Employing paradoxical intention in the treatment of agoraphobia

EMPLOYING PARADOXICkL INTENTION IN THE TREATMENT OF AGORAPHOBIA L. MICHAEL ASCHER Deparrmentof Psychiatry, TernpIe University School of Medicine, c/a E.P.P.I., 33W Henry Avenue. P~i~ade~ph~~ PA f9129, U.S.A. (Receioed 3 March 1981)

present study assessed the efficacy of paradoxical intention in amehorating the travel restriction of agoraphobics. A combined score indicating proximity to two dif%cutt target locationsrepresentedthe dependent variable. A multiple baseline across subjects was used with each of two groups of five clients. This was accomplished by sequentially staggering introduction of treatment. At the conclusion of baseline phase, Group A received 6 weeks of gradual exposure followed by paradoxical intention to criterion. Group B received paradoxical intention to criterion immediately after baseline. Results indicated that paradoxical intention produced greater movement toward targets for clients in Group B when compared both with their baseline and with the performance of Group A following an equal period of gradual exposure.

Summary-The

INTRODUCTION

Although agoraphobia is a multi-symptom difficulty (Goldstein and Chambless, J978; Hudson, 1974). the most safient aspect of the problem, and often the presenting complaint, is the avoidance of situations which the individual considers to be unsafe. The subsequent restriction of freedom can result in the extreme, but not uncommon, circumstance in which the individual finds himself or herself housebound (Weekes, 1972). During the past decade, a number of treatment programs which have focused on this avoidance aspect of agoraphobia were exposed to more or less acceptable methods of clinical testing. Several of these procedures were demonstrated to be relatively effective in assisting the agoraphobic to increase their time and distance away from home. It is generally agreed that exposure to the anxiety-related external situation is a necessary component of such clinical techniques and, in fact, the procedures which were most successful with agoraphobics all incorporated some type of exposure. FIooding in imagination and in v&o (Emmelkamp and Wessels, 1974; Hand er uf., 19741, are prime examples of such therapeutic methods. Recently, attention has been directed toward the possibility of reducing the role of the therapist and increasing the participation of the agoraphobic individual in his or her own treatment. The self-help methods labeled successive approximation (Everaerd er al., 1973) and self-observation (Emmelkamp and Ultee, .1974), as well as a home-based program (Mathews et at,, 1977, 1979) are derived from this perspective. Although there are important differences among them. the three procedures have two significant aspects in common: they are each organized around a central component involving in r$vo exposure; and the active participation of the therapist in this exposure is kept to a minimum, The method of exposure which is employed by the three self-help programs is based on a gradual approach to the anxiety-related situations. The therapist emphasizes the instructions that upon experiencing discomfort the client is to immediately return home (Everaerd et nl.. 1973; Emmelkamp and Wltee, 1974), though Mathews et al. (1979) may vary to some extent from this proscription against experiencing anxiety. It is possible that a more active exposure procedure, as would be the case with some variant of flooding. could produce superior results for the self-help methods in terms of the speed *Aspects of this paper were presented at the Association for the Advancement of Behavior Therapy Convention. New York. November 1980. 533

534

L.

MICHAEL

ASCHER

with which therapeutic goals are.achieved (i.e. in terms of time and distance away from home). However. it has been suggested that the utilization of flooding within a self-help program is impractical (Mathews rt LZ:.,1977. 1979). One therapeutic strategy, paradoxical intention, which has been largely ignored by behavior therapists working with agoraphobics, could possibly fulfill the requirements of a more active exposure procedure as well as reduced therapist participation. Paradoxical intention has been the subject of a number of case reports suggesting that this technique might be effective with the avoidance aspect of agoraphobia (Ascher, 1980, Frankl, 1960). .4n analysis of the procedure shows that the exposure aspects of this technique are similar to flooding (Marks. 1972). permitting the client to be actively exposed to a wide variety of anxiety associated stimuli both in riro and in imagination. However. in contrast to flooding, paradoxical intention requires less of the therapist’s time to administer and involves little or no direct supervision of the client. In fact. Frank) (1975) reports the receipt of letters from former agoraphobics (whose freedom of movement was severely restricted) in which they describe the successful self-administration of paradoxical intention. Therefore, paradoxical intention would seem to have considerable potential as a self-help procedure for agoraphobics. The purpose of the present study was to assess the efficacy of paradoxical intention in ameliorating restricted range of travel, a central component of the agoraphobic syndrome. A second goal of the study was an initial comparison of paradoxical intention. an active exposure method, with the more gradual exposure procedures employed in previous self-help studies. Because of the unique characteristics of a single subject experimental design for the assessment of clinical techniques within a clinical context (Barlow. 1980; Hersen and Barlow, 1976). the study reported below employed a multiple baseline design.

METHOD Design Two groups of five clients composed the present experiment. A multiple baseline across subjects was used with each group by sequentially staggering the introduction of the treatment procedure. At the conclusion of a variable baseline period ranging from 4 to 8 weeks. the clients in Group A received a standard 6-week in riro exposure program. followed by paradoxical intention instructions. Clients in Group B were immediately provided with paradoxical intention instructions subsequent to completion of the baseline period. Subjects

All clients were referred to the author by mental health professionals. Among the ten clients who are the focus of the present report, nine were female and one was male. ranging in age from 23 to 58 years. (Two females and one male originally included in the study dropped out because of difficulty fulfilling the requirements of the procedure.) They were selected from a larger pool of subjects on the basis of several factors. First. it was necessary that they fulfilled certain significant aspects of a definition of agoraphobia based on the author’s understanding of and experience with this clinical problem. The most salient criteria were: fear of a hypothesized disastrous consequence following peak levels of anxiety (e.g. cardiac arrest, suffocation. vomiting in public, ‘going crazy’); severe restriction of movement when alone (i.e. clients did not feel comfortable going into numerous situations on their own. some could not leave their home. others could not go to certain very discomforting places, e.g. supermarkets, theaters, restaurants). Second. they had to agree to meet the requirements of the procedure. These included: completing a behavior approach test weekly throughout the course of therapy beginning with the week following the initial intake session; agreeing to wait for treatment during the baseline period which ranged between 5 and 8 weeks; maintaining their availability for a weekly

Paradoxical intention

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therapy session and for five daily assignments each week. Those who did not or could not meet these criteria for inclusion in the study were provided with suitable alternative treatment. Procedure The behavior approach test. During the first session the client was interviewed in an effort to determine those places to which he or she would have liked to have gone al&e but chose to avoid as the result of anxiety. Two maximally difficult target locations were selected such that the client reported experiencing 100 subjective units of discomfort (SUDS; Wolpe, 1973). One practical consideration concerning target selection was the necessity for the client to be able to reach the target within l-l.5 hours of leaving home. For each assigned target there was a prearranged plan of travel which, along with activity specific to the actual target location, was divided into ten serial components. For example, several clients were unable to go unaccompanied to supermarkets. For one such client, the assignment to go to a specific supermarket was divided in the following manner: (a) leave home headed for the target; (b) enter automobile; (c) drive past a landmark which represents the completion of approximately one-third of the trip; (df drive past a landmark which represents the completion of approximately two-thirds of the trip; (e) see the target for the first time; (f) park in lot adjacent to target; (g) walk toward target; (h) enter store; (i) engage in food selction until comfortable; (j) stand in long check-out line. Each target assignment ended with the client remaining in the situation until he or she was comfortable. At every point in each of the two assignments, the client was to record whether or not he or she was able to fulfill the requirements of that specific aspect. The client was asked to complete as much of the test as he or she was able in a relatively comfortable manner during a single day of the following week. Baseline interval. In order to meet the requirements of a multiple baseline design, the initiation of treatment was staggered for the two groups of five ciienls. Thus, the first client in each group began treatment after 4 weeks of baseline data were collected. The second client in each group began after submitting 5 weeks of baseline data. This progression was continued to the fifth client in each group who began therapy after 8 weeks of baseline data were collected. Every client was required to attempt the behavior approach test during each week of the baseline period. Clients were contacted by the therapist at the beginning of every week to determine the day on which they were to complete the behavior approach test for the week. On the assigned day the therapist drove to the client’s house to obtain the data sheet. This procedure served the dual purpose of reliably collecting the data and maintaining contact with clients during the baseline period when the attrition rate could be high. Graded exposure. On the first session following the completion of the baseline interval the therapist provided one group of five clients (Group A) with instructions typically employed with graded exposure assignments (e.g. Emmelkamp, 1974). Thus clients were told that each time they attempted to go to their respective targets they were to travel as far as they could without experiencing discomfort. As soon as they did feel anxious they were to return home immediately. It was suggested that they could, if they wished, begin another trial but that they should not attempt more than two trials on a single day. They were further instructed to attempt a trial on each of five days per week. Weekly sessions of 30-45 min focussed on the experiences, difliculties, and questions associated with the client’s graded exposure activity of the previous week. At the close of each session, plans were made for exposure during the subsequent week. Clients in Group A engaged in the graded exposure program for 6 weeks. Paradoxical intention. On the last graded exposure session, the therapist suggested to clients in Group A that any improvement which was experienced might be enhanced by an alternative therapeutic strategy. Paradoxical intention was then introduced to the client and the remainder of the session was devoted to a description and explanation of the procedure.

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ASCHER

Those in the second group of five clients (Group B) were provided with paradoxical instructions immediately upon completion of the baseline period. They did not initially receive graded exposure as did the clients in Group A. While a more detailed description of the rationale of paradoxical intention may be found in Ascher (1980), for the purpose of the present study the following are the major components of this presentation: (a) the avoidance of, or escape from, certain parts of the client’s environment associated with anxiety results in their restriction of movement and a strengthening of the anxiety bond; (b) attempts to control anxiety, often through the use of various cognitive strategies, serve to increase the level of discomfort experienced at that time, and also contribute to the long-term strengthening of the anxiety bond; (c) anxiety is seen by clients as the precursor of some anticipated disastrous consequence; it is not so much the anxiety, per se, which the client fears, but the disastrous consequence; (d) the anticipated disastrous consequence will not follow even the highest levels of anxiety that the client is capable of experiencing (see Ascher, 1980); (e) anxiety. per se. is not necessarily bad and need not be avoided at all cost; (f) an alternative approach which has worked for individuals complaining of difficulties similar to those of the client is to focus on the most prominent aspect of the physiological experience of anxiety and to try to increase this symptom in an attempt to court the anticipated disastrous consequence. Clients were to complete each serial component of their individual assignments until they reached a component at which they experienced what they considered to be too much anxiety to proceed (clients in Group A were instructed to proceed from the point at which they ended on the last session of the 6-week graded exposure condition). At that point they were to apply the paradoxical instruction and remain until they became comfortable. Then they could attempt to proceed or return home. If they attempted to proceed they were to again apply paradoxical intention when they felt uncomfortable. On the next day they were to begin again with the same assignment attempting to go further each day. The client was expected to engage in this activity at least 5 days of each week. During the next office session, the explanation of paradoxical intention was reviewed. and questions based on relevant experiences acquired while performing the daily assignments were answered. Any progress in the assignments was noted and discussion moved to plans for engaging in assignments during the following week. This session generally represents the model for therapy as it was conducted for the period described in the present study. That is, each session was devoted to a discussion of paradoxical intention and any difficulties or concerns which clients may have had either in thinking about or carrying out the instructions. Attention would then shift to those situations which clients attempted to approach on the previous week and those with which they planned to deal during the following week. Clients were required to attempt a behavior approach test once during the weekly interval between each therapy session. thus being able to present the therapist with a completed data sheet on each session. Weekly therapy sessions devoted to paradoxical intention continued until the client exhibited the criterion behavior. Discussion of other aspects of the agoraphobic problem was kept to a minimum during the in vivo exposure phase of treatment. Concerns about such things as domestic difficulties became the focus of therapy following satisfactory completion of the paradoxical intention phase. Criterion. Each client was assigned two individualized targets. The criterion behavior for each of these targets consisted of the client leaving his or her house, proceeding directly to the assigned target location, utilizing the prescribed course, and remaining until comfortable. The criterion of success for the study was achieved when the client could exhibit the criterion behavior with both assigned targets in a single week. At this point, the exposure component of treatment, which formed the focus of the present study, was terminated. Follow-up. During a j-month follow-up period, most of the clients remained in therapy for varying periods of time. However, little or no attention was directed toward the previous in viuo program to which they had been exposed. Naturally, there were times

Paradoxtcal

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intention

when the client would mention some difficulty he or she experienced in traveling, or some triumph they had achieved. Appropriate comment was made, after which the therapist returned to other matters as quickly as possible. RESULTS

The behavior approach test which each client attempted during each week of the study was composed of two target trips. Each trip included ten spatially ordered components. For each component of the target trips which the client was able to complete he or she received one point. Thus, each weekly behavior approach test score could range from 0 (unable to leave home) to 20 (able to travel to both target locations and remain until comfortable), The mean behavior approach test score which each client achieved during the course of the present study appears in Table 1. For clients in Group A, the mean behavior approach test score for the baseline period was 2.07 (SD = 0.92). During the 6 weeks that these clients participated in the gradual exposure program their mean scores increased to 5.03 (SD = 3.09). After the period of gradual exposure clients in Group A shifted to paradoxical intention to criterion. For this phase of the study their mean weekly behavioral approach test score was 13.87 (SD = 2.11). The mean score for the total treatment period (this includes both gradual exposure and paradoxical intention) was 10.05 (SD = 1.62). The mean behavioral approach test score for the baseline of Group B clients was 2.08 (SD = 0.52). The mean score for clients in Group B during the first 6 weeks of paradoxical intention was 11.4 (SD = 4.27). This is comparable to the gradual exposure phase of the program for Group A clients. The mean behavioral test score for the total course of paradoxical intention for these clients w.as 13.55 (SD = 2.52). Comparable to the mean score for the total treatment of clients in Group A. The individual performance for each subject during the entire program is depicted in Fig. 1 (Group A) and in Fig. 2 (Group B). A comparison of the baseline data for both groups yielded t = 0.73, df = 9, P < 0.10. This indicates that at least on this measure, the two groups were initially equivalent.

Table

1. Mean behavioral

approach

test score achieved

weekly during

Group

Baseline Client 1 2 3 4 5 Total

each phase of in ciro exposure

program

A

Gradual exposure (1st 6 weeks)

Paradoxical intention to criterion

Total treatment

Means

SD

Means

SD

Means

SD

Means

SD

3.25 2.0 1.4 2.71 1.0

1.26 1.23 0.89 1.98 0.76

7.33 3.0 3.83 9.17 1.83

1.03 1.10 1.72 1.17 0.98

15.78 13.42 10.86 16.0 13.30

3.15 5.78 6.96 5.66 3.97

12.0 9.94 7.62 10.88 9.79

5.68 6.89 6.23 3.94 6.23

2.01

0.92

5.03

3.09

13.87

2.11

10.05

1.62

Group

B

Paradoxical intention (1st 6 weeks)

Baseline

Paradoxical intention to criterion (total treatment)

Client

Means

SD

Means

SD

Means

SD

1 2 3 4 5

2.25 2.0 2.83 1.43 1.88

0.96 0.71 0.98 0.79 0.84

10.67 10.0 5.33 15.33 15.67

7.06 4.60 1.75 4.18 5.13

13.78 13.64 9.35 15.33 15.67

5.22 5.45 5.10 4.18 5.13

2.08

0.52

11.4

4.27

13.55

2.52

Total

L. MICHAEL ASCHER

538

20 16 Ii? 6 4:

4 2

4

6

8

J .* -* I I ~11111~1~1~~~~~J IO 12 14 16 I8 20 22 24

26 26 30

Weeks in treatment

Fig. 1. Weekly

behavioral

approach

test score of clients study.

in Group

A through

three

phases

of

In order to determine the degree to which the treatments produced change following the baseline period, two intra-group tests were performed. The first was between the mean baseline scores achieved by clients in Group A on the behavior approach test and their mean scores following the &week gradual exposure program. This comparison yielded t = 2.48, u” = 9, P < 0.10. The comparable intra-group test for clients in Group B included their baseline data and their mean scores following 6 weeks of paradoxical intention. This resulted in t = 9.62, df = 9, P c 0.01. Thus, 6 weeks of gradual exposure failed to produce a significant change from baseline. In contrast, 6 weeks of a paradoxical intention program brought clients significantly closer to their target than they were during the baseline period. In a related test, the mean behavior approach test scores for clients in Group A achieved during the weeks of gradual exposure, were compared with the mean behavior approach test scores for the clients in Group B for the first 6 weeks of paradoxical intention. The significant results t = 2.08, df = 9, P < 0.05 was consistent with the finding that 6 weeks of paradoxical intention produced a significant change from baseline while 6 weeks of gradual exposure did not.

Paradoxical

(

20eosdlne

Paradomol . ‘.,r

16

;tsntmn /

/

12

3

539

intention

20 16 12 6 4

4

20 I6 12 6 4

5

20

J

16

.I

I2

2

4

6

6

10

12

I4

I6

16

20

22

24

26

28

30

Weeks in treatment

Fig. 2. Weekly behavioral

approach

test score of clients in Group

B through

two phases of study.

Finally, a comparison between the mean behavior approach test scores for both groups of clients during the total treatment phases yielded t = 4.07, df = 9, P < 0.01. This suggests that clients in Group B approached significantly further to the target locations during each week of treatment than did the clients in Group A. Of the original ten clients, seven were attending therapy sessions on a regular basis at the time of the 3-month follow-up (three from Group A, four from Group B). None reported any difficulty in reaching criterion on the behavioral approach test. One of the three Group A) not in therapy at the time also submitted a behavioral approach data sheet indicating criterion had been reached on the initial attempt. The remaining two achieved scores of 18 (Group A) and 17 (Group B) for their first attempt, but on the second week of the follow-up both reached criterion. DISCUSSION The results provide support for the efficacy of paradoxical intention in ameliorating the restriction of movement of agoraphobics. This was most clearly demonstrated by the significantly greater approach to the target locations of clients in Group B following the

540

L. MICHAEL ASCHER

introduction of paradoxical intention when compared to their baseline performance. These data become more impressive when they are contrasted with the finding that an equal period of gradual exposure did not produce a significant increase in approach behavior for Group A clients as compared to their baseline scores. The results suggest the possibility that self-help programs utilizing paradoxical intention might be more efficient than those employing procedures which involve more gradual exposure of clients to discomforting events. Since paradoxical intention would seem to incorporate as active an exposure procedure as does flooding, the superior performance of this procedure in the present study appears to contradict, to some extent, the findings of Emmelkamp (1974). In his study, Emmelkamp failed to obtain differences between flooding and a self-help procedure. using gradual exposure when employed with agoraphobics. However, differences in the results of the two studies are most appropriately attributed to the differences in the administration of the gradual exposure procedure in the present study and the ‘selfobservation’ procedure in Emmelkamp’s (1974) study. In addition, the dependent variable in the present study was a measure of the distance toward maximally difficult targets which the client traversed. Emmelkamp (1974) was primarily concerned with the length of time in which the client remained outside the house, and to a lesser extent, the length of time that the client could remain in four phobic settings (the relative degree of difficulty of these settings is unclear). It is therefore possible that the dependent variable employed in the present study provided agoiaphobics with a more difficult task than that required of the clients in the Emmelkamp (1974) study. Thus the higher ceiling of the present study, in contrast to that of Emmelkamp (1974), produced conditions which were more favorable for the appearance of differences. An explanation of the role of paradoxical intention in the progress manifested by the agoraphobic clients is best understood in the context of a conception of the central defining feature of the disturbance. The two most widely accepted defintions of agoraphobia focus on different sources of fear. One conception of this syndrome suggests it to be a phobic response to public places (e.g. Marks, 1970). More recently, some authors have shifted the focus of the definition from fear of public places to fear of the anxiety which agoraphobics experience in discomforting situations. Thus, Weekes (1976), for example, refers to a ‘fear of fear’ concept. She suggests that the focus of treatment be aimed at reducing discomfort associated with the experience of anxiety which the agoraphobic reports when in places which he or she defines as dangerous, rather than at the anxiety directly associated with places themselves. The present author suggests a third definition of agoraphobia by viewing this syndrome as being comprised of three fear components: (a) conditioned fear of specific places in the presence of which anxiety has been experienced (a la Marks); (b) fear of physiological manifestations of anxiety (a la Weekes); and (c) fear of anticipated catastrophic consequences of high levels of anxiety. It is further suggested that the third component is the most crucial, the other two components gaining their fear arousing properties by their association with it. The fear that some disastrous consequence (e.g. cardiac arrest) will follow the experience of peak levels of anxiety, places the requirements on the agoraphobic of maintaining a low level of arousal. Thus, when the agoraphobic approaches a situation in which he or she may have experienced discomfort in the past, it is hypothesized that he or she will self-monitor to assess level of anxiety. This level will invariably be judged as being too high and some procedure will be employed in an attempt to reduce the anxiety. The individual will again monitor and, finding the level of anxiety still uncomfortably high, become more anxious since the coping devices have failed to reduce discomfort. This continuously increasing level of anxiety is eventually compounded by concerns that the anxiety will reach a peak and will result in the disastrous consequence. This self-maintaining circular reaction involving-anxiety, self-monitoring,. attempted coping, self-monitoring, increased anxietyhas implicated in a variety of problems (Ascher, 1980): e.g. insomnia (Ascher and Efran. 1978; Fogle, 1980. Frankl. 1967; Storms

Paradoxical

intention

541

and Nisbett. 1970: Ribordy and Denney, 1977), sexual dysfunction (Frankl. 1967; Hurry, 1915) and psychogenic urinary retention (Ascher, 1979). The circular process which serves to exacerbate the agoraphobic’s condition continues until the individual, shocked by the realization that he or she has lost control, escapes from the situation. In reality, most agoraphobics report that on occasion they have been unable to escape under these circumstances, have experienced peak anxiety, and eventually experienced the extinction of this anxiety. Unfortunately, these occasions do not serve to indicate to the individual that a disastrous consequence will not result from anxiety. but rather they are perceived as ‘lucky escapes’ from the inevitable. It is assumed that one reason for the success of paradoxical intention with agoraphobia is the assistance provided by the technique in aiding the individual to break the performance anxiety circle. Typical paradoxial instructions suggest to the agoraphobic that, instead of fighting their anxiety and physical symptoms, it would be better to allow the anxiety to have free reign, i.e. to relinquish ‘control’ and abandon oneself to anxiety. More specifically, the client is instructed .to focus on that symptom of sympathetic activity which is most salient (e.g. heart rate) and to try to amplify the operation of the related physiological process (e.g. increase your heart rate). When the client is able to follow these instructions the goal of accepting and increasing anxiety rather than that of being free from anxiety becomes the object. Thus, when the client enters a discomforting situation he or she cannot fail to be successful since control of an involuntary process is not being required. In most cases panic levels of anxiety result from the efforts of the agoraphobic to control the activity of the sympathetic nervous system. with panic occurring when the coping procedures fail. Since such coping is not encouraged in a paradoxical intention program, failure does not occur and panic is not usually experienced. In fact, in most cases little anxiety need be experienced through the course of the program. It was noted in the introduction that agoraphobia is a multifaceted syndrome. The focus of treatment in the present study was a single component of this complex difficulty. It is not suggested that paradoxical intention alone is sufficient to enable the agoraphobic to attain a satisfactory adjustment. Rather, paradoxical intention should be considered to be a component of a complete program aimed at guiding agoraphobics through the variety of problems which they encounter in their environment. REFERENCES ASCHER L. M. (1979) Paradoxical intention in the treatment of urinary retention. Behac. Res. Ther. 17, 267-270. ASCHER L. M. (1980) Paradoxical intention. In Handbook of Behavioral Inreroentions: A Clinical Guide (Edited by GOLDSTEIN A. and FOA E. B.). Wiley, New York. ASCHER L. M. and EFRAN J. S. (1978) The use of paradoxical intention in a behavioral program for sleep onset insomnia. .I. consult. c/in. Psycho/. 8, 547-550. BARLOW D. (1980) Behavior therapy: the next decade. Behar. Ther. 11, 315-328. EHMELKAMP P. M. G. (1974) Self-observation vs flooding in the treatment of agoraphobia. Behac. Res. Ther. 12, 229-237. EMMELKAMP P. M. G. and ULTEE K. A. (1974) A comparison of “successive approximation” and “self-observation” in the treatment of agoraphobia. Behaa. Ther. 5, w13. EHMELKAMP P. M. G. and WESSELS H. (1974) Flooding in imagination vs flooding in rice for agoraphobics. Br. J. Psychiar. 124, 7-15. EVERAERD W. T. A. M.. RUKEN H. M. and EMMELKAMP P. M. G. (1973) A comparison of ‘flooding’ and ‘successive approximation’ in the treatment of agoraphobia. Behar. Res. Ther. 11, 105-l 17. F~GLE D. 0. (1980) Effects of a paradoxical “giving-up” treatment for chronic, self-defined insominia. Unpublished dissertation, Universiiy of Waterloo, Ontaiio. FRANKL V. E. (1960) Paradoxical intention: a logotherapeutic technique. Am. J. Psychother. 14, 520-535. FRANKL V. E. il967j Psychotherapy and Existenr~alism. Souvenir Press, London. FRANKL V. E. (1975) Paradoxical intention and dereflection. Psychother.: Theory, Res. Pracrice 12, 226-227. GOLDSTEIN A. and CHAMBLESSD. (1978) A reanalysis of agoraphobia. Behac. Ther. 9, 47-59. HAND J., LAMONTAGNE Y. and MARKS I. M. (1974) Group exposure (flooding) in ciao for agoraphobics. Br. J. Psychiar. 124, 588-602. HERSEN M. and BARLOW D. H. (1976) Single-Case Experimenral Designs: Srraregies for Studying Behavior Change. Pergamon Press, New York. HUDSON B. (1974) The families of agoraphobics treated by behavior therapy. Br. J. sot. Wk 4, 51-59. HURRY J. B. (1915) The vicious Circles of Neurasthenia and Their Trearmenr. Churchill, London. MARKS I. M. (1970) The origins of phobic states. Am. J. Psychother. 24, 652-676.

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MARKS I. M. (1972) Flooding (implosion and related treatments). In Eehacior Modijcufion Prrnciples und Clinical Applications (Edited by AGRAS W. S.): Little Brown, Boston. MATHEWS A., TEASDALE J., MIJNBY M., JOHNSON D. and SHAW P. (1977) A home-based treatment program for agoraphobia. Behav. Ther. 8,915924. MATHEWS A.. JANNOUN L. and GELDER M. (1979) Self-help methods in agoraphobia. Paper presented at the European Association of Behavior Therapy, Paris. September, 1979. RIBORDY S. C. and DENNEY D. P. (1977) The behavioral treatment of insomnia: an alternative to drug therapy. Eehau. Res. Ther. 15, 39-50. STORMS M. D. and NISBETT R. E. (1970) Insomnia and the attribution process. J. Person. sot. Psychol. 16. 319-328. WEEKES C. (1972) Peace from Neroous Suflering. Angus & Robertson. London: Hawthorn Books, New York. WEEKES C. (1976) Simple, Eficrioe Treatment of Agoraphobia. Hawthorn Books. New York. WOLPE J. (1973) The Practice of Behavior Therapy. Pergamon Press. New York.