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In a hospital setting, psychotherapy is usually offered to only a small proportion of patients. Because of the limitation of staff time, these patients are nearly always those who are motivated for psychotherapy, or who are in other ways good therapeutic "prospects." The rest of the patients have interpersonal contacts that are chiefly administrative.
This paper reports on a project specifically designed for "unmotivated" patients. Need for the project developed because in an earlier and concurrent research investigation [2] into psychotherapy with schizophrenics a difficult problem arose: how to initiate psychotherapy with patients who were "unmotivated," who, in fact, refused continuing contacts. Such patients could not be dropped from research without biasing the results. On the other hand, this unbiased selection of patients often brought about immediate failure. Patients would not willingly agree to further therapy interviews. Therefore therapeutic relationships with them could not get started. Therapists set aside hours in their schedules which were wasted in waiting, or, patients experienced pressure and coercion from a therapist to continue contacts perceived by them as undesirable or threatening.
The patient whose socio-economic background gives him no familiarity with psychotherapy, and whose emotional difficulty involves many experiences of hurtful interpersonal relationships, is not likely to understand or to welcome the pressureful and puzzling advances of a psychotherapist. Verbal explanations and introductions appeared to be of little help in the actual situation where the problem arose.
The usual procedure of initiating psychotherapy with these "unmotivated" patients involved much time and emotional effort, focused on the patient's unwillingness to continue the meetings. In some instances, contacts were permanently broken off before [Page 135] psychotherapy could begin. The present paper reports an experiment with a procedure of initiating psychotherapy, designed to overcome this difficulty.
Twenty-four patients were placed on one ward of a state hospital building. They were selected according to only two criteria: (a) their records did not indicate brain damage or mental defect; (b) the ward physician felt that they were not likely to be released or transferred in the foreseeable future. As a group, the patients had widely ranging degrees of reality contact. Some were sociable; others nearly mute and withdrawn. Many were actively hallucinating. All were in a building which houses patients considered too disturbed for open wards; and all had been transferred there relatively long before, from the admission and treatment wards. For the most part, the patients had already been given what a highly advanced, treatment-oriented and well-staffed hospital usually offers.
The therapists in the project represented somewhat different orientations, but shared some general attitudes and emphases. They all endeavored to understand the patients' experiences and feelings as they appear to the patients. Some therapists offered interpretations, but these were most often really personal expressions of those therapists, and occurred when the relationship had developed sufficiently so that the patients could recognize them as such. Attempts to evaluate, convince, or manipulate the patient were clearly contrary to the spirit and aim of the therapists. Each attempted to form a relationship between himself and the patient as the two real persons they were. Patients' confidences were respected and not passed on to members of the hospital staff or entered in the hospital records. Pressure on the patient to talk was minimal. The therapists attempted to welcome the patient's communications, whatever their form or content.
Eight psychotherapists [3] agreed to spend a total of about 13 hours a week on the ward. As a rule, each therapist spent two hours a week there. An office was available at the end of a long [Page 136] hall leading from the day room. For purposes of later analysis, all contacts in this office were recorded on a tape recorder visible to the patient. Patients were told that the therapists were engaged in research and that the recording would not be given to other hospital staff members. At the start of the project the patients were informed that they could meet with any or each of the therapists who would come to the ward.
In practice, the initiation of psychotherapy occurred in two ways: (a) The patient came into the office of his own accord (two patients out of the 24) or stood outside the office, tentatively making contact with the therapist as he went in and out (five patients); or (b) the therapist met patients in the day room or the hall. An interpersonal relationship in the latter case began by a meeting of eyes or by sitting down next to a patient, or standing next to him. The therapist might introduce himself and ask, "Would you come to the office to talk with me?" This invitation might be accepted or refused. Even when refusing the invitation, however, some patients seemed glad to converse where they sat or stood, and did so immediately and freely whenever they were approached.
Others would not answer or look up at all. The therapist might then remain for a few minutes or longer. Such a patient might, a few days later, indicate by word or gesture that he knew the therapist, sometimes that he was looking for and expecting the therapist. For some weeks a therapist and a patient might carry on a thin strand of relationship. For example, the therapist would spend a few minutes of each visit to the ward standing silently by a silent patient, perhaps saying, "I'd like to stand here with you. I'll leave if you want me to." There may be no response or a minimal response. Several therapists might continue tentative relationships with one patient, or one therapist might find himself in a deepening relationship with a patient whom none of the other therapists had met.
There was relatively little communication among the therapists. Each worked out somewhat individual ways of initating relationships with various patients.
As a group, judging from the verbally expressive patients in the day room, the patients' attitudes toward the therapy project at the beginning were negative. With the exception of two patients (who can be considered "motivated" at the start) no one came to the office directly, and completely of his own accord. Patients [Page 137] were frightened, silent, or politely avoided the therapists. When a therapist addressed the group as a whole with, "Who would like to talk with me?" there was either no response at all, or one of the two "motivated" patients would come to the office.
As time went on, one by one, individually and in individual ways, relationships were formed. (See the table.) At the time of writing (the fifth month) half or more of the patients have definite relationships with one or more therapists whom they often expect to meet in the therapy office.
Some of these relationships involve frequent, continuing meetings. Time pressure prevents other patients from being seen as frequently. Some therapists limit their meetings to 20 minutes with a given patient.
| Patients | Initial Status | Number of weeks from start of project to fifth recorded interview | Office contacts from start, June 27, 1959, to November 24, 1959. Number of recorded contacts in the therapy office. | Total hours spent by therapists (approx.) |
|---|---|---|---|---|
| A | motivated | 1 | 145 | .. |
| B | motivated | 1 | 41 | 130 |
| C | unmotivated | 5 | 49 | .. |
| D | " | 4 | 16 | .. |
| E | " | 7 | 16 | .. |
| F | " | 7 | 14 | .. |
| G | " | 6 | 14 | .. |
| H | " | 4 | 13 | .. |
| I | " | 5 | 9 | .. |
| J | " | 8 | 9 | .. |
| K | " | 7 | 7 | .. |
| L | " | 10 | 6 | .. |
| M | " | 5 | 6 | .. |
| N | " | 17 | 6 | .. |
| O | " | 15 | 6 | .. |
| P | " | 11 | 6 | .. |
| Q | " | .. | 4 | .. |
| R | " | .. | 3 | .. |
| S | " | .. | 2 | .. |
| T | " | .. | 2 | .. |
| U | " | .. | 2 | .. |
| V | " | .. | 2 | .. |
| W | " | .. | 1 | .. |
| X | " | .. | 1 | 120 |
Of the remaining patients, some are now engaged in the highly tentative, irregular, often silent but meaningful, interaction which characterized the earlier contacts with patients now being seen regularly. The patients as a whole range at present from engaging in activities that can be described as ongoing therapy to activities that still indicate a high degree of avoidance or fear of a relationship with any of the therapists.
With all but a few patients, however, the project has reached the stage where lack of motivation as the chief problem has given way to lack of time. Therapy is being continued, and is now raising new and different problems of procedure, time allotment, and evaluation of outcomes. These problems no longer concern lack of motivation and therefore fall outside the scope of this study.
The table shows the gradual development of contacts. It also shows that the total time spent with 22 "unmotivated" patients over the five-month period was less than the time spent with the two patients who were motivated from the beginning. The approximate figures of time distribution indicate that the work with the 22 unmotivated patients required a five-month average of only six hours per week. This figure was almost certainly smaller in the early stages of the project, and greater as relationships became established.
The procedure adopted in this project appears to have been successful in initiating continuing psychotherapy with patients who were "unmotivated," that is to say, who were passively neutral, or who avoided and were frightened of, or resistive to forming, therapeutic relationships. (All but two of the initial group may be described in this way.)
The procedure differed from the usual initiation of psychotherapy in the following ways:
A clinical procedure is presented to deal with the problem of initiating psychotherapy with hospitalized patients who refuse continuing meetings with a therapist. Eight therapists spent a total of 13 hours a week on a state hospital ward with 24 patients. The therapists were available to the patients in a therapy office on the ward, but also initiated relationships, often tentative and silent, in the hall or day room. In a large proportion of cases, therapy relationships gradually began, and regular meetings became possible. Some significant points of this procedure are discussed.
Psychiatric Institute
University of Wisconsin
1402 University Avenue
Madison, Wis.
[1] This project was supported by the Society for the Investigation of Human Ecology and the Wisconsin Alumni Research Foundation, with the contribution given through the Research Committee of the University of Wisconsin.
[2] The project was connected with a larger current investigation into psychotherapy with hospitalized schizophrenics under the sponsorship of Carl R. Rogers, Ph.D., conducted at Mendota State Hospital, Wis., with the collaboration of Drs. Urben, Tybering, and Coletti.
[3] The therapists in the project were: William Fey, Ph.D.; Eugene T. Gendlin, Ph.D.; Mrs. Vilma Ginsberg, M.A.; Joe T. Hart, M.A.; Philippa Mathieu, M.A.; Allyn Roberts, Ph.D.; Carl J. Rogers, Ph.D., and Ferdinand van der Veen, Ph.D.
