What Is Psychotherapy? Proc. 9th Int. Congr. Psychother., Oslo 1973 Psychother. Psychosom. 25: 76-82 (1975)

Group Therapy for Agoraphobics: Real-Life Retraining by Floodings in vivo Iver Hand, Y. Lamontagne and l.M. Marks

This paper gives a brief outline of a study conducted at the Maudsley Hospital, London, in order to economize and improve short-term psychotherapy for phobias (for a detailed report of the experimental aspects, cf. 5). The ap­ proach taken in this study was to combine the behaviour therapy technique of flooding in vivo (9) with the possible therapeutic effects of the social dynamics of the small group (6). Flooding in vivo for phobics, like several similar techniques, consists of prolonged exposure of the patient to the real phobic situation regardless of his feelings. The prevention of the phobic behavioural response (avoidance) allows him to realize that the phobic emotional and cognitive responses (anxiety and anticipation of disaster) are tolerable and decreasingly uncomfortable. The pa­ tient may be given different coping advices, but exposure should last for about 2 h per session (10). So far, this seems the most effective treatment for agora­ phobia (9). Application of this method to groups of patients was expected not only to be more economical, but also more effective, because studies in social psychol­ ogy, group psychotherapy and behaviour therapy indicate positive effects of small-group dynamics on risk-taking and task achievement (5, 6). Nevertheless, it seemed possible that a group of severely phobic individuals exposed to the phobic situation might suffer negative effects from social cohesion, mutual rein­ forcement and modelling, resulting in group panic rather than in coping behav­ iour. Furthermore, group training might not help the individual to cope on his own later on in daily life. No clinical experiments have so far been conducted to investigate these questions.

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Psychiatrische Universitätsklinik, Hamburg

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Methods Twenty-five agora- travel- and social-phobic patients with a mean age of 35 and an average symptom duration of 8.5 years were treated in six groups, each consisting of four to five members. All were taken off their usual tranquilizer medication 1 week before treat­ ment. In three of these groups, cohesion was fostered (S = structured); in the other groups (U = unstructured), patients were treated as individuals with minimal peer interaction. The differential group conditions were maintained throughout follow-up (4, 12 and 24 weeks). The effects of the group situation were investigated in this way rather than by comparing group versus individual exposure, because the latter approach would not have allowed one to conclude which components of the group setting were therapeutic. Treatment. All groups received 12 h of training in the real phobic situation, spread over 4 h on 3 days of 1 week. These exercises were to be continued after the treatment for about 1 h daily at home until the phobic responses had ceased. All patients received the same rationale for their phobias and treatment: in the phobic situation they were advised to describe to themselves the real environment and their actual psychophysiological state, anticipating neither unreal negative (phobic) nor unreal positive consequences of the situa­ tion. By strict concentration on reality, avoidance of avoidance, and toleration of their emotional reaction, they would learn anxiety management by reality testing and thus expe­ rience a gradual reduction of their anxiety. They were asked to see the therapists as trainers who would teach them how to use this method. This would require their active collabora­ tion instead of a passive reception of help. The assessment interview included discussion of a variety of problems other than the phobia, particularly marital difficulties, but patients who wanted help for these insisted in having the phobia treatment first. During treatment, only the phobias were dealt with, but patients knew that afterwards help for other problems would be available. For half-an-hour before and after each training session, there were symptom-focussed discussions in the hospital, in S as group discussion and in U between the individual patient and therapist. These were repeated once an hour for 15 min during each treatment day, and for about half-an-hour on each follow-up. S patients were instructed to do the exercises with minimal therapist contact and under maximum mutual help, also with regards to achieving behavioural independence from the group. They were to follow the speed of the slowest in the group. U patients were to relate to the therapist like individual patients and do their exercises independently of their peers. For all patients, the criterion for moving from one phobic situation to the next was decrease of anxiety rather than its absolute level. In S, both therapists acted in unison, in U each patient had the same amount of contact with either of the two therapists. The last two groups (one S, one U) were conducted by only one therapist (I.H.). In all groups, main emphasis was on the achievement of independence. From the second day of training, the therapists usually remained at ‘check points’ in the treatment area, in the center of London. During the exercises, the patients frequently rated several parameters of their peer and therapist interactions as well as treatment effects on their behaviour and emotion. Before and after treatment, patients, therapists and independent assessors rated the phobic symp­ tomatology, work adjustment, social contacts and leisure activities. Most ratings were sub­ jected to multivariate analyses of variance.

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Predictions. It was predicted that during treatment, U patients would find the training more difficult to tolerate but at the same time more helpful than S patients, because agoraphobics are often able to enter the feared situation, if accompanied, without experi-

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cncing any relief of their phobia. However, if social pressure in S would enable patients to go out alone towards the end of the treatment, this too might motivate them to carry out post-treatment exercises more conscientiously than U patients. This then might lead to further improvement and better relapse-prevention than in U.

In both conditions, A and U, there were strong, spontaneous trends towards the development of cohesion, which for the therapists was easy to foster in S and often rather a strain to hinder in U. U and S showed a statistically significant difference in the various cohesion parameters. As the other treatment variables were largely identical in both conditions, this allowed one to relate differences in outcome to the differential degree of cohesion. The training was much easier for patients and therapists in S, especially in the one-therapist-condition. S groups were most cooperative in trying to apply the treatment principle on their own. During the first half of the treatment in U the risk of patients escaping the treatment situation was much higher and more correlated with their anxiety level. As predicted, during training itself, S patients rated less improvement than U patients, but only 3 days later this difference had disappeared. Improvement remained highly significant for both groups together until the end of the 6-month follow-up. During this time, however, U patients began to relapse whereas S patients continued to do better (S versus U statistical­ ly significant). This result is supported by the fact that only one of four drop­ outs and one of four complete relapses occurred in S groups, whereas all five patients who needed further treatment for their phobia were from U groups. Work, social contacts and leisure activities also improved significantly, but the differences between S and U were non-significant. Apart from helping 15 patients sufficiently in their phobias, this short-term intensive treatment had several additional effects. Under high external pressure and in a clear-cut task, cohesion developed much faster than in long-term discussion-oriented groups with a greater variety of problems (8). Cohesion fostered mutual trust and openness about the phobic symptomatology in the group, and quite a few patients transferred this experi­ ence into real-life situations. When frightened, they learned to get relief merely from admitting their phobia to strangers next to them. On their own or with the help of their group, many overcame inhibitions to look at other people in public transport systems, to ask for directions in the streets or to eat in restaurants, as these situations formed part of their treatment exercises. A common and spontaneously invented coping mechanism was the use of humor (vide paradoxical intention, 4). In particular, S patients soon started to make jokes about each other’s phobic behaviour. It seemed that by laughing

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Results

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about a peer’s phobic behaviour, patients learned to laugh about the same prob­ lem in themselves (mutual modelling of humorous dereflection). Peers surpris­ ingly accepted being laughed at, although in daily life phobics are usually very afraid that others might joke about their ‘uniquely ridiculous’ problems. Many patients eventually seemed to become less worried about what others might think of them. Group panic never occurred. However, several patients had ‘horror dreams’ or depressive episodes at night or on the free day between treatment sessions. These occurred particularly after sessions where rapid progress was made under little anxiety. In these dreams, patients went through those disasters that are typically part of phobic anticipation, but which never happened during expo­ sure. Subsequent group discussions and especially new in vivo training lifted quickly the depression and often even led to euphoria by the end of the day. These patients needed repeated experience of successful performance to learn to trust themselves again. Depressive episodes of this kind did not occur during follow-up. After the treatment, the only major complication was the comparatively high frequency of acute marital crises. Twenty-one of our patients were married, 14 of them had reported marital difficulties in the pre-treatment assessment. After treatment, six of these 14 and one of the others complained about such se­ vere exacerbation of their chronic problem that marital treatment was either asked for by them or offered by us. But of the seven couples, only three went into joint marital therapy; two patients refused such aid, as did two spouses. Clearly, this is not an example of symptom substitution as with one exception these patients were well aware of this problem before treatment but did not want it to be treated at that time (a discussion of the dynamics is in preparation).

Flooding in vivo is confirmed as a most effective short-term treatment for agoraphobia. Application of this technique under the social dynamics of the task-oriented small group makes it easier to tolerate for the patient and to conduct for the therapist. Group variables also seem to account for better fol­ low-up results. The discussion of the theory of flooding is still open. Exposure to a certain event can be traumatic as well as therapeutic, depending partly on cognitive and attitudinal processes at that time. Response prevention, i.e. getting the patient (by motivation through therapist and group) to stay in the phobic situation regardless of his anxiety, was a main variable in this study. However, exposure treatments that allow brief intermittent avoidance according to the anxiety level have also been successful (2, 3). Still, most patients in this study reported their

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Discussion

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first successful toleration of a panic as a decisive experience to initiate change, and afterwards they usually made rapid progress. This seems understandable as many phobics, even after days of panic-free exposure to a phobic situation, still tend to complain that they have no guarantee that this would stay the same in the future. For most patients, the first successful panic-management enhanced their self-confidence and trust in themselves to cope with future unpleasant situations. This change in attitude may also serve as a safeguard against a recon­ ditioning of the phobia by attacks of free-floating anxiety which often compli­ cate treatment of agoraphobia. The first group member with such an experience usually becomes the most convincing therapist for his peers. Generally, patients experienced rather low anxiety during exposure. Accord­ ingly, all except one did not feel that they had suffered unduly. This result questions the original concept of flooding (in fantasy) which claimed the experi­ ence of ongoing maximum anxiety as essential in order to achieve its ‘exhaus­ tion’. Our patients gained improvement from brief intermittent experiences of panic management in a setting that generally allowed a rather pleasant re-habi­ tuation to reality. Behaviour-focussed confrontation with the real phobic situation has strong effects on emotion and cognition, and little is yet known about interactions between these three levels. In this study, behaviour change preceeded changes in cognition and emotion. In a number of patients, anxiety was not extinguished but they became able to continue their exercises after treatment as a self-help technique until sufficient anxiety reduction was achieved. Flooding as applied in this study is thus less a concept of extinction than of self-regulation or cognitive control, and for many patients it meant hard work until the task was achieved. The group dynamics were an additional therapeutic factor. Experiments in social psychology indicate that high cohesion, task-orientation and external pres­ sure improve task-achievement of small groups (6, 7) and that group discussions increase the preparedness to take risks (risky-shift phenomenon; 1). This seems transferable to a cohesive group of agoraphobics that has a phobia-focussed treatment-task and receives training in the stressful phobic situation. ‘Coping models’ who first are fearful and gradually learn to cope have already previously been found as particularly motivating for others to do equally well (10). This therapeutic peer-modelling effect is confirmed in our study; ‘negative’ phobia modelling did not occur. Most patients experienced relief when seeing peers as frightened as themselves, whereas in daily life the encounter with fearless nor­ mals (‘mastering models’) had made them feel even more ‘abnormal’. The ‘group spirit’ has also been useful in self-help groups like Weight Watchers or Alcoholics Anonymous (AA) and recently, psychotherapists have been paying more attention to its therapeutic potential (6). But, non-directed ‘we-ness’ can also be harmful, as in peer self-help groups for agoraphobics which

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sometimes seem to give a lot of mutual support but little relief of the phobia. Unlike AA and similar groups where controlling the symptom is a precondition of ongoing membership, phobic groups sometimes determine membership on practising the symptom. Some of our successfully treated patients tried to offer their help to one of these groups and did not meet with interest. Peer groups of phobics especially seem to need a teacher-trainer at the start to remain taskoriented and avoid reinforcement of their problem. Motivation certainly is an important variable in such a treatment. Patients who accept this kind of treatment, which sounds much tougher than it is, may well be particularly determined to overcome their phobia. In the assessment interview, the therapist may use only gentle persuasion to motivate a doubtful patient for this approach. During treatment, persuasion is sometimes necessary to get patients to do exercises properly but it is not the curative factor. For the therapist who conducts groups under stressful conditions we feel it is necessary to foster an atmosphere of mutual understanding and trust among the peers and to prevent envious competition which is likely to result in a high number of dropouts (6). We therefore gave at least as much reinforcement for helping and caring as for coping behaviour. Group pressure to change has to be a motivational, not a threatening force. Before treatment, several patients had experienced by chance beneficial effects of exposure to the phobic situation, but had not dared to repeat this themselves. Others had received suggestions to try exposure from acquaintances or relatives, but had resentfully refused to follow. The therapist has to be careful not to get involved in this kind of double-bind. The treatment has to be a challenge that both patient and therapist meet together rather than a weapon in a dyadic power struggle. Many patients commented that the active involvement of the therapist during treatment enhanced their motivation for further exercises during follow-up. Patients who overcome relapses on their own gave as a reason that they ‘did not want to let the others (and/or the therapists) down’. The treatment rationale and the coping advice were generally accepted as encourag­ ing ‘pep talks’. The group motivating effect for post-treatment exercises was apparently much higher in S than U. On follow-ups, individual achievements were discussed and further individual exercises encouraged when necessary (cf. ‘treatment’). As intended, S patients rarely did post-treatment exercises together or in dyads, but rather motivated each other to do exercises alone. Paradoxically, dependence on the group-norm led to independence in individual behaviour. Only three patients had difficulties in separating from the therapy situation. The results support earlier claims for a need of structuring the immediate post-treatment period to help the carry-over of treatment results into everyday life. This period was in fact decisive for the particularly good results with the S groups.

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To summarize: group flooding in vivo as part of a hospital program can be seen as a means of teaching the principle and prodding agoraphobics into carry­ ing it out as self-help in their natural social milieu. It is thus one facet of a many-sided program of rehabilitation in the community.

References

Request reprints from: I. Hand, MD, Psychiatrische Universitätsklinik, Martinistrasse, D -2000 Hamburg 20 (BRD)

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1 Clark, R.D.: Group-induced shift towards risk: a critical appraisal. Psychol. Bull. 76: 251-270 (1971). 2 Crowe, M,; Marks, I.M.: Agras, 1P.S., and Leitenberg, H.: Time-limited desensitization, implosion and shaping for phobic patients: a crossover study. Behav. Res. Ther. 10: 319-328 (1972). 3 Everaerd, W.T.; Rijken, H.M., and Emmelkamp, P.N.: A comparison of'flooding’ and successive approximation in the treatment of agoraphobia. Behav. Res. Ther. 11: 105-117 (1972). 4 Frank!, V.E.: Paradoxical intention: a logotherapeutic technique. Anter. J. Psychother. 14: 520 -535 (1960). 5 Hand, I.; Lamontagne, Y., and Marks, I.M.: Group exposure (flooding) in vivo for agoraphobics. Brit. J. Psychiat. 124: 588-602 (1974). 6 Hand, I.: Symptom-zentrierte Gruppentherapie bei Phobien die problem-orientierte Arbeitsgruppe in der Psychotherapie. Fortschr. Neurol. Psychiat. (in press, 1974). 7 Liberman, R.: Behavioural group therapy: a controlled study. Brit. J. Psychiat. 119: 535-544 (1971). 8 Meichenbaum, D.H.: Cognitive factors in behavior modification: what clients say to themselves. Paper to Ass. for Advancement of Behav. Ther. (Washington, D.C. 1971). 9 Marks, I.M.: Flooding (implosion) and related treatments; in Agras Behaviour modifica­ tion. Principles and clinical applications, chap. 6 (Little, Brown, Boston 1972). 10 Stern, R.S. and Marks, I.M.: Brief and prolonged flooding: a comparison in agorapho­ bic patients. Arch. gen. Psychiat. 28: 270-276 (1973).

Group therapy for agoraphobics: real-life retraining by floodings in vivo.

What Is Psychotherapy? Proc. 9th Int. Congr. Psychother., Oslo 1973 Psychother. Psychosom. 25: 76-82 (1975) Group Therapy for Agoraphobics: Real-Life...
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