Changes in Semantic Uses of First Person Pronouns as Possible Linguistic Markers of Recovery in Psychotherapy

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changes in Semantic Uses of First Person Pronouns as Possible Linguistic Markers of Recovery in Psychotherapy
  Changes in semantic uses of first person pronouns as possible linguistic markers of recovery in psychotherapy C. W. Van Staden, K. W. M. Fulford Objective: To examine changes in linguistic markers in the course of psychotherapy,drawing on Frege’s logic of relations to define semantic variables distinct from syntacticvariables. Method: From a sample of 73 patients, 10 patients with the best and 10 patients with theworst outcomes were selected. Forty transcribed sessions of each outcome group werecompared statistically for change between commencement and termination of psychotherapyin: (i) the syntactic usage of first person pronouns (‘I’, ‘me’, ‘we’, ‘us’, ‘implied I’, ‘implied me’);(ii) semantic usage of first person pronouns (expressing alpha, omega, or unclear positions);and (iii) non-pronoun linguistic variables (passive voice, negative, copula, auxiliary verbsexpressing a sense of obligation). Results: There were no significant differences between the best and worst outcome groupsin the change of either syntactic usage, or of the non-pronoun linguistic variables. However,the outcome groups differed significantly in the change of their semantic usage (alpha:p = 0.002; omega: p = 0.028): The best outcome group showed an increase of alphapositions and a decrease of omega positions, whereas the worst outcome group showed theinverse (i.e. decrease of alpha and increase of omega positions). Conclusions: Results suggest only semantic, that is meaning-driven, usage of first personpronouns marks recovery in the course of psychotherapy. If replicated, this finding could beused to monitor treatment responses. Replication in other kinds of treatment could meanthese semantic changes are markers of recovery more generally than in psychotherapy. Key words: Australian and New Zealand Journal of Psychiatry 2004; 38:226–232  language, outcome, psychotherapy, self. This paper describes the use of variables derived fromlinguistic theory in a comparative empirical study of changes in the use of first person pronouns in the courseof psychotherapy.That changes in person pronoun use should occur inpsychotherapy is suggested by the importance of con-cepts such as ‘self’ and ‘ego’ in psychotherapeutic andpsychoanalytic theory [1,2], these being commonlyassumed to be expressed by first person pronouns, ‘I’,‘me’, etc. [2–5]. Changes in personal pronoun use, more-over, if they occur, could be of practical importance:they might be helpful in monitoring change, for exam-ple, or in providing a simple measure of outcome (seeDiscussion section). Yet apart from some suggestivefindings in Spence’s studies of the patient–therapistrelationship [6,7], empirical evidence that changes in Werdie Van Staden, Associate Professor (Correspondence) Department of Psychiatry, University of Pretoria, PO Box 667, Pretoria,0001, South Africa. Email: cwvanstaden@icon.co.za Bill Fulford, Professor of Philosophy and Mental Health Department of Philosophy, University of Warwick, Coventry andUniversity Department of Psychiatry, Warneford Hospital, Oxford, UK This research was part of the first author’s MD study at the University of Warwick (UK; 1999), titled ‘Linguistic changes during recovery: a philo-sophical and empirical study of first person pronoun usage and the semanticpositions of patients as expressed in psychotherapy and mental illness’.A copy is obtainable from WVS.Received 17 February 2003; revised 3 October 2003; accepted 17 November2003.  C.W. VAN STADEN, K.W.M. FULFORD227 first person pronoun use do indeed occur in the course of psychotherapy has not previously been reported.There is growing interest in linguistically definedvariables for empirical research in psychiatry [8]. In thepresent study we drew on linguistic theory to define twodistinct uses of the personal pronouns, syntactic andsemantic. We also examined a number of non-pronounlinguistic variables, partly for comparison with pronounvariables, partly for their interest in their own right inrespect of psychoanalytic and psychotherapeutic theory(see Discussion section).Syntactic and semantic uses of the personal pronounsdiffer broadly as to grammar and meaning, respectively.As such, they do not always run parallel. For example, in‘I chased the dog’ and ‘the dog was chased by me’, thesyntactic uses of the first person pronouns, ‘I’ and ‘me’,are different even though the two expressions haveessentially the same meaning [9].Semantic uses of the first person pronouns, in reflect-ing individual meanings, could be defined in many dif-ferent ways [10,11]. There are indications from both thephilosophy and sociology of medicine, that illness andrecovery are most likely to be associated with semanticuses of the first person pronouns expressing specifically agentic  aspects of these meanings: thus, the experienceof illness is associated with incapacity (or loss of agency) [12,13]; and Holmes and Lindley [14] argue thatrecovery of autonomy (hence of agency) is the centralaim of most kinds of psychotherapy.Frege’s semantic theory [15] and the related logic of relations [16,17] provide a resource for defining seman-tic variables connected with agency. Drawing on thisresource, we defined two semantic positions, ‘alpha’ and‘omega’. The details of this derivation, including theprecise relationship between our semantic positions,Frege’s ‘argument places’, and the ‘owner’ and ‘acci-dental’ of relations, are described elsewhere [18]. Inbrief, the alpha semantic position is characterized byoccupancy of the ‘owner’ of a relation as defined insemantic theory, and the omega position is characterizedby occupancy of the ‘accidental’ of a relation. In respectof verbs expressing actions, the alpha position is occu-pied by the agent. Thus, in both ‘I chased the dog’ and‘the dog was chased by me’, I occupy the alpha positionand the dog occupies the omega position. These seman-tic positions, however, are not restricted to actions.Similar positions are expressed by other classes of verb:for example, verbs expressing attitudes (  x  is against  y )and states (  x  needs  y ).The concept of a semantic position may be unfamiliaroutside philosophical logic. However, the alpha andomega positions proved to be readily operationalizablethrough a set of explicit rules and exemplars, which,with a brief period of training, showed a high degree of interrater reliability (see Method section).This study was designed to compare statistically a bestoutcome group with a worst outcome group for anincrease/decrease in, respectively, syntactic and seman-tic first person pronoun variables between commence-ment and termination of a course of psychotherapy. Method Data and subjects Our data were derived from a series of verbatim transcripts of psychotherapy sessions. The transcripts were srcinally made in the1970s as part of the Pennsylvania Psychotherapy Study [19] and arenow archived at the Ulm Textbank at the University of Ulm inGermany. All patients consented to the audio-recording of thesessions for the purposes of transcription and analysis. Names bywhich patients or other people could be identified were omitted orchanged.A major methodological advantage of the Penn Study for our analy-sis was that, from a total of 73 patients, the Penn investigators identi-fied 10 patients with the best and 10 with the worst outcomes. This keyselection process had thus been carried out completely independentlyof the present study.Outcomes in the Penn Study were assessed by 14 psychometricinstruments including patients’ self-report measures, therapists’ rat-ings, and independent clinical observer ratings. Using multiple regres-sion analysis of the scores on each measure, ‘residual gain’ and ‘ratedbenefit’ scores were calculated. ‘Residual gain’ was calculated on thebasis of ratings made at the beginning and again at the end of treat-ment. ‘Rated benefits’ was based on all the ratings immediately afterthe end of treatment. The ‘rated benefits’ and the ‘residual gain’ werehighly correlated (r = 0.75). Hence the best outcome and the worstoutcome groups were defined in the Penn Study by extreme scores oneither of these measures. In the best outcome group, seven wereselected on the basis of residual gain, three by rated benefits; in theworst outcome group, eight were selected by residual gain, two byrated benefits.A disadvantage of the Penn Study for our purposes was that,having been carried out in the 1970s, diagnostic information wasrelatively unsophisticated by present standards. The subjects of thePenn Study were diagnosed with depressive neurosis, anxiety neuro-sis, and mixed neurosis. The two groups (best and worst outcomes)appeared similar overall (in particular, there were no psychoticsubjects) but formal diagnostic comparisons were not possible fromthe available data.The best and worst outcome groups were also not significantlydifferent in age, gender, marital status or religion. All subjects hadeither one or two sessions each week. Eighteen psychodynamicallyorientated therapists were involved in the study (two therapists had twocases and the rest one case each). They had a minimum of eight to amaximum of 264 sessions, with a median of 32 sessions over a medianof 34 weeks. Best outcome patients were in therapy longer than worstoutcome (median 61 and 43 weeks, respectively).  228LINGUISTIC MARKERS OF RECOVERY Definition of variables (i) Overall use of first person pronouns and verb phrases.  Weexamined the commencement and termination frequencies for all verbphrases that were associated with a first person pronoun, and all thatwere not.(ii) Syntactic usage of first person pronouns.  The variables definedfor investigating syntactic usage were ‘I’, ‘me’, ‘we’, ‘us’, as well as‘implied I’ and ‘implied me’ (e.g. as in ‘I ate my food and (I) talked toher’, and ‘she said (to me) . . .’).(iii) Semantic usage of first person pronouns . The variables forassessing semantic usage were the ‘alpha position’ and ‘omegaposition’, as described earlier. We used ‘unclear position’ for expres-sions where the patient’s semantic position was not clearly evident(e.g. in ‘I was bored’).(iv)  Non-pronoun linguistic variables . Non-pronoun variables wereuse of the passive voice, negatives (‘not’ and ‘never’), copulas (e.g. ‘tobe’, ‘seem’, ‘appear’), and auxiliary verbs expressing a sense of obligation (e.g. ‘ought to’, ‘got to’, ‘have to’, ‘must’, ‘should’). Recording and procedures The basic unit of observation was a verb phrase. Besides a main verb,a verb phrase may also include auxiliary verbs. For example, in ‘I oughtto have written to Jim’, the verb phrase is ‘ought to have written’. Eachverb phrase was examined for the presence or absence of all the abovevariables in association with that verb phrase.For each of the 20 subjects, two commencement sessions and twotermination sessions were examined, giving a total of 80 sessions. Inall cases we followed the definitions of commencement and termina-tion sessions adopted by the Penn investigators. Thus, for a givensubject, the commencement sessions were sessions 3 and 5; thetermination sessions were the session in which 90% of the therapy wascomplete and the immediately preceding session. All terminationsessions were within five sessions of the end of therapy. The first 200verb phrases of each of the 80 sessions were analyzed.The presence or absence of the variables in each verb phrase wasrecorded in binary code. Frequencies of the variables in the samplewere calculated as the ratio (expressed as a percentage) of the numberof ‘present’ recordings for a particular variable to the total number of analyzed verb phrases in the relevant two sessions (i.e. either the twocommencement or the two termination sessions). This generated acommencement frequency and a termination frequency for each vari-able for each patient.The change between commencement and termination frequencies of variables was calculated for each patient as the difference betweencommencement frequency (C) and termination frequency (T) propor-tionate to the commencement frequency, expressed as a percentage.Thus, % change = 100 ×  (C–T)/C.Since the transcripts were not edited, operational rules of recordingwere developed to deal consistently with phenomena like half-sentences and single word expressions. The operational rules (avail-able on request from WVS) included for example: a verb phrase shouldbe identifiable before any recording is made; repetitions (likestuttering) of a first person pronoun associated with a certain verbphrase should be omitted; colloquial use of first person pronounsshould not be corrected; direct quotations by a patient from someoneelse should be excluded.The reliability of the recording procedures was assessed by sampling100 verb phases from a randomly selected psychotherapy transcriptand subjecting them to blind analysis by five sixth-year medicalstudents from the University of Pretoria (South Africa). All the above-mentioned variables were present among these verb phrases. Thestudents had a preliminary 15 minute training session in the operation-alized procedures for identifying and recording variables. The meanconcordance rate between the study recordings and the studentrecordings was 94% (SD = 1.85%; range: 92–96.7%). The KendallCoefficient of Concordance among the recordings of the students was0.0011, which is highly satisfactory. Statistical analysis The best and the worst outcome groups were compared using eitherthe independent samples t  -test or the Mann–Whitney U  -test. The t  -testwas used where the distribution of the changes in frequencies betweencommencement and termination of therapy was consistent with anormal distribution. This test did not assume equal variances. Wherethe data did not follow a normal distribution, the Mann–Whitney U  -testwas used. The extent to which the data followed a normal distributionwas assessed by visual inspection of graphic representations of the dis-tributions of the cumulative frequencies, and by the Kolmogorov-Smirnov and Lilliefors tests. Results Overall use of first person pronouns and verb phrases The commencement frequencies of all first person pronouns takentogether were similar for the best outcome (mean = 62.89%,SD = 5.41%) and the worst outcome patient groups (mean = 62.19%,SD = 7.46%). The termination frequencies were lower in both groups,the best outcome group showing a mean decrease of 10.14%(SD = 12.07%), the worst outcome group a mean decrease of 10.05%(SD = 6.74%). These decreases were not significantly differentbetween the two groups (t = 0.021, df = 14.11, p = 0.984, meandifference = 0.0913, 95% CI = –9.28–9.46).Correspondingly, there was no significant difference between thebest and the worst outcome groups for change in verb phrases that were not   associated with a first person pronoun (t = –0.041, df = 16.05,p = 0.968, mean difference = –0.279, 95% CI = –14.75–14.20). Syntactic usage of first person pronouns No statistically significant differences were found between the bestand the worst outcome groups in their syntactic usage of first personpronouns.The frequency of ‘I’ showed a very small increase between com-mencement and termination of psychotherapy for both patient groups(best outcome patients: mean increase of 0.33%, SD = 9.11%; worstoutcome patients: mean increase of 0.50%, SD = 6.63%) (Fig. 1). Thedifference between the best and the worst outcome patients in thisrespect was not statistically significant (t = 0.049, df = 16.15,p = 0.962).  C.W. VAN STADEN, K.W.M. FULFORD229The mean frequency of ‘me’ increased for both groups (bestoutcome patients = 5.73%; worst outcome patients = 31%) (Fig. 1) butthe standard deviations were large (43.7% and 68.62%, respectively).Correspondingly, no statistically significant differences were foundbetween the two groups of patients in their change in the usage of ‘me’(t = 0.099, df = 15.27, p = 0.339).The frequency of ‘we’ showed larger mean increases than ‘I’ or ‘me’for both patient groups between commencement and termination.Moreover, the best outcome patients’ mean increase in the frequencyof ‘we’ (215.22%, SD = 347.45%) was higher than the worst outcomepatients’ mean increase (43.83%, SD = 171.98%). The differencebetween the patient groups in this respect, however, still did not reachthe 0.05 level of statistical significance ( U  -test = 23.0; p = 0.131). Thisis most likely due to the large variance in the patients’ changes of frequencies (cf. the large SD values cited earlier). Missing data mayalso have contributed to the non-significant result since two of theworst outcome patients did not use ‘we’ at all during the analyzed partof the commencement sessions, and hence (as zero scores) had to beexcluded from calculating the percentage change between commence-ment and termination of therapy.The best outcome group showed a mean decrease of frequency of ‘us’ (28.85%, SD = 104.54%); and the worst outcome group showed amean increase (69%, SD = 143.99%). As for ‘we’, statistical testingbetween the groups was not useful because commencement frequen-cies were zero for two of the best outcome and six of the worstoutcome patients, and therefore had to be excluded from calculatingthe percentage change between commencement and termination of therapy.No statistically significant differences were found between thebest and worst outcome patient groups in their uses of ‘implied I’( U  -test = 35.0, p = 0.257) or ‘implied me’ ( U  -test = 38.0, p = 0.364). Semantic usage of first person pronouns In contrast with the syntactic usage of first person pronouns, signifi-cant changes were found in semantic usage. These positive findings arecompared with the negative findings for the syntactic variables, ‘I’ and‘me’, in Figure 1.Thus, the alpha position increased among the best outcome patients(mean increase of 7.14%, SD = 7.38%) and decreased among the worstoutcome patients (mean decrease of 4.40%, SD = 6.46%). The differ-ence between the best outcome and the worst outcome patients washighly significant (t = –3.72, df = 17.69, p = 0.002, mean difference =–11.54, 95% CI = –5.06 – –18.07). The upper value of the confidenceinterval suggests an increase of the alpha position in at least 95% of similar comparisons.The omega position changed in the opposite direction from the alphaposition. The omega position decreased among the best outcomepatients (mean decrease of 17.79%, SD = 19.95%) and increasedamong the worst outcome group (mean increase of 20.18%,SD = 38.74%). The difference between the patient groups was statisti-cally significant ( U  -test = 21.0, p = 0.028).The changes in the alpha and the omega positions for individualsubjects are shown in Figure 2 (alpha position) and Figure 3 (omegaposition). Visual inspection shows opposite directions of the changesfor the two groups of subjects: the predominant response shown bysubjects in the best outcome group was an increase in the alpha anda corresponding decrease in the omega positions, whereas in theworst outcome group the predominant response was a decrease inthe alpha and an increase in the omega positions. This means that anincrease in frequency of the alpha position has a sensitivity andspecificity of 0.8 to identify correctly both the best and worstoutcome groups, and a decrease in the omega position has a sensitiv-ity of 0.8 and specificity of 0.6 to identify the best and worst outcomegroups, respectively.For the ‘unclear position’, no statistically significant differenceswere found between the patient groups ( U  -test = 42, p = 0.545). Figure 1.Mean changes of ‘I’, ‘me’, alpha positions and omega positions between commencement and termination of psychotherapy for best and worst outcome groups.Figure 2.Change in the frequency of the alpha  positions between commencement and termination of  psychotherapy for each case.
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