Journal oj Abnormal Psychology1968, Vol. 73, No. 2, 119-130

TWO-YEAR FOLLOW-UP OF SYSTEMATIC DESENSITIZATIONIN THERAPY GROUPS1

GORDON L. PAUL 2

University of Illinois

The long-term effects of treatment for social-evaluative anxiety by modifiedsystematic deserialization in time-limited intensive therapy groups were evalu-ated in a matched-groups design. 10 chronically anxious college males, treatedby the group method, were reassessed on personality and anxiety scales thathad previously shown significant improvement against an "own-control" period,and compared to 4 equated groups that had received individual programs ofsystematic desensitization, insight-oriented psychotherapy, attention-placebotreatment, or no-treatment. 10 no-treatment controls who were matched onall important variables provided a base line for evaluating extratreatmenteffects on academic performance as an objective, public criterion. 100% returnrates were obtained for all treated Ss, revealing maintenance of improvementfound earlier for group desensitization, with additional improvement over thelong-term follow-up period. No evidence of relapse or symptom substitutionwas obtained, although specifically sought. Group desensitization appears toprovide an efficient and effective treatment for anxiety and is not limited tospecific phobias.

The introduction of group-treatment tech-niques has had a considerable impact on thefields of counseling and psychotherapy(Hunt, 1964). However, with a few notableexceptions (e.g., May & Tuma, 1964; Sny-der & Sechrest, 1963), experimental evalua-tions of specific treatment innovations ingroups have lagged even more than adequateassessment of individual psychotherapeuticoutcome (Paul, 1966b). This state of affairsis further pronounced with respect to follow-up studies of the enduring effects of psycho-logical treatment. Such studies are scarce(Fiske & Goodman, 1965), and the few pub-lished investigations of change or stability fol-lowing treatment termination for noninstitu-tionalized adults treated for emotional prob-lems have suffered considerable methodologi-cal difficulty (Sargent, 1960).

Among the problems of follow-up research,1 Appreciation is expressed to the Graduate Col-

lege Research Board of the University of Illinoiswhose support made this study possible. Earlierdata utilized in this paper were drawn from a studysupported in part by Public Health Services Fellow-ship 1 Fl MH-19, 873, 01 from the National Insti-tute of Mental Health, and in part by the Coopera-tive Research Program of the Office of Education,United States Department of Health, Educationand Welfare, Contract No. 4-10-080, Project S-006.

2 Thanks are extended to Tom Brudenell for hisaid in collecting and analyzing FUa data.

the following stand out as those that havelimited the value of almost all attempts atlong-term evaluation of treatment effects(Paul, 1967): Assessment procedures areoften of unknown or unproven validity; in-struments used at follow-up are seldom thesame as those used at pretreatment and post-treatment; appropriate no-treatment controlgroups for assessing change in the absence oftreatment have not been included; many cli-ents obtain additional treatment during theposttreatment period, thus invalidating cause-effect relationships for treatments being eval-uated; differential return-rates within treat-ment groups result in selective attrition ofthe sample. The problem of differential drop-out combined with the fact that interveninglife experiences are likely to be more impor-tant on clients' follow-up status than a briefperiod of treatment some months or yearsearlier have severely handicapped the scien-tific value of even the better follow-up studiesof group therapy (e.g., Stone, Frank, Nash,&Imber, 1961).

The present study is a 2-yr. follow-up ofan earlier investigation which evaluated thefeasibility and effectiveness of treating social-evaluative anxiety by a modified form ofWolpe's (1961) systematic desensitization inthe context of intensive group therapy (Paul

119

120 GORDON L. PAUL

& Shannon, 1966). In the earlier study, groupdesensitization was found to produce signifi-cant reductions in interpersonal performanceanxiety (the treatment target) for "chroni-cally" anxious males when pre-post treatmentchanges on personality and anxiety scaleswere compared with changes during an un-treated wait-period of equal length prior totreatment. Group-desensitization 5s were alsofound to show a significant increase on anextra-experimental index of performance, thecollege grade-point average (GPA), whencompared with an untreated control groupmatched on all significant variables. Further,when the effects of group desensitization wereevaluated against the results obtained throughindividual treatment programs with compa-rable 5s, the group method was found to beas effective as the individual application ofsystematic desensitization, and significantlybetter than insight-oriented psychotherapyand attention-placebo treatments. Contrary totraditional theories regarding the nature andtreatment of emotional problems, no evidenceof "symptom substitution" was found. In fact,there was considerable evidence of positivegeneralization of treatment effects.

A recent long-term follow-up of the com-parative outcome of individual treatment pro-grams was able to overcome methodologicaldifficulties more adequately than previous in-vestigations (Paul, 1967). The results of thatstudy found that treatment techniques de-rived from a "learning" model producedgreater long-term improvement than othertreatment and control groups, with evidenceof additional generalization after treatmenttermination. Further, not even suggestive evi-dence was found for differential "relapse" or"symptom substitution" effects which wouldbe expected on the basis of traditional theo-ries. The apparent effectiveness and efficiency(i.e., less than 2 hr. therapist time per client)of the group-desensitization procedure, com-bined with predictions of "relapse" and"symptom substitution" from traditionaltheories, make a long-term follow-up of thegroup-treatment method especially desirable.

In the study reported below an attempt hasbeen made, more adequately than in previousstudies, to evaluate the long-term effects ofan innovation in group therapy for emotional

problems. The major purpose was to evaluatethe extent and stability of improvement, re-sulting from administering modified syste-matic desensitization in groups, by (a) eval-uating changes on personality and anxietyscales from pretreatment to 6-wk. and 2-yr.follow-ups for "chronically" anxious clients;(b) evaluating the lasting effects of groupdesensitization on an extra-experimental indexof performance, the GPA, against a matcheduntreated control group; (c) comparingchanges from pretreatment to 2-yr. follow-upresulting from the group method with thoseobtained for comparable 5s with individualtreatments and without treatment. Specificfrequency data were also obtained to allowassessment of the influence of external stress,and possible occurrence of "symptom substi-tution."

METHODSubjects

The 5s included in the present investigation con-sisted of 4 groups of 10 males each, who previouslyreceived group desensitization, or individual pro-grams of systematic desensitization, insight-orientedpsychotherapy, or attention-placebo treatment, and10 males who composed an untreated control groupmatched with the group-desensitization 5s for col-lege, class, age, and all personality and anxietyscales. This includes all 5s from the previous out-come study (Paul & Shannon, 1966). Additionally,while the original 10 matched controls were all thatwere available for meaningful GPA comparisons, 22more untreated controls were added for test com-parisons, bringing the total sample to # = 72. Atpretreatment assessment all were undergraduates(Mdn = Soph) enrolled in a required public-speak-ing course at the University of Illinois, ranging inage from 19 to 24 yr. (Mdn = 21). Each 5 wasselected from a population of 380 students who re-quested treatment for interpersonal performanceanxiety on the basis of indicated motivation fortreatment, highest scores on performance anxietyscales, and low falsification. While public-speakingsituations were reported to be the most upsettingcondition, almost any social, interpersonal, or evalu-ative situation was reported to produce strong tosevere anxiety prior to treatment. These emotionalreactions were reportedly long standing (2-20 yr.).Before treatment these 5s also differed from the"normal" student population by obtaining lower ex-troversion and higher general anxiety and emo-tionality scores. All Ss were drawn from a largerpopulation initially taking part in a comprehensiveevaluation of treatments derived from the conflict-ing "learning" and "disease-analogy" models of emo-tional disturbance (Paul, 1966a).

SYSTEMATIC DESENSITIZATION 121

Procedure

Pretreatment assessment (Test 1) consisted ofclassroom administration of a battery of personalityand anxiety scales to students enrolled in the speechcourse the week following their first classroomspeech. The battery was constructed to assess focaltreatment effects and generalization or symptomsubstitution if such processes were operating, andthus included forms of (a) IPAT Anxiety ScaleQuestionnaire (Cattell, 1957); (6) Pittsburg SocialExtroversion-Introversion and Emotionality Scales(Bendig, 1962); (c) Interpersonal Anxiety Scales(Speech before a large group, Competitive contest,Job interview, Final course examination) of theS-R Inventory of Anxiousness (Endler, Hunt, &Rosenstein, 1962); (d) a scale of specific anxiety ina referenced speech performance, the PRCS short-form (Paul, 1966a).»

Following additional assessment procedures, whichare not of concern here, three individual treatmentgroups (modified systematic desensitization, insight-oriented psychotherapy, and attention-placebo treat-ment) and two control groups ("wait-list" and "no-contact") were formed, equating all groups (M andSD) on performance anxiety measures. Four weeksafter Test 1, the individual treatments were begun,running concurrently for S hr. over a 6-wk. periodwhile all 5s continued in the speech course. Fiveexperienced therapists (of Rogerian and Neofreudianpersuasion) worked with two 5s in each individualtreatment group. Six weeks following terminationof individual treatments, the test battery was againadministered to the entire population (Test 2), andimprovement ratings given by treated 5s.

The 10 5s who were assigned to the group-desensi-tization procedure were treated during the secondsemester, after completion of the speech course.These latter 5s were selected from the "wait-list"controls of the first semester who showed no reduc-tion in anxiety scores from Test 1 to Test 2, inaddition to matching individual treatment groups onperformance anxiety measures. The 10 matcheduntreated controls were drawn from the "no-contact"controls of the first semester and equated withgroup-desensitization Ss on all variables as indicatedabove, for evaluating effects of the group treatmenton GPA. The additional 22 untreated controls con-sist of the remaining untreated males from the firstsemester who were equated with all groups on per-formance anxiety measures. Test 1 and Test 2 thusprovide pretreatment and 6-wk. follow-up (FUi)assessments for individual treatments, and delineatea "wait period" for group desensitization.

Group desensitization began 4 wk. after Test 2and continued for a total of nine sessions on aweekly basis. Two experienced therapists, one ofwhom had been a therapist for the individual treat-ments, and the other, the supervisor for all indi-

8 The original battery also included a form of theAnxiety Differential (Husek & Alexander, 1963).This form was excluded from follow-up analysissince an additional stress administration was notobtained.

vidual treatments, conducted the group treatment inclosed groups of five 5s each. A 6-wk. follow-up(FUi) administration of the test battery, includingself-ratings of improvement, was also obtained ontermination of the group treatment. After Test 2,all 5s except those treated by group desensitizationwere not contacted again until the 2-yr. follow-up(FUn). However, the names of the matched controlsv/ere placed on file for later determination of aca-demic performance. The details of all aspects ofprocedure and results through FUi, including treat-ment and therapist characteristics, are reported inthe earlier study (Paul & Shannon, 1966).

The 2-yr. follow-up (FUa) procedure consisted"simply" of tracking down 5s for another adminis-tration of the test battery, and obtaining GPAs 2yr. after treatment termination. The FUa test batterywas augmented with behavioral questionnaires inorder to obtain specific frequency data concerningthe occurrence of stress during the posttreatmentperiod, the frequency of external behaviors whichwould reflect predicted symptom substitution, andinformation regarding additional psychological treat-ment or use of drugs which might affect S's behav-ior or response to anxiety scales. Information onstress was obtained by asking Ss to indicate thefrequency of occurrence of each of a number ofevents in five major areas, for example, illness ordeath of loved ones. The behavioral frequencies re-garding possible symptom substitution included 13items designed to assess the minimal symptom-sub-stitution effects expected from traditional "dynamic"theory (Fenichel, 194S) of increased dependency(e.g., In the past two weeks, how many times didyou seek advice, guidance, or counsel from: friends?spouse/fiance? instructor/supervisor? Parents? phy-sician? others?), introversion (e.g., To how manyclubs or organizations do you currently belong?),and social anxiety (e.g., How many times have youparticipated in group discussion in the past month?).The complete behavioral questionnaires and validitydata are presented elsewhere (Paul, 1967).

Additional information was also requested regard-ing the date and audience size of public appearancesin order to analyze appropriately the PRCS and SR-speech scales. Even though self-ratings of improve-ment had previously failed to discriminate betweengroups, the same ratings of "specific" and "other"improvement were obtained from treated Ss at FU»as had been obtained at FUi, Final semester GPAswere also obtained from the University registrar 2yr. after treatment termination.

Since multiple contact is necessary to allow timefor location of 5s in order to prevent differentialresponse rates in our highly mobile population (e.g.,Fiske & Goodman, 196S) the following FUs-contactprocedure was established: A packet containing thetest battery, behavioral questionnaires, and ratingscales was mailed to the last known address ofeach 5 exactly 24 mo. from the date of treatmenttermination. A cover letter designed to elicit coop-eration and explaining the importance of participa-tion for one last time accompanied the packet. Thisletter set a date 3 wk. in the future by which com-

122 GORDON L. PAUL

pleted forms were to be returned. Those Ss notreturning forms by the first due date were immedi-ately sent a personal letter which further stated theimportance of their participation and established anew due date 2 wk. in the future. A complete newpacket was sent by registered mail to those Ss notresponding to the second letter, and to 5s for whomnew addresses were necessary, requesting immediatereturn. Those Ss not responding to the third letterwere personally contacted by telephone, and a prom-ise elicited to return data immediately. An arbi-trary cutoff date, exactly 27 mo. after treatmenttermination, determined "nonreturnee" status,

RESULTSReturn Rate

The adequacy of the follow-up procedurefor locating Ss and eliciting their cooperationwas the first major concern. Even though thesample was highly mobile (Paul, 1967), com-plete data were returned by 100% of treatedSs (N = 40) and 69% of controls (N = 22).Of the 10 nonreturning controls, 1 flatly re-fused, 6 failed to return after multiple con-tact, and 3 could not be located. Since thepurpose of long-term follow-up was to deter-mine the effects of the specific treatmentswhich were previously evaluated, Ss who hadmore than two contacts with any psycholog-ical helper during the posttreatment periodwere excluded from further test analyses.Two Ss were excluded from the insight group,on this basis, and one from individual syste-matic desensitization, while 10 untreated con-trols received treatment during the follow-upperiod. One additional control S was excludedon the basis of an extreme falsification score.It appears that most of the treated controlsand one treated insight S received treatmentfor anxiety-related difficulties, while one in-sight S and the individual-desensitization Ssought primarily vocational counseling. NoSs were excluded from group-desensitizationor attention-placebo treatments.

Although data from pretreatment and FUirevealed no significant differences betweenthe treated Ss who sought additional treat-ment during the follow-up period and thosewho did not, there is no question but thatthe retained controls constitute a biasedsubsample. The nonreturning controls werefound to differ from retained controls in show-ing significantly greater Pre-FUi increases ongeneral and examination anxiety scales, anda higher rate of academic failure over the

follow-up period (60% versus 27%). Thosecontrols excluded for receiving treatmentduring the follow-up period also differed fromretained controls over pretreatment and FUiassessments by showing a greater decrease ingeneral anxiety, lower extroversion scores,and significantly greater increases on all spe-cific anxiety scales. Thus, even though nodifferences were found on demographic vari-ables between retained controls and those lostor excluded, the retained controls appear tobe those who improved more from pretreat-ment to FUi, therefore raising the possibilitythat test comparisons with controls at FU2are likely to underestimate treatment effects.

Test-Battery Data over the 2-Yr. Follow-UpPeriod for Group-Desensitization Subjects

The overall evaluation of the stability oftreatment effects, and a test of differencesattributable to the two therapists administer-ing group desensitization, is most reasonablymade by analysis of changes from the secondpretreatment assessment (Pre2) to FUi andFU2, since Prei-Pre2-FUi comparisons weresubjected to detailed analyses earlier. Twoscales of the test battery (PRCS and SR-Speech) focus specifically on performanceanxiety in the speech situation which wasthe specific treatment target for all groups.Unlike earlier assessments, however, there wasno common reference speech for PRCS, andthe size of audiences to which Ss had beenexposed varied so greatly that the separatedistinction of SR-Speech was no longermeaningful (Paul, 1966a). Therefore, thesetwo scales were converted to T scores andcombined to form a Speech Composite scorebefore analyses were undertaken. The SR-Exam scale also provides assessment of spe-cific target anxiety for group-desensitizationSs, while the additional SR-scales report onperformance anxiety in two different interper-sonal-evaluative situations, neither of whichwas the specific focus of treatment. Theselatter scales, along with the general scales onExtroversion, Emotionality, and IPAT-Anxi-ety provide information on generalization, orconversely, symptom substitution.

A three-way trend analysis (therapists,Pre2-FUi-FU2, subjects) was performed ondata for each scale of the test battery. The

SYSTEMATIC DESENSITIZATION 123

TABLE 1ANALYSES OF VARIANCE ON SPECIFIC ANXIETY SCALES PROM PRETREATMENT (PREJ) TO 6-WEEK

(FUl) AND 2-YE AS (FUJFOLLOW-UPS FOR SUBJECTS TREATED BY GROUP DESENSITIZATION

Source

TherapistsError

Prej-FUi-FUsLinear componentQuadratic component

Therapist X Prej-FUx-FUaError

a

182

!1)1)2

16

Scale

Speech Composite

MS

3162.14110.17

3564.945985.801144.07168.1381.49

F

28.70**

43,75**73.45**14.04**2.06

SR-Exam

US

218.70292.33436.13871.20

1.075.20

17.08

F

—25.54**51.00**

——

SR-Interview

MS

9.64102.00391.44708.05

74.8241.6346.58

F

—8.40**

15.00**1.61

—

SR-Contest

MS

104.54100.53224.94423.20

26.672.13

23.28

F

1.04

9.66**18.18**1.15

—

Note.—N = 10.*p <.OS.

**# <.OJ.

summary of these analyses for the group 5sis presented in Table 1 for specific anxietyscales, and Table 2 for general scales. Themeans and standard deviations for all scalesunder the three administrations are presentedin Table 3.

Inspection of Tables 1 and 2 reveals nosignificant main effect for therapists excepton the Speech Composite which, as determinedearlier, was the result of higher initial scoreson the SR-Speech scale for one treatment sub-group. More importantly, the Therapist XPre^FUi-FUs interaction failed to approachsignificance on a single scale. The latter find-ing indicates that the subgroups did not differin movement over time, and, further, thatlong-term as well as short-term changes ef-fected by the two therapists were comparable.

Since earlier analyses bad found significantPrez-FUi improvement on all scales forgroup-desensitization Ss, significant Prea-FUi-FUs main effects were expected in thepresent analyses. Tables 1 and 2 show thatthese expected main effects were found, indi-cating significant movement over the threetesting periods. Of more interest are the linearand quadratic components of the Prea-FUi-FU2 effect. Since the earlier analyses ofPrea-FUi change had found significant im-provement for all scales of the test battery,a significant linear component in the absenceof a significant quadratic component (curva-ture) in the present analyses would indicatecontinued improvement from FUj to FUa inaddition to the significant improvementinitially obtained. Such an effect was found

TABLE 2ANALYSES or VARIANCE ON GENERAL SCALES FROM PRETREATMENT (PREJ) TO 6-WEEK (FUi) AND 2-YEAR

FOLLOW-UPS FOR SUBJECTS TREATED BY GROUP DESENSITIZATION

Source

TherapistsError

Prea-FUi-FUaLinear componentQuadratic component

Therapist X Prej-FUi-FUaError

if

182

(1)(1)2

16

Scale

Extroversion-Introversion

MS

158.70196.4348.54

.8096.2710.007.81

F

6.22**

12.33**1.28

Emotionality

MS

112.1476.72

127.44252.05

2.821.239.54

F

1.46

13.36**26.42**

——

IPAT-Anxiety

MS

213.33265.48339.70661.25

18.1511.4440.61

F

8.37**16.28**

——

Note.—N - 10,*# < .05.

**# <.01.

124 GORDON L. PAUL

TABLE 3MEAN SCORES ON SELF-REPORT SCALES OVER PRE-

TREATMENT (PREj), 6-WEEK (FUl), AND 2-YEAR(FUj) FOLLOW-UP ASSESSMENTS FOR

SUBJECTS TREATED BY GROUPDESENSITIZATION

Speech compositeSR-ExamSR-InterviewSR-ContestI PAT AnxietyEmotionalityExtroversion

Pres

M

118.245.540.136.842.720.415.7

SD

10.199.468.677.18

12.256.028.38

FU.

M

87.838.530.830.235.317.519.7

SD

13.608.897.076.088.795.458.10

FU2

M

83.632.328.227.631.213.316.1

SD

18.5211.336.706.679.654.977.58

Note.—N - 10.

for the SR-Exam scale, and for SR-Interview,SR-Contest, Emotionality, and IPAT-Anxiety.Inspection of the means for the latter scalesover the three assessments (Table 3) verifiesthe additional improvement from FUi to FU2

which these analyses indicate. For the SpeechComposite, which was the major focus of thegroup treatment, both linear and quadraticcomponents of the Pre2-FUi-FU2 effect weresignificant. As the means in Table 3 show, thesignificant linear component reflects improve-ment over the treatment period (Pre2-FUi)while the significant quadratic component re-flects stability of mean improvement from FUito FU2.

The only scale on which a significant quad-ratic component alone was obtained wasExtroversion. As the Extroversion means(Table 3) show, a Pre2-FUi increase in Ex-troversion score was followed by a slightFUj.-FU2 decrease. While this trend occurringon any other scale (except Emotionality)would be suggestive of "relapse," it shouldbe noted that the initial Pre2-FUi increasein Extroversion was previously found to bea linear continuation of a Prei-Pre2 increase,rather than a significant Pres-FUj. deflectionas on the other scales. Specific informationconcerning relapse may be seen better in theindividual data presented below.

Academic Performance of Untreated Controlsand Group-Desensitization Subjects

Since the primary bases of grading at theuniversity level are examinations and class-room participation, the GPA provides an ex-cellent external measure of effectiveness in the

treatment of interpersonal performance anxi-ety. A highly significant change in GPA fromthe semester prior to treatment to the semes-ter following treatment was obtained earlierfor Ss receiving group desensitization as com-pared with matched controls. To evaluate thelong-term effects of the group treatment onexternal performance, the GPAs for the fourthsemester following treatment termination wereobtained for Ss still in school, and the GPAsfor the last semester in school were obtainedfor 5s who had either been dropped or whohad graduated.

Although the 2-yr. follow-up GPAs are notbased upon a common semester, due to 5sbeing dropped from school or graduating,Figure 1 reveals that the mean change fromthe pretreatment semester remains essentiallythe same as that for the posttreatment semes-ter (posttreatment Ms = 3.562 for group de-sensitization and 2.573 for matched controls;FUz Ms = 3.S34 and 2.413, respectively;r=.62, p<.0l). The interaction betweengroups and Pre-FUg GPA was also highlysignificant (F = 8.57, df = 1/18, p < .01).Of even greater interest is the rate of aca-demic success (graduation or still in schoolin good standing) versus academic failure(dropped) for group-desensitization Ss andmatched controls. Two years after treatmenttermination, 90% of group-desensitization Sswere successful academically versus only 40%of controls matched for college, class, age, andpersonality variables (p < .05, Fisher-Yatestest).

1.00

•jo.60

.10

.20

0

-.20

-.40

-.60

SEMESTER SEMESTERTWO-YEAR

FOLLOW-UP

Fio. 1. Mean GPA change from pretreatment se-mester to posttreatment and 2-yr. follow-up semes-ters for 5s treated by group desensitization andmatched controls.

SYSTEMATIC DESENSITIZATION 125

SPEECHCOMPOSITE

oI-uo£-10

uXz< -20

CL -30

zbjs

IPAT-ANXIETY EMOTIONALITY

-12 -

SR-CONTEST

-12 -

INTROVERSION

-8

-12

-12 —

LEGEND

GROUPDESENSITIZATION

SYSTEMATICOESENSITIZATION

INSIGHT-ORIENTEDPSYCHOTHERAPY

ATTENTION-PLACEBO

CONTROL

FIG. 2. Mean reduction on personality and anxiety scales from pretreatment to 2-yr. follow-up (FU«)for 5s retained at FUa.

These results indicate that group desen-sitization did effect significant and lastingchanges in the extra-experimental performanceof treated 5s, adding support to the lastingbenefits found from self-report data. It istherefore of interest to compare the extentof long-term effects following group desen-sitization with those of the individual treat-ments.

Comparison of Group Desensitization withIndividual Treatments from Pretreatment toFU*

For purposes of comparison, the meanPre-FU2 reduction for each personality andanxiety scale common to all groups is pre-sented in Figure 2. The data for Extroversion-Introversion have been reflected to showdecrease in introversion, rather than increasedextroversion, for consistency of presentation.

Since the data and tests of differences amongindividual treatments and controls and indi-vidual 5 data for these groups have been re-ported in detail elsewhere with larger groups(Paul, 1967), concern here will be only inthe comparison of group desensitization withthe comparable 5s of the individual treatmentand control groups.

Inspection of Figure 2 reveals that the long-term gain for the group treatment equaled orexceeded that obtained for individual atten-tion-placebo treatment, insight-oriented psy-chotherapy, and untreated controls on everyscale except Extroversion-Introversion. Thecoefficient of concordance over all sevenscales was found to be highly significant(W = .76, p < .01), with the relative orderof improvement following: individual syste-matic desensitization, group desensitization,insight-oriented psychotherapy, attention-

126 GORDON L. PAUL

placebo treatment, and untreated controls.The two scales of most importance for theevaluation of specific treatment effects arethe Speech Composite, which reflects focalchanges for all groups, and SR-Exam, whichreflects change in an additional "target" forgroup desensitization. The Pre2-FU2 anxietyreduction obtained for group desensitizationwas significantly greater than for controls onboth Speech Composite and SR-Exam (t =2.57 and 4.18, respectively, p < .01). Addi-tionally, the long-term improvement for groupdesensitization on SR-Exam was significantlygreater than for insight-oriented psychother-apy (t = 2.07, p < .05) and attention-placebotreatments (£ = 2.84, p < .01). Differencesbetween individual and group desensitizationdid not approach significance on either scale,nor did mean differences between the grouptreatment and either insight- or attention-placebo groups reach statistical significanceon the Speech Composite (t < 1). The latterfinding is a result of additional mean improve-ment over the 2-yr. follow-up period for in-sight and attention-placebo groups (Paul,1967).

Tests of significance on the other scales ofthe test battery found group desensitization toproduce significantly greater long-term reduc-tions in Emotionality than all individualtreatment and control groups, and a signif-icantly greater reduction than the controlgroup on SR-Contest. Differences approach-ing significance (p < .10) were found betweengroup desensitization and insight on IPAT-Anxiety, and between group desensitizationand both attention-placebo and untreated con-trols on SR-Interview. No significant meandifferences between group desensitization andother groups were found for Extroversion-In-troversion (dotted lines in Figure 2 showPrei-FU2 change). Except for the Emotional-ity scale, no significant differences were foundbetween the individual and group applicationsof systematic desensitization, even thoughthe group treatment was not aided initiallyby concurrent enrollment in the speech course.

Although mean differences presented abovesuggest that the group treatment producedstable treatment effects with positive gen-eralization as effectively as individual de-sensitization, and more effectively than other

procedures, clinical workers are more oftenconcerned with percentage case improvementthan with parametric group differences. Addi-tionally, because negative^ treatment effects, or"symptom substitution," would be more easilyidentified from data on individuals, all testdata were further evaluated on the basis of in-dividually significant Pre-FUa change scores.4

Overall improvement rates presented inTable 4 disclose significant differences infavor of both desensitization treatments forfocal effects reflected by the Speech Com-posite, and for group desensitization comparedwith all other groups combined on the SR-Exam scale. Especially striking is the findingthat not a single case retained at FU2 fromany group showed a significant increase on theSpeech Composite, nor did a single desensitiza-tion 5 show a significant increase on the SR-Exam, although both attention-placebo andinsight groups did show a small percentage ofcases changing in the "worse" direction onthat scale. The "other comparisons" in Table4 reveal generalization of positive treatmenteffects for both densensitization treatments,with neither desensitization group showinggreater than chance (2.5%) shifts in the"worse" direction which might be interpretedas "symptom substitution."

Before concluding that the symptom-substitution effects and relapse expected onthe basis of traditional theories had not oc-curred, a more sensitive analysis was madeof individual data from FUi to FU2. Aninstance of "relapse" would be identified asa case who had previously shown a signifi-cant Pre2-FUi decrease on Speech Compositeor SR-Exam scales, who later showed a sig-nificant FUi-FU2 increase. Similarly, if asymptom-substitution process were operating,a FUi-FU2 change in the "worse" directionshould be obtained on nonfocal scales forgroup-desensitization Ss who maintained im-provement on the Speech Composite and SR-Exam. Classifying each FUi-FU2 changescore on the basis of one-tailed .OS level

4 An individual case was classified as "signifi-cantly improved" or "significantly worse" on thebasis of two-tailed .05 level cutoffs established bymultiplying the standard error of measurement foreach instrument (previously determined from a pop-ulation of 523, Paul, 1966a) by 1.96.

SYSTEMATIC DESENSITIZATION 127

TABLE 4

PERCENTAGE OF CASES SHOWING SIGNIFICANT CHANGEFROM PBETREATMENT TO 2-YEAR FOLLOW-UP

Treatment

Focal treatment (SpeechComposite) :•

Group desensitizationSystematic desensitlzationInsight-oriented psychotherapyAttention-placebo treatmentUntreated controls

Focal treatment (SR-Exam) ;bGroup desensitlzationSystematic desensltizationInsight-oriented psychotherapyAttention-placebo treatmentUntreated controls

All other comparisons (fivescales) :°

Group desensltizationSystematic desensitlzationInsight-oriented psychotherapyAttention-placebo treatmentUntreated controls

Signifi-cantly"Im-

proved"

80%89%50%50%27%

70%44%25%20%9%

38%42%30%24%22%

NoChange

20%11%50%50%73%

30%56%62%70%81%

60%58%65%68%71%

Signifi-cantly

"Worse"

—————

——13%

10%

2%

5%8%7%

Note.—2V — 11 for controls, 10 for group desensltizationand attention-placebo, 9 for systematic desensltization, 8 forInsight. Due to small expectancies in cells, chl-squares werecomputed with the following grouping: Both desensitlzationvs. Insight + Attention-Placebo vs. Controls, df = 2. Classi-fications derived by two-sided .05 cutoffs on each change score.

• x» -9.91, p < .01.b x* •* *-16. P < -IS; Fisher exact probability for group

desensitlzation versus all others, p *» .003.<X* =5.89, p <.06.

cutoffs,6 not a single group-desensitization Sshowed evidence of relapse on the SpeechComposite or SR-Exam scales. Of the SOadditional comparisons, which would reveal"symptom substitution," only three scoreswere in the "significantly worse" direction,and two of these were accounted for by thesame 5 who failed to show significant im-provement initially. Thus, as previouslyfound for individual-treatment 5s (Paul,1967), FUi-FUg changes in the "worse"direction for group-desensitization 5s did notexceed chance expectation.

The frequency data obtained from the 13-item behavioral questionnaire specifically con-structed to reveal hypothesized symptom-substitution effects if such a process wereoperating, also failed to provide any supportfor the symptom-substitution hypothesis.Kruskal-Wallis one-way analyses of varianceby ranks over the five groups on each itemproduced an H < 4.88 (p > .30) for all itemsbut one. On the remaining item, the five

"One-tailed cutoffs for "relapse" and "symptomsubstitution" were established by multiplying thestandard error of measurement for each instrumentby 1.6S.

groups were divergent at only the .20 level.Similarly, Kruskal-Wallis analyses over thefive groups for frequencies in each of thefive areas of stress found none divergent atless than the .20 level of significance.

While client self-ratings of improvementhave consistently failed to discriminate be-tween treatments (Paul, 1966a, 1967), directstatements of perceived improvement stillappear to be of interest. Mean ratings of im-provement specific to speaking, examinations,and "other areas" obtained at the 2-yr.follow-up for Ss treated by group desensitiza-tion were as high or higher than those forany individual treatment, falling at "muchimproved" for the speech situation, and"somewhat-much improved" for examinationand other areas. In addition, no significantdifferences were found in correlational analy-ses between group desensitization and theresults previously obtained for individualtreatments (Paul, 1967). The FUi-FU2 sta-bility coefficients were generally in the high.60s, and Prea-FUg improvement was pre-dictable from earlier improvement scoresbased upon different instruments and situa-tions (r's in .50s and .60s). Thus, the FU2

data for group desensitization may also beconsidered reliable, predictable, and valid.

DISCUSSION

In general, the results of the presentinvestigation substantiate the earlier findings(Paul & Shannon, 1966) that the method ofsystematic desensitization found effective inindividual treatment (Paul, 1966a, 1967) canbe efficiently combined with group discussionand administered in groups without loss ofeffectiveness in the treatment of interpersonalperformance anxiety. Analysis of both self-report measures, and the public behavioralcriterion of academic success, indicates thatthe significant reduction in maladaptive anx-iety and increased extratreatment effective-ness found earlier were maintained over thelong-term follow-up period, with evidence ofadditional generalized improvement in relatedareas. When these results are compared withlong-term effects obtained for comparable 5streated by individual programs of systematicdesensitization, insight-oriented psychother-apy, and nonspecific attention-placebo tech-

128 GORDON L. PAUL

niques, the group-desensitization treatmentwas superior to both the insight-oriented andattention-placebo programs.

In agreement with previous findings (Ban-dura, 1961; Grossberg, 1964; Paul, 1966a,1967; Ullmann & Krasner, 196S), the resultsof this study give added support to the in-creasing evidence against the occurrence of"relapse" and "symptom substitution" whichtraditional "dynamic" theories predict. Notonly did relapse not occur for either of thedesensitization treatments, but improvementwas also maintained for attention-placebo Ss.Further, differences between groups on de-pendency and extroversion, predicted on thebasis of the symptom-substitution hypothesis,were not found and generalized decreases inanxiety were obtained for desensitizationtreatments—exactly opposite to symptom-sub-stitution expectations, and in favor of a learn-ing interpretation. While no direct evidencewas available for assessing differential increasesin rigidity, as predicted from traditional the-ories, indirect evidence suggests that all 5sbecame, if anything, more spontaneous in theirbehavior. Thus, behavioral data reveal highfrequencies of participation in group discus-sions, social activities, clubs, and organiza-tions and a considerable amount of entertain-ing for Ss in all treatment groups. Addition-ally, the examples of "other areas" in whichSs treated by group desensitization reportedimprovement include statements such as:"self-confidence in general—more at ease withothers," "exercise, sleeping, relaxation," and"all times with people in general"—certainlynot indicative of increased rigidity.

While the assessment procedures and timeof follow-up of the present investigation dif-fer from those of the original investigationof group desensitization by Lazarus (1961),a comparison of outcomes for the two studiessuggests that group desensitization need notbe limited to treatment of specific phobias,but that it may be even more effective intreating generalized social-evaluative anxiety.Thus, in contrast to recent misconceptionswhich have appeared in the literature (e.g.,Patterson, 1966), this form of treatment isnot limited to specific isolated "symptoms,"nor are relationship and interview-discussionfactors considered unimportant. The failure

to find significant differences attributable totherapists lends support to the evidence thatthe methods themselves are the primaryfactor for outcome with group desensitiza-tion; however, it should be noted that thetherapists had considerable general clinicalexperience, and were also experienced withthe modified desensitization method. Addi-tionally, the therapists did attach importanceto the establishment of a personally involvedrelationship and were quite similar to oneanother in attitudes and techniques (Paul &Shannon, 1966).

Although the purpose of the present studywas not to pit group desensitization againsttraditional group methods, the effectivenessof group desensitization is enhanced uponcomparison with previous group studies whichhave utilized academic success or GPA asextratreatment indexes of improvement. Incontrast to occasional investigations whichreport improved academic performance fol-lowing "study skills" groups with college stu-dents (Ofman, 1964), previous studies oftraditional group treatment for anxiety andemotional problems have failed to obtainsignificant improvement in academic per-formance (see Chestnut, 1965; Paul & Shan-non, 1966). The one published study whichdid report an overall improvement in GPAfollowing traditional group treatment (Spiel-berger & Wietz, 1964) is difficult to interpretdue to the isolation of a unique personalitypattern in a subgroup of Ss which accountedfor the overall improvement, while those Ssmost similar to those of the present studyactually showed less initial GPA improve-ment than untreated controls (Paul & Shan-non, 1966). Even with individual treatment,Shepard (1965) reports only 32% academicsuccess for Ss treated for emotional problems,as compared to 37% for untreated controls,whereas the similar percentages for group-desensitization Ss and matched controls inthe present investigation were 90% and 40%.In addition to the present study, Katahn,Strenger, and Cherry (1966) also report im-proved GPA resulting from a different group-desensitization procedure and two studies ofindividual desensitization directed toward im-proving academic performance both reportsuccess (Johnson, 1966; Paul, 1964). Thus,

SYSTEMATIC DESENSITIZATION 129

while a controlled comparative investigationof differing group and individual treatmentsis desirable, results to date suggest thatgroup desensitization may be a more effectivegroup treatment of anxiety than other avail-able approaches. However, caution should beexercised in comparing the overall results ofthe individual treatments with the grouptreatment in the present study. Even thoughthe only series of investigations directlycomparing group treatment (mean contact= 23.7 hr.) with individual treatment ofshorter duration (mean contact = 17.7 hr.)found no significant differences to obtain(Imber, Frank, Nash, Stone, & Gliedman,1957), the additional 4 hr. of contact forgroup-desensitization 5s do result in a slightlack of comparability which may or may nothave important influences.

While this investigation was able to over-come difficulties of follow-up studies moreadequately than previous attempts at long-term assessment of group treatment, it stillsuffered from problems inherent to the natureof follow-ups in general. The untreated con-trols were known to be a favorably biasedsubgroup which may have overestimatedthe improvement attributable to intercur-rent life experiences, and underestimatedlong-term treatment effects. Total assessmentof cause-effect relationships was not possibledue to the necessary exclusion of Ss whoreceived additional treatment of unknownnature. Since the discriminating power ofany controlled investigation is likely to becontaminated by intervening experience, thefindings of the present study support previoussuggestions that more scientifically useful in-formation is likely to be obtained if futureefforts are directed toward short-term follow-ups of noninstitutionalized clients in whichtotal sample assessment may be obtained(May, Tuma, & Kraude, 196S; Paul, 1966b,1967; Stone etal., 1961).

Note should also be made of the short-term treatment involved in this study. Al-though most textbooks and case reports inthe literature suggest that individual andgroup treatments of "neurotic" problems arenecessarily long-term, the only "evidence"that long-term treatment is more effectivethan short-term treatment comes from thera-

pist ratings (Frank, 19S9; Lorr, 1962). Infact, there is some evidence that time-limited short-term therapy may be at leastas effective as and more efficient than long-term treatment, even with traditional meth-ods (Muench, 196S; Shlien, Mosak, &Dreikurs, 1962). Further, even in settingswhere long-term treatment may be favored,short-term treatment is more likely. Forexample, Strupp (1962) reports that a"large proportion" of psychiatric outpatientsare seen less than five times after diagnosticworkup at the North Carolina Memo-rial Hospital; Matarazzo (196S) states". . . [the] fact is that the majority of [out]patients . . . are typically seen for a grandtotal of fewer than ten sessions"; Leventhal(1964) reports less than 10 sessions for 88%of university counseling bureau clients; whileyoung adults treated for emotional problemsat counseling bureaus are reported to receivea mean of 6.4 sessions by Shepard (1965)and 4.06 sessions by Callis (1965). In thosecases where maladaptive behaviors and emo-tional reactions are more widespread andsevere, treatment would likely take longer.However, neither the severity of the problemsnor the length of treatment involved in thepresent study appears to differ significantlyfrom the majority of problems and treatmentdurations existing for other noninstitutional-ized adults. To summarize the conclusionsreported earlier by Paul and Shannon (1966),". . . since the combined group desensitiza-tion procedure required an average of lessthan two hours therapist time per client, thisshort-term, time-limited approach appears tobe not only effective, but efficient as well[p. 134]."

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(Received August 30, 1966)