Psychological Reports, 1975, 37, 911-919. @ Psychological Reports 1975
NATURALISTIC ANALYSIS OF VERBAL BEHAVIOR IN PSYCHOTHERAPY DENNIS P. SACCUZZO1~"a
Middle Tennessee State Uniuersity Summary.-A parallel-response questionnaire, the Therapy Session Report, was administered to the 57 patients and 1 9 therapists of the Kent State Universiry Psychological Clinic immediately following each intake session. The purpose of the study was to provide normative data on the content of dialogue in psychotherapy and to extend the generalizability of previous results., Data analysis focused on the frequency, structure, and patient-therapist agreement of the topics discussed. Items most frequently endorsed by both patients and therapists were: "Relations with the opposite sex," "Mother," and "Hopes or fears about the future." Factor analysis resulted in 7 factors for therapists and 7 for patients, 5 of which were highly similar. Results were interpreted as underscoring the necessity of specificity in process research. A proposal for conducting process research is presented.
There are numerous approaches to the study of the process of psychotherapy through the analysis of verbal behavior. These approaches range from che study of linguistic or paralinguistic phenomena ( e.g., Birdwhistell, 1961; Dittman & Wynne, 1961; Scheflen, 1965), through acoustical analysis (e.g., Ostwald, 1964, 1965), and the scudy of other formal aspects of verbal processes (e.g., Matarazzo, Wiens, Matarazzo, & Saslow, 1968). Some researchers (e.g., Dollard 8: Auld, 1959) have focused on theoretically defined concent categories, while others (e.g., Laffal, 1969) have developed approaches to total content analysis of speech in psychotherapy. Although these individual studies are excellent in quality, as a whole they exemplify the unsystematic approach taken by process researchers, which has been noted in the literature (e.g., Auld & Murray, 1955; Marsden, 1965, 1971). Furthermore, despite the hope that such research would provide "a venerable technique of naturalistic documentary research (Marsden, 1971), naturalistic studies of the process of psychotherapy through an analysis of verbal behavior are scarce (Howard, Orlinsky, & Hill, 1969). The report on the therapeutic session (Orlinsky & Howard, 1966b) is a methodological procedure which allows a naturalistic examination of patiencs' verbal behavior, from the point of view of both participants of psychotherapy, the patient and the therapist. Employing this procedure, Howard, et al. (1969) 'An extended version of this article was submitted to Kent State University, Ohio, as partial fulfillment of the requirements for the degree of Master of Arts. The author wishes to exmess his indebtedness to Dr. Larry Killian and Mrs. Lorraine S. Saccuzzo for their genero& assistance. ?Requests for reprints should be sent to Dennis P. Saccuzzo, who is now at the Department of Psychology, San Diego State Universiry, San Diego, California 92182. 'This research was supported by a grant awarded to the author by Middle Tennessee Srate Universiry, Murfreesboro, Tennessee.
912
D. P. SACCUZZO
found the most frequently discussed topics in a population of female outpatients were relations with the opposite sex and hopes or fears about the future; the least often mentioned topics were religious feelings, strange or unusual ideas or experiences, and dreams or fantasies. Patients and therapists were quite similar in their reports of the frequency and underlying dimensions of the therapeutic dialogue. Howard, et al. (1969) concluded that the typical content of dialogue in psychotherapy, with middle-aged female outpatients, focuses predominantly on the outer or interpersonal sphere of the patient's experience, and least upon the inner or intrapersonal aspect. Like other investigators (e.g., Hariton & Singer, 1974), however, they cautioned that the generalizability of their results may be limited. In the present study, the generalizability of Howard, et al.'s ( 1969) analysis of verbal behavior in psychotherapy was extended by applying the Therapy Session Report to a college student population.
METHOD Instrument
The present study is part of a larger analysis of psychotherapeutic processes which employs a methodology analogous to the Psychotherapy Session Project (Orlinsky & Howard, 1966a). The Psychotherapy Session Project enlists both patients and therapists as participant-observer of a therapy session, through the use of two essentially parallel structured-response questionnaires, the Therapy Session Reporcs, Forms P and T (Orlinsky & Howard, 1966b). Both forms were designed for the patients of a midwestern out-patient mental health clinic but were slightly changed in the present study for use with college students. This consisted of breaking down item seven of the Therapy Session Reports, "Work, Career, and Education," into three separate items. The same methodology employed by Howard, et al. (1969) was utilized. Thus, both forms contain sections which survey the dialogue of a session. The patient form asks, "What did you talk about during this session?" The therapist form asks, "What subjects did your patient taLk about during this session?" In each form there follows a list of 20 topics reflecting different areas of life involvement and personal experience, and the participant is asked to circle a number after each to indicate the extent to which it was calked about ( 0 = No; 1 = Some; 2 = A lot). The actual items are shown in Table 1. Subjects
The data for this study were collected at the Kent State University Psychological Clinic. All 57 patients ( 2 4 males, 3 3 females) were undergraduates whose ages were between 18 snd 24. The majority, 47, referred themselves. The 19 therapist-subjects were clinical psychology graduate students working at the clinic as part of their training program. Some therapists saw as
VERBAL BEHAVIOR IN PSYCHOTHERAPY
913
many as eight of the client subjects; others saw as few as one. Of the therapists, two were female. Five had Mascer's degrees. For three instructional quarters, patients and therapists completed the Therapy Session Report Questionnaire as a regular part of the intake procedure. The length of the intake varied 30 min. to 2 hr., however, the mean and mode were both an hour. The therapist was not given feedback during the study.
Data Analysis A tally was made of the frequency of which subjects used the categories "No," "Some," and "A lot" for each item. Next, the items were incercorrelated and factor analyzed. In order to estimate the number of factors, a principal components analysis (Hotelling, 1933) was performed with unities in the major diagonals. The number of facrors with eigenvalues greater than or equal to one were thus determined (Kaiser's criterion). Then, Cattell's scree test (Catcell, 1966) was used to check the validity of the number of factors extracted. Because it is more harmful to underestimate than to overestirnace the number of factors extracted for analysis (Cooley & Lohnes, 1962), the plan was to choose the method, Kaiser or cattell, which resulted in the greatest-number of factors and to use that number of factors in the final factor analysis. Following the determination of the number of factors to retain, a principal axis analysis (Harman, 1960) was performed, specifying the appropriate number of faccors. Squared multiple Rs were used in the major diagonals as an original estimate of the communalities, and then new cornmunalities were determined by iteration. With the aim of finding the simple suucture of the faccors, the appropriate number of faccors were rotated by the Normal Varimax Method (Kaiser, 1958). Since parallel-structured questionnaires were used, Tucker's Congruence Coefficienc (Tucker, 1951) was also computed to compare the resulting factor matrices.
RESULTS AND DISCUSSION Table 1 shows the frequency of endorsement for each dialogue item for the two samples. Inspection of the frequencies reveals that patients typically discussed, "Relations with the opposite sex," "Mother," "Hopes or fears about the future," "Education," "Father," "Adolescence," "Relations with the same sex," "Brothers or sisters," and "Childhood memories and experiences." The least mentioned topics of dialogue were: "Feelings about being a parent," "Religious feelings and experiences," "Problems with money," "Household responsibilities or activities," and "Feelings about spouse or about being married." Factor analysis determined the underlying dimensions of the 20 dialogue items. The two methods used to determine the number of factors were in agree-
914
D. P. SACCUZZO
TABLE 1 FREQUENCY OF ENDORSEMENT FOR EACHTOPICOF DIALOGUE IN PSYCHOTHERAPY BY PATIENTS AND THERAPISTS Items No
1. My mother. 2. My father. 3. My brothers or sisters. 4. My childhood. 5. My adolescence. 6. Religious feelings or experiences. 7 . Work. 8. Career. 9. Education. 10. Relations with others of same sex. 11. Relations with opposite sex. 12. Problems with money. 13. Feelings about spouse or about being married. 14. Household responsibilities or acuvities. 15. Feelings about being a parent. 16. Bodily functions, symptoms, or appearance. 17. Strange or unusual ideas and experiences. 18. Hopes or fears about the ~ U N I ~ . 19. Dreams or fantasies. 20. Other.
Patients* Some A lot
No
8
37
9
15
17 5
23
4
37
12
31 13 37 30
17 27
Therapistst Some A lot
12
7
38
11
16
29 11
7 11 3 5
42 33
18
*N= 57. t N = 56. ment. The principal axis analysis indicated that the seven patient and seven therapist factors accounted for 50% and 60% of the total variance respectively. Table 2 shows Tucker's Congruence Coefficient comparing the two factor matrices. Tables 3 and 4 present the factor structure of dialogue for the patient and therapist samples respectively. The major loadings on Factor I, Parental Family, were almost identically constituted for both samples. The topics which defined both of these factors were: "Mother," "Father," "Brothers or sisters," "Childhood," and "Adolescence." Howard, et al. (1969), who found exactly the same factor suggests that: The theme tying these topics together seems to be a discussion of past experiences in the context of the patient's family of origin. This theme may indicate a search on the part of the patient for determinants or explanations of his present problems, as well as discussion of continuing familial relationships (pp. 399-400).
The major loadings on Factor I1 for both samples were identical.
VERBAL BEHAVIOR IN PSYCHOTHERAPY
915
TABLE 2
CONGRUENCECOEPPIC~ENT COMPARING FACTOR MATRICES*FOR PATIENTS AND THERAPISTS Patients I
I I1 I11 IV
V VI VII
I1
111
Therapists IV v
VI
VII
-5 1
-90 -83 -7 3
48 34
-33 75
41
-72
-3 7 -37
47
33 -37
*Decimals omitted. Only correlations above .3 ate included.
These items were "Education," and "Career." The theme tying these two items together seems to be a discussion of current and future life involvements. This factor was called Education and Career. Factor 111 for both samples was highly similar. Items which loaded high on both factors were: "Dreams or fantasies," and "Strange or unusual ideas and experiences." This dimension, Fantasy, was also found by Howard, e t 01. (1969). Also very similar was Factor IV. The items which loaded heavy on both of these factors were: "Feelings about being a spouse or about being married," "Household responsibilities or activities," and "Feelings about being a parent." This factor was called Domestic Affa:rs. The theme of domestic affairs and relationships suggests an exploration of the patient's adult marital and parental involvements. Factor V in both samples was again similar. The major loadings for this factor were: "Relations with the opposite sex," and "Relations with the same sex." The descriptive name given to this factor was Sex Relations. The high agreement in the factor structure breaks down at Factors VI and VII. Both of these factors, for patients as well as therapists, contain items appearing on other factors. Furthermore, none of these factors account for more than 10% of the common variance. Patient Factor VI was called Psychophysical Reactions, and therapist Factor VI Religion. Patient Factor VII was called Finance; therapist Factor VII was called Other. With the exception of concerns about educational involvements, the topics most frequently discussed by college student patients were highly similar to those topics discussed by middle-aged female outpatients. These topics primarily center around heterosexual involvements and hopes or fears about the future. The results and similarity between Howard, el a/. (1969) and the present study perhaps suggest the importance of heterosexual involvements and the future to middle-aged females and college student patients. On the other hand,
D. P. SACCUZZO TABLE 3 FACTOR STRUCTURE FOR PATIENT'S REPORTS OF THE DIALOGUEOF PSYCHOTHERAPY* Item No.
I
I1
I11
Factors IV
18 57 19 61 20 47 O/o Common ua 29 12 15 14 % Total d 1 5 6 7 7 "Decimals omitted. Only load~ngsabove .30 are shown.
ba
v
VI
VII
40 45 42 12 6
9 5
9 5
TABLE 4 FACTOR STRUCTUREFOR THERAPIST'SREPORTS OF THE DIALOGUEOF PSYCHOTHERAPY*: Item No. I
I1
I11
Factors IV
v
v1
LV
% Common
22 11 14 21 % Tocal o3 1 3 7 8 1 *Decimals omitted. Only loadings above .30 are shown. ua
12 10 2 6 6
ha VII
.10 8
..
VERBAL BEHAVIOR IN PSYCHOTHERAPY
917
in view of the possible influence of the therapist on patient verbal behavior (e.g., Matarazzo, et al., 1968) the similarity in categories found in the two studies may be due to the common interest of the therapist-subjects. In this case, the results of the present study may reflect the central importance given to heterosexual involvements and hopes or fears about the future by both experienced and inexperienced therapists. Nevertheless, whether they are brought up by pacients, therapists, or both, the empirical verification of the high frequency of occurrence of these topics increases the descriptive knowledge of psychotherapy. Since the purpose of the present study was to extend the generalizability of previous research, differences between the present and previous investigation may be of more importance than the similarities, at least insofar as these differences illustrate a point about process research in psychotherapy. It is now commonly accepted (e.g., Bergin, 1971; Paul, 1969) that it is fruitless to ask the question, "Is psychotherapy effective?" As Kiesler ( 1971) has noted, much of OLU research on the effectiveness of psychotherapy is ruined by "uniformity assumption myths." Despite recent methodological advances in evaluating the outcome of psychotherapy there has not been a similar effort to study the relevant variables as they relate to the process of psychotherapy. The proper question to be asked by researchers studying the process of psychotherapy is: "What are the underlying mechanisms of this treatmenr as practiced by that type of therapist for those kinds of patients and treatmenc goals, and why are these underlying mechanisms effective?" When a discovery is made about the process of psychotherapy it stands to reason, if our present treatment of the outcome question is correct, that this discovery does not apply to all patients, all therapists, all settings, and all therapy goals. The same need for specificity that exists for outcome research also exists for process research. I n view of the above discussion, even the analyses and generalizations of the present investigation are too broad. One of the limitations of the experimental approach, as it is conceptualized in psychology, however, is that it is neither practical nor feasible to study all variables simultaneously (e.g., Frank, 1971). Studies of the process of psychotherapy must, by necessity, begin with the general and move to the specific. Lazarus and Davison ( 1971) suggest the case study method as one way to begin a general analysis. A few more studies of the present type on different populations, e.g., inpatient veterans administration hospital, inpatient state hospital, outpatient community mental health center, would also constimte a general naturalistic analysis of verbal behavior in psychotherapy. Subsequent research must then become more specific, controlling or varying the variables which are known to be important, such as those related to the therapist (e.g., experience, sex, race, orientation, level of offered conditions), to the patient (e.g., sex, age, race, socio-economic back-
918
D. P. SACCUZZO
ground, IQ), to the setting (e.g., inpatient, outpatient), and to goals (e.g., personality reconstruction, specific behaviors). Analogue research, such as studies of linguistic phenomena and acoustic analysis, could be conducted simultaneously with, and compliment naturalistic examinations, with the path between the clinic and the laboratory a two-way street (Lazarus & Davison, 1971). Eventually, specific hypotheses could be tested by experimental designs which allow a determination of cause-effect relationships. If process research were to proceed in this fashion, it is likely chat basic questions about the nature of psychotherapy will be answered long before the final systematic study is completed. REFERENCES AULD,F., JR., & MURRAY,E. J. Content-analysis studies of psychotherapy. Psychologicd Bulletin, 1955, 52, 377-395. BERGIN,A. E. The evaluation of therapeutic outcomes. In A. E. Bergin & S. L. Garfield (Eds.), Handbook o f psychotherapy and behavior change. New York: Wiley, 1971. Pp. 217-270. BIRDWHISTELL, R. L. Paralanguage 25 years after Sapir. In H. W . Brosin (Ed.), Lectures on experimental psychiatry. Pittsburgh: Univer. of Pittsburgh, 1961. Pp. 43-63. CATTELL,R. B. The scree test for the number of factors. Multivariate Behavioral Research, 1966, 1, 245-276. COOLEY,W . W., & LOHNES, P. R. Multivariate procedures for the behlwioral sciences. New York: Wiley, 1962. D I ~ NA. ,T., & WYNNE,&. C. Linguistic techniques and the analysis of emotionality in interviews. Journal of Abnormal and Social Psychology, 1961, 63, 201-204. DOLLARD,J., & AULD, F., JR. Scoring human motives: a manual. New Haven: Yale Univer. Press, 1959. FRANK,G. H . The measurement of personality from the Wechsler tests. Progress in Experimental Personality Research, 1970, 5, 169-194. HARITON,E. B., & SINGER,J. L. Women's fantasies during sexual intercourse: normative and theoretical implications. Journal of Consulting and Clinical Psychology, 1974, 42, 313-322. HARMAN,H . D. Modern factor analysir. Chicago: Univer. of Chicago Press, 1960. HOTELLING,H. Analysis of a complex of statistical variables into principal components. Journal of Educational Psychology, 1933, 24, 417-441. HOWARD,K. I., ORLINSKY, D . E., & HILL, J. A. Content of dialogue in psychotherapy. Journal of Counseling Psychology, 1969, 16, 396-404. KAISER, H. F. The varimax criterion for analytic rotation in factor analysis. Psychometrika, 1958, 23, 187-200. KIESLER, D. L. Experimental designs in sychotherapy research. In A. E. Bergin & S. L. Garfield (Eds.), Handbook o f psychotherapy and behavior change. New York: Wiley, 1971. Pp. 36-74. LAFPAL,J. An approach to the total content analysis of speech in psychotherapy. In J. M. Shlien ( E d . ) , Research in psychotherapy. Vol. 3. Washington, D. C.: American Psychological Association, 1968. Pp. 277-294. LAZARUS,A. A,, & DAVISON, G. C. Clinical innovation in research and practice. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley, 1971. Pp. 196-213. MARSDEN,G. Content-analysis studies of therapeutic interviews: 1954 to 1964. Psychological Bulletin, 1965, 63, 298-321.
VERBAL BEHAVIOR IN PSYCHOTHERAPY
919
MARSDBN,G. Content-analysis studies of psychotherapy: 1954 through 1968. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley, 1971. Pp. 345-407. MATARAZZO,J. D., WIENS, A. N., MATARAZZO,R. G., & SASLOW,G. Speech and silence behavior in clinical psychotherapy and irs laboratory correlates. In J. M. Shlien (Ed.), Research in psychotherapy. Vol. 3. Washington, D. C.: American Psychological Association, 1968. Pp. 347-394. ORLINSKY, D. E., & HOWARD,K. I. T h e experience o f psychotherapy: a prospectus on the psychotherapy session project Chicago: Institute for Juvenile Research, 1966. (Research Report No. 3:8) ( a ) ORLINSKY, D. E., & HOWARD,K. I. Therapy session reports, Forms P and T . Chicago: Institute for Juvenile Research, 1966. ( b ) OSTWALD,P. F. Acoustic manifestations of emotional disturbance. In D . M. Rioch & E. A. Weinstein (Eds.), Disorders in communicatiofi. Vol. 42. Baltimore: Williams & Wilkins, 1964. Pp. 260-291. OSTWALD,P. R. A c o ~ ~ t imethods c in psychiatry. Scientific American, 1965, 212 ( 3 ) , 82-91. PAUL,G. L. Behavior modification research: design and tactics. In C. M. Franks (Ed.), Behavior therapy: ap@aisal and status. New York: McGraw-Hill, 1969. Pp. 29-62. SCHBPLIKN,A. E. Stream and structure o f communicational behavior. Commonwealth of Pennsylvania: Eastern Pennsylvania Psychiatric Institute, 1965. (Behavioral Studies Monograph No. 1 ) TUCKER,L. A. A method of synthesis of factor analysis personnel research section. Report for the Department of Army, Washington, D. C., 1958.
Accepted August 19, 1975.
NATURALISTIC ANALYSIS OF VERBAL BEHAVIOR IN PSYCHOTHERAPY DENNIS P. SACCUZZO1~"a
Middle Tennessee State Uniuersity Summary.-A parallel-response questionnaire, the Therapy Session Report, was administered to the 57 patients and 1 9 therapists of the Kent State Universiry Psychological Clinic immediately following each intake session. The purpose of the study was to provide normative data on the content of dialogue in psychotherapy and to extend the generalizability of previous results., Data analysis focused on the frequency, structure, and patient-therapist agreement of the topics discussed. Items most frequently endorsed by both patients and therapists were: "Relations with the opposite sex," "Mother," and "Hopes or fears about the future." Factor analysis resulted in 7 factors for therapists and 7 for patients, 5 of which were highly similar. Results were interpreted as underscoring the necessity of specificity in process research. A proposal for conducting process research is presented.
There are numerous approaches to the study of the process of psychotherapy through the analysis of verbal behavior. These approaches range from che study of linguistic or paralinguistic phenomena ( e.g., Birdwhistell, 1961; Dittman & Wynne, 1961; Scheflen, 1965), through acoustical analysis (e.g., Ostwald, 1964, 1965), and the scudy of other formal aspects of verbal processes (e.g., Matarazzo, Wiens, Matarazzo, & Saslow, 1968). Some researchers (e.g., Dollard 8: Auld, 1959) have focused on theoretically defined concent categories, while others (e.g., Laffal, 1969) have developed approaches to total content analysis of speech in psychotherapy. Although these individual studies are excellent in quality, as a whole they exemplify the unsystematic approach taken by process researchers, which has been noted in the literature (e.g., Auld & Murray, 1955; Marsden, 1965, 1971). Furthermore, despite the hope that such research would provide "a venerable technique of naturalistic documentary research (Marsden, 1971), naturalistic studies of the process of psychotherapy through an analysis of verbal behavior are scarce (Howard, Orlinsky, & Hill, 1969). The report on the therapeutic session (Orlinsky & Howard, 1966b) is a methodological procedure which allows a naturalistic examination of patiencs' verbal behavior, from the point of view of both participants of psychotherapy, the patient and the therapist. Employing this procedure, Howard, et al. (1969) 'An extended version of this article was submitted to Kent State University, Ohio, as partial fulfillment of the requirements for the degree of Master of Arts. The author wishes to exmess his indebtedness to Dr. Larry Killian and Mrs. Lorraine S. Saccuzzo for their genero& assistance. ?Requests for reprints should be sent to Dennis P. Saccuzzo, who is now at the Department of Psychology, San Diego State Universiry, San Diego, California 92182. 'This research was supported by a grant awarded to the author by Middle Tennessee Srate Universiry, Murfreesboro, Tennessee.
912
D. P. SACCUZZO
found the most frequently discussed topics in a population of female outpatients were relations with the opposite sex and hopes or fears about the future; the least often mentioned topics were religious feelings, strange or unusual ideas or experiences, and dreams or fantasies. Patients and therapists were quite similar in their reports of the frequency and underlying dimensions of the therapeutic dialogue. Howard, et al. (1969) concluded that the typical content of dialogue in psychotherapy, with middle-aged female outpatients, focuses predominantly on the outer or interpersonal sphere of the patient's experience, and least upon the inner or intrapersonal aspect. Like other investigators (e.g., Hariton & Singer, 1974), however, they cautioned that the generalizability of their results may be limited. In the present study, the generalizability of Howard, et al.'s ( 1969) analysis of verbal behavior in psychotherapy was extended by applying the Therapy Session Report to a college student population.
METHOD Instrument
The present study is part of a larger analysis of psychotherapeutic processes which employs a methodology analogous to the Psychotherapy Session Project (Orlinsky & Howard, 1966a). The Psychotherapy Session Project enlists both patients and therapists as participant-observer of a therapy session, through the use of two essentially parallel structured-response questionnaires, the Therapy Session Reporcs, Forms P and T (Orlinsky & Howard, 1966b). Both forms were designed for the patients of a midwestern out-patient mental health clinic but were slightly changed in the present study for use with college students. This consisted of breaking down item seven of the Therapy Session Reports, "Work, Career, and Education," into three separate items. The same methodology employed by Howard, et al. (1969) was utilized. Thus, both forms contain sections which survey the dialogue of a session. The patient form asks, "What did you talk about during this session?" The therapist form asks, "What subjects did your patient taLk about during this session?" In each form there follows a list of 20 topics reflecting different areas of life involvement and personal experience, and the participant is asked to circle a number after each to indicate the extent to which it was calked about ( 0 = No; 1 = Some; 2 = A lot). The actual items are shown in Table 1. Subjects
The data for this study were collected at the Kent State University Psychological Clinic. All 57 patients ( 2 4 males, 3 3 females) were undergraduates whose ages were between 18 snd 24. The majority, 47, referred themselves. The 19 therapist-subjects were clinical psychology graduate students working at the clinic as part of their training program. Some therapists saw as
VERBAL BEHAVIOR IN PSYCHOTHERAPY
913
many as eight of the client subjects; others saw as few as one. Of the therapists, two were female. Five had Mascer's degrees. For three instructional quarters, patients and therapists completed the Therapy Session Report Questionnaire as a regular part of the intake procedure. The length of the intake varied 30 min. to 2 hr., however, the mean and mode were both an hour. The therapist was not given feedback during the study.
Data Analysis A tally was made of the frequency of which subjects used the categories "No," "Some," and "A lot" for each item. Next, the items were incercorrelated and factor analyzed. In order to estimate the number of factors, a principal components analysis (Hotelling, 1933) was performed with unities in the major diagonals. The number of facrors with eigenvalues greater than or equal to one were thus determined (Kaiser's criterion). Then, Cattell's scree test (Catcell, 1966) was used to check the validity of the number of factors extracted. Because it is more harmful to underestimate than to overestirnace the number of factors extracted for analysis (Cooley & Lohnes, 1962), the plan was to choose the method, Kaiser or cattell, which resulted in the greatest-number of factors and to use that number of factors in the final factor analysis. Following the determination of the number of factors to retain, a principal axis analysis (Harman, 1960) was performed, specifying the appropriate number of faccors. Squared multiple Rs were used in the major diagonals as an original estimate of the communalities, and then new cornmunalities were determined by iteration. With the aim of finding the simple suucture of the faccors, the appropriate number of faccors were rotated by the Normal Varimax Method (Kaiser, 1958). Since parallel-structured questionnaires were used, Tucker's Congruence Coefficienc (Tucker, 1951) was also computed to compare the resulting factor matrices.
RESULTS AND DISCUSSION Table 1 shows the frequency of endorsement for each dialogue item for the two samples. Inspection of the frequencies reveals that patients typically discussed, "Relations with the opposite sex," "Mother," "Hopes or fears about the future," "Education," "Father," "Adolescence," "Relations with the same sex," "Brothers or sisters," and "Childhood memories and experiences." The least mentioned topics of dialogue were: "Feelings about being a parent," "Religious feelings and experiences," "Problems with money," "Household responsibilities or activities," and "Feelings about spouse or about being married." Factor analysis determined the underlying dimensions of the 20 dialogue items. The two methods used to determine the number of factors were in agree-
914
D. P. SACCUZZO
TABLE 1 FREQUENCY OF ENDORSEMENT FOR EACHTOPICOF DIALOGUE IN PSYCHOTHERAPY BY PATIENTS AND THERAPISTS Items No
1. My mother. 2. My father. 3. My brothers or sisters. 4. My childhood. 5. My adolescence. 6. Religious feelings or experiences. 7 . Work. 8. Career. 9. Education. 10. Relations with others of same sex. 11. Relations with opposite sex. 12. Problems with money. 13. Feelings about spouse or about being married. 14. Household responsibilities or acuvities. 15. Feelings about being a parent. 16. Bodily functions, symptoms, or appearance. 17. Strange or unusual ideas and experiences. 18. Hopes or fears about the ~ U N I ~ . 19. Dreams or fantasies. 20. Other.
Patients* Some A lot
No
8
37
9
15
17 5
23
4
37
12
31 13 37 30
17 27
Therapistst Some A lot
12
7
38
11
16
29 11
7 11 3 5
42 33
18
*N= 57. t N = 56. ment. The principal axis analysis indicated that the seven patient and seven therapist factors accounted for 50% and 60% of the total variance respectively. Table 2 shows Tucker's Congruence Coefficient comparing the two factor matrices. Tables 3 and 4 present the factor structure of dialogue for the patient and therapist samples respectively. The major loadings on Factor I, Parental Family, were almost identically constituted for both samples. The topics which defined both of these factors were: "Mother," "Father," "Brothers or sisters," "Childhood," and "Adolescence." Howard, et al. (1969), who found exactly the same factor suggests that: The theme tying these topics together seems to be a discussion of past experiences in the context of the patient's family of origin. This theme may indicate a search on the part of the patient for determinants or explanations of his present problems, as well as discussion of continuing familial relationships (pp. 399-400).
The major loadings on Factor I1 for both samples were identical.
VERBAL BEHAVIOR IN PSYCHOTHERAPY
915
TABLE 2
CONGRUENCECOEPPIC~ENT COMPARING FACTOR MATRICES*FOR PATIENTS AND THERAPISTS Patients I
I I1 I11 IV
V VI VII
I1
111
Therapists IV v
VI
VII
-5 1
-90 -83 -7 3
48 34
-33 75
41
-72
-3 7 -37
47
33 -37
*Decimals omitted. Only correlations above .3 ate included.
These items were "Education," and "Career." The theme tying these two items together seems to be a discussion of current and future life involvements. This factor was called Education and Career. Factor 111 for both samples was highly similar. Items which loaded high on both factors were: "Dreams or fantasies," and "Strange or unusual ideas and experiences." This dimension, Fantasy, was also found by Howard, e t 01. (1969). Also very similar was Factor IV. The items which loaded heavy on both of these factors were: "Feelings about being a spouse or about being married," "Household responsibilities or activities," and "Feelings about being a parent." This factor was called Domestic Affa:rs. The theme of domestic affairs and relationships suggests an exploration of the patient's adult marital and parental involvements. Factor V in both samples was again similar. The major loadings for this factor were: "Relations with the opposite sex," and "Relations with the same sex." The descriptive name given to this factor was Sex Relations. The high agreement in the factor structure breaks down at Factors VI and VII. Both of these factors, for patients as well as therapists, contain items appearing on other factors. Furthermore, none of these factors account for more than 10% of the common variance. Patient Factor VI was called Psychophysical Reactions, and therapist Factor VI Religion. Patient Factor VII was called Finance; therapist Factor VII was called Other. With the exception of concerns about educational involvements, the topics most frequently discussed by college student patients were highly similar to those topics discussed by middle-aged female outpatients. These topics primarily center around heterosexual involvements and hopes or fears about the future. The results and similarity between Howard, el a/. (1969) and the present study perhaps suggest the importance of heterosexual involvements and the future to middle-aged females and college student patients. On the other hand,
D. P. SACCUZZO TABLE 3 FACTOR STRUCTURE FOR PATIENT'S REPORTS OF THE DIALOGUEOF PSYCHOTHERAPY* Item No.
I
I1
I11
Factors IV
18 57 19 61 20 47 O/o Common ua 29 12 15 14 % Total d 1 5 6 7 7 "Decimals omitted. Only load~ngsabove .30 are shown.
ba
v
VI
VII
40 45 42 12 6
9 5
9 5
TABLE 4 FACTOR STRUCTUREFOR THERAPIST'SREPORTS OF THE DIALOGUEOF PSYCHOTHERAPY*: Item No. I
I1
I11
Factors IV
v
v1
LV
% Common
22 11 14 21 % Tocal o3 1 3 7 8 1 *Decimals omitted. Only loadings above .30 are shown. ua
12 10 2 6 6
ha VII
.10 8
..
VERBAL BEHAVIOR IN PSYCHOTHERAPY
917
in view of the possible influence of the therapist on patient verbal behavior (e.g., Matarazzo, et al., 1968) the similarity in categories found in the two studies may be due to the common interest of the therapist-subjects. In this case, the results of the present study may reflect the central importance given to heterosexual involvements and hopes or fears about the future by both experienced and inexperienced therapists. Nevertheless, whether they are brought up by pacients, therapists, or both, the empirical verification of the high frequency of occurrence of these topics increases the descriptive knowledge of psychotherapy. Since the purpose of the present study was to extend the generalizability of previous research, differences between the present and previous investigation may be of more importance than the similarities, at least insofar as these differences illustrate a point about process research in psychotherapy. It is now commonly accepted (e.g., Bergin, 1971; Paul, 1969) that it is fruitless to ask the question, "Is psychotherapy effective?" As Kiesler ( 1971) has noted, much of OLU research on the effectiveness of psychotherapy is ruined by "uniformity assumption myths." Despite recent methodological advances in evaluating the outcome of psychotherapy there has not been a similar effort to study the relevant variables as they relate to the process of psychotherapy. The proper question to be asked by researchers studying the process of psychotherapy is: "What are the underlying mechanisms of this treatmenr as practiced by that type of therapist for those kinds of patients and treatmenc goals, and why are these underlying mechanisms effective?" When a discovery is made about the process of psychotherapy it stands to reason, if our present treatment of the outcome question is correct, that this discovery does not apply to all patients, all therapists, all settings, and all therapy goals. The same need for specificity that exists for outcome research also exists for process research. I n view of the above discussion, even the analyses and generalizations of the present investigation are too broad. One of the limitations of the experimental approach, as it is conceptualized in psychology, however, is that it is neither practical nor feasible to study all variables simultaneously (e.g., Frank, 1971). Studies of the process of psychotherapy must, by necessity, begin with the general and move to the specific. Lazarus and Davison ( 1971) suggest the case study method as one way to begin a general analysis. A few more studies of the present type on different populations, e.g., inpatient veterans administration hospital, inpatient state hospital, outpatient community mental health center, would also constimte a general naturalistic analysis of verbal behavior in psychotherapy. Subsequent research must then become more specific, controlling or varying the variables which are known to be important, such as those related to the therapist (e.g., experience, sex, race, orientation, level of offered conditions), to the patient (e.g., sex, age, race, socio-economic back-
918
D. P. SACCUZZO
ground, IQ), to the setting (e.g., inpatient, outpatient), and to goals (e.g., personality reconstruction, specific behaviors). Analogue research, such as studies of linguistic phenomena and acoustic analysis, could be conducted simultaneously with, and compliment naturalistic examinations, with the path between the clinic and the laboratory a two-way street (Lazarus & Davison, 1971). Eventually, specific hypotheses could be tested by experimental designs which allow a determination of cause-effect relationships. If process research were to proceed in this fashion, it is likely chat basic questions about the nature of psychotherapy will be answered long before the final systematic study is completed. REFERENCES AULD,F., JR., & MURRAY,E. J. Content-analysis studies of psychotherapy. Psychologicd Bulletin, 1955, 52, 377-395. BERGIN,A. E. The evaluation of therapeutic outcomes. In A. E. Bergin & S. L. Garfield (Eds.), Handbook o f psychotherapy and behavior change. New York: Wiley, 1971. Pp. 217-270. BIRDWHISTELL, R. L. Paralanguage 25 years after Sapir. In H. W . Brosin (Ed.), Lectures on experimental psychiatry. Pittsburgh: Univer. of Pittsburgh, 1961. Pp. 43-63. CATTELL,R. B. The scree test for the number of factors. Multivariate Behavioral Research, 1966, 1, 245-276. COOLEY,W . W., & LOHNES, P. R. Multivariate procedures for the behlwioral sciences. New York: Wiley, 1962. D I ~ NA. ,T., & WYNNE,&. C. Linguistic techniques and the analysis of emotionality in interviews. Journal of Abnormal and Social Psychology, 1961, 63, 201-204. DOLLARD,J., & AULD, F., JR. Scoring human motives: a manual. New Haven: Yale Univer. Press, 1959. FRANK,G. H . The measurement of personality from the Wechsler tests. Progress in Experimental Personality Research, 1970, 5, 169-194. HARITON,E. B., & SINGER,J. L. Women's fantasies during sexual intercourse: normative and theoretical implications. Journal of Consulting and Clinical Psychology, 1974, 42, 313-322. HARMAN,H . D. Modern factor analysir. Chicago: Univer. of Chicago Press, 1960. HOTELLING,H. Analysis of a complex of statistical variables into principal components. Journal of Educational Psychology, 1933, 24, 417-441. HOWARD,K. I., ORLINSKY, D . E., & HILL, J. A. Content of dialogue in psychotherapy. Journal of Counseling Psychology, 1969, 16, 396-404. KAISER, H. F. The varimax criterion for analytic rotation in factor analysis. Psychometrika, 1958, 23, 187-200. KIESLER, D. L. Experimental designs in sychotherapy research. In A. E. Bergin & S. L. Garfield (Eds.), Handbook o f psychotherapy and behavior change. New York: Wiley, 1971. Pp. 36-74. LAFPAL,J. An approach to the total content analysis of speech in psychotherapy. In J. M. Shlien ( E d . ) , Research in psychotherapy. Vol. 3. Washington, D. C.: American Psychological Association, 1968. Pp. 277-294. LAZARUS,A. A,, & DAVISON, G. C. Clinical innovation in research and practice. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley, 1971. Pp. 196-213. MARSDEN,G. Content-analysis studies of therapeutic interviews: 1954 to 1964. Psychological Bulletin, 1965, 63, 298-321.
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MARSDBN,G. Content-analysis studies of psychotherapy: 1954 through 1968. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change. New York: Wiley, 1971. Pp. 345-407. MATARAZZO,J. D., WIENS, A. N., MATARAZZO,R. G., & SASLOW,G. Speech and silence behavior in clinical psychotherapy and irs laboratory correlates. In J. M. Shlien (Ed.), Research in psychotherapy. Vol. 3. Washington, D. C.: American Psychological Association, 1968. Pp. 347-394. ORLINSKY, D. E., & HOWARD,K. I. T h e experience o f psychotherapy: a prospectus on the psychotherapy session project Chicago: Institute for Juvenile Research, 1966. (Research Report No. 3:8) ( a ) ORLINSKY, D. E., & HOWARD,K. I. Therapy session reports, Forms P and T . Chicago: Institute for Juvenile Research, 1966. ( b ) OSTWALD,P. F. Acoustic manifestations of emotional disturbance. In D . M. Rioch & E. A. Weinstein (Eds.), Disorders in communicatiofi. Vol. 42. Baltimore: Williams & Wilkins, 1964. Pp. 260-291. OSTWALD,P. R. A c o ~ ~ t imethods c in psychiatry. Scientific American, 1965, 212 ( 3 ) , 82-91. PAUL,G. L. Behavior modification research: design and tactics. In C. M. Franks (Ed.), Behavior therapy: ap@aisal and status. New York: McGraw-Hill, 1969. Pp. 29-62. SCHBPLIKN,A. E. Stream and structure o f communicational behavior. Commonwealth of Pennsylvania: Eastern Pennsylvania Psychiatric Institute, 1965. (Behavioral Studies Monograph No. 1 ) TUCKER,L. A. A method of synthesis of factor analysis personnel research section. Report for the Department of Army, Washington, D. C., 1958.
Accepted August 19, 1975.
