548 LETTERS TO THE EDITOR

ioral research and therapy ( Vol. 1). New York: Academic Press.

Jannoun, L., Munby, M., Catalan, J., & Gelder, M. (1980). A home-based treatment program for agoraphobia: Replication and controlled evaluation. Behavior Therapy, 11, 294-305.

Kanner, A. D., Coyne, J. C , Schaefer, C., & Lazarus, R. S. (1981). Comparison of two modes of stress management: Daily hassles and uplifts versus major life events. Journal of Behavioral Medicine, 4, 1-39.

THOMAS J. D 'ZURILLA State University of New York

at Stony Brook

Problem Solving: Not a Treatment for Agoraphobia. A Reply to D'Zurilla (1985)

T o the Ed i to r . - - D'Zurilla has raised some interesting questions about both the analysis and the interpre- tation of the results that we reported in Cullington, Butler, Hibbert and Gelder (1984). As these do not sub- stantially alter our conclusions we are grateful for this opportunity to reply. Each of the questions raised is discussed separately below.

The first point is that examina- tion of the trends in ratings of pho- bic severity from pretreatment to 6-month follow-up suggests that three of the four therapists were at least moderately successful in ap- plying a problem-solving treatment to agoraphobia. D'Zurilla's calcu- lation that the difference between Therapists 1 and 3 at 6-month fol- low-up is a third less than it was at the post t reatment assessment is c o r r e c t .

Further analysis using repeated measures analysis of variance (Dix- on, Brown; Engelman, Frone, Hill,

Jennrich, & Taporek, 1981) shows there is both a significant linear trend from pretreatment to 6-month follow-up, F(1, 24)= 40.88, p < .001, and a significant interaction between therapist and linear trend, F(3, 24)= 4.20, p < .02. The de- crease in phobic severity ratings be- tween pre- and posttreatment for Therapist 1 is significant (p < .01, Tukey test), whereas the increase between 3- and 6-month follow-up for Therapist 4 is not significant. So this interaction is likely to be due to the success of Therapist 1 during the treatment period rather than to the failure of Therapist 4 during fol- low-up. The exceptional therapist is Therapist 1, and we were unable to replicate her success despite making every effort to use the same treat- ment methods.

Taking all four therapists togeth- er it is therefore clear that problem solving does not reliably reduce agoraphobia as quickly as does an equivalent amount of programmed practice involving only 31/2 hours of therapist contact (Jannoun, Mun- by, Catalan, & Gelder, 1980). We know from long-term follow-up data (Munby & Johnston, 1980) that the effects of this treatment persist at least 9 years. So it cannot easily be argued that the effects of prob- lem solving are more durable, though they may be broader, and might be larger, after a long period of treatment.

D'Zurilla's second point is based on the calculation that the average phobic severity score of the three most successful therapists at the 6-month follow-up was 3.8, indi- cating "moderate" severity, com- pared to 6.0 pretreatment, indicat- ing "h igh" severity. This is

LETTERS TO THE EDITOR 549

interpreted as showing that the problem-solving treatment was moderately effective for the group of patients treated by these three therapists. But there is no reason to believe that these patients differed from those treated by Therapist 4. It would be more valid to compare the means of patients treated by all four therapists at pretreatment and at 6-month follow-up: 6.1 and 4.4 respectively. This degree of im- provement must be seen as modest when compared with the 6-month follow-up score of 2.3 for the pa- tients treated with programmed practice.

The third point is that we do not report data for time away from home and number of journeys made. In the Jannoun et al. study there was an unexpected increasing trend in both these diary measures from 3- to 6-month follow-up for all patients treated with problem solving. However the decreasing trend in both measures after pro- grammed practice was not observed in patients treated by both thera- pists, as D'Zurilla claims, but only in those treated by the unexpectedly successful therapist. Interpretation of this finding can only be specu- lative as the original differences were small and diary measures are diffi- cult to collect accurately over a long period. Their validity as measures of phobic severity has not been demonstrated, so no additional data are provided.

The last point is that future stud- ies should obtain adequate mea- sures of the frequency as well as of the severity of reported problems. This would provide addi t ional valuable information, though rat- ing frequency may not always be

possible. It would be appropriate for "'daily hassles" but may not be for housing or employment problems. Nevertheless D'Zurilla's point sug- gests that problem solving may work by reducing maladaptive responses to problems as well as by reducing the problems themselves, a possi- bility that cannot easily be evalu- ated by measuring problem severity alone.

Conclusions The original conclusion that our

results do not confirm that the problem-solving treatment we used is an effective treatment for agora- phobia must stand. We were unable to replicate the success of Therapist 1 in the original study. We do not however wish to claim that other versions of problem solving would produce the same results. Two characteristics of our problem-solv- ing treatment may be partly re- sponsible for our results. In the first place t rea tment was very brief. Longer treatment may be more ef- fective, but would also be more ex- pensive in therapist time. In the second place exposure of all kinds was excluded from problem solving so as to clarify the comparison with programmed practice. It is likely that agoraphobics treated with problem solving under less restric- tive conditions would use some form of exposure as a means of solving their agoraphobic problem. This should increase the effective- ness of problem solving but would make it harder to find out which factor was responsible for change.

Lastly our suggestion that Ther- apist 1 had a particularly highly motivated group of patients is pure- ly speculative. As is made clear this

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is based on the possibility that the groups differed in some important attribute that was not measured. Motivation is only one amongst many possibilities. Our original finding may have been due to chance, so further replication may be appropriate.

References Cullington, A., Butler, G., Hibbert, G., &

Gelder, M. (1984). Problem solving: Not a treatment for agoraphobia. Be- havior Therapy, 15, 280-286.

Dixon, W. J., Brown, M. B., Engelman, L., Frone, J. W., Hill, M. A. Jennrich, R. I., & Taporek, J. D. (1981). BMPD

Statistical Software. Berkeley: Univer- sity of California Press.

Jannoun, L., Munby, M., Catalan, J., & Gelder, M. (1980). A home-based treatment program for agoraphobia: Replication and controlled evaluation. Behavior Therapy, 11, 294-305.

Munby, M., & Johnston, D. W. (1980). Agoraphobia: The long-term follow-up of behavioural treatment. British Jour- nal of Psychiatry, 137, 418-427.

GILLIAN BUTLER MICHAEL GELDER University of Oxford The Warneford Hospital Oxford OX3 7JX, England