PERSPECTIVES 0F PSYCHOTHERAPY PROCESS: SELF -INTERNALIZATION AMONG MALE AND FEMALE CLIENTS Thesis for the Degree of M. A. MICHIGAN STATE UNIVERSITY MICHAEL H. FIGLER 1968 ' ”"TRRARY IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ;_._ 31293008089165 . . ‘ Umvcmt) f by.»- mun-u ‘— BINSlNa av ' HUM: a SUNS' 9 9925.§"’1‘~.8.Y.J!9- S HAY ABSTRACT PERSPECTIVES OF PSYCHOTHERAPY PROCESS: SELF-INTERNALIZATION AMONG MALE AND FEMALE CLIENTS By Michael H. Figler This investigation is a content analysis of psycho- therapy process with special reference to the frame of ref- erence and focus of therapist and client expressions. First, middle, and next to last interviews of completed therapies of ten male and ten female clients seen by male psychotherapists were transcribed from previously tape recorded interviews. These transcriptions were coded inde- pendently by three judges and satisfactory reliability was obtained for the coding procedures. Based on the literature in developmental psychology which suggests differences in the expression of affect be- tween males and females and relating this to psychotherapy process, the following hypotheses are presented: 1. Female clients self-internalize significantly more during the initial session than do male clients. By self-internalizing is meant responses by the client using the self-frame of reference and hav- ing an internal focus. Example: Michael H. Figler "I'm just plain mad." (hostility content category, self-frame of reference, inter- nal focus of attention). 2. The rate of therapist self-internalizations during the initial interview is significantly higher for male clients than for female clients. Self- internalizations by the therapist are responses which utilize the self—frame of reference of the client and have an internal focus. Example: Th: "How are you feeling about yourself today?" (self-frame of reference, inter- nal focal point). 3. The rate of self-internalizations for both sexes of clients is significantly less during the initial session as compared to the terminal session. 4. There remains a significant difference between male versus female client self-internalizations at the end the therapy (next to last session). Females still rate prOportionately higher. None of the experimental hypotheses are supported. Further analyses were performed in an attempt to illuminate the findings. It is shown that male and female clients in this sample differ with regard to available MMPI data. Male clients appear more deviant (greater number of MMPI scales above a T score of 70) than female clients, and ‘vhile both males and females are more deviant than their Michael H. Figler non-client undergraduate counterparts, male clients are much more deviant than their non-client male counterparts. Considering this finding, male and female clients were Separated into high and low "disturbance" groups using the number of deviant MMPI scales prior to therapy as criterion. After matching male and female clients for degree of "disturbance," three of the original hypotheses were reanalyzed using this matching as a control. No sup— port for the hypotheses was found. Then a series of post- hoc analyses was undertaken, concerning self-internalization behavior, sex of client, and utilizing the control for level of disturbance described above. One interesting sidelight and the only significant finding (post-hoc) was the positive relationship between therapist rating of suc- cess and total self-internalization responses, when clients were pooled irrespective of sex and degree of MMPI devia- tion. Basically this study finds no significant differ- ences between male and female clients along the investigated dimension of client and therapist behaviors. The author speculates that these findings raise some doubts with re- gard to the attacks on patient uniformity assumptions in the recent literature. Perhaps when the client population is relatively homogeneous and the therapists do not differ extensively in their approach to patients (i.e., most of ‘the therapists were relationship oriented in their approach, Michael H. Figler though with differing theoretical tendencies) there is a measure of patient uniformity with regard to certain vari- ables. Since self-internalization contains a strong affec— tive component, it is possible that this variable tran- scends other patient differences. This supposition will need to be tested further, and specific recommendations are made in this study. 00ml IIMe Chairman, Thesis Committee Date IQTI- 6 (768 PERSPECTIVES OF PSYCHOTHERAPY PROCESS: SELF-INTERNALIZATION AMONG MALE AND FEMALE CLIENTS BY \ Michael H. Figler A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Psychology 1968 To Sonia ACKNOWLEDGMENTS My sincerest appreciation goes to Dr. Norman Abeles for his suggestions, patience, and enthusiasm in the under- taking of this thesis. Along with Dr. Abeles, who served as my committee chairman, I am also indebted to the other members, Dr. Gary Stollak and Dr. Dozier Thornton. I would also like to thank Dr. James Alexander who, while working on content in this subject area, took me into his research, providing me with the impetus and cooperation in under- taking this thesis. Along with Dr. Alexander, Bonnie Green is to be commended for her help in coding the overwhelming amount of raw data, and accomplishing the task so nicely. Acknowledgments are made to the psychotherapists and clients at the Michigan State University Counseling Center for their cooperation in making the typescripts available on which this study is based. Sincere apprecia- tion also goes to the United States Public Health Service who provided the grant which enabled me to have the free- dom to carry out this research. Finally, without the deep love of my wife, Sonia, this study could never have been accomplished. iii TABLE OF CONTENTS ACKNOWLEDGMENTS . . . . . . . . LIST OF TABLES . . . . . . . . . LIST OF FIGURES . . . . . . . . LIST OF APPENDICES . . . . . . . INTRODUCTION . . . . . . . . . . REVIEW OF THE LITERATURE . . . . Content Analysis Systems . . Sex Differences . . . . . . Self Frame of Reference . . Internalizing-Externalizing HYPOTHESES O O O O O O O O O O O Hypothesis I . . . . . . . . Hypothesis II . . . . . . . Hypothesis III . . . . . . . Hypothesis IV . . . . . . . METI'iOD O O O O O O O O O O O O O Source of Data . . . . . . . Selection of Cases . . . . . Coding Procedure . . . . . . Scoring Reliability . . . . RESULTS 0 O O O O O O O O O O 0 Reliability . . . . . . . . Hypotheses . . . . . . . . . Hypothesis I . . . . . . Hypothesis II . . . . .' Hypothesis III . . . . . Hypothesis IV . . . . . iv Page iii vi vii viii w gumbo.) 11 ll 12 12 13 15 15 19 21 23 23 27 27 29 3O 32 Page DISCUSSION 0 O O O I O O O O O O O O O O O O O O O 35 Original Hypotheses . . . . . . . . . . . . . 36 POSt-HOC Analyses o o o o o o o o o o o o o o 39 SUMMARY 0 O O O O O O O O I O O O O O O O O O O O 45 REFERENCES 0 O O O O O O O O O O I O O O O O O O O 49 APPENDICES O O O I O O O O O O O O O O O O O O O O 52 LIST OF TABLES Page Descriptive Summary of Client and Therapist Characteristics . . . . . . . . . . . . . . . 17 Experience Level and Duration of Treatment. . . l7 Reliability of Scoring Categories . . . . . . . 24 Mean Frequency of Client Self-Internalizations. 29 Mean Frequency of Therapist Self- Internalizations. . . . . . . . . . . . . . . 32 Summary Table of Post-Hoe Analyses in Order of Presentation in Discussion . . . . . . . . 37 vi Figure l. 2. LIST OF FIGURES Client Self-Internalizations . . Therapist Self-Internalizations. vii Page 28 31 LIST OF APPENDI CES Appendix Page A. Scoring Manual . . . . . . . . . . . . . . 53 B. Frequency of Client Self-Internalizations . 76 C. Frequency of Therapist Self- Internalizations . . . . . . . . . . . . . 77 viii INTRODUCTION Puzzling over this problem of getting at the proc- ess has led me to realize how little objective research deals with process in any field. Objective research slices through the frozen moment to provide us with an exact picture of the interrelationships which exist at that moment. But our understanding of the ongoing moment--whether it be the process of fermentation, or the circulation of the bloOd, or the process of atomic fission--is generally provided by a theoretical formu- luation, often supplemented, where feasible, with a clinical observation of the process. I have thus come to realize that perhaps I am hoping for too much to expect that research procedures can shed light directly Upon the process of personality change. Perhaps only theory can do that (Rogers, 1961, p. 127). Although the present author shares some of the above views, he feels that continued efforts at process research are a most fruitful undertaking and will provide foundations for future inferences. Prior to the efforts of Carl Rogers in initiating this type of research, psycho- therapy was deemed necessary as early in its development as Freud. He recognized the need for research, but pre- ferred it in the mode of uncontrolled observation. His findings were inferred from direct observations or on con- clusions drawn from them. Objective evidence for his sup— positions was difficult to obtain, particularly in demon- strating the process involved in psychotherapy. He con- sidered demonstration to an independent observer to be impossible, since it was posited that the patient would become mute (Freud, 1920). Therefore, controlled experi- mentation was impossible, with the little research under— taken being global in nature or based upon the subjective impressions of the therapist. Thus, little was contributed by the analytic school in terms of controlled, empirically validated data. A prominent breakthrough seems to have occurred with Covner's (1942) method of phonographic recording of the therapeutic session. As previously mentioned, the Rogerian school provided a great advance in the research of psychotherapy, since it Opened up the phenomena to scientific investigation by means of trained observers and Operationally defined concepts (Cartwright, 1957). The enormous quantity of data derived from these advances necessitated the development of content analyses systems which are reviewed and criticized by Auld and Murray (1955). Concurrent contributions were also offered by Dollard and Miller (1950) who translated Freudian theory into learning terms, thus making the latter's work more amenable to sci- entific investigation. Skinner (1953, 1957) also influenced the development of psychotherapeutic research with his in- sistence that verbal expressions were as much behaviors as anything else, and thus subject to experimental manipula- tion. REVIEW OF THE LITERATURE Content Analysis Systems In the evolution of content analysis systems, the work of Murray (1956) seems to have been one of the pio- neering efforts. He studied actual psychotherapy sessions from a learning standpoint, using client category and therapist approach-avoidance dichotomies. It was found that categories of client statements followed by therapist approach increased, while a decrease in such statements occurred when the therapist avoided them. Bandura EE_El° (1960) slightly modified Murray's system, having used a different definition of approach-avoidance. Moreover, the former researchers were interested in the effect of thera— pist approach-avoidance on the rate of client hostility statements. An analogous system was proposed by Winder gE_§l. (1962), with a slight variation in the definitions of approach and avoidance. In that study interest was focused upon the dependency statements of the client as a function of approach and avoidance on the part of the therapist. Further modifications were incorporated into a molecular content analysis system utilized by Caracena (1963). The system of coding used in the present study was derived mostly from Kopplin (1965) whose system gathered from those discussed above. Since all of the previous work in this area was instrumented by means of tape-recorded interviews, it is obvious that non-verbal, global aspects of the total psychotherapeutic interaction were excluded from the coding system. It is the present author's conten- tion, however, as previously stated by Auld and Murray (1955, p. 391) and Schuldt (1964) that one cannot expect a single content analysis system to account for all the infi- nitely large number of variables concerned. An adequate research method will probably come by a combination of many different methods, each of value in its own area of emphasis. Sex Differences In reviewing the literature for significant differ- ences in client behavior as a function of the sex of client or therapist, the present investigator found a noticeable lack of research which controlled sex as a variable. Most studies have either ignored the issue by using clients of one sex or by using pooled males and females as subjects (e.g., Bandura eE_§l. 1960; Winder gE_gl. 1962; KOpplin, 1963, 1965; Varble, 1964; Schuldt, 1964; Kammerschen, 1965). The general findings of the social learning approach sup- port the assumptions that males and females are behaviorally different along many dimensions. These behaviors have rarely been investigated as to how they carry over into the psychotherapy session. Fuller (1963) found that in the counseling situation more feeling was expressed in counselor-client pairs including a female, regardless of whether the female was a client or a counselor with an increase in the amount of feeling expressed from intake interview to later counseling interviews. When counselor sex and experience, client sex, presenting problem, and preference regarding sex of counselor were controlled, it was found that females expressed more feeling than did males in the sample. Under these circumstances no differ- ences in expression of feelings was due to the sex of the counselor. In the present study, the clients were divided into two groups according to sex, keeping sex of counselor constant. In this fashion it was hoped that any behavioral variation due to sex of clients would be more exposed, though it leaves Open the question of potential differen- tial counselor-client effects. Self Frame of Reference Using the self-frame of reference in the present study, as derived from Lennard and Bernstein's (1960) role system or frame of reference, combined with the internal- external dichotomy of KOpplin (1965), a number of hypoth- eses are generated. In terms of a frame of reference sys- tem, Lennard and Bernstein make the following statement: Our emphasis now is in classifying communication as referring to the various systems or role relationships in which the patient participates. We are particularly concerned here with identifying prOpositions in which the therapist or the patient discuss their roles and expectations with regard to therapy. It was assumed that one of the ways in which a patient "learns" about his own and the therapist's roles is through the refer- ences which the therapist makes to these roles, that is through role information provided by the therapist. They go on to elaborate a frame of reference system con- taining five categories: Primary, secondary, self, other, and family role relationships. The present author modified the original system to end up with eight mutually exclusive and exhaustive categories covering the relationship that is the focus of the statement, either by therapist or client. These categories are primary, secondary, self, family, tertiary, therapist, other, and non-reference. The categories are defined and discussed in the scoring manual (see Appendix A). The present study focuses particularly on the self— role system or frame of reference. This emphasis on the concept of self stems mostly from the attention it has received in personality theory from such diversified sources as Jung, Adler, Sullivan, Freud, Allport, Cattell, and Rogers, to mention a few (Hall and Lindzey, 1957). Although each theorists's definition of the concept of self is unique to a degree, there is a wide measure of overlap in agree- ment. The operational definition of the self frame of reference used in the present system is an attempted syn- thesis of the various definitions which have previously 7 been offered. If one theorist would have to be mentioned as most similar in respect to the present study's concep- tion of self, it would probably be Rogers (1961). Lennard and Bernstein initially defined the self frame of reference as references to life experiences past, present, and future that do not refer directly to other reference systems. However, this rather sketchy definition is expanded by the present author and is elaborated upon in the scoring man- ual as follows: Self system references are those relating to the client's life experiences which do not involve interactions with members of any other reference systems. Included are expressions of the client's own individuality, or behaviors so general to be relatively independent of environmental variations. Any expression which refers explicitly to the client in some way, and is not scored as Primary, Secondary, Family, or Tertiary is scored as Self (Appendix A). Examples: Cl. I'm scared. C1. I'm always playing hero. C1. I'm generally unhappy. Much of the rationale for the hypotheses generated in this study is derived from the emphasis on the self concept found in the work of Rogers (1961), as well as in social learning theory. Internalizing:Externalizing A component of the content analysis system used in the present study is an internalizing-externalizing ciimension derived from the work of Kell and Mueller (1966) as used previously in the investigation undertaken by Kop- plin (1965). The operational definitions of externalizing- internalizing are to be found in Appendix A. As is gener- ally accepted in the field of psychotherapy, clients may utilize less mature defenses against experiencing their conflicts as internal. Adolescents, as used in this study, are specially apt to externalize their problems and feelings. The basis for their difficulties are frequently blamed on the outside environment. Kell and Mueller have concluded from their experience that counselor responses are insti- gated on the assumption that the client can expand the feelings associated with his conflicts, enabling him to internalize his problems. Expansion and elaboration of feelings are basic to internalizing, but inevitably in- crease the conflict of the client. However they feel that this is a necessary (experience conflict as internal) pre- lude to the development of new controls and alternatives. Elaborating further in the words of the authors: Clients approaching the counseling relationship often regard their problems as environmental, and they fore- see the process of resolving the problem as being that of learning new ways to manipulate their environment. We feel that clients may attempt to structure the coun- seling relationship in this way to defend against their anxiety about dealing with the problem as an internal one. This client motivation to externalize does not mean that a client cannot be helped to internalize. It does create a problem for the counselor, however, in that the client may devote much energy in attempts to change the counselor or to somehow try to prevent him from helping the client to internalize his feelings. In the conception of the present study, the internal- external dichotomy reflects the focus of the client state- ment as being (at least in part) on his own needs, feelings, and reactions (Internal focus), versus a focus "outside" of himself (External focus). The defining characteristic is that the expression explicitly describes or relates the clients internal state, i.e., past or present affective feeling or need. Investigating this dimension, Kopplin (1965) found it to be extremely important in the conceptualization of the psychotherapeutic process. Using his molecular system of interaction, it was confirmed that if therapists include an internalizing component in their verbal statements with clients, the clients tend to respond with affective expres- sion. Also, if the therapist avoids internalizing state- ments, and focuses upon factors external to the client, the latter is less likely to respond with affective expres- sion. Furthermore, the therapist is more apt to follow an internalized statement by the client with further encour- agement of internal as Opposed to client external state- ments. In other words, apprOpriate content and affective expression on the part of the client can be elicited by therapist's statements and vice-versa, to a great degree. A final finding of interest is that clients are more likely to respond affectively to therapist elicitation of client non-affective statements compared to therapist elicitation 10 of externalized material following previous client affec- tive statements. In evaluating the above findings of Kop- plin, it should be taken into consideration that only the initial session of psychotherapy was studied, and the effects of client sex were not controlled. HYPOTHESES Hypothesis I Female clients will self-internalize significantly more during the initial interview than will male clients. This expectation is grounded in social learning theory, in that it is general knowledge that in our society as a whole, expression of feeling is more highly condoned for females than for males. Especially among male adolescents, one would expect a control on "emotionality" in keeping with the stereotyped model of the cool, unmoved teenager. It is realized, however, that a male client pOpulation coming for therapy may differ significantly from late male ado- lescents in general, which may interfere with this predic- tion. Also, this hypothesis is an attempt to replicate the findings of Fuller (1963) who found that female clients express more feeling than male clients when counselor sex and experience, client sex, presenting problem, and pref- erence regarding sex of counselor are controlled. She found that more feeling is expressed in pairs including a female, regardless of whether the female is a client or a counselor. Expressing feeling is similar to the internal focus used in the present study. 11 12 Hypothesis II The rate of therapist self-internalizations during the initial session will be significantly higher for males than for females. This hypothesis follows logically from Hypothesis I. Since the male clients are less apt to inter- nalize in their statements as compared to females, the therapist will necessarily have to "probe for feeling" in order to help the client internalize his problems, expand upon them, and "work" them through (Kell and Mueller, 1966). Somewhat beyond the scope of this study is to what extent therapists function differently with male versus female clients. As is previously mentioned when elaborating upon the internal—external dimension (in a preceding sec- tion), experiencing a problem as internal is a prelude to the develOpment of new controls and alternatives. There- fore, the therapist is expected to focus on helping the client to see most of his difficulties as being internal, and the probing is a necessary vehicle for the expansion and working through of these internal difficulties. Hypothesis III The rate of self-internalizations for both male and female clients will be significantly less during the ini- tial session as compared to the terminal session. In other words, it is expected that expression of affect in relation to the self frame of reference will increase generally 13 through therapy. Theoretical justification for this con- jecture comes, for the most part, from the work of Rogers (1961), who views tine process of therapy and personality change as an increasing ability to be in contact with and express feelings related to the self. Learning approaches to psychotherapy would also posit an increase in self—inter- nalizations throughout therapy, if they are being reinforced by the therapist. In other words, both a learning and Rogerian position would predict an increase in the hypoth- esized direction. Hypothesis IV At the terminal session of therapy, although both male and female clients will show a general increase in self (frame of reference) internalizations, there will remain a significant difference between male and female clients with respect to this dimension. Male clients will still be expected to self-internalize to a lesser degree than females, due to the strong residue of socio-cultural influences. However, as stated in Hypothesis III, males will significantly increase in the rate of self-internalizing statements over the course of therapy, but the basic "emo- tionality differential" between the sexes will still exist. Being that the course of therapy undertaken by the subjects in this study is of short duration, basic sexual socialization 14 differences to a large part will be relatively unaffected. Stated less stringently, "boys will be boys, and girls will remain girls" even after brief psychotherapeutic interven- tion. METHOD * Source of Data The cases used in the present study are part of a library of tape-recorded psychotherapeutic sessions carried out at the Michigan State University Counseling Center. All research participants were self referred, late adoles- cent undergraduates at the University. The presenting problems were of a personal or social nature. Having pre- sented themselves at the Center, each client was initially seen in an intake interview, and if accepted in therapy, was asked to participate in the research project. Most clients were assigned to their respective therapists on the bases of time availabilities of both client and therapist and any special competencies of the therapists involved. The final assignment of the clients was contingent upon agreement by the therapist to accept the particular client. Intake notes and personal impres- sions of the intake counselsor were made available to the therapist in order to aid him in his decision as to whether or not to accept the particular client in question. it The method and basic data used are identical to those used by the present author's associates, James Alexander (1967) and Bonnie Green (personal communication). 15 16 Some additional selection of cases occurred, because not all therapists at the Counseling Center who do psychother- apy participated in the study. The therapists involved in the present investigation divide into two groups. The staff group was composed of four Ph.D. level clinical and counseling psychologists with between 2 and 20 years of experience in psychotherapy. Also involved were 11 intern counselors, who were advanced doctoral candidates in clinical or counseling psychology with a mean of two years of intensive supervision in psy- chotherapy. All interns had successfully completed their practicum experience. In distributing the case load, four of the staff saw five clients, with the remainder of the 20 being seen by 11,interns. Two of the interns saw two clients each, with one seeing three clients. All thera- pists involved in the study were male, while the client group was divided into 10 males and 10 females. A summary description of client and therapist characteristics appears in Table 1. Generally clients and therapists at the Counseling Center met for one hour a week. The policy of the Coun- seling Center encourages relatively short-term therapy, i.e., 10-20 interviews, although treatment may frequently exceed this duration. Table 2 provides a summary of ther- apist experience level and duration of treatment. 17 Table l.--Descriptive Summary of Client and Therapist Characteristics Sex Mean Years Experience Therapists N Male Female in Psychotherapy Staff 4 4 . . 7.5 Interns ll 11 . . 2.0 Sex Mean Number of Clients N Male Female Interviews Clients Seen by Staff 5 2 3 12.2 Clients Seen by Interns l5 8 7 14.9 Table 2.--Experience Level and Duration of Treatment Sessions Experience Level 5-8 9-12 13-18 17-20 21+ Staff 2 0 2 l 0 Interns 3 4 0 6 2 Total 5 4 2 7 2 18 Selection of Cases In the present investigation tape recordings rep- resenting the first, middle, and next-to-last therapy ses- sions were selected. The selection of cases was based on a number of criteria: (1) At least 4 therapy sessions were involved; (2) The therapist was male; (3) The client was administered the MMPI prior to beginning therapy; (4) Ther- apy had been terminated. Twelve female and ten male clients met these criteria. Two of the female client cases than were randomly dropped from the sample so that an equal num- ber of male and female clients existed for the analysis. The 60 tape recordings representing the final sam- ple were typewritten by professional transcribers. This procedure was prompted in part by the comments of Kammer- schen (1965) and Kopplin (1965) who suggest that inter- judge reliability is difficult to attain without a great deal of training. An additional consideration underlying the use of typewritten transcripts was more theoretical. The hypoth- eses involved in this study are related to rates and types of verbal behaviors. Tape recordings contain these behav- iors, but involve also such vocal but nonverbal cues as slight voice inflections and halting speech. These vocal but nonverbal cues are of course an immensely important aspect of the psychotherapy process. They are not, how- ever, aspects of the rigorously and operationally defined 19 verbal constructs which are examined in the present study. It is assumed that their exclusion will provide for in- creased precision and reliability. Coding Procedure The coding procedure used was in part the same as that used by Caracena (1963), Kopplin (1963), Schuldt (1964) and Varble (1964), which were modifications of the system developed by Bandura eE_al. (1960) and Winder gt_al. (1962). The category of client-internal versus external expression, and the therapist response category of externalizing versus internalizing, were taken from Kopplin (1965). The concept of frame of reference or role system was originated by Lennard and Bernstein (1960). The manual used in this study, which includes operational definitions of terms and examples, is contained in Appendix A. The client expression content categories that were coded were dependency, hostility, and other, with other referring to statements not classifyable as dependency or hostility. Client statements were also scored as to the role system referred to: primary (the therapy situation itself); secondary (client and therapist in a relationship other than the primary role system); tertiary (the client as a member of a family or other social system); self (the client not interacting with any others); therapist (the therapist in a role other than the primary or secondary 20 role systems); other (interaction between peOple but not involving the client or therapist; and non-reference (im- personal facts, opinions, etc.). Client statements were dichotomized into internal- ized and externalized expressions following the system introduced by KOpplin (1965). Internalized client expres- sions include those where the intrapsychic state would be scored as simple need, anxiety, guilt, frustration-hurt, frustration-aggression, and satisfaction; and where the therapeutic relevance category would be scored as present or past affective feeling. Externalized client statements include those where the intrapsychic state would be scored as simple agreement-disagreement or unstated; and where therapeutic relevance would be scored as behavior within the family, participant behavior, observed behavior, and impersonal events, facts, and opinions. Therapist variables that were coded were the di- chotomous approach (intended to elicit continuance by the client of the content present in the previous client state- ment) versus avoidance; internalizing (a therapist response focusing on the client's feelings, etc.) versus external- izing; therapist initiated dependency and therapist ini— tiated hostility; and frame of reference or role system referred to in the therapist response. The scoring for the study can be summarized as follows: The judge reads a client speech and determines 21 which content category(ies) is (are) verbally expressed. The focus of the statement is then scored as to the inter- personal reference system involved, and the expression is scored as being an internal or external statement. The therapist response is then scored as an approach or avoid- ance. Any new content, non-present in the client's pre- vious response, introduced by the therapist is also noted. The judge then scores each approach, avoidance, or intro- duction as an internalizing or externalizing response, also scoring the frame of reference used in the therapist state- ment. An example of a scored client and therapist state- ment follows: Client: I just couldn't think--I was so angry (content-- Hostility, frame of reference--se1f, focus-- internal). Therapist: you were quite angry with yourself, moreso than usual (approach--reflection, frame of reference--self, focus--interna1, no inter- personal category initiated). Scoring Reliability Since the 60 therapy sessions used in this study were transcribed, scoring consisted of visual inspection. In coding, primary attention was focused on the overt state- ments, rather than inferring any covert or latent meanings. Other than theoretical justification, this practice makes for much better reliability among the typescript coders. The units were scored by three trained raters, the author and his two associates involved in the investigation. 22 Two of the raters are masters candidates in clinical psychology including the present writer, with the remaining being a doctoral candidate in the same area. The judges initially acquainted themselves with the scoring system by scoring a number of transcripts tOgether. None of these practice data were part of those used in the present study. The reliability sample, itself, consisted of a quartile taken randomly from each of the 60 psychotherapy transcriptions. Each of these quartiles having been randomly selected, were coded by all three judges. The remaining transcriptions, exclusive of the reliability quartiles, were divided equally among the judges and also scored individually. In order to take into consideration the effects of practicing and forget- ting by the raters in conjunction with coding, the scoring of reliability transcripts was arbitrarily spaced through- out the entire time the transcripts were coded. RESULTS Reliability To obtain the index of consistency of the scoring manual, the study utilized the approach of estimating vari- ance components suggested by several authors (i.e., Ebel, 1951; Lindquist, 1956; Guilford, 1956). Table 3 contains the frequencies, reliability coefficients, and 95% confi- dence limits for the 32 scoring categories; each was com- puted independently following Lindquist's procedure (Lind- quist, 1956) and using the facilities of the Michigan State University Computer Center. As Table 3 shows, all coefficients are significant: Content, Relationship, and Focus categories being consis- tently strong; the Initiation categories (dependency and hostility) being less stable, which reflects the disadvan— tage of using non-exhaustive scoring categories. Specifi- cally, scorers reported attending less to the (non-exhaustive) Initiation categories than to all the other categories, because they were not scored for every response. As expected, the magnitude of reliability coeffi- cients is roughly prOportional to frequency, yet infre- quently used categories (i.e., clients' Therapist relation- ship, clients' Other relationship, therapists' Nonreference 23 24 «mam. comm. memm. Hmmm Hence unmaao 33.08 mama. Shem. mmmm. mam mmummmflounmmnma ommm. «mom. mama. momm Hmcnmuxm memo. sums. seem. moms Hmcumqu mooom memo. meme. Heme. ems museummmucoz ammo. Hmom. mums. om Hmepo mmmm. mama. make. em umammsosa Nmmm. vmhm. ommm. omoa mumflsuma mmmm. smsm. seem. Hmm masses mmmm. msmm. mosm. osmm “Hem mmms. seem. smsm. mos sumucoomm emmm. hams. deem. Nae mumsflum mHmmoneaqmm memo. msom. mesa. «mas nonpo mosm. moom. mmkm. mmm suaaflumom some. omsm. Naom. mmm moamccmmma Bzmezoo umzoq Momma ucmwOHmwmou mocwsqmum mcoflmmmumxm ucmflau muHEHA muHHHQMHHmm Ilmuommumu mcHHOOm mesmeflmcoo wmm mmfluomwumu msfluoom mo muflaflnmwammll.m OH£ME 25 mmmm. mmma. amam. mmm “meuo mmmm. mmmm. ommm. amm mummmumom ammm. mmmm. mmmm. mmm monomcmmmo onamHeHzH mmma. mama. amma. mmmm acmmmmmaumuxm mmma. mmma. mmma. mmmm acmmmmmnumuqm mpoom mama. mmaa. mmaa. ammm memos Samoa mmmm. mmom. ammm. mom mocmmmmmuqoz ommm. mmmm. mmmm. mm Hmeuo mamm. ommm. ommm. mmm ummmmumem mmma. mmma. mmma. mam mummpuwe mmma. mmma. mmma. mmm mmmamm mmma. mama. mmma. ommm mmmm momm. mamm. mmmm. mmm mummcoomm momm. mmma. mmam. mam mumEmua mmmmonsmqmm mmmm. mamm. mmma. mom monummo>a mmma. mama. mmma. mmmm aomoummm momommma Hmzoq Momma usmmommmmou aocmdvmum msommmmumxm #mmmmumne mumfimq mumamnmmamm Inmuomwumu mcmuoom OOGOUHHGOU wmm «a mmaamucoona.m mmnme 26 relationship) reflect impressive stability. Therapists' Avoidance represents the only extremely low reliability score (.4373), yet is still significant. As Kammerschen (1965) noted, the establishment of scoring reliability requires extensive training. Even with typewritten transcripts, judges required many hours of pretraining to obtain the high level of consistency reported above. With any scoring method, reliability will be a direct function of the amount of pretraining. The use of typewritten transcripts, however, contributed to the stability of scoring categories in several ways. By providing easily discernable units, the transcripts allowed the scorer to focus immediately on the content and process variables; whereas in other studies the first determination necessarily involved the scoring unit itself. But the most important contribution of typewritten transcripts involved the early pretraining stages. After scoring several pages independently, scorers met as a group and discussed each unit. As units were already num- bered, judges were able to skip from page to page or tape to tape instantly to discuss similar scoring examples,. subtle differences, and contradictions. This is not pos- sible with taperecordings, placing a much greater burden on the scorer's memory. All scoring categories, except client Internal- External, were established prior to any scoring. 27 Originally the manual contained the category of client Affective-Nonaffective as defined in Kopplin (1965), but the category of client Internal-External quickly replaced it for two reasons. First, the client Affective-Nonaffective category did not logically parallel the therapist category of Internalizing-Externalizing, although there was consid- erable overlap. More importantly, however, scorers were unable to agree sufficiently on their own interpretation, and subsequent scoring, of the client Affective-Nonaffective category. The absence of vocal cues, resulting from the use of transcripts, probably contributed to this lack of agreement. Finally, the term "affect" implies "emotion- ality," an important dimension but not the focus of this study. The Internal-External dimension, on the other hand, is both an important aspect of psychotherapy (i.e., see LKell and Mueller, 1966), and lends itself to the other scoring categories. Hypotheses Hypothesis I: Female clients will self-internalize significantly more during the initial session than will males . Figure l and Table 4 show that males self- internalize during the initial session at a greater fre- quency than females, although the difference is not 28 30. 25.9 20‘ 10» First Middle Last Phase of therapy Figure 1. Client self—internalizations 29 Table 4.--Mean Frequency of Client Self-Internalizations Phase of Therapy N First Middle Last Males 10 22.4 16.1 25.9 Females 10 18.0 17.4 21.1 significant (df=l8, crit. t (03.05)=2.101>t=.629 N.S.). The results did not confirm the supposition that females internalize using the self frame of reference at a fre- quency significantly higher than did males; the results show the reverse to be the case, although not to a signif- icant degree. As can be seen from Table 4, the mean fre- quency of client self-internalizations during the initial session of psychotherapy is 22.4 for the male clients and 18.0 for the female clients. Hypothesis II: The frequency of therapist self- internalizations during the initial interview will be significantly higher for male clients than for female clients. Again, the second hypothesis is a logical extension of the first one. Since male clients, it was supposed, are less apt to self-internalize as compared to females during the initial session (Hypothesis I), the therapist will necessarily have to "probe for feeling" in order to help the client internalize his problems expand upon them, 30 and "work" them through (Kell and Mueller, 1966). The results illustrated in Table 5 and Figure 2 show a dif- ference in the expected direction, but a non-significant one (df=l8, crit.t(a:.05)=2.101 >t=.290 N.S.). These findings further complicate explanation since the males self-internalize during the initial session at a greater frequency than do the females, the antithesis of what was hypothesized. Hypothesis III: The rate Of self internalizations for both male and female clients will be significantly less during the initial session as compared to the terminal session. Matched t-tests were computed for each group (males and females). In both cases, the general trend, as can be seen from Figure l, is in the hypothesized direction. However, the differences were not significant. For the males in the sample, the mean frequency during the initial session was 22.4 as opposed to 25.9 for the terminal ses- sion (df=9, crit.t(a:.05)=2.262,>t=.750 N.S.). Similarly, for the female clients, the trend was as expected, 18.0 for the first session and 21.1 for the last session (see Table 4). As with the male sample, the difference in means for the females is not significant (df=9, crit.t(a:.05)= 2.262 >t=.618 N.S.). 31 20 10 0 —’ — ~V‘ " '-- ’ "'J"-.‘.‘-'-" '..,"" --¢munm. .—': First Middle Last Phase of therapy Figure 2. Therapist self—internalizations 32 Table 5.--Mean Frequency of Therapist Self-Internalizations Phase of Therapy N First Middle Last Males 10 25.9 18.8 30.2 Females 10 24.9 19.8 23.6 Hypothesis IV: At the terminal session of therapy, although both male and female clients will show a gen- eral increase in self (frame of reference) internal- izations, there will remain a significant difference between male and female clients with respect to this dimension. Consistent with the other results, the above hy- pothesis is not supported. The trend of the results is antithetical to the hypothesized direction. Again, from Figure l and Table 4, it is noted that the mean frequency of client self-internalizations in the terminal session is 21.1 for female clients and 25.9 for the males. Not only is there no significant difference between the groups (df=l8, crit. t=(a:,05)=2.101>’t=.650 N.S.), but the data showed a higher mean for the males in this sample. Thus, the hypothesis is not supported. In general, since none of the hypotheses were supported, it was decided, post-hoc, that t-tests should again be calculated for the data, this time using propor- tion of self-internalizations instead of raw frequencies. That is, for each client a proportion was generated using 33 self-internalizations/total self responses. To illustrate, suppose that client A self-internalized during the initial session 25 times, and client B had a score of 30 during the same time-span. The difference between these two clients would seem not too outstanding when looking only at these raw frequency counts. However, if it were known that client A self-internalized 25 times out of 26 responses using the self-frame of reference, and client B self-inter- nalized 30 times out of 90 statements using the self-frame of reference, client A would have a proportion of 25/26 and client B would be given a 30/90 rating. A proportional score would correct for the possibility of a client simply using the self-frame of reference more, or even more likely, simply talking more than other clients. The same propor- tional procedure could be calculated for the therapist's performance. Using this rationale, the mean proportion of client and therapist self-internalizations/total responses using ‘the self-frame of reference were obtained for each of the ‘three sampling points of therapy: the first, middle and last sessions. Again,t-tests were calculated using these Hueans instead of raw frequency means. Apparently, this gnast-hoc querying was in vain, since all hypotheses once again proved to be unsupported. In other words, males don't talk more and/or use the self—frame of reference 34 significantly more than do females in this sample, or vice- versa. The hypotheses, as in the calculations using raw frequencies of responses, remain totally unsupported as a whole. DISCUSSION The lack of significant differences in self- internalizing behavior concerning male and female under- graduate clients presents some interesting interpretive issues. There are a number of explanations for the failure of hypothesis confirmation in the present study. Since the assumptions underlying hypothesized dif- ferences in behavior for males and females are based on "normal" males and females, one of the issues is that these clients may not be representative of the general college population. It is possible that male clients are more similar in reSponse patterns to female clients than to undergraduate males, in general. As Alexander (1967) has pointed out, working with the same sample as the present study, the males and females used in this sample differed in at least two crucial ways when compared with male and female college students, as a whole. First, they found it necessary to seek professional help in dealing with their personal problems. Second, although female clients in the present sample do not differ greatly from college females generally, with respect to the number of deviant MMPI scales, the males in our sample show significantly more deviant scales when compared to non-client college 35 36 males. Similar findings by Kaufman (1956) using a sample which closely approximates that of the present study, sug- gests that male clients have more feminine interests than controls, and seem less self-assertive and may be more easily subdued by adverse circumstances as a group. With these observations in mind, the present author decided to attempt to control for these differences in degree of "pathology" or deviant scales as shown on MMPI data. The male clients whose profiles were most deviant were paired with females whose profiles closely approxi- mated the high deviation males (see Alexander, p. 51). In other words, both male and female groups were separated into high and low pathology groups using the number of deviant MMPI scales as the criteria. Then a number of analyses were performed post-hoc with the implementation of this new control (see Table 6). Initially, an attempt was made to confirm the ori- ginal hypotheses, using the control for level of pathology as discussed in detail above. Reanalyzing Hypothesis I, which stated that females will self-internalize signifi- cantly more than males in the initial session, the data again proved to be non—significant. Even when males and females in the present sample are matched for MMPI devia- tion, there is still no difference in the frequency of client self-internalized statements in the first session. Also,with this new control implemented, Hypothesis II is 37 .mOHmE somumm>mp 30H can» mmamE somumm>mv 30H: How Hmummnm hassmommmcmmm mm Hmuou .Ammamom Hmzz psmm>mov momma somumm>mp 30H .m.z . componmamsumusmlmamm .mummmmnmse .m> momma somumm>mp 30mm .m .Hmuou.mmHmEmm swap.mmamfi Mom .Hmzz so chHpmm>mp Hoummum haucmommmsmmm mm Hmuos mo mmummp was Hogans so .m.z comummmamcumuamlmamm m.ummmmumna omnoymfi memE .m> mommamm .m .HMOOp mama swap mezz so somumm>mp Hmumwum handsommmcmmm mm Hmuou no.0mummp cam Hogans so .m.z sampmNmHmsumusmlmamm .mmamfimm Umsouma mmamfi .m> mmamfimm .e A>H mmmmnsommm mmmv .mmHmE Op can» commmmm Hmcmsumu map msmusp .Hmzz so mcompmm>mp mums “museum aaucmommmsmmm mo mmummp UGO Hmnfiss c0 .m.z m um mmmamsnmnsmlmamm mmmmfimm thrones momma .m> mmamfimm .m IHH mmmmeuommm mmmv .commmmm ammuasm map mcmust .mmHmEmm How smzu momma . .Hmzz so mcomumm>mp How Hmummum maucmonmcmmm mum mo mmnmmc tam nomads co .m.z mcomumNHHmsHmnsmlmamm mumflQMHmna Umnopma momma .m> mmamfimm .m AH mmmmnuomwm mmmv .sommmmm Apsmo ammumsm was OOHHOU .mmHmE can» .Hmzz so mCOmumm>mp Immmcmmm pocv Open Hmummum mausmonmsmmm mo moummp tam Hoses: :0 .m.z m an mmmamsumpcmnmawm mmHmEmm Umsoume memE .m> mmHmEmm .H emuHSmmm pmumme mmmmnuommm UONHHHDD mswmz museum commmsommo CH somumucmmmnm mo HOUHO cm mommamcd Oomlumom mo magma hHwEE§w||.m magma 38 .Amo. W av mammfi Ozu smmsuwn mosmummmmp mom ummulp Omammnlosam .mucmmao HammmmOOOmss 0U swap coaumsmfiumn Op commmmm Hams Imam Scum msompmNmHmcumusmlmamm cm mmmmnosm Hmummuo handsommms .AUOHHOHHQOO nos moamnnzummc mo mmummp tam HO>OHV UOHOOQ mmamfimm Use mmHmE num3 mucmmao .m.z Imam m m>ms musmmao Hammmmoosm Hsmmmmoosmcs .m> Hammmmoosm .HH .AOOHHOHDOOO .musmmao Hummmmo no: mocmnusummp mo mmummp I nonmss 0O swap mcompmNmHmcuwpcm use HO>OHV Umaoom mmamfimm mo. v a lumen mo Hmuou “mama: handsommms tam mmHmE num3 mucmmao unmommmcmmm Immm m m>ms musmmao Hammmmoosm Hammmmuosmss .m> anymmmoosm .oa .Hmuos .mOHmEOm OOmumm>mO rams swap Hmpmmum haucmommmc .Ammamom Hmzz ucmm>mpv Immm mm Hmuop comummmamsnmpsm mmamfiwm OOHDMH>0© 30H .m> .m.z Imamm .mmHmem cemumm>mp 30a mmamfimm sembmm>mp comm .m .Hmqu .mOHmE comp Imm>wp Emma menu Hmummum Mausmom .Ammamom Hmzz sawm>mpv Inflammm mm Hmuou coaummmamcnmucm momma soHumm>m© 30H .m.z Inflow .mmHmE comumH>mO 30a .m> mmHmE somummbmp swam .m .mmamfimm coaumH>mU 30m smnu mmmmfimm somumm>mp 30H: How .Ammamom HAZE ucmm>mpv Hmummnm haucmommmcmmm mm Hmuou mOHmEOm cOmpmm>mU 30H .m.z compmNmHmcMmucmlmamm .mummmmumsa .m> mmHmEmm comwmm>mp swam .n «muasmom Omumma mmmmnuomhm OONHHHHD mane: msouw Umscmusouul.m magma 39 still unsupported. Therapists do not use the self-internal statement significantly more for males than females in the first session of psychotherapy. Finally, Hypothesis IV remains unsupported when re-run with the variable of degree of disturbance controlled: there still is no difference be- tween: client self-internal responses for females as opposed to males during the last session. Since the original hypotheses remained unconfirmed, attention was turned to the more general issues, utilizing this gross measure of "pathology" control. First of all, males and females matched for high deviation on the MMPI scales were checked for differences in the total number of self-internalizations summed for the three sampling points in therapy, using client and therapist responses in sepa- rate analyses. Thus, controlling for degree of MMPI devia- tion, it was hypothesized that male clients would differ from female clients when total self—internalizations were compared. This comparison of client self—internalizations proved non-significant using a t-test for differences be- tween means. Therefore, even when roughly matched for degree of disturbance, male clients do not significantly differ from female clients in total number of self-inter— nalized statements in therapy. A further comparison of high "pathology" group males and females shows that the therapist does not use the self-internalized response sig- nificantly more for male clients than for female clients. 40 Also shown in further analysis is that therapist activity along the investigated dimension does not significantly differ when the high deviation male clients were compared with low deviation male clients in the rest of the sample. The same lack of significance is apparent when high devia- tion group female clients are compared with the lower devia- tion group of females in the present sample. Finally, for both male and female clients, there is no support for the supposition that the low deviation group has a greater total number of self-internalization statements than the high deviation group of the same sex. What the above analyses seem to point toward is that therapist activity along the self-internalized dimen- sion and client activity along the same dimension do not seem significantly different for male clients as Opposed to female clients, even when a control is added for degree of deviation on a pre-therapy MMPI scale. Although the difficulty involved with using the MMPI as the criterion is recognized, this was the only uniform criterion avail- able in establishing a control, since the present line of inquiry was post-hoc. In further investigations, more rigorous criteria should be used for measuring the type and degree of personal problems presented by clients. IFrom.the present data, one may reasonably make the assump- tion that there are no sex differences when the total num- ber of therapist self-internalizations and client 41 self—internalizations in therapy are used for analysis. At least for the present sample, male clients do not dif- fer from female clients, in terms of the number of self- internalization responses. What may be Operating here is a constant process irrespective of client sex. One might speculate that the response unit measured is something so basic to the therapeutic process as to be invariant in terms of biological sex of the client. A form of patient uniformity may be present, with respect to the response unit being observed in this study. This finding seems contrary to Kiesler's (1966) attack upon the "patient uniformity assumption." The evidence obtained from the present study, which focuses on only one particu- lar circumscribed response unit, exposes a uniformity among undergraduate clients, regardless of biological sex. Again it must be noted that the criterion for es- tablishing degree of disturbance (MMPI deviations) is extremely crude, since this aspect wasn't a part of the original study. Therefore, the matching of male and fe— Inale clients by this criterion is questionable, at the least. More important, however, is the proposition that one is dealing in this study with a rather restricted pOpu— lation in terms of pathology, so that differences detected in degree of disturbance really don't have too much bear- ing upon the variable under investigation. That is, the sample involved in this study may be very homogeneous in 42 terms of type and level of disturbance. Then one would not be surprised to find little difference between sexes in this sample when broken down into high and low pathology groups. The final post-hoc inquiry in this study concerned the relationship between total client self-internalizations and ratings of therapeutic success by the particular thera- pist involved with the client. The success ratings were obtained from Alexander (1967) who pooled males and female clients together into successful and unsuccessful groups, as rated on a four point scale by the therapist (see Alexander, p. 43). When the present author proceeded to ascertain whether these two groups are differentiated by the total frequency of self-internalizations across all three session sampling points, it was found that the suc- cessful-unsuccessful groups are different at the .05 level using a t-test with the above criterion. This finding means that, for the present sample, clients who were judged as successful by his therapist at the termination of therapy, used the self-internal statement at a signifi- cantly greater total frequency, than the group of clients placed in the unsuccessful category. This particular find- ing holds regardless of the sex of the client. The final post-hoc supposition was that those clients (male or fe- male) who have been rated as successful have a significantly greater increase of client self-internalizations from the 43 initial session to termination (last session minus first session) than those classified into the unsuccessful group. This supposition proved to be unsupported. In conclusion, it may be speculated that the self- internalization response may be something so basic to psychotherapy, that this particular variable is invariant with respect to biological sex. This phenomenon may be due to self-internalization by itself, or due to a possibly heavy loading of affect within the self-internalization response. It must be cautioned however, that some of the variables in the present study were inadequately controlled, such as therapist experience level, particular therapeutic orientation of each therapist, duration of therapy, and degree and type of distress of the client. Of course, with research with the degree of complexity of prOcess re- search, it is almost impossible to control for the infi- nitely large number of variables operative in the thera- peutic interaction between client and therapist. Further research is recommended which will provide controls for the above mentioned variables, especially those that have to do with degree and type of client problem. Also, since the present study focused solely upon the self-frame of reference and internal focus, more research should be undertaken to investigate the internal focus as used with the frames of reference other than self. It is entirely possible that some clients focus internally using, perhaps, 44 the family frame of reference instead of the self referent. Or, it may be that males differ along the internal focus dimension when compared to females, but males use a dif— ferent frame or frames of references in utilizing it. With the objectivity and reliability of the scoring system used in the present study, research possibilities seem to be vast, indeed. The self-frame of reference and the in- ternal focus of attention were only two of a much larger number of concepts integrated into a complex and promising content analysis system of psychotherapy. S UMMARY This investigation is a content analysis of psycho- therapy process with Special reference to the frame of ref- erence and focus of therapist and client expressions. First, middle, and next to last interviews of completed therapies of ten male and ten female clients seen by male psychotherapists were transcribed from previously tape recorded interviews. These transcriptions were coded inde- pendently by three judges and satisfactory reliability was obtained for the coding procedures. Based on the literature in develOpmental psychology which suggests differences in the expression of affect be- tween males and females and relating this to psychotherapy process, the following hypotheses are presented: 1. Female clients self-internalize significantly more during the initial session than do male clients. By self-internalizing is meant responses by the client using the self-frame of reference and hav- ing an internal focus. Example: "I'm just plain mad." (hostility content category, self-frame of reference, inter- nal focus of attention). 2. The rate of therapist self-internalizations during the initial interview is significantly higher for 45 46 male clients than for female clients. Self- internalizations by the therapist are responses which utilize the self-frame of reference of the client and have an internal focus. Example: Th: "How are you feeling about yourself today?" (self-frame of reference, inter- nal focal point). 3. The rate of self-internalizations for both sexes of clients is significantly less during the initial session as compared to the terminal session. 4. There remains a significant difference between male versus female client self-internalizations at the end of therapy (next to last session). Females still rate proportionately higher. None of the experimental hypotheses are supported. Further analyses were performed in an attempt to illuminate the findings. It is shown that male and female clients in this sample differ with regard to available MMPI data. Male clients appear more deviant (greater number of MMPI scales above a T score of 70) than female clients, and while both males and females are more deviant than their non-client undergraduate counterparts, male clients are much more deviant than their non-client male counterparts. Considering this finding, male and female clients were separated into high and low "disturbance" groups 47 using the number of deviant MMPI scales prior to therapy as criterion. After matching male and female clients for degree of "disturbance," three of the original hypotheses were reanalyzed using this matching as a control. No sup- port for the hypotheses was found. Then a series of post- hoc analyses was undertaken, concerning self-internalization behavior, sex of client, and utilizing the control for level of disturbance described above. One interesting sidelight and the only significant finding (post-hoc) was the positive relationship between therapist rating of suc- cess and total self-internalization responses, when clients were pooled irrespective of sex and degree of MMPI devia- tion. Basically this study finds no significant differ- ences between male and female clients along the investigated dimension of client and therapist behaviors. The author speculates that these findings raise some doubts with re— gard to the attacks on patient uniformity assumptions in the recent literature. Perhaps when the client population is relatively homogeneous and the therapists do not differ extensively in their approach to patients (i.e., most of the therapists were relationship oriented in their approach, though with differing theoretical tendencies) there is a measure of patient uniformity with regard to certain vari- ables. Since self-internalization contains a strong 48 affective component, it is possible that this variable transcends other patient differences. This supposition will need to be tested further, and specific recommenda- tions are made in this study. REFERENCES Alexander, J. F. PerSpectives of psychotherapy process: dependency, interpersonal relationships, and sex differences. Unpublished doctoral dissertation, Michigan State Univ., 1967. Auld, F., Jr., and Murray, E. J. Content-analysis studies of psychotherapy. Psychol. Bull., 1955, 52, 377- 395. Bandura, A., Lipsher, D. H., and Miller, P. E. Psycho- therapists' approach-avoidance reactions to patients' expressions of hostility. J. Consult. Psychol., 1960, 24, 1-8. Caracena, P. F. Verbal reinforcement of client dependency in the initial stage of psychotherapy. Unpublished doctoral dissertation, Mich. State Univ., 1963. Cartwright, D. S. Annotated bibliography of research and theory construction in client-centered therapy. J. Counsel. Psychol., 1957, 4, 82-100. Covner, B. J. Studies in phonographic recordings of verbal material: The use of phonographic recordings in counseling practice and research. J. Consult. Psychol., 1942, 6, 105-113. Dollard,J}, and Miller, N. E. Personality and Psychotherapy. New York: McGraw-Hill, 1950. Ebel, R. Estimation of the reliability of ratings. Psycho- Freud, S. A General Introduction to Psychoanalysis. New York: Liveright CO., 1920: Fuller, F. Influence of sex of counselor and of client on client expression of feeling. J. Counsel. Psychol., 1963, 10 (1), 34—40. Guilford, J. P. Fundamental Statistics in Psychology and Education. New York: McGraw-HiIl, 1956. 49 50 Hall, C., and Lindzey, G. Theories of personality. New York: John Wiley and Sons, Inc., 1957. Hays, W. L. Statistics for Psychologists. New York: Holt, Rinehart and Winston, Inc., 1963. Kammerschen, K. Inter-judge reliabilities and selected client-therapist variables: A content analysis of initial psychotherapeutic interviews. Unpublished masters thesis, Mich. State Univ., 1965. Kaufman, P. Changes in MMPI as a function of psychiatric therapy. In G.S. Welsh and W. G. Dahlstrom (eds.) Basic Readings on the MMPI in Psychiatry and Medi- cine. MinneapoIis: UniVerSity of Minnesota Press, 1956. Keisler, D. J. Some myths of psychotherapy research and the search for a paridigm. Psychol. Bull., 1966, 65, 110-136. Kell, B. L., and Mueller, W. J. Impact and Change: A Study of Counseling Relationship_. New York: Appleton-Century-Crofts, 1966. Kopplin, D. A. Hostility of patients and psychotherapists' approach-avoidance responses in the initial stage of psychotherapy. Unpublished doctoral disserta- tion, Mich. State Univ., 1965. . Eliciting responses in client—therapist inter- action.: A content analysis of initial psycho- therapeutic interviews. Unpublished doctoral dis- sertation, Mich. State Univ., 1965. Lennard, H. L., and Bernstein, A. The Anatomy of Psycho- thera . New York: Columbia University Press, I960. Lindquist, E. F. Design and Analysis of Experiments in Psychology and Education. Boston: Houghton-Mifflin Company, 1956. Murray, E. The content-analysis method of studying psycho- therapy. Psychol. Mongg., 1956, 70 (whole No. 420). Rogers, R. R. On Becoming a Person. Boston: Houghton- Mifflin Company, 1961. 51 Schuldt, W. J. Psychotherapists'approach-avoidance reac- tions and clients' expressions of dependency, a longitudinal analysis. Unpublished doctoral dis- sertation, Mich. State Univ., 1964. Skinner, B. F. Science and Human Behavior. New York: Macmillan CO., 1953. . Verbal Behavior. New York: Appleton-Century- Crofts, 1957. Varble, D. L. An exploratory analysis of hostility in psychotherapy. Unpublished doctoral dissertation, Mich. State Univ., 1964. Winder, C. L., Ahmad, F. Z., Bandura, A., and Rau, L. C. Dependency of patients, psychotherapists' responses, and aspects of psychotherapy. J. Consult. Psychol., 1962, 26, 129-134. APPENDICES APPENDIX A SCORING MANUAL The categories of dependency and hostility, therapist ap- proach and avoidance, therapist internalizing and external- izing, and therapist initiated dependency and hostility are a replication of the manual developed by: Kopplin, D. A. Eliciting responses in client-therapist interaction: a con- tent analysis of initial psychotherapeutic interviews. Un- published doctoral dissertation, Michigan State Univ., 1965. The categories of client internal-external focus and simple agreement-disagreement are a modification of the manual de- veloped by Kopplin (1965). The relationship categories are a modification of the system developed by: Lennard, H. L. and Bernstein, A. The Anatomy_of Psychotherapy. New York: Columbia University Press, 1960. I. Scoring Unit and Interaction Sequence. A. Definition. A unit is the total verbalization of one speaker bounded by the preceding and succeeding speeches of the other speaker with the exception of interruptions. There are three types of scoring units: the "client statement" (C St), the "therapist response" (T R), and the "client response" (C R). A sequence of these three units composes an "interaction se- quence." The client response not only completes the first interaction sequence but also initiates the next sequence and thereby becomes a new client statement. Example: C. I can't understand how you can stand me. (C St) T. You seem to be very aware of my feelings. (T R) C. I am always sensitive to your feelings. (C R) 53 54 Pauses. If a speaker pauses between statements, his verbalizations are not scored as separate units. The verbalization before and after the pause is considered one unit. Interruptions. Statements of either therapist or client which interrupt the other speaker will be scored only if the content and/or temporal continu- ity of the other speaker is altered by the inter- ruption. Then the interrupting verbalization be- comes another unit and is scored. A non-scored interruption is never taken into account in the con- tinuation of the other speaker. Interruption scored as one unit: C. I asked him to help me and - - - T. Why was that?‘ C. - - he refused to even try. Non-interruption scored as 3 units, one interaction sequence: C. I asked him to help me and - - — T. Why was that? C. I don't know. Verbalizations such as "Um hmm," "yes," "I see" are ignored in scoring unless they are so strongly stated as to convey more than a listening or re- ceptive attitude. Client requests of the therapist to repeat his re- sponses are considered interruptions and are not scored. Therapists' requests of this sort are scored as units (as approach or avoidance of the client statement) except for simple requests to the client to repeat a few words. II. Categories of Client Statements. A. Interpersonal Content Categories. There are three major categories: Dependency, Hostility, and Other. They are scored as exhaustive categories. All dis- criminations are made on the basis of what is ex- plicitly verbalized by the speaker in the unit 55 under consideration. One statement or unit may be scored for both categories of Hostility and De- pendency. 1. Hostility (Hos): Hostility statements include description or expression of unfavorable, critical, sarcastic, depreciatory remarks; oppositional attitudes; antagonism; argument, expression of dislike, disagreement, resent- ment, resistance, irritation, annoyance, anger; expression of aggression and punitive behavior, and agressive domination. The following examples group under a series of types of hostility. These types aid in identification of hostility statements, but are not differentiated in the scoring. a. Anger: expresses or describes feelings or actions which indicate anger. C. I'm just plain mad. (Hos,se1f,I)* C. I just couldn't think--I was so angry. (Hos,se1f,I) C. My uncle was furious at my aunt. (Hos,Oth,E) b. Dislike: expresses dislike or describes actions which would usually indicate dis- like. C. I just couldn't get interested in them and would rather be somewhere else. (Hos,Ter,I) C. I've never felt I like them and I don't suspect I ever will. (Hos,Ter,I) C. He hates editorials. (Hos,NR,E) *Complete scoring of examples is listed to aid in training coders. The sequence is: Interpersonal content category, Relationship, Internal focus. When a statement is scored for two interpersonal categories, two separate scorings are listed. 56 Resentment: expresses or describes a per— sistent negative attitude which does or might change to anger in a specific occa- sion. C. They are so smug; I go cold whenever I think about having to listen to their "our dog" and "our son." Boy! (Hos,Ter,I) C. I was always jealous of my brother; he was their favorite. (Hos,Fam,I) Antagonism: expresses or describes anti- pathy or enmity. C. It's really nothing definite, but we always seem at odds somehow. (Hos, Ter,E) C. There is always this feeling of being enemies. (Hos,Ter,I) Opposition: expresses or describes Oppo- sitional feelings or behavior. C. If he wants to do one thing, I want to do another. (Hos,Ter,I) C. It always seems she is against things. She is even against things she wants. (Hos,NR,E) C. No, I don't feel that way (in response to T's assertion). (Hos,Self,I) Critical attitudes: expresses negative evaluations or describes actions which usually imply negative evluations. C. If I don't think the actors are doing very well, I just get up and walk out. (Hos,Self,I) C. There is something to be critical about in almost everything anyone says or does. (Hos,NR,E) 57 g. Aggressive actions: acts so as to hurt another person or persons either physically or psychologically. C. He deserves to suffer and I'm making it that way every way I can. (Hos, Ter,I) C. I can remember Mother saying: "We slap those little hands to make it hurt." Dependency (Dep): Dependency statements in- clude expressions of needs to depend on some- one; let someone else take the initiative; to be told what to do; to be helped; to be cured by an outside agent; description of dependent behavior; approval seeking and concern about disapproval; dependent agreement with others; accepting nurturant actions from others; making personal security contingent on another; exe presses concern about parental plans and ex- pectations regarding the client; expresses need to confide in, write to or communicate with parents; includes discussion of the relation- ship between the client and therapist. The types listed below aid in identification, but are not differentiated in scoring. a. Problem description: states problem in coming to therapy; gives reasonsfor seek- ing help; expresses a dependent status or a general concern about dependency. C. I wanted to be more sure of myself. That's why I came. (Dep,Prim,I) C. I wanted to talk over with you my reasons for drOpping out of school next quarter. (Dep,Prim,I) C. Part of the reason I'm here is that everything's all fouled up at home. (Dep,Prim,I) C. I depend on her--I am tied to her. (Dep,Ter,I) C. I want to be babied and comforted. (Dep,Se1f,I) 58 Help seeking: asks for help; reports ask- ing for help; describes help-seeking be- havior; describes going to see a teacher, therapist or other professional. C. I asked him to help me out in this situation. (Dep,Ter,I) C. I try to do it when he can see it's too hard for me. (Dep,Ter,I) Approval-seeking: requests approval or ac- ceptance; asks if something has the ap- proval of another; reports having done so with others; tries to please another; con- fides in parents for support or approval; expresses fear of "hurting" parents and superiors; seeks acceptance or approval by achievement; expresses or describes some activity geared to meet his need. C. I hope you will tell me if that is what you want. (Dep,Sec,I) C. If there was any homework, I did it so Dad would know I was studying like a good girl. (Dep,Pam,I) C. Is it all right if I talk about my girl's problem? (Dep,Prim,E) C. That's the way I see it, is that wrong? (Dep,Sec,I) C. I asked him if I were doing the right thing. (Dep,Ter,E) Succorance: a wish to be taken care of; to seek another's help when troubled, de- pressed or hurt; to seek encouragement from others; to have others be sympathetic and understanding about personal problems; to go home to see one's parents, feel close to one's parents in the sense of being loved; to receive nurturant behavior from others (especially parents, authorities and therapist). C. It looks like it will be another lonely weekend, and who's going to cheer me up? (Dep,Self,I) 59 C. Instead of studying, I go talk with the guys about my problems. (Dep,Ter, E) C. I went home just for the day; I told my mother to make a home cooked meal because that is what I was coming home for. (Dep,Pam,I) C. My father isn't rich, but he's putting me through college, and he gives me all the money I want; he's always given me everything I've ever wanted. (Dep,Pam, I) Information seeking: asks for cognitive, factual, or evaluative information; ex- presses a desire for information from others; arranges to be the recipient of information. C. I asked him why he thought a girl might do something like that. (Dep, Ter,E) C. I'm planning to change my major. I'd like to know how to do it. (Dep, Prim,E) Concern about disapproval: expresses fear, concern, or unusual sensitivity about dis- approval of others; describes unusual dis- tress about an instance of disapproval, insecurity, or lack of support. Little or no action is taken to do something about the concern. C. She didn't ever say a thing but I kept on wondering what she doesn't like about me. (Dep,Ter,I) C. My parents will be so upset about my grades, I don't even want to go home. (Dep,Pam,I) C. It seems like I always expect I won't be liked. (Dep,Self,I) C. I can't understand how you can stand me when I smoke. (Dep,Sec,I) 60 9. Initiative seeking: asks the therapist or others to initiate action, to take the re- sponsibility for starting something (to start discussion, determine the topic); arranges to be a recipient of the thera- pist's initiative; may solicit suggestions. C. Why don't you say what we should talk about now. (Dep,Prim,E) C. If you think I should keep on a more definite track, you should tell me. (Dep,Prim,E) C. I got my advisor to pick my courses for next term. (Dep,Ter,E) C. Tell me what.to do in these circum- stances. (Dep,Sec,E) 3. Other (0th): Includes all content of client's verbalizations not classified as Hostility or Dependency. Items scored in this category continue to be scored for Frame of Reference and Internalized Affective State. When Other is integral to another category, do not score. To score Other, the statement must be distinct from the discussion of another major category. FOCUS: INTERNAL-EXTERNAL: Each client statement is scored according to the mutually exclusive and exhaustive dichotomy of Internal and External, ex- cept when the client expression is scored as a simple agreement-disagreement. This category reflects the focus of the client statement as being (at least in part) on his own needs, feelings and reactions (Internal Focus), versus a focus "outside" of himself (External F Focus). The defining characteristic is that the expression explicitly describes or relates the client's Internal state, i.e., past or present affective feeIing or need. 61 All discriminations are made on the basis of what is explicitly verbalized by the speaker in the unit under consideration. When both categories could be scored for the same interpersonal content cate— gory, the unit is always scored as Internal. 1. Internal (I): In this category the content re- fers to the client's own feelings, needs, and reactions to the stimuli impinging on him. To be scored as Internal, a client expression must directly refer to the client, although not all client personal expressions are scored Internal. Any expression of interpersonal need is scored Internal. ' Note: The definition of Internal represented in the present scoring system is not to be equated with a broad concept of "emotionality." The defining characteristic is the presence of a client Personal reference describing a present or past affective feeling, or reflect- ing an interpersonal need. The following examples aid in identification but are not differentiated in the scoring. a. Present affective feeling: includes ex- pression or description of client's present feelings; affective problem analyzing or affective problem solving; affective dis- cussion of client's actions, motivations and their consequence. The feeling may be related to a past event which has carried into the present. C. I'm just plain mad. (Hos,Self,I) C. I hope he calls me for Saturday night. (Oth,Ter,I) C. I want to get a 4-point. (Oth,Self,I) b. Past affective feeling: includes expres- sion or description of the client's past feeling; analysis of client's past feel- ings; affective discussion of client's past actions, motivations and their consequences. C. I didn't want to move; I didn't want to leave the friends I had there and so I hated it for the longest time. (Hos,Self,I) 62 C. I used to feel masturbation was very bad. (Oth,Self,A) External (B): Any expression not categorized as Internal or simple agreement-disagreement is scored as External. All expressions which do not directly refer to the client are scored Ex— ternal, although the action or feelings de-. scribed or attributed to others may be quite affective in nature. Statements involving the client are scored External if they do not in- volve present or past affective feeling or needs or the Internal state of the client. The following represents examples to aid in identification but are not differentiated in scoring. a. Participant behavior: includes descrip- tion of actions of the client; includes description of behavior, feelings, actions, attitudes of others when the client is a participant in the scene; includes brief comments which are personal in reference but with little if any affective signifi— cance. The expressions are of a lower energy level, and without mention of the client's internal feelings about the be- havior described. C. Last spring I used to go out drinking occasionally. (Oth,Self,E) C. If dad doesn't like what I'm doing he just grumbles about it. (Hos,Fam,E) C. My parents always ask if I'm getting enough sleep. (Dep,Pam,E) C. If I don't hop out of bed the.second the alarm goes off, I know I'd roll over and go back to sleep. (Oth,Self, E) b. Observed behavior: includes description of the actions of specifiable others where the client is only an observer or reporter, rather than a participant in the scene. Again there is no mention of the client's internal feelings about the behavior of others. 63 C. My uncle was furious at my aunt. (Hos,Oth,E) C. Bill reads all the editorials. (Oth,NR,E) c. Description of impersonal events, facts, opinions: includes statements with no psychological significance to any signifi- cant individual; discussion of intellectual, abstract or philosophical matters. Includes statements where the Client may be manifest- ing affective expression, but the expression is like a speech he could give to any one or group, usually stylized by certain patterns (soap-box). C. Most people have a liberal attitude about sex; what people do privately is their own business. (Oth,NR,E) C. The individual is only a number here; the place is so large. (Oth,NR,E) NOTE: Client expressions which are scored as re- ercting the Relationship categories (see III, page 65) of Therapist, Other, or Nonreference cannot by definition be scored as Internal as these cate- gories do not involve the client in any way (except as speaker). Relationship categories of Primary, Secondary, Self, Family, and Tertiary may or may not be scored as Internal depending on whether or not the expression involves a reflection or descrip- tion of the client's internal state. 3. Simple Agreement or Disagreement (Agr): This category includes those statements of the client which simply acknowledge, agree or disagree without elaboration to the preceding statement of the therapist. Note: In all cases the Relationship of the expression is that contained in the previous response. C. Yes C. Surely C. I agree C. I think so III. 64 C. I don't think so C. No (as a matter of fact without hostility). By definition, simple agreement by the client covers all categories that the therapist ap- proaches or introduces. C. (A client statement scored Dependency and Hostility; Family relationship.) T. You've got some feelings about needing t them (Score approach to Dep and Hos; Fam frame of reference; internalizing). C. Yes. (Dep,Pam,Agr) (Hos,Fam,Agr) RELATIONSHIP or ROLE SYSTEM: Categories of Client and Therapist Expressions. AEEEh client and therapist ex- pression is scored in one of the eight mutually ex- clusive and exhaustive categories covering the relation— ship that is the focus of the expression: primary, secondary, self, tertiary, therapist, other and non- reference. Scoring is done on the basis of the re- lationship, if any, that is primarily the explicit focus of the expression. In.most cases the scoring will re— flect a: description of actual interaction (i.e., "I talked to him."). Some relationships, however, will be structural rather than behavioral (i.e., "He and I are in the same class."). If a unit contains more than one relationship, score in the category that best represents the main focus of the expression. If the main focus is on more than one category, then score each category that constitutes the main focus. Each expression is scored independently of the next, and all discriminations are made on the basis of what is explicitly verbalized by the speaker in the unit under consideration with the following exceptions: 1. When a personal pronoun is present which obviously re- fers to a relationship explicitly discussed previously; 2. When the unit is the obvious completion of an ex- pression initiated by the other speaker (See Therapist reflection, IV,A,l,b); 3. When the expression consti- tutesalfrequently used and culturally accepted state- ment which obviously stands for a longer and more precise statement. For example, in response to the question "How are you?", the statement "Fine" will be scored as if the statement had been "I am fine." This inference is made when the expression is an answer to an immedi— ately preceding question. 65 Following each category description below are examples of both client and therapist expressions scored in that category. A. Primary system (Prim): Expressions in this cate- gory refer to the treatment process itself; the roles, goals and accomplishments of therapy. In- cluded in this category are expressions concerning. frequency and duration of sessions, costs and ex- pectations. Any question or discussion of what is appropriate or relevant to therapy is scored as primary. C. I want to be cured. C. Is it all right to talk about my girl's problems? C. What do you tape for? T. -There's no homework; it's all done here. T. Today we'll quit at quarter 'til. T. You think I should answer questions more? Secondary system (Sec): The manifest content re- fers to the therapist and client in other than their primary roles as therapist and client. In- cluded in this category are all expressions about the relationship between the therapist and client which do not fall into the primary category. Questions or statements directed toward the thera- pist seeking approval or acceptance which are not scored as primary fall here, as does what is usually defined as "transference" phenomena. C. I want you to treat me like a child. C. I trust you. C. I'm not used to being treated like this. T. I'm not angry with you. T. You've gotten angry before when I said that. T. How does that relate to your feelings about me? 66 Family system (Fam): Expressions relating to the- client as a member of the family unit. This cate- gory essentially covers all expressions of inter- action between the client and parents or siblings, Spouse or children. C. I can remember talking to my father like this. C. I guess I keep waiting for them to change. C. It scared me when they used to argue. T. You were the favorite child. T. What did you father say about you then? T. That's the way you were at home? Tertiary system (Ter): Covers references to other social systems. References in this category are to a Specified individual or group, other than the family, in interaction with the client. Such references may include dates, friends, teachers, etc. C. The boss complimented me. C. I get angry with my friends. C. What's wrong with drinking with them? T. The instructor made you mad. T. Why do you feel this way about this girl? T. So what's keeping you from asking him? The Self (Self): Self system references are those relating to the client's life experiences which do not involve interactions with members of any other reference systems. Included are expressions of the client's own individuality, or behaviors so general to be relatively independent of environmental varia- tions. Any expression which refers explicitly to the client in some way and is not scored as Primary, Secondary, Family, or Tertiary is scored as Self. C. I'm scared. C. I am always playing hero. 67 C. I'm generally unhappy. T. You feel depressed? T. Your feelings are - - -? T. You liked the concert. The Therapist (Th): Therapist system references are those which involve the therapist but not the client, i.e., the therapist in a family, self, or other social system relationship. C. Do you ever feel scared? C. Do you have a family? C. Did you go to the game Saturday? T. I will be away for five days. T. I guess I'm tired. T. Yes, I teach a course. Other system (Oth): Other system references are those which involve interaction between members of any reference systems but not involving the client or therapist” Generally these expressions involve interaction between family members, friends, associates. C. They fight a lot. C. The secretary argued with the boss. C. My parents travel all over. T. He liked her? T. How did you mother answer your father? T. He flunked out, huh? Nonreference system (NR): Statements not scorable in terms of interaction among members of any refer- ence system. This category covers impersonal events, facts, and opinions, and the solitary be- havior of others. C. Bill reads a lot. C. What time is it? 68 C. I'll bet he's a louse. T. Honesty is a good thing. T. It's nice today. T. Two packs a day is a lot. IV. Categories of Therapist Responses A. Approach-Avoidance Response: Therapist responses to each scored client statement are divided first into two mutually exclusive classes, approach and avoidance responses. When both approach and avoids ance are present, score only the portion which is designed to elicit a response from the client. Ex- amples of approach and avoidance responses are grouped in sub-types to aid scoring, but the judge must decide first that a response is an approach or avoidance before he considers the various sub-types. 1. Approach responses (Ap): An approach response is any verbalizatiOn by the therapist which seems designed to elicit from the client further expression or elaboration of the dependent, hos- tile, Or other expression which was scored in the client's immediately preceding statement. Approach is to the major category, not neces- sarily to the Specific subcategories or the par- ticular content of the client's preceding speech. The following subcategories are exhaustive. a. Exploration (probing): includes remarks or questions that encourage the client to de- scribe or express his feelings, attitudes, or actions further; asks for further elabor- ation, clarification, descriptive informa- tion, continuance; calls for details or examples; probing opinions which direct the client to reconsider more carefully a pre- vious statement. Should demand more than a "yes" or "no" answer, if not, may be a label. C. How do I feel? I feel idiotic.f' T. What do you mean, you feel idiotic? (I)* A *To aid in training judges, approach and avoidance responses are also marked as (I) for internalizing responses and (E) for externalizing responses (cf. IV,C,1 and 2). 69 C. I can't understand his behavior. T. What is it about his behavior that you can't understand? (E) T. Tell me how you felt. (I) T. I don't completely follow that sequence. (E) Reflection: repeats or restates a portion of the client's verbalization of feeling, attitude or action. May use phrases of synonymous meaning. Therapist finishes client statement in an obvious manner. C. I wanted to spend the entire day with him. T. You wanted to be together. (I) C. His doing that stupid doodling upsets me. T. It really gets under your Skin. (I) Labeling: the therapist gives a name to the feeling, attitude or action contained in the client's verbalization. May be a tentative and broad statement not clearly aimed at ex- ploration. Includes "bare" interpretation, i.e., those not explained to the client. May be a question easily answered by yes or no. It may be more than a simple clause, but it is a statement of fact, opinion or situation without elaboration. C. I just don't want to talk about that any more. T. What I said annoyed you. (I) C. She told me never to come back and I really did have a reaction. T. You had some strong feelings about that—~maybe disappointment or anger. (I) Interpretation: points out and explains patterns or relationships in the client's feelings, attitudes and behavior; explains the antecendents of them, shows the similari- ties and discriminations in the client's feelings and reactions in diverse Situations or at separate times. 70 C. I had to know if Barb thought what I said was right. T. This is what you felt earlier about your mother. (I) Support: expresses sympathy, reassurance, approval, agreement or understanding of the client's feelings, attitudes or behavior. Includes strongly emphasized, "Mm Hmm," "yes"' offers explicit permissiveness. Note: Therapist expressions such as strong- ly stated "Mm Hmm," yes," "and . . .," con- tain no direct reference to a relationship or Internal-External Focus. The intent, however, is for the client to continue along the same line as is represented in the pre- vious response. Based on such an assumption these therapist responses will be scored as an "approach" not only to the content present in the preceding client unit (Dep, Hos, or 0th), but also the relationship and the Focus (Internal-External) present in that expression. Thus the Relationship and the Focus categories scored in the previous client expression will be scored in the therapist response. C. I hate to ask favors from people. T. I can understand that would be diffi- cult for you. (I) C. But this, I don't know whether I am cheating myself or not. Well, I want to feel, you see. . You're feeling. (I) T C. May I just be quiet for a moment? T. Certainly. (E) C T . I have my girlfriend's problems on my mind. Could we talk about them? . Why don't we talk about that. (E) In some-instances such verbalizations as "Um hmm," "I see," "yes" occur between two related succeeding expressions. Such verbalizations will be scored as units only when they occur after a natural ending on the first of the two succeeding expressions. 71 Example: "Support" expression scored as separate unit: C. I said I felt bad. . . . T. Um hmm C. and he said he did too. Example: "Interruption," not scored as sepa- rate unit: C. I said I felt bad and he T. Um hmm C. said he did too See I,C for the definition of "Interruption." f. Information: gives factual information or therapist opinion to general, direct or im— plied questions; includes general remarks about the counseling procedure; tells the client what to do; points out that the client's feelings are natural or common (generalization). C. Shall I take tests? T. I feel in this instance tests are not needed. (E) C. What's counseling all about? T. It's a chance for a person to say just what's on his mind. (E) C. I don't like to talk about this. T. Mary, we have to deal with this some- how. (I) Avoidance Resppnses (Av): The following sub— categories are exhaustive. An avoidance re- sponse is any verbalization by the therapist which seems designed to inhibit, discourage or divert further expression of the dependent, hostile or other categories. The therapist attempts to inhibit the feelings, attitudes or behavior described or expressed in the imme- diately preceding client statement which de- termined its placement under the major cate- gory. Avoidance is of the major category, not specific subcategories or relationship. 72 Disapproval: therapist is critical, sar— castic or antagonistic toward the client or his statements, feelings or attitudes, ex- pressing rejection in some way. May point out contradictions or challenge statements. (Note: remember you must decide response is an avoidance before you consider subtypes.) C. Why don't you make statements? Make a statement. Don't ask another question. ‘T. It seems you came here for a reason. (E) C. Well, I wonder what I do now? T. What do you think are the possibilities? You seem to have raised a number of logical possibilities in our discussion. (E) C. I'm mad at him: that's how I feel. T. You aren't thinking of how she may feel. (E) v Topic transition: therapist changes or in- troduces a new topic of discussion not in the immediately preceding client verbaliza- tion. Usually fails to acknowledge even a minor portion of the statement. C. Those kids were asking too much. (It. would have taken too much of my time. T. We seem to have gotten away from what we were talking about earlier. (E) C. My mother never seemed interested in me. T. And what does your father do for a living? (E) Ignoring: therapist responds to only a minor part of the client response or re- Sponds to content, ignoring affect. He misses the point of the client statement. May under- or over-estimate affect. May approach the general topic but blatantly ignore the affect verbalized. C. You've been through this with other people so help me out, will you? T. You are a little uneasy. (I) 73 C. You can see I don't know what to do and I want you to give me advice. T. Just say what you feel is important about that. (I) C. My older sister gets me so mad I could scream. T. Mm-Hmm. How old did you say she was? (E) C. We went out for Chinese food; he's so easy to get along with. T. Is he from New York? (E) Major Interpersonal Category Initiated py Therapist: Scored whenever the therapist introduces the tOpic of dependency or hostility when the client state- ment was not scored as the category which the thera— pist attempts to introduce. Each category so intro- duced is also scored for internalizing or external- izing elicitation. l. Dependengy Initiation (Dep Init): C. Last week I talked about Jane. T. You've mentioned a number of things you've done to please her. (E) C. (Enters office) T. Now, how may I help you? (I) 2. Hostility Initiation (Hos Init): C. I was late for class this morning. T. I wonder if you dislike the teacher or the class? (I) C. I don' t really understand,but that really makes me anxious. T. You get mad when I open up some feel- ings in you. (I) C. He's the only dog I ever cared for. T. Do you feel that your mother sort of rejects you or isn't giving you enough attention and love. (I) (Init both Dep and Hos) .:._._..._.7 TA I... ”31‘3“ «n- T"\. .7726 dean‘s-um .. i 74 3. Other Initiation (Oth Init): This category is scored in two special circumstances only: 1) The therapist initiates the interaction for the session, and this initiation cannot be scored as Dep Init. or Hos Init.; 2) After a client Simple Agreement-Disagreement when the initi- ation is not of dependency or hostility. (See II,B,3, page 63). Internalizing or Externalizing Responses: Therapist responses of approach, avoidance, or initiation area scored in one of two mutually exclusive classes: internalizing or externalizing responses. When both types are present, score the portion of the response which is designed to elicit a response from the client. l. Internalizing (I): In this category the focus is on the cIient'S concept of himself, his feelings and reactions to the stimuli impinging on him. The therapist is encouraging the client to express his feelings. The therapist may label the client's feeling; he may verbally act them out with feeling or sensory words; he may explore the feelings by eliciting the client to discuss the idiosyncratic edges of his feelings and the impulse edge of his feelings. T. What would you like to talk about today? (I) T. You keep a pretty close check on those you let yourself love because it's pretty dangerous. (I) T. Can you accept the fact that some of your ambitions will be frustrated? (I) T. You want to be a boy, but if you were you couldn't have children. (I) 2. Externalizin (E): The distinction is between a focus outSlde or inside the client. Here the therapist joins with the client on focusing on something that is "outside" the client or re- sponds in such a way as to encourage the client to focus on something outside himself. Re- sponse may refer to the client and still be placed here if it is a behavioral description of the client as an external object. There is a clear absence in this category of any focus on how the client "feels." 1. :1" It!“ Airman—“l." '.c ‘9 .NJJ’ tum. . ‘ - . __ ’ 75 T. In a sense you're being compared to people who are not doing things. (E) T. How old is your sister? (E) T. What did your mother feel when you said that? (E) Note: In the case of certain avoidance re- sponses, it may be impossible to score a re- sponse as internalizing or externalizing. a. Silence responses cannot be scored, but are listed as E. b. Topic transition responses are scored in respect to the discussion they intended to elicit, e.g., if a discussion of dependency is introduced, score it also on the basis of whether it attempts to internalize or externalize the client's response about de- pendency, and not in regard to the preceding client discussion. C. And so we went shopping. T. Let's go on to something else; how did you feel about last week's hour? (I) c. Disapproval can be scored either internal- izing or externalizing. d. Ignoring can be scored either internalizing or externalizing on the basis of what the therapist said which was scored ignore. e. Mislabel can be scored either internalizing or externalizing. APPENDIX B FREQUENCY OF CLIENT SELF-INTERNALIZATIONS II Phase of therapy Males First Middle Last T°tal (1) Bill 18 29 34 81 (2) Mr. A 26 15 30 71 (3) E 5 9 27 41 (4) Jim 22 21 43 86 (5) Hans 36 34 17 87 (6) Ben 20 7 14 41 (7) David 21 21 5 47 (8) Pete 12 5 17 34 (9) Leon 50 18 62 130 (10) Tom 14 2 10 26 Phase of therapy Females First Middle Last Total (1) Jane 36 27 18 81 (2) Elaine 4 9 4 l7 (3) Pam 16 16 28 60 (4) June 58 18 37 113 (5) Joan 7 l9 9 35 (6) Lorrie 13 21 31 65 (7) Edith 6 20 10 36 (8) Band 12 25 45 82 (9) Pear 11 7 14 32 (10) Carol 17 12 15 44 76 m”_ "”w_'F—“—vv ' ' ,.'_.‘_I..‘..P' APPENDIX C FREQUENCY OF THERAPIST SELF-INTERNALIZATIONS Phase of therapy Males First Middle Last Total (1) Bill 26 35 44 105 (2) Mr. A 38 22 46 106 (3) E 11 12 31 54 (4) Jim 24 27 38 89 (5) Hans 42 32 23 97 (6) Ben 20 8 16 44 (7) David 28 21 10 59 (8) Pete 16 ll 15 42 (9) Leon 39 59 15 113 (10) Tom 15 5 20 40 Phase of therapy Females First Middle Last Total (1) Jane 51 31 27 109 (2) Elaine 12 16 14 42 (3) Pam 26 20 5 51 (4) June 53 19 37 109 (5) Joan 7 13 12 32 (6) Lorrie 19 23 38 80 (7) Edith 7 20 11 38 (8) Band 24 30 57 111 (9) Pear 15 5 13 33 (10) Carol 26 21 22 69 77 Q\\n.\ \e\ "IIIIII'LIIIII'III'IIIIII“