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Attachment, Anxiety, and

Agoraphobia
a
Pat Sable PhD
a
Adjunct Assistant Professor, University of Southern
California School of Social Work; and Private Practice
(Psychotherapy), Los Angeles
Published online: 18 Oct 2008.

To cite this article: Pat Sable PhD (1991) Attachment, Anxiety, and Agoraphobia, Women &
Therapy, 11:2, 55-69, DOI: 10.1300/J015V11N02_06

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 Attachment, Anxiety, and Agoraphobia
Pat Sable

INTRODUCTION
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Agoraphobia has been receiving increasing public cxposurc and interest

as well as greater professional attention. Conceptualized as fear of leaving
familiar surroundings, especially when alone, il is now included in DSM
111-R (American Psychiatric Association, 1987) as an anxiety disorder
where it is classified with and without a relationship to panic rcsponscs.
The symptoms of agoraphobia vary from person to person and include
fears of going into places such as crowded stores or restaurants, moving
about in the street, or traveling. In most cases the two main fcercd situa-
tions arc venturing into strange and distant arcas and being alone when
away from home. The person may fear that something dreadful will hap-
pen while away from home, such as dying or becoming hclplcss. The
fears usually occur with some degree of anxiety, depression, dcpcrsonal-
ization, or psychosomatic manifestations such as palpitations and dizzi-
ness. Panic is an intensification of these reactions, for instance, it sense of
impending doom with shortness of breath and palpitations, and is charac-
teristic of some agoraphobia even though panic disordcrs arc also now
considered distinct syndromes. Sometimes there are accompanying social
fears, such as fear of visibly trembling or being stared at (Ballengcr, 1989;
Barlow, 1988; Bowlby 1973; Clarke & Wardman, 1985; Frances & Dunn,
1975; Marks, 1970; Michelson, 1987).
Agoraphobia is considered to be the most prevalent and distressing pho-
bia in adult patients. When it is severe, it can be very disabling, even
leading a person to become housebound. The condition occurs mainly in
women, specifically young, adult, married women. Studies of agorapho-

Pat Sable, PhD, received her degree from the University of Southcrn Califor-
nia. She is Adjunct Assistant Professor at the University of Southern California
School of Social Work and has a private practice of psycho~hcrapyin Los
Angeles.
Women & Therapy. Vol. 1 l(2) 1991
Q 1991 by The Haworth Press, Inc. All rights rcscrvcd. 55
 56 WOMEN & THEMPY

bia have found that 7580% of those who have the disorder tend to be
women (Barlow, 1988; Clarke & Wardman, 1985; Goodwin. 1983;
Marks, 1970; Michelson, 1987). One study, by Burns and Thorpe (1977),
found the proportion of women to be as high as 88%.
Reasons given for the higher incidence in women range from biological
and cultural factors to how the condition is defined and reported. It has
been suggested, for example, that men are taught to be tough and master
their fears, whereas women are socialized to be "dependent," helpless,
and also allowed to say they feel afraid and then withdraw from frighten-
ing situations (Barlow, 1988; Wdor, 1974; Wolfe, 1984). This attitude
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derives partly from traditional psychological theory which views normal-

ity and maturity from a male perspective, and in terms of the person's
developing independcnce, without considering the importance of interper-
sonal relationships (Gilligan, 1982). Agoraphobia has been attributed to
fixation, regression, and projection or displacement of sexual and aggres-
sive drives. The focus has been on individual psychopathology and im-
pulses, such as unacceptable sexual feelings that the person was struggling
to repress. Agoraphobics were assumed to be dependent personalities who
were overprotected as children. Their tendency to stay near or "cling" to
familiar people or places was construed as providing them with secondary
gains (Andrews, 1966; Barlow, 1988; Deutsch, 1929; Rycroft, 1968;
Weiss, 1964).
Although therapists now recognize fear of leaving home as the main
symptom of agoraphobia, the influence of close personal relationships in
the development and maintenance of the disorder is relatively neglected or
unclear. For example, Buglass and colleagues (1977), in a study of 30
married agoraphobic women, found no differences between the women
and a matched control group other than the agoraphobic symptoms them-
selves. By way of contrast, flolmes (1982), in a study of 12 agoraphobic
patients, found both childhood experiences and a current adult relation-
ship relevant to understanding agoraphobia, and furthermore, that treating
the couple together reduced agoraphobic symptoms. Although there is
support for this technique (see Barlow & colleagues, 1981), Cobb and
colleagues (1984) found that including the spouse in treatment was not
helpful. The mixed results of couple treatment led Barlow to conclude that
the dynamics of each couple must be assessed individually. The inconsis-
tencies of the findings, including those related to the influence of a current
partner on developing symptoms or affecting the outcome of treatment,
suggest there may be other factors involved in understanding the behavior
and its treatment. Regardless of etiology, treatment generally consists of
 Pal Sable 57

medication and/or behavioral therapy for immediate symptom relief,

without exploring underlying dynamics (Parad, 1988). However, the suc-
cess of the use of medication andlor behavioral therapy has not been dcm-
onstrated (Ballenger, 1989; Barlow, 1988; Bowlby, 1973; Chambless &
Goldstein, 1981; Mathews, Gelder & Johnson, 1981).
John Bowlby (1973) suggests that agoraphobia can be understood as a
condition of "anxious attachment" related to fear and apprehension over
the availability and responsiveness of key attachment figures. He regards
agoraphobic behavior as a response to experiences of separation or threat
of separation. Within this interpersonal context (Stroebe, Stroebe & Hans-
son, 1988), the focus of treatment is to understand the impact of these
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experiences, both current and past, in order to change fear behavior pat-
terns.
This paper will use Bowlby's (1969, 1973, 1980) framework of attach-
ment to consider whether i t may provide an approach from which to better
conceptualize and treat agoraphobia. Clinical applications follow a pre-
sentation of the theory. The paper concludes with a discussion of how the
ideas may enable therapists to step back from some traditional biases,
particularly where these have interfered with helping women understand
their natural desire for close emotional ties with others.

ATTACHMENT THEORY
.Attachment theory is a way of explaining the propensity of infants to
become emotionally attached to their caregivers and the significance this
has for personality development, feelings of security, and laler adult rela-
tionships. Derived from psychoanalytic-object relations theory, combined
with ethology (animal behavior) and developmental psychology, the ap-
proach conceives a behavioral system of atti~chmentwhich enables the
child to attain proximity to a few key persons, especially a primary parent
figure, for safety and protection (Ainsworth, 1989; Bowlby, 1969, 1980;
Karen, 1990; Sable, 1989).
Another fundamental system of behavior, which operates in balance to
attachment, is exploration. When attachment figures are available and ap-
propriately responsible, there develops a feeling of trust in others. As
described by Erikson (1950), Mahler, Pine and Bergman (1075), and
Bowlby (1969, 1988b) a reliable parent figure enables the young child to
begin to build an inner sense of a secure base in rela~ionshipsfrom which
to move out and explore the world and to which to return when feeling
anxious, alarmed, tired, or ill. Of special relevance for understanding
agoraphobia as a fear behavior is the tendency of attachment to take prece-
 58 WOMEN & THERAPY

dence over exploration. Individuals of any age will venture forth and ex-
plore if they are feeling secure in the knowledge that attachment figures
will be there for them. Without this confidence, attachment behavior is
elicited and there is an urge to establish or continue contact with an attach-
ment figure in order to maintain the security of the bond. From the per-
spective of attachment, agoraphobia represents a distortion of attachment
behavior and exploration, resulting from certain "separation experi-
ences," both current and past, which intensify anxiety and insecurity
about exploring alone, away from familiar people and places.
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SEPARATION AND FEAR

Beginning with Freud, theorists have noted and puzzled over the rela-
tionship between separation, fear of separation, and anxiety (Bowlby,
1973; Wolfe, 1984). In 1926, Freud (192611959) defined anxiety as a
reaction to the danger of losing a loved person, but he also determined that
it was irrational, and thus pathological to be anxious if there was no real or
objective source of danger. Thus, a simple separation, such as a partner
going away for a few days, would not necessarily be dangerous, so it
appears unrealistic to feel afraid. However, an ethological perspective on
attachment, which emphasizes its protective function, explains fear of
separation as one of a group of naturally occurring clues to whether a
given situation represents safety or danger. Others are strangeness, isola-
tion, changes in sound or light, and sudden movement. Though not intrin-
sically dangerous, these signal an increase in the risk of danger and evoke
responses intended to ensure survival (Bowlby, 1970, 1973, 1988b).
There are research studies of different animal species which show that
separation from or loss of an attachment figure can, in itself, cause fear
and anxiety, affecting exploratory behavior. Harlow, who separated in-
fant rhesus monkeys from their mothers and raised them on mother surro-
gates, demonstrated that the monkeys who had cloth mother surrogates
were terrified when placed in a strange environment and did not explore
their surroundings if their cloth dummy mother was absent. When the
cloth dummy mother was present, they would cling to it and then begin to
move about (Bowlby, 1973; tiinde, 1966). Ainsworth has reported simi-
lar results in the one-year-old children she studied in the Strange Situation
procedure. When the mother was present, the children used her as a base
from which to play and explore. However, when the mother left the room,
a majority of the children were distressed and restricted their exploratory
behavior. While the mother was away, they cried and searched for her,
and also rcsponded more intensely to frightening situalions (Ainsworth &
 Pat Sable 59

Bell, 1970; Ainsworth, Blehar, Waters & Wall, 1978). Other studies re-
port that some children react by staying fixed to a single spot while sepa-
rated from their mother (Bowlby, 1973, 1975).
Behavior following reunion, in both the monkey and human studies,
reflects the effects of separation. The studies of monkeys done by Spen-
cer-Booth and Hinde (1967) found that young monkeys cling more to thcir
mothers and explore less than monkeys who have not endured a scpara-
tion. They also exhibited greater timidity and fear of strange situations.
Heinicke and Westheimer (1966) observed that young children became
more clinging and afraid to be left alone following a separation.
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These studies support the view that separation from the mother causes
protest and distress, as well as greater fear responses to strange situations.
There is increased attachment behavior and reduced exploration both dur-
ing and following a separation experience. It is important to note that there
is also greater sensitivily to any threat of another separation, as well as a
tendency for the sensitivity to persist over time (Bowlby, 1973; Waters,
1978).

AGORAPHOBIA AS ANXIOUS ATTACIIMENT

Bowlby (1973, 1988a) perceives agoraphobic individuals as experienc-
ing a chronic state of anxiety over the availability and responsivcncss of
their attachment figures. Because of thcir uncertainty and fear of desertion
or worry that they may not be cared for, they seek to maintain proximity
to assure contact with attachment figures. The apprehension about their
relationships hampers their going forth into the world and also their cop-
ing with stressful conditions such as separation and loss when they do
occur.
Bowlby applies the concept of anxious attachment to understand this
fear of separation from attachmen1 figures. Generally, a child is reassured
in early life by the continuing relationship with her mother (or other care-
giving figure), and gradually becomes more able to tolerate separation in
time and space (Sable, 1979). As she moves out into the world, she
spends longer periods away and she makes affcctional bonds with others.
A oerson who erows UD lo be anxiously attached, however. has been
subjected withinher family of origin to-actual or threatened~~e~aration
.experiences
. which have undermined her confidence in relationships, leav-
ing her uneasy about separation from them'. Besides actual separation or
loss there may have been physical abuse or neglect, a succession of differ-
ent caregivers, threats to abandon or not love their child, or threats to
commit suicide. In another pattern predisposing to anxious attachment, a
 60 WOMEN & THERAPY

parent demands that the child become the parent's caregiver, reversing the
usual order. Often this is reinforced by making the child feel incapable of
doing well on her own or instilling fear that the outside world is dangerous
(Bacciagiluppi, 1985; Bowlby, 1977a, 1988b; Sable, 1989).
The influence of these patterns of "disturbed family interaction"
(Bowlby, 1973, p. 313) tends to persist, becoming part of the individual's
experiences which are organized internally into "working models" of the
self and relationships with others (Ainsworth, 1989; Bowlby, 1988a).
Adults who suffer agoraphobia symptoms do not have the sense of a se-
cure base which would have enabled them to overcome the natural fears of
unfamiliar people and places. Instead, they feel anxiety and/or panic if
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they go far from attachment figures or familiar surroundings and can

maintain security only by staying close and "clinging" to whatever base
they have (Guidano & Liotti, 1983; Parad, 1988).

TREATMENT OF AGORAPHOBIA
A therapist guided by attachment theory applies the concepts of attach-
ment and separation to treatment (Bowlby, 1977b; Sable, 1983). The role
of the therapist is to provide a reliable relationship within which to experi-
ence an attachment relationship and from which to gain the confidence to
explore present and past relationships and experiences with others. There
is a particular emphasis on exploring and understanding attachment and
separalion experiences, including those that arise with the therapist during
treatment. Further, current emotions and behavior are considered in rela-
tion to these actual events. By connecting certain experiences (such as
memories of being threatened with abandonment) to present responses,
the therapist is calling attention to their relevance in understanding her
patient's history (Bowlby, 1988b; Sable, 1983). In so doing, the therapist
clearly distinguishes the basic human desire for close bonds with others
from a concept of dependency (Sable, 1979). The therapist also conveys
respect and sympathy for feelings such as anxiety, anger, and yearning
which may arise when a person wanted for comfort is not accessible or
responsive.
A distinctive feature of Bowlby's approach is the perception of defen-
sive processes as the defensive exclusion of certain information and feel-
ings, based on experiences the individual has had with others, beginning
in childhood (Bennun, 1986; Bowlby, 1980). When a client feels secure
with her therapist she will begin to retrieve and review these memories,
many of which are painful or unhappy. This process of recollection may
be more difficult if her parents prohibited their children from viewing
 Pat Sable 61

parental behavior accurately. For instance, a parent might reinforce a

child's fear of leaving home and going to school rather than rcmcmbcr that
this behavior began when the parent threatened to dcscrl the family or
possibly following the parent's attempted suicide. As a rcsull, such indi-
viduals will defensively exclude information which they are not yet rcady
to acknowledge or share with their therapist. The case of Kelly, reported
clsewhcrc (Sable, 1983), is an example of a woman who had blocked the
memory of hcr mother's frequent suicide threats when Kclly was young.
Kelly rcporled agoraphobic symptoms, including fear of driving her car
into "strange areas" and fear of going most places, such as shopping,
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alone. I n addition, she stayed away from theaters because she was afraid
of crowds. Thcre were times she would stay at home, going out only to
work.
Thcse behaviors illustrate two issues that arc especially important in
treating agoraphobia: fear of being alone and fear of strangc pl;tccs. A
frequent complaint of agoraphobic patients is that they feel childish and
over-dependent because of their fear of being alone, especially in strangc
situations or other settings such as a supermarket which common sensc
says are not dangerous. When i t is recognized how a trusted companion
reduces anxicty, especially under strange conditions, i t is appreciated that
the absence of such security may increase fear. I f an individual wants
emotional support or actual help, yet feels an attachment figure cilnnot be
counted on to be available, she is more prone to be afrarid when conditions
are strange or frightening than i f she confidently knows there arc othcrs on
whom she could depend.
The therapist and patient work together to sort out the Ii~ttcr'satt;lch-
ment-relatcd experiences. This includes explaining that scparation anxiety
is a natural response to separation or threat of scparation which may have
been intensified by pathogenic family experiences. Whcre events may
have been misconstrued, either with her therapist or with othcrs, the pa-
tient is encouraged to examine whether or not she is responding as she had
learned in the past, thereby reappraising and possibly modifying long-
standing patterns of response to fit with present day expericnccs.
These aspects of attachment and transference in therapy arc illustrated
by the following clinical examples. Although some patients seek trcnt-
ment for agoraphobic symptoms, others describe a variety of compli~ints
such as anxiety or depression, but then begin to reveal patterns of agora-
phobia.
Until recently, agoraphobia was not adequately recognized by mental
health professionals. As a result, therapists sometimes did not know what
 62 WOMEN & THERAPY

bchavior to look for or how best to conceptualize it. They have also found
it difficult lo treal (Bennun, 1986; Goodwin, 1983). People suffering from
the syndrome themselves cannot usually understand what is wrong.
Achicving a grasp of the meaning of this cluster of anxiety symptoms can
be relieving and enlightening. The patient may feel that someone under-
stands her for the first time.
Lizzy
The account of a thirty-two year old, very thin, pale and highly anxious
woman, Lizzy, demonstrates the role of family experiences in Ihe forming
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and continuation of agoraphobia. It also shows how the disorder affects

the interaction of all family members, restricting and altering the behavior
of each.
L i n y came into therapy because she was suffering from anxiety, de-
pression, and a series of fear symptoms which were affecting her relalion-
ship with her family. She had become anxious if separated too frequently
from her husband, which was upsetting him, and was afraid lo drive alone
beyond certain precise boundaries, because she would "have no one lo
count on." She was beginning to expect the oldest of her three children to
go places with her so that Lizzy would not feel afraid, and the daughter
had herself become a behavior problem.
During therapy I.izzy described a painful childhood, where her family
had moved, sometimes abruptly, from city to city because her father had
difficulty keeping a job. Lizzy found it hard to make friends, so she re-
mained close to her family. Even now her parents lived nearby. Her
mother was described as afraid to be alone or to drive a car, relying on
Lizzy to take her places and stay with her when the father traveled. This
held her as an attachment figure to her mother and suggests a pattern of
reversal which had existed since Lizzy's childhood. She also passed on
cues of what Lizzy should fear, such as moving too far away from her.
Lizzy had Ihe impression that her mother thought L.izzy could not manage
on her own.
Lizzy's anxious attachment and fear of separation can be connected to
licr reill experiences. As the therapy relationship furnished her with a fa-
miliar and secure base, she was able to share fears and feelings such as
fear of being alone, without having them seen as childish and inappro-
priate. It also enabled her to link up anxiety over separation to actual
events with her parents and her husband. As she came to understand her
bchavior as a response to family experiences, she was able to release her
child from the reversed caregiving. She and her husband worked on their
relationship, examining whether her perceptions of his lack of accessibil-
 Pat Sable 6.1

ity and responsiveness might partially be related to her early experiences.

As she came to see that she had expected him to behave in a ccrtain way,
she was able to let him be a more reasonable attachment figure for hcr.
I-Ier symptoms subsided.

Chcryl, a thirty-six year old, pleasant, soft spoken woman who came
into therapy because she was feeling depressed and sad, provides an ex-
ample of agoraphobia occurring in combination with feelings of grief and
mourning. Cheryl moved and talked slowly, with little emotional exprcs-
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sion, and had difficulty talking about herself. She had been married to Jim
for fifteen years, and had three children.
Cheryl reported she was feeling troubled by recent changes in hcr
moods and behavior. For no apparent reason she would suddenly want to
cry. She frequently felt tense and upset or angry. At social gatherings, she
saw herself as an "outsider" looking at others. Sometimes she awoke in a
panic in the middle of the night with a premonition of doom, frightened
but not knowing of what she was afraid. In addition, she had become
increasingly afraid to both walk about "in the open" or to be in a car.
Driving on the freeway especially frightcncd her as she worried that a car
might cross thc line, smashing into her, and she would die. She noted that
she feared death, never realizing how final it was until her mother's death
eight years before.
Chcryl had also always been afraid to fly and was only able to do this
and certain other activities if accompanied by a trusted companion, such
as, her husband. However, she stated that her confidence in Jim had be-
come "shaky" due to marriage and work problems, and she no longer
saw him as "strong and independent." This left her feeling misunder-
stood and alone. An upcoming vacation, where she felt unable to fly, was
another factor that led to treatment.
In thcrapy, Cheryl recounted her life experiences. The younger child of
parents who did not gel along, Cheryl's mother was silent and submissive
to a controlling and critical husband. Neither approved of Cheryl's
friends. I-ler father was himself fearful, for example, of flying and was
overprotcctive and restrictive of Cheryl's activities. ficr mother, although
usually at home, was withdrawn from the family, not taking c;rre of her
appearancc or her house. Cheryl saw her mother's life as empty and was
determined not lo be like her, but to become strong and independent. She
left home at eighteen, resolved to work and not marry, but, once married,
was devoted to hcr family and was successful in working part-time for a
sales company.
 64 WOMEN & THERAPY

It appears that Cheryl grew up anxiously attached in her close relation-

ships with others. She wanted to be loved and cared for but had not been
made to feel deserving of love and care. Instead, she sought to be indepen-
dent, stating that she would be "weak" and overly dependent if she relied
on others or shared fcars and feelings. These mixed feelings, which seem
to reflect societal biases about independence, confused Cheryl and led her
to invent reasons to justify support. tIer struggles to make sense of wom-
en's feelings and experiences were further compounded by unresolved
mourning for hcr mother.
After six months of therapy, Cheryl had completed some grieving for
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her mother and reappraised her family experiences, including her fears of
separation and the pain of loss. This work enabled her to reassess her
relationship with Jim. The therapist helped her understand how earlier
experiences of insecure attachment were being imposed on her adult rela-
tionships. Her marriage improved, and her fears of moving about and her
panic attacks ceased. Therapy concluded when she and Jim prepared for a
plane trip. A final comment to her therapist revealed Cheryl's trust in
therapy as a secure base as well as her understanding of her fear behavior:
"1 know I could call and you would talk to me all the way to New York."

ANXIOUS ATTACHMENT AND WOMEN

A person may develop anxious attachments as well as fears about ex-

ploring out in the world if exposed to certain separation experiences. Each
of the women discussed in this paper had experienced repeated threats of
separation and/or actual separation experiences and reversed parenting in
their early years. All described pathology in their parents. A current prob-
lem with an attachment figure (or a difficulty in making affectional bonds)
precipitated treatment. In addition, these agoraphobic women felt social
pressure to appear independent, and they were unable to resolve this de-
mand with their desire for secure attachment.
Treatment providcd a temporary secure base which focused on under-
standing attachment and separation experiences, both present and past,
including responses to the therapist. The women were helped to under-
stand that feelings of anxious attachment are basically an adaptive re-
sponse to a signal of danger, that of separation or threat of separation or
unreliability in attachment relationships. By examining their experiences,
with the support and confirmation of the therapist, the women began to
reconstruct their working models of relationships, as well as their attitudes
and expectations of being deserving of affection and care, and were able
to let go of agoraphobic behavior.
 The approach of the therapist was to be reasonably avail;~l)lc- for cx-
ample, to accept phone calls between sessio~~s-butgenerally the confi-
dence that the therapist could be relied upon was enough lo rcducc anxicty
and/or panic and extra contact was rarely sought. Kelly (S;~blc, 1983)
once related that "just knowing" she could reach l~crther;~pist if she
needed her was ;tII that was necessary to rcducc her anxiety. Likewise,
Clieryl did not call her thcrapist bcforc taking her plane trip thorlgl~shc
had conveyed to her thcrapist that she fclt she could call without bcing
scen as childisli or ovcrdcpcndent. By clarifying the concept of ;~ttachmcnt
;IS separate and distinct from a concept of dependency (Sable, 1979),
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Cheryl and the other women wcrc itble to discuss concerns about wanling
to be close lo others without ncgi~tivcconnotations or Iilbeling as overdc-
pcndct~t.It is important for therapists to be aware of this distinction bc-
tween attachment and dependency, so thcy do not compound existing so-
cial attitudes which demand that womcn be independent without allowing
for affectional bonds with othcrs.
Attachment theory provides additional support to Miller (1976) and
Gilligen's (1982) assertions that women's rclationsliips arc central to thcir
lives. There is evidence that womcn are more affected by the ;~v;~il;~bility
of attachmcnt figures, especially at times of adversity, than arc mcn (Ilcn-
dcrson, 1982). I-Iowevcr, rather tIi;~n acconimodate these findings, psy-
chological theory still views normalily from the male perspective of au-
tonomy and independence. Woman hnve been taught and hnve accepted
the vicw that their attitudes about relationships indicate ovcrdcpcndc;icy.
This kind of societal pressure forces them to exclude and discount some of
their basic feelings which results in their blaming thcmsclvcs and Ici~vcs
them vulnerable to developing psychological distress.
It remains to be understood why some individuals develop anxious at-
tachment and subsequently agoraphobia while othcrs do not. As Wolfe
(1984) has noted, even though there is ;I higher incidence of the disorder
among women, all women do not develop agoraphobia. A variety of fac-
tors appears to influence behavior and it is difficult to draw casual infcr-
ences (Barlow, 1988; Brown, 1982; Sable, 1989). I-lowcvcr, Parkcs and
Wciss (1983) and Sablc (1989) identified anxious attachment in bcrci~vc-
mcnt studies of womcn which thcy found related to a range of scparation
and loss expcricnccs. Sablc, for instance, discovered that women who
reported more separation cxpcriences in childhood grew up to bc morc
anxiously attached in their adult rcli~tionships.These womcn also had
morc difficulty adjr~stingto the death of their spouses.
It is possible that womcn, at this period in time, arc raised in a way that
 66 WOMEN & THERAI'Y

may bring about a higher incidence of anxious attachment, especially

when compounded by certain family experiences. Fodor (1974), for in-
stance, suggests that girls may be socialized and overprotected in a way
that discourages assertiveness. The women discussed in this paper were
told that the outside world was dangerous and they also observed parents
who modeled fearful behaviors. Parental behavior and injunctions, there-
fore, added to a natural inclination to feel afraid in certain situations rather
than providing a secure base which could diminish feelings of fear.
An ethological view of attachment accounts for the security found in an
affectional bond, not only in childhood but also throughout life. I1 enables
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therapists to listen to the material presented in a new way (Karen, 1990).

If there are differences between women and men, they in no way imply
women are less capable, but recognize that behavior is intended to pro-
mote survival. Certainly in our modern world there is risk of danger that
calls for knowing what people and places can offer safety. We do a disser-
vice to our patients as well as ourselves if we think of such behavior under
these conditions as pathological clinging, childishness, or overdepen-
dency.

CONCLUDING COMMENTS
The influence of both theory and cultural attitudes on agoraphobia de-
serves further attention. For instance, research has focused on white, mid-
dle class populations, but what evidence there is suggests there is more
agoraphobia in other minority groups, including the poor, than generally
assumed (Michelson, 1987). Some of this might be related to actual dan-
gers in which these women live (Al Issa, 1980). In addition, there is need
for a clearer understanding of agoraphobia, especially as it concerns rela-
tionships with others. It is detrimental for women when the value they
place on their relationships is not acknowledged by the larger society.
Fear behavior is stigmatized rather than allowing for an appraisal of close
affectional bonds.
I t should not be construed as pathological dependency to desire the
comfort and security of another, but rather, an integral part of human
nature, both to seek bonds with others and to explore the world. A firm
emotional atlachment leaves one free for exploration, promoting confi-
dence and a sense of security and competence. Self-reliance reflects a
harmonious balance between attachment and exploratory behaviors. 11
comes only when there is confidence in one's attachment figures, know-
ing they are readily available and responsive should they be called upon.
As mental health workers, it is our (ask to help our patients understand
 Pat Snble 67

how much lheir attachment relationships affect their eniotional and social
well being.

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