Couples treatment of agoraphobia: A two-year follow-up

BEHAVIORTHERAPY18, 401-415, 1987

Couples Treatment of Agoraphobia: A Two-Year Follow-Up JEROME A. C~R~Y Indiana State University

DAVID H. BARROW MICHELLE G. CgASKE WILLIAM G. HIMADI State University of New York at Albany Agoraphobics treated in a self-paced exposure-basedprogram either with their spouse directly involved in all aspects of treatment (n -- 28) or without their spouses ( n = 14) were followed up for two years. The results indicate that agoraphobics treated with their spouse maintain an improving trend over the two-year period, and do significantly better on most measures than agoraphobics treated without their spous~ Nonspouse group members do not show continued improvement at one-year follow-up and even deteriorate slightly, although their improving trend resumes at the two-year follow-up. Involvement of the spouse also seems to produce less disruption in work and leisure activities during the year following treatment. No differences were evident on more general measures of psychopathology between groups. Marital satisfaction generally improved in both groups and was correlated with improvements in phobic behavior. These data would seem to confirm the importance of attending to the interpersonal context of behavior change, in this case, by including the spouse directly in the behavior change process.

The interpersonal or social system of the individual forms the context for behavior change. With the increasing sophistication and success of a technology of behavior change, clinicians and clinical investigators are finding it necessary to pay more attention to the interpersonal system of the patient. There are numerous ways in which the social system can interact with behavior change technologies either positively or negatively. For example, within the areas of depression, addictive behaviors, eating disorders, obesity, and schizophrenia, the interpersonal system may play an important role in the success or failure of treatment (Paolino & McCrady, 1977; BrowneU & Foreyt, 1985;

Reprint requests should be addressed to Dr. David H. Barlow, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, NY, 12203. William G. Himadi is now at Florida State Hospital, Chattahoochee, FL. 401 0005-7894/87/0401-041551.00/0 Copyright 1987 by Association for Advancementof Behavior Therapy All rights of reproduction in any form reserved.

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McCrady, 1985; Rousaville, Weissman, Prusoff, & Herceg-Baron, 1979; Falloon, Boyd, McGill, Williamson, Razani, Moss, Gilderman, & Simpson, 1985). For several years we have been investigating the advantages and disadvantages of including the spouse in the process of treating agoraphobia (Barlow & Waddell, 1985). Our rationale was based on findings that practice between sessions seems to be important in overcoming avoidance behavior associated with panic disorder and agoraphobia (Michelson, Mavissakalian, Marchione, Dancu, & Greenwald, 1986; Barlow, in press). Including a motivated partner might help the patient over the "rough spots" and insure that practice in the home environment is accomplished. In addition, negotiating a specific role for the spouse, usually the husband, might preclude any attempts at interfering with treatment goals. That is, any "surprises" or misunderstandings on the part of the husband during treatment that might potentially have a detrimental effect on the marriage could be addressed during therapy. Also, increased social support during the stresses of treatment might in and of itself facilitate outcome. A variety of early studies seems to support the conclusion that increased social support and the inclusion of a significant other in treatment of agoraphobia are beneficial (e.g., Hand, Lamontagne, & Marks, 1974; Mathews et al., 1977; Sinnott, Jones, Scott-Fordham, & Woodward, 1981). Several years ago we experimentally analyzed the feasibility and benefit of including the spouse directly in treatment (Barlow, O'Brien, & Last, 1984; Barlow, O'Brien, Last, & Holden, 1984). In this program, 28 agoraphobic women received a core self-paced exposure-based treatment program where they were encouraged to practice exposing themselves to feared situations around their home in a systematic way. At 12 weekly sessions, they received a variety of suggestions for accomplishing these practices in a systematic manner. In addition, they received basic education concerning the nature of agoraphobia as well as cognitive interventions aimed at negative attitudes and thought processes concerning panic and anticipatory anxiety. The husbands of all 28 women agreed to accompany their wives to treatment sessions if necessary, but only 14 were invited to do so. The others were told that in their particular case it would not be necessary. All subjects improved with this program. Overall the improvement rate was in line with typical improvement rates from around the world (Jannson & Ost, 1982). However, a significantly greater number of agoraphobics in the spouse group were classified as "responders" at posttest. A variety of additional measures also showed either a statistically significant advantage for the spouse group or a trend in that direction. These results surprised us somewhat since we had hypothesized that any beneficial effect of including the spouse would occur during the follow-up period. Now, two additional studies have appeared exploring the same issue. One study by a very competent group of investigators evaluated the effects of including the spouse in a similar manner to the Barlow et al. experiment (Cobb, Mathews, Childs-Clarke, & Blowers, 1984). This experiment failed to reveal any positive effect of including the spouse at a posttest or six-month followup compared to a nonspouse group. One procedural difference stands out that might account for this discrepancy. In this study, all therapeutic contact took

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place in the patient's home where the therapist spent approximately 5 hours. During the first visit, as well as all subsequent assessment sessions, spouses in both the spouse and the nonspouse groups were included, interacting with both patient and therapist. Therapists reported that spouses in the nonspouse group "showed an interest" in therapy during this initial session. Possibly they became more active during therapy because of this interest. In the Barlow et al. (1984) study all groups met at the clinic and therapists never met the spouse in the nonspouse group, although questionnaires were sent home for them to return by mail. Thus, they may not have become as "interested" or active as the spouses in the Cobb et al. study. A second study approached the question in a somewhat different way. Arnow, Taylor, Agras, & Telch (1985) exposed agoraphobics and their spouses to phobic situations in a standard manner for 4 weeks and then divided them into two matched groups based on their change scores on behavioral measures of agoraphobia. These groups were determined by random assignment. One group then received a communication training package which focused on dealing with agoraphobic situations. The other group received relaxation training in a couples format. At both posttest and eight-month follow-up, a significant advantage existed for the group receiving communication training over the relaxation group on measures of agoraphobia. This suggests that improvements in communication may mediate any beneficial effects of including the spouse in treatment. In the face of these somewhat conflicting results we have followed up patients in the original Barlow et al. (1984) study as well as patients treated subsequently for 2 years in order to determine the long-term effects of including the spouse in treatment. Our original hypothesis was that the benefits of including the spouse would be most evident during this period.

METHOD Subjects Forty-one married female agoraphobics completed the treatment program. The DSM-III diagnosis was determined from the Anxiety Disorders Interview Schedule (ADIS; Di Nardo, O'Brien, Barlow, Waddell, & Blanchard, 1983) conducted by a staff clinician. Sixteen clients received two independent interviews, and a second clinician independently reviewed the interview data for the remainder. Rare diagnostic disagreements were presented at a staff meeting to determine a consensus diagnosis. In order to be included in the study, clients had to obtain a score of at least 4 (moderate level) on a 0-8 point scale of symptom severity and the spouse had to agree to participate in the therapy sessions. Subjects were randomly assigned to either the spouse or nonspouse therapy formats.

Procedure A detailed description of the original design and treatment used in this study has been reported in Barlow, O'Brien, and Last (1984) and in Himadi, Cerny, Barlow, Cohen, and O'Brien (1986).

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Twenty-seven of the women and their spouses completed the behavioral treatment program, and the remaining 14 women completed the same program without their spouses. The treatment program consisted of eight weekly and four biweekly group sessions, with three to six patients per group. During these sessions the nature of agoraphobia, treatment rationale, and cognitivebehavioral techniques for coping with anxiety and panic attacks were discussed. In addition, clients were assigned specific in vivo homework practice from their Fear and Avoidance Hierarchy. In the spouse groups, spouses were instructed in ways to assist, support, and encourage their partners.

Assessments Assessments were completed before and after treatment, and at 12- and 24month follow-up periods, with the actual time since treatment averaging 14.14 (SD = 2.56) months for the one year follow-up and 28.67 (SD = 8.42) for the two-year follow-up. At each assessment period, the following measures were administered.

Behavioral Measures During an individualized behavioral avoidance test (BAT), a clinician observed the client attempting feared situations in her home environment. Five items, selected from the client's individualized Fear and Avoidance Hierarchy, were used for behavioral observation. The client was instructed to attempt each of these 5 hierarchy items in an ascending order of difficulty. Dependent variables included the number of items completed and Subjective Units of Disturbance (SUDS) ratings for each item on a 0-8 scale. Clinician Rating At posttreatment and at each follow-up, a clinician rating of severity was again obtained based on a condensed version of the ADIS administered by a clinician not involved with treatment or aware of group assignment. The 0-8 point scale of phobic severity reflected levels of overall distress and disability. Self-Report Measures 1. The Fear and Avoidance Hierarchy (FAH) is a 10-item individualized fear and avoidance measure that was rated by the client at each treatment session and at periodic assessment points on a 0-8 anxiety and avoidance scale. 2. A variety of questionnaires were also administered. These included the Fear Questionnaire (FQ) (Marks & Mathews, 1979), the Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Middlesex Hospital Questionnaire (MHQ) (Crown & Crisp, 1966), Subjective Symptom Scales (SSS) (Hafner & Marks, 1976), and the Marital Adjustment Test (MAT) (Locke & Wallace, 1959). Finally, the Marital Happiness Scale (MHS) (Azrin, Naster, & Jones, 1973) was administered weekly. Of these measures, spouses were asked to complete the BDI, MHQ, MAT, and the MHS.

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Composite Measures of Change Two composite measures o f clinically significant change were developed to assess the client's response to treatment (Himadi, Boice, & Barlow, 1986). One is concerned with the degree o f change during treatment (e.g., Barlow et al., 1984), the other with the client's endstate functioning (e.g., Mavissakalian & Michelson, 1983).

Theatment Responder This composite-based criterion specifies a 20°70 improvement in at least three o f the following five measures: 1. Total score on the ten-item FAH rated by clients on a 0-8 scale. 2. Behavioral performance on the five-item Individualized BAT. 3. Total SUDS ratings from the five BAT items. 4. Client rating from the phobia self-rating scale (0-8) from the FQ. 5. Clinician's ratings of phobic severity. A decrement criterion was also included in the determination o f posttreatment responder status. A client was considered a treatment nonresponder if a deterioration o f 20~/0 or greater occurred on any one o f the five measures from pre- to posttreatment, irrespective o f the degree o f improvement obtained on the other measures.

Endstate Functioning This criterion reflects a client's absolute level o f functioning at posttreatmerit and was applied only to treatment responders, who were assigned to either low endstate (LES) or high endstate (HES) categories, depending on their level o f functioning. (In contrast, responder and nonresponder categories reflected degree o f improvement). At least three o f the following five criteria had to be obtained for high endstate status: 1. Total score o f 20 or less on the client's FAH, plus a mean score o f no greater than 3 for the five most problematic items. 2. Total score o f 20 or less on the spouse's ratings o f the client's FAH, plus a mean score o f no greater than 3 for the five most problematic items. 3. Completion o f all five items from the BAT, plus a total SUDS score of 10 or less with no SUDS score exceeding 3 for any one item. 4. A score of 2 or less from the client's rating on the 0 to 8 point phobia self-rating scale of the FQ. 5. A score o f 2 or less on the clinician's 0 to 8 point rating scale o f phobic severity. For a detailed discussion of treatment responder and endstate functioning measures, see Himadi et ai. (1986).

Classification of Marital Adjustment A marital adjustment index was based on both the client's and spouse's scores from the Locke-Wallace Marital Adjustment Test (MAT). Using MAT scores, any given couple could be assigned to one o f four possible index categories:

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highly satisfactory marriage (+ 3), satisfactory marriage (+ 1), unsatisfactory marriage ( - 1), or highly unsatisfactory marriage ( - 3). See Himadi et al. (1986) for a more detailed discussion of this procedure.

RESULTS Repeated measures univariate tests were used to compare spouse and nonspouse groups across posttreatment, one- and two-year follow-up assessment periods. Muiltivariate analyses were deemed inappropriate given the limited number of subjects, despite the increased chance of Type 1 error resulting from univariate procedures. Some missing data values were estimated in order to enhance the power o f the analyses. When possible, data missing at the twelvemonth follow-up assessment were estimated by averaging the subject's scores on the same variable at a 6-month follow-up and at the 2-year follow-up. Data missing at the two-year assessment period were replaced with group means if at least 75070 of the group's data were available for a given variable. Consequently, two-year missing data estimations were calculated for clinical severity ratings and percentage of behavioral test items completed from the nonspouse group. From a total of 779 data points, 25 missing data points were estimated at the twelve-month assessment period and 7 missing data points were estimated at the two-year assessment period. Because o f these procedures, as well as the fact that not all patients completed all of the follow-up measures and one measure (the MHQ) was not administered to all patients, the N's vary somewhat within each follow-up period. The number o f people from each treatment group who participated in the assessment process at each point is presented in Table 1. The number who

TABLE 1 Styan~CT FLOW Spouse group

Nonspouse group

Pretreatment

27

14

Posttreatmer~t

27

14

1-year Data sufficient to determine responder status Minimal data Refused Untraceable

20 l 3 3

11 2 0 1

2-year Data sufficient to determine responder status Minimal data Refused Untraceable

17 2 5 3

11 2 0 1

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TABLE 2 COMPARISONS BETWEEN COMPLIERS AND NONCOMPLIERS AT 1- AND 2-YEAR ASSESSMENTS

1-Year

Subjects assigned response status Clinician rating of severity Pre Post Percent of items from BAT Pre Post

.X 5.6 (0.9) 3.5 (1.7)

N 31

68.0 (26.7) 87.1 (22.6)

30

31

28

2-Year

Subjects assigned response status

Subjects not assessed X 6.0 (0.7) 4.3 (1.0)

N 7

80.0 (12.7) 84.0 (26.1)

6

7

5

'X 5.6 (0.8) 3.8 (1.6)

N 28

71.7 (24.3) 86.7 (19.3)

27

28

24

Subjects not assessed X 5.8 (0.9) 3.3 (1.7)

N 9

78.3 (16.2) 90.0 (21.4)

9

9

8

Note: Standard deviations in parentheses.

completed enough measures to allow determination of responder status also is indicated. Of the three subjects who refused assessment after 1 year, only one reported (during telephone contact) poor progress. Of the five who refused assessment after 2 years, one reported poor progress. The remainder reported good progress but were unwilling to be assessed due to other time commitments, etc. Table 2 presents mean scores from the pre- and postassessment of subjects who completed a sufficient number of measures to enable determination of responder status at the one- and two-year assessments compared to subjects who did not complete any part of the assessment at those times. (Subjects who provided minimal data were not included in these analyses.) These groups did not differ in terms of clinicians' ratings of severity or percent of items completed from the BAT either before or after treatment (analyzed using independent samples t-tests). At each follow-up period, the dependent measures were arranged into the following sets: (a) measures related to phobic behaviors (agoraphobic subscale of the FQ) and measures used in the determination of responder statusspecifically, average clinical severity rating, SUDS from BAT, Phobia SelfRating, Fear and Avoidance Hierarchy, and percent of BAT items completed; (b) measures related to social functioning-- specifically, work, home management, private leisure, social functioning, and family activities subscales of the Subjective Symptoms Scale; (c) measures related to nonphobic psychopatho l o g y - specifically, Middlesex Hospital Questionnaire subscales (excluding anxiety and phobia subscales), Beck Depression Inventory, and depersonalization, depression, and obsession subscales from the Subjective Symptoms

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Scale; and (d) marital satisfaction measures-specifically, client and spouse Marital Adjustment Tests.

Between-Group Differences Phobia Measures. Client scores on the set o f phobia measures at posttreatment, one- and two-year follow-ups, are presented in Table 3. Two (group) × three (post, 1 year, 2 year) analyses were performed with those variables for which sufficient data were available at the two-year assessment: clinician's rating of severity and percent o f items completed from the BAT. Two x two analyses were performed for the remaining variables, with the exception of SUDS, due to insufficient nonspouse group data one year after treatment. In the analyses o f simple effects, separate variance t tests were performed when Levene's test for homogeneity of variance was significant. A significant group x assessment interaction was obtained from the analysis of clinical ratings [F(2,58) = 3.49, p < .05]. Examination of tests of simple effects shows that clients treated in the spouse format were rated as less severe than nonspouse subjects 12 months [t(35) = -2.87, p < .01] and 24 months [t(29) = -2.70, p < .02] after treatment. The groups did not differ immediately after treatment on this variable. In the analysis of BAT data, the spouse group completed more items than the nonspouse group overall IF(l,15) = 6.55, p < .03], but the interaction effect was not significant. From the 2 x 2 analyses, significant interaction effects emerged from the FAH [F(1,25) = 6.53, p < .02] and agoraphobic subscale [F(1,26) = 4.66, p < .05] data. The spouse group reported lower FAH ratings [t(25) = -2.60, p < .02] and scored less on the agoraphobia subscale [t(15.6) = -2.16, p < .05] than the nonspouse group 12 months after treatment. The groups did not differ significantly on either variable at postassessment. No significant effects emerged from the analysis o f self-rating scores. The data suggest that with the exception of BAT data, the spouse group continued to improve on phobic measures from posttreatment to 2 years. The nonspouse group evidenced deterioration on four o f the six measures from post to 1 year, followed by an improving trend at 2 years. Social Measures. Table 4 presents the data from each measure of social adjustment. Two x two repeated measures analyses were performed for each social adjustment scale, given the restrictive sample size at the two-year assessment. The overall group effect was significant for working abilities IF(l,17) = 7.27, p < .02]. The spouse group reported less interference with working abilities than the nonspouse group. The general pattern for the spouse group was of continuing improvement from posttreatment to 1 year to 2 years. The nonspouse group trend was for increased severity on four measures o f social adjustment from posttreatment to 1 year. Psychopathological Measures. The third set of measures assessed psychological symptoms not necessarily related to agoraphobia; i.e., more general measures o f psychopathology. There were no significant differences between the spouse and nonspouse groups with regard to MHQ, BDI, or the deper-

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CERNY ET AL. TABLE 4 A V E R A G E CLIENT SCORES AT POST, 1- A N D 2-YEAR FOLLOW-UPs FOR SPOUSE A N D NONSPOUSE GROUPS: SOCIAL MEASURES

Spouse group Posttreatment Variable name

X

N

Nonspouse group

l-Year

2-Year

.X

.X

N

Posttreatment

N

.X

N

1-Year

2-Year

X

X

N

N

Work

2.13 16 0.67 15 0.80 10 3.75 12 3.25 12 1.00 (1.67) (0.90) (1.14) (2.86) (2.70) (1.16)

4

Home management

1.56 16 0.80 15 0.60 10 1.67 12 2.04 12 1.00 (1.50) (0.94) (0.84) (1.37) (2.16) (1.41)

4

Private leisure

3.50 16 1.73 15 2.40 10 3.33 12 3.79 12 2.50 (2.25) (2.38) (2.95) (2.43) (2.98) (2.65)

4

Social functioning

2.44 16 1.20 15 1.20 10 2.00 12 2.67 12 2.25 (1.86) (0.94) (1.99) (2.34) (2.81) (1.71)

4

Family activities

2.07 15 1.27 15 0.89 (1.53) (1.10) (1.36)

4

9

2.25 12 2.33 12 1.50 (1.55) (2.66) (1.29)

Note: Standard deviations appear in parentheses.

sonalization, depression or obsession subscales from the SSS across assessment intervals.

Responder Status Pretreatment Predictors. In a retrospective fashion, we asked if outcome at 1-year follow-up was related to any o f the patients' pretreatment scores. To this end, we reclassified all subjects into nonresponder (n = 11), LES (n = 11), and H E S (n = 9) groups, and conducted Hotelling's T tests (multivariate) on each o f the three sets of pretreatment scores (phobia, social, and psychopathological measures). Thirty-one subjects had sufficient data at the oneyear follow-up to be classified into one of those three groups. Scores from the pretreatment phobia measures did not differentiate nonresponders from LES, nor LES from H E S groups. However, nonresponders were differentiated f r o m HES: T2(5,14) = 21.84, p < .04. Subsequent univariate t tests indicated that HES subjeccts performed significantly more items from the BAT at pretreatment in comparison to nonresponders" respective means (and standard deviations) were 88.89 (14.53), and 67:27 (22.4), It(18) = - 2.49, p < .03]. The only pair o f groups to differ in terms of pretreatment social adjustment scores were LES and HES" T2(5,8) = 29.17, p < .05. Subsequent univariate tests indicated that H E S functioners reported significantly higher interference at pretreatment than LES functioners with respect to private/leisure activities: respective means were 5.71 (1.70) and 3.14 (2.61), It(12) = -2.18, p < .05]. In terms o f measures of general psychopathology, LES and H E S groups differed significantly at pretreatment; T2(8, 6.7) = 77.06, p < .04. Subsequent univariate tests indicated that the groups did not differ significantly on any single

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variable at pretreatment. However, in general, HES functioners scored higher than LES functioners in regard to the somatic, depression, and hysterical subscales of the Middlesex Hospital Questionnaire, the Beck Depression Inventory, and the depersonalization, depression, and obsessive subscales of the Subjective Symptom Scale.

Between Group Differences Maintenance of treatment outcome was assessed with our composite measures of treatment effectiveness. In view of the degree of missing data, response status was determined when at least three of the five criterion variables were measured for a given client. However, the requirement of improvement in at least three measures remained the same. At the one-year follow-up, 14 of the 20 (70070) in the spouse group and 6 of the 11 (55070) in the nonspouse group were rated as responders. These proportions did not differ significantly (Chi-square tests were considered inappropriate given the small cells involved in the nonspouse group). At the two-year follow-up, the spouse group had significantly more responders (14 of 17, for 82070) than the nonspouse group (5 of 11, for 46070): Z = 3.03, p < .05. The responder percentages are depicted in Figure 1. HES functioning at the 1-year follow-up was achieved by 7, or 35070 of the spouse group clients and by 2, or 18070,of the nonspouse responders. Eight, or 47070, of the spouse group and 3, or 27070, of the nonspouse group

t.1 (D z u

Q

SPOUSE NONSPOUSE I-YEAR FOLLOW-UP

SPOUSE NONSPOUSE 2-YEAR FOLLOW-UP

FIG. 1. Percentage of spouse and nonspouse treatment groups classified as ~sponder l-year and 2-year follow-ups.

412

CERNY ET AL. TABLE 5 MEAN MARITALADJUSTMENT SCORESFOR THE SPOUSEAND NONSPOUSETREATMENT GROUPS AT POSTTREATtdmNT AND AT 1- AND 2-Y~dz FOLLOW-UPs Posttreatment Spouse group

Patient Spouse

Nonspouse group

N

"X

SD

N

"X

SD

25 26

112.16 106.04

19.36 24.70

12 10

95.17 107.30

27.35

31.27

l-Year Follow-Up Spouse group

Patient Spouse

Nonspouse group

N

'X

SD

N

'X

SD

17 16

102.18 112.56

22.94 12.78

10 6

99.70 106.92

24.05 33.50

2-Year Follow-Up Spouse group

Patient Spouse

Nonspouse group

N

'X

SD

15 11

104.87 97.00

16.99 31.45

N 6 4

R

SD

102.33 92.75

16.87 37.13

fell into the HES category at two-year follow-up. The proportions do not differ significantly at either assessment period. These data need to be considered cautiously because o f the small number of patients; nevertheless, the increased number of responders across the 2-year follow-up period among patients treated in the spouse group format is encouraging. Marital Patterns MAT scores for the spouse and nonspouse groups are presented in Table 5. The group sizes in Table 5 differ because data were not available for all the patients' spouses. None o f the differences in these data were significant. Examination of the marital satisfaction index at one-year follow-up showed that six couples in the spouse group had changed from a dissatisfied status at pretreatment to a satisfied status at the one-year follow-up, ten couples showed no change in their marital satisfaction index, while only two couples had become dissatisfied. For the five nonspouse group couples, one couple became satisfied, and four couples remained the same. At the two-year followup, four spouse group couples had changed from a dissatisfied to a satisfied status, eight remained the same, and one became less satisfied than at pretreatment. Due to the dearth o f responses from spouses, we were able to calculate marital satisfaction indices for only four couples in the nonspouse group, all o f whom remained at the same marital satisfaction level at the one-year follow-

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up. It is difficult to compare the groups due to the small cell sizes in the nonspouse group. On the whole, the above data suggests that the majority o f couples from both groups, who provided MAT data, tended to maintain the same level o f marital satisfaction over time. Approximately 30070 o f spousegroup couples reported a change in marital status from dissatisfaction to satisfaction. Preassessment marital satisfaction did not relate systematically to responder status at either 1 or 2 years. Responders at those periods were equally likely to have been categorized as maritally satisfied or dissatisfied at initial assessment. The same was observed for posttreatment marital status.

DISCUSSION Follow-up assessment demonstrates that the advantage o f including the spouse noticed immediately after termination o f treatment is maintained and even increases somewhat. These results are particularly evident on measures o f phobic behavior I year after treatment. At this point the spouse group continued to improve while the nonspouse group demonstrated no further improvement and even a slight deterioration on some measures. Results 2 years after treatment are clouded somewhat by the small N in the nonspouse group on some measures but, in general, the nonspouse group resumes its improving trend. However, our composite measure of change which focuses on individual responding rather than group averages suggests an even greater advantage for the spouse group at the two-year follow-up. Involvement o f the spouse also produces less disruption in work and leisure activities during the year following treatment, although at 2 years, this advantage was no longer apparent. On the other hand, there seems to be no significant advantage to including the spouse on more general measures o f psychopathology. Measures o f marital satisfaction reflect the now common observation o f improvement in marital satisfaction correlated with improvement in phobic behavior (e.g., Himadi et al., 1986). No particular differences emerged between groups in terms o f increases in marital satisfaction, although the small amount o f data preclude a definitive statement. These data would seem to confirm recent thinking concerning the importance o f attending to the interpersonal system o f the patient. Nevertheless, the mechanism o f action accounting for this beneficial effect is not yet clear. We had hypothesized earlier that inclusion o f the spouse in treatment would increase the amount o f between-session practice during treatment as well as after treatment. However, posttreatment analysis did not reveal any differences between groups in the number or duration of practice sessions based on diary measures (Barlow et al., 1984). O f course, this may be due to the relative crudeness of our measure several years ago. Increasingly sophisticated diary measures in our setting and elsewhere are beginning to show differences in amount o f practice during treatment that correlate with outcome (e.g., Michelson et al., 1986). Therefore, it is still possible that increased practice is one mechanism contributing to the advantage o f the spouse group. It is also possible that we might now observe increased practice not only during treatment but in the all-important period following treatment with our improved measurement capabilities.

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CERNY ET AL.

But another, perhaps more important, factor is the facilitating effect of enhanced communication skills on phobic improvement recently demonstrated by Arnow et al. (1985). Although we did not specifically target communication skills, as did Arnow et al., recent evidence from video-taped observations of marital interactions indicate that the amount and quality of communication surrounding agoraphobic issues does, in fact, improve during treatment in our spouse groups. Thus, increases in communication skills surrounding phobic issues may play a major role in the observed advantage of the spouse group. Targeting communication skills more directly may further increase this advantage. Finally, our couples treatment protocol several years ago did not focus directly on reducing panic, although panic management techniques were certainly taught. But in view of the fact that reductions in anxiety and panic are the best predictors of overall outcome on agoraphobia phobic behavior (Michelson, Mavissakalian, & Marchione, 1985), it is possible that inclusion of the husband facilitated reductions in panic, particularly in the all-important period following treatment. One way in which this might happen is through an overall reduction in marital stress which can be a major factor in triggering panic attacks. Inclusion of a treatment module directly targeting panic attacks into couples treatment of agoraphobia may well boost substantially the number of individuals attaining high endstate functioning.

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