PERSPECTIVES OF PSYCHOIHERAPY PROCESS: DEPENDENCY, INTERPERSQML RELATION- SHIFfi, AND $EX DIFFERENCES TI‘IGSIS Io:- IIw Degree of DII. D. MICHIGAN STATE UNIVERSITY James F. Alexamder 1967 ”IiigiWLiI/IW University This is to certify that the thesis entitled Perspectives of Psychotherapy Process: ff-fDéper'idfenc‘y, Interpersonal Relation- ships, and Sex Differences presented by James F. Alexander has,l)een accepted towards fulfillment of the requirements for Ph . D degree in Psychology II IN AA A I . /:/'I(//‘t/L£J Date November 13, 19 I 0-169 -W..-_,_._._._4_k 44 “EH--_* —...——~H-- m ABSTRACT PERSPECTIVES OF PSYCHOTHERAPY PROCESS: DEPENDENCY, INTERPERSONAL RELATION- ‘ SHIPS, AND SEX DIFFERENCES by James F. Alexander Each dependency statement of twenty clients in psychotherapy was classified into one of eight relationship categories, which included: the relationship between the therapist and client, the client and his family, and the client in other social relationships. The study's purpose involved relating the frequency of dependency expressions in each of these relationship categories to two variables: the sex of the client and the phase of therapy. Three judges, showing impressive reliability, scored sixty typewritten tapes, representing the first, middle, and next to last interviews of 10 male and 10 female clients, all with a male counselor. In addition, the study examined pre-therapy MMPI performance as well as therapists' ratings of success. The study evaluated two sets of hypotheses, one set involving predicted differences between male and female clients, the other involving differences between the three phases of therapy. In general, the investigation predicted James F. Alexander female clients would make more dependency statements, and would express dependency more directly. These predictions of sex differences were not supported by the data, as clients' verbal behavior failed to reflect any differences in de- pendency due to the sex of the client. Auxiliary MMPI data, however, showed that males produced more deviant MMPI scale scores; and male clients, unlike female clients, scored sig- nificantly above their norm group on the Mf scale (i.e., more feminine). Eight pairs of clients (male-female) could be matched on Mf scale standard scores, and 6 pairs were matched on the number of deviant MMPI scales. The data from these matched groups supported the same conclusion: male and female clients did not differ in frequency of verbal de- / pendency behaviors. Significant changes in dependency in several relation- ship categories arose, some in support ofthe study's hy- potheses, some contrary. As predicted, dependency expres- sions classified as pertaining to the formal process of therapy (the role expectations, frequency of meetings, etc.) decreased from the beginning through the end of therapy. On the other hand, dependency expressions involving the relation- ship between the client and therapist increased significant- ly from the beginning to the middle of therapy, then remained stable. The inverse occurred with dependency involving the James F. Alexander client's family, which initially decreased then remained con- stant. These results suggest that these late adolescent clients refocus their dependency needs and conflicts from their original locus (the family) to the therapy situation (manifested in the client—therapist relationship). Finally, dependency involving social relationships initially in- creases, then decreases by the end of therapy. This sug— gests the possibility of two processes occurring through therapy: first a refocusing of the topic of dependency from the family to social relationships; then a decrease in the frequency of dependency expressions involving social relation- ships, reflecting the resolution of dependency concerns and conflicts. It was noted that the trends in dependency involving family and social relationships that emerge during therapy follow the form suggested by the principles of human develop- ment and the process of socialization, as if therapy repre- sents a compact developmental experience. Finally, the investigation produced findings that suggest, although tentatively, that therapists' rating of success is related to the amount of dependency involving the client-therapist relationship during the middle phase of therapy. Short term clients, those frequently rated as un- successful, expressed significantly more dependency in the James F. Alexander client-therapist relationship category early in therapy (3-5 sessions). It was suggested that with this type of client therapists develop techniques to adequately handle the in- tense demands this places upon the therapist, so the clients may remain longer in therapy and increase the probability of a successful therapeutic experience. PERSPECTIVES OF PSYCHOTHERAPY PROCESS: DEPENDENCY, INTERPERSONAL RELATION; SHIPS, AND SEX DIFFERENCES' BY A Md James F? Alexander A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1967 ACKNOWLEDGMENTS My deepest thanks go to Dr. Norman Abeles for the guidance, enthusiasm, and understanding he has shown me during my doctoral program. As chairman of both the doctor- al and dissertation committees, he has contributed im- measurably to my progress. To Drs. C. L. Winder, William Mueller, and M. Ray Denny I also offer my sincere appreci— ation: in addition to being on both committees, each of them has contributed uniquely to my growth as a psychologist and a clinician. In my professional future I hope to re- flect the integrity, professional involvement, and competence represented in each of these four men. I also wish to thank Drs. Bill Kell and Gary Stollak, whose views have had a great impact on my thinking. Without the support of the National Institutes of Health (NIMH Research Fellowship Award number S-Fl-MH-BO, 965+02) this dissertation could not have taken its present form. Finally, to Bonnie Green and Mike Figler I also offer my thanks for their many hours of training and scoring: a trying task they accomplished nicely. ii TABLE OF CONTENTS ACKNOWLEDGMENTS LIST OF TABLES LIST OF FIGURES . . . . . . . . . INTRODUCTION . REVIEW OF THE LITERATURE Content analysis systems Interaction sequence Dependency . Sex differences EXPERIMENTAL HYPOTHESES Dependency Sex differences METHOD . Source of the data Selection of cases Sampling of tapes Scoring manual Scoring reliability RESULTS Reliability . . . . . . . . . . . . . . . . Total dependency . . . . Primary System dependency Secondary system dependency Self system dependency Family system dependency Tertiary system dependenCy . . . . Therapist system dependency . . . . . Other system dependency, NOnreference system dependency . . . . . . iii Page ii vii w (DUMP-b) ll 13 15 15 17 _19 19 20 22 22 27 29 31 33 35 37 39 41 Page Length of therapy . . . . . . . . . . . . . . 43 Psychological characteristics . . . . . . . . . . 50 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . 55 Sex differences . . . . . . . . . . . . . 55 Phase of therapy and dependency . . . . . . . . 58 Length of therapy, success, dependency . . . . . . 62 SUMMARY . . . . . . . . . . . . . . . . . . . . . . . 67 REFERENCES . . . . . . . . . . . . . . . . . . . . . . '70 APPENDIXA......................'74 iv Table 10. ll. 12. l3. 14. LIST OF TABLES Descriptive summary of client and therapist characteristics Experience level and duration of treatment Reliability of scoring categories Total dependency analysis of variance table Primary dependency analysis of variance table . . . . . . . . Secondary dependency analysis of variance table . . . . . . . . . . . . . . . Self system dependency analysis of variance table. . . . . . . . . . . . . . . . Family system dependency analysis of variance table . . . . . . . . . Tertiary system dependency analysis of vari— ance table . . . . . . . . . . Therapist system dependency analy sis of .variance table . . . . . . . . Other system dependency analysis of variance table '. . . . . . . . . . . . . . . Nonreference system dependency analysis of variance table . . . . . . . . Intercorrelation matrix: Clients' dependency, Mf score, length of therapy, and success: total client sample . . . . . . . . . Length of therapy and therapists' rating of success: total client sample . . . Page l7 17 22 28 3O 32 34 36 38 4O 42 42 44 44 Table 15. 16. 17. 18. Page Number of deviant MMPI scales, Mf standard scores, success rating, and length of therapy: total client sample . . . . . . . 51 Clients' scores on the Masculinity- femininity (Mf) scale of the MMPI . . . . . 52 'Total verbal dependency scores for the 6 male and 6 female clients who could be matched on the number of deviant MMPI scales . . . . . . . . . 53 Total verbal dependency scores for the 8 male and 8 female clients who could be matched on Mf standard scores . . . . . . . . . . . 54 vi Figure N 0‘me 10. 11. LIST OF FIGURES Total dependency . Primary system dependency Secondary system dependency Self system dependency . Family system dependency Tertiary system dependency Therapist system dependency Other system dependency NOnreference system dependency Short versus long term therapy dependency Summary graphs of Clients' dependency scored as Primary, Secondary, Family, and Terti— ary system . . . . . . . . . vii Page 27 29 31 33 35 37 39 41 41 46 6O INTRODUCTION The need for research into the rich and complex pro- cess of psychotherapy was recognized as early as 1920. At that time Freud stated that the legitimate investigation of psychotherapy could only be accomplished through relatively uncontrolled observation by the therapist, because the presence of an objective observer would cause the patient to "become mute" (Freud, 1920). With the advent of Covner's method for the phonographic recording of interviews (Covner, 1942), however, it became possible to examine rigorously at least the verbal interaction between client and therapist. Although only a part of the total levels of communication be— tween client and therapist (i.eg see Kell and Mueller, 1966; Satir, 1964), verbal behavior nevertheless constitutes the most unambiguously defined and evaluated mode of communi- cation, and is the basis for many psychotherapies presently used. Thus at our present level of research sophistication it is most apprOpriate to operationalize and objectively ex- amine aspects of the verbal interaction in psychotherapy. This approach conceives of psychotherapy as an interaction system, characterized by interdependence between variables where a "sequential process of action and reaction takes place" (Lennard and Bernstein, 1960). Using clearly defined operational constructs and a reliable molecular and interactive scoring system, one aim of this study is to explore at several stages of therapy the relationship between the client and therapist as reflected by verbal dependency expressions. Although Schuldt (1964) has analyzed dependency at various stages of psychotherapy using a similar scoring system, he did not evaluate the re- lationship (or "role system"; Lennard & Bernstein, 1960) focus of the*dependency. The present study examines this important aspect of interaction in psychotherapy. In addition, this investigation examines a specifi- cally defined client pOpulation. The study contrasts de— pendency behavior between male and female clients with the sex of the therapist controlled (i.e., male therapists). This variable of the sex of the client has been consistently ignored-in the research on dependency and the psychotherapy process. REVIEW OF THE LITERATURE Content analysis systems Several systems of molecular content analysis have been developed recently, beginning with the revision of Murray's content scoring system (Murray, 1956) by Bandura, Lipsher, and Miller (1960), and Winder, Ahmad, Bandura, and Rau (1962) for coding taperecorded interviews. In these studies, the Clients' statements were scored for content (de- pendency, hostility, and sex) and the therapists responses were classified as approach or avoidance, referring to the therapists' intent to elicit further discussion of the con- tent from the client. Kopplin (1965) devised a more complex scoring system, adding the content categories of affiliation, self assertion, vague, and other. He also scored the Clients' statements as to the presence or absence of affect, and identified the subject and object of the behavior described. In addition to therapist approach—avoidance, Kbpplin scored the therapists' responses for internalizing-externalizing, referring to whether or not the therapist attempted to focus on the client's feelings. Appendix A contains a more complete description of the terms, taken from these sources, used in the present study. Interaction squence Essentially the interaction sequence consists of a client statement followed by a therapist's response which is in turn followed by a client statement (see Appendix A). Each client statement may then be viewed as both an inde- pendent or a dependent event. Using this system, Bandura §t_a1. (1960) studied how the therapists' approach or avoidance of hostility affected the clients' continuance of hostility. As predicted by social learning theory, clients expressed significantly more hostility after the therapist approached, rather than avoided, the client's previous hostility statement. Winder_gt_gl. (1962) replicated these findings, reporting similar results with verbal dependency. Subsequently Caracena (1963) and Kbpplin (1963; 1965) verified these basic parameters with a sample of university students. Furthermore, therapists' ap- proach behavior elicited a greater continuance rate of ex- pressions dealing with sex, self assertion, and affiliation- from clients than did therapists' avoidance (Kopplin, 1965). Classifying Clients' statements as either affect or non- affect, Kbpplin also found that when the therapist internal- ized in response to a client statement, clients continued with affect more than when therapists externalized (Kepplin, 1965). While the above studies of dependency behavior used only taperecordings of the initial phase (first and second interview), Varble (1964), studying hostility, sampled from the first and next to last interviews, plus the taperecord- ings representing the 25th, 50th, and 75th percentile points of therapy. An examination of Clients' statements classi- fied as hostility indicated that the facilitating effect of the therapists' approach (as opposed to avoidance) responses remained constant throughout the points sampled (Varble, 1964). Dependengy Schuldt (1964), using the same tapes as Varble, found somewhat different results with the dependency di— mension: the facilitating effect of therapists' approach on continuance of dependency statements decreased as therapy progressed; this decrease accompanied a steady decrease in the rate of dependency initiated by the client and a slight decrease in the proportion of dependency statements. Schuldt explained that his sample consisted of (late adolescent) uni- versity undergraduates, at an age when conflicts about and expressions of dependency needs are often frequent and in- tense. As these needs are met and the conflicts attenuated or resolved, these Clients' dependency would be expected to decrease. Thus Schuldt's study implies that as therapy pro- gresses, the dependency needs of the client decrease somewhat steadily. This conclusion corresponds with Roger's (1951) pre— dictions that while dependency attitudes exist "in some degree in the majority of cases," in a client-centered situ- ation dependency is expected to decrease as self actualization and independence develope. Snyder (1963) reported the case histories and de- pendency scores for two quite dependent male clients. As therapy progressed dependency scores first increased until approximately midway through therapy, then returned slowly to the original level. These data differ from Schuldt's (1964), perhaps for several reasons. First, while Schuldt's sample consisted of undergraduates who referred themselves to the counseling center, Snyder's two cases were graduate students in the clinical psychology program. Such a differ— ence in their relationship with their therapist, as well as psychological sophistication, may have affected dependency behavior a great deal. Similar effects due to differences between therapists may have Operated, for example therapists' style, involvement with the clients, etc. The differences may also stem from the contrasts in the measures used. Whereas Schuldt used verbal statements scored as dependency (versus hostility and other) which covered a broad range of statements (see Appendix A), Snyder used a dependency scale based on client yes-no responses to a questionnaire regarding the day‘s therapy session (e.g., “Today I feel that I just couldn't manage without these counseling hours."). The scale included the 55 questions which correlated most highly with the MMPI dependency score I (Navran, 1959) combined with two psychologists' ratings of dependency behavior. Thus Snyder's dependency measure re- ferred much more directly to the specific therapy relation- ship and the Clients' feelings about it. Kammerschen discussed an additional limitation of the scoring category of dependency used by Schuldt and others (e.g., Kbpplin, 1965; Kammerschen, 1965). In response to Clients' statements classified as dependency, therapists ap- proached non-affect dependency at a higher rate than de- pendency scored as affect: a surprising result of the in- clusion of all client questions in the dependency category, questions which were generally non-affect but were consistent— ly approached, i.e., answered (Kammerschen, 1965). Also, as Sears (1963) has concluded, the low intercorrelations of various measures of dependency force the conclusion that de- pendency, as defined by various authors, is not a unitary concept. So while the category of dependency as defined in earlier studies may describe content sufficiently, the focus of the dependency expression requires more precise definition. Lennard and Bernstein (1960) developed the concept of the "frame of reference" or "role system" in psychotherapy, classifying the relationship involved in the verbal expres- sion: Primary System references involve the formal structure of the treatment process (for example the goals of therapy, reasons for coming to therapy, frequency of sessions, etc.); Ng- Secondary references relate the client and therapist in other than their primary roles (e.g., feelings toward one another, “transference“ phenomena); the Tertiary System involves inter- action with members of other social systems (e.g., friends, dates, etc.); Family references involve the client as a member of a family unit; the Self System includes references to the client's life experiences not directly involving other individuals (Lennard and Bernstein, 1960). For an exhaustive classification system, the present study uses three addition- al categories: Therapist System statements refer to the therapist's life experiences not involving the client; Other System references involve interaction between people but not involving the client or therapist; anreference expressions describe impersonal facts, events, and unscorable verbali— zations. For a complete description, including examples, of the Relationship categories see Appendix A. Sex differences Little research has been done on the differences be- tween the dependency behavior of male and female clients in psychotherapy. Some studies (e.g., Snyder, 1963) have used subjects of only one sex and avoided the issue; others have ignored the issue and pooled male and female subjects (e.g., see Bandura §£_21., 1960; Winder_g§_a1., 1962; Kbpplin, 1963, 1965; Schuldt, 1964; Kammerschen, 1965). Yet the assumptions of developmental-social learning theory approaches to indi- vidual differences would suggest that males and females emit different kinds and frequencies of dependency behavior. And while texts on psychotherapy such as Kell and Mueller (1966) critically evaluate the influence of the sex of clients and therapists, these discussions are anecdotal and provide hy- potheses, not solutions, for subsequent experimental manipulation. Several studies on sex differences touch on dependency in psychotherapy. For example Apfelbaum (1958) studied the role expectations of new patients, finding a marked tendency for female patients to have a "model" type role expectancy for the therapist (i.e., permissive listener, neither criti- cal nor protective). -Ma1es on the other hand anticipate a "critic" (i.e., critical and analytical, making the patient assume considerable responsibility). Heiss (1962) did not study psychotherapy, but found in unmarried male-female re- lationships people tend to prefer male dominance when the re- lationship is casual or beginning. These studies imply that initially in the psychotherapy interaction males will not only prefer to act less dependent than females, they feel in ad— dition that they will be expected to act in a less dependent manner. In a vocational counseling situation the sex of the therapist did not relate to the amount of feeling clients expressed, yet female clients expressed more feeling than males (Fuller, 1963). With (non client) college students, males and females can be reliably differentiated in terms of lO occupational values (wagman, 1965) and scholastic and occu- pational interest variables (Long, 1964). Female clients also tend to persist in counseling longer (Snyder, 1953) and receive higher mean success ratings (Rogers and Dymond, 1954). These findings, coupled with Snyder's (1963) report that suc- cessful clients were those rated more dependent, imply that females will be more dependent in psychotherapy. Heiss' (1962) study suggests, however, that the differences related to the sex of the client may decrease as therapy progresses. Specifically, he applied the Bales Sys- tem to the interaction between unmarried male-female couples that varied in how much they knew each other. Initially males tended to dominate in the task sections of the re- lationship, while females dominated in the positive reactions sections. But as the relationship became more intimate, the original sex differences decreased (Heiss, 1962). EXPERIMENTAL HYPOTHESES Dependency Hypothesis Ia: The frequency of all client state- ments scored as dependency will decrease from the beginning through the middle to the end of therapy. This hypothesis constitutes an attempted replication of Schuldt's (1966) findings, also involving university undergraduates in a counseling center. The hypothesis as— sumes that these late adolescent clients initially experience intense dependency needs and conflicts; as therapy resolves these needs and conflicts, dependency statements will decrease. Hypothesis Ib: Clients' ddpendency expressions classified in the relationship category of Primary System will decrease steadily from the beginning to the end of therapy. (Primary references involve the formal process of therapy: expectations, roles, etc.) Lennard and Bernstein (1960) focused on the relation— ship involved in the Clients' and therapists' statements, re— porting that references classified in the Primary category decreased markedly as therapy progressed. They concluded that initially there is a great deal of mutual exploration and clarification of role expectations as well as goals and outcome. This of course decreases as the roles, goals, etc., are clarified. In the present study, then, a similar trend 11 12 is predicted for dependency classified in the Primary System relationship category. Hypothesis Ic: Clients' dependency classified as Secondary will increase from the beginning through the middle to the end of therapy. (Secondary re- lationship involves the client and therapist inter— acting as people, i.e., "transference" phenomena are scored Secondary.) Hypothesis IQ: Clients' dependency classified in the Self System will increase from the beginning through the middle to the end of therapy. (Self references involve expressions about the client alone, i.e., not in a relationship with anyone else.) Hypothesis Ie: Clients' dependency classified in the Therapdst System relationship category will increase from the beginning through the middle to the end of' therapy. (Therapist references involve the therapist not in relation to the client, i.e., in terms of his own family.) Although the counselors involved in the present study cannot be meaningfully assigned to any school of therapy, a rather pervasive assumption exists about the client-therapist relationship. Specifically, the actual therapeutic relation— ship not only provides for the expression of basis conflicts, but also provides a vehicle for subsequent change. As Kell and Mueller state, "participants of the therapeutic encounter have an increasingly intense and reciprocal impact on each other" (Kell and Mueller, 1966). For the present investi- gation, this implies that dependency statements regarding the participants (Secondary, Self, and Therapist System refer- ences) will increase as therapy progresses. Hypothesis If: Clients' dependency classified in the Family System relationship category will decrease from the beginning through the middle to the end of 13 therapy. (Family refers to the client as a member of a family unit.) Hypothesis Ig: Clients' dependency classified in the Tertiary System relationship category will de— crease from the beginning through the middle to the end of therapy. (Tertiary involves all social re- lationships of the client other than Family, Pri- mary, and Secondary.) These hypotheses reflect the assumption that as therapy progresses clients become more autonomous in family and other relationships, and this will be reflected in fewer dependency statements by the clients involving these relationships. Sex differences Hypotheses IIa . . . IIi: These hypotheses imvolve initial differences between male and female clients. Initially, female clients will make more dependency statements classified in the following relationship categories: IIa: Total dependency ____: Primary System _;Ig: Secondary System IId: Self System .Iggz Family System .Ilfz Tertiary System Initially, male clients will make more dependency. statements classified in the following relationship categories: _;Iq: Therapist System IIh: Other System : NOnreference System Hypothesis 111: By the terminal phase of therapy, male and female clients will not differ in frequency of dependency expressions. The hypotheses represented above are based in part on the studies of Fuller (1963), Snyder (1953), and Rogers 14 (1954), who concluded that differences due to Clients' sex do exist in the therapeutic situation. More specifically, the predictions arise out of expectations generated from general developmental-social learning theory: females do and should act more dependently than males. That is, this study assumes that parents, and later others, expect and reinforce more direct expression of dependency by females than by males (i.e., see Sears, 1963). Furthermore, these cultural expectations operate at the initial point of therapy, and should be reflected by: female clients expressing more de— pendency (total); female clients making more direct dependency statements, i.e., referring directly to themselves (Self) or to relationships in which they are involved (Primary, Second— ary, Family, and Tertiary System). In contrast, male clients will express dependency less directly, i.e., a higher fre- quency of dependency expressions classified as Therapist, Other, or anreference System. Finally, as the therapy re— lationship becomes a relatively more powerful elicitor of be— havior, these initial sex differences should disappear. METHOD Source of data The cases involved in the present investigation constitute a part of the library of taperecorded psycho- therapies developed at the Michigan State University Counsel— ing Center. All clients who participated in this research project were university undergraduate students, typically late adolescents, who came to the counseling center without referral requesting counseling with personal and social problems. During an intake interview, a screening counselor and the prospective client determined if the client was to be seen in psychotherapy at the counseling center. If ac— cepted, the screening counselor asked the clients to partici— pate in the research project if they had not been seen pre- viously in psychotherapy. Most of the clients were assigned to the therapists participating in the research project on the basis of time availability and special competencies of the therapists in- volved. Final assignment of clients was contingent upon ac- ceptance by the therapist, to whom intake notes and personal impressions of the intake counselor were made available. 15 16 Some additional selection of cases occurred because not all therapists at the counseling center who do therapy partici— pated in the study. The psychotherapists divide into two groups: the staff group including 4 Ph.D. level clinical and counseling psychologists with 2 to 20 years of psychotherapy experience; the intern counselors being 11 advanced doctoral candidates in clinical or counseling psychology with an average of two years of intensive supervision in psychotherapy. All in— terns had completed their practicum experience. The 4 staff counselors saw 5 of the clients, one of them seeing 2 clients. .The remaining 15 clients were seen by the 11 interns, with 2 interns seeing 2 clients each and one intern seeing 3 clients. All counselors in the present investigation were male, while 10 clients were male and 10 female. See Table 1 for a summary description of client and therapist characteristics. Generally clients and therapists at the counseling center met for one hour a week. The policy of the counseling center encourages relatively short term therapy, ile., 10-20 interviews, although treatment occasionally exceeds this duration. Table 2 provides a summary of therapist experi— ence level and duration of treatment. 17 Table 1. Descriptive summary of client and therapist characteristics. Sex Mean years experi~ Therapists N Male Female ence in therapy Staff 4 4 —- 7.5 Interns . 11 11 -- 2.0 Sex Mean number of Clients N Male Female interviews Clients seen by staff 5 2 3 12.2 Clients seen by interns 15 8 7 14.9 Table 2. Experience level and duration of treatment. _— v__ Sessions Experience level 5—8 9-12 13-18 17-20 21+ Staff 2 0 2 1 0 Interns 3 4 0 6 2 Total 5 4 2 7 2 Selection of cases In the present investigation taperecordings repre- senting the first, middle, and next to last therapy sessions of each client were selected. The selection of cases was based on a number of criteria: 1) At least 5 therapy 18 sessions were involved; 2) The therapist was male; 3) the client had been administered the MMPI prior to beginning treatment; 4) Therapy had been terminated; 5) Therapists had rated the success of therapy. Twelve female and ten male clients met these criteria, with only two exceptions: 1) Two cases were missing the initial interview, thus second inter- views were substituted; 2) The success of therapy had not been recorded in one case. The 66 taperecordings representing the final sample were typewritten by professional transcribers. This pro- cedure was prompted in part by the comments of Kammerschen (1965) and Kopplin (1965) who suggested that interjudge re— liability of taperecordings is difficult to obtain without a great deal of training. A more important consideration also underlay the use of typewritten transcripts. Specifically, the hypotheses involved in the present study are related to rates and types of verbal behaviors. Taperecordings contain these behaviors, but also involve such vocal but nonverbal cues as slight voice inflections and halting speech. And while these vocal but nonverbal cues are an immensely im— portant aspect of the psychotherapy process, they are not aspects of the rigorously and operationally defined verbal constructs which the present study examines. .It is assumed that their exclusion will provide for increased precision and reliability. 19 Sampling of tapes The present study sampled entire tapes from selected phases of therapy (initial, middle, terminal), rather than sampling from segments of each therapy session. Such a method provides one distinct advantage and one distinct dis— advantage; sampling at selected phases provides the most powerful method of evaluating characteristics at those par- ticular phases, primarily due to a larger N. Unfortunately, trends changing from session to session are at best obscured and may be entirely missed when sampling only from phases of therapy. Yet because the present study represents the first attempt to simultaneously evaluate the effects of the sex of the client, verbal dependency behavior, and the relationship involved in the dependency, sampling selected phases consti- tuted the most efficient way to evaluate several hypotheses and generate several more. Scorinqimanual The scoring categories and coding procedure follow the general pattern found in several previous studies (Bandura_§£_§1., 1960; Winder_e£_al., 1962; Caracena, 1963; Schuldt, 1964; Varble, 1964; Kbpplin, 1965). Unique in the present study is the category of Clients' statements scored as internal or external, complimenting the therapist category of internalizing-externalizing originated by Kopplin (1965). Also the present study adds the Relationship categories, an 20 extension of the system originated by Lennard and Bernstein (1960). Appendix A contains the manual used in this study, including operational definition of terms and examples. The scoring process may be summarized as follows: After determining the content of the client's statement, the judge classified the relationship involved and its internal- external focus. Then the judge scored the therapist's re— sponse in the categories of approach or avoidance, relation- ship, and internalizing or externalizing, noting also any new dependency or hostility content. To avoid contamination in scoring, each unit was scored before the next. Scoring reliability The present study used three reliability scorers (the author and two first year graduate students in clinical psy- chology); one aim of the study involved demonstrating great stability of the scoring system by the simultaneous agreement of three raters. For the actual scoring, judges determined units simply by visual inspection since the interviews were typewritten. After studying and discussing the scoring manual carefully, the judges scored together a series of transcripts taken from another source. After the judges demonstrated familiarity with the manual, a practice pool was established, consisting of transcripts from other sources and the 6 tapes of two female_§§ randomly drOpped from the subject sample. The judges scored portions of these practice 21 tapes independently, then discussed the unit by unit scoring in semi-weekly meetings. When consistency among judges had been reached, the reliability sample was created. Each of the final 60 tran- scripts was divided into quarters in terms of units. One of the quarters of each transcript was then randomly selected and scored independently by each of the three judges, making up the reliability sample. Finally the judges divided the 60 transcripts among themselves and scored the remaining portions of the tapes. RESULTS Reliability To obtain the index of consistency of the scoring manual, the study utilized the approach of estimating vari- ance components suggested by several authors (i.e., Ebel, 1951;.Lindquist, 1956; Guilford, 1956). Table 3 contains the frequencies, reliability coefficients, and 95% confi- dence limits for the 32 scoring categories; each was computed independently following Lindquist's procedure (Lindquist, 1956) and using the facilities of the Michigan State Uni— versity Computer Center. Table 3. Reliability of scoring categories. —‘—‘ —7 Scoring Category - Reliability 95% Confidence Client Expressions Frequency Coefficient Limits Upper Lower CONTENT Dependency 958 .8012 .8436 .7504 Hostility 532 .8799 .9065 .8463 Other 4154 .9448 .9073 .9546 RELATIONSHIP Primary 422 .8711 .8997 .8357 Secondary 405 .8424 .8764 .7995 Self 2370 .9408 .9543 .9233 Family 831 .9641 .9724 .9533 Tertiary 1090 .9680 .9754 .9582 Therapist 97 .8713 .8998 .8359 Other 60 .7572 .8081 .6981 NOnreference 434 .6971 .7578 .6273 Table 3.—-Continued 23 Scoring Category - Reliability 95% Confidence Client Expressions Frequency Coefficient Limits Upper Lower FOCUS Internal 1969 .9444 .9571 .9279 External 2803 .9522 .9632 .9380 Agree-Disagree 815 .9225 .9714 .9516 TOTAL Client Total 5591 .9948 .9960 .9932 Scoring Category — Reliability 95% Confidence Therapist Expressions Frequency Coefficient Limits Upper Lower APPROACH Approach 4474 .9736 .9797 .9661 Avoidance 206 .4373 .5145 .3243 RELATIONSHIP Primary 495 .8912 .9155 .8606 Secondary 453 .8585 .8898 .8203 Self 2360 .9535 .9646 .9402 Family 816 .9677 .9752 .9580 Tertiary 892 .9752 .9810 .9677 Therapist 116 .8120 .8530 .7493 Other 51 .7333 .7861 .6670 NOnreference 405 .6359 .7058 .5568 TOTAL Total 5524 .9941 .9955 .9897 FOCUS Internalizing 2142 .9434 .9564 .9267 Externalizing 3382 .9469 .9591 .9312 INITIATION Dependency 221 .6814 .7466 .6119 Hostility 149 .6510 .7175 .5726 Other 713 .8939 .9156 .8566 24 As Table 3 shows, all coefficients are significant: Content, Relationship, and Focus categories being consistent— ly strong; the Initiation categories (dependency and hostili- ty) being less stable, which reflects the disadvantage of using non-exhaustive scoring categories. Specifically, scorers reported attending less to the (non-exhaustive) Initiation categories than to all the other categories, be— cause they were not scored for every response. As expected, the magnitude of reliability coefficients is roughly proportional to frequency, yet infrequently used categories (i.e., Clients' Therapist relationship, Clients' Other relationship, therapists' Nonreference relationship) reflect impressive stability. Therapists' Avoidance repre- sents the only extremely low reliability score (.4373), yet is still significant. As Kammerschen (1965) noted, the establishment of scoring reliability requires extensive training. Even with typewritten transcripts, judges required many hours of pre— training to obtain the high level of consistency reported above. With any scoring method, reliability will be a di- rect function of the amount cf pretraining. The use of type- written transcripts, however, contributed to the stability of scoring categories in several ways. By providing easily discernable units, the transcripts allowed the scorer to focus immediately on the content and process variables; whereas in other studies the first determination necessarily involved the scoring unit itself. 25 But the most important contribution of typewritten transcripts involved the early pretraining stages. After scoring several pages independently, scorers met as a group and discussed each unit. As units were already numbered, judges were able to skip from page to page or tape to tape instantly to discuss similar scoring examples, subtle differ— ences, and contradictions. This is not possible with tape— recordings, placing a much greater burden on the scorer's memory. All scoring categories, except client Internal— External, were established prior to any scoring. Originally the manual contained the category of client Affective— NOnaffective as defined in Kbpplin (1965), but the category of client Internal—External quickly replaced it for two reasons. First, the client Affective-anaffective category did not logically parallel the therapist category of Internalizing-Externalizing, although there was considerable overlap. More importantly, however, scorers were unable to agree sufficiently on their own interpretation, and subse- quent scoring, of the client Affective-anaffective category. The absence of vocal cues, resulting from the use of tran- scripts, probably contributed to this lack of agreement. Finally, the term "affect" implies "emotionality," an im— portant dimension but not the focus of this study. The Internal-External dimension, on the other.hand, is both an important aspect of psychotherapy (i.e., see Kell 26 and Mueller, 1966), and lends itself to the other scoring categories. Figler, for example, is using the same system to investigate both therapist and client verbal behaviors along this Internal-External dimension (Figler, personal communication). Table 3 shows an interesting trend has occurred be- ginning with Winder_e£_al. (1962), through Schuldt (1965), to the present study. Specifically, the rate of therapists' approach (i.e., to dependency) has shown an increase, with a parallel decrease in rate of avoidance. This trend probably reflects two changes: first in the definition of approach and avoidance (there has been an increased emphasis on the therapists' intent); second, therapists may be changing their behavior as a result of the literature on therapist behavior, i.e., they may be approaching at a greater rate (Winder, personal communication). Figure l and Table 4 indicate that although the data follow predicted trends, they fail to support the hypotheses statistically: neither the sex of the client nor the phase of therapy significantly affect the frequency of total de- pendency expressions. Thus, consonant with Heller and Gold— stein (1961) and Cartwright, Kirtner, and Fiske (1963) who studied overt dependency with similar samples, the present study finds no change in overall dependency from the be- ginning to the end of therapy. Total dependenpy Hypothesis Ia: 27 Total dependency will decrease (total dependency is the sum of dependency statements scored in each of the relationship categories). Hypothesis IIa: Female clients will initially make more dependency statements. Hypothesis IIi: By the terminal phase female and male clients will net differ in frequency of dependency expressions. 400 416 Total 368 341 0 a 300 o c m 3 a 2254‘.“ _§emales m “ -..‘%20 ~ ‘~.__ 1 200 19 -.1? Males 148 168 100 First Middle Terminal- Figure 1. Stage of Therapy Total dependency. 28 Table 4. Total dependency analysis of variance table. Sum of Effect Squares DF Mean Square F P Sex 141.07 1 141.07 0.842 .371 Error 3015.87 18 167.55 Phase 292.50 2 146.25 1.287 .289 Phase x Sex 87.03 2 43.52 0.383 .675 Error 4091.13 36 113.64 Total 7627.60 59 29 Primary system dependency Hypothesis Ib: Clients' dependency expressions scored as Primary system (therapy process, roles, goals) will decrease steadily. Hypothesis IIb: Initially, female clients will make more dependency statements classified as Primary system. 150 127 0 >1 0 s: 100 (D :5 O‘ m H In so 0 __ First Middle Terminal Phase of therapy Figure 2. Primary system dependency. 30 Table 5. Primary system dependency analysis of variance table. Sum of Effect Squares Df Mean Square F P Sex 13.07 1 13.07 .688 .418 Error 342.00 18 19.00 Phase 194.43 2 97.22 3.920 .029 Phase x Sex 0.43 2 0.22 .008 .722 Error 891.80 36 24.77 Total 1441.73 59 As predicted in hypothesis Ib, primary references decrease steadily from the beginning to the terminal phase of therapy. But male and female subjects do not differ significantly, thus the data offer so support for hypothesis IIb. 31 Secondary system dependency Hypothesisylg: Clients dependency classified in the Secondary relationship (client and therapist interacting as people) will increase throughout therapy. Hypothesis IIc: Initially, female clients will make more dependency statements classified as Secondary system. 80 67 68 ' O 60 >1 2 Total m s U' 3 m 38 4O 34 Females, ’0 m 33 \Q, 26 /’ 20 13 13 0 First Middle Terminal Phase of Therapy Figure 3. Secondary system dependency. 32 Table 6. Secondary system dependency analysis of variance table. Sum of Effect Squares Df Mean Square F P Sex 0.82 1 0.82 .045 .833 Error 322.83 18 17.94 Phase 57.43 2 28.72 2.453 .100 Phase x Sex 2.43 2 1.22 .104 .902 Error 421.47 36 11.71 Total 804.98 59 Although the increase in Secondary dependency from the first to the middle phase is significant (t = 7.66; P < .01), the trend does not continue through the end of therapy; thus the data fail to support hypothesis IIc. Figure 3 and Table 6 show that no sex differences exist in verbal dependency classified as Secondary. 33 Self system dependency HypotheSis Id: Clients! dependency classified in the Self system relationship category will increase through- out therapy. (Self system statements refer to the client specifically, not in a relationship with others). Hypothesis IId: Initially, female clients will make more dependency statements classified as Self system. 100 91 80 79 Total 60 >, 60 o c m s O" m s... m 40 20 0 First Middle Terminal Phase of therapy Figure 4. Self system dependency 34 Table 7. Self system dependency analysis of variance table. Sum of Effect Squares Df Mean Square F P Sex 0.27 1 0.27 .016 .899 Error 288.73 18 16.04 Phase 24.43 2 12.22 1.458 .246 Phase x Sex 21.23 2 10.62 1.267 .294 Error 301.67 36 8.38 Total 636.33 59 Hypotheses Id and IId receive no statistical support: neither the sex of the client nor the phase of therapy sig— nificantly affect the frequency of dependency expressions classified as Self system. 35 Family system dependency Hypothesis If: Clients' dependency classified in the Family systgm category will decrease throughout therapy. Hypgthesis IIe: Initially female clients will make more dependency statements classified as Family system. 120 100 80 60 Frequency 40 20 115 \ \33 emales X \‘ 22 \\19 ¢)_' _~o tk-"M§1es First Middle TerminaI Figure 5. Family system dependency. 36 Table 8. Family system dependency analysis of variance table. Sum of Effect Squares Df Mean Square F P Sex 4.27 1 4.27 .152 .701 Error 505.00 18 28.06 Phase 108.93 2 54.47 1.615 .213 Phase x Sex 68.13 2 34.07 1.011 .374 Error 1213.59 36 33.71 Total 1899.93 59 Although the initial decrease in Family system ex- pressions is significant (t = 6.84; p < .01), the trend does not continue through the end of therapy; hypothesis If is not supported. No significant difference exists between male and female clients. 37 Tertiary‘eystem dependency _Hypothesis Ig: Clients' dependency classified in the Tertiary system (client in interaction with other people) will decrease throughout therapy. Hypothesis IIf: Initially female clients will make more dependency statements classified as Tertiary system. 80 m 60 o c o e O" m H m 40 20 9 0 First Middle Terminal Phase of therapy Figure 6. Tertiary system dependency. 38 Table 9. Tertiary system dependency analysis of variance table. Sum of Effect Squares Df Mean Square F P Sex 10.42 1 10.42 1.407 .251 Error 133.23 18 7.40 Phase 35.23 2 17.62 3.712 .034 Phase x Sex 5.23 2 2.62 .551 .581 Error 170.87 36 4.75 Total 354.98 59 As Table 9 indicates, significant differences in fre— quency of Tertiary system dependency exist across the three phases of therapy; after an initial increase from the first to the middle phase (contrary to the predicted trend), clients make fewer dependency statements classified as Tertiary by the terminal phase of therapy, as predicted in Hypothesis Ig. On the other hand, Hypothesis IIf receives no support; males and females do not differ in frequency of dependency expressions scored as Tertiary. 39 Therapist system dependency Hypothesis Ie: Client's dependency classified in the Therapist system (the therapist relating to his own family, friends, etc.) will increase throughout therapy. Hypothesis Igg: Initially male clients will make more dependency statements scored as Therapist system. 20 5: 15 c w s O" w :2 10 5 5 3 o 1- First Middle Terminal Phase of therapy Figure 7. Therapist system dependency. 40 Table 10. Therapist system dependency analysis of variance table. Sum of Effect Squares Df Mean Square F P Sex 0.27 l 0.27 .100 .755 Error 47.67 18 2.65 Phase 4.43 2 2.22 1.611 .214 Phase x Sex 2.03 2 1.02 .739 .485 Error 49.53 36 1.38 Total 103.93 59 The data fail to support hypotheses Ie and IIg: neither sex of the client nor the phase of therapy signifi- cantly affect the frequency of dependency expressions classi- fied as therapist system. 41 Other system dependency; NOn- reference system dependency Hypothesis IIh: Initially males will make more dependency statements scored as other system (people other than the client or therapist in interaction). Hypothesis IIi: Initially males will make more dependency statements scored as anreference system (impersonal facts, opinions, unscorable expressions). 10 ' E‘ Total w s 5 U 4 ‘, iar~Eema1es 0) I I 5 ~ § H o:— "" ‘64 First Middle Terminal Figure 8. Other system dependency. Total 22 20 c 17 5. Female ,—’o C / 0 12 7’ 5 0’ O‘ 10 p ’ g 6 Male a. / , § 5 4.0” 0 2 First Middle Terminal Figure 9. NOnreference system dependency. 42 Table 11. Other system dependency analysis of variance table. Sum of Effect Squares Df Mean Square F P Sex 0.82 l 0.82 3.127 .094 Error 4.70 18 0.26 Phase 0.43 2 0.22 .429 .655 Phase x Sex 0.03 2 0.02 .033 .968 Error 18.20. 36 0.51 Total 24.18 59 Table 12. NOnreference system dependency analysis of vari- ance table. , Sum of Effect Squares Df Mean Square F P Sex 6.02 l 6.02 1.820 .194 Error 59.50 18 3.31 Phase 7.23 2 3.62 1.572 .221 Phase x Sex 2.63 2 1.32 .572 .569 Error 82.80 36 2.30 Total 158.18 59 43 Hypotheses IIh and 111 are not supported: no sig— nificant differences exist between the frequencies of Other system and NOnreference system dependency expressions of male and female clients. Similarly, the phase of therapy has no effect on the frequency of dependency expressions classified as Other relationships or anreference. Length of therapy, Success Therapists rated the success of therapy on a 4 point scale: successful (1); partially successful (2); partially unsuccessful (3); unsuccessful (4). This rating reflects only the therapists' judgment; no objective criteria were re- quired. For the 20 clients, therapists rated the therapy as successful or partially successful in 14 cases (7 males and 7 females): a success rate of 70%. (Although showing no re— lationship between success and either dependency behavior nor MMPI scores on the Mf scale, Table 13 shows success and length of therapy to be strongly related (r = -.668). That is, longer term clients tend to be rated by their therapists as more successful. Table 14 reflects an interesting aspect of this re- lationship between length of therapy and success. While males are relatively evenly distributed, females tend to group into two types: short length of therapy with an un- successful rating; long therapy with a successful rating. 44 Table 13. Inter-correlation Matrix. Clients' dependency, Mf score, Length of therapy, and Success: total client sample. 1 2 3 4 l. Dependency 1.000 2. MMPI Mf .166 1.000 3. Length of therapy .181 -.001 1.000 4. Success —.103 —.061 -.668* 1.000 *Significant at P's .05. Table 14. Length of therapy and therapists' rating of suc- cess: total client sample. Length of Therepy: Short: Medium: Long: (5-10 (ll-l7 (18-22 Therapists' rating sessions) sessions) sessions) F Successful F M F F Partially F M M M F Successful M M F Partially F M Unsuccessful F M M Unsuccessful F N = 7 N = 6 N = 7 M represents a male client. F represents a female client. 45 Because neither outcome (i.e., success) nor length of therapy constitutes the main focus of this study, no pre— dictions regarding their relationship to dependency were made. It was felt, however, that longer term (i.e., more successful) clients might differ in important ways from short term clients in the focus (relationship) of their dependency throughout therapy. In order to accentuate and evaluate these possible differences in dependency behavior, the client sample was divided into thirds in terms of length of therapy (5-10, 11—17, 18—22 sessions). Short (N = 7) and long (N = 7) term clients were then contrasted in terms of total dependency and dependency classified in each of the eight relationship categories (see Figure 10). As expected from the positive correlation between dependency and length of therapy, the mean total dependency score for short term clients was lower at each phase of therapy. Using even extreme groups, however, the differences are not significant. In fact, Figure 10 shows that only two comparisons yield a significant difference: the middle phase in the Secondary relationship category (t = 2.73) and the middle phase in the Self category (t = 2.35). Thus the effect of short term as opposed to longer term "types" of clients was minimal in terms of clients' dependency behavior. 46 Mean Total Dependency 30 23. , 21.4 C: 20 O-~ ‘ X long 19.]. (D ‘0\ 3 19.2\\ \ short ‘\.\ 10 T16 Mean Primary System Dependency 6.00 6 S 4 $2" 2 b 0.86 First Middle Terminal Phase of therapy Figure 10. Short (N = 7) versus long (N = 7) term therapy dependency. 47 Mean Secondapy:§ystem Dependency 6/.€4\3* 6 / /’ \ Short 5.29 c: / 3 4 / \ 2 /'/ \ 2.43 c/ \0 2 ong 0.86 1°1V/T57‘." Mean Self System Dependency 6 5.57* Rog/X 4.56 c g ‘4 z 3.71°‘\ \\ ,.J’ \x ,, 3.00 2 \\ short /' \ / \O’ / . 1.86* First Middle Terminal Phase of Therapy _ .*Diff9rence significant at p_$ .05. Figure 10.--Continued 48 Mean Family System Dependency 5 5.43 5 4 1mg 4 57 c \‘ 4.00 I '0 4 \ . / (D X 2 \ / \ short // 2 \ ’ ' \ / 2.71 ‘\ / \\ / \Y 0.71 Mean Tertiary System Dependency 4 3.57 2.71 _, , ’/ (\\l°ng 2 r’/3 28 .71 \ 2 00 \. C 2 short \ m o \ Z '\ \7 0.71 First :Middle Terminal Phase of Therapy Figure 10.--Continued 49 Mean Therapist System Dependency 1.0 1.00 c 8 2 0.5 \ \. \\9.00 O 1.0 Mean Other Syetem Dependency E: 0.5 0.28 ‘\0.00 First Middle Terminal Phase of therapy Figure 10.--Continued 50 Mean NOnreferencegpependency Mean First Middle Terminal Phase of therapy Figure 10.--Continued Psychological cheracteristics Although not used to select clients for the study, several aspects of MMPI pretesting require examination: first to more precisely define the client sample; secondly to offer some hypotheses about data previously described. To attempt to reflect the degree of "pathology" represented in the sample, the frequencies of deviant (i.e., standard scores of 70 or greater) scores on the clinical scales are summarized in Table 15. As can be seen, male clients achieved many more deviant scale scores. These results 51 Table 15. Number of deviant MMPI scales, Mf scale standard scores, success rating, and length of therapy: total client sample. Subject Number of deviant Mf scale Length Rating Number MMPI scales standard of of above 75 above 70 score therapy success Females l 4 1 56 18 2 2 2 1 47 22 2 3 l 0 62 20 2 4 0 3 73 7 2 5 0 l 49 18 1 6 0 0 54 6 4 7 0 0 40 8 3 8 0 0 51 6 3 9 O 0 58 22 1 10 0 0 43 11 1 Males 1 3 1 71 14 2 2 2 1 67 10 3 3 1 0 52 17 2 4 0 2 69 17 2 5 0 3 61 16 2 6 2 4 43 12 3 7 0 0 49 18 2 8 l 2 56 5 3 9 3 2 61 9 2 10 3 1 56 19 1 reflect the generality of the "type of client represented in the present study. Cooke and Kiesler (1967), for example, report almost identical MMPI data with their counseling center sample: Male clients, unlike female clients, had significantly more T scores above 70 than their same sex 52 (non client) controls. Moreover, in the Cooke and Kiesler study the mean number of deviant scores for each sex repli- cate those of the present sample (1.7 for males, .55 for fe— males; the present study found a mean of 1.5 for males, .70 for females). More directly related to the hypotheses involved in the present study, the Mf scale of the MMPI also reflects a difference between male and female clients. Table 16 shows that the male clients scored significantly above their male college student norm, while female clients in the sample did not differ from the norm for college females in general. Thus the MMPI performance of the study's male and female clients differs in two important ways. These differences question the appropriateness of comparing the dependency of 'the male and female client groups in terms of general sex differences. Table 16. (Clients' scores on the Masculinity-feminity (Mf) scale of the MMPI. MALES FEMALES N Mean SD N Mean SD Client raw scores 10 31.64 4.37 10 38.50 4.38 Nerm group 260 26.28 5.06 205 37.38 4.53 Raw scoresa Difference 5.35* 1.12 A T aMichigan State University student norms: Dr. Williavaueller, personal communication. *Significant at P_g .05 level (t = 3.45). 53 Fortunately there is sufficient overlap between groups for individual subjects to be matched. Specifically, 6 males and 6 females produced similar frequencies of deviant MMPI scores; and 8 males and 8 females scored nearly identi- cal standard scores on the Mf scale of the MMPI. Tables 17 and 18 portray the comparison of these closely matched sub— jects, which replicates the findings with total groups: fe— male clients do not express significantly more dependency than male clients, even when matched on a measure of path— ology and masculinity—femininity. Table 17. Total verbal dependency scores for the 6 male and 6 female clients who could be matched on the number of deviant MMPI scales. Males Females Subject Verbal I Verbal Subject number dependency Difference dependency number 1 63 - 55 l 2 21 + 106 2 3 47 + 56 3 4 79 - 25 4 5 35 + 61 5 7 49 + 51 8 sum = 294 N.s.* sum = 354 i: 49.0 i: 59.0 *NOnsignificant. 54 Table 18. Total verbal dependency scores for the 8 male and 8 female clients who could be matched on Mf standard scores. Males Females Subject Verbal Verbal Subject number dependency Difference dependency number 6 33 + 57 10 7 37 + 61 5 8 91 — 55 l 10 48 + 61 6 3 47 - 37 8 9 63 - 25 3 5 35 + 58 9 l 63 - 56 4 sum = 417 N.s.* sum = 140 31:52.1 3'1: 51.2 *NOnsignificant. DISCUSSION Sex differences The study hypothesized different frequencies of de- pendency expressions from male and female clients in all re— lationship categories. Although male and female clients differed in the predicted direction in total dependency (fe- males expression more), the difference was small and non— significant. Data from the relationship categories also fail to support the hypothesis of a difference between sexes. The male and female clients used in the study, of course, differ in at least two crucial ways from male and female college students in general. First, they are clients, i.e., they have felt it necessary to ask for professional help. Second, the males show significantly more feminine re- sponse patterns on the MMPI than non-client college males. This finding, paralleling that of Kaufmann (1956) with a similar sample, suggests that: . . male patients, generally having more feminine interests than the controls, are a less self as- ‘sertive group than the controls. One might further suggest that to a certain extent they are more 71:56) subdued by adverse circumstances (Kaufmann, Thus the assumptions regarding sex differences in normals (which were the underlying bases for the hypotheses 55 56 of this study) may not be at all applicable to male versus female therapy clients. Because no sex differences were found in dependency even when male and female clients were matched on degree of pathology (MMPI deviation) or on masculinity-femininity relative to their own sex (Mf scale standard scores), the findings may hold for male and female clients in general. Several areas of investigation bear on the issue that questions if these results are sample specific. Sears (1963), studying children, reported significant differences in the dependency behaviors of boys and girls; more im- portantly, different antecedent conditions underly these be- haviors. Thus under constant conditions (i.e., in therapy with a male counselor) it remains a question if the sex differences in dependency would be elicited. As previously mentioned, with normal college males and females Wagman and Long report significant sex differences in occupational values (wagman, 1965) and scholastic and interest patterns (Long, 1964). Yet Stuart_e£_el. (1965) question the assumed de- pendency differences between male and female college stu- dents. Specifically, they found no differences in field de- pendence between male and female students on Witkin's Embedded Figures Test, Short Form. Further, Stone (1962) studied stu— dents' willingness to take risks (guess at unknown items) and 57 found no sex differences, along with no relationship between risk taking willingness and vocational choice. Heilbrun (1963) studied the discrepency between subs jects' ratings of social desirability of EPPS items and their own responses. He had previously found, as did the present study, that adjusted (non client) males were more masculine than less adjusted (client) males (Heilbrun, 1960). These males with poorer adjustment also showed poorer identification with their fathers (Heilbrun, 1962). Heilbrun (1963) thus predicted that females, hypothesized to be in more sex role conflict (i.e., the independence required of students in college) than males, would show more discrepency between their EPPS responses and their rating of social de- sirability of those responses. Of all 210 items, however, only those constituting achievement motivation differentiated between males and females. Heilbrun concluded that females reflected the sex-role conflict only in terms of achievement motivation and not in a wider range of interpersonal roles (i.e., the EPPS also contains the autonomy and deference scales, often used to assess dependency). These studies, in summary, yield inconsistent find- ings. On the one hand it may be that the sex differences evident in childhood become less evident by college age. Yet, as Sears (1963) warns, dependency may not be a unitary concept; requiring more definition to consistently relate to sex differences. 58 The results of the present investigation cannot be taken to indicate that normal males and females do not differ in terms of dependency behavior: an investigation of therapy cannot by definition test the difference between normals. The study does conclude, however, that for male and female college student clients in therapy with male counselors, no differences in dependency exist attributable to the (biological) sex of the client. Phase of therapy and dependency In summary, overall differences in Clients' verbal dependency across the phases of therapy were found in two re- lationship categories: the formal process of therapy (Pri- mary system), which includes discussion of the roles and expectations of therapy, the client's decision to be in therapy, frequency of sessions, etc.; showing a steady de- crease in frequency; and social relationships (Tertiary Sys— tem) which increased through the middle of therapy then de- creased by the end of therapy. Mere specific significant changes were found between the initial and middle phases in ,two additional relationship categories: the relationship be- tween the client and therapist (Secondary System) where the frequency of dependency expressions increased; and the Family System, showing a decrease in frequency. After these initial changes, Secondary and Family references remained 59 constant through the terminal phase of therapy. Figure 11 represents summary graphs depicting these trends. In terms of the assumptions underlying hypotheses Ia- 19, these findings have several implications. Consonant with the results of Lennard and Bernstein (1960), the present study found that Clients' dependency expressions concerning the formal process of therapy (Primary System) decreased as therapy progressed. Such a trend probably characterizes all extended forms of psychotherapy. That by the middle phase of therapy clients make sig— nificantly more dependency statements in reference to the re— lationship between the therapist and client (Secondary Sys- tem) than they do at the beginning of therapy is consistent with the study‘s assumptions. Specifically, as the client and therapist encounter an "increasingly intense and recipro- cal impact on each other" (Kell and Mueller, 1966), the client focuses dependency increasingly on their relationship. Interestingly, the increase in Secondary relationship de— pendency accompanies a significant decrease in clients' de- pendency classified in the Family relationship category. As the university experience probably represents the first ex- tensive experience away from the family for most of the clients used in this study, and as they were experiencing difficulties (i.e., they were clients), the inverse relation- ship between Family and Secondary System dependency becomes understandable. Thus contrary to the assumptions underlying 6O Primapy eystem 150 _ a 127 o c 8 100 8' H 78 m 50 49 Family system 115 100 a o c 8 U 70 w u ‘" 50 52 First, Middle Terminal Phase of therapy Figure 11. Summary graphs of Clients' Secondarygeystem 67 A 68 60 40+ 26 20 Tertiaryvsystem “67 54 50 30 25 First Middle Terminal Phase of therapy dependency scored as Primary, Secondary, Family, and Tertiary System. 61 Hypothesis If, the decrease in Family dependency from the initial to the middle phase of therapy may represent a re— focusing of dependency and dependency conflicts from their original locus (the family) to their current manifestations (the client-therapist relationship). A similar past-to-present refocusing of conflicts may characterize the increase, from the initial session to the middle phase, of Teritary (social relationships) de- pendency expressions. The subsequent decrease in Tertiary expressions through the terminal phase of therapy suggests that the effects of therapy on verbal dependency are quite specific. That is, the study assumed that a decrease in total dependency would reflect the resolution of dependency conflicts by the terminal phase. If, however, the process of therapy does involve the resolution of dependency con- flicts, resulting in a decrease in dependency expressions, the data show this process to be specific to the category of social relationships (i.e., Tertiary System). Thus this study shows that to discuss dependency in psychotherapy, without specifying the category of relationships involved, constitutes an unwarranted and unrealistic oversimplification. Note that the changes in dependency that occur through therapy parallel child-developmental trends. Initially, the child depends heavily on the family. Then with increasing maturation some of the dependency shifts to other systems of interaction, for example school teachers and peers 62 (paralleling the Secondary and Tertiary Systems?). Finally, although perhaps no less dependent overall, the young adult exercizes a degree of increased autonomy in social relation— ships (i.e., the decrease in Tertiary System dependency). This view suggests that relatively short term therapy with college students may represent a highly compact developmental experience. Length of therapy, success, dependency As mentioned previously in this paper, the therapists participating in the study shared the assumption that the relationship between the client and therapist is an important element: it provides a stage where the clients' conflicts may be generated (e.g., dependency conflicts); it provides a situation where the therapist may relate past (reported) ex- periences with present (observed) behavior; it provides a vehicle for change (i.e., by interpretation of past or present behavior, reinforcement of different responses, modeling, etc.). Thus the present study assumes that the nature of the relationship must be at least in part an element of these therapists' ratings of success. And while the direct re- lationship between the client-therapist interaction (Second- ary System) and success rating was not studied, the data con- tain an intriguing finding. That is, length of therapy and therapists' rating of success were significantly related (r = 9(668). And being a 63 subjective rating, this correlation may represent a therapist set, depending at most on the clients' verbal report of extratherapy behavior and the therapists' perception of therapy behavior. Added to this is the tentative (i.e., post hoc) finding that short (5-10 sessions) and longer term (18-22 sessions) clients differed significantly in their fre— quency of dependency expressions only at two points, both in the middle phase of therapy, in the relationship categories of Secondary and Self. Summarizing the above, shorter term clients (i.e., those frequently rated as less successful) were those that in the present study expressed: significantly more Secondary System dependency (i.e., the client-therapist relationship) during the middle phase of therapy; significantly less Self System dependency during the same period. Coupled with the fact that female clients are heavily represented in the short and long groups (i.e., 4 of 7 and 5 of 7 respectively), these data imply that the focus of the Clients' dependency may influence the course of therapy, especially with male counselors. That is, clients who focus dependency concerns and conflicts on the client-therapist relationship, rather than more generally on themselves independent of a specific relationship, early in the therapy situation (i.e., the middle phase of therapy for short term clients corresponds to 3 to 5 sessions) place intense demands on the therapist. If, as it appears, these therapists cannot meet nor otherwise 64 adequately handle these dependency expressions, then these clients tend to terminate, often with unsuccessful ratings by the therapist. If, on the other hand, the client and therapist can remain in a therapeutic relationship for a longer period of time, therapy is generally rated as suc- cessful by the therapist (i.e., 12 of the 13 clients seen for 11 or more sessions were rated by their therapists as successful or partially successful). Because the present study used a counseling center population, termination may have involved not only the clients' and/or therapists' decision, but also a time limitation imposed by the end of the school year. Thus the trends discussed above may not be at all applicable to other than counseling center and insurance cases which have a clear time limitation. As previously mentioned, however, the data of the present study find many parallels with studies per- formed at various counseling centers. Cartwright, Kirtner, and Fiske (1963), for example, not only reported no change in overt dependency (as did the present study); they found also that length of therapy correlated significantly with only 2 of 84 total change measures: both of these measures reflected therapists' rating of success. Cartwright 2E_él- also found that the pattern of intercorrelations of 28 clients with 37 or more sessions paralleled the pattern characteristic of shorter term clients (3—36 interviews). Thus with counseling center 65 clients, the relationship between length of therapy and suc- cess holds for an extended period of time. Of course, therapists' ratings of success suffer from many drawbacks as criteria of success. Further, success constitutes only a tangential issue in this investigation. So the implications of the above are only tentative, if interesting, hypotheses. But it would seem crucial, with college students who are see— ing a male counselor and who develop rapid and intense de- pendency in the client-therapist relationship, to develop techniques for therapists to deal adequately with this de— pendency. In this way, these clients may remain longer in therapy for hopefully a more successful conclusion. The failure, in the present study, to replicate the "failure zone" (13-21 sessions) of Cartwright (1955; Kirtner and Cartwright, 1958) with counseling center clients may re- flect a number of differences. First, the therapists' ratings of success or failure may reflect grossly different criteria. Kirtner and Cartwright (1958) found that their "failure zone" group showed the greatest disturbance in sex- role and identification. In the present study male clients, who showed sex-role deviation in terms of deviant Mf scores, constituted the majority of cases in of 13-21 sessions duration. Yet these cases, in the present study, were all judged as successful. Until the criteria of success becomes public, such discrepancies will probably remain. 66 Another difference may be that the number of sessions do not represent the same temporal span in the two studies. Because of the term system, a frequency of 10 sessions in the present study usually covered a period of 11—12 weeks. Kirtner and Cartwright's sample, on the other hand, may have averaged more than one session a week. Third, the intake interview, characteristic of the procedure used at the counseling center represented in the present study, may serve to foreshorten or preclude some of the processes that may otherwise evolve during therapy. Finally, therapist or client characteristics unique to the present study (i.e., therapists' style) may have operated to shorten the "failure zone" to 5-10 interviews. Further study of these hypotheses is required. SUMMARY Each dependency statement of twenty clients in psycho- therapy was classified into one of eight relationship cate- gories, which included: the relationship between the therapist and client, the client and his family, and the client in other social relationships. The study's purpose involved re- lating the frequency of dependency expressions in each of these relationship categories to two variables: the sex of the client and the phase of therapy. Three judges, showing impressive reliability, scored sixty typewritten tapes, representing the first, middle and next to last interviews of 10 male and 10 female clients, all with a male counselor. In addition, the study examined pre-therapy MMPI performance as well as therapists' ratings of success. The study evaluated two sets of hypotheses, one set involving predicted differences between male and female clients, the other involving differences between the three phases of therapy. In general, the investigation predicted female clients would make more dependency statements, and -would express dependency more directly. These predictions of sex-differences were not supported by the data, as Clients' verbal behavior failed to reflect any differences 67 68 in dependency due to the sex of the client. Auxiliary MMPI data, however, showed that males produced more deviant MMPI sclae scores; and male clients, unlike female clients, scored significantly above their norm group on the Mf scale (i.e., more feminine). Eight pairs of clients (male—female) could be matched on Mf scale standard scores, and 6 pairs were matched on the number of deviant MMPI scales. The data from these matched groups supported the same conclusion: male and female clients did not differ in frequency of verbal de- pendency behaviors. Significant changes in dependency in several relation- ship categories arose, some in support of the study's hy- potheses, some contrary. _As predicted, dependency expres- sions classified as pertaining to the formal process of therapy (the role expectations, frequency of meetings, etc.) decreased from the beginning through the end of therapy. On the other hand, dependency expressions involving the relation- ship between the client and therapist increased significantly from the beginning to the middle of therapy, then remained stable. The inverse occurred with dependency involving the client's family, which initially decreased then remained con- stant. These results suggest that these late adolescent clients refocus their dependency needs and conflicts from their original locus (the family) to the therapy situation (manifested in the client-therapist relationship). Finally, dependency involving social relationships initially increases, 69 then decreases by the end of therapy. This suggests the possibility of two processes occurring through therapy: first a refocusing of the topic of dependency from the family to social relationships; then a decrease in the fre— quency of dependency expressions involving social relation- ships, reflecting the resolution of dependency concerns and conflicts. It was noted that the trends in dependency involving family and social relationships that emerge during therapy follow the form suggested by the principles of human develop- ment and the process of socialization, as if therapy repre— sents a compact developmental experience. Finally, the investigation produced findings that suggest, although tentatively, that therapists' rating of success is related to the amount of dependency involving the client-therapist relationship during the middle phase of therapy. Short term clients, those frequently rated as un- successful, expressed significantly more dependency in the client-therapist relationship category early in therapy (3—5 sessions). It was suggested that with this type of client therapists develop techniques to adequately handle the in— tense demands this places upon the therapist, so the clients may remain longer in therapy and increase the probability of a successful therapeutic experience. REFERENCES Apfelbaum, D. Dimensions of Transference in Psychotherapy. Berkeley: University of California Press, 1958. Bandura, A., Lipsher, D. H., and Miller, P. E. Psycho- therapists' approach-avoidance reaction to patients' expressions of hostility. Journal of Consulting Psychology, 1960, 24, 1-8. Caracena, P. F. Elicitation of dependency expressions in the initial stage of psychotherapy. Journal of Counseling Psychology, 1965,_12, 268-274. Cartwright, D. S. Success in Psychotherapy as a function of certain actuarial variables. Journal of Consulting Psychology, 1955, 12, 357-363. Cartwright, D. S., Kirtner, W. L., and Fiske, D. W. Method factors in changes associated with psychotherapy. Journal of Abnormal and Social Psychology, 1963, 66 Cooke, M. K., and Kiesler, D. K. Prediction of college stu— dents who later require personal counseling. Journal of Counseling Peychology, 1967,_14, 346-349. Covner, B. J. Studies in phonographic recordings of verbal material: The use of phonograph recordings in counseling practice and research. Journal of Con- sulting Psychology, 1942, 6, 105-113. Ebel, Robert. Estimation of the reliability of ratings. Psychometrica, 1951,.16, 407-424. . Freud, Sigmund. A General Introduction to Psychoanalysis. New York: Liveright Co., 1920. Fuller, F. F. Influence of sex of counselor and of client on client expression of feeling. Journal of Counseling Guilford, J. P. Fundamental Statistics in Psychology and Education. New York: McGraw—Hill, 1956. 70 71 Heilbrun, A. B. Personality differences between adjusted and maladjusted college students. Journal of Ap- plied Psychology, 1960, 44, 341—346. . Parental indentification and college adjustment. Psychological Reports, 1962, 19, 853-854. . Sex-role identity and achievement motivation. Psychological Reports, 1963, 12, 483-490. Heiss, J. S. Degree of intimacy and male-female interaction. Sociometry, 1962, 25, 197-208. Heller, K., and Goldstein, A. P. Client dependency and therapist expectancy as relationship maintaining variables in psychotherapy. Journal of Consulting Psychology, 1961,.25, 371-375. Kammerschen, K. Inter-judge reliabilities and selected client-therapist variables: A content analysis of initial psychotheraputic interviews. Unpublished masters thesis, Michigan State University, 1965. Kaufmann, P. Changes in MMPI as a function of psychiatric therapy. In G. S. welsh and W. G. Dahlstrom (Eds.). Basic Readings on the MMPI in Psychiatryyand Medi- cine. Minneapolis, Minn: University of Minnesota Press, 1956. Kell, Bill L., and Mueller, William J. Impact and Change: A Study of Counseling Relationships. New York: Appleton-Century-Crofts, 1966. Kirtner, W. L., and Cartwright, D. 8. Success and failure in client-centered therapy as a function of client personality variables. Journal of Consulting Psy- chology, l958,_22, 259—264. Kepplin, D. A. Hostility of patients and psychotherapists‘ approach-avoidance responses in the initial stage of psychotherapy. Unpublished masters thesis, Michigan State University, 1963. Eliciting responses in client-therapist inter- action: a content analysis of initial psychothera-, putic interviews. Unpublished doctoral dissertation, Michigan State University, 1965. Lennard, H. L. and Bernstein, A. The Anatomy of Psycho- therapy. New Ybrk: Columbia University Press, 1960. 72 Lindquist, E. F. Design and Analysis of Experiments in Pey- chology and Education. Boston: Houghton—Mifflin Co., 1956. Long, John M. Sex differences in academic prediction based on scholastic, personality and interest factors. Journal of Experimental Education, 1964, 32, 239-348. Murray, E. The content—analysis method of studying psycho- therapy. Psychological Monographs, 1956, 10 (whole No. 420). Navran, L. A rationally derived MMPI scale to measure de— pendence. Journal of Consulting Psychology, 1954, 18, 192. Rogers, C. R. Client—centered Therapy: Its Current Practice, IImplications, and Theory. Boston: Houghton, 1951. Rogers, C. R., and Dymond, R. F. (Eds.). Psychotherapy and Personality Change. Chicago, Ill: University of Chicago Press, 1954. Satir, Virginia. Conjoint Family Therapy. Palo Alto, California: Science and Behavior Books, Inc., 1964. Schuldt, W. J. Psychotherapists' approach-avoidance re— actions and Clients' expressions of dependency, a longitudinal analysis. Unpublished doctoral disser- tation, Michigan State University, 1964. Sears, Robert R. Dependency motivation. In M. R. Jones (Ed.), Nebraska Symposium on Motivation. Lincoln, Nebraska: University of Nebraska Press, 1963. Snyder, W. V. Group report of a program of research in psychotherapy. Ann Arbor, Michigan: University Microfilms, 1953. A .pependency in Psychotherapy. New York: W. W. Norton and Co., Inc., 1953. Stone, L. A. .The relationship of utility for risk to college year, sex, and vocational choice. Journal of Counsel— ing Peychology, 1962, 2, 87. Stuart, I. R., Breslow, A., Brechner, S., Ilyus, R. B., and Wblpoff, M. The question of constitutional influence on perceptual sytle. Perceptual and Metor Skills, 1965, 29, 419-420. Varble, Wagman, Winder, 73 D. L. An exploratory analysis of hostility in psychotherapy. Unpublished doctoral dissertation, Michigan State University, 1964. Morton. Sex and age differences in occupational values. Personnel and Guidance Journal, l965,_44, 258-262. C. L., Ahmad, F. 2., Bandura, A., and Rau, Lucy C. Dependency of patients, psychotherapists' responses, and aspects of psychotherapy. Journal of Consulting Psychology, 1962,_2§, 129-134. APPENDIX A SCORING MANUAL The categories of dependency and hostility, therapist ap- proach and avoidance, therapist internalizing and external- izing, and therapist initiated dependency and hostility are a replication of the manual developed by: Kepplin, D. A. Eliciting responses in client-therapist interaction: a con- tent analysis of initial psychotheraputic interviews. Un- published doctoral dissertation, Michigan State Univ., 1965. The categories of client internal—external focus and simple agreement-disagreement are a modification of the manual de- veloped by Kbpplin (1965). The relationship categories are a modification of the system developed by: Lennard, H.L. and Bernstein, A. The Anatomy of Psychotherapy. New York: Columbia University Press, 1960. I. Scoring Unit and Interaction Sequence. A. Definition. A unit is the total verbalization of one speaker bounded by the preceding and succeeding speeches of the other speaker with the exception of interruptions. There are three types of scoring units: the "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) 74 75 Pauses. If a speaker pauses between statements, his verbalizations are not scored as separate units. The verbalization before and after the pause is considered one unit. Interruptions. Statements of either therapist or client which interrupt the other speaker will be scored only if the content and/or temporal continu- ity of the other speaker is altered by the inter- ruption. Then the interrupting verbalization be- comes another unit and is scored. A non-scored interruption is never taken into account in the con— tinuation 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 interaction 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 re— sponses 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 Content Categories. There are three major categories: Dependency, Hostility, and Other. They are scored as exhaustive categories. All dis- criminations are made on the basis of what is ex- plicitely verbalized by the speaker in the unit 76 under consideration. One statement or unit may be scored for both categories of Hostility and Dependency. l. 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. 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 indicate anger. C. I'm just plain mad. (Hos,se1f,I)* C. I just couldn't think--I was so angry. (Hos,self,I) C. My uncle was furious at my aunt. (Hos,0th,E) b. Dislike: expresses dislike or describes actions which would usually indicate dislike. C. I just couldn't get interested in them and would rather be somewhere else. (Hos,Ter,I) C. I've never felt I like them and I don't suspect I ever will. (Hos,Ter,I) C. He hates editorials. (Hos,NR,E) *Complete scoring of examples is listed to aid in training coders. The sequence is: Interpersonal content category, Relationship, Internal focus. When a statement is scored for two interpersonal categories, two separate scorings are listed. 77 Resentment: expresses or describes a per- sistent negative attitude which does or might change to anger in a specific occassion. C. They are so smug; I go cold whenever I think about having to listen to their “our dog" and "our son." Boy: (Hos,Ter,I) C. I was always jealous of my brother; he was their favorite. (Hos,Fam,I) Antagonism: expresses or describes anti- pathy or enmity. C. Its really nothing definite, but we al- ways seem at odds somehow. (Hos,Ter,E) C. There is always this feeling of being enemies. (Hos,Ter,I) Opposition: expresses or describes oppo- sitional feelings or behavior. C. If he wants to do one thing, I want to do another. (Hos,Ter,I) “ C. It always seems she is against things. She is even against things she wants. (Hos,NR,E) C. No, I don't feel that way (in response to Tie assertion). (Hos,Self,I) 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,Self,I) C. There is something to be critical about in almost everything anyone says or does. (Hos,NR,E) 78 g. Aggressive actions: acts so as to hurt an- other person or persons either physically or psychologically. C. He deserves to suffer and I'm making it that way every way I can. (Hos,Ter,I) C. I can remember Mother saying: "We slap those little hands to make it hurt." (Hos,Fam,I) 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; ex- presses concern about parental plans and ex- pectations regarding the client; expresses need to confide in, write to or communicate with parents; includes discussion of the 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 seeking 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,Prim,I) C. I wanted to talk over with you my reasons for dropping out of school next quarter. (Dep,Prim,I) C. Part of the reason I'm here is that everything's all fouled up at home. (Dep,Prim,I) C. I depend on her--I am tied to her. (Dep,Ter,I) C. I want to be babied and comforted. (Dep,Se1f,I) 79 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,Ter,I) C. ,I try to do it when he can see it's too hard for me. (Dep,Ter,I) 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; 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,Sec,I) C. If there was any homework, I did it so Dad would know I was studying like a good girl. (Dep,Pam,I) C. Is it all right if I talk about my girl's problem? (Dep,Prim,E) C. That's the way I see it, is that wrong? (Dep,Sec,I) C. I asked him if I were doing the right thing. (Dep,Ter,E) 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 being loved; to receive nurturant behavior from others (especially parents, authorities and therapist). C. It looks like it will be another lonely weekend, and who's going to cheer me up? (Dep,Se1f,I) 80 C. Instead of studying, I go talk with the guys about my problems. (Dep,Ter,E) C. I went home just for the day; I told my mother to make a home cooked meal be- cause that is what I was coming home for. (Dep,Fam,I) 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,Fam,I) 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,Ter,E) C. I'm planning to change my major. I'd like to know how to do it. (Dep,Prim,E) Concern about disapproval: expresses fear, concern, or unusual sensitivity about dis- approval of others; describes unusual dis- tress 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,Ter,I) C. My parents will be so upset about my grades, I don't even want to go home. (Dep,Fam,I) C. It seems like I always expect I won't be liked. (Dep,Se1f,I) C. I can't understand how you can stand me when I smoke. (Dep,Sec,I) Initiative seeking: asks the therapist or others to initiate action, to take the re- sponsibility for starting something (to start discussion, determine the topic); 81 arranges to be a recipient of the therapist's initiative; may solicit suggestions. C. Why don't you say what we should talk about now. (Dep,Prim,E) C. If you think I should keep on a more definite track, you should tell me. (Dep,Prim,E) C. I got my advisor to pick my courses for next term (Dep,Ter,E) C. Tell me what to do in these circum— stances . (Dep, Sec,E) 3. Other (0th): Includes all content of client's verbalizations not classified as Hostility or Dependency. Items scored in this category continue to be scored for Frame of Reference and Internalized Affective State. When Other is integral to another category, do not score. To score Other, the statement must be distinct from the discussion of another major category. FOCUS: INTERNAL-EXTERNAL: Each client statement is scored according to the mutually exclusive and exhaustive dichotomy of Internal and External, ex- cept when the client expression is scored as a simple agreement-disagreement. This category reflects the focus of the client statement as being (at least in part) on his own needs, feelings and reactions (Internal Focus), versus a focus "outside" of himself (External Focus). The defining characteristic is that the expression explicitly describes or relates the client's Internal state, i.e., past or present af— fective feeling or need. All discriminations are made on the basis of what is explicitly verbalized by the speaker in the unit under consideration. When both categories could be scored for the same interpersonal content cate— gory, the unit is always scored as Internal. 82 Internal (I): In this category the content re— fers to the client's own feelings, needs, and reactions to the stimuli impinging on him. To be scored as Internal, a client expression must directly refer to the client, although not all client personal expressions are scored Internal. Any expression of interpersonal need is scored Internal. Note: The definition of Internal represented in the present scoring system is not to be equated with a broad concept of "emotionality." The defining characteristic is the presence of a client Personal reference describing a present or past affective feeling, or reflect- ing an interpersonal need. The following examples aid in identification but are not differentiated in the scoring. a. Present affective feeling: includes ex- pression or description of client's present feelings; affective problem analyzing or affective problem solving; affective dis— cussion of client's actions, motivations and their consequence. The feeling may be related to a past event which has carried into the present. C. I'm just plain mad. (Hos,Self,I) C. I hope he calls me for Saturday night. (Oth,Ter,I) C. I want to get a 4—point. (Oth,Self,I) b. Past affective feeling: includes expres— sion or description of the client's past feeling; analysis of client's past feel- ings; affective discussion of client's past actions, motivations and their consequences. 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. (Hos,Self,I) C. I used to feel masturbation was very bad. (0th,Se1f,A) 83 External (E): Any expression not categorized as Internal or simple agreement-disagreement is scored as External. All expressions which do not directly refer to the client are scored Ex- ternal, although the action or feelings de- scribed or attributed to others may be quite affective in nature. Statements involving the client are scored External if they do not in— volve present or past affective feeling or needs or the Internal state of the client. The following represents examples to aid in identification but are not differentiated in scoring. a. Participant behavior: Includes description of actions of the client; includes de- scription 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 signifi- cance. 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. (Oth,Self,E) C. If dad doesn't like what I'm doing he just grumbles about it. (Hos,Fam,E) C. ‘My parents always ask if I'm getting enough sleep. (Dep.Fam,E) 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,Self,E) b. Observed behavior: includes description of the actions of specifyable 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 feelings about the behavior of others. C. My uncle was furious at my aunt. (HOS, 0th, E) C. Bill reads all the editorials. (Oth,NR,E) 84 c. Description of impersonal events, facts, opinions: includes statements with no psychological significance to any signifi- cant individual; discussion of intellectual, abstract or philosophical matters. Includes statements where the client may be manifest- ing affective expression, but the expression is like a speech he could give to any one or group, usually stylized by certain patterns (soap-box). C. Most people have a liberal attitude about sex; what people do privately is their own business. (Oth,NR,E) C. The individual is only a number here; the place is so large. (Oth,NR,E) NOTE: Client expressions which are scored as re- flecting the Relationship categories (see III, page 86) of Therapist, Other, or NOnreference cannot by definition be scored as Internal as these categories do not involve the client in any way (except as speaker). Relationship categories of Primary, Secondary, Self, Family, and Tertiary may or may not be scored as Internal depending on whether or not the expression involves a reflection or description of the client's internal state. 3. Simple Agreement or Disagreement (Agr): This category includes those statements of the client which simply acknowledge, agree, or disagree without elaboration to the preceding statement of the therapist. the: In all cases the Relationship of the ex— pression is that contained in the previous response. C. Yes C. Surely C. I agree C. I think so C. I don't think so C. No (as a matter of fact without hostility). III. 85 By definition, simple agreement by the client covers all categories that the therapist ap- proaches or introduces. C. (A client statement scored Dependency and Hostility; Family relationship.) T. You've got some feelings about needing them (Score approach to Dep and Hos; Fam frame of reference; internalizing) C. Yes. (Dep,Fam,Agr) (Hos,Fam,Agr) RELATIONSHIP or ROLE SYSTEM: Categories of Client and Therapist Expressions. Each client and therapist ex- pression is scored in one of the eight mutually ex— clusive and exhaustive categories covering the relation- ship that is the focus of the expression: primary, secondary, self, tertiary, therapist, other and non- reference. Scoring is done on the basis of the re— lationship, if any, that is primarily the explicit focus of the expression. In most cases the scoring will re- flect as description of actual interaction (i.e., "I talked to him."). Some relationships, however, will be structural rather than behavioral (i.e., "He and I are in the same class."). If a unit contains more than one relationship, score in the category that best represents the main focus of the expression. If the main focus is on more than one cate- gory, then score each category that constitutes the main focus. Each expression is scored independently of the next, and all discriminations are made on the basis of what is explicitly verbalized by the speaker in the unit under consideration with the following exceptions: 1. When a personal pronoun is present which obviously re— fers to a relationship explicitly discussed previously; 2. When the unit is the obvious completion of an ex- pression initiated by the other speaker (See Therapist reflection, IV,A,1,b); 3. When the expression consti- tutes a frequently used and culturally accepted state- ment which obvious stands for a longer and more precise statement. For example, in response to the question "How are you?", the statement "Fine“ will be scored as if the statement had been “I am fine." This inference is made when the expression is an answer to an immediate— ly preceding question. Following each category description below are examples of both client and therapist expressions scored in that category. 86 Primapy system (Prim): Expressions in this category refer to the treatment process itself; the roles, goals and accomplishments of therapy. Included in this category are expressions concerning frequency and duration of sessions, costs and expectations. Any question or discussion of what is appropriate or relevant to therapy is scored as primary. C. I want to be cured. C. Is it all right to talk about my girl's problems? What do you tape for? There's no homework; it's all done here. Today we'll quit at quarter 'til. 03 0-3 I-EI 0 You think I should answer questions more? Secondary,eystem (Sec): The manifest content refers to the therapist and client in other than their pri- mary roles as therapist and client. Included in this category are all expressions about the relation- ship between the therapist and client which do not fall into the primary category. Questions or state- ments directed toward the therapist seeking approval or acceptance which are not scored as primary fall here, as does what is usually defined as "transfer- ence" phenomena. C. I want you to treat me like a child. C. I trust you. C. I'm not used to being treated like this. T I'm not angry with you. T. You've gotten angry before when I said that. T. How does that relate to your feelings about me? Family system (Fam): Expressions relating to the client as a member of the family unit. This cate— gory essentially covers all expressions of inter- action between the client and parents or siblings, spouse or children. D. 87 C. I can remember talking to my father like this. C. I guess I keep waiting for them to change. C. It scared me when they used to argue. T. You were the favorite child. T. What did your father say about you then? T. That's the way you were at home? Tertiary system (Ter): Covers references to other social systems. References in this category are to a specified individual or group, other than the family, in interaction with the client. Such references may include dates, friends, teachers, etc. C. The boss complimented me. C. I get angry with my friends. C. What's wrong with drinking with them? T. The instructor made you mad. T. Why do you feel this way about this girl? T. So what's keeping you from asking him? The Self (Self): Self system references are those relating to the client's life experiences which do not involve interactions with members of any other reference systems. Included are expressions of the client's own individuality, or behaviors so general to be relatively independent of environmental variations. Any expression which refers explicitly to the client in some way and is not scored as Pri- mary, Secondary, Family, or Tertiary is scored as Self. C. I'm scared. C. I am always playing hero. C. I'm generally unhappy. 88 T. You feel depressed? T. Your feelings are — - -? T. You liked the concert. The Therapist (Th): Therapist system references are those which involve the therapist but not the client, i.e., the therapist in a family, self, or other social system relationship. C. Do you ever feel scared? C. Do you have a family? C. Did you go to the game Saturday? T. I will be away for five days. T. I guess I'm tired. T. Yes, I teach a course. Other system (0th): Other system references are those which involve interaction between members of any reference systems but not involving the client or therapist. Generally these expressions involve interaction between family members, friends, associates. C. They fight a lot. The secretary argued with the boss. . My parents travel all over. He liked her? How did your mother answer your father? *9 *3 D-] O O . He flunked out, huh? NOnreference system (NR): Statements not scorable in terms of interaction among members of any refer— ence system. This category covers impersonal events, facts, and opinions, and the solitary be- havior of others. C. Bill reads a lot. C. What time is it? 89 C. I'll bet he's a louse. T. Honesty is a good thing. T. It's nice today. T. Two packs a day is a lot. IV. Categories of Therapist Responses A. .Approach-Avoidance Response: Therapist responses to each scored client statement are divided first into two mutually exclusive classes, approach and avoidance responses. When both approach and avoid— ance are present, score only the portion which is designed to elicit a response from the client. Ex- amples of approach and avoidance 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 considers 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 dependent, hos- tile, or other expression which was scored in the client's immediately preceding statement. Approach is to the major category, not neces— sarily to the specific subcategories or the par- ticular content of the client's preceding 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 elabor- ation, clarification, descriptive infor- mation, continuance; calls for details or examples; probing opinions which direct the client to reconsider more carefully a pre- vious statement. Should demand 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. IV,C,1 and 2). 90 C. I can't understand his behavior. T. What is it about his behavior that you can't understand? (E) T. Tell me how you felt. (I) T. 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 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 ex- ploration. Includes "bare" interpretation, i.e., those not explained to the client. May be a question easily answered by yes or no. It may be more than a simple clause, 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) Interpretation: points out and explains patterns or relationships in the client's feelings, attitudes and behavior; explains the antecedents of them, shows the similari— ties and discriminations in the client's feelings and reactions in diverse situations or at separate times. 91 C. I had to know if Barb thought what I said was right. T. This is what you felt earlier about your mother. (I) e. Support: expresses sympathy, reassurance, approval, agreement or understanding of the client's feelings, attitudes or behavior. Includes strongly emphasized, "Mm Hmm," "yes"; offers explicit permissiveness. NOte: Therapist expressions such as strong— ly stated "Mm Hmm," "yes," "and . . . ," con- tain no direct reference to a relationshio or Internal-External Focus. The intent, how- ever, is for the client to continue along the same line as is represented in the pre- vious response. Based on such an assumption these therapist responses will be scored as an flapproach" not only to the content present in the preceding client unit_(Dep, Hos, or 0th), but also the relationship and the Focus (Internal-External) present in that expression. Thus the Relationship and the Focus categories scored in the previous client expression will be scored in the therapist response. 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. . You're feeling. (I) T C. May I just be quiet for a moment? T. Certainly. (E) C T I have my girlfriend's problems on my mind. Could we talk about them? . Why don't we talk about that. (E) In seme instances such-verbalizations as "um hmm," "I see," "yes" occur between two related succeeding expressions. Such verbalizations will be scored as units only when they occur after a natural ending on the first of the two succeeding expressions. 92 Example: "Support" expression scored as separate unit: C. I said I felt bad. . T. Um hmm C. and he said he did too. Example: QInterruption," not scored as separate unit: C. I said I felt bad and he T. Um hmm C. said he did too See I,C for the definition of "Interruption." f. 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) C. What's counseling all about? T. wIt's a chance for a person to say just what's on his mind. (E) C. I don't like to talk about this. 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 or other categories. The therapist attempts to inhibit the feelings, attitudes or behavior described or expressed in the im— mediately preceding client statement which de- termined its placement under the major category. Avoidance is of the major category, not specific subcategories or relationship. 93 Disapproval: therapist is critical, sar- castic or antagonistic toward the client or his statements, feelings or attitudes, ex- pressing rejection in some way. May point out contradictions or challenge statements. (Nete: remember you must decide response is an avoidance before you consider subtypes.) C. Why don't you make statements? Make a statement. Don't ask another question. T. It seems you came here for a reason. (E) C. Well, I wonder what I do now? T. What do you think are the possibilities? You seem to have raised a number of logical possibilities in our discussion. (E) C. I'm mad at him: that's how I feel. T. You aren't thinking of how she may feel. (E) Topic transition: therapist changes or in- troduces a new topic of discussion not in the immediately preceding client verbali- zation. Usually fails to acknowledge even a minor portion of the statement. C. Those kids were asking too much. It would have taken too much of my time. T. We seem to have gotten away from what we were talking about earlier. (E) C. My mother never seemed interested in me. T. And what does your father do for a living? (E) Ignoring: therapist responds to only 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 ig- nore the affect verbalized. C. You've been through this with other people so help me out, will you? T. You are a little uneasy. (I) C. T. 94 You can see I don't know what to do and I want you to give me advice. Just say what you feel is important 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 aut for Chinese food; he's so easy to get along with. Is he from New York? (E) Major Interpersonal Category Initiated by_Therapist: Scored whenever the therapist introduces the topic of dependency or hostility when the client state- ment was not scored as the category which the therapist attempts to introduce. Each category so introduced is also scored for internalizing or ex- ternalizing elicitation. l. Dependency Initiation (Dep Init): C. T. C. T. Last week I talked about Jane. You've mentioned a number of things you've done to please her. (E) (Enters office) New, how may I help you? (I) 2. Hostility Initiation (Hos Init): C. T. I was late for class this morning. I wonder if you dislike the teacher or the class? (I) I don't really understand but that really makes me anxious. You get mad when I Open up some feel— ings in you. (I) He's the only dog I ever cared for. Do you feel that your mother sort of rejects you or isn't giving you enough attention and love. (I) (Init both Dep and Hos) 95 3. Other Initiation (Oth Init): This category is scored in two special circumstances only: 1) The therapist initiates the interaction for the session, and this initiation cannot be scored as Dep Init. or Hos Init.; 2) After a client Simple Agreement-Disagreement when the initi— ation is not of dependency or hostility. (See II,B,3, page 85). Internalizing or ExternalizingyResppnses: Therapist responses of approach, avoidance, or initiation 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 response from the client. 1. Internaliging (I): In this category the focus is on the client's concept of himself, his feelings and reactions to the stimuli impinging 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 today? (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) 2. 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." 96 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) Note: In the case of certain avoidance re— sponses, it may be impossible to score a re- sponse as internalizing or externalizing. a. b. 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 dependency is introduced, score it also on the basis of whether it attempts to internalize or externalize the client's response about de— pendency, and not in regard to the preceding client discussion. C. And so we went 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 internalizing or externalizing. ‘11111111111