The following paper is a pre-publication version of the original

DAVID KRAFT, London

Abstract

Agoraphobia is an extremely complex disorder to treat in clinical practice (Chambless, 1982; Kaplan & Sadock, 1991) and patients are often resistant to therapy (Fava, Savron, Zielezny, Grandi, Rafanelli & Conti, 1997; Kellerman, 2010). Resistance takes on many forms including refusing to visit the practitioner in the first place, confrontation, symptom substitution, over-reliance on a ‘safe person’ (Carter, 1998), focussing on and increasing the intensity of psychosomatic manifestations, refusing actively to participate during treatment, intellectualization, somatisation and, in many instances, the family can take an active role in perpetuating the condition. The following paper focuses on the treatment of agoraphobia and, specifically, on how hypnosis is employed in order to counteract resistance, thus reducing negative transference and providing the patient with the coping skills to become independent in the outside world. The efficacy of the additional use of in vivo desensitization, Ericksonian strategies and ‘rationale therapy’ (Clarke & Jackson, 1983) is discussed.

Key words: agoraphobia, resistance, psychosomatic manifestation, safe person/safe partner

Introduction
According to DSM IV (American Psychiatric Association, 1994), agoraphobia is characterized by anxiety and/or panic situations outside the comfort of the home or ‘safe zone’ (Chambless, 1982a; McCabe, 2010). Many agoraphobics fear situations in which they feel that they are unable to escape (Harris, 1991), and in which there is noone to help if they were to have an unexpected or situationally-induced panic attack. A common element in agoraphobia is the fear of losing control (Chambless, 1982b; Salzman, 1982; Basoglu, Marks, Sengun, 1992). In many cases, agoraphobia begins with a phobic response to one stimulus, for example, driving (Collins, 1996) or crossing a bridge (Tilton, 1983) and this develops into full-blown agoraphobia: as the condition worsens, individuals experience a great deal of anticipatory fear (Burns, 1982; Stafrace, 1994), and many worry that they will have a panic attack. This phenomenon has been described as the ‘fear of the fear’ (Harris, 1991; Hoffart, Friis & Martinson, 1992; Evans & Coman, 2003; Kraft & Kraft, 2005; Kraft & Kraft, 2006). Typical features of agoraphobia are as follows: being alone and outside the house, queuing, being in a crowd, standing on a bridge, travelling on public transport, going shopping, walking amongst tall buildings, meeting friends, and some even fear different types of weather.

Agoraphobia is often perpetuated by family behaviour and, in many instances, members of the immediate family?particularly partners and parental figures?help to maintain phobic anxiety (Arnow, Taylor, Agras & Telch, 1985; Oatley & Hodgson, 1987). Some patients come to rely on these ‘safe partners’ (Kraft, 2011); and, as a result, this decreases independence which then in turn effects overall quality of life (Leon, Portera, Weissman, 1995). Agoraphobia is associated with a huge amount of avoidance behaviour: individuals tend to avoid situations because of a marked fear that they might have a panic attack; indeed, many sufferers fear that they will lose control and will embarrass themselves in these situations. These panic attacks are accompanied by some of the following concomitant symptoms:
a) dizziness
b) palpitations
c) trembling or shaking
d) chest pain/tightness of chest
e) fear of losing control
f) fear of dying
g) fear of going mad
h) nausea
i) choking sensations
j) abdominal pain
k) shortness of breath
l) hyperhidrosis
m) paresthesia
n) hot flushes
o) feelings of depersonalization and/or derealisation
A number of studies have shown that agoraphobia responds well to behaviour therapy: successful results have been reported using systematic desensitization (Kraft, 1967; Wolpe, 1973), flooding (Matthews, Johnston, Lancashire, Munby, Shaw, Gelder, 1976); in vivo exposure therapy (Emmelkamp, 1980; Andrews, 1990; Fava, Savron, Zielezny, Grandi, Rafanelli & Conti, 1997; Fava, Rafanelli, Grandi, Conti, Ruini, Mangelli & Belluardo, 2001) and group exposure (Teasdale, Walsh, Lancashire, Matthews, 1977). Further, behavioural techniques?particularly in vivo exposure therapy?have been employed successfully in conjunction with hypnosis (Jackson & Elton, 1985; Schmidt, 1985; Milne, 1988; Harris, 1991; Mellinger 1992; Roddick, 1992; Stafrace, 1994; Collins, 1996).

Due to the fact that the source of agoraphobia is complex (Kaplan & Sadock, 1991) and it is inextricably interconnected with the family situation (Stafrace, 1994; Kraft, 2011), it is difficult to treat (Mathews, Gelder, Johnston, 1981; Chambless, 1982; Hobbs, 1982): thus, therapy often tends to be lengthy (Milne, 1988). The source of this condition centres on complex and/or disturbing relationships with?normally over-powering?parental figures (Craske, 1999), and the parent?s persistently damaging behaviour reduces patients? independence, causing them to be resistant in treatment. In addition, Hafner (1977) and Hand and Lamontague (1976) have stressed how important it is to investigate the relationship between patients and partners or spouses, as this, if not entirely responsible for the problem, can quite often have a deleterious effect on the patient?s mobility and overall sense of well being. A number of therapists have reported resistance in agoraphobic patients and have suggested possible interventions using CBT (Mavissakalian, Matig, Michelson, Greenwald, Kornblith & Greenwald, 1983; Beck, Emery, 1985; Marchione, Karen, Michelson, Greenwald & Dancu, 1987; Taylor 2000), and psychotherapy (Bassler & Hoffmann, 1994; Shilkret, 2002; Winter & Metcalfe, 2008; Kellerman, 2010). The following report, however, focuses on the treatment of agoraphobia using a combination of approaches with hypnosis, and how, specifically, hypnosis has been employed to counteract resistance?unconscious or otherwise?in patients? behaviour as well as in the behaviour of members of the family. Cognitive-behavioural techniques and the use of ‘rationale therapy’ (Clarke & Jackson, 1983) are also considered.

Refusing to visit the therapist and the role of home visits and telephones sessions in treatment
Agoraphobics, due to the nature of their condition, are sometimes unable to go to the consulting room for treatment. If the patient is unable to see the therapist, even with the help of a ‘safe person’, a home visit is probably the only option. Schmidt (1985), in the treatment of a 28 year-old female, decided to arrange telephone sessions to deal with this problem, but, this was done after he had made a house call, and once he had established a treatment programme. The programme consisted of systematic desensitization in hypnosis, using a graded hierarchy of her own invention. The therapist provided the patient with weekly tapes to this end and, over a period of six months, the tapes gradually moved her closer towards being able to visit the shopping mall on her own.

Schmidt did find that there was some resistance at the house call: the patient insisted that her neighbour was present during the session. It is often the case that agoraphobic patients have one or more safe people that stay with them in the house, help them with shopping and doing other jobs for them: these individuals, often with the best intentions, help to perpetuate or even worsen the condition. Sometimes this safe person is a spouse or loved one, and this, as we will see later, can have more serious effects in perpetuating the agoraphobia. Schmidt dealt with this intrusion by ignoring it and by teaching the patient autogenic training (Jencks, 1973; Wallnöfer, 1980) so that she could practise this in the comfort of her on home (and on her own). They jointly devised a treatment plan, which consisted of using a combination of tapes which, employing guided imagery, would gradually desensitize her to what she perceived to be threatening public places. They also decided that she should follow up each new scenario with a telephone appointment: the purpose of these sessions was to reinforce her progress, providing her with more control over the pace of the therapy. They also gave her the opportunity to explore the meaning of her thoughts triggered by the exercises on tape. Teaching her the autogenic training (self hypnosis) right from the start, and organizing one-to-one telephone sessions, helped to make sure that her safe person would not interfere with her progress.

Collins (1996) reported the successful treatment of man who had been suffering from agoraphobia for 6 years due to the collapse of his business. The patient, referred to as Roger, had been experiencing panic attacks while driving and this had gradually worsened so that he was unable to leave the residential estate in which he lived?he was also unable to go anywhere on foot and could not tolerate being a passenger on public transport nor in anybody?s car. Interestingly, the family were dubious about the selectiveness of his condition, particularly as he very much enjoyed his domestic role and was able to drive his own car. Roger resisted treatment at the hospital, refusing to attend the appointment; it was then that the psychologist arranged for a home visit.

At the first appointment, Collins explained the rationale of treatment and reinforced the fact that Roger would be in control of both his therapy and the speed at which it progressed?this comment served the purpose of ensuring his active involvement in the process. He was also taught self hypnosis. Collins arranged weekly visits and Roger made significant process using hypnosis and by working through the Subjective Units of Disturbance Scale (SUDs) (Wolpe, 1969). He was told that in vivo desensitization would not be employed until he was able to reduce his levels of anxiety during these visualizations to a 3 (on a scale where 0=no anxiety and 10=maximum anxiety).

Roger made significant improvement, meticulously recording his levels of anxiety for each potentially anxiety-provoking visualization; however, further resistance occurred after 6 weeks of treatment. He had reduced his anxiety to a zero on all the scenarios, but had found that he was unable to drive on a particular road?the same road in which his business had failed?and this represented for him an insurmountable psychological barrier in his treatment. However, the therapist helped Roger gradually to be able to move towards this final goal: first, he was instructed to drive closer and closer to the road, secondly, to sit in his car alongside the road, and, thirdly, to do this while employing visualization techniques and coping strategies. In the sessions that followed, both he and the therapist were able to chain the small segments of the road together so that he could build up an image in his mind of a complete journey using this specific road.

Resistance within the family context
Often resistance can come from members of the immediate family and this is particularly difficult to deal with when it is a spouse or partner. Jackson and Elton (1985) reported a case of a 41-year old married woman who had been suffering from agoraphobia for many years and had controlled her condition with medication including amitriptyline and, clorazepate and chlordiazepoxide. While this had the effect of reducing her overall anxiety, it did not reduce her avoidance behaviour or lessen the frequency of her panic attacks. After 4 weeks of intensive in vivo exposure, with some initial success, her train phobia remained at an 8 on the 0-8 Main Phobia 1 Rating Scale, as derived from the Fear Schedule (FSS) (Hafner & Marks, 1976; Marks, 1977). The patient complained that she was still experiencing a great deal of anticipatory anxiety and had had multiple panic attacks on trains; it was then decided that hypnosis should be used as an adjunct to therapy.

Using age regression, it was revealed that, at the age of 8, she was publicly humiliated, undressed and fondled by her mother?s male friends at a party. At this point, she abreacted, screaming at her mother. She claimed that she projected the abuser?s faces onto strange men on the trains. Following this important session, she began to use trains more freely.

However, after approximately 2 months of treatment, as the patient was making significant improvement, her husband began to become increasingly introspective, and, as a result, her supportive mechanism was taken away. In addition, he increased his alcohol intake, demanded to do the shopping for her and underplayed her treatment gains. In order to counteract this problem, she was encouraged, during the hypnosis, to express her anger about her husband?s behaviour; the therapy then focussed on her working through her feelings of guilt about continuing in vivo exposure therapy?this was done both in the hypnosis and in the psychodynamic psychotherapy. This combined approach made it possible for her to continue her in vivo work, and also to make a complete recovery.

Physical Manifestations
Patients suffering from agoraphobia frequently report that their anticipatory anxiety often leads to a panic attack, and that this often means that they avoid any situation that may precipitate this chain of events. Stafrace (1994) reported the case of a man, Peter, who had been suffering from agoraphobia as well as a constant fear that he was on the verge of having a heart attack?indeed, he experienced many of the associative features of a myocardial infarction, including palpitations, shortness of breath, chest pains, dizziness, perioral numbness and tingling sensations in his fingers. Having excluded any cardiac or other organic causes for these manifestations, he was referred for assessment. Stafrace used the first two sessions to take a history, to plan the treatment together and to educate his patient about his condition?a process described by Clarke and Jackson (1983) as ‘rationale therapy’.

However, Peter still believed that his ‘symptoms’ were a result of some sort of heart disease. The therapist reassured him that none of the cardiac investigations supported this and designed a treatment strategy using CBT, hypnosis and a starting dose of Imipramine 25mg, gradually increasing to 150-200mg over a 3 week period. The CBT component to the therapy consisted of exposure therapy, initially in vitro and moving on towards in vivo, and the keeping of a diary which would record his feelings of anxiety on a scale of 0-10. He was also asked to record any physical sensations and negative cognitions associated with each attack and to reframe these negative thoughts in order to reduce his anxiety in each feared situation. However, Peter still believed that he was experiencing angina-type symptoms. Scafrace suggested to him that his palpitations were due to his selective attention to, and heightened awareness of, his heart rate: he taught Peter ideomotor signalling (Waxman, 1989), and asked him to focus on his heart rate and to signal when occasionally it would miss a beat. Following this, Scafrace used special place imagery, followed by suggestions of calmness and tranquillity to encourage him to experience the imagined scene without any negative connotations?and, specifically, without palpitations. Importantly, Scafrace did not use direct suggestions to eliminate the symptoms so as not to challenge Peter?s sense of self control; instead he used ego strengthening and symptom relief in order to provide the patient with a feeling of self control and confidence (Waxman, 1989; Yapko, 2003). After this session, although more exploratory work needed to be done, he was able to recognize that the palpitations were a manifestation of anticipatory anxiety and was able to stop these ruminations from developing into a full blown panic attack.

Resistance to Hypnotherapy
Some agoraphobics are resistant to hypnotherapy altogether (Chase, 1991). During the induction, the body begins to experience a number of physiological changes, as well as changes in perception which can, in the first instance, be frightening. For example, some individuals may even anticipate that these changes could precipitate a panic attack. Hobbs (1982) pointed out that it is important to combine suggestions of relaxation with positive reinforcement, but that agoraphobics? obsessional and introspective ideation will often block the induction process. She, therefore, recommended that, for the first two to three sessions, patients should be educated about the physiological changes that occur during hypnosis (see for example, Crasilneck & Hall, 1959; Clarke & Jackson, 1983), using diagrams and a specially-prepared audio tape which should be used at home. In the case report, Hobbs explained that, apart from normalizing hypnosis as a perfectly safe and natural process, the tapes helped the patient to feel more comfortable with the therapist?s voice. Gradually, Hobbs added to these tapes, suggestions of relaxation using guided imagery. She pointed out that deepeners could be incorporated as the therapy progressed; she also stressed that, by using audio tapes at home, the patient was able to exercise more control of the treatment and that this would reduce resistance. Indeed, it has been found that after the initial education, and once trust had been established between therapist and patient, agoraphobics often become excellent hypnotic subjects and are able to respond and effect change using guided imagery and coping strategies (Mellinger, 1992).

It is important to note here that Hobbs gradually introduced hypnosis to the patient. Indeed, some therapists re-frame the term ‘hypnosis’ and gradually introduce altered states of awareness in the form of ‘hypno-relaxation’?a process similar to meditation (Milne, 1988). Another example of this gradual process is one provided by Roddick (1992) who also spent 3 or 4 sessions building rapport and helping his patients to get used to be able to relax in his presence before introducing hypnosis. He recognized that agoraphobics tend to suffer from a lack of confidence which gradually becomes worse as the phobia develops. He suggested that this lack of confidence causes patients to be unable to relax sufficiently during sessions, and that hypnotic inductions are not entirely effective until they feel that they can trust the therapist. The treatment programme consisted of the stages as shown below, and this was demonstrated in a single case study (Roddick, 1992). Note that the client in this case study had a particular aversion to being driven in a car and that these principles can be adapted to suit the needs of the patient.
1 Relaxing in the presence of the therapist; case history {approx. 4 sessions}
2 a) Hypnosis is introduced using PMR induction
b) Experiencing special place imagery?desert island beach
c) Addressing the unconscious mind focussing on i) the importance of practising relaxation,
ii) Being able to travel in a car, iii) being able to eat and drink ‘as well as ever’
3 a) Direct suggestions of bringing the three parts together
b) Ideomotor signalling used to ascertain whether the strategy has worked and was acceptable
c) Re-integration of unconscious mind and conscious mind on the desert island beach
4 a) ‘Throwing out’ of negative thoughts
b) Direct suggestions that the skills that the patient has learnt in the special place can be utilized at any time
After 8 sessions of using this technique, the patient was able to drive herself to sessions and continued to make further progress thereafter.

On occasions during hypnosis, patients resist direct suggestions and the guided imagery that is introduced and this can cause significant problems for clinicians. In his model for treating agoraphobia using hypnosis, ‘subliminal therapy’ and paradoxical intention, Yager (1988) pointed out that negative comments about a feared situation can be utilized in treatment. In his approach, he recommended that patients be first introduced to hypnosis by experiencing an early, pleasant memory, followed by the teaching of self hypnosis. He then would ask patients to read his approach to subliminal therapy (Yager, 1984) which, it was hoped, would educate them about how to use the unconscious mind to facilitate positive change. Yager pointed out that paradoxical intention (Raskin & Klein, 1976; Lankton & Zeig, 1989; Zeig, 2008) can also be employed in order to counteract any anticipatory fear of, and resistance to, clinical hypnosis?he would suggest to patients that they should welcome the fear and that, paradoxically, this fear would lose its strength and meaning. In addition, he advised that this ‘intentional effort’ exerted by the patient at this time would help him or her to gain more control over the response (Michelson, Ascher, 1984). In addition, he advised that if patients suggest that they are worried that they are going to faint or sweat profusely during in vitro desensitization, humour can be employed in order to contradict this fear. Comments such as, ‘I’ll show the world that I’m the best fainter anywhere’, or, ‘I only sweated out a quart before, but now I?m going to pour out at least ten quarts’ have been used effectively (Frankl, 1973; Yager, 1988).

The growing popularity of stage hypnosis in the media has produced a huge amount of fear about hypnosis in general. This has had several effects. A positive effect of this is that hypnosis has been brought into the limelight, and many potential patients are aware of the immense power of hypnosis in the hands of a fully-qualified clinician (Calvert, 2007). However, poor education and misunderstanding of the difference between clinical hypnosis and stage hypnosis, on occasions, have caused immense fear and resistance during treatment. An example of this can be found in the case study of a female agoraphobic patient who had been unable to travel abroad for a significant amount of time (Harris, 1991). Having been resistant to various other forms of treatment including NLP and insight-orientated psychotherapy, it was decided that hypnosis be employed in order to help her to gain control of her behaviour. Aware of her scepticism of hypnosis and its efficacy, the therapist, like Hobbs (1982), began by re-educating her about its effects in clinical practice?specifically focussing on the control that would be given to her during the process. She was taught progressive muscle relaxation, involving the gradual tensing and releasing of muscle groups (Susskind, 1970); however, she harboured a number of myths about hypnosis and stage hypnosis and worried that, contrary to what she had just be taught, her therapist would have control over her.

Thus, as a result, Harris had to move very slowly, using PMR and ego strengthening until the patient had more confidence in her. Only after this confidence had been built was the therapist able to move onto employing systematic desensitization in vitro: Harris combined this with the use of positive imagery, self-efficacy training and suggestions which reinforced her ability to cope with stress and tension. She also used the direct suggestion, ‘You’re body knows what to do’. The patient re-iterated this positive statement post-hypnosis, intimating that she was beginning to feel that she had control of the situation. Harris commented that this was a pivotal point in the therapy in that it increased her confidence and her ability to cope in stressful situations. After 10 weeks of hypnosis and in vivo desensitization, she was able to travel abroad successfully and said that she was symptom free.

Tilton (1983) reported the case of an agoraphobic man who had resisted hypnotic intervention by falling asleep during the process?this was evidenced by snoring, ‘hypnic jerks’ (head bobbing) and his refusal to respond. The therapist dealt with this by using arm catalepsy and by frequently asking him to respond verbally. It was revealed that the patient?s agoraphobia began with his anxiety of specific bridges, and this developed into severe agoraphobia, a fear of all bridges, aeroplanes, highways and open spaces. The patient asked to be treated intermittently (and, therefore, slowly), and required 2 years of treatment which consisted of systematic desensitization, age regression, NLP and Ericksonian techniques in hypnosis. Thus, the patient felt that he had control over the pace of the therapy; and, as a result, his panic attacks reduced significantly and he overcame many of his phobias.

Tilton experienced a second resistance from this patient during the course of treatment. Approximately one month before a holiday with his family, the patient stated that he was extremely anxious about this trip because it involved crossing various bridges and flying on an aeroplane. The therapist gave him ego strengthening, used systematic desensitization, and encouraged him to practise visualizing enjoying various situations on the proposed trip. In the final session before the holiday, he reported that he was concerned about 3 situations?particularly, a proposed fishing trip?and he displayed a huge amount of resistance, refusing to visualize these scenarios in the hypnosis. Tilton re-hypnotized the patient and, using pseudo-orientation, transported him to a time shortly after what he described to be as a successful trip away. He asked the patient about these three specific situations, but unfortunately he responded that he had not done any of them. The therapist cleverly, using an authoritative and sincere tone, expressed surprise and told the patient that he had already enjoyed doing all these activities; furthermore, and without pausing, he described a made-up story about one of these activities in great detail. He repeated these stories until he became somewhat confused. Tilton explained that, as the patient trusted him, he was placed in a double bind: if he believed his therapist, it meant that he had done these activities and had subsequently forgotten about them, but if he didn?t believe him, it meant that his therapist was lying. Finally, he acknowledged the fact that he had done these activities, accepted the successful outcome of the ensuing holiday, and, as a result, was able to enjoy his vacation with his family the following week.
Resistance to in vivo therapy
Mellinger (1992) reported a case of a lady suffering from agoraphobia with panic attacks. The first 8 weeks of treatment consisted of case history taking and a heuristic explanation of her phobic anxiety, the latter of which was subsequently used as a base of her cognitive-behavioural treatment. She then began a programme of in vivo desensitization. She decided that her first in vivo task would be to travel, at midnight, to the local shopping mall with her husband; however, although she used relaxation techniques to prepare herself for this task, she exercised a huge amount of resistance and, as she began to think more negatively about the situation, her anxiety increased and she abandoned her shopping, and rushed home to safety.

The therapist, in the following session, decided to postpone the in vivo work and to use hypnosis in order to enhance her coping strategies. Mellinger used a permissive induction, and employed an anchoring technique which consisted of her touching her fingertips to her solar plexus: this helped her to breathe more slowly and evenly and to relax. Further, during the hypnosis, she was encouraged to watch a pleasant scene on a television screen and was invited to adjust the volume, the brightness and the focus controls (Clarke & Jackson, 1983); this enabled her, in subsequent sessions, to reduce the intensity of affect. She was also given the opportunity to practise shopping in vitro and this reduced her anxiety further. Six weeks after her initial panic and considerable resistance, she was able to resume her in vivo work, and made considerable progress.

Resistance to Psychotherapy
It is always important as a therapist to consider any secondary gains a patient may have for remaining phobic such as not having to go to work, having a safe person to do the shopping, and gaining constant sympathy and protection from loved ones. Gruenewald (1971) reported a case of a woman with severe agoraphobia who had a huge amount of support from her husband. On the surface, and perhaps with the best of intentions, he provided her with continued care and support; nevertheless, he was partly responsible for maintaining and perpetuating her condition. Interestingly, when her husband?s health worsened, and consequently his ability to protect and take care of her lessened, she had fewer secondary gains from having her condition and thus had a renewed motivation for treatment.

In the first session, both therapist and client agreed that they should embark on a treatment strategy consisting of psychodynamic psychotherapy and systematic desensitization (in vitro); they also set a time limit of between 3 to 6 months. Gruenewald also pointed out that her active co-operation was required throughout the treatment. The patient was then encouraged to express her opinions about hypnosis and, during this process, she displayed a huge amount of resistance and ambivalence towards her therapist through her body language and in her choice of answers to questions. She also deliberately remained silent for long periods of time. Furthermore, she pointed out that she had already taken part in a stage hypnosis show and had been unable to be hypnotized; she told her therapist that she felt that it was, therefore, unlikely that she would be able to experience hypnosis in the consulting room.

It was evident that the patient was trying to manipulate and undermine her therapist. Grunewald dealt with this by ignoring these demands and authoritatively invited her to lie down on the couch in order to experience ‘a new kind of relaxation’. After the deepener, she spontaneously abreacted and her therapist followed this up with suggestions of soothing relaxation, reintegration and advice about future hypnosis sessions. This had an immediate effect on her and she left the consulting room in amazement. In the following sessions, hypnosis was employed to strengthen the patient?s coping strategies and to increase her understanding of previous traumas.

Later in treatment, Gruenewald experienced more resistance from this patient. Although she was able to experience progressive muscle relaxation and ego strengthening, whenever her active participation was required, she refused to cooperate. She was not prepared to visualize any of the anxiety-provoking situations?even the first on her hierarchical list?and refused to communicate using ideomotor signalling. In addition, she did not carry out any of the self hypnosis tasks at home. She also developed a new psychosomatic symptom?sciatic pain. Her therapist coped with these resistances by pointing out to her in hypnosis that she did not have to acquire a new symptom in order to recover from the old one, but that she could consult a physician about her problem. The thought of having to pay a private doctor an extortionate amount of money was enough to remove this ‘symptom substitution’. The patient did finally improve significantly a year later, although she continued to test her therapist throughout treatment.

Huang (2008) commented that some of his patients?many of them Chinese?felt ashamed about their anxieties and were often reluctant to explore, or begin to come to terms with, their emotional problems. In many cases, their resistance manifested itself through intellectualizations or somatisation (Cheung, Gan & Lo; 2005; Huang, 2008). He recommended that, for some patients, it was important to use hypnosis as an adjunct to the treatment strategy in order to facilitate more significant progress (Kirsch, Montgomery & Sapirstein, 1995; Schoenberger, 2000), and that, because there might be additional resistance to hypnotherapy, it should be used flexibly and informally?that is to say, without a marked or traditional induction. Alternatively, if formal hypnosis is used, it should be accompanied by a clear explanation of the process in order to eliminate any unnecessary anticipatory fear.

In the treatment of a female college student, aged 29, he found that, during the initial psychotherapy, she was unable to concentrate and was both ashamed and reluctant to reveal any of the possible causes for her condition. Huang dealt with this by reframing hypnosis as a ‘special operation’ which would help her to become ‘mentally relaxed’; in the hypnosis, she felt comfortable enough to recall an episode 6 months previously in which she was knocked down by a car. The driver was drunk and, although he helped her to the side of the road, appeared threatening, and this had caused her to panic. She was then invited to re-experience this event in a calm fashion in order to reduce and then remove her feelings of panic. This session was an important turning point in the therapy and, after 8 sessions, she was able to travel freely without symptoms.

Comment
However complex the combination of inner conflicts are in producing the phobic displacement, the protective mechanism of agoraphobia is at the core of this condition (Katan, 1951; Grunewald, 1971; Mahoney, 2000). This report has shown that hypnosis is a highly effective adjunct to psychodynamic psychotherapy (Kirsch, Montgomery, Sapirstein, 1995). It helps to reduce the risk of negative transference, which might be detrimental to the patient, certainly in the early stages of therapy (Gruenewald, 1971), it provides the patient with the space to come to terms with inner conflicts and any feelings of guilt (Huang, 2008), it allows individuals to practise a series of gradually anxiety-provoking situations (Jackson & Elton, 1985) and helps to build up their coping strategies to be utilized in vivo (Mellinger, 1992).
Agoraphobia is a frustrating disorder to treat because many individuals fear or feel guilty about being independent, and their phobic anxiety, perpetuates their dependence on significant others or parental figures (Goldstein & Chambless, 1982a; Shilkret, 2002). In therapy, patients often display resistance by unconsciously testing their therapist in the transference: this is done by inviting the therapist to act like the severe, punishing parent or, alternatively, by acting like the parent, and treating the therapist as the child. However, the unconscious desire is that the therapist will not re-enact these damaging behaviours and will provide the client with a safe environment in which to practise more independent behaviour. It is important here that hypnosis is used in order to create a positive transference which shows the therapist to be a competent, authoritative and caring figure, providing the patient with the coping mechanisms necessary later to become more independent (Hadley & Staudacher, 1989). Indeed, it has been demonstrated that teaching coping skills in many areas of psychiatry, including agoraphobia, has improved the efficacy of the systematic desensitization (Meichenbaum, 1972; Tilton, 1983; Golden, 2007). The most important feature of this is providing the patients with control of their own therapy?for, if they are not in control in the consulting room, they will not be able to take control of their lives. For this reason, it is extremely important for them to go at their own pace. The author also recommends that it is helpful to provide agoraphobic patients with a thorough understanding of their condition and the physiological changes that take place during a panic attack?that is to say, that panic attacks are often a result of a misinterpretation, and exaggeration of, certain bodily sensations (Clark, 1986; Marks, 1987).

A positive transference having taken place, and rapport having been built, there is less likely to be resistance, and thus more significant progress can be made in the hypnosis and in the psychodynamic psychotherapy. It is here, in this safe but unrestricted environment, that patients are able to use these coping strategies so that they can move systematically further away from home. And, with the help of ego-strengthening and positive suggestions, they can become more confident and independent outside the consulting room. This independence can then be increased by the use of in vivo desensitization and continued psychotherapeutic support.
References
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington DC: Author.
Andrews G (1990). The diagnosis and management of pathological anxiety. Medical Journal of Australia., 152: 656-659.
Arnow BA, Taylor CB, Agras WS & Telch MJ (1985). Enhancing agoraphobia treatment outcome by changing couple communication patterns. Behavior Therapy, 16 (5): 452-67.
Basoglu M, Marks IM & Sengun S (1992). A prospective study of panic and anxiety in agoraphobia with panic disorder. British Journal of Psychiatry, 160: 57-64.
Bassler M & Hoffmann SO (1994). Inpatient psychotherapy of anxiety disorders?a comparison of therapeutic effectiveness in patients with generalized anxiety disorder, agoraphobia and panic disorder. Psychotherapie, Psychosomatik, Medizinische Psycholgie, 44 (7): 217-25.
Beck A & Emery G (1985). Anxiety disorders and phobias: a cognitive perspective. New York: Basic Books.
Burns LE (1982). Fears and phobias?epidemiological and phenomenological aspects. Psychiatry in Practice, 1 (8): 25-28.
Calvert T (2007). Clinical Hypnosis and Psychoneuroimmunology (PNI) Therapy. Lecture at the meeting of the Brief Strategic Therapy and Clinical Hypnosis Foundation, School of Hygiene and Tropical Medicine, 12 May, 2007.
Carter MM & Schultz KM (1998). Panic disorder with agoraphobia: its impact on patients and their significant others. (pp29-56). In J Calson & L Sperry (eds.) The Disordered Couple. Pennsylvania: Brunner/Mazel.
Crasilneck HB & Hall JA (1959). Physiological changes associated with hypnosis: a review of the literature since 1948. International Journal of Clinical &Experimental Hypnosis, 7: 9-49.
Chambless DL (1982a). A comparative view of treatments for agoraphobia. In D. Chambless & A. Goldstein (Eds.), Agoraphobia: Multiple Perspectives on Theory ad Treatment (pp215-219). New York: Wiley.
Chambless DL (1982b). Characteristics of agoraphobia. In DL Chambless & AJ Goldstein (eds.) Agoraphobia: Multiple Perspectives on Theory and Treatment (pp1-18). John Wiley: New York.
Chase JS (1991). Hypnosis revisited: towards an integrated approach . International Review of Psycho-Analysis, 18: 513-526.
Cheung FM, Gan YQ & Lo PM (2005). Personality and psychopathology: insights from Chinese studies. In WS Tseung, SC Chang & M Nishizono Ieds.), Asian Culture and Psychotherapy: Implications for East and West. Honolulu HI, University of Hawaii Press.
Clark DM (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24 (4): 461-470.
Clarke JC & Jackson JA (1983). Hypnosis and Behavior Therapy. New York: Springer Publishing Company.
Collins M (1996). Hypno-desensitization in established agoraphobia. European Journal of Clinical Hypnosis, 3 (3): 17-19.
Craske M (1999). Anxiety Disorders: Psychological Approaches to Theory and Treatment. Colorado: Westview Press.
Emmelkamp PMG (1980). Agoraphobics? interpersonal problems: their role in the effects of exposure in vivo therapy. Archives of General Psychiatry, 37: 1303-1306.
Evans BJ & Coman GJ (2003). Hypnosis with treatment for the anxiety disorders. Australian Journal of Clinical Experimental Hypnosis, 31 (1): 1-31.
Fava GA, Savron G, Zielezny M, Grandi S, Rafanetti C & Conti S (1997). Overcoming resistance to exposure in panic disorder with agoraphobia. Acta Psychiatrica, 95 (4): 306-312. Fava GA, Rafanelli C, Grandi S, Conti S, Ruini C, Mangelli L & Belluardo P (2001). Long-term outcome of panic disorder with agoraphobia treated by exposure. Psychological Medicine, 31: 891-898.
Frankl VE (1973). The Doctor and the Soul: from Psychotherapy to Logotherapy (trans. R & C Winston). New York: Vintage Books.
Golden WL (2007). Cognitive-behavioral hypnotherapy in the treatment of irritable-bowel-syndrome-induced agoraphobia. International Journal of Clinical and Experimental Hypnosis, 55 (2): 131-146.
Goldstein AJ & Chambless DL (1978). A reanalysis of agoraphobia. Behavior Therapy, 9 (1): 47-59.
Gruenewald D (1971). Agoraphobia: a case study in hypnotherapy. International Journal of Clinical and Experimental Hypnosis, 19: 10-20.
Hadley J & Staudacher C (1989). Hypnosis for Change: a Practical Manual of Proven Hypnotic Techniques (2 edn.). Oakland, CA: New Harbinger.
Hafner RJ (1977). The husbands of agoraphobic women: assortative mating or pathogenic interactions. British Journal of Psychiatry, 130: 233-239.
Hafner J & Marks I (1976). Exposure in vivo of agoraphobics: contributions of diazepam, group exposure, and anxiety evocation. Psychological Medicine, 6: 71-88.
Hand I & Lamontague Y (1976). The exacerbation of interpersonal problems after rapid phobia-removal. Psychotherapy: Theory, Research & Practice, 13: 405-411.
Harris GM (1991). Hypnotherapy for agoraphobia: a case study. International Journal of Psychosomatics 38 (1-4): 92-94.
Hobbs M (1982). A treatment programme for agoraphobia with emphasis upon hyper-suggestibility and sensitization. The Australian Journal of Clinical Hypnotherapy and Hypnosis, 3 (2): 111-114.
Hoffart A, Friis S & Martisen EW (1992). Assessment of fear of fear among agoraphobic patients: the agoraphobic cognitions scale. Journal of Psychopathology and Behavioural Asessment, 14 (2): 175-187.
Huang WC (2008). Application of hypnosis in psychotherapy for the Chinese in Taiwan. World Cultural Psychiatry Research Review, January 3 (1): 28-31.
Jackson HJ and Elton V (1985). A multimodal approach to the treatment of agoraphobia: four case studies. Canadian Journal of Psychiatry, 30 (7): 539-43.
Jencks B (1973). Exercise Manual for J.H. Schult?s Standard Autogenic Training and Special Formulas, Salt Lake City, Utah.
Kaplan HI & Sadock BJ (1991). Synopsis of Psychiatry (6 edn.). Baltimore: Williams & Wilkins.
Katan A (1951). The role of ?displacement? in agoraphobia. International Journal of Psychoanalysis, 32: 41-50.
Kellerman H (2010). “I?m not going to work today”: a case of agoraphobia. In H Kellerman The Psychoanalysis of Symptoms (pp107-110). New York: Springer Verlag.
Kirsch I, Montgomery G, Sapirstein G (1995). Hypnosis as an adjunct to cognitive-behavioural psychotherapy: a meta-analysis. Journal of Consulting Clinical Psychology, 63: 214-220.
Kraft D (2011). The place of hypnosis in psychiatry part 4: its application to the treatment of agoraphobia and social phobia. Australian Journal of Clinical & Experimental Hypnosis (In press).
Kraft T (1967). Treatment of housebound housewife syndrome. Psychotherapy and Psychosomatics, 15: 446-453.
Kraft T & Kraft D (2005). Conference presentation of the Section of Psychiatry, Royal Society of Medicine, London, UK.
Kraft T & Kraft D (2006). The Place of Hypnosis in Psychiatry: its Applications in Treating Anxiety Disorders and Sleep Disturbances. Australian Journal of Clinical and Experimental Hypnosis, 34, (2): 187-203.
Kroger WS & Fezler WD (1976). Hypnosis and Behavior Modification: Imagery Conditioning. Philadelphia: Lippincott.
Lankton SR & Zeig JK (1989). Extrapolations: Demonstrations of Ericksonian Therapy. Ericksonian Monographs Number 6. New York: Brunner/Mazel.
Leon AC, Portera L & Weissman MM (1995). The social costs of anxiety disorders. British Journal of Psychiatry, 166 (Suppl. 27): 19-22.
Mahoney DM (2000). Panic disorder and self states: clinical and research illustrations. Clinical Social Work Journal, 28 (2): 197-212.
Marchione KE, Michelson L, Greenwald M & Dancu C (1987). Cognitive behavioral treatment of agoraphobia. Behavior Research & Therapy, 25 (5): 319-328.
Marks IM (1977). Nursing in Behavioural Psychotherapy: an Advanced Clinical Role for Nurses. London: Royal College of Nursing of the United Kingdom.
Marks IM (1987). Behavioral aspects of panic disorder. American Journal of Psychiatry, 144: 1160-1165.
Mavissakalian M, Michelson L, Greenwald D, Kornblith S & Greenwald M (1983). Cognitive-behavioral treatment of agoraphobia: paradoxical intention vs self-statement training. Behavior Research & Therapy, 21 (1): 75-86.
McCabe RE (2010). Agoraphobia. In IB Weiner & WE Craighead (eds.) Psychology (4th edn.) (pp55-56. Hoboken, New York: John Wiley.
Matthews AM, Gelder MG & Johnston, DW (1981). Agoraphobia: Nature and Treatment. London: Guilford.
Matthews AM, Johnston DW, Lancashire M, Munby M, Shaw PM & Gelder MG. (1976 ) Imaginal flooding and exposure to real phobic situations: treatment outcomes with agoraphobic patients. British Journal of Psychiatry, 129: 362-371.
Meichenbaum DH (1972). Cognitive modification of test anxious college students. Journal of Consulting and Clinical Psychology, 39: 370-380.
Mellinger DI (1992). The role of hypnosis and imagery technique in the treatment of agoraphobia: a case study. Contemporary Hypnosis, 9 (1): 56-61.
Michelson L & Ascher LM (1984). Paradoxical intention in the treatment of agoraphobia and other anxiety disorders. Journal of Behavior Therapy & Experimental Psychiatry, 15 (3): 215-220.
Milne G (1988). Hypnosis in the treatment of single phobia and complex agoraphobia: a series of case studies. Australian Journal of Clinical and Experimental Hypnosis, 16 (1): 53-65.
Oatley K & Hodgson D (1987). Influence of husbands on the outcome of their agoraphobic wives? therapy. The British Journal of Psychiatry, 150: 380-386.
Raskin DE & Klein ZE (1976). Losing a symptom through keeping it: a review of paradoxical treatment and rationale. Archives of General Psychiatry, 33 (5): 548-555.
Roddick IC (1992). A case of agoraphobia cured by hypnotherapy. Australian Journal of Clinical and Experimental Hypnosis, 20 (2): 133-134.
Salzman, L. (1982). Obsessions and agoraphobia. In D L Chambless & A J Goldstein (Eds.),
Agoraphobia (pp. 19?42). New York: John Wiley & Sons.
Schmidt FK (1985). A case of agoraphobia treated thru hypnosis and audio tapes. Hypnos (The Swedish Journal of Hypnosis in Psychotherapy and Psychosomatic Medicine, 12 (2): 99-102.
Schoenberger NE (2000). Research on hypnosis as an adjunct to cognitive-behavioral psychotherapy. International Journal of Clinical and Experimental Hypnosis, 48: 154-169.
Shilkret CJ (2002). The role of unconscious pathogenic beliefs in agoraphobia. Psychotherapy: Theory/Research/Research/Practice/Training, 39 (4): 368-365.
Stafrace S (1994). Hypnosis in the treatment of panic disorders with agoraphobia. Australian Journal of Clinical and Experimental Hypnosis, 22 (1): 73-86.
Susskind D (1970). The idealized self-image (ISI): a new technique in confidence training. Behavior Therapy, 1:538-540.
Taylor, S (2000). Understanding and Treating Panic Disorder: Cognitive-Behavioral Approaches. John Wiley, New York.
Teasdale JD, Walsh PA, Lancashire M, Matthews AM (1977). Group exposure for agoraphobics: a replication study. British Journal of Psychiatry, 130: 186-193.
Tilton P (1983). Psuedo-orientation in time in the treatment of agoraphobia. American Journal of Clinical Hypnosis, 25 (4): 267-269.
Walln?fer H (1980). Theory and Practice of Autogenic Training, Presentation at Carrier Foundation, New Jersey.
Waxman D (1989). Hartland?s Medical and Dental Hypnosis (3rd edn.). London: Balliere Tindall.
Winter DA & Metcalfe C (2008). From constriction to experimentation: personal construct psychotherapy for agoraphobia. In D Winter & L Viney (eds.) Personal Construct Psychotherapy: Advances in Theory, Practice and Research. London: Whurr.
Wolpe J (1969). The Practice of Behaviour Therapy. New York: Pergamon Press.
Wolpe J (1973). The Practice of Behavior Therapy, 2 edn. Elmsford, New York: Pergamon.
Yager EK (1984). Subliminal Therapy: Utilizing the Unconscious Mind. Subliminal Training Institute, Inc.: San Diego.
Yager EK (1988). Treating agoraphobia with hypnosis, subliminal therapy and paradoxical intention. Medical Hypnoanalysis Journal, 3 (4): 156-160.
Yapko MD (2003). Trancework: an Introduction to Clinical Hypnosis. New York: Irvington Publishers.
Zeig JK (2008). Positive addictions: choosing your habits wisely. Psychotherapy in Australia, 14 (3): 66-70.
*********

Correspondence to David Kraft, 10 Harley Street, London, W1G 9PF, UK
E-Mail: David Kraft (dmjkraftesq@yahoo.co.uk)
Phone: 0207 467 8564