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 Biographical sketch

Group Title: effect of client preparation upon involvement and continuation in psychotherapy /
Title: The effect of client preparation upon involvement and continuation in psychotherapy /
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Permanent Link: http://ufdc.ufl.edu/UF00098630/00001
 Material Information
Title: The effect of client preparation upon involvement and continuation in psychotherapy /
Physical Description: vii, 68 leaves : ; 28 cm.
Language: English
Creator: Barnett, Mark Harold, 1952-
Publication Date: 1981
Copyright Date: 1981
Subject: Psychotherapist and patient   ( lcsh )
Psychotherapy   ( lcsh )
Clinical Psychology thesis Ph. D   ( lcsh )
Dissertations, Academic -- Clinical Psychology -- UF   ( lcsh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
Thesis: Thesis (Ph. D.)--University of Florida, 1981.
Bibliography: Bibliography: leaves 63-67.
General Note: Typescript.
General Note: Vita.
Statement of Responsibility: by Mark Barnett.
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Bibliographic ID: UF00098630
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000294371
oclc - 07712263
notis - ABS0696


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Table of Contents
    Title Page
        Page i
        Page ii
        Page iii
    Table of Contents
        Page iv
    List of Tables
        Page v
        Page vi
        Page vii
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    Biographical sketch
        Page 68
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        Page 70
Full Text







Copyright 1981


Mark Barnett


I would like to thank some of the people who have

helped to make my graduate life a most positive experience.

First, are the members of my graduate committee, whose

input and understanding have made it possible for me to

overcome many hurdles along the way--Dr. Ira Fischler,

Dr. Robert Ziller, Dr. Marilyn Holly, Dr. Eileen Fennell,

and Dr. Paul Satz. Most importantly, I would like to

extend my warmest gratitude to Dr. Hugh Davis, who not

only has been my mentor during the last six years but

has also shown me the value of taking responsibility

for myself.

I would also like to thank the staff of the North

Central Florida Community Mental Health Center who

participated as therapists in this study. In particular,

Dr. David Gilbert contributed his ideas and time to

supervise the data collection described herein.








ACKNOWLEDGMENTS -------------------------

LIST OF TABLES --------------------------

ABSTRACT ---------------------------------

INTRODUCTION -----------------------------

METHODS ----------------------------------

Subjects ------------------------------
Procedures ----------------------------
Instruments ---------------------------
Analysis ------------------------------

RESULTS ----------------------------------

DISCUSSION -------------------------------


READINESS SCALE DATA ------------------


SCALE ---------------------------------

REFERENCES -----------------------------------------

BIOGRAPHICAL SKETCH --------------------------------

























Abstract of Dissertation Presented to the
Graduate Council of the University of Florida
in Partial Fulfillment of the Requirements for
Degree of Doctor of Philosophy



Mark Barnett

March 1981

Chairman: Dr. Hugh C. Davis

Major Department: Clinical Psychology

The present study was designed to assess the effect

of pretherapy client preparation upon factors associated

with the initial phases of psychotherapy. These dimensions

included levels of client involvement and counseling

readiness during the initial patient/therapist contact.

The second set of dependent measures included attendance

and dropouts rates of clients involved in this study.

The comparable groups of twenty incoming therapy

clients at a community mental health center were exposed

to an intake procedure that either included a protherapy

preparatory interview of the normal intake interview. Time

and therapist contact were equal for both groups. Tapes

of these sessions were made and analyzed for level of

client involvement by means of the Experiencing Scale.

At the close of the intake session, all subjects were

asked to fill out the Adjective Checklist in order to

derive Counseling Readiness Scale scores. Attendance

rates and dropout rates were recorded subsequent to the

intake session for a period of six weeks and eight weeks,


Results indicate that attendance was significantly

higher in the experimental interview group. Dropout rates

were almost double in the control group although this did

not achieve a statistically significant level. Further-

more, not only were level of involvement scores signifi-

cantly higher in the experimental group but these scores

also achieved a significant positive correlation with

attendance in therapy for all subjects. Finally, Counseling

Readiness Scale data failed to differentiate between

subject groups and did not relate in a meaningful way to

other measures obtained in this study.

Findings of this study attest to the importance of the

initial patient/therapist contact in forming the therapeutic

relationship. Here, as in previous studies of this kind,

pretherapy client preparation seems to relate to improved

attendance and continuation in therapy. Furthermore, level

of involvement is seen as a significant factor related to

continuation in therapy.


While much research has been devoted to outcome

measures of psychotherapy, a problem has been overlooked

or underestimated which precedes that consideration. That

is, according to Baekeland and Lundwall (1975), between

30% and 60% of patients in outpatient mental health clinics

terminate prematurely. In community centered clinics

these figures are the highest: Overall and Aronson (1963)

reported figures of 57% of patients dropping out after the

initial interview; Saltzman, Luetgert, Roth, Creaser, and

Howard (1976) found that three quarters of the incoming

clients they studied dropped out by the sixth session.

Studies generally have shown dropouts to occur at the

highest rates at the start of treatment (Freedman, Engelhardt,

Hankoff, Glick, Kaye, Buchwalk, and Stark, 1958; Rosenthal

and Frank, 1958; Overall and Aronson, 1963; and Baekeland

and Lundwall, 1975). Furthermore, the problem of patient

dropouts is compounded by the finding that these people

rarely seek treatment elsewhere, according to Garfield,

Affleck and Muffly (1963) and Reiss and Brandt (1965).

These people undoubtedly have a more negative attitude

toward mental health treatment as a result. Hollingshead

and Redlich (1958) point out that this is particularly

a problem with the growth of the community mental health

movement and its lower socio-economic status clients.

One bit of evidence which testifies to the detriment

of dropping-out is the numerous studies which relate

duration of treatment to treatment outcome (Lorr, Katz,

and Rubinstein, 1958; Bailey, Warshaw, and Eichler, 1959;

Luborsky, Auerbach, Chandler, and Cohen, 1971; and Saltzman

et al., 1976). Of course, it seems an obvious point that

therapy certainly cannot help anyone who does not return

after their initial visit. No matter what value researchers

assign to therapeutic elements, the premature terminator

will not be exposed to them.

In examining early terminators, we are faced with the

consideration of those elements which are particular to

the development of a therapeutic relationship. One such

element which has received attention recently is that of

client involvement. Client involvement can be thought of

as the degree to which a patient is willing to invest and

express himself in therapy as well as his self-awareness.

This concept will be explored more fully in this paper.

Lennard and Bernstein (1960) were among the first to

identify client involvement as a key to the Formation of

the therapeutic relationship. They observed in their

research that the necessary precondition for therapy was

the ability of client and therapist to be able to carry on

meaningful communication and to mutually perceive their

roles in therapy. In their research among low socio-

economic status patients. Overall and Aronson (1963)

felt the greatest obstacle to psychotherapy is a

patient's minimal involvement in the initial phases of

treatment. Kirtner and Cartwright (1958) observed that

patient involvement from the outset--for them acknowl-

edging responsibility and examining feelings and experience--

was related to improvement. Rice and Wagstaff (1967) con-

curred with this finding.

More recently, Saltzman et al. (1976) conducted

in-depth research into the relationship between involvement,

continuation, and improvement. With particular emphasis on

uncovering features of the earliest sessions, these

researchers used both client and therapist measures of the

patient's experience. Using subscales of the Multiple

Affect Adjective Checklist that they devised for clients,

they were able to gain some measures of therapeutically

important features such as understanding, openness, scrutiny,

continuity, movement, uniqueness, and respect. They found

that these scales were able to differentiate the continues

from the dropouts as early as the first session and most

significantly at the third, for those subjects who remained

in therapy that long. Additionally, the therapist reports

of these same factors differentiated continues from termi-

nators also as early as the first session and slightly more

clearly at the third, with the most significant variables

being their ratings of patient involvement, responsibility

and movement. Interestingly, none of the variables gained

any predictive strength after the third session in their

ability to discriminate continues from non-continuers.

This research provided a great deal of testimony for the

importance attached to patients' experience during the first

few sessions of treatment, and the particular significance

of client involvement in the continuation of treatment.

Another contribution to understanding the importance

of client involvement to the therapeutic endeavor has come

from the research of Klein, Mathieu, Gendlin, and Kiesler

(1970). They became involved with this concept through

the development of the Experiencing Scale (EXP). The

Experiencing Scale is a process measure which evaluates a

patient's level of involvement during any point in a therapy

session. As shall be seen, this measure has been shown to

be a reliable and valid tool in the assessment of patient

involvement (Klein et al., 1970).

Among the findings provided by the Experiencing Scale

research is that greater levels of patient involvement are

associated with higher verbal productivity and expressiveness

as well as better ratings of outcome (Rogers, Gendlin,

Kiesler, and Truax, 1967). This study also provided evidence

of the stability of the instrument and its sensitivity

during short periods taken from therapy sessions. Other

research has also shown the relationship of patient involvement

as measured by the EXP and a variety of positive process

and outcome measures.

Kiesler (1969) was able to demonstrate an associa-

tion between EXP ratings and outcome based on counselors'

ratings of improvement. Subjects involved included

schizophrenic as well as psychoneurotic samples. Van der

Veen (1965) related EXP level to rapidity of the formation

of the therapeutic relationship and patient motivation.

Across the many studies employing the EXP scale, Kiesler

notes that, "the most powerful and consistent finding is

that successful therapy patients start, continue, and end

therapy at a higher level of experiencing than do less

successful patients" (p. 11). The research attesting to

the usefulness, reliability, and validity of this scale

shall be reviewed in greater detail later in this paper.

A similar line of research is that based on the posi-

tive relationship between patient emotional involvement and

therapy readiness, first reported by Burham in 1952.

Heilbrun and Sullivan (1962) conceived of therapy readiness

as a necessary ingredient towards developing a therapeutic

relationship. In light of this they developed a Counseling

Readiness Scale (CRS) to help identify those clients who

would be most likely to continue in therapy and derive some

benefit from it. Over the course of several studies, they

found this measure of therapy readiness (CRS) to be able to

discriminate not only between successful and non-successful

therapy outcomes, but also between continues and non-continuers

in treatment (Heilbrun, 1962; Heilbrun and Sullivan, 1962).

The concept of counseling readiness and its relationship

to client involvement has provided researchers greater

insight into the crucial early stages of the therapeutic

relationship. The concept of counseling readiness and the

Counseling Readiness Scale of the Adjective Checklist shall

be discussed further in the following section.

Another significant research program into the client

involvement question was reported by Gomes-Schwartz in

1978. Thirty-five male counseling patients were assigned

to therapists of varying levels of experience and either

analytical or experiential in orientation. The process

measure employed was the Vanderbilt Psycho-therapy Process

Scale which was factored into seven derived scales that

tapped dimensions hypothesized as predictors of outcome.

These proved to be internally consistent and reliably

rated throughout the project. The client factors which

obtained significant validation consisted of patient explora-

tion patient participation, and patient hostility. These

process factors were related to a variety of outcome measures

that reflected the viewpoints of clients, therapists, and

clinical observers. Gomes-Schwartz concluded that theoret-

ical orientation and therapist experience did not have an

impact on outcome. More importantly, all outcome measures

including ratings by therapists, patients, and clinical

observers were significantly predicted by "the patients'

willingness and ability to become actively involved in the

therapy interaction" (1978, p. 1032). That is, patients'

involvement during the early stages of interaction was

the most consistently predictive measure of therapy outcome.

In her discussion of these findings, Gomes-Schwartz

places a great deal of emphasis upon client involvement

from the outset of treatment. She asserts:

If the patient's willingness nnd capacity
to participate in the therapy interaction
are among the most important determinants
of improvement in short-term therapy, one
of the aims of future research should be
to determine if and how positive involve-
ment in therapy could be increased. (p. 1032)

She goes on to suggest role-induction procedures for just

this purpose:

If patients abilities to become involved
in the therapy process were as much a
product of inappropriate expectations
about the psychotherapy enterprise as a lack
of willingness to take responsibility for
their own behavior, role induction proce-
dures might be useful. . (p. 1032)

In line with this suggestion is an array of research

testifying to the importance of client expectations for

the formation of a beneficial therapeutic relationship.

Also, research has provided abundant evidence for the merits

of pre-therapy client preparation to overcome the obstacles

supposedly created by inappropriate expectations. More

specifically, studies have provided significant evidence

that disconfirmation of participants' expectations may have

adverse effects upon the formation of the therapeutic

alliance and continuation in therapy (Freedman et al.,

1958; Lennard and Bernstein, 1960; Goldstein, 1960;

Overall and Aronson, 1963; Horenstein and Houston, 1976).

Lennard and Bernstein point out that dissymmetry of

expectations between patient and therapist not only inter-

feres with the therapeutic task, but can actually lead to

the premature death of the therapy system, itself. Heine

and Trosman (1960) concluded that a significant factor in

predicting continuance in therapy is mutuality of expecta-

tions between patient and therapist.

It was the findings in this research exploring expec-

tational factors which gave rise to the client preparation

programs. These programs were aimed at correcting inappro-

priate expectations and providing a role orientation for

clients entering treatment. Their success has been docu-

mented in many forms. Orne and Wender (1968) designed the

Anticipatory Socialization Interview with the belief that

providing patients with the correct set about their role

in therapy would lead to a "more rapid engagement in the

working alliance" (p. 1203). Hoehn-Saric, Frank, Imber,

Nash, Stone, and Battle (1964) modified this Anticipatory

Socialization Interview into their own Role Induction

Interview which covered four topics: (1) a general discus-

sion of what psychotherapy is; (2) the expected behaviors

of both patient and therapist; (3) preparation for certain

phenomena and topics in therapy, such as resistance; and

(4) expectations for duration of treatment. They designed

a study using 40 subjects classified as "psychologically

unsophisticated psychoneurotic patients." Half of the

subjects randomly selected were administered the Role

Induction Interview and compared to the half who received

no pretherapy orientation. They found significant differences

between treatment and control groups on three measures:

the experimental group scored highest on the Therapy

Behavior Scale in the third session, had a better attendance

record, and received a better rating of the therapeutic

relationship by the therapists. The findings of this

research has been replicated in several different efforts

involving individual adult incoming therapy clients

(Nash, Hoehn-Saric, Battle, Stone, Imber, and Frank, 1965;

Sloane, Cristol, Pepernik, and Staples, 1970; Liebcrman,

Frank, Hoehn-Saric, Stone, Imber, and Pande, 1972). This

form of role induction interview has been employed with

equal success in group therapy (Heitler, 1973, 1974; and

Yalom, 1975)..

Other forms of client preparation have also been

attempted with positive results. Martin and Shewmaker (1962)

used written instructions and found that their instructions

fostered constructive patient behaviors, according to

therapists. Strupp and Bloxon (1973), feeling that a more

economical system was necessary, designed a role-induction

film and compared it to a normal Role Induction Interview

as well as a no-treatment control situation. They found

that both client preparatory procedures were significantly

more effective than control in terms of contributing to

patient behavior, attitudes, satisfaction, attractiveness,

and progress. Venema (1972) found videotape role prepara-

tion to have a positive effect on the therapeutic process

in the form of patient behavior and satisfaction. Truax

and his co-researchers (Truax, Wargo, Carkhuff, Kodman,

and Moles, 1966; Truax, Shapiro, and Wargo, 1968) used

audiotapes of actual group sessions, comprised of desirable

interactions, and found improvements on various measures

of self-concept and therapy experience. Schlotthober (1975)

employed a video-tape model and written instructions to

prepare clients for a leaderless group. Finally, Whalen

(1969) compared modeling versus modeling with instructions,

measuring interpersonal openness as rated by independent

judges, and found that modeling combined with instructions

resulted in more interpersonal openness and feedback.

All of these studies have shown that client preparation

is effective in helping patients to establish a therapeutic

relationship and to derive benefits from treatment. While

all of the client preparation studies have attempted to

introduce some manipulation of intake procedures, they are

lacking in measures of the particular effects of the manipu-

lation. Gomes-Schwartz (1978) suggested the crucial ingre-

dient to be client involvement. She felt that the reason

the client preparations were successful was in their

ability to help patients understand therapy and their role

in it, and as a result, to be able to become involved in


The present study is an attempt to shed more light

on the role of client involvement as it relates to earliest

stages of client therapy readiness and patient continuation.

Research has shown a problem that leads to premature termina-

tions is the inability to become involved in therapy. This

is due, in large part, Lo the lack of understanding of the

therapeutic process or the patient's role in it. Because

it is up to the patient to "vote with his feet" on his

commitment to the therapeutic relationship, it can be seen

that the level of patient involvement could be a deciding

factor in patient dropouts.

It has also been shown in research that there are

methods which can help offset the barriers to patient

involvement. There are several forms of special client

preparation techniques which have all shown significant

ability to improve patient continuation, (see Barnett,

1979). Those researchers who have employed process and

outcome measures, as well as attendance and continuation

assessments, have found positive relationships with client


The present method involves a comparison of a client

preparation technique to a normal intake procedure in a

community mental health center. This comparison was made

on the basis of client involvement and counseling readiness

measures in addition to attendance and dropout rates.

Client involvement is seen as the most salient of the

intervening variables between intake and continuation in

therapy. The primary hypotheses of this study were:

(1) significantly higher rates of attendance and continua-

tion expected in the experimental group; (2) significantly

higher ratings of client involvement expected in the

experimental group; and (3) a significant positive corre-

lation between client involvement and continuation measures

was expected. The secondary hypotheses of this study

included: (1) significantly higher ratings of client

counseling readiness expected in the experimental group;

(2) a significant positive correlation expected between

counseling readiness and continuation measures; and

(3) a significant positive correlation expected between

client involvement and counseling readiness measures.


The goal of this study was to compare the usefulness

of a client orientation interview to normal intake proce-

dures at a community mental health center. It was designed

to provide data concerning the role of client involvement

and counseling readiness in the continuation of patients

in therapy.


Consecutive incoming adult clients at the North

Central Florida Community Health Center designated for

individual therapy were included in Lhe subject population.

There was a total of twenty subjects in both the experi-

mental treatment group and the control group. Assignment

to either condition was completed randomized. This was

accomplished by designating assignment to either group on

the basis of a blind drawing of scaled intake packets. This

was performed by the therapist already assigned to the case

at the beginning of the intake session. Assignment to

therapists followed normal procedures. Six adult unit staff

therapists participated in this study. Therapists were not

aware of the research design, instead believing that an

ongoing evaluation of several intake procedures was occurring.

The subject population did not include those clients desig-

nated for alcoholic rehabilitation of chemical therapy in

that they were assigned to separate sections of the facility.


The half of the subjects who were assigned to the

treatment condition were administered the "Client Prepara-

tory Interview." This interview was based on the Role

Induction Interview developed by Orne and Wender (1968)

and Hoehn-Saric et al. (1964) and is shown in Appendix A.

The instructional set designed for the therapists is included

in Appendix B. The therapist spent between ten and fifteen

minutes with the subject going over this form and reviewing

the essential points. This interview form has been adopted

by several other researchers with positive results mentioned

previously in this paper--most notably Yalom (1975) and

Heitler (1973, 1974). The interviewwas designed to cover

four main topics: (1) a general discussion of what psycho-

therapy is; (2) the expected behavior of both the patient

and therapist; (3) preparation for certain phenomena and

topics in therapy,such as resistance; and (4) expectations

for duration of treatment.

The orientation interviews were conducted by therapists

who were assigned automatically to subjects on a rotating

basis. In this way, the normal intake interview timing was

not interfered with and, therefore, there was no problem with

the confounding effect of extra attention in the experimental

group. Control subjects engaged in normal intake procedures

for the same amount of time--one hour--with therapists who

went on to become the patients' regular therapists. The

control intake procedure included obtaining identifying

information such as age, sex, marital status, race, and

education. It also included having the patient describe

his presenting problem along with specific symptoms, when

they began, precipitating factors, how they affect his life,

and why he decided to come to the clinic at this time. This

procedure may have included an evaluation of the patient's

mental status and formal testing to derive this information

although this was rarely performed. Finally, an effort was

made to obtain relevant history including psychiatric history,

medical history, family background, and personal history such

as social, sexual, and employment adjustment. While this

intake format was included for both treatment and control

group subjects, it was simply extended for the control sub-

jects not receiving the orientation interview for the first

few minutes of intake.

In order to test the hypothesis that the client prepar-

atory interview has an immediate effect upon level of client

involvement, all subjects were measured on this variable

during their initial session by means of the Experiencing

Scale (EXP). This process measure is designed to be

especially sensitive to levels of patient involvement and

was used to rate audiotapes of short therapy segments taken

from the last half of the intake hour. Two three minute

segments were obtained from these samples for each subject.

All of these segments were taken from the identical

moments during the intake session.

In order to attain data reflecting counseling readi-

ness, the Counseling Readiness Scale (CRS), which is a

subscale of the Adjective Checklist was also administered.

All subjects filled out this checklist at the very end of

the intake interview session. A list of the adjectives

contained in the Counseling Readiness Scale are contained

in Appendix D.

The second set of dependent measures involved discrim-

inating measures of continuation and attendance. One

measure consisted of the complete attendance records of all

subjects for the six weeks subsequent to the intake pro-

cedure, that is, the total number of sessions attended

during that period based on once a week standard scheduling.

In this way, between group comparisons of attendance were

possible after the first six weeks of treatment. Another

measure consisted of the number of subjects in each group

who dropped out by the fourth session. This was designated

as those clients who are not present for their fourth

session and who made no contact with the center for another

four weeks, measured at the eight-week follow-up period.

This particular criterion was arrived at through the results

of pilot research conducted at the Community Mental Health

Center which showed that 50% of all patients drop out by the

second session and that 70% drop out by the fourth session

(Barnett, 1979). By the fourth session, most dropouts are

accounted for and beyond this point other factors of

treatment have become salient in the decision to drop out.


The Experiencing Scale (EXP) provides a measure for

evaluating patient involvement in psychotherapy directly

from tape recordings or transcripts of the therapy session.

The concept of Experiencing, and for the purposes of this

study, involvement, refers to "the quality of an individual's

exporiencing of himself, the extent to which his ongoing,

bodily, felt flow of experiencing is the basic datum of

his awareness and communication about himself, and the

extent to which this inner datum is integral to action

and thought," (Klein et al., 1970, p. 1).

The scale designed to give an estimate of level of

experiencing on a continuum broken down into seven stages.

These distinct levels are scored on a one to seven scale.

An outline of each level is provided in Table 1. At low

levels of experiencing, the patient's discourse is super-

ficial and impersonal. As one moves up the scale there is

a progression towards inwardly elaborated descriptions of

feelings and away from simple, limited, or externalized

self-references. At higher levels of experiencing, feelings

are explored more deeply and new perspectives are achieved.

Klein et al. (1970) state:


Stage Content

1 Abstract, superficial discussion of external
events; content not about the speaker.

2 External events are described; behavioral or
intellectual self-description. There is
association between content and speaker but
no feelings attached.

3 Association between content and speaker
including some feelings; personal reactions
to specific events; limited self-description;
behavioral descriptions of feelings.

4 Content is a clear presentation of speaker's
feelings and personal experience. Experience
rather than events are subject of discourse--
but, interior events are not interrelated or
used as basis for systematic self-examination.

5 Purposeful exploration of speaker's feelings
and experiencing. Must include defining a
problem about himself explicit in terms of
feelings plus exploring the problem in a way
which leads to expanded awareness of it.

6 Synthesis of realized feelings and experiences
to produce personally meaningful structures or
to resolve issues. Present or emergent experience
is part of content.

7 Same synthesis as Stnge 6 with Lhe addiLion that
the speaker's new ideas be applied to an expanding
range of inner events or give rise to new insights.
Speaker sees his solution as a process that he can
apply to new situations.

Independent of specific pathology or problem
content, and apart from details of therapists
technique, this scale attempts to assess the
degree to which the patient communicates his
personal, phenomenological perspective and
employs it productively in the therapy session.
(p. 1)

Most importantly, for data collection in this particular

context, the authors go on to point out that:

It is sensitive to shifts in patient involve-
ment, even within a single interview session,
making it useful for microscopic process
studies, for example, to evaluate the effec-
tiveness of therapist interventions, .. to
appraise different patterns of interaction
between patients and therapists, or to establish
a profile of patient performance within the
therapy hour. (p. 1)

The unit typically scored by judges (two to four are

recommended) is a two to eight minutes tape segment. These

segments are, of course, edited for names and identifying

material. In a study to determine the ideal unit length,

EXP ratings were compared for two, four, eight, and sixteen

minute intervals by Kiesler, Mathieu, and Klein (1964).

They found that "the reliabilities, the range and the dis-

criminatory power of the ratings were independent of the

length of the segments" (p. 34). In this study, two three-

minute segments were taken during the last third of the

intake session hours. Specifically, three minute segments

were obtained at the fortieth and fiftieth minute of the

intake session. Three judges were trained in the form pre-

scribed by the Manual of the Experiencing Scale to rate

these tapes. This training consists of practice sessions

in which a total of sixteen hours of random segments from

therapy sessions are rated.

Interrater reliabilities obtained on this scale have

been high. The statistical approach has been to both esti-

mate the reliability of the means of the judges rating (rkk)

and to estimate the average intercorrelation of all possible

judge pairs (rii). The r.. values obtained in various studies

have ranged from 0.44 to 0.67 while the more crucial rkk

coefficients have ranged from 0.76 to 0.91 (see Klein et al.,

1970, p. 45).

Extensive research has gone into the attempt to validate

the Experiencing Scale. Detailed summaries of these studies

can be found in the Research and Training Manual (Klein et al.,

1970) as well as in Rogers et al. (1967). This section will

review some of the studies contributing to the val.idity of

the Experiencing Scale.

In the most extensive study to date, using schizophrenic

inpatients as subjects, Rogers et al. (1967), compared EXP

ratings to data from testing (WAIS, TAT, and others), ratings

of therapists, and behavior evaluations. EXP level was asso-

ciated with an initial absence of depression, high verbal

ability, and high verbal productivity and expressiveness.

EXP level was also related to independent judges ratings of

the therapist accurate empathy, and to patients' perceptions

of favorable therapist attitudes. The EXP level was associ-

ated with the following indices of change and outcome: MMPI

Sc scale, Hs scale, and Pd scale improvement; self rated Q-

sort adjustment; clinician evaluation of change; and percent

of time out of the hospital.

Also in this study, the more successful patients had

smoother trends on EXP level, "with less backsliding and

more consistently maintained their initial levels." The

study most clearly revealed that the EXP scale, "taps dif-

ferences in patients' verbal behavior, which is a function

of initial expressive capacity of motivation for therapy"

(Rogers et al., 1967, p. 136). It also made clear the

sensitivity of the scale during short periods of therapy.

Kiesler's study (1969) associating EXP and outcome

included ratings of fourteen schizophrenic and twenty-six

psychoneurotic patients. Counselors ranged widely in

technique and orientation. The outcome criterion was the

counselor rating of improvement made on the Kogan-Hunt

Movement Scale. Two different sets of four judges rated

four-minute segments drawn from each of the first thirty

interviews for each patient. Results were consistent and

reliable: for one to thirty interviews there were signif-

icant main effects for outcome and no significant inter-

action effects either for outcome and diagnosis or outcome

and time.

In a study of the effectiveness of psychoanalytic psycho-

therapy with schizophrenics Karon and VandenBos (in Klein et al.

1969) used EXP along with other scales of process and condi-

tion including Relationship, Problem Expressions, and Personal

Constructs. With reliabilities of the four judges ranging

from .54 to .72, correlation among all four process scales

were extremely high. Researchers suggested that it is the

consistency of therapists' behavior in all areas that is

correlated with EXP. EXP was also strongly related to

ratings of mental health made from the Clinical Status

Interview and to the length of hospitalization.

Other studies have been consistent with the above findings

and contribute to its construct validation. Van der Veen

(1965) found ratings of EXP level were associated with the

"speed (in days) with which the patient took advantage of

the therapy offered and the frequency of his contact, factors

reflecting patient motivation" (p. 24). Corney (in Klein

et al., 1969) tested the relationship between EXP scores

and a rating of focusing ability, which are thought to be

measures of the same construct (see Gendlin, Beebe, Cassens,

Klein, and Oberlander, 1968). A positive correlation was

formed and provided evidence of the validity of the measure

of experiencing. Mintz (in Klein et al., 1969) compared

the information gathered from ratings of the whole hour of

sixty sessions to briefer four-minute segments. Correlations

ranged from .62 to .99 and so Mintz concluded that, "ratings

of brief segments tap the same experiencing quality as ratings

over the whole sessions" (p. 67). In a factor analysis of the

same material, "EXP saliently loaded a factor interpreted as

Patient Involvement that also included Patient Receptiveness,

Therapist Impact on Patient, Patient Evaluation, and Patient

Dependency" (p. 67). EXP can be seen as being particularly

sensitive to the degree of patient involvement and his

capacity to engage in therapy, based on these studies.

A second instrument that was used in this project

is the Counseling Readiness Scale developed by Heilbrun

and Sullivan (1962), a subscale of the Adjective Checklist.

This scale is designed to provide a measure of client

preparedness for treatment and is filled out by the

patient. The Adjective Checklist Manual (Cough and ]Heilbrun,

1965) identifies the main function of the CRS as "identi-

fying counseling clients who are ready for help and who

seem likely to profit from it." Heilbrun and Sullivan

felt one purpose in developing the CRS was to provide a

tool which would identify the client who would remain in

treatment long enough to benefit from it as well as the

premature terminator. It was intended for use as early in

treatment as was feasible and much of the data involving

the CRS was gathered during initial sessions of therapy.

The developers felt an important use of this tool would

be to take immediate steps to deal with factors leading to

premature termination with those clients who show poor

counseling readiness.

The use of the Counseling Readiness Scale in this

research study was to provide a secondary source of data

for the concept of patient involvement in therapy. In the

literature, counseling readiness has been discussed as a

factor associated with client involvement. Burham (1952)

first conceived of therapy readiness as an initial set,

and found significant positive relationships between

therapy readiness and emotional involvement, as measured

by the therapists, for clients in short-term therapy. In

this context, CRS is being employed to provide more detailed

information on the relationship between client preparation,

client involvement and continuation in therapy.

The Counseling Readiness Scale was developed to dis-

criminate between continues and non-continuers in treatment.

Heilbrun and Sullivan (1962) attempted to validate their

scale on vocational counseling clients. With this sample

they found counseling readiness to successfully differen-

tiate successful from non-successful outcomes among male

subjects. Heilbrun (1962) was able to provide improved

scale'predictions for women clients as well. These studies

have also provided evidence that "therapy-ready clients"

remain longer in therapy, were therapy-minded, and less


The CRS provides a raw score which, using separate

conversion tables for male and female subjects, is con-

verted into a T-score ranging in numbers from 2-107. The

mean T-score is set at 50, and the standard deviation at

10. Reliability of these scores have been assessed in two

ways. Test-retest correlations are as follows: college

males over ten weeks = .71, adult males over six months =

.65, medical students over five and one-half years = .54.

Interrater reliability was obtained by having ten judges

Fill out the checklist to describe one hundred assessees.

Five of these cases were scored for inter-group reliability

coefficients (and corrected by the Spearman-Brown prophecy

formula) and yielded scores of .70, .63, .61, .75, .61.

Futhermore, social desirability was assessed for its

influence upon this measure using Edward's Social Desir-

ability Scale. It was found to have a median correlation

of +.L6 with a range from -.41 to +.45. Thus, the social

desirability factor is not as prominent in CRS scores as

it is in most personality tests.


The design of this research study was suggested by

Campbell and Stanley (1963) as the most clear procedure for

measuring the central question of whether treatment does

have an effect. They point out:

While the pretest is a concept deeply
embedded in the thinking of research
workers, it is not actually essential
to true experimental designs. For
psychological reasons, it is difficult
to give up "knowing for sure" that the
experimental and control groups were
"equal" before the differential experi-
mental treatment. Nonetheless, the most
adequate all-purpose assurance of lack
of initial biases between groups is
randomization. (p. 25)

The design is as follows:

Experimental Treatment Group R X 01 01b Continuation measure

Control Group R 02a02b Continuation measure

where R=randomization, X=experimcntal treatment, and

01-02=simultaneous measures of client involvement and

counseling readiness.

One reason this design is desirable is due to its

amenability to clear statistical analysis. Once again

this is pointed out by Campbell and Stanley (1963) who

recommend a between-groups t-test--"this design is perhaps

the only setting for which this test (the t-test) is


So analysis took the form:

I. between-groups t-tests of:

A) client involvement scores (EXP);

B) therapy readiness scores (CRS);

C) continuation and attendance measures;

II. Pearson Product-Moment correlations of all
subjects' scores on:

A) client involvement X continuation measures;

B) therapy readiness X continuation measures;

C) therapy readiness X client involvement.

Finally, data were analyzed for any differential therapist

effect or subject group differences. In this way, analysis

produced information relating to treatment effects on client

involvement, therapy readiness, and continuation. It also

provided evidence of the relationship between client involve-

ment and continuation, as well as between counseling readi-

ness and continuation. Lastly, this analysis was to reveal


any relationship between the measures of client involvement

and client therapy readiness.

While training of the three raters was in the form

prescribed in the Experiencing Scale Training Manual, it

was also necessary to check the reliability of their ratings

during the rating process, itself. This was also performed

in accordance with the manual. Six samples from among the

forty rating segments were submitted to a reliability test

of the means of the judges scores (rkk) and the average

intercorrelation of all possible judge pairs (rii).


The treatment group and the control group were compared

on attendance, dropout rates, Experiencin Scale ratings,

and Counseling Readiness Scale data. These raw data are

all contained in Appendix B. This was performed by t-test

comparisons between means (see Table 2) as well as by

Pearson Product-Moment correlations between all three

possible groups (See Table 3). These measures seemed to

support the primary hypotheses involving the significance

of attendnace and Experiencing Scale data. However, the

analyses failed to provide any meaningful support for the

secondary hypotheses involving the Counseling Readiness

Scale measures.

T-tests comparing attendance data showed the tendency

for treatment group subjects to attend therapy significantly

more often than the control group subjects. All clients

were scheduled weekly for sessions for at least six weeks

immediately subsequent to the intake session. In fact,

total attendance for the treatment group was twice that of

control group subjects during the six-week follow-up period.

Additionally, the number of dropouts recorded after the

eight-week follow-up period numbered 13 out of 20 for the

control group and only 8 out of 20 for the treatment group.


Mean Mean Mean
Control Treatment Difference df t

6-week attendance 1.35 2.70 1.35 38 3.29 p .005*

Experiencing Scale 2.69 3.21 .52 38 2.26 pc .025*

Counseling Readi-
ness Scale 58.00 57.30 .70 38 .74

Dropouts 1-week .55 .10 .45 38 2.25 p<.025*

Dropouts 8-weeks .65 .40 .25 38 1.14 p, .15"



Measure r Value

Experiencing Scale Data X +.54 p .001*
6-week attendance rates

Counseling Readiness Scale Data X +.078
6-week attendance rates

Experiencing Scale Data X +.134
Counseling Readiness Scale Data


The difference in attendance achieved a statistical signif-

icance of .005 (one-tailed). The difference in group

dropout rates does not reach the conventional statistical

significance level of .05, but does reach a probability

level of .15.

An interesting aspect of the attendance measures was

the fact that 11 subjects in the control group failed

to attend even one therapy session after intake as compared

to only 2 subjects in the treatment group. This difference

is statistically significant at the .025 level (one-tailed).

Comparisons of the Experiencing Scale means between-

groups show the treatment group to have a significantly

higher level of interaction than did subjects in the con-

trol group. This seems to reveal a higher level of partic-

ipation on the part of clients involved in the experimental

orientation program. Furthermore, when Experiencing Scale

measures were correlated with attendance data, a positive

relationship (r = +.54, p <.001) was demonstrated.

In order to determine the reliability of the three

raters involved in the Experiencing Scale ratings, inter-

rater reliabilities were obtained for six randomly selected

samples among the forty protocols. As in cases where more

than two raters are employed, it was preferable to use

Ebel's intraclass method which produces not only an esti-

mate of the reliability of the means of the judges' ratings

(rkk), but also the more stringent estimate of the average

intercorrelation of all possible judge pairs (rii). This

second measure reveals the amount of variance present for

each rater versus every other rater. Results of this

analysis yielded ratings that are considered quite high

when three raters are employed (see Table 4). Interrater

reliabilities averaged .83 for rkk and .64 for rii for mode

scores and .95 for rkk and .87 For rii for peak scores.

This would provide support for those findings involving

the Experiencing Scale data.

Data obtained for the Counseling Readiness Scale

provided no significant information along any of the dimen-

sions involved in this study. Comparison of the means of

treatment and control groups provided no differentiation

according to Counseling Readiness Scale mrle;isLrcs A

correlation between Counseling Readiness Scale scores and

attendance for all subjects achieved on a +.03 relationship

which is insignificant by an standard. The correlation

between Counseling Readiness Scale and Experiencing Scale

scores was only slightly higher at +.13. All in all, this

scale seems unrelated to factors which relate either to the

client's level of interaction as measured by the Experiencing

Scale or those that lead to increased participation in

therapy as measured by attendance and dropout rates. Given

this finding, this study could only provide negative support

for the validity of the Counseling Readiness Scale.


Sample 1 (treatment group)

Sample 2 (treatment)

Sample 3 (treatment)

Sample 4 (control group)

Sample 5 (control)

Sample 6 (control)

TOTAL (modes)

Peak Scores

Rating Reliabilities
rkk rii
.78 .54

.90 .75

.92 .83

.81 .59

.74 .48

.85 .66

.83 .64

.95 .87

As part of data examination, several Adjective Check-

list subscales other than the Counseling Readiness Scale

were calculated in order possibly to shed more light on

factors related to this study. It must be noted that

what became apparent during these calculations was the

limitations of the Adjective Checklist, itself. The very

nature of a checklist lends itself to many interfering

elements such as reading ability, perceived time pressure,

and so on.

Adjective Checklist subscale measures of defensive-

ness and need for succorance failed to achieve any statis-

tical differences between groups or any meaningful rela-

tionships to either attendance or Experiencing Scale data.

One subscale which consisted of the total number of adjec-

tives checked, was difference between groups. Subjects in

the experimental group tended to check a significantly

greater number of adjectives than those subjects in the

control group (69.5 versus 83.0, p< .05, one-tailed test).

According to the Adjective Checklist Manual, "checking

many adjectives seems to reflect surgency and drive, and

a relative absence of repressive tendencies .. the man

with low scores tends more often to be quite and reserved,

more tentative and cautious in his approach to problems,

and perhaps at times unduly taciturn and aloof" (p. 5).

While the groups did differ on this characteristic, there

was no relationship found between number of adjectives

checked and either attendance or Experiencing Scale data.

As part of the analysis, the two groups of subjects

were compared on a number of relevant demographic variables

in order to see if the groups were comparable. The vari-

ables consisted of age, color, sex, income, education, and

diagnosis. It was found that the control and experimental

groups were almost identical along all of the mentioned

variables. As is expected in an outpatient community

setting, the subjects were young, with little education and

low income, mostly white, and mostly female. Table 5 pro-

vides a complete breakdown and description of the subject

composition. Appendix C contains this raw data in its

entirety. It should be noted that comparisons were made

between groups on therapist effects and that no differences

could be attributed to this factor.

In conclusion, data analyses of measures obtained in

this study provide support for the hypotheses that the

experimental treatment leads to increased attendance and

higher levels of involvement in therapy. Additionally,

the hypothesis that predicted a significant positive

relationship between level of experiencing and attendance

was supported.


I Age
(Average =

8 9
6 2
6 2 5 3 3

20 25 30 >35 20 25 30 >35
25 30 35 25 30 35
Control Group Experimental Group

II Education 6

1 0
Grade Iligh Coll .ce Grnade 11i fh Collcge
School School School School
Control Group Experimental Group

III Race

3 0 _
LL I IL_- __ 1 1
White Black Other White Black Other
Control Group Experimental Group

Table 5 continued



Female Male
Control Group



Female Male
Experimental Group

5 5

$0 $5000 $5-10,000 1$10,000 annually

V Income
(Average =

VI Diagnoses

Control Group

5 6
4 5 6 3

$0 $5000 $5-10,000 7$10,000 ;innuially
Experimental Group


Neuroses Personalnty Adjustment
Disorder Reaction
Control Group

6 5 5

Neuroses Personality Adjustment
Disorder Reaction
Experimental Group

IV Sex



This study was conceived and designed to elucidate the

factors involved with client preparation and how they relate

to continuation and involvement in therapy. The major

hypotheses of this research were, primarily, that client

preparation would have a significant effect on client con-

tinuation and involvement and that continuation would be

positively related to involvement. The secondary hypothesis

predicted that counseling readiness would be higher in the

experimental group and would be positively related to the

continuation and involvement measures employed in this study.

The present study employed a client prcparatLon

technique consisting of a personal interview since the

literature has consistently pointed to the superiority

of this technique across many types of research designs.

Client involvement was assessed by means of Experiencing

Scale and counseling readiness by means of the Counseling

Readiness Scale contained in the Adjective Checklist. These

measures are described in detail in the Method section of

this paper.

Data obtained from this experimental program tend to

support the major hypotheses. However, the secondary hypoth-

eses received no support. Continuation measures, consisting

of attendance rates over six weeks and dropout rates after

eight weeks were both significantly better in the experi-

mental treatment group than in the control group. Level

of involvement as measured by the Experiencing Scale also

was higher in the experimental treatment group. Also, a

positive correlation was found to exist between level of

involvement and continuation in therapy.

The secondary hypotheses involving counseling readiness

measures achieved no significant levels. That is, Counseling

Readiness Scale scores were not different between groups and

were unrelated to either attendance measures or level of

involvement. These experimental findings will all be dis-

cussed in more adequate detail.

The Einding that client preparation did seem to have

an effect upon attendance and dropout rates falls very

much in concordance with other studies previous to this one.

Specifically, in this study, attendance was doubled in the

experimental group and dropout rate was almost half (7

versus 13) of that in the control group. Other studies

employing a live interview very similar to this one have

had the most significant effect on continuation measures

and therapy variables.

The most significant of these studies was the research

program initiated by Hoehn-Saric et al. (1964). Their

interview was based on the Orne and Wender model, as was

the present study, which was finally published in 1968.

Subjects in that study were remarkably similar to those

utilized in this study: 40 psychoneurotic patients with

a mean age of 30 and a mean education of 11 years. There

were 17 males and 23 females, 35 white and 5 black subjects.

The major differences between their design and the present

one were to employ a separate therapist to perform the

Role Induction Interview instead of the subjects' therapists

and, for some reason, to replace subjects who dropped out

by the fourth session. This last element seemed inexplic-

able in that they were measuring attendance rates. Even

though their main assumption was that their procedure

would provide appropriate expectations of therapy for new

clients, their dependent measures consisted of attendance

records, therapy behavior ratings, and client/therapist

ratings of client improvement--omitting expectational

data completely.

As predicted, they found significant differences

which favored the experimental treatment group: better

attendance over a four month period, higher scores on the

Therapy Behavior Scale in the third session, and they

received a better rating of the therapeutic relationship

as perceived by the therapists. These findings seem to

parallel those obtained in the present study. While

attendance rates were obtained for six weeks and client

involvement was measured during the first session, simi-

larities are obvious. Attendance was improved for the

experimental group in both studies, and the comparable

process measures were also more favorable in the group

prepared for therapy.

This same research group replicated this study and

found that in addition to better attendance records, the

treatment group had better ratings for improvement from

both clients and therapists (Nash et al., 1965). This

form of individual interview prior to therapy has been

replicated with similar findings by: Baum and Felzer

(1964) who reduced dropout rates from 60% to 35% in five

sessions; Sloane et al. (1970) who found the same results

with or without giving prospective clients an expectation

for a cure in four months; and Lieberman et al. (1972).

What the present study has added to this research field

was to standardize the interview procedure including a

written form in addition to verbal and to add a specific

measure designed to elucidate the particular factor medi-

ating client preparation with continuation, that is, client


One important factor in all of these studies was the

use of low Socio-Economic Status subjects who were considered

to be most likely to have unrealistic expectations. In

assuming that these clients had the most to gain from pre-

therapy orientation procedures, studies in this area have

overlooked the possible benefits to other socio-economic

classes. Future studies may wish to have several SES

classes represented in their research in this area.

Other studies employing various client preparatory

techniques have met with similar but somewhat less signif-

icant findings. As seen in the introduction section of

this paper, various forms of pre-therapy orientation such

as videotape, audiotape, and even in written forms have

had positive results. While not identical in their depen-

dent measures, many are parallel to the present findings.

This would point to the conclusion that while some effect

can occur while the client is prepared alone, he will

probably respond more positively when the technique is

interpersonal. Of particular importance in supporting this

conclusion is the study performed previous to this one in

the identical setting (Barnett, 1979). Using most of the

same therapists, in fact, conditions were very similar to

the present study with the difference being the orientation

procedure. In the first study, a videotape procedure

covering the same topics was presented to incoming clients.

While there was improvement in attendance in the first

study, it did not compare to the increase seen in the present

study. This would indicate that studies in the future,

hoping to employ the optimal client preparatory technique,

should consider the live interview methods outlined here.

Data obtained from the Experiencing Scale during this

study have led to other significant findings. The Experi-

encing Scale proved to be a clear and accessible measure

in this study. As indicated in the EXP Manual, it is

easy to rate because the differences between EXP scale

levels are easy to understand. Raters felt that during

the six minute segments they listened to, they were able

to obtain a clear idea of subjects' EXP level which seemed

stable for this period. This, then is why high inter-

rater reliabilities were possible.

One less desirable aspect of this scale during this

particular study was that most clients seem to fall onto

the lower parts of this scale. In fact, not one statement

was rated over Level 5 during the entire period, and sub-

jects were fairly similar in ratings of their scale levels.

This, of course, leaves us unable to learn if higher scores

on EXP lead to higher degrees of continuance or whether a

"threshold" exists beyond which higher EXP scores are

irrelevant. This study can only conclude that those with

a score of 3 or 4 on EXP are more likely to continue in

therapy than those with an EXP score of 2.

What is important, though, in using this scale, is

understanding what it measures, that is, what is level of

Experiencing. During this study, this tool was employed

to provide some idea of the level of involvement. But,

this concept is not defined identically by all those who

consider it. This leads to the most essential aspect of

this scale--it is very clear about what it is measuring.

As seen in the description of each level on the EXP Scale

in the Method section of this paper, there is excellent

face validity for those aspects of communication which

relate to the closeness of the subject, the sense of emotion

experienced, and the degree to which a person is able to

integrate the different aspects of his or her experience.

To put it another way, when a client describes his feelings,

the distinction between impersonal (you, people, etc.)

and personal subject is one that reflects something that

is seen to be important in therapy. If the client is able

to discuss his feelings or only the weather, this also is

a difference that will possibly reflect his ability to

enter into a productive therapeutic relationship. These

elements are what is meant by "Level of Experiencing" and

what is functionally defined as involvement for the purposes

of this research. From what has been seen in this research

study, this concept seems to be related to continuation

measures in therapy. Furthermore, and quite importantly,

this factor seems accessible to manipulation in the form

of client preparation.

In direct contrast to the clearness of the EXP Scale

is the Counseling Readiness Scale. The present study found

there to be no relationship whatsoever between Counseling

Readiness scores and either involvement or attendance data.

This is surprising in that the Counseling Readiness Scale

was derived to differentiate between continues and

non-continuers in therapy. In this study there was no

difference between experimental and control group scores

even though these groups had significantly different

attendance rates. This tool attempts to quantify a measure

that is possibly too vague for it ever to be properly

validated. As noted in the Results section, this scale

and other Adjective Checklist scales had too many limitations

to instill any confidence in their use. Calculations

seemed to produce only random numbers in arbitrary patterns.

Scatter charts of scale frequencies in relation to any

meaningful variables testified to this.

In addition to the Counseling Readiness Scale, other

subscales of the Adjective Checklist were calculated with

the intention of providing some other related characteris-

tics to the variables measured in this study. Defensiveness,

need for slccorance, and total number oF adjective checked

were among those studied. Defensiveness and the need for

succorance displayed the same kind of arbitrary pattern as

did Counseling Readiness. These scales failed to organize

themselves into any meaningful pattern whatsoever on their

own or in relationship to any other measure. While total

number of adjectives was found to yield a higher average

in the experimental group, it also failed to relate

meaningfully to other factors measured. While this might

support the notion of more openness in the experimental

group and more repression in the control group as suggested

by the Adjective Checklist Manual, it can only be considered

a vague testimony.

The Adjective Checklist in its present form does not

seem to provide a stable, meaningful tool. Scale deriva-

tions and calculations are inadequate and cannot be

validated properly. Limitations in the use of the

Checklist range from methodological problems such as

subject vocabulary and administrative controls to computa-

tional formulas which fall far short of their ability

to offset confoundLng subject variables. Present clinical

research cannot be advanced with a tool such as this

because it fails to provide a measure which relates

realistically to the already vague concepts which are

identified. It can be of more use as a qualitative clinical

tool, to be interpreted as such.

While providing support for client preparation, the

main focus of this study was to identify some elements

that are associated and possibly predictive of client

continuance. Many studies have provided support for any

number of different client preparatory techniques, and

many have shown the positive effects of these techniques

upon continuance and other positive therapy factors. But,

the gap in this research area has been identifying any

variables that mediate client preparation and positive

outcome. Most studies have simply assumed this factor to

be induced appropriate expectations. The belief has been

that when a prospective client is provided with appropriate

expectations for the therapy experience, he will be able

to participate more comfortably and thus, productively.

The limited research into the expectational factor

has provided no evidence as of yet that would account for

the large effect produced by client orientation techniques.

Of particular significance is the lack of any validated

tool to assess patient expectations. An attempt was made

in a previous study (Barnett, 1979) to determine the inter-

action of client expectations with client preparation and

continuance in therapy. Using the only client expectation

questionnaire available (derived from Overall and Aronson,

1962), results failed to yield any meaningful relationship

between expectational conditioning and continuance in

therapy. There was, however, a significant rise in attendance

subsequent to this orientation procedure. In light of this,

the expectational variable has to be discounted as a mean-

ingfulfactor until further tools are developed which could

possibly indicate otherwise.

The present study certainly supports the concept of

client preparation for therapy. It seems to lead, according

to this study, to higher levels of involvement and more con-

tinuance in therapy. While client involvement remains a

less than optimally specified factor, it does seem to relate

meaningfully to client preparation. As such, it is one of

the few factors which have been isolated to relate client

preparation to improved therapy attendance and fewer drop

outs. It would seem that there is finally a cloudy yet

significant area being identified to elucidate this particular


In recent years, this concept of client involvement

has received more attention and empirical support. As

research has focused our attention on the initial thera-

peutic interaction, it has also identified client involve-

ment as a key factor during this critical period.

Gomes-Schwartz wrote in 1978:

More striking data on the importance of
patient attitudes come from studies of
behavior in early therapy sessions.
Patients who were involved in the therapy
process from the outset of treatment--
acknowledging their own responsibility
for changing their behavior and actively
examining their feelings and experiences--
were most likely to improve. (See Kirtner
and Cartwright, 1958; Rice and Wagstaff,
1967; Saltzman et al., 1976) (p. 1025)

Gomes-Schwartz's concept of client involvement as

stated above is nearly identical to that as conceived and

measured in this study. As seen in the present study and

in the previously mentioned descriptions of the studies by

Gomes-Schwartz and Saltzman et al., the concept of involve-

ment during the initial client-therapist contact related

positively with improved attendance. Gomes-Schwartz and

Saltzman et al., also were able to show a relationship

between involvement and improved process and outcome measures.

In this study, the relationship between preparation,

involvement, and continuation appeared tightly woven. Not

only was there a significant positive relationship between

Level of Experiencing and attendance, but there was also a

significant difference in Level of Experiencing between

control and experimental groups. This last point provides

strong support for the ability to manipulate level of

involvement by means of appropriate client orientation.

What makes this preparatory technique and others so

effective has only been tentatively speculated. Given

the experience of the present study, it seems that Truax

and Carkhuff (1967) had the most accurate assessment of

this effect. They used learning theory terms to generalize

about the value of pre-therapy preparation procedures and

felt that the evidence on the values of experiential and

cognitive structuring fit well with what was known about

human learning.

If psychotherapy or counseling is indeed
a process of learning and relearning, then
the therapeutic process should allow for
structuring what is to be learned rather
than what amount to "incidental learning,"
where the client does not have clearly in
mind from the outset what it is he is
supposed to learn. (Truax and Carkhuff,
1967, p. 363)

During the course of the present study, the element

identified as client involvement has shown itself to be a

meaningful factor in the relationship between client

preparation and continuance in therapy. In the larger

frame of reference, interpersonal elements in the early

therapeutic encounter seem to be more predictive of con-

tinuance and a more positive therapeutic relationship than

do any intrapersonal variables. One early example of this

idea in the literature is the finding that patient and

therapist expectational congruence is more predictive of

positive outcome than is the patient's own confirmed or

disconfirmed expectations (Lennard and Bernstein, 1960;

Ieine and Trosman, 1960; Goldstein, 1960; Garfield et al.,


What this means is that, instead of trying to select

the optimal clients for therapy in the hope of diminishing

dropout rates, therapists may be rewarded more by providing

a proper foundation for therapy in their initial sessions.

While no specific content or format has been positively

identified, the preparatory techniques discussed in this

paper have already proven their significance in this

endeavor. It is hope these techniques will be further

refined in the future. This will probably come about

only when it is understood more clearly and specifically

what therapeutic variables at what times are critical towards

the formation of the beneficial patient-therapist alliance.


I. What is therapy about?

A. It is active participation by both members.
B. It is not just cheap advice.
C. It is not someone telling you what to do, or
what is right.
D. It is to help you to find out for yourself how
you are going to solve your problem.
E. It is to help you understand why you do things
the way you do.
F. It is to help you find alternatives that satisfy
your needs.

II. What goes on in treatment itself?--What do you talk
about, what do you do?

A. You can talk about anything--wishes, dreams,
thoughts or feelings--from now or in the past.

I. Your therapist will not judge what you say.
2. lie will help you get at what you really want.
3. He will not try to make decisions for you
but help you make decisions.

B. Your therapist will help you understand when
you are kidding yourself--how two things you
are saying just don't fit together.
C. He will help you keep in mind all of the important
facts and feelings so that you can come to a
solution that takes them all into account.
D. He will hlep you to understand all of your
feelings that sometimes seem confused.

1. Understanding the causes of your feelings
helps you understand why you are the way
you are.
2. By becoming aware of this, you can treat them
more realistically.

III. What kinds of things might I expect over time?

A. As you begin to change, friends and family may
be puzzled or troubled by this difference.

1. It isn't a bad sign--it just means you are
2. It helps to take the time to make them
understand what you are going through.
B. You may feel worse or discouraged at some stages
of treatment.

1. These very feelings are often good indica-
tions that you are working and that it's
2. It's very important that you don't give in
to these temporary feelings when they come
C. A funny thing happens when things are getting
rough for you in therapy--suddently you have
trouble keeping your appointments.

1. What this means is that you are getting down
to something difficult and important--some
sensitive issues.
2. These are the most important times to bring
yourself to your therapy meetings. Decide
beforehand that you will make your appointment.
3. You can postpone a session for good reason,
if you discuss it with your therapist beforehand.

IV. Therapy can help you find the solution to your problems
that suit you best. Sometimes it's hard to do this--
if it were not hard you wouldn't be here. Don't
expect overnight miracles--give yourself the time
to work things out the right way!

APPENDIX A continued

Procedure for Intake Program

1. At the very beginning of the intake, look inside the
manilla envelope to determine whether the client is
to be assigned to an experimental procedure or the
normal procedure.

2. Write down the client's name, your name, and the date.

3. If the client is in the experimental group, administer
the Preparatory Interview. Remember to cover each
point carefully in the interview outline and to be
open to client questions.

4. For all clients in intake, tape record the last 30
minutes of the sessions--if you might forget, turn
on the recorder early.

5. At the end of the session, have each client fill out
the AdjecLive ChecklisL in the envelope.

6. Make sure the cassette and the Adjective Checklist and
the identifying page are all in the packet when you
seal it:



Control Group Results
Subject Attendance EX'P CRS
Number Therapis t 6-weeks Score Score

1 A 0 2.2 56
2 B 0 3.0 49
3 C 0 2.1 52
4 B 0 2.3 66
5 D 4 3.4 83
6 E 2 3.0 56
7 C 2 2.7 54
8 D 0 3.1 56
9 B 0 2.4 52
10 B 2 2.3 51
11 A 5 3.5 62
12 F 0 2.8 56
13 F 0 1.9 52
14 E 0 2.8 57
15 A 4 3.5 67
16 E 4 2.3 49
17 1' 0 2.3 59
18 F 0 2.6 63
19 C 2 2.8 66
20 E 2 2.8 54
TOTAL 27 53,8 1160
MEAN 1.35 2.69 58

APPENDIX B continued

Treatment Group Results

Subject Attendance EXP CRS
Number Therapist 6-weeks Score Score

I D 2 4.3 62
2 C 4 4.0 56
3 F 1 3.0 62
4 C 4 3.8 56
5 B 3 2.6 66
6 E 4 3.2 53
7 E 2 2.6 57
8 F 4 3.0 59
9 F 5 3.0 53
10 D 3 3.2 61
II B 1 3.8 56
12 A 1 2.4 47
13 A 3 3.0 35
14 E 4 3.5 78
15 F 0 3.1 67
16 B 0 2.6 57
17 E 3 2.5 51
18 B 1 3.1 49
19 C 3 3.2 56
20 A 6 4.3 56
TOTAL 54 64 2 1146
MEAN 2.7 3.21 57.3



Control 1 ed




APPENDIX C continued








HS = 1

APPENDIX C continued




B= 3

Exper iinen Lal




W 18
B 2

APPENDIX C continued





F = 12
M 8




F = 13
M = 7


APPENDIX C continued



MEAN 96.33



APPENDIX C continued



Neuroses =
Disturbance =
Reaction =


6 Neuroses = 7
5 Disturbance = 4
5 Reaction = 3

Miscellaneous = 4

Miscellaneous =6


+ Items

mode rate
pecul i a
sensi tive
timi d
wi thdrawn


boast Cul
dcte-rm i ned
egoti sLical
to u'gh

+ Items Items

effemi nate
cnterpr rising
una Efccted



r -


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Mark Barnett was born in New York in 1952. He

moved to the Miami area in 1957 and remained there until

graduating from high school in 1970. He attended

Princeton University as an undergraduate and developed

there an interest in his major field of study--psychology.

His exposure to volunteer work in counseling as an under-

graduate led him into pursuing a graduate degree in

clinical psychology. After graduating from Princeton in

1974, he was accepted into the Graduate School of the

University of Florida. He obtained his master's degree

in clinical psychology in 1979 and completed his intern-

ship at the Miami VA in 1980. His research has been

focused particularly on the critical aspects of patient-

therapisr interaction in psychotherapy lie hopes to

work with the psychological components of medical problems

after graduation.

1 certify that I have rend this study nnd that inl
my opinion it conforms to acceptable standards of scholarly
presentation and is fully ndlequnto, in scope and qualityt,
as a dissertation for Lhe degree of Doctor of Philosophy.

c g c.CCc-'______
ngIh CT iDavis, CliaFirman
1'Folessor, Clinical Psychology

I certify Lhnt I have rend LIhis 'st.ldy and thlnt in iy
opinion it conforms to acceptnale standards of scholarly
presentation and is fIlly ndequnte, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.

Irn si- sch er
Associate PIrofessor, Psychology

I certify that I have read this study and taint in my
opinion it conforms to acceptable standards of scholarly
presentations and is fully aderqunte, in scope and quality,
as a dissertation for the degree of Doctor oC Philosophy.

MariI yn I HoLly
Associate Professor, l'hilosophy

I certify thnt I have rend this study and that in my
opinion it conformsll to acceptable stalndrds of schlairly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.

C li{C __,a
irlecn i1. I'cntiic ll
Assisltanti Prolessor, Clinical
I'sycilo loy

I certify that 1 have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.

Robert C. 7ilTer
Professor of Psychology

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