A study of the influence of attitude on the outcome of therapy in a captive population

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Content A STUDY OF THE INFLUENCE OF ATTITUDE ON THE
OUTCOME OF THERAPY IN A CAPTIVE POPULATION
by
Jan Celia Harrell
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Education)
June, 1978
UMI Number: DP24282
All rights reserved
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a note will indicate the deletion.
Dissertation Rubi 5h*nq
UMI DP24282
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
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U N IV E R S IT Y O F S O U T H E R N C A L IF O R N IA
THE G R A D U A T E S C H O O L
U N IV E R S IT Y P A R K
L O S A N G E L E S . C A L IF O R N IA 9 0 0 0 7
This dissertation, written by
Jan Celia Harrell
under the direction of h Dissertation Com
mittee, and approved by all its members, has
been presented to and accepted by The Graduate
School, in partial fulfillm ent of requirements of
the degree of
'Ph.D.
EoL
'iz
D O C T O R O F P H I L O S O P H Y
Deait
DISSERTATION COMMITTEE
TABLE OF CONTENTS
Page
LIST OF TABLES............................. iv
Chapter
I. INTRODUCTION..................... . .
Statement of the Problem
Purpose of the Study
Importance of the Study
Definitions of Terms
Organization of Remainder of
the Dissertation
II. REVIEW OF THE LITERATURE
Theoretical Considerations
Comparative Studies of Voluntary
and Nonvoluntary Clients
Positive Outcomes from Nonvoluntary
Client Status
Unsuccessful Outcomes from Nonvoluntary
Client Status
Positive Outcomes from Voluntary Client
Status
Comparison of Voluntary and Nonvoluntary
Treatment Programs
Summary
III. METHODOLOGY. ................................ 32
Research Design
Study Setting
Population Sample
Instrumentation
Procedures Followed
Statistical Analysis
Conceptual Assumptions
Methodological Assumptions
Limitations
IV. FINDINGS...................................... A 2
Results and Data Analysis
Summary and Interpretations
ii
Chapter Page
Y. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS. . . . 53
Summary of Procedures
Summary of Findings
Conclusions and Recommendations
REFERENCES............................................. 61
iii
LIST OF TABLES
Table Page
1. Distribution of Willingness Groups Among
Counselors...................................... 33
2* Means and Standard Deviations of the
"Total P" Score of the T.S.C.S. and of
the M.A.S.T. by Assigned Groups at an N
of 3 8 .......................................... 43
3. Means, Standard Deviations and t-Values
of Differences Between Pre- and Post-Scores
on the "Total P" Score of the T.S.C.S. and
on the M.A.S.T. by Assigned Groups............. 44
A. T-Values for Between Group Comparisons......... 45
5. Distribution of Subjects Among Willingness
Groups.......................................... 4?
iv
CHAPTER I
INTRODUCTION
This is an era of the individual* As in no other time
in history, the focus of man's concern is concentrated on
accepting and affirming both his own self and others'
selves. In a country born of the longing for freedom, the
rights of the individual have a long history of primacy.
The Declaration of Independence established as the very
basis and foundation of the break with England the inalien
able rights of men, "life, liberty and the pursuit of happi
ness." A predominant societal and political struggle in our
country has been to achieve the equality and rights of stig
matized segments of our citizenry, from Oriental Americans
to Black Americans to female Americans.
In this time of individuation, people are resistant to
being told by their government, church, schools and families
what to do. There is a widespread desire to be self-deter
mining. Yet despite this atmosphere, there is a paradoxical
attitude in our culture toward one stigmatized group - those
defined as mentally ill, or emotionally disturbed. There is
a tendency in our society to make counseling or psychother
apy mandatory for these people or to exert a "kindly pres
sure" to seek it. It is an accepted practice of many insti
1
tutions in our society, as the courts, prisons, schools and
mental hospitals to enforce mandatory therapy. Those la
beled emotionally disturbed have no choice about receiving
treatment; the Bill of Rights for them is denied.
This practice raises four issues of concern, the first
regarding the definition and origin of mental illness. Dr.
Benjamin Rush, the father of modern psychiatry, did not dis
cover, but rather defined and created mental illness. He
saw sanity as the "aptitude to judge things like other men
(andj insanity (asj a departure from this" (Rush, 19^8, pp.
3^8-351). The Public Health Service (1967. pp. 13^-135) in
a statement on mental health, described persons with disor
ders of the personality as being "ill primarily in terms of
society and the prevailing culture," thus defining noncon
formity as an illness. Here is another great paradox - that
while people struggle against determination by others, at
the same time they fear just those differences in others
which differentiate people as individuals.
The second issue is the legality of enforced counsel
ing, as it is in direct opposition to the right to be self
determining. If people limit themselves in the types of be
havior they consider "healthy" and "normal" and if it is be
lieved a healthy person behaves in these accepted ways, then
it is a short step to saying those who deviate from the dom
inant societal standard do not know and therefore cannot
protect their own best interests. Important is not the de-
viation from the norm, hut the significance society attachesj
to the deviation (Szasz, 1970). Benjamin Rush declared that
, f the absence of reason annuls a man's social compact, disen
franchises him, takes away testimony, morality..." (Rush,
19^8, pp. 3^8-351)* Rush believed this a part and conse
quence of "insanity." Yet it is individuals with power, not
styles of behavior, which impose legal limitations on other
men.
This raises the third issue - what is effective coun
seling, how can it be achieved, and who is to determine its
goals? A basic assumption underlying mandatory counseling
must be that without the volition of the client, it is pos
sible for him to have a "successful" counseling experience.
Nonvoluntary counseling rests on the medical model in which
the patient can be treated and cured by another, without an
investment of his own. Here again, it is often not the
client, but society via the therapist who determines what
the "cure" should be. Denying the idea that the individual
has created his life, identity and way of interacting for
the best of all possible reasons (Ofman, 197*0» the possi
bility of helping the client accept his preferred behavior
or life style, to value his individuality more than the dic
tates of others, simply does not occur to people following
the medical model (Szasz, 1970).
There are many parallels between nonvoluntary therapy,
especially when practiced in mental hospitals, as discussed
"by Goffman (1957)» and Chinese thought reform, as described
by Frank (1959)* In both, someone in distress must depend
on someone else for relief, and in both, the person is re
quired to examine and reformulate the meanings of his past.
Both use group and individual pressures to destroy the in
dividual's sense of identity and induce him to accept a new
one incorporating the attitudes and values of those who have
power over him. In both, the individual's environment is
completely controlled. He is taken away from his usual ac
tivities, divested of his usual means of personal identity,
as possessions, clothes, associates, and immersed in a to
tally different culture and environment. In both, the in
dividual feels himself to be completely in the power of the
staff. In both situations, the individual knows that he
will be released when his "captor" gets what he wants, but
he often is unclear about exactly what is wanted, and so
tends to scrutinize him carefully for clues. Frank points
out that the apparent ease with which such patients learn to
make statements in line with their therapist's expectations
indicates the extent to which they are motivated to win his
approval. He also comments that the most probable reason
for this behavior is their hope that he will relieve their
distress. Lastly, both the interrogator and the therapist
have the attitude that "we know best," that they are trying
to get the individual to discard his unhealthy ways in favor
of the healthier ones they offer.
5
In an outpatient nonvoluntary situation, Goffman points
out, the therapy continues until the therapist is satisfied,
or in other words, when the goals of the therapist, not of
the client, are met.
The last of the issues is that of the side effects, the
unintended learning, the metacommunication that is a part
and result of mandatory nonvoluntary therapy. The very con
cept of nonvoluntary therapy is a psychiatric disparagement
of human experiences and differences. It communicates that
there exists in reality a "correct" way to be, that there is
a standard outside of man, himself. It is an encouragement
for the individual to abnegate responsibility for himself,
to look instead to someone else to define for him what is
right and what is wrong - to live in Sartrean bad faith. It
invites the individual to accept the world as a "serious
world,” so structured that it demands a way of living which
is the right one (Barnes, 1965) • It communicates that the
individual is like an object which can be fixed up without
its volition. A behaviorist, deterministic view of man is
inseparable from the attitude that he is an object. This,
again, encourages the individual to escape his responsibil
ity for himself, and to turn to someone else to provide him
with a self-image. He is encouraged to structure his inner
life according to an outside picture, rather than living
from within outwards (Lawrence, 1963). By focusing on
change, society via the therapist affirms the deception (to
6
which the individual is also susceptible) that the indivi
dual is trapped in a position or way of being he should not |
j
be in (Ofman, 197*0* The assumption is that society/the
therapist knows what is right for him.
Statement of the Problem
Mandatory therapy has become an alternative form of
penalty for various offenses in our society. At the discre
tion of judges, parole officers, parents, spouses, an indi
vidual can be sentenced to terms of therapy or to commitment
in a mental institution. Rather than being sentenced to
punishment for crime, some individuals are treated as "sick"
or "disturbed. " One argument favoring this course of action
is that therapy is not perceived as an alternative by many
for dealing with their problems, and that they need to be
educated, exposed to the therapeutic experience, for soci
ety's and their own good. Very few studies, however, have
attempted to evaluate if, in fact, sentences of this nature
io fulfill their function and do benefit the individual and
his society. This research is designed to explore this
question in one such treatment center, for drivers convicted
of driving under the influence of alcohol and suspected of
having an emotional disturbance - alcoholism.
Purpose of the Study
This study was designed to explore the contradictions
inherent in the philosophy and practice of mandatory therapy
7
and counseling: to discern the effect of the degree of
l
client voluntariness on treatment outcome; to evaluate if j
therapy with high degree nonvoluntary clients is a worth
while treatment procedure.
Importance of the Study
Willingness to engage in counseling is assumed to some
degree by almost every theoretical school, from Freudian to
existential. Despite this, people are continually being re
quired to participate in therapy.
Scott and Wertheimer (1962) suggest that the research
attitude of a practitioner should require him to assess the
truth or falsehood of every important principle he uses.
With mandatory therapy affecting so many people in our soci
ety, it seems imperative to investigate further the differ
ential outcomes of voluntary and nonvoluntary therapy, to
see if it indeed has the effect desired. A study needs to
be done to directly compare similar populations, one wishing
to engage in counseling, the other not wishing to engage in
counseling.
Definitions of Terms
Mandatory - subject is assigned to the therapeutic
program by the Los Angeles County Court; concept
that therapy rests on the medical model that a
subject can be treated by another without an in
vestment of his own.
8l
!
2. Degree of voluntariness/willingness - determined by
subject’s self-assignment on a scale from one to
seven, and by the clinician’s evaluation at the in
take interview; amount of desire to enter therapy.
3* Degree of self-esteem - characteristics represented
by the ’ ’ Total P” score on the Tennessee Self Con
cept Scale (T.S.C.S.).
4. Change - positive or negative differences in self
esteem as measured by the T.S.C.S., and in behav
ioral indices, as measured by the Michigan Alcohol
ism Screening Test (M.A.S.T.).
Organization of Remainder of the Dissertation
This chapter has introduced the study by discussing the
background of the problem, the statement of the problem, the
purpose of the study and the importance of the study.
Chapter II reviews the literature in the areas of the
oretical considerations and studies of voluntary and nonvol
untary clients.
Chapter III explicates the methodology used in this
study: instrumentation, methods, procedures, conceptual and
methodological assumptions, and limitations.
Chapter IV presents the findings of this study together
with analysis and interpretations.
Chapter V presents, in addition to a summary of the
procedures and the findings, conclusions and recommendations.
CHAPTER II
REVIEW OF THE LITERATURE
Theoretical Considerations
The authors of the theoretical articles were in agree
ment that the client must perceive himself as being in need
of help if therapy is to be successful. Two authors sug
gested that the client need not, at the beginning of ther
apy, feel motivation for change, that this can be developed
as therapy proceeds. One author suggested that there is no
such thing as an unmotivated client, that rather there may
be a discrepancy between the goals of the client and of the
therapist.
As early as 1936, Kubie addressed the issue of counsel
ing success depending on the cooperation and willingness of
the client. Unless the client perceives himself as needing
help, he will only go through the motions of treatment.
Wallerstein and Robbins (1956) found that a motivation
for change was among the variables most relevant to the
treatment outcome. The client, himself, must desire the
goals of therapy if those goals are to be reached.
Combs and Snygg (1959) suggested that the client must
himself perceive the need for change to increase the likeli
hood of change. They declared that there must be a stimulus
9
from within or without, the impingement of a new feeling or
experience, a disturbance or change in their internal or ex
ternal environment. They also suggested that this can occur
by the individual being confronted with inconsistencies,
discrepancies or questions about his way of looking at him
self or his environment. They found three factors to be
pivotal in determining the possibility of change occurring.
The first is the place of the new idea in the present organ
ization of the client's self, finding that more resistant to
change are those concepts most central in that organization.
The second concerns the relationship of the new idea to the
basic needs of the client, with change occurring most easily
when the client does not feel the need to defend himself.
The last factor is the clarity of the experience of the new
idea; the self-perception is more likely to result in
changes if the experience is vivid.
Ends and Page (1959) posited the hypothesis that the
need for therapy and the desire for change via therapy do
not necessarily have to be understood or accepted by the
client at the onset of therapy, but can develop as therapy
proceeds.
Frank (1959) found that the people whose values were
such that the goals and methods of psychotherapy made sense
to them were more likely to remain in treatment, with the
degree of their distress being the most important determi
nant of their faith in the therapy. Therefore, people who
n j
perceive themselves to he in need of therapy, as evidenced
by their perceived discomfort, are more willing to be in
therapy. This type of client will be more likely to be an
active participant in the therapy, thus committing himself
to change, and lessening the mobilization of resistances,
for he is working towards his own goals.
Patterson (1964) stressed that it is the responsibility
of the therapist to provide the client with opportunities to
accept and to use the counseling relationship; if the client
does not, it should not be forced upon him. He discouraged
the use of pressure, coercion and threats, for they lessen
the possibility of a future acceptance of therapy. He
thinks the belief that these devices are motivating is
false, finding, instead, that the absence of threat is the
prime condition for change. Patterson claimed that there is
no such thing as an unmotivated person, but rather that
there may be a discrepancy between the goals of the client
and those of the therapist or others concerned with the
client. The client*s motivation is always in terms of his
self-concept, the organization of percepts about the self,
which influences the perceptions of and attitudes about the
world. Patterson neglected the concept of the client seek
ing relief from distress in his discussion of motivation.
Meltzoff and Kornreich (1970) thought it axiomatic that
the individual must be motivated for therapy and want to
change if any change is to take place. They see psychother-
12
apy as a dynamic process in which the client willingly takes
an active role, rather than as a process in which he enduresj
something being done to him whether or not he desires it.
They did find, however, that initial motivation is not ab
solutely a necessary requirement for improvement. Defining
"well-motivated" as referring not only to a desire to change
but also to an implied desire to change in ways congruent
with the goals of the therapist, they found that it is just
as possible for highly motivated patients to lose their in
terest and willingness in therapy after their first experi
ence, as it is for poorly motivated patients to increase
their desire for therapy.
In discussing therapeutic factors in therapy, Frank
(1971) emphasized that if a client distrusts his therapist,
he will not accept the therapeutic rationale or listen to
the information he receives, and he is unlikely to gain hope
or experience success. Frank feels that strengthening the
individual's expectation of help is a common feature of all
therapeutic approaches. If the individual does not have
this expectation, therapy will be of little use to him.
Antonelli (1971) cautioned that the therapist must try
to understand the factors influencing the patient to seek
help. If the patient enters therapy due to situational
pressures, as from a court, he cannot benefit from therapy.
Appelbaum (1972) examined two basic types of client mo
tivation j the motivation to come to psychotherapy, and the
motivation to continue treatment. Assuming voluntariness on
the part of the client, she then considered what is neces
sary to stay and work in therapy, stressing that the client
must have a capacity for being interested in someone else's
feelings towards him, and that the client must not be fear
ful or suspicious about the therapist's motives for listen
ing to him. It is also important for the client not to feel
contemptuous towards the therapist.
Strupp (1973) defined client willingness, in a more
Freudian framework, as being the client's openness and re
ceptiveness. He found psychotherapy to be potentially of
use to the client when the client is responsive to "parental
type influences," but to be "essentially futile where such
receptivity has either never existed or has been severely
frustrated."
Three factors of therapeutic success were postulated by
Senior and Smith (1973)* They saw the accuracy of the diag
nosis and the appropriateness of the therapy as being limit
ed by the third factor, the cooperation of the patient.
This cooperation, they have found, is significant in deter
mining whether or not the individual will benefit from the
therapy he receives.
Comparative Studies of Voluntary and Nonvoluntary Clients
Two of the three authors studying characteristics of
self- versus other-referred clients found that the self-
referred tended to have a more positive self-image and______
m
perception and expectation of counseling. One author found
basically no differences between them.
Grant (1962) gathered data to compare the personality
characteristics of clients who are self-referred and clients
who are other-referred to a counseling center. He gathered
all of his information prior to the clients' contact with
the counselor, and did find some distinct differences.
Self-referred clients had more positive perceptions of and
expectations about counseling than did other-referred
clients. This was true for total group comparisons and for
females, but not for males alone. Self-referred clients
also see their problems more in internal terms. This was
true for total group comparisons and for males, but not for
females, alone. Although he hypothesized that self-referred
clients would be less guarded, less hostile and less defer
ent due to their desire for counseling, Grant did not find
this to be true. The author looked at variables relevant to
the therapeutic situation. The study had a limited design,
as it only looked at characteristics of clients, not the
effect of these characteristics on the therapeutic process
and outcome.
In order to provide a firmer basis for a decision to
use either voluntary or involuntary counseling at a junior
college, Anderson (1969) designed a study to compare and
describe characteristics of voluntary and involuntary cli
ents. His basic hypothesis was that there would be found no
15
significant differences in the characteristics of the two
types of clients. In reviewing 537 clients, he found two
basic differences* involuntary clients had higher scores on
the Nelson-Denny Reading Test, and voluntary clients had a
greater desire for counseling on academic or personal ad
justment problems. No baseline data was obtained to compare,
for example, intelligence or attitudes towards counseling.
Anderson found that in his study the voluntary and involun
tary clients appeared to be more alike than different, and
concluded that the choice of establishing either a referral
system or a voluntary counseling center would be an arbi
trary decision to be based on specific goals or philoso
phies. Both the milieu and the instrumentation of this
study, by their academic nature, limit the study's generali-
zability.
Schumaker (1970) studied the distinguishing character
istics of adult males who voluntarily seek career counsel
ing. Comparing them to a general college population, he
found the study population rated themselves higher on their
self-concepts, acceptance of self and ideal self. No effort
was made to control for differences in the subjects due to
maturation.
Positive Outcomes From Nonvoluntary Client Status
Six authors found positive effects resulting from non
voluntary counseling. Several found that nonvoluntary cli
ents made greater gains than those who did not participate
16
at all in counseling. An advantage pointed out of nonvolun
tary counseling was that it gives help to some people, who |
i
for varying reasons, may not want to seek it directly.
In 1955» Harris, Firestone and Wagner found that non
voluntary psychotherapy with army recruits who had a history
of enuresis was instrumental in reducing the number of ad
missions to the army psychiatric ward. The subjects in the
control group had only the regular entry screening generally
given recruits. The design was simple and the results
straightforward.
Imber, Frank, Gliedman, Nash and Stone (1956) studied
57 outpatients assigned to therapeutic treatment in order to
determine the effects of suggestibility on the acceptance of
psychotherapy. They found that therapy can be beneficial
even though an individual may not have sought it on his own
desire. If he is responsive to suggestion and, especially,
if he is susceptible to the influence of an authority, he
will likely accept therapy if it is recommended by a pro
fessional expert, his doctor. Although unusual, the study
was well designed and analyzed.
Gliedman, Stone, Frank, Nash and Imber (1957) made
another study of the progress of 91 outpatients in a commun
ity clinic. They found two types of expressed incentives
for seeking counseling. Type A were reasons congruent with
expectations of therapists, the traditional motivations for
seeking treatment! relief of emotional distress, improvement
it]
I
of interpersonal relationships, increase of self-awareness |
and personality growth. Type B were reasons not congruent !
!
with the expectations of therapists: situational or environ-j
mental pressures. Approximately two-thirds of the research
population were Type B. These patients stayed for about the
same number of sessions as the Type A patients. Types A and
B patients were found to have improved comparably on the two
criteria employed, measures of discomfort and of social in
effectiveness. The authors suggested a possible explanation
for this. In our culture, there is an emphasis placed on
independence and self-reliance. Seeking therapy, admitting
the need for help, may jeopardize an individual's self
esteem. Possibly, Type B patients assumed their attitudes
as a self-protective measure. Although studying a limited
and unconfirmed aspect of therapeutic initiation, the study
was a worthwhile examination of the relationship between
outcome and initial attitude of the client.
Wolk (1963) found that individuals in nonvoluntary
therapy made greater changes than did individuals not enga
ging in therapeutic treatment. Men referred to group ther
apy because of poor institutional adjustment or in order to
deter potential or future anti-social behavior tended to
make a better adjustment to the institution than did men not
receiving therapy. This study is limited by having the sole
criteria of success adjustment to the institution which
sponsored the groups.
Glasser (1965). in describing his work with delinquent |
girls at the Ventura School for Girls, and the program at I
i
the Veterans Administration Neuropsychiatric Hospital in Losj
i
Angeles found that nonvoluntary therapy can succeed if the
therapist can instill hope and values in the patient. He
believes reality therapy works because of its premises. The
therapist is involved with the patient, so the patient can
face reality and see how his behavior is unrealistic. The
therapist must reject the unrealistic behavior but still
accept the patient and maintain involvement. It is the role
of the therapist to teach the patient better ways within the
confines of reality to fulfill his needs. Glasser quoted
Mainord (1962) as similarly finding that reality therapy
seems to work because it gives the patient hope. Crediting
involvement with being the key to producing results through
nonvoluntary therapy, Glasser believes that once it is
established, even the most resistant patient will stop
defending his irresponsible behavior rather than have to
leave therapy.
Sviland (1972), in working with heroin addicts, found a
program of nonvoluntary psychotherapy to be highly effective,
One hundred and seventeen heroin addicts were involved in a
nine month rehabilitation program. The addicts met daily
in mandatory inpatient psychotherapy groups which had limit
ed goals. Although the addicts were initially hostile and
negative to the group, she found that their therapy-resist
19,
ant messages could be worked through. The addicts had the j
t
attitude that they had no problems and were only there for ]
methadone, which had, as its price, psychotherapy; most
thought therapy was useless. Sviland saw the addicts as
resistant to insight formations into the bases of their ad
diction, and angry at society for viewing them as psycho
logically disturbed. This program resulted in less than ten
percent of the addicts returning to heroin addiction at the
end of the program.
The results of Glasser and Sviland must be evaluated
with consideration of Frank’s (1959) research on Chinese
thought reform and the effect of total milieu control
(Goffman, 1957).
TTnPinfirAflPsful Outcomes From Nonvoluntarv Client Status
Three studies found no measurable differences in sub
jects as a result of counseling. One study showed that sub
jects who participated in an activity group actually had
more improvement than those in a therapy group. Another
study consistently found involuntary admission related to
schizophrenic patients who did not improve. One study dis
cussed the complete failure of a program with nonvoluntary
participants.
Ankler and Walsh (1961) studied the effects on chronic
schizophrenics of nonvoluntary participation in group ther
apy and/or a special activity group, dramatics. The study
’was designed to study the effects of these therapies com
bined with the effect of group homogeneity, Although they
hypothesized significant improvements in behavioral adjust
ments resulting from all treatment groups, they found that
only one, the activity group, actually produced positive
significant changes. In this situation of no choice, the
activity group proved more effective than therapy on mea
sures of behavioral improvement. The staff had minimal con
tact in the activity groups, as compared to the constant
contact occurring in the therapy groups, where although the
atmosphere was permissive, designed to promote a feeling of
"belongingness,” not as much improvement was evidenced. No
attempt was made to isolate variables contributing to the
success of the activity group.
Kingsley and Scheller (1966) reported on an attempt to
facilitate the adjustment of transfer students to a general
college by the use of individual and group forced counsel
ing. They found that short term (six sessions) forced
counseling was ineffective in dealing with problems of un
derachievement# There were no significant differences among
the groups, and no significant long range effects. The
length of treatment time limits the generalizability of this
study.
Brown, Lowinger and Tsao (1970) analyzed the records of
psychiatric hospital patients in order to determine the
characteristics of schizophrenic patients who failed to
21]
I
I
improve during the period of their hospitalization. They |
scrutinized the records of 3^9 schizophrenic patients who
had used the hospital in a five year period. Two hundred
and sixty of the patients were considered improved, while
89 of them were discharged unimproved. Six characteristics
were found to be inconsistently associated with those
patients who did not improve: they were admitted involuntar
ily, were less educated, unmarried, from a lower social
class, had an insidious onset of their illness, and had an
unfavorable initial prognosis. The biggest problem of this
study was the lack of standardization procedures in the
original evaluation of who was schizophrenic and of who was
improved.
Felker (1970) studied the effect of forced counseling
on counselor trainee effectiveness. Thirty-two trainees
were matched into control and experimental groups on the
oasis of the O'Hern Test of Sensitivity. Those in the
experimental group had five sessions with professional
counselors or advanced doctoral students. Felker found that
there were no differences between the groups according to
the O'Hern Test of Sensitivity, client ratings, practicum
supervisor ratings and peer ratings. He concluded from his
study that a moderate number of forced counseling sessions
in which trainees assumed the role of client had little
observable effect on the counseling effectiveness of the
trainees. As with the Kingsley and Scheller study, the
22
length of treatment time is a drawback to the value of this
study.
Newmann and Tamerin (1971) were involved with a highly
successful voluntary rehabilitation program for alcoholics,
which was asked to expand its clientele to include a group
of adolescent drug addicts. Twenty-two addicts joined 55
alcoholics, 30f o of whom were adults, in participating in the
facility's program, The attempt was a fiasco, and the
authors attempted to analyze why. Comparing the character
istics, attitudes and basis for arrival of the two groups,
the authors found what seemed a perfect polarity. The alco
holic who did well was self-referred; the more the pressure
for referral resided within the individual, the greater the
likelihood of a successful rehabilitation. The addicts, on
the other hand, came because they were forced to by their
parents or relatives, or because by coming they would avoid
punishments or have court sentences postponed. The alco
holic who derived the most benefit from the program recog
nized his drinking as a serious problem, whereas the addict
neither accepted the "severity" nor "reality" of the problem
of drugs in general, nor recognized the relevance of the
problem to himself. Alcoholics had experienced discomfort
as a consequence of their drinking, while the addicts had
not suffered negative effects of their addiction; they were
not uncomfortable, their parents were. The alcoholic was
willing to change his life goals, his attitudes and orienta
23
tion, for he felt himself to be self-destructive. The
addict, on the other hand, had no interest in changing his
orientation, attitudes or drug taking behavior. The two
groups also had different attitudes towards the treatment
center. The alcoholics transferred to it their prior depen
dence on alcohol, and saw the therapists as their allies in
their struggle to change. The addicts had neither of these
feelings. To them, the treatment center was merely another
instrument of "the establishment”; they had no desire to
ally themselves with the therapists, for they had no wish to
change. The program did have success with some of the
addicts, but they had characteristics and attitudes like
those of the alcoholics. This study provided an excellent
opportunity to compare voluntary and nonvoluntary subjects
with the treatment variable held constant.
Bartels (1972) undertook a study to determine the rela
tionship of required counseling of freshman, college male
athletes to three criteria: their adjustment to school,
their acceptance of themselves and others, and their GPA.
Thirty-four subjects participated, 1? in a control group, 17
in the treatment group, which had a minimum of ten sessions
with experienced therapists. Bartels found no difference
between the groups in their conception of their physical,
family or social selves, or in their level of identity, self-
satisfaction, behavior or self-criticism. There was no dif
ference in the three main criteria of the study. The control
~24j
group was shown to have a higher self-concept at the end of
the study, Bartels attempted no explanation for this find- !
ing. The treatment group thought counseling was meaningful
and many requested to continue after the termination of the
study. Bartels concluded that this resulted from some
aspect of required individual counseling not measured by the
three criteria of his study. The subjects in this study
were from a very limited population, and the instrumentation
was not well described.
Positive Outcomes From Voluntary Client Status
Two studies dealt with the expressed desire of indivi
duals for a voluntary counseling program in high schools.
The five other studies all showed positive results from
voluntary counseling in various circumstances.
Cabeen and Coleman (1961) reported on a successful
therapeutic program for institutionalized sex offenders.
The atmosphere of the entire institution was described as
therapeutic, with the inmates having some responsibility for
themselves, and with various activities for them to partici
pate in. The formal psychotherapy was conducted strictly on
a voluntary basis, with the inmates having to request to
participate in it. Their desire to enter therapy was taken
at fave value. Of 120 inmates who volunteered for therapy,
79 were deemed improved to the extent that they could be
returned to society. After an average period of 17 months,
only three of those 79 were arrested for a sex offense. A
statistically significant relationship was found between the
amount of formal therapy received and the improvement of thej
inmates. The lengthy follow-up period reinforces the posi
tive evaluation of the effectiveness of the treatment.
Feder (1962) explored the possibility that group ther
apy may promote therapeutic readiness and facilitate insti
tutional adjustment. The participation of all of the boys
in the study was voluntary. The boys in the experimental
group made significantly greater gains than those in the
control groups, becoming motivated within two months to
recognize their problems more freely and to develop readi
ness for the therapeutic process. Feder found the results
of his study to be consistant with Shoben*s (1953) concep
tion of therapy as involving learning over time, based on a
developing positive feeling towards the therapeutic exper
ience.
Cartwright and Lerner (1963) studied 28 self-referred
clients at a university counseling center to test the hy
pothesis that the degree of the client's need to change is
directly related to the improvement occurring with psycho
therapy. The hypothesis was strongly supported. There was
no attempt to correlate self-ratings of need to change with
an outside judgment.
Pine and Boy (1966) used a survey to determine high
school students' attitudes regarding voluntary versus re
quired counseling. They found that preferred a volun-
26!
tary system of counseling. One of the reasons given by many
of the 17$ preferring required counseling was that students
who did not feel comfortable asking for help could still
receive help. The authors postulated that an increasing
percentage of students will use the counseling service if it
is held in positive regard by the students, and according to
the degree of quality of the program. The authors raise two
issues* in required counseling, are the rights of the indi
vidual to maintain privacy of his inner world disregarded;
and in required counseling, whose needs are being met - the
students', counselors' or administration's? No treatment
was given to test the effect of therapy on change and on
attitudes, although relevant questions were raised about the
issue of nonvoluntary counseling.
McKenzie (19&9) also surveyed the preference of high
school students for voluntary or compulsory counseling. His
survey was taken after the high school had established and
maintained a self-referral counseling program for two years.
This program was based on the belief that individuals can
best determine their own needs. Seventy-eight percent of
the students preferred the voluntary system, expressing two
basic reasons: that compulsory counseling wastes the time of
many individuals; and that they did not like the pressure to
be counseled. McKenzie concluded that effective counseling
takes place because the client has indicated a desire for
change.
2?
Salomone (1970) wanted to determine if clients judged j
to be motivated are more likely to be successfully rehabili-j
i
tated than those judged unmotivated. He found some evidence
to support this idea - the files of the "motivated" were
more often closed with the client being employed. He also
found, however, that the client labeled "unmotivated" may
just have different goals than the therapist, which is an
important distinction to be made in evaluating any study
results.
The issue Redding (1971) explored was whether or not
counseling should be voluntary. He used as the measure of
the study outcome the completion of the educational goals of
the subjects. He concluded that self-referred students are
apparently more persistent in pursuing their educational
goals, and that they may have been more motivated and held
a more positive perception of counseling than other-referred
students, those who sought counseling at the suggestion of a
faculty member. He concluded that counseling seems to be
more beneficial in terms of educational achievement to stu
dents who utilize counseling services at their own initia
tive. A limitation to the study is that no personality com
parisons were made between subjects before therapy, so that
there is a question as to whether the results are due to the
therapeutic situation or to a function of the individual's
personality.
28
Comparison of Voluntary and Nonvoluntary Treatment Programs
Brown and Calia (1968) found no differences in the ratej
of return between clients who voluntarily initiated counsel-j
ing and those who were initially forced, but later given
their choice. Mandatory counseling was a greater threat for
the counselors than for the clients in this study. Counse
lors saw themselves responding less positively to nonvolun
tary clients, and thought that they were less helpful and
effective with them than they were with voluntary clients,
although the perceptions of the clients did not support
this. This study focused on academic counseling which con
sisted of only a one hour session. While the treatment is
too limited for wide generalization, the insight into the
reaction of the counselors indicates a worthwhile avenue for
future study.
One year after treatment ended, Smart (197*0 compared
treatment outcomes of mandatory ("constructive coercion")
versus voluntary therpeutic programs for alcoholics in two
treatment environments, an institution and an industry.
Contrary to the hypothesis that those who felt a high degree
of coercion would improve more than those who felt a lesser
degree of coercion, Smart found that voluntary patients in
both environments improved significantly more in overall
behavior? only in terms of drinking behavior did mandatory
and voluntary patients improve equally. Smart hypothesized
that the most valuable aspect of mandatory counseling is
-----------------------------------------------------------------------------i
29
that it provides early intervention into the problem, thus
increasing the probability of successful rehabilitation.
The amount of pressure to enter therapy was compared with
treatment outcome, but was not shown to be significant in
determining rehabilitation outcome. Smart stated that if a
nonvoluntary client is to improve, he must become voluntary
in the sense that he generates his own motivation indepen
dently of any pressures exerted on him. Smart concluded
that whereas a "voluntary” patient usually has decided to
alter his drinking behavior before he seeks help, there
probably are no patients who enter treatment completely vol
untarily, without pressure from family, friends or employer.
With the two treatments of such different natures, indivi
dual treatment variables could not be analyzed due to the
lack of controls. The study nonetheless offers theoretical
insights for future research.
Summary
This review of literature was conducted for the purpose
of comparing the outcomes of voluntary and nonvoluntary
counseling and therapy. Most theoretical statements pro
fessed the belief that the client must perceive himself as
needing help and must himself desire the goals of therapy if
those goals are to be attained. It was suggested by two
authors that the client need not, at the onset of therapy,
perceive the need for therapy, that this need can develop as
therapy proceeds.______________________________________________
In studying the characteristics of voluntary and non-
i
voluntary clients, a few basic differences were found. Vol-i
1
untary clients tended to have a more positive perception and
expectation of therapy, had a greater desire for counseling
on academic or personal adjustment problems, and tended to
rate themselves higher on their self-concept and acceptance
of self.
In the area of studies in which the subjects had no
choice about their participation in therapy, authors re
ported both positive and negative outcomes. Several authors
found that nonvoluntary clients made greater improvements
than did those who did not participate in therapy at all.
Glasser found nonvoluntary therapy to be highly effective
if the therapist can instill hope and values in the client,
and become personally involved with him. Gliedman, et al.
in two studies, formulated two possible explanations for
their findings that nonvoluntary clients made gains compar
able to voluntary clients. They suggested that a person
susceptible to the influence of an authority will likely
accept therapy and gain from it. They also thought an indi
vidual's nonvoluntary stance may protect him from a loss of
self-esteem. Three studies found no measurable differences
in subjects as a result of counseling, whereas one study
actually found those in therapy improved less than those in
a relatively independent activity group. Another study con
sistently found involuntary admission related to schizo-
31
phrenic patients who did not improve. Newmann and Tamarin
compared the highly successful alcoholic rehabilitation
program with the disastrous attempt to rehabilitate nonvol
untary drug addicts in the same program.
Studies in which the subjects had a choice about par
ticipation in therapy reported positive outcomes. Cabeen
and Coleman found a voluntary group therapy program to be
highly successful with institutionalized sex offenders.
The review of the literature on the outcomes of volun
tary and nonvoluntary counseling and therapy has shown that
either can produce positive results. A major weakness in
this area is a lack of studies directly comparing voluntary
e
and nonvoluntary attitudes towards therapy, and the result
ing outcomes of therapy.
CHAPTER III
METHODOLOGY
This chapter details the methodology of the study under
the following headings: (1) Research Design, (2) Study Set
ting, (3) Population Sample, (*0 Instrumentation, (5) Pro
cedures Followed, (6) Statistical Analysis, (7) Conceptual
Assumptions, (8) Methodological Assumptions and (9) Limita
tions.
Research Design
A simple pretest/posttest design was used. Three
experimental groups were established. The independent vari
able was the degree of willingness to be in counseling. The
dependent variables were the scores on two measures: the
Tennessee Self Concept Scale (T.S.C.S.) and the Michigan
Alcoholism Screening Test (M.A.S.T.).
Study Setting
The Southwest Drivers Benefits Program, located in
Torrance, California, is a center for the education and
counseling of persons engaged in the various stages of alco
holism. The facility consists of a suite of counseling
offices, with two large rooms for groups and classes. The
counselors are licensed as Marriage, Family and Child Coun-
32
33
selors, or have a Masters Degree in the field of counseling.
The philosophical orientation of the staff is grounded in
humanistic existentialism.
The clientele is referred to the program by the Los
Angeles County Municipal Courts as an alternative for the
usual penalty for drunk driving: a $315*50 fine for the
first offense? a $AA0.50 fine, a minimum jail sentence of
^8 hours and the loss of the driving license for one year
for the second offense. These penalties may be waived upon
successful completion of the program, and the charge will be
dropped from drunk to reckless driving.
Population Sample
The subjects in this study were the first 50 drivers
assigned to the Southwest Drivers Benefits Program during
the month of June, 1977* Twelve subjects were returned to
court for the resolution of their cases before they comple
ted the program. The remaining 38 consisted of first,
second and third offense drunk drivers, 37 men and one
woman, ages 19 through 57*
With the exception of the 19 year old, all subjects
had been previously convicted of one or more drunk or reck
less driving offenses. Nineteen of the subjects were un
skilled workers. Ten were skilled workers, five were pro
fessionals, and four were students. Fifteen subjects were
married, 1*1 separated or divorced, and 12 unmarried.
3^
Instrumentation
I
In order to assess the subjects' degree of willingness
to be in counseling, and the influence this willingness had
on the outcome of counseling, three measures were used.
A Likert-type self-assignment scale was developed by
the author to determine willingness of the subject to be
involved in the counseling program. On the basis of subject
response to the question "How do you feel about being in
this counseling program?” the sample was divided into three
groups of low, medium and high willingness to be in coun
seling. Those in the low group responded "very unhappy,"
"unhappy" or "somewhat unhappy." Those in the medium group
responded "neutral" or "not against it." Those in the high
willingness group responded "pleased" or "very pleased."
The "Total P" score of the T.S.C.S. was employed as a
measure of self-esteem. The Scale is comprised of 100
descriptive statements which the subject uses to portray
his/her self-image. The "Total P" score reflects the over
all level of self-esteem and consists of three components!
"Identity" (self-perception); "Self-satisfaction" (feelings
about the self-perception); and "Behavior" (perception of
behavior).
The Scale was originally normed against a broad sample
of 626 people from a wide range of geographical, social,
economic and educational backgrounds. Samples drawn from
different populations do not show appreciable differences in
35
scores. Test-retest reliability for the "Total P” score is
.92.
The Scale was validated in four areas. (1) Content
validity: each item was retained only if the judges agreed
unanimously that it was correctly classified. (2) Discrim
ination between groups; on the psychological health con
tinuum, the Scale has been found to differentiate patients,
non-patients and people characterized as high in personality
integration, and to discriminate among diagnostic psychia
tric categories. (3) Correlations with other measures! the
scores of the Scale and the Minnesota Multiphasic Personal
ity Inventory correlate in predicted ways. There were
clear nonlinear relationships between scores on the Scale
and on the Edwards Personality Preference Schedule. (^)
Personality changes under particular conditions: the Scale
has been shown sensitive to changes in self-concept as a
result of a significant experience (Ashcraft and Fitts,
196^) and to changes in degree of defensiveness (Runyan,
1958).
The M.A.S.T. was originally tested (Selzer, 1971) on
five different groups! hospitalized alcoholics, people con
victed of drunk and disorderly behavior, drivers whose
licenses were under review, and a control group. Validity
of the test was established by correlating test scores with
evidence of problem drinking obtained from medical facili
ties, social agencies, hospitals, the probation department
36
and arrest and traffic records, which included information
|
from other states. Although the questions have great face
validity, the author found evidence that alcoholics have
difficulty lying about their drinking behavior. He hypothe
sized that their dependency and need to receive help for
their alcoholism leads to at least occasional correct
responses to the series of questions relating to alcoholism.
In an earlier study (Selzer and Ehrlich, 1967) the M.A.S.T.
e identified 92 out of 99 hospitalized alcoholics who had been
asked to attempt to conceal their drinking problem when tak
ing the test. Later studies showed the M.A.S.T. to be valu
able in identifying alcoholics in the military (Favazza and
Pires, 197*0. in a psychiatric hospital (Moore, 1972), and
in a tuburcular population (Bailey et al, 1973)* The inter
nal consistency of the items was shown to be satisfactory
(Selzer et al, 1975; Zung and Gharalampous, 1975)*
Procedures Followed
For purposes of statistical analysis, a self-assignment
scale was used to assign subjects to one of three groups
which varied in degrees of willingness to participate in
counseling. In order to assess the validity of this self
assignment procedure, an experienced clinician gave his
evaluation, at the intake interview, of the subject's atti
tude towards entering counseling. From these evaluations,
another set of three groups was established.
In order to obtain baseline data for the subjects, the
37
T.S.C.S. and the M.A.S.T. were administered as pretests.
Each subject was randomly assigned to one of ten counselors,
according to clinic schedule and counselor availability, who
did not know to which group the subject belonged (single
blind design). Table 1 presents the distribution of will
ingness groups among counselors.
To account for its possible effects on subject willing
ness towards therapeutic participation, ignorance about
counseling was controlled for by having the subject once
again rate his degree of willingness toward being in coun
seling after eight weeks of treatment.
Individual hour-long counseling sessions were held
once weekly for 16 weeks for all subjects. All counseling
was insight oriented. At the end of 16 weeks, the subjects
were given the T.S.C.S. and the M.A.S.T. as posttests.
Statistical Analysis
The null hypotheses are presented below.
1. There will be no significant change on either the
"Total P" score of the T.S.C.S. or on the M.A.S.T.
within the sample as a whole.
2. There will be no significant change on either the ;
"Total P" score of the T.S.C.S. or on the M.A.S.T.
within each willingness group.
3. There will be no significant differences among
groups in the mean change score on the "Total P"
score of the T.S.C.S.
TABLE 1
Distribution of tAfillingness Groups
Among Counselors
Assignment
HML HML HML H3VLL HML HML HML HML HML HML
Other 310 130 020 222 152 112 110 Oil Oil 130
Self 022 202 002 222 008 202 020 002 002 022
“ I 2 3 5 5 5 7 5 9 10
Counselors
There will be no significant difference among
groups in the mean change score on the M.A.S.T.
5. There will be no significant difference in score
on either test between subjects who changed self
assignment at the eight week testing period enough
to enter a different willingness group, and those
who did not.
6. There will be no significant difference in composi
tion of willingness groups due to self- and other-
assignment procedures.
7. There will be no significant difference in pre-
and post-self-assignments to willingness groups.
T-tests were utilized for the above hypotheses to meas
ure the changes in self-esteem and overt behavior within
each group, and to measure the variability among groups.
39
This was done for both the classifications resulting from
subject self-assignment and from clinician assignment. An
alysis of variance was used to analyze correlation between
the two modes of assignment procedures and the scores on the
"Total P" score of the T.S.C.S. and on the M.A.S.T. for the
following hypothesis.
8. There will be no significant difference in the
ability of the self- or other-assignment procedures
to predict the mean changes in scores on either
test.
The null hypotheses were tested at a significance
level of of = .05.
Conceptual Assumptions
1. Indices of self-esteem can be modified by thera
peutic contact and thus could be demonstrated to be
subject to measurable change.
2. Indices of overt behavior can be modified by thera
peutic contact and thus could be demonstrated to be
subject to measurable change.
3. The degree of willingness to enter counseling has a
relationship to the amount of change an individual
will undergo.
Jf. The subjects in all three groups will be of compar
able socio-economic status, ethnic and cultural
backgrounds.
5. The measures detailed on the "Total P” score of the
T.S.C.S. accurately represent essential dimensions |
i
of self-esteem. !
i
i
The measures detailed on the M.A.S.T. accurately
represent essential dimensions of overt alcoholic
behavior.
Findings of this study will be applicable to other
mandatory therapeutic situations.
Methodological Assumptions
The research design, control procedures, mode of
group division and statistical analysis completed
were appropriate and adequate to permit the reali
zation of a satisfactory degree of internal valid
ity of the experiment.
The reliability and validity of the scores provided
by the T.S.C.S. and the M.A.S.T. were sufficient to
permit inferences regarding the relationship of
changes in self-esteem and overt behavior to will
ingness to participate in counseling.
The level of skill of counselors was essentially
equivalent.
The data of this study were obtained, recorded and
analyzed correctly.
Random assignments of subjects to counselors equal
ized basic differences among counselors and sub
jects .
5 l )
I
Limitations
The reliability and validity of the instruments j
I
used affected the outcomes of the study.
The sample size was limited to 50 subjects.
The sample was limited to a population which was
diagnosed as having problems related to excessive
drinking.
The impact of different counselors with varying de
grees of expertise upon different subjects may not
have been fully controlled for by randomization.
Randomization of counselor assignment may not have
completely controlled for differences in subject
age, sex, previous therapeutic experience, socio
economic status and previous number of drunk
driving offenses.
The 16 sessions of weekly counseling might not have
been sufficient either in length or intensity to
permit either short or long term changes in self
esteem or overt behavior.
CHAPTER IV
FINDINGS
This chapter reports the results of the statistical an
alysis used in examining the data to determine the effect of
willingness to be in therapy on the outcome of therapy.
Table 2 shows the means and standard deviations of the
"Total P" score of the Tennessee Self Concept Scale
(T.S.C.S.) and the Michigan Alcoholism Screening Test
(M.A.S.T.) by assigned groups at an "N" of 38.
Results and Data Analysis
Findings for the Sample as a Whole
A paired comparison t-test was performed on the means
of the differences between the pre- and posttests of the
"Total P" score of the T.S.C.S. and the M.A.S.T. for the
sample as a whole. The t-value for the T.S.C.S. was .42,
for the M.A.S.T., .04. No significant difference was found.
Therefore, the following null hypothesis was accepted:
There will be no significant change on
either the "Total P" score of the
T.S.C.S. or on the M.A.S.T. within the
sample as a whole.
Findings for Within Each Willingness Group
Paired comparison t-tests were performed on the means
of the differences between the pre- and posttest scores of
42
43]
TABLE 2
Means and Standard Deviations of the "Total P" Score
of the T.S.C.S. and of the M.A.S.T. by
Assigned Groups at an N of 38
Mean S.D.
Total P"
pre
post
difference
328.32
342.58
14.26
168.17
240.51
12.18
M.A.S.T.
pre
post
difference
17.11
16.42
.68
10.63
10.16
3.88
Other 3.68 1.32
Self
pre
post
difference
2.53
2.0 5
.4?
1.11
.90
.85
the T.S.C.S. and the M.A.S.T. for all willingness groups,
both self- and other-assigned. No significant difference
was found in any group. The t-values are reported in Table
3. In scoring the M.A.S.T., negative values resulted in
some posttests due to an increase in reported alcoholic
behaviors, thus accounting for the resulting low mean and
higher standard deviation found in Table 3« The following
null hypothesis was accepted:
44
There will be no significant differ
ence in the mean change of score on
either the ’ ’Total P” score of the
T.S.C.S. or on the M.A.S.T. within
each willingness group.
TABLE 3
Means, Standard Deviations and t-Values of
Differences Between Pre- and Post-Scores
on the ’ ’Total P” Score of the T.S.C.S.
and on the M.A.S.T. by Assigned Groups
"Total P"
Mean
Difference SD T N
Self H
13.15
12.02
.65
24
(pre) M 15.20
13-43 .41 10
L 18.50 15.02 .30 4
Other H 26,00
14.55 .93
8
M
13.50 12.76
.53
20
L 6.4
5.29
1.22 10
M.A.S.T.
Mean
Difference SD T N
Self H 1.00
4.31 .27
24
(pre) M -.40
3.85 .09
10
L
1.5 1.50 3.16 4
Other H
-3.5
4.78 .52 8
M 2.1 3.61
.79
20
L 1.2
3.69 .29
10
Comparisons Between Groups - the "Total P" Score of the
T.S.C.S.
Two sample t-tests were performed to compare mean
changes of scores on the "Total P" score of the T.S.C.S.
between different willingness groups. This was computed
45
for both the self- and other-assigned groups. There was a
!
trend in both sets of groups for the amount of change in thej
mean score to increase as the amount of willingness in
creased. The trend was slightly stronger in the other-
assigned groups, however, no significant differences were
found. T-values are reported in Table 4. The following
null hypothesis was accepted*
There will be no significant differ
ences among groups in the mean change
of score on the "Total P" score of the
T.S.C.S.
TABLE 4
T-Values for Between Group Comparisons
"Total P" M.A.S.T
Self High-med .43 .89
(pre) Med-low A O .94
High-low .80 .23
Other High-med 2.25 3*39
Med-low 1.68 .64
High-low 3*97 2.37
Comparisons Between Groups - the M.A.S.T.
Two sample t-tests were performed to compare mean
changes of scores on the M.A.S.T. between different willing
ness groups. This was computed for both the self- and
other-assigned groups. No significant differences were
found among the self-assigned groups. A significant differ
ence (p <.05) was found among the other-assigned groups*
46
but the direction was not consistent. The high willingness
group tended to reveal more alcoholic behaviors after ther
apy. T-values are reported in Table 4. Therefore, for the
self-assigned groups, the following null hypothesis was
accepted*
There will be no significant dif
ferences -among groups in the mean
change of score on the M.A.S.T.
This null hypothesis was rejected for the other-assigned
groups.
Comparisons Between Subjects Who Changed Self-Assignment and
Those Who Did Not
Only eight subjects changed their self-assignments
enough to enter a new willingness group. (Distribution of
subjects among groups is reported in Table 5'*) Four sub
jects moved from the medium willingness group to the high,
four from low to medium. Two sample t-tests were performed
to compare their scores on the "Total P" score of the
T.S.C.S. and on the M.A.S.T. with those subjects who did not
change willingness group assignment. No significant differ
ence in the scores was found. The t-value for the T.S.C.S.
was .391 f*or the M.A.S.T. it was 1.48. Therefore, the fol
lowing null hypothesis was accepted:
There will be no significant dif
ferences in scores on either test
between subjects who changed self
assignment at the eight week test
ing period enough to enter a dif
ferent willingness group, and those
who did not.
47
Comparison of Group Composition - Self- and Other Assign
ment Procedures I
i
j
A two sample t-test was performed to compare the dif
ferences in group composition due to different assignment
procedures. Distribution of subjects among groups is re
ported in Table 5* A significant difference was found; the
t-value was 4-. 4-5. The clinician tended to rate subject
willingness to be in counseling lower than did the subjects,
themselves. The following null hypothesis was rejected
(p <.005)*
There will be no significant dif
ferences in composition of willing
ness groups due to self- and other-
assignment procedures.
TABLE 5
Distribution of Subjects Among Willingness Groups
High Medium Low
Self Pre 24- 10 k
Post 30
8 0
Other 8 20 10
Comparisons of Group Composition - Pre- and Post-Self-
Assignment
A paired comparison t-test was performed to analyze
the differences between pre- and post-self-assignment to
willingness groups. The difference was found to be signif
icant (p^.005). The t-value was 3.23. Although only
48
eight subjects changed their self-assignments enough to en
ter a new willingness group, there was a tendency to move to
a higher self-evaluation of willingness, with only four sub
jects lowering their evaluations and ten subjects remaining
the same. The following null hypothesis was therefore re
jected*
There will be .no significant differ
ence in pre- and post-self-assign-
ments to willingness groups.
Findings for the Predictive Value of the Self- and Other-
Assignment Procedures
Analysis of variance was used to analyze the correla
tion between the two modes of assignment procedures and the
mean differences in scores on the "Total P" score of the
T.S.C.S. and on the M.A.S.T. Self-assignment was found to
be unrelated to changes in scores. The F ratio for the an
alysis was 105 for the M.A.S.T. and 2.28 for the T.S.C.S.
There was a significant correlation (p<.05) between
the mean change of scores on the "Total P" score of the
T.S.C.S. and the other-assignment procedure. The F ratio
for the analysis of variance was 8.17 for the M.A.S.T. and
8.32 for the T.S.C.S. The other-assignment procedure was
therefore found to be a better indicator of probable change
than the self-assignment procedure. The following null
hypothesis was therefore rejected*
There will be no significant differ
ence in the ability of the self- or
other assignment procedures to pre
dict the mean changes in scores on
I _______________ei th ertest. ____________________________________
^9
Summary and Interpretations
This chapter reported the findings of the statistical
analysis of the data in order to assess the effect of will
ingness to be in therapy on the outcomes of therapy.
T-tests were performed to compare the mean change of
score on the ' ’ Total P" score of the T.S.C.S. and on the
M.A.S.T. within the sample as a whole, within each group and
between groups, to compare the variation in group composi
tion due to different assignment procedures and due to the
effect of counseling.
A significant difference was found between the other-
assignment procedure and the mean change of scores on the
M.A.S.T., but the direction of change was not consistent.
The high and the low willingness groups tended to reveal
more alcoholic behaviors after participating in counseling
than they did when firsts entering the counseling program.
This might have been due, in part, to the fact that 21 of
the 25 items on the measure use the word "ever." Thus, even
had the subject ceased a particular behavior during the
treatment period, he would still have been instructed to
answer such a question in the affirmative if it had ever ap
plied to him. A second possible contributing factor might
have been the experience of counseling, itself. Ignorance
about counseling and discomfort or lack of trust in a new
situation might account for fewer alcoholic behaviors being
reported at the onset of the treatment program. A positive
50
counseling experience might have increased the possibility
that a subject would feel freer to reveal himself.
A significant difference was found between group compo
sition due to self- and other-assignment procedures. The
clinician tended to rate subject willingness to be in coun
seling lower than did the subjects themselves. This could,
again, have been due to the subject having been in a new,
possibly threatening environment, certainly an environment
he needed in order to avoid legal penalties. Also, no ob
jective standard definition of "willingness" was provided
and so each subject and the clinician judged willingness
from his own subjective assumptive base.
A significant difference was found in the mean change
of willingness group self-assignment. It is possible that
the same variable of ignorance about counseling, as pre
viously discussed, may have influenced the initial lower
evaluation of willingness to participate in counseling. It
is also possible that resistance or resentment about having
to be in counseling was lessened as a result of a positive
counseling experience.
Analysis of variance was used to analyze correlation
between the two modes of assignment procedures and the
scores on the "Total P" score of the T.S.C.S. and on the
M.A.S.T. to assess possible predictive value of the proce
dures. A significant correlation was found between the mean
change of scores on the "Total P" score of the T.S.C.S. and
51
on the M.A.S.T., and the other-assignment procedure. The
assumptive base of the clinician, in assigning subjects to
willingness groups, may have been grounded on previous ex
perience of what types of subjects are more successful in
counseling, in terms of objectively measured changes. This
may be a factor involved in the other-assignments having
more correlation than the self-assignments to mean changes
of scores.
No significance was found for the other comparisons,
although there was a trend, stronger in the other-assigned
groups, for the amount of change in the mean score of the
"Total P" score of the T.S.C.S. to increase as the amount
of willingness increased.
There are several factors which may account for the
lack of significant differences found. It is possible that
there may not have been enough differentiation among the
willingness groups. All subjects participated in the coun
seling program semi-voluntarily, it being the preferred al
ternative to legal prosecution. Comparing an absolutely
voluntary group with an absolutely mandatory group might
have yielded more differentiated results. There is a prob
lem, however, in this, also, for so many clients who come to
counseling voluntarily face many pressures from home or work
to do so. Likewise, many clients who are forced into a
counseling situation, adopt their nonvoluntary stance, as
Gliedman, et al. (1957) suggested, to protect their self
52
esteem. Thus, many subjective and situational factors are
involved in defining an individual as voluntary or nonvolun
tary.
Related to the issue of serai-voluntary participation in
counseling is the possibility that since even those in the
high willingness groups were assigned by the courst to the
counseling program, subjects may have thus had varying
amounts of resistance and resentment towards participating
in the program.
Another factor which may have influenced the attempt to
measure behavioral changes is the instrument used. Its
wording may limit its value to only diagnostic uses. Beha
vioral changes might have occurred which were not measured
by the M.A.S.T.
The final factor which may have influenced the results
of this study was the length of treatment time. It is pos
sible that the duration of the counseling experience was of
insufficient length to accomplish not only changes in self-
esteem and overt behavior, but also to establish an atmo
sphere of trust and to overcome ignorance and resentments
about counseling.
CHAPTER V
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
The purpose of this study was to determine the effect
of the degree of client voluntariness on the outcome of
therapeutic treatment. Methods of determining degree of
olient willingness were compared. A review of the litera
ture revealed that although positive results have occurred
from both voluntary and nonvoluntary therapy and counseling,
very few studies have been done directly comparing the treat
ment outcome of subjects with varying degrees of willingness
to be in therapy. Most theoretical statements suggested
that the client must perceive himself as needing help and
must himself desire the goals of therapy if those goals are
to be attained. Ends and Page (1959) suggested that the
iesire for therapy can develop as therapy proceeds, and need
not be present at the onset. Glasser (19&5) found nonvolun
tary therapy to be highly effective if the therapist can
instill hope and values in the client and become personally
Involved with him. Gliedman, et al. (1957) posited the view
that an individual's nonvoluntary stance may protect him
from a loss of self esteem.
This chapter presents, in addition to a summary of the
procedures and the findings, conclusions and implications,
53
54
as well as recommendations for further study.
Summary of Procedures
A simple pretest/posttest design was used to test the
following null hypotheses:
1. There will he no significant change on either the
"Total P" score of the Tennessee Self Concept Scale
(T.S.C.S.) or on the Michigan Alcoholism Screening
Test (M.A.S.T.) within the sample as a whole.
2. There will be no significant change on either the
"Total P" score of the T.S.C.S. or on the M.A.S.T.
within each willingness group.
3* There will be no significant differences among
groups in the mean change score on the "Total P"
score of the T.S.C.S.
4. There will be no significant differences among
groups in the mean change score on the M.A.S.T.
5. There will be no significant difference in score on
either test between subjects who changed self
assignment at the eight week testing period enough
to enter a different willingness group, and those
who did not.
6. There will be no significant difference in composi
tion of willingness groups due to self- and other-
assignment procedures.
7. There will be no significant difference in pre- and
_________post-self-assignments to willingness groups._______
55
T-tests were utilized for the above hypotheses to mea
sure the changes in self-esteem and overt behavior within
each group, and to measure the variability among groups.
This was done for both the classifications resulting from
subject self-assignment and from the clinician's assign
ments. Analysis of variance was used to analyze correlation
between the two modes of assignment procedures and test
scores for the following hypothesisi
8. There will be no significant difference in the
ability of the self- or the other-assignment pro
cedures to predict the mean changes in scores on
either test.
The null hypotheses were tested at a significance level
of a = .05.
The first 50 drivers assigned to the Southwest Drivers
Benefits Program in Torrance, California during the month of
June, 1977 were used as the subjects in the study. Twelve
subjects were returned to court before completion of the
program; the remaining 38 consisted of first, second and
third offense drunk drivers.
Three instruments were used in this study. A Likert-
type self-assignment scale was developed by the author to
determine willingness of the subjects to be involved in the
counseling program. The sample was divided into three
groups of high, medium and low willingness. The "Total P"
score of the T.S.C.S. was employed as a measure of self
56
esteem* The Scale has a test-retest reliability of .92 and
has been shown to discriminate changes in self-concept as a
result of a significant experience. The third instrument
was the M.A.S.T., a widely used behavioral measure.
At the intake interview, each subject and an experi
enced clinician independently assigned the subject to a
willingness group using the Likert-type scale. The T.S.C.S.
and the M.A.S.T. were given as pretests to all subjects, who
were then randomly assigned to counselors. To account for
its possible effects on subject willingness towards thera
peutic participation, ignorance about counseling was con
trolled for by having the subject once again rate his degree
of willingness towards being in counseling after eight weeks
of treatment. Individual hour-long counseling sessions were
held once weekly for 16 weeks for all subjects. All coun
seling was insight oriented. At the end of the 16 weeks,
all subjects were given the T.S.C.S. and the M.A.S.T. as
posttests.
Summary of Findings
T-tests were performed to compare the mean change of
scores on the "Total P" score of the T.S.C.S. and on the
M.A.S.T. within the sample as a whole, within each group and
between groups, and to compare the variation in group compo
sition due to different assignment procedures and due to the
effect of counseling. A significant difference was found
between the other-assignment procedure and the mean change
57
of scores on the M.A.S.T., but the direction of change was
not consistent. A significant difference was found in the
mean change of willingness group self-assignment. A signi
ficant difference was found between group composition due to
self- and other-assignment procedures.
Analysis of variance was used to analyze correlation
between the two modes of assignment procedures and the
scores on the "Total P” score of the T.S.C.S. and on the
M.A.S.T. to assess possible predictive value of the proce
dures. A significant correlation was found between the mean
change of scores on both instruments and the other-assign
ment procedure.
No significant differences were found for the other
comparisons, although there was a trend, stronger in the
other-assigned groups, for the amount of change in the mean
score of the "Total P” score of the T.S.C.S. to increase as
the amount of willingness increased.
Conclusions and Recommendations
The conclusions from this study are several. The self
perceived degree of willingness to be in counseling does not
have a significant effect on the outcome of counseling.
Client willingness, as evaluated by an experienced clinician,
can, however, be predictive of therapeutic outcome. Experi
ence in counseling, it was found, does have an influence on
the amount of willingness to participate in counseling. The
general cultural mythology of counseling being only for
5£
"sick” people or people who cannot "make it on their own”
may contribute to a general lower willingness to be in
counseling at the onset of treatment, as compared to the
higher estimation of willingness, after being in counseling.
Short-term counseling with alcoholics was shown to have
little effect on changes in self-esteem and overt behavior.
This study was one of very few to directly study the
effect of client willingness to be in therapy on the outcome
of therapy. Although no significance was found in the mean
change of scores on the measures of self-esteem, the tenden
cy for scores to increase, the predictive value of the
other's assessment of willingness in indicating probable
score changes, and the tendency towards the direct correla
tion of willingness and/test scores indicates the value of
replicating this study, with the possibility of a few
revisions or variations.
The duration of the study was relatively short-term.
It is possible that with more time in counseling, more
changes could have been discerned. Dr. Vernell Fox, direc
tor of the Long Beach General Hospital Alcoholic Program,
has stated that three years of treatment are necessary be
fore a significant change in an alcoholic's lifestyle will
occur. It is recommended that a long-term study be con
ducted, especially if an alcoholic population is used.
In this study, differing degrees of client willingness
were explored for their effect on the outcome of counseling
59
in a captive population. If a comparable design were used
with matched situations of voluntary and captive subjects, a
clearer picture of the effect of willingness on counseling
might be attained.
The use of population samples other than an addictive
one could be explored. Many other populations, as divorce
applicants and criminals, are assigned to counseling and
could be matched with voluntary clients.
Ignorance about counseling has been shown to be a fac
tor in the degree of willingness to be in counseling. In
this study, the other was a better predictor than the client
of outcome of counseling. A post-assignment by the other to
compared with the self-post-assignment might yield further
information about the value of enforcing mandatory counsel
ing, especially for high degree nonvoluntary clients. It
might be valuable to learn if, after an experience of coun
seling, self- and other-evaluations of willingness are more
in agreement.
Lastly, it is recommended that an instrument other than
the M.A.S.T. be found to measure overt behavioral change.
This study began the exploration of a crucial issue in
our culture - the benefit of mandatory therapy to the indi
vidual and to his society. Many questions are as yet unan
swered. If, as Sartre says, the only limit to one's free
dom is the freedom of other men (Barnes, 1959» P» 81), we
must continue to examine the current practice of mandatory
60
nonvoluntary therapy to see if it is indeed justified, con
sidering its ostensible results and the four issues raised
in the introduction of this work* the origin of the defini
tion of mental illness, the legality of forced therapy, the
true beneficiary of therapy, and the metacommunication
regarding the nature of man which such therapy imparts to
the "client."

62
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Asset Metadata

Creator Harrell, Jan Celia (author)

Core Title A study of the influence of attitude on the outcome of therapy in a captive population

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Degree Doctor of Philosophy

Degree Program Education

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, clinical

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Permanent Link (DOI) https://doi.org/10.25549/usctheses-c26-467356

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