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L Li...) . 1 1.1.. 1 :141. 31:77:11 111.12.! “11.1.7111... . . r» 71...» 1 .3...LL.«.1... n. . .1. 31:11.51; 1. . :71..1..\...119\1U.H 1 .....>11.. 1 1.. . 11.1.2.1: . 771 .1113 . . 1311 2.133.... . . . .11.. 31:12.. .1 1.1.. .1... . . . . . . .. .. . . . . , . , .. . . ; . _ 2.-.. 333.3%...«31 LW..W.HI............... 9...... 352?..&.$..a.§.zsfi¢§§a..n?£-.u4h.fiu...§?ir m................1:..c.au.:w..§. .1D1...7nWm)3..cle;.1.I.c.o11.1111(.. .9111. .1414. 11:117.} 11112...1.519.1111111111111111i.§0‘001l..101 1:1}113!..191I..t\v#tn1111.‘191 .. . ....... géggwfii .érégi ,I- 3.3.x 1§fi$¥u¢¢§fl3i -1 : ms” LIBRAR 1/ Michigan Sum University This is to certify that the thesis entitled A Study of the Process and Outcomes of Related Arts Therapy with the Adult Schizophrenic Patient presented by Betty J. Keem has been accepted towards fulfillment of the requirements for 7 fidegree in Education Mhi'of professor Date November 11, 1965 0-169 1 i ! E t A STUDY OF THE PROCESS AND OUTCOMES OF RELATED ARTS THERAPY WITH THE ADULT SCHIZOPHRENIC PATIENT 3)’ Betty J. Keem AN ABSTRACT OF A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY College of Education 1965 ABSTRACT A STUDY OF THE PROCESS AND OUTCOMES OF RELATED ARTS THERAPY WITH THE ADULT SCHIZOPHRENIC PATIENT by Betty J. Keem The central purpose of this study was to report findings of an investigation to study the process and outcomes of related arts therapy with adult schizophrenic patients confined in three Michigan psychiatric hospitals. The study was designed so that the outcomes would provide answers to questions raised about the effectiveness of related arts therapy. The study was basically concerned with uncovering factors which interact and produce beneficial results, and just as important, factors which do not interact and do not produce beneficial results, thereby determining the effectiveness of related arts therapy. This kind of knowledge is of value to hsopital milieu treatment teams when making decisions regarding treatment as it relates to the needs of the adult schizophrenic patient. A total population of sixty subjects for this study was selected by stratified random sampling from the IBM card file in each of the three hospitals--thirty males and thirty females. The male and female populations were then randomly divided into two subgroups, experimental and control. A comparison of the two groups was made in accordance with the objectives of the study. The data analysis varied due to availa- bility of statistical models. The Findings revealed that the two groups were dissimilar in tfteir CQ-set personality profiles after therapy. Sex was not a factor. 7718 patients in the experimental group exhibited a significant personality -2- improvement. This improvement appeared to move the eXperimental schizophrenic personality profile closer to that of the optimally adjusted personality profile. The personality profile of the patients in the control group remained as it was before the study was initiated. From the data collected about ward status changes it was possible to determine that the majority of experimental patients exhibited a move toward a more open environment--open ward or out patient basis. The control group remained in the same environment after therapy as it was before therapy. The findings also indicated that the personality of the therapist was a factor in measuring the effectiveness of the related arts therapy treatment. Therapists whose patients received the most beneficial re- sults from therapy scored higher in (1) original thinking, (2) personal relations, (3) emotional stability, and lower in (1) cautiousness, (2) vigor, (3) sociability than therapist whose patients received fewer beneficial results from therapy. It was also uncovered by the findings that related arts therapy had little or no effect on the actual illness itself--the psychotic syndromes and morbidity patterns. During the three month therapy period, there was a significant improvement in the psychotic syndromes and morbidity patterns, which could be attributed only to the hospital milieu therapy treatment. Further, the findings revealed that related arts therapy seemed to produce an adverse effect on the hospital adjustment of the experi- mental group. It was found, in this study, that although related arts therapy did not have an effect on the psychotic illness, it did have an effect -3- on reorganizing the personality of the adult schizophrenic patient. Further, the personality reorganization seemed to promote the adult schizophrenic patient closer to the ultimate treatment goal--release from psychiatric treatment. This study represents an effort to identify and measure factors of related arts therapy which interact and produce beneficial results, when applied as part of the milieu therapy treatment presribed for the adult schizophrenic patient. It is hoped that additional studies will eventually produce a body of knowledge which will give those concerned with prescribing treatment for mental health a clearer picture of related arts therapy effectiveness. Only when this picture is completed, through additional research, will related arts be able to function at a maximum level in order to meet the needs of humanity beseiged with mental health problems. A STUDY OF THE PROCESS AND OUTCOMES OF RELATED ARTS THERAPY WITH THE ADULT SCHIZOPHRENIC PATIENT By {‘61. Betty J? Keem A Thesis Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY College of Education 1965 ACKNOWLEDGMENTS The writer wishes to express her gratitude and appreciation to Dr. Harold J. Dillon, Chairman of her Guidance Committee, for his encouragement and guidance during the planning and preparation of this thesis. Appreciation is also extended to other members of the Guidance Committee: Dr. John Howell, Dr. Clyde M. Campbell, and Dr. Max 5. Smith who provided the conceptual and organizational insights necessary for the completion of the project. The author also wishes to acknowledge her special indebtedness to Dr. Curtis W. Page--Traverse City State Hospital, Dr. Clemens H. Fitzgerald-~Mayne County Psychiatric Unit, and Dr. John Hsu--Pontiac State Hospital who made the resources of their respective hospitals available to the writer. Also, special mention must be made of the clinical psychologist, registered nurses, and therapists who so capably assisted in the testing and collection of behavior reports from which the data of this study were derived. ii CONTENTS ACKNUMED GmENTS O O O O O O O I O O O O O O 0 O C O 0 LIST OF TABLES C O O O O O O O O O C 0 C O O O O 0 0 Chapter I. INTRODUCTION . . . . . . . . Reason for this Study. . . Statement of Purpose . . . The HypotheSiS o o o o e a Principle Features of the Following C O O O 0 O O O O O O haptr PART ONE II. HISTORICAL BACKGROUND . . . . . . . . . . Originsofflhsic............ Music and Medicine in Primitive Cultures Music and Medicine in Antiquity. . . . . Music and Medicine in the Middle Ages. . Music and Medicine from the Middle Ages to Twentieth Century. e e o o o o o e 0 Early Twentieth Century. a o o o o e a o 0 Status of Music as Therapy Prior to World WarII...........o.o O O O O O Developments in Allied Professions . . . . Psychoanalysis . . . . . . . . . . . . . m.iliauTharapy.......-.ooo. Social Psychology and Group Dynamics . . III. THE DEVELOPMENT OF RESEARCH IN MUSIC THERAPY RELATED ARTS THERAPY DEFINED WITH CLINICAL EXANPLESeoooooooooooooocco Research 0 o o o o o o o o o o o o o o o o Emergence. o o o o o o o o o o o o o o o Pivot Point. 0 o o e o o o o o o o 0 Current Trends . . . . . . Music Related Arts Therapy Definition with Clinical ExamlBSO o o o o o o o o o 0 Definition 0 o o o o o e o o o o o o o 0 Clinical ExamleSo o o o o o a o o o o 0 iii cod-coco. 33000-0 O 0 O O 0 comes... ND 0 O O O I O O O O O O C O O O O O C 0 O O O O O 0 -e oxu1-s-a 25 27 27 32 Chapter Page PART TWO IV. pROCEDURE AND DESIGN OF STUDY . o o e o o o e o o o 55 Setting 0 o o o o o o o o o o o o o o o o o o o o 55 Geographic Location 0 o o o o o o o o o o o o o 55 Hospital Administration 0 o o o o o o o o c o o 56 SUbjeCtSo o o o I o o o o o o o o o o o o o o o o 59 Population. 0 o o o o o e o o o e o o o o o o o 59 Sampling. 0 o o o o o o o o o o o o o o o o o e 62 General Treatment 0 o o o o o o o o o o o o o o o 56 Roles of Hospital personnel 9 o o o o o o o o o 66 Specific Treatment. 0 o o o e o o o o o c o o o o 70 Dafinition o o e o o c e o o o o o o o o o o o 70 prescriptions o o o o o o o o o o o o o o o o o 75 Data Gathering Instruments. 0 o o o o o o o o o o 77 IWPS . . . . . C . O . O O O . O . . O O . . . 78 HAS 0 o o o a e o o o e o e o e o o o o o o o o 81 California O-Set. o o o o o o o o e o e e o o o 84 Gordon Personal Profile . . . . . . . . . . . . 86 Gordon Personal Inventory . . . . . . ... . . . BB Therapy Behavior Checklist. . . . . . . . . . . 89 V. FINDINGS AND CASE STUDIES . . . . . . . . . . . . o \D N Statistical Treatment of Data in the Study. . . . 92 Specific Analyses of the Effectiveness of Related Arts Therapy. . . . . . . . . . . . . 93 Chi-Square o e o o o o o o o o o a o o o o o 93 Three Way Analysis of Variances-IND . . . . . . 106 Three Way Analysis of Variance--HAS . . . . . . 111 Case Studies 0 o o o o a O o o o o o o o o o o o 113 Case History: (Female) 0 o o o o o o o o o o o 114 Case History: (Male) . . . . . . . . . . . . . 116 VI. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS o . o . o 119 Summary 0 o o o o o o o o o o o o o o o o o o o o 119 COUCIUSion o e o o o o o o o o o o o o o o o e e 121 RECOMmendations e o a o o o o o a o o o e e o o o 123 Concluding Statement 0 o e o o o o o a e o o o o 124 BIBLIDmApHY O O O O C O C O O O O O O O O O 0 C 0 O O O 0 125 REPENDICESO . O O O O O O ‘ 0 I O O O C C O C O O O O O O . 136 Table 1. 5. 6. 7. 8. 13. LIST OF TABLES HOSPITAL 1--ADMINISTRATIVE ORGANIZATIONAL PLAN (SCH EmE) O O O O O C O O O D O O O I O I O O O O O HOSPITAL 2--ADMINISTRATIVE ORGANIZATIONAL PLAN . . HOSPITAL 3--ADMINISTRATIVE ORGANIZATIONAL PLAN . . SCHIZOPHRENIC REACTION DISTRIBUTION OF 60 SUBJECTS IN THIS STUDY. O O O C O O O O O I D O O O O O O D PROGNOSIS, AGE DISTRIBUTION OF 60 SUBJECTS IN THIS STUDY 0 O O O O O O O O O I O O O O O O O C I RELATED ARTS PRESCRIPTIONS FOR 30 EXPERIMENTAL SUBJECTS IN THIS STUDY . . . . . . . . . . . . . . 2 APPRAISAL OF CO-SET ITEM CHANGES BETWEEN THOSE WHO HAD RELATED ARTS THERAPY AND THOSE WHO DID NOT A CO-SET DESCRIPTION OF THE 60 SCHIZOPHRENIC SUBJECTS IN THIS STUDY . . . . . . . . . . . . . . A CO-SET DESCRIPTION OF THE OPTIMALLY ADJUSTED PERSONALITY AS VIEWED BY CLINICAL PSYCHOLOGISTS. . AFTER THERAPY WARD STATUS CHANGE FOR 60 SUBJECTS IN THIS STUDY 0 O D O O O O O O 0 O O O O O O O I A COMPARISON OF THE THREE THERAPISTS EIGHT PERSONALITY TRAITS, DEEMED IMPORTANT IN THE ADJUSTMENT OF THE NORMAL INDIVIDUAL . . . . . . . CQ-SET SIGNIFICANT PERSONALITY TRAIT CHANGES AFTER THERAPY FOR 30 EXPERIMENTAL SUBJECTS IN THIS STUDY SUBDIVISION OF THREE VARIABLES AND RESULTANT O INTERACTIONS FOR INP SYNDROMES AND MORBIDITY Scores. Page 57 SB 60 64 65 76 96 97 99 101 104 105 107 Table 14. 15. LIST OF TABLES (Continued) Page MEAN AND STANDARD OEVIATION OF THREE VARIABLES, RESULTANT INTERACTIONS AND SUBFACTDRS THEREIN FOR mp SYNDROMES AND MORBIDITY SCORES . . . . . . 109 SUBDIVISION OF THREE VARIABLES FOR HAS SCORES. . . 112 MEAN AND STANDARD DEVIATION OF VARIABLE TWO HAS SCURESUBFACTDRSOODCOOCOOOOOOOOOI 112 V1 CHAPTER I INTRODUCTION Reason for this Study In this century research has become more and more an outstanding characteristic of our cultural development. Scientific method of inquiry has spurred on the advancement of medicine.1 The effects of music to some extent defy objective investigation,2 because music is communica- tion of a nonverbal and nonlogical nature. Aesthetic feeling, highly subjective, tends to resistscientific inquiry. Defense of this use of music in therapy, however, rests in the ability of musicians, therapists, and psychiatrists to scientifically examine and revaluate the assumed values of music in therapy. This research study is one of the first in the field of inter- action in related arts therapy, using music as a basis, for the mentally ill. Prior to World War II musicians had applauded the use of music as a therapy for the ill but most claims were merely unscientific recitals of personal observations. Further, within the related disciplines little scientific attention had been paid to the subject. There were, of course. a few exceptions to this, notably reports from Van do Well. 1Dorothy M. Schullian and Max Schoen (eds.), Music and Medicine (New York: Henry Schuman, Inc., 1948). 2Carlos Chavez, Musical Thought (Cambridge: Harvard University -2- After World War II a number of research projects concerned with -understanding the various aspects of the effects of music therapy in psychiatric disorder came into existence. Some gave emphasis to the significance of the "intra" psychology movement, and some to the "inter” psychology influence. Only recently has the interaction of multi disci- plines in therapy been scientifically investigated. An upsurge of interest in mental illness was undoubtedly influ- enced by the war.3 The reasons were manifold. Some were diffuse and part of the general shaking up experienced by people everywhere; some reflected greater awareness of the severe emotional problems confronting mankind in a changing society. Another factor was the apparently high prevalence of psychiatric disorder found in the course of selection for military service. Moreover, psychiatrists, in caring for the health of military units rather than individuals only, noticed striking differences evidently due to conditions of living, battle and morale and were con- fronted with the problems of rehabilitating those who had been psychiat- rically disturbed. More recently, the late President Kennedy focused national attention on mental illness when he stated: I propose a national mental health program to assist in the inauguration of a wholly new emphasis and approach to the care of the mentally ill. Government at every level-~federal, state, and local--private foundations, and individual citizens must all face up to their responsibilities in this area. 3Leo Srol, at. al., Mental Health in the Metro olis (New York: McGraw Hill and Company, 1962 , p. VII-VIII. 4u.s., president, 1961-63 (J. F. Kennedy). Message from the 13resident of the United States Relative to Mental Health and Mental fietardation, 88th Congress, 1st Session, February 5, 1963. House Ekacument No. 58, p. 2. -3- After the President's mandate was delivered psychiatry and its adjunctive therapies were plunged into a major revolution.5 First order of the revolution was a national mental health survey.6 It brought to light the following pertinent facts about mental illness. 1. 2. 3. 4. 5. At least 1 person in every 10--19,000,000 peoples in all-~has some form of mental or emotional disturbance (from mild to severe) that needs psychiatric treatment. Mental illness is known to be an important factor in many physical illnesses, even heart disease and tuberculosis. At least 50% of all the millions of medical and surgical cases treated by private doctors and hospitals have a mental illness complication. There are more people in hospitals with mental illness, at any one time, than with all other diseases combined, including can- cer, heart disease,-tuberculosis, and every other killing and crippling disease. Illnesses and ages of mental hospital patients fall principally into the following diagnoses and approximate age groups: (a) Schizophrenia--about 23% of new patients are schizophrenics; most of these fall between ages 15 and 34. They make up about 50% of all the resident population of mental hospitals, because of their youth on admission and long-term hospital- ization. (b) Senile brain disease and cerebral arteriosclerosis-~these psychosis account for about 23% of new admissions, usually over the age of 60. Because of high death rates among these patients, they represent only about 14% of the hospital population. (c) Involutional psychosis-~about 4.2% of new patients admitted to mental hospitals: usually between the ages of 45 and 60. (d) Manic-depressive and psychotic depressive reactions-~about 3.5% of new admissions; usually between 35 and 50. (6) Alcohol intoxication and addition-~about 12% of new admis- sions; usually between 25 to 55. (f) Personality disorders other than alcoholism--about 7% of new admissions; between 15 and 35. (9) Other disorders make up almost 28% of new admissions, each of low incidence. 5George A. Stanford, "Orchestration of the New Mental Hospital Theme," Journal of Music Therapy, Vbl. 1., No. 4 (December 1965), pp. 124-1280 6D. M. Martin, M.D., The Mentally Ill Do Get Well (Pontiac, Michigan: Pontiac State Hospital, 1963), pp. 7-10. 7Ibid. -3- After the President's mandate was delivered psychiatry and its adjunctive therapies were plunged into a major revolution.5 First order of the revolution was a national mental health survey.6 It brought to light the following pertinent facts about mental illness. 1. 2. 3. 4. 5. At least 1 person in every 10--19,000,000 peoples in all--has some form of mental or emotional disturbance (from mild to severe) that needs psychiatric treatment. Mental illness is known to be an important factor in many physical illnesses, even heart disease and tuberculosis. At least 50% of all the millions of medical and surgical cases treated by private doctors and hospitals have a mental illness complication. There are more people in hospitals with mental illness, at any one time, than with all other diseases combined, including can- cer, heart disease, tuberculosis, and every other killing and crippling disease. Illnesses and ages of mental hospital patients fall principally into the following diagnoses and approximate age groups: (a) Schizophrenia--about 23% of new patients are schizophrenics; most of these fall between ages 15 and 34. They make up about 50% of all the resident population of mental hospitals, because of their youth on admission and long-term hospital- ization. (b) Senile brain disease and cerebral arteriosclerosis-~these psychosis account for about 23% of new admissions, usually over the age of 60. Because of high death rates among these patients, they represent only about 14% of the hospital population. (c) Involutional psychosis-~about 4.2% of new patients admitted to mental hospitals; usually between the ages of 45 and 60. (d) Manic-depressive and psychotic depressive reactions-~about 3.5% of new admissions: usually between 35 and 50. (e) Alcohol intoxication and addition--about 12% of new admis- sions; usually between 25 to 55. (f) Personality disorders other than alcoholism--about 7% of new admissions; between 15 and 35. (9) Other disorders make up almost 28% of new admissions, each of low incidence. 5George A. Stanford, "Orchestration of the New Mental Hospital Theme,” Jgurnal of Music Therapy, Vol. 1., No. 4 (December 1965), pp. 124-123. 6D. W. Martin, M.D., The Mentally Ill Do Get Well (Pontiac, Michigan: Pontiac State Hospital, 1963), pp. 7-10. 7Ibid. -4- Over half a million children in the United States are classified as psychotic or borderline cases. "bet of these children are suffering from childhood schizophrenia. Only a small percentage are receiving any kind of psychiatric care. About 18,300 children and young people, with serious mental disorders, are admitted as patients to public mental hospitals each year. Three thousand are under 15 years of age and 15,300 are between 15 and 24 years of age. Conservatively estimated, an additional 241,000 children under 18 are treated at psychiatric clinics each year, for less severe mental disorders.8 There are approximately 72,000 hospital beds in Michigan and over half of these beds are occupied by the mentally ill.9 Mental health appears to be not only a real medical problem but also a gigantic social problem. Broader medical and social concepts are needed for the treat- ment of the mentally ill. Broader programs in research are in demand. The impending forces have motivated many new research projects. Implicit is the need for appropriate targets for investigation. Milieu therapy10 is currently, in Michigan, a concern of a large number of persons engaged in the prevention of mental illness-—namely teachers, particularly teachers in urban centers. The field is broad and many scientific studies are needed to refine, define, and describe desirable directions. The research project reported in this dissertation was designed to study a small but vital segment of the whole. Results of this study combined with results of similar studies with other types of subjects provide a Ibid. 91bid., p. 2. 10Kenneth Artiss, Lt. Col., Milieu Therapy in Schizoghrenia (New York: Grune and stratton, 1962). -5- necessary link in establishing psychiatric adjunctive therapeutic programs for both curative and preventative purposes. Statement of Purpose It is the purpose of this dissertation to report findings of an investigation to study the process and outcomes of related arts therapy with certain psychotic patients, selected at random and confined in three Michigan psychiatric hospitals. To do this the therapy sessions were recorded and the process of therapy was described through the use of meaningful categories of behavior as measured by the recorded type- scripts. The outcomes of therapy were studied through the use of objec- tive measures of personal level of functioning before and after a three months therapy period. Several converging lines of theory and research are involved in this study. First, the study addresses itself to the lawfulness of behavior in therapy. Second, the study questions the interaction of re- lated arts, therapist, and patients. Third, it raises the question of the kind of personality reorganization to be postulated as a result of the interaction of related arts therapy. As a point of departure for category construction and hypothesis formulation this study accepted the conceptions of interpersonal relations 13 14 suggested by Ruesch,11 Menninger,12 Maslow, and Bennie. According to 11Jurgen Ruesch, Psychiatric Care (New York: Orune and Stratton, 1964). 12Karl Menniger, Vital Balance; The Life Process in Mental Health and Illness (New York: Viking Press, 1963). 13Abraham H. Maslow, "Some Basic Propositions of a Growth and Self-actualization Psychology," in PerceivingI Behaving, and Becoming, 1952 ASCD Yearbook, ed. Arthur Combs (Washington D.C.: A500, 1962). 14W. G. Bennie, £§2_gl., Inter ersonal D namics (Homewood, Illinois: The Dorsey Press, 1964). - 5 - necessary link in establishing psychiatric adjunctive therapeutic programs for both curative and preventative purposes. Statement of Purpose It is the purpose of this dissertation to report findings of an investigation to study the process and outcomes of related arts therapy with certain psychotic patients, selected at random and confined in three Michigan psychiatric hospitals. To do this the therapy sessions were recorded and the process of therapy was described through the use of meaningful categories of behavior as measured by the recorded type- scripts. The outcomes of therapy were studied through the use of objec- tive measures of personal level of functioning before and after a three months therapy period. Several converging lines of theory and research are involved in this study. First, the study addresses itself to the lawfulness of behavior in therapy. Second, the study questions the interaction of re- lated arts, therapist, and patients. Third, it raises the question of the kind of personality reorganization to be postulated as a result of the interaction of related arts therapy. As a point of departure for category construction and hypothesis formulation this study accepted the conceptions of interpersonal relations 13 14 suggested by Ruesch,11 Menninger,12 Maslow, and Bennie. According to ) 11Jurgen Ruesch, Psychiatric Care (New York: Bruno and Stratton, 1964 . 12Karl Menniger, Vital Balance; The Life Process in Mental Health and Illness (New York: Viking Press, 1963). 1Z'Abraham H. Maslow, ”Some Basic Propositions of a Growth and Self-actualization Psychology," in Perceiving, Behaving, and Becoming, 1962 A500 Yearbook, ed. Arthur Combs (Washington o.c.: A500, 1962). 14M. G. Bennie, et. al., Interpersonal Dynamics (Homewood, Illinois: The Dorsey Press, 1964). these conceptions, interpersonal relationships are carried on in terms of persistent patterns of attitudes toward self and others. The nature of these relationships as a consequence of therapy can be specified. The sample used in this study was limited to mental patients of the psychotic group. Both the descriptive constructs and predictions have been formu- lated with this in mind. The Hypothesis This thesis, an analysis of related arts therapy with adult psychotic patients, was specifically designed to determine: 1. the actual value of the interaction between this type of therapy and the behavior of the adult psychotic patient, 2. the effectiveness of related arts therapy on the psychotic syndromes and morbidity patterns of the adult psychotic patient, 3. the actual value of this type of therapy as it relates to the personality of the adult psychotic patient, 4. the actual value of the related arts therapist personality as the therapist interacts with the adult psychotic patient, 5. the identification of factors and interactions that are most conducive to the success of related arts therapy with adult psychotic patients. The general or collective hypothesis to be proved by this study is that related arts therapy, although apparently effective by consensus of those practicing the art, can be objectively proved to be an effective therapy. Further, its potentialities can be insured by correctly identi- fying those factors which enhance and support its effectiveness. -7- Principle Features of the Following Chapters A frame of reference for examining this research project is given in Part One, chapters II and III. Chapter II is richly woven with the history of music therapy, and chapter III traces the development of research in the field from its emergence to current trends leading up to a definition of related arts therapy demonstrated with clinical examples. To establish this frame of reference data were collected from: historical records of the National Association of Music Therapy as reported in the Volumes of Proceedings, "A Historical Study of the National Association for Music Therapy," unpublished doctoral dissertation by Ruth Boxberger on file at the University of Kansas, Department of Education; literature pertinent to the use of music in healing; related psychiatric and psychological literature; and a review of current music therapy and re- lated therapies practices reported in published articles. In addition to the above, data were collected from personal interviews with directors of music therapy programs in higher education. These included Robert K. Unkefer, Michigan State University, East Lansing, Michigan; Erwin H. Schneider, Ohio State University, Columbus, Ohio; william w. Sears, Indiana State University, Bloomington, Indiana; directors of education and research in psychiatric hospitals: Clemens F. Fitzgerald, M.D., Wayne County General Hospital, Psychiatric Unit, Eloise, Michigan; John ,Hsu, M.D., Pontiac State Hospital, Pontiac, Michigan; and Curtis W. Page, Ph.D., Traverse City State Hospital, Traverse City, Michigan; and clinical director, Arthur M. Dundon, M.D., Traverse City State Hospital, Traverse City, Michigan. A final source of material was gathered from experiences of the following practicing music therapists: Ruth Vancil, Pontiac State Hospital, Pontiac, Michigan, Christine Smith, Wayne County General -8- Hospital, Psychiatric Unit, Eloise, Michigan, and Betty J. Keem, Traverse City State Hospital, Traverse City, Michigan. ' ' ' ' Part II includes chapters IV, V, & VI. Chapter IV outlines the design and procedure of this research project "A Study of the Process and Outcomes of Related Arts Therapy with Certain Psychotic Patients." The presentation and analysis of data with case studies is reported in chapter V. The final chapter, chapter VI, a summary, includes conclusions and recommendations. PART ONE CHAPTER II HISTORICAL BACKGROUND Origins of Music The origin of music is not understood. Diserens and Fine1 have reviewed the following theories about the origin of music. Darwin claimed that music played a role supplementing the process of natural selection whereby the male or female progenitor of mankind acquired musical tones and rhythm for the sake of charming the opposite sex. Knight has objected to this idea on the grounds that many songs of primitive peoples are songs of war, exploit, and lamentation. Spencer thought that music originated from impassioned speech. Stumpf also thought the vocal element was im- portant and assigned the beginnings of music to early signal calls. The concept that music is a potent and effective agent is not new. Music and the art of healing have been inextricably entwined since the dawn of civilization. Many ancient mythological figures were the gods of both music and healing.2 To what extent music has a place in treatment of a disease is linked to the socio-cultural environment and the philosophy that prevails at a particular stage of civilization. 1Charles M. Diserens and Harry Fine, Psychology of Music (Cincinnati: College of Music, 1939), p. 19-44. 2Ruth Boxberger, "A Historical Study of the National Association for Music Therapy," (unpublished doctoral dissertation, Department of Education, University of Kansas, 1963), p. B. - 11 - eigeriet3 calls attention to the fact that human life unfolds itself in an environment that is both physical and social. The social physical environment, responsible for most disease, is in turn shaped by the civilization that has altered man‘s life. Religion, philosophy, education, social and economic conditions-- whatever determines a man's attitude toward life-~will also exert great influence on his individual disposition to diseases and the important of these cultural factors is still more evident when we consider the environmental causes of disease.4 Music as a social art is not difficult to understand if there is an awareness of art's function in society. To understand and appreciate music as an art, there has to be an understanding of the role of the arts in society at various stages of civilization, for "serious art be- comes so only if the elements of its content are always some projection of life in its entirety."5 Music and medicine cannot, therefore, be considered other than as a part of the social phenomena of civilization. The role of music in therapy is conditioned by the prevailing physical and socio-cultural environment in which it operates. The practice of music therapy is in- fluenced by the prevailing philosophy of the era. Music and Medicine in Primitive Cultures Victims of illness and disease usually become isolated socially, because the individual who is ill is different from those around him. Primitive peoples were often more concerned with the socio-economic effects 3Henry Sigeriet, Civilization and Disease (Ithaca, New York: Cornell University Press, 1944 , pp. 1-5. 4Ioid., p. 3. 5Paul Henry Lang, "The Role Music Plays Among the Arts," Music Quarterly, xxxv (October, 1949), p. 603. I+‘ \ - 12 - of illnesses than they were with the pain or other distressing physical symptoms. Illness and disease became a great concern for primitive man when he could no longer live the life of the tribe.6’ 7’ B Sigerestg considers primitive medicine to have been related primarily to magical practices, although it contained a few religious elements. Rational treatment was applied as part of ritual. The incanta- tion pronounced over the drug provided the power to cure disease and alleviate suffering. Magical religious and empirical elements are blended in primitive music by the catalystic qualities of magic. Schneider,1D from analyzing primitive music, believes that many of the supposed non- sensical syllables have a magic quality and have the power to evoke a spirit or frighten it away. Schneider11 also points out that primitive music and dancing created a movement which apparently generated something that is more than the original movement itself. As primitive man sang and danced he seemed to discover in himself an intense liberating healing power unknown in everyday life. Music permeated every aspect of primitive society. Thus it is difficult to differentiate between the style of music used specifically 6Paul Radin, "Music and Medicine Among Primitive Peoples," Music and Medicine, ed. Dorothy M. Schullian and Max Schoen (New York: Henry Schuman, Inc., 1948), pp. 3-24. 7Sigerist, op. cit., pp. 131-146. BFrances Densmore, "The Use of Music in the Treatment of the Sick by the American Indians," Music and Medicine, ed. Dorothy M. Schullian and Max Schoen (New York: Henry Schuman, Inc., 1948), pp. 24-45. 9eigeriet, op. cit., pp. 131-147. 10Marious Schneider, "Primitive Music," The New Oxford History of Music, Vol. I: Ancient and Oriental Music, ed. Egon Mellesz(London: Oxford University Press, 1957), p. 2-4 11Ibid., p. 4. l'RH - 13 - as part of the healing process and music as practiced in other areas of community life. The relation between the musical style and the content of the song (i.e., words) lies not in the external occasion (rain, war) but in the prevailing psychological tension. If the witch doctor implores the spirit of disease to release his patients, the song will be friendly: if he fights it with his spear the song will be warlike; yet both-will be medicine songs.12 The musician, who may be called a medicine man, priest-practi- tioner, priest-magician, or shamon, had considerable importance in tribal life.13' 14 While all members took part in musical activities, a differentiation can be made between certain individuals who have special powers or privileges and the other participating musicians. In general the musician is highly esteemed while practicing his art, because he is regarded as the possessor of a higher power. But he is also feared or despised. He is honoured in public but avoided in private. That he is able to traffic with the world of the spirits makes him a somewhat sinister figure, and the more intensely a community feels his power the more it tries to keep him at arm's length. 5 In setting up the healing ritual or seance, primitive tribes assigned to the musician-priest not only the task of discovering which spirit was responsible for the illness, but to use the right healing song to entice the spirit from the patient's body. while considerable importance was attached by many tribes to find the right song for the healing scenes, the importance of the group to the rituals must not be overlooked. Radin16 and Densmore17 both describe healing seancee where 12161d., p. 39. 13Edward Sapir, Culture, Language and Personality, ed. David C. Mandelbaum (Berkeley: University of California Press, 1958), p. 137. 14rrank Boas, primitive Art (Cambridge: Harvard University Press, 1927), p. 9. 15Schneider, op. cit., p. 41. 15Red1n, op, cit., pp. 14-23. 17Densmore, op. cit. as part of the healing process and music as practiced in other areas of community life. The relation between the musical style and the content of the song (i.e., words) lies not in the external occasion (rain, war) but in the prevailing psychological tension. If the witch doctor implores the spirit of disease to release his patients, the song will be friendly; if he fights it with his spear the song will be warlike: yet both will be medicine songs.12 The musician, who may be called a medicine man, priest-practi- tioner, priest-magician, or shamon, had considerable importance in tribal life.13’ 14 While all members took part in musical activities, a differentiation can be made between certain individuals who have special powers or privileges and the other participating musicians. In general the musician is highly esteemed while practicing his art, because he is regarded as the possessor of a higher power. But he is also feared or despised. He is honoured in public but avoided in private. That he is able to traffic with the world of the spirits makes him a somewhat sinister figure, and the more intensely a community feels his power the more it tries to keep him at arm's length. 5 In setting up the healing ritual or seance, primitive tribes assigned to the musician-priest not only the task of discovering which spirit was responsible for the illness, but to use the right healing song to entice the spirit from the patient's body. While considerable importance was attached by many tribes to find the right song for the healing scenes, the importance of the group to the rituals must not be 6 17 overlooked. Radin1 and Densmore both describe healing seancee where 12Ibid., p. 39. 13Edward Sapir, Culture, Language and Personality, ed. David C. Mandelbaum (Berkeley: University of California Press, 1958), p. 137. 14Frank Boas, primitive Art (Cambridge: Harvard University Press, 1927), p. 9. 158chneider, op. cit., p. 41. 15Radin, op. cit., pp. 14-23. 17Densmore, op. cit. a chorus of sorts functions to help heighten the patient's desire to get well. It was expected that the participation of the sick man's friends and relatives in the healing rituals would intensify the emotional effects of the music upon the patient. Music and Medicine in Antiguity The primitive man who was sick enjoyed a special position in society. He was the guiltless victim of secret powers which were recognized and warded off by the medicine man. In higher stages of civilization, man was not an innocent victim, but rather one who, through suffering, had to atone for his sins. Where such a view was prevalent, the sick person was socially isolated in a particularly severe way. This approach to healing and disease was held by Babylonian society, and can be found in the Old Testament of the Bible.18 In the developing civilizations of the Babylonians and Egyptians the theory of disease shifted from magic to religion. Babylonian medicine was an elaborate system of relgious medicine; all disease came from the gods, and the task of the priest-physician was to discover and interpret the intention of the gods so he could placate them. By the time of the golden age of Greece, a rational system of medicine came into being that attempted to interpret the nature of health and disease.19 In the civilizations of the Hebrews, Babylonians, and Egyptians the close relationship between music and medicine is clearly apparent since they both were infused by the religious philosophy that prevailed in the cultures of these peoples. The account of David's playing of the 1BSigerist, op. cit., pp. 65-86. 191bid., pp. 132-133. - 15 - harp for King Saul during his attacks of melancholy has been repeated innumerable times. This account from the Old Testament of the Bible does not necessarily attribute miraculous powers to the music, but it does serve to illustrate the belief held by the Hebrew people that music had the power to affect the emotions and feelings of individuals. The music that was part of the temple rites of the Egyptians and Babylonians also served when medical aid was sought through healing rituals. The incantations of the medical papri were to be emitted with the proper "voice" and contained the elements of music. The fact that the rituals were not to be varied made them more comprehensible and communicative to the bearer. Diserens and Fine20 define the difference between the magical approach and the religious approach to healing as the contrast between an aggressive approach to drive out illness and a submissive attitude seeking relief through supplication and entreaty of the deities. The efforts to appease or persuade the gods must at all time assume a communal form, which in turn helps to determine the individual behavior of the believers. Music is used to bring about a like-mindedness on the part of the group, to enhance suggestibility, and to lull or abolish criticism. The theory of the four cardinal humors, that exerted a tremendous influence over medicine for the following two thousand years, was advanced during the time of Hippocrates. The four humors were:21 blood, originat- ing in the heart; phlegm, in the brain; yellow bile, in the liver; and black bile, in the spleen. This theory was further developed by Galen 20Diserens and Fine, op. cit., pp. 125-141. 21Sigeriet, op. cit., pp. 148-163. - 15 - and still more by the Arabs--particu1arly in the eleventh century, A.D. Each humor had elementary qualities; i.e., blood was hot and moist like air; phlegm, cold and moist like water; yellow bile, hot and dry like fire; and black bile, cold and dry like earth. When the humors were normal in quantity and quality and well mixed, man was in good health; when one humor came to dominate in an abnormal way, the balance was up- set and the individual was sick. The practical consequence was that physicians were taught to direct the treatment so as to assist the innate healing power of the body. This theory of disease causation was not the only one in antiquity; there were other schools of physicians, especially the Empiricists, who pointed out that the purpose of medicine was to cure sick people, and that doctors belonging to very different schools still procured the same results.22 While it is possible to present two contrasting theories of disease in the life of the ancient Greeks, the rational and the mystical (religious), it is apparent that in practice they are intermingled depend- ing upon the philosophy of the individual sufferer and the circumstances of the illness. The use of music along with ratibnal methods of medicine as practiced by Hippocrates and the Empiricists contrasts with the religious-mystical system practiced by the followers of the "cult of Aesculapius." The prevailing belief in the ethical and moral powers of music to bring man into harmony with himself and his universe were no doubt utilized in many illnesses that had a psychosomatic genesis. There are accounts from Aeclepiadee,23 the Roman physician, who calmed seditious mobs through a change in the music or the playing of a 221bid. 23 Bruno Meinecke, "Music and Medicine in Classical Antiquity," Music in Medicine, ed. Dorothy M. Schullian and Max Schoen (New York: Henry Schuman, Inc., 1948), pp. 70-85. ?———————_‘ particular type of music. The cure of insomnia was believed to be aided I by hearing harmonious strains of music from a distance; Asclepiades also treated insanity through the medium of harmonious sounds. Xenocrates ‘ used the music of the organ with life results. Caelius Aurelianus used the Phrygian key to treat dejection at one time and rage at another since it is both pleasing and stimulating; the Dorian key was to be played for those who were affected with laughing and childish giggling. It was generally believed that music was a cure for snakebites. There was also the general belief that music was effective in combating pestilence; the ancients recognized that a downcast spirit with its resulting fatigue might predispose the body to disease while a relaxed, joyful frame of mind strengthened its resistance. Capella24 asserted that fevers as well as wounds healed with music. Persons subject to sciatica or lumbago would be free from its attacks if the flute were played in the Phygian mode over the area affected. Galen recommended music as an antidote to the bite of vipers and scorpions.25’ 26 It may be assumed then, for the ancient Greeks and later the Romans, the use of music as a therapeutic agent was closely allied with the particular type of treatment employed, rational or mystical (religious). For the physician who employed rational methods in the treatment of diseases, music became an adjunct in the over-all course of the treatment since there was a very strong orientation toward the use of music for moral and ethical purposes. Where there was a strong suggestion that music provided a cure for a disease or disorder, it is more often linked 241bid., p. 84. 25Ibid. 26Diserens and Fine, op. cit., pp. 145-150. - 13 - to temple cults of healing or to events where the propitiation of the gods had become important to secure relief from disease and to regain health. As Henderson27 points out music was like a second language to the classical Greek minds, capable of expressing the passions and emotions of the people. This is, perhaps, unparalleled in Western culture, but certainly it is the antithesis of the idea of music as a closed world existing for its own sake on its own terms. It was like all Greek art, "mimetic" or representative, a direct photography, as it were, of mental objects formed by the "ethos" and "pathos" of the soul. The Romans took over much of Greek culture including the religious figures and the approach to the power of music to influence behavior; however, in Roman civilization music continued the decline that began in later Greek antiquity--the trend away from the moral and ethical purposes held during Plato's time to more emphasis on the sensuous and emotional effects of music. Music and Medicine in thgpflggdle Ages Christianity introduced the most revolutionary and decisive change in the attitude of society towards the sick. It came into the unrld as a religion of healing, a restorative both spiritual and physical. It taught that disease was not a disgrace or a sin, nor was the sick man an inferior. When Christianity became the religion of the state, society aesumed the obligation to care for its sick members. The sick man assumed a preferential position which has been his ever since that time. However, attitudes that prevailed before the Christian era were never entirely ¥ 27Isabel Henderson, "Ancient Greek Music," The New Oxford History 9? Music, Vol. I: Ancient and Oriental Music, ed. Egon Wallesz (London: Oxford University Press, 1957), pp. 376-402. overcome. For this reason, disease in many instances was still considered a punishment and a sin.28 Coleman points out that mental illness was associated with demonology. Many of the crude, harsh measures employed for the treatment of the insane were the reflection of the belief that a demon had gained control of the sick person and this demon had to be "exorcised."29 Greek medicine was a pagan art for which there was no room in the early Christian Church. Gradually, however, a~reconciliation took place. When Christianity became the official religion of the Roman state, it had to compromise with necessity by taking over the cultural heritage of the past. The rational medical systems of antiquity were saved but, for centuries, little progress was made because religious medicine was close to the people. Elements of faith healing have survived' through all ages. Today the American doctor is a physician of body and mind alike. He cannot underestimate the importance of social and psycho- logical factors in the genesis of disease and its treatment.30 Throughout the scholastic Middle Ages, art was considered to be the servant of the Church. The scholars took Pythagoras as one of their principal figures from antiquity. Their theoretical writings show a pre- occupation with symbolism and number mysticism rather than with sounds and melodies. By contrast, the theologians were quite cognizant of the Power of music. For them, heathen music was diabolic and the faithful had to be protected from its influences. Thus a similarity to Greek thought becomes apparent--music must be carefully regulated and molded by 28Sigerist, op. cit., pp. 65-71. 29James C. Coleman, Ab rmal Ps cholo and Ever da Life (New York: Scott, Foresman and Company, 1956 , pp. 22-23. 3OSigeriet, op. cit., pp. 138-142. F__————7 V the Church otherwise association with profane music would have a dele- terious effect on the hearers, especially on the young people. In the prevailing atmosphere of music for every occasion whether for solemn public ceremonies, private receptions, or music to accompany the armies that went to war, it is to be expected that the use of music for therapeutic purposes would be the rule rather than the exception. Music was not silenced even during the worst of the plague according to the accounts of music in daily life from the "Decameron"31 by Boccaccio. The theories of music therapy practiced in antiquity continued to be advocated during the Middle Ages. The scholars and philosophers of this era venerated the ancients and accepted the use of music in therapy as part of the teachings of antiquity. Religion influenced all phases of life during the Middle Ages. Medicine was largely religious t32 medicine. Sigeris gives examples of hymns that were used as remedies for colds; music was composed in honor of the saints who protected man- kind from illness. Whenever persons of high rank were ill, it was the custom of the court musician to write special compositions for them, if not to help them, then, at least, to cheer them during their suffering. Wheic and Medicine From the Middle Ages to the Igentietg Century 33 Both Carapetyan and Sigerest34 discuss the treatment of disease during the Renaissance in terms of the classical theory of the four humors * 31Giovani Boccaccio. The Decameron, trans. by John Payne (New York: Scott, Foresman and Company, 1956), pp. 22-23. 3ZSigerist, op. cit., pp. 96-98. . 33Armen Carapetyan, "Music and Medicine in the Renaissance and 1n the 17th and 18th Centuries," Music and Medicine, ed. Dorothy M. Schullian and Max Schoen (New York: Henry Schuman, Inc., 1948), pp. 117-140. 34Sigeriet, op. cit., pp. 131-146. the Church otherwise association with profane music would have a dele- terious effect on the hearers, especially on the young people. In the prevailing atmosphere of music for every occasion whether for solemn public ceremonies, private receptions, or music to accompany the armies that went to war, it is to be expected that the use of music for therapeutic purposes would be the rule rather than the exception. Music was not silenced even during the worst of the plague according to the accounts of music in daily life from the "Decameron":31 by Boccaccio. The theories of music therapy practiced in antiquity continued to be advocated during the Middle Ages. The scholars and philosophers of this era venerated the ancients and accepted the use of music in therapy as part of the teachings of antiquity. Religion influenced all phases of life during the Middle Ages. Medicine was largely religious medicine. Sigerist32 gives examples of hymns that were used as remedies for colds; music was composed in honor of the saints who protected man- kind from illness. Whenever persons of high rank were ill, it was the custom of the court musician to write special compositions for them, if not to help them, then, at least, to cheer them during their suffering. Music and Medicine From the Middle Ages to the Twentietg Century 33 Both Carapetyan and Sigerest34 discuss the treatment of disease during the Renaissance in terms of the classical theory of the four humors L 31Giovani Boccaccio, The Decameron, trans. by John Payne (New York: Scott, Foresman and Company, 1956 , pp. 22-23. 32Sigerist, pp. cit., pp. 96-98. 33Armen Carapetyan, "Music and Medicine in the Renaissance and in the 17th and 18th Centuries," Music and Medicine, ed. Dorothy M. Schullian and Max Schoen (New York: Henry Schuman, Inc., 1948), pp. 117-140. 34Sigeriet, op. cit., pp. 131-146. in the body--blook, phlegm, yellow bile, and black bile. Out of this came the four temperaments--eanguine, phelgmatic, choleric, and melan- ohoiio.3 Just as medicine set forth the four component humors of the body, the theories of music set forth four musical elements and related them to cosmic elements. They formed a harmony in music just as the four humors formed a harmony in the body. These four elements were: soprano compared with fire; alto with air; tenor, water; and bass, earth.36 The humors were also extended to include the four musical modes:37 Dorian, phlegm, and water; constituted the phlegmatic temperament; Phrygian, fire and yellow bile, the choleric temperament; Lydian, air and blood, the sanguine temperament; and the mixolydian, earth and black bile, the melancholic temperament. Carapetyan has described the relation- ship thusly: . . . . while medicine utilized a concept more commonly known in music, musical theory in turn borrowed from medicine by defining harmony in music in exactly the same terms by which medical theory defined the harmony that was health. . . . the word harmony would be meaningless if it did not signify a bringing together of elements totally different from one another, whether in the cosmos, in the human body, or in music.38 It may be assumed that certain effects of music that were believed to be therapeutic were actually practised, and within the context of the times were, no doubt, effective. The scientific approach to medicine had its beginnings in the Renaissance with the study of anatomy taking a central position. The 35Carapetyan, op. cit., p. 121. “LI-gig... p. 122. 371919." pp. 122-123. 381pip,, p. 123. - 22 - pathological method in physiology developed during the eighteenth century and clinical medicine had its development during the early nineteenth century. The one field that was not influenced by a scientific approach was therapy. Traditional methods of treatment remained in practice. As a whole, the treatment of disease in the early nineteenth century had not progressed much beyond that of Hippocrates and Galen.39 Gradually, in the late nineteenth and early twentieth century, therapy began to reflect the many discoveries in anatomy, surgery, bacteriology, and biochemistry. Scientific discoveries and methods were incorporated into the treatment of disease. The knowledge in the various areas of medicine no longer sought only to explain the causes of disease, they endeavored to treat and prevent them. Medicine had made a long journey through magic, religion, and philosophy to reach the scientific stage. While the late eighteenth and the nineteenth century still die- closed an affinity of music and medicine, it was during this time that the divergence of the two fields had its beginning. Not until the middle of the twentieth century was there to develop another philosophy of medical treatment that included the arts in its theory of treatment. This does not mean that music was not used for treatment during this period but that the use of music as therapy was examined more critically in terms of scientific methods and procedure. The circumstances of its Use are usually described as special cases, rather than as representa- tive of a general theory or commonly held belief.40 39$igeriet, op. cit., pp. 229-242. 4URuth Boxberger, "Historical Bases for the Use of Music in Therapy," Music Therapy, 1961 Eleventh Book of Proceedings of the NAMT, ed. Erwin H. Schneider (Lawrence, Kansas: Allen Press, 1962), pp. 125-166. W Accounts of music as therapy prior to World War I follow the pattern of the nineteenth century. They are individual case histories rather than descriptions of music as part of a larger field of therapy. With the advent of the phonograph there was more interest shown in the use of music in the hospital setting. Music was used in wards as a diversion during the day and as an aid for sleep at night.41 Its use was also reported in the operating rooms to mitigate the dread of opera- tions and it was considered effective during local analgesia.42 Its use was also suggested for dentist's waiting rooms and other areas where patients waited their turn to see the physician.43 From reports of the use of music with mental patients, it may be assumed that it had considerably more use in mental hospitals than in general hospitals during this period of time. The actual therapeutic value of the music is not clearly stated since the accounts stress the efficacy of the music and give little or no information about the total treatment situation. This is not meant to discount the value of music in the clinical setting but rather to stress that these accounts cannot be used as objective evidence of the value of music as a therapeutic medium.44' 45 41E. 0. Kane, "The Phonograph in the Operating Room,'"Journal of the American Medical Association, XLII (June, 1914), p. 1829. 42W. P. Burdick, "The Use of Music During Anesthesia and Analgesia," The American Yearbook of Anesthesia and Anal esia, ed. F. H. McMechan (New York: Surgery Publishing Company, 1916), pp. 164-167. 43Jessie A. Jarvis, "From the Outside Looking In,"The American Yearbook of Anesthesia and Analgesia, ed. F. H. McMechan (New York: Surgery Publishing Company, 1916, pp. 168-170 44Sidney Licht, Music In Medicine (Boston: New England Conserva- tory, 1946), pp. 11-12. 459oris Soibelman, Therapeutic and Industrial Uses of Music (New York: Columbia University Press, 1948), pp. 10-13. . ,,..- hen-r— .—— .—._._.._.~ One of the leading figures advocating the use of music therapy during this time was Eva Vescelius, a musician, who devoted great efforts toward the development of the field. She was the author of a number of articles and a booklet, Music in Health. Shortly before her death in 1917 she completed a lengthy manuscript which summarizes much of her work in music therapy.46 She revealed that she relied strong on vibra- tions, produced by music, saying, "We are organized vibrations. The object of all curse is to change discordant vibrations into harmonious ones."47 Vescelius appeared to have had some success in her work at the various hospitals. How much of this was due to novelty of the experience for the patients, to her own personal enthusiasm, and to the music is difficult to ascertain. In 1903, she founded the National Therapeutic Society of New York City. She exerted considerable influence on a number of other persons who were active in the field of music therapy. In 1919 Columbia University announced a course in "Musiotherapy" to be taught by Margaret Anderton, who had gained experience in the field during her work with wounded service men during World War I. The course was to stress an approach based on the needs of the patient. First, in terms of the manner in which music can be administered to neuropsychia- trie patients whose difficulties are largely mental and sacond, the way music can be used in conjunction with physical medicine to assist patients Whose difficulties are largely orthopedic.48 k 45Eva c. Vescelius, swusic and Health," Music Quarterly, IV (July 19181.99. 376-400. 47Ibid., p. 378. 48”Columbia University to Heal Wbunded by Music," Literary Digest. (March 1, 1919), pp. 59-62. Two other advocates for the use of music for therapeutic purposes were Isa Maude Ilsen (a nurse, hospital executive, and music director), and Harriet Ayer Seymour (pianist and teacher). Mrs. Seymour published a guide to the therapeutic use of music, What Music Can Do For You.49 During the years between the two World Wars, there was interest in utilizing scientific methods in the study of the effects of music. The studies centered on the discrimination of pitch differences, ending preferences, consonance and dissonance, and the development of tests in music. The studies on the effective qualities of music centered upon two main streams of investigation such as the physiological responses and the psychological responses to music. The value of these studies for the field of music in therapy has been in supplying reliable information useful in the development of methods and techniques for clinical work. Reports of these studies have appeared in leadino music. psychological and education journals.50 The growing interest in the influence of music on behavior employing experimental methods for the study of music as therapy provided a more objective approach to the field. Status of Music as Therapy Prior to world war II. Although music was being used during this time in the hospitals, there was not yet a general philosophy of treatment that considered music was one of the forms of therapy. The power of music to influence human behavior too often was espoused by musicians who made extravagant claims For its therapeutic qualities without providing scientific evidence to support them. In those areas where scientific investigations of the 49Harriet Ayer Seymour, What Music Can Do for You (New York: Harper and Brothers, 1920). 50A comprehensive bibliography of the outstanding studies was compiled by Max Schoen, Chairman of the Committee on the Psychology of Music Teachers National Association. The bibliography was published in the Volume of Proceedings of the MTNA for 1940, 1941, and 1942. effects of music were being made, the results were applicable only indirectly to the therapeutic uses of music. The term "music therapy" enjoyed a certain vogue prior to World War II. However, there was little evidence that would merit the claim that it was a professional field and as such could demand of higher education a degree training program.51 The brief period from the end of World War II to the present has seen music therapy established as one of the professions contributing to the care of the mentally ill, and currently launching a preventative treatment for persons with a potential for becoming mentally ill. Some attempts were made to use music in military hospitals after World War I.52 World War II, however, was largely responsible for music therapy as we know it today. The USO showed that such a potent morale force helped develop the idea that permanent music programs could be used to help patients get well.53 As early as 1948, a survey conducted by the National Music Council showed that 117 hospitals had the services of full- time music therapists.54 The National Association for thic Therapy was organized in 1950 with less than 100 members. Today the association numbers more than 700.55 Fifteen institutions of higher learning offer degrees in music 51Betty J. Keem, "A Study of the Historical Aspects of Music Therapy Leading to a Degree Program," (unpublished research paper prepared for Education 8048: Higher Education in the U. S., Michigan State University, East Lansing, Michigan, Fall 1963). 52gb1d. 53”Red Cross Music," National Music Council Bulletin, September 1945, pp. 20-21. 54“Hospital Music Survey," National Music Council Bulletin, September 1948, pp. 10-11. 55”Membership Directory,” Journal of Music Therapy Vbl. II, No. 1 (Lawrence, Kansas: Allen Press, March 1965), pp. 25-35. - 25 - effects of music were being made, the results were applicable only indirectly to the therapeutic uses of music. The term "music therapy" enjoyed a certain vogue prior to World War II. However, there was little evidence that would merit the claim that it was a professional field and as such could demand of higher education a degree training program.51 The brief period from the end of World War II to the present has seen music therapy established as one of the professions contributing to the care of the mentally ill, and currently launching a preventative treatment for persons with a potential for becoming mentally ill. Some attempts were made to use music in military hospitals after World War 1.52 World War II, however, was largely responsible for music therapy as we know it today. The USO showed that such a potent morale force helped develop the idea that permanent music programs could be used to 53 help patients get well. As early as 1948, a survey conducted by the National Music Council showed that 117 hospitals had the services of full- time music therapists.54 The National Association for thic Therapy was organized in 1950 with less than 100 members. Today the association numbers more than 700.55 Fifteen institutions of higher learning offer degrees in music 51Betty J. Keem, "A Study of the Historical Aspects of Music Therapy Leading to a Degree Program,“ (unpublished research paper prepared for Education 8040: Higher Education in the U. 5., Michigan State University, East Lansing, Michigan, Fall 1963). 521bid. 53"Red Cross Music," National Music Council Bulletin, September 1945, pp. 20-21. 54"Hospital Music Survey," National Music Council Bulletin, September 1948, pp. 10-11. 55"Membership Directory," Journal of Music Therapy Vol. II, No. 1 (Lawrence, Kansas: Allen Press, March 1965), pp. 25-35. !lIIlllIIIlllIlllllllIIIIIIIIIIIIIIIIIIIIIIIEf——————————————————————————————— — - 27 - therapy, and sixteen hospitals are approved as clinical training institutions.56 The brief period from 1945 to the present has seen the synthesis of the earlier music therapy concepts into the beginnings of a systematic science or art with a respectable body of discipline and competent clinical procedures. To some extent this rapid growth can be attributed to the significant amount of research completed. Equally important has been the development of the National Association for Music Therapy. Most of the credit must be given to the complex of mental health professions in our pragmatic society, that have created a climate in which music therapy is needed. Within the context of this historical background the framework for the research project will be further built by briefly examining the development of allied professions that aided the growth of music therapy and its subsequent transformation to related arts therapy. DeveIOpments in Allied Professions Psychoanalysis. Around the turn of this century, Freud initiated the psychoanalytic movement that became, within a relatively short period of time, the dominant movement in psychiatry. It seems safe to say that the most important developments in psychiatry during the first thirty years of this century were accomplished either in amplification or 57 criticism of Freud's theories. Even our most recent advances in social psychology and group dynamics owe much, conceptually and semantically, to 56Kaem, OE. Cite, pp. 24-350 57Karl Menniger, The Human Mind (New Yorke Alfred A. Knopf, 1959) pp. 276-361. - 23 - his earlier discoveries. Freud's views on conflict changed as his theories developed. However, the psychoanalytic view on a basic type of conflict remained fairly stable.58 Freud stated that unconscious striv- ings of the individual, often unacceptable socially, came into conflict with the prohibitive part of the personality, made up generally of socially acquired controls. These two aspects of the psyche, the "I will" and the "thou shalt not" compromise and find expression in the third part--the conscious, acting part of us. Topographically, this could be stated in this manner: the id comes in conflict with the super- ego, and compromises between these two are expressed by the 390.59 A story often told in psychology classes illustrates this phenomenon. A young men, while walking down the street, sees a beautiful young lady. The id says, "Let's go after her"; the superego says, "Leave her alone"; and the ago says, "Let's go get a sandwich, and wel'll come back later and see if she's still here." The analytic concept of a conflict, a part of which was discussed above, can be taken as an illustration of the individual-oriented, or "intra" psychology. According to this view, both theory and therapy are concerned with the individual. The main core of psychoanalytic therapy consists in the uncovering of repressed material in the individ- ual's unconscious, usually through the technique of free association.60 Freud recognized a type of group behavior, but even here his views were individual-oriented. Collective behavior was considered to be an extension 58Ibid., pp. 274-380. 59Sigmund Freud, Grou Ps cholo and the Anal sis of the E (New York: Boni and Liveright, 1932). 60Menniger, op. cit., p. 269. of individual action with cultural restraints removed. Therefore, an individual interacting in a crowd could behave in an unrestrained manner because he felt free to "throw off the repressions of his unconscious instincts."61 A consequence of the individual-oriented psychology is that it required a one-to-one relationship in therapy. Since all psychological conflict is viewed as emanating from within the psyche, the therapist is required to spend many hours alone with the patient in order to work through the repressed material. It would be impossible to submit the large numbers of patients in our hospitals today to psychoanalysis or any type of depth therapy. It would require several times the number of psychiatrists available to extend adequate coverage.62 Milieu Therppy. An outgrowth of the Freudian movement provides a second event of importance to music therapists. Milieu terapy was developed at the Menniger Clinic in Topeka, Kansas during the 1930's. Under this concept, a protective, controlled environment was initiated as an adjunct to the treatment of psychiatric patients. Recreation activities such as basketball, volleyball, golf, touch football, tennis, and boxing; arts and crafts activities including leatherwork, ceramics, painting, weaving, and metalwork; and musical activities such as orchestra, dance band, and private lessons on the various musical instruments were made available to patients. Use of these activities were not unusual at this time. Most institutions had recreational programs of various kinds.63 61Freud, op. cit., pp. 81-89. 62Michigan State Psychiatric Hospital patient populations average 3,000 per hospital. The psychiatric staff varies from one (Kalamazoo) to thirty (Pontiac and Traverse City) full-time staff psychiatrists. 63Wi11iam Van do Well, Music in Institutions (New York: Russell Sage Foundation, 1936). However, an important advance occurred when these activities were analyzed for their inherent therapeutic values and, at times, were prescribed much as drugs were being prescribed at other institutions.64 For example, a patient with a considerable amount of unconscious hostility might be assigned to menial, unpleasant activities such as gardening, sawing wood, or scrubbing the floor with a toothbrush. The goal in a situation such as this might be to "work off" hostility, and to bring some of it to the surface so that it could be expressed consciously.65 This aspect of the milieu program must still be placed under the heading of "intra" psychology in that the utilization of activities was still directed toward the inner life of the individual. Another impor- tant potential of the activity program, however, was being utilized at the same time. Each activity was conceived and utilized as a "life situation," and close attention was paid to interpersonal relationships developed by the patient in these activities. Questions such as, "How did basketball practice go today?" became an integral part of the treat- ment program. Relationships between patient and therapist, patient and patient, and patient and grOUp could be assessed and manipulated in therapy.66 For the first time the music therapist became a primary agent in the treatment of patients. He was required to know the patient's medical and social background as well as his immediate and long-term goals. His activities were guided by psychiatric prescription and frequent staff consultations. 64Interview with Robert K. Unkefer, Director of Music Therapy Training Program, Michigan State University, February, March and April, 1964. 651bid. 66 Karl Menniger, A Manual for Psychiatric Case Study (New York: Grune and Stratton, 1962), p. 52. The use of prescribed activities with the emphasis on relation- ships, marks the beginning of what might be called the "inter" phase of psychiatric treatment. Group situation is now used to effect personality modification even though theoretical guidance is still derived from psychoanalytic principles. Milieu therapy has exerted a considerable amount of influence in the psychiatric institutions of this country.67 Certain aspects of the milieu program, such as prescribed activities, 68, 69 are now commonplace, but difficulties have been encountered in its utilization in the large psychiatric hospital. Therapeutic effectiveness of the milieu program depends upon the close cooperation between psychiatrist and activity therapist. Such cooperation is usually difficult to achieve in larger institutions because of the scarcity of psychiatrists. Milieu therapy has given music, occupational and recrea- tional therapists a valid theoretical framework in which to operate and has helped create an identity for them in the psychiatric profession.70’71’72 67Maxwell Jones, et al., The Therapeutic Community (New York: Basic Books, 1953). Balbid. 69Jurgen Ruesch, Therapeutic Communication (New York: W. W. Norton and Company, 1961), pp. 11-27. 700b ectives and Functions of 0ccu ational There , compiled by the American UccUPational Therapy Association Dubuque, Iowa: William C. Brown, 1959). 71Yearbooks of National Association of Music There ~ Articles and Procee in s of National Conferences Vols. I-XII 1951-1962 (Lawrence, Kan- sas: Allen Press, 1952-63). 72Objectives and Functions of Music Iherapy, currently being com- piled by the National Association of Music Therapy under the guidance of E. Thayer Gaston, Director of Music Therapy Training Program and Music Education, University of Kansas, Lawrence, Kansas. - 32 - Soci Ps cholo and Grcu D namics. A third development, parallel to the second, should be mentioned as important to music therapists. This concerns the emergence of two professions that possibly are accomplishing the first major revolution in psychiatric treatment since the advent of the psychoanalytic movement. These professions are social psychology and group dynamics. Social psychology is concerned with the development of the individual in relation to his environment, and particularly with the influences that groups in the environment exert on his beliefs and actions.73 Group dynamicists are interested in the acquisition of knowledge, through empirical means, about the structure and function of various types of groups.74 Both of these professions have helped develop the realization that mental health and illness is often caused by the individual's interaction in groups and that groups may be used as agents in his treatment or prevention of illness.75’ 75 A number of social psychologists and social psychiatrists are now actively engaged in therapy in our mental institutions. A few are currently engaged in public school research projects, such as "inner-city" school programs and teacher effectiveness.77' 78 Their emphasis on the 73Tamotsu Shibutoni, Societ and Personalit : An Interactionist Approach to Socipl ngchology (New York: Prentice-Hall, 1961). 74Matthew 8. Miles, Learning to Work in Groupp (New York: Bureau of Publications--Teachers College, Col. University, 1959). 75Leo Srcle, et al., Mental Health in the Metro olis (New York: McCraw-Hill and Company, 1962 . 760cc of the multi-concepts of the Flint Community School organiza- tion, Flint, Michigan. 77Allison Davis is currently engaged in such a study in the Chicago ”inner-city" public schools. Similar studies are being conducted in Detroit, Michigan, New York City, and Cleveland, Ohio schools. 733ruoe J. Biddle and William J. Ellena (eds.), Contepporary Research on Teacher Effectiveness (New York: Rinehart and Winston, 1964). ..33- etiological and therapeutic potentials of groups have given music therapists new and important theoretical constructs with which to operate. 79 and his associates has demonstrated As an example, the work of Jones that patients, when placed in groups, may be effectively helped by other patients when elements such as group cohesiveness and group pressures are introduced and utilized. Similar findings have been uncovered in a recent "inner-city" school disturbed youth study.Bo Within this historical framework the development of music therapy leading to a more complex related arts therapy will be traced, and a definition of related arts therapy illustrated with clinical examples will be advanced. 79Jones, et.al.I op. cit. 80Report of the "Personalized Curriculum Program: (PCP) for Junior and Senior High School Drop-outs," (Flint, Michigan, Flint Community Schools, 1965). CHAPTER III THE DEVELOPMENT OF RESEARCH IN MUSIC THERAPY AND RELATED ARTS THERAPY DEFINED WITH CLINICAL EXAMPLES Research Emergence. An interesting analogy can be noted in the growth of psychiatry, milieu therapy, social psychology, and group dynamics, and the development of music therapy research. As stated before, Freud and his psychoanalytic concepts dominated American institutional psychiatry after 1910. These concepts were given the label of "intra" psychology. The immediate history of music therapy also shows considerable concern with the effects and affects of music on the individual. Such early investigators as Hyde and Scalopino,1 Diserens,2 and Treves:5 noted the effects of music on the pulse rate, blood pressure, striated musculature, and respiration rate. Schoen and Catewood,4 investigating the mood affects of music using 20,000 subjects, found these effects to be 1Ida H. Hyde and W. Scalopino, "Influence of Music Upon Electro- cardiogram and Blood Pressure," American Journal of Physiology, No. 46 (April 1918), pp. 35-38. 2Charles M. Diserens, The Influence pf_Mpsic on Behavior (Prince- ton, New Jersey: Princeton University Press, 1926). 3N. E. Treves, "Study of Music on Cancer Patients," No. 16 (August 1927), pp. 123-131. 4Max Schoen and Ester L. Gatewood, "An Experimental Study of the Nature of Musical Enjoyment," in Effects of Music ed. Max Schoen (New York: Harcourt, Brace and Company, 1927 . -34.. - 35 - “strikingly uniform." Altshuler and Shebesta5 reported favorable results in a study titled "Music as an Aid in the Management of the Psychotic Patient.“ 6 showed that the unmusical as An unpublished study by Dreher well as the more musical exhibit galvanic changes while listening to music. But these electrical changes were found to be much weaker in the unmusical subjects.7 Shrift,8 in a later galvanic study, determined that the human organism reacts in a significantly different manner to stiumulative music than it does to sedative music. Husband's9 laboratory findings indicated that different types of music increased the sway of people who were attempting to stand still. Jazz caused greater sway than music of other styles. Work at Stanford University laboratories carried the Husband study further to show that even thinking of jazz music can increase sway.1o Jensen11 studied the effects of jazz and dirges on 5Ira M. Altshuler and B. H. Shebests, “Music as an Aid in the Management of the Psychotic Patient," Journal of Nervpus and Meptpl gig- gggggg,uo. 94 (August 1941). pp. 179-183. 6R. E. Dreher, ”The Relationship Between Verbal Reports and Galvanic Skin Responses to Music" (unpublished Thesis on file at Indiana University, Bloomington, Indiana, 1947). 7The galvanic skin response refers to the fact that the electrical resistance of the skin is measurably decreased whenever, during emotional states, perspiration is produced on the skin surfacee:. R. I. Henkin, ”The Prediction of Behavior Response Patterns to Music," urne f P o 44 (1957), pp. 111-127. 8Donald C. Shrift, ”The Galvanic Skin Response to Tue Contrasting Types of Music,“ W 1956 ed. E. Thayer Gaston (Lawrence, Kansas: Allen Press, 1957 , pp. 235-239. 9R. W. Husband, ”The Effects of Musical Rhythms and Pure Rhythms on Bodily Sway." gppgnpl pf Generpl ngphplogy, 11 (1934), pp. 328-336. 1oThat music can stimulate compensatory movement which can aid one's sense of balance has been demonstrated by W. Levers in "The Influence of ‘ Musical Training and Musical Accompaniment on the Sense of Equilibrium” (unpublished Thesis, Syracuse University, Syracuse, New York 1950). 11M. B. Jensen, ”The Influence of Jazz and Dirge Music Upon Speed and Accuracy of Typing," gpurnpl pf §dpcptionpi Psychology, 22 (1939), pp. 458-462. typing. Although jazz seemed to have no effect on the speed of his subjects' typing it did increase the errors. Dirges, on the other hand, decreased the typing speed but had no effect on errors. Pivot Point. Early in 1950, music therapy entered a new phase. Graduate students, under the direction of E. Thayer Gaston,12' 13 were investigating problems such as the sedative effects of music on acutely 15 disturbed patients,14 the effects of music on children's drawings, and postural responses to music.16 Shatin reported positive behavioral differ- ences in two studies17’ 18 exploring the applications of rhythmic stimuli to long term schizophrenic patients. Research by Alward and Rule (Keem)19 shows that unaccepted behavior of emotionally disturbed children in a public school classroom can be changed, in certain cases, to more acceptable 12Interview with William W. Sears, Director of Music Therapy Training Program, Indiana University, Bloomington, Indiana, October 1964. 1:5Interview with Erwin H. Schneider, Acting Dean, School of Music, Ohio University, Columbus, Ohio, November 1964. 14Donald E. Michel, "A Study of the Sedative Effects of Music for Acutely Disturbed Patients in a Mental Hospital," Music Ther 1951 ed. E. G. Gilliland (Lawrence, Kansas: Allen Press, 1952), pp. 182-183. 15Danny E. Orton, "Development of Criteria for Study of the Influ- ences of Music on Children's Drawings," Musi Thar , 1952 ed. E. G. Gilliland (Lawrence Kansas: Allen Press, 1953), pp. 261-265. 16William W. Sears, "Postural Responses to Recorded Music," is Therapy, 1951 ed. E. G. Gilliland (Lawrence, Kansas: Allen Press, 1952 , pp. 197-198. 17Leo Shatin, "The Application of Rhythmic Music Stimuli to Long Term Schizophrenic Patients,” Music Ther , 1957 ed. E. Thayer Gaston (Lawrence, Kansas: Allen Press, 1958), pp. 169-178. 18 , "The Influence of Rhythmic Drumbeat Stimuli Upon the Pulse Rate and General Activity of Long Term Schizophrenic,"Journal of Mentgl Sciepcee No. 430 (London, England: January 1957), p. 103. 19Eileen Alward and Betty Rule (Keem), "An Experiment in the Use of Music with Emotionally Disturbed Children," M sic Ther 1959 ed. Erwin H. Schneider (Lawrence, Kansas: Allen Press, 1960), pp. 125-129. -37- behavior when subjected to music therapy. It should be noted that the majority of research at this time was still concerned with the "intro" point of view. One reason for the predominant interest in this line of research was the realization that certain types of music could be used to control behavior.20 Sedative music could sometimes be used to quiet disturbed wards,21 and stimulative music could often be used to raise the mood level of apathetic patients.22 Sedative music also was found to be helpful when used for mental patients experiencing tension and anxiety during 23 dental procedures. Also, during this period the “isc principle” was started by Altshuler.24 This principle, which originated with the ancient Greeks,25 is homeopathic in that moods are matched by music and the music is than altered to bring about a desired mood change. For example, highly stimulative music might be played for disturbed patients and as the music becomes quieter or more sedative, the moods and behavior of the patients often change with the music.26 20Paul R. Farnsworth, The Social Psychology of Mugic (New York: Dryden Press, 1958), pp. 259-264. 21Robert F. Burns, "A Study of the Influence of Familiar Hymns on Moods and Associations: Potential Applications in Music Therapy” (unpub- lished Thesis, University of Florida, 1958). 22Ibid. 23Harold Lee Jacobson, "A Study of the Effects of Sedative Music on the Tension and Anxiety Experienced by Mental Patients During Dental Procedure,“ Bulletin of the National Association of Music Thar No. 5 (September 1956), pp. 9-10. 24Ira M. Altshulsr, ”The Part of Music in Resocialization of Mental Patients," Occupatipnal Igorppy and Rehabilitation No. 20 (1941), Pp. 75-86. 25Julius Portnoy, The Philosophpr and Music (New York: Humanities Press, 1955), pp. 163-171. 26Altshuler, op. cit., p. 76. -38- Testing the "isc principle” with apathetic schizophrenic patients, Skelly and Haslerud27 found that the patients general activity seemed to follow the mood of the music. When stimulating march music was played apathy decreased, and when sedative music was played the apathy increased. Simon,28 et.al. reported that psychotic patients recognized and accepted ”mood music" although it had little effect on their overt behavior. Orton determined the effects of the iso principle to be the same with both normal and psychotic subjects.29 The prevalence of electric shock treatment (EST) during this period was another area that affected music therapy research. Mental patients seemed to need some type of therapy to aid them when coming out of electric shock treatment. Shatin, Gilmore, and Cotter30 found a defin- ite positive relationship between music and post-electro-shcck awakening. An earlier study by Murdock and Eaton31 attempted to SUpport the use of music as an adjunct to electroshock therapy by a series of observational case studies. 27C. G. Skelly and G. M. Haslerud, ”Music and the General Activity of Apathetic Schizophrenics,” gournpl pf Apnormal Social Psychology No. 47 (April 1952). pp. 188-192. ' 28Benjamin Simon, gt al., ”The Recognition and Acceptance of Mood in Music by Psychotic Patients," Jcprnel of Nervogs and Mental Qisordpps, No. 114 (1951). pp. 66-78. 29Mary Ryder Orton, "Application of the Iso-Moodic Principle in the Use of Music and Psychotic and Normal Subjects" (unpublished Thesis, University of Kansas, Lawrence, Kansas, 1953). 3°Leo Shatin, T. Gilmore, and W. Kctter, ”A Study of the Relation- ship Between Music and Pcst-Elactro-Shock Awakening," Qisopder of Nervous Sygtem No.8 (August 1954), p. 15. 31Harry M. Murdock and Merrill T. Eaton, "Music as an Adjunct to Electroshock Treatment,” gpurngl of Nervous and Mental Disorder No. 116 (1952), pp. 336-339. Current Trends. The discovery of tranquilizing drugs along with their use, on a massive scls, seriously curtailed the “intra” type of research. Behavior could be altered much faster and for longer periods of time with drugs than was possible before. This led music therapy research in other directions. In the past eight years one of the main experimental facets has been music as a rehabilitation factor. Many of the experiments being conducted today generally concern the use of music in the facilitation of social interaction. Shatin,32 Blair and Brooking,33 and Goward and Licht,34 concluded in their studies that music plays an important role in the rehabilitation of the mentally ill. Zanker and Glatt35 found that certain kinds of music had a positive affect on the successful rehabilitation of alcoholic and neurotic patients, whereas other kinds of music had a negative affect. An unpublished report by Keem36 cites the successful use of music in the rehabilitation of a psychotic patient. Another unpublished report by 32Leo Shatin, “Some Psychiatric Aspects of Long-Term Hospitaliza- tion. The Rehabilitative Role of Recreational and Special Activities,” Mental Hygiene No. 41 (April 1957), pp. 487-496. 33Donald Blair and Mair Brooking, "Music as a Therapeutic Agent,“ Mpntpl Hygiene No. 41 (April 1957), pp. 228-237. . 34Barbara Goward and Sidney Licht, "Music for the Hospitalized Patients," eds. W. R. Dutton, Jr. and Sidney Licht 0ccu ational Thar , Pglnglplpp gng Practices (Springfield, Illinois: Charles Thomas, 1957), pp. 127-141. 35A. Zanker and M. M. Glatt, ”Individual Reactions of Alcholic and Neurotic Patients to Mlsic,” ={nuptial pf Nernps pnd Mental Dis- orders No. 123 (1956), pp. 395-402. 36Betty J. Keem, "Employment of Public School Teachers with Mental Illness Histories" (unpublished document of case studies filed in office of music consultant, Flint, Michigan public schools). 37 recites the success of an ongoing case study in the use of Paterson music in the rehabilitation of a schizophrenic patient. Griffin, Cotter, and Kurz38 reporting on the influence of music on geriatric patients concluded that music activities: increased inter- est in environment: provided a happier and more congenial atmosphere in the dining room; and served, either directly or as a tool, to reduce the sound level of a female geriatric day hell by inducing a more favorable atmosphere for both staff and patient. Dillinger,39 in a case study titled ”Music and Music Therapy as the Patient Experiences Them,“ reports favorable interaction taking place between the psychotic patient and the therapist. Sommer4o found that suitable background music increased the frequency of interactions and pause lengths in group psychotherapy sessions. An unpublished study by Kerr41 showed that more positive interaction with psychotic patients takes place when listening to music performed by musicians in person than when listening to the same music coming from a phonograph. In a study of handball ringing as a music 37Janet M. Patterson, "Rehabilitation of a Schizophrenic Female Patient: Case Study" (unpublished case study on file in Occupational Therapy office of Traverse City State Hospital, Traverse City, Michigan). 38Jack Griffin, Vance Cotter, and Charles Kurz, ”The Influence of Music on Geriateric Patients," myglg_1pg§gpy, 1957 ed. E. Thayer Gaston (Lawrence, Kansas: Allen Press, 195 . pp. 159-166. ngbcrge E. Dillinger (M.D.), ”Music and Music Therapy as a Patient Experiences Them,” Musi Ther , 1958, ed. Erwin H. Schneider (Laurence, Kansas: Allen Press, 1959), pp. 193-214. 4ODorothy T. Scmmer, "The Effect of Background Mosic on Frequency of Interaction in Group Psychotherapy," Mpglp Thergpy, 1957 ed. E. Thayer Gaston (Lawrence, Kansas: Allen Press, 1958), pp. 167-168. 418. J. Kerr, “A Study to Determine the Effects of ‘Live' and 'Canned' Music on Psychotic Patients“ (unpublished paper on file Cincinnati Conservatory of Music, Cincinnati, Ohio, 1942). ———i 7 - 41 - therapy operation, l-‘ultz4l2 reports that handbell group membership opened up communication lines, and patterns of interaction developed where they care previously non-existent. In an article titled ”'Scribbling' in Music Therapy"43 Ruppenthal sums up three case studies by strongly recommending that the music therapist must and can accept ”music scrib- blings' as a may of opening the door of communication. Furthermore, the music therapist must and can tolerate ”musical scribblings” until the time comes for more positive interaction with the patient. In a cooperative related arts therapy study, Goldstein, Lingas, and Sheafor,44 present data resulting from an evolutionary process rather than from an isolated experience or idea. The purposes of the study were threefold: 1. to show that interpretation or creative movement to music can serve as a means of sublimating inappropriate emotional feelings or responses:‘ 2. to show that nonverbal communication can be used as an effective means of group unification: and 3. to show the benefits which can be derived when adjunctive thera- pists from different disciplines combine their knowledge and talents in unified efforts.45 This study reflects the movement of the therapeutic team approach and the close interaction and exchange of information among all disciplines con- 46 corned, including the patient himself. The latest research points 42Arthur F. Fultz, ”A Study of Handball Ringing as a Music Therapy Epuration,” my§1§_1nggggy_lg§lled. Erwin H. Schneider (Lawrence, Kansas: Allen Press, 1962), pp. 169-182. 4:f'iilayne Ruppenthal, "'Scribbling' in Music Therapy,” urn of fiygi§_lgggggx, Mel. II, No. 1 (March 1965), pp. 8-18. . 44Carole Goldstein, Catherine Lingas, and Douglas Sheafor, “Interpretive or Creative Movement as a Sublimation Tool in Music Therapy," . _ 3 -- --' V010 II, ~00 1 (March 1955), PP. 11-150 - 451_;g,, p. 11. 46George 4. Stanford, "Orchestration of the New Mental Hospital ”W Vol. I, No. 4 (December 1964), pp. 124-128. T———7 strongly to related arts therapy rather than straight music therapy. Al- 49, 50, 51, 52, 53, 54 55, 56, 57 though artists,47’ 48 dancers, and actors 47According to Charles Beal, Art Consultant, Flint Public Schools and Stuart Hodge, Director of Flint Institute of Arts, artists in general in United States have avoided moving into the area of therapeutic art. The art world prefers to have the art discipline image remain singularly as an artistic expression of a culture rather than take the chance of being relegated to a "lesser societal" role with therapeutic value. 48Reports of therapeutic art are spasmadic and usually pertain to accounts of artists, such as Van Gogh, who have been institutionalized or paintings by patients requested by psychiatrists in hopes of reaching the patient's "inner-self.“ Examples of the latter case are: Naumborg, Margaret. Psychoneurotic Art! Its Function in Psychotherapy (New York: Bruno and Stratton, Inc., 1953); and . chizophrenia Art: Its Fugption in Psychotherppy (New York: Grune and Stratton, Inc.,1950 . 49Marian Chace, “Dance as an Adjunctive Therapy with Hospitalized Mental Patients,” Bulletin of the Menniger Clinic No. 17 (November 1953), pp. 219‘2250 50 , "Measurable and Intangible Aspects of Dance Sessions," Mpsic TherapyI 1957 ed. E. Thayer Gaston (Lawrence, Kansas: Allen Press, 1958 , pp. 151*1560 51 , "Report of a Group Project, St. Elizabeth's Hospital," Mu ic The 954 ad. E. Thayer Gaston (Lawrence, Kansas: Allen Press, 1958), pp. 151-156. 52 , ”Rhythm in Movement as Used in St. Elizabeth's Hospital," Group Ppychotherapy ed. J. Moreno (New York: Beacon House, 1946). 53Elizabeth Rosen, "Dance as a Therapy for the Mentally Ill," Teaphers College Recprd No. 55 (New York: Columbia University, 1954), Pp. 215-222. 54 , Dance Ps chothera (New York: Teachers College, Columbia University, 1957 . 55Performers of drama have not formally or unformally alluded to their art as a therapeutic tool. However, therapists in other disciplines have attempted to use dramatic art in several ways. Most research accounts refer to psychodrama. Many hospitals have drama clubs, but the inherent values have not been scientifically tested. 56 J. L. Moreno, "Psychodrama and Group Psychotherapy,” Sociometry No. 9 (May/August 1946), pp. 249-253. 57 _ , "Psychomusigg",Esxghngzama ed. J. L. Moreno (New York: Beacon House, 1946), pp. 277-314. F"T"""""""""""”" 58: 59 have alluded to the use of their discipline as a therapeutic tool, there has not been a body of formal research built nor an organiza- tion formed to support the dance, art, or drama discipline in therapy. Music therapy appears to be the only formalized therapeutic art discipline, and therefore the undergirding for the arts in therapy. 's R lat d Arts Thar Definition ith Clinical Exa es Definition. Music and/or related arts therapists today are con- cerned with persons who are not communicating adequately with others. Their patients may be physically, emotionally, or mentally handicapped individuals with varying degrees of disability ranging from temporary to chronic diagnosis. The larger majority of music-related arts therapists work with psychiatric patients confined to mental institutions. Within the past two years music therapists have formally expanded their activities in public schools. Currently, in Michigan, two public school systems employ music therapists.60 A recently formulated definition of related arts therapy advanced for this research project by Keem states that the directed use of related SBEva F. Rudyar, “Methods of Sound and Movement as an Adjunct to Psychodrama,” Ppychodrama No. 4 (1951), pp. 44-99. 59R.'Wittenberg, ”Psychiatric Concepts in Group Work Applied Through the Media of Drama and Music," American dournpl of Drthopsychiatry No. 14 (January 1944), pp. 76-83. 60The role of the music therapist is different in these two school systems. In the Lansing, Michigan public schools the therapist is con- sidered a consultant in music for the teachers of the mentally handicapped children. In the role the therapist is expected to ”teach” music in the special education classrooms. In Flint, Michigan schools the therapist works directly with the physically and emotionally handicapped children, in addition to the severely mentally disturbed students. In the latter school system music therapy for the mentally handicapped program is, by tradition, an integral part of the regular school music program. - 44 - arts therapist as an agent in the treatment, rehabilitation (and/or learning), and entertainment of patients. Because music is conceived to be the basis of related arts therapy the term music therapy and related arts therapy is used interchangeably in the report of this research project. In modern psychiatric hospitals it is assumed that psychiatric patients need treatment because they can no longer communicate adequately with other people. A patient's interpersonal relationships have dis- rupted to the point he must have a controlled, non-threatening environ- ment in which to erect new, realistic defenses to meat the strains of everyday living. The hospital serves as a ”mikrokosmos," or small world,61 in which staff members exert every effort to give the patient new experiences in living, new methods for meeting everyday problems and new ways of getting along with people. Therapy is designed to enable the patient to experience fully, to accept that he has experienced, and to share these experiences with others.62 Each staff member has a rather well-defined part to play in this effort and the cooperative efforts of the combined staff are mobilized toward returning the patient to the 1arger--outside community as a responsible, well-functioning member of society. This cooperative approach is known as the ”psychiatric team” concept.63 Because many patients require physical as well as psychological care, the psychiatrist, with his medical a1willian Caudell, mg ngphigtgig Hospital pp 2 Seal; Sogigtz (Caubridge: Harvard University Press, 1953). pp. 235-301. 62Jurgen Ruesch, Thepppeutip Communication (New York: M. M. Norton and Company, 1961), pp. 482-484. ' 63Karl Menniger,-A Mange; fpp Psychiatrip Case Study (New Mark: GrUflB and Strattflfl, 1962), Pa 180 background, is traditionally the team leader. The other treatment team members include all the activities therapists, psychologists, psychiatric social workers, psychiatric nurses, nursing aides, attendants and other psychiatrists. In public schools the team usually is headed up by the principal of the building and includes the classroom teacher, home visitor, psychologist, medical adviser, music supervisor, music therapist and other pertinent teaching personnel, and/or occupational therapists.64 A distinction is made in the definition between the use of music and the music therapist. This is due to the belief that there are some therapeutic values inherent in the music itself.65 This is closely re- lated to the "intra" concept discussed earlier. Philosophers, educators and medical personnel have emphasized the therapeutic potentials of music for several centuries. Probably the best summary of these ideas is ex- pressed by Gaston. Music is basically a means of communication and many times succeeds in communicating when less subtle means fail. There would be no music, and perhaps no need for it, if we could communicate verbally that which we so easily can communicate with music. . . The fine arts, especially music, have always offered man a means for expres- sion more true and deeper than words. Such use is generally beneficial.56 While inherent therapeutic elements in music and fine arts are easily inferred, empirical investigation appears to be almost an impossibility. For this reason, and because of current psychiatric practices, the emphasis is placed on a well-trained musician with a well-rounded fine arts knowledge and a strong, formally acquired psychological;background. 5‘A description of the Flint Community Schools ”therapeutic team." 65Carlos Chavez, Mpg 19:1 Ihouppt (Cambridge: Harvard University ' pra‘s, 1961), pp. 1903‘. 66E. Thayer Gaston, ”Nature and Principles of Music Therapy,” Music In» ppy, 1954 ed. E. Thayer Gaston (Lawrence, Kansas: .Allen Press, 1955), p. 154. -46- The use of the term "treatment" or "therapy" for patients has had a considerable amount of controversy. Without probing the semantics of the question, such as what is treatment and what is therapy, it is possible to state that in certain specific areas, music therapists do engage in therapy. These areas include therapeutic potentials inherent in the activity, direct, controlled procedure with supervision and goal- direction as a prerequisite for therapeutic procedure.67 Clinicpl Examples. Inherent therapeutic potentials in music _should not be confused with those potentials found in the music therapy activity. While the two are interrelated, it is helpful to think of them as separate entities. Most music therapists conduct ward programs with- out supervision by medical personnel.66 In some hospitals as much as fifty per cent of the therapist's working hours are spent in the wards. Several types of activities, including group singing, rhythm band, exercise to music and simple dance programs are used. These activities may be therapeutic if the therapist formulates realistic goals and works toward their accomplishment. For example, when patients are confined to closed wards, muscles tend to become flaccid, and many patients show progressive loss of attention span and increased disorientation. This is particularly true of geriatric patients. Regular exercise and a simple 69 dance program show psychological benefits. If the therapist is careful to learn each patient's name and manages to speak with him during the 67RUBSCh, OE. cit., pp. 460-457. 68Examples of activities like this can be found in the following midwest hospitals: Indiana--8eatty Memorial Hospital, Richmond State Hospital, Larue Carter Hospital; Wisconsin--Madison State Hospital, Mil- waukee County Hospital. 69Observed by Betty J. Keem as ongoing activities in the following Michigan psychiatric hospitals (or units)t Traverse City State Hospital (June 1964-June 1965); Wayne County General Hospital: Psychiatric Unit (January 1965-June 1965)l Winchester (Genesee County) Hospital (October 1962-May 1965). - 47 - activity, the session becomes even more beneficial. In this exanple, a certain activity is initiated with specific therapeutic goals in mind. The activity becomes therapeutic,and the music therapist is practicing therapy. In another example, a patient, diagnosed as schizophrenic,paranoid type, was present at bi-monthly closed ward sings conducted by the music therapist in a Michigan hospital. This patient was noted for his uncoop- erativeness and hostility. The music therapist noticed that he seemed to have a good voice. After receiving the doctor‘s permission, the patient was invited to join the church choir. After a few months working with the music therapist, the patient learned to cooperate to a certain extent with other members of the group and gradually exhibited much less hostility during the sessions and on his ward. He was eventually moved to an open ward. As the musical activity was the only change in his schedule, it can be assumed that it contributed to his improvement.70 In this instance, the music therapist was working without direction and with a patient who was not in psychotherapy. It seems reasonable to distinguish these accom- plishments as therapeutic and the carrying out of the activity as therapy. In a public school example, an emotionally disturbed nonverbal communicating fifth grade girl transferring into a school was observed by the music therapist furtively peeking at a creative dance class. After receiving permission from the principal and classroom teacher, the music therapist asked the disturbed student to join the creative dance group. In a few weeks the student began to verbalize vile complaints to members of the group. The complaints were indicative of a poor body image. By manipulating comments of the group the music therapist promoted a more perfect body image for the disturbed student. As the 70Interview with Clemens F. Fitzgerald, M.D., Director of Psychiatric Research and Education,Wayne County General Hospital,January 1965. student's self-esteem increased the disturbance lessened and more accept- able verbal communication was exhibited. Other school personnel were "clued in" to current happenings in the creative dance class. The case is not yet closed. The "therapeutic team" is working toward an even more acceptable communication pattern, even though positive communication 7‘ Certainly this activity could be classified progress has been reported. as therapeutic. The second therapeutic area, that of direct controlled procedure under psychiatric or principal supervision, may utilize some techniques employed in the first area. The difference lies in the amount of super- vision given and in the way in which the activity fits into the over-all hospital or school treatment program. As stated earlier, the "psychiatric team" concept implies that all professional staff members work together in an integrated program designed to help the patient or student get well. The following example may serve as an illustration of a hospital . procedure: A Caucasian female, age 17, was brought to the hospital by her mother. She was untidy, sullen, hostile and occasionally seemed to lose contact with reality. She was given the tentative diagnosis of schizophrenia, paranoid type. The prognosis was guarded. Because it was felt this patient could not stand groups, she was assigned to individual activities in the recreation department, occupational therapy and in the music department. In music she expressed a desire to play the piano and lessons were begun. After a few weeks, it was found that the strongest relationships she had made were in the recreation and music departments. 71Raported by m. Ann Johnson, R.M.T., Flint Community Schools. The school setting for this report is one of Flint's "inner city" schools with a specialized BTU (Better Tomorrow for Urban Youth) curriculum. -49.. Consequently the occupational activities were dropped and most of her time was spent in the other two departments. Almost daily the doctor would check her progress report. The doctor directed the music therapist to give the patient support and gratification whenever possible and to work toward building her self-esteem. Progress was to be praised real- istically and failure minimized or ignored. Since the patient had come from a home dominated by her mother and grandmother, she was assigned exclusively to male therapists. After a month the patient's hostility had diminished considerably, autistic tendencies were no longer observed and it was possible to include her in group activities. During this period she expressed an interest in dixieland jazz. Records were found, and she spent one hour a week with the music therapist listening to records and discussing everything from music to men. At this time the doctor directed the therapist to begin commenting on the patient's appearance. This led to discussion of clothes and the patient asked to be accompanied downtown to purchase new clothing and cosmetics. A trip to the beauty shop for a shampoo and set, a bath, new clothes and make-up caused considerable comment among the patients and staff members. After approximately four months, the patient was discharged and seemed to make a good adjustment in the commnity.72 The next example shows some events leading up to a patient's dis- charge under an integrated hospital therapy program. During the hospital- ization period, a psychiatric social worker made several trips to the patient's home, discussed her illness with the family and was able to 72Interview with John Hsu, M.D., Director of Research, Pontiac State Hospital, February 1965. -50.. convince them that some changes were desirable in the home environment. A psychologist assisted in the original diagnosis and gave the patient several tests before she left the hospital. Nursing personnel, occupa- tional, recreational and music therapists knew the patient's medical history and gave her as much support and encouragement as possible under a blanket prescription. The psychiatrist directed the therapeutic team, prescribed appropriate medication and was responsible for the patient in therapy. A parallel case in the public schools can be cited. A pre- school deaf male child with an unusual amount of fear of people, causing regressed behavior, was referred to the adjunctive therapies division of his special school by the diagnostician. The referral was supported by medical advice from the Children's Health Clinic. Individual finger painting and dance-drama were the two forms of therapy he seemed to enjoy. After several weeks of individual dance-drama, the music therapist was directed to involve one, then two other pre-school deaf children. In several months the subject was well integrated with his peer (pre- school deaf) group, which, in turn, was in the process of growing in communication with the larger school-community' world.73 In the latter case, the team consisted of a school diagnos- tician, medical personnel, classroom teacher, home visitor, music therapist, music supervisor and building principal. The term ”rehabilitation” generally has two meanings. One refers to the returning or restoring of a person or object to an original state 73Report by Eileen Alward, Principal of Durant-Tuuri-Mott Community School, Flint, Michigan. Durant-Tuuri-Mott houses "normal” as well as ”orthopedic” children. -51- or condition. The second refers to the restoring of one's capacity to make a living. In the public sch00i it is used in these two ways but carries the connotation of ”learning" or “relearning,” for K-12, junior college and adult education division.74 while many hospitals prepare patients to make a living through manual arts training and work assign- ments, the term "psychiatric rehabilitation refers to a somewhat different meaning. It refers to those activities that are aimed specifically toward the preparation of the patient to get along socially in the larger community outside the hospital or school.75 As stated earlier, a patient enters the hospital because of a disturbance in interpersonal relationships with the people around him. He no longer has the capacity to interact in a satisfactory manner. While therapy is concerned with modifications in the patient's personality, rehabilitation must be concerned with outward behavioral manifestations that might either inhibit or facilitate relationships with people around him. Many psychiatric patients tend to be unprepossessing. They are often untidy, fail to dress appropriately and pay little attention to hair or fingernails. Some people have disgusting eating habits and relatively few know how to dance or play card games. It is a function, or should be, of the activity therapists to assess each patient's social capabilities and deficiencies. Capabilities should be developed and deficiencies corrected. To discharge an untidy patient, for example, would invite readmission. Music therapists work with other activity therapists in all of the mentioned areas. In 74This is an integral part of the Flint Community School philosophy. 751nterview with Arthur m. Dundon, M.D., Clinical Director, Traverse City State Hospital, Traverse City, Michigan, June 1964. addition, they would teach the patient social and square dancing, develop any musical talent that might foster recognition and acceptance for the patient in a group and direct the patient in art activities. such as painting, sketching, or dancing. In the same manner, the recreation therapist would give the patient skills in volleyball, tennis, baseball, badminton and other sports that would prepare him for effective group interaction. The community school situation can be equated in a parallel fashion. The last part of the definition states that music therapists are concerned with entertainment of subjects whether patients or pupils. This is an important part of any hospital or school music program. Activities in this area include patient/student dances, the utilization and supervision of outside entertainment groups, entertainment for special programs, such as Chritmas shows, bus trips76 etc. The importance of entertainment should not be minimized. It helps make hospital/school routine more bearable and tends to create a better atmosphere which facilitates the more serious business of therapy-learning. In addition, it helps to promote qualitative use of leisure time.77 Within this broad frame of reference the chapters in part two will be devoted to delineating the research project designed to study 76Bus sight-seeing trips, sponsored by Dale Claphem, R.T., are particularly popular at the Traverse City State Hospital. One of the patients' favorite recreational-entertainment bus trips is going to a concert at the National Music Camp, Interlochen, Michigan. 77Significant "leisure time" conceptual changes have occurred within the past five years. Leisure and the Schools: 1961 Yearbogk of the Ameri n Asso 1 tion r Hea th Ph ical Education and Recr t n. Editor John L. Hutchinson amashington D.C.: American Association for Health, Physical Education, and Recreation, 1961), pp. 5-12. the process and outcomes of related arts therapy with certain psychotic patients selected at random and confined in three Michigan psychiatric hospitals. Findings will be reported and implications will be discussed followed by a brief summary including conclusions and recommendations. PART TWO CHAPTER IV PROCEDURE AND DESIGN OF STUDY Setting Geographic Locatign. Three Michigan psychiatric hospitals were selected to participate in the investigation to study the process and outcomes of related arts therapy with certain psychotic patients. The hospitals were chosen according to the following criteria: 1. American Psychiatric Association approval for the complete three year residency program in which ‘graduate medical doctors may obtain the additional necessary education and training to become fully certified psychiatrists. 2. Approval by the Joint Commission on Accreditation of Hospitals. 3. Membership in the Michigan Hospital Association and American Hospital Association. 4. Facilities for the psychiatric affiliation of student nurses from General Hospitals and college programs throughout the state. 5. American Occupational Association and Music Therapy National Association approval for internship to complete the necessary training to become registered occupational end/or music therapists. 6. An education and research department that is recognized by the associations named in the above items as making an outstanding contribution to the field of knowledge concerning the care and treat- ment of the mentally ill. In addition, theei‘hospitals are recognized by the above mentioned medical associations for their out-patient clinics and competent - 55 - -56- American Red Cross Gray Ladies. They are also approved by the Council for Clinical Training as centers for clinical pastoral training for students of theology in the United States and Canada. Two of the three hospitals selected for this study are state supported institutions. The third is county supported. The first state supported institution, located in an industrial urban center, has a committing area of six rural counties as well as four urban counties. The second state supported institution is situated in a city of 18,432 permanent residents, increased by 210,000 ten-week summer residents, according to its 1966 chamber of commerce report. Thirty nine counties, in lower Michigan, make up the committing area of this hospital. The thirty nine county area, considered rural, contains a few scattered service centers and one industrial town. The remaining hospital, the third in this study, is the psychiatric unit of a complex county health department. Its supporting and committing area is one, densely populated, industrial, urban county. Hospital Administration. The state supported hospitals have similar organizational plans. (See Tables 1, 2.) Both hospitals have a medical superintendent at the top administrative level. The clinical director, director of the children's unit, and the business executive are at the second administrative level and each of these directors report to the medical superintendent. Reporting to the clincial director, in each hospital, are the directors of education and research, nursing, and social services. The occupational and recreational therapies in hospital one, are two separate departments with a director who is res- ponsible to the clinical director. Related arts therapy, in this hospital, is attached to the recreational department. In the second - 57 - xpuuaomw moumma Hoccoanoo routes rosette erasure. oceauoaom >uacseeou uopuouwo Camauosu I. moua>uom mooH>nom wouw>nom aconaodca cowmwweoq ucoauoacH .oaoeou Learnt. Leann odes swarm, T ||I .h.m so anaconda nouoouao a. ram .» .u a.uoa searchers scrasoaca to .uso to .us, H asses .oso,. to .aso ,ncoz .uao assosooxu .ro re .naaru Honorees meocaeam nouoouuo _ riaooacuau é museums “usuzumv zeua oaonea~Hzau¢o u>aeuom ocosoooca oaoooo oraru wouw>emm pronounce Tomas roaru. a more ouuommz cascades- acouuoc ; . owuooaou a“: presumes» fl coumowom spawned»: accommom . oossosom so .oso .oooz .oso oz .oeo uwcaeeou _ 4. wt. .4 _ a saucepan mcwfimaz_mdi .uenoouao _ ososmmro Tn: a o>fiuaooxu camoumam a no so users nouuouwo uoaomlwqdeI— Hmuwcuam _ acoocoucauoaam zquo oazoaea~az¢umo o>HeemcmHszo¢na~ oaeuomo: .N mamas ..59- hospital the therapies, occupational, recreational and related arts are classified under the adjunctive therapies department with one director who reports to the clinical director. A comparable organizational plan can be outlined for the psychiat- ric unit of this county supported health department (see Table 3). In this unit the psychiatric director is given the role equivalent to the role of the clinic director in the state institutions. The directors of education and research, nursing, male and female wards, psychology and ancillary programs report to the psychiatric director. Related arts therapy in this institution, is a vital and well established program attached to the ancillary division. other salient features of these three hospitals can be pointed out as: (1) hospital beds--2925 (first state hospital), 2950 (second state hospital), and 2998 (county institution); (2) the average of 30 full-time psychiatrists for each hospital; (3) total number of hospital enployees--821 (hospital 2), 989 (hospital 3), and 910 (hospital 1); and (4) over 50 per cent of the newly admitted patients, in each hospital, has a psychotic disorder. Subjects Population. A psychotic disorder defined by Coleman1 is a‘ functional psychoses, meaning: personality disintegration with dis- 2 orientation for time, place, and/or person. Coleman further delineates psychotic disorders by categorizing them into four groups, namely: 1James C. Coleman, Abnormal Ps cholo and Modern L fe (Chicago: Scott Foresman and Co., 1956 , pp. 224-314. ZIbid. -60- you: 0 ooa>nom caupodzoxmn at unaccoucauooaw‘wonocou z<4a quoHHHh<¢hm~2HEonoucoewau 3 .383 cacoaoaasocoea page . acoaa .....lmlll. .mmcom can cocoa aesuclasaasnloowo> commooomau succumau mflflfln p lacoualmucooiwuwo> . mgr: n Hosanna: N anemone: . Hosanna: >oahm mnzh 2H mhuuflmam Achzusnmuaxu on can mzomhnmmumuzn mh¢¢ oub<4u¢ .0 u4mwuomoc n w «omcoco mauuqmoc u a "consensus“ acoowuacmam no emcozo as no omcozo cc u o .ocou .cm s so.onuuve . .cm .NN .n u ~c.onuu1a n .vm .mm .ov .mr .F : mo.oHUd.a m I owmcozo accoumacmaw xeedocomnoa «melon m ”anoeesm mo. saucepan coo oocou so. 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Nc.o c mms.m P so.m co. cm.~ cm.s~ so. cm.~ cm.s~ successes as cases seas a n cc.mm as. so. co.cn so. cc.m oc.mm co. mc.c a cc.a cc. cc.~ cc.m~ cc. cc.~ cc.mu escapades assess use cm~.s a cc.sm co. co. cc.cn so. cc.a cc.s~ .aooasassa .Hacasaau as u s _..._am_c_o_._o2_a_cmam aucmuom in... . dimmed .....m s o.._....__.__ :M _. s so Hoses «cm a somszou .axu sue” summon secs one oza umoxh 02¢ >n a very original thinker ........................... a somewhat slow and leisurely person ............. tends to be critical of others ...................... makes decisions only after a great deal of thought. . . believes that everyone is essentially honest ......... likes to take it relatively easy at work or play ....... has a very inquiring attitude ..................... tends to act on impulse .......................... a very energetic person .......................... doesn’t get angry at other people .................. dislikes working on complex and diflicult problems. . prefers gay parties to quiet gatherings ............. enjoys philosophical discussions .................. gets tired somewhat easily ....................... considers matters very carefully before acting ...... does not have a great deal of confidence in people. . . likes to work primarily with ideas ................. does things at a rather slow pace .................. very careful when making a decision .............. finds a number of people hard to get along with ..... a great person for taking chances ................. becomes irritated at other people quite readily ...... can get a great deal done in a short time ........... spends considerable time thinking of new ideas ..... a very patient person ............................ seeks thrills and excitement ...................... able to keep working for long stretches ............ would rather carry out a project than plan it ....... feels very tired and weary at the end of the day ..... inclined to make hurried or snap judgments ........ doesn’t get resentful toward other people .......... has a great thirst for knowledge ................... does not act on the spur of the moment ............ becomes irritated by faults in others ............... lacks interest in doing critical thinking ............ prefers to work rapidly .......................... inclined to become very annoyed at people ......... likes to keep “on the go ” all the time ............. would rather not take chances or run risks ......... prefers work requiring little or no original thought. . Turn the page and go on. Mark your answers in column B ————+ 3456789101112 a very cautious person .............................. prefers to work rather slowly ........................ very tactful and diplomatic ......................... would rather not occupy the mind with deep thoughts. . loses patience readily with people .................... has somewhat less endurance than most people ........ tends to be creative and original ..................... doesn’t care much for excitement ..................... tends to act on hunches ............................. has a great deal of vigor and drive .................... doesn’t trust people until they prove themselves ........ enjoys questions involving considerable thought ........ doesn’t like to work at a fast pace .................... has great faith in people ............................ tends to give in to the wishes of the moment ........... enjoys working out complicated problems ............. a very energetic worker ............................. accepts criticism with very good grace ................ dislikes problems requiring a great deal of reasoning. . . . inclined to act first and think afterward ............... speaks nothing but the best about other people ......... very cautious before proceeding ..................... not interested in thought-provoking discussions ........ does not hurry in going from place to place ............ doesn’t have an inquiring mind ...................... doesn’t act on impulse .............................. generally bursting with energy ....................... becomes irritated by weaknesses in other people ........ able to get more things done than other people ......... enjOys taking chances just for the excitement ........... takes offense when subjected to criticism .............. would rather work with ideas than things ............. very trustful of other people ......................... prefers work that is routine and simple ................ does things on the spur of the moment ................ full of vigor and vitality ............................. makes decisions much too quickly .................... has a great liking for everybody ...................... maintains a lively pace at work or play ................ does not have a great interest in acquiring knowledge. . . Percentile y Leonard V. Gordon Rank 99— - - . — 95— -- -- —- J- 90— —— —— —— +- Sex _ __ . 75 “ " " "‘ ‘— ame Age ate—— Marital Status 50 — —— —- —- -r- :hool or Firm 25— —— —- —— _- 104 -- —- j— -- 54 -— —- -- -- rade or Occupation ity State 1 _i ...— ...— __ -— Score —> Percentile Rank —>— Norms used irections: In this booklet are a number of descriptions of personal characteristics of people. These descriptions are grouped sets of four. You are to examine each set and find the one description that is most like you. Then make a solid ack mark between the pair of dotted lines following that statement, in the column headed M (Most). Next examine the other three statements in the set and find the one description that is least like you; then make a lid black mark between the pair of dotted lines following that statement, in the column headed L (Least). Do ”5 make any marks following the two remaining statements. i i are is a sample set,- prcfers to get up early in the morning .............. I l i M L doesn’t care for popular music ..................... has an excellent command of English ............... .: obtains a poorly balanced diet ..................... I Suppose that you have read the four descriptive statements in the sample and have decided that, although several the statements may apply to you to some degree, “obtains a poorly balanced diet” is more like you than any of the hers. YOu would fill in‘ the space following that statement in the column headed M (Most), as shown in the sample. You would then examine the other three statements to decide which one is least like you. Suppose that “prefers to at up early in the morning” is less like you than the other two. You would fill in the space following that statement the column headed L (Least), as shown in the sample above. For every set you should have one and only one mark in the M (Most) column, and one and only one mark in the (Least) column. There should be no marks following two of the statements. In some cases it may be difficult to decide which statements yOu should mark. Make the best decisions you can. emember, this is not a test; there are no right or wrong answers. You are to mark certain statements in the way in hich they most nearly apply to you. Be sure to mark one statement as being most like you and one as being least be you, leaving two statements unmarked. Do this for every set. Turn the booklet over and begin. blished 1963. Copyright © 1956', 1.955, by Harcourt. Brace dz World, Inc., New York. All rights reserved. The reproduction of any part of this form by mimeoaraph. toaraph, or in any other way, whether the reproductions are sold or are furnished free for use, is a violation of the copyright law. a III "r Mark your answers in column A a good mixer socially .......................... lacking in self-confidence ..................... thorough in any work undertaken .............. tends to be somewhat emotional ............... not interested in being with other people ........ free from anxieties or tensions ................. quite an unreliable person .................... takes the lead in group discussion .............. acts somewhat jumpy and nervous ............. a strong influence on others .................... does not like social gatherings ................. a very persistent and steady worker ............ finds it easy to make new acquaintances ........ cannot stick to the same task for long ........... easily managed by other people ................ maintains self-control even when frustrated ...... able to make important decisions without help. . does not mix easily with new people ............ inclined to be tense or high—strung ............. sees a job through despite difficulties ........... not too interested in mixing socially with people. . doesn't take responsibilities seriously ........... steady and composed at all times .............. takes the lead in group activities .............. a person who can be relied upon ............... easily upset when things go wrong ............. not too sure of own opinions .................. prefers to be around other people .............. finds it easy to influence other people ........... gets the job done in the face of any obstacle ..... limits social relations to a select few ............ tends to be a rather nervous person ............ doesn’t make friends very readily. . . .i .......... takes an active part in group affairs ............ keeps at routine duties until completed .......... not too well-balanced emotionally .............. Turn the page and go on. wiv' 'v I. Mark your answers in column B ————>- assured in relationships with others .............. feelings are rather easily hurt .................... follows well-developed work habits ............... would rather keep to a small group of friends ...... becomes irritated somewhat readily .............. capable of handling any situation .............. ’. . does not like to converse with strangers ........... thorough in any work performed ................. prefers not to argue with other people ............ unable to keep to a fixed schedule ................ a calm and unexcitable person ................... inclined to be highly sociable .................... free from worry or care ......................... lacks a sense of responsibility .................... not interested in mixing with the opposite sex ...... skillful in handling other people .................. finds it easy to be friendly with others ............ prefers to let others take the lead in group activity. . seems to have a worrying nature ................. sticks to a job despite any difficulty ............... able to sway other people’s opinions .............. lacks interest in joining group activities ........... quite a nervous person .......................... very persistent in any task undertaken ............ calm and easygoing in manner ................... cannot stick to the task at hand .................. enjoys having lots of people around ............... not too confident of own abilities ................. can be relied upon entirely ...................... doesn’t care for the company of most people ....... finds it rather difficult to relax ................... takes an active part in group discussion ........... doesn’t give up easily on a problem .............. inclined to be somewhat nervous in manner ........ lacking in self-assurance ........................ prefers to pass the time in the company of others. . M I. A . Percentile By Leonard V. Gordon Rank A R E S 99 — r— " ‘— 95 — -r -- -* ‘- 90" "r " -' ‘— Name Age Sex 75_ __ __ .1- -. D t _ M_ Ma 'tal Stat j a e r1 us 50 __ __ __ _- School or Firm 25 - —r -r —- 4- Grade 01' Occupation _ __ __ __ l- City State 10 5 — —— —- —- J— 1 _ J- __ _ ._ Score —>- Percentile LR_ank —>— Norms used Directions: In this booklet are a number of descriptions of personal characteristics of people. These descriptions are grouped in sets of four. You are to examine each set and find the one description that is most like you. Then make a solid black mark between the pair of dotted lines following that statement, in the column headed M (Most). Next examine the other three statements in the set and find the one description that is least like you; then make a solid black mark between the pair of dotted lines following that statement, in the column headed L (Least). Do not make any marks following the two remaining statements. Here is a sample set: has an excellent appetite .......................... M L gets sick very often ............................... I follows a well-balanced diet ....................... 2: doesn’t get enough exercise ........................ I Suppose that you have read the four descriptive statements in the sample and have decided that, although several of the statements may apply to you to some degree, “ doesn’t get enough exercise” is more like you than any of the oth- ers. You would fill in the space following that statement in the column headed M (Most), as shown in the sample. You would then examine the other three statements to decide which one is least like you. Suppose that “ gets sick very often” is less like you than the other two. You would fill in the space following that statement in the column headed L (Least), as shown in the sample above. For every set you should have one and only one mark in the M (Most) column, and one and only one mark in the L (Least) column. There should be no marks following two of the statements. In some cases it may be difficult to decide which statements you should mark. Make the best decisions you can. Remember, this is not a test; there are no right or wrong answers. You are to mark certain statements in the way in which they most nearly apply to you. Be sure to mark one statement as being most like you and one as being least like you, leaving two statements unmarked. Do this for every set. Turn the booklet over and begin. Published 1.96.3. Copyright © 1953‘. 1901.14, Harcourt, Brace & World Inc.. Nan York All rights reserved. The reproduction of any part of (his form by mimrogrnph hectoqraph. or in any other nay, u hcther the reproductions are sold or are furnished free for use, is a violation of the cnpyr iyh! [nu U123h0123h0123h0123k0123h0123h0123h0123k -... I.'-A--'-- any-m nu- I! II. 123k0123h0123h0123k012350123h0123h0123h ttfiw s hwws HWMMs w 11 W U u w c 3 a . .. a m 1 . 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"h an .... _ . ~ ~148- ANSWER SHEET INPATIENT MULTIDIMENSIONAL PSYCHIATRIC SCALE (IMPSI PATIENT'S NAME CODE # HOSPITAL WARD No. TYPE OF WARD SEX AGE DIAGNOSTIC IMPRESSION RATER's NAME POSITION 0F RATER DATE OF RATING RATING PERIOD DIRECTIONS CIRCLE ONE POINT ON EACH NUMBERED VERTICAL SCALE AS ILLUSTRATED BELOW. ASTERISKED ITEMS APPEAR IN BRIEF SCALE. EXTREMELY 3 a e a MARKEDLY 7 7 7 ® 7 DISTINCTLY 6 6 6 6 6 EXAMPLE: ON THE CHARACTERISTIC ASSESSED BY SCALE 1 THE PATIENT Is RATED ”MODERATELY” QUITE A BIT 5 5 5 s 5 COMPARED WITH THE NORMAL PERSON. ON SCALE MODERATELY Q) 4 4 4 4 2 HE IS RATED "EXTREMELY", AND ON SCALE 3 HE IS RATED "NOT AT ALL". ON SCALE 4 HE Is MILDLY 3 3 3 3 3 II II RATED MARKEDLY . ON SCALE 5 HE Is RATED A LITTLE 2 2 2 2 2 "VERY SLIGHTLY". VERY SLIGHTLY I I 1 1 6) NOT AT ALL 0 O 0 0 SCALENO. (1) (2) (3) (4) (5) CONSULTING PSYCHOLOGISTS PRESS, INC. . EXTREMELY 8 8 8 8 8 8 o 8 8 8 8 o 8 8 8 MARKEDLY 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 DISTINCTLY 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 QUITE A BIT 5 s 5 5 s 5 5 5 5 5 5 5 5 5 s MODERATELY 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MILDLY 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 A LITTLE 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 VERY SLIGHTLY 1 1 1 1 1 I 1 1 1 1 1 1 1 1 1 NOT AT ALL 0 o o o o o o o o o o o o o o SCALE No. *( 1) *( 2) *( 3) (4) *( 5) *( 6) ( 7) (a) *t 9) (10) (11) (12) (13)*(14) £15) EXTREMELY 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 MARKEDLY 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 DISTINCTLY 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 QUITE A BIT 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 MODERATELY 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MILDLY 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 A LITTLE 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 VERY SLIGHTLY 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 NOT AT ALL 0 o o o o o o o o o o o o o ‘ o SCALE N0. *(16) (17) (18) (19) (20) *(21) (22) (23) (24) *(25) (26) (27) (28) (29) (30) EXTREMELY 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 MARKEDLY 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 DISTINCTLY 6 6 6 6 6 6 6 6 6 6 6 6 6 . 6 6 QUITE A BIT s s 5 5 S 5 s 5 S 5 5 5 5 5 s MODERATELY 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MILDLY 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 A LITTLE 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 VERY SLIGHTLY 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 NOT AT ALL 0 o o o o o o o o o o o o o o SCALE NO. (31) (32) (33) (34) *(35) (36) (37) (38) (39) (40) (41) (42) (43) (44) (Q VERY OFTEN 4 4 4 4 4 4 4 4 4 4 4 4 4 FAIRLY OFTEN 3 3 3 3 3 3 3 3 3 3 3 3 3 A FEW TIMES 2 2 2 2 2 2 2 2 2 2 2 2 2 ONCE OR TWICE 1 1 1 1 1 1 1 1 1 1 1 1 1 NOT AT ALL 0 o o o o o o o o o o o o SCALE No. (46) *(47) (48) (49) (50) (51) (52) *(53) (54) (55) *(56) (57) (58) YES 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 No 0 o o o o o o o o o o o o o o o o 1"(59) (60) *(61) (62) Q3) *(64) (65) $556) $7) (68) *(69) (70) *(71) (72) (73) (74) * 75) INPATIENT MULTIDIMENSIONAL PSYCHIATRIC SCALE SCORING SHEET Exc ITE MENT (EX 0) 7. UNRESTRAINED * 9. HURRIED SPEECH 12. ELEVATED MOOD 15. SUPERIORITY 17. DRAMATIZATION 20. LOUD 26. OVERACTIVE *35. EXCESS SPEECH 37. DOMINATES HOSTILE BELLIGERENCE (HOS) * 5. VERBAL 11. CONTEMPT 18. ATTITUDE *25. IRRITABILITY 28. BLAMES OTHERS 32. BITTER 34. COMPLAINTS 36. SUSPICIOUS PARANOID PROJECTION (PAR) 44. DELUSIONAL *59. X8 REFERENCE 60. xe PERSECUTION *61. X8 CONSPIRACY 62. X8 PEOPLE CONTROLLING 63. X8 EXTERNAL CONTROLLING 68. X8 BODY DESTRUCTION GRANDIOSE EXPANSIVENESS (G RN) 15. SUPERIORITY 54. x2 VOICES EXTOLL *64. xe UNUSUAL POWERS 65. X8 GREAT PERSONALITY *69. XS DIVINE MISSION PERCEPTUAL DISTORTION (PCP) 45. HEARS VOICES *53. x2 VOICES ACCUSE 55. x2 VOICES THREATEN *56. x2 VOICES ORDER 57. x2 VISIONS 58. x2 OTHER .HALLUC. 67. X8 IDEAS OF CHANGE MORBIDITY SCORES I. EXC + HOS - RTD = 2. PAR + GRN + PCP = 3. RTD + DIS + MTR + CNP= ANXIOUS INTROPUNITIVENESS (INP) *14. *21. 24. 27. 29. 31. 39. 40. 41. 42. 66. BLAMES SELF ANXIETY (SPECIFIC) APPREHENSIVE SELF DEPRECIATING DEPRESSED GUILT -1 INSIGHT SUICIDAL OBSESSIVE FEARS 8 SINFULNESS 8 SCORING CONSTANT >< RETARDATION AND APATHY (RTD) * I. 8. 13. *16. 19. 22 23. 33 38. SLOWED SPEECH LACK OF GOALS FIXED FACIES SLOWED MOVEMENTS MEMORY DEFICIT SPEECH BLOCKING APATHY WHISPERED SPEECH FAILURE TO ANSWER DISORIENTATION (DIS) 7O *71. 72. 73. 74 *75. o —1 HOSPITAL x—I STATE x‘-1 KNOWS NO ONE —1 SEASON -1 YEAR x-I AGE 6 SCORING CONSTANT >< >< >< MOTOR DISTURBANCES (MT R) * 6. IO. 30. 46. *47. 48. 51. 52. POSTURING TENSION SLOVENLY x2 GIGGLING x2 GRIMACING x2 REPET. MOVEMENTS x2 TALKS To SELF 2 STARTLED GLANCES >< CONCEPTUAL DISORGANIZATION (CNP) * 2. * 3. 4. 49. 50. IRRELEVANT INCOHE'RENT RAMBLING 2 NEOLOGISMS 2 STEREOTYPY X X PATIENT'S NAME CODE # RATER'S NAME DATE OF RATING PROFILE SHEET IMPS STANDARD EXC HOS PAR GRN PCP RTD DIS MTR CNP STANDARD SCORE RAW SCORES (TWO RATERS) 8.0 104 115 55 68 130 122 81 56 8.0 — 101 112 53 67 127 119 79 55 - — 98 109 52 65 124 116 8 77 53 - - 96 106 50 63 121 113 75 52 - — 93 103 110 49 61 118 110 73 50 — 7.5 90 100 107 47 59 114 107 71 49 7.5 — 88 98 104 46 57 111 104 7 69 47 - - 85 95 101 44 55 108 101 67 46 - - 82 92 98 43 53 105 98 66 44 - - 80 89 94 41 52 102 95 64 43 - 7. 0 ---------- 77----- 86 ----- 91 ----- 4o ----- 50 ----- 99 ----- 93 ----- 6 ----- 62 ----- 41---------- 7. 0 - 74 83 88 38 48 96 90 60 40 - - 7 80 85 37 46 92 87 56 38 - - 69 77 82 35 44 89 84 56 37 - — 66 75 79 33 42 86 81 5 54 35 - 6. 5 63 72 76 32 4o 83 78 52 34 6. 5 - 61 69 73 30 38 80 75 so 33 - - 58 66 70 29 37 77 72 48 31 — - 55 63 67 27 35 74 69 4 46 30 - — 53 60 64 26 33 71 66 44 28 - 6. 0 ---------- 50---—- 57—---- 61————— 24-———- 31 ----- 67—---- 63—--—- ----- 42 ----- 27 ---------- 6.0 - 47 55 58 23 29 64 61 40 25 - - 45 52 55 21 27 61 57 3 38 24 - - 42 49 52 20 25 58 55 :16 22 - - 39 46 49 18 24 55 52 34 21 - 5. 5 37 43 46 17 22 52 49 32 19 5.5 - 34 40 43 15 20 49 46 2 3o 18 - - 31 37 40 14 18 45 43 28 16 - — 29 34 37 12 16 42 4o 26 15 - — 26 32 34 10 14 39 37 24 13 - M 5.0 ---------- 23----- 29 ----- 31 ————— 9 ----- 12 ----- 36 ----- 34 ----- 0-1 ----- 22 ----- 12 ---------- 5.0 M — 20 26 28 7 10 33 32 20 11 - — 18 23 25 6 9 30 29 18 9 - — 15 20 22 4 7 27 26 16 a — - 12 17 19 3 5 24 23 14 6 - 4.5 10 14 16 1 3 20 20 12 5 4. 5 - 7 12 13 0 1 17 17 10 3 - - 4 9 10 o 14 14 8 2 - - 2 6 7 11 11 6 o - — o 3 4 8 8 4 - 4.0 o 1 5 5 2 4.0 - 0 2 2 o - _ o o _ * ONLY THE BOTTOM SCORE OF EACH CLASS INTERVAL l5 GIVEN. INCLUDING THE NEXT HIGHER SCORE. STRAIGHT LINES. EACH INTERVAL EXTENDS FROM THE GIVEN SCORE UP TO BUT NOT TO PROFILE, CIRCLE THE PATIENT'S SCORE IN EACH COLUMN AND CONNECT CIRCLES WITH Mlllllllllllllllll llllllllllllll lllllllllls 31293 03083 1931