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The role of relaxation in systematic desensitization: Revisiting an unresolved issue
1. Behav. Then & Exp. Psychiar. Vol. 8. pp. 359.364.
Pergamon Press. 1977. Printed m Great Britain
THE ROLE OF RELAXATION IN SYSTEMATIC DESENSITIZATION: REVISITING AN UNRESOLVED ISSUE* GERALD T. O’BRIEN? and T. D. BORKOVEC University of Iowa
Summary-Forty-three socially anxious females received systematic desensitization, noncontiguous relaxation, hierarchy exposure only, or no treatment. Analysis of pre-posttest fear in a laboratory social interaction task revealed virtually no treatment effects on self-report or behavioral measures. Analysis of continuously monitored heart rate, however, indicated reduced anticipatory activity among subjects receiving relaxation training and reduced reactive activity for desensitization subjects.
Despite extensive research, the question of the facilitative role of muscular relaxation in the systematic desensitization process has remained unresolved. A recent review (Borkovec and O’Brien, 1976) of 22 studies related to this question indicates that the evidence is inconclusive, contradictory, and based on studies involving two methodologically problematic characteristics: (1) preponderant use (68%) of small animal “phobics” and (2) frequent absence of a critical, component-control condition, i.e., desensitization with noncontiguous relaxation. Animal-fear analogue studies have consistently failed to employ sufficiently stringent selection criteria to insure that subjects demonstrate significant anxiety in the presence of the target stimulus (Bernstein and Paul, 1971; Cooper, Furst and Bridger, 1969). Consequently, demand effects (Orne, 1962) may easily confound treatment effects (Borkovec, 1973a, 1973b). Perhaps more importantly, physiological reactivity does not appear to be a functionally relevant component of the anxiety process for most animal “phobic” subjects (Borkovec, 1976). Thus, a major dimension of anxiety has been virtually ignored in past desensitization component research. In tests of the
theoretical basis of techniques like systematic desensitization whose underpinnings rest on notions of the classical conditioning of autonomic responses (Wolpe, 1958). the absence of a substantial physiologicval reaction to the feared stimulus and/or the failure to measure that component reduces the significance of conclusions derived from such research. Second, the majority of previous desensitization component studies have not assessed the importance of temporal pairing of relaxation with visualization of aversive scenes. This contiguity question is critical. The reciprocal inhibition (Wolpe, 1958) or counterconditioning (Davison, 1968) model of desensitization predicts that the anxiety-antagonistic response must be present during hierarchy visualization for desensitization to be maximally effective. The extinction model maintains that CS exposure is the only necessary condition for anxiety reduction (Lomont, 1965; Wilson and Davison, 1971). Simple comparison of desensitization to CS exposure only is an insufficient test, however, since the mere inclusion of relaxation training at any point in therapy may promote positive outcome (McGlynn, 1969). Only four component
*Requests for reprints should be addressed to T. D. Borkovec. Department of Psychology, University of Iowa, Iowa City, Iowa 52242. tThis paper is based on the thesis of the first author in partial fulfillment of the Masters Degree requirements of the University of Iowa and was supported in part by NIMH Grant MH27484 awarded to the secondauthor. 359
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studies have attempted to evaluate directly the importance of CS-visualization/relaxation contiguity. Lomont and Edwards (1967) and Persely and Leventhal (1972) obtained results supporting the importance of contiguity, whereas Nawas, Mealiea and Fishman (1971) and Aponte and Aponte (1971) found results questioning the need for contiguity. However, these studies employed elaborate and perhaps questionable procedures to obtain contiguity, limited dependent measures, and/or a completely standardized systematic desensitization procedure. The purpose of the present study was once again to investigate the facilitative role of progressive relaxation in systematic desensitization, while attempting to avoid the above methodological problems. Social anxiety was selected as the target fear, since this behavior has been demonstrated to be relatively unsusceptible to demand effects and characterized by substantial physiological reactivity that fails to habituate over repeated exposures (Borkovec, Stone, O’Brien and Kaloupek, 1974). Socially anxious females were individually exposed to a laboratory social interaction test situation and then randomly assigned to one of four experimental conditions: (1) hierarchy visualization with contiguous relaxation (systematic desensitization), (2) hierarchy visualization with non-contiguous relaxation, (3) hierarchy visualization only, or (4) no treatment. Subsequent to four therapy sessions, all subjects were again exposed to the laboratory test. This design can no longer be viewed as a critical test of reciprocal inhibition vs extinction models, since Wilson and Davison (1971) have suggested that relaxation may function as an extinction facilitator. An adequate demonstration of that facilitative effect remains to be made, however. Given the equivocal nature of earlier investigations and our own predilection to remain neutral with regard to theoretical bias, our only expectation was that the functional role of relaxation should be most clearly evident in the continuous physiological measures obtained during testing.
and T. D. BORKOVEC
METHOD Subjects Forty-three female undergraduates indicating some fear or greater of being with a member of the opposite sex on Geer’s (1965) Fear Survey Schedule (FSS) participated in the study. Each subject received research credit for her participation. Procedure Pretest and posttest social interactions. Primary dependent measures were obtained from pre- and posttest laboratory social interactions following the procedures of Borkovec et al. (1974). Posttesting was conducted approximately 7 weeks after the pretest and 1-2 weeks after the final therapy session. Upon arrival at the laboratory, electrodes were attached to the subject’s arms for heart rate monitoring. The subject was then informed by taperecorded instructions that her task was to engage in a 3-min social interaction with a male research assistant, performing as well as possible and remaining as relaxed and nonanxious as she could. The subject was informed that the assistant was a confederate instructed not to talk or respond to her in any way. Self-report measures from pre- and posttests included Rehm and Marston’s (1968) Situation Questionnaire administered prior to each interaction and three instruments administered at the conclusion of each interaction: Husek and Alexander’s (1963) Anxiety Differential; Mandler, Mandler and Uviller’s (1958) Autonomic Perception Questionnaire; and a Self-Report of Performance Questionnaire. In addition, two observers rated the subject’s behavior for overt signs of anxiety during the interactions on a modified form of Paul’s (1966) Timed Behavioral Checklist (TBCL). Interrater reliability on this measure was high (r = 0.87, P< 0.01). The subject’s verbalizations during the tests were tape-recorded and later scored for speech disfluencies (Mahl, 1956) and percentage of speaking time. Immediately after the interaction, the male confederate rated the subject’s performance on a seven-item Confederate’s Rating Questionnaire. Continuous heart rate was monitored throughout the session. Ten-second heart rate samples were obtained from the Beckman RM dynograph recordings at five anticipatory and four reactive phases from both the pretest and posttest: phases (l)-(2) just prior to and just after the general instruction tape; phases (3)-(4) the first and last 10 set of a I-min quiet period during initial confederate presence; phase (5) the last 10 set of the final instruction tape askina the subject to begin her interaction; phases (6)(9) the first IO set of the interaction and 10 set at the end of each minute. Correlations between the scores of two raters on 20 complete records ranged from 0.97 to I .OO (mean = 0.994).
Confederates Three male undergraduate psychology majors serving as confederates were instructed to remain silent throughout the 3-min interaction, to maintain comfortable eye contact with the subject, to smile occasionally but noncontingently, and to avoid making nonverbal responses (e.g. head nods, shrugs, facial expressions). Although this
THE ROLE OF RELAXATION IN SYSTEMATIC DESENSITIZATION form of social situation is highly artificial and may have little direct relevance to naturally occurring social situations, the purpose of this study was to provide a limited test of theoretical notions under highly standardized conditions. Scheduling of confederates, blind to the treatment condition of the subject, was arranged so that no subject interacted with the same confederate during both the pretest and posttest.
Therapists Two male graduate students in clinical psychology treated half of the subjects in each treatment group. Treatment manuals were employed during therapy to insure that exactly the same procedures were followed.
Treatment conditions After pretesting, subjects were randomly assigned to one of three treatment groups (10 subjects per group) or to a no-treatment condition (13 subjects). Treated subjects received four weekly group therapy sessions, each session being approximately one hour long. All treatment sessions were conducted in a room different from that in which the pretest and posttest were conducted. During the first therapy session, the therapist presented the appropriate rationale and assisted subjects in ranking I5 standard anxiety hierarchy items based directly upon situations involved in the social interaction pretest. Average rankings determined the final hierarchy for the group. Again, choice of this highly circumscribed hierarchy was based on our effort to maximize anxiety reduction effects relevant to the pre-posttest situation, even though this meant a reduced relevance to clinical, social anxiety. Following hierarchy item ranking, subjects were trained in progressive relaxation and/or visualization, depending on their treatment condition. At the conclusion of the first session, subjects completed a four-item Credibility Questionnaire (Borkovec and Nau, 1972) assessing their confidence in the treatment for reducing social anxiety. A therapist by Treatment analysis of variance indicated that the treatment groups did not differ on this measure. Systematic desensitization (SD). During the first therapy session, SD subjects received training in both imagery visualization with one pleasant image and progressive relaxation (Bernstein and Borkovec, 1973) and were instructed to practice relaxation twice daily throughout the study’s duration. During the second through fourth sessions, systematic desensitization was conducted exactly following Paul’s (1966) procedure, e.g. two IO-set visualizations without signalling anxiety were required before moving to the next item; anxiety signalling during of the resulted in termination any visualization visualization, reestablishment of reports of deep relaxation, and a requirement of 3. 5. IO and 20-set visualizations without anxiety before moving to the next item. Since treatment was conducted in groups, progress through relaxation and through the anxiety hierarchy proceeded at the rate of the slowest subject. Five hierarchy items were completed during each session. Non-contiguous relaxation (NCR). NCR subjects also received training in both imagery visualization and
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progressive relaxation during the first session and were instructed to practice relaxation twice daily throughout the study’s duration. The first half of sessions two throunh four consisted of hierarchy item visualization only. Subjects sat upright in chairs with their eyes closed. The procedures for presenting hierarchy items, signalling of anxiety with termination of visualization, and for proceeding from one item to the next were identical to that employed in the SD condition. Instead of focusing on relaxation between visualizations, however, subjects were instructed to count slowly backwards to themselves between scene visualizations to prevent item visualization or relaxation while equating groups on time between visualizations. After the successful visualization of the five hierarchy items, subjects reclined and progressive relaxation training, identical to that employed in SD. was administered during the remaining half of the session. Thus, subjects in this condition received both hierarchy visualization and progressive relaxation, but in a noncontiguous manner. Hierarchy visualization only (HO). Subjects in the HO condition did not receive training in progressive relaxation. Therefore, to equate groups for lenath of contact with the therapist during the first‘session aid for daily homework assignments, these subjects practiced visualization of five pleasant images, completed a demographic “Survey Questionnaire”, and were instructed to practice visualizing the pleasant images twice daily throughout the duration of the study. The first half of sessions two through four was spent visualizing the subjects’ five pleasant images. After this visualization nractice. hierarchy visualization was begun. The same procedure utilized for NCR subjects was followed. i.e. subiects sat upright in chairs with-their eyes closed, were not relaxed, were instructed to count silently between visualizations, and progress through the hierarchy, determined by the same procedures outlined for SD and NCR, proceeded at the rate of the slowest subject. After the successful visualization of five hierarchy items, the session was terminated. No-treatment (NT). After the pretest, W subjects were informed by phone that their names had been placed on a waiting list and that they would be contacted later for treatment scheduling. Later, they were told by phone that it would first be necessary to repeat the social interaction test before treatment sessions began. This information was supplied, since subjects in the three treated conditions knew that a second social interaction test would occur subsequent to treatment. Posttesting for NT subjects occurred during the same weeks of posttesting for treated subjects.
RESULTS Therapbt effects
To test for therapist effects, three-way repeated measures analyses of variance (Test by Therapist by Treatment) were computed for each of the self-report and behavioral measures
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and four-way repeated measures analyses of variance (Phase of Interaction by Test by Therapist by Treatment) for the heart rate scores. With one exception, no significant interaction or main effects of Therapist were obtained.* For all remaining analyses, therefore, the therapist factor was collapsed. Treatment effects Initial analyses on all pretest measures revealed that treatment groups did not differ on any measure. Due to generally high pretestposttest correlations within each measure, however, analysis of covariance was employed to assess treatment effects. Self-report and behavioral measures. Selfreport and behavioral measures were analyzed by a simple analysis of covariance. No main effect of treatment was found on any self-report measure or on the confederate’s rating, speech disfluencies, or percentage of speaking time measures. The main effect of treatment was significant for the TBCL, F (3, 38) = 4.15, PCO.05.; adjusted posttest means: 11.7 for SD, 9.0 for NCR, 10.3 for HO, and 13.5 for NT. Post hoc comparisons by the Scheffe method (Edwards, 1968) revealed only one significant pairwise comparison: NCR subjects demonstrated significantly fewer overt signs of anxiety during the posttest than did NT subjects. In addition, the multiple comparison of the collective effects of SD, NCR, and HO groups with the weighted mean of the NT group was significant; treated subjects showed significantly fewer anxiety signs that did NT subjects. Heart rate measures. The heart rate scores were analyzed by means of a two-factor repeated measures (Phase by Treatment) analysis of covariance (cf. Winer, 1971, pp. 796-809). Posttest phase means were adjusted for differences on pretest phase means. Figure 1 displays the adjusted posttest means during the nine phases of the interaction for each treat-
ment condition.
Fig. 1. Adjusted Posttest Heart Rate for Systematic Desensitization (SD), Non-Contiguous Relaxation (NCR). Hierarchy Exposure Only (HO).-and No-Treatment OI(Tj Conditions During the Anticipatory and Reactive Periods of the Social Interaction Task.
As is typically found in studies involving complex cognitive-motor tasks, heart rate accelerated dramatically at the initiation of the interaction. Even nonanxious subjects show such acceleration (e.g., Borkovec et al., 1974). What is of importance is the relative level of preceding anticipatory and subsequent reactive activity among conditions. A significant Phase by Treatment interaction was obtained, F (24, 311) = 1.62, P
*On the percentage of speaking time, the main effect of Therapist was significant, F (1. 23) = 7.75, P
THE ROLE OF RELAXATION
IN SYSTEMATIC
rate compared to SD subjects. The significant interaction effect was not large; consequently, straightforward selection of post hoc comparisons to statistically support the above observations were not significant. DISCUSSION Imaginal CS exposure of any type resulted in significantly greater decreases in overt signs of anxiety than no-treatment. Since social anxiety as measured by the present procedure is relatively immune to demand/suggestion effects (Borkovec et af., 1974), it is likely that this change reflected an active treatment effect. A previous review of the desensitization component research indicated that the majority of studies employing five or fewer sessions or subject control over progress through the hierarchy found equivalence among component conditions on behavioral measures (Borkovec and O’Brien, 1976). The present study is in agreement with this observation. What is remarkable, however, is that with the exception of the above TBCL outcome, treatment had no effect on behavioral and selfreport measures. Apparently, when a target behavior, unsusceptible to demand influence and involving a substantial physiological fear component, is employed, the improvement generated by brief systematic desensitization is far less than one would ordinarily expect from reading the small-animal phobic literature. The weak treatment effects under these experimental conditions may have been due to the nature of the social interaction test, i.e., it may be more stressful than real life social situations. The fact that the test situation does reliably distinguish anxious and nonanxious subjects (Borkovec ef 1974) does argue for its experimental al., relevance for testing theoretical anxiety questions, even though its external validity is limited. The majority of desensitization research has ignored the physiological response component and its measurement, despite Wolpe’s (1958) autonomic definition of anxiety. From this per-
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363
spective, then, the component effects found in the present study on posttest heart rate are of great interest and potential importance. Although the Treatment by Phase interaction did not account for a large percentage of the heart rate variance and post hoc analyses failed to identify the source of the significant effect, it did indicate significantly different patterns of autonomic activity among the four conditions. Inspection of Fig. 1, in the absence of significant comparisons, suggests that the presence of the relaxation component, either contiguous or non-contiguous with hierarchy exposure, lowered heart rate during the anticipatory period of the social interaction posttest. Systematic desensitization, however, produced the greatest decrement in heart rate activity in response to the occurrence of the interaction. The latter outcome suggests a facilitative role for relaxation in the desensitization process at the autonomic level. The general absence of behavioral and self-report improvement may have been a function of lag effects hypothesized by Mathews (1971) to occur between autonomic change and changes in other response systems. Finally, some evidence was found in the heart rate results for a possible sensitization effect among exposure-only subjects; HO subjects showed higher anticipatory heart rate than NT subjects (Fig. 1). although this difference was not statistically significant. Exposure to feared stimuli, even in graduated form, may thus produce an autonomic incubation phenomenon (Eysenck, 1968) if relaxation is not contiguously elicited or does not occur shortly after such exposure.
REFERENCES Aponte J. F. and Aponte C. E. (1971) Group preprogrammed systematic desensitization without the simultaneous presentation of aversive scenes with relaxation training. Behav. Res. & Therupy 9, 337-346. Bernstein D. A. and Borkovec T. D. (1973) Progressive Relaxation Training, Research Press, Champaign. Bernstein D. A. and Paul G. L. (1971) Some comments on therapy analogue research with small animal “phobias”. J. Behav. Ther. & Exp. Psychiat.
2.225-237.
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Borkovec T. D. (1973a) The effects of instructional suggestion and physiological cues on analogue fear, Behav. Therapy 4. 185-192. Borkovec T. D. (1973b) The role of expectancy and physiological feedback in fear research: A review with special reference to subject characteristics, Behav. Therapy 4.491-505. Borkovec T. D. and Nau S. D. (1972) Credibility of analogue therapy rationales, J. Behav. Ther. & Exp. Psychiar. 3.257-260. Borkovec T. D. and O’Brien C. T. (1976) Methodological and target behavior issues in analogue therapy research. In Progress in BehaviorModijication (Ed. by Hersen M., Eisler R. M. and Miller P. M.), pp. 133-172, Academic Press, New York. Borkovec T. D.. Stone N. M., O’Brien G. T. and Kaloupek D. G. (1974) Evaluation of a clinically relevant target behavior for analgue outcome research, Behov. Therapy 5.504-514. Cooper A., Furst J. B. and Bridger W. H. (1969) A brief commentary on the usefulness of studying fears of snakes, J. abnorm. Psychol. 74,413-414. Davison G. C. (1968) Systematic desensitization as a counterconditioning process, J. ubnorm. Psycho/. 73, 91-99. Edwards A. L. (1968) Experimental Design in Psychological Reseurch, Holt, Rinehart & Winston, New York. Eysenck H. J. (1968) A theory of the incubation of anxiety/fear responses, Behav. Res. & Therapy 6. 309-321. Geer G. H. (1965) The development of a scale to measure fear. Behav. Res. & Therupy 3,45-53. Husek T. R. and Alexander S. (1963) The effectiveness of the Anxiety Differential in examination stress situations, Educ. psycho/. Meusur. 23,309-318. Lomont J. F. (1965) Reciprocal inhibition or extinction? Behav. Res. & Therapy 3,209-219. Lomont J. F. and Edwards J. E. (1967) The role of relaxation in systematic desensitization, Behav. Res. &
and T. D. BORKOVEC 7hefupy 5. 1 l-25. Mahl G. F. (1956) Disturbances and silences in the patient’s speech in psychotherapy, J. abnorm. sot. Psychol. 53, I-15. Mandler C.. Mandler J. M. and Uviller E. T. (1958) Autonomic feedback: The perception of autonomic activity, 3. abnorm. sot. Psychol. 56. 367-373. Mandler G. and Sarason S. B. (1952) A study of anxiety and learning, J. ubnorm. sot. Psycho/. 47, 166-173. Mathews A. M. (1971) Psychophysiological approaches to the investigation of desensitization and related procedures, Psych. Bull. 76,73-91. McClynn F. D. (1969) On evaluating the role of counterconditioning in systematic desensitization: A methodological note, Psych. Rep. 25, 157-158. Nawas N. M., Mealiea W. L. and Fishman S. T. (1971) Systematic desensitization as counterconditioning: A retest with adequate controls, Behuv. Ther. 2, 345-356. Orne M. T. (1962) On the social psychology of the psychological experiment: With particular reference to demand characteristics and their implications, Am. Psychol. 17,776-783. Paul G. L. (1966) Insight vs Desensitization in Psychotherupy. Stanford University Press, Stanford. Persely G. and Leventhal D. B. (1972) The effects of therapeutically oriented instructions and of the pairing of anxiety imagery and relaxation in systematic desensitization, Behav. Ther. 3.417-424. Rehm L. P. and Marston A. R. (1968) Reduction of social anxiety through modification of self-reinforcement: An instigation therapy technique, /. consult Psycho/. 32, 565-574. Wilson G. T. and Davison G. C. (1971) Processes of fear reduction in systematic desensitization: Animal studies, Psych. Bull. 76, l-14. Winer B. H. (1971) Statistical Principles in Experimental Design, McGraw-Hill, New York. Wolpe J. (1958) Psychotherapy by Reciprocal Inhibition, Stanford University Press, Stanford.
Pergamon Press. 1977. Printed m Great Britain
THE ROLE OF RELAXATION IN SYSTEMATIC DESENSITIZATION: REVISITING AN UNRESOLVED ISSUE* GERALD T. O’BRIEN? and T. D. BORKOVEC University of Iowa
Summary-Forty-three socially anxious females received systematic desensitization, noncontiguous relaxation, hierarchy exposure only, or no treatment. Analysis of pre-posttest fear in a laboratory social interaction task revealed virtually no treatment effects on self-report or behavioral measures. Analysis of continuously monitored heart rate, however, indicated reduced anticipatory activity among subjects receiving relaxation training and reduced reactive activity for desensitization subjects.
Despite extensive research, the question of the facilitative role of muscular relaxation in the systematic desensitization process has remained unresolved. A recent review (Borkovec and O’Brien, 1976) of 22 studies related to this question indicates that the evidence is inconclusive, contradictory, and based on studies involving two methodologically problematic characteristics: (1) preponderant use (68%) of small animal “phobics” and (2) frequent absence of a critical, component-control condition, i.e., desensitization with noncontiguous relaxation. Animal-fear analogue studies have consistently failed to employ sufficiently stringent selection criteria to insure that subjects demonstrate significant anxiety in the presence of the target stimulus (Bernstein and Paul, 1971; Cooper, Furst and Bridger, 1969). Consequently, demand effects (Orne, 1962) may easily confound treatment effects (Borkovec, 1973a, 1973b). Perhaps more importantly, physiological reactivity does not appear to be a functionally relevant component of the anxiety process for most animal “phobic” subjects (Borkovec, 1976). Thus, a major dimension of anxiety has been virtually ignored in past desensitization component research. In tests of the
theoretical basis of techniques like systematic desensitization whose underpinnings rest on notions of the classical conditioning of autonomic responses (Wolpe, 1958). the absence of a substantial physiologicval reaction to the feared stimulus and/or the failure to measure that component reduces the significance of conclusions derived from such research. Second, the majority of previous desensitization component studies have not assessed the importance of temporal pairing of relaxation with visualization of aversive scenes. This contiguity question is critical. The reciprocal inhibition (Wolpe, 1958) or counterconditioning (Davison, 1968) model of desensitization predicts that the anxiety-antagonistic response must be present during hierarchy visualization for desensitization to be maximally effective. The extinction model maintains that CS exposure is the only necessary condition for anxiety reduction (Lomont, 1965; Wilson and Davison, 1971). Simple comparison of desensitization to CS exposure only is an insufficient test, however, since the mere inclusion of relaxation training at any point in therapy may promote positive outcome (McGlynn, 1969). Only four component
*Requests for reprints should be addressed to T. D. Borkovec. Department of Psychology, University of Iowa, Iowa City, Iowa 52242. tThis paper is based on the thesis of the first author in partial fulfillment of the Masters Degree requirements of the University of Iowa and was supported in part by NIMH Grant MH27484 awarded to the secondauthor. 359
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studies have attempted to evaluate directly the importance of CS-visualization/relaxation contiguity. Lomont and Edwards (1967) and Persely and Leventhal (1972) obtained results supporting the importance of contiguity, whereas Nawas, Mealiea and Fishman (1971) and Aponte and Aponte (1971) found results questioning the need for contiguity. However, these studies employed elaborate and perhaps questionable procedures to obtain contiguity, limited dependent measures, and/or a completely standardized systematic desensitization procedure. The purpose of the present study was once again to investigate the facilitative role of progressive relaxation in systematic desensitization, while attempting to avoid the above methodological problems. Social anxiety was selected as the target fear, since this behavior has been demonstrated to be relatively unsusceptible to demand effects and characterized by substantial physiological reactivity that fails to habituate over repeated exposures (Borkovec, Stone, O’Brien and Kaloupek, 1974). Socially anxious females were individually exposed to a laboratory social interaction test situation and then randomly assigned to one of four experimental conditions: (1) hierarchy visualization with contiguous relaxation (systematic desensitization), (2) hierarchy visualization with non-contiguous relaxation, (3) hierarchy visualization only, or (4) no treatment. Subsequent to four therapy sessions, all subjects were again exposed to the laboratory test. This design can no longer be viewed as a critical test of reciprocal inhibition vs extinction models, since Wilson and Davison (1971) have suggested that relaxation may function as an extinction facilitator. An adequate demonstration of that facilitative effect remains to be made, however. Given the equivocal nature of earlier investigations and our own predilection to remain neutral with regard to theoretical bias, our only expectation was that the functional role of relaxation should be most clearly evident in the continuous physiological measures obtained during testing.
and T. D. BORKOVEC
METHOD Subjects Forty-three female undergraduates indicating some fear or greater of being with a member of the opposite sex on Geer’s (1965) Fear Survey Schedule (FSS) participated in the study. Each subject received research credit for her participation. Procedure Pretest and posttest social interactions. Primary dependent measures were obtained from pre- and posttest laboratory social interactions following the procedures of Borkovec et al. (1974). Posttesting was conducted approximately 7 weeks after the pretest and 1-2 weeks after the final therapy session. Upon arrival at the laboratory, electrodes were attached to the subject’s arms for heart rate monitoring. The subject was then informed by taperecorded instructions that her task was to engage in a 3-min social interaction with a male research assistant, performing as well as possible and remaining as relaxed and nonanxious as she could. The subject was informed that the assistant was a confederate instructed not to talk or respond to her in any way. Self-report measures from pre- and posttests included Rehm and Marston’s (1968) Situation Questionnaire administered prior to each interaction and three instruments administered at the conclusion of each interaction: Husek and Alexander’s (1963) Anxiety Differential; Mandler, Mandler and Uviller’s (1958) Autonomic Perception Questionnaire; and a Self-Report of Performance Questionnaire. In addition, two observers rated the subject’s behavior for overt signs of anxiety during the interactions on a modified form of Paul’s (1966) Timed Behavioral Checklist (TBCL). Interrater reliability on this measure was high (r = 0.87, P< 0.01). The subject’s verbalizations during the tests were tape-recorded and later scored for speech disfluencies (Mahl, 1956) and percentage of speaking time. Immediately after the interaction, the male confederate rated the subject’s performance on a seven-item Confederate’s Rating Questionnaire. Continuous heart rate was monitored throughout the session. Ten-second heart rate samples were obtained from the Beckman RM dynograph recordings at five anticipatory and four reactive phases from both the pretest and posttest: phases (l)-(2) just prior to and just after the general instruction tape; phases (3)-(4) the first and last 10 set of a I-min quiet period during initial confederate presence; phase (5) the last 10 set of the final instruction tape askina the subject to begin her interaction; phases (6)(9) the first IO set of the interaction and 10 set at the end of each minute. Correlations between the scores of two raters on 20 complete records ranged from 0.97 to I .OO (mean = 0.994).
Confederates Three male undergraduate psychology majors serving as confederates were instructed to remain silent throughout the 3-min interaction, to maintain comfortable eye contact with the subject, to smile occasionally but noncontingently, and to avoid making nonverbal responses (e.g. head nods, shrugs, facial expressions). Although this
THE ROLE OF RELAXATION IN SYSTEMATIC DESENSITIZATION form of social situation is highly artificial and may have little direct relevance to naturally occurring social situations, the purpose of this study was to provide a limited test of theoretical notions under highly standardized conditions. Scheduling of confederates, blind to the treatment condition of the subject, was arranged so that no subject interacted with the same confederate during both the pretest and posttest.
Therapists Two male graduate students in clinical psychology treated half of the subjects in each treatment group. Treatment manuals were employed during therapy to insure that exactly the same procedures were followed.
Treatment conditions After pretesting, subjects were randomly assigned to one of three treatment groups (10 subjects per group) or to a no-treatment condition (13 subjects). Treated subjects received four weekly group therapy sessions, each session being approximately one hour long. All treatment sessions were conducted in a room different from that in which the pretest and posttest were conducted. During the first therapy session, the therapist presented the appropriate rationale and assisted subjects in ranking I5 standard anxiety hierarchy items based directly upon situations involved in the social interaction pretest. Average rankings determined the final hierarchy for the group. Again, choice of this highly circumscribed hierarchy was based on our effort to maximize anxiety reduction effects relevant to the pre-posttest situation, even though this meant a reduced relevance to clinical, social anxiety. Following hierarchy item ranking, subjects were trained in progressive relaxation and/or visualization, depending on their treatment condition. At the conclusion of the first session, subjects completed a four-item Credibility Questionnaire (Borkovec and Nau, 1972) assessing their confidence in the treatment for reducing social anxiety. A therapist by Treatment analysis of variance indicated that the treatment groups did not differ on this measure. Systematic desensitization (SD). During the first therapy session, SD subjects received training in both imagery visualization with one pleasant image and progressive relaxation (Bernstein and Borkovec, 1973) and were instructed to practice relaxation twice daily throughout the study’s duration. During the second through fourth sessions, systematic desensitization was conducted exactly following Paul’s (1966) procedure, e.g. two IO-set visualizations without signalling anxiety were required before moving to the next item; anxiety signalling during of the resulted in termination any visualization visualization, reestablishment of reports of deep relaxation, and a requirement of 3. 5. IO and 20-set visualizations without anxiety before moving to the next item. Since treatment was conducted in groups, progress through relaxation and through the anxiety hierarchy proceeded at the rate of the slowest subject. Five hierarchy items were completed during each session. Non-contiguous relaxation (NCR). NCR subjects also received training in both imagery visualization and
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progressive relaxation during the first session and were instructed to practice relaxation twice daily throughout the study’s duration. The first half of sessions two throunh four consisted of hierarchy item visualization only. Subjects sat upright in chairs with their eyes closed. The procedures for presenting hierarchy items, signalling of anxiety with termination of visualization, and for proceeding from one item to the next were identical to that employed in the SD condition. Instead of focusing on relaxation between visualizations, however, subjects were instructed to count slowly backwards to themselves between scene visualizations to prevent item visualization or relaxation while equating groups on time between visualizations. After the successful visualization of the five hierarchy items, subjects reclined and progressive relaxation training, identical to that employed in SD. was administered during the remaining half of the session. Thus, subjects in this condition received both hierarchy visualization and progressive relaxation, but in a noncontiguous manner. Hierarchy visualization only (HO). Subjects in the HO condition did not receive training in progressive relaxation. Therefore, to equate groups for lenath of contact with the therapist during the first‘session aid for daily homework assignments, these subjects practiced visualization of five pleasant images, completed a demographic “Survey Questionnaire”, and were instructed to practice visualizing the pleasant images twice daily throughout the duration of the study. The first half of sessions two through four was spent visualizing the subjects’ five pleasant images. After this visualization nractice. hierarchy visualization was begun. The same procedure utilized for NCR subjects was followed. i.e. subiects sat upright in chairs with-their eyes closed, were not relaxed, were instructed to count silently between visualizations, and progress through the hierarchy, determined by the same procedures outlined for SD and NCR, proceeded at the rate of the slowest subject. After the successful visualization of five hierarchy items, the session was terminated. No-treatment (NT). After the pretest, W subjects were informed by phone that their names had been placed on a waiting list and that they would be contacted later for treatment scheduling. Later, they were told by phone that it would first be necessary to repeat the social interaction test before treatment sessions began. This information was supplied, since subjects in the three treated conditions knew that a second social interaction test would occur subsequent to treatment. Posttesting for NT subjects occurred during the same weeks of posttesting for treated subjects.
RESULTS Therapbt effects
To test for therapist effects, three-way repeated measures analyses of variance (Test by Therapist by Treatment) were computed for each of the self-report and behavioral measures
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and four-way repeated measures analyses of variance (Phase of Interaction by Test by Therapist by Treatment) for the heart rate scores. With one exception, no significant interaction or main effects of Therapist were obtained.* For all remaining analyses, therefore, the therapist factor was collapsed. Treatment effects Initial analyses on all pretest measures revealed that treatment groups did not differ on any measure. Due to generally high pretestposttest correlations within each measure, however, analysis of covariance was employed to assess treatment effects. Self-report and behavioral measures. Selfreport and behavioral measures were analyzed by a simple analysis of covariance. No main effect of treatment was found on any self-report measure or on the confederate’s rating, speech disfluencies, or percentage of speaking time measures. The main effect of treatment was significant for the TBCL, F (3, 38) = 4.15, PCO.05.; adjusted posttest means: 11.7 for SD, 9.0 for NCR, 10.3 for HO, and 13.5 for NT. Post hoc comparisons by the Scheffe method (Edwards, 1968) revealed only one significant pairwise comparison: NCR subjects demonstrated significantly fewer overt signs of anxiety during the posttest than did NT subjects. In addition, the multiple comparison of the collective effects of SD, NCR, and HO groups with the weighted mean of the NT group was significant; treated subjects showed significantly fewer anxiety signs that did NT subjects. Heart rate measures. The heart rate scores were analyzed by means of a two-factor repeated measures (Phase by Treatment) analysis of covariance (cf. Winer, 1971, pp. 796-809). Posttest phase means were adjusted for differences on pretest phase means. Figure 1 displays the adjusted posttest means during the nine phases of the interaction for each treat-
ment condition.
Fig. 1. Adjusted Posttest Heart Rate for Systematic Desensitization (SD), Non-Contiguous Relaxation (NCR). Hierarchy Exposure Only (HO).-and No-Treatment OI(Tj Conditions During the Anticipatory and Reactive Periods of the Social Interaction Task.
As is typically found in studies involving complex cognitive-motor tasks, heart rate accelerated dramatically at the initiation of the interaction. Even nonanxious subjects show such acceleration (e.g., Borkovec et al., 1974). What is of importance is the relative level of preceding anticipatory and subsequent reactive activity among conditions. A significant Phase by Treatment interaction was obtained, F (24, 311) = 1.62, P
*On the percentage of speaking time, the main effect of Therapist was significant, F (1. 23) = 7.75, P
THE ROLE OF RELAXATION
IN SYSTEMATIC
rate compared to SD subjects. The significant interaction effect was not large; consequently, straightforward selection of post hoc comparisons to statistically support the above observations were not significant. DISCUSSION Imaginal CS exposure of any type resulted in significantly greater decreases in overt signs of anxiety than no-treatment. Since social anxiety as measured by the present procedure is relatively immune to demand/suggestion effects (Borkovec et af., 1974), it is likely that this change reflected an active treatment effect. A previous review of the desensitization component research indicated that the majority of studies employing five or fewer sessions or subject control over progress through the hierarchy found equivalence among component conditions on behavioral measures (Borkovec and O’Brien, 1976). The present study is in agreement with this observation. What is remarkable, however, is that with the exception of the above TBCL outcome, treatment had no effect on behavioral and selfreport measures. Apparently, when a target behavior, unsusceptible to demand influence and involving a substantial physiological fear component, is employed, the improvement generated by brief systematic desensitization is far less than one would ordinarily expect from reading the small-animal phobic literature. The weak treatment effects under these experimental conditions may have been due to the nature of the social interaction test, i.e., it may be more stressful than real life social situations. The fact that the test situation does reliably distinguish anxious and nonanxious subjects (Borkovec ef 1974) does argue for its experimental al., relevance for testing theoretical anxiety questions, even though its external validity is limited. The majority of desensitization research has ignored the physiological response component and its measurement, despite Wolpe’s (1958) autonomic definition of anxiety. From this per-
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spective, then, the component effects found in the present study on posttest heart rate are of great interest and potential importance. Although the Treatment by Phase interaction did not account for a large percentage of the heart rate variance and post hoc analyses failed to identify the source of the significant effect, it did indicate significantly different patterns of autonomic activity among the four conditions. Inspection of Fig. 1, in the absence of significant comparisons, suggests that the presence of the relaxation component, either contiguous or non-contiguous with hierarchy exposure, lowered heart rate during the anticipatory period of the social interaction posttest. Systematic desensitization, however, produced the greatest decrement in heart rate activity in response to the occurrence of the interaction. The latter outcome suggests a facilitative role for relaxation in the desensitization process at the autonomic level. The general absence of behavioral and self-report improvement may have been a function of lag effects hypothesized by Mathews (1971) to occur between autonomic change and changes in other response systems. Finally, some evidence was found in the heart rate results for a possible sensitization effect among exposure-only subjects; HO subjects showed higher anticipatory heart rate than NT subjects (Fig. 1). although this difference was not statistically significant. Exposure to feared stimuli, even in graduated form, may thus produce an autonomic incubation phenomenon (Eysenck, 1968) if relaxation is not contiguously elicited or does not occur shortly after such exposure.
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