The main purpose of this study was to compare three approaches to group psychotherapy with specific reference to their outcomes in treating interpersonal anxiety in introverts and extroverts. A discussion of the results relative to these hypotheses appears in the section entitled “Treatment Effects.” In addition, a number of hypotheses were generated regarding the effects of no treatment at all and simple attention. A discussion of these results appears below. Finally, a brief analysis of the role of the counselor, the generalization of treatment effects, and implications for future research is also presented.
A comparison of the treatment versus the control Ss revealed the clear and significant superiority, in terms of anxiety reduction, of the former groups over the latter. On the average the Ss in the treatment groups were roughly 70 percent less anxious at post-testing and follow-up than those in the control groups.
In addition to the above, each form of counseling was compared separately to no treatment at all (no-contact control) and then to simple attention or the non-specific, ancillary benefits derived from personal contact, interviewing, and expectation of future treatment and relief (no-treatment, placebo control). The expectation, incorporated into hypotheses 5 and 6 (Chap. 1), that any of these forms of counseling would prove more anxiety reducing than either the no-contact or no-treatment (placebo) controls was upheld by both the outcome and follow-up results of this investigation. On the average, the Ss in the treatment groups were about 60 percent less anxious than those in the no-treatment (placebo) control group and approximately 80 percent less anxious than those Ss in the no-contact control group. Thus, the conclusion that psychotherapy does produce a greater measurable reduction in anxiety than either attention-placebo conditions or simply the passage of time seems warranted by these findings.
The prospect, incorporated into hypotheses 7 and 8, that simple attention-placebo conditions would be sufficient in and of themselves to bring about a significantly lowered level of anxiety over the simple passage of time was also upheld by the outcome and follow-up results of this study. On the average, the no-treatment (placebo) control condition was approximately 50 percent more effective in reducing interpersonal and general anxiety than no treatment at all.
A comparison of introvert-extrovert differences revealed further that the superiority of the no-treatment (placebo) control groups over the no-contact control groups was limited almost exclusively to the introverted Ss. The extroverts in both groups showed about the same amount of anxiety reduction at both outcome and follow-up. One possible explanation for this finding is that the extroverts in both control groups were so much more active socially than the introverts (see Index of Interpersonal Activity) that they extinguished many of their own social fears, or at least, as many as were dissipated via the interaction provided by the no-treatment (placebo) control procedures. On the other hand, the no-contact control intro verts by their very inactivity, that is, avoiding social situations failed to encounter the feared, conditioned stimulus. Further more, each time the latter evaded or avoided this testing oJ reality they were, in effect, consolidating the very behavioi pattern which constituted their “neuroses” (Eysenck, 1967).
It is noteworthy that the introverts in the no-treatmenl (placebo) control group did show significantly more anxiety reduction than the no-contact control introverts. Paul (1966) has elucidated a number of factors which seem to account foi the anxiety reduction noted in attention-placebo groups such as the one employed here. First, the implicit and explicit suggestion and reassurance offered by an “expert” that anxiety is not unique and it can be overcome, coupled with the promise of future treatment and relief, undoubtedly served to modify the 5”s attitudes about themselves and their “crazy” behavior. This initial change very well may have served to break the maladaptive “vicious circle” of anxiety, lowered self-esteem, and heightened anxiety, replacing it with a more adaptive progression involving positive changes in self-attitudes, lessened anxiety, new hope and self-confidence, and further anxiety re™ duction. In addition, changes in expectancies due to increased attention may have further served to reinforce this more adaptive spiral progression by instilling intermittently increased hope, confidence, and feelings of self-worth and importance. Finally, the calm and confidence of the group leader, coupled with the rewards for pro-social behaviors which he encouraged with warmth, understanding, and interest, may have served to extinguish further a number of social fears among the Ss and so sharpen the latter’s social skills in interpersonal relationships.
While no hypotheses were offered regarding the overall superiority of any one treatment approach independent of S personality type, there does seem to be sufficient evidence to warrant a tentative conclusion in this regard. When the problem to be treated is anxiety and the desired goal is a reduction in cognitive complaints and behavioral manifestations of anxiety, then SD appears to be the best choice of therapy. With the exception of the Index of Interpersonal Activity, both the CC and RT treatments were significantly less effective, resulting in approximately 30 percent less anxiety reduction than the SD approach.
As noted previously, the overwhelming success rate mentioned above was due to the fact that the SD treatment was equally effective with both introverted and extroverted Ss. Because the findings involving SD ran somewhat contrary to the hypotheses stated in Chapter 1, a number of explanations regarding what seemed to be the differential effects of group and individual SD treatment with introverts and extroverts seem relevant here.
The evidence upon which hypotheses 1 through 4 were based suggested that introverts learn more rapidly and permanently than extroverts because of a higher level of cortical excitation (Eysenck, 1960), or as Gray (1967) has suggested, a higher level of arousal. Because of this higher level of cortical arousal, the introvert is more alert, more sensitive,.and less dependent than the extrovert on external stimulation. It is partly for this reason that Eysenck (1967) maintains that SD is sufficiently stimulating, albeit quite “mechanical,” for introverts while boring and repetitive for extroverts, According to Eysenck, the latter group requires for maximal learning efficiency considerable external stimulation, preferably in the form of interpersonal interaction.
Yet it is because of this difference in level of arousal that it has been suggested that group SD treatment favors extroverts rather than introverts (Weinstein, 1968). By placing introverts in a group setting, their already highly aroused state, which normally serves to facilitate learning, surpasses optimal level functioning and creates overstimulation and distraction due to the competing stimuli of other people. On the other hand, the extrovert’s initially low arousal level is enhanced to facilitate focusing, concentration, and learning in the presence of others. Gray (1967) has found some support for this hypothesis in the fact that introverts perform more efficiently on a vigilance task undertaken in isolation, whereas extroverts perform at maximum efficiency in a group.
If the introvert performs most efficiently (Gray, 1967) and studies most effectively (Estabrook & Sommer, 1966) away from others, then it is not surprising that he will derive less than maximal benefit from group SD. Extroverts, on the other hand, work to advantage in the presence of others. Thus, since SD was conducted in groups, the extroverts received the additional stimulation necessary for their optimal level of functioning, while introverts were overstimulated and, consequently, distracted.
A second possible biasing factor which would favor extroverts relates to group treatment and the nature of the target behaviors presently under study. Cooke (1966) found that while both high and moderately anxious Ss performed equally well with in vivo SD, high anxious Ss showed significantly greater fear reduction than moderately anxious Ss when an imaginai hierarchy was employed. Since the target behavior in the present study was interpersonal anxiety, and since Ss were treated in groups, with one class of Ss reporting more anxiety at pre-testing (introverts) than the other (extroverts), the present study seems somewhat analogous to the one reported by Cooke (1966). If this comparison is valid, then the ancillary effects derived from the “built in” in vivo components of the present study would indirectly favor the less anxious extroverts by maximizing the unanticipated in vivo benefits.
Finally, in a recent article, Davison (1968) discussed some practical limitations of the SD treatment. One such limitation, possibly affecting the outcome of group SD with introverts, was the level of relaxation achieved by the introverted Ss. It is extremely likely that group SD exerts an inhibitory influence on introverts by preventing them from achieving the level of deep muscle relaxation commensurate with effective counter-conditioning. This seems even more likely in view of their initially heightened arousal state and high anxiety level, which is further exacerbated by the presence of the group. If relaxation were less complete with introverts, then the entire process of reciprocal inhibition may have been greatly retarded for them.
In view of the above considerations, it is not surprising that the introverts and extroverts treated by means of SD showed no significant differences. However, the fact that the SD treatment was significantly less effective than the RT treatment in increasing interpersonal activity outside of treatment (see Index of Interpersonal Activity) does seem somewhat of an enigma. Disregarding the crudeness of the Index of Interpersonal Activity (IIA) and the fact that required homework assignments may have “forced” the RT introverts to report spuriously high interpersonal activity levels, one hypothesis which also seems consistent with the aforementioned findings does seem to provide a partial explanation of this phenomena.
As Wolpe (1958) has suggested, the successful treatment of Ss by SD results from an inhibition of avoidance behavior which is achieved by relaxation before approach or copying behaviors begin to emerge. If this is correct, along with the assumption that the introverts’ excessive anxiety level and heightened arousal state in the group inhibited or retarded their process of deep muscle relaxation, then the fact that the SD introverts were slower and less successful than the RT introverts in developing approach behaviors outside of treatment is more understandable. The less deep the relaxation is, the less effectively each hierarchial item is desensitized, that is, the less reduction in avoidance behavior. The less reauction in avoidance behavior which occurs, the slower the emergence of approach or copying behaviors such as those assayed on the IIA. This, coupled with the fact that relaxation is not central to RT, seems to account for a good part of the discrepancy between the SD and RT introverts’ scores on the IIA.
It should be noted that the entire aforementioned rationale is simply an attempt to explain the obtained results, not an endeavor to justify the maintenance of the original hypotheses concerning the effects of SD with introverts and extroverts. These findings are viewed as positive and should be considered a valuable aspect of the SD treatment. Whether or not the effects of individual versus group SD will actually emerge as salient will have to await further investigation.
In spite of the above findings, the results of the CC and RT treatments did conform to the expectations incorporated into Hypotheses 1 through 4. As anticipated, no significant differences were obtained between the CC and RT approaches on any of the self-reports or behavior ratings of anxiety, independent of S personality type. More specifically, the CC treatment resulted in the most anxiety reduction with extroverts, while the RT treatment was most effective with introverts. As a group, the CC introverts and the RT extroverts showed no greater anxiety reduction at outcome and follow-up than the comparable no-treatment (placebo) control.
Any explanation of the above findings must somehow incorporate the obvious co-variation between the level of client intrapersonal exploration during treatment and process, outcome, and follow-up measures of anxiety reduction. The findings here leave little doubt that the level of client self-exploration is a paramount factor in accounting for the ultimate outcome of traditional verbal counseling and psychotherapy. Those Ss who explored their personal problems most and at the deepest levels showed the greatest amount of anxiety reduction both during and following treatment. In the case of introverted Ss, deep levels of intrapersonal exploration were also associated with increased pro-social behaviors and “positive” personality changes, that is, increased extroversion. These findings have been numerously documented (Carkhuff & Berenson, 1967; Rogers et al, 1967; Truax & Carkhuff, 1967) and are well supported by the results of the present investigation.
The process measures incorporated into the present design suggest a number of promising, as well as a number of fruitless, leads in understanding what is involved in eliciting therapeutic levels of client self-exploration. There is no evidence here to suggest that counselor-client personality similarity is a salient factor, in and of itself, in eliciting therapeutic levels of client intrapersonal exploration. If nothing else, the higher overall success rate of counselors c and R over counselors C and r seems to clearly imply this fact. Similarly, the so-called “central therapeutic ingredients” of accurate empathy, non-passive warmth, genuineness, etc. do not seem to play a prominent role in this regard. However, an. examination of the characteristics of CC and RT per se, as well as a consideration of the possible course of development of maladaptive anxiety with special reference to introversion-extroversion, does seem to offer a promising lead in understanding what causes some clients to engage in therapeutic levels of self-exploration.
Paul (1966) has summarized at least three forms of maladaptive anxiety which seems relevant here. First, anxiety may itself be a learned reaction in which previously neutral stimuli, for example, people, become associated with anxiety in a fashion analogous to the classical conditioning paradigm. With reference to interpersonal anxiety, such factors as deprivation, pain, punishment, negative reinforcement, loss of customary support, trauma, disconfirmation of expectancies, etc. may have served as the environmental events which led to the view of people as anxiety stimuli. The important point is that in cases such as these anxiety is the maladaptive behavior, occurring inappropriately in conjunction with real, that is, original or related, or imaginary stimuli. This seems to be the central feature in the symptom complex of interpersonal anxiety for extroverts. Second, behavioral deficits, or maladaptive behaviors (including ideas and attitudes as well as motor behaviors) resulting from inappropriate learning, may, in turn, produce anxiety as a reaction to ineffectual social gestures. In this instance, both the reactive anxiety and behavioral deficits are the maladaptive behaviors or presenting problem. Third, anxiety may be related to inappropriate learning, as in the case of maladaptive behaviors learned and maintained by anxiety reduction, for example, withdrawal. In instances such as these, the “defense mechanisms,” learned via anxiety reduction, are the maladaptive behaviors or presenting problem. While all three forms of anxiety are undoubtedly present in both introverts and extroverts, the latter two examples seem more illustrative of the symptom complex of interpersonal anxiety for introverts.
With the foregoing as a theoretical base, the ability of the CC and RT counselors to elicit therapeutic levels of client self-exploration with extroverts and introverts, respectively, appears somewhat more comprehensible. Tables 3.8 and 3.10 indicate that the focus of the RT counselors was the Ss maladaptive or irrational cognitions and behaviors. If the aforementioned analysis of anxiety development is correct, then it is precisely these maladaptive or irrational ideas, attitudes, or philosophies of living, (that is, behavioral deficits) and their concomitant social ineffectiveness which are the major source of the introverts interpersonal anxiety and which give rise to such defensive maneuvers as withdrawal and seclusiveness (see IIA), in an attempt to escape that anxiety.
Direct and forceful confrontations in the areas of these behavioral deficits may have directed the introverts toward exploring, examining, and revamping these “defective cognitions,” replacing them with more adaptive or rational ones. While much of this “cognitive revamping” was done initially by the RT therapists, the process was soon imitated by the introverts (see Tables 3.9 and 3.10) via modeling and reinforcement. The implosive character of the RT treatment, while initially raising the introverts’ anxiety level (see Figure 3.2), may well have been required to mobilize and direct the initial effort needed to engage these Ss in self-exploration. As one of the introverts in the CC group so aptly put it, “Most of the time we just sat around and looked at each other. It just made me more anxious.” Unlike the extroverts, the introverts did not volunteer to the counselors much material or data with which to work. By and large, they were quite inactive when left to their own devices.
In addition, required homework assignments undoubtedly encouraged a sharpening of social skills. Thus, the process of self-exploration, or discrimination learning, leading to attitudinal changes, coupled with the teaching of new and more effective pro-social behaviors might be expected to attenuate or limit the spiral progression of poor social skills, anxiety, lowered self-esteem due to ruminations, heightened anxiety. In addition, the uncovering and examining of irrational and maladaptive attitudinal complexes, with its attendent anxiety reduction, may have served to maintain and further encourage the continuation of the process of self-exploration, as might the counselor’s direct and indirect reinforcements for emitting such behavior.
On the other hand, cognitive, attitudinal, or behavioral deficits, while undoubtedly present, do not seem to be the central problem in the symptom complex of interpersonal anxiety for extroverts; nor does withdrawal seem to be their means of controlling that anxiety. They are very active socially, in spite of their self-reported fear and anxiety, and quite skillful in interpersonal relationships (Eysenck, 1960). However, if their anxiety is a product of unfortunate or traumatic learning experiences, as Indicated above, and if the extroverts “excessive” activity is an attempt to avoid or circumvent awareness of hurt or traumatized feeling (Fenichel, 1941), as their heightened pre-test defensiveness might suggest, then the effectiveness of CC with extroverts becomes somewhat more comprehensible. That is, the permissive atmosphere created by the CC counselor’s attentive listening, non-critical acceptance and reflection, and self-disclosures undoubtedly led to considerable reassurance that their problems were not unique and that, in this group at least, every effort would be made to understand and accept the S and his view of the problem. Similarly, if traumatized (negatively reinforced) feelings are the major source of the extroverts’ interpersonal anxiety, then an approach such as CC, which deals almost exclusively with feeling states (see Tables 3.8 and 3.10), may be the treatment of choice.
The sequential reduction of anxiety with the CC approach is viewed as similar to that resulting from the RT approach, with the exception of treatment technique and focus. The process of self-exploration, that is, discrimination learning and extinction, is viewed as the central therapeutic ingredient in both of these approaches, with the effectiveness of the techniques and treatment focus dependent on the S’s presenting problem and their pre-treatment personality make-up. In the case of the CC treatment, the counselor’s and groups’ non-critical acceptance and attentive listening might well lead to a sufficient reduction in anxiety to allow each S to feel secure enough to begin exploration of his formerly traumatized or negatively reinforced feelings. During the initial interviews, the appropriateness of the therapist’s actions in relation to the S’s personality type and presenting problem seem to be the major impetus for eliciting or failing to elicit client self-exploration. The immediate reduction in anxiety resulting from this process, due to a reversal of incubation effects (White, 1956), may encourage further gestures at self-exploration. As the S’s attempts at intrapersonal exploration approximate the therapists “ideal,” the latter may subtly and directly reinforce and so encourage the 5”s efforts in this vein, shaping and directing the S’s behaviors as the therapist sees fit. Self-elimination of errors by Ss may also be a salient factor, since theoretically these abortive or “incorrect” self-exploratory behaviors would lead to little or no anxiety reduction. The self-reinforcing, “error correcting” nature of this process may stimulate further client self-exploration at increasingly deeper levels, with only intermittent guidance and variably spaced reinforcements on the part of the therapist.
The effects of self-exploration, once initiated, seem to be somewhat universal (Paul, 1966; Dollard & Miller, 1950). Clients begin to discriminate aspects of their own feelings in relation to the realities of the current situation, halting the “vicious circle” created by the overgeneralization of anxiety responses and beginning a clearer realization of their feelings. While this can be done by a client by exploring the past and present feelings from his daily life, the interaction, expression, and self-analysis of feelings toward and about other group members and the therapist provide working data which is “more alive” from an affective standpoint and more easily extinguishable from the point of view of contiguity. Also, in addition to the “partitioning-off” or discrimination process, extinction of anxiety related to social or interpersonal situations might be expected to take place as the S talks and continues to explore anxiety producing material in greater quantity and at deeper levels in the presence of others and within the context of a relaxed, non-threatening therapeutic atmosphere.
While many of the effective therapeutic ingredients of traditional verbal counseling and psychotherapeutic approaches, such as CC and RT, are undoubtedly similar to those of the attention-placebo condition described earlier (Paul, 1966), the former interventions are applied in a more direct, controlled, and efficient manner, at least by effective therapists. Indeed, many of their differences may be analogous to the differences between experienced and inexperienced counselors, the latter producing only “average benefits” (Truax & Carkhuff, 1967) which in some instances are no more effective in reducing anxiety than simply the passage of time. More important, however, is the fact that under placebo conditions Ss may feel much better but typically learn very little. With CC and RT, Ss may learn what their problem areas are, how they got to be problems, how they are presently being maintained, etc. But what is even more important, they learn a process (e.g., self-exploration), a process which by its very nature prevents the incubation and overgeneralization of anxiety responses into “vicious circles” of neuroses.
Thus, the central therapeutic benefits of both CC and RT in reducing anxiety are believed to reside in their ability to teach and maintain the process of self-exploration. Their differential effectiveness with extroverts and introverts is believed to be due primarily to the characteristics of CC and RT per se, as well as to the differential nature of the symptom complex of interpersonal anxiety for introverts and extroverts. When the treatment techniques and therapeutic focus are not appropriate to the S’s presenting problem and personality type, self-exploration is superficial and essentially non-therapeutic, that is, little or no anxiety reduction results. This may well explain the nominal success of RT and CC with extroverts and introverts, respectively.
While much of the aforementioned rationale must, for the present, remain largely theoretical, this same notion of “matching” treatment and client personality type has recently been put forth by Kell and Burrow (1969). They classify clients into two categories: thinking types and feeling types. A client is classified as either a “thinker” or a “feeler” on the basis of his exclusive, or nearly exclusive, reliance on one or the other of these modes of responding to problem situations. In many respects this dichotomy is similar to the dimension of extroversion-introversion. In any case, Kell and Burrow maintain that successful treatment for the thinking-type client must center on his achieving trust in his own feelings, whereas successful therapy for the feeling-type client must center on his acquiring the ability to think and plan his life more carefully, so that he is not flooded or overwhelmed by unmodulated feelings provoked by a problem situation.
The results of this investigation seem to suggest that the above is a laudable approach to treatment planning. The underlying goal of this “matching” approach to treatment is to get the client functioning in a unified, wholistic manner, so that thoughts, feelings, and behavior “flow together” harmoniously, with no mode of response employed as a defense against the other.
If the foregoing analysis is correct, it would seem that the notion of one “ideal therapeutic relationship” (Truax & Carkhuff, 1967) independent of therapist and client, is just as much a myth as the assumption of homogeneity of treatment (Kiesler, 1966). What is suggested here is that the key to anxiety reduction in traditional verbal counseling and psychotherapy is the level of client self-exploration, and that different counselor behavoirs are required to elicit and maintain this process during, and hopefully following, the course of treatment. Thus, there are innumerable numbers of “ideal therapeutic relationships” dependent on the client’s presenting problem and personality make-up.
While no specific hypotheses were offered regarding the overall superiority of any one or two counselors, independent of treatment approach and S personality type, there seems little doubt that the counselor’s role as an implementor of therapeutic techniques is paramount. Although the two SD therapists were about equally effective in -reducing anxiety with both introverts and extroverts, counselors C, c, R, and t showed considerable variability. Both CC counselors were equally effective with extroverts, and both RT counselors were equally effective with introverts. However, counselor c was significantly more effective than counselor C with introverts, while therapist R was significantly more effective than therapist r with extroverts. Counselors c and R were approximately 25 percent more effective, across S personality type, than counselors C and r in reducing anxiety.
The process measures incorporated into the present design suggest that counselor personality type probably was not a salient factor. As noted previously, the assessed personality characteristics of the counselors in the present study were as similar as they were different. Furthermore, the obtained differences do not seem to coincide with the counselors’ stated theoretical orientation. However, the number of years of therapy experience and the number of hours of personal therapy did seem to differentiate counselors C and r from counselors c and R. The latter group of therapists had nearly twice as much actual therapy experience as the former and anywhere from 25 to 40 hours more of personal analysis and/or therapy.
Although experience may well be the “great teacher,” experience level per se should not be considered synonymous with expertness (Fey, 1958). As Kell (1968) has pointed out, there is a considerable difference between a therapist with ten years of experience and one who has repeated the same year’s experience ten times. It is probably more accurate to conclude that some relatively inexperienced therapists are rather rigid and perservative in their therapeutic interventions, while some experienced therapists are sensitive and flexible and can change their counseling style depending on the client’s presenting problem and personality make-up. It may well be that the amount of personal therapy and/or certain personality characteristics, not assessed here, allow some therapists to profit from their experiences, while others do not. Whatever experience level and amount of personal counseling mean operationally, they were certainly the hallmarks of the top-notch counselors in the present study.
Although neither the personality nor the “general” anxiety scales employed here were concerned with the specific target behaviors of interpersonal anxiety, they were included to aid in identifying the sample and check on the generalization effects of treatment, or conversely, symptom substitution. According to learning theory principles, there should be no change in behaviors that are not specifically the focus of treatment, except in the case of behaviors that are altered by generalization to similar situations or behaviors that had previously been inhibited by the target behaviors being treated (Paul, 1966). Within the context of the present study, a successful reduction in interpersonal anxiety might be expected to lead to the Ss becoming less anxious, generally, less introverted, etc.
The date presented earlier on changes in “general” anxiety and introversion-extroversion (see Tables 3.13 and 3.21) suggest that a substantial degree of generalization was contingent on the amount of anxiety reduction in the area of the target behaviors treated. For example, those introverts who achieved the most interpersonal anxiety reduction also showed the lowest levels of “general” anxiety, the largest increments in extroversion, and the most adaptive changes in interpersonal behavior outside of the therapy session. While the extroverts showed no changes in either extroversion or interpersonal behavior outside of treatment, the amount of reduction in “general” anxiety by these Ss was commensurate with the amount of interpersonal anxiety reduction. Finally, none of the treatment or control Ss showed significant changes in defensiveness, as measured by the Edwards Social Desirability Scale.
Thus, the familiar litany of symptom substitution, frequently leveled against such basically re-educational approaches to therapy as SD and RT (Bookbinder, 1962), seems - unwarranted by the findings of the present investigation. Even at the time of the three month follow-up, no changes in client behaviors which would not be predicted on the basis of known learning principles were observed (Grossberg, 1964).