She had
infrequent
desires to scream which were hard to stifle.
Bowlby - Separation
nbrunn with his mother, which he usually enjoyed.
On this occasion, however, he had not wished to go, had cried, and had been frightened in the street when going there.
On the return journey 'he said to his mother, after much internal struggling: "I was afraid a horse would bite me.
"' That evening before bedtime he had remarked apprehensively: 'The horse'll come into the room.
'
The symptoms, as might be expected, had not come out of the blue. According to father's record, Hans had been upset throughout the preceding week. It had begun when Hans had woken up one morning in tears. Asked why he was crying he had said to his mother: 'When I was asleep I thought you were gone and I had no Mummy to coax with. ' ( Coax was Hans expression for cuddle. ) Some days later his nursemaid had taken him to the local park, as usual. But in the street he had begun to cry and asked to be taken home, saying that he wanted to 'coax' with his mother. When later that day he had been asked why he had refused to go any further, he would not say. During that evening he had again become very frightened and cried,
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and he had demanded to stay with his mother. The next day, his mother, eager to find out what was wrong, had taken him on the visit to Scho? nbrunn, when the horse phobia was first noticed.
Looking back further into the history, we find that the week preceding the onset of the phobia had not been the first time that Hans had expressed fear that his mother might disappear. Six months earlier, during the summer holiday, he had made remarks such as 'Suppose I was to have no Mummy' or 'Suppose you were to go away'. Looking further back still, Hans's father recalled that, when Hanna was born, Hans, aged three and a half, had been kept away from his mother. In father's opinion, Hans's 'present anxiety, which prevents him leaving the neighbourhood of the house, is in reality the longing for [his mother] which he felt then'. Freud endorses that opinion and describes Hans's 'enormously intensified affection' for his mother as 'the fundamental phenomenon in his condition' ( SE 10: 24-5; also 96 and 114 ).
Thus, both the sequence of events leading up to the phobia and Hans's own statements make it clear that, distinct from and preceding any fear of horses, Hans was afraid that his mother
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might go away and leave him. Since, in the light of present knowledge, the expression of such fear should alert to the possibility that mother might have uttered threats, explicit or implicit, to leave the family, it is of interest to ask whether there is any evidence of her having done so.
Early in the record it becomes apparent that mother is inclined to use rather alarming threats. For example, when Hans is only three she is described as having threatened him that, if he touched his penis, she would send for the doctor to cut it off ( SE 10: 7-8). And we know too that, over a year later, at the time the phobia was first reported, mother was still trying to break him of the habit (p. 24 ). She is said to have 'warned him' not to touch his penis, though we are not told the nature of the warnings she was then uttering.
Three months later, however, and buried deep in the 'analytic' record, Hans lifts the curtain. He had come into father's bed one morning and in the course of talk had told his father: 'When you're away I'm afraid you're not coming home. ' Father expostulates: 'And have I ever threatened you that I shan't come home? ' 'Not you,' retorts Hans, 'but Mummy. Mummy's told me she won't come back. ' Father concedes the point. 'She said that', he replies, 'because you were naughty. ' 'Yes,' assents Hans ( SE 10: 44-5).
In the passage following father reflects, reasonably enough: 'His motive for at the most just venturing outside the house but not going away from it, and for turning round at the first attack of anxiety when he is half-way, is his fear of not finding his parents at home because they have gone away. ' Soon after, however, father reverts to an explanation along oedipal lines.
Even Hans's expressed fear that a horse might bite him is consonant with the view that fear of mother's departure was the principal source of his anxiety. This is shown by an incident that had occurred during the summer holiday of the previous year and to which Hans referred, by way of refutation, when father was trying to reassure him that horses do not bite. When Lizzi, a little girl who was staying in a neighbouring house, had gone away, the luggage had been taken to the station in a cart pulled by a white horse. Lizzi's father was there and had warned her: 'Don't put your finger to the white horse or it'll bite you' ( SE 10: 29). Thus, we find
218
Hans's fear of being bitten by a horse is closely linked in his mind to someone's departure. There is other evidence also that horses are identified with departures (e. g. p. 45 ).
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On all these issues, it is evident that Freud was thinking along lines very different from those proposed here. Hans's insistent desire to remain with his mother is seen, not in terms of anxious attachment, but as the expression of his love for his mother, held to have been genitally sexual in character, having reached an extreme 'pitch of intensity' ( SE 10: 110-11). The dream that his mother had gone away and left him is held to have been, not an expression of Hans's fear that his mother would carry out a threat to desert the family, but an expression of his fear of the punishment due to him for his incestuous wishes ( SE 10: 118). The episode when Hans heard a neighbour warn that the white horse might bite is linked to a postulated wish that his father should go away, not to a fear lest his mother desert. Mother's displays of affection to Hans and her allowing him to come into bed with her are seen, not simply as a natural and comforting expression of motherly feeling, but as actions that might have encouraged, in a rather unfortunate way, Hans oedipal wishes ( SE 10: 28).
A tailpiece that tends to support the present hypothesis is that, subsequent to these events, Hans parents separated and later divorced ( SE 10: 148). (The fact that Hans was separated from his younger sister suggests that mother may have kept the little girl with her and left Hans with his father. )
There the matter must be left since there is no way of knowing which of the alternative constructions is nearer the truth. In the light of the evidence, both from the case itself and from other cases of childhood phobia reviewed earlier, the hypothesis advanced here seems no less plausible than the one adopted by Freud: it is not implausible to believe that the presenting symptom in the case of Little Hans can best be understood in terms of family interaction of pattern B.
The Case of Peter
In the literature on behaviour therapy the case of another young child, Peter, aged two years and ten months, who also suffered from intense fear of animals, has achieved some fame because it is the first recorded example of fear being deconditioned. Although the therapist, a student of Watson, assumes that the child had come to be afraid of animals through having been conditioned to fear them at some time unknown, explicit evidence regarding the way his mother treated him suggests that threats from his mother had probably played a principal part.
'When we began to study him', writes Mary Cover Jones
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( 1924b), 'he was afraid of a white rat, and this fear extended to a rabbit, a fur coat, a feather, cotton wool etc. , but not to wooden blocks and similar toys. ' At the sight of a white rat in his crib ' Peter screamed and fell flat on his back in a paroxysm of fear', and he proved to be even more afraid of a rabbit. Since other children of the same age were not particularly afraid of these creatures the researchers decided to see whether they could help Peter to become less afraid of them.
219
A principal procedure used to 'decondition' Peter was for him to play each day with three other children chosen because of 'their entirely fearless attitude toward the rabbit'; during a part of the play period the rabbit was brought in. After about nine sessions, a second procedure was added: each time before the rabbit appeared Peter and the other children were given candy. Altogether some forty-five sessions were given, strung out over a period of nearly six months, during which there was a two-month interruption while Peter was in hospital for scarlet fever. From time to time Peter's progress was tested by presenting him with the rabbit when he was alone. At the end of the process Peter was no longer afraid of the rabbit or of the feather and he was much less afraid of the rat and the fur coat.
From the viewpoint of this work two aspects of the case command attention.
First, Peter is described as having come from a disturbed family that was living in impoverished conditions. Throughout the experiment, it seems, he was in a residential nursery 1 or else a hospital. His mother is described as 'a highly emotional individual who cannot get through an interview without a display of tears'. Peter's older sister had died and the parents were said thenceforward to have lavished 'unwise affection' on him. Discipline was 'erratic' and in her attempts to control him mother is said to have resorted to threats: the example given is 'Come in Peter, someone wants to steal you'. The pattern of family interaction suggested by this limited information is pattern C.
The second point of interest is the effect on the deconditioning process of the presence or absence of a particular student assistant of whom Peter was fond and who he insisted was his father.
____________________
1 Although it is not stated explicitly that Peter was resident in the nursery in which
deconditioning took place, a phrase (near the end of the paper) that 'he has gone home to a difficult environment' suggests that this was so.
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On each of two occasions when this assistant was present Peter became decidedly less afraid, although the assistant made no overt suggestions. On this phenomenon Jones comments, 'it may be that having him there contributed to Peter's general feeling of well-being and thus indirectly affected his reactions'.
Animal phobias in childhood
There is no disposition to argue here that every case of animal phobia in childhood and later life is but the tip of an iceberg the great bulk of which comprises intense fear of losing an attachment figure. In some individuals, no doubt, an animal phobia has developed because as children they had some frightening experience in which they were attacked by an animal of that species. In other cases, seeing or hearing about such events, perhaps in dramatic circumstances and at an age when misunderstanding and fallacious over-generalization are common, may be responsible. In yet others, prolonged exposure to a parent or other adult who habitually responds with fear to a particular species of animal may play a part. Whatever the causes, Marks ( 1969) presents evidence suggesting that there are individuals who are acutely afraid of a particular species of animal but who do not suffer from any other form of emotional disturbance.
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Yet, although cases of true and limited animal phobia may well exist, there can be little doubt that, in very many children and probably adults also who are more than usually afraid of animals, the principal source of anxiety lies in the home and not outside it. It is already suggested that the cases of Little Hans and Peter can usefully be considered in that light. Further and substantial evidence stems from the finding that, as already described, many school-refusing children number among their heterogeneous symptoms a fear of animals. Furthermore, just as any expressed fear of school sinks into oblivion once the disturbed family situation is recognized and dealt with, so does any expressed fear of animals. Because that is so and because difficulties at home are so frequently kept a secret, it is wise when confronted by a patient complaining of animal phobia always to examine carefully the pattern of interaction within the family from which the patient comes.
The wisdom of this course is well illustrated by a case of animal phobia in an adult reported by Moss ( 1960). The patient was a woman of forty-five who had suffered since childhood from an intense fear of dogs. After seeing a film ( The Three Facesof Eve
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of Eve) in which a woman is treated for phobia by means of hypnosis, she sought hypnotic treatment for herself.
During the course of treatment the patient recalled a tragic event that had occurred when she was aged four. It appeared that she had been playing in the backyard of her home with her younger sister when the family dog, Rover, knocked the little sister down. A splinter entered the child's cheek, the wound went septic and a few days later the child died. The patient recalled how her mother had accused her of having knocked her sister down and had openly blamed her for the death, and also how thenceforward she had deeply disliked Rover and had become afraid of dogs of every kind. A few years later, after another sister had been born, she recalled that she had been much afraid lest a puppy attack that sister also.
After the patient had recalled how her mother had blamed her for her sister's death, much in her life seemed to her to fit into place. For example, the episode seemed to explain, at least in part, why she had always felt misunderstood by her mother, why she had suffered from a chronic sense of guilt and a compulsive desire to please, and why her relationship to her mother had been so deeply ambivalent.
When an event that a patient recalls has occurred many years previously it is extremely difficult to be sure how valid the recalled details may be. In this case it was possible to obtain limited corroboration of the patient's story. An elder brother confirmed the presence of Rover and also that at the time of the fatal accident his two little sisters had been alone, because he and his brother, who seem to have been left in charge, had gone off to watch a fire. The patient's youngest sister recalled how in later years the patient had anxiously protected her from the approach of any and every dog. There was, however, no corroboration that mother had blamed the patient for the accident, and mother herself, who was still alive, denied having done so.
Experience in family psychiatry shows, nevertheless, that, when a young child dies, it is by no means uncommon for a parent, distraught by what has happened and perhaps feeling guilty over failure to have taken some precaution, impetuously to attribute blame to an older child. In some families the older child then becomes a scapegoat; in others the parent, after
221
recovering from the shock of acute grief, may forget, and then deny, having ever made the accusation. But in either case the accusation cuts deep, even when memory of it is repressed.
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That is what seems likely to have occurred in the case described. If that were so, there would be little wonder that the accused child had come to hate and fear the animal that she believed responsible for her disgrace. Nor would there be wonder that she should have felt thenceforward that her mother, and therefore all others to whom she might look for comfort and support, would disown her and treat her with nothing but contempt.
Enough has been said perhaps to show that the theory of anxious attachment outlined in earlier chapters can illuminate many a case in which a child is intensely and persistently afraid of some situation in circumstances that are perplexing to all around him and perhaps also to the child himself. In the next chapter the problem of agoraphobia in adults is considered in the light of the same theory.
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Chapter 19
Anxious Attachment and 'Agoraphobia'
It follows from the nature of the facts . . . that we are obliged to pay as much attention in our case histories to the purely human and social circumstances of our patients as to the somatic data and the symptoms of the disorder. Above all, our interests will be directed towards their family circumstances . . .
SIGMUND FREUD ( 1905a)
Symptomatology and theories of 'agoraphobia'
When a psychiatrist used to dealing with children and families examines the problem of 'agoraphobia' 1 he is at once struck by its resemblance to school phobia. In both types of case the patient is alleged to be afraid of going into a place filled with other people; in both the patient is apt to be afraid of various other situations as well; in both the patient is prone to anxiety attacks, depression, and psychosomatic symptoms; in both the condition is precipitated often by an illness or death; in both the patient is found to be 'overdependent', to be the child of parents one or both of whom suffer from long-standing neurosis, and frequently also to be under the domination of an 'overprotective' mother. Finally, a significant number of agoraphobic patients were school refusers as children.
Although minor degrees of agoraphobia are probably common and, when of recent origin, probably have a high remission rate ( Marks 1971), patients who come to the attention of psychiatrists are usually those who are suffering either from a chronic condition of some severity or else from an acute attack. Often a patient is intensely anxious, apt to panic when unable
____________________
1 The condition under discussion appears in the literature under many names, including
222
anxiety hysteria, anxiety neurosis, anxiety state, and phobic anxiety-depersonalization syndrome ( Roth 1959). The name most widely adopted at present is agoraphobia ( Marks 1969). Since criteria used to select cases differ from study to study, the extent to which findings are comparable remains in doubt.
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to get home quickly, and to be afraid of an extraordinarily broad range of situations (typically, crowded places, the street, travelling) or of collapsing or even dying when out on his own. From among this heterogeneous and variable collection of situations feared it is possible, none the less, to identify two that are feared in virtually every case and are also the most feared. These situations are, first, leaving familiar surroundings and, second, being alone, especially when out of the house. Since the argument advanced here turns on the fact that fear of these situations is at the heart of the syndrome, let us consider the evidence.
During the past decade there has been very active interest in the syndrome by psychiatrists in the United Kingdom. Roth and his colleagues in Newcastle upon Tyne describe two series of cases, each numbering over one hundred ( Roth 1959; 1960; Harper & Roth, 1962; Roth, Garside & Gurney 1965; Schapira, Kerr & Roth 1970). Special aspects of the condition to which they give attention are: the high incidence of traumatic precipitating events, notably actual or threatened physical illness, bereavement and illness in the family; the high incidence of depersonalization; and the close relation of the condition to states of anxiety and depression. Another programme of research into the condition, with special reference to the efficacy of different methods of treatment, is one conducted at the Maudsley Hospital, London, by Marks and Gelder (for references to their numerous papers see Marks 1969 and 1971). A third study of value is by Snaith ( 1968) who reports on forty-eight cases of phobia in adult patients, twenty-seven of whom were typically agoraphobic. Roberts ( 1964) describes results of a follow-up of thirty-eight patients, all married women.
Although none of these workers approaches the problem from a standpoint in any way similar to that adopted here, each endorses the view that a principal feature of the condition is fear of leaving home. Roth ( 1959) speaks of 'a fearful aversion to leaving familiar surroundings'; Marks ( 1969) holds that 'fear of going out is probably the most frequent symptom from which others develop'; Snaith ( 1968) finds that, in twentyseven of his forty-eight cases, the principal source of fear is leaving home and its attendant circumstances. Furthermore he reports, first, that the more anxious an agoraphobic patient becomes the more intense grows his fear of leaving home and, second, that when a patient becomes more anxious his fear of leaving home is magnified in intensity by a factor many times
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greater than is his fear of anything else. These findings lead Snaith to suggest that the condition is not a true phobia and that a more appropriate label for it would be 'non-specific insecurity fear'. In keeping with Snaith's perspective is the criterion that Roberts ( 1964) laid down for inclusion in his series, namely a patient's inability to leave his house without a companion.
Not only do these workers find that fear of leaving home when unaccompanied is the principal feature of agoraphobia, but each of them reports also that most patients have been anxious individuals all their lives: some for decades have been uneasy about going out alone (
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Marks 1969). Between 50 and 70 per cent of patients are reported to have suffered from fears and phobias during their childhood ( Roth 1960; Roberts 1964; Snaith 1968). In a recent survey of 600 cases using a questionnaire, between one-fifth and one-sixth described themselves as having been in some degree 'school phobic' ( Berg, Lipsedge & Marks, in preparation).
Again, although psychoanalysts working in the classical tradition have an approach to the problem entirely different from that of any of the workers so far cited, and different also from that adopted in this work, they report almost exactly the same findings. For example, in an early paper describing the case of a small boy, Abraham ( 1913) notes that the boy 'does not speak of fear, but of his desire to be with his mother'. This leads Abraham to conclude that the basic problem in patients suffering from agoraphobia is that their 'unconscious . . . does not permit them to be away from those on whom their libido is fixated'.
Both Deutsch ( 1929) and, in recent years, Weiss ( 1964) endorse Abraham's view. Weiss notes especially that a patient's anxiety is apt to increase the further from home he goes, which leads him to define agoraphobia as 'an anxiety reaction to abandoning a fixed point of support'.
Thus, despite great variation in the approach and outlook of these many workers, the findings they report are impressively consistent. Only when attempts are made to accommodate the findings within a theoretical framework do differences and difficulties arise.
Three Types of Theorizing
Here, as so often elsewhere, the two rival types of theory that dominate the field are psychoanalytic theory and learning
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theory. In the case of agoraphobia, however, a third type of theory has also been advanced, namely Roth's psychosomatic theory which invokes both psychological and neurophysiological processes ( Roth 1960). Strikingly enough, despite all the telltale hints that a major part is played by relationships within the patient's family of origin, a fourth type of theory, namely one that invokes pathogenic patterns of family interaction as major aetiological agents, is conspicuous by its absence.
1. Psychoanalytic theories of agoraphobia come in two main variants according to whether they focus on fear of being in the street or fear of leaving home.
Freud tends to concentrate on fear of being in the street, which he sees as a displacement outward of the patient's fear of his own libido. Even though in 1926 Freud began a major revision of his views and reached the conclusion that 'the key to an understanding of anxiety' is 'missing someone who is loved and longed for' (see Chapter 2 of this volume), he never applied his new theory to agoraphobia. 1 As a result, his original hypothesis continues to be invoked by a number of psychoanalysts who still see sexual temptation, of one kind or another, as the principal situation that an agoraphobic patient fears (e. g. Katan 1951; Friedman 1959; Weiss 1964).
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Other psychoanalysts in their theorizing take as their focus a patient's fear of leaving home and, in doing so, advance theories very similar to those their colleagues advance to account for the similar fear found in children diagnosed as suffering from school phobia. Thus Deutsch ( 1929) notes that the reason an agoraphobic patient feels compelled to remain near his mother (or other loved person) is that he entertains unconscious hostile wishes against her and so has to remain with her to ensure that his wishes are not enacted. For Weiss ( 1964) the patient's urge to remain at home is to be understood as due to a 'regression to unresolved dependency needs'. This is also the view of Fairbairn ( 1952), although in his case histories he attributes a causal role to the very insecure childhoods his patients had experienced.
In none of the psychoanalytic formulations, apart perhaps
____________________
1 In one of his last works, New Introductory Lectures ( 1933), Freud writes: 'the agoraphobic
patient is . . . afraid of feelings of temptation that are aroused in him by meeting people in the street. In his phobia he brings about a displacement and henceforward is afraid of an external situation' ( SE 22: 84).
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from Fairbairn's, is there any suggestion that a patient's refusal to leave home is a response to the behaviour of one of his parents, not only behaviour that may have occurred at some time during the past but behaviour that may be occurring still in the present.
2. During the past decade or so a new approach to a theoretical understanding of phobic conditions of all sorts has been made, this time by learning theorists; and formulations that attempt to account for each of the various situations feared have been advanced. Whereas this approach may well help us to understand some of the discrete animal phobias, how much it can contribute to an understanding of agoraphobia remains in doubt. Describing the present position as he sees it Marks ( 1969), who has made a special study of agoraphobia and draws extensively on learning theory, writes as follows:
Certain phobias, especially agoraphobia, are commonly found together with multiple other symptoms such as diffuse anxiety, panic attacks, depression, depersonalization, obsessions and frigidity. Learning theory does not explain why these symptoms develop, why they occur together, nor why they are associated more often with agoraphobia than with any other type of phobia.
Furthermore, in Marks's view, 'the origin of the panics, depression and other symptoms is not indicated by learning theory' (p. 93 ).
How the panics and depressions do originate is, for Marks, the most puzzling aspect of the condition. For, in his opinion, not only is learning theory unable to account for them but no other theory can do so either (p. 93 ). Admitting the quandary, Marks leaves the matter open; but he tends to the view that anxiety attacks probably have an unknown physiological origin. Nowhere does he consider the possibility that they may originate in family situations that create psychological distress.
Having recognized frankly the difficulties in accounting for agoraphobic symptoms entirely in terms of learning theory, Marks believes nevertheless that the theory has much to offer. The
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hypothesis he advances is based on the idea, suggested by learning theory, 'that panic attacks and depression [may] act as super-reinforcers which facilitate phobic conditioning' whenever a patient who happens to be experiencing such affects goes out of his home. This line of thought leads Marks to propose that, in the development of agoraphobia, the anxiety
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attack comes first and the situations that the patient reports he fears come to be feared only later, either as a result of a secondary conditioning effect or as a result of rationalization. In that context both fear of going out of the house and fear of becoming separated from a companion, the two symptoms most characteristic of agoraphobic patients, are held to develop through a process of secondary conditioning.
In keeping with his hypothesis, Marks expresses much scepticism regarding the causal role of precipitating factors, holding that they probably act simply as 'non-specific stressors in a patient already liable to the disorder . . . or that the disorder was already present, but hidden until the stressor elicited or exacerbated it'. In support of his position he lays much emphasis on his claim that 'not a few phobias start suddenly without any obvious change in the life- situation of the patient' (p. 128 ).
Both the sequence of events that Marks postulates and the weakness of his position are illustrated in his description of the case of a woman who sought treatment at the age of thirtythree on account of depression with suicidal ideas. The account she then gave was that, ten years earlier when she was aged twenty-three, she had developed anxiety, sweating, and shaking of the legs while travelling to work by train. Subsequently she had discovered that she felt better if her husband was present and so had taken a job in the firm in which he worked. After a few months, however, she had become afraid of separation from him, had to know exactly where he was and had telephoned him frequently. If for any reason she could not contact him immediately she would panic, feel completely lost and want to scream.
The only information Marks gives regarding this patient's childhood is that 'as a small child [she] used to be frightened when her parents were out and once sent out her younger brother to find them.
She had infrequent desires to scream which were hard to stifle. These disappeared in her late teens. '
Despite the uncertain validity of the retrospective data, Marks seems confident about the sequence of symptoms: 'First came the travel phobia and depersonalization, then came the discovery of relief in the presence of her husband and after this he became indispensable. Finally the patient presented for treatment of separation anxiety. ' In accounting for the symptoms Marks proposes two distinct pathologies. On the one hand is the agoraphobia and on the other is the anxiety about
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separation, to which he believes the patient had been sensitized as a child. Originating independently, the two pathologies are held subsequently to have interacted.
There are several flaws in Marks's position. First, in the light of the childhood history of this patient, it is difficult to accept his confident assertion that agoraphobia came first and separation anxiety afterwards. Second, in his ready acceptance of this and other patients'
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accounts that the initial anxiety attack came 'out of the blue', he makes no allowance for a patient's witting or unwitting suppression of information, a process we know to be extremely common and often to hide clues vital for understanding the condition. Third, to postulate two distinct psychopathologies for a pair of symptoms that habitually go together 1 is far from parsimonious. Finally, as Marks himself admits, he can give no explanation of how or why this patient (or any other) first started to experience anxiety and panic attacks.
An alternative hypothesis to account for this patient's symptoms is that, during her childhood, she had been subjected to repeated and realistic threats of being abandoned, so that even after reaching adult life she had continued to be acutely sensitive to any such danger. The case is discussed further below (p. 307 ).
As regards the part played by a patient's parents in the genesis of agoraphobia, learning theorists share with traditional psychoanalysts the same shadowy picture. Whereas neither group attributes much importance to parental behaviour, in so far as they do so both invoke the theory of spoiling. As Andrews ( 1966) points out, Wolpe ( 1958) and Lazarus ( 1960), two leading learning theorists, both regard a patient's tendencies to withdraw to and to remain at home as responses he has learnt during interaction with over-protective parents. Marks ( 1969) in his discussion of prevention implies the same process. Some years earlier Terhune ( 1949), a psychiatrist whose outlook is in many ways similar to that of present-day learning theorists, wrote confidently: 'The phobic person is one who has been over-protected, brought up "soft". '
3. The third main type of theorizing about agoraphobia,
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1 Marks rests his argument on his finding that about 5 per cent of agoraphobic patients are
not helped by company and prefer to be alone while travelling ( Marks 1969: 98). in most syndromes, however, cases occur that lack one or more typical symptoms; an example is measles without a rash. Such atypical cases require special study.
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initiated by Roth ( 1959; 1960), regards the condition as being truly psychosomatic. In presenting his theory, Roth lays much emphasis on the vulnerable personalities of his patients, on the precipitating role of stressful events, and on depersonalization, which he regards as a core symptom of the syndrome. The psychological factors to which he points include both situations that, acting perhaps from early childhood, are thought to have contributed to the development of an anxious dependent personality, and stressful events, such as bereavement and illness, that appear to act as precipitants. The somatic factor he postulates is a specific cerebral mechanism that, once triggered, is difficult to inactivate. After considering certain disturbances of perception and consciousness that he finds in these patients, together with symptoms that he attributes to temporal lobe dysfunction, Roth concludes that the somatic pathology is probably to be understood as arising in the mechanisms regulating awareness, which he postulates to have become chronically deranged. Although he gives little detail of how he believes a difficult childhood and stressful situations of later life interact to produce an agoraphobic syndrome, Roth's approach is not incompatible with that presented here.
We turn now to consider a fourth type of theory, namely the one that results when the problem of agoraphobia is looked at in the theoretical perspective developed in this work.
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Throughout our further discussion it is important to bear in mind that, as all workers now agree, the central symptom of the condition under scrutiny is fear of leaving home.
Pathogenic patterns of family interaction
Whether the theory of anxious attachment, applied already to problems of school phobia, can help to solve problems of agoraphobia also must remain in doubt. For, apart from some limited and mostly rather crude observations, there are few data yet available on patterns of interaction within an agoraphobic patient's family of origin. Almost all the data yet published come either from the patient himself or from a single interview with a relative, with the many distortions and omissions that we know such clinical procedures entail. What is missing, but so necessary to have, is first-hand observations of how a patient and his parents are currently behaving towards one another. In the absence of such data all that is possible here is to draw attention to certain reasonably well-attested findings
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that are at least consonant with the view that many, if not all, cases of agoraphobia can be understood as products of pathogenic patterns of family interaction. There is much evidence of a rather general kind which, although it gives little information about specific patterns of interaction, points to a high incidence of disturbance in the families from which agoraphobic patients come. Before considering specific patterns, therefore, we consider this general evidence. Most reports agree that a majority of agoraphobic patients come from homes that are intact, in the sense that there are two parents living continuously together. Yet there is also substantial evidence that, within these homes, relationships are often far from harmonious; and it is repeatedly indicated that the parents of patients are neurotic or disturbed in some other way. Taking as a criterion clear-cut neurotic breakdown in first-degree relatives, Roth ( 1959) finds an incidence of 21 per cent. Nor should it be overlooked that a minority of patients, in one study as high as 25 per cent, come from homes broken by death, divorce, or other cause. In a recent study of eighty-seven consecutive London patients by M. S. Lipsedge (unpublished), a high incidence of disturbance in the families of origin is reported. The patients ranged in age from twenty-two to sixty-four years; fourteen were men and seventy- three women. Almost all the information was obtained from the patients themselves during an initial interview, though occasionally it was supplemented by information from a general practitioner. Inadequate though this method is for obtaining the information required, it is unlikely to exaggerate the degree of disturbance in the families from which the patients came. On the basis of this information, the patients' families can be divided very roughly into three categories:
I. I intact and reasonably stable families
II. II intact families in which there was much quarrelling, violence, and alcoholism, and/or
almost complete absence of affection
III. III families broken by death or divorce, or in which a parent was chronically ill, and/or
the patient had had prolonged separations from or changes of parent figure.
The number and proportion of patients from families in each category are shown in the following table.
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228
Category of No.
of % of patients
42 30 28 100
family
I
II
III Total
patients
37 26 24 87
Category I: There were thirty-seven patients who described their home life as having been happy or who gave no particularly adverse information about it. Nevertheless, two of these patients described a parent as having been agoraphobic (one father and one mother), and two others described themselves as having been 'over-protected'. Ten of the patients referred to themselves as having been notably fearful as children; of these, two had been school refusers and one agoraphobic. Thus neurotic trouble of one kind or another is reported in members of about one-third of these not overtly disturbed families.
Category II: There were twenty-six patients whose homes appear to have been intact but who described themselves as having had an extremely unhappy family life when children. Eighteen patients described their parents as having engaged in perpetual quarrels, including violence, and often made worse by alcohol. Another eight complained of having received no affection and/ or of having been rejected. In three of these twenty-six cases the patient's mother had been agoraphobic. Two of the patients had themselves been school refusers as children.
Category III: Of the remaining twenty-four patients, there were twenty-one whose family life had been disrupted by death, divorce, or desertion and/or who had experienced many changes of mother figure. Of these, ten had lost one or both parents by death before their tenth birthday (six a father, three a mother, and one both). In five cases mother had deserted and in at least one other father. Two patients when young children had been evacuated for several years from wartime London, starting in one case at the age of three years and in the other at four. A number of children had been brought up by relatives. In addition to the twenty-one patients who had experienced disruption of affectional ties, three had been brought up by chronically sick mothers: in one case mother had had multiple sclerosis from the time the patient was aged seven.
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Of this total of twenty-four patients three had had a parent figure who had been agoraphobic: one a father, one a mother, and one the grandmother with whom she lived. Eight patients described themselves as having suffered from anxiety as children; of these two were school refusers and one was agoraphobic.
Despite the manifest limitations of this evidence there is good reason to believe that in over half the cases (namely those from families in categories II and III) there was extensive disturbance of family life during the patient's childhood. Of the minority who were said to
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have come from stable homes there is clear evidence of covert disturbance in about a third of them.
Some Specific Patterns
Since, as already noted, there is a striking resemblance between cases of agoraphobia in adults and school refusal in children, there are strong prima facie grounds for suspecting that the paticular patterns of interaction present in the families of agoraphobic patients may be the same as, or similar to, those found in families of school-refusing children. Despite the very poor quality of the evidence available, such evidence as there is supports this expectation.
The following three patterns of interaction found commonly in the families of school-refusing children are probably to be found fairly frequently also in the families of agoraphobic patients:
Pattern mother, or more rarely father, is a sufferer from chronic anxiety regarding attachment A figures and either did in the past or still does retain the patient at home to be a
companion
Pattern the patient fears that something dreadful may happen to mother, or possibly father, B while he (the patient) is away from her; he therefore either remains at home with her
or else insists that she accompany him whenever he leaves the house
Pattern the patient fears that something dreadful may happen to himself if he is away from C home and so remains at home to prevent that happening.
As in the case of families with a school-refusing child, these differing patterns of interaction are not incompatible; mixed cases are probably common.
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The fourth pattern of interaction found in the families of school-refusing children -- pattern D, in which a parent fears for the safety of the child and therefore keeps him at home -- is not directly recorded in the families of agoraphobic patients, but indirect evidence suggests that it probably does occur.
Family Interaction of Pattern A
Much evidence suggests that pattern A, in which a parent is retaining a son or daughter at home to be a companion, is common in these families. Thus the dominant and controlling role that parents, usually mothers, have played and may still be playing in the lives of their children is emphasized in almost every study. Roth ( 1959) describes the relationship of his women patients with mother as tending to be 'close and intense' and as excluding often any contacts outside the immediate family circle. An 'emotionally immature' young woman, whom Roth presents as typical of his series of cases, is reported to have been prevailed upon by her 'masterful domineering mother' to break off her engagement with a quiet clergyman and so to remain at home. Snaith ( 1968) reports that in at least seven of his twenty-seven cases there was clear evidence of 'overprotection'. Webster ( 1953), who studied twenty-five cases, reports all but one of the patients' mothers to have been dominant and over-protective.
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Terhune ( 1949), reviewing eighty-six cases, concludes that the phobic syndrome arises 'when an apprehensive, dependent, emotionally immature person is trying to realize his ambitions to become an independent member of society'.
Despite these consistent findings, no student of the syndrome seems yet to have given thought to the question why a mother should treat her daughter (or son) in this dominating and possessive way, or by what techniques she succeeds in maintaining her hold over her offspring. In a case reported in the psychoanalytic literature by Deutsch ( 1929), however, we find evidence to the effect that the patient's mother was making insistent demands upon her daughter to act as companion and caretaker to her. But Deutsch does not discuss why the mother should have behaved in this way.
In presenting the case, that of a twenty-year-old girl who suffered from typical and severe agoraphobic symptoms, Deutsch describes the patient's mother as being 'highly neurotic' and as having from the first 'concentrated all her unsatisfied libido on the child', her only one. By contrast, the
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patient's father is said to have been treated by mother as a nonentity. Although mother claimed that 'ever since her daughter's birth she had been a slave to her' and that her daughter could never bear her to be away, the evidence suggests strongly that, as in similar cases of school refusal, the account given by mother was the inverse of what the relationship had really been and still was. In other words, it seems likely that, while claiming that her daughter was making great demands upon her, mother was herself making great demands upon her daughter. Support for this interpretation comes from the unpublished study by Lipsedge already referred to. Of the eighty-seven patients in his series, no fewer than eight reported that one or other parent figure was agoraphobic.
Admittedly the findings referred to amount to no more than presumptive evidence for the presence of pattern A in a number of the families from which agoraphobic patients come. At the least they point to the need for systematic research, not only into the relations between a patient and his parents but also into the relations between parents and grandparents. For, if a proper understanding of the psychodynamics of the condition as it passes from one generation to another is to be obtained, it is vital that the neurotic difficulties of the parents of patients should be looked at sympathetically in the context of their own experiences as children. It is also necessary to examine the relationship between an agoraphobic patient and his (or her) spouse. Fry ( 1962) reports seven patients whose husbands were also agoraphobic, though covertly so. In some of these cases the husband was most insistent that his wife needed to have him with her, though on examination it turned out that the pressure for the other's company was more his than hers.
Family Interaction of Pattern B
A patient's fear that something dreadful may happen to one of his parents is only rarely reported in the literature on agoraphobia. Whereas that might mean that fear of such an eventuality is truly uncommon, it may mean no more than that it goes unreported, either because patients find themselves unable to talk about the situations they fear or else because psychiatrists, ignorant of the significance of family interaction, fail to inquire. 1
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1 another reason might be that a psychiatrist without training in the recognition of pathogenic
patterns of family interaction fails to report the situations a patient says he fears and, instead, describes the patient
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The picture, given by Lipsedge, of disturbed interaction in many of the families of agoraphobic patients is such that it would hardly be surprising had some of his patients been living during their childhood in chronic fear of what might happen to one or both of their parents. Eleven of his eighty-seven patients reported that one or both parents had shown violent behaviour, and another seven described perpetual quarrels between them. Anyone with experience of children or adults who have grown up in such homes knows how terrifying to a child the violent and quarrelsome behaviour of parents can be. In the first place, violent acts may seem to be of literally murderous intent. In the second, the mere threats uttered may fill a child with horror; for, in quarrels between parents, threats to desert the family or to commit suicide are probably extremely common. The constant apprehension of losing one or both parents by murder or suicide that pervaded Mrs Q's life as a child is described in Chapter 15.
In addition to the threats that are aimed principally at a spouse are the threats that may be used by a parent as a means of controlling the children. And it must be remembered that threats, for example that if a child does not behave mother will get ill or die or commit suicide, can be continued not only throughout adolescence but into adult life as well, and, if applied consistently, can result in an adult's being reduced to a state of permanent intimidation.
A family situation of this kind, it is plausible to believe, may have lain behind one of the cases of agoraphobia already alluded to (p. 303 ), that of the girl of twenty on whom, in Deutsch's words, mother 'had concentrated all her libido'. Let us consider the case material further.
In this young woman a principal symptom was fear that something dreadful might happen to mother. When her mother left the house she was afraid lest she be run over; each day she waited anxiously at the window and heaved a sigh of relief when she saw her mother return safe and sound. Alternatively, the patient was afraid lest, while she herself was away from the house, something dreadful should happen to mother before she got back.
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1 simply as suffering from 'irrational fears', a category to which are too often consigned clues
that are among the most illuminating for understanding a patient's condition. Of thirty agoraphobic patients described by Harper & Roth ( 1962) nineteen are reported by them to have suffered from irrational fears.
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In commenting on the origin of this patient's anxiety, Deutsch adopts, without discussion, the hypothesis that she claims would be adopted by anyone versed in analytic work: that the patient's 'exaggeratedly affectionate anxiety' is an over-compensation for unconscious hostile wishes directed against mother; and that these hostile wishes have arisen as a result of the patient's oedipus complex. Although there are many psychoanalysts who would still adopt that hypothesis (though they might attribute the hostility to a pre-oedipal rather than an oedipal phase), others, through their experience in family psychiatry, would be aware of
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several other possibilities. One is that this 'highly neurotic' mother was given to threatening suicide. Another, which assumes Deutsch to be right in thinking that the patient was afraid mainly that her own hostile impulses might be enacted, is that the patient's mother had evoked such wishes by the insistent yet unacknowledged demands she had made upon her daughter over many years. Furthermore, prone as offspring are to adopt patterns of behaviour observed in a parent, it should be borne in mind that this patient, in developing a wish to push her mother under a tram (as Deutsch reports she did wish), might have taken her cue for such an action from a perhaps oft-repeated threat of her mother to throw herself under one.
In view of what we know can happen in families, though we are hardly ever told that it does, none of these ideas is fanciful. Yet all too often such possibilities are not even dreamed of by a clinician because the theory he is applying has no place for them. Only if every case is explored anew with knowledge of the part that can be played by family influences of these kinds are we likely to make progress in understanding and helping our patients.
Family Interaction of Pattern C
Fear that something dreadful may happen to themselves while they are out of the house is an extremely common symptom in agoraphobic patients. The principal situations mentioned as feared are of dying and of becoming helpless. Not infrequently such fear is linked to the various physical symptoms the patients experience -- palpitations, dizziness, weakness of legs -- which are interpreted by them as signs of imminent disability or death. By other patients again their fear is described as an overwhelming feeling of insecurity.
Although the situations a patient says he fears are frequently
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dismissed without further ado as irrational, knowledge of what can sometimes lie behind fear of similar happenings in children who refuse to go to school should alert us to the possibility that an agoraphobic patient is being, or at least has been, subjected to threats either of being abandoned or of being ejected from the family. As in the case of school-refusing children, information about such threats is hard to come by, but there is enough in the literature to make it clear that systematic investigation is required.
In most of the studies that have been referred to it is apparent that the possibility has never occurred to the researchers that the symptoms from which their patients suffered may have been a response to threats of being abandoned to which they may have been exposed during many years of childhood and adolescence. An example of the type of case that should clearly be considered in this light is the agoraphobic patient described by Marks ( 1969), and referred to earlier in this chapter, who recalled how as a child she had often been frightened when her parents left the house and how once she had sent her younger brother to find them.
Among the many studies of agoraphobia published, there appears to be but one in which threats are mentioned and are moreover, considered to have played a causal role in the patients' condition. This is a study by Webster (1953) who reports findings on twenty-five married women suffering from agoraphobia, all of whom had been in psychotherapy for a minimum of three months. Using as his data the clinicians' notes, Webster rated the attitude of the mothers of these patients towards their daughters. Of twenty-five mothers, twenty-four were rated as being dominant and over-protective. In making these ratings Webster adopted as
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his main criterion that the mother 'be most solicitous of the daughter's welfare, rewarding her often without good reason and rejecting or threatening to reject her or actually telling her she would not love her any more if she did not behave'. The patients' feelings of insecurity, Webster suggests, were probably a direct result of their having been treated in this kind of way. 1
As it happens, some years ago I treated a patient in her mid-twenties whose symptoms were typical of severe agoraphobia. Although for a year or more she insisted with great emphasis that nothing too good could be said of her mother,
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1 Webster does not discuss the possibility that some of these mothers may have threatened to
abandon or eject their daughters. -307-
later she described her mother as 'a tartar' who had always used the most dreadful and violent threats, including outright rejection, to get her own way and still used them. Her father, she said, was frightened of his wife and occupied himself as much as possible outside the home; the patient said she was fond of her father and felt sorry for him. The consistency of the story, and especially the coercive and threatening way in which the patient often treated her analyst, suggested that the picture she painted of her mother was probably not exaggerated. Were I to be treating this patient today I should give far greater attention than I did then to the part I now believe her mother's threats to have played both in the aetiology and in the maintenance of her condition.
Support for the view that a substantial proportion of agoraphobic patients have been subjected to harsh treatment in their homes comes, as we have seen, from the unpublished study by Lipsedge. In addition, Snaith ( 1968) presents evidence that, whereas the mothers of some agoraphobic patients are indeed over-protective, others are rejecting: in his series of twentyseven patients, seven are reported to have been over-protected and eight others to have been rejected. 1
Nevertheless, these simple categories are likely to be far too crude to do justice to the facts. Not infrequently a parent who gives the impression of being consistently over-protective is found on occasion to be exactly the reverse; while a parent who appears to be consistently rejecting can on occasion be affectionate. The behaviour of the parents of many agoraphobics, like that of the parents of many school refusers, is probably very often intensely ambivalent. In both types of case the parental behaviour is usually, no doubt, a direct legacy of similar behaviour that the parents in their turn have suffered from one or other grandparent.
Family Interaction of Pattern D
In pattern D a parent is afraid that harm will come to the child and so, in the interests of the child's safety, keeps him at home. In the case of school-refusing children a main reason for a parent's fear of such happenings is the memory of some tragic event that has occurred earlier in his own life.
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1 In the remaining twelve cases evidence either was inconclusive or suggested that
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relationships were 'normal'; though in view of other findings it seems open to question that this was so.
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No direct evidence of this pattern in the families of agoraphobic patients seems to be on record, though repeated references to the over-protectiveness of parents make it likely that the pattern does occur.
This completes our attempt to discover to what extent the clinical features of agoraphobia can be understood in terms of one or other of the four patterns of disturbed family interaction that emerge so clearly in our study of cases of school refusal. With the quality of the data available on agoraphobic patients and their families so ill fitted for the task, the verdict must remain open. It is hoped, nevertheless, that our examination is such as to ensure that, in future studies of the syndrome, skilled attention will be given to interaction within the patients' families of origin, extending, whenever possible, over at least two generations. Only if data are specially gathered for the purpose will it be possible to explore further the set of hypotheses sketched and, in due course, to subject them to systematic test.
'Agoraphobia', bereavement, and depression
There is at least one other respect in which a close resemblance is found between agoraphobic adults and school-refusing children. This is that, in a high proportion of cases of both conditions, acute symptoms are found to have been precipitated by a bereavement, a serious illness (of relative or of patient), or some other major change in family circumstances. In most clinical accounts such events are mentioned only in passing. In the study by Roth ( 1959; 1960), however, statistics of precipitating events are given.
In Roth's series of 135 cases of agoraphobia, a bereavement, or a sudden illness in a close relative, 'usually a parent, upon whom the patient had been extremely dependent', is reported in 37 per cent. In a further 15 per cent there had been a severance of family ties or some other domestic crisis. Illness of the patient or some other acute danger to him had occurred in yet a further 31 per cent. That gives a total of 83 per cent of cases in which a precipitating event could be identified. Beyond noting the similarity of these findings to those found in cases of school refusal, however, little can be said until cases are reported in far more clinical detail than hitherto. In particular, Roth's material casts no light on the possible mode of action of the events he records.
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Nevertheless, there is already evidence that in the psychopathology of agoraphobia bereavement plays a specific part, and not just, as Marks is inclined to argue (see above, p. 297) an incidental one. Using a specially designed projection test consisting of seven poorly structured diffused faces, each of which, the tester suggests, represents a person who has 'experienced trouble' at one time or another in his life, Evans & Liggett ( 1971) found that a sample of ten agoraphobic patients tended to identify the 'trouble' as a bereavement significantly more often than did matched patients suffering from some other form of phobia, and also more often to identify the bereaved person in the picture as themselves.
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To pursue further the relation of anxiety to bereavement would take us beyond the bounds of this volume. It can, however, be noted that studies of bereaved people, for example those of Parkes ( 1969; 1971a), show that it is very common for them to suffer panic attacks and other symptoms of anxiety. Reflection on these findings suggests that there is a spectrum of cases towards one end of which are patients diagnosed by psychiatrists as agoraphobic and towards the other end of which are the much larger proportion of people whose symptoms are either less severe or less long-lasting and who are, therefore, never seen by psychiatrists.
Relevant also to the overall argument of this work is the close link that exists between agoraphobia and depression. First, symptoms of agoraphobia and of depression tend to change simultaneously and in the same direction, either both getting worse or both getting better (Roth 1959; Snaith 1968). Second, agoraphobic patients stand a higher risk of developing depressive illnesses than do other people (Schapira, Kerr & Roth 1970). In the third volume it is hoped to explore these relationships and their implications in greater detail.
A note on response to treatment
In a thoughtful review, Andrews ( 1966) has pointed out that, in their ways of treating agoraphobic patients, therapists of quite different schools often have more in common than they suppose. In both the behaviour therapy tradition and in some psychoanalytic traditions (e. g. Freud 1919; Fenichel 1945: Alexander & French 1946), it is believed desirable for the patient's relationship with the therapist to develop through two phases. During the first the patient comes to look to the therapist for support. During the second the therapist uses this
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relationship to urge the patient to confront the situations he most fears. 1 Since the technique of confrontation has been carried furthest by behaviour therapists, who claim some measure of success with it, it may be useful to consider what implications for theory that may have. During recent years a series of trials of the efficacy of different forms of psychological treatment has been conducted by Marks and Gelder at the Maudsley Hospital, London. Behaviour therapy has been given in two forms: (a) graded retraining together with systematic desensitization in imagination; and (b) flooding, a technique in which a patient is encouraged to visualize his most frightening phobic images continuously and without relief for a fifty- minute session, while the therapist talks constantly about the phobias and endeavours to maintain anxiety at maximum pitch. After the fifth and sixth sessions, moreover, the patient, accompanied by the therapist, spends a further hour exposing himself to all the situations that he believes frighten him most. In a recent report of the results of a crossover trial of the two treatments (Marks, Boulougouris & Marset 1971), improvements in the patients' condition, seen immediately after treatment and maintained twelve months later, are described. In the case of nine agoraphobic patients a combination of both treatments reduced symptom level from severe or very severe to moderate or mild. Of the two techniques flooding proved the more effective. A question that can properly be raised is whether these results are compatible with the hypotheses advanced in this chapter or incompatible with them. When treatment started the patients were of an average age of thirty-three years and had had their symptoms for about twelve years. They were all highly motivated towards treatment. Many of them regarded the flooding method as a challenge to prove that they could face the phobic situation, and for some it was the first time in years that they had exposed themselves to it. That they benefited from the experience might be attributable, on the basis of the present theory, to two circumstances:
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a. The phobic situations, e. g.
The symptoms, as might be expected, had not come out of the blue. According to father's record, Hans had been upset throughout the preceding week. It had begun when Hans had woken up one morning in tears. Asked why he was crying he had said to his mother: 'When I was asleep I thought you were gone and I had no Mummy to coax with. ' ( Coax was Hans expression for cuddle. ) Some days later his nursemaid had taken him to the local park, as usual. But in the street he had begun to cry and asked to be taken home, saying that he wanted to 'coax' with his mother. When later that day he had been asked why he had refused to go any further, he would not say. During that evening he had again become very frightened and cried,
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and he had demanded to stay with his mother. The next day, his mother, eager to find out what was wrong, had taken him on the visit to Scho? nbrunn, when the horse phobia was first noticed.
Looking back further into the history, we find that the week preceding the onset of the phobia had not been the first time that Hans had expressed fear that his mother might disappear. Six months earlier, during the summer holiday, he had made remarks such as 'Suppose I was to have no Mummy' or 'Suppose you were to go away'. Looking further back still, Hans's father recalled that, when Hanna was born, Hans, aged three and a half, had been kept away from his mother. In father's opinion, Hans's 'present anxiety, which prevents him leaving the neighbourhood of the house, is in reality the longing for [his mother] which he felt then'. Freud endorses that opinion and describes Hans's 'enormously intensified affection' for his mother as 'the fundamental phenomenon in his condition' ( SE 10: 24-5; also 96 and 114 ).
Thus, both the sequence of events leading up to the phobia and Hans's own statements make it clear that, distinct from and preceding any fear of horses, Hans was afraid that his mother
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might go away and leave him. Since, in the light of present knowledge, the expression of such fear should alert to the possibility that mother might have uttered threats, explicit or implicit, to leave the family, it is of interest to ask whether there is any evidence of her having done so.
Early in the record it becomes apparent that mother is inclined to use rather alarming threats. For example, when Hans is only three she is described as having threatened him that, if he touched his penis, she would send for the doctor to cut it off ( SE 10: 7-8). And we know too that, over a year later, at the time the phobia was first reported, mother was still trying to break him of the habit (p. 24 ). She is said to have 'warned him' not to touch his penis, though we are not told the nature of the warnings she was then uttering.
Three months later, however, and buried deep in the 'analytic' record, Hans lifts the curtain. He had come into father's bed one morning and in the course of talk had told his father: 'When you're away I'm afraid you're not coming home. ' Father expostulates: 'And have I ever threatened you that I shan't come home? ' 'Not you,' retorts Hans, 'but Mummy. Mummy's told me she won't come back. ' Father concedes the point. 'She said that', he replies, 'because you were naughty. ' 'Yes,' assents Hans ( SE 10: 44-5).
In the passage following father reflects, reasonably enough: 'His motive for at the most just venturing outside the house but not going away from it, and for turning round at the first attack of anxiety when he is half-way, is his fear of not finding his parents at home because they have gone away. ' Soon after, however, father reverts to an explanation along oedipal lines.
Even Hans's expressed fear that a horse might bite him is consonant with the view that fear of mother's departure was the principal source of his anxiety. This is shown by an incident that had occurred during the summer holiday of the previous year and to which Hans referred, by way of refutation, when father was trying to reassure him that horses do not bite. When Lizzi, a little girl who was staying in a neighbouring house, had gone away, the luggage had been taken to the station in a cart pulled by a white horse. Lizzi's father was there and had warned her: 'Don't put your finger to the white horse or it'll bite you' ( SE 10: 29). Thus, we find
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Hans's fear of being bitten by a horse is closely linked in his mind to someone's departure. There is other evidence also that horses are identified with departures (e. g. p. 45 ).
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On all these issues, it is evident that Freud was thinking along lines very different from those proposed here. Hans's insistent desire to remain with his mother is seen, not in terms of anxious attachment, but as the expression of his love for his mother, held to have been genitally sexual in character, having reached an extreme 'pitch of intensity' ( SE 10: 110-11). The dream that his mother had gone away and left him is held to have been, not an expression of Hans's fear that his mother would carry out a threat to desert the family, but an expression of his fear of the punishment due to him for his incestuous wishes ( SE 10: 118). The episode when Hans heard a neighbour warn that the white horse might bite is linked to a postulated wish that his father should go away, not to a fear lest his mother desert. Mother's displays of affection to Hans and her allowing him to come into bed with her are seen, not simply as a natural and comforting expression of motherly feeling, but as actions that might have encouraged, in a rather unfortunate way, Hans oedipal wishes ( SE 10: 28).
A tailpiece that tends to support the present hypothesis is that, subsequent to these events, Hans parents separated and later divorced ( SE 10: 148). (The fact that Hans was separated from his younger sister suggests that mother may have kept the little girl with her and left Hans with his father. )
There the matter must be left since there is no way of knowing which of the alternative constructions is nearer the truth. In the light of the evidence, both from the case itself and from other cases of childhood phobia reviewed earlier, the hypothesis advanced here seems no less plausible than the one adopted by Freud: it is not implausible to believe that the presenting symptom in the case of Little Hans can best be understood in terms of family interaction of pattern B.
The Case of Peter
In the literature on behaviour therapy the case of another young child, Peter, aged two years and ten months, who also suffered from intense fear of animals, has achieved some fame because it is the first recorded example of fear being deconditioned. Although the therapist, a student of Watson, assumes that the child had come to be afraid of animals through having been conditioned to fear them at some time unknown, explicit evidence regarding the way his mother treated him suggests that threats from his mother had probably played a principal part.
'When we began to study him', writes Mary Cover Jones
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( 1924b), 'he was afraid of a white rat, and this fear extended to a rabbit, a fur coat, a feather, cotton wool etc. , but not to wooden blocks and similar toys. ' At the sight of a white rat in his crib ' Peter screamed and fell flat on his back in a paroxysm of fear', and he proved to be even more afraid of a rabbit. Since other children of the same age were not particularly afraid of these creatures the researchers decided to see whether they could help Peter to become less afraid of them.
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A principal procedure used to 'decondition' Peter was for him to play each day with three other children chosen because of 'their entirely fearless attitude toward the rabbit'; during a part of the play period the rabbit was brought in. After about nine sessions, a second procedure was added: each time before the rabbit appeared Peter and the other children were given candy. Altogether some forty-five sessions were given, strung out over a period of nearly six months, during which there was a two-month interruption while Peter was in hospital for scarlet fever. From time to time Peter's progress was tested by presenting him with the rabbit when he was alone. At the end of the process Peter was no longer afraid of the rabbit or of the feather and he was much less afraid of the rat and the fur coat.
From the viewpoint of this work two aspects of the case command attention.
First, Peter is described as having come from a disturbed family that was living in impoverished conditions. Throughout the experiment, it seems, he was in a residential nursery 1 or else a hospital. His mother is described as 'a highly emotional individual who cannot get through an interview without a display of tears'. Peter's older sister had died and the parents were said thenceforward to have lavished 'unwise affection' on him. Discipline was 'erratic' and in her attempts to control him mother is said to have resorted to threats: the example given is 'Come in Peter, someone wants to steal you'. The pattern of family interaction suggested by this limited information is pattern C.
The second point of interest is the effect on the deconditioning process of the presence or absence of a particular student assistant of whom Peter was fond and who he insisted was his father.
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1 Although it is not stated explicitly that Peter was resident in the nursery in which
deconditioning took place, a phrase (near the end of the paper) that 'he has gone home to a difficult environment' suggests that this was so.
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On each of two occasions when this assistant was present Peter became decidedly less afraid, although the assistant made no overt suggestions. On this phenomenon Jones comments, 'it may be that having him there contributed to Peter's general feeling of well-being and thus indirectly affected his reactions'.
Animal phobias in childhood
There is no disposition to argue here that every case of animal phobia in childhood and later life is but the tip of an iceberg the great bulk of which comprises intense fear of losing an attachment figure. In some individuals, no doubt, an animal phobia has developed because as children they had some frightening experience in which they were attacked by an animal of that species. In other cases, seeing or hearing about such events, perhaps in dramatic circumstances and at an age when misunderstanding and fallacious over-generalization are common, may be responsible. In yet others, prolonged exposure to a parent or other adult who habitually responds with fear to a particular species of animal may play a part. Whatever the causes, Marks ( 1969) presents evidence suggesting that there are individuals who are acutely afraid of a particular species of animal but who do not suffer from any other form of emotional disturbance.
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Yet, although cases of true and limited animal phobia may well exist, there can be little doubt that, in very many children and probably adults also who are more than usually afraid of animals, the principal source of anxiety lies in the home and not outside it. It is already suggested that the cases of Little Hans and Peter can usefully be considered in that light. Further and substantial evidence stems from the finding that, as already described, many school-refusing children number among their heterogeneous symptoms a fear of animals. Furthermore, just as any expressed fear of school sinks into oblivion once the disturbed family situation is recognized and dealt with, so does any expressed fear of animals. Because that is so and because difficulties at home are so frequently kept a secret, it is wise when confronted by a patient complaining of animal phobia always to examine carefully the pattern of interaction within the family from which the patient comes.
The wisdom of this course is well illustrated by a case of animal phobia in an adult reported by Moss ( 1960). The patient was a woman of forty-five who had suffered since childhood from an intense fear of dogs. After seeing a film ( The Three Facesof Eve
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of Eve) in which a woman is treated for phobia by means of hypnosis, she sought hypnotic treatment for herself.
During the course of treatment the patient recalled a tragic event that had occurred when she was aged four. It appeared that she had been playing in the backyard of her home with her younger sister when the family dog, Rover, knocked the little sister down. A splinter entered the child's cheek, the wound went septic and a few days later the child died. The patient recalled how her mother had accused her of having knocked her sister down and had openly blamed her for the death, and also how thenceforward she had deeply disliked Rover and had become afraid of dogs of every kind. A few years later, after another sister had been born, she recalled that she had been much afraid lest a puppy attack that sister also.
After the patient had recalled how her mother had blamed her for her sister's death, much in her life seemed to her to fit into place. For example, the episode seemed to explain, at least in part, why she had always felt misunderstood by her mother, why she had suffered from a chronic sense of guilt and a compulsive desire to please, and why her relationship to her mother had been so deeply ambivalent.
When an event that a patient recalls has occurred many years previously it is extremely difficult to be sure how valid the recalled details may be. In this case it was possible to obtain limited corroboration of the patient's story. An elder brother confirmed the presence of Rover and also that at the time of the fatal accident his two little sisters had been alone, because he and his brother, who seem to have been left in charge, had gone off to watch a fire. The patient's youngest sister recalled how in later years the patient had anxiously protected her from the approach of any and every dog. There was, however, no corroboration that mother had blamed the patient for the accident, and mother herself, who was still alive, denied having done so.
Experience in family psychiatry shows, nevertheless, that, when a young child dies, it is by no means uncommon for a parent, distraught by what has happened and perhaps feeling guilty over failure to have taken some precaution, impetuously to attribute blame to an older child. In some families the older child then becomes a scapegoat; in others the parent, after
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recovering from the shock of acute grief, may forget, and then deny, having ever made the accusation. But in either case the accusation cuts deep, even when memory of it is repressed.
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That is what seems likely to have occurred in the case described. If that were so, there would be little wonder that the accused child had come to hate and fear the animal that she believed responsible for her disgrace. Nor would there be wonder that she should have felt thenceforward that her mother, and therefore all others to whom she might look for comfort and support, would disown her and treat her with nothing but contempt.
Enough has been said perhaps to show that the theory of anxious attachment outlined in earlier chapters can illuminate many a case in which a child is intensely and persistently afraid of some situation in circumstances that are perplexing to all around him and perhaps also to the child himself. In the next chapter the problem of agoraphobia in adults is considered in the light of the same theory.
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Chapter 19
Anxious Attachment and 'Agoraphobia'
It follows from the nature of the facts . . . that we are obliged to pay as much attention in our case histories to the purely human and social circumstances of our patients as to the somatic data and the symptoms of the disorder. Above all, our interests will be directed towards their family circumstances . . .
SIGMUND FREUD ( 1905a)
Symptomatology and theories of 'agoraphobia'
When a psychiatrist used to dealing with children and families examines the problem of 'agoraphobia' 1 he is at once struck by its resemblance to school phobia. In both types of case the patient is alleged to be afraid of going into a place filled with other people; in both the patient is apt to be afraid of various other situations as well; in both the patient is prone to anxiety attacks, depression, and psychosomatic symptoms; in both the condition is precipitated often by an illness or death; in both the patient is found to be 'overdependent', to be the child of parents one or both of whom suffer from long-standing neurosis, and frequently also to be under the domination of an 'overprotective' mother. Finally, a significant number of agoraphobic patients were school refusers as children.
Although minor degrees of agoraphobia are probably common and, when of recent origin, probably have a high remission rate ( Marks 1971), patients who come to the attention of psychiatrists are usually those who are suffering either from a chronic condition of some severity or else from an acute attack. Often a patient is intensely anxious, apt to panic when unable
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1 The condition under discussion appears in the literature under many names, including
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anxiety hysteria, anxiety neurosis, anxiety state, and phobic anxiety-depersonalization syndrome ( Roth 1959). The name most widely adopted at present is agoraphobia ( Marks 1969). Since criteria used to select cases differ from study to study, the extent to which findings are comparable remains in doubt.
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to get home quickly, and to be afraid of an extraordinarily broad range of situations (typically, crowded places, the street, travelling) or of collapsing or even dying when out on his own. From among this heterogeneous and variable collection of situations feared it is possible, none the less, to identify two that are feared in virtually every case and are also the most feared. These situations are, first, leaving familiar surroundings and, second, being alone, especially when out of the house. Since the argument advanced here turns on the fact that fear of these situations is at the heart of the syndrome, let us consider the evidence.
During the past decade there has been very active interest in the syndrome by psychiatrists in the United Kingdom. Roth and his colleagues in Newcastle upon Tyne describe two series of cases, each numbering over one hundred ( Roth 1959; 1960; Harper & Roth, 1962; Roth, Garside & Gurney 1965; Schapira, Kerr & Roth 1970). Special aspects of the condition to which they give attention are: the high incidence of traumatic precipitating events, notably actual or threatened physical illness, bereavement and illness in the family; the high incidence of depersonalization; and the close relation of the condition to states of anxiety and depression. Another programme of research into the condition, with special reference to the efficacy of different methods of treatment, is one conducted at the Maudsley Hospital, London, by Marks and Gelder (for references to their numerous papers see Marks 1969 and 1971). A third study of value is by Snaith ( 1968) who reports on forty-eight cases of phobia in adult patients, twenty-seven of whom were typically agoraphobic. Roberts ( 1964) describes results of a follow-up of thirty-eight patients, all married women.
Although none of these workers approaches the problem from a standpoint in any way similar to that adopted here, each endorses the view that a principal feature of the condition is fear of leaving home. Roth ( 1959) speaks of 'a fearful aversion to leaving familiar surroundings'; Marks ( 1969) holds that 'fear of going out is probably the most frequent symptom from which others develop'; Snaith ( 1968) finds that, in twentyseven of his forty-eight cases, the principal source of fear is leaving home and its attendant circumstances. Furthermore he reports, first, that the more anxious an agoraphobic patient becomes the more intense grows his fear of leaving home and, second, that when a patient becomes more anxious his fear of leaving home is magnified in intensity by a factor many times
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greater than is his fear of anything else. These findings lead Snaith to suggest that the condition is not a true phobia and that a more appropriate label for it would be 'non-specific insecurity fear'. In keeping with Snaith's perspective is the criterion that Roberts ( 1964) laid down for inclusion in his series, namely a patient's inability to leave his house without a companion.
Not only do these workers find that fear of leaving home when unaccompanied is the principal feature of agoraphobia, but each of them reports also that most patients have been anxious individuals all their lives: some for decades have been uneasy about going out alone (
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Marks 1969). Between 50 and 70 per cent of patients are reported to have suffered from fears and phobias during their childhood ( Roth 1960; Roberts 1964; Snaith 1968). In a recent survey of 600 cases using a questionnaire, between one-fifth and one-sixth described themselves as having been in some degree 'school phobic' ( Berg, Lipsedge & Marks, in preparation).
Again, although psychoanalysts working in the classical tradition have an approach to the problem entirely different from that of any of the workers so far cited, and different also from that adopted in this work, they report almost exactly the same findings. For example, in an early paper describing the case of a small boy, Abraham ( 1913) notes that the boy 'does not speak of fear, but of his desire to be with his mother'. This leads Abraham to conclude that the basic problem in patients suffering from agoraphobia is that their 'unconscious . . . does not permit them to be away from those on whom their libido is fixated'.
Both Deutsch ( 1929) and, in recent years, Weiss ( 1964) endorse Abraham's view. Weiss notes especially that a patient's anxiety is apt to increase the further from home he goes, which leads him to define agoraphobia as 'an anxiety reaction to abandoning a fixed point of support'.
Thus, despite great variation in the approach and outlook of these many workers, the findings they report are impressively consistent. Only when attempts are made to accommodate the findings within a theoretical framework do differences and difficulties arise.
Three Types of Theorizing
Here, as so often elsewhere, the two rival types of theory that dominate the field are psychoanalytic theory and learning
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theory. In the case of agoraphobia, however, a third type of theory has also been advanced, namely Roth's psychosomatic theory which invokes both psychological and neurophysiological processes ( Roth 1960). Strikingly enough, despite all the telltale hints that a major part is played by relationships within the patient's family of origin, a fourth type of theory, namely one that invokes pathogenic patterns of family interaction as major aetiological agents, is conspicuous by its absence.
1. Psychoanalytic theories of agoraphobia come in two main variants according to whether they focus on fear of being in the street or fear of leaving home.
Freud tends to concentrate on fear of being in the street, which he sees as a displacement outward of the patient's fear of his own libido. Even though in 1926 Freud began a major revision of his views and reached the conclusion that 'the key to an understanding of anxiety' is 'missing someone who is loved and longed for' (see Chapter 2 of this volume), he never applied his new theory to agoraphobia. 1 As a result, his original hypothesis continues to be invoked by a number of psychoanalysts who still see sexual temptation, of one kind or another, as the principal situation that an agoraphobic patient fears (e. g. Katan 1951; Friedman 1959; Weiss 1964).
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Other psychoanalysts in their theorizing take as their focus a patient's fear of leaving home and, in doing so, advance theories very similar to those their colleagues advance to account for the similar fear found in children diagnosed as suffering from school phobia. Thus Deutsch ( 1929) notes that the reason an agoraphobic patient feels compelled to remain near his mother (or other loved person) is that he entertains unconscious hostile wishes against her and so has to remain with her to ensure that his wishes are not enacted. For Weiss ( 1964) the patient's urge to remain at home is to be understood as due to a 'regression to unresolved dependency needs'. This is also the view of Fairbairn ( 1952), although in his case histories he attributes a causal role to the very insecure childhoods his patients had experienced.
In none of the psychoanalytic formulations, apart perhaps
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1 In one of his last works, New Introductory Lectures ( 1933), Freud writes: 'the agoraphobic
patient is . . . afraid of feelings of temptation that are aroused in him by meeting people in the street. In his phobia he brings about a displacement and henceforward is afraid of an external situation' ( SE 22: 84).
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from Fairbairn's, is there any suggestion that a patient's refusal to leave home is a response to the behaviour of one of his parents, not only behaviour that may have occurred at some time during the past but behaviour that may be occurring still in the present.
2. During the past decade or so a new approach to a theoretical understanding of phobic conditions of all sorts has been made, this time by learning theorists; and formulations that attempt to account for each of the various situations feared have been advanced. Whereas this approach may well help us to understand some of the discrete animal phobias, how much it can contribute to an understanding of agoraphobia remains in doubt. Describing the present position as he sees it Marks ( 1969), who has made a special study of agoraphobia and draws extensively on learning theory, writes as follows:
Certain phobias, especially agoraphobia, are commonly found together with multiple other symptoms such as diffuse anxiety, panic attacks, depression, depersonalization, obsessions and frigidity. Learning theory does not explain why these symptoms develop, why they occur together, nor why they are associated more often with agoraphobia than with any other type of phobia.
Furthermore, in Marks's view, 'the origin of the panics, depression and other symptoms is not indicated by learning theory' (p. 93 ).
How the panics and depressions do originate is, for Marks, the most puzzling aspect of the condition. For, in his opinion, not only is learning theory unable to account for them but no other theory can do so either (p. 93 ). Admitting the quandary, Marks leaves the matter open; but he tends to the view that anxiety attacks probably have an unknown physiological origin. Nowhere does he consider the possibility that they may originate in family situations that create psychological distress.
Having recognized frankly the difficulties in accounting for agoraphobic symptoms entirely in terms of learning theory, Marks believes nevertheless that the theory has much to offer. The
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hypothesis he advances is based on the idea, suggested by learning theory, 'that panic attacks and depression [may] act as super-reinforcers which facilitate phobic conditioning' whenever a patient who happens to be experiencing such affects goes out of his home. This line of thought leads Marks to propose that, in the development of agoraphobia, the anxiety
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attack comes first and the situations that the patient reports he fears come to be feared only later, either as a result of a secondary conditioning effect or as a result of rationalization. In that context both fear of going out of the house and fear of becoming separated from a companion, the two symptoms most characteristic of agoraphobic patients, are held to develop through a process of secondary conditioning.
In keeping with his hypothesis, Marks expresses much scepticism regarding the causal role of precipitating factors, holding that they probably act simply as 'non-specific stressors in a patient already liable to the disorder . . . or that the disorder was already present, but hidden until the stressor elicited or exacerbated it'. In support of his position he lays much emphasis on his claim that 'not a few phobias start suddenly without any obvious change in the life- situation of the patient' (p. 128 ).
Both the sequence of events that Marks postulates and the weakness of his position are illustrated in his description of the case of a woman who sought treatment at the age of thirtythree on account of depression with suicidal ideas. The account she then gave was that, ten years earlier when she was aged twenty-three, she had developed anxiety, sweating, and shaking of the legs while travelling to work by train. Subsequently she had discovered that she felt better if her husband was present and so had taken a job in the firm in which he worked. After a few months, however, she had become afraid of separation from him, had to know exactly where he was and had telephoned him frequently. If for any reason she could not contact him immediately she would panic, feel completely lost and want to scream.
The only information Marks gives regarding this patient's childhood is that 'as a small child [she] used to be frightened when her parents were out and once sent out her younger brother to find them.
She had infrequent desires to scream which were hard to stifle. These disappeared in her late teens. '
Despite the uncertain validity of the retrospective data, Marks seems confident about the sequence of symptoms: 'First came the travel phobia and depersonalization, then came the discovery of relief in the presence of her husband and after this he became indispensable. Finally the patient presented for treatment of separation anxiety. ' In accounting for the symptoms Marks proposes two distinct pathologies. On the one hand is the agoraphobia and on the other is the anxiety about
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separation, to which he believes the patient had been sensitized as a child. Originating independently, the two pathologies are held subsequently to have interacted.
There are several flaws in Marks's position. First, in the light of the childhood history of this patient, it is difficult to accept his confident assertion that agoraphobia came first and separation anxiety afterwards. Second, in his ready acceptance of this and other patients'
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accounts that the initial anxiety attack came 'out of the blue', he makes no allowance for a patient's witting or unwitting suppression of information, a process we know to be extremely common and often to hide clues vital for understanding the condition. Third, to postulate two distinct psychopathologies for a pair of symptoms that habitually go together 1 is far from parsimonious. Finally, as Marks himself admits, he can give no explanation of how or why this patient (or any other) first started to experience anxiety and panic attacks.
An alternative hypothesis to account for this patient's symptoms is that, during her childhood, she had been subjected to repeated and realistic threats of being abandoned, so that even after reaching adult life she had continued to be acutely sensitive to any such danger. The case is discussed further below (p. 307 ).
As regards the part played by a patient's parents in the genesis of agoraphobia, learning theorists share with traditional psychoanalysts the same shadowy picture. Whereas neither group attributes much importance to parental behaviour, in so far as they do so both invoke the theory of spoiling. As Andrews ( 1966) points out, Wolpe ( 1958) and Lazarus ( 1960), two leading learning theorists, both regard a patient's tendencies to withdraw to and to remain at home as responses he has learnt during interaction with over-protective parents. Marks ( 1969) in his discussion of prevention implies the same process. Some years earlier Terhune ( 1949), a psychiatrist whose outlook is in many ways similar to that of present-day learning theorists, wrote confidently: 'The phobic person is one who has been over-protected, brought up "soft". '
3. The third main type of theorizing about agoraphobia,
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1 Marks rests his argument on his finding that about 5 per cent of agoraphobic patients are
not helped by company and prefer to be alone while travelling ( Marks 1969: 98). in most syndromes, however, cases occur that lack one or more typical symptoms; an example is measles without a rash. Such atypical cases require special study.
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initiated by Roth ( 1959; 1960), regards the condition as being truly psychosomatic. In presenting his theory, Roth lays much emphasis on the vulnerable personalities of his patients, on the precipitating role of stressful events, and on depersonalization, which he regards as a core symptom of the syndrome. The psychological factors to which he points include both situations that, acting perhaps from early childhood, are thought to have contributed to the development of an anxious dependent personality, and stressful events, such as bereavement and illness, that appear to act as precipitants. The somatic factor he postulates is a specific cerebral mechanism that, once triggered, is difficult to inactivate. After considering certain disturbances of perception and consciousness that he finds in these patients, together with symptoms that he attributes to temporal lobe dysfunction, Roth concludes that the somatic pathology is probably to be understood as arising in the mechanisms regulating awareness, which he postulates to have become chronically deranged. Although he gives little detail of how he believes a difficult childhood and stressful situations of later life interact to produce an agoraphobic syndrome, Roth's approach is not incompatible with that presented here.
We turn now to consider a fourth type of theory, namely the one that results when the problem of agoraphobia is looked at in the theoretical perspective developed in this work.
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Throughout our further discussion it is important to bear in mind that, as all workers now agree, the central symptom of the condition under scrutiny is fear of leaving home.
Pathogenic patterns of family interaction
Whether the theory of anxious attachment, applied already to problems of school phobia, can help to solve problems of agoraphobia also must remain in doubt. For, apart from some limited and mostly rather crude observations, there are few data yet available on patterns of interaction within an agoraphobic patient's family of origin. Almost all the data yet published come either from the patient himself or from a single interview with a relative, with the many distortions and omissions that we know such clinical procedures entail. What is missing, but so necessary to have, is first-hand observations of how a patient and his parents are currently behaving towards one another. In the absence of such data all that is possible here is to draw attention to certain reasonably well-attested findings
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that are at least consonant with the view that many, if not all, cases of agoraphobia can be understood as products of pathogenic patterns of family interaction. There is much evidence of a rather general kind which, although it gives little information about specific patterns of interaction, points to a high incidence of disturbance in the families from which agoraphobic patients come. Before considering specific patterns, therefore, we consider this general evidence. Most reports agree that a majority of agoraphobic patients come from homes that are intact, in the sense that there are two parents living continuously together. Yet there is also substantial evidence that, within these homes, relationships are often far from harmonious; and it is repeatedly indicated that the parents of patients are neurotic or disturbed in some other way. Taking as a criterion clear-cut neurotic breakdown in first-degree relatives, Roth ( 1959) finds an incidence of 21 per cent. Nor should it be overlooked that a minority of patients, in one study as high as 25 per cent, come from homes broken by death, divorce, or other cause. In a recent study of eighty-seven consecutive London patients by M. S. Lipsedge (unpublished), a high incidence of disturbance in the families of origin is reported. The patients ranged in age from twenty-two to sixty-four years; fourteen were men and seventy- three women. Almost all the information was obtained from the patients themselves during an initial interview, though occasionally it was supplemented by information from a general practitioner. Inadequate though this method is for obtaining the information required, it is unlikely to exaggerate the degree of disturbance in the families from which the patients came. On the basis of this information, the patients' families can be divided very roughly into three categories:
I. I intact and reasonably stable families
II. II intact families in which there was much quarrelling, violence, and alcoholism, and/or
almost complete absence of affection
III. III families broken by death or divorce, or in which a parent was chronically ill, and/or
the patient had had prolonged separations from or changes of parent figure.
The number and proportion of patients from families in each category are shown in the following table.
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Category of No.
of % of patients
42 30 28 100
family
I
II
III Total
patients
37 26 24 87
Category I: There were thirty-seven patients who described their home life as having been happy or who gave no particularly adverse information about it. Nevertheless, two of these patients described a parent as having been agoraphobic (one father and one mother), and two others described themselves as having been 'over-protected'. Ten of the patients referred to themselves as having been notably fearful as children; of these, two had been school refusers and one agoraphobic. Thus neurotic trouble of one kind or another is reported in members of about one-third of these not overtly disturbed families.
Category II: There were twenty-six patients whose homes appear to have been intact but who described themselves as having had an extremely unhappy family life when children. Eighteen patients described their parents as having engaged in perpetual quarrels, including violence, and often made worse by alcohol. Another eight complained of having received no affection and/ or of having been rejected. In three of these twenty-six cases the patient's mother had been agoraphobic. Two of the patients had themselves been school refusers as children.
Category III: Of the remaining twenty-four patients, there were twenty-one whose family life had been disrupted by death, divorce, or desertion and/or who had experienced many changes of mother figure. Of these, ten had lost one or both parents by death before their tenth birthday (six a father, three a mother, and one both). In five cases mother had deserted and in at least one other father. Two patients when young children had been evacuated for several years from wartime London, starting in one case at the age of three years and in the other at four. A number of children had been brought up by relatives. In addition to the twenty-one patients who had experienced disruption of affectional ties, three had been brought up by chronically sick mothers: in one case mother had had multiple sclerosis from the time the patient was aged seven.
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Of this total of twenty-four patients three had had a parent figure who had been agoraphobic: one a father, one a mother, and one the grandmother with whom she lived. Eight patients described themselves as having suffered from anxiety as children; of these two were school refusers and one was agoraphobic.
Despite the manifest limitations of this evidence there is good reason to believe that in over half the cases (namely those from families in categories II and III) there was extensive disturbance of family life during the patient's childhood. Of the minority who were said to
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have come from stable homes there is clear evidence of covert disturbance in about a third of them.
Some Specific Patterns
Since, as already noted, there is a striking resemblance between cases of agoraphobia in adults and school refusal in children, there are strong prima facie grounds for suspecting that the paticular patterns of interaction present in the families of agoraphobic patients may be the same as, or similar to, those found in families of school-refusing children. Despite the very poor quality of the evidence available, such evidence as there is supports this expectation.
The following three patterns of interaction found commonly in the families of school-refusing children are probably to be found fairly frequently also in the families of agoraphobic patients:
Pattern mother, or more rarely father, is a sufferer from chronic anxiety regarding attachment A figures and either did in the past or still does retain the patient at home to be a
companion
Pattern the patient fears that something dreadful may happen to mother, or possibly father, B while he (the patient) is away from her; he therefore either remains at home with her
or else insists that she accompany him whenever he leaves the house
Pattern the patient fears that something dreadful may happen to himself if he is away from C home and so remains at home to prevent that happening.
As in the case of families with a school-refusing child, these differing patterns of interaction are not incompatible; mixed cases are probably common.
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The fourth pattern of interaction found in the families of school-refusing children -- pattern D, in which a parent fears for the safety of the child and therefore keeps him at home -- is not directly recorded in the families of agoraphobic patients, but indirect evidence suggests that it probably does occur.
Family Interaction of Pattern A
Much evidence suggests that pattern A, in which a parent is retaining a son or daughter at home to be a companion, is common in these families. Thus the dominant and controlling role that parents, usually mothers, have played and may still be playing in the lives of their children is emphasized in almost every study. Roth ( 1959) describes the relationship of his women patients with mother as tending to be 'close and intense' and as excluding often any contacts outside the immediate family circle. An 'emotionally immature' young woman, whom Roth presents as typical of his series of cases, is reported to have been prevailed upon by her 'masterful domineering mother' to break off her engagement with a quiet clergyman and so to remain at home. Snaith ( 1968) reports that in at least seven of his twenty-seven cases there was clear evidence of 'overprotection'. Webster ( 1953), who studied twenty-five cases, reports all but one of the patients' mothers to have been dominant and over-protective.
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Terhune ( 1949), reviewing eighty-six cases, concludes that the phobic syndrome arises 'when an apprehensive, dependent, emotionally immature person is trying to realize his ambitions to become an independent member of society'.
Despite these consistent findings, no student of the syndrome seems yet to have given thought to the question why a mother should treat her daughter (or son) in this dominating and possessive way, or by what techniques she succeeds in maintaining her hold over her offspring. In a case reported in the psychoanalytic literature by Deutsch ( 1929), however, we find evidence to the effect that the patient's mother was making insistent demands upon her daughter to act as companion and caretaker to her. But Deutsch does not discuss why the mother should have behaved in this way.
In presenting the case, that of a twenty-year-old girl who suffered from typical and severe agoraphobic symptoms, Deutsch describes the patient's mother as being 'highly neurotic' and as having from the first 'concentrated all her unsatisfied libido on the child', her only one. By contrast, the
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patient's father is said to have been treated by mother as a nonentity. Although mother claimed that 'ever since her daughter's birth she had been a slave to her' and that her daughter could never bear her to be away, the evidence suggests strongly that, as in similar cases of school refusal, the account given by mother was the inverse of what the relationship had really been and still was. In other words, it seems likely that, while claiming that her daughter was making great demands upon her, mother was herself making great demands upon her daughter. Support for this interpretation comes from the unpublished study by Lipsedge already referred to. Of the eighty-seven patients in his series, no fewer than eight reported that one or other parent figure was agoraphobic.
Admittedly the findings referred to amount to no more than presumptive evidence for the presence of pattern A in a number of the families from which agoraphobic patients come. At the least they point to the need for systematic research, not only into the relations between a patient and his parents but also into the relations between parents and grandparents. For, if a proper understanding of the psychodynamics of the condition as it passes from one generation to another is to be obtained, it is vital that the neurotic difficulties of the parents of patients should be looked at sympathetically in the context of their own experiences as children. It is also necessary to examine the relationship between an agoraphobic patient and his (or her) spouse. Fry ( 1962) reports seven patients whose husbands were also agoraphobic, though covertly so. In some of these cases the husband was most insistent that his wife needed to have him with her, though on examination it turned out that the pressure for the other's company was more his than hers.
Family Interaction of Pattern B
A patient's fear that something dreadful may happen to one of his parents is only rarely reported in the literature on agoraphobia. Whereas that might mean that fear of such an eventuality is truly uncommon, it may mean no more than that it goes unreported, either because patients find themselves unable to talk about the situations they fear or else because psychiatrists, ignorant of the significance of family interaction, fail to inquire. 1
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1 another reason might be that a psychiatrist without training in the recognition of pathogenic
patterns of family interaction fails to report the situations a patient says he fears and, instead, describes the patient
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The picture, given by Lipsedge, of disturbed interaction in many of the families of agoraphobic patients is such that it would hardly be surprising had some of his patients been living during their childhood in chronic fear of what might happen to one or both of their parents. Eleven of his eighty-seven patients reported that one or both parents had shown violent behaviour, and another seven described perpetual quarrels between them. Anyone with experience of children or adults who have grown up in such homes knows how terrifying to a child the violent and quarrelsome behaviour of parents can be. In the first place, violent acts may seem to be of literally murderous intent. In the second, the mere threats uttered may fill a child with horror; for, in quarrels between parents, threats to desert the family or to commit suicide are probably extremely common. The constant apprehension of losing one or both parents by murder or suicide that pervaded Mrs Q's life as a child is described in Chapter 15.
In addition to the threats that are aimed principally at a spouse are the threats that may be used by a parent as a means of controlling the children. And it must be remembered that threats, for example that if a child does not behave mother will get ill or die or commit suicide, can be continued not only throughout adolescence but into adult life as well, and, if applied consistently, can result in an adult's being reduced to a state of permanent intimidation.
A family situation of this kind, it is plausible to believe, may have lain behind one of the cases of agoraphobia already alluded to (p. 303 ), that of the girl of twenty on whom, in Deutsch's words, mother 'had concentrated all her libido'. Let us consider the case material further.
In this young woman a principal symptom was fear that something dreadful might happen to mother. When her mother left the house she was afraid lest she be run over; each day she waited anxiously at the window and heaved a sigh of relief when she saw her mother return safe and sound. Alternatively, the patient was afraid lest, while she herself was away from the house, something dreadful should happen to mother before she got back.
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1 simply as suffering from 'irrational fears', a category to which are too often consigned clues
that are among the most illuminating for understanding a patient's condition. Of thirty agoraphobic patients described by Harper & Roth ( 1962) nineteen are reported by them to have suffered from irrational fears.
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In commenting on the origin of this patient's anxiety, Deutsch adopts, without discussion, the hypothesis that she claims would be adopted by anyone versed in analytic work: that the patient's 'exaggeratedly affectionate anxiety' is an over-compensation for unconscious hostile wishes directed against mother; and that these hostile wishes have arisen as a result of the patient's oedipus complex. Although there are many psychoanalysts who would still adopt that hypothesis (though they might attribute the hostility to a pre-oedipal rather than an oedipal phase), others, through their experience in family psychiatry, would be aware of
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several other possibilities. One is that this 'highly neurotic' mother was given to threatening suicide. Another, which assumes Deutsch to be right in thinking that the patient was afraid mainly that her own hostile impulses might be enacted, is that the patient's mother had evoked such wishes by the insistent yet unacknowledged demands she had made upon her daughter over many years. Furthermore, prone as offspring are to adopt patterns of behaviour observed in a parent, it should be borne in mind that this patient, in developing a wish to push her mother under a tram (as Deutsch reports she did wish), might have taken her cue for such an action from a perhaps oft-repeated threat of her mother to throw herself under one.
In view of what we know can happen in families, though we are hardly ever told that it does, none of these ideas is fanciful. Yet all too often such possibilities are not even dreamed of by a clinician because the theory he is applying has no place for them. Only if every case is explored anew with knowledge of the part that can be played by family influences of these kinds are we likely to make progress in understanding and helping our patients.
Family Interaction of Pattern C
Fear that something dreadful may happen to themselves while they are out of the house is an extremely common symptom in agoraphobic patients. The principal situations mentioned as feared are of dying and of becoming helpless. Not infrequently such fear is linked to the various physical symptoms the patients experience -- palpitations, dizziness, weakness of legs -- which are interpreted by them as signs of imminent disability or death. By other patients again their fear is described as an overwhelming feeling of insecurity.
Although the situations a patient says he fears are frequently
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dismissed without further ado as irrational, knowledge of what can sometimes lie behind fear of similar happenings in children who refuse to go to school should alert us to the possibility that an agoraphobic patient is being, or at least has been, subjected to threats either of being abandoned or of being ejected from the family. As in the case of school-refusing children, information about such threats is hard to come by, but there is enough in the literature to make it clear that systematic investigation is required.
In most of the studies that have been referred to it is apparent that the possibility has never occurred to the researchers that the symptoms from which their patients suffered may have been a response to threats of being abandoned to which they may have been exposed during many years of childhood and adolescence. An example of the type of case that should clearly be considered in this light is the agoraphobic patient described by Marks ( 1969), and referred to earlier in this chapter, who recalled how as a child she had often been frightened when her parents left the house and how once she had sent her younger brother to find them.
Among the many studies of agoraphobia published, there appears to be but one in which threats are mentioned and are moreover, considered to have played a causal role in the patients' condition. This is a study by Webster (1953) who reports findings on twenty-five married women suffering from agoraphobia, all of whom had been in psychotherapy for a minimum of three months. Using as his data the clinicians' notes, Webster rated the attitude of the mothers of these patients towards their daughters. Of twenty-five mothers, twenty-four were rated as being dominant and over-protective. In making these ratings Webster adopted as
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his main criterion that the mother 'be most solicitous of the daughter's welfare, rewarding her often without good reason and rejecting or threatening to reject her or actually telling her she would not love her any more if she did not behave'. The patients' feelings of insecurity, Webster suggests, were probably a direct result of their having been treated in this kind of way. 1
As it happens, some years ago I treated a patient in her mid-twenties whose symptoms were typical of severe agoraphobia. Although for a year or more she insisted with great emphasis that nothing too good could be said of her mother,
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1 Webster does not discuss the possibility that some of these mothers may have threatened to
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later she described her mother as 'a tartar' who had always used the most dreadful and violent threats, including outright rejection, to get her own way and still used them. Her father, she said, was frightened of his wife and occupied himself as much as possible outside the home; the patient said she was fond of her father and felt sorry for him. The consistency of the story, and especially the coercive and threatening way in which the patient often treated her analyst, suggested that the picture she painted of her mother was probably not exaggerated. Were I to be treating this patient today I should give far greater attention than I did then to the part I now believe her mother's threats to have played both in the aetiology and in the maintenance of her condition.
Support for the view that a substantial proportion of agoraphobic patients have been subjected to harsh treatment in their homes comes, as we have seen, from the unpublished study by Lipsedge. In addition, Snaith ( 1968) presents evidence that, whereas the mothers of some agoraphobic patients are indeed over-protective, others are rejecting: in his series of twentyseven patients, seven are reported to have been over-protected and eight others to have been rejected. 1
Nevertheless, these simple categories are likely to be far too crude to do justice to the facts. Not infrequently a parent who gives the impression of being consistently over-protective is found on occasion to be exactly the reverse; while a parent who appears to be consistently rejecting can on occasion be affectionate. The behaviour of the parents of many agoraphobics, like that of the parents of many school refusers, is probably very often intensely ambivalent. In both types of case the parental behaviour is usually, no doubt, a direct legacy of similar behaviour that the parents in their turn have suffered from one or other grandparent.
Family Interaction of Pattern D
In pattern D a parent is afraid that harm will come to the child and so, in the interests of the child's safety, keeps him at home. In the case of school-refusing children a main reason for a parent's fear of such happenings is the memory of some tragic event that has occurred earlier in his own life.
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1 In the remaining twelve cases evidence either was inconclusive or suggested that
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relationships were 'normal'; though in view of other findings it seems open to question that this was so.
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No direct evidence of this pattern in the families of agoraphobic patients seems to be on record, though repeated references to the over-protectiveness of parents make it likely that the pattern does occur.
This completes our attempt to discover to what extent the clinical features of agoraphobia can be understood in terms of one or other of the four patterns of disturbed family interaction that emerge so clearly in our study of cases of school refusal. With the quality of the data available on agoraphobic patients and their families so ill fitted for the task, the verdict must remain open. It is hoped, nevertheless, that our examination is such as to ensure that, in future studies of the syndrome, skilled attention will be given to interaction within the patients' families of origin, extending, whenever possible, over at least two generations. Only if data are specially gathered for the purpose will it be possible to explore further the set of hypotheses sketched and, in due course, to subject them to systematic test.
'Agoraphobia', bereavement, and depression
There is at least one other respect in which a close resemblance is found between agoraphobic adults and school-refusing children. This is that, in a high proportion of cases of both conditions, acute symptoms are found to have been precipitated by a bereavement, a serious illness (of relative or of patient), or some other major change in family circumstances. In most clinical accounts such events are mentioned only in passing. In the study by Roth ( 1959; 1960), however, statistics of precipitating events are given.
In Roth's series of 135 cases of agoraphobia, a bereavement, or a sudden illness in a close relative, 'usually a parent, upon whom the patient had been extremely dependent', is reported in 37 per cent. In a further 15 per cent there had been a severance of family ties or some other domestic crisis. Illness of the patient or some other acute danger to him had occurred in yet a further 31 per cent. That gives a total of 83 per cent of cases in which a precipitating event could be identified. Beyond noting the similarity of these findings to those found in cases of school refusal, however, little can be said until cases are reported in far more clinical detail than hitherto. In particular, Roth's material casts no light on the possible mode of action of the events he records.
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Nevertheless, there is already evidence that in the psychopathology of agoraphobia bereavement plays a specific part, and not just, as Marks is inclined to argue (see above, p. 297) an incidental one. Using a specially designed projection test consisting of seven poorly structured diffused faces, each of which, the tester suggests, represents a person who has 'experienced trouble' at one time or another in his life, Evans & Liggett ( 1971) found that a sample of ten agoraphobic patients tended to identify the 'trouble' as a bereavement significantly more often than did matched patients suffering from some other form of phobia, and also more often to identify the bereaved person in the picture as themselves.
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To pursue further the relation of anxiety to bereavement would take us beyond the bounds of this volume. It can, however, be noted that studies of bereaved people, for example those of Parkes ( 1969; 1971a), show that it is very common for them to suffer panic attacks and other symptoms of anxiety. Reflection on these findings suggests that there is a spectrum of cases towards one end of which are patients diagnosed by psychiatrists as agoraphobic and towards the other end of which are the much larger proportion of people whose symptoms are either less severe or less long-lasting and who are, therefore, never seen by psychiatrists.
Relevant also to the overall argument of this work is the close link that exists between agoraphobia and depression. First, symptoms of agoraphobia and of depression tend to change simultaneously and in the same direction, either both getting worse or both getting better (Roth 1959; Snaith 1968). Second, agoraphobic patients stand a higher risk of developing depressive illnesses than do other people (Schapira, Kerr & Roth 1970). In the third volume it is hoped to explore these relationships and their implications in greater detail.
A note on response to treatment
In a thoughtful review, Andrews ( 1966) has pointed out that, in their ways of treating agoraphobic patients, therapists of quite different schools often have more in common than they suppose. In both the behaviour therapy tradition and in some psychoanalytic traditions (e. g. Freud 1919; Fenichel 1945: Alexander & French 1946), it is believed desirable for the patient's relationship with the therapist to develop through two phases. During the first the patient comes to look to the therapist for support. During the second the therapist uses this
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relationship to urge the patient to confront the situations he most fears. 1 Since the technique of confrontation has been carried furthest by behaviour therapists, who claim some measure of success with it, it may be useful to consider what implications for theory that may have. During recent years a series of trials of the efficacy of different forms of psychological treatment has been conducted by Marks and Gelder at the Maudsley Hospital, London. Behaviour therapy has been given in two forms: (a) graded retraining together with systematic desensitization in imagination; and (b) flooding, a technique in which a patient is encouraged to visualize his most frightening phobic images continuously and without relief for a fifty- minute session, while the therapist talks constantly about the phobias and endeavours to maintain anxiety at maximum pitch. After the fifth and sixth sessions, moreover, the patient, accompanied by the therapist, spends a further hour exposing himself to all the situations that he believes frighten him most. In a recent report of the results of a crossover trial of the two treatments (Marks, Boulougouris & Marset 1971), improvements in the patients' condition, seen immediately after treatment and maintained twelve months later, are described. In the case of nine agoraphobic patients a combination of both treatments reduced symptom level from severe or very severe to moderate or mild. Of the two techniques flooding proved the more effective. A question that can properly be raised is whether these results are compatible with the hypotheses advanced in this chapter or incompatible with them. When treatment started the patients were of an average age of thirty-three years and had had their symptoms for about twelve years. They were all highly motivated towards treatment. Many of them regarded the flooding method as a challenge to prove that they could face the phobic situation, and for some it was the first time in years that they had exposed themselves to it. That they benefited from the experience might be attributable, on the basis of the present theory, to two circumstances:
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a. The phobic situations, e. g.
