uhl ii 1968

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Subjective Change With

Medical Student TherapistsII.Some Determinants of Change in Psychoneurotic Outpatients

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

P SYCHOTHERAPY is a powerful proce-dure which can be either helpful or harm-

ful.1,2(p21) In a study3 of subjective distress

reported by a group of 128 primarily psy-choneurotic outpatients over some six week-ly psychotherapeutic interviews with seniormedical students, the group's mean sympto-matic distress decreased by 22%. Individualpatients within the group, however, variedmarkedly in their responses: 72% felt im-

proved and 26% actually felt worse at ter-

mination. This paper explores some sourcesof the individual variation observed in symp-tomatic response.

The present approach to this problem as-sumes that manifest psychological events

are determined jointly by multiple factors.Further

assumptionsinclude the

following:(1) Many of these factors may be related to

one another, and to this extent their individ-ual effects are confounded. (2) The effectsof some factors may be contingent upon theeffects of others (interaction4,5).

The determinants of symptomatic changeover the series of interviews were examinedin 105 patients with complete data on 35variables representing two broad domains6:(1) characteristics of the patient, such as

initial clinicalstatus, history

of thepresentillness, 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 detailedin Tables 1 and 2. Special interest centeredon the possible importance of the student'scharacteristics and the "match" between pa¬tient and student. This match was repre¬sented by the statistical interaction between

seven pairs of corresponding characteristicsmeasured in the patient and in the student.

Method

This study took place in the Outpatient De¬

partment of the Henry Phipps PsychiatricClinic. It relied upon quantitative observationsmade during the training in individual psycho¬therapy offered as part of the nine-to-ten-weeksenior clinical clerkship in psychiatry.

The study included all adult outpatients as¬

signed to senior medical students for at leastsix weekly interviews during the academic

years 1963 to 1966, except (1) patients whose

conditions were diagnosed sociopathic disorderor 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 pastweek: not at all = 0, a little ß 1, quite a

bit = 2, or extremely = 3. A total weightedsymptom checklist score (TOT WTD SCL)was computed by summing the weights for the65 individual symptoms. Weighted scores were

computed in the same way for five symptomclusters:

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

psychiatrist.A multiple covariance procedure with a step-

wise search option, programmed for the IBM70948 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.

Submitted for publication Dec 11, 1967.

From the departments of psychiatry and behavioralsciences (Dr.Uhlenhuth) and statistics and biosta-tistics (Dr.Duncan), Johns Hopkins University,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/




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This analysis provides an estimate of the inde¬

pendent, simultaneous effects of several vari¬

ables, including quantitative data, such as age,and qualitative (classification) data, such as

marital status. It also deals effectively with a

disproportional distribution of subjects among

categories of classification data. The method

combines, in effect, the functions of analysis of

variance, analysis of covari-

ance, and multiple regressionanalysis in a form sufficientlyflexible to cope with manyproblems in the statisticalevaluation of quantitative ob¬servations in real life situa¬tions.

The analyses reported here

employed the change in total

weighted symptomchecklist

score as the dependent vari¬able. This criterion of symp¬tom change was analyzed withrespect to a pool of inde¬

pendent variables includingall of the characteristics of the

patient and all of the charac¬teristics of the student listedin Tables 1 and 2. (The dura¬tion of the patient's presentillness in months was trans¬

formed to its natural log, andthe interaction between the

patient's race and sex also was

included in the pool.)As noted earlier, the pos¬

sible importance of the matchbetween the patient and hisstudent was a topic of specialinterest. These effects were

represented by generating andincluding in the pool a set oflinear by linear interactions

between corresponding char¬acteristics of the patient andhis student, including age,marital status, social classindex,9 A-B Scale score,1·*SVIB Psychiatrist Scale

score, optimism about the

treatment, and patient's diag¬nosis student's A-B Scalescore. (The A-B Scale con¬

sists of 13 items from theSVIB. According to studies

by Whitehorn and Betz,n a

high score, which character¬izes "Type A" therapists, pre¬

dicts success with schizo¬phrenic patients. According

to McNair et al,10 a low score, which char¬acterizes "Type B" therapists, predicts success

with psychoneurotic patients.) A second type ofinteraction effect was included in the pool bygenerating the absolute value of the differencebetween the corresponding scores of the patientand his student on the same

characteristics,except for marital status.

Table 1.—Characteristics of 105 Patients

Variable Class Range Mean

Age 105 18 to 51 30.96

Sex Male

Female3768

Race White

Nonwhite90

15

Religion ProtestantCatholic

Other or none

57

36

12Marital status Single 19

Married or widowed 67

Separated or divorced 19

Children? Yes

No

82

23

Social class index

(Hollingshead)105 11 to 73 52.01

Mother's age when

patient was born105 15 to 44 26.18

Age when family < 1 yrs.was disrupted by 1-6

death or separa- 7-12tion of a parent >12

1314

1266

Months ill 105 Ito 360 53.31

Diagnosis (APA*Nomenclature)

Psychotic disorders

Psychoneuroticdisorders

Personality disordersTransient situational

personality disorders

6526

Days between con¬

sultation and firststudent interview

105 0 to 264 36.14

Initial weightedscore for

AnxietyDepressionAnger

CompulsionsOther symptoms

105

105

105

105

105

Oto 19

Oto 230 to 60 to 8

5 to 79

8.8410.11

2.652.73

38.17Initial Ego Strength

Scale score

(Barron)

105 18 to 58 37.94

Treatment expected TalkingMedicationOther or none

9285

Optimism abouttreatment

105 -3.77 to 1.79 —0.02

A-B Scale score

(Whitehorn-Betz)105 1 to 12 7.91

SVIB PsychiatristScale score

105 3 to 54 29.05

Number ofappointments

105 6 to 10 7.98

Number of

appointments kept

105 1 to 10 6.35

*APA = American Psychiatric Association.






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Table 2.—Characteristics of 105 Senior Medical Students

Variable Class Range

Age 105 22 to 33

Sex MaleFemale

9510

Marital status SingleMarried

50

55Children? Yes

No

10

95

Social class index

(Hollingshead,family of origin)

105 1 l.to 66

Mother's age whenstudent was born

105 18 to 45 28.42

Age when family <7 yrs.disrupted by death 7-12or separation of > 12

parent

7

4

94

Optimism about

patient'sprognosis

105 —2.41 to 2.70 0.02

Interest in patient 105 —3.37 to 2.24 0.03

AB Scale score

(Whitehorn-Betz)105 1 to 12

SVIB PsychiatristScale Score

105 25 to 67 48.1Í

Each analysis included two steps. First, a

multiple covariance analysis of the symptomchange scores in relation to the complete set of

independent variables in the pool was per¬formed. This resembles the usual multiple

regression analysis. During inversion of thecorrelation matrix, however, five variablesshowing a multiple correlation above 0.95 withthe preceding variables in the matrix were

dropped from the analysis.Second, the independent variables in the

pool were searched stepwise for the subset con¬

tributing most reliably to the change in total

weighted symptom checklist score. In order tobe selected from the pool and to remain in theselected subset, a variable was required at ev¬

ery step to show an F ratio of 2.76 (for 1 df).

This value represents approx¬

imately the 10% level of sig¬nificance in the present case

with 105 patients.

Determinants of

Symptomatic Changeat the Final Interview

The complete multiple co-

variance analysis at the finalinterview revealed a multi¬

ple correlation of 0.82 be¬tween the change in total

weighted symptom check¬list score and the pool of

independent variables. Put

otherwise, the complete setof independent variables ac¬

counted for about 67% of

the variation in the criterion.The overall F ratio was

1.894, with a computed = 0.012. Apparently the variables in the poolmade an important contribution to the pa¬

tient's symptomatic change across the series

of interviews with the senior medical student.

Thestepwise

search of the pool revealedthat a relatively small subset of independentvariables jointly contributed most to symp¬

tomatic change. Table 3 shows the multiplecovariance analysis which emerged from

the search procedure. The six variables in

the table gave a multiple correlation of 0.61

with the criterion, explaining about 37% ofits variation.

The most important determinant of the

patient's symptomatic change was his initial

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 Mean

Initial wtd depression score 13075.45 29.10 2.23 0.41 5.39 10.10

Patient's initial optimism 1594.87 3.55 4.12 2.19 1.88 -0.02

Days waiting for Rx 3705.11 8.25 -0.13 0.04 2.87 36.14

Natural log of No. months ill + 1 5395.99 12.01 5.83 1.68 3.47 3.19

Student's SVIB Psych score 1363.39 3.03 0.43 0.25 1.74 48.18

Square of mother's age when student born 3357.61 7.47 0.17 0.06 2.73 23.20

Mother's age when student born 323.66 0.72 -0.39 0.45 0.85 28.42

Total regression 3718.99 8.28Error 97 449.37

Total deviations 104 669.44

Correction term 19858.44

TOT WTD SCL change —36.73 13.75






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weighted depression score, which alone cor¬related 0.41 with the criterion. Patients witha higher initial level of depression improvedmore (Fig 1).

The following characteristics of the pa¬tient also contributed to relief of symptomat-

ic distress: (1) greater general optimism at

the outset about the probable outcome of

treatment, as measured on a simple 7-pointscale (Fig 1), (2) a shorter waiting periodbetween 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 responsivenessoccurring 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 successfulpsychiatrists as measured by the SVIB (Fig1), 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 Changeat the Second Interview

The complete multiple covariance analy¬sis at the second interview revealed a multi¬

ple correlation of 0.72 between the changein 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 significantlyto symptomatic change.

However, there is strong prior evidencethat change in biological functions is relatedto their initial level.12 In order to test thisspecific hypothesis and to provide leads for

Fig 1.—Four variables and symptom relief at finalinterview in 105 patients. Independent linear effects of(1) patient's initial weighted score on depression symp¬tom cluster, (2) student's SVIB Psychiatrist ScaleScore, (3) patient's initial optimism about treatment,and (4) number of days patient waited between psy¬chiatric consultation and treatment.

60

WAIT\

20 h 0 INITIAL DEPR 25

25 ST.'S PSYCH SC. 75-3.5 PT.'S OPTIMISM 1.5

0 DAYS WAITING 250

Fig 2.—Duration of present illness and symptomrelief at final interview.

£: tr 8o w

< -i o

o co

40

20

52cl2

2

X °

o O . 20

10 20

YEARS ILL

Fig 3.—Mother's age when student was born and

symptom relief at final interview.

25 35

AGE IN YEARS






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future work, the pool was searched stepwisefor individual variables possibly contrib¬

uting to change in distress, despite the pre¬vious nonsignificant finding.

The eight variables and their interactionswhich 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 initialweighted score on the cluster of "other"

symptoms, which correlated 0.99 with theinitial level of the criterion itself.

The following characteristic of the patientalso 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) greaterage when the family of origin was disruptedby death, separation, or divorce of a parent.

The following interactions between char¬acteristics of the patient and characteristicsof 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 ofthe 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 psychoneuroticdisorders 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 dependableresult.

Comment

The results of this study support the viewthat the direction and amount of sympto¬matic change in psychoneurotic outpatientsduring 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 initiallevel of depression is in accord with clinical

experience. Since depressive affect is fluc¬

tuating and self-limited, proportional im-

provement, regardless of treatment, is ex¬

pected. Previous studies also show that theinitial 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 symptomclusters 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 welldocumented.1518 This study confirms therole of one such expectation, the patient'sinitial general optimism about change. The

present results, however, differ from some ofthe 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 studies17·18·"22)'19 empha¬

size the relationship between the patient'sexpectation 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 symptom cluster scores.

These discrepancies probably reflect the dif¬

fering techniques of eliciting the patients'

expectation of relief. In previous studiesthese measures were tied to specific symp¬

toms, whereas the present study dealt with a

global attitude evaluated without referenceto a list of symptoms.

The finding that patients who enter

treatment soon after the psychiatric consul¬tation improve more than patients who mustwait longer for a treatment opening agreeswith the clinician's experience that prompttreatment brings the best result. Patients

awaiting formal treatment, of course, oftenimprove in response to informal therapeuticinfluences20 which are not yet fully under¬stood. Therefore, patients who still want

treatment after a prolonged waiting periodare, by and large less likely to respond read¬

ily to therapeutic influences, whether formalor informal. The extraordinarily high im¬

provement rate in a recent study of placebotreatment21 probably is attributable in large

measure to the retentionof

highly responsivepatients in the sample by instituting treat¬

ment immediately.In this study the association of more

chronic illness with greater improvement is






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puzzling. Possibly the chronic patients inthis sample had mainly fluctuating illnesses22and a realistic expectation, derived from pastexperiences with treatment, of partial relieffrom the acute exacerbation.

The finding that students with interest

patterns more like trained psychiatists are

more successful with their patients seems

eminently reasonable. One can only specu¬late how well these interest patterns cor¬

relate with therapist variables influencingoutcome in most other studies, such as "atti¬tudes toward psychiatry"17 and the "thera¬

peutic conditions" of empathy, warmth, and

genuineness.2 Intuitively all of these charac¬teristics seem to be closely related. The A-B

Scale score is the one therapist characteris¬

tic represented in this study which predictedoutcome in previous studies. This study,however, furnishes no convincing evidence of

its importance in symptomatic change, ei¬ther directly or through correlation with theSVIB Psychiatrist Scale score.

The superior results obtained by studentsborn of unusually young and especially unu¬

sually old mothers are another surprise find¬ing in this study. The predicted effect of

the student's mother's age was, of course, in

the opposite direction. Perhaps students ex¬

posed to the special problems of a young or

aging mother had developed greater inter¬

personal sensitivity.Another related consideration is the possi¬

ble confounding of effects due to the moth¬er's age and the student's birth order. Stu¬dents with older mothers more likely wouldbe last born children and so occupy a spe¬cial, though not yet well understood, statusin the family. Students with younger moth¬

ers more likely would be first born children.There is already some evidence that first

born and only children, perhaps because oftheir unique relationship with the mother,more strongly seek out, maintain, and use

relationships with other people.23 <pll2>·24

The high reliability of the student's moth¬

er's age in determining symptomatic im¬

provement is impressive. It suggests, like the

studies on birth order, that early experi¬ences with the mother

may determinenot

only severe pathological developments in a

wide range of people,-'5 but also subtler

quantitative responses, especially in the af¬

fective sphere. These studies provide some

encouragement to explore such relationshipsin greater detail.

The curvilinear form of the effects due to

the student's mother's age (quadratic) and

the chronicity of the patient's illness (loga¬rithmic) is another point of special interest.

It confirms increasingly frequent referencesin the literature26(p40) to the probable inade¬

quacy of linear models in psychology. This

finding, then, indicates yet another directionfor further exploration.

Interaction between patient characteris¬tics and treatment factors has been reportedin drug studies.827 The results presentedhere offer no support for the analogous ideathat the "match" between certain character¬

istics of the patient and his therapist may be

critical determinants of symptomatic relief.Absence of positive findings in such a study,however, cannot refute a hypothesis. Cer¬

tainly the experienced clinician will considerthe method rather than the hypothesis as

faulty in this case.

On the other hand, it is worth consideringseriously the obvious difficulty in assessingintuitively the nature of such highly com¬

plex situations. Can clinical acumen sense

whether events arise from many interacting

determinants, that is, with effects contingentone upon another, or from many determi¬nants contributing their effects in an addi¬tive pattern? Perhaps not, as the number of

concurrent elements in the situation be¬comes large.

In this connection it is interesting that in¬teractive effects do appear in certain prelim¬inary analyses of the data which have not

been reported here. In the presence of more

powerful determinants, however, the impor¬tance of these interactions fades out.

The most striking development in this

study, perhaps, concerns the contrast be¬tween the findings at the last interview and

at the second interview. In the analysis ofrelief at the last interview, an array of relia¬

ble determinants emerges. (These determi¬

nants remain surprisingly similar in an

analysis of symptomatic change from thesecond to the final interview, ie, omitting the

first week'schange.

This

finding strengthensthe view that these determinants are specificto the longer-term response and not to the

shorter-term response.) Although the analy¬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 theleads generated should pass further tests,they still would indicate markedly different

patterns of determination for shorter- andlonger-term changes.

The first report of this study describesseveral characteristic differences in sympto¬matic change at the second interview and atthe final interview. Ainslie,28 Jones,29 Stein-book,30 and their collaborators also note dif¬ferences in earlier and later symptomaticchange. All of these findings together strong¬ly suggest that symptomatic relief is not a

unitary phenomenon, but is rather a develop¬ment with at least two relatively distinct,characteristic phases.

The first phase is brief, lasting perhapsone to four weeks. It is marked by a precipi¬tous decline of subjective distress, largelydue 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 reliabledeterminant of relief.

This first phase of symptomatic changeresembles many responses of living organ¬isms which depend upon the initial level of

the responding function.12·31 Affective re¬

sponses may be special examples of the broadclass of responses governed mainly by thecentral tendencies of biological systems in

general.The first phase of symptomatic changemay be designated a "non-specific" or "pla¬cebo" response. Such responses correlatewith a variety of other psychological varia¬

bles, including the patient's expectation of

relief17·19 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)·33Frank34 repeatedly has pointed out the last¬

ing value, often underestimated, of "non¬

specific" interventions which promote the

return to a more satisfactory state of psy¬chological equilibrium.

The second phase of symptomatic re¬

sponse is longer, lasting more than four

weeks. It is marked by a more gradual anderratic decline of subjective distress, due to

a decrease in both the number and the mean

intensity of symptoms. All types of symp¬toms appear to share more equally in the re¬

sponse. The change is significantly related to

an identifiable array of specific variablesrepresenting several definable areas. Theemphasis shifts from the patient himself to

include his interplay with a broader inter¬personal field.

During this phase a therapeutic systemdevelops with at least two critical partici¬

pants (components), the patient and thetherapist. Probably this notion can be ex¬

tended to include other participants, such as

members of the clinic staff, family, col¬

leagues, and other patients.The characteristic effects of most thera¬

peutic factors may be especially evident inthe second phase of symptomatic response.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 internalphysiological milieu, however, they must

play a role when they are administered in

the first phase of relief too. A previousstudy8 suggests that the effects of drugs oper¬ate quite differently in the two phases, and itwill be interesting to pursue this possibility.

The biphasic formulation of symptomaticresponse also raises many other questions.The two phases certainly blend into each

other. How clearlycan

their limits be estab¬lished? Or would it be more useful to thinkin terms of two modes of response which are

always operative but in different propor¬tions? Do other phases characterized by stilldifferent modes of response follow whentreatment extends over a longer period of

time? Alternatively, do the phases observedin this time-limited treatment correspond to

those commonly observed in longer-termtreatment? If so, what leads to their compres¬

sion or expansion? With these and the ques¬tions posed earlier, the concept of a biphasicresponse 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 inpsychiatry. The sample includes all "fresh"adult patients who were able to cooperatewith the procedures for the study and whowere assigned to medical students for at

least six interviews during the academicyears 1963 to 1966. Each patient saw a dif¬ferent student, and the assignment of pa¬tients to students was random. Each patientreported 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) andcharacteristics of the student (current atti¬

tudes, past history). The independent con¬

tributions of these variables to symptomaticchange were assessed by a multiple covari¬

ance analysis including the complete set ofindependent variables.

Analysis of the total symptom changescore from the first to the last interview re¬

vealed a multiple correlation coefficient of

0.82 with the set of independent variablesand 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

improvedmore.

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

years.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 especiallyto unusually old mothers.

Analysis of the total symptom changescore from the first to the second interviewrevealed 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 "placeboresponse." The second phase seems to mark

a shift to a therapeutic system embracingother participants as well as the patient.

This investigation was supported by Public HealthService grants MH-06350 and 2-K3-MH-18,611 fromthe National Institute of Mental Health (NIMH).The statistical procedures were developed in partunder grant No. MH-04732 from the NIMH. Compu¬tations were performed at the Computing Center ofthe Johns Hopkins Medical Institutions which is

supported by grant No. FR-00004 from the NationalInstitutes of Health.

Mrs. Ruth Boggs, Mrs. Susan Bryan, Mr. Clay

Kallman,Mrs.

MarySewell, and Mrs. Carol Taylor

aided in their technical assistance.

References

1. Bergin, A.E.: "Some Implications of Psycho-therapy Research for Therapeutic Practice," inStollak, G.E.; Guernsey, B.G.; and Rothenberg, M.

(eds): Psychotherapy Research, Chicago: RandMcNally & Co.,1966.

2. Truax, C.B., and Carkhuff, R.R.: Toward

Effective Counseling and Psychotherapy: Trainingand Practice, Chicago: Aldine Publishing Co., 1967.

3. Uhlenhuth, E.H., and Duncan,D.B.:

Subjec-tive Change With Medical Student Therapists: I.Course of Relief in Psychoneurotic Outpatients,Arch Gen Psychiat 18:428-438 (April) 1968.

4. Fisher, S.,et al: "Drug-Set Interaction: TheEffect of Expectations on Drug Response in Outpa-

tients," in Bradley, P.B.; Fl\l=u"\gel,F.; and Hoch,P.(eds.): Neuropsychopharmacology, Amsterdam: El-

sevier,1964, vol 3, pp 149-156.5. Uhlenhuth, E.H., et al: Drug, Doctor's Verbal

Attitude and Clinic Setting in the Symptomatic Re-

sponse to Pharmacotherapy, Psychopharmacologia9:392-418, 1966.

6. Levinson, D.J.: "The Psychotherapist's Con-

tribution to the Patient's Treatment Career," in

Strupp, H.H., and Luborksy, L. (eds.): Research in

Psychotherapy, Washington, DC: American Psy-chological Association, 1962, vol 2, pp 13-24.

7. Parloff, M.B.; Kelman, H.C.; and Frank, J.D.:

Comfort, Effectiveness and Self-Awareness as Cri-






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teria of Improvement in Psychotherapy, Amer JPsychiat 111:343-351, 1954.

8. Uhlenhuth, E.H.; Duncan, D.B.; and Park,L.C.:"Some Non-Pharmacologic Modifiers of the

Response to Imipramine in Depressed, Psychoneu-rotic Outpatients: A Confirmatory Study," in May,P.R.A., and Wittenborn, J.R. (eds.): PsychotropicDrug Response: Advances in Prediction, Spring-field, Ill: Charles C Thomas, Publisher, to be pub-lished.

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