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An
Objective Study of Communication in Psychiatric Interviews
Joseph
Jeffe,
H.D.
From
the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks,
Read
at the
New
York
N.Y.
Divisional MBeting, A.P.A. November, 1957.
Supported by Grant 565561 of the Foundations' Fund for Research in Psychiatry.
14’!
10-1h-S7
�The
clinical interview is the psychiatrist's primary tool for the
diagnosis of psychopathology, the modification of behavior, and the
collection of research data.
Only
in recent years, however,
have the
actual transactions which comprise the interview been studied objectively.
Investigators of the interview have usually employed systems of
content analysis (1), which are based upon various theories of psychodynamics.
Currently, there
is increasing
emphasis upon formal aspects
of interaction such as temporal patterns of speech (1h) drastic change
of subject (3), PHYSiological relationships of the participants (2),
grammatical patterns of language (S, 6, 9), and speech disturbances and
silences (10). These aspects, in contrast to content categories, are
relatively independent of theoretical preconceptions,
and are more
readily
quantified and studied statistically.
In many investigations of these formal variables, however, the
total context of the
interview. These approaches neglect the fact that the psychiatrist is a
participant observer, i.e., a significant variable in the interaction
(11). Others have attempted to control this variable by means of
structured interviews in.which the doctor's contribution is standardized
patient's
communications are abstracted from the
according to a predetermined experimental design (6, 7, 1h). These
structured situations delete the very quality of living relationship that
is the ultimate
concern of the psychotherapist (7).
methods of verbal
We
are in need of
interaction analysis that neither preclude nor
prescribe the doctor's clinical responses.
The
this paper is to present a method of interview
a) is objective and quantitative, b) preserves the
purpose of
analysis which
�.2...
natural patient-therapist relationship,
and
c)
treats the interview
as an integrated system of interpersonal communication. This
is
accom-
plished by including the doctor's usual clinical behavior in the data
to be studied.
the
The raw
material is not the patient's speech, but rather
total verbal output of the
"two person" or "dyadic" group.
�Method:
tape recorded interview
The
is precisely transcribed,
without regard
to the speaker of the words. Careful attention is given to subtle
repetitions such as "I - I mean," "well as - as I say,"
polated expressions such as "you know,"
The
inter"so to speak," "as I said," etc.
and to
transcript is then arbitrarily divided into consecutive units of
100, 50 or 25 words depending on the discreteness of the phenomena to
be investigated. Thus a unit contains contributions of words from either
doctor or patient alone, or from both in varying proportions.
The measurement
applied to these units of dyadic Speech is the typetoken-ratio (TTR). This is an index of the balance between repetition
variety of words (12). The TTR is the ratio of the number of
different words (types), to the total number of words (tokensL in a
sample of language. For example, in a 100 word sample the repetition
of the identical word 100 times in succession would produce the lowest
and
possible ratio of .01
of 1.0 would
different
result
if
(l
type/100 tokens). The highest possible
every one of the 100 successive words were
(100 types/100
tokens). These extremes of stereotypy and
diversity are rarely encountered,
situations (8).
The
i.e.
"word-type,"
ratio
and then only
the numerator of the
in grossly pathological
TTR,
is arbitrarily
defined. All words are different which are pronounced or spelled
differently. Thus, ive, gives, gave, given and gizipgfl are considered
different types, as are "know" and "no." Vocalizations not clearly
"
�.u-‘
identifiable as
which
is
words are omitted, with the major exception of
"mmhmm"
a frequent utterance of the interviewer in our records.
Contractions are retained as single words, but vulgarisms such as "I
dunno" are
edited to read "I don't know."
The TTR
scores
is calculated for
is graphically plotted,
additional precision, the units
may be advanced 25 words
the
last half
at
unit
each
as
and the
illustrated in Figures
may be
first half
unit. This often smoothes the resultant curve.
is illustrated in Figure 3.
TTR
have
in a single person's language (12).
1 and
2. For
overlapped, e.g. 50 word units
a time, so that each unit
of the preceding and the
Previous studies of the
pattern of consecutive
is
composed
of
of the subsequent
The
overlapping technique
dealt with the overall average
The
sequential pattern in dyadic language.
present method studies the
�Observations:
In the
last eighteen
months approximately
sixty recorded interviews
this method.
The
material includes forty
patients in all diagnostic categories.
The
dyadic
have been inveStigated by
found to be sensitive
to a variety of clinical
TTR
patterns have been
phenomena
(8). This
report illustrates the changes in language interaction occurring during
the course of hospitalization and therapy, as well as changes in rapport
in individual interviews.
and defensive operations
A
- andic
TTR
Pattern in Clinical Change.
first
Figure 1 shows the pattern of the
three separate
1500 words of
interviews during the clinical course of one patient. The doctor is the
in each. This case
same
was
selected as an unequivocal example of gross
clinical change. In the first interview the patient
was
agitated and
depressed. She refused to be seated and paced about the room, reiterating
stereotyped self-recriminations, crying hysterically, with marked
pressure of speech. At the time of the second interview, following a
course of grand mal electroshock, the clinical picture was grossly altered.
She was
less agitated and
complaining of a memory
appeared
more
deficit.
cooperative, although withdrawn and
On
alert, poised, conversational
insightful.
She had been
The TTR of
later,
discharge two months
and,
she
at times, surprisingly
rated clinically as "recovered."
consecutive 25 word units of interaction, for each of
the three periods described, is graphically represented in Fig. 1.
Consecutive points are connected by lines so that the fluctuations in the
graph
reflect the difference
between successive scores.
The mean TTR
for
�~6-
the complete interview from which these samples were taken is represented
line through each graph.
by a horizontal
strates
The
a
The
fluctuating equilibrium about the
pattern of scores
mean.
interviews of these three successive stages
changes.
The mean
demon-
show a sequence
of
level of the interaction is seen to increase as the
clinical status changes from psychosis to "recovery." There is a concomitant restriction in the amplitude of the pattern, i.e. a decrease in
variation about the mean.
Comment:
The sequence of change
in the
TTR
pattern parallels the progressive
in interpersonal communication that
improvement
clinically.
was apparent
This suggests an approach to the quantification of
clinical
change, defined
as an altered pattern of verbal interaction in the interview.
B
-
in Communication‘within the Interview:
Changes
Figure
shown
2
is
an enlargement of the
in Figure 1.
first
of the three interactions
Here the sequence of changes
within a.single interview
are examined rather than comparing the patterns of successive interviews.
As
described before, the patient was speaking continuously in a disorgan-
ized affective outburst.
mflrich
The lower
line indicates the
the interviewer participated. Following
remarks, units
3
-
12
fine
25 word
units in
doctor's introductory
represent the patient's uninterrupted speech.
Wide
oscillations of the pattern are prominent. From samples 13 onwards the
doctor made repeated efforts to communicate with the patient. Two independent judges reviewed the transcribed protocol, and both identified
three areas in which there seemed to be an understandable, rational
�-7interchange between the participants. These periods are labelled
"rapport" in the upper
line.
tions of the pattern are
much
During these three periods the
constricted.
Compare
oscilla-
other non-rapport
periods such as 23-2h and 39-hl, in which the doctor's participation
amplified the oscillations.
Cmmmnh
This
illustrates
a method of quantifying
interpersonal phenomena,
such as the degree of "contact" with a severely disturbed
patient.
The
affective pattern in this patient represents the psychotic integration,
for this reason, the occasional occurnnces of conventional,rational
conversation are described as periods of "rapport." The restriction in
and
the amplitude which characterizes these periods
is similar to the
overall pattern at the time of "recovery."
0
- Analysis
Figure
3
of a Complete Interview.
initial
demonstrates the
dvadic
TTR
analysis of a complete
interview. This interview is the discharge evaluation of a patient
had been hospitalized following a
months of
hospitalization, she
who
bizarre suicide attempt. After seven
had "improved"
clinically. This took the
form of a hypomanic mood and a gross denial of her severe emotional
conflicts.
word
The
interview
units advancing by
is
scored by the method of successive 50
ZS word
steps.
The mean TTR
for the interview
is shown by the horizontal line drawn through the graph. The pattern
falls into several natural segments. There are two areas in which ten
consecutive points fall below the mean (areas h and 7). These are
unusual in this interview. There are also areas of gross deviation
�~8from the mean (such as area
determine our
criteria for
2).
Thus we allow the
phenomena
for persistent changes in the
TTR
to be studied. In general,
we
look
level, gross trends or sudden shifts.
Several of the deviant areas are described to
The
objective pattern to
illustrate the
method.
interview begins with a hypomanic monologue in which the patient
visit
describes her successful
home,
her euphoric outlook and plans for
a rosy future.
Area 2 has been delineated because of gross deviation from the mean.
The
beginning of
this period coincides with
a change of topic to her plans
is interrupted
by a period of confusion as she tries, with some difficulty, to recall
one of the details of the job. The end of the gross fluctuation coincides
with the rationalization "I don't think I'll have too much trouble."
Area h was delineated as one of the two sections in which 10 consecutive
for going back to her job
scores
fall
two days hence.
Her optimism
Its beginning coincides with
below the mean.
about her depression on admission to the hOSpital.
a statement
This area ends with
the lowest score of the interview which,precedes by only a few words a
spontaneous reference to her suicide attempt. This large deviation
at
the end of area h embodies the main characteristics of the following area.
Area 5
The
is characterized
by large
content of this area
attempts to prove
at the
is
how much
fluctuations
above and below the mean.
completely on the theme of suicide. She
live. The doctor's queries
with increasing resistance. In the begin-
she now wants to
end of the period meet
ning of the next segment (area 6) she stubbornly refuses to discuss the
subject of suicide further, at which point she changes the subject
abruptly.
�-9Area
7 was
delineated
on
precipitous drop in the
the basis of
TTR,
criteria. It begins with
”two
a
followed by 10 consecutive scores below
rise. Its
the mean, and ends with an equally abrupt
beginning coincides
with a change of subject by the doctor in the form of a question about
her feelings at that
the "you-me" relationship,
period ends
Area
9
when she
in the interview. This content area, 1.6.
moment
is
at
a very
It
The
of an extremely low score enclosed by two
coincides with a brief mention of a meeting with
a young man who told her how well she looked.
remark and her statement
These examples
repetitive level.
abruptly changes the subject.
is delineated because
large deviations.
pursued
"I decided to get
illustrate areas
him
It
ends with an embarrassed
off the topic."
of disturbance or disequilibrium in
the verbal interaction pattern. In contrast, areas
I
3, 6,,23 and 10 are
areas of relative stability or equilibrium in the record. These stable
areas are marked by a different quality of communication. They consist
either of a euphoric,
hypomanic monologue which avoids
all stressful areas.
or of evasion of the doctor's probing questions by superficial rational-
ization and conventional cliches.
Comment:
Recent reports of objective interview studies using other techniques
(10), have noted that the interaction goes through a series of definable
phases, which
may
and successful defense
and the events
The
stressful disorganization
correspond to periods of
respectively.
The
phases demonstrated here,
that delineate them, suggest
an analogous fonmulation.
content areas that disturbed the pattern in this final interview
�also did so
the
initial
interview seven months earlier. we
anticipate that the discussion of a subject that had resulted in disequilibrium but now no longer does so, may constitute an operational
on
definition of "resolution of an area of conflict."
�Discussion and Conclusions:
Diverse and highly personal interpretations of interview data limit
the growth of psychiatry as a science. Systematic study of the actual
transactions
may
lead to operational definitions of hitherto subjective
it is
likely that the patterns of verbal
diversification presented here constitute part of the subliminal cues to
phenomena.
For example,
therapists
affect, etc.
which
reSpond when.making
clinical
judgments of anxiety,
Objective investigations of the interview must encompass the behavior
of both participants since the events observed are interpersonal processes.
Gill,
Heuman &
Redlich (h) define even the
initial interview
as "the
diagnostic evaluation of an interpersonal relationship." Reusch (13)
has recently stated
have the
that “observations
made
in social situations
characteristics of a scientific procedure in which
do
not
one aSpect
is studied in detail while all other variables are held constant."
The method presented here is an attempt to convert these concepts
into practical research methodology.
It
permits a quantitative statement
of various clinical phenomena occurring either within single interviews
or in the course of therapy. Disturbances of verbal interaction are
defined operationally in terms of the configuration of the
Applications to the definition of clinical change and
pattern.
transactions
TTR
within the interview have been presented.
The TTR
is
only one of many quantifiable aspects of dyadic speech.
interaction, time reference, and relative amounts of participation
doctor and patient may also be measured. Further applications of these
Pace of
by
techniques are under investigation.
�REFERENCES
1. Auld, F.
and Murray,
E.J. (1955): Content-Analysis Studies of
Psychotherapy, Pslchol. Bull. 2a: 377-395.
2. Coleman, R., Greenblatt,
and Solomon, H.C. (1956): Physiological
M.
Evidence of Rapport During Psychotherapeutic Interviews,
Dis . Nerv.
3. Eldred, S.H.,
sttem,
ll:
2-8.
E.R., Salzman, L., Meyersburg,
Hamburg, D.A., IHWOOd,
(l95h):
H.A. and Goodrich, G.
A
Procedure for the Systematic
Analysis of Psychotherapeutic Interviews, §§zchiatry, l1:
337-3h5.
h. Gill,
M., Néwman, R. and Redlich, F.C. (l95b): The
in szchiatric Practice.
Press.
5. Goldman-Eisler, F. (195h):
A
New
York:
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Interaction in the Behavior of
Interviews, Jour.. Rent. Sci.
6.
Initial_1ntervigg
International Universities
Some
Aspects of Language in
lQQ: 177-197.
Gottschalk, L.A., Gleser, G.C. and Hambidge,
Behavior Analysis, Arch. Neur. and
G.
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ngchiat.,
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7. Grinker, R.R., Sabshin, M., HaMburg, D.A., Board, F.A., Basowitz, H.,
Korchin,
Use
m?
S.J.,
Persky, H. and Chevalier, J.A. (1957): The
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Its
Meaning to the
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8.
daffe, J.: Language of the Dyad:
A
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Interaction Analysis
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9. Lorenz, M. and Cobb, S. (195h): Language Patterns in PBychotic
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Psychoneurotic Subjects, Arch. Neur. and Pszchiat., 1g: 665-673.
�REFEREEIJCES
lO. Mahl, G.F., (1956): Disturbances and Silences in the Patient's
Speech in Psychotherapy, Jour. Abnorm. Soc. Psxcholu
§_3__:
1-15.
11. Handler,
G. and
Kaplan,
:‘J.K.
(1956): Subjective Evaluation and Re-
enforcing Effect of a Verbal Stimulus, Science,
l2.
Mowrer, O.H. (1953): Verbal Behavior
(Ed.) szchotheragz:
T1139
1.2143
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582-583.
Mowrer
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13. Ruesch, J. (1957): Disturbed Commnication,
New
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1h. Saslow, G., Matarozzo, J.D. and Guze, S.B. (1955): The Stability of
Interaction Chronograph Patterns in Psychiatric Interviews,
Jour. Consult. P§Xcholu
1.2: 14174430.
�
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Research Files and Unpublished Works
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Joseph Jaffe: An Object Study of Communication in Psychiatric Interviews, 1957
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1957
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Jaffe, Joseph
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