The design and conduct of community-based self-help groups for the treatment of agoraphobia are discussed. Such groups incorporate procedures encouraging members to engage in prolonged therapeutic exposure to anxiety-evoking situations. Exposure therapy and its variants have been empirically established as the treatment of choice for agoraphobia, and self-help groups lend themselves extremely well to community mental health outreach and service efforts

Thyer, Bruce A.

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The Journal of Sociology & Social WelfareVolume 14Issue 3 September Article 10September 1987Community-Based Self-Help Groups for theTreatment of AgoraphobiaBruce A. ThyerFlorida State UniversityFollow this and additional works at: https://scholarworks.wmich.edu/jsswPart of the Clinical and Medical Social Work Commons, and the Social Work CommonsThis Article is brought to you for free and open access by the Social Work atScholarWorks at WMU. For more information, please contactmaira.bundza@wmich.edu.Recommended CitationThyer, Bruce A. (1987) "Community-Based Self-Help Groups for the Treatment of Agoraphobia," The Journal of Sociology & SocialWelfare: Vol. 14 : Iss. 3 , Article 10.Available at: https://scholarworks.wmich.edu/jssw/vol14/iss3/10COMMUNITY-BASED SELF-HELP GROUPSFOR THE TREATMENT OF AGORAPHOBIA*BRUCE A. THYERSchool of Social WorkFlorida State UniversityThe design and conduct of community-based self-help groups for thetreatment of agoraphobia are discussed. Such groups incorporate pro-cedures encouraging members to engage in prolonged therapeutic ex-posure to anxiety-evoking situations. Exposure therapy and its variantshave been empirically established as the treatment of choice for agorapho-bia, and self-help groups lend themselves extremely well to communitymental health outreach and service efforts.Anxiety disorders are one of the most prevalent forms ofmental illness, and agoraphobic patients comprise the largestsubcategory of such conditions (Turns, 1985). The majority ofagoraphobics appear to be women and the disorder has a meanage of onset of 26 years (Thyer, Parrish, Curtis, Nesse & Cam-eron, 1985). Agoraphobia can be quite disabling, being charac-terized in its extreme form by individuals unable to leave thehome alone, to venture forth without a trusted companion, oreven to be alone in their own home (American Psychiatric As-sociation, 1980). Agoraphobic symptomatology may wax andwane from day to day, occupational and social functioning isoften quite impaired, and its sufferers are at risk for the devel-*Requests for reprints should be addressed to Bruce A. Thyer, Ph.D., Schoolof Social Work, Florida State University, Tallahassee, Florida 32306. A list ofagoraphobia self-help groups located in southeast Michigan is available fromthe author. Nationwide, inquiries may be directed to The Phobia Society ofAmerica, 6193 Executive Ave., Rockville, MD 20852.opment of secondary depression or alcohol abuse. The role ofpredisposing factors is unclear; speculation that childhood sep-aration anxiety disorder is a precursor to adult agoraphobia hasnot been born out by empirical research (Thyer, Nesse, Cam-eron & Curtis, 1985).Although traditional interventions such as dynamic or sup-portive psychotherapy or sedative drugs are not, as a rule,efficacious in relieving agoraphobia, the last 15 years have wit-nessed the development and clinical testing of effective treat-ments based upon the principle of therapeutic exposure. Intheir recent review of exposure-based therapies for agorapho-bia, Janssen and Ost (1982) found 24 well-controlled clinicaltrials, involving a total of 654 patients, with follow-up periodsof up to nine years. They concluded that ". . . apparently 60-70 percent of the patients treated with exposure in vivo showedclinically significant improvements in agoraphobic problemsimmediately after treatment and at a six-month follow-up"(Janssen & Ost, 1982, p. 311).At its core, exposure therapy involves the patient beinginduced to gradually enter into phobic situations of increasingseverity, remaining in each such situation until anxiety sub-sides and the patient becomes calmer, prior to attempting amore difficult assignment. It is usually assumed that agorapho-bic avoidance is resistent to "natural" extinction due to con-sistent avoidance, whenever possible, of feared situations.Complete detailed descriptions of the conduct of exposuretherapy are available in the social work literature (Thyer, 1983,1985, 1987; Selan, 1985), with adjunctive variations includingtherapist-assisted exposure, modeling techniques, contin-gently-delivered verbal praise accompanying successes, con-commitant training in somatic relaxation techniques or calmingself-instructions, waning doses of tranquilizers, or exposureconducted in small groups. It is clear, however, that the criticalingredient to the success of therapeutic exposure is real-lifepractice by the phobic patient in feared situations (Barlow &Wolfe, 1981; Marks, 1981).Due to this latter point, of the singular importance of self-exposure to phobic situations, a number of clinical researchershave investigated the extent to which agoraphobia treatmentcan be conducted on a self-help basis. Several self-help man-uals designed for the agoraphobic and their spouse or supportperson are now commercially available (Marks, 1978; Mathews.Gelder, & Johnston, 1981), and have been subjected to carefulevaluation. It now appears that exposure therapy is equallyefficacious, regardless of whether or not treatment consists ofdirect therapist accompaniment into phobic situations, thera-pist-delivered instructions and homework assignments to becarried out by the patient, computer-delivered exposure as-signments, or by the patient independently pursuing thecourses of action outlined in the treatment manuals (Mathews,Teasdale, Munby, Johnston & Shaw, 1977; McDonald, Sartory,Grey, Cobb, Stern & Marks, 1979; Jannoun, Munby, Catalan &Gelder, 1980; Ghosh, Marks & Carr, 1984).These findings suggest that exposure therapy techniquesmay be fruitfully employed by non-professional, community-based self-help groups aimed at relieving phobic anxieties, in-cluding agoraphobia. During the last five years the author be-came aware of the establishment of six such groups in thesoutheast Michigan area, each comprising from 8 to 125 activemembers meeting on a weekly basis. Contact with thesegroups lead to the establishment by the author of a further self-help group, affiliated with a university hospital-based anxietydisorders program, and more recently, another associated witha local community mental health center in Florida. The forma-tion of each of these groups, except the hospital-based group,was assisted by a recovered or recovering agoraphobic. Meet-ing locations were at local churches, schools or private homes,although the latter two formed by the author met at the hospi-tal and community mental health clinic, and were advertisedby word-of-mouth, radio and television interviews, and new-paper reports.GROUP SERVICESAgoraphobia self-help groups serve at least three primaryfunctions. In the first, these groups establish an invaluable so-cial support network. Agoraphobics often believe that they arethe only sufferers of this inexplicable malady and are relievedto find other individuals similarly afflicted. Equally important,recovered and recovering agoraphobics serve as role models forthe newer members, conveying a message of potential recov-ery. Usually members establish a mutual telephone supportnetwork whereby panicky individuals can receive reassuranceor request aid from other members of the group.The second major service provided by agoraphobia self-help groups is educational in nature. All groups with which theauthor is familiar have made handouts, books and magazinearticles available to their members, usually popular press mate-rials such as Weekes (1972), Smith (1978) or Marks (1978).These materials serve to educate the agoraphobic about thenature of their condition and help set the stage for aggressiveattempts at recovery. Professionals active in the treatment ofanxiety disorders are usually eagerly sought to give talks andlead discussions at these agoraphobia self-help groups andoften a reciprocal relationship is arranged, wherein individualsresistent to self-help approaches are referred for professionaltreatment, and professionally-treated patients are referred tothe self-help group for follow-up care or adjunctive services.Lastly, the community-based self-help group can serve asan effective catalyst for the individual to take the necessarysteps of engaging in therapeutic exposure activities. The bookLiving with Fear by Isaac Marks (1978) is a particularly usefulself-help manual containing explicit instructions for the patientand their support person on how to gradually engage in thisprocess of entering phobic situations and remaining there untilanxiety subsides. These groups usually allocate a portion of themeeting's program for members to report on self-exposuretasks attempted during the previous week, to receive publicacclaim and support for their efforts, and for members to pub-licly state their personal goals for the coming week (i.e., 'I willgo to the grocery store and purchase five items'). Networks ofsupport persons may be established, whereby advanced mem-bers of the group accompany newer members on their initialexposure tasks. Generally, initial successful self-exposure expe-riences serve as an impetous for further attempts in more fear-provoking situations. Set-backs are dealt with by experiencedmembers in a matter-of-fact manner, and the explanation giventhat such experiences are an expected component of the recov-ery process. Also of great value are field trips arranged bygroup members to travel en mass to particularly fear-evokingsituations such as shopping malls, grocery stores, church ser-vices or express-way driving. Joint journeys by train or bushave been arranged, as well as group visits to concerts or plays.With continued practice, the agoraphobic can gradually ex-pand his/her effective radius of action. Most groups encouragelargely recovered agoraphobics to individually work with new-er members, and this helping relationship often serves to con-solidate the gains made by the more experienced groupmember.SUMMARYSelf-help groups have been shown to be an effective meansof support and recovery for a variety of mental and physicaldisorders (Lieberman & Borman, 1979) including schizophrenia(Levy, 1981), pathological gambling (Scodel, 1964), obesity(Wagonfeld & Wolowitz, 1968), substance abuse (Robinson,1979), rape trauma (Underwood & Fiedler, 1983) and chronicillness (Gussow & Tracy, 1976).Agoraphobia treatment seems particularly well suited tothe ideology of self-help groups (Suler, 1984) and the ther-apeutic exposure techniques lend themselves for direct use byrecoverying agoraphobics, or their peers and support persons.Accordingly, self-help groups for the treatment of agoraphobiaand other anxiety disorders may be a valuable adjunct to com-munity mental health treatment and outreach efforts. Gener-ally, a few advertisements placed in local newspapers an-nouncing the formation of such a group are sufficient togenerate an adequate number of inquiries to establish a self-help group. Clinical social workers and other human serviceprofessionals can play a valuable role in helping recoveringagoraphobics develop and maintain such self-help groups(King & Mayers, 1985), providing another interventive toolbased upon empirically validated practice techniques.REFERENCESAmerican Psychiatric Association. (1980). Diagnostic and statistical manual ofmental disorders, (third edition). Washington, DC: Author.Barlow, D.H. & Wolfe, B.E. (1981). Behavioral approaches to anxiety disor-ders: A report of the NIMH-SUNY, Albany, research conference. Journalof Consulting and Clinical Psychology, 49, 448-454.Ghosh, A., Marks, I.M. & Carr, A. (1984). Controlled study of self-exposuretreatment: A preliminary communication. Journal of the Royal Society ofMedicine, 77, 483-487.Gussow, Z. & Tracy, G.S. (1976). The role of self-help groups in adaptation tochronic illness and disability. Social Science and Medicine, 10, 407-414.Jannoun, L., Munby, M., Catalan, J. & Gelder, M. (1980). A home-basedtreatment program for agoraphobia: Replication and controlled evalua-tion. Behavior Therapy, 11, 294-305.Jansson, L. & Ost, L. (1982). Behavioral treatments for agoraphobia: An eval-uative review. Clinical Psychology Review, 2, 311-336.King, S.W. & Mayers, R.S. (1985). The role of the clinician in the develop-ment and maintenance of self-help/mutual-aid groups. In C.B. Germain(Ed.). Advances in Clinical Social Work Practice. Silver Spring, MD: Na-tional Association of Social Workers.Levy, L.H. (1981). The National Schizophrenia Fellowship: A British self-helpgroup. Social Psychiatry, 16, 129-135.Lieberman, M.A. and Borman, L.D. (1979). Self-help groups for coping withcrisis: Origins, members process and impact. San Francisco, CA: Jossey-Bass.Marks, I.M. (1978). Living with fear. New York: McGraw-Hill.Marks, I.M. (1981). Cure and care of neurosis. New York: Wiley.Mathews, A.M., Gelder, M.G. & Johnston, D.W. (1981). Agoraphobia: Natureand treatment. New York: Guilford.Mathews, A.M., Teasdale, J.D., Munby, M., Johnston, D.W. & Shaw, P.M.(1977). A home-based treatment program for agoraphobia. Behavior Ther-apy, 8, 915-924.McDonald, R., Sartory, G., Grey, S.J., Cobb, J., Stern, R. & Marks, I. (1979).The effects of self-exposure instructions on agoraphobic outpatients.Behaviour Research and Therapy, 17, 83-85.Robinson, D. (1979). Talking out of alcoholism: The self-help process of AlcoholicsAnonymous. Baltimore: University Park Press.Scodel, A. (1974). Inspirational group therapy: A study of Gamblers Anony-mous. American Journal of Psychiatry, 28, 115-125.Selan, B.H. (1985). Successful treatment of agoraphobia. In C.B. Germain(Ed.). Advances in Clinical Social Work Practice. Silver Spring, MD: Na-tional Association of Social Workers.Smith, M.J. (1978). Kicking the fear habit. New York: Bantam.Suler, J. (1984). The role of ideology in self-help groups. Social Policy, 15, 27-141Thyer, B.A. (1983). Treating anxiety disorders with exposure therapy. SocialCasework, 64, 77-82.Thyer, B.A. (1985). The treatment of phobias in their natural contexts. Journalof Applied Social Sciences, 9(1), 73-83.Thyer, B.A. (1987). Treating anxiety disorders: A guide for human service profes-sionals. Newberry Park CA: Sage Publications.Thyer, B.A., Nesse, R.M., Cameron, O.G., and Curtis, G.C. (1985). Agora-phobia: A test of the separation anxiety hypothesis. Behaviour Researchand Therapy, 23, 75-78.Thyer, B.A., Parrish, R.T., Curtis, G.C., Nesse, R.M. and Cameron, O.G.(1985). Ages of onset of DSM-III anxiety disorders. Comprehensive Psychi-atry, 26, 113-122.Turns, D.M. (1985). Epidemiology of phobic and obsessive-compulsive disor-ders among adults. American Journal of Psychotherapy, 39, 360-370.Underwood, M.M. & Fiedler, N. (1983). The crisis of rape: A communityresponse. Community Mental Health Journal, 19, 227-230.Wagonfeld, S. & Wolowitz, H.M. (1968). Obesity and the self-help group: Alook at TOPS. American Journal of Psychiatry, 125, 145-148.Weekes, C. (1972). Peace from nervous suffering. New York: Hawthorn.

Community-Based Self-Help Groups for the Treatment of Agoraphobia

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Community-Based Self-Help Groups for the Treatment of Agoraphobia

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