Space and the secure base in agoraphobia: a qualitative survey

Area (2008) 40.3, 375–382 Blackwell Publishing Ltd Space and the secure base in agoraphobia: a qualitative survey Joshua Holmes The Tavistock and Portman NHS Foundation Trust, Tavistock Centre, London NW3 5BA Email: [email protected] Revised manuscript received 18 February 2008 An important aspect of agoraphobia is a fear of being in crowded public spaces. This inherent spatiality means that it has aroused geographical interest. Feminist geographers have argued that the underlying dynamic of agoraphobia is the patriarchal structuring of public space. Using Attachment Theory, which draws on ideas from psychoanalysis and ethology, agoraphobia is conceptualised as a response to perceived threat in the absence of a ‘secure base’, represented by a known person or space. In an attempt to elicit the lived experience of agoraphobia, vignettes were constructed typifying aspects of agoraphobic experience. Participants (n=123) were recruited from Internet agoraphobia self-help forums. Males experiencing agoraphobia (18) formed a significant minority of respondents. Using qualitative methodology, responses to these vignettes, as well as transcripts of parallel telephone interviews, were analysed. Participants’ responses were synthesised into a composite narrative, ‘Charlotte’s Story’. The study suggests the central dichotomy in agoraphobia is not that between public and private space but between threat and security. Individuals experiencing agoraphobia feel secure when in space (a ‘secure base’) that is private, bounded, and where they feel sovereign and active. Threat arises in the absence of these conditions, exacerbated by the gaze of strangers, and is mitigated by the presence of a trusted companion. Further qualitative evidence supported feminist accounts of the fragility of the agoraphobic self, and suggested that self-experience is intimately connected with the experience of space. This study extends previous geographical and psychological accounts of agoraphobic ‘life worlds’. Key words: agoraphobia, Attachment Theory, vignettes, public space, secure base With agoraphobia a more or less stable world does exist, and that is the home; so long as they stay within that charmed circle they feel competent – only beyond it is the frightening public space, the agora. One symptom of this affliction is the fear of crossing any large and open space. The sufferer feels dizzy, as though his [sic] body, like the space stretching before it, were about to lose its center and limits . . . the agoraphobic’s greatest fear is the loss of control. (Tuan 1979, 204) Introduction According to the Anxiety Disorders Association of America (2008), people with panic disorder who avoid places or situations where they previously had a panic attack have agoraphobia. They typically avoid public places where the need for immediate escape might be difficult, such as shopping malls, public transportation, or large sports arenas. In that its symptoms are overtly spatial, agoraphobia is thus of particular relevance to geography (Davidson 2000 2003; Bankey 2001 2002 2004; Callard 2003 2006a 2006b). Agoraphobia predominantly affects women. Most studies suggest between 70 and 90 per cent of people diagnosed with agoraphobia are female (Bekker 1996; Reuter 2002). Feminist geographers have argued that Area Vol. 40 No. 3, pp. 375–382, 2008 ISSN 0004-0894 © The Author. Journal compilation © Royal Geographical Society (with The Institute of British Geographers) 2008 376 Holmes the relative powerlessness and vulnerability of women makes them especially prone to agoraphobia (Bankey 2001), but this does not explain why not all women experience agoraphobia, nor the fact that a significant proportion of people experiencing agoraphobia are male (Brehony 1983). Building on feminist approaches, this empirical study has drawn on Attachment Theory as a wider explanatory framework for the spatiality of agoraphobia. Attachment Theory was first developed by psychoanalyst John Bowlby (1969 1980 1988 1998). Bowlby’s collaborator, social psychologist Mary Ainsworth, developed the concept of the ‘secure base’ (Ainsworth 1982), which suggests a geographical aspect of Attachment Theory. When a child is exposed to threat, is ill or tired, attachment behaviour is activated, leading the child to seek physical proximity to his or her secure base – a comforting, safe, protective person, usually a parent or care-giver. Exploratory behaviour is inhibited until attachment needs are satisfied. In a pioneering naturalistic study (Bowlby 1988), toddlers and their care-givers (parents or nannies) were observed in a London park. The children played freely while care-givers chatted on park benches. There appeared to be an invisible line or ‘comfort zone’ beyond which the children would not go, and the further from their secure base they strayed, the more they looked at their care-giver to determine their whereabouts and vigilance. The attachment link to a secure base thus operates across space and is defined by the emotional relationship between the child and the person supplying the secure base. Ainsworth et al. (1971, 119) describe Attachment Theory as a spatial theory concerning the attachment bond between one person and another: ‘a tie . . . in space . . . and time’. An important aspect of Attachment Theory is the distinction between secure and insecure attachment. Not all care-givers are able to provide the responsive security, empathy and consistency implicit in the idea of a secure base. Parents can be rejecting, unloving, inconsistent or chaotic in their approach to child-care (Hesse 1999). This psychobiological mechanism continues into adult life, influencing the ways in which people relate to romantic partners and friends, as well as to their children and parents (Main et al. 1985; Hazan and Shaver 1987; Shaver and Hazan 1993; Brennan et al. 1998). From an attachment perspective, agoraphobic responses to the threat posed by public spaces can be seen as an anxiety-driven attempt to find a secure base, represented by a safe person or a space associated with such a person. Thus attachments and their role in helping subjects to negotiate the delicate balance between exploration and security are not confined to childhood, but continue to operate throughout life (Slade 1999). When stressed or threatened, adults turn just as readily to their secure base (usually a spouse, partner, child or parent) as do children. We need to know where our loved ones are in space at any time, and if that knowledge is deficient, anxiety results and exploratory projects are temporarily inhibited. Attachment Theory also posits a symbolic connection between person and place. Initially the attachment tie is to a person, presumably to their physical characteristics: warmth, familiar appearance, smell, reassuring sound of their voice. Later that link is extended to the place where they are to be found (Ainsworth et al. 1978). Our first ‘home’ is the mother; later ‘home’ comes to symbolise where our mother is, and, when stressed or threatened, comfort is derived from the familiar surroundings, sounds, sights and smells that constitute ‘home’. The ‘secure base’, initially a metaphor of place projected onto a person, has now become a reminder of a person projected onto a place. As Dupuis and Thorns put it, home is ‘a site where people feel most in control of their lives . . . a secure base around which identities are constructed’ (1998, 29). Previous studies have equated spaces of fear and spaces of security with the public and private domains respectively (Chambless 1982). The Attachment perspective suggests a more nuanced account of spatial experience in agoraphobia. For instance, in this study some people who experience agoraphobia continued to feel panic while at home, while others, unable to go out, felt trapped and isolated by the very privacy of the home. Conversely the threatening aspects of public space were found to be mitigated when there was a link, physical or telephonic, with a trusted companion. Freud, feminism and agoraphobia For Freud (1985 [1887]), a fear of going out represents a turning away from desire, imagined as taking the form of untrammeled sexuality (‘the prostitute’). Whatever the validity of Freud’s specific theories, he was certainly right to focus on agoraphobia as an issue mainly affecting women. In addition, the Freudian approach tries to decode the symptom’s meaning as a disguised expression of a deeper and more authentic communication. These two points are the basis for today’s feminist interpreters of Area Vol. 40 No. 3, pp. 375–382, 2008 ISSN 0004-0894 © The Author. Journal compilation © Royal Geographical Society (with The Institute of British Geographers) 2008 Space and the secure base in agoraphobia 377 agoraphobia. Unlike Freud, however, most see women’s vulnerability not in terms of sexual repression, but of unequal distribution of power (Benkler 1998). Women, it is argued: (a) are socialised to see themselves as weak and vulnerable in comparison with men (Ferguson 1984), and (b) are objectively disadvantaged in terms of power, control and influence (Crosby 1984). The argument follows that in patriarchal societies women are inherently liable to develop agoraphobia. According to Bem (1974), men are positively reinforced for behaviours that are aggressive, independent and competent, while women for those that are submissive, passive, fearful and non-assertive. Agoraphobia and panic then become ‘typical’ responses of the ‘weaker sex’ when faced with threat or stress, leading Foa et al. to describe it as a ‘women’s syndrome’ (1984, 445). If the streets ‘belong’ to men, then they will be experienced as threatening to women, whose response will be to retreat into the privacy of the home (Madigan and Munro 1999), where they may (unless faced with an abusive husband) still hold sway (Omata 1995). Some scholars (de Swaan 1981; Brown 1987; da Costa Meyer 1996; Bankey 2001; Callard 2006a) buttress this feminist sociology with a historical approach to explain agoraphobia’s association with women, Bankey relating agoraphobia to the nineteenthcentury notion of the ‘hysterical woman’ (2001, 37). The key concept in her analysis is fear of loss of control. People experiencing agoraphobia typically fear that they will lose consciousness or go mad (Chambless and Goldstein 1981). In addition, Bankey – like Capps and Ochs (1995) and Bordo et al. (1998) – focuses on the lived lives of people with agoraphobia (Bankey 2001 2002). Such approaches are relevant to this study in that they focus on the interaction between the interior landscape of the mind and the external environment, whether private or public. An important theme in feminist discourse, emerging from analysis of the clinical phenomena of depersonalisation and derealisation, is the fragility of the agoraphobic self (Davidson 2000; Bankey 2002). The female psyche is seen as inherently more at risk than its male counterpart, and links with the susceptibility of people experiencing agoraphobia to the gaze of the other. People with agoraphobia typically feel ‘visible’ in public spaces, fear that they will ‘make fools of themselves’ and consequentially avoid the anxiety associated with such imagined ridicule. The individual with agoraphobia feels penetrated (a metaphor bringing together the Freudian sexual viewpoint with feminist emphasis on female vulnerability); stripped bare of her public self, her privacy and bodily functions are liable to erupt into public view. Here a geographical perspective bears directly on the sense of self. Methodology Researching agoraphobia is problematic since being ‘out of the house’ is feared in ‘virtually every case’ (Bowlby 1998, 335). Coomber (1997) suggests using the Internet ‘where the group being researched is normally difficult to reach and/or the issues being researched are of a particularly sensitive nature’. The Internet is an important resource for sufferers of panic disorders (Campbell et al. 2006). Literature highlights its convenience (Jacobson 1999) and anonymity (Joinson 1999) in conducting research, especially when investigating sensitive issues (Grinyer 2002). In an attempt to elicit experience-rich data, participants were presented with vignettes (see Figure 1) illustrating typical aspects of agoraphobic phenomena. Vignettes used in a research context are ‘short stories about hypothetical characters in specified circumstances’ to whose situation the participant is invited to respond (Finch 1987, 105). Vignettes have been identified as an effective method for researching ‘sensitive’ topics (Rahman 1996; Hughes 1998; Neale and Smart 2000). As prior studies suggested (Finch 1987; Hughes 1998), vignettes stimulate participants to write about their own feelings through identifying with the feelings of others – an easier task than writing directly about their own feelings. Vignette material was developed through literature review and a pilot study and a number of telephone interviews. In all cases ethical permission was sought and granted. Six vignettes were used. After each vignette, participants were given a ‘question’, and were asked to write ‘as much’ or ‘as little’ as they chose (see Figure 1). Participants appeared to identify with the characters in the stories: ‘It’s nice to read that others have the problems I have’ (Female, 59, UK; participant 8). It could be argued that participants’ positive responses to the vignettes merely reflected the compliant and unassertive characteristics of people with agoraphobia, i.e. responses to ‘leading questions’. Against this was the observation that some participants vigorously reacted against the story, for example: ‘what a nightmare! Mandy’s [from vignette 4] co-dependency is excessive, as well as being selfish beyond belief’ (Female, 45, UK; participant 98). Area Vol. 40 No. 3, pp. 375–382, 2008 ISSN 0004-0894 © The Author. Journal compilation © Royal Geographical Society (with The Institute of British Geographers) 2008 378 Holmes Figure 1 Vignette example The Internet-vignette methodology seemed to create an intimate relationship with the researcher, for example: This might not make any sense to you but I’m sorry I find this really hard to do but I’m trying my best, please bear with me. (Female, 20, UK; participant 87) Vignette responses and interview transcripts were scrutinised line-by-line and emerging themes noted. Wherever possible, key words were then identified associated with each theme. Results The responses, along with interview transcripts, were synthesised into a hypothetical narrative, ‘Charlotte’s Story’, describing the phases of an agoraphobic episode and its aftermath. This approach is consistent with those that advocate the presentation of data in such a way that they resemble the phenomenon under investigation (Chenail 1995). The aim was to remain true to the stories and language of the participants themselves. However, it is difficult to honour the variety of individual experience while at the same time attempting to draw general conclusions about common themes. Feminist geographers (e.g. Davidson 2003) emphasise the importance of difference. There is a danger of conflating differences among agoraphobic experiences and presenting complex and varied experiences as if they are uniform. However, ‘Charlotte’s Story’ can be justified in that it was made up of words and phrases employed by vignette and interview respondents. Each episode of the narrative is supported by direct quotations from anonymised participants. This ‘bank’ of quotations provides the supporting evidence for the validity of the fictional narrative. Each episode is accompanied by a theoretical commentary on emerging themes. For reasons of space only one episode is presented here.1 Episode one – panic in the supermarket Charlotte, 30, has experienced agoraphobia for two years. We join her on her weekly shopping expedition, but all is not well . . . Charlotte begins to feel anxious the moment she joins the checkout queue. Her normal routine is to go grocery shopping every Monday morning when the supermarket is normally less crowded. However today – she had forgotten it was a Bank Holiday – strange faces surround her, the queue is six people deep. ‘It’ll take forever to get through this’, she thinks. Being trapped in this dreaded queue is intensifying her panic. Worse, the bright lights and shiny floors, which she so hates but can usually ignore, seem to be amplified. She starts to feel unreal; it is as though she’s in a dream, about to spin off into space. She hangs onto the trolley, gripping it so tightly her knuckles hurt. This helps a bit and reminds her she is ‘there’. But it also reminds her of her fear. She is deeply aware now of everyone around her. It is as though everyone is looking at her. She feels scrutinised in the most searching way by these strangers. ‘What are they thinking?’ – They must think I’m going mad. ‘What if I pass out?’, ‘what if I throw up?’ She decides she Area Vol. 40 No. 3, pp. 375–382, 2008 ISSN 0004-0894 © The Author. Journal compilation © Royal Geographical Society (with The Institute of British Geographers) 2008 Space and the secure base in agoraphobia 379 Figure 2 Episode one quotation box must escape at once. Leaving her shopping, she rushes to the car park. (Figure 2.) Episode one – commentary This section exemplifies the onset of a panic attack, a central clinical feature of agoraphobia (Anxiety Disorders Association of America 2008). The first trigger is the crowdedness of the supermarket, which is a further shock because it is at variance with Charlotte’s typical agoraphobic tactic of avoiding crowds. Situations where people are immobilised or trapped are widely reported (Chambless 1982; Liotti 1996) triggers of agoraphobic anxiety. This is consistent with Carter’s (2002) theorisation of agoraphobia as a movement inhibition. From an attachment perspective, immobility is experienced as threatening because it inhibits the search for secure base proximity associated with activated attachment behaviour. During the panic attack, Charlotte experiences depersonalisation and derealisation. For some feminist scholars, people with agoraphobia have a fragile sense of self (Davidson 2000; Bankey 2002). Depersonalisation understood in this light is a consequence of the fluid permeable boundaries (Davidson 2003) of the agoraphobic self. Charlotte uses a typical agoraphobic strategy: she finds something over which she does have control – her hands in contact with the trolley, and uses this to stabilise herself. Charlotte’s fear also seems to be influenced by feelings of being observed by the strangers surrounding her, or being under the gaze of the other. Such fear is a major part of agoraphobia (e.g. Bankey 2001; Davidson 2003). The gaze of the other is threatening because it emphasises a lack of privacy and control. The public self of the person experiencing agoraphobia, behind which private feelings and bodily functions are concealed, suddenly becomes transparent. Indeed, often it is acts that could be ‘safely’ carried out in private spaces that are specifically feared, such as vomiting. In this way we see that Freud’s (1985 [1887]) conception of agoraphobia, as the private (in his analysis, sexual) self manifesting itself publicly, has some validity. Discussion Analysing agoraphobia from an attachment perspective suggests a normalisation of agoraphobic experience (Minde 2003). The activation of attachment behaviours (seeking proximity to a person or place perceived as safe) is a normal response to threat. However, Area Vol. 40 No. 3, pp. 375–382, 2008 ISSN 0004-0894 © The Author. Journal compilation © Royal Geographical Society (with The Institute of British Geographers) 2008 380 Holmes people vary in their vulnerability, from ‘secure’ to ‘insecure’ patterns of attachment. Public spaces represent a potent threat and are therefore liable to evoke attachment behaviours. This study suggests that by shopping with friends and family, using mobile phones and generally overcoming the passivity that augments agoraphobic anxiety, vulnerable women can still successfully negotiate public spaces. This analysis can also encompass male agoraphobia in that insecure attachment is not confined to women. Seen this way, agoraphobia is not a qualitatively distinct abnormal ‘condition’, but rather a way of responding which may at different times and in different circumstances be a part of most people’s, especially women’s (Valentine 1989), experience. How we feel about who we are depends on where we are, and with whom. This study suggests that the anxiety and panic of the person experiencing agoraphobia, usually but not always when without support in a public space, typically triggers a loss of sense of self. Conversely, reaching a secure base in the shape of a car or home or known supportive other brings the person experiencing agoraphobia back to her or himself. As anxiety lessens, so self coherence re-emerges. Although a secure base is preferentially a close family member, such as spouse or parent, it was a noticeable finding in this study that the use of familiar objects, such as mobile phones, shopping trolleys and prams were also able to reduce anxiety in the face of threat in public spaces. How and why this should be so merits further investigation. One might speculate that these positively invested objects have a communicative aspect: a voice that can be heard on a mobile phone or a hand reaching out for a reassuring response. An important finding of this study was that there are a number of significant self-concepts associated with security which for people who experience agoraphobia are problematic. The most important of these are: being in control, being mobile, being bounded and having privacy. In people who do not experience agoraphobia, these dimensions remain intact even when in spaces of threat. However, for the person experiencing agoraphobia, given her or his fragile self-boundary, these basic needs are questionable. Lacking ‘internal’ security, people experiencing agoraphobia are reliant on the external spatial manifestations of security, provided by their car or home, and/or the ability to be active and in control. When these are not available, such people are most at risk for agoraphobic experience. Studying agoraphobia lends support to the concept of the ‘geographical self’. Aspects of the self are externalised into safe space (‘home is where the heart is’). The self also is an internal ‘home’ which can protect us when in potentially threatening spaces (‘the heart is where the home is’). Implicit in this study and analysis is that these represent the poles of a continuum from diagnosable ‘agoraphobia’ through to those who appear impervious to anxiety, with most people lying somewhere between the two. Throughout this study we have been working at a meeting point between a geographical (narrowly defined) perspective emphasising space and a psychological perspective emphasising experience. Attachment Theory has been helpful in bringing together these strands into a unified psycho-geographical approach, showing how relationships, and their ever-changing rhythm of proximity and distance, take place within space. It explicitly illustrates the relationship, whether free or constricted, between individuals and the spaces which they inhabit. Attachment Theory may make a useful contribution to other areas of social and cultural geography. Conclusions Using an Internet survey was productive. The use of vignettes meant participants were able to respond freely and with a surprising amount of self revelation. Rich data were yielded for qualitative analysis. This study allows us to draw conclusions about communicating with people with agoraphobia, as well as presenting and interpreting their stories. The study looks behind the quasi-medical concept of ‘agoraphobia’ to the lived experience of women and men, for whom certain defined spaces represent threat. Hearing their stories has led to a deeper understanding of the inescapable spatiality of the agoraphobic self: feeling secure is inseparable from the capacity to find a safe place within which to be. Acknowledgements Thanks to Dr Ben Page and Dr Felicity Callard for their help in the preparation of this paper, and to anonymous reviewers for their useful comments. Note 1 The other episodes with quotations and commentary are available from the author. Area Vol. 40 No. 3, pp. 375–382, 2008 ISSN 0004-0894 © The Author. 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