Effectiveness of Structured Psyche-Drama and Systematic Desensitization in Reducing Test Anxiety David A

Home , Counseling psychology, Psychodrama

Journal of Counseling Psychology 1978, Vol. 25, No. 6, 499-505

Effectiveness of Structured Psyche-drama and Systematic Desensitization in Reducing Test Anxiety David A. Kipper and Daniel Giladi Bar Ilan University, Ramat-Gan, Israel

Thirty-six students with examination anxiety volunteered to take part in a study of the effectiveness of two kinds of treatment, the structured psychodrama method and the systematic desensitization procedure, in reducing test anxiety. They were randomly assigned to one of three groups: structured psychodrama, systematic desensitization, and a no-treatment control. All the subjects were tested before and after the treatments on two tests, the Suinn Test Anxiety Behavior Scale (STABS), which measures test anxiety, and the Neuroticism scale of the Eysenck Personality Inventory (EPI-N scale), which measures level of neurotic behavior. The results showed that subjects in both treatment groups significantly reduced their test-anxiety scores compared with the controls. This was also congruent with gains as tested in vivo. A comparison between the two treatments, however, showed no significant differences. Also, there were no statistical differences among the three groups on the measure of neuroticism either before or after the treatments. It is con- cluded that the structured psychodrama method is as effective a mode of counseling as systematic desensization in treating test anxiety.

One of the outstanding observations of possibility is that the diversity of the rec- the literature on the modification of test ommended treatments reflects a state of anxiety is the plethora of interventions uncertainty marked by the lack of consensus suggested for the treatment of this disorder. regarding the most effective forms of treat- In the long list of the reported treatment ment for test anxiety. On the other hand, it modalities one finds procedures such as could also signify a positive trend of systematic desensitization (Anton, 1976), a supplying a variety of treatment options to combination of systematic desensitization choose from in rendering services. This may and self-study instructions (Osterhouse, have a substantial appeal to practicing 1972), autogenic relaxation (Reed & Meyers, counselors who recognize that no single 1974), cue-controlled relaxation (Russell & treatment can be equally effective for every Sipich, 1974), self-counseling with relaxation client and who are frequently confronted (Allen, 1973), covert positive reinforcement with the task of adjusting treatment proce- (Finger & Galassi, 1977, Guidry & Randolph, dures to suit the needs of the individual case. 1974), cognitive modification (Meichen- In that respect widening the range of effec- baum, 1972), rational-emotive treatment tive treatment options might be regarded as (Goldfried & Sobocinski, 1975), implosive a useful development. therapy (Smith & Nye, 1973), and modeling Despite their diversity, however, the (Sarason, 1975), to mention only a few. The counseling approaches for test anxiety seem implications of the existence of this long and to have two interesting characteristics in diversified list are not entirely clear. One common. One is that nearly all of them stem from learning principles and utilize psychological technologies associated with The study was supported by Grant 01-3394 from Bar behavior therapy. For the proponents of the Ilan University. Thanks are extended to Zipora behavioristic approach this represents an Fleishman for her valuable contribution. Requests for reprints should be sent to David A. asset, an added validation for their orienta- Kipper, Department of Psychology, Bar Ilan University, tion. But for those psychologists who ad- Ramat-Gan, Israel. here to other approaches, widening the range

499 500 DAVID A. KIPPER AND DANIEL GILADI of treatment options within the traditional chodrama are required to use their sponta- behavioristic framework may have a rather neity rather than their memories (Moreno & limited appeal. Unfortunately for them the Kipper, 1968). Sponaneity, for all practical research with techniques other than those purposes, implies developing an appropriate designated as behavior therapy has not been response to a new situation or a new, as well very helpful so far. as appropriate, response to an old situation The second common characteristic is that (Moreno, 1946). To enhance this process many of the reported approaches for dealing numerous psychodramatic techniques have with test anxiety seem to have followed one been devised. Among the better known ones basic principle. This principle maintains are the empty chair, the double (sometimes that the most important factor governing the known as the alter-ego), and the role rever- extinction of phobias is "arranging for the sal. It seems, therefore, that the method of phobic client to successfully confront (ima- psychodrama might be an ideal medium for ginally or in vivo) the sources of his anxiety implementing the principle of anxiety ex- without experiencing the catastrophic consequences neurotics typically anticipated" tinction and prove to be an effective method (O'Leary & Wilson, 1975, p. 233). Thus, to deal with psychological disorders char- regardless of the different learning principles acterized by excessive anxiety reactions. underlying the suggested treatments, in The purpose of the present study was to practice most of them employed technical test the hypothesis that the structured psy- procedures which, in fact, represent an im- chodrama method—a variant of psycho- plementation of this aforementioned basic drama—is as effective a mode of treatment principle. for test anxiety as the systematic desensiti- But adherence to this principle is not ex- zation procedure. clusively contingent upon the adoption of those procedures traditionally associated with behavior therapy. It is quite possible Method to follow this principle using other interventions. One example of these is the techniques used in psychodrama. Subjects The psychodrama method (Moreno, 1946) stems from theoretical concepts that differ Thirty-six students (27 women, 9 men) from Bar Ilan from those underlying the behavior therapy University participated in the study. They were vol- unteers who responded to a public announcement so- approach. In practice, however, it uses liciting applicants for an experimental program for procedures and techniques which can easily treating test anxiety. The announcement described the implement the components described in the exploratory nature of the program, its requirement, and above principle of the extinction of phobias. duration. The original 40 students who applied were The psychodramatic treatment is based on randomly assigned to one of three groups, but subse- quently 4 students withdrew, leaving only 36 subjects the simulation of environmental and psy- in the program. The three groups to which the subjects chological realities. In these simulated were assigned included two experimental treatment constellations a client can explore, through groups and one waiting-list control group. Of the two acting, past, present, and if desired, even treatment groups, one received structured psycho- future behavior in a special learning condi- drama treatment. It consisted of 14 subjects with a tion. This special, simulated condition mean age of 28.3 years (SD = 9.3). The second treatment group received systematic desensitization treat- protects the client from being the victim of ment. This group consisted of 10 subjects with a mean uncontrolled adversive consequences which age of 28.1 years (SD = 11.1). The control group con- may result from his or her actions. The sisted of 12 subjects with a mean age of 26.3 years (SD , awareness of such a protection facilitates = 6.1). confrontations with hitherto fearful situa- The subjects were 20 undergraduate and 16 graduate tions and thus provides an opportunity to go students from the social sciences and the liberal arts. Twenty-one of them had been, in the past, in some form again through the motions experiencing new, of counseling or psychotherapy directly or indirectly nonthreatening emotions. In psychodra- related to their coping difficulties in testing situa- matic terminology, the participants in psy- tions. PSYCHODRAMA TREATMENT OF TEST ANXIETY 501 Treatments proper. One was the empty chair, a psychodramatic technique that was elaborated and widely used in Ges- Two kinds of psychological treatments were included talt therapy. In the present application it involved in the study, one for each experimental group. These talking to an imaginary person or even an imaginary were a systematic desensitization method and a struc- behavioral quality as represented by an empty chair. tured psychodrama method. A detailed description of Examples of such qualities are fear, anxiety, ambition, these modes of treatment is provided in the fol- and so on. The second technique was role reversal, lowing. which requires the subjects to change their identity with Systematic desensitization. This treatment proce- that of another significant person as portrayed by a dure followed the desensitization method advocated by fellow subject acting as a helper. The helper could be Wolpe (1969) with the exception that it was rendered in small groups of three or four participants each rather representing a real person, for example, the examiner, than on an individual basis. It began with an intro- a personified aspect of the actor's personality, for ex- ductory session to familiarize the participants with each ample, the lazy part, or even a personified inanimate other, share and discuss their test-anxiety experiences, object, for example, a notebook, an examination ques- and receive information about the nature of the proce- tionnaire, a watch, and the like. The third was the dure. The next two sessions were devoted to the double technique, which involved a fellow subject in the practice of a muscular-relaxation technique (see Rimm role of an extension of the actor's own self. This double & Masters, 1974). In each of these sessions the subjects usually portrayed the unexpressed part of the actor, the were directly relaxed by their counselor. During the 2 inner voice. Acting alongside the actor, the double weeks between the sessions they were asked to practice strived to facilitate a fuller expression of the feelings and at home, once a day, using a preprepared cassette re- thoughts embedded in the portrayed situation. The cording of the relaxation instructions. They were also practice of these three techniques used non-test-anxiety instructed to record their progress on a chart which was related situations such as arguing with a friend about discussed in the sessions. The ensuing 10 sessions which movie to attend. comprised the desensitization proper. This was based The ensuing 10 sessions comprised the structured on a preprepared 20-item (situations) hierarchy related psychodrama method proper. It was based on the en- to test anxiety. These items were arranged in a pro- actment of the same 20-item (situations) hierarchy used gressive order from the least to the most anxiety-evok- in the desensitization method. The procedure of the ing situations. The subjects were asked to imagine each item as it enactment was as follows: The 20 items were classified was read to them by their counselor. They were relaxed into psychodramatic units. Such units were comprised before and after each item exposure. An item was of one item, sometimes two or three pooled together, considered desensitized when it was visualized by all the which constituted an interrelated behavioral sequence. group members three successive times, for 30 seconds An example of a one-item unit was "sitting at your desk each, without evoking anxiety. Typically, a desensiti- the evening before the examination." An example of zation session covered three items. It began with a re- a multi-item unit was "sitting in the examination room, hearsal of the last one or two items desensitized in the and watching the examiner enter the room with a pile previous session and then proceeded with the new items. of questionnaires under his or her arm." Each unit was The last part of each session, about 15 minutes, was enacted in three successive parts. The first part was devoted to a discussion of the subjects' experiences exposing the actor to the situation as simulated in the during the desensitization procedure. The final session therapy room. There he or she was asked to soliloquize, included a summary and evaluation of the entire loudly, the feelings and thoughts, and to confront an treatment. empty chair. In the second part, still the same situa- Structured psychodrama. This mode of therapy was tion, helpers were introduced as doubles, and any other based on the psychodrama method originated by Mo- pertinent role depending on the situation. In this part reno (1946). It varied slightly, however, from the classic the actor typically reversed roles with the helpers, again psychodrama procedure in that it was rendered in a according to the content of the situation and the infor- structured format which was repeated for each subject mation elicited by the double. The third part was a rather than the highly spontaneous manner which complete reenactment of the entire unit, only this time characterizes Moreno's original method. To denote this the way the actor would have liked it to happen. To aid difference the presently employed procedure was the actor a double was typically introduced as a rein- termed structured psychodrama. As a rule, the structured psychodrama method fol- forcer of the desired behavior. The time required for lowed the general procedural structure used in the the enactment of one unit in its entirety ranged from 10 systematic desensitization. It was also rendered in to 20 minutes depending on the number of items com- small groups of three or four participants each, had an prising the unit. introductory session, two practice sessions, and 10 Each unit was role played, repeatedly, by each par- treatment meetings followed by a summary session. ticipant with the other group members taking turns as The first session allowed the participants to introduce helpers. A treatment session covered the enactment themselves to each other, share their test-anxiety ex- of one or two units by every participant. The last 15 periences, and receive information about the procedure. minutes of every structured psychodrama session was The next two sessions were devoted to the practice of devoted to a brief discussion of the subjects' experi- the following three psychodramatic techniques, which ences. The final session included a summary and were to be used extensively during the treatment evaluation of the entire treatment. 502 DAVID A. KIPPER AND DANIEL GILADI Procedure Table 1 Means and Standard Deviations of STABS Upon signing up for the program the subjects were and EPI-N Scale Scores Obtained by the given two psychological tests: the Suinn Test Anxiety Three Groups Before and After the Behavior Scale (STABS; Suinn, 1969) and a general Treatments neuroticism test, the Neuroticism scale of the Eysenck Personality Inventory (EPI-N scale; Eysenck, 1947). In STABS EPI-N addition, a background information form was admin- Group n Before After Before After istered. This included questions regarding familial history, study habits, subjects of studies, and treatment Psychodrama 14 history. The testing situations were conducted indi- M 168.42 149.92 10.92 10.57 vidually. On the basis of the obtained information, a SD 26.92 23.52 2.97 2.62 20-item (situations) hierarchy was established to serve Desensitization 10 both treatment modalities used. M 154.30 142.00 10.80 10.20 The subjects were randomly assigned to one of two SD 33.55 36.30 2.93 2.93 experimental treatment groups and a waiting-list group. Control 12 The treatments were offered in small groups, once a M 169.75 169.16 13.58 12.66 week, for a period of 14 weeks. Each treatment was SD 37.50 33.36 3.42 2.34 rendered by a trained counselor. One counselor had studied psychodrama in a graduate program under the Note. STABS = Suinn Test Anxiety Behavior Scale; EPI-N supervision of the senior author and had 1 year of ex- = Neuroticism scale of the Eysenck Personality Inventory. perience; the other counselor had 1 year of experience in behavior therapy. Subjects assigned to the control group were informed that there are no more openings analyses of variance, one for the STABS and in the treatment groups and that they would have to one for the EPI-N scale. For the STABS wait for their turn about 3 months. At the end of the scores the results were nonsignificant, F(2, 14-week period all the subjects were retested on the 35) = .7. For the EPI-N scale scores, how- STABS and the EPI-N scale. Again, the testing was conducted individually. The participants in the two ever, the results were close to but not quite treatment groups were also asked for their subjective significant, F(2,35) = 3.0, p = .06. In terms evaluation of their gains. The program was designed of the difference between the first (before) so that the last treatment session fell during the exam- and the second (after) testing results, Table ination period. At that point, the subjects had already 1 shows that on the measure of test anxiety had the opportunity to test their gains in vivo and pro- vide realistic feedback. (the STABS) there was a decrease in the mean scores obtained by both the structured Results psychodrama and the systematic desensitization groups. The scores of the controls on Table 1 presents the means and standard the same test remained almost identical in deviations of the STABS and the EPI-N the two testing conditions. By contrast, the scale scores obtained by the structured results on the measure of neuroticism, the psychodrama, desensitization, and control EPI-N scale were remarkably similar in both groups. These are shown separately for the testing conditions for all three groups. pretreatment and the posttreatment testing To determine the significance of the dif- conditions under the headings before and ferences among the scores obtained by the after. three groups in the second testing condition, The scores obtained by the three groups two separate analyses of covariance were on the STABS in the before testing condi- conducted, one for the STABS and one for tion were equivalent to the 85th-95th per- the EPI-N scale. In these analyses the centiles of the American samples (Suinn, scores obtained in the pretreatment testing 1969). In the after testing condition they fell condition were held as covariates. The re- to the 65th-70th percentile except for the sults showed significant differences among controls, whose scores remained in the 95th the three groups only on the measure of test percentile. The scores on the EPI-N scale anxiety (the STABS), F(Z, 35) = 8.3, p < for the three groups in both testing condi- .001, but not on the measure of neuroticism tions were within the normal range for Israeli (the EPI-N scale). For the scores obtained subjects. on the latter measure the main effect was The significance of the differences among nonsignificant, F(2, 35) = .3. the three groups in the first (before) testing Following these findings an additional conditions was determined by two separate analysis of covariance with the STABS PSYCHODRAMA TREATMENT OF TEST ANXIETY 503 scores was conducted. This analysis aimed between these two measures was .44 in the at determining the usefulness of receiving pretreatment testing condition and .41 in the treatment, regardless of kind, in reducing second testing condition. test anxiety. The STABS scores of the two Finally, upon the completion of the treatment groups on the second testing treatments the subjects were asked for their condition were pooled together and com- subjective evaluation of the outcomes. It pared with those of the control group with should be recalled that at that time they had the scores obtained on the first testing con- already had opportunities to test their gains dition held as covariates. The results in vivo. Nearly all the responses were posi- showed a significant main effect for the tive, indicating a considerable reduction of factor of treatment, F(2,35) = 15.8, p < .001. test anxiety. It appears, therefore, that both treatment groups reduced their test anxiety as measured Discussion by the STABS significantly more than the controls who received no treatment at all. The fact that both modalities, the struc- The next question was which of the two tured pyschodrama method and the sys- treatments was the more effective modality. tematic desensitization procedure, proved The answer to this question was sought to be equally successful gives credence to the through yet another analysis of covariance value of the former mode of treatment. It comparing the STABS scores obtained on demonstrated that the structured psycho- the second testing by the structured psy- drama method can reduce test anxiety as chodrama group with those of the systematic effectively as the systematic desensitization desensitization group. Again, the STABS procedure, which has been one of the most scores obtained in the first testing served as recommended methods to deal with test covariates. The results showed a nonsigni- anxiety (e.g., Richardson & Suinn, 1974; ficant main effect, F(l, 23) = .9, indicating Scissons & Njaa, 1973). The practical ad- that both modes of counseling were equally vantages of having structured psychodrama effective. as a competitive form of treatment are first, The scores of all the subjects in the first that it provides counselors with a wider administration of the STABS and the EPI-N range of treatments to choose from and sec- scale were also analyzed according to seven ond, that this choice may also accommodate background factors. A series of separate practitioners of a wider range of counseling one-way analyses of variance and t tests orientations. showed no significant differences on either An important implication of the results of test for six of these factors, namely, age, this study concerns the use of desensitization marital status, length of stay in Israel, years as a target by the structured psychodrama of study, major subject, and past involve- method. The extinction of anxiety reac- ment in psychotherapy. On the factor of the tion(s) with the desensitization procedure is sex of the participants, however, females an innovation introduced by the behavio- scored on the STABS significantly higher ristic approach and not by psychodrama. In than males but only in the pretreatment fact, a comparison of the theoretical princi- testing (M = 172.07, SD = 31.1 vs. M = ples underlying these two treatment 143.55, SD = 27.1), t(35) = 2.44, p < .01. modalities shows some incompatible dif- The issue of sex differences was not pursued ferences. For example, psychodrama theory beyond this analysis due to the small number adheres to dynamic concepts such as ca- of male participants (two in each treatment tharsis and spontaneity which are rejected group). by behavioristic theories. Despite the the- The relationship between the measure of oretical differences, in practice some simi- test anxiety (the STABS) and that of neu- larities are also evident. These can be il- roticism (the EPI-N scale) remained the lustrated in the case of the procedures used same throughout the entire study in spite of for desensitizing test anxiety. Thus, de- the reduction of test anxiety by the treated sensitization can be broadly defined as a groups. The product-moment correlation procedure that exposes the phobic person to 504 DAVID A. KIPPER AND DANIEL GILADI the sources of the anxiety but without ex- range. With the absence of abnormally high periencing the catastrophic consequences he EPI-N scale scores there is no reason to ex- or she typically anticipates. In the system- pect any significant effect of the intervention atic desensitization procedure the exposure on neuroticism. is done by visual imagination, whereas in the An issue that requires a further comment structured psychodrama method it is concerns the meaning of the changes in the achieved by simulating the anxiety-evoking STABS scores following the two treatments. situations. In systematic desensitization the Although these changes proved to be statis- catastrophic consequences are prevented by tically significant, the posttest scores of the pairing the exposure with relaxation. On two treated groups were equivalent to the the other hand, in structured psychodrama 65th-70th percentile of the American norms. they are prevented by introducing the fol- Such results raise the question of whether or lowing two interventions: One is the use of not the treatments could be considered the double technique, which offers instan- clinically successful. The subjective, overall taneous support, and the role-reversal evaluation of the outcomes given by the technique, which provides temporary de- treated subjects tends to support the effec- tachment from the emotional state. The tiveness of the interventions. As to the rel- other intervention is providing the client atively high percentile level of the posttest with the opportunity to experience an al- STABS scores, two possible explanations ternative, desired situation. Also, in both might be advanced. First, the final testing forms of treatment the client is given a sub- on the STABS was conducted immediately stantial degree of control over the perfor- at the termination of the treatments and mance. Thus, the structured psychodrama, during the school's examination period. At although traditionally considered a dynamic this point the subjects had already taken one form of treatment, in the present case can be or two exams but did not have their results. regarded as a variant of in vivo desensitiza- It is quite conceivable that the absence of tion, or rather a simulated in vivo desensit- these results left a residual higher anxiety ization. level which was also reflected in their per- The notion of a simulated in vivo de- formance on the STABS. Thus, from the sensitization procedure raises an additional point of view of research strategy, termi- possibility. It suggests that perhaps the nating the counseling shortly before the structured psychodrama method may be school's examination period has both ad- used as a substitute for in vivo desensitiza- vantages and disadvantages. The advantage tion where access to the original anxiety- is that it allows the subjects to test their evoking situation is either difficult or im- gains in vivo. The disadvantage is that practical. self-reports regarding the attained anxiety The results also showed that the two forms level may be contaminated by the tension of treatment reduced the level of test anxiety characterizing this period. Second, a com- of the treated subjects but did not change parison between the present STABS scores significantly their level of general neuroti- and the American norms must be inter- cism. In fact, the EPI-N scale scores of all preted with caution. One should bear in three participating groups hardly changed mind the possibility of norm variations due from the first to the second testing condi- to cultural differences between American tions. The effect of the treatments was, and Israeli samples and the fact that the therefore, restricted to their intended target, average age of the present subjects was un- the reduction of test anxiety. Similar re- doubtedly much higher than that of the stricted effect was also noted in other studies students in the American sample (Suinn, (e.g., Anton, 1976; Bedell, 1976). It is pos- 1969). sible, however, that the lack of decrease in Interpreting the present results as a con- the general neuroticism level could be at- firmation of the effectiveness of the em- tributed to the groups' baseline, that is, their ployed treatments could be challenged on pretreatment EPI-N scale scores. This the ground of demand characteristics. It baseline showed scores within the normal could be argued that the obtained difference PSYCHODRAMA TREATMENT OF TEST ANXIETY 505 between the treated groups and the control Goldfried, M. R., & Sobocinski, D. Effect of irrational beliefs on emotional arousal. Journal of Consulting group was due to the counselors' expectation and Clinical Psychology, 1975,43, 504-510. for the treated subjects to get well. Or it Guidry, L. S., & Randolph, D. L. Covert reinforcement could be that the treated groups received in the treatment of test anxiety. Journal of Coun- special attention, irrespective of content or seling Psychology, 1974,21, 260-264. Meichenbaum, D. H. Cognitive modification of test procedure, while the controls did not. Ac- anxious college students. Journal of Consulting and cording to this a firmer conclusion regarding Clinical Psychology, 1972,39, 370-380. the effectiveness of the treatments employed Moreno, J. L. Psychodrama (Vol. 1). New York: could have been reached had the study in- Beacon House, 1946. Moreno, J. L., & Kipper, D. A. Group psychodrama cluded a placebo treatment control group. and community centered counseling. In G. M. Gazda Obviously, the lack of a placebo control (Ed.), Basic approaches to group psychotherapy and group is a limitation of studies such as the group counseling. Springfield, 111.: Charles C present one. Unfortunately, however, there Thomas, 1968. O'Leary, K. D., & Wilson, G. T. Behavior therapy: are practical as well as ethical problems Application and outcome. Englewood Cliffs, N.J.: which make the inclusion of this kind of Prentice-Hall, 1975. control difficult, as already pointed out by Osterhouse, R. A. Desensitization and study-skills Finger and Galassi (1977). Furthermore, it training as treatment for two types of test-anxious students. Journal of Counseling Psychology, 1972, might be recalled that about 60% of the 19, 301-307. participants had been, prior to the onset of Reed, R., & Meyers, R. G. Reduction of test anxiety via the present study, in psychological treat- autogenic therapy. Psychological Reports, 1974,35, ments regrading their difficulties, including 649-650. Richardson, F. C., & Suinn, R. M. Effects of two test anxiety. If the counselors' expectations, short-term desensitization methods in the treatment attention getting, or being involved in some of test anxiety. Journal of Counseling Psychology, supervised activities by themselves could 1974,21, 457-458. have reduced test anxiety in the present Rimm, D. C., & Masters, J. C. Behauior therapy: Techniques and empirical findings. New York: study, why did they not have similar effect Academic Press, 1974. in the previous treatments? Russell, R. K., & Sipich, J. F. Treatment of test anxiety by cue-controlled relaxation. Behavior Therapy, 1974,5, 673-676. 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