BEHAVIOR THERAPY 8, 1 7 - 2 3 (1977)

Comparison of Self-Report and Overt-Behavioral

Procedures for Assessing Acrophobia

D A V I D CHESTNEY COHEN

California State College, Bakersfield

Adults seeking systematic desensitization treatment for acrophobia were as-

sessed through laboratory-type behavioral tests of height-related behavior and
through several self-report measures of general and height-related fearfulness. An
Acrophobia Questionnaire (AQ) developed on 30 Sample l subjects was used in
conjunction with behavioral tests and standard anxiety measures for 48 treated
and 22 waiting list subjects in a second sample. Although the behavioral approach
measure showed moderate correlation with AQ Avoidance and Anxiety self-
report scores at the pretreatment assessment, significant treated vs. waiting list
pre- to post-treatment differences were found only for the AQ. Moreover, pre- to
post-treatment AQ change showed moderate correlation with other self-report
change scores but only slight correlation with behavioral test change. Issues
involving the adequacy of laboratory-type behavioral tests for "real life" phobias
and the value of augmenting behavioral tests with carefully formulated self-report
indices are briefly discussed.

Systematic desensitization research has appropriately focused atten-

tion on the need for objective and behavioral measures of treatment
outcome, such as overt-behavioral tests (BT), in addition to the subjective
ones commonly employed. However, behavior therapists who seek to
change important real-life behaviors find it hard to justify laboratory-
based BT as the major criteria for change. As Baker and Kahn (1972, p.
96) point out: "Self report has the advantage of eliciting information on
relevant behaviors which the standardized laboratory test may easily
miss." Accurate and complete assessment requires better and more com-
prehensive self-report measures as a supplement to other methods of
measurement.

This article is based in part on a doctoral dissertation submitted in partial fulfillment of the
requirements for the Ph.D. degree at Harvard University. Some of the data were presented
at the 52nd Annual Meeting of the Western Psychological Association, Portland, April 27,
1972. This research was supported by grants from the Foundations' Fund for Research in
Psychiatry and from the Harvard University Program in Technology and Society. The
author thanks Martin Van Denburgh for administering all of the post-test assessment tasks.
Requests for reprints and for copies of the instruments used should be sent to David C.
Cohen, Department of Psychology, California State College, Bakersfield, CA 93309.

17
Copyright © 1977 by Association for Advancement of Behavior Therapy.
All rights of reproduction in any form reserved.
18 DAVID CHESTNEY COHEN

Generally, only modest correlations have been reported between self-

report and BT measures. For 44 snake phobic subjects, Lang (1968)
reported behavioral avoidance to be correlated .43 with a self-report
rating of anxiety in the test situation and .31 with a general self-report of
fear. When unselected college subjects were asked to pick up a harmless
cockroach (Fazio, 1969), actual behavior correlated .37 with a specially
inserted "cockroach" item on the Fear Survey Schedule and .41 with a
composite score from six insect items. Schroeder and Craine (1971) found
a correlation of .41 between a snake-touching BT and scores on the Lang
Snake Questionnaire; however, a special snake item form of the S-R
Inventory of Anxiousness correlated only .22 with the BT. Muller (Note
1) assessed public speaking fear by a self-report questionnaire and by a
laboratory-type BT; correlations of .06 and - . 11 were found between two
self-report scales and the judges' ratings of the BT anxiety. Self-report of
anxiety in the BT situation correlated .04 with judges' ratings of overt-
anxiety.
The present paper reports relationships among several self-report mea-
sures and a specially designed series of BT situations measuring ac-
rophobia (fear of heights). An Acrophobia Questionnaire (AQ) was spe-
cially constructed to provide more precise acrophobia-related items than
the more typical "global" or single item self-report measures. Informa-
tion was sought concerning the relationships among these measures prior
to treatment and as pre-post measures of outcome, since subjects were
assessed as part of their participation in a treatment program which used
variants of systematic desensitization to treat fear of heights.

METHOD
Subjects
Subjects consisted of two samples of acrophobic adults seeking treatment for their fears at
a university-based "research and treatment clinic" set up for this project. Sample 1 con-
sisted of 9 males and 21 females (median age = 32 years) from the first clinic recruitment
effort (Baker, Cohen, & Saunders, 1973). Sample 2 consisted of 108 subjects who were
among more than 300 phobic applicants for a second clinic program. Thirty-eight of these
were never called for interviews, but provided no-contact self-report data through the mails;
the other 70 (25 male and 45 female, median age: 38 years, "clinic subjects") were seen in
the assessment and treatment program. Forty-eight received one of three variants of system-
atic desensitization treatment; 22 were placed on a waiting list.

Assessment Instruments
Acrophobia Questionnaire (AQ). This 40-item self-report questionnaire concerns (a) de-
gree of anxiety on a 0-6-point scale and (b) degree of avoidance on a 0-2-point scale for each
of 20 common height-related situations. Sums of points for the two 20-item scales yield
separate Anxiety and Avoidance scores. This instrument was developed on the basis of
initial interviews with the Sample 1 subjects (Baker et al., 1973) and shows reasonable inter-
nal consistency and test-retest reliability (median r = .82) for both samples. Two nonphobic
 ASSESSMENT OF ACROPHOBIA 19

college samples and nonacrophobic applicants for the clinic at which Sample 2 subjects were
seen received significantly lower scores than the acrophobic subjects.
Acrophobia Behavioral Tests (BT). Sample 2 subjects participated in three BT for ac-
rophobia conducted in the office building where the clinic was located. BT 1 involved eight
steps of approach in a 14th floor hallway, ending with the subject standing at a floor-to-
ceiling plate glass window, looking down into a parking lot. For BT 2, the subject went
through six approach steps terminating in leaning over a 14th floor stairwell railing and
looking down. BT 3 consisted of nine approach steps ending with the subject out on a
concrete-walled balcony on the 15th floor, leaning over a metal railing, and looking at the
street below. The BT Approach score for each sequence indicates the last step the subject
completed in that BT sequence.
Overall Improvement Self-Rating. At post-test, all subjects answered on a 7-point scale
this single question: "In general, how would you rate your acrophobia NOW as compared
with a few months ago, when you came in for the interview here?" The scale ranged from 1
= very much worse, through 4 = about the same, to 7 = very much improved.
Other measures. The Fear Survey Schedule-II1, the Willoughby Personality Schedule,
and the Marlowe-Crowne Social Desirability Scale were also administered prior to treat-
ment.

Treatment Procedures
Systematic desensitization treatment was provided in one of three varieties for each of the
treated subjects, while waiting list subjects received no treatment.
Regular desensitization involved twice-weekly meetings with a graduate student therapist
for relaxation training and imaginal pairing of hierarchy items with relaxation in the usual
fashion. Self-directed desensitization was in one of two forms: twice-weekly either at a clinic
office with tape-recorded instructions or at home with a phonograph record. For both
self-directed therapies, assistance from a therapist in developing the subjects' hierarchies
and periodic written or telephoned consultation were employed. Procedures for self-directed
desensitization were adapted from and remained similar to those described elsewhere
(Baker et al., 1973; Kahn & Baker, 1968).

RES U LTS
Pre-Test Assessment
B e c a u s e the t h r e e B T A p p r o a c h scores w e r e s t r o n g l y i n t e r c o r r e l a t e d
(r = .68, .74, a n d .56) t h e y w e r e c o m b i n e d b y p o o l i n g z s c o r e s for each
s u b j e c t a c r o s s the three s i t u a t i o n s . I n g e n e r a l , self-report m e a s u r e s
s h o w e d m o d e r a t e i n t e r c o r r e l a t i o n , while B T w a s r e l a t e d o n l y to the A Q at
a b o u t the s a m e m o d e r a t e level ( T a b l e 1).

P r e - to P o s t - t e s t A s s e s s m e n t
T r e a t e d s u b j e c t s in S a m p l e 2 s h o w e d large a n d highly significant de-
c r e a s e s in b o t h A Q scale scores (see T a b l e 2), while w a i t i n g list a n d
n o - c o n t a c t g r o u p s s h o w e d o n l y slight n o n s i g n i f i c a n t c h a n g e s . F o r S a m p l e
1, 16 t r e a t e d s u b j e c t s also s h o w e d significantly m o r e c h a n g e t h a n 13 W L
s u b j e c t s o n e a c h A Q scale. O v e r a l l I m p r o v e m e n t Self-Rating m e a n scores
c o n f i r m e d this finding for b o t h s a m p l e s . H e n c e , b o t h the detailed q u e s -
20 DAVID CHESTNEY COHEN

TABLE 1
SAMPLE 2 INTERCORRELATIONS AMONG MAJOR PRETEST MEASURES

Measure (2) (3) (4) (5) (6) (7)

(1) AQ Avoidance .84*** .33*** .24** .27** .02 -.46***

(2) AQ Anxiety .46*** .36*** .27** .03 -.32"**
(3) FSS-II1 Total .34*** .49*** -.09 -.03
(4) FSS-III Item 18 .22* -.01 -.01
(5) Willoughby Total -.31"** .10
(6) Social Desirability -.03
(7) BT Pooled Approach

Note. n = 70 for each correlation.

* p < .10.
** p < .05.
*** p < .01.

tionnaire and global self-report measures showed large effects of treat-

ment.
However, the BT scores tell a different story: For the BT Pooled
Approach score and for each separate BT situation (not shown), the

TABLE 2
SAMPLE 2 PRE- TO POST-TEST CHANGE SCORES ON ACROPHOBIA

Measure Treated Waiting List No-Contact

AQ Anxiety Scale
Pretest 60.64 61.82 64.84
Post-test 32.04 60.46 62.61
Change a -28.60 b - 1.36 -2.23
n 47 22 31
AQ Avoidance Scale
Pretest 13.83 15.00 14.71
Post-test 7.11 13.68 13.84
Change a 6.72 b - 1.32 -0.87
n 47 22 31
BT Pooled Approach
Pretest .032 - .076
Post-test .046 - . 100
Change .014 -.024
n 46 21

a Mean change for Treated group different from both Waiting List and No-Contact groups
(p < .01).
b P r e - p o s t change for Treated group significantly greater than zero (p < .01).
 ASSESSMENT OF ACROPHOBIA 21

pre-post mean change for treated subjects was not significant and did not
differ significantly from that for waiting list subjects.

Intercorrelations among Outcome Measures

The three separate BT Approach change scores showed moderate
consistency (r = .35, .37, and .51) and were again pooled into a single
measure. As indicated in Table 3, both AQ change scores showed

TABLE 3
SAMPLE2INTERCORRELATIONSAMONG MAJOR OUTCOME MEASURES

Measure (1) (2) (3) (4) (5) (6)

(1) A Q Anxiety Change -- .74*** -.11 -.64*** .51'** .42***

(2) AQ Avoidance Change 47 -- -.20 -.43*** .41"** .40***
(3) BT Pooled A p p r o a c h
Change 46 44 -- - .07 .11 .04
(4) Overall I m p r o v e m e n t
Self-rating 47 47 46 -- -.35** -.46***
(5) FSS-III Change 47 47 45 47 -- .53***
(6) Willoughby C h a n g e 47 47 46 47 47 --

Note. Correlation coefficients appear above the diagonal and n values appear below.
*p < .10.
** p < .05.
*** p < .01.

moderate correlations (median r = .43) with the three other self-report

change measures and minimal correlations with BT change. Overall Im-
provement Self-Rating and BT change were essentially uncorrelated. For
the 16 treated Sample 1 subjects (for whom no BT data are available), the
Overall Improvement Self-Rating showed correlations with the AQ of
- . 5 4 (AQ Anxiety change) and - . 4 7 (AQ Avoidance change). Thus, for
outcome change measures, the BT procedure seems largely independent
of any self-report measure, while self-report measures of acrophobia and
of general anxiety show considerable interrelatedness.

DISCUSSION
Results reveal a discrepancy between self-report and BT measures of
acrophobia change following desensitization treatment, although at pre-
test assessment the AQ and BT measures showed moderate relatedness
entirely consistent with that found by other researchers. Even at that,
correlations of magnitude .32 and .46 warn quite clearly that self-report
and BT measures behave differently as indicators of acrophobia. An
additional caution is obtained from the disturbing finding that all self-
22 DAVID CHESTNEY COHEN

report outcome measures (including measures of general anxiety) show

larger intercorrelations than any acrophobia self-report outcome measure
obtains with the BT ones. Correlations between BT and AQ measures all
increased slightly (BT by AQ Avoidance: -.51 and -.47; BT by AQ
Anxiety: - . 3 6 and -.34) with effects of the Willoughby and FSS-III
(respectively) partialled out, suggesting that the relationship between
self-report and BT measures of acrophobia does not depend upon
generalized anxiety effects.
Although the principal results reported here are consistent with other
reports, it is small comfort to find moderate intercorrelations among
measures of ostensibly the same phenomenon, especially since the BT
results alone suggest that subjects did not improve from treatment. Some
fault probably belongs with the specific features of this set of BT sequenc-
es. They probably do not even roughly approximate an interval scale of
measurement, and therefore psychometric considerations cast doubt on
the results for this measure. Moreover, many subjects at pretest told the
experimenter in advance of actually attempting the BT sequences that it
would be no problem to complete them because the "laboratory" BT
were not sufficiently similar to the real life height situations where the
subjects encountered extreme avoidance. Between 50 and 63% of sub-
jects were able to complete the last step of a pretest BT sequence, in spite
of ratings of extreme anxiety (not reported here) while doing them. The
presence of another person recording BT results made the situations
different; the layout of the window or balcony situation may have allowed
the subject to perform behaviors which (s)he insisted could not be executed
in his/her own life space.
There are two other indications that the BT sequences might be more at
fault than the self-reports. First, each Sample 2 subject had been asked in
the pretest interview to specify five actual height situations from his/her
own life where (s)he had experienced extreme anxiety and which (s)he
would or does now avoid. At post-test, treated subjects reported actually
trying out a significantly higher proportion of these behaviors than waiting
list subjects (2( = 39% vs. 28%, ×2 -_ 3.11, p < .10) and reported
significantly less anxiety while doing them. Although treated subjects
could be lying, they could hardly be mistaken about this specific report of
attempting to engage in fear arousing situations. Perhaps when self-report
items are made sufficiently precise to preclude unintentional distortion
they should be regarded as quasi-behavioral measures from the subject's
own (nonlaboratory) real life experiences.
The second suggestion comes from the AQ and concerns the concep-
tualization of acrophobia itself. A principal components factor analysis of
the AQ Anxiety scale pretest responses for 110 subjects (including two
later excluded from the sample) suggests no large single factor, with
 ASSESSMENT OF ACROPHOBIA 23

Factor I accounting for only 23.6% of the total variance (and 40.3% of the
variance shared by the first five factors). Moreover, an orthogonal var-
imax rotation resulted in content-based, interpretable factors suggesting
that at least five subvarieties of acrophobia may be reflected in AQ scores.
The three BT situations seem in content to fall within only two of those
subvarieties. Hence, a more careful delineation of what one means by
acrophobia both in self-report and in BT measures and a reliance upon
questionnaires with sets of items oriented to specific aspects of fear of
heights may both lead to more accurate measurement of acrophobia. Such
detailed examination seems indicated for any phobia which is complex,
multifaceted, and important in the lives of those it afflicts, even if assess-
ment can be greatly simplified for other, unitary, laboratory-type phobias.

REFERENCE NOTE
1. Muller, J. P. Sense of competence and self-desensitization. Unpublished doctoral dis-
sertation, Harvard University, 1971.

REFERENCES

Baker, B. L., Cohen, D. C., & Saunders, J. T. Self-directed desensitization for acrophobia.
Behaviour Research and Therapy, 1973, 11, 79-89.
Baker, B. L., & Kahn, M. A reply to "Critique of 'Treatment of insomnia by relaxation
training': Relaxation training, Rogerian therapy or demand characteristics." Journal
of Abnormal Psychology, 1972, 79, 94-96.
Fazio, A. F. Verbal and overt-behavioral assessment of a specific fear. Journal of Consult-
ing and Clinical Psychology, 1969, 33, 705-709.
Kahn, M., & Baker, B. L. Desensitization with minimal therapist contact. Journal of
Abnormal Psychology, 1968, 73, 198-200.
Lang, P. J. Fear reduction and fear behavior: Problems in treating a construct. In J. M,
Shlien (Ed.), Research in psychotherapy (Vol. 3). Washington, D. C.: A.P.A., 1968. Pp,
90-102.
Schroeder, H., & Craine, L. Relationships among measures of fear and anxiety for snake
phobics. Journal of Consulting and Clinical Psychology, 1971, 36, 443.

RECEIVED: August 6, 1975

FINAL ACCEPTANCE: January 22, 1976