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Effects of covert practice of modeling and of assertiveness on group flooding in vivo in the treatment… Leader, Leslie G. 1981

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EFFECTS OF COVERT PRACTICE OF MODELING AND OF ASSERTIVENESS ON GROUP FLOODING IN VIVO IN THE TREATMENT OF AGORAPHOBIA by LESLIE G. LEADER B . S c , B. Com. U n i v e r s i t y of Cape Town 1964 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF PSYCHOLOGY We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1981 © L e s l i e G. Leader, 1981 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f VCM0<-G6r^i The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Date Mjlj I 3 J ' W / 11 ABSTRACT T h i s study i n v e s t i g a t e d whether the a d d i t i o n of cov e r t modeling. with an a s s e r t i v e model (CM) and of cov e r t a s s e r t i v e n e s s (CA) would augment the e f f e c t s of prolonged group exposure i n v i v o i n the treatment of agoraphobia. T h i r t y - t w o agoraphobic s u b j e c t s were d i v i d e d i n t o three groups. One group (FL/A) r e c e i v e d exposure augmented with CM and CA; the second group (FL) r e c e i v e d s i m i l a r exposure with placebo imagery; and the t h i r d group served as w a i t i n g - l i s t c o n t r o l s . Therapy was b r i e f , t i m e - l i m i t e d , and i n t e n s i v e . Each group of about f i v e members met f o r three s e s s i o n s evenly spaced over f i v e days with each f i v e - h o u r s e s s i o n i n c l u d i n g about 2-1/2 hours of i n v i v o exposure. Both treatment groups were encouraged to use s e l f - p a c e d , home-based exposure p r a c t i c e . S u b j e c t i v e s e l f - r e p o r t measures, a b e h a v i o u r a l d i a r y , and assessment of s o c i a l performance by a s i g n i f i c a n t other were used'to e v a l u a t e outcome. A one month follow-up was done. Both t r e a t e d groups made s i g n i f i c a n t gains compared to c o n t r o l s at posttreatment and at follow-up. S u b j e c t i v e measures of anx i e t y and avoidance showed stronger e f f e c t s than b e h a v i o u r a l r e s u l t s . M a r g i n a l d i f f e r e n c e s were found between t r e a t e d groups with the FL/A group improving on the FL group with more t o t a l time spent away from home (and i n p a r t i c u l a r when unaccompanied), and with decreased a n x i e t y d u r i n g 111 exposure s e s s i o n s . Group exposure i n v i v o i s recommended as an e f f i c i e n t and e f f e c t i v e therapy for agoraphobia. TABLE OF CONTENTS A b s t r a c t L i s t of Tables L i s t of F i g u r e s Acknowledgements I n t r o d u c t i o n D e s c r i p t i v e C h a r a c t e r i s t i c s of Agoraphob Treatment I F l o o d i n g II Modeling and Covert Modeling III Covert A s s e r t i v e n e s s C o n s i d e r a t i o n s in the Design of T h i s Study Method Subjects T h e r a p i s t Des ign Treatment Instruments Assessment R e s u l t s Group Equivalence Treatment Process Measures Treatment Outcome Measures D i s c u s s i o n Process F i n d i n g s Outcome F i n d i n g s References Appendices V LIST OF TABLES Page Table .1 Demographic Characteristics of .Subjects Table 2 Subjective Anxiety Scores by Exposure Session -- Group Comparison Table 3 ANCOVA by Treatment — Fear Questionnaire Table 4 Two-way ANCOVA (Treatment versus Phase) --Fear Questionnaire Table 5 Cross-tabulation (Treatment versus Imagery Practice Level) of Agoraphobia Score --Fear Questionnaire Table 6 Two-way ANOVA (Treatment versus Imagery Practice Level) of Agoraphobia Score --Fear Questionnaire Table 7 ANCOVA by Treatment — SCL90 Table 8 ANCOVA by Treatment — Behavioural Diary Table 9 Two-way ANCOVA (Treatment versus Phase) --Behavioural Diary Table 10 ANCOVA by Treatment — Gambrill & Richey Assertiveness Inventory Table 11 ANCOVA by Treatment — Katz Adjustment Scales 35 47 38 41 43 44 48 51 52 54 55 LIST OF FIGURES Page F i g u r e 1 Assessment Timeplan 33 F i g u r e 2 S u b j e c t i v e Anxiety Score by Exposure 45 Session -- Group Comparison y i i ACKNOWLEDGEMENTS I am indebted to a number of people who helped me i n d i f f e r e n t ways: Ken C r a i g (my s u p e r v i s o r ) f o r sh a r i n g h i s resear c h wisdom and g i v i n g the study broad d i r e c t i o n ; Ralph Hakstian f o r h i s i n v a l u a b l e s t a t i s t i c a l a d v i c e ; Dr. L e s l i e Solyom f o r f r i e n d l y encouragement, c l i n i c a l a d v i c e , and f o r screening a l l group-members; V i r g i n i a Green f o r generous a s s i s t a n c e with data p r o c e s s i n g ; and to Eve my sine qua non. 1 INTRODUCTION Agoraphobia has been d e s c r i b e d as a d e b i l i t a t i n g d i s o r d e r which a f f e c t s many asp e c t s of s o c i a l , m a r i t a l and care e r f u n c t i o n i n g . I t can be a m e l i o r a t e d i n many cases by behaviour therapy (Mathews, Gelder, & Johnston, 1981). Prolonged i n v i v o exposure has been r e p o r t e d to be the treatment of ch o i c e ( M a v i s s a k a l i a n & Barlow, 1981). T h i s study attempted to respond to the demands d i c t a t e d by p r a c t i c a l aspects of d e l i v e r y of s e r v i c e with a treatment programme which i n t e g r a t e d knowledge gained from r e s e a r c h . I t was d e s i r a b l e for therapy to be short-term to b r i n g r a p i d r e l i e f . Therapy should be t i m e - e f f i c i e n t f o r t h e r a p i s t s because of the la r g e numbers of agoraphobics r e q u i r i n g treatment. T h i s would suggest an agency-based ( r a t h e r than a home-based) programme where p o s s i b l e . Exposure should cover as wide a range of s i t u a t i o n s as p o s s i b l e and therapy techniques should be amenable to group a p p l i c a t i o n . D e s c r i p t i v e C h a r a c t e r i s t i c s of Agoraphobia The d i a g n o s t i c l a b e l "agoraphobia" was chosen by Westphal and d e r i v e s from the Greek "agora" meaning "the market p l a c e , " (Westphal, 1871). Current usage not only r e f e r s to the fear of open spaces but a l s o r e f l e c t s the fear of being i n s i t u a t i o n s of p u b l i c assembly. However, the main f e a t u r e s of agoraphobia have been unchanged s i n c e Westphal's d e s c r i p t i o n : f e a r s of going out i n t o the open; i n t o s t r e e t s , shops and crowds; i n t o 2 c l o s e d spaces (such as e l e v a t o r s , t h e a t r e s and cinemas); of t r a v e l on p u b l i c t r a n s p o r t or t r a v e l l i n g alone; of being alone at home or of l e a v i n g home alone (Marks, 1969). The DSM I I I (1980) d e s c r i b e d an agoraphobic as one who has marked fear of (and thus avoids) being alone or being i n p u b l i c p l a c e s from which escape might be d i f f i c u l t , or h e l p not a v a i l a b l e , i n case-of sudden i n c a p a c i t a t i o n . In a survey of 1,200 agoraphobics i n B r i t a i n , three major symptom c l u s t e r s were found (Marks & Herst, 1970): 1. Non-phobic symptoms: exhaustion, g i d d i n e s s , fear of f a i n t i n g , headache, shaking, p a l p i t a t i o n s , t e n s i o n , d e p e r s o n a l i z a t i o n , obsessions and p a n i c . 2. Phobic symptoms: fear of t r a v e l l i n g on t r a i n s and buses; of crowds, shops and tu n n e l s ; of going to t h e a t r e s and h a i r d r e s s e r s ; and of r i d i n g i n e l e v a t o r s . 3. S o c i a l t i m i d i t y . F a c t o r a n a l y s i s of data c o l l e c t e d from phobic o u t p a t i e n t s by Hallam & Hafner (1978) i d e n t i f i e d a d i s t i n c t c l u s t e r of fe a r s of p u b l i c p l a c e s , of shopping, and of t r a v e l which was present f o r agoraphobics but not i n a group of misc e l l a n e o u s phobics. Agoraphobics a l s o tended to be more f e a r f u l and depressed than other phobics and to score more h i g h l y on a gene r a l symptom c l u s t e r of items that i n c l u d e d b r e a t h i n g d i f f i c u l t i e s and d i z z i n e s s . I t was found that the agoraphobic c l u s t e r was not r e d u c i b l e to a d i f f e r e n t subset of f e a r s or to a general t r a i t of f e a r f u l n e s s . 3 A r r i n d e l l (1980), r e p o r t e d on a f a c t o r - a n a l y s i s of responses to the Fear Survey Schedule from a l a r g e sample (N=703) of n o n - i n s t i t u t i o n a l i z e d phobics, and confirmed Hallam & Hafner's (1978) f i n d i n g s of the s p e c i f i c i t y of the agoraphobic c l u s t e r . I t has been r e p o r t e d that the c l i n i c a l f e a t u r e s of agoraphobia are s i m i l a r i n Europe, America and A u s t r a l i a (Roth, G a r s i d e , & Gurney, 1965). Marks (1967) found that an agoraphobic f a c t o r , suggested by a n a l y s i n g r e p l i e s to a phobic q u e s t i o n n a i r e , c o i n c i d e d w e l l with independent c l i n i c a l diagnoses. Thus, there has been c o n s i d e r a b l e evidence to support the p o s i t i o n that there i s a d i s t i n c t and r e l i a b l e set of d e s c r i p t o r s which i d e n t i f i e s the agoraphobic syndrome. The prevalence of agoraphobia in America has been estimated v a r i o u s l y as 6 per 1000 p o p u l a t i o n (Agras, S y l v e s t e r , & O l i v e a u , 1969) and 5 per 1000 p o p u l a t i o n (DSM I I I , 1980). In England, i t was r e p o r t e d that about 60% of a l l phobics seen at the Maudsley H o s p i t a l i n London were agoraphobics and t h e r e f o r e c o n s t i t u t e d the commonest phobia group. 75% of t h i s agoraphobic group was female (Marks, 1969). In the Marks & Herst (1970) survey, 95% of the sample was female but they a t t r i b u t e t h i s high p r o p o r t i o n to s e l e c t i o n b i a s r e s u l t i n g from t h e i r sample having been d e r i v e d from members of a s e l f - h e l p c l u b . The DSM III (1980) a l s o notes the higher frequency of agoraphobia i n women. Agoraphobia has been c h a r a c t e r i z e d as a p a r t i c u l a r l y d e b i l i t a t i n g d i s o r d e r . Agoraphobics l i v e with d i s t o r t e d s o c i a l 4 r e l a t i o n s h i p s due to t h e i r i n c a p a c i t a t i n g dependence on others (Andrews, 1966). Hallam & Hafner (1978) found i n t h e i r f a c t o r a n a l y t i c study, that s o c i a l f e a r s were p a r t i c u l a r l y prominent f o r agoraphobics. T h i s i s l i k e l y to be a s s o c i a t e d with the l i m i t a t i o n s of t h e i r c o n t r a c t e d s o c i a l environment. There has been some evidence that being agoraphobic was a s s o c i a t e d with c a r d i a c d y s f u n c t i o n . Kantor, Z i t r i n & Z e l d i s (1980) r e p o r t e d that m i t r a l value p r o l a p s e syndrome (MVPS) occured more f r e q u e n t l y among female agoraphobics than i n a female c o n t r o l group. Although they hypothesized.that MVPS-induced p a l p i t a t i o n s l e a d to panic a t t a c k s and to the development of agoraphobia i n p s y c h o l o g i c a l l y s u s c e p t i b l e i n d i v i d u a l s , they d i d not address the p o s s i b i l i t y that the repeated c a r d i a c s t r e s s a s s o c i a t e d with a g o r a p h o b i c - r e l a t e d a n x i e t y might be the cause and not the r e s u l t of MVPS. 5 TREATMENT I. F l o o d i n g Hafner & Marks (1976) c o n t r a s t e d group with i n d i v i d u a l exposure i n v i v o f o r agoraphobics. No s i g n i f i c a n t d i f f e r e n c e s on phobic avoidance emerged between those t r e a t e d i n d i v i d u a l l y and those t r e a t e d i n groups. Emmelkamp and Emmelkamp-Benner (1975) s i m i l a r l y reported no d i f f e r e n c e s between i n d i v i d u a l and group exposure. Hand, Lamontagne & Marks (1974) have compared the e f f e c t s of prolonged group exposure i n v i v o i n s t r u c t u r e d (S) and u n s t r u c t u r e d (U) groups. The S groups had many advantages. Whereas at t e r m i n a t i o n of 1 week's i n t e n s i v e therapy (12 hours of group exposure in vivo) the S and U groups had made s i m i l a r g a i n s , at 3 and 6 month follow-up the S group continued to progress but the U group d i d not. Other advantages c h a r a c t e r i z i n g group treatment were: both S and U members i n d i c a t e d a p r e f e r e n c e f o r " group as compared to i n d i v i d u a l therapy; good group s p i r i t and f r i e n d l y c o m petition spurred members to t r y harder; spontaneous humour ai d e d therapy; the s o c i a l environment provided by the group promoted s k i l l development and a s s e r t i v e n e s s . I t was found that members of the S group f e l t l e s s tendency to escape from the a n x i e t y -provoking s i t u a t i o n s and were q u i c k e r to move up t h e i r h i e r a r c h y of d i f f i c u l t s i t u a t i o n s . A r e p l i c a t i o n study by Teasdale, Walsh, L a n c a s h i r e & Mathews (1977) employed only S groups but no U groups or c o n t r o l s . I t was found t h a t , while t r e a t e d s u b j e c t s improved an e q u i v a l e n t amount up to 6 posttreatment stage (when compared to the Hands et a l S group), t h i s l e v e l of a n x i e t y and avoidance was maintained over 12 and 24 weeks. They d i d not continue to improve to at l e a s t three months as Hands e_t a_l had found. When compared to systematic d e s e n s i t i z a t i o n , a combination of imaginal and i n v i v o f l o o d i n g was found to be a s u p e r i o r treatment f o r agoraphobia (Marks, Boulougouris, & Marset, 1971). T h i s f i n d i n g was not r e p l i c a t e d by Gelder e_t a l , (1973). While f l o o d i n g therapy might, at face value, appear to be an unpleasant, even harrowing, experience, t h i s study reported that i n p r a c t i c e i t i s s u r p r i s i n g l y a c c e p t a b l e to s u b j e c t s , and i n some cases p r e f e r a b l e to systematic d e s e n s i t i z a t i o n . The f a c t that a treatment i s a n x i e t y provoking does not n e c e s s a r i l y make i t unacceptable to s u b j e c t s . Hand, Lamontagne & Marks (1974) r e p o r t on the p a l l i a t i v e e f f e c t s that being a member of a s t r u c t u r e d group has on the f l o o d i n g experience. Emmelkamp (1974) compared the treatment of agoraphobics by f l o o d i n g ( F ) , s e l f - o b s e r v a t i o n (SO), and a combined f l o o d i n g / s e l f - o b s e r v a t i o n procedure (F/SO), with a no-treatment c o n t r o l . In the SO c o n d i t i o n s u b j e c t s were to re t u r n from t h e i r e x c u r s i o n s when they f e l t "undue a n x i e t y . " In the FL group s u b j e c t s were exposed to 45 minutes of f l o o d i n g imaginal and 45 minutes of f l o o d i n g i n v i v o d u r i n g each s e s s i o n . Emmelkamp found that a l l treatments l e d to s i g n i f i c a n t improvements compared to the c o n t r o l group with no s i g n i f i c a n t d i f f e r e n c e s between the FL and SO groups. The F/SO 7 group had made s u p e r i o r gains over the FL and the SO group both at post-treatment and 3 month follow-up. He concluded that e x p e r i e n c i n g a n x i e t y was not a p r e r e q u i s i t e f o r s u c c e s s f u l treatment because the FL and SO groups d i f f e r e d on t h i s dimension. However, the design i s confounded s i n c e h i s SO s u b j e c t s must have experienced some an x i e t y f o r an u n s p e c i f i e d p e r i o d of time in order to know when to r e t u r n home. As t h i s was not s t r i c t l y o p e r a t i o n a l l y d e f i n e d , s u b j e c t s may have used d i f f e r e n t c r i t e r i a f o r t h i s c r i t i c a l l e v e l of a n x i e t y . In a c r o s s - o v e r design study with treatment groups s i m i l a r to Emmelkamp (1974), Everaerd, R i j k e n , & Emmelkamp (1973) reached s i m i l a r c o n c l u s i o n s to Emmelkamp. However these were flawed by a s i m i l a r problem; s u b j e c t s i n t h e i r " s u c c e s s i v e approximation" group were r e q u i r e d to r e t r e a t from a d i f f i c u l t s i t u a t i o n "as soon as they f e l t a n x i e t y . " Everaerd et a l (1973) found no s i g n i f i c a n t d i f f e r e n c e s between the s u c c e s s i v e approximation and f l o o d i n g groups in that both groups had s i g n i f i c a n t improvement without c l e a r s u p e r i o r i t y . P a r t i c u l a r components of f l o o d i n g therapy f o r agoraphobia have been examined. Long-duration f l o o d i n g s e s s i o n s have been shown to be more e f f e c t i v e than s h o r t - d u r a t i o n s e s s i o n s (Stern & Marks, 1973). I t was found t h a t , using a combined i n i m a g i n a t i o n / i n v i v o f l o o d i n g treatment, long d u r a t i o n exposure of two hours had s u p e r i o r e f f e c t s to s e s s i o n s each c o n s i s t i n g of four h a l f - h o u r exposures broken by short r e s t s . S t u d i e s using agoraphobics have found that i n v i v o f l o o d i n g i s s u p e r i o r to imaginal f l o o d i n g (Emmelkamp & Wessels, 1975; 8 Watson, M u l l e t t , & P i l l a y , 1973). Foa, Jameson, Turner & Payne (1980) have shown that massed p r a c t i c e of 2 hour f l o o d i n g i n v i v o s e s s i o n s (10 d a i l y s e s s i o n s ) i s s u p e r i o r i n reducing avoidant behaviour of agoraphobics compared to spaced p r a c t i c e (10 once-weekly s e s s i o n s ) . T h i s study had the l i m i t a t i o n s of a 7 day follow-up p e r i o d , and of using i n s u f f i c i e n t measurement (only r a t i n g s of c l i e n t avoidance and a n x i e t y by an independent e v a l u a t o r were r e p o r t e d ) . In the b e h a v i o u r a l treatment of phobias, a n x i e t y i s an important v a r i a b l e . I t i s g e n e r a l l y accepted that a n x i e t y i s manifested in three l a r g e l y independent modes: b e h a v i o u r a l , s u b j e c t i v e and p h y s i o l o g i c a l (Lang, 1969; Borkovec & O'Brien, 1976). The q u e s t i o n has a r i s e n as ,to which mode or modes should be c o n s i d e r e d as p r o v i d i n g the s i g n a l f o r t e r m i n a t i n g f l o o d i n g s e s s i o n s when evidence on the responses of the three systems i n f l o o d i n g treatments i n d i c a t e s desynchrony ( M a r s h a l l , G authier, & Gordon, 1979). M a r s h a l l et a l (1979) suggested that t e r m i n a t i o n c r i t e r i a f o r each f l o o d i n g s e s s i o n d e r i v e d from the d i f f e r e n t systems might y i e l d d i f f e r e n t t h e r a p e u t i c outcomes. Marks (1972) suggested that i t might be necessary to continue f l o o d i n g s e s s i o n s beyond the p o i n t at which the s u b j e c t no longer d i s p l a y e d m a n i f e s t a t i o n of a n x i e t y (whether b e h a v i o u r a l l y , p h y s i o l o g i c a l l y , or s u b j e c t i v e l y ) . There has been no e m p i r i c a l evidence to date to support or r e f u t e t h i s c o n t e n t i o n . Thus, while longer unbroken exposure seems p r e f e r a b l e to s h o r t e r i n t e r r u p t e d exposure, the optimal 9 d u r a t i o n of exposure and temporal p a t t e r n i n g of exposure s e s s i o n s have not been e m p i r i c a l l y s p e c i f i e d to date. I I . Modeling £ Covert Modeling Modeling procedures have only r e l a t i v e l y r e c e n t l y been adopted by behaviour therapy (Bandura, 1969). In c o n s i d e r i n g the c l i n i c a l a p p l i c a t i o n s of modeling theory and r e s e a r c h , Rachman (1972) concludes that "the f e a r - r e d u c i n g value of t h e r a p e u t i c modeling ' i s regarded as c o n v i n c i n g l y demonstrated." While some some modeling treatments are r e l a t i v e l y e a s i l y t r a n s l a t e d to a c l i n i c a l s e t t i n g (e.g. a model hand l i n g a snake f o r snake-phobics, or exposing h i m s e l f or h e r s e l f to water f o r water-phobics), agoraphobia has by i t s nature o f t e n not been s u i t e d to t h i s type of l i v e modeling. T h i s i s mainly because the s i t u a t i o n s evoking the agoraphobic response are not e a s i l y r e c o n s t r u c t e d i n c l i n i c a l s e t t i n g s . While t h e r a p e u t i c modeling u s u a l l y has used l i v e or f i l m e d (symbolic) models, the modeling cues r e q u i r e s y m b o l i c a l coding by the observer (Bandura, 1977). The c o v e r t r e p r e s e n t a t i o n a l processes of these modeled behaviours have been proposed as subsequently g u i d i n g observer behaviour (Bandura, 1977). Thus, ra t h e r than r e f e r r i n g to the form (or medium) by which a model conveys cues to an observer, o b s e r v a t i o n a l l e a r n i n g r e f e r s p r i m a r i l y to the processes by which an observer encodes stimulus cues. According to t h i s a n a l y s i s , i n v i v o or symbolic modeling p r e s e n t a t i o n i s not e s s e n t i a l f o r s a l u t a r y treatment e f f e c t s 10 to be obtained because the s t i m u l u s cues are a l s o a v a i l a b l e through c o v e r t modeling r e h e a r s a l . C a u t e l a (1971, 1976) suggested that c o v e r t modeling, in which s u b j e c t s imagine a model engaging i n behaviours that they wish to develop, would be e f f e c t i v e i n reducing avoidant behaviour. The imagined model would perform v a r i o u s behaviours with p a r t i c u l a r consequences, depending on treatment o b j e c t i v e s . C a u t e l a , Flannery & Hanley (1974) demonstrated that c o v e r t and o v e r t modeling were e q u a l l y e f f e c t i v e i n reducing avoidance behaviour in s u b j e c t s f e a r f u l of r a t s . While there were no s i g n i f i c a n t d i f f e r e n c e s between co v e r t and overt modeling groups on three b e h a v i o u r a l and two s u b j e c t i v e measures, the o v e r t group was s u p e r i o r on one s u b j e c t i v e measure. Both groups improved s i g n i f i c a n t l y on a l l measures compared to a c o n t r o l group. T h i s i n d i c a t e s that c o v e r t modeling and overt modeling a f f e c t s i m i l a r b e h a v i o u r a l parameters. T h i s f i n d i n g was not confirmed by Thase & Moss (1976) using s n a k e - f e a r f u l c o l l e g e students. They found t h a t , while both a p a r t i c i p a n t modeling and a c o v e r t modeling group produced s i g n i f i c a n t changes, the former group had g r e a t e r g a i n s . The p a r t i c i p a n t modeling paradigm (Bandura, 1977) not only r e q u i r e s exposure to models but a c t u a l exposure to the feared s i t u a t i o n as w e l l . N e v e r t h e l e s s , the evidence r e g a r d i n g the r e l a t i v e e f f i c a c y of c o v e r t and overt modeling treatments f o r fear r e d u c t i o n has been e q u i v o c a l . Both the C a u t e l a et a l (1974) and the Thase & Moss (1976) s t u d i e s used analogue 11 p o p u l a t i o n s and there have been no r e p o r t s comparing these treatments with c l i n i c a l s u b j e c t s . M a n i p u l a t i o n of the parameters of imagery has been examined with the aim of f i n d i n g the optimal combination of imaginal model c h a r a c t e r i s t i c s . In g e n e r a l , the g r e a t e r the s i m i l a r i t y between in v i v o models and t h e i r o b s e r v e r s , the g r e a t e r the impact of modeling e f f e c t s (Rachman, 1972). Kazdin (1974a), t r e a t i n g s n a k e - f e a r f u l student s u b j e c t s with c o v e r t modeling (CM), found that there were gre a t e r gains in behaviour, a f f e c t , and a t t i t u d e to snakes i n the group using models s i m i l a r i n age and sex. T h e r e f o r e the r e l a t i v e c o n t r i b u t i o n of each of these a t t r i b u t e s i s not known. Again working with s n a k e - f e a r f u l c o l l e g e students, Kazdin (1974b) found no s i g n i f i c a n t d i f f e r e n c e s i n treatment e f f e c t s whether the models imagined i n CM scenes were se l f - m o d e l s (the observers themselves) or other-models. Thase & Moss (1976) confirmed t h i s f i n d i n g . The r e l a t i v e e f f e c t s of using a multiple-model image versus a single-model image in CM treatment of s n a k e - f e a r f u l c o l l e g e students were i n v e s t i g a t e d by Kazdin (1974c). He found t h a t , while the CM treatment was i n v a r i a b l y e f f e c t i v e in reducing avoidance, a n x i e t y , and a r o u s a l ; the use of m u l t i p l e models l e d to a g r e a t e r decrease i n avoidance than the use of s i n g l e models. (Whether one or two snakes were used i m a g i n a l l y , however, had no d i f f e r e n t i a l e f f e c t s ) . T h i s e f f e c t of using m u l t i p l e models was r e p l i c a t e d i n Kazdin's (1975) study using u n a s s e r t i v e s u b j e c t s . 12 Kazdin (1974a, b), t r e a t i n g s n a k e - f e a r f u l c o l l e g e students with CM, r e p o r t e d that on b e h a v i o u r a l , a r o u s a l , a n x i e t y , and a t t i t u d i n a l measures, s u b j e c t s using coping models improved more than those using mastery models. These e f f e c t s were maintained at 3 week follow-up. T h i s r e p l i c a t e s and extends an e a r l i e r study using s n a k e - f e a r f u l s u b j e c t s (Kazdin, 1973). These CM s t u d i e s have r e s u l t s c o n s i s t e n t with Meichenbaum's (1971) r e s e a r c h which used f i l m e d p r e s e n t a t i o n of models. Coping models were d e f i n e d as those who' i n i t i a l l y showed a n x i e t y s i m i l a r to the anxious su b j e c t but e v e n t u a l l y coped with the s i t u a t i o n . Mastery models d i s p l a y e d no fear at any stage and showed complete confidence throughout the s i t u a t i o n . Kazdin (1975) p r o v i d e d a u s e f u l framework f o r c o n c e p t u a l i z i n g the sequence of events o c c u r r i n g during a CM episode. He made d i s t i n c t i o n s among the "context" i n which the model i s imagined to act (e.g. for.agoraphobia t h i s might be at the door of crowded department s t o r e with the model f e e l i n g a n x i o u s ) , the "response" of the model to the context ( c o n t i n u i n g the example, the model might use a covert a s s e r t i v e statement); and then the "consequences" that followed the model's performance (the model e n t e r i n g the s t o r e and f e e l i n g r e l a x e d and pleased with the s u c c e s s ) . While most r e p o r t s of imaginal f l o o d i n g r e s e a r c h p r o v i d e d too l i t t l e d e t a i l about the procedure to determine unambiguously whether or not c o v e r t models were components of the treatment u n w i t t i n g l y , some d e s c r i p t i o n s i n d i c a t e that CM 13 c o u l d have been present ( a l b e i t i n f o r m a l l y ) . For example, Mathews & Rezin (1977) used imaginal f l o o d i n g with s u b j e c t s who feared d e n t a l treatment by asking them to imagine an incompetent d e n t i s t i n j e c t i n g t h e i r tongues i n e r r o r . One group r e c e i v e d coping r e h e a r s a l and another d i d not. S u b j e c t s must have used e i t h e r a s e l f - or other-model i m a g i n a l l y , but the modeling e f f e c t s were not d i s c u s s e d i n the r e p o r t . Emmelkamp & Wessels (1975) r e q u i r e d a group of agoraphobics using imaginal f l o o d i n g to p i c t u r e such scenes as walking alone or s i t t i n g i n a room f u l l of people. A l l the scenes presented i n v o l v e d some degree of c o v e r t s e l f - m o d e l i n g . As can be seen from these examples imaginal f l o o d i n g with scenes in which people are present must almost i n v a r i a b l y i n v o l v e e i t h e r s e l f - or other-modeling. Rachman (1972) draws a t t e n t i o n to the commonalities between f l o o d i n g and modeling methods. In Kazdin's schema for CM r e f e r r e d to above, these imaginal f l o o d i n g procedures u s u a l l y stop at the "context" or "response" stages, but another f a c t o r to be c o n s i d e r e d would be how imagined consequences f o l l o w i n g performance by a c o v e r t model a f f e c t e d observer behaviour. Kazdin (l974d) found-that when a s s e r t i v e behaviour by c o v e r t 'models was rewarded by fa v o u r a b l e consequences, t h i s treatment group tended to show gr e a t e r i n c r e a s e s i n a s s e r t i v e n e s s at post-treatment and follow-up than for groups where a s s e r t i v e model behaviour was not p r e s e n t . S i m i l a r r e s u l t s were obtained (Kazdin, 1975) using m u l t i p l e models: rewarding consequences l e d to enhancement of modeling e f f e c t s . The consequences of modeled 1 4 behaviour have been r e f e r r e d to by Hayes (1976) in h i s dual component model of phobic behaviour. In h i s a n a l y s i s phobic avoidance behaviour (a) removes access to r e i n f o r c i n g events and/or (b) r e s u l t s i n a v e r s i v e events o c c u r r i n g to the i n d i v i d u a l . Thus, by p r o v i d i n g access to r e i n f o r c i n g events and/or by a v o i d i n g a v e r s i v e events, approach behaviour may be p o s i t i v e l y or n e g a t i v e l y r e i n f o r c e d . He suggested that the consequation of f l o o d i n g procedures ( i n v i v o or imaginal) should be taken i n t o account i n d e s i g n i n g t h e r a p e u t i c a p p l i c a t i o n s . Bruch (1978) p o i n t s out that modeling and o b s e r v a t i o n a l l e a r n i n g should not be equated with simple matching of a model's over t behaviour by the observer. In d e s i g n i n g modeling treatments the s p e c i f i c behaviours to be demonstrated can be the focus of the design and t h e r e f o r e of the observer's l e a r n i n g . On the other hand the presence and e f f e c t s of v e r b a l and a f f e c t i v e responses accompanying the overt behaviour of the model may be i n c o r p o r a t e d i n the design to inform the observer of the covert processes that l e a d to the model's overt behaviour. Sarason (1973) l a b e l l e d t h i s approach " c o g n i t i v e modeling." S p e c i a l a t t e n t i o n was given to f a c i l i t a t i n g a c q u i s i t i o n by the observer of the model's s t r a t e g i e s f o r generating the a p p r o p r i a t e r e a c t i o n to a s i t u a t i o n r a ther than simple i m i t a t i o n of the a p p r o p r i a t e r e a c t i o n . In the above-mentioned example of an agoraphobic f e e l i n g anxious before e n t e r i n g a department s t o r e , modeling i n s t r u c t i o n i n the use of a covert a s s e r t i v e statement c o u l d 15 be regarded as p r o v i d i n g a s t r a t e g y that c o u l d r e s u l t i n an a p p r o p r i a t e r e a c t i o n to the s i t u a t i o n ( v i z . e n t e r i n g the s t o r e and f e e l i n g comfortable about doing s o ) . Thus CM i s a technique which has been e x t e n s i v e l y researched on a number of parameters l e a d i n g to a s u b s t a n t i a l body of knowledge. However, the use of CM with c l i n i c a l p o p u l a t i o n s remains to be documented as almost a l l r e s e a r c h with the technique has used analogue p o p u l a t i o n s . It holds promise in the treatment of agoraphobia f o r , while i t would be expected that i n v i v o exposure to a feared s i t u a t i o n would l e a d to t h e r a p e u t i c g a i n s , there i s an inherent problem i n using i n v i v o exposure when a p p l i e d to the treatment of agoraphobia: treatment access to the feared s i t u a t i o n i s o f t e n p r o b l e m a t i c a l f o r the agoraphobic. I t i s time-consuming for t h e r a p i s t s to accompany c l i e n t s on e x c u r s i o n s to feared s i t u a t i o n s . Treatment programmes in which t h e r a p i s t s v i s i t the homes of c l i e n t s (e.g. Emmelkamp, 1974; Everaerd, R i j k e n & Emmelkamp, 1973; Mathews, 1981) have s i m i l a r l y been time-consuming for t h e r a p i s t s compared with c l i n i c - b a s e d programmes. However, where the agoraphobic i s t o t a l l y homebound c l i n i c - b a s e d programmes would be i n a c c e s s i b l e of course. Therapy techniques which o f f e r agoraphobics the o p p o r t u n i t y to approach f e a r e d s i t u a t i o n s f r e q u e n t l y and r e g u l a r l y both at the c l i n i c and at home would be d e s i r a b l e and CM holds promise i n t h i s r e gard. I I I . Covert A s s e r t i v e n e s s A d i f f e r e n t approach to promoting a n x i e t y r e d u c t i o n has 16 been to t r a i n f e a r f u l or phobic i n d i v i d u a l s i n the use of a response incompatible with the a n x i e t y r e a c t i o n s produced i n the t a r g e t s i t u a t i o n . Thus, systematic d e s e n s i t i z a t i o n (Wolpe, 1958, 1969, 1973) has employed muscle r e l a x a t i o n as the response that t h e o r e t i c a l l y i n h i b i t s the a n x i e t y e l i c i t e d by a h i e r a r c h y of phobic s t i m u l i . A wide v a r i e t y of responses other than r e l a x a t i o n a l s o has been used. These i n c l u d e a s s e r t i v e , s e x u a l , and motor responses (Wolpe, 1958); p r e s e n t a t i o n of toys and p a r e n t a l body c o n t a c t i n the treatment of c h i l d r e n ( B e n t l e r , 1962); and "emotive imagery" such as p r i d e , m i r t h and excitement (Lazarus & Abramovitz, 1962). G o l d s t e i n , Serber & Piaget (1970) reported s u c c e s s f u l l y using a r t i f i c i a l l y induced anger to counteract fear with c l i n i c a l s u b j e c t s . Although not d e s c r i b e d as a CM technique by G o l d s t e i n e_t a l (1970), the treatment i n v o l v e d t r a i n i n g s u b j e c t s i m a g i n a l l y to self-model angry responses to a n x i e t y - p r o v o k i n g t a r g e t s i t u a t i o n s and then to use these responses i n v i v o . While the technique of thought stopping has most o f t e n been used i n the treatment of obsessions, Rimm (1973) has s u c c e s s f u l l y a p p l i e d i t in combination with c o v e r t l y expressed a s s e r t i v e responses to the treatment of phobias. He l a b e l l e d the i n t e r v e n t i o n s t r a t e g y "covert a s s e r t i o n " (CA). Although d i a g n o s t i c a l l y , o bsessive d i s o r d e r s are d i s t i n g u i s h e d from phobic d i s o r d e r s , c e r t a i n c o g n i t i v e t h e o r i s t s would see a commonality i n that both behaviours are marked by a tendency to engage in s e l f - d e f e a t i n g i m p l i c i t v e r b a l i z a t i o n s ( E l l i s , 1962; Beck, 1970). 1 7 Rimm (1973) r e p o r t e d on the s u c c e s s f u l a p p l i c a t i o n of CA in a s e r i e s of case r e p o r t s i n v o l v i n g phobic c l i e n t s . A c o n t r o l l e d experimental study (Rimm, Saunders & Westel, 1975) using s n a k e - f e a r f u l female c o l l e g e students r e p o r t e d s i g n i f i c a n t l y g reater r e d u c t i o n s i n f e a r f u l n e s s and i n c r e a s e d approach behaviour i n a CA group compared to a t t e n t i o n placebo and no-treatment c o n t r o l groups. In another i n v e s t i g a t i o n using CA, L i t t l e (1976) i n v e s t i g a t e d the r e l a t i v e c o n t r i b u t i o n s of thought-stopping and CA i n the treatment of speech a n x i e t y i n • undergraduates. No d i f f e r e n t i a l e f f e c t i v e n e s s between the groups (thought-stopping only; CA statements; or a combination treatment group) was found. There has been some evidence that agoraphobics are t i m i d and u n a s s e r t i v e : a s o c i a l t i m i d i t y f a c t o r was found by Marks _ Herst (1970), and Hallam _ Hafner (1977) r e p o r t e d a s o c i a l f e a r s f a c t o r . Hand, Lamontagne & Marks (1974) made the ob s e r v a t i o n t h a t , i n t h e i r group treatment of agoraphobics, many of t h e i r c l i e n t s were, f o r example, i n h i b i t e d about e a t i n g i n r e s t a u r a n t s and unable to ask s t r a n g e r s f o r d i r e c t i o n s i n the s t r e e t , perhaps as a r e s u l t of t h e i r s o c i a l i s o l a t i o n . Because they had had to cope with v a r i e d s o c i a l s i t u a t i o n s i n the course of therapy, i t was re p o r t e d that some of them had overcome these problems by the post-treatment p e r i o d . I f agoraphobics are shy and u n a s s e r t i v e a treatment regimen which f o s t e r s a s s e r t i v e e x p r e s s i o n would seem p a r t i c u l a r l y a p p r o p r i a t e . Covert a s s e r t i v e n e s s was c o n s i d e r e d to be a p o t e n t i a l l y u s e f u l technique which would tend to 18 in c r e a s e the l i k e l i h o o d of agoraphobics p r a c t i c i n g non-avoidant behaviour i n everyday l i f e . As f a r as i s known, the l i t e r a t u r e c o n t a i n s only one r e p o r t of the treatment of agoraphobia by a technique s i m i l a r to CA. T h i s s i n g l e case study r e p o r t e d that the c l i e n t was s u c c e s s f u l l y t r a i n e d i n the use of induced anger and vigorous muscular a c t i v i t y to i n h i b i t a n x i e t y responses i n agoraphobic s i t u a t i o n s ( B u t l e r , 1975). Borkovec & O'Brien (1976) have c r i t i c i z e d analogue s t u d i e s of f e a r r e d u c t i o n techniques (which o f t e n use small animal phobias as t h e i r treatment t a r g e t ) on the grounds that t a r g e t c h a r a c t e r i s t i c s were i n t r o d u c e d ; of s u s c e p t i b i l i t y to n o n - s p e c i f i c treatment e f f e c t s ; of absence of a s u b s t a n t i a l p h y s i o l o g i c a l f e a r component; and of i r r e l e v a n c e to c l i n i c a l l y s i g n i f i c a n t a n x i e t y . These t h r e a t e n the i n t e r n a l and e x t e r n a l v a l i d i t y of c o n c l u s i o n s reached. The f l o o d i n g s t u d i e s reviewed above most o f t e n used c l i n i c a l agoraphobic p o p u l a t i o n s e.g. Emmelkamp, 1974; Emmelkamp & Emmelkamp-Benner, 1975; Emmelkamp, Kuipers & Eggeraat, 1978; Emmelkamp & Wessels, 1975; Everaerd, R i j k e n & Emmelkamp, 1973; Hand, Lamontagne & Marks, 1974. However analogue s t u d i e s have predominated i n the CM l i t e r a t u r e e.g. C a u t e l a , Flannery & Hanley, 1974 ( r a t - f e a r f u l undergraduates); Kazdin 1973, 1974a, 1974b, 1974c; Lowe, 1978; Thase & Moss 1976 ( s n a k e - f e a r f u l c o l l e g e s t u d e n t s ) ; Kazdin I974d, 1975, 1976 ( s u b - c l i n i c a l u n a s s e r t i v e r e c r u i t s ) . T h i s i s the case, too, with CA s t u d i e s e.g. Rimm, Saunders & Westel, 1975 19 ( s n a k e - f e a r f u l u n d e r g r a d u a t e s ) ; and L i t t l e , 1976 ( p u b l i c -s p e a k i n g c o u r s e s t u d e n t s ) . Thus w h i l e many s t u d i e s e x i s t which i n v e s t i g a t e a s p e c t s of f l o o d i n g as a treatment f o r a g o r a p h o b i a and which use c l i n i c a l p o p u l a t i o n s , t h i s i s not the case f o r CM and CA t e c h n i q u e s which have almost e x c l u s i v e l y used analogue p o p u l a t i o n s . 20 CONSIDERATIONS IN THE DESIGN OF THIS STUDY The p r e s e n t study examined: ( 1 ) the e f f e c t i v e n e s s of i n v i v o f l o o d i n g f o r ag o r a p h o b i a i n an attempt t o r e p l i c a t e European f i n d i n g s , and ( 2 ) whether a s u p e r i o r t r e a t m e n t outcome would be o b t a i n e d when the f l o o d i n g t h e r a p y was supplemented by t r a i n i n g i n c o v e r t modeling and c o v e r t a s s e r t i v e n e s s . To t h i s end a c l i n i c a l sample of .agoraphobics was randomly a s s i g n e d among t h r e e groups: one, the FL/A group, u s i n g f l o o d i n g p l u s the c o v e r t p r a c t i c e of a s s e r t i o n ( t h r o u g h CM w i t h an a s s e r t i v e model and the use of a s s e r t i v e s e l f - s t a t e m e n t s ) ; the second, the FL group, u s i n g an i n v i v o f l o o d i n g p r o c e d u r e ; and the t h i r d , the C g r o u p , s e r v e d as a w a i t i n g l i s t c o n t r o l . I t was h y p o t h e s i z e d t h a t b oth f l o o d i n g groups would improve and t h a t the FL/A group would d i s p l a y g r e a t e r improvement i n phobic a v o i d a n c e of ago r a p h o b i c s i t u a t i o n s than the FL group. I t was f u r t h e r h y p o t h e s i z e d t h a t t h i s e x p e c t e d r e s u l t would be m a i n t a i n e d a t one month f o l l o w - u p . In d e s i g n i n g a t r e a t m e n t programme f o r ag o r a p h o b i a an attempt was made t o i n t e g r a t e the knowledge t h a t r e s e a r c h has p r o v i d e d w i t h the p r a c t i c a l demands of d e l i v e r y of s e r v i c e . I t was deemed d e s i r a b l e f o r the t r e a t m e n t regimen t o have the f o l l o w i n g c h a r a c t e r i s t i c s : 1. I t s h o u l d be s h o r t - t e r m i n d u r a t i o n i f p o s s i b l e . The d e b i l i t a t i n g s o c i a l consequences of ag o r a p h o b i a i n d i c a t e t h i s . A p r o l o n g e d exposure ( f l o o d i n g ) approach has been e s t a b l i s h e d as the t r e a t m e n t of c h o i c e . The advantages of massed p r a c t i c e 21 exposure s e s s i o n s over spaced s e s s i o n s have been documented by Foa, Jameson, Turner & Rayne (1980). F u r t h e r , t h i s approach was amenable t o group a d m i n i s t r a t i o n . 2. I t s h o u l d be t i m e - e f f i c i e n t f o r t h e r a p i s t s . Given the r e l a t i v e l y h i g h i n c i d e n c e of a g o r a p h o b i a , a group t h e r a p y approach was i n d i c a t e d . T h i s has been found t o be s u c c e s s f u l , (Hand, Lamontagne & Marks, 1974, T e a s d a l e , et a l , 1977). 3. I t would be p r e f e r a b l e f o r t h i s t h e r a p y t o be agency-based r a t h e r than home based. Here a g a i n , i t would be more eco n o m i c a l of t h e r a p i s t s * time compared t o a home-based programme such as E v e r a e r d , R i j k e n & Emmelkamp (1973), and Emmelkamp (1974) have used. U n l e s s the th e r a p y i s agency-based i t cannot be conducted i n group f o r m a t . I f ag o r a p h o b i c c l i e n t s were unable t o t r a v e l t o an agency on t h e i r own, a r r a n g i n g f o r them t o be accompanied would e n a b l e them, i n most c a s e s , t o make the j o u r n e y . 4. S i n c e the treatment programme s h o u l d p r o v i d e as much exposure t o f e a r e d s i t u a t i o n s as p o s s i b l e and s h o u l d e x t e n d the range of these s i t u a t i o n s from those e x p e r i e n c e d i n the group exposure s e s s i o n s , the CM t e c h n i q u e seemed a p p r o p r i a t e . Drawing from r e s e a r c h f i n d i n g s , the model t o be used s h o u l d have the f o l l o w i n g a t t r i b u t e s : s i m i l a r - a g e d and same-sexed; c o p i n g i n n a t u r e ( r a t h e r than d i s p l a y i n g m a s t e r y ) ; u s i n g c o v e r t a s s e r t i o n as a s t r a t e g y f o r d e a l i n g w i t h d i f f i c u l t s i t u a t i o n s ; r e c e i v i n g p o s i t i v e consequences f o r su c c e s s i n these s i t u a t i o n s . 5. The treatment s h o u l d p r o v i d e some means of e x t e n d i n g 22 e f f e c t s over t i m e . To promote such d u r a b i l i t y , the CA t e c h n i q u e was c o n s i d e r e d t o h o l d p r o m i s e . I t was proposed t h a t t h i s approach would f a c i l i t a t e exposure t o d i f f i c u l t s i t u a t i o n s and p r o v i d e c l i e n t s w i t h an a i d t o use o u t s i d e group s e s s i o n s . 23 METHOD S u b j e c t s S u b j e c t s were 32 o u t p a t i e n t s on the w a i t i n g l i s t of the B e h a v i o u r Therapy U n i t a t Shaugnessy H o s p i t a l , Vancouver, B.C., who had been d i a g n o s e d as b e i n g a g o r a p h o b i c a c c o r d i n g t o DSM I I I c r i t e r i a (1980) ( d i a g n o s t i c c a t e g o r i e s 300.21 agora p h o b i a w i t h p a n i c a t t a c k s and 300.22 ag o r a p h o b i a w i t h o u t p a n i c a t t a c k s ) . E x c l u s i o n a r y c r i t e r i a f o r s u b j e c t s e l e c t i o n were the presence of a major d e p r e s s i v e e p i s o d e , o b s e s s i v e - c o m p u l s i v e d i s o r d e r , p a r a n o i d p e r s o n a l i t y d i s o r d e r , or s c h i z o p h r e n i a (as r e q u i r e d by DSM I I I , 1980). In a d d i t i o n , the n a t u r e of the t r e a t m e n t program r e q u i r e d s u b j e c t s t o be p r e s e n t at the c l i n i c but none had t o be e x c l u d e d because of i n a b i l i t y t o do so. S u b j e c t s were not e x c l u d e d because of use of p s y c h o a c t i v e m e d i c a t i o n . Some s u b j e c t s were u s i n g a n t i d e p r e s s a n t s or a n x i o l y t i c s and they were r e q u e s t e d not t o i n c r e a s e or decrease dosage d u r i n g t h e r a p y but t o c o n t i n u e w i t h t h e i r u s u a l t h e r a p e u t i c dose. S u b j e c t s on m e d i c a t i o n had been judged, p r i o r t o commencement of t h i s s t u d y , t o be e i t h e r u n r e s p o n s i v e t o t h e i r m e d i c a t i o n , or t o have b e n e f i t t e d i n a d e q u a t e l y from i t . S u b j e c t s were randomly a s s i g n e d t o the t h r e e groups by a matching p r o c e d u r e ( K a z d i n , 1980). They were ranked p r i m a r i l y by age and s e c o n d a r i l y by y e a r s of e d u c a t i o n , and then c o n s e c u t i v e l y a s s i g n e d t o groups randomly, from h i g h e s t t o 24 l o w e s t r a n k e d . T h e r a p i s t The t h e r a p i s t f o r a l l t r e a t m e n t groups was a male graduate s t u d e n t i n c l i n i c a l p s y c h o l o g y at the U n i v e r s i t y of B r i t i s h Columbia w i t h e x p e r i e n c e i n b e h a v i o u r t h e r a p y . D e s i gn There were t h r e e groups i n the s t u d y . 1. F l o o d i n g p l u s c o v e r t p r a c t i c e of a s s e r t i v e n e s s group (FL/A) T h i s group r e c e i v e d group f l o o d i n g i n v i v o as w e l l as CM p r a c t i c e w i t h a c o v e r t l y a s s e r t i v e model ( i . e . one whose s t r a t e g y w a s t o use a s s e r t i v e s t a t e m e n t s c o v e r t l y t o d e a l w i t h a n x i e t y ) . C l i e n t s were asked t o imagine the model as " c o p i n g " ( i . e . i n i t i a l l y a n x i o u s but e v e n t u a l l y overcoming a n x i e t y ) . In a d d i t i o n , s u b j e c t s were t r a i n e d i n CA, which was t o be used both d u r i n g f l o o d i n g s e s s i o n s and d u r i n g e x c u r s i o n s made from t h e i r homes d u r i n g "homework" a s s i g n m e n t s . 2. F l o o d i n g group (FL) T h i s group r e c e i v e d group f l o o d i n g i n v i v o s i m i l a r t o the FL/A group. As a c o n t r o l f o r the time and a t t e n t i o n which the FL/A group r e c e i v e d d u r i n g i n s t r u c t i o n i n the CM p r o c e d u r e and f o r t h e i r home p r a c t i c e of CM, t h i s group was asked t o p r a c t i c e v i s u a l i z i n g the same scenes as the FL/A group but w i t h o u t a model, f o r an e q u i v a l e n t p e r i o d of t i m e . In a d d i t i o n a p e r i o d of time e q u i v a l e n t t o t h a t spent by the FL/A group on 25 c o v e r t a s s e r t i o n t r a i n i n g , was a l l o c a t e d t o a group d i s c u s s i o n of the p a r t i c u l a r o r i g i n s of phobic a v o i d a n c e f o r each group member. 3. W a i t i n g l i s t c o n t r o l group (C) These s u b j e c t s were t o l d t h a t t h e r a p y was not a v a i l a b l e a t p r e s e n t but would be a v a i l a b l e a p p r o x i m a t e l y s i x t o e i g h t weeks l a t e r . The purpose of u s i n g t h i s group was t o c o n t r o l f o r the t h r e a t s t o v a l i d i t y of h i s t o r y , m a t u r a t i o n , t e s t i n g , i n s t r u m e n t a t i o n , r e g r e s s i o n , s e l e c t i o n , m o r t a l i t y , and i n t e r a c t i o n s between these (Campbell & S t a n l e y , 1963). Assessments u s i n g . the same i n s t r u m e n t s as f o r the two e x p e r i m e n t a l groups were made. To form the t h e r a p e u t i c groups, each of the t h r e e groups d e s c r i b e d above was randomly s p l i t i n t o t h r e e subgroups of about f i v e s u b j e c t s i n each. To promote e q u i v a l e n c e of tre a t m e n t f o r subgroups w i t h i n each t r e a t m e n t c o n d i t i o n , a t h e r a p i s t ' s manual (see appendix A) s e r v e d as a s t a n d a r d i z e d t r e a t m e n t p r o t o c o l . Treatment 1. The FL/A group The t h r e e t r e a t m e n t s e s s i o n s a l l took p l a c e on the f i r s t , t h i r d , and f i f t h day of one week. Each s e s s i o n i n v o l v e d a minimum of 2 hours of group exposure t o f e a r e d s i t u a t i o n s such as shopping m a l l s or a l a r g e p a r k . D u r i n g the f i r s t s e s s i o n group members r e c e i v e d t r a i n i n g i n c o v e r t m o d e l i n g (CM) w i t h a c o v e r t l y a s s e r t i v e model and i n c o v e r t a s s e r t i o n (CA) f o r one hour. These t e c h n i q u e s were a l s o r e h e a r s e d a t the second and 26 t h i r d s e s s i o n s . At each s e s s i o n time was devo t e d t o a d i s c u s s i o n of home-work a s s i g n m e n t s , whether t o be done or a l r e a d y a t t e m p t e d . D u r i n g the i n t e r - s e s s i o n days 2 and 4, members were t o p r a c t i c e CM t w i c e d a i l y f o r about 10 minutes a t each p r a c t i c e s e s s i o n and a l s o attempted t o e x t e n d the d i s t a n c e and time of e x c u r s i o n s t h e i r own away from home. T h i s homework was t o c o n t i n u e f o r 30 days a f t e r the f i n a l group s e s s i o n . 2. The FL group The t r e a t m e n t f o r t h i s group was s i m i l a r t o t h a t p r o v i d e d f o r the FL/A group w i t h two d i f f e r e n c e s : i n p l a c e of CM w i t h an a s s e r t i v e model, the i d e n t i c a l scenes were r e h e a r s e d w i t h o u t a model, and, t o r e p l a c e the CA t r a i n i n g and p r a c t i c e , a group d i s c u s s i o n of the e a r l y i n s t a n c e s of agor a p h o b i c e x p e r i e n c e s of group members was h e l d . D u r i n g t h i s d i s c u s s i o n members r e l a t e d examples of ag o r a p h o b i c e p i s o d e s . The t h e r a p i s t d i d not o f f e r i n t e r p r e t a t i o n (e.g. p r e c i p i t a t i n g e v e n t s , f a m i l y h i s t o r y ) r e g a r d i n g these e p i s o d e s t o m i n i m i z e the p o s s i b i l i t y of t h i s c o n f o u n d i n g t r e a t m e n t e f f e c t s . 3. W a i t i n g - l i s t c o n t r o l group (C) No t r e a t m e n t was p r o v i d e d t o members o f J t h i s group u n t i l a f t e r e x p i r y of a 30 day f o l l o w - u p p e r i o d . Members were t o l d a t the o u t s e t t h a t t h e i r t r e a t m e n t would commence o n l y a f t e r about 6 weeks had passed because of demands on t h e r a p i s t s ' t i m e . 27 I n s t r u m e n t s 1. B e h a v i o u r a l D i a r y ( B P ) : (appendix B) Hand, Lamontagne & Marks (1974) r e p o r t e d d i f f i c u l t i e s i n u s i n g a s t r u c t u r e d , t a s k - o r i e n t e d b e h a v i o u r a l t e s t t o measure av o i d a n c e b e h a v i o u r . They found t h a t a t p o s t - t r e a t m e n t , s u b j e c t s reached the most d i f f i c u l t t a s k so f r e q u e n t l y t h a t a c c u r a t e e v a l u a t i o n of p r o g r e s s was not p o s s i b l e . Marks & Mathews (1979) have suggested t h a t a BD y i e l d i n g the t o t a l time spent out of the house each day y i e l d s a b e t t e r measure of everyday non-avoidant b e h a v i o u r by a g o r a p h o b i c s . The p r e s e n t s t u d y used s e l f - r e p o r t i n g i n a BD of t o t a l number of minutes spent away from home as a dependent measure. The BD a l s o p r o v i d e d f o r a n x i e t y r a t i n g s t o be r e c o r d e d f o r each e x c u r s i o n . 2. S u b j e c t q u e s t i o n n a i r e (SQ): (appendix C) Demographic d a t a and o t h e r i n f o r m a t i o n of r e l e v a n c e t o the s t u d y were c o l l e c t e d p r i o r t o t r e a t m e n t u s i n g t h i s q u e s t i o n n a i r e . 3. Fear q u e s t i o n n a i r e (FQ): T h i s was a one-page, s e l f - r a t i n g form which y i e l d e d s c o r e s f o r main p h o b i a , g l o b a l p h o b i a , t o t a l phobia and a n x i e t y - d e p r e s s i o n , a g o r a p h o b i a , s o c i a l p h o b i a , and b l o o d -i n j u r y p h o b i a . The i n s t r u m e n t i s s h o r t , r e l i a b l e , and v a l i d (Marks & Mathews, 1979). The a g o r a p h o b i a s u b - s c o r e has been found t o have a t e s t - r e t e s t r e l i a b i l i t y of 0.89 over one week. The s c a l e has been f a c t o r a n a l y s e d on over 1,000 phobic s u b j e c t s and, on independent a n a l y s i s , c o n s i s t e n t l y y i e l d e d 28 f o u r s i m i l a r f a c t o r s ( a g o r a p h o b i a , tissue-damage p h o b i a , s o c i a l p h o b i a , and a n x i e t y - d e p r e s s i o n ) . I t was s e n s i t i v e t o c l i n i c a l improvement a f t e r t r e a t m e n t (Marks & Mathews, 1979). E x t e n s i v e n o r m a t i v e d a t a have not y e t been r e p o r t e d . 4. C r e d i b i 1 i t y / e x p e c f a n c y f o r improvement s c a l e s (CES): (appendix D) The s c a l e s proposed by Borkovec & Nau (1972) t o r a t e c r e d i b i l i t y and the expectancy f o r improvement i n th e r a p y were adapted f o r t h i s s t u d y . I t was i m p o r t a n t t o det e r m i n e whether the r a t i o n a l e s and, l a t e r , the t h e r a p i e s used f o r the d i f f e r e n t t r e a t m e n t groups were e q u i v a l e n t i n c r e d i b i l i t y t o s u b j e c t s and whether they r e s u l t e d i n e q u i v a l e n t e x p e c t a t i o n s f o r improvement a c r o s s groups. The CES was completed a f t e r the t r e a t m e n t r a t i o n a l e had been p r e s e n t e d a t s e s s i o n 1; and then a g a i n a f t e r c o m p l e t i o n of s e s s i o n 3. 5. G a m b r i l l & R i c h e y A s s e r t i o n I n v e n t o r y (GRAI): The GRAI was deve l o p e d as a s e l f - r e p o r t , i n s t r u m e n t w i t h two s c a l e s : an index of response p r o b a b i l i t y and a second s c a l e i n d i c a t i n g the degree of d i s c o m f o r t f e l t i n f o r t y s i t u a t i o n s i n v o l v i n g a s s e r t i v e b e h a v i o u r ( G a m b r i l l & R i c h e y , 1975). I t was completed by s u b j e c t s b e f o r e t r e a t m e n t commenced and then a g a i n a t f o l l o w - u p , 30 days a f t e r c o m p l e t i o n of t r e a t m e n t . 6. Imagery Assessment Q u e s t i o n n a i r e (IAQ): (appendix E) One of the e x p e r i m e n t a l m a n i p u l a t i o n s i n t h i s s tudy 29 i n v o l v e d the presence or absence of a c o v e r t model. I f p r e s e n t , s u b j e c t s were r e q u i r e d t o imagine p a r t i c u l a r model a t t r i b u t e s . I t was im p o r t a n t t h e r e f o r e t o determine whether s u b j e c t s i n f a c t imagined scenes and models a p p r o p r i a t e t o t h e i r t r e a t m e n t c o n d i t i o n ( K a z d i n , 1974a, 1974b, 1974c, I974d, 1976). The IAQ was a d m i n i s t e r e d t o a l l e x p e r i m e n t a l group s u b j e c t s and e n q u i r e d as t o the age, sex, and i d e n t i t y of the model ( s e l f or o t h e r ) ; the d i f f i c u l t y the model had i n p e r f o r m i n g the t a s k s ; the c l a r i t y of imagery d u r i n g the s e s s i o n ; the degree of a n x i e t y e x p e r i e n c e d i n i m a g i n i n g the scenes as d e s c r i b e d . 7. S u b j e c t i v e A n x i e t y S c a l e (SAS): (appendix F) A f t e r each group exposure s e s s i o n s u b j e c t s were asked t o r a t e the peak a n x i e t y f e l t on these o c c a s i o n s on the SAS. Wolpe (1973) d e s c r i b e d the u n i t s on t h i s s c a l e as SUDS ( s u b j e c t s u n i t s of d i s t u r b a n c e ) . The range i s from 0 SUDS ( s t a t e of a b s o l u t e calm) t o 100 SUDS (worst a n x i e t y ever e x p e r i e n c e d by a s u b j e c t ) . 8. Symptom C h e c k l i s t 90 (SCL 90) The SCL 90 i s an i n s t r u m e n t which has been s t a n d a r d i z e d f o r o u t p a t i e n t s ( D e r o g a t i s , 1977). T h i s was completed by s u b j e c t s a t p r e t r e a t m e n t and a t 30 day f o l l o w - u p . I t y i e l d e d n i n e symptom dimensions i n c l u d i n g a phobic a n x i e t y r a t i n g which i s c l o s e l y a l l i e d t o a g o r a p h o b i c symptomatology. The g l o b a l s e v e r i t y index (GSI) i s a good i n d i c a t o r of the depth of d i s o r d e r , r e f l e c t i n g the number of symptoms and the i n t e n s i t y of p e r c e i v e d s t r e s s ( D e r o g a t i s , 1977). The SCL 90 i s 30 r e p o r t e d t o have good i n t e r n a l c o n s i s t e n c y (Cronbach's o 0.95 over f o u r weeks) and a t e s t - r e t e s t r e l i a b i l i t y of 0.94 over two weeks (Edwards, 1978). 9. K a t z Adjustment S c a l e s (R form) (KAS): A t t e n t i o n has r e c e n t l y been d i r e c t e d t o the importance of the p o s s i b i l i t y of a d i s c r e p a n c y between s t a t i s t i c a l s i g n i f i c a n c e of change (a p r o b a b i l i t y - b a s e d c r i t e r i o n f o r j u d g i n g whether a t r e a t m e n t e f f e c t i s r e l i a b l e ) and c l i n i c a l s i g n i f i c a n c e (the p r a c t i c a l v a l u e t o a c l i e n t of an i n t e r v e n t i o n ) , ( G a r f i e l d , 1978; K a z d i n , 1980). C l i n i c a l u s e f u l n e s s cannot be a p p r a i s e d by s t a t i s t i c a l t e s t s a l o n e ; o t h e r means of e v a l u a t i n g outcome s h o u l d be used t o a s s e s s c l i n i c a l outcome. One approach i n e v a l u a t i n g c l i n i c a l s i g n i f i c a n c e of_ change has been t o o b t a i n r a t i n g s of a s u b j e c t ' s b e h a v i o u r from a s i g n i f i c a n t o t h e r b e f o r e and a f t e r t r e a t m e n t . The KAS (R form) appeared s u i t a b l e because i t i s a b r o a d - r a n g i n g i n s t r u m e n t d e s i g n e d t o be completed by a r e l a t i v e or s i g n i f i c a n t o t h e r . The respondent i s asked t o r a t e 205 items, on f o u r - p o i n t s c a l e s ( K a t z & L y e r l y , 1963). I t c o v e r s such parameters as p s y c h i a t r i c symptomatology, s o c i a l b e h a v i o u r , the r e s p o n d e n t ' s l e v e l of e x p e c t a t i o n f o r the s u b j e c t ' s performance i n s o c i a l a c t i v i t i e s , l e v e l of f r e e - t i m e a c t i v i t i e s , and the respondent's s a t i s f a c t i o n w i t h t h e s e . The KAS (R form) has been w i d e l y used i n r e s e a r c h ( c f . F i s k e i n Waskow & P a r l o f f , 1975). H o g a r t y , K a t z & Lowery (1967), used the s c a l e s i n a study of day h o s p i t a l and o u t p a t i e n t 31 t r e a t m e n t . The s c a l e s were s e n s i t i v e t o changes from p r e t r e a t m e n t to 2 month and then t o 12 month f o l l o w - u p . Norms were a v a i l a b l e i n the Hogarty _ K a t z (1971) study on 450 normals and 133 p s y c h i a t r i c o u t p a t i e n t s . The KAS have been found t o have h i g h c o n c u r r e n t v a l i d i t y and good d i s c r i m i n a t i v e a b i l i t y between w e l l - and p o o r l y - a d j u s t e d groups (Katz & L y e r l y , 1963). The s c a l e s have d i s p l a y e d h i g h i n t e r r a t e r r e l i a b i l i t y ( c f . Hogarty i n Waskow _ P a r l o f f , 1975). In the p r e s e n t study the KAS were completed by a s i g n i f i c a n t o t h e r a t p r e t r e a t m e n t and then a t 30 day f o l l o w -up. 10. Homework Record (HR): (appendix G) To a s s e s s whether s u b j e c t s p r a c t i c e d the CM and c o v e r t scene p r e s e n t a t i o n e x e r c i s e s t w i c e a day as r e q u i r e d , they were asked t o r e c o r d p r a c t i c e s d a i l y on the HR from the f i r s t day of t r e a t m e n t t o the t h i r t i e t h day a f t e r the l a s t f l o o d i n g s e s s i o n . 11. Consent form: (appendix H) T h i s o u t l i n e d the programme and i t s s c h e d u l i n g , and ended w i t h a s e c t i o n f o r p a r t i c i p a n t s t o s i g n t h e i r consent t o p a r t i c i p a t e . 3 2 Assessment The t i m e s of assessment appear on f i g u r e 1. P r e t r e a t m e n t i n s t r u m e n t s were completed one t o two weeks b e f o r e t r e a t m e n t . D u r i n g t r e a t m e n t i n s t r u m e n t s were a d m i n i s t e r e d as i n d i c a t e d . A f o l l o w - u p f o r the two tr e a t m e n t groups was co n d u c t e d 30 days a f t e r the f i n a l group t r e a t m e n t s e s s i o n . S u b j e c t s were asked t o keep a BD f o r the seven day p e r i o d s t a r t i n g 30 days a f t e r t h e r a p y s e s s i o n s had ended. On t h i s day they were a l s o asked t o complete a FQ, SCL-90, GRAI, IAQ and HR. The same s i g n i f i c a n t o t h e r who completed the KAS at p r e t r e a t m e n t completed t h e s e a g a i n at 30 days p o s t - t r e a t m e n t . The f o l l o w - u p was conducted through the m a i l . S u b j e c t s i n the w a i t i n g l i s t c o n t r o l group completed the same i n s t r u m e n t s as the two tr e a t m e n t groups, except f o r the IAQ and the HR, a t a f o l l o w - u p 30 days a f t e r t h e i r i n i t i a l a ssessment. CO CO Assessment Time-plan Pretreatment Treatment Follow-up Flooding Session 1 Flooding Session 2 Flooding Session 3 Follow-up (1 month) Assessment a^y_L. 1 3 5 35 Subject Questionnaire SQ / Fear Questionnaire FQ / / / Behavioural diary BD y / / Global s e v e r i t y index GSI / / Credibility/expectancy for success CES / / Katz Adjustment Scales KAS / / Gambrill and Richey Assertiveness Inventory GRAI / / Subjective anxiety scale SAS / / / Imagery assessment questionnaire IAQ / / / Homework record HR / / 34 RESULTS T h i r t y - t w o of the 36 s u b j e c t s r e c e i v i n g t r e a t m e n t p r o v i d e d the d a t a r e q u i r e d f o r a n a l y s i s . Twelve had been randomly a l l o c a t e d t o the f l o o d i n g w i t h c o v e r t a s s e r t i v e n e s s (FL/A) group, n i n e t o the f l o o d i n g (FL) group, and e l e v e n t o the c o n t r o l (C) group. T a b l e 1 summarizes demographic c h a r a c t e r i s t i c s of these s u b j e c t s . A p a r t from t h e s e 32 s u b j e c t s whose d a t a were a n a l y s e d , an a d d i t i o n a l f o u r s u b j e c t s withdrew from t h e r a p y and t h e i r d ata were not i n c l u d e d i n t h i s s t u d y . One s u b j e c t , o r i g i n a l l y i n the FL/A group, r e p o r t e d h a v i n g been p r e v e n t e d from a t t e n d i n g two t h e r a p y s e s s i o n s by c o m p u l s i v e r i t u a l s . W i th r e g a r d t o the FL group, one s u b j e c t missed two t h e r a p y s e s s i o n s due t o job demands and a second had t o be h o s p i t a l i z e d f o r m u l t i p l e p s y c h o l o g i c a l problems i n c l u d i n g d e p r e s s i o n . One c o n t r o l s u b j e c t withdrew from the study b e f o r e c o m p l e t i n g f o l l o w - u p measures as he judged h i m s e l f t o have r e c o v e r e d . Group E q u i v a l e n c e : A MANOVA among the t h r e e groups on the v a r i a b l e s age, d u r a t i o n of i l l n e s s , and l e n g t h of e d u c a t i o n , y i e l d e d no s i g n i f i c a n t d i f f e r e n c e s F(6.54)=.58, p_>.73. The p r o p o r t i o n s of males and females i n the groups were t e s t e d f o r independence from group membership and no a s s o c i a t i o n was 2 found, c h i = .18, £>.91. Thus the groups appeared t o be e q u i v a l e n t and w e l l - m a t c h e d on t h e s e demographic p a r a m e t e r s . One-way a n a l y s e s of v a r i a n c e on each of the 19 dependent T a b l e 1 Demographic C h a r a c t e r i s t i c s of T r e a t e d S u b j e c t s ( E x c l u d i n g Drop-outs) Group FL/A (n=12) FL (n = 9) C o n t r o l ( n = 1 1 ) T o t a l (n=32) Age at s c r e e n i n g ( y e a r s ) Mean SD Range 37 .75 1 1 .83 29--65 40. 33 15 .60 19--66 31 . 36 5 .46 24--39 36 . 28 1 1 .67 19--66 D u r a t i o n of a g o r a p h o b i a ( y e a r s ) Mean SD Range 1 1 . 75 14.31 1--50 14.44 16.35 1--53 8.91 7 .85 2--30 1 1 .53 12.90 1--53 P o s t - g r a d e 12 e d u c a t i o n ( y e a r s ) Mean SD Range 5 .67 2 .90 1--1 1 5 .00 3.54 0--12 5 . 73 1 .85 3--9 5.50 2.72 0--12 Sex no.(%) Male Female R a t i o : male/female (%) 3(25.0%) 9(75 .0%)' (33.3%) 3(33.3%) 6(66.7%) (50.0%) 3(27.3%) 8(72.7%) (37.5%) 9(28.1%) 23(71.9%) M a r i t a l S t a t u s no.(%) L i v i n g w i t h p a r t n e r L i v i n g a l o n e 6(50.0%) 5(55.6%) 6(54.5%) 17(53.1%) 6(50.0%) 4(44.4%) 5(45.5%) 15(46.9%) 36 v a r i a b l e s from the f i v e i n s t r u m e n t s measuring t r e a t m e n t outcome i n d i c a t e d no s i g n i f i c a n t d i f f e r e n c e s among groups on any v a r i a b l e a t p r e t r e a t m e n t except f o r a s i g n i f i c a n t t r e a t ment e f f e c t on the p h o b i c - a n x i e t y s u b s c a l e of the SCL-90, F (2 , 28) =4 . 33 , p_<.05. On t h i s measure group means were 1.62 (FL/A g r o u p ) , 2.89 ( F L ) , and 2.32 ( c o n t r o l s ) . However, on these 19 v a r i a b l e s p l u s the f i v e demographic c h a r a c t e r i s t i c s i n s p e c t e d , i t was not u n l i k e l y t h a t t h e r e c o u l d be one e r r a n t p r e t r e a t m e n t measure s i g n i f i c a n t l y d i f f e r e n t among groups by chance a l o n e . Treatment P r o c e s s Measures: The mean s c o r e s of the two treatment groups a f t e r the t h i r d ( f i n a l ) exposure s e s s i o n on the " c r e d i b i l i t y / e x p e c t a n c y f o r s u c c e s s " s c a l e were compared. On a s c a l e r a n g i n g from 0 t o 40 the s e means were 30.75 f o r the FL/A group and 32.00 f o r the FL group. The d i f f e r e n c e between them was found t o be n o n s i g n i f i c a n t on a two-sample t - t e s t , t ( 18) = .37, p_>-71 • The imagery assessment q u e s t i o n n a i r e (IAQ) was d e s i g n e d t o gauge t o what e x t e n t the imagery used by s u b j e c t s was as p r e s c r i b e d f o r t h e i r t r e a t m e n t group. On the IAQ each of the f o l l o w i n g f i v e a t t r i b u t e s was s c o r e d c o r r e c t i f responded t o i n the a p p r o p r i a t e d i r e c t i o n : p resence/absence of model; same/opposite sex of model; s a m e / d i f f e r e n t age of model; c o p i n g / m a s t e r y s t y l e of model; and presence/absence of a s s e r t i v e statement by model. Thus a maximum s c o r e of f i v e c o u l d be a t t a i n e d . On t h i s b a s i s t h e r e was no s i g n i f i c a n t 37 d i f f e r e n c e between the FL/A group w i t h a mean sc o r e of 85% c o r r e c t and the FL group w i t h 87.5% c o r r e c t , t ( l 8 ) = . l 8 , £>.86. Both groups adhered v e r y c l o s e l y t o the imagery parameters s p e c i f i e d f o r t h e i r t r e a t m e n t c o n d i t i o n . I t i s important t o know t o what e x t e n t the t r e a t m e n t group s u b j e c t s c o m p l i e d i n f r e q u e n c y and d u r a t i o n of home p r a c t i c e of the imagery e x e r c i s e s . When p r a c t i c e was measured by c a l c u l a t i n g the d a i l y mean number of minutes f o r each imagery s e s s i o n over the 35 day imagery p r a c t i c e p e r i o d and comparing the means of the groups FL/A and FL by a two-sample t - t e s t , no s i g n i f i c a n t d i f f e r e n c e was found (means 7.11 minutes and 5.06 minutes r e s p e c t i v e l y ; t ( l 3 ) = 1 . 0 7 , 2 >«30). S i m i l a r l y when an a l t e r n a t i v e method of e s t i m a t i n g c o n s i s t e n c y i n c o n d u c t i n g homework imagery e x e r c i s e s was used, i . e . the number of days on which a t l e a s t one imagery s e s s i o n was h e l d a t home, no s i g n i f i c a n t group d i f f e r e n c e s were found (mean f o r FL/A group 20.71 days, and mean f o r the FL group 19.38 days; t (13 ) = .35, p>.30. Treatment Outcome Measures:  Fear Q u e s t i o n n a i r e : An a n a l y s i s of c o v a r i a n c e by t r e a t m e n t s was computed on the p o s t t r e a t m e n t s c o r e s f o r each s u b s c o r e on the f e a r q u e s t i o n n a i r e (FQ) u s i n g p r e t r e a t m e n t s c o r e s as the c o v a r i a t e . T a ble 3 summarizes the a d j u s t e d p o s t t r e a t m e n t means f o r each group and the F v a l u e s r e s u l t i n g from the a n a l y s e s of t h e s e s i x s u b s c o r e s . The d a t a i n d i c a t e d t h a t t h e r e were s i g n i f i c a n t T a b l e 3 co CO R e s u l t s o f A n a l y s e s of C o v a r l a n c e Performed on the Fear Q u e s t i o n n a i r e S c o r e s O b t a i n e d a t P o s t t r e a t m e n t and One Month Follow-up Group Means Measure C o n t r o l FL/A FL MSw G l o b a l p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 6.00 6 .05 4.63 3.59 3 . 33 3.99 2.32 3.23 6 . 56 5 . 76 <.01 <.01 T o t a l p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 59.31 59.66 43. 12 42 . 24 35.51 42 .09 163.85 287.23 8 . 27 3.84 <.ooi <.05 Ago r a p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 25.46 25.84 13.97 13 . 73 12.61 15 . 23 27 .63 66.68 17 . 29 7.18 <.0001 <.01 B l o o d - I n j u r y p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 14 .82 15. 13 1 1 .47 12 .03 10. 24 13.28 36 . 18 40.52 1 .44 .69 >.25 >.50 S o c i a l p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 19. 19 18 .68 17.40 16.34 12.77 13.82 22.77 25.58 3.93 2 . 29 <.05 > . 12 A n x i e t y - d e p r e s s 1 on p o s t t r e a t m e n t one month f o l l o w - u p 22 . 21 22.82 17 .05 12.56 14.24 13.43 40.91 65.59 3.63 5 . 29 < .05 < .01 Note: a MSb f o r t r e a t m e n t s a r e r e p r o d u c i b l e from F X MSw b O n e - t a i l e d p r o b a b i l i t y e s t i m a t e s due to d i r e c t i o n a l hypotheses c P r e t r e a t m e n t s c o r e s a r e the c o v a r l a t e d df a t p o s t t r e a t m e n t a r e 2,23. At f o l l o w - u p df are 2.27 f o r g l o b a l p h o b i a and a n x i e t y - d e p r e s s i o n , and 2,28 f o r the o t h e r measures 39 treatment e f f e c t s (g<.05) on g l o b a l p h o b i a , t o t a l p h o b i a , a g o r a p h o b i a , s o c i a l p h o b i a , and a n x i e t y - d e p r e s s i o n s u b s c o r e s but not on b l o o d - i n j u r y p h o b i a s u b s c o r e s . When s u b s c o r e s a t p o s t t r e a t m e n t were t e s t e d by p l a n n e d o r t h o g o n a l c o n t r a s t s t o determine whether t h e r e were s i g n i f i c a n t d i f f e r e n c e s between s u b j e c t s from t r e a t m e n t groups on the one hand and those i n the c o n t r o l group on the o t h e r , s i g n i f i c a n t d i f f e r e n c e s (g<.05) were found f o r the s u b s c o r e s : g l o b a l p h o b i a , t o t a l p h o b i a , a g o r a p h o b i a , a n x i e t y - d e p r e s s i o n , and s o c i a l p h o b i a . On a l l c o m p a r i s o n s , the t r e a t m e n t groups c o n s i s t e n t l y performed b e t t e r than the c o n t r o l group. There was no s t a t i s t i c a l l y s i g n i f i c a n t t r e a t m e n t e f f e c t on b l o o d - i n j u r y s u b s c o r e s . Planned o r t h o g o n a l c o n t r a s t s between the two t r e a t m e n t groups at p o s t t r e a t m e n t y i e l d e d no s i g n i f i c a n t d i f f e r e n c e s on any s u b s c a l e . A s i m i l a r a n a l y s i s of c o v a r i a n c e at one month f o l l o w - u p w i t h p r e t r e a t m e n t s c o r e s as the c o v a r i a t e i s p r e s e n t e d below the p o s t t r e a t m e n t s c o r e s on T a b l e 3. In g e n e r a l t h e r e seemed t o be a somewhat a t t e n u a t e d p a t t e r n of t r e a t m e n t e f f e c t . W h i l e s i g n i f i c a n t t r e a t m e n t e f f e c t s (p_<.05) were s u s t a i n e d on g l o b a l p h o b i a , t o t a l p h o b i a , a g o r a p h o b i a and a n x i e t y - d e p r e s s i o n , these were g e n e r a l l y l e s s marked than a t p o s t t r e a t m e n t . Once a g a i n the b l o o d - i n j u r y s c o r e d i d not i n d i c a t e s i g n i f i c a n t t r e a t ment e f f e c t s . There were no s i g n i f i c a n t t r e a t m e n t e f f e c t s on the s o c i a l phobia s c a l e a t t h i s phase. P l a n n e d o r t h o g o n a l c o n t r a s t s a t one month f o l l o w - u p once a g a i n i n d i c a t e d s i g n i f i c a n t d i f f e r e n c e s between the c o n t r o l group and the 40 t r e a t m e n t groups on the s u b s c a l e s f o r g l o b a l p h o b i a , t o t a l p h o b i a , a g o r a p h o b i a , s o c i a l p h o b i a and a n x i e t y - d e p r e s s i o n . On each c o n t r a s t the tr e a t m e n t group s c o r e s were s i g n i f i c a n t l y lower than c o n t r o l s c o r e s . There were no s i g n i f i c a n t d i f f e r e n c e s between the r e s u l t s of the two t r e a t m e n t groups. To pursue f u r t h e r the p o s s i b i l i t y t h a t t h e r e was a change i n t r e a t m e n t e f f e c t s a two-way a n a l y s i s of c o v a r i a n c e was computed u s i n g the p r e t r e a t m e n t s c o r e as c o v a r i a t e . The two f a c t o r s were t r e a t m e n t s and phases ( p o s t t r e a t m e n t and one month f o l l o w - u p ) . C o n t r o l group d a t a c o u l d not be i n c l u d e d because t h i s group had not been a s s e s s e d a t a time e q u i v a l e n t t o t e r m i n a t i o n of t r e a t m e n t . The a d j u s t e d means and the F v a l u e s f o r the tr e a t m e n t f a c t o r a re p r e s e n t e d i n Table 4. No s i g n i f i c a n t t r e a t m e n t or i n t e r a c t i o n e f f e c t s were found but the phase e f f e c t on the a n x i e t y - d e p r e s s i o n v a r i a b l e was s i g n i f i c a n t , F ( 1 , 1 3 ) =4.09, p_<.05, w i t h a d j u s t e d mean s c o r e s i n d i c a t i n g c o n t i n u e d d e c r e a s e s from p o s t t r e a t m e n t t o one month f o l l o w - u p . The FQ a d m i n i s t e r e d p r e - t r e a t m e n t , r e q u i r e d s u b j e c t s t o r a t e t h e i r degree of av o i d a n c e f o r v a r i o u s a g o r a p h o b i c s i t u a t i o n s when they were remote from t h e s e s i t u a t i o n s . T y p i c a l l y these FQs were completed a t home and s u b j e c t s e s t i m a t e d t h e i r degree of a v o i d a n c e when they were removed i n time and p l a c e from the s i t u a t i o n s l i s t e d . When p r e - t r e a t m e n t i n d i v i d u a l a g o r a p h o b i a s u b s c o r e s on the FQ were compared w i t h the means of i n d i v i d u a l peak a n x i e t y r a t i n g s r e p o r t e d i m m e d i a t e l y a f t e r each exposure s e s s i o n on the s u b j e c t i v e T a b l e 4 R e s u l t s of Two-Way A n a l y s e s of Cova r l a n c e . Performed on Fear Q u e s t i o n n a i r e S c o r e s O b t a i n e d at P o s t t r e a t m e n t and One Month Follow-up Group Means Measure FL/A FL MSw G l o b a l p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 4.51 3.13 3.56 3.70 4 .69 .05 >.83 T o t a l p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 43 .44 38 . 55 34.43 36.86 459 . 24 . 47 > .50 Ag o r a p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 13.32 9.99 12.58 13.01 100.23 .09 >.76 B l o o d - I n j u r y p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 1 1 .85 12.30 10.47 1 1 . 76 22.96 .31 > .58 S o c i a l p h o b i a p o s t t r e a t m e n t one month f o l l o w - u p 17.27 15 . 27 12.65 13 . 36 54 . 73 1 . 53 > . 23 A n x i e t y - d e p r e s s i o n p o s t t r e a t m e n t one month f o l l o w - u p 17 .66 10.54 14 . 32 1 1 .96 62 . 16 1 1 > .74 Note: a MSb f o r t r e a t m e n t s a r e r e p r o d u c i b l e from F X MSw b O n e - t a i l e d p r o b a b i l i t y e s t i m a t e s due to d i r e c t i o n a l hypotheses c P r e t r e a t m e n t s c o r e s a r e the c o v a r i a t e d Data a r e p r e s e n t e d on the treatment f a c t o r o n l y e df f o r g l o b a l p h o b i a and a n x i e t y - d e p r e s s i o n a r e 1,12 and a r e 1,13 f o r the o t h e r measures 42 a n x i e t y s c a l e (SAS) t h e r e was a h i g h l y s i g n i f i c a n t c o r r e l a t i o n , r=.59, p_<.U1. T h i s i n d i c a t e d a h i g h degree of a s s o c i a t i o n between the FQ a g o r a p h o b i a a v o i d a n c e s u b s c o r e s ( a n t i c i p a t e d ) and SAS mean s c o r e s ( r e p o r t e d as e x p e r i e n c e d by s u b j e c t s ) , and added v a l i d i t y t o the FQ as a measurement of a g o r a p h o b i c a v o i d a n c e . An a n a l y s i s of v a r i a n c e ( t r e a t m e n t s X imagery p r a c t i c e ) was computed on the v a r i a b l e a g o r a p h o b i a s c o r e (from the f e a r q u e s t i o n n a i r e ) a t one month f o l l o w - u p , w i t h groups p a r t i t i o n e d u s i n g as c u t - o f f the median number of days d u r i n g which at l e a s t one imagery p r a c t i c e s e s s i o n had been h e l d , i n t o h i g h p r a c t i c e and low p r a c t i c e groups. C e l l means ar e r e p o r t e d i n T a b l e 5 and r e s u l t s of the a n a l y s i s of v a r i a n c e i n T able 6. S i g n i f i c a n t e f f e c t s were found f o r the t r e a t m e n t f a c t o r , p_<.05, and the imagery p r a c t i c e l e v e l f a c t o r , p_<.05, w i t h lower s c o r e s ( b e t t e r outcomes) b e i n g r e p o r t e d by the FL/A and h i g h imagery p r a c t i c e l e v e l groups. The i n t e r a c t i o n e f f e c t was not s i g n i f i c a n t . The a n a l y s i s was then r e p e a t e d w i t h GSI a t one month f o l l o w - u p as the s e l f - r e p o r t measure. E f f e c t s d i d not r e a c h s i g n i f i c a n c e , (p_>.05). S u b j e c t i v e A n x i e t y S c a l e : A p r o f i l e a n a l y s i s was performed on the SAS f o r the two t r e a t m e n t groups ( F i g u r e 2 ) . The t e s t f o r e q u a l i t y of means ( f l a t n e s s of p r o f i l e ) produced an F ( 2 , 18) = 1 .03, p_>.37, which i n d i c a t e d t h a t f o r b o t h groups, d i f f e r i n g l e v e l s of a n x i e t y were e x p e r i e n c e d when comparing T a b l e 5 C r o s s - t a b u l a t i o n of C e l l Means f o r Agoraphobia Score (Treatment v e r s u s Imagery P r a c t i c e L e v e l ) on the Fear Q u e s t i o n n a i r e Treatment Imagery P r a c t i c e L e v e l (days) FL/A FL Low High 15.50 (3) 2.00 (3) 24.25 (4) 15.50 (4) Note: a ( ) I n d i c a t e s number of s u b j e c t s T a b l e 6 R e s u l t s o f Two-way A n a l y s e s o f V a r i a n c e (Treatment v e r s u s Imagery P r a c t i c e L e v e l ) on Agoraphobia S c o r e of Fear Q u e s t i o n n a i r e at One Month Fo l l o w - u p Source MSb F Treatment 4 4 4 7 3 4 4 8 < 0 5 imagery p r a c t i c e l e v e l 4 4 4 - ™ * 4-*8 <-05 I n t e r a c t i o n (Treatment X P r a c t i c e L e v e l ) 20.83 0.21 > 6 5 MSw=99.34 O n e - t a i l e d p r o b a b i l i t i e s due to d i r e c t i o n a l hypotheses df=1,11 FIGURE 2 Subjective peak anxiety reported by FL (flooding) and FL/A (flooding + covert practice) groups f o r flooding sessions. 46 the t h r e e d i f f e r e n t i n v i v o exposure s i t e s . The t e s t f o r p a r a l l e l i s m i n d i c a t e d t h a t a n x i e t y p r o f i l e s f o r the two groups were p a r a l l e l , F(2,18)=.08, p>.92, s u g g e s t i n g t h a t the FL/A group and the FL group ranked the a n x i e t y e x p e r i e n c e d v e r y s i m i l a r l y . For both the FL/A and the FL t r e a t m e n t groups the e x c u r s i o n t o a downtown underground shopping m a l l ( s e s s i o n t h r e e ) was most a n x i e t y - p r o v o k i n g ; f o l l o w e d by the e x c u s i o n t o a suburban department s t o r e . The t r i p t o a medium-sized suburban park was l e a s t a n x i e t y - p r o v o k i n g ( s e s s i o n o n e ) . On the l e v e l s t e s t , i t was found t h a t the. two groups d i f f e r e d s i g n i f i c a n t l y from each o t h e r i n the mean l e v e l of a n x i e t y over the t h r e e s e s s i o n s , F(1,19)=3.77, rj<.05, w i t h the FL/A c o n s i s t e n t l y r e p o r t i n g l e s s s u b j e c t i v e a n x i e t y than the FL group. The SAS s c o r e s f o r each exposure s e s s i o n a r e p r e s e n t e d i n T a b l e 2. SCL-90: U s i n g the p r e t r e a t m e n t s c o r e as the c o v a r i a t e , an a n a l y s i s of c o v a r i a n c e was computed between groups a t one month f o l l o w - u p on the g l o b a l s e v e r i t y index ( G S I ) , phobic a n x i e t y , and d e p r e s s i o n s u b s c o r e s of the SCL-90 q u e s t i o n n a i r e . These a d j u s t e d means are summarized i n T a b l e 7 t o g e t h e r w i t h F v a l u e s r e s u l t i n g from the a n a l y s e s of t h e s e t h r e e s u b s c o r e s . S i g n i f i c a n t e f f e c t s on the t r e a t m e n t f a c t o r were i n d i c a t e d on the GSI, p_<.05; p h o b i c - a n x i e t y , p_<.00l; and d e p r e s s i o n s c o r e s , P_<.01. Plan n e d o r t h o g o n a l c o n t r a s t s i n d i c a t e s i g n i f i c a n t d i f f e r e n c e s between tr e a t m e n t groups on the one hand and the c o n t r o l group on the o t h e r on a l l t h r e e of t h e s e v a r i a b l e s T a b l e 2 Mean S u b j e c t i v e A n x i e t y S c o r e s by Exposure S e s s i o n -- Group Comparison Treatment Exposure S e s s i o n FL /A FL 29.75 26.08 31.42 48.89 42.22 51.1.1 Note: a On S u b j e c t i v e U n i t s of D i s t r e s s S c a l e range 0--100 co T a b l e 7 R e s u l t s of A n a l y s e s of C o v a r l a n c e Performed on SCL-90 S c o r e s at One Month Fo l l o w - u p Group Means _ C t Measure C o n t r o l FL/A FL MSw F p GSI one month f o l l o w - u p 1-64 1.10 1.14 .21 4.47 '<.05 P h o b i c a n x i e t y „_ . one month f o l l o w - u p 2.67 1.35 1.61 .36 14.30 <.0001 D e p r e s s i o n _ __ .^ _ . one month f o l l o w - u p 2.00 1.17. 1.54 .32 5.70 <.01 Note: a MS f o r treatments a r e r e p r o d u c i b l e from F X MSw b O n e - t a i l e d p r o b a b i l i t y e s t i m a t e s due to d i r e c t i o n a l hypotheses c df=2,26 d P r e - t r e a t m e n t means a r e the c o v a r l a t e 49 (jg<.01). C o n t r a s t s between the two t r e a t m e n t groups d i d not r e a c h s i g n i f i c a n c e , (p_>.05). As an i n d i c a t i o n of whether t h e r e was a c o r r e l a t i o n between l e n g t h of i l l n e s s and the d i f f e r e n t i a l i n p o s t t r e a t m e n t compared w i t h p r e t r e a t m e n t g l o b a l s e v e r i t y index (GSI) s c o r e s , a p a r t c o r r e l a t i o n was computed ( G l a s s & S t a n l e y , 1970). T h i s i s the c o r r e l a t i o n of d u r a t i o n of i l l n e s s ( i n y e a r s ) w i t h the p o s t t r e a t m e n t GSI, a f t e r t h a t p o r t i o n of the p o s t t r e a t m e n t GSI which can be p r e d i c t e d l i n e a r l y from the p r e t r e a t m e n t GSI has been removed from the p o s t t r e a t m e n t GSI. A s i g n i f i c a n t c o r r e l a t i o n was o b t a i n e d between t h i s r e s i d u a l g a i n s c o r e and d u r a t i o n of i l l n e s s , r_=.53, p_<.05. Higher GSI s c o r e s i n d i c a t e d more se v e r e symptomatology. B e h a v i o u r a l D i a r y : Four s u b s c o r e s computed from the d a t a on the b e h a v i o u r a l d i a r y (BD) were s u b j e c t e d t o a n a l y s i s of c o v a r i a n c e f i r s t a t p o s t t r e a t m e n t phase, and then a t one month f o l l o w - u p . P r e t r e a t m e n t s c o r e s were the c o v a r i a t e . D a i l y time away was computed as the mean d a i l y number of hours spent away from home over a seven-day p e r i o d . T h i s mean was p a r t i t i o n e d between mean d a i l y hours spent on a c t i v i t i e s when the s u b j e c t was accompanied and when unaccompanied. The f o u r t h s u b s c o r e , mean a n x i e t y , was computed as f o l l o w s : the d i a r y forms r e q u i r e d s u b j e c t s t o r a t e t h e i r peak s u b j e c t i v e a n x i e t y f o r each change i n a c t i v i t y away from home (e.g. a b u s r i d e t o a d e n t i s t f o l l o w e d by l u n c h a t a r e s t a u r a n t would produce t h r e e r a t i n g s ) . The weekly a r i t h m e t i c mean of t h e s e r a t i n g s p r o v i d e d 50 the i n d e x . R e s u l t s of the a n a l y s i s of c o v a r i a n c e by t r e a t m e n t s on t h e s e f o u r v a r i a b l e s w i t h the p r e t r e a t m e n t s c o r e s as c o v a r i a t e a r e r e p o r t e d i n Table 8. For each measure, a d j u s t e d means a t p o s t t r e a t m e n t phase and a t one month f o l l o w - u p were r e c o r d e d . At p o s t t r e a t m e n t no s i g n i f i c a n t t r e a t m e n t e f f e c t s were found, w h i l e at one month f o l l o w - u p the v a r i a b l e d a i l y time away (unaccompanied) y i e l d e d s i g n i f i c a n t t r e a t m e n t e f f e c t s , s i g n i f i c a n t , F (2 , 25) =2 . 95, p_<.05, w i t h both t r e a t m e n t groups spending more time away from home when unaccompanied than the c o n t r o l s , a l t h o u g h not s i g n i f i c a n t l y so. Wh i l e t r e a t m e n t e f f e c t s j u s t m issed s i g n i f i c a n c e f o r d a i l y time away ( a l o n e or accompanied) a t one month f o l l o w - u p , F ( 2 , 25) = 2 . 34 , p_=.058, pl a n n e d o r t h o g o n a l c o n t r a s t s c o n f i r m e d a s i g n i f i c a n t d i f f e r e n c e between the two t r e a t e d group a d j u s t e d means on t h i s measure w i t h the FL/A group spending s i g n i f i c a n t l y more t o t a l time away from home than the FL group. T h i s t r e a t m e n t e f f e c t was s t r o n g l y c o n f i r m e d on a two-way a n a l y s i s of c o v a r i a n c e ( T a b l e 9) ( t r e a t m e n t s v e r s u s phases, w i t h p r e t r e a t m e n t s c o r e s as c o v a r i a t e ) by a h i g h l y s i g n i f i c a n t t r e a t m e n t e f f e c t (p<.0l) w i t h the FL/A group spending s i g n i f i c a n t l y more t o t a l time away from home than the FL group. No o t h e r t r e a t m e n t , phase, or i n t e r a c t i o n e f f e c t s reached s i g n i f i c a n c e on t h i s a n a l y s i s . G a m b r i l l & R i c h e y A s s e r t i v e n e s s I n v e n t o r y : T a b l e 10 p r e s e n t s the r e s u l t s of an a n a l y s i s of c o v a r i a n c e by t r e a t m e n t s on T a b l e 8 R e s u l t s of A n a l y s e s of C o v a r l a n c e * Performed on B e h a v i o u r a l D i a r y S c o r e s a t P o s t t r e a t m e n t and One Month Fol1ow-up Group Means Measure FL/A FL MSw Da1ly time away p o s t t r e a t m e n t one month f o l l o w - u p 4 . 22 4 .44 5. 16 6. 10 4.01 4.40 1 .86 3.68 1 . 16 2 . 34 > . 33 > . 1 1 D a l l y time away (accompanied) p o s t t r e a t m e n t one month f o l l o w - u p 2 .07 2. 16 2 . 19 1 .99 1 .59 1 .66 1 .03 1.19 .63 .45 > .54 > .64 D a l l y time away (unaccompanied) p o s t t r e a t m e n t one month f o l l o w - u p 1 .78 2 .22 3.36 4 . 16 2.45 2 . 72 2 .64 3.42 1 .87 2.95 >. 18 < .05 Mean a n x i e t y p o s t t r e a t m e n t one month f o l l o w - u p 33.54 34 . 71 19.61 15. 17 24.31 234.44 29.42 347.92 1 .57 2.48 > . 23 >. 10 Note: a MS f o r t r e a t m e n t s a r e r e p r o d u c i b l e from F X MSw b O n e - t a i l e d p r o b a b i l i t y e s t i m a t e s due to d i r e c t i o n a l hypotheses c P r e t r e a t m e n t s c o r e s a r e the c o v a r l a t e d Mean hours per day spent away from home over seven-day p e r i o d e Mean a n x i e t y p e r day w h i l e away from home over seven-day p e r i o d f df at p o s t t r e a t m e n t a r e 2.19. At f o l l o w - u p df a r e 2.25 f o r a l l measures except f o r a n x i e t y d e p r e s s i o n 2,24 C M i n T a b l e 9 R e s u l t s of Two-Way A n a l y s e s of C o v a r i a n c e on B e h a v i o r a l D i a r y Scores a t P o s t t r e a t m e n t and One Month Follow-up Group Means Measure FL/A FL MSw D a i l y time away 4" p o s t t r e a t m e n t one month f o l l o w - u p e D a i l y time away (accompanied) p o s t t r e a t m e n t one month f o l l o w - u p D a i l y time away (unaccompanied)' p o s t t r e a t m e n t one month f o l l o w - u p Mean a n x i e t y ^ p o s t t r e a t m e n t one month f o l l o w - u p 6.01 6.56 2 . 27 2 . 14 3.53 4.21 12.01 4.67 3. 72 3.30 1 .64 1 .64 2.42 2.00 26.90 27 .85 3.50 2.00 7 . 19 388.28 8.59 .96 1.61 2 .69 < .01 > . 34 > . 23 > . 13 Note: a MSb f o r treatments a r e r e p r o d u c i b l e from F X MSw b O n e - t a i l e d p r o b a b i l i t y e s t i m a t e s due to d i r e c t i o n a l hypotheses c P r e t r e a t m e n t s c o r e s a r e the c o v a r i a t e d df=1,10 e Mean hours per day spent away from home over seven-day p e r i o d f Mean a n x i e t y per day w h i l e away from home over seven-day p e r i o d g Data a r e p r e s e n t e d on the treatment f a c t o r o n l y 53 a d j u s t e d means of the G a m b r i l l and R i c h e y A s s e r t i v e n e s s I n v e n t o r y a t one month f o l l o w - u p w i t h p r e t r e a t m e n t s c o r e s as the c o v a r i a t e . A l t h o u g h t h e r e were no s i g n i f i c a n t t r e a t m e n t e f f e c t s a t t h i s time on e i t h e r of the s u b s c a l e s ( d i s t r e s s r a t i n g and response p r o b a b i l i t y ) , p l a n n e d o r t h o g o n a l c o n t r a s t s i n d i c a t e d t h a t t r e a t e d s u b j e c t s had s i g n i f i c a n t l y lower d i s t r e s s r a t i n g s f o r a s s e r t i v e b e h a v i o u r than c o n t r o l s u b j e c t s . On n e i t h e r of the s u b s c a l e s were t h e r e s i g n i f i c a n t d i f f e r e n c e s between the FL/A and FL groups. K a t z Adjustment S c a l e s : An a n a l y s i s of c o v a r i a n c e by t r e a t m e n t s a t one month f o l l o w - u p was computed on f o u r s u b s c o r e s from the Katz Adjustment S c a l e s w i t h p r e t r e a t m e n t s c o r e s as c o v a r i a t e . These a d j u s t e d s c o r e s a r e r e p o r t e d i n Table 11. The R1 s u b s c a l e r e f l e c t s r a t i n g s of symptoms and s o c i a l b e h a v i o u r ( h i g h e r s c o r e s i n d i c a t i n g i n c r e a s i n g p a t h o l o g y ) . The R2 s u b s c a l e a s s e s s e s the l e v e l of performance of s o c i a l l y e x p e c t e d a c t i v i t i e s ( h i g h e r s c o r e s r e f l e c t i n g b e t t e r s o c i a l p e r f o r m a n c e ) . The R3 s u b s c a l e t a p s the l e v e l of e x p e c t a t i o n s f o r the s u b j e c t ' s performance of s o c i a l a c t i v i t i e s w i t h h i g h e r s c o r e s i n d i c a t i n g i n c r e a s i n g e x p e c t a t i o n s by s i g n i f i c a n t o t h e r s . D i s s a t i s f a c t i o n i s a d i s c r e p a n c y s c o r e r e f l e c t i n g t h e l e v e l of d i s c o n t e n t m e n t w i t h a s u b j e c t ' s s o c i a l a c t i v i t i e s and i s computed by summing r a t i o s computed a t the item l e v e l from the f o r m u l a 100(R3—R2)/R3. Higher s c o r e s suggest i n c r e a s i n g d i s s a t i s f a c t i o n . L O T a b l e 10 R e s u l t s of A n a l y s e s of C o v a r l a n c e on G a m b r l l l Richey A s s e r t 1veness I n v e n t o r y at One Month Fo l l o w - u p Group Means Measure C o n t r o l FL/A FL a c MSw F D i s t r e s s r a t i n g one month f o l l o w - u p 108.31 102.22 89.60 363.32 2.44 >.10 Response p r o b a b i l i t y one month f o l l o w - u p 115.87 109.50 113.25 67.06 , 1.74 > . 19 Note: a MSb f o r t r e a t m e n t s are r e p r o d u c i b l e from F X MSw b O n e - t a i l e d p r o b a b i l i t y e s t i m a t e s due t o d i r e c t i o n a l h ypotheses c df=2.28 d P r e - t r e a t m e n t means a r e the c o v a r l a t e L O L O T a b l e 11 R e s u l t s of A n a l y s e s of C o v a r i a n c e on Katz Adjustment S c a l e s at One Month Follow-up Group Means Measure C o n t r o l FL/A FL MSw D 1 s s a t 1 s f a c t Ion one month f o l l o w - u p 5.41 8.58 6.55 38.03 .33 >.72 R1 s c o r e one month f o l l o w - u p 227.13 209.17 220.79 201.08 3.44 < .05 R2 s c o r e one month f o l l o w - u p 38.14 35.65 38.41 9.29 1.63 >.22 R3 s c o r e one month f o l l o w - u p 36.26 39.41 40.29 9.28 3.84 < .05 Note: a MSb f o r t r e a t m e n t s a r e r e p r o d u c i b l e from F X MSw b O n e - t a i l e d p r o b a b i l i t y e s t i m a t e s due to d i r e c t i o n a l h ypotheses c P r e - t r e a t m e n t means are the c o v a r i a t e Degrees of freedom a r e 2,17 f o r d i s s a t i s f a c t i o n s c o r e ; 2.21 f o r R1 s c o r e ; 2,19 f o r R2 s c o r e ; 2,18 f o r R3 s c o r e d 56 For the v a r i a b l e s R1 and R3 a s i g n i f i c a n t t r e a t m e n t e f f e c t was found w i t h p l a n n e d o r t h o g o n a l c o n t r a s t s i n d i c a t i n g a s i g n i f i c a n t d i f f e r e n c e between a d j u s t e d mean s c o r e s f o r the c o n t r o l s u b j e c t s on the one hand and t r e a t e d s u b j e c t s on the o t h e r , on each of t h e s e two v a r i a b l e s . S i g n i f i c a n t d i f f e r e n c e s were not found by p l a n n e d o r t h o g o n a l c o n t r a s t s between the two t r e a t m e n t groups. Throughout a n a l y s e s on t r e a t m e n t outcome measures, wherever t r e a t m e n t e f f e c t s y i e l d e d s i g n i f i c a n t d i f f e r e n c e s between groups, these c o n s i s t e n t l y i n d i c a t e d b e t t e r performance by t r e a t e d groups compared t o the c o n t r o l group. 57 DISCUSSION P r o c e s s f i n d i n g s The r e s u l t s of the impact of the e x p e r i m e n t a l t r e a t m e n t s on p r o c e s s measures w i l l be c o n s i d e r e d f i r s t . These concern d a t a r e l e v a n t t o the p r o c e s s of t h e r a p y i t s e l f , as d i s t i n c t from the outcome d a t a . S u b j e c t s i n both t r e a t m e n t groups, t h r o u g h t h e i r responses on the c r e d i b i l i t y / e x p e c t a n c y f o r s u c c e s s s c a l e r e p o r t e d , on average, by the end of the l a s t exposure s e s s i o n , t h a t they "were very c o n f i d e n t " about s u c c e s s w i t h the t h e r a p y o f f e r e d and t h a t " i t seems v e r y l o g i c a l . " T h i s e x p e c t a t i o n r e p r e s e n t e d an o v e r a l l improvement over the c o u r s e of the treatment programme f o r 75% of the s u b j e c t s . T h i s f i n d i n g was of i n t e r e s t as f l o o d i n g t h e r a p i e s are r e p u t e d t o have n e g a t i v e c o n n o t a t i o n s f o r many c l i e n t s y e t t h i s f i n d i n g s u g g e s t s i n c r e a s i n g a c c e p t a b i l i t y from f i r s t t o l a s t exposure s e s s i o n . In s upport of t h i s i t was noted t h a t no s u b j e c t t e r m i n a t e d t h e r a p y b e f o r e the t h r e e exposure s e s s i o n s were completed f o r the reason t h a t the exposure was too a v e r s i v e or too d i f f i c u l t t o endure. One s u b j e c t f l e d from the group and h i d h e r s e l f i n the c l i n i c j u s t as the group was about t o l e a v e on the f i r s t e x c u r s i o n but c o n t i n u e d w i t h the o u t i n g a f t e r a group d i s c u s s i o n . She u l t i m a t e l y completed t h e r a p y w i t h , as i t t u r n e d o u t , one of the more d r a m a t i c g a i n s . Of the 60 s u b j e c t -s e s s i o n s conducted, o n l y one was missed. Thus a l t h o u g h 58 f l o o d i n g has the r e p u t a t i o n of b e i n g "one of the most un p l e a s a n t of the b e h a v i o u r t h e r a p i e s " (Rimm & M a s t e r s , 1979, p. 307); and has been d e s c r i b e d as a ' s i n k - o r - s w i m " t e c h n i q u e ( B e r n s t e i n _ N i e t z e l , 1980, p. 370), the e v i d e n c e from s u b j e c t s i n d i c a t e s t h a t i t i s an a c c e p t a b l e form of t h e r a p y . The s e l f r e p o r t e d a n x i e t y d a t a suggested t h a t the group r e c e i v i n g c o g n i t i v e s t r a t e g i e s i n a d d i t i o n t o f l o o d i n g (FL/A) e x p e r i e n c e d a lower l e v e l of a n x i e t y than the group r e c e i v i n g f l o o d i n g ( F L ) . S i n c e members of each group had had o n l y f o u r days t o p r a c t i c e imagery i t was l i k e l y t h a t the c o v e r t a s s e r t i v e n e s s p r a c t i c e a c c o u n t e d f o r d i m i n i s h e d a n x i e t y r e p o r t e d by FL/A group members. T h i s c o r r o b o r a t e d the r a p i d p r o g r e s s r e p o r t e d by Rimm (1973) whose phobic c l i e n t s showed s i g n i f i c a n t d e c r e a s e s i n a n x i e t y a f t e r o n l y one or two t r a i n i n g s e s s i o n s i n t h i s t e c h n i q u e . The c o n s i s t e n c y w i t h which s u b j e c t s i n each tr e a t m e n t group ranked the t h r e e e x c u r s i o n s i n terms of l e v e l of a n x i e t y e x p e r i e n c e d r a i s e s the q u e s t i o n of the o r d e r i n g of e x p o s u r e , i . e . the e f f e c t of p r e s e n t i n g s i t u a t i o n s i n h i e r a c h i e s of a s c e n d i n g , d e s c e n d i n g or mixed o r d e r . In g e n e r a l f i n d i n g s on t h i s have been e q u i v o c a l i n the case of s y s t e m a t i c d e s e n s i t i z a t i o n (Rimm & M a s t e r s , 1979), a l t h o u g h t h i s parameter has not been i n v e s t i g a t e d i n the case of f l o o d i n g . S u b j e c t s appeared t o u n d e r s t a n d and comply w i t h the p r e s c r i b e d image a t t r i b u t e s i n t h e imagery e x e r c i s e s , w i t h about 86% of t h e s e b e i n g c o r r e c t i n each t r e a t m e n t group. One can thus be r e a s o n a b l y c o n f i d e n t t h a t , when p r a c t i c e d , the 59 images produced conformed t o t h e r a p e u t i c s p e c i f i c a t i o n s . The two t r e a t m e n t groups were v e r y s i m i l a r w i t h r e g a r d t o d i l i g e n c e i n p r a c t i c i n g imagery. The mean l e n g t h of imagery s e s s i o n s h e l d a t home was v e r y s i m i l a r f o r both groups and these were h e l d on about the same number of days. The homework r e c o r d r e s u l t s i n d i c a t e d t h a t i n many c a s e s d u r i n g the f i r s t t h r e e weeks e x e r c i s e s were done q u i t e c o n s i s t e n t l y but t h i s d e c l i n e d over the l a s t two weeks. There were no s i g n i f i c a n t d i f f e r e n c e s between the two t r e a t m e n t groups on d i f f e r e n c e s of homework p r a c t i c e . Outcome f i n d i n g s There was a c l e a r i n d i c a t i o n on s e l f - r e p o r t s c o r e s of the e f f e c t i v e n e s s of the t r e a t m e n t package o f f e r e d , w i t h t r e a t e d s u b j e c t s i m p r o v i n g s i g n i f i c a n t l y more than c o n t r o l s . In g e n e r a l , t a r g e t symptoms, g l o b a l measures, and d e p r e s s i o n a l l s i g n i f i c a n t l y b e n e f i t t e d , but t h e r e were no c l e a r advantages g a i n e d by augmenting f l o o d i n g w i t h c o v e r t p r o c e d u r e s on t h e s e outcome measures. S i g n i f i c a n t g a i n s were made by s u b j e c t s i n both t r e a t m e n t groups on the two s e l f - r e p o r t i n s t r u m e n t s used, the f e a r q u e s t i o n n a i r e (FQ) and the Symptom C h e c k l i s t - 90 (SCL-90). The t a r g e t symptom, a g o r a p h o b i a , showed h i g h l y s i g n i f i c a n t improvements on both t h e s e i n s t r u m e n t s a t p o s t t r e a t m e n t and one month f o l l o w - u p . C o n s i s t e n t w i t h t h i s , b roader measures of phobic p a t h o l o g y ( t o t a l and g l o b a l p hobia on the FQ), and g e n e r a l p s y c h o p a t h o l o g y ( g l o b a l s e v e r i t y index on the SCL-90) i n d i c a t e d improvement of a more g e n e r a l n a t u r e . 6 0 At p o s t t r e a t m e n t the improvements on FQ s u b s c a l e s tended t o be s t r o n g e r than a t one month f o l l o w - u p . T h i s might r e f l e c t i n c r e a s e d m o t i v a t i o n and h o p e f u l n e s s i m m e d i a t e l y a f t e r t h e r a p y which s u b s i d e d to more r e a l i s t i c l e v e l s i n the weeks t h e r e a f t e r . T u r n i n g t o the p o s s i b i l i t y of t h e r a p e u t i c e f f e c t s g e n e r a l i z i n g a c r o s s symptoms, i t was c l e a r t h a t the b l o o d -i n j u r y s u b s c a l e on the FQ was l a r g e l y u n a f f e c t e d by t h e r a p y . There was some i n d i c a t i o n t h a t improvement i n s o c i a l p h o b i a was m a n i f e s t a t p o s t t r e a t m e n t , and a t one month f o l l o w - u p t r e a t e d s u b j e c t s had s i g n i f i c a n t l y b e t t e r s c o r e s than c o n t r o l s . Agoraphobia i s f r e q u e n t l y accompanied by d e p r e s s i o n (Bowen, 1979; DSM I I I , 1980; H a l l a m & H a f n e r , 1978). Both measures i n t h i s study which t a p t h i s domain ( s u b s c a l e s of the FQ and the SCL-90), showed s t r o n g t r e a t m e n t e f f e c t s which were w e l l m a i n t a i n e d from p o s t t r e a t m e n t t o f o l l o w - u p . T h i s c o n f i r m e d f i n d i n g s by Mathews e_t a_l (1976) a f t e r i n v i v o exposure t r e a t m e n t and by Emmelkamp and K u i p e r s (1979) a f t e r a f o u r year f o l l o w - u p . R e s u l t s of a n a l y s i s of the b e h a v i o u r a l d i a r y (BD) showed t h a t the s t r o n g e f f e c t s i n d i c a t i n g p o s i t i v e t h e r a p e u t i c g a i n s found on many of the s u b j e c t i v e measures were l e s s e v i d e n t on the b e h a v i o u r a l measure. Those s i g n i f i c a n t g a i n s t h a t were found i n the BD seemed t o d e v e l o p between p o s t t r e a t m e n t and one month f o l l o w - u p s i n c e none of the a n a l y s e s on the f o u r b e h a v i o u r a l i n d i c e s r e v e a l e d change at p o s t t r e a t m e n t but group 61 d i f f e r e n c e s emerged a t f o l l o w up. The l a g g e d response t h a t b e h a v i o u r showed when compared t o the r e p o r t s of s u b j e c t i v e e x p e r i e n c e has been d e s c r i b e d as desynchrony by Rachman and Hodgson (1974). T h i s term d e s c r i b e s a low or i n v e r s e c o r r e l a t i o n between d i f f e r e n t response systems r e f l e c t i n g common p s y c h o l o g i c a l p r o c e s s e s ( i n t h i s case c o g n i t i v e and b e h a v i o u r a l ) . Most s t u d i e s w i t h a g o r a p h o b i c s have i n v e s t i g a t e d the r e l a t i o n s h i p between p h y s i o l o g i c a l measures and e i t h e r c o g n i t i v e ( s e l f - r e p o r t ) or b e h a v i o u r a l measures of a n x i e t y ( e . g . Hafner & Marks, 1976; Mathews, J o h n s t o n , L a n c a s h i r e , Munby, Shaw, _ G e l d e r , 1976; S t e r n & Marks, 1973). The broad f i n d i n g has been one of desynchrony among the response systems. I t c o u l d be t h a t the i n i t i a l changes would be i n the c o g n i t i o n s of group members c o n c e r n i n g t h e i r a b i l i t i e s t o cope w i t h f e a r e d s i t u a t i o n s , or i n t h e i r i n c r e a s e d c o n f i d e n c e t h a t dreaded consequences, such as f a i n t i n g , screaming or f l e e i n g , would not happen d u r i n g the s t r i n g e n t demands , of the exposure s e s s i o n s . These might then be f o l l o w e d w i t h some l a g , by b e h a v i o u r a l m a n i f e s t a t i o n s of an improved c o g n i t i v e s e t . T h i s p r o p o s a l c o r r e s p o n d s c l o s e l y t o the o p i n i o n s of Emmelkamp e_t a_l (1978), seconded by E l l i s ( 1979), who f e e l t h a t the e f f e c t s of p r o l o n g e d exposure may l e a d c l i e n t s t o change n e g a t i v e s e l f - s t a t e m e n t s about dreaded consequences of b e i n g i n c e r t a i n s i t u a t i o n s t o p o s i t i v e ones. T h i s would be r e c o n f i r m e d f o r c l i e n t s t h r o u g h c o n t i n u i n g exposure i n t h e i r day-to-day l i v e s . The FL/A group spent s i g n i f i c a n t l y more t o t a l time away from home than the FL group 6 2 a t f o l l o w - u p . I t was a l s o found the FL/A t r e a t m e n t package had a s i g n i f i c a n t e f f e c t on the time spent unaccompanied away from home. One of the c h a r a c t e r i s t i c s of a g o r a p h o b i a i s a s t r o n g p r e f e r e n c e or an i n s i s t e n c e by s u f f e r e r s t o be accompanied on e x c u r s i o n s from home. I t was e n c o u r a g i n g t h e r e f o r e t o note t h a t i n c r e a s e d time spent away from home appeared t o be due t o an i n c r e a s e i n unaccompanied v e n t u r e s a t the expense of accompanied v e n t u r e s and not the c o n t r a r y . R e p o r t s on the Katz Adjustment S c a l e s (KAS) were p r o v i d e d by s i g n i f i c a n t o t h e r s i n an attempt t o o b t a i n e c o l o g i c a l v a l i d a t i o n of the changes r e p o r t e d by group members the m s e l v e s . One month f o l l o w - u p i n d i c a t e d s i g n i f i c a n t l y i n c r e a s e d e x p e c t a t i o n s by t h e s e s i g n i f i c a n t o t h e r s f o r the s o c i a l performance of s u b j e c t s . I t may be t h a t they were encouraged by the r e d u c t i o n s i n d e p r e s s i v e symptomatology and by the g a i n s made i n i n c r e a s e d unaccompanied time spent away from home by s u b j e c t s . C e r t a i n l y the t r e n d on the s u b s c a l e r e f l e c t i n g g e n e r a l symptomatology and s o c i a l performance i n d i c a t e d t h a t s i g n i f i c a n t o t h e r s d e t e c t e d improvement. A l t h o u g h a s s e r t i v e n e s s - t r a i n i n g was not p a r t of t h i s t h e r a p y package, i t was i n t e r e s t i n g t o note t h a t a t one month f o l l o w - u p the t r e a t m e n t groups were s i g n i f i c a n t l y improved compared t o the c o n t r o l group. I t may have been t h a t the improvement was a s s o c i a t e d w i t h i n c r e a s e d s o c i a l i n t e r a c t i o n f a c i l i t a t e d by the h i g h e r l e v e l of m o b i l i t y a c h i e v e d . On the o t h e r hand the improvements i n s o c i a l s k i l l s and a s s e r t i v e b e h a v i o u r may have been the r e s u l t of the group p r o c e s s i t s e l f 63 which c a l l e d f o r e x t e n s i v e d i s c u s s i o n , open exchanges on the i m p l i c a t i o n s of b e i n g a g o r a p h o b i c , o p p o r t u n i t i e s f o r g i v i n g and r e c e i v i n g p r a i s e , a n d empathic s u p p o r t . Thus the t r e n d d i s p l a y e d on the s o c i a l p h o b i a s u b s c a l e of the FQ where t h e r e were s i g n i f i c a n t group d i f f e r e n c e s between c o n t r o l s u b j e c t s and t r e a t e d s u b j e c t s both at p o s t t r e a t m e n t and one month f o l l o w - u p , may be a s s o c i a t e d w i t h d e c r e a s e d d i s c o m f o r t r e p o r t e d i n s i t u a t i o n s r e q u i r i n g a s s e r t i v e n e s s . The study by Mathews, J o h n s t o n , L a n c a s h i r e , Munby, Shaw, and G e l d e r (1976) suggested t h a t l o n g e r d u r a t i o n of a g o r a p h o b i a was a s s o c i a t e d w i t h worse outcome ( a l t h o u g h t h e i r c o r r e l a t i o n n a r r o w l y m issed s i g n i f i c a n c e and they d i d not i n d i c a t e how outcome was measured). In c o n t r a s t the p r e s e n t study f i n d s a s t r o n g p o s i t i v e c o r r e l a t i o n between r e s i d u a l g a i n on the g l o b a l s e v e r i t y index (which measures l e v e l of g e n e r a l p s y c h o p a t h o l o g y ) at one month f o l l o w - u p , and d u r a t i o n of i l l n e s s . Longer d u r a t i o n of i l l n e s s was t h u s a s s o c i a t e d w i t h an. i n c r e a s e i n GSI s c o r e s ( i . e . a more s e v e r e g e n e r a l symptomatology) above t h a t which would have been p r e d i c t e d from p r e t r e a t m e n t GSI. T h i s i m p l i e d a more r e f r a c t o r y response t o t h i s t h e r a p y f o r l o n g e r i l l n e s s d u r a t i o n but on the o t h e r hand, a more r e s p o n s i v e outcome f o r s h o r t e r d u r a t i o n . I t was c l e a r t h a t t r e a t e d s u b j e c t s o u t p e r f o r m e d c o n t r o l s u b j e c t s on most of the s u b j e c t i v e and b e h a v i o u r a l outcome measures. However, t h e r e were few s i g n i f i c a n t d i f f e r e n c e s between the two treatment groups. W h i l e t h e r e was a c o n s i s t e n t t r e n d f o r the FL/A group t o o u t p e r f o r m the FL group, the 64 d i f f e r e n c e s r e a c h s i g n i f i c a n c e i n few i n s t a n c e s . One outcome measure i n d i c a t e d b e t t e r b e h a v i o u r a l performance f o r the FL/A group. The t o t a l time spent away from home by t h e s e s u b j e c t s was s i g n i f i c a n t l y g r e a t e r a t one month f o l l o w - u p than f o r FL s u b j e c t s . In one sense t h i s i s a p i v o t a l measure f o r , w i t h o u t t a n g i b l e p r o o f t o group-members t h a t they were a b l e t o spend more time out a f t e r t h e r a p y than b e f o r e , one c o u l d not r e a s o n a b l y expect any g a i n s i n c o n f i d e n c e t h a t the i d i o s y n c r a t i c dreaded event (e.g. f a i n t i n g , h e a r t f a i l u r e , screaming) was u n l i k e l y t o o c c u r . There were, however, no concommitant d e c r e a s e s i n the a n x i e t y r a t i n g s r e p o r t e d on d i a r i e s . One p r o c e s s measure, the SAS, i n d i c a t e d c l e a r l y t h a t , d u r i n g t h e r a p y , the group p r o v i d e d w i t h c o v e r t t e c h n i q u e s r e p o r t e d s u b s t a n t i a l l y l e s s a n x i e t y than the group w i t h o u t . I n d i c a t i o n s were t h a t i t was the c o v e r t a s s e r t i v e n e s s t e c h n i q u e t h a t was the major agent c a u s i n g the decrement. I t was u n l i k e l y t h a t the c o v e r t m o d e l i n g p r a c t i c e c o u l d have had much chance t o make a s i g n i f i c a n t impact as e a r l y as the f i r s t , second or even the t h i r d group exposure s e s s i o n g i v e n the b r i e f p r a c t i c e t i m e s i n v o l v e d . On the o t h e r hand, c o v e r t a s s e r t i v e n e s s has been found t o be c l i n i c a l l y e f f e c t i v e a lmost from the f i r s t a p p l i c a t i o n of the t e c h n i q u e , (Rimm, 1973). Spontaneous v e r b a l comments from group members i n t h i s study a t t r i b u t e d marked r e l i e f from a n x i e t y t o the use of c o v e r t a s s e r t i v e n e s s . T h i s l e n d s s u p p o r t t o the u s e f u l n e s s of t h i s t e c h n i q u e i n a l l e v i a t i n g a n x i e t y i n phobic d i s o r d e r s . I t i s 65 a l s o p o s s i b l e t h a t the c o m b i n a t i o n of c o v e r t a s s e r t i v e n e s s w i t h c o v e r t m odeling p o t e n t i a t e d the e f f e c t of c o v e r t a s s e r t i v e n e s s . C o n s i d e r i n g the e f f e c t s of c o n t i n u e d p r a c t i c e of c o v e r t m o d e l i n g , t h i s study found t h a t the FL/A group had lower a g o r a p h o b i a s c o r e s a t one month f o l l o w - u p than the FL group w i t h h i g h - l e v e l p r a c t i c e i n each group a s s o c i a t e d w i t h lower s c o r e s than l o w - l e v e l p r a c t i c e . These e f f e c t s d i s a p p e a r e d however when i n i t i a l d i f f e r e n c e s between the two groups a t p r e t r e a t m e n t were c o v a r i e d o u t . When the a l t e r n a t i v e measure of l e v e l of homework p r a c t i c e was used (mean number of minutes per s e s s i o n ) no d i f f e r e n c e s were found. The e f f e c t of p r a c t i c e l e v e l must t h e r e f o r e remain an u n c e r t a i n , or a t best a weak, f i n d i n g . I t would have been d e s i r a b l e to have had f o l l o w - u p p e r i o d s l o n g e r than a month; many s t u d i e s ( e . g . Hand e_t a_l 1974; T e a s d a l e et a l , 1977) p r o v i d e three-month f o l l o w - u p d a t a . I t i s p o s s i b l e t h a t a f t e r a t h r e e month p e r i o d f u r t h e r d i f f e r e n c e s between t r e a t m e n t s would have become a p p a r e n t . In d i s c u s s i n g the i m p l i c a t i o n s of c o g n i t i v e c o n c e p t s f o r b e h a v i o u r t h e r a p y , M a r z i l l i e r (1980) makes a u s e f u l d i s t i n c t i o n among t h r e e c a t e g o r i e s of usage of c o g n i t i o n s . C o g n i t i v e e v e n t s may be c o n s t r u e d as t h o u g h t s or images o c c u r r i n g i n the stream of c o n s c i o u s n e s s . S e c o n d l y , c o g n i t i v e p r o c e s s e s t r a n s f o r m and p r o c e s s i n t e r n a l and e x t e r n a l s t i m u l i and t h e r a p y o p e r a t i n g a t t h i s l e v e l aims t o remedy d e f i c i e n c i e s i n t h e s e p r o c e s s e s . The t h i r d usage p o s t u l a t e s 66 c o g n i t i v e s t r u c t u r e s and d e s c r i b e s more deep-seated c o g n i t i v e a s p e c t s of f u n c t i o n i n g which s e r v e t o o r g a n i s e and d i r e c t e x p e r i e n c e a t a more fundemental l e v e l . The c o v e r t t e c h n i q u e s used i n t h i s study c o n s t i t u t e " c o g n i t i v e t h e r a p y " o n l y i n s o f a r as they d e a l w i t h c o g n i t i v e e v e n t s . The c o g n i t i v e r e s t r u c t u r i n g t e c h n i q u e s used by Emmelkamp, K u i p e r s , and Eggeraat (1978) f o c u s s e d on c o g n i t i v e p r o c e s s e s and s t r u c t u r e s and were found t o be c l e a r l y l e s s e f f e c t i v e than p r o l o n g e d exposure. A study by W i l l i a m s and Rappoport (note 1) which f o c u s a e d on the d r i v i n g p h o b i a a s p e c t of a g o r a p h o b i a used the c o g n i t i v e s t r a t e g i e s of d i s t r a c t i o n , c o g n i t i v e r e s t r u c t u r i n g , and use of p o s i t i v e s e l f - s t a t e m e n t s i n t h e r a p y . These cover M a r z i l l i e r ' s c a t e g o r i e s of both c o g n i t i v e e v e n t s and p r o c e s s e s . I t was found t h a t i n v i v o exposure was a s u p e r i o r approach t o thought m o d i f i c a t i o n . Thus, i n the l i m i t e d r e s e a r c h r e p o r t e d u s i n g c o g n i t i v e t e c h n i q u e s w i t h a g o r a p h o b i a , i t appears t h a t they are r e l a t i v e l y i n e f f e c t i v e i n i m p r o v i n g outcome measures. In c o n t r a s t the p r e s e n t study found c o v e r t a s s e r t i v e n e s s u s e f u l as a t e c h n i q u e f o r r e d u c i n g a n x i e t y d u r i n g e x p o s u r e . The e f f i c i e n c y of u s i n g a group exposure approach i n the t r e a t m e n t of agoraphobia was c o n f i r m e d . One t h e r a p i s t c o m f o r t a b l y managed f i v e group members and over t h r e e s e s s i o n s of about f i v e hours each, t h r e e t h e r a p i s t - h o u r s per group-member were expended. To t h i s s h o u l d be added one hour f o r a p r e t r e a t m e n t i n t e r v i e w . U n l i k e the Hand et a l (1974) s t u d y no f u r t h e r meetings w i t h the t h e r a p i s t were s c h e d u l e d a f t e r 67 exposure s e s s i o n s a l t h o u g h group-members were t o l d t h a t i f t h e i r problem was not i m p r o v i n g or i f t h e i r s i t u a t i o n seemed i n t o l e r a b l e , f u r t h e r i n d i v i d u a l t h e r a p y was a v a i l a b l e . Only two of the 32 s u b j e c t s r e q u e s t e d t h i s by one month f o l l o w up. A t r e a t m e n t s t r a t e g y t h a t uses b r i e f group t h e r a p y as the p r i m a r y i n t e r v e n t i o n on the assumption t h a t i t i s e f f e c t i v e f o r most a g o r a p h o b i c s , c o u l d then be supplemented by f u r t h e r i n d i v i d u a l or group t h e r a p y f o r the few t h a t r e q u i r e i t . The t h e r a p y o f f e r e d i n t h i s s tudy might be c o n c e p t u a l i z e d as a t r e a t m e n t package ( K a z d i n , 1980). The s t u d y i n v e s t i g a t e d whether a m u l t i - f a c e t e d approach might enhance t h e r a p e u t i c e f f e c t s when compared t o the b a s i c f l o o d i n g i n v i v o s t r a t e g y . S i n c e t h e r e was e v i d e n c e t h a t t h i s was the case i n some r e s p e c t s , p a r t i c u l a r components of the package might now be s u b j e c t e d to f i n e r - g r a i n e d a n a l y s i s i n f u t u r e r e s e a r c h t o d e termine more p r e c i s e l y t h e i r i n d i v i d u a l c o n t r i b u t i o n s t o b e h a v i o u r change. 6 8 REFERENCE NOTE 1. W i l l i a m s , S. L., _ Rappoport, J . A. B e h a v i o r a l p r a c t i c e  w i t h and w i t h o u t thought m o d i f i c a t i o n f o r a g o r a p h o b i c s . Paper p r e s e n t e d a t the American P s y c h o l o g i c a l A s s o c i a t i o n c o n v e n t i o n , M o n t r e a l , Canada, September 1 9 8 0 . 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T h e r a p i s t ' s Manual COVERT PRACTICE OF ASSERTIVENESS GROUP (FL/A group) S e s s i o n j_ TIME (Mins) 0--10 10--30 I n t r o d u c t i o n and welcome Members are i n t r o d u c e d t o each o t h e r and welcomed to the programme. Advantages of group t h e r a p y a r e o u t l i n e d . A broad r a t i o n a l e i s g i v e n f o r exposure t h e r a p y : t h a t r e s e a r c h has shown r e p e a t e d p r o l o n g e d exposure t o v a r i o u s a n x i e t y - p r o v o k i n g s i t u a t i o n s t o d e c r e a s e a n x i e t y i n these s i t u a t i o n s . Group exposure s e s s i o n s w i l l p r o v i d e p r o o f t o group-members t h a t dreaded e v e n t s e.g. f a i n t i n g , s c r e a m i n g , h e a r t f a i l u r e , e t c . , almost never happen even when a n x i e t y i s h i g h and members remain i n the d i f f i c u l t s i t u a t i o n s . I t i s s t r e s s e d t h a t they w i l l r e c e i v e l o t s of support from the t h e r a p i s t and o t h e r group members and t h a t t h i s approach t o t h e r a p y has been found t o be s u c c e s s f u l w i t h many a g o r a p h o b i c s . I t i s e x p l a i n e d t h a t t h e r a p y i s a l s o t o i n c l u d e t e c h n i q u e s t o h e l p a r r e s t the e s c a l a t i o n of a n x i e t y , and i m a g i n a l p r a c t i c e t o e x t e n d the range and f r e q u e n c y of e x posure. Co v e r t a s s e r t i v e n e s s (CA) t r a i n i n g (a) Group members, w i t h the a s s i s t a n c e of the t h e r a p i s t g e n e r a t e a s s e r t i v e s t a t e m e n t s which would be a p p r o p r i a t e f o r them t o use i n a g o r a p h o b i c s i t u a t i o n s . Examples: "I r e f u s e t o get a n x i o u s " "I can do i t t o o " " I ' l l go i n and show them" "I'm not g o i n g t o get h o t " When 8--10 such s t a t e m e n t s have been suggested by the group, each member on a c a r d w r i t e s 3 of them t h a t he or she i s most c o m f o r t a b l e u s i n g . (b) The s e l e c t e d s t a t e m e n t s a r e r e h e a r s e d a l o u d by each member i n t u r n w i t h the t h e r a p i s t modeling and e n c o u r a g i n g a s s e r t i v e e x p r e s s i o n " I ' d l i k e you t o t r y and say i t w i t h f e e l i n g i n a c o n v i n c i n g and i n s i s t e n t way l i k e t h i s : The s t a t e m e n t s a r e r e p e a t e d by members u n t i l they a r e 76 e x p r e s s e d i n an a s s e r t i v e manner. (c) Each member c o v e r t l y r e h e a r s e s the stat e m e n t s s e l e c t e d a f t e r the t h e r a p i s t has d e s c r i b e d t h r e e agoraphobic s c e n e s : b o a r d i n g a bus e n t e r i n g a department s t o r e s i t t i n g i n crowded s p o r t s s t a d i u m (d) T h e r a p i s t s remind group members t h a t even though s t a t e m e n t s a re e x p r e s s e d i n w a r d l y and not a l o u d , i t i s i m p o r t a n t t o e x p r e s s them " w i t h f e e l i n g " and a s s e r t i v e l y . A l l sta t e m e n t s s e l e c t e d by each member s h o u l d be used i n any one day, r a t h e r than u s i n g any one of them r e p e a t e d l y . (e) A s s e r t i v e s t a t e m t e n t s s h o u l d be used d u r i n g the group exposure s e s s i o n s and i n agora p h o b i c s i t u a t i o n s i n r e a l l i f e whenever the s t a r t of the r i s e of a n x i e t y was f e l t . C o v e r t modeling (CM) w i t h an a s s e r t i v e model (a) I n t r o d u c t i o n & r a t i o n a l e "The procedure we a r e goi n g t o use i s based on a number of e x p e r i m e n t s i n which p e o p l e l e a r n new h a b i t s by o b s e r v i n g o t h e r people i n v a r i o u s s i t u a t i o n s . The way t h i s i s u s u a l l y done i s t h a t p e o p l e a c t u a l l y o bserve o t h e r s d o i n g t h i n g s . What I am go i n g t o do i s t o v a r y t h i s p rocedure somewhat by h a v i n g you observe c e r t a i n scenes i n i m a g i n a t i o n r a t h e r than h a v i n g you d i r e c t l y o bserve a movie or a c t u a l i n t e r a c t i o n among p e o p l e . I am g o i n g t o use scenes t h a t I t h i n k w i l l h e l p you change the b e h a v i o u r we agreed needs c h a n g i n g . In a minute I ' l l ask you t o c l o s e your eyes and t r y t o imagine, as c l e a r l y as p o s s i b l e , t h a t you are o b s e r v i n g a c e r t a i n s i t u a t i o n . Try t o use a l l the senses needed f o r a p a r t i c u l a r s i t u a t i o n e.g. t r y t o hear a v o i c e or see a pers o n v e r y c l e a r l y . A f t e r I d e s c r i b e the scene I w i l l ask you some q u e s t i o n s c o n c e r n i n g your f e e l i n g s about the scene and how c l e a r l y you imagined i t . " (b) Warm up To f a c i l i t a t e t he g e n e r a t i o n of r e a s o n a b l y 77 c l e a r imagined scenes, members are asked t o c l o s e t h e i r eyes and t o imagine the foods they a t e and drank a t t h e i r most r e c e n t meal or snack. The c o l o u r s , t e x t u r e s and aromas of the foods s h o u l d be r e f e r r e d t o by t h e r a p i s t s as i m p o r t a n t t o r e c a l l and imagine. C o v e r t m o d e l i n g p r a c t i c e The t h e r a p i s t w r i t e s on the board a l i s t of problem s i t u a t i o n s e x t r a c t e d from the f e a r q u e s t i o n n a i r e s and s u b j e c t q u e s t i o n n a i r e s of t h i s p a r t i c u l a r group. Each group member chooses f i v e scenes he would l i k e t o work on and w r i t e s them on a c a r d . C o n s e c u t i v e l y members a r e asked t o imagine t h e s e f i v e scenes i n which a c o p i n g , same-sexed, and s i m i l a r - a g e d model: ( i ) i n i t i a l l y approached an a n x i e t y -p r o v o k i n g s i t u a t i o n i n a h e s i t a n t , a n x i o u s way ( i i ) used a CA statement ( i i i ) and then i s rewarded by b e i n g a b l e t o complete the a c t i o n and by f e e l i n g p l e a s e d and e l a t e d . An example of a s c r i p t f o r a scene f o l l o w s : Preamble: " P l e a s e s i t back and t r y t o r e l a x . Try to imagine the scene I am g o i n g t o d e s c r i b e . Imagine you are r e a l l y t h e r e . In a d d i t i o n t o s e e i n g what I d e s c r i b e t r y t o use your o t h e r senses as w e l l . I f , i n the scene you a r e s i t t i n g i n a c h a i r , f o r example, t r y t o imagine t h a t you can f e e l the c h a i r a g a i n s t your body. I f you a r e i n a f o r e s t , t r y t o imagine you can hear b i r d s c h i r p i n g and l e a v e s r u s t l i n g . Remember, the main p o i n t i s t h a t you a r e a c t u a l l y e x p e r i e n c i n g e v e r y t h i n g . Ready? Good. Now p l e a s e c l o s e your eyes and t r y t o r e l a x . " Scene p r e s e n t a t i o n : " I ' d l i k e you t o imagine a model you would l i k e t o use i n a l l the mode l i n g scenes I'm g o i n g t o d e s c r i b e . The model s h o u l d be a p p r o x i m a t e l y the same age as you 78 are and the same sex as you. As you s i t h e r e , t r y t o imagine such a p e r s o n . See what the pers o n i s wearing and what the c o l o u r of the c l o t h e s a r e . "You can see your model s t a n d i n g a t a b u s - s t o p . He or she i s s t a n d i n g on the s i d e w a l k w a i t i n g f o r the bus t o a r r i v e . You can hear the sound of p a s s i n g c a r s and see them go by. Your model seems t o be q u i t e w o r r i e d and a n x i o u s because he or she has a t e n s e , nervous e x p r e s s i o n on the f a c e . F i n a l l y the bus a r r i v e s . You can hear the sound of the bus doors opening and you can see passengers g e t t i n g o f f . Your model h e s i t a t e s t o board the bus. Then she says i n w a r d l y "I r e f u s e t o get a n x i o u s " (her c o v e r t a s s e r t i o n s t a t e m e n t ) , w i t h g r e a t f e e l i n g and i n t e n s i t y . You can now see your model's f o o t on the s t e p of the bus as she boards i t . As your model pays the d r i v e r , you can see him or her s m i l i n g . Your model i s l o o k i n g p l e a s e d and r e l a x e d as he or she s i t s down on the bus. You can see no t r a c e of a n x i e t y . (PAUSE) Now open your eyes." (d) Homework Members a r e g i v e n a homework r e c o r d (HR) sheet l i s t i n g the f i v e scenes and a r e asked t o have two p r a c t i c e s e s i o n s of CM each of about 10 minutes each day. At each homework s e s s i o n t h e i r chosen f i v e scenes a r e imagined t w i c e . Homework s e s s i o n s s h o u l d commence on the a f t e r n o o n of the f i r s t day of group t r e a t m e n t and c o n t i n u e u n t i l 30 days a f t e r the t h i r d and f i n a l group s e s s i o n CM p r a c t i c e t i m e s s h o u l d by r e c o r d e d on the HR s h e e t s . Group exposure ( i ) T h e r a p i s t s s h o u l d not mention the word " f l o o d i n g " i n t h e i r p r e s e n t a t i o n of r a t i o n a l e s , or a t any time i n t h e r a p y . " F l o o d i n g " may, f o r some s u b j e c t s have adver s e r e a c t i o n s e i t h e r t h r o u g h p r e v i o u s t h e r a p y or h e r e s a y , or r e a d i n g . I t i s suggested t h a t the phrase "group exposure" be used i n i t s p l a c e . ( i i ) T h e r a p i s t e x p l a i n s t h a t r e s e a r c h has shown t h a t r e p e a t e d , p r o l o n g e d exposure (something of the o r d e r of 2 hours) t o a 79 f e a r e d s i t u a t i o n has brought v e r y e f f e c t i v e and r a p i d r e l i e f from a n x i e t y f o r many a g o r a p h o b i c s . When the group goes on a group exposure o u t i n g , some a n x i e t y i s t o be expected by group members. I t i s i m p o r t a n t t o s t a y • i n the a n x i e t y - p r o v o k i n g s i t u a t i o n . The a n x i e t y w i l l s u b s i d e a f t e r a w h i l e even though a group member may s t i l l be p r e s e n t i n the s i t u a t i o n . T h i s i s the key t o s u c c e s s f u l t r e a t m e n t . W h i l e e x p e r i e n c i n g the a n x i e t y , members_.should not engage i n any p h y s i c a l a v o i d a n c e ( i . e . l e a v i n g the s i t u a t i o n ) or mental a v o i d a n c e (e.g. t h i n k i n g of o t h e r t h o u g h t s t o d i s t r a c t a t t e n t i o n , p r e t e n d i n g t o be e l s e w h e r e ) . Members s h o u l d r a t h e r c o n c e n t r a t e on d e s c r i b i n g t o themselves t h e i r s u r r o u n d i n g s , b o d i l y f e e l i n g s , and mental e v e n t s . ( T h e r a p i s t t o model t h i s ) . The c r i t e r i o n f o r moving from one phobic s i t u a t i o n t o the next i s t o be a decrease of a n x i e t y r a t h e r than i t s a b s o l u t e l e v e l . Members would thus l e a r n t h a t peak a n x i e t y does not l a s t v e r y l o n g , c o u l d be t o l e r a t e d and, a f t e r a few s u c c e s s f u l e x e r c i s e s they would g a i n c o n f i d e n c e i n t h e s e p r e v i o u s l y a n x i e t y - p r o d u c i n g s i t u a t i o n s . ( i i i ) Group members s h o u l d remember w h i l e they a r e e x p e r i e n c i n g "group exposure" t h a t t h e r e a re o t h e r group members who a r e i n the same s i t u a t i o n . ( i v ) When members f e e l a n x i e t y b e g i n n i n g t o r i s e , they s h o u l d " i n w a r d l y " use t h e i r a s s e r t i o n s t a t e m e n t s . (v) Group members a r e t o l d t h a t , d u r i n g group exposure s e s s i o n s , a t h e r a p i s t w i l l remain at a s p e c i f i e d l o c a t i o n nearby members. Members s h o u l d aim a t e x p e r i e n c i n g the exposure a l o n e ; s h o u l d r e s i s t the urge t o r e t u r n t o the t h e r a p i s t , and s h o u l d o n l y r e t u r n t o the t h e r a p i s t i f the s i t u a t i o n became i n t o l e r a b l e . 70--90 Members walk i n d i v i d u a l y t o the bus s t o p (about 25 y a r d s a p a r t ) . The group t r a v e l s by bus t o a nearby shopping c e n t r e ( O a k r i d g e ) . Members and t h e r a p i s t s a re t o s i t s e p a r a t e l y on the bus ( i . e . not grouped t o g e t h e r ) . 80 90 — 210 Two hours of c o n t i n u o u s exposure a t a department s t o r e (Woodwards) i n the Oakridge Shopping C e n t r e (as d e s c r i b e d i n ( v ) ) . 2 1 0 — 2 3 0 Return t o c l i n i c by bus and walk i n d i v i d u a l l y (about 25 y a r d s a p a r t ) back t o the c l i n i c . 5. D i s c u s s i o n 230--270 Group d i s c u s s i o n t o share e x p e r i e n c e s ; t o d i s c u s s use of CA; answer q u e s t i o n s ; and d i s c u s s homework a s s i g n m e n t s . Group members are a d v i s e d t h a t i t i s i m p o r t a n t f o r them t o extend t h e range and d u r a t i o n of t h e i r unaccompanied e x c u r s i o n s from t h e i r homes s t a r t i n g t h a t a f t e r n o o n . Each day t h e r e s h o u l d be some p r a c t i c e i n d o i n g t h i n g s which were d i f f i c u l t f o r them. The l e v e l of d i f f i c u l t y was t o be l e f t up t o the i n d i v i d u a l t o d e t e r m i n e f o r h i m s e l f or h e r s e l f . Each member i s then asked t o d e s c r i b e one t a s k t o be done t h a t a f t e r n o o n and a n o t h e r t o be done on the f o l l o w i n g day. The t h e r a p i s t s h o u l d review each t a s k w i t h the group member i n o r d e r t o o p e r a t i o n a l i z e and p i n p o i n t g o a l s e.g. walk a l o n e t o supermarket a l o n g Main S t r e e t ; buy a t l e a s t t e n i t e m s ; check out through r e g u l a r c a s h i e r (not e x p r e s s l a n e ) ; walk home a l o n g High Road a l o n e . S e s s i o n s 2 & 3_ 0 — 3 0 1. D i s c u s s i o n of homework 3 0 — 6 0 2. CA and CM p r a c t i c e . 6 0 — 2 3 0 3. Group exposure: s e s s i o n 2 t o Van Dusen Gardens (a l a r g e p u b l i c p a rk) s e s s i o n 3 t o P a c i f i c C e n t r e M a l l ( the b u s i e s t downtown underground shopping m a l l ) 230--270 4. Group d i s c u s s i o n . 81 T h e r a p i s t ' s Manual FLOODING GROUP (FL group) S e s s i o n 1 TIME (Mins) 0--1 0 I n t r o d u c t i o n and welcome Members a r e i n t r o d u c e d t o each o t h e r and welcomed t o the programme. Advantages of group t h e r a p y a r e o u t l i n e d . A broad r a t i o n a l e i s g i v e n f o r exposure t h e r a p y : t h a t r e s e a r c h . has shown r e p e a t e d p r o l o n g e d exposure t o v a r i o u s a n x i e t y - p r o v o k i n g s i t u a t i o n s t o d ecrease a n x i e t y i n these s i t u a t i o n s . Group exposure s e s s i o n s w i l l p r o v i d e p r o o f t o group-members t h a t dreaded e v e n t s e.g. f a i n t i n g , s c r e a m i n g , h e a r t f a i l u r e , e t c . , almost never happen even when a n x i e t y i s h i g h and members remain i n the d i f f i c u l t s i t u a t i o n s . I t i s s t r e s s e d t h a t they w i l l r e c e i v e l o t s of s u p p o r t from the t h e r a p i s t and o t h e r group members and t h a t t h i s approach t o t h e r a p y has been found t o be s u c c e s s f u l w i t h many a g o r a p h o b i c s . I t i s e x p l a i n e d t h a t t h e r a p y i s a l s o t o i n c l u d e i m a g i n a l p r a c t i c e t o e x t e n d the range and frequency of exposure. 10 — 30 2. Group d i s c u s s i o n of members' h i s t o r i e s of a g o r a p h o b i a I t i s e x p l a i n e d t h a t i t would be u s e f u l t o d i s c u s s the o r i g i n s and e a r l y e p i s o d e s of members' a g o r a p h o b i c problems. The t h e r a p i s t s h o u l d not attempt to i n t e r p r e t or p r o v i d e i n c H a h r r o t h e s e et pt t o i n t e r p r e t or pro^ i n s i g h t t o t h e s e e p i s o d e s but s h o u l d r a t h e r a c t as c h a i r p e r s o n t o r e g u l a t e the d i s c u s s i o n . The t h e r a p i s t s h o u l d make notes s h o u l d be a d d r e s s e d i n d i v i d u a l l y i n d e t a i l s of the e p i s o d e s . and members r o t a t i o n f o r 30--60 3. Scene p r e s e n t a t i o n (a) "The p r o c e d u r e we are g o i n g t o use i s based on a number of e x p e r i m e n t s i n which p e o p l e l e a r n new h a b i t s by o b s e r v i n g v a r i o u s s i t u a t i o n s . The way t h i s i s u s u a l l y done i s t h a t p e o p l e a c t u a l l y e x p e r i e n c e t h e s e s i t u a t i o n s . We are g o i n g t o v a r y t h i s p r ocedure somewhat by h a v i n g you d i r e c t l y observe a movie or a c t u a l i n t e r a c t i o n among p e o p l e . I am g o i n g t o use scenes t h a t I t h i n k w i l l h e l p you change the b e h a v i o r we 82 agreed needs c h a n g i n g . In a minute, I ' l l ask you t o c l o s e your . eyes, and t r y t o imagine, as c l e a r l y as p o s s i b l e , t h a t you are o b s e r v i n g a c e r t a i n s i t u a t i o n . Try t o use a l l the senses needed f o r the p a r t i c u l a r s i t u a t i o n , e.g. t r y t o a c t u a l l y hear a v o i c e or see a person v e r y c l e a r l y . A f t e r I d e s c r i b e the scene, I w i l l ask you some q u e s t i o n s c o n c e r n i n g your f e e l i n g s about the scene and how c l e a r l y you imagined i t . " (b) Warm-up To f a c i l i t a t e the g e n e r a t i o n of r e a s o n a b l y c l e a r imagined scenes, members a r e asked t o c l o s e t h e i r eyes and t o imagine the foods they a t e and drank a t t h e i r most r e c e n t meal or snack. The c o l o u r s , t e x t u r e s and aromas of the foods s h o u l d be r e f e r r e d t o by t h e r a p i s t s as i m p o r t a n t t o r e c a l l and imagine. (c) P r e s e n t a t i o n of scenes Members a r e asked t o imagine f i v e d i f f e r e n t a g o r a p h o b i c scenes. No mention s h o u l d be made by the t h e r a p i s t of the presence of e i t h e r a model or the member h i m s e l f (or h e r s e l f ) a c t u a l l y b e i n g an element i n these imagined scenes. The t h e r a p i s t w r i t e s on the board a l i s t of problem s i t u a t i o n s e x t r a c t e d from the f e a r q u e s t i o n n a i r e and s u b j e c t q u e s t i o n n a i r e s of t h i s p a r t i c u l a r group. Each group member chooses f i v e scenes he would l i k e t o work and w r i t e s them on a c a r d . An example of a s c r i p t f o r a scene f o l l o w s : Preamble: " P l e a s e s i t back and t r y t o r e l a x . Try t o imagine the scene I am g o i n g t o d e s c r i b e . Imagine you a r e r e a l l y t h e r e . I n a d d i t i o n t o s e e i n g what I d e s c r i b e t r y t o use your o t h e r senses as w e l l . I f , i n the scene you a r e s i t t i n g i n a c h a i r , f o r example, t r y t o imagine t h a t you can f e e l the c h a i r a g a i n s t your body. I f you a r e i n a f o r e s t , t r y t o imagine you can hear b i r d s c h i r p i n g and l e a v e s r u s t l i n g . Remember, the main p o i n t i s t h a t you a r e a c t u a l l y e x p e r i e n c i n g e v e r y t h i n g . Ready? Good. Now 83 p l e a s e c l o s e your eyes and t r y t o r e l a x . " Scene p r e s e n t a t i o n : "Imagine the scene a t a b u s - s t o p . R i d i n g on a bus i s an a n x i e t y - p r o v o k i n g s i t u a t i o n f o r many a g o r a p h o b i c s t o be i n . Imagine the bus a r r i v i n g a t a bus s t o p . You can hear the sound of the doors opening and, as you t h i n k of r i d i n g i n a bus a l o n e , f a r away from your home, you can f e e l your a n x i e t y r i s i n g . The bus i s crowded. P i c t u r e t h e - c r u s h of p e o p l e — some s i t t i n g , some s t a n d i n g . As the bus p u l l s away your a n x i e t y c o n t i n u e s t o r i s e . Now h o l d t h a t scene i n your mind f o r an o t h e r minute or so (PAUSE) Now open your eyes." S c r i p t s i n c o r p o r a t i n g s i m i l a r elements a r e used f o r the o t h e r scenes. Each scene i s p r e s e n t e d once d u r i n g the group s e s s i o n . (d) Homework Members a r e g i v e n a homework r e c o r d (HR) sheet l i s t i n g t he f i v e scenes and are asked t o have two imagery s e s s i o n s each of about 10 minutes each day. At each homework s e s s i o n t h e i r chosen f i v e scenes a r e imagined t w i c e . Homework s e s s i o n s s h o u l d commence on the a f t e r n o o n of the f i r s t day of t r e a t m e n t and c o n t i n u e u n t i l 30 days a f t e r the t h i r d and f i n a l group s e s s i o n . Imagery p r a c t i c e t imes s h o u l d be r e c o r d e d on the HR s h e e t s . In a d d i t i o n t o t h i s s u b j e c t s s h o u l d t r y t o e x t e n d the range and d u r a t i o n of s o l i t a r y e x c u r s i o n s . Each day t h e r e s h o u l d be some p r a c t i c e . These s h o u l d be r e c o r d e d on the b e h a v i o u r a l d i a r y . 4. Group exposure 60--70 ( i ) T h e r a p i s t s s h o u l d not mention the word i n t h e i r p r e s e n t a t i o n of or a t any time i n t h e r a p y , may, f o r some s u b j e c t s have adverse r e a c t i o n s e i t h e r t h r o u g h p r e v i o u s t h e r a p y , or h e r e s a y , or r e a d i n g . I t i s suggested t h a t the phrase "group exposure" be used i n i t s p l a c e . " f l o o d i n g " r a t i o n a l e s " F l o o d i n g " ( i i ) T h e r a p i s t e x p l a i n s t h a t r e s e a r c h has shown t h a t r e p e a t e d , p r o l o n g e d exposure (something of the o r d e r of 2 hours) t o a 84 f e a r e d s i t u a t i o n has brought v e r y e f f e c t i v e and r a p i d r e l i e f from a n x i e t y f o r many a g o r a p h o b i c s . When the group goes on a group exposure o u t i n g , some a n x i e t y i s t o be e x p e c t e d by group members. I t i s imp o r t a n t t o s t a y i n the a n x i e t y - p r o v o k i n g s i t u a t i o n . The a n x i e t y w i l l s u b s i d e a f t e r a w h i l e even though a group member may s t i l l be p r e s e n t i n the s i t u a t i o n . T h i s i s the key t o s u c c e s s f u l t r e a t m e n t . W h i l e e x p e r i e n c i n g the a n x i e t y , members s h o u l d not engage i n any p h y s i c a l a v o i d a n c e ( i . e . , l e a v i n g the s i t u a t i o n ) or mental a v o i d a n c e ( e.g. , t h i n k i n g of o t h e r t h oughts t o d i s t r a c t a t t e n t i o n , p r e t e n d i n g to be e l s e w h e r e ) . Members s h o u l d r a t h e r c o n c e n t r a t e on d e s c r i b i n g t o themselves t h e i r s u r r o u n d i n g s , b o d i l y f e e l i n g s , and mental e v e n t s . ( T h e r a p i s t s s h o u l d model t h i s ) . The c r i t e r i o n f o r moving from one phobic s i t u a t i o n t o the next i s t o be a decrease of a n x i e t y r a t h e r than i t s a b s o l u t e l e v e l . Members would thus l e a r n t h a t peak a n x i e t y does not l a s t v e r y l o n g ; c o u l d be t o l e r a t e d and, a f t e r a few s u c c e s s f u l • e x e r c i s e s they would g a i n c o n f i d e n c e i n these p r e v i o u s l y a n x i e t y -p r o d u c i n g s i t u a t i o n s . ( i i i ) Group members s h o u l d remember w h i l e they are e x p e r i e n c i n g "group exposure" t h a t t h e r e a re o t h e r group members who are i n the same s i t u a t i o n . ( i v ) Group members are t o l d t h a t , d u r i n g group exposure s e s s i o n s , t h e r a p i s t s w i l l remain at a s p e c i f i e d l o c a t i o n nearby members Members s h o u l d aim a t e x p e r i e n c i n g the exposure a l o n d ; s h o u l d r e s i s t the urge t o r e t u r n t o the t h e r a p i s t , and s h o u l d o n l y r e t u r n t o the t h e r a p i s t i f the s i t u a t i o n became i n t o l e r a b l e . 7 0 — 9 0 Members walk i n d i v i d u a l l y t o the bus s t o p (about 25 y a r d s a p a r t ) . The group t r a v e l s by bus t o a nearby shopping c e n t r e ( O a k r i d g e ) . Members and t h e r a p i s t s a r e t o s i t s e p a r a t e l y on the bus ( i . e . not grouped t o g e t h e r ) . 90 — 210 Two hours of c o n t i n u o u s exposure a t a department s t o r e (Woodwards) i n the Oakri d g e Shopping C e n t r e (as d e s c r i b e d i n ( v ) ) . 85 2 1 0 — 2 3 0 Re t u r n t o c l i n i c by bus, and walk i n d i v i d u a l l y (about 25 y a r d s a p a r t ) back t o the c l i n i c . 5. D l s c u s s i o n 230--270 Group d i s c u s s i o n t o share e x p e r i e n c e s ; t o d i s c u s s homework assignments and t o answer q u e s t i o n s . Group members a r e a d v i s e d t h a t i t i s i m p o r t a n t f o r them t o extend the range and d u r a t i o n of t h e i r unaccompanied e x c u r s i o n s from t h e i r homes s t a r t i n g t h a t a f t e r n o o n . Each day t h e r e s h o u l d be some p r a c t i c e i n d o i n g t h i n g s which were d i f f i c u l t f o r them. The l e v e l of d i f f i c u l t y was t o be l e f t up t o the i n d i v i d u a l t o det e r m i n e f o r h i m s e l f or h e r s e l f . Each member i s then asked t o d e s c r i b e one t a s k to be done t h a t a f t e r n o o n and another t o be done on the f o l l o w i n g day. The t h e r a p i s t s h o u l d review each t a s k w i t h the group member i n o r d e r t o o p e r a t i o n a l i z e and p i n p o i n t g o a l s e.g. walk a l o n e t o supermarket a l o n g Main S t r e e t ; buy a t l e a s t ten i t e m s ; check out t h r o u g h r e g u l a r c a s h i e r (not e x p r e s s l a n e ) ; walk home a l o n g H i g h Road a l o n e . S e s s i o n s 2 & 3 0---10 1. D i s c u s s i o n of homework. 1 0 — 3 0 2. C o n t i n u a t i o n of d i s c u s s i o n of member's e x p e r i e n c e s i n agoraphobic s i t u a t i o n s . 30--60 3. Scene p r e s e n t a t i o n p r a c t i c e . 60--230 4. Group exposure: s e s s i o n 2 t o Van Dusen Gardens (a l a r g e p u b l i c p ark) s e s s i o n 3 t o P a c i f i c C e n t r e M a l l (a busy downtown underground shopping m a l l ) 2 3 0 — 2 5 0 5. Group d i s c u s s i o n . APPENDIX B 8 6 o > H tn Time l e f t home Time reached destination Total mins. Anxiety r a t i n g Were you accompanied? £1 fD < 3 po g3' w CO Time l e f t d estination Time reached home Total mins, Anxiety Rating Were you accompanied? 3? ro rt c l-i 3 H' 3 po 3 fD Description Distance from home(in yards, blocks or jmiles) Walk Car Bus B i c y c l e Other (describe ) 2S o w CO 1-3 M H M O 2 O If' fD O 3 fD fD i-t o S CO o pa H O 1 Cu Name Address APPENDIX C Subject Questionnaire Male / /, Female / / Date Day Month Year 87 Phone Numbers: Home Age: years; Work Postal Code: / / / / / / / Contact M a r i t a l status For how long have you been agoraphobic (approximately)? years months Which s i t u a t i o n s do you f i n d p a r t i c u l a r d i f f i c u l t y i n handling? Would you please name a person below whom we can ask to answer a se r i e s of simple questions by r a t i n g your s o c i a l , work & l e i s u r e a c t i v i t i e s on a questionnaire. This w i l l be completed three times: 1. before treatment 2. 30 days a f t e r completion of treatment 3. 90 days a f t e r completion of treatment A. Spouse or l i v i n g partner ( f i r s t p r i o r i t y ) Name: Address: (If same as above write "same"). Phone: Home Work: Posta l Code 111/1/ I APPENDIX C (continued) B. Parent, brother, s i s t e r , or good friend ( i f f i r s t p r i o r i t y not a v a i l a b l e ) Relationship to you Name: Address: (If same as above write "same") Phone: Home Work Postal Code: I I I I I I I Education: Grade completed i n high school? Grade ' Number of years of education a f t e r high school? ' years Medication: Are you now taking any medication? Name of drug: Dosage: Signed Date 89 APPENDIX D CES Scale Name: Date: Please rate the f i v e questions below by choosing a number from the scale which shows how you f e e l about the question asked. Then write the number i n the box opposite the question. I have no confidence i n t h i s . /This i s not l o g i c a l . I am somewhat confident about t h i s . /This i s somewhat l o g i c a l , I am confident about t h i s . /This seems l o g i c a l . I am very confident indeed about t h i s . / T h i s seems very l o g i c a l . I have every confidence f o r t o t a l /This makes perfect sense-success i n t h i s . extremely l o g i c a l . i A. How l o g i c a l does t h i s type of treatment seem to you? / / B. How confident are you that t h i s treatment would be succes s f u l i n eliminating your agoraphobia? / / C. How confident would you be i n recommending t h i s treatment to a f r i e n d who was extremely anxious i n agoraphobic s i t u a t i o n s ? / / D. How w i l l i n g are you to undergo such treatment for agoraphobia? / / E. How successful do you f e e l t h i s treatment would be i n decreasing a fear d i f f e r e n t to agoraphobia; f o r example, strong anxiety about t a l k i n g to strangers or about being c r i t i c i z e d (for example)? / / 90 APPENDIX E •Imagery Assessment Questionnaire (IAQ) Name Date As part of your therapy you have been asked to imagine various scenes. Please i n d i c a t e below how these imagined scenes appeared to you: 1. Was a person who acted as a model disp l a y i n g reactions to the various s i t u a t i o n s present i n these scenes? Yes / / No / / If your reply i s "No", please skip questions 2, 3 & A and go on to Question 5. If a model was present i n your imagined scene, was the model: the same sex as you ? / / the opposite sex to you ? / / What was the approximate age of the model? - much older than you (more than 10 years older) / / about the same age as you (not more than 10 years older nor 10 years younger than you) / / much younger than you (more than 10 years younger) / / Was the model you imagined: yourself ? / / someone else ? / / If a model was present, please describe how the model handled the tasks you imagined: - model was i n i t i a l l y anxious but ultimately coped with the s i t u a t i o n / / - model was i n i t i a l l y confident and relaxed and had no problems i n dealing with the s i t u a t i o n n If a model was present did the model say anything to himself or herse l f when confronting the d i f f i c u l t s i tuation? Yes / / No -If your answer i s "yes", please give example(s) of what the model said : APPENDIX E (continued) How cl e a r was the image you imagined during the scenes? not at a l l clear 0 / r 1 / i reasonably clear 2 / i 3 / i very clear 4 / i How much anxiety did you experience while imagining these scenes? (If "100" i s the worst anxiety you have ever experienced, or can imagine experiencing; and "0" represents the state of being absolutely calm, how would you rate the peak anxiety you f e l t while imagining the scenes?) Rating / / When you imagined these scenes, how often were you able to imagine them exactly as described by your therapist? never 0 / / seldom 1 / / about ha l f the time 2 / / nearly always 3 / / always 4 / / APPENDIX F Subjective Anxiety Scale (SAS) Name Date A. Think of the worst anxiety you have ever experienced, or can imagine experiencing, and assign to t h i s the number 100. B. Now think of the state of being absolutely calm and c a l l t h i s zero. C. Now you have a scale of anxiety. D. On t h i s scale how w o u l d y o u r a t e t h e p e a k ( h i g h e s t ) / / a n x i e t y y o u f e l t d u r i n g o u r t r i p t h i s m o r n i n g ? APPENDIX G Name Date , v . Homework Record (HR) You should have two scene imagination sessions every day s t a r t i n g from the f i r s t day of therapy and continuing for 35 days. At each session go through y o u r l i s t of f i v e scenes twice i n your imagination. Please record your p r a c t i c e sessions below. If you have skipped a session, record a "0" under Time. Day Date F i r s t P r a ctice Second Practice Time (in minutes) Time (in minutes) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 .. .. ... APPENDIX H Consent Form We are conducting a research programme at Shaughnessy Hospital to examine dif-ferent treatments for people with problems similar to yours. Treatment involves group v i s i t s to various nearby locations and in addition training in the use of some psychological s k i l l s that might help you control your problem. We are evaluating in our research the value of these s k i l l s , but the basic treatment programme has been extensively used and found to be effective. Participants are free to withdraw from the programme at any stage. If you choose to withdraw you wi l l receive the regular treatment for agoraphobia at Shaughnessy Hospital. Treatment Programme: Therapy is to be conducted in small groups consisting of about seven members. These groups meet with therapists for three mornings in one week (Monday, Wednesday & Friday) for about 3*5 hours each morning. During these sessions you w i l l be intro-duced to the therapy techniques, followed by group visi t s to nearby locations such as Oakridge Shopping Centre and a downtown shopping mall. The atmosphere w i l l be supportive throughout and i t has proven helpful for many people with agoraphobia to get to know and to work in small groups with others who have the same problem. After the week of intensive therapy you wi l l be encouraged to do homework assignments at your own pace/ These are excursions from your home on your own, but the nature and extent of these w i l l depend on you. Participation: You wi l l f i r s t be given an individual interview in which background information relating to your particular circumstances wi l l be discussed and some questionnaires completed by you. If you qualify for the programme and agree to participate, you will be assigned to one of three treatment groups. Because of scheduling of therapists' time, your therapy might commence at any time from about 2 weeks to 8 weeks from now. If you choose not to participate in this programme or i f you do not qualify for this programme, the regular treatment f a c i l i t i e s at Shaughnessy Hospital w i l l be- available to you. There is no charge for participation but persons who consent to participate wi l l be expected to attend a l l three sessions of the group to which they are assigned and to be available to complete a l l questionnaires. Quest ionnaires: During the week of intensive therapy, you w i l l be asked to complete some questionnaires. Also, 1 month and 3 months after treatment you wi l l be asked to complete some questionnaires and to mail these to us. , You are free to refuse to answer any questions i f you so wish. You w i l l be asked to nominate someone who knows you well and w i l l be prepared to complete a questionnaire which will be mailed to them, taking about 20 minutes to complete, and involving questions about your activities at work, at home, and during leisure. These wi l l be completed f i r s t before treatment commences, then at 1 month and 3 months after treatment ends. A l l data w i l l be treated in strictest confidence. CONSENT I have read the preceding description of the programme. I have had a l l my questions answered to my satisfaction and I do hereby consent to participate in the programme. Signature Date . Witness's Signature 

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