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Automaticity in clinical psychology

ARTICLE in AMERICAN PSYCHOLOGIST AUGUST 1999
Impact Factor: 6.87 DOI: 10.1037/0003-066X.54.7.504 Source: PubMed

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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.

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
irvingk@uconnvm.uconn.edu.

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 implicationsdepression 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 groupsa 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 theorizingand 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 intentionsalthough 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.

Conclusions
A variety of different therapeutic approaches, either implicitly or explicitly, harness the power of expectancies to
establish, shape, and fulfill treatment goals. Similarly, the
experimental literatures on priming and on ironic processes
are paralleled by strategies developed by therapists from
diverse schools of therapy. Given this overlap, it seems
likely that attention to the experimental literature could
lead to further improvements in therapeutic technique. At
the same time, additional research is needed to validate the
use of these automatic processes in psychotherapy.
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