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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 o f 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  in THE FACULTY OF GRADUATE STUDIES (Department o f P s y c h o l o g y )  We a c c e p t t h i s d i s s e r t a t i o n as conforming to t h e r e q u i r e d  standard  THE UNIVERSITY OF BRITISH COLUMBIA September, 1977 C o p y r i g h t R o l a n d G l e n Bowman  In presenting t h i s thesis in p a r t i a l  fulfilment of the requirements for  an advanced degree at the University of B r i t i s h 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 B r i t i s h Columbia 2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5  Da  Abstract  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 o f 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 t e c h n i q u e f o r m u l t i - p r o b l e m c l i e n t s . I n d i v i d u a l s who responded  t o a newspaper a d v e r t i s e m e n t  offering  a s s i s t a n c e i n t e n s i o n management and who r e p o r t e d t h a t they e x p e r i e n c e d a n x i e t y i n a t 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 a s s i g n e d to t h e f o l l o w i n g t r e a t m e n t (1) (3)  conditions:  Self-instructional training  Skills training  ( n = l l ) and (4)  ( n = l l ) , (2)  Awareness  (n=ll),  Minimal treatment c o n t r o l  (n=9).  Therapy was conducted over a six-week p e r i o d w i t h t h e r a p i s t s i n t h e f i r s t t h r e e e x p e r i m e n t a l c o n d i t i o n s meeting sessions.  Clients  s m a l l groups f o r 1%-hour  i n a l l c o n d i t i o n s were encouraged  t o adopt a  s i t u a t i o n a l v i e w o f a n x i e t y and t o r e c o r d t h e d e t a i l s o f t h e s t r e s s f u l situations  they encountered  throughout t h e c o u r s e o f t r e a t m e n t .  I n the  f i r s t c o n d i t i o n , Meichenbaum's (1974) t r e a t m e n t manual was used as a guide.  C l i e n t s were taught t o a n a l y z e t h e i r problems a c c o r d i n g t o a  c o g n i t i v e model of a n x i e t y and t o adopt t h e use o f c o p i n g s e l f - s t a t e m e n t s in stressful situations.  Clients  i n c o n d i t i o n two r e c e i v e d .a s i m i l a r  t r e a t m e n t r a t i o n a l e , b u t d i d n o t s p e c i f i c a l l y p r a c t i c e t h e use o f c o p i n g self-statements.  The t h i r d c o n d i t i o n p r o v i d e d a c o m b i n a t i o n of r o l e -  p l a y i n g and c o a c h i n g t o a s s i s t c l i e n t s t o change t h e i r b e h a v i o r i n s t r e s s f u l situations.  F i n a l l y t h e m i n i m a l t r e a t m e n t group a t t e n d e d a two-hour s e s s i o n  i n which t h e 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 p r o c e d u r e was e x p l a i n e d t o them and was a p p l i e d t o some o f t h e i r  problems.  ii Analysis of s e l f - and S i g n i f i c a n t Other reports found no s i g n i f i c a n t differences among treatment conditions, although  there  was s i g n i f i c a n t change on almost a l l measures f o r the c l i e n t sample as a whole.  These inconclusive findings were discussed i n r e l a t i o n  to differences between the present c l i e n t sample and c l i e n t s who have served as subjects i n previous research.  It was suggested that a  promising area f o r future research might be the i n v e s t i g a t i o n of the r o l e of c e r t a i n c l i e n t c h a r a c t e r i s t i c s i n determining  treatment outcome,  e s p e c i a l l y l e v e l s of t r a i t anxiety and the duration and s p e c i f i c i t y of stressful situations.  iii  Table of Contents Page  Chapter 1  Fear a n x i e t y and s t r e s s  1  Chapter 2  Cognitive factors i n anxiety  4  Chapter 3  Cognitive behaviour m o d i f i c a t i o n i n the t r e a t m e n t o f a n x i e t y  9  Component a n a l y s i s o f s e l f - i n s t r u c t i o n a l training  15  C o g n i t i v e t h e r a p y and s k i l l s t r a i n i n g  17  P r a c t i c a l considerations i n stressmanagement programmes  20  Chapter 5  Statement o f t h e problem  24  Chapter 6  Method  Chapter 4  Subject recruitment  and s e l e c t i o n  D e s c r i p t i o n o f f i n a l sample Trainingiand  26 28  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  P r e t r e a t m e n t measures  34  P o s t t r e a t m e n t measures  36  F o l l o w - u p p r o c e d u r e and measures  37  Chapter 7  Results  38  Chapter 8  Discussion  44  Footnotes  51  References  52  Appendix 1  Interview guides  57  Appendix 2 Appendix 3  Instruments Problem s i t u a t i o n s and t y p i c a l t h e r a p y interactions  65 71  iv  L i s t of Tables  Page Table 1  Means and s t a n d a r d d e v i a t i o n s f o r outcome measures  39  Table 2  Summary of a n a l y s e s of v a r i a n c e  41  V  Acknowledgement I would l i k e to thank Dr Allan Best, Dr Lynn Alden and Dr Robert Knox f o r t h e i r assistance i n designing and carrying out this research. I am also grateful to Dr Park Davidson, Dr Peter McLean and Dr Thomas Storm  f o r serving on the f i n a l d i s s e r t a t i o n committee. In addition I want to acknowledge the assistance of Kathleen Sun,  Sandra M i l l s , Kathy Douglas and Thomas Bowers who conducted assessments interviews,and Carol Macpherson, Gerald Hover, Adam Horvath, Ian Hunt, Frank C o l l i s t r o and Ann Chusid  who served as therapists on this project.  CHAPTER ONE F e a r , A n x i e t y and S t r e s s The  terms " f e a r , " " a n x i e t y " and " s t r e s s " o c c u r w i t h h i g h f r e q u e n c y  i n t h e p s y c h o l o g i c a l l i t e r a t u r e , b u t u n f o r t u n a t e l y t h e r e a r e s t i l l no u n i v e r s a l l y a c c e p t e d c o n v e n t i o n s w h i c h govern t h e i r u s e .  This  situation  does n o t e x i s t because d e f i n i t i o n a l problems have been i g n o r e d ;  on t h e  c o n t r a r y , many t h e o r i s t s have attempted t o make m e a n i n g f u l d i s t i n c t i o n s among t h e s e r e l a t e d c o n c e p t s .  Some o f t h e i r f o r m u l a t i o n s w i l l be b r i e f l y  d i s c u s s e d below i n o r d e r t o 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 . O f t e n " f e a r " and " a n x i e t y " a r e used i n t e r c h a n g e a b l y .  F o r example,  b e h a v i o u r t h e r a p i s t s have w r i t t e n about " f e a r o f d a t i n g " and " h e t e r o s e x u a l anxiety."  I n t h e same way, " e x a m i n a t i o n a n x i e t y " can be d e s c r i b e d as  "fear of tests."  A l t h o u g h t h e s e examples i n d i c a t e t h a t " f e a r " and  " a n x i e t y " can s e r v e as l a b e l s f o r t h e same emotion, they a l s o  illustrate  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 t h e two: t h e o b j e c t 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 t h e s t i m u l u s s i t u a t i o n w h i c h provokes a n x i e t y i s l e s s c i r c u m s c r i b e d symbolic  and o f t e n a l s o more a b s t r a c t and  (Lazarus and A v e r i l l , 1972).  I n a d d i t i o n t o a d i s t i n c t i o n made on t h e b a s i s o f t h e s t i m u l u s s i t u a t i o n , s e v e r a l a u t h o r s have suggested t h a t f e a r r e s p o n s e s c a n be d i f f e r e n t i a t e d from a n x i e t y r e s p o n s e s .  E p s t e i n (1972) argues t h a t such  r e s p o n s e d i f f e r e n c e s a r e c r u c i a l f o r an adequate u n d e r s t a n d i n g emotions.  o f t h e two  He d e s c r i b e s f e a r as an a v o i d a n c e m o t i v e , and a n x i e t y as a  d i f f u s e s t a t e o f a r o u s a l w h i c h cannot be channeled i n t o a c t i o n .  Thus,  w h i l e a p e r s o n who i s a f r a i d w i l l f l e e o r o t h e r w i s e  with  avoid contact  c e r t a i n s t i m u l i , an a n x i o u s i n d i v i d u a l i s u n a b l e t o t a k e such a c t i o n f o r any o f a v a r i e t y o f r e a s o n s w h i c h might i n c l u d e i n d e c i s i o n , o r a c o n f l i c t  2 between opposing c o u r s e s o f a c t i o n .  L a z a r u s and A v e r i l l  (1972) make a  r a 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 t h e case o f f e a r , t h e r e i s a tendency t o 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 t o evoke i n t r a p s y c h i c ( i . e . , c o g n i t i v e ) r e s p o n s e s . Are these conceptual research?  d i s t i n c t i o n s u s e f u l i n behaviour  L a z a r u s and A v e r i l l b e l i e v e t h a t they a r e .  therapy  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 o f c o g n i t i v e systems."  Reports that  s y s t e m a t i c 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 t h e treatment o f s p e c i f i c f e a r s , b u t of o n l y l i m i t e d u s e f u l n e s s when a p p l i e d t o more, p e r v a s i v e a n x i e t y (see, e.g., Marks, B o u l o u g o u r i s  and M a r s e t , 1971) s u p p o r t t h i s  p o i n t of view. Thus, d e s p i t e t h e f a c t t h a t t h e r e i s a c o n s i d e r a b l e degree of o v e r l a p between t h e two c o n c e p t s , fully differentiated.  i t appears t h a t f e a r and a n x i e t y can be meaning-  Such i s p r o b a b l y  n o t t h e case f o r s t r e s s and  a n x i e t y s i n c e i t i s p o s s i b l e t o use t h e s e two terms i n t e r c h a n g e a b l y 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 .  across  A p p l e y and Trumble  (1967) have n o t e d t h e g r e a t p o p u l a r i t y of t h e concept o f 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 t h e l i t e r a t u r e by S e l y e i n 1936.  S e l y e was i n i t i a l l y  concerned w i t h t h e common p h y s i o l o g i c a l e f f e c t s o f extreme e n v i r o n m e n t a l or i n t e r n a l demands on an organism. a response r a t h e r than a s t i m u l u s . i s "probably extenuating  best conceived circumstances,  c o n c l u s i o n i s important  He used t h e term " s t r e s s " t o d e s c r i b e As A p p l e y and Trumble p o i n t o u t , s t r e s s  as a s t a t e o f t h e t o t a l organism under r a t h e r than an event i n t h e environment."  Their  because s t r e s s h a s , i n f a c t , o f t e n been d e f i n e d i n  terms o f e n v i r o n m e n t a l s t i m u l i .  T h i s useage can o n l y l e a d t o c o n f u s i o n .  3 On t h e b a s i s of t h e r e s p o n s e d e f i n i t i o n o f s t r e s s , Martens  (1971)  has suggested t h a t s t r e s s i s f u n c t i o n a l l y e q u i v a l e n t t o S p i e l b e r g e r ' s notion of s t a t e anxiety.  Spielberger  (1972a) d e s c r i b e s 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 t h e p e r s o n w h i c h o c c u r s when a s i t u a t i o n i s i n t e r p r e t e d as t h r e a t e n i n g .  He p r e f e r s t o p l a c e " s t r e s s " i n the environment  as a cause of a n x i e t y , but a t o t h e r t i m e s he d e s c r i b e s e n v i r o n m e n t a l e v e n t s 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 t h a t the  e f f e c t of a s t r e s s o r s h o u l d be s t r e s s r a t h e r t h a n s t a t e a n x i e t y . l e a s t i n t h e 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 a n x i e t y appear t o be e q u i v a l e n t For t h i s r e a s o n , t h e y w i l l be used i n t e r c h a n g e a b l y  At  constructs.  i n this dissertation,  and e v e n t s w h i c h provoke a n x i e t y w i l l sometimes be d e s c r i b e d as " s t r e s s f u l . "  4  CHAPTER  TWO  Cognitive Factors i n Anxiety  There appears to be a growing consensus among personality and  clinical  psychologists that cognitive factors play a c r i t i c a l r o l e i n 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 Opton, 1970; view  Lazarus and A v e r i l l , 1972).  and  Lazarus and his associates  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 l e v e l s of appraisal.  At the f i r s t l e v e l , primary appraisal, the person  makes a judgement that a s i t u a t i o n i s l i k e l y to pose a threat.  Then, he  forms an opinion about the a v a i l a b i l i t y of coping mechanisms which might be used to deal with possible danger (secondary appraisal). he reappraises may  the s i t u a t i o n on the basis of any new  Finally,  information which he  have acquired, and i n l i g h t of the l i k e l y effectiveness of his coping  strategies.  Appraisal at a l l l e v e l s i s affected by (1) the immediate  stimulus s i t u a t i o n , (2) the environmental context within which that s i t u a t i o n i s embedded, and  (3) enduring personality d i s p o s i t i o n s .  The outcome of appraisal can be either d i r e c t action or further cognitive a c t i v i t y .  In the former case, an anxious person may  deal with his f e e l i n g by attacking or avoiding. may  attempt to  In the l a t t e r , anxiety  be handled by adopting a more r e a l i s t i c view of the s i t u a t i o n or  through the use of various defenses.  5 L a z a r u s and h i s coworkers have demonstrated t h e i m p o r t a n c e o f a p p r a i s a l s and d e f e n s e mechanisms i n a s e r i e s o f e x p e r i m e n t s employing m o t i o n p i c t u r e s as s t r e s s o r s (see L a z a r u s e t a l . , 1970, f o r a r e v i e w of t h i s work).  For example, L a z a r u s ,  Speisman, M o r d k o f f and D a v i s o n  (1966)  showed s u b j e c t s a movie w h i c h d e p i c t e d 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 m a n i p u l a t e d by v a r y i n g t h e s o u n d t r a c k i n d i f f e r e n t experimental promoted  conditions.  Results i n d i c a t e d that soundtracks which  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  produced d i f f e r e n t l e v e l s o f a n x i e t y .  or trauma  In general, 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 t h e d e f e n s i v e  soundtrack conditions.  L a z a r u s and A v e r i l l r e v i e w more r e c e n t e x p e r i m e n t s 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 t h e r o l e s o f a n t i c i p a t i o n and i n anxiety arousal.  uncertainty  I n one such s t u d y , Nomikos, Opton, A v e r i l l and  L a z a r u s (1968) c u t and s p l i c e d a woodshop s a f e t y f i l m t o c r e a t e 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  a c c i d e n t s w h i c h caused p h y s i c a l i n j u r y .  I n one v e r s i o n of t h e f i l m , s u b j e c t s were g i v e n 20 and 26 seconds i n w h i c h t o 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 o n l y 4 and 7  seconds were used i n t h e second v e r s i o n . l o n g e r i n t e r v a l s produced g r e a t e r a n x i e t y s k i n conductance changes).  scene  (as measured by h e a r t r a t e and  Most of t h e autonomic change w h i c h  observed i n b o t h cases o c c u r r e d during the accident  Nomikos e t a l . found t h a t  was  during a n t i c i p a t i o n periods r a t h e r than  itself.  To a s s e s s 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 L a z a r u s  (1972)  conducted an experiment i n w h i c h the t h r e a t of shock was used t o provoke anxiety.  I n two " u n c e r t a i n t y c o n d i t i o n s , " s u b j e c t s were i n f o r m e d e i t h e r t h a t  (1) t h e r e was a 50% chance t h a t they would r e c e i v e shock, but t h a t t h e y would r e c e i v e i t a t a p a r t i c u l a r t i m e i f i t was g i v e n  (event u n c e r t a i n t y ) ,  .6  of the  (2) t h e r e was shock was  a c e r t a i n t y t h a t they would be shocked, but the time of  not s p e c i f i e d  (time u n c e r t a i n t y ) .  p h y s i o l o g i c a l and s e l f - r e p o r t  In the f i r s t  condition,  i n d i c e s f o l l o w e d a U-shaped curve w i t h  greatest anxiety occurring i n i t i a l l y  and immediately p r e c e d i n g the shock.  S u b j e c t s i n the time u n c e r t a i n t y c o n d i t i o n showed an i n i t i a l s m a l l i n c r e a s e i n a n x i e t y f o l l o w e d by a g e n e r a l d e c l i n e .  Data on c o p i n g  s t r a t e g i e s used by s u b j e c t s to d e a l w i t h shock t h r e a t suggested t h a t d e c l i n e was  a s s o c i a t e d w i t h an avoidance of thoughts about shock.  e n t l y such a v o i d a n c e was was  this Appar-  p o s s i b l e o n l y when t h e time of the noxious event  unknown. E p s t e i n and Roupenian  u n c e r t a i n t y about  (1970) have a l s o m a n i p u l a t e d an a s p e c t of  the o c c u r r e n c e of shock.  In t h e i r study, s u b j e c t s were  asked to draw a card from a deck and then informed t h a t t h e c c a r d s e l e c t e d would determine whether they r e c e i v e d a shock.  They were f u r t h e r  informed t h a t t h i s shock would occur ( i f they had s e l e c t e d the "shock at  the count of t e n i n a count-up.  95% shock expectancy groups. the  first  S u b j e c t s were a s s i g n e d to 5%,  card")  50% or  Heart r a t e showed a g r e a t e r i n c r e a s e f o r  two c o n d i t i o n s , than f o r the 95% expectancy group s u g g e s t i n g  t h a t more u n c e r t a i n t y produces g r e a t e r a r o u s a l . From another p e r s p e c t i v e , s o c i a l psychology r e s e a r c h has shown t h a t the  s t r e n g t h and d i r e c t i o n o f e m o t i o n a l responses depend not o n l y on a  person's a p p r a i s a l of a s i t u a t i o n , but a l s o on h i s p e r c e p t i o n s of h i s p h y s i o l o g i c a l responding. Singer to  In t h e i r well-known experiment,  (1962) found t h a t s u b j e c t s who  a t t r i b u t e d an a l t e r e d s t a t e of a r o u s a l  the e f f e c t of a drug were l e s s l i k e l y  manner than s u b j e c t s who  S c h a c t e r and  to behave i n an emotional  b e l i e v e d t h a t t h e i r heightened a r o u s a l 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 o f such f i n d i n g s , S c h a c t e r  (1972) has c o n c l u d e d t h a t " g i v e n 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 for  w h i c h 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  label  his  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. 1 6 ) . In  the S c h a c t e r and S i n g e r s t u d y s u b j e c t s were m i s l e d about the  causes o f t h e i r emotion;  more r e c e n t r e s e a r c h has d e c e i v e d s u b j e c t s  about t h e e x t e n t of t h e i r emotion. V a l i n s and Ray  B e g i n n i n g w i t h an experiment by  (1967), t h e r e have been s e v e r a l a t t e m p t s t o reduce f e a r  t h r o u g h t h e 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 s t u d y , t h e e x p e r i m e n t e r s s u c c e s s f u l l y i n c r e a s e d approach b e h a v i o u r i n snake p h o b i c s . t h i s f i n d i n g have f a i l e d .  However, s e v e r a l a t t e m p t s t o r e p l i c a t e In reviewing t h i s research,  Kopel  and  A r k o w i t z (1975) c o n c l u d e d that- f a l s e feedback m a n i p u l a t i o n s w i l l s u c c e s s f u l o n l y when l e v e l s o f a r o u s a l a r e f a i r l y low.  be  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 t h e m i s a t t r i b u t i o n r e s e a r c h i n d i c a t e s t h a t b e l i e f s about t h e s t r e n g t h o f one's own emotion can a f f e c t b e h a v i o u r i n c e r t a i n cases. I n a d d i t i o n t o s t u d i e s i n m i s a t t r i b u t i o n , e x p e r i m e n t s conducted w i t h i n t h e framework of Bern's (1972) s e l f - p e r c e p t i o n t h e o r y s u p p o r t t h e v i e w t h a t b e l i e f s a f f e c t emotion.  F o r example,  K q p e l and A r k o w i t z (1974)  have r e p o r t e d t h a t s u b j e c t s who r o l e - p l a y " u p s e t " b e h a v i o u r show decreased p a i n t h r e s h o l d s and lower t o l e r a n c e f o r shock.  I t i s as  though p e o p l e i n t h i s s i t u a t i o n o b s e r v e t h e i r own b e h a v i o u r and r e a s o n t h a t t h e y must be upset because t h e y a r e d i s p l a y i n g s i g n s w h i c h a r e 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 t h e o r e t i c a l position that cognitions play a major r o l e i n anxiety arousal and maintenance.  The research of Lazarus and his associates indicates  that the experience of anxiety i s i n a large part determined by an individual's b e l i e f that a s i t u a t i o n 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 b e l i e f s about present l e v e l of coping are also  important.  The research cited above points toward several kinds of therapeutic intervention i n anxiety:  (1) decreasing uncertainty and ambiguity  i n stimulus situations, (2) a s s i s t i n g c l i e n t s to change their appraisals of threatening situations, and (3) providing c l i e n t s with feedback which indicates that they are coping successfully.  The f i r s t of these  approaches i s employed i n therapeutic programmes which use cognitive and behavioural rehearsal.  Lazarus' research i s relevant to the second, since  i t i l l u s t r a t e s the anxiety-reducing effect of changing the way one views a threatening s i t u a t i o n .  Under c e r t a i n conditions, i t should be possible  to confront s t i m u l i which once provoked anxiety i n a calmer state because of altered appraisals.  F i n a l l y , f a l s e feedback studies suggest that  the b e l i e f that one i s coping well can reduce fear (at least i n low-fear situations).  I t may be that a treatment which helps c l i e n t s 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 C o g n i t i v e B e h a v i o u r M o d i f i c a t i o n i n t h e Treatment o f A n x i e t y  C o g n i t i v e techniques of b e h a v i o u r t h e r a p y .  are r a p i d l y gaining popularity i n the p r a c t i c e  Mahoney (1977) s u g g e s t s t h a t 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 p e r s o n a l approaches and a s t r i c t l y b e h a v i o u r a l p e r s p e c t i v e .  Cognitive  b e h a v i o u r t h e r a p i s t s acknowledge t h e c a u s a t i v e r o l e s o f b o t h p r i v a t e events —  e x p e c t a t i o n s , a t t i t u d e s , memories, e t c . —  contingencies important  i n human e x p e r i e n c e  W h i l e t h e l a t t e r have t y p i c a l l y  t h e m o d i f i c a t i o n o f c o g n i t i o n s t o be a complex and t i m e -  consuming p r o c e s s ,  c o g n i t i v e b e h a v i o u r 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 modifiable e n t i t i e s . one  However, i t i s  t o n o t e t h a t 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. considered  and b e h a v i o u r .  and e n v i r o n m e n t a l  They a s s e r t t h a t a p e r s o n can r e p l a c e  thought w i t h another i n much t h e same way as he can r e p l a c e one  b e h a v i o u r w i t h a n o t h e r (see, e.g., Meichenbaum, 1972, 1974). To some e x t e n t c o g n i t i v e b e h a v i o u r 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 t h e 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  r e p o r t e d i n t h e 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 b e h a v i o u r a l s t r a t e g i e s . For example, i n c o v e r t m o d e l l i n g  t h e f e a r f u l c l i e n t i s asked t o imagine  a n o t h e r p e r s o n engaging i n c o p i n g b e h a v i o u r i n v o l v i n g t h e p h o b i c s t i m u l u s . T h i s p r o c e d u r e i s d i r e c t l y borrowed from m o d e l l i n g used l i v e o r f i l m e d models (Bandura, 1969).  s t u d i e s w h i c h have  I n a s i m i l a r way,  c o g n i t i v e behavioural rehearsal p a r a l l e l s overt behavioural  rehearsal;  i n s t e a d o f a c t u a l l y r e h e a r s i n g a b e h a v i o u r i n t h e presence o f t h e t h e r a p i s t , c l i e n t s rehearse  t h e event m e n t a l l y .  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  i n the development of c o g n i t i v e b e h a v i o u r  important  m o d i f i c a t i o n , other i n f l u e n c e s  a r e a l s o apparent.  S e v e r a l i n v e s t i g a t o r s have adopted and  the R a t i o n a l - e m o t i v e  t h e r a p y of E l l i s  (1961).  elaborated  I t i s E l l i s ' view that  e m o t i o n a l d i s t u r b a n c e i s caused by i r r a t i o n a l b e l i e f s w h i c h p e o p l e h o l d about the n a t u r e of the w o r l d and an i m p o r t a n t expectations.  t h e i r place i n i t .  These b e l i e f s  are  cause of g u i l t and a n x i e t y because they l e a d t o u n r e a l i s t i c For example, an i n d i v i d u a l who  b e l i e v e s t h a t he must be  l o v e d 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 t o g a i n sweeping p o s i t i v e r e g a r d w h i c h he e x p e c t s and may i s not a w o r t h w h i l e  person.  Ellis'  the  a c c o r d i n g l y f e e l t h a t he ...  therapy c h a l l e n g e s such i r r a t i o n a l  t h i n k i n g and a t t e m p t s t o p r o v i d e the c l i e n t w i t h a more r e a l i s t i c v i e w of  life. R e c e n t l y t h e r e has been an attempt t o c o n c e p t u a l i z e  Therapy w i t h i n a c o g n i t i v e b e h a v i o u r  Rational-emotive  m o d i f i c a t i o n framework.  Decenteceo and Weinberg (1974) have d e s c r i b e d a p r o c e d u r e they " s y s t e m a t i c r a t i o n a l r e s t r u c t u r i n g " w h i c h has f i v e components: t o an a n x i e t y - p r o d u c i n g  Goldfried, label (1) exposure  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 f a n t a s y , (2)  self-  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  t h o u g h t s w h i c h t h e c l i e n t has i n t h e s i t u a t i o n ,  u a t i o n of these t h o u g h t s , reevaluation.  Although  and  (5) n o t i n g a n x i e t y l e v e l changes a f t e r  i n t h i s paper the a u t h o r s  of s p e c i f i c a n x i e t y - p r o d u c i n g  (4) r a t i o n a l e v a l -  thoughts,  s t r e s s the m o d i f i c a t i o n  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 D a v i s o n (1976) d e s c r i b e s t h e 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 S e v e r a l s t u d i e s have supported  Ellis'  contention that  thoughts.  irrational  11 b e l i e f s a r e an i m p o r t a n t c o l l e g e students  cause of a n x i e t y .  Rimm and L i t v a k (1969) had  read s e l e c t e d E l l i s " t r i a d s "  be good enough, I may  ( e . g . , my  f a i l o u t , t h a t would be a w f u l ) .  grades may  not  T h i s group  showed s i g n i f i c a n t l y g r e a t e r 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 e m o t i o n a l  a r o u s a l ) than a c o n t r o l group who  t r i a d s t o themselves.  G o l d f r i e d and S o b o c i n s k i  read n e u t r a l  (1975) have r e p o r t e d  c o r r e l a t i o n between the tendency t o h o l d c e r t a i n i r r a t i o n a l b e l i e f s q u e s t i o n n a i r e s c o r e s f o r s o c i a l , speech and i n v e s t i g a t o r s a l s o found t h a t e m o t i o n a l was  greater f o r subjects  these s i t u a t i o n s . have r e p o r t e d  who  test anxiety.  a and  These  u p s e t i n imagined s o c i a l s i t u a t i o n s  subscribed  t o i r r a t i o n a l b e l i e f s about  F i n a l l y , Newmark, F r e r k i n g , Cook and Newmark (1973)  t h a t 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 s t a t e m e n t s than e i t h e r p a t i e n t s who c h a r a c t e r d i s o r d e r or normal c o l l e g e  had been d i a g n o s e d  students.  A d d i t i o n a l s u p p o r t i s g i v e n t o the R a t i o n a l - e m o t i v e  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 t r e a t m e n t s t u d i e s w i t h speech a n x i o u s c l i e n t s ( T r e x l e r and K a r s t , 1972; Straatmeyer and W a t k i n s , 1974;  K a r s t and T r e x l e r ,  1970;  Thorpe, Amatu, B l a k e y and B u r n s , 1976).  Wein, N e l s o n and Odom (1975) have a l s o r e p o r t e d a p r o c e d u r e 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 " t o be e f f e c t i v e i n r e d u c i n g t h e i r s t u d y , s y s t e m a t i c d e s e n s i t i z a t i o n and  snake f e a r .  the c o g n i t i v e p r o c e d u r e  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 b e h a v i o u r , l a t t e r had  the e f f e c t of r e d u c i n g e x p e r i e n c e d  t h i s f i n d i n g i t i s important  In  fear.  but o n l y  the  In i n t e r p r e t i n g  t o bear i n mind t h a t the t r e a t m e n t  by Wein e t a l . d i d not f o c u s 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 ;  described  instead  12  the e x p e r i m e n t e r s attempted t o b r i n g about a r e a t t r i b u t i o n o f f e a r from e x t e r n a l events t o i n t e r n a l c o g n i t i o n s .  W h i l e t h i s approach i s  r e l a t e d t o E l l i s ' work, t h e i r e x p e r i m e n t a l r e s u l t s s u p p o r t t h e e f f i c a c y of  R a t i o n a l - e m o t i v e Therapy o n l y i n a g e n e r a l way. In  contrast to E l l i s '  emphasis on t h e r o l e o f b e l i e f  systems  i n a n x i e t y , Meichenbaum (1972, 1974a) has developed a t r e a t m e n t  procedure  to m o d i f y s p e c i f i c t h o u g h t s .  training,  H i s approach, s e l f - i n s t r u c t i o n a l  c o n c e p t u a l i z e s thoughts as s e l f - s t a t e m e n t s , i . e . , as s t a t e m e n t s made t o oneself.  Meichenbaum s u g g e s t s t h a t a n x i e t y - p r o d u c i n g s e l f - s t a t e m e n t s  e m i t t e d by a p e r s o n 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 t o t h e d i s c o m f o r t ' w h i c h he e x p e r i e n c e s .  The g o a l o f t h e r a p y i s  to make t h e c l i e n t aware o f t h e n a t u r e of h i s n e g a t i v e t h i n k i n g , and t o have him r e p l a c e a n x i e t y - e n g e n d e r i n g thoughts w i t h c o p i n g s e l f - s t a t e m e n t s . In  t h e f i r s t study t o a p p l y 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 t o a n x i e t y  t r e a t m e n t , Meichenbaum, G i l m o r e and F e d o r o v i c i u s (1971) worked w i t h speech a n x i o u s s t u d e n t s who responded  t o a campus newspaper a d v e r t i s e m e n t .  S u b j e c t s were a s s i g n e d t o one o f t h r e e t r e a t m e n t c o n d i t i o n s :  insight-oriented  p s y c h o - t h e r a p y , s y s t e m a t i c d e s e n s i t i z a t i o n , o r a c o m b i n a t i o n o f t h e two; or  they became p a r t of one o f two c o n t r o l c o n d i t i o n s :  or w a i t i n g l i s t . psychotherapy  placebo-discussion  They met i n s m a l l groups f o r e i g h t s e s s i o n s .  The  c o n d i t i o n "emphasized t h e r a t i o n a l e t h a t speech a n x i e t y  i s t h e r e s u l t o f 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 a r e e m i t t e d when t h i n k i n g about t h e speech s i t u a t i o n .  which  S u b j e c t s were i n f o r m e d  t h a t t h e g o a l s o f t h e r a p y were f o r each p e r s o n t o become aware ( g a i n i n s i g h t i n t o ) t h e 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 w h i c h he e m i t t e d i n  13  the anxiety-producing  interpersonal s i t u a t i o n s , and, i n addition, to  produce both incompatible  instructions and incompatible  behaviour."  The investigators decision to l a b e l this condition "insight-oriented" i s unfortunate since i t c l e a r l y includes a cognitive change component as well as promoting i n s i g h t . .Results of this study indicated that both treatments were superior to the control conditions, but the effects of cognitive modification (or insight) were not s i g n i f i c a n t l y d i f f e r e n t from those produced by systematic desensitization on either s e l f - r e p o r t or behavioural measures. A post hoc analysis revealed that, while systematic desensitization was more e f f e c t i v e for subjects who suffered only from speech anxiety, cognitive therapy was superior f o r subjects who experienced anxiety i n a wider range of s o c i a l s i t u a t i o n s . In a^siibsequent  experiment, Meichenbaum (1971) combined 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 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 s e l f - r e p o r t measures indicated greater fear reduction i n the coping model condition, and the superiority of this treatment was e s p e c i a l l y apparent when the model provided an example of coping s e l f - i n s t r u c t i o n s as well as coping behaviour. Meichenbaum (1972) next investigated the r e l a t i v e e f f i c a c y of desensitization 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 i n the treatment of test anxiety.  Therapy was conducted i n small groups which met for one  hour per week of an eight week period.  An analysis of treatment  14  outcomes f a v o u r e d 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 this  c o n d i t i o n had s i g n i f i c a n t l y lower s c o r e s 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 o b t a i n e d a g r e a t e r improvement i n g r a d e - p o i n t - a v e r a g e . A more r e c e n t s t u d y by H o l r o y d (1976) e s s e n t i a l l y r e p l i c a t e d findings.  these  F o l l o w i n g a t r e a t m e n t p r o c e d u r e 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  s u b j e c t s w i t h t r a i n i n g i n f o c u s i n g , 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. i s l i k e l y t o r e s u l t i n t h e replacement w i t h coping s e l f - i n s t r u c t i o n s .  In practice this strategy  o f a n x i e t y - p r o d u c i n g thoughts  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 r e d u c i n g 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 i m p r o v i n g g r a d e - p o i n t average than e i t h e r s y s t e m a t i c d e s e n s i t i z a t i o n o r a c o m b i n a t i o n o f t h e two t r e a t m e n t s . Meichenbaum and Cameron (1973) have a l s o used  self-instructional  t r a i n i n g t o t r e a t c l i e n t s w i t h f e a r s o f b o t h snakes and r a t s .  The major  i n n o v a t i o n i n t h i s r e s e a r c h was t h e 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 s e s s i o n s  over s i x weeks.  Those-assigned  t o t h e i n o c u l a t i o n c o n d i t i o n were taught  to v i e w t h e i r a n x i e t y i n terms o f t h e S c h a c t e r i a n model o f emotion and received training i n s e l f - i n s t r u c t i o n .  D u r i n g t h e l a s t two s e s s i o n s they  p r a c t i c e d t h e c o p i n g s k i l l s they had l e a r n e d i n a random shock  situation.  Other s u b j e c t s i n t h i s s t u d y were a s s i g n e d t o 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 w h i c h 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 t o s u b j e c t s i n t h e i n o c u l a t i o n c o n d i t i o n except t h a t they d i d n o t p r a c t i c e i n t h e shock s i t u a t i o n , a s y s t e m a t i c 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 w h i c h  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 terms of performance on a behavioural was  superior to a l l others i n  approach task.  Desensitization  s i g n i f i c a n t l y more e f f e c t i v e than i n s t r u c t i o n a l rehearsal for the  treated phobia, but less e f f e c t i v e for the untreated subjects who  phobia.  That i s ,  had been desensitized to rats were more l i k e l y to handle rats  than subjects i n the i n s t r u c t i o n a l rehearsal condition, but they were also less l i k e l y to handle snakes than the l a t t e r group.  These findings  suggest that the b e n e f i c i a l e f f e c t s of a cognitive treatment are more l i k e l y to generalize to extra-therapy situations i n the c l i e n t ' s d a i l y life. The research described above provides support for the  therapeutic  effectiveness 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 n 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. 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 can be conceptualized components:  as having three  (1) a treatment rationale which attributes the cause of  anxiety to negative thoughts, ((2) an insight or awareness factor, and (3) s p e c i f i c training i n the use of p o s i t i v e self-statements.  It may  be  that a l l three aspects are e s s e n t i a l 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 t h i s issue.  Component analysis 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 Only a few studies i n the l i t e r a t u r e are d i r e c t l y 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 i m p o r t a n c e of awareness o f u n p r o d u c t i v e  t h i n k i n g and  specific training in substitution  of coping s e l f - s t a t e m e n t s f o r anxiety-producing anxious to  thoughts.  Speech  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 a s s i g n e d  the f o l l o w i n g treatment  conditions:  (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 c o m b i n a t i o n r e h e a r s a l , or (4) no-treatment c o n t r o l .  of awareness and  instructional  T h e r a p i s t s i n the  first  c o n d i t i o n e x p l a i n e d the r o l e o f n e g a t i v e s e l f - s t a t e m e n t s 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 a n x i e t y - p r o d u c i n g during p u b l i c speaking  situations.  imagined p u b l i c s p e a k i n g  thoughts w h i c h o c c u r r e d  I n the second c o n d i t i o n , s u b j e c t s  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 -  s t a t e m e n t s . C o n d i t i o n t h r e e combined the p r o c e d u r e s f o r the o t h e r c o n d i t i o n s and  the c o n t r o l group was  seen o n l y a t p r e - and  two  post-assessment.  A n a l y s i s o f 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 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 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  to  treatment  not p o s s i b l e to a s s e s s p o s s i b l e  d i f f e r e n c e s among them. A r e c e n t study by Thorpe, Amatu, B l a k e y and Burns (1976) p r o v i d e s d a t a w h i c h suggest t h a t 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 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 .  be l e s s  important  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 s e s s i o n s f o r h i g h s c h o o l s t u d e n t s who for  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 s p e a k i n g  met  i n s m a l l groups f o r e i g h t 30 m i n u t e s e s s i o n s .  volunteered  anxiety.  The f i r s t  Subjects  treatment  c o n d i t i o n ( g e n e r a l i n s i g h t ) p r o v i d e d 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 ( s p e c i f i c insight) dealt with  four i r r a t i o n a l b e l i e f s which were considered to be especially relevant to speech anxiety.  Students i n the third condition ( i n s t r u c t i o n a l  rehearsal) focussed on four ideas which were the opposite of those discussed i n condition two.  The f i n a l condition combined s p e c i f i c insight  and i n s t r u c t i o n a l rehearsal. Results of self-report measures indicated s i g n i f i c a n t l y greater improvement f o r subjects i n the two insight conditions than for subjects in the remaining  treatments.  behavioural measures.  There were no differences among groups on  These findings suggest that the actual emission  of coping self-statements may be less c r u c i a l to therapeutic effectiveness than had beenjsupposed;  awareness of unproductive  s u f f i c i e n t to bring about change.  cognitions may be  However, i t should be noted that the  s e l f - i n s t r u c t i o n a l rehearsal procedure described by Thorpe et a l . d i f f e r s considerably from Meichenbaum's (1974) treatment.  The l a t t e r had  subjects u t i l i z e p o s i t i v e self-statements which are relevant to a very s p e c i f i c stimulus s i t u a t i o n as a replacement for thoughts which had arisen i n that s i t u a t i o n .  In contrast, subjects i n the research just described  rehearsed rather general s e l f - i n s t r u c t i o n s .  Probably  self-instructional  training w i l l have i t s maximum therapeutic value when statements are concrete and s i t u a t i o n - s p e c i f i c .  Nevertheless, Thorpe et a l . ' s finding  of a poorer outcome for groups which rehearsed  coping self-statements i s  i n t r i g u i n g and merits further investigation.  Cognitive therapy and s k i l l s training Behaviour therapy t h e o r e t i c a l l y r e l i e s on a functional analysis of  18 b e h a v i o u r , f o l l o w e d by a t t e m p t s t o change the environment t o e l i c i t and m a i n t a i n d e s i r a b l e b e h a v i o u r .  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 t o m o d i f y t h e i r b e h a v i o u r . C u r r e n t p r o c e d u r e s w h i c h attempt t o d i r e c t l y m o d i f y b e h a v i o u r t h r o u g h p r o v i d i n g c o p i n g models, b e h a v i o u r a l r e f e r r e d t o as s k i l l s t r a i n i n g .  r e h e a r s a l and  coaching are  often  These t e c h n i q u e s have been w i d e l y  i n a s s e r t i v e t r a i n i n g (see H e r s e n , E i s l e r and M i l l e r , 1973)  and  used  have been  s u c c e s s f u l l y employed t o i n c r e a s e the f r e q u e n c y of d a t i n g b e h a v i o u r (e.g. Bander, S t e i n k e , A l l e n and Mosher, 1975;  Twentyman and M c F a l l , 1975).  A l t h o u g h 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 b e h a v i o u r m o d i f i c a t i o n , t h e r e has been l i t t l e attempt t o 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  problems.  i n dealing with  I t might be expected t h a t the former would be the  Of c h o i c e when the c l i e n t f a i l s  specific treatment  t o 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 b e h a v i o u r s i n h i s , r e p e r t o i r e .  On the o t h e r hand,  c o g n i t i v e change t e c h n i q u e s ought t o be more e f f e c t i v e when c l i e n t s know how  t o p e r f o r m the d e s i r e d a c t i o n but a r e p r e v e n t e d from d o i n g so by  presence of overwhelming a n x i e t y , o r , a l t e r n a t i v e l y , when c l i e n t s a c t u a l l y b e h a v i n g e f f e c t i v e l y but c o n t i n u e situations.  the  are  to f e e l anxious i n c e r t a i n  At p r e s e n t t h e r e i s l i t t l e r e s e a r c h w h i c h d e a l s w i t h  this  question. I n 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 e t a l . (1973) r e p o r t e d t h a t r e p e a t e d exposure t o a s t r e s s f u l s i t u a t i o n d i d not l e a d t o increase i n assertiveness. s u b j e c t s d i d not know how a n x i e t y had  They argue t h a t t h i s o c c u r r e d  because  t o behave a s s e r t i v e l y so t h a t h a b i t u a t i o n of  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 .  G l a s s , Gottman and  an  More r e c e n t l y ,  Shmurak (1976) d e s i g n e d a d i r e c t comparison of  self-  i n s t r u c t i o n a l training and s k i l l s training i n a treatment f o r dating anxiety.  Subjects i n a l l their experimental conditions attended one  90 minute group session followed by three or four one-hour individual training sessions. and  Those assigned to s k i l l s training received modelling  coaching of e f f e c t i v e behavioural responses.  The s e l f - i n s t r u c t i o n a l  training conditions provided a model f o r coping self-statements along with reinforcement f o r appropriate responses.  An additional  treatment  condition combined the two approaches. Although s e l f - i n s t r u c t i o n a l training and s k i l l s training were equally e f f e c t i v e i n producing changes i n performance i n role-playing  situations v  for which s p e c i f i c training had been given, subjects i n the former treatment condition showed better performance i n role-playing they had not been trained  and made a better impression on the women they  telephoned as part of the post-treatment procedure. their findings  situations f o r which  Glass et a l . interpret  as indicating that, at least f o r t h i s target problem, the  effects of s e l f - i n s t r u c t i o n a l training are more l i k e l y non-therapy situations.  to generalize to  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 t h e d e s i g n of stress-management programmes Because o f t h e 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 t r e a t m e n t b o t h 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 c a r e , i t i s not o n l y n e c e s s a r y t o d e v e l o p p r o c e d u r e s 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 ; costs.  we must a l s o be concerned w i t h t r e a t m e n t  I t i s c l e a r t h a t a t r e a t m e n t which r e q u i r e s l i t t l e  therapist  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 w i d e l y used a more time-consuming  than  and complex p r o c e d u r e i f t h e two approaches  result  i n s i m i l a r outcomes. One way  t o reduce t r e a t m e n t c o s t s i s t o g i v e 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 b e h a v i o u r m o d i f i c a t i o n t e c h n i q u e s w h i c h they can a p p l y t o 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  their  u s e f u l n e s s 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 s t u d y h a b i t s ( M o f f a t , 1972; J a c k s o n and Van Z o o s t , 1972). I n many of these s t u d i e s , c l i e n t s have s e t t h e i r own d i s p e n s e d t h e i r own rewards and punishments,  treatment g o a l s ,  applied stimulus c o n t r o l to  reduce the f r e q u e n c y o f u n d e s i r a b l e b e h a v i o u r and m o n i t o r e d b e h a v i o u r change.  Not o n l y have self-managed  t r e a t m e n t s 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 t r e a t m e n t s .  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 n o t e t h a t even t h e  s i m p l e 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 e x p e r i m e n t s  (Johnson and White, 1971;  Moura and Wade, 1973).  M c F a l l and Hammen, 1971; Mahoney,  F o r t h i s r e a s o n s e l f - m o n i t o r i n g s h o u l d be  c o n c e p t u a l i z e d as a t h e r a p y t e c h n i q u e as w e l l as a method of d a t a 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 p r o c e d u r e s i n the t r e a t m e n t of  a n x i e t y i s not a new (1968) d e s c r i b e d anxiety.  phenomenon.  Almost a decade ago Rehm and  Marston  the i m p l e m e n t a t i o n of such a programme f o r speech  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  t o g r a d u a l l y approach f e a r e d 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 g o a l s , use s e l f - r e i n f o r c e m e n t c o n t r a s t to c o n t r o l groups who  and  behavioural  s e l f - m o n i t o r problem s i t u a t i o n s .  were g i v e n 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 m i n i m a l u r g i n g toward s e l f - h e l p , the former s u b j e c t s showed d e c r e a s e s on s e v e r a l measures of  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;  and R a t i o n a l - e m o t i v e  greater  anxiety.  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 systematic  reconceptualized  G o l d f r i e d and T r i e r ,  I n b o t h cases they suggest t h a t  t e c h n i q u e s should be taught as c o p i n g t o any number of a n x i e t y - p r o v o k i n g  s k i l l s which can be a p p l i e d by  situations.  clients  I n s u p p o r t of t h e ^ . e f f i c a c y  t o a c o n d i t i o n i n w h i c h r e l a x a t i o n was  who  p r e s e n t e d as a  s k i l l showed a g r e a t e r r e d u c t i o n i n speech a n x i e t y and a n x i e t y , than s u b j e c t s who  1974)  the  of t h i s approach, G o l d f r i e d and T r i e r (1974) found t h a t s u b j e c t s were a s s i g n e d  1974)  t h e r a p y ( G o l d f r i e d , Decenteceo and Weinberg,  as t r a i n i n g i n s e l f - c o n t r o l .  In  coping  a l s o i n more g e n e r a l  were i n f o r m e d t h a t 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 p r o c e d u r e i s another example of a method w h i c h p r o v i d e s w h i c h he h i m s e l f  the c l i e n t w i t h a t e c h n i q u e  can a p p l y i n a n x i e t y - p r o d u c i n g  situations.  It will  r e c a l l e d t h a t t h i s t r e a t m e n t was  more e f f e c t i v e f o r a n i m a l p h o b i a . t h a n  s e v e r a l comparison t r e a t m e n t s .  T h i s f i n d i n g has broad i m p l i c a t i o n s  for  s t r e s s management s i n c e i t s u g g e s t s t h a t p r a c t i c i n g newly  acquired  be  22  self-management s k i l l s i n t h e o f f i c e o f 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 The  situations.  self-management s t r a t e g i e s j u s t d e s c r i b e d 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 f o r t h i s reason. .  they were not o r i g i n a l l y  designed  S e v e r a l r e c e n t r e p o r t s i n the a r e a of w e i g h t 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 i m p o r t a n c e of t h e r a p i s t c o n t a c t time w i t h the g e n e r a l f i n d i n g t h a t even m i n i m a l t h e r a p i s t i n v o l v e m e n t can produce t h e r a p e u t i c g a i n s .  For example, 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 conditions.  Subjects assigned  self-management  t o " s i m p l e self^management" met  groups f o r 10 t o 15 m i n u t e s o v e r a 10 week p e r i o d . self-management" c o n d i t i o n p r o v i d e d  Hall,  i n small  A comparison "combined  75 m i n u t e weekly group m e e t i n g s .  In-  the s i m p l e self-management c o n d i t i o n , s u b j e c t s were p r o v i d e d w i t h w r i s t counters  t o m o n i t o r d a i l y b i t e s of food and were i n s t r u c t e d t o g r a d u a l l y  d e c r e a s e the number, w h i l e s u b j e c t s 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 b e h a v i o u r a l t e c h n i q u e s weight r e d u c t i o n .  B o t h o f these t r e a t m e n t s  aimed a t  produced g r e a t e r w e i g h t l o s s  t h a n n o - t r e a t m e n t c o n t r o l , but they d i d not d i f f e r from each o t h e r a t 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 w e i g h t r e d u c t i o n t h e r a p y  conducted by m a i l .  The  mail-contact  group s e l f - m o n i t o r e d food i n t a k e and sent weekly r e c o r d s t o t h e  experimenter.  A n o t h e r group of s u b j e c t s met w i t h the e x p e r i m e n t e r f o r weekly s e s s i o n s a t w h i c h they r e c e i v e d m i l d s o c i a l a p p r o v a l f o r p r o g r e s s .  Results indicated  t h a t the two approaches were e q u a l l y e f f e c t i v e and b o t h were s u p e r i o r t o a control condition.  I n a somewhat s i m i l a r s t u d y , L i n d s t r o m ,  Reese (1976) m a i n t a i n e d  weekly telephone  Balch  and  c o n t a c t w i t h one group o f o v e r w e i g h t  23 subjects and met treatment period.  personally with another group over a nine week Again there were no differences between the  therapy conditions, although subjects i n both of them l o s t  two  significantly  more weight than no-treatment control subjects. In summary, the research described above indicates that treatments which require a r e l a t i v e l y small investment i n 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 i d e a l l y include minimal treatment comparison conditions which teach c e r t a i n basic s k i l l s .  This addition may  enable investigators  to decide whether the therapeutic gains which result from intensive treatment a c t u a l l y j u s t i f y expenditures resources.  i n therapist time and agency  24 CHAPTER FIVE Statement of the problem The present research had two major aims:  (1) to determine whether  s e l f - i n s t r u c t i o n a l rehearsal i s an essential component of the s e l f instructional  training procedure, and  (2) to compare the r e l a t i v e  effectiveness of s e l f - i n s t r u c t i o n a l training and s k i l l s  training.  Although the s e l f - i n s t r u c t i o n a l aspect of Meichenbaum's treatment i s what makes i t unique, there i s s t i l l l i t t l e evidence that s p e c i f i c training i n the emission of coping self-statements actually to anxiety reduction. instructional  It may  contributes  be that the awareness component of s e l f -  training i s s u f f i c i e n t to explain c l i n i c a l improvement.^  A search of the l i t e r a t u r e found only two studies which bear d i r e c t l y on this issue.  One of these, Barrett's d i s s e r t a t i o n ,  f a i l e d to demonstrate  that a combined awareness and i n s t r u c t i o n a l rehearsal condition was more e f f e c t i v e than either treatment presented  individually.  The  other,  (Thorpe et al.) reported results which suggest that awareness may actually be more improtant  than i n s t r u c t i o n a l rehearsal.  The experiment reported below i s an attempt to c l a r i f y this  situation.  Because of problems inherent i n conducting a group treatment without  an  awareness component, the r o l e of s e l f - i n s t r u c t i o n a l rehearsal was investigated by comparing s e l f - i n s t r u c t i o n a l training  (awareness plus s e l f - i n s t r u c t i o n a l  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 l i t e r a t u r e reviewed suggests that s e l f - i n s t r u c t i o n a l training i s superior to s k i l l s  25  t r a i n i n g i n stress management although there are few studies which have d i r e c t l y compared the two approaches.  This superiority probably occurs  because s k i l l s training i s f a i r l y s p e c i f i c to i n d i v i d u a l problems while 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 o f f e r s a more general approach to anxiety reduction.  When c l i e n t s have a variety of problems, not a l l of which  are necessarily  dealt with during treatment sessions, the  expected for the cognitive  generalization  procedure may account for better  overall  outcome. In contrast to most e a r l i e r research i n 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 the present research did not share a common problem. they reported s i g n i f i c a n t stress i n a variety of situations.  Instead  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 1.  following  hypotheses were proposed i n t h i s d i s s e r t a t i o n :  S e l f - i n s t r u c t i o n a l training produces a greater reduction i n  anxiety and a greater a b i l i t y to cope with stress than an awarenessoriented 2.  treatment. 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 superior to s k i l l s t r a i n i n g i n  anxiety reduction and stress-management.  26 CHAPTER SIX Method S u b j e c t r e c r u i t m e n t 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 p l a c e d 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 r e s p o n d e n t s were asked q u e s t i o n s  about  the n a t u r e o f s t r e s s - p r o d u c i n g s i t u a t i o n s , t h e d u r a t i o n of t h e problem, c u r r e n t treatment offered.  regimens and i n t e r e s t i n t h e type o f treatment  I n d i v i d u a l s were c o n s i d e r e d  programme o n l y i f they e x p e r i e n c e d  being  s u i t a b l e f o r t h e treatment  a s i g n i f i c a n t amount of s t r e s s i n a t  l e a s t two s i t u a t i o n s . The i n i t i a l p o o l o f 167 p e o p l e was reduced t o 64 t h r o u g h t h e telephone  screening interviews.  by i n d i v i d u a l s who expressed Other c a l l e r s i n t e n d e d  I n some cases i n q u i r i e s had been made  o n l y an e d u c a t i o n a l i n t e r e s t i n t h e programme.'  t o be out o f town d u r i n g t h e treatment  d i d n o t w i s h t o p a r t i c i p a t e i n a group t r e a t m e n t .  period or  Several prospective  c l i e n t s were c u r r e n t l y s e e i n g o t h e r t h e r a p i s t s and wished t o c o n t i n u e d o i n g s o , and many i n d i v i d u a l s d e s c r i b e d " 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 c o n s i d e r e d a p p r o p r i a t e f o r treatment  then :  p a r t i c i p a t e d i n more e x t e n s i v e assessment i n t e r v i e w s i n w h i c h i n f o r m a t i o n concerning 1.  t h e 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 : The s e v e r i t y o f t h e 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 d u r i n g w h i c h the c l i e n t an u n c o m f o r t a b l e  experienced  l e v e l of a n x i e t y  (c) e x t e n t t o w h i c h a n x i e t y i n t e r f e r e d w i t h d a i l y 2.  D e s c r i p t i o n of s t r e s s f u l  situations  (a) s p e c i f i c i t y of a n x i e t y - p r o d u c i n g  stimuli  (b) a b i l i t y o f c l i e n t t o r e c o g n i z e c o m m o n a l i t i e s stressful  across  situations  3. , The n a t u r e and outcome of p a s t attempts 4.  living  t o reduce s t r e s s  M o t i v a t i o n f o r treatments  F o l l o w i n g t h e 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 o f 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 t r e a t m e n t ,  p r e s e n t c l i n i c a l a n x i e t y l e v e l , c u r r e n t l e v e l of d e p r e s s i o n and hood of p s y c h o s i s a l c o h o l i s m . on t h e f i r s t two d i m e n s i o n s ,  likeli-  The i d e a l c l i e n t o b t a i n e d h i g h s c o r e s a moderate s c o r e on t h e t h i r d , and  low  r a t i n g s f o r t h e r e m a i n i n g two s c a l e s . Of t h e 64 people who  were i n t e r v i e w e d , 59 were r a t e d as s u i t a b l e  c a n d i d a t e s f o r t r e a t m e n t and were a c c o r d i n g l y a s s i g n e d to conditions.  T h i s group comprised  experimental  47 females and 12 males.  The  sex  d i s p r o p o r t i o n o c c u r r e d because the i n i t i a l s u b j e c t p o o l c o n t a i n e d f a r more women t h a n men,  n o t because t h e r e j e c t i o n r a t e was h i g h e r f o r  A d a t a d e p o s i t cheque of $20 was conditions.  r e q u i r e d o f c l i e n t s i n group  A l l t h r e e group t h e r a p y c o n d i t i o n s were f i l l e d  s u b j e c t s were a s s i g n e d t o s e l f - h e l p groups.  The procedure  men.  therapy  before f o r telephone  c a l l - b a c k a c t e d t o m i n i m i z e any s y s t e m a t i c b i a s by h a v i n g 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 s u b j e c t s whose names o c c u r r e d a t t h e end of b l o c k s i n s t e a d  28  of  c o m p r i s i n g o n l y t h e l a s t p e o p l e who telephoned t h e c l i n i c . A t t h e o u t s e t o f t r e a t m e n t , 13-16 c l i e n t s were a s s i g n e d t o each  experimental condition. D e s c r i p t i o n o f f i n a l sample S e v e r a l c l i e n t s were l o s t over t h e course o f t h i s s t u d y . the o r i g i n a l group o f 59, 52 i n d i v i d u a l s a t t e n d e d t h e i r f i r s t t r e a t m e n t s e s s i o n and 45 completed  treatment.  Of scheduled  The seven c l i e n t s who  d i s c o n t i n u e d t r e a t m e n t were d i s t r i b u t e d almost e q u a l l y a c r o s s t h e e x p e r i m e n t a l c o n d i t i o n s w i t h two d r o p - o u t s c o n d i t i o n s and one i n t h e s e l f - h e l p  i n each o f t h e group t h e r a p y  condition.  The mean age f o r t h e f i n a l sample was 41.7 y e a r s ; i n age from 21 t o 65 y e a r s .  clients  ranged  There were e i g h t males and 37 f e m a l e s .  22% were s i n g l e , 62.2% m a r r i e d and t h e r e m a i n i n g 15.6% s e p a r a t e d o r divorced.  The m a j o r i t y r e p o r t e d t h a t t h e i r problems were of more  than f i v e y e a r s d u r a t i o n ( 6 0 % ) , and a f u r t h e r 24.4% had e x p e r i e n c e d a h i g h l e v e l of s t r e s s f o r more than one year b u t 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 h a n d l i n g l o n g - s t a n d i n g stress-management problems.  C h i - s q u a r e 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 o f t h e 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 w h i c h brought the f o l l o w i n g :  c l i e n t s t o treatment i n c l u d e d  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 e x a m i n a t i o n s , meeting j o b d e a d l i n e s , p u b l i c s p e a k i n g , meeting  strangers, being alone, entertaining guests, dealing  w i t h s u p e r v i s o r s and employees, and a t t e n d i n g p a r t i e s (see Appendix 3 f o r a complete  l i s t i n g ) . Most of t h e s e l o g i c a l l y f a l l i n t o t h e c a t e g 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 . c l i e n t presented  T r a i n i n g and  Each  w i t h two or more problem s i t u a t i o n s .  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 Masteris students  G l i n i c a l P s y c h o l o g y programme, a l l o f whom had c o u r s e on i n t e r v i e w i n g t e c h n i q u e s .  The  completed a  e x p e r i m e n t e r met  in a  practicum with  this  group on s e v e r a l o c c a s i o n s b e f o r e the study began t o d i s c u s s the purposes of the i n t e r v i e w and  t h e g e n e r a l aims of the experiment.  Throughout  the c o u r s e 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 w h i c h a r o s e were d i s c u s s e d w i t h the e x p e r i m e n t e r .  I n almost a l l cases the same g r a d u a t e  conducted b o t h the t e l e p h o n e and  face-to-face interviews with  student an  individual client.. Graduate s t u d e n t s i n C o u n s e l l i n g P s y c h o l o g y 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 t h e r a p y  conditions.  leadership experience.  Before  A l l had p r e v i o u s  supervised  group  t r e a t m e n t began a s e r i e s of meetings  were h e l d t o 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 p r o c e d u r e s i n v o l v e d .  0.974b) t r e a t m e n t manual was and  used as a g u i d e f o r two of the  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 ;  book c h a p t e r  conditions  G o l d f r i e d and D a v i s o n ' s (1976)  on b e h a v i o u r a l r e h e a r s a l served  treatment c o n d i t i o n .  Meichenbaum's  as a model f o r the  remaining  A l l s e s s i o n s were taped^and weekly meetings were  h e l d 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 t o d i s c u s s problems and  progress.  Conditions C l i e n t s i n the t r e a t m e n t c o n d i t i o n s met  i n groups of s i x t o e i g h t  30 members for a series of s i x one and one-half hour weekly group sessions followed by a post-treatment assessment session.  Over this period,  a l l c l i e n t s were asked to monitor d e t a i l s of s t r e s s f u l s i t u a t i o n s . The control groups were informed that, because of the overwhelming response to our advertisement, a l l weekly group positions had been filled.  They were offered a two hour workshop instead.  Self-instructional training.  This condition was s i m i l a r to  Meichenbaum's treatment as described i n his manual.  During the f i r s t  session group members made statements about the factors which had l e d them to seek help.  Therapists encouraged a s i t u a t i o n a l analysis of  the problems presented and fostered a discussion of thoughts and feelings i n s t r e s s f u l s i t u a t i o n s . The treatment rationale was presented to the group i n 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 s i t u a t i o n i n very d i f f e r e n t ways. (At this point an example was given.) Since i t w i l l be necessary to go through many s t r e s s f u l situations i n one's d a i l y l i f e , i t i s u n r e a l i s t i c to try to avoid them. A much better approach i s to change the way you think about them. In a way, thinking i s l i k e talking to yourself. When you are i n a s t r e s s f u l s i t u a t i o n , you may t e l l yourself things which are r e a l i s t i c and h e l p f u l or things which only upset you more. The focus of our treatment i s 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 i n their stead to bring about a reduction i n anxiety and tension. The group then discussed baseline monitoring data which c l i e n t s had brought with them to the session.  At the end of the session i t was  suggested that group members continue to monitor s t r e s s f u l s i t u a t i o n s , while paying close attention to stress-provoking environment.  s t i m u l i i n the  31  Sessions two through six each began with c l i e n t s presentations of monitoring data  concerning s t r e s s f u l situations.  Other  group members were encouraged to offer their opinions on what each person was "saying to himself" i n monitored this to their own experience.  situations and to r e l a t e  An attempt was made to i d e n t i f y themes  i n problem s i t u a t i o n s . During the second and t h i r d sessions the focus of discussion was mainly on the analysis of negative thoughts.  Later meetings focused  almost e n t i r e l y on the rehearsal of coping s e l f - i n s t r u c t i o n s .  Clients  were asked to find p o s i t i v e , but r e a l i s t i c self-statements which they could try out i n problem situations.  As an aid i n this process, they  rehearsed new p o s i t i v e self-statements i n the group before  committing  themselves to using them during the coming week. Awareness.  This condition provided an analysis of anxiety i n terms  of negative self-statements, but did not offer s p e c i f i c training i n changing unproductive modes of thought., Session one began with group members descriptions of their problems.  As i n the f i r s t condition,  therapists encouraged a s i t u a t i o n a l focus and fostered a discussion of thoughts and feelings i n s t r e s s f u l situations.  He/she offered the  following treatment r a t i o n a l e : Anxiety i s 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 s i t u a t i o n i n e n t i r e l y d i f f e r e n t ways. (An example was given.) The major goal of our treatment i s f o r 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. U n t i l you understand very c l e a r l y what your negative thoughts are, or i n other words, what you are saying to yourself, c e r t a i n situations w i l l continue to upset you. In our group discussions we w i l l spend most of the time  32  c a r e f u l l y 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, c l i e n t s were asked to continue self-monitoring while paying attention to negative thinking. Sessions two through six began with each c l i e n t going over h i s 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. was made to f i n d commonalities  An attempt  across the problem situations presented  by i n d i v i d u a l c l i e n t s . To a s s i s t i n c l a r i f y i n g 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 f a i l u r e s to cope well i n problem situations. S k i l l s training.  In t h i s condition, an attempt was made to change  overt behaviour i n s t r e s s f u l situations.  During the f i r s t session,  c l i e n t s described the circumstances which had brought them to therapy. Therapists focused attention on the s i t u a t i o n a l determinants of the d i s t r e s s experienced by c l i e n t s and on the behaviours which had l e d to an unsatisfactory outcome.  They also provided the following treatment  rationale: To a considerable extent, anxiety i s a product of the situations i n which we find ourselves and of our own behaviour i n 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. I t i s useful to translate statements l i k e " s o c i a l situations upset me" into " i n certain s o c i a l situations I do not behave e f f e c t i v e l y . " The second statement i s better  33 because i t points to a solution — you can change your behaviour. A l t e r i n g your behaviour can have several b e n e f i c i a l e f f e c t s : 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 i n which no one could cope effectively. The focus of our treatment w i l l be on i d e n t i f y i n g problemjsituations and on specifying the causes of d i s t r s s i n each. Then we w i l l t r y to come up with new ways of dealing with situations which w i l l lead to a f e e l i n g of accomplishment rather than anxiety. Baseline monitoring data was a behavioural focus.  then discussed, with therapists maintaining  The homework assignment required that c l i e n t s con-  tinue to monitor s t r e s s f u l situations paying p a r t i c u l a r attention to the s t i m u l i which provoked anxiety. Sessions two through s i x commenced with a discussion of monitoring data.  During the second and t h i r d sessions, discussion centred on  the i d e n t i f i c a t i o n of anxiety-producing s t i m u l i .  Sessions four through  six focused on the development of alternative behaviours to use i n stressf u l situations.  Modelling, role-playing and behaviour rehearsal were  used to t r a i n c l i e n t s . Self-help•.treatment.  Clients met  i n two small groups.  The  experimenter presented a s i t u a t i o n - s p e c i f i c 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 s t i m u l i which triggered anxiety and the .thoughts which provoked stress.  They were  given monitoring instructions and encouraged to record the d e t a i l s of s t r e s s f u l situations as a f i r s t step i n gaining control over them.  They  were also instructed to change the nature of t h e i r thinking, and especially to try out coping self-statements i n problem situations.  At the end of  34 the m e e t i n g they were r e q u e s t e d on t h e i r  t o r e t u r n a f t e r s i x weeks t o r e p o r t  progress.  An attempt was made throughout t o p r e s e n t therapy.  t h i s c o n d i t i o n as  The group l e a d e r made an e f f o r t t o p r o v i d e what a s s i s t a n c e  he c o u l d w i t h i n t h e b r i e f t i m e a v a i l a b l e , and a l t h o u g h aware t h a t they were n o t r e c e i v i n g t h e " f u l l "  c l i e n t s were  t r e a t m e n t , many  expressed  g r a t i t u d e and o p t i m i s m a t t h e end o f t h e s e s s i o n . D u r i n g t h e second m e e t i n g , c l i e n t s d e s c r i b e d t h e i r u s i n g t h e suggested c o g n i t i v e t e c h n i q u e s .  experiences  I t was c l e a r t h a t some o f  them had made l i t t l e attempt t o m o d i f y t h e i r t h i n k i n g , b u t s e v e r a l r e p o r t e d t h a t m o n i t o r i n g and t h e u s e o f c o p i n g s e l f - s t a t e m e n t s had been helpful.  The group l e a d e r r e i t e r a t e d much o f what had been s a i d  the i n i t i a l s e s s i o n t o c o r r e c t any m i s c o n c e p t i o n s  during  w h i c h had a r i s e n and  encouraged c l i e n t s t o c o n t i n u e t o u s e what they had l e a r n e d . Pre-treatment  measures  I n t e r v i e w e r Assessment Form. to  I n t e r v i e w e r s used t h i s r e c o r d sheet  n o t e t h e i r o b s e r v a t i o n s o f each c l i e n t .  (Refer to "Subject  recruitment  and s e l e c t i o n " f o r c o n t e n t a r e a s and t o Appendix 2 f o r a copy o f t h i s form.) S t a t e - t r a i t Anxiety Inventory.  T h i s q u e s t i o n n a i r e has been w i d e l y  used i n t h e assessment o f a n x 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 d e s i g n e d  to test Spielberger's  of s i t u a t i o n a l and g e n e r a l a n x i e t y , c a n d many i n v e s t i g a t i o n s have  theory supported  the r e l a t i v e independence o f these two c o n s t r u c t s (see Smith and Lay, 1974, for  a review).  S e v e r a l s t u d i e s have r e p o r t e d d e c r e a s e s 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;  Spielberger et a l . ,  1970).  35 S o c i a l Avoidance and D i s t r e s s S c a l e .  T h i s measure was  developed  by Watson and F r i e n d (1969) to a s s e s s one a s p e c t 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 in social  situations.  Fear of N e g a t i v e E v a l u a t i o n .  Another s c a l e r e p o r t e d by Watson and  F r i e n d (1969), t h i s i n s t r u m e n t has 30 i t e m s which r e f l e c t a n x i e t y s u r r o u n d i n g a c t u a l or imagined c r i t i c i s m from o t h e r p e o p l e .  The  initial  s t u d y p r o v i d e s v a l i d i t y d a t a f o r b o t h of Watson and F r i e n d ' s s c a l e s . S e v e r a l groups of i n v e s t i g a t o r s have employed them i n t h e r a p y r e s e a r c h (Meichenbaum e t a l . , 1971;  Bander e t a l . ,  P a s t Week T e n s i o n Thermometer.  1975;  Thorpe e t a l . ,  A s i m p l e 1-10  point rating  1976). scale  s i m i l a r to Walk's (1956) Fear Thermometer was used t o o b t a i n an o v e r a l l tension rating. S i t u a t i o n a l S t r e s s Assessment.  T h i s procedure was  s p e c i f i c a l l y f o r the present r e s e a r c h .  developed  Because i t was not f e a s i b l e to  use e i t h e r b e h a v i o u r a l o b s e r v a t i o n o r r o l e - p l a y i n g measures due t o the d i v e r s i t y o f t a r g e t problems,  c l i e n t s a s s i g n e d t o the f i r s t t h r e e c o n d i t i o n s  were asked t o 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 u a t i o n i n the p r e - t h e r a p y week.  A s i t u a t i o n was  s e l e c t e d (by t h e i n t e r v i e w e r  and c l i e n t i n t h e assessment i n t e r v i e w ) which would be m o d e r a t e l y and of r e l a t i v e l y h i g h f r e q u e n c y o f o c c u r r e n c e .  sit-  C l i e n t s recorded  difficult their  e x p e r i e n c e s on a form p r o v i d e d f o r t h i s purpose, and a l s o r a t e d t h e i r a n x i e t y on t h e S u b j e c t i v e S t r e s s S c a l e (Berkun, B i a l e k , K e r n and Y a g i , 1962). The l a t t e r i s an e q u a l a p p e a r i n g i n t e r v a l s c a l e o f 15 words. word has an a t t a c h e d v a l u e , r a n g i n g from 1 f o r " w o n d e r f u l " t o 94 f o r "scared s t i f f . "  Berkun e t a l . p r o v i d e e v i d e n c e t h a t t h e s c a l e i s  Each  36  s e n s i t i v e t o 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 . r e c e n t l y a d i s s e r t a t i o n by N e u f e l d  More  (1972) found t h a t t h e s c a l e was  s e n s i t i v e t o a n x i e t y caused by s l i d e s o f h o m i c i d e v i c t i m .  In  a d d i t i o n , t h e s c a l e has been used t o 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 , R i c h and J a c k s o n ,  Post-treatment  1969).  measures,  A l l o f t h e q u e s t i o n n a i r e s were r e a d m i n i s t e r e d a t t h e t e r m i n a t i o n o f i  therapy.  I n t h e case o f t h e S i t u a t i o n a l S t r e s s Assessment, t h e c l i e n t s  were asked t o expose themselves t o t h e same s t r e s s o r w h i c h they had encountered i n t h e pre-assessment.  I n a d d i t i o n , a t t h i s time c l i e n t s  responded t o t h e q u e s t i o n n a i r e s d e s c r i b e d below. Relationship Inventory. assessed  by t h i s i n s t r u m e n t  C l i e n t s ' p e r c e p t i o n s o f t h e r a p i s t s were w h i c h was developed w i t h i n t h e framework o f  c l i e n t - c e n t r e d t h e r a p y by B a r r e t t - L e n n a r d  (1962).  The q u e s t i o n n a i r e  p r o v i d e s s c o r e s f o r L e v e l o f Regard, U n c o n d i t i o n a l i t y , Empathy and Congruence.  I n a r e v i e w paper, B e r g i n and Suinn  (1975) n o t e t h a t some  i n v e s t i g a t o r s have found t h a t p e r c e i v e d l e v e l s o f R o g e r i a n c o n d i t i o n s , as a s s e s s e d  facilitative  by t h e R e l a t i o n s h i p I n v e n t o r y , a r e a b e t t e r  p r e d i c t o r o f t h e r a p e u t i c outcome than r a t i n g s c o r e s d e r i v e d from t h e r a p i s t behaviour. Programme E v a l u a t i o n Form.  We o b t a i n e d c l i e n t s ' i m p r e s s i o n s o f  c l i n i c a l improvement by u s i n g f i v e r a t i n g s c a l e s a s s e s s i n g changes i n t e n s i o n l e v e l , a b i l i t y t o d e a l w i t h personal problems, a b i l i t y t o f u n c t i o n under p r e s s u r e , tendency t o become upset and d u r a t i o n o f " u p s e t s . " I n 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 o f t h e i r problem had been handled by t h e treatment  and r a t e d 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 i n t e r n a l consistency of the three scales which made up the Programme Evaluation form, item-to-total correlations were calculated f o r each of them.  Correlations f o r the f i v e Self-rated  Change items ranged from .58 to .82.  Only four of the f i v e items i n  the Therapist Competence Scale showed a c o r r e l a t i o n above .50 with a t o t a l 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 t o t a l scores derived from the revised scales (see Appendix f o r items and c o r r e l a t i o n s ) . S i g n i f i c a n t Other Questionnaire.  C l i e n t s were asked to have a  r e l a t i v e or close friend provide his/her impressions  of change which had  occurred during the s i x week treatment period on a questionnaire made up of the f i v e scales used i n the Self-rated Change form.  Again,  item-  t o - t o t a l correlations were calculated, a l l of which exceeded .50 (see Appendix 2 for c o r r e l a t i o n s ) . Follow-up procedure and measures One month after the l a s t treatment session, c l i e n t s were sent several questionnaires which they were asked to complete and return by mail. These included the S t a t e - t r a i t 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 p r e - t r e a t m e n t  s=3, m=5,  n=17.5) was  scores.  The o b t a i n e d Heck v a l u e (Heck=0.15,  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 conditions.  For mean p r e - s c o r e s by group r e f e r to T a b l e  The group as a whole had a mean s c o r e of 6.47 T e n s i o n Thermometer. tension.  (s.d.=1.39) on  1.  the  T h i s 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  Mean s c o r e s f o r A - s t a t e and A - t r a i t were 42.4  r e s p e c t i v e l y ( s . d . 9 . 5 0 and 8.93). a  The  and  47.4,  t r a i t s c o r e i s s i m i l a r t o the  average s c o r e r e p o r t e d f o r a group o f 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 e t a l . i n the manual f o r the S t a t e - t r a i t Anxiety Inventory.  On t h e o t h e r hand, on A - s t a t e  the p r e s e n t sample i s comparable t o g e n e r a l m e d i c a l p a t i e n t s whose s c o r e s a r e a l s o g i v e n by S p i e l b e r g e r e t a l . Fear of N e g a t i v e E v a l u a t i o n and S o c i a l A v o i d a n c e and D i s t r e s s mean s c o r e s were s i m i l a r to those r e p o r t e d by Watson a n d . F r i e n d normal undergraduate s t u d e n t s (X=16.7 and 10.6, respectively).  "nervous."  s.d.=8.4 and  C l i e n t s o b t a i n e d a mean s c o r e o f 69.5  Subjective Stress Scale.  (1969) f o r 8.2,  (s.d.=17.8) on  The word a s s o c i a t e d w i t h t h i s v a l u e i s  The average s c o r e o b t a i n e d i s comparable t o t h o s e r e p o r t e d  f o r s u b j e c t s who  underwent s i m u l a t e d , but a p p a r e n t l y r e a l , emergency  s i t u a t i o n s i n Berkun e t a l . (1962).  Mean s c o r e s v a r i e d from 69 t o 74  f o r t h e t h r e e 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 latter  study.  the  i n the  39  Table 1 Means and Standard Deviations f o r Outcome Measures Treatments Measures  3  0  SIT(n=ll) X  s.d.  AWARE(N=ll) X  s.d.  ST(n=ll) X  s.d.  SH(n=9) X  s.d.  TT Pre Post Follow-up  .6:33 • I.V23.J .6.50 4.67 1.97 4.50 5.18 1.54 5.18  1.73 1.57 1.33  , :7.00 .'1.48.V 6.00 . 0.94 5.50 1.27 6.00 1.55 5.55 1.86 5.67 1.22  FNE Pre Post Follow-up  18.75 9.64 14.67 11.31 14.18 10.78  13.42 8.42 11.91 8.84 11.55 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  9.08 9.83 10.36  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 11.21 32.17 7.43 35.46 9.61  40.50 9.32 35.25 8.29 37.55 11.19  44.82 10.27 42.'27 10.74 48.09 12.14  40.40 6.60 39.40 9.69 37.11 10.98  A-trait Pre Post Follow-up  47.50 43.33 45.36  9.02 9.42 9.90  43.92 8.92 41.92 11.34 41.00 8.20  49.82 10.64 47.91 9.99 48.18 11.94  48.70 44.50 40.55  6.48 6.95 6.42  SSS Pre Post  65.58 19.39 45.25 38.15  63.75 27.26 53.25 23.26  79.27 9.18 58.72 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 and SH=self-help.  9.35 8.96 8.86  7.28 8.58 9.11  t r a i n i n g , AWARE=awareness, ST=skills t r a i n i n g  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 s i g n i f i c a n t . 2 for a summary of these analyses).  (See Table  Tukey hsd tests for i n d i v i d u a l  comparisons revealed the following differences among means:  pre was d i f f e r e n t  from post and follow-up for Tension Thermometer, pre was d i f f e r e n t from followup for Fear of Negative Evaluation, for State Anxiety, pre was d i f f e r e n t from post and pre was s i g n i f i c a n t l y d i f f e r e n t from post and follow-up for T r a i t Anxiety, and for the Subjective Stress Scale, pre was d i f f e r e n t from post. (This l a s t c f i n d i n g should be interpreted with caution because of heterogeneity of variance among conditions on the Subjective Stress Scale.) To further evaluate d i f f e r e n t i a l treatment e f f e c t s , one-way between MANOVA's were performed separately on post and follow-up f o r a l l measures except the Subjective Stress Scale.  The r e s u l t i n g Heck values were not  s i g n i f i c a n t (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 e a r l i e r  analyses, t h i s indicates that the treatments offered did not produce d i f f e r e n t  outcomes, either at the termination of treatment or a f t e r a period of one month, although s i g n i f i c a n t change did occur for the c l i e n t group as a whole. Therapist effects Another one-way between MANOVA found no s i g n i f i c a n t differences .. among the three group therapy conditions on c l i e n t s ' 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 o f V a r i a n c e Summary T a b l e s  Measure TT  FNE  SAD  A-state  A-trait  SSS  3  Source  Sum o f Squares  d.f.  Mean Squares  Conditions Error(between) Time ConditionsXTime Error(within)  11.89 127.28 37.91 9.62 136.40  3 37 2 6 74  3.96 3.44 18.95 1.60 1.84  Conditions Error(between) Time ConditionsXTime Error(within)  757.69 8624.36 250.87 118.58 854.21  3 37 2 6 74  252.56 233.09 125.44 19.76 11.54  Conditions Error(between) Time ConditionsXTime Error(within)  129.67 7814.69 25.27 51.50 516.12  3 37 2 6 74  43.22 211.21 12.64 8.58 6.98  Conditions Error(between) Time ConditionsXTime Error(within)  1100.83 7083.25 481.68 581.43 4123.63  3 37 2 6 74  366.94 191.44 240.84 96.91 55.73  Conditions Error(between) Time ConditionsXTime Error(within)  670.18 8143.06 311.18 87.76 1470.56  3 37 2 6 74  2362.533 31104.88 5124.30 383.67 9957.19  2 32 1 2 32  Conditions Error(between) Time C o n d i t i o n s XTime Error(within)  See n o t e s on T a b l e 1.  F  P  1.15  .341  10.28 0.87  .001 .52  1.08  .368  10.87 1.70  .001 .130  0.21  .893  1.81 1.23  .171 .301  1.92  .144  4.32 1.74  .017 .124  233.39 227.38 155.59 14.63 19.87  0.98  .412  7.83 0.74  .001 .622  1181.27 972.03 5124.30 191.84 311.16  1.21  .310  16.47 0.62  .001 .546  42 analysis included  t h e f o u r s c o r e s from t h e R e l a t i o n s h i p  w e l l as s c o r e s f o r T h e r a p i s t  Competence and Group Warmth.  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 way a n a l y s e s o f v a r i a n c e from 5 t o 7) .  I n v e n t o r y as As a  i n c l i e n t s ' perceptions,  one-  were c a r r i e d out f o r s m a l l groups (n's v a r i e d  None o f the_F's o b t a i n e d 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 t h e 8 groups. Although c l i e n t s i n d i f f e r e n t conditions  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 t h a t t h e r a p i s t s were not e q u a l l y effective. variance  To t e s t t h i s h y p o t h e s i s a s e r i e s o f three-way a n a l y s e s o f  (ConditionsXGroupsXTime) w i t h s m a l l groups n e s t e d w i t h i n t r e a t m e n t  c o n d i t i o n s were p e r f o r m e d .  These a n a l y s e s r e v e a l e d  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 o f t h e outcome measures.  Relationships  between p r o c e s s 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 t o 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 p e r c e p t i o n s o f t r e a t m e n t and a c t u a l t r e a t m e n t outcomes.  Where r e p e a t e d t e s t i n g had been done, p r e - p o s t  d' s c o r e s were used as i n d i c e s o f outcome.  F o r t h e r e m a i n i n g 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 Q u e s t i o n n a i r e ) c o r r e l a t i o n s were s i m p l y c a l c u l a t e d between t h e s i n g l e s c o r e s a v a i l a b l e and  process scores.  L e v e l of Regard s c o r e s from t h e R e l a t i o n s h i p  were p o s i t i v e l y r e l a t e d t o S e l f - r a t e d Change (r=,34, p<.05). Congruence were r e l a t e d t o t h e S u b j e c t i v e r=.35, p<.05).  Of t h e s c a l e s c o n s t r u c t e d  Inventory  Empathy and  S t r e s s S c a l e (r=.30, p<.05 and 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 t h e Subjective  S t r e s s S c a l e (r=.28, p<.05 and r=.31, p<.05).  In a d d i t i o n ,  t h e r e 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 state anxiety  (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 r e p r e s e n t calculated.  o n l y a s m a l l p r o p o r t i o n o f those  Thus, o f 48 c o e f f i c i e n t s o n l y 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 t h e s e were n o t l a r g e i n magnitude. one i n t e r e s t i n g p a t t e r n w h i c h seems t o emerge i s t h a t c l i e n t s tend t o be r e l a t e d  t o change on measures o f s p e c i f i c a n x i e t y  However, perceptions (Subjective  S t r e s s S c a l e and S t a t e A n x i e t y ) b u t n o t t o more g e n e r a l measures of s p e c i f i c a n x i e t y (Fear o f N e g a t i v e E v a l u a t i o n , S o c i a l A v o i d a n c e 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 r e s u l t s of t h i s study indicate that s i g n i f i c a n t changes occurred on outcome measures for the c l i e n t sample as a whole, but contrary to expectations, the treatments provided did not have d i f f e r e n t i a l e f f e c t s . Because there were no s i g n i f i c a n t differences between the f i r s t three treatment conditions and the self-help condition, i t i s necessary to consider whether the o v e r a l l changes a c t u a l l y indicate a reduction i n anxiety.  I t might be argued that they are due to the operation of a  Hawthorne e f f e c t , or to s t a t i s t i c a l a r t i f a c t due to repeated testing. In the absence of a no-treatment control group i t i s not possible to r u l e 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 i n favour of a minimal treatment  group f o r two reasons.  F i r s t , i t i s e t h i c a l l y questionable to withhold  treatment from people who are i n need.  I f 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 e t h i c a l objection to a no-treatment group, but for p r a c t i c a l reasons t h i s alternative was not f e a s i b l e i n the present research. The second point i n 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 p a r t i c u l a r treatment approach  i s able to produce better r e s u l t s than minimal treatment, the additional costs of the former are not j u s t i f i e d .  From a more t r a d i t i o n a l  45 experimental control perspective,  a minimal treatment group i s also  able to provide a control f o r certain "non-specific" factors (e.g., s i t u a t i o n a l demand c h a r a c t e r i s t i c s , expectations of help and.opportunity to share emotional experiences) which are present i n any therapy. Thus, an investigator can f e e l reasonably confident which i s superior  that a therapy  to a minimal treatment i s actually e f f e c t i v e .  However, when differences do not emerge, there are problems i n interpreting experimental r e s u l t s .  On the basis of the data obtained i n the present  study, one might conclude that, for p r a c t i c a l purposes, a l l of the treatments offered were of equal effectiveness. i s probably unwarranted.  Such a strong  In a l l therapy research,  conclusion  treatment outcome i s  due to an i n t e r a c t i o n of c l i e n t , therapist and technique variables. Very often c l i e n t and therapist e f f e c t s may obscure the operation of s p e c i f i c treatment variables by increasing the variance  on outcome measures.  Clients i n the present study were diverse i n terms of age, sex, p s y c h i a t r i c history and s p e c i f i c presenting  problems.  Although there were no s i g n i f i c a n t  differences among treatment conditions, either on these variables or on pre-scores f o r outcome measures, within-condition large.  variances were generally  The same was true for within-groups scores on process measures;  again an absence of s i g n i f i c a n t differences among groups was accompanied by large score variances. Analysis of variance  (groups nested within condition) did not find  s i g n i f i c a n t groups by time interactions.  However, t h i s finding does not  necessarily indicate that therapist c h a r a c t e r i s t i c s were unimportant, since ANOVA with small n's may be unreliable.  A v a r i e t y of differences  among therapists i n background, training and therapy s t y l e may have been  46  r e l a t e d t o treatment outcome d e s p i t e the f i n d i n g t h a t 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 a s p e c t s of the t r e a t m e n t s themselves may 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.  have  F i r s t , i t should  be noted t h a t i n some ways t h e i n d i v i d u a l t r e a t m e n t s were a c t u a l l y r a t h e r similar.  A l t h o u g h t h e r e were d i f f e r e n c e s i n t r e a t m e n t r a t i o n a l e and i n  the s p e c i f i c t e c h n i q u e s used i n t h e r a p y , s i m i l a r i t i e s may weigh'jacli t h e 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 f o c u s ,  a l l used s e l f - m o n i t o r i n g , a l l attempted change was  have o u t -  t o c r e a t e an atmosphere i n which  expected t o o c c u r , and a l l p r o v i d e d t h e o p p o r t u n i t y f o r s h a r i n g  u p s e t t i n g e x p e r i e n c e s and r e c e i v i n g e m o t i o n a l s u p p o r t . have argued t h a t n o n - s p e c i f i c v a r i a b l e s may t r e a t m e n t f a c t o r s ( s e e , e.g., S h a p i r o , 1971;  Several authors  be as i m p o r t a n t as a c t u a l Mahoney, 1974).  In the  l i g h t of the f a c t t h a t a l l c o n d i t i o n s shared b o t h n o n - s p e c i f i c and s i m i l a r i t i e s , t h e 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  technique  surprising.  P o s s i b l y a more p r o t r a c t e d t h e r a p y i s n e c e s s a r y f o r m u l t i - p r o b l e m clients. may  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 o r more problems  be more d i f f i c u l t t o h e l p t h a n c l i e n t s w i t h o n l y 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 s h a r e 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 p a i d t o any one c l i e n t under these c o n d i t i o n s .  Under such c i r c u m s t a n c e s , none of the t r e a t m e n t s  have been g i v e n a f a i r t r i a l .  may  I n a d d i t i o n , i t s h o u l d be noted t h a t the  d a t a a v a i l a b l e from t h e p r e s e n t s t u d y 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 d o i n g i n t h e t r e a t m e n t c o n d i t i o n s .  Although they r e p o r t e d  t h a t they were a p p l y i n g the t e c h n i q u e s taught i n t h e group s e s s i o n s t o  extra-therapy situations, we have no way of d i r e c t l y assessing their compliance.  In order to investigate this question, future research  should more systematically c o l l e c t information on c l i e n t s ' application of treatment  techniques.  One implication to be drawn from the r e s u l t s of the present study i s that i t i s unwise to assume that therapists with rather limited experience and t r a i n i n g can necessarily bring about therapeutic change merely by following manuals which describe treatment approaches. such manuals are admirable i n that they standardize treatment  While  procedures  in research, i t i s probably u n r e a l i s t i c 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. note that when asked at post-assessment  I t i s of interest to  about the success of the treatment  received, a majority of the c l i e n t s (76%) responded of their problem remained to be coped with.  that at least  75%  When one takes into account  the reluctance of c l i e n t s 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 i n the future.  Since a d d i t i o n a l therapist training and  experience i n the s e l f - i n s t r u c t i o n a l procedure might have produced  a  stronger treatment effect f o r this condition even with the present c l i e n t population, the r e s u l t s as they stand should only be generalized to other research with r e l a t i v e l y inexperienced therapists. It may be that s e l f - i n s t r u c t i o n a l training was not r e a l l y an appropriate treatment for the present sample.  Its effectiveness has been demonstrated  mainly with f a i r l y circumscribed fears i n normal c l i e n t s .  Although the  48  s c r e e n i n g p r o c e d u r e attempted t o e x c l u d e i n d i v i d u a l s who had g e n e r a l or f r e e - f l o a t i n g a n x i e t y , t h e h i g h t r a i t a n x i e t y s c o r e s w h i c h c l i e n t s obtained  suggest t h a t t h e p r e s e n t  group may have been more g e n e r a l l y a n x i o u s  than s u b j e c t s i n c l u d e d i n e a r l i e r s t u d i e s . our c l i e n t s had e x p e r i e n c e d  I n a d d i t i o n , many o f  stress-management problems f o r a l o n g t i m e  (60% f o r more than f i v e y e a r s ) and 30% had had p r e v i o u s p s y c h i a t r i c t r e a t ment a t one time i n t h e i r l i v e s .  Probably  make b e n e f i c i a l change l e s s l i k e l y  to occur.  t h e s e f a c t o r s combined t o  I n o r d e r t o d e t e r m i n e 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 t o t r e a t m e n t outcome, P e a r s o n ' s r_'s were c a l c u l a t e d between t h e s e measures and outcome s c o r e s f o r t h e t o t a l N.  D u r a t i o n was  s i g n i f i c a n t l y r e l a t e d t o change on t h e T e n s i o n Thermometer  ( r — . 4 2 , p .01)  and S u b j e c t i v e S t r e s s S c a l e (r=.33, p . 0 1 ) , w h i l e i n i t i a l t r a i t  anxiety  s c o r e s were s i g n i f i c a n t l y c o r r e l a t e d o n l y w i t h changes on t h e Fear of N e g a t i v e E v a l u a t i o n (r=.25, p . 0 5 ) .  The d i r e c t i o n o f t h e s e r e l a t i o n s h i p s  does s u p p o r t t h e v i e w 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 s c o r e s and l o n g s t a n d i n g problems show l e s s improvement w i t h t r e a t m e n t .  Most of t h e  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 r e s e a r c h i n a n x i e t y t o d a t e has been conducted w i t h student Holroyd,  c l i e n t s ( e . g . Meichenbaum e t a l . , 1971; Meichenbaum, 1972;  1976; Thorpe e t a l . , 1976).  Perhaps t h e t e c h n i q u e  requires  more i n t e n s i v e a p p l i c a t i o n o r some k i n d o f m o d i f i c a t i o n t o m a x i m a l l y 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 o f no d i f f e r e n c e s between t h e 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  t h e c o n c l u s i o n o f Thorpe e t a l . , t h a t  the i n s i g h t component o f 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 s p e c i f i c technique.  However, i n view of the f a i l u r e of  s e l f - i n s t r u c t i o n a l training to out-perform minimal treatment i t i s not possible to draw d e f i n i t e conclusions on the basis of t h i s finding. Because such differences between treatments may  have r e l a t i v e l y weak effects  i n comparison to the c l i e n t and therapist variables discussed above and also i n comparison to non-specific effects i t seems more appropriate to investigate this question with subjects who common problem.  are similar to each other and who  share a  Probably future research should focus on more homogeneous  samples. S e l f - i n s t r u c t i o n a l 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 i n diverse situations. worthwhile  It i s certainly  to continue to investigate i t s usefulness with multiproblem  c l i e n t s , but future studies with a community population should pay closer attention to c l i e n t variables with a view to discovering c h a r a c t e r i s t i c s which w i l l predict good treatment outcomes.  Findings from the present  study suggest that problem duration and l e v e l of t r a i t anxiety may important.  be  It also seems l i k e l y that the nature of the s p e c i f i c stress-  producing s t i m u l i w i l l be related to outcome.  Not only might better  r e s u l t s be expected when the s t r e s s f u l s i t u a t i o n can be specified i n d e t a i l , but the treatment may bring about greater anxiety reduction with c l i e n t s who  experience stress i n p a r t i c u l a r types of situations.  For example,  i t may be that people who become anxious i n work situations are more e a s i l y helped than those who  f i n d d i f f i c u l t y coping with situations which a r i s e  i n the context of intimate relationships. therapist variables may  In addition to c l i e n t variables,  also partly determine therapeutic effectiveness.  50 For this reason, future research should provide f o r an analysis of therapist effects so that t h i s source of variance can be extracted to better assess the effectiveness of treatment. However, before c l i e n t and therapist variables are investigated, a more lengthy and intensive treatment programme should be considered for multiproblem  c l i e n t s similar to those who served as subjects i n the  present research.!  At this point, the f i r s t p r i o r i t y i s to develop an  e f f e c t i v e programme f o r t h i s population.  Later research can then be  devoted to a comparison of d i f f e r e n t treatment approaches i n s t r e s s management .  51  FOOTNOTES  See Appendix 3 f o r t y p i c a l therapy interactions. The Subjective Stress Scale was not included i n this analysis because scores were a v a i l a b l e f o r 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 A p p l e y , M. and Trumble R. Psychological Stress. Appleton-Century-Crofts, 1967. A r n o l d , M. (Ed.)  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J o u r n a l of C o u n s e l i n g P s y c h o l o g y , 1972, 19, 192-195. J e f f r e y , D. A comparison of t h e 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 t h e m o d i f i c a t i o n and maintenance of w e i g h t . J o u r n a l of Abnormal P s y c h o l o g y , 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 change. B e h a v i o u r Therapy, 1971, 2, 488-497.  behavioural  K a r s t , T. and T r e x l e r , L. I n i t i a l study u s i n g f i x e d - r o l e and r a t i o n a l emotive t h e r a p y 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 C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1970, 34, 360-366/ K o p e l , S. and A r k o w i t z , H. and b e h a v i o u r change. 1974, 29, 677-686.  R o l e - p l a y i n g as a s o u r c e 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 P s y c h o l o g y ,  54  Kopel, S. and Arkowitz, H. The r o l e of a t t r i b u t i o n 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 i n 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 c l i n e t i c a l formulations and experimental findings. In C. S p i e l berger (Ed.) Anxiety and behaviour. New York: Academic Press, 1966. Lazarus, R., Speisman, J . , Mordkoff, A. and Davison, L. A laboratorystudy of psychological stress produced by a motion picture f i l m . 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. E i s l e r and P. M i l l e r (Eds.), Progress i n 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. L i p i n s k i , D., and Nelson, R. The r e a c t i v i t y and u n r e l i a b i l i t y of s e l f 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. Ballinger, 1974.  Cambridge, Mass.:  Mahoney, M. Reflections on the cognitive-learning trend i n psychotherapy. American Psychologist, 1977, J32, 5-13. Mahoney, M., Moura, N., and Wade, T. Relative e f f i c a c y of self-reward, self-punishmentaand self-monitoring techniques for weight l o s s . 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 r o l e of non-specific factors i n smoking reduction. Journal of Consulting -- and C l i n i c a l Psychology, 1971, _3_7> 80-86. Meichenbaum, D. behaviour.  Examination of model c h a r a c t e r i s t i c s i n 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. General Learning Press, 1974'.aja)  Morristown, N.J.:  Meichenbaum, D. Therapist manual f o r 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 i n treating speech anxiety. Journal of Consulting and C l i n i c a l Psychology, 1971, _36, 410-421. Moffat, S. Contingency contracting with study behaviours using a c t i v i t y 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 ' i r r a t i o n a l b e l i e f s 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 i n the production of stress reaction. Journal of Personality and Social Psychology, 1968, 8, 204-208. Rehm, L. and Marston, A. Reduction of s o c i a l anxiety through modification of self-reinforcement: An i n s t i g a t i o n therapy technique. Journal of-Consulting and C l 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, s o c i a l and physiological determinants of emotional state. Psychological Review, 1962, 6_9, 379-399. Shapiro, A. Placebo effects i n medicine, psychotherapy, and psychoanalysis. In A. Bergin and S. G a r f i e l d (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 i n theory and Research (vol 1), New York: Academic Press, 1972. (a)  56 S p i e l b e r g e r , C. C o n c e p t u a l and m e t h o d o l o g i c a l i s s u e s i n a n x i e t y r e s e a r c h . I n C. S p i e l b e r g e r (Ed.) Anxiety: C u r r e n t t r e n d s i n t h e o r y and r e s e a r c h . ( v o l 2 ) , New Y o r k : Academic P r e s s , 1972.(b) S p i e l b e r g e r , C., Gorsuch, R. and Lushene, R. Manual f o r t h e 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 Psychologists P r e s s , 1970. S t r a a t m e y e r , A. and W a t k i n s , J . R a t i o n a l - e m o t i v e t h e r a p y and t h e 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 . , B l a k e y , R. and B u r n s , 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 " t o t h e 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. B e h a v i o u r Therapy, 1976, 7_, 504-511. T r e x l e r , L. and K a r s t , T. R a t i o n a l - e m o t i v e t h e r a p y , p l a c e b o and no-treatment e f f e c t s on 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 o f Abnormal P s y c h o l o g y , 1972, 7_9, 60-67. Twentyman, C. and M c F a l l , R. B e h 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 P s y c h o l o g y , 1975, 43, 384-395. V a l i n s , S. and Ray, A. E f f e c t s o f 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 a v o i d a n c e behaviour. J o u r n a l o f P e r s o n a l i t y and S o c i a l P s y c h o l o g y , 1967, 7_, 345-350. Walk, R. S e l f - r a t i n g s of fear i n a fear-invoking s i t u a t i o n . Abnormal and S o c i a l P s y c h o l o g y , 1956, _52, 171-178.  J o u r n a l of  Watson, D.,and F r i e n d , R. Measurement o f 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 o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1969, _33, 448-457. Wein, K., N e l s o n , 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 o f 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 t o t h e e f f e c t i v e n e s s o f c o g n i t i v e r e s t r u c t u r i n g . B e h a v i o u r Therapy, 1975, 6^, 459-474. Wine, J . I n v e s t i g a t i o n s o f 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, O n t a r i o , 1970.  57  Appendix 1 I n t e r v i e w Guides  58 TELEPHONE CALL-BACK Time:  15 m i n u t e s maximum B e g i n the c o n v e r s a t i o n by a s k i n g what s o r t of problems the respondent has  been h a v i n g . at  this point.  P r o b a b l y 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  Try to f o c u s the c o n v e r s a t i o n by a s k i n g s p e c i f i c q u e s t i o n s .  about the d u r a t i o n o f the problem ("how was wrong?"), the e x t e n t use the c l i e n t ' s words — situations arise?").  ("how  Ask  l o n g have you been f e e l i n g t h a t something  much do your f e e l i n g s o f a n x i e t y o r t e n s i o n "  " 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  stressful  A l s o t r y to f i n d out whether t h e a n x i e t y e x p e r i e n c e d  is fairly  c o n s t a n t and a l l p e r v a s i v e o r 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 t h e r e t i m e s when you don't f e e l a n x i o u s o r t e n s e ? " ) . Then move on to a d e s c r i p t i o n o f 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 a l r e a d y g i v e n examples, use one of t h e s e .  about where i t happens, when i t happens (time o f day, f o l l o w i n g some o t h e r 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 o t h e r people  r e s p o n s e s t o the r e s p o n d e n t ' s upset. d e t a i l how  he e x p e r i e n c e s h i s a n x i e t y .  Ask event),  i n the s i t u a t i o n ,  their  Then ask the respondent to d e s c r i b e i n some How  does he know t h e r e ' s a p r o b l e m ( s ) ( i s  he weak and t r e m b l y , p h y s i c a l l y t e n s e , nauseous, p a n i c k y ,  etc.).  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 o f treatment  programme.  I n t r o d u c e t h i s d e s c r i p t i o n w i t h the statement,  the  " I ' l l give  you a s h o r t d e s c r i p t i o n o f our programme so you can d e c i d e i f i t sounds l i k e what you a r e l o o k i n g f o r . " people.  Say t h a t the treatment  w i l l , t a k e p l a c e i n groups of 6 to 8  There w i l l be one group meeting per week l a s t i n g about 1% hours.  groups w i l l p r o b a b l y meet i n the evening. important  Most  Treatment w i l l l a s t f o r 7 weeks.  t h a t the c l i e n t s commit t h e m s e l v e s to b e i n g t h e r e f o r a l m o s t a l l o f  sessions. The  ;  group l e a d e r s w i l l be g r a d u a t e s t u d e n t s i n psychology  who  have had  It i s the  59  experience  i n therapy  and a r e b e i n g  members ( p r o f e s s o r s ) .  several questionnaires. and  but i n r e t u r n they w i l l be expected to f i l l  I f questioned,'  say t h a t "we  i t has worked f o r many p e o p l e .  i n o r d e r to o b t a i n d a t a to support our  They  out .  b e l i e v e our approach i s a  However, we want to c a r r y out  research  belief."  Don't answer more s p e c i f i c q u e s t i o n s about the content Say  faculty  Make sure you mention t h a t t h i s i s a r e s e a r c h p r o j e c t .  w i l l r e c e i v e f r e e treatment,  good one,  s u p e r v i s e d by c l i n i c a l p s y c h o l o g y  t h a t t h i s w i l l be d i s c u s s e d at the i n i t i a l  of the t h e r a p y  sessions.  interview.  A r r a n g e an i n t e r v i e w i f : 1 ) the p e r s o n seems to be i n genuine d i s c o m f o r t  and  i s eager f o r h e l p .  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 a b l e to d e s c r i b e 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 . f e e l t h a t what he says makes sense —  some c o n f u s i o n because of h i g h a n x i e t y . delusions.)  '  ' allowing for  He does not r e p o r t h a l l u c i n a t i o n s or  60  ASSESSMENT INTERVIEW GUIDE Time:  30-45 minutes of interview and 15-30 minutes for questionnaires.  In t h i s interview you w i l l be interested i n the same material as you covered i n the telephone call-back, but i n more d e t a i l .  As a guide to the interview, please  follow the Interviewer Assessment Form.  f i l l i n the c l i e n t ' s  You may  responses  as you go along, or complete the form after the interview i s concluded. taste.  Suit your  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 i n t u i t i o n s to go on.  Follow these ,  i f you have no hard data. Begin the interview by asking the respondent  to describe h i s problems i n more  d e t a i l , and d i r e c t the conversation so that a l l of the necessary questions are asked, i n any order you l i k e .  After you have obtained answers to these questions,  leave the c l i e n t , taking the Interviewer Assessment Form with you.  Complete the  assessment ratings at the bottom of the second page and a r r i v e at a decision about the s u i t a b i l i t y of the c l i e n t for the stress management programme. If the person i s judged inappropriate: T e l l him/her that he probably wouldn't be happy with the treatment we are o f f e r i n g .  If he asks where he should go, suggest  that he consult his family doctor. If the person i s judged appropriate: the treatment programme.  Answer questions he/she may  have about  Emphasize that i t w i l l .deal with s p e c i f i c techniques which  can be used to deal with s t r e s s f u l situations.  If pressed for d e t a i l s , 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 s p e c i f i c about i t now. Make i t very clear that the c l i e n t i s expected to attend a l l treatment sessions, since t h i s i s a b r i e f intensive course of therapy and that a l o t of hard work i s  expected of him. Assign him to a group according to h i s time preferance  (refer  to a master-list which w i l l be posted somewhere). Self-Monitoring:  Give the c l i e n t a copy of the Self-Monitoring Instructions.  Tell  him that an e s s e n t i a l 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 t h i s purpose and ask that he begin to use i t during the coming week. Data Deposit:  Show the c l i e n t a copy of the Data Deposit Agreement.  Ask him to  bring a cheque for $20 payable to a charity of h i s 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 t h i s pro-  cedure has been found necessary to avoid loss of information which we need for the research part of t h i s project. Situational Stress Task:  Give the c l i e n t 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 s i t u a t i o n •. should cause discomfort but not absolute panic.  (Should f a l l aroung 7 on the tension-rating scale,) arrange,  It should be r e l a t i v e l y easy to  i f i t w i l l not occur n a t u r a l l y during the coming week.  Stress the importance  of carrying out the task. The Questionnaires:  After your interview the c l i e n t 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 c l i e n t 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 f o r the f i r s t group meeting (or an arrangement has been made to do t h i s ) .  4.  He has completed a l l the necessary questionnaires.  63  Interviewer  Assessment: Form  Client's name Age  M a r i t a l Status  ^  1.  When did you f i r s t notice that you had a problem?  2.  What have you done about i t ? (eg, consulted  3.  Are you currently seeing a p s y c h i a t r i s t ?  a doctor, taken p i l l s )  (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 i s the brand nar.e of the medication?  (Explain that the c l i e n t w i l l be expected to continue to take t h i s medication a t his present l e v e l durinp. the course of treatment) 5.  What aspects of your l i f e do you manage well?  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 s i t u a t i o n s ) , Situation 1: a) when? b) where?  (eg. work, marriage, children)  _____ _________________________ .  c) exactly what do you think i s upsetting about the situation?  Situation 7.~ a) when? b) where? c) exactly what do you think i s upsetting about the situation?  Situation 3-  '  a) when? b) where? c) exactly what do you think i s upsetting about the situation?  64  Have you considered r e c e i v i n g treatment the recent past?  for a drinking problem i n  .  Have you been feeling depressed  lately?  (er;. withdrawing, losinp  interest i n 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 s u i t a b i l i t y Please rate the c l i e n t  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 c h a r a c t e r i s t i c and 7= a great, deal of the c h a r a c t e r i s t i c .  Note•  1)  Motivation for treatment  2)  S p e c i f i c i t y of stress  3)  Present c l i n i c a l anxiety l e v e l  4)  Current l e v e l of depression  5)  Liklihood of alcoholism  6)  Liklihood of psychosis  The ideal c l i e n t w i l l come out high on the f i r s t two measures,  moderate on anxiety l e v e l during the interview, and low on the l a s t three measures.-  65  Appendix 2 Instruments  66  PAST WEEK TENSION THERMOMETER  Date  Name  Think back over the past week.  Take each day separately and remember  as much as you can of what you d i d , how the day went, and p a r t i c u l a r l y the l e v e l of tension you experienced. to rate your average  Now, use the thermometer below  l e v e l of tension f o r the past week.  - 1 0 completely tense (not relaxed at a l l )  - 9 - 8 very tense (only s l i g h t l y 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 w i l l have chosen a situation which you w i l l undergo during the coming week. This exercise w i l l 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  didn't bother me  panicky  scared s t i f f  unsafe  frightened  wonderful  timid  steady  indifferent  nervous  unsteady  fine  worried  68 SIGNIFICANT OTHER QUESTIONNAIRE  In o r d e r t o e v a l u a t e t h e e f f e c t i v e n e s s o f o u r programme we would l i k e to f i n d o u t i f changes a r e o c c u r r i n g i n t h e d a i l y l i v e s o f group members. S i n c e you know one o f these people w e l l , we would l i k e you t o g i v e us your i m p r e s s i o n s . P l e a s e respond h o n e s t l y and t h o u g h t f u l l y t o t h e f o l l o w i n g q u e s t i o n s . 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 , p l a c e i t i s i t s envelope and m a i l i t t o u s . Your answers w i l l n o t be seen by t h e p e r s o n you a r e d e s c r i b i n g u n l e s s y o u choose t o r e v e a l them y o u r s e l f . The i n f o r m a t i o n o b t a i n e d w i l l be used f o r r e s e a r c h purposes o n l y . For t h e items below, p l e a s e c i r c l e t h e number p r e c e d i n g t h e response which most a c c u r a t e l y d e s c r i b e s changes you have observed over t h e p a s t s i x weeks. Item t o t o t a l r 1. G e n e r a l t e n s i o n l e v e l : 1) much reduced .69 2) somewhat reduced 3) no change 4) somewhat h i g h e r now 5) much h i g h e r now A b i l i t y to deal with personal problems:  A b i l i t y t o f u n c t i o n under _. • -• . p r e s s u r e :  4.  1) 2) 3) 4) 5)  much improved somewhat improved no change somewhat reduced much reduced  1) much improved 2) somehwat improved 3) no change 4) somewhat reduced 5) much reduced  Tendency t o become upset  1) 2) 3) 4) 5)  much more e a s i l y upset now somewhat more e a s l i t y upset no change somewhat l e s s e a s i l y upset much l e s s e a s i l y upset now  D u r a t i o n o f "upsets'  1) 2) 3) 4) 5)  n o t n e a r l y so l o n g now n o t q u i t e so l o n g no change somewhat l o n g e r now much l o n g e r now  . 7 9  .54  ,68  , 7 0  69 PROGRAMME EVALUATION FORM Name ' •  ..  -  .  Date  A.  S e l f - r a t e d Change  For  t h e items below, p l e a s e c i r c l e t h e number w h i c h precedes t h e response  which most a c c u r a t e l y d e s c r i b e s changes y o u have observed i n y o u r s e l f you f i r s t came t o t h e T e n s i o n Management 1.  General tension l e v e l :  2.  Ability  3.  Ability  1) 2) 3) 4) 5)  since  Clinic.  much reduced somewhat reduced no change somewhat h i g h e r now much h i g h e r now  Item-to-total .76  t o d e a l w i t h p e r s o n a l problems: 1) much improved 2) somewhat improved 3) no change 4) somewhat reduced 5) much reduced t o f u n c t i o n under p r e s s u r e : 1) much improved 2) somewhat improved 3) no change 4) somewhat reduced 5) much reduced  .65  .58  4.  Tendency t o become u p s e t :  1) 2) 3) 4) 5)  much more e a s i l y upset now somewhat more e a s l i y upset no change somewhat l e s s e a s i l y upset much more e a s i l y upset now  .69  5.  Duration of "upsets":  1) 2) 3) 4) 5)  n o r n e a r l y as l o n g now n o t q u i t e as l o n g no change somewhat l o n g e r now much l o n g e r now  .79  6.  What p e r c e n t a g e of your problems remain t o be coped w i t h ? 1) 0% 2) 25% 3) 50% 4) 75% 5) 100%  .82  70  B. T h e r a p i s t r a t i n g P l e a s e i n d i c a t e y o u r f e e l i n g s about y o u r group l e a d e r by r e s p o n d i n g t o the items below u s i n g 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 = strongly disagree NOTE: Group l e a d e r s w i l l not be r e a d i n g t h i s form; the r e s u l t s w i l l be used f o r r e s e a r c h purposes o n l y . Item-to-total r 1. S/he seems t o be s u r e of what s/he i s d o i n g . .58 2. I f i n d h i s / h e r e x p l a n a t i o n s of my b e h a v i o u r c o n f u s i n g . .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 s u g g e s t i o n s 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 e x p e r i e n c e . . 6 5 C. Group atmosphere U s i n g t h e 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 t h e o t h e r members of your group. 1. I f e l t c l o s e t o most of t h e members of my group. 2. There were many a s p e c t s of my l i f e which I d i d not f e e l I c o u l d d i s c u s s i n t h i s group. 3. I l o o k e d f o r w a r d t o group m e e t i n g s . 4. I f e l t v e r y u n c o m f o r t a b l e i n my group. 5. I sometimes f e l t l i k e an o u t s i d e r . 6. I f e l t s a f e to e x p r e s s my deepest f e e l i n g s i n t h i s group. 7. I f e l t t h a t o t h e r group members r e a l l y c a r e d >about me as a p e r s o n . 8. Sometimes i t seemed t o me t h a t everyone was o n l y our t o help himself. 9. I f e l t t h a t some of t h e p e o p l e i n t h e group d i s a p p r o v e d of me. 10. There was an atmosphere o f warmth and s u p p o r t i n t h e group.  .61 .45 .51 .76 .54 .61 .68 .37 .58 .51  71  Appendix 3 Problem situations and t y p i c a l therapy interactions  72 S t r e s s f u l Situations Reported by Clients Incidence of problem' 1.  S o c i a l Situations a. groups of any kind b. parties c. meeting new people d. entertaining guests e. public speaking f. making requests of others g. using telephone h. eating i n front of others. 2. Work Situations a. dealing with unreasonable supervisors b. interruptions i n on-going a c t i v i t i e s c. s t a r t i n g new projects d. unreasonable requests from co-workers e. meeting deadlines f. supervising others g. work p i l i n g up. h. dealing with c o n f l i c t s among co-workers i . making presentations j . using the telephone k. dealing with tenants 3. School Situations a. writing exams b. giving seminars c. writing thesis 4. Situations Involving S i g n i f i c a n t Others a. dealing with spouse's disapproval b. d i s c i p l i n i n g children c. handling unreasonable demands from spouse d. dealing with domineering r e l a t i v e s e. responding to c r i t i c i s m from others f. handling unreasonable requests from parents 5. Other Situations a. d r i v i n g i n heavy t r a f f i c b. v i s i t i n g doctors c. being i n enclosed spaces d. being alone e. being i n high places f. walking near heavy t r a f f i c . g. shopping h. meeting a stranger while walking alone  a  i.21) 7 6 5 5 3 2 1 1 (41) 5 5 3 2 6 5 3 5 4 2 1 ( 4) 2 1 1 (19) 4 4 3 3 3 2 (12) 3 2 2 1 1 1 1 1  This column indicates the number of c l i e n t s who reported anxiety i n each of the problem s i t u a t i o n s .  73  S t r e s s f u l Situations for Individual Clients Cl: C2: C3: C4: C5: C6: C7: C8: C9: CIO: Cll: C12: C13: C14: C15: C16: C17: C18: C19: C20: C21: C22: C23: C24: C25: C26: C27: C28: C29: C30: C31: C32: C33: C34: C35: C36: C37: C38: C39: C40: C41: C42:  dealing with supervisors, supervising others. attending group meetings, teaching i n classroom. having d e f i n i t e time committments, c r i t i c i s m from friends. upsets i n work routime, co-ordinating co-workers. talking to strangers, groups. c o n f l i c t s among co-workers, meeting new people. speaking to large groups, enclosed spaces. interrupations i n on-going a c t i v i t i e s , confrontations with others entertaining guests, being alone. d i s c i p l i n i n g children, having suggestions ignored at work. parties, f i r s t meetings, housework p i l i n g up. small s o c i a l gatherings, dealing with people on the telephone at work. s t a r t i n g new projects, eating i n front of others, meeting deadlines. dealing with tenants, disapproval of spouse. driving i n heavy t r a f f i c , interference from parents. going to doctors, meeting a stranger while alone on street, d r i v i n g . dealing with supervisors, c o n f l i c t among co-workers, spouse's disapproval. meeting deadlines, preparing for guests, responding to unreasonable requests from co-workers. p a r t i e s , shopping, s t a r t i n g new projects. work deadlines, s o c i a l groups. work p i l i n g up, upsets i n normal routine. dealing with unreasonable requests from spouse, group situations. work deadlines, interference from parents, giving seminars. deadlines at work, unreasonable demands from parents. c o n f l i c t s among co-workers, dealing with supervisor. examinations, making requests of others. public speaking, confronting co-workers, dealing with domineering r e l a t i v e s . dealing with supervisor, supervising others, entertaining guests. c o n f l i c t among co-workers, making presentations at work, dealing with spouse's disapproval. s o c i a l gatherings, d i s c i p l i n i n g children. public speaking, dealing with unreasonable requests from co-workers. d i s c i p l i n i n g children, s t a r t i n g new projects. dealing with domineering r e l a t i v e s , meeting new people. upsets i n routine, dealing with spouse's unreasonable demands, supervision of others. entertaining guests, using the telephone, large groups of people, making presentations, driving, working on thesis. dealing with unreasonable demands of spouse, entertaining guests, making presentations. p a r t i e s , using the telephone at work, meeting new people, supervising others, interruptions i n routine, dealing with unreasonable requests from co-workers. d i s c i p l i n i n g children, work p i l i n g up. meeting deadlines, examinations, v i s i t i n g doctor. bridges and other high places, walking near t r a f f i c 7  74  Typical Therapy Interactions Condition 1; Interaction 1: Client:  I get very upset when somebody's sick.  Therapist: C:  Just anyone, or d i d something happen l a s t week?  No, a l l the time.  I l i v e with my aunt who has asthma, and she gets  attacks sometimes and she doesn't need me r e a l l y , they pass on t h e i r own, but when I hear her coughing I f e e l nervous. T:  Can you give a s p e c i f i c situation?  I t w i l l work better i f you can  give d e t a i l s . C:  Two nights ago. Tuesday maybe.  (Pause)  I'd just gone to bed and  I heard her coughing i n her room and I f e l t so tense, knots i n my stomach and t i g h t i n back, you know? T:  What did you thing when you heard her coughing?  C:  I thought she'd suffocate or something.  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. T:  Then a f t e r I couldn't go  I guess I'm too nervous.or something.  As I see this s i t u a t i o n you're saying tension-producing things to  yourself.  Correct me i f I'm wrong, but aren't you thinking things l i k e ,  "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  e f f e c t do you think that has?  C: I don't know i f I think anything. What I f e e l i s tense. T:  Why don't you t r y paying attention to what you're saying to yourself  75 next time t h i s 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, I t 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: T:  Not r e a l l y .  Then i t i s n ' t just the s i t u a t i o n , not just what's out there that's  bothering you.  I t ' s how you see i t i s n ' t i t ?  76  Interaction 2 : Client: office  I was walking back to my own o f f i c e and my boyfriend has an near there and I was going to stop i n and pick up a book. And  I walked i n the o f f i c e and t h i s secretary i s s i t t i n g there, you know, with a l l these engineers and people. a l l working.  It's dead quiet i n there, they're  I walked i n and said "Hi" to her., and t o l d the secretary  what I wanted, and my f r i e n d was on the phone i n this o f f i c e . r e a l l y uncomfortable, standing there.  I felt  everything's so quiet and I'm just sort of l e f t  Didn't know i f I should wave to him or just stand there  and somehow make myself inconspicuous.  The sort of f e e l i n g was that  somehow I was not the same as those people.  I f e e l that maybe they look  down on me and I f e e l on the spot, people looking at me.  My stomach  started to hurt, aad f i n a l l y a f t e r 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 o f f i c e i f I'm near him or h i s friends, I f e e l l i k e that. Therapist: office. C:  I f e e l l i k e a l i t t l e country bumpkin or something.  Can we go back to the beginning.  When d i d you begin to f e e l  F i r s t you walked into the  uncomfortable?  I t was dead quiet and I f e l t l i k e I didn't want to take another step.  I f e l t f a r 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 f e e l i n g , somebody please be f r i e n d l y , 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 e a r l i e r that somehow they're more sophistocated than you are. C:  I f e e l I'm  not on equal footing.  T:  Seems to me l i k e the thought, "I'm  may  be upsetting you.  Seems l i k e you're also saying to yourself,"  they're a l l n o t i c i n g me, C:  not as sophistocated as they are  I'm  i n the way,  I wonder how  I look".  Well, I sort of thought, they're just s i t t i n g there, and i t was  so  quiet and I wondered what they thought. T:  What e f f e c t do you think those thoughts had on you?  C:  I'm  T:  Did i t matter what those people thought.  C:  I suppose not, they probably didn't care much one way  T:  That's r i g h t .  not sure.  or-the other.  So what i f you had changed what you said to yourself?  Instead of upsetting yourself l i k e you did, you could have thought, "I have a r i g h t to be here, they aren't noticing me anyway, I know I look a l l right". C:  I t would be hard because I always f e e l odd when I go to that o f f i c e .  T:  You don't think you could change.  Let's t r y i t here.  (They go on to rehearse coping self-statements which the c l i e n t can use i n this s i t u a t i o n ) .  78  Condition 2: Interaction 1: Client:  I brought my s i s t e r and her r e a l l y young baby and the whole  time I was on the freeway I was r e a l l y tense because I was sort of thinking unconsciously maybe, what i f I had an accident with them i n the car as well.  And i t was extra-bad going over the bridge.  Therapist: C:  When did you s t a r t to notice the tension?  Well I notice i t a l i t t l e as soon as I get onto the freeway. I t " s  not enough to r e a l l y bother me. T:  Where do you f e e l i t ?  C:  In my neck, my legs, my whole body r e a l l y .  T:  Does i t get worse as time goes on?  C:  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,  Sometimes i t gets better, but usually i t gets worse.  what a t e r r i b l e 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 i n 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 s i s t e r talks a l o t , 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 r e a l l y bad, a feeling of fear,  s t i f f e n i n g up a l l over.  I guess that's the f i r s t sign of stress I have.  And then I s t a r t 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 f e e l i n g I had had of overconfidence  because of thinking I'd gotten something out of t h i s .  I don't r e a l l y  f e e l bad about myself - i t ' s a b i t of a letdown. T:  How?  C:  I t makes me r e a l l y mad.  T:  I'm not sure what you're angry a t .  C:  I'm angry at myself because I l e t myself get tense.  I feel I  can't control i t . T:  So when you're coming across the bridge you're just s t a r t i n g to get  onto the freeway and I think your thoughts go something l i k e , "I don't think I can make i t across the bridge, I hope at least I'm sucessful i n getting across, I hope I'm not i n an accident, I'm getting t i g h t , i f I got i n an accident now I could hurt myself, my s i s t e r and her baby, i t looks l i k e I'm not going to make i t across the bridge, I'm r e a l l y tense, I can't even do t h i s , I'm out of control with i t . " C: Yes, that's r e a l l y the way I think. T:  Did anyone see anything  Another C l i e n t :  i r r a t i o n a l i n that sequence?  A l o t of i t was i r r a t i o n a l .  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 C l i e n t :  I had the f e e l i n g 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 i s keep track of exactly how you f e e l each time  you cross the bridge on a f i v e point scale. of how you're doing.  That way you can get an idea  Without that kind of thing you don't know.  80  Interaction 2 : C:  I was c a l l e d i n by an a r c h i t e c t at the l a s t minute to f i n i s h a job  a f t e r someone else was  fired.  T:  How  d i d you feel?  C:  I was distraught.  T:  Did you shake?  C:  I didn't have the shakes when I went down to meet the man but p r i o r  I was very tense a l l over.  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 s i t u a t i o n l i k e l y 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  T:  Would that have made you f e e l more comfortable?  C:  Yeah, I guess so.  fired.  I don't l i k e 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 i n two days.  I  couldn't do that. T:  Can you t e l l me what you were saying to yourself.  C:  Well p r i o r to the meeting I didn't <fieel uptight.  How were you feeling? I t was  the moral  objection, about taking over for the other builder. T:  Just before the meeting?  C:  Well I could f e e l tension building up, because the other guy got f i r e d .  81 Anyway at the meeting I t o l d him I just couldn't have things ready as soon as he wanted —  that i t wasn't humanly possible.  He seemed annoyed,  but i n 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 i n those terms, I probably said, "I wonder i f this w i l l  work out, because the other guy got f i r e d , and I need t h i s job".  Maybe  I also thought I'd not do i t very w e l l . T:  So maybe you were making i t hard for yourself?  C:  Yes, I suppose I was r e a l l y . When I think about i t now, I didn't  r e a l l y need the job and a l l that hassle, d i d I?  82 Condition3: Interaction 1: Therapist:  At the end of l a s t week i t weemed that you had some s p e c i f i c  s i t u a t i o n or some incident that was going to be happening soon. Client:  Well, today, I was very busy with d i c t a t i n g 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 f o r mistakes are supposed to c a l l before that. T:  Yes.  C:  And this morning the manageress came b a r e l l i n g down before ten o'clock  and said i n 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 y o u ' l l have to f i n i s h this up."  She drops a p i l e 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 s e t 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 d i d . go through what was actually done.  The c l i e n t has responded  possibly do the work before the cutoff time. care.  ( F i r s t they thatshe can't  Manageress says she doesn't  C l i e n t feels very upset because she knows she can't do i t alone.'  The group discusses alternative solutions.  I t i s decided that the best  approach to take i s for the c l i e n t to suggest that she wants to do the best job she can and that she i s worried that she won't be able to do i t under the present circumstances.)  83 T:  Why don't you t r y i t here?  A Second C l i e n t :  (role playing)  I'm going to have to take the women to  the board and you w i l l have to f i n i s h these tapes. C:  I'm sorry but we're actually r e a l l y swamped.  Is there any possible  way that I can have somebody give me a hand? C2: C:  No, you're going to have to f i n i s h them a l l . I'm a f r a i d I won't be able to before deadline.  C2:  I'm sure y o u ' l l be able to.  T:  Maybe you shouldn't s t a r t out i n the beginning by saying that the  s i t u a t i o n i s impossible.  Say that you're very w i l l i n g but i t i s n ' t  possible.  Indicate you're w i l l i n g f i r s t .  She can't argue i f you agree  with her.  (The c l i e n t agrees to t r y t h i s out.)  84 Interaction 2: C:  I have something that happened.  me tense to think of i t even now.  I don't f e e l good about i t , makes  (laughs)  T:  Could you t e l l us about i t ?  C:  I supervise people who work as docents, at the g a l l e r y .  Sometimes  I have to speak to them about poor performance and I had to talk -to a _  woman l a s t week. T:  Could you be more s p e c i f i c ?  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 f e e l nervous for the whole day.  But i t s part of my job.  T:  What did you do?  C:  I c a l l e d her into my o f f i c e and t o l d her that she should change her  attitude. T:  I was frank with her.  I thought I should be.  But you didn't f e e l good about i t ? Could you say more about bothered  you? C:  Not r e a l l y , i t seems that other people always make me f e e l I don't  have the r i g h t to do what I do. T:  What did you say to her?  C:  I said maybe she should t r y 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 d i d . Second C l i e n t :  Wasn't she paid?  C:  No, docents are volunteers.  T:  Can anyone suggest how M--—"  Another C l i e n t :  could have behaved d i f f e r e n t l y ?  Seems l i k e you were too timid.  Sometimes that seems to  85 be an i n v i t a t i o n . T:  What else could M  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  have done?  what else might you have said?  C:  I could have been more d e f i n i t e .  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  myself better, but why why  should I, she knows I'm  I would have explained  i n charge.  I don't see  I can't just say what I think and not f e e l so upset.  Other C l i e n t :  I t ' s l i k e out next door neighbour..  in such a mess. T:  for me to speak to her.  So I t e l l them and they get  They leave t h e i r yard  mad.  Since what you t r i e d before hasn't made you comfortable,  i t seems to  me that maybe you should l i s t e n to suggestions from others i n the group. Another C l i e n t :  Like she said before, she should be more d e f i n i t e , l e t  the woman know where she T: C2: T:  How  stands.  could she do that?  She could explain h e r s e l f . Yes, she could rehearse a l i t t l e speech i n which she t e l l s the woman  in a straightforward way  how  she feels and what i s required.  I think she  could say something l i k e "I have heard that there i s some kind of c o n f l i c t between you and the other docents. point of view i s ?  Would you l i k e to t e l l me what your  Let's t r y role-playing i t i n the group.  proceed to role-play the scene and afterward M new  (They  agrees to t r y out the  approach the next time a similar s i t u a t i o n arises.)  

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