- Email: [email protected]
Impact of therapist on patient satisfaction in group psychotherapy
Impact
By Carol
of Therapist in Group
M. Anderson,
Martin
on Patient Satisfaction Psychotherapy
Harrow,
Arthur
H. Schwartz,
and
David J. Kupfer
I
N THIS “AGE OF GROUPS,” an ever increasing variety of small groups are gaining in popularity and interest. T-groups, study groups, encounter groups, nude encounter groups, marathon groups, nude marathon groups, etc., have been added to the more conventional forms of therapy groups. There are many speculations as to the forces responsible for the increased utilization and diversification of this treatment modality. Some believe that the general satisfaction derived by members and leaders from these group experiences is a partial replacement for such missing ingredients of our industrial society as intimacy and involvement. However,. even if we accept this explanation, the necessary elements that contribute to this general satisfaction or to the effectiveness and desirability of the experience still remain unidentified. Clearly, whatever factors are responsible for this positive feeling, they are crucial for the effective use of groups in therapeutic settings. Without some degree of member satisfaction, continuity, a prerequisite to effective treatment of any type, cannot be assured. In outpatient settings, even such coercive factors as the family’s pressure and the therapist’s recommendations cannot guarantee a patient’s attendance if he is displeased with his group. In both inpatient and outpatient settings, the value a member places upon the group and his therapist will affect the degree to which he is willing to exploit and learn from the therapeutic experience. Although member satisfaction has not been studied in groups of psychiatric patients, some data can be extrapolated from investigations of nonpatient groups. The relevance of the three major factors reported by Heslin and Dunfy’ as contributing to member satisfaction (status consensus, perceived freedom to participate, and progress toward group goals), along with other factors of importance for groups of psychiatric patients, have been the subject of previous investigations in our setting.2-5 The present paper will examine the impact of the therapist upon the group by attempting to identify which
From the Department of Psychiuty, Yale New Haven Hospital, New Haven, Conn.
University
School
of Medicine,
and the Yale-
CAROL M. ANDERSON, M.S.W., A.C.S.W.: Chief Psychiatric Social Worker, Yale-New Haven Hospital; Instructor, Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. MARTIN HARROW, PH.D.: Chief Psychologist, Yale-New Haven Hospital; Associate Professor, Department of Psychiatry, Yale University School of Medicine, New Haven, Corm. ARTHUR SCHWARTZ, M.D.: Chief, General Clinical Inpatient Division, Connecticut Mental Health Center; Assistant Professor, Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. DAVID J. KUPFER, M.D.: Director, Dana Psychiatric Clinic, Yale-New Haven Hospital; Assistant Professor, Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. Comprehensive
Psychiatry,
Vol. 13, No. 1 (January), 1972
33
ANDERSON
34 Table
Sex Male Female Age (Mean = lo-19 20-29 30-39 40-49 5059 60 and over
l.-Demographic
No.
Per Cent
28 33
45.9 54.1
10 26 10 5 6 4
16.4 42.6 16.4 8.2 9.8 6.6
ET AL.
Data No.
Per Cent
14 22
22.9 36.0
7 6 4
11.4 9.8 6.5
5
8.2
8
a.2
1 1
1.6 1.6
32 22 0 3 4
52.5 36.1
Diagnosis
31.08
Schizophrenic reaction Depressive reaction Manic-depressive reaction Character disorder Organic brain syndrome Psychophysio!ogical reaction Adolescent adjustment reaction Adult situational reaction Borderline state
yr)
Education Graduate school, completed Graduate school, some College, professional or business school, completed College, professional or business school, some High school, completed High school, some
of the therapist’s
actions,
6 6
10.1 10.1
16
27.2
11 10 10
18.6 16.9 16.9
characteristics,
Marital Status Single Married Widowed Divorced Separated
or
4.9 6.6
feelings are essential to the creation
of a positive group experience for patients. On the basis of clinical impressions and previous research, formulate and test the following hypotheses:
we decided to
(1) Those variables in the therapist that are commonly believed to be essential in the establishment of a relationship, such as interest, understanding, and satisfaction, will be positively related to patient satisfaction with group sessions. We assumed that the establishment of a relationship is central to any satisfactory therapeutic encounter. Furthermore, since the majority of acutely ill patients have a high level of anxiety, we might also expect that those of the therapist’s activities which convey concern and empathy will tend to modify this anxiety and thus be important in providing patient satisfaction. (2) The level of the therapist’s activity will be positively correlated with patient satisfaction in the group. We assumed that patients in severe difficulties would prefer an active, structuring, and perhaps even authoritarian leader. We speculated that activity would be interpreted as support. (3) The degree of the therapist’s directiveness will be positively correlated with patient satisfaction with the group. As an extension of the hypothesis stated above, we assumed that directiveness is important to satisfaction, provided patients were capable of considering the type and content of the therapist’s activity, independent of its frequency.
PATIENT
SATISFACTION
IN GROUP
35
PSYCHOTHERAPY
METHOD
Setting This research took place at the acute psychiatric inpatient service of the Yale-New Haven Medical Center. The primary goal of this treatment facility is the rapid return of severely ill patients to productive life in the community. The treatment program emphasizes the reduction of symptomatology and the restoration of those social and interactional skills which enhance the patient’s effectiveness in dealing with his environment.6+’ Individual, family and group therapy are conducted within a therapeutic milieu in order to focus upon and modify nonfunctional, disruptive, and otherwise maladaptive hehaviors.“q9 Because of the stress placed upon responsible social and interactional functioning, groups of one type or another provide the main vehicles for treatment and serve also to transmit the ward’s value systern.l0sll These groups include patient-family groups, unled patient groups, patient government groups, and small group therapy groups.
Population The data reported in this paper was derived from four open-ended therapy groups, each composed of six to eight patients. The groups met twice weekly over the IS-wk study period. Altogether, we studied a total of 120 group sessions, involving 61 patients. All major psychiatric disorders necessitating hospitalization were represented in these groups, although acute psychotic reactions and depressions were most frequent. Patients ranged in age from 14-65, the mean age being 31.08 yr. A large proportion of the patients had attended college or professional school, indicative of an over-representation of patients from advantaged socioeconomic groups. The sexes were about equally represented, 33 females and 28 males. The mean length of hospital stay for the patients studied was 93.05 days. Table 1 presents a detailed analysis of the sex, age, marital status, education, and diagnosis of the patient sample, The primary therapists in the study were four second-yr psychiatric residents. All had attended a basic cOurse in groups, and were provided with group supervision as part of their training program.
Procedure A questionnaire” containing 34 items was distributed to all patients following each group therapy meeting. A similar questionnaire was given to each of the four resident psychiatrists leading the groups, making comparative ratings possible. Participants were asked to rate a number of group and therapist variables on a 6-point scale by giving their subjective first impressions on such items as comfort, interest, and participation in regard to themselves, their peers, and their therapists. Some of the specific questions used to assess therapist behavior are listed below. Patient
Questions:
In general, how satisfied were you with today’s meeting? very - - - - - - not at all How understanding do you think your therapist very - - - - - - not at all
was of you and your problems
today?
How verbal was your therapist in today’s meeting? very - - - - - - not at all How was your therapist’s mood today? good - - - - - - bad Today he seemed pleased - - - - - - displeased
‘A copy of the questionnaire can be obtained from Carol M. Anderson, A.C.S.W., ment of Psychiatry, Yale University School of Medicine, New Haven, Conn. 06510.
Depart-
36
ANDERSON
ET AL.
Today he seemed interested - - - - - - uninterested How much did your therapist direct today’s meeting? a great deal - - - - - - not at all Therapist
Questions:
In general, how satisfied were you with today’s meeting? very - - - - - - not at all. In today’s meeting, did you feel understanding of the problems of your patients? yes - - - - - - no Therapist’s participation (activity) was very active - - - - - - not at all active Therapist’s interest was high - - - - - - low How would you rate your general mood today? good - - - - - - bad How directive were you in today’s meeting? very - - - - - - not at all Once collected, the data was analyzed by using Z scores to obtain average r’s The statistical significance of the average r’s was then assessed .I* Due to the large sample, to maintain strict statistical standards, only probability levels at the 0.01 level of confidence were accepted as significant. In order to diminish “halo” effects, we disregarded results based on the internal comparisons of various patient ratings, and report only findings based on the comparison of independent ratings made by patients and therapists.
RESULTSAND DISCUSSION
In this investigation we sought to validate a number of clinical impressions regarding the effect of the therapist’s feelings and behaviors upon patients. Therefore, before testing our specific hypotheses, our first task was to determine whether or not patients could in fact accurately assess these therapist variables. Table 2 presents the results in this area and also for the three hypotheses formulated earlier. The data showed that patient ratings of therapists did correlate with therapist self-ratings on nearly all questions at the 0.01 level of confidence. It may be of some importance that even anxious and disturbed patients are capable of assessing their environment in a reasonable manner. Most practitioners have observed patients modifying their behavior in an attempt to give their therapist what he wants to hear, and 0rlinsky13 obtained similar results Table B.-Comparison of Patient and Therapist Ratings Level of Significance Therapist
understanding
(‘0.01
Therapist
interest
Therapist
pleasure
Therapist
mood
Therapist
activity
Therapist
directiveness
N.S.
Table 3.-Levels of Significance of Correlations Between Patient Satisfaction and Thempist Variables Patient Assessment vs. Therapist Assessement Patient satisfaction vs. Therapist interest Therapist pleasure Therapist understanding Therapist activity Therapist directiveness
Level of Significance
PATIENT
SATISFACTION
IN GROUP
PSYCHOTHERAPY
37
when he studied patients in individual therapy. Using patients’ and therapists’ ratings to arrive at some consensus of what constituted a “good” hour, he concluded that patient evaluations contained a good deal of informed critical judgment. One might anticipate that such evaluations may have even greater value in groups, since members can provide cross-validation of one another’s ratings. It is of considerable interest that patients in our study were not only able to rate the therapist’s overt behavior with fair accuracy, but that they were also capable of gauging such feeling variables as his levels of interest, satisfaction, and understanding. The one area they were unable to rate with accuracy was the therapist’s mood. However, it is understandable that patients would be better able to assess the therapist’s feelings about the encounter itself than his underlying (and perhaps even consciously concealed) feelings existing at the time of the encounter, since these have less direct relevance to the patient. An interesting sidelight here was that patients in groups led by the two therapists with a psychoanalytic orientation were consistently less able to approximate their therapist’s self-ratings than those in the groups of the “eclectic” therapists. This too could have been anticipated, since whatever is included in the definition of an “analytic approach,” the one common denominator of all these techniques is generally less direct feedback to the patient. Of the three hypotheses described in the introduction, the first one predicting that therapist feeling variables would be positively related to patient satisfaction has been confirmed. Results show that therapist feelings of interest, pleasure, and understanding were each related to patient satisfaction at the 0.01 level of confidence (Table 3). It might be concluded that in a time of excessive anxiety, patients do seem to experience empathic responsiveness in their therapist as reassuring and therefore of primary importance in rendering the encounter therapeutic. While feedback may be central to satisfaction in any human encounter, it is likely that it is of even greater sign& cance in the lives of disturbed and isolated individuals. One might even speculate that it is the presence or absence of such feedback iu addition to the type of therapy that determines whether it is perceived as effective or ineffective. Indeed, professional preoccupation with technique and theoretical refinement may encourage some to underestimate the importance of the therapist’s capacity to reach out and relate in any treatment modality. This suggests that in the evaluation of any type of psychotherapy, the patient’s experience of his therapist is a primary factor to consider, The second hypothesis that the therapist’s activity level will be positively related to member satisfaction, was not confirmed (Table 3). Although patients were able to rate his activity level, and there was some tendency toward increased satisfaction when they rated him as active, there was no relationship between patient satisfaction and the number of interventions the therapist saw himself as making. This seems to indicate that the actual level of the therapist’s activity is not as relevant to patient satisfactiou as their overall perception of him and the climate he creates. Future research in this area
38
ANDERSON
ET AL.
might explore such topics as how relevant, penetrating, or searching his comments were, in addition to their frequency. The last hypothesis was related to the directiveness of the therapist, and proposed that patients would be pleased if he seemed unquestionably “in charge.” We felt that patients would see him as supportive and strong even if he was not particularly active, provided those comments he did make were intended to give direction and were so perceived by the patients. Interestingly, although patients were able to rate therapist directiveness, there was no correlation between the level of his directiveness and patient satisfaction (Table 3). One interpretation would be that patients do not need to regard the therapist as the final authority or as a strong father figure. However, as mentioned earlier, the prevailing value system in this particular therapeutic setting motivates patients to seek primarily peer support and to achieve social responsibility, rather than to rely upon the therapist. Thus, whatever personal desires the patients may have in this regard may be overshadowed by the strong impact of the ward culture. In other words, it may be that patients are only giving the responses expected of them, whatever their intrapsychic needs or even conscious desires. Another alternative might be that the system itself provides adequately for the patients’ needs of comfort, direction, and dependency, and as a result patients need, want, and expect less from their therapists. Some evidence for the last two hypotheses has been provided in a series of this unit.‘lv’” In conclusion, evidence indicates that it is possible to use patients to evaluate at least some aspects of the treatment process, and that they can perform this task with a fair amount of sophistication. That the type of emotional feedback a patient experiences from his therapist may be of equal importance to the therapist’s specific activities and comments underlines the importance of human relationship variables and the climate created in the group. We do not mean to imply that insightful, penetrating, and even caustic comments are not useful, but that the effects of these interventions can be maximized by creating the appropriate climate in which the therapist’s work is valued. Other research on psychotherapy 15-li has shown that such variables as therapist interest are not only related to patient satisfaction, but also to the outcome of treatment in certain types of psychiatric disorders. Since many therapists do not give much direct feedback (whether due to their training and discipline or for other reasons), it is possible that some patients who have had experience with individual psychotherapy may subsequently seek group treatment modalities. In therapy groups, they will be exposed to the comments of their fellow members when they feel they cannot productively participate and/or the therapist is unresponsive. Thus, while feedback variables may help to explain why so many types of therapy seem to produce positive results, they may also account for the increased popularity of groups. Furthermore, since a common reason for referral to group therapy is lack of social skills and the individual’s social isolation, it is clear that whether we like it or not, the therapist will become one of the patient’s role models. Of course, this raises the question of what kind of behavior the therapist must display to best qualify him as a role model for socially isolated, inexperienced,
PATIENT
SATISFACTION
IN GROUP
PSYCHOTHERAPY
39
or inept individuals. It would appear that, for such patients, a therapist who provides direct feedback about the patient’s behavior and whose own conduct in the process of treatment allows the patient to acquire social skills by imitation and identification is most useful. Finally, since considerable time is required to learn social skills, the therapist’s ability to maintain the continuity of the group’s life again becomes important. Our data suggests that a therapist can do much to promote the patient’s satisfaction and attendance by communication, empathy, and responsiveness. SUMMARY Patient and therapist ratings of therapist behavior in group psychotherapy were compared. Patients were able to accurately rate their therapist’s behavior, and his feelings about the group, but they were not able to rate his general mood. A significant correlation was found between therapist “relationship” variables and patient satisfaction, confirming our first hypothesis. However, neither the therapist’s activity level nor his directiveness level was related to patient satisfaction in the group. The results suggest that patients in therapy groups consider some of the same ingredients important to their satisfaction as do nonpatients in social groups. REFERENCES 1. He&n, dimensions groups.
II.,
and
of member
Dunphy,
Human Relations
2. Astrachan, R., Schwartz, united
patient
3. -,
17:99,
group
M., Becker, J. C.:
as a therapeutic
Psychother.
Schwartz,
Three in small
1964.
B. M., Harrow, A. H., and Miller,
Int. J. Group Harrow,
D.:
satisfactions
17:178,
A. H.,
tool.
1967.
Becker,
M.: The psychiatrists’
The
R.,
and
effect on the
behavior and interactions of therapy Amer. J. Psychiat. 123:1379, 1967.
groups.
4. Harrow, M., Astrachan, B. M., Becker, R., Miller, J. C., and Schwartz, A. H.: An investigation family chiat.
therapy 37:888,
5. -, Schwark,
group.
on
therapy.
6. Detre,
of the patient
Amer.
J.
Orthopsy-
1967.
Becker, A. H.:
chotherapist group 1967.
into the nature
R., Miller, J. C., and The influence of the psythe
emotional
Human
climate
Relations
in
20:49,
T. P., Kessler, D. R., and Sayers,
J.: A socio-adaptive approach to treatment of acutely disturbed psychiatric inpatients. In Proceedings of Third World Congress of Psychiatry, Toronto, University of Toronto Press, 1961, p. 501. H.
7. -, C.:
Sayers, J., Norton, N. M., and Lewis, An experimental approach to the
treatment of the acutely ill psychiatric patient in the general hospital. Conn. Med. 25: 613, 1961. 8. Norton, N. M., Detre, T. P., and Jarecki, H. G.: Psychiatric services in general hospitals: A family-oriented redefinition. J. Nerv. Ment. Dis. 136:475, 1963. 9. Detre, T. P., Kessler, D. R., and Jarecki, H G.: The role of the general hospital in modem community psychiatry. Amer. J. Orthopsychiat. 33:690, 1963. 10. Almond, S.:
The
unit. 545,
value
Arch.
R., Keniston, system
Gen.
K., and Bo!tax,
of a milieu
Psychiat.
therapy
(Chicago)
19:
1968.
11. -,
Keniston,
tient value change Gen. Psychiat.
K., and Bo!tax, in milieu
(Chicago)
S.:
therapy.
20:339,
Pa-
Arch.
1969.
12. Ferguson, G. A.: Statistical Analysis in Psychology and Education. New York, McGraw-Hill,
1966, p. 412.
13. Orlinsky,
D. E.,
and Howard,
K. I.:
The good therapy hour. Arch. Gen. Psychiat. (Chicago) 16:621, 1967. 14. Astrachan, B. M., Harrow, M., and Flynn, H.: The infhrence of the value system of a psychiatric setting on behavior in group therapy meetings. 15. Bek,
B. J.:
Sot. Psychiat. Studies
3: 165, 1968.
of the therapist’s
40 role in the treatment of the schizophrenic patient. Amer. J. Psychiat. X3:963, 1967. 16. Campbell, D. P., Stevens, J. H., Uhlenhuth, E. H., and Johansson, C. B.: An extension of the Whitehom-Betz A-B
ANDERSON
ET AL.
Scale. J. Nerv. Ment. Dis. 146:417, 1968. 17. McNair, D. M., Callahan, D. M., and Lorr, M.: Therapist “type” and patient response to psychotherapy. J. Consult. Clin. Psychol. 26:425, 1962.
By Carol
of Therapist in Group
M. Anderson,
Martin
on Patient Satisfaction Psychotherapy
Harrow,
Arthur
H. Schwartz,
and
David J. Kupfer
I
N THIS “AGE OF GROUPS,” an ever increasing variety of small groups are gaining in popularity and interest. T-groups, study groups, encounter groups, nude encounter groups, marathon groups, nude marathon groups, etc., have been added to the more conventional forms of therapy groups. There are many speculations as to the forces responsible for the increased utilization and diversification of this treatment modality. Some believe that the general satisfaction derived by members and leaders from these group experiences is a partial replacement for such missing ingredients of our industrial society as intimacy and involvement. However,. even if we accept this explanation, the necessary elements that contribute to this general satisfaction or to the effectiveness and desirability of the experience still remain unidentified. Clearly, whatever factors are responsible for this positive feeling, they are crucial for the effective use of groups in therapeutic settings. Without some degree of member satisfaction, continuity, a prerequisite to effective treatment of any type, cannot be assured. In outpatient settings, even such coercive factors as the family’s pressure and the therapist’s recommendations cannot guarantee a patient’s attendance if he is displeased with his group. In both inpatient and outpatient settings, the value a member places upon the group and his therapist will affect the degree to which he is willing to exploit and learn from the therapeutic experience. Although member satisfaction has not been studied in groups of psychiatric patients, some data can be extrapolated from investigations of nonpatient groups. The relevance of the three major factors reported by Heslin and Dunfy’ as contributing to member satisfaction (status consensus, perceived freedom to participate, and progress toward group goals), along with other factors of importance for groups of psychiatric patients, have been the subject of previous investigations in our setting.2-5 The present paper will examine the impact of the therapist upon the group by attempting to identify which
From the Department of Psychiuty, Yale New Haven Hospital, New Haven, Conn.
University
School
of Medicine,
and the Yale-
CAROL M. ANDERSON, M.S.W., A.C.S.W.: Chief Psychiatric Social Worker, Yale-New Haven Hospital; Instructor, Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. MARTIN HARROW, PH.D.: Chief Psychologist, Yale-New Haven Hospital; Associate Professor, Department of Psychiatry, Yale University School of Medicine, New Haven, Corm. ARTHUR SCHWARTZ, M.D.: Chief, General Clinical Inpatient Division, Connecticut Mental Health Center; Assistant Professor, Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. DAVID J. KUPFER, M.D.: Director, Dana Psychiatric Clinic, Yale-New Haven Hospital; Assistant Professor, Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. Comprehensive
Psychiatry,
Vol. 13, No. 1 (January), 1972
33
ANDERSON
34 Table
Sex Male Female Age (Mean = lo-19 20-29 30-39 40-49 5059 60 and over
l.-Demographic
No.
Per Cent
28 33
45.9 54.1
10 26 10 5 6 4
16.4 42.6 16.4 8.2 9.8 6.6
ET AL.
Data No.
Per Cent
14 22
22.9 36.0
7 6 4
11.4 9.8 6.5
5
8.2
8
a.2
1 1
1.6 1.6
32 22 0 3 4
52.5 36.1
Diagnosis
31.08
Schizophrenic reaction Depressive reaction Manic-depressive reaction Character disorder Organic brain syndrome Psychophysio!ogical reaction Adolescent adjustment reaction Adult situational reaction Borderline state
yr)
Education Graduate school, completed Graduate school, some College, professional or business school, completed College, professional or business school, some High school, completed High school, some
of the therapist’s
actions,
6 6
10.1 10.1
16
27.2
11 10 10
18.6 16.9 16.9
characteristics,
Marital Status Single Married Widowed Divorced Separated
or
4.9 6.6
feelings are essential to the creation
of a positive group experience for patients. On the basis of clinical impressions and previous research, formulate and test the following hypotheses:
we decided to
(1) Those variables in the therapist that are commonly believed to be essential in the establishment of a relationship, such as interest, understanding, and satisfaction, will be positively related to patient satisfaction with group sessions. We assumed that the establishment of a relationship is central to any satisfactory therapeutic encounter. Furthermore, since the majority of acutely ill patients have a high level of anxiety, we might also expect that those of the therapist’s activities which convey concern and empathy will tend to modify this anxiety and thus be important in providing patient satisfaction. (2) The level of the therapist’s activity will be positively correlated with patient satisfaction in the group. We assumed that patients in severe difficulties would prefer an active, structuring, and perhaps even authoritarian leader. We speculated that activity would be interpreted as support. (3) The degree of the therapist’s directiveness will be positively correlated with patient satisfaction with the group. As an extension of the hypothesis stated above, we assumed that directiveness is important to satisfaction, provided patients were capable of considering the type and content of the therapist’s activity, independent of its frequency.
PATIENT
SATISFACTION
IN GROUP
35
PSYCHOTHERAPY
METHOD
Setting This research took place at the acute psychiatric inpatient service of the Yale-New Haven Medical Center. The primary goal of this treatment facility is the rapid return of severely ill patients to productive life in the community. The treatment program emphasizes the reduction of symptomatology and the restoration of those social and interactional skills which enhance the patient’s effectiveness in dealing with his environment.6+’ Individual, family and group therapy are conducted within a therapeutic milieu in order to focus upon and modify nonfunctional, disruptive, and otherwise maladaptive hehaviors.“q9 Because of the stress placed upon responsible social and interactional functioning, groups of one type or another provide the main vehicles for treatment and serve also to transmit the ward’s value systern.l0sll These groups include patient-family groups, unled patient groups, patient government groups, and small group therapy groups.
Population The data reported in this paper was derived from four open-ended therapy groups, each composed of six to eight patients. The groups met twice weekly over the IS-wk study period. Altogether, we studied a total of 120 group sessions, involving 61 patients. All major psychiatric disorders necessitating hospitalization were represented in these groups, although acute psychotic reactions and depressions were most frequent. Patients ranged in age from 14-65, the mean age being 31.08 yr. A large proportion of the patients had attended college or professional school, indicative of an over-representation of patients from advantaged socioeconomic groups. The sexes were about equally represented, 33 females and 28 males. The mean length of hospital stay for the patients studied was 93.05 days. Table 1 presents a detailed analysis of the sex, age, marital status, education, and diagnosis of the patient sample, The primary therapists in the study were four second-yr psychiatric residents. All had attended a basic cOurse in groups, and were provided with group supervision as part of their training program.
Procedure A questionnaire” containing 34 items was distributed to all patients following each group therapy meeting. A similar questionnaire was given to each of the four resident psychiatrists leading the groups, making comparative ratings possible. Participants were asked to rate a number of group and therapist variables on a 6-point scale by giving their subjective first impressions on such items as comfort, interest, and participation in regard to themselves, their peers, and their therapists. Some of the specific questions used to assess therapist behavior are listed below. Patient
Questions:
In general, how satisfied were you with today’s meeting? very - - - - - - not at all How understanding do you think your therapist very - - - - - - not at all
was of you and your problems
today?
How verbal was your therapist in today’s meeting? very - - - - - - not at all How was your therapist’s mood today? good - - - - - - bad Today he seemed pleased - - - - - - displeased
‘A copy of the questionnaire can be obtained from Carol M. Anderson, A.C.S.W., ment of Psychiatry, Yale University School of Medicine, New Haven, Conn. 06510.
Depart-
36
ANDERSON
ET AL.
Today he seemed interested - - - - - - uninterested How much did your therapist direct today’s meeting? a great deal - - - - - - not at all Therapist
Questions:
In general, how satisfied were you with today’s meeting? very - - - - - - not at all. In today’s meeting, did you feel understanding of the problems of your patients? yes - - - - - - no Therapist’s participation (activity) was very active - - - - - - not at all active Therapist’s interest was high - - - - - - low How would you rate your general mood today? good - - - - - - bad How directive were you in today’s meeting? very - - - - - - not at all Once collected, the data was analyzed by using Z scores to obtain average r’s The statistical significance of the average r’s was then assessed .I* Due to the large sample, to maintain strict statistical standards, only probability levels at the 0.01 level of confidence were accepted as significant. In order to diminish “halo” effects, we disregarded results based on the internal comparisons of various patient ratings, and report only findings based on the comparison of independent ratings made by patients and therapists.
RESULTSAND DISCUSSION
In this investigation we sought to validate a number of clinical impressions regarding the effect of the therapist’s feelings and behaviors upon patients. Therefore, before testing our specific hypotheses, our first task was to determine whether or not patients could in fact accurately assess these therapist variables. Table 2 presents the results in this area and also for the three hypotheses formulated earlier. The data showed that patient ratings of therapists did correlate with therapist self-ratings on nearly all questions at the 0.01 level of confidence. It may be of some importance that even anxious and disturbed patients are capable of assessing their environment in a reasonable manner. Most practitioners have observed patients modifying their behavior in an attempt to give their therapist what he wants to hear, and 0rlinsky13 obtained similar results Table B.-Comparison of Patient and Therapist Ratings Level of Significance Therapist
understanding
(‘0.01
Therapist
interest
Therapist
pleasure
Therapist
mood
Therapist
activity
Therapist
directiveness
N.S.
Table 3.-Levels of Significance of Correlations Between Patient Satisfaction and Thempist Variables Patient Assessment vs. Therapist Assessement Patient satisfaction vs. Therapist interest Therapist pleasure Therapist understanding Therapist activity Therapist directiveness
Level of Significance
PATIENT
SATISFACTION
IN GROUP
PSYCHOTHERAPY
37
when he studied patients in individual therapy. Using patients’ and therapists’ ratings to arrive at some consensus of what constituted a “good” hour, he concluded that patient evaluations contained a good deal of informed critical judgment. One might anticipate that such evaluations may have even greater value in groups, since members can provide cross-validation of one another’s ratings. It is of considerable interest that patients in our study were not only able to rate the therapist’s overt behavior with fair accuracy, but that they were also capable of gauging such feeling variables as his levels of interest, satisfaction, and understanding. The one area they were unable to rate with accuracy was the therapist’s mood. However, it is understandable that patients would be better able to assess the therapist’s feelings about the encounter itself than his underlying (and perhaps even consciously concealed) feelings existing at the time of the encounter, since these have less direct relevance to the patient. An interesting sidelight here was that patients in groups led by the two therapists with a psychoanalytic orientation were consistently less able to approximate their therapist’s self-ratings than those in the groups of the “eclectic” therapists. This too could have been anticipated, since whatever is included in the definition of an “analytic approach,” the one common denominator of all these techniques is generally less direct feedback to the patient. Of the three hypotheses described in the introduction, the first one predicting that therapist feeling variables would be positively related to patient satisfaction has been confirmed. Results show that therapist feelings of interest, pleasure, and understanding were each related to patient satisfaction at the 0.01 level of confidence (Table 3). It might be concluded that in a time of excessive anxiety, patients do seem to experience empathic responsiveness in their therapist as reassuring and therefore of primary importance in rendering the encounter therapeutic. While feedback may be central to satisfaction in any human encounter, it is likely that it is of even greater sign& cance in the lives of disturbed and isolated individuals. One might even speculate that it is the presence or absence of such feedback iu addition to the type of therapy that determines whether it is perceived as effective or ineffective. Indeed, professional preoccupation with technique and theoretical refinement may encourage some to underestimate the importance of the therapist’s capacity to reach out and relate in any treatment modality. This suggests that in the evaluation of any type of psychotherapy, the patient’s experience of his therapist is a primary factor to consider, The second hypothesis that the therapist’s activity level will be positively related to member satisfaction, was not confirmed (Table 3). Although patients were able to rate his activity level, and there was some tendency toward increased satisfaction when they rated him as active, there was no relationship between patient satisfaction and the number of interventions the therapist saw himself as making. This seems to indicate that the actual level of the therapist’s activity is not as relevant to patient satisfactiou as their overall perception of him and the climate he creates. Future research in this area
38
ANDERSON
ET AL.
might explore such topics as how relevant, penetrating, or searching his comments were, in addition to their frequency. The last hypothesis was related to the directiveness of the therapist, and proposed that patients would be pleased if he seemed unquestionably “in charge.” We felt that patients would see him as supportive and strong even if he was not particularly active, provided those comments he did make were intended to give direction and were so perceived by the patients. Interestingly, although patients were able to rate therapist directiveness, there was no correlation between the level of his directiveness and patient satisfaction (Table 3). One interpretation would be that patients do not need to regard the therapist as the final authority or as a strong father figure. However, as mentioned earlier, the prevailing value system in this particular therapeutic setting motivates patients to seek primarily peer support and to achieve social responsibility, rather than to rely upon the therapist. Thus, whatever personal desires the patients may have in this regard may be overshadowed by the strong impact of the ward culture. In other words, it may be that patients are only giving the responses expected of them, whatever their intrapsychic needs or even conscious desires. Another alternative might be that the system itself provides adequately for the patients’ needs of comfort, direction, and dependency, and as a result patients need, want, and expect less from their therapists. Some evidence for the last two hypotheses has been provided in a series of this unit.‘lv’” In conclusion, evidence indicates that it is possible to use patients to evaluate at least some aspects of the treatment process, and that they can perform this task with a fair amount of sophistication. That the type of emotional feedback a patient experiences from his therapist may be of equal importance to the therapist’s specific activities and comments underlines the importance of human relationship variables and the climate created in the group. We do not mean to imply that insightful, penetrating, and even caustic comments are not useful, but that the effects of these interventions can be maximized by creating the appropriate climate in which the therapist’s work is valued. Other research on psychotherapy 15-li has shown that such variables as therapist interest are not only related to patient satisfaction, but also to the outcome of treatment in certain types of psychiatric disorders. Since many therapists do not give much direct feedback (whether due to their training and discipline or for other reasons), it is possible that some patients who have had experience with individual psychotherapy may subsequently seek group treatment modalities. In therapy groups, they will be exposed to the comments of their fellow members when they feel they cannot productively participate and/or the therapist is unresponsive. Thus, while feedback variables may help to explain why so many types of therapy seem to produce positive results, they may also account for the increased popularity of groups. Furthermore, since a common reason for referral to group therapy is lack of social skills and the individual’s social isolation, it is clear that whether we like it or not, the therapist will become one of the patient’s role models. Of course, this raises the question of what kind of behavior the therapist must display to best qualify him as a role model for socially isolated, inexperienced,
PATIENT
SATISFACTION
IN GROUP
PSYCHOTHERAPY
39
or inept individuals. It would appear that, for such patients, a therapist who provides direct feedback about the patient’s behavior and whose own conduct in the process of treatment allows the patient to acquire social skills by imitation and identification is most useful. Finally, since considerable time is required to learn social skills, the therapist’s ability to maintain the continuity of the group’s life again becomes important. Our data suggests that a therapist can do much to promote the patient’s satisfaction and attendance by communication, empathy, and responsiveness. SUMMARY Patient and therapist ratings of therapist behavior in group psychotherapy were compared. Patients were able to accurately rate their therapist’s behavior, and his feelings about the group, but they were not able to rate his general mood. A significant correlation was found between therapist “relationship” variables and patient satisfaction, confirming our first hypothesis. However, neither the therapist’s activity level nor his directiveness level was related to patient satisfaction in the group. The results suggest that patients in therapy groups consider some of the same ingredients important to their satisfaction as do nonpatients in social groups. REFERENCES 1. He&n, dimensions groups.
II.,
and
of member
Dunphy,
Human Relations
2. Astrachan, R., Schwartz, united
patient
3. -,
17:99,
group
M., Becker, J. C.:
as a therapeutic
Psychother.
Schwartz,
Three in small
1964.
B. M., Harrow, A. H., and Miller,
Int. J. Group Harrow,
D.:
satisfactions
17:178,
A. H.,
tool.
1967.
Becker,
M.: The psychiatrists’
The
R.,
and
effect on the
behavior and interactions of therapy Amer. J. Psychiat. 123:1379, 1967.
groups.
4. Harrow, M., Astrachan, B. M., Becker, R., Miller, J. C., and Schwartz, A. H.: An investigation family chiat.
therapy 37:888,
5. -, Schwark,
group.
on
therapy.
6. Detre,
of the patient
Amer.
J.
Orthopsy-
1967.
Becker, A. H.:
chotherapist group 1967.
into the nature
R., Miller, J. C., and The influence of the psythe
emotional
Human
climate
Relations
in
20:49,
T. P., Kessler, D. R., and Sayers,
J.: A socio-adaptive approach to treatment of acutely disturbed psychiatric inpatients. In Proceedings of Third World Congress of Psychiatry, Toronto, University of Toronto Press, 1961, p. 501. H.
7. -, C.:
Sayers, J., Norton, N. M., and Lewis, An experimental approach to the
treatment of the acutely ill psychiatric patient in the general hospital. Conn. Med. 25: 613, 1961. 8. Norton, N. M., Detre, T. P., and Jarecki, H. G.: Psychiatric services in general hospitals: A family-oriented redefinition. J. Nerv. Ment. Dis. 136:475, 1963. 9. Detre, T. P., Kessler, D. R., and Jarecki, H G.: The role of the general hospital in modem community psychiatry. Amer. J. Orthopsychiat. 33:690, 1963. 10. Almond, S.:
The
unit. 545,
value
Arch.
R., Keniston, system
Gen.
K., and Bo!tax,
of a milieu
Psychiat.
therapy
(Chicago)
19:
1968.
11. -,
Keniston,
tient value change Gen. Psychiat.
K., and Bo!tax, in milieu
(Chicago)
S.:
therapy.
20:339,
Pa-
Arch.
1969.
12. Ferguson, G. A.: Statistical Analysis in Psychology and Education. New York, McGraw-Hill,
1966, p. 412.
13. Orlinsky,
D. E.,
and Howard,
K. I.:
The good therapy hour. Arch. Gen. Psychiat. (Chicago) 16:621, 1967. 14. Astrachan, B. M., Harrow, M., and Flynn, H.: The infhrence of the value system of a psychiatric setting on behavior in group therapy meetings. 15. Bek,
B. J.:
Sot. Psychiat. Studies
3: 165, 1968.
of the therapist’s
40 role in the treatment of the schizophrenic patient. Amer. J. Psychiat. X3:963, 1967. 16. Campbell, D. P., Stevens, J. H., Uhlenhuth, E. H., and Johansson, C. B.: An extension of the Whitehom-Betz A-B
ANDERSON
ET AL.
Scale. J. Nerv. Ment. Dis. 146:417, 1968. 17. McNair, D. M., Callahan, D. M., and Lorr, M.: Therapist “type” and patient response to psychotherapy. J. Consult. Clin. Psychol. 26:425, 1962.