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RETURN TO THE MARKETPLACE: STRUCTURAL CHANGE IN PERSONAL CONSTRUCTION ON RECOVERY FROM THE EXPERIENCE OF AGORAPHOBIA.
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Nigel J. Hopkins
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Formerly Consultant Clinical Psychologist, Sheffield
Health Authority, U.K.
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Abstract
A group of women, who avoided travel away
from their home, agreed to participate in a programme of therapy and assessment
that extended over a period of one year. On recovery, they demonstrated a
tightening of personal construction and a greater sense of closeness to others
and a more positive view of others and themselves. A non-agoraphobic group of
volunteer participants, who were otherwise equally depressed and displaying a
similar profile of complaints, displayed contrasting changes. On recovery their
personal construction loosened and their judgemental view of themselves and
others did not change significantly on the measures used, save for their
perceiving an increase in their own capacity to care for others. The
agoraphobic participants placed greater emphasis upon a need to demonstrate
caring and unselfish behaviours than did the non-agoraphobic participants. The
results appeared to be consistent with the notion that a major disruption of
core structure could be causally linked to the mobilisation of a set of
protective responses that might underlie agoraphobic avoidance.
Key words: Agoraphobia, core structure,
threat, attachment, narrative disruption.
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INTRODUCTION
The model of agoraphobia set out in Hopkins
(1995) describes a hypothetical process of personal construct system reorganisation
that could be seen in instances where there have been unexpected and sudden
breaks in experience. In PCT (Personal Construct Theory) terms the agoraphobic
‘syndrome’ is conceptualised as a set of protective responses brought into play
by a person who wishes to preserve the validity of their construct system when
faced with this discontinuity in their anticipation of events.
Cases of bereavement, and other traumatic
events including those that sometimes lead to suicide, display parallels with
agoraphobic avoidance in that each deal with the struggle to comply with the
joint demand to preserve and regrow in the face of changed circumstances. It is
in this sense that it is suggested that the prolonged nature of the response
seen in the agoraphobic person is akin to that seen in the unresolved grief
reaction or the suicidal person who is unable to accept a new ‘reality’ brought
about by their changed circumstances. (cf. Neimeyer, 2000, 2009)
Winter and Gournay (1987) point out that
agoraphobic avoidance is a good example of the PCT process of ‘constriction’.
Constriction is seen as a deliberate attempt to protect the integrity of a
person’s construct system against sources of information that cannot be
comprehended, or worse, threaten the predictive validities of their system. It
is a way of avoiding anxiety by shrinking the world attended to, to a size that
can be managed. The extremely anxious person who stops listening to the news or
reading newspapers to avoid distress provides an example of constriction.
Is PCT 'threat' the basis of the ‘panic’ seen in agoraphobia?
The hypothesis put forward here is that, in
the case agoraphobia, in addition to the ‘constriction’ identified by Winter
and Gournay, the PCT condition of ‘threat,’ that is, “the awareness of imminent
comprehensive change in one’s core structures” (Kelly, 1955, Vol. I, p. 489),
has been created. The suggestion is that this comes about owing to the scale of
the redefinition of their core structure that the agoraphobic person
anticipates they will need to make in order to accommodate a new construction
of themselves and their world. This ‘elaboration’ of meaning becomes necessary
when we are confronted with a need to take on board new circumstances. (cf.
Dunnett, 1988)
The self-characterisation study reported in
Hopkins (1995, 2012) indicated that many people who have become agoraphobic
have a ‘nurturant’ self-image and typically say that they would “do anything
for anyone”. This self-image contrasted with the self-descriptions of most of
the control group of non-agoraphobic patients.
Hopkins (1995) linked this ‘nurturant’ role
activity to the onset of agoraphobic avoidance via the invalidating impact of
certain life events (cf. Faravelli, 1985; Roy-Byrne et al., 1986). The mechanism
of this invalidation process arises from role change stemming from alterations
to the person’s life situation. It is suggested that the core structure under
threat arises out of a particular attachment style, and earlier investigators
have linked agoraphobic responding to attachment (Guidano & Liotti, 1983;
Liotti, 1991; Strodel & Noller, 2003). The inner narrative here could be:
“I must show that I am putting others first in order to receive the security
provided by my principal carers.” This attachment-linked mechanism could be so
vital to the person that elaboration away from this self-definition cannot be
contemplated. To protect their construct system against invalidating
information there may be consequences not only of Kellian constriction (Winter &
Gournay, 1987), but also of PCT ‘hostility’ (Kelly, 1957, 1964), which may also
come into play in the form of the person striving to argue the case for their
now partially invalidated views and values.
The disappointment accompanying their
reluctance to change may be diverted towards others around them, rather than be
understood as a sign of resistance to accepting the invalidation of part of
their construct system in order to move on and construe the new circumstances. This
disappointment may take the form of the agoraphobic feeling to be let down by
other people’s failure to care for them now they are in need. This negative
view of theirs is in itself difficult for the agoraphobic person to handle for
as Winter and Gournay (1987) found they tend to ‘submerge’ the low ’tenderness’ pole.
The unacceptable ‘frame of mind’ the
agoraphobic may find themselves in is given further colour if Stanley’s (1985)
finding is considered. It seems that offenders are likely to characterise themselves
as being ‘socially alienated’, describing few people as being similar either to
themselves or their ideal self. If, as proposed, agoraphobics are socially
alienated in a similar way, then their experience of themselves in this
anti-social frame of mind will be incompatible with their core structure and be
very likely to contribute towards the conditions for ‘threat’. (The socially alienated person has a dim view
of both themselves and other people,
whilst the self alienated person has
a dim view of themselves, but perceives others as being much more like "the way
they would like to be themselves.")
OUTLINE OF THE STUDY
Measures of distances
between elements (in PCT this relates to
the degree of similarity-dissimilarity between people).
The above loss of role and possible loss of
faith in others was hypothesised to be reflected in PCT measures developed by
Norris and Makhlouf-Norris (1976) from ‘distance between elements’ data
produced by a principal components analysis of individual repertory grids using
the INGRID programme devised by Slater (1972). These authors describe a
self-identity system having three major components: the actual self, the social
self and the ideal self. The identity status of a person can be described
through four measures derived from a consideration of the way in which these
components inter-relate. The four measures are:
-
Self-Alienation
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Social-Alienation
-
Actual Self-Isolation
-
Self-Convergence.
These can be composed from measures of ‘distances’
between the self and ideal self and other people in the
subject’s life as defined by the overall degree of similarity between scores on
the various construct dimensions.
‘Social alienation’
occurs when the person’s self and ideal self is represented as being unlike all
other people. Both Actual Self and Ideal Self are separated from all but two
non-self elements by a distance of 0.80 or greater.
For this study a ‘continuous’ measure of ‘social
alienation’ was developed from the Makhlouf-Norris discrete definition described
above calculated as follows: 20 minus the number of self-other and ideal-self
other distances closer than a distance of 0.80, i.e. larger scores if the
number of distances less than 0.8 are less.
‘Self-Alienation’
takes place when the Actual self and Ideal self are completely dissimilar, but
others may be more similar to the person’s Ideal self. (This can be expected to
be seen in cases of social anxiety). Actual self is separated from Ideal self by
a distance of 1.2 or more and there are not more than two non-self elements
more distant from the Ideal self than is the Actual self.
In this study a continuous measure of ‘self-alienation’
was defined as the self - ideal-self distance divided by 1 plus the number of
ideal-self - other distances above 1.2.
‘Actual Self Isolation’
means the Actual Self is isolated and has little basis for social interaction.
'Tenderness'
Construct
pole descriptions meeting Landfield’s post-coding criteria for ‘tenderness’ were identified by the
author using Landfield’s post coding manual. No systematic reliability check
was carried out, although Landfield’s coding directions are explicit and coding
‘tenderness’ content seemed to be an unambiguous process; Landfield’s manual
indicates an interjudge agreement for ‘tenderness’ in excess of 75%.
Landfield
(1965) codes both ‘nurturant’ and ‘motherly’ as high ‘tenderness’, and on-going
‘social interaction’ and ‘tenderness’ was used in this study as a measure of a
nurturant dimension. ‘Tenderness’ (p.12
of the 1965 coding manual):
“Any statement denoting susceptibility to
softer feelings towards others such as love, compassion, gentleness, kindness,
considerateness”.
‘Looseness-Tightness’
The initial and then repeated experiences of
unexpected and disruptive life events may be capable of providing the
conditions for what Bannister (1960, 1962, 1963, 1965) described as ‘serial invalidation’.
People who have their judgments consistently confirmed, or validated, tend to
tighten their construing with the effect of sharpening up their discriminating
powers in relation to the accuracy of their anticipations. But if a person’s
predictive judgments are disconfirmed or invalidated, then they tend to loosen
their construing to make their predictions less precise and therefore less open
to further invalidation. The loosening of construction, then, can indicate a
construct system that is being subjected to an invalidating process (cf. Lawlor
& Cochran, 1981).
The measure of loosened construction,
elsewhere described as an ‘intensity’ score, was defined in Bannister’s series
of studies on invalidation cited above as the extent to which constructs correlated
with each other, and in this study the count was of correlations significant at
the 1% level.
Stefan (1977) considers the function of our
core role structure and likens it to a strategy that shapes our life in the way
it influences our perceptions and choice. Faced with ‘uptown’ a person with an
invalidated core structure may lack the sense of purpose that gives focus and
direction to attentional processes especially important in environments that present
many distractions and uncertainties. The sense of depersonalisation and
unreality and other perceptual disturbances, that are reported to be
experienced away from the familiarity of home, may be a direct reflection the
loosened construction and loss of linkage with other people that is a
consequence of the invalidation at the level of core structure.
Both constriction and loosened construction,
although limiting a person’s ability to function, are viewed as methods of
protecting a construct system under challenge. When constriction is not in play
the conditions develop for ‘threat' to occur, for example when away from home.
Measurement of various dimensions of personal
construction whilst a person is agoraphobic would, whilst demonstrating important
differences between them and other non-agoraphobic patients, fail to
discriminate between ‘state’ and ‘trait’ characteristics. A partial solution to
this problem could be to measure these personal construction processes again
once the person has recovered from agoraphobia. The design of a study would
then include the incorporation of a substantial programme of therapy. Such an
investigation was undertaken (Hopkins, 1995). This paper describes a study that
attempts to test out the predictions of the heuristic PCT model outlined above
by comparing agoraphobic patients’ construct systems with those of
non-agoraphobic patients, with an otherwise similar pattern and intensity of
symptomatology, both before and after the completion of a successful
therapeutic programme.
HYPOTHESES
Hypotheses pre-therapy
(a) Overall there would be little initial
difference between the two clinical groups in terms of their level of distress
and the pattern of presenting symptom ‘scatter’. The obvious exception being
that agoraphobics would be more ‘phobic’, and additionally, as previous
clinical observation of agoraphobic people suggested that they may be expected
to enjoy social interaction, they might be less socially anxious than the
Contrast group. The two groups were expected to be equally depressed.
(b) Agoraphobic patients will have experienced
major life events in the twelve month period prior to the onset of their
complaint.
(c) Agoraphobics will have looser construct
systems than non-agoraphobic patients.
(d) Agoraphobics will be more ‘socially
alienated’ whereas the contrast group, who might have a more positive view of
others than of themselves, will be more ‘self alienated’ (Makhlouf-Norris &
Jones, 1971; Stanley, 1985).
(e) Personal construct elicited grid analysis
of agoraphobic construction content will emphasise higher levels of
preoccupation in caring about others as evidenced by a greater frequency of
construct poles coded as ‘tenderness’ using Landfield’s post coding manual
(Landfield, 1965; 1971).
Hypotheses post-therapy
(a) The former agoraphobic participants will
evidence a tightening of construction and a reduction in their level of social
alienation.
(b) They will maintain their greater levels of
preoccupation with ‘tenderness’ construction as this is thought to be an
enduring characteristic rather than a state variable.
(c) Non-agoraphobic participants, due to the nature of
their presenting complaints, were expected to have formerly construed aspects
of their life and others in a more rigid and limited manner and following
therapy will show a loosening of construction, and a reduction in self-alienation.
(d) Both
groups will demonstrate reduced levels of depression.
METHOD
Procedure
Participants
Sixteen women referred by a number of GPs in
the northeast of Sheffield satisfied the DSM III criteria for a classification
of agoraphobia with panic disorder. This group completed therapy and provided a
full set of data. The mean age of this group at the time of first interview was
37.00, SD= 13.21, median 35.5, range 18-61.
Fourteen non-agoraphobic female patients
referred from the same general practitioners also completed therapy and
provided a full set of data. The mean age of this group at the time of first
interview was 34.5, SD=12.11, median 34.00, range 19-59.
There was no significant difference in age
between the two groups. (t (28) = 0.537 N.S.)
Initial interviews
The first interview initially focused on
obtaining a description of the person’s complaint and was informed by the
approach to differential diagnosis in agoraphobia set out by Gorman et al
(1984). The patient was also asked to complete a range of questionnaires and
rating scales.
Characterising measures
Several measures were chosen to provide tests
of equivalence between the two patient groups and also to serve as measures of
variables of expected change.
The Crown-Crisp
Experiential Index (CCEI) (Crown and Crisp, 1979), provides an overall
measure of symptomatology by totalling data on six individual sub-scales each
of which provide usefully descriptive indices of disturbance.
The degree of agoraphobia was measured using
an adaption of Johnston et al.’s (1984) Guttman Scale measures of agoraphobic
avoidance, described here as Cumulative
Agoraphobia Scales
(CAS).
Depressed mood was measured by the Beck Depression Inventory (BDI) (Beck et
al, 1978), and social anxiety was measured by Watson and Friend’s Social Avoidance and Distress (SAD) and Fear of Negative Evaluation (FNE) scales
(Watson and Friend, 1969).
Life Events prior to the
onset of agoraphobia.
A review of life event studies indicated the
likelihood of life events being associated with the onset of agoraphobia and
the model of agoraphobia proposed here predicts the presence of significant
life events in the twelve months period leading up to an established onset
date. Hopkins (1995) confirms that both agoraphobic avoiders and the contrast
group reported such life events. (cf. Faravelli, 1985; Roy-Byrne et al., 1986).
Construct system measures derived from repertory
grid technique
(a) Loosened construction
(b) Social Alienation
(c) Self Alienation
(d) Further combinations of ‘distances’ between
elements (people).
(e) Consideration of ‘raw’ grid ratings of
elements on the construct pole of ‘tenderness', in particular ‘self” and ‘ideal
self’, and non-self elements ‘others’.
Comparison between the two groups of the average
number of high scoring ratings on ‘high tenderness’ (1-2 or 6-7 dependent on
whether the emergent or contrast pole was coded as ‘high tenderness’) per
construct, were applied to the ‘myself as I am” element, on a simple counting
of only those constructs with one pole coded as measuring ‘tenderness’. For ‘others’ elements, comparison
between those participants with ratings of ‘tenderness’ by consideration of above
average scores on that ‘tenderness’ pole (counting ratings of 123 or 567,
dependent on whether ‘tenderness’ is on the emergent or contrast pole)
Grid administration
Elicitation of constructs for the repertory
grid began during the second interview and the scoring of the grid took place
during the third session.
In the case of the agoraphobics, a graded
hierarchy of situations associated with their avoidance was obtained at this
point.
Kelly (1955) described several methods of
eliciting constructs; and these are reviewed by Fransella and Bannister (1977).
The method selected for this investigation was the Minimum Context Card Form,
which uses triadic elicitation; a seven point rating scale was used to place
each element on each bi-polar construct dimension. The resultant matrix was
subject to a principal components analysis using the ‘customised’ INGRID
programme produced by Slater (1972).
All constructs were elicited with twenty as
the goal. Eighteen elements were specified with the option to add two more and
this was encouraged, e.g. “anyone you know well missing?” The supplied element
titles were: myself now, how I would like to be, my former self, father,
mother, brother, sister, (or other close relatives, cousins for example), good
friend, person in authority, spouse, liked teacher, neighbour, disliked person,
trusted person, successful person, attractive person, happy person, son or
daughter, (or nephew or niece, or other known young person.)
Therapeutic programme
The agoraphobic patients’ therapy
programme involved:
(1) An anxiety management programme.
(2) Incremental exposure ‘in vivo’, as individuals
and along with other group members, to those situations described by the
patient as being associated with the threat of an occurrence of the disturbing
experiences they sought to avoid.
Each group member was issued with a copy of a
programmed guide for part of her course of treatment (Mathews, Gelder &
Johnston, 1981). A commercially produced set of relaxation exercises on
audiocassette was provided with instruction to practice daily in appropriate
surroundings.
The therapy programme for the ‘contrast’ or
comparison group of non-agoraphobic patients consisted of individual
‘constructivist’ psychotherapy sessions that worked to help an ‘elaboration’ of
the nature of their complaint. This included, but went beyond the treatment of
symptoms towards the construction of a psychological framework or context
within which their wider experiences could be better understood by themselves,
so that they could resolve issues and plan for the future.
RESULTS
Pre-therapy comparisons
between the agoraphobic and contrast groups
Symptoms
Table1 indicates
that the two groups were equivalent in terms of their overall initial levels of
symptomatology as measured by the CCEI: the agoraphobic group had a total score
of 55.06 and the contrast group had a score of 55.5 (t (28) = 6.66E-02, NS).
The groups differ on two of the sub-scales: as
predicted the agoraphobic group is more phobic, but the contrast group mean
score is higher on the hysteria sub-scale. This last result is in the opposite
direction to that suggested by the Chambless and Goldstein (1982) studies and
this unexpected difference on the CCEI hysteria scale requires explanation. The
CCEI norms (Crown & Crisp, 1979) indicate that the average score of 5.31
achieved by the agoraphobia group is about what might be expected in female
anxiety and phobic populations (6.1 and 5.5 respectively). A Personality
Disorder group (N = 81) scored 6.7. Whilst this suggests that the contrast
group is slightly more disturbed in this direction (Average Hysteria = 7.57),
although compared to agoraphobics at this pre-therapy stage, the median scores
of each group are equal at 6.5.
Table 1: Crown-Crisp
experiential Index (CCEI)
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means
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means
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Subscale
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N=16
Agora
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N=14
Non-ag.
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t (28) or
Mann-Whitney
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p
2 tail
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Free floating anxiety
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12.31
(2.65)
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12.43
(1.74)
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0.139
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NS
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Phobic anxiety
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11.94
(2.17)
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8.07
(3.81)
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U=42.5
U’=167
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0.001
1 tail
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Obsessionality
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8.56
(2.68)
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9.86
(3.28)
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1.189
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NS
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Somatic
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8.50
(2.85)
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7.79
(3.29)
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0.945
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NS
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Depression
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8.63
(2.22)
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9.79
(3.47)
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1.106
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NS
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Hysteria
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5.31
(2.77)
(median
6.5)
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7.57
(3.25)
(median
6.5)
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2.05
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<0.05
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Total level
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55.06
(11.06)
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55.50
(10.69)
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6.66E-02
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NS
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Table 2 indicates that there was no
significant difference between the two groups on the Beck Depression Inventory
(BDI), both groups being moderately depressed with the agoraphobic group’s mean
being 17.30 compared to the contrast group’s mean of 18.57. There was no initial
difference between the two groups on the scale of Social Avoidance and Distress
(SAD) or on the Scale Fear of Negative Evaluation (FNE). Both groups then were
pre-therapy socially avoidant and feared personal criticism. As expected, the
groups differed markedly on the measure of agoraphobic avoidance.
Table 2: Pre-therapy measures of
symptoms
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N = 16
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N = 14
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df = 28
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Variable
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Agoraphobic
group
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Non-agoraphobic
(contrast) group
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Mean
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s.d.
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Mean
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s.d.
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t
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p
(1 tail)
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Agoraphobic Avoidance
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32.00
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3.97
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15.43
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4.05
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11.30
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.0001
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Beck Depression Inventory (BDI)
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17.30
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7.12
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18.57
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11.43
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0.036
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NS
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Social Avoidance and Distress (SAD)
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13.75
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6.88
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15.64
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6.66
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0.763
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NS
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Fear of Negative Evaluation (FNE)
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17.81
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6.91
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21.29
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6.29
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1.431
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2 tail
0.163 NS
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Thus, prior to therapeutic intervention, the
two clinical groups were equivalent on seven of the ten measures used and of
the three significant differences, two reflect the avoidance and phobic characteristics
of the agoraphobic group. The ambiguous hysteria scale difference may indicate
that the contrast group possess a marginally higher level of this trait or are
responding more in this way due to their level of stress.
With the above qualification in mind, the
contrast group could serve as a valid control for a series of comparisons in
symptom change and co-variation. The underlying assumptions were (1) that the
two groups have arrived at this same level of poor mental health by different
routes and may reverse this process as they recover, and (2) that the recovered
profiles of these two groups may be a more accurate reflection of their earlier
more enduring construction of others and events.
Measures of personal
construction
The mean number of constructs for the
agoraphobic group was 19.31 and the mean for the non-agoraphobic group 19,
t(28) = 0.55, p = 0.59 2 tail, NS; the mean number of elements for the agoraphobic
group was 19.5 and the mean number for the non-agoraphobic group was 18.93.
A further check found there were no
significant correlations between measures of the number of ‘tenderness’
constructs, 'looseness-tightness', 'social alienation', or 'self-alienation', and
the number of constructs elicited and the number of elements elicited.
Table 3: Pre-therapy measures of grid analyses, INGRID and GAB programmes
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Variable
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Agora
N = 16
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Non-
Agora
N = 14
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df=28
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Mean
(s.d.)
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Mean
(s.d.)
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t/Mann-
Whitney
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p
(1 tail)
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|
Tightness
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32.19
(14.51)
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49.29
(27.05)
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U=158
U’=52
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Adjusted for ties
0.028
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Social Alienation
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14.94
(2.84)
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12.71
(1.94)
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2.47
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0.01
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Self Alienation
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0.35
(0.24)
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0.51
(0.34)
|
1.48
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NS
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|
Ideal self/Other (distances <0.8 count
measure)
|
4.06
(2.84)
|
5.79
(1.97)
|
1.90
|
0.032
|
|
Self now/Ideal self (distance)
|
1.26
(0.29)
|
1.32
(0.33)
|
0.48
|
NS
|
|
Spouse/Others (distances <0.8 count)
|
4.19
(2.46)
|
4.36
(2.68)
|
0.181
|
NS
|
|
Spouse/ideal self (distance)
|
1.03
(0.24)
|
0.87
(0.23)
|
1.56
|
NS
|
|
Spouse/self now (distance)
|
1.29
(0.28)
|
1.27
(0.32)
|
0.15
|
NS
|
|
Self/Others (distances <0.8 count)
|
1
(1.36)
|
1.36
(1.69)
|
0.70
|
NS
|
|
‘Tenderness’ construct pole count
|
2.63
(1.86)
|
1.43
(1.28)
|
2.02
|
0.026
|
|
‘Tenderness’ high score poles count (unequal variances)
|
2.14
(2.11)
N = 14
|
0.50
(0.71)
N = 10
|
U=34.5
U’=85.5
|
Adjusted for ties.
0.02
|
|
‘Tenderness’: average of high scores per construct pole.
|
0.60
(0.43)
N = 14
|
0.25
(0.35)
N = 10
|
2.10
|
0.024
|
The ‘looseness-tightness’ of a construct
system is measured by counting the number of correlations between constructs
significant at the 1% level. As shown in Table 3, non-agoraphobic patients have
significantly more correlations and therefore have tighter construct systems at
this pre-therapy stage, Mann-Whitney (adjusted for ties), 1 tail p= 0.028. (t
test not used as score variances were unequal.)
The 'looseness-tightness' or ‘intensity’ measure
used here refers to tightness in a proportional way and so where in seven cases
subjects produced less than twenty constructs – three agoraphobics with 15, 16
and 18 thereby reducing their group mean number of constructs to 19.31, and
five members of the contrast group with 16,17,17,17 and 19 constructs giving a
group mean of 19 constructs – a count of significant correlations between
constructs would under-estimate their relative tightness and a correction
factor was required. It was decided to increase the scores of these six people
by multiplying their correlation count by the ratio found by having the total
construct pairings in a 20 x 20 grid (190) divided by the number of construct
pairings in their grid. In the case of a 16x16 grid this would be 120 and the
multiplier would be 1.58.This allowance increased the 'looseness-tightness' mean
of the agoraphobic group by 0.90 and increased the 'looseness-tightness' mean of
the contrast group by 3.00. The significance of the difference between the
groups was not affected by this correctional procedure as this difference of 17
was considerable.
The 'social
alienation' measure distinguished between the two groups with agoraphobic
patients being more socially alienated. (t (28) =2.48 p<0.01), r = 0.43 a
medium effect size. The distance between elements measure of the ideal
self-other dimension described earlier (number of elements less than 0.80 from
the ideal self), also distinguishes between the two treatment groups. (agoraphobic
and non-agoraphobic means = 4.06 and 5.79 respectively, t (28) =
1.90,(p=0.032,1 tail, r = 0.29, a small to medium effect.) 'Social alienation' correlates
r = -0.92 with the ideal self/other dimension.
These results suggest that non-agoraphobic
patient participants have a higher regard for others than do agoraphobics at
this pre-treatment stage.
The 'self
alienation' measure did not distinguish between the two groups at the
pre-therapy stage.
Tenderness
A simple count measure of the number of ‘tenderness’
construct poles elicited gave the agoraphobic group a mean score = 2.63 (S.D.=
1.86), and the non-agoraphobic contrast group’s mean score = 1.43 (S.D.= 1.28),
1 tail p = 0.026, r = .36 (i.e. 13% of the variance), a medium effect. This result
is consistent with the self-characterisation findings reported by Hopkins
(1995, 2012).
Comparison at this pre-therapy stage between
the two groups of the average number of high scoring ratings on ‘high tenderness’, (1-2 or 6-7 dependent
on whether the emergent or contrast pole was coded as ‘high tenderness’) per
construct, applied to the ‘myself as I am’ element, on a simple counting of
only those constructs with one pole coded as measuring ‘tenderness’ (agoraphobics N=14, non-agoraphobics N = 10, for
participants with at least one tenderness pole) gave an agoraphobic mean = 0.60
(S.D. = 0.43) and a non-agoraphobic mean = 0.25 (S.D. = 0.35), 1 tail p =
0.024, again demonstrating a contrast between the two groups as to how they
describe themselves before therapy.
A measure of the extent to which the non-self
“others’ elements were rated on the ‘tenderness’ construct dimensions was
defined by a count of the higher than average ratings made in the ‘tenderness’ direction (123 or 567 depending on
whether the ‘tenderness’ pole was the emergent or contrast pole.) The mean
Agoraphobic participants score for N=14 was 26.93 and the mean Contrast group’s
was 15.1 for N=10.
Post-therapy measures
Symptoms
Table 4 shows that on completion of therapy
the agoraphobic group were still significantly more avoidant, but less
depressed than the contrast group. At the post-therapy point, agoraphobics had
become significantly less fearful of negative evaluation (FNE) than the
contrast group (means of 15.28 versus 20.61, t (28) = 2.063 1 tail p = 0.024),
suggesting a relative recovery of composure, or ‘self confidence’.
Table 4: Post-therapy
variables
|
Variable
|
Agoraphobic
group
N=16
|
Contrast
group
N=14
|
|
|
|
|
Mean
(s.d.)
|
Mean
(s.d.)
|
t
(28)
|
p
(1 tail)
|
|
Agora
Av
|
20.85
(6.48)
|
16.38
(6.46)
|
1.83
|
p<0.05
|
|
BDI
|
8.00
(6.01)
|
14.84
(12.64)
|
1.82
|
p<0.05
|
|
SAD
|
14.14
(8.02)
|
14.07
(7.64)
|
0.02
|
NS
|
|
FNE
|
15.28
(8.19)
|
20.61
(7.26)
|
2.063
|
p
= 0.024
|
Table 5 indicates that post-therapy there was
no difference between the groups on the measure of ‘looseness-tightness’, but
the agoraphobic group perceived their husbands/partners as being closer to
others than the contrast group (measured by the counting of ‘other’ elements
closer than 0.80). Aside from this last result, the two groups were more
similar post-therapy. The ‘tenderness’ results, using the elicited personal
construct technique, although in line with previous findings, that agoraphobic
avoiders demonstrate ‘tenderness’ construction content with greater frequency
than do the non-agoraphobic comparison group, also suggest that, following
therapy, when non-agoraphobic people do consider whether they are
considerate and caring, thoughtful about and understanding of others they rate
themselves just as highly as the agoraphobic participants. The difference is
that such a question is not one that they ask of themselves quite as often as
the agoraphobic person appears to.
Table 5: Post-therapy measures of grid analyses:
INGRID and GAB programmes
|
|
Agora
N = 16
|
Non-agora
N = 14
|
df = 28
|
|
|
Variable
|
Mean
(s.d.)
|
Mean
(s.d.)
|
t/Mann-
Whitney
|
p
(1 tail)
|
|
Tightness
|
40.23
(21.27)
|
36.15
(21.60)
|
0.37
|
NS
|
|
Social Alienation
|
12.81
(4.32)
|
11.57
(4.11)
|
0.80
|
NS
|
|
Self Alienation
|
0.29
(0.24)
|
0.39
(0.14)
|
1.34
|
NS
|
|
Ideal
self/Others (distances <0.8 count)
|
4.71
(2.87)
|
6.28
(3.24)
|
1.26
|
NS
|
|
Self now/Ideal self (distance)
|
1.04
(0.42)
|
1.18
(0.40)
|
1.27
|
NS
|
|
Self/Others
(distances <0.8 count)
|
2.5
(2.99)
|
2.14
(2.88)
|
0.332
|
NS
|
|
Spouse/Others
(distances <0.8 count)
|
5.75
(2.84)
|
3.43
(2.14)
|
2.50
|
p<0.01
|
|
Spouse/Ideal self
(distance)
|
0.94
(0.30)
|
0.91
(0.37)
|
0.28
|
NS
|
|
Spouse/Self now
(distance)
|
1.11
(0.33)
|
1.17
(0.30)
|
0.68
|
NS
|
|
Tenderness:
average of high scores per elicited tenderness construct pole.
|
0.73
(0.36)
|
0.60
(0.46)
|
0.808
|
NS
|
Pre- to post-therapy
comparisons
Reduction in agoraphobic avoidance
Agoraphobic avoidance was reduced in the case
of the agoraphobic group from a CAS score of 32 down to 20.85 t(15) = 6.55, p
<0.0001, effect size r = 0.86, a large effect. The contrast group scores
were not significantly different.
Reduction in depression
Both groups were less depressed following
therapy, with the agoraphobic participants scoring a mean of 8.19 on the BDI
compared to a pre-therapy score of 17.31, t(15) = 4.67, p = 0.0002, effect size
r = 0.77, a large effect; and the contrast group mean scores were 18.57 down to
13.50, t(13) = 2.015, p = 0.032, effect size r = 0.49, a medium to large
effect.
Tightening of construction
On recovery, there was a tightening of
construction in the case of the agoraphobic group (40.23 from 32.19, t (15) =
2.45, p = 0.014, r = 0.53, a large effect.) , whereas the contrast group showed
a loosening effect (49.28 to 36.15, t (13) = 2.64, p = 0.01, r = 0.59, a large
effect). At the post-therapy point there was no difference between the two
groups on this measure (agoraphobics mean = 40.23, contrast group 36.15, t(28)
= 0.55, NS).
Social alienation and closeness of self and ideal
self to others.
Recovered agoraphobics, who were more socially
alienated than the contrast group at the pre-therapy state, no longer are, the
previously agoraphobic participants now demonstrating significantly reduced
scores on this measure whilst the post-therapy contrast group show no significant
change. (Agoraphobic scores 14.94 down to 12.81, t(15) = 2.376, p = 0.016, r =
0.52, a large effect.) This composite measure of 'social alienation' reflects not
only the perceived gap between other people and the rater’s ‘ideal’ self, but also
the gap between themselves ‘self now’ (as agoraphobics initially) and others.
These findings indicated that pre-therapy the agoraphobic participants not only
view themselves as not living up to their own self-ideals, something they have
in common with the contrast group (in addition to feeling themselves to be
different to others), but also that when agoraphobic they had taken a much
dimmer view of the significant people in their lives than did the
non-agoraphobic contrast group participants.
Post-therapy the previously agoraphobic participants
perceive their husbands/partners as being closer to others with means of 4.19
to 5.75 (distances <0.08 count) t(15) = 3.65, 1 tail p 0.0012, and closer to
their ideal self with means of 1.03 to 0.89 (distance measure) t(15) = 1.84, 1
tail p = 0.04. Further, they perceive their spouse to be more similar to (or
less unlike) themselves, with means of 1.29 down to 1.13, t(15) = 1.85, 1 tail
p <0.05. They also perceive themselves as closer to others (as reflected in
the Social Alienation measure), with means of 1 up to 2.5 (distances<0.08
count), t(15) = 2.02, 1 tail p = 0.03, although they do not rate others as
being closer to their ideal self.
However the non-agoraphobic contrast group
does not show movement on their partners closeness to others, and no change in
their partners closeness to their ideal self; neither do they perceive that their
partner has become closer to themselves.
Self now
Agoraphobics rated their ‘self now’ more
highly on tenderness constructs post-therapy than did the contrast group.
The agoraphobic group trend was towards even
higher ratings post-therapy, but this did not reach a significance level.
The contrast group did rate their ‘self now’
as being significantly more tender minded post-therapy than they did
pre-therapy, with means of 0.50 to 1.2, t(9) = -2.09, 1 tail p<0.05
Table 6: Pre-therapy: Average number of high rating
scores (1 and 2, 6 and 7) on high tenderness pole of construct.
|
|
|
|
Mann-Whitney
|
|
|
|
agoraphobic
|
contrast
|
U, U’
|
1 tail p
|
|
|
N = 14
|
N = 10
|
|
|
|
Self-now
|
2.14
|
0.50
|
34.5, 85.5
|
0.02
|
Table 7: Post therapy: Average number of high rating
scores (1 and 2, 6 and 7) on high tenderness pole of construct.
|
|
|
|
t
|
|
|
|
agoraphobic
|
contrast
|
|
1 tail p
|
|
|
N = 14
|
N = 10
|
|
|
|
Self-now
|
2.36
|
1.2
|
1.96
|
0.032
|
‘Tenderness’
‘Tenderness’ traits in ‘others’ were rated more highly to a greater extent post
therapy by agoraphobics with a mean increase of 7.90 in number of above average
(i.e. 567 or 123) ratings (N=14), compared to a mean increase of 1.6 in above
average ratings of others by the contrast group (N=10). For related measures
t(13) = 2.54, 1 tail p = 0.012 for agoraphobic participants and t(9) = 1.163, 1
tail p = 0.137, NS.
Self now and ideal self
discrepancy
On recovery the mean ‘self now’ and ‘ideal
self’ distance was reduced in the case of the agoraphobics indicating an
increase in the similarity of these two self-descriptions (mean pre-therapy
=1.26, SD = 0.29, mean post-therapy = 1.04, SD = 0.42, t(15) = 3.44, p = 0.002,
1 tail, r = 0.66, a large effect). In the case of the contrast group there was
no significant decrease in this distance measure (mean pre-therapy = 1.31, SD =
0.33, mean post-therapy =1.17, SD = 0.40, t(13) = 1.15, NS).
Co-variation of change in measures with
recovery
Subtraction of the post-therapy
‘self- ideal self’ distances from the pre-therapy distances provided a measure
of the extent of the increase in similarity and as predicted this correlated
significantly with the changes in Fear of Negative Evaluation (FNE) in the case
of both the agoraphobic group and the contrast group.(r = 0.78, t(14) = 4.11,
p<0.001,1 tail, and r = 0.53, t(12) = 2.19, p<0.25, 1 tail,
respectively).
Another difference between the two groups is
seen in the reversal of the relationship between the ideal self/other distance
reduction (indicated by an increase in the number of ‘other’ elements less than
0.80 distant.), and the BDI score reduction. The agoraphobics BDI improvement
correlates r = +0.53 (df = 14, p<0.05, 2 tail), with the perceived increase
in closeness of others to their ideal self descriptions, whereas this
covariation of changes on these measures in the contrast group was in the
opposite direction (r = -0.59, df = 12, p<0.05, 2 tail). As non-agoraphobics
perceive others as being closer to their ideal so they appear to be more
depressed, a function of social anxiety and lowered self esteem perhaps. Put
another way perhaps, as their mood improves their idealisation of others
lessens.
The expected covariation between 'looseness' and
'tightness' changes, 'social alienation' changes, and ideal self-other distance
change was not found suggesting a degree of independence between the processes
underlying these measures.
Covariation of agoraphobic avoidance and
depressed mood
Improvement in agoraphobic avoidance and
improvement in BDI measures of depression correlated r = 0.75 (df = 14,
p<0.001) in the case of agoraphobics and r = 0.84 (df = 12, p<0.001) in
the case of the contrast group. (In this instance the agoraphobic avoidance
measure CAS was probably functioning more as a measure of the contrast group’s
avoidance due to social anxiety than agoraphobia).
The idea that a loosening of construction is
closely implicated in the process of becoming agoraphobic is supported by the
finding that the degree of recovery from agoraphobia (defined in terms of a
reduction in the CAS measure of agoraphobic avoidance) correlates significantly
with the extent of the tightening observed (r =+0.46, df =14, p<0.05).
DISCUSSION OF RESULTS
The model of personal construct theory put
forward suggested that, in the case where a condition of ‘threat’ exists, signs
of protective processes would be evident and these would include loosened
construction and Social Alienation. Compared to the non-agoraphobic contrast
group the agoraphobic group did show looser construing, and on recovery there
was a tightening of construction.
The 'social alienation', evident when
agoraphobic, is greatly reduced post therapy suggesting the return of a more
positive view of others and the self. In particular, they perceive their husbands/partners
as being closer to others and closer to their ideal self. Further, they
perceive their partner to be closer to themselves.
Both of the above changes could reflect a
return to their pre-agoraphobic way of being, 'loosening' and 'social alienation' being
agoraphobic ‘state’ variables.
Agoraphobic avoidance itself can be seen as a
good example of the ‘constriction’ of the person’s perceptual field, and this
is also a protective device. In this case we know that this is a state variable
having not been evident prior to the person’s difficulties.
Consistent with the self-characterisation findings
of Hopkins (1995) the elicitation procedure resulted in a greater emphasis on ‘tenderness’
construction for the agoraphobic group compared to the non-agoraphobic
controls. On recovery this difference in emphasis is maintained supporting the
possibility that this quality forms an important part of the core structure of
people in this avoidant group, the disruption of which in turn may be a
significant causal part of the threat/panic mechanism. The developmental
pathways leading to the elevated importance of caring for others might include
particular attachment experiences that relate to a sense of security and these
have been incorporated into core (or self) structure which might then be
especially sensitive to an absence of opportunities to validate it as might
occur if life events create social disruption.
In general the impact of the largely
behavioural programme of therapy seems to have helped in a return to the
agoraphobic participants pre-avoidance approach to their life. Other
elaborations of core structure cannot of course be discounted, but
vulnerabilities may remain.
Non-agoraphobic participants in contrast
loosened their construing, but showed no change on the 'social alienation'
measure. Neither did they, post therapy, demonstrate the increases in closeness
of their partner to others, or to their own self and their ideal self.
Whilst both groups were less depressed
following their therapy, and reached a mutual agreement along with the
therapist that their therapy programme could end, the above results suggest
qualitatively different outcomes were achieved.
In the case of the agoraphobics, the largely
behavioural approach may have resulted in a ‘slot rattling’ process and a
return to a form of personal construction similar to that utilised prior to
developing agoraphobic avoidance. The loosened construction observed in the
non-agoraphobic group could indicate a reduction in rigidity perhaps by finding
ways of escaping from the ‘cage’ of their former construing. That is they found
a way of understanding their past and were freed to develop solutions and move
on with their lives.
Clinical observation suggested that something
along these lines was achieved, but the present study was not designed to highlight
this possibility. In the case of both groups of participants a fresh
elicitation of personal construction post therapy might have clarified the
extent of any re-construction that had been made, but the re-rating of the
initial pre-therapy grid was chosen in order to provide the pre and post
comparisons.
Neimeyer (2006) presents the idea of ‘re-storying
loss’ following a life experience that produces a traumatic discontinuity in a
person’s anticipation of events. If a core construction of the self, developed
through a particular attachment relationship, were threatened, as is suggested
in the case of agoraphobia, such a discontinuity could be a result, and a
constructivist approach to restoring and developing that person’s self
narrative may form part of the appropriate therapy. (cf. Winter & Metcalfe
(2005) and Winter, Metcalfe & Rossotti (2006).
This study considered the case of women and it
is likely that males with agoraphobic problems similarly develop this
complaint
through the experience of a ‘panic attack,’ construed here as the
experience of 'threat', but their imminent comprehensive change in core
structure may relate
to disruptions, other than the loss of opportunities to express
tenderness towards
others, in the validation of their anticipations. For example, such
discontinuities caused by job loss, relationship breakdowns,
bereavements and
other life events might disrupt major maintenance functions for their
‘male’
core structure, whatever that may be.
Naturally, both men and women may also be
affected by the same life changing events, and similar aspects of core
structure invalidation. The ‘caring for others’ emphasis focused on in this
study is likely to be one of a number of dimensions found in a persons core
structure.
Although the behavioural programme reduced
agoraphobic avoidance, further help to elaborate the participants personal
construction, had it been undertaken, could have led to an increase in the
range of anticipations beyond that which currently gives their lives direction.
The generalisability of this study is limited
by the small sample sizes and the marked differences in the therapeutic
approach taken for each group. Set against this weakness the effect size of
many of the statistical comparisons were in the medium to strong range which
suggests the findings had significant clinical relevance, at least for this
subset of participants. A larger and more stratified sample of the population
would give an improved sense of the generalisability of these results.
The therapeutic aim was the same for both
groups, that is, to reduce each person’s stated complaint and at least return
them to their prior more stable lives. In the main this goal was realised, but
more may have been possible.
In essence this investigation is a pilot study
made under clinical conditions, and whilst the results are encouraging they
require cautious interpretation and further more powerfully controlled studies
are required.
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Postscript |
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The author had the privilege of
studying Personal Construct Theory under the guidance of the late Dr Gavin
Dunnett prior to the design of the current study and many of the ideas
presented here arose out of our discussions.
This study was carried out whilst the author was working
as a Consultant Clinical Psychologist at Sheffield’s Northern General Hospital.
It is an aspect of a broader investigation into the problems of panic and agoraphobia
using a Personal Construct Theory approach submitted to the Faculty of Medicine
of the University of Sheffield in part fulfillment of the degree of Doctor of
Philosophy. |
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ABOUT
THE
AUTHOR
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 Nigel Hopkins: After completing training in Clinical
Psychology at Birmingham University England in 1971 I worked for the next
twenty-five years mainly with Adults. In 1996 I took up posts based in Forensic
settings. From 2005 I worked in Cornwall with adolescents in Residential Care,
and then, in Plymouth, I practised as the team psychologist. Starting out in
1971 with behavioural skills, and like many others supplementing these, first
with Rogerian approaches and then with Rational Emotive Therapies, I moved onto
Beck, and Cognitive Behavioural inspired ways of working. Around 1982 I began
to take a serious ‘look’ at Personal Construct Theory and, following
substantial training, made PCT my default starting point when putting case
formulations together.
Correspondence address: nigel.hopkins4@btinternet.com
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REFERENCE
Nigel
J. Hopkins (2014). Return to the market place: Structural change in
personal construction on recovery from the experuence of agoraphobia.
Personal Construct Theory & Practice, 11, 38-54, 2014
(Retrieved from http://www.pcp-net.org/journal/pctp14/hopkins14.html)
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Received: 31 October 2013 – Accepted: 1 June 2014 –
Published: 9 October 2014
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