Psychotherapy of Schizophrenia: An Empirical Investigation. of the Relationship of Process to Outcome

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1 Psychotherapy of Schizophrenia: An Empirical Investigation of the Relationship of Process to Outcome Leonard L. Glass, M.D., Howard M. Katz, M.D., Robert D. Schnitzer, Ph.D., Peter H. Knapp, M.D., Arlene F. Frank, Ph.D., and John G. Gunderson, M.D. The Boston Psychotherapy Study found no major differences in the effects of insight-oriented and supportive psychotherapies in the treatment of schizophrenia. The authors of the current study looked beyond the assignments to those treatment designations and used blindly rated transcripts oftape-recorded sessions to examine the relationship of therapist interventions and patient outcomes at 2 years. They found significant relationships between skillfully conducted psychodynamic exploration and greater improvements in negative symptom areas of schizophrenia. The authors note the limitations and implications of these findings for clinical practice and research. (Am J Psychiatry 1989; 146: ) A lthough the two different types of psychotherapy in the Boston Psychotherapy Study (1, 2) fostered similar overall outcomes, there were sufficient differences in the findings to lend support to the concept of specific differential effects. One type of therapy, reality-adaptive-supportive, had preferential effects on recidivism and role performance, whereas a contrasting form of treatment, expressive-insight-oriented, exerted modestly preferential effects in areas of ego functioning and cognition. This support for specific differential impacts emerged despite the fact that the expected differences between the two types of therapy in the amount of supportive techniques were not found, even though expressive-insight-oriented therapists differed from reality-adaptive-supportive therapists by meeting more frequently with their patients and by focusing more on unconscious motivations and undercurrents of feelings (1). This finding prompted us to undertake analyses that go beyond nominal assignment to expressive-insight-oriented or reality-adaptive-supportive therapies, i.e., analyses that explore whether spe- Received July 15, 1987; revision received Sept. 22, 1988; accepted Nov. 3, From the Psychosocial Research Program, McLean Hospital. Address reprint requests to Dr. Glass, McLean Hospital, 115 Mill St., Belmont, MA Supported in part by NIMH grant MH Copyright 1989 American Psychiatric Association. cific types of therapeutic interventions are associated with specific types of outcomes. In this paper we will report on the relationship between therapists activities and patients outcomes for those patients for whom we have more detailed psychotherapy process data. Using therapists interventions that were blindly rated from transcripts of taperecorded sessions, we explored the relationship of specific process factors to the 2-year outcomes among this group of patients with nonchronic schizophrenia. METHOD Methods used to select patients and therapists for the overall study are more fully described elsewhere (1). The therapists were all experienced in working with schizophrenic patients (averaging 10 years in practice), and the majority had had personal psychoanalyses. The subjects were all newly hospitalized, adtively psychotic, but nonchronically ill patients who were given both clinicians diagnoses and research diagnoses (3) of schizophrenia. Despite changing diagnostic standards, checks were made to assure that the sample would be within even narrow diagnostic critena (1). Therapists and patients were asked to audiotape all sessions to avoid the influence on performance during individual sessions of having only those selected sessions taped. Two consecutive sessions occurring 6 months after the start of treatment were transcribed in their entirety and served as the basis for rating therapist activity. These data were available for 39 subjects. Twenty-two process rating scales focusing on therapist techniques and skills were used. These scales were selected after review of the rating schemes reported in the literature and relied heavily on those developed in the Pennsylvania Psychotherapy Study (4, 5). Scales were chosen to represent dimensions exammed in previous research on dynamic psychotherapy with schizophrenic patients (6). All scales were given specific descriptive anchors for each of five scale points. Seven experienced clinicians made process ratings from the transcripts. Each of these clinicians had at Am J Psychiatry 146:5, May

2 PSYCHOTHERAPY OF SCHIZOPHRENIA TABLE 1. Factor Analysis of Ratings of Two Psychotherapy Sessions Each for 39 Schizophrenic Patients Factor Loading of Variable Percent of Variance Accounted for Skillful dynamic exploration 41.3 Overall dynamic skill 0.90 Sensitivity to undercurrents 0.88 Responsiveness andlor adequacy of technique 0.85 Empathy 0.68 Focus on improving ego functions 0.65 Softens conscience 0.64 Emphasizes unconscious 0.63 Focus on past 0.44 Supportive activity 25.3 Self-expression 0.79 Gives encouragement and/or reassurance 0.73 Self-disclosure 0.62 Is warm and giving 0.44 Directive activity 13.4 Gives suggestions and/or advice 0.82 Supports reality orientation 0.76 Assertiveness 0.50 least 60 hours of reliability training. Despite such training, the intraclass reliabilities calculated for all raters on 15 pairs of sessions were often weak (range= , mean r=0.46, median r=0.47). As a result, the process ratings that were used in all analyses were derived from the ratings of at least two clinicians who made independent ratings on each tape and then met to reach consensus. The interrelations of the 22 process variables were first examined by applying the principal components factor analysis of the Statistical Package for the Social Sciences (SPSS) (7) with an orthogonal (varimax) rotation to the ratings of the 39 sets of tapes. After all factors with an eigenvalue of less than 1.0 were deleted, three principal factors emerged: skillful dynamic exploration, supportive activity, and directive activity (table 1). Skillful dynamic exploration had three major cornponents: overall dynamic skill, sensitivity to undercurrents, and responsiveness and/or adequacy of the therapist s technique. Sensitivity to undercurrents was a measure of the therapist s attunement to the unexpressed preconscious and unconscious motivational background from which the patient s mood, thinking, and behaviors emerged. Responsiveness and/or adequacy of the therapist s technique was the rater s estimate of the relevance, consistency, and timing of the therapist s interventions. As shown in table 1, lesser contributions to the skillful dynamic exploration factor came from five other variables. Supportive activity had four components. Selfexpression measured the extent to which a therapist expressed emotional responses to the patient. Self-disclosure reflected whether therapists shared aspects of their private lives and personal experiences. The therapist s providing encouragement and/or reassurance and being warm and giving were the other two components contributing to this factor. Directive activity had three components, the leading element of which was the therapist s giving suggestions and/or advice. Support of a reality orientation reflected the emphasis therapists placed on their patients adaptation to the environment and their encouragement of more realistic functioning. The third component, assertiveness, indicated that therapists presented their views in a forceful and straightforward manner. Therapists with higher directive activity ratings more clearly and explicitly attempted to shape their patients behavior by actively advising, by reinforcing behaviors perceived as adaptive, and by an energetic, leading style. The relationship between process and outcome was studied for 23 of the 39 patients. These 23 patients remained in treatment for at least 6 months, and their data included both tape recordings at 6 months and outcome at 2 years. The majority (N=19) had been given expressive-insight-oriented therapy; four had been given reality-adaptive-supportive therapy. We included these four patients to increase our small sample, to broaden the spectrum of therapist activities, and to increase the relevance of our findings to clinical practice. The 23 patients were similar in baseline psychopathology to the 20 patients for whom 6-month tape data were received but who did not remain in therapy for 2 years and to the four patients who remained in therapy for 2 years but for whom sufficient tapes were not available. Outcome measures consisted of scores at 2 years on nine clusters of variables. The clusters were cognitive disorganization (Chronbach s a = 0.6 1, intraclass 0.95), primary process thinking (a=0.90, r=0.81), denial of illness (a=0.72, r=0.97), ego weakness (a= 0.53, r=0.94), positive attitude (a0.72, r not applicable; self-report), global psychopathology (a=0.62, r= 0.93), anxiety-depression (a 0.85, r ), retardation-apathy (a=0.82, r=0.56), and social dysfunction (a0.75, r=0.88). Appendix 1 shows their components. References, annotated descriptions, and reliabilities for the instruments listed in appendix 1 are given in Stanton et al. (1). Each domain included a number of discrete variables selected from the instruments administered blindly at baseline and at 24 months. The method for selecting and testing the psychometric adequacy of the outcome clusters is more fully described elsewhere (1). The nine outcome domains were chosen from the 15 used in the larger study to cover a range of nonoverlapping domains that reflect aspects of function considered to be targets of psychotherapy. To examine the relationship between process and outcome, we first computed simple (zero-order) correlations between the three process measures and the nine outcome measures (table 2). We also computed the correlations between scores on each outcome mea- 604 Am J Psychiatry 146:5, May 1989

3 GLASS, KATZ, SCHNITZER, ET AL. TABLE 2. Simple Correlationsa of Psychotherapy Process With Outcome for 23 Schizophrenic Patients Correlation With Proces s Factor Two-Year Outcome Correlation With Dynamic Supportive Directive Variable Baseline Functioning Exploration Activity Activity Cognitive disorganization Primary process thinking Denial of illness 043b Ego weakness Positive attitude Global psychopathology d Anxiety-depression 0.67e 0#{149}47b 038d Retardation-apathy Social dysfunction atwotailed df range= b<005 Cp<o.ol. d<010 Cp<#{216}#{216}01 TABLE 3. Stepwise Regression Analysis of Process and Outcome of Psychotherapy for 23 Schizophrenic Patients Correlation Between Outcome Variable and Predictor Variables. F Item R2 R (df=2, 19)a Increment in Variance Accounted for by Predictor Variable of denial of illness < 019b Baseline denial of illness Dynamic explorative therapy 023b of global psychopathology <0.10 Baseline global psychopathology Dynamic explorative therapy of anxiety-depression <0.001 Baseline anxiety-depression Directive therapy of retardation-apathy <0.05 Baseline retardation-apathy Dynamic explorative therapy adf2 18 for analysis of 2-year outcome of global psychopathology and baselineglobal psychopathology. b p<0.05. Cp<o.ool. d<010 ep<o.oos b 045C 009d 0#{149}09d #{216}25C sure at baseline with scores on that measure at 2 years to get some idea of the stability of functioning over time. Next, we performed a series of stepwise multiple regression analyses to determine whether our three process measures of therapist activities could add to prediction of outcome after differences among patients in baseline levels of functioning on the respective variables were statistically eliminated. The multiple regression analysis thereby became our most telling analysis about the relationship of therapist activities to outcome in this sample. In these analyses we specified that baseline scores in each of the nine outcome domains be entered first because of their temporal primacy. Then the three process measures were entered in order of their predictive power, provided that they made at least a marginally significant contribution to the multiple regression analysis. This analysis allowed us to see the relationship to outcome when all of the process measures were taken into account. The results of these analyses are presented in table 3. RESULTS The most striking findings from the simple correlation analysis (table 2) was the significant relationship between skillful dynamic exploration and better outcome. Specifically, higher levels of skillful dynamic exploration, assessed at 6 months, were associated with significantly lower levels of patient denial of illness and retardation-apathy and higher levels of anxiety-depression. Higher levels of skillful dynamic exploration were also associated with marginally lower levels of global psychopathology at 2 years. The only other no- Am J Psychiatry 146:5, May S

4 PSYCHOTHERAPY OF SCHIZOPHRENIA TABLE 4. Summary of Correlations Between Psychotherapy Process and Outcome Variables for 23 Schizophrenic Patients Significance (p) Simple (zero-order) Increment in Outcome Process Factor Outcome Variables Correlation Variance Accounted fora Dynamic explorative therapy Reduced denial of illness Reduced global psychopathology 0.10 Reduced retardation-apathy Increased anxiety-depression n.s. Supportive therapy Reduced anxiety-depression 0.10 n.s. Directive therapy Reduced anxiety-depression n.s abeyond that accounted for by baseline level of functioning. table correlation was a trend between therapist supportive activity and lower levels of anxiety-depression. The stepwise multiple regression analysis (table 3) confirmed the importance of skillful dynamic exploration in predicting outcome in the domains of denial of illness, global psychopathology, and retardationapathy; for each area the predictive power of skillful dynamic exploration exceeded the predictive power of baseline measures. The association between skillful dynamic exploration and greater anxiety-depression was not found when baseline variations in anxietydepression were controlled. However, a trend emerged for directive activity to be associated with greater reductions in anxiety-depression. Table 4 presents a summary of the correlations between process and outcome. DISCUSSION The difficulty in obtaining the data used in this report makes replication unlikely but underscores the value of learning whatever is possible from it. Nonetheless, limitations in the methodology point to the need for caution in interpreting the results. A major problem is the relatively small sample size, which limits generalizability and impinged on our statistical management. Specifically, our factor analysis might have come out differently with a different and larger sample, and it was not feasible to control for all baseline variables in doing the stepwise multiple regression analysis. In addition to the problems associated with the sample size, other limitations in this study resulted from the relatively weak reliability of our process variables-a reflection of the era in which the study was done and the levels of inference required to assess dinically relevant therapeutic processes (8). A final problem in methodology is that questions could be raised about the representativeness of two consecutive sessions from 6 months and outcome measures at 2 years. These limitations notwithstanding, the results create, at a minimum, informed hypotheses derived from much better data than have previously been used to explore these issues for schizophrenic patients. The use of blind ratings of actual (as opposed to expected or reported) therapist activities is a major advance over previous reports on psychotherapy of schizophrenia. The finding that was most robust, most pertinent to the main study questions, and most clinically relevant is the relationship of skillful dynamic exploration to the 2-year outcome of these schizophrenic patients. Our skillful dynamic exploration factor primarily reflected the extent to which the therapist was judged to show a sound psychodynamic understanding and adcurate attunement to patients underlying concerns. A notable relationship emerged between skillful dynamic exploration and relatively large reductions in patient denial of illness, retardation-apathy, and global psychopathology assessed at 2 years. Indeed, the level of skillful dynamic exploration was an even better predictor of outcome in these domains than were pretreatment levels of disturbance in these same areas. The statistical significance of this relationship is particularly impressive in view of the constraints imposed by the small number of patients, length of observation, and the fact that most of the therapists were oriented toward dynamic exploration. The relationship between dynamic exploratory activity and reductions in the so-called negative symptoms of schizophrenia (9), such as retardation-apathy and denial of illness, is especially noteworthy insofar as these symptoms are generally unresponsive to psychopharmacological and other interventions and may be core aspects of schizophrenic psychopathology (10). These findings lend credence to the claims by psychodynamically oriented therapists that their activities should have a role in treating schizophrenic patients (1 1, 12). The connection of skillful dynamic exploration with outcome is largely congruent with the earlier studies of Truax et al. (13-16). The therapist empathy and/or sensitivity component of our skillful dynamic exploration factor probably overlaps with the triad of empathy-genuineness-nonpossessive warmth that Truax et al. found to be associated with positive outcome in psychotherapy with schizophrenic patients. Certainly our results underscore the importance of empathic interactions that have been highlighted in recent years for psychoanalytic therapies by Kohut (17, 18). However, some of what Truax et al. identified as nonpossessive warmth corresponds more closely to our factor 606 Am J Psychiatry 146:5, May 1989

5 GLASS, KATZ, SCHNITZER, ET AL. of support, which in this study did not correlate with better outcome. The findings of our factor analysis demonstrate the prominence of supportive and directive techniques in the work of these dynamically oriented therapists. The finding that high mean scores were given to primarily dynamic therapists for directive activity and supportive activity (data not presented) is consistent with that of others (19-21). Wallerstein (20) particularly emphasized the strong (and unexpected) contribution of supportive factors in psychoanalytic therapies of patients with serious ego weakness. Such results suggest that the distinction historically made between supportive and dynamic psychotherapy obscures the role played by supportive elements within psychoanalytic psychotherapies. In line with this, the trend for directiveness to be associated with a greater reduction in anxiety-depression at 2-year follow-up makes clinical sense. One might expect that therapists who elect to direct patients rather than explore their difficulties will have different effects. By providing more active guidance in the real world, directive therapist activities could engender a less depressed and less apprehensive outlook in these patients. On the other hand, we have seen that greater dynamic exploratory activity was associated with larger improvements in the target symptoms that are more specific for schizophrenia (global psychopathology, denial of illness, and retardation-apathy). The different therapeutic emphases seem to address different aspects of patients psychopathology and are associated with different types of outcome. As such, the results of the present analyses add support to the suggestion of differentiated types of impact of dynamic exploratory and supportive therapies that were noted in the main effect study (2). This study provides empirical support for a specific relationship between a type of therapeutic processskillful dynamic exploration-and specific aspects of outcome-denial of illness and withdrawal. The impression of an overall lack of main effect differences between the two types of therapy in our earlier report (2) appears to have concealed discrete processes within the therapies that have important and specific effects. This underscores the importance of more microscopic process versus outcome analyses for other comparative outcome studies, such as the National Institute of Mental Health Treatment of Depression Collaborative Research Program (22), where analyses of main effects have been disappointing. REFERENCES 1. Stanton AH, Gunderson JG, Knapp PH, et al: Effects of psychotherapy in schizophrenia, I: design and implementation of a controlled study. Schizophr Bull 1984; 10: Gunderson JG, Frank AF, Katz HM, et al: Effects of psychotherapy in schizophrenia, II: comparative outcome of two forms of treatment. Schizophr Bull 1984; 10: Carpenter WT Jr, Strauss JS, Bartko JJ: Flexible system for the diagnosis of schizophrenia: report from the WHO International Pilot Study of Schizophrenia. Science 1973; 182: Mintzi, Luborsky L, Auerbach AH: Dimensions of psychotherapy: a factor analytic study of psychotherapy sessions. J Consult Clin Psychol 1971; 36: S. Lubonsky L, Chandler M, Auenbach AH, et al: Factors influencing the outcome of psychotherapy: a review of quantitative research. Psychol Bull 1971; 75: Katz HM, Frank A, Gunderson JG, et al: Psychotherapy of schizophrenia: what happens to treatment dropouts. J Nerv Ment Dis 1984; 172: Nie NH, Hull CH, Jenkins JG, et al: Statistical Package for the Social Sciences (SPSS), 2nd ed. New York, McGraw-Hill, Koenigsberg HW, Kernberg OF, Haas G, et al: Development of a scale for measuring techniques in the psychotherapy of borderline patients. J Nerv Ment Dis 1985; 173: Andreasen NC: Positive vs negative schizophrenia: a critical evaluation. Schizophr Bull 1985; 11: Carpenter WT, Heinrichs DW, Wagman AMI: Deficit and nondeficit forms of schizophrenia: the concept. Am i Psychiatry 1988; 145: Gomes-Schwartz B: Effective ingredients in psychotherapy: prediction of outcome from process variables. J Consult Clin Psychol 1978; 46: I 2. GundersoniG: Controversies about the psychotherapy of schizophrenia. Am J Psychiatry 1973; 130: Truax C, Carkhuff R: Toward Effective Counseling and Psychotherapy: Teaching and Practice. Chicago, Aldine, Rogers CR, Gendlin GT, Kiesler DJ, et al: The Therapeutic Relationship and Its Impact: A Study of Psychotherapy With Schizophrenics. Madison, University of Wisconsin Press, Truax CB: Effects of client-centered psychotherapy with schizophrenic patients: nine-year pretherapy and nine-year posttherapy hospitalization. J Consult Clin Psychol 1970; 35: Truax CB, Mitchell KM: Research on certain therapist interpersonal skills in relation to process and outcome, in Handbook of Psychotherapy and Behavior Change: An Empirical Analysis. Edited by Garfield SL, Bergin AE. New York, John Wiley & Sons, Kohut H: The Analysis of the Self. New York, International Universities Press, Kohut H: The Restoration of the Self. New York, International Universities Press, Luborsky L, Singer B, Luborsky L: Comparative studies of psychotherapies: is it true that everybody has won and all must have prizes? Arch Gen Psychiatry 1975; 32: Wallerstein R: Forty-Two Lives in Treatment. New York, Guilford Press, Waldinger Ri, Gunderson JG: Effective Psychotherapy With Borderline Patients. New York, Macmillan, Elkin I, Panloff MB, Hadley SW, et al: NIMH Treatment of Depression Collaborative Research Program: background and research plan. Arch Gen Psychiatry 1985; 42: APPENDIX 1. Item Composition of Psychotherapy Outcome Clusters COGNITIVE DISORGANIZATION Psychiatric Status Schedule speech disorganization Psychiatric Status Schedule disorientation-memory Inpatient Multidimensional Psychiatric Scale (IMPS) conceptual disorganization WAIS vocabulary scatter: performance negative WAIS vocabulary scatter: verbal negative PRIMARY PROCESS THINKING Rorschach percent of primary process responses Rorschach density Rorschach mean defense demand Rorschach content level 1 Rorschach formal level 1 Rorschach primary process level 1 Am J Psychiatry 146:5, May

6 PSYCHOTHERAPY OF SCHIZOPHRENIA DENIAL OF ILLNESS Psychiatric Status Schedule denial of illness IMPS anxiety-intropunitiveness Camarillo Dynamic Assessment Scale: insight Camarillo Dynamic Assessment Scale: motivation EGO WEAKNESS Camarillo Dynamic Assessment Scale: ego strength Camarillo Dynamic Assessment Scale: sense of personal identity POSITIVE AlTITUDE Soskis Attitude Toward Illness Questionnaire: positive Soskis Attitude Toward Illness Questionnaire: integrates Soskis Attitude Toward Illness Questionnaire: insight positive Soskis Attitude Toward Illness Questionnaire: future positive GLOBAL PSYCHOPATHOLOGY Menninger Health-Sickness Rating Scale: total score Psychiatric Status Schedule total score IMPS total score Camarillo Dynamic Assessment Scale: weighted total score Katz Adjustment Scale-Subject: symptom discomfort Katz Adjustment Scale-Relative: general psychopathology ANXIETY-DEPRESSION Psychiatric Status Schedule anxiety-depression Psychiatric Status Schedule suicide and/or self-mutilation Psychiatric Status Schedule anxiety Psychiatric Status Schedule depression-suicide Psychiatric Status Schedule guilt Psychiatric Status Schedule phobias IMPS anxiety-intropunitiveness RETARDATION-APATHY Psychiatric Status Schedule retardation Psychiatric Status Schedule lack of emotion Psychiatric Status Schedule psychomotor retardation Psychiatric Status Schedule social isolation IMPS retardation-apathy Camarillo Dynamic Assessment Scale: affective contact SOCIAL DYSFUNCTION Psychiatric Status Schedule social isolation Psychiatric Status Schedule daily routine Psychiatric Status Schedule summary role Camanillo Dynamic Assessment Scale: object relations Katz Adjustment Scale-Subject: performance of socially expected activities Katz Adjustment Scale-Subject: performance of leisure activities Katz Adjustment Scale-Relative: withdrawal Katz Adjustment Scale-Relative: performance of socially expected activities Katz Adjustment Scale-Relative: performance of leisure activities 608 Am J Psychiatry 146:5, May 1989