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Changes in semantic uses of first person

pronouns as possible linguistic markers of

recovery in psychotherapy

C. W. Van Staden, K. W. M. Fulford

Objective: To examine changes in linguistic markers in the course of psychotherapy,

drawing on Frege’s logic of relations to define semantic variables distinct from syntactic
Method: From a sample of 73 patients, 10 patients with the best and 10 patients with the
worst outcomes were selected. Forty transcribed sessions of each outcome group were
compared statistically for change between commencement and termination of psychotherapy
in: (i) the syntactic usage of first person pronouns (‘I’, ‘me’, ‘we’, ‘us’, ‘implied I’, ‘implied me’);
(ii) semantic usage of first person pronouns (expressing alpha, omega, or unclear positions);
and (iii) non-pronoun linguistic variables (passive voice, negative, copula, auxiliary verbs
expressing a sense of obligation).
Results: There were no significant differences between the best and worst outcome groups
in the change of either syntactic usage, or of the non-pronoun linguistic variables. However,
the outcome groups differed significantly in the change of their semantic usage (alpha:
p = 0.002; omega: p = 0.028): The best outcome group showed an increase of alpha
positions and a decrease of omega positions, whereas the worst outcome group showed the
inverse (i.e. decrease of alpha and increase of omega positions).
Conclusions: Results suggest only semantic, that is meaning-driven, usage of first person
pronouns marks recovery in the course of psychotherapy. If replicated, this finding could be
used to monitor treatment responses. Replication in other kinds of treatment could mean
these semantic changes are markers of recovery more generally than in psychotherapy.
Key words: language, outcome, psychotherapy, self.

Australian and New Zealand Journal of Psychiatry 2004; 38:226–232

This paper describes the use of variables derived from changes in the use of first person pronouns in the course
linguistic theory in a comparative empirical study of of psychotherapy.
That changes in person pronoun use should occur in
Werdie Van Staden, Associate Professor (Correspondence) psychotherapy is suggested by the importance of con-
Department of Psychiatry, University of Pretoria, PO Box 667, Pretoria, cepts such as ‘self’ and ‘ego’ in psychotherapeutic and
0001, South Africa. Email: psychoanalytic theory [1,2], these being commonly
Bill Fulford, Professor of Philosophy and Mental Health assumed to be expressed by first person pronouns, ‘I’,
Department of Philosophy, University of Warwick, Coventry and ‘me’, etc. [2–5]. Changes in personal pronoun use, more-
University Department of Psychiatry, Warneford Hospital, Oxford, UK
over, if they occur, could be of practical importance:
This research was part of the first author’s MD study at the University of
Warwick (UK; 1999), titled ‘Linguistic changes during recovery: a philo- they might be helpful in monitoring change, for exam-
sophical and empirical study of first person pronoun usage and the semantic ple, or in providing a simple measure of outcome (see
positions of patients as expressed in psychotherapy and mental illness’.
A copy is obtainable from WVS. Discussion section). Yet apart from some suggestive
Received 17 February 2003; revised 3 October 2003; accepted 17 November findings in Spence’s studies of the patient–therapist
2003. relationship [6,7], empirical evidence that changes in

first person pronoun use do indeed occur in the course of with a brief period of training, showed a high degree of
psychotherapy has not previously been reported. interrater reliability (see Method section).
There is growing interest in linguistically defined This study was designed to compare statistically a best
variables for empirical research in psychiatry [8]. In the outcome group with a worst outcome group for an
present study we drew on linguistic theory to define two increase/decrease in, respectively, syntactic and seman-
distinct uses of the personal pronouns, syntactic and tic first person pronoun variables between commence-
semantic. We also examined a number of non-pronoun ment and termination of a course of psychotherapy.
linguistic variables, partly for comparison with pronoun
variables, partly for their interest in their own right in
respect of psychoanalytic and psychotherapeutic theory
(see Discussion section). Method
Syntactic and semantic uses of the personal pronouns
differ broadly as to grammar and meaning, respectively. Data and subjects
As such, they do not always run parallel. For example, in
Our data were derived from a series of verbatim transcripts of
‘I chased the dog’ and ‘the dog was chased by me’, the
psychotherapy sessions. The transcripts were originally made in the
syntactic uses of the first person pronouns, ‘I’ and ‘me’, 1970s as part of the Pennsylvania Psychotherapy Study [19] and are
are different even though the two expressions have now archived at the Ulm Textbank at the University of Ulm in
essentially the same meaning [9]. Germany. All patients consented to the audio-recording of the
Semantic uses of the first person pronouns, in reflect- sessions for the purposes of transcription and analysis. Names by
ing individual meanings, could be defined in many dif- which patients or other people could be identified were omitted or
ferent ways [10,11]. There are indications from both the changed.
philosophy and sociology of medicine, that illness and A major methodological advantage of the Penn Study for our analy-
recovery are most likely to be associated with semantic sis was that, from a total of 73 patients, the Penn investigators identi-
uses of the first person pronouns expressing specifically fied 10 patients with the best and 10 with the worst outcomes. This key
selection process had thus been carried out completely independently
agentic aspects of these meanings: thus, the experience
of the present study.
of illness is associated with incapacity (or loss of
Outcomes in the Penn Study were assessed by 14 psychometric
agency) [12,13]; and Holmes and Lindley [14] argue that instruments including patients’ self-report measures, therapists’ rat-
recovery of autonomy (hence of agency) is the central ings, and independent clinical observer ratings. Using multiple regres-
aim of most kinds of psychotherapy. sion analysis of the scores on each measure, ‘residual gain’ and ‘rated
Frege’s semantic theory [15] and the related logic of benefit’ scores were calculated. ‘Residual gain’ was calculated on the
relations [16,17] provide a resource for defining seman- basis of ratings made at the beginning and again at the end of treat-
tic variables connected with agency. Drawing on this ment. ‘Rated benefits’ was based on all the ratings immediately after
resource, we defined two semantic positions, ‘alpha’ and the end of treatment. The ‘rated benefits’ and the ‘residual gain’ were
‘omega’. The details of this derivation, including the highly correlated (r = 0.75). Hence the best outcome and the worst
precise relationship between our semantic positions, outcome groups were defined in the Penn Study by extreme scores on
either of these measures. In the best outcome group, seven were
Frege’s ‘argument places’, and the ‘owner’ and ‘acci-
selected on the basis of residual gain, three by rated benefits; in the
dental’ of relations, are described elsewhere [18]. In
worst outcome group, eight were selected by residual gain, two by
brief, the alpha semantic position is characterized by rated benefits.
occupancy of the ‘owner’ of a relation as defined in A disadvantage of the Penn Study for our purposes was that,
semantic theory, and the omega position is characterized having been carried out in the 1970s, diagnostic information was
by occupancy of the ‘accidental’ of a relation. In respect relatively unsophisticated by present standards. The subjects of the
of verbs expressing actions, the alpha position is occu- Penn Study were diagnosed with depressive neurosis, anxiety neuro-
pied by the agent. Thus, in both ‘I chased the dog’ and sis, and mixed neurosis. The two groups (best and worst outcomes)
‘the dog was chased by me’, I occupy the alpha position appeared similar overall (in particular, there were no psychotic
and the dog occupies the omega position. These seman- subjects) but formal diagnostic comparisons were not possible from
tic positions, however, are not restricted to actions. the available data.
The best and worst outcome groups were also not significantly
Similar positions are expressed by other classes of verb:
different in age, gender, marital status or religion. All subjects had
for example, verbs expressing attitudes (x is against y)
either one or two sessions each week. Eighteen psychodynamically
and states (x needs y). orientated therapists were involved in the study (two therapists had two
The concept of a semantic position may be unfamiliar cases and the rest one case each). They had a minimum of eight to a
outside philosophical logic. However, the alpha and maximum of 264 sessions, with a median of 32 sessions over a median
omega positions proved to be readily operationalizable of 34 weeks. Best outcome patients were in therapy longer than worst
through a set of explicit rules and exemplars, which, outcome (median 61 and 43 weeks, respectively).

Definition of variables The reliability of the recording procedures was assessed by sampling
100 verb phases from a randomly selected psychotherapy transcript
(i) Overall use of first person pronouns and verb phrases. We and subjecting them to blind analysis by five sixth-year medical
examined the commencement and termination frequencies for all verb students from the University of Pretoria (South Africa). All the above-
phrases that were associated with a first person pronoun, and all that mentioned variables were present among these verb phrases. The
were not. students had a preliminary 15 minute training session in the operation-
(ii) Syntactic usage of first person pronouns. The variables defined alized procedures for identifying and recording variables. The mean
for investigating syntactic usage were ‘I’, ‘me’, ‘we’, ‘us’, as well as concordance rate between the study recordings and the student
‘implied I’ and ‘implied me’ (e.g. as in ‘I ate my food and (I) talked to recordings was 94% (SD = 1.85%; range: 92–96.7%). The Kendall
her’, and ‘she said (to me) . . .’). Coefficient of Concordance among the recordings of the students was
(iii) Semantic usage of first person pronouns. The variables for 0.0011, which is highly satisfactory.
assessing semantic usage were the ‘alpha position’ and ‘omega
position’, as described earlier. We used ‘unclear position’ for expres-
Statistical analysis
sions where the patient’s semantic position was not clearly evident
(e.g. in ‘I was bored’).
The best and the worst outcome groups were compared using either
(iv) Non-pronoun linguistic variables. Non-pronoun variables were
the independent samples t-test or the Mann–Whitney U-test. The t-test
use of the passive voice, negatives (‘not’ and ‘never’), copulas (e.g. ‘to
was used where the distribution of the changes in frequencies between
be’, ‘seem’, ‘appear’), and auxiliary verbs expressing a sense of
commencement and termination of therapy was consistent with a
obligation (e.g. ‘ought to’, ‘got to’, ‘have to’, ‘must’, ‘should’).
normal distribution. This test did not assume equal variances. Where
the data did not follow a normal distribution, the Mann–Whitney U-test
Recording and procedures was used. The extent to which the data followed a normal distribution
was assessed by visual inspection of graphic representations of the dis-
The basic unit of observation was a verb phrase. Besides a main verb,
tributions of the cumulative frequencies, and by the Kolmogorov-
a verb phrase may also include auxiliary verbs. For example, in ‘I ought
Smirnov and Lilliefors tests.
to have written to Jim’, the verb phrase is ‘ought to have written’. Each
verb phrase was examined for the presence or absence of all the above
variables in association with that verb phrase. Results
For each of the 20 subjects, two commencement sessions and two
termination sessions were examined, giving a total of 80 sessions. In
Overall use of first person pronouns and verb
all cases we followed the definitions of commencement and termina-
tion sessions adopted by the Penn investigators. Thus, for a given
subject, the commencement sessions were sessions 3 and 5; the
The commencement frequencies of all first person pronouns taken
termination sessions were the session in which 90% of the therapy was
together were similar for the best outcome (mean = 62.89%,
complete and the immediately preceding session. All termination
SD = 5.41%) and the worst outcome patient groups (mean = 62.19%,
sessions were within five sessions of the end of therapy. The first 200
SD = 7.46%). The termination frequencies were lower in both groups,
verb phrases of each of the 80 sessions were analyzed.
the best outcome group showing a mean decrease of 10.14%
The presence or absence of the variables in each verb phrase was
(SD = 12.07%), the worst outcome group a mean decrease of 10.05%
recorded in binary code. Frequencies of the variables in the sample
(SD = 6.74%). These decreases were not significantly different
were calculated as the ratio (expressed as a percentage) of the number
between the two groups (t = 0.021, df = 14.11, p = 0.984, mean
of ‘present’ recordings for a particular variable to the total number of
difference = 0.0913, 95% CI = –9.28–9.46).
analyzed verb phrases in the relevant two sessions (i.e. either the two
Correspondingly, there was no significant difference between the
commencement or the two termination sessions). This generated a
best and the worst outcome groups for change in verb phrases that were
commencement frequency and a termination frequency for each vari-
not associated with a first person pronoun (t = –0.041, df = 16.05,
able for each patient.
p = 0.968, mean difference = –0.279, 95% CI = –14.75–14.20).
The change between commencement and termination frequencies of
variables was calculated for each patient as the difference between
commencement frequency (C) and termination frequency (T) propor- Syntactic usage of first person pronouns
tionate to the commencement frequency, expressed as a percentage.
Thus, % change = 100 × (C–T)/C. No statistically significant differences were found between the best
Since the transcripts were not edited, operational rules of recording and the worst outcome groups in their syntactic usage of first person
were developed to deal consistently with phenomena like half- pronouns.
sentences and single word expressions. The operational rules (avail- The frequency of ‘I’ showed a very small increase between com-
able on request from WVS) included for example: a verb phrase should mencement and termination of psychotherapy for both patient groups
be identifiable before any recording is made; repetitions (like (best outcome patients: mean increase of 0.33%, SD = 9.11%; worst
stuttering) of a first person pronoun associated with a certain verb outcome patients: mean increase of 0.50%, SD = 6.63%) (Fig. 1). The
phrase should be omitted; colloquial use of first person pronouns difference between the best and the worst outcome patients in this
should not be corrected; direct quotations by a patient from someone respect was not statistically significant (t = 0.049, df = 16.15,
else should be excluded. p = 0.962).

The mean frequency of ‘me’ increased for both groups (best Semantic usage of first person pronouns
outcome patients = 5.73%; worst outcome patients = 31%) (Fig. 1) but
the standard deviations were large (43.7% and 68.62%, respectively). In contrast with the syntactic usage of first person pronouns, signifi-
Correspondingly, no statistically significant differences were found cant changes were found in semantic usage. These positive findings are
between the two groups of patients in their change in the usage of ‘me’ compared with the negative findings for the syntactic variables, ‘I’ and
(t = 0.099, df = 15.27, p = 0.339). ‘me’, in Figure 1.
The frequency of ‘we’ showed larger mean increases than ‘I’ or ‘me’ Thus, the alpha position increased among the best outcome patients
for both patient groups between commencement and termination. (mean increase of 7.14%, SD = 7.38%) and decreased among the worst
Moreover, the best outcome patients’ mean increase in the frequency outcome patients (mean decrease of 4.40%, SD = 6.46%). The differ-
of ‘we’ (215.22%, SD = 347.45%) was higher than the worst outcome ence between the best outcome and the worst outcome patients was
patients’ mean increase (43.83%, SD = 171.98%). The difference highly significant (t = –3.72, df = 17.69, p = 0.002, mean difference =
between the patient groups in this respect, however, still did not reach –11.54, 95% CI = –5.06 – –18.07). The upper value of the confidence
the 0.05 level of statistical significance (U-test = 23.0; p = 0.131). This interval suggests an increase of the alpha position in at least 95% of
is most likely due to the large variance in the patients’ changes of similar comparisons.
frequencies (cf. the large SD values cited earlier). Missing data may The omega position changed in the opposite direction from the alpha
also have contributed to the non-significant result since two of the position. The omega position decreased among the best outcome
worst outcome patients did not use ‘we’ at all during the analyzed part patients (mean decrease of 17.79%, SD = 19.95%) and increased
of the commencement sessions, and hence (as zero scores) had to be among the worst outcome group (mean increase of 20.18%,
excluded from calculating the percentage change between commence- SD = 38.74%). The difference between the patient groups was statisti-
ment and termination of therapy. cally significant (U-test = 21.0, p = 0.028).
The best outcome group showed a mean decrease of frequency of The changes in the alpha and the omega positions for individual
‘us’ (28.85%, SD = 104.54%); and the worst outcome group showed a subjects are shown in Figure 2 (alpha position) and Figure 3 (omega
mean increase (69%, SD = 143.99%). As for ‘we’, statistical testing position). Visual inspection shows opposite directions of the changes
between the groups was not useful because commencement frequen- for the two groups of subjects: the predominant response shown by
cies were zero for two of the best outcome and six of the worst subjects in the best outcome group was an increase in the alpha and
outcome patients, and therefore had to be excluded from calculating a corresponding decrease in the omega positions, whereas in the
the percentage change between commencement and termination of worst outcome group the predominant response was a decrease in
therapy. the alpha and an increase in the omega positions. This means that an
No statistically significant differences were found between the increase in frequency of the alpha position has a sensitivity and
best and worst outcome patient groups in their uses of ‘implied I’ specificity of 0.8 to identify correctly both the best and worst
(U-test = 35.0, p = 0.257) or ‘implied me’ (U-test = 38.0, p = 0.364). outcome groups, and a decrease in the omega position has a sensitiv-
ity of 0.8 and specificity of 0.6 to identify the best and worst outcome
groups, respectively.
For the ‘unclear position’, no statistically significant differences
were found between the patient groups (U-test = 42, p = 0.545).

Figure 1. Mean changes of ‘I’, ‘me’, alpha positions

and omega positions between commencement and Figure 2. Change in the frequency of the alpha
termination of psychotherapy for best and worst positions between commencement and termination of
outcome groups. psychotherapy for each case.

could not be investigated. For example, we could not

account for diagnostic details, knowing only that patients
were diagnostically heterogeneous and included none
with psychotic disorders. Furthermore, the detailed analy-
sis required of the transcripts (examination of 16 000
verb phrases for each of 13 variables) meant that we
were able to study only a relatively small number of
patients (i.e. 20 from a sample of 73).
Granted these constraints, what is the significance of
our findings?

Practical utility

Our results provide quantitative evidence to support

Figure 3. Change in the frequency of the omega the clinical observation that recovery brings about a
positions between commencement and termination of change from a passive position to a more active (agent)
psychotherapy for each case. position. Active and passive positions, however, should
not be directly equated with alpha and omega positions
[18]. The active–passive distinction is at times ambigu-
Non-pronoun linguistic variables ous, for example in passive aggression, whereas the
alpha–omega distinction derives its clarity from philo-
No significant differences were found between the best and the worst sophical logic.
outcome groups for change in any of the non-pronoun linguistic vari- Our results suggest further that psychotherapeutic
ables, namely the passive voice (U-test = 48.0, p = 0.880), the negative recovery could be tracked linguistically. Doing so may
(U-test = 43.0, p = 0.597), a copula (t = –0.608, df = 17.07, p = 0.551,
prove useful to enhance the therapeutic process. As
mean difference = –5.25, 95% CI = –23.46–12.97), and auxiliary verbs
considered elsewhere in more detail, cognizance of
that express a sense of obligation (t = 1.715, df = 11.26, p = 0.114,
mean difference = 38.36, 95% CI = –10.72–87.46).
the semantic positions could supplement the dynamic
understanding in analytic therapies and could aid the
restructuring of thoughts and behaviour in cognitive-
Discussion behavioural therapies [18].
Diagnostically, the shift from omega to alpha positions
The main finding of this study is that semantic (mean- could provide the basis for the development of relatively
ing-driven) usage of first person pronouns changed over simple ‘litmus tests’ of progress and outcome in psycho-
the course of good outcome psychotherapy. Occupancy therapy. Psychotherapy, in all its forms, is both costly
of what we have defined as the alpha (semantic) posi- and notoriously difficult to assess. Linguistic markers,
tion increased, while occupancy of the omega position being comparatively simple to use, would allow treat-
decreased, in patients with good outcome. Occupancy of ment plans to be fine-tuned, avoiding blind alleys in
the two positions, furthermore, was inversely related. therapy, and building on approaches which look promis-
That is, occupancy of the alpha position was taken up at ing. As measures of outcome, similarly, linguistic
the expense of occupancy of the omega position in a markers, being relatively objective, could contribute to
majority of individual patients. Syntactic (grammatical) the development of more accurate clinical guidelines on
usage of first person pronouns, by contrast, and a the profiles of patients likely to benefit from this or that
number of non-pronoun linguistic variables, all showed particular form of therapy.
no significant changes between the best and worst
outcome groups. Future research
The study clearly has limitations as well as strengths.
The resources of the Penn Psychotherapy Project gave us Further work is required to determine whether such
access to a series of verbatim psychotherapy transcripts, tests are indeed valid and viable. Findings of this study
collected originally for purposes unrelated to our research, suggest that an assessment of the semantic positions
and independently grouped for outcome on a series of of patients, rather than an assessment of syntactic use of
outcome measures. This supported a valid measure first person pronouns, would be a valid measurement
of outcome in this study, but the influences of potential of recovery in psychotherapy. This validity is so far
confounding variables had not been known to us and based on the rigorous theoretical description of the

semantic positions (i.e. the content validity) [18], and on expressed verbally in the use of negatives, of course; nor
the ability to distinguishing between contrasting groups are all verbal expressions of the negative reflections of
that had been independently grouped for outcome psychological denial. But the finding, which so far as
(i.e. the external criterion validity which is demonstrated we are aware is reported here for the first time, is at
in the concurrent validity by using t-tests and Mann- least suggestive. Similarly, the absence of any change in
Whitney U-tests, and in the ability to predict the the use of auxiliary verbs expressing obligation (‘I
outcome groups based on either an increase in the fre- must . . .’, ‘I have to . . .’, ‘I should . . .’, etc.) is contrary
quency of alpha positions or a decrease in the frequency to the expectations of rational emotive theory, a key
of the omega positions) [20]. However, these are the first component of which is to challenge and then relinquish
steps for a comprehensive testing of validity in the thoughts of obligation [22].
future. The reasons are that convergent validity was not Furthermore, the bearing of our findings on psycho-
tested, because the specific measurements of the Penn analytic and other theories about first person pronouns
study had not been available, and our results need to be need to be researched. A connection with the work of
replicated using other psychotherapy materials (the Penn Jacques Lacan was outlined by Gillett [23], and other
Project transcripts might be unusual in some way). It will theoretical connections with egotism and narcissism are
also be necessary to examine specific diagnostic groups to be expected. For example, egotism is commonly asso-
and other forms of treatment. The heterogeneous nature ciated with the excessive use of first person pronouns
of our subjects, and the theoretical links (noted in the [24], but our findings suggest that the overall frequency
Introduction section) between our semantic variables of first person pronouns does not differ significantly
and agentic aspects of illness and recovery, suggest that between the best and the worst outcome patients, neither
taking up occupancy of alpha positions and relinquishing at commencement nor at termination of psychotherapy.
occupancy of the omega positions may be a generic, or This may mean that egotism, and likewise narcissism,
at any rate a general, marker of progress and good may be relevant to some but not all instances of first
outcome. But whether or not this is so, only further person pronoun use. One hypothesis could be that
research will show. egotism and narcissism present in certain kinds of rela-
The reliability and practical utility of using linguistic tions (e.g. recognition, admiration, appreciation) rather
markers in this way would have to be assessed under than in all relations expressed in association with first
‘field’ conditions. The medical students involved in our person pronouns [25].
reliability study achieved a highly satisfactory level of
inter rater reliability after only 15 min of training in the Methodological innovation
scoring methods. But they were working under ideal
conditions, away from the demands of clinical work, Meanings, as no less a figure than Karl Jaspers empha-
and on materials in which they had no direct interest, sized, are crucially important alongside causes in psycho-
personal or professional. pathology [26], and are set to become more, not less,
Additional work is needed to determine the dynamics important in psychiatry with advances in the neuro-
of the shift from omega to alpha semantic positions. We sciences [27,28]. Our study shows that it is possible
sampled the commencements and terminations of the to draw on philosophical logic as a source of reliably
psychotherapy transcripts. But if the shift from omega operationalizable variables for quantitative research on
to alpha is to be used as a measure of progress, we need meanings related to first person pronouns. It is in this
to know whether it occurs continuously over the course respect that it is methodologically innovative.
of therapy or discontinuously; if discontinuously, whether There have been other philosophical resources for
it is an early or late change; and we need to know studying meanings in relation to first person pronouns.
whether the dynamics are the same or different for dif- The philosophical pragmatists Mead and Pierce focused
ferent diagnostic groups and from patient to patient. on the purposes of using ‘I’ and ‘me’ as symbols [29,30].
The connection with psychotherapeutic and psycho- So did some psycho-analytical theorists [2–4,31]. This
analytic theory, suggests that linguistic variables might study, however, investigated empirically the meaning as
be helpful in sharpening and developing therapeutic revealed within patient expressions irrespective of the
models of disorder. Non-pronoun as well as pronoun underlying purposes of using these pronouns [32].
variables could be helpful here. In this study, for exam- Phenomenology is another philosophical resource, one
ple, among non-pronoun variables, we found no signifi- on which Jaspers drew in developing his ‘Ich-störungen’
cant changes in the use of the negative. This is surprising (i.e. disorders of ‘I’) in psychopathology. Phenomenol-
given the significance attached to overcoming denial in ogy is currently reinventing itself as an empirical disci-
psychodynamic therapy [21]. Denial is not necessarily pline [33] with considerable potential in this respect [34].

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