PSYCHOTEERAPY OR ACTEVE FOCUSED PROBLEM SOLVENG FOR PERSONS 2N CRESIS Bissertaiion for the Degree of Ph. D. MECHEGW STAE 3NIVERSITY RiC'fiARD S. ZEPPER 1976 PSYCHO'I'HERAPY OR .ACTIVE FOCUSED This is to certify that the thesis entitled PROBLEM SOLVING FOR PERSONS IN CRISIS presented by Richard S. Zipper has been accepted towards fulfillment of the requirements for Ph.D. Date May 12: 1916 degree in Social Science fizz/4 gA/a/ Major professor ? amomc. av “7' "ME 5 SONY BMK BlNUERY INC. L' "RARY amosns .- :RrJIchIOA! ABSTRACT PSYCHO ERAPY OR ACTIVE FOCUSED PROBLEM ' CRISIS Interest in studying the various effects of crisis intervention with a public mental health clinic population was born out of the great demand for public services, coupled with a shrinking availability of public funds to support such services; by a burgeoning literature in crisis intervention theory, coupled with a dirth of research data on outcome; and by a recognition of the national problem of treatment dropouts (50%) and their concentration in the lower socioeconomic classes. The project examined the appropriateness of offering either supportive psychotherapy services or active goal focused crisis intervention services to persons of lower socio- economic levels. All patients had asked for a mental health service from the Livingston County Community Mental Health Center, within 30 days of an identified precipitating event. Richard S. Zipper Forty clients were selected, 20 of whom were seen in traditional supportive psychotherapy for 10 sessions, and 20 of whom were seen in 6 session problem solving focused crisis intervention. Of principle concern were the frequency of patients failing to complete the treatment contract (dropout) and the relative degree of change in, and satisfaction with, each of the two treatment offerings, as rated by both patient and therapist. Twenty-one of the original 40 subjects finished their treatment contracts, 14 experimental (crisis inter- vention) and 7 control (supportive) while 7 experimental and 13 control subjects dropped out prior to completion. The result (.124) while not significant was biased by a nonrandom distribution of patients by marital status. Single persons dropped out far more regularly than did persons of any other marital status. When services are offered only to married, or once married subjects, crisis intervention is found to be completed significantly more frequently (>.OS) than the supportive method. While change occurred in both groups, there was no evidence that either group changed more or differently from the other. There were, however, strong indications that patients who initially saw themselves in relatively better control of their lives, and thus felt less over- whelmed, were rated as better treatment candidates (both groups) and rated the therapy as having resulted in Richard S. Zipper greater positive change than those who felt less in con- trol. Therapists' ratings of similar issues correlated highly with patient ratings. A significant finding, not originally expected, was that the greater the liking of the therapist for the patient, the greater the patient's reporting of sig- nificant positive change, and the more likely was the patient to finish the treatment contract. There are strong indications for needed further investigation in the area of therapist's liking or dis- liking of patient as strongly influencing outcome. Sim- ilar findings confirming previous research indicate that treatment outcomes, and particularly dropouts, are related to factors which are not only clinical but are in many areas also demographic and actuarial, i.e., differing social classes between therapist and patient- socioeconomic levels, etc. Further research on case assignment procedures as they affect outcome is advisable. While further research is indicated, the most critical issue for public agency practice is clear. The crisis intervention group changed and was as satis- fied with their experience as was the supportive treat- ment group, but achieved these results utilizing 40% fewer resources. The demands for public service forces the clinician to address this conservation of staff resources--even if those resources are expended on Richard S. Zipper persons who, rather than dropping out, complete a treat- ment contract having achieved more limited short-term goals. The implications for changing professional practice are clear. Crisis intervention is a legitimate alternative to short-term supportive therapy for persons who seek mental health services in a period of acute psychological upheaval. PSYCHOTHERAPY OR ACTIVE FOCUSED PROBLEM SOLVING FOR PERSONS IN CRISIS BY ”49.!“ Richard ST'Zipper A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Interdisciplinary Social Science 1976 PREFACE Chapter I. TABLE OF CONTENTS INTRODUCTION AND REVIEW OF LITERATURE Introduction . . . . . . . Thesis Statement . . . . . . Review of the Literature: History Effectiveness of Brief Treatment . Definitions . . . . . . . . Crisis Intervention. . . . . Stress . . . . . . . . Clinical-Theoretical Considerations Homeostasis . . . . . . . Precipitating Events . . . . Restoration of Homeostasis . . Goals . . . . . . . . . Objectives of Crisis Intervention Goal-Focused Technique. . . . The Technique of Crisis Intervention. Duration and Frequency. . . . Early Intervention . . . . . Activity Level . . . . . Command of a Theoretical Reference. Strategy of Crisis Intervention. The Process of Crisis Intervention. Variables in Crisis Intervention . Mutuality of Expectation . . . Social Class . . . . . . . The Use of Time . . . . . . The Dropout . . . . . . . Indications for Crisis Treatment Special Problems/Cases. . . . ii Page Vi 22 22 22 26 28 30 31 33 33 35 36 39 40 50 54 54 S4 56 57 60 63 Chapter Page II. METHOD . . . . . . . . . . . . . 65 Hypotheses . . . . . . . . . . 65 Setting for the Study . . . . . 66 Criteria for Inclusion/Exclusion From the Study. . . . . . . . . . . 67 Sampling. . . . . . . . . . . . 70 Experimental Technique . . . . . . . 70 Instrumentation . . . . . . . . . 78 Nature of the Data . . . . . . . . 80 Statistical Procedures . . . . . . . 81 Study Sample . . . . . . . . . . 82 III. RESULTS. . . . . . . . . . . . . 89 Hypothesis 1 . . . . . . . . . . 89 Hypothesis 2 . . . . . . . . . . 92 Hypothesis 3a . . . . . . . . . . 93 Hypothesis 3b . . . . . . . . . . 93 Hypothesis 4 . . . . . . . . . . 93 IV. DISCUSSION. . . . . O . . . . . . 96 Hypothesis 1 . . . . . . . . . . 96 Hypothesis 2 . . . . . . . . . . 101 Hypothesis 3a . . . . . . . . . . 103 Hypothesis 3b . . . . . . . . . . 105 Hypothesis 4 . . . . . . . . . 106 Practical Considerations . . . . . . 109 APPENDICES APPENDIX A. TABLE OF RANDOM NUMBERS . . . . . . . 112 B. ADULT INTAKE FORM . . . . . . . . . 113 C. ADJECTIVE - SYMPTOM CHECKLIST (ASCL) PRE- TREATMENT - POST-TREATMENT. . . . . . 117 D. SEVEN SCALES FROM THE MMPI . . . . . . 118 E. PATIENT RATING FORM (PRF). . . . . . . 126 F. THERAPIST RATING FORM (TRF) . . . . . . 128 iii APPENDIX Page G. TABLE OF COVARIATES . . . . . . . . . 130 H. MATRIX OF COVARIATES. . . . . . . . . 134 I. FEE SCHEDULE . . . . . . . . . . . 135 REFERENCES . . . . . . . . . . . . . . 136 iv Table 1. LIST OF TABLES Distribution of Precipitating Events . . Recommended Techniques for Crisis Inter- vention . . . . . . . . . . . Pre-Treatment Data/Experimental Control . Pre-Treatment Testing/Finishers vs. Drops Pre-Post-Treatment Testing Data for Finishers . . . . . . . . . . Analysis of Co-Variance Post-Treatment Outcome Variables. . . . . . . . Dropout Rates and Marital Status . . . Table of Covariates. . . . . . . . Matrix of Covariates . . . . . . . Fee Schedule . . . . . . . . . . Page 24 44 84 86 90 91 94 130 134 135 PREFACE As society continues to undergo the technical- evolutionary process which began with the industrial revolution, individuals have found it increasingly dif- ficult to successfully ply a course of adequate social- ization and integration with the larger group. The increased difficulty (stress) is the likely result of the interplay between two factors. The first is the increase in the quantity and variability of social roles and expectations with which the individual must contend. Change itself has become a value. Second, western society has participated in the devaluation of the extended family, the church, and the community; insti- tutions which have historically functioned as agents of emotional support and social control. The result of greater stress and fewer resources has been an increased number of social casualties, countable in almost every item in the social disorgani- zation index. Histories of individual casualties are replete with typically stressful life events, which were resolved in manners which functioned to the adaptational detriment of the individual. vi Theorists such as Erikson regard the developmental process as a hierarchy of challenge whose mastery generates an increasingly complex repertoire of coping skills. These are reflected in a more dif- ferentiated sense of identity and a growing sense of self-worth. . . . . A fluid expansive adapta- tional system is well suited for mastering adversity, novelty or even monotony, when it becomes burdensome. (Barten, p. 13) During transitional periods, " . . . problem solving strategies must be developed or reactivated" (Barten, p. 13). An adequate level of self-esteem and a varied repertoire of coping techniques, greatly enhance the individual's capacity to accept and master new challenges. The less well equipped individual is more likely to be temporarily overwhelmed. . . . (Barten, pp. 14-15) We have known for some time through clinical work that adaptational dysfunction often occurs in response to a crisis. Occasionally, however, a person emerges from a crisis in a clearly superior mental state than had been the case prior to the crisis (Caplan, 1967, pp. 337-338). A crisis . . . may be dealt with in an adaptive way by realistic modification of the environment and by intrapsychic readjustments. On the other hand, the solution may be (1) postponed, (2) maladap- tive, or (3) (result in the) development of psy- chiatric symptoms. (Caplan, p. 337) Thus crisis theory holds that the individual in a crisis state is at a crucial point of vulnerability to change and to therapeutic intervention. vii The present gap between the number of people needing help, and the professional manpower available to provide it will become greater in the next few years. Hence, our manpower resources must be conserved and the efficiency of the ser- vices now rendered increased. (Strupp, Fox, & Lessler, p. XVII) A rethinking of service delivery is in order. A short-term psychotherapy approach to persons in acute psychological distress which aims to facilitate the resolution of the distress can increase future adapta- bility and prevent psychological deterioration. It is toward such a service delivery method that the follow- ing proposal for research in crisis intervention is directed. viii CHAPTER I INTRODUCTION AND REVIEW OF LITERATURE Introduction Since 1965, a burgeoning system of mental health centers has appeared on the national scene; the result in large part of an unparalleled availability of federal funds channeled to state governments. The objective of this vast expenditure is and has been the provision of preventative as well as remedial mental health care to all persons. This bright promise quickly dimmed with the nationwide realization that the greater the proliferation of mental health centers, the greater the incidence of identified emotional dysfunction. Coleman observes, Soon after the clinic is established, a familiar pattern asserts itself: the overwhelming demand for service quickly gluts up the lines which feed into the clinic from the community. With the subsequent 6-12 month waiting list and the need for precise scheduling of patients, the clinic loses any ability to deal with the earliest mani- festations of mental illness, at the time when we can probably be most helpful, i.e., during the crisis situation before the psychiatric ill- ness has been incorporated deeply into the personality. (p. 980) Paralleling the increased demand for mental health services was the general lengthening of the treatment process in both the private and public sectors. Stierlin asks, What factors account for this lengthening process? (1) the passivity and therapeutic perfectionism of the therapist; (2) the sense of timelessness inbuilt into the psychoanalytic situation; (3) the notion of the over-determination and rootedness of neurosis in early childhood; and (4) the develop- ment of a lengthy transference neurosis with a con- comitant regression and dependence of the patient on the analyst. (p. 357) The need-demand-waiting list syndrome has forced the realization that "Psychological maldevelopment, maladaption, and illness are so prevalent that treatment of established cases can never be expected to deal ade- quately with more than a fraction of the cases which occur" (Caplan, 1967, p. 331). Although the demand for services has been the driving force behind the re- emergent interest in short-term treatment, several other factors deserve mention. "The emphasis on ego psychology of how the individual's or family's coping repertoire can be mobilized to improve social functioning with respect to specific and limited treatment goals" (Parad & Parad, p. 347) has provided a needed theoretical framework; they are: The realization that "psychosocial disequilibrium or 'crisis' is by its very nature time- limited; dissementation of numerous papers advocating the use of crisis techniques; and the existential thrust which demands solutions in the here and now" (L. Parad, p. 119). Thesis Statement It is the belief of this author that persons in Crisis who are seeking assistance from a mental health facility are not at that moment appropriate candidates for traditional psychotherapeutic intervention, but appear to be seeking primarily a rapid stabilization of their psychic and social equilibrium. The following research design is intended to demonstrate that this stabilization is more apt to occur more rapidly and more thoroughly by applying the method detailed in the following pages. Review of the Literature: History Most sources indicate only a recent interest in brief treatment and crisis intervention, beginning with Erik Lindeman's landmark 1944 paper, "Symptomatology and Management of Acute Grief." Freud, however, addressed himself to brief therapy with the statement, "The best way to shorten psychoanalysis is to do it right" (Socarides, p. 345). "It is very probable . . . that the application of our therapy to numbers will compel us to alloy the pure gold of analysis plentifully with the c0pper of direct suggestion" (L. Parad, p. 130). Freud also practiced brief psychotherapy: as with Bruno Walter (Mayerson, p. 77). The practice of shortening the treatment process preceded descriptive and theoretical presentations of technique. The Parads note, Interest in applying psychoanalytic principles to brief psychotherapy, generated by such leaders as Franz Alexander and Feliz Deutsch, was in- tensified by the tremendous need for immediate therapeutic services for servicemen and their families during World War II. (p. 347) During the forties most of the articles and books on short term therapy stressed the following factors: (1) use of a controlled relationship and modification of the use of the transference, with emphasis on positive transference; (2) focus upon carefully delineated presenting or central problems; (3) focusing on the ego and mobilization of its capacities to deal with stress; (4) the linking of present conflicts to past unresolved conflicts; and (5) the therapeutic goal of restoration of functioning. (L. Parad, p. 132) Those clinical behaviors recommended by Fern Lowry were (1) relevant history-taking; (2) the need to distinguish between those cases in which the request was precipitated by a crisis, whether "immediate" or a result of slowly accumulating pressures, and cases of chronic crisis; and (3) the use of a direct approach (Parad & Parad, p. 124). The historical statistical view of.treatment services in agencies would seem to indicate that in reality most casework practice has always been short-term and most frequently environmentally oriented. A major reason for the aforementioned finding has been the problem of treatment dropouts which statistically shorten the average number of visits or duration of contact at a particular agency. Treatment dropouts, or those who receive unplanned brief service, are defined as those persons who attend six or fewer sessions (Rosenthal & Frank, p. 342; Katz, p. 86; Rogers, p. 89; Errora, p. 456; McCleod, p. 193; Brown, p. 431). Between 38% and 50% of all applicants for psychological assistance fit within the dropout definition. Only 25% to 33% of all applicants appearing for one interview appear for more than five (Roger, p. 89). "Regardless of what type of treatment . . . over half of all patients 'dropout' prior to the seventh session" (Brandt, p. 81). "By the eighth interview, not one single agency reported as many as half their cases still in treatment" (Rogers, p. 89) and "one-third of all patients came only once, one-third less than five times and one-third continue for more than five interviews" (Katz, p. 86). Treatment dropout rates are generally higher for the acutely disturbed, and for all persons of the lower socioeconomic classes (Mayerson, p. 94). In short, the more disorganized and disadvantaged the patient, the greater the likeli- hood that he will drOp out of, and thus fail to benefit from, psychotherapy. It is this patient population and treatment problem (the dropout) that the following proposal is most Specifically directed. The growing body of literature on the subject of outpatient brief psychotherapy with acutely disturbed, disorganized and agitated patients is found to include almost exclusively theoretical material, Opinions and reports of crude studies which invariably recommend replication with a well-controlled study. No clearly delineated definitions, parameters, variables or cri- teria for outcome or description of a method which might legitimately be termed brief or crisis psychotherapy can be found. It is widely accepted that insight based psychotherapies seem to be less effective with public psychiatric clinic outpatients than with patients in some other (private) settings (Rosenthal, p. 342). Bellack (1967a, p. 128) finds there (is) great divergence in conception and definition of variables among authorities in the field. How long is "brief" psychotherapy? Bellack's answers range in length of time from a single interview to a total of 65 interviews extending over a period of 17 months (Alexander, p. 145). Sifneos defines short-term therapy as lasting anywhere from two months to one year, with an average of four months, and crisis intervention at lasting up to two months (1971, p. 83). Whittington limits brief therapy to 20 hours (p. 503), Cartwright to 12 (1955a, p. 362), Errara to six hours (p. 456) and many to only one or two contacts. Other conceptions of brief or crisis psycho- therapy do not address themselves to duration of con- tract. Barten states, Brief therapy is characteristically a technique which is active, focused, goal-oriented, cir- cumscribed, warmly supportive, action-oriented, V and concerned with present adaptation. Brief therapy deals with a specific problem constel- lation. It may aim for the resolution of a present conflict or discomfort, and its objec- tives indeed may be of an emergency or stop-gap nature. (p. 9) ' Effectiveness of Brief Treatment Rapoport crystallizes the principle concerns about briefer therapies stating, Discussion about briefer forms of treatment always elicit questions concerning whether any changes brought about are lasting. This question reveals another erroneous assumption, namely, that if change is going to be long lasting it can be achieved only by a long process. There is another, more important assumption embedded in the question of the lasting nature of change. It presupposes a static life-model; that life-circumstances and experience are predictable and stable, and that, once conflicts have been resolved, no major problems in adaptation will arise. (1967, p. 32) Cartwright feels, . . . in regard to the two therapies, (long vs. short) that they differ in kind of problems brought in by the client. It is possible that short case clients had mainly situational problems. (1955a, p. 362) This statement is characteristic of the skepticism voiced regarding the psychic impact of brief therapy. Mental health professionals are becoming increasingly aware of the impossibility of affording traditional remedial psychotherapy to all persons in need. The Community Mental Health movement is committed to the reduction of the incidence of emotional and social dysfunction. Psychoanalysis and psychotherapy are forms of therapy designed to heal the psychological ‘casualities already identified as being in significant on-going distress. Primary prevention focuses upon reducing the incidence of new cases in a population. Efforts are directed at both modifying the environment and strengthening the individual's capacity to c0pe with situations. Bloom writes, Many believe that good mental health is in large measure the result of a life history of successful crisis resolutions; and, therefore, by providing therapeutic intervention to people while they are v/ in crisis, the incidence of subsequent mental disorder in these persons may be significantly reduced. (p. 498) Regarding short-term therapy. Sarvis states, It will be seen that this concept of therapy pre- supposes that much working through and consoli- dation may occur outside therapy, during a planned interruption, or a termination based on the under- standing that the patient may return as needed for further clarification of the problem or with new problems which may have come up. (p. 366) Further, regarding the trauma-neurosis model, There is no logic in assuming that only a mis- fortune can have a permanent effect on one's personality. A single, equally intensive, beneficient experience can also leave its mark. If a treatment can provide such a restorative experience to counter-balance the misfortune, the effect of the trauma may be undone. (Alexander, p. 164) Wolberg optimistically states, There are those who, once introduced to a new way of thinking about themselves, and recognizing that their current upset is rooted in their past history, challenge the fundamental conceptions which have ruled their existence. Having achieved a state in this new logic during a few sessions of psychotherapy, improvement then becomes self- perpetuating. Sometimes through forces that we cannot divine, a chain reaction occurs in the absence of any apparent conscious deliberation. Follow-up studies may reveal extensive shifts that were scarcely discernable at the time of termination, and that justify the Optimistic pronouncement of successful achievement equivalent to what we might have expected had the patient remained in therapy over a period of years. (1965, p. 190) In psychoanalysis, the goal is the systematic elaboration, understanding, and interpretation of the patient's total psychic structure, insofar as this is possible. This is achieved by the induction and systematic working through of a regressive transference neurosis by the use of, or in conjunction with, techniques which result in a focus on irrational, repressed, warded-off, unconscious processes. These techniques are free association, frequent visits, relative anonymity and invisibility of the analyst, and so on. (Sarvis, p. 278) Intensive analytically oriented psychotherapy has a similar, although perhaps more limited goal-- limited either in the extensiveness of character- ological exploration, or by the introduction of some unanalyzed perimeters. In some situations, the frequency of interviews is less than in classical analysis, and within this limitation, the patient's motivation and tolerance for anxiety do not permit essentially analytic goals. (Sarvis, p. 278) 10 Clearly, the goal in both therapies is a sig- nificant impact upon the patient's personality which leads to change. "A meaningful personality change, though mostly deriving from an enduring future-bound relationship, may also emerge from significant short term encounters" (Sterlin, p. 366). With ego supportive treatment, the goals are more exclusively restorative, with unconscious derivi- tives and characterologic manifestations left unin- terpreted. Rather, those processes identified may be clarified, defensive alignments may be strengthened, and super ego constraints eased in the context of the treatment relationship. Definitions Crisis Intervention While it is recognized that crisis intervention and other modalities can be therapeutic, for the pur- poses of this study, crisis intervention is distinguished from psychotherapy in that the former is characterized as a technique which is exclusively active, problem focused, time limited, and principally clarificative. Psychotherapy is herein considered to focus upon trans- ference, and the elaboration of unconscious material through the gathering of patient associations, and their subsequent interpretation. 11 Published reports of the use of brief psycho- therapy and crisis intervention are quite general in their description, and quite vague concerning their outcome criteria and the methods employed. For instance, with regard to duration and frequency of contact, Alexander recommends from one to 60 sessions (p. 163); Bellack between one and six (1967, p. 70); Socarides two or three (p. 344); six sessions by Paul (1966b, p. 49); a maximum of 12 sessions by both Shaw (p. 411) and Haskill (p. 546); 15 sessions by Campbell (p. 146); and from four to five months by Sifneos (1960, p. 169). Frequency varies from once every two weeks (Haskill, p. 546) to as many as two or three sessions per week (Morley, p. 487), and length of the session ranges from 15 minutes (Haskill, p. 546) to over one hour (Frontiers, p. 42). No standard or even most common practice exists in research material and clinical practice. Clinical work in crisis intervention has been conducted by prac- titioners from psychiatric nursing, social work, psy- chology-psychiatry, guidance and counseling, vocational rehabilitation, physical therapy, unpaid volunteers, and others. All agree, however, on one dimension, We have failed to realize that by the time a client is seen for diagnosis, after a waiting period, or for treatment after an even longer wait, he is no longer the same person as when he first applied for help. We have failed to note that the sympto- matology may have shifted and that something has 12 probably happened to his defensive system, namely, that he is more guarded and better defended against his initial anxiety, and, most important of all, that something may have happened to his accessi- bility which may make it more difficult to work with him effectively and economically. (Rapoport, 1967, p. 34) It is assumed that the person who applies for service in a state of crisis is experiencing a highly stressful situation. "A stressful situation is one which elicits painful emotions in an individual" (Sifneos, 1960, p. 176). "Stress is defined as the anticipation of an inability to respond adequately (or at reasonable cost) to perceived demand, accompanied by anticipation of nega- tive consequences for inadequate response" (McGrath, p. 23). Stress is generally experienced as an intensif- ication of the previous level of anxiety, which also signals the person that some initial perception of threat is at hand (McGrath, p. 23). "When these stresses are acute, unexpected, not susceptible to ready solution, or beyond the individual's coping ability, the resulting situation may be a crisis" (Beeker, pp. 296-297). Research concerned with the scientific measure- ment of stress and crisis phenomena is still in a state of infancy, and no adequate models appear to be applicable. It is herein presumed that while crises occur to persons who are in need of psychotherapy) and to 13 persons who are not, and the crisis itself occurring with an individual does not of itself dictate a psy- chotherapy intervention. The individual stress is presumed to be of a normative or typical nature, rather than of a psychopathologic one. "Another useful notion is that a crisis is not an illness, nor is it to be equated with psychopathology. It may be superimposed on psychopathology" (Beeker, 1967, p. 36). Stresses are of differing types and are perceived differentially. Stress According to Cath, What may be stress for one person is merely a challenge for another. It is generally acknowledged that at any point of crisis the ability to adapt or integrate is related to the maturity of certain ego functions, that is, the capacity to tolerate tension, endure anxiety, postpone pleasures for reality demands, and synthesize the past and present within the current situation. The human ego can tolerate tremendous shock and loss and still expand, grow, and create. (p. 175) Stress may result from too much or too little stimulus input. There are particular limits, upper and lower, or tolerances for each individual human being, and they are idiosyncratic (McGrath, p. 18). Stressful conditions may be of relatively long or short duration (McGrath, p. 23). Stress involves a series of at least four classes of events, or stages. The first of these is external, and takes place in the environment--the 14 psychosocial system in which the individual is living. This class of events can be called demand for response, or load of input, or stressor, or environmental force. Second, there is the perception of that objective demand for response which can be labeled objective demand, or strain, or personal definition. Third, there is the organism's response or responses to the then subjective demand at all levels, physiological, psychobiological, behavioral, and social-interactive. Fourth, there are the consequences of the response both for the person and for the larger system or environment in which he is imbedded (McGrath, pp. 15-16). Betz states, The anxieties signaling such distress are responded to in a range of patterns. They may be coped with effectively from a repertoire of conscious and unconscious defense mechanisms, when the individual is relatively mature for his age. Or, the patterns for responding to anxiety may be so narrow in scope, or rigid, as to constitute a problem in themselves--as in withdrawal patterns, or depres- sions, or in severe obsessive or other neurotic patterns. Or the defensive repertoire may be inadequate to contain the distress, and the indi- vidual decompensates into a state of social incompetency as in the psychosis. (p. 478) He continues, It should be emphasized further that a crisis presents a problem in the current life situation. Nevertheless, the current problem may be linked with old conflicts which may or may not have been satisfactorily resolved in the past but which in any case are to some extent reactivated by the current stress. This reactivation of old conflicts is likely to arise because the stresses leading to 15 a crisis very often serve as a threat to the gratification of instinctual needs. It is in this manner that "Stress is assumed to have a pathogenic potential." (1962, p. 211) When under great stress, persons often find that their memories of situations which are analogous to the stress situation, suddenly and unpredictably, come into consciousness, or labeled "surge of unmanageable impulses" the result appears to be an "unrepression" of impulses idiosyncratically determined which are threatening to the particular individual (Janis, p. 179). It is presumed, thus, that psychological stress is that salient factor the management of which utilizes psycho- logical energy which disturbs the person's homeostatic balance. Duhl (p. 297) and others simply refer to crisis as a significant upset in a steady psychological state. For the purpose of this proposal, this latter definition will be accepted. It must be noted that crisis only refers to the idiosyncratic psychological state of the reacting individual (Rapoport, 1967, p. 35) where reaction is synonymous with defensive psychological mechanism (Sifneos, 1960, p. 176). Reactions are typically acute with specific identifiable onsets and a relatively brief period of duration, regardless of whether the outcome is adaptive or maladaptive (Kaplan, p. 400). 16 There is no disagreement as to the fact that crisis states are limited in time, lasting four to six weeks, and that they constitute a transitional period which represents both danger of increased psychological vulnerability and at the same time opportunity for personality growth (G. F. Jacobson, p. 210). Crisis, then, is viewed as an environmentally precipitated painful emotional reaction to which the individual is compelled to react, wherein it is the individual's idiosyncratic perception of the precipi- tant situation, within his own subjective framework, which determines both the nature and the intensity of the crisis. Concerning the significance of crises, Rapoport states, Although studies have been conducted by people with different approaches and different topics, with no single set of theoretical and clinical interests, there is a common factor among them in that the crises being considered are viewed as turning points--as points of no return. If the crisis is handled advantageously, it is assumed the result for the individual is some kind of maturation or development. If the stresses engendered by the crisis are not well c0ped with, it is assumed that old psy- chological conflicts may be evoked or new con- flicts may arise and a state of poorer mental health may be the result. (1965, p. 75) Most theorists agree that several elements must be present for an individual to experience a crisis. Initially, there must be a hazardous emotional or environmental situation. A situation that is experienced 17 as difficult or dangerous to the individual as he idio- syncratically defines danger or difficulty is a hazard (Sifneos, 1960, p. 175). Maladaptive psychological reactions to these situations may lead to painful feelings. The painful state is simply defined as an unpleasant emotional state of being (anxiety, anger, or fear) (Sifneos, p. 176). These feelings in turn may develop into an emotional crisis in one individual, or in members of his immediate family if the feelings are experienced as overwhelming to the ego. Such emotional crises usually appear before the onset of psychiatric symptoms (Sifneos, p. 176). The painful state involved in both change and in the anticipation of the unknown provokes the crisis when relief or resolution is not imminent. The crisis state has been defined as a further intensification or aggravation of a painful state because of a failure of the reactions to cope with the situation. It is a turning point for better or worse (Sifneos, p. 176). Caplan finds the state provoked when a person faces an obstacle to important life goals that is insur- mountable through the utilization of the person's typical methods of problem solving (G. F. Jacobson, p. 209). Paul states that, Crisis is a term reserved for the actue and often prolonged disturbance to an individual or to a social orbit as the result of an emotionally hazardous situation (crisis is not the same as emergency). (Sifneos, 1966a, p. 141) 18 Erikson describes what are essentially normal or norma- tive crisis points which result from physiologic, social, and psychological maturational stresses. Each precipitant becomes the focal point for the crisis experience because of what it borrows from other subjective experiential definitions of the patient (Erikson, p. 274). The basic functions of "personality" are: per- ceptual taking in of cues to events within and outside the self; processing such perceptions (coordinating them with previous experiences and current aims); and producing action (behavior). (Betz, p. 481) When studying the effectiveness of techniques indicated for intervention in these situations, a pre— condition is a clear assessment of the existence and characteristics of the crisis state (Cath, p. 300). In practice, A crisis is defined primarily in terms of a pre- cipitating event and, secondly, in terms of a slow resolution. Known precipitating events are generally judged to lead to crises if (a) there is no reaction or if (b) there is a reaction of any kind and resolution requires more than a month. (Bloom, p. 502) Review of the relevant literature suggests that the crucial elements in the identification of the crisis state appear to be (a) a stressful precipitating event of which the individual is aware; (b) significant subsequent rapid cognitive and affective disruption unusual for that par- ticular individual; and (c) duration of the dis- ruption of at least several days. (Bloom, p. 449) Schenberg and Sheldon observed, (1) The greater the objective severity of the situation, the greater the probability of a crisis experience; (2) The greater the number and variety of difficult situations which the person 19 has encountered and resolved, the lower the proba- bility of a crisis experience in a given environ- mental situation; (3) The fewer or less adequate are one's real or perceived abilities to resolve a confrontation, the more threateningly it will be interpreted and the greater the probability of a crisis experience; (4) the more intense the crisis which is being experienced, the more potentially amenable is the individual to suggestion or environ- mental influence. (p. 553) Six classes of crisis precipitants have been identified by Rapoport (1967, pp. 36-37) and others. They are: (1) loss or the threat of loss of a signifi- cant object; (2) developmental crisis such as adolescence or menopause; (3) external or situational disorder such as a disaster, war, fire, trauma, and the like; (4) role transition, such as adjustment after a divorce, school graduation, or retirement; (5) identification or fear of identification with another person, as in the homosexual panic; and (6) poorly managed or repressed instinctual needs or impulses. This list resembles the causes of neurosis delineated by Freud who mentioned frustration due to loss of an object, inability to adapt to a chal- lenge such as marriage, inhibition in development, and biologic maturation (Caplan, 1967, p. 337). Forrer has dichotomized crisis in terms of nar- cissism. A crisis of primary narcissism indicates a weakening of integration and autonomy within the ego itself. "Crises of secondary narcissism require the ego to disavow important aspects of the self which 20 are continually being reactivated by relationships with other persons" (p. 279). At the most descriptive levels, crises involve one or more of the following internal psychological changes: (1) an unusual increase in anxiety or other affect or symptom; (2) the break-through to threshold level of intensity of some counteracted need or attitude of the self or identity fragment; (3) loss or weakening of a psychological defense or external support for a defense; (4) the qualita- tive change through loss or otherwise, of a com- plementary relationship which forces the ego to assume new responsibilities; (5) the internali- zation of a new standard of activity which is at variance with former capacities and inclinations or role change. . . . (Forrer, p. 278) In the initial phase, there is a rise in tension in response to the initial impact of stress. During this period habitual problem-solving mechanisms are called forth. If the first effort fails, there will be an increase in the level of tension with an increase in feeling upset and ineffective. This state may then call forth emergency problem-solving mechanisms (Rapoport, 1962, p. 214). When the emergency measures fail, the state of crisis ensues. It is likely that the initial rise in tension will be perceived as a problem with which the individual must deal. Lindeman's study of bereavement reactions suggests that in the course of everyday living, there occur a wide variety of events which precipitate acute dislocations for the individual. These dislocations are reflected in lowered levels of social function- ing and higher levels of anxiety and personal distress. (Kaplan, 1962, p. 18) 21 A crisis calls for new action; the challenge it provokes may bring forth new coping techniques which may serve to strengthen the individual's adaptive capacity and thereby in general to raise his level of mental health (Rapoport, 1962, p. 212). Other reactions to crisis are also possible. The individual may deal with the hazardous event and his feelings about it with magical thinking or with excessive fantasy; he may respond with regressive forms of behavior, with somatization, or in extreme situations, with withdrawal from reality. (Rapoport, 1962, p. 215) The person in crisis verbalizes a number of extremely uncomfortable feelings. He feels anxious, and thought processes are often confused and ineffective. He is preoccupied with the problem which precipitated the upset, and memories of similar situations from the past. Feelings of frustration and helplessness char- acterize the crisis in varying degrees for the duration of the crisis which usually lasts from four to six weeks (Caplan, 1967, p. 339). Rapoport suggests concerning helplessness that In part this may be a state of cognitive con- fusion wherein the individual literally does not know how to think of his problem, how to evaluate reality, and how to formulate and evaluate the outcome of the crisis and the possibilities for problem-solving. In extreme states, there may also be perceptual confusion such as in the temporal or spatial sense. (Rapoport, 1962, p. 215) 22 Clinical-Theoretical Considerations Homeostasis According to Kalis, the crisis intervention approach is based in large part upon a concept of psy— chosocial homeostasis. Psychiatric theory pictures the mental apparatus of an individual continuously maintaining and re- establishing its stability after disturbances by external and internal stimuli. Whenever this stabilizing process fails, a type of emergency state arises. Anxiety which represents repetitions of early traumatic states appears. The continuation of such unresolved tensions eventuates into overt psychopathology. (pp. 27-28) Caplan believes that effective intervention in the emer- gency state can avert the formation of pathological coping patterns and enhance the functioning of the individual. We try all kinds of things which we did not try before in order to see if we can handle this situation; and eventually, and this is the par- ticular thing about it, I think it has something to do with the homeostatic mechanisms of life-- eventually we will find some way. That is why the crisis does not last longer than about four to six weeks. (1961, p. 41) Precipitating Events Crisis theory assumes the existence of a spe- cific precipitating event, which creates a state of disequilibrium in the usual manner of functioning (Parad & Parad, p. 420; Jacobson, p. 1177; Caplan, 1961, p. 40; Kaplan, 1962, p. 19; Kalis, p. 28). 23 Kaplan has observed that, Acute situational problems occur when three con- ditions have been met. The first condition is the existence of the relevant nonpathological characteristic(s) in an individual without which the problem cannot occur; fertility, for birth problems; racial traits, for problems of discrim- ination; appropriate age for retirement; and so on. The second condition consists of those values inherent in the individual by virtue of which an event is perceived as a personal threat; thus premature birth is a problem for a mother when she values carrying the pregnancy through to term; retirement constitutes a threat to an individual when he places a high value on his position as an active, productive person and perceives retirement as involving a loss of this position. The internalized individual values generally reflect the values of the culture and the sub- culture to which he belongs. The third condition consists of the occurrence of events that consti- tute a threat to the individual: premature birth, death in the family, diagnosis of a chronic ill- ness, and so on. (1962, p. 19) The third condition need not occur if the second is suf- ficiently invested that the fear of the event is as threatening as the event itself. A crisis occurs when an individual is unable to solve an important problem through customary methods and when alternatives are not readily apparent. Numerous authors and agencies have surveyed the precipitating events and presenting complaints of patients or clients making application for service to psychiatric out- patient clinics and social agencies. Many of the pre- senting complaints are not the result of symptomatology or psychiatric illness, but rather are the result of the individual experiencing everyday events typically 24 experienced by everyone in the course of a lifetime. McCleod, in a study of 100 applicants for psychiatric services, found the following distribution of precipi- tating events: Table 1 Distribution of Precipitating Events Separation 27 Death 16 Pregnancy 12 New Role for Patient 11 Illness or Injury to Patient 10 Divorce 4 Marked Change in Children 4 Job Loss 3 Marital Discord 3 Role Change in Other 3 Illness of Other 3 Unclassified __4_ Source: McCleod, p. 193 Gary Jacobson (p. 720), surveying the precipitants of distress in persons applying to a mental hygiene clinic, found that " . . . about one quarter of the patients (26%) reported the loss of an important friend or rela- tive in the month prior to their contacting the clinic." In family service agencies clients tended to apply most frequently for marital difficulties (21.9%), maturational and transitional events (14.3%), school and family problems (10% each), and all categories of loss or threatened loss of object (41%) (Parad & Parad, p. 420). 25 Anxiety and depression were found by Sifneos (1960, pp. 170-171) to be the most frequently mentioned affects associated with presenting complaints. The Parads (p. 421) in a comparative survey of psychiatric clinics and family service agencies found that over 20% of the family service applicants requested help within four days of the precipitating event. In the psychiatric clinic pOpulation the corresponding figure was under 10%. Similar data are reported at 7, 10, and 14 days. These data tend to suggest that people will wait slightly longer before calling for psychiatric assistance than they will for a service which is perhaps perceived as less threatening, such as family counseling. Approxi- mately half of the applicant population from both groups, however, applied for service within 30 days of the pre- cipitating event. Regardless of agency, orientation of the clinical staff, or type of patient, it is apparent that for at least half of all applicants, in the recent past, an event has taken place which as a precipitating factor, seemed to bring anxiety into the open, thus motivating the individual to seek assistance (Sifneos, 1960, p. 171). Fenichel points out that "there are precipitating factors for psychoneurosis or non-neurotic acute upset states which can be compared with traumata. A person may have evolved from old infantile con- flicts into a state of relative equilibrium between repressed and repressing forces. An external alteration may mean a disturbance of 26 this equilibrium, and thus make a hitherto attained adjustment more difficult.“ The anxiety indicates the re-emergence of conflict which recapitulates early traumatic states, and a new equilibrium must be sought. (Harris, p. 466) Restoration of Homeostasis One of the two major techniques for restoration of balance is reducing the severity of the crisis. This is accomplished primarily through clarification of the situation and separation of the external event from its internal definition. The second technique is stabilizing the individual by restoring defenses that had, prior to his crisis, enabled him to function more satisfactorily (wolberg, 1967, p. 922). This is accomplished by encouraging the use of the previously effective defenses in gradually more difficult areas. Rapoport attends to finding new adaptive patterns as ways of handling conflict or finding solutions to problems before they become heavily conflicted. The enhancement of coping patterns is achieved by a process that has decided educational com- ponents, such as anticipatory guidance, rehearsal for future reality, learning new social and interpersonal skills, and enlarging the capacity for anticipatory thinking and prediction. The educational process may be less verbal and more based upon identification. Here the therapist consciously offers himself as a model for identification and encourages rehearsal of behavior and attitudes in regard to new roles. (1967, p. 48) 27 This intrapsychic process is described by Brockbank as follows: Adaptation or fitting together as Hartman refers to it, is a highly complex process involving all three components of the human psyche and is not merely a function of the ego. It involves par- ticularly the integrative and synthetic functions of the ego, and the relationship of the id and the superego to these ego activities. (p. 322) Adaptation, therefore, refers to ego defenses, whereas c0ping mechanisms refer more to the adaptive capacity of the ego to take appropriate and rational action in response to the perception of stimuli. (p. 323) When the individual feels need to find new resolution of a felt difficulty, if his coping mechanisms are still open and fluid, he will likely achieve mastery of the difficulty without personality constriction. If coping methods are not fluid and available, he may compromise with the difficulty and find some less adequate adjustment, or may even use regressive devices, detrimental to his future mental health (Porter, p. 14). Progressive adaptations are those which occur in the direction of development. Regressive adaptations hinder the normal developmental process (Brockbank, p. 323). Post-crisis readaptations will vary with many factors, including the previous level of psychic equil- ibrium, the severity of the disruption, the availability of coping mechanisms and environmental supports, and the speed and appropriateness of intervention (Harris, p. 467). 28 9231.2 When an individual or organization attempts to provide an intervention system for a person or persons in acute stress or in psychological crisis, central is the need for a genuine acceptance of the concept of limited goals (Rapoport, 1967, p. 37). Preoccupation with the grand strategy of comprehensive concepts fre- quently blinds the therapist to the impact and signifi- cance of immediate issues (Regan & Small, p. 84). Four short-term goals can be identified, any or all of which may be appropriate. These are (l) the restoration of the individual's previous balance; (2) the resolution of the stress-producing event; (3) simple symptom removal; and (4) the resolution of the psychic derivatives which facilitated the precipitation of the crisis state. Restoration of the previous balance is the mini- mum goal. The thesis here is that if the previous level can be sufficiently strengthened, the individual is not likely to experience a succession of crises, eventuating in a lower adaptational level (Gary Jacobson, p. 1180; Wolberg, 1967, p. 921). Many believe that with short-term work, the only goal is the removal or amelioration of specific symptoms. Typical is the view of Bellack, 29 In its symptom-directed orientation, brief psy- chotherapy seeks to improve the individual psy- chodynamic situation sufficiently to permit the person to continue functioning, to allow "nature" to continue the healing process, and where indi- cated, to increase the self-supporting ability of the individual sufficiently so that he may be enabled to continue with more extensive psycho- therapy. (1965, p. 9) Mayerson (pp. 94-95) is in essential agreement that through removal of debilitating symptomatology the patient can be more easily returned to premorbid levels of functioning. This is primarily accomplished with the additional exploration and clarification of the reasons for, and gain involved in, the symptom's existence. For Harris (pp. 466-467) and McGuire (p. 84) the aim is the resolution of that portion of the patient's difficulty which causes his internal stress. The reso- lution of any difficulty, regardless of at what level, necessarily alters the structure as a whole. "Indeed, long-term psychotherapy is frequently described as the working through of a succession of derivations" (Harris, p. 467). There is further a deliberate avoidance of conflict areas which are not a part of the current crisis situation, as in the case of character problems. In addition Harris advocates clarification and resolution of the precipitating stress. Precipitating stress is resolved through exploration of the conflict derivatives involved in that stress (p. 465). Gerald Jacobson (p. 209) and Rapoport (1967, p. 40) are clear 30 that while conflict derivatives are explored, one would not expect him (the patient) to work through all of his problems, but rather only those that the material indi- cates are necessary to handle the acute situation. Objectives of Crisis Intervention Objectives at termination are the patient's being able to utilize his own adaptive reactions and environmental resources, and to return to a state where there is little or no pain (Sifneos, 1960, p. 178). The patient is seen as being able to anticipate impending crises prior to their evolving (Rapoport, 1967, p. 43). His sense of autonomy and mastery is enhanced, and he has learned toutilize his assets to best interest to minimize his liabilities, to avoid crises, in relation- ships to peOple to organize his activities around his character, and to discover and release some positive qualities within himself (Wolberg, 1967, p. 85). Bellack suggests that later life crises are more easily avoided or worked through because of structural changes which are begun during the therapeutic contact (Bellack, 1967a, p. 131). Wolberg argues that the patient in short-term or crisis psychotherapy should be acquainted with other personality problems that inhibit a more productive life adjustment; educated to the availability of other forms 31 of therapy such as long-term; and learn remedial measures that can be applied to environmental diffi- culties (Wolberg, 1965, pp. 129-130). Goal-Focused Technique While agreement is common that a focused treat- ment technique is appropriate in crisis intervention, there is disagreement as to what are goals to be focused upon. Rapoport argues, Certain basic principles requisite to goal focused and time limited treatment may be delineated as follows. A little help, rationally directed and purposefully focused at a strategic time, is more effective than more extensive help given at a period of less emotional accessibility. This suggests that one should make use of anxiety when it is at its height. A corollary to this principle is that there needs to be continuity of contact, and a use of time, structured as to its limits and, within such limits, flexibly arranged. (1967, p. 21) To capture anxiety, treatment must focus upon the immediate problem, the crisis, or stress-producing event, rather than upon long-standing pathology or well- established characterological problems (Gerald Jacobson, p. 210). The term "focus" or "focal problem" is a designation for the major problem, along with histori- cally important dynamic relations, patterns of adaptation, external environmental difficulties, or physiologic imbalances--on which therapeutic work is concentrated (Gerald Jacobson, p. 894). The selection of one of the patient's "problems" as the "focal problem," and then 32 the selection of a critical area for treatment within that focus becomes an expression of the major concen- tration of the therapeutic effort (Regan & Small, pp. 292-294). Disagreement exists too on what, why, and how to focus the intervention plan. Kaplan (1968, p. 155) suggests focusing upon the client in the context of his family and community caretaking relationships. Kalis (p. 33) and Semrad (p. 594) both recommend focusing upon the precipitating event, but for differing reasons. Kalis would have the therapist understand the derivatives (unconscious) of the precipitant, while Semrad recommends an attempt to resolve the external factors in the stress- producing event. Harris (p. 467) quotes from Fenichel, Conflicts arise when new experiences occur that are connected with what had previously been repressed. Then there is a tendency on the part of the repressed to use the new events as an opportunity for an outlet; it tends to displace its energies to it, to turn the new event into a derivative. Elsewhere he states, We must work not only at the point of actual instinctual conflicts, but at the point of the most important current instinctual conflicts. It is the point of the most important conflicts at the moment. (p. 468) Caplan states, The short-term focus of this preventative model is on the pattern of adaptation to develoPmental and situational life crises. These crises represent transitional points, at each of which the person may move nearer or farther away from adaptive patterns of functioning. (1967, p. 332) 33 Whittington (p. 516), Kalis (p. 33), and Regan and Small (p. 896) expand upon Caplan's statement, feeling that the area of immediate focus should be selected by a process of enlightened guesswork, based upon a clinical judgment as to what defensive, resistive, repressive, and adaptational patterns existed in the past, and what the current presentation of the patient constitutes a more or less pathological or morbid process. Regan and Small warn of the seriousness of the selection process, stating, A well selected critical area is one in which the patient experiences considerable anxiety, an area where he may be reasonably expected to exert effort to alter the characteristic pattern, and where his chances of changing the pattern are good. The cri- terion of success is not necessarily insight, but change in the pattern. If the area in which the focal problem is explored is not sufficiently critical, only intellectual insight is achieved, because the experience is not sufficiently mean- ingful emotionally. If the critical area carries too heavy an emotional charge, the patient is not able to handle it and will retreat. Such a retreat may take the form of panic or suicide, withdrawal from treatment, increased symptomatology, or increased resistance in treatment. (p. 896) The Technique of Crisis Intervention Duration and Frequency Considerable variability exists among practi- tioners in the structure, process, and content of crisis intervention techniques. Masserman (p. 78) believes that emergency psychotherapy is administered through no more than five or six interviews at intervals of no 34 longer than one week. The interview is to be no longer than one hour. McCleod (p. 195) prefers initial visits on a one-hour or longer basis, and follow-up visits of 15 minutes in duration with a frequency of one session every two weeks, ranging to three sessions per week. Levy (p. 40) limits the number of sessions to six, ranging three per week for two weeks to one visit every few weeks. Paul, who favors six sessions states, The limit of six interviews tends to thwart the client from becoming too reliant on the therapist and thus lessen his own self-reliance, self-esteem, and functional competence. In turn, the time limit compels the therapist to mobilize both his and his client's resources for achieving their goal of social restoration, and also acts as to diminish any covert omnipotent strivings the therapist may have. (1966b, p. 50) Barten (p. 87) recommends face-to-face interviews once, twice, or even three times weekly, lasting anywhere from a few minutes to an hour. He limits the contact to a period of two or three months. All theorists agree that crisis intervention should occur as quickly as possible after the perception of the difficulty is conscious. Practitioners disagree as to the length of time that may exist between the precipitant and the intervention, such that the therapy is still crisis intervention. The variability ranges from 24 hours to three months, and all are set arbitrarily. 35 Early Intervention The argument for early intervention consists of the fact that since during crisis, the person's usual defenses are weakened, he is more apt to reveal more pertinent information more quickly. Further, it is felt that conflicts are more accessible since they are still active, and that secondary gain which is a frequent impediment to change, has not yet had much of a chance to solidify (H. Parad, p. 278). It is further argued by Kalis that the application for help means that some- thing has happened which makes that patient unable to continue the successful adaptation which he had pre- viously achieved (p. 28). The question of why a person comes at the time he does, . . . is broadly conceived as including not only what is going on that is distressing, but also what is it that is expected from the institution in the way of help for this distress. In answer to this question, the patient frequently cites long-standing difficulties, refers to the build-up of tension, or offers rationalized explanations. (Harris, p. 467) This phenomenon occurs because the patient is typically not aware of the consequences of the precipitating stress and its relationship to the current distress (Rapoport, 1967, p. 216). It is also the case that even if the individual is aware of the precipitant and some relationship to the present functioning, that he 36 is unaware of the unconscious processes that caused the event to escalate into something of crisis proportions (Rapoport, 1962, p. 216). Activity Level Paul (1966b, pp. 49-50) and Stricker (p. 153) recommend a very high degree of activity on the part of the therapist to direct the patient away from his long- standing complaints (typically used to defend against the anxiety attendant to the crisis) and towards the present situation. Another approach recommended by Sifneos involves the therapist attempting to, . . . convince the patient that he (the therapist) is eager to help, and allow him to talk freely without interruption. He (the therapist) "lends himself" to the patient by taking over some of his decision making functions. He helps him to understand the ways in which he handled his feel- ings when faced with hazardous situations. He predicts the future behavior on the basis of past performances and thus, prepares him to avoid future difficulties. (1971, p. 87) A high degree of therapist activity underscores the fact that a therapist is doing something. This process facilitates the development of hope and the expectation that the patient will be helped. Frank (p. 349) has observed, "If hopelessness can kill, it seems reasonable to suppose that activities designed to raise a sufferer's hopes can promote healing." It has further been demonstrated that mutual expectations of patient improvement by therapist as well as patient 37 are significantly correlated with patient improvement, regardless of the instrument or criteria for positive outcome. The greater degree of therapeutic activity has one significant pitfall. Referring to the crisis inter- ventionist, Townsend states, He can and must understand the person and his problem as fully as possible, but must never lose sight of the fact that the problem remains the client's and, if anything is to be done about it, the client himself must be the one ultimately to do it. (p. 378) There is, then, a difference between doing with, and doing for, the patient. The former breeds autonomy while the latter breeds dependency. The goal is to enable the patient to "see" and contemplate "rationally" the alternative courses that are open to him to "resolve" his predicament, not to "resolve" it for him (Strickler, p. 150). Semrad (p. 578) argues that the therapist must remain watchful lest he stray from a strict problem- solving approach in crisis intervention. Strickler has found that this approach has much in common with what has been traditional social work professional practice. Social work is the most characteristically problem-solving oriented of all the mental health professions. In both casework and group work, treatment is focused on current problems related to emotional and social relationships, and per- tinent areas of social dysfunction which are selected as the target for intervention; the importance of precipitating events is recognized; time limited goals are set; active focusing 38 techniques are used; and treatment is geared to the level of conscious and near-conscious emotional conflict. This is equally true of crisis treat- ment. (p. 150) Because they are offered to different kinds of patients and are technically dissimilar, psychotherapies of short duration may be divided into two groups: (1) anxiety provoking or dynamic and (2) anxiety sup- pressive or supportive. A certain degree of anxiety is necessary, even in supportive therapy, and too much anxiety provoked through confrontation will cause the patient to flee. The balance of a workable amount of anxiety and a supportive focusing of that anxiety on a workable problem is the hallmark of crisis intervention. The therapist must maintain a high degree of flexibility, concentrating not only on the affective balance in his patient, but on environmental forces as well. An optimal blend of dynamic theory and common sense will inevitably lead the crisis therapist into numerous areas, and to a consciously more superficial coverage of those areas than would be the case with tra- ditional psychotherapy. For agitated patients for whom words come with great difficulty, Wolberg recommends the initial focus be upon the distressing symptoms. The patient is only too eager to talk about these. Their exploration may lead to a discovery of provocative anxieties and conflicts that initiate and sustain them. The importance of giving some meaning to disturbing or mysterious complaints 39 cannot be overemphasized. So long as a symptom remains unidentified, it is autonomous and a frightening foreign body. To label it, to explain its significance gives the individual a measure of control by helping him to restore his sense of mastery. This enables him to function better, since in finding out some reasons for his symptoms, he can utilize his energies to correct their source. (1965, pp. 159-160) The energies to which Wolberg refers are those that are freed up when the person no longer has to use them for worry or fear of the unknown--the strange--the dangerous that is happening "to him." This type of initial explor- ation and clarification is an example of the case wherein patients can make great use of just one or two interviews of primarily diagnostic work, and experience a great sense of relief (Gary Jacobson, p. 718). The simple act of focusing upon one thing at a time often places the problem segments in such bold relief, that possible solutions which may have been overlooked become readily apparent (Barten, p. 17). Understanding a number of segments may prove a catalyst for the discovery of broader solutions for the patient's difficulty (Gary Jacobson, p. 16). Command of a Theoretical Reference More than any other form of therapy, crisis intervention relies upon the therapist's thorough under- standing of dynamic theory. The therapist is deliber- ately pressured to formulate case material during the 40 first interview into a dynamic diagnosis, and is urged to tentatively test these hypotheses in that initial hour (McCleod, p. 192). Fenichel, referring to psychotherapeutic pro- phylaxis, states, An analyst is able to use the patient's symptoms, history, behavior, and utterances for the pur- pose of establishing a "dynamic diagnosis" about the patient's leading conflicts, the relative strength of the repressing and repressed forces respectively, of the defense system and its weak spots, of the patient's rigidity or elasticity, of his general accessibility. This dynamic diag- nosis will enable him to predict with a certain degree of probability what the patient's reaction to certain measures will be. Combinations of limited interpretations, provocations of certain types of transferences, providing well-chosen substitute outlets, alteration of the environment, suggestions or prohibitions of unconsciously tempting or reassuring situations or activities, the verbalizing of actual conflicts, and advice about mental hygiene can very well be systematized. (p. 565) Strategy of Crisis Intervention Strategy in crisis intervention must be care- fully but quickly conceived. What seems most par- simonious for one patient might be quiet inappropriate for the next. Since the crisis therapist should work toward the management of only that material needed to work through the acute disorder, the work plan must be as individualized as the idiosyncratic response to the original precipitant was for the individual patient (Strickler, p. 153). Awareness of dosage or pacing the experiencing of affect in the treatment is also 41 essential. Too little affect likely will mean relatively little improvement. Too much affect will risk an over- whelming of the patient's ego. This can lead to pre- cipitous regression, to intensification of defenses, and quite possibly, to the patient dropping out of treatment (McCleod, p. 193). Sifneos articulates five basic tenets of crisis intervention practice. The patient's motivation should be utilized in making the therapeutic work a joint venture. The patient should be helped to review and under- stand the steps that led to the development of the emotional crisis. The psychiatrist, on the other hand, must challenge and minimize the value of actions that he considers to be antitherapeutic and which may lead to further complications. The therapist must also try to teach the patient to anticipate situations likely to give rise to emotional difficulties similar to the ones he is experiencing. (He must) avoid by all means getting involved in the patient's characterological diffi- culties. (1966, PP. 125-126) Such statements as "We had better find out how this thing happened," or "Let's take a look at your situation so we can figure a way out of it together," are examples of enlisting the patient in a "joint" venture with the therapist. Further, however, the open expression of the therapist's interest in the patient and concern for him as a person, is not only supportive, but causes the patient to want to help the therapist in their mutual task. This is one of the foundations of all elementary training in the mental health professions. 42 Most, if not all, clinical endeavors focus upon a dynamic etiology in the early phases of the therapy. Public agency practice forces the therapist to verbalize his interest in the area due to time considerations and the need for rapid diagnostic formulations. Questions of etiology are raised by intake forms and intake workers as a matter of agency policy as well as clinical practice. In crisis intervention, connections between the current time and recent events which may have been disruptive, or evocative of the current conflict, are fully explored. There should be a clarification linkage between current stresses and previous preconscious or unconscious conflicts that was not entirely successfully resolved (Rapoport, 1967, p. 38). According to Whitaker and Malone, In brief depth therapy, the emphasis shifts from an objective analysis of the historical deter- minants in the patient's behavior to a contemporary participation and response to the patient's behavior during the interview. The therapist accepts, as a point of departure, the notion that all of the patient's therapeutic participation is essentially symbolic in character. (p. 505) Deeper issues may be explored, and yet not resolved in crisis intervention. They are only inadver- tantly discussed as the patient may bring them up. If they become a major part of the therapy, short-term goals must be abandoned (McGuire, p. 85). One avoids picking up trends which are not directly related to the presenting 43 problems, and refrains from pushing certain aspects of the patient's problems which have roots too deep to probe in this type of therapy (Pumpian, p. 647). "Early dependent needs and problems with passivity, which create entanglements and lead to complications during treatment, are especially avoided" (Sifneos, 1961, p. 171). In reviewing the suggested techniques of 10 of the most prolific author-practitioners of crisis inter- vention, one finds over 50 different descriptions of their own recommended techniques to be used in practice. They range in complexity from Beeker's single suggestion (p. 298) "The interviewer, if his intervention is to be truly preventative, should simply lend the kind of sup- port which the person in crisis needs in order to work out the solutions himself," to a 15-point plan put forth by Wolberg. These numerous recommendations appear, how- ever, to group under a few broad areas. The following table outlines that breakdown (p. 44). Matters of individual style and semantics account for a majority of the differing recommended interventa- tive techniques. There appears, however, to be general agreement that the traditional analytic stance is less than optimal for crisis intervention. There also appears to be general agreement on the overall focus of thera- peutic activity. Rapoport states, 44 sown nmuflamsuoma lacuna Hmumom awmamxm smenmeo ucommum can ummm SmeHmHo meeumHo on» uomceoo Hmnmq coaumNflHm whoumflm hyaucocH Isuomaampsfl mfioumESm xcmm mEmHQonm mo cofiumNflHm umumom mEmHnonm ucmfimmwmm< Isuooaaoucw mflmuonumo musecofififl m50flomcoo Hmpmom HoumOM SMHHMHO SmaucmmH endow cmeummmmz xomaawm cmHEwm meQH03 cwauwum HomqqmazH mEmHnoum =uommmp: mEoHnoum ouocmw =mmmp= mem>fimmmm muocoH weH>Hmmam Hmcnmw mnmnaoz szz¢qm whammmom pcoumnou Eflmaoxm cannon coaumfihownH pcmfifiou cowumucoumcou Emmemssuam monomnmm cowomu mo mmD pcmfim>ao>cH ummmmsm cowmmsomwp nomonmmm o>auom mma>m¢ m>auow m>auo¢ Am>mq Hamnusw stnmo cmufiom saanmpm MBH>HBU< cowucm>umacH mwmfiuu How mosqflcnoms cwccmEEoomm N manna 45 ma .9 .umcumu “mea 1mm .o .eeme .uuoooomm “omeumem .oo .cmeoesm 1mm .m .Hemnuso “an .o .ame .Q .memH .Hamm nummmmz “and .o .Memma .xomaeom “mmmuwmm .oo .omeswm «mmm .m .eeeuoum mmozmmmmmm owumwamasm uconmnoo m>flummmc muocmH amwnmao Hm3om esp gmaxomeg mummmmom: m>wpmmwz whammmmm HMSUOm mbfluflmom ma wmanm O umnmumucH mmsomao mo huwamsqm may muocmH mozmmmmm24ma uuomommm xomaamm mhmaaoz Hsmm :HHHmum mo mmD mace pmccmfifiooon Hmwnmumfi uoz Hmcoauapmue HmcoHuHUMHB Hmcofluapmue mSOHomcooon mmmmmmmm cmwmfidm Hamsusw Hmchmw mumnHOK Eomummlmamm can .HOanoo ommnquSm :0flmmmnmon copcofifioomn m>fiu© mo coflumc one.m oam.m hm.m mv.~ vm.m n ema.¢ mnm.v om. mh.~ mh.m m me.m ~m¢.m mm.m vm.m hm.m m hma.v oo~.v wm.m Hm.~ vm.m v mma.v anh.m ab.~ ~m.~ eH.m m mmm.v o>¢.v mm.~ Hm.~ v~.v m mmo.v Hmm.v mm.m an.~ mv.m H mHmom mmwumm pummmumna mmm.me Hom.me ma.me me.me mm.vm mswumu m>wummoz mmm.mm mmo.mm Ho.mm mm.mm mm.ev weapon m>wuwmom umHH Ixomno m>fluommcm mvm.ba oam.na mm.hH mh.ma mw.mH mamom um mmm.ma moo.o~ hm.ma mm.a~ wm.m~ maoom w: vmo.om mHo.mm mm.mm nm.vm mH.om mamom am mma.mm Hem.am mm.H~ mH.m~ hm.nm mHmom a mvm.aa wen.HH HO.HH om.~a mm.mH mamom mm Hmo.OH hom.m mh.m Hm.~H oo.mH mamom x Hmm.OH nmm.aa Hm.HH «H.0H mm.HH mamom m emm.m ovm.v ma.v mm.m mm.e wamom A Hmzz w u 2 ea n z Hm n z mmHQMHHm> m m x monmACHm monmflcflm Omuomunoo Omuomunoosp I Houusoo amusoeflummxm ucmfiumoue ucmfiummua ucoEumMHB numoe lemon 1 He mumsmwsflm How sumo msflumma ucmfiummnalumomloum m OHQMB 91 Table 6 Analysis of Co-Variance Post-Treatment Outcome Variables Experimental Control Signifi- Finishes Finishes cance Variable Number N=14 N=7 MMPI 77) L Scale 4.540 3.394 .589 78) F Scale 11.527 10.881 .619 79) K Scale 9.567 10.081 .391 80) Hs Scale 11.747 11.348 .818 81) D Scale 21.241 22.192 .933 82) Hy Scale 25.018 26.034 .728 83) Ma Scale 20.009 18.996 .566 84) Pt Scale 17.510 17.546 .942 Adjective Checklist 85) Positive rating score 36.095 35.855 .493 86) Negative rating score 43.361 42.659 .415 Patient Rating 87) 4.351 4.062 .360 88) 4.470 4.352 .749 89) 3.731 4.156 .321 90) 4.200 4.137 .692 91) 3.482 3.661 .592 92) 4.279 4.184 .735 93) 3.810 3.740 .194 94) 3.357 3.900 .049 95) 3.621 3.575 .785 96) 3.464 3.653 .673 97) Total 39.994 39.252 .241 Therapist Rating 98) 3.571 2.810 .460 99) 2.580 2.573 .986 100) 2.768 2.594 .580 101) 2.817 2.039 .634 102) 3.802 3.351 .663 103) .875 .660 .500 104) 2.657 2.697 .988 107) 2.388 1.673 .051 108) 3.359 3.415 .954 109) 2.935 3.017 .395 110) 1.103 1.306 .339 111) 3.076 3.005 .950 112) 2.903 2.617 .693 113) 3.305 3.292 .897 114) 2.549 2.605 .844 115) 3.109 3.148 .838 116) 3.117 3.095 .902 117) 1.898 1.896 .991 ¥ 92 Simple correlations were computed between the drop/ finish variable and all other pre-treatment variables and it was determined that the following variables were sig- nificantly correlated: marital status; pre-MMPI scales F and Ma; and the pre-treatment positive A/C/L score. An analysis of covariance was computed with the aforementioned variables as covariates, and the result was not signifi- cant (.124 level). Hypothesis 2 Members Of the experimental group will evidence significantly greater change than will those of the con- trol group. The outcome variables germain to this question were those administered both before and after therapy, i.e., MMPI scales, adjective checklist, and therapist ratings 1-7 (TRF 1-7). The covariate analysis of the MMPI, A/C/L, and TRF yielded nothing in the way Of supporting evidence for the acceptance of the hypothesis. This was true for both individual scale scores, and total results for each instrument. While it was evident that change occurred, in nO case was the difference between experi- mental and control therapy significant. 93 Hypothesis 3a The experimental group will self-rate a greater degree of positive change resulting from the therapy experience than will members of the control group. Questions 1, 4, 5, 6, 9, and 10 on the PRF speak to the issue Of self-rated change (variables 87, 90, 91, 92, 95, and 96 respectively). The result Of the computed analysis of covariance provided no evidence for the acceptance of this hypothesis (see Table 7). Hypothesis 3b The experimental group will self-rate a greater degree of satisfaction with the therapy experience than will members Of the control group. PRF items 2, 3, 7, and 8 (variables 88, 89, 93, and 94) were utilized. There was some minimal support for the notion that the patient felt better towards the experimental treatment than the control, but only one Of the four variables designed address Ho 3b was sig- nificant (variables 94, .049). This was not sufficient evidence to warrant the acceptance of the hypothesis. Hypothesis 4 Therapists will rate the experimental group as significantly more changed than the control group. There was no evidence to support the acceptance of this hypothesis from the TRF. Only question 10 on 94 e m m N m o a m eoumumeom m m N o m H n H OOOHO>HQ I m o o H a H e 338 eH n m HH m H m NH OOHHHmz on so .mx m CH mom mace mom H u u m n H .h 0 a . .m G .Opm .oum mspmum nmflsflh noun HmuHHmz Hmuoe Honpsoo HousmEHHOmxm Hobos Hmuoa OHQMHHO> msumum Hmuwumz can mmumm usomoua h OHQOB 95 the TRF (degree to which counter-transference was a problem) was significantly greater with the experimental than with the control group (.05). CHAPTER IV DISCUSSION Hypothesis 1 Members Of the experimental group will drop out significantly less frequently than those of the control group. Finishers tended to be Older, earn slightly more, and to have had an unsuccessful marriage, whereas persons who dropped out averaged three years younger, $1,000 less income (family of four) and were still mar- ried. None of these differences were, however, signifi- cant. While initial Observation indicated that the experimental method facilitated the completion of the clinical contract (14 finishers in the experimental group as Opposed to seven finishers in the control group), the analysis of covariance yields a nonsignificant result (.124). Much of the washing out Of significant findings was accounted for by the fact that while a total of 40 cases was selected for the study, the dropping out Of 19 (13 control and six experimental) left a total Of only 21 finishers (seven controls and 14 experimentals). These small numbers facilitate the appearance Of numerous 96 97 biasing variables. Marital status, for example, was a frequent covariate for most other variables. Four Of the five single patients dropped. Seven of the eight divorced patients finished. It is presumed that a larger N would yield a greater number of finishers and that a greater N of finishers would Offer a greater opportunity for either a randomization Of these variables, or a demonstration that the method is more or less successful with particular marital status; single, divorced, separated, married. The outcome Of the biased distribution of all single persons (N=5) being in the experimental group was to disguise a significant finding. Four Of the five single patients dropped from the study. Four Of the six experimental group dropouts were single. When all five single persons are not considered in the statistical analysis, one finds that the experi- mental method was significant beyond the .05 level. Several factors appear to account for the differences between persons who are, or have been, married and those who were never married. Single persons tended to be younger, and younger persons tended to drop out more frequently than older persons. Perhaps more important, however, was the notion that persons who are married have demonstrated a desire and an ability to form a close personal relationship with another human being. Further, 98 persons who were separated or divorced would be assumed to have had such a desire and, while not married in the traditional sense, were found to be (a) living with some- one, (b) applying because Of the breakup Of a relation- ship, Or (c) came in because of acute feelings Of loneli- ness. It may be thus concluded that these married or once married persons were at similar positions concerning their ability or desire to form significant (love) Object relationships. They also had a more fully developed net- work Of social supports, i.e., husband, children, home, neighborhood, than did single persons who tended to live alone, in apartments, and have fewer stable social relationships, i.e., job, home, school, etc. The interaction between the single persons more impoverished interrelatedness (relative to the married or once married) and the Offering of a time limited (six session) contract might prove an interesting area for further research. These persons might be asking for more of a relationship than the six sessions can presume to Offer. They, as Opposed to the married group, would be less likely to enjoy the security of a supportive relationship outside of the therapy and might well be asking for that support from the therapist. In the crisis method the accent is on problem-solving, not on supportive work, and this factor may well discourage single persons from finishing the contract. 99 A replication study of the experimental method with two matched groups, 20 single and 20 married persons, might yield supportive data for the aforementioned specu- lations. A second set Of covariates resulted from the use of the MMPI wherein the low F and inversely related high Ma scales were significantly correlated with the drOp vs. finish variable. It is accepted that these three MMPI scales are generally correlated with a patient's finish- ing or dropping. Finally, the positive A/C/L indicating that the person was reporting the experiencing of more and more intense positive feelings also correlated (.050) significantly with persons dropping out. Stated dif- ferently, persons who felt better to begin with had the tendency to not finish the treatment contract. It should be stated that all but one of the 19 drops occurred in either the first or second Of the six- or lO-session contracts. The single exception was a drOp from the control group after the fourth session. While it is possible that marital status affects outcome sufficiently to account for the success or failure Of crisis intervention techniques, two groups of at least 20 finishers in each group would be required to demonstrate that the weight Of a demographic variable was in fact a finding, and not simply a random statistical anomoly. Ideally, crisis intervention research should be 100 conducted in an agency which serves a population larger than that of the setting in this study. If a crisis intervention agency is used, much Of screening for whether or not the case is a crisis can be eliminated. A larger agency with more crisis cases would require a shorter period of time for data collection on a greater number Of cases. It was found that during the study, 42% Of the calls to the study agency were crisis calls but that over half Of those persons calling had either been taking tranquilizers or had been in a crisis state for longer than 30 days and had been con- tinuing to deteriorate. Because of the limits for the study population, these persons had to be disqualified. The economic requirement for low/middle income also pre- sented problems in this study in that seven of 10 appli- cants for service exceeded the income requirements of the study. Simply put, most persons who call in crisis at the study agency earned more family income than the study allowed, had seen their family physician who pre- scribed tranquilizers, and had also tried a number Of other possible solutions and support systems prior to their contacting the Mental Health Center. The Center seemed to be a "last resort" for persons in crisis. See Table 7. 101 Hypothesis 2 Members of the experimental group will evidence significantly greater change than will those Of the con- trol group. On none of the measures designed to deal with the question of change did the analysis demonstrate that the experimental method produced greater change than did the control method. It was apparent on all measures that change occurred. On the MMPI scales, for all finishers the Hs, D, Hy, and Ma scales were considerably closer to the mean of the normal population after treatment than before. It is noteworthy that these four scales changed for both groups. In MMPI scoring, the Hs, D, Hy relation- ship is referred to as the neurotic triad, indicating the patient experiencing anxiety surrounding typical psycho- neurotic concerns. The Ma scale is considered predictive Of the relative likelihood of the patient "acting out" problems rather than "working out" the difficulty. The lowering of these four subscales, thus, would indicate for both groups that there is a lessening Of the impulse to act out, and a lessening of the experiencing of psychoneurotic symptomatology. The results of pre- and post-treatment testing on the adjective checklist, while not significantly dif- ferent between groups, were interesting in themselves. 102 It is Obvious that patients in both groups experienced something as changing over the course of therapy. Affects typically considered positive were experienced more frequently at termination than at the beginning of treatment, while a corresponding deminution of affects typically considered unpleasant was also reported. The practical implications of an easily admin- istered change measure are truly great given the pressure for accountability in the public mental health sector. More research in varied settings could yield a simple device, economically feasible, which would validate on an Objective scale change in affect as a treatment out- come. Therapists' ratings of defensiveness, anxiety, and degree of disturbance were all lower for finishers, both experimental and control. Capacity for insight, personal liking for the patient, ego strength, and overall adjustment were all rated higher upon the completion of treatment. It can be stated that there was essentially no difference in the ratings and for scores between the two groups. This point will be further discussed later in this section under the heading "Practical Consider- ations." The consistency with which the MMPI subscales K, Hs, D, and Hy appeared as covariates with Therapist Rating Form items 1, 3, 5, 6, 7, and 8 might well 103 indicate that they are similarly sensitive to similar clusters Of data. The two instruments both attempted to get at the assessment issue in the clinical interview. More study of the relationship between the TRF and the abbreviated MMPI would be required for a fuller expla- nation Of this effect. Hypothesis 3a Members Of the experimental group will self-rate a greater degree Of positive change resulting from the therapy experience than will members of the control group. While sufficient evidence did not exist in the results of data analysis for accepting the hypothesis, two trends were identified. First there was a tendency towards agreement between the patient and the therapist in the following manner: Patients who rated themselves as feeling more overwhelmed at the beginning of therapy, and as benefiting less from treatment, were generally rated by their therapist as being more anxious, more defensive, and more disturbed while being less motivated for treatment, having less ego strength, and a diminished capacity for insight. Therapists also liked these patients less. These Observations held true for both groups when the patient rating was as mentioned above. The patient who presented as being overwhelmed and the victim Of circumstances outside Of his own control most 104 frequently wanted to have the treatment "done to" him and tended to resist a sense Of personal involvement in the working process. Therapists interested in doing well and in alleviation of their patient's distress apparently were "angered" by the "refusal" of the patient to "get well." The lack of a "we-ness" in the initial interview produced indeed a poorer prognosis with the techniques in this study. A second Observation needing mention is that persons in the control group tended to rate their degree of change in the extreme. They tended to report either a great deal of change, or none at all. The experimental group, on the other hand, rated change more consistently as positive but not extremely so. The explanation for this difference likely rests in the explicit acceptance in crisis intervention of the notion of limited goals, along with the verbalization between patient and therapist that problems exist with which they will not deal in the therapy. With control group patients, termination can be accomplished without any exploration Of other problem areas. Perhaps control group patients thought in terms of cured, or not cured, regarding their difficulties more as an illness than a problem. The experimental group was explicitly encouraged to adopt a problem-solving stance regarding their troubles. Future research in this area should be designed to look at the patient's 105 perception (illness to be cured vs. problem to be solved) of his difficulties as variable affecting outcome. Hypothesis 3b Members of the experimental group will self-rate a greater degree Of satisfaction with the therapy exper- ience than will members of the control group. The thinking behind this hypothesis centered around the belief that the patient would feel better about the active overt character Of the therapist's involvement in the treatment than he would about a passive, non- directive approach. This thinking would appear to be confirmed only with variable 94 (PRF 8) "How adequately do you feel you are dealing with any present problems?" While experi- mental group patients were able to accept the notion that they can still be having problems, they felt that they were still "normal" and that their problems could be solved. The solving process bred a sense of competence and confidence in their own abilities. There exists nothing in traditional short-term nondirective treatment which would accentuate and develop this patient perception. Variables 88, 89, and 93 (PRF 2, 3, and 7) dealt less specifically with problems, and more globally with gain, benefit, and satisfaction with the treatment. No significant results were found with the analysis of these 106 items. It might be well to frame other questions in patient rating which are designed to narrowly speak to a specific issue (state why satisfied) in addition to Obtaining global satisfaction ratings. In retrospect, it only makes sense that persons who finish a treatment contract would tend to be satisfied with it. It would be assumed that an extremely dissatisfied patient would number among treatment dropouts before too long. Thus, the question of patient satisfaction might have been better asked of the treatment dropouts, again with an instrument designed to elicit the specific reasons for satisfaction or dissatisfaction. Hypothesis 4 Therapists will rate members of the experimental group as significantly more changed than members of the control group. While therapists rated that change Occurred, there was no evidence to support the hypothesis that the experi- mental group would be rated as changing more than the control group. Further, there was no tendency towards significance. Neither was there any evidence of the control patients changing more than the experimental patients. Rather, the therapists' ratings tended to be remarkably similar for all finishers, regardless of group. In essence, therapists stated that their 107 patients (who completed treatment) changed as an out- growth Of therapy regardless of method. The therapist rating form items (20) were more frequently and more highly correlated with both demo- graphic variables, and with pre-test data, than any of the other evaluation instruments. Within this form (TRF), rating 10 (degree to which countertransference was a problem), rating 7 (the extent to which the thera- pist liked the patient), TRF 14 (the degree to which the therapist felt warmly towards the patient), and TRF 15 (how much emotional investment the therapist had in the client) were all frequently correlated with numerous demographic variables (between 16 and 26). TRF scores were lower (poorer) for persons of lower income, less education, and for unemployed persons, and for those with more than four persons in the family. These highly class-oriented variables rated as they were indicate that therapists felt these persons were poorer treatment risks than were better educated, employed persons with higher incomes and four or fewer persons in the family. It must be noted that nine of the 10 therapists involved in the study were themselves of a middle class, relatively well-educated family of orientation, with four or fewer persons in their family, and all had more than six, and as many as 10, years Of university education. While research into the relationship between patient and 108 therapist social class and other characteristics has been conducted, one can only wonder what the impact of these issues might be in the more active crisis approach. It is clear that the greater the gratification, liking, or warmth for the patient (TRF 14) or from the therapy (TRF 16), the higher was the overall rating on the TRF, and the higher was the patient rating of change in, and satisfaction with, the clinical contact. These phenomena occurred without respect for group assignment. The implications of this finding, not only for further research, but for clinical practice, are compelling and must be examined. In short-term methods where the relationship does not have the luxury of time to "build" the initial impressions of like or dislike of the patient may be crucial to the outcome. One might also ask for patient information about liking or disliking the thera- pist. Should cases be assigned not only on the basis of degree of skill required, experience and the like, but also on the relative intangibles of personal liking or therapists anticipated gratification from working with a particular patient? Should the client "shop" for a therapist of his or her liking? What would be the out- come results of such matching? The logistics Of such research are mind-boggling but the effort may well be unavoidable in the age of accountability which demands increased cost effectiveness and cost efficiency. 109 In retrospect, it would have been very interest- ing to have included an item in the TRF which spoke to the question "Will the patient complete the treatment contract, and why?" The results of this question when correlated with the other TRF items might lend important information concerning the assignment of cases for maxi- mum benefit Of patient/therapist matching. Further, a structured training and/or review process preceding the study might have sharpened differences between the two groups, and should be considered in future research. Practical Considerations There remains one critical question as yet unexplored and not dealt with in the hypotheses. In the introduction, the reader will recall that the author's interest in this research was stimulated, not only out of a belief that the method worked, but also by notions Of extreme pressure for dealing more rapidly and more appropriately and cost effectively with an ever—increasing demand for services in a time with ever- shrinking resources. The lack of significant differences between groups, while certainly not providing evidence for the greater effectiveness of the experimental method also does not demonstrate a greater effectiveness of the more traditional approach. Calling it a "draw" makes crisis intervention the "winner" by reason of necessity. Simply put, when one gets such similar results with the 110 experimental method in six sessions, why should one choose to achieve the same sort Of result with tradi- tional methods in 10 sessions? With clinical costs approaching and surpassing $40 per hour, the savings Of four sessions yields a direct savings of $160 per patient or a 40% reduction in costs per patient, savings of hours and perhaps most important, where waiting lists exist, a 40% shorter wait for resolution of the painful state which precipitated the crisis situation. Further, there may well be a significantly greater number of persons who will not drop out of treatment with the experimental method. While not statistically significant (.124) it is clear that twice as many people finished treatment in the experimental group as compared to the control. A larger study (N) with fewer restrictions for admission to the study is nearly underway to determine what result the greater randomization Of demographic variables will have on the patient dropout statistics. The state Of the clinical art is such that when a sig- nificance Of .124 is achieved it must be pursued. Anything that can impact upon the traditional 50% drop- out rate will have a great effect upon the acceptance of psychotherapy by both clients and funding bodies. Short-term psychotherapy outcome research is difficult to conduct but must be undertaken if we are to change what is now an art into an artistic science. 111 The numerous problems of length of time required, expen- sive statistical analyses, and sanction by governing bodies must be solved. Results in new areas of research may yield more questions than answers and may simply demand more research but in spite Of these potential Obstacles, efforts must be begun and continued. APPENDICES APPENDIX A TABLE OF RANDOM NUMBERS APPENDIX A TABLE OF RANDOM NUMBERS 0390) 10401 937l0 10504 98953 7323) 30528 72484 82474 25503 35555 05554 3:550 50750 00055 I5005 5IOI0 I57Il 53342 44270 I7540 7370! 0205: 402I5 I50I7 '00253 07550 IOI20 h:0I! 225:0 3:0I3 5250! 055I0 0053! IO0I0 00II3 00707 0I235 I3574 7200 00572 05777 305I0 35005 0524! 35I50 40!54 25I03 20503 650:7 24 l '22 00501 27000 Uh I04 (I3 I 52 l‘Jl2l 344 H 52157 50557 55057 0II00 3024) 0:002 0I773 2:!00 75505 03440 75:03 4!:50 I052: 30532 2I701 |027I I::0: 0!:05 20350 070I0 00070 03:00 455I7 04755 07500 75507 207I7 5:037 I0205 70I05 0IIIO 52102 00:50 45223 03370 55753 47010 57I5! 37220 0I70! 3055: 0I737 2I04I 550I8 1010! 4I200 073!2 7IX57 I505? 43515 35247 18010 13074 7I200 23553 05570 0IIIO 0275! 20340 75!:2 !I7:4 74027 73707 27054 55000 02444 00005 0402! 7370! 0200! 1314l 32302 10703 50503 00514 20:47 5I750 45I07 25332 00002 03742 75404 2250! 33504 00750 45I00 55555 l5I0l 10782 04072 II503 02005 30757 00500 75754 00533 25053 0!20! 4l340 10l52 00023 12302 80753 75035 70207 435:0 003I5 35354 7470! 30024 00407 70370 4|005 55050 00455 05722 50740 00I04 4043! 0I455 7425! 0504! 40507 57530 05523 0I5I3 “I000 5II55 53I30 5II55 3!:I3 4007s 35I5: I05I5 003I! 74I57 0050! 7:5!3 lIb34 7505! 030:0 47005 0435: 34077 55300 7IOI0 043!5 I0325 81540 60305 04053 35075 33040 45405 075:! 0I3I5 3I555 IIII3 7005! 03700 4:I0: 50023 34II: 507I7 07277 70503 3I5I3 30003 775I4 32000 07I05 30100 53232 I05:0 00070 IIhJI 00503 02th! 05in! 10322 535I5 57020 52000 0505: 27370 02552 55500 05445 03534 11220 0I7I7 07300 37405 70375 95220 01150 03207 10022 4830! 3!?5! 57200 08000 05330 335:! 20005 55523 470!! 502:5 3170! 55402 00352 14454 UI50! 50550 40007 005:! 41575 40707 0I037 30044 4774! 07I5l 530:0 2055! 0I!00 00277 45:57 505I0 070I0 22555 45503 27400 05743 50IOI 7:050 430I7 5I050 43552 50003 75212 I0003 35002 01350 420I4 20207 0!0!8 253I0 25I03 0I550 700I4 I502! 0007! !!403 3I004 4I371 7007! 14730 05:5 07020 37230 34:05 !5477 050:: 00355 4I000 III33 07550 305I5 430:5 15037 37500 14707 Itvnfl 00I07 05040 75I35 00530 0I307 II002 05327 H2I02 h37I5 22507 45500 23020 27452 45470 0I5!5 25024 05000 070!” 10030 3330! !5!7O 48355 5505! 22500 0370! 00573 43253 X4I45 20308 07I20 20004 05077 745I3 03II3 I435? 00315 50554 00:70 4II00 37450 73755 00533 25507 20I05 5I32I 022I0 50055 77074 000I0 3I075 00530 45I20 740:2 hI0I7 7:!72 00005 00500 I500: 35352 5II3! 44372 15450 0574! !I0!4 05I00 55300 031:0 1510! 70052 05IIO 1501! 1024! 00083 24053 84000 58232 4!840 81517 40850 52320 553l0 I500? 05355 00500 20735 47702 40352 330I0 00:43 03I00 0II00 070I0 55I2I 20:5! 50070 07030 II057 0020! II0I3 3I702 15027 00572 000!! 05030 70335 03770 5:70! ”5447 50303 57415 00I4! 55007 I4000 400I0 205I0 000I0 57:75 30505 6130! 45555 32024 0600! 14545 40072 0I055 77l00 20557 73I50 70284 24320 0500! 7:! I55 4 I530 55352 I720? 700 I3 1504.! 5 I02! 004I5 030! I :0I255 :I|00II :00.55 23.00! I000! I35520 SI200! -!5207 10100! (I:Il5 50102 05046 7IIIO 53I00 33:05 33474 770I3 100I0 5515: 00050 0076: 03!?5 53152 07;:3 35003 5207: 35055 32150 45I3I 035I5 Source: Paul G. Hoel, Elementary Statistics (New York: John Wiley & Sons, 1960), p. 241. 112 APPENDIX B ADULT INTAKE FORM LIVINGSTON COUNTY COMMUNITY MENTAL HEALTH CENTER APPENDIX B ADULT INTAKE FORM Date Today Last Name: First Name: Middle Name: Maiden Name: Address: City: Home Phone: Business Phone: Township: Living Situation: (Check as many as apprOpriate) ( ) Urban ( ) Rent Home ( ) Rural ( ) Apartment ( ) Own (or buying) home ( 1 Trailer How long have you lived in Livingston County? who referred you to the Center (check one)? ( ) Self ( ) Minister ( ) ( ) Friend ( ) Doctor ( ) ( ) Spouse ( ) Employer ( ) ( ) Court Date of Hearing: INDIVIDUAL DATA: .Age: Birth Date: School State Hospital Other (list) Education: Sex: Birth Place: Nationality: Religion Now: Religion in Childhood: Occupation: Firm: How long have you worked for present firm? ldilitary Service? If yes, list branch: Date of military service: MEDICAL INSURANCE INFORMATION: Do»you have Blue Cross? Blue Cross Number: Company: Type of Discharge: Other medical insurance? Please submit insurance card to receptionist. Blue Shield Number: Policy Number: Group Number: Service Code: Policyholder: 113 114 ( ) Single ( ) Divorce Pending: ( ) Remarried Date Applied For: Date Remarried: ( ) Divorced ( ) Married Date Final: Date Married: ( ) Widowed ( ) Separated Date Widowed: Date Separated: PLEASE SUPPLY THE FOLLOWING INFORMATION ABOUT YOUR SPOUSE: Name: Age: Birth Date: Birth Place: Nationality: . Education: Occupation: Firm: How long with present firm? Military service; branch, date and type of discharge: How long did you date? PLEASE SUPPLY THE FOLLOWING FINANCIAL INFORMATION: Your weekly gross pay: Spouse's weekly gross pay: Total income from other sources (child support, social security, etc.): Total Weekly income: List any unusual expenses that you have at this time: CHILDREN: Children by present marriage (list names and ages): Children from any previous marriages (list names, ages and comment on residence, custody, support, etc.): 115 FATHER: Age now (if living): Age at death 8 date: Education Completed: Occupation: Religion: Age at marriage: MOTHER: .Age now (if living): Age at death a date: Education Completed: Occupation: Religion: Age at marriage: Rate your parent's marriage: ( ) Very Happy ( ) Unhappy ( 1 Happy ( 1 Very Unhappy ( ) Average . , List names, ages and sex of brothers & sisters: As a child, did you live with your parents (if no, explain): Iflhen you lived with your parents, name 5 describe other persons living in the house: PHYSICAL HEALTH DATA: ‘Describe your present health: ( )_ Very Good ( 1 Average ( ) Good ( ) Poor List present illnesses, symptoms, (include allergies): Idst childhood and other illnesses, surgery, handicaps, etc. (Underline any whic! caused serious difficulty) When was your last medical check-up? Doctor? Reason for this and findings: List and describe the purpose of any medication you are now taking: 116 Have you ever had a serious mental disturbance of a ”nervous breakdown”? ( ) No ( ) Yes When? Treated By: Hospitalized At: How Long? Date of Discharge: List all previous psychotherapy, counseling, or other treatment for personal and family problems: Has any other member of your family been seen at this agency? Name and date of service: PRESENT PROBLEM: (Describe your present problem and explain why you are coming to the Center at this time) (use back of page if necessary) APPENDIX C ADJECTIVE - SYMPTOM CHECKLIST (ASCL) PRE-TREATMENT - POST-TREATMENT APPENDIX C ADJECTIVE - SYMPTOM CHECKLIST (ASCL) PRE-TREATMENT - POST-TREATMENT Recently I have been feeling: Always Frequently Sometimes Seldom Never Calm Aggressive Bored Kind Nervous Energetic Cheerful Moody Friendly Selfish Contented High Strung Good Tempered Mature Suspicious Tense Independent wofrying Flexible Trustful Dependent Irritable Jealous Relaxed Reliable Lonely Frightened Sleeping well Impatient Active AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA VVVVVVVVVVVVVVVVVVVVVVVvvvvvvv AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA VvvvvvvvvvvvvVVVVVVVVVVVVVVVVV AAA/NINAAAAAAAAAAAAAAAAAAAAAAAAA AAAArsAAAAAAAr-NAAAAAAAAAAAAAAAAA Vvvvvvvvvvvvvvvvvvvvvvvvvvvvvv AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA vvvvvvvvvvvvvvvvvvvvvvvvvvvvvv 117 APPENDIX D SEVEN SCALES FROM THE MMPI 3 C C C C C C C C C C C C C 3 C C C c C C C C c c c c C C c 3 C c c C Mada?» C C 3 c C C c C C 3 C C 3 C c C C C C c C C C c C 3 C C C C C c C C MDmH. .98sz xom 503m @2533 Em _ same .395 Loam? .«o EsoEm 092 33325: cm xcEc _ .2QO 9.25m.“ m cm; .796: 9am; u w J2: 0“ ox:— . 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Jag—$0.525 .52 E 96:09 _ 33$me 08 9355 £033 8.85m a 5 «so xmmun H .vmmmmtmnEw can? .mmEConm .Uoo m 2 9.9: 96:02 _ .on _ mef E @8026 9 “omaxm p.296: _ .08 950.3 :0 wEom mm? 3:3 20:: _ 50E? 5 “:5 £00QO no mucmEm>oE mE Hohcou go: 3300 H 225.: E 332?. was 0.8: _ .wESmEOm 302m acrmpuoz 2mm>.E cc: aficmsoo: u .MEQEE. Lo 9:533: mgumsE ME 2:? 0330.: on no 3:: 02w: H .mE 3 ham Bacon pars: p.36 35.. $95.. _ CD a) N m m to u: 0 dbllen m C‘IC‘INNNC‘) C If) .wwm .Sm .mvm C‘ '1‘ N APPENDIX E PATIENT RATING FORM (PRF) ()1 APPENDIX E PATIENT RATING FORM (PRF) How adequately do you feel you were dealing with any problems at the time you entered therapy? II II II II I] H II H II I] ll very adequately fairly adequately neither adequately nor inadequately fairly inadequately very inadequately ow much have hou benefited from your therapy? a great deal a fair amount to some extent very little not at all Everything considered, how satisfied are you with the results of your psycho- therapy experience? ——-fi——.—o—— extremely satisfied fairly satisfied somewhat satisfied fairly dissatisfied very much dissatisfied ow upset were you when you entered therapy? tremendously very fairly slightly not at all [low upset have you generally felt since your therapy? tremendously very fairly slightly not at all How much do you feel you have changed as a result of your therapy? H H H H H a great deal a fair amount somewhat very little not at all 126 8. f). 10. 127 ()n the whole, how well do you feel you are getting along now? [I extremely well [I fairly well [I neither well nor poorly || fairly poorly [J extremely poorly How adequately do you feel you are dealing with any present problems? I] very adequately l] fairly adequately I] neither adequately nor inadequately l] fairly inadequately [I very inadequately To what extent have your complaints or symptoms that brought you to therapy changed as a result of treatment? I] completely disappeared I] considerably improved [I somewhat improved [I no change at all [1 got worse Do you feel a need for further therapy? [I no need at all I] slight need I] could use more [] considerable need I] very great need APPENDIX F THERAPIST RATING FORM (TRF) patients whom you see in psychotherapy. K] o .‘l‘. 10. 11. 12. 13. 14. APPENDIX F THERAPIST RATING FORM Please rate each of the following items, comparing the patient with other Defensiveness before after Anxiety before after Ego‘Strength before after Degree of before disturbance after Capacity for before insight after Over-all before adjustment after Personal liking before for patient after Motivation for before therapy Improvement before expected (prognosis) Degree to which countertransference was a problem in therapy Degree to which you usually enjoy working with this kind of patient in psychotherapy Degree of symptomatic improvement Degree of change in basic personality structure Degree to which you felt warmly toward the patient Very little llllllllllllllll llllllllllllllll 1 Some l 128 Moderate Fairly great llllllllllllllll l l Very great Ililllllllllllll Appendix 'l‘herapist Rating Form 129 page 2 15. 16. 17. 18. 19. 20. Very Some Moderate li‘airly Very little ‘ great great How much of an "emotional investment" did you have with. this patient? Degree to which you think the patient felt warmly to you ()vcr-all success of therapy How would you characterize your working relationship with this patient? Extremely Fairly Neither good Fairly Extremely poor poor nor poor good good [low satisfied do you think the patient was with the results of his therapy? Extremely li‘airly Neither satisfied F‘airly Extremely dissatisfied dissatisfied nor dissatisfied satisfied satisfied How would you characterize the form of psychotherapy you conducted with this patient? I l I l l Largely Intensive supportive analytical APPENDIX G TABLE OF COVARIATES APPENDIX G TABLE OF COVARIATES Table 8 Variable Covariates thflfl Post L Scale Post F Scale Post K Scale Post Hs Scale Post D Scale Post Hy Scale Post Ma Scale Post Pt Scale Marital status; number of children; number of persons supported; income, Pre L, K, Hs, D, Hy Scales; pre therapist ratings 1, 3, S, 6 and 8 Pre L, F, K, scales; therapist rating 8 Marital status; number of children; relation; Pre K, Hs, D Scales; pre positive A/C/L; therapist ratings 3 and 5 Age; age squared; number of persons supported; employment; religion; pre K, therapist ratings 1, 2 and 8 Age; marital status; number of children; employ- ment; religion, pre F, Hs, Pt; pre-postive A/C/L; pre therapist ratings 2, 3, S and 8 Sex; marital status; number of persons supported; employment; years in the county; own home; pre K, Hs, D, Hy, Pt; Negative A/C/L; pre therapist rating 3, S, and 6 Marital status; number of persons supported; pre L, Ma scales; pre therapist ratings 1, 2 and 7 Sex; marital status; employment; years in county; Pre K, Ma, Pt; Pre therapist ratings 1, 4 and 8 Adjective Check List Negative Positive Marital status; number of persons supported; number of children; employment; years in county; Pre K, D, Hy; pre therapist ratings 1, 3, 6, 7 and 8 Age; age squared; number of persons supported; employment; religion; Pre F, D, Hy, Ma; positive pre A/C/L; therapist ratings 3, S, 7 and 8 130 131 variable Covariates Patient Rating Scale P1 P2 P3 P4 P5 P6 f7 P8 P9 T10 Pating Rating Total Pre therapist rating 2 Age; marital status; employment; income; own home; religion; Pre D, Pt; therapist rating 1, 3, 4, 6 and 8 Age; marital status, number of persons supported; employment; income; own home; religion; Pre F, K; pre therapist 1, 3, 4, S, 6 and 8 Age; income; own home; Pre F, K, D, Hy, Pt; pre therapist I, 3, 4, 5, 6 and 8 Age; number of persons supported; employment; income; religion; Pre F, K, Hy, Pt scales; pre therapist ratings 1, 4 and 5 Age; income; religion; Pre Hy, Pt scales; pre therapist I end 4 Age; marital status; children; number of persons supported; income; own home; religion; Pre F, K, D scale; pre therapist ratings 2, 3, 4, S and 8 Age; marital status; number supported; employment; own home; pre F, K, D, Hy, Ma; pre therapist rating 3, 4, 6 and 8 Age; marital status; income; Pre F, K; pre therapist 1 Income; pre L scale; pre therapist rating 3 and 5 Age; marital status; number supported; income; years in county; own home; religion, Pre K, Hy, Pt scale; therapist rating 1, 3, 4, 5 and 6 132 variable Covariates Post Treatment TherapistiRatings T1 T2 T3 T4 trs T6 T7 T10 T11 T12 T13 T14 T15 Sex; marital status; employment; own home; religion; pre K, D, Hy, Pt; pre negative A/C/L; pre therapist rating 1, 3, 5, 6, and 8 Age; marital status; children; children supported; employment; years in county; own home;_pre K, Pt scale; pre therapist rating 1, 2, 3, 5, 6 and 8 Children; number of persons supported; religion; pre Hs Scale; pre therapist rating 3 Pre Pt scale; pre therapist rating 4 and 5 Marital status; children; number supported income; years in county; own home; pre F, D, Hy scale; pre therapist 1, 2, 3, S and 6 Marital status; pre therapist rating 6 and 9 Age; marital status; children; number supported; years in county; own home; religion; pre F, K, Hs, D scales; pre therapist ratings 3, 6, 7 and 8 Age; marital status; number of persons supported; employment; years in county; religion; pre F, K, Pt scales; pre A/C/L; pre therapist rating 1, 3 and 8 Marital status; number supported; employment; income; religion; pre L, F, K, D, Pt; pre therapist rating 1, 3, 4, S and 6 Marital status; number supported; employment; own home; religion; pre F, K, D, Hy scale; pre therapist rating 1, 3, 4, 5, 6 and 8 Marital status; number supported; employment; income; own home; religion; pre F, D, Hy scales; pre therapist ratings 1, 3, 4, S, 6 and 8 Age; marital status; number supported; employment; income; own home; religion; pre K, Hy, Pt scales; pre therapist rating 4, 5, 6 and 8 Age; employment; income; own home; religion; pre F, K, D, Hy, Pt scale; pre therapist ratings 3, 4, S and 8 133 Variable Covariates Post Treatment Therapist Ratings (Continued) T16 T17 T18 T19 T20 Number of supported; employment; income; own home; religion; pre F, K, D, Ma, Pt scales; pre therapist ratings 3, 4, 5, 6 and 8 Age; marital status; own home; religion; pre K, D, Hy scales; pre therapist ratings 1, 4, S, 6 and 8 Marital status; employment; income; religion; pre K scale; pre therapist rating 1, S, 6 and 8 Age; marital status; employment; income; religion; pre F, K, D, Hy, Pt scales; pre therapist ratings 1, 3, S, 6 and 8 Marital status; number supported; employment; own home; religion; pre F, K, Pt scales; pre therapist rating 1, 4, 5, 6 and 8 APPENDIX H MATRIX OF COVARIATES um» I JUm< 4 qum< .u—oum an .opcom ox .u—oum x: .mpmum o oymum m: .mpmum x .upuom u .m_nom 4 max; ... ..xucaou a_ mcour ..... .c0mtmo can muuucH .....ouooonuc...CUwamPU¢ ...-«......oo...0uhr C30 3:023... 3023 ..o .3552 ..ucoanam a—wqoc.co mucaom ................:owamnnuuo ..... ..cocu__cu do Lauenz ... .................xow .. . ...mauoum .ou_coz ......vwcoacm mm< ..............Uo< “coeuoocp anon ucoEuuoch mun mmuo_co>ou co xwguaz m GHQMB mMBde¢>OU ho XHmaflz m anzmmmd 134 APPENDIX I FEE SCHEDULE LIVINGSTON COUNTY COMMUNITY MENTAL HEALTH CENTER Gross Weeklanncome, 0. _;_.36150 ;§;51_:_“4Q.00 49.Qlu:__61.50 m 61.51-:_“74;OO 74.01 - _86.SO ]. 99 00 _ 86.51 - 99.01 - 111.50 111.51:"124.00 124.01-fl136.50 1361511ml49;00 149.01: 161,50 161.51- 174.00 174.01-_186,50 186.51;_199,00 APPENDIX I FEE SCHEDULE 199,01;_211,SO _ 211,51;_224,00 224.01:”236.50 236.51- 249.00 249.01-.261.SO 261.50;_274.00 274.0l-.286.50 286.51- 299.00 299.01-U311.50 311.51- 324.0 324.011_ 336.5 336.51-_349.oo 349.01-_361.50 361.51- 374.00 374.01- 386.50 386.§1-M399,00 399 01- 411.50 135 Table 10 -11-“ _- _L"_" _1__3"”- ._ 43.. 9: :7 . :-____~ 1: -91 1.: ---100 -___ _ _ _ _ - __ _._~ -1200 ___ __ 1 __,_ g, __ 300 _ __100 ~_ _ _ _. 400 _ ”.200 ‘_ _ _ __ __ ,_500 300 ___ ,“100 __- _ __ ‘_600 .400 _ 1 200 _ g _ _700 - _ -.500 , 300 _ _100. p 8 0 . ..600 400 1 _ 200 9 0 __700 . _500 _ _ ..300 __ “10 0 __- ~M800 600 . >_400‘ _11 0 900 700 ,500| 12 0 _1000 _ '800 , 600: _13 0 1100 900 -700 ,_ 14 0 __1200 q 1000 _ _800 fl_p_15 0 1300 1100 400 -16 0 - _ , 1400 _ 1200 _ 7- _1000. _17 o _ A 1500 __.. _1300 _ 1 .1100. L8 0 _ 1600 - 1400 1 ‘1200_ #9 0 _1700 1500 ,1300‘ ~4-—2P o __ _ _1800 1. H600 _ +_ #1400 31 0 - —H900 1700 1500 22 0 4000 D800 _ D600 _ 43 0 1 2100 1900 ‘700 g 34 0 2200 2000 r800 ___4__2§ 0 4300 2100 1 00 A6 0 .2400 2200 2 00 27 0 ; 2500 2300 2100 28 0 2600 2400 ‘ 2200 2900 2700 2500 4. 2.00 _3000 n_._ _2800 52600 11 2400 31 0 2900 2700 .2500 REFERENCES REFERENCES Adler, G. Valuing and devaluing in psychotherapeutic process. Archives of General Psychiatry, 1970, 33' 454-461. Alexander, F. The efficacy of brief contact. In F. Alexander & T. French (Eds.), Psychoanalytic psychotherapy. New York: Ronald Press, 1946. Barten, H. Expanding the spectrum of the brief therapies. In H. Barten (Ed.), Brief therapies. New York: Behavioral Publications, 1971. Battle, C. C., et al. Target complaints as criteria of improvement. American Journal of Psychotherapy. Bellack, L. An experimental exploration of the psycho- analytic process. In D. Spence (Ed.), The broad scope of psychoanalysis. 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