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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.
UMI
300 N. Zeeb Rd.
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AG O RAP HO BIA: T HE SY ND RO ME AND INT E RNAL
L IFE CHANG E S W HICH O CCUR T HRO UG HO UT T RE AT ME NT
by
Marianne Intoccia
April 29, 1988
Submitted to T he G raduate Faculty of P olitical
and Social Science of the New School for Social
Research in partial fulfillment of the
requirement for the degree of D octor of
P hilosophy.
D issertation Committee:
D r. Jerome Bruner
D r. Herbert Schlesinger
D r. Arnold W ilson
Abstract
O ne of the most intriguing avenues of study in the field of
psychology is the ongoing exploration of man's view of himself
within his world, the manner in which he shares this self view
within his social network, the capacity of this view to change,
and the manner in which this view can come to be the driving
force in his life. T hese issues were explored by focusing on
the internal life changes that occur in an agoraphobic
population, throughout the course of successful psychotherapy.
A total of 14 patients participated in the treatment program.
T hree patients were selected for an in-depth analysis. P atients
underwent a 12-week cognitive behavioral treatment program for
agoraphobia. D ependent variable measures included linguistic
analysis of the following utterances both pre- and post-
treatment: positive and negative statements, positive and
negative self-statements, self-as-agent, self-as-recipient,
self-as-agent of success, and self-as-agent of failure.
Additional dependent variable measures, taken pre-, mid- and
post-treatment included the Fear Questionnaire, Behavioral
T esting, T he Beck D epression Inventory, and T he D epressive
E xperience Questionnaire. By the end of treatment, patients
reported an increase in their mobility, as well as a decrease in
felt symptoms of anxiety and depression. T hese changes were
noted in the more traditional objective measures mentioned
above. In addition, the following changes were observed in
patients' verbalizations by the end of treatment: an increase in
the accounting of the agoraphobia as something determined,
controlled or at least understood; an increase in agentive power
within one's world; a decrease in passive recipiency in terms of
failure experiences, along with an increase in agency in terms
of success experiences; a decrease in negative statements and
negative self-statements; and an increase in positive statements
and positive self-statements. T hese changes occurred in
reference to the agoraphobia as well as to other life areas.
Qualitative changes in expression were also noted and discussed.
It is suggested that successful psychotherapy can facilitate
patient reformulation of their world views. T he instrumental use
of language in this process is discussed, along with a proposed
view of the relationship between language, behavior and
intrapsychic processes.
T ABL E of CO NT E NT S
Chapter
1. An Introduction to the W orld of the Agoraphobic 1
2. T he Research Investigation 22
3. T he P atients Speak 36
4. Agency ...52
5. W hat About D epression? 74
6. In Quest of a New W orld View 105
7. References 113
8. Appendices:
A. T he Initial Interview 121
B. T he P ost-T reatment Interview 122
ii
L IST of T ABL E S
1. Fear Questionnaire Results - P opulation 123
2. Agent and Recipient Statements - Sample 124
3. Agoraphobic and Non-Agoraphobic Statements - Sample 125
4. Beck D epression Inventory Results - Sample 126
5. D epressive E xperience Questionnaire - Sample 127
6. D epressive E xperience Questionnaire - P opulation 128
7. Beck D epression Inventory Results - P opulation 130
8. P ositive and Negative Statements - Sample 131
i i i
Chapter 1: An Introduction to the W orld of the Agoraphobic
T he field of P sychology is dedicated to the search for a
more complete understanding of man, the most complex and
sophisticated of all beings. O ur search has been intense, the
scope of which ranges from an in-depth exploration and
measurement of specific aspects or elements of man's being, to
more encompassing and integrating hypotheses regarding his very
nature. O ne of the most intriguing, as well as controversial
avenues of study is the ongoing exploration of man's view of
himself within his world, the manner in which he shares this
self view within his social network, the capacity of this view
to change, and the manner in which this view can come to be the
driving force in his life. T he present exposition is an attempt
to contribute to this area of exploration.
L et us begin by taking a look at some of the work which has
already been done in this area. It seems most fitting to begin
our discussion with the work of Sigmund Freud (1856 - 1939), one
of the greatest contributors within the history of modern
psychological thought. Freud's early view of man was
deterministic in nature. He did not believe that free choice or
personal volition had any role to play in terms of human
behavior. Instead, he believed that all human behavior,
feelings and thoughts were determined by the powerful instincts
of sex and aggression. In addition, he noted that one's early
1
2
childhood family constellation and parental influence have an
irreversible and significant impact on the shaping of
personality. In fact, according to his psychoanalytic theory,
the basis of personality is determined by the age of five or
six. In terms of Freud's view of psychopathology, symptoms are
motivated by unconscious factors, which stem from childhood
experiences. T he task of the Freudian psychotherapist is to
uncover these early life events along with unconscious urges and
defenses. O nce the unconscious is made conscious, the
individual is believed able to deal with internal conflicts. At
the point of successful resolution the patient's symptoms will
presumably be eliminated.
Freud did recognize that the memory for early childhood
experiences is not veridical, but rather that it is colored by
distortions generated by each patient's individual defense
system (e.g., displacement, condensation, etc.). It is important
to note however that his early thinking suggested that complete
and successful analysis could remove the distortions, enabling
the original image to emerge.
Although a number of Freud's views have not been confirmed
by modern scientific research, his contributions have had a far-
reaching and profound impact within the field of psychology.
His views provoked much thought within the field, and he had
many followers. E rik E rikson (1902 - ) was one such follower.
3
E rikson felt that his own views were a mere extension of
Freud's, although it is quite clear that some of his ideas
represent a significant departure from traditional
psychoanalytic thought. I would like to briefly discuss some of
his ideas, as I see them as having made a significant impact on
our current understanding of the development of man's views of
himself within his world.
E rikson did accept many of the tenets of traditional
psychoanalytic theory (e.g., the unconscious, biological
determinism, etc.). According to E rikson however, personality
is not determined by age five or six as Freud believed, but
rather continues on in terms of its development throughout one's
lifetime. He described (1963) "E ight Stages of Man" which span
from birth through to late adulthood. In addition, E rikson
stressed that our parents are not the only people who have a
significant effect on our development, but that we are likewise
influenced by a number of significant others, including siblings
and peers, individuals associated with many social institutions,
such as schools and colleges, as well as professional, social
and political organizations. He agreed with Freud that man has
many internal conflicts to deal with. However, he felt that
these conflicts were psychosocial, rather than psychosexual.
W hile Freud's focus was on the exploration of unconscious
mental life and the retracing of early life events as they
contribute to the development of adult psychopathology (i.e., a
more archeological point of view), E rikson's focus was on man's
potential to overcome the psychosocial crises he encounters
along life's way. W hat we see here is the optimistic view that
man can achieve control over his life, as well as over those
things that he experiences throughout his lifetime.
It is interesting to note that a close reading of Freud's
later work (1937) suggests that he too was moving in the
direction of believing that man has some form of influence
concerning who he is, or who he becomes throughout his
lifetime. He seems to suggest the idea that man "constructs"
his experiences. T hat is, he suggests that man adds his own
perceptions to those things which are actually happening around
him. In this sense then, we may never be able to be true to the
field of archeology and dig up past events as they have
actually occurred. W hat we can achieve is contact with what the
memories of those events have come to mean to us within our
world.
T hese very ideas have been the focus of much modern day
thinking within the field of psychoanalysis. T hree individuals
who are responsible for a great deal of this work are G eorge
Klein (1973), Roy Schafer (1983) and D onald Spence (1982). Klein
suggests that the psychoanalyst is not engaged in an
archeological venture, but rather that the psychoanalyst's role
5
is to be more active in facilitating the construction of a more
consistent and productive accounting of the patient's life
experiences.
Spence discusses some of the same ideas. In doing so, he
differentiates "historical truth" from "narrative truth."
"Historical truth" is defined (p. 31) as: "concrete objects and
events that happened at some earlier period and that can be
brought forward to the present." "Narrative truth" on the other
hand is defined as: "the criterion we use to decide when a
certain experience has been captured to our satisfaction; it
depends on continuity and closure and the extent to which the
fit of the pieces takes on an aesthetic finality." Spence
discusses the power of "narrative truth," noting that such
constructions are not only responsible for giving shape to the
past, but in addition, have the potential for actually becoming
the past. In this sense then, historical truth is inaccessible,
and it is narrative truth which becomes not only accessible, but
also utilizable. Spence states:
O nce expressed in a particular set of sentences, the memory
itself has changed, and the patient will probably never
again have quite the same vague, non-specific and unspoiled
impression. T hus, the very act of talking about the past
tends to crystalize it in specific but somewhat arbitrary
language, and this language serves in turn to distort the
early memory. More precisely, the new description becomes
the early memory. In a very real sense, memories are being
created in the course of analysis... (p. 92)
Schafer (1983) makes a similar point, emphasizing that the
analyst and the analysand embark on a joint effort, as they
retell the past, thus developing the narrative accounting of
events. He states:
In psychoanalysis, the versions of significant events
change as the work progresses, and with these changes go
changes in what is called the experience of these events.
T he analyst never takes immediately available or emphasized
subjective experiences as the final or definitive version
of anything, for the analyst views that experience as
always being constructed or reconstructed; it can be
encountered only in explicit or implicit narrative
accounts. (p. 186)
Schafer adds that these narratives usually become focused
on the analysand as "agent" rather than "victim." He states:
T he great extent to which the analysand is unconsciously
the agent or author of his/her life gets established beyond
doubt. T he analysand emerges as deeply implicated in
his/her suffering even if not as the only agent or source
of the pain. O n this basis, though not in any strict
7
sequence, the analysand is better able to envision and
pursue desirable alternatives to those aspects of existence
that heretofore and consciously were passively suffered or
at least perpetuated in an unquestioning manner, (p. 191)
An additional point that is worth noting is that it has
been argued (Ricoeur, 1977; Schafer, 1983; and Spence, 1982)
that it is not important that we discover patient experiences as
they actually occurred. Rather, the focus of therapy should be
on the meaning or interpretations the individual has assigned to
these experiences.
In view of all that has been thus far stated, my focus has
been on two major ideas. T he first is that man does not merely
respond in some deterministic manner to those things which he
encounters in his life, but rather that he adds something to
these experiences. T his idea is not new, nor is it limited to
the field of psychoanalysis. T he power of mental activity has
been discussed, among many others, by P avlov (1957) in his
discussion of the "Second Signal System" and "Semantic
G eneralization;" Vygotsky (1962) in his discussion of the "Zone
of P roximal D evelopment;" by attribution theorists including Bern
(1972), Heider (1944, 1958), Kelly (1972), Schachter (1964),
Schachter and Singer (1962), and Seligman (1979); by Bruner
(1986) in his presentation on the "Narrative Mode of T hought,"
and (1987) in his conceptualization of "autobiographical
8
narratives," by G oodman (1984) in his discussion of "W orld
Making;" and by cognitive learning therapists such as Beck
(1976), E llis (1971), and Meichenbaum (1977) in their views on
conscious thought playing an important role in mediating both
instrumental and emotional behavior.
T he second idea that I have been focusing on is that there
are limits to how much we can trust the accuracy of our
memories of the past. It is important to note that this idea
is supported by much of the work which has been conducted in
terms of human memory. L et us review some of this work.
Research into the field of human memory was launched by
E bbinghaus in 1885. He emphasized that given the complexity of
memory (i.e., that memory can be influenced by such things as
interest, moods, expectations), it is important to study
tractable aspects under tightly controlled conditions. It is
certainly to the credit of E bbinghaus that 102 years later many
of his findings still hold up under scientific scrutiny.
Bartlett (1932) chose to study memory via a different route
(i.e., he attempted to study memory in everyday life). Beginning
in the 1960's, and even more strongly by the mid-1970's, his
emphasis on studying the complexity of human memory as it
exists has been the predominant mode of study within the
field. Bartlett and more recently Neisser (1967), among others
(e.g., Bransford and Frank, 1971; Hunter, 1957; L oftus and P almer,
9
1974) have emphasized that memory is not a passive process, but
rather that it is an active constructive process. W hat has been
suggested is that the memorial process of retrieval is very
intimately tied to the process of such things as comprehension,
rehearsal and organization during initial acquisition; updating
and accommodative distortions of the original memory; as well as
confusion and/or blurring together of memories. T hus, it
appears that what one currently holds in memory is the world as
personally experienced (i.e., interpretations based on
expectations, bias, prejudices, etc.). T hese things are
important not only in terms of the way information is stored in
memory, but they are also important in terms of information
retrieval.
Although we are not at a point where we can comfortably say
that we have concluded our work in this area, we are certainly
at a point where we can draw the interim conclusion that there
are definite limits to how much we are able to rely on our
memory as being an accurate representation of our past. It is
certainly clear that memory is a very significant element in
terms of the development of one's view of self, as it is memory
which allows us to experience a contiguity of our present with
our past. Certainly, any limitations in terms of the
accuracy of memory, then would have serious implications for
the development of a view of self.
W hat is this concept of "self" which I have thus far been
alluding to? It is important to note that some researchers and
theoreticians reject the idea and/or label of "self." Hazel
Markus (1983), consistent with the views of others, such as
Kelly (1955) and E pstein (1973), has bravely provided us with a
definition of self which is not only conceptually helpful, but
in addition is amenable to research. Markus views self as a set
of cognitive structures or schemas that have the capacity to
organize, direct, change as well as integrate one's
functioning. According to Markus, "Self-schemas develop from
the repeated similar categorization and evaluation of behavior
by oneself and others, and result in a clear idea of the kind of
person one is in a particular area of behavior." She notes that
these structures are not static, but rather, they are dynamic
growing and changing in response to both internal and
external experiences.
I would like to stress a few things which are of paramount
importance in terms of this view. First of all, Markus espouses
a constructivist view of the self. T hat is, as individuals we
are actively involved in the process of the development of
self. Secondly, other people are also involved in this
development. Clearly, we respond to the evaluations and
feedback others give us about ourselves. W hen self and other
evaluations converge, a consistently fortified sense of self
ensues. W hen self and other evaluations diverge, it is the
responsibility of the self to effectively deal with these
opposing views in a way that is acceptable to the self. At
times, this will involve the mobilization of one's defenses, so
that the others' evaluation is denied, ignored, or viewed as
unimportant. At other times, these evaluations can lead to a
change in one's view of self. At any rate, man's participation
within a verbal, transactional world is viewed to play a large
role in terms of the development of self. Bruner (1982) would
agree with this. He states:
...I would like to urge that it is precisely in the
negotiation of intended meaning that the self is formed in
such a way that we can relate ourselves not only to the
others immediately around us...particularly to the family
(and its myths about social reality)...but also to the
broader culture into which we must eventually move. It is
in this process that we create the internal scripts in
terms of which we interpret the transactional world in
which we move as socialized human beings, (p. 5)
'T alking things through,' operating conversationally in the
context of real events, making intentions clear and
learning to assign flexible interpretations to ambiguously
expressed intentions...these are the instruments for the
forming of the Self, not the only ones, but indispensable
12
ones. T hey provide the means for entering and mastering
the scenarios that one must cope with, or if not, avoid.
(p. 20)
Bruner (1982) goes on to argue that transactional
relationships are of paramount importance in this development.
As such, the more effective families, marriages, friendships and
other significant relationships in offering an opportunity for
the "mastery of the arts of exchange," as well as in providing
the necessary medium for such an exchange, the less needed will
be psychologists and psychiatrists for interventions at a later
point in time.
After reading Bruner, one is left with the impression that
although a healthy view of self relies very strongly upon the
family and other significant relationships, the therapeutic
relationship can become the correcting medium for those
important elements which may have been missing within primary
relationships. Such is an uplifting view, as it offers hope for
the many individuals with a history of impoverished relating,
and a thwarted view of themselves. Clinical populations abound
with such individuals.
O ne specific clinical population in which these ideas seem
very strongly to apply is that of agoraphobics. Although the
term "agoraphobia" has been around since its initial use by
W estphal in 1871, it is only within the past decade or so that
13
the nature and treatment of this psychiatric disorder is being
more fully understood.
P resently, agoraphobia is classified as a separate category
in the American P sychiatric Association's 3rd E dition (Revised)
of the D iagnostic and Statistical Manual of Mental D isorders
(D SM III-R, 1987). T he term, which was derived from the G reek
root "agora," meaning assembly, the place of assembly, and
market place is used due to the quite consistent clinical
features of this very common and highly distressing phobic
disorder. G enerally speaking, the disorder is characterized by
a fear of being alone, or going out into public places (open and
crowded places), where escape might be difficult, or assistance
not available in the event of sudden helplessness. T he
individual develops a pattern of actual avoidance of these
feared situations. T he fears may or may not be accompanied by
panic attacks, which according to the D SM III-R, include at
least four of the following symptoms: dizziness, vertigo, or
unsteady feelings; feelings of unreality, paresthesias; hot or
cold flashes; sweating; faintness; trembling or shaking; fears
of dying, going crazy, or doing something uncontrolled during an
attack.
Very often, anxiety attacks are experienced early in the
development of the disorder. T he individual, in an attempt to
make sense of the symptoms, attributes them to those places or
things which were occurring during the time of the attack. T he
individual develops an anticipatory fear of experiencing these
attacks and will thus set up an avoidance pattern which is
centered around those places and things which have been
associated with the attacks. L eft untreated, the attacks often
continue and the fears begin to generalize, resulting in
increasing degrees of incapacitation. T he anxiety, the fears
and the avoidance behaviors come to dominate the individual's
life. In the most extreme cases, these individuals can become
so preoccupied with their illness that they have little time or
energy left to focus on anything else.
In addition to all of this, there are many nonphobic
symptoms which have been found to be associated with
agoraphobia. O ne such symptom is that of depression (Bowen &
Kohout, 1979; Marks, 1970). Agoraphobics frequently report
feeling depressed, irritable and hopeless. Many of them readily
note that they experience frequent crying spells, a lack of
interest in their work and previously enjoyed activities,
difficulty with sleep, as well as suicidal thoughts. T hey often
present with feelings of helplessness, depletion and being
unloved. It is interesting to note that in 1977, Buglass,
Clarke, Henderson, Kreitman and P resley found depression
strongly evidenced in 30% of their sample, and minimally present
in another 17% of their subjects. In addition, Bowen and Kohout
(1979) found that the incidence rate of primary affective
15
disorders was about 91% for the 55 agoraphobics in their
study.
Another very important symptom which appears to be related
to agoraphobia is that of depersonalization (Marks, 1970;
Mathews, G elder & Johnson, 1981). Agoraphobics frequently
report a temporary feeling of strangeness, unreality, or
disembodiment. T he individual may report the experience of
apparent perception of himself from a distance, as though he
were cut off or far away from the reality of his environment.
He may feel "mechanicaland/or not in complete control of his
functions and/or actions. Bug!ass et al. (1977) report a 37%
incidence rate of this symptom among the agoraphobics in their
study.
In working with agoraphobics for the past seven years, I
have become aware of how distraught such individuals really
are. Initially, these patients appear to have a lack of
understanding as to the origin of their symptoms. T he only
thing they are sure of is that they experience these intense
attacks of anxiety on most occasions when they are alone and/or
away from their homes. Nothing appears to be effective in terms
of controlling the anxiety. P atients speak invariably of their
essential helplessness, discouragement, and fear of losing
control. "I'm afraid of going crazy," "I fear I'm losing my
mind," "I'm afraid I'm going to faint," are some of the most
common statements made by the patient. T he patient experiences
16
himself/herself as being very fragile. Although he/she may be
relaxed and relatively able to care for himself/herself and his/
her needs at one moment, the next minute might bring with it
that feared uncontrollable panic. W ith such a fragile sense of
himself/herself, the individual begins avoiding more and more of
the activities and situations previously enjoyed. He/she begins
to feel that it is only the surrounding of his/her home which
potentially offers any type of protection. W hile at home, it
is a common occurrence that the felt symptoms of depression and
depersonalization intensify. In many cases, the individual
begins to experience anxiety even when surrounded by the
familiarity of his/her own home. At this point, in a state of
depression, many individuals seek treatment.
W ho is this person they have become? From what I have
experienced in a clinical setting, family members often lack as
much understanding as does the patient. O ften the person
receives the message that he/she is being "silly," "immature," or
perhaps he/she really is "crazy." T he patient is often involved
in an infinite number of these transactions. Slowly his/her
view of himself/herself appears to become even further depleted.
At this point, many individuals report having great difficulty
communicating with anyone. "I feel so inferior," are the words
so often heard on an initial interview
How does this illness develop? W hat differentiates those
17
who develop the disorder from those who do not? T he question of
etiology has been explored from a great number of avenues.
Constitutional, cognitive, and environmental factors have all
been the focus of investigation. O ne area of research has been
the patient's family of origin.
G oldstein and Stainback (1987) state that as a result of
all of their work with hundreds of agoraphobics, they have been
able to identify six categories within which most agoraphobics
are reared. T hese include:
1) T heir parents over-protected them; 2) T oo much
responsibility was thrust upon them because they had to
take care of a mother or father who was chronically ill,
alcoholic, or agoraphobic; 3) T heir parents' behavior was
unpredictable because they were alcoholic, agoraphobic or
psychotic; 4) T heir parents were perceived to be
overcritical, often impossible to please; 5) T he youngsters
either felt threatened by or were actually subjected to the
premature loss of or separation from one or both parents;
6) T he youngsters were sexually abused, usually by an adult
male in the family. O ften the abuser was intoxicated.
(p. 13)
In addition, these authors hypothesize that agoraphobia occurs
most often during those times of increased interpersonal conflict.
It is interesting to note that additional studies
conducted in this area offer some interesting results. For
example, W ebster (1953) reports that the fathers of a studied
population of agoraphobics were more frequently absent from the
family home than were fathers of other clinical populations.
Snaith (1968) found that the family backgrounds of agoraphobics
were more unstable than the backgrounds of other phobics.
Similarly, Buglass et al. (1977) found that the families of
agoraphobics included a significantly greater number of adopted,
or step-relatives. In addition, some studies (Solyom, Beck,
Solyom & Huge!, 1974; Solyom, Siberfeld & Solyom, 1976;
W ebster, 1953) report that there appears to be a tendency for
mothers of agoraphobics to be more overprotective than those of
other groups, and for agoraphobics to display more dependency in
general (Shafer, 1976).
Although the results of these studies are interesting and
would support the line of reasoning thus far presented, it is
important to note that the findings are far from conclusive.
T he most notable difficulties with the research would include:
1) the fact that all of these studies were in some way dependent
upon the subjective ratings and/or statements of the patients
themselves, without any validity measures being taken in terms
of other family members, objective others, etc,; 2) all of the
19
obvious difficulties involved in terms of collecting
retrospective ratings after the development of a psychiatric
disorder; and 3) the correlational nature of the data.
T he limitations of these studies are shared by the majority
of research which has been conducted in search of the cause of
agoraphobia. T herefore, the evidence is far from being
conclusive in view of the etiology of this disorder.
Researchers have been somewhat more successful in discovering a
promising treatment. Recent research (Marks, 1981; Mathews,
G elder & Johnston, 1981; Mavissakalian & Barlow, 1981) points to
the effectiveness of the behavioral treatment of exposure.
E xposure involves the therapist assisting the patient to enter
and remain within all feared situations until the anxiety
dissipates. T he individual is exposed to these situations until
doing so is accompanied by a lack of anxiety. According to
Marks (1975), improvement rates are about 60% with the use of
this treatment modality.
It is interesting to note that in a recent study
(E mmelkamp & Mersch, 1982), it was found that exposure led not
only to improvement in phobic anxiety and avoidance measures,
but also to improvements in depression. Improvements were also
found for a cognitive restructuring program on the same
measures. In addition, at a 1-month follow-up, it was the
cognitive restructuring which showed significant improvement in
20
terms of depression, internal locus of control, and
assertiveness. Such findings appear to warrant further
investigation of cognitive treatment modalities for
agoraphobia.
In reviewing the literature and looking at exactly what
treatment entails, I have been struck by the similarity of
supposedly divergent treatments. It is clear that most
cognitive treatments focus on the individual's belief system.
T hrough intense transactions with the therapist, irrational
beliefs are discovered and corrected. T he scenarios which
individuals must enter into and deal with are focused upon. T he
meaning of one's behaviors, symptoms and intentions are
negotiated. If it is true that language and transactions are so
paramount in the development of a healthy view of oneself, then
it is understandable how such a treatment would lead to a
decrease in symptons - to an enhanced sense of personal
competence and control. T hus, one would not be surprised to
read of the findings of the E mmelkamp & Mersch (1982) study in
view of cognitive treatment.
But what about exposure treatments where action vs. verbal
transaction seems so important? T his writer suggests that the
difference is more apparent than real. A closer look at
exposure treatments reveals that therapist/patient transaction
is of utmost importance. T hrough verbal interaction, the
21
patient is led to a clearer understanding as to the nature of
the phobia. He/she is informed as to the uncomfortable, but
harmless nature of his/her symptoms. He/she is informed that
remaining within the feared situation will lead to a decrease
of anxiety. New meaning is assigned to the patient's symptoms.
It is this verbal transaction, this first phase of treatment,
which appears so primary in motivating the patient to enter the
second, action phase of treatment.
In a sense, what we are looking at here is the patient's
development of a new "narrative" or more specifically, a new way
of construing himself/herself and his/her participation within
the social world as he/she progresses through psychotherapy.
Although others (Klein, 1973; Spence, 1982; & Schafer, 1983)
have argued that this is what occurs in successful psychoanalysis,
I would like to argue that there is a similar process at work
even in effective short-term psychotherapy which is cognitive
behavioral in nature. Focusing on an agoraphobic population,
the construction of a new narrative with an emphasis on the self
as a responsible agent should be correlated with an increase in
one's ability to travel outside of one's home without
experiencing uncontrollable anxiety; a decrease in experienced
anxiety and fear, as well as a decrease in any depressive
symptomatology that resulted from a sense of loss over
incapacitation due to the illness.
Chapter 2: T he Research Investigation
ME T HO D
In this chapter I would like to discuss the methods
employed in the present research investigation. A thorough
understanding of the methods will facilitate an appreciation for
the obtained results. T hese results will be discussed in
Chapters 4 and 5.
SUBJE CT S
T he research program was conducted in the Adult O ut-P atient
Services of T he Scranton Counseling Center, Scranton, P A. T he
program was advertised by means of the press and local radio in
Scranton, P A, and by circulars to consultant psychiatrists and
general practitioners in the area. T reatment was announced as a
special 12 week program for Agoraphobia which would include both
individual and group psychotherapy.
P rovided the following criteria were met, an individual was
automatically incorporated into the research program (T horpe and
Burns, 1983).
1) T he diagnosis of agoraphobia was confirmed by the
therapists, O ut-P atient Service D irector, and the staff
psychiatrist.
22
2) T he subject was available for treatment two times
weekly.
3) T he subject was not completely housebound, and was
able to attend the clinic for all meetings.
4) T he subject had no incapacitating illness such as a
psychotic reaction, alcoholism, etc.
5) T he subject was willing to sign a contract agreeing
to complete the treatment program.
6) T he subject did not have any incapacitating physical
illness.
A successful attempt was made to wean subjects from any
tranquilizers they may have been taking at treatment outset.
T his was accomplished via the assistance of the staff
psychiatrist.
A total of 14 patients participated in the treatment
program. E leven patients completed the program. T hree dropped
out of the program during its initial phase. All 11 patients
who completed the program were tested and treated according to
the assessment and therapeutic program described below. In
order to preserve the quality of the very rich material
obtained, three patients were selected for an in-depth
analysis. T hese particular patients were selected because of
their being representative of variations among the agoraphobic
population studied.
T he first patient, Mary, developed her agoraphobia
apparently as a result of hyperthyroidism. Upon intake, she
appeared to be a very psychologically healthy individual. She
did not appear to be clinically depressed, and did not appear to
possess any character!ogical traits which were debilitative in
nature. She had suffered from agoraphobia for approximately one
year before seeking treatment. By the end of treatment, Mary
reported feeling fully recovered.
P am, the second patient, apparently developed her illness
during a time of interpersonal and intrapersonal conflict
thirteen years prior to coming to the Mental Health Center for
treatment of her agoraphobia. Upon intake, it was apparent that
P am's dependent nature had been an interfering factor in her
life. Aside from being a very anxious individual, P am appeared
moderately depressed during her initial visit to the Center. By
the end of treatment, P am reported that she felt she was fully
recovered.
E llen, the third patient, also appeared to develop her
agoraphobia during a time of interpersonal and intrapersonal
conflict. E llen presented herself as feeling woefully
inadequate, and unable to move to resolution of conflicts.
Histrionic and strong dependent traits marked her personality
style. E llen appeared significantly anxious and depressed at
25
intake. She reported that she had been suffering from
agoraphobia for the past 17 years and had been hospitalized five
times for "emotional problems." She had a long history of
involvement within the O ut-P atient Mental Health system as well,
having received treatment from within both private and public
sectors. By the end of the present treatment program, E llen
reported feeling that she had conquered 50% of her illness.
T HE RAP IST S
T he researcher, Marianne E . Intoccia, served as the
primary therapist. Burton C. Reilly served as the secondary
therapist and co-facilitator for the therapeutic group program.
At the time of the study, both therapists were employed as Adult
O ut-P atient therapists at T he Scranton Counseling Center. Both
therapists are experienced in the cognitive-behavioral approach
for the treatment of agoraphobia.
INST RUME NT AT IO N
I. L ING UIST IC T RE ND S
Since one of our major hypotheses has to do with the change
in narrative accounting that occurs as one progresses through
successful psychotherapy and since language is such an
important element in one's development, as well as the fact that
therapy is so intimately tied to verbal interactions, it seems
very appropriate that one explore language usage in clinical
research. In the present research, a number of the therapy
sessions were audiotaped with the patients' permission. T his
not only allowed for patients' narrative accounting of
themselves as they moved through treatment, but also allowed for
an analysis of linguistic trends. An examination was conducted
by transcribing and linguistically analyzing the following
sessions of three patients: the first individual session; the
first group session; the mid-treatment group session; the final
group session; the final individual session; and the follow-up
group session which occurred four weeks post-treatment.
A thematic analysis of the material was conducted. For the
purpose of this research, all patient discourse was analyzed
for major themes. T hese topics or thematic statements were then
analyzed as discussed below.
T hematic statements were divided into two separate
categories: those where there was an expression of success and
those where there was an expression of failure. E xpressions of
success were defined as including any of the following:
positive self-evaluation, support or encouragement from others;
statement of a completed desired action; the experiencing of a
'positive emotion' (e.g., pleasure, joy, relief, love, etc.) or
the failure to experience a 'negative emotion
1
(e.g., fear, rage,
27
anger, etc.). E xpressions of failure, on the other hand, were
defined as including "negative self-evaluation, criticisms from
others; statement of inability to complete a desired action; the
experiencing of a 'negative emotion' or the failure to
experience a 'positive emotion'."
All independent themes were analyzed, and the frequency of
the following were tabulated for each of the subjects: positive
and negative statements (statements having a positive or
negative valence); positive and negative self-statements
(statements made with direct reference to the self);
self-as-agent (statements referring to the self as active,
responsible and/or in charge); self-as-recipient (statements
referring to the self as passive or impotent); self-as-agent of
success (statements referring to the self as responsible for
success experiences as defined above), and self-as-agent of
failure (statements referring to the self as a passive recipient
of a failure experience as defined above).
All themes were analyzed by this researcher, as well as by
independent rater, Joseph Buzad, a certified reading
specialist, to allow for the testing of reliability of results.
Inter-rater agreement was as follows: positive/negative
statements - .94; positive/negative self-statements - .91;
self-as-agent/recipient - .92; self-as-agent/recipient of
success/failure - .92. O btained results utilizing the sign test
indicated a failure to reject the hypothesis (at the .05 level)
that there was no difference in inter-rater scoring.
II. O BJE CT IVE ME ASURE S
T he following instruments were administered to the subjects
prior to treatment, mid-treatment, as well as the week after
termination of treatment.
1) T he Fear Questionnaire (Marks and Mathews, 1979). T his
is a patient self-rating scale designed to assess patients' fear
in many different situations. T his scale provides patients with
an opportunity to rate their avoidance of their own most
important phobic situations, as well as their avoidance of 15
situations which are specified in the questionnaire. T his
questionnaire also provides a composite measure of anxiety and
depression, as well as giving an overall rating of disability
due to the phobia. T est-retest reliability of .80 has been
reported (Marks and Mathews, 1979), for a one week interval.
Marks and Mathews further report that for a sample of 63
agoraphobics seen for follow-up and rated years after their
behavioral treatment, a correlation of .87 was obtained in terms
of the relationship berween the patients' score for this scale
with research workers' ratings of their disability.
2) Behavioral T esting. Behavioral testing of the patients'
capacities was conducted as a direct measure of patient
mobility. Mobility is defined here as the patient's ability to
travel outside of his/her home, without experiencing a sense of
uncontrollable panic. T his measure was intended to compliment
the Fear Questionnaire, which depends upon the patients'
recollections and expectations. T he procedure has been
described by Mathews, G elder and Johnston (1981) as follows.
P rior to treatment, a hierarchy is constructed by initially
asking patients to describe one situation in which he/she feels
totally relaxed, and then describing a second situation which is
the most difficult situation imaginable for him/her. T he patient
is then asked to bisect the interval between these two situations,
describing a third situation which would occupy a central
position. T his procedure is continued until a 15-item hierarchy
is produced. An attempt is made, prior to treatment, to ensure
that the patient is able to carry out three or four of the
hierarchy items, thus allowing room for both deterioration and
improvement. T he constructed hierarchy is then used as the
basis for an in vivo test of the feared situations. T esting
begins by asking the patient to attempt the most difficult item
of which he/she feels capable at the time. If the item is
successfully accomplished, the patient is encouraged to try a
more difficult item. If the patient is not successful, an item
of lesser difficulty is attempted. T he test is terminated when
the patient fails a particular item, or refuses to attempt a
more difficult one.
3) T he Beck D epression Inventory (BD I, Beck et al., 1961).
T his is a well validated and easily administered measure of the
number and severity of depressive symptoms. T his measure has
been found (Rehm, 1976) to be significantly correlated with
other measures of depresion. T hese other measures include
psychiatrists' ratings, the Hamilton Rating Scale For
D epression, observational measures of depressive behavior, the
D epression Adjective Check L ist, the Minnesota Multiphasic
P ersonality Inventory (MMP I) D epression Scale, and Zung's
Self-Rating D epression Scale. E stimates of internal consistency
are high, with an odd-even item correlation of .86 (Beck et
al., 1961). In addition, test-retest correlations of .75 and .74
have been reported (Rehm, 1976) respectively for 1-month and
3-month intervals.
4) T he D epressive E xperience Questionnaire (D E Q). T he D E Q
was developed by Blatt, D 'Afflitti & Quinlan (1976a), and
revised and revalidated by W elkowitz, L ish and Bond (1984). It
is a 66 item questionnaire. Rather than tapping direct manifest
symptoms of depression, this questionnaire has been designed to
measure general interpersonal relations and aspects of feelings
about the self which are believed to be relevant in depression.
Research (Blatt, D 'Afflitti & Quinlan, 1976b) has indicated that
this questionnaire measures three factors which are related to
31
depression. T hese factors include dependency, self-criticism
and efficacy. T he Cronbach Alphas for each of these scales are
.81, .86, and .72, respectively. Correlations of the two
depressive factors with the BD I are significantly different,
i.e., anaclitic (.42) and introjective (.64).
P RO CE D URE
Subjects contacting the Center for participation in the
study were screened over the phone for a preliminary diagnosis
of agoraphobia. T hose individuals who appeared via this brief
contact to satisfy the D SM III-R criteria for agoraphobia, were
set up for the first available initial intake interview with the
primary and secondary therapists. At the time of intake, all
patients filled out a P atient Questionnaire, and were
interviewed to determine the diagnosis of agoraphobia. T he
session was audiotaped with the permission of the patients.
T he initial interviews were devoted to an exploration of
the patients presenting complaints. T hese interviews were
somewhat structured, in the sense that a fixed set of questions
was used as guidelines for the questions asked (See Appendix
A). A Mental Status E xamination was also conducted during the
initial interview. T he following items were examined and noted:
appearance; behavior; emotional state; thought processes;
thought content and perceptions; sensorium and intelligence.
32
T he second sessions were intended as history taking sessions.
T hese interviews were comprehensive in nature, and included
questions concerning previous mental health problems and
treatment; family history; developmental history; educational
history; marital history; vocational history; military status;
history of drug and/or alcohol use, and legal history. Such
extensive interviews were conducted to facilitate proper
diagnosis. T he patients were diagnosed as agoraphobic only if
they met all of the criteria for this disorder, as outlined in
D SM III-R (1987).
After the second session, the interviewing therapist
consulted with the staff psychiatrist, service director and
co-therapist for corroboration of the initial diagnosis. If the
patient met this, as well as all other selection criteria, as
outlined above, he/she was automatically incorporated into the
research program. At that time, patients were asked to sign
informed consent statement, giving their consent for voluntary
participation in the research study.
As part of the intake procedure, patients were administered
T he Beck D epression Inventory, T he D epressive E xperience
Questionnaire and the Fear Questionnaire. T he behavioral testing
of the patients' capacities were assessed by the primary
therapist at the third session. T his testing was accomplished
via utilization of the 15 item fear hierarchies as discussed
33
above. It is important to note that each individual developed
his/her own fear hierarchy. T his process allowed each patient
to list 15 situations which were personally feared by him/her.
T he items were set up in a hierarchial fashion so that items
higher up on the list represented those situations which were
most intensely feared by the patient, and items lower on the
list were those situations experienced to be less anxiety
producing. T hese same items were then utilized as individual
treatment goals. As patients progressed throughout their
treatment, it was expected that they would move up their
individualized fear hierarchies, being able to accomplish
increasingly difficult goals.
O nce the initial assessment phase was completed, all
patients underwent treatment for a 12 week period. T he first
two weeks of treatment involved two individual sessions per
week, where the following treatment plan was followed:
a) further exploration of the patients' presenting
concerns;
b) explanation of the nature of agoraphobia;
c) discussion of treatment and rationale for treatment;
d) instruction in diaphragmatic breathing and relaxation
exercises, along with other anxiety coping techniques,
such as systematic desensitization, the use of humor,
paradoxical intention, distraction, positive imagery,
and thought stopping.
34
e) session with spouse and/or significant others to
explain the nature of the patient's problem and to
elicit their help as co-therapists.
T o facilitate the initial stage of treatment, each patient
was presented with a client manual (Mathews, G elder & Johnston,
1981). T his manual covers issues such as the nature and
treatment of agoraphobia.
Following the first two weeks of treatment, one individual
session and one group session were conducted each week for 10
weeks of treatment. T he primary mode of therapy was the
behavioral exposure treatment program suggested by Marks (1981).
T his program involves the therapist assisting the patient in
entering and remaining within all feared situations until
anxiety dissipates. T he individual is exposed to these
situations until doing so is accompanied by a lack of anxiety.
In addition, areas such as self-sufficiency, social anxieties,
interpersonal conflicts and inappropriate labeling of emotions
were a focus of attention within the treatment sessions
(Chambless & G oldstein, 1980, G oldstein and Stainback, 1987),
with the treatment taking on a more cognitive behavioral style.
Following treatment, a post-treatment interview was
conducted with each patient. T hese interviews were
semi-structured with a fixed set of questions (See Appendix B)
35
being used as guidelines in the session. In addition, a
follow-up group session was conducted four weeks
post-treatment.
RE SUL T S
All of the data in the present study are quantifiable and
interval in nature. T he results can be found in Chapters 4 and
5, as well as in T ables 1-8. T here are many qualitative
differences which are quite clinically significant. T hese will
be discussed, along with the quantitative differences, in the
following chapters.
SUMMARY
As stated earlier, what is being looked at in this study is
internal life change (i.e., the process of change which occurs
within the individual) as it occurs throughout the course of
therapy, in concert with an increase of mobility which is
indicative of clinical improvement with this specific patient
population.
In order to gain an appreciable understanding of such
internal changes, it appears to be most fitting to begin with a
knowledge of the manner in which patients present themselves
during their initial therapy sessions. It is to this end that I
devote the following chapter.
Chapter 3: T he P atients Speak
I would like to use this chapter to more fully introduce
three very important people. Mary, P am and E llen represent the
core of the present exposition. T hey have taught me more than
they could ever imagine. I introduce them now, since all the
hypothetical derivatives in the world aren't as convincing as
real life situations.
MARY : UP O N INT AKE
Mary is a 31 year old married female caucasian. She noted
that for the past year, she has experienced varying levels of
anxiety which are very distressing. Mary stated that she
experiences a mild level of anxiety all of the time; however,
when she attempts to drive or walk moderate distances away from
her home or designated "safety zone," she begins feeling
intensely anxious. Mary notes that at these times, she will
shake, have knots in her stomach, experience heart palpitations,
weakness in her limbs, a distortion of time and place, and
difficulty concentrating. T he patient also reports that she
feels as though she is losing control. D ue to the intensity of
these feelings, along with Mary's fear of experiencing them, she
has established an elaborate pattern of avoidance. At this
time, Mary will only travel short distances from her home while
unaccompanied. It is important to note, however, that when Mary
is accompanied by others her mobility is unimpaired.
36
37
According to Mary's report, she first experienced a panic
attack a few months after the birth of her second child. She
noted that at that time, she had been suffering from post-partum
hyperthyroidism, although she was not aware of this at the time
of her first attack. It was at that time that Mary began
establishing a pattern of avoidance. E ven when her thyroid
condition was under control, Mary continued to avoid many
situations. According to her report, the avoidance and the
anticipation of panic have intensified over the past several
months.
D E VE L O P ME NT AL HIST O RY :
Mary is the oldest of five children. She reports having a
very happy and active childhood while growing up in New Y ork.
Mary recalls getting along very well with her siblings, and
having many friends. W hen Mary was a junior in high school, her
one brother died in a car accident. Mary unknowingly came upon
the accident which occurred a short distance from her home,
after being dropped off by her boyfriend. According to the
patient's report, her parents had a very difficult time
dealing with his sudden death. She recalls consciously deciding
to be the strong one in the family. W hile the rest of her
family was mourning their loss, Mary tried holding the family
38
together by taking over all of the domestic responsibilities.
Mary reports that it was years later when she began crying over
the loss of her brother.
O ne month after Mary's brother died, her maternal
grandmother died. T his was quite a tramatic experience for
Mary, since she was very close to her grandmother and had spent
many summers staying with her.
E D UCAT IO NAL HIST O RY :
Mary graduated from a Catholic high school, which holds
many pleasant memories for her. She reports that she was
involved with a very close group of friends with whom she would
engage in many activities. Upon graduating from high school,
Mary moved to Northeastern P ennsylvania, where she completed a
4-year undergraduate program in medical technology. Mary
reports that moving away from home was an adjustment for her,
but that she made friends quickly and did well academically in
her program. D uring the summer months, Mary would return to her
hometown in New Y ork, where she was employed as a nurse's aide.
Mary also completed an intership in New Y ork.
E MP L O Y ME NT HIST O RY :
Upon graduating from college, Mary accepted a job in a
laboratory, where she has been employed as a medical
technologist for the past nine years. Mary reports that she
39
enjoys her work, and gets along very well with her supervisors
and fellow workers. In the initial stages of her employment
career, Mary reported that she also held several part-time
jobs. She did so in an effort to save money to get married.
MARIT AL HIST O RY :
Mary was married at age 24, and has been married for the
past 7* 5 years. Mary had dated her husband on and off since
she was a freshman in college. She reports having a very good
relationship with her husband. However, she notes that
recently she has begun feeling depressed over her limitations of
mobility and that she has thus been less involved, or
interested in sharing as many activities with her husband as she
had in the past. Mary also notes a decrease in her sex drive.
Mary has two daughters, ages 3 and 1. Both children were
planned and Mary reports having a good relationship with both
children. Both she and her husband spend much time with the
children. O n occasion when neither is able to be with the
children due to their work schedules, the children spend time
with the babysitter with whom they get along very well. Mary
does not feel that her children are influenced by her current
problem, as she feels she is quite successful at hiding it from
them.
ME D ICAL HIST O RY :
P resently, Mary states that she is in very good physical
health. She is not taking any medication for medical or
emotional problems. She has a history of post-partum
hyperthyroidism which developed after the birth of her second
child. She was hospitalized and medically treated for this
problem. At this time, her thyroid functioning is normal.
ME NT AL ST AT US UP O N INT AKE :
T he patient is a 31 year old married female caucasian who
appears her stated age. T he patient was casually dressed for
the interview. She was cooperative and friendly throughout the
interview. Her eye contact was excellent and her speech was
appropriate to the material she presented. Her thought
processes are productive, organized and spontaneous. T here is
no evidence of delusional or hallucinatory thought. Her
sensorium is clear, and the patient is oriented in all spheres.
Both her short-term and long-term memory appear functionally
intact, as do her attending and concentrating skills. Mary is
motivated for treatment.
P AM: UP O N INT AKE
P am is a 33 year old, married female caucasian who appears
her stated age. She reported symptoms of anxiety which she has
experienced more or less intensely for the past 13 years. P am
41
reports that whenever she goes shopping, attends church or
social functions, eats in a restaurant, walks great distances
from her home or drives on unknown highways, she experiences
intense panic. Feelings of panic include sweating,
palpitations, irregular breathing, weakness in arms and legs,
fear of fainting, and a desire to escape. P am currently takes
one milligram of Valium about two times per week, to control her
anxiety.
D E VE L O P ME NT AL AND E D UCAT IO NAL HIST O RY :
P am is one of two children. She has an older brother, age
38. P am recalls her early childhood as being the happiest time
of her life. Her family was very close and they shared many
activities together. P am described her mother as an extremist.
She was sometimes very happy, affectionate and loving, then
would swing to being very angry and moody. At those times, she
would scream and often hit P am. P am's father would often step
in, resulting in the parents arguing among themselves. P am
remembers listening to her parents argue, and she, herself,
reacting by getting an upset stomach. P am describes her mother
as being very strict, and often abusing alcohol.
G rade school and high school were very positive experiences
for P am. She reports doing very well academically, making the
honor roll each semester. P am was quite active at that time,
taking piano and twirling lessons.
42
W hen P am was 16, her father was diagnosed as having
cancer. He died 1% years later. P am recalls her father's
illness and death as being the worst time of her life. She
stated that her father was "everything" to her. W hen he died,
P am became very angry. She stated that the wouldn't go to
church and felt very alone and scared.
After her husband's death, P am's mother became very
depressed. She refused to go anywhere or do anything. It was
at that point that P am took over all domestic responsibilities
for her mother. She was angry and upset over the lack of help
from her older brother. P am missed many high school activities
because of her felt responsibilities at home.
W hen P am was 17, her mother met a boyfriend. She would go
out socializing and drinking, coming home drunk quite often.
P am recalls hearing her mother and her mother's boyfriend
getting intimate. P am would react with an upset stomach.
P am stated that after her father died, she was never very
close to her mother. She felt her mother did not care about her
feelings. High school was a very stressful time for P am and she
would faint quite often, as well as feel nauseous and vomit. At
one point P am's mother took her to a physician because of these
symptoms, telling the physician that P am was pregnant. P am was
very hurt and angry over this episode.
W hen P am was 18, her mother remarried. P am's mother was
pregnant at the time. T he two were married for six weeks.
After four weeks of fighting and throwing things, this man moved
out. He moved back four days later. After having been
reunited for two weeks, P am's mother and stepfather went out for
the evening. P am's stepfather came home alone. P am's mother
was missing for four days. Finally P am's boyfriend found the
mother's body in the garage. T he coroner determined that she
had been dead for four days, and had died of carbon monoxide
poisoning. Although her death was determined to be suicide,
P am believes her death was accidental. Since P am's mother had
no will, the stepfather sold the house and kept all the money.
He also kept $9,000 which was found in the house, believed to be
the money obtained from P am's father's life insurance.
P am states that she was never the same after her mother's
death and that she misses her even more than her father. P am
does not understand this, especially given the very strained
relationship she had with her mother.
MARIT AL HIST O RY :
P am married one month after the death of her mother. She
married the boy she had dated since the age of 13. T he two had
been engaged for three months, and had set the date of their
wedding for O ctober. T hey decided to move the wedding up to
April, since P am did not want to stay in her mother's home. T he
44
couple moved in with the husband's family. T wo months after the
wedding, P am's husband went away for six months, serving in the
Reserves. Shortly thereafter, P am found out she was pregnant.
L iving with her mother-in-law proved to be very difficult
for P am. She never had any privacy, and her mother-in-law was
always commenting on the amount of cleaning she did, and on how
to care for the baby, etc. W hen the baby was born, P am's
husband was not very affectionate with his child. He would not
hold or feed her. P am was quite hurt by his reactions. It was
right after the birth of her daughter, while shopping at J.C.
P enney that P am had her first anxiety attack.
T he marriage continued to deteriorate, with P am's husband
developing a drinking problem. T he two would constantly argue
over his drinking and excessive protectiveness. P am finally
divorced her husband, after seeing that the problems in the
relationship were negatively affecting her daughter, who was
becoming very fearful and whose schoolwork began to decline.
P am found her own apartment and began supporting herself.
She then met her current husband and lived with him for one year
before getting married. P am has been married for three years.
She feels that she and her husband are a very good match. She
is very pleased with the relationship, as well as the way her
husband gets along with her daughter. P resently, she is three
months pregnant and both she and her husband are very excited
45
about their having another child. P am reported that she feels
as though her relationship with her husband strengthened her, as
far as her symptoms are concerned. She is quite upset that her
symptoms have become quite intense once again over the past lh
years. T he only precipitant that is perceived by P am is her
moving into her aunt's house. P am had taken care of this aunt
over an extended illness, and the house holds many unpleasant
memories.
E MP L O Y ME NT HIST O RY :
For the past 18 years, P am has been employed part-time as a
twirling teacher. She reportedly is satisfied with her job.
ME D ICAL HIST O RY :
P am has a history of high blood pressure. She takes
Inderol, as prescribed by her family physician.
ME NT AL ST AT US UP O N AD MISSIO N:
P am is a 33 year old female who was fashionably dressed for
the interview. P resently, P am is three months pregnant. P am
was cooperative and pleasant throughout the interview. Speech
was expressive, and eye contact was excellent. P am presented
herself in a mildly depressed and anxious mood. Her affect was
appropriate to the material she presented, with P am becoming
tearful at certain points throughout the interview. Her thought
46
was spontaneous and organized, and there was no evidence of
psychosis. Her sensorium is clear, and P am is oriented in all
spheres. Both her short- and long-term memory appear
functionally intact, as do her attending and concentrating
skills. P am is motivated for treatment.
E L L E N: UP O N INT AKE
E llen is a 45 year old, divorced white female. She
discussed symptoms of anxiety which she has experienced for the
past 17 years. According to E llen's report, she experiences
frequent anxiety attacks. She notes that she will develop a
weakness in her limbs, feel dizzy and nauseous. She also
experiences anticipatory anxiety. Because of her anxiety
symptoms, E llen's mobility is severely restricted. She will
only venture away from her home when it is absolutely necessary
(e.g., groceries) and only for very brief periods of time. In
addition, E llen reports a fear of being alone. Although E llen
describes this problem as chronic in nature, she did note that
she experienced some improvement following her divorce from her
husband. She notes that she was doing fairly well for a period
of time, and then became increasingly symptomatic this past
D ecember when her daughter moved out, deciding to go to college
in P hiladelphia. E llen also reports that since Christmas, she
has experienced sleep onset and sleep continuation disturbance
along with a decrease in appetite. E llen has lost 38 pounds
47
since Christmas. According to E llen's own report, she has been
treated with tranquilizers up until last month. According to
her, she has been doing much better since her medication was
discontinued.
In terms of describing any difficulties she has in dealing
with people, E llen notes, "I repeat myself constantly. I
apologize for everything I do or explain why I did it or said
something. I feel lower than the other person, and never feel
free to express my opinion."
D E VE L O P ME NT AL HIST O RY :
E llen is the youngest of five children. She describes her
home life as "happy" throughout her childhood. E llen stated
that her whole family was very close and that everyone did
things together. She describes her mother as "pleasant,
hard-working, kind-hearted, always putting her children first."
W hen E llen was 21 years old, her mother died. Her father had a
difficult time adjusting to this loss. He became depressed and
seemed to experience what E llen described as a phobic reaction.
She stated that he was always nervous, couldn't ride in cars,
and was fearful of going places. E llen's father died 15 years
ago from arteriosclerosis. E llen cared for him until he was
placed in a sanitarium. Around that same time, E llen also took
care of her brother's three children, after their mother died of
cancer. It was during the same year that her father died, that
48
E llen first entered the hospital for "emotional problems."
According to her report, she has been hospitalized four times
during the past 15 years for her problems with anxiety and
depression.
E D UCAT IO NAL HIST O RY :
E llen is a high school graduate. She reports that she did
not experience any academic or social problems.
O CCUP AT IO NAL HIST O RY :
According to E llen' s report she held a number of minimum
wage factory positions during her lifetime. She was employed
prior to the birth of her first child, and again after her
oldest daughter entered kindergarten. P resently, she is
unemployed and receiving W orkman' s Compensation.
MARIT AL HIST O RY :
After a short courtship, at age 21 E llen married a man who
was 9 years her senior. According to E llen' s report, he was
ready to be married and she just went along with the idea.
Shortly after the marriage, E llen reports that the two began
having marital problems. She stated that he was very frequently
physically abusive, that he never allowed her to do anything
(e.g., spend any money, visit with friends, plan vacations,
etc.). She noted that it was very clear that "he was in
charge", and she would have to listen to what he wanted her to
do. She stated that at times he would force her to leave the
house and stay outside in the cold because she did not pay half
of the heating bill.
T wo daughters were born from this union, and E llen
remembers feeling badly because she was not able to bear a son
for her very traditionally minded husband. Four years ago,
E llen began receiving W orkman' s Compensation after aggravating a
back injury. After years of physical and psychological abuse,
E llen finally found a way of being able to support herself. She
divorced her husband and found an apartment for her younger
daughter and herself.
E llen reports having a difficult time initially, adjusting
to the change. She then reports an improvement in her
condition, with a concurrent increase in her mobility. She
dates the return of more severe symptoms to last year, when her
youngest daughter began planning to go away to college.
ME D ICAL HIST O RY :
E llen has experienced a number of medical problems.
P resently she is receiving D isability after re-injuring her back
five years ago. She first had back surgery in 1969, at which
time she had two discs removed and one fused. In addition, she
presently takes medication for high blood pressure. She also
50
takes P remarin for hormonal changes associated with
menopause.
ME NT AL ST AT US UP O N INT AKE :
E llen is a 45 year old female caucasian who was neatly
dressed for the interview. She was very verbal and related in a
coherent and relevant fashion. E llen gave evicence of
significant anxiety and depression. Her affect was appropriate
to the material she presented. Her sensorium is clear and there
is no evidence of a thought disorder. Both her short- and
long-term memory appear functionally intact, as do her attending
and concentrating skills. P resently she seeks treatment, other
than medication, to assist her in overcoming her fears.
SUMMARY
Mary, P am and E llen were presented in the above
comprehensive fashion primarily to give you, the reader, an
appreciation for the severity of the patients' distress as they
began treatment, as well as an understanding of some of the
situations and experiences which contributed to the development
of their illness. In the following chapters, I will be tracing
the changes that occurred in these patients as they progressed
throughout the course of their psychotherapy, with a special
focus on changes in agency and depression. It will be helpful
to keep the material of this chapter in mind as we watch these
changes unfolding in the following chapters. T his material
should be especially helpful when reviewing the qualitative
changes that will be discussed, since the patients will be
making references to background information that they had
discussed early on in psychotherapy.
Chapter 4: Agency
Now that you have met some of the patients, let us review
the behavioral changes that occurred throughout the course of
psychotherapy. In view of the patients' own goals as presented
in their individualized behavioral hierarchies (see Chapter 2),
the range for those eleven patients who completed the 12-week
treatment program was 9 to 11 completed goals, out of a
possible 15 goals. T he mode for these patient goals was 14,
the mean 12.7, and the median 13.
Similar findings were found on the Fear Questionnaire. O n
this scale, patients rate on a 0 to 8 point scale their own
avoidance of two situations of which they are very fearful,
along with 15 important phobic situations which are specified
on the Questionnaire. In addition, this scale gives a
composite score for the patients' overall rating of disability
caused by the agoraphobia. T his scale ranges from 0 = No
phobias present/no disturbances, to 8 = Very severely
disturbing/disabling. T he results of this scale can be found in
T able 1. In terms of the Agoraphobia subscale of the Fear
Questionnaire, patients started treatment with a mean score of
5.1 per item. T hey completed treatment with a mean score of 1.8
per item. In addition, patients moved from an initial mean
disability score of 5.1 (Markedly disturbing/disabling) to a
mean disability score of 2.1 (Slightly disturbing/not really
disturbing) by treatment termination.
Having reviewed the behavioral, as well as the subjective
ratings of the patients, let us now review the performed
linguistic analyses. T he expectation here was that patients
would move from an initial position of speaking of themselves as
a recipient of those things which were going on around them to
being a more responsible agent within their world at treatment
termination. It is important to note that this is exactly what
is found when the data are analyzed via the Chi Square Statistic
(see T able 2).
1) D uring the first session, 43 statements out of 72 made
by Mary were expressions of self-as-recipient, whereas 11
statements were expressions of self-as-agent. By the final
session, 44 statements out of 135 were self-as-recipient
statements, whereas 63 were statements of self-as-agent
(Significant at .001 level).
2) D uring the first session, 23 out of 48 statements made
by P am were statements of self-as-recipient, whereas 17
statements were expressions of self-as-agent. By the final
session, 12 out of 52 statements were statements of
self-as-recipient, whereas 23 were statements of self-as-agent
(Significant at .05 level).
3) For E llen, the trend was in the same direction, although
not quite as dramatic as for Mary and P am. D uring the first
session, 31 out of 57 statements made by E llen were statements
of self-as-recipient, whereas 12 statements were expressions of
self-as-agent. By the final session, 45 out of 86 statements
made by E llen were statements of self-as-recipient, whereas 31
were statements of self-as-agent.
An even further exploration of these results is
interesting. T hat is, one might be curious as to the
differential distribution of self-as-recipient of failure vs.
self-as-agent of success statements. T hat is, given their
enhanced sense of self-control, we would expect to find that
patients move from a position of seeing a great amount of
negative things happening to them (self-as-recipient of
failure), along with seeing themselves as having little agentive
power over success experiences (self-as-agent of success), to a
point where they experience a decrease in the amount of negative
things happening to them (self-as-recipient of failure), with a
concurrent increase in their agency in terms of positive events
(self-as-agent of success). Utilizing the Chi Square Statistic,
consistent trends are found (see T able 2).
1) For Mary, 41 of her 54 statements during the first
session were self-as-recipient of failure statements vs. 29
out of 106 in the final session. O n the other hand, 4 of her
statements out of 54 during the first session were self-as-agent
of success statements vs. 43 out of 106 in the final session
(Significant at .001 level).
2) For P am, 20 of her 40 statements during the first
session were self-as-recipient of failure statements vs. 11
out of 35 in the final session. Self-as-agent of success
statements were made 6 times out of 40 during the first session,
and 23 times out of 35 during the final session (Significant at
.001 level).
3) For E llen, 26 of her 43 statements during the first
session were self-as-recipient of failure statements vs. 41
out of 79 in the final session. Self-as-agent of success
statements were made 4 times out of 43 during the first session,
and 29 times out of 79 during the final session (Significant at
.01 level).
From these analyses, it becomes quite clear that the
patients are speaking of themselves as moving in the direction
of activity from a level of passivity. More specifically, they
express themselves as being more active in terms of creating
success for themselves and less passive in their experiencing
of failure.
It is interesting to note that similar changes can be
noted when we actually listen to the ways in which they express
themselves verbally. W hat I would like to focus on first is the
56
patients' narrative accounting of their illness. It is important
to note that some very significant changes appear to have taken
place over the course of therapy. O ne is immediately struck by
what appears to be a change in the patients' narrative accounts
of the development and/or their understanding of their
agoraphobia. As is clear from the following accounts, these
patients moved from giving a verbalized accounting of the
development of their symptoms as something mystical which merely
"happened to them," to an accounting of their illness as
something which is in some ways determined, "controlled," or at
least understood by them. P lease note that what we are looking
at here is not the capacity of this given treatment program to
facilitate patient change, but rather we are looking at the
types of changes which occur in a treatment program which does
appear relatively successful.
P AM: INIT IAL SE SSIO N
T herapist: P am, thinking back, can you remember when you
first noticed this as a problem?
P am: UmmHmm. It was right after she was born (her
daughter) and umm... I hadn' t been out for about a
month. And a...my husband said, "W hy don' t we go shopping
or something...we' ll go out and get something to
eat...we' ll go up the mall." I said, "O h sure." Y ou
know. So we left her with my mother-in-law. And we were
in the middle of the mall, and I met a friend...one of my
girlfriends...and we stopped to talk. And as she is
talking...all of a sudden...I...that was the first time
that I had the feeling dizzy and you know...weak...and
I just said in the middle of her conversation. "Jean, I
don' t feel good. I have to leave." And we left. And that
was the first experience that I had And that was
thirteen years ago
T herapist: Could you tell me about that time of your life?
P am: A...everything seemed good you know. I just had a
baby, and a...everything seemed normal enough. Because I
never had one up until then. Y ou know. I was fine. I
don' t know why, you know. I really don' t know why. I just
remember standing in P enney' s...in J.C. P enney' s...and I...
I just had to leave.
W hat is interesting to note about this first session is
that P am was able to recognize upon further in-depth
questioning that she was experiencing much stress during that
time of her life. W hat is curious is that she was not able to
connect the experiencing of stress with her felt anxiety
symptoms. T his appeared to change by the end of treatment.
P AM: FINAL SE SSIO N
58
T herapist: W hat' s your understanding of it P am? W hat' s
your understanding of how this whole thing developed?
P am: W ell, losing my mother. It was...L osing my mother,
getting married the next month...moving in with people I
did not know...getting pregnant a few months after that.
Being totally alone. L ike so many times, people have said
to me...If I ever went through what you' ve gone through,
I' d be in Clarks Summit (a State P sychiatric Hospital).
Y ou know...and that' s how I...I even feel that way about
myself. I think I really am strong, because I have
survived. Y ou know, and it really was tramatic...it
really was hard.
T herapist: So, you feel as though it was all of the
stressors together that led to this?
P am: Y eah...and the being alone. T he being so alone.
Cause I was, you know...like no family...no husband...he
was away. Being with strangers, living somewhere where I
have lived for 18 years of my life, and all of a sudden, I
don' t live there...and that' s not my house anymore. I
can' t go back and visit...there' s no one there...
59
AFT E R FURT HE R D ISCUSSIO N, T HE T HE RAP IST ASKS
T herapist: And what about if you start feeling nervous
again? O r I should ask, what are you going to do when you
feel nervous again? Because you will.
P am: Y eah, I know. Cause I am. I don' t mean right now.
I mean I know what you mean. I just...I know what the
reason is. So, it will be like any other thing. I have
to get through the situation Cause I' ve learned to...
I' ve learned to say this is not what you think it is.
T herapist: T o differentiate your feelings.
P am: Y eah...yeah
As we listen to the narrative account of Mary, we get a
similar feeling that the initial mystical understanding of the
disorder changes to a greater sense of understanding and control
by the end of treatment. T he following excerpts are
illustrative of that change.
MARY : INIT IAL SE SSIO N
T herapist: Mary, can you remember back to when you first
started having these feelings?
Mary: UmmHmm...1 was really physically sick and didn' t know
it. I was hyperthyroid...I was running around like that
for a long time. I was hospitalized for the
hyperthyroidism in May. But when I looked back on it
afterwards, it had been going on for a couple of months.
Because I was going on no sleep...hopping up at 4 o' clock
in the morning. It was as if I was on speed. And I was
just going...going. And I had just had a baby...But at the
time when I...in May...she was 6 months old...so she was
only 3 months old when this whole thing started. And I
come to find out that the whole thing is called post-partum
hyperthyroidism. It did have a name. But I thought...
you know...I feel like a million bucks I can do anything.
go any...anything...And then all of a sudden it just...all
of a sudden it just...it must have just started wearing
down on me...all of a sudden, it was a ton of bricks...
this whole thing hit me. I had a...well, I had a racing
heart...it was 125 beats per minute. T hat was from the
thyroid. But it was since that condition cleared up...
it was still as if I had all this too.
W hat is very interesting about Mary' s first session is that
she does have some vague sense of how the agoraphobia got
started. However, she clearly felt as though the anxiety just
hit her out of the blue. In addition, she did not have any
61
understanding as to controlling the anxiety. Her narrative
account by the end of treatment shows a dramatic difference.
MARY : FINAL SE SSIO N
Mary: Y ou know what? I was sitting thinking today...
before when I was afraid to go places and do things. I
think a lot of times I really wasn' t afraid. I didn' t want
to go. O .K. Y ou know how sometimes you really don' t want
to do things. I was so afraid of doing so many things,
that when I didn' t want to do it...I thought I was afraid
to do it.
T herapist: Y ou couldn' t tell the difference?
Mary: Right. I couldn' t tell the difference. But now I
can. L ike today....
AFT E R FURT HE R D ISCUSSIO N, T HE T HE RAP IST ASKS MARY ABO UT T HE
D E VE L O P ME NT O F HE R P RO BL E M.
Mary: W ell, it never happened to me before in my
life...until that time. W ell, I was sick, and didn' t know
it. And I just had a terrible panic attack on 307. It was
terrible. And I was by myself with the kids. And it was
after that...it was...O h no, what was this? It was...
this is going to happen again...and it was constantly.
It was, of course it will happen again because you
kept thinking about it happening again. And I didn' t
know what was going on.
T herapist: How do you make sense of all that now?
Mary: I think it was two....fold things. I was
sick...my thyroid was hay wire. I was run down. I was
tired. I was going on 4 hours of sleep a night. And
I was doing everything under the sun. T rying to play
super-mom...you know how it is. Compulsive. And I just
think that did it. Y ou know, you can only take so much.
And that was it And there' s no making sense of
it. It' s just over with now. I was a mess.
T herapist: W hat do you mean, "No making sense of it?"
Mary: I just can' t make sense of the whole thing. It was
just...W ell, I can see what I did!! I worked myself into
it...partially. And the other part I didn' t have control
over (referring to the hyperthyroidism). So I just won' t
ever let myself get into that rut mentally, let' s
say...again, because I know what can happen.
E llen' s narrative accounting is similar.
63
E L L E N: INIT IAL SE SSIO N
T herapist: Can you remember when you first started having
this problem?
E llen: A long time ago. I mean I wasn' t as bad in the
beginning...after I got married...I' d say, I started to
get bad three years after...I got married...that I could
feel these things coming on. Maybe I was, you know...But
they weren' t really bad then. I didn' t really have these
fears of going places...as far as nerves...and I started
headaches, you know, and I don' t know why I was depressed
...and all that stuff. But I' ll tell you when those fears
and phobias really started. I can remember. Right after
my back surgery. T hat was in ' 69, and I got all these
things that all of a sudden, I couldn' t go places. It
didn' t really affect me in the house at that time. But
I just felt every time I went somewhere, that this was
coming on me...that...get me out of here. I started to
feel that right after that. Somehow it just got
continuously worse.
T herapist: Right after the back surgery?
E llen: T hat' s how I remember it. T he next year, all of a
sudden, it was right after Christmas.... I remember that
every place I went out, I started to feel that way. I
64
didn' t run out...I would leave because I would say, "I
don' t feel good." I' m so dizzy, I' m weak all over. I
just felt, I couldn' t stay in the place. I just got
worse I really did.
Although by the end of the treatment program, E llen does
not speak of her understanding of what caused her illness, she
does speak about her increased understanding of her symptoms.
E L L E N: FINAL SE SSIO N
E llen: I understand them more and I saw the difference in
our group meetings even associating things such as it' s
humid outside everybody else feels hot. It doesn' t
mean that because I feel that way that something happened.
I learned to see the difference. I learned to see that
when I feel that it' s always a panic...I learned to know
that I feel very nervous because this happened, and it
isn' t, you know, a panic attack. And those kinds of
things. T hat I have, you know, learned a lot of that.
In looking at these verbalizations, one is automatically
struck by the fact that all of these women appear to have moved
from a position where they viewed themselves as having no
control over their illness (passivity), to a point where they
now believe that there are things which they can do to take
control (agency). T he next obvious question that one might ask,
is whether or not this degree of agency and recipiency are
65
limited to changes in the patients' experiencing of their
symptoms, or whether this extends into other life areas as
well.
L et us take a further look at this issue before we review
the analyses of results. If the treatment of agoraphobia is
limited to an increase in the patients' mobility and a decrease
in felt as well as anticipated anxiety, it is still quite
beneficial, although apparently restricted to those specific
areas focussed on directly in treatment. O n the other hand, if
we see the individual making changes in the same direction in
other areas as well, then it would appear that treatment has
penetrated to an ever deeper level. T hat is, it has become part
of the patient' s conscious way of being in her world, rather
than merely being her way of dealing with agoraphobic symptoms.
Now, it is quite interesting to note that when we take a
look at tabulated linguistic results, the trend of patients
moving beyond mere improvement of the phobic condition to other
areas as well is strongly suggested. T he following results are
to be noted. In order to make these comparisons, patient
statements were divided into those in which reference was made
to the agoraphobic condition, and those in which reference was
made to situations or experiences other than those related to
the phobic condition. Results were analyzed via the Chi Square
Statistic (see T able 3).
66
1) For Mary, when considering only agoraphobic related
statements, 38 of her 51 statements made during the initial
session were self-as-recipient of failure statements, while 4
were self-as-agent of success statements. By the end of
treatment, 22 of her 68 statements were self-as-recipient of
failure statements, while 24 were self-as-agent of success
statements (Significant at .001 level). W hen statements other
than those related to the agoraphobia were considered, all 3 of
her statements made during the initial session were
self-as-recipient of failure statements, while none were
self-as-agent of success statements. By the end of treatment, 7
of her 38 statements were self-as-recipient of failure
statements, while 19 were self-as-agent of success statements
(Significant at .05 level).
2) For P am, when considering only agoraphobic related
statements, 15 of her 34 statements made during the initial
session were self-as-recipient of failure statements, while 5
were self-as-agent of success statements. By the end of
treatment, 7 of her 22 statements made were self-as-recipient of
failure statements, while 13 were self-as-agent of success
statements (Significant at .05 level). W hen statements other
than those related to the agoraphobia were considered, 5 of her
6 statements made during the initial session were
self-as-recipient of failure statements, while 1 was a
self-as-agent of success statement. By the final session, 4 of
67
her 13 statements were self-as-recipient of failure statements,
while 9 were self-as-agent of success statements (Significant at
.05 level).
3) For E llen, when only agoraphobic related statements were
considered, 21 of her 28 statements during the initial session
were self-as-recipient of failure statements, while none were
self-as-agent of success statements. By the end of treatment,
19 of her 46 statements were self-as-recipient of failure
statements, while 23 were self-as-agent of success statements
(Significant at .001 level). W hen statements other than those
related to the agoraphobia were considered, 5 of her 6
statements during the initial session were self-as-recipient of
failure statements, while none were self-as-agent of success
statements. By the end of treatment, 22 of her 33 statements
were self-as-recipient of failure statements, while 6 were
self-as-agent of success statements.
L ooking at patient verbalizations gives further support
for the finding that the changes are beyond the actual phobia
itself. T he following examples from the patients' final
sessions are representative of such statements.
MARY
Mary: Maybe it' s my attitude that' s better. I think
before, all I was thinking about I wasn' t just thinking
68
about myself, but I was too inward...that I didn' t look at
other things. I just...I just wasn' t involved. I mean I
tried...maybe I was trying too hard. I used to think that
everything that went wrong was my fault. And now I see it
wasn' t. Y ou know, you' re only human, and you can only do
so much, but when you' re not feeling well, you think, "O h,
it has to be my fault." And you take all the blame. It
only makes you feel...it makes you feel worse on top of it,
because...But things now are just...maybe it' s...I have a
better attitude. I' m more...I' m saying what I feel now.
Instead of just letting it ride, and thinking it' s all my
fault. But things...this isn' t right...that isn' t right.
I' m saying, L isten...L ike I' m starting...L ike this is how
I used to be...like T his isn' t my fault...don' t get on
my back. Y ou know...Before, I was just quiet, and I said,
"O .K., all right, O .K.".
And now I don' t have to worry, because I feel good.
And when you feel good...you feel good about yourself...if
people aggravate you, it' s not that upsetting. W hen I got
upset before, I got real upset. Cause I felt rotten to
begin with.
...I' m in control. I don' t feel 100% in control yet...but
I don' t think I ever want to be like that again.
...Before this ever happened to me, I was in control
of everything. Job...home...everything was just perfect
...just fit in. No problem...And then I went to zero
control. Now, I don' t want everything in place.
Because if one thing is out of place, I' ll be, "O h, no".
T hen, you kill yourself to make everything right, and
nobody cares anyway. Nobody knows the difference except
yourself.
...Y esterday, I came home from work...and I just had one
of those types of days. And I said to G eorge, "W e' re
going out to dinner, I' m paying. I' m not cooking. I' m
not doing anything in this house, because I have no
energy." 1 had a rotten day, so I made it good.
RAM
P am: Umm...I' m happier...A lot happier. Umm...E asier
going...Not that I was not an easy going person before,
but I' m more so now. I enjoy things. I enjoy things...
that I honestly couldn' t say I even enjoyed before.
T herapist: L ike what?
P am: D riving...anything...little things. Being with
people. Silly little things. I just did not enjoy
70
before. Y our common everyday was like Ahh...you know, do
I have to do this, and I must enjoy.
...O h, my confidence is definitely better. I' m...I know
I' m a lot more confident. W ell, I am confident
...And people have noticed a change in me.
T herapist: W hat do they notice?
P am: 0, G ee, "Y ou look so good, and you' re always you
know, smiling, and" because I am. It' s like
before...you know...go to twirling...put in my hours...
you know, I was just umm...umm. I am a fun person, don' t
get me wrong...but it would be fun on my terms. Y ou know
...to my limitations. And if you put me in another
situation, I was just there.
T herapist: And now you' re feeling that way more often?
P am: Y eah, like go and have a good time, I' m having a good
time. It' s a terrific feeling again.
P AM T AL KS ABO UT HAVING W O RKE D T HRO UG H T HE FACT T HAT HE R
MO T HE R CO MMIT T E D SUICID E .
P am: I feel very peaceful about that part of my life
now. T hat I can' t say that I' ve been peaceful for 13 years
with...and I haven' t. And I feel strong. Strong in the
71
sense that, look, after all this time, I can say this is
what it was, and I' m better for it than I was before.
T herapist: W hat do you mean, "T his is what it was?"
P am: D efine...1 ike my mother' s suicide...T hat' s what it
was. Y ou know, instead of pretending. Still pretending,
O h, it was an accident. Y ou know, and that is what it
was 1!!
T herapist: So, being truthful with yourself about the
situation has
P am: Helped me.
T herapist: It sounds as though it has led to a sort of
freedom inside of you.
P am: Y eah yeah Freedom...I was talking to my
mother-in-law yesterday...because they came up to visit.
And she asked me how I was doing...and how many more. And
I said this was my last week and everything. And I told
her, I said, I have finally buried my mother. Cause that' s
how I feel. I have. But it' s not the sorrowful...you
know...it' s just a calm. L ike I let go. I' m not carrying
her with me...with everything I do, and everywhere I go.
And I don' t know...I think that that was such a
major...major problem for me.
E L L E N
72
E llen: T he past 12 weeks, I just learned a lot...that I
have a little bit more confidence in myself...1 ike you
know, to do things for myself and see the difference of
how I was taken advantage of by people...
...W ell, as far as being with the different people...I
learned that I could say no sometimes without feeling
guilty...although I' m nore really totally free of that
either. But I have said no even yesterday
...I mean every bit counts...to me it does. T hat little
push...or pat on the back...I' ve even started that...
(laughs)...patting myself on the back So, the
other night, I did make progress, you know. O f course, I
don' t have somebody to talk to all of the time, and it' s
not abnormal to talk to yourself, right? And I just said,
"W ell, nobody gave you credit today E llen, but I think you
did great today"...I said, "G ood girl".
W hen the actual progress notes of these patients are
reviewed, along with the audiotaped sessions, it becomes very
clear that in the beginning of treatment, these patients are so
focused on their agoraphobia that it appears as though they can
focus on little else. O nce they start to experience some
73
success with overcoming their agoraphobic symptoms, they start
looking at and working on other life areas as well. By the end
of treatment, we see that these patients have a different
orientation to the world. T hey have creatively restructured
their view of the world as a place where they have control, if
not over the things which actually happen to them, then at least
over their reaction to these events.
Chapter 5: W hat About D epression?
As was noted in the opening chapter, many agoraphobics
experience feelings of depression. Although quite a bit of
research has been done in this area, there remain many
unanswered questions based on equivocal results. L et us review
some of this work.
Bowen and Kohout (1979) found that the incidence rate of
primary affective disorders was around 91% for the 55
agoraphobics in their study. Bug!ass et al. (1977) found that
depression was clearly demonstrated in 30% of their sample. It
was present to a minimal degree in a further 17% of their
sample. In addition, Munjack and Moss (1970) found that 41% of
their agoraphobic sample experienced depressive episodes.
Although evidence does suggest that these disorders tend to be
associated with one another, the relationship between the two
appears to be far from clearly specified.
Marks (1970) suggests that agoraphocia and depression
interact, but that the two run distinct courses. He notes that
often agoraphobics do report a depressed mood, feel hopeless and
irritable, as well as experience crying spells. He notes that
often the depression and agoraphobia increase at the same time.
In addition, the depression and phobia may improve
concurrently. T hus, although he sees the disorders as distinct,
74
75
he suggests that agoraphobia may be aggravated during a
depressive episode, and that as the phobia gets better, the
depression may be lifted. O ther theorists hold differing views
as to the relationship of agoraphobia and depression. For
example, Bowen and Kohout (1979) suggest that agoraphobia is
secondary to primary affective disorders, with the phobia
masking the affective disorder. Shapira and associates (1970),
on the other hand, have argued that agoraphobia and depression
are actually variants of a common disorder.
In view of the above, it is clear that theories as to the
relationship of agoraphobia to depression span a wide continuum.
Clinical evidence does not support the theory that
agoraphobia and depression represent a common disorder.
E vidence suggests that not all agoraphobics are depressed, nor
are depressed individuals agoraphobic. In addition,
pharmacological evidence (Kelly et al., 1970; T yrer, Candy and
Kelly, 1973) suggests that when agoraphobics are treated with
drugs, the panic will often decrease, but the depression will
not. W ith the exception of this theory, the presented theories
as to the relationship of these disorders appear plausible,
with no one theory predominating.
T he failure to clearly specify the relationship between
76
these two disorders appears to be related to several factors.
O f special importance seems to be the correlation and post
hoc nature of the research conducted in an effort to find
support for these hypotheses. O f even more significance
appears to be the fact that these studies define depression
according to variable criteria, while some studies simply do not
define depression at all.
Many of these problems speak to the current state of
affairs in regard to views of depression itself. D epression has
been defined variably as an affect, as a developmental stage, as
a symptom, as a syndrome, as well as a character style. W hen
looking at the incidence rate of depression, very much depends
upon the manner in which depression itself is defined.
A significant advance in the field has been made by Beck
(1961). Beck has developed a self-report inventory for
depression, which has been found to be quite reliable, as well
as valid. T his inventory was developed in an attempt to provide
both a standardized, as well as a consistent measure of
depression, which would not be sensitive to inconsistencies in
administration or theoretical orientation.
Another advancement in the area of depression has been made
by Blatt (1974). Blatt attempted to provide an integration of
the diversity of formulations and observations which have been
77
made about depression. In doing so, he made a distinction
between two types of depression: anaclitic and introjective.
Anaclitic depression is characterized by feelings of
helplessness, weakness, and depletion. T here are intense
fears of abandonment and desperate struggles to maintain
direct physical contact with the need-gratifying object.
Introjective depression, in contrast, is characterized by
feelings of worth!essness, guilt, and a sense of having
failed to live up to expectations and standards. T here are
intense fears of loss of approval, recognition, and love
from the object, (p. 107)
Blatt, D ' Afflitti and Quinlan (1976) add that anaclitic
affect is not in and of itself pathological, but that it may
become pathological when it occurs within severe
psychopathology, or when it re-emerges as a reaction to conflict
or trauma within important interpersonal relationships.
Introjective depressive affect, on the other hand, is
hypothesized to be centered around the patient' s ambivalent
feelings which he/she has about the perceived or judgmental
sense of the parents. In addition, they note that these two
forms of depression are not necessarily mutually exclusive and
that they may, in fact, combine in certain individuals, with a
compounded form of depression emerging. Blatt et al. attempted
to develop an objective way of differentiating these two
78
dimensions. From their investigations, the D epressive
E xperience Questionnaire was developed. T hree factors
differentially related to these dimensions were found. T hese
include D ependency, Self-criticism, and E ffiacy. T he scale has
been revised and revalidated by W elkowitz, L ish and Bond (1984).
In view of the paucity of knowledge we have concerning
depressive experiences within an agoraphobic population, the
present investigation is an attempt to take advantage of these
two advances in the area of depression, as well as to utilize
language usage, in an effort to come to a better understanding
of depression within an agoraphobic population. W hat I would
like to suggest is that many agoraphobics are depressed and
that this depression may be of different degrees as well as
forms. If this is the case, it would make clear why statistical
studies based on large populations would bear equivocal
results. At the same time, however, one would expect that
successful treatment would be correlated with a decrease in
depressive symptomatology.
L et us begin by taking a look at our three patients as
they present on intake in response to the question, "D o you ever
get sad or depressed?"
79
MARY
Mary: I do...only because of this whole thing. It' s
like...It' s like you' re caught in a spider' s web...and
everyday you get up and say, "O h, maybe I' ll be better
today." Y ou know, and sometimes I guess you know...things
just don' t go your way, and everything just gets...it gets
to you. Y ou get extremely depressed. I don' t walk around
depressed all of the time...but it does get to me.
P AM
P am: UmmmHmmm. Y eah. Holidays are terrible.
T herapist: Is there a reason for that?
P am: O h, yeah... I just think, you know...all my relatives
are gone. Y ou know...and it' s so hard to go through a
holiday when a...you don' t miss them.
T herapist: Are there other times when you get sad?
P am: Uhh...O h, I don' t know...sometimes just...umm...doing
something that I' ve done. And half the time...like when I
was young (tearful). Y ou know what I mean, like being at
the lake on a picnic. And all of a sudden it will hit
me...G ee...I remember, you know, being with my mother or my
father. Y ou know...stuff like that.
80
T herapist: So most of your sadness is about missing people
who are no longer here with you?
P am: Y eah.
T herapist: W hat do you do when you get sad or depressed?
P am: Cry (laughing while tearful). I cry.
T herapist: D oes that make you feel better?
P am: Sometimes. Sometimes it does.
E L L E N
E llen: T here are things I know I shouldn' t do...like dwell
on the past...but I can' t seem to do anything about it.
E llen speaks further of her depressed feelings in the first
group session. T he following excerpt gives us a good feel for
what she is experiencing.
E llen: And it was, I guess it was prolonged tension that
brought it on throughout the years. It was just an unhappy
home. And to take care of the kids by yourself...and under
that pressure constantly. So, but then, this is a problem
that I had years ago...that didn' t let me get out of, you
know, the situation...because I felt I was just...I can' t
shift for myself...and that' s why I stayed in that
situation...which made it worse. So, I don' t know where
...I just felt that there was no hope...I better do
something about it. And I don' t know...and this is a
problem now...with me... I can' t stand on my own two feet.
Y ou know, to just go out socially...it just brings you
back into a depression. Y ou can' t do what other people do,
and But I feel if I could conquer this then I could be
just a little bit better at anything else. But I haven' t
for years ever gone with my daughters anywhere...and I
always felt guilty because I wasn' t a mother. I wasn' t
able to attend the school functions...1 did try
sometimes...but I was defeated before I got there. And you
stand in the back, and then looking for a ride to go home,
because you couldn' t stay there. But I...then I used to
get into a depression because I felt guilty that I wasn' t
even a mother. But still...my goals are at least if I
could enjoy it a little bit, and go visit my daughters
away from here. Stuff like that, but a it just makes it
harder for me to see, because I have that fear of being
alone now, because I' m this way. But maybe with a little
bit of practice, and you know
W hat is interesting here is that all three women admit to
feelings of depression, yet one is immediately struck by the
difference in the way they talk about them. Mary seems to get
depressed in reaction to the limitations of her agoraphobia,
especially as related to her interpersonal relationships. P am,
on the other hand, seems to experience depression as grief over
losses which occurred many years ago. Finally, E llen appears to
be experiencing depression due to a number of things. She states
that she feels depressed because of the way her agoraphobia
limits her. In addition, she feels unable to let go of past
pain, and often feels helpless and weak. As E llen talks about
her life in the first several sessions, it is quite apparent
that depression has been experienced by E llen for many years of
her life. In addition, she spends much time talking about how
alone she is, and how no one seems to understand her.
W hen we look at the Beck D epression Inventory (see T able 4),
what is seen is that these three women are suffering from
varying degrees of depression. According to the results of this
Inventory, Mary' s depression at the beginning of treatment was
mild; P am' s was moderate; and E llen' s was severe. It is also
interesting to note that by the end of treatment, all three
women experienced a decrease in depression. According to the
Beck D epression Inventory, by the end of treatment neither Mary
nor P am were depressed, and E llen was only mildly depressed.
Similar changes are evidenced as we review the results of the
D epressive E xperience Questionnaire (see T able 5). W hat is
evidenced is a decrease in both anaclitic and introjective
83
depressive affects for all three patients. As can also be
seen from T ables 6 and 7, these same trends exist for the
entire population studied.
W hen linguistic trends are considered, the same results are
suggested. T hose things which were looked at in this regard
were the percentage of positive and negative statements made,
and the number of positive and negative self-statements made.
T he following findings, as analyzed via the Chi Square
statistic, are illustrative (see T able 8).
la) For Mary, during the first session, 48 out of 72
statements made were negative, while 56 out of a total of 135
statements were negative by the end of therapy. O n the other
hand, 12 out of 72 statements made were positive during the
initial session, while 72 out of 135 were positive during the
final session (Significant at .001 level).
lb) For Mary, 37 out of 72 statements made during the first
session were negative self-statements, while 46 of such
statements out of 135 statements were made by the end of
therapy. In addition, 7 of the 72 statements made during the
first session were positive self-statements, while 59 of such
statements out of 135 were positive by the end of treatment
(Significant at .001 level).
lc) For Mary, when only statements related to agoraphobia
84
were considered, 45 of these statements out of 67 made during
the first session were negative, while 41 of those statements
out of 75 made during the final session were negative. In terms
of positive statements, 12 out of 67 were made during the
initial session, while 34 out of 75 were made during the final
session (Significant at .01 level).
Id) For Mary, again only when considering agoraphobia
related statements, 34 of such statements out of 67 made during
the initial session were negative self-statements, while 36 of
such statements out of 75 were made during the final session.
In terms of positive self-statements, 7 were made out of 67
during the first session, while 29 out of 75 were made during
the final session (Significant at .01 level).
le) For Mary, when only those statements relating to issues
other than the agoraphobia were considered, 3 out of 5 were
negative during the first session, while 15 out of 60 were
negative during the final session. O n the other hand, none of
the 5 statements made during the first session were positive,
while 38 out of 60 were positive by the end of the treatment
program (Significant at .05 level).
If) For Mary, again when only taking into consideration
statements related to issues other than agoraphobia, 3
statements out of 5 were negative self-statements during the
beginning of treatment, while 10 out of 60 were negative by the
85
end of treatment. O n the other hand, none of the 5 statements
made during the initial part of treatment were positive
self-statements, while 30 out of 60 were positive by the end of
treatment (Significant at the .01 level).
2a) For P am, 37 of 48 statements made during the initial
session were negative in nature, while only 15 such statements
were made of 52 by the end of treatment. O n the other hand,
11 of all 48 statements made during the initial session were
positive in nature, while 35 such statements out of 52 were
made during the final session (Significant at .001 level).
2b) For P am, 28 of all 48 statements made during the
initial session were negative self-statements, while only 11
of 52 were made by the end of treatment. In terms of
positive self-statements, 9 out of 48 were made during the
initial session, while 34 of 52 were made during the final
session (Significant at .001 level).
2c) For P am, when only statements related to agoraphobia
were considered, 29 of these statements made during the first
session of 38 were negative, while 8 of those statements of
the 27 made during the final session were negative. In terms
of positive statements, 9 of 38 were made during the initial
session, while 12 out of 27 were made during the final session
(Significant at .01 level).
2d) For P am, again only when considering agoraphobia
related statements, 25 of 38 made during the initial session
were negative self-statements, while 7 statements out of 27 were
made during the final session. In terms of positive self-
statements , 7 of these statements of 38 were made during the
first session, while 17 of 27 were made during the final
session (Significant at .001 level).
2e) For P am, when only those statements relating to issues
other than the agoraphobia were considered, 8 out of 10 were
negative during the first session, while 5 out of 25 were
negative during the final session. O n the other hand, 2 of the
statements out of 10 made during the first session were
positive, while 18 out of 25 were positive by the end of the
treatment program (Significant at .01 level).
2f) For P am, again only when taking into consideration
statements related to issues other than agoraphobia, during the
initial session 3 out of 10 were negative self-statements,
while 4 of such statements out of 25 were made by the end of
treatment. O n the other hand, 2 positive self-statements were
made out of 10 during the initial part of treatment, while 17
out of 25 were positive by the end of treatment.
3a) For E llen, during the first session, 40 of all 57
statements made were negative, while 47 of 86 were made by the
87
end of therapy. O n the other hand, 11 of all 57 statements
made were positive during the initial session, while 34 out of
86 were positive during the final session (Significant at .05
level).
3b) For E llen, 25 of all 57 statements made during the
first session were negative self-statements, while only 27 of
such statements out of 86 were made by the end of therapy. In
addition, 7 of all 57 statements made during the first session
were positive self-statements, while 32 of such statements out
of 86 were made by the end of treatment (Significant at .01
level).
3c) For E llen, when only statements related to agoraphobia
were considered, 32 of these statements out of the 46 made
during the first session were negative, while 23 of those
statements out of 50 made during the final session were
negative. In terms of positive statements, 10 out of 46 were
made during the initial session, while 25 out of 50 were made
during the final session (Significant at .01 level).
3d) For E llen, again only when considering agoraphobia
related statements, 19 out of 4 were negative self-statements
within the initial session, while 19 of such statements out of
50 were made during the final session. In terms of positive
self-statements, 6 out of 46 were made during the first session,
88
while 25 out of 50 were made during the final session
(Significant at .01 level).
3e) For E llen, when only those statements relating to
issues other than the agoraphobia were considered, 8 out of 11
were negative during the first session, while 24 out of 36 were
negative during the final session. O n the other hand, 1 of the
11 statements made during the first session was positive, while
9 out of 36 were positive by the end of the treatment program.
3f) For E llen, again when only taking into consideration
statements related to issues other than the agoraphobia, 6 of
such statements out of 11 were negative self-statements in the
beginning of treatment, while 8 out of 36 were negative by the
end of treatment. O n the other hand, 1 of such self-statements
out of 11 was positive in nature during the initial part of
treatment, while 7 out of 36 were positive by the end of
treatment.
W hat is strikingly significant here is the fact that for
all three patients there was a consistent decrease in the number
of negative and negative self-statements made, as well as a
consistent increase in the number of positive and positive
self-statements made throughout the course of treatment. It is
important to note that although patients do not cease to make
negative statements by the end of treatment, a careful review of
89
the linguistics gives evidence of a demonstrable change that is
not only quantitative as discussed above, but also qualitative.
As a first example of such changes, in the beginning of
treatment patients have a tendency to focus on all of those
things which they are unable to do. As mentioned previously,
patients are usually so consumed by their agoraphobic symptoms
that they speak little of anything other than these symptoms.
W hat we see in the beginning of treatment then are numerous
verbalizations concerning behavioral restrictions due to their
anxiety symptoms. W hen they speak of something they can do, it
is generally qualified, i.e., patients tend to make statements
about the qualificatory circumstances which make such behavior
possible. O n the other hand, by the time patients reach
treatment termination, they tend to speak quite enthusiastically
of all of the things which they are able to do. W hat gets
qualified at that point are those things which the patients
are unable to do or have not yet accomplished. In these cases,
patients have a tendency to state that these things really
aren' t that difficult, but that they just haven' t had an
opportunity to accomplish them. In other cases, they will speak
of the relative unimportance of those things. E ven when they
talk about negative feelings (e.g., panic attacks), the statement
is made that the feelings are mild compared to the intensity of
those experienced pre-treatment.
90
T hese qualitative changes become clear when we look at the
way in which patients talk about their agoraphobic symptoms in
the beginning of treatment vs. the end of treatment. T he
following excerpts are indicative.
MARY : FIRST SE SSIO N
Mary: My main problem is...I have a fear of going places
alone...outside of a certain radius. I can bring my
children to the baby sitter, which is all the way in North
Scranton, and I live in South Side, but I have to go the
same route every way...every day...and then back to work.
I can' t go to the mall. I won' t go to CI arks Summit
anymore I just...I' 11 go down to the grocery
store...it' s only a couple blocks away...but only within
the small radius of my home I' m scared. I just get
panicky. I say, I' m just going to turn around and go back
home. Some days even places close to the house, I go
to, but I' ll be real shaky. I' ll just do what I have to
do, and go right back home. T hen some days things don' t
bother you as much for some reason. I don' t know why. But
other days, it' s like, I just won' t even go...If I don' t
have to leave the house to go someplace, I just won' t
bother.
FINAL SE SSIO N
91
Mary: E verything is so much better. I mean there are still
some things...like I' m still kind of funny about hopping in
the car and driving to NJ all by myself. Cause I didn' t
do it yet. I just haven' t had the time. It' s but
it' s not the idea of panic. Before, it was NO W AY !!! But
now, it' s I don' t think it will be that bad. But it' s not
...I' m hopping to go do it.
T herapist: So you don' t have the feeling of panic anymore?
Mary: No...I don' t get panicky...sometimes I' ll get a
little nervous.
T herapist: W hat do you mean?
Mary: Y ou know when you get nervous...when you have a big
test or something. T hat kind of little bit nervous. But
it passes. W here panic is gripping fear. I don' t get that.
T herapist: Basically, you' ve accomplished all of the goals
you initially set for yourself, with the exception of going
over your favorite bridges.
Mary: W ell, I really haven' t had a chance to go over them.
But I still, I don' t even think that enters into this.
T hat' s a deep seated problem. I probably have to get
psychoanalyzed for that (laughs), but I' m not going to
bother. It' s just one of those things. And I could
probably get on ski lifts again. I just have a fear of
heights. I mean, a million people have it...millions of
people have it. If that' s the only thing that I have in my
life, then that' s too bad. I mean, I' ll live with that...I
couldn' t live with the way I was before.
P AM: FIRST SE SSIO N
Ram: It' s been years...years...it' s not just lately...and
sometimes it gets better and sometimes it' s terrible and
always there. Umm... I have a problem shopping in the
Acme or G iant...any big food store. And I will go in if it
is not crowded. And I will go to the nearest checkout that
has no line. And then when I' m in line, even if I' m the
first one and there' s nobody in front of me, I... by the
time they ring it up, I' m already sweating, and I' m
"Hurry up please, I have to get out, I have to leave."
Y ou know? T hat happens shopping...It even happens
clothes shopping...and when I do go, I always go when it' s
not crowded...when it' s not busy, I...I will go at a busy
time I get dizzy...it doesn' t seem...the aisles
seem...I feel like I get tunnel vision. Y ou know what I
mean? T hat I can' t look around right. And if I' m
93
searching for something on a shelf, it' s...there are so
many different ones, that I can' t even decide. Y ou know
what I mean? T hat I can' t find what I' m looking for.
Because everything seems to get...there' s too many.
P AM: FO L L O W -UP G RO UP SE SSIO N
P am: I can' t sit there and honestly say that it' s gone,
because I still think about it. I still...sometimes I' m a
little...umm...I get a little nervous if I' m going to do
something. My thing is anticipation. O nce I' m there...I' m
all right. It' s always been the anticipation...and I can
get myself worked up, which I don' t...but I still think
about it. I can' t honestly say that it' s gone...that I
don' t think about it...cause I do. But I' m working on it.
Coming here today... I haven' t been here in so long...
it' s something new again...but it was just the anticipation.
Member: D id you accomplish all of your goals?
P am: Y eah...the only thing is the orthodontist with my
daughter, but I don' t even see that as a big thing anymore.
E L L E N: FIRST SE SSIO N
94
E llen: Now yesterday was the first time since before
Christmas that I got in the car and drove to O lyphant.
Simply because I think I was forced to do it, because my
nephew has invited me so many times...that he' s just
disgusted...cause I never come...and I thought if I don' t
go...they' re not going to bother with me again...So, I just
forced myself to go. And I knew that my sister' s husband
was driving...But all week I was thinking about it...and I
had myself sick all week just because I had to go up
there.
SP E AKING O F A T IME W HE N SHE FE L T SHE W AS D O ING MUCH BE T T E R,
E L L E N ST AT E S:
...I told you, I was never free of it, but I was able to...
I would go to restaurants...of course, I would ask for
that table by the door...I would sometimes...I would be
you know, be with my friends...and I would get through
a little meal...you know, get it down...but it was...
get me out of here quick...I' m glad it' s over with...
watching the clock to go home...but yet I was able to do
that much...I was able to go...O f course, I never really
went anywhere alone...I always had somebody with me even
if I went shopping for a little bit. But no matter, even
when I felt better...if I was in the middle of the store
...maybe if I was just there for a few minutes, I wouldn' t
think about it...cause I was busy maybe concentrating on
something...But the minute it hit me...it was...look where
you are...I' d have to just go.
E L L E N: FINAL G RO UP
AL T HO UG H NO T CO NSIST E NT L Y P O SIT IVE , E L L E N ST AT E S:
E llen: W ell, I feel that I accomplished a lot. I know I' m
not as far ahead as they are. But...I didn' t accomplish
half of my goals...but I feel that I, you know,
accomplished a lot of them. But...what I learned and
everything here...I just feel I' m just going to keep at
it...and I will...accomplish...you know...them in
time...but I did, you know, a lot better. And am doing
it...than I did before. So, I think I...I accomplished a
lot by coming here. Just the fact of being in here
now...which I couldn' t have done before. So, I' m very
happy with it.
...and I still feel I can' t. But then, if I sit and think,
I' ll say, wait...why can' t I? So O .K. push and do it.
T he above excerpts give evidence suggesting not only that
patients are feeling more mobile by the end of treatment, but
also that they have re-framed their views concerning those
things which they are still unable to do, or have yet to
accomplish. Y et another qualitative difference in patient
expressions has to do with the manner in which these patients
speak of themselves relative to their illness. Initially, they
make statements to the effect that they feel badly about
themselves in general, or more specifically in certain important
roles that they have. Some statements appear self-condemning in
nature, as the patient discusses how the illness encompasses so
much of their lives. As the patients progress through treatment
they begin to experience themselves as being successful in
overcoming certain symptoms, as well as over behavioral
limitations. T hey begin to feel better about their lives in
general as well as in their capacity to function effectively
within their given roles.
MARY : SE SSIO N O NE
Mary: I have days a lot, where I' m just...panicky...
anxious...and I feel like I' m walking in a fog. T his
happens just about everyday. It' s like I can' t think
clear.
1 work in the clinical labs, and I work with isotopes.
I have to do pregnancy testing, and things like that. And
97
before, where I used to just check off positive and
negative, I' m just not so sure of myself, anymore. I' ll go
back and I' ll look...and I' ll look...I' m just not that
confident or conscious.
SP E AKING ABO UT HE RSE L F IN HE R RE L AT IO NSHIP MIT H HE R
HUSBAND , SHE ST AT E S:
I' m not as much fun as I used to be...Umm...I don' t get
enjoyment out of a lot of things. I don' t care to go out.
L ike he' ll say, let' s go here or there, and I don' t really
care about it. And our sex life is not as great as it used
to be, but then there are the two kids. But then, I' m just
not as interested in that as I used to be...Umm, just doing
things, you know, that used to be fun for me...just aren' t
anymore.
MARY : FINAL SE SSIO N
Mary: ...I wasn' t rational before, let' s put it that way.
O .K. and now, I can think things out...I don' t do stupid
things. W ell, maybe not stupid things, but you' re more
level headed...or clear headed.
...I' m getting back to my old self. I' m just more
interested in things...more aware. I' m not looking at
myself...I' m looking out now.
98
(About my progress, I feel...) G reat!!! I mean
everything is so much fun now E verything before was
like a drudgery. It was like a fight to do everything.
...I want to do stuff all the time.
SP E AKING ABO UT HE R CHIL D RE N, SHE ST AT E S:
And my kids needed a lot of attention. T hey' re young
kids. But now...it' s no problem paying attention to them.
Now it' s just so much better.
...I used to think that everything that went wrong was my
fault. And now, I see that it wasn' t. Y ou know, you' re
only human, you can only take so much, but when you' re not
feeling well, you think, "O h, It has to be my fault."
SP E AKING O F P RO BL E MS SHE HAD IN HE R RE L AT IO NSHIP W IT H HE R
HUSBAND , SHE ST AT E S:
...(T he problems were)...not just my fault. Cause
he...well, he couldn' t understand He...I think
before just didn' t know what was going on...he didn' t know
how to handle it. So I think he tried to ignore it. And
ignoring that...he ignored me...And I figured if you' re
going to ignore me...I' m going to ignore you. And we were
at each other' s throats all of the time. Cause you' re
99
aggravated with that person, and all they have to say is
one thing...that turns you wrong...and that' s it.
...I think we both changed.
P AM: SE SSIO N O NE
P am: I feel like I' m hurting my daughter a lot, because I' m
not doing the mother/daughter things that are pleasant,
besides mother/daughter things that have to be done. Y ou
know, like going...the ballet is tonight, and yes, you know
mom will be there. W hich it is the pleasant little things
I can' t...I don' t think I can, I know that I don' t feel...I
feel that she is missing out on experiences with me.
...I feel like such a failure. I feel like why can' t I be
like the other mothers and say, "Come on Honey, we' re going
down to the mall."
...I' m tired of feeling weak...weak...Because feeling
weak, you know, I can' t do it. I can' t do it. Y ou know,
I want to but I can' t. It makes me feel very weak. I
don' t mean physically, I mean just a weak person.
P AM: FINAL G RO UP SE SSIO N
100
SP E AKING O F T HING S SHE IS NO W ABL E T O D O W IT H HE R D AUG HT E R,
SHE ST AT E S:
...I took Carol to the lake...Just she and I went. And
I...it was the first time I drove...well it was the second
time actually, but the first time I went up there to spend
the afternoon, you know. Umm...I' ve got to tell you, I
felt so normal...NO RMAL T his was the first time,
since she was born, that I felt normal.
P AM: FINAL SE SSIO N
SP E AKING O F T HO SE P AST E X P E RIE NCE S W HICH CO NT RIBUT E D T O HE R
IL L NE SS, SHE ST AT E S:
...I think I really am strong, because I have survived.
Y ou know, and it really was tramatic...it really was hard.
E L L E N: SE SSIO N O NE
E llen: I have tried even to go and take on a job with
children. A friend of mine asked me to watch her
children. I told her I couldn' t evey stay at her
house...and that' s open...I couldn' t do that because I was
away from my house all day... I couldn' t take care of the
101
kids...I can' t stay at the house. And there' s really no
reason...because I could walk outside. So I couldn' t do
that...I really can' t do anything.
SP E AKING ABO UT HO W D IFFICUL T IT W AS FO R HE R T O G E T O UT O F
HE R D ISRUP T E D MARRIAG E , E L L E N ST AT E S:
...T his is a problem that I had years ago...that didn' t let
me get out of, you know, the situation...because I felt I
was just...I wouldn' t be able to exist by myself...I can' t
shift for myself.
...And I don' t know...this is a problem now with me...that
I can' t stand on my own two feet. L ike you know, to just
go out socially...it just brings you back into a
depression. Y ou can' t do what other people do, and...But
I feel if I could conquer this, then I could be just a
little bit better at anything else. But I haven' t for
years, ever went with my daughters anywhere...and I always
felt guilty, because I wasn' t a mother. I wasn' t able to
attend the school functions...I did try sometimes...but I
was defeated before I got there. And you stand in the
back, and then looking for a ride to go home, because you
couldn' t stay there. But I...then I used to go into a
depression because I felt guilty that I wasn' t even a
mother. But it was...I just couldn' t do it but a it
102
just makes it harder for me see, because I have that fear
of being alone now, because I' m this way. But maybe with a
little bit of practice, and you know...
E L L E N: FINAL G RO UP
...I know I have a lot of hard work to do. But I don' t
know, I just feel that I' m heading in the right direction
this time.
E llen discusses that she has learned to start recognizing
that some of the relationships she is in are demanding more from
her than she feels comfortable giving. She held on to all of
these relationships in the past partly because she had
difficulty refusing people, but mainly because of her dependency
needs. In becoming somewhat more self-reliant she slowly begins
to set limits within these relationships.
E llen speaks about her coming to the realization that her
daughters are demanding. She talks about setting the limits
with them. T his is something she was unable to do before
because of her feelings that she was an inadequate mother.
...T hey' ll slam the door, and say..."T ake care of yourself
mom", and boom, I won' t see them for how long...Until
there' s a problem...they need something...so no. And I
103
feel like this...I raised them, believe me all by
myself...and provided for them...I did it!!! T hey' re not
babies...one' s almost 19 and one' s almost 23, and I
think...I feel like this...if something happened to me
tomorrow...they' re going to survive.
In summary, it is clear that all of the patients in the
present study initiated treatment with some degree of
depression. Upon careful analysis, it appeared that this
depression differed in terms of intensity. W ith most patients,
there was a heavier balance of anaclitic affect vs. introjective
affect. It is important to note, however, that the presence of
introjective affect was noted. T his greater emphasis on the
anaclitic factor is consistent with the etiological evidence
(G oldstein & Stainback, 1987) mentioned earlier. T hat is, that
agoraphobia typically precedes some type of conflict in terms of
interpersonal relating. T his depressed affect assumed an
important role for the patients prior to treatment. As such, it
was evidenced not only on objective measures of depression, such
as the BD I, and the D E Q, but more strikingly, in the utilization
of the patients' language apparatus.
Initially, all three patients' instrumental means of coping
appeared to involve a sense of passivity. T his was played out
in the patients' language usage. Behaviorally, there was a
tendency to depend on others for support.
104
As patients progressed throughout treatment, they became
involved in a significant number of healthy relationships (i.e.,
with the therapist and with group members), where they had an
opportunity to develop alternative interpretations of their
personal experiences, as well as being accepted, aided in
working through problems and taught anxiety coping skills.
Moving through such treatment, their instrumental means of
dealing with depression began to change to a more active coping
style. O nce again, this was played out in the patients'
language usage. T heir active coping style behaviorally allowed
them to become more mobile in their worlds, with a decreased
dependency on others for such movement.
By treatment termination, some patients still appeared to
possess some depressive affect, but the depression was not as
predominant. D epressive symptoms appeared decreased, with the
patients beginning to gratify their needs via their own
self-managed activities.
Chapter 6: In Quest of a New W orld View
T he present exposition has been an attempt to take a
preliminary look at patients' internal life changes as they occur
throughout the course of successful psychotherapy. Not only are
the actual findings of this study clinically significant, but in
addition these very findings point to some important
considerations.
L et me begin by reviewing the major findings of the present
investigation. Since we are focusing on changes which occur
throughout successful psychotherapy .with agoraphobics, it is
important to first define just what successful therapy would
entail in terms of an agoraphobic population. In view of this,
I would like to suggest the following:
1) An increase in patients' mobility (i.e., an increase in
the patients' ability to travel outside of their homes without
experiencing uncontrollable panic); and
2) A decrease in felt symptoms of anxiety, as well as
depression related to the experienced limitations of the
disorder.
As is clear from previous chapters, all of the patients in
the present investigation were successful in terms of achieving
the above criteria. In view of tracking internal life changes
105
the verbalizations of three individuals were utilized as the
primary medium for exploration. In summary, the following
changes have been noted:
1) P atients moved from giving an initial verbalized
accounting of the development of their symptoms as something
mystical which merely "happened to" them, to an accounting of
their illness as something which is in some ways determined,
"controlled," or at least understood by them.
2) P atients moved from speaking of themselves as a
recipient of those things which go on around them to speaking
of themselves as a more responsible agent within their world.
3) P atients moved from a position of seeing a great amount
of negative things happening to them (self-as-recipient of
failure), along with seeing themselves as having little agentive
power over success experiences (self-as-agent of success), to a
point where they spoke of themselves as being less passive in
terms of negative things happening to them (self-as-recipient of
failure), with a concurrent increase in their agency in terms of
positive events.
4) As patients moved through treatment they began making
more positive agentive statements and less negative recipiency
statements not only about those issues having to do with their
disorder, but in terms of many other life areas as well.
107
5) T he patients were depressed and this depression was of
different degrees as well as forms. As patients moved through
treatment, this depression decreased.
6) As patients moved through treatment, there was a
consistent decrease in the number of negative statements and
negative self-statements made, as well as a consistent increase
in the number of positive statements and positive
self-statements made.
7) Although patients did not cease to make negative
statements by the end of treatment, there was a demonstrable
qualitative change in the way they presented themselves as they
made such statements. T hat is, during the initial phase of
treatment, patients had a tendency to focus on how vast their
limitations were. W hen they spoke of something they could do,
it was generally qualified in terms of the circumstances which
made such behavior possible. In contrast, by treatment
termination, they had a tendency to speak enthusiastically of
all of the things which they were able to do, qualifying those
things which they found unable to do or had not yet
accomplished.
8) In the beginning of treatment, patients had a tendency
to speak negatively of themselves not only in terms of their
disorder, but also in terms of themselves in general, especially
108
in view of the special roles that they played (e.g., mother, wife,
employee). As the patients progressed through treatment, they
began to speak of themselves not only as successful in terms of
overcoming certain symptoms, but also about their lives in
general, as well as in their capacity to function more
effectively within their given roles.
In view of the above findings, it seems most fitting to
argue that internal life changes certainly do appear to be
taking place as patients moved along in terms of their
treatment. O ne significant change that seems to have occurred
is that patients began to experience themselves as being more
responsible agents. In addition, this sense of agentive power
seemed to become their conscious way of being in the world,
rather than merely being limited to their sense of control over
their agoraphobic symptoms. In line with this, it is important
to point out that there was an actual change in patients'
narrative accounting of past events as they progressed
throughout their treatment.
A second clinically significant change is that as patients
made progress in treatment, they became less and less
depressed. Again, this was reflected in objective measures
(D E Q, BD I), as well as in the increased frequency of their
positive statements and positive self-statements, as well as
the decreased frequency of negative statements and negative
109
self-statements. In addition, it is important to stress that
these statements were made not only in reference to their
agoraphobic symptoms, but also in terms of general life areas as
well.
In view of these clinically significant changes, I would
like to argue from a constructivist position that the patients
in this investigation created a new world view for themselves as
they moved through psychotherapy. In the beginning of
treatment, these patients saw themselves as impotent failures.
T hey viewed themselves as living in a world full of
uncontrollable experiences...a world in which there was no
protection from the ravages of unpredictable negative
occurrences.
In the process of talking throughout their therapy, as well
as through learning certain cognitive behavioral oriented
control techniques, the patients seemed to begin reformulating
their world views. T his approach allowed patients to consider
different alternatives, seeing the world and their place in it
as possibly amenable to different interpretations. T his
appeared to be accompanied by a sense of empowerment. W hat is
significantly striking is that this sense of potency
generalized beyond the mere capacity to control the anxiety
symptoms which they came into therapy with to a structured and
functional view of the world.
110
Although the above considerations mark the findings
regarding the primary hypotheses of the present research, it is
important to point out a number of additional considerations
which have grown out of the present investigation. T he first
consideration speaks to the use of language, given the fact that
psychotherapy is so intimately tied to verbal transactions.
Most of the findings of the present study were only made
possible through consideration of the language apparatus. T he
present study seems to offer insight into the process of change
which can be evidenced as treatment progresses, i.e., change as
viewed through the use of the language apparatus as an
instrumental means of dealing with distress, as well as giving a
fuller appreciation of the use of the language apparatus as a
means of objective analysis within the clinical field. It is
strikingly significant that such high inter-rater reliability
was obtained utilizing linguistically derived measures.
Second, and perhaps more important, the present
investigation has relevance for the issue of the relationship
between language, behavior and intrapsychic processes. T here
are a number of positions that can be taken on this issue. For
example, one could argue that changes in language occur as a
result of intrapsychic changes and/or as a result of changes in
behavior. L ooking at the flip side of this position, one might
argue that it is language which leads one to thought and then
into action. I would like to put forth the hypothesis that both
I l l
of the above positions may be representative of the actual
processes at work. More specifically stated, I would like to
offer the view that language does indeed have a capacity to
alter behavior, as well as intrapsychic functioning. In
addition, behavior and intrapsychic processes appear capable of
changing language. Both of these processes appear to work in
concert with each other, flowing together to produce a perfect
harmony. T his harmony has the capacity to constantly change
throughout the course of psychotherapy, as well as throughout
the course of life.
A third consideration I would like to discuss relates to
the relevance, as well as the effectiveness of short-term
cognitive behavioral psychotherapy in terms of facilitating
internal life changes which have traditionally been considered
within the realm of more long-term psychoanalytic
psychotherapy. T he question of whether such internal life
changes would occur within other populations, given successful
short-term psychotherapy, remains unanswered. Although this
psychologist would hypothesize that such would indeed be the
case (most notably where depression and anxiety form the core of
the illness vs. character pathology and psychosis), we must
await further research.
In view of the above findings, further investigation does
appear warranted. I would like to suggest that further
112
exploration include a larger sample of patients to determine the
validity of the present findings. In addition, in a more
advanced study, the therapists should be other persons than
those conducting the analyses, to prevent experimenter
bias. G iven more advanced research, it is the hope of this
researcher/clinician that a more complete understanding of the
therapeutic process would be gained. Such an understanding has
the potential for providing us with a more stable base upon which
we can not only establish more effective treatment planning for
an agoraphobic population, bit also for clinical populations in
general.
113
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121
Appendix A
Initial Interview
1. How would you describe what you' ve been experiencing?
2. Is there anything that makes it worse or better?
3. Is it always this way, or does it sometimes let up?
4. Can it happen in any situation, or does it occur in some
specific situations only?
5. D oes it seem to be something in you that creates this
problem, or is it something in your environment that seems
to make such a thing happen?
6. W hat is the feeling like?
7. W hen this thing comes over you, does the world look
different? How?
8. D id you ever feel as though you were going crazy?
9. D o these symptoms ever make you feel blue?
10. T hink back over the past year. W hat was the worst day
like? W hat was the best day like?
122
Appendix B
P ost-T reatment Interview
1. How would you compare yourself now, with the way you were
three months ago?
2. W hat do you think you learned in the past three months?
3. W hat do you feel you could do now, that you could not do
three months ago?
4. W hat things can you still not do, or have great difficulty
doing?
5. Has there been any improvement in important life areas such
as self-confidence, depression, home life, relationships, etc.?
6. Has there been any deterioration in your agoraphobic
difficulties, or in other areas?
7. L ooking back, how do you suppose your troubles got started?
8. D o you anticipate your symptoms to be a problem for you in
the future? If yes, what will you do then?
123
TAB L E 1
FE AR QUE ST IO NNAIRE RE SUL T S - P O P UL AT IO N
T IME
1 2 3
Agoraphobia 35.7 21.5 12.4
mean= 5.1 mean= 3.1 mean = 1.8
Social P hobia 13.5 10.5 7.3
Blood P hobia 15.7 12.0 10.2
Anxiety & D epression 28.5 16.8 12.9
D isability mean= 5.1 mean= 3.5 mean = 2.1
124
Table 2
AG ENT and RECIPIENT STATEMENTS - SAMPL E
1A Mary
P re-
P ost-
2A P am
P re-
P ost-
3A E llen
P re-
P ost-
SAR
43
44
23
12
31
45
SAA
11
63
17
23
12
31
X
signif.
level
.001
.050
SARF SAAS
IB Mary
P re-
P ost-
2B P am
P re-
P ost-
3B E llen
P re-
P ost-
41
29
20
11
26
41
4
43
6
23
4
29
.001
.001
.010
Note. Abbreviations used.
SAR Self-As-Recipient
SAA Self-As-Agent
SARF Self-As-Recipient of Failure
SAAS Self-As-Agent of Success
125
Table 3
AG ORAPH OB IC and NON-AG ORAPH OB IC STATEMENTS - SAMPL E
X
signif.
ASARF ASAAS level
1A Mary
P re- 38
P ost- 22
2A P am
P re- 15
P ost- 7
3A E llen
P re- 21
P ost- 19
4
24 .001
5
13 .050
0
23 .001
NASARF NASAAS
IB Mary
P re- 3 0
P ost- 7 19 .050
2B P am
P re- 5 1
P ost- 4 9 .050
3B E llen
P re- 5 0
P ost- Z2 6
Note. Abbreviations used.
ASARF Agoraphobic Self-As-Recipient of Failure
ASAAS Agoraphobic Self-As-Agent of Success
NASARF Non-Agoraphobic Self-As-Recipient of Failure
NASAAS Non-Agoraphobic Self-As-Agent of Success
126
Table 4
BE CK D E P RE SSIO N INVE NT O RY RE SUL T S - SAMP L E
T IME
1 2 3
Mary
P am
E llen
11
19
31
2
6
28
0
2
14
127
Table 5
DEPRESSIV E EX PERIENCE Q UESTIONNAIRE - SAMPL E
Mary
P am
E llen
Anaclitic Introjective E fficacy
T ime 1 4.5 4.7 5.3
T ime 2 3.8 4.1 5.8
T ime 1 5.2 5.1 5.9
T ime 2 4.8 4.0 5.9
T ime 3 4.1 2.7 5.9
T ime 1 5.8 5.9 3.1
T ime 2 5.8 5.6 3.6
T ime 3 5.6 5.1 4.6
128
Table 6
DEPRESSIV E EX PERIENCE Q UESTIONNAIRE - POPUL ATION
Anaclitic Introjective E ffciacy
X mean X mean X mean
E llen
T ime 1
T ime 2
T ime 3
115 5.8
116 5.8
111 5.6
89 5.9
84 5.6
77 5.1
25
29
37
3.1
3.6
4.6
Karen
T ime 1 105 5.3 80 5.3 29
T ime 2 95 4.8 42 2.8 32
T ime 3 68 3.4 26 1.7 35
T ime 1 103 5.2 76 5.1 47
T ime 2 95 4.8 60 4.0 47
T ime 3 82 4.1 40 2.7 47
Fran
T ime 1
T ime 2
T ime 3
82 4.1
96 4.8
92 4.6
58 3.9
81 5.4
70 4.7
43
45
45
5.4
5.6
5.6
Margaret
T ime 1 99 5.0 72 4.8 23 2.9
T ime 2 81 4.1 45 3.0 30 3.8
T ime 3 82 4.1 53 3.5 29 3.6
Mary S.
T ime 1 92 4.6 41 3.0 35 4.4
T ime 2 66 3.3 31 2.1 32 4.0
T ime 3 63 3.2 30 2.0 36 4.5
Mary B.
T ime 1
T ime 2
T ime 3
101 5.1
101 5.1
84 4.2
63
36
42
4.2
2.4
2. 8
32
34
34
4.0
4.3
4.3
(table continues)
129
Table 6
DEPRESSIV E EX PERIENCE Q UESTIONNAIRE - POPUL ATION
Anaclitic Introjective E ffiacy
X mean mean X mean
Mary K.
T ime 1
T ime 2
89
75
4.5
3.8
71
61
4.7
4.1
42
46
5.3
5.8
E rin
T ime 1
T ime 2
89
80
4.5
4.0
49
33
3.3
2. 2
51
51
6.4
6.4
Helen
T ime 1
T ime 2
122
124
6. 1
6. 2
76
54
5.1
3.9
42
38
5.3
4.8
Barbara
T ime 1
T ime 2
106
104
5.3
5.2
85
82
5.7
5.5
35
36
4.4
4.5
130
Table 7
B ECK DEPRESSION INV ENTORY RESUL TS - POPUL ATION
T IME
1 2 3
E llen 31 28 14
Karen 21 1 0
P am 19 6 2
Fran 16 23 13
Margaret 15 2 1
Mary S. 6 4 0
Mary B. 4 0 0
Mary K. 11 2 0
E rin 9 6
E llen 23 8
Barbara 34 18
X =189
mean=17.2
X =98
mean=8.9
X =30
mean=3.8
131
Table 8
POSITIV E and NEG ATIV E STATEMENTS - SAMPL E
X
signif.
NS P S level
1A Mary
P re- 48 12
P ost- 56 72 .001
2A P am
P re- 37 11
P ost- 15 35 .001
3A E llen
P re- 40 11
P ost- 47 34 .050
NSS P SS
IB Mary
P re- 37 7
P ost- 46 59 .001
2B P am
P re- 28 9
P ost- 11 34 .001
3B E llen
P re- 25 7
P ost- 27 32 .010
Note. Abbreviations used.
NS Negative Statements
P S P ositive Statements
NSS Negative Self-Statements
P SS P ositive Self-Statements
(table continues)
132
Table 8
POSITIV E and NEG ATIV E STATEMENTS - SAMPL E
1C Mary
P re-
P ost-
2C P am
P re-
P ost-
3C E llen
P re-
P ost-
ANS
45
41
29
8
32
23
AP S
12
34
9
12
10
25
X
signif.
level
.010
.010
.010
ANSS AP SS
ID Mary
P re-
P ost-
20 P am
P re-
P ost-
30 E llen
P re-
P ost-
34
36
25
7
19
19
7
29
7
17
6
25
.010
.001
.010
Note. Abbreviations used.
ANS Agoraphobic Negative Statements
AP S Agoraphobic P ositive Statements
ANSS Agoraphobic Negative Self-Statements
AP SS Agoraphobic P ositive Self-Statements
(table continues)
133
Table 8
POSITIV E and NEG ATIV E STATEMENTS - SAMPL E
X
signif.
NANS NAP S level
IE Mary
P re- 3 0
P ost 15 38 .050
2E P am
P re- 8 2
P ost- 5 18 .010
3E E llen
P re- 8 1
P ost 24 9
NANSS NAP SS
IF Mary
P re- 3 0
P ost- 10 30 .010
2F P am
P re- 3 2
P ost- 4 17
3F E llen
P re- 6 1
P ost- 8 7
Note. Abbreviations used.
NANS Non-Agoraphobic Negative Statements
NAP S Non-Agoraphobic P ositive Statements
NANSS Non-Agoraphobic Negative Self-Statements
NAP SS Non-Agoraphobic P ositive Self-Statements