SYSTEMATIC DESENSTTTZATTON, FLOOfiING, AND RELAXATION TRAENTNG AS TREATMENTS FOR TEST ANXIETY Thesis for the Degree of Ph. D. MECHIGAN STATE UNWERSITY PETER TQDD HAMPTON 1971 This is to certify that the thesis entitled SYSTEMATIC DESENSI'T‘IZATIOIT', FLUODIN’}, Mm RELAXATION TRAINING AS TREATMEBTS FOR TEST ANXIETY presented by Peter Todd Hampton has been accepted towards fulfillment of the requirements for PhD degree in Clinical PsyChOIOgy SYSTEMATIC DESENSITIZATION, FLOODING, AND RELAXATION TRAINING AS TREATMENTS FOR TEST ANXIETY BY Peter Todd Hampton This study compared the effectiveness of three therapies, systematic desensitization, flooding, and re- laxation training, in reducing the test anxiety of college students. Forty-four subjects scoring high on test anxiety and volunteering for treatment of test anxiety were ob- tained from a population of students enrolled in two ele- mentary psychology courses at Michigan State University. Subjects were assigned to one of four groups: systematic desensitization treatment group, flooding treatment group, relaxation treatment group, or no-treatment control group. Before and after the treatment period, subjects completed self-report measures of test anxiety and self-esteem. The subjects' pre and posttherapy academic quarter grade-point- averages and psychology course exam grades were also ob- tained. Treatment subjects and therapists made ratings on various aspects of the therapy experience. Several of the measures were completed by the subjects again in a follow- up assessment the next quarter. Peter Todd Hampton The results of this study did not indicate general differences between the effectiveness of the three thera- pies in reducing subjects' test anxiety or in increasing subjects' self-esteem. The relaxation treatment, however, was rated by therapists as requiring less time to complete than the flooding treatment. Each of the three therapies was more effective than the no-treatment control condition in decreasing subjects' self-report measure test anxiety scores and in increasing subjects' self-esteem scores. No significant improvement on either of the academic grade measures was achieved by the therapy treatments or the control condition. The relation of these findings and others to the findings of previous research was discussed. Implications for further research and clinical practice were commented upon. Thesis Committee Dr. Donald L. Grummon, Chairma Dr. George W. Fairweather Dr. Lawrence A. Messe Dr. Dozier W. Thornton SYSTEMATIC DESENSITIZATION, FLOODING, AND RELAXATION TRAINING AS TREATMENTS FOR TEST ANXIETY BY Peter Todd Hampton A THESIS Submitted to Michigan State University- in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1971 ACKNOWLEDGMENTS I am grateful to the many people who assisted me in this research. First and foremost I would like to thank my adviser Dr. Donald Grummon for the active support and patient counsel he has extended to me in this research and throughout my graduate career. My association with Dr. Grummon has been one of the most rewarding aspects of my graduate education. I am also indebted to Drs. Dozier Thornton, Larry Messe, and George Fairweather for their constructive criticism and assistance in implementing the research and analyzing its results, and I am appreciative of the excellent graduate instruction I have received from them. My sincere thanks is extended to Ginette Balsam, Frank Barron, Enid Cheney, Bill Graff, Ken Hall, David Jordan, Jay Lazier, Carol Loutzenhiser, Thomas Negri, Holly Van Horn, and Charlia Von Buchwald. These individ- ‘uals graciously gave of their time and skill to serve as therapists in this study. I also appreciate the assist- ance Dr. Paul Bakan, Dr. Bertram Karon, Joshua Jaffe, and Raymond Penney gave me in recruiting and testing subjects from their introductory psychology courses. Finally, I am grateful to my wife Janet for her continued support and assistance during all phases of this research. ii TABLE OF CONTENTS LIST OF TABLES O O O O O I O O O .0 O O O O I 0 LIST OF APPENDICES O O O O O O O O O I O O O 0 Chapter I 0 INTRODUCTION 0 I O l O O O O O O O O O 0 Purpose of Study and Review of the Literature . . . . . . . . . . . . . . Hypotheses to be Tested . . . . . . . II. METHOD . . . . . . . . . . . . . . . . . Instruments . . . . . . . . . . . . . Therapists . . . . . . . . . . . . . . Treatments . . . . . . . . . . . . . . Subjects . . . . . . . . . . . . . . . Procedure 0 O 0 O O O O O O O O O O 0 III. RESULTS . . . . . . . . . . . . . . . . Statistical Procedure . . . . . . . . Sample Size Variations . . . . . . . . Data Analyses . . .,. . . . . . . . . Relationship between Outcome Criteria Summary of Major Findings . . . . . . Decisions Regarding Hypotheses . . . . iii Page vii 14 16 16 19 21 22 24 28 28 29 30 46 51 54 Chapter Page IV. DISCUSSION 0 O O O I O O O O O O O O O O O O O 57 Explanation of Effects . . . . . . . . . . . 57 Implications for Research and Practice . . . 6O Suggestions for Further Research . . . . . . 63 REFEMNCES O O O I O O O O O O O O O O O O O O O O O 6 6 APPENDICES O O O O O O O O O O O O I O O O O O I O O 7 1 iv Table 10. 11. LIST OF TABLES Comparison of the typical circumstances under which relaxation is taught or practiced and the circumstances of a stress situation, such as taking an exam . . . . . . . . . . General experimental design and procedure . . Analysis of variance on test anxiety scores . Mean pre-post-follow-up test anxiety scale scores 0 O O O O O O O O O O O C O O O O 0 Analysis of-variance on anxiety differential scores 0 I O O O O O O O O O O O O O O O 0 Mean pre-post anxiety differential scores . . Analyses of variance on midterm and final exam psychology course grades (standard— ized) and pre-post term grade-point- averages . . . . . . . . . . . . . . . . . Mean midterm and final psychology course exam grades (standardized) and pre-post term grade-point-averages . . . . . . . . . Analysis of variance for Tennessee Self Concept Scale Personal Self subscale and Total Positive subscale scores . . . . . . Mean Tennessee Self Concept Scale Personal Self subscale and Total Positive subscale scores 0 O O O O O O C O O O O O O O O O 0 Analyses of variance on subject ratings of specific improvement in test anxiety and improvement in other areas . . . . . . . . Page 11 25 30 31 32 33 34 35 37 38 40 Table 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Page Mean subject ratings of specific improvement in test anxiety and improvement in other areas 0 O O O O O O O O I O O O O O O O O O O 41 Analysis of variance of subjects' post— therapy ratings of their therapists' competence and likeability . . . . . . . . . 42 Mean subject post-therapy ratings of therapist competence and likeability . . . . 43 Analysis of variance for subjects' midterm and final study and preparation ratings . . . 44 Mean subject midterm and final study and preparation ratings . . . . . . . . . . . . . 45 Analyses of variance for therapists' ratings of confidence in each technique, comfort in working with each technique, Specific im- ‘ provement in subject, other improvement in subject, apprOpriateness of length of therapy for subject, and appropriateness of type of therapy for subject . . . . . . . . . 47 Mean therapist ratings of confidence in each technique, comfort in working with each technique, specific improvement in subject, other improvement in subject, appropriate- ness of length of therapy for subject, and appropriateness of type of therapy for subject . . . . . . . . . . . . . . . . . . . 48 Correlations between outcome criteria at post— testing 0 O C O O O O O O O C O O C C O O O O 49 Correlations between outcome criteria at fellow-up testing 0 o o o I o o o o o o o o o 50 Summary of statistically significant compar- isons between treatment groups on the major outcome criteria . . . . . . . . . . . . . . 52 Summary of statistically significant compar- isons between control group and treatment groups on the major outcome criteria . . . . 53 vi Appendix A. B. C. D. LIST OF APPENDICES Test Battery Forwards . Instruments . . . . . . Treatment Manuals . . . Therapy Summary Sheets vii Page 71 79 91 112 CHAPTER I INTRODUCTION Purpose of Study and Review of the Literature This study compares the effectiveness of three therapies, systematic desensitization, flooding, and re- laxation training, in reducing the test anxiety of college students. Of these three therapies systematic desensiti- zation is probably the best known. Certainly one of the most notable developments of the last decade of psycho— therapy research is the widespread application and inves- tigation of this particular technique. Since the early delineation of the technique (Wolpe, 1954, 1958), a host of papers have been published reporting the success of systematic desensitization in treating a broad range of disorders in which anxiety was of fundamental importance (see Paul, 1969a,b for recent summaries of this research). Now some of the more recent research on systematic desen— sitization is focusing on comparisons of the technique with other types of therapy and on investigations of the contributions of various components of the technique to the therapy outcome. A comparison of systematic desensitization to implosive or flooding therapy and to relaxation therapy relates to both these research focuses since the latter techniques are distinct therapies from desensitization, yet they share some common components with desensitization. A description of the techniques will illustrate this. In treating phobic or anxiety reactions systematic desensitization first involves: (a) training in muscular relaxation using an abbreviated version of Jacobson's (1938) progressive relaxation technique, and (b) identifi- cation of stimuli or situations which elicit the client's anxiety reaction. The stimuli are incorporated into an anxiety hierarchy consisting of carefully graded situations ranging from those which elicit very little anxiety from the client to those which elicit maximum anxiety. Desen- sitization proper then consists of verbally presenting the situations to the deeply relaxed client to imagine for a short time (5-30 seconds). The scenes are presented in hierarchical order beginning with the least and progressing to the most anxiety provoking scene. Each scene is re- peatedly presented to the client until he indicates that it no longer makes him anxious. WOlpe proposes that the effectiveness of the treatment is due to a countercondi- tioning process. He states: If a response antagonistic to anxiety can be made to -occur in the presence of anxiety evoking stimuli so that it is accompanied by a complete or partial sup- pression of anxiety responses, the bond between these stimuli and the anxiety responses will be weakened (Wolpe, 1958, p. 71). The response antagonistic to anxiety is relaxation. Flooding (Wolpe & Lazarus, 1966) and implosive therapy (Stampfe & Levis, 1967) are two related techniques in which the client is also asked to imagine scenes related to his fear. No minimally anxiety arousing scenes are presented, but rather the subject is asked to visualize highly anxiety arousing scenes. No relaxation training is involved in this technique. Although some investigators equate the flooding and implosive techniques (Rachman, 1969), the two seem somewhat different in that the scenes imagined in implosive therapy are often chosen to relate to conflict areas suggested by psychoanalytic theory (e.g. orality, anality, castration) while those in the flooding technique are usually chosen without regard to psycho- analytic theory. For both techniques, however, it is hypothesized that anxiety reduction is produced via a process of extinction rather than counterconditioning as in systematic desensitization. The extinction hypothesis assumes that the client's anxiety is a classically condi- tioned response to the phobic stimuli, and that if the phobic stimuli are presented to the client without the unconditioned stimulus punishment, then the anxiety re— sponse to the phobic stimuli will diminish or extinguish. Relaxation therapy consists of teaching the client how to relax himself. An abbreviated version of Jacobson's (1938) progressive relaxation training is most commonly used for this purpose. This involves successive tensing and releasing gross muscle groups throughout the body on instruction from the therapist. Attention is focused upon identification of localized tension and relaxation. The goal of the therapy is to make the person generally more relaxed and also to provide him with a technique to combat anxiety should it arise in any particular situation. As in systematic desensitization the relaxation response is considered to be incompatible with the anxiety response. Thus the counterconditioning process underlies the techni- que. The client's invoking his relaxation in an actual fear producing situation is similar to in vivo systematic desensitization (desensitization using the actual feared stimuli rather than having the client imagine them) except that there may be a more abrupt confrontation of the feared stimuli and the client rather than the therapist instigates and controls his-own relaxation. Since desensitization, flooding or implosive ther- apy, and relaxation therapy are used to treat similar types of disorders, comparisons of the effectiveness and efficiency of the techniques are eSpecially interesting. Research along this line has tended to contrast systematic desensitization against flooding or implosive therapy and against relaxation training rather than comparing the latter techniques. Barrett (1969) in treating snake phobic subjects found no difference in effectiveness of systematic desen- sitization and a modified implosive therapy (the scenes were notchosen to relate to psychoanalytic theory). The implosive therapy, however, took less time and was hence concluded to be more efficient. Cohen (1969) treated test-anxious subjects with either standard systematic desensitization or systematic desensitization using only high anxious hierarchy items (except for the use of relaxa- tion the latter treatment resembles flooding). Again there was no difference in the effectiveness of the two techni- ques, but the flooding-like treatment took less time. Rachman (1966) found systematic desensitization to be more effective than flooding which was no better than no-treat- ment control in treating spider phobic subjects. Rachman had his subjects image for 2- minute intervals, and it has been suggested (Staub, 1968) that this short exposure time may have prevented extinction of anxiety and actually re- inforced withdrawal from the feared stimuli. Wolpin and Raines (1966) report success in treating snake phobic- subjects with a flooding technique using scene presenta- tions of quite long duration (2-30 minutes). Two other studies report results related to the issue of length of stimulus presentation and extinction of fear to that stimulus: Paul (1969a) found that repeated short (5-20 second) imagining of an anxiety arousing scene while the subject was not deeply relaxed increased the subject's fear response to the stimulus; Baum (1969) reports that short periods of forced confrontation of a feared stimulus were ineffective in reducing an avoidance response in rats, but that long periods were effective. Nothing very definite can be concluded from the studies reviewed above, although they do hint that flood- ing-type treatments may be more efficient than systematic desensitization. The evidence also suggests that, to be on the safe side, the duration of stimulus presentation in flooding techniques should be relatively long, unless this variable is itself being investigated. ‘ Studies comparing systematic desensitization and relaxation training have produced even more of a variety of results than those comparing desensitization and flood- ing. Lang, Lazovik and Reynolds (1965) and Davison (1968) treated snake phobic subjects with either desensitization or relaxation and imagining of innocuous scenes unrelated to snakes. In both studies desensitization produced more change than relaxation, which produced the same results as no treatment. Rachman (1965) compared spider phobic sub- jects given group desensitization to subjects merely re- laxed in each therapy session. The sample size was too small for statistical analysis, but on qualitative evaluation the desensitization appeared to have produced greater improvement than relaxation. Cooke (1966) reports a study with results not entirely in accord with the three studies just mentioned. In treating students who were afraid of rats, he found no posttreatment criterion measure differences between subjects receiving systematic desensi- tization; desensitization with relaxation training but without relaxation induction during desensitization; re- laxation only, but with an initial ranking of a hierarchy which was not presented; hierarchy ranking only, or no treatment at all. The findings, however, are clouded by the fact that: (a) many of the desensitization subjects did not finish their hierarchies, (b) the groups were not shown to be equated on pretreatment criterion scores, and (c) many of the subjects were not very afraid of a labora- tory rat even before treatment began. The four.studies cited above are in agreement in illustrating that merely relaxing the client in several therapy sessions does not produce a decrement in his anxiety reaction when he is later faced with the phobic stimuli. This seems to indicate that the effect of de- sensitization is not due merely to the client's learning how to relax and then incidentally applying this ability in actual stress situations. In the above studies the clients were not specifically instructed to use relaxation when confronted with disturbing situations. McReynolds (1969) ventures that such instruction is a necessary and important part of relaxation treatment, and at least three studies support this position. Snider and Getting (1966) treated test-anxious students with autogenic training, a type of relaxation training, and instructed the subjects to use the training whenever they were under tension, particularly during exams. The students reported being less tense and anxious in many situations, and they all showed improvement on examination marks. The grade-point-average (GPA) of the group went from C+ to B+. There was, however, no control or comparison treatment group in this study, and no sta- tistical analyses of the data were made. Zeisset (1968) utilized a relaxation treatment which also included train- ing in how to use relaxation in stressful situations. This treatment was as effective as desensitization and more effective than attention-placebo treatment or no treatment in reducing interview anxiety in male psychiatric patients. Fokins, Lawson, Opton, and Lazarus (1968) re— port the third study in which instructing the subjects to utilize their relaxation training proved beneficial.- They compared the effects of three brief treatments on autonomic and verbal responses to a stress-producing motion picture film. The stress treatments were an analog desensitization therapy, relaxation therapy with instructions to use it while viewing the film, and a flooding-type-therapy involving imagining frightening scenes similar to those used in the film. On the posttest.all the treatment groups when compared to a control group yielded lower anxiety scores on an adjective checklist, and on a skin conductance measure taken during the film. There was also a tendency for the relaxation and the visualization-only groups to show lower conductance than desensitization sub— jects. This study and the Zeisset study have been criti- cized (by Lang, 1969 and Paul, 1969c, respectively) for flaws in the desensitization treatments used. One last study comparing systematic desensitization and relaxation with test anxious students was done by Johnson and Sechrest (1968). The relaxation group sub- jects were told in an intake interview that knowing how to relax could allow them to inhibit tension and anxiety in any disturbing situation. However, unlike subjects in the three studies just reviewed, Johnson and Sechrest's sub- jects were not specifically instructed to apply relaxation in the test situation--it was merely suggested to them that treatment procedures would result in greater relaxa— tion for them when they were test anxious (Johnson, 1969). In the therapy sessions they were given relaxation training and then when relaxation had been induced the therapist left the room, instructing the client to continue relaxing for the rest of the session. Subjects were also told to practice relaxation at home. The results revealed' 10 significantly greater improvement in performance in a standardized multiple-choice examination for the desensi- tization group than for either the relaxation or no-contact control groups which did not differ in effectiveness. On the other major criterion, the Alpert-Haber test anxiety scale, there were no significant differences between any of the groups. One confounding factor in this study is- the fact that the desensitization subjects received more attention from and had more contact with their therapists than did the relaxation subjects. In five of the eight studies reviewed above re- laxation training was ineffective in reducing the client's anxiety reaction. In each of these five studies the sub- ject was not specifically instructed to use his training to relax himself in anxiety provoking situation, whereas in the three studies in which relaxation training was effective the subject had been instructed to use it when he was anxious. It may be that a crucial element for the success of relaxation training is insuring that the sub- ject can and will transfer his relaxation training to extra-therapy situations. One aspect of promoting this transference seems to be specifically instructing the subject to use his relaxation training in stress situa- tions. Another means of promoting the subjects' transfer of relaxation skills to extra-therapy situations might be 11 the use of extensive relaxation practice homework assign- ments for the clients. This would prevent the relaxation response from coming under the specific stimulus control of the therapy setting. The comparison in Table l of the circumstances in which relaxation is often taught and practiced as opposed to those in which it is to be applied in an actual stress situation, like taking an exam, sug- gests why the response is not transferred to the stress situation. Table 1. Comparison of the typical circumstances under which relaxation is taught or practiced and the circumstances of a stress situation, such as taking an exam. Training Situation Exam Situation 1. Small room 1. Large room 2. Dim lighting 2. Normal lighting 3. Very quiet 3. At least some noise from coughing, shuffling, etc. 4. Eyes shut 4. Eyes Open 5. Client alone or with 5. Many others present only therapist present 6. No anxiety aroused 6. Anxiety aroused Emery (1969) notes that subjects experience some difficulty in utilizing relaxation techniques even in the solitude and privacy of their own room. He states: . . . the large majority of clients find the relaxation exercises to be more effective in the counselor's 12 darkened office while in a reclining chair. They report that it is easier for them to relax if someone else is telling them what to do (p. 281). With this in mind, it is not hard to see why it would be difficult for subjects to relax in an actual stress situa- tion. A more effective relaxation treatment than those typically used would be one which focused on getting the client to instigate and practice relaxation in a wide variety of extra-therapy situations. In addition, to prepare the client for the relatively greater difficulty he will experience in trying to relax when he is anxious, the client should be forewarned of this difficulty. This should help to keep the client confident in the technique when he actually tries to apply it in a stress situation,‘ just as a two-sided communication preserves more attitude change than a one-sided communication when the subject is exposed to subsequent counterprOpaganda (Cohen, 1964). In the present comparison of the effectiveness of systematic desensitization, flooding, and relaxation ther— apy in treating students suffering from undue test anxiety, the criteria of therapy effectiveness will include grade- point-averages, grades on examinations in an introductory psychology course, self-report measures of anxiety in the testing situation, and client and therapist ratings of the success of therapy. These measures are at least fairly directly related to the therapy target problem of test 13 anxiety. A somewhat indirectly related measure, level of self—esteem, will also be used as an outcome criterion in this study. The use of change in clients' selféesteem and self-concept as a criterion of therapy success has long been popular with insight oriented therapists, particularly the Rogerian group (Rogers and Dymond, 1954; Rogers, Gendlin, Kiesler, and Truax, 1967). This criterion has, however, been neglected by investigators of behavior ther- apies. One might expect that a high predisposition to anxiety would lower one's self-esteem. The highly anxious person may have a lower opinion of himself because he realizes that he is more easily threatened and frightened than his fellows. In addition high anxiety may interfere with performance of various skilled behaviors, thus causing the highly anxious person to appear less competent than his less anxious peers. An inverse relationship between general anxiety level and self-esteem has been reported by a number of investigators (Rosenberg, 1962; Suinn and Hill, 1964; Fitts, 1965). Suinn and Hill also found a correla- tion of -.58 between a self-acceptance measure and a measure of test anxiety. Similarly, Sarason and Ganzer (1962) and Sarason and Koenig (1965) found that high test- anxious subjects made more self-deprecatory remarks in a free verbalization situation than did low test-anxious subjects. If systematic desensitization, flooding, or relaxation therapy decreases test anxiety and perhaps, 14 through generalization, also reduces general or trait anxiety, then they may also increase clients' self-esteem. This seems worth investigating. The results of the studies discussed above suggest a number of research questions which are further explored in the present study. The most central of these are: (a) Which, if any, of the three therapies is most effective in reducing a target anxiety, as for instance test anxiety, (b) do any of the three therapies produce an increase in clients' self-esteem, and if so which produces the greatest increase, and (c) which, if any, of the three therapies is most economical in terms of time? These questions are reformulated into hypotheses below. Hypotheses 1, 3, and 5 are stated in null hypothesis form rather than as direc— tional hypotheses since this study is mainly exploratory to determine what if any differences there are among the outcomes of the three techniques. Hypotheses to be Tested (1) There will be no difference in the effective- ness of systematic desensitization, flooding, or relaxation therapy in reducing clients' test anxiety. (2) Systematic desensitization, flooding, and re- laxation therapy will all be more effective than no treat- ment at all in reducing clients' test anxiety. 15 (3) There will be no difference in the effective- ness of systematic desensitization, flooding, or relaxation therapy in increasing clients' self-esteem. (4) Systematic desensitization, flooding, and re- laxation therapy will all be more effective than no treat- ment at all in increasing clients' self-esteem. (5) Therapists' estimates of the amount of therapy time necessary to conduct systematic desensitization, flooding, or relaxation training with test-anxious stu- dents will not differ. CHAPTER II METHOD Subjects scoring high on text anxiety and volun- teering for treatment of test anxiety were obtained from a pOpulation of students enrolled in two elementary psy- chology courses at Michigan State University. Subjects were assigned to one of four groups; systematic desensi— tization treatment group, flooding treatment group, relaxa- tion treatment group, or no-treatment control group. Before and after the treatment period, subjects completed self- report measures of test anxiety and self-esteem. Treat- ment subjects and therapists also made ratings on various aspects of the therapy experience. Several of the meas- ures were completed by the subjects again in a follow-up assessment the next quarter. Instruments Test Anxiety Scale (TAS).--This scale (Appendix B) is Sarason's (Sarason and Ganzer, 1962) 16 item true-false version of Mandler and Sarason's (1952) Test Anxiety Questionnaire (TAQ). Subjects' scores on the TAQ have been shown to be significantly related to: (a) subjects' 16 17 skin conductance while taking a test (Raphelson, 1957; Kissel and Littig, 1962), and (b) observer ratings of subjects' behavioral manifestations of anxiety while taking a test (Sarason and Mandler, 1952). These validity data should hold true for the TAS to the extent that it is related to its parent instrument the TAQ; however no cor- relations between the two tests are reported.‘ Several studies have shown the TAS to be sensitive to changes resulting from systematic desensitization treatment of test anxiety (Katahn, Strenger, and Cherry, 1966; Garlington and Cotler, 1968; Suinn, 1968; Cohen, 1969). The test-retest reliability of the TAS over a five week period is reported as .78 (Suinn, 1969). Anxiety Differential (AD).--The Anxiety Differen- tial (Appendix B) (Husek and Alexander, 1963) is an 18 item inventory with a Semantic Differential format. The inventory has been shown to discriminate between the anxiety level of students completing the measure imme— diately before beginning their midterm or final exam and the anxiety level of students completing the measure dur- ing a regular class session (Wittrock and Husek, 1962; Husek and Alexander, 1963). The test has also differen- tiated the anxiety reduction produced by three different relaxation procedures (Paul, 1969c) and three different types of psychotherapy (Paul, 1966). In the latter study the Anxiety Differential was also significantly correlated 18 with two other self-report measures of anxiety (S-R Inven— tory of Anxiousness, Personal Report of Confidence as a Speaker) and with observers' ratings of subjects' behav- ioral manifestations of anxiety while giving a speech. Tennessee Self Concept Scale (TSCS).--The TSCS (Fitts, 1965) consists of 100 self-descriptive statements. The subject portrays his own picture of himself by rating each item's degree of applicability to him-on a five-point scale, ranging from "completely false" to "completely true." The Personal Self subscale (PS) of this test is used as the primary measure of self-esteem for this study. The score on this scale "reflects the individual's sense of personal worth, his feeling of adequacy as a person and his evaluation of his personality-apart from his body or- his relationships to others (Fitts, 1965, p. 3)." Scores on the Personal Self subscale correlate .90 with scores on the Total Positive subscale (TP). The latter scale is the TSCS measure of overall level of self-esteem. It is used as the secondary rather than primary measure of self-esteem in this study because it contains many items, particularly those concerning satisfaction with one's physical appear- ance, which would not be expected to change as a result of a decrease in test anxiety. Fitts reports the test-retest reliabilities of the Personal Self and Total Positive subscales over a two week period to be .85 and .92 respectively. Both scales have 19 been shown to be sensitive to changes produced by psycho- therapy (Ashcraft and Fitts, 1964). Subject and Therapist Posttreatment and Followeup Questionnaires.-—The Subject Posttreatment Questionnaire, Subject Follow—up Questionnaire, and the Therapist Post- treatment Questionnaire (Appendix B) are slightly modified versions of subject and therapist rating forms used by Paul (1966). The subject's ratings include an evaluation of the effectiveness of his therapy and the competence and likeability of his therapist. The therapist ratings on their subjects' are for: likeability, responsiveness to treatment, appropriateness of length and type of treatment, degree of reduction of test anxiety, degree of improvement in other areas, indication of necessity for further treat- ment, and therapist comfort in working with the client. Therapists The eleven therapists who volunteered their serv- ices for this study were a somewhat varied lot--five were upper level graduate students in counseling or clinical psychology who were enrolled in a behavior therapy seminar the quarter the research was conducted, three were first year graduate students in clinical psychology whose ther- apy experience was limited mainly to graduate level clin- ical assessment courses, one was a second year graduate student in clinical psychology who was enrolled in the 20 therapy practicum at the Psychology Clinic, one was a college graduate who had worked with in-patients at a community mental health center and who was a volunteer worker at a crisis intervention center, and one was a staff psychologist at the Michigan State University Coun- seling Center with 18 months of post-Ph.D. psychotherapy experience. Of these therapists, six were males and five were females. The seminar students were trained in syste- matic desensitization in the seminar and had begun using the technique with another subject before their contacts with their research subjects. The staff psychologist had used systematic desensitization and relaxation therapy with two clients outside the research project. The other therapists had no prior experience with the desensitiza— tion, flooding, or relaxation techniques. Each therapist began treatment with three subjects --one receiving systematic desensitization, one flooding, and one relaxation training. The treatment manuals in Appendix C, which are adaptations of Paul's (1966) Syste- matic Desensitization Treatment Manual, were used to pro- vide the therapists with guidelines for each treatment. In addition the therapists read selected articles on the techniques, observed a flooding session with a test anxious subject, and discussed the techniques and proced-, ures with the investigator. 21 Treatments Systematic Desensitization.--This treatment con— sists of a somewhat modified form of the desensitization treatment delineated by Paul (1966) and originated by Wolpe (1958). Tape recorded relaxation instructions were used, and two one-hour and three one-half—hour sessions were allotted as treatment time. The specific treatment procedure is described in Appendix C. Flooding.-—This treatment consists of a modified form of the flooding treatment described by Wolpe and Lazarus (1966). The treatment procedure is described in Appendix C, and it also included two one-hour and three one-half—hour therapy sessions. Relaxation Training.--This treatment consists of the same abbreviated Jacobson relaxation training given to subjects in the desensitization treatment with the addi- tion of two modifications. Cautela's (1969) technique of using the word "relax" as a conditioned stimulus for re- laxation was included. This involves having the subject say "relax," either aloud or to himself, ten times each time he practices relaxation. The word "relax" is prob- ably already a conditioned stimulus which will elicit relaxation in many people (Wolpe, 1969), and Cautela's procedure may increase the eliciting value of the word. Thus the client might be able to become relaxed both by 22 voluntarily releasing the tension in his muscles and also by telling himself to relax. The second addition to the abbreviated relaxation training was an intensive concen- tration on the client's practicing relaxation outside of the therapy session.‘ The client was instructed to prac- tice relaxation in a variety of surroundings, and during the therapy sessions the client's experiences during re- laxation practicing were reviewed. Two one-hour and three one-half—hour sessions were allotted as treatment time. The treatment procedure is more fully described in Appen- dix C. Subjects A total of 44 subjects (10 males, 34 females), ranging in age from 17 to 22 years with a median age of 19, participated in this study. Of these subjects, 24 were freshmen, 10 sophomores, 6 juniors, and 4 seniors. The grade-point-average of these subjects for the academic quarter immediately preceding the treatment ranged from a high of 3.91 to a low of 1.08, with a mean on 2.471 These subjects were selected from the population of 794 students enrolled in two introductory psychology courses who had completed the Pretreatment Battery. This 1The grading scale at Michigan State University ranges from O (F) to 4.5 (A+). 23 battery included the Test Anxiety Scale, and a cover sheet (Appendix A) which stated the purpose of the study, de- scribed the amount of time involved in participation, and asked for volunteers. Of those students who expressed a desire for treatment, the ones who scored 10 or above on the TAS (upper 17% of the total population) were contacted individually by telephone for a screening interview ap- pointment. At the screening interview some subjects were excluded from the study for the following reasons: (a) failing to appear for the appointment, (b) currently re- ceiving psychotherapy elsewhere, (c) not being sufficiently concerned about test anxiety to commit themselves to the study. Forty-four subjects were accepted after screening, and eleven subjects were assigned to each of the three treatment groups and to the control group. Of the 44 subjects who began treatment, 9 (all females) are not included in the final data analysis. Two subjects (one in the control group, one in the flooding group) were excluded from the analysis because they had received extensive psychotherapy at the University Counsel- ing Center during the period the study was conducted. (One subject in the relaxation group who had had only one and one-half therapy sessions at the Counseling Center was included in the analysis since after talking to his thera- pist the investigator decided this minimal contact would not confound the research results.) Seven subjects 24 voluntarily attritted from the treatment. One of these from the flooding group dropped out of school even before her first therapy session. The other six subjects repeat- edly missed therapy appointments, and gave excuses that they were too busy to participate in the research. None of these subjects completed more than two therapy sessions. Comparisons between the attrition subject group and the group which remained in treatment revealed no significant (a = .05) differences between the two groups' mean pre- treatment TAS, AD, TSCS PS, TSCS TP, midterm grade, or GPA scores. What the status of the attrition subjects would have been on the anxiety and self-esteem measures when they exited from therapy is unknown. It is, of course, possible that when they left therapy the attrition sub- jects were either more or less anxious than the subjects who remained in therapy. For instance, by focusing on the subjects' anxiety, the therapy may have made these subjects even more anxious and less willing to continue in therapy. On the other hand, these subjects may have experienced a remission of their test anxiety which caused them to feel less need for therapy and less desire to continue with it. Procedure The basic plan of the study is presented in Table 2. The Pretreatment Battery was administered in class to all the students attending the lectures of-the two 25 ucmfiumouu oz 0 .1 mcflsflmuu cowumxmamm m L A] mufimscowummzv HflmccoHDmmsv QSISOHHOM smaummnuumom mcwpoon am 36.33 nomflnsm show. moamo mmamom mnoumwc moms mafia moms 653m Hmcomnmm was ill: soaumN Iauwmcmmmp may 9“ m5. onnmsmummm n2 moms semen uo>oo om pcofimmmmmd mem mumupmm ucmfiumona mem 3mw>umucH mumuumm msouw mslzoaaom Hmcflm ucoEpmonuumom Enoupfiz mcflsoouom ucoEpmouumum .mnscmooum was smflmmc amusmfiflnmmxo Hmumsmw .N manna 26 introductory psychology courses. During the screening interview the rationale and course of treatment which the subject was to undergo was explained to him. Control group subjects were told that due to limitations on the number of therapists available they could not be treated that quarter but could receive treatment the following quarter. They were asked to participate in the testing aspect of the study in order to aid the research endeavor. At the end of the screening interview all subjects com- pleted the Tennessee Self Concept Scale and a Personal History Form (Appendix A). The midterm exam in one of the introductory psy- chology courses was given before the screening interviews and in the other after. Immediately before starting the exam all students, including the experimental subjects, completed the Anxiety Differential and two rating scales (Appendix B) asking how much the student had studied for the exam and how well prepared he felt. The latter two scales were included to determine if the treatments af- fected the students' preparation for the exam. The grades the subjects received on the exam were converted to stand- ard scores and recorded. After the midterm, treatment subjects began the therapy which continued for five weeks. Before the therapy began, therapists made ratings of their degree of confidence in their ability to effect improvement with each technique (Appendix B). At the end of each 27 therapy session the therapist and subject completed a sum- mary sheet describing the session (Appendix D). After the last therapy session therapists filled out the Therapist Posttreatment Questionnaire. They also gave their subjects a packet containing the Test Anxiety Scale, the Tennessee Self Concept Scale, the Subject Posttreatment Question- naire, and the Anxiety Differential and asked the subject to complete and to mail back the first three forms when they were done with their final exams. The subjects were instructed to bring the Anxiety Differential with them to their psychology exam and to fill it out just before the exam and return it to the investigator after the exam. Similar written instructions (Appendix A) were included with the test packet. A postcard with about the same in- structions was sent to the subjects during finals week as a reminder. Control group subjects were contacted by the investigator and given the same instructions. They were also sent the postcard. The subjects' final exam grades were converted to standard scores and recorded. As a short follow-up, sub- jects were mailed the Test Anxiety Scale, the Tennessee Self Concept Scale, and the Subject Follow-up Questionnaire during the fourth week of the following academic quarter. After the control group subjects returned their forms they were contacted by the investigator and offered therapy. CHAPTER I I I RESULTS Statistical Procedure Since there were no significant (p < .05) differ- ences between the pretreatment means of the groups on any of the criterion measures, the results of this study were examined with analyses of variance. The data is analyzed with either single factor analysis of variance or with analysis of variance for a two-factor (treatments X pre- post-follow-up) experiment with repeated measures on the second factor (Winer, 1962). Although the same therapists participated in each treatment, the treatment factor was not treated as a repeated measure since preliminary Kendall Coefficient of Concordance tests revealed that individual therapists' subjects' criterion scores were not signif- icantly intercorrelated. When the apprOpriate F test of the analysis of variance was significant or approached significance the individual therapy treatment means were compared with a two-tailed Tukey Honestly Significant Dif- ference procedure (Winer, 1962). Regardless of the outcome of the F test, each of the three therapy groups was com- pared to the control group with a one-tailed Dunnett's E 28 29 statistic (Winer, 1962) since the a priori prediction had been made that the treatment groups would show more im- provement on the outcome measures than the control group. Sample Size Variations Two subjects, one in the control group and one in the flooding group, did not return the follow-up question- naires. Thus for the analyses of the follow-up data in- volving the TAS, TSCS, and subject ratings the sample size is generally 7 subjects for the flooding group, 8 for the relaxation group, and 9 for both the desensitization group and the control group. For analyses on the other criteria (AD, psychology course grades, GPA, therapist ratings) the sample size is generally 8 for both the flooding and the relaxation group, 9 for the desensitization group, and 10 for the control group. Exceptions to these sample sizes are noted when they occur. At follow-up one subject in the relaxation group had been dismissed from the University for academic reasons and one had transferred to another university. Two subjects in the flooding group also did not return to school the term after treatment. Data from these four subjects is included in the analyses. 30 Data Analyses Anxiety scales: test anxiety scale; anxiety differential Table 3 presents the results of the 4 x 3 (treat- ments, pre- post-follow-up) analysis of variance on the TAS scores, and Table 4 presents the TAS means and standard deviations for pretreatment, posttreatment, and follow-up conditions. The treatment-by-pre—post-follow-up interac- tion approaches significance (p < .10) indicating differ- ential changes between groups. Table 3. Analysis of variance on test anxiety scores. Source df MS F Between Ss treatment 3 45.70 3.22** error 29 14.18 Within 83 pre-post-follow-up 2 61.50 20.68*** treatment-by-pre-post-follow-up 6 6.44 2.16* error 58 2.97 *p < .10 **p < .05 ***p < .01 Individual comparisons revealed no significant differences between therapy group TAS means at posttesting. However at follow-up the mean TAS score of the relaxation group was significantly (p < .05) higher than the mean 31 .uxou may cw pmunomou mum mam>oa evacuamwsmwm uomxo who: .Am Ho .H .u .m .xv HonE>m mEMm on» macaw mos» we Hm>oa mo. onu ummma um um usoummmac hausmowmwcmflm one 3ou m sflcuwz memos oBu was «ouoz sm.a muuma.oa mo.s msm~.m sm.~ ux-.m mm.a umxms.ma mansoaaom vm.a nom.oa mm.m mah.m mm.m. xmm.m mm.m meaa.ma umom vm.a mh.ma mv.a mm.~a hb.a mm.HH hm.a mm.~H mum am new: om cam: am new: am new: Gowuwpsoo cowpmmemm mswpoon cowumN Houucou Iwuwmcmmma .mmnoom onom huoflxsm ummu msl3oaaom umomumum saw: .v magma 32 scores of both the desensitization and flooding groups. The differences, however, were just barely significant, and it is likely that if the mean TAS score of the relaxa- tion group had not been slightly higher to begin with, these differences would not have been significant. The mean anxiety scores of the desensitization, flooding, and relaxation groups were significantly lower than the mean scores of the control group both at post (p < .005, p < .005, p < .05, respectively) and at follow—up testing (all p's < .005). The 4 x 2 (treatments, pre-post) analysis of var- iance for anxiety differential scores is summarized in Table 5, and the means and standard deviations for the pretreatment and posttreatment conditions are listed in Table 6. Again the significant (p < .01) treatment-by- pre-post interaction effect indicates differential changes between groups. Table 5. Analysis of variance on anxiety differential scores. Source df MS F Between 53 treatment 3 253.87 1.11 error 31 229.39 Within 88 pre-post 1 342.72 3.58* treatment-by-pre-post 3 466.48 4.87** error 31 95.76 *p < .10 **p < .01 33 .uxou mnu cw pmuuommu mum mam>ma mOQMOAMHsmwm uomxo who: .Au no .a .xv HOQEMm 05mm map oumnm moan ma Ho>oa mo. may ummma um um uconommac handmOAMHcmwm mum 30H m caspflz manna 03» was «ouoz hm.va umm.wm em.o %N0.Hh Hm.NH xv¢.mm m¢.NH Naxom.mm rumom mm.mH mm.wh hm.HH mm.hh hh.oa NN.mh mm.m ov.mw mum am new: am new: am new: am can: coauflpsou coaumxmaom mcflcoon cowumN Houusou Iapamcmmoa .mwnoom amaucmHmMMHp mumflxcm umomloum new: .w manna 34 There were no significant differences between the mean posttreatment AD scores of the desensitization, flooding, and relaxation groups.. However the mean post- therapy anxiety score of each of these groups was signif- icantly less than that of the control group (p < .005, p < .025, p < .005, respectively). Grades Two grade measures were used as outcome criteria in this study: (a) standardized midterm and final exam grades in the psychology course from which subjects were solicited, and (b) pretreatment and posttreatment term grade-point-averages. The 4 x 2 (treatments-by-pre-post) analyses of variance for these two measures are presented in Table 7, and the means and standard deviations for pre- treatment and posttreatment conditions are listed in Table 8. The insignificant (p > .10) treatments-by-pre-post Table 7. Analyses of variance on midterm and final exam psychology course grades (standardized) and pre-post term grade-point-averages. Course Grades GPA Source df MS F MS F Between 83 treatment 3 429.12 2.23 .941 1.12 error 31 192.80 .844 Within Ss pre-post l 65.57 2.27 .069 .42 treatment-by-pre-post 3 40.22 1.39 .006 .03 error 31 28.84 .164 35 .uxwu on» :w counomon mum mao>ma monsowmasmam pomxm who: .Axv HonENm seem on» mumnm hose ma Ho>oa mo. on» “mama um um ucmewmwc advancemesmflm mum 3cm m swnufi3 mcmmfi 03» and ”0902 mom. mN.N hmm. ww.m mNm. mv.N mmm. HB.N umom mam. mN.N mmo. om.~ mmm. m¢.N mmm. om.~ mum .mmmmum>MIncflomlmUmuw Hm.m mm.dv om.m xmm.mm «H.HH mh.o¢ Hm.m Nam.vv Hmafim «v.5 va.mv hm.oa ma.mm hm.ma hm.mv mv.m ma.am Ehmupflz mmcmum onusoo mmoHonOMmm am new: am new: am smoz am new: coflpwpcou cowumxmaom msficooam sofiumN Houusoo Iauflmcomon .mommuo>MIusflomuopmum Sump umomloum can Acouwtum upcmumv mmomum amxo mmHsoo mmoaonowmm Hanan can EH0#UHE new: .m magma 36 interaction effects for both analyses of variance indicate no differential pre-post change between therapy groups. Comparisons with Dunnette's t statistic of the control group's mean standardized final exam score and mean post- treatment GPA to the mean exam score and GPA of each treatment group revealed no significant differences be- tween these groups, except that the mean standardized final exam score of the control group was significantly (p < .025) less than that of the flooding group. As can be seen from Table 8, however, this difference is not due to grade improvement in the flooding group but rather to marked grade deterioration in the control group. None of the treatments produced significant improvement on either grade measure. Self-esteem measures The 4 x 3 analyses of variance for the Tennessee Self Concept Scale Personal Self subscale and Total Posi- tive subscale scores are summarized in Table 9, and the PS and TP means and standard deviations at pretreatment, posttreatment, and follow-up are listed in Table 10. The insignificant (p > .10) treatments-by-pre-post-follow-up interaction effect for both analyses of variance indicates no differential change between therapy groups. Dunnette E statistic comparisons of the control group's mean post and follow—up PS and TP scores to the mean scores of each 37 treatment group revealed no significant differences for either measure at posttesting. However, at follow-up the mean PS and TP scores of the desensitization, flooding, and relaxation groups were significantly higher than those of the control group (all p's < .005 for PS scores, and p < .005, p < .005, p < .025, respectively for TP scores). Table 9. Analysis of variance for Tennessee Self Concept Scale Personal Self subscale and Total Positive subscale scores. Personal Self Total Positive Source df MS F MS F Between 53 treatment 3 196.00 1.59 3342.05 1.37 error 29 123.36 2436.41 Within 88 pre-post-follow-up 2 79.86 4.13* 115.31 .38 treatment-by-pre- post—follow-up 6 34.45 1.78 466.93 1.53 error 58 19.32 306.01 *p < .01 Since the mean PS and TP scores for the control group are smaller at follow-up than at pretesting, it was possible that the significant follow-up results were due to deterioration in the control group rather than improve- ment in the treatment groups. This possibility, however, is discounted by the fact that additional individual 38 .uxou one cw copuommu mum mam>oa wocmoHMHcmfim pomxm who: .AN no .m .xv Honamm menu on» mumsm hos» ma Hm>ma mo. map Momma um um pneumMMHp MHMGMUHMHsmHm mum 30H m casufl3 mammfi 03» and “muoz mm.m~ noo.m~m om.m~ sm~.ssm vm.mH xoo.msm me.sv Nexmm.som mausoaaom cm.m~ ma.n~m ms.- He.omm mo.mH ss.mmm mm.mm so.-m “mom mm.om ~H.m~m as.mm oo.mmm mm.oH mm.mmm mo.sm mm.mam mum manomndm m>HuHmom Hmuoa am.s nom.~e HH.A smm.oe mm.m xem.qm s~.m Nsxmm.sm asuzoaaom mm.e NH.mm sm.s va.mm oe.m Ha.mm sm.m mm.mm umom NH.m oo.mm om.h mv.am mN.m oo.om Hm.m mh.mm mum manomnsm mamm HMGOmHom am saws am com: am new: am new: soauwpcou cofipmmeom mcflcoon coflumN Honucou Iwuwmcmmmo .mmuoom manomnsm w>wuwmom Hmuoe can manomQSm mawm Hmcomuom mamom ammocou maom mommossma cows .oa wanna 39 comparisons revealed that the mean follow-up PS score was significantly (p < .01) greater than the mean pretreatment PS score for each of the therapy groups, and that for the desensitization and flooding group the mean follow-up TP score was significantly greater (p < .01, p < .05, re- spectively) than the mean pretreatment TP score. Subject ratingsl Table 11 presents the summary of the 3 x 2 (treat- ment, post-follow-up) analyses of variance for subjects' ratings of specific improvement (reduction of test anxiety) and other improvement accruing from their therapy experi- ence. Table 12 lists the means and standard deviations for the posttreatment and follow-up test conditions. The insignificant F ratios for the Specific improvement rat- ings indicate no significant differences between therapy groups on this criterion measure. The §_ratio for the treatment-by-post-follow-up interaction effect for subject ratings of other improvement was significant (p < .05). Individual comparisons between treatment means revealed that at posttesting the mean subject rating of other im- provement was significantly (p < .05) greater for the re- laxation than for the desensitization or flooding group. 1The control group is not included in analyses of subject and therapist ratings since these ratings relate to the therapy treatments themselves and thus were obtained only from subjects who received therapy. 40 At follow-up, however, the comparisons were no longer significant. Table 11. Analyses of variance on subject ratings of specific improvement in test anxiety and im- provement in other areas. Specific Other Source df MS F MS F Between 83 treatment 2 .272 .31 2.14 2.14 error 21 .869 1.00 Within 85 treatment-by- post-follow-up 2 .001 .01 .395 4.12* error 21 .134 .096 *p < .05 Table 13 presents the summary of the single factor analyses of variance for subjects' posttherapy ratings of their therapists' competence and likeability. All thera- pists were rated as competent or very competent and like- able or very likeable. None were rated as incompetent or unlikeable. The means and standard deviations of these ratings are listed in Table 14. The E ratio of the anal- ysis of variance for competence ratings was significant (p < .01) so the group means were compared with Tukey's procedure. The mean competence rating desensitization 41 Table 12. Mean subject ratings of specific improvement in test anxiety and improvement in other areas. Desensiti- zation Flooding Relaxation Condition Mean SD Mean SD Mean SD Specific improvement Post 2.75 .408 2.50 .707 2.56 .682 Follow-up 2.78 .885 2.54 .713 2.56 .464 Other improvement Post 2.33X .677 2.29y .452 3.12XY .781 Follow-up 2.58 .833 2.14 .639 2.75 .661 Note: Any two means within a row are significantly different at at least the .05 level if they share the same symbol (x or y). More exact significance levels are re- ported in the text. 42 subjects gave their therapists was significantly (p < .01) higher than that given by flooding group subjects to their therapists. The differences between the mean ratings for the relaxation and desensitization and relaxation and flooding group were not significant. The §_ratio for subjects' ratings of their therapists' likeability was insignificant, indicating no significant differences be- tween these treatment means. Table 13. Analysis of variance of subjects' posttherapy ratings of their therapists' competence and likeability. Competence Likeability Source df MS F MS F Treatment 2 1.10 7.09* .113 .63 Error 22 .156 .178 *p < .01 Like the subject ratings of therapist competence and likeability, the ratings which subjects made on the quality of their imagery or relaxation during the therapy sessions are of interest in describing the adequacy of certain components of the therapy treatments. The mean imagery rating across treatment session was 1.89 for de- sensitization subjects and 2.08 for flooding subjects. 43 These correspond approximately to the rating of "vivid" imagery. The mean relaxation rating across treatment ses— sions was 1.33 for desensitization subjects and 1.69 for relaxation subjects. These ratings fall between the scale ratings of "excellent" and "good" relaxation. Table 14. Mean subject post-therapy ratings of therapist competence and likeability. Desensiti- zation Flooding Relaxation Condition Mean SD Mean SD Mean SD Competence Post 2.97x .679 2.25x .433 2.62 .484 Likeability Post 2.81 .360 2.62 .484 2.84 .330 Note: Any two means within a row are signif- icantly different at at least the .05 level if they share the same symbol (x). More exact significance levels are reported in the text. Table 15 presents the summary of the 4 x 2 (treat— ments, pre-post) analyses of variance for subjects' ratings of how much they had studied for and how prepared they felt for their psychology course midterm and final exams. The means and standard deviations of the ratings are listed in Table 16. The F_ratio for the treatment-by- 44 pre-post interaction effect in the analysis on study rat- ings approached significance (p < .10), and further indi- vidual comparisons revealed that this was due to a signif— icant (p < .01) decrease in the amount of time relaxation group subjects rated themselves as having devoted to studying for their final exam as opposed to their midterm exam. The insignificant F_ratio for the analysis on preparation ratings indicates no significant differences between groups on how prepared the subjects felt for their midterm or for their final exam. Table 15. Analysis of variance for subjects' midterm and final study and preparation ratings. Study Preparation Source df MS F MS F Between 83 treatment 3 2.88 1.77 1.28 1.48 error 28 1.63 .86 Within 83 pre-post 1 .99 3.50* .37 1.10 treatment-by-pre-post 3 .66 2.32* .21 .60 error 28 .28 .34 *p < .10 Note: Several subjects failed to complete the forms, thus the N was 10 subjects for the control group, 8 for the desensitization group, and 7 for both the flood- ing and the relaxation group. 45 Table 16. Mean subject midterm and final study and prepa- ration ratings. Desensi- Control tization Flooding Relaxation Condition Mean SD Mean SD Mean SD Mean SD Study ratings Midterm 3.80 .980 3.87 .331 3.00 1.07 3.57x 1.29 Final 3.65 .950 3.87 .599 3.00 .756 2.71x 1.03 Preparation ratings Midterm 2.90 1.04 3.00 .707 2.71 .452 2.57 .728 Final 3.00 .632 3.38 .484 3.00 .534 2.43 .904 Note: Any two means within a column are signif- icantly different at at least the .05 level if they share the same symbol (x). More exact significance levels are reported in the text. Therapist ratings Not all the ratings the therapists completed are analyzed here, since some are not of direct relevance to the issues investigated in this study. The ratings which were examined are therapists' pretreatment ratings of their degree of confidence in reducing test anxiety with each treatment, therapists' posttreatment ratings of com- fort in working with each technique, and therapists' post- treatment ratings of specific improvement (reduction of test anxiety), other improvement, appropriateness of 46 length of therapy, and appropriateness of type of therapy for each of their subjects. Table 1? summarizes the single factor analyses of variance for these measures, and Table 18 lists the means and standard deviations for each treat- ment group. The F ratios indicate no significant differ- ences between groups for the ratings of specific improve- ment, other improvement, appropriateness of type of therapy, therapist confidence in reducing test anxiety, or therapist comfort in working with each technique. Tukey individual comparisons made after the significant §_ratio obtained for the treatment length ratings revealed that the relaxation technique was rated as requiring signif- icantly (p < .01) less time than the flooding treatment. Relationship between Outcome Criteria The relationship between the various outcome measures used in this study is depicted in Tables 19 and 20. Table 19 presents the correlation matrix for subject post—therapy ratings of specific and other improvement, therapist post-therapy ratings of specific and other im- provement, and post-therapy change scores (Post minus Pre) of the TAS, AD, TSCS PS, TSCS TP, psychology course test grade, and GPA criteria. Table 20 presents the correlation matrix for the subject follow-up ratings of Specific and other improvement and follow-up change scores (Follow—up minus Pre) of the TAS, TSCS PS, and TSCS TP criteria. 47 .msonm nomm ca w mm3 2 one mmcflumu moose mom .mmHSmmoE pounmmmu so one mmcflumu wmwsu Mom ooscanm> mo mommHmsm on» mmsmoon mmma mum mmcflumu uH0mEoo can mocopflmcoo How Eocomum mo mmoumma ”0002 Ho. v as hH.H mm. mm.H NM.H NN mh.H Nb. 0H HOHHm hm.m oo.m «Nm.m mm.m we. am. mm. mm. N mo.m mm.m mm.N N>.H N usmfipmmua h m2 m m2 m m: h w: MU b w: h m: MU moufiom mama sumcoq Hmsuo owmwommm uuomfioo mocmv ufimsou .uoonnsm How mmmnmnu mo ommu m0 mmocoumanmoummm use .uomMQSm How Samson» mo summed mo mmmcoumflnmonmmm .uoonnsm CH ucmEm>0HmEfl Honpo .uomnnsm ca unofi Io>oumfiw oamaoomm .msvficsoou some saga mcwxnos cw unomEoo .oswflsnoou comm GA mocmcflmcoo mo mmcaumu .mpmflmmnmnu no“ mosmwnm> mo mommamsm .na manna 48 Table 18. Mean therapist ratings of confidence in each technique, comfort in working with each techni- que, specific improvement in subject, other im- provement in subject, apprOpriateness of length of therapy for subject, and appropriateness of type of therapy for subject. Desensiti- zation Flooding Relaxation Condition Mean SD Mean SD Mean SD Confidence Pre 4.00 .816 3.17 1.21 4.17 .687 Comfort Post 4.50 .764 2.67 1.25 4.00 1.15 Specific improvement Post 3.44 1.42 3.19 .864 2.87 .781 Other improvement Post 2.11 1.10 2.50 1.22 2.75 .968 Length of therapy Post 2.67 .667 2.25x .661 3.50x .707 Type of therapy Post 4.00 1.05 2.87 1.17 3.12 .781 Note: Any two means within a row are significantly different at at least the .05 level if they share the same symbol (x). More exact significance levels are reported in the text. 49 .ofluouwuo uonuo on» mo sumo Op wouoaouuoo mao>wuomoc pso Honpo cooo spas couoaonuoo >Ho>fluwmom on casonm .ucofiooumo.3osm on .30A53 m can m ownouwuo mom umooxo .ofinouwno coo3uon msofluoaonuoo o>HuHmom an couoofloca on caso3 oHHouHHo soo3pon usoEoonm .psoaumonu co>flooou 0:3 muoonnzm Mano o>Ho>cfl mmcfluon umwmouosa no poonQSm maficsHosfl meoHuoHoHHoo can oamfiom Houou one o>ao>sw mouoom omsoco soosuon mGOHuoHoHHoo .oanou one Soum coupHEo oHo msmflm msHm "ouoz umou eoasmuuoco .Ho. v ass pump eoanmuuoco .mo. v as HH.: mo. mo. mo.u mo.- mo.: «464. so. on. mmmho>6uucnomuoomho .oH mo.- on.- -.- -.u 6H.n HH.- sm.u sm.u oemhm smxm .m «4mm. mH.| om. «em. ma. mm. mo. oaoomnsm o>flufimom Hopoa .m mH.I AM. ha. Ho.| mm. oa. oaoomQSm maom assemuom .5 AH. ma. mo.u om. oa.n HmnncmhoMMH6 snonxqa .6 NH. mm.l ma. oa.l oaoom muoflxso umoe .m mouoom omsonu No.I «we. HH.I ,ucoEo>ouQEw Hosuo .v mo. ssmm. usoEo>onmEfl ownwoomm .m msfluon umflmouoca mm. usofio>oumsfl Honuo .m paofio>onm8w oamaoomm .H mswuou poonndm .wcfiuoou Doom no ofluoufluo oEoouso soo3uon msowuoaonuoo .ma oanoa 50 Table 20. Correlations between outcome criteria at fol- low-up testing. l 2 3 4 Subject rating 1. Specific improvement 2. Other improvement .36* Change scores 3. Test anxiety scale -.24 -.13 4. Personal self subscale‘ .25 -.05 -.17 5. Total positive subscale .26 .31 -.35* .89** *p < .05, one-tailed test **p < .01, one-tailed test Note: Plus signs are omitted from the table. Correlations between change scores involve the total sam- ple, and correlations including subject ratings involve only subjects who received treatment. Agreement between criteria would be indicated by positive correlations be- tween criteria except for criteria 3 which would be nega— tively correlated with each of the other criteria. A survey of the tables reveals that the Personal Self and Total Positive self-esteem subscales were strongly related both at post and at follow-up testing. Therapist ratings of specific improvement were significantly related to subject ratings of specific improvement and to change in grade-point-average. Therapist ratings of other im- provement were significantly related to subject ratings of other improvement and to change on the Total Positive sub- scale. Subject follow-up ratings of specific and other improvement were moderately related, and finally, follow-up change scores for the Test Anxiety Scale and Total Positive 51 subscale were negatively and significantly related. The post-therapy Test Anxiety Scale and Anxiety Differential change scores were not significantly related; however the correlation (not listed in the Tables) between the follow— up Test Anxiety Scale and post-therapy Anxiety Differential change scores was significant (r = .34, p < .05). Summary of Major Findings Before relating the results of this study to the hypotheses originally proposed, a summary of some of the major findings may prove useful. Table 21 presents a sum- mary of statistically significant comparisons between treatment groups on the major outcome criteria. At post- testing the relaxation treatment group evidenced greater improvement on subject ratings of other improvement than did the desensitization or flooding group. At follow-up the desensitization and flooding groups evidenced greater improvement on the Test Anxiety Scale than did the relaxa- tion group. Other comparisons were not statistically sig- nificant. Table 22 presents a summary of statistically significant comparisons between the control group and the treatment groups on the major outcome criteria. At post— testing each treatment group evidenced greater improvement than the control group on the Test Anxiety Scale and on the Anxiety Differential. At follow—up each treatment group demonstrated greater improvement than the control 52 Table 21. Summary of statistically significant comparisons between treatment groups on the major outcome criteria. Condition Criterion Post Follow-up TAS None SD, F1 > R AD None TSCS PS None None TSCS TP None None GPA None Exam scores None Subject rating spec. improvement None None Subject rating other improvement R > SD, F1 None Therapist rating spec. improvement None Therapist rating other improvement None Note: The sign (>) indicates that the treatment. group(s) listed to the left of the sign evidenced signif- icantly greater improvement on the listed criterion meas— ure than the treatment group(s) listed to the right of the sign. The word "None" indicates that there were no significant differences between the treatment groups. 53 Table 22. Summary of statistically significant comparisons between control group and treatment groups on the major outcome criteria. Condition Criterion Post Follow-up TAS SD, Fl, R control SD, Fl, R > control AD SD, F1, R control TSCS PS None SD, F1, R > control TSCS TP None SD, F1, R > control GPA None Exam scores Control > R Note: The sign (>) indicates that the treatment group(s) listed to the left of the sign evidenced signif- icantly greater improvement on the listed criterion meas- ure than the treatment group(s) listed to the right of the sign. One exception occurs with the exam scores where the control group evidenced significantly less deteriora- tion in scores than the relaxation group, but neitherw group demonstrated improvement in scores. The word "None" indicates that there were no significant differences be- tween the control and treatment groups. 54 group on the Test Anxiety Scale and on the Tennessee Self Concept Scale Personal Self and Total Positive subscales. Other comparisons were not statistically significant, ex- cept that the control group evidenced statistically less deterioration in psychology course exam scores than did the relaxation group; however neither group evidenced im- provement in exam scores. Decisions Regarding Hypotheses The null Hypothesis 1 which states that there is no significant difference in the effectiveness of the systematic desensitization, flooding, and relaxation therapies in reducing clients' test anxiety cannot be rejected since there were no significant differences be- tween these groups on the anxiety differential, psychology course grade, grade-point-average, subject ratings of specific improvement, and therapist ratings of specific improvement and appropriateness of type of therapy cri- teria. As mentioned earlier, the significant differences at follow-up testing for the test anxiety scale appear to be an artifact of the initially higher test anxiety scale scores of the relaxation group. Hypothesis 2 which states that each of the therapy treatments is more effective than no treatment in reducing clients' test anxiety was supported by the analyses on the test anxiety scale and the anxiety differential, but not 55 by the analyses of psychology course exam grades and term grade-point-averages. The latter two criteria were per- haps not good indicators of test anxiety for this study, since in the intake interview some subjects stated that they felt their anxiety did not interfere with their test performance even though it was an unpleasant emotion they wished to be rid of, and since some subjects had pre-therapy psychology course midterm grades and term grade-point- averages which were too high (above 90th percentile) to allow much improvement. The null Hypothesis 3 stating that there is no significant difference in the effectiveness of systematic desensitization, flooding, or relaxation therapies in in- creasing clients' self-esteem cannot be rejected since there were no significant differences between these groups on the Tennessee Self Concept Scale Personal Self subscale or Total Positive subscale. Hypothesis 4 which states that each of the therapy treatments is more effective than no treatment in increas- ing clients' self-esteem was not supported by the post- therapy analyses on the Tennessee Self Concept Scale Personal Self and Total Positive subscales but was sup- ported by the follow-up analyses on these scales. Appar- ently a time delay is necessary before the full impact of these treatments on self-esteem is realized. 56 The null Hypothesis 5 which states that there are no significant differences in therapists' estimates of the amount of time necessary to conduct systematic desensiti- zation, flooding, and relaxation training with test anxious students is rejected since therapists rated the relaxation technique as requiring significantly less time than the flooding technique. In general the therapists rated the two one-hour and three one—half hour sessions which were allotted as treatment time in this study as more than enough time to conduct the relaxation treatment, but not quite enough time to conduct the flooding or desensitiza- tion therapies. CHAPTER-IV DISCUSSION Explanation of Effects The main effects of this study to be explained are the decrease in clients' self-report of test anxiety and the increase in clients' self-esteem accruing from the therapy treatments investigated here. The decrease in test anxiety was evidenced only on self-report measures of test anxiety, and not on the grade measures. Thus it is possible that the treatments were effective in reducing only the subjective or the self-report component of test anxiety. The correlations reported between self-report measures of_anxiety and physiological and behavioral meas- ures of anxiety have often been discouragingly low. How- ever, as was reported earlier in the method section of this paper, the self-report measures of anxiety employed in this study have been shown to be significantly corre- lated to physiological and behavioral measures of anxiety; thus there is some evidence for the general nature of the reduction of test anxiety evidenced on the self-report measures of this study. 57 58 There are several possible explanations of the decrease in clients' self-report of test anxiety and in— crease in clients' self-esteem observed in this study. The first and perhaps primary explanation is that the clients' improvement was the result of the specific proc- ess proposed as the rationale for each treatment. As was discussed in the introduction of this report, such a process would be the extinction of test anxiety in the flooding treatment and the counterconditioning of test anxiety via relaxation in the systematic desensitization and relaxation treatments. These two processes could ac- count for the reduction of test anxiety experienced by the treatment subjects but these processes cannot adequately account for the clients' increase in self-esteem since the correlations between test anxiety change scores and self- esteem change scores were generally low and nonsignificant. Increase in self-esteem was apparently fairly independent of reduction in test anxiety. The increase in self-esteem may have resulted from a general placebo effect, as will be discussed shortly; or perhaps, to take a Rogerian posi- tion, from positive regard extended to the client by the therapist or even from client self-exploration which may have been stimulated by the client's commitment to therapy or discussion of test anxiety. Another possible explanation of the clients' im- provement is that the clients merely conformed to the 59 demand characteristics of the experiment, and reported a decrease in test anxiety and an increase in self-esteem because they thought this was what was expected of them. This possibility is somewhat discounted by the fact that the systematic desensitization technique has been demon- strated to produce changes over and above those which could be accounted for by subjects' conforming to experi- ment demand characteristics (Paul, 1966; Johnson and Sechrest, 1968), and by the fact that if a global acquies- cence to demand characteristics were operating in the present study one would expect higher correlations between the subject self-report outcome criteria than those ac- tually obtained. A third possible explanation of the clients' im- provement is that it is a result of what has been termed the "placebo effect" (Rosenthal and Frank, 1958). That is, that it is change resulting from therapist attention di- rected toward the client and the faith which this engenders in the client that change will occur and that the therapist or therapy will help him. For the changes in anxiety level obtained in this study, this possibility is somewhat discounted because: (a) previous studies (Lang, Lazovik & Reynolds, 1965; Paul, 1966; Zeisset, 1968) have shown that systematic desensitization is capable of producing a level of anxiety reduction greater than that which could be attributed to a placebo effect, (b) another study 60 (Johnson & Sechrest, 1968) found no placebo effect reduc— tion of test anxiety accruing from a relaxation therapy treatment, and (c) a study (Zeisset, 1968) using a relaxa- tion therapy somewhat similar to the one employed in the present study demonstrated a level of anxiety reduction from the treatment greater than that which could be attri- buted to a placebo effect. Still, the absence of a pseudotreatment or attention-placebo control group in the present study precludes definitely ruling out the placebo effect as the cause of the clients' reduction in test anxiety and increase in self-esteem. Implications for Research and Practice This study yields a number of implications and findings relating to the research and practice of psycho- therapy. One of the most interesting of these is the demonstration that the three behavior therapies investi- gated here appear to be capable of increasing clients' self-esteem in addition to alleviating the target symptom of test anxiety. This is one of the first controlled in- vestigations demonstrating an increase in self-esteem as a result of a behavior therapy, and also one of the first studies demonstrating the effectiveness of relaxation therapy and flooding therapy as treatments for test anxi- ety. For subjects who are not responsive to systematic 61 desensitization because of their difficulties in achieving adequate relaxation or imagery, the flooding and relaxa- tion therapies might be especially useful treatments since the flooding technique does not require relaxation and the relaxation technique does not require imagery. The im- portance of emphasizing to subjects in a relaxation treat- ment that they practice relaxation outside of the therapy sessions and actually try to relax themselves in stressful situations is illustrated by the significant reduction of test anxiety achieved in this study where such instructions were stressed, as compared to the absence of significant test anxiety reduction obtained by Johnson and Sechrest. (1968) who did not thus instruct their relaxation subjects. It should be kept in mind, however, that none of the three therapies was shown to be effective in improving subjects' academic performance, although as discussed earlier, this may have been due in part to characteristics of the sample employed in this study. The results of this study did not reveal a general tendency for any one of the three therapies to be most effective in reducing test anxiety or increasing self- esteem. However, before generalizing from this finding to conclude that the three therapies are basically of compar— able effectiveness, it must be cautioned that the therapies as applied in this study are somewhat different than de- sensitization, flooding, or relaxation therapies applied 62 in clinical practice. For instance the therapies were constrained by a set time limit and by a fairly standard- ized procedure, and the therapists had relatively little therapy experience and particularly little experience with the desensitization, relaxation, and flooding techniques. It is unknown whether basic differences in the effective- ness of the three therapies might have been evidenced if the therapies had been conducted by more experienced therapists given greater latitude in applying the techni- ques. The findings of this study also demonstrate the feasibility of using short-term desensitization, flooding, or relaxation therapies and relatively inexperienced therapists in treatments for test anxiety, and perhaps for other anxieties as well. This is not, however, to say that longer treatments and more experienced therapists might not achieve even better results. More extensive training of therapists in the flooding technique might also be profitable in future studies investigating this technique, since in this study the competence ratings given therapists by flooding subjects were significantly lower than those given by desensitization subjects, and since therapists rated themselves as (nonsignificantly) less comfortable and confident with the flooding technique. Perhaps, also, the therapists' lesser confidence and com- fort with the flooding technique is responsible for their 63 rating the flooding subjects as requiring lengthier therapy than the relaxation or desensitization subjects--a1though only the difference in ratings for flooding and relaxation subjects was significant. The finding of earlier studies (Barrett, 1969; Cohen, 1969) that flooding treatments re— quire less time than systematic desensitization treatments was not supported by the therapist ratings of this study. Two further implications for psychotherapy research designs can be drawn from the results of this study. The generally low correlations between the outcome criteria reemphasize the desireability of using multiple criteria rather than relying on a single criterion measure in out- come research, and the lack of consistent differences be- tween the three therapy treatment groups illustrates the desirability of including a pseudotreatment group in the research design in order to be able to assess whether other treatments achieve more than a placebo effect. Suggestions for Further Research Several suggestions for further research can be derived from this study. Since the therapists rated the relaxation treatment as requiring less time than was al- lotted to it in this study, a more abbreviated relaxation training might be explored. Such a treatment could include one or two initial relaxation training sessions, and then subsequent telephone contacts to check up on the client's 64 progress in practicing relaxation and to discuss any dif- ficulties the client might be experiencing in learning the technique. Another possible treatment procedure is sug- gested by the fact that in the intake interviews subjects in each of the treatment groups expressed varying degrees of confidence that the treatment might help them. A study could be done investigating the effectiveness of explaining each of the treatments to the subjects and then letting them choose the treatment they wished to participate in as compared to just randomly assigning subjects to treatments. Perhaps allowing the subjects to choose their own treatment would increase their responsiveness to and benefit from the treatments. Perhaps also such a procedure would de- crease the subject dropout rate. There are a number of other therapy comparisons relating to the present study's findings which might be of interest. The addition of study skills training to any of the three therapies investigated here might produce a greater decrement in test anxiety and a greater improvement in academic performance than that obtained by any of the therapies alone. Group applications of the relaxation and flooding procedures might be investigated, and a flooding procedure of the type employed in this study might be compared to the type of implosive therapy described by Stampfl and Levis (1967) which includes anxiety scene presentations chosen along more psychodynamically oriented 65 lines. A final comparison of interest would be that of each of the therapies used in this study to a pseudotreat- ment therapy in order to determine if the three therapies achieve more than a placebo effect. REFERENCES REFERENCES Ashcraft, C. and Fitts, W. H. Self-concept change in psychotherapy. 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A study of anxiety and learning. Journal of Abnormal and Social Psy- chology, 1952, 41,‘I66-l73. McReynolds, W. T. A note on relaxation treatment groups in studies of systematic desensitization. Journal of Abnormal Psyghology, 1969, 14, 561-562. 68 Paul, G. L. Insi ht vs. desensitization inpaychotherapy: Ap_exper1ment in'anxietygreduction. Stanford: StanfbrdUniversiEy Press,’l966} Paul, G. L. Outcome of systematic desensitization. I. Background, procedures, and uncontrolled reports of individual treatment. In C. M. Franks (Ed.) Behavior Therapy: Appraisal and Status. New York: McGraw Hill, 1969Ta). Paul, G. L. Outcome of systematic desensitization. II. ~ Controlled investigations of individual treatment, technique variations, and current status. In C. M. Franks (Ed.) Behavior Thera : A raisal and Status. New York: McGraw HiIT, I965i5). Paul, G. L. Physiological effects of relaxation training and hypnotic suggestion. Journal of Abnormal Psy- chology, 1969, 14, 425-437(c). Rachman, S. Studies in desensitization. I. The separate effects of relaxation and desensitization. Behav- ior Research and Therapy, 1965, 4, 245-252. Rachman, S. Studies in desensitization. II. Flooding. Behavior Research and Therapy, 1966, 4, 1-6. Rachman, S. Treatment by prolonged exposure to high in- tensity stimulation. Behavior Research and Therapy, 1969, 1, 295-302. ‘ Raphelson, A. C. The relationships among imaginative, direct verbal, and physiological measures of anxiety in an achievement situation. Journal of Abnormal and Social Psycholggy, 1957, E4, I3-I8. Rogers, C. R. and Dymond, R. F. (Eds.) Psychothera and parsonality change. Chicago: University 0 Chicago Press,. 9 4. Rogers, C. R., Gendlin, E. T., Kiesler, D. and Truax, C. B. (Eds.) The therapeutic relationship and its im- pact: A study cfipsychotherapy wish schizophrenics. .1 Madison: University of Wisconsin Press, 1967. Rosenberg, M. The association between self—esteem and‘ anxiety. Journal of Psychiatric Research, 1962, 4, 135-151. 69 Rosenthal, D. and Frank, J. D. Psychotherapy and the placebo effect. In C. F. Reed, I. E. Alexander,_ and S. S. Tomkins (Eds.) gaychotherapyi_ A source book. Cambridge: Harvar University Press, 1958. Sarason, I. G. and Ganzer, V. J. Anxiety, reinforcement, and experimental instructions in a free verbaliza- tion situation. Journal of Abnormal and Social Psychology, 1962, §§, 300-307. Sarason, I. E. and Koenig, K. P. Relationships of test anxiety and hostility to description of self and parents. Journal of Personality and Social Pay- chology, 1965, a, 617-621. Sarason, S. B. and Mandler, G. Some correlates of test anxiety. Journal of Abnormal and Social Paychol- 2a, 1952' fl, 810-8170 Snider, J. G. and Getting, E. R. Autogenic training and the treatment of examination anxiety in students. Journal of Clinical Psychology, 1966, 44, 111-114. Stampfl, T. G. and Levis, D. J. The essentials of implos- ive therapy: A learning theory based on psycho- dynamic behavioral therapy. Journal of Abnormal Psychology, 1967, 13' 496-503. Staub, E. Duration of stimulus exposure as determinant of the efficacy of flooding procedures in the elimi- nation of fear. Behavior Research and Therapy, 1968, 4, 131-132. Suinn, R. M. The desensitization of test anxiety by group and individual treatment. Behavior Research and Suinn, R. M. Changes in non-treated subjects over time: Data on a fear survey schedule and the test anxiety scale. Behavior Research and Therapy, 1969, 1, 205-206. Suinn, R. M. and Hill, H. Influence of anxiety on the relationship between self-acceptance and acceptance of others. Journal of Consulting Psychology, 1964, 44, 116-119. Winer, B. J. Statistical Pringiples in Experimental Design. New York: McGraw HilI,Tl962. 70 Wittrock, M. C. and Husek, T. R. Effect of anxiety upon retention of verbal learning. Psychological Reports, 1962, 44, 78. Wolpe, J. Reciprocal inhibition as the main basis of psychotherapeutic effects. Archives of Neurolpgy. and Psychiatry, 1954, 14, 205-226. Wolpe, J. Psychotherapy by-recippogal inhibition. Stan— ford: Stanford University Press, 1958. WOlpe, J. How can "cognitions" influence desensitization. Behavior Research and Therapy, 1969, Z, 219. Wolpe, J. and Lazarus, A. A. Behayior therapy Eechnigues: A guide t9 the treatment of neuroses. London: Pergamon Press, 1966. Wolpin, M. and Raines, J. Visual imagery, expected roles and extinction as possible factors in reducing fear and avoidance behavior. Behavior Research and Therapy, 1966, 4, 25-37. Zeisset, R. M. Desensitization and relaxation in the modification of psychiatric patients interview behavior. Journal of Abnormal Paychology, 1968, 23, 18-24. APPENDICES APPENDIX A TEST BATTERY FORWARDS Pretreatment Battery Cover Sheet Dear Student: Today you are being asked to complete the accom- panying questionnaire in conjunction with a study we are conducting in the Department of Psychology. We are con- cerned with the number of students who experience undue tension and anxiety during examinations. Although most students are somewhat tense during exams, some students are so upset, worried, and lacking in confidence that their feelings actually interfere with effective perfor- mance, thus lowering grades and generally making life at college less pleasant. Psychological principles, train- ing, and therapeutic procedures have been successfully' used to help such students both here and at other univer- sities. The purpose of the present study is to determine which people benefit most from the specific psychological procedures involved. You, as an individual, may or may not experience these feelings. If you do, we may be able to help you to overcome them, but in any case your re- sponses will be most helpful to us, even if you have no major difficulty with your emotional reactions during exams. All students in Psych 225 are being asked to com- plete the accompanying questionnaire. Additionally, we will be able to meet with a number of students this quarter and next to help them overcome anxieties experienced dur- ing exams and become more confident in the testing situa- tion. Of course, not all students will be bothered by these problems, nor will all students feel they have the time or need for these services. On the Personal History Form, you are asked to indicate whether you would or would not be interested in obtaining help with these difficulties, and whether you have the time available to participate. This program will require approximately six or seven hours total participa- tion time during the quarter, although a sHortage of qual— ified therapists may necessitate that some students begin treatment next quarter rather than this quarter. About one half-hour will be spent in a pretherapy interview to explain the program more fully; another half-hour to hour will involve some further testing; and the remaining five or so hours will consist of meeting with a trained spec- ialist once a week for an hour or less over a five week period. 71 72 Needless to say, your answers to the questions in the attitude questionnaire, and participation in the other phases of the study will be used for research purposes only; under no circumstances will they influence the grading in Psych 225. Thank you for your cooperation. Dr. Donald Grummon Dr. Dozier Thornton Peter Hampton 73 co m 0. ON oquH omuHH omuoa ca O. 0-! min film mlm oauv ooum om .pooE on oanoawo>o on non pasoz so» noflns msHHsc BoHon oasconom one so mnooan onu usoux omooam .ouomflofluuom on nods 90> MH oz mow "muoflxco umou ma oospon on uoononm menu :H ouomHOHpHom on anB H moonccs osonm TEMZ .m0¢m UZHBOAQOh mm& 20 HMH¢ZZOHBmmDO WEB MBWAQZOU OB mmmzmzmm mmfimflm 74 Personal History Form Name Age Sex______ Present Address Phone Permanent Address Phone Class Major Indicate below the members of your family, including par- ents, husband or wife, brothers, and sisters. Education (highest grade Relationship Age Occupation completed) Have you ever had psychological counseling previously? If so, where? About how long have you been bothered by anxiety or tense- ness during tests? 75 Posttreatment Battery Cover Sheet There are four short questionnaires in this packet. Take the first one with you to your Psych 225 final exam and fill it out while you are waitin for the test to be. handed out. Turn in this questionnaire along with your finai at the end of the exam period. If you forget to bring this questionnaire to the final, look for Peter Hampton (the fellow you first talked to about this project) to give you another one before the exam. It will be more convenient, though, if you remember to bring the question- naire to the exam. Complete the other three questionnaires after you are done with approximately half_your finals for Ehis term. MaiI them back in the self-addressed envelope provided} IT IS VERY IMPORTANT THAT YOU FILL OUT THESE FORMS AT THE TIMES SPECIFIED ABOVE! We will mail you one more set of questionnaires next quarter. If, after you complete these last materials and mail them back, you wish information about the purpose or results of this study or about your test results you may call me at 355-5907 and I will be glad to make an ap- pointment with you to discuss these things. If you are one of those persons who did not start treatment for test anxiety this quarter, we will contact you after you return the research materials next quarter and arrange to begin treatment then. Thank you very much for the assistance you have given and are giving us in this research--your help is well appreciated. Peter Hampton Follow-up Battery Cover Sheet for Therapy Subjects April 22, 1970 Dear Enclosed are three short forms we would like you to fill out again for the last time as part of our research project. Please complete them this week and mail them back in the enclosed envelope. If after you complete these last materials and mail them back, you wish informa- tion about the purpose of this study, or about the roughly tabulated results, or about your test results, call me at 355-5907 and I will be glad to make an appointment with you to discuss these things. Thanks again for all your help. Sincerely, Peter Hampton 76 Follow-up Battery Cover Sheet for Control Subjects April 22, 1970 Dear Enclosed are two short forms we would like you to fill out again for the last time as part of our research project. Please complete them this week and mail them back in the enclosed envelope. After you return the forms I will call you to arrange to begin the treatment for test anxiety if you still wish to participate. We would like to begin the treatment the week of May 4th, and continue it for the next three or four weeks (4 or 5 sessions total). Please also fill out the information on the at- tached sheet. Thanks for your help. Sincerely, Peter Hampton 77 78 e 00 mix mlh him elm 0H m omuH ovuma omuHH omuoa ca .0 0‘ oo u m .uooE on oanoaao>o on no: pHsOB so» nowns msflnsp Soaon oasponom onn no mnooHn onn unclx omooam .onmmfloaunom on nmw3 90% MH oz no» "huoflxno noon >8 ooscon on usofiuoouu menu :H ouomHOAHHom on nmfls Hawum H mmouccm osonm OEMZ APPENDIX B INSTRUMENTS Test Anxiety Scale DIRECTIONS: A number of statements which students have used to describe themselves are given below. Read each statement and decide whether it is true or false as applied to you. If a statement is true, or mostly true as ap- plied to you, blacken the space between the brackets marked T on the answer sheet. If a statement is false, or mostly false as applied to you, blacken the space be- tween the brackets marked F on the answer sheet. Please write your name and student number at the top of the answer sheet. 1. While taking an important examination, I perspire a great deal. 2. I get to feel very panicky when I have to take a surprise exam. 3. During tests, I find myself thinking of the conse- quences of failing. 4. After important tests, I am frequently so tense that my stomach gets upset. 5. While taking an important exam I find myself thinking of how much brighter the other students are than I am. 6. I freeze up on things like intelligence tests and final exams. 7. If I were to take an intelligence test I would worry a great deal before taking it. 8. During a course examination, I frequently get so nervous that I forget facts I really know. 9. During course examinations, I find myself thinking of things unrelated to the actual course material. 10. If I knew I was going to take an intelligence test, I would feel confident and relaxed beforehand. 11. I usually get depressed after taking a test. 12. I have an uneasy, upset feeling before taking a final examination. 13. When taking a test, my emotional feelings do not interfere with my performance. 79 14. 15. 16. 80 Getting a good grade on one test doesn't seem to in- crease my confidence on the second. After taking a test I always feel I could have done better than I actually did. I sometimes feel my heart beating very fast during important tests. Anxiety Differential Name Student No. The purpose of this instrument is to determine what certain words or concepts mean to on. Each numbered item presents a CONCEPT (such as DOG) an a scale (such as high-low). You are to rate the concept on the seven point scale indicated. If you feel that the concept is vepy closely assoc- iated with one end of the scale, you would place your checE-mark as follows: DOG high X : : : :1ow OR high : : : : : : X :1ow If you feel that the concept was closely related to one side of the scale, you would check as follows: TREE straight : X :crooked OR straight : : : : : X : :crooked If the concept seems only sligptly related to one side as opposed to the other, you might cfiéck as follows: CLOUD easy : : X : : : : :difficult OR easy : : : : X : : :difficult If you consider the scale completely irrelevant, or that both sides are eqpally associated, you would check the middle space: CAR idealistic : : : X : : : :realistic Remember: Never pat more than one check-mark on any scale. Also be sure to check evepy item. For this instrument, work at a fairly high rate of speed without worrying or puzzling over individual items. It is your first impressions that we want. Go right ahead now. 81 82 1 . F INGERS straight : : : : : : :twisted 2. ME helpless : : : : : : :secure 3. BREATHING tight : : : : : : :loose 4. SCREW strong : : : : : : :weak 5. HANDS wet : : : : : : :dry 6 . TODAY loose : : : : : : :tight 7. ME frightened : : : : : : :fearless 8. GERMS deep :shallow 83 9. HANDS good : : : : : : :bad 10 . BREATHING careful : : : : : : :carefree 11. FINGERS stiff : : : : : : :relaxed 12. ME calm : : : : : : :jittery 13. HANDS tight : : : : : : :loose 14. BREATHING hot : : : : : : :cold 15. SCREW loose : : : : : : :tight 16. ME carefree : : : : : : :worried 17. clear 84 ANXIETY :hazy 18. loose : FINGERS :tight Subject Study and Preparation Ratings DIRECTIONS: Answer the following two questions by circl- ing one of the five alternatives on the scale. Please mark your answers on one of the alternatives, and not be- tween two alternatives. Your answers will be held in confidence--they will not be reviewed by any 225 instructor. 1. How much have you studied for this exam? / / / j / very some a a lot a little moderate very amount lot 2. How prepared do you feel for this exam? L / A / . / very poorly moderately well very poorly prepared prepared prepared well prepared prepared 85 Subject Posttreatment Questionnaire N ame 1. To what degree do you feel that the treatment sessions you attended this quarter have helped you to overcome anxieties or nervousness related to taking tests? / ./ l/ / ‘ not at somewhat much very muEhfi all 2. To what degree have these sessions been helpful to you in other areas, in addition to the exam or testing situation? / / not ail somewhat much very much all Please indicate other situations or areas in which these meetings have helped 3.4 What is your opinion of the person with whom you met, these five sessions? / / / incompetent competent very competent / l/ / unlikeable likeaBle very likeable 4. Did you meet with anyone for help of-a psychological nature during this quarter, not in conjunction with this project? -_— (yes; no) If yes (name) 5. Comments: 86 Name Subject Follow-up Questionnaire To what degree do you feel that the treatment sessions you attended last quarter have helped you to overcome anxieties or nervousness related to taking tests? _/ A L / not at somewhat mucH" very muEh all To what degree have these sessions been helpful to you in other areas, in addition to the exam or testing situation? / / / / not at somewhat much very much all Please indicate other situations or areas in which these meetings have helped Comments: 87 Therapist Posttreatment Questionnaire Client: Please complete each of the following questions for the client indicated on completion of the last treatment session. 1. 2. 3. Was this client likeable? Very Very Uplikeable Likeable Was this client responsive to treatment? Very Very- gpresponsive Responsive Was treatment of appropriate length for this client to significantly reduce test anx1ety? Too Short Too Long a. If length was inappropriate, how many sessions would you estimate to have been more apprOpriate? sessions. Was this typeof treatment appropriate for this client for reducing test anxiety? Very Very Ipappropriate Appropriate a. If type was other than appropriate, what type of treatment would have been more appropriate? To what degree has this client's test anxiety been reduced? None Very Much a. How confident are you of this rating? p = 88 10. ll. 89 To what degree has this client improved in areas other than test anxiety? None Very.Much a. How confident are you of this rating? p = Is further treatment indicated for this client for test anxiety? Strongly Not at all Indicate Number of sessions completed? Is further treatment indicated for this client in areas other than test anxiety? Strongly Not at all Indicate Did you feel comfortable working with this form of treatment with this client? Very Very Upcomfortable Comfortable Any further comments you have about this subject, this treatment, or any other aspect of this study would be appreciated (use back of page if necessary). Therapist Confidence Ratings Name Date How confident are you in effecting change (reducing test anxiety) with each technique? Please make this rating before you begin working with your subjects. systematic desensitization confident unconfident flooding confident unconfident relaxation confident unconfident 90 APPENDIX C TREATMENT MANUALS Systematic Desensitization Treatment Manual This treatment is basically the Systematic Desensi- tization Therapy of Wolpe, with several modifications directed toward reducing the number of sessions required for anxiety reduction. There are five major procedures involved in the use of this technique: (1) exploration of history and current status of symptoms; (2) explanation of rationale; (3) construction of anxiety hierarchy; (4) training in progressive relaxation; and (5) desensitization proper--working through the hierarchy under relaxation. Although flexibility is normally the rule with this approach, the goals of research require that all therapists follow the outlined procedures as closely as feasible. Unlike the interpretation given by several writers in the area, this procedure is not to be carried out as a cold, manipulative operation; ifigtead the thera- pist should be as warm, interested, and helpful as he would be in any helping relationship. The main difference between this approach and more traditional methods is that the therapist openly guides and directs the course and content of treatment, with a minimum of time and effort spent on introspection, and little or none spent on the client's searching for etiological factors. All happen- ings and incidences will be interpreted within this system if questioned, and dynamics left uninterpreted unless questioned. If questioned, interpret in a eneral manner --on1y superfically. In any case, it is most important that the therapist remain confident and stay with this specific treatment. Since the—‘iarget behavior" (test anxiety) will have been determined prior to the therapist's contact with the client, focus in retraining will begin with the first session, with desensitization proper begin- ning in the second session. The following time schedule should handle most clients. First session: 1. Exploration of history and current status of symp- toms (5-10 minutes). 2. Explanation of rationale and course of treatment (5 minutes). 3. Construction of anxiety hierarchy (15-20 minutes). 4. Training in progressive relaxation using the tape- recorded instructions (30-35 minutes). Test imagery if time available. 5. Give subject your telephone number in case he has to cancel an appointment. 91 92 Second session: 1. Check on anxiety outside of treatment (i.e. current status of symptoms) and complete construction of anxiety hierarchy (5-10 minutes). 2. Check on success of relaxation and correct any problems arising (2-10 minutes). 3. Induce relaxation with relaxation tape, and then present visualizations. 4. Check on adequacy of relaxation and imagery (use therapy summary sheet for this). Third and fourth sessions: 1. Check on anxiety outside of treatment. Check on success with relaxation and correct any problems arising (2-10 minutes). 2. Induce relaxation with your own instructions, and present visualizations. 3. Check on adequacy of relaxation and imagery (use therapy summary sheet for this). Fifth session: 1. Continue as in sessions three and four, except at end of session give subject the test packet and instructions on how to complete it. SPECIFIC PROCEDURES 1. Exploration of history and current status of sypptoms. For the research project, this phase wilI be re atively short, serving primarily as an "icebreaker" and as a period in which to establish rapport. To help de- scribe subjects and to further therapist understanding, determine (a) how lon the subject has experienced test anxiety, (b) to what He ree test anxiety interferes with functioning, and (c) w ether other evaluative situations also arouse anxiety. This should be completed in no more than 10 minutes of the first session. 2. Explanation of rationale and course of treat- ment. Both thé theory and—courseghi treatment should be Briefly explained to the subject and repeated if questions arise. It should be made clear that anxiety is the result of learning, and that the treatment is a learning process. If any subject seems to have trouble understanding, re- phrase your explanation in language he can understand. Be sure to allay any doubts the more soPhisticated subjects may have, e.g., "this does not produce inhibitions that might lead to symptom substihhtion, but is desensitizing-- removing the problem." The following brief explanation usually suffices for introductory purposes. 93 "The emotional reactions that you experience are a result of your previous experiences in testing situations; these reactions oftentimes lead to feelings of anxiety or tenseness which are really inappropriate and interfering. Since perceptions of situations occur within ourselves, it is possible to work with your reactions right here in the office by having you image or visualize those situations. "The specific technique we will be using is one called desensitization. This technique utilizes two main procedures--re1axation and counterconditioning--to reduce your anxiety. The relaxation procedure is based upon years of work that was started in the 1930's by Dr. Jacob- son. Dr. Jacobson developed a method of inducing relaxa- tion that can be learned very quickly, and which will allow you to become more deeply relaxed than ever before. Of course, the real advantage of relaxation is that the muscle systems in your body cannot be both tense and re- laxed at the same time; therefore, once you have learned the relaxation technique, it can be used to counter anxiety, tenseness, and feelings like those you experience in the exam situation. "Relaxation alone can be used to reduce anxiety and tension, and I'll be asking you to practice relaxation between our meetings. In addition, though, we are going to combine the relaxation technique with the psychological principle of counterconditioning to further desensitize you to testing situations so that you no longer become overly anxious in such situations. "The way in which we will do this is to determine the situations in which you become progressively more anxious, building a hierarchy from the least to the most anxious situations with regard to taking an exam. Then I will teach you the technique of progressive relaxation, and have you practice this. You will see how this operates in a few minutes when we actually start training. After you are more relaxed than ever before, we will then start counterconditioning. This will be done by having you re- peatedly image the specific situations from the anxiety hierarchy while under relaxation. By having you visualize very briefly, while you are deeply relaxed, the situations that normally arouse anxiety, those situations gradually become desensitized, so that they no longer make you an- xious. We start with those situations that bother you the least, and gradually work up to the examination itself. Since each visualization will lower your anxiety to the next, a full-fledged anxiety reaction never occurs. Most of these procedures will become clearer after we get into them. Do you have any questions before we begin? 94 3. Construction of the anxiety_hierarchy. The anxiety hierarchy is one of the most important aSpects of this treatment. The object is to determine situations related to exams which run from very slight, controllable amounts of anxiety to the most extreme anxiety attendant upon the actual exam situation. It is not necessary to determine every instance, since generalization from one instance to another will bridge the gap. It is necessary to determine situations close enough together to allow generalization to occur. 3a. The basic test-anxiety hierarchy. Based upon interviews with students and analysis of {he situation, the following hierarchy may be used as a beginning frame- work, thus reducing the time involved. The (0) item should be unanxious and used to test imagery. (0) Lying in bed in room just before going to sleep--describe room. (1) The teacher announces and discusses a course examination (to be held in three weeks) with the class. (2) Studying for an important examination that is two weeks away. (3) Studying for an important examination that is two days away. (4) Studying for an important examination that is the next day. (5) Going to sleep, the night before an important exam--thinking about the test. (6) Studying the day of the exam--one hour left until exam time. (7) Leaving your room at your living quarters to go to an important exam. (8) Entering the room where the exam is being given and sitting down. (9) The exam is being handed out--you receive a c0py. (10) Reading over the instructions to a final exam and surveying the exam. (11) Taking an exam and working on a question to which you do not know the answer. (12) While trying to think of an answer to an exam question you notice everyone around you writing very rapidly. (13) People are leaving and you're only 1/2 through the exam. (14) You're taking a final and see that most of the material is unfamiliar. 95 This hierarchy is to serve only as a guide; the final hierarchy should be carefully individualized and should consist of items which the client perceives as realistic and relevant. The procedure is as follows. First explain that you wish to determine specific situa- tions from the least to the most anxiety producing. Ask the subject when he first notices feelings of tenseness and anxiety; then work through each of the fourteen items to determine if others should be included, or if the order of some of the items should be rearranged. If there are any situations or circumstances which the client perceives as particularly relevant to his test anxiety devise hier- archy items which will include these situations. Write down the specifics associated with each item, so that you may better control the imagery of the subject, i.e., ex- actly where the subject studies, cues in the room, times, etc. You should have enough understanding so that, if necessary, you may "fill in" another item during desensi- tization without help from the subject. Most hierarchies will not be shorter than 10 items, nor longer than 15 items. 4. Training inyprggressive relaxation. This is a most important procedure, and one that should be mastered. It should be explained to the subject that this technique will take some time (25-30 minutes) at first, but as he learns, the time for inducing deep relaxation will be shortened. Training begins by having the subject syste- matically tense his gross-muscle systems, holding them tense until the tape says "relax," at which time the sub- ject lets go immediately. If the muscles are first tensed, they will relax more deeply when they are released. Also explain that you want the subject to focus all his atten- tion on each muscle system as the tape works through the various groups, so that after practice he will not have to tense the muscles first in order to achieve deep relaxa- tion. 4a. The Method. Seat the subject in a comfortable chair, with the therapist sitting slightly to one side. Have him take out his contact lens if he wears them. Legs should be extended, head resting on the back of the chair or on his chest, and arms resting on the arms of the chair. No part of the body should require the use of muscles for support. Have the subject close his eyes to minimize ex- ternal stimulation. The room should be quiet and lights dimmed if possible. Instruct the subject not to open his eyes when you turn off the tape, but to remain relaxed. Begin the tape-recorded relaxation instructions. 96 The tape will play for 28 minutes of relaxation instruction. After you turn it off, continue suggestions of relaxation for a couple of minutes, and then bring the subject back to "normal" with the numerical method of trance termination: "I'm going to count from one to four. On the count of one, start moving your legs; two, your fingers and hands; three, your head; and four, open your eyes and sit up. One--move your legs; two--now your fin- gers and hands; three--move your head around; four--open your eyes and sit up." Always check to see that the sub- ject feels well, alert, etc., before leaving. The subject should be instructed to practice re- laxation twice a day between sessions. He should not work at it more than 15 minutes at a time, and should not prac- tice twice within any three-hour period. He should also practice alone. Relaxation may be used to get to sleep if practiced while horizontal; if the subject does not wish to sleep, he should practice sitting up. Properly timed, relaxation can be used for a "second wind" during study. By the third session, if the subject has been practicing well, relaxation may be induced by merely focusing attention on the muscle groups, and instructing the subject to "concentrate on muscles becoming relaxed, "warm," etc. However, if the subject has difficulty fol- lowing straight suggestions, return to the use of tension- release under the therapist's instructions. The taped instructions will be used only in sessions one and two. 5. Desensitizationpioper--working through the hierarchy under relaxation. Preparatory to desensitization proper, usually at the end of the first session, the sub- ject's imagery should be tested. This may be done by asking him to visualize item (0): "Now visualize yourself lying in bed in your room just before going to sleep. Describe what you see. Do you see it clearly? Do you see color? Do you feel as if you were there? All right, now stop visualizing that and go on relaxing." Some subjects may report clear, distinct images, as if they were watch- ing a movie; this is fine, but not necessary. The minimum requirement is that their visualizations be as clear as a very vivid memory. Describing these visualizations as a dream is often helpful. With more practice, images will usually become clearer. It is also important that the subject can start and stop an image on request, and this should be determined. If difficulties arise in any of these areas, present a few more common, unanxious images, describing for the subject just what he should experience; for example, entering the office. It is important that the subject visualize situations as if he were there--ppp watching himself! 97 Before inducing relaxation in the second session, explain exactly what you'll be asking the subject to do, since his verbalizations are to be kept at a minimum. Tell him that if anytime during the session he feels any tension or nervousness whatever, to signal by raising his right index finger. This is important, and should be made clear from the beginning. After relaxation is induced, presentation of images begins with item (1), whatever it may be: "Now I want you to visualize yourself sitting in.c1ass while the teacher announces and discusses with the class an exam to be held in three weeks" (10 seconds). "StOp visualizing that, and go on relaxing." Ask if the subject felt any tension and if he was able to start and stop the image on request. Then repeat item (1) again. "One more time, visualize yourself sitting in class while the instructor announces and discusses an exam to be held in three weeks" (10 sec- onds). "Stop visualizing that, and go on relaxing--com- pletely relaxed, no tension anywhere in your body, warm and relaxed." Follow the above paradigm throughout the hierarchy if the subject does not become anxious: i.e., present each'item in the hierarchy, specifying all major aspects of the image. Allow 10 seconds to elapse after each presentation, then instruct the subject to "stop visualiz- ing that, and go on relaxing." Continue suggestions of warmth, relaxation, lack of tension, heaviness, etc., for 30 to 45 seconds, and again present the image. Present each item in the hierarchy at least twice. If the subject does not signal anxiety, and the therapist does not detect anxiety during two 10-second presentations of an item, move on to the next item in the hierarchy. If, on the other hand, the subject signals anxiety or the therapist detects anxiety in the subject, imme-1 diately instruct the subject to "stop visualizing that, and go on relaxing." Then continue with suggestions of relaxation (at least one minute) until the subject reports as deep a relaxation as before. Then inform him that you will shorten the presentation so that anxiety will not occur. Then, present the same item again for a period of only 3 to 5 seconds. If anxiety is still aroused, drop back to a lO-second presentation of the previous item in the hierarchy. If, however, the 3- to 5-second presenta- tion does not arouse anxiety, give 30 to 45 seconds of relaxation suggestions, and present the same item again for 5 seconds, then 10 seconds, then 20 seconds. If the item can be presented for 20 seconds, move on to the next item in the hierarchy. 98 It is precisely at these points that clinical sensitivity must guide the presentations; one must know when to go back, when to construct new items, and when to move up the hierarchy. However, the above guides should handle most situations. Some items may require as many as 8 to 12 presentations of differing time intervals, with lower level items interspersed. Most items should be handled successfully in 2 to 4 presentations. Never end the session with a presentation that arouses anxiety. Approximately 5 to 10 minutes before the end of a session, either stop with a successful item, or go back to the previous item in the hierarchy. "Awaken the subject, and discuss the session with him, reassuring him about any difficulties that may have come up. If by some quirk any of the presentations are nullified, or they do not carry over into real life, rapidly repeat those items in the next session. Normally, each session will begin with a single presentation of the last successfully completed item. All subjects should complete the hierarchy in the five sessions. However, if any subject does not complete the hierarchy, take note of the number of items still to be covered, so this fact may be taken into account in evaluation. Be sure to keep a record of the items covered in each session, so that the proper items are presented each session. ' Flooding Treatment Manual This treatment consists of a modified form of the flooding treatment described by Wolpe and Lazarus in which the client is required to imagine highly anxiety arousing scenes related to his fear. The treatment is also similar to Stampfl's implosive therapy, except there is no specific consideration of psychoanalytic theory in choosing scenes for the client to visualize. There are four major.proced- ures involved in the use of this technique: (1) explora- tion of history and current status of symptoms; (2) expla- nation of rationale; (3) identification of anxiety cues to be incorporated into the scenes for the client to imagine; and (4) stimulus flooding-presenting anxiety arousing scenes for the client to imagine. In this treatment the therapist should be as warm, interested, and helpful as he would be in any helping relationship. At times, however, he may have to be firm in adhering to the technique by not allowing the client to avoid the anxiety aroused by his visualizations. The therapist will Openly guide and direct the course and con- tent of treatment, with a minimum of time and effort spent on introspection, and little or none spent on the client's searching for etiological factors. All happenings and incidences will be interpreted within this system if ques- tioned, and dynamics left uninterpreted unless questioned. If questioned, interpret in a eneral manner--only super- ficially. In any case, it is most important that the therapist remain confident and stay with this specific treatment. The following time schedule should handle most clients. First session: 1. Exploration of history and current status of symptoms (5-10 minutes). 2. Explanation of rationale and course of treatment (5 minutes). . Identification of anxiety.cues (40-50 minutes). 4. Test imagery if time available. . Give subject your telephone number in case he has to cancel an appointment. Between sessions one to five: 1. Plan flooding scenes to be presented to client next session. 99 100 Second to fourth sessions: 1. Check on anxiety outside of treatment (i.e. current status of symptoms). 2. Present visualizations. 3. Identify new anxiety cues which can be incorporated into visualizations. 4. Check adequacy of imagery, and degree of anxiety experienced by the client toward the beginning and toward the end of the visualization portion of therapy (use therapy summary sheet for this). Fifth session: 1. Check on anxiety outside of treatment. 2. Present visualizations. 3. Check adequacy of imagery and degree of anxiety experienced by the client toward the beginning and toward the end of the visualization portion of therapy (use therapy summary sheet). 4. Give subject the test packet and instructions on how to complete it. SPECIFIC PROCEDURES 1. Exploration of histopy and current status of s m toms. For the researdh project, this phase WilI be reIatively short, serving primarily as an "icebreaker" and as a period in which to establish rapport. To help de- scribe subjects and to further therapist understanding, determine (a) how long the subject has experienced test anxiety, (b) to what de ree test anxiety interferes with functioning, and (c) whet er other evaluative situations also arouse anxiety. This should be completed in no more than 10 minutes of the first session. 2. Explanation of rationale and course of treat-. ment. Both the theory and course of treatment should be briefly explained to the subject and repeated if questions arise. It should be made clear that anxiety is the result of learning, and that the treatment is a learning process. If any subject seems to have trouble understanding, re- phrase your explanation in language he can understand. The following brief explanation usually suffices for in- troductory purposes. "The emotional reactions that you experience are a result of your previous experience with testing situations; these reactions oftentimes lead to feelings of anxiety or tenseness which, when they become very strong, are really inappropriate and interfering. Since perceptions of 101 situations occur within ourselves, it is possible to work with your reactions right here in the office by having you image 0r visualize those situations. "The specific technique we will be using is one called extinction. You may have already read about the general process of extinction in your 151 class since the extinction process is one of the basic laws in psychology. Essentially what happens during extinction is that when a person persistently confronts or exposes himself to a sit- uation to which he has learned to be afraid without ex- periencing punishment or what we call negative reinforce- ment in that situation, then gradually his anxiety in this situation diminishes or extinguishes. The process, then, consists of unlearning the too intense anxiety reSponse which you have learned to make to testing situations. "The way in which we will do this is to determine aspects of the testing situation which make you anxious, and have you confront these in your imagination. When you first begin to imagine a particular scene relating to test-taking you will become anxious, perhaps very anxious, but gradually, through the process of extinction, this anxiety will diminish and finally disappear. Then we will repeat the process with a different test-taking scene, and so on, until you have unlearned your anxiety reaction to taking tests. Most of these procedures will become clearer after we get into them. Do you have any questions before we continue? 3. Identification of anxiety cues. This consists of determining cues or shimuli reIating to test-taking which can be incorporated into the scenes which the client will visualize. The cues should elicit at least a moderate amount of anxiety from the client, and should be comparable to the items which would appear in the upper half or quarter of a systematic desensitization anxiety hierarchy. 3a. Basic-test-anxietchues. Based upon interviews with students and analysih of the situation, the following items might be incorporated into flooding scenes. The (0) item should be unanxious and used to test imagery. The other items are not intentionally listed in any particular order. (0) Lying in bed in room just before going to sleep--describe room. (1) Studying the day of the exam--one hour left until exam time. 102 (2) Leaving your room at your living quarters to go to an important exam. (3) Entering the room where the exam is being given and sitting down. (4) The exam is being handed out--you receive a copy. (5) Reading over the instructions to a final exam and surveying the exam. (6) Taking an exam and working on a question to which you do not know the answer. (7) While trying to think of an answer to an exam question you notice everyone around you writing very rapidly. (8) People are leaving and you're only 1/2 through the exam. (9) You're taking a final and see that most of the material is unfamiliar. (10) You suddenly realize that this exam will make the difference between a C and a D in the course. These items are to serve only as a guide to choos- ing the final items which should be carefully individual- ized so as to be perceived by the client as realistic and relevant. The procedure is as follows. First explain that you wish to determine specific aspects of the test- taking situation or pre test-taking situations which make the client anxious. Ask the client to name any such as- pects which he can think of. Write these down. When the client has described as many details as he can, work through the basic items suggested above to determine if any of these are anxiety-provoking. Write down the spe- cifics associated with each item, so Ehat you may better control the imagery of the subject. The more an item re- lates to this particular client's concerns, the easier it will be for him to imagine it. The anxiety cues identified from conversation with the subject should be incorporated into extended scenes or sequences of scenes which the client will be asked to imagine during the flooding portion of therapy. These scenes can be develOped by the therapist between sessions 103 in preparation for the coming therapy session. The client will be imagining the scene or sequence for extended lengths of time varying probably from five to fifteen min- utes, thus the scene descriptions will have to be much more complex and lengthy than those of systematic desensi- tization. A typical scene might progress from a client's entering the exam room through to his completion of the test--with a variety of incidents occurring in between. Examination anxiety does not offer as many possibilities for scene variations as do certain other types of anxieties (e.g. snake or spider phobias) so there may be a fair amount of repetition of detail in different scenes. Some scene variation can be produced by focusing on different kinds of tests (e.g. quizes, midterms, finals, multiple- choice tests, essay tests, tests for different courses, achievement tests, college board tests, intelligence tests, etc.). Scenes can, and probably should also be constructed which describe the subject studying or worrying in situa- tions several hours before the exam since this is a par- ticularly stressful period for most test-anxious students. Additional scenes can be developed by asking the subject to describe the most anxiety provoking experience he has had in a testing situation and also the most anxiety pro- voking experience in a testing situation he can imagine, and then using these as the basis for flooding descrip- tions. Experiences of test-anxiety outside of therapy should be inquired about in each session, and if any have occurred they can serve as the basis for flooding descrip- tions. 4. Stimulus flooding. This consists of actual presentation ofiscenes to the client for him to visualize. The scenes should be described as vividly as possible. Try to phrase the descriptions in the subject's own lan- guage. The subject may attempt to avoid or lessen the anxiety elicited by visualizations by engaging in exces- sive conversation or in repetitive body movements (e.g. foot tapping). Discourage this; try to make the subject experience the scene as realistically as possible--encour- age him to imagine the scenes as if he were really in them now. Occasionally interrupting your description and asking the subject to describe what he is visualizing will serve to prevent him from avoiding the visualizations and will also inform you about how effective your descriptions are. At each stage of the scene description an attempt should be made by the therapist to attain a maximal level of anxiety evocation from the client. When a high level of anxiety is achieved, the client should, if possible, be 104 held on this level until some signs of spontaneous reduc- tion in the anxiety inducing value are indicated. At times this may require a longer description of the scene than the therapist is capable of providing, in which case the scene will have to be terminated without the anxiety reduction. After you have completed the scene description, discuss it with the client to determine what aspects were most anxiety arousing. These should be stressed in later scene presentations. Also determine if the manner of presentation (vocabulary, voice expression, speed of de- scription, etc.) should be altered in any way to allow the client to visualize the scenes more vividly. The scene should be repeatedly described until a significant diminu- tion in the anxiety elicited by the scene occurs. Then a new scene should be introduced, and worked through in the same way. Relaxation Treatment Manual This treatment starts with the abbreviated Jacobson training in progressive relaxation, and is supplemented with two additional procedures: (1) training to establish the word "relax" as a conditioned stimulus for the relaxa- tion response, and, most importantly, (2) training to maximize the subject's ability to relax himself in extra- therapy situations, particularly test-taking situations. There are four major procedures involved in the use of this technique: (1) exploration of history and current status of symptoms; (2) explanation of rationale; (3) training in progressive relaxation and in establishing the word "relax" as a conditioned stimulus for relaxation; and (4) assigning relaxation homework practices to the client and checking on his success in carrying out these assign- ments. In this treatment the therapist again should be as warm, interested, and helpful as he would be in any helping relationship. The therapist will openly guide and direct the course and content of treatment, with a minimum of time and effort spent on introspection, and little or none spent on the client's searching for etiological factors. All happenings and incidences will be interpreted within this system if questioned, and dynamics left uninterpreted unless questioned. If questioned, interpret in a eneral manner--only superficially. In any case, it is most im- portant that the therapist remain confident and stay with this specific treatment. The following time schedule should handle most clients. First session: 1. Exploration of history and current status of symp- toms (5-10 minutes). 2. Explanation of rationale and course of treatment (5 minutes). 3. Training in progressive relaxation using the tape- recorded instructions. When subject is completely relaxed have him say "relax" 10 times (30 minutes). 4. Have subject practice (repeat) the exercises just completed as best he can without the taped in- structions and without instructions from the therapist. After completion of practice, correct any mistakes or omissions made by the subject (10-15 minutes). 105 6. Second 1. 2. 106 Instruct the subject to practice relaxation. (This relaxation homework assignment should be the same as that for desensitization (see page of desensi- tization manual) except that when the subject is completely relaxed at the end of each practice session he is to say the word "relax" 10 times. Give subject the summary sheet listing muscle groups to be relaxed during practice. Give subject your telephone number in case he has to cancel an appointment. session: Check on success with relaxation and correct any problems arising (10-15 minutes). Training in progressive relaxation using the tape- recorded instructions but with eyes open. Have subject say "relax" ten times at end (30 minutes)? Check adequacy of relaxation using therapy summary sheet. Have subject practice the exercises just completed, but without the taped instructions. After comple- tion of practice correct any mistakes or omissions made by the subject (10-15 minutes). Instruct the subject to practice relaxation in the same manner as during the previous week, but this time with his eyes Open. Third and fourth sessions: 1. 2. Check on success with relaxation and correct any problems arising. Have subject induce his own relaxation and say "relax" ten times. Question him about how the various muscle groups felt when he did this. Check adequacy of relaxation using therapy summary sheet. Instruct subject to relax himself (by this time he should not need to tense his muscles to do so) in the following extra-therapy situations: a. While lying in bed, before falling asleep. b. At mealtimes. c. While studying or doing homework. d. In classes, especially before the lecture begins. e. While riding as a passenger in a bus or car if this opportunity arises. f. While watching television, a movie, a concert, a basketball game, etc., especially before the event begins or during intermission. 9. While talking on the phone or when talking to friends. 107 h. When taking an exam or quiz if he is nervous. i. In any situation in which he is tense or anxious. j. In as many other situations as possible. Fifth session: 1. Check on success with relaxation and correct any problems arising. 2. Have subject induce his own relaxation and say "relax" ten times. Question him about how the various muscle groups felt when he did this. Check adequacy of relaxation using therapy summary sheet. 3. Instruct subject to continue practicing relaxation and to utilize it during exams. Forewarn him that it may be a little more difficult to induce re- laxation in the testing situation and that he need not become completely relaxed. 4. Give subject the test packet and instructions on how to complete it. SPECIFIC PROCEDURES 1. Exploration of history and current status of s m toms. For the research project, this phase wiII he reIatively short, serving primarily as an "icebreaker" and as a period in which to establish rapport. To help de- scribe subjects and to further therapist understanding, determine (a) how long the subject has experienced test anxiety, (b) to what de ree test anxiety interferes with functioning, and (c) w et er other evaluative situations also arouse anxiety. This should be completed in no more than 10 minutes of the first session. 2. Eaplanation of rationale and course of treat- ment. Both the theory and course of treatment shOuld be briefly explained to the subject and repeated if questions arise. If any subject seems to have trouble understanding, rephrase your explanation in language he can understand. The following brief explanation usually suffices for in- troductory purposes. "The relaxation procedure we will be using is based upon years of work that was started in the 1930's by Dr. Jacobson. Dr. Jacobson develOped a method of inducing relaxation that can be learned very quickly, and which will allow you to become more deeply relaxed than ever before. Of course, the real advantage of relaxation is that the muscle systems in your body cannot be tense and relaxed at the same time; therefore, once you have learned 108 the relaxation technique, it can be used to counter anxiety, tenseness, and feelings like those you experience in the exam situation. In fact once you learn the relaxa- tion technique you can use it to counter anxiety in other situations in which you may become upset. It is also a good way to induce sleep when you begin to have a restless night in bed--actually it is quite a valuable skill to acquire. In learning how to relax it is important that you be able to induce relaxation here with me, but most important, it is necessary that you can relax yourself in real life situations. In order to accomplish this you will have to practice relaxation on your own in a number of situations apart from our meetings here. Thus I will be instructing you to practice relaxation a few minutes each day between our meetings. The procedure will become clearer after we get into it. Do you have any questions before we continue? 3. Training in progressive relaxation. This, of course, is a most important procedure, and one that must be mastered. It should be explained to the subject that this technique will take some time (25-30 minutes) at first, but as he learns, the time for inducing relaxation will be shortened. Training begins by having the subject systematically tense his gross-muscle systems, holding them tense until the tape says "relax," at which time the subject lets go immediately. If the muscles are first tensed, they will relax more deeply when they are released. Also explain that you want the subject to focus all his attention on each muscle system as the tape works-through the various groups, so that after practice he will not have to tense the muscles first in order to achieve deep relaxation. When the subject is completely relaxed he should say "relax" ten times. Explain that after this is prac- ticed many times the words "relax" will become associated with the state of relaxation and will become somewhat cap- able Of eliciting it. Thus saying "relax" to himself will also help the subject to relax. 3a. The Method. The method is the same, as for desensitization (see desensitization manual, pp. 95-96) except the subject is told to whisper the word "relax" ten times toward the end of each practice period. 4. Relaxation assignments. At the end of each treatment session the subject wiII be instructed to prac- tice relaxation in various situations outside of therapy. The importance of the subject's carrying out these assign- ments should be stressed, since the extra-therapy practice 109 is vital to establishing the subject's ability to relax himself in naturally occurring situations. A major por- tion of sessions 3-5 will consist of checking on the sub- ject's success in carrying out relaxation assignments. To do this, ask the subject to describe his experience on each occasion during which he practiced relaxation the week before the present therapy session. On the relaxa- tion therapy summary sheet jot down a phrase describing each situation in which the subject has practiced relaxa- tion. For any one week he may describe seven to fourteen or more situations, many of which will be identical except for time of the day or day of the week. Don't bother re- cording situations which are very similar. As the subject describes situations, ask specific questions concerning what he was thinking about, what he was looking at, where his appendages were placed, and how various muscle groups felt. Give verbal praise and encouragement for the sub- ject's reports of relaxation practice, but explain to him early that you want accurate reports and that he should not fabricate reports because he believes that is what you want to hear. The above procedure should serve several purposes: (1) It should elicit difficulties the subject is experiencing with relaxation which he might otherwise fail to mention due to his being unaware of them, forget- ting them, Or considering them too unimportant to bring up, (2) it should motivate the subject to practice relaxa- tion outside of therapy, and (3) it should serve as a means of filling out the therapy hour (or half hour) for subjects who make rapid progress and experience few diffi- culties in learning the technique. Summary Sheet on Relaxation Procedures You cannot be anxious while you are relaxed. Practice relaxation twice a day by completing the proced- ures below. Sufficient practice will enable you later to relax yourself quickly, easily, and without first tensing your muscles as is done here. Concentrate on noticing the difference between tension and relaxation. After each tensing note howgyour muscles feel when_you relax them, when you "Iet themgo." Always relax your muscles after tensing, and pay attention to that relaxation. 1. Make a fist with your left hand, tensing the muscles until they tremble. Feel the tenseness of the muscles. Now "let go," and relax--feel how your muscles relax. 2. Same with right hand. 3. Bend left hand up at wrist. Feel tension. Let go, and feel relaxation. 4. Same with right hand. 5. Flex biceps of both arms by bringing hands up to shoulders. Feel tension, then relax. 6. Shrug both shoulders, bringing them up as if to touch your ears. Feel tension in back and neck, then relax. 7. Wrinkle up forehead. 8. Close eyes tightly. 9. Press tongue up into roof.of mouth. 10. Press lips together--pucker your lips. 11. Push your head back. 12. Bend your head forward, burying your chin into your chest. 13. Arch your back, sticking your chest and stomach out. 14. Take deep breath and hold it. 110 15. 16. 17. 18. 19. 20. 21. 22. 111 Suck in your stomach. Tense your stomach muscles; make them hard. Push your seat into the chair, tensing your buttocks. Stretch both legs straight out, Off the floor. Stretch your thigh muscles. Point your toes upward, stretching the muscles in the calves. Curl toes of both feet downward, feel the tension in your arches. Let your whole body relax. Let the tension drain out of all your muscles. When you are completely relaxed say the word "relax" to yourself 10 times. APPENDIX D THERAPY SUMMARY SHEETS Therapy Summary Sheet (systematic desensitization) Date Your Name Session Number ‘S's Name Length of session Location of session On a separate sheet of paper list the hierarchy when it is develOped. On this sheet list the hierarchy items covered today, and the number of presentations of each item. Items Covered Today Number of Presentations 112 Therapy Summary Sheet (desensitization) S's rating of the quality of his imagery. 6. REALISTIC. Like being in the real situation. VIVID. Very clear but was not totally im- mersed in the situation. CLEAR. Like watching myself in the situation. FLEETING. Imagery not clear at all times, felt superficially involved. FUZZY. Could not maintain imagery; simply thought about the scene. Somewhat like looking at a picture with little or no in- terest. NONE. Unable to imagine the described scene. Rating of the quality of overall relaxation. E's rating S's ratipg_ 1 2 New problems raised by S 1 EXCELLENT. Felt completely relaxed. 2 GOOD. Felt relaxed but thinks it could be deeper. 3 FAIR. Some specific areas of the body were not relaxed. 4 POOR. Unable to relax. Problems you are having: 113 Supplement to Relaxation and Desensitization Summary Sheets for Second and Third Session Your Name S's Name Date Ask the subject how many times he practiced re- laxation the previous week, and about how long, on the average, one of these practice sessions lasted. No. of times relaxation practiced Average practice time or duration minutes 114 Therapy Summary Sheet (relaxation) Rating of the quality of overall relaxation. E's rating, S's rating 1 l EXCELLENT. Felt completely relaxed. 2 2 GOOD. Felt relaxed but thinks it could be deeper. 3 3 FAIR. Some specific areas of the body were not relaxed. 4 4 POOR. Unable to relax. New problems raised by §_ Problems you are having: 115 Therapy Summary Sheet (relaxation) Date Your Name Session Number S's Name Length of Session Location Of session Jot down a phrase to describe each different situation the subject reports having practiced relaxation in during the week previous to this session. Don't make duplicate en- tries for situations which are very similar or identical. 116 Therapy Summary Sheet (flooding) For the subject: Instructions Draw a line across the scale Draw a line across the scale below to indicate the amount below to indicate the amount of anxiety or tenseness you of anxiety or tenseness you felt when you started to felt just before you quit imagine scenes today. imagining scenes for today. Extreme Anxiety Extreme Anxiety No Anxiety No Anxiety 117 Therapy Summary Sheet (flooding) S's rating of the quality of his imagery. l. REALISTIC. Like being in the real situation. 2. VIVID. Very clear but was not totally im- mersed in the situation. 3. CLEAR. Like watching myself in the situation. 4. FLEETING. Imagery not clear at all times, felt superficially involved. 5. FUZZY. Could not maintain imagery; simply thought about the scene. Somewhat like looking at a picture with little or no interest. 6. NONE. Unable to imagine the described scene. New problems raised by g Problems you are having: 118 Therapy Summary Sheet (flooding) Date Your Name Session Number S's Name Length of Session Location of Session Give a brief description of each scene presented to the subject today, and record how many times the scene was presented and approximately how long a single presentation or description lasted. 119 "'T’Hfiliflfllfljflgllfillflflflflfflifliflflflifllflifif“