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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
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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.
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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
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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
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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
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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
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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
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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 ,
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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.
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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
d e v e l o p m e n t
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
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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
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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
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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
d e v e l o p m e n t
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
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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
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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
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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
e x p e r i e n c e d
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
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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.
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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
a g o r a p h o b i c s
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
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19
o b v i o u s difficulties involved in t e r m s
of collecting
retrospective ratings
after
the
d e v e l o p m e n t
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
a g o r a p h o b i a .
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
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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
a g o r a p h o b i a .
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
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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
d e v e l o p m e n t
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
e x p e r i e n c e d
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.
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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
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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.
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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
a g o r a p h o b i a
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
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25
intake.
She reported
that s h e h a d b e e n
suffering
f r o m
a g o r a p h o b i a
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
e x p e r i e n c e d
in
the
cognitive-behavioral
a p p r o a c h
for
the treatment of
a g o r a p h o b i a .
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
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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,
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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
( s t a t e m e n t 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
( s t a t e m e n t s
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
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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
a g o r a p h o b i c s
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
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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
a g o r a p h o b i a .
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
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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.
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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
a g o r a p h o b i a .
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