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Self-instructional training in stress management Bowman, Roland Glen 1977

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SELF-INSTRUCTIONAL TRAINING IN STRESS MANAGEMENT by ROLAND GLEN BOWMAN M.A., U n i v e r s i t y of B r i t i s h Columbia, 1973 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES (Department of Psychology) We accept t h i s d i s s e r t a t i o n as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1977 Copyright Roland Glen Bowman In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of Br i t ish Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of U^^^J^^^r--Y^ The University of Br i t ish Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Da A b s t r a c t This d i s s e r t a t i o n r e p o r t s an e v a l u a t i o n of S e l f - i n s t r u c t i o n a l t r a i n i n g as a stress-management technique f o r multi-problem c l i e n t s . I n d i v i d u a l s who responded to a newspaper advertisement o f f e r i n g a s s i s t a n c e i n te n s i o n management and who reported that they experienced an x i e t y i n at l e a s t two r e l a t i v e l y s p e c i f i c s i t u a t i o n s were assigned to the f o l l o w i n g treatment c o n d i t i o n s : (1) S e l f - i n s t r u c t i o n a l t r a i n i n g ( n = l l ) , (2) Awareness ( n = l l ) , (3) S k i l l s t r a i n i n g (n=ll) and (4) Minimal treatment c o n t r o l (n=9). Therapy was conducted over a six-week period w i t h t h e r a p i s t s i n the f i r s t three experimental c o n d i t i o n s meeting small groups f o r 1%-hour sessions. C l i e n t s i n a l l c o n d i t i o n s were encouraged to adopt a s i t u a t i o n a l view of anxiety and to record the d e t a i l s of the s t r e s s f u l s i t u a t i o n s they encountered throughout the course of treatment. In the f i r s t c o n d i t i o n , Meichenbaum's (1974) treatment manual was used as a guide. C l i e n t s were taught to analyze t h e i r problems according to a c o g n i t i v e model of anx i e t y and to adopt the use of coping self-statements i n s t r e s s f u l s i t u a t i o n s . C l i e n t s i n c o n d i t i o n two rece i v e d .a s i m i l a r treatment r a t i o n a l e , but d i d not s p e c i f i c a l l y p r a c t i c e the use of coping s e l f - s t a t e m e n t s . The t h i r d c o n d i t i o n provided a combination of r o l e -p l a y i n g and coaching to a s s i s t c l i e n t s to change t h e i r behavior i n s t r e s s f u l s i t u a t i o n s . F i n a l l y the minimal treatment group attended a two-hour s e s s i o n i n which the s e l f - i n s t r u c t i o n a l t r a i n i n g procedure was explained to them and was a p p l i e d to some of t h e i r problems. i i Analysis of self - and Significant Other reports found no significant differences among treatment conditions, although there was significant change on almost a l l measures for the client sample as a whole. These inconclusive findings were discussed in relation to differences between the present client sample and clients who have served as subjects in previous research. It was suggested that a promising area for future research might be the investigation of the role of certain client characteristics in determining treatment outcome, especially levels of t r a i t anxiety and the duration and specificity of stressful situations. i i i Table of Contents Page Chapter 1 Fear a n x i e t y and s t r e s s 1 Chapter 2 C o g n i t i v e f a c t o r s i n a n x i e t y 4 Chapter 3 C o g n i t i v e behaviour m o d i f i c a t i o n i n the treatment of a n x i e t y 9 Component a n a l y s i s of s e l f - i n s t r u c t i o n a l t r a i n i n g 15 Co g n i t i v e therapy and s k i l l s t r a i n i n g 17 Chapter 4 P r a c t i c a l c o n s i d e r a t i o n s i n s t r e s s -management programmes 20 Chapter 5 Statement of the problem 24 Chapter 6 Method Subject recruitment and s e l e c t i o n 26 D e s c r i p t i o n of f i n a l sample 28 T r a i n i n g i a n d s u p e r v i s i o n of i n t e r v i e w e r s and t h e r a p i s t s 29 Conditions 29 Pretreatment measures 34 Post treatment measures 36 Follow-up procedure and measures 37 Chapter 7 R e s u l t s 38 Chapter 8 D i s c u s s i o n 44 Footnotes 51 References 52 Appendix 1 Interview guides 57 Appendix 2 Instruments 65 Appendix 3 Problem s i t u a t i o n s and t y p i c a l therapy 71 i n t e r a c t i o n s i v L i s t of Tables Page Table 1 Means and standard d e v i a t i o n s f o r outcome 39 measures Table 2 Summary of analyses of v a r i a n c e 41 V Acknowledgement I would like to thank Dr Allan Best, Dr Lynn Alden and Dr Robert Knox for their assistance in designing and carrying out this research. I am also grateful to Dr Park Davidson, Dr Peter McLean and Dr Thomas Storm for serving on the fin a l dissertation committee. In addition I want to acknowledge the assistance of Kathleen Sun, Sandra Mills, Kathy Douglas and Thomas Bowers who conducted assessments interviews,and Carol Macpherson, Gerald Hover, Adam Horvath, Ian Hunt, Frank Collistro and Ann Chusid who served as therapists on this project. CHAPTER ONE Fear, A n x i e t y and Stress The terms " f e a r , " " a n x i e t y " and " s t r e s s " occur w i t h high frequency i n the p s y c h o l o g i c a l l i t e r a t u r e , but u n f o r t u n a t e l y there are s t i l l no u n i v e r s a l l y accepted conventions which govern t h e i r use. This s i t u a t i o n does not e x i s t because d e f i n i t i o n a l problems have been ignored; on the contra r y , many t h e o r i s t s have attempted to make meaningful d i s t i n c t i o n s among these r e l a t e d concepts. Some of t h e i r formulations w i l l be b r i e f l y discussed below i n order to c l a r i f y useage i n t h i s d i s s e r t a t i o n . Often " f e a r " and "a n x i e t y " are used interchangeably. For example, behaviour t h e r a p i s t s have w r i t t e n about " f e a r of d a t i n g " and "heterosexual a n x i e t y . " In the same way, "examination a n x i e t y " can be described as "fe a r of t e s t s . " Although these examples i n d i c a t e that " f e a r " and "a n x i e t y " can serve as l a b e l s f o r the same emotion, they a l s o i l l u s t r a t e the most common b a s i s f o r making a d i s t i n c t i o n between the two: the object of f e a r i s u s u a l l y f a i r l y s p e c i f i c , w h i l e the stimulus s i t u a t i o n which provokes an x i e t y i s l e s s circumscribed and o f t e n a l s o more a b s t r a c t and symbolic (Lazarus and A v e r i l l , 1972). In a d d i t i o n to a d i s t i n c t i o n made on the b a s i s of the stimulus s i t u a t i o n , s e v e r a l authors have suggested that f e a r responses can be d i f f e r e n t i a t e d from an x i e t y responses. E p s t e i n (1972) argues that such response d i f f e r e n c e s are c r u c i a l f o r an adequate understanding of the two emotions. He describes f e a r as an avoidance motive, and anx i e t y as a d i f f u s e s t a t e of a r o u s a l which cannot be channeled i n t o a c t i o n . Thus, w h i l e a person who i s a f r a i d w i l l f l e e or otherwise avoid contact w i t h c e r t a i n s t i m u l i , an anxious i n d i v i d u a l i s unable to take such a c t i o n f o r any of a v a r i e t y of reasons which might i n c l u d e i n d e c i s i o n , or a c o n f l i c t 2 between opposing courses of a c t i o n . Lazarus and A v e r i l l (1972) make a ra t h e r s i m i l a r d i s t i n c t i o n when they suggest t h a t , i n the case of f e a r , there i s a tendency to d i r e c t a c t i o n , w h i l e a n x i e t y i s more l i k e l y to evoke i n t r a p s y c h i c ( i . e . , c o g n i t i v e ) responses. Are these conceptual d i s t i n c t i o n s u s e f u l i n behaviour therapy research? Lazarus and A v e r i l l b e l i e v e that they are. They suggest t h a t , w h i l e f e a r may be s u c c e s s f u l l y d e a l t w i t h by h a b i t u a t i o n , a n x i e t y may r e q u i r e a " r e s t r u c t u r i n g of c o g n i t i v e systems." Reports that systematic d e s e n s i t i z a t i o n i s s u c c e s s f u l i n the treatment of s p e c i f i c f e a r s , but of only l i m i t e d usefulness when a p p l i e d to more, pervasive a n x i e t y (see, e.g., Marks, Boulougouris and Marset, 1971) support t h i s p o i n t of view. Thus, d e s p i t e the f a c t that there i s a considerable degree of overlap between the two concepts, i t appears that f e a r and anxiety can be meaning-f u l l y d i f f e r e n t i a t e d . Such i s probably not the case f o r s t r e s s and an x i e t y s i n c e i t i s p o s s i b l e to use these two terms interchangeably across a v a r i e t y of s i t u a t i o n s w i t h l i t t l e l o s s of c l a r i t y . Appley and Trumble (1967) have noted the great p o p u l a r i t y of the concept of s t r e s s s i n c e i t s i n t r o d u c t i o n i n t o the l i t e r a t u r e by Selye i n 1936. Selye was i n i t i a l l y concerned w i t h the common p h y s i o l o g i c a l e f f e c t s of extreme environmental or i n t e r n a l demands on an organism. He used the term " s t r e s s " to de s c r i b e a response r a t h e r than a sti m u l u s . As Appley and Trumble point out, s t r e s s i s "probably best conceived as a s t a t e of the t o t a l organism under extenuating circumstances, r a t h e r than an event i n the environment." Their c o n c l u s i o n i s important because s t r e s s has, i n f a c t , o f t e n been defined i n terms of environmental s t i m u l i . This useage can only lead to confusion. 3 On the b a s i s of the response d e f i n i t i o n of s t r e s s , Martens (1971) has suggested that s t r e s s i s f u n c t i o n a l l y equivalent to Sp i e l b e r g e r ' s n o t i o n of s t a t e a n x i e t y . S p i e l b e r g e r (1972a) describes s t a t e a n x i e t y as a t r a n s i t o r y s t a t e i n the person which occurs when a s i t u a t i o n i s i n t e r -preted as t h r e a t e n i n g . He p r e f e r s to place " s t r e s s " i n the environment as a cause of a n x i e t y , but at other times he describes environmental events as " s t r e s s o r s " ( S p i e l b e r g e r , 1972b). I t would seem that the e f f e c t of a s t r e s s o r should be s t r e s s r a t h e r than s t a t e a n x i e t y . At l e a s t i n the case of p s y c h o l o g i c a l l y t h r e a t e n i n g (rather than p h y s i c a l l y dangerous) s i t u a t i o n s , s t r e s s and anxiety appear to be equivalent c o n s t r u c t s . For t h i s reason, they w i l l be used interchangeably i n t h i s d i s s e r t a t i o n , and events which provoke an x i e t y w i l l sometimes be described as " s t r e s s f u l . " 4 CHAPTER TWO Cognitive Factors in Anxiety There appears to be a growing consensus among personality and c l i n i c a l psychologists that cognitive factors play a c r i t i c a l role in anxiety. While many authors have emphasized the importance of such processes as expectancy, appraisal and evaluation (e.g., Arnold, 1970; Epstein, 1972) the cognitive view of anxiety has become most firmly associated with the writings of Lazarus (Lazarus and Opton, 1966;, Lazarus, A v e r i l l and Opton, 1970; Lazarus and A v e r i l l , 1972). Lazarus and his associates view cognition as a mediator between stimulus situations and the phenomenological and physiological aspects of emotion. In the case of anxiety, they suggest that cognitive responses can occur at three levels of appraisal. At the f i r s t level, primary appraisal, the person makes a judgement that a situation is l i k e l y to pose a threat. Then, he forms an opinion about the availability of coping mechanisms which might be used to deal with possible danger (secondary appraisal). Finally, he reappraises the situation on the basis of any new information which he may have acquired, and in light of the l i k e l y effectiveness of his coping strategies. Appraisal at a l l levels is affected by (1) the immediate stimulus situation, (2) the environmental context within which that situation i s embedded, and (3) enduring personality dispositions. The outcome of appraisal can be either direct action or further cognitive activity. In the former case, an anxious person may attempt to deal with his feeling by attacking or avoiding. In the latter, anxiety may be handled by adopting a more r e a l i s t i c view of the situation or through the use of various defenses. 5 Lazarus and h i s coworkers have demonstrated the importance of a p p r a i s a l s and defense mechanisms i n a s e r i e s of experiments employing motion p i c t u r e s as s t r e s s o r s (see Lazarus et a l . , 1970, f o r a review of t h i s work). For example, Lazarus, Speisman, Mordkoff and Davison (1966) showed subjects a movie which depicted p r i m i t i v e s u b i n c i s i o n r i t e s . A p p r a i s a l was manipulated by v a r y i n g the soundtrack i n d i f f e r e n t experimental c o n d i t i o n s . Results i n d i c a t e d that soundtracks which promoted i n t e l l e c t u a l i z a t i o n , d e n i a l , r e a c t i o n formation or trauma produced d i f f e r e n t l e v e l s of an x i e t y . In g e n e r a l , p h y s i o l o g i c a l measures i n d i c a t e d l e s s a r o u s a l i n the defensive soundtrack c o n d i t i o n s . Lazarus and A v e r i l l review more recent experiments performed i n t h e i r l a b o r a t o r y which h i g h l i g h t the r o l e s of a n t i c i p a t i o n and u n c e r t a i n t y i n a n x i e t y a r o u s a l . In one such study, Nomikos, Opton, A v e r i l l and Lazarus (1968) cut and s p l i c e d a woodshop s a f e t y f i l m to create d i f f e r e n t a n t i c i p a t i o n i n t e r v a l s preceding accidents which caused p h y s i c a l i n j u r y . In one v e r s i o n of the f i l m , subjects were given 20 and 26 seconds i n which to a n t i c i p a t e two a c c i d e n t s . A n t i c i p a t i o n i n t e r v a l s of only 4 and 7 seconds were used i n the second v e r s i o n . Nomikos et a l . found that longer i n t e r v a l s produced greater a n x i e t y (as measured by heart r a t e and s k i n conductance changes). Most of the autonomic change which was observed i n both cases occurred during a n t i c i p a t i o n periods r a t h e r than during the accident scene i t s e l f . To assess the e f f e c t of u n c e r t a i n t y , Monat, A v e r i l l and Lazarus (1972) conducted an experiment i n which the t h r e a t of shock was used to provoke an x i e t y . In two " u n c e r t a i n t y c o n d i t i o n s , " subjects were informed e i t h e r that (1) there was a 50% chance that they would r e c e i v e shock, but that they would r e c e i v e i t at a p a r t i c u l a r time i f i t was given (event u n c e r t a i n t y ) , .6 of (2) there was a c e r t a i n t y that they would be shocked, but the time of the shock was not s p e c i f i e d (time uncertainty). In the f i r s t condition, p h y s i o l o g i c a l and s e l f - r e p o r t indices followed a U-shaped curve with greatest anxiety occurring i n i t i a l l y and immediately preceding the shock. Subjects i n the time uncertainty condition showed an i n i t i a l small increase i n anxiety followed by a general decline. Data on coping str a t e g i e s used by subjects to deal with shock threat suggested that t h i s decline was associated with an avoidance of thoughts about shock. Appar-ently such avoidance was possible only when the time of the noxious event was unknown. Epstein and Roupenian (1970) have also manipulated an aspect of uncertainty about the occurrence of shock. In t h e i r study, subjects were asked to draw a card from a deck and then informed that theccard selected would determine whether they received a shock. They were further informed that t h i s shock would occur ( i f they had selected the "shock card") at the count of ten i n a count-up. Subjects were assigned to 5%, 50% or 95% shock expectancy groups. Heart rate showed a greater increase f o r the f i r s t two conditions, than f o r the 95% expectancy group suggesting that more uncertainty produces greater arousal. From another perspective, s o c i a l psychology research has shown that the strength and d i r e c t i o n of emotional responses depend not only on a person's appraisal of a s i t u a t i o n , but also on h i s perceptions of h i s p h y s i o l o g i c a l responding. In t h e i r well-known experiment, Schacter and Singer (1962) found that subjects who a t t r i b u t e d an altered state of arousal to the e f f e c t of a drug were l e s s l i k e l y to behave i n an emotional manner than subjects who believed that t h e i r heightened arousal was the 7 r e s u l t of a s o c i a l s i t u a t i o n . On the b a s i s of such f i n d i n g s , Schacter (1972) has concluded that "given a s t a t e of p h y s i o l o g i c a l a r o u s a l f o r which an i n d i v i d u a l has no immediate e x p l a n a t i o n , he w i l l l a b e l h i s s t a t e and d e s c r i b e h i s f e e l i n g s i n terms of the c o g n i t i o n s a v a i l a b l e to him" (p. 16). In the Schacter and Singer study subjects were misled about the causes of t h e i r emotion; more recent research has deceived s u b j e c t s about the extent of t h e i r emotion. Beginning w i t h an experiment by V a l i n s and Ray (1967), there have been s e v e r a l attempts to reduce f e a r through the use of f a l s e p h y s i o l o g i c a l feedback. In the i n i t i a l m i s a t t r i b u t i o n study, the experimenters s u c c e s s f u l l y increased approach behaviour i n snake phobics. However, s e v e r a l attempts to r e p l i c a t e t h i s f i n d i n g have f a i l e d . In reviewing t h i s research, Kopel and Arkowitz (1975) concluded that- f a l s e feedback manipulations w i l l be s u c c e s s f u l only when l e v e l s of a r o u s a l are f a i r l y low. Nevertheless, from a t h e o r e t i c a l p e r s p e c t i v e the m i s a t t r i b u t i o n research i n d i c a t e s that b e l i e f s about the s t r e n g t h of one's own emotion can a f f e c t behaviour i n c e r t a i n cases. In a d d i t i o n to s t u d i e s i n m i s a t t r i b u t i o n , experiments conducted w i t h i n the framework of Bern's (1972) s e l f - p e r c e p t i o n theory support the view that b e l i e f s a f f e c t emotion. For example, Kqpel and Arkowitz (1974) have reported that subjects who r o l e - p l a y "upset" behaviour show decreased pain thresholds and lower t o l e r a n c e f o r shock. I t i s as though people i n t h i s s i t u a t i o n observe t h e i r own behaviour and reason that they must be upset because they are d i s p l a y i n g signs which are c h a r a c t e r i s t i c of d i s t r e s s . 8 In summary, there i s considerable support for the theoretical position that cognitions play a major role in anxiety arousal and maintenance. The research of Lazarus and his associates indicates that the experience of anxiety is in a large part determined by an individual's belief that a situation poses a threat to him. This appraisal i s most l i k e l y to occur when he anticipates a noxious stimulus about which there i s some degree of uncertainty. Misattribution and self-perception studies provide evidence that beliefs about present level of coping are also important. The research cited above points toward several kinds of therapeutic intervention in anxiety: (1) decreasing uncertainty and ambiguity in stimulus situations, (2) assisting clients to change their appraisals of threatening situations, and (3) providing clients with feedback which indicates that they are coping successfully. The f i r s t of these approaches i s employed in therapeutic programmes which use cognitive and behavioural rehearsal. Lazarus' research i s relevant to the second, since i t illustrates the anxiety-reducing effect of changing the way one views a threatening situation. Under certain conditions, i t should be possible to confront stimuli which once provoked anxiety in a calmer state because of altered appraisals. Finally, false feedback studies suggest that the belief that one i s coping well can reduce fear (at least in low-fear situations). It may be that a treatment which helps clients to focus on the successful aspects of their behaviour w i l l have the effect of reducing anxiety. The next section w i l l discuss therapies which have employed such cognitive strategies. 9 CHAPTER THREE Co g n i t i v e Behaviour M o d i f i c a t i o n i n the Treatment of Anxiety C o g n i t i v e techniques are r a p i d l y g a i n i n g p o p u l a r i t y i n the p r a c t i c e of behaviour therapy. Mahoney (1977) suggests that t h i s development i n d i c a t e s an emerging rapprochment between t r a d i t i o n a l i n t r a p s y c h i c / i n t e r -personal approaches and a s t r i c t l y b e havioural p e r s p e c t i v e . C o g n i t i v e behaviour t h e r a p i s t s acknowledge the caus a t i v e r o l e s of both p r i v a t e events — expe c t a t i o n s , a t t i t u d e s , memories, e t c . — and environmental contingencies i n human experience and behaviour. However, i t i s important to note that they d i f f e r from t r a d i t i o n a l t h e r a p i s t s i n t h e i r treatment of mental contents. While the l a t t e r have t y p i c a l l y considered the m o d i f i c a t i o n of c o g n i t i o n s to be a complex and time-consuming process, c o g n i t i v e behaviour t h e r a p i s t s t r e a t c o g n i t i o n s as d i r e c t l y m o d i f i a b l e e n t i t i e s . They a s s e r t that a person can re p l a c e one thought w i t h another i n much the same way as he can rep l a c e one behaviour w i t h another (see, e.g., Meichenbaum, 1972, 1974). To some extent c o g n i t i v e behaviour m o d i f i c a t i o n — had i t s o r i g i n s i n the l e a r n i n g l a b o r a t o r y , and, i n f a c t , s e v e r a l c o g n i t i v e techniques reported i n the l i t e r a t u r e c l o s e l y resemble e a r l i e r behavioural s t r a t e g i e s . For example, i n covert modelling the f e a r f u l c l i e n t i s asked to imagine another person engaging i n coping behaviour i n v o l v i n g the phobic st i m u l u s . This procedure i s d i r e c t l y borrowed from modelling s t u d i e s which have used l i v e or f i l m e d models (Bandura, 1969). In a s i m i l a r way, c o g n i t i v e behavioural r e h e a r s a l p a r a l l e l s overt behavioural r e h e a r s a l ; i n s t e a d of a c t u a l l y rehearsing a behaviour i n the presence of the t h e r a p i s t , c l i e n t s rehearse the event mentally. 10 Although the p r i n c i p l e s and paradigms of l e a r n i n g were important i n the development of c o g n i t i v e behaviour m o d i f i c a t i o n , other i n f l u e n c e s are a l s o apparent. Se v e r a l i n v e s t i g a t o r s have adopted and elaborated the Rational-emotive therapy of E l l i s (1961). I t i s E l l i s ' view that emotional disturbance i s caused by i r r a t i o n a l b e l i e f s which people hold about the nature of the world and t h e i r place i n i t . These b e l i e f s are an important cause of g u i l t and a n x i e t y because they lead to u n r e a l i s t i c expectations. For example, an i n d i v i d u a l who b e l i e v e s that he must be loved or approved of by v i r t u a l l y everyone w i l l o f t e n f a i l to gain the sweeping p o s i t i v e regard which he expects and may a c c o r d i n g l y f e e l t h a t he ... i s not a worthwhile person. E l l i s ' therapy challenges such i r r a t i o n a l t h i n k i n g and attempts to provide the c l i e n t w i t h a more r e a l i s t i c view of l i f e . Recently there has been an attempt to conceptualize Rational-emotive Therapy w i t h i n a c o g n i t i v e behaviour m o d i f i c a t i o n framework. G o l d f r i e d , Decenteceo and Weinberg (1974) have described a procedure they l a b e l "systematic r a t i o n a l r e s t r u c t u r i n g " which has f i v e components: (1) exposure to an anxiety-producing s i t u a t i o n i n e i t h e r r e a l - l i f e or fantasy, (2) s e l f -e v a l u a t i o n of a n x i e t y l e v e l i n t h i s s i t u a t i o n , (3) i d e n t i f i c a t i o n of a n x i e t y -producing thoughts which the c l i e n t has i n the s i t u a t i o n , (4) r a t i o n a l e v a l -u a t i o n of these thoughts, and (5) n o t i n g anxiety l e v e l changes a f t e r r e e v a l u a t i o n . Although i n t h i s paper the authors s t r e s s the m o d i f i c a t i o n of s p e c i f i c anxiety-producing thoughts, a l a t e r d i s c u s s i o n of r a t i o n a l r e s t r u c t u r i n g by G o l d f r i e d and Davison (1976) d e s c r i b e s the m o d i f i c a t i o n of i r r a t i o n a l b e l i e f systems (a l a E l l i s ) as w e l l as s p e c i f i c thoughts. Several s t u d i e s have supported E l l i s ' contention that i r r a t i o n a l 11 b e l i e f s are an important cause of a n x i e t y . Rimm and L i t v a k (1969) had c o l l e g e students read s e l e c t e d E l l i s " t r i a d s " (e.g., my grades may not be good enough, I may f a i l out, that would be a w f u l ) . This group showed s i g n i f i c a n t l y greater changes i n r e s p i r a t i o n r a t e ( i n the d i r e c t i o n of emotional arousal) than a c o n t r o l group who read n e u t r a l t r i a d s to themselves. G o l d f r i e d and Sobocinski (1975) have reported a c o r r e l a t i o n between the tendency to hold c e r t a i n i r r a t i o n a l b e l i e f s and q u e s t i o n n a i r e scores f o r s o c i a l , speech and t e s t a n x i e t y . These i n v e s t i g a t o r s a l s o found that emotional upset i n imagined s o c i a l s i t u a t i o n s was greater f o r subjects who subscribed to i r r a t i o n a l b e l i e f s about these s i t u a t i o n s . F i n a l l y , Newmark, F r e r k i n g , Cook and Newmark (1973) have reported that n e u r o t i c p s y c h i a t r i c p a t i e n t s endorsed a l a r g e r number of i r r a t i o n a l statements than e i t h e r p a t i e n t s who had been diagnosed character d i s o r d e r or normal c o l l e g e students. A d d i t i o n a l support i s given to the Rational-emotive Therapy f o r m u l a t i o n by the g e n e r a l l y p o s i t i v e r e s u l t s of treatment s t u d i e s w i t h speech anxious c l i e n t s ( T r e x l e r and K a r s t , 1972; Karst and T r e x l e r , 1970; Straatmeyer and Watkins, 1974; Thorpe, Amatu, Blakey and Burns, 1976). Wein, Nelson and Odom (1975) have a l s o reported a procedure c a l l e d " c o g n i t i v e r e s t r u c t u r i n g " to be e f f e c t i v e i n reducing snake f e a r . In t h e i r study, systematic d e s e n s i t i z a t i o n and the c o g n i t i v e procedure were e q u a l l y e f f e c t i v e i n i n c r e a s i n g approach behaviour, but only the l a t t e r had the e f f e c t of reducing experienced f e a r . In i n t e r p r e t i n g t h i s f i n d i n g i t i s important to bear i n mind that the treatment described by Wein et a l . d i d not focus d i r e c t l y on i r r a t i o n a l b e l i e f s ; i n s t e a d 12 the experimenters attempted to b r i n g about a r e a t t r i b u t i o n of f e a r from e x t e r n a l events to i n t e r n a l c o g n i t i o n s . While t h i s approach i s r e l a t e d to E l l i s ' work, t h e i r experimental r e s u l t s support the e f f i c a c y of Rational-emotive Therapy only i n a general way. In c o n t r a s t to E l l i s ' emphasis on the r o l e of b e l i e f systems i n a n x i e t y , Meichenbaum (1972, 1974a) has developed a treatment procedure to modify s p e c i f i c thoughts. His approach, s e l f - i n s t r u c t i o n a l t r a i n i n g , c onceptualizes thoughts as s e l f - s t a t e m e n t s , i . e . , as statements made to one s e l f . Meichenbaum suggests that anxiety-producing self-statements emitted by a person i n c e r t a i n problem s i t u a t i o n s c o n t r i b u t e i n a major way to the discomfort'which he experiences. The goal of therapy i s to make the c l i e n t aware of the nature of h i s negative t h i n k i n g , and to have him r e p l a c e anxiety-engendering thoughts w i t h coping s e l f - s t a t e m e n t s . In the f i r s t study to apply s e l f - i n s t r u c t i o n a l t r a i n i n g to an x i e t y treatment, Meichenbaum, Gilmore and Fe d o r o v i c i u s (1971) worked w i t h speech anxious students who responded to a campus newspaper advertisement. Subjects were assigned to one of three treatment c o n d i t i o n s : i n s i g h t - o r i e n t e d psycho-therapy, systematic d e s e n s i t i z a t i o n , or a combination of the two; or they became part of one of two c o n t r o l c o n d i t i o n s : p l a c e b o - d i s c u s s i o n or w a i t i n g l i s t . They met i n small groups f o r eight sessions. The psychotherapy c o n d i t i o n "emphasized the r a t i o n a l e that speech a n x i e t y i s the r e s u l t of s e l f - v e r b a l i z a t i o n s and i n t e r n a l i z e d sentences which are emitted when t h i n k i n g about the speech s i t u a t i o n . Subjects were informed that the goals of therapy were f o r each person to become aware (gain i n s i g h t i n t o ) the s e l f - v e r b a l i z a t i o n s and s e l f - i n s t r u c t i o n s which he emitted i n 13 the anxiety-producing interpersonal situations, and, in addition, to produce both incompatible instructions and incompatible behaviour." The investigators decision to label this condition "insight-oriented" is unfortunate since i t clearly includes a cognitive change component as well as promoting insight. .Results of this study indicated that both treatments were superior to the control conditions, but the effects of cognitive modification (or insight) were not significantly different from those produced by systematic desensitization on either self-report or behavioural measures. A post hoc analysis revealed that, while systematic desensitization was more effective for subjects who suffered only from speech anxiety, cognitive therapy was superior for subjects who experienced anxiety in a wider range of social situations. In a^siibsequent experiment, Meichenbaum (1971) combined self-instructional training with modelling i n the treatment of animal phobia. Fearful subjects observed either a "mastery" or "coping" model approaching a snake. The mastery model was fearless and unhesitating while the coping model showed a degree of fear and reluctance. Both behavioural and self-report measures indicated greater fear reduction in the coping model condition, and the superiority of this treatment was especially apparent when the model provided an example of coping self-instructions as well as coping behaviour. Meichenbaum (1972) next investigated the relative efficacy of desensitization and self—instructional training in the treatment of test anxiety. Therapy was conducted in small groups which met for one hour per week of an eight week period. An analysis of treatment 14 outcomes favoured s e l f - i n s t r u c t i o n a l t r a i n i n g ; subjects i n t h i s c o n d i t i o n had s i g n i f i c a n t l y lower scores on an a n x i e t y c h e c k l i s t and showed b e t t e r performance i n an analogue t e s t i n g s i t u a t i o n . They a l s o obtained a greater improvement i n grade-point-average. A more recent study by Holroyd (1976) e s s e n t i a l l y r e p l i c a t e d these f i n d i n g s . F o l l o w i n g a treatment procedure developed by Wine (1971) Holroyd's c o g n i t i v e m o d i f i c a t i o n c o n d i t i o n provided t e s t anxious subjects w i t h t r a i n i n g i n focusing , on t a s k - r e l e v a n t s e l f - i n s t r u c t i o n s w h i l e i g n o r i n g t a s k - i r r e l e v a n t thoughts. In p r a c t i c e t h i s s t r a t e g y i s l i k e l y to r e s u l t i n the replacement of anxiety-producing thoughts w i t h coping s e l f - i n s t r u c t i o n s . I t was s i g n i f i c a n t l y more e f f e c t i v e i n reducing t e s t a n x i e t y i n an analogue t e s t i n g s i t u a t i o n , and i n improving grade-point average than e i t h e r systematic d e s e n s i t i z a t i o n or a combination of the two treatments. Meichenbaum and Cameron (1973) have a l s o used s e l f - i n s t r u c t i o n a l t r a i n i n g to t r e a t c l i e n t s w i t h f e a r s of both snakes and r a t s . The major in n o v a t i o n i n t h i s research was the i n t r o d u c t i o n of a " s t r e s s - i n o c u l a t i o n " procedure. C l i e n t s were seen i n d i v i d u a l l y f o r one hour weekly sessions over s i x weeks. Those-assigned to the i n o c u l a t i o n c o n d i t i o n were taught to view t h e i r a n x i e t y i n terms of the Schacterian model of emotion and rec e i v e d t r a i n i n g i n s e l f - i n s t r u c t i o n . During the l a s t two sessions they p r a c t i c e d the coping s k i l l s they had learned i n a random shock s i t u a t i o n . Other subjects i n t h i s study were assigned to an i n s t r u c t i o n a l r e h e a r s a l c o n d i t i o n , i n which they were t r e a t e d i n a f a s h i o n s i m i l a r to subjects i n the i n o c u l a t i o n c o n d i t i o n except that they d i d not p r a c t i c e i n the shock s i t u a t i o n , a systematic d e s e n s i t i z a t i o n c o n d i t i o n , i n which they 15 received treatment for either rat fear or snake fear ( a l l subjects feared both animals), or a waiting l i s t control. The stress-inoculation treatment was superior to a l l others i n terms of performance on a behavioural approach task. Desensitization was significantly more effective than instructional rehearsal for the treated phobia, but less effective for the untreated phobia. That i s , subjects who had been desensitized to rats were more lik e l y to handle rats than subjects in the instructional rehearsal condition, but they were also less l i k e l y to handle snakes than the latter group. These findings suggest that the beneficial effects of a cognitive treatment are more lik e l y to generalize to extra-therapy situations in the client's daily l i f e . The research described above provides support for the therapeutic effectiveness of self-instructional training in the treatment of speech anxiety, test anxiety and phobias. However, i t does not indicate which aspects of the treatment procedure are responsible for observed improvement. Self-instructional training can be conceptualized as having three components: (1) a treatment rationale which attributes the cause of anxiety to negative thoughts, ((2) an insight or awareness factor, and (3) specific training in the use of positive self-statements. It may be that a l l three aspects are essential for the success of treatment, or that only one or two are necessary. The following section w i l l discuss several experiments which provide some data on this issue. Component analysis of self-instructional training Only a few studies in the literature are directly concerned with 16 a n a l y z i n g the components of s e l f - i n s t r u c t i o n a l t r a i n i n g . In h i s d i s s e r t a t i o n , B a r r e t t (1975) i n v e s t i g a t e d the r e l a t i v e importance of awareness of unproductive t h i n k i n g and s p e c i f i c t r a i n i n g i n s u b s t i t u t i o n of coping self-statements f o r anxiety-producing thoughts. Speech anxious inmates i n a c o r r e c t i o n a l i n s t i t u t i o n were randomly assigned to the f o l l o w i n g treatment c o n d i t i o n s : (1) awareness o n l y , (2) s e l f -i n s t r u c t i o n a l r e h e a r s a l , (3) a combination of awareness and i n s t r u c t i o n a l r e h e a r s a l , or (4) no-treatment c o n t r o l . Therapists i n the f i r s t c o n d i t i o n explained the r o l e of negative self-statements and a s s i s t e d c l i e n t s i n i d e n t i f y i n g the anxiety-producing thoughts which occurred during p u b l i c speaking s i t u a t i o n s . In the second c o n d i t i o n , subjects imagined p u b l i c speaking s i t u a t i o n s and p r a c t i c e d t a s k - o r i e n t e d s e l f -statements .Condition three combined the procedures f o r the other two c o n d i t i o n s and the c o n t r o l group was seen only at pre- and post-assessment. A n a l y s i s of b e h a v i o u r a l , p h y s i o l o g i c a l and s e l f - r e p o r t measures f a i l e d to r e v e a l a s i g n i f i c a n t r e d u c t i o n i n a n x i e t y f o r any of the treatment c o n d i t i o n s . s o , u n f o r t u n a t e l y , i t was not p o s s i b l e to assess p o s s i b l e d i f f e r e n c e s among them. A recent study by Thorpe, Amatu, Blakey and Burns (1976) provides data which suggest that s e l f - i n s t r u c t i o n a l r e h e a r s a l may be l e s s important than i n s i g h t i n e f f e c t i n g a r e d u c t i o n i n a n x i e t y . These i n v e s t i g a t o r s conducted f i v e t r a i n i n g sessions f o r highschool students who volunteered f o r a programme o f f e r i n g a s s i s t a n c e f o r p u b l i c speaking a n x i e t y . Subjects met i n small groups f o r e i g h t 30 minute sessions. The f i r s t treatment c o n d i t i o n (general i n s i g h t ) provided f o r a d i s c u s s i o n of a v a r i e t y of 17 irrational beliefs. Condition two (specific insight) dealt with four irrational beliefs which were considered to be especially relevant to speech anxiety. Students in the third condition (instructional rehearsal) focussed on four ideas which were the opposite of those discussed in condition two. The f i n a l condition combined specific insight and instructional rehearsal. Results of self-report measures indicated significantly greater improvement for subjects in the two insight conditions than for subjects in the remaining treatments. There were no differences among groups on behavioural measures. These findings suggest that the actual emission of coping self-statements may be less crucial to therapeutic effectiveness than had beenjsupposed; awareness of unproductive cognitions may be sufficient to bring about change. However, i t should be noted that the self-instructional rehearsal procedure described by Thorpe et a l . differs considerably from Meichenbaum's (1974) treatment. The latter had subjects u t i l i z e positive self-statements which are relevant to a very specific stimulus situation as a replacement for thoughts which had arisen in that situation. In contrast, subjects i n the research just described rehearsed rather general self-instructions. Probably self-instructional training w i l l have i t s maximum therapeutic value when statements are concrete and situation-specific. Nevertheless, Thorpe et al.'s finding of a poorer outcome for groups which rehearsed coping self-statements i s intriguing and merits further investigation. Cognitive therapy and s k i l l s training Behaviour therapy theoretically relies on a functional analysis of 18 behaviour, followed by attempts to change the environment to e l i c i t and m a i n t a i n d e s i r a b l e behaviour. However i n p r a c t i c e , . t h e r a p i s t s o f t e n encourage c l i e n t s themselves to modify t h e i r behaviour. Current procedures which attempt to d i r e c t l y modify behaviour through p r o v i d i n g coping models, beha v i o u r a l r e h e a r s a l and coaching are o f t e n r e f e r r e d to as s k i l l s t r a i n i n g . These techniques have been widely used i n a s s e r t i v e t r a i n i n g (see Hersen, E i s l e r and M i l l e r , 1973) and have been s u c c e s s f u l l y employed to increase the frequency of d a t i n g behaviour (e.g. Bander, Steinke, A l l e n and Mosher, 1975; Twentyman and M c F a l l , 1975). Although the s k i l l s t r a i n i n g approach has developed s i d e by s i d e w i t h c o g n i t i v e behaviour m o d i f i c a t i o n , there has been l i t t l e attempt to evaluate the r e l a t i v e e f f e c t i v e n e s s of the two i n d e a l i n g w i t h s p e c i f i c problems. I t might be expected that the former would be the treatment Of choice when the c l i e n t f a i l s to behave e f f e c t i v e l y because he does not have the r e q u i s i t e behaviours i n his, r e p e r t o i r e . On the other hand, c o g n i t i v e change techniques ought to be more e f f e c t i v e when c l i e n t s know how to perform the d e s i r e d a c t i o n but are prevented from doing so by the presence of overwhelming a n x i e t y , or, a l t e r n a t i v e l y , when c l i e n t s are a c t u a l l y behaving e f f e c t i v e l y but continue to f e e l anxious i n c e r t a i n s i t u a t i o n s . At present there i s l i t t l e research which deals w i t h t h i s question. In t h e i r paper on a s s e r t i v e t r a i n i n g , E i s l e r et a l . (1973) reported that repeated exposure to a s t r e s s f u l s i t u a t i o n d i d not lead to an i n c r e a s e i n a s s e r t i v e n e s s . They argue that t h i s occurred because sub j e c t s d i d not know how to behave a s s e r t i v e l y so that h a b i t u a t i o n of a n x i e t y had l i t t l e e f f e c t on t h e i r l e v e l of a s s e r t i v e n e s s . More r e c e n t l y , G l a s s , Gottman and Shmurak (1976) designed a d i r e c t comparison of s e l f -instructional training and s k i l l s training in a treatment for dating anxiety. Subjects in a l l their experimental conditions attended one 90 minute group session followed by three or four one-hour individual training sessions. Those assigned to s k i l l s training received modelling and coaching of effective behavioural responses. The self-instructional training conditions provided a model for coping self-statements along with reinforcement for appropriate responses. An additional treatment condition combined the two approaches. Although self-instructional training and s k i l l s training were equally effective in producing changes in performance in role-playing situations v for which specific training had been given, subjects in the former treat-ment condition showed better performance in role-playing situations for which they had not been trained and made a better impression on the women they telephoned as part of the post-treatment procedure. Glass et a l . interpret their findings as indicating that, at least for this target problem, the effects of self-instructional training are more lik e l y to generalize to non-therapy situations. 20 CHAPTER FOUR P r a c t i c a l c o n s i d e r a t i o n s i n the design of stress-management programmes Because of the l a r g e number of p o s s i b l e a p p l i c a t i o n s of s t r e s s -management treatment both i n t r a d i t i o n a l p s y c h i a t r i c s e t t i n g s and i n p u b l i c h e a l t h care, i t i s not only necessary to develop procedures which are t h e r a p e u t i c a l l y e f f e c t i v e ; we must a l s o be concerned w i t h treatment c o s t s . I t i s c l e a r that a treatment which r e q u i r e s l i t t l e t h e r a p i s t time and a minimum of s p e c i f i c t r a i n i n g w i l l be more widely used than a more time-consuming and complex procedure i f the two approaches r e s u l t i n s i m i l a r outcomes. One way to reduce treatment costs i s to give the c l i e n t more r e s p o n s i b i l i t y f o r h i s own treatment. C l i e n t s can be taught c e r t a i n u s e f u l behaviour m o d i f i c a t i o n techniques which they can apply to t h e i r own problems. A v a r i e t y of self-management s t r a t e g i e s have proved t h e i r usefulness w i t h such t a r g e t problems as o b e s i t y (Mahoney, Moura and Wade, 1973;"Mahoney, 1974: J e f f r e y , 1974), smoking (see L i c h e n s t e i n and Daraher, 1976) and poor study h a b i t s (Moffat, 1972; Jackson and Van Zoost, 1972). In many of these s t u d i e s , c l i e n t s have set t h e i r own treatment goals, dispensed t h e i r own rewards and punishments, a p p l i e d stimulus c o n t r o l to reduce the frequency of undesirable behaviour and monitored behaviour change. Not only have self-managed treatments been more e f f e c t i v e than no-treatment c o n t r o l s , i n some cases they have performed as w e l l as t h e r a p i s t -managed treatments. I t i s p a r t i c u l a r l y i n t e r e s t i n g to note that even the simple procedure of s e l f - m o n i t o r i n g has had a t h e r a p e u t i c e f f e c t i n a number of experiments (Johnson and White, 1971; M c F a l l and Hammen, 1971; Mahoney, Moura and Wade, 1973). For t h i s reason s e l f - m o n i t o r i n g should be conceptualized as a therapy technique as w e l l as a method of data c o l l e c t i o n . 21 The a p p l i c a t i o n of self-management procedures i n the treatment of a n x i e t y i s not a new phenomenon. Almost a decade ago Rehm and Marston (1968) described the implementation of such a programme f o r speech an x i e t y . Subjects assigned to a systematic s e l f - h e l p group were i n s t r u c t e d to g r a d u a l l y approach feared s i t u a t i o n s , o b j e c t i v e l y s t r u c t u r e behavioural goals, use s e l f - r e i n f o r c e m e n t and s e l f - m o n i t o r problem s i t u a t i o n s . In c o n t r a s t to c o n t r o l groups who were given e i t h e r n o n - s p e c i f i c c o u n s e l l i n g or minimal urging toward s e l f - h e l p , the former subjects showed greater decreases on s e v e r a l measures of a n x i e t y . More r e c e n t l y G o l d f r i e d and h i s a s s o c i a t e s have reconceptualized systematic d e s e n s i t i z a t i o n ( G o l d f r i e d , 1971; G o l d f r i e d and T r i e r , 1974) and Rational-emotive therapy ( G o l d f r i e d , Decenteceo and Weinberg, 1974) as t r a i n i n g i n s e l f - c o n t r o l . In both cases they suggest that the techniques should be taught as coping s k i l l s which can be a p p l i e d by c l i e n t s to any number of anxiety-provoking s i t u a t i o n s . In support of the^.efficacy of t h i s approach, G o l d f r i e d and T r i e r (1974) found that subjects who were assigned to a c o n d i t i o n i n which r e l a x a t i o n was presented as a coping s k i l l showed a greater r e d u c t i o n i n speech anxiety and a l s o i n more general a n x i e t y , than subjects who were informed that r e l a x a t i o n t r a i n i n g would a u t o m a t i c a l l y reduce a n x i e t y . Meichenbaum and Cameron's (1973) s t r e s s - i n o c u l a t i o n procedure i s another example of a method which provides the c l i e n t w i t h a technique which he himself can apply i n anxiety-producing s i t u a t i o n s . I t w i l l be r e c a l l e d that t h i s treatment was more e f f e c t i v e f o r animal phobia.than s e v e r a l comparison treatments. This f i n d i n g has broad i m p l i c a t i o n s f o r s t r e s s management s i n c e i t suggests that p r a c t i c i n g newly acquired 22 self-management s k i l l s i n the o f f i c e of a t h e r a p i s t may help a c l i e n t to c o n t r o l h i s a n x i e t y i n a v a r i e t y of r e a l - l i f e s t r e s s f u l s i t u a t i o n s . The self-management s t r a t e g i e s j u s t described have o f t e n r e s u l t e d i n a saving i n t h e r a p i s t time, although they were not o r i g i n a l l y designed f o r t h i s reason. . Several recent r e p o r t s i n the area of weight c o n t r o l have more s y s t e m a t i c a l l y i n v e s t i g a t e d the importance of t h e r a p i s t contact time w i t h the general f i n d i n g that even minimal t h e r a p i s t involvement can produce t h e r a p e u t i c gains. For example, H a l l , H a l l , Hanson and Borden (1974) compared the e f f e c t i v e n e s s of two self-management c o n d i t i o n s . Subjects assigned to "simple self^management" met i n s m a l l groups f o r 10 to 15 minutes over a 10 week p e r i o d . A comparison "combined self-management" c o n d i t i o n provided 75 minute weekly group meetings. In-the simple self-management c o n d i t i o n , subjects were provided w i t h w r i s t counters to monitor d a i l y b i t e s of food and were i n s t r u c t e d to g r a d u a l l y decrease the number, w h i l e subjects i n the combined self-management c o n d i t i o n r e c e i v e d i n s t r u c t i o n i n a v a r i e t y of behavioural techniques aimed at weight r e d u c t i o n . Both of these treatments produced greater weight l o s s than no-treatment c o n t r o l , but they d i d not d i f f e r from each other at e i t h e r p o s t - t e s t i n g or follow-up. B e l l a c k , Schwartz and Rozensky (1974) i n v e s t i g a t e d the t h e r a p e u t i c e f f e c t s of weight r e d u c t i o n therapy conducted by m a i l . The m a i l - c o n t a c t group self-monitored food i n t a k e and sent weekly records to the experimenter. Another group of subjects met w i t h the experimenter f o r weekly sessions at which they r e c e i v e d m i l d s o c i a l approval f o r progress. R e s u l t s i n d i c a t e d that the two approaches were e q u a l l y e f f e c t i v e and both were su p e r i o r to a c o n t r o l c o n d i t i o n . In a somewhat s i m i l a r study, Lindstrom, Balch and Reese (1976) maintained weekly telephone contact w i t h one group of overweight 23 subjects and met personally with another group over a nine week treatment period. Again there were no differences between the two therapy conditions, although subjects in both of them lost significantly more weight than no-treatment control subjects. In summary, the research described above indicates that treatments which require a relatively small investment in therapist time are sometimes effective. Since such therapies are desirable from a cost-benefit perspective, stress-management research (and indeed a l l treatment outcome studies) should ideally include minimal treatment comparison conditions which teach certain basic s k i l l s . This addition may enable investigators to decide whether the therapeutic gains which result from intensive treatment actually j u s t i f y expenditures in therapist time and agency resources. 24 CHAPTER FIVE Statement of the problem The present research had two major aims: (1) to determine whether self-instructional rehearsal is an essential component of the sel f -instructional training procedure, and (2) to compare the relative effectiveness of self-instructional training and s k i l l s training. Although the self-instructional aspect of Meichenbaum's treatment is what makes i t unique, there is s t i l l l i t t l e evidence that specific training in the emission of coping self-statements actually contributes to anxiety reduction. It may be that the awareness component of self-instructional training is sufficient to explain c l i n i c a l improvement.^ A search of the literature found only two studies which bear directly on this issue. One of these, Barrett's dissertation, failed to demonstrate that a combined awareness and instructional rehearsal condition was more effective than either treatment presented individually. The other, (Thorpe et al.) reported results which suggest that awareness may actually be more improtant than instructional rehearsal. The experiment reported below is an attempt to c l a r i f y this situation. Because of problems inherent in conducting a group treatment without an awareness component, the role of self-instructional rehearsal was investigated by comparing self-instructional training (awareness plus self-instructional rehearsal) with a treatment aimed only at promoting awareness of the causes and effects of negative self-statements. With respect to the second purpose of the study, the literature reviewed suggests that self-instructional training i s superior to s k i l l s 25 training in stress management although there are few studies which have directly compared the two approaches. This superiority probably occurs because s k i l l s training i s f a i r l y specific to individual problems while self-instructional training offers a more general approach to anxiety reduction. When clients have a variety of problems, not a l l of which are necessarily dealt with during treatment sessions, the generalization expected for the cognitive procedure may account for better overall outcome. In contrast to most earlier research in self-instructional training, subjects in the present research did not share a common problem. Instead they reported significant stress in a variety of situations. This sample was recruited because i t was f e l t that they would more nearly resemble a c l i n i c a l group and thus provide a more stringent test of the treatments offered. The following hypotheses were proposed in this dissertation: 1. Self-instructional training produces a greater reduction in anxiety and a greater a b i l i t y to cope with stress than an awareness-oriented treatment. 2. Self-instructional training i s superior to s k i l l s training i n anxiety reduction and stress-management. 26 CHAPTER SIX Method Subject recruitment and s e l e c t i o n Advertisements announcing a p u b l i c s e r v i c e a t e n s i o n management programme were placed i n Vancouver's two major d a i l y newspapers. I n q u i r i e s were made by 167 i n d i v i d u a l s . In telephone i n t e r v i e w s respondents were asked questions about the nature of st r e s s - p r o d u c i n g s i t u a t i o n s , the d u r a t i o n of the problem, current treatment regimens and i n t e r e s t i n the type of treatment being o f f e r e d . I n d i v i d u a l s were considered s u i t a b l e f o r the treatment programme only i f they experienced a s i g n i f i c a n t amount of s t r e s s i n at l e a s t two s i t u a t i o n s . The i n i t i a l pool of 167 people was reduced to 64 through the telephone screening i n t e r v i e w s . In some cases i n q u i r i e s had been made by i n d i v i d u a l s who expressed only an ed u c a t i o n a l i n t e r e s t i n the programme.' Other c a l l e r s intended to be out of town during the treatment period or d i d not wish to p a r t i c i p a t e i n a group treatment. Several p r o s p e c t i v e c l i e n t s were c u r r e n t l y seeing other t h e r a p i s t s and wished to continue doing so, and many i n d i v i d u a l s described " f r e e - f l o a t i n g " a n x i e t y r a t h e r than s i t u a t i o n - s p e c i f i c s t r e s s . Respondents who were considered appropriate f o r treatment then : p a r t i c i p a t e d i n more extensive assessment i n t e r v i e w s i n which i n f o r m a t i o n concerning the f o l l o w i n g t o p i c s was s y s t e m a t i c a l l y c o l l e c t e d : 1. The s e v e r i t y of the problem (a) number of s t r e s s f u l s i t u a t i o n s 27 ^ (b) amount of time during which the c l i e n t experienced an uncomfortable l e v e l of a n x i e t y (c) extent to which anxiety i n t e r f e r e d w i t h d a i l y l i v i n g 2. D e s c r i p t i o n of s t r e s s f u l s i t u a t i o n s (a) s p e c i f i c i t y of anxiety-producing s t i m u l i (b) a b i l i t y of c l i e n t to recognize commonalities across s t r e s s f u l s i t u a t i o n s 3. , The nature and outcome of past attempts to reduce s t r e s s 4. M o t i v a t i o n f o r treatments F o l l o w i n g the i n t e r v i e w , L i k e r t s c a l e s were used by i n t e r v i e w e r s to r a t e the s p e c i f i c i t y of s t r e s s f u l s t i m u l i , m o t i v a t i o n f o r treatment, present c l i n i c a l a n x i e t y l e v e l , current l e v e l of depression and l i k e l i -hood of psychosis a l c o h o l i s m . The i d e a l c l i e n t obtained high scores on the f i r s t two dimensions, a moderate score on the t h i r d , and low r a t i n g s f o r the remaining two s c a l e s . Of the 64 people who were i n t e r v i e w e d , 59 were rated as s u i t a b l e candidates f o r treatment and were a c c o r d i n g l y assigned to experimental c o n d i t i o n s . This group comprised 47 females and 12 males. The sex d i s p r o p o r t i o n occurred because the i n i t i a l subject pool contained f a r more women than men, not because the r e j e c t i o n r a t e was higher f o r men. A data deposit cheque of $20 was r e q u i r e d of c l i e n t s i n group therapy c o n d i t i o n s . A l l three group therapy c o n d i t i o n s were f i l l e d before subjects were assigned to s e l f - h e l p groups. The procedure f o r telephone c a l l - b a c k acted to minimize any systematic b i a s by having i n t e r v i e w e r s s e l e c t biocks=of subjects to contact. Thus, the s e l f - h e l p group was made up of subjects whose names occurred at the end of b l o c k s i n s t e a d 28 of comprising only the l a s t people who telephoned the c l i n i c . At the outset of treatment, 13-16 c l i e n t s were assigned to each experimental c o n d i t i o n . D e s c r i p t i o n of f i n a l sample Several c l i e n t s were l o s t over the course of t h i s study. Of the o r i g i n a l group of 59, 52 i n d i v i d u a l s attended t h e i r f i r s t scheduled treatment s e s s i o n and 45 completed treatment. The seven c l i e n t s who discontinued treatment were d i s t r i b u t e d almost e q u a l l y across the experimental c o n d i t i o n s w i t h two drop-outs i n each of the group therapy c o n d i t i o n s and one i n the s e l f - h e l p c o n d i t i o n . The mean age f o r the f i n a l sample was 41.7 years; c l i e n t s ranged i n age from 21 to 65 years. There were eight males and 37 females. 22% were s i n g l e , 62.2% married and the remaining 15.6% separated or divor c e d . The m a j o r i t y reported that t h e i r problems were of more than f i v e years d u r a t i o n (60%), and a f u r t h e r 24.4% had experienced a high l e v e l of s t r e s s f o r more than one year but l e s s than f i v e . Thus, most of our c l i e n t s had come f o r a s s i s t a n c e i n handling long-standing stress-management problems. Chi-square t e s t s i n d i c a t e d no s i g n i f i c a n t d i f f e r e n c e s among c o n d i t i o n s on any of the demographic v a r i a b l e s . The s t r e s s f u l s i t u a t i o n s which brought c l i e n t s to treatment included the f o l l o w i n g : being i n e l e v a t o r s or other enclosed spaces, d r i v i n g i n t r a f f i c , shopping, t a k i n g examinations, meeting job d e a d l i n e s , p u b l i c speaking, meeting s t r a n g e r s , being alone, e n t e r t a i n i n g guests, d e a l i n g w i t h s u p e r v i s o r s and employees, and attending p a r t i e s (see Appendix 3 f o r a complete l i s t i n g ) . Most of these l o g i c a l l y f a l l i n t o the categ o r i e s of 29 performance a n x i e t y , i n t e r p e r s o n a l a n x i e t y , or s p e c i f i c f e a r s . Each c l i e n t presented w i t h two or more problem s i t u a t i o n s . T r a i n i n g and s u p e r v i s i o n of i n t e r v i e w e r s and t h e r a p i s t s Interviewers f o r t h i s projectuwere four M a s t e r i s students i n a G l i n i c a l Psychology programme, a l l of whom had completed a practicum course on i n t e r v i e w i n g techniques. The experimenter met w i t h t h i s group on s e v e r a l occasions before the study began to d i s c u s s the purposes of the i n t e r v i e w and the general aims of the experiment. Throughout the course of i n t e r v i e w i n g , any d i f f i c u l t i e s which arose were discussed w i t h the experimenter. In almost a l l cases the same graduate student conducted both the telephone and f a c e - t o - f a c e i n t e r v i e w s w i t h an i n d i v i d u a l c l i e n t . . Graduate students i n C o u n s e l l i n g Psychology and S o c i a l Work and one p r a c t i c i n g c l i n i c a l p s y c h o l o g i s t from the community served as t h e r a p i s t s i n the group therapy c o n d i t i o n s . A l l had previous supervised group l e a d e r s h i p experience. Before treatment began a s e r i e s of meetings were held to d i s c u s s the purposes of the p r o j e c t , the r a t i o n a l e s u n d e r l y i n g the chosen t h e r a p i e s , and the s p e c i f i c procedures i n v o l v e d . Meichenbaum's 0.974b) treatment manual was used as a guide f o r two of the c o n d i t i o n s and a l s o f o r the s e l f - h e l p c o n d i t i o n ; G o l d f r i e d and Davison's (1976) book chapter on b e h a v i o u r a l r e h e a r s a l served as a model f o r the remaining treatment c o n d i t i o n . A l l sessions were taped^and weekly meetings were held i n d i v i d u a l l y w i t h t h e r a p i s t s to d i s c u s s problems and progress. Conditions C l i e n t s i n the treatment c o n d i t i o n s met i n groups of s i x to eight 30 members for a series of six one and one-half hour weekly group sessions followed by a post-treatment assessment session. Over this period, a l l clients were asked to monitor details of stressful situations. The control groups were informed that, because of the overwhelming response to our advertisement, a l l weekly group positions had been f i l l e d . They were offered a two hour workshop instead. Self-instructional training. This condition was similar to Meichenbaum's treatment as described in his manual. During the f i r s t session group members made statements about the factors which had led them to seek help. Therapists encouraged a situational analysis of the problems presented and fostered a discussion of thoughts and feelings in stressful situations. The treatment rationale was presented to the group in a statement similar to the following: Anxiety i s to a considerable extent produced not by what happens to you, but by how you thank about what happens. Two people may interpret a situation in very different ways. (At this point an example was given.) Since i t w i l l be necessary to go through many stressful situations in one's daily l i f e , i t i s unrealistic to try to avoid them. A much better approach i s to change the way you think about them. In a way, thinking is like talking to yourself. When you are in a stressful situation, you may t e l l yourself things which are r e a l i s t i c and helpful or things which only upset you more. The focus of our treatment is to analyze the negative things which you are currently saying to yourself to produce anxiety, and then come up with coping self-statements which can be substituted in their stead to bring about a reduction in anxiety and tension. The group then discussed baseline monitoring data which clients had brought with them to the session. At the end of the session i t was suggested that group members continue to monitor stressful situations, while paying close attention to stress-provoking stimuli in the environment. 31 Sessions two through six each began with clients presentations of monitoring data concerning stressful situations. Other group members were encouraged to offer their opinions on what each person was "saying to himself" in monitored situations and to relate this to their own experience. An attempt was made to identify themes in problem situations. During the second and third sessions the focus of discussion was mainly on the analysis of negative thoughts. Later meetings focused almost entirely on the rehearsal of coping self-instructions. Clients were asked to find positive, but r e a l i s t i c self-statements which they could try out in problem situations. As an aid in this process, they rehearsed new positive self-statements in the group before committing themselves to using them during the coming week. Awareness. This condition provided an analysis of anxiety in terms of negative self-statements, but did not offer specific training in changing unproductive modes of thought., Session one began with group members descriptions of their problems. As in the f i r s t condition, therapists encouraged a situational focus and fostered a discussion of thoughts and feelings in stressful situations. He/she offered the following treatment rationale: Anxiety is to a considerable extent produced not by what happens to you, but by how you think about what happens to you. Two people may interpret the same situation in entirely different ways. (An example was given.) The major goal of our treatment is for each group member to become aware of the factors which are contributing to his anxiety. As we continue our meetings you w i l l discover just how closely your thoughts are tied to your feelings. Until you understand very clearly what your negative thoughts are, or in other words, what you are saying to yourself, certain situations w i l l continue to upset you. In our group discussions we w i l l spend most of the time 32 carefully examining the self-statements you are presently using. As you gain insight into exactly what i s bothering you, you w i l l gain control over your anxiety. At this point, monitoring data was discussed. Later, as a homework assignment, clients were asked to continue self-monitoring while paying attention to negative thinking. Sessions two through six began with each client going over his monitoring data for the week and describing any negative self-statements which he had become aware of. Other group members offered their views about how such self-statements were maintaining anxiety. An attempt was made to find commonalities across the problem situations presented by individual clients. To assist in clarifying negative thinking, group members were involved i n role-playing situations which required that they verbalize negative self-statements. Therapists pointed out connections between these self-statements and failures to cope well in problem situations. S k i l l s training. In this condition, an attempt was made to change overt behaviour in stressful situations. During the f i r s t session, clients described the circumstances which had brought them to therapy. Therapists focused attention on the situational determinants of the distress experienced by clients and on the behaviours which had led to an unsatisfactory outcome. They also provided the following treatment rationale: To a considerable extent, anxiety i s a product of the situations in which we find ourselves and of our own behaviour in these situations. Anxiety i s usually a signal that we are not behaving effectively. Often we get ourselves into trouble by the way we look at a problem. It i s useful to translate statements lik e "social situations upset me" into "in certain social situations I do not behave effectively." The second statement i s better 33 because i t points to a solution — you can change your behaviour. Altering your behaviour can have several beneficial effects: i t can reduce anxiety because you know that you've done well, i t can lead other people to change their behaviour toward you so that they make you less anxious, and i t may allow you to avoid absolutely impossible situations in which no one could cope effectively. The focus of our treatment w i l l be on identifying problemjsituations and on specifying the causes of distrss in each. Then we w i l l try to come up with new ways of dealing with situations which w i l l lead to a feeling of accomplishment rather than anxiety. Baseline monitoring data was then discussed, with therapists maintaining a behavioural focus. The homework assignment required that clients con-tinue to monitor stressful situations paying particular attention to the stimuli which provoked anxiety. Sessions two through six commenced with a discussion of monitoring data. During the second and third sessions, discussion centred on the identification of anxiety-producing stimuli. Sessions four through six focused on the development of alternative behaviours to use in stress-f u l situations. Modelling, role-playing and behaviour rehearsal were used to train clients. Self-help•.treatment. Clients met in two small groups. The experimenter presented a situation-specific view of stress and described the treatment methods of Meichenbaum and E l l i s . The groups then described their problems while the therapist focused attention on the stimuli which triggered anxiety and the .thoughts which provoked stress. They were given monitoring instructions and encouraged to record the details of stressful situations as a f i r s t step in gaining control over them. They were also instructed to change the nature of their thinking, and especially to try out coping self-statements in problem situations. At the end of 34 the meeting they were requested to r e t u r n a f t e r s i x weeks to rep o r t on t h e i r progress. An attempt was made throughout to present t h i s c o n d i t i o n as therapy. The group leader made an e f f o r t to provide what a s s i s t a n c e he could w i t h i n the b r i e f time a v a i l a b l e , and although c l i e n t s were aware that they were not r e c e i v i n g the " f u l l " treatment, many expressed g r a t i t u d e and optimism at the end of the sessi o n . During the second meeting, c l i e n t s described t h e i r experiences using the suggested c o g n i t i v e techniques. I t was c l e a r that some of them had made l i t t l e attempt to modify t h e i r t h i n k i n g , but s e v e r a l reported that monitoring and the use of coping self-statements had been h e l p f u l . The group leader r e i t e r a t e d much of what had been s a i d during the i n i t i a l s e s s i o n to c o r r e c t any misconceptions which had a r i s e n and encouraged c l i e n t s to continue to use what they had learned. Pre-treatment measures Interviewer Assessment Form. Interviewers used t h i s record sheet to note t h e i r observations of each c l i e n t . (Refer to "Subject recruitment and s e l e c t i o n " f o r content areas and to Appendix 2 f o r a copy of t h i s form.) S t a t e - t r a i t Anxiety Inventory. This q u e s t i o n n a i r e has been widely used i n the assessment of anx i e t y (manual by S p e i l b e r g e r , Gorsuch and Lushene, 1970). I t was o r i g i n a l l y designed to t e s t S p i e l b e r g e r ' s theory of s i t u a t i o n a l and general anxiety,cand many i n v e s t i g a t i o n s have supported the r e l a t i v e independence of these two co n s t r u c t s (see Smith and Lay, 1974, fo r a review). Several s t u d i e s have reported decreases i n s t a t e a n x i e t y w i t h p s y c h o l o g i c a l treatment ( A l l e n , 19.71; S p i e l b e r g e r et a l . , 1970). 35 S o c i a l Avoidance and D i s t r e s s Scale. This measure was developed by Watson and F r i e n d (1969) to assess one aspect of s o c i a l a n x i e t y . The s c a l e c o n s i s t s of 28 t r u e - f a l s e items d e a l i n g w i t h a n x i e t y responses i n s o c i a l s i t u a t i o n s . Fear of Negative E v a l u a t i o n . Another s c a l e reported by Watson and Friend (1969), t h i s instrument has 30 items which r e f l e c t a n x i e t y surrounding a c t u a l or imagined c r i t i c i s m from other people. The i n i t i a l study provides v a l i d i t y data f o r both of Watson and Friend's s c a l e s . Several groups of i n v e s t i g a t o r s have employed them i n therapy research (Meichenbaum et a l . , 1971; Bander et a l . , 1975; Thorpe et a l . , 1976). Past Week Tension Thermometer. A simple 1-10 point r a t i n g s c a l e s i m i l a r to Walk's (1956) Fear Thermometer was used to o b t a i n an o v e r a l l t e n s i o n r a t i n g . S i t u a t i o n a l S tress Assessment. This procedure was developed s p e c i f i c a l l y f o r the present research. Because i t was not f e a s i b l e to use e i t h e r b ehavioural observation or r o l e - p l a y i n g measures due to the d i v e r s i t y of t a r g e t problems, c l i e n t s assigned to the f i r s t three c o n d i t i o n s were asked to r a t e t h e i r own a n x i e t y as they went through a s t r e s s f u l s i t -u a t i o n i n the pre-therapy week. A s i t u a t i o n was s e l e c t e d (by the i n t e r v i e w e r and c l i e n t i n the assessment i n t e r v i e w ) which would be moderately d i f f i c u l t and of r e l a t i v e l y high frequency of occurrence. C l i e n t s recorded t h e i r experiences on a form provided f o r t h i s purpose, and a l s o r a t ed t h e i r a n x i e t y on the S u b j e c t i v e Stress Scale (Berkun, B i a l e k , Kern and Y a g i , 1962). The l a t t e r i s an equal appearing i n t e r v a l s c a l e of 15 words. Each word has an attached v a l u e , ranging from 1 f o r "wonderful" to 94 f o r "scared s t i f f . " Berkun et a l . provide evidence that the s c a l e i s 36 s e n s i t i v e to s t r e s s provoked by l i f e - t h r e a t e n i n g s i t u a t i o n s . More r e c e n t l y a d i s s e r t a t i o n by Neufeld (1972) found that the s c a l e was s e n s i t i v e to anx i e t y caused by s l i d e s of homicide v i c t i m . In a d d i t i o n , the s c a l e has been used to measure s t r e s s i n h o s p i t a l p a t i e n t s ( P a r i s e n , Rich and Jackson, 1969). Post-treatment measures, A l l of the questionnaires were readministered at the ter m i n a t i o n of i therapy. In the case of the S i t u a t i o n a l Stress Assessment, the c l i e n t s were asked to expose themselves to the same s t r e s s o r which they had encountered i n the pre-assessment. I n a d d i t i o n , at t h i s time c l i e n t s responded to the questionnaires described below. R e l a t i o n s h i p Inventory. C l i e n t s ' perceptions of t h e r a p i s t s were assessed by t h i s instrument which was developed w i t h i n the framework of c l i e n t - c e n t r e d therapy by Barrett-Lennard (1962). The que s t i o n n a i r e provides scores f o r L e v e l of Regard, U n c o n d i t i o n a l i t y , Empathy and Congruence. In a review paper, Bergin and Suinn (1975) note that some i n v e s t i g a t o r s have found that perceived l e v e l s of Rogerian f a c i l i t a t i v e c o n d i t i o n s , as assessed by the R e l a t i o n s h i p Inventory, are a b e t t e r p r e d i c t o r of ther a p e u t i c outcome than r a t i n g scores derived from t h e r a p i s t behaviour. Programme E v a l u a t i o n Form. We obtained c l i e n t s ' impressions of c l i n i c a l improvement by using f i v e r a t i n g s c a l e s assessing changes i n te n s i o n l e v e l , a b i l i t y to d e a l w i t h personal problems, a b i l i t y to f u n c t i o n under pressure, tendency to become upset and d u r a t i o n of "upsets." In a d d i t i o n , i n d i v i d u a l s i n d i c a t e d how much of t h e i r problem had been handled by the treatment and rated t h e r a p i s t competence and group warmth 37 on a series of rating scales. In order to assess the internal consistency of the three scales which made up the Programme Evaluation form, item-to-total correlations were calculated for each of them. Correlations for the five Self-rated Change items ranged from .58 to .82. Only four of the five items in the Therapist Competence Scale showed a correlation above .50 with a total score. The low item was accordingly dropped. For the same reason two of the 10 items were dropped from the Group Warmth scale. The analysis of the data used total scores derived from the revised scales (see Appendix for items and correlations). Significant Other Questionnaire. Clients were asked to have a relative or close friend provide his/her impressions of change which had occurred during the six week treatment period on a questionnaire made up of the five scales used in the Self-rated Change form. Again, item-to-total correlations were calculated, a l l of which exceeded .50 (see Appendix 2 for correlations). Follow-up procedure and measures One month after the last treatment session, clients were sent several questionnaires which they were asked to complete and return by mail. These included the State-trait Anxiety Inventory, the Fear of Negative Evaluat ion Scale, the Social Avoidance and Distress Scale, and the Self— rated Change Scale from the Programme Evaluation Form. 38 CHAPTER SEVEN Results Pre-measures A one-way between groups m u l t i v a r i a t e a n a l y s i s of v a r i a n c e (MANOVA) 2 was performed on pre-treatment scores. The obtained Heck value (Heck=0.15, s=3, m=5, n=17.5) was not s i g n i f i c a n t , i n d i c a t i n g no d i f f e r e n c e s among experimental c o n d i t i o n s . For mean pre-scores by group r e f e r to Table 1. The group as a whole had a mean score of 6.47 (s.d.=1.39) on the Tension Thermometer. This r a t i n g i n d i c a t e s a moderate l e v e l of o v e r a l l t e n s i o n . Mean scores f o r A-state and A - t r a i t were 42.4 and 47.4, r e s p e c t i v e l y (s.d. a9.50 and 8.93). The t r a i t score i s s i m i l a r to the average score reported f o r a group of p s y c h i a t r i c p a t i e n t s w i t h a d i a g n o s i s of a n x i e t y r e a c t i o n c i t e d by S p i e l b e r g e r et a l . i n the manual f o r the S t a t e - t r a i t Anxiety Inventory. On the other hand, on A-state the present sample i s comparable to general medical p a t i e n t s whose scores are a l s o given by S p i e l b e r g e r et a l . Fear of Negative E v a l u a t i o n and S o c i a l Avoidance and D i s t r e s s mean scores were s i m i l a r to those reported by Watson and.Friend (1969) f o r normal undergraduate students (X=16.7 and 10.6, s.d.=8.4 and 8.2, r e s p e c t i v e l y ) . C l i e n t s obtained a mean score of 69.5 (s.d.=17.8) on the S u b j e c t i v e Stress Scale. The word as s o c i a t e d w i t h t h i s value i s "nervous." The average score obtained i s comparable to those reported f o r s u bjects who underwent simulated, but apparently r e a l , emergency s i t u a t i o n s i n Berkun et a l . (1962). Mean scores v a r i e d from 69 to 74 f o r the three l i f e - t h r e a t e n i n g emergency s i t u a t i o n s encountered i n the l a t t e r study. 39 Table 1 Means and Standard Deviations for Outcome Measures Measures0 Treatments3 SIT(n=ll) AWARE(N=ll) ST(n=ll) SH(n=9) X s.d. X s.d. X s.d. X s.d. TT Pre Post Follow-up .6:33 4.67 5.18 • I.V23.J 1.97 1.54 .6.50 4.50 5.18 1.73 1.57 1.33 , :7.00 6.00 5.55 .'1.48.V 6.00 1.55 5.50 1.86 5.67 . 0.94 1.27 1.22 FNE Pre Post Follow-up 18.75 14.67 14.18 9.64 11.31 10.78 13.42 11.91 11.55 8.42 8.84 10.56 18.91 18.82 15.82 8.36 8.93 9.50 15.80 12.50 10.67 6.03 7.09 7.48 SAD Pre Post Follow-up 12.00 9.92 11.18 9.35 8.96 8.86 9.08 9.83 10.36 7.28 8.58 9.11 12.09 11.46 10.64 9.72 9.37 9.21 9.30 10.30 7.88 6.26 7.33 6.51 A-state Pre Post Follow-up 44.00 32.17 35.46 11.21 7.43 9.61 40.50 35.25 37.55 9.32 8.29 11.19 44.82 42.'27 48.09 10.27 10.74 12.14 40.40 39.40 37.11 6.60 9.69 10.98 A-trait Pre Post Follow-up 47.50 43.33 45.36 9.02 9.42 9.90 43.92 41.92 41.00 8.92 11.34 8.20 49.82 47.91 48.18 10.64 9.99 11.94 48.70 44.50 40.55 6.48 6.95 6.42 SSS Pre Post 65.58 45.25 19.39 38.15 63.75 53.25 27.26 23.26 79.27 58.72 9.18 24.39 SRC Post 22.75 2.83 22.93 3.32 20.27 2.61 20.60 3.31 SOQ Post 20.82 3.13 22.46 1.92 19.82 4.54 19.13 3.36 SIT=self-instructional training, AWARE=awareness, ST=skills training and SH=self-help. TT =Tension Thermometer, FNE=Fear of Negative Evaluation, SAD=Social Avoidance and Distress, SSS=Subjective Stress Scale, SRC=Self-rated Change, and S0Q=Significant Other Questionnaire. 40 Treatment outcome A series of two-way analyses of variance (Conditions X Time) were used to test for changes on a l l instruments for which repeated measures had been obtained. Significant main effects for Time were found on a l l outcome measures except Social Avoidance and Distress. None of the Condition main effects or the Conditions X Time interactions were significant. (See Table 2 for a summary of these analyses). Tukey hsd tests for individual comparisons revealed the following differences among means: pre was different from post and follow-up for Tension Thermometer, pre was different from follow-up for Fear of Negative Evaluation, for State Anxiety, pre was different from post and pre was significantly different from post and follow-up for Trait Anxiety, and for the Subjective Stress Scale, pre was different from post. (This lastcfinding should be interpreted with caution because of heterogeneity of variance among conditions on the Subjective Stress Scale.) To further evaluate differential treatment effects, one-way between MANOVA's were performed separately on post and follow-up for a l l measures except the Subjective Stress Scale. The resulting Heck values were not significant (Heck=0.25, s=3, m=1.5, n=15 for post; Heck=0.19, s=2, m=1.5, n-12'..5 for follow-up). In combination with the findings from the earlier analyses, this indicates that the treatments offered did not produce different outcomes, either at the termination of treatment or after a period of one month, although significant change did occur for the client group as a whole. Therapist effects Another one-way between MANOVA found no significant differences .. among the three group therapy conditions on clients' perceptions of therapists or group atmosphere (Heck=0.19, s=2, m=1.5, n=12.5). This Table 2 A n a l y s i s of Variance Summary Tables Measure 3 Source Sum of Squares d.f. Mean Squares F P TT Conditions 11.89 3 3.96 1.15 .341 Error(between) 127.28 37 3.44 Time 37.91 2 18.95 10.28 .001 ConditionsXTime 9.62 6 1.60 0.87 .52 E r r o r ( w i t h i n ) 136.40 74 1.84 FNE Conditions 757.69 3 252.56 1.08 .368 Error(between) 8624.36 37 233.09 Time 250.87 2 125.44 10.87 .001 ConditionsXTime 118.58 6 19.76 1.70 .130 E r r o r ( w i t h i n ) 854.21 74 11.54 SAD Conditions 129.67 3 43.22 0.21 .893 Error(between) 7814.69 37 211.21 Time 25.27 2 12.64 1.81 .171 ConditionsXTime 51.50 6 8.58 1.23 .301 E r r o r ( w i t h i n ) 516.12 74 6.98 A-state Conditions 1100.83 3 366.94 1.92 .144 Error(between) 7083.25 37 191.44 Time 481.68 2 240.84 4.32 .017 ConditionsXTime 581.43 6 96.91 1.74 .124 E r r o r ( w i t h i n ) 4123.63 74 55.73 A - t r a i t Conditions 670.18 3 233.39 0.98 .412 Error(between) 8143.06 37 227.38 Time 311.18 2 155.59 7.83 .001 ConditionsXTime 87.76 6 14.63 0.74 .622 E r r o r ( w i t h i n ) 1470.56 74 19.87 SSS Conditions 2362.533 2 1181.27 1.21 .310 Error(between) 31104.88 32 972.03 Time 5124.30 1 5124.30 16.47 .001 Conditions XTime 383.67 2 191.84 0.62 .546 E r r o r ( w i t h i n ) 9957.19 32 311.16 See notes on Table 1. 42 a n a l y s i s included the four scores from the R e l a t i o n s h i p Inventory as w e l l as scores f o r Therapist Competence and Group Warmth. As a f u r t h e r check on p o s s i b l e d i f f e r e n c e s i n c l i e n t s ' p erceptions, one-way analyses of va r i a n c e were c a r r i e d out f o r small groups (n's v a r i e d from 5 to 7) . None of the_F's obtained were s i g n i f i c a n t i n d i c a t i n g no d i f f e r e n c e s among the 8 groups. Although c l i e n t s i n d i f f e r e n t c o n d i t i o n s apparently d i d not perceive t h e r a p i s t s d i f f e r e n t l y , i t i s p o s s i b l e that t h e r a p i s t s were not e q u a l l y e f f e c t i v e . To t e s t t h i s hypothesis a s e r i e s of three-way analyses of var i a n c e (ConditionsXGroupsXTime) w i t h small groups nested w i t h i n treatment c o n d i t i o n s were performed. These analyses revealed no s i g n i f i c a n t GroupsXTime i n t e r a c t i o n s on any of the outcome measures. R e l a t i o n s h i p s between process and outcome measures C o r r e l a t i o n s c o e f f i c i e n t s (Pearson r's) were c a l c u l a t e d to i n v e s t i g a t e the r e l a t i o n s h i p between c l i e n t s perceptions of treatment and a c t u a l treatment outcomes. Where repeated t e s t i n g had been done, pre-post d' scores were used as i n d i c e s of outcome. For the remaining outcome measures ( S e l f - r a t e d Change and S i g n i f i c a n t Other Questionnaire) c o r r e l a t i o n s were simply c a l c u l a t e d between the s i n g l e scores a v a i l a b l e and process scores. L e v e l of Regard scores from the R e l a t i o n s h i p Inventory were p o s i t i v e l y r e l a t e d to S e l f - r a t e d Change (r=,34, p<.05). Empathy and Congruence were r e l a t e d to the Su b j e c t i v e Stress Scale (r=.30, p<.05 and r=.35, p<.05). Of the s c a l e s constructed f o r the present research, both t h e r a p i s t Competence and Group Warmth were p o s i t i v e l y c o r r e l a t e d w i t h the Su b j e c t i v e Stress Scale (r=.28, p<.05 and r=.31, p<.05). In a d d i t i o n , there was a s i g n i f i c a n t r e l a t i o n s h i p between Group Warmth r a t i n g s and changes i n s t a t e a n x i e t y (r=.27, p<.05). 43 Any i n t e r p r e t a t i o n of the obtained c o r r e l a t i o n c o e f f i c i e n t s must be made w i t h c a u t i o n s i n c e they represent only a small p r o p o r t i o n of those c a l c u l a t e d . Thus, of 48 c o e f f i c i e n t s only s i x were s i g n i f i c a n t beyond the .05 l e v e l , and even these were not l a r g e i n magnitude. However, one i n t e r e s t i n g p a t t e r n which seems to emerge i s that c l i e n t s perceptions tend to be r e l a t e d to change on measures of s p e c i f i c anxiety ( S u b j e c t i v e Stress Scale and State Anxiety) but not to more general measures of s p e c i f i c a n x i e t y (Fear of Negative E v a l u a t i o n , S o c i a l Avoidance and D i s t r e s s and T r a i t A n x i e t y ) . 44 CHAPTER EIGHT Discussion The results of this study indicate that significant changes occurred on outcome measures for the client sample as a whole, but contrary to expectations, the treatments provided did not have differential effects. Because there were no significant differences between the f i r s t three treatment conditions and the self-help condition, i t is necessary to consider whether the overall changes actually indicate a reduction i n anxiety. It might be argued that they are due to the operation of a Hawthorne effect, or to s t a t i s t i c a l artifact due to repeated testing. In the absence of a no-treatment control group i t is not possible to rule out these alternative explanations for the results obtained. With limited resources i t was possible to include only one "control" condition in the present study. A choice was made in favour of a minimal treatment group for two reasons. F i r s t , i t i s ethically questionable to withhold treatment from people who are in need. If psychologists advertise a treatment programme, they should commit themselves to treating as many of the people who respond as their resources allow. A waiting l i s t control can partly overcome the ethical objection to a no-treatment group, but for practical reasons this alternative was not feasible in the present research. The second point in favour of a minimal treatment i s that such a condition can provide a more adequate baseline against which to compare the effects of a more complex therapy. Unless a particular treatment approach is able to produce better results than minimal treatment, the additional costs of the former are not jus t i f i e d . From a more traditional 45 experimental control perspective, a minimal treatment group i s also able to provide a control for certain "non-specific" factors (e.g., situational demand characteristics, expectations of help and.opportunity to share emotional experiences) which are present in any therapy. Thus, an investigator can feel reasonably confident that a therapy which i s superior to a minimal treatment i s actually effective. However, when differences do not emerge, there are problems in interpreting experimental results. On the basis of the data obtained in the present study, one might conclude that, for practical purposes, a l l of the treatments offered were of equal effectiveness. Such a strong conclusion is probably unwarranted. In a l l therapy research, treatment outcome is due to an interaction of client, therapist and technique variables. Very often client and therapist effects may obscure the operation of specific treatment variables by increasing the variance on outcome measures. Clients in the present study were diverse in terms of age, sex, psychiatric history and specific presenting problems. Although there were no significant differences among treatment conditions, either on these variables or on pre-scores for outcome measures, within-condition variances were generally large. The same was true for within-groups scores on process measures; again an absence of significant differences among groups was accompanied by large score variances. Analysis of variance (groups nested within condition) did not find significant groups by time interactions. However, this finding does not necessarily indicate that therapist characteristics were unimportant, since ANOVA with small n's may be unreliable. A variety of differences among therapists in background, training and therapy style may have been 46 r e l a t e d to treatment outcome d e s p i t e the f i n d i n g that c l i e n t s d i d not view t h e i r t h e r a p i s t s d i f f e r e n t l y . F i n a l l y , s e v e r a l aspects of the treatments themselves may have decreased the l i k e l i h o o d of d i f f e r e n t i a l outcome. F i r s t , i t should be noted that i n some ways the i n d i v i d u a l treatments were a c t u a l l y r a t h e r s i m i l a r . Although there were d i f f e r e n c e s i n treatment r a t i o n a l e and i n the s p e c i f i c techniques used i n therapy, s i m i l a r i t i e s may have out-weigh'jacli the d i f f e r e n c e s . A l l c o n d i t i o n s adopted a s i t u a t i o n a l focus, a l l used s e l f - m o n i t o r i n g , a l l attempted to create an atmosphere i n which change was expected to occur, and a l l provided the opportunity f o r sharing u p s e t t i n g experiences and r e c e i v i n g emotional support. Several authors have argued that n o n - s p e c i f i c v a r i a b l e s may be as important as a c t u a l treatment f a c t o r s (see, e.g., Shapiro, 1971; Mahoney, 1974). In the l i g h t of the f a c t that a l l c o n d i t i o n s shared both n o n - s p e c i f i c and technique s i m i l a r i t i e s , the absence of s i g n i f i c a n t d i f f e r e n c e s may not be s u r p r i s i n g . P o s s i b l y a more p r o t r a c t e d therapy i s necessary f o r multi-problem c l i e n t s . From a common-sense p e r s p e c t i v e , c l i e n t s w i t h two or more problems may be more d i f f i c u l t to help than c l i e n t s w i t h only one problem. This i s e s p e c i a l l y l i k e l y when group members do not share a common problem, s i n c e r e l a t i v e l y l i t t l e t h e r a p i s t a t t e n t i o n can be paid to any one c l i e n t under these c o n d i t i o n s . Under such circumstances, none of the treatments may have been given a f a i r t r i a l . In a d d i t i o n , i t should be noted that the data a v a i l a b l e from the present study does not i n d i c a t e e x a c t l y what c l i e n t s were doing i n the treatment c o n d i t i o n s . Although they reported that they were applying the techniques taught i n the group sessions to extra-therapy situations, we have no way of directly assessing their compliance. In order to investigate this question, future research should more systematically collect information on clients' application of treatment techniques. One implication to be drawn from the results of the present study is that i t is unwise to assume that therapists with rather limited experience and training can necessarily bring about therapeutic change merely by following manuals which describe treatment approaches. While such manuals are admirable in that they standardize treatment procedures in research, i t is probably unrealistic to suppose that their use w i l l necessarily produce dramatic success. The changes which were obtained in the present research were of small magnitude. It i s of interest to note that when asked at post-assessment about the success of the treatment received, a majority of the clients (76%) responded that at least 75% of their problem remained to be coped with. When one takes into account the reluctance of clients to admit that they have received absolutely no assistance, these reports suggest that treatment was actually of l i t t l e value to them. Certainly one would expect them to go on to seek further treatment in the future. Since additional therapist training and experience in the self-instructional procedure might have produced a stronger treatment effect for this condition even with the present client population, the results as they stand should only be generalized to other research with relatively inexperienced therapists. It may be that self-instructional training was not really an appropriate treatment for the present sample. Its effectiveness has been demonstrated mainly with f a i r l y circumscribed fears in normal clients. Although the 48 screening procedure attempted to exclude i n d i v i d u a l s who had general or f r e e - f l o a t i n g a n x i e t y , the high t r a i t a n x i e t y scores which c l i e n t s obtained suggest that the present group may have been more g e n e r a l l y anxious than subjects included i n e a r l i e r s t u d i e s . In a d d i t i o n , many of our c l i e n t s had experienced stress-management problems f o r a long time (60% f o r more than f i v e years) and 30% had had previous p s y c h i a t r i c t r e a t -ment at one time i n t h e i r l i v e s . Probably these f a c t o r s combined to make b e n e f i c i a l change l e s s l i k e l y to occur. In order to determine whether t r a i t a n x i e t y and problem d u r a t i o n were r e l a t e d to treatment outcome, Pearson's r_'s were c a l c u l a t e d between these measures and outcome scores f o r the t o t a l N. Duration was s i g n i f i c a n t l y r e l a t e d to change on the Tension Thermometer (r—.42, p .01) and S u b j e c t i v e S t r e s s Scale (r=.33, p .01), w h i l e i n i t i a l t r a i t a n x i e t y scores were s i g n i f i c a n t l y c o r r e l a t e d only w i t h changes on the Fear of Negative E v a l u a t i o n (r=.25, p .05). The d i r e c t i o n of these r e l a t i o n s h i p s does support the view t h a t c l i e n t s w i t h h i g h t r a i t a n x i e t y scores and lo n g -standing problems show l e s s improvement w i t h treatment. Most of the s e l f - i n s t r u c t i o n a l t r a i n i n g research i n anxiety to date has been conducted w i t h student c l i e n t s (e.g. Meichenbaum et a l . , 1971; Meichenbaum, 1972; Holroyd, 1976; Thorpe et a l . , 1976). Perhaps the technique r e q u i r e s more i n t e n s i v e a p p l i c a t i o n or some ki n d of m o d i f i c a t i o n to maximally b e n e f i t more " c l i n i c a l " groups. The f i n d i n g of no d i f f e r e n c e s between the awareness c o n d i t i o n and s e l f - i n s t r u c t i o n a l t r a i n i n g supports the conc l u s i o n of Thorpe et a l . , that the i n s i g h t component of s e l f - i n s t r u c t i o n a l t r a i n i n g i s more important 49 than the specific technique. However, in view of the failure of self-instructional training to out-perform minimal treatment i t i s not possible to draw definite conclusions on the basis of this finding. Because such differences between treatments may have relatively weak effects in comparison to the client and therapist variables discussed above and also in comparison to non-specific effects i t seems more appropriate to investigate this question with subjects who are similar to each other and who share a common problem. Probably future research should focus on more homogeneous samples. Self-instructional training i s a promising approach to stress-management because i t offers a method of analysis and a technique which can be applied to the problem of anxiety in diverse situations. It is certainly worthwhile to continue to investigate i t s usefulness with multiproblem clients, but future studies with a community population should pay closer attention to client variables with a view to discovering characteristics which w i l l predict good treatment outcomes. Findings from the present study suggest that problem duration and level of t r a i t anxiety may be important. It also seems lik e l y that the nature of the specific stress-producing stimuli w i l l be related to outcome. Not only might better results be expected when the stressful situation can be specified in detail, but the treatment may bring about greater anxiety reduction with clients who experience stress in particular types of situations. For example, i t may be that people who become anxious in work situations are more easily helped than those who find d i f f i c u l t y coping with situations which arise in the context of intimate relationships. In addition to client variables, therapist variables may also partly determine therapeutic effectiveness. 50 For this reason, future research should provide for an analysis of therapist effects so that this source of variance can be extracted to better assess the effectiveness of treatment. However, before client and therapist variables are investigated, a more lengthy and intensive treatment programme should be considered for multiproblem clients similar to those who served as subjects in the present research.! At this point, the f i r s t priority i s to develop an effective programme for this population. Later research can then be devoted to a comparison of different treatment approaches in stress-management . 51 FOOTNOTES See Appendix 3 for typical therapy interactions. The Subjective Stress Scale was not included in this analysis because scores were available for only three groups. A univariate analysis of variance found no difference on pre-treatment measures (see Table 2) but because of heterogeneity of variance among conditions this finding may be unreliable. 52 REFERENCES Appley, M. and Trumble R. P s y c h o l o g i c a l S t r e s s . New York: Appleton-Century-Crofts, 1967. A r n o l d , M. P e r e n n i a l problems i n the f i e l d of emotion. In M. Armold (Ed.) F e e l i n g s and Emotions. New York: Academic P r e s s , 1970. Bander, K., Steinke, G., A l l e n , G., and Mosher, D. E v a l u a t i o n of three d a t i n g - s p e c i f i c treatment approaches f o r heterosexual d a t i n g a n x i e t y . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 1975, 43, 259-265. Bandura, A. P r i n c i p l e s of behaviour m o d i f i c a t i o n . New York: H o l t , Rinehart and Winston, 1969. B a r r e t t , T. Parameters of s e l f - i n s t r u c t i o n a l t r a i n i n g . Unpublished d o c t o r a l d i s s e r t a t i o n . West V i r g i n i a U n i v e r s i t y , 1973. Barrett-Lennard, G. Dimensions of t h e r a p i s t response as causal f a c t o r s i n t h e r a p e u t i c change. P s y c h o l o g i c a l Monographs, 1962, 7_6, No. 43 (whole No. 562). B e l l a c k , A., Schwartz, J . and Rozensky, R. The c o n t r i b u t i o n of e x t e r n a l c o n t r o l and s e l f - c o n t r o l i n a weight r e d u c t i o n program. J o u r n a l  of Behaviour Therapy and Experimental P s y c h i a t r y , 1974, _5, 245-249. Bern, D. S e l f - p e r c e p t i o n theory. I n L. Berkowitz (Ed.) Advances i n experimental s o c i a l psychology ( v o l . 6). New York: Academic P r e s s , 1972. B e r g i n , A. and Suinn, R. I n d i v i d u a l psychotherapy and behaviour therapy. In M. Rosenzweiz and L. P o r t e r (Eds.) Annual Review of Psychology ( v o l . 26). Palo A l t o , C a l i f . : Annual Reviews Inc., 1975. Berkun, M., B a i l e k , H., Kern, R., and Y a g i , K. Experimental s t u d i e s of p s y c h o l o g i c a l s t r e s s i n man. P s y c h o l o g i c a l Monographs, 1962, 76. no. 15, whole no. 534. E l l i s , A. Reason and emotion i n psychotherapy. New York: L y l e S t u a r t , 1962. E p s t e i n , S. The nature of a n x i e t y w i t h emphasis upon i t s r e l a t i o n s h i p to expectancy. In C. S p i e l b e r g e r (Ed.) Anxiety: Current trends  i n theory and research ( v o l . . 2 ) . New York: Academic P r e s s , 1972. E p s t e i n , S. and Roupenian, A. Heart r a t e and s k i n conductance during experimentally induced a n x i e t y : The e f f e c t of u n c e r t a i n t y about r e c e i v i n g a noxious s t i m u l u s . J o u r n a l of P e r s o n a l i t y and S o c i a l  Psychology, 1970, 16, 20-28. 53 G l a s s , C., Gottman, J . and Shmurak, S. Response-acquisition and c o g n i t i v e self-statement m o d i f i c a t i o n approaches to d a t i n g - s k i l l s t r a i n i n g . J o u r n a l of Counseling Psychology, 1976, 23, 529-526. G o l d f r i e d , M. Systematic d e s e n s i t i z a t i o n as t r a i n i n g i n s e l f - c o n t r o l . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 1971, 37_, 228-234. G o l d f r i e d , M. and Davison, G. C l i n i c a l behaviour therapy. New York: H o l t , Rinehart and Winston, 1976. G o l d f r i e d , M., Decenteceo, E. and Weinberg, L. Systematic r a t i o n a l r e s t r u c t u r i n g as a s e l f - c o n t r o l technique. Behaviour Therapy, 1974, 5, 247-254. G o l d f r i e d , M. and S o b o c i n s k i , D. E f f e c t of i r r a t i o n a l b e l i e f s on emotional a r o u s a l . J o u r n a l of Consulting and C l i n i c a l Psychology, 1975, 43, 504-510. G o l d f r i e d , M. and T r i e r , C. E f f e c t i v e n e s s of r e l a x a t i o n as an a c t i v e coping s k i l l . J o u r n a l of Consulting and C l i n i c a l Psychology, 1974, 83, 348-355. H a l l , S., H a l l , R., Hanson, R. and Borden, B. Permanence of two s e l f -managed treatments of overweight i n u n i v e r s i t y and community populations. J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 1974, 42, 781-786. Hersen, M., E i s l e r , R., and M i l l e r , P. Development of a s s e r t i v e responses: C l i n i c a l measurement and research c o n s i d e r a t i o n s . Behaviour Research  and Therapy, 1973, 11, 505-521. Holroyd, K. C o g n i t i o n and d e s e n s i t i z a t i o n i n the group treatment of t e s t a n x i e t y . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 1976, 44, 991-1001. Jackson, B. and Van Zoost, B. Changing study behaviours through r e i n f o r c e -ment contingencies. J o u r n a l of Counseling Psychology, 1972, 19, 192-195. J e f f r e y , D. A comparison of the e f f e c t s of e x t e r n a l c o n t r o l and s e l f - c o n t r o l on the m o d i f i c a t i o n and maintenance of weight. J o u r n a l of Abnormal  Psychology, 1974, 83, 404-410. Johnson, S. and White, G. S e l f - o b s e r v a t i o n as an agent of behavioural change. Behaviour Therapy, 1971, 2, 488-497. K a r s t , T. and T r e x l e r , L. I n i t i a l study using f i x e d - r o l e and r a t i o n a l -emotive therapy i n t r e a t i n g p u b l i c - s p e a k i n g a n x i e t y . J o u r n a l of  Co n s u l t i n g and C l i n i c a l Psychology, 1970, 34, 360-366/ Kopel, S. and Arkowitz, H. and behaviour change. 1974, 29, 677-686. Ro l e - p l a y i n g as a source of s e l f - o b s e r v a t i o n J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology, 54 Kopel, S. and Arkowitz, H. The role of attribution and self-perception in behaviour change: Implications for behaviour therapy. Genetic Psychology Monographs, 1975, 92, 175-212. Lazarus, R. and A v e r i l l , J. Emotion and cognition: with special reference to anxiety. In C. Spielberger (Ed.) Anxiety: Current  trends in theory and research (vol 2). New York: Academic Press, 1972. Lazarus, R., A v e r i l l , J. and Opton, E. Towards a cognitive theory of emotion. In M. Arnold (Ed.) Feelings and Emotions. New York: Academic Press, 1970. Lazarus, R. and Opton, E. The study of psychological stress: a. summary of cli n e t i c a l formulations and experimental findings. In C. Spiel-berger (Ed.) Anxiety and behaviour. New York: Academic Press, 1966. Lazarus, R., Speisman, J., Mordkoff, A. and Davison, L. A laboratory-study of psychological stress produced by a motion picture film. Psychological Monographs, 1972, 7_6 (34, whole No. 553). Lichtenstein, E. and Danaher, B. Modification of smoking behaviour: A c r i t i c a l analysis of theory, research and practice. In M. Hersen, R. Eisler and P. Miller (Eds.), Progress in behaviour modification (vol 3). New York: Academic Press, 1976. Lindstrom, L., Balch, P. and Reese, S. In person versus telephone t treatment for obesity. Journal of Behaviour Therapy and Experimental  Psychiatry, 1976, _7, 367-369. Lipinski, D., and Nelson, R. The reactivity and unreliability of self-recording. Journal of Consulting and C l i n i c a l Psychology, 1974, 42, 118-123. Mahoney, M. Self-reward and self-monitoring techniques for weight control. Behaviour Therapy, 1974, j>, 48-57. Mahoney, M. Cognition and behaviour modification. Cambridge, Mass.: Ballinger, 1974. Mahoney, M. Reflections on the cognitive-learning trend in psychotherapy. American Psychologist, 1977, J32, 5-13. Mahoney, M., Moura, N., and Wade, T. Relative efficacy of self-reward, self-punishmentaand self-monitoring techniques for weight loss. Journal of Consulting and C l i n i c a l Psychology, 1973, j40, 404-407. Marks, J., Boulougouris, J., and Marset, P. Flooding versus desensitization in the treatment of phobic patients: A cross-over study. British  Journal of Psychiatry, 1971, 119, 353-375. McFall, R. and Hammen, C. Motivation, structure and self-monitoring: The role of non-specific factors in smoking reduction. Journal of Consulting -- and Clinical Psychology, 1971, _3_7> 80-86. Meichenbaum, D. behaviour. Examination of model characteristics in reducing avoidance Journal of Personality and Social Psychology, 1971, 17_, 298-307. 55 Meichenbaum, D. Cognitive modification of test anxious college students. Journal of Consulting and C l i n i c a l Psychology, 1972, 39, 370-380,' Meichenbaum, D. ^Cognitive behaviour modification. Morristown, N.J.: General Learning Press, 1974'.aja) Meichenbaum, D. Therapist manual for cognitive behaviour modification. Unpublished manuscript, University of Waterloo, Ontario, 1974T(b) Meichenbaum, D. and Cameron, R. Stress inoculation: A s k i l l s training approach to anxiety management. Unpublished manuscript, University of Waterloo, 1973. Meichenbaum, D., Gilmore, B., and Fedorovicius, A. Group insight vs. group desensitization in treating speech anxiety. Journal of Consulting and Cl i n i c a l Psychology, 1971, _36, 410-421. Moffat, S. Contingency contracting with study behaviours using activity reinforcers. Unpublished Master's Thesis, University of Utah, 1972.. Monat, A., A v e r i l l , J. and Lazarus, R. Anticipatory stress and coping reactions under various conditions of uncertainty. Journal of Personality and Social Psychology, 1972, 24, 237-253. Newmark, C., Frerking, R., Cook, L. and Newmark, L. Endorsement of E l l i s ' irrational beliefs as a function of psychopathology. Journal of C l i n i c a l Psychology, 1973, 29_, 300-302. Nomikos, M., Opton, E., A v e r i l l , J. and Lazarus, R. Surprise and suspense in the production of stress reaction. Journal of Personality and  Social Psychology, 1968, 8, 204-208. Rehm, L. and Marston, A. Reduction of social anxiety through modification of self-reinforcement: An instigation therapy technique. Journal  of-Consulting and Cl i n i c a l Psychology, 1968, J32, 565-574. Schacter, S. The interaction of cognitive and physiological determinants of emotional state. In C. Spielberger (Ed.), Anxiety and Behaviour. New York: Academic Press, 1966. Schacter, S. and Singer, J. Cognitive, social and physiological determinants of emotional state. Psychological Review, 1962, 6_9, 379-399. Shapiro, A. Placebo effects in medicine, psychotherapy, and psychoanalysis. In A. Bergin and S. Garfield (Eds.) Handbook of psychotherapy and  behaviour change. New York: Wiley and Sons, 1971. Spielberger, C. Anxiety as an emotional state. In C. Spielberger (Ed.) Anxiety: Current trends in theory and Research (vol 1), New York: Academic Press, 1972. (a) 56 S p i e l b e r g e r , C. Conceptual and methodological i s s u e s i n an x i e t y research. In C. S p i e l b e r g e r (Ed.) Anxiety: Current trends i n theory and  r e s e a r c h . ( v o l 2 ) , New York: Academic Press, 1972.(b) S p i e l b e r g e r , C., Gorsuch, R. and Lushene, R. Manual f o r the S t a t e - T r a i t  Anxiety Inventory. Palo A l t o , C a l i f o r n i a : Consulting P s y c h o l o g i s t s Press, 1970. Straatmeyer, A. and Watkins, J . Rational-emotive therapy and the r e d u c t i o n of speech a n x i e t y . R a t i o n a l L i v i n g , 1974, 9_, 33-37. Thorpe, E., Amatu, J . , Blakey, R. and Burns, L. C o n t r i b u t i o n s of overt i n s t r u c t i o n a l r e h e a r s a l and " s p e c i f i c i n s i g h t " to the e f f e c t i v e n e s s of s e l f - i n s t r u c t i o n a l t r a i n i n g : A p r e l i m i n a r y study. Behaviour Therapy, 1976, 7_, 504-511. T r e x l e r , L. and K a r s t , T. Rational-emotive therapy, placebo and no-treatment e f f e c t s on pub l i c - s p e a k i n g a n x i e t y . J o u r n a l of Abnormal Psychology, 1972, 7_9, 60-67. Twentyman, C. and M c F a l l , R. Beh a v i o u r a l t r a i n i n g of s o c i a l s k i l l s i n shy males. J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 1975, 43, 384-395. V a l i n s , S. and Ray, A. E f f e c t s of c o g n i t i v e d e s e n s i t i z a t i o n on avoidance behaviour. J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology, 1967, 7_, 345-350. Walk, R. S e l f - r a t i n g s of f e a r i n a f e a r - i n v o k i n g s i t u a t i o n . J o u r n a l of  Abnormal and S o c i a l Psychology, 1956, _52, 171-178. Watson, D.,and F r i e n d , R. Measurement of s o c i a l e v a l u a t i v e a n x i e t y . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 1969, _33, 448-457. Wein, K., Nelson, R. and Odom, J . The r e l a t i v e c o n t r i b u t i o n s of r e a t t r i b u t i o n and v e r b a l e x t i n c t i o n to the e f f e c t i v e n e s s of c o g n i t i v e r e s t r u c t u r i n g . Behaviour Therapy, 1975, 6^, 459-474. Wine, J . I n v e s t i g a t i o n s of an i n t e n t i o n a l i n t e r p r e t a t i o n of t e s t a n x i e t y . Unpublished d o c t o r a l d i s s e r t a t i o n . U n i v e r s i t y of Waterloo, Waterloo, Ontario, 1970. 57 Appendix 1 Interview Guides 58 TELEPHONE CALL-BACK Time: 15 minutes maximum Begin the conversation by asking what sor t of problems the respondent has ; been having. Probably you w i l l get a r a t h e r d i s o r g a n i z e d stream of vague complaints at t h i s p o i n t . Try to focus the conversation by asking s p e c i f i c questions. Ask about the d u r a t i o n of the problem ("how long have you been f e e l i n g that something was wrong?"), the extent ("how much do your f e e l i n g s of a n x i e t y or t e n s i o n " — use the c l i e n t ' s words — " i n t e r f e r e w i t h your d a i l y l i f e ? " , "how o f t e n do s t r e s s f u l s i t u a t i o n s a r i s e ? " ) . Also t r y to f i n d out whether the a n x i e t y experienced i s f a i r l y constant and a l l pervasive or r e l a t e d to s e v e r a l s i t u a t i o n s ( " A r e there times when you don't f e e l anxious or tense?"). Then move on to a d e s c r i p t i o n of a p a r t i c u l a r s i t u a t i o n which causes a n x i e t y i n the respondent. I f he/she has already given examples, use one of these. Ask about where i t happens, when i t happens (time of day, f o l l o w i n g some other event), how o f t e n i t happens, the c h a r a c t e r i s t i c s of other people i n the s i t u a t i o n , t h e i r responses to the respondent's upset. Then ask the respondent to describe i n some d e t a i l how he experiences h i s a n x i e t y . How does he know there's a problem(s) ( i s he weak and trembly, p h y s i c a l l y tense, nauseous, panicky, e t c . ) . I f the respondent i s s t i l l w i t h you, give., him a b r i e f d e s c r i p t i o n of the treatment programme. Introduce t h i s d e s c r i p t i o n w i t h the statement, " I ' l l g i v e you a short d e s c r i p t i o n of our programme so you can decide i f i t sounds l i k e what you are l o o k i n g f o r . " Say that the treatment w i l l , take place i n groups of 6 to 8 people. There w i l l be one group meeting per week l a s t i n g about 1% hours. Most groups w i l l probably meet i n the evening. Treatment w i l l l a s t f o r 7 weeks. I t i s important that the c l i e n t s commit themselves to being there f o r almost a l l of the s e s s i o n s . The group leaders w i l l be graduate students i n psychology who have had 59 experience i n therapy and are being supervised by c l i n i c a l psychology f a c u l t y members ( p r o f e s s o r s ) . Make sure you mention that t h i s i s a research p r o j e c t . They w i l l r e c e i v e f r e e treatment, but i n r e t u r n they w i l l be expected to f i l l out . s e v e r a l q u e s t i o n n a i r e s . I f questioned,' say that "we b e l i e v e our approach i s a good one, and i t has worked f o r many people. However, we want to c a r r y out research i n order to o b t a i n data to support our b e l i e f . " Don't answer more s p e c i f i c questions about the content of the therapy sessions. Say that t h i s w i l l be discussed at the i n i t i a l i n t e r v i e w . Arrange an i n t e r v i e w i f : 1 ) the person seems to be i n genuine discomfort and i s eager f o r help. 2) h i s a n x i e t y i s t i e d to s p e c i f i c s i t u a t i o n s . (He i s able to describe a n x i e t y - f r e e p e r i o d s , he can say what provokes h i s s t r e s s r e a c t i o n . ) ' ' 3) he i s not p s y c h o t i c . (You .feel that what he says makes sense — a l l o w i n g f o r some confusion because of high a n x i e t y . He does not report h a l l u c i n a t i o n s or delusions.) 60 ASSESSMENT INTERVIEW GUIDE  Time: 30-45 minutes of interview and 15-30 minutes for questionnaires. In this interview you w i l l be interested in the same material as you covered in the telephone call-back, but in more detail. As a guide to the interview, please follow the Interviewer Assessment Form. You may f i l l in the client's responses as you go along, or complete the form after the interview is concluded. Suit your taste. For the rating scales at the end of the Assessment Form, your judgement w i l l be required because you may have only vague intuitions to go on. Follow these , i f you have no hard data. Begin the interview by asking the respondent to describe his problems in more detail, and direct the conversation so that a l l of the necessary questions are asked, in any order you like. After you have obtained answers to these questions, leave the client, taking the Interviewer Assessment Form with you. Complete the assessment ratings at the bottom of the second page and arrive at a decision about the suitability of the client for the stress management programme. If the person is judged inappropriate: T e l l him/her that he probably wouldn't be happy with the treatment we are offering. If he asks where he should go, suggest that he consult his family doctor. If the person is judged appropriate: Answer questions he/she may have about the treatment programme. Emphasize that i t w i l l .deal with specific techniques which can be used to deal with stressful situations. If pressed for details, say that the techniques used w i l l be to some extent dependent on the nature of his problems and that i t isn't possible to be very specific about i t now. Make i t very clear that the client i s expected to attend a l l treatment sessions, since this i s a brief intensive course of therapy and that a lot of hard work i s expected of him. Assign him to a group according to his time preferance (refer to a master-list which w i l l be posted somewhere). Self-Monitoring: Give the client a copy of the Self-Monitoring Instructions. T e l l him that an essential aspect of the stress-management programme i s that he keep a record of situations which cause anxiety or tension. Provide him with a booklet for this purpose and ask that he begin to use i t during the coming week. Data Deposit: Show the client a copy of the Data Deposit Agreement. Ask him to bring a cheque for $20 payable to a charity of his choice to the f i r s t group meeting, at which point he w i l l be expected to sign the form. Explain to him that this pro-cedure has been found necessary to avoid loss of information which we need for the research part of this project. Situational Stress Task: Give the client a copy of the Situational Stress Sheet. The two of you should select one of the situations which have been discussed during your interview. This situation •. should cause discomfort but not absolute panic. (Should f a l l aroung 7 on the tension-rating scale,) It should be relatively easy to arrange, i f i t w i l l not occur naturally during the coming week. Stress the importance of carrying out the task. The Questionnaires: After your interview the client should complete the following questionnaires: 1) Self-evaluation Questionnaire (both sides) 2) Social Avoidance and Distress Scale (SAD) 3) Fear of Negative Evaluation Scale (FNE) 4) Past week tension thermometer.. 62 Before the client leaves make sure that: 1. He has received copies of the Situational Stress Form and Self-Monitoring Instructions. 2. He has been given a self-monitoring booklet. 3. He has been given a time and place for the f i r s t group meeting (or an arrangement has been made to do this). 4. He has completed a l l the necessary questionnaires. 6 3 Interviewer Assessment: Form Client's name Age Marital Status ^ 1. When did you f i r s t notice that you had a problem? 2. What have you done about it? (eg, consulted a doctor, taken p i l l s ) 3. Are you currently seeing a psychiatrist? (Explain that we cannot take people who are currently receiving other treatments) 4 . Are you currently taking medication for your nerves? a) When did vou obtain the most recent prescription? b) What is the brand nar.e of the medication? (Explain that the client w i l l be expected to continue to take this medication at his present level durinp. the course of treatment) 5. What aspects of your l i f e do you manage well? (eg. work, marriage, children) 6. Do you often have periods of hours or days during which you experience l i t t l e anxiety or tension? 7. What kinds of situations pose a problem for you? (Try to get descriptions of. three situations), Situation 1: _____ a) when? _________________________ b) where? .  c) exactly what do you think is upsetting about the situation? Situation 7.~ a) when? b) where? c) exactly what do you think is upsetting about the situation? Situation 3- '  a) when? b) where? c) exactly what do you think is upsetting about the situation? 64 Have you considered receiving treatment for a drinking problem in the recent past? . Have you been feeling depressed lately? (er;. withdrawing, losinp interest in l i f e , beinc; very s e l f - c r i t i c a l , havinp, l i t t l e motivation to do anything) a) Row lonn do these periods last? Assessment of su i t a b i l i t y Please rate the client u3in?r the following dimensions. In each case use a 7 point scale, on which 1= very l i t t l e of the characteristic and 7= a great, deal of the characteristic. 1) Motivation for treatment 2) Specificity of stress 3) Present c l i n i c a l anxiety level 4) Current level of depression 5 ) Liklihood of alcoholism 6 ) Liklihood of psychosis Note• The ideal client w i l l come out high on the f i r s t two measures, moderate on anxiety level during the interview, and low on the last three measures.-65 Appendix 2 Instruments 66 PAST WEEK TENSION THERMOMETER Name Date Think back over the past week. Take each day separately and remember as much as you can of what you did, how the day went, and particularly the level of tension you experienced. Now, use the thermometer below to rate your average level of tension for the past week. -10 completely tense (not relaxed at a l l ) - 9 - 8 very tense (only slightly relaxed) - 7 - 6 tense - 5 - 4 relaxed - 3 - 2 very relaxed - 1 - 0 completely relaxed (not tense at a l l ) 67 SITUATIONAL STRESS SHEET Name During your interview you will have chosen a situation which you will undergo during the coming week. This exercise will help to make you more aware of how you experience anxiety. Please give a description of the situation as i t actually occurred: Using the monitoring scale of tension (0 to 10) rate how upsetting this experience was for you. In addition, please circle.the word or phrase in the l i s t below which best described yourvfeeling: comfortable panicky unsafe wonderful steady nervous didn't bother me scared stiff frightened timid indifferent unsteady fine worried 68 SIGNIFICANT OTHER QUESTIONNAIRE In order to evaluate the e f f e c t i v e n e s s of our programme we would l i k e to f i n d out i f changes are o c c u r r i n g i n the d a i l y l i v e s of group members. Since you know one of these people w e l l , we would l i k e you to give us your impressions. Please respond honestly and t h o u g h t f u l l y to the f o l l o w i n g questions. When you have completed t h i s b r i e f q u e s t i o n n a i r e , place i t i s i t s envelope and m a i l i t to us. Your answers w i l l not be seen by the person you are d e s c r i b i n g unless you choose to r e v e a l them y o u r s e l f . The inf o r m a t i o n obtained w i l l be used f o r research purposes only. For the items below, please c i r c l e the number preceding the response which most a c c u r a t e l y describes changes you have observed over the past s i x weeks. 1. General tension l e v e l : 1) much reduced 2) somewhat reduced 3) no change 4) somewhat higher now 5) much higher now Item to t o t a l r .69 A b i l i t y to deal w i t h personal problems: 1) much improved 2) somewhat improved 3) no change 4) somewhat reduced 5) much reduced . 7 9 A b i l i t y to f u n c t i o n under _. • -• .pressure: 1) much improved 2) somehwat improved 3) no change 4) somewhat reduced 5) much reduced .54 4. Tendency to become upset 1) much more e a s i l y upset now 2) somewhat more e a s l i t y upset 3) no change 4) somewhat l e s s e a s i l y upset 5) much l e s s e a s i l y upset now ,68 Duration of "upsets' 1) not n e a r l y so long now 2) not q u i t e so long 3) no change 4) somewhat longer now 5) much longer now , 7 0 69 PROGRAMME EVALUATION FORM Name ' • . . - . Date A. S e l f - r a t e d Change For the items below, please c i r c l e the number which precedes the response which most a c c u r a t e l y describes changes you have observed i n y o u r s e l f s i n c e you f i r s t came to the Tension Management C l i n i c . I t e m - t o - t o t a l 1. General tension l e v e l : 1) much reduced .76 2) somewhat reduced 3) no change 4) somewhat higher now 5) much higher now 2. A b i l i t y to de a l w i t h personal problems: 1) much improved .65 2) somewhat improved 3) no change 4) somewhat reduced 5) much reduced 3. A b i l i t y to f u n c t i o n under pressure: 1) much improved .58 2) somewhat improved 3) no change 4) somewhat reduced 5) much reduced 4. Tendency to become upset: 1) much more e a s i l y upset now .69 2) somewhat more e a s l i y upset 3) no change 4) somewhat l e s s e a s i l y upset 5) much more e a s i l y upset now 5. Duration of "upsets": 1) nor ne a r l y as long now .79 2) not q u i t e as long 3) no change 4) somewhat longer now 5) much longer now 6. What percentage of your problems remain to be coped with? 1) 0% 2) 25% .82 3) 50% 4) 75% 5) 100% 7 0 B. Therapist r a t i n g Please i n d i c a t e your f e e l i n g s about your group leader by responding to the items below using the f o l l o w i n g r a t i n g s c a l e : 1 = s t r o n g l y agree 2 = agree 3 = mixed f e e l i n g s 4 = disagree 5 = s t r o n g l y disagree NOTE: Group leaders w i l l not be reading t h i s form; the r e s u l t s w i l l be used f o r research purposes only. I t e m - t o - t o t a l r 1. S/he seems to be sure of what s/he i s doing. .58 2. I f i n d h i s / h e r explanations of my behaviour confusing. .35 3. An o l d e r t h e r a p i s t would have been b e t t e r f o r me. .80 4. Any suggestions s/he made were w e l l thought out and c l e a r l y presented. .59 5. S/he would be a b e t t e r t h e r a p i s t i f s/he had more experience..65 C. Group atmosphere Using the same r a t i n g s c a l e , i n d i c a t e your f e e l i n g s about the other members of your group. 1. I f e l t c l o s e to most of the members of my group. .61 2. There were many aspects of my l i f e which I d i d not f e e l I could d i s c u s s i n t h i s group. .45 3. I looked forward to group meetings. .51 4. I f e l t very uncomfortable i n my group. .76 5. I sometimes f e l t l i k e an o u t s i d e r . .54 6. I f e l t safe to express my deepest f e e l i n g s i n t h i s group. .61 7. I f e l t that other group members r e a l l y cared >about me as a person. .68 8. Sometimes i t seemed to me that everyone was only our to help h i m s e l f . .37 9. I f e l t that some of the people i n the group disapproved of me. .58 10. There was an atmosphere of warmth and support i n the group. .51 71 Appendix 3 Problem situations and typical therapy interactions 72 Stressful Situations Reported by Clients Incidence of problem' 1. Social Situations i.21) a. groups of any kind 7 b. parties 6 c. meeting new people 5 d. entertaining guests 5 e. public speaking 3 f. making requests of others 2 g. using telephone 1 h. eating in front of others. 1 2. Work Situations (41) a. dealing with unreasonable supervisors 5 b. interruptions in on-going activities 5 c. starting new projects 3 d. unreasonable requests from co-workers 2 e. meeting deadlines 6 f. supervising others 5 g. work pil i n g up. 3 h. dealing with conflicts among co-workers 5 i . making presentations 4 j . using the telephone 2 k. dealing with tenants 1 3. School Situations ( 4) a. writing exams 2 b. giving seminars 1 c. writing thesis 1 4. Situations Involving Significant Others (19) a. dealing with spouse's disapproval 4 b. disciplining children 4 c. handling unreasonable demands from spouse 3 d. dealing with domineering relatives 3 e. responding to criticism from others 3 f. handling unreasonable requests from parents 2 5. Other Situations (12) a. driving i n heavy t r a f f i c 3 b. v i s i t i n g doctors 2 c. being i n enclosed spaces 2 d. being alone 1 e. being i n high places 1 f. walking near heavy t r a f f i c . 1 g. shopping 1 h. meeting a stranger while walking alone 1 a This column indicates the number of clients who reported anxiety in each of the problem situations. 73 Stressful Situations for Individual Clients C l : dealing with supervisors, supervising others. C2: attending group meetings, teaching in classroom. C3: having definite time committments, criticism from friends. C4: upsets in work routime, co-ordinating co-workers. C5: talking to strangers, groups. C6: conflicts among co-workers, meeting new people. C7: speaking to large groups, enclosed spaces. C8: interrupations in on-going a c t i v i t i e s , confrontations with others C9: entertaining guests, being alone. CIO: disciplining children, having suggestions ignored at work. C l l : parties, f i r s t meetings, housework p i l i n g up. C12: small social gatherings, dealing with people on the telephone at work. C13: starting new projects, eating in front of others, meeting deadlines. C14: dealing with tenants, disapproval of spouse. C15: driving in heavy t r a f f i c , interference from parents. C16: going to doctors, meeting a stranger while alone on street, driving. C17: dealing with supervisors, conflict among co-workers, spouse's disapproval. C18: meeting deadlines, preparing for guests, responding to unreasonable requests from co-workers. C19: parties, shopping, starting new projects. C20: work deadlines, social groups. C21: work pil i n g up, upsets in normal routine. C22: dealing with unreasonable requests from spouse, group situations. C23: work deadlines, interference from parents, giving seminars. C24: deadlines at work, unreasonable demands from parents. C25: conflicts among co-workers, dealing with supervisor. C26: examinations, making requests of others. C27: public speaking, confronting co-workers, dealing with domineering relatives. C28: dealing with supervisor, supervising others, entertaining guests. C29: conflict among co-workers, making presentations at work, dealing with spouse's disapproval. C30: social gatherings, disciplining children. C31: public speaking, dealing with unreasonable requests from co-workers. C32: disciplining children, starting new projects. C33: dealing with domineering relatives, meeting new people. C34: upsets in routine, dealing with spouse's unreasonable demands, supervision of others. C35: entertaining guests, using the telephone, large groups of people,7 C36: making presentations, driving, working on thesis. C37: dealing with unreasonable demands of spouse, entertaining guests, making presentations. C38: parties, using the telephone at work, meeting new people, supervising others, C39: interruptions i n routine, dealing with unreasonable requests from co-workers. C40: disciplining children, work pil i n g up. C41: meeting deadlines, examinations, v i s i t i n g doctor. C42: bridges and other high places, walking near t r a f f i c 74 Typical Therapy Interactions Condition 1; Interaction 1: Client: I get very upset when somebody's sick. Therapist: Just anyone, or did something happen last week? C: No, a l l the time. I live with my aunt who has asthma, and she gets attacks sometimes and she doesn't need me really, they pass on their own, but when I hear her coughing I feel nervous. T: Can you give a specific situation? It w i l l work better i f you can give details. C: Two nights ago. Tuesday maybe. (Pause) I'd just gone to bed and I heard her coughing in her room and I f e l t so tense, knots in my stomach and tight in back, you know? T: What did you thing when you heard her coughing? C: I thought she'd suffocate or something. Then after I couldn't go to sleep, for hours. That's the way i t i s when I get tense. T: Was your aunt a l l right? C: She always i s . The doctor says there's nothing to worry about but what good does that do. I guess I'm too nervous.or something. T: As I see this situation you're saying tension-producing things to yourself. Correct me i f I'm wrong, but aren't you thinking things like, "Oh my God, she's coughing again, i t sounds awful, I wonder i f I should go to her, my. stomach i s getting knotted up, I ' l l never get to sleep now", and so on? What effect do you think that has? C: I don't know i f I think anything. What I feel is tense. T: Why don't you try paying attention to what you're saying to yourself 75 next time this happens? Another C: Seems to me that i t s enough that her aunt i s sick, I know that would make me tense. I remember when my mother was sick, It upset me so much to see her, I f e l t tense a l l the time. T: But are you always upset by people being sick? Other C: Not really. T: Then i t isn't just the situation, not just what's out there that's bothering you. It's how you see i t isn't i t ? 76 Interaction 2 : Client: I was walking back to my own office and my boyfriend has an office near there and I was going to stop in and pick up a book. And I walked in the office and this secretary i s sit t i n g there, you know, with a l l these engineers and people. It's dead quiet in there, they're a l l working. I walked in and said "Hi" to her., and told the secretary what I wanted, and my friend was on the phone in this office. I f e l t really uncomfortable, everything's so quiet and I'm just sort of l e f t standing there. Didn't know i f I should wave to him or just stand there and somehow make myself inconspicuous. The sort of feeling was that somehow I was not the same as those people. I feel that maybe they look down on me and I feel on the spot, people looking at me. My stomach started to hurt, aad fi n a l l y after ten minutes he was s t i l l on the phone and I l e f t without anything. Every time I go to that office i f I'm near him or his friends, I feel like that. I feel like a l i t t l e country bumpkin or something. Therapist: Can we go back to the beginning. F i r s t you walked into the office. When did you begin to feel uncomfortable? C: It was dead quiet and I f e l t like I didn't want to take another step. I f e l t far too loud and cheery. T: OK, so you were saying to yourself, "I'm too loud/ too cheery". C: I was just sort of disturbing everybody. T: OK, kind of explore, what else were you saying to yourself? C: I was feeling, somebody please be friendly, somebody say something, don't just leave me standing there. T: Mmhmm. So you were saying, "nobody i s noticing me? I heard you say 77 something earlier that somehow they're more sophistocated than you are. C: I feel I'm not on equal footing. T: Seems to me like the thought, "I'm not as sophistocated as they are may be upsetting you. Seems like you're also saying to yourself," they're a l l noticing me, I'm in the way, I wonder how I look". C: Well, I sort of thought, they're just sitt i n g there, and i t was so quiet and I wondered what they thought. T: What effect do you think those thoughts had on you? C: I'm not sure. T: Did i t matter what those people thought. C: I suppose not, they probably didn't care much one way or-the other. T: That's right. So what i f you had changed what you said to yourself? Instead of upsetting yourself like you did, you could have thought, "I have a right to be here, they aren't noticing me anyway, I know I look a l l right". C: It would be hard because I always feel odd when I go to that office. T: You don't think you could change. Let's try i t here. (They go on to rehearse coping self-statements which the client can use in this situation). 78 Condition 2: Interaction 1: Client: I brought my sister and her really young baby and the whole time I was on the freeway I was really tense because I was sort of thinking unconsciously maybe, what i f I had an accident with them in the car as well. And i t was extra-bad going over the bridge. Therapist: When did you start to notice the tension? C: Well I notice i t a l i t t l e as soon as I get onto the freeway. It"s not enough to really bother me. T: Where do you feel i t ? C: In my neck, my legs, my whole body really. T: Does i t get worse as time goes on? C: It gets worse. Sometimes i t gets better, but usually i t gets worse. T: Do you know what you're saying to yourself before you get tense? C: I guess when I f i r s t got on the freeway I was thinking, " Oh Heavens, what a terrible long t r i p I have ahead of me, a l l the way across Vancouver". And I think I started to tense up then thinking about a l l the time i t was going to take. T: Was there noise in the car? C: I don't think so. Well, we were talkingand the baby was crying some of the time but not very much. My sister talks a lot, you know sort of steady conversation, I think that made me a b i t tenser. T: How did i t work out? C: When I got to the bridge i t got really bad, a feeling of fear, stiffening up a l l over. I guess that's the f i r s t sign of stress I have. And then I start to think about i t . And now when I go over the bridge 79 I think about how I've talked about i t here (in the group). T: What were you saying to yourself when you were crossing the bridge and became aware that you weren't doing as well as you had hoped? C: I thouqht mavbe i t was just a feeling I had had of overconfidence because of thinking I'd gotten something out of this. I don't really feel bad about myself - i t ' s a b i t of a letdown. T: How? C: It makes me really mad. T: I'm not sure what you're angry at. C: I'm angry at myself because I let myself get tense. I feel I can't control i t . T: So when you're coming across the bridge you're just starting to get onto the freeway and I think your thoughts go something like, "I don't think I can make i t across the bridge, I hope at least I'm sucessful in getting across, I hope I'm not in an accident, I'm getting tight, i f I got in an accident now I could hurt myself, my sister and her baby, i t looks like I'm not going to make i t across the bridge, I'm really tense, I can't even do this, I'm out of control with i t . " C: Yes, that's really the way I think. T: Did anyone see anything irrational in that sequence? Another Client: A lot of i t was irrational. I noticed that you got to the point where you couldn't cross the bridge and made a jump to being out of control. A Third Client: I had the feeling that fear of something had taken control of her and overwhelmed her to the point where she couldn't reason. T: One thing you can do is keep track of exactly how you feel each time you cross the bridge on a five point scale. That way you can get an idea of how you're doing. Without that kind of thing you don't know. 8 0 Interaction 2: C: I was called in by an architect at the last minute to finish a job after someone else was fire d . T: How did you feel? C: I was distraught. I was very tense a l l over. T: Did you shake? C: I didn't have the shakes when I went down to meet the man but prior to i t I was very upset. T: Do you know what would have made i t easier for you? C: The best would be I'd say not to take i t too seriously. Perhaps I did take i t a l i t t l e too seriously. T: Is that situation likely to happen again because of the profession you're in? C: Oh probably, probably. Anyway, when I went to meet the owner he showed me some rough plans, layouts and- so on. T: I was wondering i f i t would have helped i f you'd had more information about the man who was fired. C: Well the other man was, I don't know why he was fired. T: Would that have made you feel more comfortable? C: Yeah, I guess so. I don't like treading on people's toes. Anyway, the owner started to make unreasonable demands on me, quoting prices too low. He asked me to do a "take-off" on these drawings in two days. I couldn't do that. T: Can you t e l l me what you were saying to yourself. How were you feeling? C: Well prior to the meeting I didn't <fieel uptight. It was the moral objection, about taking over for the other builder. T: Just before the meeting? C: Well I could feel tension building up, because the other guy got fired. 81 Anyway at the meeting I told him I just couldn't have things ready as soon as he wanted — that i t wasn't humanly possible. He seemed annoyed, but in the end I got more time to do i t i n . T: I wonder what you were t e l l i n g yourself before you met with him? C: Well put in those terms, I probably said, "I wonder i f this w i l l work out, because the other guy got fired, and I need this job". Maybe I also thought I'd not do i t very well. T: So maybe you were making i t hard for yourself? C: Yes, I suppose I was really. When I think about i t now, I didn't really need the job and a l l that hassle, did I? 82 Condition3: Interaction 1: Therapist: At the end of last week i t weemed that you had some specific situation or some incident that was going to be happening soon. Client: Well, today, I was very busy with dictating and the manageress came down before ten o'clock. Well, the dictaphones are on over night and they take orders and we have to clear them, and we have an eleven o'clock cut-off time when we're supposed to be completely finished. A l l the work i s written up and everything done. People who c a l l back for mistakes are supposed to c a l l before that. T: Yes. C: And this morning the manageress came barelling down before ten o'clock and said in a very nasty tone, "I want a l l these women at the board, we're very busy and they're supposed to take in-coming c a l l s ' . And you'll have to finish this up." She drops a pile of orders on my desk. T: What were you doing then? C: I was working on my machine. T: As you're describing i t why don't we set up the situation? Move your chair. Set up for role-playing. Want to pick someome to work with you? If she's going to play you, she has to know what you did. (First they go through what was actually done. The client has responded thatshe can't possibly do the work before the cutoff time. Manageress says she doesn't care. Client feels very upset because she knows she can't do i t alone.' The group discusses alternative solutions. It i s decided that the best approach to take i s for the client to suggest that she wants to do the best job she can and that she is worried that she won't be able to do i t under the present circumstances.) 83 T: Why don't you try i t here? A Second Client: (role playing) I'm going to have to take the women to the board and you w i l l have to finish these tapes. C: I'm sorry but we're actually really swamped. Is there any possible way that I can have somebody give me a hand? C2: No, you're going to have to finish them a l l . C: I'm afraid I won't be able to before deadline. C2: I'm sure you'll be able to. T: Maybe you shouldn't start out i n the beginning by saying that the situation i s impossible. Say that you're very willing but i t isn't possible. Indicate you're willing f i r s t . She can't argue i f you agree with her. (The client agrees to try this out.) 84 Interaction 2: C: I have something that happened. I don't feel good about i t , makes me tense to think of i t even now. (laughs) T: Could you t e l l us about it? C: I supervise people who work as docents, at the gallery. Sometimes I have to speak to them about poor performance and I had to talk -to _a woman last week. T: Could you be more specific? C: Well one of the docents has a poor attitude toward other members of her teaching team and they complained to me so I had to talk to her and i t make me feel nervous for the whole day. But i t s part of my job. T: What did you do? C: I called her into my office and told her that she should change her attitude. I was frank with her. I thought I should be. T: But you didn't feel good about i t ? Could you say more about bothered you? C: Not really, i t seems that other people always make me feel I don't have the right to do what I do. T: What did you say to her? C: I said maybe she should try to change her attitude. Then she said she didn't know what I meant at a l l and anyway she wasn't being paid for what she did. Second Client: Wasn't she paid? C: No, docents are volunteers. T: Can anyone suggest how M--—" could have behaved differently? Another Client: Seems like you were too timid. Sometimes that seems to 85 be an invitation. T: What else could M have done? C: I.suppose Xrset myself up for i t . T: Perhaps i f you went over what you were going to say before you did i t i t would help. Now what else might you have said? C: I could have been more definite. T: How? C: Well, I could have said that i t was part of her job to make things run smoothly so i t was necessary for me to speak to her. I would have explained myself better, but why should I, she knows I'm in charge. I don't see why I can't just say what I think and not feel so upset. Other Client: It's like out next door neighbour.. They leave their yard in such a mess. So I t e l l them and they get mad. T: Since what you tried before hasn't made you comfortable, i t seems to me that maybe you should list e n to suggestions from others in the group. Another Client: Like she said before, she should be more definite, let the woman know where she stands. T: How could she do that? C2: She could explain herself. T: Yes, she could rehearse a l i t t l e speech in which she t e l l s the woman in a straightforward way how she feels and what is required. I think she could say something like "I have heard that there is some kind of conflict between you and the other docents. Would you like to t e l l me what your point of view is? Let's try role-playing i t in the group. (They proceed to role-play the scene and afterward M agrees to try out the new approach the next time a similar situation arises.) 

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