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Enhancing effectiveness of paradoxical intention in treating travel restriction in agoraphobia
BEHAVIORTHERAPy 17, 124--130 (1986)
BRIEF REPORT Enhancing Effectiveness of Paradoxical Intention in Treating Travel Restriction in Agoraphobia L. MICHAEL ASCHER Temple University
DAVID E. SCHOTTE Lifehealth Assoch~tes JOHN B. GRAYSON
Rosemont Counseling Associates Techniques ancillary to paradoxical intention were employed to reduce anxiety and depression in agoraphobic clients. It was suggested that such enhancement would produce greater improvement in terms of increased travel capabilities during the initial portion of therapy than would be the case for individuals receiving component treatment. Three groups, each containing five agoraphobic clients, were provided with the enhanced paradoxical intention procedure, the paradoxical intention alone, or the enhancement package alone. Following the fourth session, subjects in the enhanced paradoxical intention group were performing significantly better than subjects in the two remaining groups.
Although it has been demonstrated that paradoxical intention is effective in the treatment of agoraphobia (Ascher 1981; Mavissakalian, Michelson, Greenwald, Kornblith, & Greenwald, 1983; Michelson, Mavissakalian, & Marchione, in press), certain difficulties inherent in the technique are at times associated with problems in its administration and generate hurdles to therapeutic progress (Ascher & Giles, in press). These difficulties appear to be associated with other self-administered exposure techniques employed with agoraphobics as well (Emmelkamp and VanderHout, 1983). Thus, although a study by Ascher (1981) found that agoraphobics achieved greater reductions in travel restrictions with paradoxical intention than with graded self-exposure, clients in the paraComponents of the data discussed herein were first reported at the Association for Advancement of Behavior Therapy, New York City, November 1980. Requests for reprints should be sent to L. Michael Ascher, Temple University Health Sciences Center, Department of Psychiatry, 3401 North Broad Street, Philadelphia, Pennsylvania 19140. 124 0005-7894/86/0124-013051.00/0 Copyright 1986 by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any form reserved.
PARADOXICAL INTENTION, AGORAPHOBIA
125
doxical intention treatment group reported difficulty in assuming a paradoxical approach to their anxiety. Inspection of the data of individual subjects in that study indicated that three of the five in the paradoxical intention treatment group did not appear to derive initial benefit from this procedure and that one of these individuals did not begin to show improvement until after twenty treatment sessions had elapsed. It follows then that an obvious way to attempt to increase the efficacy of paradoxical intention with agoraphobic individuals would be to assist clients in utilizing the procedure earlier in the course of therapy. The present paper presents the results of a preliminary investigation designed to accelerate the effects of paradoxical intention through the addition of ancillary cognitive therapy techniques and in vivo and imaginal exposure.
PROCEDURE Subjects. Clients chosen for the present study were selected from individuals referred sequentially to the senior author by area mental health professionals or from the outpatient clinic of the Behavior Therapy Unit. Selection for participation was based on three criteria. First, each subject had to meet the DSM-III diagnostic description for agoraphobia. Second, individuals had to exhibit severe travel restriction, particularly when alone, in association with fear of disastrous consequences following peak levels of anxiety. Third, subjects were required to comply with the following procedural components: (a) submission of weekly behavioral approach tests throughout the baseline and treatment phases; (b) attendance at weekly sessions; and (c) completion of five travel assignments during each intersession interval. Subjects selected for participation in the study were then randomly assigned in equal numbers to one of three treatment procedures: paradoxical intention, enhanced paradoxical intention, or the enhancement procedure alone. Those who did not fulfill these requirements were provided with suitable alternative treatment. Of the 15 subjects who participated, 13 were female and 2 were male. The mean age of the subjects was 38, with a range of 22 to 61 years of age. Three subjects who otherwise fulfilled the requirements for inclusion were dropped prior to the initiation of treatment procedures because they felt that personal time constraints precluded their participation in aspects of the program. Treatment sessions were approximately one hour in length although one and one-half hours were available for the first three. All sessions were conducted by experienced threrapists who were aware of the hypotheses being investigated. Behavioral approach tests. The behavioral approach test employed was conducted in the following manner (see Ascher, 1981, for additional details). During the initial interview, prior to the institution of the baseline phase, subjects were requested to indicate those situations which they would have liked to have entered but had avoided because of excessive anxiety. Two target locations, each having a minimal subjective discomfort rating of 70, were selected for every subject. For all targets selected,
126
ASCHER, SCHOTTE, AND GRAYSON
a prescribed travel plan was developed and divided into ten serial components. The final component of the series required that the subject remain in the designated situation until he or she was comfortable. The subject was asked to complete as much of both of the behavioral approach tests as possible on one occasion during each week of the baseline and treatment phases. The client received one point for every component of each target that he or she traversed. Scores on the behavioral approach test ranged between 0-20. Baseline interval. After providing subjects with details of the study and obtaining their consent to participate, the subjects were informed that treatment would begin three weeks subsequent to the initial interview. Although pertinent client information was obtained at this time, active therapeutic strategies were withheld. Each subject completed two behavioral approach tests during this period. Subjects were then randomly assigned to a treatment group and received the appropriate procedure to criterion. Clients were considered to have reached criterion when they reported the ability to remain comfortably at each of their two target locations (thereby earning a score of "20"). Paradoxical intention (PI). Subjects in this group were provided with instructions for paradoxical intention following the baseline phase (see Ascher, 1980, 1981, for a more detailed description). Subjects were requested to complete each component of their individual travel assignments until they reached a point at which they experienced a level of anxiety which they considered to be sufficient to preclude further progress. Upon reaching this stage of their exposure assignment, subjects were instructed to increase the most prominent component of their physiological experience of anxiety and court their hypothesized disastrous consequences. This procedure was meant to guide and supplement the standard paradoxical intention instructions (e.g., Ascher, 1980, 1981) previously administered. The subjects were then to remain in the situation until they became comfortable, after which they could return home or proceed to the next serial component. On the next outing, they were to begin at the stage reached previously but were to progress further each day. The subjects were instructed to engage in these activities at least once five days each week. Therapy sessions focused on a review of the rationale for paradoxical intention, a discussion of the subject's experiences during travel assignments, of progress in therapy, and of plans for the next assignment. Subjects were further required to attempt a behavioral approach test once each week during this phase and to present the therapist with a data sheet for each weekly assignment. Enhanced paradoxical intention (EP1). Subjects in the EPI condition received a variety of adjunctive treatment procedures (e.g., cognitive techniques, in vivo and imaginal exposure) in an effort to aid them in following standard paradoxical intention instructions (e.g., Ascher, 1980, 1981) earlier in therapy. The cognitive therapy techniques, derived from the work of Ellis (e.g., 1962) and Beck (e.g., 1976), focused mainly on teaching clients to identify
PARADOXICAL INTENTION, AGORAPHOBIA
127
and record negative self-descriptions. The nature of the cognitive and reality distortions inherent in their self-statements, once identified, was discussed and replaced with cognitions containing appropriate positive self-descriptions. Clients were encouraged to employ this technique as frequently as possible in their daily activities. In vivo and imaginal graded exposure were utilized with subjects in this group to reduce discomfort associated both with fear-provoking environmental stimuli and with the most prominent aspects of their pattern of physiological arousal associated with anxiety. For example, an individual who feared cardiac arrest during peak levels of anxiety was exposed to a graded series of suggestions and activities involving increased cardiac output, first in imagination and then in vivo. The imaginal intervention involved the use of two components. In the first segment, treatment focused on the imagined employment of paradoxical intention in the discomforting situations which the client anticipated encountering during the subsequent week. Each scene required the subject to imagine entering one of the target situations, progressing through serial components until anxious, employing paradoxical intention and remaining at that point until comfortable. Both stimulus and response components (Lang, 1977) of the anxiety complex were incorporated into the scene presentations. The second imaginal component involved each subject imagining his or her hypothesized disastrous consequence with particular emphasis on the interpersonal aspects of the final stages of the disaster. The subject was asked to produce a personal "soap opera," and was encouraged to conclude with absurd and, it was hoped, humorous consequences. In this way, each subject received imaginal exposure to his or her anticipated disastrous consequences with the characteristic humor of paradoxical intention (Frankl, 1955). The length of time per session devoted to each component varied with the needs of each client. Enhancement procedure alone (EP). Subjects in this group received nearly the same three-component enhancement procedure during weekly sessions as that administered to those in the EPI group. The only difference was that these subjects were asked to imagine self-exposure assignments without the use of paradoxical manipulations. At the conclusion of ten sessions they were provided with paradoxical intention instructions and encouraged to use the procedure as often as possible. These subjects were allowed to continue in treatment until they were able to enter their target situations without experiencing significant discomfort. In order that the amount of therapist contact would be generally the same for each client, the length of the therapeutic sessions did not vary across the three treatment groups. Sessions were for one hour although the initial three "orientation" meetings could be extended for an additional thirty minutes. The relatively greater number of techniques used in the enhanced paradoxical intention program necessitated efficient use of each session. Pressure on the therapist was great at first but ebbed as the client became familiar with procedures and assignments. Occasionally,
128
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II Baseline
I Session I
I I I Session 2 Session3 Session 4
SESSION NUMBER FIG. 1.
Group m e a n travel scores reported during the four initial sessions of treatment.
the agenda for a particular meeting was not completed and had to be finished in the succeeding session. This was not usually a problem, however, because some sessions permitted more flexibility than others and because events sometimes removed the need to complete the overlap from the previous week. The reduced amount of time required to administer the enhancement package alone enabled that program to be more easily accommodated to the exigencies o f session length. The administration o f the paradoxical procedure alone required some client practice in the therapist's presence and the use of examples illustrating employment o f the technique. Here again, the flexibility of the technique and collateral procedural details provided the therapist with enough flexibility to maintain the sixty minute session length throughout the course o f therapy. RESULTS
In order to verify that there were no initial differences among the experimental groups prior to the onset of the treatment phase, the baseline behavioral approach test scores for the subjects in each group were averaged. These mean scores were then subjected to a one-way ANOVA. No significant differences were found. The average approach test score across all groups was 2.51 (p < .05). Since treatment was terminated when the client reached criterion, a one-way ANOVA comparing the three groups was performed upon the number o f sessions needed to reach criterion. A significant main effect
PARADOXICAL INTENTION, AGORAPHOBIA
129
for treatment group was found: F(2, 12) = 8.61, p < .05. The means for paradoxical intention alone (PI), the enhancement procedure alone (EP), and enhanced paradoxical intention (EPI) were 11.2, 18.8 and 7.4 respectively. Pairwise comparisons using Tukey's method demonstrated that the EPI group reached criterion in significantly fewer sessions than the EP group: t(12) = 5.36, p < .01. No other comparisons were significant. Thus, it appears that the EPI group achieved treatment gains more rapidly than the EP group. All patients required at least four sessions to reach criterion. A twoway repeated measures ANOVA (treatment group + averaged baseline and sessions 1-4) was performed upon the behavioral approach test scores to examine patient progress in each group. There was a main effect for group o f time, F(4, 48) = 25.89, p < .001, which was modified by a group x time interaction: F(8, 48) = 3.44, p < .005. These results are depicted in Figure 1. Using Dunn's technique, six post hoc comparisons were made. The averaged baseline and Session 4 scores within each group were compared and the Session 4 scores were compared among groups. Both PI and EPI showed significant improvement from baseline to Session 4, t(48) = 5.24, p < .01; t(48) = 8.61, p < .01, respectively. The between groups comparisons o f Session 4 indicated that the EPI group showed greater improvement than both the PI, t(48) = 3.57, p < .01, and the EP, t(48) = 6.00, p < .01, groups. To summarize, the EPI procedure was clearly superior to its components. The EP procedure alone did not result in significant improvements during the initial phase of treatment and the gains eventually accrued by clients in this group were achieved at a rate significantly slower than in the EPI group. PI alone fell between the other two groups. By Session 4 there was significant improvement within the PI group, but this improvement was not as great as was improvement in the EPI group.
DISCUSSION The results o f the present study corroborate previous data by demonstrating the effectiveness of paradoxical intention in ameliorating the travel restrictions o f agoraphobic individuals (Ascher, 1981; Mavissakalian et al., 1983; Michelson et al., in press). In addition, the findings demonstrate that the efficacy of paradoxical intention can be enhanced through the inclusion o f ancillary cognitive and behavioral treatment components. Subjects who received in vivo and imaginal exposure and cognitive procedures in addition to paradoxical intention showed more rapid improvement on behavioral approach tests than did subjects who received either paradoxical intention or the enhancement procedures alone. Thus, although paradoxical intention resulted in significant improvement, the present study demonstrates that amelioration of travel restriction in agoraphobics can be achieved more rapidly through the addition of adjunctive techniques.
130
ASCHER, SCHOTTE,AND GRAYSON
Perhaps due to recent e c o n o m i c concerns, procedures involving reduced therapist contact have b e c o m e a popular focus o f investigation. In the case o f agoraphobia, techniques based largely on self-exposure have shown promise as effective, low-cost alternatives, especially when amelioration o f travel restrictions is the goal. T h e y include self-observation (Emmelk a m p & Vanderhout, 1983), spouse-assisted p r o g r a m m e d practice (Mathews, Gelder, & Johnston, 1981), and paradoxical intention (Ascher, 1981; Mavissakalian et a1.,1983; Michelson et al., in press), and all o f them have been associated with increased c o m f o r t a n d mobility in agoraphobic individuals. The present study has d e m o n s t r a t e d that treatment gains using one such approach (e.g., paradoxical intention) can be further enhanced without significant increases in therapist time.
REFERENCES Ascher, L.M. (1980). Paradoxical intention. In A. Goldstein and E. B. Foa (Eds.), Handbook of behavioral interventions: ,4 clinical guide (pp. 266-322). New York: Wiley. Ascher, L. M. (1981). Employing paradoxical intention in the treatment of agoraphobia. Behavior Research and Therapy, 19, 533-542. Ascher, L. M., & Giles, T. R. (in press). Paradoxical intention: Some obstacles and treatment strategies. In Education for responsibility: Proceedings of the second world congress of logotherapy.
Beck, A.T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Emmelkamp, P., & VanderHout, A. (1983). Failure in treating agoraphobia. In E. B. Foa & P. M. Emmelkamp (Eds.), Failures in behavior therapy (pp. 58-82). New York: Wiley. Frankl, V. (1955). The doctor and the soul: From psychotherapy to logotherapy (2nd ed.). Alfred A. Knopf, New York. Lang, P.J. (1977). Imagery in therapy: An information processinganalysis of fear. Behavior Therapy 8, 862-886. Mathews, A. M., Gelder, M. G., & Johnston, D. W. (1981). Agoraphobia: Nature and treatment. New York: Guilford. Mavissakalian, M., Michelson L., Greenwald, D., Kornblith, S., & Greenwald, M. (1983). Cognitive-behavioraltreatment of agoraphobia:Paradoxical intention vs. self-statement training. Behavior Research and Therapy 21, 75-86. Michelson, L., Mavissakalian, M., & Marchione, K. (in press). Cognitive and behavioral treatments of agoraphobia: Clinical, behavioral and physiologicaloutcome. Journal of Consulting and Clinical Psychology.
RECEIVED:August 5, 1985 FINALACCEPTANCE:September 12, 1985
BRIEF REPORT Enhancing Effectiveness of Paradoxical Intention in Treating Travel Restriction in Agoraphobia L. MICHAEL ASCHER Temple University
DAVID E. SCHOTTE Lifehealth Assoch~tes JOHN B. GRAYSON
Rosemont Counseling Associates Techniques ancillary to paradoxical intention were employed to reduce anxiety and depression in agoraphobic clients. It was suggested that such enhancement would produce greater improvement in terms of increased travel capabilities during the initial portion of therapy than would be the case for individuals receiving component treatment. Three groups, each containing five agoraphobic clients, were provided with the enhanced paradoxical intention procedure, the paradoxical intention alone, or the enhancement package alone. Following the fourth session, subjects in the enhanced paradoxical intention group were performing significantly better than subjects in the two remaining groups.
Although it has been demonstrated that paradoxical intention is effective in the treatment of agoraphobia (Ascher 1981; Mavissakalian, Michelson, Greenwald, Kornblith, & Greenwald, 1983; Michelson, Mavissakalian, & Marchione, in press), certain difficulties inherent in the technique are at times associated with problems in its administration and generate hurdles to therapeutic progress (Ascher & Giles, in press). These difficulties appear to be associated with other self-administered exposure techniques employed with agoraphobics as well (Emmelkamp and VanderHout, 1983). Thus, although a study by Ascher (1981) found that agoraphobics achieved greater reductions in travel restrictions with paradoxical intention than with graded self-exposure, clients in the paraComponents of the data discussed herein were first reported at the Association for Advancement of Behavior Therapy, New York City, November 1980. Requests for reprints should be sent to L. Michael Ascher, Temple University Health Sciences Center, Department of Psychiatry, 3401 North Broad Street, Philadelphia, Pennsylvania 19140. 124 0005-7894/86/0124-013051.00/0 Copyright 1986 by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any form reserved.
PARADOXICAL INTENTION, AGORAPHOBIA
125
doxical intention treatment group reported difficulty in assuming a paradoxical approach to their anxiety. Inspection of the data of individual subjects in that study indicated that three of the five in the paradoxical intention treatment group did not appear to derive initial benefit from this procedure and that one of these individuals did not begin to show improvement until after twenty treatment sessions had elapsed. It follows then that an obvious way to attempt to increase the efficacy of paradoxical intention with agoraphobic individuals would be to assist clients in utilizing the procedure earlier in the course of therapy. The present paper presents the results of a preliminary investigation designed to accelerate the effects of paradoxical intention through the addition of ancillary cognitive therapy techniques and in vivo and imaginal exposure.
PROCEDURE Subjects. Clients chosen for the present study were selected from individuals referred sequentially to the senior author by area mental health professionals or from the outpatient clinic of the Behavior Therapy Unit. Selection for participation was based on three criteria. First, each subject had to meet the DSM-III diagnostic description for agoraphobia. Second, individuals had to exhibit severe travel restriction, particularly when alone, in association with fear of disastrous consequences following peak levels of anxiety. Third, subjects were required to comply with the following procedural components: (a) submission of weekly behavioral approach tests throughout the baseline and treatment phases; (b) attendance at weekly sessions; and (c) completion of five travel assignments during each intersession interval. Subjects selected for participation in the study were then randomly assigned in equal numbers to one of three treatment procedures: paradoxical intention, enhanced paradoxical intention, or the enhancement procedure alone. Those who did not fulfill these requirements were provided with suitable alternative treatment. Of the 15 subjects who participated, 13 were female and 2 were male. The mean age of the subjects was 38, with a range of 22 to 61 years of age. Three subjects who otherwise fulfilled the requirements for inclusion were dropped prior to the initiation of treatment procedures because they felt that personal time constraints precluded their participation in aspects of the program. Treatment sessions were approximately one hour in length although one and one-half hours were available for the first three. All sessions were conducted by experienced threrapists who were aware of the hypotheses being investigated. Behavioral approach tests. The behavioral approach test employed was conducted in the following manner (see Ascher, 1981, for additional details). During the initial interview, prior to the institution of the baseline phase, subjects were requested to indicate those situations which they would have liked to have entered but had avoided because of excessive anxiety. Two target locations, each having a minimal subjective discomfort rating of 70, were selected for every subject. For all targets selected,
126
ASCHER, SCHOTTE, AND GRAYSON
a prescribed travel plan was developed and divided into ten serial components. The final component of the series required that the subject remain in the designated situation until he or she was comfortable. The subject was asked to complete as much of both of the behavioral approach tests as possible on one occasion during each week of the baseline and treatment phases. The client received one point for every component of each target that he or she traversed. Scores on the behavioral approach test ranged between 0-20. Baseline interval. After providing subjects with details of the study and obtaining their consent to participate, the subjects were informed that treatment would begin three weeks subsequent to the initial interview. Although pertinent client information was obtained at this time, active therapeutic strategies were withheld. Each subject completed two behavioral approach tests during this period. Subjects were then randomly assigned to a treatment group and received the appropriate procedure to criterion. Clients were considered to have reached criterion when they reported the ability to remain comfortably at each of their two target locations (thereby earning a score of "20"). Paradoxical intention (PI). Subjects in this group were provided with instructions for paradoxical intention following the baseline phase (see Ascher, 1980, 1981, for a more detailed description). Subjects were requested to complete each component of their individual travel assignments until they reached a point at which they experienced a level of anxiety which they considered to be sufficient to preclude further progress. Upon reaching this stage of their exposure assignment, subjects were instructed to increase the most prominent component of their physiological experience of anxiety and court their hypothesized disastrous consequences. This procedure was meant to guide and supplement the standard paradoxical intention instructions (e.g., Ascher, 1980, 1981) previously administered. The subjects were then to remain in the situation until they became comfortable, after which they could return home or proceed to the next serial component. On the next outing, they were to begin at the stage reached previously but were to progress further each day. The subjects were instructed to engage in these activities at least once five days each week. Therapy sessions focused on a review of the rationale for paradoxical intention, a discussion of the subject's experiences during travel assignments, of progress in therapy, and of plans for the next assignment. Subjects were further required to attempt a behavioral approach test once each week during this phase and to present the therapist with a data sheet for each weekly assignment. Enhanced paradoxical intention (EP1). Subjects in the EPI condition received a variety of adjunctive treatment procedures (e.g., cognitive techniques, in vivo and imaginal exposure) in an effort to aid them in following standard paradoxical intention instructions (e.g., Ascher, 1980, 1981) earlier in therapy. The cognitive therapy techniques, derived from the work of Ellis (e.g., 1962) and Beck (e.g., 1976), focused mainly on teaching clients to identify
PARADOXICAL INTENTION, AGORAPHOBIA
127
and record negative self-descriptions. The nature of the cognitive and reality distortions inherent in their self-statements, once identified, was discussed and replaced with cognitions containing appropriate positive self-descriptions. Clients were encouraged to employ this technique as frequently as possible in their daily activities. In vivo and imaginal graded exposure were utilized with subjects in this group to reduce discomfort associated both with fear-provoking environmental stimuli and with the most prominent aspects of their pattern of physiological arousal associated with anxiety. For example, an individual who feared cardiac arrest during peak levels of anxiety was exposed to a graded series of suggestions and activities involving increased cardiac output, first in imagination and then in vivo. The imaginal intervention involved the use of two components. In the first segment, treatment focused on the imagined employment of paradoxical intention in the discomforting situations which the client anticipated encountering during the subsequent week. Each scene required the subject to imagine entering one of the target situations, progressing through serial components until anxious, employing paradoxical intention and remaining at that point until comfortable. Both stimulus and response components (Lang, 1977) of the anxiety complex were incorporated into the scene presentations. The second imaginal component involved each subject imagining his or her hypothesized disastrous consequence with particular emphasis on the interpersonal aspects of the final stages of the disaster. The subject was asked to produce a personal "soap opera," and was encouraged to conclude with absurd and, it was hoped, humorous consequences. In this way, each subject received imaginal exposure to his or her anticipated disastrous consequences with the characteristic humor of paradoxical intention (Frankl, 1955). The length of time per session devoted to each component varied with the needs of each client. Enhancement procedure alone (EP). Subjects in this group received nearly the same three-component enhancement procedure during weekly sessions as that administered to those in the EPI group. The only difference was that these subjects were asked to imagine self-exposure assignments without the use of paradoxical manipulations. At the conclusion of ten sessions they were provided with paradoxical intention instructions and encouraged to use the procedure as often as possible. These subjects were allowed to continue in treatment until they were able to enter their target situations without experiencing significant discomfort. In order that the amount of therapist contact would be generally the same for each client, the length of the therapeutic sessions did not vary across the three treatment groups. Sessions were for one hour although the initial three "orientation" meetings could be extended for an additional thirty minutes. The relatively greater number of techniques used in the enhanced paradoxical intention program necessitated efficient use of each session. Pressure on the therapist was great at first but ebbed as the client became familiar with procedures and assignments. Occasionally,
128
ASCHER, SCHOTTE, AND GRAYSON (n
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Enhancement Procedure Alone Paradoxical Intention Enho
II Baseline
I Session I
I I I Session 2 Session3 Session 4
SESSION NUMBER FIG. 1.
Group m e a n travel scores reported during the four initial sessions of treatment.
the agenda for a particular meeting was not completed and had to be finished in the succeeding session. This was not usually a problem, however, because some sessions permitted more flexibility than others and because events sometimes removed the need to complete the overlap from the previous week. The reduced amount of time required to administer the enhancement package alone enabled that program to be more easily accommodated to the exigencies o f session length. The administration o f the paradoxical procedure alone required some client practice in the therapist's presence and the use of examples illustrating employment o f the technique. Here again, the flexibility of the technique and collateral procedural details provided the therapist with enough flexibility to maintain the sixty minute session length throughout the course o f therapy. RESULTS
In order to verify that there were no initial differences among the experimental groups prior to the onset of the treatment phase, the baseline behavioral approach test scores for the subjects in each group were averaged. These mean scores were then subjected to a one-way ANOVA. No significant differences were found. The average approach test score across all groups was 2.51 (p < .05). Since treatment was terminated when the client reached criterion, a one-way ANOVA comparing the three groups was performed upon the number o f sessions needed to reach criterion. A significant main effect
PARADOXICAL INTENTION, AGORAPHOBIA
129
for treatment group was found: F(2, 12) = 8.61, p < .05. The means for paradoxical intention alone (PI), the enhancement procedure alone (EP), and enhanced paradoxical intention (EPI) were 11.2, 18.8 and 7.4 respectively. Pairwise comparisons using Tukey's method demonstrated that the EPI group reached criterion in significantly fewer sessions than the EP group: t(12) = 5.36, p < .01. No other comparisons were significant. Thus, it appears that the EPI group achieved treatment gains more rapidly than the EP group. All patients required at least four sessions to reach criterion. A twoway repeated measures ANOVA (treatment group + averaged baseline and sessions 1-4) was performed upon the behavioral approach test scores to examine patient progress in each group. There was a main effect for group o f time, F(4, 48) = 25.89, p < .001, which was modified by a group x time interaction: F(8, 48) = 3.44, p < .005. These results are depicted in Figure 1. Using Dunn's technique, six post hoc comparisons were made. The averaged baseline and Session 4 scores within each group were compared and the Session 4 scores were compared among groups. Both PI and EPI showed significant improvement from baseline to Session 4, t(48) = 5.24, p < .01; t(48) = 8.61, p < .01, respectively. The between groups comparisons o f Session 4 indicated that the EPI group showed greater improvement than both the PI, t(48) = 3.57, p < .01, and the EP, t(48) = 6.00, p < .01, groups. To summarize, the EPI procedure was clearly superior to its components. The EP procedure alone did not result in significant improvements during the initial phase of treatment and the gains eventually accrued by clients in this group were achieved at a rate significantly slower than in the EPI group. PI alone fell between the other two groups. By Session 4 there was significant improvement within the PI group, but this improvement was not as great as was improvement in the EPI group.
DISCUSSION The results o f the present study corroborate previous data by demonstrating the effectiveness of paradoxical intention in ameliorating the travel restrictions o f agoraphobic individuals (Ascher, 1981; Mavissakalian et al., 1983; Michelson et al., in press). In addition, the findings demonstrate that the efficacy of paradoxical intention can be enhanced through the inclusion o f ancillary cognitive and behavioral treatment components. Subjects who received in vivo and imaginal exposure and cognitive procedures in addition to paradoxical intention showed more rapid improvement on behavioral approach tests than did subjects who received either paradoxical intention or the enhancement procedures alone. Thus, although paradoxical intention resulted in significant improvement, the present study demonstrates that amelioration of travel restriction in agoraphobics can be achieved more rapidly through the addition of adjunctive techniques.
130
ASCHER, SCHOTTE,AND GRAYSON
Perhaps due to recent e c o n o m i c concerns, procedures involving reduced therapist contact have b e c o m e a popular focus o f investigation. In the case o f agoraphobia, techniques based largely on self-exposure have shown promise as effective, low-cost alternatives, especially when amelioration o f travel restrictions is the goal. T h e y include self-observation (Emmelk a m p & Vanderhout, 1983), spouse-assisted p r o g r a m m e d practice (Mathews, Gelder, & Johnston, 1981), and paradoxical intention (Ascher, 1981; Mavissakalian et a1.,1983; Michelson et al., in press), and all o f them have been associated with increased c o m f o r t a n d mobility in agoraphobic individuals. The present study has d e m o n s t r a t e d that treatment gains using one such approach (e.g., paradoxical intention) can be further enhanced without significant increases in therapist time.
REFERENCES Ascher, L.M. (1980). Paradoxical intention. In A. Goldstein and E. B. Foa (Eds.), Handbook of behavioral interventions: ,4 clinical guide (pp. 266-322). New York: Wiley. Ascher, L. M. (1981). Employing paradoxical intention in the treatment of agoraphobia. Behavior Research and Therapy, 19, 533-542. Ascher, L. M., & Giles, T. R. (in press). Paradoxical intention: Some obstacles and treatment strategies. In Education for responsibility: Proceedings of the second world congress of logotherapy.
Beck, A.T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Emmelkamp, P., & VanderHout, A. (1983). Failure in treating agoraphobia. In E. B. Foa & P. M. Emmelkamp (Eds.), Failures in behavior therapy (pp. 58-82). New York: Wiley. Frankl, V. (1955). The doctor and the soul: From psychotherapy to logotherapy (2nd ed.). Alfred A. Knopf, New York. Lang, P.J. (1977). Imagery in therapy: An information processinganalysis of fear. Behavior Therapy 8, 862-886. Mathews, A. M., Gelder, M. G., & Johnston, D. W. (1981). Agoraphobia: Nature and treatment. New York: Guilford. Mavissakalian, M., Michelson L., Greenwald, D., Kornblith, S., & Greenwald, M. (1983). Cognitive-behavioraltreatment of agoraphobia:Paradoxical intention vs. self-statement training. Behavior Research and Therapy 21, 75-86. Michelson, L., Mavissakalian, M., & Marchione, K. (in press). Cognitive and behavioral treatments of agoraphobia: Clinical, behavioral and physiologicaloutcome. Journal of Consulting and Clinical Psychology.
RECEIVED:August 5, 1985 FINALACCEPTANCE:September 12, 1985