Exposure with acceptance-based versus habituation-based rationale for public speaking anxiety

166 Pages·2010·2.16 MB·English

by  England, Erica Lee

Exposure with Acceptance-Based versus Habituation-Based Rationale
For Public Speaking Anxiety

A Thesis
Submitted to the Faculty
of
Drexel University
by
Erica Lee England
in partial fulfillment of the
requirements for the degree
of
Doctor of Philosophy
May 2010
© Copyright 2010
Erica L. England. All Rights Reserved.
ii
Dedications

To my mother, Patty, for all of your love and support, and for being the best mom anyone
could ask for. I can only do what I do because of you.

To my dad and stepmom, Jeff and Michele, for always being there to feed me and for
making me believe.

To my brother, Cole, for teaching me to make coffee, without which I could not have
completed my dissertation.

To Matthew, who has spent countless hours studying in coffee shops with me.
Thank you for making my return to Maine even better than I expected it to be.

To the rest of my family, I am so thankful to have you in my life. To my Uncle Steve and
cousin Jessica, thank you for making LOST night so entertaining. To my grandparents,
Nana, Grampa, and Nana Kate, for love and wisdom. Auntie, Nicole, Isabel, Auntie
Lynne, and Dugan, thank you for being there. Last but not least, thanks to Gizmo, Dolce,
and Rufus, for helping us to remember what’s really important. I love you all.
iii
Acknowledgements

I would like to thank my mentor and committee chair, Dr. James Herbert, for making this
project possible. Thank you for all of your help and guidance over the past five years, and
for helping to make my graduate school experience so positive and rewarding. To my co-
mentor, Dr. Evan Forman, thank you for your kindness and support throughout my time
at Drexel. I could not have asked for a better team of mentors, and I am truly grateful for
all you both have done for me.

Thank you to my dissertation committee members, Drs. Rosette Biester, Douglas Chute,
and Kirk Heilbrun, for contributing your time, knowledge, and expertise not only to my
dissertation, but also to my clinical and research training over the past several years.

To my co-therapists, Stephanie Rabin and Adrienne Juarascio, I am extremely grateful
for your assistance throughout this project. It is because of you that our participants
benefitted as much as they did. To my research assistants, Stephanie Goldstein, Amanda
Barbieri, Adriana Del Vecchio, and Catherine Venable, thank you so much for all of your
help with assessments, role-plays, and data management. Faheem Johnson, thank you for
your generous help with video ratings. Without all of you, this study would not have been
possible. Thank you for all of your time and for carrying on with the study after I left for
internship. I never had to worry knowing that I had such a wonderful team working for
me.

Thank you to all of my other lab members and fellow Bellet-dwellers for assisting with
role-plays.

Finally, I owe a great debt of gratitude to the participants who volunteered for the study.
Thank you for speaking up.
iv
Table of Contents

LIST OF TABLES............................................................................................................vii
LIST OF FIGURES.........................................................................................................viii
ABSTRACT.......................................................................................................................ix
1. INTRODUCTION...........................................................................................................1
1.1. Distinction Between Generalized Social Phobia and Public Speaking
Anxiety..............................................................................................................3 2
1.2. Public Speaking Anxiety...................................................................................7
1.3. Treatment of Social Anxiety Disorder..............................................................8
1.3.1. Pharmacological Treatment....................................................................8
1.3.2. Psychodynamic Treatments..................................................................10
1.3.3. Relaxation Training and Systematic Desensitization...........................10
1.3.4. Cognitive Treatments............................................................................11
1.3.5. Other Treatments..................................................................................12
1.3.6. Summary of Treatments for SAD/Public Speaking Anxiety................13
1.4. Exposure.........................................................................................................14
1.4.1. Mechanisms of Action..........................................................................14
1.4.2. Clinical Application Issues...................................................................14
1.5. Exposure in the Treatment of SAD/Public Speaking Anxiety........................16
1.5.1. Component Studies of Exposure-Based Treatments.............................16
1.5.2. Presentation Context of Exposure.........................................................19
1.6. Exposure in the Context of Cognitive Defusion and Acceptance...................22
1.7. Acceptance-Based Treatment for Social Anxiety...........................................24
1.8. Current Study: Rationale, Design, and Hypotheses........................................26
2. METHODS....................................................................................................................28
2.1. Participants......................................................................................................28
v
2.2. Measures.........................................................................................................30
2.2.1. Diagnostic Measures.............................................................................30
2.2.1.1. Structured Clinical Interview for DSM-IV Axis I Disorders
(SCID)......................................................................................30
2.2.1.2. Anxiety Disorders Interview Schedule (ADIS-IV)..................31
2.2.2. Outcome Measures................................................................................31
2.2.2.1. Personal Report of Communication Apprehension
(PRCA-24)...............................................................................31
2.2.2.2. Personal Report of Confidence as a Speaker
(PRCS)—Short Form...............................................................32
2.2.2.3. Self-Statements During Public Speaking (SSPS)....................33
2.2.2.4. State-Trait Anxiety Inventory (STAI)—State Scale................33
2.2.2.5. Quality of Life Inventory (QOLI)............................................34
2.2.2.6. Clinical Global Impression Scale (CGI)..................................34
2.2.2.7. Behavioral Assessment Test (BAT).........................................35
2.2.2.8. Between-Session Exposure Exercises......................................37
2.2.2.9. Demographics Form.................................................................37
2.2.3. Mediational/Process Measures..............................................................37
2.2.3.1. Drexel Defusion Scale (DDS)..................................................37
2.2.3.2. Philadelphia Mindfulness Scale (PHLMS)..............................38
2.2.3.3. Acceptance and Action Questionnaire – II (AAQ-II)..............39
2.2.3.4. Before-Session Questionnaire (BSQ)......................................40
2.2.3.5. Reaction to Treatment Questionnaire (RTQ)...........................40
2.3. Procedure........................................................................................................41
2.3.1 Treatments..............................................................................................43
2.3.1.1. Exposure with Acceptance/Defusion Context (ACT)...............44
2.3.1.2. Exposure with Habituation Context (HAB)..............................45
2.4. Ethical Issues..................................................................................................46
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3. RESULTS......................................................................................................................47
3.1. Preliminary Analyses......................................................................................47 2
3.2. Main Analyses................................................................................................47
4. DISCUSSION................................................................................................................53
4.1. Strengths and Limitations...............................................................................58
4.2. Conclusions and Future Directions.................................................................59
LIST OF REFERENCES...................................................................................................61
APPENDIX A: Treatment Protocols.................................................................................99
APPENDIX B: Personal Report of Communication Apprehension (PRCA-24):
Public Speaking Subscale......................................................................122
APPENDIX C: Personal Report of Confidence as a Speaker (PRCS): Short Form........123
APPENDIX D: Self-Statements During Public Speaking (SSPS)..................................124
APPENDIX E: State-Trait Anxiety Inventory (STAI): A-State......................................125
APPENDIX F: Philadelphia Mindfulness Scale (PHLMS).............................................126
APPENDIX G: Drexel Defusion Scale (DDS)................................................................127
APPENDIX H: Acceptance and Action Questionnaire – II (AAQ-II)............................128
APPENDIX I: Quality of Life Inventory (QOLI)............................................................129
APPENDIX J: Before-Session Questionnaire (BSQ)......................................................130
APPENDIX K: Reaction to Treatment Questionnaire (RTQ).........................................131
APPENDIX L: Demographics Questionnaire.................................................................133
APPENDIX M: Treatment Handouts/Worksheets..........................................................135
VITA................................................................................................................................153
vii
List of Tables

1. Schedule of Assessments.............................................................................................42
2. Descriptive Statistics for Outcome Measures at Pre-Treatment..................................77
3. Descriptive Statistics for Outcome Measures at Mid-Treatment (Self-report only)
— Intent-to-Treat.........................................................................................................78
4. Descriptive Statistics for Outcome Measures at Post-Treatment (Intent-to-Treat).....79
5. Descriptive Statistics for Outcome Measures at 6-Week Follow-Up
(Intent-to-Treat)...........................................................................................................80
6. Descriptive Statistics for Process Measures at Pre-Treatment....................................81
7. Descriptive Statistics for Process Measures at Mid-Treatment (Intent-to-Treat)........82
8. Descriptive Statistics for Process Measures at Post-Treatment (Intent-to-Treat)........83
9. Descriptive Statistics for Process Measures at 6-Week Follow-Up (Intent-to-Treat).84
10. Effects of Time and Treatment Condition on Outcome (Intent-to-Treat)...................85
11. Effects of Time and Treatment Condition on Process Measures (Intent-to-Treat).....86
12. Correlations Between Residualized Pre-to-Mid-Treatment Change in Predictor
Variables and Residualized Mid-to-Post-Treatment Change in Outcome
Variables — Intent-to-Treat (Significant Correlations Only)......................................87
13. Correlations Between Residualized Pre-to-Mid-Treatment Change in Predictor
Variables and Residualized Mid-to-Follow-Up Change in Outcome Variables —
Intent-to-Treat (Significant Correlations Only)...........................................................88
14. Correlations Between Residualized Pre-to-Post-Treatment Change in Predictor
Variables and Residualized Mid-to-Follow-Up Change in Outcome Variables —
Intent-to-Treat (Significant Correlations Only)...........................................................89
15. Correlations Between Residualized Pre-to-Post-Treatment Change in Predictor
Variables and Residualized Post-to-Follow-Up Change in Outcome Variables —
Intent-to-Treat (Significant Correlations Only)...........................................................90
16. Correlation Matrix of Baseline Measures....................................................................91
17. Correlations Between Baseline Predictor Variables and Residualized Change
Scores on Outcome Variables — Intent-to-Treat (Significant Correlations Only).....92
viii
List of Figures

1. Mean Scores on the Personal Report of Communication Apprehension (PRCA) by
Assessment Point and Treatment Condition..................................................................93
2. Mean Scores on the Personal Report of Confidence as a Speaker (PRCS) by
Assessment Point and Treatment Condition..................................................................94
3. Mean Scores on the Self-Statements During Public Speaking – Positive Subscale
(SSPS-Positive) by Assessment Point and Treatment Condition..................................95
4. Mean Scores on the Self-Statements During Public Speaking – Negative Subscale
(SSPS-Negative) by Assessment Point and Treatment Condition.................................96
5. Mean Peak Self-Reported Anxiety (Subjective Units of Discomfort; SUDS) During
BAT Speech by Assessment Point and Treatment Condition.......................................97
6. Mean Scores on the Drexel Defusion Scale (DDS) by Assessment Point and
Treatment Condition......................................................................................................98
ix

Abstract
Exposure with Acceptance-Based versus Habituation-Based Rationale For Public
Speaking Anxiety
Erica L. England
James D. Herbert
Evan M. Forman

Social Anxiety Disorder (SAD) is a potentially debilitating condition affecting
approximately 12% of the population at some point in their life (Ruscio et al., 2008).
SAD is divided into two subtypes: generalized and nongeneralized. Nongeneralized SAD
refers to individuals whose fears are limited to one or two social situations, most
commonly public speaking. Empirically supported treatments for public speaking anxiety
generally include an exposure component (usually in vivo/simulated exposure). Exposure
is often presented within the context of a habituation rationale, but cognitively- based
therapies utilize a rationale for exposure based on cognitive restructuring and belief
modification. Research investigating the incremental benefit of adding other treatment
components to exposure has yielded mixed results; however, there is preliminary
evidence that the context in which exposure is presented can have an impact on treatment
outcome. Recently, acceptance-based therapies have begun to frame exposure as an
opportunity to increase one’s willingness to experience anxiety while engaging in valued
behaviors, rather than as a vehicle for modifying maladaptive cognitions and reducing
anxiety. However, little research has been conducted on the efficacy of acceptance-based
therapies for public speaking anxiety, and no component control studies have examined
the utility of an acceptance/cognitive defusion rationale and context for exposure. The
present study compared exposure within an acceptance/defusion context to exposure with
a habituation-based rationale in the treatment of public speaking anxiety. Treatment was