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CONTEMPORARY HYPNOSIS AND INTEGRATIVE THERAPY
28(3): 235–248 (2011) 235
28(3): 235–248 (2011)Copyright © 2011 British Society of Clinical and Academic Hypnosis
Published by Crown House Publishing Ltd
DAVID KRAFT
ABSTRACT
Agoraphobia is an extremely complex disorder to treat in clinical practice (Chambless,
1982a; Kaplan & Sadock, 1991) and patients are often resistant to therapy (Fava et al.,
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 & Schultz, 1998), focusing on and increasing the intensity of psychoso-
matic manifestations, refusing actively to participate during treatment, intellectualization,
somatization 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 character-
ized 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 no one 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 et al.,
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
et al., 1992; Evans & Coman, 2003; Kraft & Kraft, 2005, 2006). Agoraphobic patients typical-
ly fear one or more of the following situations: being alone and outside the house, queuing,
being in a crowd, standing on a bridge, travelling on public transport, going shopping, walk-
ing 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 et al., 1985; Oatley & Hodgson, 1987). Some patients come to rely
on these ‘safe partners’ (Kraft, 2011) and, as a result, this decreases independence which in
turn affects overall quality of life (Leon et al., 1995). Agoraphobia is associated with a huge
COUNTERACTING RESISTANCE IN AGORAPHOBIA USING
HYPNOSIS
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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 they will lose control
and will embarrass themselves in these situations. These panic attacks are accompanied by
some of the following concomitant symptoms:
1. Dizziness
2. Palpitations
3. Trembling or shaking
4. Chest pain/tightness of chest
5. Fear of losing control
6. Fear of dying
7. Fear of going mad
8. Nausea
9. Choking sensations
10. Abdominal pain
11. Shortness of breath
12. Hyperhidrosis
13. Paraesthesia
14. Hot flushes
15. Feelings of depersonalization and/or derealization
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 (Johnston et al., 1976), in vivo exposure therapy (Emmelkamp, 1980; An-
drews, 1990; Fava et al., 1997, 2001), and group exposure (Teasdale et al., 1977). Further,
behavioural techniques—particularly in vivo exposure therapy—have been employed suc-
cessfully 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
inextricably interconnected with the family situation (Stafrace, 1994; Kraft, 2011), it is dif-
ficult to treat (Mathews et al., 1981; Chambless, 1982b; 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 sug-
gested possible interventions using cognitive-behavioural therapy (CBT) (Mavissakalian et
al., 1983; Beck & Emery, 1985; Marchione et al., 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
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of members of the family. Cognitive-behavioural techniques and the use of ‘rationale ther-
apy’ (Clarke & Jackson, 1983) are also considered.
REFUSING TO VISIT THE THERAPIST AND THE ROLE OF HOME VISITS AND TELEPHONE
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 hypno-
sis 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’ who stay with them in the house, help them with
shopping, and do 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 perpetuat-
ing 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 own home (and on her own). They jointly devised a treatment plan
that 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 as triggered by the exercises on tape. Teaching her 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 six 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 or
in anybody else’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 progress using hypnosis and by working through the Subjective Units of Distur-
bance Scale (SUDS) (Wolpe, 1969). He was told that in vivo desensitization would not be
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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
six weeks of treatment. He had reduced his anxiety to a zero in all the scenarios, but had
found that he was unable to drive on a particular road—the same road in which his busi-
ness 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 tech-
niques 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, cloraze-
pate, 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 four
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) (Haf-
ner & Marks, 1976; Marks, 1987). 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 trains. Following this important session, she began to use trains more freely.
However, after approximately two 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 focused on her working through her feel-
ings 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 leads
to a panic attack, and 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 suf-
fering from agoraphobia as well as a constant fear that he was on the verge of having a
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heart attack—indeed, he experienced many of the associative features of a myocardial
infarction, including palpitations, shortness of breath, chest pains, dizziness, perioral numb-
ness, 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
25 mg, gradually increasing to 150–200 mg over a three-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 atten-
tion 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 sug-
gestions 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 (Yapko, 1984;
Waxman, 1989). 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 posi-
tive 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
over 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
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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 reframe the term ‘hypnosis’ and slowly 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 provided by Roddick (1992) who also
spent three or four sessions building rapport and helping his patients to get used to being
able to relax in his presence before introducing hypnosis. He recognized that agorapho-
bics tend to suffer from a lack of confidence which slowly 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 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 here 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 progressive muscle relaxation (PMR) induction
b) Experiencing special place imagery—desert island beach
c) Addressing the unconscious mind by focusing on (i) the importance of practising
relaxation, (ii) being able to travel in a car, and (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) Reintegration 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 eight sessions of using this technique, the patient was able to drive herself to the
clinic 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 hypno-
sis 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; Lank-
ton & 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 the ‘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 ad-
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dition, he advised that if patients express that they are worried they are going to faint or
sweat profusely during in vitro desensitization, humour can be employed in order to contra-
dict 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 is that hyp-
nosis 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). How-
ever, poor education and misunderstanding of the difference between clinical hypnosis and
stage hypnosis, on occasions, may cause 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 neurolinguistic programming
(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 focusing 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 on to employing systematic desensitization in vitro: Harris com-
bined 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:
‘Your body knows what to do’. The patient reiterated this positive statement post-hypnosis,
intimating that she was beginning to feel that she had control of the situation. Harris com-
mented that this was a pivotal point in the therapy in that it increased her confidence and
her ability to cope in stressful situations. After ten weeks of hypnosis and in vivo desensi-
tization, 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 in-
tervention 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 two years of treat-
ment 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
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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 three
situations—particularly a proposed fishing trip—and he displayed a huge amount of resist-
ance, 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
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, us-
ing 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 the patient 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 woman suffering from agoraphobia with panic at-
tacks. The first eight 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 desensitiza-
tion. 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 pre-
pare 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 & Jack-
son, 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 shop-
ping, 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
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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 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 treat-
ment strategy consisting of psychodynamic psychotherapy and systematic desensitization
(in vitro); they also set a time limit of between three to six months. Gruenewald also point-
ed out that her active cooperation 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 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.
Gruenewald 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 immedi-
ate 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 symp-
tom—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 ‘symp-
tom 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 somatization (Cheung et al.; 2005; Huang, 2008). He rec-
ommended 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 et al., 1995; Sch-
oenberger, 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 ex-
planation of the process in order to eliminate any unnecessary anticipatory fear.
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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 six 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 in-
vited 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 eight
sessions, she was able to travel freely without symptoms.
COMMENT
However complex the combination of inner conflicts is in producing the phobic displace-
ment, the protective mechanism of agoraphobia is at the core of this condition (Katan,
1951; Gruenewald, 1971; Mahoney, 2000). This report has shown that hypnosis is a highly
effective adjunct to psychodynamic psychotherapy (Kirsch et al., 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
it 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, 1978; 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 be-
haviour. 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 fea-
ture 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 vital for them to go at their own pace. The author also recommends providing
agoraphobic patients with a thorough understanding of their condition and the physio-
logical changes that take place during a panic attack—that is to say, 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
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further away from home. And, with the help of ego strengthening and positive sugges-
tions, 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 Dis-
orders, Fourth Edition (DSM-IV). Washington, DC: American Psychiatric Association.
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 out-
come by changing couple communication patterns. Behavior Therapy 16(5): 452–467.
Basoglu M, Marks IM, Sengun S (1992). A prospective study of panic and anxiety in agora-
phobia with panic disorder. British Journal of Psychiatry 160: 57–64.
Bassler M, Hoffmann SO (1994). Inpatient psychotherapy of anxiety disorders: A com-
parison of therapeutic effectiveness in patients with generalized anxiety disorder,
agoraphobia and panic disorder. Psychotherapie, Psychosomatik, Medizinische Psy-
cholgie 44(7): 217–225.
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. Psy-
chiatry 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, London
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. In Calson J, Sperry L (eds) The Disordered Couple. Philadelphia,
PA: Brunner/Mazel, pp. 29–56.
Chambless DL (1982a). A comparative view of treatments for agoraphobia. In Chambless
DL, Goldstein A (eds) Agoraphobia: Multiple Perspectives on Theory and Treatment. New
York: Wiley, pp. 215–219.
Chambless DL (1982b). Characteristics of agoraphobia. In Chambless DL, Goldstein AJ
(eds) Agoraphobia: Multiple Perspectives on Theory and Treatment. New York: Wiley, pp.
1–18.
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: Insight from Chinese
studies. In Tseung WS, Chang SC, Nishizono M (eds) Asian Culture and Psychotherapy:
Implications for East and West. Honolulu, HI: University of Hawaii Press, pp. 21–39.
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.
Collins M (1996). Hypno-desensitization in established agoraphobia. European Journal of
Clinical Hypnosis 3(3): 17–19.
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.
KRAFT
28(3): 235–248 (2011)
246
Copyright © 2011 British Society of Clinical and Academic Hypnosis
Published by Crown House Publishing Ltd
Craske M (1999). Anxiety Disorders: Psychological Approaches to Theory and Treatment.
Boulder, CO: 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, 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 Medi-
cine 31: 891–898.
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.
Frankl VE (1973). The Doctor and the Soul: From Psychotherapy to Logotherapy, tr. R & C
Winston. New York: Vintage Books.
Golden WL (2007). Cognitive-behavioral hypnotherapy in the treatment of irritable-bow-
el-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 (2nd edn). Oakland, CA: New Harbinger.
Hafner J, Marks I (1976). Exposure in vivo of agoraphobics: Contributions of diazepam,
group exposure, and anxiety evocation. Psychological Medicine 6: 71–88.
Hafner RJ (1977). The husbands of agoraphobic women: Assortative mating or pathogenic
interactions? British Journal of Psychiatry 130: 233–239.
Hand I, Lamontague Y (1976). The exacerbation of interpersonal problems after rapid pho-
bia-removal. Psychotherapy: Theory, Research & Practice 13: 405–411.
Harris GM (1991). Hypnotherapy for agoraphobia: A case study. International Journal of
Psychosomatics 38: 92–94.
Hobbs M (1982). A treatment programme for agoraphobia with emphasis upon hyper-sug-
gestibility and sensitization. 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 pa-
tients: The agoraphobic cognitions scale. Journal of Psychopathology and Behavioural
Assessment 14(2): 175–187.
Huang WC (2008). Application of hypnosis in psychotherapy for the Chinese in Taiwan.
World Cultural Psychiatry Research Review 3(1): 28–31.
Jackson HJ, Elton V (1985). A multimodal approach to the treatment of agoraphobia: Four
case studies. Canadian Journal of Psychiatry 30(7): 539–543.
Jencks B (1973). Exercise Manual for J. H. Schultz’s Standard Autogenic Training and Special
Formulas. Salt Lake City, UT: Author.
Johnston DW, Lancashire M, Mathews AM, 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. Kaplan HI, Sadock BJ (1991). Synop-
sis of Psychiatry (6th edn). Baltimore, MD: Williams & Wilkins.
COUNTERACTING RESISTANCE IN AGORAPHOBIA 247
28(3): 235–248 (2011)Copyright © 2011 British Society of Clinical and Academic Hypnosis
Published by Crown House Publishing Ltd
Katan A (1951). The role of ‘displacement’ in agoraphobia. International Journal of Psychoa-
nalysis 32: 41–50.
Kellerman H (2010). ‘I’m not going to work today’: A case of agoraphobia. In Kellerman H,
The Psychoanalysis of Symptoms. New York: Springer Verlag, pp. 107–110.
Kirsch I, Montgomery G, Sapirstein G (1995). Hypnosis as an adjunct to cognitive-behav-
ioural 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,
38(2) & 39(1): 91–110.
Kraft T (1967). Treatment of housebound housewife syndrome. Psychotherapy and Psycho-
somatics 15: 446–453.
Kraft T, Kraft D (2005). Conference presentation of the Section of Psychiatry, Royal Society
of Medicine, London, 8 March 2005.
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.
Lankton SR, Zeig JK (1989). Extrapolations: Demonstrations of Ericksonian Therapy. Erick-
sonian Monographs No. 6. New York: Brunner/Mazel.
Leon AC, Portera L, Weissman MM (1995). The social costs of anxiety disorders. British Jour-
nal of Psychiatry 166 (Suppl. 27): 19–22.
McCabe RE (2010). Agoraphobia. In Weiner IB, Craighead WE (eds) Psychology (4th edn).
New York: Wiley, pp. 55–56.
Mahoney DM (2000). Panic disorder and self states: Clinical and research illustrations. Clin-
ical 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 Nurs-
es. London: Royal College of Nursing of the United Kingdom.
Marks IM (1987). Behavioral aspects of panic disorder. American Journal of Psychiatry 144:
1160–1165.
Mathews AM, Gelder MG, Johnston DW (1981). Agoraphobia: Nature and Treatment. Lon-
don: Guilford Press.
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.
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.
KRAFT
28(3): 235–248 (2011)
248
Copyright © 2011 British Society of Clinical and Academic Hypnosis
Published by Crown House Publishing Ltd
Oatley K, Hodgson D (1987). Influence of husbands on the outcome of their agoraphobic
wives’ therapy. 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 Clin-
ical and Experimental Hypnosis 20(2): 133–134.
Salzman L (1982). Obsessions and agoraphobia. In Chambless DL, Goldstein AJ (eds) Ago-
raphobia: Multiple Perspectives on Theory and Treatment. New York: Wiley, pp. 19–42.
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 psy-
chotherapy. International Journal of Clinical and Experimental Hypnosis 48: 154–169.
Shilkret CJ (2002). The role of unconscious pathogenic beliefs in agoraphobia. Psychother-
apy: Theory/Research/Research/Practice/Training 39(4): 368–365.
Stafrace S (1994). Hypnosis in the treatment of panic disorders with agoraphobia. Austral-
ian 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 Approach-
es. Chichester, UK: John Wiley.
Teasdale JD, Walsh PA, Lancashire M, Mathews AM (1977). Group exposure for agora-
phobics: 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.
Wallnöfer H (1980). Theory and practice of autogenic training. Presentation to the Carrier
Foundation, New Jersey.
Waxman D (1989). Hartland’s Medical and Dental Hypnosis (3rd edn). London: Balliere Tin-
dall.
Winter DA, Metcalfe C (2008). From constriction to experimentaton: Personal construct
psychotherapy for agoraphbia. In Winter D, Viney L (eds). Personal Construct Psycho-
therapy: Advances in Theory, Practice and Research. London: Whurr.
Wolpe J (1969). The Practice of Behaviour Therapy. Elmsford: NY: Pergamon Press.
Wolpe J (1973). The Practice of Behavior Therapy (2nd edn). Elmsford, NY: Pergamon Press.
Yager EK (1984). Subliminal Therapy: Utilizing the Unconscious Mind. San Diego, CA: Sublim-
inal Training Institute, Inc.
Yager EK (1988). Treating agoraphobia with hypnosis, subliminal therapy and paradoxical
intention. Medical Hypnoanalysis Journal 3(4): 156–160.
Yapko MD (1984). 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 Dr David Kraft, 10 Harley Street, London, W1G 9PF, UK
Email: David Kraft (dmjkraftesq@yahoo.co.uk)
Phone: +44 (0)207 467 8564