ELICITING RESPONSESEIN CLIENT-THERAPIST mmmmom ;, 7 -. A» CONTENT ANALYSIS 0:: may.“ i _ * * PSYCHOYHERAPEUHC INIERVIEWS‘" 159;: , A , - ‘— Thesis Io» I‘In Dengue oI pl! D MICHIGAN STATE UNIVERSITY David A Kopplm I 1965:.V‘f9 \, t V_,- u“; nun "I'mx.is\;j z, . aunt-u '41u~W';J§’ 1:153:55 [:3 :3 7'} 3; Michigan fix-:3 University will“; IIIIIIWMIW This is to certify that the thesis entitled - vl-jg-t, \ (N '1". "\ mu ('7 T A C” I FLICL (IT-BIG R 02301;)er .L:‘I CLI'HI w 1.4.".1Ua I; f ITITI'LAD'KL'MT: A C’TT'LWT ANALYSIS (“F I‘T ' TIM “SYS‘T‘A "1"er “VUTIC IT’ WV?" 38 presented by I DIVI") .3. lint-“WIT? has been accepted towards fulfillment of the requirements for _Eh.._D__ degree in Wag y {/g/wééw Major professor Date-August 10, 1965 0-169 ABSTRACT ELICITING RESPONSES IN CLIENT-THERAPIST INTERACTION: A CONTENT ANALYSIS OF INITIAL PSYCHOTHERAPEUTIC INTERVIEWS by David A. Kopplin A mutual elicitation effect occurs in the inter- action between a client and his psychotherapist. The client enters the relationship by expressing a need for assistance in coping with his problems in living; the psychotherapist responds in turn by helping the client to express in the therapeutic relationship all the essential elements of his conflicts. The subsequent interaction between the partici- pants involves not only the choices of content in the inter— views but also the sequences and modes of expression. This study examines the effect of therapists' re— sponses of approach and avoidance upon the clients' con— tinuing statements of hostility, dependency, affiliation, self—assertion, sex and vague effect. It also examines the effect of therapists' responses which are designed to elicit affective expression by the cIients. Hypotheses, in general derived from social learning theory, state that when thera— pists approach clients' statements, clients continue the David A. Kopplin same topic; however, when therapists avoid, clients discon— tinue the topic. A further hypothesis states that therapist responses which focus upon the client's self—concept, his feelings and reactions to impinging stimuli will elicit affective ex— pressions from the client; on the other hand, therapist re— sponses which focus upon something "outside" the client will elicit noneaffective client statements. The elicitation model is reversed to state that expression of client affect elicits therapist responses which focus upon clients' in— ternalized feelings while non-affective client statements elicit therapist responses which do not focus on client feelings. A content analysis is made of 46 taperecorded initial psychotherapeutic interviews at a university counsel— ing center; the clients are treated by 31 psychotherapists at three levels of experiences doctoral, interne, and be- ginning practicum students. Client-therapist interactions are coded by a scoring-manual developed for the study. Client statements are coded for expressions of hostility, dependency, affiliation, self—assertion, sex and vague af— fect. Each client expression is also scored for internal- ized affect, and for the subject and object of the behavior described. Therapist responses are scored for approach, David A. Kopplin avoidance and initiation of topics and for elicitation of internalized affective expression. The basic unit of analy— sis is the interaction sequence: client statement, therapist response and succeeding client response. The results follow: 1. Clients are more likely to respond with affective responses following therapist elicitation of internalized feeling compared with therapist elicitation of externalized material. 2. Clients are more likely to respond affectively to therapist elicitation of internalized feeling following pre— vious client non-affective statements compared to therapist elicitation of externalized material following previous client affective statements. 3. Therapists are likely to follow client affective ex— pression compared to non—affective client expression with further elicitation of internalized feeling. 4. Therapists'ratings of successful or unsuccessful treatment at termination fail to relate to the percentages of client affect or therapist elicitation of affect in the first interview. 5. Clients are likely to continue to express hostility, dependency, affiliation, self-assertion, sex or vague affect David A. KOpplin after approach by the therapist; they are likely to change the tOpic after avoidance by the therapist. 6. The presence or absence of affect in the client's previous statement, and the presence or absence of elici- tation of affect in the therapist's approach response do not significantly effect. the percentages of continuance after approach; the same conclusion holds for continuance after avoidance. 7. Clients are likely to follow therapist initiation of hostility, dependency, affiliation, self—assertion, sex or vague affect with continuing expression of the topic. Implications for further process research in psycho- therapy are offered in light of both the substantive results and the high degree of inter-judge reliability attained with the scoring manual. APPROVED { / We. Chairman, Thesis Committee DATE ELICITING RESPONSES IN CLIENT-THERAPIST INTERACTION: A CONTENT ANALYSIS OF INITIAL PSYCHOTHERAPEUTIC INTERVIEWS BY . \e“ . DaVid A. KOpplin A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1965 ii TO FAITH AND KRISTIN AC KNOWLEDGME NT S The writer is extremely grateful to Miss Karen S. Kamerschen for her collaboration in this project. She has not only worked arduously as secondary judge, but has al- so contributed significantly to the development of the scoring manual. Appreciation is also extended to the writer's guidance committee for their constructive help: Dr. C. L. Winder, chairman, Dr. Charles Hanley, Dr. Bill L. Kell, Dr. Lucy C. Rau and Dr. Robert E. SChell. Special ap- preciation is due Dr. Winder for the original ideas which generated this study and for his able direction of the project and Dr. Kell for his generous and frequent counsel. Acknowledgments are made to Mrs. Carol Boice, Miss Mary Berk and Mrs. Nancy Whitman for their as- sistance in judging and data analyzing. Finally, appreciation must be expressed to the psychotherapists and clients at the Michigan State Uni- versity Counseling Center for their cooperation; particular acknowledgment is made to Dr. William J. Mueller, chairman of the center's research committee, who developed the re— search library of taperecorded psychotherapies. This study was supported by predoctoral fellowship, l—Fl-MH-24,343—Ol (MTLH)ifixm1the National Institute of Mental Health, United States Public Health Service. iii Chapter II. III. IV. VI. TABLE OF CONTENTS INTRODUCTION THE DEVELOPMENT OF A SCORING MANUAL The Bandura—Winder scoring system The selection of additional client variables . . Therapist variables Outline of the scoring manual STATEMENT OF HYPOTHESES Hypothesis I . A correlary hypothesis Hypothesis II Hypothesis III . METHOD . . . . . . . Source of data SeleCtion of cases . Coding of Client-psychotherapist interaction . . Scoring reliability RESULTS Hypothesis I . . Corollary hypothesis . Hypothesis II . Hypothesis III DISCUSSION Inter-judge reliability . . . Client affect and internalizing and ex— ternalizing responses . . . . . . Approach, avoidance and initiation effects iv Page 15 18 l9 I9 20 21 22 24 24 27 29 3O 33 33 38 39 SO 56 57 57 6O Chapter Page Comparison of approach and internal— izing responses . . . . . . . 62 Implications for further research . . . . 63 VII. SUMMARY . . . . . . . . . . . . . . . . . . . 66 REFERENCES . . . . . . . . . . . . . . . . . . . . . . 7O APPENDICES . . . . . . . . . . . . . . . . . . . . . . A—l Table LIST OF TABLES Characteristics of therapists and clients Experience level and duration of treatment Inter-judge reliability coefficients for Hypothesis I . . ‘ Comparison of client affect—no affect units and therapist internalizing-externalizing responses . . . . Inter-judge reliability coefficients for Hypothesis II Comparison of continued client expression after therapist responses of approach and avoidance . . . . . . . . . . . . . . Inter-judge reliability coefficients for Hypothesis III Continuance after initiation Comparison of continued client expreSSion after therapist initiation and approach vi Page 25 28 34 36 42 44 52 53 55 Appendix A. B. C. LIST OF APPENDICES SCORING MANUAL . . . . . RATING SHEET FOR THERAPISTS CODING SHEET FOR JUDGES vii I . INTRODUCTION Theoretical formulations of the psychotherapeutic process are intricate and varied. Many practitioners feel the complexity of the process defies meaningful research. This writer is committed to the premise that research on psychotherapies can be meaningful. He proposes that a complex phenomenon need not be analyzed by complex theo- retical constructs. Too often studies are noncomparable and not replicable because the yariables analyzed are distinctive to an individual study or school. Elaborate formulations of highly abstract concepts are not necessary; in fact, often they complicate the research by attempting to fit the data to the theory rather than the design to the data. It is most appropriate, in View of the limited amount of substantial research evidence available at present, to attempt investigations which clearly oper— ationalize a limited number of variables which are common to most theories of personality and psychotherapy. Theoreti— cal constructs such as dependency, hostility, sex, anxiety, affectivity, and guilt are basic to most conceptualizations of personality and are frequently used in clinical reports. With clearly defined operational definitions for basic con— structs, molecular and interactive analyses can be reliably executed and replicated. The analysis can be applied to actual psychotherapeutic interviews using taperecorded sessions. II. THE DEVELOPMENT OF A SCORING MANUAL The present study divides into two sequential stages. The first stage, discussed in this chapter, involves the se— lection of specified variables, their operational defi— nitions, and the development of a scoring manual. The second stage applies the scoring process to a series of initial interviews, establishing inter-judge scoring relia— bility and testing selected hypotheses about the pyscho— therapeutic process. The Bandura-Winder coding system: A system for a molecular analysis of the verbal interaction in the thera— peutic session has been proposed by Murray (1956) and re— fined by Bandura, Lipsher and Miller (1960) and Winder, Ahmad, Bandura and Rau (1962). The scoring system used in this study has been developed as an extension of the Bandura- Winder system. The basic model of their scoring procedure is the interaction sequence: a client statement, a therapist response and a following client response. In these studies client statements were grouped into classes. The main classes of client statements were expressions of hostility, dependency and sex. These investigators divided the therapist responses into two general classes: approach and avoidance reactions. They assumed that therapist approach reactions would act as positive reinforcements and would therefore function to encourage a client to continue to ex- press feelings of hostility, dependency or sex. They as- sumed that therapists' avoidance reactions serving as nega— tive reinforcements would not encourage continued expression, but would inhibit further expression of hostility, dependency or sex. The subsequent client expression after approach or avoidance tested the reinforcing or inhibiting effect of the contingent stimuli. Bandura et a1. (1960) confirmed the pre- dicted effects of approach and avoidance for client ex- pressions of hostility,and Winder §£_al. (1962) confirmed the effects of approach and avoidance for client expressions of dependency. The present investigator (1963) and others, Barnes (1963), Caracena (1963), Lerman (1963), Schuldt (1964) and Varble (1964) have replicated these basic para— meters. This sequence of related studies establishes the Bandura—Winder scoring system as a reliable methodology for observational investigations of the psychotherapeutic process. The use of learning theory in the Bandura—Winder system assumes that verbal responses can be accounted for by the same principles as are non-verbal responses. Verbal expression is a behavioral response and, as such, is amenable to experimental manipulation. Applying the principles of learning theory, therapist responses are considered as contingent stimuli which occur selectively as though to shape the client's behavior. The scoring manual developed for this study utilizes the basic elements of the Bandura-Winder system: the interaction sequence, the approach—avoidance dichotomy for therapist reactions to various types of client expressions, and the three main classes of client statements: hostility, dependency and sex. The selection of additional client variables: The two categories of contingent stimuli, approach and avoidance, have a global and generic nature in that they can be used to describe therapists' reactions to nearly any class of be- havior. Therefore, the first step in the development of the present scoring system was the selection of major client variables in addition to dependency, hostility, and sex. Several premises served as guiding principles in this selection process. The first premise is that the most appropriate variables are those commonly used in clinical settings to describe people and their ways of coping with others, i.e., the variables selected should be common to most of the theories of personality and psychotherapy. In addition they must be variables which can be operationalized with sufficient precision so that trained judges, working independently, can reliably score them by listening to tape— recorded psychotherapeutic interviews. This necessarily excludes non-verbal variables which can only be scored when the judges visually observe the interviews. An additional premise is based upon the inter- personal emphasis of psychotherapeutic interviews. In the interaction with the psychotherapist the client often re— veals the nature of his problems; the quality of this inter— action suggests the ways that the client has learned to c0pe with.his interpersonal environment in order to reduce his anxiety. The neo-analyatic schools of psychotherapy, par- ticularly Harry Stack Sullivan (1953), have demonstrated how present interpersonal behavior stems from earlier relation— ships with such significant persons as parents and siblings. The classes of dependency, hostility and sex fulfill these requirements. They have been Operationalized with sufficient precision in the Bandura-Winder system so that independent judges can score them reliably. They express styles of interpersonal behavior that are common to the major theories of personality and psychotherapy. While these par- ticular labels may vary across theories, it is difficult to consider ways of describing human behavior without using these central concepts. In fact, these conceptS’are not exclusive to psychological theories at all; rather they are used widely on a common-sense basis. If you say to a man on the street, "that person was angry or resentful," he understands that you are referring to a sample from the class of behavior conceptualized as hostility. If you should say, "that person is always looking for help or ap— proval," your listener understands you by invoking the con- cept of dependent behavior. The same situation holds for statements grouped in the class of sex. These three classes seem almost universal for both lay and professional classifi— cations of interpersonal behaviors. After listening to a series of taperecorded inter- views and reading a number of typescripts of interviews, we decided to add two other classes of behavior which we labeled "self—assertion" and "affiliation." Self—assertion refers to expression of needs to be independent, achieving, dominant, mature, ambitious and competitive. It includes the basic drive for mastery and self-confidence. This class also fulfills the previously specified requirements for se- lection of client variables. It is interpersonal in character. we have been able to operationalize the defi— nition and preliminary scoring of this class appears to be reasonably reliable across independent judges. It is also a central concept to both lay and SOphisticated theories of human behavior. If you suggest that a man is dominant or ambitious, your listener understands the class of behavior to which you are referring. Affiliation refers to the expression of needs for friendly social relationships. It includes the needs for social group activities, admiration and affection for others, and the maintenance of friendships. This class also fulfills the requirements of interpersonal orientation and common— ality across lay and professional conceptualizations of personality. Preliminary scoring suggests that we have formulated operational definitions which facilitate reliable judging. We feel that these five categories encompass a large proportion of the styles of interpersonal behavior expressed by clients in psychotherapeutic interviews. Operational definitions for these classes are listed in Section II A of Appendix A. It is instructive to compare four of these classes with the conceptual scheme of interpersonal behavior de— veloped by Leary (1957). Hostility, dependency, self— assertion and affiliation are very similar to the four di— mensions generated by Leary. He organizes interpersonal be— havior along two orthogonal dimensions: dominance—submission and hostility-affection. After describing the empirical development of his double axis circumplex model, Leary compares the corre— spondence of these four systematically related variables to theories of personality from Hippocrates to Talcott Parsons. The four possible quadrants of Leary's interpersonal system rather closely fit the classical humors of Hippocrates: choleric (hostility—dominance), melancholic (hostility— submiSsion), phlegmatic (submission-affection) and sanguine (affection-dominance). Leary indicates a second corre— spondence with Freud: The same fourfold classification reappears in Freudian thought. Freud's treatment of the indi- vidual stresses two basic motives—-love and hate. His theories of social phenomena and group inter— action, on the other hand, emphasize domination, power, and the interaction of the weak versus the strong. (1957, p. 71) Leary outlines a third correspondence with Parson's "para- digm of motivational process.” Parsons suggests that de— viance from conformity to a normative pattern structure in— volves four basic directions. They are aggressiveness and withdrawal on the alienative side and compulsive performance and compulsive acceptance on the side of compulsive con— formity. These four directions roughly correspond to Leary's four dimensions and to hostility, dependency, self— assertion and affiliation respectively, as we have classi- fied interpersonal behavior. Although the class of behavior labeled sex by Murray (1955) and included in the Bandura-Winder system could be encompassed under the other four styles or classes of inter— personal behavior, we have retained this class because of its centrality to personality theories and its saliency in client expressions. Sex covers a distinct class of behavior; to score such expressions only as hostile, friendly, de— pendent or assertive would mask this saliency. Clients focus their discussion of interpersonal difficulties around 10 problems of sex as well as around difficulties with de- pendency, hostility, self—assertion and affiliation. In the development of the scoring manual we noted another limitation in the Bandura-Winder system. The limitation has to do with the styles of interpersonal be- havior. Statements receive identical scorings despite ob- vious differences in the therapeutic value of the verbali- zation. For example, consider these two statements: "I am so afraid, like I am going to panic; I want to be babied and comforted," and "may I borrow your matches?" The first statement involves material which clearly expresses the present state of the client's feelings, while the second only verbalizes an incidental and relatively insignificant request. Yet both statements are scored identically: de- pendency bids directed at the therapist. We have attempted to solve this limitation by de— velOping secondary scorings for the interpersonal categories. The main premise for this development is that client ex- pression of affect or feelings is an important component of the therapeutic process. Although the importance of af— fective expression has been present in theories of psycho— therapy since the time of Freud and Breuer, ROgers has been most articulate in stressing that therapeutic success is de- pendent upon an interactive process which focuses upon ex- pression of the client's feelings. Simply stated, ex— pression of client affect is more relevant than expression ll of client action. Kell and Mueller (in press) have de- veloped the premise that client change often depends upon the ability of the therapist to explore the affect associ— ated with the client's conflicts. Often a client presents "compacted experiences" which he has compressed in order to avoid experiencing the anxiety associated with the original conflict. The client, perhaps ambivalently, wishes to con— ceal the full meaning of his experiences because of the pain and anxiety associated with past failures in relating to others successfully. Based on these considerations, we have formulated a series of classes which we labeled intrapsychic states be— cause they focus upon the extent and nature of the feelings or affect expressed by the client. In order to arrange a series of classes which can encompass the range of affective expression, we have examined the various ways in which clients express their feelings. After scoring a series of interviews we determined eight classes of intrapsychic states which can be used as secondary scorings for any of the interpersonal classes. "Guilt" covers client expressions where the client internalizes the blame for this diffi- culties. "Frustration—hurt" covers those expressions where the client neither blames himself nor others but expresses feelings of hurt, discomfort or lack of satisfaction because a major drive or need has been frustrated by some external source: the hurt is the reaction to frustration. 12 "Frustration—aggression" covers those statements where the client blames others for his frustrations. "Satisfaction” covers those statements where the client expresses gratifi- cation or satisfaction in regard to a major need. "Anxiety" covers the more general expressions of fear and anxiety in regard to a major need. "Simple need" covers those affective expressions which state a need or drive on the part of the client but are not stated with sufficient elaboration to permit scoring in one of the above classes. "Unstated" covers those statements of the client without affective ex— pression; the client has not said "how he feels” about the topic or behavior discussed. The eighth class was added for scoring convenience; "simple agreement—disagreement" covers those statements of the client which-only respond to what the therapist said ("yes," "no," etc.). The eight cate- gories are exhaustive but the first five are not mutually exclusive. At this point we were still not satisfied that the secondary scorings sufficiently discriminated classes of therapeutic relevance. we were certain that affective dis— cussion was most relevant, but clients also describe their actions and the behaviors of others. All statements of this type are not of equal relevance for the therapeutic process. we attempt to solve this problem by adding two more series of scorings in addition to the interpersonal and intrapsychic classes. The first addition, in part taken from the l3 Bandura-Winder system, scores the subject and object of the behavior stated in the client's verbalization. This is a relatively simple process. Usually the client is the sub- ject; he describes his feelings, thoughts or actions. The object is the recipient or referrent for the stated feelings, thoughts or actions of the subject. Possible subjects and objects are client, therapist, family members, peers and "others.” Scoring subjects and objects provides analysis of client behavior in regard to specific individuals, e.g., is the client's hostility primarily expressed in relation to his parents? Subjects and objects are noted for each inter- personal category scored. The second addition is a series of six ranked classes we have labeled "therapeutic relevance." A number of assumptions underlies the ranking: WE believe that ex— pression of client affect is most relevant, and references to present feelings or conditions are more relevant than past feelings or conditions. References to the client him— self are more relevant than references to others. References to family members are more relevant than references to others. References to significant individuals are more relevant than intellectual or impersonal discussions. And discussion of events in which the client is a participant are more relevant than discussion of events in which the client is only an observer or reporter. 14 The six categories we developed follow beginning with the most relevant: l) client's present affective feel- ing; 2) client's past affective feeling; 3) behavior within the client's family; 4) behavior in which client partici- pates; 5) behavior which client observes or reports; and 6) impersonal events, facts or opinions. Trial coding with these categories suggests that judges can reliably score them. Therapeutic relevance becomes the fourth or last stage in scoring a client statement. Each paired interpersonal-intrapsychic scoring receives a relevance score. The six categories are exhaustive and mutually exclusive. Utilizing the relevance coding, we could study changes in relevance over time, we could analyze the rele— vance quality of various interpersonal or intrapsychic ex— pressions, and we could compare relevance across clients. Only two other additions were made to complete the scoring of client statements. So-that any client unit could receive an "interpersonal scoring," we added two more classes. Although these are not truly ”interpersonal" classes, they make the series exhaustive. "Vague affective" responses include expressions of feeling which do not fit into any of the first five interpersonal categories. "Other" includes all other client statements. A brief summary of the scoring process for client statements follows. Detailed directions and definitions are 15 given in Appendix A. The judge listens to a client speech and scores one or more of the interpersonal classes: hostility, dependency, affiliation, self—assertion, sex, vague and/or other. For each class selected the judge indi— cates which intrapsychic states should be scored: guilt, frustration—hurt, frustration-aggression, satisfaction, anxiety, simple need, unstated and simple agreement— disagreement. Next the judge indicates the subject(s) and object(s) and finally selects one class of therapeutic rele- vance for each interpersonal class scored. Therapist variables: At this point we turned our attention to the scoring of therapist responses. As dis— cussed above the Bandura—Winder dichotomy of approach and avoidance provides generic categories which relate the therapist response to the client statement. As contingent stimuli they are designed to analyze the therapist's manipu— lation of client expression. we are simply extending the use of this dichotomy to additional interpersonal categories and their paired intrapsychic states. Each paired interpersonal-intrapsychic scoring is followed by either an approach or avoidance scoring, depending upon whether the therapist response was designed to elicit continued client discussion-of that category or to inhibit that particular discussion. 16 We have also retained the scoring of "therapist initiation of an interpersonal category." Whenever the therapist initiates the discussion of an interpersonal cate— gory which was not scored in the previous client speech, a scoring notes the class introduced. Despite our interest in and acceptance of the approach—avoidance dichotomy, we noted a major limitation similar to the one mentioned above for client scorings. The approach-avoidance dichotomy does not indicate whether the therapist in his response focuses upon the affective quality of the client's statement. For example: "How did you feel when your father threatened to make you break your date?" "Did your father carry out his threat?" Both statements would be scored as approaches to hostility. The first, how— ever, attempts to elicit the client's feelings about parental control, while the second only asks about the father's be- havior, i.e., the outcome of a particular conflict. If the therapist fails to focus his responses upon the feelings presented by the client, the client may not receive Optimum benefit from psychotherapy. Often clients avoid full expression of their feelings in respect to their problems in living because of the pain and anxiety this usually entails. It is necessary for therapists to explore fully the affect the client feels in regard to certain be— haviors in order to expand the "compacted experiences." This expansion provides for sufficient abreaction by the 1? client, a reduction in his anxiety about the behavior or ex- perience in question, and an Opportunity to change his patterns of interpersonal behavior. In order to discriminate the ways in which therapists react to the affective components of client statements, we first attempted to arrange a series of ranked categories similar to the client categories of therapeutic relevance. This proved too cumbersome and trial inter-judge scoring reliability was low. Often therapist responses are brief and are not highly specific. Finally we adopted a sug— gestion to use another simple dichotomy similar to the approach-avoidance dichotomy.l Therapist responses can focus upon the client's internal feelings as though designed to elicit affective expression, or they can focus upon description of external behavior as though designed to elicit non-affective material. The former we labeled "eliciting internalized feelings," and the latter, "eliciting ex— ternalized behavior;" in both cases the client's feeling is the reference point. This dichotomy is modeled after the approach—avoidance dichotomy and is used to increase discrimi— nation in scoring therapist responses. Here again we apply the principles of learning theory; therapist "internalizing” 1For this suggestion we are indebted to Dr. Bill Kell. The concepts of internalized and externalized ex- pression in relation to client affect in the psychothera— peutic process are delineated and discussed more fully in Kell and Mueller (in press). l8 and ”externalizing" responses are considered as contingent stimuli which occur selectively as though to shape client ex- pression of affect. The subsequent statement of the client serves to test the eliciting effect of the contingent stimuli, i.e., whether the client follows with affective ex- pression or non-affective material. In practice each therapist response is first scored for approach, avoidance and initiation. Then each scoring receives an "E" or an "I" to indicate whether it is designed to elicit internalized feeling or externalized discussion. These judgments are made before the judge listens to the following client statement. Outline of the scoring procedure: The operational elements of the scoring system as it finally developed are presented in complete detail in Appendix A. III. STATEMENT OF HYPOTHESES In the second stage of this research the scoring manual was used in a study of initial taperecorded psycho— therapeutic sessions. Our promise is that research in the complex area of psychotherapy should begin with testing relativelysimple hypotheses about the psychotherapeutic process, especially when a new instrument is being evaluated. we are interested in the moment to moment behavior of the client and the therapist, differences between "successful" and "unsuccessful" therapies and the interaction between the two participants. At this early stage it is also necessary to demonstrate that judges can independently score thera— peutic interactions with a significantly reliable degree of intra—judge agreement. In a parallel study using the same data Kamerschen (1965) investigates several therapist variables. ,Hypothesis I predicts that clients will respond with affective responses more than non—affective responses after therapist "internalizing" statements, and that clients will respond with non—affective responses more than affective re- sponses after therapist "externalizing" statements.. The general model is also reversed to predict that therapists l9 20 will respond with "internalizing" more then "externalizing" responses after affective client statements and that therapists will respond with "externalizing" more than "in— ternalizing" responses after non-affective client statements. Here we consider the interaction of client affective expression and therapist elicitation of affective expression: qualities of therapeutic relevance. Tests are made for the effect of each participant upon the other. First, the test is of the eliciting effect of therapist internalizing re— sponses upon client expression of affect compared to the in—' hibiting effect of externalizing responses upon client af— fect. Secondly, the test is of the tendency of therapists to respond to client affect with internalizing responses which are designed to elicit continued expression of affect. Finally the test is of the tendency of therapists to respond to absence of client affect with responses which encourage continued externalized, non-affective responses. A corollary hypothesis predicts that successful therapies compared to unsuccessful therapies manifest a) greater proportion of client affective responses, b) greater proportion of therapist internalizing responses, c) greater proportion of affective responses following therapist internalizing responses and d) greater prOportion of internalizing responses after client affective responses. This exploratory hypothesis is designed to detect a possible 21 differentiation between successful and unsuccessful therapy. One goal of the therapy process is the expression of client feelings. Therapists strive to elicit such feelings. When clients are not expressing feeling or when therapists avoid eliciting client feelings, therapy probably is failing to help the client since the discussion is not focusing on the material considered most therapeutically relevant. _Hypothesis II predicts that clients will continue discussion of an interpersonal need significantly more after ”approach" to such content by the therapist than after "avoidance" by the therapist. This hypothesis has been demonstrated in previous studies for several interpersonal categories: Winder gtflgl. (1962) Caracena (1963) and Lerman (1963) confirmed this hypothesis for expressions of de— pendency in the early stages of therapy. Schuldt (1964) ex- tended these findings by investigating selected interviews over the course of therapy. Bandura §£_al. (1960), Winder _§E_§I. (1962), KOpplin (1963), confirmed the hypothesis for hostile expressions early in therapy and Varble (1964) validated the findings over the course of therapy by ana— lyzing selected interviews. Lerman (1963) and Barnes (1963), 'using the same sample, verified the approach—avoidance hypothesis for continued expression of sex. This hypothesis probably stands without need of further validation on dependent and hostile expression. Our 22 study extends the hypothesis to expressions of affiliation and self—assertion, and provides a replication for sex. "Vague affective" expressions must be considered separately because approach by the therapist will tend to clarify the client's feelings. Thus, the succeeding client speech may or may not be scored "vague" since the therapist's approach encourages the client to specify his feelings in an interpersonal context. However, avoidance responses could also tend to cause the client to express an interpersonal concern; the avoidance inhibits the present expression so the client turns to a new topic which is likely to be one of the interpersonal categories. Therefore, the general hy— pothesis will not be discredited if the eliciting effect of approach and the inhibiting effect of avoidance is not con— firmed for vague expressions. Hypothesis III predicts that when the therapist introduces expression of an interpersonal category not dis— cussed by the client in his preceding speech, the client tends to express that interpersonal category in his following speech. This hypothesis also serves to compare the effects of "approach" to the effects of "initiation" by the therapist. First we will analyze the frequency for the instances when the client continues the topic initiated by the therapist against the times when the client ignores the initiated tOpic. Secondly, we will compare continuance after approach 23 against continuation after initiation, predicting no sig- nificant difference. This analysis will cover all five interpersonal categories to detect possible differences in client response to initiation of the several tOpics. IV . METHOD Source of data: Table 1 presents information on the clients and psychotherapists. Taperecordings of first inter— views with forty-six clients who requested psychotherapy at a university counseling center provide raw material for the study. The psychotherapists divide into three groups: staff counselors are Ph.D. level clinical and counseling psychologists with three to twenty years of psychotherapy experience; interne counselors are advanced doctoral candi— dates in counseling and clinical psychology who have one year or more of intensive supervision in psychotherapy at the counseling center; they have completed all the required courses and practica in psychotherapy; practicum counselors are less advanced graduate students in clinical psychology who are carrying their first cases at the counseling center; they are enrolled in an introductory practicum course offered at the center. The clients are undergraduates and characterically are late adolescents experiencing newly found independence and separation from home. Each client approached the center without referral to seek help with his personal-social problems. In each case an intake interviewer decided that therapy was indicated. 24 25 Table 1. Characteristics of therapists and clients. Male Therapists Female Therapists Therapist Experience Male Female Male Female Level Clients Clients Clients Clients Total Staff 3 7 2 2 l4 Interne 6 ll 1 5 23 Practicum 2 3 l 3 9 Total 11 21 4 ll 46 26 The cases are from the center's library of tape— recorded psychotherapies which developed as follows: All self—referred clients who seek personal counseling see a psychologist who serves as an intake interviewer to determine whether the student is suitable for psychotherapy. These interviewers asked randomly selected clients to participate in the center's research program, but only after the client had accepted the offer for treatment and knew his problems were apprOpriate for psychotherapy. Only clients without previous psychotherapy were asked to participate. A client's participation included research testing and the re- cording of all interviews. The testing includes the MMPI, Semantic Differential and Personal Data Sheet before and after treatment and the Semantic Differential once a month throughout treatment. Generally research clients and therapists met for an hour each week except that practicum therapists saw their clients twice a week. Assignment was made by matching therapist hours to the client's available hours. Final as- signment depended upon the therapist agreeing to work with the client; therapists had access to the intake notes and they could also talk to the intake interviewer if they wanted to know more about how the client presented himself. Some selection enters the library's sampling of psycho— therapists and patients since all psychologists who do psychotherapy at the center did not participate. This study 27 analyzes only the taperecording of the first session with the assigned therapist. Selection of cases: The library divides in two ways: a) staff, interne, and practicum therapists, and b) successful and unsuccessful cases. To be considered suc- cessful, the therapist must judge the case as successful or partially successful at termination. Unsuccessful cases were those judged by therapists as unsuccessful or partially unsuccessful at termination. Table 2 presents information on therapist experience level and duration of treatment. A )(2 test reveals no significant differences for lengths of treatment across the three groups of therapists as grouped in Table 2. Since the center has few female therapists and the majority of psychotherapy clients are female, balancing for sex differences is not feasible. Thirty—one of forty—six clients are female. Ten of the thirty-one therapists are female. Three therapists saw three clients each; nine therapists saw two clients each. There are fifty—four recorded psychotherapies in the library. However, eight cases could not be used: four cases do not have recorded first sessions due to mechanical and human failure; two interviews were judged too difficult to hear because of insufficient'difference between sound and noise levels on the recordings; two cases involved.the principal investigator as therapist. 28 Table 2. Experience level and duration of treatment. Number of Interviews Experience Level '1-5 6-10 11—15 16-20 21—- Staff 5 4 2 2 l Interne 6 6 2 8 l Practicum l 2 2 3 l Note: X2 test is not significant: x = 4.154, df II (D 29 Coding of client—psychotherapist interaction: Initial scoring with four judges revealed considerable inter— judge disagreement with the scoring of the intrapsychic states. The scoring of other variables demonstrated that reliable scoring should be achieved with a moderate period of training. Therefore, we decided to reduce the complexity of the system for this initial study. The scoring of the intrapsychic states and the categories of psychotherapeutic relevance were reduced to one dichotomy: statements were divided into affective and non—affective client expressions. Affective client statements include those where the intra- psychic state would be scored as simple need, anxiety, guilt, frustration-hurt, frustration—aggression and satisfaction, and where the therapeutic relevance category would be scored as present or past affective feeling. Non-affective client statements included those where the intrapsychic state would be scored as simple agreement—disagreement or-unstated and where therapeutic relevance would be scored as behavior with— in the family, participant behavior, observed behavior and impersonal events, facts and opinions. The scoring of therapist responses as described above was not altered. The scoring for this study summarizes as follows: The judge listens to a client speech and determines which interpersonal categories are verbally expressed: hostility, dependency, affiliation, self-assertion, sex, vague affect and "other." Then the judge decides whether the 3O scored categories are affective or non-affective expressions. Finally the subject and object of the behavior are scored. Subsequently the judge scores the therapist response as ap— proach or avoidance to the scored interpersonal statements and notes the introduction by the therapist of any inter- personal categories not expressed in the preceding client statement. The judge also marks each approach, avoidance or introduction as an internalizing or externalizing response. Operational definitions for these variables appear in the Scoring Manual, Appendix A. Scoringireliability: The scoring process divides into two distinct aspects: the determination of client and therapist units and the subsequent scoring of these units. If each judge works independently on both aspects of the scoring, disagreements on the division of units confound measures of inter—judge reliability for the actual scoring of the units. Therefore the two aspects are separated in this study so that a more accurate measure of scoring relia- bility obtains. The first step establishes a division of units in each taperecording. The sessions are rerecorded on one track of a stereophonic system. While listening to this track, a judge separates units by recording brief "beeps" on the parallel track. Judge A "beeped" all the tapes; judge B inde— pendently "beeped" three of the tapes to demonstrate 31 inter-judge agreement for this procedure. Subsequently all scorings were made on tapes with units differentiated in this fashion. The second aspect involves the actual scoring of units. Our initial experience with four judges revealed that previous study of psychology enhanced scoring accuracy, i.e., the more courses a judge had taken in psychology, the greater the initial agreement with the scoring of the principal investigator. The four judges differed in experi- ence as follows: Judge A, the principal investigator and developer of the scoring manual, is completing his doctoral training in clinical psychology specializing in psycho- therapy; judge B is a first year graduate student in clinical psychology without previous experience with psychotherapy; judge C, is a third quarter undergraduate senior who has been accepted for a graduate program in experimental psy- chology; judge D is‘a housewife with limited knowledge of academic psychology. Judge D, the least reliable scorer in the initial period, dropped out of the study. The other three continued with further training by mutually coding a series of inter— views. Additional training enhanced inter—judge agreement. The reliability sample consists of twenty—five inter— views coded independently by judges A and B. In order to measure the degree of inter-judge reliability, summary scores for each of the 122 variables used in subsequent 32 analyses were determined for each interview. Then Pearson product-moment correlation coefficients were computed for each variable to compare the scorings of the two judges for these twenty-five interviews. Since only judge A scored all cases, the hypotheses are evaluated on the basis of his coding. To avoid contami— nation in scoring, each judge scores each unit before listening to the following unit. V. RESULTS ,Hypothesis I predicts the differential effect of internalizing and externalizing psychotherapist responses on the immediately succeeding client expression of affect. Psychotherapist internalizing responses encourage the client to express his self concept, his feelings or his reaction to stimuli impinging upon him; when the client does, these units are labeled "affect" units. Psychotherapist external— izing responses focus upon something "outside" the client and are not expected to elicit affective responses from the client; these client units are labeled "no affect" units. In addition, the analysis reverses the model and considers the differential effect of affect and no affect client statements upon the succeeding therapist internalizing or externalizing responses. The interjudge reliability coefficients for the scoring of the relevant variables are presented in Table 3. All the coefficients indicate highly reliable scoring (2 41.01). _Pr0portions are determined for each variable on every interview; for example, the proportion of client af— fect units following therapist internalizing responses is computed by dividing the frequency of internalizing re— sponses into the frequency of client affect responses which 33 34 Table 3. Inter—judge reliability coefficients for Hypothesis I. Variable 13* N** Client Affect Units .995 25 Therapist Internalizing Units .969 25 Internalizing Responses following Affect .972 25 Internalizing_3 not following Affect .895 24 Subsequent Client Expression of Affect: After Internalizing 3 following Affect .964 25 After Internalizing 3 not following Affect .871 24 After Externalizing 3 following Affect .853 25 After Externalizingug not following Affect .925 25 *All correlation coefficients are significant at the .01 level. **All variables were not judged to be present in every interview. Therefore, every correlation coefficient for this and later tables is not based on a N of 25. 35 immediately follow a therapist internalizing response. (2 af— fect units following internalizing statements/2 of internal- izing statements.) Other scores in Tables 3 and 4 have a similar derivation: given a certain condition of preceding unit or units, how often does the client (or therapist) follow with a particular type of response. Clearly internalizing responses by the psychotherapist elicit affective responses from the client in the succeeding unit (Table 4). In all 46 interviews affect units follow internalizing responses more than 50% of the time, in 36 cases the percentage is 75 or more. The media proportion across interviews is .84. As can be seen from Table 4, in— ternalizing responses compared to externalizing responses elicit more affective client statements. In 43 of the 46 interviews the proportion of affect units following therapist internalizing responses exceeds the proportion following externalizing responses; the sign test is highly significant (E. (.001). The median proportion of affect units following externalizing responses is .52, indicating an appreciable tendency for clients to express affect even after therapist responses which focus upon non-affective externalized material. The elicitation model is reversed to demonstrate that client expression of affect elicits internalizing responses from the therapist more often than not. In all 46 inter— views internalizing responses follow client expression of 36 Table 4. Comparison of client affect—no affect units and therapist internalizing-externalizing responses. Proportion Variables of Sign Test_p. Compared Interviews (Two—tailed) Client Affect after Internalizing it) Client Affect after External— izing 3 43/46 .001 Internalizing 3 after Affect) Internalizing_g after No Affect 40/46 .001 Individual Comparison of 3 Unit Sequences for 4 Conditions:* (A) Affect - Internalizing R - Affect) (B) Affect — Internalizing R - No Affect 33/46 .007 (B) Affect — Internalizing_g - No Affect) (c) Affect - Externali- zing_§ - Affect 35/43 .001 (C) Affect — Externalizing R — Affect) (D) Affect — Externalizing R - No Affect ' 32/43 .002 2 *Friedman Two—way Analysis of Variance by Ranks: )(r = 67.19, p<.OOl. 37 affect more than 50% of the time; in 35 cases the proportion is .75 or more. The median proportion is .81. In 40 of the 46 interviews the prOportion of internalizing responses following affect exceeds the proportion following no effect units (Table 4,.p <:.001). The median proportion for the latter variable is .52 indicating that therapists frequently focus upon client feelings even when clients have expressed no affect in the preceding statement. Since client affect statements compared to no affect statements elicit greater proportions of internalizing re— sponses and since therapist internalizing responses compared to externalizing responses elicit a greater prOportion of affect responses by the client, the proportion of internal- izing responses by the therapist should correlate with the prOportion of affect units by the client. Such a corre— lation is demonstrated: r = .488, N = 46, p (.01. It is interesting to note that the mutual elicitation effect leads to high proportions of client affect units in the interviews. The median proportion for interviews is .72 and only one client expressed affect less than 51% of the time. Correspondingly, all therapists used responses de- signed to elicit affect more than 50% of the time (median .75). Because this mutual elicitation effect is so evi— dent, a further analysis compares proportions of affect for three unit sequences; initial client statement (affect or no 38 affect), therapist response (internalizing or externalizing), and criterion client responses (affect or no affect). Four conditions are considered: (A) client affect responses following internalizing therapist responses after initial client affect statement; (B) affect responses following internalizing responses after initial no affect statement; (C) affect responses following externalizing responses after initial affect statement; and (D) affect responses following externalizing responses after initial no affect statement. A Friedman two-way analysis of variance by ranks indicates that the conditions produce significant differences on the criterion measure: the immediately following expression of client affect (X: = 67.19, p (.001) . The median pro- portions for the four conditions are: A, 88; B, 70; C, 57; and D, 38. Three sign tests establish a significant order effect. Condition A has a significantly greater proportion of immediately following affect than does condition B (E<:.007); similarly the affect following condition B is sig- nificantly greater than that after condition C (p.<.001); and the affect following condition C is significantly greater than that after condition D (p( .002) . The mutual elicitation hypothesis of client affect upon therapist internalizing responses and vice versa is clearly confirmed. A corollary hypothesis explores the influence of af— fect units and internalizing responses upon the outcome of 39 therapy: the therapist's judgment of successful treatment at termination. There is no statistical support for the hypothesis that cases judged successful and unsuccessful differ on percentage of affect units, internalizing re- sponses, affect units following internalizing responses, or internalizing responses following affect; the correlary hy— pothesis is not borne out. Hypothesis II predicts the differential effect of approach and avoidance responses by the therapist upon the subsequent expression by the client. For example, when the therapist responds to client hostility statements with ap- proach responses, the hypothesis predicts that the client will respond with further expression of hostility; when the therapist responds to client expression of hostility with avoidance responses, the hypothesis predicts the client will not follow with further expression of hostility. When the therapist responds with approach or avoidance to client ex- pressions of the other major interpersonal categories, de— pendency, affiliation, self—assertion, sex or vague state— ments, similar predictions follow for subsequent client ex~ pression of that particular interpersonal category. Dividing the interpersonal client categories into affect and no af— fect statements and dividing the therapist approach and avoidance responses into internalizing and externalizing responses provides a more detailed analysis of the differ— ential effects of approach and avoidance. 1:; 40 For this general hypothesis the variables derive from proportions determined by three unit interaction sequences. Every client speech initiates a sequence and the judges score that statement for the major interpersonal cate- gories; for each category marked the judges also note whether the expression for that category was affective or not. The middle unit in the sequence, the therapist speech, determines the response to the scored categories from the client's preceding statement. First, the judges dichotomize the responses into approach and avoidance; secondly, they de— termine which approaches and avoidances are designed to elicit affective expression by the client, i.e., dichoto— mizing every approach and avoidance into internalizing and externalizing responses. Finally, the judges score the third unit, the succeeding client statement,as either a con— tinuance or non continuance of the interpersonal category expressed in the initial client statement. This scoring be— comes the criterion measure for the variable: given a speci— fied sequence of initial client statements and succeeding therapist responses, how often does the client continue with further expression of the initially scored interpersonal category. For instance, the continuance of hostility follow? ing therapist internalizing approach to client affect ex— pression of hostility is derived by dividing the frequency of sequences in which affect hostility expression is followed by an internalizing approach into the frequency of such 41 sequences in which the client continues to express hostility. (2 hostility expressions following internalizing approaches to previous affect hostility statements/2 of internalizing approaches following affect hostility.) Inter-judge scoring reliability coefficients for these variables are presented in Table 5. The analysis in- volves 96 variables; only 10 variables are not scored re- liably at the .05 level of significance; these variables are noted in the analysis. Most of the nonsignificant coef- ficients are associated with low frequencies of occurrence of the category. Despite these 10 variables the over—all reliability is extremely high: of the 96 coefficients 35 are greater than .900, 61 are greater than .800 and 73 are greater than .700. The comparison of client continuance of particular interpersonal categories after therapist approach and avoidance divides into three parts. Table 6 lists the re- sults. Part I treats the effects of approaches and avoidances without dichotomizing them into internalizing and external— izing responses. The results are unequivocal: Continuance of the client expression is more apt to follow therapist approach responses than avoidance responses. This is true for all the major interpersonal categories of client state— ments: hostility, dependency, affiliation, self—assertion, sex and vague. ,All sign tests are significant (p <;.001). Furthermore approach and avoidance continuances maintain "H 42 Table 5. Inter-judge reliability coefficients for Hypothesis II. Part I: Continuances following Approach All Approach Approach I Approach E Initial Unit Continuance Continuance Continuance g N .r_ N .£ N Hostility .783 24 .673 24 .947 17 Affective .799 22 .688 22 .942 12 Non-affective .964 16 .853 16 .905 11 Dependency .928 24 .906 24 .702 23 Affective .911 24 .894 23 .747 16 NOn-affective .891 24 .761 23 .752 21 Affiliation .972 17 .994 16 .000* 6 Affective .976 15 .970 15 ** 2 Non-affective .433* 13 .504 10 .000* 4 Self-Assertion .779 22 .807 20 .695 14 Affective .934 19 .923 17 .936 11 Non-affective .567 13. .830 11 -.102* 5 Sex .847 18 .913 16 .941' 10 Affective .985 16 .807 15 .854 7 Non—affective .454 16 .441* 13 .975 8 Vague .899 25 .893 25 .786 17 *p >.05. All other coefficients: 3 (.05. **Correlation procedures require that NC>2. 43 Table 5. Con't. Part II: Continuances following Avoidance _ All Avoid Avoid I Avoid E Initial Unit Continuance Continuance Continuance 5 N _r N _g N Hostility .914 25 .897 25 .947 20 Affective .915 24 .901 22 .902 15 Non-affective .772 21 .792 20 .327* 12 Dependency .909 25 .886 25 .891 21 Affective .888 25 .913 25 .849 12 Non-affective .679 24 .676 21 .893 17 Affiliation .908 25 .978 24 .886 17 Affective .927 24 .964 21 .853 14 Non-affective .098* 24 .441 21 .983 11 Self—Assertion .812 25 .817 24 .281* 17 Affective .817 25 .714 24 .477 14 NOn—affective .831 18 .799 14 .698 9 Sex .845 23 .831 21 .997 15 Affective .385* 18 .582 18 1.000 9 Non—affective .921 18 .841 15 .993 13 Vague .932 25 .832 23 .857 22 p >.05. All other coefficients: p (.05. 44 Table 6. Comparisons of continued client expression after . therapist responses of approach and avoidance. Part I: Continuance After All Approaches and Avoids Approach Avoid P. Sign Test Initial Client Cont. Cont. App. Conte> p. Variable Median Median Av. Cont. (twoJEailed) Hostility 71 25 40/44 .001 Affective 75 30 33/37 .001 Non-affective 50 14 27/33 .001 Dependency 60 18 40/44 .001 Affective 73 16 36/40 .001 Non-affective 57 23 35/39 .001 Affiliation 64 ' 12 32/35 .001 Affective 67 0 ‘29/31 .001 Non—affective* 60 0 17/21 .008 Self-Assertion 67 15 35/38 .001 Affective 71 14 32/34 .001 Non—affective 95 0 18/20 .001 Sex 80 11 32/35 °001 Affective* 75 0 23/25 ~ .001 NOn—affective 90 0 25/28 .001 Vague ' 67 24 43/44 .001 *Indicates that the inter-judge reliability co- efficient is not significant for one or both of the variables compared (3 >.05). 45 Table 6. Con't. Part II: Continuance After Internalizing Approach and Avoid Approach I Avoid I P. . Sign Test Initial Client Cont. . Cont. App. Cont. .2. Variable Median Median Av. Cont. (two-tailed) Hostility 70 25 38/43 .001 Affective 73 27 31/38 .001 Non-affective 60 0 24/30 .002 Dependency 64 17 40/44 .001 Affective 71 0 32/37 .001 Non-affective 56 0 27/32 .001 Affiliation 67 11 26/28 .001 Affective 67 0 22/23 .001 Non-affective 57 0 13/15 .008 Self—Assertion 78 14 31/33 .001 Affective 75 14 29/31 .001 Non—affective 100 0 15/18 .008 Sex 79. 7 28/31 .001 Affective 81 0 23/26 .001 Non—affective* 96 0 17/19 .001 Vague 70 20 42/43 .001 *Indicates that the inter-judge reliability co- efficient is not significant for one of the variables com— pared (p > .05). |___-A 46 Table 6. Con't. Part III: Continuance After Externalizing Approach and Avoid Approach E Avoid E P. Sign Test Initial Client 'Cont. Cont. App. ContJ) .2. Variable Median Median Av. Cont. (two-tailed) Hostility 75 33 23/27 .001 Affective 90 33 15/17 .002 Non-affective* 67 0 12/16 n.s. Dependency 63 0 28/35 .001 Affective 67 0 14/18 .030 Non-affective 50 0 21/25 .001 Affiliation* 100 0 9/11 6.5. Affective* 100 0 6/7 n.s. Non—affective* 100 0 4/4“‘ n.s. Self—Assertion* 88 0 13/15 .008 Affective 85 0 10/12 .038 Non-affective* 80 0 6/6 .032 Sex 100 0 16/19 .004 Affective , 92 0 10/11 .012 Non-affective 100 0 11/13 .022 Vague 67 20 18/21 .002 *Indicates that the inter-judge reliability co— efficient is not significant for one of the variables com— pared (p > .05). 47 their differential effects even when the major categories are divided into affect and no affect sequences. (Vague Statements cannot be so divided since they are affective by operational definition in the scoring manual.) This division refers to the client statement before therapist approach and avoidance and not to the following criterion measure of client continuance. Again all sign tests are highly sig- nificant (p<<.008). For two variables, sequences beginning with no affect expressions of affiliation and affect ex— pressions of sexuality, the judges failed to achieve reliable scoring. Parts II and III of Table 6 demonstrate that the differential effects of approach and avoidance remain evi— dent even when the approaches and avoidances are dichotomized into internalizing and externalizing responses. Part II shows comparisons for continuance scores between internal— izing approaches and internalizing avoidances for major interpersonal categories and for the categories when they are dichotomized into affect and no affect expressions. All of the sign tests are highly significant (p (3008). On only one variable, no affect sex, did the judges fail to score reliably. Similarly Part III shows comparisons for continuance scores between externalizing approaches and avoidances. All of the sign tests are significant (p (1.05) except for four of the six variables which could not be scored reliably by 48 the judges. Lower frequencies may account for the lack of reliability and significance. The differential effects of therapist approach and avoidance upon client continuance of expression for the major interpersonal categories also manifests itself in an examination of the median proportions for the variables com— pared in Table 6. All of the median proportions for con— tinuance after approach are equal to or greater than .5. Of the 48 medians 43 are equal to or greater than .6; 22 are greater than .75. .All the median proportions for con— tinuance after avoidance are less than .35; 44 of the 48 are equal to or less than .25; and 26 are 0. Hypothesis II is clearly confirmed. In addition the differential effects of approach and avoidance are not de— pendent upon the presence or absence of affect in the initial Client expression of the three unit sequences. Furthermore, ”the effects are not dependent upon the affect eliciting character of the approaches and avoidances, i.e., the dichotomy into internalizing and externalizing approaches and avoidances. Since the differential effects of approach and avoidance upon subsequent client expression are so con- sistent, it is relevant to inquire whether different types of approaches to various categories and types of client statements are equally effective in eliciting continuance. The relevant question is whether the reinforcing or eliciting 49 effect of approach is relatively constant across differing types of interaction sequences. Similarly, is the inhibiting effect of avoidance constant across differing types of inter— action sequences. To investigate this question several analyses are necessary. First approach continuances were compared across the interpersonal categories of hostility, dependency, affilit ation, self-assertion, sex and vague. A Friedman two-way analysis of variance by ranks reveals no significant differ- ences. Secondly, the four conditions possible within each interpersonal category are compared for approach continuance. The conditions are: (A) continuance following an internal- izing approach after client affect expression (of hostility, dependency, etc.); (B) continuance following an externalizing approach after affect expression; (C) continuance following internalizing approach after non-affective client expression; and (D) continuance following externalizing approach after non-affective expression. Five analyses, one each for se- quences of hostility, dependency, affiliation, self-assertion and sex, reveal no significant differences (Friedman tests). For vague sequences only the first two conditions are possi- ble since by Operational definition vague is affective ex- pression; a sign test between these sequences is also not significant. There is no statistical support that approach is not a consistent elicitor of continuance of client ex- pression both across and within these six categories of client expression. 50 Identical tests compare various types of avoidance sequences. First, a Friedman test reveals significant differences for the inhibiting effect of avoidance upon hostility, dependency, affiliation, self—assertion, sex and vague sequences ()f: = 13.68, N = 44, d.f. = 5,.p <(.02). Avoidance has a differing inhibiting effect upon the con— tinuance of various types of client interpersonal expression. The ranks suggest that hostility is inhibited least by avoidance, while affiliation is inhibited most effectively. Secondly, the four conditions within each interpersonal cate- gory are compared. The conditions are the same as before, except they are now for avoidance rather than approach se— quences. Five Friedman tests and one sign test (for vague) are non—significant. Within the various interpersonal cate— gories, there is no statistical evidence that avoidance is not a consistent inhibitor of continued client expression. Hypothesis III predicts that when the therapist . initiates expression of an interpersonal category which was not mentioned in the preceding client statement, the client will tend to discuss that category in his succeeding re— sponse. Two types of analyses follow. First, the frequencies are computed for the proportion of instances when the client continues with the topic initiated by the therapist, pre- dicting that the clients will continue more often than not. Secondly, continuance after initiation is compared to 51 continuance after approach to a preceding client experssion, predicting no significant differences. Variables for initiation continuance derive in a fashion similar to the preceding analyses. For example, the continuance of hostility after initiation of hostility by the therapist is the proportion computed by dividing the frequency of hostility initiations into the frequency of sequences in which the client follows the initiation of hostility with further expression of hostility. The inter— judge reliability coefficients for initiation variables are presented in Table 7. Of the 18 variables the judges scored 17 reliably (p <;.05). The other correlation is based on an N of 3. Table 8 presents the first analysis. Clients do tend more Often than not to continue expression of topics introduced by the therapist in the preceding speech. (Sign tests p.‘<201). Only with statements of self-assertion is the hypothesis not confirmed. When the initiations of the various categories are dichotomized into internalizing and externalizing groups, the hypothesis is still confirmed for the internalizing initiations except for self-assertion again (sign tests .2 .(.01). For the externalizing initiations the hypothesis is confirmed only with expression of sex (p (1.01). However, externalizing initiations are less frequent; none of these 52 Table 7. Inter—judge reliability coefficients for Hypothesis III. All Initiation Initiation I Initiation E Variable Continuance Continuance Continuance g. N .3 y‘N .p N Hostility .702 18 .628 18 .985 6 Dependency .930 23 .937 23 .928 ll Affiliation .929 14 .861 13 1.000 4 Self-Assertion .518 16 .652 14 ' 1.000 3 Sex .954 13 .803 11 1.000 4 Vague .603 24 .897 23 .000* 3 *p.;>.05. All other coefficients: .2’ 4.05. Table 8. Continuance after initiation. Continuance PrOportion Sign Test p. Variables Median .50 (two-tailed) Hostility 75 32/37 .001 —Internalizing 80 30/37 .001 -Externalizing 100 11/14 n.s. Dependency 73 36/44 .001 -Internalizing 73 37/44 .001 —Externalizing 100 14/19 n.s Affiliation 100 21/27 .007 -Internalizing 100 5/25 .004 -Externalizing 50 3/5 n.s Self-Assertion 50 19/31 n.s —Internalizing 50 17/28 n.s -Externalizing 100 5/7 n.s Sex 86 24/27 .001 —Internalizing 100 22/25 .001 -Externalizing 100 10/10 .002 Vague 86 40/43 .001 -Internalizing 100 40/43 .001 —Externalizing* 100 4/4 n.s. *Indicates that the inter—judge reliability co— efficient is not significant (p ;>.05). 54 variables appeared in more than 19 of the interviews (range 3 to 19). Table 9 presents the comparison for the continuance effects of therapist initiation against therapist approach. The sign tests are mostLy nonsignificant Only 3 of 18 comparisons are significant (p <:.05). The comparisons for the continuance of vague statements and for the continuance of vague and affiliation after internalizing responses by the therapist indicated that initiation is a more powerful elicitor of continuance than is approach. Hypothesis III is clearly confirmed. 55 Table 9. Comparison of continued client expression after therapist initiation and approach Init. App.‘ P. Sign Test Variables Cont. Cont. Init. C.) .2- Compared Median Median App. C. (two—tailed) Hostility 75 71 24/36 n.s. —Internalizing 80 70 22/33 n.s. —Externalizing 100 75 8/12 n.s. Dependency 73 60 28/44 n.s. -Internalizing 73 64 25/41 n.s. —Externalizing 100 63 10/16 n.s. Affiliation 100 64 16/23 n.s. -Internalizing 100 67 16/21 .026 —Externalizing* 50 100 0/1 n.s. Self—Assertion 50 67 14/27 n.s. —Internalizing 50 78 13/26 n.s. —Externalizing 100 88 2/2 n.s. Sex 86 80 13/22 n.s. —Internalizing 100 79 12/22 n.s. —Externalizing 100 100 5/7 n.s. Vague 86 67 31/42 .003 —Internalizing 100 70 31/42 .003 —Externalizing* 100 67 2/2 n.s. *Indicates that the inter—judge reliability co— efficient for one of the variables compared is not signifi— cant (p( .05) . VI . DISCUSSION Psychotherapists in the present study participated in the selection of their clients since they had access to intake interview reports. If they felt any dislike toward the client on the basis of these notes, or if they felt an— other therapist could work more adequately with a particular client or type of psychological problem, they were not obligated to see an assigned client. In addition the therapists and clients are not representative of therapists and clients in general because they are all associated with a particular university. Those therapists who constitute the interne and practicum groups are all supervised by the staff therapists. A similar method of treatment, including the initial approach, is quite probable. Since the clients are all college undergraduates and self-referred, they do not represent psychotherapy clients in general. Therefore, generalization of these findings to psychotherapists and clients in general is not warranted. On the other hand the study offers a point of departure for further analyses of psychotherapy as well as a methodology for the molecular analysis of interaction process. 56 57 Interfijudge reliability: An implication of this study which is worthy of note by itself is that two inde— pendent judges can achieve a high degree of scoring relia- bility using this scoring manual. Clinical judgments and diagnoses are notorious for lack of independent inter-judge agreement. Here it is evident that clinicians who train themselves in the use of a rather complex scoring instrument can become reliable judges not only for distinct client and therapist variables but also for three unit interaction se— quences. Since the first two units of the interaction se- quence are judged for both a cognitive quality (client inter— personal category and therapist approach—avoidance) and an affective quality (client affect-no affect and therapist internalizing-externalizing responses), the scoring relia— bility of the interaction sequences demonstrates support for the utility of this approach to researching psychotherapeutic interactions. Kamerschen (1965) presents a more detailed discussion of these scoring reliabilities and their impli- cations for further research. Client affect and internalizing and externalizing responses: If therapists include an "internalizing" com— ponent in their verbal interactions with clients, the clients i tend to respond with affective expression. On the other hand, if therapists avoid internalizing statements_and focus upon factors external to the client, the clients are less 58 likely to respond with affective expression. This hypothesis is clearly supported by the data. One of the difficulties often encountered with psychotherapy clients is the frequency with which they tend to experience their problems as being in the environment, rather than as being internal to themselves. Kell and Mueller (in press) indicate how clients may externalize their problems as a defense against the anxiety which comes in dealing with the problems as internal to themselves and this defense resists client progress. One effective way in which clients manage this defense is by attributing the source of their diffi- culties, and even their feelings to the environ- ment. . . . Realistically speaking, it is unlikely that parents, for'instance, can be changed easily. Yet the battle which may have gone on for years is hard to give up, since the alternative is to change oneself which of necessity inVOlves pain, anxiety, and much that is unknown. The greateSt unknown is, of course, whether the change in one's self will be more satisfying in terms of the ensuing new kinds of responses from others. we believe, however, that for many clients the decision must be made, usually with the counSelOr's help, that this risk ' must be taken . . . we believe such internal change can best occur by acknow1edging, internalizing and experiencing that the feelings a person has are truly his own. (Chapter III) Since a therapist internalizing response is a relatively consistent elicitor of client affect, such elicitors become a significant,variable in the therapeutic process. The data demonstrate, unequivocally, that therapists do influence the client to talk about himself and to express his feelings and his reactions to impinging 59 stimuli: a commonly accepted condition if the client is to benefit from treatment. The order effect of the various sequential conditions highlights this assertion. As.might be expected, the condition of client affect followed by an internalizing response elicits further affect most fre- quently and the condition of a no affect unit followed by an externalizing response inhibits affective expression most severely. But the revealing finding appears in the superi— ority of the condition, no client affect followed by therapist internalizing response, over the condition, client affect.followed by externalizing responses, as an elicitor of further affective expression; the therapist's response is more powerful than the client's own preceding statement as a stimulus to provoke a client to reveal his inner feelings. Here is support for the assertion that psychotherapists are instrumental in activating client's conflicts and anxieties so that in a therapeutic way they can help clients to change their feelings and consequent behavior. The failure to find the affect and internalizing— externalizing variables related to improvement ratings does not necessarily lessen their significance. Psychotherapy is both a complex and extended form of treatment. First inter— views with previously screened clients who are presumed to be well motivated and who represent a relatively homogeneous population may not reveal the significant differences in af— fective expression which relates to successful outcome. In 60 addition, a therapist's rating at termination provides only a crude and subjective criterion for improvement. A defini— tive test of this exploratory hypothesis rests with improved measures for therapeutic outcomes and analyses of full psychotherapies. Approach, avoidance and initiation effects: In this study the prediction that approach responses by the therapist elicit further discussion by the client while avoidance re— sponses inhibit further discussion is clearly confirmed for a series of categories of verbal expression. The results replicate the findings of Bandura e£_§l. (1960), Barnes (1963), Caracena (1963), Kopplin (1963), Lerman (1963), Schuldt (1964), Varble (1964), and Winder e§_al. (1962), for the approach—avoidance effects upon dependency, hostility and sex. In addition, these results extend this parameter to statements of affiliation, self-assertion and vague af— fective expressions. Since the eliciting dynamics of the approach-avoidance dichotomy consistently interact with a series of variables commonly used to describe interpersonal behavior, this dichotomy offers one parsimonious method for analyzing the psychotherapeutic process. Initiation also serves as a particularly salient variable to elicit discussion of a particular topic. There is evidence that it may be a more powerful elicitor than ap— proach, for the proportion of interviews on which continuance 61 after initiation is greater than continuance after approach is equal or greater than .5 on all six interpersonal categories. The lack of significant differences for the types of approach sequences both across interpersonal categories and within categories accent approach as the parsimonious variable for stimulating clients to talk about interpersonal behavior. At least there is no evidence that internalizing or externalizing approaches significantly differ in the elicitation of such expression. Nor is there evidence that approach works differently following affective or non- affective expression of these topics. within the limitations of this research approach is a relatively stable and con— sistent elicitor. The same conclusion follows for avoidance as an in- hibitor of client expression within interpersonal categories. Internalizing and externalizing avoidances whether they follow affective or non-affective expression reveal no sig— nificant differences. Only when avoidance is compared across the inter— personal categories do significant differences appear. Ex- pressions of hostility are inhibited least by avoidance while expressions of affiliation are inhibited most ef- fectively. One explanation of this difference is that peOple receive relatively little encouragement to express hostility in ordinary interactions. So, if psychotherapists encourage more expression of hostility than people in 62 general do, clients feel a significantly greater freedom to express within treatment a drive whose strength has built up because of inhibition. The salient feature to the client then is the therapist's tolerance rather than prohibition of hostile expression. In addition these clients are adoles- cents who usually are not encouraged by authority figures to express strong aggressive drives. Thus, they are more apt to verbalize continued hostility in the presence of a psycho- therapist who often elicits their feelings of hostility. In contrast avoidance toward affiliation within psychotherapy may be more salient than approach since ordinary conversations often encourage affiliative ex— pression. Both explanations account for the present findings. Simply stated, clients see therapists as more interested in hostility and less interested in affiliation compared to people in general. This difference might be particularly salient in first interviews. Comparison of approach and internalizing responses: Since the two dichotomies of psychotherapist behavior in— vestigated in this study influence different dimensions of verbal behavior, a comparison and suggested integration of their effects is relevant. Since psychotherapy is a verbal method of treatment, client benefit is dependent upon af— fective expression by the client about his conflicts and anxieties. Therefore, if a therapist needs to explore with 63 his client a particular dimension of interpersonal behavior, he will do well to initiate discussion in this area and to respond with approaches whenever his client speaks about such behavior. In addition, if he feels that it is neces— sary for the client to speak affectively if psychotherapy is to help alleviate his problem in living, then the therapist does well to use internalizing responses which elicit ex- pressions of clients'feelings, i.e., tensions, anxieties, guilt and frustrations. Since mere discussion Of an area without affective involvement by client or general ex- pression of affect without focus upon the areas of diffi— culty will likely provide little benefit to the client, both types of therapist responses are crucial. Research with this scoring instrument can investi- gate both dimensions simultaneously. Because both internal- izing and approach responses are consistent elicitors for differing dimensions of verbal behavior, we would hypothesize that the appropriate internalizing approaches would elicft affective discussion of the various interpersonal categories equally well. This simply combines the criteria for hy— potheses I and II. Such an analysis of the present data is planned, but conclusive research will depend upon replication. Implications for further research: Psychotherapy is the interaction of two peOple, both of whom focus upon the 64 client's conflicts, anxieties, frustrations, etc. The scoring manual developed in this research provides a promising method for analysis of the moment to moment psycho- therapeutic process. Because the present study initiates its use and refines its definitions through the process of training the judges, it does not use all the discriminations provided in the manual. Now since adequate scoring relia— bility for the major dimensions is demonstrated, an in— tensified use of the intrapsychic states and categories of therapeutic relevance is appropriate. Use of these di- mensions offers promise for understanding the process of psychotherapy. Anxiety, guilt, frustration—hurt, frustration— aggression and satisfaction are critical variables in the process for they express the different ways people react to significant experiences. Within therapy certain discussions are clearly more relevant than others. Variations along the relevancy dimension may explain differences in outcome. What types of therapist behavior encourage more relevant client discussion? Secondly, the use of the manual can be extended to research full psychotherapies. Do frequencies of these variables change over the course of treatment? For example, does expression of anxiety in regard to conflict areas di— minish over time? Do expressions of satisfaction in various interpersonal areas increase? Can points of excessive re— sistance and critical incidents be detected by noting changes 65 in the eliciting effect of the therapist's responses? How do successful and unsuccessful treatments vary? Can they be predicted early? Changes in affective expression and a de— crease in internalizing responses may indicate deteriorating relations between the participants. How do clients steer therapists away from conflict and painful areas? Thirdly, this method has grown out of a series of studies at one university counseling center. Comparable analyses with other populations of therapists and clients is in order. Will older clients react differently? Will these elicitors work differently for therapists of different orientations? Finally, how do these variables relate to various personality characteristics of clients and therapists? Here the possibilities are infinite. VII . SUMMARY .A mutual elicitation effect occurs in the inter— action between a client and his psychotherapist. The client enters the relationship by expressing a need for assistance in coping with his problems in living; the psychotherapist responds in turn by helping the client to express in the therapeutic relationship all the essential elements of his conflicts. The subsequent interactiOn between the partici- pants involves not only the choices of content in the inter— views but also the sequences and modes of expression. This study examines the effect of therapist's re- sponses of approach and avoidance upon he clients' con- tinuing statements of hostility, dependency, affiliation, self-assertion, sex and vague affect. It also examines the effect of therapists' responses which are designed to elicit affective expression by the clients. Hypotheses, in general derived from social learning theory, state that when thera— pists approach clients' statements, clients continue the same tOpic; however, when therapists' avoid, clients discon- tinue the topic. A further hypothesis states that therapist responses which focus upon the client's self—concept, his feelings and reactions to impinging stimuli will elicit affective 66 67 expressions from the client; on the other hand, therapist responses which focus upon something "outside" the client will elicit non-affective client statements. The elici— tation model is reversed to state that expression of client affect elicits therapist responses which focus upon clients' internalized feelings while non-affective client statements elicit therapist responses which do not focus on client feelings. A content analysis is made of 46 taperecorded initial psychotherapeutic interviews at a university counsel- ing center; the clients are treated by 31 psychotherapists at three levels of experience: doctoral, interne, and be— ginning practicum students. Client—therapist interactions are coded by a scoring manual developed for the study. Client statements are coded for expressions of hostility, de- pendency, affiliation, self-assertion, sex and vague affect. Each client expression is also scored for internalized af— fect, and for the subject and object of the behavior de- scribed. Therapist responses are scored for approach, avoidance and initiation of topics and for elicitation of internalized affective expression. The basic unit of analy— sis is the interaction sequence: client statement, therapist response and succeeding client response. The results follow: 1. Clients are more likely to respond with affective responses fOllowing therapist elicitation of internalized 68 feeling compared with therapist elicitation of externalized material. 2. Clients are more likely to respond affectively to therapist elicitation of internalized feeling following pre- vious client non-affective statements compared to therapist elicitation of externalized material following previous client affective statements. 3. Therapists are likely to follow client affective ex- pression compared to non-affective client expression with further elicitation of internalized feeling. ~4. Therapists'ratings of successful or unsuccessful treatment at termination fail to relate to the percentages Of client affect or therapist elicitation of affect in the first interview. 5. Clients are likely to continue to express hostility, dependency, affiliation, self-assertion, sex or vague affect after approach by the therapist; they are likely to change the topic after avoidance by the therapist. ,6. The presence or absence of affect in the client's previous statement, and the presence or absence of elici— tation of affect in the therapist's approach response do not significantly effect the percentages of continuance after ap- proach; the same conclusion holds for continuance after avoidance. 7. Clients are likely to follow therapist initiation of hostility, dependency, affiliation, self—assertion, sex or _ vague affect with continuing expression of the topic. 69 Implications for further process research in psycho— therapy are offered in light of both the substantive results and the high degree of inter—judge reliability attained with the scoring manual. REFERENCES Bandura, A., Lipsher, D., and Miller, P.E. Psychotherapists' approach-avoidance reactions to patients' expressions of hostility. J. Consult. Psychol., 1960, 24, 1-8. Barnes, E. J. Psychotherapists' conflicts, defense prefer- ences, and verbal reactions to certain classes of client expressions. Unpublished doctoral disser— tation, Michigan State Univ., 1963. Butler, J., Rice L., and Wagstaff, A. On the naturalistic definition of variables: an analogue of clinical analysis. In H. Strupp & L. Luborsky (Eds.), Research in Psychotherapy, Vol. II, Washington: American Psychological Association, 1962. Caracena, P. Verbal reinforcement of client dependency in the initial stage of psychotherapy. Unpublished doctoral dissertation, Michigan State Univ., 1963. Kamerschen, K. Inter—judge reliabilities and selected client-therapist variables: a content analysis of initial psychotherapeutic interviews, Unpublished master's thesis, Michigan State Univ., 1965. Kell, B. L., and Mueller, W. J. Impact and change: A Study of Counseling Relationships. New York: Appleton— Century—Crofts, In Press. Kopplin, D. A. Hostility of patients and psychotherapists' approach—avoidance responses in the initial stage of psychotherapy. Unpublished master's thesis, Michigan State Univ., 1963. Leary, T. Interpersonal Diagnosis of Personality. New York: Ronald Press, 1957. Lerman, H. A study of some effects of the therapist's person— ality and behavior and of the client's reactions in psychotherapy. Unpublished doctoral dissertation, Michigan State Univ., 1963. 70 71 Mills, D. Liking as a therapist variable in the psychothera- peutic interaction. Unpublished doctoral disser— tation, Michigan State Univ., 1964. Schuldt, w. J. PsychotherapiSts"approach avoidance re- actions and clients' expressions of dependency: A longitudinal analysis. Unpublished doctoral disser— tation, Michigan State Univ., 1964. Sullivan, H. S. The Interpersonal Theory of Psychiatry. New York: W. W. Norton, 1953. Varble, D. L. An exploratory analysis of hostility in psychotherapy. Unpublished doctoral dissertation, Michigan State Univ., 1964. Winder, C. L., Ahmad, F. A., Bandura, A., and Rau, L. C. Dependency of patients, psychotherapists' responses, and aspects of psychotherapy. J. Consult. Psychol., 1962, 26, 129-134. APPENDIX A SCORING MANUAL (The categories of dependency, hostility, approach and avoidance are a modification of manuals used in the follow— ing studies: Winder, C. L., Ahmad, F. Z., Bandura, A., & Rau, L. C., Dependency of patients, psychotherapists' re- sponses, and aspects of psychotherapy: J. Consult. Psychol., 1962, 26, 129—134; Bandura, A., Lipsher, D. H., & Miller, P. E., Psychotherapists' approach—avoidance reactions to patients' expressions of hostility, J. Consult. Psychol., 1960, 24, 1-8. The definition for internalizing and externalizing responses is drawn in part from the section on "Functional Level of Response" in Butler, John M., Rice, Laura N., & Wagstaff, Alice K., On the naturalistic defi- nition of variables: an analogue of clinical analysis, In Hans H. Strupp & Lester Luborsky (Eds.), Research in Psycho— therapy, Vol. II, Washington: American Psychological Associ— ation, 1962.) I. Scoring Unit and Interaction Sequence. A. Definition. A unit is the total verbalization of one speaker bounded by the preceding and succeed- ing speeches of the other speaker with the ex- ception of interruptions. There are three types of scoring units: the "client statement" (C St), the "therapist response" (T R), and the "client response" (C R). A sequence of these three units composes an "interaction se- quence." The client response not only completes the first interaction sequence but also initiates the next sequence and thereby becomes a new client statement. Example: C. I can't understand how you can stand me. (C St) T. You seem to be very aware of my feelings. (T R) C. I am always sensitive to your feelings. (C R) A-2 B. Pauses. If a speaker pauses between statements, his statements are not scored as separate units. The verbalization before and after the pause is considered one unit. Therapist silences are scored as prescribed under III,A,2,e, of this manual. There are no client silences in this system. C. Interrpptions. Statements of either therapist or client which interrupt the other speaker will be scored only if the content and/or temporal conti— nuity of the other speaker is altered by the interruption. Then the interrupting verbalization becomes another unit and is scored. A non—scored interruption is never taken into account/in the continuation of the other speaker. Interruption scored as one unit: C. I asked him to help me and—- T. Why was that? C. ——he refused to even try. Non—interruption scored as 3 units, one inter- action sequence: C. I asked him to help me and—- T. Why was that? C. I don't know. Verbalizations such as "um hmm," "yes," "I see" are ignored in scoring unless they are so strongly stated as to convey more than a listening or re— ceptive attitude. Client requests for the therapist to repeat his response are considered interruptions and are not scored. Therapists' requests of this sort are scored as units (as approach or avoidance of the client statement) except for simple requests to the client to repeat a few words. II. Categories of Client Statements A. Interpersonal Categories: There are seven major categories: Dependency, Hostility, Affiliation, Self-assertion, Sex, Vague, and Other» They are A-3 scored as exhaustive categories. All discrimi— nations are made on the basis of what is explicitly verbalized by the speaker in the unit under con— sideration. One statement or unit may be scored for several categories. 1. Hostility (Hos): Hostility statements include description or expression of unfavorable, critical, Sarcastic, depreciatory remarks; oppositional attitudes; antagonism, argument, expression of dislike, disagreement, resent- ment, resistance, irritation, annoyance, anger; expression of aggression and punitive behavior, and aggressive domination. Hostility which the client directs at himself is not scored as hostility; it is scored as vague. The following examples group under a series of types of hostility. These types aid in identification of hostility statements, but are not differentiated in the scoring. a. Anger: expresses or describes feelings or actions which indicates anger. C. I'm just plain mad! (Hos;N;C;O;1)* C. I just couldn't think—-I was so angry. (Hos;N;C;O;1) C. My uncle was furious at my aunt. (HOS;-70;O75) b. Dislike: expresses dislike or describes actions which would usually indicate dislike. C. I just don't get interested in them and would rather be somewhere else. (Hos;N;C;O;l) C. I've never ever felt I liked them and I don't suspect I ever will. (Hos;N;C;O;l) *Complete scoring of examples is listed to aid in training coders. The sequence is: interpersonal category; intrapsychic state(s); subject(s); object(s); and thera— peutic relevance. When a statement is scored for two inter— personal categories, two separate scorings are listed. A-4 C. He hates editorials. (Hos;-;O;O;5) Resentment: expresses or describes a per— sistent negative attitude which does or might change to anger on a specific occasion. C. They are so smug; I go cold whenever I think about having to listen to their 'our dog' and 'our son.’ Boy! (Hos;N;C;O;l) C. I was always jealous of my brother; he was their favorite. (Hos;N;C;H;2) Antagonism: expresses or describes an— tipathy or enmity. C. It's really nothing definite, but we always seem at odds somehow. (Hos; UnS;C;0;4) C. There is always this feeling of be— ing enemies. (Hos;N;C;O;l) - Opposition: expresses or describes oppo— sitional feelings or behavior. C. If he wants to do one thing, I want to do another. (Hos;N;C;O;l) C. It always seems she is against things. She is even against things she wants. (Hos;-;O;O;5) C. No, I don't feel that way (in re— sponse to T's assertion). (Hos;N;C; T71) Critical attitudes: expresses negative evaluations or describes actions which usually imply negative evaluations. C. If I don't think the actors are doing very well, I just get up and walk out. (Hos;N;C;O;l) C. There is something to be critical about in almost everything anyone says or does. (Hos;Uns;C;O;6) A-S g. Aggressive actions: acts so as to hurt another person or persons either physically or psychologically. C. He deserves to suffer and I'm making it that way every way I can. (Hos; N;C;O;1) C. I can remember Mother saying: 'We slap those little hands to make it hurt.’ (Hos;UnS;M;C;3) Dependency (Dep): Dependency statements in— clude expressions of needs to depend on some— one; let someone else take the initiative; to be told what to do; to be helped; to be cured by an outside agent; description of dependent behavior; approval seeking and concern about disapproval; dependent agreement with others; accepting nurturant actions from others; making personal security contingent on another; expresses concern about parental plans and expectations regarding the client; expresses need to confide in, write to or communicate with parents; includes discussion of relation— ship between the client and therapist. The types listed below aid in identification, but are not differentiated in scoring. a. Problem Description: States problem in coming to therapy; gives reason for seek— ing help; expresses a dependent status or a general concern about dependency. C. I wanted to be more sure of myself. That's why I came. (Dep;N;C;T;1) C. I wanted to talk over with you my reasons for dropping out of school next quarter. (Dep;N;C;T;l) C. Part of the reason I'm here is that everything's all fouled up at home. (Dep;N;C;T;l) C. I depend on her—~am tied to her. (Dep7N7C;O;1) C. I want to be babied and comforted. (Dep7N7C:O:l) A—6 Help-seeking: Asks for help; reports ask— ing for help; describes help-seeking be- havior; describes going to see a teacher, therapist or other professional. C. I asked him to help me out in this situation. (Dep;Uns;C;O;4) C. I try to do it when he can see it's too hard for me. (Dep;Uns;C;O;4) Approval-seeking: Requests approval or ac— ceptance; asks if something has the ap— proval of another; reports having dOne so with others; tries to please another; con— fides in parents for support or approval; expresses fear of "hurting" parents and superiors; asks for or needs support or security; seeks acceptance or approval by achievement; expresses or describes some activity geared to meet his need. C. I hope you will tell me if that is what you want. (Dep;N;C;T;l) C. If there was any homework, I did it so Dad would know I was studying like a good girl. (Dep;N;C;F;2) C. Is it all right if I talk about my girl's problem? (Dep;N;C;T;l) C. That's the way I see it, is that wrong? (Dep;N;C;T;l) C. I asked him if I were doing the right thing. (Dep;N;C;O;2) Succorance: A wish to be taken care of: to seek another's help when troubled, de— pressed or hurt; to seek encouragement frOm others; to have others be sympathetic and understanding about personal problems; to go home to see one's parents, feel close to one's parents in the sense of be— ing loved; to receive nurturant behavior from others (especially parents, authori— ties and therapist). A-7 C. It looks as if it'll be another lonely weekend, and who's going to cheer me up? (Dep;FH;C;O;l) C. Instead of studying, I go talk with the guys about my problems. (Dep; Uns;C;O;4) C. I went home just for the day; I told my mother to make a home cooked meal because that is what I was coming home for. (Dep;Uns;C;M;4) C. My father isn't rich, but he's putting me through college, and he gives me all the money I want; he's always given me everything I've ever wanted. (Dep;Sat;C;F;l) Information-seeking: Asks for cognitive, factual or evaluative information; ex— presses a desire for information from Others; arranges to be the recipient of information. C. I asked him why he thought a girl might do something like that. (Dep; Uns;C;O;4) C. I came over here to see about tests you have to offer. I want to know what they say. (Dep;Uns;C;T;4) I'm planning to change my major. I;d like to know how to do it. (Dep; N;C;T;4) Dependent agreement with another: Responds with dependent agreement with others,’ readily accepts the therapist's reflection; often illustrates therapist's remarks with eXamples, draws a parallel example to indi— cate agreement; may accept preceding state— ment on authority. C. Oh, yes! You're absolutely right about that. (Dep;Uns;C;T;4) C. Immediately I felt he was right and I had never thought about it that way. (Dep;N;C;O;l) A-8 g. Concern about disapproval: Expresses fear, concern, or unusual sensitivity about disapproval of others, describes unusual distress about an instance of disapproval, insecurity, or lack of support. -Little or no action is taken to do something about the concern. C. She didn't ever say a thing but I kept on wondering what she doesn't like about me. (Dep;N;C;O;l) 0. My parents will be so upset about my grades, I don't even want to go home. (Dep;N;C7MF71) C. It seems like I always expect I won't be liked. (Dep;FH;C;O;l) C. I can't understand how you can stand me when I smoke. (Dep;N;C;T;l) h. Initiative—seeking: Asks the therapist or others to initiate action, to take the responsibility for starting something (to start discussion, determine the topic); arranges to be a recipient of therapist's initiative; may solicit suggestions. C. Why dOn't you say what we should talk about now? (Dep;Uns;C;T;4) C. If you think I should keep on a more definite track, you should tell me. (Dep;Uns;C;T;4) C. I got my advisor to pick my courses for next term. (Dep;N;C;O;2) C. Tell me what to do in these circum— stances. (Dep;N;C;T;l) Affiliation (Aff): Affiliation statements in- clude description or expression of needs for- appreciation of or concern about friendships, group activities, affectionate relationships, loyalty to friends, sharing with others; in— cludes expression of confiding with or Sharing experiences and feelings with peers or sib— ' lings. The focus is upon social relationships A-9 where the participants are broadly social equals. Relationships where the individual clearly receives nurturant behavior from others, or clearly manifests dependent behavior, are scored as dependency rather than as affiliation. Social behavior related to dating is generally scored as sex; to be scored here there must be expression of activity with other people, such as double dating, card playing. The following examples group under a series of types of affiliation which aid in the scoring, although not differentiated in scoring. a. Company seeking: Describes or expresses a need or wish to be with people; describes making arrangements to do so; describes ef- forts to be with others; talks about being with others; needs to do things with friends rather than alone; seeks the at- tention of peers and siblings. C. I only joined so I could be in a . group. (Aff;Uns;C;O;4) C. We try to see if other kids we know will be going. (Aff;Uns;C;O;4) C. I used to spend a lot of time over a coke at the union. (Aff;Uns;C;O;4) C. Last spring, I used to go out drink- ing occassionally. (Aff;Uns;C;O;4) C. we eat almost all our meals together and it's nice that way. (Aff;Sat;C; P71) . C. To be with other people, oh, I don't know, I could be with myself, it wouldn't make any difference. I don't care. (Aff;Anx;C;O;l) b. Friendship seeking: Describes efforts to make friends; expresses need to haVe as many friends as possible; expresses a de— sire to be popular among peers. C. I like peOple to want me as their friend. (Aff;N;C;O;1) A-lO C. Whenever I move to a new dorm, I make an effort to get to know the people around me. (Aff;Uns;C;P;4) c. Affection: Describes or expresses needs for and appreciation of relationships of love and affection; affectionate behavior where all participants generally give and receive alike; confides or shares feelings and experiences with peers or siblings; expressed feelings for entering into af— fectionate relationships; needs for feel— ings of strong liking, giving affection and accepting others. C. My roommate and I get along very well. (Aff;Sat;C;O;1) C. I like people to like me. (Aff;N;C;O;1) C. I like even the unpopular peOple; I like people for what they are, not just because they are popular. (Aff;N;Cr071) d. Loyalty and admiration: Describes or ex- presses a need or desire to help friends, relatives and associates; keeping up freinds through letters and telephone calls; holding someone in high regard with respect and appreciation; doing something positive for or with another person. C. I always try to help my friends out of a bind. (Aff;N;C;P;1) C. Last night I tutored Jane in her math. (Aff;Uns;C;P74) C. I write so many letters to friends I use tons of stationery. (Aff;Uns; C;O;4) C. I admire Jean because she has so many wonderful qualities. (Aff;N;C;P;1) 4. Self—assertion (SA): Self—assertion includes expression of needs to be independent, achieve- ing, self-assertive, mature, ambitious, A-ll competitive and adult; standing up for one's rights; expressing an Opinion; accomplishing difficult tasks; being respected as a success. The following examples group under a series Of type which aid in the scoring, though not individually scored. a. Achievement: Expressions of needs to do one's best; to be successful; to accomplish tasks requiring skill and effort; to ac— complish something of great significance; to solve problems and puzzles; to express concern about or lack of self—confidence; express concern about academics and study— ing; expresses desire to be looked upon as a success or authority. C. I'm sure I can pull a better grade in the course. (SA;N;C;O;1) C. I want to get a 4—point. (SA;N;C;O;1) C. I love to work crossword puzzles. (SA;Sat;C;O;l) C. Preparing gourmet foods are such a challenge for me. (SA;Uns;C;O;4) Independence: Expression of needs to be independent, adult and mature; saying "no" when one has to; planning and executing behavior where one acts on his own; making decisions independent of others; to act withOut regard for what others may think; to be able to come and go as desired; to do things that are unconventional. C. I just had to tell him I thought it was better if he did it himself. (SA;N;C;O;2) C. After thinking about it for a while, I figured out how to solve our dilemma. (SA;Uns;C;O;4) C. I'm going to arrange it so mother can't move in with me. (SA;Uns;C;M;3) C. If I want to grow a beard, I'll grow a beard. (SA;N;C;O;1) A-12 C. I had to be home by 11:00. I didn't want to. (SA;FH;C;O;2) c. Self—assertiveness: Expression of needs to be competitive, ambitious, assertive;‘ standing up for one's rights, defending against attack; overcoming; to give a personal opinion; to articulate ideas, plans and goals; to stand up to those in positions of authority. C. I can only achieve growth by meeting new situations. (SA;Uns;C;076) C. I just didn't think he was the best person for that job and said so. (SA;N;C;O;2) C. I used to be afraid to assert myself to my mother. (SA;Anx;C;M;2) C. He didn't want my opinion but I told him anyhow. (SA;N;C;O;2) C. I told my roommate it was her turn to clean the room. (SA;Uns;C;P;4) Sexuality (Sex): Statements of sexuality in— clude all statements referring to the positive approach component of the sexual drive; direct expression Of sexual needs and wishes, de— scription of sexual attraction and arousal; sexual actiVity; planning for sexual satis— faction; courtship and dating among unmarried people where the erotic element is present al- though it may be institutionalized; deScrip— tions of behavior or wishes to form friend— ships with someOne of the opposite sex; wishes to be regarded as sexually attractive by members of the Opposite sex; description of homosexual feelings and sexual perversions; descriptions of masturbation; discussion of normal sex education. The following examples group under a series of types which aid in identification. a. Heterosexual behavior: Includes expression of sexual intercourse and related behavior and feelings; discussion of petting; ex— pression of sexual excitement. A-13 C. He wanted to have sexual relations with me. (Sex;Uns;P;C;4) C. I like to make out but I'm not sure where to stop. (Sex;Anx;C:P;l) C. Physically, we are very compatible; our relations are tremendously satisfying. (Sex;Sat;C;P;l) Dating: Discussion of wishes to go out with members of the Opposite sex, to en— gage in social activities with a member of the Opposite sex; being in love with some— one Of the opposite sex. C. I hOpe he calls me for Saturday night. (SeX7N7C7P;l) C. Jim and I went with the other couples to the party. (Sex;Uns;C;P;4) (Aff;Uns;CP;P;4) C. I just met the greatest boy the other night and he's asked me out. (SeX;Sat;C;P;2) Homosexuality and perversions: Discussions of homosexual feelings and behavior; dis— cussion of sexual perversions. C. I have a very liberal attitude about sex; what people do privately is their own business. (Sex;Uns;C;0;6) C. They were saying she was a Lesbian, and so they kind of avoid her. (Sex;-7O7O:5) Autoerotic behavior: Descriptions of masturbation; discussion about mastur— bation and autoerotic behavior. C. I used to feel masturbation was very bad, but I don't anymore. (SeX7Guilt7C7C72) C. I used to wonder if anyone else masturbated. (Sex;Uns;C;O;4) C. I guess I masturbate mostly to re— lieve tension. (Sex;N;C;C;l) A-14 e. Generalized discussion of sexuality: In— cludes discussion of normal sex education; general discussion about sex; discussion of needs to be regarded as physically at- tractive by those of the opposite sex; con- cern about sexual role and identity; in— cludes discussion of menstruation. C. I am a girl, there is nothing I can do about it. (Sex;FH;C;C;l) C. Tell me, does this make me less manly? (Sex;Anx;C;O;l) (Dep;N;C;T;l) C. Our bull sessions frequently revolve around sex. (Sex;Uns;C;O;4) C. When I first menstruated, I was scared a little. (Sex;Anx;C;O;2) Vague affective expressions (Vag): Vague in— cludes affective expressions which cannot be scored in one of the previous categories but which have a reference to some affective intra- psychic or interpersonal need of the client. This category is not scored if the feelings are related to a scored interpersonal category, unless there is a clear indication of some vague intrapsychic state as depression, anxiety, euphoria, etc. which the client doesn't connect to any other need. Examples group under several subtypes to facilitate scoring. a. Generalized anxiety: Includes all psycho- logical and somatic expressions of anxiety which are not related explicitly to a' major category; general "free floating" anxiety and guilt. C. I feel scared about dying. (Vag;Anx;C;O;l) C. I just feel Very tense and anxious. (Vag;Anx;C;O;l) C. I dream of being chased and scared. (Vag;Anx;C;O;l) A-15 C. I often feel pessimistic about the future. (Vag7Anx7C707l) C. I hear about couples getting married and then one of them is killed on the honeymoon. I worry about the lives of peOple. You never know. (Vag;Anx;C;O;l) b. Undefined feeling: Includes expression of a feeling, condition or concern of the client which is not related to one of the five major drives. C. I just feel good today. (Vag;Sat7C;O;l) C. Right now I feel pretty good. (Vag;Sat;C;O;l) C. Very often I just get real depressed about everything. (Vag;Anx;C;O;l) C. I don't know why I do this. (Va97N:C:O;l) C. I find myself reluctant to tell you how I feel about it. (Vag;Anx;C;T;l) Other (0th): Includes all content of client's Verbalizations not classified as one of the previous six categories. Included here are many topics of disCussion which are not sig— nificantly interpersOnal Or affective. Often the items are actions, events, facts, stereo- typed comments. Items scored in this category usually will have a relevance score of 4, 5, or 6. (See II, D) When other is integral to another category, do not score. To score other, the other state- ments must be distinct from the discussion of another major category. C. I grew up in Chicago. (Oth7-7C7074) C. Everyone ought to have a liberal education. (Oth;-;C;O;6) A-16 C. My aunt went to Smith. (Oth;-;M;O;5) Client Intra-psychic States: For each major inter— personal category that is scored for a single client speech except for the category "other," a coding is also given for the intra-psychic state of the client. The following eight categories are exhaustive: need, anxiety, quilt, frustration- hurt, frustration-aggression, satisfaction, simple agreement-disagreement, and unstated. Intra— psychic states for other individuals or groups mentioned in the client speech are not scored. One or more of the intrapsychic states can be sCored for a single major interpersonal category (excluding "other"). Note: When need, guilt, anxiety, frustration— aggression or satisfaction are scored, the rele— vance category usually is l or 2. (cf. II, D.) When "unstated" is scored, the relevance category usually is 3, 4, 5 or 6. When simple agreement- disagreement is scored, no relevance category is scored. 1. Simple Need (N): Includes expression of an interpersonal need or drive; direct expression of the positive Or approach component of the drive or wish; description of plans, or activi- ty which will satisfy the need. 'When guilt, anxiety, frustration-hurt, frustration- aggression, Or satisfaction can be scored, this category is usually not scored because the other categories are considered to include the existence of the interpersonal need. However, to score this category, there must be some ex- pression of feeling, affect or analysis of be— havior in regard to the client's needs. C. I like people to like me, to be my friends. (Aff;N;C;O;l) C. I depend on her, am tied to her. (Dep;N;C;Orl) C. I always get this terrible impression youlre trying to make me angry. (This is hostility need, not frustration, since therapist is not preventing or blocking his need to be angry.) (Hos;N;C7T71) A-l7 Anxiety (Anx): Includes expressions of fear and anxiety in regard to a major category; ex— pressions of nervousness, irrational fears, phobias, compulsions, hopelessness, confusion, helplessness, internal conflict, avoidance be— havior, denial of the interpersonal need, nega- tive attitude toward the need, feelings of in— adequacy; somatic symptoms; worry about future disappointment. C. It is hard for me to take things serious- ly, to work without a whole lOt of pres— sure on me,and yet I certainly don't en— joy it. (SA;Anx;C;O;l) C. To be with other people, oh, I don't know, I could be with myself and it wouldn't make any difference. I don't care. (Aff;Anx;C;O;l) C. My money just slips away; I get so irri— tated with myself why I forgot to do this. (Vag;Anx;C;C;l) (Not Hos.) Guilt (Gu): Includes expressions of guilt and self-depreciating behavior; acCepting blame when things do not go right; needing punish- ment for wrong doing; needing to confess errors. C. I resent the way I'm so observant cuz if they don't know, I wish I Was like them and didn't bother to care about little things like that. (SA;Anx,Gu;C;0;l) C. I know how I feel, and I know how other people feel, and I feel angry that I feel this way, but I can't help it. (Vag7Gu;C;O:l) C. It makes me feel bad because I want to do good. (SA;Gu;C;O;l) C. I feel like I disappointed my father very badly. (Dep7Gu;C;F;1) Frustration-hurt (FH): Includes expression of feelings of hurt, discomfort and lack of satis— faction because a drive or need of the client (major Category sacred) has been frustrated by some external agent or situation; the client A-18 expresses his discomfort as a reaction to the frustration of the drive. The frustrating agent is seen by the client as other than him— self. When the client indicates that he caused the frustration himself, score guilt or anxiety. C. I always had to be home by 11:00; and I didn't want to. (SA;FH;C;O;2) C. we didn't feel accepted socially. (Aff;FH;CO;O;2) C. Darn it, there aren't any eligible men around. (Sex;FH;C;O;l) C. I'm discouraged because therapy isn't helping me; I just feel worse. (Dep;FH;C;T71) C. I've tried, but jobs are hard for women to get. (SA;FH;C;O;1) C. As far as I know, mother loved my sister more than me. (Dep;FH;C;MH;2) C. Dad had to work all the time and take care of the shop, that's why we never had enough time to get close to him. (Dep;FH7C7F71) Frustration-aggression (FA): Includes hate, anger and criticism about the frustration of a major drive (dependency, hostility,sex, affili— ation, self-assertion or vague); the aggression must be indicated as a reaction to the frus—’ tration caused by some external agent or situ— ation, usually the attitude or behavior Of an— other person. When this category is scored, hostility is also scored as a major category since the reaction to frustration is hostility. When frustration is caused by the client him— self, score guilt or anxiety. C. My stingy mother just wouldn't send me the money when I needed it; (Dep;FA7C7M72) (Hos;N;C7M72) C. My wife just doesn't do things for me the Way my mother used to; I resent it. (Dep;FA7C;P;l) (Hos;N;C;P;l) A-19 C. I hate my mother for the way she domi— nated me in high school and didn't let me do anything on my own. (Hos;N;C;M;l) (SA;FA;C;M72) C. It's just damn hard to study at home with everybody in the way. (SA;FA;C;H;1) (Hos;N;C;H;l) 6. Satisfaction (Sat): Includes expressions of the client's satisfaction and gratification in regard to a major interpersonal need. C. I just feel good today. (Vag:Sat;C;O;l) C. We eat almost all of our meals together and it is nice that way. (Aff;Sat;C;P;l) C. He does nice things for me and yet he is not a puppy dOg. He has enough strength to make him masculine. (Sex;Sat;C;P;l) (Aff;Uns;P;C;4) C. Finally I told my roommate what I thought about her sloppiness, and I felt good I did. (Hos;Sat;C;P;2) (SA;Sat;C;P;2) C. It was a tough job; but I'm glad I did it. (SA;Sat7C70;2) C. It was great when Dad took us to the Ice Follies each year. (Dep;Sat;C;F;2) 7. Simple Agreement or Disagreement (Agr): This category includes those statements of the client which simply acknowledge, agree or dis— agree without elaboration to the preceding statement of the therapist; this category is not used if one of the preceding six can be scored. Note: In all cases the subject of this statement is the client and the object is scored as the therapist; see subject and Object below (Section II, C.). When simple agreement or disagreement is scored, relevance scorings are omitted; (Section II, D.). C. Yes, C. Surely. C. I agree. A-20 C. I think so. C. I don't think so. C. No (as a matter of fact without hostility). By definition, simple agreement by the client covers all categories that the therapist ap- proached or introduced. Special example: C. (A client statement which scored sex, affiliation, and dependency.) T. You sound as though you have been a pretty lonely girl. (Score approach to sex, affiliation and dependency.) C. Yes. (Sex;Agr;C;T;-) (Aff;Agr;C;T7-) (Dep7Agr7C7T7-) T. Is that right? ‘(Approach to sex, affili— ation and dependency.) c. Yes. (Sex;Agr;C;T;—) (Aff;Agr;C;T;-) (Dep;Agr;C;T;-) Unstated (Uns): Includes all the statements when any of the above Categories cannot be scored becauSe the client has not expressed his affective feelings. Usually these state- ments will be simple expressions about the activity of the client or other people. C. We went to the show. (Aff;Uns;C;P74) C. I asked him why he thought a girl might do something like that. (Dep;Uns;C;O;4) C. I do lots of crossword puzzles. (SA;Uns;C;O;4) Special case: When the client is not a partici— pant in the described behavior, do not score any intra—psychic state. C. My aunt really chewed out my uncle. (HOS7-707075) 0. Mary went out with Bill last night. (SeX7-7P7P;5) A-21 Subject and Object: For each major category scored for a client statement, the subject and the object of the client's expression in regard to that major category is also scored. 1. Subject: The subject Of statement is the person whose attitude, feeling or behavior is being expresSed. This may not be the gram— matical subject of the sentence. 2. Object: The object of the statement is the person or situation that receives the action, feeling or attitude of the subject. Objects need not be the direct object of any verb. Symbols: C, Client; M, client's mother; F, client's father; T, client's therapist; P, client's peers; H, other members of client's immediate family or the family as a unit; 0, other (people, situations, events, etc.). These are exhaustive, but not mutually ex- clusive in scoring. C. My uncle was furious at my aunt. (H087-70;O;5) C. I've always felt my mother loved my sister more than me. (Dep;FH;C;MH;3) Psyghotherapeutic Relevance for Client Statements: For each major categOry scored, a relevance score is marked, except when the psychic state is scored as simple agreement—disagreement.' These six cate- gories are exhaustive and mutually exClusive. When’two categories could be sCored for the same interpersonal drive, score only the lower numbered choice. Note: When the psychic state is scored as need, guilt, anxiety, frustration—hurt, frustration- aggression or satisfaction, a relevance score of l or 2, generally is scored. When the psychic state is scored as "unstated," the relevance score usually is 3, 4, 5 or 6. 1. Present Affective Feeling (1): Includes ex- pression or description of client's present feelings; analysis of client's present fee1—' ings; affective prOblem analyzing or affective problem solving; affective discuSsion of client's actions, motivations and their A-22 consequences.' For any scoring in this cate- gory the statement must express a present feel— ing or analysis of a feeling or behavior of the client. If the feeling related to a past event, the feeling must continue into the present to be scored "1". C. I'm just plain mad. (Hos;N;C;O;1) C. Is it all right if I talk about my girl's problem? (Dep;N;C;T;l) C. I hope he calls me for Saturday night. (SeX7N7C7P71) C. I want to get a 4—point. (SA;N;C;0;1) Past Affective Feeling (2): Includes ex- 'pression or description of client's past feel— ings; analysis of client's past feelings; af— fective discussion of client's past actions, motivations and their consequenCes. For any scoring in this category the statement must express a past feeling which is not stated as carrying over to the present feelings of the client. Score as category 1, when a past feel- ing continues into the present. C. I didn't want to move; I didn't want to leave the friends I had there and so I hated it for the longest time. (Aff;FA,FH;C;P;2) (Hos;N;C;O;Z) Behavior Within the Family (3): Includes ex- pression of behavior of parents, siblings or spouse; discussion of their behavior toward the client and of the client toward them; analy— sis of their behavior where the client is seek— ing to understand their behavior as it has af— fected the client. C. If dad doesn't like what I do, he just grumbles about it. (Hos;Uns;F;C;3) C. My mother was furious about it. (HOS:-7M;O73) C. When my mother and father quarrel, my siSter is always on my father's side. (H087-7H:H:3) A—23 C. My parents always ask if I am getting enough sleep. (Dep;Uns;MF;C;3) C. Dad resents all her questions. (HOS;-:F:O;3) Participant Behavior (4): Includes description of actions of the client; includes description of behavior, feelings, aCtions, attitudes of others when the client is a participant in the scene; includes brief comments which are personal in reference but with little if any affective significance. The expressions are of a lower energy level and without mention of the client's internal feelings about the be- havior described. C. Last spring I used to go out drinking occasiOnally. (Aff:Uns:C;P;4) C. Yes, John is one of the exceptions in our group. (Oth;-;O;O;4) ‘C. I don't think they resent my doing that. (Hos;Uns;C;C74) C. If I don't hOp out of bed the second the alarm goes off, I know I'd roll over and go back to sleep. (Oth;—;C;O;4) Observed Behavior (5): Includes description of the actions of specifiable others where the client is only an observer or reporter, rather than a participant in the scene. Again there is no mention of the client's internal feel- ings about the behavior of others. C. My uncle was furious at my aunt. (HOS:-:O;O:5) C. Bill reads all the editorials. (0th:-7O;O75) Description of Impersonal Events, Facts, Opinions (6): Includes statements with no psychologiCal reference to any significant individual? discuSsion of intellectual, ab- Stract or philoSophical matters. Includes statements where the client may be manifesting affective expression, but the expreSSion is like a speech he could give to any one or any group, usually stylized by cadence or rhythmic patterns (soap—box). A-24 C. Most people'have a liberal attitude about sex; what people do privately is their own business. (Sex;Uns;C;O;6) C. The individual is only a number here; the place is so large. (Oth;—;C;O;6) III. Categories of Therapist Responses. A. Approach—Avoidance Response: Therapist responses to each scored client interpersonal category are divided first into two mutually exclusive classes, approach and avoidance responses. When both ap— proach and avoidance are present, score only the portion which is designed to elicit a response from the client. Examples of approach and avoid— ance responses are grouped in sub—types to aid scoring. But the judge must decide first that a response is an approach or avoidance before he con- siders the various sub-types. 1. Approach responses (Ap): An approach response is any verbalization by the therapist which seems designed to elicit from the client further expression or elaboration of the de— pendent, hostile, affiliate, self-assertive, sexual, vague or other expression which Was scored in the client's immediately preceding statement. Approach is to the major category, not necessarily to the specific subcategories or the particular content of the client's pre— ceding speech. The following subcategories are exhaustive. a. Exploration (probing): Includes remarks or questions that encourage the client to de- scribe or express his feelings, attitudes, or actions further; asks for further clarification, elaboration, descriptive information, continuance; calls for details or examples; probing opinions which direct the client to reconsider by more careful thinking a previous statement. Should de— mand more than a yes or no answer; if not, may be a "label." C. How do I feel? I feel idiotic. T. What do you mean, you feel idiotic? (I)* *To aid in training judges, approach and avoidance reSponses are also marked as (I) for internalizing reSponses and (E) for externalizing responses. (cf. III, C.) A-25 I can't understand his behavior. What is it about his behavior you can't understand? (E) Tell me more how you felt. (I) I don't completely follow that sequence. (E) Reflection: Repeats or restates a portion of the client's verbalization of feeling, attitude or action. May use phrases of synonymous meaning. Therapist may some— times agree with his own previous response; if the client had agreed or accepted the first therapist statement, the second ' therapiSt statement is scored asia re— flection 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. (I) C. His doing that stupid doodling upsets me. T. It really gets under your skin. (I) 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" in— terpretation, 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, but it is a statement of fact, opinion or situation without elaboration. C. I just don't want to talk about that any more. ' T. What I said annoyed you. (I) 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. (I) A-26 Interpretation: Points out and explains patterns or relationships in the client's feelings, attitudes. and behavior: ex- plains the antecedents of them, shows the similarities 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 . . . (I) Support: Expresses sympathy, reassurance, approval, agreement or understanding of Client's feelings, attitudes or behavior. Includes strOngly emphasized, "Mm Hmm," BYes"; Offers explicit permissiveness. C. It's hard for me to just start talking. T. I think I know what you mean. (I) C. I hate to ask favors from peOple. T. I can understand that would be diffi— cult for you. _(I) 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. (I) C. May I just be quiet for a moment? T. Certainly. (E) C. I have my girlfriend's problems on my mind. Could we talk about them? T. Why don't we talk about that? (E) Information: Gives factual information or therapist opinion to general, direct or im— plied 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 (generalization). C. Shall I take tests? T. I feel in this instance tests are not needed. (E) A-27 C. What's counseling all about? T. It's a chance for a person to say just what's on his mind. (E) C. I don't like to talk about it. T. Mary, we have to deal with this somehow. (I) Avoidance Responses (Av): The following sub— categories are exhaustive. An avoidance re- sponse is any verbalization by the therapist which seems designed to inhibit, discourage or divert further expression of the dependent, hostile, affiliation, self-assertion, sex, vague or other categories. The therapist at- tempts to inhibit the feelings, attitudes or behavior described or expressed in the im- mediately preceding client statement which determined its placement under the major cate— gory. Avoidance is avoidance of the major category, not specific subcategories or psychic states. a. Disapproval: Therapist is critical, sar— castic or antagonistic toward the client or his statements, feelings or attitudes, expressing rejection in some way. May point out contradictions or challenge statements. (Note: remember you must de— cide response is an avoidance before you consider sub-types.) 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. (E) 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. (E) C. I'm mad at him: that's how I feel. T. You aren't thinking of how she may feel. (E) b. Topic Transition: Therapist changes or introduces a new tOpic of discussion not in the immediately preceding client verbali— zation. USually fails to acknowledge even a minor portion of the statement. A+28 Those kids were asking too much. It would have taken too much of my time. we seem to have gotten away from .what we were talking about earlier . . . (E) My mother never seemed interested in me. And what does your father do for a living? (E) Ignoring: Therapist responds only to a minor part of the client response or re— sponds to content, ignoring affect. He misses the point of the client statement. May under— or over—estimate affect. May approach the general tOpic but blatently ignore the affect verbalized. C. T. C. T. You've been through this with other people so help me out, will you? You are a little uneasy. (I) You can see I don't know what to do and I Want you to give me advice. Just say whatever you feel is im— portant about that. (I) My older sister gets me so mad I could scream. Mm-hmm. How old did you say she was? (E) we went out for Chinese food; he's so easy to get along with. Is he from New York? (E) Mislabeling: Therapist names attitudes, feelings 'or actions which are not present in the actual verbalization preceding the response. C. I just felt crushed when she said that. ’ T. Really burned you up, huh? (I) C. I don't know how I felt-—confused, lost-— T. I wonder if what you felt was re— sentment. (I) A-29 C. I may drop out of Honors College. T. You mean Arts and Letters. (E) C. No—-Honors College. e. Silence: Scored when it is apparent that the client expects a response from the therapist but none is forthcoming within five seconds after the client stops talk— ing. If the therapist approaches after five seconds have elapsed, silence cannot be scored and the therapist's response is merely "delayed." C. If you think I should keep on a more definite track, tell me because I'm just rambling. T. (five second silence) (E) C. It is very confusing to know what to do. Major Interpersonal Category Initiated by Therapist. Scored whenever the therapist introduces the tOpic of dependency, hostility, affiliation, self— assertiveness, sex or vague affective feelings when the client statement was not scored as the category which the therapist attempts to introduce. Each category so introduced is also scored for internalizing or externalizing elicitation. 1. Dependency Initiation (Dep Init): C. Last week I talked about Jane. T. You've mentioned a number of things you have done to please her. (E) C. (Enters Office) T. Now, how may I help you? (I) 2. Hostility Initiation (Hos Init): C. I was late for class this morning. T. I wonder if you dislike the teacher or the class? (I) I like to run around in blue jeans. You hate your mother. (I) I don't really understand but that really makes me anxious. You get mad when I Open up some feelings in you. (I) *3 O HO A-30 C. He's the only dog I ever cared for. T. Do you feel that your mother sort of re- jects you or isn't giving you enough at— tention and love. (I) (Init both Dep and Hos) 3. Affiliation Initiation (Aff Init): T. Do you join lots of campus organi— zations? (E) T. Do you want to stick up for your friends when they're criticized? (I) 4. Self-Assertion Initiation (SA Init): T. I was wondering if you felt you have been studying more efficiently lately. (I) T. Tell me something about your needs to be independent. (I) 5. Sex Initiation (Sex Init): T. Do these feelings have anything to do with sex? (I) T. Did your mother ever prepare you to know what menstruation would be like? (E) 6. Vague Initiation (Vag Init): T. Have you started feeling anxious in the last few minutes? (I) T. What are you feeling right now? (I) T. . . . because we won't be able to deal with your feelings that are tender and I suspect that this is really what we need to deal with. (I) Internalizing or Externalizing RespOnses: Thera- pist responses of approach, avoidance or initi- ation are scored in one of two mutually exclusive classes: internalizing or externalizing responses. When both types are preSent, score the portion of the response which is designed to elicit a re- sponse from the client. A—31 Internalizing (I): In this category the £0 is on the client's concept of himself, his feelings and reactions to the stimuli imping— ing on him. The therapist is encouraging the client to express his feelings. The therapist may label the client's feeling; he may verbally act them out with feeling or sensory words; he may explore the feelings by eliciting the client to discuss the idiosynCratic edges of his feelings and the impulse edge of his feelings. T. What would you like to talk about to— day? (I) T. You keep a pretty close Check on those you let yourself love because it's pretty dangerous. (I) T. Can you accept the fact that some of your ambitions will be frustrated? (I) T. You want to be a boy, but if you were you couldn't have children. (I) T. What did you think your mother meant by - that? (I) T. What is it about his behavior you can't understand? (I) Externalizing (E): The distinction is between a focus outside or inside the client. Here the therapist joins with the client on focusing on Something that is "outside" the client_ or re— sponds in such a way as to encourage the Client to focus On something outside himself. Re— sponse may refer to the client and still be placed here if it is a behavioral description of the client as an external object. There is a clear absence in this category of any focus on how the client "feels." T. In a sense you're being compared to people who are not doing things. (E) T. How old is your sister? (E) T. What did your mother feel when you said that? (E) A-32 Note: In the case of certain avoidance re— sponses, it may be impossible to score a re- sponse as internalizing or externalizing. a) b) d) e) Silence responses cannot be scored, but are listed as E. TOpic transition responses are scored in respect to the discussion they intended to elicit, e.g., if a discussion of sex is introduced, score it also on the basis of whether it attempts to internalize or externalize the client's response about sex, and not in regard to the preceding client discussion. C. And so we went downtown shopping. T. Let's go on to something else; how did you feel about last week's hour? (I) Disapproval can be scored either internal— izing or externalizing. Ignoring can be scored either internalizing or externalizing On the basis of what the therapist said which was scored ignore. Mislabel can be scored either internal— izing or externalizing. APPENDIX B A RATING SHEET FOR THERAPISTS Client Counselor You saw the client listed above for counseling. Now that you have terminated your relationship with him, how would you judge the success of your contacts with him? (Check one) ( ) Successful ( ) Partially Successful ( ) Mainly Unsuccessful ( ) Unsuccessful Page Counter No. 04648 Coder __ Tape No. Date of Coding Code Name Interview N0. 14 15 16 17 18 19 20 21 Interview Date 22 23 24 25 26 27 28 29 3O 31 P~S Coding Sheet 32 33 34 35 1 APPENDIX .6 I I MIC 11mm