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The Therapeutic System as Viewed by

Depressive Inpatients and Outcome: An


Expanded Study
STEFAN PRIEBE, M.D., Diplom.-Psychologistt
WILFRIED POMMERIEN, M.D.t

In an expansion of a previous study, we been developed (Coyne & Segal, 1982;


examined in which way depressive inpa- Fisch, Weakland, & Segal, 1982;
tients' views of psychiatrists' and signifi- Watzlawick, Weakland, & Fisch, 1974;
cant others' attitudes toward the severity of Weakland, Fisch, Watzlawick, & Bodin,
their illness were related to outcome. 1974). A central principle of brief therapy
Fifty-six patients were asked a two-part is that one evaluates which solutions have
question- "Who regards your illness as so far been attempted for the patient's
being more severe: (a) you or your signifi- problem, and then to try a different
cant others; (b) you or your psychiatrist?" solution in therapy. That is, one tries
Two subsamples of patients were identified: solutions that are different from or even
those who viewed the psychiatrists' and the opposite of what has already been
significant others' attitudes as similar and tried, for instance, by patient's significant
those who viewed them as dissimilar. Both others. Applying this principle to basic
groups showed
, substantial and significant attitudes toward a patient's illness, it may
improvement during hospital treatment; be hypothesized that, in therapy, patients
but the group that viewed the attitudes should experience ~mattitude toward their
held bypsychiatrists and significant others illness that is different from the one they
as dissimilar had significantly fewer de- are used to from their significant others.
pressive symptoms by the end of a 3-month Thus, patients who view their therapists'
followup period. The findings were consis- attitude to their illness as different from
tent with those of the original study, and their significant others' attitude, should
with the hypothesis as derived from the benefit more from therapy than those who
Mental Research Institute brief therapy view therapists' and significant others'
principles. attitudes as similar. In a simplified fash-
Fam Proc 31:433-439, 1992 io~, t?is hypothesis,. referring to a general
prmcIple of MRI brief therapy and not to
specific therapeutic interventions, was
T the Mental Research Institute (MRI) tested in hospital treatment of depressive

;'
A in Palo Alto, an Ericksonian-based patients in a previous study (Priebe, 1989).
and solution-oriented brief therapy has Forty-one depressive inpatients were
asked a two-part question-"Who regards
t Department of Social Psychiatry, Freie Univer- your illness as being more severe: (a) signif-
sitiit Berlin, Platanenallee 19, 1000 Berlin 19, icant others or you yourself (or is there no
Germany. difference); and (b) the psychiatrist or you
433
0014-7370/92/3104-0433/$02.00/0 @ 1992 Family Process, Inc.
434 / FAMILY PROCESS

yourself (or is there no difference)?" Two ratings the Von Zerssen Depression Scale
subsamples of patients were identified: 26 (DS) and a visual analogue scale (VAS-
patients viewed psychiatrists' and signifi- extreme points: 0 = "my condition is gen-
cant others' attitudes toward the illness as erallygood," 100 = "myconditionisgener-
similar ("equally structured systems") and ally bad") were used. (See Aitkin, 1969,
15 patients viewed them as dissimilar ("dif- and Bond & Lader, 1974, for studies using
ferently structured systems"). Both groups the VAS). The same clinical and self-
did not differ in treatment variables that ratings were made 3 months after dis-
were recorded in the first study. They charge. This application of standardized
showed equal and significant improvement rating scales to assess outcome after the
during hospital treatment; but the group followup phase was different from the
that viewed attitudes held by psychiatrists method used in the original study. In that
and significant others as dissimilar more study, after followup, patients just made a
often reported improvement within a 3- to statement as to whether their condition
4-month followup after discharge. The re- was generally better than, equal to, or
sults from the first study were regarded as worse than at discharge.
being consistent with the hypothesis. How- Patients were asked the same two-part
ever, one had to be cautious about the question, as in the original study, by an
findings since they were the result of a interviewer not otherwise involved in ther-
preliminary study. apy. If required, a short explanation was
We now report an expanded study that given. Unlike the original study, patients
was carried out in the same setting, but
were asked not on the day after admission,
examined a larger sample and used more
but on the day before discharge. On the
established methods to assess outcome af-
day after admission, patients' views of the
ter discharge. Like the original study, this
psychiatrist and his or her attitudes were
expanded study was not intended to inves-
based upon the experience of only one
tigate effects of properly administered brief
intensive interview. At discharge, patients
therapy, but to analyze therapeutic sys-
had experienced their psychiatrist in many,
tems in cQnventional psychiatry according
usually daily, contacts during the entire
to principles of brief therapy . We tested
whether the structure of the therapeutic period of hospital treatment. Therefore,
system was associated with outcome. patients' statements at discharge were
likely to be more reliable than on the day
METHOD after admission.
AJI patients were admitted to a moder- According to their answers, two subsam-
ately sized psychiatric university hospital, pIes of patients were formed: one group
and suffered from a depressive syndrome. that viewed attitudes of significant others
Inclusion criterion was a score on the Von and psychiatrists as being similar, and the
Zerssen (1986) Depression Scale DS + other group that did not. In the first group
DS' > 24. Only patients with organic or were those patients who stated that both
schizophrenic formal thought disturbances psychiatrists and significant others re-
were excluded in order to avoid a priori garded their illness as being more, equally,
restrictions on the basis of conventional or less severe than they did themselves. In
psychiatric criteria, such as formal diagno- the second group were those patients who
sis. Depressive symptoms were assessed at viewed the attitudes of psychiatrists and
the beginning and end of inpatient treat- significant others as being different, regard-
ment. For clinical ratings the Hamilton less of the kind of difference. The first
(1960) Depression Scale (HAMD), for self- group, therefore, viewed the therapeutic
PRIEBE and POMMERIEN / 435
system-consisting of patient, significant mostly eclectic. During followup, 37 pa-
others, and psychiatrist-as equally struc- tients were regularly seen by a psychia-
tured; the second group viewed it as differ- trist, 37 also took some psychotropic medi-
ently structured, according to the first cation, and 8 were in psychotherapy.
study's definition. These two groups were
compared in outcome during hospital treat- Patients'Viewsof the TherapeuticSystem
ment and after a 3-month followup. How patients assessed the attitude of
psychiatrists and significant others toward
RESULTS the severity of the illness, as compared
Sampleand PsychiatricTreatments
with their own attitude, is summarized in
Table 1. Table 2 shows how these answers
Fifty-six patients (38 females, 18 males), to the two questions were related. Accord-
who were treated on six different wards, ing to the definition of the original study,
were examined. Their ages ranged from 21 40 patients viewed the therapeutic system
to 72 years (mean = 46, SD = 14.2). The as equally structured, and 16 as differently
primary psychiatric diagnoses, made by structured.
the clinicians according to ICD-9 classifica- The two groups did not significantly
tion (1977), were schizophrenia (n = 2), differ in sociodemographic data (gender,
endogenous depression (n = 15), depres- age, marital and occupational status), in
sion in bipolar affective psychosis (n = 4), psychiatric history (duration of illness and
paranoid syndromes (n = 2), anxiety states outpatient treatment, frequency of previ-
(n = 5), neurotic depression (n = 8), other ous hospitalizations, previous psychother-
neurotic (n = 3) and personality (n = 4) apy), nor in diagnostic classification (de-
disorders, alcohol dependence (n = 2), de- pression versus no depression). As for
pressive reaction (n = 10), and adjustment variables of inpatient treatment (ward as-
disorder (n = 1). In seven patients the signment, length of stay, medication, par-
secondary diagnosis was drug abuse or ticipation in group therapies) and outpa-
dependence. tient care after discharge (regularly seen
The patients were hospitalized from 4 to by psychiatrist, medication, psychother-
223 days (mean = 64, SD = 47.6). During apy, readmission), there were no signifi-
this time, 41 patients received antidepres- cant differences between the two subsam-
sives, 18 received neuroleptics, four re- pIes.
ceived benzodiazepines, and six received
lithium; nine patients received no medica- Outcome
tion. On an average, 1.6 different psycho- Figures 1-3 show HAMD-scores and
tropic drugs per patient were given during self-ratings on DS and on VAS for the two
hospitalization. Two patients received elec-
troconvulsive therapy. In addition to the TABLE1
ordinary ward program, 19 patients partic- Two-Part Question to Patients: Who Regards Your
ipated in occupational therapy, 11 patients Illness as More Severe?
in psychoanalytic group therapy, 13 pa-
(a) Significant others or yourself?
tients in a group for assertive and concen-
Significant others: 12
tration training, and 14 patients in music No difference: 20
therapy. The type and amount of individ- Myself 24
ual psychotherapeutic activities depended (b) Your psychiatrist or yourself?
on the nature and extent of the psychia- Psychiatrist 7
No difference: 23
trist's psychotherapeutic training and on
Myself 26
the ward's atmosphere and staff, and were

Fam. Proc., Vol. 31, December, 1992


436 / FAMILY PROCESS

TABLE2 DS + DS'
Relation of Different Answers on Two-Part Question:
Who Regards Your Illness as More Severe?
70
60
I 59.4
-+- Equally structured
-e- Differently struc.
(a): Significant others 50
or yourself?
40
No
Others difference Myself 30
(b): Psychiatrist
20
or yourself
Psychiatrist: 5* 1** 1** 10 16.0
No difference: 3** 16* 4**
Myself 4** 3** 19* 0
Admlsslonl Dlscbarge 2 Follow-up 3
*equally structured systems (n = 40)
**differently structured systems (n = 16)
I: n.s. 2: n.s. 3: t . 3.30; P ( 0.01

groups after admission, before discharge, FIG. 2. Von Zerssen Depression Scale self-ratings
and at 3-month followup. In the total for equally or differently structured patient groups
upon admission, before discharge, and at 3-month
sample, the reduction of symptoms during followup.
hospital treatment was significant on each
scale (t-tests for paired samples ranged
from t = 6.91 to t = 1l.63,p < .001). Dur- peutic approaches led to a marked improve-
ing followup, the entire sample did not ment on average.
change significantly. Subsequently, differ- Between the two groups there were no
ences between scores on day after admis- clear differences after admission in any
sion and those after followup were also sig- scale. Before discharge, patients within
nificant on each scale (t = 5.81 to t = 9.99, differently structured systems had signifi-
p < .001). Therefore, conventional psychi- cantly lower scores only in the HAMD.
atric treatment combining various thera- Within the followup period, patients who
viewed their therapeutic systems as equally
HAMD
VAS(General condlllon)
21.3 80 r 75.4
Equally structured
25 r *- 72.7 -+- Equally structured
20 DIUerenlly struc.
-a- Dlllerenlly struc.
60

15
10.9
40
10

5 20
5.3 21.9
4.6

0
Admission 1 Dlscbarge 2 Follow-up 3 o
Admlsslonl Discharge 2 Follow-up 3

1: n.s. 2: t . 2.35: p ( 0.05 3: t . 2.65; P ( 0.01

FIG. 1. Hamilton Depression Scale clinical ratings


1: n.s. 2: n.S. 3: t . 2.79; P ( 0.01

for equally or differently structured patient groups FIG. 3. Visual analogue scale self-ratings by equally
upon admission, before discharge, and at 3-month or differently structured patient groups upon admis-
followup. sion, before discharge, and at 3-month followup.
PRIEBE and POMMERIEN / 437
structured deteriorated, while those pa- scale and for each point of time. However,
tients who had been in differently struc- the change of symptoms over time was
tured systems improved on each scale. similar in all three subgroups, and no
This opposite tendency in symptom change group showed a significantly worse deterio-
leads to a substantially increased differ- ration after discharge than did the other
ence between the two groups at 3 months two groups.
after discharge, significant at a 1% level in DISCUSSION
each rating.
Partly during the hospital treatment The findings of this expanded study are
similar to those of the original study, and
itself, but particularly within the followup
consistent with the hypothesis as derived
period, patients within differently struc-
from MRI brief therapy principles. In
tured systems show a more positive change
contrast to the first study, the course of
in symptoms, so that they evidently had
symptoms within the followup period was
benefited more from hospital treatment as
now assessed by more exact, standardized,
a whole than did patients within equally and well-established methods. Thus, the
structured systems. This finding is sup-
results, that patients who view the thera-
ported by results of two-factorial analyses
peutic system as being differently struc-
of variance-the two factors being the tured benefit more from treatment by the
structure of the therapeutic system (as end of the followup period, seem to be
viewed by the patient) and point of time more reliable than those of the first study.
(admission, discharge, followup). In these It remains an open question whether
analyses, interactions, group (structure of clearer differences would have been found
the therapeutic system) X time, are statis- had shorter or longer followup periods
tically significant for scores on DS been studied. However, it should be taken
(F = 3.76, df = 2, p < .05) and on VAS into account that patients' views of the
(F = 3.66, df = 2, p < .05), but failed to therapeutic system were again assessed by
reach statistical significance for ratings on only one question. More detailed variables
HAMD. of interactions within the therapeutic
Fina1Iy, we were interested in whether system were not assessed. In the second
the less favorable course of symptoms in study, we did try to validate patient's
patients within equally structured systems statements about their views of attitudes
would be mainly attributable to subgroups within the therapeutic system and to
within that group. Therefore, we com- relate them to specific "attempted solu-
pared (1) patients who stated that both tions" by the psychiatrist and by signifi-
psychiatrist and significant others re- cant others (Priebe & Haug, 1992; Priebe,
garded their illness as being less severe Saupe, & Kuhn, 1991). Therefore, we
than they themselves did (n = 19 in the asked patients standardized, open ques-
lower right of Table 2), (2) those patients tions as to what solutions psychiatrists
who viewed both psychiatrist's and signifi- and significant others had tried and what
cant others' attitude as similar to their specific recommendations they had made.
own (n = 16 in the middle of Table 2), and However, patients' statements about at-
(3) those who believed that psychiatrist tempted solutions and recommendations
and significant others would regard their varied from very vague to extremely spe-
illness as more severe than they them- cific. Because these statements could not
selves did (n = 5 in the upper left of Table be sufficiently categorized, a satisfactory
2). The first group of patients tended to formation of subgroups (similar versus
have a higher degree of symptoms on each different solutions attempted) and further

Fam. Proc., Vol. 31, December, 1992


438 / FAMILY PROCESS

analysis were not possible. It remains attitudes, and influence patients' view of
unclear which actual interactions in the interactions between significant others and
family and in therapy affected the patients' themselves. When patients have returned
views, as assessed in this study, and how to living with their significant others after
those views develop and change over time. discharge, that changed view might result
Patients within equally or within differ- in altered interactions and lead to different
ently structured systems did not differ in behavior, better adaptation, and improve-
basic clinical and treatment data. In future ment. It is possible that, for this group of
studies, more detailed variables about the patients, their psychiatrists may have suc-
patients' history, about their interaction cessfully applied principles of MRI brief
with significant others, and about the ther- therapy without being aware of it. Other
apeutic relationship should be obtained in patients who do not perceive a new atti-
tude toward their illness by their psychia-
order to get a notion of what different
views of a therapeutic system are based on, trists also benefit markedly from conven-
tional hospital treatment, but they
and how they may be related to other
deteriorate when factors of inpatient treat-
treatment variables. So far, one can only
ment-such as institutional protection, ac-
speculate as to which therapeutic factors
tivation by staff, frequent contacts with
are associated with the patients' views of
fellow-patients and psychiatrists-are not
the therapeutic system, and which might effective any more, and when they experi-
account for the difference in outcome.
ence the same interaction with their signif-
The present study seems to provide sup- icant others as before admission. At fol-
port for some assumptions made in discus- lowup, the difference between the two
sion of the results of the original study. groups is of clinical relevance. Mean fol-
First, the attitude toward the severity of a lowup scores in patients having been in
patient's illness is a relevant feature of equally structured systems (HAMD-
many therapeutic systems; second, to some score> 10) usually indicate a need of fur-
extent it is possible to analyze the therapeu- ther psychiatric treatment, while-on the
tic system even when only three basic average and despite mild remaining symp-
components of it-patient, psychiatrist, toms-treatment success may be regarded
and significant others-are considered. In as satisfactory in the other group.
interpretation of the results, we suggested Of course, alternative models of explana-
an explanation in accord with MRI brief tion cannot be ruled out yet. For example,
therapy principles: while living with signif- the patients' perceptions of any difference
icant others, patients were exposed to a between other people's attitudes toward
certain attitude toward their illness. It is their illness might indicate a cognitive
this interaction with significant others in flexibility as a pre-condition for a better
which the disorder had developed and in outcome of therapy. Since the present study
which admission to a hospital was thought has been done in the same setting as the
necessary. During hospital treatment, some original one, the findings might depend on
patients, those within differently struc- factors in the specific setting and cannot
tured systems, experience a new attitude easily be generalized to other treatment
toward their illness. This new attitude is settings as yet.
presented by a specialist and is unlike the
CONCLUSIONS
attitude they were used to. This new expe-
rience may change the perception and eval- In both studies the simplification ofMRI
uation of their own and significant others' brief therapy principles and the categoriza-
PRIEBE and POMMERIEN / 439
tion of patients' views into two subgroups, (eds.), Handbook of interpersonal psychother-
based on a two-part question, may be seen apy. New York: Pergamon Press, 1982.
as inadequate to reflect the real complexity Fisch, R., Weakland, J.H., & Segal, L. (1982).
of human interactions. Simplification and The tactics of change: Doing therapy briefly.
San Francisco: Jossey-Bass.
categorization were applied to allow an Hamilton, M. A rating scale for depression
operationalized approach for investiga- (1960). Journal of Neurology, Neurosurgery,
tion. This approach is intended to produce and Psychiatry 23: 56-62.
empirical support for a hypothesis derived Priebe, S. (1989). Can patients' views of a
from systemic thinking, and-to some therapeutic system predict outcome? An
extent-to follow the rules of conven- empirical study with depressive patients.
tional, psychiatric empirical research in Family Process 28: 349-355.
order to improve the reputation of ap- _, & Haug, H.-J. (1992). Interactional
proaches based on systems theory in pattern in sleep deprivation therapy: An
psychiatry (Priebe & Haug, 1992; Priebe, empirical study. Journal of Nervous and
Mental Disease 180: 59-60.
Saupe, & Kuhn, 1991). That goal requires
_, Saupe, R., & Kuhn, S. (1991). Interac-
definition of hypotheses as well as inven-
tional guidelines for the therapeutic team in
tion, and further development of special treatment of chronic neurotic inpatients [in
and adequate methods for assessment. German]. Psychiatrische Praxis 18: 85-91.
Although the results might be interpreted von Zerssen, D. (1986). Clinical self-rating
as providing some empirical evidence of scales (CSr-S) of the Munich psychiatric
MRI brief therapy principles, the therapeu- information system (PsychIS, Miinchen) (pp.
tic consequences are limited. It still re- 270-303). In N. Sartorius & T.A. Ban (eds.),
mains open as to how far therapeutic Assessment of depression. Berlin: Springer-
decisions and interventions can influence Verlag.
patients' views, as tested in these studies Watzlawick, P., Weakland, J., & Fisch, R.
and as found to be associated with out- (1974). Change: Principles of problem forma-
come. tion and problem resolution. New York: W.W.
Norton.
Weakland, J.H., Fisch, R., Watzlawick, P., &
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Fam. Proc., Vol. 31, December, 1992