Behav. Res. Ther. Vol. 21. No. 1. pp. 75-86. 1983 Printed 0005-7967/83/010075-12S03.

00/0
in Great Britain. All rights reserved Copyright © 1983 Pergamon Press Ltd

COGNITIVE-BEHAVIORAL TREATMENT OF
AGORAPHOBIA: PARADOXICAL INTENTION VS
SELF-STATEMENT TRAINING

MATIG MAVISSAKALIAN,1 LARRY MICHELSON, DEBORAH GREENWALD, SANDER

KORNBLITH and MICHAEL GREENWALD
Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Department of Psychiatry.
3811 O'Hara St, Pittsburgh. PA 15261, U.S.A.

(Received 1 June ml)

Summary—Twenty-six agoraphobics were randomly assigned to either Paradoxical Intention (PI) or Self-Statement Training (SST)
which consisted of 12 weekly 90-min group sessions with 4-5 patients per group. Major assessments were carried out at pre-treatment, 6th
week and 12th week of treatment, and at 1- and 6-month follow-ups. Measures included clinical ratings of severity of condition, phobia,
anxiety and depression. Furthermore, a behavioral test was administered during which changes in subjective units of discomfort and
cognitions were assessed. The results indicated statistically-significant improvement over time with both treatments. ANCOVAs
performed revealed superior effects on several agoraphobia measures for the PI condition at post-treatment. However, by the 6-month
follow-up assessment, the groups were equivalent due to marked improvement during the follow-up phase in the SST condition. Cognitive
changes were marked by a decrease in self-defeating statements without concomitant increase in coping statements. These results and
recommendations for future research are discussed.

INTRODUCTION

Cognitive-behavioral treatments have been recently added to the therapist's armamentarium (Beck and Emery,
1979; Beck et ai, 1979). However, despite the recognition of the important role of cognitions (Coleman, 1981;
Chambless and Goldstein, 1981; Ellis, 1979) none of the many variants of cognitive strategies have undergone
systematic research in agoraphobia. In contrast, there is a voluminous literature consisting largely of
methodologically excellent studies of analogue populations, that demonstrates the effectiveness of cognitive
interventions in regard to anxiety management (Barios and Shigetomi, 1980).
Anxiety management is a crucial aspect of the treatment of agorphobia even though the prominence of avoidance
behavior might at first overshadow this aspect and emphasize deficits in performance. Nevertheless, once the
patient attempts exposure, the task of treatment naturally shifts toward making this and subsequent attempts
positive therapeutic experiences. Although under proper stimulus conditions (e.g. intensity, duration etc.),
habituation or extinction is likely to occur, this cannot be taken for granted. As discussed by Rachman (1980) many
factors influence emotional processing, with cognitive factors being among the most important. Catastrophic
thoughts, and the compulsive efforts to prevent them can cause high degrees of distress which elevate
psychophysiological arousal to levels prohibiting habituation (Lader and Mathews, 1968). The overall avoidant
attitude, the concern with security cues, and the ten-dancy to employ distracting thoughts can virtually block
effective exposure, even when the patient is in the actual phobic situation. Furthermore, there are many
agoraphobics who, following years of greater handicap, manage to enter several previously-avoided situations but
who pay the price of undue discomfort and anxiety. Another well-known clinical variant seems to be patients who
enter phobic situations but take inordinate precautionary measures such as sitting in the back of church, sitting near
an exit at a restaurant, going to the market at a

whom all reprint requests should be addressed.

1
2 MATIG MAVISSAKALIAN et al.

specified time (e.g. off-hours), taking the bus only to go a specified itinerary, going out only on 'good days',
carrying tranquilizers even though they have not taken one in months etc. In such cases, the primary objective of
treatment would seem to be that of cognitive restructuring and improved anxiety-management skills.
Three controlled studies investigating cognitive therapy of agoraphobia have recently been reported.
Emmelkamp et al. (1978) studied the effectiveness of cognitive restructuring and prolonged in-vivo exposure in a
cross-over design with 21 agoraphobics. Cognitive treatment produced little change and was clearly inferior to
in-vivo exposure. Unfortunately the duration of cognitive treatment was greatly restricted (e.g. 5 days, 2 hr per
day) thereby severely attenuating and restricting opportunities for internalization and practice. In a subsequent
study, Emmelkamp. (1979) compared flooding with cognitive restructuring and a combined treatment in a
between-group design. Treatment duration was slightly longer, consisting of 8 2-hr sessions conducted over a 2\
week period. Once again, at post-treatment cognitive restructuring was decidedly inferior. However, at the
1-month follow-up assessment this difference was no longer apparent due to further improvement in the
cognitively-treated group. No clear advantages emerged from the combined treatment. The third study (Williams
and Rappoport, 1982) investigated the effects of combining cognitive therapy and in-vivo practice with 20
agoraphobics who suffered from severe fears of driving, unaccompanied. Despite the documented utilization of
the cognitive techniques while driving, the combination treatment failed to show significantly greater
improvement compared to practice alone. However, neither treatment produced major behavioral gains in this
study.
The main criticism of all three studies is that both the number of sessions as well as the duration of treatments
were limited, which probably restricted opportunities for patients to learn, integrate and practice their new coping
skills in the natural environment. It is worth noting that in these studies, systematic instructions to practice in real
situations between sessions were either not given or, in the latter case, were prohibited (Williams and Rappoport,
1982). Recognizing the limitations of these earlier studies, we planned this pilot study to assess the clinical
effectiveness of cognitive therapies in agoraphobia. To avoid the same pitfalls, we chose a treatment period of 3
months and instructed our patients to practice self-directed prolonged exposure in vivo. It is our view that rationale
and instructions to practice should be integral aspects of cognitive interventions. Furthermore, our current
knowledge of the treatment of agoraphobia renders clinical treatment programs without instructions to practice
exposure unimaginable (Mathews et al., 1981).
As to the choice of the actual cognitive strategies, we selected Meichenbaum's (1975, 1977) Self-Statement
Training (SST) because it is one of the better recognized strategies, and it was the technique utilized in the three
preceding studies. The rationale for using Paradoxical Intention (PI) (Frankl, 1960, 1975) was based on positive
clinical experiences and anecdodal reports suggesting that is may be an effective cognitive strategy in the
treatment of agoraphobia (Gerz, 1962, 1967). However, despite the widespread application of PI to other
anxiety-related problems such as insomnia (Ascher and Efran, 1978), sexual dysfunction (Ascher and Clifford,
1977) and obsessive-compulsive disorder (Gerz, 1967; Wolpe and Ascher 1976; Solyom et a l , 1972) there is
presently a paucity of research in agoraphobia (Ascher, 1980). A recent exception, is the study by Ascher (1981)
demonstrating that PI induces greater approach behavior in agoraphobics compared to gradual exposure in vivo.
An additional factor determining the choice of these two cognitive strategies was their diametrically-opposed
specific instructional sets and content. Thus, whereas SST is a rational process of cognitive restructuring
endeavoring to replace self-defeating cognitions, PI has an intuitive and experiential quality instructing patients
from the first, to try to increase anxiety and become as panicky as possible. A further aim of this study was
therefore, to explore the differential effect, if any, of these two cognitive instructional sets in agoraphobia and to
assess whether the so-called specific instructions do in fact have 'cognitive specificity', or whether they are
incidental to the whole Gestalt of cognitive therapies which have many factors in common, including; therapeutic
focusing on symptoms, labeling of emotions and introduction of alternative cognitive mediational strategies.
 Cognitive-behavioral treatment of agoraphobia 3

METHOD

Patients
Twenty-six patients meeting DSM III criteria for agoraphobia were randomly assigned to either Paradoxical
Intention (PI) or Self-Statement Training (SST) treatment conditions. Additional inclusion criteria consisted of
onset prior to age 40 and a duration of illness of at least 1 year. Social phobics and anxiety neurotics, without
typical fears of leaving home or of entering public places, were excluded. Also excluded were patients in a major
depressive episode or patients with a history of depression preceding the onset of the agoraphobia. Patients were
instructed to gradually withdraw and discontinue psychotropic medications over a 2-week period before treatment
started. In the case of patients who continued to use tranquilizers, their intake was monitored to ascertain, as a
naturalistic outcome measure, either increases or decreases over the treatment course and at the follow-up
assessments.
The mean age of the sample was 41.5 yr and all patients, except one, were Caucasian. There were 22 females
and 4 males; 81% were married and 50% were unemployed. The average duration of illness was lOyr, with 92% of
the patients having received previous outpatient treatment for agoraphobia. Previous treatment which averaged 18
months for the entire sample, consisted of individual psychotherapy (89%), anxiolytic agents (62%) and
antidepressant medication (35%). Two patients dropped out from treatment resulting in a final breakdown of 12
patients in each treatment condition. No significant differences were obtained between the two groups at
pre-treatment.

Treatment conditions and procedure

Treatment was conducted at the clinic and consisted of 12 weekly, 90-min group sessions. Patients were seen in
groups of 4-5 with three groups being conducted in each treatment condition. The first 2 sessions were identical
across both treatment conditions, providing patients with the same rationale and information about the nature of
agoraphobia and the role of habitual avoidance and faulty cognitions in maintaining their fears. A conditioning
model of agoraphobia was presented. Specifically, patients were told that agoraphobia usually began during a
stressful period, a time in which environmental events cause increases in anxiety. During such stressful periods,
individuals become 'sensitized' in that their high level of physiological arousal makes them more susceptible to
panic attacks. Since the individual is usually unable to explain their increased physiological responses, he/she
invents a cause such as "I'm having a heart attack" or "I'm going crazy". The person typically escapes from the
situation and returns to the home environment, resulting in great relief. These feelings of relief make it more likely
that the patient will escape and/or avoid future encounters with these and similar situations. The individual then
becomes hesitant to re-enter the situation in which the panic attack was experienced for fear that these unpleasant
bodily sensations will re-occur. Moreover, this first panic attack is typically followed by numerous subsequent
panic attacks in various environmental situations due to generalization. Since the anxiety feelings may occur in
practically any situation, the patient then becomes fearful of any situation requiring them to leave the safety of
their home environment.
Next, patients were told that a significant portion of the anxiety they experienced in feared situations was
caused by the type of statements they were saying to themselves. Each patient was asked to recall what they said to
themselves in feared situations. Typically, these statements include "What is happening to me, I'm going to die, I'm
going crazy and will be taken off to the state mental hospital", or, "I'm going to faint and everyone is going to look
at me lying on the ground". In most instances, the patients' thoughts center on methods of escaping from the
situation, or on ways of distracting themselves from their physiological arousal which usually results in
intensification of this arousal. Patients were then informed that treatment sessions would focus on teaching them
how to change these self-defeating statements in ways that would help them cope more effectively with their
feelings of phobic anxiety and phobic avoidance.
In addition, the importance of in-vivo exposure practice was explained to all patients. Briefly, they were told
that in order to overcome their fears they should reverse their habitual avoid
4 MATIG MAVISSAKALIAN et al.

ance and start entering phobic situations. It was also strongly suggested that once in a phobic situation, they
should remain there until their anxiety/discomfort decreased to comfortable levels and/or their urge to escape
abated (i.e. until habituation takes place). Patients were informed that the cognitive coping strategies they were
about to learn, were intended to help them confront and/or remain in their phobic situations, without undue
anxiety. In this study therefore, the emphasis of treatment was not just on increasing approach behavior but also
on the management of anticipatory and phobic anxiety experienced in vivo. The specific treatments were
introduced at the third session and continued throughout the treatment phase.

Self-Statement Training ( S S T )
SST closely paralleled Meichenbaum's approach (1975, 1977) and consisted of training patients to emit
productive self-statements in the following order: (1) preparing, (2) confronting, (3) coping and (4) reinforcing.
Patients were told
"Initially, you will learn how to prepare for the stressful situation by replacing thoughts such as: I'll never
be able to handle shopping in malls, or I'll certainly make a fool of myself if I go shopping in a mall and
faint; with, I'll be able to cope with the situation even though I may not feel perfectly relaxed, it won't be
impossible to handle; or, even though I may experience some anxiety, it certainly is no worse than the
discomfort I experience in other situations, and I am able to handle those situations alright; or, I have coped
with much worse situations in the past and will be able to tolerate the temporary stress because I know it
will lead me to experience even less discomfort the next time because I'll get used to being in those
situations. After you have learned to prepare for the stressful situation, you will then be instructed on how
to handle the stressor. Such self-statements as: I can't stand this anxiety or I'll never be able to stay in this
situation, will be replaced with more productive self-statements such as: I may be anxious, but I can cope
with the anxiety, it is not dangerous it will just make me feel uncomfortable for a little while, or, this stress
is not pleasant, but it isn't the worst feeling I've ever had either, or, even though it may be uncomfortable, it
is helping me get over my fears so that the next time I won't be as afraid. After you have learned to prepare
and handle the feared situation, you will then be instructed on how to cope with the feelings of being
overwhelmed. Such self-statements as: I'm going crazy or Til fall apart if I stay in the mall, will be replaced
with more rational and therapeutic statements such as: I have gone through this before and I've never gone
crazy, I can do it again, or even though I may feel like I'm being overwhelmed, I am in control, I will be able
to manage regardless of what happens, I must concentrate on the business at hand-shopping, driving, etc.
Finally, you will learn and be encouraged to reinforce and reward yourself for appropriate coping skills by
verbalizing statements such as: I did pretty good, I didn't let my anxiety get out of control, or, I realize that
I am capable of coping with almost any anxiety provoking situation, or, I can prepare, handle and cope with
walking in the mall, or, I feel really proud that I was able to stay in the mall without feeling overwhelmed,
or, I'm very happy with myself for not running out and letting my irrational thoughts get the best of me".

Paradoxical Intention ( P I )
Patients assigned to the PI condition were told that anticipatory anxiety brings about precisely what one fears,
while excessive intention with regard to one's own performance, interferes with functioning. Examples mentioned
included the insomniac's excessive intention to fall asleep to no avail, and the self-imposed pressures for sexual
performance which usually lead to failure. A more relevant example was the patient's usual pattern of trying hard
to control the anxiety with its paradoxical intensifying effect.
"So you see, the more you apprehensively anticipate becoming fearful in a situation, the greater is the
tendency to become fearful in that situation. And once there, the more you struggle to reduce and control
the anxiety, the more you become anxious.
 Cognitive-behavioral treatment of agoraphobia 5

PI tries to reverse this vicious cycle of fearful responding. If, for instance, instead of working to avoid being
afraid, you welcome the fear and instead of trying to subdue it, you intend it to become exaggerated and
worsen; in other words— if you reverse your ideas and thoughts, your total approach to the fear, you will
find that, paradoxically, the fear loses all its strength and meaning. Over the next few months the aim of
these sessions will be to teach you how to practice, master, and apply it skillfully in your previously fearful
situations".

During each session patients, were asked individually, to describe an anxiety-provoking situation. Typically,
difficulties in entering phobic situations during the previous week were made the focus of the in-session practice
for each patient. Patients were then asked to imagine themselves in that situation and were instructed to verbalize
the appropriate cognitive technique. For example, patients assigned to SST, imagined they were entering a fearful
situation and that they were learning to prepare, handle, cope and reinforce themselves with appropriate
self-statements drawn from the examples given above. Patients in the PI condition, imagined they were entering a
fearful situation with the intention of becoming anxious, panicky and of sweating, blushing, fainting etc., at that
moment. The therapist provided feedback and, when indicated, modeled alternative statements. In addition, in the
PI condition, the therapist encouraged the introjection of humor which is felt to be a crucial component of the
treatment by it's originator (i.e. "I will show the world that I am the best fainter anywhere", or, "I hope people
around here know how to swim because I am really going to sweat a lot"). Patients practiced the procedure twice
during each session and were encouraged to practice their newly-learned cognitive coping strategies regularly and
to apply them in actual anxiety-provoking situations.

Therapists
The therapist was a clinical psychologist (LM), experienced in both behavioral and cognitive treatments of
agoraphobia. A masters level research associate was present at all sessions and provided treatment for three
consecutive sessions in the second month of treatment, for four (2 SST, 2 PI) groups when the main therapist was
absent. To insure that treatment procedures were administered consistently, weekly meetings were held to discuss
and review treatment sessions.

Assessment
A comprehensive assessment battery consisting of clinical ratings of severity of illness, clinical ratings of
phobia, anxiety, panic, depression as well as direct measures of agoraphobia in behavioral, self-report and
cognitive-response systems were administered at pre-treatment, mid-treatment, post-treatment and at 1- and
6-month follow-up assessments.

Severity
Global Assessment of Severity (GAS) is a 5-point scale rated by the clinician in which a score of 1 represented
no complaints and normal activity; a score of 2—symptoms complained of by patient but not interfering with
normal work or social activities; a score of 3—symptoms interfering with normal work or social activities in minor
ways; a score of 4—normal work or social activities interfered with markedly, but not prevented or radically
changed; and a score of 5—normal work or social activities either radically changed or prevented (Kelly et al.,
1970; Colgan, 1975). A score on this scale was determined during regular staffings and by a consensus between
the two therapists. In cases where there was uncertainty between two scores, the highest number was consistently
assigned.
Self-Rating of Severity (SRS) is a 9-point analogue scale rated by the S in answer to the following question:
"How would you rate the present state of your phobic symptoms on the scale below?" On this scale, 0 meant no
phobias present; 2—slightly disturbing but not really disabling; 4—definitely disturbing and disabling;
6—markedly disturbing and disabling; and 8—very severely disturbing and disabling (Marks and Mathews,
1979).

ll.R.l. 211 1
6 MATIG MAVISSAKALIAN et al.

Phobia
The Fear Survey Schedule (FSS; Wolpe and Lang, 1964) was used as a measure of general fearfulness. The
Fear Questionnaire (FQ; Marks and Mathews, 1979) was used because it has an agoraphobia subscale (FQ-AG)
in addition to yielding a total phobia score (FQ-T). In addition, each S rated their five major and most severe
phobic situations on a 9-point rating scale of phobic anxiety and avoidance (PAA) following the practice
introduced by Marks and Gelder (1965) and later modified by Watson and Marks (1971). A rating of 0 on this
scale means no anxiety and no avoidance; a rating of 2—slightly anxious, hesitation to enter but rare avoidance; a
rating of 4—definite anxiety and occasional avoidance; a rating of 6—marked and frequent anxiety and usual
avoidance; and a rating of 8—very severe, continuous anxiety, near panic and complete phobic avoidance. The
scores of the five situations were averaged to yield a mean clinical measure of PAA.

Anxiety and panic

Changes in clinical anxiety were assessed by the use of an abbreviated version of the Taylor Manifest Anxiety
Scale (MAS) since the 28 items of this abbreviated version correlate highly with the remaining 22 items of the
original scale (Taylor, 1953).
The panic measure used was a 9-point scale instructing the S to rate "frequency and intensity of panic attacks,
palpitations, breathlessness, sweating or trembling which you have had for no obvious reason during the past three
days". On the scale, 0 represented no panic; 2—mild panic; 4—moderate panic; 6—severe panic; and 8—very
severe panic.

Depression
Depression was assessed by the use of The Beck Depres sion I mentorv (BDI) (Beck gt cil., 1961).

Behavioral measure
A direct measure of agoraphobia was performed which consisted of a behavioral avoidance test. The test
consisted of a standardized course (S-BAT), 0.4 miles in length leading from the front door of the hospital to a
crowded urban center and ending at a congested bus stop. Each S was asked to walk the course alone for as far as
they could go and to return only when his or her level of anxiety reached a degree which could not be tolerated.
The course was divided into 20 steps and the performance was scored by assigning the number of the last step
completed. In addition, at each step, Ss also rated their anxiety on a 9-point SUD (Subjective Unit of Discomfort)
scale. The SUDS scores of the completed steps were averaged to yield a mean value per assessment (S-SUDS).

Cognitive assessment
Prior to each behavioral assessment test, patients were instructed to verbalize whatever they were thinking
about during their walk. Patients' verbalizations were recorded using a small portable cassette recorder which was
non-obtusive. A microphone was attached, inconspicuously, near the patients lapel, for maximum sound
recording. All tapes were combined into a pool from which transcripts were prepared for further coding by a
secretary blind to the purpose of the study. The text in each transcript was divided into phrases by a single coder, in
order that differences among respondents in speaking style and talk time would not enter into the analyses as
confounding influences.
An assistant reproduced 25% of the sectioned transcripts and divided all transcripts for all tapes into three
envelopes for coding. Each envelope possessed a random anonymous set of transcripts, unmarked with respect to
treatment condition or time of assessment. Packets were created in such a fashion as to allow a 25% overlap on
identical transcripts in order that reliability among coders could be computed.
Three psychologists (D.G., S.K., M.G.), working independently, rated the three packets of transcripts. Each
rater was familiar with cognitive-behavioral procedures, and the coding system was developed as a result of
meetings among the three. Each coder assigned a category
 Cognitive-behavioral treatment of agoraphobia 7

to each transcript segment. A segment or phrase received one code, depending on which category in which it could
most reasonably be placed. Four coding categories were employed: (1) Self-Defeating (SDCOG) statements
included any of the following: doubts about ability to cope, catastrophic expectations, focus on negative feelings
or sensations, avoidance statements and negative self-evaluation; (2) Coping statements (COPGOG) offered
self-encouragement about ability to cope, appraised the environment in a way that reduced the level of threat,
referred to steps or plans pertinent to the task, for coping with distress, focused on positive feelings and sensations
or expressed positive self-evaluation; (3) Paradoxical intention statements prescribed a symptom with the intent
of its exaggeration (in duration, frequency, timing, intensity, consequences or context); and (4) all
Neutral/task-irrelevant statements were coded as a single remaining category. Since very few statements in the PI
category were observed, reliabilities were calculated on the basis of the other statements. Reliabilities between
raters ranged from 0.90 to 0.99, averaging 0.96 across raters for both categories.

Data analysis
All data were key-punched and verified prior to analysis at the University of Pittsburgh Computer Science
Center. All analyses were performed on the DEC-10 system using the Statistical Package for the Social Sciences
(SPSS) and Biomedical Data Series (BMD). SPSS was employed for the various parametric (ANCOVAs, f-tests)
and non-parametric (Chi-squares) analyses, whereas BMD was employed for the repeated measures analyses.

RESULTS

A series of univariate repeated measures analyses of variance were performed across all assessment phases to
ascertain the significance of changes over time and of treatment main effects. The results, as presented in Table 1,
revealed significant temporal improvement on almost all measures. Except for BDI, none of the measures showed
a significant treatment effect, indicating that the clear, overall trend for patients to improve over the assessment
period was not dependent upon type of treatment received.
Next, the data were analyzed for possible between-group differences at the mid-treatment, post-treatment and
follow-up assessments by analysis of covariance, using the pre-treatment measure as the covariate. The results,
which consistently favored PI, revealed major and significant differences only at the post-treatment assessment
(see Table 1) on measures of anxiety and fears including those directly assessing agoraphobia. By the 6-month
follow-up phase, however, PI had lost its advantage over SST and the two treatments were equivalent.
Subsequently, matched pair correlated t-tests were performed to examine patterns of within-group changes in
the treatment and follow-up phases, respectively. The results, which are also presented in Table 1, revealed that in
pre-post analyses, PI evidenced statistically-significant (P ^0.05) improvement on 10 variables, whereas SST
achieved significance only on three measures. Both on a quantitative and qualitative basis, PI manifested
improvements on measures judged to be most critical in regard to agoraphobia (GAS, SRS, FSS, FQ-T, FQ-AG,
PANIC and S-SUDS). Although SST was effective on a number of important measures, in each case, the PI group
demonstrated clinically, if not statistically superior changes. In the post-treatment to 6-month follow-up analysis,
PI did not obtain significant gains whereas SST did manifest improvement on GAS, PAA, FQ-AG, FQ-T and
PANIC, with no significant declines on other variables.
Figure 1 illustrates these results on selected outcome measures. PAA reflects the overall improvement achieved
in both conditions, while GAS and FQ-AG, illustrate the differential patterns of change across the two treatments
(e.g. PI improving more during treatment, SST 'catching up' in the follow-up phase). Furthermore, it can be seen
that both treatments induced substantial decreases in self-defeating statements.

U s e of anxiolytic medication
As a naturalistic outcome measure the percent of patients using anxiolytic medication was assessed. In the PI
condition, 67% of the patients were using this type of medication at
8 MATIG MAVISSAKALIAN et al.

pre-treatment. These figures declined to 37, 19 and 12% at the post-treatment, 1- and 6-month follow-up
assessments, respectively. Similarly, the percentages of SST patients taking anxiolytic medication were 75% pre-,
45% post-, 50% 1-month and 40% at the 6-month follow-up. Thus, there was evidence of clear diminution in the
use of anxiolytic medication. There was also
3.9 2.8 2.7t 2.4 2.3
h
Table 1. Repeated measures analyses of (0.9) (1.4) PI and SST
variance between (0.9)"
with ANCOVAs(l.2) (1.1)pair (-test
and matched
3.5 3.8 3.3
analyses 3.2 2.6++
(0.7) (1.0) (1.3) (1.2) (1.3)
4.7 2.0 1.7+ 1.3 2.3 Repeated
(2.1) (0.0) (0.6) (0.6) (1.5)
Measure/ 4.9 3.8 4.5 3.5 3.4 Treatment measures
(1.6) (1.2) (1.9) (1.9) (1.9)
treatment Pre- 6th week Post- 1-month 6-month main effects effects
group treatment treatment treatment follow-up follow-up F-ratio F-ratio
Severity
PI
GAS 1.84 15.87*
SST

PI
SRS 2.99 15.36*
SST

Phobia
133.7 110.7 80.1 + 79.6 84.7
PI
(47.2) (27.8) (\5.ir (15.0) (24.0)'
FSS 120.0 118.0 113.2 110.9 106.8 21.99***
(43.0) (40.5) (45.1) (42.5) (50.1)
SST 47.4 43.0 29.lt 28.3 27.9
(24.9) (19.8) (20.6)» (21.3) (18.4)
51.9 46.1 45.1 + 41.1 36.9++
PI (19.2) (18.2) (19.0) (15.2) (18.9)
23.0 20.4 13.6+ 13.3 13.0
FQ-T (13.6) (12.4) (12.4)* (12.6) (12.5) 1.10 19.95*
SST 22.0 18.3 17.7 16.7 12.3++
(9.0) (6.3) (8.0) (6.9) (6.3)
7.0 4.5 3.1 + 2.8 2.6
(1.0) (1.6) (2.2) (2.1) (2.1)
PI 6.9 5.0 4.1 + 4.0 3.7++
(1.1) (1.5) (1.2) (1.5) (1.6)
FQ-AG <1 16.13***
SST

PI

PAA <1 95.40*

SST

Anxiety 16.7 13.1 9.0 13.4 12.7

PI (5.0) (4.2) (5.5r (10.2) (12.8)
19.2 15.9 17.2+ 17.1 16.6
MAS (4.4) (6.9) (4.2) (6.0) (4.8) 2.43 2.84*
SST 5.2 1.4 1.8+ 2.2 2.4
(1.9) (0.9) (1.1) (1.5) (1.1)
4.0 4.8 3.5 4.0 2.3+t
(1.6) (1.3) (2.4) (0.0) (1.7)
PI
PANIC 2.09 21.39**
SST
Depressio
n 12.4 7.9 6.9+ 9.1 7.7
(7.8) (6.1) (3.5) (6.5) (7.9)
16.7 16.6 16.3 16.6 14.9
(8.5) (10.7) (10.9) (8.2) (8.1)
 Cognitive-behavioral treatment of agoraphobia 9

Table 1.—com.

Repeated Treatment measures Pre- 6th week Post- 1-month

Measure/ 6-month main effects effects treatment treatment treatment follow-up follow-up F-ratio
treatment F-ratio
group

Behavioral
Measures
16.3 18.9 18.0 18.0 18.0
PI (6.3) (3.5) (6.3) (6.3) (6.3)
S-BAT 19.5 19.8 20.0 16.4 17.5 <1 <1
(1.4) (0.7) (0.0) (7.3) (7.1)
SST 2.3 0.9 0.5+ 0.1 0.2
(1.4) (0.90) (0.08)" (0.1)" (0.4)
1.9 1.6 1.9 0.6 0.5
(2.6 (2.3) (1.9) (0.8) (0.7)
PI
5.6 2.6 0.8 1.2 1.0
S-SUDS (6.5) (3.0) (1.3) (2.2) (1.2) <1 5.28**
4.8 3.8 5.5 3.3 3.8
SST (3.2) (4.5) (5.8) (4.3) (3.9)
9.0 8.8 0.8 1.0 0.4
Cognitions (8.0) (10.9) (1.3) (1.0) (0.5)
14.5 15.0 3.0 3.0 1.8
PI (14.7) (23.5) (4.2) (3.6) (2.1)
COPCOG 2.74 <1
SST

PI
SDCOG <1 3.96*
SST
*P ^ 0.05; **P < 0.01; ***P sc 0.001.
ANCOVAs P ^ 0.05; a = pre-post; b = pre-1 month; c = pre 6-month follow-up. t-tests P ^ 0.05; t =
pre-post; ++ = post-6-month follow-up.

anecdotal evidence of decreased dosage and regimen. However, the widely varying types and dosages as well as the
inconsistent and irregular use of these medications precluded quantitative analyses of the data.

DISCUSSION

The results of the present study are encouraging and suggest that cognitive-behavioral strategies accompanying
instructions to practice self-directed exposure can be effective treatments of agoraphobia. PI in particular,
evidenced greater gains at the end of the 12-week treatment period. However, SST made substantial improvements,
continuing far past the termination of treatment. This 'catching-up' resulted in the equivalent long-term
effectiveness of the two treatments. These findings clearly indicate the need for extended assessment periods in
future studies investigating the effectiveness of cognitive-behavioral strategies.
The relative contribution of cognitive restructuring and exposure to the changes observed in this pilot study is not
clear. Future large scale controlled studies are needed to investigate this issue as well as the importance of
non-specific factors such as therapeutic attention and passage of time. The different rates of improvement between
the two treatments however, given that both were similar in respect to all non-specific treatment factors, could be
attributed to the specific cognitive strategies.
A possible explanation of the varying rates of improvement between the two treatments is suggested by their
diametrically-opposed instructional sets. PI is a confrontative and experiential technique requiring the presence of
anxiety symptoms and focusing the patient's attention on their most feared consequences. It is therefore eminently
consonant with a flooding paradigm (Marks, 1972; Ascher, 1980) and with the instructions of prolonged in-vivo
exposure given in this study. SST on the other hand, has a deliberative, rational/logical approach which
10 MATIG MAVISSAKALIAN et al.

Fig. 1. Measures of agoraphobia, severity of condition and self-defeating cognitions a pre-treatment. 6th week (mid) and 12th
week (post) of treatment and a t 1- and 6-month follow-up assessments. PI = Paradoxical Intention; SST = Self-Statement
Training.

emphasizes reasoning perhaps making it difficult to apply immediately, particularly in the face of intense and
maintained anxiety. Thus, the SST process might have been dissonant with instructions for prolonged exposure. It
is also possible that the emphasis placed on preparing oneself to confront phobic situations might have unduly
delayed actual exposure in vivo.
The assessment of cognitive changes revealed several interesting findings. As expected, there was a clear trend
for self-defeating thoughts to decline with both treatments. The observation that these changes occurred late (e.g.
between the 6th and 12th weeks of treatment) underscores the tenacity of faulty cognitions and the longer periods
required to change them. Self-defeating thoughts however, were not 'replaced' by therapeutic statements. This
was particularly the case in the PI group, as PI statements were virtually absent. As for coping statements, they
essentially remained unchanged from their pre-treatment levels with SST while they were gradually eliminated in
the PI group.
The absence of PI statements is puzzling and might suggest that patients were not applying this strategy.
However, the fact that their pre-treatment coping statements were gradually eliminated suggest that patients in the
PI group were actively changing their habitual ways of dealing with anxiety. One might speculate whether the
intuitive/experiential quality of PI does not allow easy verbalization although, clearly, patients did not have
difficulty verbalizing during the treatment sessions. Unlike PI statements, SST type coping statements seemed to
be familiar to agoraphobics. Thus, the lack of substantial increase in these cognitions might be partly due to their
presence at the pre-treatment assessment. However, their continued use, in contrast to the decreases in PI, suggest
continued application of the prescribed treatment.
 Cognitive-behavioral treatment of agoraphobia 11

The importance of cognitive assessments in cognitive-behavioral treatments cannot be overstated. Our results
provide some evidence for the 'cognitive specificity' of PI and SST and warrant further methodologically refined
studies assessing cognitive changes in agoraphobia. In addition to a standardized test, assessment of cognitions in
idiosyncratic situations in the patients' own environment, might provide invaluable data. In this study for example,
the behavioral test did not seem to be as 'phobic' as was anticipated. This might have contributed to the frequent
neutral and task irrelevant statements. Future studies might also consider specific training of recognition and
verbalization of ongoing thoughts (Ericsson and Simon, 1980) to facilitate 'greater output' of targeted
self-statements and to minimize the 'noise' of task irrelevant thoughts.
Also needed are studies assessing cognitive changes with effective behavioral and pharmacological treatments
of agoraphobia. Thus, it may be that the increased sense of mastery and self-efficacy (Bandura, 1977)
accompanying behavioral improvement might obviate the necessity of formal training in cognitive strategies in
most cases treated with flooding. The situation may be quite different with pharmacotherapy where attributional
factors might contribute to the high relapse rates (Mavissakalian, 1982). In this case, the addition of cognitive
mediational strategies might have the beneficial effect of combining increased potency with maintenance, if not
continuing improvement, following the cessation of pharmacotherapy.
Finally, although PI might have the advantage of novelty and be more rapid than SST, clinical experience
shows that some patients just cannot get the 'hang' of it. The clinician, free of methodological constraints, has the
option of selecting the modality which might be most efficacious for each particular patient. Future studies
investigating patient characteristics are needed to elucidate the relationship of such factors as attitudes and mental
sets and the differential effect of the various cognitive strategies as well as the behavioral and pharmacological
treatments in agoraphobia.

Acknowledgements—This work was partly funded by Grant MH34177 from the National Institute of Mental Health to the first author.

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