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Journal of Consulting and Clinical Psychology

1979, Vol. 47, No. 1, 140-146

Effects of Enhanced Psychological Test Feedback on

Treatment Outcome: Therapeutic Implications
of the Barnum Effect
Keith M. Halperin and C. R. Snyder
University of Kansas

The Barnum-effect literature has consistently shown that the recipients of

diagnostic feedback tend to accept such feedback. The present study sought
to expand the potential impact of this phenomenon by ascertaining whether
diagnostic feedback not only may be accepted, but also may have a positive
influence on treatment outcome. Snake-fearful females (N = 48) initially
took psychological tests and were then randomly assigned to one of three
conditions: (a) a no-treatment control group, (b) a treatment-only group,
and (c) an enhanced-personality-feedback-with-treatment group. Two ma-
nipulation check items indicated that the enhanced-personality-feedback ma-
nipulation was successful. As hypothesized, the greatest therapeutic improve-
ment, as measured by change in pre- to posttest self-report and behavioral
measures, resulted for the enhanced-personality-feedback-with-treatment
group as compared to the treatment-only group; in turn, the treatment-only
group improved significantly more than the no-treatment control group.
Implications are drawn for the clinical setting, and the potential importance
of the person's expectations that he or she is the source of positive ther-
apeutic change is discussed.

Recent research has shown that the recip- Barnum effect, Snyder, Shenkel, and Lowery
ients of psychological test feedback report a (1977) caution clinicians that clients' ac-
consistently high acceptance of such feed- ceptance of diagnostic feedback should not
back. This growing body of literature is best be interpreted as validation of either the
known under the term Barnum effect, which psychologist or the assessment tools used.
has come to stigmatize the relatively undis- While the Barnum-effect literature certainly
cerning acceptance of psychological-test- provides precautions to clinicians, it need not
based feedback by clients. After reviewing have totally negative implications for the
the variety of factors that contribute to the diagnostic/therapy process. On the con-
trary, it has been suggested that the clinician
may purposefully use the Barnum effect to
The authors acknowledge the comments of help facilitate change in the client (Snyder,
Sharon S. Brehm, B. Kent Houston, Douglas R. 1976; Snyder & Clair, 1977). That is, the
Denney, Raymond L. Higgins, and Dennis H.
Karpowitz on earlier versions of this article. The clinician could deliver psychological-test-
assistance of James Butcher, Vern Devine, Paula based feedback to the client that he or she
Savage, and Liz Voss on various aspects of the has the positive potential for change, and in
present project is also gratefully acknowledged. the process of accepting such feedback, the
The first author is now at Personnel Decisions,
Inc., 821 Marquette Avenue, Foshay Tower, Min-
person may actually initiate therapeutic
neapolis, Minnesota 55402. change. The present study sought to test this
Requests for reprints should be sent to C. R. theorization by examining the effects of en-
Snyder, Graduate Training Program in Clinical hanced psychological test feedback on treat-
Psychology, 305 Fraser Hall, Department of Psy-
chology, University of Kansas, Lawrence, Kansas ment outcome.
66045. The present research may be conceptual-

Copyright 1979 by the American Psychological Association, Inc. 0022-006X/79/4701-0140$00.75


ized within the general framework of previ- tations of treatment, it may be useful to
ous research related to "placebo" or "non- examine the therapeutic effects of feedback
specific" factors in psychotherapy. Placebo that enhances the clients' expectations of
or nonspecific factors refer to the supposedly their own potential for change. In this re-
inert by-products of psychotherapy that have gard, Cartwright and Cartwright (1958)
beneficial effects for clients. In this regard, have reasoned that enhanced expectations
it has been suggested that treatment effec- related to personal potential for change
tiveness may be enhanced by such placebo or should prove most effective because such
nonspecific factors as client expectations, expectations result in an active, independent,
suggestibility, and so on (Frank, 1963; and responsible client; J conversely, en-
Rosenthal & Frank, 1956; Shapiro, 1964). hanced expectations related solely to treat-
Bloom, Weigel, and Trautt (1977) have re- ment may be symptomatic of a passive, de-
cently asserted that such placebo factors are pendent, and irresponsible client who need
not merely inert by-products of therapy, not be fully invested in therapy. In a similar
but rather may be considered as factors that vein, it has been suggested that the process
serve an active treatment function. These and content of diagnostic feedback can facil-
authors suggest that "therapeugenic" fac- itate therapeutic improvement by positively
tors, as they term them, should be fully influencing clients' self-perceptions (Mosak
utilized by clinicians to help foster client & Gushurst, 1972). The aforementioned rea-
change. Indeed, several theorists have im- soning suggests that the Barnum-effect
plied that the clinician may purposefully em- phenomenon may be utilized to enhance
ploy all forms of social influence to increase clients' personal belief in change and, in
client expectations and, in turn, successful turn, facilitate therapy improvement.
treatment outcome (Brehm, 1976; Fish, Tn order to test the therapeutic effects of
1973; Gillis, 1974; Goldstein, Heller, & psychological test feedback, three groups of
Sechrest, 1966). subjects were employed in the present study.
Farly research in the area of placebo ex- Subjects were snake-fearful individuals
pectancies produced inconsistent results whose changes in snake avoidance were
(Friedman, 1963; Goldstein, 1960; Gold- tested by self-report and behavioral measures
stein & Shipman, 1961; Lipkin, 1954). This taken at the beginning and the end of the
research is difficult to interpret because it is experiment. All subjects were initially ad-
not clear whether expectancy emphasizing ministered a battery of psychological tests.
treatment efficiency or expectancy related to Subjects in the first group, the enhanced-per-
the client's own personal ability to change
sonality-feedback-with-therapy group, were
was manipulated. Likewise, these early
given feedback that their psychological
studies have been criticized because expec-
tancy was not correlated with any objective
measures of improvement (Wilkins, 1973a, 1
Cartwright and Cartwright (1958) note that
1973b). A more recent body of placebo client expectancy is made up of the following four
literature has examined the effects of manip- sets of beliefs: (a) belief that positive changes will
ulated treatment expectancies on behavior occur, (b) belief in the therapist as the primary
therapy outcome studies. Results for this source of help, (c) belief in the therapeutic proce-
body of research are mixed (see Rosen, dures as the primary source of help, and (d) belief
in oneself as the primary source of help. The
1976, for a review). To date, therefore, present study sought to emphasize the last kind of
placebo studies have evolved to emphasize expectancy—the belief in oneself as the primary
manipulated treatment expectancies. Unfor- source of help. Technically, however, in accentuat-
ing a person's belief that he or she is the primary
tunately, however, the manipulated enhanced source of change, it is also probable that the other
treatment expectancies have not consistently aforementioned beliefs may be influenced to a lesser
elicited improved treatment outcome. degree. Overall, the present study sought primarily
to enhance the person's belief in himself or herself
Given the previous inconsistent results as the source of change and secondarily to enhance
related principally to enhanced client expec- the person's belief that change would occur.

test results indicated they had the personal Procedure

potential to facilitate positive change. These
subjects then received the treatment. A sec- Pretesting. The pretest consisted of three parts.
First, the experimenter told subjects "this investi-
ond group did not receive any feedback gation is looking at the relationship between the
based on the psychological tests but did re- common irrational fear of snakes and personality
ceive the treatment. A third group did not factors." Subjects, in individual sessions, completed
receive either diagnostic test feedback or the Snake Questionnaire, and a bogus "personality
test" comprised of approximately SO objective ques-
treatment and thus represented a no-treat- tions taken from various presently existing per-
ment control group. It was predicted that sonality scales. The personality test was not scored,
therapeutic improvement, from highest to but rather administered to make the subsequent
lowest, would result from the enhanced- personality interpretation credible to subjects in the
personality feedback condition. Following this test
personality-feedback-with-treatment group, battery, a female research assistant administered
treatment-only group, and the no-treatment the audiotaped Behavioral Avoidance Test as the
control group. second part of the pretest. The taped instructions
stated that subjects should try to approach the
snake as closely as possible but stop whenever they
Method become too uncomfortable. The female research
assistant remained behind the subject while the
subject attempted as many steps of the Behavioral
Materials Avoidance Test as possible. The point at which the
subject was unwilling to continue this procedure
The self-report change measure employed was was recorded as the subject's pretest behavioral
the Snake Questionnaire (Klorman et al., 1974), level of fear.
a 30-item true-false test tapping fear of snakes. Experimental manipulation. The experimental
The behavioral change measure was the Behavioral manipulation occurred during the third part of the
Avoidance Test (Nawas, 1971), which taps sub- pretest. First, all subjects were randomly assigned
jects' objective fear level of snakes. This measure to one of the three conditions. The researcher told
consists of 20 steps ranging from "standing 10 feet subjects in the no-treatment control group that
[3.05 m] away looking at the cage" to "reaching their personality test batteries would be correlated
into the cage, picking up the snake, petting it, and and validated with the Behavioral Avoidance Test
allowing it to crawl up your arm." A 4i-foot score. Subjects in this no-treatment control group
(1.37 m) corn snake was used for the Behavioral were not informed that they were members of a
Avoidance Test. control group, nor were they told that they would
receive treatment at a later point in time. They
were instructed to return in 5 weeks for posttest-
Subjects and Design ing. Subjects in either the treatment-only group
or the enhanced-personality-feedback-with-treatment
The experimenter randomly telephoned female group were told that for the next few weeks they
introductory psychology students from the Uni- would receive a treatment previously used with
versity of Minnesota's research pool asking them people who were uncomfortable around snakes.
to participate in the experiment's screening proce- Subjects in the enhanced-personality-feedback-
dure. Since Klorman et al. (1974) found that female with-treatment condition read a handwritten bogus
students had a greater fear of snakes than males, personality interpretation purportedly derived from
only females participated in this study to assure a their bogus personality test. This feedback at-
more fearful sample. Forty-eight subjects who were tempted to enhance subjects' belief that they could
unwilling to touch the corn snake with a gloved be a source of change because they had a personal-
hand on the Behavioral Avoidance Pretest (the ity suitable for change in treatment (see Footnote
criterion as established by Borkovec, 1973) were 1). The interpretation stated:
included in the study. All subjects participated in
this experiment as one means of fulfilling their The personality test you have taken has been
course requirements for introductory psychology. found to predict inner potential for change in
These 48 subjects were randomly assigned to one treatment. In the past, it has been shown that
of the three conditions: a no-treatment control, a people with similar personality scores as yours
treatment-only group, and a positive-personality- have a strong capacity for change. This profile
feedback-with-treatment group. The dependent shows that you have inner resources enabling
measures of change taken before and after the you to learn effective means of adapting to the
treatment period were (a) self-reported fear of environment. You have a great deal of unused
snakes (Snake Questionnaire) and (b) behavioral potential you have not yet turned to your ad-
approach to a live snake (Behavioral Avoidance vantage, and thus you have the personality to
Test). successfully utilize this treatment.

The test also suggests that you display ability for tions. All but the no-treatment control group sub-
personal integration and many latent strengths, jects rated their current assessment of "How suit-
as well as the ability to maintain a balance be- able are your personal attributes for change in
tween your inner impulses and the demands of treatment?" (For this question, 1 = not at all suit-
outer reality. Therefore, your personality is such able to 10 = extremely suitable.) This served as a
that you have a strong potential for improvement postexperimental check on the enhanced personality
during this treatment. manipulation.
Finally, subjects were debriefed carefully and
After reading this interpretation, each subject in told the true nature of the experiment. Subjects in
this enhanced-personality-feedback-with-treatment the no-treatment control were offered the desen-
condition rated the extent to which the interpreta- sitization treatment.
tion described her own personality on an 8-point
scale (l = very poor to 8 = excellent). The mean
acceptance rating for this feedback was 6.15, indi-
cating that the members of this group accepted the In order to ascertain whether the per-
feedback, a finding that is consistent with the
Barnum-effect literature (see Snyder et al., 1977). sonality feedback enhanced clients' expecta-
Subjects in the treatment-only condition received tions, comparisons were made between the
no interpretation and were told that the personality manipulation check items for the treatment-
test was being validated for populations afraid of only condition as compared to the enhanced-
Finally, a manipulation check was administered
personality-feedback-with-treatment condi-
asking subjects in the two experimental conditions tion. On the first manipulation check item
to respond to the following question: "Judging ("Judging only from your own personal
only from your own personal characteristics, how characteristics, how much change do you
much change do you think you will make?" (For think you will make?") taken after the
this question, 1 = no change in problem to 10 =
extreme improvement in the problem.) To reduce manipulation but prior to treatment, the en-
both response demand characteristics and sensitiza- hanced - personality - feedback - with-treatment
tion to the true nature of the experiment, this ques- condition subjects reported significantly
tion was incorporated into a purportedly unrelated higher expectations than the treatment-only
questionnaire mailed to the University Ethics Com-
condition subjects : Ms = 7.88 and 6.00, re-
Treatment. All subjects (except the no-treat- spectively; t(26) - 3.77, p < .001. Similar-
ment control group) received the same desensitiza- ly, on the manipulation check item taken
tion treatment, which was held once a week for 3 during the posttesting period ("How suit-
consecutive weeks. Each session lasted 45 minutes, able are your personal attributes for change
and subjects were randomly assigned to small group
sessions (4 or 5 subjects per group). All three in treatment?"), the enhanced-personality-
desensitization sessions were recorded on audiotape, feedback-with-treatment condition subjects
and the experimenters were not present during again reported significantly higher expecta-
these sessions. Each of the three tape sessions be- tions than the treatment-only condition sub-
gan with a therapeutic explanation of the procedure,
followed by 15 minutes of training in Lazarus's
jects : Ms = 7.58 and 5.50, respectively;
progressive muscle relaxation, and finally proceed- t(26) = 3.53, p < .002.
ing through the same 20-step hierarchy used in the A base-free measure of change (cf. Ben-
Behavioral Avoidance Test. One third of this hier- jamin, 1967; Tucker, Uamarin, & Messick,
archy was presented at each weekly session. Sub-
1966) was employed in the present study in
jects were asked to imagine each step for 15 sec
and then relax for 30 sec. This procedure was com- order to account for the influence of pretest
pleted twice for each hierarchy step (Schneider, responses on subsequent posttest responses
1973). (i.e., the "law of initial values"; Wilder,
Posttesting. Individual posttesting sessions were 1962). Thus, residualized change scores (cf.
scheduled for all subjects approximately 1 week
following the third treatment session. Forty sub-
Cronbach & Furby, 1970) were calculated
jects (12 in the control group, 15 in the treatment- for both the self-report (Snake Avoidance
only group, and 13 in the personality-feedback-with- Questionnaire) and behavioral (Behavioral
treatment group) successfully completed the experi- Avoidance Test) dependent measures for
ment; the other 8 subjects dropped out of the subjects in each of the three conditions of the
study at various points. The Snake Questionnaire
and Behavioral Avoidance Test were readministered independent variable. These residualized or
to these 40 subjects by the female research assist- adjusted scores reflect the difference between
ant who was blind to subjects' experimental condi- the actual obtained posttest score and the

predicted posttest scores based on a linear Afs = 6.07 (SD=1.98) to 11.20 (SD =
regression adjusted for treatment conditions 4.38) ; and (c) for the enhanced-personality-
from pretest scores. Even though the differ- feedback-with-treatment group (n = 13),
ences in pretest scores for groups may not he Ms= 5.77 (SD = 2.35) to 13.62 (SD =
statistically significantly different, these in- 4.35). The enhanced-personality-feedback-
itial differences may contribute to either a with-treatment group (adjusted M = 13.84)
main effect of interaction in a pre-post evidenced significantly more behavioral im-
analysis of variance procedure. This is espe- provement than the treatment-only group
cially true when there are significant differ- (adjusted M = 11.05) or the control group
ences in pretest scores of groups, as was the (adjusted M = 6.60), t(26) = 1.82, p <
case in the Snake Questionnaire data for the .04 and / ( 2 3 ) = 5 . 5 1 , p < .0001, respec-
present experiment. For these reasons, tively. The treatment-only group showed
therefore, the adjusted scores are preferable significantly greater behavioral improvement
because they measure change independently than the control group, 1(25) =4.65, p <
from (or correcting for) initial pretest level .0001. Since it was hypothesized on an a
of response on self-report and behavioral priori basis that the treatment-plus-en-
measures. hanced-personality-feedback group should
A one-way analysis of variance (control, evidence more improvement than the treat-
treatment-only, and enhanced-personality- ment-only group, which in turn should
feedback-with-treatment) on the adjusted improve more than the control group, all
Snake Questionnaire was significant, F(2, post hoc t tests are one-tailed.
37) = 16.77, p < .0001. The raw pretest
and posttest Snake Questionnaire scores Discussion
reflecting this effect for each of three
groups are as follows: (a) For the control Both manipulation check items indicated
group (n = 12), Ms = 12.58 (SD = 3.63) that the enhanced-personality-feedback-with-
to 12.67 (SD = 3.17); (b) for the treat- treatment group had a significantly greater
ment-only group (n = 15), Ms= 14.07 expectation for change than the treatment-
only group. Unlike previous studies that em-
(SI) = 3.33) to 18.27 (SI) = 2.76) ; and
(c) for the enhanced-personality-feed- phasized manipulating treatment expectan-
hack-with-treatment group (n = 13), Ms = cies, the present study manipulated peoples'
16.38 (SD = 5.28) to 22.31 (SD = 4A6).
expectancies in order to emphasize that they
The enhanced - personality - feedback - with - had the potential to facilitate change (see
treatment group (adjusted M = 20.68) Footnote 1). Based on these results, it does
showed significantly greater self-reported appear possible to enhance the client's belief
improvement than the treatment only (ad- that she can be an effective source of change
justed M = 18.51) and controls groups (ad- with regard to a particular problem. This
finding should not be surprising when con-
justed M = 14.11), t(26) = 1.73, p < .05
and t(23) = 5.66, p < .0001, respectively. sidered in light of Barnum-effect results
The treatment-only group also showed sig- showing that the recipients of diagnostic
nificantly greater self-reported improvement feedback are highly acceptant of such infor-
than the control group, if(25) = 5.06, p <
.0001. The one-way analysis of variance on Beyond simply demonstrating that per-
the adjusted Behavioral Avoidance Test was sonal beliefs in potential for self-change may
be enhanced, the present study indicates
also significant, F(2, 37) = 14.32, p < .001.
that enhanced personal expectations may
The raw pretest and posttest Behavioral actually facilitate therapeutic improvement.
Avoidance Test scores reflecting this effect Several precautions need to be carefully ex-
for each of the three groups are as follows: amined, however, before considering the im-
(a) For the control group (n = 12), Ms = plications of the present therapy outcome
6.00 (SD = 2.66) to 6.67 (SD = 3.23) ; results. First, it cannot be discerned from the
(b) for the treatment-only group (n = 15), present data whether the relatively superior

performance of the enhanced-personality- sons, one needs to be extremely cautious in

feedback-with-treatment groups was due to generalizing beyond the present sample.
the enhanced content of the information or Because of the aforementioned precau-
merely the fact that they received diagnostic tions, it is most accurate to view the present
feedback information. Comparison groups in experimental analogue as providing a prom-
which subjects received either neutral or ising first piece of supporting evidence with
negative feedback would be needed to address regard to the potentially positive therapeutic
this question. Although the content of psy- effects of enhanced personal expectations for
chological test feedback may be rather nega- change. While both the treatment-only
tive in the actual clinical setting, it would not and the enhanced-personality-feedback-with-
be ethically plausible to give one group of treatment group improved significantly more
subjects negative feedback in an experi- than the no-treatment control group,
mental analogue setting. the enhanced - personality - feedback - with -
A second set of precautions relates to the treatment group showed improvement be-
subject sample employed in the present yond that attained by the treatment-only
study. The present subjects evidenced only group. Since diagnostic testing is typically
mildly fearful behavior. Previous research part of the process of receiving psychological
reveals that highly fearful subjects may be help (Wade & Baker, 1977), the present
less susceptible to expectancy manipulations. results suggest that diagnostic test feedback
Likewise, mildly fearful people appear to be may be utilized to facilitate improvement.
especially sensitive to demand characteristics Perhaps clinicians may be advised to espe-
(Borkovec, 1973), and thus the superior cially emphasize the strengths of the person
performance for the enhanced-personality- as revealed through diagnostic testing. In
feeclback-with-treatment group may be re- the process of accepting such positive feed-
lated to such demand characteristics alone. back, the person may in turn initiate thera-
Other precautions related to the present sub- peutic change. This change may be achieved
ject sample are that only females with mild because the individual comes to perceive him-
snake fears were employed. Obviously, infer- self or herself as an active, responsible per-
ences for male samples, other phobias, and son who is capable of effecting a change
other potential problems that a client may (Cartwright & Cartwright, 1958). This is a
bring to therapy are tenuous at best. goal that most all clinicians would hold for
A third precaution stems from the fact their clients. One is reminded of the classic
that subjects in the present study performed children's story about a train trying to strug-
the behavioral avoidance test in the presence gle up a hill. The train tells itself, "I think
of an experimenter. As such, the present I can, I think I can." Psychological test feed-
change in snake fear results are consistent back may be one of many potentially effec-
with previous studies suggesting that be- tive means of generating such enhanced ex-
havioral improvement occurs when the ex- pectations of personal power for change.
perimenter is present for the behavioral
avoidance test, but improvement does not References
occur when the experimenter is not present
for this test (Bernstein & Nietzel, 1973). Benjamin, L. Facts and artifacts in using analysis
of covariance to "undo" the law of initial values.
Therefore, the fact that the experimenter Psychophysiology, 1967, 4, 187-206.
was present during the behavioral avoidance Bernstein, D. A., & Nietzel, M. T. Procedural
test needs to be considered as one contextual variations in behavioral avoidance tests. Journal
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is that the present results represent findings "Therapeugenic" factors in psychotherapy: Ef-
from only one study, and thus replications fects of office decor and subject-therapist sex
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