Dr. Di Loreto’s efforts have produced one of the few studies in the area of psychotherapy which can be called well designed, well executed, and meaningful. Particularly impressive, in terms of design, is the fact that the input variables (forms of therapy) across groups are definably different. There was a very adequate check to determine that each therapist was performing essentially within the guidelines of his theoretical approach. The pertinent variables under consideration were well delineated and defined. As to execution, apparently the problems often encountered, such as dropout rate leading to uneven and unmatched groups, variability of number of sessions across groups, etc., were anticipated and avoided. This study is particularly meaningful in that it deals with a target, maladaptive behavior (interpersonal anxiety) which is central to most theoretical models of neurosis and more importantly is the most salient presenting complaint of the large majority of people presenting themselves for treatment. The ubiquity of this problem is dramatically demonstrated by the fact that approximately 35 percent of the college freshman class in this study reported interpersonal anxiety to a degree sufficient to motivate them to be treated for it.
I find no serious flaws in the study; however, the method of S selection renders the research less than ideal. While it may be so that procurement of a sufficient number of Ss from the population at hand required solicitation, it has yet to be demonstrated that solicited Ss do not differ significantly from those who decide on their own to present themselves for treatment. Ideally, the Ss would be selected from the population of people seeking therapy on their own, as this is the population to which the results must be generalized. A further limitation to generalization is a result of the fact that almost 25 percent (51 out of 217) of the Ss volunteering were eliminated on the basis of falling into the midrange on the introversion-extraversion continuum. This leaves open the question of the treatment-outcome relationship for a significant proportion of prospective clients, particularly for CC and RT treatments, since their effectiveness is shown to be related to extra-version and introversion, respectively. The outcome of SD treatment appears to be unrelated to the introversion-extra-version variable, so that it is highly probably that SD would prove to be as effective with midrange Ss as with the included extremes. However, it would be a comfort to have this empirically confirmed.
While it cannot be considered a criticism of the present study, it is important to note that systematic desensitization is not equal to behavior therapy. The CC and RT therapists were given an opportunity to operate within the full range dictated by their theoretical positions, but the SD groups were limited to systematic desensitization only. It appears that the SD technique was misunderstood to be typical of ‘ the course that behavior therapists take with all their patients. Unfortunately, this sort of misconception is widespread and is probably due to several causes. Since classically oriented behaviorists conceptualize most neuroses as maladaptive behaviors (including thoughts and feelings as well as overt motor behavior) driven by anxiety and or the avoidance of anxiety, then they tend to focus upon communicating about ways in which “desensitization” may be accomplished. Again, desensitization is not equal to systematic desensitization, but systematic desensitization is the most publicized technique by which desensitization may be brought about and has. apparently become the shorthand connotation of behavior therapy to many who have only passing knowledge of the field.
This oversimplification error is compounded by the fact that the overwhelming number of behavioral studies in the literature deal with systematic desensitization. Of course, these studies represent simplification of the therapy regime, as they must, in order to be useful in delineating and sharpening effective treatment techniques as well as disqualifying ineffective ones. Scientific rigor dictates isolation of some variable so that it may be tested with as little contamination as possible. Undoubtedly, it would be naive not to consider that the interaction of variables is important, but it is essential to start with the delineation of the effects of each variable separately before attempting to determine interaction effects. While this procedure is the appropriate one for a scientific inquiry, therapists attempting to deal with problems that need immediate solution cannot afford such investigative rigor. The usual approach is one in which a number of interventions are employed simultaneously. In the case of interpersonal anxiety, behavior therapists might be giving instruction in assertive training, employing systematic desensitization, advising, giving “homework,” correcting misconceptions, all in the context of a warm and accepting atmosphere.
In order to decide upon what is appropriate the therapist must make as detailed a behavioral analysis as possible. It is important to get the particulars of the stimuli that elicit anx iety. The variety of classes of people and circumstances that may elicit anxiety leads to large variation between patients as to disturbing stimuli. While one person may respond with anxiety to authority figures and situations that require the assumption of responsibility, another may do quite well with such persons and situations, but become anxious when in the company of peers and respond with anxiety when feeling that he is in any way being compared to others. If, after a thorough behavioral analysis, systematic desensitization is indicated, of course the most effective hierarchy will take into account the specifics of the individual case. The most commonly included technique when treating interpersonal anxiety is “assertive training” (Wolpe 1958) which refers not only to appropriate aggressive behavior but also to the outward expression of friendly, affectionate, and other non-anxious feelings. This is particularly appropriate to interpersonal anxiety, as such anxiety is often the result of interpersonal inadequacy. Training , in appropriate assertive responsiveness serves two ends. It offers responses antagonistic to anxiety which when used cause reduction of anxiety in subsequent encounters. Secondly, it serves the purpose of teaching the patient effective coping mechanisms so that his ability to handle people and situations is increased.
Mrs. S., a married mother of three children in her early thirties, sought treatment, complaining of chronic depression marked by feelings of being totally inadequate. She reported that she was unable to deal with people without feeling anxious, and that even her husband or children’s presence was anxiety provoking. Inquiry into the onset of these difficulties revealed that she had “always” been somewhat uncomfortable with people, but that things had become worse for her since her marriage 10 years before to a rather demanding, critical man. Further investigation of particulars revealed that she responded to anxiety in the following circumstances: (1) Criticism—She was anxious when performing in any way that might be criticized by her husband—this included cleaning the house, choice of clothes, budgeting of money, etc. She was also anxious in the presence of anyone else who might make remarks that could be construed as critical. For example, she became anxious in the grocery store when selecting a cereal for fear that another shopper might make a critical remark about that brand. (2) People who behave peculiarly—Although she was unable to clarify this very well, it turned out that each example she gave involved drunkenness or the possibility of another having consumed alcohol. For example, parties were anxiety producing, and the more certain she was that they would be drinking, the more anxious she was. If her husband began to drink, she would become so disturbed that she would have to leave. She was even disturbed by movie scenes in which people were drinking. (3) Sick people—Again it was difficult for her to isolate the details, but with the examples given, it became apparent that wheezing and difficulty with breathing was the particular anxiety provoking component. Examples included hearing the children breathing heavily while sleeping, people coughing, and contact with, or knowledge of, people with respiratory infections.
In addition to the above, information about her general asser-tiveness in life was ascertained. She was asked questions such as, “When someone gets in front of you in the grocery store checkout line, what do you do?”; “If you should find that you have been shortchanged after leaving a store, what would you do?”; “Do you make it a point to tell your husband about the things that he does that make you feel good?”; “Do you give honest compliments to your friends?” Answers to these questions and others revealed a general lack of ability in appropriate interpersonal behavior. She indicated that to be appropriately assertive in these circumstances might be perceived as “pushy”.
Her history revealed that she had been quite attached to her father, and that his disapproval was the worst thing that could have happened. She recalled instances of being frightened many times when he would come home smelling of alcohol and with slurred speech. He became ill about two years after Mrs. S. was married, and the disorder was diagnosed as emphezema. She recalled with great distress the five year course of the illness terminating in his death. These facts were embedded in a complete history, of course, and she seemed unaware of any connection between the father and the present difficulties for which she largely blamed her husband’s inconsiderateness.
The treatment plan consisted, primarily, of assertive training and systematic desensitization. She was urged to see it as standing up for her rights when asking people to please take their place in the back of the line, to return for her change, and feeling free to comment to others about things she liked about them. We practiced such interchanges in the office, and she was given assignments each week which included speaking to any casual acquaintance she might see, asking for change at stores without buying anything, and informing her husband in a non-threatening way of her sexual frustration when left unsatisfied. She was instructed in ways of engaging others in conversation and the art of being a good listener, for which she got almost immediate positive feedback from friends and family. These endeavors resulted in a considerable boost in her self-concept and self-confidence and led to concrete satisfactions such as a very mutually satisfactory sexual relationship with her husband that had never existed before. He revealed that he had been feeling inadequate about his performance, sensing that she was not satisfied, but did not know what she needed. This apparently accounted for a good deal of his hostilities toward her. Areas isolated for desensitization were: ( 1) criticism, (2) others’ drunkenness, (3) heavy breathing and wheezing. The last two hierarchies led back to memories of her father, and the top of both included such memories. Particularly potent dickers of anxiety were memories of her father just before death, as he struggled to breath.
Throughout the treatment regime (22 sessions over the course of 6 months), Mrs. S’s husband was in touch with the therapist, and after discussing his own difficulties in relation to his wife, he was given reassurance and urged to encourage the changes taking place which at first were quite threatening to him. A one year follow-up showed continued increase in self-assurance and no areas of unadaptive anxiety.
While it may be hypothesized that a straightforward systematic desensitization to interpersonal situations seemingly responsible for anxiety would have reduced Mrs. S’s interpersonal anxiety, it is highly unlikely that it would have resulted in either sufficient or lasting benefit. I cannot stress this point too much. To be deceived as to the simplicity of an appropriate behavior therapy technique is to be led into a therapy regime producing disappointing results or a return of maladaptive behaviors upon subsequent stress.
How then can the progress of the SD groups in the present study be perceived? In most cases in which SD is employed, the beginning hierarchy items are anchored in present situations eliciting anxiety. However, the items employed in this study are grouped into central themes, each of which is exhausted through an organized presentation of scenes along a gradient from least to most disturbing. The present study employed a shotgun approach, apparently hitting most of the present day anxiety provoking situations without an attempt at organizing them into themes. Actually, the SD therapists have presented the least disturbing items of several potential hierarchies. For example, counselor B’s introverts were presented 24 items, some of which can be broken down into themes. For instance, it can be seen that items 1, 5, 6, and 16 through 19 all probably relate to sensitivity to rejection, while items 2, 23, and 24 could all relate to sensitivity to being seen making mistakes. Of course, the central themes would have to be determined with each individual because the meaning of the situation will vary from one person to another. For instance, item 15, “you are asking for a refund on bad merchandise” might elicit anxiety in one person because he responds anxiously to anger in others, but to another person this may be anxiety provoking because he responds with anxiety whenever he feels taken advantage of. Since the scenes presented to the Ss in the present study are very likely the beginning items of many potential hierarchies, we expected that a reduction in anxiety corresponding to the progress of systematic desensita-tion would occur. The diversity of items undoubtedly is due to the attempts by the experimenter to make as many items meaningful to as many of the five Ss in the group as possible, but at some sacrifice in meaningfulness to any given S. A part of the reduction in anxiety of the SD subjects may be attributed to the relaxation training which took place within the mixed group. To whatever degree same sex and opposite sex peers and the therapist were anxiety provoking to these Ss, simply repetitively practicing relaxation in the group resulted in an in vivo interpersonal desensitization which we would expect to generalize to other people and situations outside the group.
The results of the present study lead to interesting hypotheses in the area defined by Kiesler (1966) as the “Patient Uniformity Myths.” Dr. Di Loreto has apparently chosen a patient personality variable ( introversion-extroversion ) which is meaningfully related to outcome with both Rogerian and Rationally-Emotive therapies. For SD, however, this appears to be an irrelevant variable. Possible assumptions concerning this finding include the following: (1) the very direct attack upon the mechanism of anxiety vitiates the importance of individual patient differences, since the core mechanism for the learning and unlearning of anxiety is approximately the same for all physically intact persons. Since interaction between therapist and patient is minimized during the use of a particular technique, personality variables of both become less important. In support of the irrelevance of the therapist’s personality, it has been demonstrated that systematic desensitization hierarchies presented by automated devices are as effective as those presented by a therapist (Donner & Guerney, 1969; Migler & Wolpe, 1967). (2) While introversion-extroversion is apparently not related to outcome of SD treatment, there are still other patient personality variables that probably are.
While there is a seed of truth in the first possibility, it is certain that the present state of development of behavior therapy leaves us far short of having enough purely technical interventions of sufficient power for the successful treatment of neurotic disorders without regard to individual differences among patients. We certainly do fail with some neurotic patients. My own experience as a therapist suggests that there are predictor variables concerning the use of behavior therapy techniques presently at hand. Research directed at determining the relationship between the outcome of behavioral therapy and the patient variables of need to control and/or degree of hostility directed toward helping others will probably result in a negative correlation.
It would not be surprising if this study should be criticized on the basis of criterion used for evaluating outcome. Kiesler (1966) raises this issue as a problem.
Here the Patient Uniformity Myth has dictated the search for the one patient “process” dimension along which beneficial patient change occurs. For analytic therapy, this dimension has resided somewhere among such variables as insight,—working through, reduction in anxiety and resistance, etc. For Rogers it is found somewhere among the 7 strands of the process of Experiencing. For behavior therapy it seems to reside somewhere in the process of anxiety reduction and symptom removal. (Kiesler, 1966, p. 129)
Rogers (1963) agrees that:
An experience which is seen by one therapist as healing, growth promoting, helpful, is seen by another as none of these things. And the experience which to the second therapist is seen as possessing these qualities is not so perceived by the first. Some people may feel that though we differ regarding specific incidents -—nevertheless, there is much agreement and unity. I think not. To me it seems that therapists are equally divergent in these realms. [See the first page of this study.]
I agree that these differences are real. I do not, however, believe that it is an issue relevant to this study or any other. Eysenck (in press) outlines the futility of attempts at resolution of these differences. Speaking of the differences between the dynamic school and the behavioral school he states :
We must now turn to one last criticism, namely that the two types of therapy attempt to do different and incommensurate things; if this were true, then no proper comparison would be possible between their achievements. As Kuhn (1962) has pointed out, this often happens when a revolution occurs in science, and a new paradigm (as he calls it) takes the place of the old. When this happens, there is a failure of comprehension; the representatives of the old do not understand what the representatives of the new are trying to do, and continue to evaluate their achievements in terms of inappropriate criteria. Similarly, the advocates of the new paradigm dismiss the old criteria as inappropriate and irrelevant. Clearly something of this kind had taken place in connection with the rejection of psychotherapy and the substitution for it of behavior therapy; there is no meeting of minds but rather a change of emphasis which carries the protagonists further and further away from each other. Max Planch, in his Autobiography, put the matter very well : “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.” Psychotherapists often have genuine difficulties in seeing that to the behaviorist not only do “symptom” and “illness” coincide, but to him the elimation of the “symptom” is all important. What they seem to be concerned with is not the symptom the patient complains about, but rather some suppositious “inner state” which they wish to change; their regard for the “symptom” is minimal. Such differences in outlook may easily lead to differences in criteria for therapeutic outcome (Malan et al, 1968). It is not easy to see how this difference can be overcome, and to the behavior therapist it probably does not seem important; within his framework the concerns of many psychotherapists can find no resting place. As the therapist, concerned with cures, the ultimate state of the soul of his patients is not his concern, nor are immeasurable and probably unspecifiable “inner states” which may be a part of the patient’s personality but do form part of the “symptom” he complains about. There is no obvious empirical way of reconciling these views or testing their values; society will have to cut the Gordian knot and decide which of these incommensurable criteria it is willing to adopt. [Eysenck, in press]
In the meanwhile, for those who find it meaningful to ask the question, “What is the most efficient and effective means of contributing to the reduction of interpersonal anxiety through therapeutic intervention?” this study is extremely helpful.
*Temple University School of Medicine, Department of Behavioral Science, Philadelphia, Pennsylvania.
Donner, L. and Guerney, B. G. Automated group desensitization for test anxiety. Behavior Research and Therapy, 1969, 7, 1–14.
Eysenck, H. J. In press. Journal of Behavior Therapy and Experimental Psychiatry.
Kiesler, D. J. Some myths of psychotherapy research and the search for a paradigm. Psychological Bulletin, 1966, 64, 110–136.
Kuhn, T. S. The structure of scientific revolution. Chicago: University of Chicago Press, 1962.
Malan, D. H., Bacal, H. A., Heath, E. S., and Balfour, F. H. G. A study of psychodynamic changes in untreated neurotic patients. British Journal of Psychiatry, 1968, 114, 525–552.
Migler, B. and Wolpe, J. Automated desensitization: A case report. Behavior Research and Therapy, 1967, 5, 133.
Rogers, C. R. Psychotherapy today or where do we go from here. American Journal of Psychotherapy, 1963, 17, 5–16.
Wolpe, J. Psychotherapy by reciprocal inhibition. Stanford: Stanford University Press, 1958.