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Subjective Change With Medical Student Therapists

I. Course of Relief in

Psychoneurotic Outpatients

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

patients especially concerned about the distressing quality of their subjective experience in living. What counts most for the patient is the way he feels about himself and his situation, and the initiation, maintenance, and interruption of the treatment situation itself follows mainly from these feelings. Novey1 has emphasized that, with such patients, the psychiatrist, too, sets goals and evaluates progress largely in terms of the patient's inner experience, and quite properly so. Psychoneurotic patients from the lower socioeconomic classes increasingly seek relief of distress through outpatient clinics associated with medical schools. Here they are usually assigned to trainees for their psychicoming for
treatment
are

PSYCHONEUROTIC

Setting
This

and

Design
outpatient de

partment of the Henry Phipps Psychiatric Clinic, where the senior medical students of the

study took place

in the

atric care2(p273) which must be integrated with the requirements of the training program. The medical student's first attempts at psychotherapy perhaps offer the greatest potential for conflict with the patient's welfare.3(p153) What relief can patients actually obtain with such untrained helpers? The lack of concrete information on this question is all the more surprising in view of the concern frequently voiced on the subject by both practicing and academic psychi-

Johns Hopkins University for many years have served a clinical clerkship of nine to ten weeks. At the beginning of this clerkship each student is assigned a previously evaluated outpatient for weekly interviews approximately an hour long. The interviews, with few exceptions, take place with only the patient and the student present. Immediately afterward, the student discusses the interview for one-half hour with an in structor who is usually a senior staff member, rarely a resident. This study approached the question of change through "naturalistic observation" of the on going clinical situation. The compromise be tween close observation and distortion of the observed phenomena4 was drawn somewhat in favor of the former: research data were col lected directly from the student and his patient. These procedures are summarized in Table 1.

Measures of

Change

atrists.

This, then, is a quantitative study of certain subjective changes occurring primarily in psychoneurotic outpatients during the course of a series of interviews with senior medical students on a clinical clerkship. The kind, amount, and course of change are described in this report. Some determinants of change will be described in a subsequent re-`
port.
Submitted for
From the

Each patient reported his symptomatic distress at intervals of one week by marking a checklist5 of 65 symptoms to indicate how much each complaint bothered him during the past week: not at all, a little, quite a bit, or extremely. The patient filled out the list prior to meeting with the student each time. Each list was scored in several ways, and all scores were adjusted proportionately for missing items. Total Number of Complaints (TOT NO SX).This score was obtained by counting how many of the 65 symptoms the patient marked as complaints (a little, quite a bit,
or

ioral Sciences (Dr. Uhlenhuth) and Statistics and Biostatistics (Dr. Duncan), Johns Hopkins University, Baltimore. Reprint requests to 601 N Broadway, Baltimore 21205 (Dr. Uhlenhuth).

publication Sept 26, 1967. departments of Psychiatry and

Behav-

Total Weighted Score (TOT WTD SCL). This score was obtained by summing the weights for the 65 individual symptoms as follows: not at all, 0; a little, 1; quite a bit, 2; and extremely, 3.

extremely).

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Total Intensity Score (TOT SCL DJT). This score was obtained by dividing the total weighted score by the total number of

Total Number of Target Symptoms (TOT NO T/S).The patient's target symptoms were defined as the complaints he marked on his first symptom checklist. On each succeeding checklist the total number of target symptoms was obtained by counting how many of the original target symptoms the patient still marked as complaints. Total Weighted Target Symptom Score (TOT WTD T/S).This score was ob tained by summing the weights for the indi vidual target symptoms as identified on the patient's first symptom checklist. Total Target Symptom Intensity (TOT T/S INT).This score was obtained by di viding the total weighted target symptom score by the total number of target symp
toms.

symptoms.

suits obtained with these scores, however, do not warrant a detailed presentation here. Average Pulse Rate (PULSE AVG). The technician counted the patient's pulse for 30 seconds immediately before and again immediately after the patient filled out each symptom checklist. The average of the two

samples was computed. Severity of the Patient's Chief Complaint (CC SEVERITY).Prior to the patient's first interview, the technician asked the pa tient to state his chief complaint and to rate
how much it bothered him
on a

scale rang

ing from 0 to 4 (not at all, just a little, quite a bit, very much, extremely). Just before the patient's final interview, the technician read the chief complaint back to the patient and asked him to rate again how much it both ered him, using the same 5-point scale. In case the patient precipitously discontinued
dent's

65 the checklist were classified into five clusters by three senior psychi atrists (Drs. John B. Imboden, E. H. Uhlenhuth, and William Webb). Table 2 lists the symptoms in each cluster: (1) anxiety; (2)

Five

Symptom Cluster Scores.The


on

interviews, the technician obtained the final rating by follow-up near the end of the stu

symptoms

clerkship period. Bendig Anxiety Scale Score7.The pa tient completed this condensed version of the Taylor Manifest Anxiety Scale during

depression; (3) anger; (4) compulsive symp toms; and (5) other symptoms. A symptom was assigned to one of the first four clusters only if all three psychiatrists' independent judgments agreed. The patient's weighted period. Barren Ego Strength Scale Score8.The score for each subgroup was computed by the weights (0 to 3) for the in patient completed this extract from the summing Minnesota Multiphasic Personality Inven dividual symptoms in each cluster. Scores also were computed for six orthogo tory (MMPI) at the same times as the nal and eight oblique factors derived earlier preceding scale.
from 404 anxious psychoneurotic outpa tients participating in drug trials. The reTable 1.General Design
On

the week before or the week after his first interview and again during the week before or the week after his final interview. Pa tients who precipitously discontinued inter views, however, often completed the second scale near the end of the student's clerkship

Selection of Patients
The study included all patients assigned to individual interviews with senior medical stu dents in the outpatient department during the three academic years 1963 to 1966, with the following exceptions: (1) aged less than 18 years; (2) diagnosed sociopathic disorder or brain syndrome; (3) transferred from a pre vious psychotherapist; (4) first appointment too late to plan for at least six interviews be fore the student's scheduled departure from the service; and (5) unable to cooperate with the procedures required for the study. There were 128 patients who entered the study during the three years.

Waiting
List
Initial evaluation Reports of distress MMPI Interview for

128 Patients Interviewed Weekly by Senior Medical Students

characteristics Interview for student's


characteristics Week of study 123456789 10

patient's

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Table

2.Symptoms Included Symptom Cluster


Anxiety
or

in Each

Table

2.Symptoms Included in Each Symptom ClusterContinued


Other

1. Nervousness
2.
3.

shakiness inside

4. 5. 6. 7. 8.

Sweating Trembling Suddenly scared for no reason Heart pounding or racing Dry mouth Trouble getting your breath Feeling tense or keyed up

9. A lump in your throat 10. Pains in the stomach 11. Pains in the lower part ot your back 12. Worrying or stewing about things 13. Having to avoid certain things, places,
because

or

activities

Depression
1. Feeling low in energy 2. Crying easily
3.
or

slowed down

14. Headaches 15. Faintness or dizziness 16. Loss of sexual interest or pleasure 17. Feeling critical of others 18. Difficulty in speaking when you are excited
19.

they frighten

you

4.

5. 6. 7. 8.

Blaming yourself for things Feeling blue Feeling no interest in things Drowsiness during the daytime Feeling hopeless about the future Thoughts of ending your life Anger

20. Trouble remembering things 21. Worried about sloppiness or carelessness 22. Pains in the heart or chest 23. Itching

Throwing

up

1. 2.

Feeling easily annoyed or irritated Temper outbursts you could not control Being unable to

1.
2.

3.

Compulsion get rid of bad thoughts or ideas Having to do things very slowly in order to be sure you were doing them right Having to check and double-check what you do
Other Bad dreams

Feeling shy or uneasy with the opposite sex Feeling fearful Hot or cold spells Feeling blocked or stymied in getting things Feeling lonely Feeling inferior to others Poor appetite

24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

Constipation Feeling confused A feeling of being trapped


Loose bowel movements

or

caught

upset stomach ask others what you should do Soreness of your muscles Difficulty in falling asleep or staying asleep Difficulty making decisions Your mind going blank Numbness or tingling in parts of your body
Nausea
or

Having to

Trouble concentrating Weakness in parts of your body Heavy feeling in your arms or legs

Stuffy
Your

nose

Heartburn

done

feelings being easily hurt Feeling others do not understand you or are unsympathetic 42. Feeling that people are unfriendly or dislike 43. Bright light hurting your eyes 44. Wanting to be alone

you

Selection of Students
The students in the study were all those treating the patients selected by the above cri teria. Students were assigned to patients by the usual clinic procedure. This constituted essen tially random assignment, since information

assignments

about the students was not available before the were made. Since each patient was interviewed by a different student, there were also 128 students in the study.

Data Collection Just before each academic quarter began, the instructors in the outpatient department provided a list showing each student ex pected during that quarter and the patient assigned to him for treatment. The research psychiatrist selected from this list the pa tients who met the criteria for inclusion in the study on the basis of their psychiatric consultation notes and any other information available in their records.

AU contact between the project and the patients was through the research technician and not through the research psychiatrist. The purpose of this arrangement was to min imize interference in the relationship be tween the student and his patient. The research technician wrote to each patient to inform him about his first ap pointment. She asked him to come to the clinic about one hour in advance. She en closed an abstract of the M M PI and asked the patient to complete this and bring it to his first visit. (These procedures substituted for the usual notice of appointment sent by the clinic registrar.) When the patient appeared for his first ap pointment, the clinic registrar asked him to wait in the student's office. The research technician entered the office, introduced her self, and explained that she would take the patient's pulse and ask him to answer some

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questions

to help us keep track of how he feels from week to week. She then took his pulse for 30 seconds. Next she reviewed the instructions for the symptom checklist with the patient and left a copy for him to fill out while he waited for the student.

Before the student arrived, the technician returned to the patient, collected the checklist, checked it for completeness, and again counted the patient's pulse for 30 seconds. The two

general objective of this procedure was to permit the evaluation of results in terms of the patient sample entering the study, rather than the sample completing the study. Every effort was made to collect complete data about each patient, even though the

Table 3.Characteristics of 128 Patients


Variable Class
128

Range
18 to 59 46

Mean

Age
Sex Race Male Female White Nonwhite
Protestant Catholic

31.08

pulse counts were averaged. A similar routine preceded each of the patient's inter
views at the clinic. After the patient's first interview with the student, the technician saw the pa tient briefly to elicit and re cord some of the patient's characteristics. These are shown in Table 3. Then she
gave the

Religion
Marital status

Other

or none

Single
Married
or

widowed

Separated or divorced
Children? Social class index Yes
No

82 108 20 68 45 15 21 82 25
101

27 127 121
11 to 73

(Hollingshead)
Mother's age when

52.10 25.87

Vocational Interest Blank (SVIB) and reviewed the instructions with him. She asked the patient to com plete the test at home dur ing the following week and bring it to his second visit. Finally, she gave the pa tient an extra symptom checklist and a stamped, self-addressed envelope to use in the event he should miss a scheduled interview. When the patient came for his next to last inter view, the research techni cian gave him a second MMPI abstract and asked him to complete it and bring it to his last visit. She col lected it at that time and checked it for completeness. The procedure for deal ing with patients who failed to complete the full series of interviews scheduled con stituted an unusual910 as pect of this study. The

patient

Strong

patient was born Age when family was disrupted by death or separation of a parent

15 to 44

1-6 7-12 13-18

<1 yr

15 20
12

>18
Never

16 21 43 128 0to360
52.15
10 77 33

Months ill

Diagnosis (APA* nomenclature)

Psychotic disorders Psychoneurotic


disorders Transient situa-

Personality

disorders

tional personality disorders

Days

between consul tation and first student interview Initial weighted score for

128

Anxiety Depression

Anger Compulsions Other symptoms

128 128 128 128 128


125

Oto Oto 0 to Oto

264 32.34 19 23 8.45 9.90 2.73 2.66

6 0 to 8 5 to 79 18 to 58

37.23
37.90

Initial

Scale

Ego Strength
score

Treatment

(Barron) expected

Talking
Medication
Other
or none

108 9 11
127 3.77 to 1.79

Optimism
A-B Scale SVIB

about 0.0 7.90


score

treatment

(Whitehorn-Betz) Psychiatrist Scale


score

126 119 128 128

1 to 12

3 to 54
6 to 10

28.71
7.90 6.04

Number of
ments

appoint

Number of appoint ments kept


*

1 to 10

APA

American Psychiatric Association.

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patient did
planned.
a

not attend the full number of interviews


same day that patient first missed an appointment, the research

Table 4.Characteristics of 128 Senior Medical Students


Variable
Class
126

Range
22 to 33

Mean
24.52

On the

Age
Sex Male Female

Marital status

Married technician contacted him Children? Yes by telephone if possible, No otherwise by mail. She re Social class index (Hollingshead, 126 11 to 66 21.22 family of origin) quested that he complete and return the extra symp Mother's age when student was born 18 to 45 126 28.37 tom checklist that she gave 0- 6yr 7 Age when family disrupted by him initially. At the same death or separation of parent 7-12 7 1318 5 time, she sent him an 7 >18 other blank checklist and Never 100 return envelope. The tech Optimism about patient's 125 -2.41 to 2.70 nician continued with this prognosis 0.01 125 0.0 -3.37 to 2.24 procedure on a week-to- Interest in patient 1 to 12 6.08 126 week basis until it became A-B Scale score (Whitehorn-Betz) 25 to 67 126 48.37 clear that the patient did SVIB Psychiatrist Scale score not plan to return for SVIB some time early in his work with the further interviews. At this time the research technician (or patient. the research psychiatrist, if it seemed neces Duration of the Relationship Between sary and advisable) contacted the patient Patient and Student and requested his continuing cooperation. She asked the patient to complete and re turn symptom checklists on the regular Every patient entering the study was weekly schedule for the remainder of the scheduled to meet with his student for at study period and to complete and return a least six weekly interviews. The distribution final MMPI abstract during the last week of of the number of interviews actually held with each patient is shown in Fig 1. The this period. If these efforts to follow the patient on a skewing of the distribution around the peak regular basis were unsuccessful, then the re at seven interviews, of course, is determined search technician again attempted to con by the fact that most patients entered upon tact the patient and obtain a final assessment the series of interviews during the first or at the end of the study period, if necessary second week of the students' nine- or tenweek academic quarter and continued until by making a home visit. The duration of the present illness, the the end. These data do not show a discrete group diagnosis, and the number of days between psychiatric consultation and first student in of early "dropouts" like that frequently sug terview were obtained from the material in gested in studies of psychotherapy.1112 the patient's clinical record. The brevity of this study, however, could The research psychiatrist elicited and re have permitted confluence of the main peak corded the student's characteristics in a and any secondary early peak in the dis brief individual interview with each student tribution of visits. between his patient's first and second inter views. These characteristics are shown in Kinds and Amounts of Change Table 4. By this time the student had met his supervisor once, so that the supervisor's The patient's total change on each crite opinions had some opportunity to make an rion measure was computed by subtracting impression on the student's attitudes toward the score at the final interview from the his patient. The research psychiatrist also score at the initial interview. The patient's asked the student to complete and return an early change on the symptom checklist meas-

Single

115 11 62 64 11 115

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and the pulse was computed by sub the score at the second interview from the score at the initial interview. A positive change score, then, except on the Ego Strength Scale, represents relief of com plaints. Patients who had only one interview were given the same final and initial scores on the symptom checklist measures and the pulse. This rule does not hold, however, for the CC severity, Bendig Anxiety Scale, and Barron Ego Strength Scale which sometimes were obtained several weeks after the final interview. Table 5 shows the mean changes on the major criterion measures for the entire group of patients from the first to the sec ond interview and from the first to the last interview. The group showed substantial and relia ble improvement at the last interview on most of the measures, with the notable ex ception of the Barron Ego Strength Scale and the average pulse. The Bendig Anxiety Scale showed a decrease in score which, al though quite reliable, was very small. The major changes occurred in sympto matic distress. The mean total weighted SCL score, for example, decreased by about 22% for the entire group of patients (N
ures

tracting

(72%) improved, 3 (2%) were unchanged, and 33 (26%) became worse according to their total weighted SCL scores. The corre sponding tallies for the patients who com pleted five or more interviews were 73 (76%) improved, none unchanged, and 23
The dimensions of symptomatic distress and change were explored in greater detail by examining the five weighted cluster scores obtained from the symptom checklist at the first, second, and final interviews as shown in Fig 2. The top of each bar repre sents the patients' mean initial score for the corresponding cluster. The second and third horizontal lines across each bar represent the mean scores at the second and final in terviews. The scores for the various clusters were rendered more comparable by dividing each cluster score by the number of symp toms in the cluster. The figure shows that this group of psy choneurotic outpatients initially reported different degrees of distress for different kinds of symptoms. Analysis of variance of the initial symptom cluster scores showed that these differences were highly significant (F 57.50, df 4/508, < 0.001). Pa tients complained more about their "feel ings" than about other symptoms. Among the clusters reflecting affects, the intensity of complaining increased from anxiety to depression to anger. This group of patients also experienced different amounts of relief from the different kinds of symptoms. Analysis of variance of the symptom cluster change scores showed that these differences in response were bor derline significant at the second interview (F 1.95, df 4/508, < 0.10), but high ly significant at the final interview (F < 0.001). Clusters 7.83, df 4/500, with higher initial levels tended to change more than clusters with lower initial levels. Patients, then, improved mainly in their affective state. However, they gained sig nificant (P < 0.05 by f-test) relief from all but compulsive symptoms by the second in terview and highly significant (P < 0.001) relief from all types of symptoms by the final interview.
=

126) and by about 24% for the patients (N 96) who completed five or more inter views. Among the entire group of patients 90
=

(24%)

worse.

Fig 1.Distribution of 128 interviews.

patients by

number of

30
CO
r-

Z LU <t

20

O or
LJ CD

10

I
I

10

NUMBER OF INTERVIEWS

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Table 5.Initial Status and


Initial Status

Change

on

Each Major Criterion Measure for 128 Patients


Change
]
From First to
Last Interview*

Change
Mean

From First to Second Interview*

Criterion CC

Bendig Anxiety 125


Barron ES

severity_84
125 121 128 128
128 128 128

Pulse average TOT NO SX TOT WTD SCL


TOTSCL INT

Mean 2.39 14.40 37.90 84.69 37.78 60.96


1.55 37.78

SD 1.05 4.29 7.78 12.34 13.58 29.71


0.33 13.58

SD

109 0.17 128 84

128

TOT NO

TOT WTD

T/S T/S
INT
as

28 28
128

4.34 O04 6.81

12.76 0.14 7.08 2.93 18.61 2.64 0.31 1.28 4.87 15.83
14.93

NS <0.01 <0.01 NS

<0.0
<0.001 NS

60.96

29.71

TOTT/S
*

28

135
score

0.33

10.70 128 0.01


score.

0.34 0.27

Mean SD 5.34 71 0.68 1.07 1.12 3.43 110 3.42 5.01 1.33 110 0.64 110 0.66 10.46 0.66 26 5\83 10.89 6.00 126 13.42 25.04 6.02 12(5 0.17 5.17 0.38 26 10.71 8.52 14.11 126 19.44 21.72 10.05 26 0.13 0.42 3.49

Pt
<0.001

<0.001

NT
NS

<0.00
<0.001 <0.001 <0.001 <0.001

<0.00l"

minus final initial Computed t Ali values are for 2-tailed tests.

Table 6 shows the correlations among the initial weighted cluster scores and the initial total weighted SCL score and the correla tions among the corresponding change scores. These correlations are moderate to rather high where the total weighted SCL score is concerned. The above results suggested that the most efficient procedure in further analyses would be to focus first on the total change rather than on the details of the symptom cluster

INT, TOT NO T/S, TOT WTD T/S, and


rate showed es the series of inter views. The symptom checklist measures, ex cept TOT SCL INT and TOT T/S INT, showed a rather sharp drop between the first and second interviews. All six measures showed a somewhat slower, but progressive, sustained decrease in mean scores over the remaining interviews. There was no evidence that symptoms tended to recur at the last two interviews of the series. For example, Fig 3 shows the curves ob tained on the total number of symptoms and on the total weighted SCL score. (The sixth point gives the mean for 12 patients with checklist data available a week after the final interview. This point was not included in the estimates of significance.) The graphs for the remaining four total symptom check list measures were similar, except as noted above. The total number of target symptoms and the total weighted target symptom score showed the sharpest decline. Analysis of vari ance indicated that the differences among in terviews were highly significant (P < 0.001) for all six symptom checklist measures. In another approach to studying the course of change, the mean score on each checklist criterion was computed at each week from all available data. Thus, patients with less than five interviews were included, as were checklists received by mail in the absence of an interview. An increasing pro portion of checklists in the last weeks were from patients who had terminated inter-

sentially

TOT T/S INT). The group's mean


no

pulse

change

over

changes.
Course of

Change

A rough picture of the course of change emerged from the two sets of criterion change scores in Table 5 and Fig 2, those set of interviews. Between the first two in

encompassing the first two interviews com pared with those encompassing the entire
terviews, the number of symptoms decreased, mean intensity did not. Target symptoms decreased more than the total list during the early period. Later on all meas ures showed improvement. The course of change was studied in greater detail for the group of patients who had five or more interviews by comparing the criterion group means at the first, second, middle, next to last, and last interviews. These interviews, on the average, occurred on the first, second, fifth, seventh, and eighth weeks. Complete data were available for 69 patients on the pulse rate and for 96 patients on the six total symptom checklist measures (TOT NO SX, TOT WTD SCL, TOT SCL
but their

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views. These

curves

were

amazingly similar to the preceding set. There was greater variability from week to week, however, and some tendency to reach
an

Table 6.Correlations Among Weighted Symptom Cluster Scores and Total Weighted SCL Score for 126 Patients
Score Cluster

Anxiety Depression Anger Compulsion


0.57

Other

Initial

Depression Anger Compulsive


Other

0.47
0.56

0.60

asymptote

or

to

curve

Total

weeks.

slightly upward in the final


Comment

Depression Anger Compulsive


Other

Total

choneurotic outpatients in terviewed by senior medical students agrees quite well with expecta tions based on clinical experience and on the properties of the measures employed in this study. These measures may be considered in relation to their speed of response, fre quency responsiveness, or state-trait respon siveness.13 <pl4<J> At one pole, the pulse rate probably responds mainly with very shortterm fluctuations13'14 to brief, discrete emo tional stimuli. In this context, the absence of change in the patients' average pulse rate at weekly intervals is not surprising. The fact that the first pulse count entering into each average tended to be higher than the second supports this interpretation. The heavy load imposed on the heart rate by physiological needs must be a further complicating factor. Patients' reports of subjective distress on a symptom checklistor to a clinician quite regularly show fluctuations within days or weeks. This measure, which proba bly best suits the time span of the present study, showed the most striking changes. The Bendig Anxiety Scale is designed to assess the tendency to experience anxiety, combining aspects of the state and the trait. The smaller change revealed by this measure in the present study is consistent with its po sition on the frequency response continuum. The Barron Ego Strength Scale, a meas ure of an ingrained mode of personality function, lies at the pole opposite the pulse rate. Its failure to show change in the present study is consistent with this position. Certainly "ego strength" in a clinical sense would not be expected to increase during the course of such a brief series of supportive interviews with an untrained therapist.

The spectrum of change shown by this group of psy

Depression Anger Compulsive


Other Total

0.75 0.80 0.56 0.44 0.42 0.69 0.78 0.63 0.44 0.49 0.71 0.79

0.65 0.81 0.86 0.48


0.51

0.4/

0.62 0.66

0.76 0.78

0.99

0.70 0.83 0.51 0.59 0.82 0.89

0.30 0.51 0.60

0.50 0.60

0.97

0.46 0.56 0.61

0.65 0.70

0.98

Perhaps it is not surprising on the basis of clinical experience that these psychoneurotic patients complained most and improved most with respect to affective symptoms. Frank and his co-workers made the same ob servation in their studies of symptom relief in response to placebo and to psychotherapy by residents in training.1B10 The present study replicates theirs in ranking the con tributions of certain specific symptom clus ters to total distress: depression, anxiety, and compulsive symptoms. The patients' consist ently greater concern with depression than with anxiety strongly suggests that depres sion deserves a more prominent place in the theory and treatment of the psychoneuroses than it has had in the past.
Fig 2.Mean weighted symptom cluster scores for patients. Upper boundary of each bar represents mean weighted cluster score at first interview. Lower horizontal lines in each bar represent mean weighted
128

cluster scores at the second and final interviews. Seven bars from left to right represent anxiety, depression, anger, compulsion, other, feeling (clusters 1, 2, and 3), and all symptoms.

1.5

1.0

Q
UJ

0.5

C 0 CLUSTER

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At least two alternate interpretations of the findings with the symptom cluster scores, however, require consideration. The observed differences in mean cluster scores may reflect simply differences in scaling of the measures rather than true differences in the intensities of the symptoms. Such scal ing differences could occur, for example, if the statements of anxiety symptoms were more strongly worded than the statements of depressive symptoms. The smaller clus

ters, including anger and compulsive symp toms, are especially vulnerable to these and
other
errors.

clusters all may measure the same variable, such as an undifferentiated state of distress or arousal,17 with varying efficiency. The differences in relief among the mean cluster scores, then, could be understood in terms of the "law of initial value."1819 The data of the study reveal two lines of evidence against the above interpretations. Figure 4 compares the mean initial symp tom cluster scores for patients with the clini cal diagnoses of "anxiety reaction" (N 28) and "depressive reaction" (N 30). These two groups of patients show sig nificant (by analysis of variance, F 3.70, df = 4/224, < 0.01) differences in cluster score profiles in the expected directions. These patterns suggest that the cluster scores at least are not grossly distorted with respect to clinical observation. The moderate corre lations among cluster scores, especially change scores, also suggest that the clusters measure somewhat different aspects of the patient's subjective state. The present evi dence indicates that further study of the in dividual cluster scores may be justifiable and useful. The course of symptomatic change shows some interesting features. The greater de crease in target symptoms than in the total list during the first week indicates that some of the initial complaints are replaced by brand new symptoms. This phenomenon has been well documented by Steinbook et al.20 As the interviews progress and fewer target
= = =

The rough association observed between mean change and mean initial score among the five symptom clusters suggests a further elaboration of the previous point. The five

results with the weighted target symptom score more closely approach those with the total weighted SCL score. Perhaps the most striking feature of the patients' course is their failure to show a definite symptomatic exacerbation near the termination of interviews. This finding sug gests that these patients did not make a strong investment in their student thera pists. The inexperience of the therapists may have contributed to this situation. The pre arranged, limited number of interviews most likely was a major factor. The degree of symptomatic change ob served in the present study may be com pared roughly with the results reported from the University of Chicago,3 where each sen ior medical student held up to 18 interviews with a psychiatric outpatient. About 75% of 249 patients showed symptomatic improve ment according to the ratings of the stuFig 3.Mean total symptom checklist scores for 96 patients with five or more interviews. Six points rep

resent first, second, middle, next to last and last in terviews, and following week.

80

60
LU

WTD SCL

O
O (O

<

40

NO SX
20

II

symptoms remain, however, earlier target symptoms may recur. Thus, the longer-term

WEEK NUMBER

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dents and their

supervisors.3<pl71> On a fol low-up questionnaire, 111 of these patients rated their change during the series of inter views as follows: 37% much improved, 45% perhaps a little better, 8% perhaps a little worse, 6% worse, and 4% no response.3<pl77> The results of the present study also may be compared roughly with a reduction of about 22% in total weighted SCL score for a group of 138 anxious outpatients who com pleted four biweekly supportive interviews with residents in a recent drug study.21 In this drug study, according to the change in total weighted SCL score, 93 (67%) patients improved, 4 (3%) remained unchanged, and 41 (30%) became worse. The amount of symptomatic improvement experienced by the psychoneurotic outpa tients in the present study, then, corre sponds roughly to the relief reported in other studies of similar patients treated by medi

able to cooperate with the for the study. Each patient saw a procedures different student, and the assignment of pa tients to students was random. Each patient reported his subjective dis tress on a checklist of 65 symptoms every week before his interview with the student. A total score and the following five symptom cluster scores were computed: anxiety, de pression, anger, compulsive symptoms, and other symptoms. The patient's pulse rate also was counted at each interview. The following three measures were taken at the beginning and at the end of the patient's se ries of interviews: severity of chief complaint 1966 who
were

on a

score, and Barron

5-point scale, Bendig Anxiety Scale Ego Strength Scale score.

cal students or residents. These results lie well within the range represented in the broader literature on the outcome of psychotherapy.22(pl3) The average outcome in the present study, as in others,23121) reflects a mixture of good and poor responses. Some determinants of this differential responsive ness will be explored in a later paper. In the meanwhile, this study confirms the earlier finding3 that the patients of medical students fare reasonably well. These findings provide no basis for overconcern about con flict between the students' needs and the pa tients' welfare within the context of the usual community clinic practice. On the contrary, these results suggest that the senior psychiatric clerkship may be an important resource for the relief of subjective distress related to the vast reservoir of psychoneu rotic illness.

Patients initially complained most of an ger and depression. Between the first and last interviews, the group of patients showed the following: (1) no change in heart rate; (2) a 22% decrease in symptomatic distress, attributable mainly to symptoms of anxiety, depression, and anger; (3) a small, reliable decrease in Bendig Anxiety Scale score; and (4) no change in Barron Ego Strength Scale score. Seventy-two percent of the patients
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Summary
of certain subjective changes occurring in 128 primari ly psychoneurotic outpatients, each inter viewed weekly from one to ten times (mean = six) by a senior medical student on his clinical clerkship in psychiatry. The sample includes all "fresh" adult patients assigned to medical students for at least six inter views during the academic years 1963 to
This is
a

quantitative study

CLUSTER
Fig 4.Mean weighted symptom cluster scores for 28 patients diagnosed anxiety reaction and 30 patients diagnosed depressive reaction. Broken lines represent initial mean weighted cluster scores for anxious pa tients, and solid lines represent mean weighted cluster scores for depressed patients. Five bars from left to right represent anxiety, depression, anger, compulsion, and other symptoms.

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the same, and 26% felt of symptomatic change was by sharp drop between the first two interviews, followed by a somewhat slower, but sustained, decrease over the re maining interviews. The earlier and the lat er course of relief also differed in other re spects. Symptoms did not recur at the last two interviews of the series. The differing phenomena of the earlier and later course of relief suggest different determinants during the two periods. The in dividual variation in response, with some patients actually becoming worse, also sug gests specific determinants operating within the general treatment situation described. The results indicate that psychoneurotic outpatients attending a university clinic for
worse.

felt

better, 2% felt
The marked
course a

brief series of interviews with senior medi cal students experience symptomatic relief roughly comparable to that provided by other forms of clinic treatment. The senior psy chiatric clerkship appears to be an impor tant community resource for the relief of subjective distress associated with psycho neurotic illness.
a

This investigation was supported by Public Health Service grants MH-06350 and 2-K3-MH-18,611 from the National Institute of Mental Health (NIMH). Statistical procedures were developed in part under grant No. MH-04732 from the NIMH. Computations were performed at the Computing Center of the Johns Hopkins Medical Institutions which is sup ported by grant No. FR-00004 from the National In stitutes of Health. Mrs. Ruth Boggs, Mrs. Susan Bryan, Mr. Clay Kallman, Mrs. Mary Sewell, and Mrs. Carol Taylor aided in their technical assistance.

References
1. Novey, S.: Behavior and Inner Experience: Parallels and Contradictions in the Appraisal of Treatment, read before the Sheppard and Enoch Pratt Hospital 75th Anniversary Program, Towson, Md, June 1966. 2. Hollingshead, A.B., and Redlich, F.C.: Social Class and Mental Illness: A Community Study, New York: John Wiley & Sons, Inc., 1958. 3. Heine, R.W. (ed.): The Student Physician as

Psychotherapist, Chicago: University of Chicago

chotherapy Research Project of the Menninger Foundation: Second Report: I. Further Notes on Design and Concepts, Bull Menninger Clin 22:117-125, 1958.
5. Parloff, M.B.; Kelman, H.C.; and Frank, J.D.: Comfort, Effectiveness and Self-Awareness as Criteria of Improvement in Psychotherapy, Amer J Psychiat 111:343-351, 1954. 6. Mattsson, N.B., et al: Dimensions of Symptom Distress in Anxious Neurotic Outpatients, Psychopharmacol Bull, to be published. 7. Bendig, A.W.: The Development of a Short Form of the Manifest Anxiety Scale, J Consult Psychol 20:384, 1956. 8. Barron, F.: An Ego-Strength Scale Which Predicts Response to Psychotherapy, J Consult Psychol 17:327-333, 1953. 9. Lasky, J.J.: The Problem of Sample Attrition in Controlled Treatment Trials, J Nerv Ment Dis

Press, 1962. 4. Wallerstein, R.S., and Robbins, L.L.: The Psy-

135:332-337, 1962.
10. Uhlenhuth, E.H., et al: Dosage Deviation and Drug Effects in Drug Trials, J Nerv Ment Dis

141:95-99, 1965. 11. Lorr, M.; Katz, M.M.; and Rubinstein, E.A.: The Prediction of Length of Stay in Psychotherapy, J Consult Psychol 22:321-327, 1958. 12. Rosenthal, D., and Frank, J.D.: The Fate of

Psychiatric Clinic Outpatients Assigned to Psychotherapy, J Nerv Ment Dis 127:330-343, 1958.

13. Cattell, R.B., and Scheier, I.H.: The Meaning and Measurement of Neuroticism and Anxiety, New York: The Ronald Press Co., 1961. 14. Greenfield, N.S.; Alexander, A.A.; and Roessler, R.: Ego Strength and Physiological Responsivity: II. The Relationship of the Barron Ego Strength Scale to the Temporal and Recovery Characteristics of Skin Resistance, Finger Blood Volume, Heart Rate, and Muscle Potential Responses to Sound, Arch Gen Psychiat 9:129-141, 1963. 15. Frank, J.D., et al: Immediate and Long-Term Symptomatic Course of Psychiatric Outpatients, Amer J Psychiat 120:429-439, 1963. 16. Stone, A.R., et al: An Intensive Five-Year Follow-Up Study of Treated Psychiatric Outpatients, J Nerv Ment Dis 133:410-422, 1961. 17. Schachter, S., and Singer, J.E.: Cognitive, Social and Physiological Determinants of Emotional State, Psychol Rev 69:379-399, 1962. 18. Uhlenhuth, E.H.: "Some Suggestions for Further Exploration of the Placebo Response," in Transactions of the 5th Research Conference on Cooperative Chemotherapy Studies in Psychiatry and Research Approaches to Mental Illness, Veterans Administration 1960, vol 5, pp 209-212. 19. Wilder, J.: Modern Psychophysiology and the Law of Initial Value, Amer J Psychother 12:199221, 1958. 20. Steinbook, R.M.; Jones, M.B.; and Ainslie, J.D.: Suggestibility and the Placebo Response, J Nerv Ment Dis 140:87-91, 1965. 21. Uhlenhuth, E.H., et al: Drug, Doctor's Verbal Attitude and Clinic Setting in the Symptomatic Response to Pharmacotherapy, Psychopharmacologia 9:392-418, 1966. 22. Frank, J.D.: Persuasion and Healing: A Comparative Study, Baltimore: Johns Hopkins Press, 1961. 23. Truax, C.B., and Carkhuff, R.R.: Toward Effective Counseling and Psychotherapy: Training and Practice, Chicago: Aldine Publishing Co., 1967.

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