Subjective Change With Medical Student Therapists

II.Some Determinants of Change in Psychoneurotic Outpatients

E.H.Uhlenhuth, MD, and David B.Duncan, PhD, Baltimore

P SYCHOTHERAPY is a powerful procedure which can be either helpful or harmful.1,2(p21) In a study3 of subjective distress reported by a group of 128 primarily psychoneurotic outpatients over some six weekly psychotherapeutic interviews with senior medical students, the group's mean symptomatic distress decreased by 22%. Individual patients within the group, however, varied markedly in their responses: 72% felt improved and 26% actually felt worse at termination. This paper explores some sources of the individual variation observed in symptomatic response. The present approach to this problem assumes that manifest psychological events are determined jointly by multiple factors. Further assumptions include the following: (1) Many of these factors may be related to one another, and to this extent their individual effects are confounded. (2) The effects of some factors may be contingent upon the effects of others (interaction4,5). The determinants of symptomatic change over the series of interviews were examined in 105 patients with complete data on 35 variables representing two broad domains6: (1) characteristics of the patient, such as initial clinical status, history of the present illness, current attitudes, and past personal history, and (2) characteristics of the stu dent, such as current attitudes and past per sonal history. These variables are detailed in Tables 1 and 2. Special interest centered on the possible importance of the student's characteristics and the "match" between pa tient and student. This match was repre sented by the statistical interaction between
Submitted for publication Dec 11, 1967. From the departments of psychiatry and behavioral sciences (Dr.Uhlenhuth) and statistics and biostatistics (Dr.Duncan), Johns Hopkins University, Baltimore. Reprint requests to 601 N Broadway, Baltimore 21205 (Dr.Uhlenhuth).

pairs of corresponding characteristics measured in the patient and in the student.

seven

Method
This study took place in the Outpatient De partment of the Henry Phipps Psychiatric

Clinic. It relied upon quantitative observations made during the training in individual psycho therapy offered as part of the nine-to-ten-week senior clinical clerkship in psychiatry. The study included all adult outpatients as signed to senior medical students for at least six weekly interviews during the academic years 1963 to 1966, except (1) patients whose conditions were diagnosed sociopathic disorder or brain syndrome, or (2) patients unable to cooperate with the procedures of the study. Each patient saw a different student, and the assignment of patients to students was random. Each patient reported his subjective distress every week before his interview by marking a checklist7 of 65 symptoms to indicate how much each complaint bothered him during the past week: not at all = 0, a little 1, quite a bit = 2, or extremely = 3. A total weighted symptom checklist score (TOT WTD SCL) was computed by summing the weights for the 65 individual symptoms. Weighted scores were computed in the same way for five symptom clusters: anxiety, depression, anger, compul sive symptoms, and other symptoms. Additional information about the patient and his treatment was obtained from the Strong Vocational Interest Blank (SVIB), an abstract of the Minnesota Multiphasic Person ality Inventory (MMPI), the clinical chart, and a brief interview by the technician. Infor mation about the student was obtained from the SVIB and a brief interview by the research
A multiple covariance procedure with a stepwise search option, programmed for the IBM 70948 was used to analyze the change in the total weighted symptom checklist score (1) be tween the first and the last interviews, and (2) between the first and the second interviews.

psychiatrist.

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analysis provides an estimate of the inde to McNair et al,10 a low score, which char pendent, simultaneous effects of several vari acterizes "Type B" therapists, predicts success ables, including quantitative data, such as age, with psychoneurotic patients.) A second type of and qualitative (classification) data, such as interaction effect was included in the pool by marital status. It also deals effectively with a generating the absolute value of the difference disproportional distribution of subjects among between the corresponding scores of the patient categories of classification data. The method and his student on the same characteristics, combines, in effect, the functions of analysis of except for marital status. variance, analysis of covariance, and multiple regression Table 1.Characteristics of 105 Patients analysis in a form sufficiently
This flexible to cope with many problems in the statistical evaluation of quantitative ob servations in real life situa tions. The analyses reported here employed the change in total weighted symptom checklist score as the dependent vari able. This criterion of symp tom change was analyzed with respect to a pool of inde pendent variables including all of the characteristics of the patient and all of the charac teristics of the student listed in Tables 1 and 2. (The dura tion of the patient's present illness in months was trans formed to its natural log, and the interaction between the patient's race and sex also was included in the pool.) As noted earlier, the pos sible importance of the match between the patient and his student was a topic of special interest. These effects were represented by generating and including in the pool a set of linear by linear interactions between corresponding char acteristics of the patient and his student, including age, marital status, social class index,9 A-B Scale score,1* SVIB Psychiatrist Scale score, optimism about the treatment, and patient's diag student's A-B Scale nosis score. (The A-B Scale con sists of 13 items from the SVIB. According to studies by Whitehorn and Betz,n a high score, which character izes "Type A" therapists, pre dicts success with schizo
Variable Class 105
Male

Range
18 to 51

Mean

Age
Sex
Race

30.96

Female White
Nonwhite

37 68 90
15

Religion
Marital status

Protestant

57

Catholic Other or

none

Single
Yes
No

Married

or

widowed
or

36 12 19 67
19

Separated
Children? Social class index

divorced

82

23
105
105

11 to 73
15 to 44

52.01

(Hollingshead)
Mother's age when

26.18

patient was born Age when family was disrupted by

death or separation of a parent Months ill

< 1 yrs.

1-6

7-12 >12

13 14 12 66 105

Ito 360

53.31

Diagnosis (APA* Nomenclature)

Psychotic disorders Psychoneurotic

disorders
Transient situational

65
26

Personality disorders personality disorders

Days between con

sultation and first student interview Initial weighted score for

105

0 to 264

36.14

Anxiety Depression

Anger Compulsions Other symptoms

Initial Ego Strength Scale score

105 105 105 105

Oto 19

105
105

Oto 23 0 to 6 0 to 8 5 to 79 18 to 58

8.84 10.11 2.65 2.73 38.17

37.94

(Barron)
Treatment expected

Talking
Medication Other or none

Optimism
A-B Scale

about
score

92 8 5 105
105 105 105 105

-3.77 to 1.79
1 to 12 3 to 54

0.02 7.91 29.05 7.98 6.35

treatment

(Whitehorn-Betz) SVIB Psychiatrist

Scale score Number of

6 to 10 1 to 10

appointments
Number of

appointments kept
*APA
=

phrenic patients. According

American

Psychiatric Association.

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Table 2.Characteristics of 105 Senior Medical Students

Variable
Class 105

Range
22 to 33

Age
Sex
Marital status

This value represents approx the 10% level of sig nificance in the present case with 105 patients.

imately

Male
Female

Single
Married Yes No

Children?

The complete multiple covariance analysis at the final Mother's age when 105 18 to 45 28.42 interview revealed a multi student was born ple correlation of 0.82 be 7 <7 yrs. Age when family tween the change in total 4 disrupted by death 7-12 > 12 94 or separation of weighted symptom check parent list score and the pool of 105 2.41 to 2.70 0.02 Optimism about independent variables. Put patient's prognosis otherwise, the complete set 105 3.37 to 2.24 Interest in patient 0.03 of independent variables ac AB Scale score 1 to 12 105 counted for about 67% of (Whitehorn-Betz) SVIB Psychiatrist 105 48.1 25 to 67 the variation in the criterion. Scale Score The overall F ratio was 1.894, with a computed Each analysis included two steps. First, a 0.012. Apparently the variables in the pool multiple covariance analysis of the symptom made an important contribution to the pa change scores in relation to the complete set of tient's symptomatic change across the series independent variables in the pool was per of interviews with the senior medical student. formed. This resembles the usual multiple The stepwise search of the pool revealed regression analysis. During inversion of the correlation matrix, however, five variables that a relatively small subset of independent showing a multiple correlation above 0.95 with variables jointly contributed most to symp the preceding variables in the matrix were tomatic change. Table 3 shows the multiple dropped from the analysis. covariance analysis which emerged from Second, the independent variables in the the search procedure. The six variables in pool were searched stepwise for the subset con the table gave a multiple correlation of 0.61 tributing most reliably to the change in total the criterion, explaining about 37% of weighted symptom checklist score. In order to with the pool and to remain in the its variation. be selected from The most important determinant of the selected subset, a variable was required at ev to show an F ratio of 2.76 (for 1 df). patient's symptomatic change was his initial ery step
(Hollingshead, family of origin)
=

Social class index

95 10 50 55 10 95 105

Determinants of
at the Final Interview
1

Symptomatic Change

l.to 66

Table

3.Multiple Covariance Analysis of Change in Total Weighted SCL Score at Final Interview Using Variables Selected From Pool by Search Option
Source
df MS

SE
29.10 3.55 8.25 12.01 3.03 7.47 0.72 2.23

Mean 5.39 1.88 2.87 3.47 10.10 -0.02 36.14 3.19

Initial wtd depression score Patient's initial optimism

Days waiting for Rx Natural log of No. months ill + 1 Student's SVIB Psych score Square of mother's age when student
Mother's age when student born

born

Total regression Error Total deviations Correction term TOT WTD SCL change

97 104

13075.45 1594.87 3705.11 5395.99 1363.39 3357.61 323.66 3718.99 449.37

669.44

4.12
-0.13 5.83
0.43

0.41 2.19

0.17 -0.39

0.04 1.68 0.25 0.06 0.45

1.74 2.73 0.85

48.18 23.20 28.42

8.28

19858.44
36.73

13.75

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score, which alone cor related 0.41 with the criterion. Patients with a higher initial level of depression improved
more

weighted depression (Fig 1).

The following characteristics of the pa tient also contributed to relief of symptomatFig 1.Four variables and symptom relief at final interview in 105 patients. Independent linear effects of
initial

tom

cluster, (2) student's SVIB Psychiatrist Scale Score, (3) patient's initial optimism about treatment, and (4) number of days patient waited between psy chiatric consultation and treatment.

(1) patient's

weighted

score on

depression

symp

60

ic distress: (1) greater general optimism at the outset about the probable outcome of treatment, as measured on a simple 7-point scale (Fig 1), (2) a shorter waiting period between psychiatric evaluation and the be ginning of treatment (Fig 1), and (3) great er chronicity of the present illness (Fig 2). The effect of chronicity was logarithmic, with the greatest increase in responsiveness occurring during the first ten years. The following characteristics of the stu dent also contributed to the patient's relief: (1) interests similar to those of successful psychiatrists as measured by the SVIB (Fig 1), and (2) his mother's age when he was born (Fig 3). The second effect was quad ratic: the most successful students were born to unusually young and especially to unusu ally old mothers. Determinants of Symptomatic Change at the Second Interview The complete multiple covariance analy sis at the second interview revealed a multi ple correlation of 0.72 between the change in total weighted symptom checklist score and the pool of independent variables. The overall F ratio in this case was only 0.988, indicating that the complete set of inde pendent variables did not relate significantly

WAIT\
20

h
-3.5 PT.'S OPTIMISM
0
0 25

ST.'S PSYCH SC.

DAYS WAITING

INITIAL DEPR

25 75

1.5 250
symptom

to their initial level.12 In order to test this specific hypothesis and to provide leads for

symptomatic change. However, there is strong prior evidence that change in biological functions is related
to

Fig 2.Duration of present illness and relief at final interview.

: tr

Fig 3.Mother's age when student symptom relief at final interview.

was

born and

40

o w < -i o o co

20

52
cl2

2
X

20

10

20

25

35

YEARS ILL

AGE IN YEARS

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future work, the pool was searched stepwise for individual variables possibly contrib uting to change in distress, despite the pre vious nonsignificant finding. The eight variables and their interactions which emerged from this procedure gave a multiple correlation of 0.63 with the crite rion. The most reliable determinant of the patient's symptomatic change was his initial weighted score on the cluster of "other" symptoms, which correlated 0.99 with the initial level of the criterion itself. The following characteristic of the patient also may have contributed to relief of symp tomatic distress: greater ego strength as measured by the initial score on the Barron Scale.13 The following characteristics of the stu dent also may have contributed to the pa tient's relief: (1) marriage and (2) greater age when the family of origin was disrupted by death, separation, or divorce of a parent. The following interactions between char acteristics of the patient and characteristics of the student also may have contributed to the patient's relief: (1) a closer match be tween the age of the student and the age of the patient, particularly among the younger patients, and (2) the match between the pa tient's diagnosis and the student's A-B Scale score. Patients with psychotic, personality, and transient situational personality disor ders felt greater relief with "Type A" stu dents, whereas patients with psychoneurotic disorders responded about the same to ei ther "Type A" or "Type B" students. Again, the preceding list of variables is presented only for its possible interest in fu ture work and in no sense as a dependable

provement, regardless of treatment, is

ex

pected. Previous studies also show that the initial level of depression is an important, nontreatment-related predictor of improve
ment

in pharmacotherapy.8'14'p96) These findings strengthen the suggestion in the first report of this study3 that the symptom clusters measure operationally different as pects of the patient's subjective state. The relation of the patient's expectations to his response to treatment is already well documented.1518 This study confirms the role of one such expectation, the patient's initial general optimism about change. The present results, however, differ from some of the previous findings in two respects: (1) The effects of the patient's optimism here is linear, rather than curvilinear.17 (3) The ef fect here is independent of his initial level of symptomatic distress. Whereas other studies1718"22)'19 empha size the relationship between the patient's expectation of relief and his initial level of distress, the patient's optimism in the pres ent study correlates no higher than 0.09 with
any of the initial

discrepancies probably reflect the dif fering techniques of eliciting the patients' expectation of relief. In previous studies these measures were tied to specific symp toms, whereas the present study dealt with a global attitude evaluated without reference
These
to

symptom cluster

scores.

result.
Comment

The results of this study support the view that the direction and amount of sympto matic change in psychoneurotic outpatients during a series of interviews depends upon a set of simultaneous effects in several broad areas including characteristics of the patient and characteristics of the interviewer. The observed effect of the patient's initial level of depression is in accord with clinical experience. Since depressive affect is fluc tuating and self-limited, proportional im-

a list of symptoms. The finding that patients who enter treatment soon after the psychiatric consul tation improve more than patients who must wait longer for a treatment opening agrees with the clinician's experience that prompt treatment brings the best result. Patients awaiting formal treatment, of course, often improve in response to informal therapeutic influences20 which are not yet fully under stood. Therefore, patients who still want treatment after a prolonged waiting period are, by and large less likely to respond read ily to therapeutic influences, whether formal or informal. The extraordinarily high im provement rate in a recent study of placebo treatment21 probably is attributable in large measure to the retention of highly responsive patients in the sample by instituting treat

ment

In this study the association of more chronic illness with greater improvement is

immediately.

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puzzling. Possibly the chronic patients in encouragement to explore such relationships this sample had mainly fluctuating illnesses22 in greater detail. The curvilinear form of the effects due to and a realistic expectation, derived from past with treatment, of partial relief the student's mother's age (quadratic) and experiences from the acute exacerbation. the chronicity of the patient's illness (loga The finding that students with interest rithmic) is another point of special interest. patterns more like trained psychiatists are It confirms increasingly frequent references in the literature26(p40) to the probable inade more successful with their patients seems eminently reasonable. One can only specu quacy of linear models in psychology. This late how well these interest patterns cor finding, then, indicates yet another direction relate with therapist variables influencing for further exploration. outcome in most other studies, such as "atti Interaction between patient characteris tudes toward psychiatry"17 and the "thera tics and treatment factors has been reported peutic conditions" of empathy, warmth, and in drug studies.827 The results presented genuineness.2 Intuitively all of these charac here offer no support for the analogous idea teristics seem to be closely related. The A-B that the "match" between certain character Scale score is the one therapist characteris istics of the patient and his therapist may be tic represented in this study which predicted critical determinants of symptomatic relief. outcome in previous studies. This study, Absence of positive findings in such a study, however, furnishes no convincing evidence of however, cannot refute a hypothesis. Cer its importance in symptomatic change, ei tainly the experienced clinician will consider ther directly or through correlation with the the method rather than the hypothesis as SVIB Psychiatrist Scale score. faulty in this case. On the other hand, it is worth considering The superior results obtained by students born of unusually young and especially unu seriously the obvious difficulty in assessing sually old mothers are another surprise find intuitively the nature of such highly com ing in this study. The predicted effect of plex situations. Can clinical acumen sense the student's mother's age was, of course, in whether events arise from many interacting the opposite direction. Perhaps students ex determinants, that is, with effects contingent posed to the special problems of a young or one upon another, or from many determi aging mother had developed greater inter nants contributing their effects in an addi tive pattern? Perhaps not, as the number of personal sensitivity. related consideration is the possi concurrent elements in the situation be Another ble confounding of effects due to the moth comes large. In this connection it is interesting that in er's age and the student's birth order. Stu dents with older mothers more likely would teractive effects do appear in certain prelim be last born children and so occupy a spe inary analyses of the data which have not cial, though not yet well understood, status been reported here. In the presence of more in the family. Students with younger moth powerful determinants, however, the impor tance of these interactions fades out. ers more likely would be first born children. The most striking development in this There is already some evidence that first born and only children, perhaps because of study, perhaps, concerns the contrast be their unique relationship with the mother, tween the findings at the last interview and at the second interview. In the analysis of more strongly seek out, maintain, and use relief at the last interview, an array of relia other people.23 <pll2>24 relationships with The high reliability of the student's moth ble determinants emerges. (These determi er's age in determining symptomatic im nants remain surprisingly similar in an provement is impressive. It suggests, like the analysis of symptomatic change from the studies on birth order, that early experi second to the final interview, ie, omitting the first week's change. This finding strengthens ences with the mother may determine not only severe pathological developments in a the view that these determinants are specific wide range of people,-'5 but also subtler to the longer-term response and not to the quantitative responses, especially in the af shorter-term response.) Although the analy fective sphere. These studies provide some sis of symptomatic change at the second

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interview produced some leads for later re search, the only reliable determinant at that point remains the patient's initial level of overall symptomatic distress. Even if the
leads

return to

a more

intensity of symptoms. All types of symp longer-term changes. The first report of this study describes toms appear to share more equally in the re several characteristic differences in sympto sponse. The change is significantly related to matic change at the second interview and at an identifiable array of specific variables the final interview. Ainslie,28 Jones,29 Stein- representing several definable areas. The book,30 and their collaborators also note dif emphasis shifts from the patient himself to ferences in earlier and later symptomatic include his interplay with a broader inter change. All of these findings together strong personal field. During this phase a therapeutic system ly suggest that symptomatic relief is not a unitary phenomenon, but is rather a develop develops with at least two critical partici ment with at least two relatively distinct, pants (components), the patient and the characteristic phases. therapist. Probably this notion can be ex The first phase is brief, lasting perhaps tended to include other participants, such as members of the clinic staff, family, col one to four weeks. It is marked by a precipi tous decline of subjective distress, largely leagues, and other patients.
due to a decrease in the number of symp toms rather than in their mean intensity. Affective symptoms, particularly angry feel ings, respond most. The decrease in pre senting symptoms is partly offset by new symptoms which appear regardless of treat ment. The initial level of the patient's symp tomatic distress is an important and reliable determinant of relief. This first phase of symptomatic change resembles many responses of living organ isms which depend upon the initial level of the responding function.1231 Affective re sponses may be special examples of the broad class of responses governed mainly by the central tendencies of biological systems in

patterns of determination for shorter- and

generated should pass further tests, they still would indicate markedly different

chological equilibrium. The second phase of symptomatic re sponse is longer, lasting more than four weeks. It is marked by a more gradual and erratic decline of subjective distress, due to
a

satisfactory

state of psy

decrease in both the number and the

mean

The characteristic effects of most thera

There are already indications that the dif ferential effects of pharmacologie agents ap pear most clearly in this phase.28 Since drugs rapidly affect the patient's internal

peutic factors may be especially evident in the second phase of symptomatic response.

physiological milieu, however, they must play a role when they are administered in the first phase of relief too. A previous study8 suggests that the effects of drugs oper ate quite differently in the two phases, and it

general.
The first phase of symptomatic change may be designated a "non-specific" or "pla cebo" response. Such responses correlate with a variety of other psychological varia bles, including the patient's expectation of relief1719 and the patient's "suggestibili

ty."30 According to Beecher, these responses re flect the "processing component" of illness, a state of high anxiety which responds read ily to a variety of interventions.32'"158)33 Frank34 repeatedly has pointed out the last ing value, often underestimated, of "non specific" interventions which promote the

will be interesting to pursue this possibility. The biphasic formulation of symptomatic response also raises many other questions. The two phases certainly blend into each other. How clearly can their limits be estab lished? Or would it be more useful to think in terms of two modes of response which are always operative but in different propor tions? Do other phases characterized by still different modes of response follow when treatment extends over a longer period of time? Alternatively, do the phases observed in this time-limited treatment correspond to those commonly observed in longer-term treatment? If so, what leads to their compres sion or expansion? With these and the ques tions posed earlier, the concept of a biphasic response in subjective distress indicates many avenues for further investigation.

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Summary
This is a quantitative study of certain subjective changes occurring in 128 primari ly psychoneurotic outpatients, each inter viewed weekly about six times by a senior

medical student on his clinical clerkship in psychiatry. The sample includes all "fresh" adult patients who were able to cooperate with the procedures for the study and who were assigned to medical students for at least six interviews during the academic years 1963 to 1966. Each patient saw a dif ferent student, and the assignment of pa tients to students was random. Each patient reported his subjective distress on a check list of 65 symptoms every week before his interview with the student. The determinants of symptomatic change were examined in 105 patients with com plete data on 35 variables including charac teristics of the patient (initial clinical status, history of the present illness and treat ment, current attitudes, past history) and characteristics of the student (current atti tudes, past history). The independent con tributions of these variables to symptomatic change were assessed by a multiple covari ance analysis including the complete set of independent variables. Analysis of the total symptom change score from the first to the last interview re vealed a multiple correlation coefficient of 0.82 with the set of independent variables and an F ratio of 1.89 (P = 0.01). The pa tient's initial depression score was the most important single determinant of change. Pa tients with a higher initial level of depres sion improved more. The following characteristics of the pa-

tient also contributed to relief of symptomat ic distress: (1) greater optimism at the out set about the probable outcome of treatment; (2) a shorter waiting period between psy chiatric evaluation and the beginning of treatment; and (3) greater chronicity of the present illness. The effect of chronicity was logarithmic, with the greatest increase in re sponsiveness occurring during the first ten The following characteristics of the stu dent contributed to the patient's relief: (1) interests similar to those of successful psy chiatrists as measured by the Strong Voca tional Interest Blank, and (2) his mother's age when he was born. The second effect was quadratic: the most successful students were bom to unusually young and especially to unusually old mothers. Analysis of the total symptom change score from the first to the second interview revealed only one reliable determinant, the
initial total symptom score. These results support the concept of a bi phasic response in symptomatic distress to therapeutic intervention. The first phase ap pears to be "non-specific," like the "placebo response." The second phase seems to mark a shift to a therapeutic system embracing other participants as well as the patient.
years.

This investigation was supported by Public Health Service grants MH-06350 and 2-K3-MH-18,611 from the National Institute of Mental Health (NIMH). The statistical procedures were developed in part under grant No. MH-04732 from the NIMH. Compu tations were performed at the Computing Center of the Johns Hopkins Medical Institutions which is supported by grant No. FR-00004 from the National Institutes of Health. Mrs. Ruth Boggs, Mrs. Susan Bryan, Mr. Clay Kallman, Mrs. Mary Sewell, and Mrs. Carol Taylor aided in their technical assistance.

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