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Running Head: EXPOSURE COMBINED WITH PSYCHOTHERAPY 1
Exposure Combined With Psychotherapy:
A Treatment for Public Speaking Anxiety
Kayla Lord
The Pennsylvania State University
EXPOSURE COMBINED WITH PSYCHOTHERAPY 2
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 3
Dosed Exposure as 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
EXPOSURE COMBINED WITH PSYCHOTHERAPY 4
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 group’s 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).
EXPOSURE COMBINED WITH PSYCHOTHERAPY 5
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 therapist’s 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
EXPOSURE COMBINED WITH PSYCHOTHERAPY 6
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-
EXPOSURE COMBINED WITH PSYCHOTHERAPY 7
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 group’s mean score
on the BAT, while there was not a significant increase in the PE group’s. 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
EXPOSURE COMBINED WITH PSYCHOTHERAPY 8
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 study’s 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
EXPOSURE COMBINED WITH PSYCHOTHERAPY 9
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
EXPOSURE COMBINED WITH PSYCHOTHERAPY 10
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.
EXPOSURE COMBINED WITH PSYCHOTHERAPY 11
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
EXPOSURE COMBINED WITH PSYCHOTHERAPY 12
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;
EXPOSURE COMBINED WITH PSYCHOTHERAPY 13
p<.05). The results should also indicate a main effect for psychotherapy treatment, such that
those receiving psychotherapy will have a larger average reduction in PRPSA scores
(M=53.333) than those in the control group (M=35; p<.05). The results should also show that
there is a significant interaction between exposure treatment and psychotherapy treatment (p
<.05). Refer to Table 1 for the expected mean group differences.
In order to define the nature of the interaction, the mean difference for each condition
between post-testing and pre-testing PRPSA scores will be plotted and are expected to look like
Figure 1. It is expected that when paired with psychotherapy the dosed exposure treatment group
on average will have a larger reduction in PRPSA scores (M=80) than those in the prolonged
exposure group (M=50) and those receiving no exposure (M=30). Additionally, it is expected
that those not receiving psychotherapy will have smaller reductions in PRPSA scores across the
dosed exposure group (M=60), the prolonged exposure group (M=40), and the control group
(M=5). Therefore, when participants receive psychotherapy, receiving exposure treatment is
expected to decrease their public speaking anxiety symptoms more than if they received
exposure treatment alone.
Discussion
The expected finding of a main effect for psychotherapy would support the idea that
talking to a professional psychologist about one’s public speaking anxiety effectively reduces
symptoms. Again, this is because psychologists are specially trained to understand and help
patients work through complex problems and because they offer so much more than just dialogue
about the problem. Psychologists will help adolescents and young adults suffering from public
speaking anxiety understand why they fear public speaking anxiety, and help them move forward
proactively (American Psychological Association, 2014). The expected finding of a main effect
EXPOSURE COMBINED WITH PSYCHOTHERAPY 14
for exposure would support the idea proposed in preliminary research that not only is exposure
treatment an effective method for treating public speaking anxiety, but also that dosed exposure
is an equally if not more effective treatment as prolonged exposure. Dosed exposure is expected
to be more effective because it is less stressful and fear inducing for the participants due to the
fact that they are able to pause and relax during the treatment.
The expected finding of an interaction effect between psychotherapy and exposure
supports the theory that the effect of exposure treatment depends upon whether or not the
participant receives psychotherapy as well. While exposure treatment has been found effective in
desensitizing adolescents and young adults, and while it is true that practice makes a better final
performance, exposure treatment when accompanied with psychotherapy is expected to be more
effective. Not only do the participants get the opportunity to experience and overcome the feared
situation, they also have the opportunity to talk about their experiences with a professional
psychologist who will help them understand the problem in a way they had not previously and
ultimately, help them solve a complex problem. In conclusion, it is expected that the participants
in the group that receives psychotherapy combined with dosed exposure treatment will
experience the greatest decrease in their public speaking anxiety symptoms.
In regards to external validity, this study’s expected results could only applied to a certain
population. Due to the sample being composed of participants between the ages of 18 to 22-
years-old, the results can only be applied to those that fall between that age range. Additionally,
since the sample is composed of participants from a large university, it is not appropriate to
generalize to individuals that either attend small universities or state colleges, or do not attend
college at all. In regards to internal validity, it is extremely difficult to ensure that the
psychologists and psychotherapy sessions will be of equal quality. Since psychotherapy is
EXPOSURE COMBINED WITH PSYCHOTHERAPY 15
individualized by nature, it cannot be scripted and therefore, variations will exist. However, the
pilot test is meant to show if the psychologists and psychotherapy sessions are of relatively equal
quality.
It is possible that the data will not support the hypothesis. If this occurs, it is possible that
there would be no interaction between psychotherapy and exposure treatment. In this instance,
there would be equal differences in the mean differences of PRPSA (McCroskey, 1970) scores
for those receiving psychotherapy and those not receiving psychotherapy across the exposure
groups, showing that the effect of exposure on public speaking anxiety symptoms does not
depend up receiving psychotherapy. In this instance, it is logical to predict that main effects for
both psychotherapy and exposure would still exist because both treatments have already been
found effective in previous research studies.
If the results support the hypothesis, the next step would be to conduct a similar study
and add a third independent variable: amount of exposure sessions per week. This future study
would serve to discover how many sessions of exposure a week causes the largest reduction in
glossophobia symptoms. This future study could also include dependent variable measures other
than a self-report measure, perhaps a behavioral measure, or physiological measure to
completely encompass the domain of symptoms. This research is important because
glossophobia is an extremely common disorder. Most people dismiss public speaking anxiety,
and believe that those that suffer from it will just grow out of it but speech anxiety continues into
adulthood if left untreated. It is exceptionally important to use adolescents in the sample, which
has not been done often up until this point. Adolescents make up a large proportion of the
population with public speaking anxiety. Research should focus on finding the best treatment for
adolescent speech anxiety so that it can be treated early.
EXPOSURE COMBINED WITH PSYCHOTHERAPY 16
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EXPOSURE COMBINED WITH PSYCHOTHERAPY 18
Figures and Tables
Table 1. Influence of Psychotherapy and Exposure Treatment on Public Speaking Anxiety
Exposure Treatment
Psychotherapy Dosed Exposure Prolonged Exposure Control
Once/Week 80 50 30
Control 60 40 5
Once/Week Control0
10
20
30
40
50
60
70
80
90
DosedProlongedControl
Psychotherapy
Mea
n D
iffe
ren
ce in
PR
PSA
Sco
res
Figure 1. Interaction Between Exposure Type and Reception of Psychotherapy
Exposure