Journal of Consulting and Clinical Psychology 1976. Vol. 44, No. 1, 77-82
A-B Distinction in a Sample of Prominent Psychotherapists Jesse D. Gellor Yale University
Juris I. Berzins University of Kentucky
Members of a nationwide sample of prominent psychotherapists, psychoanalysts, and behavior therapists were asked to fill out the A-B therapist "type" scale and comment on their possible differential effectiveness in treating schizoid/schizophrenic versus neurotic patients. Psychometric analysis (N — 95) disclosed that their scale scores were reliable, distributed comparably to other therapists and collegiate males, and denotative of two correlated interestaptitude dimensions. Professionals typed as As or Bs showed a greater reluctance to accept the research-generated implications of their A-B status than subjects whose scores fall into neither of these categories. Although the data did not provide strong evidence for a relationship between A-B scale scores and theoretical orientation, the distribution of scores did suggest that B therapists desire and seek more complex and exciting sensory-cognitive inputs during therapy hours than A therapists. The relevance of this finding to the previously established personality correlates of the A-B scale are discussed.
The widely held assumption that therapists' personalities, orientations, and techniques render them differentially effective with different types of patients is not as yet supported by research-generated guidelines for therapist-patient matching. One therapist variable of apparent relevance to this issue, the A-B therapist "type" distinction, however, has shown initial promise. (See reviews by Betz, 1967; Carson, 1967; Razin, 1971.) This distinction, based on a scale measuring interests in selected manual-technical activities (the A-B scale), has generated an "interaction hypothesis," according to which "A" therapists are expected to be more effective in the treatment of schizoid-disaffiliative patients than of neurotic patients, whereas "B" therapists are expected to show the opposite success pattern. Due to the paucity of clinical studies employing the necessary factorial design, the interaction hypothesis has not been fully evaluated, although one recent factorial study supported the hypothesis in a college clinic setting (Berzins, Ross, & Friedman, 1972). Moreover, a sizable number of analogue studies have sup-
ported many aspects of the hypothesis in quasi-therapeutic settings (e.g., Anzel, 1970; Barnes, 1972; Berzins & Seidman, 1968, 1969; Berzins, Ross, & Cohen, 1970; Berzins, Seidman, & Welch, 1970; Carson, Harden, & Shows, 1964; Dublin & Berzins, 1972; Sandier, 196S; Scott & Kemp, 1971; Segal, 1970; Seidman, 1971; Trattner & Howard, 1970). Although almost all of this research has involved male subjects, recent evidence also indicates that the personality correlates of A and B status are relatively invariant across such widely differing populations as practicing therapists, undergraduates, and college clinic patients (Berzins, Dove, & Ross, in press). fn light of the general belief that prominent therapists may derive their distinctive emphases in good part from the characteristics of their preferred clientele (Ford & Urban, 1965; Nydes, 1964; Stein, 1961), it seemed interesting to see whether nationally promiment therapists' A-B scale scores would in some way reflect their "specialization" with particular types of patients. Ideally, of course, prominent A-type therapists should specialize in treating schizoid-disaffiliative patients; B therapists should focus on neurotic patients. It was accordingly decided to solicit the A-B scale scores of a sample of psychotherapists, psychoanalysts, behavior therapists, and therapy researchers whose profes-
The authors are indebted to Wesley F. Ross for his helpful comments on the manuscript. Requests for reprints should be sent to Jesse D. Geller, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06S19.
77
78
JESSK D. GELLER AND JURIS I. BERZINS
sional and scientific attainments are wellknown. This unique sample would also supply important psychometric data regarding (a) the differences, if any, between the A-B scores of prominent therapists and those of prior normative samples; (b) differences possibly associated with professional affiliation or with theoretical orientation; and (c) the internal consistency, reliability, and factorial structure of the scale in this sample. Since research with the A-B variable classifies therapists into only three categories— A, B, or neither—most therapists understandably minimize the applicability of the interaction hypothesis to themselves. One would expect prominent therapists, in particular, to show strong resistances to being "typecast," since the "acceptance" of one's A-B status would—in the case of A and B therapists— imply limited effectiveness with those kinds of patients whom therapists of the opposite type are supposedly better able to help. A second objective of this study accordingly concerned these therapists' reactions to feedback regarding their status on the A-B scale. Each participating therapist was informed of his A-B status, given a "synopsis of the interaction hypothesis," and invited to permit his name and classification (as well as reactions to the feedback, if any) to be published. Only A and B therapists, of course, could regard the feedback as implying differential effectiveness with the two classes of patients, neurotic ("neurotic, depressive, trusting, intropunilive") and schizoid ("schizoid, disaffiliative, extrapunitive"). Unlike the agreement one expects from subjects in traditional experiments involving "personal validation" (e.g., Forer, 1949; Snyder & Larson, 1972), prominent therapists who were told that they qualified for A or B status should overtly or covertly resist the feedback, whereas indeterminate (hereafter "AB") therapists, whose feedback carried no differential effectiveness implications, should react more agreeably. Finally, it was felt that the publication of the A-B scores of cooperative therapists might facilitate investigations by other researchers with access to data on the differential performances of these therapists with actual patients.
METHOD Subjects and Procedure No means exist for securing a representative sample of "nationally prominent therapists" since the parameters of this population are ill denned and constantly changing. Even though no claim is thus made that the individuals who participated in this survey represented this population (indeed, several respondents objected to being identified as practitioners or as nationally prominent), we endeavored to sample prominent psychiatrists and psychologists, founders of "schools of psychotherapy," influential members of the American Psychoanalytic Association and the American Academy of Psychotherapists, and selected authors whose publications have been noteworthy in the fields of behavior modification and psychotherapy. The subjects were recruited by a letter that briefly outlined the general purpose of the research and that included the A-B scale. Cooperation was uncommonly good: Of 134 subjects initially contacted, 95 (71%) completed and returned the A-B scale. By profession, 63 (72%) of the approached psychiatrists and 32 (68%) of the psychologists cooperated. Moreover, 66 (71%) of the cooperating respondents gave written permission to cite their names and A-B scale scores in this report. Finally, regardless of permission, 52 (55%) respondents made at least some comments regarding the feedback they received subsequently. These response rates are considerably higher than those obtained in prior mail surveys of mental health professionals (e.g., Bednar & Shapiro, 1970; Moser, 1958; Sundland & Barker, 1962; Wallach & Strupp, 1960).
Measures The 19-ilcm version of the A-B scale used in this study is derived from, and correlates highly with, the 23-item scale developed in the original Whitehorn-Betz studies (Betz, 1967) and a slightly different 23-item version recommended by Schiffman, Carson, and Falkenbcrg (Note 1) and Kemp and Stephens (1971) on the basis of rigorous item, scaling, and validity analyses. Thirteen of the present, items are also identical to those published by Lorr and McNair (1966) in a 15-itcm scale whose internal consistency was .91. The scale was scored in the B direction. Although cutting scores have varied slightly from study to study, a common convention has been to designate the first and fourth quartiles as A and B, respectively, leaving the middle half of scorers as indeterminate (AB). Three orientation categories (insight, relationship, action) were employed to code the chief orientations of these therapists. Even though these categories have been applied in prior research (Berzins, Herron, & Seidman, 1971), they were modified to conform to the following definitions. The insight category denoted therapists who emphasize the reduction of conflicts and restoration of functioning through interpretation-mediated insight. (About 85% of sub-
A-B DISTINCTION IN A SAMPLE OF PSYCHOTHERAPISTS jects assigned to this category wore psychoanalysts). The relationship category was comprised of therapists who stress therapist-patient involvement, affective interchange, expressive spontaneity, and genuineness as vehicles for effective therapy. Into the action category were placed therapists who rely on direct reinforcement of behavior, action-oriented techniques, and environmental manipulation. (This group included all of the behavior therapists.) The percentages of therapists in these categories were 46 for insight, 18 for relationship, and 23 for action. The remaining 13% were assigned to an "other" category, usually because the therapists were explicitly eclectic in orientation. These categorizations should be regarded as approximate only; although they were made by the authors without reference to therapists' A-B scale scores, obviously other pairs of judges could have arrived at different categories and placements. Therapists' reactions to feedback were measured by two unobtrusive measures: (a) their willingness to have their A-B scale scores and comments, if any, made public and (b) the very presence or absence of comments. The hope that the comments themselves could be submitted to some form of content analysis was obviated by the free-form responding employed by subjects and by variable cell sizes. Note was made, however, of the extent to which the subjects explicitly agreed with the feedback.
RESULTS A-B Scale Score Distribution The group of 95 professionals earned a mean score of 10.36, with a standard deviation of 3.63. Both values are virtually identical to those observed in a nationwide sample of 133 practicing therapists (Berzins et al., 1971), a sample of 94 Midwest therapists and trainees, and a sample of 661 male psychology students (Berzins et al., in press). Within the present sample, psychiatrists (M — 10.27) did not differ from psychologists (M = 10.53), nor did subjects who permitted their scores to be published (M = 10.09) differ from those who did not (M=11.00). Table 1 shows the scores of the 66 professionals who consented to make the information public. Examination of the full distribution of scores does not contradict the interaction hypothesis, although, to be sure, the scores per se shed no reliable light on the performance of these therapists with the two types of patients under consideration. Although several pioneers in the treatment of schizo-
79
TABLE 1 DISTRIBUTION OF A-B SCORES FOR 66 RESPONDENTS Respondent
A-B score
Silvano Arieti, Hans Kysenck Dexter Bullard, Don Jackson, Cyril Franks, John Kirchncr Leonard Krasncr O. Spurgeon English, Stanley Rachman Ralph Greenson, Arnold Lazarus, Tom Leland, Gerald Patterson, David Rioch, Leon Salzman, Albert Scheflen, Richard Sterba Rudolf Ekslein, Allen Endow C. Knight Aklrich, Leopold Bellak, Edward Bordin, Paul Chodoff, Gerard Chrzanowski, Gerald Davison, Sandor Feldman, Robert Hogan, Thomas Stampfl, Lyman Wynne Eugene Brocly, Albert Ellis, Victor Raimy, Frederick Thome, Otto A. Will, Jr., Joseph Wolpe Norman Cameron, Rudolf Drcikurs, Maxwell Jones, David Lazovik, L. Borje Lofgren, Gordon Paul, William Schutz, Lewis Wolberg Richard Felder, Sidney Jourard, Fritz Perls, Nathaniel Ross, John Warkentin, Carl Whitaker Krnst Beier, Harold Kelman, Sandor Lorand, John Rosen, John Spiegel, Charles Truax Samuel Kraines, Carl Rogers Reuben Fine, Louis Gottschalk, Irving Harm, Rudolph Lowenstein, E. Lakin Phillips, Victor Rosen Donald Baer Jules Barron
3 4 5 6
7 8
9 10
11 12 13 14 IS 16 17
Note. Low scores refer to the A end of the scale, high scores, to the B end.
phrenic/schizoid patients are appropriately classified as As (e.g., S. Arieti, D. Bullard, O. S. English, D. Jackson, as well as several others who regrettably did not wish to be identified), a few others are classified as Bs (notably John Rosen) or ABs (e.g., O. A. Will, Jr., E. Brody, L. Wynne). Similarly, even though a number of therapists recognized for their treatment of neurotics are appropriately placed toward the B end of the distribution (e.g., H. Kelman, N. Lowenstein, C. Rogers, N. Ross, and others), there are a number of exceptions as well. Interestingly, the middle (AB) group does include an appreciable number of therapists who profess to be eclectic or whose technical armentarium is
80
JESSE D. GELLER AND JURIS I. BERZINS
extremely wide ranging (e.g., E. Bordin, V. Raimy, F. Thome, L. Wolbcrg). With regard to the 83 subjects placed into cither the insight (M = 10.17), relationship (M = 11.76), or action (M = 9.59) orientation categories, only the contrast between relationship and action subjects approached significance, *(37) = 1.97, p < .06. This trend was corroborated by a 3 X 2 (Orientation X Above/Below the Group Mean) chi-squarc analysis that yielded a value of 8.31 (df — 2, p < .025), principally because 14 of 17 (82%) relationship subjects earned scores greater than 11. There thus appears to be some association between the B end of the scale and a therapists' affinity for affective interchange, self-disclosure, confrontation, and other relationship-emphasizing ingredients. Psychometric Analyses With regard to the psychometric adequacy of the A-B scale in this sample, an item analysis showed that 17 of 19 scale items correlated significantly (p < .OS or better) with total scores (minus that item), the median item-total correlation being .42. The Kuder-Richardson reliability coefficient for the total scale was .73 (.77 if the two nousignificantly correlating items are excluded), indicating satisfactory reliability for research purposes. When the total score distribution wais divided into four successive quartiles (7 or below, 8-10, 11-13, 14, or greater), with associated Ns ranging from 22 to 26, univariate F tests across the four groups yielded significant ratios for 16 items, none of which showed a curvilinear order as total scores increased. To explicate the principal content dimensions of the scale in this sample, a series of factor analyses (principal components, principal factors, alpha and image analyses) were conducted, employing both orthogonal (varimax) and oblique (direct oblimin) rotational procedures. Although as many as six eigenvalues exceeded unity in the principal components analysis, generally only two factors were salient in all analyses. The first dimension, which may be entitled manual interests, concerned "do it yourself" interests and aptitudes (e.g., carpentry, cabinetmaking,
manual training, liking for mechanics magazines, having mechanical ingenuity). The second dimension, labeled engineering interests, was defined principally by professed interests in mechanical engineering, marine engineering, toolmaking, photoengraving, and radio-set construction. The two dimensions may be considered as positively but not highly related with a correlation of about .40 in oblique solutions. These results suggest that high (B) scores on the scale may result from (a) an affinity for manual hobbies ("being handy with tools"); (b) having interests in technical, complex, precisionrequiring vocations; or (c) both. Reactions to Feedback If prominent therapists are especially reluctant to be typecast, A and B therapists who received feedback implying differential success with schizoid and neurotic patients should permit the publication of their scores less often than therapists who for various reasons did not wish to be considered "prominent therapists." A 2 X 2 (As plus Bs vs. ABs X Gave Permission vs. Did Not) chisquare analysis confirmed these expectations, X 2 ( l ) = 4.71, p < .05. Only 59% of the extreme (A and B) scorers granted permission, in contrast to &0% of the ABs. A comparable analysis was conducted to determine whether the very presence or absence of comments regarding the feedback would similarly differentiate the groups. This analysis yielded a chi-square of 2.70 which, with 1 degree of freedom, denotes only a trend (p < .10). The direction of the differences, however, was consistent with the data on permission rates: 44% of the extreme scorers and 61% of the ABs furnished comments regarding their reactions to the feedback. The reluctance of A and B therapists to be typecast was further corroborated by an inspection of the available comments. Even though 20 (10 A and 10 B) subjects gave no comments whatever, 18 therapists (9 As and 9 Bs) engaged in various forms of disagreement, qualification, quibbling, or evasion; only 5 subjects (2 As and 3 Bs) agreed with
A-B DISTINCTION IN A SAMPLE OF PSYCHOTHERAPISTS
the applicability of the interaction hypothesis to themselves.1 DISCUSSION The present survey indicated that the A-B scale scores of these prominent professionals were reasonably reliable, denotative of two main content dimensions, and distributed comparably to those of other therapists and collegiate males. Although no quantitative conclusions regarding the agreement of the score distribution with the requirements of the interaction hypothesis could be drawn, other investigators, with access to process or outcome data involving some of these therapists, may find it possible to examine the hypothesis empirically. One could of course argue that a prominent therapist's A-B status is a mere curiosity that should be viewed in the context of, and subordinated to, such characteristics as personal charisma, intellectual brilliance, unusual capacity for empathy, innovative flexibility, technical expertise, and so forth. Prominent therapists may differ from other therapists in many ways, one of which might be their aptitude for treating a wide variety of patient types with equal or near-equal success—• regardless of their own A-B status. This formulation would supply a veridical base for these therapists' reluctance to be typecast by researchers, a reluctance documented by the present study. Whatever the fate of the interaction hypothesis in this population, the factorial structure of the A-B scale indicated that B-type therapists exceed A-type therapists in professing interests in manual-mechanical hobbies and similar pursuits requiring an interest in precise, complex detail. Whereas B-type subjects in this sense, as well as in the light of prior research, can be regarded as more culturally "masculine" than A-type subjects, personological studies of the A-B distinction have also aligned the B end of the scale with high levels of risk taking, variety seeking, seeking and enjoying physical sensations, interpersonal ascendancy, and "counterdependence" (Berzins et al., in press). The latter findings, cross-validated across four very different populations, appear conceptu-
81
ally consistent with the orientation differences detected in the present study; that is, therapists classified as relationship-oriented were overrepresented among subjects scoring toward the B end of the scale. In this vein, it appears more than coincidental that several members of the client-centered group (Jourard, Rogers, Truax), members of the Esalen Institute (Perls, Schutz), and members of the so-called Atlanta group (Felder, Warkentin, Whitaker) scored toward the B end of the distribution. Whether the B pole, in this population, denotes the personality correlates cited above, an attraction to or aptitude for complex interpersonal transactions (e.g., family and group therapy, encounter groups, multiple therapy), or therapists' "needs" to receive complex, exciting inputs from patients is difficult to say. It appears to us, however, that most of the therapists at the B end of the distribution are more oriented toward complex, involving, exciting experiences with patients than most of the therapists at the A end of the distribution. A number of the B therapists, in fact, have increasingly "gravitated" in the direction of greater involvement with patients, affective interchange, expressive spontaneity, and so on, over the course of their professional careers; similar trends are rare among A therapists. Should this information be even approximately valid, it could be speculated that the presumed superiority of A-type therapists in working with process and chronic schizophrenics (Betz, 1967) may result from a greater tolerance for communications and behaviors that B-type therapists may more rapidly become impatient with. 1 After this article was accepted for publication, one B scorer withdrew permission to be identified. His name and score have been accordingly deleted from Table 1. His reaction would appear to strengthen the "reluctance to be typecast" hypothesis.
REFERENCE NOTE 1. Schiffman, H., Carson, R. C., & Falkenburg, P. A psychometric analysis of the Whitehorn-Betz A~B scale. Unpublished manuscript, Duke University, 1967.
82
JESSE D. GELLER AND JURIS I. BERZINS REFERENCES
Aiizel, A. A-B typing and patient sociocconomic and personality characteristics in a quasi-therapeutic situation. Journal of Consulting and Clinical Psychology, 1970, 35, 102-115. Barnes, D. F. A and B college students as interviewers of schizophrenic and neurotic inpalients: A test oj the interaction hypothesis. Unpublished doctoral dissertation, University of Kentucky, 1972. Bcdnar, K. L., & Shapiro, J. G. Professional research commitment: A symptom or a syndrome? Journal of Consulting and Clinical Psychology, 1970, 34, 323-326. Berzins, J. I., Dove, J. I,., & Ross, W. F. Crossvalidational studies of the personality correlates of the A-B therapist "type" distinction among professionals and nonprofessionals. Journal oj Consulting and Clinical Psychology, in press. Berzins, J. I., Hcrron, E. W., & Seidman, E. Patients' role behaviors as seen by therapists: A factor-analytic study. Psychotherapy: Theory, Research, and Practice, 1971, 8, 127-130. Berzins, J. I., Ross, W. F., & Cohen, 1). I. The relation of the A-B distinction and trust-distrust sets to addict patients' self-disclosures in brief interviews. Journal of Consulting and Clinical Psychology, 1970, 34, 289-296. Berzins, J. L, Ross, "W. F., & Friedman, W. H. The A-B therapist distinction, patient diagnosis, and outcome of brief psychotherapy in a college clinic. Journal oj Consulting and Clinical Psychology, 1972, 38, 231-237. Berzins, J. I., & Seidman, E. Subjective reactions of A and B quasi-therapists to schizoid and neurotic communications: A replication and extension. Journal of Consulting and Clinical Psychology, 1968, 32, 342-347. Berzins, J. I., & Seidman, E. Differential therapeutic responding of A and B quasi-thcrapists to schizoid and neurotic communications. Journal of Consulting and Clinical Psychology, 1969, 33, 279-286. Berzins, J. I., Seidman, E., & Welch, R. D. A-B therapist "types" and responses to patient-communicated hostility: An analogue study. Journal of Consulting and Clinical Psychology, 1970, 34, 27-32. Bclz, B. J. Studies of the therapist's role in the treatment of the schizophrenic patient. American Journal of Psychiatry, 1967, 123, 963-971. Carson, R. C. A and B therapist "types": A possible critical variable in psychotherapy. Journal of Nervous and Mental Disease, 1967, 144, 47-54. Carson, R. C., Harden, J. A., & Shows, W. D. A-B distinction and behavior in quasi-therapeuticsituations. Journal of Consulting Psychology, 1964, 28, 426-433. Dublin, J . E., & Berzins, J. I. The A-B variable and reactions to nonimmediacy in neurotic and schizoid communications: A longitudinal analogue of psychotherapy. Journal of Consulting and Clinical Psychology, 1972, 39, 86-93.
Ford, D. IT., & Urban, It. B. Systems of psychotherapy: A comparative study. New York: Wiley, 1965. Forcr, B. R. The fallacy of personal validation: A classroom demonstration of gullibility. Journal oj Abnormal and Social Psychology, 1949, 44, 118123. Kemp, D. E., & Stephens, J. H. Which A-B scale? A comparative analysis of several versions. Journal oj Nervous and Mental Disease, 1971, 152, 23-30. Lorr, M. E., & McNair, D. M. Methods relating to evaluation of therapeutic outcome. In L. A. Gottschalk & A. H. Auerbach (Eds.), Methods of research in psychotherapy. New York: AppletonCentury-Crofts, 1966. Moser, C. A. Survey methods in social investigation. London: Heincmann, 1958. Nydcs, J. Interpersonal relations: A critique. In E. A. Southwell & M. Merbaum (Eds.), Personality: Readings in theory and research. Bclmont, Calif.: Wadsworth, 1964. Razin, A. M. The A-B variable in psychotherapy: A critical review. Psychological Bulletin, 1971, 75, 1-21. Sandier, D. Investigation of a scale of therapeutic, effectiveness: Trust and suspicion in an experimentally induced situation (Doctoral dissertation, Duke University, 1965). Dissertation Abstracts International, 1965. (University Microfilms No. 66-1382) Scott, R. W., & Kemp, D. E. The A-B scale and empathy, warmth, genuineness, and depth of selfexploration. Journal of Abnormal Psychology, 1971, 77, 49-51. Segal, B. A-B distinction and therapeutic interaction. Journal of Consulting and Clinical Psychology, 1970, 34, 49-51. Seidman, E. A and B subject-therapists' responses to videotaped schizoid and intropunitivc-ncurotic prototypes. Journal of Consulting and Clinical Psychology, 1971, 37, 201-208. Snyder, C. R., & Larson, C. R. A further look at student acceptance of general personality interpretations. Journal oj Consulting and Clinical Psychology, 1972, 38, 384-388. Stein, M. I. (Ed.) Contemporary psychotherapies. New York: Free Press of Glencoe, 1961. Sundland, D. M., & Barker, E. N. The orientation of psychotherapists. Journal of Consulting Psychology, 1962, 26, 201-212. Trattner, J. H., & Howard, K. I. A preliminary investigation of covert communication of expectancies to schizophrenics. Journal oj Abnormal Psychology, 1970, 75, 245-247. Wallach, M. S., & Strupp, H. Psychotherapists' clinical judgments and attitudes toward patients. Journal oj Consulting Psychology, 1960, 24, 316-323. (Received May 19, 1975)
A-B Distinction in a Sample of Prominent Psychotherapists Jesse D. Gellor Yale University
Juris I. Berzins University of Kentucky
Members of a nationwide sample of prominent psychotherapists, psychoanalysts, and behavior therapists were asked to fill out the A-B therapist "type" scale and comment on their possible differential effectiveness in treating schizoid/schizophrenic versus neurotic patients. Psychometric analysis (N — 95) disclosed that their scale scores were reliable, distributed comparably to other therapists and collegiate males, and denotative of two correlated interestaptitude dimensions. Professionals typed as As or Bs showed a greater reluctance to accept the research-generated implications of their A-B status than subjects whose scores fall into neither of these categories. Although the data did not provide strong evidence for a relationship between A-B scale scores and theoretical orientation, the distribution of scores did suggest that B therapists desire and seek more complex and exciting sensory-cognitive inputs during therapy hours than A therapists. The relevance of this finding to the previously established personality correlates of the A-B scale are discussed.
The widely held assumption that therapists' personalities, orientations, and techniques render them differentially effective with different types of patients is not as yet supported by research-generated guidelines for therapist-patient matching. One therapist variable of apparent relevance to this issue, the A-B therapist "type" distinction, however, has shown initial promise. (See reviews by Betz, 1967; Carson, 1967; Razin, 1971.) This distinction, based on a scale measuring interests in selected manual-technical activities (the A-B scale), has generated an "interaction hypothesis," according to which "A" therapists are expected to be more effective in the treatment of schizoid-disaffiliative patients than of neurotic patients, whereas "B" therapists are expected to show the opposite success pattern. Due to the paucity of clinical studies employing the necessary factorial design, the interaction hypothesis has not been fully evaluated, although one recent factorial study supported the hypothesis in a college clinic setting (Berzins, Ross, & Friedman, 1972). Moreover, a sizable number of analogue studies have sup-
ported many aspects of the hypothesis in quasi-therapeutic settings (e.g., Anzel, 1970; Barnes, 1972; Berzins & Seidman, 1968, 1969; Berzins, Ross, & Cohen, 1970; Berzins, Seidman, & Welch, 1970; Carson, Harden, & Shows, 1964; Dublin & Berzins, 1972; Sandier, 196S; Scott & Kemp, 1971; Segal, 1970; Seidman, 1971; Trattner & Howard, 1970). Although almost all of this research has involved male subjects, recent evidence also indicates that the personality correlates of A and B status are relatively invariant across such widely differing populations as practicing therapists, undergraduates, and college clinic patients (Berzins, Dove, & Ross, in press). fn light of the general belief that prominent therapists may derive their distinctive emphases in good part from the characteristics of their preferred clientele (Ford & Urban, 1965; Nydes, 1964; Stein, 1961), it seemed interesting to see whether nationally promiment therapists' A-B scale scores would in some way reflect their "specialization" with particular types of patients. Ideally, of course, prominent A-type therapists should specialize in treating schizoid-disaffiliative patients; B therapists should focus on neurotic patients. It was accordingly decided to solicit the A-B scale scores of a sample of psychotherapists, psychoanalysts, behavior therapists, and therapy researchers whose profes-
The authors are indebted to Wesley F. Ross for his helpful comments on the manuscript. Requests for reprints should be sent to Jesse D. Geller, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06S19.
77
78
JESSK D. GELLER AND JURIS I. BERZINS
sional and scientific attainments are wellknown. This unique sample would also supply important psychometric data regarding (a) the differences, if any, between the A-B scores of prominent therapists and those of prior normative samples; (b) differences possibly associated with professional affiliation or with theoretical orientation; and (c) the internal consistency, reliability, and factorial structure of the scale in this sample. Since research with the A-B variable classifies therapists into only three categories— A, B, or neither—most therapists understandably minimize the applicability of the interaction hypothesis to themselves. One would expect prominent therapists, in particular, to show strong resistances to being "typecast," since the "acceptance" of one's A-B status would—in the case of A and B therapists— imply limited effectiveness with those kinds of patients whom therapists of the opposite type are supposedly better able to help. A second objective of this study accordingly concerned these therapists' reactions to feedback regarding their status on the A-B scale. Each participating therapist was informed of his A-B status, given a "synopsis of the interaction hypothesis," and invited to permit his name and classification (as well as reactions to the feedback, if any) to be published. Only A and B therapists, of course, could regard the feedback as implying differential effectiveness with the two classes of patients, neurotic ("neurotic, depressive, trusting, intropunilive") and schizoid ("schizoid, disaffiliative, extrapunitive"). Unlike the agreement one expects from subjects in traditional experiments involving "personal validation" (e.g., Forer, 1949; Snyder & Larson, 1972), prominent therapists who were told that they qualified for A or B status should overtly or covertly resist the feedback, whereas indeterminate (hereafter "AB") therapists, whose feedback carried no differential effectiveness implications, should react more agreeably. Finally, it was felt that the publication of the A-B scores of cooperative therapists might facilitate investigations by other researchers with access to data on the differential performances of these therapists with actual patients.
METHOD Subjects and Procedure No means exist for securing a representative sample of "nationally prominent therapists" since the parameters of this population are ill denned and constantly changing. Even though no claim is thus made that the individuals who participated in this survey represented this population (indeed, several respondents objected to being identified as practitioners or as nationally prominent), we endeavored to sample prominent psychiatrists and psychologists, founders of "schools of psychotherapy," influential members of the American Psychoanalytic Association and the American Academy of Psychotherapists, and selected authors whose publications have been noteworthy in the fields of behavior modification and psychotherapy. The subjects were recruited by a letter that briefly outlined the general purpose of the research and that included the A-B scale. Cooperation was uncommonly good: Of 134 subjects initially contacted, 95 (71%) completed and returned the A-B scale. By profession, 63 (72%) of the approached psychiatrists and 32 (68%) of the psychologists cooperated. Moreover, 66 (71%) of the cooperating respondents gave written permission to cite their names and A-B scale scores in this report. Finally, regardless of permission, 52 (55%) respondents made at least some comments regarding the feedback they received subsequently. These response rates are considerably higher than those obtained in prior mail surveys of mental health professionals (e.g., Bednar & Shapiro, 1970; Moser, 1958; Sundland & Barker, 1962; Wallach & Strupp, 1960).
Measures The 19-ilcm version of the A-B scale used in this study is derived from, and correlates highly with, the 23-item scale developed in the original Whitehorn-Betz studies (Betz, 1967) and a slightly different 23-item version recommended by Schiffman, Carson, and Falkenbcrg (Note 1) and Kemp and Stephens (1971) on the basis of rigorous item, scaling, and validity analyses. Thirteen of the present, items are also identical to those published by Lorr and McNair (1966) in a 15-itcm scale whose internal consistency was .91. The scale was scored in the B direction. Although cutting scores have varied slightly from study to study, a common convention has been to designate the first and fourth quartiles as A and B, respectively, leaving the middle half of scorers as indeterminate (AB). Three orientation categories (insight, relationship, action) were employed to code the chief orientations of these therapists. Even though these categories have been applied in prior research (Berzins, Herron, & Seidman, 1971), they were modified to conform to the following definitions. The insight category denoted therapists who emphasize the reduction of conflicts and restoration of functioning through interpretation-mediated insight. (About 85% of sub-
A-B DISTINCTION IN A SAMPLE OF PSYCHOTHERAPISTS jects assigned to this category wore psychoanalysts). The relationship category was comprised of therapists who stress therapist-patient involvement, affective interchange, expressive spontaneity, and genuineness as vehicles for effective therapy. Into the action category were placed therapists who rely on direct reinforcement of behavior, action-oriented techniques, and environmental manipulation. (This group included all of the behavior therapists.) The percentages of therapists in these categories were 46 for insight, 18 for relationship, and 23 for action. The remaining 13% were assigned to an "other" category, usually because the therapists were explicitly eclectic in orientation. These categorizations should be regarded as approximate only; although they were made by the authors without reference to therapists' A-B scale scores, obviously other pairs of judges could have arrived at different categories and placements. Therapists' reactions to feedback were measured by two unobtrusive measures: (a) their willingness to have their A-B scale scores and comments, if any, made public and (b) the very presence or absence of comments. The hope that the comments themselves could be submitted to some form of content analysis was obviated by the free-form responding employed by subjects and by variable cell sizes. Note was made, however, of the extent to which the subjects explicitly agreed with the feedback.
RESULTS A-B Scale Score Distribution The group of 95 professionals earned a mean score of 10.36, with a standard deviation of 3.63. Both values are virtually identical to those observed in a nationwide sample of 133 practicing therapists (Berzins et al., 1971), a sample of 94 Midwest therapists and trainees, and a sample of 661 male psychology students (Berzins et al., in press). Within the present sample, psychiatrists (M — 10.27) did not differ from psychologists (M = 10.53), nor did subjects who permitted their scores to be published (M = 10.09) differ from those who did not (M=11.00). Table 1 shows the scores of the 66 professionals who consented to make the information public. Examination of the full distribution of scores does not contradict the interaction hypothesis, although, to be sure, the scores per se shed no reliable light on the performance of these therapists with the two types of patients under consideration. Although several pioneers in the treatment of schizo-
79
TABLE 1 DISTRIBUTION OF A-B SCORES FOR 66 RESPONDENTS Respondent
A-B score
Silvano Arieti, Hans Kysenck Dexter Bullard, Don Jackson, Cyril Franks, John Kirchncr Leonard Krasncr O. Spurgeon English, Stanley Rachman Ralph Greenson, Arnold Lazarus, Tom Leland, Gerald Patterson, David Rioch, Leon Salzman, Albert Scheflen, Richard Sterba Rudolf Ekslein, Allen Endow C. Knight Aklrich, Leopold Bellak, Edward Bordin, Paul Chodoff, Gerard Chrzanowski, Gerald Davison, Sandor Feldman, Robert Hogan, Thomas Stampfl, Lyman Wynne Eugene Brocly, Albert Ellis, Victor Raimy, Frederick Thome, Otto A. Will, Jr., Joseph Wolpe Norman Cameron, Rudolf Drcikurs, Maxwell Jones, David Lazovik, L. Borje Lofgren, Gordon Paul, William Schutz, Lewis Wolberg Richard Felder, Sidney Jourard, Fritz Perls, Nathaniel Ross, John Warkentin, Carl Whitaker Krnst Beier, Harold Kelman, Sandor Lorand, John Rosen, John Spiegel, Charles Truax Samuel Kraines, Carl Rogers Reuben Fine, Louis Gottschalk, Irving Harm, Rudolph Lowenstein, E. Lakin Phillips, Victor Rosen Donald Baer Jules Barron
3 4 5 6
7 8
9 10
11 12 13 14 IS 16 17
Note. Low scores refer to the A end of the scale, high scores, to the B end.
phrenic/schizoid patients are appropriately classified as As (e.g., S. Arieti, D. Bullard, O. S. English, D. Jackson, as well as several others who regrettably did not wish to be identified), a few others are classified as Bs (notably John Rosen) or ABs (e.g., O. A. Will, Jr., E. Brody, L. Wynne). Similarly, even though a number of therapists recognized for their treatment of neurotics are appropriately placed toward the B end of the distribution (e.g., H. Kelman, N. Lowenstein, C. Rogers, N. Ross, and others), there are a number of exceptions as well. Interestingly, the middle (AB) group does include an appreciable number of therapists who profess to be eclectic or whose technical armentarium is
80
JESSE D. GELLER AND JURIS I. BERZINS
extremely wide ranging (e.g., E. Bordin, V. Raimy, F. Thome, L. Wolbcrg). With regard to the 83 subjects placed into cither the insight (M = 10.17), relationship (M = 11.76), or action (M = 9.59) orientation categories, only the contrast between relationship and action subjects approached significance, *(37) = 1.97, p < .06. This trend was corroborated by a 3 X 2 (Orientation X Above/Below the Group Mean) chi-squarc analysis that yielded a value of 8.31 (df — 2, p < .025), principally because 14 of 17 (82%) relationship subjects earned scores greater than 11. There thus appears to be some association between the B end of the scale and a therapists' affinity for affective interchange, self-disclosure, confrontation, and other relationship-emphasizing ingredients. Psychometric Analyses With regard to the psychometric adequacy of the A-B scale in this sample, an item analysis showed that 17 of 19 scale items correlated significantly (p < .OS or better) with total scores (minus that item), the median item-total correlation being .42. The Kuder-Richardson reliability coefficient for the total scale was .73 (.77 if the two nousignificantly correlating items are excluded), indicating satisfactory reliability for research purposes. When the total score distribution wais divided into four successive quartiles (7 or below, 8-10, 11-13, 14, or greater), with associated Ns ranging from 22 to 26, univariate F tests across the four groups yielded significant ratios for 16 items, none of which showed a curvilinear order as total scores increased. To explicate the principal content dimensions of the scale in this sample, a series of factor analyses (principal components, principal factors, alpha and image analyses) were conducted, employing both orthogonal (varimax) and oblique (direct oblimin) rotational procedures. Although as many as six eigenvalues exceeded unity in the principal components analysis, generally only two factors were salient in all analyses. The first dimension, which may be entitled manual interests, concerned "do it yourself" interests and aptitudes (e.g., carpentry, cabinetmaking,
manual training, liking for mechanics magazines, having mechanical ingenuity). The second dimension, labeled engineering interests, was defined principally by professed interests in mechanical engineering, marine engineering, toolmaking, photoengraving, and radio-set construction. The two dimensions may be considered as positively but not highly related with a correlation of about .40 in oblique solutions. These results suggest that high (B) scores on the scale may result from (a) an affinity for manual hobbies ("being handy with tools"); (b) having interests in technical, complex, precisionrequiring vocations; or (c) both. Reactions to Feedback If prominent therapists are especially reluctant to be typecast, A and B therapists who received feedback implying differential success with schizoid and neurotic patients should permit the publication of their scores less often than therapists who for various reasons did not wish to be considered "prominent therapists." A 2 X 2 (As plus Bs vs. ABs X Gave Permission vs. Did Not) chisquare analysis confirmed these expectations, X 2 ( l ) = 4.71, p < .05. Only 59% of the extreme (A and B) scorers granted permission, in contrast to &0% of the ABs. A comparable analysis was conducted to determine whether the very presence or absence of comments regarding the feedback would similarly differentiate the groups. This analysis yielded a chi-square of 2.70 which, with 1 degree of freedom, denotes only a trend (p < .10). The direction of the differences, however, was consistent with the data on permission rates: 44% of the extreme scorers and 61% of the ABs furnished comments regarding their reactions to the feedback. The reluctance of A and B therapists to be typecast was further corroborated by an inspection of the available comments. Even though 20 (10 A and 10 B) subjects gave no comments whatever, 18 therapists (9 As and 9 Bs) engaged in various forms of disagreement, qualification, quibbling, or evasion; only 5 subjects (2 As and 3 Bs) agreed with
A-B DISTINCTION IN A SAMPLE OF PSYCHOTHERAPISTS
the applicability of the interaction hypothesis to themselves.1 DISCUSSION The present survey indicated that the A-B scale scores of these prominent professionals were reasonably reliable, denotative of two main content dimensions, and distributed comparably to those of other therapists and collegiate males. Although no quantitative conclusions regarding the agreement of the score distribution with the requirements of the interaction hypothesis could be drawn, other investigators, with access to process or outcome data involving some of these therapists, may find it possible to examine the hypothesis empirically. One could of course argue that a prominent therapist's A-B status is a mere curiosity that should be viewed in the context of, and subordinated to, such characteristics as personal charisma, intellectual brilliance, unusual capacity for empathy, innovative flexibility, technical expertise, and so forth. Prominent therapists may differ from other therapists in many ways, one of which might be their aptitude for treating a wide variety of patient types with equal or near-equal success—• regardless of their own A-B status. This formulation would supply a veridical base for these therapists' reluctance to be typecast by researchers, a reluctance documented by the present study. Whatever the fate of the interaction hypothesis in this population, the factorial structure of the A-B scale indicated that B-type therapists exceed A-type therapists in professing interests in manual-mechanical hobbies and similar pursuits requiring an interest in precise, complex detail. Whereas B-type subjects in this sense, as well as in the light of prior research, can be regarded as more culturally "masculine" than A-type subjects, personological studies of the A-B distinction have also aligned the B end of the scale with high levels of risk taking, variety seeking, seeking and enjoying physical sensations, interpersonal ascendancy, and "counterdependence" (Berzins et al., in press). The latter findings, cross-validated across four very different populations, appear conceptu-
81
ally consistent with the orientation differences detected in the present study; that is, therapists classified as relationship-oriented were overrepresented among subjects scoring toward the B end of the scale. In this vein, it appears more than coincidental that several members of the client-centered group (Jourard, Rogers, Truax), members of the Esalen Institute (Perls, Schutz), and members of the so-called Atlanta group (Felder, Warkentin, Whitaker) scored toward the B end of the distribution. Whether the B pole, in this population, denotes the personality correlates cited above, an attraction to or aptitude for complex interpersonal transactions (e.g., family and group therapy, encounter groups, multiple therapy), or therapists' "needs" to receive complex, exciting inputs from patients is difficult to say. It appears to us, however, that most of the therapists at the B end of the distribution are more oriented toward complex, involving, exciting experiences with patients than most of the therapists at the A end of the distribution. A number of the B therapists, in fact, have increasingly "gravitated" in the direction of greater involvement with patients, affective interchange, expressive spontaneity, and so on, over the course of their professional careers; similar trends are rare among A therapists. Should this information be even approximately valid, it could be speculated that the presumed superiority of A-type therapists in working with process and chronic schizophrenics (Betz, 1967) may result from a greater tolerance for communications and behaviors that B-type therapists may more rapidly become impatient with. 1 After this article was accepted for publication, one B scorer withdrew permission to be identified. His name and score have been accordingly deleted from Table 1. His reaction would appear to strengthen the "reluctance to be typecast" hypothesis.
REFERENCE NOTE 1. Schiffman, H., Carson, R. C., & Falkenburg, P. A psychometric analysis of the Whitehorn-Betz A~B scale. Unpublished manuscript, Duke University, 1967.
82
JESSE D. GELLER AND JURIS I. BERZINS REFERENCES
Aiizel, A. A-B typing and patient sociocconomic and personality characteristics in a quasi-therapeutic situation. Journal of Consulting and Clinical Psychology, 1970, 35, 102-115. Barnes, D. F. A and B college students as interviewers of schizophrenic and neurotic inpalients: A test oj the interaction hypothesis. Unpublished doctoral dissertation, University of Kentucky, 1972. Bcdnar, K. L., & Shapiro, J. G. Professional research commitment: A symptom or a syndrome? Journal of Consulting and Clinical Psychology, 1970, 34, 323-326. Berzins, J. I., Dove, J. I,., & Ross, W. F. Crossvalidational studies of the personality correlates of the A-B therapist "type" distinction among professionals and nonprofessionals. Journal oj Consulting and Clinical Psychology, in press. Berzins, J. I., Hcrron, E. W., & Seidman, E. Patients' role behaviors as seen by therapists: A factor-analytic study. Psychotherapy: Theory, Research, and Practice, 1971, 8, 127-130. Berzins, J. I., Ross, W. F., & Cohen, 1). I. The relation of the A-B distinction and trust-distrust sets to addict patients' self-disclosures in brief interviews. Journal of Consulting and Clinical Psychology, 1970, 34, 289-296. Berzins, J. L, Ross, "W. F., & Friedman, W. H. The A-B therapist distinction, patient diagnosis, and outcome of brief psychotherapy in a college clinic. Journal oj Consulting and Clinical Psychology, 1972, 38, 231-237. Berzins, J. I., & Seidman, E. Subjective reactions of A and B quasi-therapists to schizoid and neurotic communications: A replication and extension. Journal of Consulting and Clinical Psychology, 1968, 32, 342-347. Berzins, J. I., & Seidman, E. Differential therapeutic responding of A and B quasi-thcrapists to schizoid and neurotic communications. Journal of Consulting and Clinical Psychology, 1969, 33, 279-286. Berzins, J. I., Seidman, E., & Welch, R. D. A-B therapist "types" and responses to patient-communicated hostility: An analogue study. Journal of Consulting and Clinical Psychology, 1970, 34, 27-32. Bclz, B. J. Studies of the therapist's role in the treatment of the schizophrenic patient. American Journal of Psychiatry, 1967, 123, 963-971. Carson, R. C. A and B therapist "types": A possible critical variable in psychotherapy. Journal of Nervous and Mental Disease, 1967, 144, 47-54. Carson, R. C., Harden, J. A., & Shows, W. D. A-B distinction and behavior in quasi-therapeuticsituations. Journal of Consulting Psychology, 1964, 28, 426-433. Dublin, J . E., & Berzins, J. I. The A-B variable and reactions to nonimmediacy in neurotic and schizoid communications: A longitudinal analogue of psychotherapy. Journal of Consulting and Clinical Psychology, 1972, 39, 86-93.
Ford, D. IT., & Urban, It. B. Systems of psychotherapy: A comparative study. New York: Wiley, 1965. Forcr, B. R. The fallacy of personal validation: A classroom demonstration of gullibility. Journal oj Abnormal and Social Psychology, 1949, 44, 118123. Kemp, D. E., & Stephens, J. H. Which A-B scale? A comparative analysis of several versions. Journal oj Nervous and Mental Disease, 1971, 152, 23-30. Lorr, M. E., & McNair, D. M. Methods relating to evaluation of therapeutic outcome. In L. A. Gottschalk & A. H. Auerbach (Eds.), Methods of research in psychotherapy. New York: AppletonCentury-Crofts, 1966. Moser, C. A. Survey methods in social investigation. London: Heincmann, 1958. Nydcs, J. Interpersonal relations: A critique. In E. A. Southwell & M. Merbaum (Eds.), Personality: Readings in theory and research. Bclmont, Calif.: Wadsworth, 1964. Razin, A. M. The A-B variable in psychotherapy: A critical review. Psychological Bulletin, 1971, 75, 1-21. Sandier, D. Investigation of a scale of therapeutic, effectiveness: Trust and suspicion in an experimentally induced situation (Doctoral dissertation, Duke University, 1965). Dissertation Abstracts International, 1965. (University Microfilms No. 66-1382) Scott, R. W., & Kemp, D. E. The A-B scale and empathy, warmth, genuineness, and depth of selfexploration. Journal of Abnormal Psychology, 1971, 77, 49-51. Segal, B. A-B distinction and therapeutic interaction. Journal of Consulting and Clinical Psychology, 1970, 34, 49-51. Seidman, E. A and B subject-therapists' responses to videotaped schizoid and intropunitivc-ncurotic prototypes. Journal of Consulting and Clinical Psychology, 1971, 37, 201-208. Snyder, C. R., & Larson, C. R. A further look at student acceptance of general personality interpretations. Journal oj Consulting and Clinical Psychology, 1972, 38, 384-388. Stein, M. I. (Ed.) Contemporary psychotherapies. New York: Free Press of Glencoe, 1961. Sundland, D. M., & Barker, E. N. The orientation of psychotherapists. Journal of Consulting Psychology, 1962, 26, 201-212. Trattner, J. H., & Howard, K. I. A preliminary investigation of covert communication of expectancies to schizophrenics. Journal oj Abnormal Psychology, 1970, 75, 245-247. Wallach, M. S., & Strupp, H. Psychotherapists' clinical judgments and attitudes toward patients. Journal oj Consulting Psychology, 1960, 24, 316-323. (Received May 19, 1975)
