THE USE OF MULTIPLE BEHAVIOR TECHNIQUES AS A TREATMENT FOR THE FEAR OF PUBLIC SPEAKING
In order to aid a physical therapist who has to give public speeches (which she fears greatly), a combination of systematic desensitization, positive instruction, and behavior rehearsal with feedback were successfully used to ease her anxiety and teach her practical skills. The combination increased her expectation that she could be helped and it is theorized that it may also be responsible for subjective as well as objective signs of a reduction in anxiety.
A widespread and debilitating fear for many people is the fear of public speaking. Fortunately, a variety of behavioral treatments have been found to help those with this fear. Therapists have used systematic desensitization (Paul, 1966; M. E. Jaremko and W. W. Wenrich, 1973; Zenmore, 1975), assertive training (Sanders, 1967; Humphreys and Berman. 1975), and in vivo desensitization (Gurman, 1973) with successful results.
Therefore, when Ms. S. sought help for this problem, there were a variety of sources to turn to for help. As systematic desensitization is a highly successful therapy having substantial empirical support, the facilitator chose this technique to be the main thrust of the treatment. It was also decided to include a combination of positive instruction with behavior rehearsal.
This decision came from several studies showing that proper rehearsal and preparation of the speech as well as objective feedback from others also reduced public speaking anxiety as well as increasing the subject’s personal confidence (Baker, Sandman, and Pepinsky, 1975), and that to combine these factors with systematic desensitization may be more effective than using any of them alone (Vrolijk, 1975; Sherman, Mulac, and McCann, 1974).
The facilitator also used this combination because, as the client’s history will show, new skills had to be learned if the client’s fear of ruining her speech were to remain unrealistic in the future. It was important for Ms. S. to be given assurance that she could be successfully helped before beginning treatment. She had never had difficulty speaking before a group of people until the eighth grade. She even remembers volunteering to give reports in elementary school.
The difficulty began when the teacher of her eighth grade English class was her father. Ms. S. was not getting along with her parents at this time and found it difficult to accept anything they said. Here, however, was a situation where she had to obey her father. For the first time, she felt very uncomfortable when she had to give class reports. She became upset that she was having this problem and this served to make her more anxious. She still had no problems answering questions or participating in class discussions, but after that year it continued to really bother her when she knew in advance that she had to give a speech in class, and would be extremely nervous before and during her presentation
The client is now a physical therapist in charge of the pediatrics unit at a large local hospital. She has a position of some responsibility which calls for her to make occasional public speeches. Once a week, all the physical therapists in the hospital (about 12 people) get together and give small, informal presentations called chart rounds. The history, treatment, and progress of the patients presently being treated are given and discussed.
The staff does not usually question each others reports. Because Ms. S. feels she is not the only one who has to speak, she does not feel nervous in this situation. The informal atmosphere relaxes her. However, she is also expected to give a formal 45-minute presentation called an “inservice speech” to all staff in her division at least once a year. The inservice speech is given in a small lecture room to about 25 people on a topic of her own choosing related to her field. The last inservice speech she gave was in November, 1976, and she was scheduled again to give another speech the first of December, 1977.
The client told the facilitator that she enjoyed the research and preparation of her presentation last year and would give more speeches if she weren’t so anxious about giving them. Ms. S. usually wrote the speech the night before she was to present it and then put it away without looking any further at it until right before she was to present. She does not write the speech out first but uses an outline on notecards. The night before her speech she is aware of feeling a little tense; in college she would get headaches.
The speech is scheduled for the last hour of that working day at 4:00. During the day, Ms. S. tries to put the speech out of her mind as much as possible. By 1:00 – 2:00 p.m. this is no longer possible and she can feel tension in her jaw, neck, and shoulders. She finds herself thinking that others will be able to see her hands shaking while speaking and see how nervous she is. She finds herself extremely talkative with her last patient at 3:00 p.m. Members of the audience begin to gather around 4:00 p.m. and there is casual conversation until the speech begins at 4:10 p.m. At this point, the client is extremely nervous and then goes over her speech for the first time.
She is very aware of how nervous she is and finds it hard to converse casually with others in the room. When she begins her speech, she is “super-aware of everything, but I feel not in control of anything.” This is a very big change in her, she feels, because she perceives herself as normally much more of a daydreamer and not as attuned to her environment.
Ms. S. also experiences an unpleasant “hot rush” when she first begins speaking. It does not cause her to feel faint but her heart rate greatly increases. She sometimes forgets what she will say next while speaking but there are no unusual pauses. She speaks quickly and makes what she estimates as “fair” eye contact. Her body remains tense and stiff throughout the speech.
Much of the tension leaves as soon as the speech is over, but it still takes her one or two hours to clam down completely. The client had already taken other steps to overcome her anxiety by the time of her first session with the facilitator. She had enrolled in a night school course on public speaking which met once a week and had already given a three minute introductory speech to the class.
She had felt very tense and her hands were shaking. The teacher had suggested improvements concerning her posture, eye contact, and hand gestures. She was to give two more speeches in this course before the date of her inservice speech.
Other than public speaking, there are no other behaviors that are giving the client unreasonable difficulty. She is comfortable in familiar social situation and is not afraid to assert herself when annoyed or angry.
Her career and social life seem to be equally balanced and she feels basically content with herself. She is also not called upon to given any formal speeches outside of those inservice speeches, though it is possible this could change in the future. Therefore, the ability to present herself effectively at her inservice speeches was the focus of treatment and new skills were taught which would carry over to any public speaking in the future.
Two 40 minute sessions were arranged per week to devote exclusively to systematic desensitization to continue on as long as necessary. The initial session, however, lasted two hours. The client’s history was obtained and systematic desensitization, relaxation, and the SUDS scale (Wolpe and Lazarus, 1966) were thoroughly explained.
The client was also shown procedures people generally follow when preparing for a speech (Gondin and Mammen, 1963). Ms. S. was unaware of what preparation went into a good speech; i.e., writing the speech far enough in advance so that it could be rehearsed and modified if necessary. The client was able to see that proper preparation and practice would reduce her rush at the last minute and also give more confidence. The client reported she put off preparing in advance because she wanted to avoid thinking of the speech as much as possible.
Thus, even preparing made her very anxious. The facilitator decided to do two hierarchies for systematic desensitization; the first to surround preparation and the second to surround the days leading up to the speech and the speech itself. The first hierarchy was drawn up (Table One). Meanwhile, since Ms. S. had to give a ten minute speech for her night class in a few days, positive instruction were given.
The speech was to be written out and put on notecards no later than two days before the class. It was then to be practiced alone two times, once in front of a mirror and once without the mirror.
1. First assigned speech. Due date December 1, 1977.
2. One week before speech is to be given, thinking must begin before writing speech on Saturday, November 26.
3. Day before speech writing is to begin. At work, thinking about it.
4. Day before speech writing is to begin. Morning at breakfast, thinking about it.
5. Night before speech writing is to begin. Painting room and thinking about it.
6. Saturday morning. Gathering writing materials and making tea.
7. Saturday morning. Sitting down at kitchen table and beginning preparation.
8. Working on speech, stops, reading what has been written over again.
9. Halfway through speech, stops.
10. Beginning speech writing.
11. Sunday morning. Finishing speech writing.
12. Saturday afternoon. Thinking that she will have to finish speech tomorrow.
13. Monday at work. Thinking that in 3 days she will have to give speech.
14. Monday evening. First, practice with mirror.
15. Tuesday evening. Second, practice alone, without mirror.
16. Tuesday at work. Thinking that in 2 days she will have to give speech.
17. Wednesday evening. Rehearsing speech in front of facilitator.
18. Wednesday at work. Thinking that tomorrow will give speech.
THE USE OF MULTIPLE BEHAVIOR TECHNIQUES AS A TREATMENT FOR THE FEAR OF PUBLIC SPEAKING
Several hours before the night class met, the client and the facilitator met and the client gave the speech once before the facilitator. The therapist gave positive and constructive feedback on her rehearsal. Later the client reported she felt much more relaxed than before but had still experienced some panic.
At the next session, the first official session using systematic desensitization, the facilitator gave Ms. S. training in cue-controlled relaxation. The client had already had a little training in self-relaxation in the past and had described herself as being able to relax deeply fairly easily on her own. She was already familiar with Wolpe and Lazarus’ method (1966) and stated that she would feel more comfortable with a less meticulous technique.
Cue-controlled or conditioned relaxation was attained in two steps following the procedure suggested by Russell and Sipich (1973) in their case study involving test and speech anxiety. Ms. S. was given a review of deep muscle relaxation with training on particularly troublesome spots (lower back, shoulders, neck, jaw). Then the relaxed state was associated with deep breathing and a self-produced cue word “relax.” The first hierarchy was then begun and took four sessions to complete.
During these sessions such avoidance behaviors as changing the presented scene for a more pleasant one, sudden rushes (while feeling her muscles remain completely relaxed), and falling asleep were systematically discovered and discouraged. At the beginning of the fifth session, the second hierarchy was drawn up (Table Two) and completed in three sessions. The last session ended one week before the inservice speech was to be given. The client and facilitator made a schedule similar to the previously mentioned one of positive instruction and behavior rehearsal and it was carried out in the same manner as had been done for the ten minute speech given earlier.
SPATIAL-TEMPORAL HIERARCHY ON SPEAKING IN PUBLIC
1. Thursday morning at breakfast. Thinking today will give inservice speech.
2. Thursday morning car, driving to work. Thinking today will give inservice speech.
3. Thursday at lunch. Thinking that in 4 hours will begin giving speech.
4. Thursday at 1:00 p.m. With patient and thinks that in 3 hours will give speech.
5. Thursday at 1:30 p.m. With patient and thinks that in 2-1/2 hours will give speech.
6. Thursday at 2:00 p.m. In-between patients and thinks that in 2 hours will begin speech.
7. Thursday at 2:30 p.m. With patient, sees clock and realizes that in 1-1/2 hours will begin speech.
8. Thursday at 2:45 p.m. Realizes that in about an hour will begin speech.
9. Thursday at 2:50 p.m. Same as above.
10. Thursday at 3:00 p.m. In between patients, realizes one hour to go.
11. Thursday at 3:10 p.m. Working with patient, sees clock.
12. Thursday at 3:20 p.m. Same as above.
13. Thursday at 3:30 p.m. 30 minutes to go.
14. Thursday at 3:40 p.m. 20 minutes to go.
15. Thursday at 3:45 p.m. 15 minutes to go.
16. Thursday at 3:50 p.m. 10 minutes to go.
17. Thursday at 3:55 p.m. Last patient of the day is leaving.
18. Gathering materials needed for speech, locking office door, preparing to leave for lecture room.
19. At doorway of lecture room, still outside in hallway.
20. At doorway, looking into room and seeing people there.
21. Preparing to begin speech at front of room, facing audience.
22. Talking to people before beginning speech.
23. Beginning speech, taking some deep breaths.
24. In middle of speech, talking to audience
25. In middle of speech, talking and showing slides to audience.
26. End of speech, answering questions from audience.
THE USE OF MULTIPLE BEHAVIOR TECHNIQUES AS A TREATMENT FOR THE FEAR OF PUBLIC SPEAKING
Ms. S. reported that she experienced no anxiety while preparing the speech. She also felt no discomfort practicing it alone or in front of the facilitator. The night before the inservice speech was to be given, she felt no tension and during the next day, when she thought about the speech, she did not try to block it out of her mind. She reported that she did think about the speech more than she had in the past but she felt much less afraid because she was well-prepared.
Before the speech she was able to chat with people in the audience and felt only a slight tension in her jaws. Once she began the speech, she relaxed completely and felt very aware of herself and also in control of herself. She felt that treatment had been successful.
Although this study is an uncontrolled application of multiple techniques to a specific behavioral problem, thus making it hard to functionally analyze the contributions of individual treatment components, the case does point to the possibility that effective combinations of behavioral techniques could be more helpful to the client. A flexible and knowledgeable attitude towards a variety of proven therapeutic methods available could offer increased chances of meeting the specific needs of the individual seeking treatment.
Ms. S.’s subjective report at the end of treatment about her feelings and behavior suggested that systematic desensitization, positive instruction, and behavior rehearsal were equally effective in reducing her fear of public speaking. All worked on different components of her fear to give an increased sense of mastery over her anxiety. However, because she had already had relaxation training in the past and it hadn’t helped the behavior before (it was not applied in connection to the behavior), she was at first very skeptical as to whether systematic desensitization could work.
Because it has been shown that the success of a treatment is significantly influenced by the client’s expectations (Bootzin, 1971: Woy and Efran, 1972; Meyer, 1975) the facilitator made sure that the client knew that this method had been very successful in the past, and she also gave positive feedback concerning Ms. S.’s own progress with systematic desensitization.
By the middle of treatment, Ms. S. saw how she was able to imagine scenes calmly, which previously had disturbed her greatly and this became self-reinforcing. After her inservice speech she stated how she felt each helped; positive instruction gave her increased knowledge and skills, behavior rehearsal, and positive feedback increased her self-confidence, and systematic desensitization made her calm enough to put what she learned and felt to use.
How dependent the success of this particular treatment plan was with this client’s expectation that she would get better is difficult to determine. It appears that such mutual dependence was present. How much any one technique was dependent on such is also hard to determine, but it should be pointed out that “in the studies where expectancy effects were reported, significant effects of systematic desensitization in the absence of positive instructions were also the rule” (Rimm and Masters, 1974, p. 73). Keeping this in mind, it was true that Ms. S. first began to feel a lot more hopeful about the treatment after her ten minute speech which was given before systematic desensitization even began. But it was not until she was well into treatment that she began to see her own progress. One possible explanation is that systematic desensitization is a more unusual type of treatment than the others used in this study and that people are prone to be suspicious of that which is unfamiliar to them.
Here, some relationship between expectancy and amount of progress in systematic desensitization appeared and it deserves further research. There have been experimenters who have been curious to determine whether the reported anxiety reduction is truly the experience of the person with the fear. Sanders (1967) showed two forms of behavior rehearsal and systematic desensitization to be equally effective in reducing objectively rated anxiety and all equally, effective in reducing subjectively rated anxiety. In this study, behavior rehearsal was confined to role playing around a hierarchy. No mention is made of controlling for positive instruction or positive feedback.
Though Ms. S. was not given pretest and post-test on an anxiety measure, she reported a subjective drop in anxiety and members of her night course in public speaking reported a more confident appearance to the audience. Though it cannot be ascertained here, it is possible that the two additional variables that Sanders did not report using may contribute to a subjective reduction in anxiety. Again, further research looking at the treatment factors in this study both in controlled combination and in isolation is necessary, not only to benefit those with a fear of public speaking, but for those with other anxieties as well.
By Joan Pastor