I III I I I I I I III 145 782 .THS_ CHEN? ATTRITION DURING PSYCHOTHERAPY AS IT RELATES TO THE VALUE STRUCTURE OF THE CLIENT AND THERAPIST Thesis for the Degree of M. A. MICHIGAN STATE UNIVERSITY R, LANCE SHOTLAND 1969 3 1293 III III I IIII III III II III III III II I II ' g (j I ABSTRACT CLIENT ATTRITION DURING PSYCHOTHERAPY AS IT RELATES TO THE VALUE STRUCTURE OF THE CLIENT AND THERAPIST By R. Lance Shotland The practice of psychotherapy has long had difficul- ties with therapy sessions that might not have been utilized to the maximum extent possible. One reason for this is the premature termination of therapy by the client. Since the decision to terminate psychotherapy often involves the value judgment that therapy is unattractive, it was decided to initiate a study investigating the relationship of value systems of clients and their attraction or lack of attrac- tion to therapy. The §s (19 males and 18 females) upon completion of their first interview at the counseling center were asked to complete both the instrumental and terminal scales of the Rokeach Value Scale, Form A. Therapists and interviewers were asked to fill out the value scale after all clients had terminated therapy. As clients terminated their contacts with the counselor they were assigned to three groups, de- pending on their length of contact. The first group had one visit to the counseling center and then terminated therapy. R. Lance Shotland The second group had between 2 and 5 visits to the counseling center. The third group had six or more visits to the coun- seling center. Instrumental values, according to Rokeach, are modes of conduct with terminal values being “end-states“ of exist- ence. The gs were instructed to look over the 12 instru- mental and 12 terminal values and rank each set of values from one to twelve, one being the most important to that g and 12 being least important. The objective of the study was to see if any of the values the clients possessed would separate the client's termination groups. It also was hypothesized that the values of the clients interacting with the values of the therapist or interviewer would predict the premature termination of therapy. The results were consistent with the objectives and hypotheses of the study and were interpreted to mean that when there is a difference of values between client and therapist or client and interviewer, the client is more likely to terminate therapy. ,,2 ~/ J Approved::?Z;m97¢a¢aL/2§ZQ£;AQ;0' y Date:‘fldgécxaiqu/ALME/x/j:y./fflli— Thesis Committee: Norman Abeles, Chairman Milton Rokeach Dozier Thornton CLIENT ATTRITION DURING PSYCHOTHERAPY AS IT RELATES TO THE VALUE STRUCTURE OF THE CLIENT AND THERAPIST BY RCTLance Shotland A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Psychology 1969 To my parents ACKNOWLEDGMENT I would like to thank the three faculty members who served on my thesis committee - Dr. Norman Abeles, the Chairman, and Doctors Dozier Thornton and Milton Rokeach. Their advice did much to improve this thesis. iii TABLE DEDICATION . . . . . . ACKNOWLEDGMENT . . . . LIST OF TABLES . . . . LIST OF FIGURES. . . . LIST OF APPENDICES . . CHAPTER I INTRODUCTION. OF CONTENTS Statement of Purpose and Background II METHOD. . . . Subjects. . Instrument. Procedures. III IV RESULTS . . . Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis Data Generated Hy oth V DISCUSSION. . BIBLIOGRAPHY . . . . . APPENDICES . . . . . . l. 2. 3. 4a 4b iv OBJECTIVES AND HYPOTHESES S Page iii vi vii 10 10 11 12 14 16 16 19 16 20 22 23 29 36 38 Table 10 LIST OF TABLES Termination Group Differentiation by the Rokeach Terminal Value Scale Using a Kruskal-Wallis, Non-Parametric, One Way Analysis of Variance . . . . . . . . . . Termination Group Differentiation by the Rokeach Instrumental Value Scale Using a Kruskal-Wallis, Non-Parametric, One Way Analysis of Variance . . . . . . . . . . . . Termination Group Differentiation by Means of a One-Tailed Mann-Whitney U. Test Indicating Between Which Termination Groups the Differences Occurred on Both the Instru- mental and Terminal Value Scales . . . . . . Contingency Table of Initial Complaints and Termination Groups . . . . . . . . . . . Similarity of the Terminal Value Structure of Clients and Interviewers. . . . . . . . . Similarity of the Instrumental Value Structure of Clients and Interviewers. . . . Means and Standard Deviations for Each Termination Group on the Seven Point Liberal-Conservative Scale . . . . . . The Percentage of Each Termination Group Associated with the Two Political Parties. . The Termination Groups' Views on CiVil Rights 0 O O O O O O O O O O O O O O O The Termination Groups' Views on the War in Viet Nam. . .-. . . . . . . . . . . . Page 17 18 19 20 21 22 25 26 27 28 Figure LIST OF FIGURES A Spearman Rho Plot of Client- Therapist Dyads Versus the Total Number of Therapy Visits Using the Terminal Value Scale . vi Page 24 LIST OF APPENDICES Appendix Page A The Rokeach Value Scales as Administered to the Clients . . . . . . . . 38 B The Rokeach Value Scales as Administered to the Interviewers and Therapists. . . . . . . . . . . . . . . 42 vii CHAPTER I INTRODUCTION The practice of psychotherapy has long had difficulties with therapy sessions that might not have been utilized to the maximum extent possible. One possible reason for this is the premature termination of therapy by the client. Since the client's decision to leave therapy often involves the value judgment that therapy for one reason or another is unattractive, it was decided to initiate a study investigating the relationship of value systems of clients and their at- traction or lack of attraction to therapy. It is important at this point to define a value. Rokeach (1968) believes that: "To say a person 'has a value' is to say that he has an enduring belief that a specific. mode of conduct or end-state of existence is personally and socially preferable toaflternative modes of conduct or end-states of existence." If then a value is an "end-state,“ "mode of conduct" or .general way or preference for living, one might hypothesize that the client‘s particular preference for a mode of life, or set of values might be incompatible with the therapist's value set or system. It could thus cause both unsuccessful and early termination of therapy. Some research has been carried out delving into the role values (of patients and therapists) play in psychotherapy. The evidence has shown that values of both clients, therapists and the interaction of these sets of values plays a signifi- cant role in the judgment of success of psychotherapy. Welkowitz, Cohen, and Ortmeyer (1967), using the Strong Vo- cational Interest Blank (SVIB) and the Way to Live Scale (WTL), investigated client therapist dyads and found that: (l) therapists and their own clients were closer in value orientations than those dyads paired at random; (2) thera- pists do not share a homogeneous value system; (3) those clients rated as “most improved" by their therapists were closer to their therapists in values than clients rated "least improved." Thus a therapist's evaluation of a client's progress during psychotherapy is influenced by the congruence of the client value profile compared to that of the therapist. The findings of Betz (1963) and Carson, Hardin, and Shaws (1964) showed (using the SVIB profiles) that certain types of therapists were more successful with schizophrenic clients while other therapists with different value profiles were more successful with psychoneurotics. Thus, it would appear that the value system of a therapist influences whom he can treat successfully. Rosenbaum, Friedlander and Haplan (1956) found that those clients who were highly religious were the clients who were rated by their therapist as least improved by psycho- therapy. Welkowitz, et. al., thought these results were re- lated to a divergence of values between religious clients and therapists. Thus, it would appear that the relationship of therapist and client value structures affects the thera- pist's perception of his ability to both treat his client and evaluate the progress of therapy. It then is not a big step to hypothesize that the relationship of therapist and client value structures affects the client’s perception of the ability of the therapist to give him help. As the topic under discussion is the prediction of those clients that terminate psychotherapy prematurely, it would be wise to discuss attitude theory. An unfavorable attitude toward psychotherapy may be one reason for termina- tion. Rokeach (1968) defines an attitude as a "relatively enduring organization of beliefs around an object-or situa- tion predisposing one to respond in some preferential manner." Rokeach goes on to say that all behavior is a function of two attitudes; an attitude towards an object (A0) and an attitude towards the situation (As)' For example, a pre- judiced Southerner, with an attitude towards Negroes such that they are regarded as an inferior group of people and should be treated in some harsh manner (A0), might react harshly in Jackson, Mississippi but not.in the City of New York. Rokeach would account for this difference in behavior by explaining that the Southerner finds himself in two dif- ferent situations, i.e., in Jackson, Mississippi where he might have the support of his peers in a discriminatory ac- tion against Negroes, and in the City of New York where he might not find peer support for his activities. The differ- ence in the attitude of the Southerners toward the situation (As) in the different locations changed the interaction be- tween A0 and As by changing As' This caused the change in behavior. Rokeach further states: “Any attitude-toward-object has the inherent property of being differentially manifested along a rangeof values rather than as a single value, depending on the situation within which the atti- tude-object is encountered, and the same may be said for any attitude-toward-situation." Thus it would seem that behavior is a function of the atti- tude towards the situation and the attitude towards the ob- ject in an interaction can be reinterpreted to read that behavior is a function of a range of values towards the object and a range of values toward the situation in an interaction. Written in an equational form it can be ex- pressed: B : f(AO, As) = f(VO, VS) - where V0 and V8 are not single values but a range of values. Attraction to psychotherapy then, can be seen as exist- ing on two distinct levels. One level of attraction can be seen as an attitude towards the object (A0) which is favor- able to psychotherapy but either with a neutral or negative attitude towards the situation, e.g., I would like to under- take psychotherapy but my friends will look down on me so I won't: or, after having gone to a therapy session, I like therapy-but that therapist cannot help me. The other level of attraction consists of both a favorable attitude towards the object and a favorable attitude toward the situation, e.g., I would like to undertake psychotherapy (A0) and people will think better of me because of therapy (As). One stage of un-attraction also is possible. This consists of both an attitude toward the object and an attitude toward the situation which is negative in both cases, e.g., I don't like psychotherapy: besides my friends will ostracize me for it. As each attitude has a range of values through which it manifests itself each of the attraction conditions along with the unattraction condition should have some set of values that will be correlated with each condition. It is thought that the S3 will have some of these values in common for each condition as the choice they have to make is approximately the same, i.e., to either enter therapy or not. At this point it would be wise to inspect some of the previous studies on the tOpic of client attrition during psychotherapy. Lorr, Katz, and Rubenstein (1958) used a test battery consisting of (l) a 39 item Behavior Disturbance Scale origin- ally devised in a longer form by Applezweig and Dibner. (2) “A self rating scale consisting of 18 five-point graphic rating scales," (the client first rates his perceived self, then his ideal self, the difference indicating a measure of self satisfaction). (3) A 30 item version of the Taylor Manifest Anxiety Scale. (4) A 15 item modification of the Stanford-Binet Vocabulary Test and (5) a 20 item F-scale taken from the original F or Authoritarian Scale. It was hOped that these measures would accurately predict those who terminated therapy from those who remained in therapy. The sample population consisted of 300 clients collected from 13 V.A. Clinics. Terminators were those clients who can- celled therapy before a 6 month period while the remainers were those clients who continued therapy visits past the 6 month criteria. Scores based on the five measures did not differentiate the scores at an acceptable level of signifi- cance “although all were in the expected direction." The authors proceeded to item analyze the data finding sub- scales of items that seemed to discriminate the 'terminators' from the 'remainers' when cross validated on an independent sample. The combined test score correlated with the criteria at .39 (significant at the .01 level). Four of six of the specific hypotheses were found significant after the item analysis and cross validation. Terminators were more fre- questly "found to have a history of frequent trouble with the law, lack of impulse controls, hostility to authority, lack of_goa1persistence, and lack of personal ties or loyal- ties." Terminators were less self dissatisfied, more authori- tarian and less likely to report anxiety. Terminators did not differ significantly in vocabulary or socio-economic level. Among the actuarial items correlated with the criterion “only race and religion proved to be consistent in predicting termination of treatment." Negro clients were more likely to terminate while Jewish clients when compared to all other ethnic and religious groups were more likely to be remainers. Ross and Lacey (1961) found a similar trend. They found, in a child guidance clinic setting, that there was a trend for the remainers to contain proportionately more Jewish than Catholic families (x2 = 2.92, p = <.lO). Gibby, Stotsky, Miller, and Hiler (1953) compared a sample population which was Split into three groups by their attitude or reaction to therapy. Group 1 consisted of indi- viduals that spent six months or longer in therapy. Group 2 consisted of those who spent 5 sessions or less in therapy. The individuals in Group 3 refused therapy. “Significant differences between the first and the other two groups on R, A%, H and F+% items on the Rorschach are interpreted as indicating a greater motivation and greater c00perativeness on the part of the patient. Lack of productivity, con- strictedness, and stereotype of the second and third group are interpreted by the authors to mean that the patients resist becoming involved in either the testing or therapeutic procedure. Significant differences were found to exist be- tween the first and the remaining two groups in that a greater awareness of anxiety was exhibited by the first group compared to the suppressive reaction of the two groups who reacted negatively to therapy. The authors cite Fenichel who states that somatic symptoms are alternatives to anxiety. Thus those “who tend to somatize to the exclusion of psychological problems should manifest fewer signs of anxiety on their Rorschach protocols." The authors found this to be signifi- cant . Hiler (1959) substantiated the above statement by Fenichel when he compared the initial complaints of ter- minators and remainers. Hiler found that: I'both groups complained equally often of bodily symptoms such as headaches, fatigue and dizzi- ness. However the patients who terminated were more apt to complain only of somatic symptoms: the remainers on the other hand tended to complain of either purely psychological symptoms or a com- bination of psychological symptoms and somatic symptoms (P<.Ol)." Hiler (1959) also substantiated the study by Lorr, Katz, gt El' when he found that remainers were troubled by such maladies as obsessions (P<.Ol), phobias (P<.05), depres- sions (P<.05), poor concentration (P<.02) and anxiety (P<.05). Terminators on the other hand tended to show more assaultive tendencies and other forms of acting out (P<.05), ideas of reference, irrational suspicions, and other paranoid and schizoid ideations (P<.05). It is not in the realm of this introduction to re- view all the reported literature in the field_but rather to report the literature that is relevant to the forthcoming hypotheses. Brandt (1965) did an extensive review of the literature on clients who prematurely terminate psychotherapy. Brandt concluded that the population samples, measuring in- struments, and other variables have in the past been so different "that no clear-cut conclusions can be drawn as to who are the premature terminators or even whether they repre- sent a distinct group." From the conclusion of Brandt, it is evident that more work must be done in this area. To reiterate, this author feels that a productive approach to the problem of distinguishing between termina- tors and remainers in psychotherapy might be found in attitude and value theory as it seems reasonable to assume that those who stay in therapy have different attitudes and values than those who terminate therapy in regards to, at least, the therapeutic situation. CHAPTER II METHOD SUBJECTS The S pOpulation used in this study consisted of 19 male and 18 female undergraduate students enrolled at Michigan State University during the Fall, Winter, and Spring quarters of the academic year 1966-67. All gs voluntarily went to the counseling center at Michigan State University request- ing therapeutic counseling. The therapist interviewer population was composed of twenty-two therapists and interviewers with various orienta- tions and experience. The therapist's experience ranged from senior counseling staff members to interns; all, how- ever, had at least the equivalent of one previous year of therapy experience. The pairing of a client with a therapist was accom- plished after an initial interview with a senior staff member. The pairing considerations were made primarily by therapist availability. 10 11 INSTRUMENT The instrument used in this study was the Rokeach Value Scale. Form A. The value scale consists of one set of 12 instrumental values and one set of 12 terminal values. Instrumental values, according to Rokeach, are modes of con- duct with terminal values being end—states of existence. The §s were instructed to look over the 12 instrumental and 12 terminal values and rank each set of values from 1 to 12, 1 being most important to that g and 12 being least important. Test, re-test reliability, reported by Rokeach, after three weeks was .65, sufficient for inter-group comparisons. The 12 terminal values in alphabetical order as listed on Form A are: "A Comfortable Life," "A Meaningful Life," "A World at Peace,“ "Equality," "Freedom," "Maturity," "National Security," “Respect for Others," "Respect from Others," "Salvation," "True Friendship," and "Wisdom." The 12 in- strumental values are: "Broadminded," “Clean," "C00perative," "Courageous,“ "Forgiving," "Honorable," "Intellectual," "Polite," "Responsible,“ "Self-Disciplined," "Tender," and "Trustful." The form also asks the S3 views on Civil Rights and Viet Nam among other biographical data such as political view, social class, etc. For greater continuity the actual wording of the items will be presented with the results of these items. See Appendix A for a specimen c0py of the Rokeach Value Scale - Form A as given to the clients. The form given 12 to the therapists and interviewers did not contain the demo- .graphic items and was arranged somewhat differently. (See Appendix B) PROCEDURES The gs upon completion of their first interview at the Counseling Center were asked to complete both the instru- mental and terminal scales of the Rokeach Value Scale, Form A. The scales were administered during the Fall, Winter, and Spring quarters of the school year 1966-1967. The initial interviewers and therapists were asked to complete both value scales during the Summer quarter of 1967 (after all inter- viewing and therapy had been completed). As clients terminated their contacts with the coun- selor they were assigned to 3 groups depending on their length of contact. The first group consisted of those gs who had only one visit, the initial classificatory interview. This group contained 15 S5. The second group consisted of those gs who had between 2 and 5 visits. This group con- tained 10 gs. The third group contains 12 gs who had re- mained in therapy between six and eighteen visits. The entire client population was assigned to two classifications based on their initial complaints. This was accomplished by a panel of three counseling center psy- chologists who were asked to read the initial interview and to arrive at a joint decision. Classification One consisted of those clients who primarily complained of internal problems. 13 Internal problems will be defined in this study as those problems the locus of which is in the 'self.‘ Examples of internal complaints would be feelingsof depression, anxiety, inferiority, etc. Classification Two consisted of those clients who primarily complained of external problems. An external problem was defined as those problems the locus of which was outside the 'self.‘ An example of this type of complaint is, "if my roommate would just stop yelling at me everything would be all right." Thus, the client is stating that he or she is not the cause of their complaint but it is the fault of somebody or something else. It should be mentioned that there is a great deal of overlap in the initial complaints of the §_so that place- ment in any one classification is no easy or perfectly valid task. The placement is dependent upon the subjective view of the initial interviewer and then upon the subjective view of the panel. CHAPTER III OBJECTIVES AND HYPOTHESES (l) The first objective of the present study is to see if individual values will discriminate between Termina- tion Groups 1, 2, and 3. More specifically it is hypothesized that those clients who terminate therapy later (Termination Group 3) will rank "humanitarian" or liberal values such as “A Meaningful Life," "Respect For Others,“ "A World at Peace," "True Friendship," "Tender," I'Trustful and Forgiving" higher than those who terminate therapy earlier (Termina- tion Group 1). Likewise those who terminate therapy pre- maturely (Termination Group 1) will rank “non-humanitarian“ or less liberal values such as "Honorable," "Polite," "Cleanliness," and "Self-Disciplined" higher than those who remain in therapy (Termination Group 3). (2) Those clients who are either unable to or do not want to talk about themselves will terminate therapy sooner than those who have no such apprehensions or in- abilities. Thus more clients with 'external complaints' are expected to be found among those who terminate therapy (Termination Group 1) than those who remained in therapy 14 15 (Termination Group 3). Likewise more patients with 'inter- nal complaints' are expected to be found among those who remain in therapy (Termination Group 3) than those who ter- minate therapy (Termination Group 1). (3) It is hypothesized that gs who rank "Salvation" high will be those who terminate therapy after fewer ses- sions (Termination Group 1) than those (Termination Group 3) who rank "Salvation" low. "Salvation“ is a traditional religious concept and thus is expected to behave like the less liberal values discussed in Hypothesis 1. (4) Relationships are hypothesized between termina- tion rates and the value structures of clients, interviewers, and therapists. More explicitly: (a) It is hypothesized that there will be less con- .gruence between value systems on interviewer client dyads for Termination Group 1 than for Termination Groups 2 or 3. (b) It is also hypothesized that a direct relationship exists between the rank order correlations between the client and his therapist‘s values and the number of therapy visits by the client. CHAPTER IV RESULTS The first objective (Hypothesfisl) was to see if the individual values mentioned will discriminate between Ter- mination Groups 1, 2, and 3. It was stated in the third hypothesis (Hypothesis 3) that gs that rank "Salvation" high will be those who terminate therapy after fewer ses- sions than those who rank "Salvation" low. To test Objec- tive 1 and Hypothesis 3, a Kruskal-Wallis, non-parametric, one-way analysis of variance was computed for all three termination groups (see Tables 1 and 2). A one-tail Mann- Whitney U test was then used as a paired comparison tech- nique to indicate between which termination groups the differences existed (see Table 3). The Mann-Whitney was performed on those values where the Kruskal-Wallis H probability value was equal to .20 or less. From the comparisons performed and illustrated in Tables 1, 2, and 3, it would appear that the values "A World at Peace," "Respect for Others," and "Tender" were more important for those who remained in therapy (Termina- tion Groups 2 and/or 3) than for those who terminated therapy early (Termination Group 1). "Salvation" and "Cleanliness" 16 17 TABLE l--Termination Group Differentiation by the Rokeach Terminal Value Scale Using a Kruskal-Wallis, Non- parametric, One Way Analysis of Variance. Termina- Termina- Termina-- Level Value tion tion tion H-Sta- of Group 1 Group 2 Group 3 tistic Signif. A Comfortable Life 259.67 §;11.00 Ee9.50 1.78 .41 s =270.0 s =228.0 s =205.o 1 1 1 A Meaningful Life 222.25 §21.33 I21.10 5.01 .08 s =342.0 s =187.0 s =174.0 1 1 1 A World at Peace 228.00 223.00 226.50 3.67 .16 s =328.0 s =136.0 s =239.0 1 2 3 Equality i=7.00 i38.00 §é7.00 1.10 .58 s =303.5 s =203.5 s =296.0 1 2 1 Freedom i25.25 I23.83 §é6.83 3.03 .22 s =296.5 s =142.0 s =264.5 1 2 3 Maturity XE6.00 227.00 226.50 .19 .91 s =283.5 s =201.5 s =218.0 1 1 1 National Security i210.60 2210.50 i510.50 .17 .92 s =287.0 s -179.0 s =237.0 1 1 1 Respect for Others £58.00 —é6.l7 §$4.50 7.94 .02 s =357.0 s =200.0 s =l46.0 1 1 1 Respect from Others ié6.00 ies.75 i25.50 .43 .81 s =299.0 s =196.0 s =208.0 1 1 1 Salvation £27.20 i211.50 £211.90 10.41 .01 s =194.5 s =204.5 s =304.0 1 1 1 True Friendship £23.13 224.50 224.17 1.49 .48 s =246.0 s =210.0 s =247.0 1 1 1 Wisdom £55.25 £54.50 ’és.17 .12 .94 s =277.5 s =187.0 s =238.5 1 1 1 Y'= median for each termination group 51: sum of the ranks for each termination group The degrees of freedom = 2 18 TABLE 2--Termination Group Differentiation by the Rokeach Instrumental Value Scale Using a Kruskal-Wallis, of Variance. Non-parametric One Way AnalySis Termina- Termina- Termina- Level Value tion tion tion H-Sta- of Group 1 Group 2 Group 3 tistic Signif. Broadminded ‘§l=6.75 825.50 i22.50 1.82 .40 s =326.0 s =182.0 s =195.0 l l 1 Cleanliness §i=9.63 §;11.50 229.00 5.24 .07 =252.0 s —256.0 s =l95.0 1 l Cooperative §s9.00 229.17 257.50 2.52 .28 s =303.0 s =219.0 s =181.0 1 1 1 Courageous £29.13 i=9.50 £29.50 .22 .90 s =292.5 s =l76.5 s =234.0 1 l 1 Forgiving £24.00 '§=3.00 §;4.00 .44 .80 s =292.5 s =l7l.0 s =239.5 1 l 1 Honorable £23.33 §a4,50 225.17 2.27 .32 s =238.5 s =201.0 s =263.5 1 1 1 Intellectual £29.13 £27.17 §é6.50 1.49 .48 s =324.0 s =170.5 s =208.5 l 1 1 Polite £29.00 2210.50 239.50 1.11 .57 s =251.5 s =203.0 s =248.5 1 1 l Responsible i=3.75 ie4.50 225.50 2.38 .31 s =246.0 s =184.0 s =273.0 1 l l Self-Disciplined 2—4.33 2%3.83 259.50 4.59 .10 s =256.5 81:154.0 sl=29z.s Tender x26.75 §é4.83 "24.50 6.51 .04 s =366.5 s =156.0 s =180.5 1 l 1 Trustful 234.00 224.50 x=4.50 1.71 .43 81:249.5 81:223.5 81:230.0 i = median for each termination group S = sum of the ranks for each termination group THe degrees of freedom = 2 19 TABLE 3--Termination Group Differentiation by Means of a One Tailed Mann-Whitney U. Test Indicating Between Which Termination Groups the Differences Occurred on Both the Instrumental and Terminal Value Scales. Between Between Between Value Termination Termination Termination Group 1 & 2 Group 2 & 3 Group 1 & 3 A Meaningful Life p<.09 A World at Peace p<.03 p<.06 Respect for Others p<.09 p<.03 Salvation p<.03 p<.08 p<.01 Cleanliness p<.03 Tender p<.01 p<.01 was more important for those who terminated therapy early (Termination Group 1) than for those who terminated therapy later (Groups 2 and/or 3). A trend (probability values of .10 or less) was found for the value "A Meaningful Life" with those who terminated therapy at a later date (Termina- tion Group 3) believing that “A Meaningful Life" is more important than those who terminated therapy early (Termina- tion Group 1). In Hypothesis 2, it was stated that more clients with external complaints would be found among terminators than remainers and that more clients with ‘internal com- plaints' would be found among remainers than terminators. 20 This relationship between the termination of psycho- therapy and the initial complaint of the patient was upheld as the data in Table 4 demonstrated. TABLE 4--Contingency Table of Initial Complaints and Termination Groups Termination Termination Termination Group 1 Group 2 Group 3 External Complaint l4 5 3 Internal Complaint 1 5 9 Of the initial complaints of Termination Group 1, 6.6% (1/15) were classified as “internal" with 93.4% (14/15) complaining about “external" problems. Likewise 50% (5/10) of Termina- tion Group 2 had internal complaints with 50% (5/10) having “externar'complaints. Termination Group 3 had 75% (9/12) of the clients with internal complaints with 25% (3/12) of the clients complaining of an "external" problem. This re- lationship across all three termination groups yielded a chi square value of 13.46 (2 degrees of freedom) significant at the .005 level with the difference existing between ter- mination groups 1 and 3 (a chi square value of 10.58 using Yates correction) also significant at the .005 level of probability (1 degree of freedom). In Hypothesis 4a it was stated that there will be less congruence between value systems on interviewer- patient dyads for Termination Group 1 than for Termination 21 Groups 2 and 3. This prediction was verified by the data using the terminal value scale but not the instrumental scale.l Looking at the terminal values, as Table 5 illustrates, the median Spearman correlation for those who terminated therapy after the initial interview was .37 while the group who terminated therapy after at least one therapy session had a Spearman correlation of .60 between the clients and their interviewers. A Mann-Whitney U value of 14 was com- puted with a significance level equal to or less than .03. This would indicate that there is a higher Spearman correla- tion between interviewer and client for those clients who remained for at least one therapy session compared to those clients who terminated after the initial interview. TABLE 5--Similarity of the Terminal Value Structure of Clients and Interviewers Those gs Who Terminated Those §s Who Terminated After After the Interview At Least One Therapy Visit Median Spearman Median No. N Median Spearman Median No. N Correlation Be- of Counsel- Correlation Be- of Counsel- tween Clients ing Center tween Clients & ing Center & their Inter- Visits their Inter— Visits viewers viewers .37 1.0 7 .60 7.5 10 1 As it is necessary to have independent interviewer- patient dyads in order to perform a significance test on the data an interviewer could only be used in one dyad. There- fore, with 17 interviewers there could only be 17 dyads. Dyads were then selected (1) so as to obtain a substantial number of patients who terminated immediately after the inter- view and (2) to provide a full range of therapy visits between 2 and 18 hours. A Mann-Whitney U Test was then chosen to test the hypothesis as correlations are not normally distributed. 22 Neither significant results nor trends were obtained using the instrumental value scale when those client-inter- viewer dyads that terminated therapy after the initial inter- view were compared to those client-interviewer dyads that stayed for at least one therapy session. As Table 6 indicates, a median correlation of .25 was obtained for those client-interviewer dyads that ter- minated therapy after the initial interview compared to a median correlation of .26 for those client-interviewer dyads that stayed for at least one therapy interview. A Mann- Whitney U value of 36 was computed for this relationship. TABLE 6--Similarity of the Instrumental Value Structure of Clients and Interviewers Those §s Who Terminated Those §s Who Terminated After After the Interview at Least One Therapy Visit Median Spearman Median No. N Median Spearman Median No. N Correlation Be- of Counsel- Correlation Be- of Counsel- tween Clients ing Center tween Clients ing Center & their Inter- Visits & their Inter: . Visits viewers viewers .25 . 1.0 7 .26 7.5 10 It was stated in Hypothesis 4b that a direct relation- ship was expected between the rank order correlations of the client’s and his therapist's values and the number of the therapy visits by the client.2 2Client-therapist dyads were selected so as to (l) obtain an equal distribution across the range of therapy visits and (2) to keep the dyads independent so as not to emphasize one therapist over others. 23 As Figure 1 (without the triangle symbols) illustrates the relationship between the client therapist terminal value structure and the number of therapy visits is curvilinear. An eta of .91 with 14 dyads and 13 d.f. for dyads and 9 d.f. for categories yielded an F = 2.17 (P<.10). If the data is viewed with all 18 dyads (Figure l with the triangle symbols) thus arbitrarily weighing some therapistsmore heavily than others, an eta of .89 is obtained with 17 d.f. for dyads and 9 d.f. for categories which is significant at the .05 level. Graphically, no relationship was visible for the client-therapist instrumental value structure and the num- ber of therapy visits. Using the independent client-thera- pist dyads a non-significant eta of .62 was obtained, and a non-significant eta of .70 was obtained for all 18 client- therapist dyads. The results of Objective 1 and Hypothesis 3 suggested to this author that the value structure of terminators (Ter- mination Group 1) was more conservative and less humanitarian than that of remainers (Termination Group 3). As data on the political and humanitarian views of the clients was available, four additional hypotheses could be tested. A. Terminators (Termination Group 1) are more politically conservative than remainers (Ter- mination Group 3) who are more politically liberal. mommo :8 4 . . monsoon mo coaumcdeuwu mommo usooummmoca . 93 um ompmeEoo mp3,; ~38.”an mo umnfisz b 24_ _ a . q _ . . . _ . a _ _ . . _ j 1 Oh. ma 5H ma ma vH ma NH Ha 0H m m h m m v m N H oo.|. S .16.. om.I.MM O¢oliwu omfkm .io . mo om |.+qo mu OHolxee . on o 11.1. To. «go oa.++.flu e 8 o d o~.+um.m EXT?” . o “Pu o o O O OQo+lmwmm 0 Re om.+r d. mwm . 8.13m . 4.: w 6 4V Obs...T T. 4 o om.+. em.+e mamom mdam> Hwaflfiuma on» mean: mafimfl> ammumna no noossz anuoe nonuo> momma oneosuocaaucosao mo soda osm ccsucoom anus mmooHa 25 B. Terminators (Termination Group 1) tend to identify themselves as Republican more often than do the remainers (Termination Group 3). Remainers should identify themselves more often as Democrats than Republicans and more often as Democrats than do the terminators. C. Terminators (Termination Group 1) will tend to be less sympathetic to the Civil Rights struggle than remainers (Termination Group 3). D. Terminators (Termination Group 1) will tend to be more satisfied with the war in Viet Nam than the remainers (Termination Group 3). To test Hypothesis A to show that tenminators are more conservative than remainers, a mean and standard devia- tion was computed for each termination group on the 7 point political scale where one was 'liberal,‘ four was 'middle of the road,‘ and seven was conservative. TABLE 7--Means and Standard Deviations for Each Termination Group on the Seven Point Liberal-Conservative Scale Termination Termination Termination Group 1 N Group 2 N Group 3 N i = 3.92 Y = 2.89 Y = 2.64 Sl=l.38 15 S1=l.20 10 Sl=0.98 12 X = the mean 81: standard deviation A one tail t-test of 2.60 significant at the .01 level and a one tail t-test of 1.81 significant at the .05 level was found respectively between Termination Groups 1 and 3, and 26 1 and 2. Thus, it would seem.that terminators tend to be more politically conservative than those who remain in therapy for a greater number of visits. Hypothesis B stated that terminators tend to identify themselves as Republicans more often than as Democrats and identify themselves as Republicans more often than do the remainers. Remainers should identify themselves more often as Democrats than Republicans and more often as Democrats than do the terminators. A test between proportions was used to test thiShypothesis. Those in Termination Group 1 tend to consider themselves to be “Republican“ more often than “Democratic" and tend to be "Republican“ more often than those in Termination Group 3 (t=1.83, one tail t sig- nificant at the .05 level). TABLE 8--The Percentage of Each Termination Group Associated With the Two Political Parties Termination Termination Termination Group 1 Group 2 Group 3 Republican .533 .200 .167 Democrat .000 .200 .250 None .467 .600 .583 Group 1 also has fewer Democrats (.000) than groups 2 (.200) or 3 (.250). In Hypothesis C, it was stated that terminators will tend to be less sympathetic to the Civil Rights struggle than remainers. The question the S; were asked to respond 27 to was: Are you sympathetic with the aims of the Civil Rights demonstrations? The choices to which the SS could respond were: (1) No, (2) Yes, but I have not personally participated in a Civil Rights demonstration, (3) Yes, and I have participated in a Civil Rights demonstration. The means and standard deviations for the three termination (groups are listed below. TABLE 9--The Termination Groups‘ Views on Civil Rights Termination Termination Termination Group 1 Group 2 Group 3 N_ N_ N__ 15 X=1.67 10 X=2.10 12 X=2.25 Sl=.47l S1=.300 Sl='433 '2 = the mean S1 = standard deviation A one tailed t value equal to 3.22 significant at the .005 level of significance was found between Termination Groups 1 and 3. A one tailed t value equal to 2.39 significant at the .025 level of significance was found between Termination Groups 1 and 2. No significant difference was found between Termination Groups 2 and 3. In Hypothesis D, it was stated that terminators will tend to be more satisfied with the war in Viet Nam than the remainers. The gs were asked: Which of the following statements best expresses your opinion on the position the United States should take in Viet Nam. The three choices were: (1) Get out of Viet Nam, (2) Stay, but continue the 28 peace efforts, (3) Increase the war efforts to bring North Viet Nam to the conference table. TABLE 10--The Termination Groups' Views on the War in Viet Nam Termination Termination ' Termination Group 1 Group 2 Group 3 N__ N__ N_ 15 X=2.40 9 X=1.88 ll x=l.45 Sl=.491 S1=.737 S1=.655 ‘i = the mean S1 = standard deviation A one tailed t value equal to 3.96 significant at the .005 level was found between Termination Group 1 and 3 in addi- tion to the one tailed probability level of .05 (t value of 1.93) found between Termination Groups 1 and 2. No signifi- cant difference was found between Termination Groups 2 and 3. CHAPTER V DISCUSSION Virtually all the results can be interpreted as ver- sions of the following hypothesis: If a client perceives a serious difference between his values and the values of the therapist, he is less likely to continue in therapy. One group of results are closely tied to a liberal— conservative, humanitarian - non-humanitarian dimension. Terminators (Termination Group 1) give a relatively high ranking to the values "Salvation" and "Cleanliness" ('cleanliness' differentiating between Termination Groups 1 and 2). Remainers (Termination Group 3), on the other hand, give a relatively high ranking to such values as "A Meaningful Life," "A World at Peace," "Respect for Others," and "Tender.“ It might be argued that the values of the remainers are much more humanitarian in scope; i.e., they are "peOple directed" in a helpful fashion rather than "self directed" in an egocentric fashion. "Respect for Others" is certainly a humanitarian or "people directed" value. It represents an effort by the individual who be- lieves the value to be important to treat others as they would like to be treated. "A World at Peace" is also not 29 30 a "self directed“ value as it represents a striving for tranquility and a limitation of pain in the world rather than the "self." "A Meaningful Life" is felt to be a value that represents an involvement in enriching the lives of others. The value "Tender" or tenderness may imply some other living being to which tenderness is displayed. It should be noticed that all the values discussed above are oriented in a positive or helping direction towards others. The values that are held to be more important by terminators than remainers have a "self directed" quality about them. The value "Salvation" is a case in point. "PeOple directed" behaviors may be displayed in order to achieve "Salvation;" however, the goal itself is saving one's own soul not that of others. The value "Cleanliness" which discriminated be- tween those clients who remained for just one therapy visit (Termination Group 1) and those clients who only stayed for a short number of therapy sessions (Termination Group 2) is another case in point. "Cleanliness" is a "self directed" value that has little beneficial meaning to others except sanitation. As a result of the value structures of terminators and remainers and the humanitarian-non-humanitarian, "self directed-peOple directed“ hypothesis, it was thought that terminators may be more politically and socially conserva- tive than remainers. This was thought to be the case be- cause individuals that are "self-directed" rather than "people directed," or believe that man should be self 31 reliant rather than cooperative, are often more conservative. As data on the political and social views of the client popu- lation were available the four additional hypotheses stated in the result section were tested. It was found that terminators are more politically and socially conservative than remainers. Terminators tend to think of themselves as more politically conservative, more often are Republican than Democratic, have a more "hawkish" view on the war in Viet Nam and tend to be unsympathetic to the Civil Rights movements when compared to remainers. Now, if we assume that the therapists are more likely to be on the more humanitarian, "peOple directed," liberal end of the continuum, then the early termination of therapy can be explained. It is thought that therapists tend to be on the more humanitarian or "people directed" end of the continuum because: (1) They have entered a "peOple direc- ted" field, or one whose purpose is to help people and (2) It has been shown that the value structures of therapists are closer-to the value structures of remainers than of terminators. The remainers value structures have already been interpreted as being more humanitarian or "peOple directed." As a more humanitarian viewpoint on such things as Civil Rights, the war in Viet Nam, political liberality, etc., accompany the value structure of remainers it may also accompany the value structure of the interviewer and therapist. Thus, the values that are not represented on the Rokeach value scale but underlie such attitudes as views 32 on Viet Nam, Civil Rights, etc., also might be different from the therapist‘s values and lead to the termination of therapy. The third and most difficult set of results to inter- pret as a difference of values are those dealing with "in- ternal" vs. "external" complaints. Here we find that the terminators are much more likely to assign part of their troubles to something in their environment. If we assume that therapists are more likely to start with the assump- tion that the patient is the source of his own difficulties, we have a difference of attitudes and values along a very salient dimension. It should be remembered that the cor- rectness or incorrectness of the therapist's viewpoint is not at stake since the crucial issue appears to relate to the difference in attitudes. Thus, all the results would appear to be an extension of the relationship found between the similarity of client-interviewer (or therapist) value structure using the terminal scale. The client-interviewer value interactions using the terminal scale was related to length of stay in therapy as was predicted. Those clients who terminated after the initial interview had a lower median correlation between their value structure and that of the interviewers. No such relationship was found using the instrumental scale. Thus one point that needs explanation is how can the client perceive the terminal value structure of the interviewer after the one lone hour interview. While this 33 accomplishment at first might look implausible it is not difficult to explain, using the hypothetical construct called stereotypes. Haire (1968) found that the replace- ment of regular coffee with that of instant coffee on a shopping list changes the perceiver's image of the house- wife who compiled the shopping list from a careful wife to a careless one. Thus a single item of information in conjunction with a stereotype can completely change the manner in which one person perceives another. If the re- placement of regular coffee for instant coffee can have such dramatic results it is not hard to see how a client observing such variables as the dress, speech, hair style, etc., of his interviewers can decide that the interviewer is not similar to himself and holds certain attitudes and values different from his own. The client-therapist interaction on the terminal scale yielded a significant eta between the client-therapist correlations and the number of visits completed in psycho- therapy. There appeared to be a direct relationship between the correlation for each dyad, and the length of stay in therapy up to the tenth therapy session. From the tenth visit on, an inverse relationship existed. The total rela- tionship between the correlations of client-therapist dyads and number of therapy visits completed might be explained as follows: If the discrepancy between the client's value structure and the therapist's value structure is too diver- 'gent the client will usually drOp out of therapy. However, 34 if the client does remain in therapy in spite of the diver- gence between his values and that of the therapist, he will remain in therapy longer, exploring the differences between their value systems. Again, no relationship was found using the instrumental scale. One more issue needs explanation. This concerns the fact that there were no significant relationships between the correlations of therapist-client or interviewer-client dyads and the length of stay in therapy when the instrumental scale was utilized. One speculation is that clients have: more difficulty and are more rigid with larger life goals (terminal values) as opposed to ways designed to achieve these goals (instrumental values). Thus terminal values that conflict with the therapist's are salient while instru- mental values that conflict are not. Another explanation exists for the premature termi- nation of psychotherapy aside from the dissimilarity of the value structure between client and therapist or inter- viewer. It is possible that a conservative or non-humani- tarian value system on the part of a client may lead to the premature termination of psychotherapy. A client that pos- sesses a conservative value system may have a more rigid concept of what is prOperly discussed with another human being. Therefore he may find some of the therapist's or interviewer's probes too personal and thus terminate therapy. A client with a more liberal value system may not feel.in- hibited by these probes and therefore remain in therapy. 35 Thus if clients with conservative or non-humanitarian value systems are more prone to terminate therapy prematurely than clients with liberal or humanitarian value systems, and most therapists have liberal or humanitarian value sys- tems, a relationship between the value systems of clients, interviewers and therapists would appear to exist when in fact it is an artifact. It should be explained that this study was designed as a preliminary investigation using relatively small sam- ples. It is suggested that this study be replicated on a larger sample of S8. It is interesting to think that some day clients might be paired with therapists by their value structure to end the premature termination of psychotherapy. BLIOGRAPHY .s. v. 0.7;: v \- . i. .0 ..O.N \ . 1).... «Sana. .wa It. to. a /fi.£&.¢.to..\.vu.._. o ...o.do IOGRAPHY BIBLIOGRAPHY BIBLIOGRAPHY 9 BIBLIOGRAPHY BIBLIOGRAPHY Betz, G. "Validation of the Differential Treatment Success of 'A' & 'B' Therapists with SchiZOphrenic Patients," American Journal of Psychiatry, 1963, 119, 883-884. Brandt, Lewis W. "Studies of ‘DrOpout' Patients in Psycho- therapy: A Review of Findings," from Stollak, Gary, Guerney, Bernard, & Rothberg, Meyer, Psychotherapy Research, Chicago (1966); Rand McNally & Co. Carson,.R., Hardin, J., & Shaws, W. “A-B Distinction & Behavior in Quasitherapeutic Situations," Journal of Consulting Psychology, 1964, 28, 426-433. Gibby, R., Stotsky, B., Miller, D., & Hiler, E. “Prediction of Duration of Therapy-from the Rorshach Test.“ Journal of Consulting Psychology, 1953, 17, 348-354. Haire, M. "Projective Techniques in Marketing Research,“ from Toch, H., & Smith, H., Social Perception, Princeton, N.J. (1968), D. Van Nostrand Co., Inc., 37-43. Hiler, E. W. "Initial Complaints as Predictors of Continua- tion in Psychotherapy." Journal of Clinical Psy- Rokeach, Milton. Attitude, Values & Behavior. San Francisco (1968), Jossey Bass & Co. Rosenbaum, M., Friedlander, J., & Kaplan, S. “Evaluation of Results of Psychotherapy,“ Psychosomatic Medicine, 1956, 18, 113-132. Ross, A., Lacey, H. "Characteristics of Terminators.& Re- mainers in Child Guidance Treatment," Journal of Consulting Psychology, 1961, 25, 420-424. Welkowitz, J., Cohen, J., & Ortmeyer, D. “Value System Similarity: Investigation of Patient-Therapist Dyads." Journal of Consulting Psychology, 1967, 31, 48-55. 37 APPENDIX A 39 Date of Birth City & State of Birth This is a scientific study of value systems, and your honest cooperation would be deeply appreciated. There are, of course, no right or wrong answers. The best answer is your personal opinion. First, we are interested in knowing something about your background. Would you please answer all the questions asked below. Sex: Male Female Political party preference: None Liberal Democrat Conservative Democrat Liberal Republican Conservative Republican Where would you rate yourself on the following scale? (Circle one number) 1— ‘— l 2 3 4 5 6 7 Liberal Middle Conservative of the Road Religious Preference: None Catholic Jewish Other denomination or reIigion (Write in) Do you attend religious services? None A few times a year About once a month Usually one time a week What year are you in school ? Your major ? Would you classify the area in which you grew up as basically: Rural Urban Suburban If you were asked to use one of these three names for your social class, which would you say you belonged in: The working class. The middle class The upper class 40 Are you sympathetic with the aims of the Civil Rights demonstrators? No Yes, but I have not personally participated in a Civil Rights demonstration Yes, and I have participated in a Civil Rights demonstration Which of these statements best expresses your Opinion about what the United States should do in Viet Nam: Get out of Viet Nam Stay, but continue the peace efforts Increase the war efforts to bring North Viet Nam to the conference table Do you have a position on Communist China? I have no opinion on Communist China Keep Communist China out of the United Nations until she becomes a peace-loving nation Admit Communist China now into the United Nations Below is a list of 12 values arranged in alphabetical order. We are interested in finding out the relative importance of these values for you. Study the list of values below care- fully. Which of these values do you feel to be the most important for you? Place a l.on the blank line to the left of this value. Now, cross this value off your list and look carefully at the remaining 11 values. Which of these values is second most important for you? Place a 2 etc. Cross this value off your list and look carefully at the remaining 10 values. Place a 3 etc. Now, rank all the remaining values in order of importance to you. The value which is least im- portant, relative to the others, should be ranked 12. When you have completed ranking all of the items, go baEE over your list to make sure they are in the proper order. A comfortable life _____National security A meaningful life _____Respect for others A world at peace __;__Respect from others _____Equa1ity _____Salvation Freedom _____True friendship Maturity Wisdom 41 Below is a list of another 12 values. Rank these in order of importance, in the same way you ranked the first list on the preceding page. Broadminded Clean Cooperative Courageous Forgiving Honorable Intellectual _____Polite Responsible Self-Disciplined Tender Trustful APPENDIX B 43 Below is a list of 12 values arranged in alphabetical order. We are interested in finding out the relative importance of these values for you. Study the list of values below care- fully. Which of these values do you feel to be the most important for you? Place a l on the blank line to the left of this value. Now, cross this value off your list and look carefully at the remaining 11 values. Which of these values is second most important for you? Place a‘g etc. Cross this value off your list and look carefully at the remaining values. Place apg etc. Now,.rank all the remaining values in order of importance to you. The value which is least important, relative to the others, should be ranked 12. When you have completed ranking all of the items, go—Back over your list to make sure they are in the proper order. A comfortable life _____National security A meaningful life _____Respect for others A world at peace _____Respect from others ‘_____Equality _____Salvation Freedom ‘_____True friendship _____Maturity _____Wisdom Below is a list of another 12 values. Rank these in order of importance, in the same way you ranked the first list on the above half. Broadminded _____Intellectua1 _____C1ean _____Polite Cooperative _____Responsible Courageous _____Se1f-Disciplined Forgiving _____Tender Honorable Trustful HICHIGRN STATE UNIV. LIBRQRIES 31293100144801