HOSTILITY OF PATENTS AND PSYCHOTHERAP {STS‘ APPROACH - AVG (DANCE: RES'P‘ONSE$ {N THE ENSTIAL STAGE Q? FS’YCHQ'z‘HEKAPY T562333 ‘or Hm Dogma of M. A. MICHIGAN STATE UNWERSHY David A. Koppiin 1963 ABSTRACT HOSTILITY OF PATIENTS AND PSYCHOTHERAPISTS' APPROACH-AVOIDANCE RESPONSES IN THE INITIAL STAGE OF PSYCHOTHERAPY by David A. Kopplin The expressions of hostility and dependency by patients and the responses of psychotherapists are signif- icant aspects of the interactive process in psychotherapy. This study examines the effect of therapists' responses of approach and avoidance upon the patients' continuing statements of hostility and dependency, and upon the dura- tion of treatment. Hypotheses, in general derived from learning theory, state that when therapists approach pa- tients' statements, patients continue the same topic; how- ever, when therapists avoid, patients discontinue the tOpic. The study also examines the effect of greater proportions of approach to hostility upon the retention of the patient in therapy. A further hypothesis states that more experienced psychotherapists will approach hostility more often than will less experienced therapists-—particularly when the therapist is the object of the patientfis hostile behavior. A meaningful goal for the resolution of conflictive feel- ings is to encourage the patient to express hostility within the treatment session. A content analysis is made of 72 tape recordings David A. Kopplin of first and second interviews obtained from 60 patients treated at a university counseling center by 30 psychothera- pists of three levels of experience: doctoral, interne, and beginning practicum trainees. The patients divide into three groups depending upon the length of treatment: pre— mature terminators, intermediates, and remainers. Patient- therapist interactions are coded for the number of times therapists responded with approach and avoidance reactions to the patients' expressions of hostility and dependency, and also for the frequency which patients continue to ver- balize the same topic following therapists' approach and avoidance interventions. The results follow: 1. Patients are likely to continue to express hos- tility and dependency after approach by the psychotherapist; they are likely to change the topic after avoidance by the therapist. 2. Although therapists approach dependency more than hostility, patients are more apt to continue express— ing hostility after approach than dependency after approach. 3. Premature termination of therapy fails to re- late to the percentage of approach therapists give to ex- pressions of hostility and dependency. 4. More experienced therapists approach hostility more often than less experienced therapists. However, these differences are not greater when hostility directed at the therapist is considered separate from other forms of hos- tility. 5. Therapists in general are more apt to approach hostility when it is directed at others rather than at them— selves. 6. Therapists show greater proportions of approach to hostility on the second interview, compared to the first interview, with the same patient. Limitations in the present methodology have impli- cations for further research. Chairman, Approved_W Date ? flag, /’é3 Thesis Commfiftee HOSTILITY OF PATIENTS AND PSYCHOTHERAPISTS' APPROACH-AVOIDANCE RESPONSES IN THE INITIAL STAGE OF PSYCHOTHERAPY By David A. Kopplin A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Psychology 1963 "I r27é{¥, 2/2/éd V v ‘ To Faith for patience for help for love ii ACKNOWLEDGMENTS The writer is extremely grateful to his chairman, Dr. Charles Hanley, for his proficient direction and en- couragement; his generous assistance in the preparation of the manuscript is deeply appreciated. The writer also wishes to express appreciation to his committee members, Dr. Bill L. Kell, Dr. Robert E. McMichael, and Dr. C. L. Winder, who not only have stimulated his interest in psy- chotherapy and research, but who have also sagaciously supervised his clinical training. Dr. Winder provided the original ideas which generated this study. Acknowledgments are made to Dr. Philip F. Caracena for his arduous work as primary judge; it was he who super- vised the collection of data. Finally, thanks must be expressed to the psycho- therapists and clients at the Michigan State University Counseling Center for their cooperation in making avail- able the tape recordings upon which this study is based. iii CHAPTER TABLE OF CONTENTS I. INTRODUCTION . . . . . . . . . . . . . . Statement of the problem . . . . . Hypothesis I . . . . . . . . . . . Hypothesis II. . . . . . . . . . . . Hypothesis III . . . . . . . . . . . O 0 O 0 II 0 METHOD 0 O O O O I O O 0 0 O O 0 O O O 0 Subjects . . . . . . . . . . . . . . Phase of treatment . . . . . . . . . . Duration of treatment. . . Page \O\D\] x] U14>NH Coding of patient— —psychotherapist interaction 11 Scoring reliability. . . . . . . . . . III. RESULTS. . . . . . . . . . . . . . . . IV. DI Reliability of raters. . . . . . . Differences between matched interviews Hypothesis I . . . . . . . . . . . . . Hypothesis II. . . . . . . . . . . . . Hypothesis III . . . SCUSSION . . . . . . . . . . . . . . . Hypothesis I . . . . . . . . . . . . . Hypothesis II. . . . . . . . . . . . . Hypothesis III . . . . . . . . . . . . V. SUWA-RY. O O O O O O O O O O O O O O O 0 REFERENCES iv l3 I5 15 l7 17 20 28 32 32 34 36 38 41 TABLE 10. ll. 12. LIST OF TABLES Page Characteristics of Therapists and Patients. . . 8 Experience Level and Interviews . . . . . . . . 10 Experience Level and Duration of Treatment. . . l2 Inter-Judge Reliability Coefficients of Scores Used to Evaluate Hypotheses. . . . . . . . . . 16 Score Changes from First to Second Interviews . 18 Experience Level and Approach-Avoidance Reactions toward Hostility Expressions . . . . 22 Experience Level and Approach-Avoidance Reactions toward Hostility when the Therapist Is the Object of Hostility . . . . . . . . . . 23 Experience Level and Approach-Avoidance Reactions when the Therapist Is Not the Object of Hostility. . . . . . . . . . . . . . 25 Experience Level and Therapist Approach to Hostility with and without the Therapist as Object . . . . . . . . . . . . . . . . . . . . 26 Experience Level and Difference Scores between Approach to Hostility with and without the Psychotherapist as Object. . . . . . . . . . . 27 Proportion of First and Second Interviews for Various Experience Levels of Psychotherapists. 29 Mean Values of Increases in Proportions of Approach to Hostility from First to Second InterViews O O O O O O 0 O 0 O O O O O O O O O 30 LIST OF APPENDICES Page I. Scoring Manual . . . . . . . . . . . . . . . . . . 42 II. Data Sheet for Therapists. . . . . . . . . . . . . 54 III. Follow-Up Questionnaire. . . . . . . . . . . . . . 55 vi I. INTRODUCTION Statement of the problem. "Psychotherapy is an undefined technique applied to unspecified problems with unpredictable outcome. For this technique we recommend rigorous training." This statement by a conference on Graduate Education in Clinical Psychology (reported by Parloff and Rubinstein, 1958) facetiously characterizes the status of research in the field of psychotherapy. Al- though many studies preceded and followed this conference, basic difficulties remain in this area of research. There is only a small structure of substantial evidence to sup- port the theories proposed to explain psychotherapy. Out- come studies suffer from inadequate criteria and usually produce insignificant results. A recent trend is toward process studies which analyze the moment-to-moment behavior changes of the patient and the psychotherapist. However, exploratory studies of this interactive process have lacked an adequate methodology to handle the complexity of psycho- therapy. A system of molecular analysis of the verbal inter- action in the therapeutic session has been proposed by Murray (1956), Bandura, Lipsher and Miller (1960), and Winder, Ahmad, Bandura and Ban (1962). At present this system is limited in scope, but it does provide a beginning methodology for observational studies. Using this system, the present study investigates the effects of the psycho- therapist upon the interactive process between patient and therapist. Hypotheses derive from social learning theory. The therapist's moment-to—moment responses of approach and avoidance influence the patient's behavior. The patient's verbalization of hostility and dependency reveal the imme— diate effects of the therapist's influence. An essential part of psychotherapeutic skill is to retain the patient as long as necessary for successful treatment. Therefore, duration of treatment often is re- garded as a global measure of the effectiveness of the thera- pist. If approach responses influence the patient's imme- diate verbalizations as well as his continuance in treat— ment, experienced therapists may utilize this technique more than trainees. The data for the study come from individual psycho- therapy sessions involving college students who voluntarily sought assistance with personal problems at a university counseling center. All received individual psychotherapy from therapists who had varying degrees of experience. Hypothesis I concerns effects of reinforcement by psychotherapists of verbal expressions by patients: thus, if expressions of hostility by the patient are approached by the psychotherapist, these approach reactions encourage patients to continue the expression of these feelings. Avoidance reactions by the psychotherapist on the other hand should inhibit expression of the same feelings. Es— sentially the same hypothesis has been confirmed in regard to hostile statements by Bandura, Lipsher, and Miller (1960) and in regard to both hostile and dependent statements by Winder, Ahmad, Bandura, and Rau (1962). Winder gt_gl (1962) also reported somewhat greater mean proportions for continuance of dependency than for continuance of hostility. The mean proportion for continu- ance of dependency by the patient following approach by the psychotherapist was .68, while continuance of hostility following approach was .51. Continuance of dependency fol- lowing avoidance was °ll, while continuance of hostility following avoidance was .02. The present study examines these differences, predicting that approach and avoidance by the psychotherapist will yield different proportions of continuance for dependent and hostile expressions on the part of patients. The hypothesis is based on the ex— pectation that dependency will yield greater continuance scores, since patients with personal problems are acting in a dependent manner when they voluntarily seek help at a counseling center and, therefore, should have little re- luctancy to verbalize dependency needs. Since hostile be- havior is generally less socially acceptable in initial contacts, the same patients will not express hostility as readily as dependency in early psychotherapy sessions de- spite equal encouragement by the psychotherapist. Hypothesis II. Experienced psychotherapists will approach hostility statements more than will less experi- enced psychotherapists--particularly when the hostility is directed toward the psychotherapist. Psychotherapy in- volves distress and discomfort; it creates personal frus- trations which provoke guilt, anxiety, and hostile feelings. A condition for the resolution of these frustrations would seem to be that the patient is permitted to express hostile and conflictive feelings within the treatment situation. A meaningful goal for a psychotherapist would be generally to promote by approach reactions continuance of hostile feelings expressed by the patient. Furthermore, a psycho- therapist should encourage a patient to express hostility which the patient feels toward the psychotherapist. In this manner the psychotherapist respects and responds to feelings which the patient may find difficult to articulate. Bandura g£_al (1960) report that psychotherapists who express hostility directly are more apt to approach and encourage the expression of hostility by their patients than are psychotherapists who express little direct hostil- ity. They also report psychotherapists who manifest low approval seeking behavior are more apt to approach hostil- ity than are psychotherapists who manifest high need for approval. Finally, these workers indicate that psychothera- pists are less inclined to approach hostility when the pa- tient's behavior is directed toward the psychotherapist than when it is directed toward another object. It is predicted, therefore, that more experienced psychotherapists when compared to relatively inexperienced psychotherapists will be more oriented to approach hostil— ity for two reasons: 1) such responses are appropriate for the resolution of patients' conflictive feelings; 2) experienced psychotherapists will have characteristics which would allow them to encourage hostile verbalization by their patients. Furthermore the difference in approach to hostil- ity between experience levels should be more pronounced when the hostility is directed toward the psychotherapist himself since such expressions are more closely related to the psychotherapist's need for approval and tolerance of hostile verbalizations. Hostility which is directed at the psychotherapist will be more anxiety provoking for the less experienced therapist; therefore, they will show greater tendency to discourage patients from continuing such expres- sion. Hypothesis III. If, during the initial sessions of psychotherapy, the psychotherapist encourages by approach reactions expression of hostile feelings by the patient more often than he discourages by avoidance, the patient will be more likely to remain in treatment; if, however, the psychotherapist tends to avoid hostile expressions by the patient more often than he approaches them, patients will tend to terminate psychotherapy prematurely. This hypothesis evolves from the same origin as Hypothesis II. Psychotherapy tends to arouse conflictive feelings about hostility to some degree in all patients. The resolution of these conflicts is promoted when the patient is permitted to express his hostility within the therapeutic session. Approach reactions by the psycho- therapist convey to the patient respect for his feelings of hostility; in this manner the psychotherapist strength- ens his relation with the patient. With avoidance reactions the psychotherapist is communicating to the patient disre- spect for his conflicts and anxieties which are related to hostility; thereby, the psychotherapist increases the patient's conflictive feelings and alienates the patient; psychotherapy is irritating to the patient and he terminates the relationship prematurely. The psychotherapist's reaction to hostility which is directed toward the psychotherapist should be more cru— cial for the continuance of treatment than is the reaction to hostility which is directed toward others. When the psychotherapist approaches the hostile feelings which the patient directs at the therapist, a condition is established for the resolution of the conflictive feelings the patient has about psychotherapy and his psychotherapist; psycho- therapy thereby becomes a gratifying experience and the patient should not terminate prematurely. Therefore, when hostility with the psychotherapist as object is considered separately, approach-avoidance ratios are expected to be more strongly related to the duration of treatment. II. METHOD Subjects. Table 1 presents information on patients and psychotherapists. Tape recorded interviews of 60 pa- tients who began psychotherapy at a university counseling center provided raw material for the study. None of the patients had previously received psychotherapy. Patients were generally assigned to a psychotherapist on the basis of availability. The psychotherapists divide into three groups on the basis of previous experience: staff psycho- therapists were doctoral level counseling and clinical psy— chologists with 4 to 10 years of psychotherapy experience; interns psychotherapists were advanced graduate students in counseling and clinical psychology who had an average of one year of intensive supervision in psychotherapy; prac— ticum psychotherapists were also advanced graduate students in counseling and clinical psychology but who were carrying their first to fourth supervised cases. The patients could be characterized as a late ado— lescent group experiencing newly-found independence and separation from home. The patients differ from those stud- ied by Bandura, Lipsher, and Miller (1960) and Winder, Ahmad, Bandura and Rau (1962), who used parents who were receiving psychotherapy at a parent-child guidance clinic. These investigators also studied psychotherapists who were rela- tively homogeneous in previous experience, i.e. graduate TABLE 1 Characteristics of Therapists and Patients Therapist Therapist Patient Experience Level N Male Female N Males Females Staff 6 4 2 ll 6 5 Interns l2 9 3 29 ll 18 Practicum 12 ll 1 2O 7 13 Total 30 24 6 6O 24 36 students in clinical psychology. Some selection entered into the composition of the present sample of psychothera- pists and patients, because all psychotherapists at the counseling center did not participate and tape recorded initial interviews were not available for all new patients who began psychotherapy within a specified period of time. Phase of treatment. First psychotherapy sessions of 48 patients and 12 second sessions (in cases where first sessions were not available) were analyzed in the study. In addition 12 second sessions with patients for whom first sessions were recorded and included in the study were an- alyzed to determine if there were significant differences between first and second sessions with the same patient on measures which were relevant to the hypotheses. Table 2 presents the distribution of interviews for various ex- perience levels. Duration of treatment. Three groups of patients form on the basis of the length of time they remain in treatment. The "terminator group" consists of 21 patients who began psychotherapy but left after no more than five sessions without the approval of the psychotherapist. The "remainer group" consists of 29 patients who attended ten or more sessions. The "intermediate group" includes 10 patients who attended six to nine sessions. Cases were not included if the client was forced to terminate treat- ment for such reality reasons as being drOpped from 10 TABLE 2 Experience Level and Interviews Therapist First Second Pairs of First & E1perience Level Interviews Interviews Second Interviews 'Staff 9 5 3 Interns 25 IO 6 Practicum l4 9 3 Total 48 24 12 11 university enrollment. While it was hoped that each psy- chotherapist would provide one "terminator" case and one, "remainer" case, this was not possible to arrange. The ratio of tsrminators and remainers for various groups of psychotherapists are: staff, 1.25; internss, 1.36; and practicum students, 1.50. The distribution is shown in Table 3. 'The differences are not significant (X2 test). Coding of patient-psychotherapist interaction. The procedure (of. Manual in Appendix I) was based on a modification of the content analysis systems employed by Bandura, Lipsher and Miller (1960) and Winder, Ahmad, Bandura, and Rau (1962). The elements of the system are as follows: 1. The scoring unit: An interaction sequence consists of three units: a beginning patient statement; the intermediate psychotherapist response; and an immedi- ately following patient response. In order to minimize contamination effects each unit is coded before the judge hears the immediately following unit. 2. Patient behavior categories: The three cats- gories scored are hostility, dependency and "other" units. Hostility is defined as any verbal expression of anger, dislike, resentment, antagonism, opposition, critical at- titudes, or aggressive action. Dependency is any verbal expression of approval-seeking, information—seeking, demand for initiation of activity or discussion by the psychothera— pist, help-seeking, company-seeking, concern about disapproval, 12 TABLE 3 Experience Level and Duration of Treatment Experience Level Terminator Intermediate Remainer Staff 4 2 5 Interns 11 3 15 Practicum 6 5 9 Total 21 10 29 13 or agreement with others. All other expressions are scored as "other." When dependency or hostility units occur, the object of the patient's behavior is also scored as psycho- therapist and/or other. 3. Psychotherapist response categories: Psycho- therapist responses in each sequence are scored in one of two general categories: approach or avoidance. Approach reactions include verbal responses which are primarily de- signed to elicit from the patient further verbalization of the topic under discussion. Sub-categories are approval, exploration, reflection, labeling, interpretation, general— ization, support and factual information. Avoidance reac- tions include responses which are designed to inhibit, dis— courage, or divert the patient from further verbalization of the topic under discussion. Sub—categories are disap- proval, topic transition, silence, ignoring, and mislabeling. Scoring reliability. Two judges, A and B, coded the interviews. Judge B was generally unfamiliar with the psychotherapists and both judges were ignorant of the dura- tion of treatment. The judges established familiarity with the scoring system by coding mutually a series of interviews. Then 10 independently coded interviews were compared for trial reliability. None of these ratings was used subse- quently. Judge A coded all 72 interviews. The reliability sample consists of 10 interviews randomly selected from the first 35 sessions scored by Judge A and another set 14 of 10 interviews randomly selected from the last 37 sessions he scored. These 20 interviews were scored by Judge B in substantially the same order as Judge A. Product-moment coefficients of the various scores included in the evalu— ation of the hypotheses were computed for the reliability sample in order to obtain a measure of inter—judge relia- bility. Since only Judge A scored all cases, the hypotheses are evaluated on the basis of his coding. III. RESULTS Reliability of raters. Coding agreement between judges is evaluated by computing product-moment coeffici- ents of the critical scores taken from each interview in the reliability sample. These coefficients are presented in Table 4. The proportions of approach reactions follow- ing various categories of patient statements constitute the psychotherapist variables. The proportion of approach to hostility, for example, is computed by dividing the fre- quency of hostility statements per interview into the fre- quency of psychotherapist approach responses which immedi- ately followed a hostile expression by the patient. (:5 psychotherapist approach following hostility/:3 hostile. statements by patient.) Patient variables in Table 4 refer to the propor— tion of sequences where the patient continues to express the same topic after approach or avoidance by the psycho- therapist. For instance, the continuance of hostility fol- lowing approach is derived by scoring the number of inter— action sequences in which a hostile expression by the pa- tient is followed by approach by the psychotherapist; this score is divided into the frequency of units in which the patient continues to express hostility after the psycho- therapist has responded with approach. (21 hostility fol- lowing approach to previous hostile statement/2’. of hostile 15 16 TABLE 4 Inter-Judge Reliability Coefficients of Scores Used to Evaluate Hypotheses Score N ‘3 Therapist Variables: Approach to Hostility 20 .85 Approach to Hostility toward Other 20 .86 Approach to Hostility toward Therapist 11* .85 Approach to Dependency 20 .61 Approach to "Other" Units 20 .70 Patient Variables: Following Approach Continuance of Hostility 19* .69 Continuance of Dependency 20 .81 Following Avoidance Continuance of Hostility 20 .83 Continuance of Dependency 18* .76 *These categories were not scored on all interviews. l7 expressions which are followed by approach.) All coeffici- ents are statistically significant (p <:.01). Differences between matched interviews. A separate analysis of 12 matched pairs of first and second interviews was made to ascertain if there were directional changes on any of the critical scores from first to second inter- views with the same patient. The results are presented in Table 5. Only the measures of psychotherapist approach to hostility showed statistically significant changes in one direction, the therapists approaching hostility rela— tively more often in the second interviews than in the first interviews with the same patients. Hypothesis I. The mean proportion of hostility statements followed by approach which were in turn followed by a further expression of hostility is .72, which clearly indicates that approach to hostility tends to be followed by further expression of hostility. The mean proportion of hostility expression followed by avoidance and then fol- lowed by further hostility is .27. The two proportions, continuance after approach and continuance after avoidance, were compared for each interview. In 66 of 69 interviews (3 interviews showed no approach to hostility) the propor- ..tion following approach exceeds the proportion of hostility following avoidance of hostility. The sign test is highly significant (p< .001). In 60 of the 69 sessions when ap- proach follows hostility, further hostility follows more TABLE 5 Score Changes from First to Second Interviews Score Increase Decrease Frequency of Directional Change* Sign Test (two-tailed) Therapist Variables: Approach to Hostility Approach to Hostility toward Other Approach to Hostility toward Therapist Approach to Dependency Approach to "Other" Units Patient Variables: Following Approach Continuance of Hostility Continuance of Dependency Following Avoidance Continuance of Hostility Continuance of Dependency 12 11 (.124) *Ties and the absence of a particular category in the scoring of an interview result in frequencies that do not total 12 in some cases. 19 than 50% of the time. In 34 of the cases hostility follows approach to hostility more than 75% of the time. Hostility, if followed by avoidance, never occurs as the next patient response in 11 of the 72 interviews. In only 7 cases does hostility follow avoidance of hostility more than 50% of the time. Hypothesis I is clearly confirmed. A separate study (Caracena, 1963) which utilizes dependency scores from the same tapes finds similar results for approach and avoidance. A comparison of dependency and hostility interaction sequences determines whether approach and avoidance elicit differing pr0portions of continuance with different patient behavior. In 43 interviews the proportion of hostility following approach to hostility is greater than the propor- tion of dependency following approach to dependency; the opposite is found for 24 interviews. The difference is statistically significant (sign test, p¢.05). Thirty- eight interviews reveal a greater proportion of hostility following avoidance of hostility than dependency following avoidance of dependency; 28 interviews show the opposite results. However, this difference is not statistically significant. 1The mean proportion of instances per interview when dependency followed approach to dependency is .63 and for dependency following avoidance of dependency is .26. In 62 of 68 interviews the proportion of dependency follow- ing approach to dependency exceeds that for dependency fol- lowing avoidance of dependency. This difference is also clearly significant (sign test, p< .001). 20 The proportion of psychotherapist approach to hos- tility has a low positive correlation with patient continu- ance of hostility after approach (3,: .30, N = 69, p «:.01). Therefore, it is relevant to inquire whether the tendency for greater patient continuance of hostility with approach than continuance of dependency with approach might be a function of a greater tendency on the part of the psycho— therapists to approach hostility as contrasted to approach to dependency. The analysis requires determining for each interview the number of times the psychotherapist approached and avoided expressions of hostility and dependency, and then computing the proportions of hostility units and de- pendency units approached. The mean proportion of approach to dependency per interview is .73, while the mean approach to hostility is .55. In 56 interviews approach to depend- ency exceeds approach to hostility; the reverse holds for 15 interviews. This difference is statistically significant (sign test, p <5.001). Psychotherapists are more apt to approach dependency than hostility. This result shows that the greater continuance of hostility after approach is not the result of relatively greater approach to hostility than to dependency on the part of therapists. Hypothesis II predicts that approach to hostility will be greater for more experienced psychotherapists. The mean proportion of approach to hostility per interview for staff level psychotherapists is .69; for interns level 21 psychotherapists it is .59; for practicum level psychothera- pists, .44. The Kruskal-Wallis H test indicates the result is not due to chance (p ¢=.Ol); thus Hypothesis II is con- firmed. The distribution of greater approach and greater avoidance proportions, using .50 as a cutting score, is shown in Table 6. The staff and interns psychotherapists are significantly more likely to approach rather than avoid patient hostility. This is not true for practicum psycho- therapists. It was predicted that the differences between ex- perience levels would be more clearly revealed on approach to hostility when the psychotherapist is its object. Sep— arate analyses of approach proportions to hostility when the psychotherapist himself is the object and when the hos- tility is directed toward some other object test this pre- diction. The mean proportions of approach to hostility with the therapist as object are: staff, .52; interns, .45; Practicum, .28; total sample, .41. These differences fail to reach statistical significance (H test, .10 :>p’:>.05). The distribution for the three groups, using .50 again as the cutting score, is shown in Table 7. Practicum students are likely to avoid hostility if they are the object of the patient's expression (sign test, p <:.02). The mean proportions of approach to hostility when the object is other than the therapist are: staff, .75; interns, .61; practicum, .48; total sample, .60. These differences are also not due to chance (H test, p <:.Ol). 22 TABLE 6 Experience Level and Approach—Avoidance Reactions following Hostility Expressions Therapist p. Approach p. Approach Sign Test p. Group > . 50 Z . 50 (two-tailed) Staff 12 2 .01 Interns 24 ll .04 Practicum 8 15 n.s. Note: Kruskal-Wallis H test: p. <5.01. 23 TABLE 7 Experience Level and Approach-Avoidance Reactions toward Hostility when the Therapist Is the Object of Hostility Therapist p. Approach p. Approach Sign Test 2. Group > . so é . 50 (two-tailed) Staff 6 6 n.s. Interns 9 15 _n.s. Practicum 4 16 .01 Note: Kruskal-Wallis H test: .10 >2. >.05. 24 The distributions are shown in Table 8. Staff and interns psychotherapists are likely to approach rather than avoid hostility directed toward another object.(sign tests, 2 <:.Ol). The distribution comparing the proportions of approach to hostility when the psychotherapist is the object of hos- tility and when another is the object is shown in Table 9. The staff, practicum and total groups show Statistically significant differences in favor of greater approach when the psychotherapist is not the object of the patients' be- havior. Not only were more experienced psychotherapists expected to approach hostility more than less experienced psychotherapists, but the difference between experience levels was predicted to be greater for approach to hostil- ity when the therapist himself is the object of the patient's expression than when he is not. Because the therapists were more apt to approach hostility when they were not the object, this prediction will be confirmed if 1) more expe- rienced therapists show either greater approach to hostil- ity when they are the object than when they are not, or small differences between the two approach scores when they are more apt to approach hostility directed toward others; and 2) the less experienced psychotherapists show large differences between the two approach scores with the larger score for approach without the therapist as object. The distribution of these difference scores is shown in Table 10. A median test fails to show significant differences 25 TABLE 8 Experience Level and Approach-Avoidance Reactions when the Therapist Is Not the Object of Hostility Therapist p. Approach p. Approach Sign Test 2. Group :>'.50 45.50 (two-tailed) Staff 14 0 .001 Interns 26 9 .006 Practicum 9 l4 n.s. Note: Kruskal-Wallis H test: p. 4:.01. 26 TABLE 9 Experience Level and Therapist Approach to Hostility with and without the Therapist as Object Other as Therapist as Therapist ObJeCt > Object > Sign Test 2. Therapist as Other as Group Object Object (two-tailed) Staff 10 2 .04 Interns 15 8 n.s. Practicum 15 4 .02 All Therapists 4O 14 .001 27 TABLE 10 Experience Level and Difference Scores between Approach to Hostility with and without the Psychotherapist as Object Therapist Scores* Group +50 to -19 ~20 to -80 Staff 8 4 Interns l2 l2 Practicum 8 12 Note: Median test: n.s. *Minus scores indicate less approach to hostility when the therapist is the object; plus scores indicate greater approach when the therapist is the object. 28 between the three experience groups. A significant increase in approach to hostility from the first to the second matched interviews in the 12 cases makes it relevant to inquire if differences between expe— rience levels are a function of the inclusion of an unequal number of first and second interviews for various groups of psychotherapists. Table 11 shows the proportion of first and second interviews for each group. A X2 test does not reveal significant differences in these frequencies. The mean increase in approach to hostility (the difference scores between the first and second interviews) for the three groups on the 12 paired interviews is shown in Table 12. Since the magnitude of increases is in reverse order, compared to the magnitude of approach for these three groups, the inclusion of second interviews would tend to reduce the significant differences reported above. Therefore, the inclusion of second interviews works against significant differences being found between experience levels for ap- proach to hostility in the initial stage of psychotherapy. Hypothesis III. It was predicted that the reactions of psychotherapists to expressions of hostility by their patients would influence the duration of treatment. If psychotherapists avoided hostility statements, particularly when they were the object of the aggressive behavior, pa— tients were expected to terminate psychotherapy prematurely. Only the earliest interview for each patient is used in 29 TABLE 11 Proportion of First and Second Interviews for Various ExperienceLevels of Psychotherapists First Interviews Second Interviews Group (N = 48) (N = 24) Staff .19 .21 Interns .52 .42 Practicum .29 .38 Note: X2 test: n.s. 30 TABLE 12 Mean Values of Increases in Proportions of Approach to Hostility from First to Second Interviews Measure Staff Interns Practicum Total Approach to Hostility .ll .25 .24 .21 Approach to Hostility toward Therapist .02 .23 .36 .20 Approach to Hostility toward Other .07 .19 .30 .10 31 the present analysis. When terminator and remainer groups are compared on psychotherapist approach to all hostility, and approach to hostility with and without the psychothera— pist as object, in no case are differences found which could not be attributed to chance (Mann-Whitney U tests, p 4:.10). In view of the results reported for Hypothesis II, it is relevant to ascertain if the differences in approach to hostility with and without the psychotherapist as object are related to duration of treatment. A psychotherapist, who shows a greater tendency to avoid hostility which is directed at him as contrasted to his tendency to approach hostility which is directed at another, might have clients who prematurely terminate the therapeutic relationship. A median test comparing terminators and remainers on dif- ferences between the approach proportions to hostility with and without the psychotherapist as object does not reach statistical significance. A parallel analysis of the dif- ference scores between approach to dependency and approach to hostility for each interview also fails to differentiate terminators and remainers. Finally two patient measures, continuance of hos- tility after approach and continuance of hostility after avoidance, fail to separate terminators from remainers. IV. DISCUSSION Psychotherapists in the present study selected the patients whose psychotherapy was recorded. The therapists themselves are not representative of psychotherapists in general, because they are all at the same institution. Those who constitute the interns and practicum groups are all supervised by the staff. The patients were all college students and thus are not representative of patients in general. Therefore, generalization of the findings to psy- chotherapists or patients in general is not warranted. Hypothesis I. In the present study approach reac- tions by the psychotherapists are more effective than avoid- ance reactions in eliciting continuance of hostile and de- pendent verbalizations by the patients. These results con— cur with those reported by Bandura, Lipsher, and Miller (1960) and Winder, Ahmad, Bandura, and Rau (1962). The measure of the psychotherapist's influence upon the patient's behavior is his immediately observable verbal response. Further investigation should examine the effects of repeated approach and avoidance over the entire course of treatment. If some measure of delayed outcome, or non-verbal behavior, had been used, the results might be different. A measure of change from the patient's base rate in expression of hostility and dependency might also serve to measure rein- forcement effects over time. Many non-verbal cues which 32 33 accompany verbal responses also influence behavior, but are not considered by this system. For example, facial expressions, gestures, and posture also serve to convey approval or disapproval. The prediction that continuance scores would be higher for dependency than for hostility is not confirmed. The results support one Opposite hypothesis, i.e. after approach by the psychotherapist continuance of hostility is greater than continuance of dependency. No differences are found for continuance after avoidance. It is important to remember that in this study psychotherapists are more apt to encourage the continuance of dependency rather than hostility; nevertheless, patients are more apt to continue to express hostile feelings than dependent feelings after encouragement by the psychotherapist. Consequently, when dependency and hostility interaction sequences are compared, the greater continuance of hostility over dependency after approach is not a result of greater approach to hostility by the psychotherapist. One explanation is that people' receive relatively less encouragement to express hostility in ordinary interactions. Therefore, when the psychothera- pist approaches the expression of hostility within the treat— ment session, the patient is permitted, indeed, encouraged to express a drive whose strength has built up because of inhibition. The psychotherapist effects the verbal release of the strong drive by weakening the inhibiting social forces. In contrast to these findings, Winder et a1 (1962) 34 report greater continuance of dependency compared to hos? tility following both approach and avoidance in first and second interviews with adult patients. However, they give no significance test for these differences. The present study shows significant differences after approach in the opposite direction. It is difficult to know how much the present results are a function of the age of the patients. Adolescents who are not allowed generally to express hos- tility in the presence of authority figures will have greater problems with strong aggressive drives. They may also have weaker controls on the expression of hostility than adults. Thus, they are more apt to verbalize considerable hostility in the presence of a psychotherapist who accepts hostile expressions. Both explanations account for the present findings. Hypothesis II. The results show that experienced psychotherapists approach hostility statements more than relatively inexperienced therapists. Staff psychotherapists approach hostility more than interns psychotherapists; in- ternes approach, more than practicum psychotherapists. Bandura gt_al (1960) report that psychotherapists who were able to express hostility directly and who mani— fested low need for approval were more inclined to encour— age the expression of hostility by their patients. The present study shows that the degree of psychotherapy ex- perience is related to psychotherapists' inclination to 35 approach hostility. Degree of psychotherapy experience may be correlated with these personality characteristics. Further research could explore these variables by studying psychotherapists over the period of their training. With increasing familiarity in psychotherapeutic practice, psy— chotherapists may show not only increasing approach to hos- tility, but also decreasing need for approval and increas- ing ability to express hostility directly in both therapeutic and ordinary interactions. The present study supports the findings of Bandura e£_al (1960) that psychotherapists are more likely to ap- proach the hostile statements which are expressed toward others than they are to approach hostility directed toward themselves. Those investigators suggested this finding may be a function of the relative inexperience of the therapists in their study. However, in the present study this differ- ence is true for psychotherapists who have completed their training as well as for therapists who are still in train- ing. It does not appear to be a characteristic of relatively inexperienced psychotherapists only. The expectation that more experienced psychothera- pists will not only show greater approach to all hostility, compared to less experienced therapists, but that the ex- perience level differences will be greater when hostility toward the therapist is considered separately, is not con- firmed. None of the groups of psychotherapists when com— pared to their individual tendencies toapproach hostility 36 toward others, are more apt to approach hostility directed at themselves. In general it can be stated that while more experienced psychotherapists do approach hostility more than less experienced psychotherapists, the difference be- tween approach to hostility with and without the psychothera- pist as object is not different for psychotherapists with different degrees of experience. An unexpected finding was the highly significant increase in approach to hostility from first to second in- terviews with the same patient. Because there were only twelve matched pairs of first and second interviews in the sample, this finding should be explored in further research. There is no parallel finding for increase in approach to dependency from first to second interviews. Further research could ascertain if the psychotherapists after a series of interviews with the patient are no longer more apt to ap- proach dependency more than hostility because of a gradual increase in their own proportion of approach to hostility. If a ceiling is reached in approach to hostility, the dif- ferences between experience levels may no longer be present after a series of interviews with the same patient. At present it can only be said that in the initial stage of psychotherapy, more experienced psychotherapists approach hostility more than less experienced psychotherapists. Hypothesis III. The prediction that psychothera- pists' responses to patients' expressions of hostility would 37 be related to premature termination of the treatment rela- tionship is not confirmed. There is no evidence that the terminator and remainer groups received different propor- tions of approach and avoidance following all hostility directed at others. The separate study by Caracena (1963) on the same interviews also fails to find differences be- tween terminator and remainer groups on the psychotherapists' management of dependency and "other" interaction units.2 It cannot be concluded that these psychotherapist variables and their effects are unrelated to the duration of treatment. The "null hypothesis" cannot be proved.’ Psychotherapy is a complex process and the content analysis system used in this study does not cover non-verbal cues. In addition, only two types of verbal statements which ef- fect changes in the interaction between the patient and the therapist have been analyzed; this analysis also does not attempt to discriminate differences in the quality of either approach or avoidance responses. All that can be concluded is that a simple analysis of dependent and hos- tile expressions occurring in the first and second sessions of psychotherapy is not able to isolate the critical factors. 2Several additional analyses do not separate the two groups: continuance of dependency or hostility after either approach or avoidance; differences between the psy- chotherapists' approach to dependency and hostility; dif- ferences between the psychotherapists' approach to hostil- ity with and without the psychotherapist as object. V. SUMMARY The expressions of hostility and dependency by patients and the responses of psychotherapists are signif- icant aspects of the interactive process in psychotherapy. This study examines the effect of therapists' responses of approach and avoidance upon the patients' continuing statements of hostility and dependency, and upon the dura- tion of treatment. Hypotheses, in general derived from learning theory, state that when therapists approach pa- tients' statements, patients continue the same topic; how- ever, when therapists avoid, patients discontinue the topic. The study also examines the effect of greater proportions of approach to hostility upon the retention of the patient in therapy. A further hypothesis states that more experienced psychotherapists will approach hostility more often than will less experienced therapists—-particularly when the therapist is the object of the patient's hostile behavior. A meaningful goal for the resolution of conflictive feel- ings is to encourage the patient to express hostility within the treatment session. A content analysis is made of 72 tape recordings of first and second interviews obtained from 60 patients treated at a university counseling center by 30 psychothera- pists of three levels of experience: doctoral, interns, 38 39 and beginning practicum trainees. The patients divide into three groups depending upon the length of treatment: pre- mature terminators, intermediates, and remainers. Patient- therapist interactions are coded for the number of times therapists responded with approach and avoidance reactions to the patients' expressions of hostility and dependency, and also for the frequency which patients continue to ver— balize the same topic following therapists' approach and avoidance interventions. The results follow: 1. Patients are likely to continue to express hos- tility and dependency after approach by the psychotherapist; they are likely to change the tOpic after avoidance by the therapist. 2. Although therapists approach dependency more than hostility, patients are more apt to continue express— ing hostility after approach than dependency after approach. 3. Premature termination of therapy fails to re- late to the percentage of approach therapists give to ex- pressions of hostility and dependency. 4. More experienced therapists approach hostility more often than less experienced therapists. However, these differences are not greater when hostility directed at the therapist is considered separate from other forms of hos- tility. 5. Therapists in general are more apt to approach hostility when it is directed at others rather than at them- selves. 4O 6. Therapists show greater proportions of approach to hostility on the second interview, compared to the first interview, with the same patient. Limitations in the present methodology have impli- cations for further research. REFERENCES Bandura, A., Lipsher, D., & Miller, P. Psychotherapists' approach—avoidance reactions to patients' expres- sions of hostility. J. Consult. Psychol., 1960, 24, l-8. . Caracena, P. Verbal reinforcement of client dependency in the initial stage of psychotherapy. Unpublished doctoral dissertation, Michigan State University, 1963.. Murray, E. The content-analysis method of studying psycho- therapy. Psycho. Monogr., 1956, 7O (13; Whole No. 420 . Parloff, M., & Rubinstein, E. Research problems in psycho- therapy. In Research in Psychotherapy, ed. Rubin- stein, E., & Parloff, M., American Psychological Association, Washington; 1959. Winder, C., Ahmad, F., Bandura, A., & Rau, L. Dependency of patients, psychotherapists' responses, and as- pects of psychotherapy. J. Consult. Psychol., 1962, _2_,6_, 129-134 0 41 APPENDIX I Scoring Manual (This manual is a modification of manuals used in the fol- lowing studies: Winder, C. L., Ahmad, F. Z., Bandura, A., & Rau, L. C. Dependency of patients, psychotherapists' responses, and aspects of psychotherapy. J. consult. Psye chol., 1962, 26, 129-134; Bandura, A., Lipsher, D. H., & Miller, P. E. Psychotherapists' approach-avoidance reac- tions to patients' expressions of hostility. J. consult. Psychol., 1960, 24, 1-8.) A. Scoring Unit and Interaction Sequence 1. Definition. A unit is the total verbalization of one speaker bounded by the preceding and succeeding speeches of the other speaker with the exception of interruptions. There are three types of scoring units: the "patient statement" (P St), the "thera ist response" (T R), and the "patient response" (P R . A sequence of these three units composes an "interaction se- quence." The patient response not only completes the first interaction sequence but also initiates the next sequence and thereby becomes a new patient statement. Example: P. I can't understand how you can stand me. (P St) T. {cu seem to be very aware of my feelings. T R P. I am)always sensitive to your feelings. P R 2. Pauses. Pauses are not scored as separate units. The verbalization before and after the pause is considered one unit. Therapist silences are scored as prescribed under Part D2e of this manual. There are no patient silences in this system. 3. Interruptions. Statements of either therapist or patient which interrupt the other speaker will be scored only if the content and temporal continuity of the other speaker is altered by the interruption. Then, the interrupting verbalization becomes another unit and is scored. A non-scored interruption is never taken into account in the continuation of the other speaker. 42 43 Interruption scored as one unit: P. I asked him to help me and-- T. Why was that? P. --he refused to even try. Non-interruption scored as 3 units, one inter— action sequence: P. I asked him to help me and-- T. Why was that? P. I don't know. Verbalizations such as "Um hmm" or "I see" are ignored in scoring unless they are so strongly stated as to convey more than a listening or receptive attitude. Patients' requests for the therapist to repeat his response are considered interruptions and are not scored. However, therapists' re- quests of this sort are scored as units (as approach or avoidance of the patient statement). Categories of Patient Statements and Patient Responses There are three categories: Dependency, Hostility, and Other. They are scored as exhaustive categories. All discriminations are made on the basis of what is explicitly verbalized by the speaker in the unit under consideration. One statement may be scored for several categories. When dependency and/or hostility units occur, the object of the patient's behavior is also scored as either psychotherapist or other. A coding of self (S) is given if the patient refers to his own behavior and a coding of other (0) is given if the client refers to someone else's behavior. 1. .Hostility category. The subcategories of hostil- ity listed below are not differentiated in the scoring but are listed here to aid in identifica- tion of hostility. a. Hostility. Hostility statements include description or expression of unfavorable, critical, sarcastic, depreciatory remarks; oppositional attitudes; antagonism, argument, expression of dislike, disagreement, resent- ment, resistance, irritation, annoyance, anger; expression of aggression and punitive behavior, and aggressive domination. l. Anger: 44 P. I'm just plain mad! P. I just couldn't think--I was so angry. P. My uncle was furious at my aunt. Dislike: expresses dislike or describes actions which would usually indicate dislike P. I just don't get interested in them and would rather be somewhere else. P. I've never ever felt I liked them and I don't suspect I ever will. P. He hates editorials. Resentment: expresses or describes a persistent negative attitude which does or might change to anger on a Specific occasion P. They are so smug; I go cold when- ever I think about having to listen to their 'our dog' and 'our son.' Boy! P. ~They don't ever do a thing for me so why should I ask them over? P. Dad resents her questions. Antagonism: expresses or describes antipathy or enmity ' P. It's really nothing definite, but we always seem at odds somehow. P. There is always this feeling of being enemies. Opposition: eXpresses or describes oppositional feelings or behavior P. If he wants to do one thing, I want to do another. P. It always seems she is against things. She is even against things she wants. P. No, I don't feel that way (in re- sponse to T's assertion). b. 45 6. Critical attitudes: expresses negative evaluations or describes actions which usually imply negative evaluations P. If I don't think the actors are doing very well, I just get up and walk out. P. There is something to be critical about in almost everything anyone says or does. 7. Aggressive actions: acts so as to hurt another person or persons, either phys- ically or psychologically P. He deserves to suffer and I'm mak- ing it that way every way I can. P. I can remember Mother saying: 'We slap those little hands to make it hurt.‘ Hostility anxiety. A statement including expression of fear, anxiety, guilt about hostility or reflecting difficulty express- ing hostility P. I just felt so sad about our argu- ment. P. I was afraid to hit her. P. After I hit her I felt lousy. Hostility acknowledgment or agreement. A statement agreeing with or acknowledging the therapist's approach toward hostility is scored as further hostility. May give example. May convey some conviction or may simply agree with therapist's response. T. You were angry. P. Yes! Dependency categories. 8.. Definition. Any explicit expression or de- scription of help-seeking, approval-seeking, company-seeking, information-seeking, agree— ment with others, concern about disapproval, or request that another initiate discussion or activity. Scoreable categories: The subcategories listed below are scored exhaustively. 46 Problem Descrippion: States problem in coming to therapy, gives reason for seeking help, eXpresses a dependent status or a general concern about de- pendency P. I wanted to be more sure of myself. That's why I came. P. I wanted to talk over with you my reasons for dropping out of school next quarter. P. Part of the reason I'm here is that everything's all fouled up at home. P. I depend on her, am tied to her. P. I want to be babied and comforted. Help-seeking: Asks for help, reports asking for help, describes help-seeking behavior P. I asked him to help me out in this situation. P. What can you do for him? P. I try to do it when he can see it's too hard for me. Approval-seeking: Requests approval or acceptance, asks if something has the approval of another, reports having done so with others, tries to please another, asks for support or security. Includes talk about prestige. EXpresses or describes some activity geared to meet his need ' P. I hope you will tell me if that is what you want. P. If there was any homework, I did it so Dad would know I was study- ing like a good girl. P. Is it alright if I talk about my. girl's problem? P. That's the way I see it, is that wrong? P. I asked him if I were doing the right thing. 47 Companyeseeking: Describes or expresses a wish to be with people, describes making arrangements to do so, describes efforts to be with others, talks about being with others P. It looks as if it'll be another lonely weekend. P. Instead of studying, I go talk with the guys. P. I only joined so I could be in a group. P. .We try to see if other kids we know are there, before we go in. Information-seeking: Asks for cogni- tive, factual or evaluative information, expresses a desire for information from others, arranges to be the recipient of information P. I asked him why he thought a girl might do something like that. P. I came over here to see about tests you have to offer. I want to know what they say. P. I'm planning to change my major. I'd like to know how to do it. Agreement with another: Responds with ready agreement with others, readily accepts the therapist's reflection. Often illustrates therapist's remarks with examples, draws a parallel example to indicate agreement. May accept pre- ceding statement on authority or if preceding statement was a therapist approach to Dependency, may simply agree with it. P. Oh, yes! You're absolutely right about that. P. Immediately I felt he was right and I had never thought about it that way. T. Then you wanted to get some help? P. Yes. 4e 7. Concern about disapproval: Expresses fear, concern, or unusual sensitivity about disapproval of others, describes unusual distress about an instance of disapproval, insecurity, or lack cf support. Little or no action is taken to do something about the concern P. She didn't ever say a thing but I kept on wondering what she doesn't like about me. P. my parents will be so upset about my grades, I don't even want to go home. P. It seems like I always expect I won't be liked. P. I can't understand how you can stand me when I smoke. P. I'm sorry I got angry at you. 8. Initiative-seeking: Asks the therapist or others to initiate action, take the responsibility for starting something (to start discussion, determine the topic). Arranges to be a recipient ‘ of T's initiative. May solicit sugges- tions . P. Why don't you say what we should talk about now? P. If you think I should keep on a more definite track, you should tell me. P. I got my advisor to pick my courses for next term. P. Tell him what to do in these cir— cumstances. 3. Other category. Includes all content of patient's _verbalizations not classified above C. Categories of Therapist Responses Therapist responses to each scored patient statement are divided first into two mutually exclusive classes, approach and avoidance responses. When both approach and avoidance are present, score only the portion which is designed to elicit a response from the patient. 49 Approach responses. The following subcategories are exhaustive. An approach response is any ver— balization by the therapist which seems designed to elicit from the patient further expression or elaboration of the Dependent or Hostile (or Other) feelings, attitudes, or actions described or expressed in the patient's immediately preced— ing statement, i.e., the part of the preceding statement which determined its placement under Dependency, Hostility or Other. Approach is to the major category, not specific subcategories. a. Approval: Expresses approval of or agree— ment with the patient's feelings, attitudes, or behavior. Includes especially strong "Mm-hmm!", "Yes" P. May I just be quiet for a moment? T. Certainly. P. I have my girlfriend's problems on my mind. Could we talk about them? T. Why don't we talk about that? b. Exploration (probing): Includes remarks or questions that encourage the patient to describe or express his feelings, attitudes, or actions further, asks for further clar- ification, elaboration, descriptive infor- mation, calls for details or examples. Should demandtmore than a yes or no answer; if not, may be a "label" . How do I feel? I feel idiotic. . What do you mean, you feel idiotic? I can't understand his behavior. What is it about his behavior you can't understand? ' Fafii FEW 0. Reflection: Repeats or restates a portion of the patient's verbalization of feeling, attitude, or action. May use phrases of synonymous meaning. Therapist may sometimes agree with his own previous responSe; if the client had agreed or accepted the first ther- apist statement, the second therapist state- ment is scored as a reflection of the client statement. P. I wanted to spend the entire day with him. T. You wanted to be together. d. ~50 P. His doing that stupid doodling upsets me. T. It really gets under your skin. Labeling: The therapist gives a name to the feeling, attitude, or action contained in the patient's verbalization. May be a tenta- tive and broad statement not clearly aimed at exploration. Includes "bare" interpreta- tion, i.e., those not explained to the pa- tient. May be a question easily answered by yes or no P. I just don't want to talk about that any more. T. What I said annoyed you. P. She told me never to come back and I really did have a reaction. T. You had some strong feelings about that-- maybe disappointment or anger. Interpretation: Points out and explains patterns or relationships in the patient's feelings, attitudes, and behavior: explains the antecedents of them, shows the similari- ties in the patient's feelings and reactions in diverse situations or at separate times P. I had to know if Barb thought what I said was right. T. This is what you said earlier about your mother . . . Generalization: Points out that patient's feelings are natural or common P. I want to know how I did on those tests. T. Most students are anxious to know as soon as possible. P. Won't you give me the scores? T. Many students are upset when we can't. Support: Expresses sympathy, reassurance, or understanding of patient's feelings P. It's hard for me to just start talking. T. I think I know what you mean. P. I hate to ask favors from people. T. I can understand that would be diffi- cult for you. 51 h. Factual Information: Gives information to direct or implied questions. Includes gen- eral remarks about the counseling procedure; P. Shall I take tests? T. I feel in this instance tests are not needed. P. What's counseling all about? . It's a chance for a person to say just what's on his mind. Avoidance responses. The following subcategories are exhaustive. An avoidance response is any verbalization by the therapist which seems designed to inhibit, discourage, or divert further expres- sion of the Dependent, Hostile, or Other patient categories. The therapist attempts to inhibit the feelings, attitudes, or behavior described or expressed in the immediately preceding patient statement, i.e., the part of the preceding state- ment which determined its placement under Depend- ency, Hostility, or Other. Avoidance is avoidance of the major category, not specific subcategories. a. Disapproval: Therapist is critical, sarcas- tic, or antagonistic toward the patient or his statements, feelings, or attitudes, ex- pressing rejection in some way. May point out contradictions or challenge statements P. Why don't you make statements? Make a statement. Don't ask another question. T. It seems that you came here for a reason. \ P. Well, I wonder what I do now? T. What do you think are the possibilities? You seem to have raised a number of log— ical possibilities in our discussion. P. I'm mad at him: that's how I feel. T. You aren't thinking of how she may feel. b. Topic Transition: Therapist changes or intro- duces a new topic of discussion not in the immediately preceding patient verbalization. Usually fails to acknowledge even a minor portion of the statement P. Those kids were asking too much. It would have taken too much of my time. T. We seem to have gotten away from what we were talking about earlier. C. 52 P. My mother never seemed interested in me. T. And what does your father do for a living? Ignoring: Therapist responds only to a minor part of the patient response or re- sponds to content, ignoring affect. May under— or over-estimate affect. May ap- proach the general topic but blatently ig— nore the affect verbalized P. You've been through this with other people so help me out, will you. T. You are a little uneasy. P. You can see I don't know what to do and I want you to give me advice. T. Just say whatever you feel is import- ant about that. P. My older sister gets me so mad I could scream. T. Mm-hmm. How old did you say she was? Mislabeling: Therapist names attitudes, feelings, or actions which are not present in the actual verbalization preceding the response P. I just felt crushed when she said that. T. Really burned you up, huh? P. I don't know how I felt--confused, lost-— T. I wonder if what you felt was resentment. Silence: Scored when it is apparent that the patient expects a response from the therapist but none is forthcoming within 5 seconds after the patient st0ps talking. If the therapist approaches after 5 seconds have elapsed, silence cannot be scored and the therapist's response is merely "delayed" P. If you think I should keep on a more definite track, tell me because I'm just rambling. T. (5 second silence) P. It is very confusing to know what to do. 53 Dependency and Hostility initiated by therapist: Scored whenever the therapist introduces the t0pic of Dependency or Hostility, i.e., when the patient statement was not scored as the category which the therapist attempts to introduce P. T. P. T. P. T. Last week I talked about Jane. You've mentioned a number of things you have done to please her. (Enters office) Now, how may I help you? I was late for class this morning. I wonder if you dislike the teacher or the class? I like to run around in blue jeans. You hate your mother. APPENDIX II Data Sheet for Therapists Please write in and tape record the information asked for in items 1 through 5: 1. Tape SIDE NUMBER: 2. Client's full NAME: Therapist's position: Staff Interns Practicum 3 4. DATE of this interview: 5 . Interview number: The purpose of this questionnaire is to identify tapes of the first two psychotherapy interviews which you have with new clients. This excludes only those interviews which you judge to be primarily educational, vocational or testing or- iented. It may be difficult to specify just which interview you start therapy in but we would include interviews in which you were assessing the client's potential for therapy by means of "trial therapy" procedures. If you judge your first interview as a therapy inter- view, then go on to record the next interview which you have with the client. If the recorded interview was not a therapy interview, please hold the tape to record a subsequent inter- view in which you begin therapy or to record another client. 6. By the above criteria, was this interview one in which you were primarily engaged in therapy? YES NO 6a. If "YES," was it the First or Second therapy inter- view? (Circle one) 6b. If "NO," what was the nature of the interview? 7. Has this client had psychotherapy prior to his seeing you? YES NO Please return this sheet with the tape when you have collected two therapy interview recordings. If you need the tape for some reason, it will be available. 54 APPENDIX III Follow-Up Questionnaire We are inquiring about the status of some of the clients whom you tape recorded for study. Please fill in the ap- propriate information and return this form to the reception- ist. CLIENT'S NAME: 1. How many hours of therapy have you had with this client? 2. How many hours of "non-therapy" contacts have there been? What was the nature of those hours? 3. Are you currently seeing him in therapy? Seeing him for some other reason? Explain 4. Has the relationship been terminated? a. If "YES," did the client terminate despite your ex- plicit or implicit feeling that he needed more therapy, i.e., did you regard the termination as premature? Explain the reasons and circumstances of ter- mination. b. Was the termination due to unavoidable situational factors? What were they? 5. Was there an agreement made by you and the client to . begin therapy? When was the agreement made? (e.g., ZpQ hour) If there was no mutual agreement on therapy, please explain the basis upon which you saw him. 6. Has the client had psychotherapy prior to seeing you? 55 "IFAWNNW