——-—— — — ~ —_ _
_ 5 _ > _ _ _ ‘ -.. -...- . .o.. . - ~ - - -’- "- -'- '- —-.-.-- """W¢‘_-,_._”

CHANGES IN AFFECT EXPRESSED ON THE TAT
BY SCHIZOPHRENICS BEFORE AND AFTER
PSYCHOTHERAPY

ThesisfortheDegreeofM.A.
mam STATE .umvmsm
NANCY KAY women
1973

“fifi'. ‘?

RRRRRRRRRRRRRRRRRRRR

 

 

ABSTRACT
CHANGES IN AFFECT EXPRESSED ON THE TAT

BY SCHIZOPHRENICS BEFORE AND
AFTER PSYCHOTHERAPY

BY

Nancy Kay Wowkanech

The purpose of this study was to investigate the
relative effectiveness of psychotherapy with schizophrenics
in producing greater affect expression. Specifically, this
study was concerned with the amount, variety, and mode of
expression of affect contained in TAT protocols of 36
schizophrenic patients who participated in a recent psycho-
therapy project (Karon and VandenBos, 1970, 1972). Schizo-
phrenics were randomly assigned to three treatment groups:
a) an "active psychoanalytic" therapy without medication;
b) an "ego—analytic" therapy, with adjunctive medication;
and c) a control group of standard hospital care, i.e.,
medication plus minimal support. Within Groups A and B,
patients were seen by an experienced therapist or one of

several inexperienced therapists.

Nancy Kay Wowkanech

TAT's obtained before therapy and during six and
twenty month follow-ups were analyzed with respect to seven
hypothesized affect dimensions (Tomkins, 1963): interest-
excitement, enjoyment-joy, surprise—startle, fear—terror,
anger-rage, distress—anguish, and the "humiliation complex"
(a combination of Tomkins' shame-humiliation, contempt-
disgust, and self-contempt—self-disgust dimensions). TAT
protocols were scored for the presence of the seven hypoth-
esized affect dimensions; each specific affect was scored.
only once per story. The sum of all affects over all
twenty stories (i.e., "total affect score") was computed.
In addition all affects were scored according to four
differing modes of expression: "felt" (but not acted out),
"felt and acted out," "acted out," and "negated." The
actual affect variables looked at in the analysis of the
data were: 1) overall "total affect," 2) overall "felt"
(but not acted out) affect, 3) overall "total felt"

("felt" plus "felt and acted out") affect, and 4) "total
felt" ("felt" plus "felt and acted out") affect for the
seven specific affect dimensions.

In addition, this study looked at quantified clin-
ical status ratings (CSI), obtained earlier (Karon and

2

Nancy Kay Wowkanech

O'Grady, 1969; Karon and VandenBos, 1970, 1972), as well as
the number of days a patient needed hospitalization subse-
quent to each assessment interval. This was done in order
to test the validity of the affect measures; i.e., corre-
lations between affect variables and CSI ratings indicated
concurrent validity, and correlations of affect variables
with days hospitalized indicated predictive validity.

The hypotheses were: 1) Schizophrenics who re—
ceived psychotherapy would show more of an increase in the
amount of "total felt" affect on the TAT than schizo-
phrenics who received medication alone; experienced ther-
apists were more likely to produce this phenomenon than
inexperienced therapists. 2) The amount of "total affect"
on the TAT would correlate positively with clinical status
ratings and negatively with days hospitalized among schiz-
ophrenics. In addition to explore the relative signifi-
cance of specific affects, the following questions were
examined: 1) Were there significant differences in spe-
cific affects related to or interacting with, differing
treatment groups and levels of therapist experience?

2) Did specific affects correlate (positively or nega—
tively) with clinical status ratings or days hospitalized

among schizophrenics.

Nancy Kay Wowkanech

Analyses of covariance revealed that there were no
significant differences between groups on either the
amount of "felt" or "total felt" affect expressed on the
TAT, twenty months after therapy. Pearson correlation
coefficients showed a non-significant positive correla-
tion between the amount of "total affect" and clinical
status ratings, and a non—significant negative correla-
tion between "total affect" and days hospitalized, over
the course of treatment. However, with respect to spe-
cific affects, results showed that the amount of "total
felt" fear—terror expressed on the TAT, increased for
schizOphrenics treated by inexperienced therapists and
decreased for schiZOphrenics treated by experienced ther-
apists relative to the control group. Other findings
were that the amount of "total felt" distress-anguish on
the TAT decreased for patients treated by experienced
therapists, and inexperienced therapists, not using medi—
cation. Schizophrenics treated by inexperienced thera-
pists using medication, as well as those in the control
group, demonstrated an overall increase in the amount of
"total felt" distress—anguish, expressed on the TAT.
Also, twenty months after therapy, fear—terror was

4

Nancy Kay Wowkanech

significantly negatively correlated with clinical status
ratings, while distress-anguish was significantly posi-
tively correlated with clinical status ratings.

These results led the author to infer that brief
psychoanalytic psychotherapy with schizophrenics can be
effective in reducing the amount of fear and "emotional
pain" felt by the patient, if he is treated by an exper-
ienced therapist. Inexperienced therapists, on the other
hand, tend to increase feelings of terror and panic in
schizophrenics, probably dependent on their own feelings
of fear and inadequacy connected with treating such dif—
ficult patients. Also, these results further support
the conclusion reached by Karon and VandenBos (1970, 1972);
chemotherapy can be seductive to the inexperienced thera-
pist; i.e., the patient will outwardly show signs of less
anguish, but his acute inner feelings of distress must
still be dealt with in therapy. Finally, it is probable
that less disrUptive feelings, such as distress—anguish,
as opposed to fear-terror, or anger—rage, reflect thera-
peutic gains with schizophrenic patients. Further research
is needed to evaluate if psychotherapy with schizophrenics
can increase the amount of affect expression.

5

CHANGES IN AFFECT EXPRESSED ON THE TAT
BY SCHIZOPHRENICS BEFORE AND

AFTER PSYCHOTHERAPY

BY

Nancy Kay Wowkanech

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Psychology

1973

DEDICATION

To Rosemary Noona who knows what

this study represents—~shades of

LePore, Cimbolic, and Ware.

ii

ACKNOWLEDGEMENTS

My deep appreciation and respect for Dr. Bertram
Karon, my chairman, whose psychotherapy project provided
the data for this study, and whose wisdom and knowledge
of psychotherapy with schizophrenics, both inspired and
guided me throughout this study.

To Dr. Gary Stollak, for his unabounding wit and
soul, which renders peace in troubled times.

To Dr. Arthur Seagull, whose patience and support
were genuinely felt during the last hectic moments.

My thanks to Gary VandenBos and Inta Silins, for
the tremendous time and effort they spent in helping me.

Gratitude to my friend, Karl Sirotkin, who has no
equal when it comes to computers.

To Sharon Berliner, for helping with the assess-
ment of the reliability of my scoring system.

Lastly, to my parents, and Chuck, whose love and

faith helped me to persevere, as always.

iii

TABLE OF CONTENTS
Page
LIST OF TABLES O 0 O O O O I O O O O O O O O O O O 0 V

INTRODUCTION . . . . . . . . . . . . . . . . . . . . 1
Theory and Supportive Research . . . . . . . . . 3
Hypotheses . . . . . . . . . . . . . . . . . . . 23

METHOD . . . . . . . . . . . . . . . . . . . . . . . ZS
Sample . . . . . . . . . . . . . . . . . . . . . 25
Procedures . . . . . . . . . . . . . . . . . . . 28
Methods of Analysis. . . . . . . . . . . . . . . 33

RESULTS. . . . . . . . . . . . . . . . . . . . . . . 37
Analyses of Covariance . . . . . . . . . . . . . 37
Correlational Analysis . . . . . . . . . . . . . 41

DISCUSSION 0 O O O O O O O C C O O O O O O O O O I O 45

REFERENCES . . . . . . . . . . . . . . . . . .'. . . 55
APPENDICES . . . . . . . . . . . . . . . . . . . . . 60
A. TABLES . . . . . . . . . . . . . . . . . . . 60
B. CHARACTERISTICS OF THE SAMPLE. . . . . . . . 69

C. SCORING KEY. . . . . . . . . . . . . . . . . 70

iv

Table

LIST OF TABLES

INITIAL MEANS FOR "FELT" AND "TOTAL FELT"
AFFECT SCORES (PRE'TREATMENT) o o o o o o o o

CORRECTED MEANS FOR "FELT" AND "TOTAL FELT"
AFFECT SCORES (SIX MONTHS AFTER TREATMENT) .

CORRECTED MEANS FOR "FELT" AND "TOTAL FELT"
AFFECT SCORES (TWENTY MONTHS AFTER
TREATMENT) O O O O C O O C O O . O O O O O O

INITIAL MEANS FOR "TOTAL FELT" AFFECT SCORES
ON SPECIFIC AFFECT DIMENSIONS (PRE-
TREATMNT) . C C O O O O O O O O O C O C O O

CORRECTED MEANS FOR "TOTAL FELT" AFFECT
SCORES ON SPECIFIC AFFECT DIMENSIONS (SIX
MONTHS AFTER TREATI‘IENT) o o o o o o o o o o o

CORRECTED MEANS FOR "TOTAL FELT" AFFECT
SCORES ON SPECIFIC AFFECT DIMENSIONS (TWENTY
MONTHS AFTER TREATMENT). . . . . . . . . . .

CORRELATIONS OF AFFECT VARIABLES WITH CLINICAL
STATUS RATINGS AND LENGTH OF HOSPITALIZATION
(PRE'TREATMENT) o o o o o o o o o o o o o c o

CORRELATIONS OF AFFECT VARIABLES WITH CLINICAL
STATUS RATINGS AND LENGTH OF HOSPITALIZATION
(SIX MONTHS AFTER TREATMENT) . . . . . . . .

CORRELATIONS OF AFFECT VARIABLES WITH CLINICAL
STATUS RATINGS AND LENGTH OF HOSPITALIZATION
(TWENTY MONTHS AFTER TREATMENT). . . . . . .

Page

60

61

62

63

64

65

66

67

68

INTRODUCTION

The purpose of this study was to investigate
the relative effectiveness of individual psychoanalytic
psychotherapy with schizophrenics, in producing in-
creased expression of affect on the TAT. Specifically,
this study focused on the amount, variety, and mode of
expression of affect contained in TAT protocols of
schizophrenics who had been randomly assigned to three
treatment groups: a) an "active psychoanalytic" therapy
without medication; b) an "ego—analytic" therapy, with
adjunctive medication; and c) a control group of stand-
ard hospital care.

Past research on the effectiveness of various
forms of therapy with schizophrenics has tended to em-
phasize assessment of intellectual, perceptual, and
behavioral functioning. However, adequate assessment
of change in affect expression among schizophrenics, has

been sorely neglected.

Theoretically, the significance of emotional
responsiveness, as a critical predictor of favorable
prognosis among schizophrenics, is well-known. Ini-
tially Bleuler (1911), in his classic monograph, Dementia

Praecox, or the Group of SchiZOphrenias, emphasized the

 

disturbance in affectivity as one of the core features
of schizophrenia. Bleuler viewed the primary emotional
deficit in schiZOphrenia, as a juxtaposition of oppo-
sites; i.e., total emotional indifference on the one
hand, and/or expression of uncontrolled extreme lability
of affect, on the other.

In addition, many theorists have asserted the
primacy of specific affects in schizophrenic disorders;
i.e., Bellak (1969) maintains that anger is the most
frequent affect in schizophrenics who are "withdrawn
and inaccessible." Fromm—Reichman (1952) adds that the
schizophrenic's fear of closeness is a response to
anxiety over his own hostile impulses. Tomkins (1963)
believes fear-terror and humiliation, predominate, espe-
cially in paranoid schizophrenics. Karon (1963) suggests

that the therapist focus on "continually decreasing the

schiZOphrenic's feelings of "anxiety, guilt, and worth-
lessness."

This research attempted to investigate the no-
tion of the relative predominance of certain affects in
schiZOphrenics, and the importance of specific affects
in relation to a successful therapeutic outcome, based
on clinical status ratings and length of hospitalization
following assessment. ‘More Specifically, it will be shown
that the amount of affect on the TAT is not an effective
outcome measure, but that the relative predominance of
certain individual affects; i.e., potentially more dis-
turbing emotions such as anger-rage, fear-terror, vs.
less disruptive feelings of distress—anguish; does corre-
late significantly with outcome criterion used in this
study. In addition, it will be shown that the experience
level of the therapist interacts with specific affects

expressed by the schizophrenic on the TAT.

Theory and Supportive Research

 

Many theorists have speculated concerning the

importance of affective functioning. Tomkins (1963)

stated that the primary motivational system is the affec-
tive system and that biological drives have motivational
impact only to the extent they are amplified by emotional
arousal. Rapaport (1950) postulated a theory concerning
how emotions become mechanized. He suggests that in-
coming perceptions initiate unconscious processes which
mobilize unconscious instinctual energies; if no free
pathway is Open for the release of these energies (i.e.,
instinctual demands conflict), they find discharge
through "emotional expression and/or emotions felt."
Rapaport concludes that:

emotional discharges of varying intensity

constantly occur besides the "genuine

emotions" described in textbooks--rage,

anger, fear, etc.,—-an entire hierarchy

of emotions exists; ranging from the most

intense to mild, conventionalized, in-

tellectualized emotions (1950, p. 37).

Tomkins (1963) argues that the critical differ-
ence between drives and affects is their "generality."
He states:

the drive is primarily a transport me—
chanism-—it emits a set of motivating
signals with a crucial but limited and
specific message. The affective system
is characterized by more flexibility of

activation, maintenance, and delay . . .
an individual may not live all his life

actually hungry, but he can live all this
life actually anxious, ashamed, sometimes
depressed, or never excited, etc. The
conditions which trigger affective re-
Sponses include drives, but are not lim-
ited to them . . . the openness and flex-
ibility of human affect accounts for the
diversity of men's motives. The sources
of both psychopathology and of rewarding
growth are found in man's affective po-
tentialities (1963, p. 6).

Wessman and Ricks (1966) add that while in the
past the prevailing notion of emotion was that of
tension-drive-reduction or conflict theory model, the
adaptive aspects of affective functioning have now
taken on increasing importance. They state:

the nature of man's encounter with his
world is determined by his affective
stance. If emergency emotions predomi-
nate, he is closed and shut—off from
growth and self—realization in the world,
and defensive security Operations con-
Strict his behavior . . . if the posi-
tive emotions predominate, he is open
and able to proceed along the path of
his own individual fulfillment and self-
realization (1966, p. 4).

The primary affect, Tomkins (1963) hypothesizes,
are contained within eight dimensions existing along a con—
tinuum of high-low intensity. The positive affects are:

interest-excitement, enjoyment-joy, the re-setting affect

called surprise-startle. The negative affects include:

distress—anguish, fear-terror, anger-rage, shame-

humiliation, and contempt—disgust. It is Tomkins' belief

that natural selection has

Operated on man to heighten three distinct
classes of affect-—affect for preservation
of life, affect for people, and affect for
novelty . . . man is equipped with innate
affective responses that bias him to want

to remain alive and to resist death, to
want to have sexual experiences, to want to
communicate, to be close to and in contact
with others of his species and to resist the
experience of head and face lowered in shame
(1963, p. 27).

The significance of affective functioning related

to therapeutic change has been discussed by Rogers (1961)

in his paper, "The Process-Equation of Psychotherapy."
states:

studies suggest that it may be a new way of
experiencing in a more immediate, more fluid
way, with more acceptance, which is the es-
sential characteristic of therapeutic change,
rather than . . . the gaining of insight or
the working through of the transference rela-
tionship or the change in self concept (1961,
p. 412).

Rogers describes the process of psychotherapy as

He

helping the client to progress along a "continuum of psy-

chologic functioning"; the lowest point being "a rigid,

static, undifferentiated, unfeeling, impersonal type of

functioning"; the highest pOint being "a state of changing-
ness, fluidity, richly differentiated reactions, by imme-
diate experiencing of personal feelings which are felt or
deeply owned and accepted."

The significance of affective functioning for
schizophrenic patients is critical. In a recent review
of the literature on schiZOphrenia, Bellak and Loeb (1969)
report that:

elation, depression of mood, anxiety and dread
are common manifestations at the "onset of a
schiZOphrenic illness." Self-criticisms may
appear and depression of mood may persist for
some time before schiZOphrenic features arise
. . . . But it is the absence of affectivity
(flatness) or inappropriate affective responses,
which are regarded as characteristic of the
illness. A result of the psychotherapeutic
work, which has been conducted over the past
25 years, has been to show that there is no
impairment or weakening of the affect in
schizophrenic psychoses. Instead it is the
manner of expression which is diSturbed. It
is of some interest, that anger is the most
commonly observed affect, particularly in
patients who are for the most part, withdrawn
and inabcessible.

 

 

 

 

Thus, working with schizophrenics, the literature
seems to suggest that measures of therapeutic outcome in-
clude some assessment of the relative amount of affect
present in the patient's behavioral repertoire before and

after therapy. Also relevant are the quality of expression

of those affects (i.e., expressed as "felt" vs. "acted out"
or "negated") and the relative significance of particular
affects which constitute the schizophrenic's inner world
of experiencing.

The TAT has been used, as a therapeutic outcome
measure, to assess different aspects of affective function-
ing. In a study with nonpsychotics, Greenwald (1959) used
affective complexity as a variable and hypothesized that
affective complexity, as inferred from TAT protocols would
increase as a result of psychotherapy, with movement in the
direction of bivalent affect, and with controlled resolu—
tion away from affective inhibition or monotonic affect.
His subjects were 20 clients in counseling at the Univer-
sity of Chicago, seen for an average of one session for 3
weeks, and a group of 20 controls, who responded to a re-
search ad in the newspaper. TAT's were administered before
and after therapy and during a six-month follow-up. More
pleasant, cheerful, and optimistic moods and fewer unplea-
sant ones were reported after therapy; a significant in-
crease in affective complexity was indicated by the exper-
imental group. The follow-up data showed a greater in—
crease in number of pleasant feelings, and a slight reduc—

tion in complexity for the experimental subjects.

Ullman (1958) abstracted the TAT variables of.
denial, projection, and impulsive behavior separately from
case records of 50 male, psychiatric patients. Patients
were ranked on each variable and were separated as "inter-
nalizers" or "externalizers." TAT's were administered and
each patient was independently assigned the previous labels
according to the number of emotional words used in the TAT
stories. The degree of emotionality or defensiveness re-
flected on the TAT was correlated with the independent
ranking of the patient's clinical status. Ullman concluded
that "emotionality can be experimentally conceptualized and
manipulated in the same way that needs or threats are dealt
with in studies of perceptual defense" and supported the
validity of the TAT as a projective measure of emotionality.

Glad, Hayne, Glad and Ferguson (1963) investigated
the changing relationships between social and projective
test behaviors in a group of paranoid schiZOphrenics using
group psychotherapy. Patients were given the D-V Emotional
Projection Test, the TAT, and a social relations test be-
fore and after a series of 15 group therapy sessions.
Projective tests were coded along the same dimensions as

the group therapy behaviors: desires about the self and

10

others and perceptions about the self and others. Inter-
rater reliability ranged from .80 to .90. The results
were:
1) a greater difference in projective test
feelings, and socially observed feelings
occurred in the early vs. later stages of
therapY; 2) behaviors categorized as socially
useful were most likely to occur in projec-
tive tests early in therapy and in social
behaviors, later on; 3) relations between
socially observed feelings and feelings de-
coded on the D-V Emotional Projective Test
were a decrease in behavioral anxiety vs.
projective anxiety over the course of therapy,
and an increase in direct expression of
anxious feelings accompanied by a decrease
of "activity responses" (e.g. "wondering,
thinking").

Rogers et al. (1967) reported significant differ-
ence in personality change on the TAT with schizophrenics
treated by client-centered therapy vs. controls. Hospital
experimentals significantly reduced defensiveness on the
TAT after therapy (i.e. need to deny or emotionally dis—
tance themselves from their TAT stories), showed signifi-
cant improvement in the appropriateness of their emotional
expression, and revealed an increased capacity to handle
interpersonal relations in a personally satisfying manner
when compared with hospital contfols.

These studies indicate some validity for the use

of the TAT as a projective device in investigating

ll

affective expression and its relationship to behavioral
correlates of clinical status.

Research concerning therapy with schizophrenics
comprises a potpourri of techniques and outcome measures,
few of which attempt to assess affective functioning. The
majority of the recent literature deals with group psycho-
therapy of varying forms of "milieu therapy"; i.e. group
living arrangements such as "lodges," ”half-way houses,"
etc. Stotsky, Daston and Vardolk (1958) did vocational
counseling with a group of 28 male, chronic schiZOphrenics.
They matched two groups with respect to symptoms, ward
adjustment, and personality measures and found the treated
group showed improvement on within-hospital work adjustment
and Bennett-Q Sort. Peyman (1956) investigated the rela-
tive effectiveness of group therapy and shock, group
therapy alone, shock alone and routine hospital care using
32 chronic schiZOphrenic females, aged 21-39. Patients
were matched on IQ and length of hospitalization and ran—
domly assigned to four groups. Pre— and post-test measures
included the WAIS, Bender-Gestalt, and Rorschach. Group
therapy comprised a one—hour session twice a week for six
months and involved role-playing. No significant differ-

ences were reported on the psychological tests. Group

12

therapy with and without shock was significantly better
than shock alone or custodial care.

Sacks and Berger (1954) compared group therapy
with no treatment using 46 chronic schiZOphrenics. They
found that 46% of treated patients moved on an improved
ward in the hospital after one year of therapy vs. 4% of
the controls. No information on matching with regard to
severity of illness, or assignment of patients to groups
or outcome measures was given; these results are ques-
tionable.

Kraus (1959) also tried to determine the effective-
ness of group psychotherapy with schizophrenics. He com-
pared two groups of eight chronic patients, matching them
on background variables and randomly assigned them to
groups. Patients were rated pre- and post- by experienced
psychiatrists on appearance, behavior, sleeping and eating
habits, stream of talk, mood, thought processes, orienta-
tion, insight and anxiety. The results of behavioral rat-
ings are questionable due to low inter-rater reliability
but ratings showed improvement for the group therapy pa-
tients. MMPI scores were also obtained and showed signif-

icant differences between the groups after therapy.

13

Coons (1957) found significant improvement on the
Rorschach with schiZOphrenics using group therapy focus-
ing on maintaining interaction with others as compared
with group therapy aimed at providing insight and self-
understanding. King, Armitage, and Tilton (1960) inves-
tigated the relative effectiveness of three variants of
therapy over no therapy. One method of therapy utilized
was the "Operant-interpersonal" method. A multiple Oper-
ant problem-solving apparatus dispensed rewards of candy
and cigarettes, first on an individual basis and then on
a group basis. The third method was recreational therapy.
Outcome measures included behavior ratings by ward per-
sonnel. King et a1. (1960) found that patients treated
by the operant-interpersonal method improved more than
others after therapy and during the six—month follow-up
although no patient was discharged.

Anker and Walsh (1961) compared group therapy with
activity programs. They found activity group patients
improved significantly on motility, communication, coop-
eration, total adjustment and at the p = .08 level for
affect, as rated by ward personnel. Psychotherapy patients
showed only a reduction in motility. There were no sig-

nificant differences in the number of patients discharged.

14

MacDonald, Blockberger and Maynard (1964) compared
patient vs. staff-led groups with 56 chronic hospitalized
patients, 48 of whom were schizophrenics. Patients were
randomly assigned to four groups: traditional group psy-
chotherapy, focusing on providing insight; discussion
groups concerning planning for discharge; autonomous group
focusing on re-entry into the community; a control group,
which never met. Behavior ratings by ward personnel indi—
cated that traditional group therapy led to more "rule ine
fractions" in ward behavior; the autonomous group showed
the most improvement in ward behavior; there was no sig-
nificant difference in the number of patients discharged
from each group. Earlier Misbach, Cadman and Brown (1954)
had found that chronic psychotics improved more than con-
trols and were discharged faster if they had been involved
in autonomous groups.

Mainord, Burk and Collins (1965) compared the
efficacy of confrontation and diversion techniques in group
therapy with chronic schizophrenics. Confrontation meant
forcing the patient to deal with emotional arousal he felt
in the group; diversion meant he was diverted from his
feelings. The study utilized three groups. One group was

exposed to three months of confrontation, followed by

15

diversion therapy for three added months. Another group
experienced both techniques in reverse order. A third
group served as a control. The only significant differ-
ence between groups was that all the patients discharged
during the study were from the confronting groups. Moore,
Chernell and West (1965) reported improvements over con-
trols with schizophrenics utilizing a series of video-tape
self-confrontations.

Clearly the evidence for group therapy is incon—
clusive. In the studies which were adequately controlled
outcome measures were mostly behavioral ratings by ward
personnel. In terms of rating adjustment, behaviors
valued by the staff may correspond more to staff needs
than patients' needs. Discharge rates for schizophrenics,
on the average, seem to be unaffected by group therapy.
Most studies lack adequate follow-up data.

Several attempts have been made to experiment with
'techniques aimed specifically at schiZOphrenics. Goertzel,
May, Salkin and Schoop (1965) used a nonverbal approach,
the "body-ego" technique. The goal was to help patients
recreate postures and movements associated with emotions
and attitudes, causing them anxiety._ Ratings of ward per-

sonnel and psychiatrists reflected improvement of

16

experimental subjects with respect to ward behavior and
appropriateness of affect. Null results were obtained,
however, on the Draw—A—Person and Bender-Gestalt tests.

Bookhammer, Meyers Schober and Piotrowski (1966)
investigated Rosen's method of direct analysis with
schizophrenics between the ages of 15—35 over a five—
year period. A committee evaluated patients on objective
behaviors, i.e., self-attitudes, attitudes towards others,
thought processes, useful work output and time spent out
of the hospital. Results demonstrated no significant
differences between experimentals and controls and were
used to support the conclusion that analytic therapy with
schizophrenics is not effective. However, the dimensions
and characteristics of the controls‘ treatment were not
specified nor were the means of evaluation, reliability,
etc.

Azima, Wittkower and Latendresse (1958) utilized
a technique based on analytic therapy, focusing on activ-
ities which denoted regressive behavior. Twelve chronic
female schizophrenics were given milk through baby bottles,
mud to play with, dolls, etc., relevant to the stage of
psychosexual development they had regressed to and then

helped to move through successive stages with the aid of

17

psychoanalytic interpretatiOns. Therapy was carried on
for six months and a three year follow-up was completed.
Subjective ratings of ward personnel and therapists indi-
cated significant imporvement with respect to reality-
testing functions, control and social behavior. However,
only one patient continued to function at the same level
at the time of follow—up. The lack of quantified data
renders these results less useful.

Zirkle (1961) found that "minimal contact" with
schiZOphrenics (25 minutes a week of individual attention
for a two—month period) resulted in significant improve-
ment over a control group receiving routine hospital care.
Improvement was rated by ward personnel and focused on the
following aspects: social contact, personal habits, emo-
tional control, spontaneity of speech, cooperation on the
ward, awareness and concern for others, participation in
activity groups, capability of handling a hospital job
and interest in returning to the community.

The most recent trend in therapy with schizophrenics
appears to be towards various forms of "milieu therapy" or
communal living. Meltzoff and Kornreich (1970) evaluated
the impact of therapeutic programs (e.g., Fairweather

et al.,l960, 1965; Saunders et al.,l962; Brandon, 1961;

18

Kris, 1964; Meltzoff & Blumenthal, 1966) and concluded
that 85% of these treatments were effective; these exper-
iences providing valuable social experiences, consensual
validation of reality, learning of communication skills,
Opportunities for assuming responsibilities, increasing
self-esteem and self-expression and an overall strengthen-
ing of ego functioning in schizophrenic participants. The
authors also reviewed 101 studies researching the effec-
tiveness of psychotherapy and state:

About one—half of the adequately controlled

studies which yielded null results were

failures of verbal therapies to bring about

improvement in chronic schizophrenics.

Therapeutic methods which fail have been

characterized as formal, conventional, tra-

ditional, verbal and insight-producing.

What they appear to have in common on the

part of the therapist is to promote self-

awareness, verbalization of feelings and

awareness of motivations underlying be-

havior (1970, p. 212).

Cowden, Zax, Hague and Finney (1956) evaluated the
use of chlorOpromazine by itself and as an adjunct to
group therapy with 24 chronic schizophrenics and compared
this to routine hOSpital care. Group therapy focused on
promoting feelings of comfort and security. Ward behavior
was assessed by staff after four months. Results indi-

cated the combination of drugs and group therapy yielded

the most improvement.

19

May and Tuma (1964, 1965) compared the effective-
ness of several forms of treatment with 200 schizophrenics
(analytic psychotherapy, mediciation, medication and psy-
chotherapy, ECT vs. a no—treatment control group). They
concluded that only medication was effective. Psycho-
therapy with or without medication made no difference.
However, Karon and VandenBos (1970) point out that May
and Tuma utilized only inexperienced therapiSts, had an
appreciable number of patients on whom follow-up data was
not obtained, and included no direct measures of thought
disorder.

Karon and O'Grady (1969) and Karon and VandenBos
(1970, 1972) reported that significant improvement in
schizophrenics patients occurred, especially with regard
to thOught disorder, six, twelve, and twenty months after
analytic psychotherapy. The patients were randomly as-
signed to three treatments: psychoanalytic therapy of an
"active" variety without medication, psychoanalytic therapy
of an ego-analytic variety using medication adjunctively,
and medication plus supportive therapy: i.e.,-routine
hospital care. In the experimental groups, patients were
treated by experienced and inexperienced therapists.

(Patients averaged approximately sixty hours of

20

psychoanalytic psychotherapy per year.) Outcome measures
utilized were the Thorndike-Gallup Vocabulary Test (TGV),
Porteus Mazes (PM), Wechsler (WAIS and WB II), Feldman-
Drasgow Visual Verbal Test (VVT), TAT, and Rorschach. Pa-
tients were also given a clinical status interview, encom-
passing the following factors: ability to take care of
self; ability to work; sexual adjustment; social adjust-
ment and relationships with friends; absence of hallucina-
tions, bizarre delusions, gross distortions of reality;
degrees of freedom from anxiety and depression; amount of
affect; variety and Spontaneity of affect; satisfaction
with life and self; achievement of capabilities and benign
vs. malignant effects on others. With respect to each
outcome measure, analysis of covariance was used to com—
pare treatments, correcting for initial performance on
that measure, and any background characteristics which
were significantly related. The authors concluded:

the most significant finding was the rele—

vance of the experience of the therapist and

its interaction with the effects of medica-

tion. Patients treated by experienced ther-

apists were hospitalized for a shorter length

of time, showed less psychotic thought dis-

order (on the VVT) and were viewed as func-

tioning at healthier level (clinical status

ratings) than control patients . . . . Pa-

tients treated by inexperienced therapists
not utilizing medication were hospitalized

21

longer than the hospital control group, but
showed dramatic improvement in their under—
lying thought disorder. Patients treated
by inexperience therapists utilizing medi-
cation were hospitalized for very short
periods of time, but showed little or no
greater improvement than controls in their
thought disorder. Thus, the experienced
therapists tended to produce more balanced
change while inexperienced therapists con-
centrate on one or another aspect of im-
provement, that aspect easiest to obtain
with their treatment modality.

 

 

In conclusion, the recent research cOncerning the
effectiveness of psychotherapy with schiZOphrenics has
suffered from the following: lack of controls, or com—
parable control groups, questionable selection procedures,
adequate information about duration of illness and hos—
pitalization prior to treatment, specification of treat-
ment techniques utilized, use of inexperienced therapists
only, lack of meaningful outcome criteria in terms of
psychological tests or quantified data and paucity of
followup data. Therefore, it is naive to assume that
standard analytical psychotherapy is ineffective with
schizophrenics. The work of Karon and O'Grady (1969,
1970), and Karon and VandenBos (1970, 1972) lends cre—
dence to the belief that experienced therapists can pro-

duce significant improvement in thought disorder, and

22

overall clinical evaluation of emotional health, with or
without the use of medication.

However, while initial results from the aforemen-
tioned project indicate that TAT and Rorschach data Were
correlated with global ratings of clinical status, the
projective data did not differentiate between treatment
groups, although the CSI ratings did. Hence, this study
was a more precise examination of the TAT data to deter-
mine what, if any, Specific changes with regard to affect,
occurred in schiZOphrenics receiving psychotherapy with
and without medication, and medication alone. Following
"Rogerian" philOSOphy, one might expect psychotherapy to
produce specific changes, quantitatively, in the amount
of affect, and qualitatively, in the manner and content
of affect expression. These changes, theoretically,
should reflect improvement with regard to developing
apprOpriate emotional awareness, and further, indicate
a relative shift in predominate feelings of pain and
suffering towards positive affects, e.g., enjoyment and

interest.

23

Hypotheses

 

The following hypotheses were proposed:

1) Schizophrenics who received psychotherapy would
show more of an increase in the amount of "felt"
affect on the TAT than schizophrenics who received
medication alone; experienced therapists were more
likely to produce this phenomenon than inexper-

ienced therapists.

2) The amount of total affect on the TAT would cor-
relate positively with clinical status ratings
and negatively with days hOSpitalized among

schizophrenics.

In addition to the immediately preceding directional
hypotheses, the analysis of data also examined the follow-

ing questions:

1) Were there significant differences in specific
affects related to or interacting with, differing
treatment groups and levels of therapist experi—

ence?

24

2) Did specific affects correlate (positively or
negatively) with clinical status ratings or hos-

pitalization among schiZOphrenics?

METHOD

Sample

The sample consisted of thirty-six schizophrenic
patients who participated in the Michigan State Psycho-
therapy Project. The patients were selected in sets of
three and then randomly assigned to treatment groups.

The original intention of the project had been to select,
clearly schiZOphrenic patients without organic pathology
or previous hospitalization and of acute onset. However,
Karon and O'Grady (1969) point out that approximately
two—thirds of patients seen in the emergency room who
appear schiZOphrenic are treated with tranquilizers and
discharged without hospitalization. Of those hospitalized,
approximately two—thirds are discharged within two weeks.
Obtaining extensive social and medical histories on pa-
tients generally took two weeks. Diagnostic examinations
after selection were conducted by diagnostic personnel
not connected with the ward staff. This took one to two

additional weeks. If patients were discharged before

25

26

information on them was complete, they were replaced in
the project by patients still hospitalized. Thus, the
emphasis on the patient being clearly schiZOphrenic and
the attempt to get a rigorous baseline of independent
measurement led to selection of more severely impaired
patients. Patients were inadvertantly selected on resis-
tance to treatment as well as severity of symptoms.

Also, patients were primarily Black, poor, and
residents of the inner city. (Selection took place less
than twelve months before the Detroit riot at Detroit
Psychiatric Institute connected with Herman Keifer Hos-
pital.) As Karon and O'Grady (1969) state, these patients
are understandably distrustful of white authorities.
Information is only to be divulged if it cannot be used
to punish the patient, etc. These individuals do not
expect help for being emotionally ill. They are hospi-
talized because they have disturbed someone else. Bizarre
behavior and emotional suffering are accepted by the pa-
tients and their environment as part of the miserable
world they live in and not as an illness to be alleviated.
Thus, these patients tend to have been ill for a long time

(by middle—class standards) before hospitalization.

27

Despite the attempts at obtaining adequate case
histories and medical screening, the patients had as much
as six weeks of previous hospitalization which, generally,
neither the patients nor relatives had revealed. Four
instances of medical problems occurred; two of the pa-
tients died of embolisms (both diagnosed as catatonic).
The first patient died before therapy had begun, so a new
patient was selected and the set of three patients was re-
randomized. The other patient lapsed into silence and
died after therapy had begun. She was not replaced for
two reasons: a new patient would not have been randomly
assigned, and the student therapist who had tried to treat
her was so traumatized by her death that he refused to
treat another psychotic patient. Further investigation
of this patient revealed that she had been a long-standing
drug addict and had undergone a long course of ECT; this
would have made her ineligible for the project.

Thus, the remaining sample consisted of thirty-
five patients; seventeen males, eighteen females; the
racial breakdown was twenty—six blacks, nine whites; age
ranged from sixteen to forty-nine; education ranged from
grade four to completion of college; the median being

approximately eleven years of schooling. Further details

28

on selection, problems incurred, and distribution of pa-
tients according to treatment groups, with respect to
age, sex, race, education, can be found in Appendix B,

and are summarized in Karon & O'Grady (1969).

Procedures

 

The TAT protocOls obtained before, six, and twenty
months after therapy, were scored according to Tomkin's
(1963) delineation of primary affects; each affect being
denoted by a double term consisting of the adjectives
which describe that affect at low and high intensity. The
"positive" affects were: interest-excitement, enjoyment-
joy; the resetting affect, surprise—startle; the "negative
affects," fear-terror, anger—rage, distress-anguish, and
the "humiliation complex."

The'"humiliation complex" incorporated Tomkins'
dimensions of shame-humiliation, contempt-disgust, and
self—contempt, and self—disgust. Tomkins (1963) distin-
guished the contempt dimension from the shame dimension
on the basis that shame-humiliation was a negative affect

"linked with love and identification," while

29

contempt-disgust was "linked with individuation and hate."
Thus, he postulated that shame-humiliation did not renounce
the object permanently, whereas contempt—disgust did; the
object of contempt-disgust, can also be, of course, one's
own self. However, Tomkins also asserted that dynamically
these affects rarely exist separately, and often interact.
He stated:

shame can be reduced by self-contempt which

totally rejects that portion of the self of

which One is ashamed, and the wish not to

lose part of oneself inevitably leads to

shame in response to self-contempt (1963,

p. 184).

Tomkins, essentially, felt that the tension be-
tween positive affects and the heightened negative aware-
ness of the self or object, gives rise to the shame-
humiliation experience. Unless this tension exists, or
is anticipated, contempt—disgust may activate "surprise,
distress, fear, or anger," as opposed to shame. Due to
the dynamic’link between these dimensions and their inter-
active effect upon one another, shame—humiliation,
contempt—disgust, and self—contempt—self—disgust were

included under one category, the "humiliation complex,"'

for scoring purposes.

30

TAT protocols were scored for the presence of the
seven hypothesized affect dimensions; each specific affect
was scored only once per story. The sum of all affeCts
over all twenty stories (i.e., "total" affect score), was
computed, as well as scores for each specific affect
(i.e., "specific" affect score).

In addition all affects were scored according to
four differing modes of expression: "felt" (but not
acted out), "felt and acted out," "acted out," and "ne—
gated." "Felt" affect was hypothesized to indicate the
most direct expression of feelings, e.g. "he is angry,"
vs. "acted out affect, e.g., "he killed the girl," vs.
negated affect, e.g., "they were not mad at each other."
With respect to therapeutic change "felt" affect and
"felt and acted out" affect seemed to be the most critical
predictors of increased expression of feelings. Thus,
each protocol was also assigned a "felt" affect score,
and a "total felt" affect score ("total felt" referred
to the sum of "felt" plus "felt and acted out affect,"
over all twenty stories for each protocol). The number
of words in each protocol were counted; enabling protocol

length to be held constant in the analysis of data,

31

thereby controlling for possible higher affect scores due
to longer protocols.

The protocols were scored by two raters.l A key
for scoring the protocols was derived by the first rater
(see Appendix C), and a second rater was trained, using
this key, to score a sample of twenty—five protocols,
chosen randomly from the data. Pearson correlation co-
efficients were computed, and inter-rater reliabilities
of at least .87 were obtained for each affect score.~

The following procedures had been employed, pre-'
viously (Karon & O'Grady, 1969; Karon & VandenBos, 1970),
to obtain quantified clinical status interview (CSI) rat-
ings, for all patients. Clinical status interviews were
given before, and six and twenty months after inception
of therapy by an experienced psychiatrist, not connected
with the ward staff, and who did not know to which treat—
ment group the patients belonged. (The same psychiatrist
conducted the clinical interviews for all patients, except
for two patients, at twenty months.) The clinical status

interviews were recorded on tape, and any clue to type of

 

l .

The first rater was the author; the second rater
was a graduate student in clinical psychology, Sharon
Berliner.

32

treatment was edited out of the tapes. Two graduate stu-
dents in clinical psychology rated degrees of emotional
health from the CSI tapes.

The.interviewer and two judges were given the
following factors as those to be taken into account:
ability to take care of self, ability to work, sexual
adjustment, social adjustment-relationship with friends,
absence of hallucinations, bizarre delusion, gross dis—
tortions of reality, degree of freedom from anxiety and
depressions, amount of affect, variety and spontaneity of
affect, satisfaction with life and self, achievement of
capabilities and benign rather than malignant effect on
others.

Ratings were made by a new scaling method (Karon
and O'Grady, 1969). The rater is presented with a 20 cm.
line and asked to record his judgment of the healthier
individual (the left end is considered the zero point).
He is then asked to consider the line to prepresent the
amount of health of the healthier individual and to mark
off on the line where the emotional health of the less
healthy individual would fall. Such as judgment is a
ratio judgment, using the healthier individual as the

standard.

33

Previous work (Carter, 1966) has shown that the
raters can make such judgments reliable and validly but
that they must rate emotional "health" rather than "sick—
ness" and that the healthier individual must be taken as
the standard if consistent judgments are to be obtained.

For computational purposes, judgments were trans-
formed to logarithms and the determination of scale
values for these logarithms became essentially the same
as calculating scale values for Thurstone's Case V of
the method of paired comparisons, once the Thurstone
data has been transformed into normal deviates. All of
this is described in further detail in Carter (1966) and

Karon and O'Grady (1969).

Methods of Analysis

 

Analyses of covariance were computed in order to
test for significant differences among the five treatment
groups, before, and at six and twenty months after therapy,
in the amount and type of affect expressed on the TAT. The
treatment groups were: a) psychoanalytic therapy without
medication, experienced therapist; b) ego—analytic therapy

with medication, experienced therapist; c) psychoanalytic

34

therapy without medication, inexperienced therapists;

d) ego-analytic therapy with medication, inexperienced
therapists, and e) medication, alone. The affect vari-
ables were: 1) overall "felt" (felt, but not acted out)
affect; 2) overall "total felt" ("felt" plus "felt and
acted out") affect; 3) overall "total" affect (sum of
all affects over all four modes of expression for each
protocol); and 4) "total felt" ("felt" plus "felt and
acted out") affect for the seven hypothesized specific
affect dimensions (i.e., interest-excitement, enjoyment-i
joy, surprise-startle, fear-terror, distress—anguish,
anger~rage, and the "humiliation complex").

The data were analyzed by analyses of covariance
using initial score on the same affect measure, and pro-
tocol length as covariates (i.e., holding initial score
and protocol length constant). Before computing the
analyses of covariance for each affect variable, the
following possible contaminating factors were taken into
account if the partial regression coefficients were sig-
nificantly related to the six, and twenty month affect

l .
scores: take vs. not take the TAT, age, sex, education,

 

l . . .
One patient did not take the TAT at Six months.

35

race, marital status, previOus hospitalization, social
class, and religion. Also, the initial scores on the
following assessment measures as reported by Karon &
VandenBos (1970), were taken into account: Thorndike-
Gallup Vocabulary Test, Drasgow-Feldman Visual Verbal
Test, Wais, TAT, Rorschach, Porteus Maze, and clinical
status ratings based upon diagnostic interviews.

Using a computer, the effects of all these co—
variates were examined simultaneously within groups, and
therapists. The covariate having the least effect was A
deleted first, and partial correlations recomputed. Var-
iables were removed one at a time because the deletion of
one variable might increase the significance of one of
the remaining variables. Covariates other than initial
score and protocol length were eliminated one at a time,
until all remaining covariates were significant at the
five percent level. These procedures are described in
more detail in Karon & O'Grady (1969).

Pearson correlation coefficients were also com-
puted between clinical status (CSI) ratings, days hospi—
talized, and all affect measures, prior to treatment,
and at six and twenty months after treatment. The pur-

poses of these correlations were to test: 1) whether the

36

amounts of "felt," "total felt," and "total" affect on
the TAT were related to clinical improvement (concurrent
validity), and length of hospitalization (predictive.
validity), and 2) to investigate the relationship of rel—
ative amounts of specific affects on the TAT with clin-
ical improvement (concurrent validity), and length of

hospitalization (predictive validity).

RESULTS

Analyses of Covariance

 

The first hypothesis stated that schiZOphrenics
who received psychotherapy would Show more of an increase
in the amount of "felt" affect on the TAT than schizo-
phrenics who received medication only. Experienced
therapists were hypothesized to be more adept at increase
ing the amount of "felt" affect indicated on the TAT than
were inexperienced therapists. The initial means for
"felt" and "total felt" (i.e., "felt" plus "felt and
acted out") affect scores can be found in Table I.
Analyses of_covariance yields significant differences
between groups for "felt" affect (p < .01) and for "total
felt" (p < .03). Thus, initially, the experimental groups
with experienced therapists were highest in the amount of
"felt" and "total felt" affect expressed on the TAT, fol—
lowed by groups with inexperienced therapists, and lastly,
by the control group.

Six months after treatment (see Table II) there
were significant differences in the amount of "felt"

37

38

affect (p < .03, but not in "total felt" affect after
adjustment for initial score, although the initial trend
was preserved. Schizophrenics treated by experienced
therapists had higher "felt" affect mean scores than
schiZOphrenics treated by inexperienced therapists and
the control groups.

Twenty months after treatment (see Table III)
there were no significant differences between groups on
either the "felt" or "total felt" affect dimensions.
Thus, the results do not substantiate the first hypoth- A
esis; schizophrenics who received psychotherapy were not
significantly different from the control group in terms
of amount of "felt" and "total felt" affect expressed on
the TAT.

However, the results Show the following interest-
ing trends: 1) "total felt" affect increased for the con-
trol group as compared to "felt" affect, which stayed
relatively the same, 2) both the "felt" and "total felt"
affect decreased for experienced therapists, and 3) both
"felt" and "total felt" affect stayed approximately the
same for inexperienced therapists, except for the "total

felt" scores which increased at twenty months.

39

The analyses of data also examined whether or not
specific affects were related to or interacted with dif—
fering treatment groups and levels of therapist experience.
Before treatment (see Table IV) there were significant
differences between groups on four specific affect dimen-
sions: interest/excitement (p < .01, distress/anguish
(p < .03), anger/rage (p < .01) and the "humiliation com-
plex" (p < .01). At six months after therapy (see
Table V) there were significant differences among groups
with respect to enjoyment/joy (p < .01) and distress/
anguish (p < .01). The data shows that twenty months
after treatment (see Table VI) three specific affect
dimensions clearly differentiate the groups: surprise/
startle (p < .01), fear/terror (p < .01) and again,
distress/anguish (p < .03).

Thus, distress/anguish was the only affect that
significantly differentiated the groups before and after
therapy. The controls showed an increase in distress/
anguish from pre—treatment to twenty months after treat-
ment. The results Show different trends for the experi—
mental groups. Within Group A (psychotherapy without
medication) overall mean scores decreased on the distress/

anguish dimension for both experienced and inexperienced

4Q

therapists. For both Group B (psychotherapy with medica-
tion) overall mean scores reflected an increase for in-
experienced therapists and relatively no change for the
experienced therapist in amount of "total felt" distress/
anguish expressed on the TAT.

The data also indicates that fear/terror was lowest
for experienced therapists and highest for inexperienced
therapists at twenty months (see Table VI). 'The trend for
this affect, taking into account the mean scores at pre-
treatment at six months and at twenty months after treat?
ment, reveals that overall mean scores for "total felt"
fear/terror decreased for experienced therapists and the
control group, and increased for inexperienced therapists.

For surprise/startle, the "re-setting" affect at
twenty months (see Table VI), schizophrenics in Group A
are significantly higher than the control group and
schizophrenics in Group B. The overall trend for surprise/
startle, taking into account scores for the three sampling
intervals, shows no consistent pattern, as do the majority
of specific affect dimenSions, except for the two discussed
above, fear/terror and distress/anguish.

Thus, with respect to the seven hypothesized af-

fect dimensions used in this study, analyses of covariance

41

indicate that the amount of "total felt" ("felt" plus
"felt and acted out") distress/anguish expressed on the
TAT decreased for schiZOphrenics in Group A, stayed
approximately the same for schizophrenics in Group B
(experienced therapist) and increased for schizophrenics
in Group B (inexperienced therapists) and in the control
group. The results also Show that fear/terror decreased
for schizophrenics treated by experienced therapists and
increased for schizophrenics treated by inexperienced

therapists when compared with the control group.

Correlational Analysis

 

The second hypothesis stated that the amount of
"total" affect on the TAT would correlate positively with
clinical status ratings (CSI), and negatively, with days
hospitalized (DH), among schizophrenics. Pearson r's for
overall "felt," "total felt," and "total" affect, and for
each of the seven specific affect dimensions, at pre-
treatment, six and twenty months after therapy, are pre-

sented in Tables VII, VIII, and IX, respectively.

42

The results show that "total" affect as well as
"felt" and "total felt" affect, on the TAT, are positively
correlated with clinical status ratings, before therapy,
and at six and twenty months after therapy. The correla-
tions are surprisingly low; however, "felt" affect is
significantly correlated with CSI ratings at pre-treatment,
r = .31, p < .10, and at six months after therapy, r = .29,
p < .10. Although most of the correlations are nonsignif-
icant, the general trend yields minimal basis for estab—
lishing concurrent validity with respect to affect varie
ables on the TAT, and clinical status ratings.

In terms of the predictive validity of affect vari—
ables on the TAT, days hospitalized is negatively corre-
lated with "felt," "total felt," and "total" affect, at
pre-treatment, six and twenty months after therapy. None
of these correlations are significant, although "felt"
affect has consistently the highest negative correlation
with days hospitalized.

The correlational analysis of the data also ex-
plored whether Specific affects correlated positively or
negatively with clinical status ratings and length of
hospitalization. The most consistent trend revealed is

for the distress-anguish dimension. It correlates‘

43

positively with CSI ratings, and negatively with days hos-
pitalized, before therapy, and at six and twenty months
after therapy. Correlations for distress—anguish with CSI
ratings are significant, r = .34, p < .05, at six months,
and r = .43, p < .001, at twenty months, after therapy.
All correlations with length of hospitalization are non-
significant.

Other significant correlations include, anger-rage
with CSI ratings, r = .44, p < .001, and enjoyment-joy
with CSI ratings, r = .39, p < .01, before therapy. Anger-
rage generally decreases from a positive correlation to a
non-significant negative correlation with CSI ratings, at
twenty months (see Table IX). Enjoyment-joy correlates
positively with CSI ratings throughout, but decreases in
magnitude. Fear-terror is positively correlated with CSI
ratings before and six months after therapy, but is sig-
nificantly negatively correlated with CSI ratings, r = -.27,
p < .10, at twenty months after therapy. No consistent
trends are apparent for other affect dimensions. Thus,
the correlational analysis indicates that distress-anguish
is most clearly related to clinical status and length of

hospitalization; being significantly positively correlated

44

with CSI ratings, and negatively correlated with number of

days hOSpitalized.

DISCUSSION

The availability of approximately sixty hours of
intensive psychoanalytic psychotherapy over a period of
one year did not produce any significant changes with re-
gard to the amount of "total affect" or the amount of
"total felt" (felt plus "felt and acted out“), affect,
expressed on TAT protocols by the schizophrenics in this.
sample. The explanation for these findings is difficult,
and as in any complex study, the picture is not clear.
However, some statements can be made regarding the limi-
tations of this study.

First, the sample consisted of "chronic" rather
than "acute" schizophrenics as the design originally called
for. It can be noted that Karon and VandenBos (1970, 1972),
found significant reductions in overall thought disorder
for patients treated by experienced therapists. Deficit
in intellectual functioning connected with schizophrenia,
may therefore be more amenable to‘change with brief psycho-

analytic psychotherapy, as opposed to emotional change,

45

46

in the form of increased affect expression. It seems
possible that enabling schizophrenics to distinguish be-
tween thoughts, wishes, and actions may improve only
reality-testing capacities; in so far as therapeutic
change is concerned, the patient may move from the realm
of psychosis into functioning at a level characteristic
of a severe neurotic; i.e., still quite distant from his
feelings. Achieving a real catharsis of emotions, in the
Freudian sense; i.e., the schiZOphrenic relives some of
the terror and pain connected with his earlier life, is a
much slower process, and, at least with schizophrenics in
this sample, affectivity did not appear to change signifi-
cantly as shown on the TAT, with therapy. Thus, it seems
unreasonable to expect that brief psychoanalytic psycho—
therapy with schiZOphrenics will lead to the "fluidity of
emotional reactions, and immediate experiencing of per—
sonal feelings," that Rogers calls the highest point on
his "continuum of psychologic functioning."

However, the schizophrenic is starting at the low-
est point on the continuum, and if he is intellectually
able to tolerate that his feelings are valid, and have some
understandable basis in unconscious processes related to

his past, as well as depend on a strong nurturant therapist

47

who will protect him, then he probably will learn to dif-
ferentiate his behaviors from powerful feelings of terror,
humiliation, etc., which threaten to overwhelm him. Given
improvement in the schizophrenic's reality-testing capa-
bilities, he will then be able to continue growing, in the
sense of learning how to express frightening and dangerous
emotions. Thus, I would submit that psychoanalytic psy-
chotherapy with schizophrenics can be effective in produc-
ing change in affect expression; in this study, the patients
were "chronic" rather than "acute," and the lack of signif-
icant results may be due to the sample characteristics, as
opposed to the therapeutic process itself.

Along this same vein, is the question of other char-
acteristics of this sample, which make it difficult to
generalize from these results. These schizophrenics were
primarily Black, poor, and from the Detroit ghetto. (The
1967 Detroit riots took place during the twelve—month
follow-up, which is not included in the present data.)
Obviously, these patients could not be expected to trust
white authority figures, and emotional pain is accepted
as a fact of life in the ghetto, rather than as an illness
which can be alleviated. It is also dangerous to directly

express anger, etc., in the ghetto. Blacks usually wind

48

up in jail, rather than in a hospital, when they are suf-
fering emotionally. Thus, it is impossible to separate
out the socio-cultural effects on affect expression for
these schizophrenic patients, from the effects of psycho-
analytic therapy. Further research is needed comparing
schizophrenics of differing economic and socio-cultural
backgrounds.

Next, the size of the sample, as well as the sta-
tistical confines imposed by the design of the study, may
have contributed to the lack of significant results. In
addition, the reliability and validity of the independent
measures of affect is questionable. The low correlations
obtained between "total affect," "felt" (but not acted out)
affect, and "total felt" ("felt" plus "felt and acted out")
affect scores, on the TAT, and clinical status ratings and
length of hospitalization support the contension that
these affect variables had relatively little concurrent
or predictive validity. Indeed, the clinical status rat-
ings may be a better predictor than the TAT of increased
affect expression, since they took into account the amount,
variety, and spontaneity of affect demonstrated by the

patient, and have been shown to correlate significantly

49

with intellectual measures and length of hospitalization
(Karon and VandenBos, 1970, 1972).

Finally, as shown by Kiesler, Klein, and Mathieu
(1965, 1967), schizophrenic patients evidence "up—down
patterns of functioning within individual sessions, and
over the course of treatment." Patients make progress in
one area, and feel safe, to explore other potentially up-
setting aspects of their lives, which may result in a tem-
porary regression to a lower level of functioning. This
data reflects trends which may be due to this hypothesis,
or may be due to chance; i.e., the analyses of covariance
reveal inconsistent patterns of decrease and increase in
the amount of specific affects, although for most of these
affects, there is not overall change. A study is currently
in progress to ascertain change in affect expression on
the TAT, using this sample of schizophrenics, with data
from a three-year follow-up. These results may be more
conclusive.

This study did produce some interesting significant
results with regard to the importance of specific affects,
namely distress-anguish, and fear-terror, in the treatment
of schizophrenics. The amoung of "total felt" ("felt" plus

"felt and acted out") distress-anguish decreased for

50

schizophrenics in Group A (psychotherapy without medica-
tion), and stayed the same for schiZOphrenics in Group B
(psychotherapy with medication, experienced therapiSt),
but increased for patients in Group B (inexperienced
therapists), and for the controls. Given that the amount
of "total felt" distreys-anguish was initially lowest in
Group B (experienced therapist), these results indicate
that, on the TAT at least, schiZOphrenics who received
psychotherapy without medication experienced a decrease
in emotional pain as a result of psychoanalytic psycho--
therapy. In Group B, medication did not appear to be the
factor in lessening distress-anguish, rather the lack of
therapist's experience was directly connected to an in-
crease in the amount of this affect expressed on the TAT.
Perhaps the inexperienced therapists relied solely on the
medication to decrease the patient's degree of emotional
suffering, rather than as an adjunct. Thus, as Karon and
foandenBos (1970, 1972) point out, chemotherapy may be
seductive to the therapist, in the sense that shorter
hospitalization and reduction of gross symptomatology may
deter the therapist from attempting to deal with intense

underlying anxiety, and effecting personality change.

51

Another significant result which more clearly demon-
strates the effect of the therapist's experience level on
affect expression on the TAT, is that the amount of fear-
terror expressed decreased over therapy, for patients
treated by experienced therapists, but increased for those
treated by inexperienced therapists, relative to the con-
trol group. Bergin (1966), Goldstein (1962), and others
suggest that the anxiety of the therapist, his fear of
treating difficult patients such as schiZOphrenics as
well as his sense of adequacy as a therapist, and his
attitudes and expectations towards therapy, significantly
influence the outcome of therapy. This study shows that
anxiety or fears of the inexperienced therapist did in-
crease the amount of fear-terror experienced by schizo-
phrenic patients, as expressed on the TAT. Given that
Tomkins (1963) asserted that fear-terror was the basic
emotion prevalent among schizophrenics, and the most sig-
nificant in perpetuating the patient's "flight from re-
ality," it seems wise to assess beginning therapists in
terms of their capacity to tolerate the intense terror
schiZOphrenics feel, and the often bizarre behavior which
stems from this panic. Karon and VandenBos (1969) have

already demonstrated that the therapist's degree of

52

"Pathogenesis" correlates highly and negatively with ther-
apist effectiveness. Thus, previous research such as May
(1968) and May and Tuma (1965) which concluded that psy-
chotherapy with schiZOphrenics, with or without medication,
made essentially no difference, is likely to be an arti-
fact of the design, which used only inexperienced thera-
pists. This study demonstrates that fear-terror is re-
duced in schizophrenics, with respect to affect expression
on the TAT, if they are treated by experienced therapists.
The results of the correlational analyses reveal
an interesting trend. Both fear-terror and anger-rage
shift from a positive correlation with clinical status
ratings (CSI), to a negative correlation at twenty months.
Tomkins (1963), Bellak (1969), and Fromm-Reichmann (1950),
among others, suggest that these two affects are predom-
inant in schizophrenics. Distress-anguish becomes in-
creasingly positively correlated with CSI ratings through—
out therapy, and is in fact, correlated with CSI ratings,
at the .001 level, twenty months after therapy. Thus,
there seems to be a shift from a predominance with the more
debilitating affects; i.e., anger-rage, and fear-terror,

to a less potentially overwhelming affect, distress-anguish,

as a result of psychotherapy with schizophrenics.

53

In conclusion, more outcome studies of brief psy-
choanalytic psychotherapy with schiZOphrenics are needed
to assess the change in affective functioning as a result
of therapy. As previously stated, most outcome studies
focus on demonstrating change in ward behavior, cognitive
functioning, etc. These variables are important, but if
psychotherapy is oriented to personality change, the im-
portance of developing appropriate emotional awareness,
and learning to express emotions clearly vs. acting them
out or negating them, cannot be overlooked. From this
study, it is clear that the TAT is ineffective with regard
to any type of global assessment of the amount of affect
the patient feels free to express after therapy. Clinical
status ratings, on the other, appear to have more validity
in this reSpect. However, more research needs to be done
concerning the importance of specific affects, such as
anger, distress, and fear on the therapeutic process with
schizophrenics, and how these affects interact with the
experience level of the therapist. This study suggests
that anger and extreme fear or terror may be predominant
at the beginning of therapy, but'the transition to a less
"potent" affect such as distress, is predictive of im-

proved clinical status at the end of therapy. Also, there

54

is some evidence that inexperienced therapists actually
increase the amount of fear felt by schizophrenics, while
experienced therapists are more successful in reducing
fear-terror in their patients. Finally, the use of medi-
cation may deter inexperienced therapists from attempting
to reduce the amount of distress-anguish in their patients.
Inexperienced therapists, on the other hand, who do not
rely on medication to reduce the emotional Suffering of
the patient, appear, at least in this study, to learn to
use their clinical skills to reduce the amount of dis-
tress experienced by their patient. Thus, this study
demonstrates that psychotherapy with or without medica-
tion, when practiced by an experienced therapist, can
reduce the amount of distress and fear expressed by
schiZOphrenics on the TAT, which reflects improved clin-

ical adjustment as shown by clinical status ratings.

REFERENCES

REFERENCES

Anker, J., Walsh, B. Group Psychotherapy, a special ac-
tivity program and group structure in the treatment
of chronic schizophreniz. Journal of Consulting
Psychology, 1961, 25! 476-481.

 

 

Azima, H., Wittkower, E., Latendresse, J. Object relations
therapy in schizophrenic states. American Journal
of Psychiatry, 1958, 115, 60—62. '

 

 

Bellak, L., Loeb, L. The Schizophrenic Syndrome. New
York: Grune & Stratton, 1969.

 

Bergin, A. E. Some implications of psychotherapy research
for therapeutic practice. Journal of Abnormal
Psychology, 1966, 11, 235-246.

 

 

Bleuler, E. ‘Dementia Praecox or the Group of SchiZOphren-
ias. New York: International Universities Press,
1950.

 

Bookhammer, R., Meyers, R., Schober, C., Piotrowski, Z.
A five-year clinical follow-up of schizophrenics
treated by Rosen's direct analysis. American
Journal of Psychiatry, 1966, 123, 602—604.

 

Brandon, M. "Exploring social service discharge plans for
mental patients." Cited in Meltzoff, J., Korn-
reich, M. Research in Psychotherapy. New York:
Atherton Press, 1970, p. 168.

 

Carter, R. The measurement of emotional health through
the use of Estavan's modified paired comparison
technique. Unpublished M.A. thesis, Michigan
State University, 1966. '

55

 

 

III! ‘II I."

 

Ill-ll I'll I‘ll‘ .Ill[ fi'.’ , J‘llclfl

56

Coons, W. "Interaction and insight in group psychotherapyJ'
Cited in Meltzoff, J., Kornreich, M. Research in
Psychotherapy. New York: Atherton Press, 1970,
p0 1840 '

 

 

1

Cowden, R., Zax, M., Hague, J., Finney, R. Chloroproma-
zine: alone and as an adjunct to group psycho-
therapy in the treatment of psychiatric patients.
American Journal of Psychiatry, 1956, 112, 898-902.

 

Fairweather, G., Simone, R., Gebhard, M., Weingarten, E.,
Holland, J., Sanders, R., Stone, G., Reahl, J.
"Relative effectiveness of psychotherapeutic pro-
grams." Cited in Fairweather, G., Social Psy-
chology in Treating Mental Illness. New York:
John Wiley, 1964.

 

 

Fairweather, G., Simon, R. A further follow-up comparison
of sychotherapeutic programs. Journal of Consult-
ing Psychology. 1963, 21, 186.

 

 

Fromm-Reichmann, F. Principles of Intensive Psychotherapy.
Chicago: University of Chicago Press, 1950.

 

Glad, D., Hayne, M., Glad, V., Ferguson, R. Schizophrenic
factor relations to four group psychotherapy
methods. International Journal of GroupyPsycho-
therapy, 1963, 13! 196—210.

 

Goertzel, V., May, P. R. A., Salkin, J., Schoop, T. Body-
ego technique: an approach to the schizophrenic
patient. Journal of Nervous and Mental Disorder,
1965, 141, 53-60.

 

Goldstein, A. P. Therapist-patient expectancies in psy—
chotherapy. New York: Pergamon Press, 1962.

 

 

Greenwald, A. Affective complexity and psychotherapy.
Journal of Projective Techniques, 1959, 23, 429-435.

 

Karon, B. P. The resolution of acute schizophrenic reac-
tions: a contribution to the development of non-
classical psychotherapeutic techniques. Psycho-
therapy: Theory, Research and Practice, 1963, 1,
27-43.

 

57

Karon, B. P., O'Grady, P. Intellectual test changes in
schiZOphrenic patients in the first six months of
treatment. Psychotherapy: Theory, Research,
Practice, 1969, 6, 88-96.

 

Karon, B. P., O'Grady, P. Quantified judgments of mental
health from the Rorschach, TAT, and Clinical
Status Interview by means of a scaling technique.
Journal of Consulting and Clinical Psychology,
1970, 34, 229-235.

Karon, B. P., VandenBos, G. R. Experience, medication,
and the effectiveness of psychotherapy with
schiZOphrenics: a note on Drs. May and Tuma's
conclusions. British Journal of Psychiatry, 116,
427v428. Also reprinted as a chapter in R. Cancro
(Ed.) The Schizophrenic Syndrome: An Annual Re-
view. New York: Brunnon/Mazel, 1971.

 

 

Karon, B. P., VandenBos, G. R. The consequences of psy-
chotherapy for schiZOphrenic patients. Psycho-
therapy: Theory, Research, and Practice, 1972,
9, 111-120.

 

Kiesler, D. J., Mathieu, P. L., Klein, M. H. Patient
experiencing level and interaction-chronograph
variables in therapy interview segments. Journal
of Consulting Psychology, 1967, 31, 224.

 

King, G., Armitage, S., Tilton, J. A therapeutic approach
to schiZOphrenics of extreme pathology: an Operant-
interpersonal method. Journal of Abnormal and
Social Psychology, 1960, 61, 276-286.

 

 

Kraus, A. Experimental study of the effect of group psy-
chotherapy with chronic psychotic patients. Inter—
national Journal of Group Psychotherapy, 1964, 4,

 

178-188.
Kris, E. "Day hospital treatment vs. intramural treatment
of mental patients." Cited in Meltzoff, J., Korn—

reich, M., Research in Psychotherapy. New York:
Atherton Press, 1970, p. 184.

 

58

MacDonald, W., Blockberger, C., Maynard, H. "Group therapy:
a comparison of patient-led and staff-led groups on
an open hospital ward." Cited in Meltzoff, J.,
Kornreich, M., Research in Psychotherapy. New
York: Atherton Press, 1970, p. 184. '

 

Mainord, W., Burk, H., Collins, L. Confrontation vs. di-
version in group therapy with chronic schizophrenics
as measured by the "positive incident" criterion.
Journal of Clinical Psychology, 1965, 21, 222-225.

 

May, P. R. A., Tima, A. The effect of psychotherapy and
stelazine on length of hospital stay, release rate
and supplemental treatment of schizophrenic pa-
tients. Journal of Nervous and Mental Disorders,
1964, 162, 362-369.

 

May, P. R. A., Tuma, A. Treatment of schizophrenia: an
experimental study of five treatment methods.
British Journal of Psychiatry, 1965, 111, 503-510.

 

Meltzoff, J., Blumenthal, R. The day treatment center:
principles, application and evaluation." Cited
in Meltzoff, J., Kornreich, M. Research in Psy—
chotherapy. New York: Atherton Press, 1970,

p. 171.

 

 

Meltzoff, J., Kornreich, M. Research in Psychotherapy.
New York: Atherton Press, 1970.

 

Misbach, L., Cadman, W., Brown, D. An assessment of round-
table psychotherapy. Psychological Monographs,
1953, 66, Whole No. 384.

 

Moore, F. Chernell, E., West, M. Television as a thera-
peutic tool. Archives of General Psychiatry,
1965, 13, 217-220.

 

Peyman, D. An investigation of the effects of group psy—
chotherapy on chronic schizophrenic patients.
Group Psychotherapy, 1956, a, 35-39.

 

Rapaport, D. Emotions and Memory. New York: International
Universities Press, 1950.

 

59

Rogers, C. R. "Process—Equation of Psychotherapy." Cited
in Stollak, G. E., Guerney, B., Rothberg, M.
Psychotherapy_Research: Selected Readings, Chi-
cago: Rand McNally, 1966, 408—419.

Sacks, J., Berger, 8. Group therapy techniques with hos—
pitalized chronic schizophrenic patients. Journal
of Consulting Psychology, 1954, 16, 297—302.

Sanders, R., Weinman, B., Smith, R., Smith, A., Kenny, J.,
Fitzgerald, B. Social treatment of the male chronic
mental patient. Journal of Nervous and Mental Dis-
orders, 1962, 166, 244-255.

Stotsky, B., Daston, P. Vardolk, C. An evaluation of the
counseling of chronic schizophrenics. Journal of
Counseling Psychology, 1955, 2, 248-255.

 

Tomkins, S. Affect, Imagery and Consciousness. New York:
Springer, Inc., Vols. I & II, 1963.

Ullman, L. Clinical correlates of facilitation and inhi-
bition of response to emotional stimuli. Journal
of Projective Techniques, 1958, 2;, 341-349.

Wessman, A., Ricks, D. Mood and Personality. New York:
Rhinehart & Winston, 1966.

Zirkle, G. Five—minute psychotherapy. American Journal
of Psychiatry, 1961, 118, 544-546.

 

APP ‘NDICES

ll llll‘l ll I'll ill I'll... [I [lllflll‘l‘i I I'll. '|‘l['[lll'i ‘1‘ {I "II

APPENDIX A

TAB LES

60

.wupmaaommm ca mucmpflmmn mouse paw

hmoaono>mm HMOHSAHO GA musmpsum mumspmum 03D mo pmumflmcou mumfimmumnu ucmpsumv
.mnumflsommm CH mucmpflmmh 03p pom

mmoaosowmm HMOAGHHO cw mucwpsum mumspmnm woman mo Umumflmsoo mumflmmumnu pampsumm

.Q.2 .mmsuwfia .Q meonB .Ho .umHHDMHBOMmm m mm? HOmfl>Hmmsmm

.Q.£m .SOHMM .m Emnuumm .HQ .umfimoaonowmm HMOHGHHO m mmz Howa>wmmoma.
AMHQO GOHDMOHUOE .mooum Honuaoovluv

AGOHDMOHOOE nuw3 mmmumnuosowwm OHDSHMGMIomOvIIm

AGOHpmowpoE usosuws mmmumsuoaommm Hecapmamsm pummcmumvllfi

 

 

mo. v m Ho. v m Hm>ma OOSMOAMHcmHm
ma.m ~H.¢ s exumflemumse unassumc m
oo.s om.m e NAHOmH>ummsmc m
as.m m~.v m mxpmfldmnmae usmesumc m
mm.m oo.s e quomfl>umdsmc a
mm.m mo.v NH Aaouuaoo Hmpflmmomc o
uommme guamm dance: summed =uamm= : museum

 

 

Aezmse<mmenmmmv,
mmmoom sommm< =eqmm nmaoa: 92¢ geqmm= mom mzemz q<HeHzH

H mqmdfi

d NHDmemd

l l Ill [I‘ll [III III lll'll'lllilll.ll 1‘75 I'- I! .(l l .

61

.949 onu oxou no: two ucofluom ocoo

.muuoflnommm ca musopflmou oouno poo

Smeaoaommm Houwcwao SH monopoum ouoowonm 03» mo woumflmcoo mumfimouonu psoUSme

.huuoflnommm ca mucopflmon OED poo
mmOHosowmm HMOHGHHO ea muaopsum ouosponm oounu mo toumflmsoo mumflmouoou usopoum

m
.o.2 .mocnowa .o moEonB .HQ .umfluuoHSOMmm o mos Hoofl>uomomm

H

AMHSO GOHDMOHUoE .msoum Honuooovllu
ASOHuoOHUoE ones mmmuoauosommm Oflomwocolomovllm
ACOADMOHpoE usosuwz mmouonuonommm Hoowumaoco pumpsopmvlnm

.o.nm .coqu .m Eouuuom .Ha .umHmOHOSOMmm Hoowcaao o mo3 HOmH>Homow

 

 

m: mo. v m Ho>oa oOGoOHMAGmHm

oa.m mm.m m exumfldmuone namesumc m

mo.s ms.m e NAHOmH>Hmmsmc m

oa.m mm.m A mxumflmmumne unmesumc «

mo.o mo.o v quomfl>uomsmc a

mm.e mm.m mHH xaoupcoo Hmufldmomv o
homom< guaom fiance: powwow guammz a mmsouo

 

 

Bzmzfifimme m0 meZOZ NHm mmfimd
mmmOUm BUMWMd zadmm AdfiOB: 02¢ =qum: mom m2¢m2 QMBUMMmOU

HH mandfi

62

.muuoHnommm SH mucoonon ooncu mam

mmOHOSOMmm HoOHcHHO :H musopspm oposooum 03D mo poumHmcoo mumHmouosu usopopmv

.muuoHQOMmm CH mucoUHmoH 03D poo

mmOHonommm HoOHcHHo SH mucopsuo ouosnoum oomnu mo poumHmaoo momHmoHoau psopoumm

N

.Q.£m .couox .m Eonpuom .Ha .umHmOHOSOMmm HoOHcHHO o mos HOmH>HomsmH
“Mano SOHuoOHUoE .moonm HOHDSOOVIIU

AGOHaoOHUoE SDHB mmmuonuosommm OHumHmsolomovllm

ASOHuoOHUoE usonqu hmouonuonUMmm HoOHumHoco pumpcoumvlld

.Q.z .hoCHoHB .Q mofione .no .HmHHuoHnommm o mo3 HOmH>Homom

 

 

ms . ms Ho>oH oOSMOHchmHm

mm.» NH.S m exudemumgs ucoosnmc m

mH.G mm.m v NAMOmH>ummsmc m

Gm.m 00.4 H mxudemumns ucmesnmc a

HH.H ms.m e AxuomH>umdsmc «

HH.H ea.v NH Aaouucoo HmuHmmomc o
powwow guamm Hmuoa=. powwow :uHom. a mesons

 

 

BZMEBfiMMB ho mmBZOZ WBZMBB mm9m¢
mmmoom BUMMMfi =qum HdBOB: 92¢ =qum= mom mz¢mz QMBUmmMOU

HHH mqmda

63

DmsmeUIHHom cam umEoDGOO

Imaom .umsmmHUIumEovcoo .GOHpouHHHfifis .oEono moOSHOGH £OH£3 aonmEOO GOHDoHHHEDS=m
omonluomsom

ansmcolmmonumHoo

Houuopluoom

oHuHoDmlomHumHSm

mohlucofimonco

.QU'U

ucofiouHoonUmoHoucHd

 

mCOHWGTEHQ “UTMMAN

 

 

mo.vaHo. v m mo. v m on on on Ho. v m Ho>oH ooooOHMHcmHm

mm. mm. m.a oo.H mum. mm. o m Amumflmmumne ucmesumc m
m~.H o m.a m~.H o oo.a mN.H e “AcmH>ummsmv m
4H.H as. H.~ mm. o A». «a. H Amumfldmumne namespmc «
om. o m.m oo.H mm. mm. ms. 4 Anemfl>ummsmc 4
mm. m.~ ~.m mo.a He. oo.a Ha. ma Aflouucooc o
mm\m om\< mm\a esxm om\m ns\m mmxH a . mesons

 

 

Aazmzfiflmmfilmmmv mZOHmzmzHQ BUflhhfi
UHmHummm ZO mmmOUm Bummmd :qum Q¢BOB= mom m2¢m2 AfiHBHZH

>H mnmfifi

64

.umsmmelumfiouaOo .GOHuoHHHan .ofioam

.Bme osu oxou no: OHU usoHuom oso

H
umommHUIHHow was umEoDSOOIMHom

moodHUGH £0H£3 aonmfioo SOHuoHHHEd£=m

omouluomcom
ansmcolwmoHumHUo
Houuouluoom
oHDHoumlomHanow
wohlucoewomco

ucoEouHOxoluwouowcH

MQU'U

 

mconcoeHo uoowmm

 

 

m: we Ho. v mg on as. v a mo Ho>oH oocoOHchon

mo. ms. mo.e om. mo. Hm. mo. m Amumfldmumne snowshoe m
mm.a ms. mm.~ mm. mm. ~H.~ em. e xuomH>umm5mc m
«N. em. om.H mm. pm. me. mm. H AmpmHmmumse namesumv e
He. He. ~G.H Ho.a Hm. HH.H om. e xuomH>uod5mc e
ms. Hm. v~.~ em. Hm. mm. Ha. HHH Aaoupcooc o
mm\m mm\< o«\o e9\m om\m nn\m mm\H a mesons

 

 

> mqmdB

Bzmzfifimmfi mmahfi mmBZOZ me mZOHmZMEHQ Bummhfl
UHmHummm ZO mmmoum Bummhd zath A¢809=

mom mdeZ QMBUmmMOU

65

.umsmmelumEoucoo .GOHuoHHHEDQ .oEonm

umSOmHUIMHom poo umfiousOOIMHom

moUSHOGH £0H£3 gxoamfioo coHuoHHHfidazm

omouluomcom

ansmcolmwouyme

HOMHQflIHMTM

O '0 (D

oHuHoumlomHumHSm

momlucoamonco

,Q

ucoEopHoxolumonoucH

rd

 

msOHmcoEHo poommd.

 

 

m: m: mo. v m Ho. v m Ho. v m on m: Ho>oH oocoOHMHcmHm

mm. om.. mm.m mm. mo. ma. mo. m Amudemumse snowshoe m

me. am. mv.a ea. ma. em.a mo.H e AAOmH>ummsmc m

we. oo.H m~.~ es. pm. we. HG.H H imumwmmuose namesumc 4

am. mm. mm.m em. es. em. mm. 4 Anomfl>ummsmc 4

Ha. mm. vo.m mm. ma. as. as. m Aaouucooc o
mm\m om\« o¢\o o9\m om\m QS\m mm\H a monouo

 

 

BZflSBdMMB mmfimfi mmBZOS MBZmBB mZOHmZMZHQ BUflhhd

UHmHUmmm ZO mmmOUm BUMWMfi

H> mqmflfi

:Bdmm dflBOB:

mom mZ¢mS Dmaummmou

66

TABLE VII

CORRELATIONS OF AFFECT VARIABLES WITH CLINICAL STATUS
RATINGS AND LENGTH OF HOSPITALIZATION (PRE—TREATMENT)

 

 

 

Affect Variables CSI Ratingsl DH2
Fa r .31 r -.24

a p < .10 a ns
TFb r .19 r -.18

a ns a ns
TC r .20 r -.15

a ns a ns

Specific Affects (TF)

 

interest-excitement r -.07 r_-.25
a ns a ns
enjoyment-joy r .39 r -.25
a p < .01 a ns
surprise—startle r .12 r -.17
a ns a ns
fear-terror r .02 r .07
a ns a ns
distress—anguish r .21 r -.20
a ns a ns
anger-rage r .44 r -.15
a p < .001 a ns
"humiliation complex" r -.13 r .19
a ns a ns

 

1

2days hospitalized, 0-6 months.

a"felt" affect
btotal "felt" affect Pfelt" plus "felt and acted out")

clinical status ratings based on diagnostic interview.

Ctotal affect.

67

TABLE VIII

CORRELATIONS OF AFFECT VARIABLES WITH CLINICAL STATUS
RATINGS AND LENGTH OF HOSPITALIZATION SIX MONTHS
AFTER TREATMENT

 

 

 

Affect Variables CSI Ratingsl DH2
Fa r .26 r -.23

1 a ns a ns
TFb r .12 r -.01

a ns a ns
TC r .29 r -.22

a p < .10 a ns

Specific Affects (TF)

 

interest—excitement r .23 r '.04
a ns a ns

enjoyment-joy r .09 r .01
a ns a ns

surprise—startle r .12 r .01
a ns a ns

fear—terror r .15 r -.18
a ns a ns

distress—anguish r .34 r -.14
a p < .05 a ns

anger—rage r .25 r -.16
a ns a ns

"humiliation complex" r .04 r -.01
' a ns a ns

 

one patient was not available for testing.

days hospitalized, 6—12 months.

"felt" affect.

total "felt" affect ("felt" plus "felt and acted out").

0" 9’ N l'-‘

Ctotal affect.

68

TABLE IX

CORRELATIONS OF AFFECT VARIABLES WITH CLINICAL STATUS

RATINGS AND LENGTH OF HOSPITALIZATION TWENTY
MONTHS AFTER TREATMENT

 

 

 

 

 

Affect Variables CSI Ratings DHl
Fa r .19 r -.20
a ns a ns
b
TF r .04 r -.05
. a ns a ns
TC r .10 r -.14
a ns a ns
Specific Affects (TF)
interest-excitement r .06 r 4.25
a ns a ns
enjoyment—joy r .23 r -.25'.
d ns a ns
surprise-startle r -.08 r -.17
a ns a ns
fear—terror r -.27 r .07
a p < .10 a ns
distress-anguish r .43 r -.20
a p < .001 a ns
anger—rage r -.11 r -.15
a ns a ns
"humiliation complex" r .20 r .19
a ns a ns
ldays hospitalized, 20—44 months.
a"felt" affect.
b

Ctotal affect.

total "felt" affect ("felt" plus "felt and acted out").

APPENDIX B

CHARACTERISTICS OF THE SAMPLE

69

APPENDIX B

CHARACTERISTICS OF THE SAMPLE

. . Group A Group B Group C
Characteristics (n = 11) (n = 12) (n = 12)
Sex

Male 5 7 5

Female 6 5 7
Race

Negro 10 7 9

White 1 5 3
Education

None

1-5 1

5—9 2 3 2

High School

Incomplete 4 5 5
High School

Complete 3 3 4
University

Incomplete 1 1
University

Complete 1

Age
16—17 1 l 1
18—22 2 3 6
23-28 4 3 2
29—35 2 3 1
36-44 2 2 1
45-49 1

IQ (Thorndike-Gallup)

-80 3 6 2
80-90 5 2 6
90-110 3 ‘ 4 4

110—120 0 O 0
120+ 0 0 0

APPENDIX C

SCORING KEY

APPENDIX C

SCORING KEY

Interest/excitement--themes emphasizing a wish to excel,
heightened curiosity, creativity and reduced passivity.

a) "felt"—-"The boy really wants to learn the violin."

b) "felt" and "acted out"-4"She's so thrilled by it
that she's jumping up and down."

c) "acted out"--"This older couple is getting ready
to go on a trip for the first time since their‘
marriage and they will start rushing around soon
buying all sorts of things, as the date for their
departure gets nearer."

d) “negated"--"The man stood, staring off into space,
bored by the surroundings."

Enjoyment/joy--themes emphasizing feelings of actions
connoting happiness, satisfaction, love, sexual attrac-
tion; includes smiling and laughing responses.

a) "felt"--"The father feels very warm towards his
eldest daughter."

b) "felt" and "acted out"--"The two peOple in the pic-
ture love each other; they are kissing each other
passionately."

c) "acted out"--"The two lovers are holding each other
and smiling." '

d) "negated"—-"This boy and his mother usually enjoy
being together; today they both look unhappy."

7O

71

Surprise/startle--themes emphasizing some sudden inter-
ruption in ongoing activity or thought processes; feel-
ing tone ranges from a brief neutral quality to a more
intense, negative quality.

a) "felt"--"The woman was shocked to see her girl-
friend with that man."

b) "felt" and "acted out"--"The mother peeked into
the room and was amazed to see all the people
there unexpectedly.

c) "acted out"--"When he learned she wanted a divorce,
his mouth dropped Open."

d) "negated"--"A1though she had not expected him to
quit his job, she stood there quietly, trying to
be calm."

Distress/anguish--themes emphasizing grief, pain, suf-
fering, emotional loss; includes crying, sobbing re—
sponses.

a) "felt"--"He feels very lonely and desperate."

b) "felt" and "acted out"--"The man is sobbing vio—
lently. His father has just died on the Operating
table and he feels tremendously bereaved."

c) "acted out"—-"The man has leaned against the lamp-
post and let his tears fall."

d) "negated"—-"Although her husband has just said he
didn't love her and is leaving, the woman feels
OK. Things aren't that bad. She won't let it
get her down."

Fear/terror--themes emphasizing sudden extreme anxiety,
panic, escape, feelings of being trapped or being pur—
sued.

a) "felt"——"She felt petrified as her mother looked
into the room. She didn't want to be discovered."

72

b) "felt" and "acted out"--"The young woman graSped
onto her lover's arm. She was worried lest he
leave her alone in their apartment while a dan-
gerous killer was walking the streets."

c) "acted out"—-”The girl started running; her friend
hid behind the tree. They knew someone was after
them."

d) "negated"--"The man stood quietly in the dark. He
heard footsteps coming towards him in the night and
decided to relax and smoke a cigarette."

Anger/rage--themes emphasizing annoyance, irritation,
general aggression, violent aggressive acts such as
murder or sexual acts, and impulses, combined with
aggression, e.g. rape.

a) "felt"--"He hated his mother for how she had stomped
on him all these years."

b) "felt" and "acted out"--"The father was very angry
at his daughter; she disobeyed him by staying out
late. He slapped her."

c) "acted out"-+"The couples had fought all evening
about sex. The woman didn't want to go to bed
with her boyfriend. Finally, the man raped his
ladyfriend."

d) "negated"--"The little girl held her brother gently
in her arms. She thought he wasn't such a pain if
only he wouldn't cry so much, but then she acci-
dently dropped him."

"Humiliation complex"-—themes emphasizing feelings of
contempt and disgust, shame, self-contempt and self-
disgust.

a) "felt"-—"The woman felt very ashamed of herself
because she had been sleeping around and knew her
friends would disapprove."

b)

C)

d)

73

"felt" and "acted out"--"The little boy felt bad
because he had failed three subjects in school
and he looked down at the floor as his Daddy read
the report card."

"acted out"--"The young boys were the hoods of the
neighborhood. They had just beat up some black
guys and were relaxing and joking with each other
about how they had showed up them niggers."

"negated"-—"She wasn't interested when her mom
walked in on her all alone with this guy. Her mom
would have found out sooner or later."

HICHIGQN STATE UNIV. LIBRQRIES

31293106356151