Be/w-. Re\. T/w. Vol. ?I. No. I. pp 63-68. lYX3 0005-7967’h’3:010063-06S03.00:0 Printed 11, Great Hr~ta~n All rtght? reser\ed Cnpqrlght c 19X.1 Pergamon Press Ltd

ASSERTIVE TRAINING FOR AGORAPHOBICS

PAUL M. G. ~M~~ELKAMP,* ADA VAN DEK HOUT

and KATRIEN DE VRIES

Academic Hospital, Department of Clinical Psychology, 9713 EZ Groningen. The Netherlands

Summary-Twenty-one unassertive agoraphobic patients were assigned to one of three treatments: (I) prolonged exposure in riro, (2) assertive training and (3) a combination of assertive training and pro- longed exposure in rim. Each treatment was conducted in groups which were led by two therapists. Assessments involved both phobic targets and assertiveness. and were made before and after treatment, and at l-month follow-up. Exposure ill rice was found to be superior to assertive training on phobic targets. Assertive training produced greater gains in assertiveness than exposure irt rka The combi- nation of treatments produced results comparable to exposure iit riro. Results indicated that the type of change produced by the treatments is a rather specific one and is related to the specific target of treatment.

INTRODUCTION

Research into the behavioral treatment of agoraphobia has focused on exposure irr-L’~Z;O pro- cedures and the effectiveness of these procedures is now well established (for reviews see Emmelkamp, 1982b; Marks, 1981). A considerable number of agoraphobias who have been treated with exposure in-ciao procedures show lasting benefits up to 4 years follow-up (Emmel- kamp and Kuipers, 1979).

In many instances it is insufficient to focus exclusively on the modification of phobic anxiety and avoidance. Since in a number of patients, agoraphobia is associated with other problems the latter may become therapeutic goals on their own. For example, Andrews (1966) considers phobic patients as generally shy, anxious and dependent in many other situations than the typically phobic situations. Fodor (1974) holds that most agoraphobics are unassertive. In her view, feelings of being dominated with no outlet for assertion. leads to the development of agoraphobia. Chambless and Goldstein (1980) note that agoraphobics are generally unasser- tive people with marked social anxieties:

‘Usually because of his/her ui~assertiveness the agoraphobic has found himself/ herself in an unhappy seemingly irresolvable relationship under the domination of a spouse or a parent. The urges to leave and the fears of being on her/his own balance out, and the agoraphobic is trapped in this conflict, unable to move and lacking the ski& to change the situation.” (Chambless and Goldstein, 1980, p. 324)

These views on agoraphobia suggest that a behavioral approach which focuses only on the phobic anxiety and avoidance-as in the case of exposure in viuo-may be less appropriate for agoraphobics whose phobic complaints are related to unassertiveness. Such patients may profit more from behaviorai approaches which focus on broader therapeutic targets, e.g. assertive training. Recent studies with obsessional patients demonstrated the value of assertive training when obsessional behavior and ruminations were related to unassertiveness (Emmel- kamp, 1982a; Emmelkamp and van der Heyden, 1980).

The present study was designed to examine the relative value of assertive training and exposure irz uiuo for unassertive agoraphobics. Three treatments were compared in a between- group design: (1) prolonged exposure in vim, (2) assertive training and (3) a combination of assertive training and prolonged exposure in nir:o.

* To whom all reprint requests should be addressed.

h4 PAUL M. G. EMMELKAMP et (11

METHOD

Design

Patients were assigned in order of their application to one of three treatment conditions: (1) exposure in U~LY~, (2) assertiveness training and (3) assertiveness training and exposure ii? uico. Treatment consisted of 10 3-hr sessions and was conducted in small groups. Treatment sessions were held 2 times a week. Each condition contained two groups.

Assessments were carried out 3 days before the start of treatment (pre-test) and 2 days after the last session (post-test). A follow-up took place I month after the post-test. No treatment was provided during this period. In a number of cases treatment was continued after the follow-up.

Subjects

Subjects were selected from agoraphobics who were referred for treatment to our depart- ment. All patients with agoraphobia as their main problem were screened for participation in the investigation. Only low-assertive agoraphobics were used as Ss. The median score on the Adult Self-Expression Scale (ASES) (Gay et al.. 197.5) was used as criterion for participation. The median score for the ASES was 106 and was based on scores of 72 agoraphobics treated previously at our department. Thirty-one patients who met this selection criterion were invited to participate in the study. Two patients did not accept the treatment offer. In order to have a homogeneous population with respect to severity, the data of patients who had a score on the

in-aim measure > 45 min at the pre-test were not processed in the data analysis (n = 4). Of the remaining 25 patients who started treatment 4 patients dropped out (exposure, II = 2; assert- iveness training, II = 1 and combined procedure, M = 1). Two patients found treatment too frightening (both dropped out during assertive training), 1 patient requested marital treatment and the fourth patient dropped out because of an illness.

The data of the remaining 21 patients, 18 women and 3 men were processed in the data analysis. The average age of the patients was 31.8 yr, the range 20-57. The average duration of the agoraphobia was 7.5 yr ranging from 6 months to 25 yr.

Assessment procedures

Assessments were carried out at pre-test, post-test and follow-up by the patient. In addition. an independent assessor-a clinical psychologist-rated the patients at pre-test and post-test.

Meusuremeiit in vivo. The patient had to walk along a certain route from the hospital towards the center of town. He was instructed to stay outside until he began to feel uncomfor- table or tense, then he had to come back straightaway. The duration of time spent outside by the patient was measured by the therapist. (The maximum time was set at 100 min in connec- tion with the calculations to be made.)

Phobic unsiet!’ arid azjoidance scules. The patient and the independent assessor rated the patient with regard to the following five situations on 9-point scales for phobic anxiety and phobic avoidance (Watson and Marks, 1971): (1) busy high street, (2) supermarket, (3) bus, (4) restaurant and (5) walking from hospital. Since correlational analyses revealed a high intercorrelation among the five subscales, the subscales were combined.

Anxious mood. The independent assessor rated the patient on a 9-point scale for anxious mood (Watson and Marks, 1971).

Moreover, the patient filled in the following questionnaires: Adult SelflEspression Scale (ASES; Gay et al., 1975, range O-192). Sculefor Interpersonal Behauior (SIG, Arrindell et ul. , 1980). This questionnaire results in

two scores: anxiety and performance (range 50-250). Other self-report measures. Additional self-report measures assessed possible generalized

effects of treatments in areas other than agoraphobia and assertion. These measures were Fear

Surce), Schedule (FSS, Wolpe and Lang, 1964, range 76380) and Self-Rating Depression Scale, (SDS; Zung, 1965, range 23-92). Variations adapted for use in The Netherlands were used,

Assertive training for agoraphobia 65

Therupists

Advanced students in clinical psychology, who had received training in behavior therapy served as therapists. Each group was led by two therapists. In order to insure that the therapists conformed to the intended experimental manipulations, therapists received a special training for the research project and extensive manuals were used. The therapists were super- vised by the senior author.

Treatrnerlt conditions

Patients were instructed not to take any anxiety reducing or antidepressant drugs during the experimental trial.

(1) Exposure in vivo. With exposure in Gino the treatment of Emmelkamp et al. (1978) was followed. During the first half-hour of the first session, the patients exchanged information about the onset and development of their phobias and the therapists gave the treatment rationale (see Emmelkamp, 1982b). The role played by avoidance behavior in maintaining phobias was emphasized and the patients were instructed to remain in the phobic situations until they had experienced anxiety reduction. Then the patients and therapists together took a short walk to the center of town, the place where the patients would have to walk more and more on their own in future. After 80 min of prolonged exposure in Go. the patients’ exper- iences were assessed in a brief group discussion at the hospital and patients received home- work assignments. The order of events in all the following sessions was: (1) a group discussion (+25 min) in which the homework assignments were reviewed and the day’s program was discussed; (2) prolonged exposure in ciao (+ 120 min); and (3) a group discussion (+ 30 min) in which the patients’ experiences were assessed and specific homework tasks were assigned. During the period of prolonged exposure in ciao the patients were exposed to situations which presented problems for them. Difficult situations for the patients were for example walking in busy streets, shopping in department stores and supermarkets and riding in buses. Not all the patients were exposed to the same type of situation, for example some patients had no diffi- culty in traveling on their own, whereas others required the presence of fellow patients.

The therapists were less and less frequently present during the exposure in-uiuo periods; they consciously faded from the groups, and after the third session were only present at the dis- cussions preceding and following the exposure periods. However, the therapists continued to assign tasks to be performed by patients in their exposure session that day. Thus, patients in the exposure condition did receive direction and guidance by the therapists beyond the third session.

The reason for less involvement of the therapists during actual practice beyond the third session was to make the in-vice practice more difficult for the patients. In our experience, knowing that a therapist is nearby prevents actual exposure to distressing situations (i.e. being alone) for a substantial number of agoraphobics. Generally, therapists were very ‘pushy’ in leading patients to confront their feared situations.

At the end of each session, the therapist emphasized the importance of practicing between sessions and for each patient specific homework instructions were given to be performed before the next session. Patients had to monitor these activities on homework assignment sheets.

(2) Assertiveness truining. The first part of the first session was designed to give the patients an explanation of their agoraphobic complaints in terms of lack of assertiveness. With the aid of neutral examples and examples provided by the Ss themselves their anxiety reactions in phobic situations were relabeled as the result of unassertiveness. It was explained to the Ss that the goal of treatment was to train them in becoming more assertive which eventually could result in an improvement of the phobias.

Patients had to report on social situations in which they were unassertive or felt uneasy. During treatment sessions these situations were discussed and a more adequate handling of these situations was trained through modeling either by the therapist or by one of the other patients and through behavior rehearsal. About half of the time in sessions 2-9 was devoted to structured exercises as keeping eye-contact, giving a speech, refusing requests, criticizing etc.

66 PAUL M. G. EMMELKAMP er (I/.

Treatment was skills oriented. Thus, therapists’ communication was focused on performance issues: irrational cognitions were not systematically dealt with.

At the end of each session, the therapist emphasized the importance of practicing the newly-learned assertive skills between sessions. Each patient received homework assignments which were tailor-made to his or her specific assertive-deficits. Patients received homework assignment sheets on which they were asked to describe their behavior in social situations.

(3) Assertive training und exposure in vivo. The first three sessions consisted of assertive training. Starting with the fourth session, the first hour of each session was devoted to assertive training, the following 2 hr consisted of prolonged exposure in viva. The exposure treatment was conducted along the same lines as the exposure alone condition. Homework assignments consisted of assertive tasks (sessions l-3) and assertive tasks plus exposure tasks (sessions

410).

RESULTS

Results of the individual treatments are summarized in Tables 1 and 2.

Within-group changes

These were tested with t-tests for dependent samples. At the post-test, exposure in tliao led to significant improvements on the iM-Uiuo measurement, phobic anxiety and avoidance scales (both self-rating and assessor’s rating), FSS and SDS. However, treatment resulted in improve- ment on only one of the three indices of assertive behavior (SIG-performance).

Assertive training led to significant improvements on the in-vioo measurement, phobic anxiety as rated by the assessor and phobic avoidance (both self-rating and assessor’s rating). In addition, assertive training produced significant improvements on all three assertive indices (ASES, SIG-anxiety and SIG-performance) and SDS. Treatment did not result in significant reductions on the FSS.

The combined procedure resulted in significant improvements on the in-Gvo measurement,

phobic anxiety and avoidance scales (both self-rating and assessor’s rating), anxious mood, FSS and SDS. In addition, treatment resulted in significant improvements on the ASES.

Between-group d@erences

Between group differences were tested with analyses of covariance. using the pre-test score as covariate. A-priori comparisons revealed that at the post-test exposure in ~‘iz’o was signifi- cantly superior to assertive training on the in-aivo measurement (F( 17) = 9.13, P < 0.01).

Table 1. Pre-test and post-test mean scores for fear measures. assertiveness scales and generahza- tion measures

Dependent measures

Exposure Assertive Combination

Pre Post Pre Post Pre Post

Frtrr nwusures In-~?w measurement Phobic anxiety

Patient Assessor

Phobic avoidance Patient Assessor

Assertirerwss ~+WUSUY~S ASES SIG-anxiety SIG-performance

Situutiond yetwrulizitiorl FSS SDS Anxious mood

24.1 62.8 19.0 31.3

6.7 3.3 6.0 4.2 7.8 3.5 1.5 4.5

7.5 3.1 7.0 5.1 7.9 2.4 7.9 5.3

83.5 84.3 14.6 106.7 13x.3 116.X 163.6 I 15.4 188.5 170.8 187.9 140.0

235.7 202.3 208.4 116.9 60.5 52.3 5x.9 42.1

5.0 3.2 4.1 2.6

17.1 62.5

6.3 3.1 7.3 3.8

6.6 3.6 7.9 4.0

X5.5 103.5 146.5 129.0 166. I 155.8

239.0 207.9 66.0 54.4

6.8 4.5

Assertive training for agoraphobics 67

Table 2. Within-group mean differences from pre-testing to post-testing

Dependent measures

Exposure Assertive Combination

4 t df t df t

Fear ,neasures In-oivo measurement Phobic anxiety

Patient Assessor

Phobic avoidance Patient Assessor

ilssel:tiwness measures ASES SIG-anxiety SIG-performance

Situational qrt7rrtrlizatiotl FSS SDS Anxious mood

5 -5.18****

5 4.18**** 5 4.29****

5 4.74**** 5 4.43****

5 -0.14 5 0.83 5 2.95**

5 2.07* 5 2.67* 5 1.70

6 -4.37****

6 1.71 6 3.42***

6 2.20* 6 3.09**

6 - 2.96** 6 2.45** 6 5.06****

6 1.77 6 3.20*** 6 1.75

7 _6,75*****

7 5.70***** 7 4.91****

7 4.34**** I 3.38***

7 - 2.50** 7 1.54 7 1.31

1 2.52** 1 3.30*** 7 2.30*

*P<o.o5;**P<o.o25:***P<o.o1; **** P c 0.005: ***** P < 0.0005.

Assertive training produced greater improvements than exposure in assertiveness on the ASES (F(17) = 5.52, P < 0.05) and on the SIG-performance (F(17) = 10.38, P < 0.01).

The combined procedure was found to be superior to assertive training on the in-viuo

measurement (F(17) = 15.55, P < 0.01). Assertive training produced significantly greater im- provements than the combined procedure on the SIG-performance (F(17) = 5.87, P < 0.05).

Between the post-test and follow-up no treatment was given. A comparison of scores at post-test and follow-up revealed that treatment effects were maintained at follow-up. The exposure group and the assertive group did not change significantly in between post-test and follow-up. The combined procedure produced significant reductions on the FSS (t(7) = 2.66, P < 0.05).

Analysis of covariance over the follow-up data revealed both exposure in vivo (F(16) = 4.74, P < 0.05) and the combined procedure (F(16) = 15.04, P < 0.01) to be significantly superior to assertive training on the in-uiuo measurement. Assertive training produced superior results to exposure in uitlo on the ASES (F(17) = 5.15, P < 0.05) and superior results to the combined procedure on the SIG-performance (F(17) = 6.33, P < 0.05).

DISCUSSION

The major findings were that: (1) exposure achieved the largest effect on phobic targets, (2) assertive training produced the largest effect on assertive behavior and (3) the effects of the combined procedure were comparable to the effects of the exposure condition. These results

indicate that both assertive training and exposure irz ciao have something to offer for unasser- tive agoraphobics. Exposure in uivo leads to rapid improvements with respect to anxiety and avoidance. On the other hand, assertive training is superior to exposure with respect to increases in assertiveness. This differential pattern of response to treatment indicates that the

type of change produced by the treatments is a rather specific one and is related to the specific target of treatment.

The lack of statistically-significant differences between the assertive group and the exposure group on anxiety and avoidance ratings requires comment. Inspection of Table 1 reveals that exposure produced nearly twice as much improvement in anxiety and avoidance than did assertive training but this difference failed to reach acceptable levels of statistical significance. Additional evidence in favor of the exposure treatment with respect to the phobic targets is provided by the differential number of patients from each group who required supplementary

68 PAUL M. G. EMMELKAMP et trl.

treatment at follow-up. Only 2 out of the 12 patients who needed additional treatment came from the exposure condition.

The positive effects of exposure ir? viva with unassertive agoraphobics are in line with previous investigations. Emmelkamp (1980) found that assertive and unassertive agoraphobics benefitted equally from exposure in vivo. Similarly, data of a study by Emmelkamp and van de Hout (1983) showed that failure of exposure treatment was unrelated to the assertiveness of the patients. Taken together these previous data and the present findings, the most efficient thera- peutic strategy seems to be to start with exposure in civo and to proceed later to assertive training if necessary.

Although the modest positive effects of assertive training on anxiety and avoidance seem to lend some support to the notion that agoraphobia is (partly) the result of unassertiveness, at least three other possible explanations must be considered. The first is that the therapists of the assertive group encouraged the patients to go out more. However, checks on tape recordings of treatment sessions revealed that this was not the case. The second explanation is that enhanced assertiveness led to enhanced efficacy expectations which generalized to other fearful situations. Based on self-efficacy theory one could predict that increased self-efficacy gained through assertive training increases coping efforts in other situations. Finally, the (limited) improvements found on anxiety and avoidance ratings may be due to non-specific influences rather than to the assertive training per se.

It is important to note that the present study was not designed to test the hypothesis that agoraphobia is the result of unassertiveness. Although clinical lore suggests that most agora- phobics are unassertive, there is little in the way of empirical evidence to substantiate this notion. For example, Buglass ef ul. (1977) found 110 differences in assertion between agorapho- bic females and controls. Clearly, further research is required to clarify this issue.

Finally, the relatively small sample in the present study may limit conclusions to be drawn. Current results need to be replicated on enlarged samples. In order to have a larger sample of unassertive agoraphobics cross-center studies may be necessary.

AckrloMle~~~~r,zrrrf.~-The authors wjish to thank F. Albersnagel, who was the independent assessor, and M. Abrahams, G. Brugman, M. Hiemstra, J. Maris and R. Westerhof who assisted in the treatment of patients,

REFERENCES

ANDR~WS J. D. W. (1966) Psychotherapy of phobias. Ps~chol. Bull. 66, 455.-480. ARRIXDELL W. A., GROOT P. M. it and WALRURG J. A. (1980) Schaul t‘oor /r~terprrsoon/ijli qedrtry (SIG) Swets &

Zeitlinger, Lisse. BUGLASS D., CLARK J., HEEDERSON A. S., KREITMAN N. and PRESLEY A. S. (1977) A study of agoraphobic housewives.

Psychol. Med. 7, 73-86. CHAMBLESS D. L. and G~LDSTEI~Z A. (1980) The treatment of agoraphobia. In Horzdhook qf Brhtrciorcrl Intmwrions

(Edited by GOLDSTEIN A. and FOA E.), pp. 322-415. Wiley, New York. E~~MFLKAMP P. M. G. (19X0) Agoraphobics’ interpersonal problems: their role in the effects of exposure in rir-o therapy.

Arclls ~~(‘,I. Psvchia!. 37, 1303-l 306. E~IM~LKAMP P. M. G. (1982a) Recent developments m the behavioral treatment of obsessive-compulsive disorders. In

Leurnimq Tlrwrt~ Approuch 10 Pswhiatr~~ (Edited by B~ULO~G~URIS J.). pp. 119 128. Wiley. New York. EMMFLKAMP P. M. G. (I 982b) Phobic cm/ Ohsrssice-_~or~~p~,/.sr~~~ Disortlers. Plenum Press, New York. E~IMI.LKAMI’ P. M. G. and HCLIXN H. VAN IXK (1980) The treatment of harming obsessions. &/XII.. A~tr/,rsrs

!Ilo~/i/. 4. 28 35. EMMIUAMI’ P. M. G. and HOLII. A. VAT DEK (1983) Failure 111 treating agoraphobia. In Ftri/urc~.s ;/I Behar-Ior T/rerapia

(Edited by FOA E. and EMMELKAMI~ P. M. G.). Wiley, New York. In press. EMMELKAMP P. M. G. and KUIPERS A. (1979) Agoraphobia: follow-up study four years after treatment. Br. J. ~s~ch~ar.

134, 352-355. EMMELKAMP P. M. G., KUIPERS A. and EC;GERAAT J. (1978) Cognitive modification vs prolonged exposure ;JT ~II‘O: a

comparison with agoraphobics. B&II.. Rev. T/w. 16, 33-41. FODOR I. G. (1974) The phobic syndrome in women. In Wonlen i/l Thc,rc~pl, (Edited by Franks V. and Burtle V.)

Brunner.‘Marcl. New York. GAY M. L.. HOLLAUUSW~RTH J. G. and GALASF~ J. P. (19751 An assertiveness inventory. J. ~,our~.sc/. P,s~,c/~o[. 22,

34@344. MARKS 1. ( 19X 1) Curr cd Cure o/ .‘L’cw~~w.~: T/wry cd Ptxcfice of Buhrr~~iorcrl P.\J,c horhrrtrp~~. Wiley. New York, WATSON J. P. and MAKKS I. M. (1971) Relevant and irrelevant fear in Ilooding. A crossover study 01’ phobic patients.

Behar. T/w 2, 275-295. WOLPE J. and LA\<; P. J. (1964) A Fear Survey Schedule for use in behavior therapy. BC/ICII.. Re.,. Tl~rr. 2, -1~~ 3~) Zrrx W. W. K. (1965) A Self-rating Depression Scale. Arch god. P,ywh~ut. 12, 63-70.