a home-based treatment program for agoraphobia

BEHAVIOR THERAPY 8, 915--924 (1977)

A Home-Based Treatment Program for Agoraphobia

ANDREW MATHEWS, JOHN TEASDALE, MARY MUNBY,

DEREK JOHNSTON, AND PHYLLIS SHAW

University of Oxford

Previous work with agoraphobic patients indicates that, in addition to showing a limited response to behavioral treatments so far developed, improvement occurs only during treatment contact, and no further gains are made during the follow-up. A home-treatment program was developed with the intention of providing an on-going alternative within the patients' own environment for the instructions and reinforcement normally given by the therapist. The program was used with 12 married women, all but one of whom made behavioral gains. In comparison with the clinic-based treatments used earlier, the home program produced at least equivalent change with a reduced expenditure of therapist time, and most patients went on to make further gains during the follow-up period.

It has been shown that, while agoraphobic patients changed more following desensitization or flooding than following a control treatment, improvement was often incomplete and no further change occurred during a 6-month follow-up period (Gelder, Bancroft, Gath, Johnston, Mathews, & Shaw, 1973). In a subsequent study comparing real-life exposure with combinations of imaginal flooding and exposure, no long-term difference was found in outcome between groups. All groups made moderate gains during the period of treatment but again did not change in the follow-up period (Mathews, Johnston, Lancashire, Munby, Shaw, & Gelder, 1976). Examination of week-to-week changes shows that patients continued to make steady gains as long as weekly treatment sessions went on, and that it was unlikely that an improvement "ceiling" had been reached (Johnston, Lancashire, Mathews, Munby, Shaw, & Gelder, 1976), An alternative explanation for this abrupt halt in progress at the end of a treatment period is that practice in progressively more difficult situations during treatment depends on instructions and reinforcement from the therapist. Without regular contact with a therapist, a crucial factor under- lying progress is thus removed.

This study was supported by the Medical Research Council, United Kingdom. Requests for reprints should be sent to Andrew Mathews, University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, United Kingdom.

915

Copyright © 1977 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved. ISSN 0005-7894

916 MATHEWS ET AL.

One method of maintaining the patient's own efforts following treatment has been suggested by Hand, Lamontagne, and Marks (1974), who treated agoraphobic patients in groups. Members of groups designated as "cohesive," that is, those in which patients were encouraged to help each other, showed some signs of making further progress during follow-up. This effect might have been due to patients' having to report on their progress in occasional follow-up meetings or to the informal contacts between patients which took place between meetings. However, we have not been able to replicate this finding using a larger sample of patients, perhaps because the effect depends on social interactions within the group which were relatively uncontrolled (Teasdale, Walsh, Lancashire, & Mathews, 1976).

An alternative method is to design a treatment program to be managed by the patient in her own environment from the start, so that there is no real division between treatment and follow-up. This was done by incor- porating the following features: detailed but easily understandable instructions given in written form as well as in discussion; all practice carried out from the patients' own homes; the patient's spouse actively involved in planning and encouraging practice attempts; and both patient and spouse asked to take overall responsibility for conducting the treatment program themselves. A standard format was developed for use with 12 married female agoraphobic patients. Our decision not to include an untreated or "pseudotreatment" control group was based on the fact that virtually no change took place over a 9-month period in a group of agoraphobic patients who had been assigned to the nonspecific control treatment in an earlier trial (Gelder et al. 1973). The present series was drawn from the same patient population and was referred from the same sources, results were assessed using the same measures, and therapists and assessors were from the same research team as in all the studies referred to above. For this reason some degree of comparability is as- sumed, despite the lack of random assignment.

METHOD Patients. Twelve patients took part, consecutive referrals of married women diagnosed

as agoraphobics. The mean age was 36 years (range 20-49), and the mean duration of symptoms 9.3 years (range: 1.5-20 years). The selection criteria used were identical to those used previously: that the main complaint was of fears of being far from home and of entering public places, that any other symptoms present were not severe enough to require im- mediate treatment in their own right, and that regular avoidance of a wide range of situations had persisted for at least the preceding 6 months. As in previous studies, patients had to be rated at point 3 or more on a five-point scale of severity. In the present series all but two were given a rating of 4, corresponding to definite disablement in several aspects of ordinary life. Such patients were typically unable to travel alone beyond neighboring houses or shops. Since extensive avoidance had been present for a prolonged period, patients had developed alternative activities, such as working at home, having groceries fetched for them, and so on.

TREATMENT FOR AGORAPHOBIA 917

Only one patient entered the program but was subsequently excluded from the results to be presented. This individual reduced her phobic avoidance markedly, but remained extremely anxious. She was subsequently treated for generalized anxiety and received marital counsel- ing. Her results are not considered further.

Therapists. Two clinical psychologists and one social worker each saw four patients. All three had extensive previous experience with agoraphobic patients.

Measures. In addition to rating phobic severity, the psychiatric assessor rated general anxiety, depression, and marital and sexual adjustment, using the five-point scales developed previously, but with ha/f-way points defined. A similar rating was made of estimated cooperation and willingness to help expressed by the patient 's spouse, and both patient and spouse independently rated phobic severity, again with scales used in the earlier studies.

The behavioral test required individual construction of a 15-item hierarchy, each item describing a journey from the patient's home placed in rank order of difficulty by the patient. The last item invariably consisted of a prolonged journey alone (typically a holiday flight abroad) and was not intended to be tested. The remaining items were to be tested and were designed to cover the range between the two extremes as evenly as possible, on the basis of the patient's own estimates of anxiety and avoidance. The main outcome measures derived from behavioral testing were the highest item on the hierarchy successfully performed and the total number that could be carried out. At each testing patients were asked to attempt successively more difficult items until all those not attempted had been refused. An additional measure available from the test hierarchy consisted of the sum of anxiety estimates for entering each phobic situation, on a 0-10 scale.

Patients also kept a diary in which they noted the time of each departure from home, time of return, anxiety experienced, distance traveled, means of transport, and whether alone or accompanied.

Treatment manuals. Detailed descriptions of the treatment rationale and procedure in step-by-step form, prepared in booklets, incorporated all those aspects that had been found helpful in previous studies, but excluded features such as imaginal flooding or intensive prolonged exposure, which pilot work with home treatment had shown to be impractical. The booklets described the development and maintenance of agoraphobic behavior in learning terms, detailed the principles of target behavior selection and regular graded practice in entering progressively more feared situations, and ended with a section on panic management. Graded practice was recommended rather than systematic desensitization because of its greater acceptability and face validity, and because the evidence cited earlier indicates that imaginal rehearsal does not significantly enhance the effects of real-life exposure. The rules given for panic management emphasized the need to remain in a phobic situation long enough for anxiety to decline and gave reassurance that this would be beneficial rather than harmful, as many patients feared. Since most patients were taking regular medication, instructions were included that tranquilizers might be used, but only prior to practice attempts with new and difficult phobic situations, as the evidence indicates that this can enhance exposure effects (Johnston & Gath, 1973).

A second manual covered the same material but was addressed directly to the husband. Additional sections gave reasons for needing his help, emphasized his role in reinforcing phobic or counterphobic behavior, detailed methods of reinforcing practice with contingent attention and praise, and listed ways in which he could take an active role during practice, for example, by prearranged meetings in a phobic situation.

In both manuals each page ended with a multiple-choice question which was to be attempted before checking the correct answer on the next page.

Procedure. Whenever possible the patient and spouse saw the psychiatric assessor for an initial interview at the clinic, or if this was impossible because of the severity of the phobia, the assessor made a home visit. Provided that the criteria described earlier were met and the

918 MATHEWS ET AL.

husband agreed to cooperate if asked (none refused), the assessor then gave the patient diary forms with instructions to fill them in every time she went out, until treatment began. Three weeks later two further interviews were arranged, in which the ratings were made and the behavioral test was carried out. Immediately after this the treatment manuals were given or sent to patient and husband, together with a date for the therapist 's first home visit. Therapists visited the patient 's home eight times in the next 4 weeks, three times in the first week, twice in the second and third week, and once in the fourth. Visits normally took place in the early evening, since both partners were required to be present. On the first visit the therapist began by discussing a treatment contract which outlined the time course and requirements of the program, such as the need to set 1 hr aside for practice every day, and emphasized the degree of responsibility to be taken by the patient and spouse, with the therapist taking the role of advisor. In all cases this was agreed and signed at the first session, and the remaining time was taken up with any questions arising from the manual and the selection of targets for graded practice.

Within the first week, the therapist arranged to be present during at least one practice session as an observer. All arrangements and decisions about the content of practice were made by the patient and spouse in collaboration, while the therapist offered advice but made no attempt to direct practice during the session. Therapists stressed the necessity for regular daily practice between visits and ensured that patients continued making a record of all outings, while husbands kept track of progress using a target record sheet. After the first week, therapists did not normally attend practice sessions, but discussed progress, gave advice about overcoming specific difficulties encountered in practice, ensured that future targets had been agreed between partners, and encouraged the use of contingent reinforcement for achieving targets. The use of material reinforcers was not demanded if this were resisted by patients, and in most cases greater emphasis was placed on the importance of regular encouragement and praise for the patient's efforts. In the later visits there was some discussion of how best to ensure continuance of the program through the follow-up period, with minimal therapist contact.

Follow-up visits for general discussion and advice were arranged at 2 weeks, 6 weeks and 3 months after the end of the intensive 4-week contact period. Those visits were usually brief and never involved the therapist in actual practice.

Further interviews with the psychiatric assessor and behavioral tester were scheduled for the fifth week after the program had started and, again, 6 months later.

Therapist time requirements. Therapists were required to record all time spent in connection with the home program. The mean total time requirement per patient averaged 17.4 hr, including traveling time to the patient's home. Eight hours were taken up with traveling, leaving 9.4 hr of contact with the patient. Of this contact time, 6.9 hr occurred during the main 4-week period of therapist involvement, with the remaining 2.5 hr spread over the following 3 months.

RESULTS

Time Away from Home

A s a c o m p l e t e r e c o r d o f al l t i m e a w a y f r o m h o m e w a s a v a i l a b l e f r o m

t h e p a t i e n t s ' d i a r i e s , i t w a s p o s s i b l e t o e s t a b l i s h w h e t h e r p a t i e n t s h a d

r e s p o n d e d t o t h e p r o g r a m r e q u i r e m e n t o f r e g u l a r d a i l y p r a c t i c e b y s p e n d -

i ng m o r e t i m e o u t o f t h e h o u s e . M e a n t i m e o u t o f t h e h o u s e d u r i n g t h e

3 - w e e k b a s e l i n e w a s 15.3 h r p e r w e e k , r i s i n g t o 21 .8 h r d u r i n g t h e s u c c e e d -

ing m o n t h . M o s t o f t h i s t i m e w a s n o t s p e n t in p h o b i c s i t u a t i o n s s u c h as

t r a v e l i n g o r s h o p p i n g , b u t a t t h e h o m e s o f n e i g h b o r i n g f r i e n d s a n d r e l a -


tives or at a place of work. Accordingly, this time was excluded. The residual time spent away from home more than doubled after the program began (Fig. 1). Increases in time spent out were not confined to a few, since all 12 patients showed increases during this time. The average increase approaches but does not reach the target of I hr of practice each day. This increase in time appears to remain stable over the full 6-month follow-up.

Behavioral Test

Although the detailed descriptive data from the patients' diaries indi- cate that they entered many previously avoided situations, the data for time away from home does not in itself demonstrate this. Individual behavioral test results demonstrate this decrease in avoidance of target situations more directly (Table 1). The best indication of the difficulty which each item initially presented to the patient is provided by the rank assigned to it by the patient. All but one patient had succeeded in entering at least one previously avoided situation after 4 weeks, and, following this initial gain, 9 of the 12 patients went on to make further gains during the succeeding 6 months. The most difficult target which was also relevant to the patients' daily life was invariably an excursion to a nearby large town, usually involving shopping alone. Nine of the 12 had successfully achieved this by follow-up (Table I). Two other measures were derived from the test. One was the total number of items successfully performed on each occasion: this averaged 3,3 at baseline, 7.4 after 4 weeks, and 8.8

BASELINE PROGRAM

1 2 -

o

~ 8 o

2 -

I I I ~ 1 I 1 2 3 4 5

FOLLOW-UP

I t I I ] / 6 7 8 9 10

WEEKS

/ I I I 29 30 31

FIG. I Average number of hours spent out of the house each week (excluding time at work or visiting others) during the baseline, the first 4 weeks of the program, the following 3 weeks, and at a 6-month follow-up.

TA

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1 M

OST

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T I

TE

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ER

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IEN

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L T

IME

R

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NIT

IAL

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NK

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(1--

15)

Pat

ient

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r w

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ollo

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p

Des

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T

ime

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Des

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(m

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E

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H

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Wal

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end

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5

2 W

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5

Wal

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p 2

3 W

alk

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4

Wal

k to

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rest

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3

Wal

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3

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9

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7

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S

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8

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rt b

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rney

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4

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op

pin

g c

ente

r 60

8

Wal

k to

sho

ppin

g ce

nte

r a

30

7 S

hopp

ing

in n

eare

st t

ow

n

60

12

Bus

to

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rest

to

wn

25

10

W

alk

to f

urth

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hop

25

6 W

alk

to l

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5

Car

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tow

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27

0 13

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ool

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ter

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us

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eare

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120

11

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rest

to

wn

60

13

V

isit

soc

ial

club

18

0 14

S

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in

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11

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180

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2

a It

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not

carr

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alon

e.


at 6 months. The second is the sum of anxiety estimates (0-10 scale) for all 15 items: this was 108 at baseline, 75 after 4 weeks, and 54 after 6 months. As before, all but one patient made gains on both measures during the first 4 weeks; eight made further gains in total items performed during the next 6 months, while 10 made further reductions in summed anxiety scores in the same period.

Self and Spouse Ratings On the 1-5 scale of severity, self ratings averaged 3.7 (spouse, 3.4) at

baseline, 2.8 (spouse, 2.8) after 4 weeks, and 2.3 (spouse, 2.2) at a 6-month follow-up. Scale point 2 corresponds to the presence of mild symptoms which are not sufficient to disturb daily life. Both patient and spouse also rated overall improvement at follow-up, on a five-point scale running from worse (1), through unchanged (2), slightly better (3), quite a bit better (4), to completely better (5). Mean patient self-rating of improvement was 4, and spouse rating of patient was 4.2. In general there was good agreement between patient and spouse ratings once the program had started, although initial agreement was poor. At baseline the product-moment correlation between severity scores was 0.24, after 4 weeks it rose to 0.74 and remained at this level at follow-up (0.75). Improvement ratings at follow-up agreed best of all (0.86).

Psychiatric Ratings As in earlier studies, most of the present patients were rated as anxious

and depressed to a mild degree at baseline and somewhat less so at follow-up. Eight patients were rated as experiencing less generalized anxiety at the end; none were worse in this respect. Nine patients were rated as less depressed and one as slightly worse, this being the only patient whose phobic avoidance did not improve. Ratings of marital and sexual relationship showed that four patients were rated as having a moderate degree of impairment in their sexual relationship, and one of these was also judged to have a moderately impaired overall marital relationship. None of these ratings changed over the program period. Of all baseline measures, the rating of marital dissatisfaction showed the highest correlation with later reduction in phobic severity (r = -0.43), but this failed to reach a statistically significant level.

In the present study, 11 of the 12 patients were assessed as improved after 4 weeks, and 9 of them as showing further improvement at follow- up. The average overall change produced is similar to all previous treatments used (except the nonspecific control), but the patients in the present program were the only group to make further gains during follow-up (Table 2).

TA

BL

E 2

R

AT

ING

S O

F PH

OB

IC S

EV

ER

ITY

IN

FO

UR

ST

UD

IES

OF

AG

OR

APH

OB

ICS

SHO

WIN

G

OV

ER

AL

L C

HA

NG

E

AN

D T

HE

RA

PIST

TIM

E R

EQ

UIR

EM

EN

T

Tim

e

Sou

rce

Tre

atm

ent

N

Pre

P

ost

F

oll

ow

-up

C

hang

e (h

r)

Gel

der

et a

l.

(197

3)

Mat

hew

s et

al.

(197

6)

Tea

sdal

e et

al.

(197

6)

Pre

sen

t st

udy

Non

spec

ific

6

4.2

3.8

3.8

0.4

18

Des

ensi

tiza

tion

6

4.8

3.2

3.3

1.5

18

Flo

odin

g 6

4.0

2.6

2.5

1.5

18

Flo

odin

g +

pra

ctic

e 12

4.

3 2.

9 2.

9 1.

4 24

F

lood

/pra

ctic

e co

mb

ined

12

4.

5 3.

0 3.

0 1.

5 24

P

ract

ice

alon

e 12

4.

4 3.

0 3.

3 1.

1 24

Gro

up p

ract

ice

18

3.6

2.8

2.6

1.0

15

(5 h

r/pa

tien

t)

Ho

me

prac

tice

12

4.

0 3.

0 2.

4 1.

6 7

(+ t

rave

l)


DISCUSSION

The main aim of the present study was to investigate the feasibility and results of a home-treatment program for agoraphobia designed to be managed by the patient and her family. No one who was asked refused to take part, and additional treatment for other symptoms was only neces- sary in the case of one patient, whose results were consequently excluded from further consideration. Surprisingly few problems of administration were encountered by therapists, and those that occurred were managed without great difficulty for the most part. For example, if a husband did not show appropriate interest in practice gains, the therapist would routinely ask him about progress at the start of each meeting and prompt him to praise the patients' efforts. If patients appeared to expect a doctor-patient relationship with the therapist and complained about anxiety symptoms, therapists limited their response to suggesting that dwel- ling on such symptoms too much tended to maintain them. Marital conflict was one of the more difficult problems to deal with, and, although no causal conclusions can be drawn, the one patient who actually dete- riorated after participation was rated as having the worst marital relationship and was also socially isolated. This may mean that alternative approaches are indicated when marital and social adjustment are very poor.

Prior to participation in the program, none of the couples had received any guidance as to the nature of the problem or on possible ways of helping themselves, and most welcomed the opportunity to do so. There was very little evidence of persisting dependence on the therapist which sometimes occurs in clinic-based treatments, and patients seemed more likely to attribute improvement to their own efforts than to help from the therapist. One side effect of this was that self-selected targets did not always coincide with those which therapists would otherwise have chosen. Increased self-reliance was considered desirable, provided that patients did not concentrate on easy short-term targets and ignore difficult but important long-term aims. It is clear from the behavioral test results that any such tendency did not prevent patients eventually being able to enter previously avoided situations which had been chosen for their practical importance for each patient by the behavioral tester.

Among other results of the program was a twofold increase in the time spent out of the house, after work and visits had been excluded, and which persisted to the end of follow-up. Taken together with the behavioral test results, this provides strong evidence that patients met the program requirements for regular practice in entering feared situations, and that this in turn reduced the number of situations avoided and the anxiety experienced in them.

Comparison of these results with those achieved in earlier treatment trials indicates that, for all measures of phobic anxiety and avoidance,

924 MATHEWS ET AL.

behavior test, self-ratings, and psychiatric assessment, the same or greater effect was obtained in the present program, despite a considerable reduction in the time spent by therapists in direct contact with patients. It is true that the time requirement per patient was less in the group treatment study, but average change achieved was also somewhat less. A second difference observed in the present study was that about a third of the total change occurred during the follow-up period, at a time when there was little contact with the therapist, while no improvement occurred during the equivalent period in the earlier studies. These two differences suggest that the home program was successful in providing an ongoing alternative within the patients' own environment to the instructions and reinforcement normally provided by the therapist.

There is a need for replication under more controlled conditions. Work is also indicated to investigate the feasibility of further reductions in therapist time, and the role of other components of the total treatment package, such as the instruction manual and the help given by the patients' husband.

REFERENCES Gelder, M. G., Bancroft, J. H. J., Gath, D. H., Johnston, D. W., Mathews, A. M., & Shaw,

P. M. Specific and non-specific factors in behavior therapy. British Journal of Psychiatry, 1973, 123, 445-462.

Hand, I., Lamontagne, Y., & Marks, I. M. Group exposure (flooding) in vivo for agoraphobics. British Journal of Psychiatry, 1974, 124, 588-602.

Johnston, D. W., & Garb, D. H. Arousal levels and attribution effects in diazepam assisted flooding. British Jottrnal of Psychiatry, 1973, 123, 463-466.

Johnston, D. W., Lancashire, M., Mathews, A. M., Munby, M., Shaw, P. M., & Gelder, M. G. lmaginal flooding and exposure to real phobic situations: changes during treatment. British Journal of Psychiatry, 1976, 129, 372-377.

Mathews, A. M., Johnston, D. W., Lancashire, M., Munby, M., Shaw, P. M., & Gelder, M. G. Imaginal flooding and exposure to real phobic situations: Treatment outcome with agoraphobic patients. British Journal of Psychiatry, 1976, 129, 362-371.

Teasdale, J. D., Walsh, P. A., Lancashire, M., & Mathews, A. M. Group exposure for agoraphobics: A replication study. British Journal of Psychiatry, 1976, 130, 186-193.

RECE]VED: May 30, 1976; REVlSED: September 3, 1976 FINAL ACCEPTANCE: October 5, 1976

a home-based treatment program for agoraphobia

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