PSYCHO?HERAFiSTS‘ APPROACH-AVOSDANCE RESPONSES AND CLIENTS' EXPRESSIONS OF DEPENDENCY: A LCNGITUDENAL ANALYSIS Thesis for the Degree of DE. D. MECHIGAN STATE UNIVERSITY Walter John Schuldt 1964 THESIS This is to certify that the thesis entitled PSYCHO THERAPI STS ' APPROACH-AVG IDAN CE RESPONSES AND CLIENTS' EXPRESSIONS OF DEPENDENCY: A LONGITUDINAL ANALYSIS presented by Walter John SChuldt has been accepted towards fulfillment of the requirements for _Eh..D__ degree in MO gy {{W% de Major professor Date Auguslb 12, 1964 0-169 LIBRAR Y1; M lCl] lgan S (:3 to University ABSTRACT PSYCHDTHERAPISTS' APPROACH-AVOIDANCE RESPONSES AND CLIENTS' EXPRESSIONS OF DEPENDENCY: A LONGITUDINAL ANALYSIS by Walter John Schuldt Clients' expressions of dependency have long been considered as important occurrences within the psycho- therapeutic relationship. This research assesses the vicissitudes of such expressions as a function of the approach~avoidance responses of therapists during the process of psychotherapy. The hypotheses are: (1) clients, in five stages of therapy. will tend to continue expressions of dependency when approached by therapists and will tend to discontinue such expressions when avoided by therapists, (2) therapists will approach dependency more during the initial stages of therapy than they will during the later stages, (3) thera- pists will approach dependency directed at themselves more than they will approach dependency directed at others. (4) experienced therapists will approach dependency more often during the initial stage of therapy than will less experienced therapists. and (5) clients will manifest more client-initiated-dependency during the initial stage of therapy than during the final stage. Walter John Schuldt The data used in this study were obtained by content- analysis of 80 tape recorded interviews with 16 clients at the Michigan State University Counseling Center. Inter— views of each client were selected at five points from the beginning to the end of treatment. Statistical analyses of data reveal that (1) clients, in all five stages of therapy, tend to continue expressions of dependency when approached by therapists and tend to discontinue such expressions when avoided by therapists. (2) therapists do not approach dependency more during the initial stage of therapy than they do during the later stages, (3) therapists approach dependency directed at themselves more than they approach dependency directed at others, (4) experienced therapists do not approach dependency more than do less expreienced therapists, and (5) clients manifest more client—initiated-dependency in the initial stage of therapy than in the final stage. Exploratory analyses were utilized to assess the statistical significance of response variation noted in the five stages of psychotherapy. The analyses of thera- pist variables indicate that (l) therapists do not manifest a significant variation in approach rate to dependency during the course of psychotherapy, (2) therapists do not manifest significant changes in their approach rates to dependency directed at themselves during the five stages of therapy, and (3) there are no significant differences between experienced and less expreienced therapists on the therapists variables being studied. Walter John Schuldt The statistical analyses of client variables indicate that (1) clients manifest significantly less continuance of dependency following approach in the later stages of therapy than in the earlier stages, (2) clients do not manifest significant changes in their continuance rate following avoidance, (3) clients do not manifest signifi- cant changes in their rate of dependency which is directed at the therapist during the five stages of psychotherapy, and (4) clients do not manifest significant changes, from the first to final interview, in their rate of client-initiated-dependency which was directed at the therapist. These results were discussed in view of theory as well as psychotherapeutic application. Moreover, limitations of the study and implications for future research were delineated. PSYCHOTHERAPISTS' APPROACH-AVOIDANCE RESPONSES AND CLIENTS' EXPRESSIONS OF DEPENDENCY: A LONGITUDINAL ANALYSIS BY Walter John Schuldt A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1964 Dedicated with love to Doris and Andrea ACKNOWLEDGMENTS This writer wishes to express respect and gratitude to his chairman, Dr. C. L. Winder, for his proficient direction of this thesis. The writer also wishes to thank Dr. Lucy C. Rau and Dr. Charles Hanley for their cooperation and valuable suggestions. Gratitude is deeply expressed to Dr. Josephine Morse for her constant support and belief in the writer. The writer also wishes to express his appreciation to Duane varble for his collaboration in the coding of the tape recordings. Above all, I wish to thank the therapists and clients of the Michigan State University Counseling Center for their willingness to allow their very intimate therapeutic relationships to be recorded and scrutinized in the interest of research. iii Chapter TABLE OF CONTENTS I. INTRODUCTION . Dependency in Psychotherapy Generation of Hypotheses II. METHOD Source of Data Clients Therapists Stage of Treatment Sampled Coding Procedures Inter—rater Reliability III. RESULTS Scores Inter-rater Reliability Statistical Evaluations of Hypotheses Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis IV. DISCUSSION . . Therapist variables I II III IV V Client Variables V. SUMMARY . REFERENCES . APPENDICES . . iv Page 14 14 15 15 16 17 18 20 20 21 21 21 23 24 25 27 29 29 36 44 47 51 Table 1. 2. LIST OF TABLES Descriptive summary of the sample . . . . . Definitions of scores . . . . . . . . . . . Inter-rater reliability coefficients of scores 0 O O O O O O O C O O O O O O 0 Mean D Ap 0% and mean D Av C% for five stages of psychotherapy . . . . . . . . Mean D Ap%,for five stages of psychotherapy Therapists' approach to dependency with therapist and other as object . . . . . Mean D Ap% during the initial stage of therapy for staff and intern psycho— therapists . . . . . . . . . . . . . . Mean CID% during the first and last stage of therapy . . . . . . . . . . Page 15 21 22 22 24 24 25 27 LIST OF APPENDICES Appendix Page I. SCORING MANUAL . . . . . . . . . . . . . . . 52 II. MEAN PROPORTIONS OF DEPENDENCY, HOSTILITY, AND OTHER IN FIVE STAGES OF PSYCHOTHERAPY 65 III. MEAN PROPORTIONS OF THE SUBCATEGORIES OF APPROACH AND AVOIDANCE T0 DEPENDENCY_ IN FIVE STAGES OF PSYCHOTHERAPY . . . . . 66 vi I . INTRODUCTION The earliest comprehensive investigations into the process of psychotherapy were conducted by Sigmund Freud. As early as 1919, he clearly recognized the need for research (Freud, 1919). However, his preferred mode of investigation was that of uncontrolled observation. He stated that his findings were founded "either on direct observations or on conclusions drawn from observations" (Freud, 1958, p. 256). Freud found it difficult to provide objective evidence for his findings and found it equally difficult to demonstrate the process of psychotherapy. He suggested that demonstration was impossible because the patient "will make the communications necessary to the analysis only under the conditions of a special affective relation- ship to the physician: in the presence of a single person to whom he was indifferent he would become mute" (Freud, 1958, p. 22). These attitudes made controlled research impossible and led to a body of knowledge based primarily on the global observations and impressions of the therapist. To this date, little controlled research has been initiated by psychoanalytically oriented psychotherapists. Rather, they tend to maintain the privity of their therapeutic interactions and report their impressions based on global observations. The great impetus for the application of controlled research methods to the process of psychotherapy can be credited to Carl Rogers and his f01lowers. In fact, the major portion of present psychotherapy research literature was generated by this group (see Cartwright, 1957). It is felt that the research productivity of this group can be primarily attributed to (l) the use of Covner's method (Covner, 1942) for the phonographic recording of interviews, and (2) the willingness of Rogerian therapists to make their therapeutic techniques open for scientific scrutiny. The use of recordings by the Rogerian therapists made possible controlled research into the process variables of psychotherapy (e.g., Raimy, 1948; Seeman, 1949; and Snyder, 1945). The great quantity of data present on electrical recordings necessitated the development of systems for the analysis of content. A comprehensive review and critique of many of these systems has been accomplished_by Auld and Murray (1955). The third major contribution to research in psycho— therapy developed out of Dollard and Miller's (1950) translation of psychoanalysis into a learning model, and out of Skinner's (1953, 1957) insistence that verbal expressions are behavioral responses and are thus subject to experimental manipulation. This has led to the recent deludge of verbal conditioning studies (see Greenspoon, 1962: Krasner, 1958: Salzinger, 1959). However, one can note the paucity of studies using data from actual thera- peutic situations. Thus, it appears that many researchers are concerned with verbal expressions within the interview situation as data to investigate propositions of learning rather than the use of learning principles to investigate the relationships of events within the interview. Murray (1956) was one of the first to study actual psychotherapy from a learning position. He analyzed content within the interaction of Carl Rogers and his client, Herbert Bryan. He devised a content scoring system in which therapists' statements could be classified as approving or disapproving. He found, basically, that categories of the client's statements which were followed by approval increased during therapy while the frequency of those categories followed by disapproval decreased. Bandura et. a1. (1960) later modified Murray's scoring system in their attempt to assess the effect of the psychotherapist approaching or avoiding patients' expressions of hostility. Their major revisions were (1) the criterion for scoring therapists responses into approach and avoidance categories, and (2) the intro- duction of the concept of the interaction sequence as the unit to be scored. In their system they defined approach reactions as verbal responses "designed to elicit from the patient further expressions of hostile feelings, attitudes, and behavior." Avoidance reactions were those verbal responses "designed to inhibit, discourage, or divert the patients hostile expressions." The interaction unit, introduced by Bandura et. al., began with a patient's verbal statement, followed by the therapist's response, which was, in turn, followed by another statement by the patient. This unit of scoring allows for the independent stady of the patient's or therapist's verbal responses as well as the interaction between them. Winder et. al. (1962) later devised a system analo-- gone to that developed by Bandura et. al. The major dif- ference was that Winder et. a1. were interested in the patient's dependency expressions while Bandura et. al. were interested in the patient's hostility expressions. In Winder's system, approach is defined as those "reactions of the psychotherapist which are designed to elicit from the patient further verbalizations of the topic under discussion": avoidance is defined as those "reactions by the psychotherapist which are designed to inhibit, discourage, or divert the patient from further verbalizations about the topic under discussion." More- over, in Winder's.system dependency was defined as "any expression of approval-seeking, information-seeking, demand for initiation of activity or discussion by the psycho- therapist, help—seeking, company-seeking, concern about disapproval, or agreement with others." These methods of content analysis can be criticized on the grounds that they might omit meaningful material of a more global nature. HOwever, this writer is in accord with Auld and Murray (1955, p. 391) where they state that "it seems unfair to expect any single content-analysis system to describe all of this complex situation" and when they comment that researchers may eventually construct an adequate method for research in psychotherapy by the combination of "a variety of measures, each useful in its own domain. . . Dependency in Psychotherapy Dependency has long been recognized as an important component of psychotherapy. In fact, Peterson et. a1. (1958) noted that dependency was one of the six areas that therapists consider to be significant foci within the therapeutic relationship. Although little controlled research has been accomplished on dependency in psycho- therapy (Snyder, 1963), much has been written about it. Freud maintained that much dependency is regenerated within therapy as a function of the process of transference. Freud defined transference as a "striking pecularity of neurotics" in which emotional reactions develop toward the therapist "which are not based upon the actual situation but are derived from their relations toward their parents" (Freud, 1944, p. 674). Mbreover, he felt that psychoanalytic therapy focuses on the resolution of this acquired trans- ference neurosis (Freud, 1958). Alexander and Ross (1952) feel that the development of dependency is necessary to face and resolve underlying conflicts with the parents. Fenichel (1945) stresses the need to resolve the transference through interpretation. Wolberg has stressed the need to reduce the client's need for dependence. He has stated that "only when the patient begins to experience himself as a person with aggressive- ness, assertiveness and independence will he be able to function with any degree of well-being" (Wolberg, 1954, p. 609). Fromm—Reichman seems to hold a view similar to that of Wolberg in that she states that the true therapeutic goal is "gaining independence from one's previous hateful or loving attachments to one's elders and gaining a non- defiant sense of self—value and independence free and apart from their judgment" (Fromm—Reichman, 1950, p. 189). This seems basically similar to Rogers' (1951) concept of a need for self-actualization. Rogers has noted also the presence of dependency and transference attitudes within the therapy situation. However, he states that "strong attitudes of a transference nature occur in a relatively small minority of cases, but that such attitudes occur in some degree in the majority of cases" (Rogers, 1951, p. 199). He feels that strong dependent relations develop within the analytic process due to the evaluatory interpretations of dependent behavior (Rogers, 1951). Moreover, he feels that in client centered therapy these attitudes toward the therapist are "mild and of a reality nature" because the therapist attempts to understand these attitudes rather than interpret them (Rogers, 1951). As therapy proceeds, he expects a decrease in dependency on the part of the client and an increase in independency and self-actualization. Most learning theorists feel that dependency develops within the therapy situation as a function of generalization of behavior learned in the context of earlier interpersonal relations. Dollard and Miller (1950) also feel that it is desirable to promote such dependency within the early phases of treatment. Snyder (1963) has described "relationship therapy" which is eclectic in nature. He feels that the theoretical underpinnings of his system has been derived out of learning theory, the contents of interpretations are based on Freudian theory, and the "spirit of therapy" has developed out of client centered therapy. Within relationship therapy, the therapist will frequently encourage dependency in the initial stages of therapy to build up a strong relationship with the client. However, the therapist has two main objectives: (1) "to change the client's attitudes about his ability to meet problem situations," and (2) "to help the client obtain experience in handling the problem situations." Snyder feels that as "clients attitudes to- ward himself change and as his experience in solving problems successfully increases, he will become able to function more independently both within and outside of the therapy situation" (Snyder, 1963, p. 5). While much has been written on the vicissitudes of dependency in psychotherapy, little controlled research has been accomplished to verify these theoretical expecta- tions. Snyder (1963) has done one of the most comprehensive longitudinal studies of dependency in psychotherapy. He found that his clients did not manifest much variation in the occurrence of dependency as therapy progressed but that his "better clients" manifested greater dependency near the middle of therapy. Snyder, in the same publication, reviews ‘ -'some of the most significant research-oriented studies of dependency in psychotherapy. However, this review does not include the recent research of Winder et. a1. (1962) and his followers (i.e., Barnes, 1963; Caracena, 1963: Kopplin, 1963; Lerman, 1963). The work of Winder et. al., and Caracena is the basis for the present research. It is stressed that the theoretical and methodological position utilized by these researchers is not considered by this writer to be the model for the investigation of dependency in psychotherapy. However, it is felt that their research is based on a well delineated theoretical position and presents a well articulated method for investigation. Generation of Hypotheses Winder et. a1. (1962) have studied dependency as it occurs within the interaction of therapist and client. They found that clients continue to express content related to dependency if the therapist approaches such content. Moreover, they found that the client will tend to dis— continue such content if the therapist avoids this content. It is to be noted that their results are based on parents seen at a child guidance clinic; the therapists were graduate students in clinical psychology. The basic findings of Winder et. al. have also been found by Caracena (1963) and Lerman (1963) utilizing a very similar method of investigation. Lerman's data were obtained from clients who were undergraduate university students and the therapists were graduate students in either counseling or clinical psychology. Caracena's study was based on clients who were also undergraduate university students; the therapists were professional staff psychologists, advanced clinical or counseling psychologists serving as interns, and inexperienced graduate students participating in a particum course in psychotherapy. It is concluded that these studies allow for the generalization of the findings of Winder et. al. in View of the diversity of clients and therapists. However, the findings are restricted by the stage of therapy from which the data were obtained. 10 The findings of Winder et. a1. and Caracena were based on data obtained from first and second interviews. Lerman's findings were based on data obtained from the first, second, fifth and some seventh interviews. Thus, generalization of these findings are limited by the fact that all the data were from early interviews and not from the entire process of psychotherapy. The following hypothesis is stated to allow generalization of the findings of Winder et. al. to the entire process of psychotherapy: Hypothesis I: When dependency expressions are approached by therapists, clients will tend to continue such expressions; when depen- dency expressions are avoided by therapists, clients will tend to discontinue such expressions. (This is hypothesized to occur regardless of the stage of therapy being investigated.) Winder et. a1. and Caracena have found that therapists manifest a high frequency of approach to dependency during the initial stage of psychotherapy. One could expect the therapist to continue this high frequency of approach to dependency during the middle stage of therapy to give support at a time when much anxiety is usually present. However, since one of the primary goals of therapy is to allow the client to develop feelings of independence, one would also expect the therapist to decrease his frequency of approach to dependency during the later stages of psychotherapy. Thus, it is hypothesized that: Hypothesis II: Therapists will tend to approach dependency more during the initial stages of psychotherapy than they Will during the later stages. 11 It is to be remembered that the therapist is a person who is participating in a therapeutic relationship. As such the characteristics of the therapist must be taken into account. Grater, Kell and Morse (1961) have con- ceptualized the therapist as an individual with a high nurturance need. If this is true, one could expect response specificity during the therapeutic hour. The scoring system utilized in this study allows one to look at the object of the client's dependency, i.e., does the client direct dependency at the therapist or at some other individual? If the therapist is a nurturant individual one could hypothesize the following. Hypothesis III: Therapists will approach dependency directed at themselves more than they will approach dependency directed at others. The degree of experience of therapists has been an important variable in psychotherapeutic research (e.g., Abeles, 1962; Chance, 1959: Fey. 1958; Fiedler, 1953: Schuldt, 1963; and Strupp, 1955a, 1955b, 1960). Caracena has noted differential performance between experienced and less experienced therapists. He found that experienced therapists approach dependency signi— ficantly more than less experienced therapists. However, this result is also based on data obtained in the initial stage of therapy. Moreover, his findings have not been replicated. The following hypothesis is stated to allow this replication: 12 Hypothesis IV: Experienced therapists will tend to approach dependency more often during the initial stage of therapy than will less experienced therapists. However, since this finding has been obtained with data from the initial stage of psychotherapy, one might question whether the differential performance of experienced and less experienced therapists might be specific to this stage of psychotherapy, i.e., will less experienced thera— pists function more similar to experienced therapists when the entire process of psychotherapy is taken into account? This is an empirical question which requires exploratory investigation. It is to be noted that Winder et. al. have been primarily concerned with dependency that continues after being approached or avoided by the therapist. However, Caracena has added to our understanding of therapy by delineating client-initiated—dependency, i.e., dependency expressions which are not in response to the therapist's approach or avoidance of dependency. Caracena has used this concept to investigate the reinforcement properties of approach. He speculated that if approach is a reinforcer, then client-initiated- dependency should increase during an interview as a function of the high reinforcement rate for dependency. However, this hypothesis was not given much support by his findings. Another hypothesis seems meaningful in view of the earlier review of dependency literature. It can be 13 noted that most psychotherapists expect clients to become less dependent as therapy progresses. One can speculate that a client will continue to talk about dependency when his dependency expression is approached by the therapist. However, one could also expect a client to initiate few dependency expressions during the later stages of therapy because of his growing feelings of independence. Thus, it is specifically hypothesized: Hypothesis V: Clients will manifest more client-initiated-dependency during the initial stage of therapy than they will during the final stage of therapy. The methods used to evaluate these hypotheses will be delineated in Chapter II. The results obtained from the statistical evaluation of the data will be contained in Chapter III. II. METHOD Source of Data The staff of the Counseling Center at Michigan State University is developing a library of tape recorded psychotherapy interviews. All interviews between therapist and client are being recorded. At present, 42 clients and 24 psychotherapists are participating in this research project. All clients participating in this project are undergraduate university students who have come to the Counseling Center requesting personal counseling. These clients were initially seen in an intake interview in which it was determined if this prospective client would be seen in psychotherapy at the Counseling Center. All accepted clients were asked to participate in the research project if they had not been previously seen in psycho- therapy. Most of the clients were assigned to the partici- pating therapists on the basis of time availability. However, the reports of the intake interview were made available to the therapists and final assignment was made contingent upon acceptance by the therapist. A descriptive summary of the clients and therapists who participated in the study is contained in Table 1. l4 15 Table 1. Descriptive summary of the sample. Sex Mean Years Experience in Therapists Number Females Males Psychotherapy Staff 6 2 4 7.5 Interns 7 2 5 2.0 Sex Mean number Clients Females Males of interviews Clients seen by staff 8 5 3 14 Clients seen by interns 8 5 3 l4 Clients The data used in the present study were obtained from tape recorded psychotherapy interviews of 16 clients (10 females and 6 males) selected from the 42 clients mentioned above. These 16 clients were selected according to the following criteria: (1) all clients had been termi- nated, and (2) the therapists had judged the client's treatment to be successful. It is to be noted that the policy of the Counseling Center encourages short-term therapy, e.g., 10-20 interviews. While treatment often exceeds this duration, therapy terminated after 10 to 20 interviews is frequently judged as successful. Therapists Two groups of therapists participated in this study-- staff psychotherapists and intern psychotherapists. The staff group was composed of 6 doctoral level counseling or 16 clinical psychologists (2 females and 4 males) with 2 to 12 years' experience in psychotherapy. All were regular staff members of the Michigan State University Counseling Center. Some selection entered into the composition of this group because (1) therapists could be included only if their research clients met the criteria for acceptance, and (2) all staff psychotherapists were not participating in the research project at this time. The intern group was composed of 7 advanced graduate students (2 females and 5 males) at Michigan State University. These interns were employed as Assistant Instructors at the Counseling Center of Michigan State University. The interns also were enrolled in the clinical psychology program, Department of Psychology, or one of the counseling programs, College of Education. All interns had completed their practicum experience in psychotherapy and had an average of two years of intensive supervision in psychotherapy. Some selection also entered into the composition of this group because interns could be included only if their research clients met the criterion for acceptance. Stages of Treatment Sampled Five interviews were selected from each of the 16 clients that participated in this research. These inter— views were selected proportional to the total number of interviews which each client was seen during treatment. The interviews that occurred at the lst, 25th, 50th, 75th 17 and 100th percentile were used as the sample tapes for each client. The initial interview, with the intake interviewer, and the final termination interview, with the therapist, were not included in the selection. These were not included because it was felt that they could not be properly called therapy interviews. Coding,Procedure The coding procedure was that used by Caracena (1963) and Kopplin (1963). This procedure is a modification of the content analysis systems employed by Bandura et. al. (1960) and Winder et. al. (1962). The manual used in this research is contained in Appendix I. The client categories that were coded are: dependency, hostility, other (see Appendix II), client- initiated-dependency, c1ient-initiated—hostility, and the object of the clients' dependency or hostility. The therapist variables that were coded are: approach, avoidance, therapist—initiated-dependency, and therapist— initiated-hostility. This coding procedure allows one to assess thera- pists' tendencies to: approach clients' expressions of dependency (Q_AEZ), approach clients' expressions of dependency which are directed at therapists (D(t) Agfi), and approach clients' expressions of dependency which are directed at persons other than therapists (Dgo) Ap%). 18 It also allows one to assess clients' tendencies to: continue expressions of dependency following approach by therapists (D Ag 0%), continue expressions of dependency following avoidance by therapists (D Av C%), initiate dependency expressions (gggz), initiate dependency expres- sions which are directed at therapists (CIDSt)%), and direct dependency expressions at therapists (thlfi). The operational definitions of these variables are con— tained in Chapter III (Table 2). Inter—rater Reliability Two raters participated in the coding of the tape recorded interviews. Both raters mutually coded a series of interviews to familiarize themselves with the scoring system. These interviews were assessed for inter-rater agreement. None of these practice tapes were used as data in this study. Eighty tape recorded interviews were used in this study. Twenty of these were arbitrarily selected as a reliability pool and independently coded by both raters. 0f the remaining 60 tapes, 30 were coded by one rater and the other 30 were coded by the other rater. The coding of reliability tapes was arbitrarily spaced throughout the entire period of time that the tapes were scored. This procedure results in a reliability estimate which takes into account the practice and forgetting 19 effects of both raters during the entire duration of time they coded. Inter~rater reliability was determined for each of the scores critical to the investigations being conducted. The statistical evaluation of inter-rater reliability will be discussed in Chapter III. III. RESULTS Scores Table 2 contains the definitions of scores utilized in this study. Table 2. Definitions of scores. Variables Definitions Therapist D Ap% Sum of therapists' approach following dependency/sum of dependency expressions by the client. D(t) Ap% Sum of dependency expressions directed at the therapist which were approached by the therapist/ sum of dependency expressions directed at the therapist. D(o) Ap% Sum of dependency expressions directed at persons other than the therapist which were approached by the therapist/sum of dependency expressions directed at persons other than the therapist. Client D Ap C% Sum of dependency following approach to preceding dependency expression/ sum of de— pendency expressions followed by approach. D Av C% Sum of dependency following avoidance to preceding dependency expression/sum of dependency expressions followed by avoidance. CID% Sum of c1ient—initiated-dependency/sum of opportunities to initiate dependency (i.e., sum of clients' dependency expressions not in immediate response to D Ap, D Av, or therapist-initiated-dependency/sum of hostile or other units which do not immediately follow therapists' D A , D Av, or therapist- initiated-dependency.) 20 21 Table 2.--Continued. Variables Definitions Client CID(t)% Sum of CID units directed at the therapist/ sum of CID units. D(t)% Sum of dependency expressions directed at the therapist/sum of dependency expressions. lTherapist-initiated-dependency is dependency introduced by the therapist simultaneously with an approach or avoidance of hostility or other. Inter-rater Reliability Inter—rater reliability is assessed by computing product moment correlation coefficients of the scores on the twenty tapes selected as a reliability sample. These coefficients are presented in Table 3. All of the cor- relation coefficients are significant at the .01 level. Statistical Evaluations of Hypotheses Hypothesis I Statement: When dependency expressions are approached by therapists, clients will tend to continue such expres- sions: when dependency expressions are avoided by therapists, clients will tend to discontinue such expressions. Outcome: The mean D Ap C% and mean D Av 0% were computed for each of the five stages of therapy under investigation. These means are contained in Table 4. 22 Table 3. Inter-rater reliability coefficients of scores. Scores N r Therapist Variables D Ap% 20 .92 D(t) Ap% 20 .64 D(o) Ap% 20 .82 Client Variables D Ap C% 20 .95 D Av C% 16* .79 CID% ' 20 .96 CID(t)% 20 ‘ .81 D(t)% 20 .63 *There were four reliability tapes in which the therapist approached all dependency expressions. These tapes were omitted as the clients had no opportunity to continue after avoidance. Table 4. Mean D Ap C% for five stages of psychotherapy. Stages Friedman Analysis of Mean Percentages 1% 25% 50% 75% 100% Variance P Mean D Ap c% .59 .53 .52 .40 .41 (.01 Mean D Av c% .14 .10 .11 .12 .20 >.05 Sign Tests p (.01 (.01 (.01 (.05 (.05 23 Five sign tests (one-tailed) were used to assess if D Ap 0% exceeded D Av C% in all stages of psychotherapy. A11 sign tests were significant as indicated in Table 4. Thus, the hypothesis is clearly supported as approach leads to further continuance of dependency while avoidance leads to inhibition of continuance. Exploratory Analyses: An exploratory analysis was conducted to assess if the clients' D Ap C% varied signifi- cantly during the five stages of psychotherapy. Friedman analysis of variance reveals statistically significant differences (Xi = 14.20, p < .01). Inspection of the means presented in Table 4 suggests that the clients decrease their D Ap C% sometime between the 50%»and 75% interview. A sign test (two-tailed) was computed to assess the change from the 50% to 75% interview. This difference (p (.05) is statistically significant. An analogous analysis was conducted to assess if clients' D Av C% varied significantly during the five stages of psychotherapy. Friedman analysis of variance reveals no significant differences (xi = .04, p >.05). Hypothesis II Statement: Therapists will tend to approach dependency more during the initial stage of therapy than they will during the later stages of therapy. Outcome: The mean D Ap% was obtained for each of the five stages under investigation. These means are P contained in Table 5. 24 Table 5. Mean D Ap% for five stages of psychotherapy. I Stages Friedman Analysis of variance 1% 25% 50% 75% 100% p .73 .78 .80 .83 .75 >.05 Friedman analysis of variance indicates that the differences are not statistically significant (x: = 5.90, p.>.05). This analysis suggests that therapists approach at a consistent rate during the entire therapeutic process. Thus, Hypothesis II is not supported. Hypothesis III Statement: Therapists will approach dependency directed at themselves more than they will approach dependency directed at others. Outcome: The mean D(t) Ap% and mean D(o) Ap% was obtained for all therapists. The frequency with which D(t) Ap% exceeds the mean D(o) Ap% is contained in Table 6. Table 6. Therapists' approach to dependency with therapist and other as object. Approach % Greater With Approach % Greater With Sign Test TherapiSt as Object Other as Object p 14 2 (.05 25 The sign test (p (.05, one—tailed) reveals that D(t) Ap% significantly exceeds the D(o) Ap%. This hypo- thesis is clearly supported. Exploratopy Analysis: An exploratory analysis was conducted to assess possible differences on D(t)% in different stages of therapy. Friedman analysis of variance (x: = 3.38, p >.05) reveals that the mean D(t)% for the five stages were not significantly different. Hypothesis IV Statement: Experienced therapists will tend to approach dependency more often during the initial stage of psychotherapy than will less experienced therapists. Outcome: The D Ap% was obtained for all therapists during the initial stage (1% interview) of psyChotherapy. The mean D Ap% was used as the score for any therapist seeing more than one client. This procedure attempts to minimize the weighting of individual therapists. The mean D Ap% for the staff and intern groups are contained in Table 7. Table 7. Mean D Ap% during the initial stage of therapy for staff and intern psychotherapists. Mann-Whitney U Experience Level Mean D Ap% p Staff .81 >.05 Intern .67 26 The significance of difference between staff and intern therapists was assessed by use of the Mann-Whitney U. This analysis revealed that the two groups did not differ significantly during the initial stage of psychotherapy (U = 10, p >.05, one—tailed) although the trend was in the predicted direction. Thus, Hypothesis IV was not supported. Exploratory Analypes: An exploratory analysis was conducted to assess possible differences in D Ap% occur at various stages of psychotherapy as a function of experience level of therapists. Friedman analysis of variance indicates no significant differences in D Ap% for staff therapists (x: = 6.27, >.05) or intern therapists (x: = 8.54, p >.05) at the various stages of psychotherapy. Moreover, the Mann—Whitney U (U = .15, p >.05) indicates that staff therapists (M = .76) and intern therapists (M = .78) do not differ significantly on their mean D Ap%.when the entire process of therapy is taken into account. A similar analysis was conducted on D(t) Ap%. Friedman analysis of variance reveals no significant dife ferences in D(t) Ap% at various stages of psychotherapy for staff therapists (x: = 1.97, p > .05) or intern thera- pists (x: = 9.37, p >.05). Moreover, the Mann-Whitney U (U = 17, p >.05) indicates that staff therapists (M = .83) and intern therapists (M = .84) do not differ significantly on their mean D(t) Ap% when the entire process of therapy is taken into account. 27 Hypothesis V Statement: Clients will manifest more client- initiatedadependency during the initial stage of therapy than they will during the final stage of therapy. Outcome: The mean CID% was obtained for the 1% interview and the 100% interview. These means are contained in Table 8. Table 8. Mean CID% during the first and last stage of therapy. Stage of Therapy Mean CID% .E East First (1%) .19 (.05 Last (100%) .12 All CID% were then transformed into angles as suggested by Walker and Lev (1963). This transformation was done be- cause of the small number of subjects in this analysis and the lack of power noted in appropriate non-parametric statistics. The 3 test (£_= 3.04, p (.05, two-tailed) indicates that clients do manifest significantly more client—initiated-dependency during the initial stage of therapy than they do during the final stage. Exploratory Apalysis: An exploratory analysis was conducted to assess if there was a significant change in CID(t)% from the 1% to 100% interview. The mean CID(t)% was obtained for the 1% (M = .50) and the 100% (M = .54) interview. All data were transformed into angles. The 28 .3 test (E = .30, p >.05) suggests that clients do not manifest significant change in CID(t)% from the initial stage of therapy to the final stage. IV. DISCUSSION This study has focused on the complex interaCtion of the therapist and client within a psychotherapeutic setting. However, to facilitate this discussion, this complex interaction will be separated into two components-- therapist variables and client variables. Therapist Variables Hypothesis II, III, and IV pertain to the character— istics of therapists within the therapeutic relationship. Therapist responses (see Appendix III) are reduced to two major categories--appraoch and avoidance. This dichotomy is implied by reinforcement learning theory as exemplified by Dollard and Miller (1950). It is to be noted that psychotherapists at the Counseling Center at Michigan State University do not profess learning theory as their basic theoretical frame of reference. It is difficult to categorize the therapists sampled in this study into any particular "school" of psychotherapy. However, if one were to make such a categorization, they would be best described as influenced by the teachings of Carl Rogers and Harry Stack Sullivan. The analysis of process which was utilized is not implied by the theoretical orientations of the therapists studied. 29 30 In spite of non-alliance to learning theory, one can see (Table 2) that the therapists' responses can reliably be categorized within an approach—avoidance model. This study of the verbal expressions of clients' dependency and related approach—avoidance responses of therapists, reveals two important characteristics of therapists. Therapists manifest (l) a relatively high rate of approach to dependency, and (2) they consistently maintain this rate of approach throughout the process of psychotherapy (Table 5). Although the results indicate very few differences among psychotherapists in approach-avoidance characteristics, one must not generalize these findings in such a way as to imply that all the therapists respond in such a way as to imply that all the therapists respond in the same manner. As one listens to the tape recorded interviews, qualitative differences between therapists seem apparent. HOwever, it is evident that these differences are in areas outside the realm of the model being utilized in this study. Most of the differences seem to be in such qualities as style of verbalization, degree of directiveness or non-directiveness, and, perhaps most importantly, ability to accept and express affect during the therapeutic relationship. These differences do not minimize the findings of this study because this research is not designed to be an all inclusive study of psychotherapy. Rather, it is designed to assess only one important "slice" of a very complex 31 process. The content-analyses which have been.done have called attention to other aspects of process. While few inter-individual differences are noted in this study, one can see intra—individual differences, i.e., therapists tend to approach dependency directed at them- selves more than they approach dependency directed at others (Table 6). The results also suggest that therapists do not vary this approach rate during the process of therapy. The writing of Grater, Kell and Morse (1961) offers one basis for explanation of the therapists' greater responsiveness towards dependency directed at themselves. Grater et. al. have conceptualized the therapist as a person with a strong need for the expression of nurturance. Moreover, they have suggested that psychotherapy is "often inherently a rather lonely kind of work" because the thera- peutic relationship is basically unilateral. The therapist is engaged in a highly specified interpersonal relationship in which the needs of the client are in primary focus while the therapist must be aware of, and appropriately limit, his own needs. He can receive gratification primarily from meeting the needs of the client. This suggests that the client's direction of dependency bids to the therapist is gratifying. The therapist, in turn, tends to approach such bids by the client to insure gratification of his nurturance needs. Munson (1960) has also assumed that therapists choose their career to gratify their need for nurturance. Moreover, she has also assessed the role of nurturance 32 within the therapeutic process. She hypothesized that highly resistive clients would bring about countertrans- ference reactions in therapists who were conflicted about nurturance, but not in non-conflicted nurturant therapists. Her results support this hypothesis. She found that con-‘ flicted therapists manifested increased avoidance behavior (e.g., "responses which inhibit, divert, or discourage a client's expression of relevant feelings and thought") when confronted with resistive clients. Moreover, the conflicted therapists tended to spend less time with the resistive clients in the initial interview, saw them for fewer interviews, and reflected greater negative affect toward them. None of these results were obtained with nurturant therapists except they were aware, with resistive clients, that they did not enjoy the therapeutic relation- ship and the degree of client resistiveness. The writing of Grater et. al. supports the specu- lation that therapists approach the dependency of clients to insure gratification of their nurturance needs. Munson finds that such therapists are able to maintain this approach to relevant feelings and thoughts even though clients tend to deprive them of these gratifications through resistive behavior. Other views of psychotherapy suggest that therapists do not approach dependency to the degree that it becomes excessive. Rather, they can also receive gratification for this nurturance need by helping others to become more individualistic and independent. 33 A recent study (Schuldt, 1963) indicates that experienced therapists manifest greater individualist valuation preferences than do less experienced therapists. That is, they tend to make valuations in accord with the psychological significance of the valuation to the person. This suggests that while therapists do have a response bias towards dependency directed at themselves, they concomi- tantly maintain awareness of the clients needs and their therapeutic goals. Snyder (1963) has delineated the therapist's goal of increased independence for the client. He states that therapists must "avoid repeating the errors that the real parent has made in producing the excessive dependency of the client." Moreover, he states: When the client finds "learning on the therapist“ too comfortable, the therapist will need to push him to make some efforts of his own. The therapist must re-condition this dependency into a striving to do things him- self (Snyder, 1963, p. 6). It is suggested that successful psychotherapists approach dependency to develop and maintain an intense, affective, and secure relationship while, conc0mitantly, fostering the clients' independence. This speculation receives some support because the data suggest that therapists maintain a constant rate of approach to dependency directed at themselves and clients follow with a constant rate of dependency which is directed at the therapist. Moreover, the decrease in client-initiated- dependency from first to final interview may be interpreted 34 as reflecting greater independence on the part of the client. This is a post-hoc explanation and that further research should be designed to assess these conceptuali— zations. Psychoanalysts have long maintained that emotional reactions (e.g., dependency) develop within the psycho- therapeutic setting as a result of transference. Inter- pretation is considered to be the preferred method of dealing with such transference phenomena. Fenichel states this very concisely: The analyst's reaction to transference is the same as any other attitude of the patient: he interprets. He sees in the patient's attitude a derivative of unconscious impulses and tries to show this to the patient (Fenichel, 1945, p. 30). An attempt was made to assess the role of interpre- tation as a specific approach to dependency. However, this attempt was found to be statistically unfeasible and psychologically rather meaningless because of the small number of therapists in this sample and the infre- quency of interpretive approaches (M = 3.6 per session) by these therapists. Another variable assessed in this study was the approach rates of therapists as a function of experience. Caracena (1963) has indicated that experienced staff therapists approach dependency expressions significantly more than do less experienced intern therapists. Caracena's finding was made from data obtained during the initial stage of psychotherapy. The present study fails to support 35 Caracena's finding (Table 7). Moreover, no significant difference in approach rate is found when the entire process of therapy is taken into account. One must be careful in interpreting these contrary findings because both studies are based on very small samples of therapists, i.e., Caracena's study involved 6 staff therapists and 12 intern therapists and the present study is based on 6 staff and 7 intern therapists. Caracena has also indicated that his sample of interns had an average of one year of experience in psychotherapy while the intern group in this study had an average of two years of experience in psychotherapy. If experience is an important factor in determining the rate of approach to dependency, the lack of significant difference between staff and intern therapists in the present study may be related to the smaller differential in experience between the two groups. The results of the present study suggest that the more experienced staff therapists and the less experienced intern therapists do not differ significantly on the approach rates to dependency. Moreover, they do not differ significantly on their approach rates to dependency which is directed at themselves. One might question whether experience, per se, is the only variable that should be considered in this analysis because the staff therapists frequently supervise the. intern therapists. It seems equally reasonable that interns act similarly to staff therapists as a function 36 of training rather than as a function of experience in psycho- therapy. This is a question that cannot be answered in this study but could be assessed in a study designed to assess the independent effects of supervision and experience. Client Variables Hypotheses I and V pertain to the response character- istics of clients during psychotherapy. Winder et. a1. (1962), Caracena (1963), and Lerman (1963) have found that clients continue to respond with dependency expressions if such expressions are approached by therapists. Moreover, they have found that clients will tend to discontinue expressions of dependency if therapists avoid such expressions. However, it has been noted that these studies are based on data obtained during the initial stage of therapy. Generalization of these findings to the entire process of psychotherapy without data would be in- appropriate. The results of this study suggest generalization of the initial findings of Winder et. al. because their procedures have been replicated and similar findings have been obtained when the process is sampled at five points, from the beginning to the end of treatment. These results indicate that approach serves as an elicitor of further dependency expression while avoidance serves as an elicitor of other responses. The elicitation effects of approach and avoidance are not specific to dependency. Similar 37 results have been found in analogous content-analyses of hostility (Bandura et. al., 1960: Kopplin, 1963: Lerman, 1963: Winder et. al., 1962) and sexuality (Lerman, 1963). Moreover, a recent study of aggression (Varble, 1964) utilizing data from the same subjects sampled in this study, found similar results at all five stages of psycho- therapy. The elicitation effects of approach and avoidance are quite clear. However, one must question whether approach and avoidance serve as reinforcers. It is difficult to ascertain if approach and avoidance are functioning as reinforcers due to the cautiousness of reinforcement theorists in delineating the role of reinforce— ment in complex human learning. For example, Dollard and Miller (1950) advocate a drive-reduction conceptualization of reinforcement. They maintain that a prompt reduction in the strength of a drive acts as a reinforcement under conditions in which the drive is a strong stimulus from an external source. However, they are much more cautious regarding secondary or learned drives. They state: The effects of these learned rewards also seem to be related to drive (they are only rein- forcing if the person wants them), but since we do not yet have independent measures of the drives involved, it is difficult to be certain that all of these learned rewards are completely without effect in the absence of drive or that each of them produces a reduction in the strength of some drive (pp. 41-42). Skinner has also indicated that the strength of an operant is strengthed if it is followed by the presentation of a reinforcing stimulus. However, he suggests that this 38 occurs during the process of acquisition. The function of reinforcement seems to change when verbal behavior has already been acquired. He states: Reinforcing consequences continue to be important after verbal behavior has been acquired. Their principal function is to maintain the response in strength. How often a speaker will emit a response depends, other things being equal, upon the over-all frequency of reinforcement in a given verbal community (Skinner, 1957, p. 30). Using a Skinnerian position in evaluation of that data of the present study, it is difficult to know if reinforcement is or is not occurring: or if dependent verbalizations should be expected to occur because these responses had been acquired prior to the therapy situation. The complexity of the operant conditioning'paradigm is demonstrated in a study by Rogers. Rogers (1960) found, in a pseudotherapy study, that operant conditioning of verbal behavior could be demonstrated in a limited way because negative self- reference statements could be increased by the interpolation of simple reinforcing stimuli. However, conditioning was not obtained with positive self-reference statements because these did not significantly increase. He found that reinforcement served only to arrest the extinction of positive self-reference statements. Denny and Adelman (1955) are also cautious in delineating the role of reinforcement within their elicitation theory model. The present study has shown that approach functions as a consistent elicitor. Within 39 elicitation theory, a consistent elicitor is theoretically delineated as a reinforcing stimulus. Moreover, elicitation theory predicts an increase in response level as a function of reinforcement. However, Denny and Adelman state: . in many typical CR situations, particularly for those using human 85 with uncontrolled atti- tudes, the US may not be the prepotent stimulus on every trial, and as a result conditioning may never reach a high level (Denny and Adelman, 1955, p. 292). It is difficult to evaluate the reinforcement effects of approach and avoidance within the context of the theories just mentioned because of their ambiguity regarding complex human behavior. Caracena (1963) has attempted to add some clarity by differentiating between the elicitation and reinforcement effects of approach. He suggests that approach functions as an elicitator if it triggers off "ready—made response pattern in the client without strengthening S—R bonds." Moreover, he indicates that reinforcement can be assessed according to the following criteria: "(1) increase in operant level of responses to therapist approach and (2) increase in operant level of responses to the therapeutic situation.” Using Caracena's criteria for the measurement of reinforcement in the present study, one can note (Table 4) that the data do not support approach as a reinforcer since no increase in operant level of the continuance of dependency is evident. Rather, the results are in the opposite direction, i.e., the continuance rate for 4O dependency which is approached by therapists decreases during the process of psychotherapy. These results suggest that something akin to extinction occurred during the process of psychotherapy even though the therapists maintained a high and stable rate of approach. These results are not congruent with a reinforcement interpretation. Yet, they are in accord with the clinical expectations of therapists who expect a decrease in dependency as therapy progresses (e.g., Fromm-Reichman, 1950; Rogers, 1951; Snyder, 1963: Wolberg, 1954). The continuance rate found in the early stages of therapy might be a function of the clients' dependency needs when they enter therapy. If this be true, one could explain the decrease in continuance rate which seems to occur sometime after the 50% interview (Table 4) as manifesting a decrease in the dependency needs of the client, i.e., the client no longer feels the degree of insecurity and dependency which compels him to respond to the approach verbalizations of the therapist. This de- crease in dependency needs seems even more strongly supported by the results associated with Hypothesis V (Table 8). The results indicate that clients signifi- cantly decrease their rate of self—initiated-dependency from the first to final stage of psychotherapy. The following attempt to conceptualize the process of psychotherapy will be restricted to the resolution of 41 dependency conflicts. Dependency conflicts are not the only emotional conflicts which bring clients into psycho— therapy. Rather, such conflicts are usually important components of more complex neurotic conflicts. The process for resolution of complex neurotic conflicts is far beyond the scope of the present research. One can describe the clients sampled in this study as late adolescents who have been living with their parents prior to attending the University. They have been fre- quently engaged in relationships in which dependency was imposed and highly approved by the parents. However, when attending the University, these students find themselves in an environment where dependency is not highly approved. The resultant dependency conflict is frequently the impetus which leads them to seek psychotherapeutic help. It is suggested that the high rate of dependency following approach and the high rate of client«initiated—dependency reflect their strong dependency needs during the early stages of psychotherapy. When a client enters psychotherapy he finds himself in a new type of interpersonal relationship. He finds that the therapist encourages dependency as a vehicle to develop and maintain an intense, affective and secure relationship. This provides the closeness and security that the client needs to allow introspection and awareness of the deep conflictual feelings which have led him to seek psychotherapeutic help. 42 The therapist also approaches attempts by the client to gain awareness of feelings, conflicts and strivings for independence. It is suggested that this allows the client to become aware of the strong respect that the therapist has for the adequacy and independence of the client. This is experienced as an extremely gratifying component of psychotherapy. The client finds that the therapist accepts his independence which allows him to test the acceptance of his independence outside of the therapeutic relation— ship. He usually finds that independence and adequacy is highly valued and approved within the larger environment. This allows him to "own" these new feelings of independence outside of the therapeutic setting. Moreover, he finds that he can be selectively dependent without the concomitant feelings of inadequacy. The above delineation of psychotherapeutic process is over-simplified and speculative. Unfortunately, the system of content-analysis used in this study cannot provide evidence about most of these speculations. Some support is given to the suggestion that clients reduce their dependency needs within the therapeutic relationship. This is evident because the therapists continue to main- tain a high and stable rate of approach to dependency while clients manifest less continuance following approach and less client-initiated—dependency. However, further research is required to empirically assess the therapists' approach rates to clients' attempts 43 to gain awareness of feelings, conflicts, and strivings for independence. This requires the elaboration of a new system of content-analysis in which these variables can be delineated, operationally defined, and quantified. More- over, it is suggested that research is needed to learn if the independence which the client acquires within psycho— therapy is also evident in his behavior outside of the therapeutic setting, i.e., does the client manifest more independence in his interpersonal relations within the social environment within which he is living? The model developed by Bandura, Winder, et. al., has been extremely valuable as a research tool because it allows simplification, operationalization, and quantification of a very complex process. But perhaps more importantly, it has served as the impetus for increased research in psychotherapy and as a tool for the generation of clearer conceptualizations of psychotherapeutic process. V. SUMMARY Clients' expressions of dependency have long been considered as important occurrences within the psycho- therapeutic relationship. This research assesses the vicissitudes of such expressions as a function of the approach—avoidance responses of therapists during the process of psychotherapy. The hypotheses are: (1) clients, in five stages of therapy, will tend to continue expressions of dependency when approached by therapists and will tend to discontinue such expressions when avoided by therapists, (2) therapists will approach dependency more during the initial stages of therapy than they will during the later stages, (3) thera- pists will approach dependency directed at themselves more than they will approach dependency directed at others, (4) experienced therapists will approach dependency more often during the initial stage of therapy than will less experienced therapists, and (5) clients will manifest more client-initiated-dependency during the initial stage of therapy than during the final stage. The data used in this study were obtained by con— tent-analysis of 80 tape recorded interviews with 16 clients at the Michigan State University Counseling Center. 44 45 Interviews of each client were selected at five points from the beginning to the end of treatment. Statistical analyses of data reveal that (1) clients, in all five stages of therapy, tend to continue expressions of dependency when approached by therapists and tend to discontinue such expressions when avoided by therapists, (2) therapists do not approach dependency more during the initial stage of therapy than they do during the later stages, (3) therapists approach dependency directed at themselves more than they approach dependency directed at others, (4) experienced therapists do not approach depen- dency more than do less experienced therapists, and 5“ (5) clients manifest more client-initiated-dependency in the initial stage of therapy than in the final stage. Exploratory analyses were utilized to assess the statistical significance of response variation noted in the five stages of psychotherapy. The analyses of thera- pist variables indicate that (l) therapists do not manifest a significant variation in approach rate to dependency during the course of psychotherapy, (2) therapists do not manifest significant changes in their approach rates to dependency directed at themselves during the five stages of therapy, and (3) there are no significant differences between experienced and less experienced therapists on the therapists variables being studied. The statistical analyses of client variables indicate that (1)c1ients manifest significantly less 46 continuance of dependency following approach in the later stages of therapy than in the earlier stages, (2) clients do not manifest significant changes in their continuance rate following avoidance, (3) clients do not manifest signifi- cant changes in their rate of dependency which is directed at the therapist during the five stages of psychotherapy, and (4) clients do not manifest significant changes, from the first to final interview, in their rate of c1ient-initiated-dependency which was directed at the therapist. These results were discussed in View of theory as well as psychotherapeutic application. Moreover, limita- tions of the study and implications for future research were delineated. REFERENCES Abeles, N. Awareness and responsiveness to affect as a function of training and supervision. Paper presented at Mich. Acad. of Sci. (Psychol. Section), Ann Arbor, Mich., March, 1962. Alexander, F., and Ross, H. Dynamic psychiatry. Chicago: Univ. of Chicago Press, 1952. Auld, F., Jr., and Murray, E. J. Content-analysis studies of psychotherapy. Psychol. Bull., 1955, 52, 377-395. Bandura, A., Lipsher, D. H., and Miller, P. E. Psycho- therapists' approach—avoidance reactions to patients' expressions of hostility. J. consult. Psychol., 1960, 24, 1—8. Barnes, E. J. Psychotherapists' conflicts, defense preferences, and verbal reactions to certain classes of client expressions. Unpublished doctoral dis- sertation, Mich. State Univ., 1963. Caracena, P. F. Verbal reinforcement of client dependency in the initial stage of psychotherapy. Unpublished doctoral dissertation, Mich. State Univ., 1963. Cartwright, D. S. Annoted bibliography of research and theory construction in client—centered therapy. J. counsel. Psychol., 1957, 4, 82—100. Chancer Erika. Families in treatment. New York: Basic Books, 1959. Covner, B. J. Studies in phonographic recordings of verbal material: I the use of phonograph recordings in counseling practice and research. J. consult. Psychol., 1942, 6, 105—113. Denny, M. R.,and Adelman, H. M. Elicitation theory: an analysis of two typical learning situations. Psychol. Rev., 1955, 62, 290-296. Dollard, J., and Miller, N. E. Personality andypsycho- therapy. New York: MCGraw-Hill, 1950. 47 48 Fenichel, O. The psychoanalytic theory of neuroses. New York: W. W. Norton, 1945. Fey, W. F. Doctrine and experience: their influence upon the psychotherapist. J. consult. Psychol., 1958, 2;, 403—409. Fiedler, F. E. Quantitative studies on the role of therapists' feelings toward their patients. In 0. H. Mower (Ed.), Psychotherapy: theory and research. New York: Ronald Press, 1953. Freud, S. Psychoanalysis: Freudian school. Encyclopaedia Britannica, 18, 1944. Freud, S. A general introduction to psychoanalysis (1920). New York: Permabooks, 1958. Freud, S. Turnings in the ways of psychoanalytic therapy (1919). In Collected_papers, Vol. 2. New Ybrk: Basic Books, 1959. Fromm-Reichman, Frieda. Principles of intensiveypsycho- therapy. Chicago: Univ. of Chicago Press, 1950. Grater, H. A., Kell, B. L., and Morse Josephine. The social service interest: roadblock and road to creativity. J. counsel. Psychol., 1961, 8, 9-12. Greenspoon, J. Verbal conditioning and clinical psychology. In A. J. Bachrach (Ed.), Experimental foundations of clinical psychology. New York: Basic Books, 1962, 510-553. Kopplin, D. A. Hostility of patients and psychotherapists approach—avoidance responses in the initial stage of psychotherapy. Unpublished M.A. thesis, Mich. State Univ., 1963. Krasner, L. Studies of conditioning of verbal behavior. Psychol. Bull., 1958, 55, 148-170. Lerman, Hannah. A study of some effects of the therapist's personality and behavior and of the clients' reactions in psychotherapy. Unpublished doctoral dissertation. Mich. State Univ., 1963. Munson, Joan E. Patterns of client resistiveness and counselor response. Dissertation Abstr., 1961, 21 2368-2369. 49 Murray, E. J. The content-analysis method of studying psychotherapy. Psychol. Monogr., 1956, 29, (13 Whole No. 420). Peterson, A., Snyder, W. U., Guthrie, G. M., and Ray, W. S. Therapist factors: an exploratory investigation of therapeutic biases. J. counsel. Psychol., 1958, Q, 169-173. Raimy, V. C. Self-reference in counseling interviews. J. consult. P§ych01., 1948, 12, 153-163. Rogers, C. R. Client—centered therapy. Boston: Houghton Mifflin, 1951. Rogers, J. M. Operant conditioning in a quasi-therapy setting. J. abnorm. soc. Psychol., 1960, 69, 247-252. Salzinger, K. Experimental manipulation of verbal behavior: a review. J. genet. Psychol., 1959, 61, 65-95. Schuldt, W. J. Evaluation modalities of therapists, J. counsel. Psychol., 1963, 19, 296. Seeman, J. A study of the process of non-directive therapy. J. consult. Psychol., 1949, 1;, 157—168. Skinner, B. F. Science and human behavior. New York: Macmillan, 1953. Skinner, B. F. Verbal behavior. New York: Appleton- Century-Crofts, 1957. Snyder, W. U. An investigation of the nature of non- directive psychotherapy. J. gen. Psychol., 1945, g;, 193—223. Snyder, W. U. Depgndengy in psychotherapy. New York: Macmillan, 1963. Strupp, H. H. An objective comparison of Rogerian and psychoanalytic techniques. J. consult. Psychol., 1955a, 12, 1-7. Strupp, H. H. Psychotherapeutic technique, professional affiliation, and experience level. J. consult. Psychol., 1955b, 12, 97-102. Strupp, H. H. Psychotherapists in action. New York: Grune and Stratton, 1960. Varble, Winder, Walker, Wolberg, 50 D. L. An exploratory analysis of hostility in psychotherapy. Unpublished doctoral dissertation, Mich- State Univ., 1964. C. L., Ahmad, F. 2., Bandura, A., and Rau, Lucy C. Dependency of patients, psychotherapists' responses, and aspects of psychotherapy. J. consult. Psychol., 1962, 26, 129-134. Helen M. and Lev, J. Statistical inference. New York: Henry Holt, 1953. L. R. The technique of psychotherapy. New York: Grune and Stratton, 1954. APPENDICES APPENDIX I SCORING MANUAL (This is the manual used in the following study: Caracena, P. F. verbal reinforcement of client dependency in the initial stage of psychotherapy. Unpublished doctoral dissertation, Michigan State University, 1963. It is a modification of manuals used in the following studies: Winder, C. L., Ahmad, F. Z., Bandura, A., and Rau, L. C. Dependency of patients, psychotherapists' responses, and aspects of psychotherapy. J. consult. Psychol., 1962, 26, 129—134: Bandura, A., Lipsher, D. H., and Miller, P. E. Psychotherapists' approach-avoidance reactions to patients' expressions of hostility. J. consult. Psychol., 1960, 114. 1-8). A. Scoring Unit and Interaction Sequence 1. Definition. A unit is the total verbalization of one speaker bounded by the preceding and succeeding speeches of the other speaker with the exception of interruptions. There are three types of scoring units: the "patient statement" (P St), the "therapist response" (T R), and the "patient response" (P R). A sequence of these three units composed an "interaction sequence.” The patient response not only completes the first interaction sequence but also initiates the next sequence and thereby becomes a new patient statement: Example: P. I can't understand how you can stand me. (P St) T. You seem to be very aware of my feelings. (T R) P. I am always sensitive to your feelings. (P R) 2. Pauses. Pauses are not scored as separate units. The verbalization before and after the pause is considered one unit. Therapist silences are scored as prescribed under Part D2e of this manual. There are no patient silences in this syStem. 52 53 3. Interruptions. Statements of either therapist or patient which interrupt the other speaker will be scored only if the content and temporal continuity of the other speaker is altered by the interruption. Then, the interrupting verbalization becomes another unit and is scored. A non-scored interruption is never taken into account in the continuation of the other speaker. Interruption scored as one unit: P. I asked him to help me and —- T. Why was that? P. --he refused to even try. Non-interruption scored as 3 units, one inter- action sequence: P. I asked him to help me and -- T. Why was that? P. I don't know. verbalizations such as "Um hmm" or "I see" are ignored in scoring unless they are so strongly stated as to convey more than a listening or receptive attitude. Patients' requests for the therapist to repeat his response are considered interruptions and are not scored. However, therapists' re- quests of this sort are scored as units (as approach or avoidance of the patient statement). Categories of Patient Statements and Patient Responses There are three categories: Dependency, Hostility, and Other. They are scored as exhaustive categories. All discriminations are made on the basis of what is explicitly verbalized by the speaker in the unit under consideration. One statement may be scored for several categories. When dependency and/or hostility units occur, the object of the patient's behavior is also scored as either psychotherapist or other. A coding of self (S) is given if the patient refers to his own behavior and a coding of other (0) is given if the client refers to someone else's behavior. 1. Hostility category. The subcategories of hostility listed below are not differentiated in the scoring but are listed here to aid in identification of hostility. 54 Hostility. Hostility statements include description or expression of unfavorable, critical, sarcastic, depreciatory remarks: oppositional attitudes: antagonism, argu- ment, expression of dislike, disagreement, resentment, resistance, irritation, annoyance, anger: expression of aggression and punitive behavior, and aggressive domination. l. Anger: P. I'm just plain madl P. I just couldn't think--I was so angry. P. My uncle was furious at my aunt. 2. Dislike: expresses dislike or describes actions which would usually indicate dislike. P. I just don't get interested in them and would rather be some- where else. P. I've never ever felt I liked them and I don't suspect I ever will. P. He hates editorials. 3. Resentment: expresses or describes a persistent negative attitude which does or might change to anger on a specific occasion P. They are so smug: I go cold when- ever I think about having to listen to their 'our dog' and 'our son.‘ Boy! P. They don't ever do a thing for me so why should I ask them over? P. Dad resents her questions. 4. Antagonism: expresses or describes antipathy or enmity P. It's really nothing definite, but we always seem at odds somehow. 55 P. There is always this feeling of being enemies. Opposition: expresses or describes oppositional feelings or behavior P. If he wants to do one thing, I want to do another. P. It always seems she is against things. She is even against things she wants. P. No, I don't feel that way (in response to T's assertation). Critical attitudes: expresses negative evaluations or describes actions which usually imply negative evaluations P. If I don't think the actors are doing very well, I just get up and walk out. P. There is something to be critical about in almost everything anyone says or does. Aggressive actions: acts so as to hurt another person or persons, either physically or psychologically P. He deserves to suffer and I'm making it that way every way I can. P. I can remember Mother saying: 'We slap those little hands to make it hurt.‘ Hostility anxiety. A statement including expression of fear, anxiety, guilt about hostility or reflecting difficulty expres- sing hostility P. I just felt so sad about our argument. P. I was afraid to hit her. P. After I hit her I felt lousy. 56 Hostility acknowledgment or agreement. A statement agreeing with or acknowledging the therapistfs apprOach toward hostility is scored as further hostility. May give example. May convey some conviction or may simply agree with therapist's response T. You were angry. P. Yes! 2. Dgpendency categories a. Definition. Any explicit expression or description of help-seeking, approval- seeking, company-seeking, information- seeking, agreement with others, concern about disapproval, or request that another initiate discussion or activity Scoreable categories: The subcategories listed below are scored exhaustively. 1. Problem Description: States problem in coming to therapy, gives reason for seeking help, expresses a de- pendent status or a general concern about dependency. P. I wanted to be more sure of my- self. That's why I came. P. I wanted to talk over with you my reasons for dropping out of school next quarter. P. Part of the reason I'm here is that everything's all fouled up at home. P. I depend on her, am tied to her. P. I want to be babied and comforted. 2. Help-seeking: Asks for help, reports asking for help, describes help- seeking behavior P. I asked him to help me out in this situation. P. What can you do for him? 57 P. I try to do it when he can see it's too hard for me. Approval-seeking: Requests approval or acceptance, asks if something has the approval of another, reports having done so with others, tries to please another,asks for support or security. Includes talk about prestige. Expresses or describes some activity geared to meet his needs. P. I hope you will tell me if that is what you want. P. If there was any homework, I did it so Dad would know I was studying like a good girl. P. Is it alright if I talk about my girl's problem? P. That's the way I see it, is that wrong? P. I asked him if I were doing the right thing. Compapy-seekipg: Describes or expresses a wish to be with people, describes making arrangements to do so, des— cribes efforts to be with others, talks about being with others P. It looks as if it'll be another lonely weekend. P. Instead of studying, I go talk with the guys. P. I only joined so I could be in a group. P. We try to see if other kids we know are there, before we go in. Information-seeking: ASks for cognitive, factual or evaluative information, expresses a desire for information from others, arranges to be the recipient of information 58 P. I asked him why he thought a girl might do something like that. P. I came over here to see about tests you have to offer. I want to know what they say. I'm planning to change my major. I'd like to know how to do it. Agpeement with another: Responds with ready agreement with others, readily accepts the therapist's reflection. Often illustrates therapist's remarks with examples, draws a parallel example to indicate agreement. May accept preceding statement on authority or if preceding statement was a therapist approach to Dependency, may simply agree with it. P. Oh, yesi You're absolutely right about that. P. Immediately I felt he was right about that. T. Then you wanted to get some help? P. Yes Concern about disapproval: Expresses fear, concern, or unusual sensitivity about disapproval of others, describes unusual distress about an instance of disapproval, insecurity, or lack of 'support. Little or no action is taken to do something about the concern P. She didn't ever say a thing but I kept on wondering what she doesn't like about me. P. My parents will be so upset about my grades, I don't even want to go home. P. It seems like I always expect I won't be liked. P. I can't understand how you can stand me when I smoke. P. I'm sorry I got angry at you. 59 8. Initiative-seeking: Asks the therapist or others to initiate action, take the responsibility for starting some- thing (to start discussion, determine the topic). Arranges to be a recipient of T's initiative. May solicit suggestions. P. Why don't you say what we should talk about now? P. If you think I should keep on a more definite track, you should tell me. P. I got my advisor to pick up courses for next term. P. Tell him what to do in these circumstances. 3. Other categpry. Includes all content of patient's verbalizations not classified above. Categories of Therapist Responses Therapist responses to each scored patient statement are divided first into two mutually exclusive classes, approach and avoidance responses. When both approach and avoidance are present, score only the portion which is designed to elicit a response from the patient. 1. Approach responses. The following subcategories are exhaustive. An approach response is any ver- balization by'the therapist which seems designed to elicit from the patient further expression or elaboration of the Dependent or Hostile (or Other) feelings, attitudes, or actions described or expressed in the patient's immediately pre— ceding statement, i.e., the part of the preceding statement which determined its placement under Dependency, Hostility or Other. Approach is to the major category, not specific subcategories. a. Approval: Expresses approval of or agree- ment with the patient's feelings, attitudes, or behavior. Includes especially strong "Mn-humi", "Yes" P. May I just be quiet for a moment? T. Certainly. d. 60 P. 'I have my girlfriend's problems on my mind. Could we talk about them? T. Why don't we talk about that? Exploration (ppobing): Includes remarks or questions that encourage the patient to describe or express his feelings, attitudes, or actions further, asks for further clarification, elaboration, descriptive information, calls for details or examples. Should demand more than a yes or no answer: if not, may be a "label" P. How do I feel? I feel idiotic. T. What do you mean, you feel idiotic? P. I can't understand his behavior. T. What is it about his behavior you can't understand? Reflection: Repeats or restates a portion of the patient's verbalization of feeling, attitude, or action. May use phrases of synonymous meaning. Therapist may sometimes agree with his own previous response: if the client had agreed or accepted the first therapist statement, the second therapist statement is scored as a reflection of the client statement. P. I wanted to spend the entire day with him. T. You wanted to be together. P. His doing that stupid doodling upsets me. T. It really gets under your skin. Labeling: The therapist gives a name to the feeling, attitude, or action con— tained in the patient's verbalization. May be a tentative and broad statement not clearly aimed at exploration. Includes "bare" interpretation, i.e., those not explained to the patient. May be a question easily answered by yes or no. P. I just don't want to talk about that any more. 61 T. What I said annoyed you. P. She told me never to come back and I really did have a reaction. T. You had some strong feelings about that-—maybe disappointment or anger. e. Interpretation: Points out and explains patterns or relationships in the patient's feeling, attitudes, and behavior: explains the antecedents of them, shows the similari- ties in the patient's feelings and reactions in diverse situations or at separate times P. I had to know if Barb thought what I said was right. T. This is what you said earlier about your mother . . . f. Generalization: Points out that patient's feelings are natural or common P. I want to know how I did on those tests. T. Most students are anxious to know as soon as possible. P. Won't you give me the scores? T. Many students are upset when we can't. g. Support: Expresses sympathy, reassurance, or understanding of patient's feelings. P. It's hard for me to just start talking. T. I think I know what you mean. P. I hate to ask favors from people. T. I can understand that would be difficult for you. h. Factual Information: Gives information to direct or implied questions. Included general remarks about counseling procedure 62 P. Shall I take tests? T. I feel in this instance tests are not needed. P. What's counseling all about? T. It's a chance for a person to say just what's on his mind. Avoidance responses. The following subcategories are exhaustive. An avoidance response is any verbalization by the therapist which seems designed to inhibit, discourage, or divert further expression of the Dependent, Hostile, or Other patient categories. The therapist attempts to inhibit the feelings, attitudes, or behavior described or expressed in the immediately preceding patient statement, i.e., the part of the preceding statement which determined its placement under Dependency, Hostility, or Other. Avoidance is avoidance of the major category, not specific subcategories. a. Disapproval: Therapist is critical, sarcastic, or antagonistic toward the patient or his statements, feelings, or attitudes, expressing rejection in some way. May point out contradictions or challenge statements. P. Why don't you make statement? Make a statement. Don't ask another question. T. It seems that you came here for a reason. P. Well, I wonder what I do now? T. What do you think are the possibilities? You seem to have raised a number of logical possibilities in our discussion. P. I'm mad at him: that's how I feel. T. You aren't thinking of how she may feel. b. Tppic Transition: Therapist changes or intro- duces a new topic of discussion not in the immediately preceding patient verbalization. Usually fails to acknowledge even a minor portion of the statement T. c. Ignoring: 63 Those kids were asking too much. It would have taken too much of my time. We seem to have gotten away from what we were talking about earlier. My mother never seemed interested in me. And what does your father do for a living? Therapist responds only to a minor part of the patient response or responds to content, ignoring affect. May under-or over-estimate affect. May approach the general topic but blatently ignore the affect verbalized P. You've been through this with other people so help me out, will you. T. You are a little uneasy. P. You can see I don't know what to do and I want you to give me advice. T. Just say whatever you feel is impor- tant about that. P. My older sister gets me so mad I could scream. T. Mm-hmm. How old did you say she was? d. Mislabeling: Therapist names attitudes, feelings, or actions which are not present in the actual verbalization preceding the response I just felt crushed when she said that. Really burned you up, huh? I don't know how I felt-—confused, lost-- I wonder if what you felt was resent- ment. 64 e. Silence: Scored when it is apparent that the patient expects a response from the therapist but none is forthcoming within 5 seconds after the patient stops talking. If the therapist approaches after 5 seconds have elapsed, silence cannot be scored and the therapist's response is merely "delayed" P. If you think I should keep on a more definite.track, tell me because I'm just rambling. T. (5 second silence) P. It is very confusing to know what to do. Dependency and Hostility initiated by therapist: Scored whenever the therapist introduces the topic of Dependency or Hostility, i.e., when the patient statement was not scored as the category which the therapist attempts to introduce P. Last week I talked about Jane. T. You've mentioned a number of things you have done to please her. P. (Enters office) T. Now, how may I help you? P. I was late for class this morning. T. I wonder if you dislike the teacher or the class? P. I like to run around in blue jeans. T. You hate your mother. MEAN PROPORTIONS OF DEPENDENCY, APPENDIX II HOSTILITY, AND OTHER IN FIVE STAGES OF PSYCHOTHERAPY Stages Categories 1% 25% 50% 75% 100% Dependency .25 .19 .20' .19 .16 Hostility .12 .11 .12 .10 .08 Other .63 .70 .68 .71 .76 65 APPENDIX III MEAN PROPORTIONS OF THE SUBCATEGORIES OF APPROACH AND AVOIDANCE TO DEPENDENCY IN FIVE STAGES OF PSYCHOTHERAPY Stages Subcategories 1% 25%. 50% 75% 100% Approach Approval .02 .01 .03 .03 .06 Exploration .38 .29 .27 .27 .30 Reflection .15 .15 .09 .08 .ll Labeling .12 .04 .06 .03 .04 Interpretation .13 .21 .30 .24 .19 Generalization .00 .01 .01 .00 .00 Support .06 .03 .02 .03 .04 Factual Information .14 .26 .22 .32 .26 Avoidance Disapproval .00 .03 .07 .07 .02 Topic Transition .25 .14 .13 .18 .13 Ignoring .75 .83 .76 .73 .81 Mislabeling .00 .00 .02 .00 .00 Silence .00 .00 .02 .02 .04 66 silt-3579 88 ABS-’S-iflsfs V » -.—-—~~._...._. .----..—- .—_-~. .1—- W —~ sea—54963.1 .1; 14! 44