Journal ofConsultingand Oinical Psychology
1988. Vol. 56. No. 4.490-495
pKignt 1988 by the American Psychological Association. Inc.
The Accuracy of Therapists' Interpretations and the Outcome of
Department of Psychiatry, University of Pennsylvania
Department of Psychiatry, University of Pennsylvania
This study developed a measure of the accuracy of therapists' interpretations based on the core
contliclual relationship theme method and examined the relation of accuracy to the outcome of
dynamic psychotherapy. Accuracy was assessed on therapists' interpretations from two early-in-
treatment sessions of 43 patients receiving moderate-length dynamic therapy. The results indicated
that accuracy about the main wishes and responses from others that were expressed in the relation-
ship themes was significantly related to outcome, even after the effects of general errors in treatment
techniques and the quality of the helping alliance had been controlled for. Our hypothesis that accu-
rate interpretations would have their greatest impact in the context of a positive helping alliance was
Within the clinical psychoanalytic literature, interpretation
has been described as the "supreme agent in the hierarchy of
therapeutic principles" (Bibring, 1954, p. 763). Focal dynamic
psychotherapy specifies the task of the psychotherapist as (a)
arriving at a succinct formulation of the patient's main mal-
adaptive relationship pattern and (b) centering interpretations
around this pattern. For example, in his manual for psychoana-
lytic psychotherapy, Luborsky (1984) suggested that the thera-
pist focus interpretations around the main maladaptive rela-
tionship pattern, which he labeled the core conjliaual relation-
ship theme. In addition, Luborsky and colleagues developed an
objective method of measuring this pattern (Luborsky, 1977;
Luborsky et al., 1985; Luborsky, Crits-Christoph, & Mellon,
1986). Similarly, Strupp and Binder's (1984) manual for time-
limited dynamic psychotherapy described the concept of the
"dynamic focus" (recently renamed "cyclical maladaptive pat-
terns"; Schacht, 1986) that becomes the central aspect of ther-
apy and guides the therapist's interpretations.
Despite clinical emphasis on the importance of interpreta-
tion, empirical studies in this area have been scarce. Early stud-
ies (Speisman, 1959; Harway, Dittman, Raush, Bordin, &
Rigler, 1955) have examined the depth of interpretations, but
no studies have been performed relating this construct to psy-
chotherapy outcome. Additionally, the results of several process
studies on interpretation have been limited by methodological
or conceptual problems. For example, both Garduk and Hag-
gard (1972) and Luborsky, Bachrach, Graff, Pulver, and Chris-
This research was supported in part by National Institute of Mental
Health (NIMH) Grants RO1-MH40472 and RO1-MH39673 and by
NIMH Research Scientist Award MH40710 to Lester Luborsky.
Correspondence concerning this article should be addressed to Paul
Crits-Christoph, 308 Piersol Building/4283, Hospital of the University
of Pennsylvania, Philadelphia. Pennsylvania 19104.
toph (1979) have examined the immediate impact of interpre-
tations on patients' levels of resistance, insight, and other vari-
ables. However, the small number of patients in these two
investigations restricted the generalizability of the results and
prohibited meaningful conclusions about the relation of inter-
pretation to outcome. In one of the few outcome studies on in-
terpretation, Marziali (1984) found significant relations be-
tween frequency of interpretations and outcome. In contrast,
Piper, Debbane, Bienvenu, De Carufel, and Garant (1986)
failed to replicate these results using more sophisticated re-
These studies, however, were conducted before a reliable
measure of central relationship patterns was developed. There-
fore, they did not question whether interpretations that accu-
rately bear on this central theme are a primary curative factor in
psychotherapy. This issue has been examined by Silberschatz,
Fretter, and Curtis (1986): In a series of three single-case stud-
ies, they demonstrated high correlations between the accuracy
of interpretation, as assessed by the compatibility between the
content of the interpretation and the content of the patient's
"plan diagnosis" (Rosenberg, Silberschatz, Curtis, Sampson, &
Weiss, 1986) and patients' levels of experiencing (Klein, Ma-
thieu, Gendlin, & Kiesler, 1970) immediately following the in-
The aims of this study were (a) to develop a measure of the
accuracy of therapist interpretations based on the core conflic-
tual relationship theme method and (b) to predict the outcome
of dynamic psychotherapy from the newly developed measure.
We also examined whether the accuracy of interpretations
would predict outcome only in the context of a positive thera-
peutic alliance as well as the overlap between the accuracy of
interpretation and a more general measure of therapist techni-
cal skill, the Errors in Technique subscale of the Vanderbilt Neg-
ative Indicators Scale, which has been shown to predict therapy
outcome (Sachs, 1983).
ACCURACY OF THERAPISTS' INTERPRETATIONS
Descriptive Characteristics of Patients
High school degree
Some graduate or professional school
Graduate or professional school
Descriptive characteristics of ihe patients are presented in Table 1,
and patient diagnoses are summarized in Table 2. These diagnoses were
obtained from the original Diagnostic and Statistical Manual of Mental
Disorders, second edition (DSM-II; American Psychiatric Association,
1968). diagnoses made by a clinical evaluator as part of a semistruc-
tured prognostic interview (Aiierbach, Luborsky, & Johnson, 1972).
Two clinicians worked together using the DSM-II diagnoses and case
notes to translate them from second edition to third edition (DSM-II1:
American Psychiatric Association, 1980) diagnoses. The majority of
patients were diagnosed with dysthymic disorder, generalized anxiety
disorder, or a variety of personality disorders.
Twenty-eight therapists participated in the research project. Each
therapist usually treated I or 2 patients. The therapists ranged in age
from 27 to 55 years (M = 35.6). The therapists had between 1 -22 years
of prior clinical experience, with an average of 5.4 years. Twelve of the
therapists were psychiatrists in private practice. The remaining 16 ther-
apists were supervised psychiatric residents.
All patients were seen in individual psychodynamic psychotherapy.
Approximately two thirds of the patients were treated at the outpatient
clinic of the Hospital of the University of Pennsylvania. The remaining
patients were seen in private settings. Treatment length varied among
the patients, ranging from 21 to 149 weeks, with an average length of
Identifying interpretations. Two judges coded therapist statements
into interpretations versus all other types of responses. A response was
considered an interpretation if it met at least one of the following cri-
teria: (a) the therapist explained possible reasons for a patient's
thoughts, feelings, or behavior (e.g., "One of the benefits of using drugs
is that it keeps you in the role of the child") and/or (b) the therapist
alluded to similarities between the patient's present circumstances and
other life experiences (e.g., "What's happening is that you keep getting
yourself into these kinds of situations like what happened on Saturday
where you put yourself in for a hell of a big rejection experience").
Interraier reliability, based on the judges' ratings for all 43 cases, was
assessed for distinguishing interpretations from other statements. Inter-
judge agreement was 95% and Cohen's (1960) kappa was .56 (p <
.0001). Only statements that were coded by both judges as interpre-
tations were retained. The number of interpretations obtained per pa-
tient ranged from 1 to 16 (M = 6.1).
Core confliaual relationship theme (CCRT) method. This method
(Luborsky, 1977) establishes guidelines for clinical judgments about the
content of patients' central relationship patterns from psychotherapy
session material. The primary data to be scored are the explicit narra-
tive episodes about relationships that patients commonly tell during
psychotherapy sessions. Typical narratives are about fathers, mothers,
brothers, sisters, friends, bosses, and therapists. These relationship epi-
sodes are identified by a separate set of independent judges before the
transcripts are given to the CCRT judges. A minimum of 10 relationship
episodes is usually used as a basis for scoring the CCRT.
The CCRT judge reads the relationship episode in the transcript and
identifies three components: (a) the patient's main wishes, needs, or in-
tentions toward the other person in the narrative; (b) the responses of
the other person; and (c) the responses of the self. For the responses,
both positive and negative t> pes are identified. Within each component,
the types with the highest frequency across all relationship episodes are
identified; their combination constitutes the CCRT.
The steps in the CCRT method formalize the usual inference process
of clinicians in formulating transference patterns. The clinician/judge
first identifies the wishes and responses to the wishes in each of the epi-
DSM-III AM* I'
Atypical eating disorder
Ego dystonic homosexuality
Generalized anxiety disorder
Inhibited sexual excitement
No Axis I diagnosis
DSM-III Axis II
Atypical personality disorder
Compulsive personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Passive-aggressive personalih disorder
Schizoid personality disorder
Schizotypal personality disorder
Mixed personality disorder
No Axis II diagnosis
Note. DSM-III = Diagnostic and Statistical Manual of Menial Disor-
ders. Numbers total more than sample size (43) because several patients
had more than one diagnosis.
* Axis 1 patients who additionally had an Axis II diagnosis included 8
with dysthymic disorder, I with ego dystonic homosexuality, and 4 with
generalized anxiety disorder.
P. CRITS-CHRISTOFH. A. COOPER, AND L. LUBORSKY
sodes and. from these, makes a preliminary CCRT formulation (Steps
1 and 2); the same judge then reviews and reformulates (Steps I'and2').
Thus, in Step 1 the judge identifies the types of wishes and responses
(both from other and of self) in each relationship episode, and in Step
2 the judge formulates a preliminary CCRT based on the frequency of
each of the types of each component. In Step I' thejudge reviews, where
needed, the types of wishes and responses based on the Step 2 prelimi-
nary CCRT. and in Step 2' thejudge reformulates, where needed, based
on the recount of all wishes and responses in Step 1'.
The CCRT judges work independently of each other. Judges are
trained by first reading the CCRT guide (Luborsky, 1986), trying several
standard practice cases, and receiving feedback from the research team
about their performance after each. Further descriptions of the CCRT
method, with case examples, can be found in Luborsky (1984) and Lu-
borsky, Crits-Christoph, and Mellon (1986).
Intenudge agreement on delineating relationship episodes and for-
mulating CCRTs was recently reported (Crils-Christoph et al., in press).
Weighted kappa values were .61 for wish and negative response of self
and .70 for negati\« response from other.
Preliminary applications of the CCRT method have indicated that it
is useful as a measure of transference. In a sample of 8 patients (Lubor-
sky et al., 1985), CCRT results were found to correspond to Freud's
(1912/1966) observations about transference that could be restated op-
erationally. For example, it was found that one main theme predomi-
nates, that the pattern is relatively unique for each person, that the pat-
tern remains relatively stable over time, and that the relationship with
the therapist mimics the general transference pattern.
Two or (occasionally) three judges scored each of the 43 patients for
the CCRT. For each case, the final CCRT selected for inclusion in the
study was a composite of the judges1 CCRT formulations. These formu-
lations included three components: wish, negative response from other,
and negative response of self. Becausejudges occasionally used different
wordings in describing their CCRT formulations, their specific wordings
were coded into a standardized language to permit direct comparisons
between formulations (Luborsky. 1986). This task was accomplished by
having three judges code the CCRT judges' formulations into standard-
ized wordings provided by standard lists of wishes, responses from other,
and responses of self. This coding task was highly reliable (i.e.. greater
than 95% agreement between judges).
Once formulations were coded into standard wordings, a composite
CCRT was derived by selecting the most frequent wishes and responses
that were noted by the different CCRT judges. The final CCRT formula-
tion for each patient consisted of up to two wishes, three negative re-
sponses from other, and three negative responses of self.
Accuracy of interpretations. Accuracy of interpretation represents the
degree of congruence between the contents of the patient's CCRT and
the contents of the therapist's interpretations. A 4-point rating scale
was used to assess the degree to which a clinical judge believed that the
therapist had addressed a particular CCRT wish, response from other,
or response of self in his or her interpretation.
The follow ing CCRT and therapist interpretation, drawn from one of
the cases used in this study, is presented to illustrate the nature of the
accuracy ratings. The patient's CCRT consisted of one wish (to make
contact with others, to be close), one negative response from other (re-
jects, distant), and three responses of self (lonely, depressed, anxious).
The therapist's interpretation follows:
I'm beginning to get a picture ofa lot of involvement that you have
with this guy still, even though he's cut IhingsolT; you haven't. And
you're not able to begin replacing him yet—the emotional invest-
ment, emotional tie you've got still to him, and pretty strongly. And
that's inhibiting you. Now, what's behind that . . . obviously he
was very important to you, more important than any other guy has
been. And that makes it harder to give him up. And the fact that
he really is the one who decided—made the choice to break, not
you—makes it harder to give him up too. I see some reaction:
What's going on?
This was regarded as an accurate interpretation of the wish and the re-
sponse from other but not ol the response of self.
For each case, three judges were presented with composite CCRT for-
mulations and interpretations that were extracted from transcripts. The
judges were directed to familiarize themselves with the patient's CCRT
formulation and to make ratings of the accuracy of each wish, response
from other, and response of self contained therein.
Ratings for the wishes were averaged to form a composite wish dimen-
sion for each patient. Similarly, ratings for the responses from other and
responses of self were averaged to yield composites on each. For each
patient, these accuracy scores were then averaged across all interpre-
tations. Interrater reliability of the accuracy scales was computed using
the intraclass correlation coefficient. Based on the sample of 43 cases,
the pooled interjudge reliabilities were (a) .84 for accuracy of the pa-
tient's wishes, (b) .76 for accuracy of the patient's responses from other,
and (c) .83 for accuracy of the patient's responses of self. Because ofa
sizable correlation (/• = .68) between wish and response from other, these
two dimensions were combined into a composite accuracy dimension
to avoid the multicolinearity of predictors in subsequent multiple re-
Errors in Technique subscale. The Errors in Technique subscale of
the Vanderbilt Negative Indicators Scale (Strupp et al., 1981) is a set of
10 items that is hypothesized to be inversely related to beneficial treat-
ment outcome. Item descriptions and reliability and validity data on the
scale were prov ided by Sachs (1983). For each case in the present study,
two judges rated the first 15 min and the second 15 min of each of
two early therapy sessions. The ratings were averaged across the two
segments, and the scores of the two sessions were then combined.
Helping Alliance Scale. The helping alliance counting signs method
(Luborsky, Crits-Christoph, Alexander, Margolis, & Cohen, 1983) was
applied by two judges to the first 30 min of each of the two early sessions
for each patient. The score for positive helping alliance signs was se-
lected for use in this analysis because this measure proved to be the
most successful predictor of outcome in a comparison of the 10 most
improved and 10 least improved cases from the Penn Psychotherapy
Project (Luborsky etal., 1983).
Treatment outcome. Two outcome measures were used: residual gain
and rated benefits (each was described in detail by Mintz, Luborsky,
& Christoph, 1979). The residual gain score was derived from general
adjustment ratings made by the patient and a clinical observer that were
obtained pre- and posttherapy and were statistically adjusted for the
effects of the patient's initial level of functioning. The rated benefits
measure consisted of ratings by the patient and the therapist assessing
actual change. Residual gain and rated benefits scores were highly corre-
lated, c(4l) = .76.
With the exception of one judge who coded interpretations and one
judge who marked off relationshipepisodes (both trained research assis-
tants), judges were experienced clinicians (clinical psychologists and
psychiatrists) trained in each task. All judges were blind to treatment
outcome and worked independently. Separate sets of judges scored each
Table 3 provides the means and standard deviations of the
accuracy dimensions. As can be seen, the average level of accu-
ACCURACY OF THERAPISTS' INTERPRETATIONS
Afeans and Standard Deviations for Accuracy Dimensions
Response of self
Response from other
Wish plus response from other
Note. The accuracy dimensions were rated on a 1-4 scale, with I indi-
cating no congruence between the content of the interpretation and the
patient's core conflictual relationship theme and 4 indicating high con-
racy was low. yet enough variability was present to allow for
relations with other variables to emerge.
The relations among the predictors were examined as a pre-
liminary step to the prediction of outcome. None of the corre-
lations attained statistical significance.
Multiple regression analyses were performed using the two
accuracy measures (wish plus response from other, response of
self), the Errors in Technique subscale. and the Helping Alli-
ance Scale as predictors and the rated benefits and residual gain
measures as outcome criteria. Table 4 presents simple corre-
lations between each predictor and the two outcome measures
as well as partial correlations (with each variable controlling for
the others) and a multiple correlation combining the predictors.
Most striking was the accuracy on the wish plus response
from other measure, which was the best predictor of outcome,
yielding statistically significant results in all cases (using both
outcome measures and simple and partial correlations). The
Errors in Technique subscale and the accuracy on the response
of self measure were not significantly related to outcome. The
Helping Alliance Scale showed significant simple correlations
with both outcome measures, as had been expected from the
Luborsky et al. (1983) study that included a sample of 20 pa-
tients, which overlapped with our sample of 43 patients. In ad-
dition, the Helping Alliance Scale demonstrated a significant
partial correlation with residual gain and a nearly significant
effect with rated benefits. Thus, the predictive effects of accu-
racy and the Helping Alliance Scale appeared to be indepen-
To test the hypothesis that accuracy interacts with helping
alliance (i.e., accurate interpretations have an impact only when
the therapeutic alliance is positive), cross-product terms be-
tween accuracy on the wish plus response from other measure
and helping alliance were entered after main effects in the multi-
ple regressions. These interactions were nonsignificant.
Because one item ("failure to address maladaptive behaviors
or distorted apperceptions") of the Errors in Technique sub-
scale overlapped conceptually with the concept of accuracy of
interpretation, we examined the correlations of this item with
the accuracy scales. For both accuracy scales, the correlations
were nonsignificant: For wish plus response from other, r(41) =
-. 11; for response of self, r(41) = -. 19.
In discussing the main results of the study, it is important to
note that the interrater reliability of the accuracy scales was
reasonably high compared with the level of reliability usually
found for psychotherapy process measures (see, for example,
Luborsky et al., 1980). The very specific nature of the rating
task (the scales were tailored to each patient's CCRT) and the
use of experienced clinical research judges probably contrib-
uted to the reliability level. By combining the ratings made on
all interpretations identified in each of two complete therapy
sessions and by averaging the ratings over three judges, a robust
measure was constructed.
The major hypothesis of this research received strong sup-
port: A statistically significant and moderately strong relation
was found between accuracy ofinterpretations (i.e., on the wish
plus response from other dimension) and treatment outcome.
These results extend the findings of Silberschatz et al. (1986),
who studied the immediate impact of accuracy (i.e., the conver-
gence of the plan diagnosis with interpretations) in the psycho-
therapies of three patients. Although a relation between accu-
racy and therapy outcome was also observed in that study, the
significance of the finding was limited by the size of the sample.
In the current research, larger and more diverse groups of pa-
tients and therapists were examined, allowing for the first sys-
tematic investigation of the relation between the accuracy of
interpretations and treatment outcome.
The results suggest that what the therapist does in dynamic
psychotherapy has an impact on outcome. The overall pattern
of results also suggests that a specific and not a general tech-
nique factor accounts for the finding. The predictive strength of
accuracy on wish plus response from other was not accountable
by other variables such as errors in technique or the quality of
the therapeutic alliance.
It is of interest that accuracy on wish plus response from
other rather than accuracy on response of self predicted treat-
ment outcome. It appears that correctly addressing the patient's
stereotypical patterns of needs and wishes, followed by address-
ing the responses of others, is an effective strategy. However, lim-
Prediction of Outcome From Accuracy, He/ping Alliance,
and Errors in Technique
Wish pi us response
Response of self
Errors in techniques
Note. All tests were two-iailed. Multiple correlations were as follows:
For rated benefits. R (4.38) = A9.p < .05; for residual gain, R (4, 38) =
.54. p < .01. When a Bonferroni adjustment was made for the number
of simple correlations computed with each outcome measure, only the
accuracy on wish plus response from other correlations remained sig-
nificant at p < .05.
P. CRITS-CHR1STOPH, A. COOPER, AND L. LUBORSKY
iting the focus ol'interpretations to the patient's usual responses
(typical feeling states) in interpersonal situations is not by itself
a productive technique. The lack of a significant relation be-
tween accuracy on the response of self with outcome is not in-
consistent with the research concerning the therapeutic effects
of focusing on patient affect. In their review of the few studies
on the relation between affect focus and outcome, Orlinsky and
Howard (1986) found that focusing on patient affect is only oc-
casionally helpful, although it is probably not harmful.
The lack of a significant interaction between accuracy of in-
terpretations and the quality of the therapeutic alliance was sur-
prising given the clinical lore that a strong alliance is necessary
for patients to tolerate and make use of interpretations. Perhaps
this relation would emerge with more severely disturbed pa-
tients than the sample used here, particularly if there was a
higher frequency of poor alliances. In our study, only three ther-
apist-patient dyads showed no signs at all of a positive alliance.
The results for the Errors in Technique subscale are discrep-
ant from the findings of the Sachs (1983) study, which showed
a significant inverse relation between errors in technique and
outcome. There are a few possible reasons for the nonsignificant
finding for errors in technique in the current research. First, the
relatively limited reliability of the Errors in Technique subscale
in this study may partly explain the results. The limited reliabil-
ity may have been a function of the generally low level of errors
in our sample (4 of 10 items did not occur, and several others
occurred infrequently). In addition, items on this scale may be
more appropriate for time-limited psychotherapy. Treatment in
Sachs' (1983) study was specified as brief therapy (maximum of
6 months) compared with the open-ended therapy used in the
current research (average length of about I year).
Interpretation of our main findings is subject to the inherent
limitations of all correlational research, such as the possible
role of a third variable that may have accounted for the relation
between accuracy and outcome. In addition, the direction of
the relation can be questioned. For example, it is possible that
patients who are making good progress in treatment may be
more likely to elicit accurate interpretations from their thera-
pists, particularly if they are becoming aware of their own rela-
tionship patterns and can articulate these issues during the ses-
sions. However, the fact that the finding was observed very early
in treatment (usually by the fifth session) provides some support
for the opposite position in which accuracy leads to favorable
The study also provided new information concerning the va-
lidity of the CCRT measure. By basing the assessment of inter-
pretation accuracy on the CCRT method, the significant rela-
tion between accuracy on wish plus response from other with
treatment outcome indirectly lends the method further validity.
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APA policy prohibits an author from submitting the
same manuscript for concurrent consideration by two or
more journals. APA policy also prohibits duplicate publi-
cation, that is, publication of a manuscript that has al-
ready been published in whole or in substantial part in
another journal. Prior and duplicate publication consti-
tutes unethical behavior, and authors have an obligation
to consult journal editors if there is any chance or ques-
tion that the paper might not be suitable for publication
in an APA journal. Authors submitting a manuscript pre-
viously considered for publication in another APA jour-
nal are invited to inform the Editor, who will then seek
to obtain independent reviews, thus avoiding the possibil-
ity of repeated reviewing by the same consultant. Also,
authors of manuscripts submitted to APA journals are
expected to have available their raw data throughout the
editorial review process and for at least 5 years after the
date of publication. Authors will be required to state in
writing that they have complied with APA ethical stan-
dards in the treatment of their sample, human or animal,
or to describe the details of treatment. (A copy of the APA
Ethical Principles may be obtained from the APA Ethics
Office, 1200 17th Street, N.W., Washington, DC 20036.)
Authors should prepare manu-
accompanied by an abstract of 100-150 words. Manu-
scripts of Brief Reports must be accompanied by an ab-
stract of 75-100 words. All abstracts must be typed on a
separate sheet of paper.
Manuscripts of regular articles must be
Brief Reports. The Journal of Consulting and Clini-
cal Psychology will accept Brief Reports of research stud-
ies in clinical psychology. The procedure is intended to
permit the publication of soundly designed studies of spe-
cialized interest or limited importance that cannot now
be accepted as regular articles because of lack of space.
Several pages in each issue may be devoted to Brief Re-
An author who submits a Brief Report must agree not
to submit the full report to another journal of general cir-
culation. The Brief Report should give a clear, condensed
summary of the procedure of the study and as full an
account of the results as space permits. Brief Reports
should be limited to three printed pages and prepared
according to the following specifications:
To ensure that a Brief Report does not exceed three
printed pages, follow these instructions for typing: (a) Set
typewriter to a 55-space (pica) or 66-space (elite) line,
with 25 lines per page, (b) Type text, (c) Count all lines
except abstract (75-100 words), title, and by-line, includ-
ing acknowledgments. If you have exceeded 325 lines,
shorten the material.
In Brief Reports, headings, tables, and references must
be counted in the 325 lines. This journal no longer re-
quires an extended report. However if one is available,
the Brief Report must be accompanied by the following
Correspondence concerning this article (and for an ex-
tended report of this study) should be addressed to /give
the author's full name and address).
The footnote should be typed on a separate sheet and no!
counted in the 325-line quota.
Submitting manuscripts. Manuscripts should be sub-
mitted in triplicate, and all copies should be clear, read-
able, and on paper of good quality. A dot matrix or un-
usual typeface is acceptable only if it is clear and legible.
Dittoed and mimeographed copies are not acceptable
and will not be considered. Authors should keep a copy of
the manuscript to guard against loss. Mail manuscripts to
the Editor, Alan E. Kazdin, Western Psychiatric Institute
and Clinic, University of Pittsburgh School of Medicine,
3811 O'Hara Street, Pittsburgh, Pennsylvania 15213.