THE IMPACT OF THE THERAPIST ON THE PROCESS
AND OUTCOME OF PSYCHOTHERAPY

By

Gerald Lee Gaffin

A THESIS

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

MASTER OF ARTS

Department of Psychology

1979

ABSTRACT

THE IMPACT OF THE THERAPIST ON THE PROCESS
AND OUTCOME OF PSYCHOTHERAPY

By
Gerald Lee Gaffin

This study investigated the relationship between
therapist personality variables, therapist behavior, and
therapy outcome. Twenty-four adult clients were seen
for therapy by five experienced therapists in a community
mental health clinic. It was hypothesized that therapist
personality needs would result in approach-avoidance
behavior to client verbalization which related to thera-
pist need areas. This hypothesis was partially confirmed.
Further, it was hypothesized that the amount of approach-
avoidance behavior in therapy would be related to therapy
outcome especially in interaction with clients' socio-
economic class. Here it was found that therapist avoid-
ance behavior was related to therapy outcome as rated
by the therapist. However, therapists did not show more

avoidance of lower class clients' verbalizations as pre-

 

dicted even though lower class clients rated therapy as
less satisfying. Implications of these findings were

discussed.

ACKNOWLEDGEMENTS

I would sincerely like to thank Dr. Norman Abeles,
chairman of this thesis committee. His willingness to
foster my personal research ideas as well as to provide
me with profound insights at times when I was "without
hope", was greatly appreciated. He helped make this
research a meaningful learning experience as well as a
document worthy of the field.

I would also like to thank Dr. Dozier Thornton and
Dr. Ralph Levine for their encouragement and helpful
ideas in the planning and execution of this research.

Further thanks need to go to Dr. Rom Kriauciunas,
Program Supervisor of the Ingham Community Mental Health
Center, and to the therapists and intake workers there.
Without their openness and cooperativeness in this
research endeavor, I would dare say that this study would
never have seen the light of day. Thanks also go to
Polly Crisp and Miquela Rivera for their entertaining
method of content analyzing this research.

Lastly, I would especially like to thank my parents
and my sister. Living in a family of three M.S.W.'s
could do no less than spur me on to great perfection in
my research endeavors to unravel the complexities of

the therapy relationship.
ii

TABLE OF CONTENTS

LIST OF TABLES
LIST OF FIGURES
CHAPTERS
I. INTRODUCTION
II. HYPOTHESES
III. METHODS

Subjects
Materials
Procedure . . . . .
Tape Rating Procedure

IV. RESULTS

Hypothesis
Hypothesis
Hypothesis
Hypothesis
Hypothesis
Hypothesis

O‘U‘l-DUJNH

V. DISCUSSION
APPENDICES
APPENDIX

A. CLIENT CONSENT FORM .

B. HOPKINS SYMPTOM CHECKLIST .

C. THERAPIST FORM

D. CLIENT FORM .

E. SCORING MANUAL

F. CLIENT STATEMENT SCORING CATEGORIES
REFERENCES

iii

Page

iv

61
63
67
7O
73
79
84

LIST OF TABLES

Table
1. Client Demographic Information .

2. Raw Scale Scores of Therapists on
Personality Measures

3. Summary of Significant Hypothesized
Correlations and Shared Variances

iv

Page
27

30

46

LIST OF FIGURES

Figure Page

1. Client Pre/Post Hopkins Symptom Check-
list Intensity Scores . . . . 42

CHAPTER 1
INTRODUCTION

The last quarter century has seen a distinct change
in the focus and assessment of psychotherapy. No longer
is there a strict reliance on theory alone to justify
psychotherapy as a worthwhile endeavor. Consumer aware-
ness has slowly crept into all facets of our world,
and therapists are now forced to display their effective-
ness to their clients, insurance companies, and to the
general public in concrete, practical terms--a task not
easily done.

This change was heralded by Eysenck (1952) when he
summarized psychotherapy literature to date and concluded
that clients treated with psychotherapy showed no more
improvement than did untreated populations of clients.
This study came under intense attack on both emotional
and scientific grounds (Rosenzweig, 1954; Luborsky,
1954). The scientific criticism appears to have been
just, that is, the criteria for improvement in the
"untreated" groups were unrelated to those used for the
"treated" groups, and the "untreated" groups actually
received an indeterminate amount of treatment. But,

from the time of Eysenck's publication on, this

controversy regarding the value of psychotherapy has
continued, and probably will not be resolved by argu-
ment and counterargument (Eysenck, 1955; Strupp, 1973;
Meltzoff and Kornreich, 1970). I am inclined to agree
with Hans Strupp (1973, p. 511) that:
The question in its crudest form, "does
psychotherapy do any good”, is largely a
specious one, and most researchers have

lost enthusiasm in attempting to answer it in
these terms...Researchers have increasingly

recognized during the last decade that there
are more important questions to be answered
by research...
These are questions such as the extent to which the
training and experience of the therapist effect outcome.

Looking at this issue of training and experience,
one way of exploring it is to assess the therapeutic
effectiveness of graduate students at various levels of
training in clinical or counseling psychology. This
will hopefully give us an index of the role of training
divorced from professional experience in effecting the
outcome of therapy.

Most of the studies looking at the therapeutic
effectiveness of graduate students at various levels of
training do not look specifically at outcome variables.
Rather, these studies look at levels of therapists'
conditions such as empathy, warmth, and genuineness
which have been shown to be necessary for effective

therapy. Carkhuff et al. (1968) investigated the

effects of the professional training of clinical graduate

students on their communication of facilitative con-
ditions. In two studies of clinical trainees cast as
counselors, one comparing first and fourth year students
and the other comparing first and second year students,
it was found that levels of empathy, regard, genuineness,
concreteness, self disclosure, and overall conditions did
not increase with level of clinical training. In fact,
there was a nonsignificant trend toward decline in levels
with increased training. Furthermore, in the study
contrasting first and fourth year students, it was

found that the ability to discriminate these conditions
from tapes showed no significant difference for training
level. On the other hand, Perlman (1973) found a
significant increase in empathy, nonpossessive warmth,
and genuineness as the training year progressed for
third year clinical graduate students enrolled in a
supervised practicum. While with second year graduate
students, who were conducting intakes but had no
supervised therapy training, there was no significant
increase in those conditions.

Another line of investigation studied the issue of
anxiety in therapists-in-training as a result of client
responses. The importance of therapists' anxiety levels
to therapy effectiveness lies in Bandura's (1956)
finding that anxious therapists are rated to be less
competent therapists, as well as Bandura et a1.'s (1960)

finding that anxiety leads to avoidance behavior of client

material which in turn leads to less effective outcome
(Winder et al., 1962). Russell and Snyder (1963), in a
counseling paradigm employing 2 actors role playing as
clients, studied the reactions of 20 clinical graduate
student counselors at various levels of training. Results
revealed that hostile client behavior led to significantly
greater anxiety than friendly behavior regardless of
training. Furthermore, counselor's level of training had
little effect on the degree of counselor anxiety for
either hostile or friendly conditions. Likewise, Murphy
and Lamb (1973) found that amount of anxiety displayed by
therapists when confronted with a hostile client did not
change as a function of training. They did find, though,
that as a result of therapy training, clinical students
did more "interpreting" of client behavior and less
"advising" than did the control group of graduate, school
psychology practicum students. This suggests that such
therapy training may effect specific interview behavior
of trainees as they relate to interactions with hostile
clients.

As for post-therapy outcome studies for therapists-
in-training, it was found by Grigg (1961) at the
University of Texas Testing and Counseling Center that
clinical trainees with 1 year of internship did not
differ significantly from inexperienced clinical trainees
with no internship or prior experience in their clients'

assessments of whether counseling had been helpful to them.

From these studies, it appears that training has
not shown itself to be the strongest ingredient in
producing effective therapy or therapeutic conditions.
Perhaps this is because training is related to therapeutic
effectiveness in other than a linear fashion. Nonethe-
less, this would seem to leave the formal experience of
the therapist as being the more crucial ingredient to
therapeutic effectiveness. It is to this issue that we
now turn.

At the client-centered setting of the University of
Chicago Counseling Center, Cartwright and Vogel (1960)
looked at the issue of therapist experience. Twenty-two
clients were seen by nineteen therapists, ten of whom
were considered experienced and nine unexperienced as
determined by the number of past clients that thera-
pists had seen. Outcome measurement was obtained by
difference scores between pre and post-therapy application
of the Butler-Haigh Q-Sort and the TAT. Results showed
that an experienced therapist is effective in improving
the patient's adjustment as revealed by both the TAT and
by self-descriptions on the Q-Sorts while the inexper-
ienced therapist was not as effective in improving the
client's self picture and may have actually brought
about a decrease in client adjustment as marked by the
TAT. These results, though, were not quite significant

at the .05 level, due possibly to the loose standards

used for measuring the experience of the therapists in
this study.

Another study also completed at the University of
Chicago Counseling Center (Barrett-Lennard, 1962) looked
at the issue of experience and outcome. Eight therapists
classified as experienced had completed at least two
years of internship and had a minimum of three years
experience at the Center while unexperienced therapists
were four first year staff interns and a research
assistant. Length of stay was taken as an indirect
measurement of outcome and the patient-therapist relation-
ship was measured by a questionnaire covering five
relationship variables. In addition, a pre-post index of
change was applied. Results showed that: 1. Length
of stay was greater for clients of experienced therapists;
2. Seventy-five percent of the clients seen by the
experienced therapists were rated "more changed" as
opposed to 43 percent of those seen by less experienced
therapists (p < .10); and 3. The measurement of the
5 relationship variables were higher for experienced
therapists although only one reached the .05 level.

Other studies looking at therapist experience such
as McNair, Lorr, and Callahan (1963) and Baum, Felzer,
D'Zmura, and Shumaker (1966) have found that more
experienced therapists have less drOpouts from therapy.

However, not all studies have shown positive results.

Fiske, Cartwright, and Kirtner (1964) found no relationship

between therapist experience and the outcome of therapy
at the University of Chicago Counseling Center. The
measure of experience used was the square root of the
number of clients seen. And Sullivan, Miller, and
Smelser (1958) found no significant relationship between
therapist experience and the length of time that clients
stayed in therapy or client improvement at a VA mental
hygiene clinic. In this study, an experienced therapist
was defined as one who had at least one year of staff
work.

While the evidence is not totally positive, addition-
al professional experience for the therapist does seem to
be a factor in therapeutic effectiveness. Furthermore,
research investigating experience as a factor in thera-
pist behavior during therapy (process research as
opposed to outcome research) shows that here also
experience has an important influence. For instance,
experience has consistently shown up as a factor in the
therapist's level of warmth (Mills and Abeles, 1965;
Strupp, 1973). It has also been a factor in the
therapist learning to limit the direct expression of his
needs in therapy and consequently be more facilitative
to the client (Mullen and Abeles, 1971). And trained,
experienced counselors avoid hostility less than trained,
unexperienced counselors (Gamsky and Farwell, 1966).
However, in addition to experience, these abilities of the

experienced therapist point to another aspect of the

therapist that seems to be of importance to effective
therapy, namely, the personality of the therapist. Being
able to limit one's needs or give nonpossessive warmth will
have a lot to do with the personality of the therapist

as well as the therapist's professional experience. In
fact, in those studies that failed to show better outcome
for more experienced therapists, it may have been the
personality factor that led to the negative results.
Possibly, certain personality characteristics of the
therapists allow them to be effective in therapy while
others do not. Let us take a look at the research in
this regard.

As far back as 1947, the American Psychological
Association's report on the training of clinical psycholo-
gists (1947) recommended characteristics that psychologists
should have. Among these were an interest in people,
self-insight, sensitivity, and warmth. What followed
from this view were studies that attempted to delineate
the personality characteristics that differentiated the
successful from the less successful therapists--studies
such as the ones done by Holt and Luborsky (1958) and
Strupp, Fox, and Lessler (1969). Holt and Luborsky looked
longitudinally at the personality patterns of psychiatrists
that came to the Menninger Clinic while the Strupp et al.
study looked at clients' perceptions of their psycho-
therapy. From these types of studies, it was concluded

that successful therapists tended to manifest stronger

interest in their clients than did less successful thera-
pists, as well as being somewhat more self-insightful,
'warm, original, and self-controlled.

Other researchers chose not to be so global in their
studies. This led to a few distinct lines of research
on the personality dynamics of the therapist and how
these characteristics affected the client. Three distinct
lines of research in this regard seemed to be followed:

1. The Whitehorn and Betz (1954) research on "A" and
"B" type therapists; 2. The Carson and Heine (1962)
research on the outcome of therapy as a function of the
personalities of both the client and therapist; and

3. The research of Rogers (1957) which suggested that
certain personality characteristics be present for
therapists to be effective in their professional work.

In their research on psychotherapy with schizo-
phrenics, Whitehorn and Betz (1954, 1957, 1960) found that
essentially two types of therapists could be discerned.
They labeled these therapists "A" and "B" and found that
they differed significantly. First, "A" therapists
were more successful in treating schizophrenics than were
"B" therapists. And secondly, ”A" therapists were more
able to gain the confidence of their clients, were more
able to grasp the personal meaning and motivation of their
clients' behavior, and were more personally involved
with their clients. This personality difference trans-

lated itself using the Strong Vocational Interest

10

Inventory as showing that "A" therapists' interests were
like those of a lawyer but not of a mathematics-

physical science teacher, while "B" therapists' interests
were just the opposite. This meant that "A" therapists
preferred activities that involved interaction with other
people. Research by McNair, Callahan, and Lorr (1962)
and Berzins and Seidman (1968) additionally found that
neurotics and less severely disabled patients tended to
improve more with "B" therapists. However, the A—B
dichotomy has been criticized as being representative of
personality types. Kemp (1966) found that "A" and "B"
types are not personality types but rather reflect two
types of therapists‘ reactions to specific patient
psychopathology (schizoid versus neurotic pathology).
Similarily, Carson, Hardin, and Shows (1964) found

"A" therapists to be more active and to be interested in
the severe (severe psychopathological) patient who turns
away from others.

Research on the outcome of therapy as a function of
the match between client and therapist is somewhat
equivocal. Carson and Heine (1962) found therapy success
to vary significantly with similarity of personality
characteristics as assessed from the MMPI for both
clients and therapists. The relationship was curvilinear
‘with extreme similarity or extreme dissimilarity being a

block to therapeutic progress. Swensen (1971) in a review

11

of the research on dyadic relationships concluded that
complimentarity on two main dimensions, interpersonal
approach-avoidance and dominance-submission would lead
to more positive relationships and hence more progress
in therapy. And Dietzel and Abeles (1975) found that the
most successful therapist was one who showed less compli-
mentarity during the middle stage of therapy but showed
the same amount of complimentarity as the less successful
therapist during the first and last stages of therapy.
Rogers (1957, 1967) found that empathy, unconditional
positive regard (warmth), and the congruence of the
therapist are significantly related to successful outcome
in therapy. Further research by Truax and Carkhuff
(1967), Truax, Carkhuff, and Kodman (1965), and Truax
and Wargo (1969) on these therapeutic conditions has
found therapy to be more effective when therapists dis-
played high levels of these conditions. However, while
the theoretical views of Rogers have tended to receive
empirical support, there are several studies whose
results fail to confirm a significant correlation between
effectiveness of psychotherapy and levels of therapist
empathy, warmth, and congruence. Garfield and Bergin
(1971) found no significant relationship between the
therapeutic conditions and effectiveness ratings from
a variety of outcome measures. It was particularly
interesting to note their finding that empathy and warmth

were significantly intercorrelated.with each other in a

12

positive direction, while congruence was negatively
correlated with the other two conditions, a trend
opposite to the negative intercorrelation found between
empathy and warmth by Truax et al. (1966). And Gurman
(1973), in his investigation of these conditions within
and across sessions within the same therapist-client
dyads, found that therapists varied considerably in
their levels of therapeutic conditions--a result that
would begin to question the direct causal link between
empathy, warmth, and congruence and positive outcome in
psychotherapy. In light of these findings and the recent
review of the literature by Bergin and Suinn (1975)
on these therapeutic conditions, it appears that there
are too many negative results to describe empathy,
warmth, and congruence as sufficient conditions for
therapeutic personality change but that they do seem to
be necessary conditions (Garfield and Bergin, 1971).
Again, as in research on training and experience,
the research on personality dynamics shows some necessary
conditions for personality change, but not sufficient
conditions. Possibly, there is a deeper level personality
dynamic that underlies such characteristics as empathy,
warmth, congruence, and complementarity that would allow

these conditions to be sufficient for personality change.

 

This deeper level personality dynamic might be seen as
the ”mental health" of the therapist. It appears that

how therapists are functioning (their own conflicts)

13

would have a profound effect on whether they can offer
those therapeutic conditions to the client that would
allow for personality change. If therapists are having
conflicts, how can they give certain therapeutic con-
ditions to their clients? So far, though, there seems

to have been little research on the effects of therapists'
conflicts on their performances. Most of the writings
dealing with therapists' conflicts have been speculative
and not grounded in research findings.

One area of investigation into therapists' conflicts
lies in psychoanalytic theory. Conflicts of the therapists
have been recognized by psychoanalytic writers, e.g.,
Freud, in their emphasis on the personal analysis of
analysts. This awareness of conflict is further stressed
by the psychoanalytic concept of countertransference.
Countertransference here meaning the transference
reactions of the therapist toward the client--reactions
based on the unconscious needs of the therapist and his
views of reality. Thus in the countertransference,
the therapist uses the client through which to work out
his own conflicts--a state mediating against therapy being
useful to the client.

An attempt to translate the effects of this counter-
transference on therapy was investigated by Cutler (1958).
Specifically, he investigated the countertransference

reactions of therapists upon: 1. their perception of

14

their own behavior; 2. upon their perception of their
patient's behavior; and 3. upon their effectiveness in
working on problems of the client that impinge on their
own self-conflicts. Of a total of 40 predictions regarding
the therapists tendency to distort reports of behavior
relevant to their needs, 28 were clearly confirmed.
Furthermore, there appeared a strong relationship between
the patient's statements of concerns which related to

the conflict areas of the therapists and the judged
inadequacy of the therapist's immediately following
response.

Bergin and Jasper (1969), in a study of the corre-
lates of empathy in psychotherapy, found that therapist
Depression (D) and Anxiety (Pt) scores on the MMPI
correlated negatively with their ability to be empathic
in the therapeutic process. Likewise, Gurman (1972)
found that therapists who are relatively without emo-
tional conflict, but who are able to admit internal
discomforts when present, are more able to understand,
accept, and respond nondefensively to their clients. And
Strupp (1973) suggests that there is a relationship be-
tween therapist attitude, clinical evaluations, and
behavior in therapy mediated by the kind of personality
variables that change as a result of the personal analy-
sis of the therapist.

Therapists' conflicts would seem to be especially

problematic with the high risk populations. These are

15

the lower socioeconomic classes as defined by levels

IV and V on the Hollingshead and Redlich Index of Social
Class (1958). While with the middle and upper class
clients (levels I, II, and III) therapists' conflicts
would possibly have less of an impact. Conceding a
strong motivation and belief in therapy as well as a
good amount of social-class similarity between the middle
and upper class client and the therapist, there may

be enough of a bond between the two to keep the client
in therapy long enough to allow the therapist to resolve
his conflicts so that he may provide therapeutic condi-
tions for the client. And the realization of this
situation is possible since middle and upper class
clients tend to stay in therapy longer than their lower
class counterparts (Myers and Bean, 1968). In fact, one
could speculate that Myers and Auld's (1955) finding, that
only patients seen more than ten times showed better
outcome with experienced therapists, may point to the
conclusion that it took these therapists up to ten
sessions to work out their conflicts and attend to the
needs of their clients. However, with the higher-risk
populations, the poor, the therapists conflicts would
seem to accentuate the problems that therapists have
already in being able to work with this population. It
is these clients (lower socioeconomic classes) that tend
to leave therapy early (Hollingshead and Redlich, 1958)

and thus won't be in therapy by the time therapists have

16

worked through their conflicts and are ready to attend

to their clients. In addition, in a study by Nash et

a1. (1965) on the relationship of client "attractiveness”
to therapy outcome, it was found that client attraction

as defined by such social class and achievement factors

as age, education, occupation, ability to relate, verbal
facility, etc. was related to outcome of therapy.
Consequently, it appears that conflicts in the therapist
will only compound the problems that the therapist already
has in being able to attend to and be attracted to the
client enough to provide what the client needs. These
already existing problems as Hollingshead and Redlich
(1958) see it are problems arising from differences in
cultural norms, values, and role expectations between
psychiatrists (psychologists, social workers, etc.)

and their lower socioeconomic clients. The failure of
therapists to be able to attend to these lower class
clients is supported by Strickland and Crowne (1963) in
their finding of a correlation of .38 between socioeconomic
status and satisfaction in therapy.

However, there has been no research attempts to
determine whether therapists' conflicts have differential
effects on outcome with different types of clients
(socioeconomic levels) as the research on social class
and psychotherapy might suggest. Furthermore, what
studies there are on the investigation of therapist

conflict areas, which I reviewed previously (Cutler, 1958;

l7

Bergin and Jasper, 1969; Gurman, 1972; Strupp, 1973), have
not controlled for the training and experience of the
therapist. Therefore, it is difficult to assess how
much it was the therapists' conflicts that affected
therapy outcome and not the lack of training or exper-
ience of the therapists. I thus propose research,
controlling for therapist training and experience, that
would be aimed at studying the differential effective-
ness of therapists with clients of various social class
1evels--a question bound up with therapists' conflicts
and the effect that these conflicts have on clients of

various social classes.

CHAPTER II
HYPOTHESES

The purpose of the present study is to examine the
relationship between therapists' personal needs and
therapy process and outcome--needs that may interfere
with a therapist's effectiveness. Research has shown the
personal needs of therapists to be important to the
outcome of therapy. Mills and Abeles (1965) observe
that counselor needs for nurturance and affiliation, as
measured by the Edwards Personal Preference Schedule
(Edwards, 1954), have an important effect on positive
outcome. Likewise, using the Edwards Personal Prefer-
ence Schedule (EPPS), Demos and Zuwaylif (1966) found
that the most successful high school counselors scored
higher on nurturance and affiliation while the least
successful counselors scored higher on autonomy, abase-
ment, and aggression. And Schuldt and Smee (1968) in
a study of graduate psychology students, found that
clinical psychology graduate students scored higher on
intraception and nurturance while experimental psychology
graduate students scored higher on autonomy and aggres-

sion.

18

19

Further research has related these personality needs
to process and outcome and has pointed to an interaction
between therapist approach-avoidance behavior to client
material produced in therapy and therapists' needs and
conflicts. Thus certain needs or levels of them in
therapists has led to an avoidance of what information
the client is producing in therapy. The importance of
this approach-avoidance behavior lies in the fact that
avoidance of client material is negatively indicated
for positive outcome in therapy (Winder et al., 1962)
and is contraindicated for the production of conditions
of empathy and warmth in the therapy session. Lerman
(1963) found a negative relationship between therapists'
dependency anxiety and the likelihood of their responding
with approach behavior toward client expression of depen-
dency. Barnes (1963) found that therapists with conflicts
in the areas of hostility, dependency, and sexuality
showed less approach behavior to client material dealing
with these areas than did less conflicted therapists.

And Bandura et a1. (1960) found that therapists who
expressed little direct hostility and who showed high
approval seeking needs were less likely to permit and
encourage their patient's hostility. Only one study
showed a positive correlation between therapist needs
and approach behavior in therapy. Mills (1964) showed

a positive correlation between therapist need for

20

nurturance and affiliation and approach to client hos-

tility.
1.

These findings lead me to speculate that:

Therapists' needs, which may connote some per-
sonal conflict as measured by scores on the
Edwards Personal Preference Schedule and the
Tennessee Self Concept Scale (Fitts, 1965),
will result in more therapist avoidance and less
approach of client material that relates to
these areas of therapists' conflicts. Specifi-
cally, therapists with conflicts (elevated
scores in some instances and lowered ones in
others) in the areas of autonomy, intraception,
dominance, abasement, nurturance, heterosexuality,
and aggression as measured by the Edwards and
in the areas of personal self, family self, and
social self as measured by the Tennessee will
show less approach and more avoidance behavior
of parallel client material than will less con-
flicted therapists. Additionally, higher
therapist scores on the State-Trait Anxiety
Inventory (Spielberger et al., 1970) will be
related to a larger percentage of avoidance
behavior while lower scores will be related to
a larger percentage of approach behavior. This
is in keeping with findings that anxiety in
therapists inhibit their ability to approach
client material (Bandura et al., 1960).

The greater amount of therapist avoidance of
client material, the less effective therapy will
be for the client as assessed from listings of
problems on the Hopkins Symptom Checklist (HSCL;
Derogatis et al., 1974) taken before the start of
therapy and 9 sessions or 4 months later (which-
ever comes first--or at some earlier termination
date agreed upon by both the client and therapist).
Additionally, this lessened effectiveness of
therapy will be found in therapists' and clients'
subjective post-therapy inventories of therapy
effectiveness (Strupp et al., 1969).

Research has also pointed to the conclusion that

lower socioeconomic clients, as defined by levels IV and V

on the Hollingshead and Redlich Index of Social Class

(1958), are less likely to stay in therapy or to obtain

satisfaction in therapy (Hollingshead and Redlich, 1958;

21

Myers and Bean, 1968; Strickland and Crowne, 1963).
Further, Nash et a1. (1965) found that client "attractive-
ness" correlated negatively with various social class
indices. These findings would seem to point to the
difficulties in working with lower class clients.
Consequently, it would appear that therapist conflicts
would compound an already difficult situation. And the
fact that lower class clients tend to leave therapy early
would mitigate against the therapist being able to work
out their own conflicts and attend to the client as would
be possible with middle and upper class (levels I, II,
and 111) clients who remain in therapy longer. Thus:

3. Therapist conflicts will relate to effectiveness
of therapy differentially according to client's
socioeconomic class (as defined by the Hollings-
head and Redlich Two-Factor Index of Social Class,
1958). This means that therapist conflicts may
tend to lead to less effective therapy outcome for
lower class clients (levels IV and V) as measured
by the Hopkins Symptom Checklist and by the
Strupp et al. Post-Therapy Client and Therapist
Inventories. This differential effectiveness is
considered to be the result of two interacting
processes. One influence is that therapists
will give a larger percentage of avoidance
responses to lower class clients as opposed to
middle and upper class clients as a result of the
therapists' difficulties in relating to lower
class clients (Hollingshead and Redlich, 1958;
Myers and Bean, 1968). And secondly, because of
therapists' difficulties in relating to lower
class clients, the lower class clients will tend
to leave therapy earlier than others. Thus
therapists will not have as long a time to get
beyond their conflicts and attend to the client
as they would with middle and upper class clients
who tend to stay in therapy longer.

Specifically, it is hypothesized that:

22

Therapist scores on the Edwards Personal Preference
Schedule will correlate with the percentage of therapist
avoidance responses to client material relating to
these need areas. Specifically, it is predicted that:

A. The higher the score for the need areas of
dominance, abasement, and aggression, the
larger the percentage of therapist avoidance
responses to client material relating to
these need areas.

B. The lower the score for the need areas
of autonomy, intraception, and nurturance,
the larger the percentage of therapist
avoidance responses to client material
relating to these need areas.

C. Scores for the need area of heterosexuality
will correlate with percentage of therapist
avoidance responses to client material
relating to this need area. However,
directionality is not predicted.

Therapists' scores on the Tennessee Self Concept

Scale for the self-concept areas of personal self,
family self, and social self will negatively correlate
with a larger percentage of therapists' avoidance
responses to client material relating to these
self-concept areas.

Therapists' scores on the State-Trait Anxiety Inventory
will positively correlate with therapists' total
percentage of avoidance responses to client material
and will negatively correlate with therapists' total
percentage of approach responses to client material

in therapy.

Percentage of therapists' avoidance responses to
client material will negatively correlate with therapy
effectiveness as measured by the change in the
clients' pre/post Hopkins Symptom Checklist and by

the Client and Therapist Post Therapy Inventories of
therapy effectiveness (Strupp et al., 1969). Con-
versely, the percentage of therapists' approach
behavior will positively correlate with therapy
effectiveness.

Clients' socioeconomic class will negatively corre-
late with the percentage of therapists' avoidance
responses to client material in therapy--meaning that
higher percentages of therapists' avoidance responses
wi 1 be found in relation to lower class clients
(classes IV and V). And a higher percentage of
therapists' approach responses will correlate with

23

material from clients in the middle and upper classes
(classes I, II, and III).

Clients' socioeconomic class will positively corre-
late with therapy effectiveness as measured by the
change in the clients' pre/post Hopkins Symptom
Checklist and by the Client and Therapist Post
Therapy Inventories of therapy effectiveness
(Strupp et al., 1969).

CHAPTER III
METHODS

This study was carried out in cooperation with the
Ingham Community Mental Health Center. This Center is a
public agency utilizing prorated fees which serves the

Ingham County community.

SUBJECTS

Two groups of subjects provided data for this study--
Ingham Community Mental Health Center therapists and their
clients.

A. Selection of Therapists--These were chosen so as
to maximize both training and experience variables. Five
therapists were chosen from the agency list of therapists
who consented to take part in the study. Two therapists
held Masters degrees in Social Work, two therapists held
Masters degrees in Counseling, and one therapist had all
but the dissertation completed for the Ph.D. in Counseling.
An attempt was made to balance the therapists for gender.
The resulting group of therapists consisted of two females
and three males. The two female therapists had 2% and
3% years of experience respectively. The three male

therapists had 9%, 7%, and 1% years of experience. Sex

24

25

of the therapist was not controlled for in this study.
The rationale for this derives from Meltzoff and Korn-
reich's (1970) finding that therapist gender is unrelated
to therapy outcome in a review of the literature on
patient improvement.

B. Selection of Clients—-These were selected from
the pool of clients applying for therapy at Ingham
Community Mental Health Center. Only clients meeting the
following criteria were used in this study:

1. The 83 were to be between the ages of 18 and

60 years old inclusive.

2. The 85 were to be in individual therapy and to
be just starting therapy with the therapists
under investigation.

3. The therapy was a chosen line of endeavor for
the Ss and not one forced on them through the
courts, etc.

4. The Ss were functioning well enough to be able
to fill out those inventories that were required
of them in order to participate in the study.

Clients used in this study were clients who met the above
criteria and who agreed to participate in the study.

A letter explaining the purpose of the study and
eliciting the clients' participation and permission for
gathering inventories and tapes (see Appendix A) was
given to these clients who agreed to participate in the
study. It was emphasized that participation in the
study would have no effect upon their right to therapy
and that all material would be coded and confidential.
Clients who refused to participate were dropped from the
study. If a client agreed to participate, that client

was considered one of the five clients being sought for

26

each of the five therapists under study. This procedure
was followed until all five therapists had five clients
each (one therapist had only four). In an attempt to
obtain clients from various socioeconomic levels for
each therapist, one modification of the procedure for
the selection of clients was followed. If in the course
of the natural assignments of cases to the therapists
under study, it was found that a therapist already had
three clients from the socioeconomic levels IV and V
(combined) or I, II, and III (combined), then further
clients referred to that therapist would not be asked

to participate in the study unless they were the
opposite socioeconomic level from the already acquired
three. Table 1 shows a breakdown on demographic variables

for the clients for each of the five therapists.

MATERIALS

 

A. Therapist Measures

1. Edwards Personal Preference Schedule--
This schedule consists of 225 pairs of statements to
which the therapists circled the one statement of the
pair that is most characteristic of him or her. The
EPPS purports to measure 15 personality need variables
derived from a list of manifest needs presented by
Murray et a1. (1938). The 15 needs that it measures

are: achievement, deference, order, exhibition,

27

IZZZEIBHZ CZEEBHZCZ {ZCZEZKHZ

BCZEIB

comm
ucmwao

InbuZPuka hflniihii EZZLHRMh

hflnhah

Hmpcmu
unmaao

>H

HHH
HH
HH

HH
HHH
>H

>H

HHH
>H
>H
HH

HHH

HHH
>
HH
>

xmch

mmm

ooo.w
A.<.mv mac:
ooo.mH
ooo.oa
ooo.qm

oom.na
Anamowmev ococ

ooo.wH

oo¢.m

ocoa

oom.NH
Asmanmmnev «so:
ooo.ma
ooo.o~
oom.mH

ooo.o~

oom.~

ooo.m
Anamowpmav mco:

wEOUCH VOCHWM HNDCC¢

mo ucmfimumum ucoHHU

coHumEhomcH ofinamuwoaon unowHo

H manna

sown
nuNH
nuna
anon
anon

puma
numa
nuNH
anon
span

rhea
anon
span
sumn
span

nuwa
nuoa
Suva

+NH

pwumaaaoo
Hoonom mo Hm>mq

HNMQ’V) Hqul-n HNMfi’I-n

91qu

uanHu
unmeo
unmeo
ucowHo
unmeo
q umwamumnH

humane
unmnHo
humane
humane

upmaao
m unnamumae

ucmHHU
uamflau
ucowau
ucmwao
ucowau
N umwmmuosa

ucmwau
uawHHo
ucowao
ucowao
H umwmmumze

28

owcmamwm u z

xomam n m

mUHé nu 3

mocmumfimmm oHHnam u .<.m
mnumum owEOSoomOHUOm u mum

: m HHH ooo.oH coma m ucmnao
3 a HHH ooo.oa soon a uanHo
3 a HH coo.m puma m unmaao
3 m >H ooo.mH nuNH N ucmwau
3 a > ooo.m coma H unmaao
m umwamnmza
momm HOUGOU NOVCH QEOUfiH Umfihmm HmDCG< fimumHQEOU

“guano ucmHHo mmm mo newsmumum humane Hoonum mo Hm>oa

A.e.ucooc H magma

29

autonomy, affiliation, intraception, succorance, dom-
inance, abasement, nurturance, change, endurance, hetero-
sexuality, and aggression. For the purposes of this
study, only seven of the need variables were investigated
for therapists. These seven are autonomy, intraception,
dominance, abasement, nurturance, heterosexuality, and
aggression.

Since this schedule can be completed by the thera-
pist without the need of the researcher being present,
a copy of the test was given to each therapist to take
at their own convenience. This test takes approximately
50 minutes. Scores for the seven need areas were taken
to be indicative of the therapists' levels of conflict
in those need areas (see Table 2).

2. Tennessee Self Concept Scale--This scale
consists of 100 self-descriptive statements which the
therapists used to portray his own picture of himself.
This was done by responding to these self descriptive
statements as being completely false, mostly false,
partly false and partly true, mostly true, or completely
true. The scores that were of interest in this study
were the ones relating to therapists' perceptions of their
personal selves, family selves, and social selves.

Scores for these three areas were considered to reflect
therapists' levels of conflict in these areas (see
Table 2). This scale can be completed by the therapist

without assistance and was given to the therapists to

30

om.~
m¢.w
H¢.m

wo.m
mm.¢
om.¢
«H.m
No.m
Ho.m
mm.q

.>mn
pumpcmum

«H.wo
mm.o~
mm.¢o

Ho.oH
on.HH
NN.mH
oo.mH
mm.mH
Nn.oH
Hm.MH

ammz
k.mom

on
we
Nu

0H
«H
«H

«H
mH
NH

<5
mm
mm

mH
HH
ON

NH

NN
oH

c

mm ON
on HR
on «m
mH NH
o w
NH «N
m m
0N «H
mN NN
«H mH
mumHmmumnaN

cm
mm
mm

OH
OH
mH

wH
mH
0H

mnmm Hmfloom
mnmm NHHamm
HHmm HmaOmHmm

mHmom unmocoo
MHmm mommoccmH

%uHHmsxomouwumm
aOHmmmhww<
mocmpnunzz

unmammmp<
wocwnHan
COHuamomuucH
haoaoun<

mHDponom mocmuommnm
HchmHom mpnm3®m

mmusmmmz huHHmcomumm co mumHamnmna mo mmuoom mHmom 3mm

N oHan

31

.mUmH paw mmmm How muonuflm ummu

%n so pmuuoamu mCOHumHDaom uHme HmEhoc no woman mGOHumH>mp puppcmum paw cmm2*

.>on
pumpcmum

mm wN om mm mN Numes< uHmuH
He NN 0N Hm NN muonc< oumum
knoucm>cH

mumec< uHmHHuoumum

cmmz m HV m N H

«.aom mumHmmnose

A.e.ucooc N mflsma

32

take at their own convenience. This test takes approxi-
mately 10-20 minutes.

3. State-Trait Anxiety Inventory-~This inven-
tory is comprised of separate self-report scales for
measuring two distinct anxiety concepts: state anxiety
and trait anxiety. The trait anxiety scale consists of
20 statements which assess how the therapists generally
feel, while the state anxiety scale consists of 20
items regarding how they feel at a particular moment in
time. This inventory was designed to be self-administered
and was given to the therapists to take at their own
convenience. Completion of this inventory takes less
than 15 minutes. Scores from this inventory are taken
to be indicative of therapists' ability to approach or
avoid client material (see Table 2).

B. Client Measures--Hopkins Symptom Checklist
(see Appendix B)--The Hopkins Symptom Checklist is a
list of problems with which people are often faced--
problems relating to the areas of neurotic feelings,
somatization, performance difficulty, fear—anxiety, and
depression. The test consists of 58 statements of
problems. The client is instructed to check those
statements that are presently a problem for them. The
checklist was given to the client by the experimenter
either immediately prior to the first therapy session

or was given to the client by the therapist at the

33

intake interview. The checklist takes approximately
15 minutes to complete.

C. Process Measures--Tape Recordings of Psycho-
therapy Sessions—-Each client in the study (total of
24), depending on their length of stay in therapy, had
their second session, their middle session, and their
last session of therapy recorded. (In total, clients
averaged 5.66 sessions each and were tape recorded an
average of 1.75 times.) The second session was used
rather than the first for it was believed that the first
session functioned as an intake interview. The middle
session was defined as the fifth session or the session
that took place nearest to the end of the second month.
The last session (in regard to this study and not
necessarily the termination session) was defined as
the ninth session or the session that took place closest
to the end of the fourth month (or at an earlier agreed
upon termination session). Clients who did not average
at least 2 in-office sessions a month were considered
terminators at that point at which 3 weeks or more had
elapsed since the last session.

D. Outcome Measures

1. Therapist Measures-~Therapist Form (see
Appendix C)--A nineteen question therapist form
(Strupp et al., 1969, shortened version) was given to
therapists at the end of therapy as defined by post

ninth session or post 4 months (or at an earlier agreed

34

upon termination date). This form tapped the therapists'
subjective beliefs about the effectiveness of therapy
and the movement that clients made on their problems.
All answers were coded on a five point scale and
effectiveness of outcome (therapists' view) was a con-
tinuous variable across clients measured as the percentage
of satisfaction and change scores on the form.
2. Client Measures

a. Client Form (see Appendix D)-—A
twenty question client form (Strupp et al., 1969,
shortened version) was given to clients at the end of
the ninth session or fourth month (or at an earlier
agreed upon termination date). This form tapped the
client's subjective beliefs about the effectiveness of
their therapy.

b. Hopkins Symptom Checklist-~the Hopkins
Symptom Checklist was administered once more at the end
of the ninth session or fourth month of therapy (or
at an earlier agreed upon termination date). Change
scores on the Hopkins as a result of therapy were looked
at from the standpoint of total number of complaints,
total weighted score, total intensity score, symptom
cluster scores, and five factor scores relating to
somatization, fear-anxiety, neurotic feelings, performance
difficulty, and depression. Research by Uhlenhuth and
Covi (1969) and Uhlenhuth and Duncan (1968a, 1968b) has

35

shown the Hopkins to be sensitive to changes in the

client as a result of therapy.

PROCEDURE

 

The procedure consisted of a four step process.
The first step entailed giving the therapists capies of
the Edwards Personal Preference Schedule, the Tennessee
Self Concept Scale, and the State-Trait Anxiety Inven-
tory to take at their own convenience. Each therapist
was given a booklet containing the three tests. Test
order was randomized in each booklet and therapists
were instructed to start at the beginning of the booklet
and work straight through. Therapists were informed
that all tests would be coded and confidential and thus
were requested to answer the questions as truthfully as
possible. The total amount of time required for all
three tests was under an hour and a half. Two weeks
‘were permitted for the therapists to complete these
measures. No other stage of the research progressed
until these measures were completed. From these tests,
the therapists' levels of need areas were determined as
‘well as their anxiety levels (see Table 2).

Step 2 entailed obtaining clients for the study
according to the procedures outlined above (see Table l
for descriptive data on the clients). Demographic
information on the clients was gathered at the time that

clients called into the center to schedule an appointment.

36

Clients who agreed to participate in the study were
requested by the experimenter to fill out the Hopkins
Symptom Checklist either prior to the first session of
therapy or at the intake interview.

Step 3 consisted of tape recording the second, mid-
dle, and last session of therapy for all research clients
seeing each of the five therapists. Consent for this
taping was obtained at the beginning of therapy when the
client was enlisted into the study.

Step 4 dealt with the outcome measures. At the end
of the ninth session or the fourth month (or at an earlier
agreed upon termination date), clients were requested
to again fill out the Hopkins Symptom Checklist.
Additionally, they filled out the shortened Strupp
et a1. (1969) form assessing the client's satisfaction
with therapy and the amount of progress they felt they
made in regard to their problems. Therapists also com-
pleted the shortened Strupp et a1. (1969) therapist form
for assessing the therapist's satisfaction with the
therapy and their view of the effectiveness of the therapy

for the client.

TAPE RATING PROCEDURE

 

The basic system used for categorizing the therapy
sessions was first used by Murray (1956) and later

modified by Bandura et a1. (1960) and Winder et a1. (1962).

37

This system is one that measured therapists' approach-
avoidance responses to the client during the therapy
session. A scoring manual for this system, with modifi-
cations in line with the purposes of this study is
presented in Appendix E.

Client statements were scored twice. Once as to
whether they expressed needs relating to autonomy,
intraception, dominance, abasement, nurturance, hetero-
sexuality, and aggression; and once as to whether they
expressed needs relating to the personal self, family
self, or social self. Statement categories were deter-
mined empirically by the questions on the Edwards and
the Tennessee that related to each of the needs (see
Appendix F). There was a miscellaneous category for
statements that didn't fall into any of the need areas.
Multiple scoring was also possible since a single client
statement could fall into more than one area.

Each therapist statement was scored as to whether
the therapist approached or avoided the expressed
client needs preceding it. Statements scored as approach
included those in which the statement was designed to
elicit further expression of feelings, attitudes, and
behavior while avoidance statements included those
designed to inhibit, discourage, or divert further
expression of feelings, attitudes, or behavior. Thera-
pist silence was scored in the miscellaneous category as

it was found by Bandura et a1. (1960) that silence was

38

responded to as an approach while other times it was
responded to as an avoidance.

The tapes were content analyzed by two third-year
graduate students in clinical psychology. Before
beginning to analyze the tapes used in the study, the
two raters practiced with tapes not in the study. They
worked together until their agreement in scoring need
categories and approach-avoidance behavior reached 75%
for need categories and 80% for approach-avoidance
categories.

All tapes used in the study were coded so that
raters could not identify the client or therapist. Each
recorded session was divided into three sections. Each
section consisted of 225 calibrations on the tape
recorder's counter or approximately 18 minutes of tape.
For each 225-unit section a random number table was
consulted to determine at what point in the first 150
units of each section rating should commence. Seventy-
five consecutive units in each of the 3 sections were
rated (or a total of 18 minutes for each tape). The
tape sections which were to be rated were all randomly
ordered so as to control for order effects. The judges
‘made independent ratings of the same measurement units,
namely, each full statement of a therapist which followed
a client's statement. The total number of ratings
obtained from each tape varied according to the number

of times the therapist spoke following a client statement

39

during the three rated segments. Technical recording
difficulties infrequently precluded ratings of some
therapists' statements, which were marked as NR (not
rated).

The resulting approach-avoidance ratios represent
the proportion of times that a therapist responded with
approach behavior and the proportion of times that the
therapist responded with avoidance behavior to client
expressions categorized in the various "need" categories.
The approach and avoidance proportions used were:

total no. of approaches to client expression
of need studied

 

 

APPROACH = total approach and avoidance to client expres-
sion of need studied
total no. of avoidances of client expression
AVOIDANCE = of need studied

total approach and avoidance to client expres-
sion of need studied

CHAPTER 4
RESULTS*

Before proceeding to the results of this study, it
may be useful to take a look at the population of clients
that participated in this study. A total of 24 clients
composed the population. Nineteen of the clients were
females, including 1 Black and 1 Hispanic, and 5 were
White males. Although there were low numbers of males
and non-Whites in this study thus preventing an eval-
uation of gender and racial variables, they were not
eliminated. This was for two reasons. One is that
research on psychotherapy has not clearly established
differentiated outcomes in therapy as a result of the
sex or race of the client or therapist (Meltzoff and
Kornreich, 1970). And two, this distribution of clients
is representative of many community mental health centers
and consequently it seemed justifiable to keep these
individuals in the study. Of these 24 clients, 18 of
them completed both the pre and post-therapy testing and
had tapes of their therapy sessions made. Six clients

did not complete the post-therapy testing, 3 White

 

*Statistics were considered significant if they
reached the p i .05 level.

40

41

females and 3 White males. Looking at Figure 1, which
depicts clients'symptom intensity scores by therapist

at pre and post-therapy, it can be seen that these six
non-completers did not differ in symptom intensity from
their counterparts for each therapist. The six non-
completers are designated by those dots lying on the
abscissa since they have a pre-therapy score but no post-
therapy score.

As detailed in the methods section, results for this
study were obtained from three sources. These sources
were therapists' personality inventories, clients'
and therapists' pre and post-therapy measures, and
clients' therapy tapes. Scale scores were obtained for
the personality inventories and therapy measures while
the therapy tapes were content analyzed. Selected taped
client segments were placed into one of seven categories
from the Edwards Personality Preference Schedule and
into one of four (three true categories and one "non—
scorable" category) from the Tennessee Self Concept
Scale by two third year clinical psychology graduate
students. In addition, therapists' responses to client
segments were rated as approaches or avoidances to the
client material. Interrater reliability for these ratings
were computed using percentage agreement. Agreement for
the Edwards categories was 78%, for the Tennessee
categories was 79%, and for the Approach-Avoidance

categories was 88%. Since the data was not ordinal, a

£42

Awsucwu ch mmuoom qumcwucH zamumzuumum
ommNwNNNonNQNMNNNHNoNonH:onHquHNHHHoHm m n o m c m N
-. _ . . . —

 

 

8.0.4 3.3.: aéfilsi «are
a c 3.8 3.3
a a
. AN.HV«
AN we « Am.HV *

A¢.HV:HN.qV a

AH.NV u... Am.MV u.»

HH.mV «Aq.mV%

Am.mv«
Hm.mv x Am.qv «

  

Aq.Nv %

coupomou mEOBQEHm who: u zuHmcoucH noummuo
popes: utoHHu n mononucwuma cH Hones: pcoomm
popes: umHamumLP n monoxucoumq CH nonesc umuHh
mouoom HuHmcoucH
umHonozo EOuesxm mcHxao: amon\mum ucmHHu

H mustm

             
  
    

 

-H
-N
-m
-q
-n
-o
-a

.o

:oH
aHH
INH
nNH
ucH
:mH
ncH
nNH
umH
umH
uoN
uHN
INN
umN

nnN
uoN
amN
uwN
uON
uOm

(sqnuan u?) $81033 Anrsuanul Adaaaqn-Jsod

43

Pearson Product Moment Correlation could not be computed.
In addition, because of the skewness of the distributions
for each of the content areas, a non-parametric correla-
tion coefficient such as Cramer's statistic could also
not be developed. The exception to this rule was with
the Approach-Avoidance categories for which a phi

coefficient of .75 could be computed.

HYPOTHESIS 1

Therapist scores on the Edwards Personal Preference
Schedule will correlate with the percentage of therapist
avoidance responses to client material relating to those
need areas. Specifically, it was predicted that:

A. The higher the score for the need areas of
dominance, abasement, and aggression, the larger the
percentage of therapist avoidance responses to client
material relating to these need areas.

B. The lower the score for the need areas of
autonomy, intraception, and nurturance, the larger the
percentage of therapist avoidance responses to client
material relating to these need areas.

C. Scores for the need area of heterosexuality will
positively correlate with percentage of therapist
avoidance responses to client material relating to this

need area. However, directionality is not predicted.

44

A. Therapists' need for dominance did not correlate
with therapists' avoidance of client material dealing
with dominance themes as defined by the Edwards. Although
therapists ranged in their scores for this need area (see
Table 2), there was little variation in therapists' ex-
pressed avoidance of this need area in therapy. What var-
iation could be found was contributed by a spuriously high
avoidance score by one therapist who avoided the one occur-
ring instance of a client dominant theme, resulting in a
100% avoidance score. Thus this category was eliminated
from further analysis.

Therapists' need for abasement was positively corre-
lated* (r = .5325) with therapists' avoidance of client
material dealing with abasement themes as defined by the
Edwards. However, this relationship was not altogether
clear since therapists' need for abasement correlated even
more highly and in a positive direction with therapists'
avoidance of client material dealing with themes of intra-
ception. Regression analysis** of the relationship between

therapists' need for abasement and avoidance found that the

 

*Correlations between therapist need areas and therapist
approach-avoidance of client material were computed
utilizing scoring categories collapsed over clients within
therapists. This procedure was chosen due to the presence
of zero or low frequency counts in the scoring categories
for individual clients.

**Only the main variable of each regression formula and
its shared variance (r2) is reported.

45

therapists' need scores accounted for 28.35% of the variance
in the avoidance of client abasement themes (r2 = .2835;
see Table 3).

Lastly, therapists' need for aggression showed the
opposite relationship than that predicted. A strong nega-
tive correlation (r = -.7809) was found between therapists'
need for aggression and therapists' avoidance of aggres-
sive client material. This was even more powerful
(r = -.9821) when one therapist's spuriously high score
was eliminated when a chi-square analysis showed that
elimination of the score did not significantly effect the
relationship. Regression analysis showed that the thera—
pists' need scores for aggression accounted for 96.45% of

the variance in the avoidance of client aggressive themes
2

(r = .9645).
B. Therapists' need for autonomy and intraception
negatively correlated (r = -.4128, r = -.4835) with thera-

pists' avoidance of client material dealing respectively
with client autonomy themes and intraception themes.
Regression analysis revealed that therapists' need scores
for autonomy accounted for 17.04% of the variance in the
avoidance of client themes of autonomy while therapists'
need for intraception accounted for 23.38% of the variance
in the avoidance of client themes of intraception

(r2 2

= .1704, r = .2338). Correlations with therapist need
for nurturance could not be computed due to the infrequent

46

wqmm.+

qmqq.

quq.

mmwe.

mNHq.

HNwm.

mNmm.+

I

you.

Nwm.om
wa.mH
Nmo.mH
Nwm.mN
N¢O.NH
Nm¢.co
Nmm.wN
.M
N

mmocmHum> pmamnm paw maoHumHmuuoo pmunmsuoahm uamoHMchHm mo humEBSm

.Hm>mH mo. w a um unmUHMchnm mwcnecflm HH<a

mmmHo
oHEonoooOHQOm quHHo

mocmpHo>m
Hmuou umHmmHmne

uaooaoo MHmm
hHHEwm umHamumne
COHuamowuuaH

How pom: umHanmnh

hfiocounm
How poms umHawumne

GOHmmmewm
How poms umHamponh

unmEmmmnm
now now: umHmwumzH

 

m manmfium>

m mHDMB

mmuoom
zuoucm>cH hmmeSH

umom uamflao

mouoom
kHOOCo>nH hamuosfi
umom umHamumnH

mmamnu MHmm hHHEmm
ucmHHo mo mocmVHo><

aoHu
ImmomuunH Ho mmEmSu
ucoHHo mo moampHo><

kaocounm mo mmsmnu
ucwHHo mo mocmpHo><

:onmmewm mo mmEonu
ucoHHo mo mocmpHo><

unmaommnm mo mmEoSu
ucmHHo mo moampHo><

 

< mflnmfium>

47

occurrences of client material dealing primarily with

nurturance themes.

C. Finally, correlations with therapists' need
for heterosexuality could not be computed due to the
infrequent occurrences of client material dealing

primarily with heterosexual themes.

HYPOTHESIS 2

Therapists' scores on the Tennessee Self Concept
Scale for the self-concept areas of personal self, family
self, and social self will negatively correlate with a
larger percentage of therapists' avoidance responses to

client material relating to these self-concept areas.

0f the three self-concept areas, only the therapists'
family self concept area showed a relationship to avoid-
ance behavior. Therapists' scores on family self nega-
tively correlated (r = -.4431) with avoidance of client
material relating to family themes. Furthermore, through
regression alalysis, it was found that therapists'
family self concept scores accounted for 19.63% of the

variance in the avoidance of client family self material

(r2 = .1963).

48

HYPOTHESIS 3

Therapists' scores on the State-Trait Anxiety
Inventory will positively correlate with therapists'
total percentage of avoidance responses to client material
and will negatively correlate with therapists' total
percentage of approach responses to client material in

therapy.

Neither therapists' scores on state anxiety nor
therapists' scores on trait anxiety showed a significant
correlation with the percentage of therapists' total
avoidance or tetal approach responses to client material.
However, there were some significant correlations between
therapists' state and trait anxiety scores and the indi-
vidual avoidance percentages that comprise the total
avoidance percentage. Therapists' state anxiety scores
positively correlated with avoidance of client material
relating to intraception (r = .4067) and family self
(r

client material relating to autonomy (r = -.4501) and

.4501), and negatively correlated with avoidance of

aggression (r = -.9567). Approach correlations were the
inverse of the avoidance correlations. Therapists' trait
anxiety scores positively correlated with avoidance of
client material relating to family self (r = .6288) and
negatively correlated with avoidance of client material

relating to personal self (r = -.4605) and aggression

49

(r = -.7601). Again, the approach correlations were the

inverse of the avoidance correlations.

HYPOTHESIS 4

Percentage of therapists' avoidance responses to
client material will negatively correlate with therapy
effectiveness as measured by the change in the clients'
pre/post HOpkins Symptom Checklist and by the Client and
Therapist Post Therapy Inventories of therapy effective-
ness (Strupp et al., 1969). Conversely, the percentage
of therapists' approach behavior will positively corre-

late with therapy effectiveness.

Of the three therapy effectiveness measures, only
the Therapist Post Therapy Inventory correlated with the
therapists' percentages of total avoidance responses to
client material (r = -.4454), and this was in a negative
direction. This meant that the larger the percentage of
therapists' avoidance, the less the effectiveness of
therapy as rated by the therapists. Therapists' total
avoidance accounted for 19.83% of the variance in
Therapist Post Therapy Inventory scores (r2 = .1983).

In addition, although change scores from the Hopkins
Symptom Checklist were not correlated overall with
therapists' total avoidance of client material, these
scores were correlated with several of the individual
avoidance percentages that comprised the total avoidance

percentages. Thus the Hopkins change scores positively

50

correlated with therapists' avoidance of client themes

of autonomy (r = .5858) and aggression (r = .5299),

and negatively correlated with avoidance of client themes
of intraception (r = -.4038). This meant that greater
positive change in therapy as measured by the Hopkins
Symptom Checklist was associated with lower avoidance of
client themes of intraception and higher avoidance of
client themes of autonomy and aggression. All corre-
lations with therapists' approach behavior for the Thera-
pist Post Therapy Inventory and the Hopkins Symptom Checklist
were the inverse of the avoidance correlations. Finally,
as for the Client Post Therapy Inventory, there were no
significant correlations with any of the approach or

avoidance percentages.

HYPOTHESIS 5

Clients' socioeconomic class will negatively correlate
with the percentage of therapists' avoidance responses to
client material in therapy--meaning that higher percentages
of therapists' avoidance responses will be found in rela-
tion to lower class clients (classes IV and V). And a
higher percentage of therapists' approach responses will
correlate with material from clients in the middle and

upper classes (classes I, II, and III).

51

No correlations were found between clients' socio-
economic class and any of the therapists' avoidance or

approach percentages.

HYPOTHESIS 6

Clients' socioeconomic class will positively
correlate with therapy effectiveness as measured by the
change in the clients' pre/post Hopkins Symptom Checklist
and by the Client and Therapist Post Therapy Inventories

of therapy effectiveness (Strupp et al., 1969).

Of the three measures of therapy effectiveness, only
the Client Post Therapy Inventory correlated with clients'
socioeconomic class (r = .5548), and this was in a
positive direction. This meant that the lower the clients'
socioeconomic class, the less the perceived effectiveness
of therapy as rated by the clients. Analysis of regres-
sion showed that the clients' socioeconomic class accounted
for 30.78% of the variance in the Client Post Therapy

Inventory scores (r2 = .3078).

CHAPTER 5
DISCUSSION

This study should be viewed as a pilot study com-
prising a limited number of clients and therapists en-
gaged in short-term therapy of an unspecified but generally
relationship oriented nature at a community mental health
center. Generalizations of the results to other client
and therapist populations is therefore limited. We will
examine the results of this study in terms of the therapists'
personality needs, clients' outcome in therapy, and clients'
socioeconomic status.

The first issue to be considered here is the relation-
ship between therapists' personality and the process of
therapy. Specifically it was asked whether there exists
a relationship between the therapists' need scores, as
measured by the Edwards Personality Preference Schedule,
and therapists' verbal approach/avoidance to client
material relating to those need areas. This would be a
relationship hypothesized to be mediated by therapists'
conflicted need areas. In research bearing on this point,
Barnes (1963) found that therapists with conflicts in
the areas of hostility, dependency, and sexuality showed

less approach behavior to client material dealing with

52

53

these areas than did less conflicted therapists.
Similarly, Bandura et a1. (1960) found that therapists
who expressed little direct hostility and who showed high
approval seeking needs were less likely to permit and
encourage their patients' hostility. Finally, Lerman
(1963) found a negative relationship between therapists'
dependency anxiety and the likelihood of their responding
with approach behavior toward client expression of depen-
dency. These studies would all seem to point to the
importance of therapists' needs to the process of psycho-
therapy and this present study is no exception. Thera-
pists' needs for abasement, autonomy, and intraception
did relate in the predicted direction with therapists'
approach/avoidance of the content areas. In addition,
therapists' need for aggression related to therapists'
approach/avoidance of aggressive themes but in a direction
opposite to that predicted. While this last finding does
not support the hypothesis, it may be a finding that is
worth exploring further in future studies.

Further evidence of the relationship between thera-
pists' personality dimensions and the therapists'
approach/avoidance behaviors was found in the negative
relationship between the therapists' family self concepts,
as measured by the Tennessee Self Concept Scale, and their
approach/avoidance of client family themes (lower the
self concept, greater the avoidance). However, the final

source of the therapists' personality factors, state-trait

54

anxiety scores as measured by the State-Trait Anxiety
Inventory, showed no correlation with therapists' Egtal
approach/avoidance behaviors. There were, though, some
significant correlations between the anxiety scores and
certain subtotal approach/avoidance percentages. This
finding regarding the anxiety scores is curious in light
of past research by Bandura et al. (1960) which found that
anxiety leads to avoidance behavior of client material.
Possibly, all the therapists in this study fell within that
range of anxiety scores that are facilitative rather than
inhibitive of effective functioning. Thus as in test
taking behavior, where some anxiety is useful while a

lot is not, none of the therapists in this study were
overly affected by their anxiety.

A second major area of findings for this research
concerns the relationship of the therapists' avoidance
behavior to therapy outcome. In this study it was found
that of the three outcome measures, only the Therapist
Post Therapy Inventory showed a direct relationship to
therapists' total avoidance of client material. The
Hopkins Symptom Checklist change scores for clients did
not show a direct relationship to the total avoidance
percentages but did correlate with subtotal avoidance
percentages for specific content areas. And the Client
Post-Therapy Inventory showed no correlations with any
avoidance measures. Research by Winder et al.,(1962)
which found that therapist avoidance of client material is

negatively indicated for positive outcome in therapy would

55
have predicted that the relationship between all the out-
come measures and therapist total avoidance should have
been significant. However, this was found to be only true in
part in this study. Where it was not true, interestingly
enough, was with the clients. Clients' perceptions of their
change in therapy did not correlate with therapists'
approach or avoidance behaviors. Possibly, as seen in the
research on therapists' empathy and warmth, this is because
clients' views of their change are not mediated by such
specific therapist behaviors as therapists' empathy, warmth,
or approach/avoidance. Rather, they are tied to their more
global feelings about the therapist such as whether they
liked the therapist and felt that the therapist cared
about them. Thus a "set" effect could result with clients
rating themselves as improved or not regardless of the
therapists' specific avoidance behaviors. On the other
hand, the therapists do seem more atuned to their avoi-
dance behaviors and did rate those clients that they
avoided more as less improved. Again, this is in line with
the research on other therapist behaviors such as empathy
in which therapists rate themselves as most empathetic and
warm.with those clients that they rate as most improved.
What is not in line with other research is the minimal
relationship between the H0pkins Symptom Checklist change
scores for the clients and the therapists' approach/
avoidance percentages. If there is a true relationship
between therapists' verbal behaviors and outcome, it

seems that it should be most seen in this "objectively"

56

measured source of change. But this did not occur
overall. Instead, the change scores correlated only

with certain of the subtotal avoidance percentages,

e.g., the change scores correlated in a negative direction
with avoidance of client material relating to intraception
and in a positive direction with client themes of auto-
nomy and aggression. This may be because avoidance of
certain content areas are more critical to change than
others and consequently when all the content area avoidances
are put together, the few significant individual content
areas get washed out. Also, a further confounding factor
is that with the exception of one client, all clients
improved to some extent in this study (see Figure l).

The result of this is that the range of change scores
becomes abbreviated when trying to show some relationship
between these scores and therapists' approach/avoidance
behaviors. With a greater range of scores, possibly the
relationship may have shown itself more.

The last major finding of this study concerned the
relationship of the clients' socioeconomic class to
therapists' approach/avoidance behaviors and to the out-
come of psychotherapy. Research has overwhelmingly
pointed to the conclusion that lower socioeconomic clients,
as defined by levels IV and V on the Hollingshead and
Redlich Index of Social Class (1958), are less likely to
stay in therapy or to obtain satisfaction in therapy

(Hollingshead and Redlich, 1958; Myers and Bean, 1968;

57

Strickland and Crowne, 1963). Further, Nash et a1.

(1965) found that client "attractiveness" correlated
negatively with various social class indices. And this
present study was no exception to this past research.
Clients' socioeconomic class did significantly relate to
scores on the Client Post Therapy Inventory of therapy
effectiveness, meaning that the lower the clients' socio-
economic class the less effective the therapy as rated by
the clients. However, what is unusual about this finding
of a lessened effectiveness of therapy as rated by the
lower class clients is that the effect was not seen in
the Therapist Post Therapy Inventory or in the Hopkins
Symptom Checklist change scores for these lower class
clients. Thus therapy may have been helpful to lower
class clients but they did not perceive it that way.
Furthermore, this lessened effectiveness of therapy as
rated by the lower class clients was not due to an inter-
action effect resulting from the greater avoidance of
lower class clients' material because of therapists'
inability to relate to these people as was hypothesized
(Hollingshead and Redlich, 1958). Rather this lessened
effectiveness may have possibly resulted from the fact
that lower class clients have more issues impinging on them
other than psychological issues, e.g., economic factors,
that may keep these clients feeling as if they got little
from therapy even when change did occur. Or alternatively,

lower class clients may come to therapy with.more concerns

58

than others due to their social position and although
they change, they do not reach the same end point in
therapy as those who come in at more advanced levels.
Thus there is a feeling that little was accomplished.

In looking over the results of this study, two con-
cerns with the data do come up. One is that although there
is a relationship between therapists' personality needs
and therapists' verbal behavior in therapy, the amount of
variance accounted for in therapists' verbal behavior
by their personality needs is relatively small. This
implies that there are other factors at work accounting
for therapists' verbal behaviors that have not shown up
in this study. Possibly a larger multifactorial design
is needed to predict therapist behavior. And in fact,
other factors such as therapist sex did at times account
for a larger percentage of the variance in predicting
therapist approach or avoidance to specific need areas.
Sex was not dealt with as a factor in this study because
an attempt was being made to look specifically at thera-
pists' personality scores, regardless of therapists' sex,
that might relate to therapy behavior. Furthermore, in
a review of the research literature on the interaction
effects between the sex of the therapist and the sex of
the client (Meltzoff and Kornreich, 1970) no significant
differences were found between male and female therapists

and outcome of psychotherapy.

59

The second concern with the results lies in the inter-
pretation of them. Although one may be justified in
drawing some connection between the therapists' personality
scores and their approach/avoidance percentages, can this
connection be thought of as the result of the presence or
absence of conflicts in the therapists? Specifically, can
one therapist be said to show conflicts in a personality
area because he or she showed a higher or lower need for
that content area than did another therapist? This is an
especially acute issue since the range of therapists'
scores on the need areas were mainly within the normal
population parameters. Thus without further verification
of these conflict areas, an interpretation suggesting
personality conflicts is left in question. This con-
clusion is all the more in question since seven out of
the ten content areas measured came from the Edwards
Personality Preference Schedule which is a forced choice
instrument.

However, in summing up the results of this study,
taking into account the foregoing reservations, three
conclusions can be made. First, it appears that therapists'
needs are related to therapists' verbal behaviors in
therapy. Specifically, therapists' personality needs are
tied to their approach and avoidance of client material
relating to these needs. Secondly, the amount of
therapists' avoidance behavior to client material is

related to therapists' ratings of therapy outcome. And

60

thirdly, therapists do not avoid lower class clients'
verbal content in therapy any more than they do with
clients of higher socioeconomic classes even though lower
class clients do feel that they benefit less from therapy.
As a final note, it would seem that these results,
if further substantiated, are important to the training
and selection of future therapists. If therapists'
needs can influence the process and outcome of therapy,
then it is important that therapists be helped in their
training to deal with those parts of their personalities
that can interfere of facilitate therapy. In this way,
therapists can learn to be more effective in working with
a greater range of client problem areas. Thus therapists
can avoid client material less and bring about greater

change in their clients.

APPENDICES

APPENDIX A

CLIENT CONSENT FORM

APPENDIX A

CLIENT CONSENT FORM

Dear Client,

In an attempt to study hOW‘Well the Ingham Com-
munity Mental Health Center serves its clients, I am
conducting some research to assess the helpfullness of
the counseling offered at Ingham in meeting the needs
and problems of its clients. It is hoped that through
this research ways may be found to even better serve
you. In order, in part, to carry out this research, I
need your help. I need for you to fill out a short
checklist before the first session of counseling and two
short checklists after your last counseling session.
These checklists look at the reasons for your coming to
counseling and how useful the counseling was for you.

In addition, I need your permission to tape up to three
of your counseling sessions. Whether or not you decide
to participate in this research, i.e., fill out the
checklists and have some sessions recorded, your right
to counseling will be in no way affected. You also have
the right to drop out of the research at any time. If
you do decide to participate, the checklists and tapes

‘will be held in strict confidence. This means that the
61

62

APPENDIX A (cont'd.)

checklist and tapes will be seen and listened to only
by those people conducting the study. All checklists
and tapes will be destroyed immediately upon completion
of the study.

Final results of this study, which will be anony-
mous, will be avaliable to the agency and all of its
clients. Enclosed is a self-addressed postcard which
should be mailed to me if you care to have a summary
copy of the results sent to you.

If you are willing to participate, please sign your
name to the statement below.

Sincerely yours,

Gerald Gaffin

****~k*****‘k'k‘k********************‘k************‘k********-k

I hereby agree to take part in this research and
grant permission for up to three of my counseling
sessions to be recorded. I grant this permission with
the understanding that my name, the checklists, and the
recorded materials will be held in strict confidence,
and that the results will be available to me at the
completion of the study.

 

APPENDIX B

HOPKINS SYMPTOM CHECKLIST

APPENDIX B

HOPKINS SYMPTOM CHECKLIST

CATEGORIES:

INSTRUCTIONS:

l. headaches

Not at all
A little bit
Moderately
Quite a lot
Extremely

Below is a list of problems and complaints
that people sometimes have. Read each one
carefully and decide how much that problem
bothered you during the past week includ-
ing today. Circle the number under the
column heading that best describes how
that problem bothered you. For example,
the first problem is headaches. If you
have been bothered by that problem a
little bit in the last week, you would
circle ”I" under the second column. Please
do not skip any items. If you change your
mind, erase the first mark completely.

If you have any questions, please ask me.

Q‘ 'fi; CE (b QE‘
v ‘V ‘3 e 6
6 (06 $6 6 99
o
”is a a *2 “a

2. nervousness or shakiness inside 0 l 2 3 4

3. being unable to get rid of bad 0 l 2 3 4
thoughts or ideas

4. faintness or dizziness 0 1 2 3 4

5. loss of sexual interest or 0 l 2 3 4
pleasure

6. feeling critical of others 0 l 2 3 4

63

10.

11.

12.
13.
14.

15.
l6.
17.
18.
19.
20.
21.

22.

23.
24.

25.

64

APPENDIX B (cont'd.)

bad dreams

difficulty in speaking when
you are excited

trouble remembering things

worried about sloppiness or
carelessness

feeling easily annoyed or
irritated

pains in the heart or chest
itching

feeling low in energy or slowed
down

thoughts of ending your life
sweating

trembling

feeling confused

poor appetite

crying easily

feeling shy or uneasy with the
opposite sex

a feeling of being trapped or
caught

suddenly scared for no reason

temper outbursts you could
not control

constipation

0

0000000

H

P‘ r4 :d P‘ F4 IH P‘

N

NNNNNNN

 

DO

wwwwwww

J-‘J-‘J—‘J—‘J—‘b-L‘

26.
27.

28.

29.
30.
31.
32.
33.
34.
35.

36.

37.

38.

39.
40.
41.
42.
43.
'44.

65

APPENDIX B (cont'd.)

blaming yourself for things

pains in the lower part of your
back

feeling blocked or stymied in
getting things done

feeling lonely

feeling blue

worrying or stewing about things
feeling no interest in things
feeling fearful

your feelings being easily hurt

having to ask others what you
should do

feeling others do not understand
you or are unsympathetic

feeling that people are un-
friendly or dislike you

having to do things very slowly
in order to be sure you are
doing them right

heart pounding or racing
nausea or upset stomach

feeling inferior to others
soreness of your muscles

loose bowel movements

difficulty in falling asleep
or staying asleep

0000000

000000

p
”’59 2.1
<3; 0

. '52,

(1 .A
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2

wwwwwww

wwwwww

J-‘J-‘J-‘J-‘J-‘J—‘D

J-‘J-‘J-‘J-‘J-‘L‘

45.

46.
47.
48.
49.
50.

51.
52.

53.
54.

55.
56.
57.
58.

66

APPENDIX B (cont'd.)

having to check and doublecheck

what you do

difficulty making decisions
wanting to be alone

trouble getting your breath
hot or cold spells

having to avoid certain places
or activities because they
frighten you

your mind going blank

numbness or tingling in parts
of your body

a lump in your throat

feeling hopeless about the
future

trouble concentrating
weakness in parts of your body
feeling tense or keyed up

heavy feelings in your arms or
legs

0 00000

O

0000

 

HHl-‘I-‘H

H

r4 :A P‘ ta

NNNNN

N

NNNN

wwwww

00

00000000

b-L‘J-‘b-L‘

b

bJ-‘J-‘L‘

APPENDIX C

THERAPIST FORM

umouw
hhm>

umoum
AHHHmm

GUNHN

Ibo:

 

mEom

mHuuHH

hho>

whomma

Hmuwm
ouomon

Hmumm
muommn

Hmumm
maomma

Houmm
whomwn

Hmumm
ouowmn

Houmm
whommn

Hmumm
ouomwn

mamumnu
How GOHum>Huoz

quHHo

How waHxHH Hmcowumm
uamfiumnmpm HHMIHo>o
ufimeSH How zuwommmo
mocmn

unnume mo common
nuwcouum owm

humec<

mmmcm>Hmaomoo

.wcHHmmcnoo CH mom :0» Boss mucmHHo
Hmsuo £OH3.ucmHHo mnu wcHHmQEoo .mEmuH wcHsoHHom mnu mo some much mmmmHm

 

Apmamemm H henna co£3 mwo use on ouv

SMOM HmHm<mmmB

U xHszmm<

"maowuonuumcH

mama m.ucmHHu

67

68

ummuw
hhm>

Immmmw
zHHHmm

wumhw

-eoz

%mmum£u mo mmmoonm HHmaum>o

50% uHmBOu kHBHmB uHmm uamHHo
mnu xcwnu 50% nngz ou omhwma

NuaoHHo mHSu
SH m>mn 50% pH@ :ucmaumm>cH

HmcoHuoEm: no mo 5058.303

ucmHHo mnu pum3ou
5H8hm3 uHmm 50% noHnB ou mouwwn

muauonhum huHHmcowumm
onmn aH owcmno mo common

acme
nm>0HQEH oHumEoumahm mo omuwmn

hmmumnu CH ucmHHo mo paHx
mwnu nuH3.waHxHoa AOHcm
AHHman 50% £0H£3 ou common

hmmuwnu aH
EmHHOHQ m mp3 monoummmcmuu
numucboo soHns cu common

AmHmocwouav
maommn wouooaxm ucw5o>oumfiH

mEom mHuunH

hhm>

A.e.ucoov o anzmmm<

.NH

.oH

.nH

.qH

.mH

.NH

.HH

.OH

69

pmHmeumm pmHmmHumm pmemHummep 505 pmwmmwummme pmemHummme
hHmEmHuxm mHuHmhl memmHumm Hofiummz mHmwwh. hHwEmHuxm

 

 

 

 

 

Nxamuosu Ho£\mHn m0 muH5m0u msu :uH3 was ucmHHo mnu xcHnu 50% on ponmHumm 30m .mH

poow poow H005 H05 H005 Moon
zflmamuuxm hHHHmm poow Homuwoz hHuamm meaouuxm

 

 

 

NucmHHo mHau SOHB mHnmSOHumHmp wcquoz H50% mNHMmuomumno 50% UH503.30m .wH

:0 . £88 0 x322“?

APPENDIX D

CLIENT FORM

APPENDIX D

CLIENT FORM

1. How much have you benefited from your therapy?

A great deal
A fair amount
To some extent
Very little
Not at all

 

 

 

 

 

2. How much in need of further therapy do you feel now?

No need at all
Slight need
Could use more

 

3. What led to the termination of your therapy?

My decision

My therapist's decision
Mutual agreement
External factors

 

4. Everything considered, how satisfied are you with
the results of your therapy experience?

Extremely dissatisfied
Moderately dissatisfied
Fairly dissatisfied
Fairly satisfied
Moderately satisfied
Highly satisfied
Extremely satisfied

 

 

 

 

Please indicate to what extent each of the following
statements describes your counseling experience. Dis—
regard that at one point or another in counseling you
may have felt differently. Use the following code and
circle your answer.

70

+2

+2

+2

+2

+2

+2

+2

+2

+2

+2

+2

+1

+1

+1

+1

+1

+1

+1

+1

+1

+1

+1

71

APPENDIX D (cont'd.)

+2
+1

-1
-2

-2

Strongly agree
Mildly agree
Undecided

Mildly disagree
Strongly disagree

5.

10.

11.

12.

l3.

14.

15.

I am convinced that the counselor
respected me as a person.

I feel that the counselor was
genuinely interested in helping
me.

I often felt I was "just another
client".

The counselor was keenly atten-
tive to what I had to say.

The counselor often used very
abstract language.

I always had the feeling that
the counselor really understood
my feelings.

Nothing the counselor said or
did ever decreased my self-
respect.

I felt there usually was a good
deal of warmth in the way the
counselor talked to me.

I feel that the counselor often
didn't understand my feelings.

I usually felt I was fully
accepted by the counselor.

I was often uncertain about
the counselor's real feelings
toward me.

16.

17.

18.

19.

20.

72

APPENDIX D (cont'd.)

How much do you feel you have changed as a result of
psychotherapy?

A great deal
A fair amount
Somewhat

Very little
Not at all

 

 

 

 

 

How adequately do you feel you are dealing with any
present problems?

Very adequately

Fairly adequately

Neither adequately nor inadequately
Somewhat inadequately

Very inadequately

 

 

 

 

 

To what extent have your complaints or symptoms that
brought you to therapy changed as a result of treat—
ment?

Completely disappeared
Very greatly improved
Considerably improved
Somewhat improved

Not at all improved
Got worse

 

 

 

 

 

 

Extremely well

Very well
Fairly well
Neither well nor poorly
Fairly poorly

Very poorly

Extremely poorly

 

 

 

How strongly would you recommend psychotherapy to a
close friend with emotional problems?

Would strongly recommend it

W0uld mildly recommend it

Would recommend it but with some reservations
ould not recommend it

Would advise against it

APPENDIX E

SCORING MANUAL

APPENDIX E

SCORING MANUAL

This manual for scoring therapist approach-avoidance
behavior is a partial replication of the manual developed
by: Kopplin, D. A., "Eliciting Responses in Client-
Therapist Interaction: A Content Analysis of Initial
Psychotherapeutic Interviews". Unpublished doctoral
dissertation, Michigan State University, 1965.

Scoring Unit

 

Definition--A unit is the total verbalization of the

client followed by the total verbalization
of the therapist.

I. Therapists' Approach-Avoidance Responses: Therapist
responses to each scored client verbalization are
divided into two mutually exclusive classes, approach
and avoidance responses. When both approach and
avoidance are present, score only the portion which
is designed to elicit a response from the client.
Examples of approach and avoidance responses are
grouped in sub-types to aid scoring.

A. Approach Responses (A ): An approach response
is any verbalization By the therapist which seems
designed to elicit from the client further
expression or elaboration of material relating
to autonomy, intraception, dominance, abasement,
nurturance, heterosexuality, aggression, personal
self, family self, or social self which was
scored in the client's immediately preceding state-
ment. Approach is to the major category, not
necessarily to the specific subcategories or the
particular content of the client's preceding

speech. The following subcategories are exhaus—
tive.

73

74

APPENDIX E (cont'd.)

Exploration (probing): Includes remarks or
questions that encourage the client to describe
or express his feelings, attitudes, or actions
further; asks for further clarification,
elaboration, descriptive information, contin-
uance; calls for details or examples; probing
opinions which direct the client to reconsider
by more careful thinking of a previous state-
ment. Should demand more than a yes or no
answer; if not, may be a "label".

How do I feel? I feel idiotic.
What do you mean, you feel idiotic?

C

T

C. I can't understand his behavior.

T What is it about his behavior you
can't understand?

T. Tell me more how you felt.
T. I don't completely follow that sequence.

Reflection: Repeats or restates a portion of
the client's verbalization of feeling, attitude
or action. May use phrases of synonymous
meaning. Therapist may sometimes agree with
his own previous response; if the client had
agreed or accepted the first therapist state-
ment, the second therapist statement is scored
as a reflection of the client statement.
Therapist finishes client statement in an
obvious manner.

C. I wanted to spend the entire day with
him.
T. You wanted to be together.

C. His doing that stupid doodling upsets
me.
T. It really gets under your skin.

Labeling: The therapist gives a name to the
feeling, attitude or action contained in the
client's verbalization. May be a tentative
and broad statement not clearly aimed at
exploration. Includes "bare" interpretation,
i.e., those not explained to the client.

May be a question easily answered by yes or
no. It may be more than a simple clause,

75

APPENDIX E (cont'd.)

but it is a statement of fact, opinion or
situation without elaboration.

C. I just don't want to talk about that
anymore.
What I said annoyed you.

T

C. She told me never to come back and
I really did have a reaction.

T You had some strong feelings about
that--maybe disappointment or anger.

Interpretation: Points out and explains
patterns or relationships in the client's
feelings, attitudes and behavior: explains
the antecedents of them, shows the similari-
ties and discriminations in the client's
feelings and reactions in diverse situations
or at separate times.

C. I had to know if Barb thought what
I said was right.

T. This is what you felt earlier about
your mother...

Support: Expresses sympathy, reassurance,
approval, agreement or understanding of client's
feelings, attitudes or behavior. Includes
strongly emphasized, "Mm Hmm", "Yes";

offers explicit permissiveness.

0. It's hard for me to just start
talking.
I think I know what you mean.

T
C. I hate to ask favors from people.
T I can understand that would be difficult

for you.

C. But this, I don't know whether I am.
cheating myself or not. Well, I want
to feel, you see.

T. You're feeling.

C. May I just be quiet for a moment?

T. Certainly.

C. I have my girlfriend's problems on my
mind. Could we talk about them?

T. Why don't we talk about that?

76

APPENDIX E (cont'd.)

f. Information: Gives factual information or
therapist opinion to general, direct or implied
questions; includes general remarks about the
counseling procedure; tells the client what
to do; points out that the client's feelings
are natural or common (generalizations).

C. Shall I take tests?
T. I feel in this instance tests are not
needed.

C. What's counseling all about?
T. It's a chance for a person to say
just what's on his mind.

C. I don't like to talk about it.
T. Mary, we have to deal with this some-
how.

Avoidance Responses (Av): The following sub-
categories are exhaustive. An avoidance response
is any verbalization by the therapist which seems
designed to inhibit, discourage 0r divert further
expression of material relating to autonomy,
intraception, dominance, abasement, nurturance,
heterosexuality, aggression, personal self, family
self, or social self. The therapist attempts to
inhibit the feelings, attitudes or behavior
described or expressed in the immediately pre-
ceding client statement which determined its
placement under the major category. Avoidance is
avoidance of the major category, not specific
subcategories or psychic states.

 

a. Disapproval: Therapist is critical, sarcastic
or antagonistic toward the client or his
statements, feelings or attitudes, expressing
rejection in some way. May point out contra-
dictions or challenge statements.

C. Why don't you make statements? Make
a statement. Don't ask another question.

T. It seems that you came here for a
reason.

C. Well, I wonder what I do now?

T. What do you think are the possibili-
ties? You seem to have raised a
number of logical possibilities in
our discussion.

77

APPENDIX E (cont'd.)

C. I'm mad at him: that's how I feel.

T. You aren't thinking of how she may
feel.

Topic Transition: Therapist changes or intro-
duces a new t0pic of discussion not in the
immediately preceding client verbalization.
Usually fails to acknowledge even a minor
portion of the statement.

C. Those kids were asking too much. It
would have taken too much of my time.

T. We seem to have gotten away from.what
we were talking about earlier...

C. My mother never seemed interested in
me.

T. And what does your father do for a
living?

Ignoring: Therapist responds only to a minor
part of the client response or responds to
content, ignoring affect. He misses the point
of the client statement. May under- or
over-estimate affect. May approach the general
topic but blatantly ignore the affect verbal-
ize .

C. You've been through this with other
people so help me out, will you?
You are a little uneasy.

You can see I don't know what to do
and I want you to give me advice.
Just say whatever you feel is impor-
tant about that.

HOV-3

C My older sister gets me so mad I
could scream.

T. Mm-hmm. How old did you say she was?

C

We went out for Chinese food; he's
so easy to get along with.
T. It he from New York?

Mislabeling: Therapist names attitudes,
feelings or actions which are not present in
the actual verbalization preceding the
response.

78

APPENDIX E (cont'd )

I just felt crushed when she said that.
Really burned you up, huh?

I don't know how I felt--confused,

lost--
I wonder if what you felt was resent-

ment .

HOD-10

I may dr0p out of Honors College.
You mean Arts and Letters.
No--Honors College.

060

APPENDIX F

CLIENT STATEMENT SCORING CATEGORIES

APPENDIX F

CLIENT STATEMENT SCORING CATEGORIES

Edwards Personal Preference Schedule--definitions
from the Edwards for determining categorization of
client verbalizations from tape recordings.

1.

Autonomy: To be able to come and go as desired,
to say what one thinks about things, to be
independent of others in making decisions, to
feel free to do what one wants, to do things that
are unconventional, to avoid situations where

one is expected to conform, to do things without
regard to what others may think, to criticize
those in positions of authority, to avoid respon-
sibilities and obligations.

Intraception: To analyze one's motives and
feelings, to observe others, to understand how
others feel about problems, to put one's self in
another's place, to judge people by why they do
things rather than by what they do, to analyze
the behavior of others, to analyze the motives
of others, to predict how others will act.

Dominance: To argue for one's point of view, to
be a leader in groups to which one belongs, to be
regarded by others as a leader, to be elected

or appointed chairman of committees, to make
group decisions, to settle arguments and disputes
between others, to persuade and influence others
to do what one wants, to supervise and direct

the actions of others, to tell others how to do
their jobs.

Abasement: To feel guilty when one does some-
thing wrong, to accept blame when things do not
go right, to feel that personal pain and misery
suffered does more good than harm, to feel the
need for punishment for wrong doing, to feel
better when giving in and avoiding a fight than
when having one's own way, to feel the need for
confession of errors, to feel depressed by in-
ability to handle situations, to feel timid

79

II.

80

APPENDIX F (cont'd.)

in the presence of superiors, to feel inferior
to others in most respects.

5. Nurturance: To help friends when they are in
trouble, to assist others less fortunate, to
treat others with kindness and sympathy, to for-
give others, to do small favors for others, to
be generous with others, to sympathize with
others who are hurt or sick, to show a great
deal of affection toward others, to have others
confide in one about personal problems.

6. Aggression: To attack contrary points of view,
to tell others what one thinks about them, to
criticize others publicly, to make fun of others,
to tell others off when disagreeing with them,
to get revenge for insults, to become angry, to
blame others when things go wrong, to read
newspaper accounts of violence.

7. Heterosexuality: To go out with members of the
opposite sex, to engage in social activities with
the opposite sex, to be in love with someone of
the opposite sex, to kiss those of the opposite
sex, to be regarded as physically attractive by
those of the opposite sex, to participate in
discussions about sex, to read books and plays
involving sex, to listen to or to tell jokes
involving sex, to become sexually excited.

Tennessee Self Concept Scale-~statements from.the
Tennessee used for empirically categorizing client
verbalizations from tape recordings.

1. Personal Self Statements

 

am a cheerful person.

have a lot of self-control.

am a calm and easy going person.
am a hateful person.

am a nobody.

HHHHHH

am losing my mind.

81

APPENDIX F (cont'd.)

am satisfied to be just what I am.

am as smart as I want to be.

am just as nice as I should be.

am not the person I would like to be.
despise myself.

wish I didn't give up as easily as I do.
can always take care of myself in any situation.
solve my problems quite easily.

take the blame for things without getting mad.
change my mind a lot.

do things without thinking about them first.

:4 :4 H P4 #4 #4 P4 :4 H P1 #4 r4

try to run away from my problems.

Family Self Statements

 

I have a family that would always help me in any
kind of trouble.

I am an important person to my friends and family.
I am a member of a happy family.

I am not loved by my family.

My friends have no confidence in me.

I feel that my family doesn't trust me.

I am satisfied with my family relationships.

I treat my parents as well as I should (use past
tense if parents are not living).

I understand my family as well as I should.

I am too sensitive to things my family say.

HHHHHH

I

82

APPENDIX F (cont'd.)

should trust my family more.

should love my family more.

try to play fair with my friends and family.
do my share of work at home.

take a real interest in my family.

quarrel with my family.

give in to my parents (use past tense if

parents are not living).

I

do not act like my family thinks I should.

Social Self Statements

 

I
I

HHHHHHHHHH

I

am a friendly person.

am popular with women.

am popular with men.

am mad at the whole world.

am not interested in what other people do.
am hard to be friendly with.

am as sociable as I want to be.

am satisfied with the way I treat other people.
try to please others, but I don't overdo it.
should be more polite to others.

am no good at all from a social standpoint.
ought to get along better with other people.

try to understand the other fellow's point

of view.

I

see good points in all the pe0ple I meet.

83

APPENDIX F (cont'd.)

I get along well with other people.
I do not feel at ease with other people.
I do not forgive others easily.

I find it hard to talk with strangers.

REFERENCES

REFERENCES

Albronda, H. F., Dean, R. L., and Starkweather, J. A.
Social class and psychotherapy. Archives of
General Psychiatry, 1964, 29, 276:283.

 

Alexander, J. F. Perspectives of psychotherapy process:
Dependency, interpersonal relationships, and sex
differences. (Unpublished doctoral dissertation,
Michigan State University, 1967.)

Alexander, J. F., and Abeles, N. Dependency changes in
psychotherapy as related to interpersonal rela-
tionships. Journal of Consulting and Clinical
Psychology, 1968, 22, 685-689.

 

Bandura, A. Psychotherapist's anxiety level, self-
insights, and psychotherapeutic competence.
Journal of Abnormal and Social Psychology, 1956,
E2, 333-337.

 

Bandura, A., Lipsher, D. H., and Miller, P. E. Psycho-
therapists' approach-avoidance reactions to
patient's expression of hostility. Journal
of Consultinngsychology, 1960, 24, -

 

Bare, C. E. Relationship of counselor personality and
counselor-client personality similarity to
selected counseling success criteria. Journal
of Counseling Psychology, 1967, 23, 419-425.

 

Barnes, E. J. Psychotherapists' conflicts, defense
preferences, and verbal reactions to certain
classes of client expressions. (Unpublished
doctoral dissertation, Michigan State Univ-
ersity, 1963.)

Barrett-Lennard, G. F. Dimensions of therapist response
as causal factors in therapeutic change.
Psychological Monographs, 1962, 29 (43, Whole
No. 562).

Baum, O. E., Felzer, S. B., D'Zmura, T. L., and Shumaker,
E. Psychotherapy, dropouts and lower socio-
economic patients. American Journal of
Orthopsychiatry, 1966, 29, 629-635.

 

 

84

85

Beery, J. W. Therapists' responses as a function of
level of therapist experience and attitude

of the patient. Journal of Consultin and
Clinical Psychology, I970, 25, 239-245.
Bergin, A. E. The evaluation of therapeutic outcomes.
In A. E. Bergin and S. L. Garfield (Eds.),
Handbook of psychotherapy and behavior change:

An empirical analysis. New York: John
Wiley & Sons, Inc., 1971, 217-270.

 

Bergin, A. E., and Jasper, L. G. Correlates of
empathy in psychotherapy: A replication.
Journal of Abnormal Psychology, 1969, 23,
477-4811

Bergin, A. E., Murray, E. J., Truax, C. B., and Shoben,
E. J. The empirical emphasis in psychotherapy:
A symposium. Journal of Counseling Psychology,
1963, 29, 244-250.

Bergin, A. E., and Solomon, S. Correlates of empathic
ability in psychotherapy. American Psycholo-
gist, 1963, 22, 393.

 

Bergin, A. E., and Suinn, R. M. Individual psycho-
therapy and behavioral therapy. In M. R.
Rosenzweig and L. W. Porter (Eds.), Annual
Review of Psychology. Palo Alto: AnnuaI
Reviews Inc., 1975, Vol. 2g, 509-556.

 

Berzins, J. I., and Seidman, E. Subjective reactions
of A and B quasi-therapists to schizoid and
neurotic communications: A replication and
extension. Journal of Consulting and Clinical
Psychology, 1963, 222, 1090-1091.

 

Bordin, E. Research strategies in psychotherapy. New
York: ’John Wiley & SOns, Inc., 1974.

Campbell, D., and Fiske, D. Convergent and discrimi-
nant validation by the multitrait-multimethod
matrix. Psychological Bulletin, 1959, 2Q,
81-105.

 

Carkhuff, R. R., Kratochvil, D., and Friel, T. Effects
of professional training: Communication and
discrimination of facilitative conditions.
Journal of Counseling Psychology, 1968, 22,
68-74.

86

Carson, R. E., Harden, J.,and Shows, W. E. A-B
distinction and behavior in quasi-therapeutic
situations. Journal of Consulting Psychology,

1964, 2s, 426-433.

 

Carson, R. E., and Heine, R. W. Similarity and success
in therapeutic dyads. Journal of Consulting
Psychology, 1962, 24, 38-43l

 

 

Cartwright, R. C., and Vogel, J. L. A comparison of
changes in psychoneurotic patients during matched
periods of therapy and no therapy. Journal of
Consulting Psychology, 1960, 24, 121-127.

 

 

Committee on Training in Clinical Psychology. American
Psychological Association. Recommended graduate
training program in clinical psychology.
American Psychologist, 1947, 2, 539-558.

 

Cowen, E. L. Social and community interventions. In
P. H. Mussen and M. R. Rosenzweig (Eds.), Annual

Review of P3 cholo . Palo Alto: Annual
Reviews Inc., 1973, Vol. 24, 423-472.
Cutler, R. L. Countertransference effects in psycho-

therapy. Journal of Consulting Psychology,
1958, 22, 349-356.

 

Demos, G. D., and Zuwaylif, F. H. Characteristics of
effective counselors. Counselor Education and

Supervision, 1965-66, 2, 163-165.

Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth,
E. H., and Covi, L. The Hopkins Symptom Check-
list (HSCL): A measure of primary symptom
dimensions. In P. Pichot (Ed.), Psychological
measurements in psychopharmacology: Modern

problems in pharmo s cfiiatr Vol. 7. Basel,
switzerland: S. Karger, I9g4, 79-IIO.
Dietzel, C. S., and Abeles, N. Client-therapist comple-

mentarity and therapeutic outcome. Journal of
Counseling Psychology, 1975, 22, 264-272.

 

 

 

 

 

 

Ebel, R. Estimation of the reliability of ratings.
Psychometrika, 1951, 24, 407-424.

 

Edwards, A. L. Edwards Personal Preference Schedule.
New York:7IThe Psychological Corporation, 1954.

 

Eysenck, H. The effects of psychotherapy: An evaluation.
Journal of Consulting Psychology, 1952, 24,
316-324.

 

87

Eysenck, H. A reply to Luborsky's note. Journal of
British Psychology, 1954, 42, 132-I33.

 

Eysenck, H. The effects of psychotherapy: A reply.
Journal of Abnormal Psychology, 1955, 29,
147-148.

 

Fiske, D. W., Cartwright, D. S., and Kirtner, W. L.
Are psychotherapeutic changes predictable?
Journal of Abnormal and Social Psychology,
I964, 62, 418-426.

 

Fitts, W. H. Tennessee Self Concept Scale. Nashville,
Tennessee: CounsElor Recordings and Tests,
1965.

 

Fix, A. J., and Haffke, E. S. Relationship between
psychotherapy skills and level of training in a
psychiatric residency program. Social Science
and Medicine, 1975, 2, 489-491.

 

Frayn, D. H. A relationship between rated ability and
personality traits in psychotherapists. American
Journal of Psychiappy, 1968, 124, 1232-1237.

 

Gamsky, N. R., and Farwell, G. F. Counselor verbal
behavior as a function of client hostility.
Journal of Counseling Psychology, 1966, 22,
I84-190.

 

Garfield, S. L. Research on client variables in
psychotherapy. In A. E. Bergin and S. L.
Garfield (Eds.), Handbook of psychotherapy and
behavior change: An empirical analysis.
geY $35k: JohnWiley & Sons, Inc., 1971,

7 - .

 

 

Garfield, S. L., and Bergin, A. E. Therapeutic con-
ditions and outcome. Journal of Abnormal
Psychology, 1971, 22, I08-114.

Goldberg, L.,and Werts, C. The reliability of clini-
cians' judgments: A multitrait-multimethod

approach. Journal of Consulting Psychology,
1966, 29, 199-206.

 

 

Gottschalk, L. A., and Auerback, A. H. (Eds.),
Methods of research in psychotherapy. New
York: Meridith Publishing Company, 1966.

 

Grigg, A. E. Client response to counselors at different
levels of experience. Journal of Counseling
Psychology, 1961, 2, 217-225.

 

88

Gurman, A. S. Therapists' mood patterns and therapeutic
facilitativeness. Journal of Counseling
Psychology, 1972, 29, 169-170.

 

 

Gurman, A. S. Instability of therapeutic conditions in
psychotherapy. Journal of Counseling Psychology,
1973, 29, 16-24.

 

Hollingshead, A. B., and Redlich, F. C. Social class
and mental illness: A community study. New
Ydrk: John Wiley & Sons, Inc., 1958.

 

 

Holt, R. R. (Ed.) New horizon for psychotherapy:
Autonomy as a profession. Neinork: Inter-
national Universities Press, Inc., 1971.

 

Holt, R. R., and Luborsky, L. Personality patterns of
psychiatrists: A study of methods for selecting
residents. New York: Basic Books, Inc.,

1958, Vols. 1 & 2.

 

 

Karl, N. J., and Abeles, N. Psychotherapy process as
a function of the time segment sampled.
Journal of Consulting and Clinical Psychology,
1969, 22, 207-212.

 

Kemp, D. E. Correlates of the Whitehorn Betz AB Scale

in a quasi-therapeutic situation. Journal of
Consulting Psychology, 1966, 29, 509-516.

 

Kiesler, D. Theyprocess of psychotherapy: Empirical
foundations and systems of analysis. Chicago:
Aidine Publishing Company,l973, 213-231;
428-430.

 

Kiesler, D., Klein, M. H., and Mathieu, P. L. Sampling
from the recorded therapy interview: The
problem of segment location. Journal of
Consulting Psychology, 1965, 22, 337-344

Kopplin, D. A. Eliciting responses in client-therapist
interaction: A content analysis of initial
psychotherapeutic interviews. (Unpublished
gggtogal dissertation, Michigan State University,

5.

Lerman, H. A study of some effects of the therapist's
personality and behavior and of the clients'
reactions in psychotherapy. (Unpublished
doctoral dissertation, Michigan State Univer-
sity, 1963.)

89

Luborsky, L. A note on Eysenck's article, 'The effects
of psychotherapy: An evaluation'. British
Journal of Psychology, 1954, 42, 129-I3I.

Luborsky, L. Perennial mystery of poor agreement among
criteria for psychotherapy outcome. Journal
of Consulting and Clinical Psychology, I97I,
22,316-319.

Luborsky, L., Chandler, M., Auerbach, A., Cohen, J.,
and Bachrach, H. Factors influencing the out-
come of psychotherapy: A review of quantitative
rzsearch. Psychological Bulletin, 1971, 22,
1 5-185.

 

Meltzoff, J., and Kornreich, M. Research in psyoho-
therapy. New York: Atherton Press,’l970.

McNair, D. M., Callahan, D. M., and Lorr, M.
Therapist "type" and patient response to psycho-
therapy. Journal of Consulting Psychology,

1962, 29, 325-429.

McNair, D. M., Lorr, M., and Callahan, D. M. Patient
and therapist influences on quitting psycho-

therapyx Journal of Consultinngsychology,
1963, 22, I0-l7.

 

Miller, D. R., and Swanson, G. E. Inner conflict and
defense. New York: Henry Holt and Campany,
Inc., I960.

 

Mills, D. H. Liking as a therapist variable in the
psychotherapeutic interaction. (Unpublished
doctoral dissertation, Michigan State Univer-
sity, 1964.)

Mills, D. H., and Abeles, N. Counselor needs for
affiliation and nuturance as related to liking
for clients and counseling process. Journal
of Counseling_Psychology, 1965, 22, 353-358.

 

Mills, D. H., Chestnut, W. J., and Hartzell, J. P.
The needs of counselors: A component analysis.
Journal of Counseling Psychology, 1966, 22,
82-84.

 

Mintz, J. What is "success" in psychotherapy? Journal
of Abnormal Psychology, 1972, 29, 11-19.

 

90

Mullen, J. A. An investigation of the variable of
liking in therapy: Its relation to the variables
of outcome, empathy, and therapist experience.
(Unpublished doctoral dissertation, Michigan
State University, 1969.)

Mullen, J. A., and Abeles, N. Relationship of liking,
empathy, and therapist's experience to outcome
of psychotherapy. Journal of Counseling Psych-

ology, 1971, 22, 39-43.

 

Murphy, W. A., and Lamb, D. H. The effect of training
in psychotherapy on therapists' responses to
client hostility. Journal of Community Psych-
ology, 1973, 2, 327:330.

Murray, H. A. Explorations in personalipy. New
York: Oxford University Press, 1938.

 

Myers, J. K., and Auld, F. Some variables related to
outcome of psychotherapy. Journal of Clinical
Psychology, 1955, 22, 51-54.

 

 

Myers, J. K., and Bean, L. L. A decade later: A
follow-up of social class and mental illness.
Neinork: JohnWileyE Sons, Inc., 1968.

 

Nash, E., Hoehn-Saric, R., Battle, C., Stone, A.,
Imber, S., and Frank, J. Systematic preparation
of patients for short-term psychotherapy. II:
Relation to characteristics of patient,
therapist and the psychotherapeutic process.
Journal of Nervous and Mental Disease, 1965,
24QT374-383.

 

Perlman, G. Change in "central therapeutic ingredients”
of beginning psychotherapists. Ps chothera :
Theopy, Research and Practice, 197%, 29,
48-51.

 

Rosenzweig, S. A transvaluation of psychotherapy--
A reply to Hans Eysenck. Journal of Abnormal
and Social Psychology, 1954, 42, 298:304.

 

Reissman, G., Cohen, J., and Pearl, A. (Eds.).
Mental health of theypoor. New York: The Free
Piess of Glencoe, 1964, 68-75.

 

Rogers, C. R. The necessary and sufficient conditions
of therapeutic personality change. Journal of
Consulting Psychology, 1957, 22, 95-1037

 

 

91

Rogers, 0. R. A theory of therapy, personality, and
interpersonal relationships, as developed in
the client-centered framework. In S. Koch (Ed.),
Psychology: A study of science. New York:
MdGraw-Hill Book Company, Inc., 1959, Vol. 2,
184-256.

 

Rogers, C. R., Gendlin, E., Kiesler, D., and Truax,
C. B. The therapeutic relationship and its
impact: A study of psychotherapy wifh’séhizo-
fihrenics. Madison, Wisconsin: University of
Eisconsin Press, 1967.

Russell, P. D., and Snyder, W. U. Counselor anxiety in
relation to amount of clinical experience and
quality of affect demonstrated by clients.
Journal of Consulting Psychology, 1963, 22
358-363.

Schaffer, N. D. The impact of therapist personality
variables on psychotherapy process. (Unpublished
doctoral dissertation, Michigan State University,
1977.)

Schuldt, W. J., and Smee, P. G. Personal needs of
graduate students in psychology. Psychological
Reports, 1968, 22, 916.

Spielberger, C. D., Gorsuch, R. L., and Lushene, R. E.
State-trait Anxiety Inventory. Palo Alto:
Consulting Psychologist Press, Inc., 1970.

 

Strickland, B., and Crowne, D. P. Need for approval and
the premature termination of psychotherapy.
Journal of Consulting Psychology, 1963, 22,
95-101.

 

Strupp, H. H. Psychotherapy: Clinical, research, and
theoretical issues. Newaork: Jason Aronson,
Inc. , I973.

 

Strupp, H. H., Hadley, S. W., and Gomes-Schwartz, B.
Psychotherapy for better or worse: Thesproblem
of nagative effects. New York: Jason Aronson,
Ihc., 1977.

 

Strupp, H. H., Lessler, R., and Fox, K. Patients view
their psychotherapy. Baltimore: John Hopkins
Pfess, 1969.

 

Sullivan, P. L., Miller, C., and Smelser, W. Factors
in length of stay and progress in psychotherapy.
Journal of Consulting Psychology, 1958, 22, 1-9.

 

92

Swenson, C. H. Commitment and the personality of the
successful therapist. In J. Matarazzo et al.

(Eds.), Ps chothera . New York: Aldine-
Atherton, Inc., 1975, 203-208.

Truax, C. B., Carkhuff, R. R., and Kodman, F. Relation-
ships between therapist-offered conditions and

patient change in group psychotherapy. Journal
of Clinical Psychology, 1965, 22, 327-329.

 

Truax, C. B., and Carkhuff, R. R. Toward effective
counseling and psychotherapy: iTraining and
practice. Chicago: AIdine Publishing Company,

 

 

Truax, C. B., and Wargo, J. D. Antecedents to outcome
in group psychotherapy with outpatients:
Effects of therapeutic conditions, alternate
sessions, vicarious therapy pre-training and
patient self-exploration. Journal of Consulting
and Clinical Psychology, 1969, 22, 440-447.

 

 

Truax, C. B., Wargo, D. G., Frank, J. D., Imber, 8.,
Battle, C., Hoehn-Saric, R., Nash, E., and
Stone, A. Therapist empathy, genuineness and
warmth and patient therapeutic outcome.
Journal of Consulting Psychology, 1966, 22,
395-401.

 

Uhlenhuth, E. H., and Covi, L. Subjective change with
the initial interview. American Journal of
Psychotherapy, 1969, 22, 415-429.

 

Uhlenhuth, E. H., and Duncan, D. B. Subjective change
with medical student therapist: I. Course of
relief in psychoneurotic outpatients. Archives
of General Psychiatry, 1968a, 22, 428-4 .

 

Uhlenhuth, E. H., and Duncan, D. B. Subjective change
with medical student therapists: II. Some
determinants of change in psychoneurotic
outpatients. Archives of General Psychiatry,
1968b, 22, 532-540.

Waskow, I. E., and Parloff, M. B. (Eds.). Psychotherapy
change measures. Rockville, Maryland: National
Institute of Mental Health, 1975.

 

Whitehorn, J. C., and Betz, B. A study of psycho-
therapeutic relationships between physicians

and schizophrenic patients. American Journal
of Psychiatry, 1954, 222, 321-331.

 

93

Whitehorn, J. C., and Betz, B. A comparison of psycho-

therapeutic relationships between physicians and
schizophrenic patients when insulin is combined
with psychotherapy and when psychotherapy is
used alone. American Journal of Psychiatry,
1957, 222, 901-910.

Whitehorn, J. C., and Betz, B. Further studies of the

doctor as a crucial variable in the outcome of
treatment with schizophrenic patients.
American Journal of Psychiatry, 1960, 222,
215-223.

Williams, H. V., Lipman, R. S., Rickels, K., Covi, L.,

Winder,

Uhlenhuth, E. H., and Mattsson, N. B.
Replication of symptom distress factors in
anxious neurotic outpatients. Multivariate

Behavioral Research, 1968, 2, 199-212.

 

C. L.,Ahmad, F. 2., Bandura, A., and Rau, L. C.
Dependency of patients, psychotherapists'
responses and aspects of psychotherapy.

Journal of Consulting Psychology, 1962, 22,
129-134.