uhl i 1968

8/6/2019 Uhl I 1968

1/11

Subjective Change With MedicalStudent Therapists

I. Course of Relief in Psychoneurotic OutpatientsE. H. Uhlenhuth, MD,and David B. Duncan, PhD, Baltimore

M PSYCHONEUROTIC patientscoming for treatment are especially con-cerned about the distressing quality of theirsubjective experience in living. What countsmost for the patient is the way he feelsabout himself and his situation, and theinitiation, maintenance, and interruption ofthe treatment situation itself follows mainlyfrom these feelings. Novey1 has emphasizedthat, with such patients, the psychiatrist,too, sets goals and evaluates progress largelyin terms of the patient's inner experience,and quite properly so.Psychoneurotic patients from the lower

socioeconomic classes increasingly seek re-lief of distress through outpatient clinics as-sociated with medical schools. Here they areusually assigned to trainees for their psychi-

atric care2(p273) whichmust

be integratedwith the requirements of the training pro-gram. The medical student's first attemptsat psychotherapy perhaps offer the greatestpotential for conflict with the patient'swelfare.3(p153) What relief can patients ac-tually obtain with such untrained helpers?The lack of concrete information on thisquestion is all the more surprising in view ofthe concern frequently voiced on the subjectby both practicing and academic psychi-

atrists.This, then, is a quantitative study of cer-tain subjective changes occurring primarilyin psychoneurotic outpatients during thecourse of a series of interviews with seniormedical students on a clinical clerkship. Thekind, amount, and course of change are de-scribed in this report. Some determinants ofchange will be described in a subsequent re-`port.

Setting and Design

This study took place in the outpatient department of the Henry Phipps PsychiatricClinic, where the senior medical students of theJohns Hopkins University for many years haveserved a clinical clerkship of nine to ten weeks.

At the beginning of this clerkship each student

is assigned a previously evaluated outpatient forweekly interviews approximately an hour long.The interviews, with few exceptions, take placewith only the patient and the student present.Immediately afterward, the student discussesthe interview for one-half hour with an instructor who is usually a senior staff member,rarely a resident.

This study approached the question of changethrough "naturalistic observation" of the ongoing clinical situation. The compromise between close observation and distortion of the

observed phenomena4 was drawn somewhat infavor of the former: research data were collected directly from the student and his patient.These procedures are summarized in Table 1.

Measures of Change

Each patient reported his symptomaticdistress at intervals of one week by markinga checklist5 of 65 symptoms to indicate howmuch each complaint bothered him during

the past week: not at all, a little, quite a bit,or extremely. The patient filled out the listprior to meeting with the student each time.Each list was scored in several ways, and allscores were adjusted proportionately formissing items.

Total Number of Complaints (TOT NOSX).This score was obtained by countinghow many of the 65 symptoms the patientmarked as complaints (a little, quite a bit,or extremely).

Total Weighted Score (TOT WTD SCL).This score was obtained by summing theweights for the 65 individual symptoms asfollows: not at all, 0; a little, 1; quite a bit, 2;and extremely, 3.

Submittedfor

publication Sept 26,1967.

From the departments of Psychiatry and Behav-ioral Sciences (Dr. Uhlenhuth) and Statistics andBiostatistics (Dr. Duncan), Johns Hopkins Uni-versity, Baltimore.

Reprint requests to 601 N Broadway, Baltimore21205 (Dr. Uhlenhuth).

at Johns Hopkins University, on June 16, 2011www.archgenpsychiatry.comDownloaded from
http://www.archgenpsychiatry.com/http://www.archgenpsychiatry.com/http://www.archgenpsychiatry.com/http://www.archgenpsychiatry.com/

8/6/2019 Uhl I 1968

2/11

Total Intensity Score (TOT SCL DJT).This score was obtained by dividing thetotal weighted score by the total number ofsymptoms.

Total Number of Target Symptoms

(TOT NO T/S).The patient's targetsymptoms were defined as the complaints hemarked on his first symptom checklist. Oneach succeeding checklist the total numberof target symptoms was obtained by countinghow many of the original target symptomsthe patient still marked as complaints.

Total Weighted Target Symptom Score(TOT WTD T/S).This score was obtained by summing the weights for the individual target symptoms as identified on the

patient's first symptom checklist.Total Target Symptom Intensity (TOTT/S INT).This score was obtained by dividing the total weighted target symptomscore by the total number of target symptoms.

Five Symptom Cluster Scores.The 65symptoms on the checklist were classifiedinto five clusters by three senior psychiatrists (Drs. John B. Imboden, E. H. Uhlen-huth, and William Webb). Table 2 lists the

symptoms in each cluster: (1) anxiety; (2)depression; (3) anger; (4) compulsive symptoms; and (5) other symptoms. A symptomwas assigned to one of the first four clustersonly if all three psychiatrists' independent

judgments agreed. The patient's weightedscore for each subgroup was computed bysumming the weights (0 to 3) for the individual symptoms in each cluster.

Scores also were computed for six orthogonal and eight oblique factors derived earlierfrom 404 anxious psychoneurotic outpatients participating in drug trials. The re-

Table 1.General DesignOn 128 Patients

Waiting Interviewed Weekly byList Senior Medical Students

Initial evaluationReports of

distress T MMPI

Interview forpatient'scharacteristics

Interview forstudent'scharacteristicsWeek of study 123456789 10

suits obtained with these scores, however, donot warrant a detailed presentation here.

Average Pulse Rate (PULSE AVG).The technician counted the patient's pulsefor 30 seconds immediately before and again

immediately afterthe

patientfilled out

eachsymptom checklist. The average of the twosamples was computed.

Severity of the Patient's Chief Complaint(CC SEVERITY).Prior to the patient'sfirst interview, the technician asked the patient to state his chief complaint and to ratehow much it bothered him on a scale ranging from 0 to 4 (not at all, just a little, quitea bit, very much, extremely). Just before thepatient's final interview, the technician read

the chief complaint back to the patient andasked him to rate again how much it bothered him, using the same 5-point scale. Incase the patient precipitously discontinuedinterviews, the technician obtained the finalrating by follow-up near the end of the student's clerkship period.

Bendig Anxiety Scale Score7.The patient completed this condensed version ofthe Taylor Manifest Anxiety Scale duringthe week before or the week after his first

interview and again during the week beforeor the week after his final interview. Patients who precipitously discontinued interviews, however, often completed the secondscale near the end of the student's clerkshipperiod.

Barren Ego Strength Scale Score8.Thepatient completed this extract from theMinnesota Multiphasic Personality Inventory (MMPI) at the same times as thepreceding scale.

Selection of Patients

The study included all patients assigned toindividual interviews with senior medical students in the outpatient department during thethree academic years 1963 to 1966, with thefollowing exceptions: (1) aged less than 18years; (2) diagnosed sociopathic disorder orbrain syndrome; (3) transferred from a previous psychotherapist; (4) first appointment

too late to plan for at least six interviews before the student's scheduled departure from theservice; and (5) unable to cooperate with theprocedures required for the study.

There were 128 patients who entered thestudy during the three years.


8/6/2019 Uhl I 1968

3/11

8/6/2019 Uhl I 1968

4/11

questions to help us keep track of how hefeels from week to week. She then took hispulse for 30 seconds. Next she reviewedthe instructions for the symptom checklistwith the patient and left a copy for himto fill out while he waited for the student.

Before the student arrived,the technician returned tothe patient, collected thechecklist, checked it forcompleteness, and againcounted the patient's pulsefor 30 seconds. The twopulse counts were averaged.A similar routine precededeach of the patient's interviews at the clinic.

After the patient's firstinterview with the student,the technician saw the patient briefly to elicit and record some of the patient'scharacteristics. These areshown in Table 3. Then shegave the patient a StrongVocational Interest Blank(SVIB) and reviewed the

instructions with him. Sheasked the patient to complete the test at home during the following week andbring it to his second visit.Finally, she gave the patient an extra symptomchecklist and a stamped,self-addressed envelope touse in the event he shouldmiss a scheduled interview.

When the patient camefor his next to last interview, the research technician gave him a secondMMPI abstract and askedhim to complete it and bringit to his last visit. She collected it at that time andchecked it for completeness.

The procedure for deal

ingwith

patientswho failed

to complete the full seriesof interviews scheduled constituted an unusual910 aspect of this study. The

general objective of this procedure was topermit the evaluation of results in terms ofthe patient sample entering the study, ratherthan the sample completing the study.Every effort was made to collect completedata about each patient, even though the

Table 3.Characteristics of 128 Patients

Variable Class Range MeanAge 128 18 to 59 31.08Sex Male

Female46

82Race White

Nonwhite

10820

Religion ProtestantCatholic

Other or none

684515

Marital status Single21

Married or widowed 82Separated or divorced 25

Children? YesNo

10127

Social class index

(Hollingshead) 127 11 to 73 52.10Mother's age when

patient was born 121 15 to 44 25.87Age when family was

disrupted by death orseparation of a parent

18

Never

1520121621

43Months ill

Diagnosis (APA*nomenclature)

Psychotic disordersPsychoneurotic

disorders

Personality disordersTransient situa-

tional personalitydisorders

12810

7733

0to360 52.15

Days between consultation and firststudent interview 128 Oto 264 32.34

Initial weighted score for AnxietyDepression

AngerCompulsionsOther symptoms

128128

128128128

Oto 19 8.450 to 23 9.90Oto 6 2.730 to 8 2.665 to 79 37.23

Initial Ego StrengthScale score (Barron) 125 18 to 58 37.90

Treatment expected TalkingMedicationOther or none

1089

11

Optimism abouttreatment 127 3.77 to 1.79 0.0

A-B Scale score

(Whitehorn-Betz) 126 1 to 12 7.90SVIB Psychiatrist Scale

score 119 3 to 54 28.71

Number of appointments 128 6 to 10 7.90

Number of appointments kept 128 1 to 10 6.04

* APA = American Psychiatric Association.


8/6/2019 Uhl I 1968

5/11

patient did not attend thefull number of interviewsplanned.

On the same day thata patient first missed anappointment, the researchtechnician contacted himby telephone if possible,otherwise by mail. She requested that he completeand return the extra symptom checklist that she gavehim initially. At the sametime, she sent him another blank checklist andreturn envelope. The technician continued with this

procedure on a week-to-week basis until it becameclear that the patient didnot plan to return forfurther interviews.

At this time the research technician (orthe research psychiatrist, if it seemed necessary and advisable) contacted the patientand requested his continuing cooperation.She asked the patient to complete and return

symptom checklists on the regularweekly schedule for the remainder of thestudy period and to complete and return afinal MMPI abstract during the last week ofthis period.

If these efforts to follow the patient on aregular basis were unsuccessful, then the research technician again attempted to contact the patient and obtain a final assessmentat the end of the study period, if necessaryby making a home visit.

The duration of the present illness, thediagnosis, and the number of days betweenpsychiatric consultation and first student interview were obtained from the material inthe patient's clinical record.

The research psychiatrist elicited and recorded the student's characteristics in abrief individual interview with each studentbetween his patient's first and second interviews. These characteristics are shown inTable 4. By this time the student had met

his supervisor once, so that the supervisor'sopinions had some opportunity to make animpression on the student's attitudes towardhis patient. The research psychiatrist alsoasked the student to complete and return an

Table 4.Characteristics of 128 Senior Medical Students

Variable Class Range MeanAge 126 22 to 33 24.52Sex Male

Female115

11Marital status Single

Married

62

64Children? YesNo

11115

Social class index (Hollingshead,family of origin) 126 11 to 66 21.22

Mother's age when studentwas born 126 18 to 45 28.37

Age when family disrupted bydeath or separation of parent

0- 6yr7-12

1318>18

Never

7757

100

Optimism about patient'sprognosis 125 -2.41 to 2.70 0.01

Interest in patient 125 -3.37 to 2.24 0.0A-B Scale score (Whitehorn-Betz) 126 1 to 12 6.08SVIB Psychiatrist Scale score 126 25 to 67 48.37

SVIB some time early in his work with thepatient.

Duration of the Relationship BetweenPatient and Student

Every patient entering the studywas

scheduled to meet with his student for atleast six weekly interviews. The distributionof the number of interviews actually heldwith each patient is shown in Fig 1. Theskewing of the distribution around the peakat seven interviews, of course, is determinedby the fact that most patients entered uponthe series of interviews during the first orsecond week of the students' nine- or ten-week academic quarter and continued until

the end.These data do not show a discrete groupof early "dropouts" like that frequently suggested in studies of psychotherapy.1112The brevity of this study, however, couldhave permitted confluence of the main peakand any secondary early peak in the distribution of visits.

Kinds and Amounts of Change

The patient's total change on each criterion measure was computed by subtractingthe score at the final interview from thescore at the initial interview. The patient'searly change on the symptom checklist meas-


8/6/2019 Uhl I 1968

6/11

ures and the pulse was computed by subtracting the score at the second interviewfrom the score at the initial interview. Apositive change score, then, except on theEgo Strength Scale, represents relief of complaints. Patients who had only one interviewwere given the same final and initial scoreson the symptom checklist measures and thepulse. This rule does not hold, however, forthe CC severity, Bendig Anxiety Scale, andBarron Ego Strength Scale which sometimeswere obtained several weeks after the finalinterview. Table 5 shows the mean changeson the major criterion measures for the entiregroup of patients from the first to the second interview and from the first to the lastinterview.

The group showed substantial and reliable improvement at the last interview onmost of the measures, with the notable exception of the Barron Ego Strength Scaleand the average pulse. The Bendig AnxietyScale showed a decrease in score which, although quite reliable, was very small.

The major changes occurred in symptomatic distress. The mean total weightedSCL score, for example, decreased by about22% for the entire group of patients (N

Fig 1.Distribution of 128 patients by number ofinterviews.

30

COr-

ZLU

8/6/2019 Uhl I 1968

7/11

Table 5.Initial Status and Change on Each Major Criterion Measure for 128 Patients

Change From First to Change From First toInitial Status Second Interview* Last Interview*

Criterion Mean SD Mean SD ( ] Mean SD PtCC severity_84 2.39 1.05 71 0.68 1.07 5.34

8/6/2019 Uhl I 1968

8/11

views. These curves wereamazingly similar to thepreceding set. There wasgreater variability fromweek to week, however,and some tendency to reachan asymptote or to curveslightly upward in the finalweeks.

Comment

The spectrum of changeshown by this group of psychoneurotic outpatients interviewed by senior medicalstudents agrees quite well with expectations based on clinical experience and onthe properties of the measures employed inthis study. These measures may be consideredin relation to their speed of response, frequency responsiveness, or state-trait responsiveness.13

8/6/2019 Uhl I 1968

9/11

At least two alternate interpretations ofthe findings with the symptom clusterscores, however, require consideration. Theobserved differences in mean cluster scoresmay reflect simply differences in scaling ofthe measures rather than true differences in

the intensities of the symptoms. Such scaling differences could occur, for example, ifthe statements of anxiety symptoms weremore strongly worded than the statementsof depressive symptoms. The smaller clusters, including anger and compulsive symptoms, are especially vulnerable to these andother errors.

The rough association observed betweenmean change and mean initial score amongthe five symptom clusters suggests a furtherelaboration of the previous point. The fiveclusters all may measure the same variable,such as an undifferentiated state of distressor arousal,17 with varying efficiency. Thedifferences in relief among the mean clusterscores, then, could be understood in terms ofthe "law of initial value."1819

The data of the study reveal two lines ofevidence against the above interpretations.Figure 4 compares the mean initial symptom cluster scores for

patientswith the clini

cal diagnoses of "anxiety reaction" (N= 28) and "depressive reaction" (N = 30).These two groups of patients show significant (by analysis of variance, F = 3.70,df = 4/224, < 0.01) differences in clusterscore profiles in the expected directions.These patterns suggest that the cluster scoresat least are not grossly distorted with respectto clinical observation. The moderate correlations among cluster scores, especially

change scores, also suggest that the clustersmeasure somewhat different aspects of thepatient's subjective state. The present evidence indicates that further study of the individual cluster scores may be justifiableand useful.

The course of symptomatic change showssome interesting features. The greater decrease in target symptoms than in the totallist during the first week indicates that someof the initial complaints are replaced by

brand new symptoms. This phenomenon hasbeen well documented by Steinbook et al.20As the interviews progress and fewer targetsymptoms remain, however, earlier targetsymptoms may recur. Thus, the longer-term

results with the weighted target symptomscore more closely approach those with thetotal weighted SCL score.

Perhaps the most striking feature of thepatients' course is their failure to show adefinite symptomatic exacerbation near thetermination of interviews. This finding suggests that these patients did not make astrong investment in their student therapists. The inexperience of the therapists mayhave contributed to this situation. The prearranged, limited number of interviews mostlikely was a major factor.

The degree of symptomatic change observed in the present study may be compared roughly with the results reported fromthe University of Chicago,3 where each senior medical student held up to 18 interviewswith a psychiatric outpatient. About 75% of249 patients showed symptomatic improvement according to the ratings of the stu-

Fig 3.Mean total symptom checklist scores for 96patients with five or more interviews. Six points represent first, second, middle, next to last and last interviews, and following week.

80

60LUfOO(O

8/6/2019 Uhl I 1968

10/11

dents and their supervisors.3 On a follow-up questionnaire, 111 of these patientsrated their change during the series of interviews as follows: 37% much improved, 45%perhaps a little better, 8% perhaps a littleworse, 6% worse, and 4% no response.3

The results of the present study also maybe compared roughly with a reduction ofabout 22% in total weighted SCL score for agroup of 138 anxious outpatients who completed four biweekly supportive interviewswith residents in a recent drug study.21 Inthis drug study, according to the change intotal weighted SCL score, 93 (67%) patientsimproved, 4 (3%) remained unchanged, and41 (30%) became worse.

The amount of symptomatic improvementexperienced by the psychoneurotic outpatients in the present study, then, corresponds roughly to the relief reported in otherstudies of similar patients treated by medical students or residents. These results liewell within the range represented in thebroader literature on the outcome ofpsychotherapy.22(pl3) The average outcome inthe present study, as in others,23121) reflectsa mixture of good and poor responses. Some

determinantsof this differential

responsiveness will be explored in a later paper.In the meanwhile, this study confirms the

earlier finding3 that the patients of medicalstudents fare reasonably well. These findingsprovide no basis for overconcern about conflict between the students' needs and the patients' welfare within the context of theusual community clinic practice. On thecontrary, these results suggest that the seniorpsychiatric clerkship may be an importantresource for the relief of subjective distressrelated to the vast reservoir of psychoneurotic illness.

Summary

This is a quantitative study of certainsubjective changes occurring in 128 primarily psychoneurotic outpatients, each interviewed weekly from one to ten times (mean=

six) by a senior medical studenton his

clinical clerkship in psychiatry. The sampleincludes all "fresh" adult patients assignedto medical students for at least six interviews during the academic years 1963 to

1966 who were able to cooperate with theprocedures for the study. Each patient saw adifferent student, and the assignment of patients to students was random.

Each patient reported his subjective distress on a checklist of 65 symptoms everyweek before his interview with the student. Atotal score and the following five symptomcluster scores were computed: anxiety, depression, anger, compulsive symptoms, andother symptoms. The patient's pulse ratealso was counted at each interview. Thefollowing three measures were taken at thebeginning and at the end of the patient's series of interviews: severity of chief complainton a 5-point scale, Bendig Anxiety Scalescore, and Barron Ego Strength Scale score.

Patients initially complained most of anger and depression. Between the first andlast interviews, the group of patients showedthe following: (1) no change in heart rate;(2) a 22% decrease in symptomatic distress,attributable mainly to symptoms of anxiety,depression, and anger; (3) a small, reliabledecrease in Bendig Anxiety Scale score; and(4) no change in Barron Ego Strength Scalescore. Seventy-two percent of the patients

UJoroo

CO

o

co

coLU

1.5

1.0

0.5

0

0=q

A D A C 0CLUSTER

Fig 4.Mean weighted symptom cluster scores for28 patients diagnosed anxiety reaction and 30 patientsdiagnosed depressive reaction. Broken lines representinitial mean weighted cluster scores for anxious patients, and solid lines represent mean weighted clusterscores for depressed patients. Five bars from left toright represent anxiety, depression, anger, compulsion,and other symptoms.


8/6/2019 Uhl I 1968

11/11

felt better, 2% felt the same, and 26% feltworse. The course of symptomatic changewas marked by a sharp drop between thefirst two interviews, followed by a somewhatslower, but sustained, decrease over the remaining interviews. The earlier and the later course of relief also differed in other respects. Symptoms did not recur at the lasttwo interviews of the series.

The differing phenomena of the earlierand later course of relief suggest differentdeterminants during the two periods. The individual variation in response, with somepatients actually becoming worse, also suggests specific determinants operating withinthe general treatment situation described.

The results indicate that psychoneurotic

outpatients attending a university clinic for

a brief series of interviews with senior medical students experience symptomatic reliefroughly comparable to that provided by otherforms of clinic treatment. The senior psychiatric clerkship appears to be an important community resource for the relief of

subjective distress associated with psychoneurotic illness.

This investigation was supported by Public HealthService grants MH-06350 and 2-K3-MH-18,611 fromthe National Institute of Mental Health (NIMH).Statistical procedures were developed in part undergrant No. MH-04732 from the NIMH. Computationswere performed at the Computing Center of theJohns Hopkins Medical Institutions which is supported by grant No. FR-00004 from the National Institutes of Health.

Mrs. Ruth Boggs, Mrs. Susan Bryan, Mr. ClayKallman, Mrs. Mary Sewell, and Mrs. Carol Tayloraided in their technical assistance.

References

1. Novey, S.: Behavior and Inner Experience:Parallels and Contradictions in the Appraisal ofTreatment, read before the Sheppard and EnochPratt Hospital 75th Anniversary Program, Towson,Md, June 1966.

2. Hollingshead, A.B., and Redlich, F.C.: SocialClass and Mental Illness: A Community Study,New York: John Wiley & Sons, Inc., 1958.

3. Heine, R.W. (ed.): The Student Physician as

Psychotherapist, Chicago: University of ChicagoPress, 1962.4. Wallerstein, R.S., and Robbins, L.L.: The Psy-

chotherapy Research Project of the Menninger Foun-dation: Second Report: I. Further Notes on Designand Concepts, Bull Menninger Clin 22:117-125, 1958.

5. Parloff, M.B.; Kelman, H.C.; and Frank, J.D.:Comfort, Effectiveness and Self-Awareness as Cri-teria of Improvement in Psychotherapy, Amer JPsychiat 111:343-351, 1954.

6. Mattsson, N.B., et al: Dimensions of SymptomDistress in Anxious Neurotic Outpatients, Psycho-pharmacol Bull, to be published.

7. Bendig, A.W.: The Development of a ShortForm of the Manifest Anxiety Scale, J Consult Psy-chol 20:384, 1956.

8. Barron, F.: An Ego-Strength Scale Which Pre-dicts Response to Psychotherapy, J Consult Psy-chol 17:327-333, 1953.

9. Lasky, J.J.: The Problem of Sample Attritionin Controlled Treatment Trials, J Nerv Ment Dis135:332-337, 1962.

10. Uhlenhuth, E.H., et al: Dosage Deviation andDrug Effects in Drug Trials, J Nerv Ment Dis141:95-99, 1965.

11. Lorr, M.; Katz, M.M.; and Rubinstein, E.A.:The Prediction of Length of Stay in Psychotherapy,J Consult Psychol 22:321-327, 1958.

12. Rosenthal, D., and Frank, J.D.: The Fate ofPsychiatric Clinic Outpatients Assigned to Psycho-therapy, J Nerv Ment Dis 127:330-343, 1958.

13. Cattell, R.B., and Scheier, I.H.: The Meaningand Measurement of Neuroticism and Anxiety, NewYork: The Ronald Press Co., 1961.

14. Greenfield, N.S.; Alexander, A.A.; and Roes-sler, R.: Ego Strength and Physiological Responsiv-ity: II. The Relationship of the Barron Ego StrengthScale to the Temporal and Recovery Characteristicsof Skin Resistance, Finger Blood Volume, HeartRate, and Muscle Potential Responses to Sound,

Arch Gen Psychiat 9:129-141, 1963.15. Frank, J.D., et al: Immediate and Long-TermSymptomatic Course of Psychiatric Outpatients,Amer J Psychiat 120:429-439, 1963.

16. Stone, A.R., et al: An Intensive Five-YearFollow-Up Study of Treated Psychiatric Outpatients,J Nerv Ment Dis 133:410-422, 1961.

17. Schachter, S., and Singer, J.E.: Cognitive, So-cial and Physiological Determinants of EmotionalState, Psychol Rev 69:379-399, 1962.

18. Uhlenhuth, E.H.: "Some Suggestions for Fur-ther Exploration of the Placebo Response," inTransactions of the 5th Research Conference on Co-

operative ChemotherapyStudies in

Psychiatry andResearch Approaches to Mental Illness, VeteransAdministration 1960, vol 5, pp 209-212.

19. Wilder, J.: Modern Psychophysiology and theLaw of Initial Value, Amer J Psychother 12:199-221, 1958.

20. Steinbook, R.M.; Jones, M.B.; and Ainslie,J.D.: Suggestibility and the Placebo Response, JNerv Ment Dis 140:87-91, 1965.

21. Uhlenhuth, E.H., et al: Drug, Doctor's VerbalAttitude and Clinic Setting in the Symptomatic Re-sponse to Pharmacotherapy, Psychopharmacologia9:392-418, 1966.

22. Frank, J.D.: Persuasion and Healing: A Com-parative Study, Baltimore: Johns Hopkins Press,1961.

23. Truax, C.B., and Carkhuff, R.R.: TowardEffective Counseling and Psychotherapy: Trainingand Practice, Chicago: Aldine Publishing Co., 1967.


uhl i 1968

Documents