01-44-3 efficacy of self-examination therapy in the treatment of generalized anxiety disorders

8/2/2019 01-44-3 Efficacy of Self-Examination Therapy in the Treatment of Generalized Anxiety Disorders

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Journal of Counseling Psychology Copyright 1997 by the American Psychological Associa~on, Inc.1997, Vol. 44, No. 3, 267-273 0022-0167/97/$3.00

Efficacy of Self-Examination Therapy in the Treatment of GeneralizedAnxiety DisorderD a n i e l B o w m a n , F o r r e s t S c o g i n , M a r k F l o y d , E U e n P a tt o n , a n d L i s a G is t

University of AlabamaTo d etermine the efficacy of self-examination therapy in the treatment of generalized anxietydisorder, 38 adults volunteered for a study in which they were randomly assigned toself-examination therapy or to a delayed-treatment group. Analyses indicated that participantsin self-examination therapy had significantly fewe r symptoms of anxiety than did participantsin the delayed-treatment group on the outcome m easures of this study, which included ratingsby trained clinicians and participants. The reduction in anxiety for people receiving self-examination therapy was maintained 3 months after treatment ended. The delayed-treatmentgroup also showed significant improvement in anxiety symptoms after receiving self-examination therapy.

Among mental disorders in the United States, anxietydisorders are the most prevalent. The 1-month combinedprevalence in the U nited States of phobias, panic disorders,and obsessive-compulsive disorders is estimated to be ap-proximately 7% (American Psychiatr ic Association [APA],1987; Myers et al. , 1984; Regier, Narrow, & Rae, 1990;Robbins et al. , 1984; Schatzberg, 1991). Generalized anxi-e ty d isorder (GAD)- -one of the most common anxie tydisorders---affects about 2- 8% of the population during anygiven year (see Weissman, 1990, for a review).Despite i ts prevalence, GAD is the least researched anx-iety disorder (Butler & Boo th, 1991). The lack o f researchon this disorder is probably related to the tendency of peoplewith GAD to seldom seek help from traditional sources oftreatment. In fact, GAD is one of the least commonly seenanxiety disorders in mental health centers (Barlow, 1985;Edelmann, 1992; Rapee, 1991). The reason people withGA D seldom seek help from traditional sources of treatmentmay be that GAD is not as distressing as most mentaldisorders (Rapee, 1991).How do people wi th GAD typica l ly manage i t? Theyoften cope with i t on their own and use self-administeredtreatments (Edelmann, 1992; Rapee, 1991). Self-administered treatments are interventions "presented in awritten or audiotaped format . . . designed to be imple-mented by the client" (Scogin, Bynum, Stephens, & Cal-hoon, 1990, p. 43) . In one study Rapee (1985) asked 48

Daniel Bowman, Forrest Scogin, and Mark Floyd, Departmentof Psychology, University of Alabama; Ellen Patton, Departmentof Social Work, University of Alabama; Lisa Gist, Department ofCounseling, University of Alabama.We would like to thank the following for their help in thisresearch: Keith Ayers, Virginia Bowman, Eileen MaloneBeach,Howard Miller, Dyan Patterson, Charlie Rickard, Beverly Thorn,the University o f Alabama Institute for Social Sciences Research,and Kelly Whitiock.Correspondence concerning this article should be addressed toDaniel Bowman, who is now in independent practice with Grayson& A ssociates, P.C., 48 Medical Park E ast Drive, Suite 150, Bir-mingham, Alabama 35235.267

people with GAD how they had been managing the disor-der . He found that people with GAD were "more likely toseek help from 'a lternative sources, ' such as . . . self-helpbooks than from more conventional [sources]" (Rapee,1991, p. 424).Recently, researchers have demo nstrated a growing inter-est in a num ber of self-administered treatments (Mahalik &Kivlighan, 1988), ranging from problem drinking (Miller ,Taylor , & West, 1980) to sexual dysfunction (Tripet-Dodge,Glasgow, & O'Neill , 1982). However, no studies haveexamined the eff icacy of self-administered treatments forGAD (see Glasgow & Rosen, 1978, and Scogin et a l. , 1990,for comprehe nsive reviews of research on self-administeredtreatments) , Although it has not been established that self-administered treatments can help reduce the symptoms ofGAD , Scogin and colleagues found effect sizes (d) rangingfrom 0.73 to 1.05 for self-administered treatments for pho-bias and affective disturbances when self-administeredtreatments were compared with no-treatment controlgroups. Thes e f indings suggest that self-administered treat-ments can reduce anxiety.

Rosen (1987) expressed concern about the number ofpeople w ho hav e received self-administered treatments be-cause most of them have not been properly evaluated.Because the research cited above suggests that people withGAD often seek help from self-administered treatments, i t isimportant to determine whether self-administered treat-ments can he lp reduce the symptoms o f GAD.In the search for effective self-administered treatments fo rGAD, it is wise to con sider self-administered treatments thathave been effective in treating depression. There is a strongrelationship between depressive disorders and anxiety dis-orders, particular ly GAD. F or example, R egier , Burke, andChristie (1990) found that one third of those who had adepressive disorder during a 6-month period also had ananxiety disorder . Because their data did not include post-traumatic stress disorder or G AD, their estimate is consid-erably low. Also, in a study of 260 people who met thecriter ia of the revised third edition of the Diagnostic andStatistical Manual o f Mental Disorders (DSM -III-R; AP A,


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2 6 8 B O W M A N , S C O G I N , F L O Y D , P A T R O N , A N D G I S T1 9 8 7 ) f o r d e p r e ss i v e d i s o r d e rs , 4 3 % o f t h o s e w i t h d e p r e s -s i v e d i s o r d e r s a l s o m e t D SM - I I I - R c r i t e r i a f o r a t l e a s t o n ea n x i e t y d i s o r d e r , a n d G A D w a s t h e m o s t f r e q u e n t l y o c c u r -r i n g c o m o r b i d d i a g n o s is : O v e r 2 0 % o f t h o s e w i t h a d ep r e s -s i v e d i s o r d e r a l s o h a d G A D ( S a n d e r s o n , B e c k , & B e c k ,1 9 9 0 ) . O t h e r s t u d i e s ( D i N a r d o & B a r l o w , 1 9 9 0 ; L y d i a r d ,1 9 9 1 ) h a v e f o u n d e v e n h i g h e r r a te s o f c o m o r b i d i t y a m o n gd e p r e s s i v e d i s o r d e r s a n d G A D .

A l t h o u g h t h e r e i s n o r e s e a r c h o n s e l f - a d m i n i s t e r e d t r e a t -m e n t s f o r G A D , s e v e r a l s e lf - a d m i n i st e r e d t r e a t m e n t s ( D .B o w m a n , S c o g i n , & L y r e n e , 1 9 9 5 ; S c o g i n , H a m b l i n , &B e u t l e r , 1 9 8 7 ; S c o g i n , J a m i s o n , & G o c h n e a u r , 1 9 8 9 ) h a v eb e e n f o u n d t o b e e f f e c t iv e i n t h e t r e a t m e n t o f d e p r e ss i o n .B e c a u s e t r a d i t i o n a l t r e a t m e n t s t h a t h a v e h e l p e d d e p r e s s i o nh a v e a l s o a i d e d G A D , s e l f - a d m i n i s t e r e d t r e a t m e n t s t h a th a v e h e l p e d d e p r e s s i o n s h o u l d a l s o i m p r o v e G A D . T h r e er e c e n t s t u d i e s ( D . B o w m a n , B a r t o n , & S c o g i n , 1 9 9 2 ; D .B o w m a n e t a l . , 1 9 9 5 ; V . B o w m a n , W a r d , B o w m a n , &S c o g i n , 1 9 9 6 ) h a v e i n d i c a t e d t h a t a s e l f - a d m i n i s t e r e d t r e a t -m e n t c a l l e d s e l f - e x a m i n a t i o n t h e r a p y ( S E T ) i s e f f e c t i v e i nr e d u c i n g t h e s y m p t o m s o f a n x i e t y a n d d e p r e s s io n . I n t h e s es t u d ie s S E T o u t p e r f o r m e d a n u m b e r o f p l ac e b o s , o t h e rt r ea t m e n t s, a n d d e l a y e d - t r e a t m e n t g r o u p s i n t h e t r e a tm e n t o fa n x i e t y a n d d e p r e s si o n ( s e e D . B o w m a n , 1 9 9 5 , f o r m o r ed e t a i l s ) . T h e r e f o r e , w e t h o u g h t S E T w o u l d b e e f f e c t i v e i nt h e tr e a t m e n t o f G A D .

I n S E T , p e o p l e a r e g i v e n a 4 5 - p a g e b o o k l e t c o n t a i n i n g a l lt h e i n f o r m a t i o n t h e y n e e d t o u s e i t . T h e S E T b o o k l e t e n -c o u r a g e s r e a d e r s t o d e t e r m i n e w h a t m a t t e r s t o t h em , t h i n kl e s s n e g a t i v e l y a b o u t t h i n g s t h a t d o n o t m a t t e r t o t h e m ,i n v e s t t h e i r e n e r g y i n t h i n g s t h a t a r e i m p o r t a n t t o t h e m , a n da c c e p t s i t u a t i o n s t h e y c a n n o t c h a n g e ( s e e D . B o w m a n ,1 9 9 5 , fo r a c o m p r e h e n s i v e e x p l a n a t i o n o f S E T ) . I n t h i ss tu d y , w e p r o v i d e d S E T f o r a g r o u p o f p e o p le w h o w e r ed i a g n o s e d w i t h G A D .

T h e t h r e e p r i m a r y h y p o t h e s e s o f th i s s t u d y w e r e t h a t ( a )a g r o u p p a r ti c i p a ti n g i n 1 m o n t h o f S E T w o u l d s h o w as i g n i f i c a n t r e d u c t i o n i n G A D s y m p t o m s w h e n c o m p a r e dw i t h a d e l a y e d - t r e a t m e n t g r o u p o n t h e o u t c o m e m e a s u r e s o ft h i s s tu d y , w h i c h r e q u i r e d r a t i n g s b y p a r t i c i p a n t s a n d c l i n i -c i a n s ; (b ) t he d e l a y e d - t r e a t m e n t g r o u p w o u l d s h o w a s i g-n i fi c a nt r e d u c ti o n i n t he s y m p t o m s o f G A D o n t h e o u t c o m em e a s u r e s o f t hi s s t u d y a f t e r r e c e i v i n g S E T ; a n d ( c ) p e o p l eo r i g i n a l l y a s s i g n e d t o S E T w o u l d c o n t i n u e t o m a i n t a i no r i g i n al t r e a tm e n t g a i n s 3 m o n t h s a f t e r S E T h a d b e e n c o m -p l e t e d . W e a l s o h y p o t h e s i z e d t h a t p a r t i c i p a n t s ' u n d e r s t a n d -i n g o f S E T a n d t h e n u m b e r o f d a y s t h e y e n g a g e d i n t r ea t -m e n t w o u l d b e p o s i t iv e l y c o r r e la t e d w i t h t h e ir i m p r o v e m e n ti n a n x i e t y s y m p t o m s .

M e t h o dP a r t i c i p a n t s

Par tic ipants were 38 individuals wh o were 18 years of age orolder (M = 42.91 y ears , SD = 14.68, range = 20- 73) . Mostpar tic ipants were m iddle-c lass to upper middle-c lass Caucasians ; 2w ere A s i ans , 3 w ere A f r i can A m er i cans , and 74% w ere w om en .A n ana lysi s o f va r i ance (A N O V A ) and a ch i - squa re t e st r evea l ed

that there were no s ignif icant group di f ferences (p > .05) in age orsex, respectively.

M e a s u r e sW e used t he A nx ie ty D i so rde r s In t e rv i ew Schedu l e - -R ev i sed(A D IS-R ; D i N ardo & B ar low , 1988) to d i agnose G A D and pan icdisorder according to DSM- I I I -R criteria. Researc h suggests th atc l in ic ians condu ct ing separate in terviews have go od agreement(Ks -> .64) in diagnosing panic disorder and GAD using theA D IS- R (B a r low & D i N ardo , 1991) . I n th i s s tudy, f ou r A D IS- Rinterviews were rand omly chos en to be audiotaped. Three separatecl in ic ians , wh o had an in ter rater agreem ent of 100% in diagnosingpanic disorder and GAD, scored the audiotaped in terviews.In addit ion to us ing the A D IS -R to evaluate the part ic ipants, weused the fol low ing measures to assess par t ic ipants before and af tert rea tment : (a) the Sym ptom Che ckl is t -9 0--R evise d (SCL-90-R;Derogatis , 1983) , (b) the Hamil ton Anxiety Rat ing Sca le- -Revised (HARS-R; R iskind, Beck, Brown, & Steer , 1987) ,(c) the Sta te-Trai t Anx iety Inventory (STA I; Spie lberger , Gorsuch,Lushene, Vagg, & Jacobs , 1983) , and (d) the SET quiz . TheSCL -90-R is a 90- i tem sel f - repor t inventory that has high re l iabil -i ty. The coefficient alphas for all scales range from .77 to .90, andtest-re test reliabilit ies for all scales rang e from .78 to .90. Thisinventory has show n const ruct , convergen t , d iscr imlnant, and con-current validities that rate high in comparison to other serf-reportinventories (Derogatis, 1983; Pauker, 1985). Ac cord ing to Pay ne(1985) , the SCL-90-R is "par t icular ly useful in evaluat ing thechanges i n sym ptom s p roduced i n a g roup by som e t r ea tm en tregime" (p . 1329). The scale of the SC L-90 -R that we used in th iss tudy was the Global Sever i ty Index, which i s an indicator ofgeneral psycho patholo gy that takes in to accoun t al l the i tems onthe SC L-90-R .The H A RS -R is a 16-i tem, in terview-based measure of anxie tysymp toms that has goo d re l iabil ity and val id i ty . The co eff ic ienta lpha o f t he H A R S -R i s . 83 , and i t ha s been show n to s i gn i fi can tl ydiscr iminate between G AD and ma jor depress ion (R iskind e t al .,1987) . In th is s tudy a t ra ined c l in ic ian conducted the HA RS -R inpe rson. A l so , f ou r H A R S-R in t erv i ew s w ere r andom ly chosen t obe audiotaped. Thr ee separate clinicians, w ho had an average exactin ter ra ter agreement o f 84% across the 16 items, w i th a range o f75-100%, scored the audiotaped in terviews.The STA I is a 40- i tem, se l f- repor t inv entory that a lso has goodreliabi li ty and val idi ty . A lph a coeff ic ients equal or exceed .90 forboth the Sta te Anxiety and the Trai t Anxiety subscales . A lso,several studies have sup ported the constru ct validities o f bothSTA I subscales . Addi t ional ly , fac tor analyt ic s tudies suppor t sep-arat ing the ST AI in to Sta te A nxiety and T rai t Anxiety subscales

(Spielberger et al., 1983).W e deve loped the SET qu i z t o m easu re know ledge o f t he SETbooklet . The qu iz comprises seven quest ions , which each havefour choices . One of the ques t ions was , "Which of the fol lowingitems was not on the sheets you we re encourage d to complete eachday?" A p i l o t s tudy i nvo lv ing 10 peop l e w ho had neve r r ead t heSET bo okle t indicated that on average they answered 2 .42 out o f7 ques t ions correct ly , w i th a s tandard devia t ion of 1 .64.

P r o c e d u r eW e used tw o new spape r and tw o t e l ev i s i on new s announce -ments to recrui t par tic ipants . Seven ty-f ive people expressed in ter -


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E F F I C A C Y O F S E L F - E X A M I N A T I O N T H E R A P Y 2 6 9e s t i n t h i s s t udy , bu t 24 f a i l e d t o m e e t e l i g i b i l i ty c r i te r i a fo r t h r e ep r i m a r y r e a s ons : ha v i ng m ode r a t e t o s e ve r e pa n i c a t t a c ks , be i ng i nps yc ho t he r a py , a nd f a i l i ng to m e e t c r i t er i a f o r G A D . T h i r t ee npe op l e c hos e no t t o pa r t i c i pa t e a f t e r l e a r n i ng t he de t a i l s o f t hes t udy .P a r t i c ipa n t s ga ve i n f o r m e d c ons e n t . W e e xp l a i ne d t ha t the yw ou l d be r a ndom l y a s s igne d t o e i the r S E T o r a de l a ye d - t r e a t m e n tc ond i t i on a nd t ha t t he de l a ye d - t r e a t m e n t c ond i t i on w a s ne c e s s a r yt o e va l ua t e t he e f f e c t ive ne s s o f S E T .

A g r a dua t e s t ude n t i n c l i n i c a l p s yc ho l ogy , s oc i a l w or k , o r c om -m un i t y c ouns e l i ng s c r e e ne d a l l pa r t i c ipa n t s a nd c ond uc t e d c l i n i c a li n t e r v i e w s by m e a ns o f t he A D I S - R . E l i g i b i l i t y c r i t e ri a w e r e ( a )be i ng d i a gno s e d a s ha v i ng G A D ; ( b ) no t be i ng i n p s yc ho t he r a py a tt he t i m e o f t he s t udy ; ( c ) no t r e c e i v i ng pha r m a c o t he r a py un l e s ss t a b i l iz e d on m e d i c a t i on t ha t one ha d t a ke n f o r a t l e a s t 2 m on t hs ;( d ) no t e v i de nc i ng o r r e po r t i ng p s yc hos i s , s u i c i da l ri s k , o r m a n i a ;a nd ( e ) no t ha v i ng pa n i c d i s o r de r w i t h pa n i c a t t a c ks tha t w e r ec ons i de r e d t o be m ode r a t e to s e ve r e by DSM-III-R c r i t e r i a .I m m e d i a t e l y a f t e r t he s c r e e n i ng , one o f t h r e e t r a i ne d c l i n i c i ansus e d t he H A R S - R t o a s s e s s pa r t i c i pa n t s w ho m e t t he i nc l u s i onc r i te r i a . T he c l i n i c ia ns w e r e un a w a r e o f t he t r e a t m e n t c ond i t i on t ow h i c h e a c h pa r t i c i pa n t w a s a s s i gne d . A f t e r t he H A R S - R i n t e r -v i e w , pa r t ic i pa n t s c om pl e t e d t he S C L - 90 - R , S T A I , a nd S E T qu i za nd w e r e r a ndom l y a s s i gne d t o e i t he r t he S E T o r t he de l a ye d -t r e a tm e n t g r oup .E a c h pa r t i c i pa n t s pe n t 4 w e e ks i n a t r e a tm e n t c ond i t i on a nd t he nw a s r e a s se s s e d o n t h e H A R S - R b y a c l i n i ci a n w h o w a s u n a w a r e o ft he pa r t i c i pa n t ' s t r e at m e n t c ond i t i on . W h e n a pa r t i c i pa n t r e t u r ne df o r t he s e c ond a s s e s s m e n t , he o r s he c om pl e t e d a s e c ond S C L -90 - R , S T A I , a nd S E T qu i z . E a c h pa r t i c ipa n t i n S E T w a s a s s e s s e da f i na l t i m e 3 m on t hs a f t e r t r e a tm e n t e nde d . T he f i na l a s se s s m e n tw a s i de n t i c a l t o t he s e c ond a s s e s s m e n t de s c r i be d a bove . A l s o , e a c hpe r s on i n t he de l a ye d - t r e a t m e n t g r oup w a s a s s e s s e d a f i na l t i m ea f t e r r e c e i v i ng 4 w e e k s o f S E T . T he i r f i na l as s e s s m e n t w a s a l s oi de n t i c a l t o t he s e c on d a s s e s s m e n t de s c r i be d a bove .

SET group. P a r t i c ipa n t s in t he S E T g r oup w e r e g i ve n t he S E Tbook l e t , w h i c h c on t a i ne d a l l t he i n f o r m a t i on t he y ne e de d t o u s eS E T . T he bo ok l e t c on t a i ne d 28 i de n t i c a l w or ks he e t s . W e e nc ou r -a ge d pa r t i c i pa n t s t o u s e a w or ks he e t e a c h da y .O n t he w o r ks he e t s , pa r ti c i pa n t s r e c o r de d w h a t m a t t e r e d t o t he m .T he y a l s o r e c o r de d a ny p r ob l e m s t he y w e r e ha v i ng . T he n t he y

c om pa r e d w ha t w a s bo t he r i ng t he m w i t h w ha t m a t t e r e d . I f w ha tw a s bo t he r i ng t he m d i d no t r e l a t e t o w h a t m a t t e r e d , the y c r o s s e di t ou t a nd l e f t the p r ob l e m a l one . B u t i f w ha t w a s bo t he r i ng t he mr e l a t e d to w ha t m a t t e r e d , t he y b r a i n s t o r m e d , l i s t ed pos s i b l e s o l u -t i ons t o t he i r p r ob l e m , a nd w e r e e n c ou r a ge d t o t r y ou t s o l u t ions . I ft he y e xha u s t e d a l l o f t he i r s o l u ti ons o r no s o l u t i ons w e r e pos s i b l e ,t he y w e r e t o l d t o a c c e p t t he i r p r ob l e m . T he t e x t o f t he boo k l e t w a sp r i m a r i l y de vo t e d t o e xp l a i n i ng how t o u s e t he w or ks he e t s . It a l s op r ov i de d de t a i l e d i n s t r uc t i ons a bou t c a r r y i ng ou t va r i ous p r oc e -du r e s , s uc h a s b r a i n s t o r m i ng o r a c c e p t i ng a p r ob l e m ( s e e D .B ow m a n , 1995, f o r a f u l l de s c r i p t i on o f S E T ) .D a n i e l B ow m a n c a l l e d pa r t i c i pa n t s onc e e a c h w e e k t o m a ke s u r et ha t no one n e e de d t o be r e f e r r e d t o a m e n t a l he a l t h p r o f e s s i ona lf o r e v i de nc i ng p s yc hos i s , s u i c i da l ri s k , hom i c i da l ri s k , o r m a n i a .N o r e f e rr a l s w e r e ne c e s s a r y . D ur i ng t he c a l l s , he a l s o o f f e r e d t oc l a r i f y a ny que s t i ons a bou t S E T , bu t no t he r a py w a s p r ov i de d .C a l l s w e r e r e s t r i c t e d t o a pp r ox i m a t e l y 5 m i n .T o be i nc l ud e d i n t h i s s t udy , pa r t i c i pa n t s r e c e i v i ng S E T w e r er e qu i r e d t o c om p l e t e a t l e a s t se ve n w or ks he e t s i n t he S E T b ook l e t .A l l pa r t i c ipa n t s w ho r e c e i ve d S E T r e po r t e d m e e t i ng t he i nc l u s i onc r i t e r ion.Delayed-treatment group. A de l a ye d - t r e a t m e n t g r oup r e c e i ve dno t r e a t m e n t un t i l 4 w e e ks ha d pa s s e d , a f t e r w h i c h pa r t i c ipa n t s i n

t h i s g r oup w e r e a s s i gne d t o S E T , w h i c h w a s t he n a d m i n i s t e r e d asd i s c us s e d a bove .A s he ha d done i n t he S E T c ond i t i on , D a n i e l B ow m a n c a l l e dpa r t i c ipa n t s onc e e a c h w e e k t o m a ke s u r e t ha t no one ne e de d t o ber e f e r re d t o a m e n t a l he a l t h p r o f e s s i ona l f o r e v i de nc i ng p s yc hos i s ,s u i c i da l r i s k , hom i c i da l r i s k , o r m a n i a . N o r e f e r ra l s w e r e ne c e s -s a r y . D ur i ng t he c a l l s , he a s s u r e d pa r ti c i pa n t s t ha t S E T w ou l d bem a de a va i l a b l e , bu t no t he r a py w a s p r ov i de d . C a l l s w e r e r e s t r i c te dt o a pp r ox i m a t e l y 5 m i n .Attrition. T w o pa r t i c ipa n t s f r om t he S E T g r oup a nd 1 f rom t hede l a ye d - t r e a t m e n t g r oup d i d no t r e t u r n f o r t he s e c ond a s s e s s m e n t .O ne pa r t i c ipa n t m ove d , 1 d i d no t r e t u r n ou r c a l l s, a nd 1 w a se xc l ude d f r om t he s t udy be c a us e s he de c i d e d t o s t a r t p s yc ho t he r -a py . A l s o , 2 pe op l e i n t he S E T g r oup a nd 3 i n t he de l a ye d -t r e a t m e n t g r oup d i d no t r e t u r n f o r t he t h i r d a s s e s s m e n t . T w o o ft he s e pe op l e m ove d a nd c ou l d no t be c on t a c t e d , a nd 3 r e po r t e dbe i ng t oo bus y t o pa r t i c ipa t e . A l s o , a f t e r t he t h i r d i n t e rv i e w o f apa r t i c ipa n t in t he de l a ye d - t r e a t m e n t g r oup , s he a s ke d t o c o m pl e t es om e s e l f -r e po r t m e a s u r e s a t hom e bu t ne ve r r e t u r ne d t hem e a s u r e s .

R e s u l t sDifferences Between Immediate and DelayedTreatment at Posttesting

W e c o n d u c t e d a m u l t iv a r i a te a n a l y si s o f c o v a r i a n c e( M A N C O V A ) u s i n g T im e 2 s co r es f ro m t h e H A R S - R , t h eT r a i t A n x i e t y a n d S t a te A n x i e t y s u b s c a le s o f t h e S T A I , a n dt h e S C L - 9 0 - R G l o b a l S e v e r i ty In d e x , w i t h T i m e 1 s c o r esf r o m e a c h o f t h e s e m e a s u r e s u s e d a s c o v a r i a t e s. A s i g n i f i -c a n t g r o u p e f f e c t w a s f o u n d , F ( 4 , 2 6 ) = 5 . 7 3 , p < . 05 . T h eT i m e 2 s c o re s f r o m t h e H A R S - R , t h e T ra i t A n x i e t y an dS t a te A n x i e t y s u b s c a l e s o f t h e S T A I , a n d t h e S C L - 9 0 - RG l o b a l S e v e r i t y I n d e x f o r th e S E T g r o u p w e r e s i g n i f i c an t l yl o w e r t h a n t h o s e f o r t h e d e l a y e d - t r e a t m e n t g r o u p . T h em e a n s a n d s t a n d a r d d e v i a t i o n s f o r t h e t r e a t m e n t g r o u p s o nt h e v a r i o u s m e a s u r e s a t T i m e s 1 , 2 , a n d 3 a r e p r e s e n t e d i nT a b l e 1 . P r e t h e r a p y c o r r e l a t i o n s b e t w e e n t h e o u t c o m e m e a -s u r e s a r e g i v e n i n T a b l e 2 .

B e c a u s e th e M A N C O V A w a s s ig n i f ic a n t , w e c o n d u c t e ds e p a ra t e u n iv a r i a te a n a l y s e s o f c o v a r ia n c e ( A N C O V A s ) f o rT i m e 2 s c o r e s o n t h e v a r i o u s m e a s u r e s , w i t h T i m e 1 s c o r e so n e a c h m e a s u r e u s e d a s c o v a r i a t e s . T h e a l p h a l e v e l f o rt h e s e f o l l o w - u p a n a l y s e s w a s a d j u s t e d t o .0 1 t o a d d r e s s t h ep o t e n t i a l f o r a l p h a i n f l a ti o n . T h e S E T g r o u p h a d s i g n i f i -c a n t ly f e w e r a n x i e t y s y m p t o m s t h a n t h e d e l a y e d - t r ea t m e n tg r o u p h a d at T i m e 2 o n th e H A R S - R , F ( 1 , 3 2 ) = 1 6 .1 5 , p .0 5 ; t h e S TA I S t a te An x ie ty su b sca l e , F (1 , 1 4 ) = 1 .9 4 ,p > .0 5 ; an d th e S CL -9 0 -R G lo b a l S ev er i t y In d ex , F (1 , 1 4 )= 0 .00, p > .05.

E f f e c t o f P a r t i c ip a t i o n o n O u t c o m eW e c a l c u l a t e d a c o r r e l a t i o n b e t w e e n t h e n u m b e r o f d a y s

c o m p l e t e d i n t h e S E T b o o k l e t a n d p o s t t r e a t m e n t s c o r e s o nt h e H A R S - R , w i t h p r e t r e a t m e n t s c o r e s o n t h e H A R S - Rp a r t ia l e d f r o m b o t h v a r i a b le s . W e a l s o c o n d u c t e d i d e n t i c a la n a l y s e s u s in g s c o r e s f r o m t h e S T A I a n d S C L - 9 0 - R . A 1 -

T a b l e 2Pretherapy Correlations Between Outcome MeasuresMeasure 1 2 3 4

1 . HA RS -R - - .66 .32 .472. SCL-90-R GeneralSeverity Index - - .67 .793. STA I State Anxiety - - .754. STA I Trait AnxietyNote. HARS-R = Hamil ton Anxiety Rat ing Scale--Revised ;SCL-90-R = Symp tom Chec ld is t -90--R; STAI = State-TraitAnxiety Inventory. State Anxiety and Trait Anxiety are the sub-scales of the STAI.


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EFFICACY OF SELF-EXAMINATION THERAPY 27 1though mos t cor r e la t ions appr oached . 30 , w hich i s the s tan-d a r d d e f i n i t io n o f a m e d i u m - s i z e d e f f e c t (C o h e n & C o h e n ,1983) , and a l l w er e in the expec te d d i rec t ion , no cor r e la t ionw a s s ig n i f ic a n t ( H A R S - R , r = - . 2 6 , p = . 0 9; S T A I T r a i tA n x i e t y s u b sc a l e, r = - . 1 8 , p > . 05 ; S T A I S t a t e A n x i e t ys u b s c al e , r = - . 2 7 , p = . 07 ; a n d S C L - 9 0 - R G l o b a l S e v e ri t yI ndex , r --- - . 2 6 , p = . 08) . W e the r e f or e cann ot conc ludet h a t t h e a m o u n t o f d a y s t h a t p a r t ic i p a n t s r e p o r te d w o r k i n g i nt h e S E T b o o k l e t w a s r e l a t e d t o a n i m p r o v e m e n t i n t h e i ra n x i e t y s y m p t o m s .

Effect of Understanding SETBe f or e tr ea tment , pa r t i c ipants ave r ag ed answ er ing 2 .54o u t o f 7 q u e s t i o n s c o r r e c t l y o n t h e S E T q u i z , w i t h a s t a n d a rddevia t ion of 1 .52 . A f te r comple t ing t r ea tment , pa r t i c ipantsa v e r a g e d a n s w e r i n g 5 . 1 6 o u t o f 7 q u e s t i o n s c o r r e c tl y , w i th

a s t an d a r d d e v i a t io n o f 1 . 27 . A o n e - w a y A N O V A r e v e a l e dtha t pos t t r ea tment qu iz scor es w er e s ign i f ican t ly h igher thanpret reatm ent scores , F(1 , 30) --- 118.10, p < .05, wh ichsugges t s tha t pa r t i c ipants l ea r ned someth ing about SETdur ing t r ea tment .W e c a l c u l a t e d c o r r e l a t i o n s b e t w e e n p a r t i c i p a n t s ' p o s t -t r e a t m e n t s c o r e s o n t h e S E T q u i z a n d t h e i r p o s t t r e a t m e n ts c o r e s o n t h e H A R S - R , w i t h p r e t r e a t m e n t s c o r e s o n t h eS E T q u i z a n d t h e H A R S - R p a r t i a l e d f r o m b o t h p o s t t r e a t -m e n t v a r i a b l e s . W e c o n d u c t e d i d e n t i c a l a n a l y s e s b y u s i n gs c o r e s f r o m t h e S T A I a n d t h e S C L - 9 0 - R . A l t h o u g h a l lcor r e la t ions w er e in the pr ed ic ted d i r ec t ion , no cor r e la t ionw a s s ig n i f ic a n t ( H A R S - R , r = - . 2 1 , p > . 05 ; S T A I T r a i tA n x i e t y s ub s c a le , r = - . 1 0 , p > . 0 5; S T A I S t at e A n x i e t ys u b s c al e , r = - . 2 4 , p = . 1 0 ; a n d S C L - 9 0 - R G l o b a l S e v e r i t yI n d e x , r = - . 1 5 , p > . 05 ) . W e t h e r e fo r e c a n n o t c o n c l u d etha t a be t te r under s tanding of the mate r ia l s ign i f ican t lydecr ease d pa r t i c ipants ' anxie ty .

D i s c u s s i o nRat ings by t r a ined c l in ic ians and pa r t i c ipants ind ica tedt h a t p e o p l e w i t h G A D p a r t i c i p a t i n g i n 1 m o n t h o f S E Ts h o w e d a s i g n i f i c a n t r e d u c t i o n i n a n x i e t y s y m p t o m s i nc o m p a r i s o n w i t h t h o s e i n a d e l a y e d - t r e a t m e n t g ro u p . T h o s ew h o i n i ti a l ly r e c e i v e d S E T m a i n t a i n e d t h e d e c r e a s e i n a n x -

i e t y s y m p t o m s 3 m o n t h s a f t e r t r e a tm e n t e n d e d . A l s o , p a r -t i c ipants in the de layed- t r ea tm ent gr oup sh ow ed a s ign i fi -c a n t r e d u c t i o n i n G A D s y m p t o m s a f t e r t h e y r e c e i v e d S E T .T h e r e d u c t i o n i n a n x i e t y s y m p t o m s f o r t h e S E T g r o u pw a s s i m i l a r t o t h e i m p r o v e m e n t in s y m p t o m s p r o d u c e d b yother s e l f - adminis te r ed t r ea tments f or phobias and a f f ec t ived is tur bances ( see Scogin e t a l . , 1990) . Fur the r mor e , thei m p r o v e m e n t i n t h e S E T g r o u p w a s s i m i l a r in m a g n i t u d e t ow h a t w e w o u l d e x p e c t t o f i n d a m o n g p e o p l e re c e i v i n gt r ad i t iona l psychother apy . For example , Smi th , G las s , andMil le r ( 1980) f ou nd in a me ta - ana lys i s o f 475 s tud ies tha tw h e n p e o p l e r e c e i v i n g t ra d i t io n a l p s y c h o t h e r a p y w e r e c o m -p a r e d w i t h p e o p l e n o t r e c e i v i n g t h e r ap y , t h e a v e r a g e p e r s o n

r e c e i v i n g p s y c h o t h e r a p y e v i d e n c e d g r e a t e r i m p r o v e m e n tt h a n 8 0 % o f t h e p e o p l e i n n o - t r e a t m e n t c o n t r o l g r o u p s. I no u r s t u d y , S E T h a d a s i m i l a r e f f e c t . T h e a v e r a g e p e r s o nr e c e i v i n g S E T s h o w e d g r e a t e r i m p r o v e m e n t i n a n x i e t ys y m p t o m s t h a n 8 2 % o f t h e p a r ti c ip a n t s i n t h e d e l a y e d -t r ea tment gr oup .T h r e e m o n t h s a f t e r t r e a tm e n t e n d e d , 4 0 % o f S E T p a r t ic -ipants ev ide nced c l in ica l ly s ign i f ican t chang e in how anx- ious they gener a l ly f e l t , and 20% show ed c l in ica l ly s ign i f -i c a n t c h a n g e i n h o w a n x i o u s t h e y h a d f e l t d u r i n g t h e p r i o r 2w e e k s . M o s t G A D t r e a t m e n t s t u d i e s h a v e n o t m e a s u r e dc l in ica l ly s ign i f ican t change , and those tha t have measur eds u c h c h a n g e h a v e u s e d d i f f e r e n t m e t h o d s ( e .g . , s e e B o r k -ovec & Cos te l lo , 1993 , and But le r , Fenne l , Robson , &G elder , 1991) , making compar i sons d i f f icu l t . N ever the les s ,B u t l e r a n d c o l l e a g u e s r e p o r t e d t h a t 4 2 % o f p a r t ic i p a n ts w h or e c e i v e d c o g n i t i v e - -b e h a v i o r a l t h e r a p y a n d 5 % w h o r e -c e i v e d b e h a v i o r a l t h e r a p y e v i d e n c e d c l i n i c a l l y s i g n i f i c a n tc h a n g e 6 m o n t h s a f t e r t r ea t m e n t e n d e d .

N e i t h e r t h e n u m b e r o f d a y s p a r t ic i p a n ts r e p o r t e d w o r k i n gi n t h e S E T b o o k l e t n o r t h e i r u n d e r s t a n d i n g o f S E T , a smeasur ed by a qu iz , w as s ign i f ican t ly as soc ia ted w i th the i ri m p r o v e m e n t i n a n x i e t y s y m p t o m s . H o w e v e r , a l l c o r r e l a -t i o n s w e r e i n t h e e x p e c t e d d i re c t io n , a n d s o m e w e r e n e a r l ym e d i u m - s i z e d e f fe c t s . T h e l a c k o f p o s i t i v e f in d i n g s m a y b ea t t r ibu ted to th i s s tudy ' s s ample s ize .This r e sea r ch , in conjunc t ion w i th th r ee pr ior s tud ies ( D .Bow man e t a l . , 1992 , 1995; V . Bow man e t a l . , 1996) ,sugges t s tha t SE T i s a v iab le a l t e r na t ive in the t r ea tmen t ofa n x i e t y a n d d e p r e s s i v e d i s o rd e r s . S e l f - e x a m i n a t i o n t h e r a p ym a y b e p a r t ic u l a r ly u s e f u l t o t h o s e w h o c a n n o t a f f o r d t ra -d i t i o n a l p s y c h o t h e r a p y o r w h o l a c k t h e t i m e o r d e s i r e t opar t ic ipa te in i t ; SET may a l so be a use f u l ad junc t tot r a d it i o n a l p s y c h o t h e r a p y . H o w e v e r , S E T w o u l d b e c o n t r a -i n d i c a te d f o r t h o s e w h o h a v e r e a d i n g d i f f i c u lt i e s o r w h o a r er e l u c t an t t o d o h o m e w o r k .A f u r t h e r l i m i t at i o n o f S E T r e s e a r c h i s t h a t p e o p l e w h ovoluntee r to pa r t i c ipa te in s e l f - adminis te r ed t r ea tments a r ep r o b a b l y m o r e c a p a b l e t h a n o t h e r s o f b e n e f it i n g f r o m t h i stype of t r ea tment . V oluntee r s f or s e l f - adminis te r ed t r ea t -ment s tud ies a r e l ike ly to expec t to benef i t f r om se l f -a d m i n i s t e r e d t r e a t m e n t s , p r o b a b l y e n j o y d o i n g t h i n g s o nt h e i r o w n , a n d m a y b e h i g h l y m o t i v a t e d .A l tho ugh se l f - adm inis te r ed t r ea tments appe ar to be e f f ec -t i v e f o r a n x i e t y a n d d e p r e s s i v e d i s o r d e r s , w e c a n n o t c o n -c lude tha t the y a r e a s e f f ec t ive as t rad i t iona l t r ea tments un t i ls e l f - adminis te r ed t rea tments a r e d i r ec t ly com par ed w i th t r a -d i t io n a l t r e at m e n t s . I n t h e f u t u r e i t w o u l d b e b e n e f i c i a l tocompar e se l f - adminis te r ed t r ea tments w i th t r ad i t iona l psy-c h o t h e r a p y a n d p h a r m a c o t h e r a p y . A l s o , f u t u r e G A D r e -s e a r ch e r s m a y p r o f i t b y b u i l d i n g o n d e p r e s s iv e d i s o r d e rr esea r ch , w hich has an expans ive base . A s th i s s tudy andother s ( s ee Bar low , 1991) have demons t r a ted , t r ea tmentst h a t w o r k f o r d e p r e s s i v e d i s o r d e r s a l s o w o r k f o r G A D .F i n a l l y , b e c a u s e p e o p l e w i t h G A D g e n e r a l l y l i k e s e l f -adminis te r ed t r ea tments ( Rapee , 1991) and r esponded w e l lto a s e l f - adminis te r ed t r ea tment in th i s s tudy , w e r ecom-m e n d a d d i t io n a l r e s e a r c h o n t h e e f f i c a c y o f s e lf -a d m i n i s t e re d t r e a t m e n t s f o r G A D .


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272 B O W M A N , S C O G I N , F L O Y D , P A T R O N , A N D G I S TRe f e r en c e s

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E F F I C A C Y O F S E L F -E X A M I N A T I O N T H E R A P Y 273S m i t h , M . , G l a s s , G . , & M i l l e r , T . ( 1 9 8 0 ) . Benefits o f psychother-apy. B a l t i m o r e : J o h n s H o p k i n s U n i v e r s i t y P r e s s .S p i e l b e r g e r , C . , G o r s u c h , R . , L u s h e n e , R . , V a g g , P . , & J a c o b s , G .

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T r i p e t - D o d g e , L . J . , G l a s g o w , R . E . , & O ' N e i l l , H . K . ( 1 9 8 2 ) .B i b l i o t h e r a p y i n t h e tr e a t m e n t o f f e m a l e o r g a s m i c d y s f u n c t i o n .Journal of Consulting and Clinical Psychology, 50, 4 4 2 - 4 4 3 .

Weissman, M. (1990). Panic and generalized anxiety: Are theyseparate disorders? Journal of Psychiatric Research, 24,157-162.Received May 23, 1996

Revision received January 6, 1997Accepted January 6, 1997

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01-44-3 efficacy of self-examination therapy in the treatment of generalized anxiety disorders

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