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THE PATIENT'S CONCERNS IN PSYCHOTHERAPY*

DAVID E. ORI/INSKY KENNETH I. HOWARD AND JAMES A. HILL

University of Chicago

Northwestern University
PROBLEM

Institute for Juvenile Research

One pertinent perspective on the psychotherapeutie process is to view it as a form of problem-solving"'. Psychotherapy is initiated by the patient, or by someone acting on his behalf, when he has problematic concerns which do not yield to ordinary efforts at solution. It is normally terminated when the patient's problematic concerns have been resolved, or are sufficiently reduced so that the patient can cope with them on his own. The patient presumably comes to his therapy sessions in order to talk about the problems for which he feels he needs help. The communications made by patients during therapy sessions may be analyzed for content with respect to (a) manifest focus and (b) expressive theme. Analysis of the manifest focus of dialogue reveals which areas of patients' experiences are most troublesome. Expressive themes, the second aspect of dialogue, define the nature of the problems with which patients are concerned. In a previous paper (", we reported an analysis of manifest focus of patient communications; here we shall concentrate on expressive themes, presenting data on their relative frequencies, their underlying structure, and their relationships to manifest focus in a session. The data for this paper were derived from a survey of the problematic concerns experienced by patients during their therapy sessions, as reported immediately afterwards by the patients themselves and by their therapists. Data analyses were focused on the following questions: (1) How prevalent are different types of problematic concern in an average therapy session? (2) How closely does the therapist's impression of his patient's concerns match her own impression? (3) What are the underlying dimensions of patients' concerns, as these are implicit in the perceptions of patients and of therapists? (4) To what extent do patterns of concerns reflect stable individual differences among patients, in contrast to session by session variation? (5) Are patterns of problematic concern differentially focused in particular regions of the patient's life-space? These questions are meant to elicit information that may be clinically useful to the practicing psychotherapist, as well as basic data about psychotherapy as a problem-solving activity.
METHODS AND PROCEDURES

Instruments. The Psychotherapy Session Project enlists both patients and therapists as participant-observers of the therapy session, and draws from each a systematic quantitative report of his experience. This is achieved through the use of two essentially parallel, structured-response questionnaires, the Therapy Session Reports (TSRs) <''". Both the patient and the therapist forms contain sections which survey the problematic concerns of the patient. The patient form of the TSR asks, "What problems or feelings were you concerned about this session?" The therapist form asks, "What did your patient seem to be concerned about this session?" In each form, there follows a list of 12 areas of potential concern (shown in Table 1), and the participant is instructed to circle a number (0 = No; 1 = Some; 2 = A Lot) after each to indicate the intensity of the concern experienced in the session. The wording of the items was virtually identical in the two forms, except item fH 10 which was phrased "Who I am and what I want" in the patient form, and "Personal identity and aspirations" in the therapist form. The areas of concern surveyed were taken generally from Erikson's'^' '> formulation of the nuclear egoconflicts comprising the content of psychosocial crises in the eight stages of the hfe cycle, and supplemented by reference to Sullivan's "^^ developmental scheme. There
*This study was supported by the Institute for Juvenile Research, Illinois Department of Mental Health, State of Illinois, and by General Research Supi)ort Grant FR-05666-02 from the General Research Support Branch, Division of Research Facilities and Resources, National Institutes of Health.

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was at least one item representing each of the eight nuclear conflicts, and additional items were selected to increase the saturation and differentiation of those areas which were judged to be most relevant for patients in psychotherapy. These judgments were based on our own experiences, consultation, and pilot data. Samples. A detailed description of the patient and therapist samples is available elsewhere<'\ Briefly, 118 patients completed TSRs on from 5 to 66 consecutive sessions. All patients were female. Their median age was 26, and 88% had had a high school education or moremost having had some college. The patients were mostly single and employed. More than half had previous psychotherapy. There is some evidence that this sample was fairly representative of an urban outpatient population'"', The patients were in treatment with 27 different therapists, 18 male and 9 female. Seventeen therapists completed TSRs after 5 to 64 sessions for from 1 to 15 different patients. The therapists had a median of 6 years experience in the practice of psychotherapy, and most were engaged in full time clinical practice. They had a median age of 36, and most were married. They had been trained in psychiatry, clinical psychology, or psychiatric social work. Most of the therapists had had personal therapy. Their theoretical orientations were generally dynamic-eclectic. The therapist sample was fairly representative of the local professional community <'. Procedures. For a period of 20 months, patients and therapists at the Katharine Wright Mental Health Clinic in Chicago completed Therapy Session Reports immediately after their psychotherapy sessions.' The time covered by the study encompassed varying treatment segments. For some patients, we have reports on the initial period of therapy; for some, later or the last segment of treatment; and for others, data on the entire treatment. All patients were in individual, face-to-face psychotherapy, mostly on a once-weekly schedule. Therapy sessions were normally of 45 minute duration. No feedback was given to patients or therapists during the data collection phase of the study.
RESULTS

How Prevalent Are Different Types Of Problematic Concern In An

Average

Therapy Session? Table 1 shows the relative frequency of endorsement for each iteni for the patient and therapist samples.^ These averages were pooled over five sessions (randomly selected from each participant) though not, in general, the same five sessions in both samples; i.e., the therapist reports do not represent a subset of the patient reports. Table 1 reveals that all of the problematic concerns surveyed were present in the average session for a substantial proportion of patients, by their own report and on the testimony of their therapists, though variation in prevalence is also evident. The most frequently endorsed item for the patient sample was -fil 10, "Who I am and what I want?" (67%), and the least frequently endorsed item was <^ 6, "Sexual feelings and experiences" (43%). All together, 6 of the 12 problematic concerns were endorsed by over half of the patient group in an average session. In addition to concern with identity, the others were expressing or exposing self (60%), meeting obligations (57%), loneliness (56%), loving (56%), and anger (53%). The intensity of patients' problematic concerns was generally in accord with their prevalence. The therapists' impressions of patients' concerns showed a greater variation in range but also a readier recognition of their presence. The most frequently endorsed item for the therapist sample was # 10, "Personal identity and aspirations" (79%), and the least frequently endorsed item was # 11, "Fearful or panicky experiences"
We wish to express our appreciation to the clinic director, S. Dale Loomis, M.D. and to the anonymous band of patients and therapists who made this study possible. 'No more than three cases from each therapist were included in computing these results.

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TABLE 1. RELATIVE FBEQUENCIES OF ENDORSEMENT FOR PATIENTS AND THERAPISTS PATIENT CONCERNS

Items 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Being dependent on others. Meeting obligations and responsibilities. Being assertive or competitive. Living up to conscience: shameful or guilty feelings. Being lonely or isolated. Sexual feelings and experiences. Expressing or exposing self to others. Loving: being able to give of self to others. Angry feelings or behavior. Personal identity and aspirations. Fearful or panicky experiences. Meaning little or nothing to others: being worthless or unlovable.

No 52 43 54 55 44 57 40 44 47 33 55 55

Patients" Some 32 36 34 29 35 26 34 32 33 33 27 27

A Lot 17 22 12 16 22 17 26 24 20 34 17 17

No 41 39 45 42 32 57 33 41 32 21 64 48

Therapists'" Some A Lot 37 43 42 36 39 30 48 46 51 42 28 35 22 19 13 22 29 13 19 13 17 36 8 17

Entries are percents based on 5 sessions from each of 118 patients (Patient TSR). 'Entries are percents based on 5 sessions from each of 32 therapist-cases (Therapist TSR).

(36%). Ten of the 12 items were endorsed by more than half of the therapist group in an average session. These high rates of endorsement should be interpreted in light of the distinction respondents made between "some" concern and "a lot" of concern. The former may be considered a relatively diffuse background, and the latter as more truly focal. The relatively low proportion of endorsement for intense concerns in an average session is consistent with French's *" view that any particular session tends to revolve about one or at most a few focal conflicts. The most prevalent intense concerns reported by patients were with identity (34%), expressing or revealing self (26%), loving or giving to others (24%), loneliness (22%) and meeting obligations (22%). The most prevalent intense patient concerns reported by therapists were identity (36%), loneliness (29%), dependency (22%), and shame and guilt (22%). Two observations on these findings are in order. First, the problematic concerns of these predominantly young adult women correspond to the psycho-social crises depicted by Erikson"' as typical developmental tasks of youth and young adulthood. These are "Identity and Repudiation vs. Identiity Diffusion" and "Intimacy and Solidarity vs. Isolation", respectively. The implication is that difficulties in current adaptation rather than more infantile themes are the typical foci of therapeutic activity. "Existential" rather than "genetic" conflicts bulk large, especially from the patients' own perspective. Second, while therapists generally endorse concerns in the same order as do the patients, the therapists show some tendency to emphasize more dynamically relevant (infantile) themes such as dependency, shame and guilt. It may be that therapists are more inclined than patients to view patients' concerns from the professional vantage points of pathology and genetic conflict. How Closely Does The Therapist's Impression Of His Patient's Concerns Match Her Ovm Impression? There were 45 cases for which both therapist and patient completed TSRs on at least five common sessions (matched-pair sample).' To answer 'The matched-pair sample consisted of 45 patients and 15 therapists.

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the question posed here, the responses of each patient and therapist to the concern items were intercorrelated across all of their common sessions, yielding 45 12 X 12 correlation matrices. Thus, the relationship between patient and therapist reports of any concern was estimated, independently, 45 times. To evaluate the statistical significance of each relationship, a binomial test was performed on the signs of the 45 estimates'*' with results summarized in Table 2.
TABLE 2. CONVBBGENT AND DISCRIMINANT AGREEMENT BETWEEN THEEAPISTS' AND PATIENTS' REPORTS OF PATIENT CONCERNS

When Therapist perceives Pt's concern as: 1. Dependency 2. Obligations 3. Assertion, Competition 4. Shame, Guilt 5. Loneliness, Isolation 6. Sex 7. Expressing, Exposing Self 8. Loving, Giving 9. 10. 11. 12. Anger Identity Fears Rejection

Patient most often is aware of concern with: 1. Dependency (.29) 10. Identity (.10) 2. Obligations (.29) 9. Anger (.20) 4. Shame, GuiU (.37) 6. Sex (.24) 11. Fears (.15) 5. Loneliness, Isolation (.34) 12. Rejection (.22) 6. Sex (.59) 4. Shame, Guilt (.25) 7. Expressing, Exposing Self (.18) 3. Assertion, Competition (.12) 7. Expressing, Exposing Self (.16) 6. Sex (.15) 8. Loving, Giving (.15) 9. Anger (.45) 1. Dependency (.16) 10. Identity (.23) 11 fears (.38) 6. Sex (.12) 12. Rejection (.26) 5. Loneliness, Isolation (.23) 7. Expressing, Exposing Self (.14)

Items italicized indicate convergent agreement. All listed relationships were significant at or beyond the .05 level, based upon sign tests. Parentheses enclose the median correlation of the 45 estimates of each of these relationships.

In answering the question of how well therapists' perceptions of patients' concerns match their patients' perceptions, we shall consider both convergent and discriminant agreement."' Inspection of T'able 2 indicates that both convergent and discriminant agreement obtained for 6 of the 12 problematic concerns: # 1 . Dependency, * 2. Obligations, 5. Loneliness, 9. Anger, # 10. Identity, and *11. Fears. In four other cases, there was good convergent agreement but poorer discriminant agreement: #4. Shame and guilt, #6. Sex, #7. Expressing or exposing self, and * 12. Being worthless or unlovable. Concerns with shame and guilt and with sex were hoth present for the patient when the therapist reported either; as we shall see in the next section, both were in fact strongly linked in a single dimension of concern. The therapist's sense of the patient's concern with rejection matched the patient's sense of it, but was also responsive to her concerns with loneliness and self-disclosure. There was generally poor agreement, both convergent and discriminant, for two problematic concerns: % 3. Assertion and Competition, and # 8. Loving, Giving. The therapists' perception of patients' concern with assertion and competition was somewhat responsive to patients' concern with anger, but not with assertion and competition. One possibility to account for this serious mismatching is that patients and therapists interpreted the item differently; some evidence of this is presented in

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the next section. The therapists' perception of patients' concern with loving, on the other hand, was somewhat convergent with the patients' sense of it, but proved even more responsive to patients' concern with self-disclosure and with sexuality. These findings, taken overall, show that with some exceptions the problematic concerns which patients experience during therapy sessions tended to be reflected in their therapists' perceptions. What Are The Underlying Dimensions Of Patients' Concerns, As These Are Implicit In The Perceptions Of Patients And Of Therapists? To answer this question, factor analyses were performed on the responses from the two samples separately. Both analyses followed the procedure described in detail in a previous paper."' Table 3 presents the factorial organization of patient concerns for the two samples,* showing the title and major item loadings of each factor. Five factors, accounting
TABLE 3. FACTORIAL ORGANIZATION OF PATIENT CONCERNS

Patients' Reports
I. ISOLATION VS. INTIMACY: being lonely or I.

Therapists' Reports
ISOLATION VS. INTIMACY: meaning little

isolated; meaning little to others, being worthless or unlovable; loving, being able to give of myself. (.46)'> II. EGO-IDENTITY: expressing or exposing myself to others; who I am and what I want; loving, being able to give of myself; being assertive or competitive. (.56)
INDEPENDENCE vs. DEPENDENCE: meet-

to others, being worthless or unlovable; being lonely or isolated; being dependent on others; loving, being able to give of self. (.47) II. IDENTITY CONFLICT: angry feelings or behavior; personal identity and aspirations; fearful or panicky experiences. (.41)
III. SELF-ASSERTION: expressing self to oth-

III.

ing my obligations and responsibilities; being dependent on others; being assertive or competitive. (.50) IV. SEX AND GUILT: sexual feelings and experiences; living up to my conscience, shameful or guilty feelings. (.41) V. ANGER AND FEAH: angry feelings or behavior; fearful or panicky experiences. (.44) ^Alpha of each factor score is in parentheses.

ers; being assertive or competitive; noi fearful or panicky experiences. (.38) IV. SEXUALITY: sexual feelings and experiences. (.31) V. CONSCIENCE: meeting obligations and responsibilities; dema;nds of conscience, shameful or guilty feelings. (.48)

for 65% of the total variance, were retained frorn the analysis of patients' reports of problematic concerns. Five factors were also retained from the analysis of therapists' reports, accounting for 64% of the total variance. Comparison of these two analyses reveals that, with some differences in nuance, the structure of problematic concerns was basically similar from both perspectives. The dominant theme in factor I focuses on the issue of exclusion from or inclusion in intimate relationships, and was named ISOLATION VS. INTIMACY because of its similarity to Stage VI in Erikson's''> theory of psychosocial development. The dominant theme reflected in patient factor II focuses on the patient's experience and conception of self, and was called EGO-IDENTITY because of its resemblance to Stage V in Erikson's'^' scheme. Therapist factor II resembled this, but placed the patients' concern with identity in a more negative, pathological context. The underlying theme of patient factor III appeared to contrast adult independence with infantile dependence, emphasizing the qualities of autonomy and initiative that Erikson''' ascribes to Stages III and IV, respectively. Therapist factor III emphasized self-assertion, which is reasonably but perhaps tangentially related to independence. 'Therapist factors have been numbered to be maximally parallel in content to the corresponding patient factor. Factor tables and correlation matrices are available from the authors.

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The fourth factors in the patient and therapist samples both focused on sexual concerns of the patient, although patients experienced this theme as mixed with guilt feelings. These latter were perceived by therapists as a separate theme in factor V. Patient factor V, on the other hand, had as its dominant theme a conscious concern with aggression, mainly with fearful aspects of hostile feelings and attendant prohibitions and guilt. The fifth factors in the patient and therapist samples bore the least resemblance to each other. To What Extent Do Patterns Of Concerns Reflect Stable Individual Differences Among Patients, In Contrast To Session By Session Variation? This question is directed to the stability of problematic concerns from session to session for particular patients. In seeking an answer to this question, factor scores rather than individual items were used to focus on the more generalizable dimensions of patient concerns. For the patient sample, items which had salient loadings on each factor were summed, with unit weight, to provide a score for each patient for each factor. Each factor was analyzed separately as follows. Using all the sessions from each patient, a patient by session table was constructed (the entries for a patient being the scores on a particular factor for all of her sessions). A one-way analysis of variance was then computedthe "way" being patients, each with a set of scores. From this analysis, an intra-class correlation <'' was computed. The intra-class correlation (alpha) reflects the proportion of variance in each score attributable to stable individual differences. A parallel analysis was carried out for the therapist sample, using the scores on the therapist factors. Table 3 shows the alpha for each factor based on the appropriate sample. As can be seen in Table 3, all of the alphas for the patient sample were relatively high, range .41 to .56. The range for the therapist sample was somewhat lower (.31 to .48), but the difference in level between the two samples was not marked. Within each sample, individual differences accounted for essentially the same variance for each of the concern dimensions. The level of these alphas indicates that, at least for the patients themselves, concerns are relatively stable over sessions. This finding supports the interpretation that these areas of concern represent nuclear conflicts or adaptational problems for the patients. The patient comes to therapy seeking resolution of these problems, and tends to be aware of them session after session. This contrasts with the topical content of the session (dialogue) which tends to be more variable from session to session.''' Are Patterns Of Problematic Concern Differentially Focused In Particular Regions Of The Patient's Life-Space? In a therapy session, the patient may or may not talk directly about her concerns, though in general we would expect these concerns to be couched in terms of current life activities and other particular regions of her lifespace. The topical content of therapeutic dialogue in the session may be used directly to exemplify areas of conscious concern, and so to make them more concrete. On the other hand, the patient may talk about various experiences without being explicitly aware of the concerns which underly her topical choice, as a vehicle of preconscious expression. Although we cannot speak directly to this difference, it would be interesting to know the relationship between what the patient talks about and what she is concerned about. A previous study'" described the major thematic dimensions of topical content based on the factor analysis of reports. These dimensions were: I. Parental Faniily (mother, fatheT, siblings, childhood and adolescence); II. Conjugal Family (household affairs, children, spouse, finances); III. Fantasy (dreams, fantasy, strange ideas or experiences); IV. Work and Peers; V. Therapy and Therapist; VI. Religion; and VII. Opposite Sex. To answer the question posed here, correlations were computed for each patient, over her reported sessions, between factor scores on dialogue topics and problematic concerns, yielding 118 7 X 5 correlation matrices. Thus, the relationship between topical content and problematic concerns was estimated, independently, 118 times. As before, the statistical significance of each relationship

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was evaluated by means of a binomial test performed on the signs of the 118 estimates'*>. The relationships noted below were significant at or beyond the .01 level. Problematic concern with ISOLATION VS. INTIMACY bore no substantial relationship to any particular region of the patient's life-space, though a significant tendency for expression through Fantasy was evident. The absence of correlates for this dimension of concern probably should be taken to indicate that it may be discussed directly in psychotherapy. That is, the patient can talk of feelings of isolation and worthlessness without placing them in a situational context. Problematic concern with EGO-IDENTITY appeared to be differentially focused in experiences with Therapy and Therapist, Opposite Sex, and Work and Peers. This suggests that EGO-IDENTITY is not an important concern in the familial context ([parental or conjugal), but rather is concentrated in the area of significant adult interpersonal relationships in the larger community. Problematic concern with INDEPENDENCE VS. DEPENDENCE was clearly differentially focused in experiences with Conjugal Faniily, and Work and Peers. These two life areas are important spheres of adult obligation and responsibility for women, and consequently areas in which dependency is most likely to have a disruptive effect. Problematic concern with SEX AND GUILT was differentially focused in experiences with Opposite Sex, Fantasy, and Parental Family. The relation of this concern to experience with men is straightforward. Presumably, it is the guilt and shame aspect of this dimension that leads to discussion of early family experiences. Finally, problematic concern with ANGER AND FEAR was differentially focused in experiences with Fantasy. This suggests that the concern pertains mainly to the patient's hostile or aggressive wishes, and her anticipations of punishment or retribution. The patterning of concerns within particular areas of experience discussed by the patient may also be noted. Of particular interest is the significant association of Fantasy with such dynamic dimensions of concern as SEX AND GUILT, ANGER AND FEAR, and ISOLATION VS. INTIMACY. This finding offers some empirical support for the contention of Whitaker and Malone'"' that therapy progresses essentially, and therefore most effectively, on the plane of fantasy process.
DISCUSSION

Considering that psychotherapy is commonly thought of as a recourse for people who "have problems"especially if they recognize their problems and are motivated to solve themit is somewhat surprising that more research has not been done on the nature and kinds of problematic concerns manifested by patients in therapy. One reason for this gap may be the lack of an accepted and proven method for studying the subjective concerns which patients have. Our results suggest that the TSR can be considered an effective instrument for that purpose. The items of the TSR bearing on problematic concerns yielded a reliable measure of individual differences, the combinations of items reflected in the factorial dimensions were clearly meaningful, and the convergence of patients' and therapists' perceptions further supported the validity of these items. The substantive findings of this study may be considered from three perspectives: Normative guidelines, theory-relevance, and clinical implications. The normative findings, principally the frequency of item endorsements based on a total of 2318 patient reports and 1091 therapist reports, speak for themselves. One may use these as baselines for comparison with the concerns expressed by patients of similar personal and demographic characteristics, or contrast them with findings based on different populations studied subsequently. Although our sample was limited to women, it seems fairly typical of the population of patients encountered in outpatient psychiatric practice, judging from our own impressions and from the report of Ryan'"> on the Boston area. On the other hand, our sample is very obviously different from the much studied patient populations of Veteran Administra-

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tion facilities and University Clinics; development of norms for these groups should yield interesting and meaningful contrasts with our own. Although this study was not designed as theory-testing research, its preparation was informed by theory and its findings have some theoretical relevance. This was apparent chiefly with regard to the emergence of factorial patterns of problematic concern approximating psychosocial crises or developmental tasks described by Erikson'*' ' ' and Sullivan'"'. Although they provide no direct validation for the developmental implications of these theories, it is interesting to note that the most commorily reported concerns were those which in theory were approximately ageappropriate for the majority of our patients, or only one stage off-pace. We might speculate that a person tends to seek therapy when she has passed the age in which a normal growth crisis is encountered without having successfully resolved it, thereby falling behind her age cohort more and more obviously. Finally, it is interesting to note a possible clinical implication in the observed pattern of relationship between manifest; content and expressive themes in dialogue. The findings suggest that therapists might encourage a focusing of dialogue on fantasy, dreams, and "unreality" experiences if they wish to mobilize more dynamic, emotional concerns in therapy, such as sex and guilt or anger and fear. Conversely, if they wish to avoid these areas in order to limit the depth of involvement, focusing of dialogue on spheres of current adjustment such as work and peers or conjugal family would be advised. These recommendations may be unnecessary for the experienced psychotherapist, but even in his case they help to put clinical practice on a firmer scientific base.
SUMMARY

Parallel structured-response questionnaires were developed to survey the experiences of patients and therapists in individual psychotherapy sessions. 118 patients and 17 therapists completed these questionnaires for a series of consecutive sessions. Analyses of reports of patients' problematic concerns indicated that these concerns were patterned consistently with Erikson's'^' ' ' and Sullivan's "^^^ conceptions of developmental tasks; that patients and therapists generally agreed when concerns were present or absent in a session, but differed in interpretive emphasis; that concerns were relatively stable from session to session for individual patients, but differed between them; and, that concerns emerged differentially in topical dialogue, e.g., "dynamic" concerns tended to be embodied in discussion of fantasy.
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