Automaticity in Clinical Psychology

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produced by hypnotic suggestions (e.g., Rainville, Duncan,. Price, Carrier ..... existential approaches from their inception (L. Greenberg,. 1994) and has been ...
Automaticity in Clinical Psychology Irving Kirsch Steven Jay Lynn

The authors provide an overview of the literature on the ability of response expectancies to elicit automatic responses in the form of self-fulfilling prophecies and link it to the broader psychological investigation of automatic processes. The authors review 3 areas of research in which response expectancies have been shown to affect experience, behavior, and physiology: placebo effects, the effects of false biofeedback on sexual arousal, and the alteration of perceptual and cognitive functions by hypnotic and nonhypnotic suggestion. Also reviewed are data suggesting that all behavior, including novel and intentional behavior, is initiated automatically. Following this review, the authors summarize some of the ways in which knowledge of response expectancy effects and other automatic processes that influence experience and behavior can enhance clinical practice.

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any of the thoughts, feelings, and behaviors that are of concern in clinical contexts appear to occur in an automatic fashion, without conscious volitional effort, and often beyond the person's control. Examples of clinically relevant automaticity are the feelings of anxiety and depression that lead people to seek psychotherapy, the reductions in physical pain produced by real or placebo analgesia, and the sexual arousal response to erotic stimuli. Automaticity is also a key characteristic of the experience of hypnosis, a clinical intervention that has been shown to enhance the effectiveness of psychotherapy to a clinically meaningful degree (see Kirsch, Montgomery, & Sapirstein, 1995). In this article we consider these phenomena in the context of a broader examination of automatic processes and their role in enhancing clinical interventions. Beginning with the seminal work of Shiffrin and Schneider (1977), there has been a burgeoning literature on automatic processes in cognition and behavior in experimental and social psychology. Separately, clinical psychologists have addressed the issue of automatic thoughts, feelings, and behaviors and the role they play in the etiology and treatment of psychological disorders (Beck, 1976; Kirsch, 1985). In this article, we provide an overview of the literature on the ability of response expectancies to elicit automatic responses in the form of self-fulfilling prophecies, and we link it to the broader psychological investigation of automatic processes. More extensive reviews of the various domains in which response expectancies affect experience and behavior can be found in Kirsch (1999). Although most mundane behaviors are experienced as being under voluntary control, emotions and their behav504

University of Connecticut State University of New York at Binghamton

ioral concomitants (e.g., laughing and crying) seem to spring up automatically. In addition, there are some circumstances (e.g., hypnosis) in which overt behavior that is normally experienced as voluntary comes to be experienced as automatic. Thoughts, feelings, and behaviors that are experienced as occurring automatically have been termed nonvolitional responses (Kirsch, 1985, 1990). As shown in this review, many nonvolitional responses are not only experienced as automatic but are in fact automatic. Many of them occur unintentionally and uncontrollably (e.g., depression and anxiety), and all of them are influenced by processes that lay outside of awareness. In fact, we argue that all responses are automatic, in the sense that they are not produced by an act of "will." A substantial body of research has indicated that nonvolitional responses can be generated and altered by the expectancy of their occurrence, a construct that has been termed response expectancy (Kirsch, 1985). Response expectancies are anticipations of automatic subjective and behavioral responses to particular situational cues, and their effects are a form of self-fulfilling prophecy. These effects differ from other self-fulfilling prophecies, however, in that they are predictions about one's own experiences and behaviors. The data indicate that response expectancies are important factors in the etiology, maintenance, treatment, and prevention of anxiety disorders, depression, substance abuse, and sexual dysfunction (Kirsch, 1999). In some ways, response expectancies are similar to intentions. Both constructs have been assessed as the subjective probability that a response will occur, and both have been shown to be excellent predictors of behavior (Ajzen & Fishbein, 1980; Kirsch, 1990, 1999). The primary distinction between them rests on the perceived volitional status of the behavior. People intend to perform voluntary behaviors (e.g., stop at a stop sign); they expect to emit automatic behaviors (e.g., cry at a wedding), even when they don't want to. We have adopted the term response set to refer to Editor's note.

Denise C. Park served as action editor for this article.

Author's note. Irving Kirsch, Department of Psychology, University of Connecticut; Steven Jay Lynn, Department of Psychology, State University of New York at Binghamton. We thank Wayne Braffman and Richard Brown for their helpful comments on earlier presentations of ideas developed in this article. Correspondence concerning this article should be addressed to Irving Kirsch, Department of Psychology, U-20, University of Connecticut, 406 Babbidge Road, Storrs, CT 06269-1020. Electronic mail may be sent to [email protected].

July 1999 • American Psychologist Copyright 1999 by the American Psychological Association, Inc. 0OO3-O66X/99/S2.00 Vol. 54, No. 7, 504-515

The harmless leaves used in the Ikemi and Nakagawa (1962) study functioned as placebos. That is, they were substances that did not have certain physical properties that were attributed to them (in this case, the property of producing skin reactions). Although most placebo responses are desired, the skin reactions produced by the harmless leaves were certainly not wanted, and this is an indication that placebo effects are automatic consequences of the person's beliefs. Besides contact dermatitis, placeboinduced response expectancies can produce changes in pain, anxiety, depression, alertness, tension, sexual arousal, asthma, and warts (reviewed in Kirsch, 1990, 1999). The literature documenting the effects of placebos is too large to be reviewed comprehensively in a single article. Here, we sample two areas in which response expectancy effects have particularly important clinical implications—depression and sexual dysfunction.

Listening to Prozac but Hearing Placebo Irving Kirsch Photo by John Manfred

response expectancies and intentions, because both of them prepare cognitive and behavioral schemas for efficient activation. The automaticity of many response expectancy effects is clear because they produce behavior that is contrary to intention, as when a placebo-induced expectancy produces anticipated noxious side effects. We argue that there is also considerable automaticity in the way in which intentions elicit behavior. In this article, we review three areas of research in which response expectancies have been shown to affect experience, behavior, and physiology: placebo effects, the effects of false biofeedback on sexual arousal, and the alteration of perceptual and cognitive functions by hypnotic and nonhypnotic suggestion. We also review data suggesting that all behavior, including novel and intentional behavior, is initiated automatically. Following this review, we summarize some of the ways in which knowledge of response-expectancy effects and other automatic processes that influence experience and behavior can enhance clinical practice.

Placebo Effects In a study reported by Ikemi and Nakagawa (1962), 13 students were touched on one arm with leaves from a harmless tree, but were told that the leaves were from a lacquer or wax tree (Japanese trees that produce effects similar to poison ivy and to which the boys had reported being hypersensitive). On the other arm, the students were touched with poisonous leaves, which they were led to believe were from a harmless tree. All 13 participants displayed a skin reaction to the harmless leaves, but only two reacted to the poisonous leaves. In this study, the effect of the harmless leaves was not only dramatic, it was also greater than the effect of the active substance. July 1999 • American Psychologist

The magnitude of the placebo effect varies as a function of the condition being treated, and depression, the common cold of mental health, is among the conditions in which it is particularly pronounced. In a meta-analysis of antidepressant medication, Kirsch and Sapirstein (1999) reported that the effect size (£>) for pretreatment-to-posttreatment changes in depression in patients given antidepressant drugs was 1.55. This is a very large effect, and it indicates that administration of an antidepressant medication results in substantial clinical improvement. However, the effect size for response to placebo was 1.16. This indicates that 75% of the effect of antidepressant medication can be duplicated by administration of an inert placebo. In contrast, analysis of the course of untreated depression over the same time period indicated an effect size of only 0.37 standard deviations. Taken together, these effect sizes suggest that about 25% of the response to antidepressant medication may be a true drug effect, another 25% may be due to the natural history of the condition, and 50% is an expectancy effect. Despite the magnitude of the placebo effect, the data in the Kirsch and Sapirstein (1999) meta-analysis indicate a reasonably sizable advantage for the active drug over placebo. However, there is reason to believe that much of this difference may be due to expectancy, rather than to the pharmacological properties of the drugs. Kirsch and Sapierstein reported that the correlation between response to medication and response to placebos across studies was .90. In an effort to track down the reason for this substantial correlation, they subdivided the set of studies by type of medication (e.g., trycyclics, selective serotonin reuptake inhibitors [SSRIs]). They found that the pretreatment-toposttreatment effect size was fairly consistent across drug type. More remarkable, the proportion of the effect size duplicated by placebo was virtually identical across medication type (range = 74% to 76%). The biggest surprise, however, came when they examined the effect size for a subset of studies in which the active drugs (amylobarbitone, lithium, liothyronine, and adinazolam) were not antidepressants. The effect of these drugs on depression (D = 505

Steven Jay Lynn

1.69) was as great as that of the antidepressants, and again an inactive placebo duplicated 76% of this effect. It seems unlikely that amylobarbitone, lithium, liothyronine, and adinazolam are in fact antidepressants with pharmacological effects as great as trycyclics, SSRIs, monoamine oxidase inhibitors, and the others. Instead, it is possible that all of these drugs function as active placebos. An active placebo is an active medication that does not have specific activity for the condition being treated. R. P. Greenberg and Fisher (1989) summarized data indicating that the effect of antidepressant medication is smaller when it is compared with an active placebo than when it is compared with an inert placebo. The reason for this difference seems to be related to the side effects produced by the drug. Because the active drugs produce more side effects than the inert placebo, most participants in studies of antidepressant medication are able to deduce whether they have been assigned to the drug condition or the placebo condition (Blashki, Mowbray, & Davies, 1971). This may produce an enhanced placebo effect in drug conditions and a diminished placebo effect in placebo groups. Thus, the apparent drug effect of antidepressants may in fact be a placebo effect, magnified by differences in experienced side effects and the patient's subsequent recognition of the condition to which he or she has been assigned. Support for this interpretation of the data is provided by a meta-analysis of fluoxetine (Prozac), in which a correlation of .85 was reported between the therapeutic effect of the drug and the percentage of patients reporting side effects (R. P. Greenberg, Bornstein, Zborowski, Fisher, & Greenberg, 1994). The Kirsch and Sapirstein (1999) meta-analysis was limited to studies of the acute effects of antidepressant drugs and placebos (the mean duration of the studies was 5 weeks). Walach and Maidhof (1999) extended these find506

ings to their long-term effects (6 months to 3 years). In the most stringent analysis of their data (reported in Kirsch, 1998), confined to studies in which dropouts were analyzed as treatment failures, the results were virtually identical to those reported in the Kirsch and Sapirstein (1999) metaanalysis. Walach and Maidhof indicated that 73% of the long-term improvement among patients treated with antidepressants was duplicated in patients treated by placebo, and the correlation between the proportion of patients responding to antidepressants and the proportion of patients responding to placebo was .93. In addition, another metaanalysis conducted on a different set of studies (Joffe, Sokolov, & Streiner, 1996) revealed pre-post drug and placebo effect sizes very similar to those reported by Kirsch and Sapirstein (1999). The close correspondence in the results of these three independently conducted metaanalyses, despite little or no overlap in the studies included for analysis (there were two studies that were included in both the Joffe et al. meta-analysis and the Kirsch and Sapirstein meta-analysis), indicate that the data they reported are very reliable. A methodological feature of the Walach and Maidhof (1999) meta-analysis provides further information on the relative advantage of active medication compared with inert placebo. Instead of using standardized mean improvement scores, as had been done in the other meta-analyses, Walach and Maidhof based their calculations on the number of patients showing long-term clinically significant improvement in the drug condition and the number showing long-term clinically significant improvement in the placebo condition. With dropouts categorized as treatment failures, 63% of the patients in drug groups improved, compared with 46% of patients in placebo groups—a difference of 17% (Kirsch, 1998). Thus, only one in six patients showed long-term clinical improvement following medication, but would not have done so following placebo.

Response Expectancy and Sexual Arousal The idea that sexual arousal and its inhibition are influenced by response expectancies has been supported by two bodies of data. One of these is research on the effects of placebo alcohol. The other is research on the use of expectancy manipulations to enhance sexual arousal in sexually dysfunctional women. Many people believe that alcohol reduces inhibition, thereby promoting expression of sexual impulses. If this were a pharmacological effect, we would expect to find it constant across cultures. In fact, the effect of alcohol on sexual behavior varies from culture to culture (MacAndrew & Edgerton, 1969). The idea that the apparent disinhibitor effect of alcohol is due to expectancy is also supported by experiments using the balanced placebo design, in which participants are given a drug or a placebo and told that they are either getting or not getting the drug (reviewed in Kirsch, 1990). In these studies, sexual behavior was affected by what participants thought was in their beverages, but not by what was actually in them. The clinical significance of expectancy effects on sexual arousal have been demonstrated in an impressive series July 1999 • American Psychologist

of studies by Eileen Palace and her colleagues (see Palace, 1999, for a comprehensive review). In one of these studies, Palace used false biofeedback of vaginal blood volume (VBV) during exposure to erotic stimuli to test her hypothesis that sexual response expectancies alter sexual response. She reported that false VBV feedback indicating arousal increased actual VBV in 100% of sexually dysfunctional women, and the increase in actual response occurred within 30 seconds of the expectation of an increase, thus providing strong evidence for the causal role of expectancy. In contrast to false biofeedback, accurate feedback of arousal does not enhance sexual arousal in women (Hoon, 1980). However, Palace (1999) was able to use accurate biofeedback to enhance arousal in sexually dysfunctional women by pairing it with anxiety-provoking films. Contrary to the common misconception that anxiety interferes with sexual arousal and thereby causes sexual dysfunction, research (reviewed in Palace, 1999) has demonstrated that the effect of anxiety is to enhance sexual arousal. Capitalizing on this phenomenon, Palace used anxiety-provoking films to provide an initial boost in sexual response to erotic stimuli. This was then followed by either accurate biofeedback, false positive biofeedback, or no feedback. The addition of feedback increased both expected and actual arousal, and the accurate feedback was more effective in doing so than the false feedback. In fact, within three minutes, the sexual responses of these sexually dysfunctional women were comparable to those of sexually functional women. Based on these data, Palace (1999) has hypothesized that female sexual dysfunction can be explained as a negative feedback loop between negative sexual arousal expectations and physiological response. Sexually dysfunctional women show less general autonomic reactivity to stimuli generally, as well as less genital response to sexual stimuli. As a result, they expect to experience less sexual arousal in sexual situations. These expectancies of low arousal further inhibit the physiological response, thus completing the feedback loop. False biofeedback can reverse this loop, but poses problems for clinical practice because of the deception that it requires. However, the negative feedback loop can be reversed even more effectively by accurate biofeedback combined with enhanced autonomic arousal, which can be produced by anxietyprovoking stimuli.

Hypnotic and Nonhypnotic Suggestion Some of the most dramatic effects of response expectancies on subjective experience are most commonly found in the context of hypnosis (see Kirsch & Lynn, 1995). Hypnotized individuals report experiences and exhibit behavior indicating involuntary movements, partial paralyses, selective amnesia, analgesia, and positive and negative hallucinations in all sensory modalities. (A negative hallucination is a failure to sense something that is in fact present.) The experience of automaticity is a hallmark of hypnotic responding (Lynn, Rhue, & Weekes, 1990), and it is the July 1999 • American Psychologist

defining characteristic of some hypnotic suggestions. In an arm levitation suggestion, for example, people are told, "Your arm is getting lighter and lighter, beginning to move all by itself, moving higher and higher" and so on. Most people respond to at least some requests for automatic movements of this sort, and having done so, they report the movement as having been involuntary. Because the overt behavior of hypnotized individuals is easy to simulate (Orne, 1959), and because many of the subjective effects accompanying these behaviors (e.g., hallucinations, analgesia, and amnesia) seem so extraordinary, the possibility has been raised that hypnotized individuals might simply be faking (Wagstaff, 1991). However, experimental data suggest that faking accounts for relatively few of these effects. Unlike simulators, highly suggestible people in hypnosis continue to respond to suggestions even when they think they are alone (Perugini et al., 1998). That is, when ostensibly alone and responding to tape recorded suggestions, these people pet hallucinated cats, swat at hallucinated mosquitoes, and nod their heads to hallucinated music. Also, brain imaging studies have begun to reveal the neurological substrates of the altered experiences produced by hypnotic suggestions (e.g., Rainville, Duncan, Price, Carrier, & Bushnell, 1997).

Expectancy and Hypnotic Response The role of expectancies in generating hypnotically suggested behaviors has been well-established. The first experimental studies of this effect were conducted by a commission headed by Benjamin Franklin (Franklin et al., 1785/1970). These elegant n = 1 experiments established that the only necessary condition for being mesmerized was the susceptible person's belief that the appropriate stimulus conditions had been met. Similarly, it is now well-accepted that any procedure in which the participant believes can be used to induce hypnosis. Among the procedures that have been used to induce hypnosis are telling people to relax, telling them to become more alert, having them pedal an exercise bicycle, instructing them to close their eyes, instructing them to keep their eyes open, flashing lights in their eyes, sounding gongs, applying pressure to their heads, and having them ingest placebo pills. Thus, a hypnotic induction is like a placebo in that its effects do not depend on its specific ingredients (e.g., instructions to relax), but rather on people's beliefs about those ingredients. It is different than a placebo, however, in that its effective use does not require deception. For this reason, hypnosis can be used as an ethical means of capitalizing on the placebo effect in clinical practice (Kirsch, 1994). A second link between hypnosis and expectancy is indicated by the fact that the behavior exhibited and experiences reported by people who have been hypnotized depend on their expectations. For example, in the 18th century, mesmerized patients displayed convulsive crises, whereas today hypnotized participants display an apparent sleeplike state. There is also a large body of research (reviewed in Kirsch, 1990) indicating that hypnotic behavior is exquisitely sensitive to expectancy manipulations. For example, depending on their beliefs and expectations 507

about hypnosis, hypnotized people do or do not experience spontaneous amnesia for the hypnotic session, breech suggested amnesia when hypnosis is "deepened," display spontaneous catalepsy, show an inability to resist suggested effects, and define their responses as involuntary. For an expected or intended response to be performed, it has to lie within the person's capabilities. For example, although voluntary behavior is instigated by intentions, the intention to fly is not likely to produce flight in a human being (at least not without an airplane). One of the striking characteristics of hypnosis is the marked variability that people show in the degree to which they respond to suggestion. Most scholars in the field have concluded that these individual differences in response are due to a relatively stable ability, and this is supported by high testretest reliability spanning periods as great as 25 years (Piccione, Hilgard, & Zimbardo, 1989). An intensive search spanning more than a half century has turned up surprisingly few correlates of hypnotic suggestibility. Meta-analysis (Council, Kirsch, & Grant, 1996) indicates that when assessed in a manner that precludes artifactual inflation of the relation, absorption shows a very modest correlation (mean r = .12) with suggestibility, and even this modest association appears to be mediated by expectancy (Council, Kirsch, Vickery, & Carlson, 1983). The relation between suggestibility and fantasy proneness (Lynn & Rhue, 1988) is more robust, although it too is at least partially mediated by expectancy (Braffman & Kirsch, in press). The best predictors of hypnotic suggestibility are waking suggestibility and response expectancy, and expectancy remains a significant predictor of hypnotic response even with waking suggestibility controlled (Braffman & Kirsch, in press; Kirsch, 1997). The impact of expectancy on hypnotic suggestibility has also been shown in experimental studies. Experimental manipulations that produce changes in expectancies also produce changes in responsiveness to suggestion (Gearan & Kirsch, 1993; Gearan, Schoenberger, & Kirsch, 1995; Kirsch, Wickless, & Moffitt, 1999; Lynn, Nash, Rhue, Frauman, & Sweeney, 1984; Vickery & Kirsch, 1991; Wickless & Kirsch, 1989; Wilson, 1967). The degree of change can be substantial, resulting in samples in which most participants score in the high range of suggestibility and none score in the low range (Wickless & Kirsch, 1989), and the correlation between expectancy change and behavior change is very high (e.g., r = .69 in Gearan & Kirsch, 1993, and r = .63 in Gearan et al., 1995).

Suggestion Without Hypnosis Many people think of hypnosis as an atypical condition, in which the rules governing the production of behavior are different from normal, and that for this reason, hypnotic phenomena do not inform us about the nature of ordinary behavior. However, it appears that all of the behaviors and experiences occurring in hypnosis can also be produced by suggestions given without the prior induction of hypnosis (reviewed in Kirsch, 1997). Braffman and Kirsch (in press, Experiment 2), for example, assessed the relation between responses to suggestion without hypnosis and responses to 508

the same suggestions after inducing hypnosis. The mean number of nonhypnotic suggestions to which participants responded was 1.99 (of a possible 7), and the correlation between expectancy and response was substantial (r = .53). Inducing hypnosis increased the mean number of suggestions to which people responded to 2.52, and a regression analysis indicated that hypnotic responding was predicted by nonhypnotic responding, expectancy, and motivation. Of these variables, nonhypnotic suggestibility was the best predictor of hypnotic suggestibility. Because the multiple correlation (R = .72) rivaled the reliability of the suggestibility scale, there appears to be little if any variance left to explain. Hypnotic responding is best regarded as nonhypnotic responding with enhancements due to increased expectancy and motivation. The next step is to establish the determinants of nonhypnotic response to suggestion. The correlation of .53 indicates that here, too, the role of expectancy is substantial, but also that considerable variance remains unexplained.

Response Sets and the Automaticity of Behavior Of the various responses seen in hypnosis, ideomotor responses are among the most common. These are the responses for which automaticity is a defining characteristic, and for that reason, they have also been referred to as automatisms. Automatisms like the Chevreul pendulum illusion, automatic writing, Ouija board spelling, dowsing, and facilitated communication commonly occur in contexts unrelated to hypnosis, and the feeling of automaticity they produce is so compelling that the behavior is often attributed to an external agent (e.g., spirits). How can a behavior that is generally performed voluntarily be elicited as an automatic response? In our theory of response sets (Kirsch & Lynn, 1997, 1998), we argued that automatisms really are automatic responses. They are responses that are primed for automatic activation by two response sets: an intention and an expectancy for their occurrence. In fact, we have proposed that at the moment of activation, all behavior is initiated automatically, rather than by a conscious intention. Accordingly, it is not the experienced automaticity of ideomotor responses that is an illusion, but rather the experience of volition that is claimed to characterize everyday behavior (Kirsch & Lynn, 1997, 1998; also see Wegner & Wheatley, 1999). Most behavior is routine. It is executed automatically under the guidance and control of cognitive structures that have been termed schemas, plans, and scripts. Even when engaged in creative processes, such as writing papers, speaking spontaneously, or driving to novel destinations, the component acts and movements are routinized responses. Their automaticity is evidenced by the speed and fluidity with which they are produced. There simply is not enough time for a conscious decision prior to the initiation of each component response. If the component movements of intentional behavior are triggered automatically, what is the role of intention in the control of behavior? Norman and Shallice (1986) have proposed an influential model in which a supervisory atJuly 1999 • American Psychologist

tentional system is a source of control over intentional behavior, especially behavior that is novel or complex. However, rather than initiating these behaviors, the supervisory attentional system "operates entirely through the application of extra activation and inhibition to schemas in order to bias their selection" (p. 6). The subsequent triggering of the intended action schema is an automatic process due entirely to the schema's activation value. Thus, the thesis that all behavior is initiated automatically is implicit in the Norman and Shallice (1986) model. We have expanded on their theory by hypothesizing that response expectancies are one of the factors that affect the activation value of action schemas. Thus, both intentions and response expectancies function as response sets, in that they prepare behavioral schemas for automatic activation (Kirsch & Lynn, 1997, 1998). In addition, if we are to avoid postulating a "ghost in the machine" that repeatedly violates the law of conservation of energy, we must conclude that the operation of the supervisory attentional system is also governed by automatic processes. The automaticity of intentional behavior is most clearly revealed in a series of studies reported by Libet (1985), in which the readiness potentials (RPs) that precede motor acts were recorded using electrodes placed on the scalp. Libet reported that awareness of the intention to initiate the response did not occur until after the onset of the RPs, indicating that cerebral initiation of these voluntary acts began unconsciously. What makes these data so important is that they pertain to a situation in which voluntary control should be particularly evident. The behavior was not performed as a component of a routinized plan. It was the focus of attention, and the instructions were to perform it at will. If behavior is activated automatically under these circumstances, it is difficult to imagine a situation in which it is not. If all behavior is instigated automatically, where does the illusion of will come from? Nisbett and Wilson (1977) argued that people may not be introspectively aware of the cognitive processes that mediate the effect of stimuli on behavior: When people attempt to report on their cognitive processes . . . they do not do so on the basis of any true introspection. Instead, their reports are based on a priori, implicit causal theories, or judgments about the extent to which a particular stimulus is a plausible cause of a given response, (p. 231) Similarly, Dennett (1991) maintained that what we call introspection is not really inner observation. Instead, it is "a sort of impromptu theorizing—and we are remarkably gullible theorizers" (pp. 67-68). Applying this hypothesis to the mediating cognitive process of intention, we have argued that the feeling of will is a judgment, rather than an introspected content (Kirsch & Lynn, 1997). Volition is the attribution of a behavior to one's own agency. It is an inaccurate judgment that is made on the basis of situational cues, culturally transmitted beliefs about the situation, and the consistency of the behavior with one's goals, motives, and intentions. July 1999 • American Psychologist

The expectancy theorist Edward Chace Tolman was chided for leaving the rats he studied buried in thought. We do not wish to make the mistake of leaving people buried without thought. People think about their behavior. They make plans and form intentions—although it can be argued that these plans and intentions are also the result of automatic processes. Intentions can prime behavior for automatic activation by environmental cues. They can also guide ongoing behavior. These two ways in which intentions influence behavior form the basis for the distinction between controlled and automatic processing, a distinction that is valid, but poorly named. It is valid because attention to an intended response may be required when one wishes to override the automatic activation of a more common response (e.g., turning left to go to a store, instead of right to go home as usual). It is poorly named because the conscious intention does not activate the desired response. Instead, it primes it, thereby making its activation more likely (Norman & Shallice, 1986).

Changing the Attribution of Volition If a self-report on the volitional status of a response is an interpretation based on prior beliefs and situational cues, then we ought to be able to change those self-reports by altering the cues and beliefs. In fact, there are a number of situations in which this is done routinely. These include hypnosis and the various nonhypnotic contexts in which automatisms are displayed. In these situations, simple behavioral acts that are normally considered voluntary are accompanied by self-reports of automaticity. In this section we examine an instance in which a very complex novel behavior is converted into a nonvolitional response by altering the context in which it is produced. The behavior is that of typing responses to questions on a keyboard, the novelty is provided by having the person guide the hand of another person, rather than pressing the keys directly, and the context is that of facilitated communication. Facilitated communication is intended to enable people with severe developmental disabilities to communicate by supporting the hand of the disabled person over a keyboard, thereby allowing the person to spell out words. Considerable research indicates that the content of the communication comes from the facilitator, rather than from the people whose communication they are trying to facilitate (Jacobson, Mulick, & Schwartz, 1995). However, the facilitators do not appear to be aware that the communication is coming from them. Thus, facilitated communication is an instance of automatic writing. In hypnotic settings, automatic writing is observed only in a minority of those to whom the suggestion for its occurrence is given, and it is interpreted as an instance of dissociation (Hilgard, 1986). However, most people who take workshops in facilitated communication appear able to learn to facilitate. This suggests that a sufficiently convincing rationale might enable most people to produce automatic writing. To test this hypothesis, we taught 40 college students to "facilitate" using a commercially available training videotape (Burgess et al., 1998). The students were then asked to facilitate the communication of a confederate, 509

who was described as developmentally disabled and unable to speak. Each was given different information about the confederate. Some were told that she had one brother; others were told that she had two. One was told that a brother's name was Bob, another that it was John, another that it was Fred, and so on. They were also given different information about her home town, favorite food, and what she enjoyed doing most. No two participants were given the same information, and except for the name "Jackie," the confederate was unaware of the information that was given to participants. After watching the videotape and being given misinformation about the confederate, the participants were brought to another room. There they were introduced to "Jackie," who sat silently in front of a computer staring at the wall behind the monitor. The participant was then instructed to support "Jackie's" hand and forearm over the computer keyboard as had been shown on the videotape, and "Jackie" was asked six questions about her brothers, her residence, and her preferences. "Jackie" continued to stare at the wall, not looking at either the monitor or the keyboard and not making eye contact with the research participant. This ensured that any coherent information that was typed would be due to the behavior of the participant and not to the behavior of the confederate. All 40 participants produced responses to the questions. All but two of the participants attributed the responses to the confederate, and 89% of the responses corresponded to the information that had been provided to the participants. The attribution of the response to the confederate was clearly an error. Just as clearly, participants were not aware of generating responses. Instead, their responses were automatic behaviors prepared by the intention to facilitate and their knowledge of the answers to the questions.

Response Expectancy as a Behavioral Response Set Evidence that expectancies can function as response sets that prepare behavioral schemas for automatic activation are provided in studies of the Chevreul pendulum illusion and nonhypnotic suggestions for other ideomotor responses. The Chevreul pendulum illusion is produced by holding a pendulum while thinking about its movement. It was first studied by Chevreul (1833/1896) in 1812. The lore at that time was that a pendulum would oscillate when held over particular substances (e.g., water, metal, or living beings). Having obtained that effect, Chevreul hypothesized that the motion of the pendulum would be stopped when other substances were interposed between it and the supposedly activating substances. This too was verified when he tried it. Next, to make sure that the movements were really produced by the substances and not by his own movements, Chevreul repeated the experiment with his fingers held steady in a support. Under these circumstances, the movements did not occur, and Chevreul concluded that the phenomenon was an illusion. The role of expectancy was indicated by his report that once he became convinced that the motion was produced by his own movement, rather 510

than by the effects of various substances on the pendulum, he was no longer able to produce it. In subsequent studies, the illusion has been produced by having a person imagine the pendulum moving in a particular direction (Easton & Shor, 1976) or trying to prevent it from moving in that direction (Wegner, Ansfield, & Pilloff, 1998). In either case, the expectancy of the motion produces small automatic hand movements, which are amplified by the pendulum, thereby producing the illusion that the mind is directly controlling the bob. Intentionally imagining the movement produces much more movement than trying to prevent the movement (Braffman, Kirsch, Milling, & Burgess, 1997), and most people find that the pendulum soon begins to move in the indicated direction, without their having any sense of moving it intentionally. Wegner et al. (1998) reported data indicating that cognitive load facilitates Chevreul pendulum responding and interpreted those data as indicating that pendulum movement is an ironic consequence of trying to suppress it. However, the data reported by Braffman et al. (1997) indicate that the inhibitory effect of cognitive load is limited to the circumstance in which people are instructed to prevent the movement. When asked to imagine the movement, rather than prevent it, cognitive load inhibited pendulum movement. Response expectancy was correlated with pendulum movement regardless of whether the person was instructed to imagine the movement or prevent it, and it partially mediated the effect of cognitive load in the prevent-movement condition. The role of expectancy in producing more complex automatic movements was confirmed experimentally by Lynn, Snodgrass, Rhue, and Hardaway (1987). As part of a "test of imagination," Lynn et al. (1987) presented a series of suggestions for motor responses to students who had scored very high or very low on a prior test of suggestibility. The students were asked to imagine each of the test suggestions, but not to make any movements in response to them. Half of the students were also asked to generate goal-directed fantasies as a means of facilitating their involvement in the suggested imaginings, and the degree of their absorption in these fantasies was assessed through essays in which they were asked to describe their thoughts, feelings, and actions during each of the imaginary tasks. Lynn et al. (1987) reported that the degree to which suggested movements occurred was best predicted by the participant's beliefs that imagination produces movement (r = .64). The correlation between imagery absorption and behavioral response was nonsignificant.

Implications for Psychotherapy and Behavior Change Many psychotherapeutic approaches capitalize on the automaticity of thought and action and achieve treatment gains by manipulating response expectancies, priming therapeutic responses, strengthening response sets, and removing impediments to the automatic execution of desired behaviors. In this section, we explore some of the ways in which automatic processes are used by psychotherapists to promote beneficial change, focusing not only on the autoJuly 1999 • American Psychologist

matic processes described in this article (the automatic effects of response expectancies and other response sets) but also on the therapeutic implications of ironic process theory (Wegner, 1994).

Enhancing Therapeutic Response Expectancies Many scholars have noted that the purpose of the brain is to anticipate the future (Dennett, 1991; Hyland, 1985; Jacob, 1982; Kirsch, 1990). Ironically, treatments are often denigrated as "mere placebos" when evidence is obtained suggesting that their effects are due to expectancy. Why should the value of a treatment be impugned if its effects are due to changes in the most basic function of the brain? Instead of trying to control expectancy effects, therapists should be trying to maximize their therapeutic impact. Fortunately, the power of expectancy effects has not been entirely lost on psychotherapists. In fact, it has long been recognized that positive expectancies about treatment outcome play an important role in stimulating behavioral change in psychotherapy (Fish, 1973; Frank, 1961; Weinberger & Eig, 1999). Although virtually all schools of psychotherapy acknowledge the importance of bolstering positive expectancies to maximize treatment gains and minimize noncompliance (see Lynn & Garske, 1985; Weinberger & Eig, 1999), behavior therapists have been most explicit with regard to specifying tactics and strategies for enhancing and shaping clients' positive expectancies. For example, Goldfried and Davison (1976) catalogued a variety of expectancy-enhancing maneuvers. These include alluding to similar clients who have achieved success, assigning relevant literature, encouraging clients to recognize that pessimistic attitudes are unrealistic, and singling out a readily changeable behavior to maximize optimism about positive therapeutic outcomes. Another way of enhancing therapeutic response expectancies is to augment treatment by establishing a hypnotic context (Kirsch, 1994; Kirsch, Capafons, Cardena, & Amigo, 1999; Lynn, Kirsch, & Rhue, 1996; Rhue, Lynn, & Kirsch, 1993). Although this may require little more than using the word "hypnosis" as a label for relaxation training and imaginal rehearsal, it can augment therapeutic expectancies and treatment outcome to a clinically significant degree (Schoenberger, Kirsch, Gearan, Montgomery, & Pastyrnak, 1997; also see Kirsch et al., 1995). Although clients' initial expectancies play an important role in determining the outcome of therapy, it is equally important to monitor and influence changing expectations throughout the course of therapy. This is facilitated by including therapeutic procedures that are likely to provide clients with feedback indicating that treatment is successfully producing therapeutic changes. Exposure treatments for phobic disorders ensure that clients will experience feedback of this sort. Repeated or prolonged exposure to the phobic stimulus produces temporary habituation, which the client interprets as evidence that the treatment is working, an interpretation that converts temporary physiological habituation into lasting therapeutic change (Kirsch, 1990). July 1999 • American Psychologist

Utilization techniques (Erickson, 1959; Haley, 1963), which involve the therapist interpreting or refraining a particular client behavior as consistent with treatment objectives, have been used to minimize performance-based feedback that treatment is less than optimally effective. For example, a yawn that occurs prior to the induction of hypnosis, and that might ordinarily be interpreted as a sign of boredom or disengagement from therapy, could be interpreted as a signal that the person is ready to "enter hypnosis." Alternatively, a failure to control premature ejaculation could be seen as an expression of great love for the partner. Expectancies vary along two independent dimensions (Kirsch, 1990). One is the degree of certainty that change will occur. The other is the speed and amount of change that is expected. Ensuring that positive feedback will be experienced during treatment can be facilitated by the expectancy that improvement will begin with small, gradual changes. This allows small increments, such as those produced by random fluctuations, to be interpreted as signs of therapeutic success. Relatedly, the assignment of easy initial tasks ensures early successes, which bolster the client's confidence in treatment (Lynn et al., 1996).

Priming Therapeutic Response Sets A large experimental literature has indicated that response sets can be primed for automatic activation. For example, if someone is first asked to pronounce the word spelled by the letters S-H-O-P, and then asked "what do you do when you come to a green light?" the most common answer is "stop," although a moment later, the person, recognizing the error, might grin sheepishly (Reason, 1992). In this section, we explore the therapeutic use of priming response sets. S. J. Sherman and Lynn (1990) described how Milton Erickson, a pioneer of strategic psychotherapy and brief hypnotic interventions, used response sets to foster treatment objectives. One of Erickson's tactics was to start with questions with an obvious "yes" answer and establish an acquiescent response set by repeatedly asking such questions. His clients would apparently agree to things they would not have agreed to in the absence of the acquiescent response set (e.g., that they were motivated to change the target behavior). Similarly, behaviors can be induced by subtly establishing the initial part of a sequence that the client completes. In one case, Erickson wanted the client to think about being warm-hearted and kind. By referring to her "cold hands," he primed the well-known phrase "cold hands, warm heart." The creative use of initiating and exploiting behavioral scripts in psychotherapy warrants more attention than it has received to date. Ideas and examples can be introduced early in therapy sessions so that clients think in certain ways later in the session or after the session. For example, Haley (1973) described how Erickson conversed with a terminally ill florist, introduced concepts relevant to plants and gardening, and used ideas that the florist might later use in thinking about his own life and situation in terms of growth, comfort, and beauty. Priming can increase the likelihood that clients make attributions and interpretations 511

that are consistent with treatment goals and that gains are generalized beyond the treatment setting. Another way of altering the accessibility of facts or events in memory is to ask people to think about or imagine likely outcomes. This can increase the salience of particular outcome expectations and bring to mind concepts and ideas consistent with positive outcomes and inconsistent with negative outcomes. When making subsequent judgments or decisions, these ideas will then be most accessible and will serve as a basis for action (S. J. Sherman, Skov, Hervitz, & Stock, 1981). For example, imagining negative outcomes of smoking and overeating and positive outcomes of not doing so can make it easier to resist those urges. Similarly, R. T. Sherman and Anderson (1987) asked first-time clients to imagine staying in therapy for at least four sessions and to explain why they were able to do this. For these clients, premature termination was substantially less than termination by clients who did not imagine remaining in treatment. By guiding clients' imagery and the kinds of outcomes they think about, it may be possible to affect how clients behave when relevant situations arise. Solution-focused therapists make use of similar strategies (de Shazer, 1985; Fish, 1996). Rather than stressing problems and their causes, these therapists direct the client's attention to exceptions to the problem, thereby priming adaptive thoughts and behaviors. Posing questions to clients such as, "How would your life change if you did XT' or "What would have to change in your life in order for you to relinquish your fear of public speaking?" might serve a similar function.

Forming and Strengthening Adaptive Response Sets Response sets take two basic forms. When they pertain to behavior that is experienced as nonvolitional, they are termed "expectancies." When they pertain to behavior that is experienced as volitional, they are termed "intentions." The data reported by Libet (1985) indicate that even intentional behavior is activated automatically. This is also implicit in Norman and Shallice's (1986) theory and is a central tenet of our response set theory (Kirsch & Lynn, 1997). In this section, we explore some of the ways in which adaptive response sets can be formed and strengthened in psychotherapy. It is widely believed (see Safran & Segal, 1990) that the therapeutic relationship is a vehicle by which a collaborative alliance can be established and expectancies and intentions can be strengthened. The finding that clients' perception of the helping alliance is an influential predictor of therapists' efficacy (Luborsky, McLellan, Diguer, Woody, & Seligman, 1997) is consistent with the proposition that a strong therapeutic alliance can increase the therapist's social influence and the client's commitment to pursue a collaborative therapeutic agenda. The use of therapeutic contracts that specify the roles, responsibilities, and intentions of the therapist and the client are common to diverse psychotherapeutic practices, ranging from psychodynamic to behavioral approaches (Lynn & Garske, 1985). Gollwitzer's (1993) work on implementation intentions suggests the advantage of discuss512

ing and committing to behavioral change at a very specific level. Rather than merely specifying behavior in general terms (e.g., being assertive), actual behavioral responses and their environmental cues should be specified. Also, because response sets can be strengthened by repetition, imaginative and behavioral rehearsal (e.g., role playing) can help promote the activation of adaptive responses. The key is to have clients practice the actual words and behaviors they intend to use in the real-life situation, rather than merely talking about what they might do.

Ironic Processes in Psychotherapy It may be as important to remove impediments to the automatic activation of behaviors and their execution as it is to create facilitative conditions for the expression of desired behaviors. Excessive or misguided attention and monitoring of action that disrupts the automatic flow of behavior or leads to response tendencies that compete with treatment goals can engender counterproductive ironic processes. Excessive control efforts (e.g., attempts to rigidly suppress compulsive or food-related thoughts or images), particularly when self-control is fragile, can result in disinhibition effects, whereby the attempt to suppress a particular thought or action increases the propensity to engage in the thought or action (Polivy & Herman, 1987; Strauss, Doyle, & Kreipe, 1994). The same can be said for avoiding or suppressing negative emotions, such as depression (Hayes & Gifford, 1997; Teasdale, Segal, & Williams, 1995). Similarly, the self-defeating effects of dietary restraint can easily be understood in terms of Wegner's (1994) ironic process model. More generally, direct suggestions or injunctions to relinquish, avoid, or control long-standing symptoms are often doomed to failure. Hayes and Gifford (1997) have argued that poorer clinical outcomes eventuate when people frequently use "coping strategies aimed at avoiding or suppressing negative emotions or thoughts" (p. 170). Acceptance and commitment therapy (see Hayes, Jacobson, Follette, & Dougher, 1994) is a behavioral approach that is designed to circumvent avoidance tendencies by accepting, rather than changing or eliminating, vexing thoughts and feelings. However, it is worth noting that facilitating selfacceptance has been a key component of humanisticexistential approaches from their inception (L. Greenberg, 1994) and has been viewed as an integral component of rational-emotive therapy, sex therapies, addiction treatments, and approaches to treating sexually abused individuals (see Hayes et al., 1994). Permissive and even paradoxical interventions (Coyne & Biglan, 1984), as well as meditation and mindfulness training (Kabat-Zinn, Lipworth, & Burney, 1985; Teasdale et al., 1995) aimed at simply being aware of thoughts and feelings in the "here and now," and "comprehensive distancing techniques" (Zettle & Rains, 1989), in which clients "step back" from, rather than attempt to suppress, their negative thinking, may be of service with clients who tend to place too great a premium on controlling the responses they wish to suppress (Wegner, 1997). July 1999 • American Psychologist

The ironic process model may provide an important key to dealing with noncompliance in psychotherapy. Resistant clients seek to block or prevent therapeutic change. On one level, they may seek such change, but on another, they may fear it. As a result, much of their effort in therapy may be directed toward blocking change. One way to counter this self-defeating strategy is to prescribe the symptom, so that the person is asked to intentionally produce the unwanted feeling, thought, or behavior. In this way, resistance facilitates a therapeutic response. Research from a number of studies (reviewed in Shoham-Salomon & Rosenthal, 1987) has indicated that paradoxical interventions are particularly effective with resistant clients. The apparent effectiveness of eye movement desensitization and reprocessing (Shapiro & Forest, 1997) may be due to a similar process. Although most of its components are derived from other cognitive-behavioral procedures, it differs from them in that clients are directed to attend simultaneously to cognitions, images, and feelings related to the trauma for which they are seeking treatment, and if this is not taxing enough, additional cognitive load is induced by having the person engage in rhythmic eye movements. Furthermore, the imagery that the client is attempting to generate is precisely that which he or she is attempting to control. Thus, the paradoxical instruction to intentionally maintain the negative images, thoughts, and feelings are undermined by cognitive load, while the unhampered automatic monitoring process finds counter images, thoughts, and feelings.

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