I have been reading your discussion of “The Case of Kathy” with great enthusiasm and interest. I would now like to make a substantive contribution.
I have had the fortune of conducting quantitative research on this case for a number of years. I am a doctoral candidate in the clinical psychology program at the University of California, Berkeley. I have also been a member of the Berkeley Psychotherapy Research Group (directed by Professor Enrico Jones).
As I mentioned earlier, Professor Jones and I have recently published a study on this case in Psychotherapy Research [8(2): 171-189]. Some of the findings from that study bear on the latest installment of “The Case of Kathy.”
I was very interested in measuring shifts in Kathy’s awareness and experience of guilt throughout her treatment. Dr. Jones and I measured guilt in a number of ways. First, we asked trained clinical judges to watch a randomized sample of videotapes from the 208 session treatment. These judges provided independent ratings of multiple aspects of the therapy process for each session (including the extent to which Kathy expressed guilt). Second, we asked the therapist (Dr. B) to complete a rating of multiple aspects of the therapy process (including the extent to which Kathy expressed guilt in a session). Dr. B did this rating at the end of every sixteenth session. Third, we asked Kathy to provide ratings of multiple aspects of the therapy process (including the extent to which she experienced guilt in a session). Kathy also provided ratings at the end of every sixteenth session. None of these raters knew at the time that I would be particularly interested in guilt in my research. Furthermore, none of the clinical judges were identified with Control Mastery Theory. In fact, some were in strong opposition to the theory.
In addition to observer reports, I also developed an “objective” measure of Kathy’s guilt. I used computer assisted content analysis to obtain a measure that I call the Topic Focus Ratio (TFR). TFRs measure the proportion of patient speech devoted to a specific topic (in this case guilt). I developed a dictionary of words related to guilt (e.g., badness, crime, guilt, guilty, sin, culpability) and counted the frequency of occurrence of any of these words in Kathy’s speech in a given session. This frequency of occurrence was then divided by the total number of words that Kathy spoke in the session. It turned out that this TFR-GUILT measure was strongly and positively correlated with Kathy’s self reported experience of guilt (r=.86, p=.01). I interpreted this to mean that TFR-GUILT measured Kathy’s conscious, subjective experience of guilt.
With these measures in hand, we attempted to answer the following question: Did Kathy become more conscious of guilt over the course of the treatment? We found a positive and significant correlation between TFR-GUILT and session number suggesting that Kathy increased in her subjective experience of guilt over the course of the treatment. I wasn’t quite satisfied with this evidence so I tried going about the problem another way. I reasoned that Kathy would be unlikely to self report feeling guilty when she was unconsciously guilty. However, I thought that at these times, both Dr. B and the trained clinical judges might rate Kathy as seeming guilty. In other words, unconscious guilt would be marked by low agreement between therapist and patient and high agreement between therapist and the clinical judges. On the other hand, as Kathy became more conscious of her guilt, I expected her to agree with both Dr. B and the clinical judges. We found that before session number 96 (about midway through the treatment), Kathy and Dr. B agreed about Kathy’s guilt 33% of the time. After session 96, they agreed 100% of the time. As predicted, Dr. B and the clinical judges agreed most of the time throughout the treatment. We also conducted a t-test comparing the mean TFR-GUILT score before session 96 and the mean TFR-GUILT score after session 96. We found that that TFR-GUILT was significantly higher after session 96 suggesting that Kathy had increased expression and experiencing of guilt after session 96. In sum, these findings support the idea that Kathy became more conscious of guilt over time (particularly after session 96).
What’s so special about session 96 you might ask? It turns out that session 96 was (among other things) the session where Kathy first discusses the “shocking thought that maybe she tried to kill herself in that near drowning after Dan's death.” I believe that these findings capture a significant clinical change episode during which Kathy first has deep insight into the implications of survivor guilt. It is my contention that it is not until Kathy remembers that she actually tried to kill herself in the same way that Dan died that the whole survivor guilt story comes to life for her. If it is true that the events leading up to session 96 were crucial to Kathy’s recovery then I believe the implications of such empirical evidence is profound. There is as yet little research on psychological changes that occur over the longer term. This change took more than a year to occur. Our data stand in contrast to the current emphasis in psychotherapy research on brief treatments and symptom change, which of course could not identify the kinds of change process that I have described. It is also worth noting in this respect that, unlike many patients suffering from major depression who are treated in brief therapy, Kathy maintained her therapeutic gains for over two years post therapy. I suspect that her resiliency is related to the depth of psychological change that occurred in this treatment.
I have more to say on empirical data on the case of Kathy but I imagine that this is quite enough for one posting. I will try to write more later. I welcome any questions about and/or alternative interpretations of these findings.