What Is Psychotherapy? Proc. 9th Int. Congr. Psychother., Oslo 1973 Psychother. Psychosom. 25: 229-235 (1975)
Outcome Criteria in Psychotherapy Research Cavin P. Leerrnn
This paper describes and illustrates the criteria by which we assess the outcome of each patient’s treatment. I should like to emphasize that the appli cability of these criteria is not limited to short-term anxiety-provoking psycho therapy. They were formulated and developed in a preliminary study utilizing a heterogeneous group of patients treated at the Beth Israel Hospital Outpatient Psychiatric Clinic. These patients underwent a variety of forms of psychother apy: individual long-term exploratory psychotherapy, individual short-term psychotherapy of various sorts, and couples psychotherapy. It is our hope that these outcome criteria will provide a framework within which not only to an swer the question — Does psychotherapy work? (once it is specified what type of therapy for what kind of patients) —but also to compare in a meaningful way the results of various forms of psychiatric treatment. Too often such compar isons, as well as comparisons between treated patients and untreated controls, have been made without explicit criteria for assessing outcomes. Our first outcome criterion is change in the patient's symptoms. We do not assume that change in symptoms necessarily demonstrates change in underlying psychopathology, but symptom change is a simple index of the patient’s com fort or discomfort. A careful review of symptoms is made before and after treatment. In follow-up examination, this review includes not only the presence or absence of the initial symptoms and of any new symptoms, but also the intensity of the symptoms, the degree to which they impinge on the patient’s life, and the patient’s attitude about them. The tendency of many psychiatric symptoms to remit spontaneously is well-known, and it is our impression that symptom-change will not prove to be the most useful criterion with which to demonstrate the effectiveness of psychotherapy. The patient’s attitude about his symptoms may change, however, as part of a more general change in his ap proach to the problems of living.
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
Boston University School of Medicine and Framingham Union Hospital, Framingham, Mass.
Leeman
(542) 230
A young woman, whom I will call Laura, who was treated for anxiety, told us ‘1 have the same symptoms I always did, but much less severe. ... 1 realize that my anxiety is like an alarm, telling me that I’m not facing something ... so I try to find out what’s disturbing me. I don’t get as annoyed with the anxiety as I used to.’ The patient first reported this change in the post-treatment evaluation 3 weeks after the conclusion of a 4-month course of therapy, and mentioned it again in a follow-up interview 2 years later, so that we know that the change was a lasting one. This result is not unusual in our experience.
I already have referred to the frequently noted phenomenon of spontaneous remission of symptoms. A classic example is offered by a case that may be aprocryphal, but which may shed some light on the meaning of ‘spontaneous remission’. A young woman developed phobic symptoms when her boy friend proposed marriage. When she came for help, she was apprehensive, and uncertain whether to accept the pro posal. She did not enter treatment, and was not heard from again until a follow-up inquiry several years later revealed her to be entirely free of symptoms. She had not married, she was working as a secretary in a nunnery, and she had not dated anyone since breaking off with her original boy friend. Quite apart from the question of values - of religious devotion versus heterosexual relationships - it is not very meaningful to put into the same category with respect to outcome, this asymptomatic secretary and her hypothetical twin sister who has become equally free of the same initial symptoms; but who also is happily married, raising two children, developing a part-time career, and enjoying several close friendships with men and women. The second sister is comfortable with several kinds of interpersonal relations, and finds them gratifying, while the first sister’s symptomatic relief clearly seems to have been achieved at the sacrifice of heterosexual relationships.
Because of the crucial importance of interpersonal relations in characteriz ing the quality of people’s lives, change in interpersonal relations is our second outcome criterion, and the pretreatment assessment of each patient includes a careful examination of all the significant interpersonal relationships in his life. Based on this review, a judgement is made as to the specific disturbance in the patient’s interpersonal relations.
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
For example, Laura, the young woman who learned to regard her anxiety as an alarm, initially had complained of difficulties with her boy friend. He made demands on her which she felt she had to satisfy. She was afraid that if she disappointed him she would lose him. At the same time, she involved her father in her conflict, coloring what she told him so as to provoke his hostility to the boy friend. She was afraid of losing her father’s love if she got more involved with the boy friend, so she really couldn’t move in either direction. By the time Laura’s treatment ended, she had broken off with her boy friend, and had begun a different kind of relationship with another young man, with whom she found she could be much more outspoken about her own wishes. As it turned out, this relationship was short lived, but at the time of the 2-year follow-up, the patient was about to marry a man she had known for more than a year. As she described their relationship, a picture emerged of mutual love, emotional intimacy, and respect, that clearly was quite different from anything in the patient’s prior experience.
Outcome Criteria in Psychotherapy Research
(543) 231
I turn now to our third criterion, change in what we call ‘specific predisposi tion’, a term introduced by Dr. David Malan of the Tavistock Clinic in London. The reason this criterion is important is that not only can some patients achieve symptomatic relief at the expense of interpersonal relations, like the convent secretary, but others can manage both symptomatic relief and improvement in interpersonal relations, provided an environmental support is given.
Dr. Malan's concept of specific predisposition, that aspect of a patient’s personality that underlies both his symptoms and his interpersonal difficulties, helps in interpreting the changes observed. We define ‘specific predisposition’ as the patient’s vulnerability, determined by the convergence of genetic and experi ential factors, to react to stress in a maladaptive way, through the development of symptoms and/or disturbances in interpersonal relations. For example, Mrs. Jordan’s specific predisposition was overdependence, which remained unchanged. By pointing this out, we do not mean to denigrate the other improvements in her life. Certainly psychotherapy does not always modify a patient’s specific predisposition, and often this kind of change is not even attempted. But when it is achieved, it is a significant result of treatment, because in a crucial sense it makes the patient less vulnerable to the vicissitudes of external events. It is important, therefore, to distinguish change in predisposition from other kinds of change. The fourth criterion is gain in self-understanding, which we assess by asking tlie patient to explain what was wrong with him and how it has changed. Self understanding, or insight, is closely bound to the verbal ability of the patient. In assessing the other criteria, we utilize the patient’s report of his experience, which we integrate in ways that are meaningful to us. But we have no way of distinguishing the patient’s understanding of himself from his ability to convey this understanding to the interviewer. In this instance we ask him what he understands, and we must rely on his ability to integrate. But perhaps this is not
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
An example of this from our own clinic is the case of Mrs. Jordan, who complained of anxiety, depression, and difficulties in her relationships to her husband and her daughter. Initial evaluation revealed an unresolved hostile-dependent relationship with her mother. When seen later, Mrs. Jordan felt better, her self-esteem had risen, and she was getting along better with both her husband and her daughter. It turned out that she had taken a lover, who appeared to be gratifying her dependency needs. Incidentally, Mr. Jordan, who also had sought help for marital difficulties, reported great improvement from his point of view as well. He knew nothing of his wife’s affair, and he felt that he and his wife had become much closer and more open with one another. In assessing the whole situation, we recognized both Mrs. Jordan’s symptomatic improvement and the improvement in her interpersonal rela tions; yet we considered that in another way Mrs. Jordan had remained essentially un changed. She still was a dependent person, but the availability of a new person to depend upon had relieved both her symptoms and the tensions within her family. The source of the changes thus was primarily outside Mrs. Jordan, rather than within her own psychic makeup.
Leeman
(544) 232
I already have referred to Laura, who came to the clinic complaining of anxiety, some depression, and difficulties in her relationships with men, especially her current boy friend. She was 22 years old and in her final year of college. She was apprehensive about her future, but her symptoms were of much longer duration than the stress of imminent graduation. In fact, she dated their onset to early adolescence, shortly after her menarche. At first she said that her childhood had been happy, and that she always had been close to her parents. On further questioning, however, it turned out that a younger sister had been born when the patient was 4 years old. She felt that she had lost her special place in the family at that time, since both of her parents had become much more involved with the new baby than with the patient. Competition with her sister was intense, and the patient felt that somehow her mother promoted it. During 4 months of once-a-week treatment the patient realized that her father was the object of much of this competition, which colored the patient’s relation with her mother, as well as with her sister. She felt that she never again achieved the special place in her father’s affections that she thought she had enjoyed before her sister was born, and that she continued to long for. As she grew up, her father was rather distant from the family. Her earliest memory, dated shortly after her sister’s birth, was of being left alone by her father, crying miserably, while he went across the street to buy food. The patient recognized that her clinging dependency on her boy friend was related to her sense that she had lost her father. Her self-esteem improved, and she gained more respect for her own opinions. She felt less panicky and indulged in fewer and less-severe eating binges. The marked change in the quality of her relationships with men has been mentioned earlier. After treatment she said that she had come to recognize that her symptoms occurred either when she felt abandoned or was afraid that she might be; that this was related to the events in her family when she was 4 years old; and that she recognized that she had longed ever since then to regain a special place in her father’s affection. To do so, however, would mean stealing him from mother, and this idea scared her.
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
such a serious drawback. Psychotherapy, after all, is a verbal treatment, and we should like to learn something about the degree to which its effectiveness in producing other kinds of change depends upon the development of self-understanding and the ability to verbalize insightfully. Finally, we examine changes in the patient's problem-solving ability. Dr. Sifneos's previous work with short-term anxiety-provoking psychotherapy showed that patients in treatment can learn new ways of solving emotional problems. As the therapist and the patient work together to define and to solve a critical problem in the patient’s life, the therapist stimulates the patient’s inter est in approaching problems in a thoughtful, self-examining way. The patient’s success with one problem often leads to his tackling other problems in the same manner on his own. If the patient really has learned new problem-solving skills, he should be able to use them in solving emotional problems that arise after the termination of his treatment. The post-treatment assessment of gains in problem-solving ability therefore relies heavily on specific examples provided by the patient from his own experience during and after therapy. Specific documen tation is crucial. To make all of these issues clearer, I should like to discuss some clinical examples, selected from the more than 20 patients whom we have studied and treated so far.
Outcome Criteria in Psychotherapy Research
(545) 233
I should like to summarize our pre- and post-treatment assessment of this patient, Laura: Symptoms. Anxiety and depression, with panicky feelings, stomach aches, and binges of overeating, related to situations of actual, anticipated, or imagined abandonment. Scored as somewhat better immediately after treatment and at 2-year follow-up. Symptoms still present, but diminished in intensity, and patient’s attitude about them changed. Interpersonal relations. Problems with boy friends; overly dependent and compliant out of fear of being abandoned. Scored as somewhat better immediately after treatment. Patient more outspoken and less afraid to express her own feelings. At 2-year follow-up scored as much better. Gratifying heterosexual relationship involving mutual respect and intimacy, duration already more than 1 year with plan to be married in 2 months’ time. Specific predisposition. At age 4 lost special place in family to younger sister; conse quent long-standing wish to regain father for herself by replacing both mother and sister made it impossible for patient to form a mature heterosexual relationship outside the family; sensitivity to abandonment even by unsatisfactory men made her overly dependent and compliant. Scored as somewhat better immediately after treatment and at 2-year follow-up, based on increased independence from parents as well as on change in relations outside the family. Patient still seems angry at people who she feels let her down, such as parents, previous boy friends, therapist; and afraid of expressing it. Subsequent follow-ups will permit evaluation of this factor, especially in patient’s marriage. Self-understanding. The patient explained the connection between her symptoms, her relationships with her boy friends, and her childhood relationships within the family. Scored as much improved in self-understanding. Problem-solving. Scored as much improved, based on separations from two unsatisfac tory boy friends and good relationship with fiance. Using residual anxiety symptoms as signals for self-exploration, and trying to learn more about her fear of expressing anger. (The issue of anger apparently had not been discussed during treatment.)
The next case, on which we also have a 2-year follow-up, introduces one of the complications with which we have had to contend in assessing therapeutic outcome. The patient entered marital counseling some months after her therapy at our clinic, so that it has become important to try to tease out the changes attributable to the two kinds of treatment. In discussing this example I also will try to illustrate how, in the pretreatment assessment, we individualize the out come criteria for each patient.
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
The overall outcome of Laura’s treatment was very favorable. She was much improved in interpersonal relations, self-understanding, and problem-solving. Symptomatic improve ment was only partial, which is not unusual for this type of treatment, but the patient’s attitude about her symptoms was very different. Only our very stringent standards for assessing change in predisposition prevent our scoring her as much improved on this crite rion. There is no doubt about her general progress, her self-esteem was greatly increased, and she expressed gratitude to the clinic.
I.eeman
(546) 234
Mrs. Robertson, a married woman in her mid-twenties, working as a psychologist, came to the clinic with the specific chief complaint: ‘My anger is interfering with my work.’ She suffered from anxiety, muscular tension, and fluctuating overweight; and also complained of an angry relationship with her husband, with no sexual intercourse for several months. She was getting along poorly at work because of her difficulty in accepting criticism from her female supervisors. Her past history revealed that she had been very much attached to her father until age 8, when her sister was born, who the patient feels displaced her in her father’s affection. She expressed considerable bitterness toward her father, whom she por trayed as a rigid, provocative person. Mother appeared to have been unavailable emotionally; she expected the patient to care for the two younger siblings. Before starting treatment, we postulated the predisposition as follows: Mrs. Robert son’s resentment toward her father, which began when he turned to her sister, served to mask her continued longing for him; she married a passive man, in contrast to her father, then became angry at him for not being more like her father, while her continued emotional involvement with father sensitized her to criticism from older women. Our specific criteria for recovery, and the findings after the completion of therapy, ten sessions, once-a-week, are: Symptoms. Anger and anxiety should diminish markedly (which they did); and the patient should achieve a stable, appropriate weight (her weight had not changed by the end of treatment, but she had begun to diet). Interpersonal relations. Improved relationship with husband, including satisfactory sexual relations; decreased sensitivity to criticism from women. (The actual findings in cluded a much better relationship with her husband. The patient had become more sympa thetic to him, and more understanding of his aspirations and difficulties. The Robertsons had resumed sexual relations, which were predominantly satisfying, although Mrs. Robert son still had not achieved orgasm. She was more productive at work, where she had a better relationship to her supervisors, and was much less sensitive to criticism. She also had become more deeply involved in other relationships, both social relationships with friends, and work relationships with clients.)
Mrs. Robertson also showed impressive gains in self-understanding and in problem solving technique. Therefore we initially scored Mrs. Robertson’s treatment as highly suc cessful on all counts. At 2-year follow-up the patient had become still more productive at work, her marriage had improved further (following a stormy period during which she and her husband consulted a marriage counselor), and the patient’s sexual relations now regu larly included orgasm. To what extent are these changes attributable to the short-term psychotherapy, and to what extent to the marital counseling? Judging by the gains apparent immediately after treatment, our opinion is that the initial therapy was crucial. It began a process that the patient continued afterwards. She said in the 2-year follow-up interview that the marital counseling had helped her to apply to her marriage the insights that she had achieved in therapy. She also reported that her husband had changed as a result of the
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
Specific predisposition. Improved relationships with parents. (At the conclusion of her treatment, Mrs. Robertson reported that she felt more comfortable with her parents, and much less angry at her father, with whom she had had a long, fond conversation. This was unprecedented during her adult life.)
Outcome Criteria in Psychotherapy Research
(547) 235
marital counseling. He had become less inhibited and more expressive and self-assertive. Our impression was that the patient’s resolution of her conflicts about her father, in short-term treatment, prepared her for a relationship with a man less passive than her husband was when she married him. The changes he achieved in marital counseling enabled her to build on the gains that she already had made.
Request reprints from: C.P. l.eeman, MD, Associate Clinical Professor of Psychiatry, Boston University School of Medicine, and Chief of Psychiatry, Framingham Union Hospi tal, 25 Evergreen Street, Framingham, MA 01701 (USA)
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We do not yet have numerical results of our research to report. So far, the patients have been predominantly young and female, with a variety of neurotic problems. The specific predisposition often derives from conflict in the relation ship with the father. Our impression at this point is that most of the patients have made changes which we have not seen in the control patients. We are not yet prepared to document this, however, and the cases presented are intended primarily to illustrate the applicability and usefulness of our outcome criteria in assessing therapeutic outcome.
Outcome Criteria in Psychotherapy Research Cavin P. Leerrnn
This paper describes and illustrates the criteria by which we assess the outcome of each patient’s treatment. I should like to emphasize that the appli cability of these criteria is not limited to short-term anxiety-provoking psycho therapy. They were formulated and developed in a preliminary study utilizing a heterogeneous group of patients treated at the Beth Israel Hospital Outpatient Psychiatric Clinic. These patients underwent a variety of forms of psychother apy: individual long-term exploratory psychotherapy, individual short-term psychotherapy of various sorts, and couples psychotherapy. It is our hope that these outcome criteria will provide a framework within which not only to an swer the question — Does psychotherapy work? (once it is specified what type of therapy for what kind of patients) —but also to compare in a meaningful way the results of various forms of psychiatric treatment. Too often such compar isons, as well as comparisons between treated patients and untreated controls, have been made without explicit criteria for assessing outcomes. Our first outcome criterion is change in the patient's symptoms. We do not assume that change in symptoms necessarily demonstrates change in underlying psychopathology, but symptom change is a simple index of the patient’s com fort or discomfort. A careful review of symptoms is made before and after treatment. In follow-up examination, this review includes not only the presence or absence of the initial symptoms and of any new symptoms, but also the intensity of the symptoms, the degree to which they impinge on the patient’s life, and the patient’s attitude about them. The tendency of many psychiatric symptoms to remit spontaneously is well-known, and it is our impression that symptom-change will not prove to be the most useful criterion with which to demonstrate the effectiveness of psychotherapy. The patient’s attitude about his symptoms may change, however, as part of a more general change in his ap proach to the problems of living.
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
Boston University School of Medicine and Framingham Union Hospital, Framingham, Mass.
Leeman
(542) 230
A young woman, whom I will call Laura, who was treated for anxiety, told us ‘1 have the same symptoms I always did, but much less severe. ... 1 realize that my anxiety is like an alarm, telling me that I’m not facing something ... so I try to find out what’s disturbing me. I don’t get as annoyed with the anxiety as I used to.’ The patient first reported this change in the post-treatment evaluation 3 weeks after the conclusion of a 4-month course of therapy, and mentioned it again in a follow-up interview 2 years later, so that we know that the change was a lasting one. This result is not unusual in our experience.
I already have referred to the frequently noted phenomenon of spontaneous remission of symptoms. A classic example is offered by a case that may be aprocryphal, but which may shed some light on the meaning of ‘spontaneous remission’. A young woman developed phobic symptoms when her boy friend proposed marriage. When she came for help, she was apprehensive, and uncertain whether to accept the pro posal. She did not enter treatment, and was not heard from again until a follow-up inquiry several years later revealed her to be entirely free of symptoms. She had not married, she was working as a secretary in a nunnery, and she had not dated anyone since breaking off with her original boy friend. Quite apart from the question of values - of religious devotion versus heterosexual relationships - it is not very meaningful to put into the same category with respect to outcome, this asymptomatic secretary and her hypothetical twin sister who has become equally free of the same initial symptoms; but who also is happily married, raising two children, developing a part-time career, and enjoying several close friendships with men and women. The second sister is comfortable with several kinds of interpersonal relations, and finds them gratifying, while the first sister’s symptomatic relief clearly seems to have been achieved at the sacrifice of heterosexual relationships.
Because of the crucial importance of interpersonal relations in characteriz ing the quality of people’s lives, change in interpersonal relations is our second outcome criterion, and the pretreatment assessment of each patient includes a careful examination of all the significant interpersonal relationships in his life. Based on this review, a judgement is made as to the specific disturbance in the patient’s interpersonal relations.
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
For example, Laura, the young woman who learned to regard her anxiety as an alarm, initially had complained of difficulties with her boy friend. He made demands on her which she felt she had to satisfy. She was afraid that if she disappointed him she would lose him. At the same time, she involved her father in her conflict, coloring what she told him so as to provoke his hostility to the boy friend. She was afraid of losing her father’s love if she got more involved with the boy friend, so she really couldn’t move in either direction. By the time Laura’s treatment ended, she had broken off with her boy friend, and had begun a different kind of relationship with another young man, with whom she found she could be much more outspoken about her own wishes. As it turned out, this relationship was short lived, but at the time of the 2-year follow-up, the patient was about to marry a man she had known for more than a year. As she described their relationship, a picture emerged of mutual love, emotional intimacy, and respect, that clearly was quite different from anything in the patient’s prior experience.
Outcome Criteria in Psychotherapy Research
(543) 231
I turn now to our third criterion, change in what we call ‘specific predisposi tion’, a term introduced by Dr. David Malan of the Tavistock Clinic in London. The reason this criterion is important is that not only can some patients achieve symptomatic relief at the expense of interpersonal relations, like the convent secretary, but others can manage both symptomatic relief and improvement in interpersonal relations, provided an environmental support is given.
Dr. Malan's concept of specific predisposition, that aspect of a patient’s personality that underlies both his symptoms and his interpersonal difficulties, helps in interpreting the changes observed. We define ‘specific predisposition’ as the patient’s vulnerability, determined by the convergence of genetic and experi ential factors, to react to stress in a maladaptive way, through the development of symptoms and/or disturbances in interpersonal relations. For example, Mrs. Jordan’s specific predisposition was overdependence, which remained unchanged. By pointing this out, we do not mean to denigrate the other improvements in her life. Certainly psychotherapy does not always modify a patient’s specific predisposition, and often this kind of change is not even attempted. But when it is achieved, it is a significant result of treatment, because in a crucial sense it makes the patient less vulnerable to the vicissitudes of external events. It is important, therefore, to distinguish change in predisposition from other kinds of change. The fourth criterion is gain in self-understanding, which we assess by asking tlie patient to explain what was wrong with him and how it has changed. Self understanding, or insight, is closely bound to the verbal ability of the patient. In assessing the other criteria, we utilize the patient’s report of his experience, which we integrate in ways that are meaningful to us. But we have no way of distinguishing the patient’s understanding of himself from his ability to convey this understanding to the interviewer. In this instance we ask him what he understands, and we must rely on his ability to integrate. But perhaps this is not
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
An example of this from our own clinic is the case of Mrs. Jordan, who complained of anxiety, depression, and difficulties in her relationships to her husband and her daughter. Initial evaluation revealed an unresolved hostile-dependent relationship with her mother. When seen later, Mrs. Jordan felt better, her self-esteem had risen, and she was getting along better with both her husband and her daughter. It turned out that she had taken a lover, who appeared to be gratifying her dependency needs. Incidentally, Mr. Jordan, who also had sought help for marital difficulties, reported great improvement from his point of view as well. He knew nothing of his wife’s affair, and he felt that he and his wife had become much closer and more open with one another. In assessing the whole situation, we recognized both Mrs. Jordan’s symptomatic improvement and the improvement in her interpersonal rela tions; yet we considered that in another way Mrs. Jordan had remained essentially un changed. She still was a dependent person, but the availability of a new person to depend upon had relieved both her symptoms and the tensions within her family. The source of the changes thus was primarily outside Mrs. Jordan, rather than within her own psychic makeup.
Leeman
(544) 232
I already have referred to Laura, who came to the clinic complaining of anxiety, some depression, and difficulties in her relationships with men, especially her current boy friend. She was 22 years old and in her final year of college. She was apprehensive about her future, but her symptoms were of much longer duration than the stress of imminent graduation. In fact, she dated their onset to early adolescence, shortly after her menarche. At first she said that her childhood had been happy, and that she always had been close to her parents. On further questioning, however, it turned out that a younger sister had been born when the patient was 4 years old. She felt that she had lost her special place in the family at that time, since both of her parents had become much more involved with the new baby than with the patient. Competition with her sister was intense, and the patient felt that somehow her mother promoted it. During 4 months of once-a-week treatment the patient realized that her father was the object of much of this competition, which colored the patient’s relation with her mother, as well as with her sister. She felt that she never again achieved the special place in her father’s affections that she thought she had enjoyed before her sister was born, and that she continued to long for. As she grew up, her father was rather distant from the family. Her earliest memory, dated shortly after her sister’s birth, was of being left alone by her father, crying miserably, while he went across the street to buy food. The patient recognized that her clinging dependency on her boy friend was related to her sense that she had lost her father. Her self-esteem improved, and she gained more respect for her own opinions. She felt less panicky and indulged in fewer and less-severe eating binges. The marked change in the quality of her relationships with men has been mentioned earlier. After treatment she said that she had come to recognize that her symptoms occurred either when she felt abandoned or was afraid that she might be; that this was related to the events in her family when she was 4 years old; and that she recognized that she had longed ever since then to regain a special place in her father’s affection. To do so, however, would mean stealing him from mother, and this idea scared her.
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
such a serious drawback. Psychotherapy, after all, is a verbal treatment, and we should like to learn something about the degree to which its effectiveness in producing other kinds of change depends upon the development of self-understanding and the ability to verbalize insightfully. Finally, we examine changes in the patient's problem-solving ability. Dr. Sifneos's previous work with short-term anxiety-provoking psychotherapy showed that patients in treatment can learn new ways of solving emotional problems. As the therapist and the patient work together to define and to solve a critical problem in the patient’s life, the therapist stimulates the patient’s inter est in approaching problems in a thoughtful, self-examining way. The patient’s success with one problem often leads to his tackling other problems in the same manner on his own. If the patient really has learned new problem-solving skills, he should be able to use them in solving emotional problems that arise after the termination of his treatment. The post-treatment assessment of gains in problem-solving ability therefore relies heavily on specific examples provided by the patient from his own experience during and after therapy. Specific documen tation is crucial. To make all of these issues clearer, I should like to discuss some clinical examples, selected from the more than 20 patients whom we have studied and treated so far.
Outcome Criteria in Psychotherapy Research
(545) 233
I should like to summarize our pre- and post-treatment assessment of this patient, Laura: Symptoms. Anxiety and depression, with panicky feelings, stomach aches, and binges of overeating, related to situations of actual, anticipated, or imagined abandonment. Scored as somewhat better immediately after treatment and at 2-year follow-up. Symptoms still present, but diminished in intensity, and patient’s attitude about them changed. Interpersonal relations. Problems with boy friends; overly dependent and compliant out of fear of being abandoned. Scored as somewhat better immediately after treatment. Patient more outspoken and less afraid to express her own feelings. At 2-year follow-up scored as much better. Gratifying heterosexual relationship involving mutual respect and intimacy, duration already more than 1 year with plan to be married in 2 months’ time. Specific predisposition. At age 4 lost special place in family to younger sister; conse quent long-standing wish to regain father for herself by replacing both mother and sister made it impossible for patient to form a mature heterosexual relationship outside the family; sensitivity to abandonment even by unsatisfactory men made her overly dependent and compliant. Scored as somewhat better immediately after treatment and at 2-year follow-up, based on increased independence from parents as well as on change in relations outside the family. Patient still seems angry at people who she feels let her down, such as parents, previous boy friends, therapist; and afraid of expressing it. Subsequent follow-ups will permit evaluation of this factor, especially in patient’s marriage. Self-understanding. The patient explained the connection between her symptoms, her relationships with her boy friends, and her childhood relationships within the family. Scored as much improved in self-understanding. Problem-solving. Scored as much improved, based on separations from two unsatisfac tory boy friends and good relationship with fiance. Using residual anxiety symptoms as signals for self-exploration, and trying to learn more about her fear of expressing anger. (The issue of anger apparently had not been discussed during treatment.)
The next case, on which we also have a 2-year follow-up, introduces one of the complications with which we have had to contend in assessing therapeutic outcome. The patient entered marital counseling some months after her therapy at our clinic, so that it has become important to try to tease out the changes attributable to the two kinds of treatment. In discussing this example I also will try to illustrate how, in the pretreatment assessment, we individualize the out come criteria for each patient.
Downloaded by: King's College London 137.73.144.138 - 3/8/2018 1:31:51 AM
The overall outcome of Laura’s treatment was very favorable. She was much improved in interpersonal relations, self-understanding, and problem-solving. Symptomatic improve ment was only partial, which is not unusual for this type of treatment, but the patient’s attitude about her symptoms was very different. Only our very stringent standards for assessing change in predisposition prevent our scoring her as much improved on this crite rion. There is no doubt about her general progress, her self-esteem was greatly increased, and she expressed gratitude to the clinic.
I.eeman
(546) 234
Mrs. Robertson, a married woman in her mid-twenties, working as a psychologist, came to the clinic with the specific chief complaint: ‘My anger is interfering with my work.’ She suffered from anxiety, muscular tension, and fluctuating overweight; and also complained of an angry relationship with her husband, with no sexual intercourse for several months. She was getting along poorly at work because of her difficulty in accepting criticism from her female supervisors. Her past history revealed that she had been very much attached to her father until age 8, when her sister was born, who the patient feels displaced her in her father’s affection. She expressed considerable bitterness toward her father, whom she por trayed as a rigid, provocative person. Mother appeared to have been unavailable emotionally; she expected the patient to care for the two younger siblings. Before starting treatment, we postulated the predisposition as follows: Mrs. Robert son’s resentment toward her father, which began when he turned to her sister, served to mask her continued longing for him; she married a passive man, in contrast to her father, then became angry at him for not being more like her father, while her continued emotional involvement with father sensitized her to criticism from older women. Our specific criteria for recovery, and the findings after the completion of therapy, ten sessions, once-a-week, are: Symptoms. Anger and anxiety should diminish markedly (which they did); and the patient should achieve a stable, appropriate weight (her weight had not changed by the end of treatment, but she had begun to diet). Interpersonal relations. Improved relationship with husband, including satisfactory sexual relations; decreased sensitivity to criticism from women. (The actual findings in cluded a much better relationship with her husband. The patient had become more sympa thetic to him, and more understanding of his aspirations and difficulties. The Robertsons had resumed sexual relations, which were predominantly satisfying, although Mrs. Robert son still had not achieved orgasm. She was more productive at work, where she had a better relationship to her supervisors, and was much less sensitive to criticism. She also had become more deeply involved in other relationships, both social relationships with friends, and work relationships with clients.)
Mrs. Robertson also showed impressive gains in self-understanding and in problem solving technique. Therefore we initially scored Mrs. Robertson’s treatment as highly suc cessful on all counts. At 2-year follow-up the patient had become still more productive at work, her marriage had improved further (following a stormy period during which she and her husband consulted a marriage counselor), and the patient’s sexual relations now regu larly included orgasm. To what extent are these changes attributable to the short-term psychotherapy, and to what extent to the marital counseling? Judging by the gains apparent immediately after treatment, our opinion is that the initial therapy was crucial. It began a process that the patient continued afterwards. She said in the 2-year follow-up interview that the marital counseling had helped her to apply to her marriage the insights that she had achieved in therapy. She also reported that her husband had changed as a result of the
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Specific predisposition. Improved relationships with parents. (At the conclusion of her treatment, Mrs. Robertson reported that she felt more comfortable with her parents, and much less angry at her father, with whom she had had a long, fond conversation. This was unprecedented during her adult life.)
Outcome Criteria in Psychotherapy Research
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marital counseling. He had become less inhibited and more expressive and self-assertive. Our impression was that the patient’s resolution of her conflicts about her father, in short-term treatment, prepared her for a relationship with a man less passive than her husband was when she married him. The changes he achieved in marital counseling enabled her to build on the gains that she already had made.
Request reprints from: C.P. l.eeman, MD, Associate Clinical Professor of Psychiatry, Boston University School of Medicine, and Chief of Psychiatry, Framingham Union Hospi tal, 25 Evergreen Street, Framingham, MA 01701 (USA)
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We do not yet have numerical results of our research to report. So far, the patients have been predominantly young and female, with a variety of neurotic problems. The specific predisposition often derives from conflict in the relation ship with the father. Our impression at this point is that most of the patients have made changes which we have not seen in the control patients. We are not yet prepared to document this, however, and the cases presented are intended primarily to illustrate the applicability and usefulness of our outcome criteria in assessing therapeutic outcome.
