Evaluation and Program Plannmg, Vol. 6, pp. 21 l-236, 1983 0149-7189183 $3.00 + .

OO
Printed in the USA. All rights reserved. Copyright 0 1984 Pergamon Press Ltd

RESEARCH ASSESSING CONSUMER SATISFACTION

WITH MENTAL HEALTH T~ATMENT:

A Review of Findings

JAY L. LEBOW

Institute of Psychiatry, Northwestern University Medical School

ABSTRACT
This article reviews the findings of studies examining consumer satisfaction with mental health
treatment. Typically, published studies find the vast majority of patients satisfied with treat-
ment, Despite the numerous methodological problems in this research, it remains highiyprob-
able that the majority of consumers are satisfied with the services received. More specific find-
ings in this Iiterature remain less weii demonstrated; there genera& are few studies relevant to
each specific question and the methodology of these studies often has been weak. However,
trends point to weak relationships between patient demographic variables and satisfaction;
significant relationships between patient diagnosis, treatment history, and psychological
status and satisfaction; strong relationships between length of treatment and manner of ter-
mination and satisfaction; a strong relationship between satisfaction andpatient global report
of outcome; and a weak relationship between satisfaction and therap~t rating of outcome.
satisfaction also appears to be mult~dime~ionaI, aIthough a Iarge general factor is evident in
most studies. A number of additional findings are catalogued; and research iying outside the
formal domain of satisfaction research, but relevant to this body of research, is reviewed.

Consumer satisfaction surveys have become relatively
common in mental health treatment settings (Larsen,
Attkisson, Hargreaves, & Nguyen, 1979; Lebow,
1982a; Sorenson, Kantor, Margolis, & Galano, 1979);
however, the results of these efforts have yet to be
comprehensively summarized. In part, this oversight
may be accounted for by the widespread acknowIedge-
ment of the methodological problems in this body of
work (Gutek, 1978; Hargreaves & Attkisson, 1978;
Locker & Dunt, 1978; Margolis, Sorenson, & Galano,
1977; Marin, 1980; Rocheleau & Mackesey, 1980;
Scheirer, 1978), suggesting possible limitations in the
validity of findings.
I believe that the data remain worth summarizing
despite the problematic nature of much of the research.
Information about this important aspect of mental
health care needs to be disseminated so that individual
efforts to assess satisfaction can be placed in the
proper context. The methodological problems must be
considered in evaluating this research, but it remains
important to glean what is available in the data. At the
very least, norms for poorly controlled studies emerge,
and a case can be made for the meaningfulness of
much of these data.
However, caution is appropriate in approaching this
relatively new and poorly controlled data base. Find-
ings are best conceptualized as hypotheses for further
exploration rather than as generalizable conclusions.
Limitations are particularly great in those instances
where only a few studies have explored significant
questions. I have considered the various sources of
bias and their potential impact on the meaning of find-
ings in this research elsewhere (Lebow, 1982a, 1983a)
and refer the reader to those papers for a consideration
of the methodological problems in this research and
how these problems can be mitigated. This paper
focuses instead on summarizing the knowledge about
consumer satisfaction with mental health treatment,
and is best considered in conjunction with these earlier
papers.

Requests for reprints should be addressed to Jay L. Leboa, Center for Famdy Studies/The Famdy Institute of Chicago, Institute of
Psychiatry, Northwestern Memorzal Hospital and Northwestern University Medical School, Suite 1530, 666 Lake Shore Drive, Chicago, IL
60611.

211
212 JAY L. LEBOW
DEFINING CONSUMER
The term consumer s~ti~fuctio~ has been used to
describe a broad range of research; often the term has
been used to denote a method of data collection, the
post-treatment patient survey, rather than any specific
content. Many studies have been labeled as “satisfac-
tion” research that have not asked about satisfaction
with treatment: For example, several studies of patient
rated outcome have been so labeled. Other relevant
research such as the studies using the Barrett-Lennard
to assess the patient’s reaction to the psychotherapist
or the Ward Atmosphere Scale to assess reaction to the
milieu in inpatient treatment (e.g., Moos & Houts,
1968, 1970), have not generally been labeled as satis-
faction studies and therefore rarely have been discussed
in conjunction with the satisfaction literature.
Given the past usage, it makes most sense to state
both a narrow and a broad definition of satisfaction.
Within the narrow definition, I include all inquiries
into the extent to which services gratify the client’s
wants, wishes, or desires for treatment. Included here
are inquiries into both the felt adequacy of treatment
and of the surrounding miheu; specific aspects may
include reactions to the quality of care, to its helpful-
ness, its cost and continuity, the availability and ac-
cessibility of the practitioner, and the reaction to sup-
porting services. This paper will basically review
studies that fall within this narrow definition.
However, a basis also exists for a broader definition
of satisfaction. Many measures correlate highly with
self-report of satisfaction, so that these measures
become indices of satisfaction. Such related in-
struments include global indices of change such as the
Global Improvement Scales (Strupp, Wallach, &
Wogan, 1964; Waskow & Parloff, 1975); records of
complaints or praise for treatment (Koltuv, Ahmed, &
Mayer, 1978); questionnaires assessing suggestions for
improving treatment; multidimensional descriptions
of the phenomenoIogy of the patient’s reaction to
treatment such as the Therapy Session Report (Orlin-
sky & Howard, 1975); descriptions of the patient’s
response to the psychotherapist such as the Barrett-
Lennard Inventory (Barrett-Lennard, 1962; Gurman,
1977); and inquiries into what was found helpful and
unhelpful in treatment (Feifel & Eels, 1963). Obviously,
any review of these disparate bodies of research would
be an enormous undertaking, well beyond the intent
and space limitations here. Fortunately, excellent
reviews of several of these research domains are avail-
able (Gurman, 1977; Garfield, 1978a; Orlinsky &
Howard, 1978; Parloff, Waskow, & Wolfe, 1978;
MEASURES OF SATISFACTION
Researchers conducting satisfaction studies have tended
to develop their own instruments; therefore, there are
SATISFACTION
Weinstein, 1979). In this paper, these relevant domains
receive secondary attention.
Indicators of utilization, such as attendance and
completion of treatment, are not reviewed here save
for when utilization is compared to direct inquiries
about satisfaction. Such measures are important, but
reflect numerous pragmatic factors other than satis-
faction Excellent reviews of these behavioral indices
are also available (Garfield, 1978a; Baekeland & Lund-
wall, 1975).
The studies of satisfaction reviewed in this paper
may be divided into four general types. The majority
of the studies fall into the first category: poorly con-
trolled studies conducted in naturalistic settings. In
these studies, usually conducted in community mental
health facilities, typical treatment is studied, but the
methodology is crude. Better controlled analogue
studies form a second group: These studies are usually
conducted in counseling settings; often involving
atypical (brief) treatment, and often assessing satisfac-
tion after only a few sessions. A third set of studies
consists of well controlled evaluations of the efficacy
of psychotherapy and psychopharmacology in which
consumer satisfaction is employed as a tangential
measure. Here, the methodology is excellent but little
attention is focused on satisfaction; often one must
carefully comb the text merely to find the data (e.g.,
Mintz, Luborsky, & Christoph, 1979). Surprisingly
few of the better studies of psychotherapy and psycho-
pharmacology outcome have even included satisfac-
tion measures. Only recently has a fourth group of
well controlled studies aimed at assessing satisfaction
in typical mental health treatments and treatment set-
tings begun to emerge (Larsen et al., 1979; LeVois,
Nguyen, & Attkisson, 1981; Strupp, Fox, & Lessler,
1969). This last group of studies is assigned dispropor-
tionate importance in this review.
I include in this review any study examining satisfac-
tion with mental health center services, psychiatric in-
patient services, day hospital services, psychotherapy,
or counseling with a personal problem focus. Studies
of satisfaction with related services (social services,
vocational counseling) are not included. An extensive
effort has been made to locate ail relevant published
studies; however, the disparate locations in which this
work appears coupled with the inconsistent labeling of
these studies, virtually guarantees some oversight. Un-
published studies have not been included save for a
few efforts of overriding interest.
few widely used instruments. The only instrument
employed in more than a few studies has been the
 Satisfaction with Mental Health Treatment
Client Satisfaction Questionnaire (CSQ) developed by
Attkisson and his colleagues at the University of
California at San Francisco (Attkisson & Zwick, 1982;
Larsen et al., 1979; LeVois et al., 1981; Nguyen, Att-
kisson, & Stegner, 1983). There are several forms of
this questionnaire; the CSQ-18 has two alternate
Is-item formats assessing a wide range of concerns;
the CSQ-8 is a shorter (&item) instrument with a high
degree of internal consistency and correlates highly
with the longer instrument. A satisfaction score may
be derived from both the CSQ-8 and CSQ-18 by sum-
ming the individual items. Attkisson and his colleagues
have also developed a promising scale, the Evaluation
Ranking Scale (Attkisson, Roberts, & Pascoe, 1983;
Pascoe & Attkisson, 1983), which combines a rating of
satisfaction on several dimensions with a weighting of
EXTENT
The use of consumer satisfaction measures has in-
creased markedly in recent years (McPhee, Zusman, &
Joss, 1975; Sorensen et al., 1979) especially in federally
supported community mental health centers, (CMHCs)
which were mandated to study the acceptability of
treatment in PL 94-63. In 1973, 35% of the federally
assisted CMHCs reported assessing satisfaction (Mc-
Phee et al., 1975); in a later survey, 48% of centers
reported such assessment (Sorensen et al., 1979).
Although the extent of efforts might be exaggerated in
these reports and some of these assessments may have
been short-lived, it does appear clear that these
methods have been widely used in CMHCs. Use has
ORIGINS AND UTILIZATION
Most efforts have been initiated by facilities or pro-
grams; few attempts have involved consumers in the
planning process (Windle & Paschall, 1981). There are
a few innovative exceptions (Kaufmann, Sorensen, &
Raeburn, 1979; Zinober, Dinkel, Landsberg, & Win-
dle, 1980).
The manner in which these data have been used is
poorly documented. Uses that have been noted for
COST
Consumer surveys are quite inexpensive. Costs rou-
tinely are less than $lOO.OO/survey once an instru-
ment has been constructed (Pandiani et al., 1982).
Cost only increases significantly when a low rate of at-
THE EXTENT OF RESPONDING
There is considerable attrition in responding to con-
sumer surveys. CMHCs report an average of 54%
compliance (Sorenson et al., 1979), a level confirmed
in the published studies. Table 1 presents data from
studies of satisfaction conducted in typical mental
213
the importance of these dimensions. As yet, this scale
has only been utilized with general medical patients,
but the scale is also applicable to mental health set-
tings. The instruments developed by the California
group are vast improvements over prior efforts.
Among the other preferred instruments are the
scales developed by Love, Caid, and Davis (1979) and
Slater, Linn, and Harris (1982) for assessing outpatient
treatment; Deiker, Osborn, Distefano, and Pryer (1981)
for assessing outpatient treatment, and Strupp et al.
(1964) for assessing psychotherapy. Several excellent
scales are also available that assess satisfaction with
medical care (Doyle & Ware, 1977; Hulka, Zyzanski,
Cassel, & Thompson, 1970, 1971; Ware & Snyder,
1976); these could easily be adapted to assess mental
health treatment.
OF USE
been widest in outpatient treatment (Kirkhart, Note 2;
Pandiani, Kessler, Gordon, & Domkot, 1982; Sorensen
et al., 1979) and least frequent in emergency care.
Whether these patterns will change as a result of the
elimination of the federal mandate for these data re-
mains to be seen.
The extent of the study of satisfaction in private set-
tings and public settings other than CMHCs is less well
documented. Nonetheless, it seems certain that satis-
faction is less frequently assessed in these settings. Few
published studies emanate from facilities that are not
CMHCs.
OF THE STUDIES
satisfaction data include the monitoring of services
(Hargeaves & Attkisson, 1978); the assessment of the
performance of specific clinicians (Braukmann, Fixsen,
Kirigin, Phillips, Phillips, & Wolf, 1975; Pandiani et
al., 1982) and public relations (Giordano, 1977).
However, there are no data suggesting the frequency
with which data are used for these purposes.
trition from the survey is sought, or when in-person in-
terviews are involved (e.g., Showstack, Hargreaves,
Glick, dz O’Brien, 1978).
TO CONSUMER SURVEYS
health facilities; the average rate of responding in these
studies is 57010.
However, these summary statistics are also
somewhat deceptive. There has been considerable
variability in rate of responding. Of the 49 studies
214 JAY L. LEBOW

TABLE 1
PERCENTAGE RESPONDING AND FREQUENCY OF SATISFACTION IN
CONSUMER EVALUATION STUDIES
-
Sample Percent Percent Satisfied:
Study (Authors and Year) Size Responding Most General Item

Ahmed & Koltuv, (1976) 25 43” 84

Attkisson et al. (Note 1) 3,282 93 **
Attkisson & Zwick (1982) 45 73 **
Balch et al. (1977) 108 40 79
Bene-Kociemba et al. (1982) 22 61 72
Birnbaum & Suits (1979) 219 25 78
Bloom & Trautt (1978) 86 - .*
Burgoyne et al. (1977) 2,000 42 91
Ciarlo & Reihman (1977) 100 100’ 84
Denner & Halprin (1974a) 66 29 71
Denner & Halprin (1974b) 86 26 65
Drstefano et al. (1980a) 30 - 73
Distefano et al. (1980b) 48 - 80
Distefano et al. (1981) 40 - 74
Eder & Kukulski (1975) - - 68
Edwards et al. (1978) 226 48 88
Eisen & Grob (1982) 87 40 **
Essex et al. (1981) 170 19 88
Fiester & Fort (1978); Frester (1979) 438 68 87
Flynn et al. (1981) 220 22 63
Frank (1974): Frank et al. (1977) 228 31 66
Getz et al. (1975) 104 39 85
Grlligan & Wilderman (1977) 60 58 75
Glenn (1978) 518 83 67
Gordon (1976) 58 68 85
Gove & Fain (1977) 260 79
Goyne & Ladoux (1973) 240 3s 78
Hart & Bassett (1975) 54 63 56
Harty & Horowitz (1976) 37 88* 54
Heineman & Yudin (1974) 92 30 91
Janoen & Aldrich (1973) 205 100 **
Justice & McBee (1978) 333 100 84
Kaufmann et al. (1979) 205 90 87
King (1977) 66 - 75
Kirchner (1981) 73 60 74
Kirchner (1982) 254 48 85
Kirchner & Hogan (1982) 99 52 67
Krssel (1974) 168 52 79
Kline et al. (1974) 580 100 85
Koltuv et al. (1978) 105 52 tt
Kotin & Schur (1969) 110 37 55
Landsberg (1973) 100 - 84
Landsberg (1975) 54 53 64
LeVois et al. (1981) 92 90 l*
Love et al. (1979) 114 80 91
Mayer & Rosenblatt (1974) 220 80* 74
McCoy et al. (1975) 93 - 86
Meier (1981) 38 - tt
Noll & Block (1979) 120 40 62
Pandiani et al. (1982) 709 l*
58
Powell et al. (1971) 65 33 73
Preston et al. (1975) 492 48 98
Pryer et al. (1981) 247 - 75
Reinhart & Cazavelan (1975) 167 36 77
Silver et al. (1975) 105 54 1100
Slater et al. (1982) 170 - fl
Slem & Cotler (1973) 56 58 68
Snelling & Walker (1978) 84 62 85
Spensley et al. (1980) 42 - *.
Strupp et al. (1969) 131 54 89
Strupp et al. (1964) 44 58 93
Woodward et al. (1978) 279 100 64
Wurmser (1979) 515 l*

Note. *highly selected sample; l * only mean for questionnaire reported; - = not reported.
 Satisfaction with Mental Health Treatment
reporting these data, 15 found response rates between
19% and 40%, 16 between 41% and 60%, 8 between
61% and 80%, and 10 between 81% and lOO%.’ This
variability is closely related to the manner of data col-
lection. The lowest rates of responding are found with
mailed questionnaires; the highest when samples are
carefully selected and interviewed directly after service
is provided. The average rate of completion of mailed
questionnaires has been 40010; for phone interviews,
43%; for interviews conducted in the client’s home,
64%; and for interviews or questionnaires presented in
conjunction with treatment, 82%. Employing both
mail and phone contacts produces somewhat better
compliance than either method alone; an average of
55% of patients respond to such a combination of
methods.
Unfortunately, the methods that produce the
highest rates of responding also are the most costly
and/or reactive (Lebow, 1982a, 1982b, 1983a, 1983b).
Employing extensive follow-up procedures and multiple
methods of contacting patients at the time of treat-
ment greatly increases reactivity. LeVois et al. (1981)
~O~PA~SONS OF RESPONDENTS AND NON-RESPONDENTS
Almost no demographic differences emerge between
respondents and non-respondents to consumer surveys
(Burgoyne, Wolken, Staples, Kline, & Powers, 1977;
Denner & Halprin, 1974a, 1974b; Flynn, Balch, Lewis,
& Katz, 1981; Silver, St. Clair, & Siegel, 1975;
Spensley, Edwards, & White, 1980; Strupp et al.,
1969; Strupp et al., 1964). Where there have been
demographic differences, the findings are counter-
balanced by conflicting findings in other studies (e.g.,
for age: Ellsworth, 1979; Grob, Eisen, & Berman,
1978; for severity of disturbance: Pandiani et al.,
1982).
However, differences emerge in treatment related
characteristics. Outpatients who respond more fre-
quently to surveys have the following characteristics:
mutual terminations (Denner & Halprin, 1974a,
1974b; Frank, Salzman, & Fergus, 1977; McWilliams,
Lewis, Balch, & Ireland, 1979; Speer & Zold, 1971),
longer treatments (Grob et al., 1978; Schainblatt,
1980; Strupp et al., 1969; Strupp et al., 1964; Speer &
Zold, 1971), better rated outcomes @peer & Zold,
1971), higher fees (Speer & Zold, 1971), and better
ratings as patients by therapists (Speer & Zold, 1971;
Strupp et al., 1964). Similarly, inpatients who respond
‘Analogue studies are not included. Given the short-term nature of
these treatments and constraints on “clients” (they may be receiving
course credit for their involvement), the rate of responding is likely
to be high. In these studies, rate of responding is almost never
reported.
215
found that oral administration increased the favor-
ability of ratings by 10% above the response to a ques-
tionnaire when other aspects of administration were
held constant. The far more reactive procedures in-
volved in data collection at the time of treatment might
be expected to result in an even greater alteration in
rating. In selecting a method of presentation, one in-
variably also chooses a set of liabilities (Lebow, 1982a,
1983a).
Trends across studies also suggest that other factors
affect the rate of responding; these include the mobility
of the population (highly transient populations have
greater attrition), the kind of treatment under study
(outpatients are more likely to respond, e.g., Schain-
blatt, 1980), the time between treatment and data col-
lection (the longer the interval, the less likely is client
to respond, e.g., Schainblatt, 1980), and the length of
the instrument and the number of instruments presented
with the satisfaction scale (the longer the instrument
and the greater the number of instruments, the lower
the response rate, e.g., Speer & Zold, 1971).
more frequently to surveys are more likely to have
planned discharges (Eisen & Grob, 1982), shorter
treatments (Bene-Kociemba, Cotton, & Fortgang,
1982), fewer prior hospitalizations ~Bene-Kociemba et
al., 1982), longer treatments (Eisen & Grob, 1982)
and better rated outcomes (Eisen & Grob, 1982; Grob
et al., 1978).
The method of presenting the survey also has an im-
pact. Murphy (1980) found that clients who responded
to a first wave of inquiry were more satisfied than
those responding to subsequent contacts; Burgoyne et
al. (1977) found that there were differences in the
clients responding across methods of distributing ques-
tionnaires.
A few studies have failed to detect a relationship
between treatment-related characteristics and the
likelihood of responding (e.g., length of treatment:
Silver et al., 1975; outcome: Ellsworth, 1979; Laporte,
McCleIland, Erdlan, & Parante, I981; multiple treat-
ment characteristics: Birnbaum & Suits, 1979; Feifel &
Eels, 1963; Flynn et al., 1981). A few studies also have
found similar levels of satisfaction among respondents
and initial non-respondents contacted through exten-
sive and atypical follow-up procedures (Ellsworth,
1979; Frank et al., 1977; Silverman & Beech, 1979).
However, the large body of findings suggesting dif-
ferences between respondents and non-respondents
suggests the value of a conservative stance in which dif-
ferences between the sample and those not responding
are presumed until the comparability of these groups is
demonstrated.
216 JAY L. LEBOW
RELIABILITY
The reliability of satisfaction reports has only been
assessed in a few studies. The better developed scales
appear reliable. Each of the versions of the Client
Satisfaction Scale (Larsen et al., 1979; LeVois et al.,
1981) have been demonstrated to have high reliability
(Attkisson & Zwick, 1982; Larsen et al., 1979; LeVois
et al., 1981; Nguyen et al., 1983). Two forms of the
CSQ-18 have also been shown to correlate highly (Le-
Vois et al., 1981). The scales developed by Love et al.
THE ACCURACY OF CLIENT REPORTS
There is little information documenting the validity of
consumer satisfaction scales. Scale validity has fre-
quently been addressed in opinion pieces (Gutek, 1978;
Lebow, 1982a, 1983a; Scheirer, 1978), but seldom
assessed in research. The only extensive information
concerns convergent and discriminant validation
(Campbell & Fiske, 1959); i.e., how the measurement
of satisfaction correlates with the measurement of
other related concepts. The results of studies assessing
the relationship between satisfaction, outcome, and
utilization presented later in this paper provide the
beginnings of a nomological net (Cronbach & Meehl,
1955) delineating the construct of client satisfaction.
However, research has yet to test the accuracy of con-
sumer reports; both high and low correlations between
consumer satisfaction with other measures can be
plausibly explained without questioning the accuracy
of the satisfaction data.
A few studies have examined the correlations be-
tween satisfaction and concepts likely to confound
client view. These studies raise suspicions about the
meaning of responses to satisfaction instruments.
LeVois et al. (1979) found a significant correlation be-
tween satisfaction with treatment and life satisfaction,
and Distefano, Pryer, & Garrison (1981) found a sig-
nificant correlation between satisfaction and general
interpersonal trust. Although interpretation of these
EXTENT OF REPORTED SATISFACTION
Most consumers report satisfaction with mental health
treatment; however, satisfaction is not universal.
Table 1 lists studies reporting the extent of satisfaction
in a sample. Examining the response to the most gen-
era1 satisfaction item in each study, the following find-
ings emerge. Among the 34 studies that report fre-
quency of satisfied consumers in outpatient settings or
in comprehensive mental health centers where most
clients receive outpatient treatment, 3 have found
satisfaction between 91% and 100%) 13 between 8 1%
and 9070, 9 between 71% and 80%, 7 between 61%
and 70%, and 2 between 41Yo and 60%. Among the 13
(1979), Slater et al. (1982), and Brown (1979) also have
demonstrated high reliability.
However, most satisfaction scales have not been
assessed for reliability. Reliability is especially likely to
be a problem where scales are short; Garwick (1976)
found only trivial correlations between single items
and total scores on a satisfaction scale. In general, the
more carefully constructed scales with proven relia-
bilities are to be preferred.
data is not a simple task (the argument can be offered
that a positive world view should be a product of a suc-
cessful treatment, e.g., Beck, 1976), these data may
imply that world view is the major determinant in con-
sumer evaluation (Gutek, 1978; Scheirer, 1978).
Ware’s (1978) finding that much of the variance in a
medical care satisfaction study could be explained by
acquiescence to the wording of items also is troubling.
The role of confounding factors in satisfaction re-
search requires intense study.
Comparisons of satisfaction across good and poor
care and across seemingly satisfying and not satisfying
care would be useful for validation; however, such re-
search is difficult to conduct. Few programs can be ex-
pected to volunteer as the examples of poor care.
However, one such study does exist. In this Indian
study (Thimmapaya & Agrawal, 1973), the better care
was rated more positively.
Some data indicate the inaccuracy of client reports
in other contexts (e.g., the reporting of contacts with
social agencies: Nealey, Taber, & Nealey, 1979); other
research suggests the accuracy of client report (e.g. the
finding that client reports of outcome are more like
those of raters than are those of therapists: Horen-
stein, Houston, & Holmes, 1973). Further study is ob-
viously needed of the validity of patient report.
inpatient studies, I found satisfaction between 91%
and lOO%, 2 between 81% and 90%) 8 between 71 @?o
and X0%, and 2 between 61% and 70%. (Weinstein,
1979, in a recent review has been able to locate 38
studies assessing the attitudes of patients in inpatient
settings. However, few of these studies directly assessed
satisfaction; rather, Weinstein rated each study as
demonstrating a favorable or unfavorable attitude.
Weinstein rated 30 of the 38 samples as displaying
favorable attitudes to hospitalization.) Among crisis
units, the percentages of satisfied consumers have been
96%, 80070,75%, and 68%. Expressed in other terms,
 Satisfaction with Mental
a mean of 78.3% of consumers express satisfaction in
outpatient studies, 75.7% in inpatient studies, and
83% in crisis unit studies.*
These represent impressive but not unanimous levels
of reported satisfaction; therefore, these findings con-
trast somewhat with surveys of facility directors (Mc-
Phee et al., 1975) and papers overviewing satisfaction
research (Larsen et al., 1979; Keppler-Seid, Windle, &
Woy, 1980) that suggest nearly universal reported
satisfaction. There are other indications of the limits in
reported satisfaction. When the number and range of
choices is extended beyond satisfaction and dissatis-
faction, an average of only 49% of clients classify
themselves as highly satisfied. Mean scores on satisfac-
tion scales do not approximate the maximum potential
score (Eder & Kukulski, 1975; Koltuv et al., 1978; Le-
Vois et al., 1981; Spensley et al., 1980; Wurmser,
1979).
A group of dissatisfied clients emerges in most
studies, but generally dissatisfaction is found in less
than 10% of clients. This has been the case even with
involuntary patients (Gove & Fain, 1977; Spensley et
al., 1980). This pattern of responding suggests dis-
satisfaction is clearly a problem when expressed by
over 10% of clients. Only a few studies have found the
frequency of dissatisfaction to be above this level (e.g.,
Eisen & Grob, 1979).
It must be emphasized that the findings still repre-
sent substantial satisfaction, particularly given that the
clients studied are basically at public facilities, and
tend to be quite naive about mental health treatment at
the onset of treatment. However, the data are incom-
patible with the notion that consumer surveys result in
undifferentiated responses of satisfaction. The level of
satisfaction appears only slightly higher than the norms
for success in outcome research in psychotherapy and
psychopharmacology (Bergin & Lambert, 1978; Gur-
man & Kniskern, 1978; Hollon & Beck, 1978; Lubor-
sky, Singer, & Luborsky, 1975).
The question remains as to how well those reported
THE RELATION OF TREATMENT AND CLIENT
Summary statistics describing the distribution of satis-
faction at mental health treatment facilities like those
just presented have utility (Hargreaves & Attkisson,
1978; Lebow, 1983a), but the assessment of satisfac-
tion under more specific conditions is far more valu-
able. Only through such specific knowledge can the ac-
2A few studies do not report the frequency of satisfied clients, but
rather the mean on the satisfaction scale. These studies show a pat-
tern of findings similar to that in the studies reporting frequency of
satisfied clients.
Health Treatment 217
levels of consumers approximate actual satisfaction.
Given the methodological problems in this research
that might result in distortion in the level of satisfac-
tion, (Gutek, 1978; Larsen et al., 1979; Lebow, 1982a,
1983a, LeVois et al., 198 1; Rocheleau & Mackesey,
1980; Scheirer, 1978), the results should be regarded as
subject to some degree of error. Selection in the re-
sponding sample, reactivity, social desirability, and
client attempts to preserve their self-interest all prob-
ably inflate reports of satisfaction (Lebow, 1982a;
LeVois et al., 1981). At the same time, the public
nature of almost all the facilities studied probably
minimizes reported satisfaction because clients at these
facilities often have unrealistic expectations about
treatment (Garfield, 1978a) and little choice of practi-
tioner or type of treatment. On the whole, it appears
highly likely that the majority of consumers are satis-
fied; the estimation of exact level of satisfaction will
require better controlled research (Lebow, 1982a).
Evaluating whether the mental health care presently
offered is sufficiently acceptable to clients involves a
difficult value judgment. We lack data suggesting
what levels of satisfaction would be under good or
ideal conditions (i.e., with expert clinicians). Such an
assessment therefore must move beyond the data, to a
judgment of what level of satisfaction society might
expect in such treatment. My assessment, based on the
data available, is a positive one. The satisfaction ex-
pressed in consumer surveys does appear at least com-
parable to that expressed with other human services
(Gutek, 1978). I believe that given the number of
negativistic personalities encountered in psychiatry,
and the general lack of knowledge about mental health
treatment in the general public, the satisfaction
reported reflects positively on the treatment offered.
Further studies assessing satisfaction under optimal
treatment conditions and satisfaction across human
services should prove helpful in enabling consideration
of this difficult value-laden judgment.
VARIABLES TO SATISFACTION
ceptability of treatment be improved. However, much
as in the early outcome studies (Kiesler, 1966) there has
been little attention to specificity in this research.
When client or treatment variables have been con-
sidered, the designs have been basically correlational
and poorly controlled. In particular, these studies are
limited by a difficult methodological problem: the
negatively skewed, non-normal distribution of satis-
faction ratings. This distribution of ratings results in
reduced confidence in the correlations calculated be-
cause deviant ratings may have a disproportionate im-
pact, and limits the likelihood that any client or treat-
 218 JAY L. LEBOW

ment variable will affect satisfaction. Because these treating such problems or the 100% follow-up Wood-
studies almost invariably involve large samples, statis- ward et al. were able to achieve, cannot be deciphered
tically significant findings may also emerge that are without further investigatioI1.
not clinically significant. For these reasons, the find- Two studies have assessed satisfaction with medica-
ings reported in the following paragraphs are best tion and medication sessions. In an outpatient Vet-
regarded as hypotheses for further testing. The possi- eran’s Administration sample with a high frequency of
bility that findings are setting-specific must always be previous hospitalization, those on a medical mainte-
considered. nance schedule reported greater satisfaction than those
Treatment Variables not receiving medication (Slater, Linn, & Harris,
Few studies have examined satisfaction across specific 1981). However, this result was not replicated in
forms of treatment. 1 review the findings within a another outpatient sample (Weyant, Dembo, & Ciarlo,
number of delimited areas as follows: 1981).

Type of Setting. Assimilating data from a number of Relationship to Satisfaction with Provider. The rela-
settings, Attkisson, Nguyen, and Stegner (Note I), tionship of satisfaction with care to satisfaction with
found satisfaction greater in outpatient treatment than provider is fairly well documented. In many studies,
in inpatient treatment. However, no similar pattern these ratings are virtually identical. In outpatient
emerges in comparing the levels of satisfaction in samples, high correlations have been found between
studies assessing exclusively inpatient or outpatient satisfaction and client rating of the therapeutic alliance
care and Pandiani et al. (1982) found the acceptabilit} (Jones & Zupell, 19821, and between satisfaction and
of outpatient treatment lowest among the components the client’s rating of therapist interest (Kirchner, 1981).
of a comprehensive mental health center. Therefore, The relationship between overall satisfaction and satis-
although there is some evidence for greater satisfaction faction with provider remains strong even in aftercare
in outpatient treatment, no clear trend can be said to (Bene-Kociemba et al., 1982).
be documented. Discipline and Experience ofPractitioner. Few studies
Group vs. Individual Treatment. Two studies have have examined satisfaction across discipline and level
found group therapy to be less satisfying than in- of experience of the practitioner. Only one study has
dividual therapy in outpatient settings (Hargreaves, compared satisfaction with mental health practitioners
Showstack, Flohr, Brady, & Harris, 1974; Koltuv et to the satisfaction with other health care providers
al., I978), but in a third (Ciarlo, 1979) no difference who treat psychiatric disturbance; in this study, Gor-
emerged. The difference in results probably stems don (1976) found outpatients with psychiatric problems
from variation in treatments, clients, and method of were more satisfied with psychiatrists than with general
measurement. In particular, Hargreaves et al. (1974) practitioners. The one study comparing satisfaction of
examined satisfaction with initiaI sessions before patients treated by the various mental health disci-
groups had a chance to consolidate and before early plines revealed no differences across discipline (Bloom
dropouts had terminated, whereas the other studies ex- & Trautt, 1978).
amined satisfaction at later points in treatment. The effect of therapist experience has been inconsis-
tent. Experience has been found to be related to satis-
Treatine~t Approaches. A few studies have examined
faction in two studies: one at a counseling center
satisfaction with specific forms of 0utpatieIlt treatment.
(Scher, 1973, the other at an outpatient facility (Slater
Most of these have found satisfaction greatest with
et al., 1981). However, two other outpatient studies
simple approaches aimed directly at problem resoIu-
(Frank et al., 1977; Stevens, 1972) have failed to find
tion (Eisenthal & Lazare, 1976; Hart & Bassett, 1975;
greater satisfaction with more experienced therapists.
Johnson, 1976; Strupp et al., 1964). Should further
research confirm these findings, it will be particularly ~o~-Spe~~~~ Aspects of Treat~ne~t. Studies of satisfac-
vital for those utilizing less direct approaches to tion with the so-called “non-specific” aspects of treat-
demonstrate the superior efficacy of their approaches. ment are also rare. The available research is mostly
Remarkably, there is only one study assessing client analogue in nature, usually involving the study of col-
satisfaction with a clearly delineated widely practiced lege students in counseling settings. These studies have
treatment. In that study, Woodward, Santa-Barbara, generally found satisfaction to be influenced more by
Levin, and Epstein (1978) examined the satisfaction oT the fu~fil~rneIlt of client expectations than by any fixed
families presenting with a disturbed adolescent with aspect of treatment (Duckro, Beal, & George, 1979;
problem-centered family therapy. They found 64% of Gladstein, 1969; Martin, Sterne, & Hunter, 1976).
these families satisfied. Whether this relatively low No consistent effect of the level of therapist direc-
level of satisfaction is a function of the treatment, or tiveness seems evident. Satisfaction has been found to
confounding factors such as the inherent difficulty in increase as treatment becomes more directive in two
 Satisfaction with Mental Health Treatment
studies (one analogue: Heilbrun, 1972; and one in a
more typical outpatient setting: Kline, Adrian, &
Spevak, 1974). However, no relationship emerged in
studies of group therapy (Anderson, Harrow, Schwartz,
& Kupfer, 1972) nor in two analogue investigations
(Heilbrun, 1974; Schmidt, 1973).
Relationships between satisfaction and goal setting
(Hill, 1969) and emotional intensity (Jones & Zupell,
1982) in outpatient samples and therapist task behavior
in outpatient group therapy sessions (Schwartz, Har-
row, Anderson, Feinstein, & Schwartz, 1970) have also
been noted, but each finding is confined to a single
study.
Other Elements of Process. Almost no research has ex-
amined the relationship between satisfaction and other
process variables. What research exists has been
limited to satisfaction with specific sessions (Orlinsky
& Howard, 1967, 1975).
Length ofTreaime~t and fanner ofTermination. The
treatment variables that have received the most atten-
tion in relation to satisfaction have been length of
treatment, number of visits, and manner of termina-
tion. The relation of satisfaction to number of visits
and length of treatment has varied. In outpatient set-
tings, one study (Wilier & Miller, 1978) found a cor-
relation of .37; others found smaller significant cor-
relations (Frank et al., 1977; Kirchner, 1981, 1982), yet
others have found almost no relationship (Attkisson et
al., Note 1; Denner & Halprin, 1974b; Larsen et al.,
1979; McCoy, Penick, Powell, & Read, 1975; Schiller,
1976; Stevens, 1972), and one study found satisfaction
decreased as number of sessions increased (Slater et
al., 1981). At the very least, these findings suggest no
strong relationship is present, a pattern also evident in
partial hospitalization (Attkisson et al., Note 1; Bene-
Kociemba et al., 1982) and inpatient settings (Attkisson
et al., Note 1; Distefano, Pryer, & Garrison, 1980a,
1980b, 1981).
The findings concerning manner of termination
have been more consistent. With one exception (Ste-
vens, 1972), studies have found that completing treat-
ment (Denner & Halprin, 1974a) and terminating ap-
propriately (Balch, Ireland, McWilliams, & Lewis,
1977; Denner & Halprin, 1974a, 1974b; Kirchner &
Hogan, 1982; Woodward et al., 1978) are related to
satisfaction.
Aspeets of the Organization. The management and
structure of the organization in which treatment is
delivered are likely to be important to satisfaction;
however, these aspects of treatment have received
almost no attention in the research. No studies have
considered the important issue of funding of treat-
ment. Koltuv et al. (1978) did find sending a welcom-
ing letter reduced the number of complaints.
219
Preparation for the Treatment. Three studies have
compared the satisfaction of clients receiving an orien-
tation to outpatient treatment and those not receiving
specific preparation. Strupp and Bloxom (1973) found
the satisfaction with either a role induction interview
or film orientation exceeded the satisfaction with a
standard initial contact. However, two studies have
failed to find any ultimate effect of preparation on
satisfaction (Heitler, 1973; Attkisson & Zwick, 1982).
The limited data appear to suggest clients value orien-
tation procedures early in treatment, but that such
procedures do not affect satisfaction in the longer
term.
The studies of preparation for treatment are par-
ticularly valuable in offering an as yet underutilized
model for satisfaction research in which satisfaction
with various specific interventions is compared. Also
notable is that the intervention here is centered on an
aspect of treatment (information) frequently noted as
a problem by clients.
Comparative Satisfaction Across Aspects of Treat-
ment. Another suggestive avenue for investigation is
the comparative satisfaction within studies across the
various aspects of treatment. Most such investigations
have centered on inpatient treatment, perhaps due to
the greater array of elements (food, shelter) to con-
sider. The least favorable ratings of satisfaction in in-
patient settings have been in response to inquiries
about information about treatment (Eisen & Grob,
1979, 1982; Snelling & Walker, 1978); amount of con-
tact with staff (Ahmed & Koltuv, 1976); physical ar-
rangements such as privacy (Ahmed & Koltuv, 1976),
facilities (Distefano et al., 1981), meals (Distefano et
al., 1981), and recreation (Distefano et al., 1981);
length of stay (Eisen & Grob, 1979); medication (Eisen
& Grob, 1982); and cost (Eisen & Grob, 1982).
Less information about comparative satisfaction
across areas of treatment is available about outpatient
settings. Slater et al. (1982) found the convenience of
appointment time, the explanation of treatment of-
fered clients, and the information about how to obtain
treatment in an emergency the most frequent areas of
dissatisfaction. Kline et al. (1974) identified the extent
of directives, and Woodward et al. (1979) the com-
prehensiveness of care as the principal areas of dissat-
isfaction.
These data suggest greater dissatisfaction with the
supportive aspects of treatment than with psychother-
apeutic or psychopharmacological treatment offered,
particularly in inpatient settings. Comparative ratings
of aspects of treatment (Eisen & Grob, 1982; Slater et
al., 1981) and the frequencies of satisfaction to specific
inquiries both suggest a high regard for the service pro-
vider.
220 JAY L. LEBOW
Client Variables
~e~og~ffp~~c Variables. Demographic variables do
not appear to be good predictors of satisfaction.
Neither age (Balch et al., 1977; Denner & Halprin,
1974a; Distefano et al., 1980b, 1981; Essex, Fox, &
Groom, 1981; Frank et al., 1977; Larsen et al., 1979;
McCoy et al., 1975; Silver et al., 1975), sex (Balch et
al., 1977; Denner & Halprin, 1974a; Distefano et al.,
1980b; Essex et al., 1981; Frank et al., 1977; Grob et
1978; McCoy et al., 1975; Scher, 1975), race
(“D*enner & Halprin, 1974a; Essex et al., 1981; Grob et
al., 1978; LeVois et al., 1981; McCoy et al., 1975;
Silver et al., 1975), marital status (Balch et al., 1977;
Larsen et al,, 1979; LeVois et al., 1981), income (Dis-
tefano et al., 1981; Essex et al., 1981; Kirchner &
Hogan, 1982; Larsen et al., 1979), social class (Balch
et al., 1977; Denner & Halprin, 1974b; Larsen et al.,
1979), or education (Distefano et al., 198Ob; Larsen et
al., 1979; LeVois et al., 1981) have been consistently
found to be related to the extent of satisfaction.
A few studies have found suggestive relationships.
In one inpatient study (Pryer, Distefano, & Dinning,
1982) and two outpatient studies (Slater et al., 1981;
Pandiani et al., 1982) older patients were more satis-
fied. Attkisson et al. (Note 1) found women more sat-
isfied across all types of service and Pandiani et al.
(1982) found women more satisfied with their coun-
selors in outpatient treatment; Larsen et al. (1979)
found women more extreme in views, both positive
and negative. One inpatient study (Mayer & Rosen-
blatt, 1974) and one outpatient study (Slater et al.,
1981) found satisfaction decreased with education.
Several outpatient studies (Attkisson et. al., Note I;
Ciarlo & Reihman, 1977; Larsen et al., 1979; Warren,
Jackson, Nugaris, & Farley, 1973) and one inpatient
study (Pryer et al., 1982) found satisfaction greater
among white than nonwhite patients. Reid, Moran, and
DeWolfe (1972) found marital status and education
related to satisfaction. Although relationships also
have been detected in several analogue studies (e.g.,
Ewing, 1974; Grantham, 1973; Hill, 1975), the fre-
quency of nonsignificant findings across all studies
dwarfs the frequency of significant findings. Because
statistical significance is enabled in satisfaction studies
by the large sample sizes and multiple tests performed,
the lack of relationship is particularly striking.
It remains possible that client demographic charac-
teristics do exert an impact when the demographic
match with provider is considered (Berzins, 1977).
Although many studies have examined the relationsllip
of client demographic characteristics to satisfaction,
few have examined the client/provider interactions. A
few studies have detected significant interactions (e.g.,
Blase, 1979; Carson & Heine, 1962; Dougherty, 1976;
Howard, Orhnsky, & Hill, 1970; Orlinsky & Howard,
1976) while at least one study has not (Jones & Zupell,
1982).
Diagnostic and History Variables. The relationship of
client diagnostic, psychological, and treatment history
variables to satisfaction appears more promising than
the relationship between demographic characteristics
and satisfaction. Several studies have found satisfac-
tion related to diagnosis: Satisfaction has been found
to be lower in psychotics and drug abusers than in
depressed clients in a crisis intervention study (Getz,
Fujita, & Allen, 1975); in antisocial and psychosomatic
clients than those with problems of “emotional dis-
tress” or aicoholism at a community mental health
center (Ciarlo, 1979); in drug abusers than other out-
patients (Distefano et al., 198Oa); in suicidal than non-
suicidal utilizers of emergency services (Richman &
Charles, 1976); in more disturbed than less disturbed
clients in a day hospital (LeVois et al., 1981) and out-
patient care (Attkisson & Zwick, 1982); in those with a
greater number of hospitalizations and less time since
the last hospitalization in outpatient treatment (Slater
et al., 1981); in those with poor prognoses in outpatient
family therapy (Woodward et al., 1978); in involuntary
rather than voluntary hospitalized patients (Spensley
et al., 1980); and in nonretarded rather than retarded
outpatients (Pandiani et al., 1982). In these studies, a
trend appears to emerge of greater satisfaction in less
disturbed clientele.
However, other studies have failed to find signifi-
cant relationships between diagnostic and history vari-
ables and satisfaction. Inpatient studies have found
no difference in satisfaction across diagnosis (Distefano
et al., 1980b; Pryer et al., 1982), time in hospital
(Distefano et al., 198Ob), history of hospitalization
(Distefano et al., 1980b), prior treatment (Distefano et
al., 1981) and voluntary vs. involuntary status (Gove &
Fain, 1977). Outpatient studies have failed to detect a
difference across the type of problem (Stevens, I972),
diagnosis (Denner & Halprin, 1974b), and prior history
(Kirchner, 1981). Therefore, although diagnostic and
history variables emerge as more promising than de-
mographic variables as predictors of satisfaction, the
pattern of findings remains insufficiently consistent to
allow for the drawing of conclusions at this time.
World View. Attitude variables also require attention.
Three studies suggest satisfaction is related to world
view. Distefano et al. (1980b) found inpatient satisfac-
tion related to the mental health ideology of the client;
having a community mental health ideology was related
to reduced satisfaction. Distefano et al. (1981) found
inpatient satisfaction to be related to the client’s in-
terpersonal trust, and LeVois et al. (198 1) found satis-
faction with day treatment related to the client’s satis-
faction with life. These latter two findings suggest that
 Satisfaction with Mental Health Treatment 221

those most positive about the world also are most pos- ing were more satisfied if specially prepared for treat-
itive about care. ment, whereas women who were rated as less ready
were less satisfied under these conditions. In a study of
Expectancy. The client variable that has been most fre-
satisfaction with initial treatment sessions, Hargreaves
quently related to satisfaction with treatment has been
et al. (1974) found clients varied in their response to
client expectancy. The majority of these largely ana-
random assignment to individual therapy, group ther-
logue studies have indicated that satisfaction is related
apy, or a minimal contact group. Shy, upset clients
to and probably depends upon the meeting of client ex-
found the contact groups most helpful and group ther-
pectations (Gladstein, 1969; Martin et al., 1976; Seve-
apy least helpful; unmotivated clients preferred in-
rinson, 1966; Silverman & Beech, 1979). However, as
dividual therapy; and articulate, outgoing clients
Duckro et al. (1979) noted in their review of this
responded most positively to group therapy. Each of
literature, the relationship is a complex one, affected
these findings would have gone undetected without an
by the other variables. Brown (1979) for example,
analysis of client by treatment interactions, suggesting
found that the effect of expectations on satisfaction in
the importance of such analysis in this research area.
a Veteran’s Administration outpatient sample was
altered by the amount of choice the client expected;
Analogue Studies
only those who expected freedom of choice and did
A number of studies have examined the effect of client
not receive it had reduced satisfaction. Similarly, in
and treatment variables under conditions so unlike
analogue studies, Wish (1978) found dissatisfaction
those of typical mental health treatment that it would
resulted if the client received less than was expected,
be counterproductive to list these with the above
not more than was expected; and Gladstein (1969)
studies. In general, these studies have assessed satisfac-
found dissatisfaction only if all client expectations
tion of college student volunteers after a single or very
were unmet.
brief contact with trainees in counseling programs. As
Studies conducted in inpatient (Moos, 1974) and
such, they are analogue along so many dimensions that
aftercare (Nevid, Capurso, & Morrison, 1980) settings
they can suggest little about satisfaction with treat-
have found satisfaction related to the extent of the dif-
ment, save for a view of very early contact between
ference between the treatment and the client’s view of
client and neophyte therapist. Studies have found
ideal treatment. The relationship of client expectancy,
reduced satisfaction when client and therapist are not
level of aspiration, and vision of ideal treatment to
of the same race (Grantham, 1973); when they are not
satisfaction is a particularly promising area for further
of the same sex (Persons, Persons, & Newmark, 1974);
research. The importance of these variables coupled
when sessions are recorded (Gelso, 1973); when clients
with the tendency of clients to expect short-term direc-
are not volunteers (Gordon, 1976); when therapist em-
tive treatment (Bergin & Lambert, 1978; Garfield,
pathy is low (Hibbs, 1976); when regard is low between
1978a) may explain the trend toward greater satisfac-
client and therapist (Heichmer, 1973); and when clients
tion of clients with structured and supportive ap-
high in moral development are matched with therapists
proaches noted above.
low in moral development rather than the complemen-
Interactions of Client and Treatment Variables tary pairing (Barkeley, 1978). Variables found unre-
Although no main effect of a variable may be ap- lated to satisfaction have included counselor exper-
parent, significant relationships may emerge in the in- ience (Hibbs, 1976); the number of sessions (Hibbs,
teractions of client and treatment variables. (Berzins, 1976); the extent of client self-disclosure (Talley,
1977). Some possible interactions (e.g., demographic 1979); the structuring of sessions (Nutter, 1976); the
variables, expectancy confirmation) have already been extent of therapist empathy and problem solving
discussed. Three additional studies highlight the possi- (Severinson, 1966); the choice or lack of choice of
ble importance of complex interactions across vari- counselor (Moore, 1977); client scores on a personality
ables. In a counseling center, Scher (1975) found that test (Wantz, 1977), stimulus response congruence
clients who returned to the same program they attended (Hasselbrook, 1977); and the change in client values
earlier showed less satisfaction than other clients, but over the course of therapy (Hurst, 1979). These studies
returning clients placed in different programs were as provide an interesting list of variables to consider in
satisfied as other clients. In an analogue study, Heil- future research, but offer little substantive informa-
brun (1972) found women rated as ready for counsel- tion.

THE DIMENSIONALITY OF SATISFACTION

Several of the better methodological efforts in con- respondents distinguish between aspects of the service
sumer satisfaction research have examined the dimen- delivery process and its content. The results of these
sionality of satisfaction responses, testing whether studies, however, have not been entirely consistent.
 222 JAY L. LEBOW

Nine factor-analytic studies have concluded that outcome and general satisfaction, and Tessler (1975)
satisfaction responses are multidimensional. Brown found factors assessing help with problem solving and
(1979) identified seven factors in a VA population: closeness. These studies are not comparable to those
satisfaction with (a) the therapist; (b) outcome; using longer scales but also suggest multidimension-
(c) clinic service; (d) felt importance; (e) access; (f) con- ality.
fidentiality; and (g) therapist intent. Love et al. (1979) However, some results suggest a unidimensional
also identified seven factors in a CMHC outpatient structure. In an outpatient study, Larsen et al. (1979)
sample including satisfaction with: (a) overall care; found one factor accounted for more than 10% of the
(b) staff responsiveness; (c) staff behavior and skill; variance in a 31-item version of the CSQ; that factor
(d) center accountability; (e) meeting needs; (f) med- accounted for 43% of the total variance and 7.5% of
icines; and (g) access. Essex et al. (1981) in another the common variance. Several additional studies have
mental health center sample, found four factors: (a) sat- reported high inter-item correlations (Frank et al.,
isfaction with services; (b) acceptability of the clini- 1977; Jansen & Aldrich, 1973; LeVois et al., 1981;
cian; (c) impact of services (outcome); and (d) dignity Silverman & Beech, 1979) suggesting a halo response.
of treatment. Slater et al. (1981, 1982) uncovered four Further, it can be argued that even in several of the
factors in an outpatient sample: (a) general satisfac- studies that conclude that responses were multidimen-
tion; (b) satisfaction with the therapeutic relationship; sional (e.g., Brown, 1979; Love et al., 1979), large ini-
(c) satisfaction with explanations and preventive care; tial factors account for much of the total variance.
and (d) satisfaction with access to care. Murphy (1980) The conflicting findings point to the need for fur-
found three factors in an outpatient sample: satisfac- ther research to assess the dimensionality of satisfac-
tion with (a) improvement; (b) advice given; and tion responses. The extent to which the differences are
(c) the therapeutic relationship. Although the specific due to variations in client sample, method of data col-
factors vary across these studies, the similarity is strik- lected, or method of factor analysis requires careful
ing, given the differences in items, samples, and study. This research has important implications: If
methods. satisfaction responses are multidimensional, longer
Three studies have found multidimensional struc- scales addressing specifics of service delivery are to be
tures with shorter scales. In an outpatient sample, preferred; if not, then short scales are preferable. Fur-
Fiester and Fort (1978) found two factors, satisfaction ther, if responses are multidimensional, satisfaction
with outcome and satisfaction with availability and ac- data are also likely to be more useful in generating
cess, plus a number of single item factors. In aftercare specific suggestions for improving care.
samples, Grob et al. (1978) found factors assessing

THE RELATIONSHIP OF CONSUMER SATISFACTION

TO MEASURES OF OUTCOME AND UTILIZATION

The relationship of consumer satisfaction to measures statistically significant relation only among those
of outcome and utilization has been assessed in several clients with mutual terminations. In three studies,
studies. Data are available assessing the relationships client satisfaction has been found significantly higher
between consumer satisfaction and therapist satisfac- than therapist satisfaction (Dowds & Fontana, 1977;
tion, satisfaction of significant others, therapist Kissel, 1974; Mayer & Rosenblatt, 1974).
estimate of client satisfaction, client rated change
measures, therapist rated change measures, recidivism, Relationship to Satisfaction of Significant Others
utilization, and completion of treatment. Because data Only one study has examined the relative satisfactions
concerned with each relationship are available from of clients and their immediate families with treatment.
only a few studies, each with a limited range of clients Grob et al. (1978) found that former inpatients and
and treatments, and because of the non-normal distri- their relatives differed in their degree of satisfaction
butions of satisfaction responses, these relationships with inpatient treatment. The relatives were more satis-
must be regarded with considerable caution. However, fied with treatment than the clients. Interestingly,
trends worthy of further investigation do appear to be Grob et al. (1978) found patients more positive about
emerging from this research. the outcome of treatment than were relatives.

Relationship to Measures of Therapist Satisfaction Relationship to Clinicians’ Estimates of Satisfaction

Five studies have compared therapist and client satis- Larsen et al. (1979) found therapists’ ratings of client
faction with treatment; a strong relationship is not evi- satisfaction correlated with client reports reasonably
dent. In outpatient studies, Larsen et ai. (1979) found well (r = .56), as did Jones and Zupell (1982)
a moderate correlation (r = .42) between therapist (r = .46). Other findings are more equivocal. Bloom
and client vievvs; Denner and Halprin (1974b) found a and Trautt (1978) found therapist ratings of client
 Satisfaction with Mental Health Treatment
satisfaction to be significantly lower than those of
their outpatient clients; Slater et al. (1981) found only
a barely significant correlation between client view and
therapist estimate. Distefano et al. (1980a) and Frank
et al. (1977) did find staff could predict whether clients
were satisfied. However, given the high base rates for
satisfaction, neither of these findings are especially im-
pressive (Garfield, 1978b): Merely predicting satisfac-
tion in all cases would result in prediction in over 70%
of cases. Further, Distefano et al. (1980a) found clini-
cians were unable to predict the items on which clients
revealed dissatisfaction. The moral seems clear: Clini-
cians should not assume they accurately can estimate
client satisfaction with treatment.
Relationship to Client Rated Change
Findings point to a strong relationship between client
assessment of satisfaction and client global reports of
outcome, but to a less strong relationship between
reported satisfaction and client reports of more
specific change. However, the findings are not entirely
consistent. Three studies have included all three types
of measures, two have found the correlation to global
outcome greater than that to specific symptom mea-
sures. In their outpatient study, Larsen et al, (1979)
found a correlation of .53 with a rating of global
change, but only .32 with two SCL-90 scale scores;
Wilier and Miller (1978) found a similar pattern in com-
paring the relationship between satisfaction, global
outcome, and goal attainment scaling in their inpatient
sample (r = .70 with global outcome; r = .49 with
goal attainment). However, Attkisson and Zwick (1982)
detected correlations of similar magnitudes (r = .34,
r = .40) in comparing satisfaction to global outcome
and SCL-90 scale scores.
A few studies have examined only one of these rela-
tionships. Edwards, Yarvis, Mueller, and Langsley
(1978) found a strong relationship between satisfaction
and globa outcome (r = .70), but Grob et al. (1978) in
their inpatient study did not (r = -28). Fiester (1979)
found a moderate correlation (r = .35) between
satisfaction and goal attainment scaling.
The timing of the assessment is likely to be an im-
portant determinant of these relationships. Edwards et
al. (1978) found a correlation of .37 between satisfac-
tion and their global measure after the second session,
but this correlation increased to .70 at follow-up. Dur-
ing the engagement process, change and satisfaction
are likely perceived more independently than later in
treatment.
Consumers appear to report a somewhat more
positive view of satisfaction than change. McPhee et
al. (1975), in their survey of unpublished studies from
Community Mental Health Centers, found reports of
satisfaction more frequent than client reports of
change. In the studies reviewed here, the average fre-
quency of satisfaction in three of four consumers is
223
slightly greater than the improvement in two of three
patients found in most efficacy studies (Bergin & Gar-
field, 1971; Garfield, 1978a; Gurman & Kniskern,
1978; Hollon & Beck, 1978; Luborsky et al., 1975).
However, in their study of family therapy, Woodward
et al. (1978) found that more clients reported change
than satisfaction. Whether Woodward et al.‘s finding
is a special aspect of family treatment needs to be ex-
plored in further research.
Relationship to Therapist and Rater Assessed Change
The correlations obtained in the few studies relating
satisfaction to therapist rated change measures have
tended to be lower than those between satisfaction and
patient rated change measures. Fiester (1979), for ex-
ample, found a correlation of .30 between therapist
goal attainment rating and satisfaction; Willer and
Miller (1977, 1978) a correlation of .14. Edwards et al.
(1978) found a correlation of .32 between satisfaction
and a global rating of outcome. Other studies have
found similar levels of correlation (Ciarlo & Reihman,
1977; Distefano et al., 1981; Stevens, 1972).
A few studies have reported stronger relationships
between satisfaction and therapist ratings of change,
but none of these results is especially impressive.
Larsen et al. (1979) found a correlation of .44 between
satisfaction and the Brief Psychiatric Rating Scale,
but no similar correlation was found between satisfac-
tion and two other outcome measures (Global Assess-
ment Scale and Global Improvement Scales) in this
study. Attkisson and Zwick (1982) found a correlation
of .33 between satisfaction and therapist global rating
of change, but almost no relationship between satis-
faction and Global Assessment Scale ratings. Wood-
ward et al. (1978) found goal attainment rated by the
therapist to be related to satisfaction, but in this in-
vestigation 30070of the satisfied clients still were not
rated as attaining their goals and 47% of the dissatis-
fied clients were rated as attaining their goals. Strupp
et al. (1969) also found less satisfaction in the group
rated as changing least, but again there were numerous
exceptions. These findings indicate that therapist
ratings of change and client ratings of satisfaction
probably tap different domains.
Factor Analytic Studies
Two studies of outpatient psychotherapy have utilized
a somewhat different methodology to assess the rela-
tionship between satisfaction and other measures,
employing factor analysis across a broad range of
measures obtained from multiple sources. Cartwright,
Kirtner, and Fiske (1963) found satisfaction loaded on
a factor with other client reports (e.g., outcome). In
contrast, Mintz et a1. (1979) found two factors which
cut across sources, one of which they labeled “rated
benefits” (the rating of treatment) and the other “ad-
justment” (the assessment of change on repeated mea-
 224 JAY L. LEBOW
sures). Satisfaction correlated .55 with adjustment and
.78 with rated benefits, loading principally on the
benefits factor. Although the findings differ, both
studies suggest the overlap between satisfaction and
other measures. Each study is also consistent with a
trend in the research just reviewed: The Cartwright et
al. (1963) study fits well with the trend of higher cor-
relations between satisfaction and other client reported
measures than satisfaction and therapist measures; the
Mintz et al. (1979) finding fits well with the trend of
stronger relationships between satisfaction and global
ratings than satisfaction and specific symptom change.
Relationship to Inpatient Recidivism
Willer and Miller (1977, 1978) found no relationship
between satisfaction and inpatient recidivism or inpa-
tients obtaining work; they also found satisfaction of
trivial importance in a regression analysis predicting
recidivism. Similarly, Pryer et al. (1982) found no pre-
diction of rehospitalization at a 2-month follow-up.
Although further study of these relationships is ob-
viously needed, the trend indicates satisfaction is a
poor predictor of recidivism.3
Relationship to Premature Termination
A few studies have examined the relationship between
satisfaction and premature termination from treat-
ment. Intuitively, a strong inverse relationship might
be expected, since termination might be assumed to
represent a behavioral sign of dissatisfaction. How-
ever, most of the relevant research has failed to con-
firm the expected strong relationship; the variables co-
vary sufficiently for their relation to be statistically
significant, but each variable explains little of the
variance in the other.
Several strategies have been employed to examine
these relationships. Four studies have utilized correla-
tional analysis. Attkisson and Zwick (1982) found a
strong relation (r = .61) when satisfaction and
premature termination were assessed 1 month after the
beginning of outpatient treatment. However, in the
outpatient studies of Larsen et al. (1979) (r = .37) and
Flynn et al. (1981) (r = .27) and the inpatient study of
Distefano et al. (1980b), the relationship between sat-
isfaction and premature termination has been weaker.
A second strategy has focused specifically on the
degree of satisfaction in those who drop out early in
treatment. The four studies of this type, all in out-
patient settings, have found the satisfaction of drop-
outs to range between 50% and 70% (Heineman &
Yudin, 1974; Kline et al., 1974; Farley, Peterson, &
‘Thts result may be the product of a complex pattern. Dissattsfied
patients may benefit less and therefore need further hospitalization;
however, they also could be expected to be less likely to seek out the
previous care setting. Rectdivtsm must be studied tn terms of care
systems, not one facility.
Spanos, 1975; Silverman & Beech, 1979). Although the
frequency of satisfaction expressed in these studies is
somewhat lower than in the studies of other popula-
tions, these studies have found an unexpectedly high
degree of satisfaction in those who might be thought
likely to be dissatisfied.
Another strategy for exploring the satisfaction of
dropouts has been to inquire about their reasons for
termination. Those linking this decision to the treat-
ment offered can be grouped as expressing dissatisfac-
tion; those noting other reasons for termination as not
necessarily dissatisfied. Several of these studies have
found that clients attribute stopping treatment pri-
marily to extra-treatment reasons (Farley et al., 1975;
Garfield & Wolpin, 1963; Garfield, 1978a; Silverman
& Beech, 1979), and thus do not view terminating as an
implicit statement of criticism. As an example, Silver-
man and Beech (1979) found clients who terminated
after a singIe outpatient session most frequentIy noted
improvement, scheduling, and transportation as the
reasons for stopping treatment.
Other studies have found treatment listed as a major
reason for termination, suggesting an intimate rela-
tionship between termination and dissatisfaction. In a
study of group outpatient treatment, Shapiro and
Budman (1973) found two thirds of the dropouts listed
the therapist’s behavior (especially inactivity) as having
primary importance; in a study of a child guidance
clinic, 35% of parents indicated their termination to be
related to dissatisfaction (Farley et al., 1975).” Sim-
ilarly, Acosta (1980) found that almost half of his psy-
chotherapy dropout sample implicated the therapist or
treatment in the reason for termination5 and Lepage,
Black, Rowe, and Spanks (1980) found dropouts often
described treatment as unsuitable. Problems with such
aspects of treatment as scheduling and transportation
(e.g., Silverman & Beech, 1979) might also be inter-
preted as difficulties residing in an important aspect of
treatment: accessibility.
What are we to make of these diverse findings? It
does seem clear that the majority of dropouts express
satisfaction, but that these rates of satisfaction are not
as high as in those continuing beyond the first few ses-
sions of treatment. Inquiries into the reasons for ter-
‘Farley et al.3 (1975) study provides an excellent example of the
variability m response pattern among groups with dissatisfactions.
Thirty-nine percent of the dropouts expressed dissattsfactton. 5R%
found their expectations unfuI~iied, 75% reported a posrttve reac-
tion to the therapist, 9% reported the therapist as the reason for ter-
mutation, and 50% would still recommend the center without reser-
vation.
“Acosta’s (1980) study provides an excellent example of the hmtts of
global inqutries. Despite the hrgh degree of responsibility assrgned to
the therapist and treatment for the client’s droppmg out, 100% of
these clients stated they would recommend the center and 75% tn-
dicated they would use the services agam.
 Satisfaction with Mental Health Treatment 225

mination show somewhat higher rates of explicit and emerge across settings; one study found dissatisfaction
implicit criticism, but even the most critical samples to be a major factor in premature termination in a
note extra-treatment reasons for termination. The sur- state-operated center, but not in a second center (Fiester
prisingly uncritical nature of these findings can be in- & Rudestrom, 1975). Differences also are likely be-
terpreted in two ways: These findings can be accepted tween studies that employ global inquiries and research
at face value (Silverman & Beech, 1979) or taken as an that more specifically assesses areas of dissatisfaction;
expression of the influence of demand characteristics global inquiries are likely to draw more reactive re-
in such brief inquiries (Gutek, 1978; Scheirer, 1978). sponses and thus less criticism. Further research is
Further research will be needed to discern which ex- needed to explicate these relationships and the causal
planation best fits the data. pathways involved.
It seems likely that early termination will emerge as
a phenomenon with multiple determinants. One group Relationship to Other Measures of Utilization
is satisfied but forced to discontinue due to life cir- Few studies have examined satisfaction in relation to
cumstances, another satisfied with the services offered other aspects of utilization. In their outpatient study,
but has problems in terms of accessibility. In a third Larsen et al. (1979) found a moderate correlation
group termination is directly related to dissatisfaction. (r = .27) between satisfaction and regularity of atten-
A fourth group begins treatment on a trial basis (Reder dance; Slater et al. (1981) found a similar level of
& Tyson, 1980) and does not find it a suitable vehicle correlation. Attkisson and Zwick (1982) found satis-
for working on their problems, yet is not dissatisfied. faction related to number of sessions attended but not
Differences in the frequency of these patterns will frequency of missed sessions.

DETERMINANTS OF SATISFACTION

Kaufmann et al. (1979) found important differences Prager & Tonaka, 1980). The particular priorities of
among groups when they asked consumers, adminis- staff and patients appear idiosyncratic to the facility
trators, and board members to rank order items for in- under study, but a priori assumptions by staff or ad-
elusion in a consumer survey. All groups emphasized ministrators that they value the same dimensions as
outcome, but the consumer group was unique in ac- clients must be regarded as potentially faulty (Meier,
tenting confidentiality and continuity of care. This 1981; Windle & Paschell, 1981). Further delineation is
study suggests clients and staff have different priorities, needed of the variables clients regard as important and
a finding also evident in other studies of what con- the weight attached to components of service in deter-
sumers regard as important (Dowds & Fontana, 1977; mining satisfaction in various types of settings.

OTHER METHODS FOR ASSESSING THE CLIENT’S VIEW OF TREATMENT

I have reviewed in the preceding sections the findings of feedback have been conducted (e.g., Allen & Barton,
studies formally assessing client satisfaction with men- 1976; Birnbaum & Suits, 1979; Eisen & Grob, 1979;
tal health treatment. However, there are many addi- Koltuv et al., 1978; Marion 8z Grabski, 1979). No
tional sources of information about the client’s view review of this literature is available.
that add to our knowledge about client satisfaction. I
briefly discuss several of the types of relevant studies; Studies of Client Reported Change
limiting my consideration to an outline of the relevance As noted above, client global reports of change appear
of the particular type of research and a brief overview to be highly correlated with client satisfaction; there-
of its present status. fore, studies of patient views of outcome also in some
sense become studies of client satisfaction. The litera-
Studies of Open-Ended Feedback ture concerned with client report of change and ef-
Studies of open-ended feedback record and sum the ficacy is a large one, summarized in several excellent
complaints and testimonials provided about treatment reviews (Bergin & Garfield, 1971; Bergin & Lambert,
(Eisen & Grob, 1979); usually these studies record un- 1978; Garfield, 1978a; Garfield & Bergin, 1978; Gur-
solicited feedback, though on occasion responses have man & Razin, 1977; Luborsky et al., 1975; Parloff,
been solicited (Koltuv et al., 1978). Studies of com- Waskow, & Wolfe, 1978; Parloff, Wolfe, Hadley, &
plaints have been particularly useful in highlighting Waskow, 1978). In general, clients regard themselves
problems in treatment missed in satisfaction scales; as changing as well as satisfied.
through this method, the client is focused on the dis-
satisfactions with treatment that may lie behind general Studies of the Process of Change
satisfaction. Meier (1981), for example, found 20 to 38 Other related studies have examined the client’s more
patients indicated some unmet need despite a high rate specific view of the change process. Relevant research
of reported satisfaction. Several studies of open-ended questions have included the extent to which treatment
226 JAY L. LEBOU

was seen as causing change (e.g., Chadwell & Howell, that the vast majority of studies indicate patients have
1979; Strupp et al., 1964); which aspects of treatment a positive attitude toward inpatient treatment. Wein-
were viewed as most important in eliciting change stein also reviews the relationships that emerge be-
(Strupp et al., 1964; Strupp et al., 1969); and which tween client and treatment characteristics and patient
client behaviors, feelings, and attitudes were viewed as attitude; his conclusions are often similar to those
most affected (Strupp et al., 1964). reviewed above emerging from the explicit study of
No specific review of these studies is available, ai- satisfaction (e.g., demographic characteristics do not
though this research has been reviewed in conjunction emerge as important).
with- several specific research issues (Garfield &
Ratings of the Psychotherapist
Bergin, 1978; Gurman & Razin, 1977). The general
Many studies have assessed client ratings of their psy-
trend in this research is consistent with the findings
chotherapists. Because an intimate relationship exists
concerned with satisfaction; most change is attributed
between satisfaction with the provider and satisfaction
to the impact of treatment (Chadwel~ & Howell, 1979).
with treatment, studies assessing the client’s view of
Assessments of the Value Assigned the therapist along dimensions that suggest favorable-
to Aspects of Treatment ness also have relevance for the study of satisfaction.
In another type of study closely related to consumer Particularly important to the satisfaction literature
satisfaction, the client is asked to rate the comparative are those studies that have assessed the client’s view of
value assigned to aspects of treatment. A comparative facilitative conditions (e.g., empathy). These studies,
rating of value is analogous to a rating of satisfaction; most of which have utilized the Barrett-Lennard Rela-
the forced choice involved has the additional advan- tionship Inventory (Barrett-Lennard, 1962) have been
tage of pressuring the client to discriminate between comprehensively reviewed by Curman (1977). Gurman
aspects of treatment. No review is available of these notes that in the majority of these studies, client
studies (e.g., Feifel & Eels, 1963; Cioby, Filstead, & responses have been multidimensional and rdated to
Rossi, 1974; Yalom, 1975; Zaslove, Ungerleider, & the patient’s view of outcome, but not to therapist
Fuller, 1966). ratings of facilitative conclusions. Gurman (1977) also
provides a review of patient ratings of other therapist
Multidimensional Studies of Treatment Environment
behaviors, including understanding, helpfulness, cred-
Numerous studies have explored the client’s response
ibility, likability, and affirmation.
to inpatient and day hospital treatment environment
using multidimensional scales. The most frequent in- Investigations of Client View of Psychotherapy Process
strument employed in these studies has been the Ward Other psychotherapy studies have utilized multidimen-
Atmosphere Scale (K&h, 1971; Klass, Growe, & sional scales to assess client reaction to the process of
Strizich, 1977; Moos, 1974; Moos & Houts, 1968, treatment during specific sessions (Orlinsky & Howard,
1970; Moos & Schwartz, 1972; Moos, Shelton, & Petty, 1975; 1976; 1978). Because satisfaction with treatment
1973; Pierce, Trickett, & Moos, 1972), but other in- is likely to be related to reactions to specific sessions,
struments including the Colorado Psychopathic Hos- these studies also provide an indirect index of satisfac-
pital Scale (Kahn & Jones, 1969), the Characteristics of tion. The broad item pools employed minimize reac-
the Treatment Environment Scale (Allen, Graham, tivity and halo judgements, leading to a wider range of
Lilly, & Friedman, 1971), the Perception of the Ward patterns of response than in direct inquiries about sat-
Scale (Etlsworth & Moroney, 1972), the Souelem At- isfaction. This work has been reviewed by Orlinsky
titude Scale (Souelem, 1955), and The Ward Evalua- and Howard (1975, 1978).
tion Scale (Rice, Berger, Klett, Sewell, & Lemkau,
Studies of the Acceptability of Treatment
1963). Simpler instruments (Keith-Spiegel, Grayson, &
Recent research has begun to address the acceptability
Spiegel, 1970) have also been utilized in this type of in-
of treatments to the general public. In these studies,
vestigation. These studies delineate the client’s view of
subjects are asked to rate the acceptability of treat-
the treatment environment, suggesting how treatment
ments for themselves or others. Most of this research
is experienced.
has been concerned with interventions in behavior
Because many of the dimensions explored contain
therapy (Braukmann et al, 1975; Kazdin, 1980a,
evaluative elements, these data are also germane to
1980b, 1981; Kazdin, French, & Sherick, 1981; Wolf,
satisfaction with treatment. Weinstein (1979) has
1978), but this type of research also has relevance for
reinterpreted the results of each of these studies as in-
other forms of treatment. No review of this small body
dicating satisfaction or dissatisfaction with treatment.
of studies is available.
Although some of Weinstein’s ratings of the satisfac-
tion expressed are necessarily forced, he does offer an Studies of Treatment Dropout
excellent summary of the Iiterature assessing patient The vast literature concerned with treatment dropout
attitudes toward hospitalization. Weinstein concludes has obvious implications for the study of satisfaction.
 Satisfaction with Mental Health Treatment 227

The high rates of early termination from treatment Studies of Related Treatments
stand in marked contrast to the favorability of ratings Studies assessing satisfaction with other types of
in satisfaction research. Garfield (1978a) and Baeke- human services also should be examined in conjunc-
land and Lundwell (1975) offer excellent reviews of tion with the mental health literature (Lebow, 1983a).
this literature. It is interesting to note that factors that The importance of findings in one field become clearer
do not predict satisfaction (e.g., client demographic when related to findings from studies employing
characteristics) do predict patterns of dropout. similar methodologies in other fields. Further, meth-
odology will improve with cross-pollination across
Studies of the Satisfaction of Others substantive areas.
with Mental Health Services Patient satisfaction with medical care has frequently
Few studies have examined the satisfaction of in- been studied (Hulka et al., 1970, 1971; Lebow, 1974;
dividuals who are affected by or involved in treatment Ware, Davies-Avery, & Stewart, 1978). Studies are
but who are not recipients of service, e.g., relatives of aiso available of satisfaction with rehabilitation pro-
clients, care providers, and community groups. Re- grams (e.g., Reagles, Wright, & Thomas, 1972a,
search assessing provider satisfaction has generally 1972b), halfway houses (Smith, Oswald, & Faruki,
been limited to studies of the acceptability of consulta- 1976), self-help groups (Knight, Wollert, Levy, Frame,
tions received from other professionals (Silverman, & Padgett, 1980), encounter groups (Lieberman,
1976). Similarly, there have been few assessments of Yalom, & Miles, 1973), treatment of exceptional chil-
community satisfaction with services (e.g., Miller, dren (Sommers & Nycz, 1978), court operated divorce
1981) or the satisfaction of those intimately involved programs (Brown & Manela, 1977; Young, 1978),
with the client (e.g., Grob et al., 1978). The evaluation parent education programs (Lochman & Brown, 1980),
of the satisfaction of these groups requires study. Pro- sheltered workshops (Litvak, 1977), and programs for
viders are central to care, intimates often bear the criminal offenders (Kloss, Sherry, Crozat, & Karan,
brunt of the effectiveness and ineffectiveness of treat- 1980). Gutek (1978) overviews efforts assessing satis-
ment (Gurman & Kniskern, 1978), and community faction with human services. A trend is evident for
groups often determine the funding and location of satisfaction to be expressed to the most global inquiries
programs. A review of these few studies would be pre- (e.g., single items); the pattern of responding to more
mature at this time. thorough instruments has been less well articulated.

DISCUSSION
To summarize the substantive findings reviewed in this manner of termination, and the degree to which the
paper : treatment is experienced as supportive.
4. In most instances, the therapist and other treat-
1. Most consumers report satisfaction. In studies of ment staff are rated most positively; information pro-
outpatient treatment, 78% of clients express satisfac- vided about treatment and pragmatic factors, such as
tion; in inpatient studies, 76% express satisfaction; convenience of appointment time, are most often the
and in studies of comprehensive treatment services, targets of criticism. In inpatient studies, physical ar-
83% express satisfaction. Attrition in the responding rangements, privacy, and other aspects of the milieu
sample and reactivity may cause these reports of are particular foci of concern.
satisfaction to be somewhat inflated; nonetheless, 5. Satisfaction has sometimes been found to be
there seems little doubt that the majority of consumers unidimensional, more often to be multidimensional. A
are satisfied with service. general factor is most often found, which may or may
2. In each study, there is a small percentage of not be supplemented by specific factors. Where found,
dissatisfied consumers, nearly always less than 10%. specific dimensions include satisfaction with the clini-
Little attention has been focused on this dissatisfied cian, outcome, access, confidentiality, medicines, and
group. facilities.
3. Few consistent trends are evident linking the 6. Satisfaction is highly correlated with the patient’s
degree of satisfaction to particular client or treatment global rating of outcome. The relationship of satisfac-
characteristics; the relevant research has basically yet tion to other measures of outcome is less strong; the
to be done. Client demographic characteristics have relationship between satisfaction and therapist rating
emerged from the limited research available as particu- of outcome is particularly weak. Satisfaction appears
larly poor predictors. More promising predictors are augmented with mutual termination and longer treat-
client expectation and level of aspiration, client ment, but there also is evidence of substantial satisfac-
diagnostic and history variables, length of treatment, tion in early treatment dropouts.
228 JAY L. LEBOW

As noted previously, many problems exist with the tion. Among research questions focused on treatment,
data reviewed. Often, only a few studies have examined I would highlight the need for studies assessing satis-
particular relationships, and many methodological faction with specific treatments, with particular ther-
problems in this research are evident. Therefore, con- apist behaviors, and methods of organizing the service
clusions must be carefully tempered. Most satisfaction delivery system. Among questions focused on the
research to date has served a simple monitoring func- client, I would highlight the need for research assessing
tion, focused upon assessing satisfaction within facili- the influence of client diagnostic variables, history
ties. There has been little attention to the specificity of variables, expectancy, and level of aspiration on satis-
findings; in this way, satisfaction research has lagged faction. The satisfaction of providers, patient relatives,
behind psychotherapy and psychopharmacology out- and community groups is also particularly worthy of
come studies (Garfield & Bergin, 1978). The extent of attention.
satisfaction, the relationship of satisfaction to client The client’s view is an important source of informa-
and treatment variables, the dimensionality of satis- tion about mental health treatment services. In addi-
faction, the relationship between satisfaction and tion to providing information about satisfaction and
other measures, and the determinants of satisfaction the related measures discussed above, the client is an
all may vary under differing conditions (i.e., clients, indispensible source of data about: (a) the path of
clinicians, settings, designs, measures). Greater speci- entering treatment and barriers to entrance (Albers &
ficity in this research is needed. Scrivner, 1977; Rosenblatt & Mayer, 1972; Spiegel &
Satisfaction research also has lacked a theoretical Keith-Spiegel, 1969); (b) attitudes toward mental ill-
basis and programmatic plan. Studies have appeared ness (McElvoy, Alond, Wilson, Guy, & Hawkins,
in relation to local data needs. Future research must be 1981); (c) expectations for treatment (Begley & Lieber-
more theoretically based, with hypotheses, hypothesis man, 1970; Burgoyne, Staples, Yamamoto, Wolken, &
testing, and robust methodologies. The work of the Kline, 1976; Lazare, Cohen, Jacobson, Williams,
group at the University of California, San Francisco as- Mignone, & Zisook, 1972); (d) factors enabling com-
sessing satisfaction with mental health treatment (Att- pletion of treatment (Garfield, 1978a); (e) events and
kisson & Zwick, 1982; Larsen et al., 1979; LeVois et change transpiring after the end of treatment (Harty &
al., 1981) and the research assessing satisfaction with Benney-Johnson, 1979); and (I) suggestions for im-
medical care (Ben-Sira, 1976; Doyle & Ware, 1977; proving treatment (Lerner & Roskos, 1979; Marion &
Fleming, 1981; Marquis, Davies, & Ware, 1982; Pen- Grabski, 1979; Quilitch & Szczepaniak, 1979).
chansky & Thomas, 1981; Pope, 1978; Ware, 1978; Measures of consumer satisfaction have an impor-
Ware, Davies-Avery, & Stewart, 1978; Ware&Snyder, tant place in the evaluation of mental health services.
1976) might serve as models for these endeavors. Although these measures are flawed, they can be quite
As there has been so little methodologically and useful when considered with these limitations in mind.
theoretically sophisticated research assessing consumer Consumer satisfaction will be most useful when em-
satisfaction with mental health treatment, the area is ployed in conjunction with other measures of service:
ripe for further research. Each area of findings re- assessments of structure and process (Donabedian,
viewed above could benefit from further investigation. 1966), and multiple points of view of outcome (i.e.,
In particular, among methodological studies, I would client, clinician, rater, significant other) (Krause &
highlight the need for research validating instruments Howard, 1976; Lebow, 1982b; 1982~; Newman &
and assessing the effects of covarying conditions (e.g., Sorensen, 1983; Strupp & Hadley, 1977; Waskow
other treatment obtained, life satisfaction) on satisfac- & Parloff, 1975).

REFERENCE NOTES
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Serrtlces Evaluatron Questionnaire: Results and norms from a na- health centers (Doctoral dissertation, Umverstty of Michtgan.
rional sample. Paper presented at the Annual Meeting of the 1979). Dksertation Abstracts International, 1979, 40, 987B.
American Psychological Association, August, 1981. Los An-
geles.

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