Can Patients' Views of a Therapeutic System Predict Outcome? An Empirical Study with Depressive Patients

• Date: 01 September 1989
• DOI: http://doi.org/10.1111/j.1545-5300.1989.00349.x
• Author: STEFAN PRIEBE
• Published date: 01 September 1989

Fam Proc 28:349-355, 1989

Can Patients' Views of a Therapeutic System Predict Outcome? An

Empirical Study with Depressive Patients

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

aDepartment of Social Psychiatry, Free University of Berlin, Plantanenalle 19, D-1000, West Berlin 19, West Germany.

Using the principles of brief therapy as developed at the Mental Research Institute (MRI) in Palo Alto, this study

examined how patients viewed psychiatrists' and significant others' attitudes toward the severity of their illness, as

compared with their own attitude, and whether these views were related to outcome. Forty-one depressive inpatients were

asked a two-part questionWho regards your illness as being more severe: (a) you or your significant others; (b) you

or your psychiatrist? Two subsamples of patients were identified: those who viewed psychiatrists' and significant others'

attitudes toward the illness as similar (equally structured systems) and those who viewed them as dissimilar (differently

structured systems). Both groups showed equal and significant improvement during hospital treatment; but the group

that viewed the attitudes held by psychiatrists and significant others as dissimilar reported improvement after discharge.

In the field of psychiatry, empirical research on the concept of systems began with a field study that led to the

Department of the double-bind theory of schizophrenia (2). Since then, such research has concentrated mainly on the

family. This has been the case in therapeutic studies as well as in field studies. The system that the present study examined

was not the family but, rather, a therapeutic system. This system includes not only the patient, his or her family, or a larger

social group, but also the therapist, the psychiatric institution, or parts of a health service system (7). The therapeutic

system is time-limited and depends on the therapeutic setting.

Our approach to a study of the therapeutic system is based upon brief therapy, as developed by the Mental Research

Institute (MRI) in Palo Alto. A principle of brief therapy is that one evaluates which solutions have so far been attempted

for the patient's problem, and to try a different one in therapy. That is, one tries solutions that are opposite of what has

already been tried, for instance, by the patient's significant others (3, 5, 10, 11). Thus, in a condensed and somewhat

simplified fashion, the relationship between patient and therapist should be different in some therapeutically decisive

respect from that between the patient and significant others.

In this study, this principle was applied not to specific attempted solutions but, by analogy, to general attitudes toward

the patient's problem or illness. Accordingly, the attitudes of both significant others and the therapist should differ in the

patient's view. For example, if the patient believes that significant others regard the illness as less severe than he or she

does, then the patient should believe that the therapist regards the illness as being equally or more severe than he or she

does. Therapeutic systems that are differently structured from the patient's point of view were hypothesized to correlate

positively with a better outcome.

To test this hypothesis, we attempted a systems description of an attitude within the therapeutic milieu of a psychiatric

hospital, using simple methods, and probing the patterns found in significant relationships with respect to outcome criteria.

Only three parts of the therapeutic system were examined: (a) the patient, (b) his or her significant others, and (c) the

psychiatrist. The role of the psychiatrist in this setting is as an expert and a representative of the psychiatric institution. The

institution is, predominantly, a biologically oriented, moderately sized psychiatric department of a university hospital for

mainly acute psychiatric disorders. According to systems theory, features or attitudes of members of a system should be

described not in absolute terms (making a comparison only with values from a different system) but, rather, in a relational

way by comparisons within the system, whereby only differences are relevant (1, 8). Any attitude held by the therapeutic

system's members should be described in the same way, that is, not only which attitude is held by the patient, the significant

others, and the psychiatrist, but also who holds this attitude to a greater or lesser extentpatient or significant others,

patient or psychiatrist. Obviously, one does not know which attitudes are relevant for the therapeutic process and which are

not. Different attitudes may be important within different therapeutic systems and at different stages of therapy.

Tentatively, this study concentrates on an attitude that is clinically relevant: the rating of severity of illness. This attitude

within the therapeutic system is not described by an observer outside the system but by persons within it. Their views about

how that attitude differs among the system's members, their "maps" of the relationship of various attitudes within the

therapeutic system, or what they said about their maps in an interview, were examined and related to outcome.

METHOD

The patients were all acutely ill and had been admitted because of severe depression, as rated by the von Zerssen

Depression Scale DS + DS' > 24 (9). Only patients with schizophrenic, bipolar affective, or organic disorders were

excluded, on the basis that lack of insight and awareness of one's illness are often found in such patients. This wide

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