Fumrn a' 1"" H

\Hbg‘ls fig-1).. ‘. '..' , o . ' . - r}:

 

 

This is to certify that the
dissertation entitled

AN INQUIRY INTO UNCERTAINTY
IN THE FIFTH PROFESSION

presented by

Sheila Bienenfeld

has been accepted towards fulfillment
of the requirements for

Ph . D. degree in Psychology

I
Major professor

Date October 29, 1982

 

MS U i: an Affirmative Action/Equal Opportunity Institution 0- 12771

 

 

MSU

LIBRARIES
m

\'

 

 

RETURNING MATERIALS:
Place in book drop to
remove this checkout from
your record. flfl§§_will
be charged if book is
returned after the date
stamped below.

 

 

 

 

 

 

AN INQUIRY INTO UNCERTAINTY
IN THE FIFTH PROFESSION

By

Sheila Bienenfeld

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1982

ABSTRACT

AN INQUIRY INTO UNCERTAINTY
IN THE FIFTH PROFESSION

By
Sheila Bienenfeld

The relationship between uncertainty in psychotherapy
and clinical psychologists' concerns about their work was
the primary emphasis of this study. Uncertainty in
outcome. theory. and technique of psychotherapy were
discussed. The ambiguous findings of psychotherapy
research were suggested as an additional source of
uncertainty. The literature touching on these areas and on
the occupational stresses associated with psychotherapy was
' reviewed.

Eight questions were posed. These concerned aspects
‘of uncertainty, clinical psychologists' concerns or

' problems as therapists. psychologists' orientations to
psychotherapy. and therapists' attitudes toward research in
' their professional lives.

Interviews were conducted with thirty-five licensed
clinical psychologists. Likert scales covering dimensions

of therapists' concerns about psychotheraDY. and attitudes

Sheila Bienenfeld

toward research were created, as was a Q-Sort deck
referring to therapist's approaches to psychotherapy.
Demographic data on such areas as gender, age, experience
level, work-load, research activity, and publication
records was collected.

Cluster analysis of the Likert scales yielded six
dimensions of therapists' concerns about psychotherapy.
These were: concerns about the separation between personal
and professional life; whether their fees were really
earned; uncertainties in psychotherapeutic technique;
therapist self-disclosure; ethical issues involving sexual
and aggressive feelings toward patients; and the lack of
theory and guidelines in psychotherapy.

Cluster analysis of the Q-Sorts yielded six dimensions
related to therapists' approaches to therapy. These were:
a psychodynamic vs. an eclectic approach; therapist
uncertainty and self-doubt; a personalized view of therapy;
research-mindedness; perceived patient demands; and a view
of therapy as guided by inspiration.

Psychologists' attitudes and approaches toward
uncertainty were also investigated. In general these
therapists were tolerant of uncertainty and tended-to
endorse supervision, further training, greater experience,
and tolerance for ambiguity as ways of dealing with

uncertainty.

Sheila Bienenfeld

Psychologists' attitudes toward the role of research
in their professional lives were also investigated. In
general, these psychologists tended to value their research
related skills and the usefulness of their research
backgrounds. They tended to see research as of limited
relevance in their current professional lives.

Similarities and differences between these and
previous findings were discussed along with this study‘s
_broader implications. Directions for future research were

suggested.

I will ‘try
to fasten into order enlarging grasps of disorder,
widening scope, but enjoying the freedom that
Scope eludes my grasp, that there is no finality of vision,
that I have perceived nothing completely,

that tomorrow a new walk is a new walk

A.R. Ammons (from Corsons Inlet)

ACKNOWLEDGMENTS

The number of people to whom gratitude is owed is
directly proportional to the time it takes to complete a
work such as this. Recognizing that I will inevitably
leave out some, I want to express my gratitude to the
people who have been outstandingly helpful to me in a

variety of ways.

First of all I thank my parents, David and Anne
Bienenfeld, who have always been generous and supportive

during my long career as a graduate student.

Bob Zucker, chairperson of my dissertation committee,
has given extraordinarily of his time, and respect. That
our friendship has grown despite some pretty rough times is

a testimonial to his skill, faith, and patience.

Lucy Ferguson has been unfailingly supportive as
chairperson of my doctoral committee and as a member of my
dissertation committee. As both a supervisor and a member
of my dissertation committee, Arnie Berkman has been a
steadfast friend and ally throughout this long process.

Don Grummon made valuable suggestiors that greatly improved
this work. He also saw to it that my orals were a
memorable experience. I

iii

Terry Stein, Annie Stern, Don Stern, and Tracy Paget
encouraged my interest in the subject of this work and made
valuable comments throughout. Teresa Bernardez has been a
loyal and generous friend throughout this project. Harold
Searles was also a source of support and inspiration. Cy

and Marsha Norby have been good friends and landlords.

Glen Fischer, Jack Hartog, and John Borriello have
contributed friendship and gainful employment during this
work. Elaine Donelson, Ellen Strommen, Cher Stone, Georgia
Strasburg, and Jean Lipman-Blumen have also been loyal and

supportive friends.

Deborah Berry, George Chang, Bill Letford, and Jane
Pearson did a splendid job of rating the interviews that
were the basis for this study. Jane Pearson was a
marvelous computer wizard as well. Sandra Weidlich and her
staff at Okemos Professional Typists, worked incredible

hours in preparing the many drafts of this work.

I am grateful to all of these peOple and I apologize to

any whose names I have neglected to mention.

iv

II
H“

TABLE OF CONTENTS

List of Tables . . . . . . . . . . . . . . . . . . . vi

List of Figures . . . . . . . . . . . . . . . . . . viii

INTRODUCTION . . . . . . . . . . . . . . . . . . . . 1
CHAPTER I
PART I - UNCERTAINTY IN PSYCHOTHERAPY . . . . 5

PART II — MANAGING UNCERTAINTY IN
PSYCHOTHERAPY . . . . . . . . . . . 30

Summary and Conclusions . . . . . . . . . 52
Statement of the Problem . . . . . . . . . 54
CHAPTER II
METHODS AND PROCEDURES . . . . . . . . . . . . 57
Respondents . . . . . . . . 57
Selection and Contact Procedure . . . . . 57
Pilot Work . . . . . . 59
Data Reduction and Rating Procedures . . . 62

CHAPTER III

I. Descriptive Characteristics of the

Study Sample . . . . . . . . . . . . . . . 71

11. Research Questions . . . . . . . . . . . . 76
CHAPTER IV

DISCUSSION . . . . . . . . . . . . . . . . . . 136
CHAPTER V .

SUMMARY AND CONCLUSIONS . . . . . . . . . . . . 157
APPENDIX A . . . . . . . . . . . . . . . . . . . . . 173

APPENDIX B . . . . . . . . . . . . . . . . . . . . . 180

APPENDIX C . 193
APPENDIX D . . 195
APPENDIX E 197

Table

10

11

12

13
14

LIST OF TABLES

Descriptive Characteristics of the
Study Sample . . . . . .

Demographic Characteristics of the Total
Study Sample: Broken down by gender,
experience level, hours per week of psycho-
theraPY. research activity, and publication
history . . . . . . . . . . . . . . . . . .

Scale Numbers Corresponding to the Different
Research Questions and Mean Inter-rater
Reliabilities for these Measures . . .

Sample (High Loading) Scales from Likert
Problem Clusters . . . . . . .

Cluster I: Likert Scales Related to Therapist
Concerns About the Separation Between Personal
and Professional Life . . . . . . . . . . . .

Cluster II: Likert Scales Related to Therapist
Concerns About Whether Fees Are Really Earned .

Cluster III: Likert Scales Related to Therapist
Concern About Uncertainty in Technique . . . .

Cluster IV: Likert Scales Related to Therapist
Concern About Self— Disclosure . . . . . . .

Cluster V: Likert Scales Related to Therapist
Concern About Ethical Issues . . .

Cluster VI: Likert Scales Related to Therapist
Concern About Lack of Therapeutic Theory and
Guidelines . . . . . . . . . ... . . .

Cluster Names and Sample High Loaded Q-Sort
Items Responding to Question 2 . . . . . .

Q-Sort Cluster 1: Psychodynamic vs. Eclectic
Orientation . . . . . . . . . . . . . . . . .

Q-Sort Cluster 2: Uncertainty, Self-Doubt
Q-Sort Cluster 3: Personalization of

Therapy . .

vi

Page

72

75

78

8O

82

84

86

88

90'

92

99

100
102

104

LIST OF TABLES (continued)

Table Page
15 Q-Sort Cluster 4: Research Mindedness . . . . 106

16 Q-Sort Cluster 5: Perceived Patient
Demands . . . . . . . . . . . . . . . . . . . . 107

17 Q-Sort Cluster 6: Therapy as Inspiration . . . 109

18 Correlations Between Likert Scales Problem
Clusters and Approaches to Therapy (Q-Sort
Clusters) . . . . . . . . . . . . . . . . . . . 115

19 Clinical Psychologists' Explicit Attitudes
Toward Uncertainty; Scale Means and Standard
Deviations . . . . . . . . . . . . . . . . . . 121

20 Cluster VII: Likert Scales Related to
Relevance of Research in Clinical Psychologists'
Professional Lives, and Cluster VIII . . . . . 129

21 Mean Scores, Standard Deviations, and Overall
Ratings on Scales Responding to Question 6: 53!.
do clinical psychologists resolve the imbalance
between their clinical and their research

EFTOP‘CST o o o o o o o o o o o o o o o o o o o 132

22 Mean Scores, Standard Deviations, and Overall
Ratings on Scales Responding to Question 7:
What effect does training in research have on
the way clinical psychoTOQists do psycho-

therapy? . . . . . . . . . . . . . . . . . . . 134

APPENDIX C

C1 Clinical Psychologists' EXplicit Attitudes
Toward Uncertainty; Correlations Between These
Attitudes and Demographic Characteristics, and
Relationships Between These Attitudes and
Therapist Concerns (Likert Scales) . . . . . . 193

CZ Master Correlation Matrix Showing
Relationships Between Therapist Concerns
(I-VIII); Approaches to Therapy (1-6);
and Demographic Characteristics . . . . . . . . 194

vii

LIST OF FIGURES

Figure

1 Correlation Linkages Between Demographic
Variables and Cluster Measures Having To Do
With the Dilemmas that Clinical Psychologists
Face in Their Work . . . . . . . . . . . . .

2 Correlation Linkages Between Demographic
Variables and Cluster Measures Having To Do
With the Ways Clinical Psychologists Approach
Their Work as Therapists . . . . . . . . .

3 Correlation Linkages Between Therapists
Approaches to Psychotherapy and Therapist
Concerns . . . . . . . . . . . . . . .

4 Correlation Linkages Between Therapists
Approaches to Uncertainty; Therapist Concerns
or Dilemmas (Likert Scales): and Demographic
Variables . . . . . . . . . . . . . . . . . .

viii

Page

94

111

116

. 122

INTRODUCTION

 

Despite its European origins, psychotherapy is a
peculiarly American phenomenon. Relying upon notions of
almost unlimited human potential, it has flourished in a
country and in a time where Opportunites for external
expansion and growth, once the hallmark of the American
ethos, have diminished. Psychotherapy charts the
unexplored internal territory that for many has replaced
the uncharted geographic terrain of earlier explorations.

Psychotherapists are themselves latter day pioneers or
the children of pioneers. The overwhelming majority are
first or second generation Americans; immigrants or the
children of immigrants. Well described as people with a
"marginal perspective," an astonishingly large percentage
share Eastern European roots and a history of religious and
social persecution. They are from predominantly urban
backgounds, tend to be of liberal political temperament,
and are often upwardly mobile both socially and
economically. Seventy percent of them describe themselves
as "psychodynamically oriented" in their approach to
therapy (Henry, Sims, and Spray, 1971, 1973).

Although psychotherapists are drawn from at least four

professions; psychiatry, psychoanalysis, clinical

psychologists and psychiatric social work, they are so
similiar in background and practice that they have been
called a "fifth profession“ (Henry, Sims, and Spray, 1971,
1973). They are people who espouse a traditionally liberal
ideology of growth and who value science as a partner in
advancing their therapeutic goals. Yet they seem to be
shockingly ineffectual by most objective standards in
translating their ideals into real-world results. One
Nobel Prize winner has described psychotherapy as "...the
most stupendous intellectual confidence trick of the
Twentieth Century...“ (Medawar, 1975). Furthermore,
numerous outcome studies have failed to demonstrate the
efficacy of psychotherapy. One might reasonably suspect
that the good-faith practice of so highly touted and
idealistic, yet empirically dubious and uncertain a
profession may arouse some conflict in its practitioners.
This study is intended as an exploration of whether
such conflicts do appear and if so, in what ways they are
manifested in the attitudes of therapists and in the
practice of psychotherapy. An additional area to be
exploref will be the role of research in addressing
uncertainty in psychotherapy. This study will focus on
clinical psychologists, the researcher-clinicians among

psychotherapists.

The following chapter presents both a review and a
synthesis of the literature that touches on uncertainty in
psychotherapy and its ramifications in the lives and
practices of psychotherapists. The discussion is organized
by the elements of my own critique and draws upon
literature from the fields of psychology, psychiatry,
psychoanalysis, social work, and the sociology of
professions. In the present discussion psychiatrists,
clinical psychologists, social workers, and psychoanalysts
are all described as "psychotherapists." This study will
focus only upon clinical psychologists however.

It should be noted at the outset that finding
literature relevant to the present topic was in one sense
easy and in another sense difficult. The identification
of uncertainty as an almost definitive aspect of
psychotherapy is almost universal. Many authors from a
variety of disciplines point to its importance, however in
virtually every case they go on to address other issues
more germane to their own disciplines. So while
uncertainty is widely acknowledged as ubiquitous and
essential for understanding the practice of psychotherapy,
it is almost never addressed as an issue that is in itself
in need of examination. In a sense then, it can be said
that vey little directly relevant literature exists; a fact

that complicates a literature review but does not

preclude one. In fact, a review of the massive, albeit not
directly relevant literature that touches upon uncertainty
in psychotherapy only highlights the potential value of a
more detailed investigation of this t0pic.

Not surprisingly, a similar problem is found with
regard to the conduct and design of research in
psychotherapy. The problems that arise in the conduct of
psychotherapy research are well known and commonly
acknowledged. But again, the relationship between
difficulties of research in psychotherapy and difficulties
in the practice of psychotherapy have only occasionally
been mentioned in the literature and never to my knowledge
have they been specifically examined. The review contained
in Chapter I may therefore be misleading. Numerous
references to publications may leave the reader with the
impression that the uncertainty of psychotherapy is both
well documented and extensively discussed. The former is
true the latter is untrue. It is partially out of that

state of affairs that the present effort grows.

CHAPTER I

 

PART I - UNCERTAINTY IN PSYCHOTHERAPY

Psychdtherapy provides, and some would say requires of
its practitioners a level of psychological accessibility,
vulnerability, and honesty unparalleled among professions
and indeed rare in all areas of social life. As one author
has pointed out, "... like few other professional groups,
they (psychotherapists) seek to heal by being made whole
themselves." (Stern, 1981). But the depth of commitment and
the potential for growth that are inherent in the work may
be a mixed blessing. 0n the one hand, the gratifications
possible are many. The psychotherapist has ~0pportunities
for intellectual stimulation and interpersonal intimacy, the
challenge of self-awareness, and the pleasures of seeing and
sharing in mutual growth and development. Psychotherapy is
also a fairly prestigious and lucrative profession.

The difficulties in psychotherapy are many however.

The therapist faces ambiguity in technique and discourse,

often extreme duration of treatment, uncertainty of outcome,
and isolation in practice. These combine to complicate the
life and professional practice of the psychotherapiSt and to

distinguish psychotherapy as one of the most “impossible" of

professions (Freud, 1937; Malcolm, l980).

For the patient therapy may be a uniquely meaningful
and gratifying experience; nonetheless the patient's life is
lived primarily in other realms. This is not the case for
the therapist, whose working life is prevaded by the comings
and going of patients. In addition to this is the
continually renewed demand for a high degree of openness and
integrity despite the ups and downs of personal and
professional life.

Three types of uncertainty inherent in all professions
have been identified (Fox, 1957). The first and second
types are quite straightforward. There is uncertainty that
arises from gaps in the knowledge base itself, i.e., any
practitioner is bound to be uncertain in some instances
because the knowledge required to resolve that uncertainty
does not yet exist. The second type of uncertainty arises
from gaps in the practitioner's mastery of his or her
discipline; i.e., a more throughly prepared colleague would
not under the same circumstances be uncertain.

The third type of uncertainty, one that goes to the
heart of the matter regarding psychotherapy, arises from
uncertainty about the source of uncertainty itself. Practi-
tioners do not know whether their subjective experience of
uncertainty arises from within themselves; from the quality

of the interaction with patients; or from within gaps

in the knowledge base of the discipline itself.

With regard to such complex types of professional
uncertainty, it has been pointed out that among those gaps
that remain unfilled in the professional knowledge base
there are some that cannot be filled because of “inherent
limitations in the scientific enterprise." Because of this,
as Thomas Kuhn has also pointed out, "Phenomena anomalous to
the profession's paradigm may be misclassified or ignored
entirely.“ (Nilson, 1979). There may be in other words,
uncertainties which cannot be labeled or resolved given the
current state of knowledge in the discipline. In such cases
the practitioner is continually subject to a type of
uncertainty whose source cannot be identified and which in
any event cannot be resolved within the existing
epistemological paradigm of the profession.

Psychotherapy is an unusually uncertain and complex
profession. As such it imposes on the practitioner burdens
and responsibilities that are rarely recognized. The
present study explores the ways in which psychotherapists
talk about the uncertainties and complexities of their
work.

The examination of the uncertainties that psychothera-
pists must cope with and the ways in which they cope is
interesting on two levels. On one level, there is the
Opportunity to examine the effects of professional uncer-

tainty on members of one occupation. This study therefore

contributes to the growing literature concerned with the
interaction between occupational characteristics and life
stress (Maccoby, 1976). On another level, the examination
of such issues becomes particularly interesting with regard
to psychotherapists, peOple whose professional lives are
often devoted to helping others deal with problems that are
increasingly recognized as significantly socially produced.
The next four sections describe some of the critical
areas of uncertainty in psychotherapy. These areas include
uncertainty with regard to outcome, theory, technique, and
research. Each will be discussed separately. Taken
together they clarify some of those aspects of psychotherapy
that may impinge on therapists' sense of professional well
being.
A. The Problems of Outcome in Psychotherapy
"... he‘s not a ‘doctor' doctor -- he don't

cure nobody. He's a psychiatrist." (Edith
Bunker, Archie Bunker's Place, Sept. 30, 1979)

Even following hundreds of hours, the patient
is quite recognizably the same person, perhaps
still living in essentially the same circum-
stances, with his usual relatives and vocation,
and with similar recurrent difficulties. Now
and then his old symptoms return, though he may
pull through such relapses more quickly than
before. Yes, he is steadier since therapy,
with fewer illusions, but existence for him
continues to be a sometime predicament. All
told, is he happier? That is hard to decide.
Does he still have problems? Of course. Is he
better off than the next person who did not
have treatment?

A real question. (Fisher, 1967, p. 86)

Psychotherapy has no proven techniques of assured
effectiveness. It uses no apparatus and has no language
which all qualified practitioners can be assumed to accept.
It is a field in which virtually nothing can be known with
certainty save that two or more people participate,
generally through verbal interaction. Generally at least
one person is defined as being in distress (most often
thought to be non-organic in origin), and at least one other
person is defined as being an expert at helping people in
distress.

We know that after some time, one or both participants
may sense that the distress has beem ameliorated although
their accounts of how and why this occurs may differ
(Maluccio, 1979). We don't know for certain why any
improvement happens or how long it will take, or how long it
will last. The uncertainty of psychotherapy exceeds the
uncertainty inherent in other professions that have clearer
"patterns and practices" and more predictable ways of
determining outcome.

The work of a sociologist, Marianne Paget, is
illuminating in this regard. Her work has centered around
the phenomenological study of medicine, particularly
regarding the issue of medical mistakes (Paget, 1978). In

her examination of medical mistakes she concluded that

IO

medicine by its very nature, is an "error ridden" activity,
because errors in medicine are knowable only by unexpected
results of medical action. In other words, a physician only
knows a mistake has been made when a clinical act produces
undesirable or "wrong“ results over time. Every medical act
initiated thus contains within it a potential mistakenness
that can only emerge through time. Paget describes a
condition of such work as a “complex sorrow", a sorrow that
attends action wherein mistakes are inevitable and
potentially irreparable. Her emphasis on the inescapable
ambiguity of clinical (medical) action with its attendant
condition of "complex sorrow" is relevant to psychotherapy
as well. While the sorrow of medical work, and indeed the
sorrow of many professions is understandable, the sorrow of
psychotherapeutic work may be especially complex and
poignant. As another author has pointed out:

Uncertainty and certainty in medicine

are not dichotomies. They are two ends

of a continuum with psychiatry at one end

and surgery close to (though not entirely

at) the other end ... in every specialty

the practitioner learns to act in the face

of some degree of uncertainty; in psychiatry,

the uncertainty is hardly to be ignored.

(Coser, 1979, p. 8)

While the both errors and the successful efforts of the

surgeon emerge within what Paget calls a "compressed" time

frame, their equivalents in psychotherapeutic work generally

(emerge in a greatly expanded time frame. The surgeon or

11

medical practitioner of any variety can hope to understand
within seconds. minutes. hours, days. weeks or even months.
whether a particular treatment effort was successful or
mistaken or even the best possible compromise. The
psychotherapist. working with less tangible material and
methods cannot ever know with a comparable degree of
certainty whether. or for how long. or to what degree
therapeutic efforts have achieved their desired goals.

The problem for the therapist is not only what leads to
successful outcome, but also how to define successful
outcome. Clearly the behaviorist and the psychoanalyst have
quite different ideas about what constitutes the apprOpriate
diagnosis. conduct. and outcome of psychotherapy. The
behaviorist might applaud the psychoanalyst's "cure" of a
snake phobia while deploring the years and thousands of
dollars that cure might have required. 50 too might the
analyst acknowledge the behaviorist's "cure" of the same
problem while at the same time decrying the "shallow".
symptomatic emphasis of the behaviorist and while raising
the specter of "symptom substitution" or posing questions
about the durability of such a symptomatic cure. Even among
analysts a "cure" by one of their own number might be label-
led a "transference cure“ or a "misalliance cure“ (Langs.
1976, 1977). particularly if the results were not durable,

and even perhaps if they were. Take for example the

12

following:
I have heard therapists claim that
should even symptom relief achieved with-
out insight prove to last the lifetime
of the patient, they would still regard
it as a transference cure and something
less than desirable. (Fisch, l977, p. 268)

The process of psychotherapy is generally lengthy;
cases in which psychotherapy continues uninterrupted for
decades are not unheard of (although such cases are rare, or
rarely reported), and it is quite common for therapy to
continue for several years. To the practitioner, the
absence of a way of knowing when and how psychotherapy will
terminate and in what status it will terminate (successful
or unsuccessful, sooner or later, permanent or temporary)
creates a framework of uncertainty. It is within this
framework that the therapist and the patient must labor hour
by hour with little theoretical guidance and with landmarks
detectable most often retrospectively and only rarely
prospectively.

The issue of durability in psychotherapeutic treatment
adds to the uncertainty about outcome in a particularly
difficult way. One can never know in even the most "suc-
cessful" cases, how the ex-patient will weather future cris-
es and developments both internal and external. To be sure,
neither external events nor internal changes can be effec-

tively predicted, and it would be fatuous to insist that

they could or should be. However, the impossibility and

13

undesirability of making such predictions does not mitigate
the "sorrow" of uncertainty that the practitioner must cape
with as a condition of the work. Not only do inescapable
"real life" uncertainties not mitigate that sorrow, but they
form the condition out of which it exists.

The therapist labors painstakingly at an intense and
time-consuming task, without demonstrably efficient
technology. Any estimate with regard to time can only be
made by excluding from consideration the forces of nature
and by assuming unflagging strength and patience in both the
therapist and the patient. Despite these problems the task
can be and frequently is accomplished. Any confidence in
success however. is of necessity based upon suspended
attention to uncontrollable factors that may render both
persons' efforts seemingly or in fact for naught.

Students of psychotherapy have long been aware of the
difficulties that arise in a field in which there is little
consensus as to the definition of successful outcome, few
ways to predict outcome, and little or no replicable technol-
ogy (Frank, 1972). Indeed, Freud was one of the first to
suggest that psychoanalysis was one of three "impossible pro-
fessions". Along with raising children and governing
nations, Freud considered psychoanalysis a profession “in
which one can be quite sure of unsatisfying results" (Freud,

1937).

14

Robert Coles has eloquently summarized these problems
in an essay about one of psychotherapy's failures, Michael
Wechsler. Michael Wechsler was Young, Attractive, Verbal,
Intelligent, and Successful (YAVIS) (Schofield, 1965), in
other words, he was the very picture of an Optimal
psychotherapy patient. Furthermore, he was the son of upper
middle-class, saphisticated parents who were willing and
able to subsidize his years of psychotherapy with eight
esteemed and experienced therapists. Despite all this, he
was a suicide at age twenty-six. Along with the parents of
Michael Wechsler, Coles struggles to understand what led to
so tragic an outcome. In doing so he touches upon the
pervasive uncertainty that is endemic to all psychotherapy.
As he says:

Psychiatric terms, apparently so
clear-cut and emphatic have
extraordinarily versatile lives:
they come and go, blend into one
another, are used by one doctor,
scorned by another. More
dangerously, they can have subtle
and not so subtle moral or
pejorative implications. "Good"
patients, liked by their doctors,
are described one way, "bad"
patients, whose mannerisms (maybe
just plain manners) or "attitude" or
deeds are found to be unattractive,
are described differently.

The difference is one of tone,
emphasis, and always, choice of
words, many of them as portentous as
they are slippery. This youth is
"obsessive," but much of his
behavior is "egosyntonic", and his
primary struggle is "oedipal", even
if his "defenses" are by no means

15

adequate, and sometimes shaky indeed.
Another youth is also "Obsessive", but
underneath are serious "pre-oedipal"
conflicts. Furthermore, his defenses
are "primitive" and he may well be.a
"borderline case". With additional
exploration we might even discover an
"underlying psychotic process“.

Needless to say, the very same youth
can be seen by one psychiatrist,
then another, and on and on, with
divergence Of Opinion. X-rays do
not affect the diagnosis. Blood
tests cannot establish without doubt
what has to be done. We are in a
world Of feeling, the doctor's as
much as the patient's, so no amount
of training or credentials or
reputation can remove the hazards of
such a wOer: inclinations of
various kinds, outright biases,
blind spots. I do not deny the
enormous value that a personal
psychoanalysis has for a future
psychiatrist, or the effect years of
supervision can also have. By the
time most psychiatrists have
finished their long apprenticeship
they do indeed tend to know what
kind of patient they ought to
avoid,and most important, what their
vulnerabilities are.

 

 

 

Still, such awareness isn't always
translated into wise clinical
decisions. Patients are accepted
who ought to be referred. Patients
are treated one way, when perhaps
another tack might make things a lot
easier for both them and their
doctors. And even when in a
particular case things dO begin to
work well, “life" is always to be
reckoned with. Not everyone can
keep at therapy or analysis for
those months that have a way of be-
coming years... There are unavoidable
accidents or emergencies...(COles,
1975, p. 73) (emphasis added)

16

And finally as another clinician has stated,

In the end one understands nothing:

the therapeutic effect may be real and
intended, real and accidental, or chimeric.
-But all therapists are familiar with this
dilemma. How they resolve it depends on
where they locate pthe therapeutic process.
(Levenson, 1972,. 15)

B. The Problem of Theory in Psychotherapy

 

As Coles makes clear, the problem Of Outcome is
inextricably tied to the problems Of language and theory in
psychotherapy. It is a field that has no commonly accepted
language with which to describe its tasks or the phenomena
upon which it works. As such, it can hardly be expected to
have a language with which to credibly pass on and evaluate
in meaningful ways what has been learned. The language Of
psychotherapy and discourse about psychotherapy Often take
on an autistic quality. This is so because the discourse is
so often idiosyncratic, and consequently dialogue between
members Of competing schools may be difficult or nearly
impossible. I

Leston Havens, like Coles and Levenson, addresses both
the inherent ambiguity of outcome and the related issues Of
ambiguous discourse and theory.

The question is asked, "Does psychotherapy help,
and,if so, with what?" NO two therapists agree

17

on how HEALTH should be measured; even its

definition is disputed. Acute psychoses seem to
existential psychiatrists an improvement over many
premorbid adaptations; but not so to community
psychiatrists. Psychoanalysts may increase symptoms
while they struggle to change underlying personality
problems; behaviorists reduce symptoms but then are
accused of ignoring what lies behind them. There is a
great babble of voices but little talking back and
forth. (Havens, 1978, p. 2) (emphasis added)

 

The lack of a common language about psychotherapy both
obscures issues of outcome and impedes dialogue between
colleagues. Language is the primary tool of psychotherapy,
but in talking about therapy, it is a double edged one. It
can be used to lay claim to one's own otherwise undetectable
success, and to discredit the concrete achievements of
ideological competitors. The interpretive stance within
psychotherapy also complicates linguistic confusion because
language that is in itself vague is used to represent even
more ambiguous constructs. Thus, as one critic writes;

....the patient's balking at interpretive hints that
may be misguided or even silly is taken as a sign of
resurgent conflict with parents and siblings. The
dissolving of this allegedly atavistic
uncooperativeness--a recalcitrance which may in fact
attest to the patient's unsurrendered common sense--is
considered to be the analyst's infinitely painstaking
task. (Crews, 1980, p. 27)

Or as another, less outraged scholar noted:

In ward meetings, the patients often complained

about the stark facilities for living; for example, the
women's dormitory had no curtains so that the sun woke
them early in the morning. (They also had to hide from
the window when dressing.) Residents, by example of
the chief, learned to respond to such complaints by
psychologizing them. In this instance: "It seems to

18

me, Mrs. is saying it's hard to wake up and
face that we're still here." (Light, l980, p. 99)

As the quotation suggests, the vagueness of
psychotherapeutic concepts and the consequent vagueness of
psychotherapeutic language, allow therapists the freedom to
define reality in accordance with their own predispositions.
They have a license to "prove“ the most ridiculous notions,
ignore or explain away the most obvious events, and justify
a sense Of success in an evidential vacuum.

Donald Light tells of staff reaction to a suicide in an
esteemed New England psychiatric facility. The patient had
left a suicide note in which he mentioned the names of
several staff members who had worked with him. He mentioned
all the relevant names except that of his therapist. From
this, the staff concluded that the therapist was so
important to the patient that he could not bring himself to
write the therapist's name in his suicide note. As the
author points out, "The Opposite inference could be made,
but the overall conclusion was that the therapist had not
made a mistake. He had failed (to keep the patient alive)
bOt he had not erred.“ (Light, 1980, p. 214)

The point here is not that the therapist did or did not
err, or that the absence of the therapist's name from the
suicide note necessarily meant anything other than what the

staff took it to mean. The point is that the ambiguity of

19

therapeutic language offers ample room for what has been
called "retrospective reorganization;" any result can be
made to fit a prior theoretical mold and thus enable the
practitioner to avoid cognitive dissonance (Nible, 1978;
Festinger, 1957).

Kahn-Hut (1974) suggests that it is the very vagueness
of psychiatric concepts that allows therapists to avoid
feelings of alienation in a field as uncertain and as condu-
cive to alienation as psychotherapy. The very vagueness
about outcome and language that Kahn-Hut predicted would
lead to feelings of futility, instead allowed psychiatrists
to see their work in a favorable and meaningful light. In
another study, the ambiguity of psychotherapy had the Oppo-
site effect on practitioners. Former psychotherapy patients
and the social workers who had served as their therapists
were interviewed. About twice as many patients described
their psychotherapy experience as having been beneficial
than did the therapists. In other words, ".....most clients
were satisfied with the Outcome, whereas most workers were
either dissatisfied or ambivalent." (Maluccio, 1977, p.
107). The author linked such findings to the emphasis in
psychotherapy on the goals of altering psychopathology and
develOpmental arrest. As he notes, these are tasks that are
difficult to define and even more difficult to perceive as

having been accomplished. The patients on the other hand,

20

tended to use changes in their external life situations as
their criteria in evaluating change. Because Of this they
were more likely to believe that therapy had been
successful. The reactions of the therapists derive from
what has been called the "UtOpia Syndrome" in psychotherapy
(Watzlawick, 1977). According to Watzlawick, vaguely defined
but highly utopian goals prolong treatment and Obscure more
prosaic forms of real-life success and failure. One result
of such vagueness is that gaps in psychotherapeutic
knowledge are filled in with politically defined goals
(Nilson, 1979), or with the personal preferences of the
therapist. Therapists may respond to uncertainty by
becoming the agents of conventional social more's or by
striving to impose their own Utopian or political values
upon the therapy. Often therapists are unconscious of such
biases and may deny having them. As another author has
written,
Value-laden psychotherapy is possible because the
imprecision of psychiatric theory, especially the
ambiguity concerning “normality," permits the
psychiatrist's moral preferences to be enunciated "in
the disguise of scientific descriptions of fact."
(Bart, 1974, p. 15) '
In summary then, the language, i.e., the theoretical
concepts of psychotherapy, are so easy to manipulate but so
difficult to define that dialogue is Often difficult. Out—

come becomes divorced from the circumstances that bring pa-

tients into therapy. and therapists are able to see success

21

where no one else might, and failure where success might be
seen. Furthermore, the political aspects of therapy may be
obscured and thus denied. This puts psychotherapy at risk
of becoming a tool of social control and a servant of
repressive conventionality.

C. The Problem of Technique in Psychotherapy

Well, you know that all hypotheses go. She may be

angry at her mother, too, but I can deal directly with

her anger at me. The point is that if you guess she is
angry at you, and she gives clear signs that she is,
then your hypothesis is right. But had you suggested
she is angry at her mother, that would be right, too.

They're all right. (psychiatric resident, in Light,

1980, p. 94)

Obviously, when Outcome is difficult to predict or even
define, and when theory and language are ambiguous, techni-
que too must be problematic. The reverse is true as well,
when technique is problematic and language is ambiguous,
then outcome is difficult to predict. These three elements,
theory, technique, and outcome, are interrelated, indeed
inseparable. In each area there are problems of uncertain-
ty, and this is what most distinguishes psychotherapy from
other professions.

There may be no agreed upon theory as to why or how as-
pirin works, yet it can be prescribed for certain problems
and relief can be reliably predicted. In physics, theory

may predict the existence of some subatomic particle or oth-

er; the technique for finding such a particle need only be

22

developed and the predicted outcome, i.e. positive
jdentification of the particle, is likely to follow. In
law, theory follows outcome generated by technique. And so
on. In psychotherapy neither theory, technique, nor outcome
can be reliably agreed upon. There are elegant theories;
the most elegant of course is psychoanalytic theory; it is
elegant in scope and economy, but in matters of technique it
is often crude and virtually impossible to standardize in
practice. Not suprisingly, outcome data are often
inauspicious. Even distinguished psychoanalysts have been
moved to comment on "this remarkable and progressively
hardening insistence upon the validity of a theoretical
structure even in the face of its failure when applied in
therapeutic context.....” (Singer, 1965, p. 377).
Indeed the problems Of uncertainty in technique are such
that,

A psychotherapist may do anything within the law and

be immune from the charge that he is incompetent,

negligent, or malicious. All he needs do is claim that

his activities are for his patient's benefit. He may

sit silently, mumble inanities, give advice, moralize,

dispense drugs, issue threats, administer electric

shocks, or give his patients affection and support.

Almost anything that takes place between

a psychiatrist and his patient has been

labeled as psychotherapy....."

(Leifer, 1969, p. 156)

Added to the uncertainties of outcome, theory, and
technique is the problem of research. It is, of course, to

research, the process of investigating and discovering, that

23

therapists turn in their efforts to resolve uncertainties of
theory, technique, and Outcome.

In the same essay in which he declared psychoanalysis
an impossible profession, Freud expressed the belief that
,eventually research would help resolve the inherent
difficulties in psychotherapy (Freud, 1937). More than
four decades of research have done little to bring Freud's
hopes to fruition.

D. The Problem of Research in Psychotherapy

There are two levels at which research in psychotherapy
is problematic. One is tied directly to the results of the
research that has been done. The other is tied to the
conflicting methods of discovery used in psychotherapeutic
practice and in conventional (quantitatively oriented)
psychotherapy research. Both compound the uncertainty of
psychotherapy.

One researcher has expressed an aspect of the problem
of research in psychotherapy in this way:

.....despite many years of experience with various

psychotherapeutic theories and practices, many

psychiatrists, psychologists, and social and behavioral
scientists question the effectiveness of conventional
psychotherapy. They recognize that there is no
objective evidence that shows that a particular theorv
and practice of psychotherapy is more helpful than any
other (since all report about two-thirds "success“) or

than an individual's life experiences.
(Hurvitz, 1974, p. 84-85)

24

This disappointing aspect Of psychotherapy research is
very well known. Numerous major studies have failed to pro-
vide guidance to practitioners concerned with finding out
what works in therapy when, on whom, by whom, with whom, and
in how long a time (Luborsky, 1972). Many, like Carl
Rogers, have given up formal research or have advocated
major changes in the way psychotherapy research is done
(Bergen and Strupp, I972; Allport, I962). The journals how-
ever, continue to be filled with studies Of psychotherapy
process and outcome that many believe contribute nothing to
progress in the field (Wachtel, 1980; Levine, 1974; Goffman,
1978).

In coming to terms with the lack of fit between
research and practice, psychotherapists have several
options. They may, on the basis of the research evidence,
doubt the effectiveness of psychotherapy, or they may doubt
the design or theoretical basis Of the research. Another
alternative, altering practice on the basis of research
findings, is theoretically possible but tends not to occur
(see Frank, 1972). Finally, the therapist may just go about
his or her business and in the main ignore the research.

The latter is the most frequent approach.

One really has to wonder however, how easy it is to
ignore such disquieting research results. Even for those
who neither conduct so-called "empirical" research nor

generally read the research literature, the issue may not be

25

easily resolved. Otto Will may speak for many when he

confesses that:

As we cannot demonstrate with precision the causes

of the disorders which we treat, or show exactly how

what we do works or does not work, we may at times be

troubled by the idea that through a more tough and
realistic research will be discovered a truth Of
etiology and treatment and prevention that will reveal
our humanistic endeavors as some sort of soft-headed

nonsense. (Will, 1979, p. 565)

The research in psychotherapy not only engenders doubts
about therapeutic effectiveness, but as Will points out, it
may tend to induce in therapists a sort of guilty anxiety.
An example of this is the reaction of a former president of
the District of Columbia Psychological Association, to
NIMH's newly begun five-year study of psychotherapeutic
effectiveness. He suggested with mixed anxiety and
resignation, that "Psychotherapy will be dead in six years,
and we're all invited to the funeral.“ (Borriello, 1980).

It is surely not all that bad for therapists to feel
troubled about the ambiguous findings of the research. But
the potentially beneficial effects of apprOpriate self doubt
must be tied to the stimulus for such self examination. If
such doubts arise from the application of inapprOpriate
types of research methodology then a cycle of futility is
set in motion. In such a case the uncertainty is of the

third type described by Fox, ie., there is uncertainty about

the source of the uncertainty itself (Fox, 1957). This type

26

of “game without end" allows no exit. The system cannot
generate the rules necessary to generate new rules.
As scientist-essayist Lewis Thomas has pointed out,

Science gets most Of its information by the
process of reductionism, exploring the details,
then the details of the details, until the
smallest bits of the structure, or the smallest
parts Of the mechanisms, are laid out for counting
and scrutiny. Only when this is done can the
investigation be extended to encompass the whole
organism or the entire system. SO we say.

Sometimes it seems that we take a loss, working
this way. Much of today's public anxiety about
science is the apprehension that we may forever be
overlooking the whole by an endless, Obsessive
preoccupation with the parts. (Thomas, 1979, p. 7)

Here Thomas questions not the scientific method, but
certain canons of scientific technique. The accepted rules
of practice in research which lead one social scientist to
conclude that:

The 'objectivity' of the social sciences is not the
expression of a dispassionate and detached view of the
social world; it is, rather, an ambivalent effort to
accomodate to alienation and to express a muted
resentment Of it.... (Gouldner, l970, p. 53)

Richard Mann echoes such thoughts, and highlights their
applicability to the clinical psychologist in particular;

When a graduate student finally blurts out his

pained awareness that what he most wants to do is ut-
terly deprived of legitimacy, the instructor of the
methods course says, "Oh, but you know how much we
value exploratory, clinical, impressionistic studies as
a first step before the really solid research gets
underway."

27

And so all of us learn, all Of our lives, that what

we call our work is trivial in their eyes, that it is

nowhere near as serious and valid as what they do, and

try so hard to make us do. The very things we most
want to do become, in their eyes and gradually in our
own as well, some kind of vague leppy self-indulgence
which they hope we will transcend as quickly as
possible.

(Mann, 1974, p. 15)

When one of the clearest outcomes of conventional
training and practice of psychotherapy research is that
therapists learn to suspect that their work is “soft-headed
nonesense" (Will, 1979) or "some kind of vague leppy self
indulgence“ (Mann, 1974), research becomes a problem in its
own right. Instead of fulfilling the need for
investigation, it contributes to uncertainty by adding
another and irresolvable source of alienation and doubt.

Not only are issues of outcome, theory, and technique
highly uncertain; the conventional ways of resolving such
uncertainty may be of little help. Research remains a
highly valued way of clarifying uncertainty in practice.

But the research must not be fundamentally incompatible with
the phenomenon under investigation. When it is, additional
uncertainty about the appropriateness of the research itself
is added to an already uncertain and ambiguous situation.

By "denaturing" the phenomenon of psychotherapy, by defining
the self, i.e., the therapist's major guide, as a source of

errOr rather than a tool needing refinement, both research

as a pursuit with its own pleasures, and psychotherapy, the

28

phenomenon under investigation, are all too often (albeit
unintentionally) discredited. The result may be aptly
described as an "anesthetization of the intellect."
(Sennet, 1977). The effect of this may be a deadening of
curiosity and imagination rather than an enhancement of the
spirit of investigation.

One notion to be explored in the present study is that
therapists are not trained in a methodology of investigation
that effectively puts their natural curiosity to work on
their professional uncertainties. Instead they are often
trained to employ "methodology" as a substitute for creative
thought. The effect of such an alienating approach to
investigation may be a genuine turn toward "vague, sloppy,
self-indulgence."

A vicious cycle may therefore result. Increased
"scientific" rigor, in the most conventionally mechanical
sense, is seen as a counterweight for the vagueness of
clinical work. The inappropriateness of this approach
however, leads to its essential rejection by clinicians who
become detached from systematic investigation. This
rejection of an empirical and systematic approach may lead
to an approach that really is vague and leppy; and this
vagueness is then seen as justification for a more
stringently scientific approach. This sets the cycle in

motion again, and so it continues. The result is a kind of

29

warm-fuzzy, touchy-feely, caricature Of intellectual and
spiritual sloth. Therapists walk a more dangerous

tight-rope than is commonly realized, and this must have an

effect.

PART II - MANAGING UNCERTAINTY IN PSYCHOTHERAPY

 

There has been a growing trend in the social sciences
toward studying the impact of the work environment Oh the
emotional health of workers. The expanding literature on
“burn-out" is one example of the recognition that the char-
acteristics of the work place and of occupations themselves.
are important in understanding both individual behavior and
the social conventions of occupational groups. It has been
pointed out elsewhere that if psychotherapists are to be
helpful in dealing with occupatinal stress in clients'
lives, the occupational stresses in therapist's lives should
also be recognized (Edelwich and Brodsky, 1980). Psycho-
therapists believe that a problem that is denied is one that
is likely to grow and have negative consequences elsewhere
in an individual's life. Clearly then, the occupational
problems that psychotherapists encounter are a worthy topic
for investigation. The following section will explore some
of the literature dealing with therapists' subjective
experience of their work.

It is important to distinguish here, between this area
and the growing interest in "burn-out". As was mentioned
above, there has been an expansion of interest in "burn-out"
among therapists, and among members of many other occupa-
tions as well (Edelwich and Brodsky, 1980). One major
finding when the issue Of burn-Out is examined among

30

31

therapists is that "Constant giving without the compensation
of success apparently produces burnout.“ (Farber and
Heifetz, 1982). The present study is partially concerned
with this issue. The major emphasis of this study however,
is not what causes burnout among therapists; but rather,
given the overwhelming number of "burn-out producing"
aspects of psychotherapy how do therapists gyoig burn-out?
Consequently the following discussion focuses on the more
global question of how do therapists manage the
uncertainties and stresses inherent in their work.

A. Therapists' Subjective Reactions to Their Work

In reviewing the psychodynamically oriented literature
one can find ample recognition of the problematic nature Of
uncertainty in psychotherapeutic practice. Psychodynamcial-
ly oriented authors, true to their calling, tend to view the
occupational difficulties Of psychotherapists as deriving
from the history and character of the patient in interaction
with the history and character Of the therapist. Uncertain-
ty in psychotherapy is thus viewed primarily as a transfer-
ence - countertransference phenomenon. As such, it is to be
dealt with, not surprisingly, through supervision, personal
therapy, and psychodynamically informed reflection and
consultation with colleagues. The focus is on therapeutic

resolution of situational or characterological uncertainty,

32

rather than on the uncertainty-inducing generic features of
the work itself.

Within the sociologically oriented literature, most
authors have examined the effect of the training situation
on psychotherapy trainees (most frequently, psychiatric
residents). While their findings are useful and will also
be reviewed, they are limited to training in psychiatry
rather than its practice by experienced therapists of
varying backgrounds. Any conclusions suggested by this
research must therefore be viewed with some caution.

To my knowledge the number of studies that examine the
reactions of experienced therapists to their work is
extremely small. The few such studies that I have located
are also reviewed below. In general it can be said however,
that these studies either lack the depth of clinical
understanding reflected in the psychodynamically oriented
literature or they lack the systems perspective to be found
in studies of the training context. Unlike the more
clinical literature these studies do focus on the critical
interaction between the individual therapist and the social
context Of psychotherapy - an area generally neglected in
the psychodynamically oriented literature.

One especially thorough study (Daniels, 1974) focused
on how experienced psychiatrists viewed the problems

inherent in their work. The researchers interviewed and

33

administered a sentence completion task to 152
psychiatrists; 81 were private practitioners; 36 were state
hOSpital employees; and 35 were military psychiatrists. One
interesting conclusion was that, "Differences in structural
position within the specialty do not affect focus on
problems concerning the specialty." (Daniels, 1974, p.
209). In other words, expected differences between
psychiatrists practicing in different settings did not
emerge to the degree expected.

Instead, the psychiatrists tended with small
institution based differences, to bring up very similar
issues. The major concerns identified were as follows:

1. Effectiveness Of Treatment

 

a. Lack Of Standards and Techniques: ".....a
general uncertainty hovers over the entire
field; there is not enough knowledge."

b. Ambiguity of Results: "There is uncertainty
about what effective results should be, how
long therapy should take."

c. Pretending to Possess Expertise:

" ..... psychiatrists worry about overselling
their product."

2. Isolation

 

a. Structured Isolation: "The practice is

physically isolated or isolating."

34

Isolation From Colleagues: "Psychiatrists also
complain that they are too isolated from other
medical doctors or from other professionals in
related fields."

Communication Difficulties: "Psychiatrists see
themselves as isolated by lack of Opportunity to
communicate.....the situation in therapy may

appear intimate but actually it is not.“

Image Trouble - Status Problems

a.

Patient Image Trouble: ".....patients do not
understand what the limitations of psychiatry
are."

General Image Trouble: I'Psychiatrists feel they
are generally seen by both the public or their
patients as 'either omnipotent or impotent.'"
Status Problems in Medicine:

".....psychiatrists see themselves as
terrifically underrated or unappreciated by
other physicians....."
Psychiatrists Create Image Trouble:
"Psychiatrists also criticize their colleagues
for not trying hard enough to project an

appropriate image.....At the same time, they do

oversell the profession."

35

4. Personal_$trains Created by the Work

 

a. Work Is TOO Hard: ”Work is too demanding of
the practitioner."

b. Too Much Pressure: ”A psychiatrist should be
careful.....it was likely to exacerbate
personal weakness."

c. Not Enough Rewards: " ..... you can only make a
limited amount of money."

d. TOO Many Temptations: ".....the nature of the
work puts temptations in their path to do
things they know they ought not to do."

5. Negative Personal Characteristics Of Colleagues

a. Overly Superior; Too Much Social Distance
Maintained: ".....psychiatrists are arrogant,
unfriendly, and uncommunicative."

b. Dependent and Overconforming: "They saw their
colleagues as "unimaginative, inhibited, lazy
and timid."

c. Mental Illness: "They remarked that their
colleagues were "masochistic," “odd," "crazy,"
"crackpots," "depressed," "senile,"

"immature" ..... "
(Daniels, 1974)
Other authors have written of similar problems
psychotherapists face. In his exploration of "Why Psycho-

therapists Fail," Chessick (1971) identified three

36

interrelated areas of difficulty that he saw
psychotherapists struggling with, they are: (1) the issue
of professional identity, i.e., concerns similar to those
identified by Daniels related to self-image and status among
psychiatrists as compared to other professionals; (2)
anxiety over psychological mindedness: i.e., concerns about
the therapist's own instinctive and intuitive grasp of
psychological processes, and (3) the convinction that
psychotherapy is meaningful; i.e., therapists' doubts about
the effectiveness of psychotherapy.

Another author has examined the ways in which
therapists integrate their work with their own "mid-life
crises" (Fisher, 1967). During this developmental crisis,
the uncertainties of individual development combine with the
uncertainties of psychotherapy. This author identified
three types of difficulties therapists may have at the same
time, and discussed the ways they sometimes seek tO resolve
these difficulties. They are: (1) the search for an
absolute; i.e., a search for safe certainty in adherence to
some theory. (2) the search for self-realization; i.e., a
search for means to accomplish personal growth; and (3) g
quasi-spjritual quest; i.e., a mystical search for peace of
mind. In each Of these quests, the therapist is driven by a

psychological "critical mass" arrived at by attempting to

37

do a job full of chronic uncertainty during a time Of acute
personal.uncertainty.

Examining an earlier developmental phase, i.e.,
psychiatric residency, another author described what he
calls the "Moral Career of the Psychiatric Resident."
(Light, 1980). During the training period Light saw the
resident as going through five stages. He described the
first as 'Feeling Different and Being Discredited,‘ during
this phase the psychiatric resident, having achieved a
minimal degree of competence as a physician, is required to
begin again, learning theories and techniques greatly
different from those mastered as a medical student and
intern. The result according to Light, is that the resident
feels incompetent and uncertain. That uncertainty is
heightened by "the vagueness of psychiatric principles".
Also there is a tendency for more senior staff (and the
residents as well) to apply psychiatric principles "to the
residents as well as the patients. In fact, it is not
always clear how the two groups differ." (Light, 1980).

The second stage that Light observed is that of {Mogal
Confusion.' As he says,

What constitutes moral conduct is unclear. Is-one's

first duty to get patients out? Or to sit through

their pain and not administer drugs? Many residents
are not sure from day to day why they are doing what
they do.

.....Each resident (like each patient) tends to think

he alone is so bewildered."
(Light, 1980, p.249)

38

The third stage is one Of 'Numbness and Exhaustion,‘ or

 

what has been called "therapeutic nihilism." As Light says,
"Nothing seems to work. Everyone is tired.....Everybody
says they're sad."

The fourth stage, 'Moral Transition' is marked by

 

"Cynicism, conversion, and (most frequently) working out
one's own beliefs within the framework Of the program"
(Light, 1980, p. 251). One result of this transition is
that "trainees increasingly attribute successes to
themselves and failures to the patients or to difficulties
of the case." Another result of this stage is that
residents increasingly value the mastery Of technique rather
than the achievement of cure. In that way they integrate
the frustrations and uncertainties of their work through
what Light calls, ".....the narrow morality of technique."

The fifth and final stage that Light describes is
'Self—Affirmation.‘ During this stage the resident develops
a "tendency to reinterpret past traumas and self-doubts by
minimizing or even ignoring them."

As in all types of professional socialization, the
resident is guided toward an acceptance of the conventions
of the profession and an identification with its
institutions. In this way, troublesome issues such as
generic uncertainty are avoided or explained away. Even

raising such isues is discouraged.

”a

39

Other reactions by therapists to the uncertainty of
their work have been described. One such reaction concerns
the guilt of the therapist. As Bugental says, ".....each
old patient I see again is an accusation; each patient of
former years will be in some measure someone who trusted me,
and whom I failed by today's standards." And as he goes on
to say, ".....I must look at my patients today and know that
every one of them is getting less than I hope I will be
giving his successor five years hence." (Bugental, 1973, p.
297).

Another writer touches on the issue of guilt by
addressing the therapist's inability to transcend (or help
the patient transcend) the alienating and oppressive social
forces that contribute to the patient's problems. This
author points out that the traditional “mechanistic" model
of psychopathology may allow therapists to feel that they
are ".....not responsible, he has done his best. But what
if the therapist treats a Hiroshima maiden for depression.
He is nO less culpable with the suburban lady. In both
instances he is the oppressor." (Levenson, 1972, p. 134).
Both Levenson and Bugental see a certain degree of guilt as
an inherent consequence of practicing psychotherapy.

Otto Will points to the "daily exposure to madness"
(Will, 1979, see also McCarley, 1975) and the transitory

nature of therapeutic relationships as occupational hazards

40

of psychotherapy. He describes the therapist as ".....in a
sense a prostitute for the lives of others, a sparring
partner, but not a contestant in the 'main event'." And as
he points out, "These repeated attachments and losses accent
the essential loneliness of our lives." (Will, 1979, p.
571). The loneliness of the therapist has also been noted
by others (Daniels, 1974; Kahn-Hut, 1974; McCarley, 1975).
In the same paper, Will also discusses stresses imposed by
the massive social needs of the public; the relatively small
numbers that the therapist can actually treat; the expense
of treatment; and the increasingly intrusive pressures of
government regulators and insurance carriers.

Eric Fromm saw “unconscious despair" as “the major

 

pitfall of the profession" (Epstein and Feiner, 1979, p.
16), and Bugental too, warns that the therapist who flees
from a healthy degree of guilt rather than using it as a
spur to growth, may become "despondent or self-punitive.“
(Bugental, 1973). Kubie too, notes the depression and
despair that often leads therapists to “retreat from
patients."

. In the present state Of knowledge, even the "best"
psychiatrist piles up a record of mixed results.....The
cumulative score breeds depression and anger rather
than complacency. (Kubie, 1972, p. 699)

Searles too, touches upon the problems of isolation,

alienation, and emotional remoteness that the practice of

41

therapy often engenders in therapists. He also discusses
the tendency Of therapists to hold a rather negative view of

their colleagues:

.....as we move into being as close to a patient
emotionally as we feel the work calls for us to be, I
think that we are not able to integrate the most
hurtful distancing images which the patient has of
us--and which we have Of the patient, also. And I
think there is a very powerful tendency for those
images to get displaced onto the colleagues, and for us
to feel those colleagues don't understand us, and feel
alienated from them.....in our work with patients we
have this simultaneous combination of intimacy and that
kind of remoteness, remoteness on our own part toward
the patient and remoteness on the patient's part toward

“SOD...
(Langs and Searles, 1980, p. 87)

8. Managing Uncertainty: Responses of Therapists in

the Conduct of Their Work

Therapists find ways to "manage" the problems inherent
in their work. Some authors believe stress among therapists
is a result of working with difficult patients. Some
believe that stress among psychotherapists is a matter of
individual psychopathology. Others believe that
psychotherapy is stressful because of the very nature and
structure of the work itself, over and above the
personalities of the participants.

Coser for example, argues that psychiatry is by
definition so uncertain a field that psychiatric residents
are subject to "structural ambivalence" (Merton and Barber,
1957). This is a condition perhaps similar to the "double
bind" (Bateson, et. al., 1954) where peOple find themselves

in situations that require the simultaneous integration of

9;

PS

fr

EX

ca

 

98‘

CO'

.01“.

tec

lee

905

of

Mr

M‘

We

42

conflicting sets of expectations and social norms. In the
case of the psychiatric resident, one set Of conflicting
.expectations is that (1) the resident knows nothing, (2) the
doctor knows best. In other words, as a physician the
resident outranks other more expert ward staff who know, as
does the resident, that he or she is utterly untrained in
making psychiatric judgments or providing expert
psychotherapy. Trainees in all fields undergo similar
experiences of "learning by doing". With regard to
psychiatric residents however, Coser notes the added strain
induced by the fact that the resident's high status derives
from the relative certainty that comes with medical
expertise. This is a type Of certainty that the resident
cannot make much use Of in the more ambiguous climate of the
psychiatric hospital.

Another point that Coser makes is that because of a
combination of structural forces existing in the training
program, residents learn to make use of psychiatric
techniques in resolving their uncertainty. These ways of
dealing with uncertainty are carried forward into their
post-residency professional lives. According to Coser, many
of the unquestioned norms of professional conduct have dual
purposes.. They define the nature of the work while
protecting its practioners from doubt. One such social

"mechanism of defense" is evasiveness; therapists' tendency

 

43

to avoid revealing their own reactions or thoughts.
Evasiveness on the part of therapists' is a well accepted
principle. It keeps the focus on the patient and nourishes
and protects the transference. But as Coser points out,

One must distinguish between a technique that

consists in taking distance from an issue that concerns

the self and evasiveness that is used as a structurally

induced mechanism of defense against having to deal

with an ambiguous issue. (Coser, 1979, p. 107)

Another such mechanism, also a major feature of
psychotherapY. is confidentiality. As Coser says,

The norm of confidentiality legitimizes the

insulation from Observability and knowledgeability

which governs the therapeutic situation, and the

therapist is, Of course, interested in maintaining this

insulation. (Coser, 1979, p. 27)

Yet another structural feature of psychotherapy that
functions not only to promote the practice of therapy. but
to promote a sense Of certainty in the therapist as well, is
the private office itself. There the therapist is free from
group or organizational demands. Privacy allows therapists
to construct reality in accordance with their own notions of
what therapy is and how it should be practiced. In other
words, the structured isolation of psychotherapy may be
subjectively experienced as painful by therapists, but it
also allows them to believe whatever they wish to believe
about the nature and quality of their work. Privacy may

lead to isolation but it allows therapists freedom from

observation and disquieting feedback.

44

Coser is not suggesting that therapists stop being
evasive, or stop maintaining confidentiality or practicing
in private Offices. She is pointing out however, the dual
functions of these aspects of therapy and their utility in
helping therapists construct reality along less ambiguous
lines than psychotherapy provides. Like Kahn-Hut (1974),
Light (1980), and Daniels (1974), Coser draws attention to
the likelihood that aside from any benefits for the patient,

some of the very features of therapy that many therapists

 

complain of, effectively protect therapists' belief in the

 

meaningfulness in their work.

 

A turn to the "narrow morality of technique" as
discussed earlier is another way therapists manage
uncertainty. A related way is to turn not only to
"microtechniques" (Light, 1980), but to turn to the broader
"hidden religions" of dogma that many therapists rely upon."
(Wheelis, 1958; Will, 1979; Witenberg, 1977; London, 1964).
As Robitscher says of this process:

At some point in his develOpment he goes through a
crisis when he doubts his own therapeutic ability and
questions the theories that underly his methods.....The
young practitioner reluctantly comes to the conclusion
that his discipline "is not what it is represented to
be, and he begins to be troubled by a vague sense of
fraudulence." From this he can retreat into dogma and
abolish his doubts by fiat and eventually he may become
a serious defender Of orthodoxy.

(Robitscher, 1980, p. 477) (emphasis added)

 

45

Dogmatism is a particularly easy way to manage the
uncertainties of psychotherapy. Theoretical and technical
ambiguities allow ample space for the generation of theories
that are self-sealing. Such theories provide the illusion
Of certainty in their tautological circularity.

A predictable consequence of the "retreat into dogma"~
is the protection of the theory against deviance or the
posing of difficult questions. Ideological dogmatism
explains contradictions between theory and reality by
reinterpreting observed events in light of theory. So, for
example, “.....a significant number of analysts have dealt
with their own protracted failure by calling the patient's
efforts incomplete and by represcribing the very medicine
that had failed to take effect." (Crews, 1980, p. 28). In
this way, the patient, as a witness to the failure of theory
or technique, is discredited. The "victim“ is blamed (Ryan,
1972).

This danger of so relying upon theoretical orthodoxy
that all phenomena must be made to fit within the confines
of theory, is well known. As Roy Schafer has pointed out,
".....there is a not uncommon tendency to begin to use
technical terminology to derogate analysands who don't work
out well. Terms begin to be used really as invectives."
(Shafer, 1979, p. 353). Not only patients who "don't work

out well," but patients who arouse the anxiety of the

46

therapist for whatever reason, tend to be held responsible,
or are "discredited" when the therapy seems stuck.

It is an old saw that the more anxious the patient

makes the therapist, the more likely he is to label or

call names. Clara Thompson once said that whenever a

candidate in supervision began referring to an analysed

as "schizophrenic" she knew that the therapist was

threatened. (Levenson, 1972, p. 201)

Others have noticed the same phenomenon (see Maluccio,
1979; Bart, 1974; Coles, 1975). As Searles has noted,

Such unconscious scorn for the patient-~for the

patient's own strength and for his ability to reach

out, himself, for help from the therapist, without the
therapist's having constantly to keep pushing the help
at him seems to me to betray much self-contempt on the

part Of the therapist. (Searles, 1979, p. 77)

In managing their own feelings of uncertainty and its
attendant guilt, depression, loneliness, anxiety, and "self
contempt,” many therapists turn to reliance upon the privacy
of psychotherapy. the adoption of rigid dogmatism,
concentration upon technical perfection, and viewing
patients with scorn. Daniels (1976) found that most of the
therapists she interviewed (79 percent) tended also to be
highly critical of their colleagues, a tendency also pointed
out by others who have commented on "unwarranted feelings of
superiority" (Sharaf and Levinson, 1964) among therapists.
Other ways of “managing" the stressful aspects Of
psychotherapy that have been mentioned are "making and

keeping the patient dependent, exaggerating one's power,

47

handling patients in a grandoise way, or institutionalizing
omnipotence....." (Light, 1980, p. 306). Many of these
points are extremely well described in Janet Malcolm's
recent examination Of psychoanalysis through the eyes of one
analyist (Malcolm, 1980).

Kubie (1972) speaks Of the "flight from patients" as
one way young therapists react to the uncertainties of their
work. He attributes such a retreat to intrapsychic factors
such as "discrepancies between conscious and unconscious
goals." (Kubie, 1972, p. 699). He does note however, that
the discussion of certain tOpics in psychotherapy may be
discouraged for reasons that are not related to the
intrapsychic conflicts of individual therapists but to
aspects of the profession itself (Kubie, 1972, p. 704).
These prohibited topics are not discussed. But the absence
of discussion does not mean that such uncertainties and
doubts are not experienced. They are experienced in privacy
and reacted to in privacy. This condition, of having
reactions that are common but which are felt to be unique
has been called "Pluralistic Ignorance" (Merton, 1957).
Generic problems are seen as idiosyncratic and are dealt
with on the individual level rather than on the level of the
profession as a whole. Each therapist feels himself or
herself to be the first and only one ever to have

experienced such conflict. Clearly, then even

48

from Kubie's primarily individually oriented point of view,
there are problems that arise in the therapist's
professional life that are not dealt with effectively within
the world of psychotherapy.

Several features of psychotherapy that have already
been mentioned contribute to the maintenance of “pluralistic
ignorance." Among them are isolation, privacy, and
confidentiality. The conventions that govern much of the
research in psychotherapy also have the effect of limiting
the types of questions that can be asked. When the language
of a narrowly defined “science" is the primary language of
professional discourse, only those tOpics amenable to that
mode Of expression can be raised. As Wittgenstein says,
"whereof one cannot speak, thereof one must be silent."
(Shapiro, 1979, p. 75). And so the conventions of science,
too, contribute to the institutionalization of “pluralistic
ignorance.“ This pluralistic ignorance becomes a part of
the structure of psychotherapy and thereby perpetuates
itself and the problems that give rise to it.

Another way therapists have been described as managing
uncertainty is the tendency Of some to become followers of
psychotherapeutic “gurus." As Havens says:

Amid the uncertainties Of psychiatry, with its.

fragmentation and often Open conflict, students may

fall easy victims to identity diffusion. Confident,
attractive, answer giving teachers, therefore, attract

enormous followings and may turn out versions Of
themselves like Fords. If, in addition, the style of

49

the teacher fits the temperament of the student,

development may stop right there. (Havens, 1973, p.

325)

In his study of a large public mental hospital, Erving
Goffman described five “role-redefinitions" that the
hOSpital psychiatrist may adopt (Goffman, 1961). Goffman
considers the structure of the hospital, more than the
structure of therapy, to be responsible for necessitating
such role redefinitions. Nonetheless, his descriptions are
relevant in a broader context, particularly considering
Daniels' finding that state hospital psychiatrists did not
differ greatly from their colleagues in the military or in
private practice in the ways they viewed their profession
(Daniels, 1974).

The five ways of caping that Goffman observed in
hospital based psychiatrists are the following: the wise
grandfather - this is the psychiatrist who devotes himself
to administration i.e., the "custodial aspects of the
institution." Another redefines his role as that of the
researcher - i.e., the person who no longer defines his
purpose as that of service, but rather sees himself as a
scientist. The third role redefinition that Goffman Observ-
ed is the psychiatrist who retreats into the elitism of
paperwork or psychotherapy with staff members and "promis-
ing“ patients only. Another role is what Goffman calls the.

"patient's man," or the psychiatrist who is Openly critical

50

of the institution and is seen as "siding" with the
patients. The fifith role definition that Goffman describes
is the role of cynic; the psychiatrist who primarily
expresses dissafection with his position in the hospital,
thus seeming to remove any investment in the goals of the
system.

Donald Light identified three similar stances among the
residents he studied. Some residents became "therapeutic"
psychiatrists, i.e., they emerged from the residency having
defined their role as therapists above all else. They were
less interested in the intellectual and research aspects of
psychotherapy, and less interested in managerial activities
such as ward administration. Others emerged as
psychiatrists whose professional identities centered around
patient management; i.e., prescribing medicatiOn, ward
administration, etc. The third group saw themselves
primarily as intellectuals; psychiatrists who practiced in
order to further their interest in theory, rather than
primarily to help their patients (Light, 1980).

All of the stresses and ways of managing them that have
been discussed can be seen as developing (mediated obviously
by aspects of personality and character) in response to the
practice of psychotherapy. They are all worth studying in

psychotherapy perhaps more than in most other professions.

51

As Robert Coles has said:

I think that our own lives and problems are part of

the therapeutic process. Our feelings, our own

disorders and early sorrows are for us in some fashion

what the surgeon's skilled hands are for his
work.....The psychiatrist's hands are himself, his

life. (Coles, 1975, p. 12)

Surgeons know the strains their work imposes on their
hands (if not their psyches), and they use that knowledge to
protect them. In the case of psychotherapy this tends to be
less true. To be sure, therapists study themselves and for
many, personal therapy becomes "a way Of life." (Henry,
Sims and Spray, 1973; Whitaker & Malone, 1953). Therapists
Often focus great attention on the neurotic needs or
maladaptive qualities they carry into professional life.
Sometimes in supervision they examine the
countertransference reactions that specific patients or
categories of patients elicit from them. Less attention is
paid however, to the phenomenology of the work itself and
its impact on therapists. To the degree that therapists are
reluctant or ill-equipped to examine the social and
occupational forces that impinge on their lives, they become
insensitive to the social and structural forces that impinge
their patients' lives as well. Furthermore, they develOp
and maintain "blind spots" in their own experience and about

the interface between the personal world and the social

world.

52
Summary and Conclusions

Part I of this chapter advanced the notion that the
practice of psychotherapy is subject to a high degree of
uncertainty. The notion that uncertainty is an inherent
characteristic of psychotherapy is in itself neither
surprising nor particularly interesting. All professions
are to some degree ambiguous and uncertain; indeed, the
reliance upon informed individual judgment in ambiguous
situations is a distinguishing characteristic of all
professions. What makes psychotherapy a critical example
and what distinguishes it among professions, is the nature
and extent of that uncertainty.

The combination of ambiguity in outcome, theory, and
technique places the psychotherapist in a situation that may
be unusually conducive to particularistic, unintegrated, and
therefore ineffective or inconsistant decisionmaking. The
potential consequences of such a condition of uncertainty in
the realm of everyday practice is clear. To mangle a phrase
Of Dostoevsky's, "If there is no guide, all things are
possible", and accordingly, virtually everything has at one
time or another been called psychotherapy.

Part II Of this chapter reviewed two aspects of
psychotherapy from the point of view of the therapist. One

section reviewed some of the literature on the subjective

53

experiences that therapists associate with their work. The
other section examined some of the everyday characteristics
Of psychotherapeutic work that may be both sources and ’
effects of uncertainty in psychotherapy.

The point of view Of the present study is that the
multiple areas of uncertainty in psychotherapy call forth
responses in both the personal and the professional realms.
Personal, i.e., individual responses to the uncertainty of
psychotherapy can be found in both the general and unique
practices and beliefs of therapists, and in their subjective
feelings and attitudes about their work. Responses of
psychotherapists to the uncertainty of their work are
evident in the settings in which psychotherapy is practiced
as well as in the idiosyncratic values of individual
therapists.

While they may be looked at separately, the two realms,
i.e., the personal and the professional, are more accurately
seen as interrelated and dynamically interactive. Indeed,
one of the problems in psychotherapy and in the research
about where and how psychotherapy is done, has been the
tendency of researchers, teachers, and therapists, to see
the two realms as separable. It is a central thesis Of the
present study that both the personal and the professional
aspects of psychotherapy must be studied jointly, and one

intention Of the present study is to do so.

54

Statement of the Problem

 

The primary objective of this study is the examination
of the ways in which clinical psychologists "manage," or
make sense Of their work. Of particular interest are the
ways therapists manage the ambiguity of psychotherapeutic
practice and technique. To focus the problem more closely;
(I) clinical work is inherently uncertain and ambiguous;
(2) much of what are assumed to be merely the everyday
attitudes and practices of psychotherapists may protect
them from the experience of uncertainty or may help them
resolve it; and (3) much of the research in psychotherapy
and the conventional ways of carrying out that research
neither reduce uncertainty nor alter practice. In fact
this approach to investigation may exacerbate problems of
uncertainty for some therapists.

The major purpose of the present study is an investi-
gation of the ways that clinical psychologists build a more
certain reality than the objective conditions of their work
would seem to allow. An additional sub-purpose, and one
not unrelated to the primary purpose, is to examine the
"clinician - researcher" aspect of clinical psychology in
light of the fact that few clinical psychologists continue
as active researchers past the completion of their train-

ing. Some causes and possible consequences of this

inactivity will be examined.

With regard to the ways clinical psychologists
“manage" the work of psychotherapy, this is to my
knowledge, the first study that focuses exclusively on the

experiences of psychologists as clinicians. Such a study

 

may not only contribute to a more thorough understanding of
clinical psychologists and psychotherapists in general, but
may also contribute to the growing literature on the nature
Of work and the interaction between the worker and the work
situation. Such a study can explore those aspects of
psychotherapy as it is commonly practiced that may be
psychologically costly not only to the therapist and the
patient, but to the field in general.

Because much of the work done previously in this area
focuses on the socialization process in becoming
psychotherapists, little is known about the experience of
more mature clinicians. The study examines those
practitioners who are the everyday representatives of what
clinical psychology is, and who presumably have come to
terms with the nature and difficulties of their work.

This study explores the following questions, all of
which are suggested in the literature about psychotherapy
but rarely explored in depth and never focused specifically

on clinical psychologists.

56

What types Of dilemmas do clinical
psychologists experience in their work as
therapists?

What tacit principles, predispositions, or
"theories in use" (Argyris, 1974) guide
clincical psychologists' reactions to the
uncertainty of psychotherapy?

How do the dilemmas that clinical
psychologists experience in their work relate
to uncertainty in psychotherapy?

What are the explicit principles, or “espoused
theories" (Argyris, 1974) that guide clinical
psychologists' reactions to the uncertainty of
psychotherapy?

What role does research play in the
professional lives and self images of clinical
psychologists who practice psychotherapy?

Do clinical psychologists experience the
imbalance between their clinical and their
research efforts as conflictual? If so, how
do they resolve such conflict? If not, how do
they understand this disparity?

What effect does training in research have on
the ways clinical psychologists practice
psychotherapy?

Are clinical psychologists satisfied with
their research training?

1. If yes, in what ways?

2. If not, in what ways?

CHAPTER II

 

METHODS AND PROCEDURES

 

Respondents

The participants in this study were 35 licensed
clinical psychologists from the greater Washington, D.C.
metropolitan area. Most of them were full-time private
practitioners of psychotherapy; all were involved at least
part time in private practice. They were well balanced
along the lines Of age, sex, and experience level, and are
described more fully in Chapter 3.
Selection and Contact Procedure

The participants were drawn from the Washington, D.C.
Yellow Pages listing of more than 200 licensed clinical
psychologists. A pool of potential respondents was created
by listing every fifth psychologist and repeating that
process until the list contained llO names. After this
master list was created, were contacted potential
respondents by telephone. In the process Of securing the
participation of 35 subjects, 78 psychologists were
contacted - an overall acceptance rate of 45%.

During the initial telephone contact, these psychol-

ogists were invited to participate in the research by

57

58

consenting to a semi-structured interview. The study was
described as an examination of clinical psychologists'
ideas and feelings about various aspects of their work (see
Appendix A (p. 173) for the standard telephone
introduction). Potential respondents were advised that
the interview would require up to two hours of their time
and could be arranged at their convenience. They were also
promised that confidentiality would be maintained, and
their names would appear nowhere in the data. All
potential respondents were assured that any questions they
had about the study would be answered as fully as possible
after the interview. All interviews were conducted at the
respondents' offices. Interviewing began in July l98l and
was completed in January 1982.

Pilot Work

 

Prior to the actual collection of data, a series of
pilot studies was done to perfect the instruments for this
work. The first two pilot studies consisted of brief
questionnaires, each filled out in writing by ten
therapists associated with a public mental hospital in
Washington, D.C. These therapists included psychologists,
psychiatrists, and social workers. The questionnaires were
designed to elicit differing aspects of therapists'

experience Of certainty and uncertainty in their work.

59

The results of these pilot studies indicated that
uncertainty was a worthwhile area for more extended
exploration. The brevity of the written responses and the
limited focus Of the questions themselves suggested that a
more extended measure was needed and that interviews would
allow a more meaningful focus on.the issues to be studied.

It was also concluded that a focus on clinical
psychologists alone would be a more appropriate vehicle for
data gathering. Consequently a third pilot study was
devised. This work included a broader range of open-ended
questions, a set of incomplete sentences adapted from a
previous study (Kahn-Hut, 1974), and a demographic
questionnaire. This interview schedule was administered to
six clinical psychologists. The interviews were
transcribed and on the basis of this study revisions were
made on the interview format. A final format was then
synthesized.
Interview Schedule

The data consisted of participants' responses to two
questionnaires. One questionnaire was a paper and pencil
survey of various aspects of their professional careers and
typical work weeks. Information obtained included their
age, gender, years since earning the Ph.D., licensure, and
personal psychotherapy experiences. Information about the

number of hours per week spent in various professional

60

activities was also Obtained (see Appendix A, p. 174-176)

for a copy of this questionnaire.)

The second questionnaire was administered as a
semi-structured interview and consisted of T7 open-ended
questions followed by a series of l4 incomplete sentences
(see Appendix A, p. 177-179) for a c0py of this question-
naire). Incomplete sentence stems were adapted partially
from Kahn-Hut (1974) and some were generated for this
study. The interview as well as the incomplete sentences
addressed respondents' subjects' attitudes and experiences
regarding the following areas:

l) Their early expectations about clinical psychology

as a profession.

2) Their present attitudes and experiences regarding

various aspects of their profession, including:

a) Clinical psychology as compared to other disci
plines within the mental health professions.

b) Occupational strains or pressures associated
with the practice of psychotherapy.

c) The balance between their personal and
professional lives.

d) Whether their notions of what psychotherapy
can accomplish have changed since the early
stages of their careers, and how these notions

have changed.

3)

4)

5)

61

e) Their definition of successful therapy
illustrated through discussion of specific
cases deemed by them to have been
"successful". What did they do to facilitate
that success?

f) Their definition of unsuccessful therapy
through discussion of specific cases deemed
by them to have been "unsuccessful". What
would they do differently now?

9) Tactical or strategic problems they are
presently concerned about in psychotherapy
through discussion of current problems with
specific cases. How will they go about
resolving these problems?

Their attitudes toward, and degree of contact

with colleagues. Do they see enough of colleagues?

What do they discuss when they see their

colleagues?

Their general theoretical orientation, and works

in the professional literature that they admire.

Their assessment of their training experiences -

particulary thOse aspects of their training they

defined as most and least valuable.

5)

7)

8)

9)

62

Their use of research literature in their present
work. Which studies have most influenced their
work?

The degree to which they are currently active as
researchers.

Their attitudes toward research as part of the
“job description" of the clinical psychologist.
Whether they experience uncertainty as a major
characteristic of their work. How do they deal

with this uncertainty if they do experience it?

Thirty-three of the interviews were tape recorded, all

with the subjects' knowledge and consent (2 subjects did

not consent to tape recording and these interviews were not

recorded). In addition to tape recording, copious, nearly

verbatim notes were taken during all of the interviews.

The basic data in this report consists of transcripts of

the 33 taped interviews, and verbatim notes from the two

interviews that were not taped, as well as the paper and

pencil demographic questionnaire data collected from all 35

subjects.

Data Reduction and Rating Procedure

 

Two sets of ratings of the interview transcripts were

employed in the process of data reduction. One set

63

consisted Of a series of 74 Likert-type scales designed to
address six of the eight research questions described in
the statement of the problem. Two advanced graduate stu-
dents in clinical psychology rated the 35 interview tran-
scripts using the Likert type scales described above.
Several meetings were held with the researcher during which
the raters were able to clarify their understanding of the
scales and apply them to pilot interview transcripts.

When a reliable degree of interrater agreement was
reached with the pilot data, raters began rating the 35
interviews. Meetings were held after each 5 of the first
15 interviews were rated. During these meetings inter-
rater reliabilities were calculated and any problems were
discussed. Appendix B (p. 180-187) contains a full list of
the Likert Scales. Instructions to Raters are contained in
Appendix D, p. 195.

The research questions are as follOws:

Qgestion I: What types of dilemmas do clinical

 

 

psychologists experience in their therapeutic work?

 

Thirty-eight Likert type scales were devised to re-
spond to this question (Scales 1-38). Thirty-eight scales
were chosen in order to cover as wide a range of dilemmas
as possible. A smaller number of scales would not have
covered a wide enough range. A much larger number of
scales would have been both unwieldy and too detailed. The

scales were created by the researcher and touched upon

64

areas described as problematic by interview participants,
pilot study participants, and the literature on
psychotherapists' experiences of their work. Ratings
ranged from 1 (very concerned), to 5 (very unconcerned) on
a variety of issues regarding:

a) Aspects of psychotherapy; e.g. how to know when
therapy is successful; the therapist's own skill
level; ethical questions; and errors the therapist
is concerned about;

b) Specific problems with patients e.g. anger toward
patients; management problems; suicide;

c) The therapist's feelings about his or her work:
e.q. stress, anxiety, isolation;

d) The therapist's attitudes toward colleagues: e.g.
reliance, rejection, cooperation.

The complete set of scales for this and the remaining
ratings along with thir anchoring points are presented in-
Appendix 8, pp. 180-182.

Question 2: What principles, predispositions, or

 

 

tacit “theories in use" guide clinical psychologists'

reactions to therapeutic uncertainpy?

 

The Q-Sort is a method introduced by Stephenson (1953)
and developed more fully by Block (1961). This method
relies upon ratings done by trained observers. The

observers are required to describe subjects through the use

65

of a series of statements which the raters sort into a
normal distribution according to the degree of salience
each statement has as a descriptor of the respondent.

The method has the advantage that it can quantify very
diverse and imprecise information, and reduce it to a
standard metric. This method was chosen in particular as a
way of quantifying the respondent data to answer Question
2. In order to do this a relevant Q-deck needed to be
generated. Appendix B, p. 188-192 presents the final set
of items used here.

The Q-deck of statements was generated in the
following manner:

1) A list of 229 statements describing therapists'
beliefs and approaches to psychotherapy were
generated from:

a) pilot study data

b) a reading of the interviews

c) the literature on therapists' reactions to
their work

2) Q-Sorts using all 229 statements were done by the

researcher, on 6 transcripts of pilot interviews.

66

3) The 100 statements that appeared most
frequently were selected and revised to clarify
their content where that seemed necessary.

4) Q-Sorts using the 100 item deck were then done on
6 additional pilot interviews.

5) To assess the stability of these ratings, and
indirectly to test the question of whether a
denotable set of characteristics could be rated,
this process was repeated after an interval of
approximately 10 days and a calculation of the
test-retest reliability was done. This was
sufficiently acceptable to justify using the deck
on the respondent data.

When the deck was in final form two additional raters,
4th year clinical psychology graduate students, one male,
one female, were trained to use the deck. During the
initial training the nature of the Q-Sort task was
explained and pilot-study interviews were rated. After
these ratings were completed, the raters met with the
author again, and unclear statements were clarified. In
some cases the statements were revised along lines
suggested by the raters. When an adequate degree of
interrater agreement (72%) was achieved on pilot data,
rating of the research interviews began. Meetings were

held after each 5 of the first fifteen interviews had been

67

rated. During these meetings initial reliabilities were
estimated and any problems that had arisen were discussed.
Q-Sort items are placed in categories ranging from 9
(most characteristic or salient statements) to 1 (least
characteristic, or negatively salient statements), with the
most neutral items in group 5. .The specified number of

statements allotted per group was as follows:

 

 

 

Number
Group of Statements
extremely characteristic or salient 5
8 quite characteristic or salient 8
7 fairly characteristic or salient 12
6 somewhat characteristic or salient 16
5 relatively neutral or unimportant 18
4 somewhat uncharacteristic or negatively
salient 16
3 fairly uncharacteristic or negatively
salient 12
quite uncharacteristic or negatively
salient 8
1 extremely uncharacteristic or negatively
salient 5
9 groups 100 Statements

Final Q-Sort scores on each item were determined by
adding the two raters' scores together (i.e., a final score
on an individual Q-deck item could range from 2 to 18), and
a final score on an individual Likert scale could range
from 2 to 10).

Question 3: How do the dilemmas or problems that

 

 

clinical psychologists experience in their work relate to

 

uncertainty in theory, technique, and outcome? There were

 

no scales or ratings specifically addressed to this
question. Instead, this question is addressed by examining
the relationships between the responses already given to

Questions 1 and 2.

68

Question 4: How do clinical psycholgists explicitly

 

view the uncertainties of their work?

Eleven Likert-type scales were devised to respond to
this question (Scales 39-49). Again, the interviews, pilot
studies, and review of the literature contributed to the
creation of these scales. Ratings ranged from I (very
characteristic) to 5 (very uncharacteristic) on a variety
of attitudes or approaches toward uncertainty. These
attitudes ranged from:

a) an acceptance of the presence of uncertainty in

psychotherapy

b) ways to deal with uncertainty; ways to minimize

uncertainty

c) a rejection of uncertainty as an important aspect

of psychotherapy. These scales are shown in
Appendix B, p. 183.

Question 5: Do clinical Psychologists experience the

 

imbalance between their clinical and their research efforts
as conflictual?

Three Likert-type scales (Scales 50-52): were devised
to assess this area. These scales are presented in

Appendix B, p. 184.

Question 6 How do clinical psychologists resolve the
imbalance between their clinical and their research

activity?

 

69

Eight scales (Scales 53-60), were devised to respond to
this question. Ratings ranged from 1 (very characteristic)
to 5 (very uncharacteristic) on a variety of attitudes
toward research.

Once again these scales were drawn from the
interviews, pilot studies, and a review of the literature.
They are shown in Appendix B, p. 185.

Question 7: What effect does training in research

 

have on the way clinical psychologjsts do psychotherapy?

Nine scales (Scales 61-69), were devised to respond

to this question. These scales concerned:

a) The respondents' view of the relevance of their
research experiences in graduate school to a
variety of present day clinical activities such as
testing, therapy, consultation, and research.

b) An overall assessment of their graduate school
research experiences.

c) Attitudes toward the role of research in the
work-life of psychotherapists.

These scales are shown in Appendix 8, pp. 185-186.

Question 8: Are clinicalypsychologists satisfied with

 

their research training?
Five scales (Scales 70-74), were devised to respond

to this question. They were designed to address the degree

70

to which the respondents viewed their research training
as:
a) relevant to their clinical training.
b) satisfactory as training in research methodology.
c) important to their professional identities as
psychologists.

These scales are shown in Appendix B, p. 187.

CHAPTER III
RESULTS
I. Descriptive Characteristics of The Study Sample

As was noted in Chapter 2, respondents in the present
study are 35 licensed clinical psychologists from the
Washington, D.C. metropolitan area. Demographic data
concerning aspects of their professional backgrounds and

current activities are summarized in Table 1 below.

 

Insert Table 1 About Here

 

As Table 1 indicates, the present sample consists
largely of a group of experienced male and female
psychotherapists who spend the majority (76%) of their
working time in the practice of psychotherapy. By far the
largest portion of the respondents' professional time is
spent in the practice of individual psychotherapy (56%).
The percentage of their time that they spend doing group,
family, and marital therapy combined adds up to about 20%
of their total professional working hours and about-26% of
their psychotherapeutic practice.

71

72

 

~.mu.o.m ~.mnm..wpuz eegmvpeem e>eg es: mueennem so»;

Am_pee ecege .mewpppnv :ewuecumpcweee we maze:
mcwupemcee ee mcee:
mcpumeu e_umecmepe we mcee:
mceee me cewmw>cee=m ye muse:
muceeeum we =e_mp>cee:m we maze:
Awpem gee .e_eev :ewmw>cee=m we mcee:
. . Amway soceemec we mcee:
mcwgeeee we muse:

Apeuwcesv Leguo

anecoguezezme szEeu

meeceguesexme eeeco

xeeceguegeame Fe:e_>wecm
AFeueav xeecmguezeame ee mcee:
Amcees peueuv xeez\xgez emece><

Aeewemwuem ace>ue .eewwm_uem== xge>ufiv

xeecesu Pecemcee sue: ce_ueemmpuem
hencenu Fecemeee cw meme» we geese: peuep
Aemumq meagegu pecemcee :_ mes?» ve ceasez
«meewueewpnee ee geesez
umpeeceguegexme e we meme»
.o.ge ee:_m mcem>
em<

O
Hc—cmMN
O

o o o o o O o o
mqumm'l-Ufi
o o o o o o o o o
NHH

SOSDQNLONNNNNkDMQ'
I‘m

HLOTNNNLDQ’mO‘OOQ'l-Om
O

CONN

O I O O
munch—1d-
O

O
WMMNNIOM ONONNH

d'u-cr-i

mooowmtxm N‘DMO‘NNNQNmQMr-id'
O

I
I
acetone-aux

 

 

 

 

we?» pecewm om
-meeece we .1
a .xeceee Ame-es mg mmmFeEew NHV mmuz

|><

erasem xeeum es» ee wepumwceueecezu e>wue_cemeo

H e_nap

73

Other professional activities, aside from psychotherapy
are minimal; these include teaching (2%), research (2%),
personal supervision for the therapist (4%), supervision of
students (2%), diagnostic testing (6%), consultation (3%)
and administrative tasks such as billing, making and
returning telephone calls, etc. (4%).

Respondents have had their Ph.D's an average of more
than l3 years and have practiced psychotherapy for roughly
the same number of years. Half of them have published in
the professional literature since completing their Ph.D.‘s
(NslB) Among those who have published, the average number
of publications is 5.7.

All but one of the respondents have been in
psychotherapy at least once, and the average number of
courses of psychotherapy per person is 2.2. The mean
combined number of years spent in therapy is 5.7 years per
person. Respondents were asked to rate the degree to which
they believed the therapy they had received was successful.
This rating was done on a 4 point scale ranging from very
unsuccessful (a rating of l) to very successful (a rating
of 4). The average rating was 3.3, indicating that
overall, these therapists rate their personal psychotherapy
experiences as having been moderately to very successful.

One purpose of the present study was to investigate

whether, or to what degree, such characteristics as gender,

74

experience level, type of therapeutic practice, research
involvement and publication history were related to the way
therapists viewed their work. Accordingly, more detailed
attention was paid to these variables; this information is
presented in Table 2 below. Table 2 presents means and
standard deviations on these variables for the total
sample, and is also broken down into a variety of
subcategories. A correlation matrix showing the degree to
which these variables are interrelated can be found in

Appendix C, p. 194.

 

Insert Table 2 About Here

 

As is apparent from an inspection of these data, the
present group is generally quite homogeneous. The only
variables that are significantly correlated are those
related to the males in the sample's somewhat greater
average age (x=47.7 for males, x=42.l for females).

Gender (i.e., in the present data, being female, since this
was scored 2, while being male was scored 1) is negatively
correlated with age (£=-.37, p<.05); and with experience
level (£=-.49, p<.02): experience level and age are also
significantly related. (3:.54, p<.02). As was indicated

earlier, both males and females earned their Ph.D's at an

75

 

 

 

 

 

 

 

 

1 1 ~.H mm. m.w m.e~ m.w o.¢~ o.w m.oe m m NH e:
N.@ w.m H.~ om.“ m.oH e.m~ w.w w.- w.e m.me m m mg we» sew—nee
m.¢ ~.~ 1 1 m.m e.m~ m.o o.m~ m.w m.¢¢ m” HH ow e:
m.w H.m m.~ H.m m.Hfi e.m~ ¢.m e.¢H w.- m.me w w m we» neceemec
m.m w.m ~.~ oH.H w.m m.m~ o.w e.e~ ~.o~ ~.ee w ea w" va amecegpegexwm
~.e ~.~ N.H mm. w.m o.mm m.o ¢.NH e.w w.m¢ o~ m mH wNA xeez\mc=e;
o.w c.e o.H e. o.m w.o~ m.~ m.w m.~ m.o¢ efi m mH va .o.;e
m.~ e.“ ~.~ mm.~ ~.oH m.m~ w.m m.e~ e.~ e.om m mH oH mpA eecwm meme»
o.H e.H o.~ m. ~.e o.m~ m.m m.oH m.m H.~e NH 1 NH epeeew
m.o e.¢ N.N m.H e.m m.e~ m.w ~.m~ m.m ~.we 1 ma m“ ewes xem
m.m m.~ ew.H w. m.m m.- e.w m.mH w.m me NH mH mm eweEem Peuew
cm N am N am m. mm m. cm H a. 2 ~33
meow» gegeemeg menses» e.ge eecwm em< xem
1eewwneew xeez\mc=ez 1eseame we meme»
xee3\mc=e:

 

 

 

 

 

 

 

.ageumw; cewueewpeee use .apw>wuee guceemeg .zeeceguesexme we xee: gee meson

.we>e— eecewceexe .ceeeem we ezee :exegm

"epesem weepm Pepe» egw we mewumwceueecego ewgeecmeseo

N owns»

76

an average age of 32. The greater average age of the men
is thus also reflected in their having their Ph.D.‘s for a
longer time.

With regard to the remaining descriptive variables,
there were no other significant correlations. Thus, for
this group of psychologists, the demographic variables are
not interrelated in any substantial way. There are no
significant relationships between demographic variables and
characteristics such as publishing or not publishing, doing
or not doing research, working full-time or part-time as a
psychotherapist.

II. Researchyguestions

As was discussed in Chapter II, the basic data for this
study consists of ratings of the 35 interview transcripts
on 74 relevant Likert-type scales, and utilization of a
Q-Sorted set of statements that also quantified the inter-
view findings. The research questions are listed below in
Table 3, along with the measures designed to address each
one. Two raters rated each measure (scale, Q-Sort):
Ratings were then pooled to obtain a respondent's score.
Interrater reliabilities for the scales related to each
research question are reported in Table 3 along with the
overall interrater reliabilities. Coefficient Alpha was
the statistic calculated to indicate reliability (Hunter,

1977, p. 103).

77

 

Insert Table 3 About Here

 

As Table 3 indicates, interrater reliability for the
entire set of 74 Likert-type scales was .86 and for the
Q-Sort, .77. Interrater reliabilities above .75 were
considered acceptable; all but one of the measures exceeded
this criterion. Thus, overall reliabilities are quite

acceptable.

This study is in two parts. One part examines the role
of uncertainty in the professional lives of the therapists
interviewed. The other part examines the role of research
in their professional lives. Four questions address each
of these parts of the study. Both the Likert scales and
the Q- Sort involved in scaling these questions were
subjected to confirmatory factor (cluster) analysis
(Hunter, l977), as a way Of simplifying and reducing the
large number of scales and items that deal with each
research question. Two sets of cluster analyses were
performed. The first such analysis was of the
Likert-scales. The Likert scales designed to address each

research question were submitted in the initial analysis.

8
7

Nu.

om.
um.
um.

mm.

cw.

xomo1o

v~1H
¢w1ow
mm1Hm

oo1mm

Nm1om

N ece w mcewumeee ceezuen
mewcmcewuewec xe nemmeceee

mu.

em.

 

ngmw<e
sewp_n~__mm
ceueg1cmucw

m¢1mm

mm1~

moweem

wheecmgeeceame we xucweuceece ex» ea mcewueeec .mumwmewezeame weewcw_e
eewem gem: cw newceeguz Le mcewuwmeemweege .mewewecwge awoeu peg:

.N

 

mewaem etmxwu we Newpwnmwwet came Fwatm>e

wmcwcwece neceemec ewes» new: eewwmweem mumwmeweseame weewcwwe ec<

exeecozaecexme ee memwmewegexme weewcwwe
we: one so e>es zeceemeg cw mcwcwecu meee Axce wwv uuewwe peg:

emewuw>weee geceemec ewes» ecu weewcwwo
ewes“ ceezuen eeceweasw on» e>wemec mumwmewegezme weewcwwe ee 3e:

wpeeuewwwcee me megewwe geceemec ewes» ecu _eewcwwo
cwezu ceezuee eeceweaew as» eecewceexe mumwmewegexme peewcwwe eo

wxcez ewes»
cw mewecweuceece ecu 3ew> awewewwexe mumwmewezexme weewcwwe ee 2e:

weeeeeee nee .eeewcgeeu .xgeezu cw speweugeece ea euewec Jae:
ewes» cw eecewceexe mumwuewegexwe Feewcwwo was» meesewwe es» ee 3e:

exec: ewueeeegezu Ewes» cw eecewgee
1xe mumwmepesexwe peewcwwe ee Ameeweece Lev messewwe we mouse peg:

.w

.m

.H

 

mcewumeed geceemem

mmcemeez emegw sew mmwuwwwnewpea seueg1ceac~ :eez ecu
mcewumeeo zeceemem ucecewwwo es» e» neweceemeggeu memnEez eweem

m m—neh

79

Scales that failed to meet the criteria for inclusion in
the clusters were placed in a residual cluster. The
analysis was repeated until clusters were formed that best
met internal and external statistical criteria as well as
the criterion of homogeneity in content. Cluster analysis
was also performed on the entire set of Q-deck ratings
(Hunter, l977). The clusters that were formed in these
analyses and their interrelationships form the basis for
this discussion. The four questions that address the issue

of uncertainty will be discussed first.

Question l: What types of problems or dilemmas do
clinical psychologists experience in their therapeutic
neck}.

The scales originally designed to respond to this
question were Likert scales l-38 (scales 34-38 were added
at the suggestion of the raters). Cluster analysis of
these scales yielded 6 clusters that summarize the content
domain assessed by these scales. The cluster names, along
with sample high loaded items, are shown in Table 4. To
distinguish these clusters from the later analyses they are

identified by Roman numerals.

 

Insert Table 4 About Here

 

80

Table 4

Sample (High Loading) Scales from Likert Problem Clusters I-VI

 

 

Scale loading in cluster
Cluster I: Personal vs. Professional Life
30 How to keep occupational stress from .79
spilling over into personal life
31 How to balance the needs of patients .79
against those of family members and/or
friends

Cluster II: Concern about earning fees
15 Whether the therapist really earns the .78
fees patients pay

33 Saving time for reduced fee patients .78

Cluster III: Uncertainty about technique
17 About specific mistakes the therapist has .94
made or tends to make in therapy

48 The way to deal with uncertainty is to seek .80
supervision

Cluster IV: Self-Disclosure
13 How much of the therapist's own history .97
and current life situation to reveal
to patients

14 How to answer questions about the .97
therapists' history and current life
situation

Cluster V: Ethical Concerns
8 How to deal with feelings of dislike or .83
contempt for a patient

34 About the therapist's own ethical standards .70

Cluster VI: Concern about lack of therapeutic
theory and guidelines
26 lAbout the absence of a generally accepted . .85
theory of psychotherapy

27 About the absence of clear technical .85
guidelines for doing therapy

81

The clusters form a continuum ranging from those
general to all professions on the one end, to those
specific to psychotherapy on the other. They are numbered
and will be discussed in that order beginning with the
clusters that describe problems or dilemmas that are
generally characteristic for professionals.

1. (Cluster I) Personal Life vs. Professional Life

This cluster consisted of two scales. One of them
referred to the difficulty of balancing the demands Of
professional life against those of family and friends. The
other scale referred to therapist concerns about how to
keep occupational stress from spilling over into personal
life. These scales belong at the "general" end of the
continuum because they are not unique to psychotherapists.
They reflect concerns to which anyone in a demanding
occupation might be susceptible. The majority of the
people studied in this project were rated as somewhat
concerned about this issue. These scales, along with their
mean ratings and standard deviations are present in Table

5.

 

Insert Table 5 About Here

82

eoeceoceece zge>uoH meecceeceu age>um ”eweem

 

 

mu.
mw.

mew
1eeew

 

m.H
m.H

om

m.m
m.¢

 

x

mecewcw
Le\e=e memesee awwEew we omega umcweme mucewuee we meme: ecu eecewea ea 2e; ueen< am
eww— weeemeee eucw ce>e mcwwwwem secw mmecum wecewueeeeee eeex e» 3e; ueen< om

neweem

 

ewwe wecewmmewece ecu wecemgee ceezpem

:ewueceeem we» ueee< mcgeeeeu unweegegw ea eeuewem meweem ugexwe "H cepmepu

m ownew

83

2. (Cluster II) Concern about earning fees.

This cluster too consisted of two scales, and it also
belongs on the more general end of the continuum. One
scale referred to therapists' concern over whether they
were earning the fees paid to them by patients. The other
scale referred to therapists' concern over whether they had
reserved enough time to see patients unable to pay their
full fees. These scales, like the ones referring to the
separation between personal and professional life, reflect
concerns that are not at all unique to psychotherapists.
Concerns about earning fees or reserving time for
reduced-fee clients exist to some degree in professions
'that are practiced in a context of greater relative
certainty. Lawyers, physicians and other professionals
certainly share such concerns at times. This cluster,

al<3ng with the scale means and standard deviations, is

Presented in Table 6.

Insert Table 6 About Here

Mean scores on the individual scales indicate that as a
QFCJUp, the psychologists in the present sample tended to be
somewhat unconcerned about these issues as applied to them.
Feflhale therapists did tend to be less concerned about this

lSSlle than male therapists however. This is indicated by

84

eecgeeceece >ge>uo~ meecgeecee age>u~ "eweem

 

 

ms.

mew

neeow

 

am

 

|x

mm

 

mucewuee eew1eee=eec Lew mew» ecw>em ueee< mm
sauces“ cow exee acewuee ems» wages egg mewccee aw—eec mw pmweecegp age cenuegz ma

me—eem

eeccem aw—eem ec< weed League: peen< mcgeeeeu unweegegw e» empowem meweem acexwe ufiH Levee—u

o ownew

85

the significant correlation (p =-.38, p<.05) between gender
and concern about whether fees are earned.

3. (Cluster III) Uncertainty in technique

This cluster consists of four scales. Unlike the two
preceeding clusters, this one is somewhat more specific to
professional uncertainty as it refers to psychotherapy.
The four scales that make up this cluster address two areas
of uncertainty (uncertainty about issues of therapeutic
technique and uncertainty about the status of psychologists
as compared to other mental health professionals) and one
rnethod for dealing with uncertainty (i.e. supervision).
‘The issue of clinical psychologists' concern over status is
riot obviously related to uncertainty. Its correlation with
scales more clearly linked to competence issues reflects
tlie concern or lack of concern that psychologists have
at>out their comparative status in the mental health
Prwofessions. This cluster along with item means and
stzandard deviations is presented in Table 7. Scores
gernerated by the sample generally indicate that these

Psychologists were somewhat concerned about these issues.

 

Insert Table 7 About Here

ewemwgeueecegece xge>uowmewumwceueecege xge>u~ we
eecceeceece >ge>uow meecceeeeo aue>u~ mm .w— .0“ ”meweem

m cewumeee seceemec ea eceemeg e» eecmwmee xwpecwmwcea

 

86

 

em. w.~ m.e auwweee ge emcee eueeeeee we one wwwwxm weewczeeu m.umweecegu one ceseezz ow
mm. o.H N.¢ mpecewmmewece
sewee; Pawnee emcee ea emceeeee me mpmwmewesemme weewcwwe we meueum ezu unee< mm
ow. H.N w.m :ewmw>cee=m xeem eu mw seaweuceoce new: ween ea he: mew mew
em. m.~ m.e xeecezu cw exee ea mace» Le meme me; umweeeege use mexeumwe ewwweeem usee< wH
mew meweem
1eeew om .m

 

 

 

eeewezoew cw aucweugeoca neen< cemeceo umweecmcw ea eeaepem meweem ucewa ”www cmpmepu

w ownew

87

4. (Cluster IV) Self-Disclosure

This cluster is made up of 2 scales both of which refer
to therapists' concern over how much of their own lives to
reveal to patients. One scale refers to the issue of how
much information therapists should reveal about their own
lives. The other scale refers to how to answer clients'
questions about the therapist's own history and current
life situation. Because of the content of these scales,
the cluster is described as having to do with issues of
self- disclosure. This cluster along with item means and

standard deviations is presented in Table 8.

 

Insert Table 8 About Here

 

An examination of the scale means indicates that these
tlierapists on the whole tended to be slightly unconcerned
at>out this issue.

5. (Cluster V) Ethical Concerns

The eleven scales that comprise this cluster touch upon
scaveral different issues of particular salience in psycho-
ttierapy. These scales are described as having to do with
etl1ical issues because they touch upon such questions of
l'mpulse control as how to deal with sexual, aggressive or
dissapproving feelings toward patients. In addition to
theese issues, this cluster touches upon more clearly ethi-

cal concerns such as therapists' doubts about their own

88

eecceeceece age>uofi meeeceecee xge>u~ "eweem

 

Na.
so.

new
1eee_

 

 

m.~ o.m cewueeuwm ewww ececcee ece xgeemw; m.umweecegu on» ueeee meewumeee cezmce ea :e: «H
m.~ w.m awwceucewe> mucewuee e»
wee>eg e» :ewueeuwm ewww aceccee wee xgeamw; cze m.pmweece;u use we sees 3e: mH
me—eem
om .m

 

 

enemewemwc1wwem ueen< mcgeeeeu unweecegw e» eeuewem moweem “cmwa ">H Leumewo
m ownew

89

ethical standards and concerns about the possibility of
malpractice suits. Mean ratings on these scales show that
this sample was rated as slightly concerned about these
issues.

This cluster also included scales that deal with uncer-
tainty about outcome in psychotherapy and the difficulties
of working with specific categories of patients. Mean rat-
ings on these scales show that this sample was rated as
somewhat concerned about these issues. This cluster is
presented along with scale means and standard deviations in

Table 9.

 

Insert Table 9 About Here

 

6. (Cluster VI) Concern About Lack of Therapeutic
Theory and Guidelines

The final cluster - and the one most specific to
psychotherapy - concerns the absence of clear and univers-
ally accepted guidelines in theory or technique of psycho-
therapy. This cluster consists Of two scales, one refer-
ring to uncertainty in theory; the other referring to
uncertainty in technique. Specifically, the scales refer
to therapists' concern over the lack of clear guidelines in

these areas. Because the therapists' concern in these

9O

eecceeceeee xge>uo—meecceeceo >ge>u~ "eweem

.weueewwec we: age exemm memo: .eepmeww cw cewmewmmw1cew weueewwec mewaewme>a

 

 

 

o
HHv—OHO—Iv—Io—Oc—t

mm
QUINONO¢N¢H
O

N
C 9
U) H

wewmme

Q' GOSSDQ’Q’CDHNOND
0
L0 mmmmemmcd-m

mucewuee we newcomeuee ewww

 

 

|x

meemmw weewgum usee< :Leeceu umweecegw on

0 «yeah

meewuee eewueecewee we xewwwnwmmee en» peee< em
eeewuee e ecezeu Lemee sew: peee e» 3e; ueen< mm
eeem seen me; xeecegu segues: mewELeuee ea :e: N «
eeuecweceu en eweegm saucegu can: zecx on :e: w

umweecegu mg» on cewueecuue weexem m.ucewuee e guwz ween ea :e: w

eeem saw: mcwxgez cw emwce page meeweece peee< ma

meceeeeum weewgue :ze m.amweece;u on» geese mcceeceu em
wees we; ecewuee ecu :ewmweee e we me>eceeemwe amweecezu egg ww ee ea pen: a

mueewuee e» cewueecuue weexem sew: weee ea :e: o
cw

ee>we>=w mw “cewuee e ewzmcewuepec e we me>eceeemwe emweecegu on» ww ee ea peg: ow
ueewuee e cow weeeucee ce exw—mwe we mmew—eew sew: Feet eu :e: m

meweum

eeee_me me_aem ecmxwe u> Leem=_e

91

scales is about issues concerning psychotherapy as a
profession, this cluster is placed at the extreme
"specific" end of the continuum. This cluster, along with
scale means and standard deviations is presented in Table
10. Mean scores show that on the whole, the respondents

tended to be slightly unconcerned about this issue.

 

Insert Table 10 About Here

 

The relationships among these problem clusters and
between these clusters and the demographic variables were
correlated. This matrix is presented in Appendix C, p.
194.. Correlations were computed in order to determine the
degree to which the problem clusters related to question l
were inter-related. In addition, correlations between
these problem clusters and the demographic variables were
done to examine possible demographic differences in degree
of concern over these areas. The significant relationships
are discussed below and are depicted in Figure l. .The
figure is a heuristic device, utilized here to chart the

degree of common relationship among the variables.

92

eoeceeceece xge>uowmee=ceecee wge>u~ “eweem

 

mm.

mew
1eeew

w.H e.m neececu mcwee Lew mecwweewsm weoweseeu Leewe we eecemne egg ueen< wm
¢.H m.m aneceguegexme we seems» eeueeeee zwwececmm e we eeeemne one ueen< om

meweem
am x

meewweeweo use aceecw
ewueeeecegw we xeee ueen< :ceeceu umweegmgw ea eeuewem meweem ugewa uw> Leumewo

o— ownew

93

 

Insert Figure l About Here

 

One way of viewing these overall relationships is to
note that they form two interlocking triads. One of these
sets of interconnections links concern about issues of
boundary maintenance (such as separating personal vs.
professional life, and issues of self-disclosure) with
concern about the lack of therapeutic theory and guidelines
in psychotherapy. The other set of relationships involves
a linkage of concerns about technical errors (i.e.,
uncertainty in technique) ethical concerns, and concern
about the lack of therapeutic theory and guidelines in
psychotherapy.

Figure 1 shows that high uncertainty in technique is
linked to having more ethical concerns, more concerns about
self-disclosure and greater concern about the lack of
therapeutic theory and guidelines. Uncertainty in
technique is also linked to gender (i.e. to femaleness) and
to a record of having published. Conversely, low
uncertainty in technique is linked to lower ethical
concerns, lower concerns about self-disclosure, lower
concerns over the lack of therapeutic theory and
guidelines, maleness, and the lack of a publication record.

This suggests that for this sample of psychologists,

94.

 

 

 

 

 

 

 

 

 

 

 

 

 

Ne.u_ a ..

 

 

 

me.v a.
Aamm.n n My
a... W 0—8 a+ n fl—930bv
meow aewecee.11111111111111111 smegma \\\
o / ..l. ,\\ it
.71 Awe—m.+uc. .x. Reamc.wuc.
/.// \\
//
eme maewcgueu e. seaweucouea -JweenW111- :1111111- mzcmezee _eewzee
. .——— Arc—m n .5 .
\\\ >
2:31.: \ 2...... .
«mew—eewam use accuse Accov. n uv
e_eeeeecmzu we xee_ geese.:coe=ee
._> 1
Aaaev. u 5. manna—unwe1w—Om .>_ A on. www111 ew__ _ecewmmewece .m) .ezemgo;
a .. .
AacmtJ. n My

mem_ee_egesaa .aw.=..e anew meese_.e on. go

 

weecogueguame we
see: cue muse:

.mcoumapu acuxwa. gee: swash :— meow

.2 ea ea mewse: mocameez seams—u use no.9ewce> ewzeecmeeeo geezeem memex=_e eewee_eaeee

_ etae.a

_

95

females, and respondents who have published may be more
concerned than others about issues of uncertainty in
therapeutic technique. This also suggests that such issues
as ethical concerns and concerns about-self-disclosure may
be specific examples of uncertainty about technique.

High concern about the lack of therapeutic theory and
guidelines was linked to concern about self-disclosure
uncertainty in technique, lack of experience (as reflected
by age), and having published. Conversely, low concern
about the lack of therapeutic theory and guidelines was
linked to low concern about self-disclosure, low concern
1about uncertainty in technique, a higher degree of
(experience, and the lack of a publication record. These
.associations indicate more generally that uncertainty, with
r~egard to both specific matters of technique and a general
'lack of guidelines, are important concerns for subgroups of
tliis sample. Specifically, therapists who are less
eatperienced as might be expected, and therapists who have
[Dublished. It may be that some therapists are more
ccnnitted to publishing as a way Of dealing with their
uru:ertainties. Conversely, these therapists may be more
aware of areas of uncertainty because of their efforts to
clarify in writing, issues of importance to them. By the

same token, greater certainty may be associated with

96

non-publishers because these therapists may be less
troubled by uncertainty and therefore less driven to seek
clarification. Conversely, therapists who do not publish
may refrain from undertaking tasks such as publication that
might require them to examine their assumptions more
closely. Although these data do not resolve this issue,
they do suggest that it would be worth more detailed
examination.

High concern about self-disclosure was linked to
uncertainty in technique, concern about the lack of
therapeutic theory and guidelines, concern about the
separation between personal and professional life, and to a
heavy case load (as reflected in the number of hours per
week spent doing psychotherapy). Conversely, low concern
about self-disclosure was linked to less concern about
uncertainty in technique, less concern about the lack of
therapeutic theory and guidelines, less concern about the
separation between personal and professional life, and a
lighter case load. These correlations suggest that issues
of boundary maintenance are of greater concern to
therapists who spend more of their time seeing patients.
Conversely, therapists who spend less time seeing patients
seem less concerned about maintaining the separation
between their personal and professional lives. As was

noted earlier, issues of uncertainty, both technical and

97

more general, were also linked to concerns about boundary
maintenance.

Concern about earning fees is associated with being
male. Conversely, less concern about earning fees is
associated with being female. These associations suggest
possible sex-role related differences in concerns about
money. The females' lesser concern about whether they were
really earning the fees paid them may reflect the point of
view of women who, having traditionally been denied access
to professions may feel especially competent by virtue of
having attained professional status. Conversely, males may
be more open to doubts about the worth of their work.

Question 2: What tacit principles, predispositions or
"theories in use" guide clinical psychologists' reactions

pp the uncertainty of psychotherapy?

 

A form of this question that is more realistically
answerable is:
What principles, predispositions, or tacit "theories
in use" guide clinical psychologists' approaches to
psychotherapy? Are these predispositions related to
uncertainty in psychotherapy?
The Q-Sort method was used to quantify the therapists'
responses to this question. The item ratings, pooled over

the two raters, were also subjected to cluster analysis.

98

Six clusters were formed in this analysis. The clusters
are summarized and sample statements are presented in Table

11.

 

Insert Table l1 About Here

 

To enable these clusters to be more easily differentiated
from the Likert clusters discussed above, the Q-Sort
clusters are designated by Arabic numberals.

These 6 clusters are described below.

l. Cluster l: Psychodynamic vs. Eclectic Approach

 

This cluster consists of 19 items that address the
degree to which subjects adhere or do not adhere to views
about psychotherapy that can be described as basically
psychodynamic as compared to basically eclectic in
approach. The reflected items in particular, dealt with a
'dimension of rejection vs. acceptance of behaviors and
ideas inconsistant with a psychodynamic orientation. This
cluster, along with item means and standard deviations, is

presented in Table l2.

 

Insert Table l2 About Here

 

Means ratings of items in this cluster indicate that
those reflecting a basically psychodynamic orientation were

rated as most salient for this sample of therapists. Items

99

Table 11

Cluster Names and Sample High Loaded Q-Sort Items
Responding to Question 2

Q-Sort Item Number loading in cluster

Cluster 1:' Psychodynamic vs. Eclectic
*18 Psychoanalysis is still the best .85
therapeutic approach

*64 Psychoanalysis is outmoded .79

lgluster 2: Uncertainty, Self doubt
27 Regardles of Who the patient is, a good .78
therapist is a good therapist

13 A therapist can never be free from .80
self-doubt

Cluster 3: Personalization of Therppy
*83 'TEErapists should be able to take from .82
their patients as well as give

77 Therapists should be careful to keep .79
their own needs outside of therapy

Cluster 4: Research Mindedness
31 Research training helps psychOlOgists to .95
think critically

*32 Alot of therapists don't know what .89
they're doing

Cluster 5: Perceived Patient Demands
69 Patients are easy to please .86

* 8 Therapists have to be very patient people .69
Cluster 6: Therapy as inspiration

*691 Talking to colleagues is helpful, it just .78
helps to have someone to talk to

 

89 A therapist should always get supervision .73
no matter how experienced he/she is

*Item reflected in order to fit cluster

100

eecewwee

_

ill

sew; zo_
e. 1 N

u eweem

.eeueewwec uec ece c:emm mcemz, .ceummwe cw cewmewecw Lew eeueewwec meweewcepm

 

 

 

toe- VNNQ‘MwamNNMMr-OLONM
0
cm mMNMNMMMMNMQNMQ'mm

O
(I)

 

ooooooo
HHH

000000
0-. v-IO—O

v—O

mix MMO‘NQ’NNHNHLOLDMNQOO‘
0
mm: ”OOMMQNHNGNQMHCDN

P‘

 

meeewcceee emeuew ecu cew: mcwuceewceexe en exe:we ewcecm mumweececw
xeecece mcwee cow sce:eEecw weewueceece ucececee e e>ec eweecm neweececu <
mucewuee ea =e>wm= e» memweececu cew xe: e mw me>ww c:e cwece ueene mcwxpew
weecece we eewmuee cew>ecee m .ucewuee ecu ce meeew eu eceeceeew mw a“
uce>eweccw awweewmee ew ucmwmcw

xeecece we meecuee =e=cu ece eewcug ecu e» xewum eweecm mHMweececw
mucewuee eu euw>ee e>wm ea umweececu e cew euewceeceeecw mw aw

eumweecece ece ececu me gmeweececug sees me ece ececw

wdecece we =—eecem= weewceemewwce e ea ecewea e» uceuceeew mw pH

ewueewee ea ea mumweecece cew amen ew pH

cewmw>cee=m mw eumweececu cow eecewceexe mcwcwecu uceuceeew ewes ecw

emwe mcwcuxce cecu ewcmecewcw exww ecee mw zeececw

wdececu mcwee cw wewewec uec mw aceecu ewEecxeecOAme

xeececuecexme we aceecu weweme ewes ecu mw wgeecu ewEecxeecexme

eeceumwmec m.uceweee ecu mw ceweeecewcw we eeceem amen m.umweececu ecw
xeececu wewmmeeeem ea xex ecu ew eececewmcecu ecu new: mcwxcez

aw mcwee

ece so» we: :ecx co» me mcep me xexe mw adececuecexme cw ee 3e» ecwcuAc<
eeee5u=e ew mwmaweceecexme

ceeeceee ewuceeececu amen ecu _wwem ew ewexweceecexme

wne
mm
Nat
owe
mm:
om
em
amt
an
n «
mm
mm«
Hm:
mm
mm
we

wme
«we
wH

 

mceee xeee1e

cewueacewco uwueepew .m> ewEecxeeceame "a ceumepo acem1o

NH e—new

101

reflecting rejection of a psychodynamic approach were rated
as negatively salient for this sample.

2. Cluster 2: Uncertainty,ySelf-Doubt

 

This cluster consists of l5 items that refer to
feelings of uncertainty or self-doubt, as well as a
generally relativistic stance toward psychotherapy. This
cluster is more problematic than others because the
interrater reliability for the statements in this cluster
is only .54. The low reliability indicates that the two
raters were in disagreement with each other when assigning
values to these statements. Consequently, the cluster is
more difficult to interpret: the mean ratings for each
_statement are skewed toward neutrality by the two sets of
ratings cancelling each other out. Even with this effect
these statements were rated overall as fairly salient for
the present group. This cluster, along with item means and

standard deviations is presented in Table l3.

 

Insert Table l3 About Here

 

eecew_em

T

1111

saw; :ew
wH. 1 N nepeom

.weeuemwwec eec ece c:ecm eceez .ceumewe cw cmwmewecw Lew eeuee—wec meweewce>«

 

O O
O O
O‘HNMOOS@HO\NHNO@O\

HHHO—O

102

0
HF.

MVMMQ’NMMMMHMNHM

H

Hemoooomooommommxo
NQCMQNO‘ONNQOONQ

D
U)

 

 

 

 

ucmceu ece eecwewexe en ce uecu _wwxm e mw heececw mm:
Ndececu we ucee uceuceeew ce mw mmec—ewaewe N «
ewcwmceemec ece unweececu ece eceweee cuee .mwwew weececu cec: Hm
Neececu we eeeeuee ecu cuw: eewwmwuem _eew xwwecme eumweececw wee
aueweem cw ceeuen cw uww epeeee mewec weececp wewmeeeeem we;
eecewem e uec .ece ce mw xeececw em
cewuece—exe mewwee aw .meeece weewmee wees—e ce mw Neecece m
emwe eceeeem cew unweecece xmeew e en cee cemcee ece cew ueweecece eeem < mm
me>wemeece eecw cone eee ueeexe meeweececw em
eceweee we ecwx Nce umeewe cew: gee: cee umweececu eecwecu wwe: < MNk
exec: meececueceAme :ec m:ecx apweec ece ez me
aucweuceece we pew e eeecepeu ea e—ee en e» e>ec sex unweececu eeee e ec ew NN
neweecece ceee e checece mw gee: cec\mwc ueeee cweeceecc mw ec: unweecece < er
ueeee1wwem eecw eecw en ce>ec cee umweececp < ma
Heweecece eeem e mw neweececu eeea e .mw ecewuee ecu ec: we mmewecemea NNe

 

eceec xeee1e
uneee1wwem .mpcweuceeca "N ceumewu acem1o
mH eweew

103

3. Cluster 3: Personalization of Psychotherapy

Cluster 3 consists of 8 statements that refer to
therapists' orientations toward the place of their own
needs in psychotherapy. These statements reflect an
acceptance Of the gratification of the therapists' needs in
therapy. They reflect a view of therapy as in many
reSpects akin to friendship. This cluster, along with item
means and standard deviations is presented in Table 14. An
examination of the item means for this cluster indicate
that these items were rated as somewhat negatively salient

for this group as a whole.

 

Insert Table 14 About here

 

4. Cluster 4: Research Mindedness.

Cluster 4 consists of 6 items that generally reflect a
set of values favorable to research as useful in develOping
the ability to think critically and make use of the
professional literature. This is coupled with a positive
view of the value Of research training and skepticism
concerning the skills of colleagues. This cluster, along
with item means and standard deviations is presented in
Table 15. An examination of the item means indicates that
Inost of these statements were rated as essentially neutral

For this sample. The importance of flexibility as a

eecewpem

w

1

new; :e_
NH . 1 N emcec

.eeueewwec uec ece c:ecm eceez .ceumewe cw cewmewecw cew eeeeewwec mewcewce>«

 

v-O

104

NMMMVQ’HN
...-Q

OONVO‘C‘OLON

mcvath-a
NMNDNNNwm

D
U)

 

 

 

 

cewmmewece Nce cece eweewwwwe awweewcue ecee ec mw weececeecexmc mac

mucewuee ce wee—e> cwece emeeew mumweececu .eu uec ace sec“ cec: ce>u me
eceueewcee uec ece Nee» uecu ueew ece ueeeee e» eumweececu cew uceuceeew mw aw HNe
meewu _we we mecewuee sew: umecec ea e» uceuceeew ew pa Nm

muceweee cwecu ewe; ce coco» eu eecw weew ewcecm mueweececw em

heececu we eewmuee meeec c:e cwecu eeex e» mumweececu cew e—nwmmeeew mw pH mm
aeececu we eewmeee meeec c:e cwecu eeex eu Fewecee en eweecm memweececw wsa

e>wm me wwe: we meceweec cwece eecw exee e» ewce en eweecm memweececw mm

 

eceew xeee1e

meececw we cewueuwwecemcee um ceumewo ecem1o

ea apnew

105

characteristic of therapists was rated as somewhat salient
for this sample. A rejection of the research literature as
helpful to therapists was rated as negatively salient for
this sample. In other words, this sample was rated as

finding the research literature useful.

 

Insert Table 15 About Here

 

5. Cluster 5: Perceived Patient Demands

Cluster 5 consists of 5 items that refer to
difficulties in meeting the expectations of patients and
the general public. This cluster, along with item means
and standard deviations is presented in Table 16. An
examination of these scores shows that for this sample, the
belief that patients are easy to please was negatively
salient as was the view that therapy should be terminated
when its initial goals have been reached. The view that
therapists have to be very patient people was rated as

salient for this sample.

 

Insert Table 16 About Here

 

eecewwem

_

{I

5.2 :2
a .. N

eacec

.eeueepwec uec ece c:ecm ecee: .ceemewe cw cewmewecw cew eeueewwec me-cewce>«

 

106

HmchN

0-0

HtOMOQ'LO
c—i

 

 

 

 

 

e>ec cee Heweececu e mewumwceueecece uceuceeew ewes ecu we ece mw auwwwewxewc om
wewewec ace> eceeeceeww wecewemewece ecu ecww xwpeeme u.cee memwcececw wme

ace: cwecu eceemceece mumwmewecexme mewec mcwcwecu ceceemea om
mumweececu ea ecwe> eweeww we aweueewepc mw mcwcwece ceceemem Nee

eccoe ec.cece Sec: 30:: e.cee memwcecece we eow< em

a—weewewce xcwc» ea muewmewecezme mepec.mcwcwece ceceeeem Hm

2e: xeeee

mmeceeecwz ceceemem "e ceemcwu ucem1o

ma e—neh

107

eecewwem

w

11

new; :ew
NH 1 N emcec

.eeueewwec uec ece c:ecm eceez .ceemewe cw cewmewecw cew eepeewwec mewnewce>«

 

 

 

 

 

mumweececa eecw cues eee ueeexe eweeec o

eeceeec ceee e>ec mweem wewuwcw new cec: eeuecwece» en epeecm xeececw ewe
acmce ece Neg» cec: macewuee caw: xce: eu eweewwwwe mw pH eN

epeeee ecewuee xces en ea e>ec mumweececw w

eeeewe e» amee ece muceweee mee

 

mceew ceee1e

meceeeo ecewuec ee>weecec ”m ceueewo ucem1o
eH ewcew

108

6. Cluster 6: Therapy as Inspiration

 

Cluster 6 consists of ll items that form a general
pattern reflecting a view of psychotherapy as a basically
intuitive process without formal guidelines. This cluster
also reflects a view of therapy as a difficult and
emotionally draining type of work. This cluster, along
with item means and standard deviations is presented in
Table 17. Means here show that a view of therapy as
emotionally draining for the therapist was rated as salient
for this sample as a whole. The view that therapy is
mostly a matter of inspiration was rated as negatively
salient for this sample, as was the view that supervision
is no longer necessary after a certain amount of

experience.

 

Insert Table 17 About Here

 

Relationships between Q-Sort clusters

A correlation matrix showing the relationships between
the Q-Sort clusters described above is presented in
Appendix C, p. 194. These correlations were computed in
order to determine the degree to which the Q-Sort clusters
related to Question 2 were inter-related. In addition,
correlations between these clusters and the demographic

variables were computed in order to examine the possibility

eecewwem

w

‘

new; :ew
my 1 N emcec

.eeuoewwec uec ece c:ecm mceez .ceumewe cw cewmewucw cew eeueewwec newnewce>e

 

LO
H
H

109

O
NQ’MMMMMNNM N
O

o o
o o
HHHO—OH

O

Oiwmmr-amo—id'Nm N
MONOMOOLDLDON
1—11—1

LDQ'GDNLDQ'NQ'Q'CD

 

 

 

D
U)

mucewuee cwecu eewem

ea :ec :ecx e» ceece cw meecewceexe ewww c:e cwece ce awec ceewe memweececw we
ceEmuwece eepwwxm e mw umweececu eeem < ow«

xce: ece; e—uuw— e ece cewuecwemcw apemee mw acececw em
umweececu ecu cew mcwcwece awweceweeEe mw heececw wee
ewcwmmee me mcwcwece .o.ce1emee sees me pea ewaecm memwmepeceamc mac
emweecece ccec e m.ec: cemcee we ecwx cweecee e m.ececw sew
Niecece we mucee aceuceeew umee ece we ece mw mewceeceee mcwuuem wee

ceece ceee exww ewes eceweee ecu ece emweececu ecu eeeeeam e» Neececu cow e
xcemmeeec appeec ceecew ec mw cewmw>cee=m .eecewceexe we “ceece cweucee e ceuw< om
mw ecmxec eeecewceexe :ec ceepee ec cewmw>ceeem pee exe:we ewcecm umweececw < ewe
ea xwe» e» eceeEem e>ec ea mepec anew aw .wcwewec mw mesmeewwee e» mcwxwew flew

 

maeuw

ceweecwemcw me Naececw 1 e ceueewo
NH eweew

110

that there might be demographic differences in these areas.
The significant relationships are discussed below and are
depicted in Figure 2. The figure is again a heuristic
device, utilized here to chart the degree of common
relationship among the variables that have significant

association.

 

Insert Figure 2 About Here

 

Figure 2 shows that a view of therapy as guided by
inspiration was negatively related to research mindedness,
a psychodynamic view of therapy, and a record of
publication. It was related to high personalization of
therapy. Conversely, rejection of the view that therapy is
guided by inspiration was associated with a record of
publication, high research mindedness, a more psychodynamic
view of therapy, and low personalization of therapy. This
points to a general pattern that reflects a highly
intuitive (or "tender-minded") approach that rejects the
formal constraints of psychodynamic theory or a critical
style of thinking associated with research. By the same
token, a less intuitive (or "tough-minded") approach is

characterized by greater adherence to a more formal

111.

Accmv.1 u my _e>e_ ee=e_ceexe
meceEee ecewuee ee>weecee.m...1.-.11-111112111-11HW1-11.. unaee1w_em .Nuc.euceeca114111111111111
«acme. n Ly N
seececuecesme
we cee: cee acne:
cewue~w ecemcee.
.1 1 cewuec.emc
A..Nc u c. 11|1ee weececu
:ewueew_a:e1111
Aaamo.1 u by

Ace—v.1 u My

meeceeecwa ceceemec .e

u:9=w>—o>:_ susflwmms HCQLLJU

c_e;w ceeeccec memwmepecesme _ee_c__u

N3. V 3..
m:.dV 1 c

..:.;e eJ=_m mceex.

 

       

 

 

Acumm.1 u wvuwuoapau .m> e:=e:>e3:e:n;.

taco. n My

mumweececw me ace:
«Ne: ecu c..: on ea mcw>ez mecamee: ceumapu ece me_ne_ce> ewceecerea cee:eem memexc_. cewee_ecceu

N ecaaww

m

~

112

psychodynamic approach or to a style of thinking associated
with research.

High personalization of therapy was related to a
greater experience level, a greater view of therapy as
inspiration and a lighter work load. Conversely, low
personalization of therapy was related to less experience,
a heavier case load, and low acceptance of the view Of
therapy as guided by inspiration. This suggests a general
pattern not unlike the one described above in most
respects. A highly personalized view of therapy in this
sample was associated with a greater degree of experience
whereas a less personalized view was associated with less
experience. It may be that for more experienced therapists
their own life's experience plays a greater role in their
work, and this may be reflected in a more personalized
view. By the same token, less experienced (i.e., younger)
therapists may have less of a store of life experience to
draw on and thus may rely more heavily on formal theory.

A high degree of uncertainty and self-doubt was related
to greater perceived patient demands and less experience.
Conversely, a low degree of uncertainty and self-doubt was
related to lower perceived patient demands, and a higher
degree of experience. This suggests that some therapists
(less experienced therapists in this sample) may feel more

uncertain about their work when they perceive their

113

patients as demanding more than they have to give. By the
same token, they may perceive their patients as too
demanding because of their own uncertainties and
inexperience. Conversely, more experienced therapists in
this sample seem more sanguine about both their own skills
and their patients' demands.

A high degree of research mindedness was related to
current research activity. Conversely, a low degree of
research mindedness was related to a lack of current
research activity. This finding is not surprising, it
merely suggests that therapists who do research value
research-mindedness, while non-researchers value

research-mindedness less.

Question 3 addresses the relationships between the
two sets of clusters discussed above:

Question 3: How do the dilemmas that clinical

 

psychologists experience in their work relate to

uncertainty in theory, technique and outcome?

 

This question was addressed by examining
inter-relationships between the clusters already identified
for Questions I and 2. Relationships between therapist
concerns (Likert Scales) and approaches to therapy

(Q-Sorts) are presented in Table 18.

114

 

Insert Table 18 About Here

 

The significant relationships from this matrix are
summarized in Figure 3. This figure is used as a heuristic
device to depict the extent of overlap between therapist
concerns or dilemmas related to Question 1 and therapists'
approaches to therapy related to Question 2. Because these
measures were originally scored in Opposite directions,
relationships between therapist concerns and the other
variables have been reflected here to facilitate

understanding.

 

Insert Figure 3 About Here

 

Figure 3 shows that a psychodynamic approach to therapy
was associated with several areas of concern.
Specifically, this approach was related to high concerns
about the lack Of therapeutic theory and guidelines,
uncertainty in technique, the separation between personal
and professional life, and concern about self disclosure.
Conversely, low ratings on this approach were associated

with less concern about the lack of theory and guidelines

115

eepeewwec ceee e>ec mceweeweccee Auceewwwcmwm .e.wv
.e1p eceumepe we mcwceem ece ea euwmeeee cewuuecwe ecu cw eeceem ece: _H~>1~ eceemewu

ceece cw

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No.vnatw
«emm.1 «aN¢.1 «som.1 om. Noo.1 «cae.
om.n N~.1 no.1 No. OH.1 «tem.1
NN.1 -.1 OH. mo. No.1 Nm.1
«om.u mm. «om.1 ON. do.1 «run.
mH.1 NH. no.1 ¢N.1 no.1 «am.1
¥«N¢.+ «mm.+ «thm.+ «twm.+ No.1 mm.1
I I I A I A
I o A I I o
d ldd . . . 33
1.4 a not. nelc|c11no Jewufie O 1.
1.1....“ 13014 [.3 "U1U190 30.0 UU.
a U u a 1.5 S I. 1.3 a D U a O u D L.
3 3 a 0 3 I. 0.0 J X.3 S n 3 a 3
u. a S u I.. 8.4 2 a 1.3 J 9
u a s e o I:A.O o J J u I.
I: «4. Itl S I... aIJu u S
.D Q 0 n u E n
n L. u A J a u 1. H.
a u P S a S D.L. 0.
1+ 1. 3 o
.1 .n.

.ecec

uce>epec .mcweceumceec: eueuwwweew e»

mo.vua«
ceweecwemcw me Aeecec»
meceEee

eceweee ee>weecee

mmeceeecwe ceceemec
aeececu we
cewueewwecemcee

uneee1wwem .xecweuceec:

ewueewee .m> ewEecxeecezme

Amceumewo ucem1ov meececw ea meceeecee< ece mceumewu sepcece ecexwe cee:uen ecewuewecceu
mH e—cew

"eeez

1316

mvzuEmfi acmpaao um>pmusmm .w.

mmeceee:_e cuceemem .e

1||1un=ee1wwee .cuc.euceec: .N

 

   

ecceucee _eewcuu .>
..«Nm .+ «L

 
 
  

chm.1nH

 

cewuecwemcw me ceececw .o

««—¢.1nm

no .IHH
«ccm.1ns «on
ecamepumwe1w_em ..—
casm.um
ew._ _ecewmeewece .es _ecemcee .—

eaewcgueu can.uc

.1 c. wucweucouc: .>_

ocmv.ns , ocmv.um
mec._ee.=c cc. cceec. 1111\1111Hwee. . e

ewueeeececu we see. uaeae cceuceu ._>

 

NO. V can
3v?

Ou~c.ug

acecezu

1M11we cewueew ecemcee .m

..me.-1e

epue .ms ewEecxeecesxe ..

ecceeceu umwcececw ece scececuecuwmc e» mecueecee< mumweececw ceezuem memexcwd cowae_ecceu

n ecsoww

117

in therapy, less concern about uncertainty in technique,
and less concern about boundary issues such as '
self-disclosure and the separation between personal and
professional life.

These findings suggest that therapists in this sample
who were identified as psychodynamic in their approach to
therapy may have been more reliant on a theoretically
consistent point of view than therapists rated low on this
dimension. Consequently, the lack of clear guidelines may
be of more conern to them. High concern about boundary
maintenance is consistent with a psychodynamic approach
which tends to discourage self-disclosure and in general
relies heavily on maintaining a strict separation between
personal and professional life.

Conversely, a more eclectic, non-psychodynamic approach
showed the opposite pattern, with less concern about the
lack of theory and guidelines in therapy, less concern
about uncertainty in technique, and less conern about
issues of boundary maintenance. A non-psychodynamic
approach was also associated with a personalized view of
therapy, and a view of therapy as a matter of inspiration.
In general, the pattern is of therapists who are leSs
reliant upon a formal theory and more reliant on their own

intuitions. Consequently there is less concern about

118

theory or about issues (such as boundary maintenance) that
are related to psychodynamic theory.

High personalization Of theory was associated with a
view of therapy as a matter of inspiration and negatively
associated with a psychodynamic approach, concern about
uncertainty in technique, concern about self-disclosure,
and ethical concern. Conversely, low personalization of
therapy was associated with a psychodynamic approach. It
was also negatively associated with a view of therapy as
inspiration, and with concerns about self-disclosure,
uncertainty in technique, and ethical concerns.

These findings suggest a pattern that is almost the
mirror image of that associated with a psychodynamic
approach. Therapists rated as having a personalized
approach to therapy seem to rely more on intuition than on
any formal theory. By the same token therapists rated as
rejecting a personalized approach tend to be rated as
accepting a psychodynamic approach.

The view of therapy as inspiration is associated with
high personalization of therapy, low concern about self
disclosure, a non-psychodynamic approach and a lack of
research-mindedness. Conversely, low ratings on a view of
therapy as inspiration were related to lack of concern
about self-disclosure, and a low degree of research-

mindedness. The rejection of this view was associated with

119

a psychodynamic approach and with low personalization of
therapy.

These findings generally mirror those related to
personalization of therapy. Once again the pattern is of
reliance on intuition rather than formal theory or research
mindedness in approach. By the same token, the rejection
of this view is associated with a research-minded view or
with adherence to psychodynamic theory.

Perceived patient demands were related to both
uncertainty, self-doubt, and a high degree of ethical
conerns. Conversely, a low degree of perceived patient
demands was associated with low uncertainty, low
self-doubt, and with less concern about ethical issues.
These linkages suggest that in this sample therapists who
perceived their patients as very demanding tended to be
highly uncertain and troubled by concerns such as
aggressive or sexual feelings toward patients. By the same
token, therapists rated as less troubled by patients'
demands were also seen as being more certain about their
own skills and less troubled by ethical issues. High
scores on this triad suggest a generally reactive stance
toward therapy in the lack of association with either the
basically intuitive or the basically theory-bound
approaches discussed earlier. High scores on this triad

may suggest a general burn-out or frustration factor, while

120

low scores on these dimensions may reflect a lack thereof.

Question 4: How do clinical psychologists explicitly

 

view the uncertainties of their work?

 

The measures designed to scale issues relating to this
question were Likert scales 39-49, which are presented in
Appendix B, p. 183. These scales failed to form a cluster
or, with one exception (scale #48) to constitute part of
any other cluster. In other words, conceptually as well as
statistically they neither belonged together nor with any
other cluster. For this reason, they are all reported
separately. These scales, along with their mean ratings

and standard deviations, are shown in Table 20.

 

Insert Table 20 and Figure 4 About Here

 

Relationships between these scales, therapist dilemma
clusters and demographic variables are shown in Table 20.
Figure 4 is presented as a heuristic device to summarize
the significant relationships between these approaches,
therapist concerns, and the demographic variables.

An examination of the means shown in Table 20 indicates
that all of these approaches were seen as slightly to

somewhat characteristic of this sample. The approach to

39

4O

41

42

43

44
45
46

47

48

49

Range: 2

121

Table 19

Clinical Psychologists'
Uncertainty;

Life is uncertain and
psychotherapy is no
different

Eventually things be-
come clear, Patience
and a tolerance for
ambiguity are the keys
Uncertainty diminishes
over time, experienced
therapists are less
uncertain than begin-
ners

Experienced therapists
are no less uncertain
than beginners, they
just tolerate un-
certainty better
Because uncertainty
stimulates the
acquisition of more
training, it is a
positive aspect of
psychotherapy
Uncertainty is a sign
of incompetence
Uncertainty is a sign
of burn-out

The best way of deal-
ing with uncertainty
is by being honest
with oneself
Therapists can best
deal with uncertainty
by having faith in
their ability to be'
helpful

The way to deal with
uncertainty is to

seek supervision
Uncertainty is usually
a countertransference
phenomenon

10

EXplicit Attitudes Toward

Scale Means and Standard Deviations

 

 

 

 

 

 

 

 

 

 

 

Y SD

4.3 1.3
4.3 1.0
4.9 1.3
5.3 1.2
4.8 1.4
5.4 1.4
6.1 1.0
4.1 1.0
4.3 1.0
3.7 2.0
5.4 1.2

 

 

 

 

very characteristic
very uncharacteristic

IJZZ

. . .mcweceumceeca eueuwpweew ea ceece cw ece; eeeee_wec ceen
e>ec nee—e) emecu ee—eewces cecee on. we “ece ea Acmwg1:e_ .m: .:e_1co.=. euwmeeee cewuoecwe ecu ce eeeew ece: «ecumeee emecu emceeem.1.
. . NO.V new
mO.V Q «
ececc.mea cecu cweaceuc:
ewe. ece mumweececu eeucewceexe
.eewu ce>e megmwc—awe wucweuceuc: ..v

             
     

mecw_eew:m

 

ececewwwe ce wceec. co cues ._>
ec mw scececuecewme mm.uw
ece c_euceec: mw ewwa ecceeceu _euwgu «-

«cce.1nu

1mm.-1u

 

ceceeecece eec cewmcecuceucaee
ce.mw>cee:m e >__eem: mw Necweuceec: .me

xeem e» a. aucweuceeca
saw: _eee ea we: egw .m 1
...e.1.nc

«www.1nm

 

ew__ sece.mmewece .m> _ecemcec ._
ceeceo mm.nu
acme.um

«ccw.ns

 

eececuegexme we uueeme eswuwmee e m_ e_
.acwcwecu ecea we cewuwmwaeee ecu
«eye—:ewum Nucweuceeca emeeuem .me

exec ecu ece >uwecwase
cew eececepeu ece eucewuee
.cee_u eeeeee mmcwcu >__e=uce>m .ce

     

«www.mu

 

eacwcceea cw aucweuceuca >—

me_cewce> ewceecmeEec ece ...qwme_eem ecexwav mecle__a ce ecceeceu unweecegw “cucweuceeca ea meceeeceec um_eececw ceezeem meeeccwe ce_ee_ecceu

v ec:a.w

123

uncertainty most characteristic of this sample was to seek
supervision.

As Figure 4 shows, a high score on this scale was
associated with high degrees of conern about uncertainty in
technique, ethical issues, and the lack of theory and
guidelines in psychotherapy. A high score on this scale
was negatively associated with gender (i.e., males scored
higher on this scale), and with not having published.
Conversely, a low score on this scale was associted with
having published, and with being female. A low score on
this scale was also associated with less concern about
ethical issues, uncertainty in technique, and lack Of
theory and guidelines.

These findings suggest that supervision is most highly
- endorsed by therapists who perceive uncertainty as
potentially resolvable through greater theoretical and
technical sophistication and perhaps attendant
clarification of ethical concerns. Conversely, these
findings suggest that therapists who do not endorse
supervision as a way of resolving uncertainty may not see
theoretical and technical SOphistication as especially
useful. Such therapists also seem less concerned about
ethical issues.

The view that uncertainty is usually a counter-

transference phenomenon was associated with greater degrees

124

Of concern about uncertainty in technique, and the lack of
theory and guidelines in psychotherapy. It was associated
with not having published, and with being male.

Conversely, this view was negatively associated with having
published, and with being female. It was also associated
with less concern about uncertainty in technique, the lack
of theory and guidelines in therapy, and with concern about
the separation between personal and professional life.

This pattern of relationships is very similar to the
pattern reported above. The only exception being the
negative relationship between this approach and concern
about the separation between personal and professional
life. This finding makes sense in that therapists who tend
not to be concerned about maintaining strict boundaries
between their personal and professional lives may be more
aware of, or sensitive to, issues of countertransference.
BY the same token, therapists in this sample who are more
concerned about the separation between personal and
professional life, may rule out countertransference as a
source of uncertainty.

A positive view of uncertainty as a spur to training
(scale 43) was associated with concerns about uncertainty
in technique, and concern about the separation between
personal and professional life. Conversely, low ratings on

this scale were associated with less concern about

125

uncertainty in technique and less concern about the
separation between personal and professional life. These
findings suggest that therapists who value advanced
training also value more clarity in technical guidelines,
and may seek more training in order to achieve such
clarity. They tend also, to be less concerned about the
separation of personal and professional life. By the same
token, therapists who do not see uncertainty as a spur to
more training may be less troubled by uncertainty in
technique. Such therapists also tend to be less concerned
about the separation between personal and professional
life.

Therapists who were rated as believing more experienced
therapists are less uncertain than beginners (scale 41),
were also rated as more concerned about the lack of theory
and guidelines in therapy. Conversely, therapists rated as
rejecting this view were less concerned about the lack of
theory and guidelines in therapy. This finding suggests
that therapists concerned about the lack of theory and
guidelines in therapy may defer some of their uncertainty
in expectation that uncertainty is resolved through
experience. Conversely, therapists who have less faith in
experience as offering resolution to uncertainty may be

less troubled by uncertainty in the first place.

126

The view that life is uncertain and psychotherapy is no
different is associated with less concern about ethical
issues. Conversely a rejection of this view is associated
with more concern about ethical issues. This finding
suggests that therapists who are highly concerned about
ethical issues view psychotherapy as posing special
problems not encountered elsewhere. By the same token,
therapists who are less concerned about ethical issues seem
more sanguine about the uncertainties of psychotherapy.

The view that eventually things become clear and that
patience and a tolerance for ambiguity are the keys to
uncertainty in psychotherapy was associated with greater
concern about uncertainty in technique and ethical
concerns. Conversely rejection of this view was associated
with less concern about uncertainty in technique and
ethical issues. These findings suggest that some
therapists who are concerned about ethical and technical
uncertainties, believe that patience and a tolerance for
ambiguity are the keys.

In summary, these therapists, with few demographic
differences, tended to view uncertainty as resolvable
through a combination of patience, tolerance for ambiguity,
experience, and supervision. Although some differences

between approaches to uncertainty and therapist concerns

127

were found, these differences form no compellingly
consistent pattern. Relationships between these approaches
demographic variables, and therapist concerns are shown in
a correlation matrix presented on p. 193. Figure 4 is
presented as a heuristic device to summarize the

significant relationships among these variables.

II. Qgestions pertaining to the role of research in the

respondents' professional lives.

 

Question 5,6,7 and 8 addressed several aspects of
psychologists attitudes toward research. The questions
were as follows:

Question 5: Do clinical psychologists experience the

imbalance between their clinical and their

 

research efforts as conflictual?

 

Question 6: How do clinical psychologists resolve the

imbalance between their clinical and their

 

research efforts?

 

Question 7: What effect does training in research have

 

on the way clinical psychologists do

 

psychothergpy?

 

Question 8: Are clinical psychologists satisfied with

 

their research training?

 

'These questions were addressed by Likert scales 50-74

Appendix B, p. 187. (Interrater reliabilities for these

128

scales have already been reported in Table 3.) The scales
intended to respond to each of these questions were cluster
analyzed. When this was completed, the scales designed to
address all four of these questions formed one large
cluster. This cluster described an overall dimension of
(high-low) research relevance in the context Of clinical
psychologists' professional lives. In addition to this
large cluster, a much smaller cluster was formed: this
cluster is best described as concerned with clinical
psychologists' views about the goals of research training.
These two research related clusters along with item means

and standard deviations are presented in Table 20.

 

Insert Table 20 About Here

 

The questions and the Likert scales related to each

will be addressed individually below:

Question 5: DO clinical psychologists experience the
imbalance between their clinical and their
research efforts as conflictual.

This question was addressed by scales 50 and 51 from

the large cluster shown in Table 20.
Scale 50: Does the therapist see his/her work life as

ycll balanced (research vs. therapy)?

1J29

ewumwceueecegeca
ewemwceueececuca

eeece_enc:
ewumwceuuececu
eeece—ence
eewwmwuemwe
uwumwceuuececu
“ceeceeewc:

ece>e_ec
ace>ewec
eceuceeew
c_uce__m

uec:eeem
e>wuemec

ecewewec
ewemwceweecece

ece>e—ec
ewemwceuuececuca

aceuceesw
aca>mpowww
c.oce._m

»_ccc._u
>wuccw_m

—ecu:ec
aec:eeem
>_ecc__m
>_ece._m
c_cce._m
uec:eeem
>_ece..m

w_ece__m
c_ece__m
cwucc__m
eecmemwe

eeccemwe
>_ece__m

c_.cc__m
>_ece..m
_ecuaec

c.cce__m
c_uce__a

:_ucew_m

wwecew_m
eecmemwe

ec.ee¢

on.

No.

co.
mm.
on.

no.
8.
an.

ac.
-eece

 

 

Q“
.~

'1me MQMQQDI‘, NO
0 o o o O o
elicit—O «Io—0 Nod—0N N—ON—i—i—I—I

NR” MK! 9‘00 COM
0 o

53

 

ON. UR CON 'O 'QN—O RUICQVVO 00
0.000 DU! DUI“ 0K vacuum GROUND“) 0‘9

.uuuwaewegewuw _euwcwwu c. sec-ence we unease—ea e» eons—ea ue_eem acexwe

 

use; u.cee euewcecega .ecu «_wwxe necweeec ceceeuec aecu mesewwee em.
guceeuec ee ea new—wawuceenec a use: nun—mewecowae wee—cwwu “ecu me>ewwee on
newuw>weoe pecewemewece cecue
ece .cuceeaoc .ocwawc: cew open—wee. on.“ ecewewwwee exec eu :ec ceece cceeceu Ne
weececu ece coca-uec cooruea «ece—ea we Jeep . geese new—wcee emeccxe ec\n ween _m
acewuwuaeeee cew newswaee co m. cuceeeec “ecu mesewwen em.
.waecegu .e» suceeuecweeece—ea _we: we ewww xce: cecxuwc eem umwcececu as» «ea: on
acwcwec. cuceeuec cuwz cewueewewuem _wecesc nw
weecece cuw: e—cwueeseec..me ceceemec m:ew> em.
waecocueguwwe ee ea ecwccee— cew ec.c.ecu cuceemec.we eecesewea ww
, weecece we euwueece ecu eececce
«as» ece wwweowuwco aces ucwca ea wocoeceu e e» ee- use; neocewceexe cuceeaea we
ceguceeuec e we «owe—swan. econ-cc e» eucewcecxe ceceenec ence we eece>e_e¢ we
mace-ecweeec peace» ounce-co we cewue—eueu cew ocwcwece ceceeaec we eecese—ec cw
oucewuu e we weececuegexme axew> mo
weecesu
ecwee we we: age c. can. ease ocw‘cws» we we: a e. eee— ceece—cacao cuceeuec we.
coco—ceexe ceceenec ceeceece we :ew> _wecese no
ucwueeu
weuwue—eguwec cw u..u.>wuue aceuecc ea ceece—ceece ceceeuec see: we eecesewea «e
ceceeuec aw weecece mesew—ee mm
uecaeeuecc uwuuecaewe ocwcceew cew ucwcwec. cuceeuec we eecesewez Nw
. «ence pecewmmewece
cacao cw aewuwewuue econ-cc e» ceece—ceece geceeuec “nee we eece>ewe¢ no.
waecesuesewue ea uce>eweccw me ceceeeec axe.» mm.
unwae—ecowac
weuwcwwu age we wuwuceew wecewuuewecc use we acne «e ceceeeec we :e.> ..ecese ow
unweecea» e a. newuwewaue aceuoce ea neocowceexe ceceenec seen we necese—ec Ne
wuecegu noes sewn we: ece ce uuewwo o—uuww eec use: ceece—cecxe cuceeueu mm"
“__> cmwmeeu

...» cones—u ece .ueswa _ecewunewecc
"__> wanna—u

5N own-h

129) a.

353.39.... bee-2 eacceuceu Des-N Nn

 

eouow—wceoc: wees-ow eeuewpwcee wce>1N .m
eooce—eacc aces-o. eeece—ea aces-N em
eowwewaeaawe wuss-e. eewwuweeu wce>.N nw
oswueuoe wue>nc_ eswuwaee wce>uN me
owuuwcoueecesec: wees-ow uwumwcoeeecece wcesuN eo.em
om.mm.om.nm
uc-uceeuwca huge-e. “ceeceelw wces.N w.
Nw._w.ew
«seen—occw wcoeoew “case—ac wue>1N we.me.~e..e
wwececuu coco-awege. wwececeu eecueuN ee.oe.we.ee
newaewce>
me—eem

.eouue—wec we: ece exec. aceox .coaaawu cw cewmcwecw cew eeuee—wec neweewcewa

I I I P

 

amw>waeaeewm soc-eaoc weeuem cecu cecuec .geceeuec eecawwcsu1euecwe>e ece
e..m.ceeeecece w.ece._m Na. m.. o.m eec ea new—wa- gs. we accuse—c:ee use a. ocwcwece ceceeaec we weee ecu me>ewwee wm
. news—uoaeecc guceemec _ecuee cecu cecaec ecwxcwcu
e.em.ce.eecece >wucew_m «a. c.w ..m «seceawc we e—weu e gownsee ea c. ocwcwece cuceeaec we _eee ecu uece «user—em1wmil
...—w auwmeee

wuw>wwe< ceceemem
weeue< we eewmuac acwcwecw cuceemem we mmecwawemz ..__> ceeme_u

.3338: 8 ......

130

The mean rating for this scale (x=6.8) indicates that
this sample was seen as viewing their professional lives as
slightly unbalanced in this regard. Only nine of the
respondents were engaged in research however. The effect
of these nine therapists on the mean rating for the whole
group may obscure the fact that most of the respondents did
no research. Regardless of the ratings, the fact remains
that 26 of the respondents , roughtly three-fourths, were
not engaged in any research or planning to be any time
soon.

Scale 51: Does s/he express conflict about a lack of
balance between research and therapy?

The mean rating (x=8.4) for this scale indicates that
this sample was seen as very unconflicted in this regard.
This rating probably reflects therapists' satisfaction with
their research involvement; i.e. both researchers and
non-researchers were unconflicted about their degree of
research activity or inactivity.

In view of these findings, the answer to Question 5 is
no; although most respondents were not engaged in research
this sample of therapists did not express conflict about an
imbalance between their activities in research and

therapy.

131

Question 6: How do clinical psychologists resolve the

 

imbalance between their clinical and their research

 

efforts?

The eight scales taken from the large research cluster
in Table 20 that address this issue are shown in Table 21
below, along with their mean scores standard deviations and

corresponding sample ratings.

 

Insert Table 21 About Here

 

As Table 21 shows, the ratings for this sample as a
whole indicated that the respondents tend to value skills
that accompany research training, i.e. the development of a
rigorous style of thinking and the ability to evaluate
research. They do not tend to view research as
incompatible or irrelevant to therapy. They tend to
believe that while they may possess research skills and see
therapy itself as research in a sense, they have no special
responsibility to do formal research. Instead they tend to
see research as an activity for academicians.

This pattern suggests that these psychologists may
resolve the imbalance between their clinical and research
efforts by making use of those research-related skills that
can be helpful in other areas of their professional lives.

They do not seem to view research activity as a

ILSZ

ewumwceueececoca wwugcw_m
ewumwceueecececc wwucmwwm
ewemwceaeecece wwwgmwwm

ewemwceeeecece wwugmwwm

ewumwceueecece w-ucmwwm
ewumwceweecece >wucmwwm
ewumwceweecececa wec3esem
ewamwceeeececocc wpzmw_m
eweEem cew

ocwuec wwece>c

uwunwceueececuca wuesuow ewuuwceuuececu aces-N ”emcem

.eouuewwecca a. eeaceeec cent .ceuuawu eww ea eeuue—wec eweem.

 

use: u.cee «yawn-case uecu u_—wxu mecwceec guceeuec ence
coca-nec ee e» haw—.awuceenec a use: uauwuewecuwae wee-cwwu “ecu
ace.e.-aeeue cew sawswuue c. a. ceceemec eec.

 

 

 

 

watewwe sec-3... :2: micd
wee—c._u cwecu coerce: ence—ecu. ecu eswenec «.mwae—eceuwe .eewc._e ee :e:

 

 

33:2. 8
m0>0.—0G mm
mo>fl——0¢ mm.

a o
a o
v m
wuwewaeaeece cocoon-c weauee cog» coca-c .cuceenec eecewwaae eueewe>e ece eeec
m._ v.m ea mew—wa- ecu we accuse—esee use a. acwcwecu cuceeeec we ween ecu mesewweo we
news—auaeece geceemec wecuee cecu ceceec acwxc.cu
c.— ..m maeceowc we «when e newesee ea aw acwcwecu ceceeaec we pace ece .ece mose._eu on
o._ n.m cuceeeec a. weecec. mesew—eo mm
c.~ m.w waececa cue: e—aueeaeecw me cuceeuec c:e.> em.
n.N o.o wcececuecuwue e. “case—ecc. we cuceeaec axe.» em.

neweem

"e cewuaeec e» neweceeaea new-um cc ocwaex _weceso ece .mcewee.>ea eceeceum .eeceem cee:

—N «was»

I33

responsibility in their professional lives. They do see
research as a relevant activity for therapists however.

Question 7: What effect does training in research have

 

on the way clinical psychologists do psychotherapy?

 

The nine scales included in the large research cluster
shown in Table 20 that address this question are shown
along with their means, standard deviations, and sample

ratings, in Table 22.

 

Insert Table 22 About Here

 

As Table 22 shows, these psychologists tend to see
their past research experiences as slightly irrelevant to
their present activities as therapists. At the same time
they seem to believe that their research experiences have
had some effect on the way they do therapy. They disagree
somewhat with the idea that research experiences may lead
to a way of thinking that gets in the way of doing therapy.
They also view their past research experiences as slightly
relevant to a variety of professional activities other than
therapy (such as testing). In sum, the pattern suggests
that these therapists tend to value slightly their past
research experiences and to view these experiences as

slightly relevant to their professional lives. Their

1J34

wwacecua eocueuwe . cw w—acecaa coca- . N mo.ee.we e-eum
ewwueaoc wce: . e. «ewe—nee wce» . N no e—eum
aceweweccw wee: - cw uc-we—ec wee: . N ee.vo.no No..e ue—eem fleece:

.eeeue—wec uec ece c:ecm “can: .ceuuewe sec-eeec ence. eecw uww ea ceece c. emcee-wec eweum.

 

 

wwuce._m eecaeewe ..N v.9 coco—ea a no waececuecuwmc c:e—w mo

eeczeeee eeceemwe w.N a.m waececu «ece saw. we: as» co seewwe owuuww eec owes meecewceexe cmueeuec we.
ececu

.eczeeem eeceemwe n.~ o.w acwee we we: as» cw can: ease acwucwgu we we: e on ece. eucewceexe ceceemec we.
weececa we euwueecc ecu eececce

.cesewec >.ece..m c.N ..m «age ece w—weowuwcu oce- acwgu ea wecoeceu - ea ee— use: «eucewceexe cuceemea we

esweeeec w_.ce._m o.~ e.o oucowcoexe sec-eooc peacea ceece-ca we :e.» ”pecese me
cwumeu

.ce>e_ec w.ecme_m a.“ w.m weuwaewecuwwe cw uewuwwwuee aceuece e» neecewceexe cuceemec gene we eucewewea we
ceece

ecesewec w_ucow.e m._ w.u ecewwwewece cease :- newuwwwueo acceecc ea newuwswuue cuceuec one: we eecesewea no.

.cese.ec w_uce.wm w.N N.o unweecegu e we w-wuwwwuee acoaece ea ceece—ceece cuceeuec case we accuse—ex No

.cese.ec wwucewwm m._ N.m cecuceoaec.e we «owe-wwueo econ-cc ea eecewceexe cuceeeec «nee we eeceseweu .o

ewceem cew
ecwuec 2825 R m. 9.23...

 

 

 

 

 

Nuancecuecuwmm ee weowuewegewwe woo—cwwo wumloca am1eweg mwceeaec c. ucwcwecu neee weewwe uec:
"w cewuueea ea ac—ececaeu new-um ce acwuec wweceso ece .acewuewsea eceeceem .ueceum cee:

NN awn-w

135

overall view of their graduate school research experiences
is slightly negative. It is not clear from the present
data whether the majority of the respondents (i.e. the 26
non-researchers) have had additional research experiences
since graduate school that they might have viewed more
positively than their graduate school experience.

Question 8: Are clincial psychologists satisfied with

their research training?

 

Four Of the scales presented in Table 20 address this
question. They are the following:

Scale 70: Relevance of research training for completion of
graduate school requirements.

An examination of the mean rating (X=5.8) shown in
Table 20 indicates that these psychologists were rated as
viewing research training as slightly important for
completing graduate school.

Scale 71: Relevance of research training for learning to
do psychotherapy. .

An examination of the mean rating (x=6.7) shown in
Table 20 indicates that these psychologists were rated as
viewing their research training as slightly unimportant in

doing psychotherapy.

CHAPTER IV

 

DISCUSSION

 

In order to further understand and make use of the

findings already presented several questions must be posed.

They are as follow:

How representative of clinical psychologists in

general are the present study's respondents?

How are the findings of this study similar to or

different from findings reported elsewhere?

What are this study's important strengths and

weakenesses?

What are the broader implications of this work
fOr: a. clinical psychology?

b. psychotherapy in general?

What further research could capitalize on the
work's strengths and/or correct its deficiencies?
These questions will be discussed one at a time in

the order listed.

136

137

I. How representative of clinical psychologists in
general are the present study's respondents?

In most respects this sample Of psychologists is quite
typical of psychologists nationally. According to a recent
national study of psychologists' activities (Stapp and
Fulcher, 1981), the percentage Of their time that these
psychologists spend in such activities as research,
administration, teaching, psychotherapy, and other
professional activities is comparable to that of
independent practitioners nationally. The differences in
these areas between the present sample and the national
sample are minimal. The experience level Of the present
sample is also comparable to that of the national sample.

There are four areas in which the present Sample is
different from the national sample. These areas are:

1. The percentage of female respondents in this study
is much higher than the percentage Of female
independent practitioners nationally. Females
were just under 50% of the present sample.
Nationally females make up only about 21% of
independent practitioners.

2. The Washington, D.C. area has the highest
concentration of licensed psychologists in the
nation. There are 11.6 licensed psychologists for

every 10,000 residents of the District of

138

Columbia. The state with the next highest
concentration of licensed psychologists is New
York, with only 2.2 licensed psychologists per
10,000 population (Dorken and Webb, 1981).

3. Although the percentage of their time that the
therapists in this study spend seeing patients is
comparable to the national sample, these
therapists tend to see more patients. In other
words they tend to work more hours than the
national average for psychologists who are
independent practitioners. Nationally, only 27.5%
of independent practitioners spend more than 30
hours a week seeing patients. In this sample
about half of the respondents spend more than 28
hours a week with patients. It is therefore
likely that these therapists carry larger case
loads than the national average.

4. No Black, Hispanic, or Asian American therapists
were interviewed in this study (several minority
therapists were interviewed in pilot studies).
Nationally 4.1% of therapists are members of
minority groups. .

The relative over-representation of women in this

study, was largely by design. NO special efforts were made

to recruit female respondents, but had the percentage of

139

females fallen much below 40% such efforts would have been
initiated. The reason for this was the wish to compare the
responses of males and females; to do this well, one needs
as robust a sample of females as possible.

The question remains as to why females made up so high
a percentage when no special efforts were made to recruit
them. Although formal data on the relative numbers of
males and females in practice in the Washington area are
unavailable, my impression is that women make up much more
than 21% of independent practitioners there. The high
sex-ratio in Washington may account for this. The
acceptance rate of females contacted was no higher than for
men, and this substantiates that impression.

Washington D.C. has the highest percentage of licensed
psychologists in the nation. Many of these psychologists
are Federal employees, working in the various branches of
the government and not engaged in private practice. Also,
most psychologists licensed in nearby Maryland and Virginia
are also licensed in the District of Columbia. Both of
these factors inflate the numbers of psychologists
nominally in Washington. Until recently, Federal
employee's insurance benefits were very generous and
therapy was quite accessible to many in the Washington
area. Furthermore, Washington is full of the young,

attractive, verbal, intelligent, and successful individuals

140

who are traditionally considered "good" patients. Because
of this, Washington has been a very attractive setting for
psychologists.

If this high density makes the present sample somewhat
atypical, it is because these respondents have more access
to resources than many psychologists do. They also have
more potential competition.

In addition to their greater numerical density,
psychologists in this sample tended to see a larger number
of patients than the national average for independent
practitioners. Again, this may be due to the greater
demand for psychotherapists in Washington. It may also be
due to the high cost of living in that area. In any event,
the present sample is representative of therapists who are
very much involved in their practices.

The present data were not compared to that from
therapists practicing in other locales and with other
client loads. Such a study would be useful. Also no
minorities were present in this study. Such a comparison
would also be of interest.

In summary then, in all most important respects this
sample is comparable to national ones investigated by both

Stapp and Fulcher (1981), and Dorken and Webb (1981).

141

II. How are the present findings similar to or different
from findings reported elsewhere?

A. Psychologists' reactions to the uncertainty of

their work.

As was noted in the introduction, the importance and
ubiquity of uncertainty in psychotherapy is very well
documented but very little explored. No previous studies
that specifically addressed this issue were located in a
review of the literature. Documentation of its importance
has come mostly from the writings of psychoanalysts and
sociologists. These writings have been based on the
Observations of the authors, either in their clinical and
professional activities or, in the case of sociologists,
from their observations in the field. Additionally, both
the psychoanalysts and the sociologists have.observed
samples very different from the present one. The analysts
write mostly Of other analysts - the majority of them
psychiatrists. Sociologists have written mostly about
psychiatric residents. Psychologists as a distinct group
have not generally been studied.

Only one study was found that focused on
psychologists, and on issues similar to those addreSsed in
the present work (Coan, 1979). That report examined the
relationship between the “personal and theoretical“

pathways of the psychologists studied. Interesting as that

142

study was, it's relevance in the present context is limited
because of the diverse specialities of the psychologists.
Coan found two basic factors, the objectivist -
subjectivist Split described in so much of the literature.
Clinicians, as one would predict, tend to be found on the
"subjectivist“ side of the fence. Coan did not examine
different personal and theoretical pathways among
clinicians separately and in that sense his work
contributes little in the present context.

In addition, there have been no studies of
psychologists alone, nor have there been studies of how
experienced therapists respond to the uncertainty of their
work.

There is, however, one study that speaks to the
current topic: Daniels, (1976) in a study of the
complaints psychiatrists have about their work found five
basic areas of concern. These were:

I. Concerns about the effectiveness Of treatment.

2. 'Concerns about the isolation involved in

'psychotherapy.

3. Concerns about the image of psychiatrists among

colleagues, patients, and the general public.

4. Concerns about the personal strains imposed by

work that is too hard; too pressured; lacking

143

adequate financial rewards; and fraught with too
many temptations.

5. Concerns about the negative personal

characteristics of many colleagues.

The present research identified six areas of concern
among clinical psychologists.' They were:

I. Concerns about maintaining the boundaries between

personal and professional life.

2. Concerns about self-disclosure.

3. Concerns about whether the therapist was really

earning the fees patients paid.

4. Uncertainty in matters of technique.

5. Concerns about ethical issues.

6. Concerns about lack of theory and guidelines in

psychotherapy.

A comparison of these two lists of problems shows that
they overlap in some areas but not in others. One large
area of overlap is the concern about the effectiveness of
treatment. In the present sample, this concern was
expressed in several of the problem areas described above.
Specifically, concerns about whether fees are really
earned; concerns about specific matters of technique; and
concerns about the lack of theory and guidelines in
psychotherapy, all seem to be related to concern about

effectiveness.

144

The concern about personal strains of the work, that
Daniels identified, is comparable to two of the dimensions
of therapist concern identified in this work. One of these
was the concern about the separation between personal and
professional life. The other was the concern about
self-disclosure found in the present research. Therapists
who were rated high on either of these dimensions were
concerned about making sure that the pressures of
psychotherapy didn't spill over into their personal lives.
Other therapists, those rated low on one or the other of
these dimensions, were not concerned about these issues.
High concern about the separation between personal life and
professional life was one type of personal strain
identified in this research. High concern about
self-disclosure is another personal strain identified in
this work.

Concern about the temptations available to
psychiatrists, as reported by Daniels, is similar to the
dimension of concern about ethical issues found in the
present sample. A high degree of concern about ethical
issues seems to overlap with concern about the temptations
of the work. A low degree of concern about ethical issues
would, of course, not overlap conceptually with the concern

about temptations that Daniels identified.

145

Two areas of concern identified by Daniels that were
not identified in the present work were concern about
isolation and rejection of colleagues. Perhaps Daniels'
respondents felt isolated because they didn't respect their
colleagues. When asked about whether they saw enough of,
and benefited from seeing colleagues, most respondents in
the present study reported that they were generally pleased
with their relationships with colleagues.

Although Daniels' study came closest to an examination
of therapists' personal responses to therapy it is limited
in its applicability in the present context for three
reasons:

1. She studied only psychiatrists.

2. Uncertainty was not a specific focus of her

study.

3. She did not attempt to differentiate between the
theoretical orientations Of the therapists she
studied.

Another study was also somewhat similar to the present
study (Kahn-Hut, 1974). Kahn-Hut studied experienced
psychiatrists, most of them psychoanalysts affiliated with
a private hospital in the Boston area. Her primary focus
was on how these analysts managed to avoid alienation given
the many characteristics of psychotherapy that might

produce alienation. Probably her most important finding

146

was that the analysts tended to attribute "successful"
outcomes to their own efforts, and "unsuccessful“ outcomes
to their patients' unreadiness for change.

One of the dimensions Of approach to therapy
identified in this study had to do with therapists'
perception that patients and the general public were too
demanding. Therapists who scored high on this dimension
were rated as viewing patients and lay-persons as too
demanding of psychotherapists. Conversely, the Opposite
was true of therapists rated low on this dimension. On the
surface, this dimension seems conceptually similar to the
tendency to blame failures on patients that Kahn-Hut
identified.

As part of the interview for the present study
therapists were asked to describe a successful case and an
unsuccessful one, and to say what factors they thought
contributed to those outcomes. A reading of the interview
transcripts shows that a few of the therapists did tend to
fit the pattern Kahn-Hut described. These therapists were
in the minority however. Both the Q-Sort statements about
therapists' approaches to therapy, and the Likert Scales
referring to therapists' dilemmas or concerns included
items that could have confirmed Kahn-Hut's findings. None
of these statements emerged as prominent descriptors Of the

present sample. It therefore seems that the psychologists

147

interviewed were not as likely as Kahn-Hut's respondents to
believe that the responsibility for failure lay more with
patients than therapists.

How can this difference be explained? Assuming for
the moment that the differences are real, to what might
they be attributed? Kahn-Hut's sample differs from the
present one in several important respects. Her respondents
were all psychiatrists, psychoanalysts, and all were
affiliated with the same hospital. Any one Of those
factors may be critical in influencing the attitudes she
observed. Light (1980), found similar notions among the
psychiatric residents he studied - but again, his sample
was of psychiatric residents, and his study took place in
the same area where Kahn-Hut's sample was based. Light's
respondents were different from Kahn-Hut's only in their
relative lack of experience. Therefore his findings do
little explain the differences.

Possible explanations of these differences include:

(1.) That present respondents were more ideologically

diverse than the analysts interviewed by
Kahn-Hut. Because of this they did not have a
particular "party-line" to rely on or to defend
when discussing cases that had not worked out

well.

148

(2.) That present respondents were not affiliated
with any single institution. They shared
neither a common peer group nor the need to

-uphold the status of a particular hospital.

(3.) That present respondents were not physicians by
training. Consequently these psychologists may
have felt less of a professional expectation
about ”cure“ than physicians. Therefore they
may have been less defensive about the image of
themselves as “healers".

B. The role of research in the professional lives of

clinical psychologists

The results indicated, not at all surprisingly, that
the respondents had somewhat mixed attitudes about
research. This is not earth-shaking, given that
three-fourths of the respondents were not engaged in
research and were not planning to be anytime soon.

What lay behind the interest in this topic was the
notion that there was something not quite right about the
way clinical psychologists often approach research. It was
felt that a profound distrust of self underlay conventional
styles Of research. That apparent distrust seemed at least
alienating if not potentially worse. Especially in a field
as uncertain as psychotherapy, it seemed that better ways

of translating subjective perceptions into testable

149

hypotheses were necessary. It also seemed that given the
realities Of a declining economy and a declining student
population, most recently trained clinical psychologists
have little likelihood of working in academic settings.
Without access to grant offices, SOphisticated computer
systems and university libraries, the conduct of research
as it is generally taught seems a difficult proposition
indeed. In sum, the approach to research that prevails
seemed inappropriate as well as nearly impossible for the
non-academician. Furthermore, other styles of
investigation more useful in non-academic settings do exist
but tend not to be taught or to be published in the
psychological literature. The issue was not the
abandonment of intellectual rigor, but a broader
methodology. Rigid adherence to inappropriate methodology
was seen as potentially leading to an atrOphy of curiosity
with consequences extending into clinical practice.

The situation seemd analogous to the person searching
for a lost car key in a brightly lit part of a parking lot.
As the story goes, the searcher is joined by a passerby who
helps him search. Finally the passerby asks the searcher
“Are you sure you dropped the key here?“ to which the
searcher replies, pointing to a darkened area at a distant
part of the lot, "No I dropped it over there." When the

passerby asks "Why then, are you searching here?" The

150

searcher replies "Because this is where the light is.“
Clearly the key will not be found and in that sense the
search becomes a waste of time.

There was, therefore, a proto-hypothesis underlying
the interest in exploring clinical psychologists' views
about research. The hypothesis was that: without more
appropriate models of investigation psychologists are left
with an unconstructive distrust of self. They are also
left without better ways to investigate the issues that
interest them or trouble them. This hypothesis was not
confirmed in the present study. The psychologists
interviewed did not seem troubled by the nature of research
in the field. Most of them rejected conventional research
as a component of their own professional lives, but for the
most part the results show that they were content with the
model.

There are several possible reasons why these ideas
were not confirmed. One of them is that they were wrong.
To some degree I believe they were. It was clear from many
of the interviews that the respondents simply ignored the
issue of research. Instead they found other ways to solve
the dilemmas their practices engendered. Many attended
workshops or enrolled in advanced training programs. Most
had peer groups with whom they met to discuss their work.

Most also tried to keep up with the clinical literature.

151

These activities constituted the respondents' research
involvement in a meaningful though broadly defined way.
Furthermore, the results indicate that the respondents
valued the skills associated with their research training.

It may also be that the socialization process involved
in completing graduate school creates a situation of
cognitive dissonance (Festinger, 1957). The institutions
of clinical psychology as it is conventionally taught and
practiced may be internalized simply because they are
commonly accepted and are the source of valuable status and
group membership.

Another possibility is that the tools to properly
investigate this issue were lacking in the present study.
One way to approach this issue would be through a
longitudinal experiment. For example, therapists could be
trained in the methodology of hermeneutics - (i.e. the
analysis of texts - a method analogous to biblical or
literary criticism, and one the present author views as
potentially of great use to therapists (Bauman, 1978)).
These therapists could be monitored over time and their
approaches to therapy could be compared to those of a
control group. Differences in their develOpment over time
would be of interest. One possible hypothesis would be
that the experimental group would tend to publish more than

the control group. What lies behind this hypothesis is the

152

possibility that therapists trained in a research
methodology more compatible with both clinical work and
with non-academic life, would have research tools that they
could more realistically and effectively apply to their
everyday professional lives. Consequently they might beel
empowered in matters of investigation in ways they may not
presently feel. Although it must be recalled that the
present sample Of psychologists do, on the whole, value
their research skills, they do not tend to do research, nor
do they tend to publish their work.

Another hypothesis would be that such a group would
do better on measures Of therapy process and outcome than a
control group. What lies behind this notion is the
hypothesis that a methodology such as hermeneutics
incorporates skills that are synergistic with therapeutic
skills, i.e., the ongoing analysis of a text Of which both
participants (patient and therapist) are co-constituents
and co-authors.

The foregoing discussion leads naturally to a discus-
sion of the strengths and weaknesses of the present study.

It also leads to a discussion of the broader implications

 

of these findings for both clinical psychology and

 

psychotherapy in general.

 

153

In my view, this study has two major strengths, one
substantive and the other methodological, but also
personal. On the substantive level this work attempted to
establish that a linkage exists between uncertainty in
psychotherapy and therapists' approaches to psychotherapy.
It established some linkages between the concerns - or lack
thereof, that therapists experience in their work and
aspects of their approaches to psychotherapy. Three areas
of concern were especially linked to uncertainty. These
were uncertainty in technique, concern about ethical
issues, and concern about the lack of theory and guidelines
in psychotherapy. These areas of concern were linked to
differing approaches to psychotherapy.

In addition, therapists' attitudes toward uncertainty
in their work and the ways they dealt with uncertainty were
also studied. On the whole, these therapists recognized
uncertainty as an aspect Of their work and were generally
rated as more tolerant than intolerant of uncertainty. The
two ways of dealing with uncertainty most characteristic of
this sample were seeking supervision and personal honesty.
Relationships between attitudes toward uncertainty, ways of
dealing with uncertainty, therapists' concerns, and.
demographic characteristics were reported and discussed.

On the whole, patience, a tolerance for ambiguity, further

training and a high value set on honesty summarizes the

154

approaches of this group to resolving uncertainty in their
work. Although some relationships were found between these
approaches to uncertainty and therapists' concerns about
their work, no other compelling patterns were identified.

Taken together, all of these findings add some support
to a broadening of interest from the level of individual
differences to the levels of group socialization processes
and the structure of institutions -- especially with regard
to professions. These findings emphasize the importance of
studying the interaction between issues inherent in the
profession and individual consciousness. Specifically,
this study emphasizes the context of psychotherapy rather
than the personalities of therapists. The influence of
training and conventional practice is recognized as being
more important than has Often been assumed, and
consequently they are seen as worthy of more in-depth
study.

The biggest strength of this work then, is the
expansion of interest to include these areas. It supports
a systems oriented view of the profession of psychotherapy.
Studying the context of practice in psychotherapy may help
psychologists anticipate, avoid, or cape better with the
problems inherent in their work.

On the level of methodolOgy this study has several

strengths. Interviews were conducted by the researcher.

155

Original measures were derived from pilot data and from
interview transcripts, and raters were trained. In each
phase attention was paid to making this research compatible
if not synergistic with clinical work itself.

These combined factors are considered a "strength" of
the work for two reasons. They involved varied and
mutually enhancing tasks, and enhanced interviewing and
conceptual skills useful in clinical work. This author
believes strongly that the integration in meaningful ways,
of clinical and research skills is an important task for
clinical psychologists. Consequently, the subjective
experiences of the researcher should be attended to where
relevant just as they are in psychotherapy.

***

In summary, it can be concluded that uncertainty is an
issue therapists deal with; that therapists have fairly
distinct orientations; and that the two areas are linked in,
some cases. It cannot be concluded from this study that
conventional approaches to research are inappropriate or
'generally viewed as problematic. They were viewed as
irrelevant in many respects, however.

One flaw in this study was the absence of personality
measures. This absence was deliberate because the major
area of interest was psychotherapy itself rather than the

personalities of practitioners. Nonetheless, it would

156

be interesting to have some sense of how the findings of
this study relate to personality variables.

The present sample was small for the somewhat
saphisticated statistical analyses to which the data were
subjected. A larger sample would have been preferable.
Thus, the size of the sample is another shortcoming of this
study.

The broadening of concern to include generic aspects
of the profession in studying therapists has potentially
important benefits. Therapists should not only know
themselves as they come already formed to psychotherapy.
They should also be conscious of the forces at work on them
that derive from the nature of the profession. They should
be enabled to systematically examine those features of the
profession that influence both ideology and personality.
Whitaker and Malone noted long ago that psychotherapy often
becomes a "way of life" for its practitioners (Whitaker and
Malone, 1953). This way of life with all its ramifications
bears examining if therapists are to become better

observers of the world around them and of their patients.

CHAPTER V

 

SUMMARY AND CONCLUSIONS

 

This dissertation concerns several aspects of
uncertainty in psychotherapy. The literature review
presented the notion that uncertainty is pervasive in
psychotherapy. Drawing upon relevant discussions from the
fields of clinical psychology, psychiatry, psychoanalysis,
social work, and the sociology of professions, findings
from these diverse areas were synthesized and analyzed to
document the relevance of uncertainty as an aspect of
psychotherapy.

The broad tOpic of uncertainty in psychotherapy was
divided into three subcategories, namely uncertainty in
outcome, theory, and technique. It was suggested that
although all professions are characterized by some types of
uncertainty, psychotherapy is distinguished by uncertainty
in all areas. It was therefore suggested that all
therapists must find ways of COping with the uncertainty of
their work if they are to continue workingwith conviction.
The literature touching upon therapists' responses to the
strains of their work was also reviewed, with particular
emphasis on uncertainty as a source of stress.

157

158

Another area of uncertainty was also discussed. This
area concerned the uncertainty of research in
psychotherapy. Much of the conventional psychological
research on psychotherapy has been unsuccessful in
providing guidance for practitioners. It was therefore
suggested that these research findings may add to the
uncertainty of psychotherapy. Such findings, by their very
lack of clarity, may become part of the problem rather than
part of the solution. In effect, the practitioner is left
in doubt as to whether the ambiguous research findings are
due to poor research or to psychotherapy itself. This
situation therefore increases rather than resolves
uncertainty.

Eight questions were posed to investigate these areas.
These questions were as follow:

l. What types of dilemmas do clinical psychologists

experience in their therapeutic work?

2. What principles, predispositions, or tacit
”theories in use" guide clinical psychologists'
reactions to therapeutic uncertainty?

3. Are these dilemmas and their resolution related to
uncertainty in theory, technique, and outcome?

4. How do clinical psychologists view the uncertainty

of their work?

159

5. 00 clinical psychologists experience the imbalance
between their clinical and their research efforts
as conflictual?

6. How do clinical psychologists resolve the
imbalance between their clinical and research
efforts?

7. What effect does training in research have on the
ways clinical psychologists do psychotherapy?

8. Are clinical psychologists satisfied with their
research training?

Clinical psychologists were to be studied exclusively
in this project because of the absence of such examination
in the earlier literature. Seventeen questions and
fourteen incomplete sentences were devised to respond to
these questions. Using an interview format, these
instruments were given to thirty-five clinical psycholo-
gists in the Washington, D.C. area. Two scaling measures
were then created and applied to the interview transcripts.
One measure consisted of 74 Likert-type scales touching on
psychologists' concerns about aspects of their therapeutic
work. These scales also addressed psychologists' attitudes
toward research in their training and in their current
professional lives. _The other measures was a 100 item
Q-Sort deck generated from pilot studies, the literature,

and the interviews, and then used by raters

160

to scale therapists' approaches to psychotherapy. Demo-
graphic data concerning age, gender, full vs. part time
practice, research involvement, and publication history
were also collected. Correlational and cluster analytic
techniques were used to analyze these findings.

Six areas of concern about doing therapy were
identified from cluster analysis of the Likert scales.
Ranging from the general (relevant to all professions) to
the specific (specific only to psychotherapy), these
problems were the following:

l. Concern about maintaining the boundary between

personal and professional life.

2. Concern about how much of their own experiences

therapists should disclose to patients.

3. Concern about whether therapists were really

earning the fees they were paid.

4. Concern about uncertainty in technique.

5. Concern about ethical dilemmas such as sexual or

aggressive feelings toward patients.

6. Concern about the lack of therapeutic theory and

guidelines.

Six basic points of view about psychotherapy were

identified from the cluster analysis of the Q-Sort

161

ratings of therapists' approaches to psychotherapy. These

were the following:
l. Psychodynamic vs. eclectic approach to therapy,
i.e, an approach to psychotherapy that was highly
theory-bound in a psychodynamic sense, vs. an approach
that rejected psychodynamic theory in favor of a more
eclectic approach.
2. Therapist uncertainty and self-doubt in psycho-
therapy, i.e. a point of view about psychotherapy that
focused heavily on therapist concerns about personal
inadequacies and technical uncertainties.
3. Personalization of psychotherapy, i.e., a point of
view about therapy that approached psychotherapy as
not unlike friendship in the gratification of the
therapist's own needs within the context of therapy.
4. Perceived patient demands, i.e., a point of view
about psychotherapy that focused heavily on the
difficulties in meeting the needs and expectations of

both patients and the lay-public.

 

5. Research mindedness, i.e., a point of view about
therapy that emphasized the role of cognitive and
research oriented or "tough-minded" empiricis in
practicing psychotherapy.

6. View of therapy as a matter of inspiration, i.e.,

a point of view about therapy that focused heavily on

162

the role of the therapist's intuition as a guide to

therapy.

Correlations between therapists' concerns about their
work and therapists' "tacit" approaches to psychotherapy
were done. Several basic approaches were found. One
approach was characterized by a basically psychodynamic vs.
an eclectic point of view. This basic orientation was
reflected in a series of relationships all of which tended
to be consistent with an approach to therapy heavily
influenced by and consistent with a psychoanalytically
oriented point of view. A non-psychodynamic point of view,
called "eclectic" in this work, was characterized by a
series of relationships the converse of those characteris-
tic of a psychodynamic point of view.

A psychodynamically oriented point of view was
characterized by a high degree of concern about such issues
as uncertainty in technique, the lack of theory and
guidelines in psychotherapy, the separation between
personal and professional life, and self-disclosure. These
concerns were negatively associated with the basically
ecletic point of view that was the obverse of the
psychodynamic approach. This point of view was highly
relativistic, forsaking formal theory in favor of a more
case-by case approach, and showing less concern about the

lack of theory and guidelines in therapy. uncertainty in

163

technique, self-disclosure, and the separation between
personal and professional life.

Another basic approach to therapy was similar to the
eclectic point of view in that it shows a pattern of
relationships almost the mirror image of the psychdynamic
approach. This approach was best characterized by the
pattern of relationships associated with a highly
personalized view of therapy. This pattern was related to
lack of concern about uncertainty in technique, self
disclosure, and ethical concerns, as well as a negative
association with a psychodynamic point of view and a
positive association with a view of therapy as largely a
matter of inspiration. In general, this pattern was
consistent with a view of therapy as an intuitive process
not unlike friendship. Conversely, a rejection of this
point of view was associated with a pattern of
relationships very similar to that associated with a
psychodynamic point of view.

A third constellation of relationships linked perceiv-
ed patient demands with both therapist uncertainty and
self-doubt and concerns about ethical issues. This pattern
was not linked with either a personalized, an eclectic, or
a psychodynamic point of view. Instead these relationships
linked the presence or absence of a perception that

patients or the lay-public were too demanding with the

164

presence or absence of concerns about ethical issues and
therapist self-doubt. High ratings on this approach were
described as generally reactive because of the lack of
association with specific approaches to therapy. Low
ratings on this approach indicate an approach of greater
certainty and sanguinity with regard to ethical concerns.

In addition, therapists' views about uncertainty in
psychotherapy and ways to resolve it were discussed. In
general, these therapists tended to view uncertainty as an
important aspect of psychotherapy. The most characteristic
approaches to uncertainty included seeking supervision,
endorsing patience and a tolerance for ambiguity, and
seeking more training and experience.

Therapists' attitudes toward the relevance of research
in their professional lives were also studied. In general,
these psychologists tended to value their competence in
research, and to recognize the value of their research
experiences and related skills. At the same time they
tended to consider research irrelevant to their present
professional lives.

Demographic characteristics of this sample were
compared with characteristics of psychologists reported in
a recent national survey. It was concluded that these
respondents were similar in most important respects to the

national sample. DisprOportionately high numbers of

165

females and low numbers of minorities in the present sample
were reported and their implications were discussed.

The overall findings of this research were summarized
and compared with findings reported in the literature.
Similarities and differences between the present findings
and those of other research were also discussed. Primary
among these differences was the fact that this sample was
composed entirely of psychologists. Another major
difference was the fact that therapists' approaches to
psychotherapy were discussed along with the problems that
the therapists experienced in their work. Neither of these
two issues as they relate to clinical psychologists had
been studied previously.

Areas for future research were suggested. Among these
were the inclusion of personality measures in a study like
the present one; a comparison between groups trained in
different research methodologies; a comparison of minority
therapists to white therapists; and comparisons with
therapists practicing in other geographical areas.

Strengths and weaknesses of this research were also
discussed. The primary strength discussed was in the
interface between the personal and the professional aspects
of psychotherapy. The primary weaknesses discussed were
the small sample size and the absence of any personality

measures.

166

The broader implications of these findings were also

discussed.

 

REFERENCES

REFERENCES

Allport, G.W. The general and unique in psychological
science. Journal of Personality, l962, pp, 405-421.

Argyris, C., & Schoen, D.A., Theory in practice: increasing
rofessional effectiveness. San Francisco:
Sossey—Bass, l974.

Bart, Pauline, M., Ideologies and utopias of psychotherapy.
In R.M. Roman and H.M. Trice, The sociolo of

psychotherapy. New York: Jason Aronson, nc., l974,

Bateson, 0., Jackson, D.D., Haley, J., & Weakland, J. Toward
a theory of schizophrenia. Behavioral Science, l956, ;,
251-264. ~

Bauman, Z. Hermeneutics and Social Science. New York:
Columbia University Press, 9 .

Bergin, A.E., & Strupp, H.H. (eds.), Chan in frontiers in
the science of psychotherapy. Chicago: Alaine, I972.

Book, H.E. On maybe becoming a psychotherapist perhaps.
Canadian Psychiatric Association Journal, 1973, lg,

Bugental, J.F.T. The person who is the psychotherapist. In
Mahrer, A.R., & Pearson, C. (eds.), Creative
Develo nts in Psychotherapy; New York: Jason Aronson
Inc., 1373. '

Chessick. R. How the resident and the supervisor disappoint
each other. American Journal of Psyghotherapy, 1971,
25, 272-283.

Chu, F.D., & Trotter, S. The madness establishment. New
York: Grossman Publishers, I97 .

Coan, R.W. Psychologists: Personal and theoretical
pathways. New York: Irvington Publishers, 1979.

Cocozza, J.J., & Steadman, H.J. Prediction in psychiatry.
Social Problems, 1978, gs, 265-276.

Coles, R., The Mind'sIFate: Ways of seging psychiatr and
psychoanalysis. Boston: Little, Brown and’CO., I975.

167

 

168

Coser, Rose, L. Training in ambiguity; learning through
doing in a mental hospital} New York: The Free Press,

Crews, F. Analysis terminable. Commentary, 1980, 19(l),
25-340

Daniels, Arlene K. What troubles the trouble shooters. In
P.M. Roman & H.M. Trice (Eds.). The sociology of
psychotherapy, New York: Jason Aronson Inc.,l974.

Dorken, H. & Webb, J.T. Licensed psychologists on the
increase, 1974-1979. The American Psychologist, 1981,
§§_(11), 1419-1426.

Edelwich, J. a Brodsky, A. Burn-out: Sta es of
disillusionment in the helping_profess ons. New York:
Human Sciences Press, 1980.

Epstein, L. & Feiner, A.H. Countertransference: The
therapist's contribution to treatment. Contemporary
Psychoanalysis, 1979, lg (4), 489-5l3.

Farber, B.A. a Heifetz, L.J. The process and dimensions of
burnout in psychotherapists. Professional Psychology,
T982, 1§(2), 293- 30l

Festinger, L. A theory of cognitive dissonance. New York:
Harper an ow, .

Fisch, R. Resistance to change in the psychiatric community.
In P. Watzlawick & J.H. Weakland (Eds.). .Ipp
Interactional View. New York: W.W. Norton, 1977.

 

Fisher, K.A. Crisis in the therapist. Psychoanalytic
Review, 1967,.§g, 81-98.

Fox, Renee. Training for uncertainty. In R.K. Merton, et
al. (Eds.). The Student Physician. Cambridge: Harvard
University Press, I957.

Frank, J.D. The bewildering world of psychotherapy. Journal
of Social Issues, 1972,‘g§(4), 27-43

Freud, 5. Analysis terminable and interminable. In J.
Strachey (Ed.). Si und Freud: Collected Papers, Vol.
‘y, New York: Bas c Books, l959, 3l6-357.

Goffman, E. Asylums. Essays On The Social Situation of
Mental Patients and—Other Inmates; Middlesex, England:
Penguin Books, l968.

169

Goffman, E. Role distance. In D. Brisset & C. Edgley

(Eds.). Life as Theater: A dramaturgical sourcebook.
Chicago: Aldine, T975, l23-l32.

Gouldner, A.W. The coming crisis of western sociology. New
York: BasiéTBOOks, l970.

Gross, M.L. Theypsychological society. New York: Random
House, l978.

Havens, L.L. Approaches to the mind: Movement of the

'psychiatric schools from sects toward science. Little,.
rown,‘Boston, l973.

Henry, W.E., Sims, J.H., Spray, S.L. The fifth profession:

becomin a psychotherapist. San FFancisco:
Jossey-gass, l97l.

Henry, W.E., Sims, J.H., Spray, S.L. Public and private

lives of psychotherapists. San Francisco: Jossey-Bass,
l973.

Hunter, J. Cluster analysis: reliability, construct
validity,apg§he multiple ihdicators approach to

measurement. Paper presented at a workshop titled
"Advanced Statistics“ given at the 0.5. Civil Service

Commission, Washington, D.C., March 1977.

Hurvitz, N. Peer self-help psychotherapy groups:
psychotherapy without psychotherapists. In P.M. Roman

& H.M. Trice. The Sociolo of Ps chothera . New
York: Jason Aronson Inc., 1974, 8*-|38.
Kahn-Hut, Rachel. Psychiatric theory as professional

ideolo . Unpublished Doctoral DiSsertation, Department
of Sociology, Brandeis University, Waltham, Mass., l974

 

Kubie, L.S. The retreat from patients, International Journal
of Psychiatry, l972 (9), 693-711.

Kuhn, T.S. The Structure Of Scientific Revolutions, second
edition. Chicago: ‘University of ChicagokPress, l97l.

Langer, Susanne, K. Mind: An essay on human feeling, Vol. I.
Baltimore: Johns Hopkins University Press, T967.

Langs,ih The Bipersonal Field, New York: Jason Aronson
Inc., 1976.

Langs,ih The Therapeutic Interaction: A Synthesis. New
York: Jason Aronson Inc., T977.

 

170

Langs, R. & Searles, H.E. Intrapsychic and interpersonal

dimensions of treatment: A clinica‘rdialogue. New York:
Jason Aronson Inc., 1980.

Leifer, R.D. In the name of mental health: The social

functions of psychiatry. New York: Science House,
T969.

Levenson, E.L. The fallacy of understandipg. New York:
Basic Books, ~

Levine, M. Scientific method and the adversary model,
American Psychologist, l974, 661-667.

Light, D.L. Becoming psychiatrists: An inside account Of the

psychiatric residency with implications fOr both the

profession and the patient. New York} W.W. Norton and
CO., 1980.

London, P. The modes and morals ofypsychotherapy. New York:
Holt, thehart, and Winston, 1964.

Luborsky, L. Research cannot yet influence clinical
practice. In A.E. Bergin & H.H. Strupp (Eds.).

Chan in frontiers in the science ofypsychotherapy.
Chicago: Aldine, l972.

Luborsky, L., Chandler, M., Auerbach, A.H., Cohen, J., &
Bachrach, H.M. Factors influencing the outcome of
psychotherapy: A review of quantitative research.
Psychological Bulletin, 1971,.Z§, l45-l85.

Maccoby, M. The gamespan: the new corporate leaders. New
York: Simon andTSchuster, 1976.

Malcolm, J. Psychoanalysis: The impgssibleyprofession.
New York: Alfred A. Knopf, 1980.

Maluccio, A.N. Learning from clients: interpersonal helping

as viewed by clients and social workers. New York: The
Free Press, l979.

Mann,iLD. The identity of the group researcher. In 6.5.

Gibbard, G.S., J.J. Hartman, & R.D. Mann (Eds.) Anal sis
of groups, San Francisco: Jossey-Bass, I974, 13- .

McCarley, T. The psychotherapist's search for self-renewal.
American Journal Of Psychiatry, 1975, l_3_2_(s), 22l-223.

Medawar, B.P. Victims of psychiatry.

New York Review of
Books, Jan. 23, l975, l7. ,

 

171

Merton, R.K. & Barber, Elinor. Sociological ambivalence.

In Sociolo ical ambivalence and other essays. New York:
The Free Press, 1976, 3-34. ,

Myrdal , G. How scientific are the social sciences? Journal
of Social Issues, 1972, gpi4), l5l-l70.

Nible, R. Interactionally based models of_personality in a
therapeutic setting. (Unpublished—Doctoral

' Dissertation) Department of Psychology, City University
of New York, New York, 1979

Nilson, Linda, B. An application of the occupational
"Uncertainty Principle“ to the professions. Social
Problems, 1979, g§(5), 570-58l.

Paget, Marianne, A. The unity of mistakes: a

henomenolo ical stu y 0 medical work. (Unpublished
Doctoral Dissertation){TDepartment of_Sociology,

Michigan State University, East Lansing, T978.

Reinharz, Shulamit On becomin a social scientist. San
Francisco: Jossey-Bass, i979

 

Robitscher, J.D.

The owers of s chiatr . Boston: Houghton
Mifflin Co., 1980.

Rosenhan, D.L. On being sane in insane places. In D.
Brisset & C. Edgley (Eds.). Life as theater: a

dramaturgical sourcebook, Chicago: Aldine, l975,

 

Ryan, W. Blaming the victim. New York: Vintage Books,
l976

Schafer, R. On becoming an analyst of one persuasion or
another. Contemporary Psychoanalysis, 1979,.l§(3).

Schofield, W.

Psychotherapy: thepurchase of friendship.
Englewood 1 s: PrentiCe-Hall,‘l964.

Searles, H.F. The "Dedicated Physician" in the field of
psychotherapy and psychoanalysis. In H.F. Searles ,
gauntertransference and Related Subjects; Selected

a

pers, New York: International Universities Press,
’ 71‘880

Shapiro, T.

Clinical Psygholinguistics. New York:
1979.

Plenum,

Sharaf,iLR., & Levinson, D.J. The quest for omnipotence in
professional training, Psychiatry, 1964, _21, l35-l49.

172

Singer, E. Key Qpcepts in psychotherapy (2nd ed.). New
York: Basic Books, 1970.

Stapp. J. & Fulcher, R. The employment of APA members. .ng
American Psychologist, 1981,.§§(11), 1216-1314.

Stent, G. Limits to the scientific understanding of man,
Science, 1978,‘l§1, l052-l057.

Stern, E.M. (ed.). The other side of the couch: what
therapists believe. New York: Pilgrim Press, l98l, 3.

Thomas L. The medusa and the sppil: more notes pf a biology
watcher. New YOFk: Viking Press, York, l979.

Wachtel, P. Investigation and its discontents: some

constraints on progress in psychological research.
American Psychologist, 1980,.§§(5), 399-408.

Watzlawick, P. The utopia syndrome. In P. Watzlawick & J.H.

Weakland (eds.). The Interactional View. New York:
"a". Norton COO, '91), 2gg-3OT.

Wheelis, A. The vocational hazards Of psychoanalysis. In

A. Wheelis, The guest For Identity. New York: W.W.
Norton and Co., , - .

Whitaker, C. & Malone, J. The Roots of Psychotherapy. New
York: Blakston, 1953.

Will, D.A., Jr. Comments on the professional life of the

psychotherapist. Contemporary Psychoanalysis, 1979,
_l_§_(4) , 560-576.

Witenberg, E.G. The inevitability of uncertainty. Journal

Of The American Academy Of Psychoanalysis, 1978, 6(3),
275-279.

APPENDIX A

Telephone Request For Subjects

Hello, my name is Sheila Bienenfeld. I am working on my
dissertation in clinical psychology from Michigan State, and
I've called you because I would like to interview you, at
your convenience, as part of my data collection.

My dissertation is called An Inquiry Into uncertainty In
The Fifth Profession, and it has to do with how clinical
psychologists feel about psychotherapy, and in general about
being clinical psychologists.

The interview is semi-structured, and it involves your
answering about twenty-five questions and filling in a brief
questionnaire. Of course I promise to maintain the strictest
confidentiality, and your name will not appear anywhere in
the data.

The interview will probably take about an hour and a
half, certainly not more than two hours.

I think it is an interesting interview, and other
psychologists I've interviewed have found it very interesting
as well.

I would be very grateful if you would participate.
Perhaps we can set a time when it would be convenient for
you.

If you have any questions, I'll be happy to answer them
when we meet, as I'm sure you understand I would rather wait
until after the interview to get into any detail about the
Specific questions I'm looking at in this dissertation.

173

Interview #

Please complete the following survey.

Date

 

Questionnaire I

If you have any questions,

pl ease feel free to inquire. Please answer all of the questions. Do
not write your name anywhere on the questionnaire.

1.
3.
4.
5.
6.

7.

Sex 2. Age

 

Are you licensed as a psychologist?

In what State?

 

When did you receive your Ph.D.?

 

For how many years (not including your training) have you been
practicing psychotherapy?

 

How many hours a week do you typically spend in the following
activities:

a. psychotherapy

 

1. individual therapy

 

2. group therapy

 

3. family therapy

 

4. other

 

b. teaching

 

1. what do you teach

 

 

c. research

 

1. what activities does that entail?

 

 

 

d. psychotherapy supervision of your own work

 

e. psychotherapy supervision of others' work

 

1. students

 

2. peers

 

174

 

175

Interview # Date

 

f. testing

 

‘1. what type of testing?

 

 

 

2. with what population?

 

 

 

g. consultation

 

1. what types of consultation?

 

 

 

h. administration

 

1. what activities does that entail?

 

 

 

8. Have you had any publications in the professional literature?

a. if yes, how many?

 

b. how would you describe them?

1. research reports

 

2. clinical reports

 

3. theoretical ideas

 

4. other

 

 

9. Have you had psychotherapy yourself? how many times

a. For how long were you in therapy in the past (list each therapy
if more than once)

 

 

in If you are currently in therapy, for how long?

 

176

 

Interview # Date

10. For each time that you have been in psychotherapy yourself,
indicate whether you consider that therapy to have been: very
successful (VS); moderately successful (MS); moderately unsuccessful

(MU); very unsuccessful (V ).

personal psychotherapy VS MS MU VU

 

first time

 

second time

 

th‘l t‘d time

 

fourth time

 

fifth time

 

 

 

 

 

 

 

Questionnaire II

‘0

What. was your image of the practice of psychotherapy when you

decided to make it your profession, e.g. How did you think you
would be spending your day?

a. What did you think would be the satisfaction of this work?

b. Dissatisfaction?

Has your idea of the profession changed in any way since you first
came into it?

a.

Since you became a psychologist has your idea of what kind of
practice you wanted to have changed at all?

b.

In what way - time, type of patients, other activities,
satisfactions, dissatisfactions?

C.

 

Would you advise someone contemplating clinical psychology to

come into this field? What would you tell them about the
problems and satisfactions of the work?

Are there any strains or pressures which you experience that seem
inherent in the work of doing psychotherapy?

DO you ever feel restricted by the requirements which practicing

therapy places on you, e.g. like to say or do something? How
often? How do you feel at such times?

How do you feel about revealing your own feelings or talking about
yourself if a patient asks you to do so?

Have your expectations about what can be accomplished in therapy
changed since you entered the field?

Tell me about one of your most successful cases, why do you think
it turned out this way?

Tell me about a case which was not successful? Why do you think
that it turned out this way?

Can you give me an example of a problem which you recently had with
a patient? Did you discuss it with anyone?

10. What sorts of things do you discuss with colleagues? Under what
conditions do you see them? Would you like to see them more
often?

177

11.

12.

13.

14.

15.

16.

I7.

178

If you were asked to recomnend one book that has most influenced
your work, what would it be?

What was the most valuable part of your training?

How so?
What was the least valuable part of your training?

How so?

Are you presently involved in any research projects? If yes,

describe. If not, do you plan to be anytime soon? How do you

feel about that?

Which research studies have had the most influence on your

thinking? How?

Does your research training influence the way you do therapy? If

yes, how? If not, do you have any thoughts about why?

During the course of your work you must encounter much uncertainty
Has this been a problem for you at any time?

and perhaps doubt.
How have you dealt with it?

H

2.

4.
5.
6.
7.

9.
IO.

11.
12.
I3.

14.

179

Sentence Completion

I'hme am doing good work when......
Smetn the warning signals that a therapy case is going badly

areOOOOO
Some of the'lessons my patients have taught me are......

Iaere my colleagues who......
'Om Hung I most dislike about research is.....
Onetming about psychotherapy that I feel certain about.....

Mylnggest problem in relating to some of my colleagues has

been....
A big influence on the way I do therapy has been.....

Some predictable milestones in the course of therapy are.....

An incident in therapy that was difficult fOr me to handle was

when......
The thing I most like about research is......

I have learned the most from patients who......

One of my biggest conflicts about my work has been.....

In my work I feel most uncertain about.....

APPENDIX B

Likert Scales

Question I: What types Of dilemmas do clinical psychologists

6.

7.

9.

10.

11.
12.

13.

14.

15.

16.

experience in their therapeutic work?
Scale: very concerned

somewhat concerned

neither concerned nor unconcerned. Can't
tell from interview

somewhat unconcerned

5 = very unconcerned

1
2
3
4

How to know when therapy should be terminated.
How to determine whether therapy has been successful.
The durability of changes that patients make in therapy.

How to behave upon meeting a patient outside of the therapy setting
(e.g. a party or a bar).

What to do if a friend requests treatment for a friend or relative
(of the friend).

How to deal with sexual attraction to patients.
How to deal with patients' sexual attraction to the therapist.

How to deal with feelings of dislike or contempt for a patient.

_What to do if the therapist disapproves of a decision a patient has

made.

What to do if the therapist disapproves of a relationship a patient
is involved in.

What to do if a patient fails to pay bills on time.

What to do if a patient makes frequent phone calls between sessions
to the therapist.

How much of the therapist's own history and current life situation
to reveal to patients voluntarily.

How to answer patient's questions about the therapist's history and
current life situation.

Whether the therapist is really earning the money that patients pay
for therapy.

Whether the therapist's technical skills are of adequate range or
quality.
180

 

181

Question 1 (continued)

17.

18.

19.
20.
21.
22.
23.

24.
25.
26.

27.
28.
29.
30.

31.

32.

very concerned

somewhat concerned

neither concerned nor unconcerned. Can't tell
from interview

somewhat unconcerned

5 = very unconcerned

Scale:

1
2
3
4

About specific mistakes the therapist has made or tends to make,
in therapy.

About special problems that arise in working with specific
categories of patients.

About feeling isolated from colleagues.

About the danger of becoming isolated from colleagues.
About the competence of other therapists.

About the ethical standards of other therapists.

About the status Of clinical psychologists as compared to other
mental health professionals.

About the possibility of malpractice actions.
About the possibility of suicide by a patient.

About the absence of a generally accepted theory of
psychotherapy.

About the absence of clear technical guidelines for doing therapy.
About how to accurately diagnose new patients.
About the stresses that are part of doing therapy.

About how to keep occupational stress from spilling over into
personal life.

'About how to balance the needs of patients against those of family

members and/or friends.

About how to make sufficient time available for writing, research,
or other professional activities.

Question 1
33. About
34. About
35. About
36 . About
37. About
38. About

182
(continued)
Scale: very concerned
somewhat concerned
neither concerned nor unconcerned. Can't tell
from interview

somewhat unconcerned
= very unconcerned

1
2
3
4
5

saving time fOr reduced-fee patients

one's own ethical standards.

dealing with feelings of anger toward a patient.

limit setting with clients in therapy.

being in therapy in order to deal with one's own issues.

having sufficient time for clients.

183

Question 4: How do clinical psychologists explicitly view the

39.
40.

41.

42.

43.

44.
45.
46.

47.

48.
49.

uncertainties in their work?
Scale: very characteristic

somewhat characteristic

neither characteristic nor uncharacteristic.
Can't tell from interview

somewhat uncharacteristic

very uncharacteristic

1
2
3
4
5

Life in general is uncertain and psychotherapy is no different.

Eventually things become clear, patience and a tolerance for
ambiguity are the keys.

Uncertainty diminishes over time, experienced therapists are less
uncertain than beginners.

Experienced therapists are no less uncertain than beginners, they
just tolerate uncertainty better.

Because uncertainty stimulates the acquisition of more training,
it is a necessary and positive aspect of psychotherapy.

Uncertainty is a sign of incompetence.
Uncertainty is a sign of burn-out.

The only way to deal with uncertainty is by being honest with
oneself.

The therapist can best deal with uncertainty by having faith in
his/her ability to be helpful.

The way to deal with uncertainty is to seek supervision.

Uncertainty is usually a countertransference phenomenon.

184

Question 5: Do clinical psychologists experience the imbalance between
their clinical and their research efforts as conflictual?

50. Does the therapist see his/her work life as well balanced in terms
of psychological research vs. psychotherapeutic practice?

very balanced

somewhat balanced

neither balanced nor unbalanced. Can't tell from interview
somewhat unbalanced

very unbalanced

01%me
II II II II II

51. If the therapist does not view his/her work life as well balanced
in terms of research vs. clinical work, does s/he express conflict
about this lack of balance?

very conflicted

somewhat conflicted

neither conflicted nor unconflicted. Can't tell from
interview

somewhat unconflicted

very unconflicted

1
2
3
4
5

52. If the therapist does not view his/her work life as well balanced
in terms of research vs. clinical activity, does s/he express
satisfaction with the ways s/he spends his/her work time?

very dissatisfied

somewhat dissatisfied

neither satisfied nor dissatisfied. Can't tell from interview
somewhat satisfied

very satisfied

mthr-a
WIIIINM

 

185

Question 6: How do clinical psychologists resolve the imbalance

53.
54.
55.
56.

57.

58.

59.

60.

between their clinical and their research activities?
Scale: very characteristic

somewhat characteristic

neither characteristic nor uncharacteristic.
Can't tell from interview

= somewhat uncharacteristic

= very uncharacteristic

1
2
3
4
5

Views research as irrelevant to psychotherapy.
Views research as incompatible with therapy.
Believes therapy is research.

Believes that the goal of research training is to develop a style
of rigorous thinking rather than actual research productivity.

Believes the goal of research training is the development of the
ability to read and evaluate published research, rather than
actual research productivity.

Believes that research is an activity fOr academicians, and that
practitioners have no special obligation to do research in a
formal sense.

Believes that clinical psychologists have a special responsibility
to do research.

Believes that research requires special skills that most
therapists don't have.

Question 7: What effect does training in research have on the way

61.
62.
63.
64.

clinical psychologists do psychotherapy?

Scale: 1 = very relevant
2 = somewhat relevant
3 = neither relevant nor irrelevant
4 = somewhat irrelevant.
5 = very irrelevant

Relevance of past research experiencese to present activities
as a reseacher.

as a therapist.

in other professional activities.

in psychological testing.

186
Question 7 (continued)

65. Overall view of graduate school research experience

1 = very positive 4 = somewhat negative
2 = somewhat positive 5 = very negative
3 = neither positive nor negative, can't tell from interview

 

66. Research experiences have led to a tendency to think more
critically and thus enhance the practice of therapy.

strongly agree

agree somewhat

neither agree nor disagree. Can't tell from interview
disagree somewhat

strongly disagree

0141-me
II II II II II

67. Research experiences lead to a way of thinking that gets in the
way of doing therapy.

strongly agree

agree somewhat

neither agree nor disagree. Can't tell from interview.
disagree somewhat

disagree strongly

68.

strongly agree

agree somewhat

neither agree nor disagree. Can't tell from interview.
disagree somewhat

strongly disagree

0145me
II II II II II

69. Views psychotherapy as a science.

strongly agree

agree somewhat

neither agree nor disagree. Can't tell from interview.
disagree somewhat

strongly disagree

m-wal-A
II II II II II

187

Question 8: Are clinical psychologists satisfied with their research

70.

71.
72.

73.

74.

training?

very relevant

somewhat relevant

neither relevant nor irrelevant, can't tell
from interview

somewhat irrelevant

= very irrelevant

Scale:

1
2
3
4
5

Relevance of research training for completion of graduate school
requirements. '

Relevance of research training for learning to do psychotherapy.

Relevance of research training for learning diagnostic
procedures.

Overall satisfaction with research training.

very satisfied

somewhat satisfied

neither satisfied nor dissatisfied, can't tell from interview
somewhat dissatisfied

very satisfied

01¢me
II II II H II

Overall view of research as part of the professional identity
of the clinical psychologist.

= very important

somewhat important

neither important nor unimportant, can't tell from interview
somewhat unimportant

very unimportant

m-thH
II II

Q-Sort Deck

Question 2: What principles, predispositions, or tacit "theories in

1.

10.
11.

12.

13.
14.

15.
16.

17.

18.
19.

20.

use" guide clinical psychologists' reactions to
therapeutic uncertainty?

Therapists who work in institutions burn-out faster.

Playfulness is an important part of therapy.

The needs of the patient should determine the therapist's approach.

People don't really understand what therapists do.

Therapy is an almost magical process, it defies explanation.
PeOple expect too much from therapists.

It is best to be an eclectic therapist.

Therapists have to be very patient people.

For therapy to succeed, the therapist and the patient must like
each other.

There are as many "therapies“ as there are therapists.

There's really no way to predict whether a patient will get better
or not.

Therapists should be content to see small changes in their
patients' lives.

A therapist can never be free from self-doubt.

Psychologists are at a disadvantage because they don't have the
power that psychiatrists have.

Psychologists should get as much post-Ph.D. training as possible.

The ambiguity Of psychotherapy is one of the things that makes it
frustrating.

If therapy is to succeed, the therapist has to be on the patient's
side.

Psychoanalysis is still the best therapeutic approach.

Psychotherapy is no more ethically difficult than any other
profession.

Therapists should stick to the "tried and true" methods of
psychotherapy.

188

' 210

22.

23.
24.
25.

26.

27.

28.

29.
30.

31.
32.
33.

34.
35.

36.
37.
38.

39.

40.

189
Q-Sort Deck (continued)

It is important for therapists to give up their omnipotent
strivings.

To be a good therapist you have to be able to tolerate alot of
uncertainty.

A well trained therapist can work with almost any kind Of patient.
It is difficult to work with patients when they are angry.

The main goal of therapy is to help patients relate better to
others.

A therapist who is uncertain about his/her work is probably a poor
therapist.

Regardless of who the patient is, a good therapist is a good
therapist.

Anything you do in psychotherapy is OK as long as you know why
you're doing it.

"Process“ is more important than “content“ in psychotherapy.

Flexibility is one of the most important characteristics a
therapist can have.

Research training helps psychologists to think critically.
Alot of therapists don't know what they're doing.

A good therapist for one person can be a lousy therapist for
someone else.

Therapy is an art, not a science.

Therapists should feel more guilty about their failures than they
do.

Psychotherapy requires risk-taking on the patient's part.
Psychodynamic theory is the most useful theory of therapy.

For therapy to succeed, the patient has to feel heard and
understood by the therapist.

The most important training experience for therapists is
supervision.

Psychotherapy works best with patients who are already doing
well.

41.

42.
43.
44.

45.

46.

47.

49.

50.

51.
52.

53.
54.
55.
56.

57.

58.

59.
60.

190
Q-Sort Deck (continued)

A therapist just has to have confidence in his/her ability to be
helpful.

The most important training experience for therapists is practice.
No one really knows how or when psychotherapy works.

When therapy becomes emotionally draining fbr the therapist it is
a sign that something is going wrong.

It is difficult fbr therapists not to take their patients'
problems home with them.

Working with the transference is the key to successful therapy.
Successful therapy helps people fit in better in society.
Therapy is emotionally draining for the therapist.

The goals of therapy should be allowed to change over time.

When it is going well, therapy is an emotionally enriching
experience for the therapist.

When therapy fails, both patient and therapist are responsible.

People are all basically alike, no matter what their socio-
economic background.

Therapy is more like friendship than anything else.
Therapy is mostly inspiration and a little hard work.
Insight is basically irrelevant.

It is important for therapists to take the patient's economic and
social situation seriously.

Therapists don't usually find the professional literature very
helpful.

Therapists don't change peOple, they are just catalysts for
change.

Therapy is a skill that can be explained and taught.

After a certain amount of experience, supervision is no longer
really necessary.

61.

62.
63.
64.
65.
66.
67.
68.
69.
70.
71.

72.
73.
74.

75.

76.
77.

78..

79.

80.

81.

191
Q-Sort Deck (continued)

Talking to colleagues is good because it just helps to have
someone to talk to.

Research training is ultimately of little value to therapists.
Intuition is one of the therapist's major tools.

Psychoanalysis is outmoded.

Humor is an important therapeutic tool.

Setting boundaries is one of the most important parts of therapy.
Life experience is one of the therapist's major tools.

Therapists usually feel satisfied with the outcome of therapy.
Patients are easy to please.

A good therapist is a skilled craftsman.

The therapist's own feelings about the patient are the best data
about how therapy is progressing.

It is the therapist's responsibility if therapy fails.
Therapy is an intrinsically slow process.

Therapy should be terminated when its initial goals have been
reached.

A therapist should have a coherent theoretical framework fbr doing
therapy.

Patients are rarely healthier than their therapists.

Therapists should be careful to keep their own needs outside
therapy.

Therapists should always be experimenting with the latest
techniques.

It is important to belong to a philosophical "school“ of
psychotherapy.

It is important to focus on the patient's behavior outside of
therapy.

Psychodynamic theory is not helpful in doing therapy.

82.
83.

84.
85.

86.
87.
88.

89.

90.
91.

92.

93.

94.
95.
96.
97.
98.
99.

100.

192
Q-Sort Deck (continued)
It is important to be honest with patients at all times.

Therapists should be able to take from their patients as well as
give.

It is inappropriate for a therapist to give advice to patients.

It is impossible for a therapist to keep his/her own needs outside
of therapy.

Therapists should feel free to touch or hold their patients.
The therapist's job is to build up the patient's self-esteem.

The therapist's best source of information is the patient's
resistance.

A therapist should always get supervision no matter how
experienced s/he is.

Research training helps psychologists understand their work.

Therapists often rely on their own life experiences in order to
know how to guide their patients.

Talking about their own lives is the way some therapists give to
their patients.

Even when they try not to, therapists impose their values on
patients.

Most therapists feel guilty about their failures.
Patients are therapists' best teachers.
Therapists expect too much from themselves.
Insight is the most important outcome of therapy.
Miracles don't happen in psychotherapy.

Ineffective therapists think their colleagues are ineffective
too.

There's a certain kind of person who's a born therapist.

APPENDIX C

193

Table C-l

Psychologists‘ Explicit Attitudes Toward Uncertainty:
These Attitudes and Delopraphic Characteristics and Between These Attitudes and
Therapist Concerns (Likert Scales)

5

hours/week of
psychotherapy

current
"SCUM

activity

Personal
vs. Profes-
sional tife

Concern

ll
about self-

disclosure

Relationships Between

Concern

fees are eamed

IV.

About denier

ihcertai nty

in technique

Concern
therapeutic and

guidelines

about lack of

 

Sliflhmu
m

b

a Mlication

i:

in

in

h

 

-.U

 

0-.

 

o.“

.10

 

.e!‘

 

 

 

 

-j

«I

 

6J5:

 

«I

.47

«D

 

 

«I!

«O.

'i

 

o.“

 

 

 

«0'

 

 

 

b

 

 

it

”I

 

‘i

 

 

 

1S74

ou~a_—.u~. cu ceece :—

.o-~ acouua—u we. ue—aa_c-s

~5.vnee

Unan-

o—oeuuuooea
nc.vae

.ocog venue—3.5 econ use: age-e.g.eo.u ..e... aeo.uo—occou «case—ac .mc.ec~.ucoec=

2.1.38... .5 .... ...: 3 3:88 8.8:... 2: ... v9.8. 82. E: 832.8

 

 

 

..o-..

mo.~n.coauacasu u—gn-sooeoa v:-
>aocmguogu>ma ou mogooocca< .....s-.. accoucou ...aacoz— eoosaou naguco.aa_o¢ 9:.3ogm x_cuox co.uo.occou guano:

«-u epoch

co. p«.-.c—v.-ca«m.+ on. acom.-aamm.- «N. ee«Q.-eacm.- on. «oo.- oe—o.- o«. «—.- cos..- «c.- m«. 0—. «p.-
oo— v«. m«.-acov. c—. on.- no.- «—.- ne.- «9. c—.- cevm.a '0. o—.- .9. o—.- c—.- 0—. n«.
cc. o—.- a—.- «0. ~«.- n—.- ——.- 0—. oo. «o.- «n.- cau«.o coco. n—. u«.- c—. o«. n—.-
cc— o«.-*ano.- «on.- _o.- o«. aon.- c«. pa.- ee«m.- o—.- «o.- a-.- esn.-ca—v. 0:. n«.-
co. m—. n—.- pa. ~—. oc.- o«.- oo.- aon.+ o«. n—.- 0—. vo.-acnv.- cap..- —n.
oo— cc«c.+ no. coon.+eesm.a ee«m.+ «o.- nn.- up. n—.- ——. up. nn.- «—.- an.
co— ma. v«. acct. ea... ~—.-ae—~. 0:. ac.- oa—m.+ «o.- —n. 0—. can...
oo- «c. —a. o—.- n«.- «a. «—. m—. m:.- :0. a«.- —o.- —c.-
so. eon. pa. n«. s«. ac. m—.- 0—. o«.- m—. c—. «—.
oe- oaco. we. ««. v«.- s«. oe.-oaov.a 0—. 0—. Q..-
09— —«.- «a. m—.- .9. ee—o.¢ «—.- «n. ea«m.- an.-
8. 2. 3.. s: z: 2.- 3.- 8. .8:
ee— «9.- o—.- —n.- no.- —p. ~—.- op.-
ee— cues.» v—.- o«. 0—.- oc.- mp.
eo— pm. nu.- no. no. pm.-
69— o—.- n:. oc.- no.
8. a: 8.- z.
oo- eevm. heat.-
00— sun.-
EL
new cl. I I el- l a P s
m... m... m..- w. w... ...... mummwmm. .- mmnmw .- m .n m w m a ....
m.1. u w W.J “mm" mfim “u‘u mu. ""6.“ w. NJN gamma; .3.4 n" mm t. I. w m
mm»... mm .... » mm mama...” ...... m m... m w um. m m w m.
MN. 35. d U. 3 o I, la a 3 It so.
.. ......“ . 3%.... . mm... . .. ...... m . .
. .. w m3... . . .... m ..
m n . ... new...“ ..... m m m a um- . .a
l. W W . l. 3 0 fl 1. no N l.-e. M
m n u I. a um s u
. .1

 

"mac:

co.uoc—nme_ a. annoys“ .o
occasou u:o_u~a.uo>.oucoa .m
nauseous—e gaseouoc .o
gases“ .0 co.uo~._ocomcoa .m
unset-upon .Auc.oucouc= .N
u_auo—o.u.5ocxuaguxmq .—
39.:guou :. nuc.uucouc: .___
Au.>.auc soc-ammo paauua
.o oa.m»:o o=.c.ocu
ucoomuc 5o huge—3‘s“: .___>
a...
_oeo.mmoaocu .ns _acomcoa .—
ocauo—um.e-~—om .>_
ace—buu.:o
sea xgooga u.u=o space
no son. “scan ccoueou ._>
«on. usage :coucau ...
mecoucou —~u_guo .>
a».— pcco_mmo‘oca c.
.aco.uao~oca :— mc.:_ocu
gucouuoc ~o ouca>o_oc .__>
gucaomoc
meo.uou__a=q
anacogu .xuox\mc:og
.a.ga cue.“ mean»
one
eeexflu

APPENDIX D

General Instructions To Raters

Before you begin rating an interview, read the
entire transcript. Once you have read the transcript
through you can begin. Although you should base your
ratings on the entire transcript there are certain portions
of it that should be especially relevant for different

groups of scales. These are as follow:

For scales 1-38 pay special attention to interview
questions 3;6;9; and 17; and incomplete sentences 6; 10;
and 14.

For scales 39-49 pay special attention to interview
questions 3;6;9; and 17; and incomplete sentences 6; 10;
and 14.

For scales 50-50 pay special attention to interview
questions 11;14;15; and 16; and incomplete sentences 5 and
11.

For scales 61-74 pay special attention to interview
questions 1;2;12;13;15; and 16; and incomplete sentences

5;8; and 11.

195

196

As a general rule, a rating of 1 (very concerned)

 

should be given when the therapist is either strongly
concerned or conflicted about an issue or the issue is
clearly one of considerable concern.

A rating of 2 (somewhat concerned) shouldbe given

 

when the therapist expresses some conflict, distress, or

concern, but the issue does not seem very important to him

 

or her.

A rating of 3 (neither concerned nor unconcerned,

 

can't tell from the interview) should be given when the

 

issue does not appear at all in the interview, or when the
therapist takes a relativistic or case by case stance
toward the issue.

A rating of 4 (somewhat unconcerned) should be given

 

when the therapist recognizes the issue as potentially

important but only for others rather than for

 

him/herself.

A rating of 5 (very unconcerned) should be given

 

when the therapist either views the issue as trivial or has
a fixed stance of one sort or another toward the issue that

allows for virtually no conflict.

 

APPENDIX E

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started

And know the place for the first time.

T.S. Eliot (Little Giddings)

197