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An exploratory study of two approaches to social anxiety, symptom-accepting, positive reinterpretation… Hodge, Catherine Theresa 1990

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AN EXPLORATORY STUDY OF TWO APPROACHES TO SOCIAL ANXIETY, SYMPTOM-ACCEPTING, POSITIVE REINTERPRETATION AND SYMPTOM-CONTROLLING, PROGRESSIVE RELAXATION. by CATHERINE THERESA HODGE B.A., Simon Fraser University, 1986 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Education We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA SEPTEMBER 1990 CATHERINE THERESA HODGE, 1990 % 5 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British 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 or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada Department Date DE-6 (2/88) Abstract This study examined the d i f f e r e n t i a l e f f e c t s of an audiotaped progressive relaxation message and an audiotaped p o s i t i v e r e i n t e r p r e t a t i o n message, repeatedly presented over three sessions to s o c i a l l y anxious subjects. Self report measures of s o c i a l anxiety, attitude towards anxiety, coping effectiveness, and acceptance of anxious s e l f , and the frequency of action taken i n target situations were examined. The subjects were 14 males and females aged 19-38 (M=2 6.14) who were randomly assigned to either p o s i t i v e r e i n t e r p r e t a t i o n or progressive relaxation treatment condition. Repeated measures analysis of variance indicated no c l e a r s t a t i s t i c a l l y s i g n i f i c a n t support for the s u p e r i o r i t y of one treatment approach over the other, or f o r the uniform d i f f e r e n t i a l effectiveness of the two treatments over time. There was a s i g n i f i c a n t difference between the two groups on the measure of s o c i a l anxiety but t h i s d i f f e r e n c e was time dependent, that i s , time interacted p o s i t i v e l y with one group r e l a t i v e to the other group at follow-up, and the reverse was true at post-test. E f f e c t s i z e indicated c l i n i c a l l y meaningful differences between treatment groups on attitude towards anxiety and on acceptance of anxious s e l f . i i i TABLE OF CONTENTS ABSTRACT i i TABLE OF CONTENTS i i i LIST OF TABLES v i LIST OF FIGURES v i i ACKNOWLEDGEMENTS. v i i i INTRODUCTION 1 Hypotheses . 4 LITERATURE REVIEW 7 The Concept of Anxiety 8 Theoretical Models of Soc i a l Anxiety 11 Conditioned Anxiety Hypothesis 12 Cognitive Self-evaluation 13 Treatments 1 5 Progressive Relaxation . . 1 5 P o s i t i v e Reinterpretation 1 8 Treatment Mode 1 9 Summary . . . . . 2 1 METHOD 2 2 Subjects 2 2 Design and Procedures 2 3 Dependent Measures 2 4 S o c i a l Avoidance & Distress Scale 2 4 Self and Anxiety Questionnaire 2 4 Action Log • 2 5 i v Screening Measures 25 Fear of Negative Evaluation .25 Beck Depression Inventory 2 6 Treatments 27 RESULTS. • • 29 Group Comparability and Subject A t t r i t i o n 29 Analysis of Data 31 Hypothesis 1 3 3 Hypothesis 2 • • 40 Hypothesis 3 44 Hypothesis 4 47 Hypothesis 5 50 DISCUSSION 52 Limitations • 55 Recommendations 56 Conclusions 57 REFERENCES 59 APPENDIX A • 68 Introduction Letter 69 Informed Consent 70 APPENDIX B 71 So c i a l Avoidance and Distress Scale 72 Self and Anxiety Questionnaire 74 Action Log 76 Fear of Negative Evaluation 78 Beck Depression Inventory 80 APPENDIX C 82 Summary: Po s i t i v e Reinterpretation 8 3 Summary: Progressive Relaxation 84 APPENDIX D .85 Tape S c r i p t : P o s i t i v e Reinterpretation 86 Tape S c r i p t : Progressive Relaxation 106 V I LIST OF TABLES Table 1. Means and Standard Deviations of Baseline Data f o r Two Groups (Positive Reinterpretation, Progressive Relaxation) 30 Table 2. Means and Standard Deviations for Two Groups (Positive Reinterpretation, Progressive Relaxation), pre-, post-, and follow-up 32 Table 3. Analysis of Variance with Repeated Measures of So c i a l Avoidance and Distress (SAD) scores 34 Table 4. Overall Mean Scores on SAD for the Two Treatment Groups (Positive Reinterpretation, Progressive Relaxation), pre-, post-, and follow-up 36 Table 5. Interaction Effects 38 Table 6. Analysis of Variance with Repeated Measures of Attitude Towards Anxiety (SAQ subscale 1) scores.. 41 Table 7 E f f e c t Size for Two Groups (Positive Reinterpretation, Progressive Relaxation) based on Pre-/Post-test, and Post-/Follow-up Change Scores. 43 Table 8. Analysis of Variance with Repeated Measures of Coping Effectiveness (SAQ subscale 2) scores....45 Table 9. Analysis of Variance with Repeated Measures of Acceptance of Anxious Self (SAQ subscale 3) scores 48 Table 10. Chi-Square Test of Association between Testing pre-, post) and Intervention (Positive Reinterpretation and Progressive Relaxation).... 51 v i i LIST OF FIGURES Figure 1. Overall Mean Scores on SAD for the Two Treatment Groups, (Positive Reinterpretation, Progresive Relaxation), pre-, post and follow-up 35 Figure 2. Interaction Ef f e c t of Testing (pre-, post-,follow-up) and Treatment (Positive Reinterpretation, Progressive Relaxation) on SAD 39 Figure 3. Overall Mean Scores on SAQ(subscale 1) f o r the Two Treatment Groups (pre-,post- and follow-up) 42 Figure 4. Overall Mean Scores on SAQ(subscale 2) for the Two Treatment Groups (pre-, post- and follow-up)....46 Figure 5. Overall Mean Scores on SAQ(subscale 3) for the Two Treatment Groups (pre-, post- and follow-up).... 49 ACKNOWLEDGEMENTS I would l i k e to express my appreciation to the chairman of my committee, Dr. I. Ishiyama, and to the members of the committee, Dr. E. Goldner and Dr. R. Young, for t h e i r guidance and support throughout my thesis project. Also, I would l i k e to express my appreciation to Dr. W. Boldt f o r consulting with me on many occasions. F i n a l l y , I would l i k e to express my appreciation to my children, Paul, Fin and Caragh, for t h e i r encouragement. 1 Introduction Anxiety i s a basic condition of human existence and s o c i a l anxiety i s p a r t i c u l a r l y prevalent i n our Western society where we p r i z e assertiveness and competitiveness and have expectations of achievement and upward mobility. An e f f e c t i v e coping technique would improve the q u a l i t y of l i f e f o r many people. The understanding and treatment of s o c i a l anxiety has attract e d attention i n recent years (Bates, Campbell & Burgess, 1990; Hartman, 1983; Ishiyama 1986a, 1987b, 1988; Leary, 1983a). S o c i a l anxiety i s a common complaint of people seeking counselling (Heubner, 1988). T y p i c a l l y , the presenting problems r e l a t e to discomfort i n s o c i a l i n t e r a c t i o n s , as well as heightened avoidance of s o c i a l s i t u a t i o n s (Clark & Arkowitz, 1975). S o c i a l anxiety often r e s u l t s i n i n h i b i t i o n of normally expected s o c i a l behavior i n frequently occurring events such as i n t e r a c t i o n with strangers, job interviews, being the centre of attention, t a l k i n g to authority figures and public speaking (Leary, 1983a). S o c i a l anxiety has been c i t e d as more pervasive, d e b i l i t a t i n g and d i s t r e s s i n g than other commonly studied types of anxiety (Curran, 1977) , and there has been a p r o l i f e r a t i o n of cognitive and behavioural approaches which focus on i t s symptomatic r e l i e f (Guidano & L o t t i , 1983). A t r a d i t i o n a l behavioral approach f o r coping with anxiety i s progressive relaxation which was developed by 2 Jacobson (1938). These relaxation procedures have been used so extensively that they have been c a l l e d the "behavioral a s p i r i n " (Russo, 1980). Progressive r e l a x a t i o n has been found e f f e c t i v e i n the treatment of s o c i a l anxiety (Bernstein & Borkovec, 1973; Canter, Kondo & Knott, 1975; H a l l & Goldberg, 1977; Paul, 1966). A standardized procedure f o r progressive relaxation t r a i n i n g has been developed by Bernstein and Borkovec (197 3) to increase g e n e r a l i z a b i l i t y and v a l i d i t y of outcome research. Their procedures w i l l be used i n t h i s study. The emerging trend i n dealing with anxiety i s towards the cognitive therapies and the focus of these approaches i s on cognitive events, such as i n t e r n a l dialogue, s e l f statements and images, as the i n i t i a l mechanism of change (Ri t t e r , 1985). The implication i s that change i n behavior occurs through c o n t r o l of anxiety symptoms. Cognitive techniques, such as r a t i o n a l r e s t r u c t u r i n g (Goldfried, 1988) and s t r e s s inoculation t r a i n i n g (Meichenbaum & Deffenbacher, 1988) have been e f f e c t i v e i n the reduction of s o c i a l anxiety. A promising intervention, the p o s i t i v e r e i n t e r p r e t a t i o n technique of Morita therapy, has also been used i n the treatment of s o c i a l anxiety (Ishiyama, 1986a, 1986c). A Japanese approach, Morita therapy, shares a s i m i l a r t h e o r e t i c a l perspective to some Western cognitive approaches to s o c i a l anxiety with respect to s e l f - d e f e a t i n g causal a t t r i b u t i o n s and excessive s e l f - f o c u s i n g (Anderson & 3 Arnoult, 1985; Brodt & Zimbardo, 1981; Crozier, 1979; Hartman, 1983; Sarason, 1975; Slivken & Buss, 1984; T e g l a s i & Hoffman, 1982). However, Morita therapy d i f f e r s from other cognitive therapies i n i t s primary mechanism of change, which i s the acceptance of undesirable f e e l i n g s . The fundamental premise of Morita therapy i s that s o c i a l anxiety can be used as a m o t i v a t o r - f a c i l i t a t o r of constructive action through acceptance of undesirable f e e l i n g s . The implication i s that change i n behavior can occur without any p r i o r control of symptoms. Some studies, using a time-series analysis of change process and outcome, have indicated that using very b r i e f Morita therapy, as b r i e f as a sing l e interview session, i s t h e r a p e u t i c a l l y e f f e c t i v e with s o c i a l l y anxious c l i e n t s (Ishiyama, 1983, 1986c, 1988b). Consequently, t h i s study used a b r i e f Morita intervention. The treatment success reported by Ishiyama (1986c) could be a t t r i b u t e d to the i n c l u s i o n of the r a p i s t empathic a t t e n t i o n within the treatment, and i t i s considered that audiotaped messages i n both treatment packages would minimize the interpersonal variables and eliminate the empathic attention component. Audiotaped progressive r e l a x a t i o n programs have been found to be e f f e c t i v e i n reducing anxiety, general tension, speech anxiety and s o c i a l phobias (Borkovec, Grayson & Cooper, 1978; Hamberger, 1983; Heidi & Borkovec, 1983; Paul & Trimble, 1970; Robar 1978). In t h i s study s p e c i a l l y prepared audiotapes of progressive 4 r e l a x a t i o n (Bernstein & Borkovec, 1973) and the p o s i t i v e r e i n t e r p r e t a t i o n technique (Ishiyama, 1986a) were used. Progressive rela x a t i o n was used i n t h i s study because i t has been shown to be e f f e c t i v e i n reducing state anxiety f o r a wide v a r i e t y of populations (Cangelosi, 1980; Heidi & Borkovec, 1983; Woolfoik, Lehrer, McCann, & Rooney, 1982) . The Morita therapy technique of reframing c a l l e d "the p o s i t i v e r e i n t e r p r e t a t i o n technique" was used because i t provides a p o s i t i v e view of anxiety and promotes action taking, and has proven successful i n t r e a t i n g anxiety-type emotional and behavioral problems i n Japan and i n the West (Ishiyama, 1986c; Kawai & Kondo, 1960; Miura & Usa, 1970; Morita, 1926/1974; Suzuki & Suzuki, 1977; Reynolds, 1976). The main objective of t h i s study was to examine the e f f e c t s of a b r i e f audiotaped p o s i t i v e r e i n t e r p r e t a t i o n message and a b r i e f audiotaped progressive r e l a x a t i o n message, repeatedly presented over three sessions to s o c i a l l y anxious subjects. Hypotheses Five research hypotheses were investigated i n t h i s study. No group experimental studies have been reported on the comparative e f f e c t s of the P o s i t i v e Reinterpretation technique of Morita Therapy and another intervention based on a d i f f e r e n t t h e o r e t i c a l o r i e n t a t i o n . There i s no 5 l i t e r a t u r e that suggests the s u p e r i o r i t y of one approach over the other. Therefore, hypotheses are stated i n a non-d i r e c t i o n a l form. The following n u l l hypotheses have been tested i n t h i s study: Hypothesis 1. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test to follow-up s o c i a l anxiety, as measured by the S o c i a l Avoidance and Distress Scale, between subjects who received i n s t r u c t i o n i n progressive relaxation and subjects who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n Hypothesis 2. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test to follow-up a t t i t u d e towards anxiety, as measured by the S e l f and Anxiety Questionnaire, subscale 1, between subjects who received i n s t r u c t i o n i n progressive r e l a x a t i o n and subjects who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . Hypothesis 3. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test to follow-up coping effectiveness, as measured by the Self and Anxiety Questionnaire, subscale 2, between subjects who received i n s t r u c t i o n i n progressive r e l a x a t i o n and subjects who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . 6 Hypothesis 4. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test to follow-up acceptance of anxious s e l f , as measured by the S e l f and Anxiety Questionnaire, subscale 3, between subjects who received i n s t r u c t i o n i n progressive r e l a x a t i o n and those who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . Hypothesis 5. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d ifference i n pretest to post-test behavioral counts, as measured by the Action Log, between subjects who received i n s t r u c t i o n i n progressive r e l a x a t i o n and subjects who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . L i t e r a t u r e Review There are varying pathways to change i n s o c i a l anxiety, and many of these advocate symptom-controlling approaches. Wolpe and Lazarus (1966), f o r example, consider that lack of s o c i a l s k i l l i s due to the i n h i b i t i o n of natural responses by anxiety and, therefore, an anxiety-reduction technique would be the treatment of choice. Beck (1976), E l l i s (1962) and Meichenbaum (1985) emphasize the r o l e of i l l o g i c a l and maladaptive cognitions about s e l f i n the maintenance of s o c i a l dysfunction and, therefore, the treatment of choice would be to i d e n t i f y and modify the anxiety producing co g n i t i v e processes and structures (Ritter 1985). In t h i s study, the former symptom-controlling approach using progressive r e l a x a t i o n (Jacobson, 1938) as a method, i s used as a comparison f o r an innovative symptom-accepting approach, using the p o s i t i v e r e i n t e r p r e t a t i o n method (Ishiyama, 1986a). The following sections contain the t h e o r e t i c a l formulations within which t h i s study i s conceptualized, with a review of the concept of anxiety. Research support i s provided for interventions such as progressive r e l a x a t i o n and the p o s i t i v e r e i n t e r p r e t a t i o n technique of Morita therapy. Furthermore, the use of audiotaped messages i s reviewed i n r e l a t i o n to treatment of s o c i a l anxiety. 8 The Concept of So c i a l Anxiety Schlenker and Leary (1982) proposed that s o c i a l anxiety can be considered conceptually d i s t i n c t from other a n x i e t i e s and has the common property of being aroused and i n t e n s i f i e d by other people. The s o c i a l anxiety factor obtained by Strahan (1974) included items such as being introduced to new people, g i v i n g a speech, being interviewed f o r a job, being i n a room f u l l of strangers, and dating someone f o r the f i r s t time. A s i m i l a r anxiety factor was obtained i n a study of children's fears and included items such as making mistakes, being c r i t i c i z e d , making someone angry, and r e c i t i n g i n c l a s s ( M i l l e r , Barrett, Hampe & Noble, 1972) . These studies provided evidence f o r an em p i r i c a l l y d i s t i n g u i s h a b l e c l a s s of anxieties that a r i s e i n response to s o c i a l events. T y p i c a l l y , s o c i a l anxiety r e f e r s to subjective discomfort i n the presence of others (Buss, 1980), and appears under such l a b e l s as: s o c i a l anxiety, shyness, s o c i a l i n e f f e c t i v e n e s s , dating anxiety, heterosexual-social anxiety, speech anxiety, communication apprehension, embarassment, and stagefright. Schlenker and Leary (1982) d i v i d e the diverse forms of s o c i a l anxiety into two broad cl a s s e s : (a) i n t e r a c t i o n anxiety which involves continuous input and feedback from others, and includes shyness and dating anxiety, and, (b) audience anxiety which involves 9 performing preplanned material before others, and includes s t a g e f r i g h t and speech anxiety. Although not i d e n t i c a l , these two forms of s o c i a l anxiety are p o s i t i v e l y c o r r e l a t e d (r=.48) and i n d i v i d u a l s who tend to experience one often w i l l manifest the other. There are differences i n the i n t e n s i t y and frequency with which i n d i v i d u a l s experience anxiety. Some experience anxiety r a r e l y while others experience anxiety i n a large number and v a r i e t y of settings. Crozier (1979) regards i n d i v i d u a l differences i n the tendency to experience s o c i a l anxiety as a t r a i t v a r i a b l e . C a t t e l l and Scheier (1958) d i f f e r e n t i a t e d between t r a i t and state anxiety. They defined t r a i t or chronic anxiety as a r e l a t i v e l y stable pe r s o n a l i t y c h a r a c t e r i s t i c , and state anxiety as a r e l a t i v e l y acute anxiety that i s t r a n s i t o r y i n nature. The s t a t e - t r a i t d i s t i n c t i o n encompasses considerations of person and s i t u a t i o n when pre d i c t i n g changes i n state anxiety. A person high i n t r a i t - a n x i e t y would be expected to disp l a y higher l e v e l s of state-anxiety i n s t r e s s f u l s i t u a t i o n s , and no d i f f e r e n c e s i n state-anxiety would be expected i n neutral s i t u a t i o n s (Goldberger & Breznitz, 1982). In addition, high t r a i t - a n x i e t y i n d i v i d u a l s perceive a wide range of stimulus as threatening and respond to these s i t u a t i o n s with high-state anxiety (Sieber, O'Neil & Tobias, 1977). More recently, s o c i a l anxiety has been defined as an a f f e c t i v e , cognitive, and behavioral response indicated by 10 f e e l i n g s of arousal, apprehension, and tendencies towards avoidance and d i s t r e s s , which r e s u l t s from the expectation of personal evaluation i n r e a l or imagined s o c i a l s i t u a t i o n s Hartman (1983). A f f e c t i v e components of s o c i a l anxiety involve unpleasant dimensions, concurrent with high i n t e n s i t y (Leary, 1983a). Cognitive components of s o c i a l anxiety include thoughts of s o c i a l inadequacy, fear of negative evaluation, concern with others' awareness of personal d i s t r e s s , and preoccupation with arousal or performance (Hartman, 1984). Behaviors associated with s o c i a l anxiety include decreased eye contact, avoidance of s i t u a t i o n s , attentive l i s t e n i n g , nodding and nervous responses such as s t u t t e r i n g and f i d g e t i n g . S o c i a l s i t u a t i o n s are s i t u a t i o n s wherein i n d i v i d u a l s may be the focus of attention of others, and where there i s the prospect of interpersonal evaluation, as when they are g i v i n g a speech or are engaged i n conversation. Schlenker and Leary (1982) consider that the perceived i n a b i l i t y to deal e f f e c t i v e l y with interpersonal evaluation p r e c i p i t a t e s s o c i a l anxiety. The prospect of interpersonal evaluation appears to d i s t i n g u i s h s o c i a l anxiety from other forms of anxiety. A r e l a t e d area of d i s t r e s s i s S o c i a l Phobia (DSM-III-R, 300.23) which i s i r r a t i o n a l fear of s o c i a l s i t u a t i o n s where the person i s i n a p o s i t i o n to be judged by others, such as p u b l i c speaking. This fear leads to a n t i c i p a t o r y anxiety which exacerbates the person's a b i l i t y to perform w e l l . In 11 t h i s way, the fear of being s o c i a l l y inadequate creates s o c i a l inadequacies (Gutsch, 1988). In other forms of anxiety the focus i s not about the evaluations of others. For example, Generalized Anxiety (DSM-III-R, 300.02) i s viewed as an i r r a t i o n a l fear or p e r s i s t e n t uneasiness which ex i s t s without appropriate cause; Agoraphobia (DSM-III-R, 3 00.21) i s fear of being alone or being i n public places marked by recurrent f e e l i n g s of panic; and Simple Phobia (DSM-III-R 300.29) wherein the person i s overcome by f e e l i n g s of fear but can do nothing to overcome them. The common concerns among these fears are snakes, insects, rodents, dogs, f l y i n g and darkness (Gutsch, 1988) . In summary, s o c i a l anxiety i s a d i s t i n c t and highly prevalent condition i n the North American c u l t u r e and i s construed as emotional d i s t r e s s i n a n t i c i p a t i o n of, or involvement i n , an interpersonal encounter. T h e o r e t i c a l Models of S o c i a l Anxiety The l i t e r a t u r e on s o c i a l anxiety may be categorized i n t o two major approaches: conditioned anxiety, and co g n i t i v e s e l f - e v a l u a t i o n (Schlenker & Leary, 1982) . Each model w i l l be b r i e f l y examined p r i o r to presenting an innovative cognitive-behavioral approach to the treatment of s o c i a l anxiety. 12 Conditioned Anxiety Hypothesis. The conditioned anxiety hypothesis has received a great deal of attention i n the behavioral l i t e r a t u r e over the years. This view states that s o c i a l anxiety i s due to the i n h i b i t i o n of interpersonal responses by anxiety (Wolpe & Lazarus, 1966). This approach suggests that autonomic arousal conditioned to s o c i a l i n teractions i n t e r f e r e s with s a t i s f a c t o r y interpersonal functioning. The procedure involves the s u b s t i t u t i o n of a favourable response which i s incompatible with the unfavourable response to the stimulus. This technique i s aimed at the a l l e v i a t i o n of maladaptive anxiety and involves the association of r e l a x a t i o n with imagery scenes of anxiety-producing s i t u a t i o n s . Learning to r e l a x while imagining the anxiety-evoking scenes a l l e v i a t e s or eliminates the anxiety response, with the r e s u l t that a c t u a l experience w i l l not evoke high l e v e l s of anxiety (Humphrey, 1984). Consequently, t h i s approach focuses on interventions based on anxiety reduction or c o n t r o l . I n d i r e c t support for t h i s hypothesis i s provided by studies i n d i c a t i n g reduction of s o c i a l anxiety through r e l a x a t i o n and systematic d e s e n s i t i z a t i o n interventions (Curran & G i l b e r t , 1975; Hartman, 1983; Trower, Yardley, Bryant, & Shaw, 1978). Direct support i s provided by studies i n d i c a t i n g reduction of t e s t anxiety (Russel & S i p i c h , 1973), speech anxiety (Goldfried & T r i e r , 1974) and 13 interpersonal anxiety (McCann, Woolfolk & Lehrer, 1987), through progressive relaxation as a primary intervention. Cognitive Self-evaluation. Despite the f a c t that there i s considerable s i m i l a r i t y between t r a d i t i o n a l behavior therapy and the second approach, cognitive therapy, there are some t h e o r e t i c a l and p r a c t i c a l d i f ferences between them. Although both approaches focus on s p e c i f i c symptoms and behavior problems, cognitive therapy concentrates on the ideation associated with the symptoms (Bedrosian & Beck, 1980). The cog n i t i v e view states that factors such as i r r a t i o n a l b e l i e f s , negative s e l f - e v a l u a t i o n , u n r e a l i s t i c performance c r i t e r i a , and i n s u f f i c i e n t self-reinforcement may be involved i n the maintenance of s o c i a l anxiety (Hartman, 1983). Cognitive procedures suggest that b e l i e f s can a f f e c t emotional reactions, e s p e c i a l l y those b e l i e f s expressed i n negative self-statements. Cognitive techniques teach i n d i v i d u a l s to develop more p o s i t i v e self-statements to a s s i s t i n reducing anxiety. Evidence f o r t h i s has been reported by many researchers such as: Goldfried and Sobocinski, (1975); O'Banion and Arkowitz, (1977); Smith and Sarason, (1975); Clarke and Arkowitz, (1975); Cacioppo, Glass, and Merluzzi, (1979); Go l d f r i e d , (1988), Malkiewich and Merluzzi, (1980); f o r reviews see Merluzzi, Glass, and Genest, (1981). 14 The cognitive approach suggests that attaching an u n r e a l i s t i c meaning to an event may r e s u l t i n an inappropriate emotional response. Further, change i n an i n d i v i d u a l ' s thinking a l t e r s the emotional response (Glass & Merluzzi, 1981). Thus, t h i s approach aims to r e l i e v e the symptoms of anxiety through d i r e c t modification of dysfunctional ideation. Controlled research on the e f f i c a c y of cognitive techniques for the problems of heterosexual shyness, nonassertiveness, and t e s t and speech anxiety has f i r m l y established that cognitive interventions s i g n i f i c a n t l y contribute to a f f e c t i v e and behavioral change. (Glass & Merluzzi, 1981). Some confirmation of actual changes i n cognitive appraisal process has been demonstrated by Alden and Cappe (1981), Arnkoff (1980), and Glogower, Fremouw, and McCroskey (1978). However, Glass and Merluzzi (1981) caution against assuming a simple causal connection between cognition and a f f e c t and viewing emotion or anxiety as a product of cogni t i v e processes. Lazarus (1980) considers that cognition i s also influenced by emotion and motivation and views these three factors as interdependent processes. Morita (1928/1974) considers that temperamental and environmental factors predispose an i n d i v i d u a l to mental c o n f l i c t , and attempts to resolve these anxieties by means of i n t e l l e c t u a l i z a t i o n magnifies the c o n f l i c t (Goldner, 1989, Ishiyama, 1986a, 1986b; Reynolds, 1984). The p o s i t i v e 15 r e i n t e r p r e t a t i o n technique of Morita therapy, which has been used as a treatment for s o c i a l anxiety, also emphasises the modification of cognitions. However, i n addition to modifying c l i e n t s 7 s e l f - d e f e a t i n g causal a t t r i b u t i o n s and excessive s e l f - f o c u s i n g , i t focuses on accepting anxiety by a l t e r i n g cognitions about emotions. Instead of attempting to manipulate the symptoms of anxiety thereby energizing and exaggerating them, p o s i t i v e r e i n t e r p r e t a t i o n focuses on acceptance of anxiety, reframing of negative ideation and focusing on constructive action (Ishiyama, 1986a). In summary, two of the major t h e o r e t i c a l formulations of s o c i a l anxiety, conditioned anxiety and cognitive modification, are viewed as anxiety symptom-controlling methods, and the cognitive component of Morita therapy, p o s i t i v e r e i n t e r p r e t a t i o n , i s introduced as a symptom-accepting approach. Treatments Progressive relaxation. Jacobson (1938) was the pioneer i n the study of progressive muscle re l a x a t i o n . He believed that r e l a x i n g the muscles and gaining voluntary control over the s k e l e t a l muscles could induce very low l e v e l s of tension i n the major muscles. v 16 Jacobson's (1938) investigations i n c l i n i c a l physiology led him to conclude that i t i s possible to regulate c e r t a i n e f f e c t s of the autonomic nervous system through self-management e f f o r t s . He discovered that anxiety can be caused by the sensation of tension experienced when muscle f i b e r s are shortened or contracted as they are during a s t r e s s f u l s i t u a t i o n . Conversely, he believed that tension cannot be present when muscle f i b e r s lengthen or rel a x . Progressive r e l a x a t i o n i s considered by Gol d f r i e d and T r i e r (1974) to be an anxiety-reducing s k i l l because i t reduces muscle tension and the i n d i v i d u a l then perceives himself/herself to be less anxious. The purpose of progressive r e l a x a t i o n i s to increase d i s c r i m i n a t i v e control over the s k e l e t a l muscles u n t i l the i n d i v i d u a l i s able to cause low l e v e l s of a c t i v i t y i n the major muscle groups. Progressive r e l a x a t i o n t r a i n i n g c o n s i s t s of learning to tense and relax various muscle groups throughout the body while at the same time paying c a r e f u l a t t e n t i o n to the feel i n g s associated with both the tension and relaxed states (Bernstein & Borkovec, 1973). This technique i s c a l l e d progressive r e l a x a t i o n because as each of the major muscle groups i s relaxed a new group i s added, u n t i l t o t a l body relaxation i s achieved. Jacobson's (1938) technique c a l l s f o r between f i f t y and two hundred t r a i n i n g sessions. Goldfried and T r i e r (1974) noted that progressive r e l a x a t i o n d i d not receive wide acceptance u n t i l Wolpe (1957) modified and shortened the technique and 17 incorporated i t i n t o the systematic d e s e n s i t i z a t i o n procedure. Numerous studies have examined the e f f e c t s of progressive r e l a x a t i o n on the reduction of anxiety (for reviews see Barrios & Shigetomi, 1979; Borkovec & Sides, 1979; Lehrer & Woolfolk, 1984). Support f o r the use of progressive r e l a x a t i o n as a therapeutic technique f o r tension reduction i s evident from research on tension headaches (Blanchard, Andrasik, & S i l v e r , 1980), hypertension (Redmond, Gaylor, McDonald, & Shapiro, 1974), and insomnia (Borkovec & Fowles, 1973). A d d i t i o n a l l y , research findings indicate that progressive r e l a x a t i o n i s an e f f e c t i v e treatment f o r phobias (for reviews see Mathews, 1978), and t e s t anxiety (Reed & Saslow, 1980). Since the a b i l i t y to use r e l a x a t i o n i n an actual anxiety producing s i t u a t i o n i s a v i t a l t e s t for therapy, two studies w i l l be reviewed that have measured the generalized e f f e c t s of t r a i n i n g . Borkovec, et a l . (1978) found progressive r e l a x a t i o n as a s i n g l e model therapy to be e f f e c t i v e i n ameliorating the symptoms of d a i l y tension and anxiety of 36 psychology undergraduates. Subjects were randomly assigned to progressive r e l a x a t i o n , relaxation without tension release and no treatment groups. The progressive r e l a x a t i o n group showed s i g n i f i c a n t reduction i n anxiety and these gains were maintained f i v e months a f t e r treatment. 18 S i m i l a r i l y , Gross and Fremouw (1982) found progressive r e l a x a t i o n showed decreased anxiety for 63 speech-anxious undergraduates compared to a w a i t l i s t control group. Subjects were randomly assigned to progressive r e l a x a t i o n , cognitive r e s t r u c t u r i n g and w a i t l i s t control groups. Both treatment groups improved on s e l f - r e p o r t measures of state anxiety, fear and s o c i a l anxiety compared to the w a i t l i s t group, but behavioral and p h y s i o l o g i c a l measures d i d not discriminate between treated and untreated groups. Consequently, as progressive r e l a x a t i o n i s an i n f l u e n t i a l and well-researched technique f o r reducing anxiety, i n t h i s study i t w i l l be used as a standard with which to compare the p o s i t i v e r e i n t e r p r e t a t i o n technique of Morita therapy. P o s i t i v e Reinterpretation. Morita therapy, which has cognitive, behavioural and e x p e r i e n t i a l components and a unique p h i l o s o p h i c a l framework and view on human experience, promotes acceptance of anxiety rather than control of i t s symptoms. The basic premise of Morita therapy i s that s o c i a l anxiety can be used as a m o t i v a t o r - f a c i l i t a t o r of constructive action through acceptance of undesirable f e e l i n g s . The i m p l i c a t i o n i s that change i n behavior can occur without any p r i o r c o n t r o l of symptoms. The p o s i t i v e r e i n t e r p r e t a t i o n technique (Ishiyama, 1984, 1986a, 1986b) advocates the m o b i l i z a t i o n of 19 energy from egocentric self-preoccupation to constructive action taking, by providing insight into the nature of emotion and emphasizing c l i e n t s ' p o t e n t i a l f o r productive l i v i n g . This d i d a c t i c and confrontational technique views the experience of anxiety as a human condition and not as an abnormal state. The purpose of t h i s technique i s to r e i n t e r p r e t c l i e n t s ' b e l i e f s and attitudes towards the experience of anxiety and the s e l f i n a constructive and s e l f - v a l u i n g way. Behavioral changes i n the d a i l y context are encouraged, and homework containing s p e c i f i c behavioral i n s t r u c t i o n s i s assigned. The p o s i t i v e r e i n t e r p r e t a t i o n technique has proven successful i n t r e a t i n g anxiety and behavioral problems i n Japan and i n the West (Ishiyama, 1986a; Kawai & Kondo, 1960; Miura & Usa, 1970; Morita 1926/1974; Reynolds, 1976). In a si n g l e case study of severe t e s t anxiety, Ishiyama (1983) found that Morita treatment was successful and a one year follow-up revealed no relapse i n t e s t anxiety. S i m i l a r i l y , Ishiyama (1986a) found the p o s i t i v e r e i n t e r p r e t a t i o n technique to be e f f e c t i v e i n dealing with fear of speaking i n groups and fear of approaching strangers. This s i n g l e case study exmined therapeutic changes associated with b r i e f Morita treatment of a s o c i a l l y anxious c l i e n t . Longitudinal studies i n Japan involving both inpatient and outpatient c l i e n t s resulted i n p o s i t i v e changes as observed i n 18 year follow-ups (Suzuki & Suzuki, 1977: Suzuki, Kataoka & Karasawa, 1982). 20 In summary, the p o s i t i v e r e i n t e r p r e t a t i o n technique of Morita therapy i s an innovative coping technique which i s based on the acceptance and reframing of anxiety. Treatment Mode The above studies on the c l i n i c a l u t i l i t y of Morita therapy d i d not i s o l a t e the e f f e c t s of Morita-based treatment from va r i a b l e s such as empathy and helping r e l a t i o n s h i p . I t i s considered that audiotaped messages i n both treatment packages would minimize the interpersonal v a r i a b l e s . Audiotaped progressive r e l a x a t i o n programs have been found to be e f f e c t i v e i n reducing t e s t anxiety, general tension, and speech anxiety (for reviews see Hill e n b e r g & C o l l i n s , 1982) . In t h i s study progressive r e l a x a t i o n using Bernstein and Borkovec's (1973) standardized audiotape w i l l be used as a standard with which to compare the p o s i t i v e r e i n t e r p r e t a t i o n technique, using s p e c i a l l y prepared audiotapes. Some studies, using single-case experimental designs, have indicated that very b r i e f or single-session Morita intervention i s the r a p e u t i c a l l y e f f e c t i v e with s o c i a l l y anxious c l i e n t s (Ishiyama, 1983, 1986c, 1988b). S i m i l a r l y , i n a review of studies demonstrating equivalency between progressive r e l a x a t i o n and control conditions, Borkovec and Sides (1979) found that the mean number of sessions was 2 . 3 0 , and only 47% of the studies used more than four 21 sessions. Consequently, t h i s study w i l l use a b r i e f i n s t r u c t i o n a l intervention over three sessions. I s r a e l and Beiman (1977) found that subjects experienced s i g n i f i c a n t reductions i n tension, as assessed by p h y s i o l o g i c a l measures, from pre- to post-treatment over three 3 0-minute sessions. In view of the fact that treatments w i l l be audiotaped t h i s study w i l l use 30-minute to 35-minute sessions. Summary In summary, evidence has been presented to support: (a) the concept of s o c i a l anxiety as being d i s t i n c t from other forms of anxiety, (b) two major t h e o r e t i c a l formulations of s o c i a l anxiety, (c) that progressive r e l a x a t i o n and p o s i t i v e r e i n t e r p r e t a t i o n are e f f e c t i v e i n dealing with s o c i a l anxiety, and (d) that audiotaped progressive r e l a x a t i o n programs have been e f f e c t i v e i n dealing with anxiety. 22 Method Subjects The subjects were r e c r u i t e d v i a posters and advertisement i n newsletters and newspapers at the U n i v e r s i t y of B r i t i s h Columbia i n v i t i n g people to p a r t i c i p a t e i n a study on s o c i a l anxiety. Of the 30 respondents, 25 completed screening questionnaires, and 24 were accepted for the program a f t e r meeting the following c r i t e r i a : (a) a score of 19 or less on the Beck Depression Inventory (Beck and Steer, 1987), which i s i n the moderate range of c l i n i c a l depression (Cappe, 1985); (b) a score of 30 (highest possible score) or less on the Fear of Negative Evaluation (Watson & Friend, 1969), as no d i s t i n c t i o n was made between high and low anxious subjects; (c) not c u r r e n t l y undergoing therapy; and (d) not c u r r e n t l y taking medication. The p a r t i c i p a n t s were male and female u n i v e r s i t y students and s t a f f , aged 18 to 45. Although 24 respondens met the requirements f o r the study and completed the questionnaires at the i n i t i a l interview, four subjects d i d not attend the f i r s t treatment session. Reasons f o r not attending included not having enough time and loss of i n t e r e s t , thereby reducing the number of subjects to 20. 23 Design and Procedures A l l subjects were screened through a personal interview with the researcher held at the University of B r i t i s h Columbia. At that time the following questionnaires were administered: Beck Depression Inventory (BDI) and Fear of Negative Evaluation (FNE). In addition, an Action Log, that i s a d a i l y record of action taken i n target s i t u a t i o n , was assigned as homework i n order to e s t a b l i s h a behavioral baseline. Subjects were subsequently separated i n t o male and female categories and randomly assigned to treatment groups. Subjects were not informed about group assignment but were informed by telephone of the date, time and place of the f i r s t treatment session. P r i o r to the beginning of the f i r s t session and a f t e r signing an informed consent, (Appendix A) the following questionnaires were administered, Watson and Friend's (1969) Soc i a l Avoidance and D i s t r e s s Scale (SAD), Ishiyama's (1987c) Self and Anxiety Questionnaire (SAQ), (see Appendix B). A l l of the subjects were reassessed with the SAD and SAQ at end of the 3-week treatment period. An Action Log was assigned as homework. Three weeks a f t e r completing the program a l l of the subjects were reassessed i n the same manner as at 3-week post-treatment. Subjects completed questionnaires i n d i v i d u a l l y i n the counselling rooms of the University of B r i t i s h Columbia Education C l i n i c . 24 Dependent Measures S o c i a l Avoidance and Distress Scale (SAD). Watson and Friend (1969) developed a measure to assess anxiety experienced i n s o c i a l s i t u a t i o n s . S o c i a l avoidance was defined by the authors as avoiding being with, t a l k i n g to, or escaping from others for any reason, whereas s o c i a l d i s t r e s s was viewed as the repeated experience of a negative emotion (such as anxiety) i n s o c i a l i n t e r a c t i o n s . This inventory i s a s e l f - r e p o r t measure consisting of 28 True/False statements. I t s t e s t - r e t e s t r e l i a b i l i t y i s r=.68 and r=.79 i n two v a l i d a t i o n samples. Research supports the v a l i d i t y of the SAD i n that i t correlates p o s i t i v e l y with s i m i l a r measures and with s e n s i t i v i t y to audiences (Watson & Friend, 1969). Se l f and Anxiety Questionnaire (SAQ). Ishiyama (1987c) developed a questionnaire comprised of four scales presented together, of which three w i l l be used i n t h i s study. These scales are designed to measure (1) how p o s i t i v e one's a t t i t u d e i s towards anxiety, (2) how e f f e c t i v e one f e e l s about coping with the target s i t u a t i o n , and (3) how accepting one i s of the anxious s e l f , a l l i n the context of an i n d i v i d u a l l y s p e c i f i e d target s i t u a t i o n . The three scales have four of s i x biopolar adjective p a i r s separated by nine spaces forming a continuum i n the manner of semantic d i f f e r e n t i a l (Osgood, Suci, & Tannenbaum, 1957). The measures are presented i n a scaled format with reverse-score 25 items as suggested by Hersen and Barlow (1976). The sum of the i n d i v i d u a l scores (1 to 9 from l e f t to right) f o r adj e c t i v e p a i r s w i l l be used as the score f o r each scale a f t e r reversing the keyed reverse items. S t a t i s t i c a l a n a l y s i s (n=100) of the data revealed high item-total c o r r e l a t i o n s and i n t e r n a l consistencies (Cronbach alpha) f o r these items. They are as follows: P o s i t i v e Interpretation of Anxiety Scale with an alpha of .95; and Anxious S e l f -Acceptance Scale with an alpha of .93, according to Ishiyama (1987c). Action Log. In accordance with common p r a c t i c e i n behaviour research, behaviour counts of action taken were recorded d a i l y i n an Action Log. Action taken was defined as any a c t i o n taken by the subjects i n the s i t u a t i o n they s p e c i f i e d as anxiety producing for them. Screening Measures Fear of Negative Evaluation Scale (FNE). Developed by Watson & Friend (1969), the FNE has a very high index of homogenity with the SAD. The FNE was used f o r i n i t i a l assessment i n order to avoid a possible problem with r e a c t i v i t y to the SAD. Fear of negative evaluation was defined by the authors as apprehension about others' evaluations, d i s t r e s s over t h e i r negative s i t u a t i o n s and expectation that others would evaluate oneself negatively. 26 This inventory i s a s e l f - r e p o r t measure c o n s i s t i n g of 30 True/False statements. Test-retest r e l i a b i l i t y procedures of the FNE yielded product-moment c o r r e l a t i o n s of r=.78 and r=.94. Research supports the v a l i d i t y of the FNE i n that i t c o r r e l a t e s p o s i t i v e l y with s i m i l a r measures (Watson & Friend, 1969). Beck Depression Inventory (BDI). I t was expected that some s o c i a l l y anxious i n d i v i d u a l s would be depressed and i t was considered necessary to control t h i s factor i n order to reduce confounding of outcomes. Therefore, a l l subjects were requested to complete the short form of the BDI (Beck, Ward, Mendelson, Mock & Erbaugh, 1961). This inventory i s an e a s i l y administered s e l f - r e p o r t measure c o n s i s t i n g of 21 categories of symptoms and attitudes. Each category describes a s p e c i f i c behavioral manifestation of depression and consists of a graded ser i e s of 4 s e l f - e v a l u a t i v e statements, with numerical values of 0 to 3 assigned each statement to indicate the degree of severity. Research has indicated a s p l i t - h a l f r e l i a b i l i t y of r=.93 fo r the BDI. Research also supports concurrent v a l i d i t y i n that the BDI c o r r e l a t e s with c l i n i c i a n s ' ratings and other standardized measures of depression. Construct v a l i d i t y has also been established (Beck & Beamesdefer, 1974). 27 Treatments The main treatment components designed to be present i n both the r e l a x a t i o n treatment and the p o s i t i v e r e i n t e r p r e t a t i o n treatment were: (a) a 3-minute i n s t r u c t i o n s tape, o u t l i n i n g l i s t e n i n g procedures, and length and number of sessions; (b) a 40-minute treatment tape, presenting a way of dealing with anxiety experienced i n various s i t u a t i o n s . (c) a one-page summary of tape content, f o r home use. The treatment components that d i f f e r e n t i a t e d the two groups were: (a) tape i n s t r u c t i o n of coping with anxiety through a progressive r e l a x a t i o n treatment, or (b) tape i n s t r u c t i o n of acceptance of anxiety through p o s i t i v e r e i n t e r p r e t a t i o n treatment. The r e l a x a t i o n tape was based on Bernstein & Borkovec's (1973) Progressive Relaxation T r a i n i n g Manual and tape, and p o s i t i v e r e i n t e r p r e t a t i o n tape was based on Ishiyama's (1986a) p o s i t i v e r e i n t e r p r e t a t i o n technique. Relaxation Treatment: The r e l a x a t i o n tape consisted of (a) a r a t i o n a l e f o r using r e l a x a t i o n as a technique f o r coping with anxiety-producing s i t u a t i o n s , and (b) i n s t r u c t i o n s f o r r e l a x i n g (tightening and r e l a x i n g muscles to a t t a i n complete relaxation) 15 muscle groups. 28 P o s i t i v e Reinterpretation Treatment: The p o s i t i v e r e i n t e r p r e t a t i o n tape consisted of (a) ra t i o n a l e f o r acceptance of anxiety, and (b) d i r e c t i o n to action taking as a means of dealing with anxiety producing s i t u a t i o n s by doing what needs to be done i n the given context, despite anxiety symptoms. A l l subjects were encouraged to read the summary and to p r a c t i c e as often as possible between treatment sessions. The i n s t r u c t i o n component of the tapes was made by the researcher, while each treatment component was made by an experienced recorder chosen for voice compabibility with treatment. The tapes were then rated by a pro f e s s i o n a l as su i t a b l e f o r the research. To reduce a t t r i t i o n , p a r t i c i p a n t s i n both groups were phoned by the researcher to remind them of t h e i r appointments for each session. 29 Results Group Comparability and Subject A t t r i t i o n P r i o r to the interventions, a l l subjects (N=25) displayed evidence of s o c i a l anxiety as demonstrated by the FNE. The o v e r a l l group mean of 19.6 (SD=6.5) was above the mean score of 15.5, (SD=8.6) reported by Watson & Friend (19 69) f o r a group of male and female college students. The two treatment groups were formed, progressive r e l a x a t i o n (n=13) and p o s i t i v e r e i n t e r p r e t a t i o n (n=12). Randomization assured comparability of the two groups. Of the i n i t i a l 3 0 respondents, f i v e were non-starters, four d i d not show up f o r the f i r s t sessions (no shows), and three did not attend more than one session (dropouts), thus reducing the treatment sample s i z e to 17. A d d i t i o n a l l y , one subject was eliminated by her high l e v e l of depression as indicated by the BDI, that i s 25 points; cut-off point f o r subject screening was 19. Another subject did not complete the follow-up questionnaires although he attended a l l treatment sessions. Consequently, the f i n a l sample was 16 (n=7 f o r progressive relaxation, n=9 for p o s i t i v e r e i n t e r p r e t a t i o n ) . In order to obtain a balanced repeated measures design the sample s i z e was equalized (n=7, n=7) by computer randomized elimination of two subjects from the p o s i t i v e r e i n t e r p r e t a t i o n group. Descriptive baseline data are given i n Table 1. 30 Table 1 Means and Standard Deviations of Baseline Data f o r Two  Groups (Positive Reinterpretation, Progressive Relaxation) Po s i t i v e Progressive Reinterpretation Relaxation (n=7) (n=7) M SD M SD Age 29.0 5.9 23.3 3.4 FNE 23.1 6.2 18.4 6.7 Note. FNE=Fear of Negative Evaluation 31 Analysis of Data Repeated Measures Analysis of Variance (ANOVA) with one repeated measure fac t o r and one grouping fa c t o r were performed separately on dependent measures of s o c i a l anxiety, a t t i t u d e towards anxiety, coping effectiveness, and acceptance of anxious s e l f . Chi-square t e s t s were computed fo r behavioral counts of action taken i n target s i t u a t i o n s . D i f f e r e n t i a l effectiveness between the treatment groups was thus analyzed. The data used to complete t h i s study included: (a) pretest, post-test and follow-up raw scores as measured by the S o c i a l Avoidance and Distress Scale, (b) the Self and Anxiety Questionnaire, and (c) the Action Log. A summary of mean scores and standard deviations f o r each dependent v a r i a b l e at each time period (pre-, post-, and follow-up) i s provided i n Table 2. In addition, e f f e c t s i z e estimates were used as a supplement to the s t a t i s t i c a l s i g n i f i c e n c e t e s t i n g i n order to get a more complete pi c t u r e of the c l i n i c a l meaning of pre- to post-test, and post-test to follow-up changes i n each group Table 2 Means and Standard Deviations f o r Two Groups (Positive  Reinterpretation, Progressive Relaxation), pre-, post and  follow-up. SAD SAQ1 SAQ2 SAQ3 M SD M SD M SD M SD Group Pos.Reinterp.(n=7) Pre 23.0 2.2 8.8 4.6 14.6 8.4 26.7 10.4 Post 21.4 3.7 15.2 4.3 18.4 7.2 29.9 4.1 Follow-up 21.0 3.7 14.2 4.5 21.4 11.4 29.9 5.4 Prog.Relaxation (n=7) Pre 16.6 5.8 13.0 6.4 24.7 12.5 33.6 5.2 Post 15.9 6.5 15.1 4.3 29.1 12.3 28.0 4.2 Follow-up 10.7 6.9 17.0 4.5 32.3 14.0 26.9 4.2 Note.SAD=Social Avoidance & Distress SAQi=Attitude towards Anxiety SAQ2=Coping Effectiveness SAQ3=Acceptance of Anxious Self 33 and between groups. E f f e c t s i z e i s calcu l a t e d as mean change score (before and a f t e r intervention) d i v i d e d by the standard deviation of the i n i t i a l mean score (Kazis, Anderson & Meenan, 1989). The e f f e c t s i z e approach i s used as a standard f o r i n t e r p r e t i n g change. Cohen (1977) defines an e f f e c t s i z e of 0.20 as small, 0.50 as moderate and 0.80 or greater as large, and h i s d e f i n i t i o n w i l l be used i n t h i s study. Hypothesis 1. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test to follow-up s o c i a l anxiety scores, as measured by the S o c i a l Avoidance and Dis t r e s s Scale, between subjects who received i n s t r u c t i o n i n progressive r e l a x a t i o n and those who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . Analysis of s o c i a l anxiety scores revealed that while there i s a s i g n i f i c a n t difference between groups ( F ( l , 12)=8.24, p_=.oi) a n d across occasions (F(2 ,24) =14 . 67, p_=.0001) there i s a s i g n i f i c a n t i n t e r a c t i o n between groups and occasions (F(2,24)=5.66, p_=.009), (see Table 3). Figure 1 i s a graphical i n t e r p r e t a t i o n of the ANOVA ta b l e i n that i t shows the o v e r a l l means (see Table 4) f o r the two groups at pretest, post-test and follow-up. As the ANOVA tabl e shows, Table 3 Analysis of Variance v i t h Repeated Measures of S o c i a l  Avoidance and Distress (SAD) scores. Source Sum of Squares df Mean Square F T a i l Prob Group 579.4 1 579.4 8.24 0.01 Error 844 .2 12 70.3 Occasion 114.3 2 57.2 14.67 0.0001 OG 44.1 2 22.1 5.66 0.009 Error 93.5 24 3.9 Greenhouse--Geisser=0.85 Note. 0G=0ccasion x Group Interaction Figure 1 o v e r a l l Mean Scores on SAD f o r the Two Treatment Groups (Positive Reinterpretation. Progressive Relaxation), pre-post-. and follow-up. Table 4 Ove r a l l Mean Scores on SAD for the Two Treatment Groups (Positive Reinterpretation, Progressive Relaxation), pre-, post-, and follow-up. B Bi B 2 B 3 X. A 2 23.00 21.42 21.00 21.80 A 2 16.57 15.85 10.71 14.38 X.. k 19.78 18.64 15.85 18.09 Note. Ai=Positive Reinterpretation A2=Progressive Relaxation Bi=pretest B2=post-test B3=follow-up XY.j^grand mean, rows X-.j.=grand mean, columns 37 t h e r e i s a s i g n i f i c a n t i n t e r a c t i o n b e t w e e n g r o u p a n d t i m e , a n d t h i s i s e v i d e n t i n F i g u r e 1 b y t h e l a c k o f p a r a l l e l l i n e s f o r t h e t w o g r o u p s . I n t h e l i g h t o f t h i s s i g n i f i c a n t t i m e d e p e n d e n c y , t h e a c t u a l i n t e r a c t i o n e f f e c t s w e r e c a l c u l a t e d a n d t h e e f f e c t s p l o t t e d o n a g r a p h g i v e n b y T a b l e 4 a n d F i g u r e 2 . I n t e r a c t i o n e f f e c t s w e r e c a l c u l a t e d b y s u b t r a c t i n g t h e r o w a n d c o l u m n m e a n s f r o m t h e o v e r a l l c e l l m e a n s t h a t a r e p l o t t e d i n F i g u r e 1 , a n d a d d i n g t h e g r a n d m e a n . T h e f o r m u l a f o r e s t i m a t i o n i s g i v e n b e l o w . &Cp> j k = ^ j k ~ ^ - k ~ ^ j • + x - » • 1 = 1 , 2 , 3 , ( c o l u m n ) k = l , 2 , ( r o w ) F i g u r e 2 s h o w s t h a t o v e r t h e p e r i o d f r o m p r e - t o p o s t -t e s t t i m e i n t e r a c t e d i n a n e g a t i v e w a y w i t h t h e p o s i t i v e r e i n t e r p r e t a t i o n g r o u p , r e l a t i v e t o t h e r e l a x a t i o n g r o u p . T h i s i s i n t e r p r e t e d t o m e a n t h a t t h e p o s i t i v e i n t e r p r e t a t i o n g r o u p b e c a m e m o r e a n x i o u s o v e r t h i s p e r i o d o f t i m e r e l a t i v e t o t h e r e l a x a t i o n g r o u p . T h i s s i t u a t i o n c h a n g e d o v e r t h e n e x t p e r i o d o f t i m e f r o m p o s t - t e s t t o f o l l o w - u p . D u r i n g t h a t p e r i o d t i m e i n t e r a c t e d p o s i t i v e l y w i t h t h e p o s i t i v e r e i n t e r p r e t a t i o n g r o u p , r e l a t i v e t o t h e r e l a x a t i o n g r o u p , s u g g e s t i n g t h a t t h e p o s i t i v e r e i n t e r p r e t a t i o n g r o u p b e c a m e p r o g r e s s i v e l y l e s s a n x i o u s d u r i n g t h i s p e r i o d r e l a t i v e t o t h e t h e r e l a x a t i o n g r o u p . Table 5 Interaction E f f e c t s B A Bj. B 2 B 3 A i -0.50 0.93 1.43 A 2 0.49 0.93 1.44 Note. Ai=Positive Reinterpretation A2=Progressive Relaxation B 1=pretest B2=post-test B3=follow-up 39 Figure 2 Interaction E f f e c t s of Testing (pre-, post-, follow-up) and  Treatment (Positive Reinterpretation. Progressive  Relaxation) on SAD Group 1 Group 2 -2 -I 1 «— 1 1 1 Pre- Post- Follow-Up 40 Based on the analysis of the data of t h i s study, Hypothesis 1, as such, was not substantiated, because time interacted with treatment to produce a complex j o i n t or i n t e r a c t i o n e f f e c t and not a simple main e f f e c t due to the treatment. Hypothesis 2. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test to follow-up a t t i t u d e towards anxiety scores as measured by the S e l f and Anxiety Questionnaire, subscale 1, between subjects who received i n s t r u c t i o n i n progressive r e l a x a t i o n and subjects who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . Analysis of a t t i t u d e towards anxiety scores revealed that there were no group by time differences (F(2,22)=0.94, rj=.41). There were s i g n i f i c a n t differences across occasions (F(2,22) =5.43, p_=.01), i n d i c a t i n g that the subjects as a group showed p o s i t i v e improvement i n a t t i t u d e towards anxiety, and these differences were mainly between p r e t e s t and post-test (see Table 6 and Figure 3). Based on the analysis of the data of t h i s study, Hypothesis 2 was held tenable. Treatment e f f e c t s i z e (Table 7) for p o s i t i v e r e i n t e r p r e t a t i o n treatment shows a very large improvement i n a t t i t u d e towards anxiety (1.4), whereas the r e l a x a t i o n group reported a low to moderate (0.4) e f f e c t s i z e . Follow-up e f f e c t s i z e s were minimal for both groups. Table 6 Analysis of Variance with Repeated Measures of Att i t u d e  Towards Anxiety (SAQ subscale 1) scores. Source Sum of Squares df Mean Square F T a i l Prob Group 52 . 4 1 5 2 . 4 0 . 54 0 . 4 8 0 Error 1077 .2 11 97 .93 Occasion 172 . 0 2 8 5 . 9 9 5.4 3 0 . 010 OG 2 9 . 6 2 14 .80 0 .94 0 . 4 0 0 Error 3 4 8 . 1 22 15 .82 Greenhouse- -Geisser=0 .85 Note. OG=Occasion x Group Interaction 42 Figure 3 O v e r a l l Mean Scores on SAO(subscale 1) for the Two Treatment Groups (pre-, post-, follow-up) 43 Table 7 E f f e c t Size for Two Groups (Positive Reinterpretation,  Progressive Relaxation) based on pre-/post-test, and post- /follow-up Change Scores E f f e c t Size Treatment 3 Follow-Up b Measures Pos.Re. Relax. Pos.Re. Relax. SAD 0.7 0.1 0.1 0.8 SAQ1 1.4 0.4 0.2 0.3 SAQ2 0.5 0.4 0.4 0.02 SAQ3 0.3 1.1 0.0 0.3 Note, aTreatment e f f e c t size=|m]_-m2|/s^, where m^  i s the pretreatment mean, m2 the post-treatment mean, and s^ the pretreatment standard deviation (nondirectional two-tailed case). Follow-up e f f e c t size=|mi-m 2|/si, where m^  i s the post-treatment mean, m2 the follow-up mean, and s± the post-treatment standard deviation (nondirdectional two-tailed t e s t ) . E f f e c t size=0.2 (small) 0.5 (moderate) 0.8 (large) SAD=Social Avoidance & Distress SAQi=Attitude Towards Anxiety SAQ2=Coping Effectiveness SAQ3=Acceptance of Anxiety 44 Hypothesis 3. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test to follow-up coping effectiveness scores, as measured by the Self and Anxiety Questionnaire, subscale 2, between subjects who received i n s t r u c t i o n i n progressive relaxation and subjects who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . Due to a large discrepancy i n coping e f f e c t i v e n s s s pretest scores between groups i t was decided to covary the pretest. Analysis of covariance with repeated measures was conducted. The difference between the two groups at pretest approached s i g n i f i c a n c e (F(1,11)=4.68, p=.053). However, when the post-test and follow-up t e s t scores were adjusted for i n i t i a l differences on pretest scores (see Table 8 and Figure 4 ), there was no s i g n i f i c a n t difference between groups (F(l,11)=0.49,p=.50) or across occasions ( F ( l , 12) =2 . 03, p_=.18). Based on the analysis of the data of t h i s study Hypothesis 3 was held tenable. On the measure of coping effectiveness, the treatment e f f e c t s i z e for p o s i t i v e r e i n t e r p r e t a t i o n treatment (0.5) was comparable to that for relaxation treatment (0.4), i n d i c a t i n g that both treatment groups may have improved. Follow-up e f f e c t s i z e s were 0.4 and 0.02 r e s p e c t i v e l y . Table 8 Analysis of Variance with Repeated Measures of Coping  Effectiveness (SAQ subscale 2) scores. 45 Source Sum of Squares df Mean Square T a i l Prob Group Cov.(Pre) Error Occasion OG Error 84.6 813 .8 1913.7 48.8 0.8 288.7 1 1 11 1 1 12 84.6 813.8 173.9 48.8 0.8 24.0 0.49 4 . 68 2 . 03 0. 04 0.500 0. 053 0. 179 0.850 Note. OG=Occasion x Group Interaction Cov.(Pre)=Covariate (Pretest) 4 6 Figure 4 Ove r a l l Mean Scores on SAO(subscale 2) for the Two Treatment  Groups (pre-, post-, follow-up) cn CD o o 2 0 CP 4 0 -3 5 •; 3 0 2 5 : 1<H 5 H P r o g r e s s i v e R e l a x a t i o n Pre-p o s i t i v e R e i n t e r p r e t a t i o n - a — G r o u p 1 - • G r o u p 2 Post- Follow-Up 47 Hypothesis 4. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test to follow-up acceptance of anxious s e l f scores, as measured by the Self and Anxiety Questionnaire, subscale 3, between subjects who received i n s t r u c t i o n i n progressive relaxation and subjects who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . Analysis of acceptance of anxious s e l f scores revealed that there were no s i g n i f i c a n t differences between groups (F(l,12)=0.46, p_=.51) or across occasions (F (2 , 24) =0 . 31, p_=.73), (see Table 9 and Figure 5). Based on the analysis of the data of t h i s study Hypothesis 4 was held tenable. The treatment e f f e c t s i z e indicated a low to moderate increase i n acceptance of anxious s e l f (0.3) for the p o s i t i v e r e i n t e r p r e t a t i o n treatment, and a large decrease (1.1) for r e l a x a t i o n treatment, which changes were not maintained f o r e i t h e r group i n follow-up e f f e c t s i z e . 48 Table 9 Analysis of Variance with Repeated Measures of Acceptance of  Anxious S e l f (SAO subscale 3) scores. Source Sum of Squares df Mean Square T a i l Prob Group Error Occasion OG Error 9.5 248 . 5 27 . 6 190.0 1050.4 1 12 2 2 24 9.5 20.7 13.8 95.0 43.8 0.46 0.31 2 . 2 0.51 0.73 0.13 Greenhouse-Geisser=0.54 Note. OG=Occasion x Group Interaction 49 Figure 5 O v e r a l l Mean Scores on SAO(subscale 3) for the Two Treatment  Groups (pre-, post-, follow-up) 50 Hypothesis 5. There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n pretest to post-test behavioral counts, as measured by the Action Log, between subjects who received i n s t r u c t i o n i n progressive r e l a x a t i o n and subjects who received i n s t r u c t i o n i n p o s i t i v e r e i n t e r p r e t a t i o n . A Chi-square analysis was used to determine i f behavioral counts of action taken i n target s i t u a t i o n between the two treatment groups d i f f e r e d from pre- to post-test. The obtained Chi-Square=0.12/1, was not s t a t i s t i c a l l y s i g n i f i c a n t at =.05 (see Table 10). Based on the analysis of the data of t h i s study Hypothesis 5 was held tenable. i i Table 10 Chi-Square Test of Association between Testing (pre-,post)  and Intervention (Positive Reinterpretation and Progressive  Relaxation). Behavior 1 Group Pre Post Total P o s i t i v e Reinterpretation 19 16 35 (18.2) (16.8) Progressive Relaxation 36 35 (36.8) (34.2) 71 To t a l 55 51 106 Chi-Square=0.12/1; not s i g n i f i c a n t at =.05 Note. a T o t a l behavioral counts per group Discussion The f i v e hypotheses investigated i n t h i s study were stated i n the nondirectional form as no l i t e r a t u r e has been reported that suggests the s u p e r i o r i t y of one treatment approach over the other. However, i t was expected that the two treatments would be e f f e c t i v e i n d i f f e r e n t ways. The p o s i t i v e r e i n t e r p r e t a t i o n intervention, which promotes the acceptance of anxiety without c o n t r o l l i n g i t , was expected to be more e f f e c t i v e than the relaxation intervention i n producing a more p o s i t i v e attitude towards anxiety, and i n increasing acceptance of anxious s e l f . The r e l a x a t i o n intervention, which promotes the reduction of p h y s i c a l tension, was expected to be more e f f e c t i v e than the p o s i t i v e r e i n t e r p r e t a t i o n intervention i n decreasing s o c i a l anxiety. I t was expected that both treatments would r e s u l t i n an increase i n coping effectiveness, and an increase i n the number of actions taken i n target s i t u a t i o n . The r e s u l t s of t h i s study indicated no c l e a r s t a t i s t i c a l l y s i g n i f i c a n t support for the s u p e r i o r i t y of one treatment approach over the other, or for the uniform d i f f e r e n t i a l effectiveness of the two treatments over time. There was s i g n i f i c a n t difference between the two groups on SAD, but t h i s difference was time dependent, so that d i f f e r e n c e between groups was not uniform. Time intera c t e d p o s i t i v e l y with one group r e l a t i v e to the other group at 53 follow-up and the reverse was true at post-test. This r e v e r s a l of r e s u l t s from negative to p o s i t i v e , and v i c e versa, due to time requires some explanation. A p o s i t i v e i n t e r a c t i o n i s interpreted to mean a reduction i n anxiety due to time, and a negative i n t e r a c t i o n i s interpreted to mean an increase i n anxiety due to time (Rosenthal & Rosr.ow, 1985) . At follow-up, time interacted with p o s i t i v e r e i n t e r p r e t a t i o n i n a p o s i t i v e way r e l a t i v e to r e l a x a t i o n . At post-test, time interacted with p o s i t i v e r e i n t e r p r e t a t i o n in a negative way r e l a t i v e to relaxation. This r e v e r s a l of r e s u l t s at follow-up indicates that the paradoxical cognitive i n s t r u c t i o n s of accepting the symptoms of anxiety required a time lag of approximately 6 weeks for a t t i t u d i n a l change to take place. This i s contrary to Ishiyama (1986a) who found a drop i n problem severity throughout the post intervention phase and i n the follow-up phase. The follow-up r e s u l t s also suggest that the p o s i t i v e r e i n t e r p r e t a t i o n group were able to apply the method outside the treatment structure. At follow-up, time dependency affected the re l a x a t i o n group negatively r e l a t i v e to the p o s i t i v e r e i n t e r p r e t a t i o n group. At post-test, time dependency aff e c t e d the rel a x a t i o n group p o s i t i v e l y r e l a t i v e to the p o s i t i v e r e i n t e r p r e t a t i o n group. This suggests that the re l a x a t i o n group may not have taken the time for p r a c t i c e , or, perhaps, they were unable to apply t h i s s e l f - d i r e c t e d method outside the treatment structure. Haney (1986) found 54 a r e l a x a t i o n treatment group did not maintain t h e i r r e l a x a t i o n p r a c t i c e from post-test to follow-up. There was s t a t i s t i c a l s i g n i f i c a n c e across occasions on a t t i t u d e towards anxiety for the two groups, i n d i c a t i n g that both groups improved on attitude towards anxiety. This was not expected for the r e l a x a t i o n group, and as E f f e c t Size indicated t h i s increase to be low to moderate i t i s considered to represent the Hawthorne E f f e c t (Borg & G a l l , 1971) which suggests that p a r t i c i p a t i o n alone i n an experiment r e s u l t s i n improvement in performance. There was no s t a t i s t i c a l l y s i g n i f i c a n t support for the d i f f e r e n t i a l effectiveness of the two treatments on action taken i n the target s i t u a t i o n . The reported lack of behavioral change i n e i t h e r group at post-test suggests i n s u f f i c i e n t time to assimilate and t r a n s l a t e new techniques int o new behaviors. An action log at follow-up might have r e f l e c t e d t h i s speculation. E f f e c t s i z e indicated trends of d i f f e r e n t i a l e ffectiveness, that i s , the treatments were e f f e c t i v e i n d i f f e r e n t ways. The r e l a x a t i o n group became les s accepting of anxious s e l f at post-test, while the p o s i t i v e r e i n t e r p r e t a t i o n group became more accepting of anxious s e l f . The former may be due to treatment as i n s t r u c t i o n s on c o n t r o l l i n g anxiety would be expected to discourage acceptance. The p o s i t i v e r e i n t e r p r e t a t i o n group reported a large increase i n p o s i t i v e attitude towards anxiety at post-t e s t as expected, while the relaxation group reported a 55 moderate increase i n p o s i t i v e a t t i t u d e . The r e l a x a t i o n group were less tolerant of anxiety because they were taught to c o n t r o l i t . Limitations The data of t h i s study provided few s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s and showed r e l a t i v e l y minor non-s i g n i f i c a n t changes. This might be a t t r i b u t e d to the following aspects of the treatment and the research design: (1) Generalization was not the immediate goal of t h i s exploratory study. However, i n terms of sampling, because a sample of convenience and not a p r o b a b i l i s t i c sample was drawn we cannot generalize to the general population. (2) There i s a general problem of s e l f reports a f f e c t i n g the v a l i d i t y of the responses desired f o r the purpose of the study. Because the present study i s based on s e l f - r e p o r t s the r e s u l t s are interpreted with some caution. (3) Although b r i e f taped procedures are commonly employed f o r progressive relaxation (Borkovec & O'Brien, 1976; I s r a e l & Beiman, 1977), the question a r i s e s of whether t h i s treatment length of three sessions was also adequate f o r p o s i t i v e r e i n t e r p r e t a t i o n treatment. (4) The repetitiveness of the audiotaped messages may have lowered the impact of both treatments by causing boredom i n the subjects. In addition, audiotaped messages may have placed the treatments on a set schedule rather than 56 at the pace of the subjects, and t h i s may have had an adverse e f f e c t on subject r e c e p t i v i t y to message. Recommendations I t i s recommended that future research pay a t t e n t i o n to the following design elements: (a) R e p l i c a t i o n of t h i s study under more i d e a l conditions, namely, use of p r o b a b i l i s t i c samples of subjects and a wider s e l e c t i o n of occasions, time and place would provide a representative sample of the population and strenghten generalization. (b) A greater number of sessions for both groups would allow more p r a c t i c e and, perhaps, better t r a n s f e r of the taped i n s t r u c t i o n s . (c) Within the audiotape i n s t r u c t i o n paradigm the messages could be divided into three more elaborate segments, with a d i f f e r e n t segment presented at each session. This would reduce boredom by introducing more novelty and might increase the effectiveness of the treatments. (c) Objective behavioral counts could be employed i n additio n to s e l f - r e p o r t measures, as using both approaches would strengthen i n t e r n a l v a l i d i t y . (d) In terms of time dependency, sequential long-term follow-ups are suggested for an experimental study as they 57 would in d i c a t e (1) whether or not there was a s i g n i f i c e n t i n tervention e f f e c t , and (b) the nature of the e f f e c t , that i s the onset of the response i n terms of gradual or abrupt, and the duration of the response i n terms of permanent or temporary. I t i s also suggested that time s e r i e s studies be conducted to determine i f treatment had s i g n i f i c e n c e and the nature of the time dependency over the long run, using s i n g l e c r i t i c a l cases chosen f o r t h e i r p o t e n t i a l to t e s t the theories more thoroughly. Conclusions The purpose of t h i s study was to determine i f a symptom-controlling intervention, (progressive r e l a x a t i o n ) , and a symptom-accepting intervention, (positive r e i n t e r p r e t a t i o n ) , had d i f f e r e n t i a l e f f e c t s i n the treatment of s o c i a l l y anxious subjects. Looking at s t a t i s t i c a l s i g n i f i c a n c e , there was no c l e a r support f o r the uniform d i f f e r e n t i a l effectiveness of these two treatments. The inconclusive r e s u l t s of t h i s study may be due to a number of l i m i t a t i o n s i n design of which there are probably two major ones, one being a sampling problem and the other the i n t e n s i t y and duration of the treatments. However, time dependency did, i n f a c t , influence the s u p e r i o r i t y of one group over the other. 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I often find social occasions upsetting. T F G. I usually feel calm and comfortable at social occasions. T F 7. I am usually at ease when talking to someone of the opposite sex. T F 8. I try to avoid talking to people unless I know them well. T F 9. If the chance comes to meet new people, ! often take it. T F 10. I often feel nervous or tense in casual get-togethers in which both sexes are present. T F 11 I am usually nervous with people unless I know them well. T F 12. I usually feel relaxed when l am with a group of people. T F 13. I often want to get away from people. T F 14. I usually feel uncomfortable when l am in a group of people I don't know. T F 15. I usually feel relaxed when I meet someone for the first time. T F 16. Being introduced to people makes me tense and nervous. T F 17. Even though a room is full of strangers, I may enter it anyway. T F 18. I would avoid walking up and joining a large group of people. T F 19. When my superiors want to talk with me, I talk willingly. T F 20. I often feel on edge when I am with a group of people. I tend to withdraw from people. I don't mind talking to people at parties or social gatherings. I am seldom at ease in a large group of people. I often think up excuses in order to avoid social engagements. I sometimes take the responsibility for introducing people to each other. I try to avoid formal social occasions. i usually go to whatever social engagements I have. I find it easy to relax with other people. SOCIAL. ANXIETY RESEARCH Code N ;ime Self and A n x i e t y Ques t i onna i r e 1. Righc now, how do you regard the anxious part of your personality that scorns to surface in the target situation ? (Place an "x.") "Mv anxious nature is " acceptable useless undesirable bea rable ] unacceptable useful desirable unbearable 2. Right now, how would you describe the way you deal with the target situation ? (P! V ) fee about myself in dealing with the target situation." competent impatient productive clear-minded unsuccessful relaxed I I I incompetent patient unproductive confused successful tense 3. Right now, what do you need to feel in order to take desirable action? (Place an "x") "I need to feel in the target situation to take desirable action." free from anxiety unsure of myself at home unable to control anxious self-confident nervous able to control emotion emotion Note '. If words or phrases are unclear in meaning to you, please ask for clarification. Make sure that you have placed an "x" for every single adjective pair to best describe your view without skipping any at all. Thank you. SOCIAL ANXIETY RESEARCH Code Name SELF AND ANXIETY QUESTIONNAIRE YOUR TARGET SITUATION Please think of one situation in which you often experience a mild or higher level of anxiety, not a situation that you encounter rarely or only occasionally. Let us call this "the target situation". It must be a situation where you become less effective than you would like to be. The target situation is a situation that you would like to deal with more effectively. Example: "speaking up in small groups at school" "crossing busy streets alone" ' "dealing with aggressive customers at work (bank)" "writing formal exams at the university" My Target Situation is: SOCIAL ANXIETY RESEARCH Your Code Name ACTION LOG Please record daily your action taken in anxiety provoking social situations, including the target situation, starting tomorrow for one complete week. Please mark the target situations with an asterisk (*). EXAMPLE: Date Action Taken July 3 (1) spoke up in class (2) asked a classmate about homework *(3) spoke to authority figure (professor) *(4) spoke to another authority figure (bank teller) SOCIAL ANXIETY RESEARCH Your Code Name ACTION LOG Date Action taken SOCIAL ANXIETY RESEARCH Name FEAR OF NEGATIVE EVALUATION Answer True or False. Circle response. T F 1. I rarely worry about seeming foolish to others. T F 2. I worry about what people will think of me even when I know it doesn't make any difference. T F 3. I become tense and jittery if I know someone is sizing me up. T F 4. I am unconcerned even if I know people are forming an unfavourable impression of me. T F 5. I feel very upset when I commit some social error. T F 6. The opinions that important people have of me cause me little concern. T F 7 I am often afraid that I may look ridiculous or make a fool of myself. T F 8. I react very little when other people disapprove of me. T F 9. I am frequently afraid of other people noticing my shortcomings. T F 10 The disapproval of others would have little effect on me. T F 11. If someone is evaluating me I tend to expect the worst. T F 12. I rarely worry about what kind of impression I am making on someone. T F 13. I am afraid that others will not approve of me. T F 14. I am afraid that people will find fault with me. T F 15. Other people 's opinions of me do not bother me. T F 16. I am not necessarily upset if I do not please someone. T F 17. When I am talking to someone, I worry about what they may be thinking about me. T F 18. I feel that you can't help making social errors sometimes, so why worry about it. 79 T F 19. 1 am usually worried about what kind of impression 1 make. T F 20. 1 worry a lot about what my superiors think of me. T F 21. If I know someone is judging me, it has little effect on me. T F 22. 1 worry that others will think 1 am not worthwhile. T F 23. 1 worry very little about what others may think of me. T F 24 Sometimes 1 think 1 am too concerned with what other people think of me. T F 25. 1 often worry that I will say or do the wrong things. T F 26. I am often indifferent to the opinions others have of me. T F 27. / am usually confident that others will have a favourable impression of me. T F 28. 1 often worry that people who are important to me won't think very much of me. T F 29. 1 brood about the opinions my friends have about me. T F 30. 1 become tense and jittery if 1 know 1 am being judged by my superiors. SOCIAL ANXIETY RESEARCH Name BECK D-l Instructions: This is a questionnaire. On the questionnaire are groups of statements. Please read the entire group of statements in each category. Then pick  out the one statement in that group which best describes the way you feel today, that is, right now! Circle the number beside the statement you have chosen. If several statements in the group seem to apply equally wel^ circle each one. Be sure to read all the statements in each group before making your choice. A. Sadness 0 I do not feel sad. 1 I feel sad or blue. 2 I am blue or sad all the time and I can't snap out ot it. 3 I am so sad or unhappy that I can't stand it. B. Pessimism 0 l am not particularly pessimistic or discouraged about the future. 1 I feel discouraged about the future. 2 I feel 1 have nothing to look forward to. 3 I feel that the future is hopeless and that things cannot improve. C. Sense of Failure 0 I do not feel like a failure. " 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of failures. 3 1 feel I am a complete failure as a person (parent, husband, wife). D. Dissatisfaction 0 I am not particularly dissatisfied. 1 I don't enjoy things the way I used to. 2 I don't get satisfaction out of anything anymore. 3 I am dissatisfied with everything. E. Guilt 0 I don't feel particularly guilty. 1 I feel bad or unworthy a good part of the time. 2 I feel quite guilty. 3 I feel as though I am very bad or worthless. F. Self-Dislike 0 I don't fee! disappointed in myself. 1 I am disappointed in myself. 2 I am disgusted with myself. 3 I hate myself. Self-Harm 0 I don't have any thoughts of harming myself. 1 I feel I would be better off dead. 2 I have definite plans about committing suicide. ; 3 I would kill myself if I had the chance. Social Withdravvl 0 l have not lost interest in other people. 1 I am less interested in other people than l used to be. 2 I have lost most of my interest in other people and have little feeling for them. 3 I have lost all of my interest in other people and don't care about them at all. Indecisiveness 0 I make decisions about as well as ever. 1 I try to put off making decisions. 2 I have great difficulty in making decisions. 3 I can't make any decisions at all any more. Self-Image Change 0 I don't feel I look any worse than I used to. 1 1 am worried that I am looking old or unattractive. 2 I feel that there are permanent changes in my appearance and they make me look unattractive. 3 I fee! that I am ugly or repulsive looking. Work Difficulty 0 I can work about as well as before. 1 It takes extra effort to get started at doing something. 2 I have to push myself very hard to do anything. 3 I can't do any work at all. Fatigability 0 I don't get any more tired than usual. 1 I get tired more easily than I used to. 2 I get tired from doing anything. 3 I get too tired to do anything. Anorexia 0 My appetite is no worse than usual. 1 My appetite is not as good as it used to be. 2 My appetite is much worse now. 3 l have no appetite at all any more. 82 APPENDIX C Summary: Positive Reinterpretation Summary: Progressive Relaxation SUMMARY: POSITIVE REINTERPRETATION TECHNIQUE Social anxiety is not an abnormal experience or personal disposition, but a common and normal human response to certain social situations. As long as you are a human, you experience social anxiety as part of your social existence. Underneath social anxiety or a fear of social failure, there is social desire or a desire to be socially safe, active, and successful. We want to be accepted and appreciated by others. We want to present ourselves in a favourable way, and live an effective, constructive and rewarding social life. Therefore, social anxiety and social desires cannot be separated from eath other. Anxiety and desire are like two sides of the same coin. Also, the denial of social anxiety means the denial of your desires to have an active and rewarding social life and to live constructively. Anxiety can be accepted as it is, and you can still make constructive choice of action. The difference between socially effective people and ineffective people is not whether they feel anxious or not, but rather whether they take action or not in spite of anxiety. The more you try to fight or manipulate the symptoms of anxiety, the more self-preoccupied you tend to get. Also, by assuming that everyone around you is aware of your anxious and nervous reactions, you become extra self-conscious unnecessarily. This egocentric preoccupation disturbs your effective thinking and action-taking. You end up neglecting what needs to be done in the given social context. By treating anxiety as your enemy, you feed attention and energy into the anxiety symptoms only to exaggerate them. If you accept anxiety and see the positive side of it, you can use your anxiety for constructive purposes. Anxiety does not have to be a personal weakness. Social anxiety is a reflection of your social sensitivity. You care about, and feel sensitive to, how others might think, feel, and respond to you. As a result, you may end up feeling nervous and anxious. However, instead of getting preoccupied with the anxiety symptoms and avoiding the situation, what needs to be done is to take advantage of your social sensitivity and redirect it to what is happening, and to what needs to be done in the given social environment. SUMMARY: PROGRESSIVE RELAXATION Progressive relaxation otters you a way of looking at social anxiety and coping with anxiety problems. You can learn how to cope with anxiety effectively by using this relaxation technique. The aim of this technique is to teach you a skill of relaxation which can be used to counteract the uncomfortable physical symptoms you usually experience in socially anxious situations. The ultimate goal is to increase your ability to identify even mild tension and to eliminate that tension. The relaxed state blocks the anxiety and you cannot be all tensed up and calm and relaxed at the same time. Once you are able to relax you can control your anxious feelings in social situations. The exercises are designed to teach you to discriminate between a state of tension and a state of relaxation. By focusing your attention on the level of tension that is produced when you tighten up certain muscles you will be able to learn and discriminate both the low and high levels of tension and where the tension arises from. We started with the muscles in the feet, worked up through the legs, through the body and, finally, up through the muscles in the face and head area. tighten, hold tension and then relax for each of the following: (10) (11) (12) (13) (14) (15) ( D (2) (3) (4) (5) (6) (7) (8) (9) Heels: Thighs: Buttocks: Stomach: Chest: Lower Back: Shoulders: Arms: Feet: Wrists: Legs: Hands: Fingers: Neck: Facial area: curl your toes point away from head point back to head straighten both legs in front of you press heels down on ground focus attention on your thighs concentrate on buttocks tighten stomach muscles take deep breaths arch your back at base of spine bring tips to front bring tips behind back biceps press elbows down on arms of chair straighten both arms rigidly bend wrists back towards body bend in opposite direction make a fist with both hands spread fingers as far out as possible touch chin on chest point chin up and away bite teeth together squint eyes wrinkle forehead furrow eyebrows OKAY, NOW RELAX APPENDIX D Tape Scri p t : Positive Reinterpretation Tape Scri p t : Progressive Relaxation 86 T A P E S C R I P T : P O S I T I V E R E I N T E R P R E T A T I O N 1 . I n s t r u c t i o n s T h a n k y o u f o r a g r e e i n g t o p a r t i c i p a t e i n t h e p r e s e n t r e s e a r c h p r o j e c t . Y o u a r e a b o u t t o l i s t e n t o a n i n s t r u c t i o n a l t a p e o n h o w t o d e a l w i t h s o c i a l a n x i e t y . T h e t a p e w i l l b e a b o u t 4 0 m i n u t e s l o n g . A s y o u w e l l k n o w , t h e e x p e r i e n c e o f s o c i a l a n x i e t y i s a r a t h e r u n c o m f o r t a b l e a n d e v e n p a i n f u l o n e . P e o p l e h a v e v a r i o u s t y p e s o f s o c i a l a n x i e t y . I t i s e x p e r i e n c e d i n c e r t a i n s i t u a t i o n s , s u c h a s a p p r o a c h i n g a n d c o n v e r s i n g w i t h s t r a n g e r s , d i s a g r e e i n g w i t h p e o p l e , b e i n g w i t h a u t h o r i t y f i g u r e s , s p e a k i n g u p i n g r o u p s a n d i n p u b l i c , s p e a k i n g t o a n a t t r a c t i v e m e m b e r o f t h e o p p o s i t e s e x , a s s e r t i n g r i g h t s , b e i n g a n i n f o r m a l a n d u n s t r u c t u r e d s i t u a t i o n , e t c . E a c h p e r s o n h a s a u n i q u e p a t t e r n o f e x p e r i e n c i n g a n x i e t y a n d t e n s i o n . W h e n y o u a r e f e e l i n g a n x i o u s a n d n e r v o u s , y o u e x p e r i e n c e v a r i o u s p h y s i c a l s y m p t o m s s u c h a s : t e n s e n e s s o f t h e b o d y , s h a k y k n e e s , f a c e t u r n i n g r e d , h a n d t r e m o r s , t r e m b l i n g v o i c e , h e a r t p a l p i t a t i o n s , s h a l l o w b r e a t h i n g , n u m b n e s s , l i g h t - h e a d e d n e s s , w e a k l i m b s , a n d o t h e r s i g n s o f d i s c o m f o r t . M e n t a l l y , y o u m a y e x p e r i e n c e p a i n f u l s e l f - c o n s c i o u s n e s s , f e a r s o f m a k i n g m i s t a k e s a n d b e i n g n e g a t i v e l y e v a l u a t e d , d i f f i c u l t y c o n c e n t r a t i n g , s e l f -c r i t i c a l t h i n k i n g , i n n e r c o n f l i c t s , a f e e l i n g o f b l a n k i n g o u t , c o n f u s i o n , a n d f r u s t r a t i o n . I n s o m e s i t u a t i o n s , y o u m a y f i n d y o u r s e l f a c t i n g p a s s i v e l y , b e i n g q u i e t a n d n o t e x p r e s s i n g y o u r s e l f , o r 8 7 a v o i d i n g a n x i e t y - p r o v o k i n g s i t u a t i o n s . A s c o n s e q u e n c e s o f s u c h d i s c o m f o r t a n d u n p r o d u c t i v e r e s p o n s e s , y o u m a y a l s o e x p e r i e n c e i n t e r f e r e n c e s o r d i f f i c u l t i e s w i t h c e r t a i n a r e a s o f s o c i a l r e l a t i o n s h i p s , a c a d e m i c p e r f o r m a n c e s , s e l f - e s t e e m , o r y o u r p u r s u i t o f p e r s o n a l g o a l s . T h i s t a p e w a s p r o d u c e d t o o f f e r p e o p l e a u s e f u l w a y o f d e a l i n g w i t h a n x i e t y e x p e r i e n c e d i n v a r i o u s s i t u a t i o n s . T h e t a p e c o n t a i n s i m p o r t a n t m e s s a g e s a n d i n s t r u c t i o n s t o h e l p y o u t o c o p e w i t h a n x i e t y - p r o d u c i n g s i t u a t i o n s i n a m o r e d e s i r a b l e w a y . We w o u l d l i k e y o u t o l i s t e n t o t h i s t a p e t h r e e t i m e s o n t h r e e s e p a r a t e o c c a s i o n s . P l e a s e d o n o t t a k e n o t e s w h i l e l i s t e n i n g . Y o u w i l l r e c e i v e a o n e - p a g e s u m m a r y o f t h e c o n t e n t s o f t h e t a p e a t t h e e n d o f t h e f i r s t s e s s i o n . I n s t e a d , p l e a s e c o n c e n t r a t e o n l i s t e n i n g t o t h e t a p e a n d t r y t o f o l l o w t h e m e s s a g e s a n d i n s t r u c t i o n s . We b e l i e v e t h a t y o u w i l l l e a r n s o m e t h i n g n e w e a c h t i m e y o u l i s t e n t o t h i s t a p e e v e n t h o u g h i t w i l l b e e x a c t l y t h e s a m e t a p e . W e h o p e y o u w i l l r e m e m b e r t h e i n s t r u c t i o n s a n d p r a c t i c e t h e m i n y o u r d a i l y l i f e . 1. I n t r o d u c t i o n P e o p l e h a v e v a r i o u s a t t i t u d e s t o w a r d t h e e x p e r i e n c e o f s o c i a l a n x i e t y a n d t h e a n x i o u s p a r t o f t h e i r p e r s o n a l i t i e s . H o w d o y o u f e e l a b o u t s o c i a l a n x i e t y ? W o u l d y o u a g r e e w i t h a n y o f t h e f o l l o w i n g s t a t e m e n t s ? (1) S o c i a l a n x i e t y i s a n e g a t i v e , u s e l e s s , a n d u n d e s i r a b l e e m o t i o n , w h i c h g i v e s n o t h i n g b u t t r o u b l e s . 88 (2) There is hardly anything positive or useful about the anxious, nervous part of ray personality. (3) I c r i t i c i z e myself for having a shy personality or for not being able to control my anxiety reactions. (4) Social anxiety prevents me from taking desirable action in certain situations. (5) If I could control my anxiety reactions and feel more relaxed and self-confident and less self-conscious, I would be much more social ly active, productive and successful. (6) If I don't control anxiety reactions in real soc ia l situations, anxiety w i l l get worse and I w i l l be a nervous wreck and won't accomplish anything. This tape offers you another way of looking at social anxiety and coping with anxiety problems. You w i l l learn how to turn anxiety into a productive energy and cope with anxiety-arousing social situations in a more constructive way. Questions such as the following w i l l be explored: (1) How can I reconcile with anxiety and my anxious nature? (2) How can I appreciate the positive meaning of anxiety? (3) How can I go beyond feeling anxious and immobilized and engage myself in desirable action in anxiety-producing situations? (4) How can I use the anxious energy in action taking and l ive more productively and constructively? Because each person is unique and different in how they experience social anxiety not everything mentioned on this tape may necessarily f i t everyone's experience. However, we 89 hope you w i l l be able to personally r e l a t e to some of the following comments and instructions and f i n d them h e l p f u l . 1. S o c i a l anxiety as a legitimate human emotion. S o c i a l anxiety i s an uncomfortable and inconvenient f e e l i n g which can sometimes i n t e r f e r e with your thi n k i n g and ac t i o n . However, i s i t an unnatural, abnormal, and unacceptable emotion? Although i t ' s an uncomfortable and inconvenient f e e l i n g , there i s nothing wrong or shameful about t h i s human emotion. P r a c t i c a l l y everyone experiences s o c i a l anxiety to varying degrees on a d a i l y basis. O r d i n a r i l y , anxiety comes and goes i n l i f e . No matter how bad your anxiety may get, i t w i l l eventually subside when i t i s l e f t unaggravated. Anxiety reactions become unnecessarily exaggerated, when you keep focussing on anxiety and r e s i s t i n g i t as i f nothing else matters at the moment. Thus, anxiety remains i n the foreground of your awareness, and you end up neglecting other important things to do. Anxious f e e l i n g s are natural human reactions to c e r t a i n people and s o c i a l s i t u a t i o n s . When you r e s i s t t h i s natural experience of anxiety, you turn i t into an unnaturally i n t e n s i f i e d one. When you are with others or performing i n f r o n t of others you may f e e l s o c i a l l y anxious and nervous. You may become p a i n f u l l y self-conscious. You worry about making s o c i a l blunders or looking nervous and being c r i t i c i z e d or negatively evaluated by others. This i s normal. As long as 90 you are a s o c i a l being and have desires to be s o c i a l l y accepted and successful, you are also s o c i a l l y vulnerable to others' p o t e n t i a l feedback and prone to s o c i a l anxiety. S o c i a l anxiety i s just one form of s o c i a l s e n s i t i v i t y and a r e f l e c t i o n of your healthy s o c i a l desires. We w i l l discuss how to use s o c i a l anxiety as a functional s o c i a l s e n s i t i v i t y l a t e r on the tape. You may think that you are a rare v i c t i m of s o c i a l anxiety. However, i t i s primarily a private experience. Often, others cannot t e l l when you are f e e l i n g anxious. We cannot always t e l l when others are f e e l i n g t h i s way, e i t h e r . Using our a t t e n t i o n a l focus l i k e a microscope, we may become excessively focussed on and extra-sensitive to f e e l i n g s and sensations within ourselves. Then, we lose touch with what i s going on outside ourselves. Thus, what i s o r i g i n a l l y a r e l a t i v e l y minor and temporary experience of anxiety symptoms can be exaggerated and escalated into a major one. And the more we focus on i t , the worse i t f e e l s . Like you, many other people experience anxiety and vulnerable f e e l i n g s i n various s o c i a l s i t u a t i o n s . You may get the impression that most people do not experience as much anxiety as you do. But l e t ' s not forget that s o c i a l anxiety i s mainly a private experience. Not everyone ov e r t l y shows or p u b l i c l y announces how nervous they are f e e l i n g . Just because you can't see obvious signs of anxiety i n others, t h i s doesn't mean you should assume that others are free from nervous fee l i n g s and inner c o n f l i c t s . 91 You may f e e l caught between the fear of s o c i a l f a i l u r e and the desire f o r s o c i a l involvement, as many others do. You may f e e l tempted to play a passive r o l e or run away from demanding s o c i a l s i t u a t i o n s . But you also see the value of doing whatever needs to be done. This i s your constructive side. Behind s o c i a l anxiety, there are healthy s o c i a l desires to be acknowledged. This i s why you f e e l so r e g r e t f u l and unfinished afterwards when you did not take action a f t e r a l l . You may utter to yourself, "I could have said t h i s and that" and "I should have taken such and such ac t i o n . " 2. Turning s o c i a l anxiety into a problem S o c i a l anxiety and s o c i a l anxiety problems are not the same. Some people f e e l p a i n f u l l y anxious and s e l f -conscious as you do, but continue on with t h e i r action and focus on more productive other things while f e e l i n g anxious. As they get more involved i n constructive and productive action, anxious f e e l i n g s go into the background of awareness. What they are doing with other people becomes more important than what i s happening to t h e i r anxious f e e l i n g s . They eventually forget about anxiety. Whether they f e e l anxious or not i s no longer a question. How constructive and purposeful t h e i r action i s becomes t h e i r major concern. So, anxiety without constructive action becomes a problem. Anxiety with action i s not a problem. 92 S o c i a l anxiety problems are r e l a t e d c l o s e l y to how you handle anxiety and how you behave or not behave i n the immediate s i t u a t i o n . When you resent yourself or the s i t u a t i o n f o r f e e l i n g anxious, your energy goes inward. When you t r y to manipulate anxiety symptoms, you get even more preoccupied with them. When you avoid s i t u a t i o n s which would make you f e e l anxious, what happens to your s o c i a l p r o d u c t i v i t y and r e l a t i o n s h i p s with others? When you place the f i r s t p r i o r i t y on avoiding or c o n t r o l l i n g anxious f e e l i n g s , what happens to your action? What happens to your desire to be s o c i a l l y active and productive? You may think that i t i s an unacceptable, negative emotion and i t must be reduced. You may think i t i s the cause of your behavioural d i f f i c u l t i e s i n c e r t a i n s o c i a l s i t u a t i o n s . You may also f e e l l i k e an incompetent person when you are not i n control of your anxiety reactions. Some people f e e l extremely nervous, vulnerable, and self-conscious i n c e r t a i n s o c i a l s i t u a t i o n s . Although i t ' s not easy, some of them s t i l l carry on with whatever they need or want to do. They t r y to be productive i n s p i t e of anxiety. They do so without defeating or c o n t r o l l i n g anxiety. They anxiously and do what needs to be done or say what needs to be said. In contrast, some others stop taking necessary action, focus on t h e i r anxious feelings which, i n turn, i n t e n s i f y them. Thus, they become unproductive when faced with anxiety-provoking s i t u a t i o n s . 93 Remember that you can choose action and purposes of your action, but you can't choose spontaneous emotions. A l l you can do i s to accept emotions as they are and l e t go of them, while you are responsible for the choice and co n t r o l of a c t i o n . We s h a l l discuss t h i s point l a t e r . Imagine how much energy' you put into dealing with anxiety. I t ' s an exhausting amount. Instead of feeding more attention and energy into r e s i s t i n g anxiety, and gett i n g even more immobilized by anxiety, i s i t possible for you to stop f i g h t i n g or avoiding anxiety? Can you r e d i r e c t your valuable time and e f f o r t into more desirable action other than r e s i s t i n g the emotion? We would say "yes". 3. Anxiety as a "Go" Signal and Consequences of Inaction You can learn to make friends with anxiety as a r e f l e c t i o n of the underlying healthy desires. Anxiety can be viewed as a "go" si g n a l , not a "stop" s i g n a l . Anxiety i s reminding you of how important i t i s for you to be as productive and successful as you want to be i n the given s o c i a l s i t u a t i o n . Becoming preoccupied with the anxiety defeats i t s constructive purpose. Overcoming anxiety problems doesn't mean manipulating an anxious human emotion or r e j e c t i n g a nervous part of your personality. You can say "yes" to anxiety and also "yes" to your desire to be ac t i v e and productive i n your l i f e through your action. When you decide not to take desirable action, you end up s u f f e r i n g from both short-term and long-term, negative 94 consequences. As the r e s u l t of not taking constructive action, you end up not expressing your valuable ideas, not helping others, and not meeting new people. You may also f e e l angry with yourself for avoiding action and not accomplishing much. In the long run, you experience a strong sense of u n f u l f i l l m e n t and f r u s t r a t i o n i n c e r t a i n areas of l i f e . You may f e e l underestimated and mistreated by others. Contrary to your burning desires to be a c t i v e l y involved with others and appreciated and wanted by others, you may end up f e e l i n g r e g r e t f u l , s e l f - c r i t i c a l , lonely and s o c i a l l y i s o l a t e d . However, you may also have successful experiences of f e e l i n g anxious and yet continuing the action you o r i g i n a l l y wanted to take. You came out of such experiences with a sense of accomplishment. How did you do that? You probably went ahead with what needed to be done i n spi t e of f e e l i n g anxious then. You persevered through such moments and l e t them go by, while focussing on the task at hand. Again, we want to stress t h i s . Anxiety i s a legitimate human emotion. Anxiety i t s e l f doesn't have to make you less of a person or stop you from constructive action taking. While f e e l i n g nervous or shy, you can s t i l l get things done rather than avoiding the s i t u a t i o n on the whole.. You can anxiously and nervously meet new people, and speak up and share your ideas and feelings openly with others. 95 4. S o c i a l Anxiety and Soc i a l Desires We have mentioned how healthy and constructive desires and s o c i a l anxiety are connected, l i k e two sides of the same coin. Let us explain. You may f e e l uncomfortable asserting yourself or approaching strangers. Who doesn't f e e l nervous approaching an a t t r a c t i v e member of the opposite sex, or speaking up i n a large group. You may f e e l anxious and vulnerable when you t a l k to persons i n authority or i n an evaluative p o s i t i o n , l i k e teachers, employers, and older people. We worry about being negatively judged, d i s l i k e d , rejected, r i d i c u l e d , and misunderstood by others. We are vulnerable to s o c i a l evaluations. The other side of the same coin i s that we want to be l i k e d , appreciated, and respected by others and develop rewarding r e l a t i o n s h i p s and contribute p o s i t i v e l y to others. We e x i s t s o c i a l l y , and we fear s o c i a l f a i l u r e . Much of our personal meaning of l i f e and sense of accomplishment and happiness i s c l o s e l y t i e d to how we are treated by others and how we r e l a t e to one another. As long as we l i v e i n a s o c i a l context, as long as we are concerned about the q u a l i t y of our s o c i a l r e l a t i o n s h i p s and s o c i a l performances, s o c i a l anxiety w i l l be part of our existence. Most people have desires to be s o c i a l l y a c t i v e , respected, successful, h e l p f u l to others, and be i n rewarding r e l a t i o n s h i p s with others. At the same time, we have fears of not adjusting to society s u c c e s s f u l l y and not 96 f u l f i l l i n g t h e s e d e s i r e s . Y o u s e e , a s l o n g a s y o u a r e a s o c i a l b e i n g , y o u h a v e t o f a c e t h e a n x i e t y s i d e o f y o u r s o c i a l n a t u r e . F e a r s d o n ' t e x i s t w i t h o u t d e s i r e s . Y o u r f e a r s a n d n e r v o u s n e s s r e f l e c t y o u r e a r n e s t d e s i r e s t o h a v e a s u c c e s s f u l s o c i a l l i f e , t o b e l i k e d a n d a p p r e c i a t e d , t o b e u s e f u l t o o t h e r s , a n d t o h a v e r e w a r d i n g a n d h a r m o n i o u s r e l a t i o n s h i p s w i t h o t h e r s . Y o u r s o c i a l a n x i e t y i s a r e m i n d e r o f s u c h c o n s t r u c t i v e d e s i r e s . S o c i a l a n x i e t y b y i t s e l f i s n o t a s i g n o f a p e r s o n a l d e f i c i e n c y a s l o n g a s t h e u n d e r l y i n g s o c i a l d e s i r e s r e c e i v e e q u a l a t t e n t i o n a n d a r e a c t e d u p o n . T o f u l f i l l y o u r v a l u a b l e d e s i r e s , w h i c h a c t i o n i s n e e d e d ? W h i c h i s b e t t e r , a n x i e t y w i t h a c t i o n o r a n x i e t y w i t h o u t a c t i o n ? I s w a i t i n g f o r a n x i o u s f e e l i n g s t o g o a w a y t h e b e s t s o l u t i o n t o t h i s c h a l l e n g e o f l i f e ? We d e s i r e t o b e a c c e p t e d , l i k e d , r e s p e c t e d , a n d s u p p o r t e d . T h e o t h e r s i d e o f t h e c o i n i s t h a t w e f e a r b e i n g r e j e c t e d , d i s l i k e d , u n d e r e s t i m a t e d , a n d a b a n d o n e d . T h i s i s s o c i a l a n x i e t y . S h a k y k n e e s , f l u s h i n g , a n d a t r e m b l i n g v o i c e a r e a l l r e m i n d e r s o f h o w i m p o r t a n t i t i s f o r u s t o b e c o n s t r u c t i v e a n d s u c c e s s f u l i n d e a l i n g w i t h s o c i a l s i t u a t i o n s . O n t h e o n e h a n d , y o u h a v e s u c h s t r o n g d e s i r e s t o p a r t i c i p a t e a c t i v e l y a n d b e p r o d u c t i v e i n s o c i a l a c t i v i t i e s . B u t o n t h e o t h e r h a n d , y o u f e e l s c a r e d , n e r v o u s , s e l f -c o n s c i o u s , a n d u p t i g h t . T h a t ' s h o n e s t a n d h u m a n . 97 You have a choice to make here. Should I respond to my anxiety e x c l u s i v e l y , be passive, and avoid r i s k i n g constructive action taking i n such s i t u a t i o n s . Or, should I choose action, which i s much more c o n t r o l l a b l e than emotion, and do something constructive i n s p i t e of how I f e e l . I t i s possible to accept and persevere with anxious f e e l i n g s and proceed to take action that i s conducive to your healthy desires. Avoiding action to protect yourself from human f e e l i n g s , or allowing anxiety to come and go and staying on task- Which i s more constructive to you? Which w i l l make your l i f e more meaningful i n the long run? 5. S o c i a l Anxiety as Social S e n s i t i v i t y You happen to be s o c i a l l y anxious. Although you may have been resenting and r e j e c t i n g t h i s part of yourself, s o c i a l anxiety can work for you. How could you make the best out of i t ? S o c i a l l y anxious people are very s e n s i t i v e to s o c i a l s i t u a t i o n s and t h e i r f e e l i n g s . Their s e n s i t i v i t y , however, tends to be used for s e l f - p r o t e c t i o n and s e l f -focus, followed by lack of action taking. S o c i a l anxiety i s a rush of energy. How you use i t i s l e f t up to you. I t ' s a form of s e n s i t i v i t y and awareness, which can be directed to the environment. How could you use your highly developed s e n s i t i v i t y f o r more e f f e c t i v e l y dealing with people and responding to demands of s o c i a l s i t u a t i o n s i n a caring, cautious, and s e n s i t i v e way? 98 When you are i n a group or i n a one-to-one conversat ion , you can pay a t tent ion to what you say or do, so that you w i l l not inappropr ia te ly jeopardize the r e l a t i o n s h i p or your reputat ion . Because you do not wish to hurt o thers ' f ee l ings and offend them, you watch your tongue and choose words c a r e f u l l y when confront ing or g i v i n g negative feedback. You can use your s e n s i t i v e awareness to no t i ce others ' nonverbal cues and understand them e f f e c t i v e l y . When you f e e l anxious about making mistakes i n g i v i n g an o r a l presentat ion , you can use your s e n s i t i v i t y to c a r e f u l planning and preparat ion . When you spot a s o c i a l l y anxious or s e l f - i s o l a t i n g person at a par ty , you can s e n s i t i v e l y respond to that person's f ee l ings and generate a conversat ion or introduce the person to someone appropr ia te . These s o c i a l s e n s i t i v i t i e s have p r a c t i c a l va lues . This i s how you could use your anxiety instead of ge t t ing preoccupied with anxiety . When s o c i a l anxiety i s used as s o c i a l s e n s i t i v i t y to help you do a bet ter job , anxiety i s no longer an enemy or a road block. 6. Anxiety as a Cue for Act ion When you f e e l anxious your s o c i a l des ires are a lso being a c t i v a t e d . You get nervous because you want to do a good job . Running away from the task at hand defeats the purpose. Anxiety i s a warning s i gna l for you to remind y o u r s e l f of what needs to be done to best serve the 99 s i t u a t i o n at hand. In a way, anxiety i s saying, "Go ahead, the job i s t h i s important. That's why you are so nervous." Do you understand? Anxiety i s a c t u a l l y a cue f o r constructive action. I t i s not a cue for f i g h t or f l i g h t . Anxiety i s an amber t r a f f i c l i g h t ; move with caution. The i n t e n s i t y of anxiety r e f l e c t s the i n t e n s i t y of the importance of the job to be done. Allow anxiety to follow i t s own course of r i s i n g and f a l l i n g , but do not lose sight of what needs to be done here and your desires for active s o c i a l involvement and contribution. 7. P r a c t i c i n g with Imperfections i s Better than Not P r a c t i c i n g at A l l Sometimes, we discourage ourselves by expecting too much without p r a c t i c e . We come down hard on ourselves when our attempts to speak up i n groups, ask someone out, or assert ourselves with aggressive i n d i v i d u a l s . But, e f f e c t i v e action taking requires practice over time. You can't expect to have a smooth r i d e i n taking new ac t i o n . I t would be a bumpy r i d e at the beginning. U n t i l you get used to jumping into anxiety-provoking s o c i a l s i t u a t i o n s and doing what needs to be done, you are l i k e l y to f e e l quite anxious and unsure of yourself about completing the desired act i o n . Remember learning how to ride a b i c y c l e . You f e l t very shaky at the beginning. You probably f e l l o f f the bike a 100 number of times. But every time you t r i e d , you got better. One step forward i s better than no step forward. 8 . P e r f e c t i o n i s t i c Self-Expectations Often what we wish to f e e l i s not the same as what we a c t u a l l y experience. Re a l i t y and i d e a l i t y do not match. In dealing with s o c i a l s i t u a t i o n s , you may say to yo u r s e l f : "I shouldn't f e e l so anxious. I must f e e l calm and relaxed. I must be able to w i l l f u l l y choose how I f e e l . I should speak up i n c l a s s f e a r l e s s l y and confidently." These are i d e a l i s t i c expectations which c o n f l i c t with r e a l i t y . Thinking t h i s way does not necessarily stop your spontaneous worries and p h y s i o l o g i c a l reactions. In f a c t , you get more preoccupied and f r u s t r a t e d with the r e a l i t y of being nervous and worried. Feelings cannot be changed, once they're there. You cannot turn i t o f f . And there i s no r i g h t or wrong emotion. Emotion IS, period! On the other hand, you choose and control your action more r e a d i l y . You l i v e with the consequences of your ac t i o n . Instead of t r y i n g to control your emotional reactions, you may better use your time and energy by going ahead with the ac t i o n which enables you to accomplish your behavioral goal i n the given s i t u a t i o n . There are people who appear to be able, e f f o r t l e s s l y and comfortably, to speak up, s o c i a l i z e with others, and confront people. Some of them f e e l quite nervous i n t e r n a l l y , but i t does not show overtly. Others have l e s s 101 nervous pe r s o n a l i t y t r a i t s to s t a r t with, or have developed ease at s o c i a l i z i n g a f t e r years of p r a c t i c e . I t i s not necessary f o r you to t r y to be l i k e them. You are you. You may simply t r y to focus on what needs to be done, and persevere with s o c i a l anxiety. Speaking up i n a shaky voice with a pounding heart i s better appreciated by others than you remaining passive without r i s k i n g to share your thoughts and f e e l i n g s with them. 9. Anxiety as Shadow A metaphor of the shadow comes cl o s e s t to what anxiety i s to us. As we walk toward the sun, symbolizing personal goals and desires toward which we s t r i v e earnestly, we also drag a shadow, whether we l i k e i t or not. As long as we l i v e , we have anxiety about death, hurts, s o c i a l r e j e c t i o n and f a i l u r e , academic f a i l u r e , and l o s i n g meaning i n l i f e or not accomplishing our personal goals. Then, a shadow, or anxiety about our physical and s o c i a l existence, i s something that stays with us as long as we l i v e . Our shadows are reminders of how desirous we are to l i v e as f u l l y as we can i n good health and meaningful r e l a t i o n s h i p s with others. Each of us c a r r i e s a shadow, with d i f f e r e n t things i n i t . Like anxiety, we sometimes notice a shadow, and then forget about i t . We continue walking toward the sun. But every time we turn around, we see i t . We cannot divorce ourselves from the shadow. If we started chasing i t away, we w i l l get f a r t h e r away from the sun, goals and meaning i n 102 l i f e . A l l we can do i s acknowledge that i t i s there and appreciate that i t i s a sign of us moving toward the sun. By the same token, a l l we can and need to do i s accept anxiety as i t i s without r e j e c t i o n or manipulation, and appreciate i t s important message to us; that i s , "Live your l i f e as f u l l y as you can and act on your healthy desires, instead of avoiding anxiety-producing s i t u a t i o n s W i l l you say "Yes" to your shadow? Can you v a l i d a t e the constructive meaning of your anxiety? A f t e r a l l , anxiety i s the reminder of your desires for a c t i v e and meaningful involvement i n l i f e . 10. Choice of Action L i t t l e can be done about anxiety. You can, however, choose what to focus on and which action to take, Nervously and f e a r f u l l y , you can approach a s i t u a t i o n . Reluctantly, you can drag your feet to a meeting, or pick up a phone and c a l l a person. You can control your body and action. You can nervously r a i s e your hand, move your mouth, and p a r t i c i p a t e i n a discussion. How constructive a c t i o n i s and how much e f f o r t you are making count much more than whether you f e l t anxious or not i n the process. As a by-product, you may enjoy p o s i t i v e feelings and a sense of accomplishment a f t e r you have taken desirable action i n sp i t e of i n i t i a l anxiety. Action can be alt e r e d much more e a s i l y than the physiology of your body. When you catch yourself avoiding 103 involvement, you can ju s t r a i s e your head and regain eye-contact i n spi t e of an anxious f e e l i n g . There i s no need to f i g h t or r e s i s t anxious f e e l i n g s . You just look f o r what you need to say, and say i t anxiously to the group, while s t i l l f e e l i n g shaky inside. True, i t i s safer and easier to s i t back and wait f o r desi r a b l e f e e l i n g s to a r r i v e , and then, only then, w i l l you conf i d e n t l y and comfortably speak up. What you benefit from i n the long run, and what others appreciate from you, i s your input and active s o c i a l involvement. 11. Summary We would l i k e to summarize our main points as follows: 1. S o c i a l anxiety i s not an abnormal experience or personal d i s p o s i t i o n , but a common and normal human response to c e r t a i n s o c i a l s i t u a t i o n s . As long as you are a human, you experience s o c i a l anxiety as part of your s o c i a l existence. 2. Underneath s o c i a l anxiety or a fear of s o c i a l f a i l u r e , there i s s o c i a l desire or a desire to be s o c i a l l y safe, a c t i v e , and successful. We want to be accepted and appreciated by others. We want to present ourselves i n a favorable way, and l i v e an e f f e c t i v e , constructive and rewarding s o c i a l l i f e . Therefore, s o c i a l anxiety and s o c i a l desires cannot be separated from each other. Anxiety and desire are l i k e two sides of the same coin. Also, the den i a l of s o c i a l anxiety means the denial of your desires to 104 have an active and rewarding s o c i a l l i f e and to l i v e c o n s t r u c t i v e l y . 3. Anxiety can be accepted as i t i s , and you can s t i l l make constructive choice of action. The d i f f e r e n c e between s o c i a l l y e f f e c t i v e people and i n e f f e c t i v e people i s not whether they f e e l anxious or not, but rather whether they take action or not i n spite of anxiety. 4. The more you t r y to f i g h t or manipulate the symptoms of anxiety, the more self-preoccupied you tend to get. Also, by assuming that everyone around you i s aware of your anxious and nervous reactions, you become extra s e l f -conscious unnecessarily. This egocentric preoccupation disturbs your e f f e c t i v e thinking and action-taking. You end up neglecting what needs to be done i n the given s o c i a l context. By t r e a t i n g anxiety as your enemy, you feed attention and energy into the anxiety symptoms only to exaggerate them. If you accept anxiety and see the p o s i t i v e side of i t , you can use your anxiety f o r constructive purposes. 5. Anxiety does not have to be a personal weakness. S o c i a l anxiety i s a r e f l e c t i o n of your s o c i a l s e n s i t i v i t y . You care about, and f e e l s e n s i t i v e to, how others might think, f e e l , and respond to you. As a r e s u l t , you may end up f e e l i n g nervous and anxious. However, instead of getting preoccupied with the anxiety symptoms and avoiding the s i t u a t i o n , what needs to be done i s to take advantage of your s o c i a l s e n s i t i v i t y and r e d i r e c t i t to what i s 105 happening, and t o what needs t o be done i n the g i v e n s o c i a l environment. 106 TAPE SCRIP: PROGESSIVE RELAXATION Instructions Thank you f o r agreeing to p a r t i c i p a t e i n the present research project. You are about to l i s t e n to an i n s t r u c t i o n a l tape on how to deal with s o c i a l anxiety. The tape w i l l be about 40 minutes long. As you well know, the experience of s o c i a l anxiety or shyness i s a rather uncomfortable and even p a i n f u l one. People have various types of s o c i a l anxiety. I t i s experienced i n cerain s i t u a t i o n s , such as appoaching and conversing with strangers, disagreeing with people, being with authority figures, speaking up i n groups and i n public, speaking to an a t t r a c t i v e member of the opposite sex, assering r i g h t s , being i n an informal and unstructured s i t u a t i o n , etc. Each person has a unique pattern of experiencing anxiety and tension. When you are f e e l i n g anxious and nervous, you experience various physical symptoms such as: tenseness of the body, shaky knees, face turning red, hand tremors, trembling voice, heart p a l p i t a t i o n s , shallow breathing, numbness, light-headedness, weak limbs, and other signs of discomfort. Mentally, you may experience p a i n f u l self-consciousness, fears of making mistakes and being negatively evaluated, d i f f i c u l t y concentrating, s e l f -c r i t i c a l thinking, inner c o n f l i c t s , a f e e l i n g of blanking out, confusion, and f r u s t r a t i o n . 107 In some si t u a t i o n s , you may f i n d yourself ac t i n g passively, being quiet and not expressing yourself, or avoiding anxiety-provoking s i t u a t i o n s . As consequences of such discomfort and unproductive responses, you may also experience interferences or d i f f i c u l t i e s with c e r t a i n areas of s o c i a l r e l a t i o n s h i p s , academic performances, self-esteem, or your pursuit of personal goals. This tape was produced to o f f e r people a u s e f u l way of dealing with anxiety experienced i n various s i t u a t i o n s . The tape contains important messages and i n s t r u c t i o n s to help you to cope with anxiety-producing s i t u a t i o n s i n a more desirable way. We would l i k e you to l i s t e n to t h i s tape three times on three separate occasions. Please do not take notes while l i s t e n i n g . You w i l l receive a one-page summary of the content of the tape at the end of the f i r s t session. Instead, please concentrate on l i s t e n i n g to the tape and t r y to follow the messages and i n s t r u c t i o n s . We believe that you w i l l learn something new each time you l i s t e n to t h i s tape even though i t w i l l be exactly the same tape. We hope you w i l l remember the in s t r u c t i o n s and p r a c t i c e them i n your d a i l y l i f e . 108 Introduction People have various attitudes toward the experience of s o c i a l anxiety and the anxious part of t h e i r p e r s o n a l i t i e s . How do you f e e l about s o c i a l anxiety? Would you agree with any of the following statements? (1) S o c i a l anxiety i s a negative, useless, and undesirable emotion, which gives nothing but troubles. (2) There i s hardly anything p o s i t i v e or useful about the anxious, nervous part of my personality. (3) I c r i t i c i z e myself for having a shy personality or f o r not being able to control my anxiety reactions. (4) S o c i a l anxiety prevents me from taking desirable action i n c e r t a i n s i t u a t i o n s . (5) I f I could control my anxiety reactions and f e e l more relaxed and self-confident and less self-conscious, I would be much more s o c i a l l y active, productive and succe s s f u l . (6) I f I don't control anxiety reactions i n r e a l s o c i a l s i t u a t i o n s , anxiety w i l l get worse and I w i l l be a nervous wreck and won't accomplish anything. This tape o f f e r s you a way of looking at s o c i a l anxiety and coping with anxiety problems. You w i l l learn how to cope with anxiety e f f e c t i v e l y by using a r e l a x a t i o n technique. The method we are going to use to achieve t h i s i s c a l l e d progressive relaxation. The aim of t h i s technique i s to learn a s k i l l of relaxation which can be used to 109 counteract the uncomfortable physical symptoms you usually experience i n s o c i a l l y anxious s i t u a t i o n s . The ultimate goal i s to increase your a b i l i t y to i d e n t i f y even mild tension and to eliminate that tension. The relaxed state blocks the anxiety and you cannot be a l l tensed up and calm and relaxed at the same time. Once you are able to relax you can c o n t r o l your anxious feelings i n s o c i a l s i t u a t i o n s . Because each person i s unique and d i f f e r e n t i n how they experience s o c i a l anxiety or shyness, not everything mentioned on t h i s tape may necessarily f i t everyone xs experience. However, we hope you w i l l be able to personally r e l a t e to some of the following comments and i n s t r u c t i o n s and f i n d them h e l p f u l . Progressive Relaxation The purpose of the following tape i s to teach you how to r e l a x more successf u l l y . We do not believe that r e l a x a t i o n i s an innate a b i l i t y which each of us has or does not have from the time we are born. Instead we believe that a state of r e l a x a t i o n and mental calmness can be achieved by a s e l f - i n i t i a t e d t r a i n i n g program. Our reason for teaching you how to relax more su c c e s s f u l l y i s because relaxation i s incompatible with tension and anxiety, that i s , when your body i s relaxed and calm then i t i s very u n l i k e l y that i t can be tense and 110 nervous at the same time. Therefore, once you learn to turn on f e e l i n g s of re l a x a t i o n you w i l l learn to turn-off f e e l i n g s of tension and anxiety. When we t a l k about tension reduction we do not mean that you w i l l be able to turn o f f a l l f e e l i n g s of tension at a l l times. In fa c t , there are some si t u a t i o n s when a c e r t a i n amount of tension a c t u a l l y improves performance. For example, i f you are interviewing f o r a new job a c e r t a i n amount of anxiety i s probably quite normal and t h i s minimal reaction may even increase your alertness. However, when t h i s anxiety reaches the point where you forget what to say, your hand shakes, your heart pounds, your stomach tightens into a knot, then t h i s tension i s probably i n t e r f e r i n g with presenting yourself p o s i t i v e l y and i t i s , therefore, unadaptive and i t i s the unadaptive and disproportionately higher l e v e l s of tension and anxiety that t h i s tape w i l l help you to control. I would now l i k e you to f i n d a comfortable p o s i t i o n . Next, I'd l i k e you to ju s t close your eyes. What I am going to present i s a se r i e s of exercises designed to teach you to discriminate between a state of tension and a state of re l a x a t i o n . We w i l l accomplish t h i s by having you tense and then relax d i f f e r e n t muscle groups. I w i l l s t a r t with the muscles i n the feet, work up through the legs, through the body and f i n a l l y up through the muscles i n the face and head area. I f you are aware of any muscle groups that have experienced trauma or inj u r y , I l l then I would suggest that you not tense these muscles as strongly as the others when we get to them or, i f you f e e l i t i s best, skip that exercise. The f i r s t thing I would l i k e you to do i s c u r l your toes, hold the tension, notice where i t comes from, now relax. As we go through these exercises I would l i k e you to release the tension immediately when I say the word rel a x . Also as you l e t loose of the tension say the word re l a x to yourself. Okay, now relax. I t s very important as we go through these exercises that you focus on where the tension comes from. Individuals are frequently aware of high states of tension but they are not aware of tension at i t s lower i n t e n s i t i e s . They are also not aware i n many instances where the tension i s coming from. By asking you to focus your attention on the l e v e l of tension that i s produced when you tighten up c e r t a i n muscles you w i l l be able to learn and discriminate both the low and high l e v e l s of tension and where the tension a r i s e s from. Okay, the next thing that I would l i k e you to do i s to point your your toes away from your head, point them down and away from your face, away from your body, hold the tension, hold i t , now relax. Again, remember to say the word relax to yourself. Okay, t h i s time I'd l i k e you to point your toes back towards your head, towards your face, hold the tension, f e e l the tension i n the back part of your leg, maybe across the 112 shins, okay, now, relax, allow your feet to again r e s t i n a comfortable p o s i t i o n . Also as we go through these tension and re l a x a t i o n exercises t r y not to move anymore than necessary those muscles that have been involved i n the previous tension and re l a x a t i o n parts. This time I would l i k e you to straighten both your legs, put both your legs s t r a i g h t out i n front of you as i f they were two str a i g h t i r o n bars, t r y to make them as s t r a i g h t as possible. Notice how the tension f e e l s below your leg, by your knee, hold i t , now relax. This time I'd l i k e you to press the heels of your feet down on the ground, press them down on the ground, hold the tension, f e e l the tension i n your thighs, now relax. The more you put into t h i s , the more e f f o r t you make i n tensing these muscle groups as we go through them, the f a s t e r you w i l l learn to discriminate between the state of tension and the state of rel a x a t i o n . The next muscle group that I would l i k e you to focus your attention on i s i n the thighs. I'd l i k e you to tighten the muscles i n your thighs, tighten them and hold the tension. Now relax. As you go through the d i f f e r e n t tension and r e l a x a t i o n exercises you may occasionally f i n d that you experience cramping i n the d i f f e r e n t muscle groups. I f t h i s occurs as you go through the tension and rel a x a t i o n exercises hold the tension for a shorter period of time. In most cases t h i s w i l l avoid any cramping that might occur. 113 Okay, next, tighten the muscles i n the buttocks and g e n i t a l area, hold the tension, f e e l the difference, notice the tension- how i t f e e l s , where i t i s coming from, now relax. Say the word relax to yourself. Just allow a l l your muscles below your waist to relax as best as you can, the muscles i n your toes, the muscles i n the arches of your feet, the tops of your feet, your ankles, your calves, your shins, the muscles behind your knees, the thighs, the buttocks, the g e n i t a l area, a l l those muscles j u s t relaxed. As we go through the d i f f e r e n t tension-relaxation exercises you may begin to experience d i f f e r e n t sensations throughout your body, feelings of a t i n g l i n g sensation, perhaps a f l o a t i n g sensation throughout your body, or a f e e l i n g o c c a s i o n a l l y of d i s o r i e n t a t i o n . These sensations are very frequently associated with learning how to relax. I f you w i l l j u s t allow yourself to experience these new sensations and not be frightened of them you w i l l f i n d that they w i l l i n f a c t become a part of the very comfortable f e e l i n g of r e l a x a t i o n that you w i l l acquire. Working up now through the trunk of the body, through the main part of the body, I'd l i k e you to tighen your stomach muscles as i f someone were about to h i t you r i g h t i n the s o l a r plexus, you saw i t coming and you tightened your stomach muscles. Okay, now relax, say the word relax to yourself. 114 Perhaps one of the most important muscle groups i s the muscles around the chest, and also our breathing. What I'd l i k e you to do at t h i s time i s take a nice deep breath, f i l l your lungs with a i r , and hold that breath of a i r . Okay, now relax, l e t loose of the breath of a i r , allow yourself to breath more deeply and more comfortably. People that are anxious tend to breathe more quickly, that i s more r a p i d l y , and more shallowly. One of the most important areas that you can focus i n on when you f e e l yourself becoming tense i s how you are breathing. By j u s t allowing yourself to breathe comfortably, deeply, smoothly, you w i l l f i n d that you can produce a greater sense of calmness and of r e l a x a t i o n throughout your body. Next, focusing on the muscles i n the lower back I'd l i k e you to arch your back, arch your back r i g h t at the base spine. Now l e t loose of that tension, allow your back to, once again, conform to the softness of the chair, of the couch or the bed, wherever you are p r a c t i c i n g the r e l a x a t i o n . This time, working with the muscle groups i n the upper part of the body, the upper back and i n the shoulders, I would l i k e you to bring the t i p s of your shoulders around and t r y to point them i n front of you as i f they were about to meet an imaginary l i n e i n the front of your body. Now relax, allow your shoulders to just come back to a comfortable p o s i t i o n . 115 Okay, t h i s time point your shoulders behind your back, t r y to bring them to meet d i r e c t l y behind your back and notice the tension from a d i f f e r e n t area t h i s time. Now, relax, say the word relax to yourself. Just allow your stomach, your chest, your lungs, your lower back, your upper back and your shoulders to relax further and further. Keep i n mind as we go through a l l these tension and re l a x a t i o n exercises that tension and relaxa t i o n are two incompatible responses, you cannot be extremely tense and extremely relaxed at the same time. Consequently, i f you can learn how to relax and be able to produce t h i s state from your own control you can l i t e r a l l y turn o f f feelings of tension, turn them o f f before they occur i n high amounts where the tension would i n t e r f e r e with what you are t r y i n g to accomplish, with what you are t r y i n g to do. Okay, moving along now to the muscle groups i n the arms, I'd l i k e you to make a muscle on both your arms, both your bisceps, make a muscle and hold i t , now relax, notice how much better that f e e l s . Okay, t h i s time, press your elbows down on the arms of the c h a i r and notice the tension also i n the upper part of your arms, now relax. Okay, t h i s time, I'd l i k e you to straighten your arms, as i f they were two str a i g h t iron bars, t r y to make them as s t r a i g h t and as r i g i d as you possibly can. Now, relax. 116 Just allow your s e l f to relax as best as you p o s s i b l y can. I t i s not intended that you f e e l t o t a l l y relaxed as you do these exercises, but rather to enable you to focus i n on the tension and feelings of relaxa t i o n and as we go through the exercises to acquire a greater sensation of r e l a x a t i o n and comfort than when you started. Okay, t h i s time bend your wrists back towards your body, bend them back towards your body, you w i l l f e e l the tension i n the lower part of the arms and i n the wrists, okay, now relax. Okay, now bend them i n the opposite d i r e c t i o n , bend them down, hold the tension, okay, now relax. This time, make a f i s t , make a f i s t with both your hands, f e e l the tension, hold the tension, f e e l i t i n your knuckles and i n the palms of your hands, now relax. This time, I'd l i k e you to spread your fing e r s , spread your f i n g e r s as f a r out as they w i l l go, spread them out, f e e l the tension, okay, now relax. Just allow your fingers to relax, your wrists, your forearms, your elbows, your upper arms, allow that f e e l i n g to merge i n with the warm, comfortable f e e l i n g i n the upper part of your body, the shoulders, chest, stomach, back and down through the legs. Okay, next we w i l l move to the muscles i n the neck area. Many in d i v i d u a l s who report tension headaches are able to reduce these headaches by teaching themselves how to rela x the muscles of the shoulders and the neck. In order to 117 get at these muscles I would l i k e you f i r s t of a l l to t r y to touch your chin on your chest, t r y to touch your chin on your chest and hold that tension, okay, now relax. This time, point your chin up and away from you, okay, now relax. Do the same thing again now, point your chin up and away from you. Okay, now, relax. Working now with the muscles i n the f a c i a l area, I'd l i k e you to b i t e your teeth together and p u l l the corners of your mouth back, okay, now relax. This time, I'd l i k e you to squint your eyes together as t i g h t l y as you can and at the same time wrinkle up your nose, okay, relax. Okay, I'd l i k e you to r a i s e your eyebrows, wrinkle your forehead by r a i s i n g your eyebrows, okay, now relax. Remember to focus on where the tension i s coming from. The reason f o r saying the word relax throughout these exercises i s because as you practice the r e l a x a t i o n more and more and use the word relax more and more frequently you w i l l f i n d that j u s t saying the word w i l l begin the process of r e l a x a t i o n . Okay t h i s time, I'd l i k e you to furrow your eyebrows, bring them close together, okay now relax. Just allow a l l the muscles of your body to relax as best as possible, beginning with the muscles i n your face, your forehead, the muscles behind your eyes, your nose, your cheeks, your jaws, the muscles i n your neck, your upper back, your shoulders, down through your arms, your forearms, 118 your hands, your fingers, as well as the muscles around your chest, your lower back, your stomach, down through the buttocks, the g e n i t a l areas, the thighs, the knees, the calves, the shins, by your ankles, the arches of your feet, and a l l the way out to the end of your toes. Just r e l a x as best as you possibly can. In a moment, I am going to count from one to f i v e . When I reach the number f i v e , I would l i k e you to take a deep breath and slowly open your eyes. Okay, one, two, three, four, f i v e . 

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