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THE PATIENT'S CONCERNS IN PSYCHOTHERAPY*D A V I D E O R I /I N SK Y K E N N E T H I H O W A R D A N D J A M E S A H I L L

University of Northwestern Institute for hicago University Juvenile Research

P R O B L E MOne pertinent perspective on the psychotherapeutie process is to view it asrm of problem -solving '. Psych otherapy is initiated b y the patien t, or by sombehalf, when he has problematic concerns which do not yieldinary efforts at solution. It is norm ally term inated when the pati en t's proble

with them on his own. The pa tien t presum ably comes to his the rapy sessioThe co mmunications made by pa tien ts during thera py sessions m ay be analyzr conte nt w ith respect to (a) manifest focus and (b) expressive them e. Analy areasof patie nts ' experiences ost troub lesom e. Expressive them es, the second aspect of dialogue, define t

of th e problem s with which patie nts are concerned. In a previous paper

The data for this paper were derived from a survey of the problematic concerby th e pa tien ts themselves and by their thera pists. D ata analyses weed on th e following questions : (1) How prev alent are different types of problemrapy session? (2) How closely does the therapisf his pa tien t's concerns match h er own impression? (3) W hat are t

erlying dimensions of p ati en ts' concerns, as these are implicit in the perceptiopat ien ts and of the rap ists? (4) To wh at extent do pa tte rns of concerns refleriat ion ? (5) Are pat te rn s of problem atic concern differentially focused in partir regions of the p at ien t's life-space? These questions are meant to elicit inform

METHODS AND PROCEDURESInstruments The Psychotherapy Session Project enlists both patients anatic qu an titat ive report of his experience. This is achieved through the u TherapySes (TSRs)

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TH E P A T I E N T ' S CONCERNS IN PSYCHOTHERAPY 1was at least one item representing each of the eight nuclear conflicts, and additionitems were selected to increase the saturation and differentiation of those arewhich were judged to be most relevant for patie nts in psych otherapy . These judments were based on our own experiences, consultation, and pilot data.

Samples. A detailed description of the patient and therapist samples is availabelsewhere

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6 DAVID E . ORLINSKY, KEN NET H I. HOWARD, AND JAMES A. HILLT AB L E 1 . R E L AT I VE F B E QUE NC I E S OF E NDOR S EM E NT F OR P AT I E NT S AND T HE R AP I S T S P AT I E NT C ONC E R NS

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I t e m sBeing dependent on others.Meeting obligations and responsibilities.Being assertive or competitive.Livin g up to conscience: shameful orguilty feelings.Being lonely or isolated.Sexual feelings and experiences.Expressing or exposing self to others.Lo vin g: bein g able to give of self t oothers.Angry feelings or behavior.Personal identity and aspirations.Fearful or panicky experiences.Meaning l i t t le or nothing to others:being worthless or unlovable.

N o52435455445740

4447335555

Pa t ien t sSome323634293 52634

323 3332727

A Lot17221216221726

2420341717

N o4139454232573 3

4132216448

Therapists'Some37434236393048

4651422835

A Lo22191322291319

131736

817

E ntrie s are percents based on 5 sessions from each of 118 patien ts (Patient T SR ).'E nt rie s are percents based on 5 sessions from each of 32 therapist-cases (Therapist TSR). Ten of the 12 item s were endorsed by more tha n half of th e therap ist gro

These high rates of endorsement should be interpreted in light of the distinctioonden ts made between som e concern and a lo t of concern. The former ma relative ly diffuse background, and the la tte r as more truly focal. T intenseconcerns in an average sessiconsistent w ith Fren ch's* view th at any particu lar session tends to revolve aboat m ost a few focal conflicts. Th e most prevalentintenseconcerns reportat ients were with ide ntity (34% ), expressing or revealing self (26% ), loving ng to o thers (24 % ), loneliness (22% ) and meeting obligations (22 % ). The mo intense patient concerns reported by therapists were identity (36%Tw o observations on these findings are in order. Firs t, the problematic co

d. These are Ide ntity and Repudiation vs.Identiity Diffusion and Iand Solidarity vs. Iso lat ion , respectively. Th e implication is that difficulturren t adap tatio n rathe r tha n more infantile them es are the typical foci rapeu tic activ ity. Ex isten tial rath er than gen etic conflicts bulk largly from th e pa tie nts ' own perspective. Second, while therapists generaconcerns in the same order as do the pa tients, th e therapists show som

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THE P A T I E N T ' S C ON C ER N S I N P S Y CH OT HE RA P Y 1the question posed here, the responses of each patient and therapist to the conceritems were intercorrelated across all of their common sessions, yielding 45 12 X 1correlation m atrices. Th us, the relationship between patien t and therapis t reporof any concern was estima ted, independently, 45 times. To evaluate th e statisticsignificance of each relationship, a binomial test was performed on the signs of th45 estimates'*' with results summarized in Table 2.

T A B L E 2 . C ON V BB GE N T A N D D I S C R I MI N A N T A G R EE M EN T B E T W E E N T H E E A P I S T S ' A N DP A T I E N T S ' RE P O R TS O F P A T I EN T C O N C ER N SWhen Therapist perceivesP t ' s

1.2.3.4.5.6.7.8.9.10.

11.12.

concern as:DependencyObligationsA ssertion, Com petitionShame, GuiltLoneliness, IsolationS exExpressing, Exposing SelfLoving, GivingAngerI d e n t i t yFearsRejection

P ati en t most often is aware ofconcern with:1.2.9.4.5.6.7.7.9 .10 .

1112 .

Dependency (.29)10 . I de nti ty (.10)Obligations(.29)A nger (.20)Shame GuiU(.37) 6. S ex (.24)11 . Fe ars (.15)Loneliness Isolation (.34)12. Re jectio n (.22)Sex (.59) 4. S ham e, Gu ilt (.25)Expressing Exposing Self (.18)3 . A ssertion, Co m petition (.12)Expressing, Exposing Self (.16)6. S ex (.15) 8. Loving Giving (.15)Anger (.45) 1. D ep end en cy (.16)Identity (.23)

fe ar s (.38) 6. S ex (.12)Rejection (.26) 5. Lon eliness,Iso lation (.23) 7. Exp ressing,Exposing Self (.14)

I tem s italicized indicate convergen t agre em ent. A ll listed relationship s were significant at beyond the .05 level, based upon sign tests. P arenthe ses enclose th e median correlation of th e estimates of each of these relationships.In answering the question of how well therapists' perceptions of patientconcerns match their patients' perceptions, we shall consider both convergent andiscriminant ag ree m en t. ' I nspection of T'able 2 indicates tha t bo th convergeand discriminant agreement obtained for 6 of th e 12 problem atic concerns: # 1Dependency, *2. Obligations, 5. Loneliness, 9. A nger, # 10. Identity, an* 1 1 . Fears.In four other cases, there was good convergent agreement but poorer dicriminant agreem ent: # 4 . S hame and guilt, # 6 . S ex, # 7 . Expressing or exposinself and *12. Being worthless or unlovab le. Concerns with shame and guilt anwith sex werehoth present for the patient when the therapist reported either as

shall see in the next section, both were in fact strongly linked in a single dimensioof concern. Th e the rap ist' s sense of th e pati en t's concern with rejection m atche

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108 DAVID E. ORLINSKY, KENNETH I. HOWARD, AND JAMESA.HILLth e next section. The ther apis ts' perceptionofpatients' concern with loving, on tother hand, was somewhat convergent with the patients' sense of it, but proved evmore responsivetopa tients ' concern with self-disclosure and w ith sexuality. Thefindings, taken overall, show that with some exceptions theproblem atic concewhich patients experience during therapy sessions tended to bereflected inththerapists' perceptions.

What re The Underlying Dimensions OfPatients Concerns, s TheseImplicitIn ThePerceptionsO f Patients ndOfTherapists To answer this questiofactor analyses were performed on theresponses from the two samples separateBoth analyses followed the procedure described in detail in a previous paperTable 3 presents the factorial organization ofpatient concernsforthe two samplesshowing thetitleand major item loadingsofeach factor. Five factors, accountiT A B L E 3. FA CTORIAL ORGANIZATION OFPATIE NT CONCERNS

Pa tien ts ' Rep orts Therapists ' ReportsI. ISOLATION VS. INTIMACY: being lonely or I. ISOLATION VS. INTIMACY: meaning littisolated; meaning little to others, being to others, being worthless or unlovabworthless orunlovab le; loving, being able being lonely orisolated; being dependeto giveof myself. (.46) > on oth ers; loving, being able to giveoself. (.47)

I I . EGO-IDENTITY: expressing or exposing II . IDENTITY CONFLICT: angry feelings or bmyself to others; who I am andwhat I havior; personal identity andaspiratiowa nt; loving, being able to giveof myself; fearful or panicky experiences. (.41)being assertiveorcomp etitive. (.56)I I I . INDEPENDENCE vs. DEPENDENCE: meet- III. SELF-ASSERTION: expressing self to oting my obligations and responsibilities; be- ers; being assertive or competitive;noing dependent onoth ers ; being assertive fearful orpanicky experiences. (.38)

or competitive. (.50)IV . SEX ANDGU ILT: sexua l feelings and ex- IV. SEXUALITY: sexua l feelings and expeperiences; living up to my conscience, iences. (.31)shameful or guilty feelings. (.41)V. ANGER ANDFEAH: ang ry feelings or be- V. CONSCIENCE: me eting obligations and rhavior;fearful or panic ky experienc es. sponsibilities; dema;nds of conscienc(.44) shameful or guilty feelings. (.48)

^Alpha of each factor scoreis in parentheses.for 65% of the total variance, were retained frorn the analysisof patients reportsprob lem atic concerns. Five factors were also retained from the analysis oftherapisreports, acco unting for 64% ofthe total variance. Comparisonofthese two analysreveals th at , with some differences innuance,thestructureofproblematic concernwas basically similar from bo th perspectives.The dominant theme infactor I focuses on theissueofexclusion from or inclusion in intimate relationships, and was named ISOLATION VS. INTIMACY becauofitssimilaritytoStageVI in Erikson's' '> theoryof psychosocial development.The dominant theme reflected in patient factor II focuses on the patientexperience andconception of self, andwas called EGO-IDENTITY becauseof its rsemblancetoStageV in Erik son's'^' scheme. Therapist factor II resembled thibut placed the pa tien ts' concern w ith iden tity in a more negative, pathologiccontext.

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T H E P A T I EN T ' S C ON C ER N S I N P S Y CH OT HE RA P Y 1The fourth factors in the patient and therapist samples both focused on sexuconcerns of the patient, although patients experienced this theme as mixed wiguilt feelings. These latt er were perceived by therap ists as a sep arate the m e factor V. P atie nt factor V, on th e other hand, had as its dom inant the m e a conscioconcern with aggression, mainly with fearful aspects of hostile feelings and attenda

prohibitions and guilt. Th e fifth factors in th e p atie nt and the rap ist samples bothe least resemblance to each other.To What Extent Do Patterns OfConcerns Reflect Stable Individual DifferenAm ong Patients, In Con trast To Session By Session Variation? Th is question directed to the stability of problematic concerns from session to session for particulapatients. I n seeking an answer to this question, factor scores rath er t ha n individuitems were used to focus on the more generalizable dimensions of patient concernFor the patien t sample, item s which had salient loadings on each factor were summ ewith unit w eight, to provide a score for each patie nt for each factor. Ea ch factor wanalyzed separate ly as follows. Using all th e sessions from each pati en t, a pa tie n

by session table was constructed (the entries for a patient being the scores on particular factor for all of her sessions). A one-way analysis of var ianc e was th ecomputedthe w ay being patien ts, each with a set of scores. From this analysian intra-class correlation

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1 0 DAVID E. ORLINSKY KENNETH I. HOWARD AND JAMES A. HILL

*>. The re lationsh ips noted below were significant at or beyond the .01 levProblematic concern with ISOLATIONVS INTIMACY bore no substantial relatir expression thro ugh F an tas y was evident. Th e absence of correlates for th

tly in psycho therapy . T hat is, th e pa tien t can talk of feelings of isolation anProblematic concern with EGO-IDENTITY appeared to be differentially focusexperiences with T herap y and T herapist, O pposite Sex, and W ork and Peers. Th EGO-IDENTITY is not an important concern in the familial conte[parental or conjugal), but rather is concentrated in the area of significant aduProblematic concern with INDEPENDENCE VS. DEPENDENCE was clearly difflly focused in experiences with Conjugal F aniily, and Work and Peers. Thefe areas are im po rtant spheres of adu lt obligation and responsibility for womeProblematic concern with SEX AND GUILT was differentially focused in expences with Opposite Sex, Fa ntasy , and Pa ren tal Fam ily. The relation of this coern to experience with men is straightforward. Presum ably, it is the guilt ane asp ect of this dimension th a t leads to discussion of early family experiences.Finally, problematic concern with ANGER AND FEAR was differentially focusiences with Fa nta sy . This suggests tha t the concern pertains mainly to thatient's hostile or aggressive wishes and her anticipations of punishment or rribution.The pa tternin g of concerns w ithin pa rticu lar areas of experience discussed bthe patie nt may also be noted. Of particu lar intere st is th e significant associatioof Fantasy with such dynamic dimensions of concern as SEX AND GUILT, ANGEND F E A R , and ISOLATION VS. INTIMACY. This finding offers some empirical suo rt for th e conten tion of W hitaker and M alo n e' ' th a t therapy progressessentially, and therefore most effectively, on the plane of fantasy process.

DISCUSSIONConsidering that psychotherapy is commonly thought of as a recourse foeople who ha ve problems especially if they recognize the ir problems and aotiva ted to solve them it is somew hat surprising tha t more research has neen done on the natu re and kinds of problematic concerns manifested by patientsrap y. One reason for this gap m ay be the lack of an accepted and proven methoor study ing th e subjective concerns which patien ts have. Our results suggest thSR can be considered an effective instrum ent for th a t purpose. The items

The substantive findings of this study may be considered from three perspe Norm ative guidelines, theory-relevance, and clinical implications. T

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THE P A T I EN T ' S CONCERNS IN PSYCHOTHERAPY 1tion facilitiesand University Clinics; developmentofnormsfor these groups shouyield interestingand meaningful contrasts withourown.A lthough this study wasnot designed as theory-testing research, its preparatiwas informed bytheory and itsfindings hav e some theoretical relevance. Thiswapparent chiefly with regardto the emergenceof factorial patterns of problemaconcern approximating psychosocial crises or developmental tasks described bErikson'*' andS ulliva n ' ' . A lthough they provide no direct validation for thdevelopmental implicationsof these theories,it isinterestingto note that themocommorily reported concerns were those which in theory were approximatelyagappropriate for them ajority of ourpatients,or only one stage off-pace. Wemigspeculate that a person tendsto seek therapy when she has passedtheageinwhia normal growth crisis is enco untered wi tho ut h aving successfully resolved ithereby falling behind her age cohort more and more obviously.Finally,it is interestingto notea possible clinical implicationin the observpatternof relationship between manifest; contentandexpressive them esindialoguThe findings suggest that therapists might encourage a focusing of dialogueofantasy, dreams,and unreality experiencesif they wishtomobilize m ore dynamemotional concernsin therapy, suchassexandguiltorangerandfear. Con verseif they wish to avoid these areasinorderto limit the depthof involvement, focusiof dialogue on spheres of curren t adjustm ent such as work and peers or conjugfamily would be advised. These recomm endations may be unnecessary for thexperienced psychotherapist,buteven in his case they help to put clinical practice a firme r scientific base.

SUMMARYParallel structured-response questionnaires were developed to survey thexperiences of patients and therapists in individual psychotherapy sessions. 11patients and 17 therapists completed these questionnaires for aseriesof consecutisessions. A nalyses of reportsof patients' problematic concerns indicated that theconcerns were patterned consistently with Erikson's'^' andS ullivan's ^ concetionsof developmental tasks; that patients and the rap ists generally agreed w hconcerns were present orabsent in a session,but differed in interpretive emphasthat concerns were relatively stable from session to sessionfor individual patienbut differed between them; and, th a t concerns emerged differentially in topidialogue, e.g., dyn am ic concerns tendedto beem bodiedindiscussionof fantasyR E F ER E N C E S

1. CAMPBELL, D . T .andFI S K E , D . W . C o n v e rg e nt anddiscriminant validationby the m u l t i tmultimethod matrix. Psychol Bull, 1959,56, 81-105.2. E R I K S O N , E . H . hildhoodand Society. N e w Y o r k : W. W.N orton, In c., 1950.3. ERIOKSON,E. H. I d e n t i t yand the life cycle. Psychol. Issues, 1959,1 1.4. FREN CH,T. M. TheReintegrativeProcessin a Psychoanalytic Treatment. Chica go: U nivers itChicago P ress, 1958.5. HAGGARD,E. A. Intradass orrelationand the Analysis ofVariance. N e w Y o r k : D r y d e n P riy 56. HENRY,W. E.,S I M S ,J. H. andS P RA Y ,S. L. Men tal h eal th p ro fe^io n als inChicago: S ome pliminary observations on origins and prac tice. In J.S hlien. ResearchinPsychotherapy. Vol.IILWashington, D. C.: A merican P sychological A ssociation, 1968.7. H O W A R D ,K. I., O R L I N S K Y , D . E. and H I L L , J. A. The content of dialogue in psychotherap/ . counsel. Psychol, 1969,16,m press.

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