Journal of Consulting Psychology

1965, Vol. 29, No. 5, 426-431

LAY MENTAL HEALTH COUNSELING.

1
THE EFFECTS OF LAY GROUP COUNSELING
ROBERT R. CARKHUFF AND CHARLES B. TRUAX 2
University of Massachusetts Arkansas Rehabilitation Research and Training
Center, University of Arkansas

8 therapeutic groups of 10 hospitalized mental patients each were seen twice a

week for a total of 24 sessions by S trained lay hospital personnel. 70 patients
served as controls. The lay personnel, primarily attendants, had been trained by
an approach integrating the didactic approach which emphasizes the shaping of
therapist behavior with the experiential approach which focuses upon therapist
development and "growth." Heavy training emphasis was placed upon research
scales assessing process variables, which had been predictive of positive patient
outcome, rather than any particular theoretical orientation. At the end of the
3-month period, significant improvement was noted in the ward behavior of the
treatment group when compared to the control group.

Since the introduction of effective tranquil-
izers and other psychomimetic compounds, a
very large percentage of the nation's hospital-
ized mental patients have become susceptible
to psychotherapeutic intervention. Further,
psychotherapeutic approaches to facilitating
constructive personality change are being
widely used in the treatment of neurotic
and emotionally disturbed persons. Essentially
psychotherapeutic approaches are used in
present-day counseling programs in schools,
industries, and rehabilitation programs
throughout the nation. It has become strik-
ingly clear, however, that available and pro-
jected manpower at the disciplines currently
practicing psychotherapy fall severely short
of the available and projected demand.
Further, recent research identifying certain
specifiable elements of effective psychotherapy
has opened new avenues for the specific train-
ing of therapists. It has been suggested
(Truax & Carkhuff, 1964a; 1964b) that the
research measuring instruments which have
successfully discriminated between specific
1
The research was supported in part by Research
and Development Grant 906-PM from the Vocational
Rehabilitation Administration to the authors. R. R.
Carkhuff's work was supported by Public Health
Fellowship 7 F2 MH-19, 912-02 from the National
Institute of Mental Health, United States Public
Health
2
Service.
The authors gratefully acknowledge the critical
technical contributions of Edward P. Williams to the
data analyses and the training program and the co-
operative efforts of John Corcella, Robert DeBurger,
and Logan Gragg.
426
behaviors of effective therapy and noneffec-
tive or psychonoxious therapy s could be ap-
plied directly to training programs. Thus,
tape-recorded samples of psychotherapy rated
very high in the known elements of effective
psychotherapy could be selected to provide
concrete examples for the beginning thera-
pists. More specifically, the measuring scales
such as the accurate empathy scale could be
used to rate samples drawn from a trainee's
own early therapeutic interviews and thus
give the trainee immediate and concrete in-
formational feedback about his own perform-
ance. Such an approach would mark a very
radical departure from current training prac-
tices which heavily emphasize intellectual
learning, too often perhaps at the expense of
learning the art of operationalizing the con-
cepts involved in effective psychotherapy.
Also, since the training of a therapist in a
clear sense involves the personality change of
the trainee, it might be expected that vari-
ables in effective psychotherapy should logi-
cally be applied to the training of the thera-
pists. This implies, for example, that the
teacher-supervisor should provide the condi-
tions of accurate empathy, unconditional posi-
tive regard, and self-congruence or genuine-
ness for the trainee during supervisory ses-
sions. The continuing use of such therapeutic
3
This term has been coined by Haim Ginott in a
personal communication to describe therapists who
provide the kind of relationship in which patient
deterioration is observed.
 THE EFFECTS OF LAY GROUP COUNSELING
conditions in a supervisory trainee program
not only would be expected to contribute to
the trainee's personality change directly, but
also to provide the trainee with a clear and
observable model of a therapist to be imi-
tated. A training program dealing in this
fashion with recent research evidence identi-
fying some of the effective elements in psy-
chotherapy has been described (Truax, Cark-
huff, & Douds, 1964). The program involves
both concrete didactic and more molar ex-
periential aspects including a quasi group-ther-
apy experience for the trainees. This training
program has been implemented both with lay
hospital personnel and with postgraduate
clinical psychology students. An analysis of
the findings (Carkhuff & Truax, 1964) indi-
cated that after a training program involving
less than 100 hours, both lay personnel and
clinical psychology trainees did not differ
markedly from a group of highly experienced
psychotherapists in the process measures of
the psychotherapeutic interviews they pro-
duced. On at least one dimension from the
only study (Bergin & Soloman, 1963) which
was available for purposes of comparison,
empathic understanding, the lay personnel
performed at levels significantly higher than
postinternship graduate students. The present
study is an attempt to evaluate the effective-
ness of the lay personnel involved in the pro-
gram by comparing the improvements ob-
served in groups of hospitalized mental pa-
tients seen by them in group psychotherapy
with equivalent control groups not receiving
lay group counseling.
Recent reported evidence suggests the po-
tential therapeutic effectiveness of minimally
trained nonprofessional personnel. Thus, Ap-
pleby (1963) demonstrated significant im-
provement in chronic schizophrenics who
were treated by hospital aides functioning in
effect as lay therapists. Mendel and Rapport
(1963) have also shown the value of lay per-
sonnel over a 51-month period of observation
in helping chronic patients remain outside of
the hospital with only periodic supportive in-
terviews.
The present program differs quite markedly
from the training program reported by Rioch
(1963), who clearly demonstrated that spe-
cially selected, bright, sophisticated, and edu-
427
cated housewives could learn from very in-
tensive and long-term training (similar to
that involved in graduate schools with good
practicum programs) and could be as well
regarded by their supervisors as those trained
in regular graduate schools. The program de-
scribed by Rioch, while important as a dem-
onstration, would be extremely difficult to
replicate elsewhere and in general would be
as expensive to duplicate as it would be to
pay for graduate school (which of course has
the advantage of professional status).
By contrast, the counseling or psychother-
apy training program described here, since it
involves less than 100 hours of training (and
less than 65 hours of supervisor time), is not
more expensive to implement than a great
many hospital aide training programs. Fur-
ther, since it relies heavily upon research in-
struments and training tapes it is more readily
replicable.
The present training program is also of
theoretical significance. A number of studies
(Barrett-Lennard, 1962; Bergin & Soloman,
1963; Braaten, 1961; Halkides, 1958; Rogers,
1962; Tomlinson & Hart, 1962; Truax, 1961;
Truax & Carkhuff, 1964a, 1964b; Wagstaff,
Rice, & Butler, 1960) have now amassed evi-
dence suggesting that three therapist-offered
conditions and one critical dimension of pa-
tient behavior are significantly associated
with constructive personality change in a va-
riety of hospitalized and nonhospitalized pa-
tients: (a) therapist accurate empathic un-
derstanding, (b) therapist communication of
warmth or unconditioned positive regard, (c)
therapist genuineness or self-congruence, and
(d) patient depth of self-exploration. These
studies have been conducted with trained and
relatively experienced therapists so that the
variables studied operated in the context of
a thorough knowledge of patient psychopa-
thology and dynamics. It could very well be
that these four elements of effective psycho-
therapy are in fact effective only in the con-
text of a thorough knowledge of psychopa-
thology and dynamics. Since the training pro-
gram with the lay personnel involved no
training in psychopathology and personality
dynamics, an evaluation of their effectiveness
would throw some light upon the necessity or
428 ROBERT R. CARKHUFF AND CHARLES B. TRUAX
value of training in psychopathology and per-
sonality dynamics.
METHODOLOGY
Five volunteer but otherwise unselected hospital
personnel 4 from Eastern State Hospital, Lexington,
Kentucky, were involved in the training program.
These volunteers consisted of three aides, a volunteer
worker, and an industrial therapist. Only the indus-
trial therapist had a college education. The hospital
personnel ranged in age from 32 to 50 (M, 41.40;
SD, 7.42).
Briefly, the training involved the supervisor didac-
tically teaching the trainee about effective therapeutic
dimensions in the context of a relationship providing
the trainee the experiential base of these dimensions.
Research scales which had successfully measured the
levels of therapeutic conditions of tape-recorded ther-
apy in research predictive of therapy outcome were
employed in teaching the trainees to discriminate
levels of the four conditions involved. The trainee
then received empathy training in which they listened
to patient statements and then were asked to formu-
late their responses in terms of the feeling and con-
tent of the communication. The trainees role-played
and finally had initial clinical interviews with hos-
pitalized patients. All phases of training were re-
corded for purposes of rating within the class so as
to give the trainees immediate and concrete informa-
tional feedback on how well they were learning to
operationalize the concepts involved.
Three of the lay personnel were assigned to two
groups each of 10 patients in each group. Due to
limitations in the population available, the two re-
maining counselors were assigned only one group
each of 10 patients. With the exception that 10 less
patients were represented in the control groups, the
patients were divided into groups according to the
years institutionalized and randomly assigned to
treatment groups. In total, then, ISO Eastern State
Hospital patients were involved, with 80 in the treat-
ment groups and 70 in control groups. Three of the
treatment groups were females (N = 30), and 24
members of the control groups were females.
Criteria for patient selection included the follow-
ing: patients who were not expected to be discharged
within a 3-month period, patients who were not cur-
rently being seen in any form of psychotherapeutic
treatment, and patients who were not diagnosed to
be mentally retarded or to have organicity. The pa-
tient population involved the typical multiplicity of
diagnostic categories not only among various pa-
tients but also within the clinical histories of the in-
dividual patients. The variety of current diagnosis
included manic-depressive reactions of the manic and
depressive types, psychotic-depressive reactions and
schizophrenic reactions, simple catatonic and schizo-
affective types, with the great majority of all pa-
tients diagnosed as hebephrenic, paranoid, or chronic
4
The lay hospital personnel who gave so much of
themselves to the training program are Jean Dansby,
Julia Hardy, Gene Lee, Mary Washington, and Polly
White.
undifferentiated types. One patient fell into each of
the following categories: psychoneurotic anxiety re-
action, sociopathic personality disturbance, passive-
aggressive personality trait disturbance, and transient
adult situational personality disturbance.
The treatment group ranged in age from 24 to 64
with an M of 50.03 years (SD, 11.14). These pa-
tients had had an average of 7.44 (SD, 3.65) years
of education, with some patients having had no
schooling and some having college degrees. The num-
ber of hospital admissions, including their present
stay, ran from the first admission to the fourth and
averaged 1.96 (SD, .92), and the length of stay dur-
ing the present hospitalization ranged from 1 to 36
years with an M of 13.62 (SD, 11.23).
The control group members varied in age from 20
to 66 (M, 46.96; SD, 11.47) and schooling from 0 to
16 grades or college (M, 7.51; SD, 3.36). The aver-
age number of hospital admissions was 2.09 (SD,
1.04) range again from 1 to 4, while the years of
the present hospitalization varied from 1 to 34 with
an M of 10.03 (SD, 8.19).
In summary, the population was essentially an
older chronic one with an average of two admissions.
While the sample was a severely disabled one, it rep-
resented the great bulk of the hospital population
which is usually not serviced by the professional staff
and thus provided a testing ground for the usefulness
of lay treatment.
The patients were seen twice a week for a total of
24 sessions over a period of approximately 3 months
in time-limited group counseling. There was no prob-
lem-oriented or personnel-oriented basis for group
assignment. Patients were simply randomly assigned
to the individual treatment and the control groups.
The sessions were recorded for the purposes of su-
pervision and any subsequent analyses. The lay coun-
selors continued to meet as a group for purposes of
being supervised twice a week for an hour each
time.
In the treatment process, the lay counselors were
oriented only toward providing high levels of thera-
peutic conditions. They had no cognitive map of
where they were going except to attempt to elicit a
degree of self-exploration relating to the problems
and concerns which the patients brought to the ses-
sion. The therapist's role was to communicate a
warm and genuine concern and depth of understand-
ing. There was no special focus for discussion; no
topics were forbidden; and in general as the sessions
evolved, they included discussions of the usual range
of emotion-laden or intellectualized topics from
sexual material to concerns regarding autonomy and
more immediate and pragmatic concerns like the
method for "getting out" of the hospital, or even
"staying in."
Outcome criteria to be assessed included hospital
discharge rates and pre- and posttreatment ratings
of ward behavior by the nurses and ward attendants
of the particular wards from which the patients
came. In all, seven wards were involved, so the
nurses and ward attendants of these seven wards
were involved in the rating. An attempt was made to
give pre- and posttesting using a battery of psycho-
 THE EFFECTS OF LAY GROUP COUNSELING 429

logical tests including the MMPI, the Q sort for Self Burger, 1964), a series of four nine-point
and Ideal Self, and an Anxiety scale. Unfortunately, scales where 9 represents the highest value in
because of the degree of chromcity and pathology as ,,
the
•,.
osltlve
j. ,. j , , ,r.
well as the general low level of educational attain- P direction and 1 represents the
ment, less .than 30% of both groups or 18 members lowest value in the negative direction. The
of the treatment group and 16 members of the con- scales assessed four critical areas: (a) "de-
trol group proved testable, so that the evaluation of gree O f psychological disturbance"; (b) "de-
patfent change was based upon changes in ward be- gree Qf construcdve interpersonal concern";

(c) "degree of constructive intrapersonal con-

RESULTS
Of the 80 patients who were seen in coun-
seling, 6 dropped out, all within the first six
sessions. Eleven of the remaining 74 patients
who continued with some great degree of
regularity were discharged after 2 or more
months of therapeutic treatment. Of the 70
control patients, 6 were discharged within the
3-month period of time. While the direction
and absolute values are meaningful, a chi-
square of 1.42 did not yield statistically sig-
nificant differences.
All of the patients were rated before and
after treatment on the short-form "Gross Rat-
ings of Patient Behavior" (Carkhuff & De-
TABLE 1
DIRECTION OP CHANGES or GROSS RATINGS OF PATIENT BEHAVIOR BY WARD PERSONNEL
cern," and perhaps most important, (d) the
"degree of overall improvement over the past
3 months," for which only postratings were
obtained. The posttreatment ratings were
available for all treatment and control group
members. Twenty of the preratings necessary
to assess the first three indexes of ward be-
havior of the control group were, however,
lost or misplaced. Analysis of the posttreat-
m
ent "overall improvement" ratings indicates
that the 20 patients whose preratings were
misplaced tended to be rated slightly worse
than the control group in general, thus sug-
gesting that the differences between treatment
and control groups on the three other scales

Patient groups

Overall improvement (N = 74) (N = 70)

(Postratings only)
Improved 38 19
Deteriorated 1 x2 = 21.47*** 12
Unchanged 35 39

Psychological disturbance (ff = 74) (N = 50)

(Pre- and postratings)
Improved 28 8
2
Deteriorated 19 x = 17.28*** 5
Unchanged 27 37

Interpersonal concerns (N = 74) (N = 50)

(Pre- and postratings)
Improved 33 16
Deteriorated 14 Xs = 11.23** 2
Unchanged 27 32

Intrapersonal concerns (N = 74) (N = 50)

(Pre- and postratings)
Improved 28 15
Deteriorated 16 X2 = 6.79* 4
Unchanged 30 31

* Significant at the .05 level.

** Significant at the .01 level.
*** Significant at the .001 level.
430 ROBERT R. CARKHUFF AND CHARLES B. TEUAX

are conservative. Five of the 20 were rated education, and who were already 50 years of
improved; 5, deteriorated; and 10, no change. age.
As can be seen from Table 1, all scale differ- Since pre- and postratings of ward behavior
ences between treatment and control groups were used as the basic measure of change,
were statistically significant by chi-square. It biased reports from the ward staff should be
is notable that only one of the treatment considered. We have long been somewhat sus-
group patients was rated as deteriorated in his picious of reported improvements when the
overall behavior over the previous 3 months, ward doctor treated patients and asked the
while 38 were judged improved. Twelve of ward staff to evaluate his effectiveness. The
the control-group members were rated be- lay counselors had no direct connection with
haviorally deteriorated overall, while 19 were any of the wards involved. It should be noted
rated improved. Furthermore, it is clear from also that in the present case the ward staff and
the other scale values that control group mem- the hospital personnel in general were initially
bers tended to remain unchanged, while there resistant to the idea that hospital attendants
was a greater variability in the treatment should even be allowed to conduct group
group ratings. counseling. The lay therapist did not initially
enjoy high status. The admitted and out-
DISCUSSION AND IMPLICATIONS spoken bias of the ward personnel involved
The evidence points to uniformly significant in the behavioral ratings was against rather
improvement in the patients treated by lay than for lay group counseling: the expecta-
group counseling when compared to control tion of the ward personnel initially was that
patients. The suggestion is that a specific but the lay group counseling would upset the pa-
relatively brief training program, devoid of tients and that therapy with nonprofessional
specific training in psychopathology, person- therapists would be harmful rather than
ality dynamics, or psychotherapy theory, can helpful.
produce relatively effective lay mental health The "attention factor" in relation to the
counselors. It is significant that three of the patients themselves should, however, be con-
five lay counselors in the present study had sidered. Most of the patients had received no
only a high-school education or less, two had special treatment, especially no psychothera-
attended college, and only one had completed peutic treatment during their many years of
college. In view of the relatively brief train- hospitalization. There was in fact great diffi-
ing, it would seem feasible to train a large culty initially in getting patients to attend
percentage of currently existing hospital aide the group sessions, although most attended
staff, at no extra cost, and thus provide regu- regularly after the first few weeks, many look-
lar lay group counseling to almost all hos- ing forward to this special form of attention
pitalized patients. which they were receiving. Although present
It is of significance that the patient popula- resources did not allow for such a control,
tion used in the present evaluation was an un- future replication should incorporate a second
selected one, by and large involving a pre- control group of patients attending "sessions"
ponderance of chronic hospitalized patients. conducted by untrained lay personnel.
A recent study by Spitzer, Lee, Carnahan, and The evidence that the treatment group pro-
Fleiss (1964) has indicated that the Ken- duced greater variability in outcome com-
tucky Hospital population is significantly pared to the control group parallels equiva-
more pathological and less communicative, lent findings in psychotherapy (Barren &
perhaps due to a lower socioeducational Leary, 19SS; Cartwright & Vogel, 1960;
status, than patient populations in similar in- Shlien, Mosak, & Dreikurs, 1960). It is per-
stitutions in northern and more urbanized haps of some significance that only one treated
states. Thus, lay group counseling produced patient was judged deteriorated in overall be-
significant improvement in patients who on havior. This compared most favorably with
the average had spent an average of 13-J years reported effects of professional group psycho-
in their current hospitalization, had had one therapy with even less chronic hospitalized
previous hospitalization, had a seventh-grade patients.
 THE EFFECTS OF LAY GROUP COUNSELING
In addition, the absolute number of treat-
ment group members getting out, while not
statistically significant due to the patient N
involved, and, while always qualified by what
goes into the process of patient discharge,
nearly doubled those of the control group.
In summary, the present research has dem-
onstrated the effectiveness of time-limited lay
group counseling, evolving from a short-term
integrated didactic and experiential approach
to training. It is felt that the results indicate
great promise for the possibly critical role
which lay personnel might play in coping with
our evergrowing mental health concerns. The
results point to the need for further and con-
tinued search and research into this poten-
tially vast and untapped resource.
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