Running Head: EXPOSURE COMBINED WITH PSYCHOTHERAPY1

EXPOSURE COMBINED WITH PSYCHOTHERAPY6

Exposure Combined With Psychotherapy:

A Treatment for Public Speaking Anxiety

Kayla Lord

The Pennsylvania State University

Abstract

Exposure treatment and psychotherapy were examined as treatments for public speaking anxiety. Students from a large university, between the ages of 18 to 22-years-old, that qualify for public speaking anxiety according to their PRPSA scores (McCroskey, 1970) were treated with exposure, psychotherapy, or both. Those in the control group were put on a wait-list for treatment. It is expected that exposure treatment will cause a decrease in public speaking anxiety symptoms. It is also expected that psychotherapy will cause a decrease in public speaking anxiety. Finally, it is expected that the effect of exposure on public speaking anxiety will depend up receiving psychotherapy. These expected results would indicate that psychotherapy and exposure treatment are successful in treating public speaking anxiety and are even more effective in combination.

Exposure Combined With Psychotherapy:

A Treatment for Public Speaking Anxiety

Public speaking anxiety is a specified form of social anxiety disorder (SAD), which is a prevalent anxiety disorder that consists of extreme fear of embarrassment, humiliation, and judgment by others in social situations (Kashdan & Herbert, 2001). The fear of public speaking, formally known as glossophobia, is a widespread condition. With a 5.5% lifetime prevalence rate in 13 to 18 year olds, SAD is the third most commonly diagnosed psychiatric disorder in the United States (Kashdan & Herbert, 2001; Kessler, Chiu, Demler, & Walters, 2005; Merikangas, et al., 2010). Social phobia prevalence rates increase with age from 13 to 18-years-old (Merikangas et al., 2010). It is especially common in adolescents who have less freedom to avoid social situations than adults do because they are typically students who have to participate in class, ask for help, and perform public speaking tasks. Being forced to enter undesirable social situations leads to severe distress. The effects of social phobia, if left untreated, are chronic. Yet, most research on the subject uses adult samples (Kashdan & Herbert, 2001). It is pertinent to find the most effective treatment for adolescents with public speaking anxiety because their well being as a student and as an adult in social situations depends on it. It has been found in previous studies focused on treating glossophobia that there are multiple ways to successfully treat it. The three research articles discussed in this paper use samples of college students in late adolescence and early young adulthood. The following three experiments not only used adolescent samples, but also studied three of the most common, successful treatments for speech anxiety.

First, virtual reality therapy (VRT) treats phobias and other psychiatric conditions by immersing patient into computer-generated virtual reality treatment environments (Harris, Kemmerling, & North, 2002). Students at a large university filled out the Personal Report of Confidence as a Speaker (PRCS) inventory (Paul, 1966). Those whose scores were higher than 16 were randomly assigned to the control or experimental group resulting in a sample size of 14 students, eight receiving treatment. The six in the control group completed pre-testing and post-testing and were put on a wait-list for treatment. All subjects attended initial interviews in which they were surveyed using the Self-Evaluation Questionnaire, STAI form X-1 (STAI) (Spielberger, Gorsuch, & Lushene, 1970), the Liebowitz Social Anxiety Scale (LSAS) (Liebowitz, 1987), and Attitudes Towards Public Speaking Questionnaire (ATPS) (North, North, & Coble, 1997). Additionally, physiological measures of heart rate, using a pulse oximeter, were taken while the participants answered an open-ended question, read a paragraph, and completed a brief relaxation exercise (Harris, et al., 2002).

Each participant in the treatment group received four VRT sessions 12-15 minutes in length, once per week, using software of an auditorium scene and a head-mounted display with head-tracker. Present during the sessions as the therapist was the first author. Each session consisted of different manipulations to a virtual auditorium scene with heart rate measures taken throughout and Subjective Units of Distress Scale (SUDS) ratings taken before, during, and after each session. Immediately after, the subjects completed post-testing, which consisted of the same measures as pre-testing (Harris, et al., 2002). The researchers found that results on self-report and physiological measures indicated that VRT was successful in reducing glossophobia symptoms in college students. Specifically, when pre- and post-testing measures were compared, the experimental groups scores significantly differed on the PRCS, the ATPS, the heart rate during speaking tasks, and the resting heart rate after Session 2 compared to the heart rate after Session 4. The results indicated significant increases on the PRCS in the experimental group, when compared to the control group. Overall, the group that received VRT showed a significant reduction in the public speaking anxiety while the control group did not (Harris, et al., 2002). The results show that exposing those with glossophobia to the feared situation effectively lessens their fear of the situation, even if the situation is computer generated.

Another study conducted with the primary goal of treating glossophobia involved using eye movement desensitization (EMD). This study is meant to discover if exposure, when accompanied with rhythmic eye movements, may be more effective than exposure alone (Foley & Spates, 1995). The secondary purpose is to discover if two alternatives to eye movement are as effective. EMD consists of concentrating on the feared situation accompanied by rhythmic eye movements. It has been theorized that the eye movements are not necessary to the treatment and that it is the dosed flooding of the memory to be desensitized that causes the decrease in symptoms. This study investigates this dosed flooding theory by having the subjects actively confront images of the feared situation for short periods of time, followed by short periods of relief from images of the feared situation during EMD treatment (Foley & Spates, 1995).

Forty subjects were recruited form college classes by means of soliciting. They were self-chosen in the event that they suffered from speech anxiety to the point that they avoided public speaking at all costs or experienced extreme distress in public speaking situations and only accepted as a participant if they scored higher than an 18 on the PRCA-24. They were randomly assigned to one of the three treatment groups or to the control group that received no treatment (Foley & Spates, 1995). Initially, the subjects were instructed to identify and think about a specific image, emotion, and/or negative cognition regarding public speaking anxiety. While thinking of the incident, Group 1 subjects followed the therapists fingers as he moved them left and right across the field of vision. Group 2 subjects were exposed to an audio stimulus (white noise) that was manually manipulated back and forth between the left and right ear. Group 3 subjects rested their eyes on their hands in their lap. Each set lasted 20-30 seconds and was followed by a brief period of blanking out the image and deep breathing. During pre-testing and post-testing, all participants were surveyed using the Personal Report of Communication Anxiety-24 (PRCA-24) (McCroskey, 1982), and the Personal Report of Public Speaking Anxiety (PRPSA) (McCroskey, 1970). Then they gave a speech while being observed and rated by two trained observers on the Behavioral Assessment of Speech Anxiety (BASA) (Mulac & Sherman, 1974), and while having their heart rate measured. The three treatment groups were also measured using Subjective Units of Discomfort (SUDs) and Validity of Cognition (VOC) scores during treatment.

All treatment groups improved significantly on PRCA-24 scores, and VOC ratings. There was a significant reduction in SUDs and in BASA scores for the treatment groups. Additionally, there was a tendency toward a significant difference between the experimental and control groups on PRPSA scores. The results indicate that all three groups had significant effects in treating public speaking anxiety in college students. However, due to the fact that EMD was rated equally as effective as the resting eyes condition, it seems that the eye movement has little to do with the desensitization (Foley & Spates, 1995). Rather, it is due to the dosed flooding that the subjects showed reduction in speech anxiety. This further justifies the theory that exposure to public speaking will reduce the negative effects of speech anxiety in adolescents.

Finally, the third study serves to be the basis for future studies on the effectiveness of dosed exposure treatment when compared to a prolonged exposure treatment (Seim, Waller, & Spates, 2010). It has been found that exposure is effective at treating anxiety, fear, and avoidance reactions. However, it has yet to be established what the most effective duration of exposure is. All of the participants attended a baseline and treatment session. During the baseline and training sessions they were surveyed using the State-Trait Anxiety Inventory State subscale (STAI-State) (Spielberger, Gorusch, Lushene, Vagg, & Jacobs, 1983), and the Personal Report of Communication Apprehension (PRCA-24) (McCroskey, 1982), and were scored by trained assessors on the Social Phobia subscale of the Anxiety Disorders Interviews Schedule (ADIS-IV) (Brown, Dinardo, & Barlow, 1994). All participants met the criteria for public speaking anxiety. One week later, the subjects attended the treatment session. A baseline heart rate was measured, and they completed a Behavioral Avoidance Test (BAT) measured according to the Time Behavioral Checklist (TBCL) (Paul, 1966), during which SUDs were measured as well. Treatment began 15 to 45 minutes after the BAT. There were two treatment groups: dosed exposure (DE) and prolonged exposure (PE). A control group did not exist because prolonged exposure is considered the standard treatment. Those subjects randomly assigned to the treatment groups were asked to choose through three to five topics to speak on to an audience of three people he or she did not know and the researcher. Those in the PE group cycled through these topics continuously until either his or her SUD level reached zero or dipped below 20 points during two subsequent measurements, the participant spoke for three hours, or the participant refused to continue or exhibited signs of extreme distress. Heart rate, SUDs, and behavioral indices of distress were measured after every five-minute interval. The DE group participants followed the same procedure but were instructed to speak and rest in 30-second intervals, instead of speaking continuously (Seim, et al., 2010).

The researchers found that there was a significant increase in the DE groups mean score on the BAT, while there was not a significant increase in the PE groups. Additionally, there were significant decreases in SUDs for both treatment groups. Plus, participants in the PE group performed a greater amount of behavioral indices of distress during treatment than did the DE group participants. Scores on the PRCA-24 indicate that all participants in the DE group experienced reductions while only some of the members of the PE group experienced reductions. In conclusion, the results are sporadic, but they show that DE treatment is just as effective as PE treatment is. In fact, some measures show that DE treatment is more effective (Seim, et al., 2010).

Similarly to the previously discussed study, my two independent variables will be exposure and psychotherapy, while my dependent variable will be public speaking anxiety. Exposure will consist of three levels: dosed, prolonged, and no treatment. Two types of exposure are included because research shows that dosed exposure is just as effective as prolonged exposure, which is the standard, while being less stressful. The breaks in between speaking allow the individual to dispel stress. This studys secondary goal is to determine whether or not one type of exposure treatment is more effective. Psychotherapy as an independent variable will consist of two levels: treatment and no treatment. Indices of public speaking anxiety will be measured using scores on the PRPSA, which is the most commonly used self-report measure of public speaking anxiety (McCroskey, 1970). I expect there to be a negative main effect of exposure treatment. Receiving exposure will cause a decrease in PRPSA scores reflecting decreased glossophobia symptoms. I also expect there to be a negative main effect of psychotherapy treatment. Receiving psychotherapy will cause a decrease in PRPSA scores reflecting decreased glossophobia symptoms. Most importantly, I hypothesize that there will be an interaction between exposure treatment and psychotherapy treatment. I hypothesize that the effect of exposure will depend upon receiving psychotherapy treatment because in order to totally relinquish a fear, one must understand why they fear what they do, and why they no longer have to fear what they do, which is what psychotherapy will help the participants do (American Psychological Association, 2004). I also expect that dosed exposure paired with psychotherapy treatment once a week will cause the largest decrease in public speaking anxiety symptoms because it is less stressful.

Method

This study will be a 3 (exposure: dosed, prolonged, control) X 2 (psychotherapy: once a week, control) pre-test/post-test between subjects factorial design, with public speaking anxiety symptoms as the dependent variable. Those placed in one or both control groups will be placed on a wait-list for treatment. Ethically, those that are included in this study must receive both treatments because they score high for anxiety, so if they are in a control group they will receive whichever treatment they do not receive during the study after the study has been completed. The study will be between subjects to avoid order effects. The study cannot be conducted within subjects or as a mixed design because the effect on public speaking anxiety symptoms could then not be attributed to one single treatment combination due to residual effects of prior treatments.

Participants

Participants will be solicited at a large university with the stipulations that they must be between the ages of 18 and 22-years-old and may not be enrolled in a public speaking class. This study is targeting college students because minimal research has been done utilizing them in the sample. Subjects may not be enrolled in a public speaking class during the study because it may act as a confounding variable by affecting speech anxiety symptoms. Flyers will be posted around the campus advertising this study as a treatment regimen for public speaking anxiety for those that experience high levels of speech anxiety and avoid public speaking at all costs or suffer through it when they have too. Once self-selected, the subjects will complete the Personal Report of Public Speaking Anxiety (PRPSA) as a screening measure (McCroskey, 1970). If they score above the threshold for high anxiety (131), they will be randomly assigned into one of the six treatment groups until each treatment group consists of 50 participants. They must score high to qualify for public speaking anxiety and be eligible for treatment.

Materials

This study requires at least three paper copies of the PRPSA per subject (900 copies), to be utilized during screening, pre-testing, and post-testing. The PRPSA is the most commonly used self-report measure of public speaking anxiety because it has excellent reliability (alpha estimate > 0.90) (McCroskey, 1970). Additionally, there will need to be audience members that the participants do not know, three per exposure treatment session. They will be undergraduate research assistants from the university. They will sit at a table facing the participants who will stand at a podium at the front of the laboratory. The audience members will be trained to remain neutral while the participants speak. They are only allowed to nod encouragingly if the participant stops for five or more seconds. A psychologist will also be present at the exposure sessions and will be trained similarly. The need for neutral reaction is so that the reaction of the audience does not affect the anxiety of the participant as a confounding variable. All audience members will be trained before the study begins and again at two weeks in to ensure constant neutrality. Psychologists who specialize in speech anxiety will be necessary for psychotherapy as well and will not know the hypothesis of the study to combat experimenter effects.

Procedure

Pre-testing will take place immediately before the first exposure treatment session or first psychotherapy treatment session respectively. Post-testing will take place immediately after the last exposure treatment session or last psychotherapy treatment session respectively. Pre-testing and post-testing will consist of participants filling out a paper form of the PRPSA (McCroskey, 1970) alone in the laboratory to avoid observer effects.

The exposure treatment sessions will take place on weekdays, from 9 a.m. to 7 p.m. Four participants, one from each combination treatment group that includes exposure, will receive treatment individually per hour. The participants will be randomly assigned to a weekday and hour slot. They will attend an exposure treatment session weekly for four weeks with a different audience present each time. This is to simulate the act of speaking to a different audience in real life, while the psychologist must be present to terminate the session in case of extreme distress. Psychotherapy sessions will take place weekdays from 10 a.m. to 8 p.m. Three participants, one from each combination treatment group that includes psychotherapy, will receive treatment individually per hour. Participants will attend psychotherapy treatment the hour after they complete their exposure treatment. Those receiving psychotherapy but no exposure will be randomly assigned to a time slot for psychotherapy treatment. They will attend a psychotherapy session weekly for four weeks with the same therapist each time. These complex assignments are meant to ensure that the effect of time of exposure treatment and time of psychotherapy treatment do not affect the scores on the PRPSA during post-testing.

During exposure treatments, the participant will enter the laboratory and be greeted by the audience. The participant will be instructed to introduce themselves and give information about themselves in a speech format at the beginning of the first session. This is to ease them into the exposure treatment. At the end of the first session, they will be asked to write a speech about their favorite memory for the second session. While the speech will be more structured, it will be about something they are comfortable talking about, again to ease them into speaking in the laboratory setting. At the end of the second session, they will be asked to choose a historical event to prepare a speech about for the third session. This topic will challenge the participants. At the end of the third session, the participants will be asked to prepare a speech on a social issue. This topic is the final topic because it is complex and requires skillful delivery. Those experiencing dosed exposure will speak on their topics of choice for one minute and then take a 15 second break and repeat up until ten minutes has passed. Those experiencing prolonged exposure will speak on their topics of choice for ten minutes straight. During psychotherapy sessions, the therapist will begin by asking the participant to identify a negative image or cognition related to public speaking. Then the sessions will consist of talk psychotherapy to allow the participants to discuss and work through their individual fear of public speaking with professional help.

A pilot test with a small number of participants will be performed to ensure that the manipulations are working properly and that the participants are not feeling extreme distress during exposure treatment. This will also ensure the quality of the psychologists by showing if the participants improve equally across all of the different psychologists.

Results

As previously mentioned, this study will be a 3 (exposure: dosed, prolonged, control) X 2 (psychotherapy: once a week, control) pre-test/post-test between subjects factorial design, with PRPSA scores as the dependent variable. An ANOVA will be conducted to examine the impact of exposure treatment and psychotherapy treatment on public speaking anxiety symptoms. The ANOVA will compare the mean group differences between pre- and post-testing scores. Scores on the PRPSA can range from 34-170 with less than 98 indicating low anxiety, and greater than 131 indicating high anxiety. 98-131 is considered the mid range, indicating moderate anxiety.

The results are expected to show that there is a main effect for exposure treatment, such that those receiving dosed exposure will have a larger average reduction in PRPSA scores (M=70) than those in the prolonged exposure group (M=45) and those in the control group (M=17.5; p