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'' CanPatients'Viewsof a Therapeutic

PredictOutcome?An EmpiricalStudywith
Deoressive Patients

STEFAN PRIEBE,M.D., Diplom.-Psychorosi3t

ma m i l yP r o c € $ . S e p l e m b elrs a s . V o u m e2 a . N u d b e r 3
R e p r i n l e d l r oF
Viewsof a Therapeutic
PredictOutcome? Studywith
An Empirical
STEFAN PBIEBE, l|.D., Diplom.-Psychologl6t+

Usine the principles of brief therupy as developmentof the double-bind theory of

de]eLopedat the MentaL ResearchInsti- schizophrenia (2). Since then, such re
tute (MRI) in Palo ALto, this study search has concentrated mainly on the
eramined. how pdtienb Dieued psJchia- family. This has been the casein therapeu-
trists' and significdnt otherc' attitudes tic studies as well as in freld studies. The
touard. the seuerity of theb illness, as syst€m that the present study examined
compared uith their oun attitud.e, and. was not the family but, rather, a therapeu-
uhether these Dieus uere related to out- tic s)5tem. This system includes not only
come.Fort!'one depressiDe inpatients u,ere the patient, his or her family, or a laryer
ashed a two-pdrt question Who reEa s social group, but also the therapist, the
lour ilLnessas beinE more seuere:(a) lou psychiatric institution, or parts of a health
or rour signiftcant others; (b) you or your sewice system(7). Th€ therspeutic syst€m
psrchiatrist? Tuo subsamplesof patients is time'limited and dependson the thera-
wereid.entified:thosewho t)ieuedpsychia- peutic setting.
trists' and signilicant others' dttitudes Our approachto s study ofthe therapeu-
touard the ilLness as similar (equo.llr tic system is basedupon b ef therapy, as
structured systems)dnd thoseuho Diebed developedby the Mental ResearchInsti
them as dissimildr (dilfercntly structured tut€ (MRI) in Palo Alto. A principle of
systems).Both groups showed equal and brief therapy is that one evaluateswhich
significant inqoDement during hospital solutions have so far been attempt€d for
treatment; but the croup tha.t uieued the the patient's problem,and to try a difierent
attitudes held by psychiatrists and signtfi- one in therapy. That is, one hies solutions
cant othersds d.issimiLarreported improDe- that are oppositeof what has alrcady been
nent after discharye. tried, for instance,by the patient's signifi
Fam Proc :349-355,1 9 cant others (3, 5, 10, 11). Thus, in a con-
densed and somewhat simplified fashion,
the rclationship betweenpatient and thera-
psychiatry. empirical pistshould be differentin sometherapeuti
I research on the concept nf syshems cally decisive respect from that between
begal with a 6eld study that led to the the patient and significantothers.
In this study, this principle was applied
not to specific attempted solutions but, by
I Depdtment ofs@isl Psy.hiahy, Free UniveBitJ
of Be.lin, Plmtsenrlle 19, D-1000, Wqt Be.lin 19, analogy, to general attitudes toward the
patient's problem or illness. Accordingly,
o 1989Family Process,Inc.

Ihe attil udesof borhsignificanr olherssno Tenlarively,lhis "tudy concenlrates or.

Ihe therapisrshoulddilTerin lhe parienr's an attitude that is clinicallyrelevant:rhe
vie*. For example.if the parient believes raling of severityof illness.This arritud.
that significantothers regard the illnessas within the therapeutic system is not de-
less severethan he or she does, then th€ scribed by an obqerverour.sidethe syslern
patient should believe that the therapist bur by persunswithin it. Their viewsabour
regardsthe illnessas being equally or rnore how that attitude differs among the sys
severethan he or she does. Therapeutic tem's membeN, their "maps" of the rela-
syst€msthat arc difierently structured from tionship of various attitudes within th€
the patient's point of vi€w were hypothe therapeuticsystem,or what they said about
sized to correlate positively with a better thefu maps in an intewiew, were exarnined
and related to outcome.
To test this hypothesis,we attempted a
systemsdescription of an attitude within METHOD
the therapeuticmilieu ofa psychiatrichos The patients were all acutely ill and had
pital, using simple methods, and probing
been admitted becaus€of severedepres-
the patterns found in significant relation, sion, as rat€d by the von ZerssenDepres-
shipswith respectto outcomec teria. Only sion ScaleDS + DS'> 24 (9). Onlypatients
three parts of th€ therapeutic systemwere with schizophrenic, bipolar afiective, or
examined: (a) the patient, (b) his or her organic disorders were excluded, on the
significant others,and (c) the psychiatrist. balis that lack of insight and awarenessof
The role of the psychiahist in this setting is one's illness are often found in such
as an expert and a representative of the patients. This wide inclusion of severely
psychiatric institution. The institution is, depressedpersonsnecessarilyled to a high
predominantly, a biologicauy oriented, variability of diagnoses,treatment meth-
moderately sized psychiat.ic department ods,and courseofillness. But, becausethis
of a univercity hospital for mainly acute study used a new approach,it did not seem
psychiatricdisorders.Accoding to systems useful to make further rcst ctions beforc-
theory, featuresor attitudes ofmembers of hand. Thus, inorder todescribedillerences
a system should be describednot in abso- in structures,the criteria for inclusionwere
lute terms (making a compadsononly with restrict€d to depressivesyndromesregard-
valuesfrom a difierentsystem) but, rather, lessof formal psychiatricdiagnosis.
in a relational way by compa sons utfftin The patients were interviewed in the
the system, whereby only dillerences are aftemoon after the day of admission.The
relevant (1, 8). Any attitude held by the regular, intensive psychiatric examination
therap€utic system's members should be by the psychiatristhad alreadytakenplace.
describedin the sameway, that is, notonly An inteviewer, not otherwise involved in
which attitude is held by the patient, the therapy, asked the patient: "Who regards
sienificantothers,and the psychiatrist,but your illness as being more severe signifi
also who hotds this attitude to a great€r or cant others or you yourcelf (or is there no
lesserextent patient or significantothers, difference), and the psychiatrist or you
pstient or psychiat st. Obviously,one does yourself (or is there no difierence)?" If
not know which attitudes are relevant for required, an identical, short explanation
the therapeutic processand which are not. with two examplesfor each question was
Difierent attitudes may be important within given.The psychiatrist was askedthe same
different therapeutic systems and at dif- question,comparing the patient's attitude
ferent stagesof therapy. with his or her own.
PRIEBE / 351

Dependingon the answers,two subsam- psychiat sts, were examined. Their ages
ples of patients were formed: one group ranged from 21 to 81 (mean : 50,
that viewed attitudes of significant others SD : 12.8).The primary psychiatricdiag'
snd psychiatristsas being similar, and the noses, according to ICD-9 classification
other group that did not. ln the first goup (12),wereendosenousdepression(n : 16),
were those patients who stated that both neurotic (n : 16) and personality (n : 1)
psychiat st and significantothen regarded disorders,depressivercaction (n : 3),alco
hol dependence(n : 3), isolatedhypochon-
their illness as being more, equally, or less
sever€ than they did themselves.In the driac delusion (n: 1), and a depressive
second group were those patienls who condition without cla fication (n : 1). ln
viewed the attitudes of psychiatdsts and 5 patients, the secondsry diagnosis was
significant others as being different than drug abuseor dependence.Among the 41
their own, regardlessof the kind of ditrer- patients, significant others were reported
ence.The tustgroup, therefore,viewedthe as spouses(n : 19), other family memberg
therapeutic system as equally structured; (n: 8), and persons outside the family
the second group viewed it as difierently (n : l4). Until the follow-up, information
structured. These two groups were com- could be obtained about all patients who
had originally enteredthe study.
The deprcssivesymptomswere assessed The patients were hospitalizedfrom 3 to
by a self'rating scale,the von ZerssenDe 223 days (mean: 58, SD:36) Dudng
pression Scale (9), and by the Hamilton this time, 32 patients received antidepres
DepressionScale (6) at the beginning and sives, 12 receivedneuroleptics,4 received
end of inpatient treatment. The Hamilton benzodiazepines, and 3 receivedlithium; 6
Scale was rat€d by the primary psychia- patients rec€ived no medication. On an
t st. In order to assess the efiect of the avemge, 2.1 different psychotropic drugs
hospital treatment as s whole, a combina- per patient were given du ng hospitaliza-
tion of simple, objective and subjective tion. Two patients receivedelectroconvul'
c teria was applied. Three to 4 months sive therapy. In addition to the odinary
after discharge, all patients were asked ward program, 12 patients participated in
whether they had been admitt€d to a psy- occupationaltherapy.The type and amount
chiatric hospital in the meantime and, if of psychotherapeuticactivities depended
not, whether their condition was generally on the nature and extent of the psychia-
better than, equal to, or wolse than it had trist's psychotherapeutictraining and on
been at the time of their discharge.These the ward's atmosphereand stafi. The ther-
crite a csn by no means be regarded as apeutic activities included group therapy
sufiicient for a comprehensiveassessment, for some patients and, for one patient,
but they are certainly one possibleroute to musictherapy.
allow an empi cal approach(?). RESULTS
Characterlstics of Palients and Psychiat' There was no positive correlation be
ric Treatm6nts tween patients' and psychiatrists' judg
Nearly all patients who were admitt€d mentsas to which oneof them regardedth€
within a given pe od of time and met the patient's disorder as being more severe
inclusion criteria could be included in the (Kendall's tau: .05, ns). This means
study. The few exceptions were due to that patients and psychiatrists describe
organizational problems. Forty-one pa- ditrerent maps ol thst attitude within their
ti€nts (30 fernales, ll males), who were rclationship, althoueh thetu judgmenls wer€
treat€d on five difierent wards by 12 based upon the expedence of the sam€


TABLE 1 T^Bll 3
Tuo-Part question to Patietts: Who Eegads yaur Qhorocteristicsol Potients uithin EquslL! dtd
IlLnes 6 More Seuerc? Dif erent l! Struc turcd Srstems

Pan 1:Sienificnt otheF or youBeu? Equally Ditre.erUy

6 Sr.uctured Stru.tutud
t1/9 r a/ 2
53.8 42.7
Parl 2rYour pBychiat.istor yoweli?
59.9 53.6
not difier in their depressives)rnptoms at
int€ractions that had occurEd between the beginning or the end of the hospital
them. How a patient assessedthe attitude beatment. None of the dillerencesbetween
of the psychiat st and significant others the two groups is statistically significant,
towad the severity of the illn€ss, as but the reduction of symptoms for each
comparedwith his or her own attitude, is scale and each group is highly significant
summarizedin Table 1. (f-tests for paired samples ranged from
Table 2 showshow these answersto the t : 4.?3to t :'7.45, p <.001).Asfar asthe
two questionswere related.More than half singlecomponentsofthe psychiatrictreat
the patients (22 in the lower right of Table ment were recorded,there were no appar
2) said that they themselveswould regard ent dillerencesbetweenth€twogroups,nor
the illness as being more severethan did did they clearly diller in diagnosesor ward
both the psychiatdst and significant oth- assrgnment.
els. ln other words, the patients believed In Table 5, some features of the treat-
that neither significantothe$ nor the psy' ment during the follow'up phaseare sum-
chiatrist could see how severely ill they marized.No difierenceis statisticallysignif-
rcally were. Therefore, according to this
study's de6nition, 26 patients were in an Three to 4 months after discharge, S
equallyshuctured syst€m(from their point patientshad beenreadmittedto a psychiat-
ofview), and 15 were in a differently struc c hospital.AI of them had beenin equally
tured system. shuctured systemsduring inpatient trcat-
Table 3 showsthe sex,age,and length of ment. Of the remaining 36 patients, 12
stay for patients within equally and differ- judged their presentcondition unchanged,
ently sbuctured systems.Only the differ- 7 judged it to be worsethan at the time of
encein ageis statistically significant(t test discharge, 1? report€d further improve
for independentsamples,, :2.55,p <.05). ment. Patients with and without further
Table 4 indicates that both groups did improvement did not signiicantly diff€r
TBc 2.
Relation ol Difrerc\t Attitudes on Tuo-Pa.t question

Part 1: Siglifcut o1he.r or your6elf?

Parr 2: P6ychiatrht or yollRlfi

2.' 22.
leqully structu€d syst€ms (26 paiients)
1'difie.ently Bt uctu€d systems (15 patienis)
PRIEBE / 353
TrBr-8,1 T,alll 6
at Beeinnincand End al
MeonDepre$ionScotes Bddtioa ol Therapeuti SystemSttucrure to
H8pitalization Beported Fwthe. Imp.atenent in l l Months
Dqually Ditrerently
Shuctu.ed Str{ctuled Equrlly Ditrerorfly
Systoms Sy6teEg Structured St.uctured
System. Sysiem.
51.0 50-,1
18.1 r9_4 6 ll

24.2 26.0
6-5 i : 9.92,df : 1,p < .01

either in diagnoses,sex,age,length of stay, Iation is oft€n sought after in MRI brief

ward assignment,and treatment variables therapy. All of those 4 patients reported
during and after hospitalization. improvementsinc€their discharye.
Table 6 shows that improvement is Ie-
ported significantly more in patients who DrscussroN
had beenin differently structued therapeu' Patients who view the therapeutic sys_
tic syst€ms.As an exampleof the relation tem as being differently shuctured in
shown in this table, 4 patients (also see terms of attitude toward the sevedty of
upper right in Table 2), who had stated their illnesssignificantlymoreoften showa
that their significant others regardedtheir further improvement during the follow-up
illness as being less severethan they did phase, an improvement that is indepen-
themselves,now said that thefu psychia- dent of specifictherapeutic measures,and
trist would regard their illness as being which occurs although both groups had
more severethan they didthemselves.Pre- already experiencedsubstantial and equal
sumably,these patients supposedthat 8ig- improvement during inpatient treatment.
nificant others believedthey would fab - In explainingtheresults, itshould be taken
cate or exaggeratetheir symptoms, and into account that many factors have not
that they did not sufer as much as they been considered,a casein point being the
claimed they did. Now they were being structuresof thempeutic systemsin which
treat€d by a specialist who supposedly the patients had been t*at€d as outpa
thought they were wolse o{f and more tients previous to or following hospitaliza
severelyill than they believed.This constel- tion. To account for the fesult, at least
TaLE 5 three assumptionsmay be msde. First, the
SoM Features ol Tredtnent durinq &4 Moaths attitude toward the severity of a patient's
Follou-uP Phue illness seems to be a rclevant featurc of
many therapeuticsystems.Second,to some
Dqually Ditrerently extent, it is possibleto analyzethe thera-
Shuctured St.u.tured
peutic syst€m even wh€n only three basic
componentsof it ar€ considered.Third, as
the results indicate, the patient's desc p-
10/ 16 3/72 tion, his or her map of the s)stem, is an
important criterion in determining the
16/10 tt/ 4 outcome of the patient's condition. These
maps eiist on a cognitivelevel.The lack of
4/22 2/13
agreementbetween patients and psychia

Fan Prot , VnL-28,Septenber,1989


trists in their judsment about who re- ther improvement after termination of
garded the illnessas more severeindicates treatment (4).
that difierent observeB of the same Although thereis no satisfactoryexplana-
"objective" interaction may have different tion for the fact that patients within difier-
maps,at leastwhenthey are participantsin ently structured s)€tems are significantly
that interaction. younger,agecannot accountfor the diffef'
Looking for a model to expiain tbis, one ence in improvement after discharge be-
could speculatethat patients, while living cause patients with and without further
with sisnificant otheru, were exposedto a improvementshownosignificantagediller-
certain attitude toward their illness,which ence. Finally, the exact value to be st-
may be viewed as in accofd with the "at tached to and the reliability of the global
tempted solution" of MRI brieftbeEpy. It answ€rspatients gsveinthe interview after
is this system in which theh disorder had the follow-up phase are unclear, although
developedand in which their admissionto patients' statements about whether they
a hospital was thought necessaryor usefui. feei better are e valid and common crite
lnpatient treatment in a psychiatrichmpi- on for psychiatric evaluationof outcome.
tal takes place in a complex situation with
many different and intedependent pto coNcLUsroNs
cesses.These processes,which are not the Although the attitude about the severity
subject of examination in this study, even- of patients' illness is in itself not a
tually result in a marked improvement for problem-relat€d solution but, rather, a
both groups.During this time, patients live basic attitude in therapy, the (h'"oth€-
on the wad and have their most ftequent sized)relationshipfound betweenthe struc
and impotant contacts with nurses, doc- turc ofthe therapeuticsyst€mand outcome
tors,and other patients.The actualinterac- can be consideredas consistentwith MRI
tion with significant others is rarcr and brief therapy pdnciples. The examination
probably less relevant than before and of patients' maps of how attitudes toward
after hospital treatment. During treat- the severity of their illness varied within
ment, some patients those with differ- the therapeutic system allows one to pre-
ently structured systems-expe ence a dict at leastonerelevant outcomec tedon.
qualitatively new attitude toward their ill It remainsopen yet as to how far therapeu-
ness, unlike the one they were used to. tic decisionsand intewentions within the
They no longer gain the impression that consistentframework of a psychiatrichos-
their sisnificant others' attitude is the only pital setting can influencethese "attitude
possible one. The difiercntly structured maps." Granted that the methods used
systemmay influenceand changethe per- weresimple,tentativ€ly applied,and borea
ception and evaluation of their own and high degreeof uncertainty, they did yield
significantothers'attitudes. When patients results. One should be cautious about the
retum to thefu usual environment, this findinss unlil replicationstudieshavebeen
difierent perception of their illness and of carried out in similar settings.That posi'
the attitudes within the system in which tive conelations were found under such
they are again living may lead to different conditions should encourageempirical re-
behavior, beiter adaptation, and further searchand field testing ofsyst€mic ideasin
improvement.This result is in accordwith psychiatry. This study has sho$'n that
the results found in diferently desisned examination of a thempeutic system's
sFt€mic b ef therapies that there is fur- structure may b€ helpful in such att€mpts.
/ 355
"psychotischen"Jusendlichen Familien'
drno.|t'ik 9: ro8 r25, tg84
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interactional approach to psychotherapv. N. Sartodu & T.A. Ban (eds.),Assess'
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Handbook of interpersonal pslchother' Ve.lag,1986.
dpy. NewYork PersamonPre$,1982 10. Watzlawick, P-, W€akland, J., & Fisch, R
4. de Shazer. S., Berg, I K., Lipchik, E., Chanee:PincipLes of problem formatian
Nunnally, E., Molne, A.. Ginserich, W., and problem soLution.Ne'JllYo.k: W.w.
& Weiner-Davis, M B.ief the.apv: Fo No.ton, 1974
cusedsolution developnent Fonilr Prc' 11. Weallmd, J., Fisch, R, Watzlawick,P., &
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lem resolution. adntly Fo.ers 13. 141
5- Fisch, R., Weakland, J., & Segal, L. ?he
focr;cs ol cnonse.San Francisco:Jossev'
12- World Heslth Organi,zationlnternatiandl
Ctassifi.cation of Dise$es (ICD's)
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Psychiairy 2& 5ffi2, 1960. Manusc pt received Novembe. 6, 1986; revi_
?. Ludewig, K., Schwar,, R., & Kowerk, H. sio.s subnitt€d March 3 and Decenber 31'
Systen;scheTherapie nit Familien von 198?;acceptedSept€nber 16.1988.

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