Br. J. med. Psycho/. (1975). 48, 207-215 Printed in Great Britain
207
Personal Questionnaire changes and their correlates in a psychotherapeutic group BY D. A. SHAPIRO,* H. L. CAPLAN,t P. D. ROHDES AND J. P. WATSON§ analysis combining three of the Hobson & Shapiro (1970) cases with three patients receiving non-directive interviews and behavioural treatments, Shapiro & Shapiro (1974) found more ‘worsening’ during interpretative interviews than during comparison periods spent in the community ward, and less ‘improvement’ during non-directive interviews than during sessions of behavioural treatment. A single-case study by Shapiro & Hobson (1972) showed ‘worsening’ during out-patient psychotherapy, despite evidence from the PQ scores of ‘improvement’ over the six months of treatment. This raises the question, crucial to the clinical significanceof short-term PQ changes, of their relationship to longer-term change. Are we to conceive of longer-term change as a cumulative function of the short-term changes effected during a series of treatment sessions? Or might it be that cognitive restructuring or affective change of any kind, irrespective of its direction, during sessions is predictive of longer-term reductions in distress? Or, finally, might it be that the process of group psychotherapy requires a necessarily painful process of restructuring and abandonment of avoidance mechanisms, such that short-term increments in distress during group sessions are associated with longerterm reductions reflecting ultimate benefit? Two questions arise from the foregoing discussion of short-term changes in self-reported affect during psychotherapy. First, what is the general directionof such changes, and, secondly, how are such changes related, if at all, to longer* ‘Lecturer in Psychology, University of Sheffield. term change, or other indices of the patient’s t Consultant Child Psychiatrist, St George’s Hosresponse to treatment (such as premature terpital, London. 4 Consultant Psychiatrist, St Mary Abbotts Hospital, mination, or the patient’s participation in the group process)? A further question addressed in London. 8 Professor of Psychiatry, Guy’s Hospital Medical this study concerns the relation between such ‘ symptomatic’ self-reports as the PQ elicits and School, London.
The study reported in this paper is the meetingpoint of two lines of inquiry. The first (Hobson & Shapiro, 1970; Mowrer ef al., 1953; Shapiro & Hobson, 1972; Shapiro ef al., 1973; Shapiro & Shapiro, 1974) is concerned with short-term changes in self-reported affects during psychological treatment sessions. The second (Caplan et al., 1975; Watson, 1970) examines the processes of group psychotherapy by means of repertory grid technique. Mowrer et al. (1953), using simple graphic rating scales of ‘tension ’ and ‘happiness ’, found that out-patients in individual psychotherapy reported reductions in both tension and depression during treatment sessions. Significantly, however, those patients who left ‘prematurely ’ showed the reverse tendency, namely for tension to increase and happiness decrease during sessions. More recently, attempts have been made to replicate the Mowrer ef al. (1953)results, using the Personal Questionnaire (PQ; Shapiro, l%l). These have not been successful, although the results have formed a fairly consistent pattern (Hobson & Shapiro, 1970; Shapiro & Hobson, 1972; Shapiro & Shapiro, 1974). The seven patients studied by Hobson & Shapiro (1970), whose data are presented more fully by Shapiro (1971), showed no evidence of reduction in tension or depression during individual psychotherapy sessions in a community ward setting. Indeed, the trend of their short-term changes during sessions was toward increased self-reported distress, which could be regarded as ‘worsening’. In an
14-2
208
D. A.
SHAPIRO AND OTHERS
the coping process, which clinicians might argue to be facilitated by psychotherapy, irrespective of any change in symptoms per se. Our previous paper (Caplan et al., 1975) was concerned with a repertory grid study of the out-patient psychotherapy group which is the subject of the present PQ investigation. Statistically significant relationships were obtained between repertory grid measures and measures of participation derived from tape recordings of group sessions. For example, discussion of sexual matters was associated with reduced selfesteem as measured in the grids of patients and therapists. Patients’ self-esteem was enhanced following sessions in which more distant relatives, not members of patients’ immediate families, were discussed at some length. Such findings were seen as validating the grid approach to the process of group therapy. However, they have few implications for outcome. Changes in patients’ reports of distressing feelings concerning the problems for which they seek help, as measured by the PQ,have a greater degree of ‘content validity ’ as measures of therapeutically relevant change than do the more inferential grid measures. On the other hand, grid measures of such factors as self-esteem and parental identifications are clearly highly relevant to an understanding of the processes of groups such as ours. It therefore seems desirable to seek correlations between repertory grid, verbal behaviour and PQ measures. This may contribute to the validation of each as a contributor to the integrated understanding of group process and outcome.
METHOD The group The group studied here has been described previously (Caplan et a/., 1975). It was taken by two therapists jointly. They were both, at the time thegroup was formed, registrars nearing the end of their postgraduate training in psychiatry. One had a year’s experience in the psychotherapycommunity ward studied by Hobson & Shapiro (1970) and conducted some of the interviews in their investigation. The other was working in an out-patient psychotherapy unit at the time of the group’s formation. The eight patients, selected from a waiting list by the therapists, showed
a variety of problems, chiefly of a moderate to severe neurotic type. Group sessions lasted 90 minutes. The technique of the therapists was interpretative. Principles such as those expounded by Foulkes & Anthony (l%5) and Bion (1%1)are likely to have been influential upon them. Data from tape-recordingsof the sessions (Caplan et a/., 1975) indicate that patients’ family members. the patients themselves and other relatives of patients were discussed more than were their jobs, the therapists or explicitly sexual matters.
Method of assessment Beginning at the ninth group meeting, each patient was required to assess the intensity of his feelings of depression, tension, inability to cope, and other distressing feelings, immediately before and immediately after each of 26 of the weekly group sessions over a 45-week period. Occasions when repertory grids were completed were omitted in order to ease the burden on the patients. Assessment was by means of the PQ which is described by Shapiro (l%l). At the formation of the group, the construction of a separate questionnaire was begun for each patient. This involved two standardized interviews held individually with the psychologist. PQs were limited to 1 1 items per patient, to facilitate speedy administration to the assembled patients in the group room. A further constraint on PQ construction was the psychologist’s attempt to include items referring to tension, depression and coping ability, whenever their relevance was admitted by the patient. Each item was made up of three statements: (i) of minimum intensity, (ii) of moderate intensity and (iii) of maximum intensity. These statements were arrived at by a hedonic scaling procedure, describedby Shapiro (l%l). The final test, administered before and after group sessions, was carried out in the form of paired comparisons, with each of the three statements being paired with the other two, the pairs being typed on 5 x3 in. index cards. An example of such a set of paired statements is the following: (i) I do not feel depressed (ii) I feel somewhat depressed (ii) I feel somewhat depressed (iii) I feel very depressed (iii) I feel very depressed (i) I do not feel depressed There were thus three cards for every item. In an actual test the cards for all the items were shuffled together. The patient took one card at a time and placed it in one of two piles on his lap, according to whether the ‘top’
Personal Questionnaire in group psychotherapy or ‘bottom ’ statement came nearer to his present state. This method yields four possible consistent response patterns, scored from 1 to 4, with 1 indicating minimum intensity and 4 maximum intensity. The method may also yield one of four inconsistent response patterns, incompatible with the original scaling of the three statements. A purely random sorting would produce 50 per cent of each kind of response pattern, thus making possible a reliability check for each patient on each occasion of testing.
Methods of data analysis The chief concern of the PQ study was with the direction of change during group sessions, summarized by means of an index of Net Percentage Improvement (NPI). This index takes into account the effects, upon the number of opportunities for change in one or other direction, of the ‘floor’ and ‘ceiling’ of the PQ scale. This provides a range of four points, with a maximum of 4 and a minimum of 1. A before-group score of 1 provides no opportunity for ‘improvement’ and a before-group score of 4 no opportunity for ‘worsening’. The formula for the NPI is as follows: NPI = [(K/X)-(J/Y)]X100, where K = number of sessions where score after session is lower than score before session (improvements), X = number of sessions where score before session is above the minimum of 1 (opportunities for improvement), J = number of sessions where score after session is higher than score before session (worsenings), and Y = number of sessions where score before session is below the maximum of 4 (opportunities for worsening). To avoid extreme cases of small X s or Y‘s giving large NPIs based on a very few observations, the arbitrary principle was introduced whereby if either X or Ywas less than 3, an Ordinary Percentage Improvement index (OPI)was calculated instead, by the simpler formula: OPI = [ ( K - J ) / S l x 100, where S = total number of sessions, and K and J are defined as above. A third index of change during sessions was concerned with the overall net frequency of improvement or worsening for the whole of a patient’s PQ. This Grand NPI was computed by the formula:
where K f = number of improvements summed for all items and for all sessions, J, = number of worsenings summed for all items and for all sessions, Kf = number
209 Table 1. Trendanalysis with unchanging median Score level 4
3 2 I
First six Last six sessions sessions Item 1 3 1 1 0 4 7
Frequency difference
4
4
+
+
-
0
Decision: ‘improvement ’ Item 2 4
3 2 1
4
3 2 I
2 3 6 2 I Decision: ‘worsening’ 0 2 8
Item 3 2 0 2 4 6 4 2 4 Decision: ‘no change ’
-
-
+ +
+ -
+ -
of opportunities for improvement summed for all items and for all sessions, and Yf = number of opportunities for worsening summed for all items and for all sessions. Fourthly, a Grand Change Index showed the relative frequency of variability irrespective of direction, for the PQ as a whole: GCI = [ ( K f + J f ) / ( S ~ N ) ] x I 0 0 , where N = number of items in PQ, and K,, J,and Sare defined as above. For the evaluation of longer-term trends in the level of distress reported via the PQ over the period studied, comparisons were made, for each PQ item, between the first and last six sessions, taking both ‘before group’ and ‘after group’ scores. For each item, trends were ascertained, in the first instance, by examination of the medians of the two sets of 12 scores. Any item showing no median difference was subjected to a more sensitive test (Shapiro, 1971) remaining consistent with the constraints imposed by the ordinal scaling of the PQ items. This procedure is illustrated in Table 1. The sign of the difference between frequencies at each level of the scale during the early and late blocks of sessions is ascertained. If all the positive differences are at higher points of the scale than all the negative differences, then ‘improvement’ may be inferred, as on Item 1 of Table 1. If, on the other hand, all the positive
D. A. SHAPIRO AND OTHERS
210
Table 2. Summary of PQ data Patient
-
/
No. of sessions assessed Within-session improvement Depression Tension Coping GNPI
Mr T.
Mrs E.
Mr A.
Mr J.
16
19
5
23
-69 -63
14 14 10
-32
I5
0 40 40 -4
4 -3 15 6
16 21 5 24
40 80 40 44
57 66
W I W
W W W
-60
-44
Within-session variability Depression Tension Coping GCI
-
Longer-term trends* Depression Tension Coping OTI
-
81 63 54
I
W W W -55
NC 33
57
59
4
Mrs M.
Mrs G.
24
19
2
- 13
0 29 -3 23
25 42 21 22
0 42 42 37
I I I 64
I W NC 9
-37
-31
Miss V. 14
-57 -28 -40 -23
71 50
50 34
I I I 30
* Obtained from a comparison of the first six sessions with the last six sessions assessed except in the case of Mr T., for whom the comparison was between the first two sessions and the last two sessions. frequency differences are at lower points of the scale than all the negative differences, then a ‘worsening’ trend may be inferred (Item 2). If however, positive and negative differences overlap, then in the absence of a median difference, no trend in either direction can be inferred without making unjustifiable scaling assumptions (Item 3). Finally, the longer-term trends exhibited by each patient were summarized by means of an Overall Trend Index (OTI). Having classified each item as showing ‘improvement ’, ‘no change ’ or ‘worsening’ following the procedure described in the preceding paragraph, the OTI for each patient was calculated as follows: OTI = [(I-
W)/NlX
100,
where I = number of items showing ‘improving’ trends; W = number of items showing ‘worsening’ trends; and N = number of items in the patient’s
PQ.
RESULTS One patient (Mr B.) left the group before FQ administrations began.
Short-term changes The FQ results are summarized in Table 2. The only substantial NPIs for depression (Mr A. and Miss V.) were negative, indicating ‘worsening’. Tension, however, showed moderate ‘improvement’ in two cases (Mr T. and Mrs G.) and moderate ‘worsening’ in two cases (Mrs M.and Miss V.). Reported coping ability showed evidence of ‘worsening’ during sessions in three cases (Mr A., Mrs M. and Miss V.), and of ‘improvement’in one case (Mr T.). GNPIs confirmed the pattern of mixed results. Three patients showed evidence of ‘worsening ’ during sessions from their full PQs (Mr A., Miss V. and, to a lesser extent, Mrs M.),whilst two showed
21 1
Personal Questionnaire in group psychotherapy
Table 3. Changes in PQ items during sessions compared with changes over the longer term During group sessions Patient Mr A.
Mr J.
Mr T.
Mrs E.
Longer-term trend
Improvement (220)
No change (20 to -20)
Worsening
I NC
0 0
0
5
W
0
1 1
I
I NC
2 0
0
W
0 0 2
5
0
I NC
2 0
0 0
W
4
4
0 0 0
I NC
0 0 I
2
W Mrs M.
Mrs G .
Miss V.
I NC W I NC W I
NC W evidence of ‘improvement’(Mrs G. and, to some extent, Mr T.).
Variability during group sessions Turning to evidence concerning variability during group sessions, the middle section of Table 2 shows that this was considerable. With GCIs ranging from 22 to 59, the absence of uniform ‘improvement ’ indices cannot be attributed to lack of variation. Tension showedaboveaverage variability for five out of six patients. Longer-term trends Longer-term trends, shown at the foot of Table 2, were evenly divided between ‘improvement’ and ‘worsening* in the case of depression, tension, coping and the PQs as a whole. Mrs M. showed clear evidence of ‘improvement’, also shown to a lesser extent by Miss V. and Mr A. Mr J., Mrs N. and Mr T. showed evidence of
1 5
(
207
Personal Questionnaire changes and their correlates in a psychotherapeutic group BY D. A. SHAPIRO,* H. L. CAPLAN,t P. D. ROHDES AND J. P. WATSON§ analysis combining three of the Hobson & Shapiro (1970) cases with three patients receiving non-directive interviews and behavioural treatments, Shapiro & Shapiro (1974) found more ‘worsening’ during interpretative interviews than during comparison periods spent in the community ward, and less ‘improvement’ during non-directive interviews than during sessions of behavioural treatment. A single-case study by Shapiro & Hobson (1972) showed ‘worsening’ during out-patient psychotherapy, despite evidence from the PQ scores of ‘improvement’ over the six months of treatment. This raises the question, crucial to the clinical significanceof short-term PQ changes, of their relationship to longer-term change. Are we to conceive of longer-term change as a cumulative function of the short-term changes effected during a series of treatment sessions? Or might it be that cognitive restructuring or affective change of any kind, irrespective of its direction, during sessions is predictive of longer-term reductions in distress? Or, finally, might it be that the process of group psychotherapy requires a necessarily painful process of restructuring and abandonment of avoidance mechanisms, such that short-term increments in distress during group sessions are associated with longerterm reductions reflecting ultimate benefit? Two questions arise from the foregoing discussion of short-term changes in self-reported affect during psychotherapy. First, what is the general directionof such changes, and, secondly, how are such changes related, if at all, to longer* ‘Lecturer in Psychology, University of Sheffield. term change, or other indices of the patient’s t Consultant Child Psychiatrist, St George’s Hosresponse to treatment (such as premature terpital, London. 4 Consultant Psychiatrist, St Mary Abbotts Hospital, mination, or the patient’s participation in the group process)? A further question addressed in London. 8 Professor of Psychiatry, Guy’s Hospital Medical this study concerns the relation between such ‘ symptomatic’ self-reports as the PQ elicits and School, London.
The study reported in this paper is the meetingpoint of two lines of inquiry. The first (Hobson & Shapiro, 1970; Mowrer ef al., 1953; Shapiro & Hobson, 1972; Shapiro ef al., 1973; Shapiro & Shapiro, 1974) is concerned with short-term changes in self-reported affects during psychological treatment sessions. The second (Caplan et al., 1975; Watson, 1970) examines the processes of group psychotherapy by means of repertory grid technique. Mowrer et al. (1953), using simple graphic rating scales of ‘tension ’ and ‘happiness ’, found that out-patients in individual psychotherapy reported reductions in both tension and depression during treatment sessions. Significantly, however, those patients who left ‘prematurely ’ showed the reverse tendency, namely for tension to increase and happiness decrease during sessions. More recently, attempts have been made to replicate the Mowrer ef al. (1953)results, using the Personal Questionnaire (PQ; Shapiro, l%l). These have not been successful, although the results have formed a fairly consistent pattern (Hobson & Shapiro, 1970; Shapiro & Hobson, 1972; Shapiro & Shapiro, 1974). The seven patients studied by Hobson & Shapiro (1970), whose data are presented more fully by Shapiro (1971), showed no evidence of reduction in tension or depression during individual psychotherapy sessions in a community ward setting. Indeed, the trend of their short-term changes during sessions was toward increased self-reported distress, which could be regarded as ‘worsening’. In an
14-2
208
D. A.
SHAPIRO AND OTHERS
the coping process, which clinicians might argue to be facilitated by psychotherapy, irrespective of any change in symptoms per se. Our previous paper (Caplan et al., 1975) was concerned with a repertory grid study of the out-patient psychotherapy group which is the subject of the present PQ investigation. Statistically significant relationships were obtained between repertory grid measures and measures of participation derived from tape recordings of group sessions. For example, discussion of sexual matters was associated with reduced selfesteem as measured in the grids of patients and therapists. Patients’ self-esteem was enhanced following sessions in which more distant relatives, not members of patients’ immediate families, were discussed at some length. Such findings were seen as validating the grid approach to the process of group therapy. However, they have few implications for outcome. Changes in patients’ reports of distressing feelings concerning the problems for which they seek help, as measured by the PQ,have a greater degree of ‘content validity ’ as measures of therapeutically relevant change than do the more inferential grid measures. On the other hand, grid measures of such factors as self-esteem and parental identifications are clearly highly relevant to an understanding of the processes of groups such as ours. It therefore seems desirable to seek correlations between repertory grid, verbal behaviour and PQ measures. This may contribute to the validation of each as a contributor to the integrated understanding of group process and outcome.
METHOD The group The group studied here has been described previously (Caplan et a/., 1975). It was taken by two therapists jointly. They were both, at the time thegroup was formed, registrars nearing the end of their postgraduate training in psychiatry. One had a year’s experience in the psychotherapycommunity ward studied by Hobson & Shapiro (1970) and conducted some of the interviews in their investigation. The other was working in an out-patient psychotherapy unit at the time of the group’s formation. The eight patients, selected from a waiting list by the therapists, showed
a variety of problems, chiefly of a moderate to severe neurotic type. Group sessions lasted 90 minutes. The technique of the therapists was interpretative. Principles such as those expounded by Foulkes & Anthony (l%5) and Bion (1%1)are likely to have been influential upon them. Data from tape-recordingsof the sessions (Caplan et a/., 1975) indicate that patients’ family members. the patients themselves and other relatives of patients were discussed more than were their jobs, the therapists or explicitly sexual matters.
Method of assessment Beginning at the ninth group meeting, each patient was required to assess the intensity of his feelings of depression, tension, inability to cope, and other distressing feelings, immediately before and immediately after each of 26 of the weekly group sessions over a 45-week period. Occasions when repertory grids were completed were omitted in order to ease the burden on the patients. Assessment was by means of the PQ which is described by Shapiro (l%l). At the formation of the group, the construction of a separate questionnaire was begun for each patient. This involved two standardized interviews held individually with the psychologist. PQs were limited to 1 1 items per patient, to facilitate speedy administration to the assembled patients in the group room. A further constraint on PQ construction was the psychologist’s attempt to include items referring to tension, depression and coping ability, whenever their relevance was admitted by the patient. Each item was made up of three statements: (i) of minimum intensity, (ii) of moderate intensity and (iii) of maximum intensity. These statements were arrived at by a hedonic scaling procedure, describedby Shapiro (l%l). The final test, administered before and after group sessions, was carried out in the form of paired comparisons, with each of the three statements being paired with the other two, the pairs being typed on 5 x3 in. index cards. An example of such a set of paired statements is the following: (i) I do not feel depressed (ii) I feel somewhat depressed (ii) I feel somewhat depressed (iii) I feel very depressed (iii) I feel very depressed (i) I do not feel depressed There were thus three cards for every item. In an actual test the cards for all the items were shuffled together. The patient took one card at a time and placed it in one of two piles on his lap, according to whether the ‘top’
Personal Questionnaire in group psychotherapy or ‘bottom ’ statement came nearer to his present state. This method yields four possible consistent response patterns, scored from 1 to 4, with 1 indicating minimum intensity and 4 maximum intensity. The method may also yield one of four inconsistent response patterns, incompatible with the original scaling of the three statements. A purely random sorting would produce 50 per cent of each kind of response pattern, thus making possible a reliability check for each patient on each occasion of testing.
Methods of data analysis The chief concern of the PQ study was with the direction of change during group sessions, summarized by means of an index of Net Percentage Improvement (NPI). This index takes into account the effects, upon the number of opportunities for change in one or other direction, of the ‘floor’ and ‘ceiling’ of the PQ scale. This provides a range of four points, with a maximum of 4 and a minimum of 1. A before-group score of 1 provides no opportunity for ‘improvement’ and a before-group score of 4 no opportunity for ‘worsening’. The formula for the NPI is as follows: NPI = [(K/X)-(J/Y)]X100, where K = number of sessions where score after session is lower than score before session (improvements), X = number of sessions where score before session is above the minimum of 1 (opportunities for improvement), J = number of sessions where score after session is higher than score before session (worsenings), and Y = number of sessions where score before session is below the maximum of 4 (opportunities for worsening). To avoid extreme cases of small X s or Y‘s giving large NPIs based on a very few observations, the arbitrary principle was introduced whereby if either X or Ywas less than 3, an Ordinary Percentage Improvement index (OPI)was calculated instead, by the simpler formula: OPI = [ ( K - J ) / S l x 100, where S = total number of sessions, and K and J are defined as above. A third index of change during sessions was concerned with the overall net frequency of improvement or worsening for the whole of a patient’s PQ. This Grand NPI was computed by the formula:
where K f = number of improvements summed for all items and for all sessions, J, = number of worsenings summed for all items and for all sessions, Kf = number
209 Table 1. Trendanalysis with unchanging median Score level 4
3 2 I
First six Last six sessions sessions Item 1 3 1 1 0 4 7
Frequency difference
4
4
+
+
-
0
Decision: ‘improvement ’ Item 2 4
3 2 1
4
3 2 I
2 3 6 2 I Decision: ‘worsening’ 0 2 8
Item 3 2 0 2 4 6 4 2 4 Decision: ‘no change ’
-
-
+ +
+ -
+ -
of opportunities for improvement summed for all items and for all sessions, and Yf = number of opportunities for worsening summed for all items and for all sessions. Fourthly, a Grand Change Index showed the relative frequency of variability irrespective of direction, for the PQ as a whole: GCI = [ ( K f + J f ) / ( S ~ N ) ] x I 0 0 , where N = number of items in PQ, and K,, J,and Sare defined as above. For the evaluation of longer-term trends in the level of distress reported via the PQ over the period studied, comparisons were made, for each PQ item, between the first and last six sessions, taking both ‘before group’ and ‘after group’ scores. For each item, trends were ascertained, in the first instance, by examination of the medians of the two sets of 12 scores. Any item showing no median difference was subjected to a more sensitive test (Shapiro, 1971) remaining consistent with the constraints imposed by the ordinal scaling of the PQ items. This procedure is illustrated in Table 1. The sign of the difference between frequencies at each level of the scale during the early and late blocks of sessions is ascertained. If all the positive differences are at higher points of the scale than all the negative differences, then ‘improvement’ may be inferred, as on Item 1 of Table 1. If, on the other hand, all the positive
D. A. SHAPIRO AND OTHERS
210
Table 2. Summary of PQ data Patient
-
/
No. of sessions assessed Within-session improvement Depression Tension Coping GNPI
Mr T.
Mrs E.
Mr A.
Mr J.
16
19
5
23
-69 -63
14 14 10
-32
I5
0 40 40 -4
4 -3 15 6
16 21 5 24
40 80 40 44
57 66
W I W
W W W
-60
-44
Within-session variability Depression Tension Coping GCI
-
Longer-term trends* Depression Tension Coping OTI
-
81 63 54
I
W W W -55
NC 33
57
59
4
Mrs M.
Mrs G.
24
19
2
- 13
0 29 -3 23
25 42 21 22
0 42 42 37
I I I 64
I W NC 9
-37
-31
Miss V. 14
-57 -28 -40 -23
71 50
50 34
I I I 30
* Obtained from a comparison of the first six sessions with the last six sessions assessed except in the case of Mr T., for whom the comparison was between the first two sessions and the last two sessions. frequency differences are at lower points of the scale than all the negative differences, then a ‘worsening’ trend may be inferred (Item 2). If however, positive and negative differences overlap, then in the absence of a median difference, no trend in either direction can be inferred without making unjustifiable scaling assumptions (Item 3). Finally, the longer-term trends exhibited by each patient were summarized by means of an Overall Trend Index (OTI). Having classified each item as showing ‘improvement ’, ‘no change ’ or ‘worsening’ following the procedure described in the preceding paragraph, the OTI for each patient was calculated as follows: OTI = [(I-
W)/NlX
100,
where I = number of items showing ‘improving’ trends; W = number of items showing ‘worsening’ trends; and N = number of items in the patient’s
PQ.
RESULTS One patient (Mr B.) left the group before FQ administrations began.
Short-term changes The FQ results are summarized in Table 2. The only substantial NPIs for depression (Mr A. and Miss V.) were negative, indicating ‘worsening’. Tension, however, showed moderate ‘improvement’ in two cases (Mr T. and Mrs G.) and moderate ‘worsening’ in two cases (Mrs M.and Miss V.). Reported coping ability showed evidence of ‘worsening’ during sessions in three cases (Mr A., Mrs M. and Miss V.), and of ‘improvement’in one case (Mr T.). GNPIs confirmed the pattern of mixed results. Three patients showed evidence of ‘worsening ’ during sessions from their full PQs (Mr A., Miss V. and, to a lesser extent, Mrs M.),whilst two showed
21 1
Personal Questionnaire in group psychotherapy
Table 3. Changes in PQ items during sessions compared with changes over the longer term During group sessions Patient Mr A.
Mr J.
Mr T.
Mrs E.
Longer-term trend
Improvement (220)
No change (20 to -20)
Worsening
I NC
0 0
0
5
W
0
1 1
I
I NC
2 0
0
W
0 0 2
5
0
I NC
2 0
0 0
W
4
4
0 0 0
I NC
0 0 I
2
W Mrs M.
Mrs G .
Miss V.
I NC W I NC W I
NC W evidence of ‘improvement’(Mrs G. and, to some extent, Mr T.).
Variability during group sessions Turning to evidence concerning variability during group sessions, the middle section of Table 2 shows that this was considerable. With GCIs ranging from 22 to 59, the absence of uniform ‘improvement ’ indices cannot be attributed to lack of variation. Tension showedaboveaverage variability for five out of six patients. Longer-term trends Longer-term trends, shown at the foot of Table 2, were evenly divided between ‘improvement’ and ‘worsening* in the case of depression, tension, coping and the PQs as a whole. Mrs M. showed clear evidence of ‘improvement’, also shown to a lesser extent by Miss V. and Mr A. Mr J., Mrs N. and Mr T. showed evidence of
1 5
(
