PATIENT THERAPIST IBENTIFTCATION IN RELATION TO BOTH PATIENT AND THERAPIST VARIABLES AND THERAPY OUTCOME Thesis for the Degree of Ph. D. MICHIGAN STATE UNIVERSITY BARRY MELNECK 1970 f‘ LIBRARY " I Michigan State 1" avers-15y 3f -. - -et-- cc ’r-vv" THE—'5‘” " f: This is to certify that the thesis entitled PATIENT THERAPIST IDENTIFICATION IN RELATION TO BOTH PATIENT AND THERAPIST VARIABLES AND THERAPY OUTCOME presented by BARRY MELN ICK has been accepted towards fulfillment of the requirements for LL! D;_degree in_P};I7ZC/C/L // / / .4 " ‘7 _/ / , '- . /( 7 c" " ' /] ' I/éf/vf? W ./ ' J; -’ ., / ’ 1» a7 a? ;,//Z I Date / A- I ‘72 0-169 ABSTRACT PATIENT THERAPIST IDENTIFICATION IN RELATION TO BOTH PATIENT AND THERAPIST VARIABLES AND THERAPY OUTCOME BY Barry Melnick The purpose of the present study was to determine whether the patient's identification with his therapist af- fected therapy outcome. Furthermore, it was predicted that those variables found in child development research to fos- ter greater identification should have similar effects on identification in psychotheraphy. It was hypothesized that the degree of the patient's identification with the thera- pist would positively correlate with (l) perceived strength of the therapist, (2) positiveness of patient's evaluation of the therapist, (3) therapist competence, (4) patient's degree of subjective feelings of weakness and helplessness, and (5) patient's dependency on the therapist. Eighteen therapy cases were sampled from the 1963- 1964 Michigan State University Counseling Center research project. Criteria for inclusion in the study were that the patient continued for 12 or more therapy sessions and that both pre- and posttherapy MMPI profiles were available. Barry Melnick Identification was measured by the before and after therapy change in the similarity between the patient's rat- ings of himself (both self and ideal self) and of his ther- apist. The patient's perception of the therapist's strength and the patient's evaluation of the therapist ("good-bad" di- mension) were assessed from the semantic differential po- tency and evaluative factor scores for the "counselor" con- cept. Therapist competence was obtained from external judge's ratings of therapist's warmth, accuracy of empathy, and genuineness. The patient's subjective feelings of weak- ness and helplessness were determined from his pretherapy MMPI g3 (manifest anxiety), Qy_(dependency needs), and as (self acceptance) scales. High manifest anxiety, strong dependency needs, and low self-esteem were assumed to indi- cate subjective feelings of weakness and helplessness. Finally, the patient's degree of dependency on the therapist and the therapist's acceptance of the patient's dependency were measured from ratings of taped therapy sessions by ex- ternal judges. Therapy outcome was measured from pre-post- therapy changes on 10 MMPI scales and three semantic dif- ferential indices. Combining the tests of significance for all 10 MMPI scales, self-therapist similarity change significantly cor- related with improved outcome on the MMPI scale change at the .05 level of significance. Increased gglfftherapist similarity significantly correlated with improvement on two of 10 MMPI scales, but these particular scales were shown Barry Melnick to be those which were the best measures of general malad- justment. Increased ideal self-therapist similarity did not significantly relate to the combined tests of significance for all 10 MMPI scales and significantly correlated with improvement on only one of the 10 MMPI scales. Increased ideal self-therapist similarity's significant relationship with improvement on the §§_MMPI scale could be attributed to chance. Increased gglfftherapist similarity was associated with both (1) patient's pretherapy subjective feelings of weakness and helplessness as indicated by increased depres- sion, greater manifest anxiety, greater dependency needs, and lower self-esteem and (2) a stronger more powerful per- ception of the therapist by the patient during therapy. The patient's perception of the therapist's strength was related to the patient's subjective feelings of weakness and helplessness rather than accurately mirroring the therapeu- tic competence. Probably, weak and helpless feeling pa- tients required a strong person to help them and they created an exaggerated image of the therapist to coincide with their needs. The exaggerated image of the therapist's power provided an adequate model for the patient and facil— itated identification. Contrary to prediction, the patient's degree of overt dependency on the therapist during therapy, the ther- apist's competence, and the favorability of the patient's Barry Melnick evaluation of the therapist bore no relation to increased. gglfftherapist similarity (identification). However, it was found that patients who reveal greater dependency on the therapist during the middle phase of therapy showed more improved self-esteem and more posi- tive attitudes towards others. Greater dependency behavior in therapy was associated with more intense patient involve- ment and participation in therapy. Even with the effects of greater patient involvement partialled out, the patient's degree of dependency on the therapist still correlated with improvement in self-esteem and more positive attitudes to- wards others. More intense patient dependency on the ther- apist was associated with higher pretherapy manifest anxiety. The therapist's warmth, accuracy of empathy, and genuineness, although not reflected in the patient's evalu- ation of the therapist (therapist strength and "good-bad" evaluation), correlated positively with many of the outcome measures. Patient ratings of the therapist's strength or "good-bad" evaluation did not correlate with improvement on the MMPI or semantic differential outcome measures. PATIENT THERAPIST IDENTIFICATION IN RELATION TO BOTH PATIENT AND THERAPIST VARIABLES AND THERAPY OUTCOME BY Barry Melnick A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1970 To Barbara ii ACKNOWLEDGMENTS I wish to express my appreciation to Dr. Karon, my Chairman, for the considerable amount of time he devoted to the revisions of the dissertation. Also, I wish to thank my committee members, Drs. Abeles, Kelly, and Rabin for their helpful criticisms. I wish to thank Dr. Richard Pierce for his ratings of the therapist's warmth, genuineness and empathy. I would like to show my appreciation to the staff at the Michigan State University Counseling Center for permit- ting me to use their research data. Without the availabil- ity of this data, it would have been impossible for me to have done this study. Also, I would like to thank the secretaries at the Counseling Center Research Office for their exceptional cooperation. Lastly, I would like to indicate my appreciation to my wife, Barbara, who has helped with the proof reading of the dissertation and has tolerated my long absences from home while I was completing the dissertation. iii TABLE OF CONTENTS LIST OF TABLES . . . . . . . . . . . LIST OF FIGURES O O O O O O O O O 0 INTRODUCTION . . . . . . . . . . . Review of the Literature on Identification in Psychotherapy . . . Therapy Variables Predicted to Affect Identification and Therapy Improvement . Therapist Variables . . . . . . Therapist Strength and Competence Therapist's Perceived Evaluation . Patient Variables, Therapy Dependency, Identification, Therapy Outcome . . . HYPOTHESES . . . . . . . . . . . . Primary Hypotheses . . . . . . . . Identification and Outcome . . . . Determinants of Identification . . . Secondary Hypotheses . . . . . . . Perceived Strength of the Therapist and the Favorability of the Evaluation the Therapist as Rated by the Patient in Relation to Other Variables in the Study . . . . . . . . . Patient' 5 Degree of Dependency on the Therapist During Therapy in Relation to Other Variables . . . . . . Therapist Competence and Therapy Outcome . . . . . . . . . . iv Page vii ix 12 14 14 l4 14 15 15 16 16 Page METHOD 0 O O O O O O O O O O O O O O 0 17 Subjects . . . . . . . . . . . . . . 17 Procedure . . . . . . . . . . . . . 18 Patient- -Therapist Identification Measures . . . . . . . . . . . 18 Computation of Therapist' s Perceived Strength and "Good- Bad" Evaluation . . . 20 Ratings of Therapist' s Competence . . . . 22 Patient' 5 Dependency . . . . 22 Pretherapy Patient Anxiety, Self— Esteem, and Dependency Needs . . . . . . . . 24 Therapy Outcome Measures . . . . . . 25 Patient Activity Level in Therapy . . . . 26 RESULTS . . . . . . . . . . . . . . . 27 Reliability . . . . . . . . . . . . 27 Patient- Therapist Identification . . . . . . 28 Testing the Hypotheses . . . . . . . . . 32 Primary Hypotheses . . . . . . . . . 33 Identification and Therapy Outcome . . . 33 Determinants of Identification . . . . 41 Secondary Hypotheses . . . . . . . . 46 Perceived Strength of the Therapist and the Favorability of the Eval- uation of the Therapist as Rated by the Patient in Relation to Other Variables in Study . . . . . 46 Patient's Degree of Dependency on the Therapist During Therapy in Relation to Other Variables . . . . 51 Therapist Competence and Therapy Outcome . . . . . . . . . . . 55 Other Findings . . . . . . . . . . . . 57 Summary of Results . . . . . . . . . . 57 DISCUSSION . . . . . . . . . . . . . . 59 Primary Hypotheses . . . . . . . . . . 59 Identification and Therapy Outcome Variables Affecting Patient- Therapist Identification Secondary Hypotheses . Limitations of the Research SUMMARY LIST OF REFERENCES APPENDICES [110va vi Page 59 60 63 64 66 69 75 75 76 77 78 79 Table 1. 10. LIST OF TABLES Inter-rater Reliabilities . . . . . Intercorrelations of the Different Patient-Therapist Similarity Measures and Semantic Differential "me" Concept Changes . . . . . . . Correlations Between Pretherapy Patient- Therapist Similarity and Similarity Change . . . . . . . . . . Correlations Between Patient-Therapist Similarity Change and Therapy Outcome . . . . . . . . . . Correlations Between Patient-Therapist Similarity Change and Therapist Strength and Good-Bad Evaluation . . Correlations Between Ratings of Thera- pist Competence and Similarity Change Measures . . . . . . . Correlations Between Patient Pretherapy MMPI Scale Scores and Patient-Ther- apist Similarity Change . . . . . Correlations Between Therapy Dependency Behavior and Patient-Therapist Similarity Change . . . . . . . Correlations Between Perceived Therapist Strength and Good—Bad Evaluation and Therapy Outcome . . . . . . . Correlations Between Perceived Therapist Strength and Evaluation and Patient Pretherapy MMPI Personality Measures vii Page 28 29 32 34 41 43 44 46 48 49 Table 11. 12. 13. 14. 15. 16. Correlations Between Therapist Strength and Evaluation and Therapy Dependency Behavior . . . . . . . . . . Correlations Between Judged Therapist Competence and Patient Perceived Therapist Strength and Good-Bad Evaluation . . . . . . . . . Correlations Between Patient Dependency on Therapist and Therapy Outcome . . Correlations Between Patient Dependency on the Therapist and Pretherapy Patient Anxiety, Dependency Needs, Self-Esteem . . . . . . . . . Correlations Between Dependency on Therapist and Therapist Acceptance of Patient Dependency . . . . . . Correlations Between Therapist Empathy, Warmth, and Genuineness and Therapy outcome 0 O O O O O O O O 0 Patient Pretherapy MMPI Raw Scale Scores . . . . . . . . . . Patient Change in Similarity to the Therapist Raw Scores . . . . . . Patient and External Judge's Ratings of the Therapist . . . . . . . . Patient's Dependency on Therapist Scores, Therapist's Acceptance of Patient's Dependency Scores, and Ratings of Patient Therapy Activity Level . . . . . . . . . . . Therapy Outcome MMPI Scale Change Scores . . . . . . . . . . viii Page 50 SO 52 54 55 56 75 76 77 78 79 LIST OF FIGURES Figure Page 1. Therapy Model for Patient-Therapist Identification with Its Contributing Variables . . . . . . . . . . . . 3 2. MMPI Outcome Measures Significantly Correlated with Pre- Posttherapy Changes on Qy_and PE MMPI Scales . . . . 36 3. Intercorrelations among Pretherapy MMPI 2, Pt, 2y, and Ag Scales . . . . . 45 ix INTRODUCTION The purpose of the present study was to determine whether the patient's identification with his therapist plays a significant role in the psychotherapeutic process. It is hypothesized that the patient increases his similarity to the therapist in order to attain the therapist's power and mastery over the environment. Thus, it was predicted that increased patient therapist similarity contributed to successful therapy outcome. Bergin (1967) suggests that identification is an underlying process of all therapies and affects therapy outcome: Modeling . . . is not so much a part of a new wave but rather an awareness of something which has also been a part of all therapies. When one is involved in an inti- mate human relationship with another person to whom he may have said 'help me' . . . the other person deliber- ate or not is going to function in some way as a model . . . not modeling of course in the sense that one be- comes a copy of the other person but rather that one utilizes some of the person . . . to develop and build his somewhat different self. What often happens too of course is that the client takes on as part of his self some of the more positive characteristics of the thera- pist as he is losing some of his own negative character- istics (pp. 210-211). Furthermore, it was predicted that those variables empiri- cally found in child development research to foster greater identification should have similar effects on identification in psychotherapy. Kagan (1958) suggested that the child's relative weakness and helplessness as compared to his stronger more skilled parents motivates the child to adopt their attri- butes. So in the therapy context, it was hypothesized that highly anxious, dependent, and low self-esteem types of patients experienced more subjective feelings of weakness and helplessness and, therefore, would be more motivated to identify with their therapists. Mussen, Conger and Kagan (1963) in their review of identification literature and research emphasized the im- portance of the model's (1) strength, (2) attractiveness, and (3) competence as determinants of identification. Therefore it was hypothesized the greater the patient's ratings of the therapists' strength and likeability and the better the therapist's therapeutic competence, the more the patient will tend to identify with his therapist. Finally, dependency on the model has been assumed to be a requisite condition for the occurrence of identifi— cation (Sears, Maccoby, & Levin, 1957). So, it would be expected that the patient's degree of dependency on the therapist would facilitate the identification process. Furthermore, it was hypothesized that the therapist's ac- ceptance of the patient's dependency on him would contrib- ute to greater patient identification with the therapist. The hypotheses are summarized in Figure 1. 333“"; mafiaflficoo 3H fig 5383353 umflmmuwfiuucoflmm you Eco: 339? H mudmflm memcmcascomh _ suEumz _ bwcummfio Mo howusoom; // A mEoouso ammumnu Ham Immmoodm muoE AI umwmmnwnu upwz newuwo Ifiuflucoofl ucoflumm Hmumwum AT! coflumsam>o ~mocmuwmeoo umflmmumcu “museum; w cumcwuum ATI..\\\\\I\\\\\\\ umflmmumnu om>fioouom kumwum _>ocwccwmmo m.ucwflumm mo mocmumwuom; moanmfium> um“ whose _Eooumou wamm ucmflumm 30H— umfimmumnu co wocmocmmmc mcouum_ATIIIIIII—moomc mocoocmmop vacuum— _Imuoaxcm ucwwumm swan; moHQMHHm> ucoflao Review of the Literature on Identification in Psychotherapy Identification broadly defined refers to the adop- tion of another individual's personality characteristics. All of the research on identification in psychotherapy has measured identification by increased similarity of the pa- tient and therapist on various personality dimensions. The operational definitions of identification and modeling are identical; however, Kagan (1958) distinguishes the two con- cepts by asserting that identification or the adoption of the model's attributes is motivated by the desire to attain the model's sense of power and mastery over the environment. In the concept of identification, the traits adopted from the model are not necessarily in themselves behaviors which facilitate better mastery. The person who identifies at- tempts to increase his similarity to the model, so that he can experience the model's sense of power and adequacy. Identification has been measured as a greater con- gruence of the patient's and therapist's values and inter- ests (Holzman, 1962; Petony, 1966; Rosenthal, 1955; Welkowitz, 1967), ego ideals (Ewing, 1954), personality traits and self-descriptions (Borrelli, 1965; Ewing, 1954; Farson, 1961; Sapolsky, 1965), need systems (Schrier, 1953; Snyder, 1964) and overt behavior (Lennard & Berstein, 1960). Furthermore, these studies employed two distinct methods of attaining the degree of patient-therapist similarity. Either the patient is asked to fill out some personality instrument for both himself and for the therapist or both the patient and the therapist complete the same instruments for themselves. In both cases, identification is inter- preted from the degree of similarity between the patient's and therapist's profiles. The majority of the reviewed studies have found that psychotherapy substantially increases patientetherapist similarity (Ewing, 1954; Holzman, 1962; Landfield & Nawas, 1964; Lennard & Berstein, 1960; Petony, 1966; Rosenthal, 1955; Sapolsky, 1965; Schrier, 1953; Welkowitz, 1967). In addition to investigating changes in similarity, several studies have explored the relationship between increased pa- tient similarity to the therapist and the degree of thera- peutic improvement (Borrelli, 1965; Ewing, 1954; Holzman, 1962; Landfield & Nawas, 1964; Rosenthal, 1955; Sapolsky, 1965; Schrier, 1953; Welkowitz, 1967). Six of the eight studies have demonstrated that increased patient-therapist similarity during the course of therapy is associated with improvement. Holzman (1962) obtained this relationship for outpatients but not for those hospitalized. From Holzman's findings, it may seem that identification does not occur in therapy with more disturbed hospitalized patients. However, Sapolsky (1965), using a population of hospitalized patients consisting of 14 schizophrenics and six psychotically de- pressed ones, obtained significant increases in identifica- tion which were associated with therapy improvement. Of the three studies performed on college counseling center populations (Borrelli, 1965; Ewing, 1954; Farson, 1961), two (Borrelli, 1965; Farson, 1961) have yielded no evidence of identification during therapy. There are some methodological problems in both Farson's (1961) and Borrelli's (1965) studies which may account for their fail- ure to obtain positive results. In Parson's study, both clients and therapists were administered the Bultler-Haigh Q-sort of a 100 self-referent statements. Since the Q-sort contains many statements related to adjustment, increased similarity to the therapist might merely be an artifact of the client's increased adjustment which only coincidentally corresponds to the relatively better adjusted therapist. Farson (1961) attempted to offset this confounding factor by demonstrating that the client's similarity to his own ther— apist is greater than his similarity to any randomly selec- ted one. In computing the similarity scores, he subtracted the mean similarity to all other therapists in the sample from the client's similarity to his own therapist. However, this procedure may have introduced additional complications. Petony (1966) and Mayfield (1962) using Q-sorts have shown that client centered and relationship oriented therapists have remarkably similar ways of sorting even when adjustment items are excluded. Farson's method for controlling the client's adjustment actually altered the identification di- mension so that the similarity score reflected only simi- larity on the therapist's idiosyncratic traits. Since the therapists in his study were client centered and probably had highly similar value systems (Petony, 1966), his method of computing similarity probably excluded pertinent informa- tion. It is important to note that although the client's self-descriptions did not resemble his own therapist more than therapists in general, Parson did find significantly greater patient-therapist congruence at the conclusion of the therapy. Farson did not relate changed patient-thera- Ipist similarity to therapy outcome. Ewing (1954) controlled for the client's increased personality adjustment in a different way. He contrasted the client's post-therapy self-ratings with both his pre- and post-personality ratings of the therapist and found that improved clients showed significantly greater similarity to the after therapy therapist ratings than to the pretherapy therapist ratings. By contrasting only the posttherapy client self-description, Ewing (1954) held client's adjust— ment constant and thereby demonstrated that the client per— ceives himself more similar to his after therapy perception of his therapist than to his earlier perception of him. Another important aspect of Ewing's analysis was that, unlike Parson (1961), he controlled for the client's level of improvement. From the hypotheses offered in the present research, it would be predicted that clients reveal differing degrees of identification with their therapists. Only the more improved patients should manifest strong identification with their therapists. Welkowitz, Cohen, and Ortmeyer (1967) used the same method of controlling posttherapy client adjustment as Farson (1961) and obtained a significant relationship be- tween the patient's identification with the therapist and therapy improvement. He showed that improved patients re- vealed greater similarity to their own therapists than to other randomly selected ones. Welkowitz 92 31, (1967) was concerned with whether the degree of identification cor- related with therapy outcome. On the other hand, Farson only investigated if there was significantly greater patient resemblance to his own therapist as compared to other ther— apists from before to after therapy. Welkowitz e£_al. therefore, questioned whether there would be differing de- grees of changed resemblance to the therapist and whether these differences would correlate with therapy outcome. Thus, the two studies are not comparable because of the different questions they attempted to answer. Borrelli (1965) failed to obtain any relationship between posttherapy patient-therapist similarity and therapy improvement based on changes in pre and post MMPI scales. Although in most respects his study was well designed, he unfortunately neglected to consider the sex differences be- tween patient-therapist pairs. Borrelli measured similari- ty with the semantic differential which has been shown to be influenced by sex differences (Jenkins & Russell, 1958; Shell, Omally & Johnsgard, 1964). These studies have found that males are rated higher on potency, importance, and evaluation which, they conclude, reflects cultural sex dif- ferences. Since Borrelli had not controlled for differen- tial patient-therapist sex pairings and computed similarity scores with the D-statistic which would be distorted by these sex differences, it is possible that his results were inaccurate. Therapy Variables Predicted to Affect Identification and Therapy Improvement Therapist Variables Child development research on identification has discovered that the degree of identification is a function of the model's power, competence, attractiveness, and nurturance (Kagan, 1958; Mussen, Conger & Kagan, 1963). It was hypothesized that the therapist's perceived strength, and evaluation should be related to the degree of the pa- tient's identification with the therapist and to therapy outcome. Objective appraisal of the therapist's competence should influence the patient's perception of the therapist's potency and evaluation and therefore affect the degree of identification and the success of therapy outcome. Therapist strength and competence: Mussen, Conger, and Kagan (1963), in their review of identification litera- ture and research, heavily emphasize the importance of the model's strength and competence as determinants of identi- fication. The child's relative weakness and inadequacy as 10 compared to his stronger, more skilled parents motivates him to adopt their attributes. Kagan (1958) has discovered that children tend to identify with the more powerful parent. Research also reveals that children exhibiting stronger identification with a particular parent perceive him as more competent, more attractive, and a more powerful source of both reward and punishment (Bandura, Ross, & Ross, 1963; Kagan, 1958; Maccoby, 1959; Mussen & Distler, 1959). In regard to therapy, Kell and Mueller (1965) con- tend that the client's perception of strength in the thera- pist is a prerequisite for client improvement. Borrelli (1965) has experimentally verified this hypothesis. Using the semantic differential potency factor for the concept "counselor" as a measure of the therapist's perceived strength, he found that the therapist's potency significant- ly related to improvement on the H1 MMPI Scale. Although Borrelli (1965) computed both counselor strength scores and after therapy client-therapist similarity scores (the latter is frequently employed as an index of identification) he did not investigate the relationship between these two dimen- sions. Truax (1968), who used objective ratings of thera- pist potency rather than patient ratings, found that thera- pist potency even with the therapist level of accuracy of empathy, warmth, and genuineness partialled out, signifi- cantly affected therapy outcome. Truax concluded that ther- apist potency, although significantly correlated with the 11 therapeutic conditions of empathy, warmth, and genuineness, affects outcome in its own characteristic way. Truax (1967) operationally defined therapist compe— tence by the dimensions accuracy of empathy, warmth, and genuineness. He presented a sufficient body of research evidence to show that these therapist dimensions coincide with therapy success. The therapeutic conditions were shown to significantly correlate with objective ratings of the therapist's potency (Truax, 1968), but the therapeutic conditions have never been related to patient-therapist identification. Farson (1961) conducted the only therapy study which has explored the relationship between the ther— apist's competence and the patient's identification with his therapist. He found that increased patient-therapist similarity negatively correlated with independent ratings of the therapist's competence. His findings were contrary to what would be predicted from previous research on identi- fication. Farson interpreted his results as demonstrating that less competent therapists force greater conformity from their patients. Therapist's perceived evaluation: It has been con- sistently reported in developmental research on identifica- tion that admiration and affection for the parental model promote better identification (Bandura, 1961; Mussen, 1961; Payne & Mussen, 1956; Sears, 1953). Children revealing greater identification with their parents tend to perceive 12 them more positively. Schrier (1953) and Sapolsky (1965) have encountered similar results in the therapy situation. Their results revealed that the degree of positive patient- therapist rapport obtained from independent ratings of therapy interviews (Schrier, 1953) and patient-therapist compatibility based on congruence of profiles on the FIRO Scale (Sapolsky, 1965) correlated significantly with iden- tification which was measured by increased similarity of patient and therapist test profiles. Both the degree of therapeutic rapport and increased patient-therapist simi- larity were associated with successful therapy outcome. Patient Variables! Therapy Dependency, Identification, Therapy Outcome Dependency on the model has been assumed to be a requisite condition for the occurrence of identification (Sears, Maccoby, & Legin, 1957). Hence, the patient's de— pendency on the therapist and the latter's acceptance of the dependency should be necessary antecedents to identification with the therapist. Two studies have found that more de- pendent children exhibit greater imitation of the model's behavior (Bandura & Walters, 1965; Jakubczak & Walters, 1959). Snyder (1963), in a comprehensive longitudinal study of dependency in psychotherapy, discovered that while all clients manifest variations in the occurrence of dependency through the course of therapy, the most improved ones 13 revealed greater dependency near the middle of therapy. He maintains that allowing the patient to become dependent on the therapist helps establish an intense therapeutic rela- tionship. Similarly, Kirtner (1958) reported that the most successful therapy cases displayed more intense dependency during therapy. It was hypothesized that high manifest anxiety, strong dependency needs, and lower self-esteem should be manifested by subjective feelings of weakness and helpless— ness. As previously mentioned, at least some theorists feel that the contrast between the child's feelings of weak- ness and relative inadequacy as compared to their stronger more adequate parents motivates the identification process so that the child can adopt the model's strength and ade- quacy. It was hypothesized that a client under greater stress will more likely become dependent on the therapist's help and identify with him to a greater extent. Both in- creased stress (McNulty & Walters, 1962; Walters, Marshall, & Shooter, 1960) and low self-esteem (Bandura & Walters, 1965) have been shown to elicit a greater imitation of the model's behavior. HYPOTHESES Primary Hypotheses Identification and Outcome Hypothesis 1: Identification of the patient with the therapist as defined by increased similarity of the patient's self and ideal self concept ratings and patient ratings of the therapist, is positively related with suc- cessful therapy outcome. Determinants of Identification Hypothesis 2: Therapist strength as perceived by the patient is positively correlated with the patient's de- gree of identification with the therapist. Hypothesis 3: Positive evaluation of the therapist by the patient is positively correlated with the patient's degree of identification with the therapist. Hypothesis 4: The therapist's competence as meas- ured by his warmth, accuracy of empathy, and genuineness is positively correlated with the patient's degree of identi- fication with the therapist. 14 15 Hypothesis 5: The patient's pretherapy manifest anxiety, dependency needs, and lower self-esteem is posi- tively correlated with the patient's degree of identifica- tion with the therapist. Hypothesis 6: The patient's degree of dependency on the therapist during therapy is positively correlated with the patient's degree of identification with the thera- pist. Secondary Hypotheses garceived Strength of the Therapist and the Favorability of the Evaluation of the Ther- apist as Rated by the Patient in Relation to Other Variables in the Stuéy Hypothesis 7: Perceived strength and "good-bad" evaluation of the therapist are positively correlated with successful therapy outcome. Hypothesis 8: Perceived strength and ”good-bad" evaluation of the therapist are positively correlated with pretherapy patient manifest anxiety, dependency needs, and low self-esteem. Hypothesis 9: Perceived strength and "good-bad" evaluation of the therapist are positively correlated with the degree of patient dependency on the therapist during therapy. l6 Hypothesis 10: Perceived strength and "good-bad" evaluation of the therapist are positively correlated with greater therapist competence, as defined by external judge- ments of therapist warmth, accuracy of empathy, and genuine- ness. Patient's Degree of Dependency on the Therapist During Therapy_ in Relation to Other Variables Hypothesis 11: Patient's dependency on the thera- pist is positively correlated with successful therapy out- come . Hypathesis 12: Patient's dependency on the thera- pist is positively correlated with pretherapy patient anxiety, dependency needs and lower self-esteem. Hypothesis l3: Patient's dependency on the thera- pist is positively correlated to the degree of therapist's acceptance of the patient's dependency on him. THerapist Competence and Therapy Outcome Hypothesis 14: Therapeutic competence as defined by external judgement of the therapist's warmth, accuracy of empathy, and genuineness is positively correlated with more successful therapy outcome. METHOD Subjects The therapy cases used in the present investigation were sampled from the 1963-1964 research project at the Michigan State Counseling Center, which was the population employed in the Borrelli study (1965). As a part of this research project, tape recordings of the therapy sessions, the semantic differential administered every fourth session, and pre- and posttherapy MMPI profiles were collected for 54 self-referred clients. For the purposes of the present study, 18 of the S4 therapy clients were selected based on the criteria that: (1) the patient continued for 12 or more therapy sessions and (2) pre- and posttherapy MMPI profiles were available. The sample contained 8 male and 10 female clients, 13 male and 5 female therapists, and 11 same-sexed and 7 different-sexed patient therapist pairs. The thera- pists' experience were distributed as follows: three coun- seling center staff members, 11 counseling center interns, and three practicum students. In the sample of 18 cases, 7 received 20 or more sessions, 6 had 16 sessions, and 5 had 12 sessions. 17 18 Procedure To test the hypotheses, it was necessary to assess (1) the change in similarity of the patient to the thera- pist from before to after therapy (identification measure), (2) the patient's evaluation of the therapist during thera- py, (3) the patient's degree of dependency on therapist dur- ing therapy and therapist's degree of acceptance of this dependency, (4) the ratings of the therapist's actual ther- apeutic competence, (5) the patient's pretherapy anxiety, dependency needs and self-esteem, and finally (6) the pre- therapy-posttherapy reduction in patient psychopathology. Patient-Therapist Identifica~ tion Measures Identification was measured from change in the pa- tient's ratings of his similarity to the therapist on the semantic differential. In the original 1963-1964 research project, the patients rated 21 concepts on 16 scales before therapy and every fourth subsequent session. The difference between the fourth session and after therapy similarity be- tween the concepts "me" and "counselor" constituted the patient's degree of identification with the therapist. Basically, two distinct measures of similarity change were employed: self-therapist similarity change and ideal self-therapist similarity change. A third similarity measure, similarity change corrected for improved person- ality adjustment (ADSMCH) was included in the study only for the purpose of determining the approximate portion of 19 the similarity change variance due to changed perceptions of the therapist. galjftherapist similarity change was derived from the patient's ratings of the "me" and "counselor" concepts on the semantic differential. Ideal self-therapist simi- larity change measure employed the ideal self concept in- stead of the "me” concept along with the "counselor" con- cept. The D-statistic (Cronbach & Gleser, 1957) was used to compute the similarity between the patient concepts and the therapist concept. The similarity change index was computed from the difference between the fourth session patient-therapist similarity and after therapy patient therapist similarity. To correct for possible sex differ- ences in same vs. opposite sexed patient-therapist pairs, separate similarity change distributions were derived for same sexed and opposite sexed patient-therapist combina- tions. Twenty-eight cases which fulfilled the requirement of having completed at least eight therapy sessions were used to establish separate same-sexed and opposite-sexed norms, so that both self-therapist and ideal self-therapist similarity change scores could be standardized. This standardization procedure was intended to eliminate differ- ential similarity change of same-sexed and opposite-sexed patient-therapist combinations. Similarity change corrected for improved patient personality adjustment (ADSMCH) contrasted the similarity between the posttherapy "me" concept ratings with both 20 fourth session and posttherapy patient ratings of "coun— selor" concepts. Since pre- posttherapy change in the "me" concept was not included in this similarity index, the con- founding effects of improved personality adjustment were excluded from the ADSMCH similarity change index. There- fore, changed perceptions of therapiSt constituted the vari- ance in this particular similarity change measure. Computation of Therapist's PerceivedjStrength and "Good-Bad" Evaluation The patient's perception of the therapist's strength or potency and good-bad evaluation were obtained from the semantic differential potency and evaluative factor scores for the counselor concept. Therapist strength and good-bad evaluation were derived from the semantic differential pro- file closest to the middle phase of therapy. The midpoint rather than the posttherapy semantic differential adminis- tration was preferred because it was believed this phase of therapy would best incorporate the patient's transference reactions toward the therapist. During therapy, the pa- tient probably reacts to his transference perceptions of the therapist; therefore, the transference reactions should be included. Potency and evaluative factor scores were computed from the factor loadings for each scale by means of a mul- tiple regression method (Thomson, 1951). Factor loadings were obtained from the factor analyses of three consecutive 21 semantic differential ratings of the concepts "me" and "counselor." Borrelli (1965) who studied the same therapy population used in the present study has performed this factor analysis for 40 clients, 240 observations, on 16 scales, by the Principal Factor Solution with Quartimax Rotation Method. The factor loadings for each factor on every scale were obtained from Borrelli's factor analysis. The factor loadings were used for the derivation of regression coefficients for a given factor on a single scale. The z-score on a given scale, which was computed from the distribution of scores on a single scale, was mul- . . . . . 1 r t1p11ed by the regress1on coeff1c1ent ITE' 1:;7-where s = 21%;: (summation across all scales for a given factor) and r is the factor loading for a particular factor on a single scale. The factor scores obtained by this method for a single scale were summed across all scales to obtain a total factor score. The z-score was computed from the distribution of scores for a particular scale. Borrelli (1965) employed the same procedure of calculating factor scores, but neglected to control for the sex of therapist. Jenkins and Russell (1958) and Shell EE.2$° (1964) have shown that male concepts are rated higher on potency, importance, and activity. To control for therapist sex differences, z-scores were com- puted from separate distributions for male and female ther- apists. For each semantic differential scale, separate male 22 and female therapist statistical distributions were calcu- lated from 39 therapy cases found in the larger research project sample. From these separate statistical distribu- tions, scale scores were transformed into z-scores. Ratiags of Therapist's Competence Ratings of the therapist's accuracy of empathy, non- possessive warmth, and genuineness were employed as opera- tional definitions of the therapist's competence. Extensive validity research has been presented for these dimensions (Truax & Carkhuff, 1967). For each therapy client, three three-minute excerpts from the beginning, middle, and end of each taped therapy session were randomly sampled and rated on the three therapist competence dimensions. Tape recorded sessions from the first, second, and third quarters of ther- apy were rated. Thus, there were nine independent ratings altogether for each client. The average of the ratings was used as the index of the therapist's competence. Two independent judges rated 25 tapes from the total number for a reliability measure. Patient's Dependenay Two measures of dependency were employed. The cli- ent's dependency needs were measured by Navran's 2y_MMPI dependency scale. This scale has been found to correlate with the Edward's Personal Preference Scale Succorance and Deference scales, and independent ratings of client's 23 dependency during therapy (Snyder, 1963). The MMPI depend- ency measure accounted for the largest portion of the com— mon variance of the dependency measures. It correlated especially high with the independent ratings of patient de- pendency during therapy. The second dependency measure employed in the present study was the patient's degree of dependency on the therapist during therapy. One therapy session from the mid- dle phase was rated for the client's dependency on his therapist. The sample tape was taken from the middle phase of therapy because two studies have shown that the client's dependency on the therapist is greatest at this point (Alexander, 1967; Snyder, 1963). The therapy tapes were analyzed by a system adopted from Winder, Ahmad, Bandura and Rau (1962) and later employed by Alexander (1967), Caracena (1963), and Schuldt (1964). The basic scoring unit is the interaction sequence consisting of the client's first verbal statement, followed by the therapist's re- sponse, and the client's subsequent reaction to the thera- pist's response. The client's reaction to the therapist's response not only completes the first interaction but also begins the next interactional unit. All the client's verbal expressions were coded for the presence or absence of dependency. The codings of de- pendency are further subdivided, according to the object of the dependency. The object categories are: (1) dependency toward therapist, (2) dependency toward person other than 24 therapist and, (3) dependency expressions without definite referent. The measures of dependency behavior relevant to the present investigation were both the total number and percentage (number of dependency on therapist statements divided by total number of patient statements) of patient dependency statements where the therapist was the object of the dependency. Dependency expressions were defined as help seeking, approval seeking, concern about disapproval, company seeking, information seeking, agreement with an- other, and concern about disapproval. The therapist's acceptance of the client's depend- ency was defined by the therapist's approach or avoidance of the client's dependency expressions. All the therapist's responses were coded as either approach or avoidance. Re- sponses coded as approach were approval, exploration, re- flection, labeling, interpretation, generalization, support, and factual information. Avoidance responses were disap— proval, topic transition, ignoring, mislabeling, and silence. The therapist's acceptance of the patient's de- pendency behavior toward himself was relevant to the present study. Pretherapngatient Anxiety, Self- Esteem, andTDependency Needs The MMPI HE (psychasthenia), Ha (self acceptance) and Qy_(dependency needs) were used as measures of the cli- ent's manifest anxiety, self-esteem, and dependency needs, respectively. The BE scale, has been found to correlate 25 about .90 with the Taylor Manifest Anxiety Scale (Dahlstrom & Welsh, 1965). Since the raw MMPI scores corresponded to different t-scores for males and females, the female raw scores were converted to the equivalent male raw score by matching the t-scores. Therapy Outcome Measures Three measures of change in self evaluation meas- ures on the semantic differential and 10 MMPI scales served as indices of therapy improvement. The semantic differen- tial outcome measures were (1) change in self-ideal self discrepancy, and (2) change in self-concept along "good-bad" evaluation and the potency dimensions. Pre- and posttherapy changes on 10 MMPI scales were also used to assess therapy outcome. Changes in symptomatol— ogy were derived from the Ha (hypochondriasis), 2,(depres- sion), Hy (hysteria), BE (psychasthenia), and Hg (schizo- phrenia) MMPI scales. The MMPI Ha (self acceptance) and H scales measured changes in self-esteem. The H_scale has been shown to relate to independent measures of self-esteem (Berger, 1955; Leary, 1957; Raymaker, 1956; Rosen, 1956, Zuckerman & Monashkin, 1957) and to covary with successful therapy (Gallagher, 1953; Kaufman, 1950). MMPI measures of ego strength (Ha scale) and dependency needs (2y scale) were also included. Therapy improvement was measured from the amount of change from before therapy to after therapy on 26 each of these MMPI scales. Positive scores on all outcome measures reflected improvement on particular measures. Patient Activity Level in Therapy Activity was a global measure of the patient's de- gree of participation in the therapy process. The degree of patient participation was rated on a five point scale from 18 therapy tapes from the middle phase of therapy. Patient activity was included in the study to differentiate dependency from helpless passivity. RESULTS Reliability Both the therapist conditions of warmth, accuracy of empathy, and genuineness and the measurement of the pa- tient's dependency behavior in therapy were derived from the rating of tape recorded therapy sessions. To establish the reliability of the warmth, accuracy of empathy, and genuine- ness ratings, 25 randomly selected tape recorded therapy sessions were independently rated by a Ph.D. Counseling Center staff member and a fourth year counseling psychology graduate student. Both raters had considerableprior ex- perience with these rating scales. The therapy dependency behavior and activity level were rated separately by the investigator and a fourth year clinical psychology graduate student (whose ratings were used in the calculation of the data). The first 25 coded patient therapist interaction units for all therapy cases used in the study (N=18) served as the reliability sample. Table 1 contains the inter-rater reliabilities for all ratings. 27 28 Table l Inter-rater Reliabilities _=:_ Rating Categories g::;:g;i::{ Therapist Conditions Therapist accuracy of empathy .91 Therapist warmth .95 Therapist genuineness .96 Therapy Dapendency Measures Therapist directed patient dependency expressions .71 Therapist approach of patient dependency on therapist .95 Activipy Level .65 Patient-Therapist Identification Table 2 presents the intercorrelations between the following variables: (1) aalgftherapist similarity change (change in similarity of the patient's ratings of self and therapist from pre to posttherapy), (2) standardized EElET therapist similarity change (self-therapist similarity change scores converted to standardized scores from sepae rate like-sexed and opposite-sexed patient-therapist pair similarity change score distributions), (3) similarity change "corrected for improved personality adjustment" (ADSMCH) (The change in similarity between ratings of self and therapist, where only the posttherapy_self ratings used in deriving similarity to both pre and posttherapy ratings 29 .Ho. v mes .mo. v m . .muwumafleflm umflmmnonuuucmfiumm Hoummum suds ommouocw mmuoom .mmusmmoe an“ IHMHHEHm Ham Mom .mmmmnuommn on» an cmuowpmum ma mflnmcofiumaou on» no coauomnfio on» mumnz mmwgmcofiumaon omen» now poms evacuamwcmwm mo ummuupoaflmu oco .ha u up “muoz NH.I mo.l AH. «smm. «smm. m NH.I «cam. mm. «NV. hm. m mo.l «Hm. «av. «HQ. «mm. v HH. mm. «mv. esmm. seam. m temm. smv. «Hfi. «emm. «svm. N sswm. hm. atom. seam. seem. «ewm. H Amozmomv mmcmno m>mmwmmm>m Assumaueflm mmcmno meflwmwmmwm wmcmno «mango a. HANNAH. HMS: gamma? imam ummocoo . oouoouuoo . ma : we emuueumeamum -mamm HmmnH mmcmno emuseumocmnm umsmmumna-mamm -— .. suflumafleflm e m s m N H mmmcmno umoocou =08: Hafiucmummwflo vaucmfiom can mousmmmz xuflumafleflm umfimmuonelpcmflumm vacquMHo can mo mcoHumHouuooumucH N magma 30 of the therapist.), (4) ideal self--therapist similarity change (change in the similarity of the patient's ratings of the ideal self and therapist from pre and posttherapy), (5) standardized ideal self-therapist similarity change (ideal self-therapist similarity change converted to stand- ard scores based on the separate distributions of change scores for like-sexed and Opposite-sexed patient therapist pairs), (6) "me" concept change on evaluative factor (me eval) (semantic differential evaluative factor scores for "me" concept). Table 2 reveals that most of the similarity change measures were at least moderately interrelated. Standard- ized and unstandardized similarity change measures highly corresponded to each other, which indicated that the sepa- ration of same and opposite-sexed patient pairs did not greatly alter the original similarity change measures. Similarity change "corrected for improved person- ality adjustment" (ADSMCH) emphasized the changed percep- tions of the therapist while minimizing the effects of improved self-evaluation. Therefore, this patient-thera- pist similarity change measure provided a rough estimate of the amount of similarity change variance in both the self and ideal self similarity change indices that could be accounted for by changed perceptions of the therapist. Improvement in self-evaluation over the course of therapy was reflected in Me Eval, which was the before and after changes in self ratings on the semantic differential. 31 Therefore, in relation to the similarity change measures, changes in self evaluation offered a gross estimate of the patient-therapist similarity change due to improved self- evaluation. The moderately high correlations between ADSMCH and both standardized (r=.53) and unstandardized (r=.61) aalgftherapist similarity change measures, (as well as the unstandardized ideal self-therapist similarity change measure» suggested a substantial portion of the sim— ilarity change variance resulted from changed before and after perceptions of the therapist. However, Me Eval's substantial relationship with both standardized and un- standardized aalg-therapist similarity change, but not ideal self-therapist similarity change, indicated that a considerable amount of the aalgftherapist similarity change variance was associated with improved self evaluation. Even though both improved self evaluation and changed ther- apist perceptions contributed to the aalgftherapist simi- larity change variance, the similarity change variance was still partially confounded by the effects of improved self evaluation. Therefore, when examining the relationship between aalgftherapist similarity change and therapy out- come measures, the similarity change variance due to im- proved self evaluation would have to be extracted. The findings in Table 3 indicated that greater pre- therapy patient-therapist dissimilarity was associated with greater patient-therapist similarity change. Since 32 Table 3 Correlations Between Pretherapy Patient-Therapist Similarity and Similarity Change ADSMCH Standardized Simgiaréty Pretherapy Patient- Standardized Ideal Self— Corregted Therapist Simi- Similarity Therapist for larity Change Similarity d Change Improve Persona11ty Adjustment Pretherapy Self- Therapist Similarity -.54* .14 .02 Pretherapy Ideal Self-Therapist Similarity -.29 -.59** -.27 *p < .05, df = 17. **p < .01, df = 17. high initial patient-therapist dissimilarity related to in- creased patient-therapist similarity change for both the self-therapist and ideal self-therapist similarity change measures, regression to the mean effects may have substan- tially contributed to the similarity change variance and therefore introduced another confounding factor into the in- terpretation of the similarity change measures. Testing the Hypotheses The primary hypotheses dealt with predictions about effects of identification (patient-therapist similarity change) on therapy outcome and the influence of specific 33 patient and therapist variables on the degree of identifi- cation. The secondary hypotheses referred to predicted re— lationships between all patient and therapist variables except identification. Primary‘Hypotheses Identification and therapy outcome: Hypothesis 1: The patient's identification with the therapist as defined by increased similarity of the patient's self and ideal self concept ratings and patient ratings of the therapist, is positively related with suc- cessful outcome. Table 4 contains the product moment correlations among similarity change measures and three semantic differ- ential self evaluation measures and 10 MMPI scales. The five repeated MMPI scales in Table 4, which were denoted by §a_following the MMPI scale abbreviation, contained scores for only those patients whose pretherapy scale scores were at least one standard deviation from the mean. This proce- dure did not yield significant findings. Therapy outcome indices were all derived from pre- posttherapy changes on each of the measures. Increased aalgftherapist similarity significantly related to improvement on two MMPI scales and one of the three semantic differential measures. Halgftherapist simi- larity change corresponded to improvement on the semantic 34 Table 4 Correlations Between Patient-Therapist Similarity Change and Therapy Outcome Standardized Standardized Self- Ideal Self- Therapy Outcome Measures Therapist Therapist Similarity Similarity Change Change Self-ideal self discrepancy .04 .03 change Semantic differential self good- .58** -.12 bad evaluation change (Me Eval) Semantic differential change in .25 .20 ratings of self potenty (Me Pot) MMPI Scales Scale Changes Dy (reduced dependency needs) .49* .28 As (increased self-esteem) .35 .03 Es (increased ego strength) .19 -.14 A0 (greater acceptance of -.03 -.17 others) K (greater self—esteem) .28 .14 Hs (reduced hypochondriasis) .12 .40* D (reduced depression) .26 .15 Hy (reduced hysteria) .11 .29 Pt (reduced manifest anxiety) .44* .11 Sc (reduced schizophrenia) .17 .03 D Sd. (N = 12)a .07 .27 Hy sa. (N = 13)a .09 .31 Pt Sd. (N = 12)a .34 -.09 Sc Sd. (N = 13)a .07 -.15 Hs Sd. (N = 12)a .20 .27 aMMPI scales denoted by S2. following MMPI Scale abbreviation, contained scores for only those patients whose pretherapy scale scores were at least one standard deviation from the mean (in direction of greater personality disburb- ance). *p < .05, one sided test of significance. **p < .01, one sided test of significance. 35 differential self evaluation (Me Eval) (r=.58), Navran's MMPI 2y dependency scale (r=.49), and the MMPI Ea (psychasthenia) scale (r=.44). However, since improved self evaluation (Me Eval), which was computed from patient semantic differential self concept ratings on the evalua- tive factor (good-bad dimension), was a component of the self-therapist similarity change measure, improved self evaluation (Me Eval) could not be considered an independent outcome measure. Using Tukey's procedure for combining the tests of significance for all 10 MMPI outcome scales, EElET therapist similarity change significantly correlated with improved outcome changes at the .05 level of significance. Moreover, aalgftherapist similarity change covaried significantly with improvement on two of the 10 MMPI scales. Navran's Qy_dependency scale (if one considers the intercor- relations between the 10 MMPI variables), accounted for the greatest common variance among all the MMPI scales. There- fore, the 2y scale, which is purported to be a measure of dependency needs, was actually the best measure of changes in global personality maladjustment. Furthermore, both the Qy_and HE scales were highly related to before and after therapy changes on the other MMPI scales (Figure 2). Hence, it can be argued that the MMPI Qy_and BE scales were par- ticularly good measures of global maladjustment. Therefore, the substantial relationships between aalgftherapist simi- larity and improvement (1) on both MMPI scales, and (2) for the combined tests of significance for all 10 MMPI scales 36 Iummoom mmamom Hmzz_mm ocm.Nm co momcmnu Ammuosuumom Imnm saws coumHouuou maucmoHMHcmHm mmusmmoz mEoouso Hmzz mcouum ommv mm 0““. mb m In» Amoco III/JUWVII/I h mm.uu o ”h. mammv me m .uu pm is Amoco IUCOQ NI Hr. nmcv o “muonuo mo mocmummoomv om m % onNH N madman Annmcmuum 0mm mm 0““ Aoocm ob. \\\AMH\p\ . H ol numooom 0% II mammv m4 as.nu so om mm H o “u: / em 37 provided adequate confirmation for the hypothesis that the patient's increased resemblance to the therapist was posi- tively related to greater therapy success. Again employing Tukey's procedure for combining the tests of significance for the 10 correlations between ideal self-therapist similarity change and the 10 MMPI out- come scales, ideal self-therapist similarity change did not significantly correlate with improved outcome on the MMPI. Table 4 revealed that ideal self-therapist similarity change corresponded to improvement on only one of the 10 MMPI scales, Ha (hypochrondriasis). Therefore, it is rea- sonable to conclude that the one significant correlation resulted from chance. Possible alternative explanations for the similarity change and therapy outcome relationships. Because of the confounding factors existing in the patient- therapist similarity change measures, there were several al- ternative explanations for why similarity change related to therapy improvement on a few of the MMPI scales. Firstly, the greater possibility of change for greater initial patient-therapist dissimilarity and greater pretherapy emo- tional disturbance on the MMPI scales may have been re- sponsible for the covariance between similarity change meas- ures and MMPI scale change outcome indices. Secondly, the patient-therapist similarity may have itself been an indi- cator of patient maladjustment. Thirdly, the self evaluation 38 component of the similarity change measure may have account- ed for the relationship to the outcome measures. Finally, with successful therapy, the patient may become more congru- ent with his ideal self. The ideal self may have coinci- dently resembled the ratings of the therapist, and thus in- creased patient-therapist resemblance may have only been a disquised expression of increased self-ideal self congruence. High pretherapy patient-therapist dissimilarity was associated with greater patient-therapist similarity change. This may be due to the greater possibility for similarity change (as well as possible regression to the mean effects). To eliminate these effects, pretherapy patient-therapist dissimilarity was partialled out of the similarity change- outcome correlations. After the statistical partialling out procedures, aalgftherapist similarity change approached sig- nificance with the 2y scale (.06 level of significance) and maintained significance with more positive self evaluation on the semantic differential (r=.49) at the .025 signifi- cance level. But the aalgftherapist similarity change--g£ MMPI scale change (r=.30) relationship dropped well below significance. Thus, the latter relationship was confounded by these effects. The second possible confounding factor was that aalfftherapist dissimilarity may have actually been an indi- cator of mental disturbance. The results indicated that ppetherapy self-therapist dissimilarity directly covaried with ppetherapngMPI Pt (r=.66), D (r=.56), Dy (r=.56), and 39 Ha (r=-.73) scales, which suggested that self-therapist dis- similarity was associated with greater emotional maladjust— ment. However, the pasttherapy»patient-therapist dissimi- larity was not significantly correlated with the pasttherapy MMPI scale scores. Posttherapy dissimilarity did not significantly correlate with Q (r=-.07), HE (r=.09), 2y (r=.25), or Ha (r=-.30) MMPI scale scores. Thus, patient— therapist similarity did not consistently in itself reflect a measure of emotional disturbance. The third alternative explanation for the findings was that similarity change corresponded to therapy improve— ment because of concurrent improvement of the self evalua- tive component of the similarity change measure and the out— come variables. To exclude self improvement on both the "good-bad" evaluative and potency dimensions, the self evaluative and potency factor changes were partialled out. With self evaluation partialled out, aalfftherapist simi— larity change still significantly related to improvement on the 2y scale (r=.46) at the .05 level, but failed to sig- nificantly correspond to £3 scale improvement (r=.23). With self potency partialled out, aalfihtherapist similarity change retained significance with both the 2y and BE scales. A fourth alternative explanation for the findings could have been that increased similarity to the therapist actually represented increased congruence of the self and ideal self, which is an indicator of improved self—concept. The increased patient-therapist similarity may only have 40 been a consequence of the movement of the self-concept to— ward the ideal self, which coincidently may have been simi— lar to the ratings of the therapist. Thus similarity change in respect to the therapist may have embodied the outcome measure self-ideal self discrepancy change. To eliminate this possibility, self-ideal self discrepancy change was partialled out of the similarity change-outcome correla- tions. galfftherapist similarity change-2y scale (r=.49), aalgétherapist similarity change-Pt scale (r=.44) and aalE- therapist similarity change-self evaluation (r=.58) rela— tionships were unaltered and retained significance. To summarize the results, aalE—therapist similarity change significantly correlated with therapy improvement on the MMPI Qy_and HE scales and with improvement for all 10 MMPI scales when the tests of significance for each MMPI scale were combined. Ideal self-therapist similarity change only related to improvement on the Ha scale and did not significantly relate to improvement on the 10 MMPI scales whose tests of significance were combined. Thus, the rela— tionship between increased ideal self—therapist similarity change and improvement on the Ha scale probably resulted from chance. Confounding factors, such as greater possibility of change for greater pretherapy patient-therapist dissimi- larity and improved self evaluation contained within the agiE-therapist similarity change measure itself, were shown not to be responsible for the relationship between aalf- therapist similarity change and 2y scale improvement. But 41 the aalf-therapist similarity change relationship with BE scale improvement was both confounded by initial similarity differences and by the fact that the self evaluation com— ponent of the similarity change measure strongly contrib— uted to the association with 32 scale change. Thus, it might be inferred that increased aalf-therapist similarity change moderately affected the improvement of general per- sonality maladjustment, but the patient's increased simi- larity to the therapist could not be considered a high powered therapeutic variable. Determinants of identification: Hypothesis 2: Perceived therapist strength as rated by the patient is positively correlated to the degree of patient identification with the therapist. Using the patient's semantic differential ratings for the "counselor" concept, therapist strength was obtained from the potency factor score. Table 5 Correlations Between Patient-Therapist Similarity Change and Therapist Strength and Good-Bad Evaluation Standardized Standardized Ideal Self-Therapist Self-Therapist Similarity Change Similarity Change Patient Ratings of Therapist Therapist Strength .46* .11 Therapist Evaluation -.18 .34 *p < .05, one tailed test of significance, df=17. 42 Therapist strength significantly related to increased aalf—therapist similarity change at the .05 level (Table 5). Thus, the greater the perceived strength of the therapist, the more the patient tended to become similar to the therapist. Hypothesis 3: Positive evaluation of the therapist by the patient is positively correlated with the patient's degree of identification with the therapist. The favorability of the patient's evaluation of the therapist ("good-bad" dimension) was measured from the pa- tient's ratings of the "counselor" concept on the evaluative factor of the semantic differential. Table 5 reveals that the favorability of the patient's evaluation of the thera— pist was not associated with either similarity change meas- ure. Hypothesis 4: The therapist's competence as measured by his warmth, accuracy of empathy, and genuine— ness is positively correlated with the patient's degree of identification with the therapist. Therapist competence was assessed from ratings of tape recorded therapy sessions. Table 6 reveals that the ratings of the therapist's therapeutic performance had no significant bearing on the degree of increased patient therapist resemblence. 43 Table 6 Correlations Between Ratings of Therapist Competence and Similarity Change Measures Standardized Standardized Ideal Self-Therapist Self-Therapist Similarity Change Similarity Change Rating of Therapist Competence Therapist empathy .09 .04 Therapist warmth .14 .14 Therapist genuineness .14 .09 Hypothesis 5:' The patient's pretherapy mani— fest anxiety and dependency needs and lower self—esteem, is positively correlated with the patient's degree of identi- fication with the therapist. The patient's pretherapy personality and psycho- pathology characteristics were measured from the patient's pretherapy MMPI. Table 7 presents the product moment cor- relations between patient-therapist similarity change indices and pretherapy patient MMPI scores. galg-therapist similarity change corresponded to elevated Q (depression) (r=.50), EE (psychasthenia) (r=.60), 2y (dependency needs) (r=.41), and lower Ha (self accept- ance) (r=.39) MMPI scales. These particular MMPI scales were highly intercorrelated (Figure 3), which suggested that symptoms and traits constituted a specific symptom con- stellation. 44 Table 7 Correlations Between Patient Pretherapy MMPI Scale Scores and Patient-Therapist Similarity Change Standardized Standardized Self- Ideal Self- Pretherapy MMPI Scales Therapist Therapist Similarity Similarity Change Change Ha (greater ego strength) -.04 —.01 59 (greater acceptance of -.35 -.27 others) K (greater self-esteem) -.21 -.37 Hs (greater hypochondriasis) -.04 .15 D (greater depression) .50* .25 Hy (greater hysteria) -.14 .13 Pt (greater manifest anxiety) .60** .21 Sc (greater schizophrenia) .36 .39 Dy (greater dependency needs) .41* .12 As (greater acceptance of self) -.39* -.16 17. *p < .05, one sided test of significance, df 17. **p < .01, one sided test of significance, df Thus, patients manifesting the symptom constella- tion depression, high anxiety, low self-esteem, and strong dependency needs tended to become more similar to their therapist. Hypothesis 6: The patient's degree of depend- ency on the therapist during therapy is positively IO IS Figure 3 Intercorrelations among Pretherapy MMPI 2, H3, 2y, and Hg Scales correlated with the patient's degree of identification with the therapist. Dependency on the model has been assumed to be a requisite condition for the occurrence of identification. The patient's therapy dependency behavior was obtained from ratings by an external judge of tape recorded therapy ses- sions during the middle of therapy. Table 8 shows the correlations between therapy de— pendency measures and similarity change measures. The de- gree of patient dependency on the therapist, and the therapist's approach or avoidance of the patient's depend- ency statements were not related to either of the similarity change measures. Therefore, the hypothesis that the more intense the patient's dependency on the therapist, the greater the patient—therapist similarity change was not con- firmed. 46 Table 8 Correlations Between Therapy Dependency Behavior and Patient-Therapist Similarity Change Patient's Degree of De- Standardized Standard1zed pendency on Therapist §El£f Ideal Self— . , Therapist Therapist and Therapist 3 Acceptance . .1 . . .1 . of Patient Dependency 51ml ar1ty S1m1 arity Change Change Percentage of therapist -.18 -.03 directed dependency statements by patient Number of therapist directed -.18 -.1O dependency statements by patient Therapist approach of therapist .04 -.44 directed dependency Secondagy Hypotheses Perceived strength of the therapist and the favor— abiliay of the evaluation of the therapist as rated by the patient in relation to other variables in stuay: Hypothesis 7: Perceived therapist strength and favorability of the evaluation of the therapist as rated by the patient (good-bad dimension) are positively correlated with successful therapy outcome. Although the patient's perception of the therapist's strength related to increased aalgftherapist similarity change (Table 5) and aalfftherapist similarity change moderately affected therapy outcome (Table 4), the therapist 47 perceived strength did not significantly correspond to therapy improvement on any of the outcome measures (Table 9). The favorability of the patient's evaluation of the therapist, also, had no relation to therapy outcome. Hypothesis 8: Perceived therapist strength and positive evaluation of the therapist as perceived by the patient are positively correlated with patient pretherapy manifest anxiety and dependency needs and lower self-esteem. Table 10 presents correlations among patient per~ ceived therapist strength and "good-bad" evaluation and pa— tient pretherapy MMPI scales. Using the patient's semantic differential ratings for the "counselor" concept, therapist strength and evaluation were obtained from the potency and evaluative factor scores. The patient's rating of the therapist's strength was influenced by the patient's pretherapy symptomatology. Therapist potency substantially correlated with pretherapy MMPI scales 2 (depression) (r=.47), BE (manifest anxiety) (r=.50), 2y (dependency) (r=.52), and Ha (self acceptance) (r=-.44). The findings suggested that a depressive, an— xious, low self-esteem, dependent type of patient tended to magnify the therapist's strength. The patient's pretherapy symptomatology had not af- fected the patient's "good-bad" evaluation of the thera— pist. 48 Table 9 Correlations Between Perceived Therapist Strength and Good-Bad Evaluation and Therapy Outcome Therapist Therapist 2 Therapy Outcome Measures Strength Evaluation Semantic differential self-ideal .17 .06 self discrepancy change (re- duced discrepancy) Semantic differential self good- .11 -.23 bad evaluation change (im- proved self evaluation) Semantic differential change in .30 .23 self-potency ratings (in- creased self potency) MMPI Scale Change Scores Dy (reduced dependency needs) .33 —.10 As (increased self acceptance) .17 .26 Es (increased ego strength) .11 -.22 A0 (increased acceptance of .02 .05 others) K (increased self-esteem) .17 -.18 Hs (reduced hypochondriasis) -.01 .31 D (reduced depression) .11 .10 Hy (reduced hysteria) .14 .29 Pt (reduced manifest anxiety) .21 -.24 Sc (reduced schizophrenia) -.08 —.28 HS 501 (N = 12) .15 .11 D 591 (N = 12) .06 .14 Hy SDI (N = 13) .07 .15 Pt SD (N = 12) .08 -.35 Sc 301 (N = 13) -.1o -.30 l MMPI scale abbreviations followed by HE contain change scores for only those patients whose pretherapy MMPI scale score was at least one standard deviation from the mean. Positive Outcome scores are in direction of im- provement (n1 particular scale dimension (improved person- ality functioning). 49 Table 10 Correlations Between Perceived Therapist Strength and Evaluation and Patient Pretherapy MMPI Personality Measures —— j Therapist Therapist Pat1ent Pretherapy MMPI Scales Strength Evaluation Es (greater ego strength) -.17 -.19 A0 (greater acceptance of others) .00 —.02 K (greater self-esteem) -.27 -.25 Hs (greater hypochondriasis) -.11 .15 D (greater depression) .47 .16 Hy (greater hysteria) .15 ..29 Pt (greater manifest anxiety) .50* -.08 Sc (greater schizophrenia) -.06 -.25 Dy (greater dependency needs) .52* .21 As (greater self acceptance) -.49* -.12 Note: Greater magnitude of MMPI scale score indi- cates greater degree of trait indicated by particular scale. *p < .05, df = 17. Hypothesis 9: Perceived therapist strength and positive evaluation as rated by the patient are positively correlated with the degree of patient dependency on the therapist during therapy. Therapist strength and evaluation were unrelated to the degree of patient dependency on the therapist (Table 11). Therefore, the hypothesis was unconfirmed. 50 Table 11 Correlations Between Therapist Strength and Evaluation and Therapy Dependency Behavior —:=_ ’1— Therapist Therapist Therapy Dependency Measures Strength Evaluation Percentage of therapist directed .14 .00 dependency Number of therapist directed .23 -.13 dependency expressions Hypothesis 10: Perceived strength and favora- bility of the evaluation of the therapist as rated by the patient are positively correlated with ratings of therapist competence as defined by therapist warmth, accuracy of em- pathy, and genuineness. It was predicted that patient's appraisal of the therapist would at least partially reflect the therapist's actual therapeutic competence. Therapist competence was determined by ratings of therapist empathy, warmth, and genuineness. Table 12 presents the interrelationships Table 12 Correlations Between Judged Therapist Competence and Patient Perceived Therapist Strength and Good-Bad Evaluation m Therapist Therapist Therapist Competence Strength Evaluation Therapist Empathy -.03 .10 Therapist Warmth .06 .23 Therapist Genuineness .00 .15 51 between the patient's and judge's ratings of the therapist. The ratings of therapist competence were uncorrelated with the patient's appraisal of the therapist's strength and "good-bad" evaluation. Patient's degree of dependency on the therapist during therapy in relation to other variables: Hypothesis ll: Patient's dependency on the therapist is positively correlated with successful therapy outcome. Patient's dependency on the therapist was rated by an external judge's ratings from taped therapy sessions during the middle of therapy. Table 13 contains both the percentage (% DT) and total number of patient dependency statements where the therapist was the object of the de- pendency and 10 MMPI scale outcome measures. Total number of dependency on therapist (DT) state— ments significantly correlated with improvement on the H (self-esteem) and §p_scales (schizophrenia). The percent- age of dependency on therapist statements (% DT) signifi- cantly correlated with the H scale and approached signifi- cance with the H3 scale. The H scale significantly corre— lated with the MMPI Hp (acceptance of others) (r=.62), Hy (dependency needs) (r=.51), and Ha (acceptance of self) (r=.48) scales, which suggested that the H scale tapped both self—esteem and attitudes toward others. The Ha scale significantly covaried with the Ag (r=-.51) and HE (manifest 52 Table 13 Correlations Between Patient Dependency on Therapist and Therapy Outcome MMPI Scale Change Outcome Measures1 Dy AS ES A0 K HS D Hy Pt SC %DT .11 .07 -.21 .13 .55** -.28 .11 -.22 .32 .37 DT .16 .18 .05 .04 .51* -.27 .10 -.26 .34 .44* 1Positive outcome change scores reflect improved personality functioning on the particular scale dimension. *p < .05, one sided test of significance, df 17. **p < .01, one sided test of significance, df 17. anxiety) (r=.65), indicating that the Hp scale also con- tained information about attitudes towards people. Thus, greater dependency on the therapist during therapy seemed to relate to improvement in self-esteem and more positive attitudes towards other people. Ratings of activity, which consisted of global rat- ings of the patient's participation and involvement in ther- apy, highly correlated with the patient's degree of depend- ency on the therapist (% DT-activity, r=.54) (DT-activity, r=.46). This finding indicated that patients who become more dependent on their therapists tended to become more involved in therapy. 53 However, since dependency on the therapist was associated with greater patient therapy participation, the therapy improvement may have resulted from the patient's greater involvement (activity) rather than from dependency pa; pa. So to differentiate dependency and activity effects on therapy outcome, activity was partialled out of the (dependency on therapist--therapy outcome) relationships. The degree of dependency on the therapist still significant- ly corresponded to improvement on the MMPI H (r=.40) scale at the .05 level but not the Hg (r=.33) scale. Thus, the patient's degree of dependency on the therapist, apart from the patient's degree of participation in therapy, had an important effect on changing attitudes towards oneself and others. Hypothesis 12: Patient's dependency on the therapist is positively correlated with pretherapy anxiety and dependency needs and lower self-esteem. Patient dependency on the therapist was rated from taped therapy sessions. The percentage (% DT) and total number (DT) of dependency on therapist statements and pa- tient's pretherapy anxiety level, dependency needs, and de- gree of self-esteem were interrelated in Table 14. Contrary to prediction, the patient's dependency on the therapist correlated neither with the patient's dependency needs (Hy) (r=.20) nor with his level of self-esteem (Ha scale and self-ideal self discrepancy). However, one of the two 54 Table 14 Correlations Between Patient Dependency on the Therapist and Pretherapy Patient Anxiety, Dependency Needs, Self-Esteem M; Pretherapy symptomatology % DT DT MMPI Scales Pt (greater manifest anxiety) .45* .29 Dy (greater dependency needs) -.12 -.13 As (greater self acceptance) .07 .02 Semantic differential self-ideal self discrepancy (greater discrepancy) .22 .31 *p < .05. measures of the degree of patient dependency on the thera- pist (% DT) was associated with the patient's pretherapy level of anxiety (Pt) (r=.45). Thus, more anxious patients appeared to become more dependent on their therapist. Hypothesis 13: Greater patient dependency on the therapist should be associated with more therapist ac- ceptance of the patient's dependency. Therapist acceptance of the patient's dependency on the therapist was operationally defined as the therapist ap- proach compared to avoidance of therapist directed depend- ency statements. The results in Table 15 indicated that the therapist's approach responses toward the patient's depend- ency statements were not associated with greater overall 55 Table 15 Correlations Between Dependency on Therapist and Therapist Acceptance of Patient Dependency M Measure of Therapist Acceptance of Patient's Dependency on Him Percentage of therapist approach of ther- .04 -.05 apist directed dependency statements patient expressed dependency. This finding suggested that the therapist response to dependency statements directed at him did not determine the degree of the patient's dependency on the therapist. Therapist competence and therapy outcome: Hypothesis 14: Therapeutic competence as de- fined by external judgement of the therapist's warmth, ac- curacy of empathy, and genuineness is positively correlated with successful therapy outcome. Table 16 contains the product moment correlations between therapist warmth, accuracy of empathy, and genuine- ness and 10 MMPI and three semantic differential change scores. These therapist conditions had a significant effect on therapy outcome. Accuracy of empathy significantly cor- related with eight of the 13 outcome measures, accounting for more of the outcome variance than either therapist warmth or genuineness. Also accuracy of empathy accounted for more outcome variance than any other variable in the 56 Table 16 Correlations Between Therapist Empathy, Warmth, and Genuineness and Therapy Outcome m _=: 1 Therapist Therapist Therapist Therapy Outcome Measures Empathy Warmth Genuineness Semantic differential self- .39* .25 .23 ideal self discrepancy change (reduced discrep- ancy) Semantic differential self -.31 .20 -.28 good-bad evaluation change (improved self evaluation) Semantic differential .10 .04 .07 change in ratings of self potency (improved self potency) MMPI Scale Dy (reduced dependency .41* .39* .40* needs) As (greater self accept- .65** .50* .47* ance) Es (greater ego strength) .69** .60** .61** A0 (greater acceptance .39* .23 .25 of others) K (greater self-esteem) .06 -.O3 ~.02 Hs (reduced hypochon- .20 .37 .40* driasis) D (reduced depression) .46* .37 .41* Hy (reduced hysteria) .43* .42* .37 Pt (reduced manifest .46* .35 .36 anxiety) Sc (reduced schizophrenia) .35 .30 .33 1 I I I I O P051t1ve outcome change scores are in direction of personality functioning improvement on particular scale di— mension. * p < .05, one sided test of significance, df ** p < .01, one sided test of significance, df 17. 17. 57 study. These findings substantiate the initial assumption that these dimensions measured the therapist's competence. Other Findings Patient activity, which reflected the patient's level of involvement and participation in therapy, related to greater pretherapy ego strength (r=.50) and both reduced pretherapy depressive (r=-.54) and hysterical (r=-.60) symptomatology. Thus, greater patient involvement in ther- apy appeared to be associated with less severe emotional distrubance. Activity corresponded to improvement on the MMPI H (r=.56) and Hg scales but was inversely related to improve- ment on the Hy scale (r=-.68). In view of the fact that activity was highly correlated with low pretherapy Hy scale scores (r=-.60), the inverse relationship between patient activity and Hy scale improvement may have been due to re- gression to mean effects. After partialling out the pre- therapy Hy scores, the activity-Hy scale change relationship (r=-.4l) using a two tailed test of significance, was no longer significant at the .05 level. Thus, it could be in- ferred that the degree of patient involvement in therapy was associated with improved therapy outcome. Summary of Results l. Self-therapist similarity change moderately cor- responded with improved therapy outcome. 58 Ideal self-therapist similarity change was not related to improved therapy outcome. Therapist strength but not therapist good-bad evaluation was associated with greater patient identification with the therapist. Therapist's actual therapeutic competence did not relate to the degree of patient therapist identification. Depressive, anxious, strongly dependent, low self-esteem patients tended to both perceive the therapist as more powerful and identify with him to a greater extent. Patient's degree of dependency on the therapist bore no relationship to the degree of identifi- cation. The relationship of variables to therapy out- 29129.- a. Therapist's competence as defined by ac- curacy of empathy, warmth, and genuineness strongly affected therapy outcome. b. Therapist strength and good-bad evaluation as perceived by the patient had no affect on therapy outcome. c. Patient's degree of dependency on the ther- apist was associated with both improved self-esteem and more positive attitudes to- wards others. DISCUSSION Primary Hypotheses Identification and Therapy Outcome The central aim of the study was to ascertain whether the patient's identification with his therapist played a significant role in improved therapy outcome. In child development identification research, the child's identification with an adequate parental model was associ- ated with a greater sense of security, adequacy, and self- esteem (Heilbrun, 1962; Jourard, 1967; Kagan, 1959). The results of the present study confirmed the hypothesis that greater patient identification with the therapist as de- fined by patient-therapist similarity change on the semantic differential, moderately corresponded to more successful therapy outcome. However, identification seemed to be a low powered therapeutic variable. Unlike previous studies which used the semantic differential to measure similarity change (Endler, 1961; Sapolsky, 1965), statistical controls were employed to control for the confounding effects of im— proved patient personality adjustment in the patient-thera- pist similarity change measure and regression to the mean. Of the three studies which have attempted to control for 59 60 changes in the patient's adjustment (Ewing, 1954; Farson, 1961; Petony, 1966) Petony (1966) and Ewing (1954) have succeeded in demonstrating that patient-therapist similarity change was associated with improved outcome. Ewing (1954), however, computed an unusual measure of similarity, con- trasting the patient's posttherapy self ratings with both his pre- and posttherapy therapist ratings, which raised doubts about whether his similarity change index actually measured similarity change. In the present study, Ewing's similarity change index was correlated with other measures of similarity change and was found to moderately covary with the more typical similarity change measures, which lends authenticity to Ewing's findings. Ideal self-therapist similarity change was not asso- ciated with improvement on the MMPI. Ewing (1954), also had failed to attain a relationship between ideal self-therapist similarity change and therapy improvement. Variables AffectingaPatient- Therapist Identification Mussen, Conger, and Kagan (1963) from their review of the identification literature and research heavily em- phasized the importance of the model's power and competence as determinants of identification. However, the present research findings indicated that the patient's perception of the therapist was primarily determined by the patient's needs and was not an accurate assessment of the therapist's actual therapeutic abilities. Depressive, anxious, low 61 self-esteem, dependent types of patients tended to both (1) exaggerate the strength of the therapist and (2) identify with him to a greater extent. The patient's ap- praisal of the therapist's strength was incongruent with the therapist's therapeutic competence as defined by the thera- pist's accuracy of empathy, warmth, and genuineness. The therapist's perceived strength as rated by the patient, but not externally judged therapist competence, related to the degree of patient identification with the therapist. Other studies have also encountered discrepancies between the pa- tient and the external judge's ratings of the therapist (Burnstein & Carkhuff, 1968; Hansen, Moore, & Carkhuff, 1968). It appeared that the patient's image of the thera- pist rather than the therapist's actual performance in ther- apy determined the degree to which the patient identified with the therapist. Probably, the patient's subjective feelings of weakness and helplessness caused him to need a strong person to help him and, therefore, the patient creat- ed an exaggerated image of the therapist to coincide with his needs. The magnified image of the therapist's strength provided a good adequate model for the patient and facili- tated identification. The present research findings were consistent with Kagan's (1958) hypothesis that the child's relative weakness and inadequacy as compared to his stronger more skilled parents is the primary motivation for adopting his parent's attributes. 62 In child development research on identification, it has been consistently reported that admiration and affection for the parental model promotes greater identification (Bandura, 1961; Payne & Mussen, 1956; Sears, 1963). Studies of identification in psychotherapy have similarly found that the degree of positive patient-therapist rapport (Schrier, 1963) and compatibility (Sapolsky, 1965) related to greater patient-therapist identification. However, the present in- vestigation revealed no relationship between patient-thera- pist identification and either the favorability of the pa- tient's evaluation of the therapist or the external judge's ratings of the therapist's warmth. The patient's dependency on the therapist was assumed to be a requisite condition for the occurrence of identification. However, the present findings revealed that the patient's degree of dependency on the therapist as judged by his behavior in therapy bore no relationship to the patient's degree of identification with the therapist. On the other hand, stronger dependency needs, which was un- related to the patient's overt dependency on the therapist in the present study, was significantly related to the de- gree of identification. Therefore, there was a discrepancy between the patient's dependency needs and overt dependency behavior. Only the patient's dependency needs determined the degree of identification with the therapist. 63 Secondagy Hypotheses The therapist's actual therapeutic competence, al- though not reflected in the patient's evaluation of the therapist, had a profound effect on therapy outcome. Pre- vious studies have shown that external ratings of the ther- apist were more predictive of therapy success than patient ratings (Burnstein & Carkhuff, 1968; Hansen, Moore, & Carkhuff, 1968). Neither the favorability of the thera- pist's "good-bad" evaluation nor his perceived strength cor- responded with therapy improvement. Therefore, more compe- tent therapists produce better therapeutic results even when the patient does not accurately perceive the true com- petence of the therapist. Again, the patient's evaluation of the therapist was strongly influenced by the patient's needs and personality. Truax (1968) who used judge's rat- ings of the therapist's strength instead of patient ratings found that the therapist's strength affected therapy out- come. His results indicate that therapist strength may be a potent therapeutic variable, but the patient's ratings of the therapist strength variable has no consequence on ther- apeutic outcome. Patient's who revealed greater overt dependency on the therapist in their therapy behavior showed more improve- ment in self-esteem and more improved attitudes towards others. Also greater dependency on the therapist was asso- ciated with the patient's more intense involvement and par- ticipation in therapy. However, even when the effects of 64 greater patient involvement were extracted from the effects of dependency pap aa, the patient's dependency on the thera- pist still contributed to improvement in self-esteem and social attitudes. Also, it was predicted that more intense patient pretherapy manifest anxiety and dependency needs and lower self-esteem would be reflected in subjective feelings of helplessness and inadequacy and, therefore, motivate the patient to become more dependent on the therapist. How— ever, only the patient's pretherapy level of manifest anxiety positively related to his degree of dependency on the therapist. The patient's dependency needs did not cor- relate with the patient's degree of overt dependency on the therapist during therapy. Limitations of the Research Almost all the therapy identification studies have compared the patient's and therapist's psychological test profiles to obtain an operational measure of identification. Since the psychological tests, including the semantic dif- ferential are sensitive to changes in personality adjust- ment, similarity change is confounded with changes in self evaluation. Thus, the relationship between patient-thera- pist similarity change and therapy improvement may be due to the fact that both measures are sensitive to personality adjustment changes. In the present study, one attempt was made to statistically control the confounding effects of improved personality adjustment, but it would be more 65 effective if test items which reflected personality adjust- ment were eliminated completely. Perhaps, it would even be better if identification was based on changes in the pa- tient's and therapist's overt behavior, which might include subtle behavior such as patterns of speech, mannerisms, patterns of affect expression, etc. Another deficiency of the present study was that only two kinds of outcome measures were used. The semantic differential outcome measures were not good indices of ther- apy improvement for this study because the semantic differ- ential was also a measure of similarity change. The 10 MMPI scales provided only questionnaire data and it would have been more effective to use several additional independ- ent outcome measures. The separate outcome measures could perhaps be fitted into a regression equation to obtain a single measure of outcome. Although the research contained methodological prob— lems, the results revealed the importance of certain rela- tionship variables in the psychotherapeutic process. Pa- tients with a specific symptom constellation tend to improve their personality through identification with the therapist. The patient's perception of the therapist is strongly influ- enced by his own dynamics. Patient dependency behavior in therapy was shown to be associated with more intense in- volvement in therapy and improved social attitudes and self evaluation. S UMMARY The purpose of the present study was to determine whether the patient's identification with his therapist affected therapy outcome. Furthermore, it was predicted that those variables found in child development research to foster greater identification should have similar effects on identification in psychotherapy. It was hypothesized greater patient-therapist identification would relate to: (l) greater therapist perceived strength and "good-bad" eval— uation, (2) better therapist therapeutic competence, (3) greater patient subjective feelings of weakness and help- lessness, and (4) greater patient dependency on the thera- pist. Eighteen therapy cases were sampled from the 1963- 1964 Michigan State University Counseling Center research project. Criteria for inclusion in the study were that the patient continued for 12 or more sessions and pre- and post- therapy MMPI profiles were available. Identification was measured from patient therapist similarity change on the semantic differential. Both EElE‘ therapist and ideal self-therapist similarity change meas- ures were employed. 66 67 The patient's perception of the therapist's strength and "good-bad" evaluation were assessed from the semantic differential potency and evaluative factor scores for the "counselor" concept. Therapist competence was obtained from external judge's ratings of the therapist's warmth, accuracy of empathy, and genuineness. The patient's subjec- tive feelings of weakness and helplessness were determined from his pretherapy MMPI HE (manifest anxiety), Hy (depend- ency needs), and Ha (self acceptance) scales. High mani- fest anxiety, strong dependency needs, and low self-esteem were assumed to create subjective feelings of weakness and helplessness. Finally, the patient's degree of dependency on his therapist and the therapist's acceptance of the pa- tient's dependency were measured from ratings of taped therapy sessions. Self-therapist similarity change (identification) corresponded with improvement on two of 10 MMPI scales and these particular MMPI scales were shown to be the best meas- ures of general maladjustment. Ideal self-therapist simi- larity change only related to improvement on the Ha MMPI scale, which measures hypochondriacal tendencies. Increased self-therapist identification was associated with both (1) the patient's subjective feelings of weakness and helpless- ness as indicated by stronger depression, anxiety, and de- pendency needs and low self-esteem, and (2) a stronger, more powerful perception of the therapist. The patient's evalua- tion of the therapist's strength was determined by the 68 patient's subjective feelings of weakness and helplessness rather than accurately mirroring the therapist's thera- peutic competence. Probably, weak and helpless feeling patients required a strong person to help them and they created an exaggerated image of the therapist to coincide with their needs. The exaggerated image of the therapist's power provided an adequate model for the patient and facil- itated identification. Contrary to prediction, the patient's degree of de- pendency on the therapist bore no relation to patient ther— apist identification. However, it was found that patients revealing greater dependency on the therapist during the middle phase of therapy showed more improved self-esteem and attitudes towards others. Greater dependency behavior in therapy was associated with more intense patient involvement and participation in therapy. Even with the effects of greater patient involvement partialled out, the patient's degree of dependency on the therapist still corresponded to improved therapy outcome. More intense patient dependency on the therapist was associated with higher pretherapy anxiety. The therapist's warmth, accuracy of empathy, and genuineness, although not reflected in the patient's eval- uation of the therapist (therapist strength and "good-bad" evaluation), profoundly affected therapy outcome. Patient ratings of the therapist's strength or "good-bad" evaluation did not relate to therapy improvement. LIST OF REFERENCES LIST OF REFERENCES Alexander, J.F. Perspectives of therapy process: depend- ency, interpersonal relationships and sex differ- ences. Unpublished Doctoral Dissertation, Michigan State University, 1967. Bandura, A. Psychotherapy as a learning process. Psycho— logical Bulletin, 1961, HH, 143-159. Bandura, A., & Walters, R.H. Hocial learning andapersonal- ity development. San Francisco: Holt, Rhinehart and Winston Inc., 1965. Barron, F. An ego strength scale which predicts response to psychotherapy. In G.S. Welsh and W.G. Dahlstrom, Basic readings on the MMPI in paychology and medi- cine. Minneapolis: University of Minnesota Press, I9 5. Pp. 226-234. Barron, F., & Leary, T.F. Changes in psychoneurotic patients with and without therapy. gournal of Con— sultingaPsychology, 1955, $2, 239-245. Berger, E.M. Relationship among acceptance of self, accept- ance of others and MMPI scores. Journal of Coun— seling Psychology, 1955, 3, 279-283. Bergin, A.E. An empirical analysis of therapeutic issues. In D.S. Arbuckle (Ed.), Counseling and psychotherapy: an overview, McGraw Hill, 1967. Pps. 176-212. Borrelli, N. The client's perception of therapist potency and changes in psychotherapy. Unpublished Doctoral Dissertation, Michigan State University, 1965. Bronfenbrenner, U. The study of identification through interpersonal perception. In R. Tagiuri and L. Petrullo (Eds.), Perception and interpersonal be- havior. Standford:—TStandford UfiiverSity Press, 1958. Pp. 110-130. 69 7O Burnstein, J.W., & Carkhuff, R.R. Objective, therapist and client ratings to therapist offered facilitative conditions of moderate to low functioning thera- pists. Journal of Clinical Psychology, 1968, 33, 240-241. Caracena, P.F. Verbal reinforcement of client dependency in the initial stage of psychotherapy. Unpublished doctoral dissertation, Michigan State University, 1963. Cronbach, L.J., & Gleser, G.C. Assessing similarity between profiles. Psychological Bulletin, 1953, HQ, 456- 473. Dahlstrom, W.G., & Welsh, G.S. An MMPI handbook. Minne- apolis: University of Minnesota Press, 1965. Endler, N.S. Changes in meaning during psychotherapy as measured by the semantic differential. Journal of Counseling Paychology, 1961, H, 105-111. Ewing, T.N. Changes in attitude during counseling. Journal of Counseling_Psychology, 1954, H, 232-239. Farson, R.E. Introjection in the psychotherapeutic rela- tionship. Journal of Counseliag Psychology, 1961, H, 337-342. Fenichel, O. The psychoanalytic theory of neurosis. New York: w.w. Norton and Co. Inc., 1945. Gallagher, J.J. MMPI changes commitant with client-centered therapy. Journal of Consulting Psychology, 1953, ll, 334-338. Gibson, R.L., Snyder, W.U., & Ray, W.S. A factor analysis of measures of change following client centered therapy. Journal of Counseling Psychology, 1955, 3, 83-90. Hannah, L. A study of some effects of the therapist's per- sonality and behavior and of the client's reactions in psychotherapy. Unpublished doctoral disserta- tion, Michigan State University, 1963. Hansen, J.C., Moore, G.D., & Carkhuff, R.R. The differen- tial relationships of objective and client percep- tions of counseling. Journal of Clinical Psychol- pgy, 1968, 31, 244-247. 71 Hartley, D.L. Perceived counselor credibility as a func- tion of the effects of counseling interaction. Journal of Counseling Psychology, 1969, HQ, 63-68. Heilbrun, A.B. Parental identification and college adjust- ment. Paychological Reperts, 1962, HQ, 853-854. Holmes, D. Male-female differences in MMPI ego strength. Journal of Consulting Psyehology, 1967, El, 408-410. Holzman, M.S. The significance of the value system of pa- tient and therapist for the outcome of therapy. Dissertation Abstracts, 1962, 3H (11), 4073. Jakubczak, L.F., & Walters, R.H. Suggestibility as depend- ency behavior. Journal of Abnormal and Social Psychology, 1959, H3, 649-658. Jenkins, J.N., & Russell, W.A. An atlas of semantic differ- ential profiles for 360 words. American Journal of Psychology, 1958, 1;, 688-699. Jourard, S.M. Identification, parent-cathexis, and self- esteem. Journal of Consulting Paychology, 1957, ‘Hi, 375-380. Kagan, J. The concept of identification. Psychological Re- view, 1958, HQ, 296-305. Kaufman, P. Changes in the MMPI as a function of psychi- atric therapy. Journal of Consulting Psychology, 1950, H2, 458-464. Kell, B., & Mueller, W. Impact and change. New York: Appleton Century-Crofts, I966. Kirtner, W.L., & Cartwright, D.S. Success in therapy as a function of client personality. Journal of Consult- ing Psychology. 1958, EH, 259-264. Landfield, A.W., & Nawas, M.N. Psychotherapeutic improve- ment as a function of communication and adoption of therapist's values. Journal of Counseling Psychol- pgy, 1964, Hi, 336-341. Leary, T.F. Interpersonal diagnosis of personality: a functional theory and methodElogy for personality evaluation. New York: RonaldTPress, 1957. Lennard, H.L., & Bernstein, A. The anatomy_of_psychother- apy. New York: Columbia University Press, 1960. 72 Maccoby, E.E. Role taking in childhood and its consequences for social learning. Child Development, 1959, HQ, 239-252. Mayfield, M. The weltanschung of Psychotherapy and selected correlates in a quasi-therapy situation. Unpub- lished doctoral dissertation, University of North Carolina, 1962. McNulty, J.A., & Walters, R.H. Emotional arousal, conflict and susceptibility to social influence. Canadian Journal of Psychology, 1962, HQ, 211-220. Mower, O.H. LearningaEheory and personaliay dynamics. New York: Ronald Press, 1950. Mussen, P.H. Some antecedent conditions and consequences of masculine sex typing in adolescent boys. Psycholog- ical Monographs, 1961, 12, No. 2, whole no. 506. Mussen, P.H., & Distler, L. Masculinity identification and father-son relationship. Journal of Abnormal and Social Psychology, 1959, H2, 350-356. Navran, L. A rationally derived MMPI scale to measure de- pendence. Journal of Consulting Psychology, 1954, 18, 192. Payne, D.E., & MusSen, P.H. Parent-child relations and father identification among adolescent boys. Journal of Abnormal and Social Psychology; 1956, ag, 358-362. Petony, P. Value change in psychotherapy. Human Relations, 1966, H2, 39-46. Raymaker, H. Relationship between self-concept, self-ideal concept and maladjustment. Dissertation Abstracts, 1957, ll, 409-410. Rosen, E. Self-appraisal and perceived desirability of MMPI personality traits. Journal of Counseling Psychology) 1956, 3, 44-51. Rosenthal, D. Changes in some moral values following psy- chotherapy. Journal of Consulting Paychology, 1955, H2, 431-436. Sapolsky, A. Relationship between patient-doctor compati- bility, mutual perception and outcome of treatment. Journal of Abnormal and Social Psychology, 1965, 12, 70-76. 73 Schrier, H. The significance of identification in therapy. American Journal of Orthopsychiatgy, 1953, HH, 585-604. Schuldt, W.J. Psychotherapist's approach-avoidance re- sponses and client's expressions of dependency: longitudinal analysis. Unpublished doctoral disser- tation, Michigan State University, 1964. Sears, P.S. Child rearing factors relating to playing sex- typed roles. American Psychologist, 1953, H, 431. Sears, R.R. Identification as a form of behavioral develop- ment. In D.B. Harris (Ed.), The concept of develop: ment. Minneapolis: University of Minnesota Press, 1957. Pp. 149-161. Sears, R.R., Maccoby, E.E., & Levin, H. Patterns of child rearing. Row, Peterson, 1957. Shell, S.A., Omally, J.M., & Johnsgard, K.W. The semantic differential and inferred identification. Psycho- legical Reperts, 1964, Hi, 547-558. Snyder, W. Dependency in psychotherapy. New York: Macmillan Co., 1963. Snyder, W. The psychotherapy relationship, New York: Macmillan Co., 1961. Thomson, Sr. G. The factorial analysis of human ability, Boston: Houghton Mifflin and Co., 1951. Truax, C., Fine, H., Moravec, J., & Mills, W. Effects of therapist persuasive potency in individual psycho- therapy. Journal of Clinical Psychology, 1968, 33, 359-362. Truax, C.B., & Carkhuff, R.R. Toward effectiye counseliag and_psychotherapy, Chicago: Aldine Puinshing Co., 1967. ’ Walters, R.H., Marshall, W.E., & Shooter, J.R. Anxiety, isolation, and susceptibility to social influence. Journal of Personality, 1960, HH, 518-529. Welkowitz, J., Cohen, J., & Ortmeyer, D. Value system similarity: investigation of patient-therapist dyads. Journal of Counseling Peychology, 1967, Hi, 48-55. 74 Winder, C.L., Ahmad, F.A., Bandura, A., & Rau, L.C. Depend- ency of patients, psychotherapist's responses and aspects of psychotherapy. Journal of Consultiag Psychology, 1962, HH, 129-134. Zuckerman, M., & Monashkin, I. Self-acceptance and psycho- pathology. Journal of Consulting Psychology, 1957, Hi, 145-148. APPENDICES APPENDIX A 75 ON NN om AN AN «N «N ON NH mm NNNm .uz NH m.mN N 0N m.NN NH N NH SN mm m mmaz m me NN om NN NN m NH Ha Ne a .n: NN ON m N ON m.mN m. oN SN mm numm mmaz m NN SN m.mN ma NN N.m NH s Hm mamumz mmNs NN NN Nm NH sN ON 0 N 0N mm cm .u: m Nm GN m.ON m.NN N.NN m.m NH ea ms 5mm mmas m mm m.mN mN m.oN m.mN m.m NH NN m.mm smumm mmaz ma «a ON NH GN ON m NN ma Nm eNn .uz NN «N m.mN m m.NN m.NN N.oN ma NH om mcamam mmaz NH on ma NH «N mN m NH NH Ne mcmm .uz ma «N N NH SN on m NN ma we cmm .uz ma NH NN ma NN «N s NH SN Nm mumm .uz SN NH oN ma NN ma N NH «N mu m .u: NN NN ON NN m.mN m.mN N N NN ms mums mmaz ma NH m.NN OH NH N.NN o N NH mm mama mass m mm m.mN m.mN em m.Nm NH NH NH ms mama mmaz N NN ma NN m.NN m.mH m.N NH NN me can mmaz mm an um um am a mm m om mm unmaumm mmuoom mamow Hmzz ammumsumum J mouoom mamom 3mm Hmzz Numuwnuoum “coaumm NIH manna APPENDIX B 76 NN. N.N NN. I m.H NNNm .uz om. I m.sI Ne. I N. m mmNz «N. N.N NN. N.m N .u: «N. N. am. I N. numm was: «N. N. I ma. o.e masses mmNz NN. N. I NN. I m. I an .m: NN.N m.m NN. G.N cmm mmNz SN. a. I mm. N.N smumm was: me. N.N NN. m.m saw .u: NN. N. I as. I N.NI mcamam mmNz «N. I N.SI em. I N.N mums .u: «N. I N. I mm. I N.N awn .us No. I m. I mN.N N.m oumm .uz NN. N.N SN.NI «.mI m .m: mN.N N.N ms.N N.N mums mmaz NN. N. I No. N. mama mmaz om. m. NN. v.N mass mmNz SN. I v.NI mm. G.N can mmaz Owcmnv %UHHMHHEflw OOCMSU muHHMHHEHm 002630 %UHHMHHEHm IWMWMMMMMWH ummmonoae umflmmuwnaumawm mmmmwMNMWHHmHNMNm Umnacumpcmum Imamm HmmpH pmufloumpcmum . sauna m III I mwuoom 3mm umflmmuone mnu on muHumHHENm ca mmcmno ucmfipmm Him manna APPENDIX C 77 .mmuoom pumocmum mum umwmmuonu mo mchumu ucmwumm "muoz m.m m.~ m.m ma. I em. I HHHm .Hz m.a m.a m.H mm. vm. m mmflz m.a m.H m.H we. mm. 4 .Hz o.m o.~ H.~ mm. av. I numm mmfiz N.N N.N N.N NN. NN. I masses was: N.N m.m ¢.~ mo. I Nm. I pm .Hz m.H m.H N.N o~.H an. new and: m.a m.a o.~ NN. vm. hmumm mmfiz m.H m.H m.H om. I am. I San .Hz H.N o.~ m.H mo. mm. I chMHm mmwz o.~ N.N m.H we. Na. man: .u: m.~ m.~ N.N mm. ma. com .Hz ~.H N.H ~.H em. I am. ovum .uz v.H m.a w.H mm.H Ha. I m .Hz m.m N.N m.~ mm.a mN.H mama mmwz o.~ m.H m.H Nv. mo. mach mm“: m.m m.~ m.~ om. mm.a wash mmwz m.H m.a o.~ we. I an. can mmwz mmmcocflscmu suaumz anummEm mo cowumsam>m sumcmuum umwmmumna umwmmuoca homnsoo< umflmmuone umwmmuona umammnmza umwmmuwcs mo mmcfiumm mumpso accumuxm was No magnumm unmaumm I III umwmmuone may no mmcHumm m.om09b Hmcuwuxm can ucowumm HIU OHQMB APPENDIX D 78 .mvw>flvoo uovooum ovoovpcw mmchoH Hocmvn .mvv>vvoo vcovvom mo mmcvvou mom "ovoz H II o HHNm .Hz m OOH co. m mmvz a II o m .Hz v ooH No. nvom nmwz II 2: mo . 3982 3N: V cm cm. on .Hz m cm mo. com mmvz N as No . Even an? H om mo. Eva .Hz v ooa no. ocwoam moaz m ooa mo. meow .Hz H ooH mo. com .Hz e ooa mu. ovom .Hz w ooa NN. m .Hz N can mo. ovox mow: m we mo. ocob omvz m cm ma. ocsh mow: c ooa ma. son now: oaoom vcwom mvcoeovovw aocoocomoa mvcoeovovw m co avv>vvo¢ vcoflvom mo oocovmooo< vmwmouona co aocopcomon vcowvom mo mmcfivom vmvmovona mo w vcowvom no a E E E Ho>oq hvw>vvo¢ muonone vcowvom no omcfivom pco .mouoom aocopcomoa m.v:oflvom mo oocovmooom m.vmwmouone .mouoom vmvmouoca co aocoocomoo m.vcovvom HIQ oHQoB APPENDIX E 79 I‘FHVHHNOONIOVWIDONHQ .oaoom uoasowvvom co vcoeo>oumav ovNONpcv mouoom o>Hvaom "ovoz NOHO‘HWHV‘VHOHmu-II-IWID!‘ HGMI‘ OHO THH I-l \OIDHNNMMONOM H H \DHFUHMMNVOONVMQMNN 0-0 H HQ’HVHI‘MHOHNMQU‘NMNO H H HFHMHHQHFHHQ‘HMOHNO I r-l NOQMHI‘MMMNHVOONHQ‘N I NNHNLOHONOHMQMI‘HHNM I U) Q' H mm o IDNHMMHOI‘HNMQ‘IOV‘Q‘W In H Havm .Hz m mow: s .u: avom mow: ovmuoz omNz pm .Hz com mow: wovom no“: Bub .Hz ocvoam mow: mcom .Hz com .uz ovom .Hz a .Hz mums muss ocob moat ocsb now: can now: m 4 mouoom omconu oHoom HA2: oeoovso amonona Him OHQMB