I III I I I — — — — — — 7'— — L: I I CO I NC) __THS CLIENT EXPECTATION OF CHANGE. MOTIVATION FOR CHANGE, AND OUTCOME OF PSYCHOTHERAPY Thesis for the Degree of M. A. MICHIGAN STATE UNIVERSITY JUDITH DAVIDS 1968 L 13‘. z I". Y Mic.:‘_x.i“ '1" ‘ "Aotc THESIS - ' Unzvcmty ABSTRACT CLIENT EXPECTATION OF CHANGE, MOTIVATION FOR CHANGE, AND OUTCOME OF PSYCHOTHERAPY By Judith Davids This study explored the inter-relationship between three measures of client expectation of change through psychotherapy and attempted to relate these measures to the outcome of psychotherapy. The original experimental sample consisted of M1 undergraduate students engaged in personal-emotional counseling at the Michigan State University Counseling Center. Of these N1 students, 25 completed all three measures of client expectation, and only 16 of these also completed the outcome measure. Client expectation of change through psychotherapy was measured by (a) the summed discrepancies between the Present Self~and Expected Self forms of Goldstein's Com- mon Problems Scale; (b) the sum of the squared discrep- ancies between the clientfs ratings of "Myself as I am now" and "Myself as I would like to be after therapy". on Cartwright and Lerner's Need to Change scale; and (c) a seven-point rating of the client's optimism that; therapy would help to solve his problems. Outcome of psychotherapy was determined by the change in the total Judith Davids positive score on the Tennessee Self-Concept Scale from before to after therapy and by the therapists' post- therapy ratings of client improvement. The results of this study indicated that client expectation of psychotherapy is a factorial rather than a unitary concept, and the implications of this finding were discussed. In this context, the question was raised as to whether the Need to Change scale, as presently worded, might not more accurately be termed a measure of client motivation rather than a measure of expectation. This study failed to find a significant relationship between client expectation of change or need to change and the actual outcome of psychotherapy. The relation of these findings to the findings of previous research was discussed. It was concluded that while the relationship of client need to change to outcome of therapy remains unclear, the client's global expectation that he will profit from therapy is probably not an important predictor of therapeutic outcome. An incidental finding was that there is no significant relationship between low client expectation of change and the tendency to drop out of treatment before therapy is completed. Implications of these findings for further Approved [I22] afléfl’m 'L Mute/week Date: ///X%/6Y / / research were mentioned. Thesis Committee Dr. Donald Grummon, Chairman Dr. Gary Stollak Dr. Albert Rabin CLIENT EXPECTATION OF CHANGE, MOTIVATION FOR CHANGE, AND OUTCOME OF PSYCHOTHERAPY By w" Judith Davids A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS College of Social Science Department of Psychology 1968 ACKNOWLEDGMENTS I am sincerely grateful to everyone who assisted me in this research. My special thanks go to Dr. Donald Grummon whose patience and active concern were instru- mental in the success of this research. The assistance and constructive criticism of Dr. Gary Stollak and Dr. Albert Rabin were also greatly appreciated. I am also indebted to the therapists and staff of the Counseling Center, without whose cooperation this study would have been impossible. In particular I would like to thank Robert Kurtz and Marilyn Wenk whose assistance in data collection and analysis was invaluable. Finally, I am grateful to my husband, Cary, for his support and encouragement during the more trying times of the research. ii TABLE OF CONTENTS _ Page ACKNOWLEDGMENTS . . . . . . . . . . . . ii LIST OF TABLES . . . . . . . . . . . . iv LIST OF FIGURES . . . . . . . . . . . . v LIST OF APPENDICES . . . . . . . . . . . vi INTRODUCTION . . . . . . . . . . . . . l Hypotheses to be Tested . . . . . . . . 8 METHOD . . . . . . . . . . . . . . . 10 Subjects . . . . . . . . . . . 10 Independent Variable . . . . . . . . . lO Dependent Variable . . . . . . . . . . 12 Procedure . . . . . . . . . . . . . 13 RESULTS. . . . . . . . . . . . . . . 15 DISCUSSION. . . . . . . . . . . . . . 27 Construct Validity of Client Expectation. . . 27 Use of the Kelly REP Test to Study Client Expectation. . 28 Client Expectation and. Outcome of Psychotherapy 29 Further Research. . . . . . . . . . 35 SUMMARY. . . . ‘. . . . . . . . . . . 37 APPENDICES. . . . . . . . . . . . . . 39 BIBLIOGRAPHY . . . . . . . . . . . . . 52 iii Table 10. LIST OF TABLES Rank~Order Correlations between Three Measures of Client Expectation. . . Analysis of Covariance for High and Low Expectancy Clients' Post- -Therapy Mean Total Positive Scores. . . . Analysis of Covariance for High and Low Expectancy Clients' Post- -Therapy Mean Total Positive Scores. . . . . Analysis of Covariance for High and Low Expectancy Clients' Post- -Therapy Mean Total Positive Scores. . . Comparison of Mean Therapist Ratings of Client Gain for High and Low Expectancy Clients on the Common Problems Scale. Comparison of Mean Therapist Ratings of Client Gain for High and Low Expectancy Clients on the Need to Change . . . Comparison of Mean Therapist Ratings of Client Gain for High and Low Expectancy Clients on the Optimism Rating. . Comparison of Mean Common Problems Scale Scores of Clients Remaining in Therapy and Clients Terminating before com- pleting Therapy. . . . . . . Comparison of Mean Need to Change Scores of Clients Remaining in Therapy and Clients Terminating Early . . Comparison of Mean Scores on the Optim- ism Rating for Clients Remaining in Therapy and Clients Terminating Early iv Page 15 23 2A 2A 25 25 25 32 32 32 Figure LIST OF FIGURES Change in Total Positive Score of the TSCS as a Function of Need to Change Scores Change in Total Positive Score of the TSCS as a Function of Common Problems Scale scores 0 O O O O O O O O I 0 Change in Total Positive Score of the TSCS as a Function of Client Optimism about Therapy. . . . . . . . . . . Therapists' Ratings of Client Change as a Function of Need to Change Scores . . Therapists' Ratings of Client Change as a Function of Common Problems Scale Scores. Therapists' Ratings of Client Change as a Function of Client Optimism about Therapy . . . . . . . . Page 17 18 19 2O 21 22 Appendix A. LIST OF APPENDICES Need to Change Scale Construct Specification . . The Common Problems Scale Items for Forms PS and ES Single-Item Rate of Client Optimism. Raw Data for the Counseling Center Client Subjects . . . . . Division of Subjects into High and Low Expectancy Groups for Analysis of Covariance . . . . . . vi Page A0 A5 148 A9 51 INTRODUCTION Broadly speaking, the psychotheraputic process can be divided into three categories of variables: client variables, process variables (including therapist var- iables), and outcome variables. The clinician is inter- ested in predicting psychotheraputic outcome on the basis of his knowledge of variables in the other two categories; particularly, since these are the variables over which he has some control, he would like to know the effects of process variables on theraputic outcome. However, until the relationship between client variables and the outcome of psychotherapy is defined with greater precision, our conclusions about the effects of process variables on psychotheraputic outcome must remain tentative. Perhaps unrealistically, researchers have been operating under the assumption that only a small number of client variables are importantly related to theraputic success or failure, and considerable time and effort have been spent trying to isolate them. Among the client var- iables which have in the past looked encouraging as pre- dictors of theraputic outcome is client expectancy. Jerome Frank, in the introduction to Goldstein's Patient-Therapist Expectancies in Psychotherapy, said, Very few aspects of human functioning can really be understood without including a person's view of the future . . . A person's expectations affect his perception of what goes on about him, and thereby his behavior. His conduct in turn affects the ways in which others perceive him and their behavior toward him. Thus one cannot understand a person's state of mind or his behavior without consideration of his expectations about himself and those with whom he interacts (Goldstein, 1962, p. ix). Historically, expectancy is closely related to the concepts of "set," "anticipation," and "hypothesis" in the area of perceptual research. Perhaps the most recent theoretical interest in this area is Bruner and Postman's hypothesis theory and Allport's subsequent elaboration of this theoretical position in terms of set dynamics and interaction. This View holds that the more basic the con- firmation of the hypothesis or expectancy to the carrying out of a goal-striving activity, the greater its strength (in Goldstein, 1962). In the field of personality theory, Rotter and Kelly support the idea that anticipatory processes are a major determinant of behavior. Rotter has said: The occurrence of a behavior in a person is deter- mined not only by the nature or importance of goals or reinforcements, but also by the person's anticipation or expectancy that these goals will occur. . . . The basic formulation of social learning theory states that one of the major predictors of behavior is the subject's expectancy of the outcome of his behavior in a given situation (195A, p. 102). Lewin's theoretical model of level of aspiration stresses, as does Rotter's principle of internal expectancy, the importance of explaining level of aspiration in terms. of the individual's personalized or subjective expectations rather than the actuarial or objective expectations which might be independently assumed to be present on the basis of past performance. Similarly, in his theory of per- sonal constructs, Kelly states (1955, p. A6), ". . . human behavior may be viewed as basically anticipatory rather than reactive, and . . . new avenues of behavior open themselves to a person when he construes the course of events surrounding him." Thus it appears that personality and perceptual theorists have arrived at generally congruent positions regarding expectations, based in large part on widely differing types of investigations and research techniques, and it seems reasonable to conclude that expectations do indeed exert a major influence on human behavior. There have been two general approaches to opera- tionalizing client expectation of psychotherapy, each of which has unfortunately been tested in only a single ex- periment. The first approach stems from the work of Kelly in the field of personality theory. In the course of his research, Kelly designed the Role Construct Repertory Test, a projective instrument designed to elicit a series of words or constructs which the client feels describe the most important aspects of his interpersonal interactions and the interactions of important others in his life. The principle advantage (and also the chief disadvantage) of Kelly's test is that each set of constructs obtained is unique to the individual being tested. While this insures that the client is able to describe his feelings in words which are personally meaningful to him, it presents serious problems for making inter—client com- parisons of test scores, for the researcher has no way of knowing precisely how representative the elicited constructs are of the client's interactional role reper- toire, nor is there any but subjective means available for determining whether the constructs obtained from any two individuals are functionally equivalent. Kelly feels that (1955, p. 567): The client's conceptualization (expectation) of psychotherapy represents a body of constructs whose permeabilityl determines how extensively he can envision theraputic change in himself. If the client sees only certain minor adjustments and certain interview room exercises as consti- tuting psychotherapy, he will not be prepared to assay sweeping changes in his style of life. If one is to move, he needs to have a framework within which that movement can take place. Lipkin (1954) supported this View in a long term study of nine of his own clients, concluding that, ". . . the client who is positively oriented toward the counselor and the counseling experience, and who anticipates that his experience in counseling will be a successful one, undergoes more (positive) change (p < .01)." 1"A construct is permeable if it is open to the addi- tion of new elements, or elements beyond those upon which it has been explicitly formed." In the case of the REP Test, it is assumed that "the constructs he (the client) verbalizes are ones which can be applied to people and interpersonal situations which he has not yet confronted." (1955, P- 229) The major experiment using this general approach to client expectancy was done by Cartwright and Lerner (1963) using Landfield's (196A) shorter and simpler version of the Kelly REP Test. Studying 28 subjects with a mean age of 27.7 years who received a mean of A0 psychotherapeutic interviews each, the authors arranged the first ten dis- crete pairs of constructs obtained by each client on the REP Test on five-point rating scales. Before they entered treatment, the subjects were asked to rate themselves both "as I am now" and "as I would like to be after ther- apy." The total squared discrepancy between these two sets of ratings was taken to indicate "felt need to change." Those subjects who were rated improved by their therapists on the basis of integration, Open vs. defensive organization (presumably of personality), and present life adjustment, had a significantly higher "felt need to change" than those rated unimproved. The second approach which has been used to study client expectancy is that of Goldstein and his colleagues. Here expectation of specific symptomatic change rather than change in more general personality factors is dealt with. In a test specifically designed to measure the relationship between client expectancy and outcome of therapy, Goldstein and Shipman (1961) gave both the "Present Self" and "Expected Self" forms of the Common Problems Scale to 30 lower socio-economic class psycho- neurotic outpatients (mean age 34 years) just before their initial therapy interview; the "Present Self" portion was re-administered following the interview. The CPS (each form) consists of 50 items selected from the Mooney Problem Checklist (Mooney and Gordon, 1950) and arranged on five-point scales from "almost never like me" to "almost always like me." Noting the parallels between expectancy and level of aspiration, Goldstein and Shipman hypothesized that improvement would be greatest for patients with moderate present—self/expected-self discrepancies on the CPS, and lowest for patients with either very high or very low discrepancies. The client's perceived symptom reduction was used as the criterion measure. Results of the study indicated a significant correlation between expected and perceived symptom reduction (Epsilon = .405; p < .05), and a concomitant test for goodness of fit indicated an equally significant departure from linearity. These findings were in accord with those of Brady, Reznikoff, and Zeller (1960), who used a projective bat- tery to measure the expectations of 135 hospitalized psychiatric patients, and with those of Goldstein (1960), who used a Q-sort form of the CPS with 30 psychoneurotic outpatients; these studies indicated a lack of linear relationship between expectancy and theraputic outcome in, respectively, highly heterogeneous and highly homo- geneous research samples. The major deficiency of Goldstein and Shipman's (1961) experiment is that it dealt with changes occurring over only one interview-~hardly enough to involve much client change--nor were any objective outcome measures used to determine whether some change had actually taken place. Another study by Brady (1959) of 1A9 hospitalized psychiatric patients on self-report and projective measures provides added support, however, for the finding of prog- nostic superiority of moderate expectation of improvement. We now find ourselves faced with a dilemma. Both the Need to Change scale and the CPS have been used with some success to study the influence of client expectancy upon therapy. However, one is forced to ask why Cart- wright and Lerner found a linear relationship between expectationand theraputic outcome instead of the curvi- linear relation found by Goldstein and Shipman. There are several possible answers to this question. One is that if Goldstein and Shipman had measured perceived symptom reduction after five or ten interviews instead of after only one, their results might have more closely resembled those of Cartwright and Lerner. The possi- bility should also be considered that the Need to Change scale may not measure the same psychological variable as does the CPS, i.e. that client expectancy may be a multi-dimensional rather than a unitary concept. The purpose of this study was to clarify the nature of the relationship between client expectancy and psychotheraputic outcome and to explore client expec- tation as a psychological concept. In addition to the Need to Change and the CPS, a seven-point rating of the client's optimism about therapy as a solution to his problems was used as a measure of client expectation. All three instruments are simple to take and require little time to administer and score. They also encom- pass an interesting variety of the factors which might reasonably be expected to constitute expectation, and not all of which may be positively inter-related. The CPS provides an objective measure of the specific sympto- matic aspects of expectancy, while the Need to Change gives a subjective, tailor-made set of expectations for each client. The Optimism Rating was included on the chance that it might in the end correlate better with theraputic outcome than either of the other more complex measures . Hypotheses to be Tested The first hypothesis to be tested is that (a) the CPS, Need to Change, and Optimism Rating all of which purport to measure the client's expectations about psycho— therapy, do in fact measure the same psychological variable. A second hypothesis is (b) that client's expectation of change in psychotherapy is related to the amount of positive change which occurs as a result of the theraputic process. Because of the conflicting reports in the literature, two sub-hypotheses are proposed: (c) that client expectation of psychotheraputic change is related to actual change in a positive, linear manner; or alter— natively, (d) that client expectation is curvilinearly related to theraputic outcome. More specifically, clients with either very high or very low expectations of psycho- theraputic change will tend to benefit less from psycho- therapy than will clients with moderate expectations. METHOD Subjects In the course of a seven-month period, Al (11 male, 30 female) clients at the Michigan State University Coun- seling Center were selected on the basis that they were undergraduates, that they were seeking help for personal problems which, if they were motivated to work on them, would involve a considerable investment of time to work through, and that they were willing to try therapy as a possible solution for their problems. Selection was made subjectively by the screening counselor who performed the intake interview with the subject. Of these Al students, only 16 (A male, 12 female) completed both the pre- and post-tests; these subjects completed a mean of 10 inter- views each. Pre-test scores were obtained on an addi- tional 11 students ( A male, 7 female), who had a mean of only 2.9 interviews each. Thus it was possible to test hypothesis "a on a population of 27 clients, while hypo- theses "b," "c," and "d" were tested with an N of 16. Independent Variable The independent variable in this study was client expectation about the outcome of psychotherapy. Three different measures of expectation were used. 10 11 The first measure of client expectation used was Goldstein's (1960, 1961) Common Problems Scale, forms PS (Present Self) and ES (Expected Self). (See Appendix B) Each form consists of 50 items taken from the Mooney Problem Checklist and placed on five-point rating scales. 0n_form PS the client is instructed to rate himself as he is at the present time; on form ES he is to rate himself as he realistically expects to be at the end of therapy. The sum of the discrepancies between the clients' ratings of forms ES anvaS was taken to represent client expec- tation of therapy.* Split-half reliability of the dis— crepancy scores between forms ES and PS was 0.85 for 25 subjects. The second measure of expectation used was the modified version of the Kelly REP Test used in previous studies by Landfield (196A) and by Cartwright and Lerner> (1963). (See Appendix A) In this version pairs, rather than sets of three as in the original Kelly version, of personal constructs are elicited from the subject; these *This was one of two methods used to score the CPS. In the second method, it was assumed that no client would want to change in a negative direction and therefore that all discrepancies between forms ES and PS which indicated an expected change in the direction of greater symptom development were interpreted as errors. These "error" discrepancies were subtracted from the total discrepancies between forms ES and PS to determine the subjects' expec- tancy scores. The expectancy scores obtained by the two methods were highly correlated (p = .998) and it was I decided to use the simpler scoring system (without con- sidering the error term) for the remainder of the analy- sis. It is not clear what method was used by Goldstein and Shipman (1961). 12 pairs of opposites are then placed at either end of five- point rating scales. The client is asked, as in the CPS, to rate himself as he is now and again as he would like to be after therapy. The term "as you would like to be" rather than "as you expect to be" was used to exactly duplicate the procedure in the Cartwright and Lerner study. For the same reason, client expectation of ther- apy (Need to Change) was computed by summing the squared discrepancies between the clients' ratings of "Myself as I am Now" and "Myself as I would like to be after therapy." Split-half reliability of the discrepancy scores between present and expected self on the Need to Change was found to be 0.80 with an N of 27. On the third measure, the client was simply asked to rate on a seven—point scale how optimistic or pessi- mistic he was that therapy would be of help to him. (See Appendix C) Dependent Variable The dependent variable in this study was the amount of improvement made by the client as a result of therapy. Amount of improvement was determined by two independent measures: a) therapist's ratings of client gain from therapy (See Appendix D), and b) the pre- to post-therapy change in the client's Total Positive score on the Tennessee Self-Concept Scale (TSCS) (Fitts, 1965). The TSCS consists of 100 self—descriptive statements 13 which the subject uses to portray his image of himself. He does this by rating the item's degree of applicability to himself on a five—point scale which ranges from "com- pletely true" to "completely false." The items of the TSCS are organized into a number of subscales such as the neurosis scale, the general mal- adjustment scale, the personality disorder scale and others. The Total Positive score is a measure of the individual's overall self-esteem, and consists of the summed positive self-ratings on each subscale. The TSCS was selected as an outcome measure because it is simple for the client to understand, requires little time to administer, is well—standardized and multi-dimensional, and has a test-retest reliability of .92 on the Total Positive Score. Previous investigation (Ashcraft and Fitts, 1964) has shown that the Total Positive score on the TSCS is an effective measure of client improvement through psychotherapy. Procedure 1. Clients were screened by one of 20 intake counselors and selected on the basis of (a) the quali- fications listed under the section on "Subjects," and (b) the current needs of the project. 2. Before their first therapy interview the clients took the Common Problems Scale, the Need to Change Scale, the Optimism Rating and the TSCS. IA 3. Clients were assigned to one of 10 female or 20 male therapists, all either first- of second-year clinical or counseling psychology interns or permanent members of the Counseling Center staff. A. After the third therapy interview, the single- item rate was readministered. Test-retest reliability for the Optimism Rating was found to be 0.96. 5. At the termination of therapy the client was again administered the TSCS. Also at this time the coun— selors were asked to rate the amount of client improvement which they felt had taken place. RESULTS To test hypothesis "a" rank-order correlations were computed between the three measures of client expectation. This particular method of correlation was selected because it avoids the assumption of equal dis- tance between the scores on the various tests. All of the correlations computed were positive but low (See Table l), and only one was significant at the .05 level of confidence: the CPS correlated significantly (p < .05) with the pre-therapy Optimism Rating. Assuming that all three of the instruments used did in fact measure client expectation, our findings indicated that the concept of client expectation of change in therapy is of a factorial rather than a unitary nature; therefore, hypothesis "a" was not confirmed. TABLE 1.——Rank-Order Correlations between Three Measures of Client Expectation Tests N r Need to Change, CPS 25 +.273 Need to Change, Optimism Rating 24 +.010 CPS, Optimism Rating 2A +.376* *p < .05 15 16 As a first step in testing hypotheses "b," "c," and "d" the scores on each measure of client expectation were plotted (See Figures 1, 2, and 3) against the cor- responding change in the Total Positive scores on the TSCS and (See Figures A, 5, and 6) against the thera- pists' post-therapy ratings of client improvement. Inspection of the scatter plots clearly failed to sub- stantiate hypothesis "d" and no further tests of this hypothesis were made. In summary, no evidence was found to substantiate Goldstein's hypothesis of a curvilinear relationship between client expectation and theraputic outcome. Although a matched-group t test showed a signi- ficant difference between the pre— and post-scores of the Total Positive scale of all subjects (t = 2.62, df = 15, p < .01), these scores were also highly cor- related (Pearson r = .71). It was therefore decided to use analysis of covariance to test the effects of high or low client expectation on the TSCS Total Positive scores. The results of this analysis for each of the three measures are presented in Tables 2, 3, and A. The exact procedure which was used to divide clients into high and low expectation groups can be found in Appendix E. The analysis of covariance did not indicate a significant linear relationship between client expectation Pre- to Post-Test Change in Total Positive Score of TSCS -110 -100 -90 -80 -70 —60 -50 —AO -30 - 20 - 10 0 + 10 + 20 + 30 1'? db- L 10 20 30 . A0 50 60 Need to Change Figure 1.--Change in Total Positive Score of the TSCS as a Function of Need to Change Scores 18 —llO “ -lOO “ U) 53—90“ B CI 0 -80~ 0) $4 8 03-70“ 0) > 13-60% ”—1 U) 0 04-50.) r-i <13 *3 - - 9-1400 . g ‘ o C m ‘ 30 bl) C1 2 O —2o~ p o E|‘-10h .p U) 0 DC: 04»- o 3 I ,+10“ ‘ a) £4 CL. +204“ - 0 +30 % ‘f i e e e 30 NO 50 6O 70 80 90 Common Problems Scale Figure 2.—-Change in Total Positive Score of the TSCS as a Function of Common Problems Scale Scores Change in Total Positive Score on TSCS Pre-to Post-Test: -llO ‘ -lOO " -90 “ -70 ‘ -60‘ -50 ‘ -140 m- ..30 " -2O ‘ _lO 4» +10i’ +20 ‘ +30 19 A I A l l [ 1 Y r I 2 3 A 5 6 7 Client's Rating of Optimism About Therapy «I. Figure 3.—-Change in Total Positive Score of the TSCS as a Function of-Client Optimism about Therapy 2O Therapist Rating of Client Improvement J: 10 2O 30 A0 50 Need to Change Figure A.—-Therapists' Ratings of Client Change as a Function of Need to Change Scores 21 ‘Therapist Rating of Client Improvement LA.) '30 A0 50 6O 70 80 ‘ 90 Common Problems Scale Figure 5.--Therapists' Ratings of Client Change as a Function of Common Problems Scale Scores Therapist Rating of Client Improvement 22 7T 64- o u a 53 ‘t - °._ . A‘» . 3" 2A- 1 e e e I + 4 1 2 3 A 5 6 7 Client's Optimism About Therapy Figure 6.--Therapists' Ratings of Client Change as a Function of Client Optimism about Therapy 23 TABLE 2.--Analysis of Covariance for High and Low Expec- tancy Clients' Post-Therapy Mean Total Positive Scores. Source of Variation df MS F Unadjusted Need to Change 1 5638 5.A7 (NS) Error 1A 1031 Total 15 Adjusted Need to Change 1 762 0.798(NS)* Error 13 955 Total 1A *In this particular instance, analysis of covariance was not an optimal test of the relationship between client expectation and theraputic outcome, inasmuch as the homos- cedasticity assumption was violated. However, because this assumption was not violated for the other two measures of expectation, where no significant relation was found between client expectancy and outcome of therapy and because on inspection of Figures 1 through 6 it appears that Need to Change has even less relation to outcome than do the other two measures of expectation,we feel justified in accepting the non—significant findings obtained in the analysis of covariance of the Need to Change scores. 2A TABLE 3.—-Analysis of Covariance for High and Low Expec- tancy Clients' Post-Therapy Mean Total Positive Scores. Source of Variation df MS F Unadjusted Common Problems Scale 1 20 .01A (NS) Error 1A 1A32 Total 15 Adjsuted Common Problems Scale 1 1716 1.865 (NS) Error 13 920 Total 1A TABLE A.--Ana1ysis of Covariance for High and Low Expec- tancy Clients' Post Therapy Mean Total Positive Scores. W Source of Variation df MS F Unadjusted Optimism Rating 1 1138 .713 (NS) Error 13 1A56 Total 1A Adjusted Optimism Rating 1 1263 1.281 (NS) Error 12 986 Total 13 25 TABLE 5.—-Comparison of Mean Therapist Ratings of Client Gain for High and Low Expectancy Clients on the Common Problems Scale. Subjects N M SD Low Expectancy 8 5.37 .566 High Expectancy 8 5.57 .99 t .27 (NS) TABLE 6.-—Comparison of Mean Therapist Ratings of Client Gain for High and Low Expectancy Clients on the Need to Change. m Subjects N M SD Low Expectancy 8 5.75 .71 High Expectancy 8 5.12 .69 t -.71 (NS) TABLE 7.-—Comparison of Mean Therapist Ratings of Client Gain for High and Low Expectancy Clients on the Optimism Rating. 1 — Subjects N M SD Low Expectancy 6 5.50 .76 High Expectancy 8 5.50 .75 t 0 (NS) 26 of therapy and actual improvement as measured by Change on the TSCS. The results of a comparison of client expectation of change and therapists' ratings of client gain are pre- sented in Tables 5, 6, and 7. Again no significant re- lation was found between client expectation of psycho- therapy and actual client improvement. Therefore, H hypotheses "b" and c" were not confirmed. DISCUSSION Construct Validity of Client Expectation Positive intercorrelations were found between all three measures of client expectation of change; however, only the correlation between the Common Problems Scale and the Optimism Rating was sufficiently high to be sig- nificant at the .05 level of confidence. It therefore seems reasonable to conclude that client pre-therapy expectation of change is not a unitary concept but rather consists of a number of component variables. Factor analysis of a number of different measures of expectation would be necessary to determine the specific components of client expectations, and this information might in turn help to explain the nature of the inter- correlations between the three instruments used in this study. One important implication of these findings is that there seems to be no justification for speaking of client expectation as a general term; nor should the findings obtained from any given measure of client expectation of change be generalized to cover other measures of expectation unless these instruments have been shown to measure the same aspects of client expectation. 27 28 Use of the Kelly REP Test to Study Client Expectation' Some remarks are also in order on the appropriate— ness of the Kelly REP Test for the study of client expectation of change in psychotherapy. On inspection of the Need to Change ratings it was found that a few of the constructs elicited, while they were appropriate descriptions of the client and important others in his life, were relatively unrelated to the theraputic task. Two examples are "musical/not musical" and intelligent/not intelligent." One would not reasonably expect the client's self-rating of either of these items to change much as a result of therapy. This irrelevance of some constructs to the theraputic process may account in part for the failure of the Need to Change scale to predict the out- come of psychotherapy. An interesting question is whether more such irrelevant constructs were elicited in this study than in the study by Cartwright and Lerner (1961) where significant findings were obtained. There is also a more serious theoretical concern. Kelly's theory of Personal Constructs predicts that effective therapy results in increased permeability of and increasing differentiation among the client's old constructs, as well as the possible formation of new constructs, rather than simply the displacement of the client's post-therapy self-concept along pre—therapy construct continua. If this is the case, it appears 29 that the net effect of the Need to Change scale is to ask the client to predict how he expects to change with respect to criteria which are likely to be meaningless to him if some change does take place. By contrast, the items on the Common Problems Scale were selected to reflect specific symptoms of psychological dysfunction and there- fore were highly relevant to the theraputic process. One further difference between the Need to Change scale and the CPS should be pointed out. In order to replicate the Cartwright and Lerner study, the clients in this investigation were instructed to rate them- selves not as they "would reasonably expect to be" (the working on the CPS) but rather as they "would like to be" after therapy. These two phrases could easily have had entirely different connotations to the client. While he might have liked and wanted a substantial personality change to take place, the client might very well not have expected any such thing to occur. The issue raised here is whether motivation (felt need to change) and expec- tation can be considered to be equivalent in psycho- therapy; this is certainly an important question to be resolved before further research in this area is undertaken. Client Expectation and Outcome of Psychotherapy This study failed to find any significant rela- tionship between three measures of client expectation 30 of change and actual theraputic outcome. These findings are in accord with those of Brady, Reznikoff, and Zeller (1960) and Goldstein (1960), but differ with those of Cartwright and Lerner (1963) and Goldstein and Shipman (1961). The question of whether the subjects in the exper- imental sample were typical of the therapy-seeking popu- lation as a whole is an important one. More specifically, we must ask here whether the nature of the sample used in this study might account for the failure to obtain significant results. The sample used in this project was different in several respects from those used in previous studies. The average client in this study was between ten and fourteen years younger than the clients used in the investigations of Cartwright and Lerner and Goldstein and Shipman. He was also probably better educated than the clients in the previous studies, and of middle class rather than of the lower socio-economic background found in the Goldstein and Shipman sample. However, it seems likely that these factors, particularly the higher edu- cational level of the subjects in this study, would serve to make their knowledge of and consequently their expec- tations about psychotherapy if anything more accurate than those of the subjects in previous investigations. A serious complicating factor was the large number of dropouts in this study. It is possible that our 31 results were computed from expectancy data which was not typical of the client population as a whole; that is, the students who dropped out of the project may have had lower expectancy scores than did those who remained in therapy until termination was mutually agreed upon by both client and therapist. However, the mean Need to Change score found for the 16 clients who also took the outcome measure (i.e. for those clients whose scores were used to relate expectancy to outcome) in this study (33.7) was very close to that found by Cartwright and Lerner (3A.A); likewise the mean CPS score for the same group was A7.38 as compared to Goldstein and Shipman's mean of between A5.0 and 59.5 depending on the clients' sourse of referral. Furthermore, 3 tests (see Tables 8, 9, and 10) between those clients who terminated early and those who terminated with their therapists' approval revealed no significant difference in mean score on the Need to Change, CPS, or Optimism Rating. In conclusion, no reason was found to indicate that these subjects differed from other client populations with respect to pre-therapy expectation of change. Specifically, there seems to be no difference between the subjects used in this project and those used in previous studies which might account for the failure to find a significant relation between client expectation of change and outcome of psychotherapy. 32 TABLE 8.-—Comparison of Mean Common Problems Scale Scores of Clients Remaining in Therapy and Clients Terminating before Completing Therapy. m Subjects N M SD Remainers 1A A5.5 16.2 Leavers 7 36.A 1A.2 t .37A (NS) TABLE 9.--Comparison of Mean Need to Change Scores of Clients Remaining in Therapy and Clients Ter- minating Early. Subjects N M SD Remainers 19 30. 1A.9 Leavers 9 21, 9.A t .506 (NS) TABLE 10.—-Comparison of Mean Scores on the Optimism Rating for Clients Remaining in Therapy and Clients Terminating Early. Subjects N M SD Remainers 16 5.2 2.0 Leavers 8 5.A l.A3. t -.329 (NS) 33 At this point it might be useful to review this study in the context of previous findings. A study by Cartwright and Lerner (1961) found a significant relationship between the client's need to change and the outcome of psychotherapy. Theirs was a well designed study, and there is no reason to mistrust its findings. We have no good explanation for the discrepancy between our results and those of the Cartwright and Lerner study other than chance factors influencing the sampling procedure or perhaps a difference in the relevance of the constructs elicited in the two studies to the thera- peutic task. Viewing the Cartwright and Lerner study in the context of the lack of significant findings in the pre— sent investigation, some doubt is cast on the generality of the findings obtained with Cartwright andLerner's subjects. Further research with other client pOpulations will be necessary to determine the relation of need to change to outcome of psychotherapy with greater confidence. Goldstein and Shipman (1961) found a significant positive relationship between client expectation of change and psychotherapeutic outcome. However, because this study covered a period of only one interview, it might be more reasonable to attribute the perceived symptom reduction which Goldstein and Shipman found to anxiety reduction or relief rather than to actual improvement in client function- ing. This is in accord with Jerome Frank's finding (1961) that while some initial symptom relief may result from the patient's eXpectations of help, actual improvement in 3A personal functioning occurs as the result of the therapeutic experience. It is felt, therefore, that the Goldstein and Shipman study does not represent an adequate test of the relationship between client expectations and the change which results from psychotherapy. In contrast to Goldstein and Shipman's findings a study by Brady, Reznikoff, and Zeller (1960) found no re- lation between the expectations of 135 hospitalized psychi- atric patients of widely variant occupational, educational, and socioeconomic backgrounds and the actual improvement they had made after four to six months of treatment. Studying 30 psychoneurotic patients, Goldstein (1960) found no relationship between client expectation of change and perceived symptom reduction after five, ten, or fifteen therapy sessions. A third study also fails to confirm a positive relationship between outcome and the client's expectation that he will be helped by therapy. Heine and Trosman (1960) divided A6 psychiatric outpatients into (1) those who had doubts that they would be helped or the con— viction that they would not be, and (2) those who had hope without conviction that they would be helped or those who were certain that they would be helped. The authors found that the client's stated opinion regarding the potential efficacy of psychiatry bore no relationship to the criterion measure of continuance in therapy. They did, however, find a significant interaction between the client's expectations 35 about the mode in which therapy works and the expectations of his therapist in this same regard. In summary, when the Goldstein and Shipman findings are viewed in the context of the absence of significant findings in this investigation and in the remainder of previous studies, we are lead to the conclusion that client pre-therapy expectation of change, as measured by the Common Problems Scale or Optimism Rating, is probably not related in an important way to the amount of client improvement which takes place as a result of psycho- therapy. We therefore believe that research effort might be more profitably expended on other variables holding more promise of accounting for therapeutic outcome. It should be stressed that this conclusion applies only to the client's general expectation about favorable outcome of psychotherapy. It does not reflect on the client's specific expectations about the manner in which psycho- therapy works or about the nature of client and therapist roles in the therapeutic relationship; nor does it reflect on the possibility of a significant interaction between the expectations of the client and therapist about how therapy can be of help. Further Research One possible explanation for the failure of client 'expectation of change to predict actual improvement was suggested by Goldstein (1960). This is that since therapy is initially a novel experience to the client, the expectancies which he brings into the first therapy inter- view are very general in nature, for example, "Therapy helped Joe, so maybe it'll help me," or "He'll probably have a beard and make me lie on a couch." These early expectancies will not necessarily be relevant to the actual task of psychotherapy. If these speculations are correct, then it might be wise to study the relationship of client expectations of change measured after the second or third interview, instead of before the initial interview, to therapeutic outcome. By this time the client would have a more realistic picture of how therapy works, how much time and effort is involved, and what kinds of change may be expected to result from therapy. This hypothesis is sup- ported by Lipkin's (195A) finding that the client's ver- balized in-therapy orientation towards treatment is posi- tively related to the amount of improvement he makes. A second hypothesis worth exploring is that since the therapist is experienced in evaluating psychopatho- logy and is more aware than the client of what kinds of change generally result from psychotherapy, the therapist's expectations about the outcome of psychotherapy may be better predictors of actual change than are the client's. This hypothesis received some support in Goldstein's (1960) study, where a significant relation (p < .05) was found between therapist expectation of client change and perceived symptom reduction. SUMMARY This study explored the inter—relationship between three measures of client expectation of change through psychotherapy and attempted to relate these measures to the outcome of psychotherapy. The original experimental sample consisted of Al undergraduate students engaged in personal-emotional counseling at the Michigan State Uni- versity Counseling Center. Of these A1 students, 25 com- pleted all three measures of client expectation, and only 16 of these also completed the outcome measure. Client expectation of change through psychotherapy was measured by (a) the summed discrepancies between the Present Self and Expected Self forms of Goldstein's Com- mon Problems Scale; (b) the sum of the squared discrep- ancies between the client's ratings of "Myself as I am now" and "Myself as I would like to be after therapy" on Cartwright and Lerner's Need to Change scale; and (c) a seven—point rating of the client's optimism that therapy would help to solve his problems. Outcome of psychotherapy was determined by the change in the total positive score on the Tennessee Self-Concept Scale from before to after therapy and by the therapists' post- therapy ratings of client improvement. 37 38 The results of this study indicated that client expectation of psychotherapy is a factorial rather than a unitary concept, and the implications of this finding were discussed. In this context, the question was raised as to whether the Need to Change scale, as presently worded, might not more accurately be termed a measure of client motivation rather than a measure of expectation. This study failed to find a significant relationship be- tween client expectation of change or need to change and the actual outcome of psychotherapy. The relation of these findings to the findings of previous research was discussed. It was concluded that while the relationship of client need to change to outcome of therapy remains unclear, the client's global expectation that he will profit from therapy is probably not an important predictor of therapeutic outcome. An incidental finding was that there is no significant relationship between low client expectation of change and the tendency to drop out of treatment before therapy is completed. Implications of these findings for further research were mentioned. APPENDI CES 10. APPENDIX A NEED TO CHANGE SCALE CONSTRUCT SPECIFICATION Write the first name of your mother or the person who has played the part of your mother, on the first diag— onal line on the Response Sheet (after number one). Write the first name of your father or the person who has played the part of your father on the second diag- onal line. Do the best you can to find people who fit the types listed. If you have to depart too far from the type designated in order to fill every diagonal, star those names which do not fit very well. Write the name of your brother nearest your own age, or the person who has played the part of such a brother. Write the name of your sister nearest your own age, or the person who has played the part of such a sister. Your wife (or husband) or closest present girl (boy) friend. Do not repeat the name of anyone listed above. Your closest present friend of the same sex as your- self. Do not repeat names. A person with whom you have worked or associated who, for some unexplainable reason, appeared to dislike you. Do not repeat names. The person with whom you usually feel most uncomfor- table. Do not repeat names. The person whom you have met who you would most like to know better. The teacher whose point of view you have found most acceptable. Do not repeat names. A0 11. 12. 13. 1A. 15. Al The teacher whose point of view you have found most objectionable. Do not repeat names. The most unsuccessful person whom you know personally. Do not repeat names. The most successful person whom you know personally. Do not repeat names. The happiest person whom you know personally. Do not repeat names. The unhappiest person whom you know personally. Do not repeat names. Under the heading "Response Sheet" there are 15 rows. In each row there are two circles, each of which corresponds to a person you have just named. way these two people are like or different from each other. Consider in what important If they are essentially different from each other, write the word or phrase describing the first person in column 1, and in column 2 write the word or phrase describing how the second person is different from the first. For example, John is (col. 1), but Jane is (col. 2). If the two people are essentially alike, write in what important way they are similar in column 1. Then choose the person on the list of names who is most uplike the first two; write the number of his name and the word or phrase describing how he differs from the first two peo- ple in the second column. For example, both John and Jane are (col. 1), but Jill is (col. 2). A2 m . hmmzm mmzoammm NEED TO CHANGE PRESENT SELF Myself as I am Now 1. L I I I 111 I I I I ’T 2 1 O 1 2 2. I I I I I I T ’T I I 2 l O l 2 3- I_ I I I I I I I I I 2 1 O 1 2 4- I, I I I I I I I ”I r 2 1 O 1 2 5- I I J I I T I I I I 2 1 O l 2 6. I I I I I .1 I I I I I 2 l O l 2 7- I I I I I_L I I I I I 2 1 O 1 2 8. I I L I AL 11 I I I I I 2 1 O 1 2 9- I I I I I I I I I I 2 1 O 1 2 10- 14, I l I J I- I I I I 2 1 O l 2 After completing the description of yourself on the "as you are now" sheet, turn the page and repeat the pro- cedure for "as you would like to be after counseling." A3 10. As I Would Like to AA be After Counseling L I I I I I I I I fir 2 1 O 1 2 L IL I J I I I I I 2 1 O 1 2 I I I I I I I I I I 2 1 O 1 2 'I I I ' ' 2 l O 1 v; L_ I I IL,_J I I I I I 2 1 O 1 2 L, I I I L I I I I I 2 1 O 1 2 I I I J L I I I I I 2 1 O 1 2 I I I, I l I I I I fi 2 1 O 1 2 I I I I I | I I I I 2 1 O 1 2 I J I I ILL I I I I I 2 1 O 1 2 J: \OmNmU'I 10. ll. 12. 13. 1A. 15. 16. 17. 18. 19. 20. APPENDIX B THE COMMON PROBLEMS SCALE ITEMS FOR FORMS PS AND ES Worry about unimportant things. Difficulty in sleeping. Feeling afraid in many situations. Nausea or upset stomach. Queer unpleasant feeling in my body. Finding it hard to keep my mind on things. Shortness of breath. Feeling useless to myself and others. Getting tired easily. Feeling lonely. Feeling that I'm getting a raw deal from life. Pains in the lower part of my back. Getting mad easily. Feeling that I'm no good at all. Feeling that no one seems to understand me. Getting upset easily. Feeling I can't do anything well. Worrying about my weight. Trouble with my bowel movements. Finding that my feelings are easily hurt. AS 21. 22. 23. 2A. 25. 26. 27. 28. 29. 30. 31. 32. 33- 3A. 35. 36. 37. 38. 39. A0. A1. A2. A3. AA. A5. A6. A6 Poor appetite. Getting discouraged easily. Trouble with my eyes or ears. Cough, sore throat, or trouble swallowing. Feeling nervous. Shaking or trembling. Headaches. Finding I can't make up my mind about things. Getting embarrassed easily. Skin eruptions or rashes. Feeling sad, getting the blues. Feeling inferior. Feeling ill at ease with other people. Pains in the arms and legs. Faintness or dizziness. Feeling I take things too seriously. Feeling guilty without a good reason for it. Feeling I have too many responsibilities. Feeling that other people aren't fair to me. Feeling that my luck is very bad. Feeling that I'm too sensitive. Worrying a lot about the future. Pains in my chest. Feeling that I don't get along with my family. Hot or cold spells. Feeling afraid without knowing why. A7. A8. A9. 50. A7 Worrying a lot about the past. Feel my heart is pounding or racing. Sore muscles. Sweating a lot, even on cold days. "hozmcm ssom cfimfiaxm ou cmfiz so» pcmssoo has oo< ofipmfis ofipmaa Mafipmo ofipmaefipqo ofipmasflpmo ofiumfiafiwmmm ofipmfisfimmom Ifimmoa mo> zaopmsmooa mappfia m omofiooocs mepHH m zaopmhooos mmm> P a _ _ _ _ _ _I H _ 1 _ _ 4 w m m z m m H .ommoHQ hopes: onwahaopaqm one mHomHo poops 50% ohm ofipmHEHmmoQ no oapmfiafluao Bo: SmHEHBmO BZMHAU mo me