THE GENERALITY OF QUESTIONNAIRE DATA: RATINGS BY PSYCHIATRIC PATIENTS

RUDOLF H. MOOS

Stanford Universily School of Medicine

The question of the extent of generality in the reactions of persons to different situations has recently received increased attention. Individual behavior is a func- tion of individual personality differences, situational or environmental variables, and the interaction of the person and the situation. When individual personality traits are most important, the behavior of the person will tend to be stable from setting to setting and data obtained on individual behavior in different situations will tend to show high intercorrelations. Knowledge about the individual will thus make it possible to predict his behavior in a number of different situations.

If, on the other hand, situational or interactional factors are most important, then behavior will change from situation to situation, and data obtained on be- havior in different situations will show varying intercorrelations, the size of which will presumably be some function of the perceived similarity between the situations. This line of logic has been well presented by Magnusson, Gerzen and Nyman") who studied the effects of variation of task and group composition on ratings of behavior of individuals in group situations. The correlations between ratings made by two independent teams of judges were significant when the conditions were the same as well as when either the task or the composition of the group was varied. When both the task and the composition of the group were simultaneously varied, the correla- tions between ratings made by the two teams of independent judges were purely random. Various other authors have also emphasized the importance of situational and interactional s s '* *).

This study investigated the generality of questionnaire ratings made by psy- chiatric patients in a sample of psychiatric ward subsettings. The major purpose was to estimate the extent to which correlations between patients' reactions to different psychiatric ward subsettings vary with the similarity of the settings.

METHOD AND SUBJECTS Sixteen Ss were each observed in each of six different ward subsettings: (1) An

intake meeting (or discharge meeting) in which the entire ward staff observed the patient being interviewed by one of the resident psychiatrists; (2) an individual therapy session; (3) a group therapy session in which the patient was a member of a group of approximately 8 patients; (4) a community meeting in which all patients and staff participated; (5) lunchtime, which occurred in a dining room on the ward; and (6) free time, which was unscheduled time on the ward during which the patient was free to engage in any activity he chose.

The initial set of observations occurred during the first and second weeks of hospitalization. A second set of observations was made approximately 90 days later on 12 of these patients the week or so before they left the ward. Four of the patients could not be observed a second time either because they had left the hospital against medical advice or because they had to be discharged without prior warning.

Patients were given a questionnaire immediately after their participation in each of the six settings. This questionnaire consisted of nine dimensions measured by three items each on each of which patients rated their experience on a 1 to 5

'Thw research was supported in part by I'SPHS Graiit MH 160'26. The author wishes to expmw his a preciation to the patienta and staff who partici ated in the renearch; to Eleanor Levine aiid Phylh Nobel, who served as behavior observers; to d)ordon Adam and William Lake, who assisted in the statistical analyses; to Bert Kopell and William Wither, who im ortantly facilitated the work; and to Mark Abramon, John Adanis aiid Sheldon Starr, who permit+etfobservations of t.heir individ- ual and group therapy sessions.

THE GENERALITY OF QUESTIONNAIRE DATA : RATINOg BY PSYCHIATRIC PATIENTS 2-35

scale. Four affect dimensions were measured: Anxiety, depression, vigor and pleasantness. Two of the dimensions meaaured the perceived worth (worthwhile, important to me) and the perceived therapeutic benefit of the setting (made me feel better, helped me gain self-confidence). The other three dimensions measured affiliation (I worked closely with others, people were friendly to me) , participation (I worked hard, I was active) and leadership (I played an important part, I helped decide what to do).

The research was conducted on an open door, 30 patient psychiatric ward located in a large Veterans Administration Hospital. The average age of the 16 patients (8 male, 8 female) was 38.8 years (SD = 7.0), and their average education was 13.4 years (SD = 1.1). The median length of hospitalization was approximately 90 days, and the number of previous hospitalizations ranged from 0 to 5. Further details about the setting, the Ss, the questionnaire and the methodology of the larger study may be found elsewhere(7*

RESULTS Each patient received a score on each of the 9 dimensions in each of the 6 sub-

settings for both sets of observations. These scores were intercorrelated separately for each set of observations. -The following three specific hypotheses were formu- lated: (1) The correlations between intake (or discharge meeting) and individual therapy would be higher than the average correlations between either intake meeting or individual therapy and the other four settings; (2) the correlations between group therapy and community meeting would be higher than the average correlations between either group therapy or community meeting and the other four settings; (3) the correlations between lunchtime and free time would be higher than the average correlations between either lunchtime or free time and the other four settings.

Both intake and individual therapy involve one patient interacting alone with one or more staff members. The task is to discuss personal problems and/or relevant personal past history. In group therapy and community meeting, on the other hand, each patient is interacting both with other patients and with staff. The task in both settings revolves around a discussion of “here and now” patient-patient and staff-patient interaction, together with some consideration of ward rules and activi- ties. Lunch time and free time tend to be much more informal settings with pa- tients mainly interacting with other patients. There is usually little or no inter- action with staff and no necessity for discussion of either personally relevant material or immediate feelings. Thus, the 6 ward subsettings fell into 3 groups on the baais both of interpersonal composition and of dominant task demands. For the first set of observations, 34 of the 54 (2 = 2.04, p < .05) comparisons were in the expected direction. For the second set of observations, 45 of the 54 comparisons (2 = 5.04, p < .001) were in the expected direction, and 5 or 6 of the 6 comparisons were in the expected direction for 8 of the 9 dimensions. Thus, setting effects may increase with increasing familiarity with the range of settings in which behavior is to take place. TABLE 1 . SETTING COHREL ~TIONS FOR PARTICIPATION, THERAPEUTIC BENEFIT AND P.\RTICIPATION

( )huewetioil 1 6 2 1 6 3 , 2 & 3 , 3 6 4 3 6 1 , 4 & 1 3 6 6 3 6 1 , 6 & 1 , 4, <i, 6 4, 5, 6 2, 5, 6 2, 5, 6 2, 3, 4 2, 3, 4

Participation 1st 2nd

.3 3 X 20 46 1 .i 02 6 2 ‘28 22 u3 32 3.5 42 18 10 67 14 .12

Therapeutic Benefit 1st .44 .,o .2.-, .16 .29 - . 2 0 .37 .3.i - .01 2nd . r,3 3 5 . 1.i .39 .10 .24 .86 .4:i .49

Affiliation 1st 2nd

.69 .4L .60 .28 .2.5 .32 .67 .5,i .44

.69 .21 .24 .41 . l l .05 ..56 .3’7 .04

236 RUDOLF H. MOOS

Table 1 shows the results for the variables of participation, therapeutic benefit and affiliation. The intercorrelations between the two similar settings were generally substantially higher than the average intercorrelations among dissimilar settings. For example, in the second set of observations, the correlation between participation in intake and individual therapy was 233, whereas the average correlation between participation in the other 4 settings was .35.

CONCLUSIONS AND SUMMARY These results provide some evidence about the limits of the generality of

patient behavior on psychiatric wards. For example, they indicate that observations in an intake meeting may be reasonably generalized to predictions about behavior in individual therapy. However, these same observations may not generate valid predictions about behavior in other ward subsettings. Similarly, observations in group therapy may generate valid predictions about behavior in community meet- ing, but not about behavior either in free time or in individual therapy.

The results also suggest possible reasons for staff-staff disagreements about patient characteristics and patient improvement. The staff member who observes a patient in individual therapy is unlikely to see the same behavior as the staff member who observes a patient in community meeting or in free time. These different sources of information might be profitably used to establish a more balanced view of the individual patient and of the variability of reactions of which the patient is capable in different ward subsettings.

In summary, the present results substantiate those of Ellsworth et aZ.(l) and Magnusson et ~ 2 . ' ' - 6 ) in concluding that consistency in behavior is seriously dis- rupted when situations change. The more the situation changes, the lower the correlations which can be expected. Research directed toward the identification of ranges of ward subsettings in which similar patient and/or staff reactions occur has high priority. It is only in this way that relevant predictions about behavior can be made either from one hospital setting to another, from one community setting to another or possibly even from a hospital to a community setting.

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