Continuance in psychotherapy as a functionof expectations and socioeconomic status

Item Type text; Thesis-Reproduction (electronic)

Authors Foote, Janis Elaine, 1949-

Publisher The University of Arizona.

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CONTINUANCE IN PSYCHOTHERAPY AS A FUNCTION OF

EXPECTATIONS.AND SOCIOECONOMIC STATUS

by

Janis Elaine Foote

A Thesis Submitted to the Faculty of the

DEPARTMENT OF PSYCHOLOGY

In Partial Fulfillment of the Requirements For the Degree of

MASTER OF ARTS

In the Graduate College

THE UNIVERSITY OF ARIZONA

1 9 7 5

STATEMENT BY AUTHOR

This thesis has been submitted in partial fulfillment of re­quirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library.

Brief quotations from this thesis are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the head of the major department or the Dean of the Graduate College when in his judg­ment the proposed use of the material is in the interests of scholar­ship. In all other instances, however, permission must be obtained from the author.

SIGNED

APPROVAL BY THESIS DIRECTOR

This thesis has been approved on the date shown below:

ACKNOWLEDGMENTS

My appreciation is extended to Tucson East Community Mental

Health Center for allowing me to conduct this research a:t their facility.

I would especially like to acknowledge the advice and support given me

by Spencer McWilliams. The suggestions of Marvin Kahn and Phillip Balch

were invaluable in the design of this study and the interpretation of

results.

TABLE OF CONTENTS

. Page

LIST OF TABLES . . . . . . . . . . . . . . . . . v

ABSTRACT ........... . . . . . . . . . vi

INTRODUCTION . . . . . . . . . . . . . . . . . . . 1

Clinic Policies ............... . . . . . . . . 2Therapist Characteristics . . . . . . . . . . . . . . . . . . 2Client Characteristics ..................... . . . . . . . . 4

METHOD......................... 12

Subjects . . . . 12Instrument . . . . . . . . . . . . . . . . . . . . . . . . . . 12Procedure .. ........ . . . . . . . . . . . . . . . . . . . 13

RESULTS . . . . . . . . . . . . . . . . . . . . . . . 15

DISCUSSION . . . . . . . . . . . . . . . . . . . . 20

APPENDIX A: EXPECTATIONS OF THERAPY . . . . . . . . . . . . . . . 24 -

APPENDIX B: PERCEPTIONS OF THERAPY ............. . . . . . . . . 26

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . 28

iv

LIST OF TABLES

Table Page

1, Social Class Differences Between Experimental andControl Subjects................. 16

2, Differences Between Experimental and Control Sub­jects Regarding Scheduled Second Appointment « « 16

3, Differences Between Experimental and Control SubjectsRegarding Return for Second Appointment . . 17

4, Socioeconomic Status and Scheduled Second Appointment . * 17

5„ Discrepancy Score and Scheduled Second Appointment . . . . 18

6, Socioeconomic Status and Return for Second Appointment , . 18

7„ Discrepancy Score and Return for Second Appointment „ 0 » 19

8» Socioeconomic Status and Discrepancy Score . . . . . . . . 19

v

ABSTRACT

In recent years, the issue has been raised as to why people fail

to return after an initial interview at a mental health center. The

present study investigated two variables which appear to distinguish

non-continuers from continuers in therapy: membership in a lower socio­

economic class, and discrepancy between expectations and perceptions of

the therapeutic situation. A questionnaire eliciting standardized demo­

graphic and historical information was administered to a total of 532

subjects at a community mental health center. Of these, an experimental

group of 340 subjects also completed a pre-interview questionnaire

recording expectation of what the therapeutic situation would be like,

and a post-questionnaire recording perceptions of the interview. No

social class differences between continuance and non-continuance were

found, and discrepancies between expectations and perceptions were not

related to continuance in therapy. Possible explanations for the discre­

pancy between these results and those reported in most prior research

were discussed.

INTRODUCTION

With the increased demand by the community in recent years for

psychiatric care has come an increased interest in the effectiveness of

mental health clinics. One major area of research involves the issue of

why people fail to return after an initial interview at a mental health

center, or terminate treatment prematurely. Various studies have shown

that from 30 to 65 percent of all patients referred to facilities repre­

senting a broad range of psychiatric service are drop-outs (Adler, Coin

and Yamamoto 1963; Eiduson 1968; Levinger 1960; Lorr, Katz and

Rubenstein 1958; Perlman 1960).

The investigation of this phenomenon is of importance for several

reasons. One of these is the economic waste involved. The intake pro­

cess involves time, money, and the energies of the clinic staff. Accord­

ing to Raynes and Warren (1971b), at a time of increasing demands by the

community for psychiatric care, and a shortage of manpower resources

available to the clinics to meet these demands, the high initial drop­

out rate of patients from clinics is an indication of their failure to

provide adequate services. A more serious problem, however, involves

the fate of the people who come to a mental health facility for the first

time. This is usually a time when their motivation is high enough to

seek help. The initial contact with the agency is of crucial importance

in determining whether the person will maintain the motivation necessary

to receive the help he is seeking.

It has been suggested that such "drop-out" behavior may be due

to a number of variables and combinations of variables, including clinic

policies, characteristics of the intake interviewer, the interviewer-

clinic relationship, and characteristics of the patients and their pre­

senting problems.

Clinic Policies

The clinic policy variable that has received the most attention

is that of the waiting period, i.e., the time between referral and

appointment. Although Gould, Paulson and Daniels-Epps (1970) and Paynes

and Warren (1971a) report that they have found no relationship between

the length of time between the potential client's initial call for an

appointment and appointment given, and show or no-show behavior, several

studies indicate that this factor might be involved in high initial drop­

out rates (Brown 1962, Heyder 1960, Korner 1963, Maholick and Shapiro

1962, Raynes and Warren 1971b). Another clinic policy, that of ex­

cessively compulsive and long-winded intake procedures, has been suggest­

ed as accounting for high initial drop-out rates (Chafetz 1962, Maholick

and Shapiro 1962). Phillips (1967) has suggested that making steps in

clinical practice less discrete, simplifying evaluation, getting patients

into treatment immediately, and delineating treatment regiments and goals

might be effective in decreasing attrition, or premature termination of

psychotherapy.

Therapist, Characteristics

As Levinger (1960) points out in a research summary, there is

little available knowledge concerning the personal characteristics of

the therapist which may have an influence on the clientfs continuance

in therapy. However, some research indicates that while the thera­

pists* professional training per se is unrelated to the patientfs con­

tinuance, his warmth and social distance from the patient may play an

important role (Levinger 1960)„ Therapist attitudes toward patients

have also been investigated as being an important variable in continu­

ance. Salzman et al. (1970) asked interviewers to complete a question­

naire regarding their attitudes toward the applicant at the end of the

initial consultation. It was found that feelings of some degree of

anger on the part of the interviewer during the initial meeting were

recorded significantly more frequently toward those applicants who sub­

sequently dropped out of. therapy than toward those who continued.

White, Fichtenbaum and Bollard (1964b) also concluded that interviewers*

attitudes of like or dislike toward outpatient applicants during the

initial consultation may be instrumental in the client's decision to

return for a second appointment. Lowinger and Dobie (1966) used a

questionnaire to investigate therapist attitudes towards clients in the

initial interview and also found that negative attitudes held by the

therapist significantly determined the number of return visits by out­

patients for treatment. Baum, Felzer, D1 Zmura and Shumaker (1966; p. 633)

describes those therapists who have a lower drop-out rate, especially

with lower socioeconomic patients, as being "more secure, more clinically

experienced, task oriented and aware of patient needs, and who are able

to make use of a broad spectrum of psychotherapy in a flexible way.11

As Levinger (1960) points out, more research is needed concerning the

4role of therapist attitudes and characteristics play in continuance in

psychotherapy.

Client Characteristics

Among the characteristics of clients that have been investigated

..in relation to client continuance in therapy are sex (Adler et al. 1963,

Heyder I960, Kidd and Euphrat 1971, Raynes and Warren 1971a, 1971b,

Salzman et al. 1970); age (Meyer 1967, Raynes and Warren 1971b); race

(Adler et al. 1963, Meyer 1967, Raynes and Warren 1971b, Salzman et al.

1970); marital status (Adler et al. 1963, Meyer 1967, Raynes and Warren

1971b, Salzman et al. 1970); previous psychiatric care (Adler et al.

1963, Raynes and Warren 1971b) ; presenting problem (Kagen 1957, Raynes

and Warren 1971b); degree or stage of problem at time of request for help

(Gould et al. 1970); religion (Salzman et al. 1970); history of parental

loss (Raynes and Warren 1971a) ; and individual referral source (Adler

et al. 1963; Raynes and Warren 1971a, 1971b). Other patient character­

istics that have been studied as possibly related to continuance in

therapy include ego defense patterns (Hoffman 1969, Lowinger and Dobie

1966); extent to which the client reports experiencing feelings and own

problems during the initial interview (Kirkner and Cartwright 1958) ;' ' >

intellectual capacity (Kagen 1957); duration of symptoms (Meyer 1967);

amount of client verbalization during the initial interview (White et al.)

1964a, 1964b); motivation for treatment (Borghi 1968, Pfouts, Wallach

and Jenkins 1963) ; anxiety and dependence (Borghi 1968); socioeconomic

class (Adler et al. 1963, Borghi 1968, Kidd and Euphrat 1971, Meyer 1967,

Overall and Aronson 1963, Salzman et al. 1970, White et al. 1964a); and

expectations of the patient concerning the therapeutic situation (Baum

and Felzer 1964, Borghi 1968, Clemes and DfAndrea 1965, Eiduson 1968;

Freedman et al. 1958, Fisher and Cohen 1972, Fisher and Turner 1970,

Goldstein 1960, 1962, Heine and Trosman I960; Kamin and Caughlin 1963;

Levitt 1966, Lorion 1973, Lorian, in press, Lorr and McNair 1964,

Overall and Aronson 1963, Perlman 1960, White et al. 1964a, Williams

et al. 1967), Among these client variables studied, three, those of

higher socioeconomic status, self-referral, and realized expectations of.

therapy seem to be consistently related to continuance in therapy. ,

Based on these studies and others, some investigators have

attempted to devise global descriptions of non-continuers in therapy.

In a summary of research findings, Shyne (1957) suggests that the

following are characteristic of people who come for help to a mental

health clinic, but don’t respond to offers of further service; lack

of acceptance of responsibility for the existence of the problem; lack

of realization of the need to participate in its solution; low motiva­

tion for solution of the problem; resistance to the therapist’s explora­

tions; and negative attitudes of other family members. Also character­

istic of patients who tend to drop out, according to Garcia and Irwin

(1962), is the tendency to use the defense mechanisms of denial and pro­

jection, and the tendency to focus on environmental pressures rather than

on personal conflicts or interpersonal relationships. Conversely, it

has been suggested by Lake and Levinger (1960) that the characteristics

of continuers at a child guidance clinic are as follows: sees the

problem himself rather than its being brought to his attention by others;

a desire to see a change in himself; higher cooperation with the counse­

lor concerning the nature of the core problem. Several other investi­

gators have also suggested descriptive summaries which they believe to

be helpful in distinguishing continuers from non-continuers (Carter

1969, Dodd 1970, Levinger 1960, Katz and Rubenstein 1958, Raskin 1961,

Taulbee 1958, Von Atta 1968, Wolff 1967)e

Within the research three client variables appear to distinguish

somewhat consistently between continuers and non-continuers. It has

generally been found that those individuals least likely to return to a

mental health clinic after their initial appointments are referred by a

physician or social agency rather than self-referred or referred by

significant others, e.g., family and friends (Adler et al, 1963; Raynes

and Warren 1971a, 1971b), are members of a low socioeconomic class

(Adler et al. 1963, Chafetz 1965, Levinger 1960, Overall and Aronson

1963, 1966, Raynes and Warren 1971a, White et al. 1964a), and experience

greater discrepancy between their expectations and their perceptions of

the therapeutic situation (Borghi 1968; Clemes and D'Andrea 1965,

Eiduson 1968; Heine and Trosman 1960; Lorion 1973; Overall and Aronson

1963, 1966; Perlman 1960).

The focus of this research is on two of the above variables,

socioeconomic class and expectations of therapy.

A focus of interest over the last several years has been the

quality of mental health services offered to individuals in lower socio­

economic groups. These people are less likely to actively participate

in treatment programs, and remain in therapy for a shorter period of

time. Members of low socioeconomic classes are also more likely to be

seen in therapy by relatively low status counselors and to receive

somatic rather than dynamic treatment.

The most widely used technique for determining the socioeconomic

status of an individual is the Hollingshead Two-Factor Index of Social

Position (Hollingshead 1957), This instrument utilizes the factors of

occupation and education to estimate the social position of individuals

in our society. It is presumed that occupation reflects the skill and

power people possess as a function of their work, and education reflects

knowledge, as well as cultural tastes. Each factor is scaled according

to a specified system of scores, and then combined by weighing the

individual scores. Multiple correlation, techniques were used to de­

termine the weights of each factor, which are 7 for occupation and 4 for

education. The combined scores are divided into a hierarchy of five

score groups. The groups are referred to as Classes I and II, repre­

senting upper socioeconomic status. Class III which refers to the middle

level of status, and Classes IV and V representing the lower socio­

economic groups.

Expectations of treatment as a function of social class have been

hypothesized to be related to differential continuance in therapy,

Hollingshead and Redlich (1958) present a description of the treatment

expectations held by lower socioeconomic patients in their discussion of

class factors in psychotherapy which includes the desire for practical

advice about how to solve their problems and run their lives, physical

treatment of problems, and the expectation of an authoritarian attitude

on the part of the therapist.

Other researchers have studied expectations and their relation

to continuance in therapy. The subject of mutuality of expectations

between the therapist and the patient has been investigated by Borghi

(1968), By conducting home interviews with 58 individuals who pre­

maturely dropped out of therapy, he found that terminators reported

expectations of therapy which were consistently incongruent with those

of the therapist. Four kinds of incongruent expectations commonly

expressed by these individuals were unrealistic expectations, expecta­

tions of advice, expectations that ,fsomething be done" about the spouse,

and expectations concerned with an answer to the question, "Am I

mentally ill?" Heine and Trosman (1960) were also interested in patient-

therapist expectations, A questionnaire devised by these investigators

to obtain information regarding the patient’s reasons for coming to the

clinic, his expectation as to the kind of help he would be offered and

how this would be given, and the degree of confidence he had that therapy

would be helpful, was administered to incoming clients at a mental health

center. They found that neither the presenting problem, nor the confi­

dence in therapy held by the potential patients were related to con­

tinuance in therapy. However, the expectations the client held re­

garding the kind of therapy he would receive, and the method by which he

would receive it, were related to continuance. These researchers also

investigated the conceptions of therapy held by the therapist and dis­

covered three modal expectation^: that the client would want a thera­

peutic relationship in which he could talk freely about himself and his

problems; that he would consider the relationship as helping relieve his

discomfort5 rather than the therapist; and that he should feel some re-)

sponsibility for the outcome of therapy. These therapist expectations

are interesting in light of the fact that some investigators have found

lower-class individuals to be very uncomfortable with "talking therapies11

being more action oriented, and more likely to be seeking direct relief

of symptoms (Riessman and Goldfarb 1964, Block 1968),

Heine aind Trosman (1960) concluded from this research that the signifi­

cant variable in continuance is mutual therapist-client expectations.

Clemes and D’Andrea (1965) used the questionnaire developed by

Heine and Trosman (1960) for their research on client expectations of

therapy and found that when clients experienced interviews which were

consistent with their expectations of what therapy would be like, they

tended to be less anxious than clients experiencing interviews which

were incompatible with their expectations.

Perlman (1960) and Eiduson (1968) were specifically concerned

with what happens during the intake phase of therapy. Perlman has sug­

gested that applicant behavior during this period may be heavily con­

ditioned by his idea of what is expected of him, and what he may in

' return expect from therapy, while Eiduson reports that intensity of

motivation and early expectancies are significant factors for therapy

continuance.

Of particular interest is a study conducted by Overall and

Aronson (1963). These investigators were interested in the expectations

of psychotherapeutic procedures of patients of low socioeconomic status

(Hollingshead and Redlich's Classes IV and V). In order to study this

10they devised a 35-item questionnaire designed to tap one of five aspects

of a therapist’s behavior: active, medical, supportive, passive and

psychiatric. This questionnaire was administered twice, immediately

preceding and at the conclusion of the initial interview. An analysis

of the results of this study indicated that the greater the discrepancy

between the expectations and the perception of the interview, the less

likely the patient was to return to the clinic after the initial inter­

view for further treatment. Although these results are relevant con­

cerning.the issue of why lower class patients become "drop-outs,11 they

fail to provide any information concerning why individuals who are not

members of low socioeconomic classes also terminate treatment prematurely.

In a later study, Overall and Aronson (1966) investigated the thera­

peutic expectations of a comparable group of middle class individuals

and concluded that this group held expectations which differed from

those of the lower socioeconomic patients. However, they did not in­

vestigate the function of the fulfillment of the middle-class group’s

expectancies in the return to treatment after an initial interview by

>these individuals.

Several recent findings have reported few social class related

differences in attitudes and expectations of therapy (Kadushin 1969,

Fisher and Cohen 1972; Fisher and Turner 1970, Calhoon, Dawes and

Lewis 1972). Lorion (in press) reports on a study in which he utilized

items from the Overall and Aronson questionnaire which discriminated

among Class III and IV and Class V and found no significant social class

differences. He suggests that the conclusion that the expectations of

11lower socioeconomic clients is significantly different or more negative

than middle or upper socioeconomic status individuals is unsupported.

The present study will investigate the Overall-Aronson findings

that the greater the discrepancy between the expectations and the per­

ceptions of the interview the less likely the lower-class patient was to

return for further treatment across classes, in order to determine if

failed expectations are also an important factor in the high initial

drop-out rate of individuals of other social classes. This study will

investigate the expectations of therapy held by individuals in all social

classes, unlike the 1974 study by Lorion in which only individuals from

Classes III, IV and V were compared.

METHOD

Subjects

Subjects were selected from consecutive therapy intakes at the

two outpatient clinics of Tucson East Community Mental Health Center for

a period of one year. Only those clients who were 18 years or older and

who were new admissions to the center were included. The total sample

size was 532 subjects. Of these, 340 were experimental subjects who

completed the test questionnaire. The control group was composed of 192

clients who did not complete the test questionnaire. The control group

was used to investigate possible effects of questionnaire taking on the

scheduling of and return for a second appointment at the clinic, and

consisted of those new initiates during 13 randomly selected weeks from

the 52-week data collection period.

Instrument

The instrument used was a modified version of a questionnaire

constructed by Overall and Aronson (1963) concerning the possible be­

haviors of a therapist in an initial interview, together with a ques­

tionnaire eliciting standardized demographic and historical information.

The expectation questionnaire consisted of 20 questions, ten of which

were devised to tap one of five aspects of a therapist1s behavior (see

Appendix A). The categories representing these aspects are as follows.

12

131. Directive. The client is actively instructed by the therapist.

2. Medical. The focus of therapy is on the client's organic or

physical problems.

3. Supportive. An attempt is made by the therapist to put the

client at ease by avoiding charged material.

4. Non-directive. The direction of the discussion is left to the

client.

5. Insight. The focus of the therapeutic situation is on emotional

or dynamic material.

The remaining ten questions concerned the client's expectation

of his own behavior in the therapeutic situation, and consisted of

questions tapping the same five areas. An affirmative response to the

questionnaire item indicated that the client expected that the therapist,

or they themselves, would engage in that behavior in the session.

Procedure

Standardized demographic and historical information needed to

determine the social class of the client was obtained as part of the

standard clinic application for services. Each client completed the

application and questionnaire immediately preceding his initial inter­

view with the therapist to obtain his expectations of the therapeutic

procedure. The expectation questionnaire was part of a larger research

project which included other information not relevant to this study.

Immediately following the conclusion of the initial interview the client

was given a post-questionnaire to record his perceptions of the interview.

14The post-questionnaire asked the patient to indicate if each of the

20 target behaviors from the questionnaire occurred during the first

session (see Appendix B).

RESULTS

Experimental and control subjects were compared on the basis of

their socioeconomic status with a chi-square analysis. The results of

this analysis (Table 1) indicated that there were no significant social

class differences between these groups.

Chi-square analyses of the differences between experimental and

control subjects regarding whether a second appointment was scheduled

(Table 2), and if so, whether it was kept (Table 3) were significant,

indicating that the administration of the questionnaire per se had no

effect on the scheduling of, or return for a second appointment.

Within the experimental group assessments of the variables of

socioeconomic status, discrepancy score, scheduled second appointment,

and return for a second appointment were performed with chi-square

analyses. No significant differences were found between socioeconomic

status and scheduled second appointment (Table 4); discrepancy scores

and scheduled second appointment (Table 5); socioeconomic status and

return for second appointment (Table 6); discrepancy score and return

for second appointment (Table 7); or socioeconomic status and discrepancy

score (Table 8).

15

16Table 1. Social Class Differences Between Experimental and Control

Subjects.

. SESI & II III ' IV V Total

Control 19(34%) 57(43%) 70(33%) 46(36%) 192

Experimental 39(67%) 75(57%) 143(67%) 83(64%) 340

Total 58 132 213 129 532

= 4.1286 with 3 df; p > .20

Table 2. Differences Between Experimental and Control Subjects Regard­ing Scheduled Second Appointment.

Control Experimental Total

Scheduled Second Appointment 159(83%) 288(85%) 447

No Second Appointment 33(17%) 52(15%) 85

Total 192 340 532

= .3274 with 1 df; p > .50

17Table 3. Differences Between Experimental and Control Subjects Regard­

ing Return for Second Appointment.

Control Experimental Total

Return

No Return

126(79%)

33(21%).

233(81%)

55(19%)

359

88

Total 159 288 447

X2 = .1778 with 1 df; p > .50

Table 4. Socioeconomic Status and Scheduledi Second Appointment.

SESI & II III IV V Total

Scheduled Second Appointment 51(88%) 114(86%) 178(84%) 104 (81%) 447

No Second Appoints ment 7(12%) 18(14%) 35(16%) 25(19%) 85

Total 58 132 213 129 532

X2 = 2.3437 with 3 df; p >,.50

18Table 5. Discrepancy Score and Scheduled Second Appointment.

Discrepancy0-1-2 3-4 5-6 7-15 Total

Scheduled Second Appointment 71(89%) 87(85%) 63(80%) 67(85%) 288

No Second Appoint­ment 9(11%) 15(15%) 16(20%) 12(15%) 52

Total 80 102 79 79 340

X2 = 2.5371 with 3 df; p > .30

Table 6. Socioeconomic Status and Return for Second Appointment.

SESI & II III IV V Total

Return 30(81%) 56.(86%) 96 (81%) 51.(75%) 233

No Return 7(19%) 9(14%) 22(19%) 17 (25%) 55

Total 37 65 118 68 288

x2 = 2.815 with 3 df; p > .30

19Table 7. Discrepancy Score and Return for Second Appointment.

Discrepancy0-1-2 3-4 5-6 7-15 Total

Return 58(82%) 67(77%) 54(86%) 54(81%) 233

No Return 13(18%) 20(23%) 9(14%) 13(19%) 55

Total 71 87 63 67 288

X2 = 1.8307 with 3 df; p > .70

Table 8. Socioeconomic Status and :Discrepancy Score.

SES Discrepancy0-2 3-4 5-6 7-15 Total

I & II 15(21%) . 11(12.5%) 5(8%) 6(9%) 37

III 18(25.5%) 24(27.5%) 11(17%) 12 (18%) 65

IV 23(32.5%) 32(37%) 32(51%) 31(46%) 118

V 15(21%) 20(23%) . 15(24%) 18(27%) 68

Total 71 87 63 67 288

x2 = 11.9387 with 9 df; p > .20

DISCUSSION

The present study fails to support the findings of prior studies

investigating the issue of why people fail to return after an initial

interview at a mental health center. No social class differences between

continuance and non-continuance were found, and discrepancies between

expectations and perceptions were not related to continuance in therapy.

These results suggest that prior findings and methodology must be re­

evaluated.

There are several explanations for the discrepancy between these

results and those reported in most prior research. The failure of this

study to find a relation between social classes and continuance in

therapy may be accounted for by the fact that the opportunity to learn

about therapy is no longer more available to the upper classes. In­

creased public exposure to mental health, through such media as maga­

zines, books, movies, and television, which have increasingly presented

information regarding psychotherapy in a favorable manner, may have

resulted in increased sophistication of the lower social classes, as

well as greater acceptance of the work of mental health professionals.

Another possible explanation that must be taken into account is

that the Hollingshead Two-Factor Index of Social Position may no longer

be an adequate method by which to differentiate and classify people into

various social classes. The variables of education and occupation/may

20

21no longer be as relevant to the.determination of social status.

Weighting of the factors needs to be re-evaluated, taking into con­

sideration the shortage of jobs, especially for highly educated indi­

viduals in our society today.

The evaluation of additional factors in the assignment of social

position should also be considered. One such additional factor which

must be given consideration is the area from which subjects are selected.

For example, the behavior, expectations and perceptions of social class

IV people who reside in a large city, as in the Overall-Aronson research

(1963, 1966) may be extremely different from social class IV people re­

siding in a smaller town or more rural area. The present study consisted

of residents of the Tucson East Community Mental Health Center catchment

area. This region is on Tucson's relatively prosperous east side, and

serves a predominately white, middle-class oriented population. The

attitudes toward psychotherapy held by social classes IV and V of this

population may be quite discrepant from the views held by lower class

individuals who have experienced life in a different city. In a recent

survey of the attitudes held by a representative sample of the population

included in the Tucson East catchment area regarding mental health

services, findings indicated that these individuals have "generally

favorable attitudes toward mental health centers, support their existence,

would use them if a need arises, and expect positive results from such

treatments" (McWilliams and Morris 1974, p. 242). The generalizability

of these findings to other populations remains to be demonstrated.

Attitudes of subjects residing in other areas, especially the class IV

and V subjects, needs to be investigated to determine if differences in

behavior, expectations and perceptions of therapy may be more a function

of characteristics of the area of residence, rather than the Hoilingshead

social status classification.

Referral source may also be an important factor in continuance

in therapy. This variable may achieve added importance when considered

in relation to the area from which the subjects are selected. Involun­

tary clients, e.g., those referred through the courts, may be more

prevalent in larger cities. These clients may be less motivated and

less willing to continue in therapy, regardless of consistent or in­

consistent expectations and perceptions, than are voluntary clients who

are actively seeking help with their problems. An investigation of

source of referral across studies conducted in different areas is neces­

sary to determine if this variable is a factor in over-all continuance

in psychotherapy (Lorian, in press). Support for this hypothesis may be

found in a recent investigation of factors associated with length of

stay in psychotherapy of lower socioeconomic status clients from a barrio

neighborhood in Tucson (Kahn and Heiman 1974). The results of this study

indicated that one characteristic of lower socioeconomic clients who

stay long term in treatment versus lower socioeconomic status clients

who do not, is self-referral. According to Kahn and Heiman (1974, p. 5),

"an increased proportion of self-referral or self-help seeking behavior

on the part of these longer staying patients, suggests that motivation

for help and perhaps also enough knowledge and sophistication to know

where and how to seek it are important."

23A further explanation for the discrepant results is that previ­

ous studies may have confounded race with socioeconomic status. Al­

though this factor has not been found to be significantly related to

continuance in therapy, the factor of race must be taken into account,

as differing expectations, perceptions and levels of continuance in

therapy may be more a function of differing cultures, rather than differ­

ent occupations and different levels of education. For example,

Overall and Aronson (1963), using Black subjects found a relationship

between socioeconomic status and continuance in therapy, whereas Lorion

(1973) and the present study, using predominately Caucasian sucjects

failed to find such a relationship.

The suggestion that differences among socioeconomic groups may

be more ones of degree than of kind (Baum and Felzer 1964; Clemes and

D1Andrea 1965; Hollingshead and Redlich 1958; Lorion, in press) needs to

be investigated. According to this viewpoint, little is initially known

about therapy, how it works, how long it continues, or what is appro­

priately discussed during therapy sessions, by people of all socio­

economic classes. The understanding of psychotherapy may be a gradual

process which is acquired at different rates by people of varying social

classes (Garfield 1971). Such differences of degree may not have been

reflected in the type of research so far conducted.

APPENDIX A

EXPECTATIONS OF THERAPY

DO YOU THINK YOUR THERAPIST WILL

1, Talk about why you behave the way you do?

2c Give you medication?

3, Give you advice?

4, Expect you to do most of the talking?

5, Sympathize with the trouble you are having?

6, Ask about personal, sensitive problems?

7» Give you a physical exam?

8. Tell you what is causing your trouble?

9c Try to understand how you feel about things?

10. Show you that things aren’t as bad as they seem?

DO YOU THINK YOU WILL

1. Talk about your thoughts and feelings?

2. Talk about your aches and pains?

3. Ask your therapist to tell you what’s wrong

with you?

4. Listen more than you will talk?

5. Try to get your mind off your troubles?

24

6, Talk about how you get along with people?

7. Talk about past illnesses and operations?

8„ Ask your therapist to tell you what to do

to solve your problems?

9. Help to figure out your own solutions to ,

problems?

10, Avoid talking about things which would upset

you?

APPENDIX B

PERCEPTIONS OF THERAPY

YES

DID YOUR THERAPIST

1, Talk about why you behave the way you do?_________ ___

2/ Give you medication? ___

3, Give you advice? ___

4, Expect you to do most of the talking? ___

5, Sympathize with .the trouble you are having? ___

6, Ask about personal, sensitive problems? ___

7, Give you a physical exam? ___

8, Tell you what is causing your trouble? ___

9, Try to understand how you feel about things?______ ___

10. Show you that things aren't as bad as they seem? ___

DID YOU

1. Talk about your thoughts and feelings?____________ ___

2. Talk about your aches and pains?__________________ ___

3. Ask your therapist to tell you what's wrong,

with you?

4. Listen more than you will talk? ___

5. Try to get your mind off your troubles? __ _

26

6. Talk about how you get along with people?

7. Talk about past illnesses and operations?

8. Ask your therapist to tell you what to do

to solve your problems?

9„ Help to figure out your own solutions to

problems?

10. Avoid talking about things which would upset

you?

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