Sot
Sri
&
Med.
Vol.
9. pp.
489
to 491
Perpmon
Press 1975
Primed m Great Bntam
RELATIONSHIP BETWEEN PSYCHOTHERAPY SKILLS AND LEVEL OF TRAINING IN A PSYCHIATRIC RESIDENCY PROGRAM A. JAMESFIX and E. A. HAFFKE Nebraska Psychiatric Institute, University of Nebraska College of Medicine, Omaha. NB 68106. U.S.A. Abstract-Five lst-year. six Znd-year. and six 3rd-year residents in psychiatry wrote responses to the Carkhuff (1969) communication scale. These were scored according to level of facilitative communication. shown in previous research to relate to patient progress in psychotherapy. The study failed to find expected superior skills in the advanced residents as compared to the novices. Consideration of providing specific training in facilitative communication is urged.
Throughout most of the history of psychotherapy. practitioners have been trained in the techniques to be applied to patients in treatment. This continues to a large degree despite the repeated failure to demonstrate empirically that specific techniques of psychotherapy have any differential effects on ultimate patient functioning [l-S]. The implication of the more recent outcome studies of psychotherapy most thoroughly presented by Berenson and Carkhuff [9] is that, if psychotherapy is effective at all, it is so only when the therapist is functioning at a high level on what Carkhuff and Berenson [lo] call the “facilitative dimensions” of communication. These researchers have given the following names to the factors they have isolated, and to these we have added brief defining statements. Respect. Conveying to the patient a sense of esteem and positive evaluation. (Objective ratings disclose that there are consistent differences among practitioners in their communication of a “respectful” attitude.) Empathy. Showing a full understanding of all the patient’s feelings, positive and negative. Self-disclosure. Allowing appropriate personal evaluations and experiences to illuminate the feelings and reflections of the patient. Genuineness. “Emotional honesty”, or the sincere communication of the therapist’s real emotional reactions Concreteness. The use of direct. non-abstract. understandable language. Confrontation. Pointing out differences between how the patient presents himself and how he is experienced by the therapist. (Confrontations can be positive or negative, but studies have found that positive confrontations are far more common from high-functioning. than low-functioning. therapists: “I know you are feeling down. and you’re thinking you’re not bright enough to compete with those other candidates; but I’ve seen you use a good deal of resourcefulness and inventiveness at times. I think I have always reacted to you as a bright person. even though I know the work will take a lot of effort.“~ These dimensions appear to underlie all forms of psychotherapy and account for a greater portion of the outcome than do the various techniques
employed. For example, a psychoanalytic therapist and a client-centered therapist would tend to elicit about the same amount of improvement in their patients as long as they functioned at nearly the same levels on these communicative dimensions. Most residency programs in psychiatry give thorough instruction in the various techniques and theoretical approaches to psychotherapy; but few, if any, provide a consistent program of training and assessment of the resident’s ability to communicate with his patients on these critical dimensions. Training for clinical psychology students is much the same in this regard. Evidence to date [l 1,123 shows that clinical psychology trainees actually tend to reduce their levels of effective communication as they progress through their training programs. This study was designed to evaluate communication levels of psychiatric residents at different stages of training to determine if more advanced residents achieve higher levels than less advanced. METHOD Seventeen residents in psychiatry at the Nebraska Psychiatric Institute responded to. the 16 taped patient expressions of feeling that comprise the Carkhuff [13] Communication Scale. Their responses were made under instructions to “write exactly what you would say to this patient at this time”. The responses were rated according to Carkhuffs and Berenson’s [I] criteria. RESULTS Scores on the Communication Scale could range from 0.0 to 5-O with intervals of 0.5. The midpoint, set at 3.0. corresponds to that level of counselor-functioning which has been associated with neither significant client improvement nor deterioration. Improvement is related to higher scores, deterioration to lower. The average scores for the present sample are found in Table 1. Comparisons between the groups were made via one-tailed t-tests. No significant difference was found between any two groups, indicating neither high nor lower facilitative communication associated
4 9
A. JAMES FIX and E. A. HAFFKE
190
indicating that responses to the CarkhutT Scale tend to indicate level of functioning in actual therapy sessions. And it could be argued. as Dublin [lh] does. Mean Carkhuff score . that the “medical stance” itself is “inherently antithetic to therapist self-disclosure (p. 407)“. or other forms Beginning residents (N = 5) 2.23 of ‘*communicative intimacy”. This “medical stance” Second-year residents (N = 6) 1.12 calls for emotional reserve and diagnostic acumen. Third-year residents (N = 6) 1.11 It discourages self evaluation and the communication Overall mean 2.15 of the physician’s immediate reactions to the patient. Perhaps most serious of all. the “medical stance” with level of experience in a psychiatric residency prosearches for pathology and focuses on a specific disorder while ignoring the manifest health in other gram. areas of the organism. For instance. the physician Normative scores for various segments of the population at large [14] were consulted to determine the asked to treat a broken finger does not exclaim. “Yes. residents’ comparative communicative functioning. but look how well your leg is functioning!” Yet in The mean score for persons in the general population the practice of psychiatry, it is often necessary to push having little knowledge of counseling or psychotherapy the patient to a recognition of the strengths and nonis approximately 1.6. For persons whose occupations pathological controls he possesses. Indeed. some include some counseling practices (i.e. teachers, psystudies [ 17,181 have shown that conselors who score chology graduate students, experienced counselors) high on the Carkhuff dimensions (and thus promote the mean scores range from 1.8 to 2.3. The overall higher improvement in their clients) tend more often mean from the present study, 2.15, compares favorato point to the strengths of their clients than do loa bly with these experienced groups, and is slightly scorers. It should be noted that no claims are made on above all but the “experienced counselors”. Therefore, the psychiatric residents of this sample are functionthe basis of this study that psychiatric residents fail ing above the untrained population at large, and equal to improve as therapists during their training. This to experienced counselors, although they still do not study simply failed to find evidence that such growth reach a level that has been shown to be related to was taking place. Because of the very small and posspositive patient change. ibly unrepresentative, number of residents surveyed. these results are quite tentative although consistent with findings from clinical psychology training proCONCLUSIONS grams. They should be taken only to stimulate thought as to whether specific training in facilitative This study found no relationship between level of training and psychotherapy skills in a small sample therapeutic communication should be incorporated of psychiatric residents. Only a longitudinal study can into psychiatric residency programs. determine if individual communicative levels change during a residency program or if the current results reflect a lack of improvement in psychotherapeutic REFERENCES skills during training. However. these lend no support : an evaluaI. Eysenck H. J. The effects of psychotherapy to an assumption that psychiatric residency training, tion. J. consult. Psvchol. 16. 319, 1952. as currently practiced. improves competence in psyIn 7% 2. Eysenck H. J. The effects of psychotherapy. chotherapeutic skills. Handbook of Abnormal Psychology (edited by Eysenck Objective tests and Board examinations show H. J.). Basic Books, New Yprk. 1960. clearly that the psychiatric resident increases acaEysenck H. J. The effects of psychotheraphy. fnt. J. demic. theoretical and medical knowledge greatly Psychother. 1, 99, 1965. during his residency. Until recently, objective meaLevitt E. E. The results of psychotherapy with children. sures of psychotherapeutic skills have not been availJ. consult. Psycho/. 21, 189, 1957. Levitt E. E. Psychotherapy with children: a further able; therefore, evaluation of the resident’s perforevaluation. Behav. Res. Ther. 1, 45. 1963. mance in this critical area has been subjective and Fiedler R. E. Quantitative studies on the role of theraimpressionistic. Often it has been inferred from the pists’ feelings toward their patients. In P.s~~chotherapy measured growth in academic knowledge that psyTheorv and Research (edited by Mowrer 0. H.) pp. chotherapeutic skills likewise increase. Other investi1963jS. Ronald Press: New Y&k, 1953. gations [ 11.151 have shown these two areas of develof 7. Fielder F. E. A method of objective quantification opment to be unrelated. or in some populations. incertain counter transference condittons. J. clin. Psvversely related. chol. 7, 101. 1951. It could be contended that this test did not adequa8. Fiedler F. E. A comparison of therapeutic relationships in osvchoanalvtic. non-directive and Adlerian therapy. tely reflect “real” therapeutic skills or actual behavior J. ;ohsult. Ps;chol. 14. 436. 1950. in therapy sessions. Residents may respond differently 9. Berenson B. G. and Carkhuff R. R. Sources of’ Guiri on this test than they might in a “real” session due Table
1. Mean
rating
of therapist responses sttmulus items
to Carkhuff
to a desire to demonstrate their “knowledge” and “competence” rather than displaying their emotional selves. In support of this was the observation that most of the responses to the stimulus items were pedantic, theoretical, or very cautious (e.g. seeking more information). On the other hand. the literature is consistent in
in Counseling and Therapy. Holt. Rinehart & W’inston. New York, 1967. IO. Carkhuff R. R. and Berenson B. G. Beyond Counseling and Therapy. Holt. Rinehart & Winston. New York. 1967. I I. Bergin A. and Solomon S. Personality and performance correlates of empathic understanding m psychotherapy. Anl. Psycho/. 18, 393. 1963.
A psychiatric residency program 12. Carkhuff R. R.. Kratochvil D. and Friel T. The effects of graduate training. J. corrnsel. Psgchol. 15. 6X. 196X. 13. Carkhuff R. R. Help&~ UII~ Humatr Relationships. Holt. Rinehart & Winston. New York. 1969. 14. Carkhuff R. R. Beyond Counsrlirtq arld Therapy. Holt. Rinehart & Winston. New York. 1967. 15. Anthony W. and CarkhufT R. R. The effects of professional training in rehabilitation counseling. J. Counsel. Psychol. In Press.
491
16. Dublin J. E. A further motive for psychotherapists: communicative intimacy. Pspchiat. 34. 401, 1971. 17. Mitchell K. M. and Berenson B. G. Differential use of confrontation by high and low facilitative therapists. .I. nerr. ment. Dis. 15, 303. 1970. 18. Mitchell K. M. and Hall L. A. Frequency and type of confrontation over time within the first therapy interview. J. consult. clin. Psycho/. 31. 437. 1971.
Sri
&
Med.
Vol.
9. pp.
489
to 491
Perpmon
Press 1975
Primed m Great Bntam
RELATIONSHIP BETWEEN PSYCHOTHERAPY SKILLS AND LEVEL OF TRAINING IN A PSYCHIATRIC RESIDENCY PROGRAM A. JAMESFIX and E. A. HAFFKE Nebraska Psychiatric Institute, University of Nebraska College of Medicine, Omaha. NB 68106. U.S.A. Abstract-Five lst-year. six Znd-year. and six 3rd-year residents in psychiatry wrote responses to the Carkhuff (1969) communication scale. These were scored according to level of facilitative communication. shown in previous research to relate to patient progress in psychotherapy. The study failed to find expected superior skills in the advanced residents as compared to the novices. Consideration of providing specific training in facilitative communication is urged.
Throughout most of the history of psychotherapy. practitioners have been trained in the techniques to be applied to patients in treatment. This continues to a large degree despite the repeated failure to demonstrate empirically that specific techniques of psychotherapy have any differential effects on ultimate patient functioning [l-S]. The implication of the more recent outcome studies of psychotherapy most thoroughly presented by Berenson and Carkhuff [9] is that, if psychotherapy is effective at all, it is so only when the therapist is functioning at a high level on what Carkhuff and Berenson [lo] call the “facilitative dimensions” of communication. These researchers have given the following names to the factors they have isolated, and to these we have added brief defining statements. Respect. Conveying to the patient a sense of esteem and positive evaluation. (Objective ratings disclose that there are consistent differences among practitioners in their communication of a “respectful” attitude.) Empathy. Showing a full understanding of all the patient’s feelings, positive and negative. Self-disclosure. Allowing appropriate personal evaluations and experiences to illuminate the feelings and reflections of the patient. Genuineness. “Emotional honesty”, or the sincere communication of the therapist’s real emotional reactions Concreteness. The use of direct. non-abstract. understandable language. Confrontation. Pointing out differences between how the patient presents himself and how he is experienced by the therapist. (Confrontations can be positive or negative, but studies have found that positive confrontations are far more common from high-functioning. than low-functioning. therapists: “I know you are feeling down. and you’re thinking you’re not bright enough to compete with those other candidates; but I’ve seen you use a good deal of resourcefulness and inventiveness at times. I think I have always reacted to you as a bright person. even though I know the work will take a lot of effort.“~ These dimensions appear to underlie all forms of psychotherapy and account for a greater portion of the outcome than do the various techniques
employed. For example, a psychoanalytic therapist and a client-centered therapist would tend to elicit about the same amount of improvement in their patients as long as they functioned at nearly the same levels on these communicative dimensions. Most residency programs in psychiatry give thorough instruction in the various techniques and theoretical approaches to psychotherapy; but few, if any, provide a consistent program of training and assessment of the resident’s ability to communicate with his patients on these critical dimensions. Training for clinical psychology students is much the same in this regard. Evidence to date [l 1,123 shows that clinical psychology trainees actually tend to reduce their levels of effective communication as they progress through their training programs. This study was designed to evaluate communication levels of psychiatric residents at different stages of training to determine if more advanced residents achieve higher levels than less advanced. METHOD Seventeen residents in psychiatry at the Nebraska Psychiatric Institute responded to. the 16 taped patient expressions of feeling that comprise the Carkhuff [13] Communication Scale. Their responses were made under instructions to “write exactly what you would say to this patient at this time”. The responses were rated according to Carkhuffs and Berenson’s [I] criteria. RESULTS Scores on the Communication Scale could range from 0.0 to 5-O with intervals of 0.5. The midpoint, set at 3.0. corresponds to that level of counselor-functioning which has been associated with neither significant client improvement nor deterioration. Improvement is related to higher scores, deterioration to lower. The average scores for the present sample are found in Table 1. Comparisons between the groups were made via one-tailed t-tests. No significant difference was found between any two groups, indicating neither high nor lower facilitative communication associated
4 9
A. JAMES FIX and E. A. HAFFKE
190
indicating that responses to the CarkhutT Scale tend to indicate level of functioning in actual therapy sessions. And it could be argued. as Dublin [lh] does. Mean Carkhuff score . that the “medical stance” itself is “inherently antithetic to therapist self-disclosure (p. 407)“. or other forms Beginning residents (N = 5) 2.23 of ‘*communicative intimacy”. This “medical stance” Second-year residents (N = 6) 1.12 calls for emotional reserve and diagnostic acumen. Third-year residents (N = 6) 1.11 It discourages self evaluation and the communication Overall mean 2.15 of the physician’s immediate reactions to the patient. Perhaps most serious of all. the “medical stance” with level of experience in a psychiatric residency prosearches for pathology and focuses on a specific disorder while ignoring the manifest health in other gram. areas of the organism. For instance. the physician Normative scores for various segments of the population at large [14] were consulted to determine the asked to treat a broken finger does not exclaim. “Yes. residents’ comparative communicative functioning. but look how well your leg is functioning!” Yet in The mean score for persons in the general population the practice of psychiatry, it is often necessary to push having little knowledge of counseling or psychotherapy the patient to a recognition of the strengths and nonis approximately 1.6. For persons whose occupations pathological controls he possesses. Indeed. some include some counseling practices (i.e. teachers, psystudies [ 17,181 have shown that conselors who score chology graduate students, experienced counselors) high on the Carkhuff dimensions (and thus promote the mean scores range from 1.8 to 2.3. The overall higher improvement in their clients) tend more often mean from the present study, 2.15, compares favorato point to the strengths of their clients than do loa bly with these experienced groups, and is slightly scorers. It should be noted that no claims are made on above all but the “experienced counselors”. Therefore, the psychiatric residents of this sample are functionthe basis of this study that psychiatric residents fail ing above the untrained population at large, and equal to improve as therapists during their training. This to experienced counselors, although they still do not study simply failed to find evidence that such growth reach a level that has been shown to be related to was taking place. Because of the very small and posspositive patient change. ibly unrepresentative, number of residents surveyed. these results are quite tentative although consistent with findings from clinical psychology training proCONCLUSIONS grams. They should be taken only to stimulate thought as to whether specific training in facilitative This study found no relationship between level of training and psychotherapy skills in a small sample therapeutic communication should be incorporated of psychiatric residents. Only a longitudinal study can into psychiatric residency programs. determine if individual communicative levels change during a residency program or if the current results reflect a lack of improvement in psychotherapeutic REFERENCES skills during training. However. these lend no support : an evaluaI. Eysenck H. J. The effects of psychotherapy to an assumption that psychiatric residency training, tion. J. consult. Psvchol. 16. 319, 1952. as currently practiced. improves competence in psyIn 7% 2. Eysenck H. J. The effects of psychotherapy. chotherapeutic skills. Handbook of Abnormal Psychology (edited by Eysenck Objective tests and Board examinations show H. J.). Basic Books, New Yprk. 1960. clearly that the psychiatric resident increases acaEysenck H. J. The effects of psychotheraphy. fnt. J. demic. theoretical and medical knowledge greatly Psychother. 1, 99, 1965. during his residency. Until recently, objective meaLevitt E. E. The results of psychotherapy with children. sures of psychotherapeutic skills have not been availJ. consult. Psycho/. 21, 189, 1957. Levitt E. E. Psychotherapy with children: a further able; therefore, evaluation of the resident’s perforevaluation. Behav. Res. Ther. 1, 45. 1963. mance in this critical area has been subjective and Fiedler R. E. Quantitative studies on the role of theraimpressionistic. Often it has been inferred from the pists’ feelings toward their patients. In P.s~~chotherapy measured growth in academic knowledge that psyTheorv and Research (edited by Mowrer 0. H.) pp. chotherapeutic skills likewise increase. Other investi1963jS. Ronald Press: New Y&k, 1953. gations [ 11.151 have shown these two areas of develof 7. Fielder F. E. A method of objective quantification opment to be unrelated. or in some populations. incertain counter transference condittons. J. clin. Psvversely related. chol. 7, 101. 1951. It could be contended that this test did not adequa8. Fiedler F. E. A comparison of therapeutic relationships in osvchoanalvtic. non-directive and Adlerian therapy. tely reflect “real” therapeutic skills or actual behavior J. ;ohsult. Ps;chol. 14. 436. 1950. in therapy sessions. Residents may respond differently 9. Berenson B. G. and Carkhuff R. R. Sources of’ Guiri on this test than they might in a “real” session due Table
1. Mean
rating
of therapist responses sttmulus items
to Carkhuff
to a desire to demonstrate their “knowledge” and “competence” rather than displaying their emotional selves. In support of this was the observation that most of the responses to the stimulus items were pedantic, theoretical, or very cautious (e.g. seeking more information). On the other hand. the literature is consistent in
in Counseling and Therapy. Holt. Rinehart & W’inston. New York, 1967. IO. Carkhuff R. R. and Berenson B. G. Beyond Counseling and Therapy. Holt. Rinehart & Winston. New York. 1967. I I. Bergin A. and Solomon S. Personality and performance correlates of empathic understanding m psychotherapy. Anl. Psycho/. 18, 393. 1963.
A psychiatric residency program 12. Carkhuff R. R.. Kratochvil D. and Friel T. The effects of graduate training. J. corrnsel. Psgchol. 15. 6X. 196X. 13. Carkhuff R. R. Help&~ UII~ Humatr Relationships. Holt. Rinehart & Winston. New York. 1969. 14. Carkhuff R. R. Beyond Counsrlirtq arld Therapy. Holt. Rinehart & Winston. New York. 1967. 15. Anthony W. and CarkhufT R. R. The effects of professional training in rehabilitation counseling. J. Counsel. Psychol. In Press.
491
16. Dublin J. E. A further motive for psychotherapists: communicative intimacy. Pspchiat. 34. 401, 1971. 17. Mitchell K. M. and Berenson B. G. Differential use of confrontation by high and low facilitative therapists. .I. nerr. ment. Dis. 15, 303. 1970. 18. Mitchell K. M. and Hall L. A. Frequency and type of confrontation over time within the first therapy interview. J. consult. clin. Psycho/. 31. 437. 1971.
