e results will

b e

d i s c u s s e d in

C h a p t e r s

4 and 5.

S U B J E C T S

T h e

r e s e a r c h p r o g r a m

was

c o n d u c t e d

in the Adult Out-Patient

S e r v i c e s of

T h e

S c r a n t o n

C o u n s e l i n g

Center, Scranton, P A .

T h e

p r o g r a m

was

advertised b y means of

the

p r e s s and local

radio

in

Scranton,

P A ,

and

b y

circulars

to

consultant psychiatrists a n d

g e n e r a l practitioners in

the area.

T r e a t m e n t was announced as

a

special

1 2

week

p r o g r a m

for A g o r a p h o b i a w h i c h

w o u l d

include

both

individual a n d

g r o u p p s y c h o t h e r a p y .

P r o v i d e d the

following

criteria w e r e

met,

an individual

was

automatically incorporated into

the r e s e a r c h p r o g r a m ( T h o r p e

a n d

B u r n s , 1 9 8 3 ) .

1)

T h e

diagnosis of a g o r a p h o b i a was

c o n f i r m e d

b y

the

therapists,

Out-Patient Service

Director,

and

the

staff

psychiatrist.

22


32/142

2 )

T h e

subject was available for treatment t w o

t i m e s

w e e k l y .

3 )

T h e subject was not

c o m p l e t e l y

h o u s e b o u n d , and was

able

to attend the clinic for

all meetings.

4 ) T h e subject h a d n o incapacitating

illness

s u c h as

a

psychotic reaction, alcoholism, etc.

5 ) T h e subject was

willing

to sign a contract a g r e e i n g

to c o m p l e t e the treatment

p r o g r a m .

6 ) T h e

subject

did

not

h a v e

a n y

incapacitating

physical

illness.

A

successful

attempt

was made to

wean

subjects

f r o m

a n y

tranquilizers t h e y may h a v e b e e n taking at treatment

outset.

T h i s was a c c o m p l i s h e d via

the

assistance

of

the staff

psychiatrist.

A

total of 1 4 patients

participated in

the treatment

p r o g r a m . E l e v e n patients c o m p l e t e d the p r o g r a m . T h r e e d r o p p e d

out of the

p r o g r a m

during its initial p h a s e . All 11 patients

who

c o m p l e t e d the p r o g r a m wer e

tested

a n d

treated according

to

the a s s e s s m e n t and therapeutic p r o g r a m described b e l o w . In

order to p r e s e r v e the quality

of the

very rich material

obtained,

three

patients w e r e selected

for an

in-depth

analysis.

T h e s e

particular patients

w e r e

selected

b e c a u s e

of

their

b e i n g

representative of

variations among the a g o r a p h o b i c

population

studied.


33/142

T h e

first

patient, M a r y ,

d e v e l o p e d

h e r a g o r a p h o b i a

apparently

a s

a

result

of

hyperthyroidism.

U p o n

intake,

s h e

a p p e a r e d

to b e a v e r y

psychologically healthy

individual.

She

did

not

a p p e a r to b e

clinically

d e p r e s s e d , and did

not

a p p e a r to

p o s s e s s a n y

character ogical

traits

w h i c h

w e r e

debilitative in

nature. She h a d suffered

f r o m a g o r a p h o b i a

for approximately one

year

before

s e e k i n g treatment. By the end of

treatment,

M a r y

reported feeling

fully recovered.

Pam, the s e c o n d patient,

apparently d e v e l o p e d h e r

illness

during

a

time of interpersonal

a n d

intrapersonal

conflict

thirteen y e a r s

prior

to

c o m i n g

to

the

M e n t a l

Health C e n t e r

for

treatment of her a g o r a p h o b i a . U p o n intake, itwas

a p p a r e n t

that

P am's

d e p e n d e n t

nature

h a d

b e e n a n

interfering

factor

in her

life. A s i d e

f r o m

being a very a n x i o u s individual, P a m a p p e a r e d

m o d e r a t e l y d e p r e sse d during her initial visit to

the

Center. By

the

end of treatment, P a m

reported

that s h e

felt s h e was

fully

r e c o v e r e d .

Ellen,

the third patient, also a p p e a r e d to d e v e l o p her


during a time of interpersonal

a n d

intrapersonal

conflict.

Ellen p r e s e n t e d

herself

as feeling woefully

i n a d e q u a t e ,

a n d

u n a b l e

to

move to

resolution

of

conflicts.

Histrionic

a n d

strong

d e p e n d e n t traits m a r k e d h e r personality

style.

Ellen

a p p e a r e d significantly

a n x i o u s

and

d e p r e s s e d at


34/142

25

intake.

She reported

that s h e h a d b e e n

suffering

f r o m


for

the past

1 7

y e a r s

and h a d

b e e n

hospitalized

five

t i m e s

for " e m o t i o n a l

problems."

She h a d a

long history of

i n v o l v e m e n t

within the

Out-Patient

M e n t a l

Health s y s t e m as well,

h a v i n g received treatment f r o m within both private a n d public

sectors.

By the end

of

the present treatment

p r o g r a m ,

Ellen

reported

feeling that s h e h a d c o n q u e r e d

5 0 %

of

her illness.

T H E R A P I S T S

T h e

researcher,

M a r i a n n e E . Intoccia, s e r v e d

a s the

primary therapist. B u r t o n

C .

Reilly s e r v e d as the s e c o n d a r y

therapist and co-facilitator for the therapeutic g r o u p p r o g r a m .

At the time of the

study,

both

therapists

wer e

e m p l o y e d

as

Adult

Out-Patient

therapists at T h e S c r a n t o n C o u n s e l i n g Center.

B o t h

therapists

are


in

the

cognitive-behavioral

a p p r o a c h

for

the treatment of


I N S T R U M E N T A T I O N

I. L I N G U I S T I C

T R E N D S

S i n c e o n e

of

our m a j o r h y p o t h e s e s h a s to do with the c h a n g e

in narrative

a c c o u n t i n g

that o c c u r s

a s o n e

p r o g r e s s e s

t h r o u g h

s u c c e s s f u l p s y c h o t h e r a p y and since

l a n g u a g e

is s u c h a n

important e l e m e n t

in

one's d e v e l o p m e n t , a s

well

a s the fact that


35/142

t h e r a p y is

s o

intimately

tied

to

verbal

interactions, it eems

v e r y appropriate

that

o n e explore

l a n g u a g e

u s a g e

in clinical

research. In the present

research,

a

number

of the t h e r a p y

s e s s i o n s

wer e a u d i o t a p e d

with

the patients'

permission. T h i s

not only allowed for patients'

narrative accounting

of

t h e m s e l v e s as t h e y moved t h r o u g h treatment,

but also allowed for

a n analysis of

linguistic

trends.

A n e x a m i n a t i o n was

c o n d u c t e d

b y transcribing a n d linguistically analyzing the following

s e s s i o n s

of

three

patients:

the

first individual

session;

the

first

g r o u p session; the mid-treatment

g r o u p

session; the final

g r o u p

session;

the final

individual

session; and

the follow-up

g r o u p s e s s i o n w h i c h occurred four

weeks

post-treatment.

A

t h e m a t i c analysis of the

material was

c o n d u c t e d . F o r

the

p u r p o s e of

this

research, all

patient

discourse

was

a n a l y z e d

for

m a j o r

t h e m e s .

T h e s e

topics

or

thematic

s t a t e m e n t s

were

t h e n

a n a l y z e d

a s d i s c u s s e d

b e l o w .

T h e m a t i c s t a t e m e n t s w e r e

divided

into t w o s e p a r a t e

categories: t h o s e w h e r e there was an e x p r e s s i o n of

s u c c e s s

and

t h o s e

w h e r e there was a n e x p r e s s i o n of failure. E x p r e s s i o n s of

s u c c e s s w e r e defined a s

including

any

of the following:

positive self-evaluation,

support or e n c o u r a g e m e n t

f r o m others;

s t a t e m e n t of a

c o m p l e t e d

desired action; the

experiencing

of a

'positive e m o t i o n '

(e.g.,

pleasure, joy, relief,

love,

etc.) or

the

failure to

e x p e r i e n c e a 'negative

e m o t i o n

1

(e.g.,

fear,

rage,


36/142

27

anger,

etc.).

E x p r e s s i o n s of failure, o n the other h a n d ,

w e r e

defined

a s

including

"negative

self-evaluation,

criticisms

f r o m

others;

s t a t e m e n t

of inability to

c o m p l e t e

a desired

action;

the

experiencing

of a 'negative emotion' or the

failure to

e x p e r i e n c e a 'positive emotion'."

All i nd ep end ent

t h e m e s

w e r e analyzed, a n d the

f r e q u e n c y

of

the

following

w e r e tabulated for e a c h of the subjects: positive

a n d

negative

s t a t e m e n t s ( s t a t e m e n t s h a v i n g

a

positive

or

negative

valence); positive

and negative self-statements

( s t a t e m e n t s made with

direct

reference to the self);

self-as-agent

( s t a t e m e n t s referring to

the

self

a s active,

responsible and/or

in

charge); self-as-recipient

( s t a t e m e n t s

referring to

the self

a s

passive or impotent); self-as-agent of

s u c c e s s


referring to the self as

responsible

for

s u c c e s s e x p e r i e n c e s

as

defined above), and self-as-agent of

failure


referring

to

the

self

as

a passive

recipient

of

a failure e x p e r i e n c e as

defined

above).

All t h e m e s wer e a n a l y z e d b y this researcher, a s well as b y

i n d e p e n d e n t

rater,

J o s e p h

B u z a d ,

a certified

reading

specialist,

to allow for the testing

of

reliability

of

results.

Inter-rater a g r e e m e n t was

a s follows: positive/negative

s t a t e m e n t s - .94; positive/negative

self-statements

-

.91;

self-as-agent/recipient - .92;

self-as-agent/recipient of

success/failure

- .92. O b t a in e d

results

utilizing

the sign test


37/142

indicated

a failure to reject

the

h y p o t h e s i s (at the . 0 5 level)

that

there

was

n o

difference

in

inter-rater

scoring.

II. O B J E C T I V E M E A S U R E S

T h e

following

instruments w e r e administered to the subjects

prior

to

treatment, mid-treatment,

as

well as the week after

termination

of treatment.

1)

T h e

F e a r

Questionnaire

( M a r k s

and

M a t h e w s ,

1979).

T h i s

is a patient self-rating

scale

d e s i g n e d

to

a s s e s s

patients'

fear

in many different situations. T h i s scale provides patients with

a n opportunity

to rate

their

a v o i d a n c e

of

their

own

m o s t

important p h o b i c situations, a s

well

as their a v o i d a n c e of

1 5

situations

w h i c h

are

specified

in

the questionnaire. This

questionnaire also provides a

c o m p o s i t e m e a s u r e

of anxiety a n d

depression, as

well a s

giving

a n

overall

rating of disability

due

to the phobia. Test-retest reliability of . 8 0

h a s

b e e n

reported ( M a r k s

a n d M a t h e w s , 1979), for

a

o n e week interval.

M a r k s

and Mathews

further report that for a

s a m p l e

of 6 3


s e e n

for follow-up a n d rated years

after

their

behavioral treatment, a correlation of . 8 7

was

obtained in t e r m s

of

the

relationship

b e r w e e n

the

patients'

score

for this

scale

with r e s e a r c h workers' ratings of their disability.

2 )

B e h a v i o r a l

Testing.

B e h a v i o r a l testing

of the

patients'


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capacities was c o n d u c t e d a s a direct

m e a s u r e of

patient

mobility.

Mobility

is

defined

h e r e

as

the

patient's

ability

to

travel

outside

of his/her home, without experiencing a s e n s e of

uncontrollable

panic. T h i s measur e

was

intended

to

c o m p l i m e n t

the F e a r

Questionnaire,

w h i c h depends upon the patients'

recollections

a n d expectations.

T h e

p r o c e d u r e h a s b e e n

described

b y M a t h e w s ,

G e l d e r

and

J o h n s t o n ( 1 9 8 1 )

a s

follows.

Prior to treatment, a hierarchy is constructed

b y

initially

asking patients

to describe o n e situation

in

w h i c h h e / s h e

feels

totally relaxed, and

then

describing a s e c o n d situation

w h i c h

is

the m o s t difficult situation i m a g i n a b l e

for

him/her. T h e patient

is

then

a s k e d to

bisect

the interval b e t w e e n t h e s e t w o situations,

describing a

third

situation w h i c h w o u l d

o c c u p y

a central

position. T h i s p r o c e d u r e is continued

until a 15-item hierarchy

is

p r o d u c e d .

A n

attempt

is

made,

prior to

treatment, to

e n s u r e

that the patient is able to

carry

out three

or

four

of

the

hierarchy

items,

t h u s allowing r o o m

for both deterioration and

i m p r o v e m e n t . T h e constructed

hierarchy

is t h e n

u s e d

as the

basis

for a n in vivo test

of

the

feared situations.

Testing

b e g i n s b y asking

the patient to

a t t e m p t

the

m o s t difficult item

of w h i c h h e / s h e feels c a p a b l e

at

the

time. If the item

is

successfully

a c c o m p l i s h e d ,

the patient

is

e n c o u r a g e d

to

try

a

m o r e difficult item. If he patient is not

successful, a n

item

of lesser

difficulty

is attempted. T h e

test

is terminated wh en

the patient fails

a particular item, or refuses

to a t t e m p t

a

m o r e

difficult

o n e .


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3 )

T h e

Beck D e p r e s s i o n Inventory (BDI, Beck et

al.,

1 9 6 1 ) .

T h i s

is

a

well validated

a n d

easily

administered

measur e

of

the

number and severity of depressive

symptoms.

T h i s m e a s u r e

h a s

b e e n

f o u n d ( R e h m ,

1 9 7 6 ) to b e significantly correlated with

other measur es of

depresion.

T h e s e other measur es

include

psychiatrists'

ratings, the H a m i l t o n

Rating

S c a l e

F o r

D e p r e s s i o n ,

observational

m e a s u r e s of d e p r e s s i v e behavior, the

D e p r e s s i o n

Adjective

C h e c k List,

the M i n n e s o t a Multiphasic

Personality

Inventory (MMPI) D e p r e s s i o n Scale, and

Z u n g ' s

Self-Rating

D e p r e s s i o n Scale.

E s t i m a t e s

of internal

consistency

are high, with a n o d d - e v e n item correlation of . 8 6 (Beck et

al., 1961).

In

addition, test-retest correlations

of

. 7 5 and

.74

h a v e been reported

( R e h m ,

1 9 7 6 ) respectively for

1 - m o n t h

and

3 - m o n t h

intervals.

4 )

T h e D e p r e s s i v e E x p e r i e n c e

Questionnaire ( D E Q ) . T h e

D E Q

was

d e v e l o p e d

b y Blatt, D'Afflitti & Q u i n l a n (1976a), and

revised

a n d revalidated b y W e l k o w i t z ,

Lish

and Bond (1984). It

is

a

6 6 item

questionnaire.

R a t h e r

than

tapping

direct manifest

sympt oms

of

depression,

this questionnaire h a s b e e n

d e s i g n e d to

measur e g e n e r a l

interpersonal

relations and

a s p e c t s

of feelings

a b o u t the self w h i c h are believed

to

b e relevant

in

depression.

R e s e a r c h

(Blatt,

D'Afflitti &

Quinlan,

1 9 7 6 b )

h a s

indicated

that

this

questionnaire m e a s u r e s three factors w h i c h are related to


40/142

31

depression.

T h e s e factors

include d e p e n d e n c y ,

self-criticism

and

efficacy.

T h e

C r o n b a c h

A l p h a s

for

e a c h

of

t h e s e

s c a l e s a r e

.81, .86,

a n d

.72, respectively. Correlations

of

the

t w o

depressive

factors

with the BDI are

significantly

different,

i.e.,

anaclitic (.42)

a n d introjective (.64).

P R O C E D U R E

S u b j e c t s

contacting the

C e n t e r for

participation in

the

study

w e r e

s c r e e n e d

o v e r the

p h o n e

for a preliminary diagnosis

of a g o r a p h o b i a . T h o s e

individuals

who a p p e a r e d

via

this brief

contact to satisfy the D S M

III-R criteria

for a g o r a p h o b i a , wer e

set

up

for

the first available

initial

intake interview with the

primary a n d

s e c o n d a r y

therapists.

At

the time

of

intake, all

patients filled out a Patient Questionnaire, and w e r e

interviewed

to

d e t e r m i n e

the diagnosis

of


T h e

s e s s i o n

was a u d i o t a p e d with

the p e r m i s s i o n

of

the

patients.

T h e

initial interviews

w e r e

d e v o t e d

to a n exploration of

the

patients

presenting

complaints. T h e s e

interviews w e r e

somewh at structured, in

the s e n s e that

a

fixed

set

of questions

was

u s e d

a s guidelines for the q u e s t i o n s

a s k e d

( S e e

A p p e n d i x

A).

A

M e n t a l

Status

E x a m i n a t i o n

was

also

c o n d u c t e d

during

the

initial

interview. T h e

following i t e m s wer e

e x a m i n e d

and noted:

a p p e a r a n c e ;

behavior; e m o t i o n a l

state; t h o u g h t p r o c e s s e s ;

t h o u g h t content

and perceptions;

s e n s o r i u m

a n d intelligence.


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32

T h e s e c o n d s e s s i o n s

w e r e

intended a s history

taking sessions.

T h e s e

interviews

w e r e c o m p r e h e n s i v e

in

nature,

a n d

included

questions c o n c e r n i n g previous m e n t a l

health

p r o b l e m s

and

treatment; family history;

d e v e l o p m e n t a l

history; educational

history;

marital

history; vocational history;

military status;

history

of

d r u g and/or alcohol

use,

and legal history.

S uc h

extensive

interviews w e r e

c o n d u c t e d to

facilitate

proper

diagnosis.

T h e patients

w e r e

d i a g n o s e d

as

a g o r a p h o b i c

only

if

t h e y met all

of

the criteria

for this

disorder, a s outlined in

D S M III-R

(1987).

After

the s e c o n d session, the interviewing

therapist

consulted

with

the

staff

psychiatrist,

service director

and

co-therapist for corroboration of

the

initial diagnosis. If he

patient

met

this,

as

well a s all other selection

criteria,

as

outlined a b o v e , h e / s h e

was automatically incorporated into the

research p r o g r a m . At

that time, patients

wer e a s k e d to

sign

i n f o r m e d

c o n s e n t statement,

giving

their

c o n s e n t

for voluntary

participation

in the research study.

A s

part

of the intake procedure,

patients w e r e administered

T h e

Beck

D e p r e s s i o n

Inventory,

T h e D e p r e s s i v e E x p e r i e n c e

Questionnaire

a n d

the

F e a r

Questionnaire.

T h e

behavioral

testing

of the

patients' capacities w e r e a s s e s s e d b y

the

primary

therapist

at

the third session. T h i s

testing

was a c c o m p l i s h e d

via utilization

of the

1 5 item fear hierarchies a s

d i s c u s s e d


42/142

33

a b o v e .

It s

important

to note that e a c h individual d e v e l o p e d

his/her

own

fear hierarchy.

T h i s

p r o c e s s

allowed

e a c h

patient

to list 1 5 situations

w h i c h

w e r e personally feared b y him/her.

T h e i t e m s wer e

set

u p in a hierarchial fashion s o that i t e m s

higher u p o n the list

represented

t h o s e

situations

w h i c h w e r e

m o s t intensely feared

b y the

patient,

and i t e m s

lower o n

the

list w e r e t h o s e situations

e x p e r i e n c e d to b e

less

anxiety

producing. T h e s e same i t e m s wer e

t h e n

utilized as individual

treatment goals. A s patients p r o g r e s s e d

throughout

their

treatment, itwas e x p e c t e d that t h e y w o u l d mo v e up

their

individualized

fear

hierarchies, b e i n g

able

to a c c o m p l i s h

increasingly difficult goals.

O n c e

the initial

a s s e s s m e n t

p h a s e was

c o m p l e t e d ,

all

patients u n d e r w e n t treatment for a 1 2 week

period.

T h e first

t w o weeks of treatment involved t w o individual s e s s i o n s p e r

w e e k , w h e r e the following treatment

plan was followed:

a) further exploration of the patients'

presenting

c o n c e r n s ;

b) explanation

of

the nature

of

a g o r a p h o b i a ;

c)

discussion of

treatment and rationale for treatment;

d) instruction

in

d i a p h r a g m a t i c

breathing

a n d

relaxation

exercises, along

with other anxiety

coping

techniques,

s u c h

as

systematic

desensitization, the

u s e

of h u m o r ,

paradoxical intention,

distraction, positive i m a g e r y ,

and t h o u g h t stopping.


43/142

34

e ) s e s s i o n with s p o u s e and/or significant others

to

explain

the nature

of

the

patient's

p r o b l e m and to

elicit their help a s co-therapists.

T o facilitate the

initial

s t a g e

of treatment,

e a c h patient

was p r e s e n t e d with

a

client

manual ( M a t h e w s , G e l d e r

&

J o h n s t o n ,

1 9 8 1 ) .

T h i s manual c o v e r s

issues

s u c h a s the

nature

and

treatment of


Following

the

first

t w o

weeks

of

treatment,

o n e

individual

s e s s i o n

and

o n e g r o u p s e s s i o n

w e r e

c o n d u c t e d

e a c h week for 1 0

weeks

of treatment.

T h e

primary mode of

t h e r a p y

was the

behavioral

e x p o s u r e

treatment p r o g r a m

s u g g e s t e d

b y M a r k s (1981).

This

p r o g r a m

involves the

therapist assisting the patient in

entering a n d r e m a i n i n g within all feared

situations

until

anxiety

dissipates. T h e individual is e x p o s e d to t h e s e

situations until doing

s o

is accompanied b y a

lack

of anxiety.

In addition, a r e a s s u c h

as self-sufficiency,

social anxieties,

interpersonal conflicts

and

inappropriate labeling

of

e m o t i o n s

w e r e

a

f o c u s

of attention within the treatment s e s s i o n s

( C h a m b l e s s & Goldstein,

1 9 8 0 , Goldstein and Stainback, 1987),

with

the treatment taking

o n a m o r e cognitive behavioral

style.

Following

treatment,

a

post-treatment

interview

was

c o n d u c t e d

with e a c h patient. T h e s e interviews w e r e

semi-structured

with

a

fixed

set of

q u e s t i o n s

(See A p p e n d i x B)


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35

being u s e d a s guidelines in the session. In

addition, a

follow-up

g r o u p

session

was

c o n d u c t e d four weeks

post-treatment.

R E S U L T S

All of the d a t a in the present

s t u d y a r e

quantifiable and

interval in

nature.

T h e results c a n b e f o u nd in

C h a p t e r s

4 a n d

5, as

well

as

in

T a b l e s

1-8.

T h e r e

are many

qualitative

differences

w h i c h

are

quite

clinically

significant.

T h e s e

will

b e discussed, a l o n g with the

quantitative

differences,

in

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