AN EXPLORATORY ANALYSIS OF HOSTILETY IN PSYCHO‘THERAPY Thesis Ior II'se Degree OI DI} D. MICHIGAN STATE UNIVERSITY Duane L. Varble 1964 masts IIIIIIIIIIIIIZIIIIIIIIIIIIIIILIIIIIIOIIIIIIIII IIIIIIII _, 01 3606 I IIIIII J LIBRARY Michigan State University This is to certify that the thesis entitled AN EXPLORATORY ANALYSIS OF ' HOSTILITY IN PSYCHOTHERAPY presented by Duane L. Varble has been accepted towards fulfillment of the requirements for Ph .D . degree inisynhnlogy amt/W Major professor 'A‘ """" "i : "‘- Da‘e ‘1 i i‘ F b ]_,_ 2 l'. v f 0-169 MSU LIBRARIES RETURNING MATERIALS: Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped beIow. ABSTRACT AN EXPLORATORY ANALYSIS OF HOSTILITY IN PSYCHOTHERAPY by Duane L. Varble The clients' expressions of hostility and the therapists' reactions to such expressions are signifi- cant variables in the psychotherapeutic process. This study is an attempt to analyze the changes in clients' hostility expressions as therapy progresses. A content analysis system for analyzing verbal behavior is used to determine what effect the therapist's "approach" reactions and "avoidance" reactions to hostility have on subsequent expressions of hostility by the client. Two classes of variables are studied: 1) client var- iables, and 2) therapist variables. The following hypotheses, derived primarily from learning theory expectations, are stated to test the client variables. Duane L. Varble l. The clients will continue expressing hostility significantly more after "approach" than after "avoid- ance" of such expressions by the therapist. As therapy progresses the reinforcement of the therapist's "approach" should lead to an increase in the client's continuance of hostility expressions after such expressions are approached. 2. There will tend to be two classes of clients, those who have higher initial hostility expression levels and those who have lower initial hostility levels. But these differences in hostility expression should be less marked in the final stages of therapy. The hypo- thetical learning experiences of clients during therapy predict the "high" group should decrease and the "low" group increase in hostility expression. The following hypotheses concerning therapist variables are derived primarily from previous research: 3. The therapists' approach rate to the clients' hostility will vary in different stages of psychother- apy, i.e., the therapists will behave differently in different stages of therapy. Duane L. Varble 4. The therapists will approach hostility expres- sions significantly more when they are not the object of the clients' behavior. 5. Staff therapists will approach hostility sig- nificantly more than less experienced therapists (in- terns) in the early stage of therapy, but this differ- ence will disappear as therapy progresses. A content analysis is made of 80 tape recorded interviews of 16 clients seen in psychotherapy by 7 interns and 6 staff therapists in a university counsel- ing center. An interview for each client is analyzed at five sample points approximating the lst, 50th, 75th, and 100th percentages of the total number of interviews for each client. All sixteen clients are terminated and considered to be successful cases by their therapists. Client-therapist interactions are coded for the number of times clients initiate hostil- ity after approach and avoidance of such expressions by the therapists. The number of times the therapists approach or avoid hostility expressions by the client are also coded. The results follow: Duane L. Varble l. Therapists' "approach" to hostility expressions of the client elicit further such expressions, while "avoidance" elicits non-hostile material at all stages of therapy. However, there is no increase in the effec- tiveness of such elicitations as therapy progresses. 2. The clients did not change significantly in the predicted manner as a result of therapy, regardless of whether they were initially high or initially low in hostility expression. Their changes are apparently individually determined. 3. The therapists as a group approach the clients' hostility expressions about 50% of the time with only minor fluctuations at different stages of therapy. There is a great deal of variation among therapists in this respect. 4. Staff therapists approach hostility directed at themselves significantly less than they approach other hostility. This is not the case with the intern therapists. 5. Staff and intern therapists generally approach the clients' hostility expressions at approximately Duane L. Varble the same rate. However, intern therapists approach hostility directed at the therapist significantly more than staff therapists. The effect of group training is suggested as an explanation for this finding. The theoretical implications of the results are discussed. Possibly avenues for further research to answer some of the questions raised by the study are suggested. AN EXPLORATORY ANALYSIS OF HOSTILITY IN PSYCHOTHERAPY BY ~< ) Duane L? Varble A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1964 Dedicated to Charle and Dyke and Valery Acknowledgments I wish to express my gratituded to my chairman, Dr. C. L. Winder for his proficient guidance and direc- tion. I also wish to express my appreciation to my committee members, Dr. Charles Hanley, Dr. Lucy Rau and especially to Dr. Josephine Morse. I wish to acknowledge the assistance provided by Dr. John Schuldt who collaborated with me in collect- ing the data for the study. Finally, I wish to express my appreciation to the therapists and clients at the Michigan State Univ- ersity Counseling Center whose tape recorded interviews provided the data for the study. iii Table Acknowledgments . . . . . List of Tables. . . . . . List of Appendices. . . . Introduction. . . . . . . Method. of Contents Hostility in psychotherapy . . . . Learning and psychotherapy . . . . The scoring procedure used in this Hypotheses of this study . . . . . Sources of data. . Clients. . . . . . Therapists . . . . Stages of psychotherapy sampled. . Coding procedure . O O O O O O O O Scoring reliability. . . . . . . . iv Page iii vi vii 10 15 17 26 26 27 27 29 29 3O Page Results . . . . . . . . . . . . . . . . . . . . 32 Reliability of raters. . . . . . . . . . 33 Hypothesis I . . . . . . . . . . . . . . 34 Hypothesis II. . . . . . . . . . . . . . 37 Hypothesis III . . . . . . . . . . . . . 38 Hypothesis IV. . . . . . . . . . . . . . 39 Hypothesis V . . . . . . . . . . . . . . 44 Discussion. . . . . . . . . . . . . . . . . . . 47 Therapist variables. . . . . . . . . . . 47 Client variables . . . . . . . . . . . . 55 Conclusions. . . . . . . . . . . . . . . 72 Summary . . . . . . . . . . . . . . . . . . . . 76 References. . . . . . . . . . . . . . . . . . . 81 Appendices. . . . . . . . . . . . . . . . . . . 91 10. 11. List of Tables Page Descriptive summary of the sample. . . . . . 28 Description of critical scores used in evaluation of the hypotheses . . . . . . . . 32 Inter-judge reliability coefficients of scores used to evaluate hypotheses . . . . . 34 Mean continuance rates after approach and after avoidance at the five sample points in therapy . . . . . . . . . . . . . . . . . 35 Mean approach ratios at the five sample points in therapy. . . . . . . . . . . . . . 37 Comparison of the approach rates of staff therapists and interns at each of the five sample points. . . . . . . . . . . . . . . . 39 Approach to hostility when other is object as compared with approach when therapist is the object. . . . . . . . . . . . . . . . 41 Means for "object" of hostility and tests for significant changes as therapy progresses 43 Mean ratios of client-initiated-hostility for "highs" and "lows" . . . . . . . . . . . 44 Tests for significance of changes in client- initiated-hostility. . . . . . . . . . . . . 45 Mean and range of proportions of client speeches concerned with hostility out of the total number of speeches in an hour. . . . . 68 vi List of Appendices APPENDIX A The scoring manual used in the coding of the tape recorded interviews. . . . . . APPENDIX B Proportions of the clients' speeches de- voted to "hostility," "dependency“ and "other" at each of the five sample points in therapy . . . . . . . . . . . . . . . . APPENDIX C The proportions of the types of hostility discussed at each of the five sample points in therapy . . . . . . . . . . . . . . . . APPENDIX D Proportions of the types of "approach" to hostility and types of "avoidance" of hos- tility at each of the five sample points in therapy . . . . . . . . . . . . . . . . vii Page 106 108 109 110 Introduction Psychotherapy is one of the most complex and, until recently, least studied human interactions. Long standing controversies concerning how psychotherapy works and how best to go about being a psychotherapist have raged for years. This led the authors of one recent book to cynically conclude: Traditional approaches to the modification of deviate behavior have largely been determined by the therapists' affiliations with particular schools, with little consideration of the type of problem presented by the client. For example, Orthodox Freudians set out to resolve oedipal conflicts, Adlerians to alter compensatory power strivings, Rankians to resolve separation anxi- eties, Rogerians to reduce discrepancies between the real and ideal self, and Existentionalists to achieve awareness of self-conciousness. School affiliations not only determine the range of tech- niques of psychotherapy that a given therapist will employ but even define the clients' central conflict or disturbance that the techniques of the school are designed to resolve. (Bandura and Walters, 1963, p. 249) However, in terms of research, the last decade has witnessed a trend toward less concern with pitting l schools of therapy against each other and more concern with variables operative in the process of psychotherapy. Tape recorded interviews and content analysis systems for scoring the client-therapist verbal interaction have added greatly to this research. The present study uses a content analysis system to study the psychotherapeutic process over time. It is essentially an exploratory in— vestigation of one important behavioral variable, i.e., the effects of the therapists' approach and avoidance behavior on the clients' expression of hOstility during different stages of psychotherapy. Hostilityinpsychotherapy:l L Freud was so impressed by the sadistic and masochistic events he found in neuroses and by the events of World War I, that he revised his theory of personality to include aggression as "an innate, inde- pendent instinctual disposition in man.” He called 1No attempt is made to differentiate "hostility" from "aggression" as it is assumed that the underlying mechanisms involved in expression of negative feelings are the same regardless of the label these expressions are given. this instinct the death wish (1950). Freud's new in— stinct theory met with considerable criticism (see Munroe, 1955). The more prevalent view is that hos- tility is a reaction to frustration or behavior learned because of the rewards it obtains. But our western culture is inconsistent with respect to expressions of hositility. Depending upon the time and circumstance such expressions may be rewarded, ignored or punished. Consequently, it is a rare individual who does not have some difficulties with aggression, and it is frequently a component of emotional conflicts in pe0ple. Fromm-Reichmann (1950) cogently expressed this viewPoint when she wrote: . . . I am not in agreement with the teachings of classical analysis, according to which people are born to be hostile and aggressive, i.e., Freud's teachings of the death instinct. In this hostile world of ours, however, every per— son--certainly every mental patient-~has suffi- cient reason for learning to develop reactions of hostility. Mental patients react with hos- tility to the hostile behavior and the short- comings of the significant adults in their en- vironment, including the failures of their therapist, and they transfer to him the anger and resentment engendered by their previous experience. Furthermore, they interpret the therapist's behavior and communications along the lines of their unfavorable past experience with other peOple. Hence, it follows that every mental patient will have to express a marked degree of hostility in the course of his inter- personal dealings with the therapist. This being so, psychotherapy can be successful only if the psychiatrist is secure enough . himself so that he will be able to deal ade- quately with the hostile reactions of his patients. (p. 22) Other psychotherapists generally agree that hostility, in one form or another, is one of the issues that must be dealt with in order for psychotherapy to be successful. The nature of the hostility differs with each client just as techniques for handling it in therapy also vary among therapists depending on theoretical orientation and individual personalities. Many clients appear to be overly inhibited in their expressions of hostility. In such cases the more traditional schools of therapy usually assume that past experiences have resulted in repression of angry feel- ings,and the anxiety about experiencing these feelings causes the individual to avoid expressing his aggres- sion even in "appropriate" situations. The therapist's task, then, becomes one of helping the client become aware of his repressed feelings through permisSiveness and/or interpretation. Once this is accomplished, the client is presumed to have considerably more free- dom. He is expected to be aware of his feelings and to be able to express them appropriately (Rogers, 1951). Learning theory accounts for the beneficial effects of conventional psychotherapy in a somewhat different manner. Bandura (1961) summarizes this point of view. Most of the conventional forms of psychotherapy rely heavily on extinction effects although the therapist may not label these as such. For example, many therapists consider permis- siveness to be a necessary condition of thera- peutic change (Alexander 1956; Dollard and Miller, 1950; Rogers, 1951). It is expected that when a patient expresses thoughts or feelings that provoke anxiety or guilt and the therapist does not disapprove, criticize, or withdraw interest, the fear or guilt will be gradually weakened or extinguished. The extinction effects are believed to generalize to thoughts concerning related topics that were originally inhibited, and to verbal and physical forms of behavior as well. (p. 147) Regardless of the methods used, one of the major goals in the treatment of overinhibited clients is to help them achieve more freedom in their expres- sion of hostility. Thus, in successful psychotherapy with such cases, the client's hostility should increase to a peak then level off to a more moderate value as therapy progresses. Clients who are undercontrolled in their expres- sions of hostility also typically have problems with it, i.e., their hostility causes conflicts in interpersonal situations. The traditional way of handling these clients' difficulties usually involves permitting free expression of affect. This is most clearly demonstrated in play therapy when hyperagressive children are encour- aged to participate in aggressive games and competitive activities to ventilate their hostile impulses and thus reduce the internal aggression level (Baruch 1949). In adult psychotherapy the same idea is frequently carried out, with the restriction that the hostility must be expressed verbally. The assumption that aggressive behavior, even in structured form, reduces the internal aggressive drive or urge is known as the catharsis hypothesis. Dollard et a1 (1939) state it this way: "The occur- rence of any act of aggression is assumed to reduce the instigation to aggression." (p. 50) There is some research evidence that, at least with children, direct or vicarious participation in aggressive activities within a permissive setting main- tains the behavior at its original level and may ac- tually increase it. (Kenny, 1952; Feshbach, 1956; Bandura, Ross and Ross, 1961, 1963a, 1963b; L6vaas, 1961a; Mussen and Rutherford, 1961; Walters, Leat and Mezei, 1963; DeRath, 1963). The findings in adult studies are less clear cut. Feshbach (1955, 1961) found that adults who were initially angered and then permitted to express aggres- sion through fantasy or were exposed to aggressive models showed a subsequent decrease in aggression. In contrast, Kahn (1960) reported an increase in aggression in angered subjects, following a display of anger in a social situa- tion in which hostile remarks were permitted and accepted. In other studies direct or vicarious participation in aggressive behavior seemed to increase the incidence of subsequent aggression (Buss, 1961; Walters and Llewelyn Thomas, 1963). One limitation of all the controlled research investigations concerning the catharsis hypothesis for reducing hostility is that they are restricted in time. That is, the experimental subjects are typically given only one or two brief opportunities to partici- pate, either directly or vicariously, in aggressive behavior before they are tested for reduction in aggres— sion. Thus, the effects of many opportunities to par- ticipate in hostile behavior over a long period of time, such as in psychotherapy, can not be determined from the above mentioned studies. Another important variable affecting the hos- tility expressed in psychotherapy is reinforcement for such behavior. Studies of learning have estab— lished that positive reinforcement of a response in- creases the probability of future occurrence of that and similar responses. The effects of negative rein- forcement or non-reinforcement are more complicated, but the response in question usually occurs less fre- quently either because of extinction or inhibition effects. The influence of positive reinforcement on the development of aggressive behavior has been demon- strated in a number of controlled studies with children (Cowan and Walters, 1963; Patterson, Ludwig and Sonoda, 1961; and Lavaas, 1961b). More relevant to the present investigation are studies of the effects of positive reinforcement of hostile verbal behavior. A number of these have used operant conditioning methods to increase the frequency with which subjects emit hostile statements or expres- sions (Binder, McConnell and Sjoholm, 1957; Buss and Durkee, 1958; Simkins, 1961; Zadek, 1959). Also, analysis of response—reinforcement con- tingencies as they occur naturally in psychotherapeutic interactions reveals that positive reinforcement by the therapists of clients' hostile verbal responses signifi- cantly increases the probability of occurrence of re- sponses of this class, whereas negative reinforcement substantially decreases the incidence of verbal aggres- sion (Bandura, Lipsher and Miller, 1960; Barnes, 1963; Lerman, 1963; and Kopplin, 1963). These studies will 10 be discussed in more detail later, but they have one limitation in common, i.e., they cover one or two in- terviews of a particular client, usually early in ther- apy, and thus do not assess the reinforcement effects on the patient over a very long time period. Learning and Psychotherapy There are numerous ways of conceptualizing the process of psychotherapy. Each method chooses somewhat different aspects of the psychotherapeutic process to emphasize. However, broadly speaking, all systems of psychotherapy assume that learning occurs in this com- plex human interaction. Several writers have attempted to use principles of learning theories to explain the process of "talking“ psychotherapy (Shoben, 1948; Dollard and Miller, 1950; Bandura, 1961). But it has been difficult to test these formulations for several reasons. The most difficult obstacles being, 1) lack of experimenter control of the therapeutic process, and 2) a way of simplifying and objectifying the in- teractions between client and therapist for measurement. 11 The first of these difficulties seemed to be lessened with the demonstration of verbal conditioning by operant methods (Greenspoon, 1950). This resulted in a phenomenal increase in interest in verbal learning, and clinicians and experimentalists alike were quick to seize the verbal conditioning paradigm as a possible method of investigating psychotherapy. But, comprehen- sive reviews of verbal conditioning by Krasner (1958), Salzinger (1959) and Greenspoon (1962) reveal relatively few studies with direct relevance to psychotherapy. Salzinger and Pisoni (1958) and Hagen (1959) obtained evidence that the verbal stimulus "mmm-humm" was effective in increasing the frequency of affect responses in schizophrenic patients. Quay (1959) found the contingent stimulus "uh-huh" was effective in in- creasing the frequency of family memories. Rogers (1960) was able to increase the frequency of positive self reference or negative self reference by selective reinforcement in a quasi-therapy situation with college students. But he found no reduction in anxiety level 12 of the subjects over the six sessions and no generali- zation of increased self references outside of the therapy setting. Waskow (1962) was able to condition statements of verbal content in a "therapy-like" situation using a reflection technique. But statements of feelings and attitudes and statements combining feelings and content did not increase as a result of the therapist's reflection of them. The above mentioned studies led the reviewer Greenspoon (1962) to conclude: "the research on verbal conditioning in both the therapy and quasi-therapy set- tings generally suggest that the verbal behavior of the patient and/or subject can be modified." (p. 544) However, he cautioned that psychotherapy is a complex process and that there are many variables yet to be studied in verbal conditioning before psychotherapy can be explained via the verbal conditioning paradigm. The second obstacle to the study of the natural history of psychotherapy via learning methods began to weaken with Murray's (1956) development of a content l3 analysis method for scoring client-therapist verbal interaction. This method provided a more objective and non-inferential system of scoring. Clients' state- ments were designated as expressing a need, expressing anxiety about a need or frustration of a need. Thera- pists' responses were categorized as mildly approving or disapproving. Bandura, Lipsher and Miller (1960) revised Murray's scoring system so that the clients' statements were scored as expressing "hostility," "dependency" or "other," and the therapists' reactions to them were classified as "approach” or avoidance." Using the assumption that "approach" by the therapist constituted positive reinforcement of the client's previous state— ment, Bandura hypothesized that clients would continue expression of hostility significantly more after approach by the therapist than they would continue after avoidance on the therapist's part. The results of an analysis of tape recordings of actual therapeutic interviews of par- ents in treatment at a parent-child guidance clinic sup- ported this hypothesis. l4 Winder et a1 (1962), using essentially the same scoring system and a similar pOpulation, repli- cated Bandura's results concerning the reinforcing effect of approach while investigating dependency rather than hostility. Since then a number of people using college student populations have confirmed the finding that clients continue discussion of the topic in question significantly more after approach by the therapist than after avoidance (Caracena, 1963 for dependency; Kopplin, 1963 for hostility; Barnes, 1963; and Lerman, 1963 for both dependency and hostility). All the above studies suggest the verbal be- havior of the client in therapy is modified by the therapist's approach or avoidance reactions to what the client says. This is similar to the findings of verbal conditioning studies and suggests learning is occurring in this way. However, it should be noted thatafll of the studies using Bandura's scoring model dealt with only one or two interviews of any particu- lar client. And that, with the exception of Bandura's (1960) work in which tapes taken randomly from several 15 clients presumably in different stages of psychotherapy were used, all subsequent investigations have been con- cerned only with initial or early interviews in therapy. Thus, one of the purposes of the present investigation is to find out if the results obtained in early inter— views hold true for all stages of psychotherapy. The scorianprocedure used in this study: This investigation is concerned with the changes in verbal content that occur over time in psychotherapy. This means an objective molecular method of coding client- therapist verbal interactions is necessary. The method used was mentioned previously, i.e., the content analysis procedure developed by Murray (1956) and subsequently modified and used by Bandura, Lipsher and Miller (1960) and Winder, Ahmad, Bandura and Rau (1962). Essentially, this model consists of scoring each of the client's “speeches" as "dependency," "hostility" or "other." Each of the therapist's "speech" reactions are then scored as "approach" or "avoidance." This constitutes 16 an interaction unit. Each unit has three parts: 1) the client's statement, 2) the therapist's response and 3) the client's subsequent statement, each of which is scored separately. The final client statement of one unit is also the initial statement of the next unit so that interaction units overlap and result in a continual record of the client-therapist interaction. The specific components of each part of the unit are explained in the scoring manual used by Kopplin (1963) and in Appendix A. The only significant modification of this scoring system for the present study is the addition of a category called c1ient-initiated—hostility, (CIH). This is impor- tant because it is a measure of hostility independent of the therapist's approach or avoidance behavior with re— spect to hostility. Caracena (1963) has shown the ana- log of CIH, client-initiated-dependency, to be useful. The procedure with minor modifications, has been used successfully by Barnes (1963); Caracena (1963); Kopplin (1963); and Lerman (1963). The advantages of this procedure are that it is a rather simple, objective, molecular method of analyzing 17 the moment to moment verbal behavior of both client and therapist. This makes it possible to discuss the beha- vior of the client and the therapist separately as well as the effect of the verbal behavior of each upon the other. The limitations of the procedure are that it deals only with manifest verbal content, consequently missing such phenomena as facial expressions, posture. voice intonations, etc. that are typically believed to be important in the communication of affect. Such lim- itations necessarily mean some of the more complex facets of the interactions may be lost. Hypotheses of this study: Insofar as it is possible, the hypotheses are stated in terms of learning theory expectations because the basic assumptions of the procedure are derived from reinforcement theory. However, because this is an ex- ploratory investigation there are times when this does not seem feasible or desirable. In such cases the hy- potheses are stated as "empirical questions." 18 Hypothesis I: The client will continue discussing hostile content significantly more after "approach" of such content by the therapist than after "avoid- ance" on the therapist's part. This has been demonstrated in a number of studies in early interviews, (Bandura et a1, 1960; Kopplin, 1963; Barnes, 1963; and Lerman, 1963). The interesting empiri— cal question is whether this relationship will be main- tained as therapy progresses and terminates. The rein- forcement principle of learning theory would lead us to expect an increase in continuance after approach as therapy progresses. Hypothesis II: The therapist's approach rate to the client's hostility will vary in different stages of psycho- therapy. This is an exploratory hypothesis since we have no good way of predicting what effect time will have on the therapist's approach rate. Kopplin (1963) found therapists showed greater proportions of approach to l9 hostility in the second interview, as compared to the first interview with the same client. This suggests a trend toward more approach behavior on the part of thera- pists as they get to know the client. Hypothesis III: Staff psychotherapists will approach hostility significantly more than the less experienced thera- pists (interns) in the early stage of therapy, but this difference will disappear as therapy progresses. This hypothesis is suggested from Kopplin's (1963) results. He found more experienced therapists approached hostility more than less experienced therapists in initial interviews. But less experienced therapists approached hostility significantly more in the second interview than they had in the first. This suggests their approach rate to hostility will become more similar to the more experi- enced therapists' approach rate over time. Hypothesis IV: The psychotherapists will approach hostility significantly more when they are not the object of the client's behavior. 20 Bandura et a1 (1960) found student therapists approached hostility significantly more when it was not directed at themselves. Kopplin (1963) replicated this finding for therapists just beginning their psycho- therapy training (practicum students) and therapists who had completed their training (staff psychotherapists) but not for therapists in the process of training (in- terns). Lerman (1963) who studied therapists in train- ing did not find any significant difference between approach to hostility directed at the therapist and approach to hostility directed at others. The thera— pists' tendency to approach hostility directed at "others" more than they approach hostility directed at the "thera- pist“ is prObably not a universal one. The experience levels of the therapists also seem to be influential in this respect. Thus, this hypothesis is stated as an attempt to replicate the finding of Bandura et a1 (1960), but differences in experience level of the therapist will be considered as part of the exploration of this question. 21 Hypothesis V: There will be significantly more variance between clients, in terms of expressing hostility. at the beginning of therapy than at the end. That is, there will tend to be two classes of clients, those who are over-inhibited in their expressions of hostility and those who are under- inhibited in their hostility. But these differ- ences in hostility expression should be less marked during the final stages of therapy. A. "Client-Initiated-Hostility" will in- crease, reach a peak, then decline to a medium value and level off above the initial level as therapy progresses for those clients initially low in hostility expression. B. "Client-Initiated-Hostility" will start high, peak early in therapy, then gradually decline to a medium value as therapy pro- gresses for those clients who are uninhibited in their expression of hostility initially. This hypothesis is based primarily upon clinical observations. Individual differences in hostility ex- pression are commonly found in psychotherapy clients, and these differences tend to cluster at either end of a continuum of inhibition of hostility expression. Suggestive evidence of the hypothesized variance in hostility expression has been found in a previous study using this model. Kopplin (1963) studied first and 22 second interviews of student clients. A small propor- tion of these interviews contained no hostility state— ments by the client and many interviews had relatively few hostility statements. At the other extreme, in several cases hostility expression dominated the client- therapist interaction. This evidence has to remain at the suggestive level, however, because of the contamin— ating effect of the therapist's tendency to approach hostility when it occurred. The sub-hypotheses A and B are in part a result of clinical observations. But these predictions would also be expected from learning theory. For the inhibited client learning theory would predict the permissiveness. and the acceptance of the therapist would result in a loosening of inhibitions as the fear and guilt feeling attached to the client's hostility expressions were gradually extinguished (Bandura, 1961). At the same time, the therapists would reinforce hostility state— ments by approaching them. Thus, the client's hostility expressions Should reach a relatively high level within the middle stages of therapy. 23 However, as therapy progresses, it seems un- likely that the therapist will continue to indiscrimi- nately approach the client's hostility when it is emitted at a high level. The therapist's approach behavior may take the form of selective reinforcement, e.g., he may tend to avoid persistent and direct attacks on himself but approach and thus reinforce such “appropriate" ex- pressions of hostility as anger at one's parents. The overall effect of such behavior by the therapist would be to reduce the client's hostility expression from a high level to a more moderate level. Other reasons for expecting the initially overly inhibited client's hostility level to decrease after reaching a peak during the middle stage of therapy are: 1) that the client's ”need" or drive to express aggres- sive feelings should decrease after repeated ventilatiOn and 2) that the therapist's behavior during the inter- view serves as a model for the client to imitate. Ban- dura, Ross and Ross (1961, 1963a, and 1963b) have demon— strated the importance of imitative learning of aggres- sion in children. Also Bandura et a1 (1960) found that 24 therapists who were more open and direct in their ex- pression of hostility obtained more hostility from their patients than therapists who were more defensive and indirect in their hostility expression. This find- ing was explained primarily in terms of the therapists' being threatened or anxious about hostility, but the model the therapists represented would seem to be just as important. Since the majority of therapists are not inclined to be overtly and consistently hostile during the interview, the client is likely to follow this behavioral model of "moderate" hostility expres- sion. Learning theory would also predict that clients who are undercontrolled in hostility expression should increase in rate of hostility because of the reinforce- ment of having the therapist approach such statements. But because the hostility expression rate is at a high level, both the catharsis hypothesis (drive reduction) and discrimination learning would predict a decrease to a moderate level. The principle of competing responses would also predict a decrease in hostility rate, e.g., 25 the client may have a strong drive for dependency which is also reinforced by the therapist and it would be difficult for the client to be overtly hostile and de- pendent at the same time. Method Sources of data: The tape recordings used in this study were obtained from the tape library of the Counseling Cen- ter at Michigan State University. This library con- sists of the recorded interviews of 42 undergraduate university students chosen for the study in a random way from the population of non-referred students who approadhed the Counseling Center seeking help with personal-social problems. In an initial intake inter- view only those students who were judged to be appro- priate cases for the Counseling Center and who had no previous psychotherapy were asked to participate in the study. Provided the client agreed to the research conditions (which included taking some tests as well as having all his interviews recorded), he was assigned by the intake interviewer to one of the 10 full time 26 27 staff members or 14 interns participating, to be seen on a once a week basis. Final assignment was contin- gent on the counselor's agreement to work with the client. This decision was based on the counselor's knowledge of the way the client presented himself in the intake interview. Clients: ‘The present investigation used tape-recorded interviews of 16 clients (10 females and 6 males) se- lected from the 42 clients mentioned above. These 16 clients were selected according to the following cri- teria: 1) all clients had been terminated, and 2) the therapists had judged the clients' treatment to be successful. A descriptive summary of the clients and therapists is provided in Table l. Therapists: The two groups of therapists who participated in this study were 6 staff members and 7 interns at the 28 Michigan State University Counseling Center. The staff psychotherapists are doctoral level counseling and clini- cal psychologists with 3-11 years of psychotherapy ex- perience. The intern psychotherapists are advanced graduate students enrolled in counseling or clinical psychology Ph.D. programs at Michigan State University. They work at least 20 hours a week at the Counseling Center and have had an average of 2 years of intensive supervision in psychotherapy. Table l.--Descriptive summary of the sample mm Therapists Number Sex Mean years experience female male Staff 6 2 4 7.5 Interns 7 2 5 2.0 Clients Clients seen by staff 8 5 3 l4 Clients seen by interns 8 5 3 l4 29 Stages of psychotherapy sampled: Five interviews were selected from each of the 16 clients included in this study. Since one of the purposes of the study was to assess the changes that occur over time in psychotherapy, spaced sampl- ing was required. Those interviews which fell at ap- proximately the lst, 25th, 50th, 75th, and 100th "per- centiles" of the total number of interviews for each client were used. Thus, for a client who terminated with the 17th therapy session, only interviews 1, 4, 8, l2, and 16 would be included as data in our study. The intake interview and the final termination interview were not included because it was felt these could not properly be called therapy interviews. Coding procedure: The coding procedure was that utilized by Cara— cena (1963) and Kopplin (1963). This procedure is a modification of the content analysis system used by Bandura et a1 (1960) and Winder et a1 (1962) mentioned 30 previously. The coding manual used in this research is contained in Appendix A. The client categories that were coded are: hostility, dependency, other, client-initiated-hostility and client-initiated-dependency. The therapist variables that were coded are: approach, avoidance, therapist- initiated~hosti1ity and therapist-initiated-dependency. Scoring reliability: Two raters participated in the coding of the tape recorded interviews. Both raters mutually coded several tapes to familiarize themselves with the scoring system. These interviews were assessed for inter-rater agreement but were not used as data in the study. A total of 80 tape recorded interviews were used in the study. Each rater coded 40 tapes. To measure inter-rater agreement each rater independently coded 10 tapes scored by the other rater. This resulted in a reliability pool of 20 mutually coded tapes. These tapes were arbitrarily chosen from all stages of therapy. 31 The coding of reliability tapes was an on-going process over the entire period in which the raters scored tapes. Inter-rater agreement was determined for each of the response categories critical for the evaluation of the stated hypotheses. These categories are: hos— tility, object of hostility, approach, avoidance, and client-initiated-hostility. The measures of inter-rater reliability were Pearson Product Moment Coefficients using ratios for each of the twenty interviews. Results The critical scores used to evaluate the hypo- theses in this study are described in Table 2. Table 2.--Description of critical scores used in evalu- ation of hypotheses Therapist variables HAp% The sum of the therapist's approach following hostility/the sum of hos- tility expressions by the client. HoAp% The sum of the therapist's approaches following hostility directed at "other" (someone other than the therapist)/the sum of the client's hostility expres- sions directed at "other." HtAp% The sum of the therapist's approaches following hostility directed at the therapist/the sum of the client's ex- pressions of hostility directed at the therapist. Client Variables HApC% The sum of the client's hostility ex- pression following the therapist's approach to preceding hostility/the sum of hostility expressions followed by approach. 32 33 Table 2.—-Continued Client Variables CIH% The sum of the client's hostility ex- pressions not in immediate response to the therapist's approach or avoid- ance to hostility or TIH/the sum of dependency and other units which do not immediately follow therapist HAp. HAV, or TIH.* Ht% The sum of hostility directed toward the therapist/the sum of hostility expressions. *Therapist-initiated-hostility is hostility in- troduced by the therapist simultaneously with approach or avoidance to dependency or other. Reliability of raters: Coding agreement between judges was evaluated by computing product-moment coefficients for the criti- cal scores taken from each interview in the reliability sample. These coefficients are presented in Table 3. 34 Table 3.--Inter—judge reliability coefficients of scores used to evaluate hypotheses Critical Scores N r Therapist variables runs. 19 .874 HOAPOO 18* o 8 28 HtAp°o 10* .692 Client variables HApC% 18* .948 HAVC% 15* .913 C1H% 16* .938 He% 19 .914 Note: One of the reliability interviews contained no hostility statements by the client. Thus, the N is re- duced by 1. *These categories did not occur in all interviews. Hypothesis I: Clients should continue expressions of hostil- ity after approach to such expressions (as measured by the ratio HApC%) significantly more than after avoidance 35 (as measured by the ratio HAVC%) by the therapist. The mean percentages of times the clients continued express- ing hostility after approach and avoidance for each of the five stages of therapy are shown in Table 4. Table 4.--Mean continuance rates after approach and after avoidance at the five sample points in therapy —_ —7 j - — 1% 25% 50% 75% 100% Continuance after y Approach: .61 .37 .52 .52 .46 Avoidance: .09 .13 .06 .10 .08 Sign test I (two tailed) p .002 p .038 p .001 p .001 p .001 The sign tests at each of the stages of therapy are highly significant, indicating consistently more continuance of hostility after approach by the therapist. In the eighty interviews coded only three had continuance rates after avoidance which exceeded the continuance rates after approach in the same interview. Thus, Hypothesis I is clearly supported at all stages of therapy. 36 Since clients' continuance rates had previously been studied only in the early phase of therapy, this hypothesis was also concerned with possible changes that might occur as therapy progressed. It can be noted from Table 4 that fluctuations in the continuance rates after both approach and avoidance do occur. Wilcoxon signed- rank tests were used to assess the statistical signifi- cance of these changes. Only the change in continuance after approach between the lst and 25th percentile points is significant (p<.05 two-tailed). That is, 12 of the 16 clients continued expressing hostility after approach by the therapist lgpp a quarter of the way through therapy as compared with their initial interviews. It may also be worthy of note that, in contrast to continuance after approach, continuance after avoid- ance reaches its maximum at the 25th percentile point. This is not a statistically significant change from the lst interview (Wilcoxon matched pairs signed—ranks test p > .05), but is a further suggestion that the 25th per- centile point may be a special point in therapy as far as expressing hostility is concerned. 37 Hypothesis II: The therapist approach rate (as measured by the ratio HAp%) will vary in different stages of therapy. This hypothesis was intended to provide one an- swer to the general question of whether or not therapists behave differently in different phases of therapy. The mean approach rates for staff members and for interns are presented in Table 5. Table 5.-—Mean approach ratios at the five sample points Group 1% 2 5% 5 0% 7 5% 100% P Staff: «46 .51 .55 .45 .62 NS Interns: .54 .45 .60 .44 .40 NS Combined: .50 .48 .57 .45 .51 NS Separate Friedman analysis of variance by ranks tests were used to assess changes over time for the staff ther- apists, interns, and the combined groups. It can be seen from Table 5 that fluctuations in approach rate do occur in the different stages of 38 therapy but no radical changes are evident. Friedman two-way analysis of variance by ranks tests were com- puted to assess the significance of changes over time. These were non-significant, at the .05 level, indicating the fluctuations may be due to chance. Generally, it can be said that the therapists consistently approach hostility about 50% of the time regardless of the stage of therapy. Hypothesis III: Staff psychotherapists should approach hostility (as measured by the ratio HAp%) significantly more than less experienced therapists (interns) in the early stages of therapy, but this difference will disappear as therapy progresses. To test these expectations separate Mann-Whitney U-tests were computed at each of the five sample points. The results are presented in Table 6. Table 6.--Comparison of the approach rates of staff 39 therapists and interns at each of the five sample points. 1% 25% 50% 75% 100% Mann—Whitney U-test 18 17 20 20 18 It can be seen from Table 6 that staff psychother- apists do not approach hostility significantly more than interns or vice versa. Furthermore, no trend over time is evident as reference to Table 5 indicates; the interns have-higher approach rates at the 1% and 50% sample points, while the staff members approach more than the interns at the 25% and 100% sample points, and there is virtually no difference at the 75% sample point. Thus, hypothesis III is not supported. Hypothesis IV: The psychotherapists will approach hostility significantly more (as measured by the ratios HoAp% 40 and HtAp%) when they are not the object of the client's behavior. To test this hypothesis, each of the clients' expressions of hostility needed to be scored for object, i.e., who the hostility is directed at--therapist or other. A difficulty arose when one of the coders scored one scoring category--”hostility agreement" with the therapist always being the object. In this case the therapist was always the object of the client's agree- ment but frequently not the object of the client's hos- tility. Therefore, the category, "hostility agreement" had to be eliminated from the data used to analyze this hypothesis. This may have changed the nature of the data in an unknown fashion. Since there were a number of interviews in which the client expressed no hostility toward the therapist and a few interviews in which the client expressed no hostility at all, mean approach rates of hostility di- rected at the therapist and hostility directed at other were computed. For example, if hostility was directed at the therapist in only 3 of the five interviews coded 41 for each client, the total percentage of approach to such hostility was divided by 3 to obtain a mean for that client and therapist. Using these means as the basic data, Wilcoxon matched-—pairs signed--ranks tests were used to test the hypothesis that therapists approach hostility more when it is directed at someone other than themselves. The results are shown in Table 7. Table 7.-—Approach to hostility when other is object compared with approach when therapist is object W N .2 Staff 8 .05 (two- tailed) Interns 8 ; NS Combined 16 i NS Thus, staff members approach hostility significantly more when it is directed at an object other than them— selves, but interns do not. Hypothesis IV is partially supported but apparently another factor such as training must be taken into consideration. 42 In further exploration of the difference between staff psychotherapists and interns, Mann—Whitney U-tests were computed for approach to hostility directed at the therapist and approach to hostility directed at others. The result was that interns approach hostility directed at the therapist significantly more than staff members (p < .05 two-tailed). There is no difference in approach rates between the two groups of therapists when the hos- tility is directed toward "other." (p > .05). In assessing the significance of possible changes over time in this part of the data, Friedman's two-way analysis of variance by rank tests were computed. The results are shown in Table 8. None of these tests are statistically signifi— cant, but there is a definite trend for the clients of staff therapists to express hostility toward the thera- pist early in therapy while the opposite is true for the clients of the intern therapists. This may reflect the closer similarity between the stimulus value of the staff and the clients' parents than is true for the interns who are a younger group. 43 Table 8.-—Means for "object" of hostility and tests for significant changes as therapy progresses 1% 25% 5 0% 7 5% 100% Hostility expressed Staff .19 .25 .13 .05 .08 toward therapist Intern .004 .005 .25 .19 .03 Combined .09 .13 .20 .12 .06 Friedman V Tests: Staff p>.10 Interns .05>p<.10 Combined p>.10 Hostility expressed Staff .00 .38 .19 .13 .13 toward therapist approached Interns .13 .00 .56 .22 .00 Combined .06 .19 .37 .17 .06 Friedman Tests: Staff p>.10 Interns .05>p<.10 Combined p>.10 Hostility expressed Staff I.53 .42 .46 .39 .64 toward "other" _ approached Intern .55 .43 .51 .45 .42 Combined .54 .43 .48 .42 .53 Friedman Tests: Staff p>.10 Interns p>.10 Combined p?.10 44 Hypothesis V: There will be two classes of clients: those who are uninhibited in their expressions of hostility and those who are inhibited in this respect. When di- vided at the median in the first interview, those who have high initiation of hostility (as measured by the ratio CIH) should decrease as therapy progresses and those who have low initiation of hostility (as measured by the ratio CIH) should increase to a moderate value by termination time. To evaluate this hypothesis the 16 clients were divided into two equal groups on the basis of the amount of client-initiated-hostility in the ini— tial interview. The mean ratios of client-initiated- hostility for each of the five sample points are de- picted in Table 9. Table 9.--Mean ratios of client-initiated hostility for ' "highs" and "lows" 1% 25% 50% 7 5% 100% "Lows" .029 .040 .038 .049 .038 "Highs" .094 .059 .046 .073 .064 45 It can be seen from Table 9 that in no point during therapy does the mean of the high group become lower than the mean of the low group and vice versa. While there are no radical changes, the trends are in the predicted direction. Wilcoxon matched-pairs signed-ranks tests were used to assess the significance of the changes which occur. The results are presented in Table 10. Table 10.-—Tests for significance of changes in client- initiated—hostility L 1 Sample-point Changed Changed .g comparisons up down "Lows " 1% - 2 5% 4 4 NS 1 - 50 3 3 NS 1 - 75 5 2 NS 1 - 100 5 2 NS "Highs" 1% — 25% 2 5 NS 1 — 50 2 5 .05 1 - 75 4 4 NS 1 - 100 2 6 NS 46 Thus, only the "highs“ changed significantly as a group. They decreased in client-initiated—hostility from the first to the 50th sample point but then rose again during the final stages of therapy. Discussion The data analyzed in this study fall into two categories: 1) therapist variables and 2) client vari— ables. Each of these categories is naturally related to and interacts with the other, but for the sake of exposition, the nuances and theoretical implications of each shall be discussed separately. Therapist variables: (Hypotheses II, III, and IV) Hypothesis II predicted therapists would ap- proach hostility at different rates in different stages of psychotherapy. Kopplin (1963) found a significant increase in approach to hostility from the first to the second interview with the same client. The pres- ent investigation found a slight decrease in mean ap- proach rates from the 1% to the 25% sample points of the total length of therapy. But the 25% sample includes 47 48 interviews ranging from the 2nd to the 6th of the series for each client. As a check on the idea that the number of the interview and not the proportion of completed therapy is the determinant of therapists' reactions to the client's hostility, the six shortest cases in the sample were checked for increase in approach rate. This meant looking at the 2nd interview in 5 cases and the 3rd interview in the remaining case. Four of these therapists decreased in their approach rates, while two therapists increased their proportions of approach to hostility. This is contrary to Kopplin's finding. For the other ten cases in the sample the approach rates decreased in 4 and increased in 6 cases. Thus, no consistent change in approach rates from the 1% to the 25% sample points are evident. Indeed, the mean approach rate remains relatively constant throughout the entire period of therapy. While there is great variation among individuals, the therapists as a group approach hostility about 50% of the time regardless of the stage of therapy. This is comparable with KOpplin's 49 finding that his total group of therapists approached hostility 55% of the time in the first interview. A possible explanation for the discrepancy be- tween Kopplin's finding of an increase in approach to hostility from first to second interview and our find- ing of no significant changes over time may lie in the experience differences between the two groups of thera- pists studied. Kopplin's sample included both experi- enced and inexperienced therapists, with differential approach rates between the groups (staff .69, interns .59 and practicum students .44). It was the inexperi- enced therapists which made the most significant in— crease in approach from the first to the second inter- view suggesting these therapists were less threatened by the client's hostility in the second interview. The present investigation found no difference between exper- ience levels of therapists in overall approach rates to hostility. Thus, the experience differential may have been the largest contributing factor in Kopplin's find- ing of increased approach to hostility from lst to 2nd interviews. 50 It was KOpplin's finding of significant differ- ences in approach rates between the different levels of experience which was the basis for the prediction in Hy- pothesis III that intern psychotherapists would initially approach hostility less than staff psychotherapists but eventually reach the same level of approach as the staff as therapy progressed. This hypothesis was not supported in any way as there were no significant differences be- tween the overall approach rates of staff therapists and intern therapists at any point in therapy. There may be several reasons for this failure to replicate Kopplin's results. The first of these is the small number of thera- pists involved (6 staff and 7 interns) in the present study Which makes statistical significance difficult to obtain. 0f more importance, probably, is the fact that the differences in experience are less marked in the present sample than in Kopplin's sample. Whereas Kopplin reported the interns in his study had an average of 1 year of experience doing psychotherapy and staff members 7.0 years, the interns in the present study had an average of 2 years' experience and the staff an average of 7.5 51 years. Therefore, the interns in the present study were further along in their training than Kopplin's group and apparently reacted more like experienced therapists in their approach behavior. In terms of years of training the staff therapists and intern therapists may be quite similar. That is, the staff therapists probably have not received much if any psychotherapy training, as such, since obtaining their Ph.D. degrees even though they have undoubtedly been learning as they have gained more experi— ence. The finding of this study is supported by Mills (1964) who studied fifth interviews of a similar p0pu- lation and also found no difference between staff and intern therapists in approach to hostility. Furthermore, Schuldt (1964) using the same interviews as the present study found no difference between staff and intern thera- pists in approach to dependency. Differences between staff psychotherapists and interns do become apparent when approach to hostility is broken down into approach to hostility directed at the therapist and approach to other hostility. Bandura et a1 (1960) and KOpplin (1963) found the therapists in 52 their studies approached hostility directed at "other" significantly more than hostility directed at the ther- apist. Hypothesis IV predicted the same finding in this study. But this hypothesis was not supported when all therapists were considered. However, when the staff and intern therapist groups were considered separately, in- teresting results became evident. The staff psychother- apists do approach hostility directed at themselves less than they approach other hostility. There is no differ- ence in this regard for the interns as a group. Further- more, when hostility directed at the therapist is con- sidered, the interns approach such hostility significantly more than the staff therapists. This is opposite to the experience difference predicted in Hypothesis III. The present finding is partially supported by Lerman (1963) who studied only intern psychotherapists. She found no difference between approach to hostility directed at the therapist and approach to other hostility. These findings are not in accord with the results of most previous studies of therapeutic experience and suggest that other variables are affecting our results. The most obvious of these var- iables which may have influenced our results is training. 53 The staff psychotherapists have varied backgrounds and orientations as they have been influenced by their pre- vious diverse training. The interns, on the other hand, are more homogeneous because they have received the ma- jority of their early psychotherapy training from four staff members at the Counseling Center not included in this investigation. Moreover, the interns all partici- pated in group supervision in which the emphasis was on using the psychotherapeutic relationship as a tool in therapy, i.e., to become aware of and deal with the client's feelings toward the therapist and vice versa. Participation in the group may have led to closer iden- tification of the interns with each other so that the tendency to focus on behavior which might influence the client-therapist relationship was accentuated. The staff psychotherapists may be reacting more naturally to hos- tility directed at themselves, assuming that the natural tendency is to avoid hostility directed at oneself. Further research is needed to determine whether or not therapist "approach" to hostility directed at the thera- pist is beneficial to the client in psychotherapy. If 54 so, training can apparently be effective in attaining that end. The present findings are in contrast to the majority of those studies of therapist experience re- viewed by Strupp (1962). That is, experience has pre- viously been found to be a more significant variable than theoretical orientation on training of the thera- pist. Further research will have to be conducted to determine whether or not therapists trained together in any institution tend to react to their clients in similar ways or whether this is a characteristic of the therapists studied in this investigation only. There is another factor which may have contri- buted to our results. The majority of the intern group were undergoing personal therapy while they were parti- cipating in this research. None of the staff therapists were concurrently in therapy While participating in the study, although some of them had personal therapy pre- viously. We have no way of determining accurately if this difference in current personal therapy influenced the therapist's behavior in any specific direction, but 55 it is plausible to argue that current personal therapy would make the therapist more aware of hostility direc- ted toward him, particularly if this were an area of conflict for the therapist. Strupp (1958) found per- sonal analysis to be a relevant factor in determining types of therapist behavior for psychoanalytically oriented therapists. Client variables (Hypotheses I and V) The hostility expressed by a client in psycho- therapy is affected by two major determinants: 1) What the client brings to the psychotherapy situation --loosely classified as the internal hostility level, and 2) what happens in the psychotherapy situation-- loosely classified as the effects of the therapist's behavior toward the client's expressed hostility. Hypotheses I and V were attempts to find out what hap- pens to the client's hostility as a result of his ex- periences in psychotherapy. 56 Hypothesis I predicted clients would continue expressing hostility significantly more after approach than after avoidance of such expressions by the thera- pist. This had been demonstrated in early therapy in- terviews by several investigators (Bandura, et a1 1960. Kopplin, 1963 and Lerman, 1963). The present study found this hypothesis to be supported in all stages of therapy. Bandura, et a1 (1963) attributed this finding to the reinforcing pr0perties of the therapist's approach to such behavior. This is a plausible explana- tion for early interviews since the finding follows the operant conditioning paradigm and is in agreement with many of the verbal conditioning studies mentioned earlier (Binder, McConnelland Sjoholm, 1957; Buss and Durkee, 1958; Simkins, 1961; and Zadek, 1959). However, our longitudinal data seem to be evidence against the idea that the client continues expressing hostility more after “approach" than after "avoidance" by the therapist because "approach" is inherently reinforcing. It is clear that "approach" elicits continuance of hostile expressions and "avoidance" elicits non-continuance 57 of such expressions, but the typical operant condition- ing paradigm used to explain many verbal conditioning results (Greenspoon, 1955) does not appear to be suffi- cient. If "approach" as a reinforcement served auto- matically to strengthen the continuance response, we would expect an increase in the continuance of hostility expressions after "approach" as therapy progressed. The data do not support this expectation. The mean approach rate remained relatively constant throughout therapy, but the continuance rate after approach decreased sig- nificantly between the lst and 25th sample points. The continuance rate after approach is highest in the first interview and consistently lower throughout the remainder of therapy. If "approach” by the therapist has inherent reinforcing properties such as the contingent stimuli "mmm humm" in verbal learning studies, the client would be expected to initiate the "approached" material more as therapy progressed. This is clearly not the case as there was no significant change in client-initiated- hostility over time in psychotherapy. Schuldt (1964) found a constant approach rate to dependency but a 58 significant decrease in c1ient-initiated-dependency from lst to last interview, indicating the consequences of "approach" to dependency are not those expected of a reinforcer, either. It might be argued that the client continues after "approach" in proportion to the approach rate, i.e., the client's response is in direct proportion to the emitted behavior of the therapist. Since the therapist approaches hostility approximately 50% of the time, the client should continue accordingly. HoWever, when the mean approach rate and the mean continuance rate after "approach" are plotted over time, they do not appear to be closely related. The two curves cross each other three times over the en- tire period of therapy. Thus, the theory that "approach" serves as reinforcement which automatically strengthens the continuance response is considerably weakened by the longitudinal data of this study. In attributing reinforcing prOperties to "approach" by the therapist, the error seems to have been in the assumption that all the categories of "approach" have 59 the same properties. It seems that "approval," for example, has more inherent reward value than "inter- pretation;" and that "exploration" has more eliciting qualities than “reflection." Consequently, while all these categories can rightfully be considered ”approach," their unique qualities may well be perceived by the client. The same is true of the "avoidance" categories. And while these categories may or may not have reinforc- ing value for the client, the therapist's responses do have definite "cue" value. The "avoidance" responses are better cues than most "approach" responses. Since the client's continuance rates after "avoidance" are significantly lower than after "approach" and the level of hostility is more nearly minimal after "avoidance" than it is maximal after "approach," the cues to "not to talk about that subject" are clearer than the cues to "continue talking about that." However, neither the "approach" or "avoidance" categories are perfectly efficient cues. Naturally, cues other than those ver— bal ones scored may also be influential. 60 Of course, this does not deny that the psycho- therapy process is a learning process, but does argue against explanations in terms of simple reinforcement principles. Rather some sort of mediation model of learning which utilizes cues would seem more appropriate. Along this same line, Berkowitz (1964) reports evidence that hostile or aggressive behavior is largely deter- mined by the cue evoking stimuli of the situation. His contention is that hostility is expressed only when stimuli associated with the anger instigator are pres- ent, either objectively or in the individual's thoughts. In the psychotherapy situation, the therapist could help provide these cues by what he says and does. This might permit the client to displace his hostility to the therapist or express his anger toward someone else or simply discuss the feeling. On the other hand, the therapist may not provide the apprOpriate cues for the client to express hostility and consequently, the client does not bring up the t0pic very often, let alone discuss it. The low rate of client-initiated-hostility and the 61 relatively low approach rates to hostility suggest this was more nearly true of the cases studied in this investigation. Since verbal conditioning is typically explained in terms of automatic strengthening of reinforced re- sponses (Greenspoon l950k our longitudinal results would appear to differentiate the process of psycho- therapy from verbal conditioning studies. However, Dulany (1961) and Spielberger and Levin (1962) report evidence which suggests verbal conditioning is better explained as a form of cognitive learning. Spielberger and Levin (1962) conducted verbal learning experiments using various contingent stimuli, "mmm humm," "good," etc., followed by intensive post-experimental inter- views. They found conditioning occurred only when the subject was aware of the contingent (reinforcing) stimuli. They conclude that "awareness" of the response- reinforcement contingencies is what is learned in verbal conditioning studies. They argue that a mediation type cognitive learning theory is the most parsimonious ex- planation of their results and that all verbal condi- tioning studies might have similar findings if intensive 62 post experimental interviewing procedures were utilized by the investigators. A mediation type theory of learn- ing which utilizes cues would also account for the re- sults of the present study. Another theoretical learning formulation which could explain the longitudinal data of this hypothesis is elicitation theory as delineated by Denny and Abel- man (1955). The basic principle of this theory is ex- plained as follows: (a) The stimulus complex (S) which closely precedes in time any response elicited by any stimulus (Se) acquires the property to elicit this response. (b) With each elicitation there results an increment to the tendency of the stimulus complex (S) to elicit this response. (c) The S-R association will not ordinarily be evident in behavior unless the response is consistently elicited in the given stimulus situation (S+Se). Thus, for all practical purposes, learning occurs only when a response is prepotent over a series of trials or over an extended period of time. (p. 290) Thus, "approach" by the therapist should serve as elicitation of further expressions of hostility and "avoidance" by the therapist serves as an elicitor of material, other than hostility. If the therapists approached hostility consistently. the continuance 63 rate of the client would be expected to increase as therapy progressed. But, since the therapists neither approach or avoid the client's hostility in a highly consistent manner, the elicitation of continuance and non-continuance presumably interfere with each other and conditioning never reaches a high level but remains relatively constant. In this sense, consistent learn- ing does not occur in psychotherapy as it was measured in this study. But the clients do at least partially respond to the cues provided by the therapist and dis- cuss material which these cues dictate. This seems to be evidence for Krasner's (1962) contention that the therapist acts as a "social reinforcement machine." However, it should be pointed out that the therapists also respond to the cues of the client, i.e., the thera- pists follow the leads of the client in their approach- avoidance behavior. Thus, the therapeutic process is an interaction process in which both parties influence and are influenced by the other. And While this inves- tigation has concentrated on the influence of the ther- apist on the client's behavior,future research could 64 appropriately study the effects of the client on the therapist's behavior. It is possible that "approach" by the therapist serves primarily to dissipate anxiety about expressing hostility on the clientés part. The finding that the client continues expressing hostility significantly more after approach than after avoidance follows logi- cally. According to the drive reduction concept of reinforcement (Dollard and Miller 1950) such reductions in anxiety should serve as reinforcements. Thus, hos- tility expressions by the client should increase as the therapist approaches hostility and the client be- comes less inhibited about expressing his hostile feel- ings. This is conceivably what happened in the early stages of the therapy of the clients studied in this investigation. The finding of lower client continuance of hostility expressions after approach by the therapist in earlier stages of therapy reflectsrrt.only a reduc- tion in anxiety but also a reduction in the learned hostility drive. Future research utilizing a measure of anxiety in conjunction with hostility expression 65 could determine if this is actually what happens in psychotherapy. Hypothesis V was concerned with both the client's initial level of hostility expression and the changes in this hostility as therapy progressed. Based on the assumption that client-initiated-hostility was a measure of the "push" of the internal level of the client's hostility, the clients were divided into two groups at the onset of therapy--those with the higher hostility levels and those with the lower hostility levels. It was then predicted that the "high" group would decrease significantly and the "low" group increase significantly over the course of therapy. The changes were in the ex— pected direction but were not statistically significant. However, since the statistical phenomena "re— gression to the mean" would have predicted the same type of change, two other approaches to the problem were attempted. The first of these uses client-initiated- hostility as the relevant variable but is concerned with the intersubject Jariance of client-initiated-hostility at the beginning of therapy and at the end. If learning 66 of a consistent nature occurs in psychotherapy, one might expect the group of clients as a whole to have significantly more variance at the beginning of therapy than at the end. To perform this analysis the propor- tional data were transformed into angles to normalize the distribution using the method reported in Walker and Lev (1953, pp. 423—424). The test used was that suggested in Walker and Lev (1953, pp. 190-191) for comparing two variances based on related scores. Con- trary to the prediction, there was actually greater variance at the end of therapy compared with the be- ginning for the group, but the test was nonsignificant (p>10). Incidental to this analysis a Pearson'Y was computed between the c1ient-initiated-hostility scores at the beginning and at the end of therapy. This was V = .02, indicating changes in client-initated-hostility are occurring from the beginning to the end of therapy but these changes are not consistent. The second additional attempt to assess changes in the client's hostility level as therapy progressed used a measure more gross than client-initiated-hostility. 67 This measure is the proportion of the total number of client "speeches" during an interview which were con- cerned with hostility. This measure was utilized with the realization that such variables as therapist approach- avoidance rates were also involved in determining the amount of hostility expressed in any given hour. In spite of this, one could expect a client to spend more time discussing content of a hostile nature, once ap- proached by the therapist, if the internal hostility level of the client "pushed" him toward such expres- sions. The "catharsis" hypothesis as delineated by Dollard et a1 (1939) would predict a decrease later in therapy in the proportion of time spent discussing hostility once the client had opportunity to repeatedly ventilate his hostile feelings in the early and middle phases of therapy. The proportion of client speeches in an inter- view devoted to hostility were computed for each of the 5 stages of therapy sampled. There is great vari- ation between stages and between clients, but no con- sistent trends are evident. The mean proportion of 68 client speeches concerned with hostility are presented in Table 11. Table 11.-—Mean and range of proportions of client speeches concerned with hostility out of the total number of speeches in an hour -— ‘— 1% 25% 50% 75% 100% Mean pro- portion of hostile speeches Range of proporé tions of hostile speeches .117 .03-.35 .112 .02-.27 .121 .00-035 .103 .04-.22 .082 .00-.28 It can be seen that the changes tion predicted but are small. The final conclusion is in the client's hostility level these changes did not emerge as in means are in the direc- that while changes occurred as therapy progressed, consistent trends. The learning experiences of the clients were apparently unique to each individual and did not lend themselves to predictions based on knowledge of the group at the beginning of therapy. This finding is in contrast to 69 the results reported by Schuldt (1964) using the same interviews. Schuldt found a consistent, significant decrease in client-initiated-dependency from beginning to end of therapy. Schuldt's finding indicates the clients did change as a result of psychotherapy. The inconsistent findings with respect to hostility may have several meanings. First, it should be noted that hostility expres- sions occur much less frequently and much more sporadi- cally than either "dependency" or "other." (see Appen- dix B) Generally, other investigators using the same scoring method and similar populations have had similar findings for early interviews (KOpplin, 1963; Lerman, 1963; and Barnes, 1963). These findings suggest that for the p0pu1ation sampled, hostility is not consis- tently dealt with in psychotherapy and is discussed only infrequently. The ups and downs of both the thera- pists' approach to hostility and the clients' continu- ance rates are further evidence of this inconsistency. Whereas dependency is conceivably an essential part of the psychotherapeutic relationship, hostility is not for the sample of cases studied. 70 Since the present sample is composed of college students whose pathology for the most part is not severe, it is quite possible that they represent only the lower portion of the total possible range of peOple with vary- ing levels of hostility. That is, the hostility levels of this group of clients are probably low compared with other client p0pu1ations, e.g., a prison population. If our sample represents a restricted range of hostility levels, consistent changes in these levels are naturally more difficult to detect. We did not have the indepen- dent measure of hostility needed to compare our sample with other samples, but this could be done in future research. It may well be that to find consistency of changes in hostility, one would have to measure the hostility every interview for each client rather than sample only a few interviews. There is also the possi- bility that changes in hostility require more time to stabilize because of the sporadic nature of the hostile expressions. Further research comparing long term 71 cases, say, 30 interviews or more, with short term cases, 15 interviews or less, could illuminate this point. It may also be true that our scoring system results in measures that are not refined enough to ascertain the subtleties of the changes in hostility. For example, most therapists would contend they are primarily concerned with the appropriateness of hos- tility expressed and less concerned with the amount. With the scoring system used in the present study we have no accurate measure of the appropriateness of the hostility expressed and thus cannot say Whether or not changes of this type occurred over time in therapy. Appendix C shows the types and proportions of the forms of hostility which were expressed by the clients studied in the present sample. Judgments of the appropriateness of the various expressions of hostility could be devel- oPed. Further research is necessary to measure possible changes in appropriateness as well as the amount of hos- tility which occurs as a result of psychotherapy. 72 Since psychotherapists are primarily interested in helping clients resolve emotional conflicts, a more meaningful approach to this research problem might be in terms of assessing changes in client's aggression conflicts as a result of psychotherapy. Mueller and Grater (1964) have developed a promising method of measuring aggression conflicts utilizing the Semantic Differential. This method could conceivably be used before, during, and after clients undergo psychotherapy in conjunction with a content analysis scoring system to discover if and how aggressive conflicts are resolved. Conclusions At this point it seems appropriate to discuss the overall significance of this study. The content analysis scoring method used to help simplify the client- therapist interaction has its roots in learning theory. Because of this fact, this investigation has been pri- marily an attempt to understand psychotherapy as a learning process. This was done with the knowledge 73 that none of the therapists studied consider themselves to be "behaviorists" and would not consciously be try- ing to use learning theory principles in their psycho— therapeutic work. In spite of this, the behavior of the therapists studied do have effects on the behavior of the clients which can generally be explained by one or more learning theory models. The most significant of these is that "approach” behavior on the part of the therapist elicits continuance and "avoidance" eli- cits non-continuance of the topic under discussion on the part of the client at all stages of the therapy. This does not mean other theories of behavior are wrong, as they also generate expectations concerning the effect of the therapist's behavior upon the client. However, our results may help to understand the pro— cess of psychotherapy without depending exclusively on such therapist variables as "transference" and "counter-transference" (psychoanalytic theory) and "unconditional positive regard" (Rogerian Theory). On the other hand, one of the major expecta- tions of this study was not supported, i.e., the 74 expectation that the clients would change in terms of hostility expression in a consistent manner. Since only cases judged successful by the relevant therapist were studied, all theories of behavior would have pre- dicted significant changes in the clients as a result of psychotherapy. Indeed, the clients did change in terms of significant decrease in dependency (Schuldt. 1964) but not in a consistent manner in terms of hos- tility. There are numerous possible reasons why this expected change was not found, e.g., small sample size. sampling method, uniqueness of the sample, gross mea- suring instruments, etc. Thus, more accurate measures can be made by correcting for such factors in future research and the expected change may be obtained. However, we should not discount the individu- ality of each client in therapy. Many theories of personality emphasize the uniqueness of the individual, e.g., Allport (1961), Rogers (1961), and May (1958). Such theories would contend that the emotionalbrhealthy individual should be free to be flexible, to change. to develop and grow. Thus. successful psychotherapy 75 should help the maladjusted individual to change in his own unique way. This is a possible explanation for our finding of inconsistent changes in hostility expression as therapy progressed. However, even with the uniqueness of each individual, lawfulness of be- havior exists. The present investigation was but a small part of the many attempts to discover this law- fulness using one behavioral variable--hostility--in one human interaction situation--psychotherapy. The scoring model used is naive and incomplete in many re- spects, but it can be reliably used. With modifications to help measure such things as affect, conflect relevance, cue value, etc., the present scoring method could help provide significant knowledge about the process of psy- chotherapy. Summary The clients' expressions of hostility and the therapists' reactions to such expressions are signifi- cant variables in the psychotherapeutic process. This study is an attempt to analyze the changes in clients' hostility expressions as therapy progresses. A con- tent analysis system for analyzing verbal behavior is used to determine what effect the therapist's "approach" reactions and "avoidance" reactions to hostility have on subsequent expressions of hostility by the client. Two classes of variables are studied: 1) client vari- ables, and 2) therapist variables. The following hypotheses, derived primarily from learning theory expectations, are stated to test the client variables: 1. The clients will continue expressing hostility significantly more after "approach" than after "avoid- ance" of such expressions by the therapist. As therapy 76 77 progresses the reinforcement of the therapist's "approach" should lead to an increase in the client's continuance of hostility expressions after such expressions are approached. 2. There will tend to be two classes of clients, those who have higher initial hostility expression levels and those who have lower initial hostility levels. But these differences in hostility expression should be less marked in the final stages of therapy. The hypo- thetical learning experiences of clients during therapy predict the "high" group should decrease and the "low" group increase in hostility expression. The following hypotheses concerning therapist variables are derived primarily from previous research: 3. The therapists' approach rate to the clients' hostility will vary in different stages of psychother- apy, i.e., the therapists will behave differently in different stages of therapy. 4. The therapists will approach hostility expres- sions significantly more when they are not the object of the clients' behavior. 78 5. Staff therapists will approach hostility sig- nificantly more than less experienced therapists (in- terns) in the early stage of therapy, but this differ- ence will disappear as therapy progresses. A content analysis is made of 80 tape recorded interviews of 16 clients seen in psychotherapy by 7 interns and 6 staff therapists in a university coun- seling center. An interview for each client is ana— lyzed at five sample points approximating the 1st, 50th, 75th, and 100th percentages of the total number of interviews for each client. All sixteen clients are terminated and considered to be successful cases by their therapists. Client-therapist interactions are coded for the number of times clients initiate hostil- ity after approach and avoidance of such expressions by the therapists. The number of times the therapists approach or avoid hostility expressions by the client are also coded. The results follow: 1. Therapists' "approach” to hostility expressions of the client elicits further such expressions, while "avoidance" elicits non-hostile material at all stages 79 of therapy. However, there is no increase in the effec- tiveness of such elicitations as therapy progresses. 2. The clients did not change significantly in the predicted manner as a result of therapy, regardless of whether they were initially high or initially low in hostility expression. Their changes are apparently individually determined. 3. The therapists as a group approach the clients' hostility expressions about 50% of the time with only minor fluctuations at different stages of therapy. There is a great deal of variation among therapists in this respect. 4. Staff therapists approach hostility directed at themselves significantly less than they approach other hostility. This is not the case with the intern therapists. 5. Staff and intern therapists generally approach the clients' hostility expressions at approximately the same rate. However, intern therapists approach hostility directed at the therapist significantly more 80 than staff therapists. The effect of group training is suggested as an explanation for this finding. The theoretical implications of the results are discussed. Possibly avenues for further research to answer some of the questions raised by the study are suggested. References Allinsmith, Beverly B. Expressive styles: II. Direct- ness with which anger is expressed. In D. R. Miller and G. E. 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New York: Grune and Stratton, 1954. Zadek, Meira E. The conditioning of verbal behavior with negative cultural connotations. J. pers., 1959, 27. 477-486. APPENDICES APPENDIX A The scoring manual used in the coding of the tape recorded interviews (This manual is a modification of manuals used in the following studies: Winder, C. L., Ahmad, F. Z., Ban- dura, A., & Rau, L. C. Dependency of patients, psy- chotherapists' responses, and aspects of psychotherapy. J. consult. Psychol., 1962, 26, 129-134; Bandura, A., Lipsher, D. H., & Miller, P. E. Psychotherapists' approach-avoidance reactions to patients' expressions of hostility. J. consult._P§ychgl., 1960, 24, 1-8; Caracena, P. verbal reinforcement of client dependency in the initial stage of psychotherapy. Unpublished doctoral dissertation, Michigan State University, 1963; Kopplin, D. A. Hostility of patients and psychothera— pists' approach--avoidance responses in the initial stage of psychotherapy. Unpublished master's thesis. Michigan State University, 1963.) A. Scoring Unit and Interaction Sequence 1. Definition. A unit is the total verbalization of one speaker bounded by the preceding and succeeding speeches of the other speaker with the exception of interruptions. There are three types of scoring units: the "patient statement" (P St), the "therapist response" (T R), and the "patient response" (P R). A sequence of these three units composes an ”interaction sequence." The patient response not only completes the first interaction sequence but also initiates the next sequence and thereby becomes a new patient statement. 92 93 Example: P. I can't understand how you can stand me. (P St) T. You seem to be very aware of my feel- ings. (T R) P. I am always sensitive to your feelings. (P R) 2. Pauses. Pauses are not scored as separate units. The verbalization before and after the pause is considered one unit. Therapist silences are scored as prescribed under Part D2e of this manual. There are no patient silences in this system. 3. Interruptions. Statements of either therapist or patient which interrupt the other speaker will be scored only if the content and temporal continuity of the other speaker is altered by the interruption. Then, the interrupting ver- balization becomes another unit and is scored. A non-scored interruption is never taken into account in the continuation of the other speaker. Interruption scored as one unit: P. I asked him to help me and-- T. Why was that? P. --he refused to even try. Non-interruption scored as 3 units, one interaction sequence: P. I asked him to help me and-— T. Why was that? P. I don't know. 94 Verbalizations such as "Um hmm" or "I see" are ignored in scoring unless they are so strongly stated as to convey more than a listening or receptive attitude. Patients' requests for the therapist to repeat his response are considered interruptions and are not scored. How- ever, therapists' requests of this sort are scored as units (as approach or avoid- ance of the patient statement). Categories 0f Patient Statements and Patient Responses There are three categories: Dependency, Hostility, and Other. They are scored as exhaustive categories. All discriminations are made on the basis of what is explicitly verbalized by the speaker in the unit under consideration. One statement may be scored for several categories. When dependency and/or hostility units occur, the object of the patient's behavior is also scored as either psychotherapist or other. A coding of self (S) is given if the patient re- fers to his own behavior and a coding of other (0) is given if the client refers to someone else's behavior. 1. Hostility category. The subcategories of hostility are listed below. a. Hostility. Hostility statements include description or expression of unfavorable. critical, sarcastic. depreciatory remarks; oppositional attitudes; antagonism, argu- ment, expression of dislike, disagreement. resentment, resistance, irritation, annoy- ance, anger; expression of aggression and punitive behavior, and aggressive domina— tion. b. The subcategories listed below are scored exhaustively. l. Anger: P. I'm just plain mad: 95 P. I just couldn't think-—I was so angry. P. My uncle was furious at my aunt. 2. Dislike: expresses dislike or describes actions which would usually indicate dislike P. I just don't get interested in them and would rather be some- where else. P. I've never ever felt I liked them and I don't suspect I ever will. P. He hates editorials. 3. Resentment: expresses or describes a persistent negative attitude which does or might change to anger on a specific occasion P. They are so smug; I go cold when- ever I think about having to listen to their 'our dog' and 'our son.' Boy: P. They don't ever do a thing for me so why should I ask them over? P. Dad resents her questions. 4. Antagonism: expresses or describes an- tipathy or enmity P. It's really nothing definite, but we always seem at odds somehow. P. There is always this feeling of being enemies. Hostility 96 5. Opposition: expresses or describes oppositional feelings or behavior P. If he wants to do one thing, I want to do another. It always seems she is against things. She is even against things she wants. No, I don't feel that way (in response to T's assertion). 6. Critical attitudes: expresses nega- tive evaluations or describes actions which tions P. 7. Aggressive actions: another person or persons, either phys- usually imply negative evalua- If I don't think the actors are doing very well, I just get up and walk out. There is something to be critical about in almost everything anyone says or does. ically or psychologically P. He deserves to suffer and I'm making it that way every way I can. I can remember Mother saying: 'We slap those little hands to make it hurt.' anxiety. A statement including expression of fear. anxiety. guilt about hostility or reflecting difficulty express- ing hostility P. I just felt so sad about our argument. acts so as to hurt C. 97 P. I was afraid to hit her. P. After I hit her I felt lousy. Hostility acknowlgdgment or agreement: A statement agreeing with or acknowledging the therapist's approach toward hostility is scored as further hostility. May give example. May convey some conviction or may simply agree with therapist's response. T. You were angry. P. Yes! 2. Dependency categories. a. b. Definition: Any explicit expression or description of help-seeking, approval- seeking, company-seeking, information- seeking, agreement with others, concern about disapproval, or request that another initiate discussion or activity. Scoreable categories: The subcategories listed below are scored exhaustively. 1. Problem Description: States problem in coming to therapy, gives reason for seeking help, expresses a depen- dent status or a general concern about dependency. P. I wanted to be more sure of myself. P. I wanted to talk over with you my reasons for dropping out of school next quarter. P. Part of the reason I'm here is that everything's all fouled up at home. P. I depend on her, am tied to her. P. I want to be babied and comforted. 2. 4. 98 Help;§eeking: Asks for help, reports asking for help, describes help-seeking behavior P. I asked him to help me out in this situation. P. What can you do for him? P. I try to do it when he can see it's too hard for me. Approval seekipg: Requests approval or acceptance, asks if something has the approval of another, reports having done so with others. tries to please another. asks for support or security. Includes talk about prestige. Expresses or describes some activity geared to meet his need P. I hope you will tell me if that is what you want. P. If there was any homework, I did it so Dad would know I was study- ing like a good girl. P. Is it alright if I talk about my girl's problem? P. That's the way I see it, is that wrong? P. I asked him if I were doing the right thing. Company-seeking: Describes or expresses a wish to be with peOple, describes mak- ing arrangements to do so. describes efforts to be with others. talks about being with others. 5. 99 P. It looks as if it'll be another lonely weekend. P. Instead of studying, I go talk with the guys. P. I only joined so I could be in a group. P. We try to see if other kids we know are there, before we go in. Information-seeking: Asks for cogni- tive, factual or evaluative information, expresses a desire for information from others, arranges to be the recipient of information P. I asked him Why he thought a girl might do something like that. P. I came over here to see about tests you have to offer. I want to know what they say. P. I'm planning to change my major. I'd like to know how to do it. Agreement with another: Responds with ready agreement with others, readily accepts the therapist's reflection. Often illustrates therapist's remarks with examples, draws a parallel example to indicate agreement. May accept pre- ceding statement on authority or if preceding statement was a therapist approach to Dependency. may simply agree with it. P. Oh, yes: You're absolutely right about that. 7. 8. 100 P. Immediately I felt he was right and I had never thought about it that way. T. Then you wanted to get some help? P. Yes. Concern about disapproval: Expresses fear, concern. or unusual sensitivity about disapproval of others. describes unusual distress about an instance of disapproval, insecurity, or lack of support. Little or no action is taken to do something about the concern P. She didn't ever say a thing but I kept on wondering what she doesn't like about me. P. My parents will be so upset about my grades. I don't even want to go home. P. It seems like I always expect I won't be liked. P. I can't understand how you can stand me when I smoke. P. I'm sorry I got angry at you. Initiative-seeking: Asks the therapist or others to initiate action, take the responsibility for starting something (to start discussion. determine the topic). Arranges to be a recipient of T's initiative. May solicit sug- gestions P. Why don't you say what we should talk about now? 101 P. If you think I should keep on a more definite track, you should tell me. P. I got my advisor to pick my courses for next term. P. Tell him what to do in these cir- cumstances. 3. Other-category. Includes all content of patient's verbalizations not classified above Categories of Therapist Responses Therapist responses to each scored patient state- ment are divided first into two mutually exclusive classes. approach and avoidance responses. When both approach and avoidance are present, score only the portion which is designed to elicit a response from the patient. 1. Approach responses. The following subcategories are exhaustive. An approach response is any ver- balization by the therapist which seems designed to elicit from the patient further expression or elaboration of the Dependent or Hostile (or Other) feelings. attitudes, or actions described or expressed in the patient's immediately pre— ceding statement, i.e., the part of the preceding statement which determined its placement under Dependency, Hostility or Other. Approach is to the major category, not specific subcategories. a. Approval: Expresses approval of or agree- ment with the patient's feelings, attitudes. or behavior. Includes especially strong "MR-hm: ll ' "Yes II P. May I just be quiet for a moment? T. Certainly. 102 P. I have my girlfriend's problems on my mind. Could we talk about them? T. Why don't we talk about that? Exploration (probing): Includes remarks or questions that encourage the patient to describe or express his feelings. attitudes. or actions further. asks for further clari- ficiation, elaboration. descriptive infor- mation. calls for details or examples. Should demand more than a yes or no answer; if not, may be a "label" P. How do I feel? I feel idiotic. T. What do you mean. you feel idiotic? P. I can't understand his behavior. T. What is it about his behavior you can't understand? Reflection: Repeats or restates a portion of the patient's verbalization of feeling. attitude, or action. May use phrases of synonymous meaning. Therapist may sometimes agree with his own previous response; if the client had agreed or accepted the first ther- apist statement, the second therapist state- ment is scored as a reflection of the client statement. P. I wanted to spend the entire day with him. T. You wanted to be together. P. His doing that stupid doodling upsets me. T. It really gets under your skin. d. e. 103 Labeling: The therapist gives a name to the feeling, attitude, or action contained in the patient's verbalization. May be a tentative and broad statement not clearly aimed at exploration. Includes "bare" in- terpretation, i.e., those not explained to the patient. May be a question easily answered by yes or no P. I just don't want to talk about that any more. T. What I said annoyed you. P. She told me never to come back and I really did have a strong reaction. T. You had some strong feelings about that--maybe disappointment or anger. Interpretation: Points out and explains patterns or relationships in the patient's feelings, attitudes, and behavior: explains the antecedents of them, shows the similar- ities in the patient's feelings and reactions in diverse situations or at separate times P. I had to know if Barb thought what I said was right. T. This is what you said earlier about your mother . . . Generalization: Points out that patient's feelings are natural or common P. I want to know how I did on those tests. T. Most students are anxious to know as soon as possible. P. Won't you give me the scores ? T. Many students are upset when we can't. 104 9. Support: Expresses sympathy. reassurance. or understanding of patient's feelings P. It's hard for me to just start talking. T. I think I know what you mean. P. I hate to ask favors from people. T. I can understand that would be dif- ficult for you. h. Factual Information: Gives information to direct or implied questions. Includes gen- eral remarks about the conseling procedure P. Shall I take tests? T. I feel in this instance tests are not needed. P. What's counseling all about? T. It's a chance for a person to say just what's on his mind. Avoidance responses. The following subcategories are eXhaustive. An avoidance response is any verbalization by the therapist Which seems de- signed to inhibit. discourage. or divert further expression of the Dependent. Hostile, or Other patient categories. The therapist attempts to inhibit the feelings, attitudes. or behavior described or expressed in the immediately pre- ceding patient statement, i.e., the part of the preceding statement which determined its place- ment under Dependency, Hostility, or Other. Avoidance is avoidance of the major category. not specific subcategories. a. Disapproval: Therapist is critical. sarcas- tic, or antagonistic toward the patient or his statements, feelings, or attitudes, ex- pressing rejection in some way. May point out contradictions or challenge statements b. C. 105 P. Why don't you make statements? Make a statement. Don't ask another ques- tion. T. It seems that you came here for a reason. P. Well, I wonder what I do now? T. What do you think are the possibilities? You seem to have raised a number of logical possibilities in our discussion. P. I'm mad at him: that's how I feel. T. You aren't thinking of how she may feel. Topic Transition: Therapist changes or in- troduces a new topic of discussion not in the immediately preceding patient verbaliza- tion. Usually fails to acknowledge even a minor portion of the statement P. 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. P. My mother never seemed interested in me. T. And what does your father do for a living? Ignoring: Therapist responds only to a minor part of the patient response or re- sponds to content, ignoring affect. May under- or over-estimate affect. May approach the general toPic but blatently ignore the affect verbalized d. T. 106 You've been through this with other people so help me out, will you. You are a little uneasy. 1 You can see I don't know what to do and I want you to give me advice. Just say whatever you feel is impor- tant about that. My older sister gets me so mad I could scream. Mm-hmm. How old did you say she was? Mislabeling: Therapist names attitudes, feel- ings. or actions which are not present in the actual verbalization preceding the response P. T. P. T. I just felt crushed when she said that. Really burned you up. huh? I don't know how I felt--confused, lost—- I wonder if what you felt was resentment. Silence: Scored when it is apparent that the patient expects a response from the therapist but none is forthcoming within 5 seconds after the patient stops talking. If the therapist approaches after 5 seconds have elapsed, si- lence cannot be scored and the therapist's response is merely "delayed" P. T. If you think I should keep on a more definite track, tell me because I'm just rambling. (5 second silence) It is very confusing to know what to do. 107 Dependency and Hostility initiated by therapist: Scored whenever the therapist introduces the topic of Dependency or Hostility, i.e., when the patient statement was not scored as the category which the therapist attempts to in— troduce P. Last week I talked about Jane. T. You've mentioned a number of things you have done to please her. P. (Enters office) T. Now. how may I help you? P. I was late for class this morning. T. I wonder if you dislike the teacher or the class? P. I like to run around in blue jeans. T. You hate your mother. APPENDIX B Proportions of the client's speeches devoted to "hostility." "dependency" and "other" at each of the five sample points in therapy. __12é fl .18. 75°10 100% "Hostility" .117 .112 .121 .103 .082 "Dependency" .250 .186 .204 .188 .162 "Other" .633 .702 .675 .709 .756 108 APPENDIX C The proportions of the types of hostility discussed at each of the five sample points in therapy. ._E& .22&. 59%. 22%. IQQE. Anger .26 .28 .40 .38 .28 Dislike .15 -.07 .04 .05 .04 Resentment .04 .01 .04 .04 .04 Antagonism .006 .02 - .00. .01 .01 Opposition .07 .10 .10 .18 .09 Critical Attitudes .06 .07 .09 .06 .09 Aggressive Actions .29 .18 .07 .11 .23 Hostility Anxiety .00 .00 .02 .01 .00 Hostility Agreement .17 .24 .23 .16 .23 109 APPENDIX D Proportions of the types of "approach" to hostility and types of "avoidance" to hostility at each of the five sample points in therapy. 42 25.8 22% 75% __9.%.10 APPROACH Approval .02 .04 .03 .03 .03 Exploration .45 .36 .34 .33 .29 Reflection .15 .14 .08 .11 .14 Labeling .09 .06 .18 .10 .14 Interpretation .27 .33 .27 .32 .35 Generalization ‘ .00 .01 .00 .01 .00 Support .01 .06 .07 .10 .06 Information giving .00 .00 .01 .00 .00 AVOIDANCE Disapproval .02 .01 .16 .05 .02 Topic transition .17 .25 .13 .18 .08 Ignoring .81 .72 .70 .75 .90 Mislabeling . .00 .00 .02 .02 .00 Silence .00 .01 .00 - .02 .00 110 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII