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Bill..- (Vat-cytrvu.$.l§r fr'f’d . .i. .551? uh.r7ri L I... .9... as" 4! .v( 5.214.! if! it {(1.}??? . Kitttrlclb’v. It... r71... 114?}..1... Lrt; .. wt. .1 fir :r , r.t~.lr!.. y L.’ .. (f ..~.~$..§)rw«"‘pltnrv. .pn. . . i9 , . : (Dir. . I .. V . -3313: ‘ ‘ . 7 . .4... rugi .L .J v‘. «Ma‘s \Ig1\\\\L\\guJLu\x\lImmufluugw ‘ 0-169 l \ LIBRARY Li lVllf: ;J; :t.CC ’ University A W This is to certify that the thesis entitled ALTmRATION OF SOMfi BODY IMAGfl'INDICES IN SCHIZOPHRENICS VIA INDUCED SOMATIC AWARENESS presented by Joel A. Darby has been accepted towards fulfillment of the requirements for _Eh.D_._ degree inminical Psychol ogy //%@%4~— Major professor Date X //é ABSTRACT ALTERATION OF SOME BODY IMAGE INDICES IN SCHIZOPHRENICS VIA INDUCED SOMATIC AWARENESS BY Joel A. Darby It has been theorized that schizophrenia involves a lack of cathexis of ego boundaries. At the most basic level this consists of a lack of bodily ego cathexis. Starting with this postulate, Des Lauriers developed a theory of psychotherapy in which the central premise is that the therapist must stimulate in the schizophrenic patient "re- actions of interest in, and attention to his bodily self as the separating boundary from what is not himself, and as the primary instrument of his contacts with and actions on his environment." The present study tested the proposition that in— ducing somatic awareness in schizophrenic patients can in- fluence their body image boundaries. Seventy—five hospital— ized schizophrenic males, 15 patients in each of five different groups, were given Form A of the Holtzman Inkblot Test (HIT), underwent the experimental or control conditions appropriate to the group to which they had been assigned, Joel A. Darby and were then administered Form B of the HIT. Only the first 25 cards of the Holtzman forms were used. The between-test conditions imposed on the different groups were as follows: A Somatic group did a number of physical exercises which induced somatic awareness in the subjects under con- ditions which maximized their involvement in the process. Subjects in an Imagination group were asked to imagine what it would feel like to do those same exercises in order to induce somatic awareness in them while at the same time keeping their involvement minimal. A Separateness group underwent a number of sensory experiences calculated to induce somatic awareness and to maximize boundary definiteness. A Fusion group also underwent a number of sensory experiences which induced somatic awareness but which, at the same time, attempted to minimize boundary definiteness. Subjects in the Control group spent the time between tests viewing colored slides through an automatic desk—top viewer. The boundary indices developed by Fisher and Cleveland, the Barrier and Penetration of Boundary scores, were used as measures of body boundary definiteness. Joel A. Darby Inducing somatic awareness in these schizophrenic patients increased their boundary definiteness as indicated by the significant increases in Barrier score achieved by the Somatic, Separateness, and Fusion groups. This was interpreted as direct support for Des Lauriers' theory. The attempt to increase boundary definiteness under conditions of minimal involvement, i.e., through cognitive means, failed. This failure was interpreted as demonstrating not so much that a cognitive approach is not feasible but that stimulation which the patient can not avoid or ignore is necessary in dealing with schizophrenic patients. The Penetration of Boundary score was only slightly affected by the experimental manipulations. It was sug- gested that this score is a measure of an affective component of perceived boundary definiteness and is indicative of anxiety about body integrity and one's ability to control what happens to it. As such, it would not be much affected by isolated experiences, but would only be subject to stabilized, longer term gains in perceived definiteness. In addition, any effects the experimental manipulation had, or might have had, on this measure were no doubt depressed by the heavy tranquilization on which these patients were maintained. Joel A. Darby A highly significant correlation between the Barrier and Penetration scores was obtained for the pretest data. In addition, the pretest boundary scores as well as the boundary score changes from pretest to posttest were corre— lated with selected demographic characteristics of the sample. The Barrier score was found to be independent of these characteristics for the most part. The Penetration score, however, was found to be positively related to the patients' ages and their ages at first hospitalization. Various ramifications of these results and their implications for the psychotherapeutic treatment of schizo— phrenic patients were discussed. In addition, areas of needed future research were delineated. Approved 3 m Date : Jig/f? ALTERATION OF SOME BODY IMAGE INDICES IN SCHIZOPHRENICS VIA INDUCED SOMATIC AWARENESS BY ( ’7 b6 Joel Al Darby A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1969 to carolyn i ACKNOWLEDGMENTS I would like to express my appreciation to my com— mittee, Drs. Albert Rabin, Joesph Reyher, Charles Hanley, and Robert Zucker. Special thanks, of course, are due to Dr. Rabin who served as chairman. I would also like to thank Dr. Austin Des Lauriers who was the source of my interest in psychotherapy with schizophrenic patients. The Veterans' Administration Hospital in Battle Creek, Michigan and its psychology staff deserve my deep— felt appreciation for providing me both the opportunity and the freedom to carry out my research. Finally, I’would like to take this opportunity to publicly thank my wife, Carolyn, whose faith in my abilities has never waivered. She has truly been a constant source of strength throughout my graduate career. TABLE OF CONTENTS Page ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . iii LIST OF TABLES . . . . . . . . . . . . . . . . . . . . vi LIST OF FIGURES . . . . . . . . . . . . . . . . . . . vii LIST OF APPENDICES . . . . . . . . . . . . . . . . . . viii INTRODUCTION . . . . . . . . . . . . . . . . . . . . . 1 Theory . l The ego and schizophrenia l The concept of the body ego 2 Des Lauriers' theory of psychotherapy with schizophrenics . 4 The Rorschach and Body Image . . 6 Fisher and Cleveland's methods of Rorschach scoring . 7 Empirical findings with the boundary scores 9 STATEMENT OF THE PROBLEM . . . . . . . . . . . . . . . 14 Development of the Present Study . . . . . . . 14 Summary of the Principle Questions to be Investigated . . . . . . . . . . . . . . . . 17 METHOD . . . . . . . . . . . . . . . . . . . . . . . . 18 Subjects . . . . . . . . . . . . . . . . . . . . . 18 Procedure . . . . . . . . . . . . . . 18 Experimental Manipulations . . . . . . . . . . . . 20 Scoring the Holtzman Protocols . . . . . . . . . . 22 RESULTS . . . . . . . . . . . . . . . . . . . . . . . 24 iv DISCUSSION . . . . . . . . . . . . . . . . . . The Barrier and Penetration Scores Discussion of the Questions . . . . . Question la . . . . . Question lb Question 2 Interpretation of the Penetration of Boundary Score . . . . . . The Correlational Analyses Implications for Treatment Areas for Further Research SUMMARY APPENDICES . . . . . Page LIST OF TABLES Table 1. Means and standard deviations for pretest and posttest Barrier scores . . . . 2. Means and standard deviations for pretest and posttest Penetration scores . . . . 3. Analyses of between group pretest boundary score differences . . . . . 4. Analyses of differences between groups in boundary score changes from pretest to posttest: Question 1 . . . 5. Analyses of differences between groups in boundary score changes from pretest to posttest: Question 2 . . . . . . . 6. Analyses of boundary score changes from pretest to posttest for each group individually . . . . . . . . 7. Correlations between pretest boundary scores and certain demographic characteristics 8. Correlations between changes in Barrier score from pretest to posttest and certain demographic characteristics for each group 9. Correlations between changes in Penetration score from pretest to posttest and certain demographic characteristics for each group vi Page 25 26 27 28 29 31 33 34 35 LIST OF FIGURES Figure Page 1. Schematic representation of the experi— mental design . . . . . . . . . . . . . . . 19 LIST OF APPENDICES Appendix A. Instructions to subjects B. Rules for scoring Barrier and Penetration responses . . . . . . . . . . . . . . C. Test scores and demographic data Page 64 69 75 INTRODUCTION In recent years, more and more clinicians have come to believe that psychotherapy can be effective in the treat— ment of schizophrenia. The study of methods of producing changes in the behavior of schizophrenic patients is, today, a major preoccupation in the fields of psychology and psy- chiatry. The present study empirically tests the basic psychotherapeutic premise developed by Des Lauriers (1962) in his work with schizophrenic children. Theory The ego and schizgphrenia. Loss of reality contact is one of the few aspects of schizophrenia on which there is overwhelming agreement. Cameron (1963) defined schizophrenia as a ” . . . regressive attempt to escape tension and anxiety by abandoning realistic interpersonal object relations " Maher (1966) stated that ”in clinical usage, it is common to regard loss of reality contact as the key difference between pathological patterns described as psychotic and those classed as neurotic.” This area of agreement also exists within the pre- dominantly structural approach the psychoanalysts have taken in their explanations of the schizophrenic behavior dis— turbance. While the hypotheses raised by different indi— viduals within the psychoanalytic school of thought are divergent in many respects, they all agree that there is a severe impairment in ego functioning and that this impairment leads to behavioral manifestations which are called schizophrenic (Bellak, 1966). Federn (1952) made an important contribution to the understanding of schizophrenia when he theorized that schizo— phrenia was not a withdrawal of object cathexis but a hyper— cathexis of objects. It was not the loss of the love object but was rather the patient's ego which had lost the cathexis. He saw the ego of schizophrenics as impoverished, inadequate— ly cathected, and unable to test reality. Federn introduced the concept of "ego boundaries” which were the center of perception of the "ego feeling.” This feeling distinguished everything that was a part of the ego from everything that was not. In schizophrenia the poorly cathected ego boundary breaks down resulting in an inability to correctly perceive reality. Thus, the schizophrenic patient is not someone who has withdrawn from the world and created a world of his own, but rather is essentially an individual who has lost the capacity to experience himself as real (Des Lauriers, 1962). The concept of the body ego. The idea that one's body is important for the establishment of personal identity is not a new one and has received considerable attention from workers in diverse areas of psychology. Schilder (1950) dealt specifically with the ap- pearance of the human body and its physiological, psycho— logical, and sociological determinents and consequences. Others, for example Gesell (1948) and Piaget (1963), empha— size bodily schemata in psychological processes in their theories of child development. Witkin's theory of psycho— logical differentiation includes the idea that ”Formation of the body concept must accordingly be viewed in the context of the total stream of psychological growth, and its study may teach us a good deal about individual development and functioning" (Witkin, 1965). Wapner and Werner (1965) based the development of their theory of perception of objects on the assumption that ” . . . there can be no perception of objects Iout there' without a bodily framework . . . " The experience of one's body has not been disregarded by the Existentialists either (e.g., Buytendjik, 1961; Strauss, 1952). Psychoanalytic theory has, of course, placed par— ticular emphasis on the importance of the body and the body ego. Freud believed that an individual's body played an im- portant role in bringing about the formation of the ego and its differentiation from the id. He stated that ”The ego is first and foremost a bodily ego . . . " (Freud, 1962). Federn (1952), Fenichel (1954), and Ferenczi (1926), as well as Freud, all emphasized that the individual's dis— covery of his own body plays a very special role in his dis- covery of reality. The body, by its capacity to experience both inner tension and stimulation from outside, is the main organ enabling the individual to work out the distinction between ego and non—ego. Reality, as an object of psycho— logical experience, comes into existence through a develop- mental process whereby the individual progressively deline— ates, differentiates and bounds himself by detaching himself from an 'outside' which he is then able to relate to as an object° The here—and-now experience of this external reality results from the fact that stimuli from the outside world are passing through a bodily ego boundary charged with a particular quality of sensation and bodily ego feeling. The continuing ability of the individual to relate to the outer world is dependent upon the maintenance of these boundaries. The outer world will remain evident only as long as the indi— vidual's bodily ego boundaries remain intact (Federn, 1952). Des Lauriers' theory of psychotherapy with schizo— phrenics. In the schizophrenic, the ego as a complex psycho— logical organization which unifies, integrates, and directs the various ego functions ceases to exist. However, the fact that the schizophrenic individual has lost his capacity to relate to reality does not mean that he lacks the libidinal ‘ and aggressive energies necessary to develop and maintain an ego.‘ The instinctual energies and their strivings for real gratifications are still present in the schizophrenic, just as are all the various ego functions. It is the cathexis, . the investment of these energies in his own bodily boundaries, which is lacking. The schizophrenic is not struggling to solve those conflicts which may be postulated to have precipitated his psychosis; he is struggling with and against the experience of being schizophrenic. He is attempting to make sense out of innumerable unintegrated experiences which are conflicting and contradictory because his various ego functions operate no longer as ego functions, but rather as unrelated and some— what independent mechanisms. His behavior, then, can be seen, not as an attempt to escape, or to withdraw, or to de— fend himself against intrapsychic conflict, but as a dis— organized, panic-stricken, and ineffective attempt to re— establish himself as real. Analysis of the schizophrenic's defense system would not lead to a conflict which, resolved, would make the schizophrenic behavior unnecessary. The defensive system broke down with the occurrence of the schizophrenic reaction. The individual's schizophrenic behavior is better viewed as coping behavior, attempts to cope with the schizophrenic ex- perience itself. Thus, an analysis of this sort would lead to a conflict which was a result of being schizophrenic, not the cause of the schizophrenia. Instead, the schizophrenic must reestablish the ability to distinguish himself from what is not himself. This experience depended originally on the narcissistic cathexis of his own bodily boundaries; and the self is ex— perienced as real only if such a cathectic investment is achieved and maintained. Because the primary model of reality, as a psychological experience, is the experience of the bodily self, as bounded, finite, limited in space, separated from what reaches it by transgressing such bodily boundaries, the focus of psychotherapy with a schizophrenic must be on helping him define his identity in terms of what has been called his body ego, i.e., as a physically and spatially separated entity. The Rorschach and Body Image Fisher and Cleveland (1958) felt that because the process of separating one's body from the world was funda- mental in the development of personal identity, the character of an individual‘s body image boundary should provide im— portant information about his adjustment strategies. Knowing that body experience could influence the perception and interpretation of unstructured stimuli, they believed that body image would be reflected in perception of Rorschach ink- blots. Consequently, they developed a new content scoring system for projective responses to the Rorschach to measure and describe body image boundary. This system is based on the properties attributed to peripheries of inkblot percepts. Fisher and Cleveland's methods of Rorschach scoring. Fisher and Cleveland (1958) developed the Barrier score index to evaluate boundary definiteness of the body image. This index is an indication of the degree to which definite structure, substance, and surface qualities are assigned to inkblot images. Operationally, the barrier score equals the number of elicited responses that are characterized by an emphasis upon the protective, containing, decorative, or covering functions of the periphery, e.g., vase, kettle or pot, cave with rocky walls, person covered with a blanket, etc. The degree of boundary definiteness is directly re— lated to the number of Barrier responses produced. A Penetration of Boundary score was also developed. It was based on the number of all inkblot responses which emphasize the destruction, evasion, or bypassing of a boundary, e.g., sword piercing armor, x-ray of the body, volcano erupting, building burning, etc. Presumably, the higher the Penetration score is, the less definite is the body image boundary. This score often has a low and some- times negative relation to the Barrier score. Fisher and Cleveland's rules for scoring both the Barrier and Pene- tration scores appear in more detail in Appendix B. Fisher and Cleveland (1958) established the following norms based on a sample of 200 normal college students: median Barrier score = 4 with a range of O — 12; median Penetration score = 3 with a range of O - 8; mean Barrier score = 4.1 with a standard deviation of 2.1; mean Pene— tration score = 3.2 with a standard deviation of 1.6. Inter— scorer reliabilities for the two scores have been found to cluster in the high .80's to the high .90's (Fisher & Cleveland, 1958; Holtzman,_st_a1., 1961). Adequate test— retest reliability has also been demonstrated (Daston & McConnell, 1962). Neither of the scores was found to be re- lated to verbal productivity, verbal facility, or intel— lectual level (Fisher & Cleveland, 1958). Some writers have criticized the Barrier and Pene— tration scores. Eigenbrode and Shipman (1960), for example, state that ”the scoring rules, in detail, have not been published," question the stability of the scoring because of the small size of the modal Barrier score (4) and the wide range (0—12), and believe that many of the major scoring categories seem arbitrary in regard to which Rorschach re- sponse fits which category. Cassell (1964) criticized the scores on the basis that both of them refer to the body boundary and advanced the notion that a more useful conceptualization of the body image might be ”boundary” and ”interior.” Consequently, he developed the body interior awareness scale which measures the degree to which a person's body interior is dominant in his body conception. Mednick (1959), in his review of Fisher and Cleve- land's Body‘Image and Personality (1958), criticized the lack of research into what relationships exist between boundary scoring and more traditional Rorschach scoring. He also questioned whether or not the newer scoring was needed at all. Empirical findings with the boundary scores. A number of studies have investigated the relationship between the boundary indices and how an individual copes with stress. Fisher and Cleveland (1958) and Landau (1960) found that individuals who indicated definite body boundaries by their Rorschach percepts dealt relatively more efficiently with the stress of present or impending body disablement than did individuals who indicated indefinite boundaries. McConnel and Daston (1961) found that the favorableness with which females viewed their pregnancies was positively linked with their Barrier score, and that following delivery the Pene— tration score declined significantly. Brodie (1959) found Barrier scores to be negatively correlated with emotional expressivity under induced laboratory stress. Davis (1960) investigated the relationship between Rorschach Barrier scores and physiological reactivity to stress. He found that the high Barrier group responded primarily in the 10 exterior measures of stress while the low Barrier group re— sponded in the interior measures of stress. In small group behavior studies, the boundary indices have been found to be related to spontaneous expressiveness, independence, promotion of group goals, warmth and friendli- ness, and willingness to face hostility (Fisher and Cleveland, 1958), number of sociometric nominations (Cleveland and Norton, 1962), and to ease of communication, management of self, and self identity as evaluated by interviewers in a 50 minute interview (Fisher, 1964). Fisher and Cleveland (1958), Cleveland and Fisher (1960), Williams and Krasnoff (1964), and Cassell (1965) have all found a consistent relationship between body atti- tudes as measured by the Rorschach and somatic symptom for- mation. Individuals with external somatic symptoms have tended to evidence higher Barrier and lower Penetration scores, while those with internal somatic symptoms have had higher Penetration and lower Barrier scores. Two general themes seem to emerge from these varied studies. First of all, boundary definiteness appears to be related to "good adjustment" in the sense that those indi— viduals with substantial boundary definiteness evidence greater competence in day—to—day type living skills and are better able to cope with stressful situations. Second, indi- viduals with an external body awareness focus tend to exhibit 11 greater boundary definiteness than those people whose focus of somatic awareness is primarily internal. Of particular interest for our present discussion are two different sets of studies, the first of which re— lates schizophrenia and the boundary indices, the second of which examines the issue of whether the boundary indices can be influenced by focusing awareness directly on the body. As was mentioned in the theory section, schizophrenia is characterized by vague body boundaries. In line with this, Fisher and Cleveland (1958) found the Barrier and Penetration scores discriminated schizophrenics, who had low Barrier and high Penetration scores, from normals and neurotics, who had high Barrier and low Penetration scores. There were no differences between the normals and the neurotics. Similar findings have been obtained using Holtzman inkblots (Holtzman, et al., 1961; Reitman and Cleveland, 1964). Cleveland (1960) also examined the Rorschach records obtained from schizo— phrenic patients both upon their admission to the hospital and upon their discharge. Those patients who had been rated as improved or well showed a significant decline in their Penetration scores. Reitman and Cleveland (1964) investigated the change in body image, as measured by the boundary scores, for neurotics and schizophrenics following sensory isolation. Twenty neurotics and 20 schizophrenics were administered the inkblot test before and after being exposed to sensory 12 isolation conditions for four hours. A schizophrenic con— trol group also received pre- and post-tests, but without the isolation conditions intervening. While no changes oc- curred in any of the scores for the control group, there were significant changes in both experimental groups. Schizophrenics obtained higher Barrier and lower Penetration scores following isolation while the neurotics obtained de— creased Barrier and increased Penetration scores. In ad- dition, following the isolation conditions, schizophrencs evidenced increased tactile sensitivity and decreased body size judgements whereas the neurotics evidenced decreased tactile sensitivity and increased body size judgements. For the schizophrenic patient, in other words, increased boundary definiteness was accompanied by increased body awareness as evidenced by increased tactile sensitivity and less expansive body size judgements (the schizophrenics generally overestimated body size initially). Thus, con— sistent relationships were demonstrated between changes in the body image, in skin sensitivity, and in perception of body size. Three recent, essentially identical studies (Fisher and Renik, 1966; Renik and Fisher, 1968; Van De Mark, 1968) dealt with the question of whether or not producing in— creased somatic awareness through directly focusing on bodily sensations could influence perception on the Rorschach ink- blots. In the most comprehensive of the three, and hence 13 the one elaborated upon here, Van De Mark (1968) utilized four experimental and two control groups, each group con- sisting of 20 normal undergraduate college students. The four experimental groups differed on two dimensions: 1. focus of awareness——either internal or external; 2. mode of inducing this awareness——either through direct somatic or cognitive means. Two of the measures used to evaluate the effects of his experimental manipulations were the Barrier and Penetration scores. His results indicated no differences between the two different modes of induction. Inducing bodily awareness achieved the same results regardless of whether it was induced by somatic or cognitive means. Van De Mark found that Penetration scores were highest in the internal awareness group, lowest in the external awareness group, and median in the control group. He also found that Barrier scores were highest for the external awareness group, next highest for the internal awareness group, and lowest for the control group. The results were conclusive in demon— strating that the boundary indices can be directly influenced by increasing body awareness and that these scores can be differentially affected depending upon the focus of this in- duced somatic awareness. STATEMENT OF THE PROBLEM Development of the Present study Reality exists for the individual because he has separated himself from what is not himself. The schizo— phrenic individual has lost contact with reality because he has lost the ability to cathect his own bodily boundaries, that is, to maintain this separateness. Thus, in providing the rationale for his method of treatment, Des Lauriers (1962) stated that "it should be possible to conceive of the process of recovery in schizophrenia as a progressive defi- nition and demarcation of the schizophrenic's ego boundaries through a systematically increased cathexis of his bodily limits and his bodily self.” The studies conducted by Fisher and Cleveland (1958) and Cleveland (1960) lend support to this conception of schizophrenia and the recovery process. It will be recalled that in the Fisher and Cleveland (1958) study schizophrenics were differentiated from neurotics and normals on the basis of their low Barrier and high Penetration scores and that in the Cleveland (1960) study improved schizophrenics achieved a decrease in the Penetration score. Hence, we are provided with some empirical support for the theoretical conception 14 15 that schizophrenics exhibit a lack in boundary definition and that as they improve their capactiy to define boundaries increases. To achieve this increased definition of ego boundaries, Des Lauriers (1962) attempts to stimulate in the schizophrenic patient "reactions of interest in, and at- tention to his bodily self as the separating boundary from what is not himself, and as the primary instrument of his contacts with and actions on his environment . . . the patient's attention is brought not only to the conscious awareness of the surface of the body but to each and every experience with the environment which, through stimulation, pleasant and unpleasant, affects each part of his body.” A crucial question for Des Lauriers' method of treat- ment is whether directly focusing the patient's awareness and attention on his own body and its separateness can ef— fect this reestablishment of boundaries. The recent studies by Fisher and Renik (1966), Renik and Fisher (1968), and Van De Mark (1968) imply, at least, that it can. They demon— strated, with normal subjects, that focusing on somatic stimuli leads to subsequent changes in the boundary definite- ness indices. However, at least one study (Reitman and Cleveland, 1964) showed that imposing the same conditions (e.g., sensory isolation) upon schizophrenics and normals resulted in op— posite alterations in these boundary indices for the two 16 groups. The present investigation was directed at establish- ing the validity of Des Lauriers' premise that focusing on body image can affect boundary definiteness in schizophrenic individuals. The extent of the active involvement of the person focusing on the somatic stimuli may also be of some im- portance. Des Lauriers endeavors to get the schizophrenic individual to perceive his body ” . . . as the primary instru- ment of his contacts with and actions on his environment” (Des Lauriers, 1962). It is important for the schizophrenic patient not only to view his body as a separate entity, but as a separate entity over which he has control and with which he can affect his environment. This study also en— deavored to investigate the differential effects of this di— mension on reestablishing body boundaries. Des Lauriers places emphasis on the body because the way to establish the psychological experience of reality in the schizophrenic individual is to help him establish the ability to distinguish himself from what is not himself, to establish his separateness. Studies conducted by Wapner and Werner and reported in their book, The Body Percept, (Wapner and Werner, 1965), have shown that imagining oneself as ”fused with" or ”separate from” an object being viewed can affect the object"s perceived position in the visual field. Since the feeling of separateness can affect perception, it is possible that perception could affect the feeling of 17 separateness. This dimension, in terms of the type of stimu— lation one presents a schizophrenic patient, is thus an im- portant one in Des Lauriers' method of treatment. A further extension of the present study was to investigate what differ— ential effects stimuli differing along the fusion—separateness dimension have on the boundary indices. Summary of the Principal Questions to be Investigated Question 1 a. Can inducing somatic awareness in schizophrenic individuals influence the boundary indices ob- tained from Holtzman Inkblot Tests? b. Does the degree of active involvement effect the obtained boundary indices? Question 2 Do stimuli differing along the fusion- separateness dimension have differential ef— fects on the obtained boundary indices? METHOD Subjects The subjects were male inpatients at the Veterans' Administration Hospital in Battle Creek, Michigan. They were randomly selected from that population of patients under 36 years of age whose current diagnosis was ”schizophrenic reaction," by means of a table of random numbers. No patient with any diagnosed Central Nervous System pathology was used. The subjects were randomly assigned to the various experimental and control grOups. Fifteen subjects were as— signed to each of five different groups——two experimental groups in Question 1, two experimental groups in Question 2, and one Control group. The same Control group was used for comparison purposes in both parts of the study. The experi- mental design is presented schematically in the accompanying diagram (see Figure 1). Procedure In order to evaluate the effect of the experimental manipulations on the body boundary measures, a pre- and post— test design was utilized. Following the administration of the first 25 cards of the Holtzman Inkblot Test, Form A, 18 19 Question 1 (1a & lb) GROUP SOMATIC IMAGINATION CONTROL* N-15 N—15 N—15 Score pre— post- pre— post— pre— post Measure test test chg test test chg test test chg BARRIER PENETRAT. Question 2 GROUP SEPARATENESS FUSION CONTROL* N=15 N=15 ' N=15 Score pre- post- pre— post- pre— post- Measure test test chg test test bhg test test chg BARRIER PENETRAT. *This group and sets of scores is the same in both questions. There is, in fact, only one Control Group. FIGURE 1 SCHEMATIC REPRESENTATION OF THE EXPERIMENTAL DESIGN 20 each 5 underwent the experimental or control conditions ap— propriate for the group to which he had been assigned. The first 25 cards of Form B of the HIT were then administered to S. S underwent the entire procedure individually with E. For a detailed presentation of the instructions given to the subjects, see Appendix A. Experimental Manipulations Question 1a. Can inducing somatic awareness in schizophrenic individuals influence the boundary indices ob— tained from Holtzman Inkblot Tests? In order to investigate this question, the "Somatic” group of Question 1 is compared to the Control group. The Somatic group subjects participated in three different activities, each lasting approximately five minutes. S was asked to focus his attention on body sensations at all times. The conditions were as follows: 1. Stretching exercises--S was requested to do six different stretching exercises. Each exercise was for a 25 second duration followed by a 20 second relaxing period. 2. Lifting weights——S was requested to do five differ— ent exercises with two lO—pound dumbbells. Each exercise was for a 25 second duration followed by a 20 second resting period. 3. Bicycle riding——S was requested to ride a stationary bicycle for four minutes. Question 1b. Does the degree of active involvement effect the obtained boundary indices? 21 In order to evaluate this question, the "Imagination" group is compared with the Somatic group. In the Imagina- tion group, E briefly demonstrated the above exercises and asked S to imagine he was doing the exercises, and to focus his attention on how he thought his body would feel if he were actually doing them. At the end of each 25 second period, E asked S to indicate which parts of his body he would have used. Question 2. Do stimuli differing along the fusion—separateness dimension have differential effects on the ob- tained boundary indices? In order to investigate this question, the "Fusion” and ”Separateness" groups of Question 2 are compared. In the Fusion group, S was requested to do the following: 1. Lie on a soft air mattress for five minutes and then to describe the bodily sensations. 2. Hold his hands, one at a time, in a large con— tainer of water heated to approximately skin temperature for a period of one minute and to describe the sensations. 3. Write down as many similarities between himself and E as he could think of in a five minute period. In the Separateness group, s was requested to do each of the following: 1. Lie on a hard table for five minutes and then to describe the bodily sensations. 2. Hold his hands, one at a time, in a large con- tainer of cold water and ice cubes and to de— scribe the feelings. 22 3. Write down as many differences between himself and E as he could think of in a five minute period. The total time for the experimental manipulations in these two groups was, as in Question 1, approximately 15 minutes. Control Group. S was requested to look at a series of slides through an automatic table viewer for a period of 15 minutes. The slides consisted of pictures of flowers, landscapes, and automobiles selected such that their content did not represent either Barrier or Penetration responses. Scoring the Holtzman Protocols The Holtzman protocols of each S were coded so that the scorer was unable to identify to which group S belonged. Barrier and Penetration indices were computed for each S using the scoring method devised by Fisher and Cleveland (1958) and revised by Holtzman, et a1. (1961) for use with the HIT. These scoring systems are reproduced, in full, in Appendix B. In brief, however, they call for a score of one to be assigned to each response which meets the requirements of the measure being scored. Since response totals on the HIT are controlled by the instructions which call for one response per card, and since each response theoretically could be scored Barrier, or Penetration, or both, the possible score range on each index is 0 — 25. 23 Two scorers were used, each scoring approximately one-half the total number of protocols. An interrater re— liability coefficient was computed on a sample of 20 proto— cols scored by both scorers. The interrater reliabilities obtained were .97 for the Barrier score and .99 for the Penetration score. Both of these coefficients are within the range originally reported by Fisher and Cleveland (1958). RESULTS The Holtzman protocols were scored and score changes from the pre—test to the post-test were computed for each subject. The data in full detail along with some demographic data of importance appear in Appendix C. Mean pre— and post- test scores as well as standard deviations and mean score changes for the various groups are presented in Tables 1 and 2. The pretest boundary scores of the five groups were compared using the Kruskal-Wallis H test, a non-parametric one-way analysis of variance. The results of these analyses indicated that no significant differences in pretest scores existed among any of the groups (see Table 3). The boundary score change data for each question were also initially analyzed by means of the Kruskal-Wallis H test. Individual group comparisons were then conducted using the non—parametric Mann—Whitney U test. The results of these analyses are presented in Tables 4 and 5. Significant variation on the Barrier score occurred among the groups in both Questions 1 and 2. In Question 1, as indicated by the individual comparisons carried out be— tween the groups, this variation is due to the increase from 24 25 TABLE 1 Means and Standard Deviations for Pretest—Posttest Barrier Scores Group Pretest Posttest Difference X S.D. X S.D. Control 3.93 2.55 3.93 2.52 0.00 Imagination 2.87 2.20 3.20 2.81 +0.33 Somatic 3.00 2.17 6.00 3.25 +3.00 Separateness 4.73 2.40 7.46 3.62 +2.73 Fusion 3.20 2.78 5.47 3.02 +2.47 26 TABLE 2 Means and Standard Deviations for Pretest—Posttest Penetration Scores Group Pretest Posttest Difference X S.D. X S.D. Control 3.87 2.85 3.67 2.32 —0.20 Imagination 2.73 2.94 2.33 2.26 —0.40 Somatic 3.47 3.15 2.33 2.72 —1.14 Separateness 2.80 1.42 2.93 1.79 +0.13 Fusion 2.47 2.17 3.07 1.62 +0.60 27 TABLE 3 Analyses of Between Group Pretest Boundary Score Differences Measure Statistic Value Barrier H = 6.272 Penetration H = 3.323 28 TABLE 4 Analyses of Differences between Groups in Boundary Score Changes from Pretest to Posttest: Question 1 Statistical Comparison Barrier Penetration* value p* value p Kruskal-Wallis H: 11.92 .01 H: 1.14 n.s. Mann—Whitney Somatic x Control = 36.50 .001 = 87.50 n.s. Imagination x Control U=106.00 n.s. =105.50 n.s. Somatic x Imagination U= 47.50 .01 U: 97.50 n.s. *all probabilities are two-tailed. 29 TABLE 5 Analyses of Differences between Groups in Boundary Score Changes from Pretest to Posttest: Question 2 Statistical Comparison Barrier Penetration value p* value p* Kruskal-Wallis H: 8.93 .02 H: 2.09 .s. Mann-Whitney Separateness x Control U: 50.50 .01 U=lO4.50 .s. Fusion x Control U= 52.50 .01 U: 76.00 .12 Separateness x Fusion U=109.00 .s. U: 94.50 .s. *all probabilities are two-tailed. 3O pretest to posttest achieved by the Somatic group. The change in the Somatic group's score was significantly greater than that evidenced by either the Imagination or the Control group. In addition, the Imagination and Control groups did not differ significantly from each other. The individual comparisons between the groups in Question 2 indicated that the variation in Barrier score here is due to the increases from pretest to posttest achieved by both the Separateness group and the Fusion group. Both groups showed increases which were significantly greater than that shown by the Control group. The Separateness and Fusion groups did not differ significantly from each other in their pretest to posttest change on this measure. The analyses of variance conducted on the Penetration score changes for both Questions 1 and 2 yielded non- significant H values which indicated no variation of signifi— cance existed among the groups on this measure. Individual group comparisons, as was then to be expected, subsequently yielded non-significant probabilities as Well. The Fusion versus Control comparison in Question 2, however, did yield a difference which approached statistical significance. When two-tailed sign tests were carried out on the boundary score changes manifested by each group individually, similar results were obtained (see Table 6). These analyses again indicated highly significant Barrier score changes in the direction expected from both theory and previous research. 31 TABLE 6 Analyses of Boundary Score Changes from Pre— test to Posttest for Each Group Individually Group Barrier Penetration * Increase Decrease p* Increase Decrease p Control 5 7 n.s. 4 5 n s Imagination 5 6 n.s. 5 7 n s Somatic 12 l .004 4 9 n s Separateness 11 2 .022 6 6 n s Fusion 11 l .006 9 2 .066 *all probabilities are two-tailed. 32 The Somatic, Separateness, and Fusion groups all evidenced significant increases in Barrier scores from pretest to post— test. Likewise, again none of the Penetration score changes achieved statistical significance. This time, however, the increase in Penetration score from pretest to posttest at- tained by the Fusion group closely approached the .05 level of significance. The various groups differed among themselves on some of the demographic variables, particularly "total length of hospitalization” (see mean values presented in Appendix C). In order to determine if any of these characteristics of the sample population were related to the boundary indices, these data were correlated with the pretest boundary scores. As is indicated in Table 7, only one of these coefficients was of statistical significance. The Penetration score was positively correlated with the age of the patient at the time of his first hospitalization. In addition, because it was felt that some of these characteristics might be related to the amount of change ex— hibited on the boundary measures, coefficients were computed between them and the amount of pretest to posttest score change. Since each group underwent different experimental manipulations, the coefficients were computed for each group separately. These data are presented in Tables 8 and 9. One further correlation coefficient was computed. Fisher and Cleveland (1958) originally predicted that 33 TABLE 7 Correlations between Pretest Boundary Scores and Certain Demographic Characteristics Measure Age Education Age of first Number of Total length Hospitali- Hospitali— of Hospitali— zation zations zation Barrier — ll .14 .10 .11 .14 Penetr. — 09 01 .21* .02 .05 *p < .05 34 TABLE 8 Correlations between Changes in Barrier Score from Pretest to Posttest and Certain Demo- graphic Characteristics for Each Group Group Age Education Age at first Number of Total Length Hospitali— Hospitali- of Hospitali— zation zations zation Control .41 .06 .17 —.O3 .30 Imagin. .06 .20 .18 -.32 .07 Somatic .25 .11 -.21 .02 .58* Separ. —.15 -.16 .15 -.08 .14 Fusion .24 —.06 —.02 -.09 .35 *p < .025 35 TABLE 9 Correlations between Changes in Penetration Score from Pretest to Posttest and Certain Each Group Demographic Characteristics for Group Age Education Age at first Number of Total Length Hospitali- Hospitali- of Hospitalir zation zations zation Control .46 .08 .58** .16 -.1o Imagin. .05 .14 .06 .02 —.05 Somatic .08 —.39 .06 .39 .02 Separ. -.29 .28 .79**** —.62*** -.15 Fusion .64*** —.17 .24 —.11 .40 *p .05 ** 025 *** .01 *‘kir‘k < 005 36 Barrier and Penetration scores would be negatively related. Contrary to their expectations, they found that with normal groups the two scores were positively correlated. They did not present data for psychotic populations. Consequently, a correlation coefficient indicating the relationship between the Barrier and Penetration scores for the present schizo— phrenic sample was computed using the pretest scores of all 75 Ss. A product-moment correlation of +.35 was obtained which is significant at the .005 level. The positive re- lationship between the two scores thus appears to exist for schizophrenic subjects as well as for normals. DISCUSSION The Barrier and Penetration Scores Fisher and Cleveland (1958) originally developed their two boundary indices on the assumption that the at— tributes of images elicited by the inkblots are correlated with differences in the way in which individuals perceive their body boundaries. They felt that the Barrier score would reflect the boundary dimension at a level of positive assertion of boundary definiteness, while the Penetration of Boundary score would tap feelings of boundary breakdown and fragility. They predicted that since, theoretically, the Barrier score measures definiteness and firmness of boundaries and the Penetration score measures penetrability of boundaries, the two scores should be negatively corre- lated. This did not turn out to be the case. The statisti— cally significant correlations between the two measures ob— tained by them were all positive (Fisher and Cleveland, 1958). In addition, while their preliminary studies indi- cated a definite relationship between body boundary and the Barrier score, the Penetration score proved to have no speci— fiable relationship to body boundary within their ”normal" 37 38 groups. They concluded that the Penetration score did not neatly represent the opposite of the Barrier score, at least not for normal subjects. Therefore, they restricted their measure of body—image boundary definiteness entirely to the Barrier score in their subsequent research with nonpatho— logical groups. The present study also indicates that a positive re— lationship exists between the Penetration and Barrier scores, in this case for a schizophrenic sample. Furthermore, it is evident from the data that the experimental manipulations had differential effects on the two measures. Thus, Fisher and Cleveland's (1958) conclusion that the two measures are not opposites appears to apply for non—normal populations as well. This causes some confusion regarding the exact sig- nificance, or meaning, of the Penetration score. As a result, the questions raised in the Introduction of this study will be dealt with here in terms of the Barrier score alone, and the issue of the meaning of the Penetration score will be examined in more detail later. Discussion of the Questions Question 1a. Can inducing somatic awareness in schizo- phrenic individuals influence the boundary indices obtained from Holtzman Inkblot Tests? The answer to this question is an unequivocal "yes.” Schizophrenic patients who engage in active physical exer— cises evidenced a highly significant increase in their 39 Barrier scores from the pretest to the posttest. Further support for this conclusion is provided by the significant increases in Barrier scores obtained by the patients in both the Fusion and Separateness groups of Question 2. Both of these groups also focused their attention on somatic stimu— lation. While the quality and type of stimulation received in each instance varied, the subsequent increases in Barrier scores obtained by each of the groups were no less evident. These results are congruent with the recent studies of Fisher and Renik (1966), Renik and Fisher (1968), and Van De Mark (1968), all of which demonstrated that boundary definiteness in normal Subjects could be influenced by focus—' ing their attention on their bodies. In addition, the re— sults provide direct empirical support for Des Lauriers' (1962) premise that the schizophrenic can be helped to re- cathect his own boundaries by forcing him to be aware of his body. Question 1b. Does the degree of active involvement effect the obtained boundary indices? The answer to this question is also ”yes." The Barrier scores of the Somatic group increased significantly more than did the Barrier scores of the Imagination group, whose Barrier scores evidenced no changes from the pretest to the posttest. In further support of this conclusion is, again, the Barrier score increases achieved by the two ex— perimental groups of Question 2. Both of these groups 4O engaged in activities which required, for the most part, a passive involvement, but none—the-less an involvement which entailed an actual interaction with the external world. The purely cognitive, non-experiential, approach was not effective in increasing boundary definiteness in these schizophrenic patients. This is in marked contrast with re— sults obtained using normal subjects (Van De Mark, 1968) which indicated that, with normals, an imagination condition is just as powerful as an actual experiential one. It would thus seem that the actual experience of the body as an entity in opposition to an external reality is an important factor with schizophrenic individuals. Two possible reasons for this difference between schizophrenic and normal Subjects are readily apparent. The first is that the normal subject is already sufficiently cognizant of his body. The schizophrenic's awareness of his own body, on the other hand, is so vague and diffuse that it is difficult for him to imagine the effects certain types of stimulation would have on it. In fact, many of the patients frequently gave completely inaccurate answers when asked what parts of their body would have been used in the various exercises. A second possibility is that the imagination task was one in which these schizophrenic patients could avoid doing what was asked of them while at the same time appearing as though they were complying with the instructions. 41 One would assume that normal subjects would be much less likely to engage in this type of avoidant behavior. However, regardless of the reason for the failure of the purely cognitive approach, it appears evident that an actual experiencing of stimulation which can be neither avoided nor ignored appears necessary to effect a change in the schizophrenic's boundary definiteness. As such, the re- sults provide empirical support for the premise that the schizophrenic's experiential involvement is an important factor in recathecting boundaries. Question 2. Do stimuli differing along the fusion- separateness dimension have differential effects on the obtained boundary indices? The answer to this question is "no." As long as the stimulation focuses the individual's attention on his body, it results in an increased definiteness of boundaries. Given the present experimental conditions, this does not seem unreasonable. Regardless of whether the bed was hard or soft, the subject was made aware of the physical sensations involved in lying on it. Regardless of the water temperature, the subject was made aware of his hands in the water. Re- gardless of whether the subject Was describing similarities or differences between himself and the experimenter, he was made to be aware of his own characteristics. Nevertheless, there does seem to be an intuitively logical trend in the mean Barrier score changes. There were 42 no changes for the Control and Imagination groups. There were, then, increasing changes from the Fusion group to the Separateness group to the Active Somatic group. A post-hoc analysis indicated that these latter three groups did not significantly differ among themselves. Nevertheless, this trend might indicate a relative difference in the strength of the effect achieved in each instance. In addition, as will be discussed presently, the different approaches had a slight differentiating effect on the Penetration score. Interpretation of the Pene— tration of Boundary Score Fisher and Cleveland (1958) originally predicted that the Penetration of Boundary score would be the inverse of the Barrier score. Instead, they found that the two measures were positively related. A positive correlation be— tween the boundary indices was found for the present schizo- phrenic sample as well. In one respect, perhaps, a positive relationship should have been expected. The penetration of a boundary, or the dissolution of one, is evidence of the individual's ability to conceive of the existence of boundaries, which is precisely what is reflected, at least in part, by the Barrier score. It would seem, then, that at least a slight positive relationship ought to exist almost by definition alone. There is another factor, however. which is probably of more significance in the determination of the positive 43 relationships which have been obtained. At one point in their book, Body Image and Personality, Fisher and Cleveland (1958) remark that the unique Penetration responses fre- quently given by schizophrenic patients point up their feel- ings of helplessness, panic, and anxiety about their bodies. This definition suggests an affective component of body per— ception, and probably an affective component made up of more than one factor. The first of these factors is anxiety about the body's integrity. In this light it must be noted that two of the three ”normalll groups on which Fisher and Cleveland (1958) got positive correlations between the two measures were those with dermatitis and those with ulcerative colitis—- both groups whose members might well be very aware of their bodies but nonetheless have some doubts or anxieties about their integrity. But, what about the present schizophrenic sample? The majority of these patients were chronic schizophrenics and all had been in the hospital at least two months prior to the testing. These patients can be assumed to have made some minimal adjustment. We can speculate that they are trying to preserve what definiteness they have attained but live in constant fear of losing it again, not being con— vinced of their ability to maintain it. In addition, those who are most aware of their bodies at this point are probably those who are most uncertain about them. 44 Anxiety as a factor can also explain, at least in part, why stimulation which fostered an increase in aware— ness of bodily limits, as was evidenced by increases in Barrier scores, was not sufficient to cause appreciable changes in the Penetration score. A brief, isolated ex— periencing of one's body, while momentarily recathecting bodily boundaries, provides no assurance that those boundaries are either stable or impregnable. Within this line of thought, it must be noted that the one change in Penetration score which approached statistical significance was in the Fusion group, and this was an increase, not a decrease. It is somewhat easier to create anxiety about the body than it is to allay it. In addition, it must also be noted that all of the patients who participated in this study were being main— tained on heavy doses of tranquilizers. If, as is being sug— gested here, anxiety is a major factor represented in the Penetration score, this medication no doubt dampened any ef- fects which the experimental manipulations had, or might have had, on the measure. Support for this contention is contained in Cleve— land's (1960) study. In this study, newly hospitalized schizophrenics were tested immediately following admission. They were then placed on tranquilizers in a double blind drug study and subsequently retested after 5 and 13 weeks. There was no Barrier score change but those patients rated 45 as improved evidenced a decrease in Penetration score. Cleveland interpreted this decrease as evidence of person— ality reorganization. However, the decrease in penetrability may just as well have been a consequence of the drop in anxiety brought on by the tranquilizers. The Penetration score as representative of an af— fective component of body perception contains a second factor of note. The penetration of a boundary generally in— volves the existence of an outside force which is effecting the penetration, as well as one's own feelings of helpless— ness in the face of that force. Fifteen minutes of induced somatic awareness of his own body, may not be sufficient time to convince him of his own control over it or over out- side forces impinging upon it. With this in mind we might look at the Penetration score changes for those groups which achieved Barrier score changes. The trend is an interesting one. The condition which fostered activity under the patient's own control, the Active Somatic condition, resulted in both the largest in— crease in Barrier score and a decrease in Penetration score. The two groups which participated in rather passive con- ditions during which things were done to them increased in Penetration scores. Furthermore, the Fusion condition, which attempted to minimize definiteness of boundaries while at the same time fostering awareness of them, resulted in the 46 lowest Barrier score increase and showed the highest Pene- tration score increase. Thus, the trends in the data tentatively support the interpretation that the Penetration score reflects feelings of anxiety over the body's integrity and lack of felt con— trol over what happens to it. In addition, it seems that these feelings are probably altered, particularly when in the direction of the alleviation of these feelings, more slowly than is simple awareness of the body itself. The Correlational Analyses A number of the correlation coefficients computed between the boundary scores and the demographic character— istics were statistically significant (see Tables 7, 8, & 9). Only one of these involved the Barrier score and this was be— tween the Barrier score change and the total length of hospitalization. The longer the patient had been hospital- ized, the greater was the increase in his Barrier score following the Somatic condition. This is possibly due to the fact that this hospital is, in large part, custodial. Many of the older patients have become quite apathetic and, consequently, for them this was the most physical stimulation they had received in a very long time. However, a great deal of weight ought not to be placed on this one signifi— cant correlation in view of the number of coefficients (30) involving the Barrier score which were computed. 47 Three of the six statistically significant corre- lations computed between the Penetration score and the demo— graphic characteristics involved the category of age at first hospitalization. On the pretest, the older the patient was at the time of his hospitalization, the greater was his Penetration score. Similarly, for the Separateness and Control groups, the older the patient when first hospitalized, the more his Penetration score was likely to increase from pretest to posttest. While no explanations for the existence of these re— lationships are readily apparent, we might speculate about a few of them from the vantage point of a process-reactive conceptualization of schizophrenia. Higgins (1964) noted that the reactive schizophrenic has good affect available to him while the process schizophrenic, on the other hand, exhibits flat affect. We can assume that the patient who is hospitalized for the first time at a later point in his life has had a better premorbid adjustment. This would mean he would more likely fall at the reactive end of the continuum. As such, this patient would have more affect, including anxiety, available to him, and hence be more able, and likely, to exhibit an increase in his Penetration score. The significant correlation between Penetration score change and the number of hospitalizations could be congruent with this conceptualization as well. The patient exhibiting fewer number of hospitalizations might also be expected to 48 fall at the reactive pole of the process-reactive continuum. Hence, he, too, would be more likely to achieve a Pene— tration score increase. This is highly speculative, however, insofar as often those patients with the fewest number of hospitalizations have been institutionalized the longest. For example, one patient with only one hospitalization had been continuously hospitalized for the past 15 years. In the Fusion and Control groups, the older the patient was, the more probable was a Penetration score in— crease. This could be because the older patient is more likely to have made some minimal adjustment to his circum- stances. As such, the experimental conditions may have been successful in disturbing this adjustment and regenerating anxiety that had previously been suppressed. Implications for Treatment Clinicians have long been impressed by, and con— cerned with, the prominence of the body and body image in the schizophrenic process. Body image distortions which oc— cur particularly frequently early in the breakdown process have long been vividly documented. Much less well docu— mented has been the role the body plays in the recovery pro- cess. However, this, too, has been observed and recorded by some clinicians, mostly those who have worked with schizo- phrenic children. 49 Bender (1952), for example, pointed out the im— portance of establishing the reality of a fundamental body image. Bettelheim (1950), in commenting upon the importance of the body to his schizophrenic children, mentioned that "one basis for development of ego is that the child is forced to recognize the body as something separate from the rest of the world, and at the same time as something that is subject to voluntary, conscious control.” Des Lauriers (1962) has probably placed the most emphasis on the importance of the body in the recovery pro— cess. He based his treatment approach on Federn's notion that schizophrenia involves a lack of cathexis of bodily ego boundaries and hence, theorized that "it should be possible to conceive of the process of recovery in schizophrenia as a progressive definition and demarcation of the schizophrenic's ego boundaries through a systematically increased cathexis of his bodily limits and his bodily self.” The studies conducted by Fisher and Cleveland (1958) and Cleveland (1960) lend some empirical support to this con- ception of schizophrenia and the recovery process. It will be recalled that in the Fisher and Cleveland (1958) study schizophrenics were differentiated from neurotics and normals on the basis of their low Barrier and high Penetration scores and that in the Cleveland (1960) study improved schizophrenics achieved a decrease in the Penetration score. 50 To achieve this needed increased definition of self, Des Lauriers (1962) attempts to stimulate in the schizo— phrenic patient ”reactions of interest in, and attention to his bodily self as the separating boundary from what is not himself, and as the primary instrument of his contacts with and actions on his environment . . . " The results of the present study provide some empirical support for his major treatment contention that inducing somatic awareness can help the schizophrenic individual to redefine himself, that is, to recathect his own boundaries. Inducing somatic aware— ness in schizophrenic patients through a variety of means re- sulted in significant increases in Barrier scores. However, assuming the Penetration of Boundary score to be indicative of feelings of vulnerability, there is some question as to whether simply inducing somatic aware— ness has any immediate therapeutic effect in reducing anxiety about the body. In a single 15 minute session, increasing body definiteness did not systematically decrease feelings of vulnerability. In fact, in one condition (Fusion) the Penetration score increased even though the Barrier score also increased. The study by Cleveland (1960) mentioned above has indicated that, presumably, penetrability goes down with im— provement in the patient. It may be that repeated experi— encing of body boundaries as evident and stable is necessary for alleviation of this bodily anxiety to occur. In accord 51 with this, Bettelheim (1950) noted that in his schizophrenic children "the fear that their bodies are in poor working con— dition persists long after the disturbance has dis— appeared . . . the fear that they may be unable to control the movements of the body usually persists much longer than their actual failure to do so." There is some suggestion that these feelings of vulnerability are closely related to the individual's per— ception of his external environment as well. Federn (1952) stated that schizophrenia involved a hyper-cathexis of ob- jects as well as a lack of boundary cathexis. And, as we have discussed, penetrability reflects the existence of out— side forces over which the schizophrenic experiences no feeling of control. A complementary treatment approach might then be to minimize the number of cathectable objects in the patient's environment and to make those present as predictable as possible. Support for this is provided by Reitman and Cleveland (1964) who found that Barrier scores of schizophrenics went up and Penetration scores went down following sensory deprivation. Des Lauriers (1952) empha- sizes this, too, when he indicates that the therapist must be a consistent object. While the results are far from definitive, there also appears to be a trend in the data indicating that ex- periences which emphasize the patient's control over his body are the most effective. This type of experience resulted 52 in the highest increase in boundary definiteness and a de— crease in penetrability. This is, of course, congruent with Des Lauriers' position as well as the position of others who emphasize the schizophrenic's concern with con— trolling himself and his environment, and his need to learn to do so. The cognitive approach used in the present study did not prove to be a successful way in which to stimulate boundary awareness. This failure probably indicates not so much that a purely cognitive treatment orientation is doomed to failure, but rather emphasizes that which has been dis— covered by most therapists who have been effective in treat— ing schizophrenic patients. The therapist must intrude upon the patient; there must be no way the patient can ignore the stimulation; he must be forced to be aware. Areas for Further Research The present research raises at least as many questions as it answers. The first question, which arises in light of the fact that induced somatic awareness can in— deed increase boundary definiteness, is "how long does the effect last?” The posttest in the present study was con— ducted immediately following the experimental conditions. That the effects achieved were as dramatic as they were is, in and of itself, remarkable. However, it would be 53 unreasonable to expect that an isolated 15 minute session would have any long term effect. Assuming the temporary nature of the effect raises a second question. "Would a consistent program of induced somatic awareness carried out over time result, as Des Lauriers' theory would lead us to assume, in a stabilized increase in boundary definiteness?" And, if so, what are some of the important parameters of such a program? For ex- ample, would the consistency with which such a program was carried out, in terms of such things as regularity of the sessions and predictability of the stimulation received, be an important variable? Would keeping the patient in an iso— lated and restful state between sessions be of benefit, as both theory and the sensory deprivation findings might give us cause to expect? Is it important for a program such as this to be an interpersonal one? An issue of particular concern is raised when the magnitude of change on the Barrier score obtained by the different groups is compared to the amount of subject activity demanded by the various between—test tasks. The magnitude of the Barrier score increases parallels the amount of activity called forth by these various tasks. There is, thus, a possibility that it is not somatic awareness which is responsible for changes in boundary definiteness, but activity per se. This possibility needs to be tested. 54 Another area of interest concerns the role of ex- perienced control. Clinicians such as Des Lauriers and Bettelheim believe that the individual's perception of his body as something over which he has control is an important step in the recovery process. The trends in the present data, as mentioned previously, indicate that experiences which emphasize the patient's control over his own body seem to be the most effective in reestablishing boundaries. As- suming that this reestablishment of boundaries is an integral part of the recovery process, the present results provide some support of an intermediate nature for this position. More definitive evidence is still needed, however. A more precise definition of the Penetration of Boundary score is of significance to future research into the recovery process. Is it, as was suggested here, really a measure of feelings of vulnerability or bodily anxiety? ‘ If so, would a consistent program of induced somatic aware— ness which resulted in a stabilized increase in body definite- ness result in a subsequent decline in the Penetration score as well? Is it related to feelings of helplessness in the face of outside forces and hence would it decrease with in— creasing feelings of experienced control? Another question which arises is ”what effects does a reintegration of body ego have on other areas of behavior, most specifically cognitive dysfunctioning?" Of particular interest is the phenomenon of over—inclusion first developed 55 operationally by Cameron (1939) and defined by him as ”the result of unstable ego organization which fails to limit the number and kind of simultaneously effective excitants to a relatively few coherent ones" (Cameron, 1963). The obvious prototype for adequate inclusion-exclusion is the accurate definition of one's own boundaries. If one can not dis— tinguish between me and not—me, which is the most basic categorization, how can he be expected to be able to dis— tinguish between this and that. Is boundary definiteness, then, related to over—inclusion and does over—inclusion de— crease with increasing boundary definiteness? SUMMARY Federn (1952) theorized that schizophrenia involves a lack of cathexis of ego boundaries. At the most basic level this consists of a lack of bodily ego cathexis. Start— ing with this postulate, Des Lauriers (1962) developed a theory of psychotherapy in which the central premise is that the therapist must stimulate in the schizophrenic patient "reactions of interest in, and attention to this bodily self as the separating boundary from what is not himself, and as the primary instrument of his contacts with and actions on his environment." The present study tested the proposition that in— ducing somatic awareness in schizophrenic patients can in— fluence their body image boundaries. Seventy—five hospital- ized schizophrenic males, 15 patients in each of five different groups, were given Form A of the Holtzman Inkblot Test (HIT), underwent the experimental or control conditions appropriate to the group to which they had been assigned, and were then administered Form B of the HIT. Only the first 25 cards of the Holtzman forms were used. The between—test conditions imposed on the different groups were as follows: 56 57 A Somatic group did a number of physical exercises which induced somatic awareness in the subjects under con— ditions which maximized their involvement in the process. Subjects in an Imagination group were asked to imagine what it would feel like to do those same exercises in order to induce somatic awareness in them while at the same time keeping their involvement minimal. A Separateness group underwent a number of sensory experiences calculated to induce somatic awareness and to maximize boundary definiteness. A Fusion group also underwent a number of sensory experiences which induced somatic awareness but which, at the same time, attempted to minimize boundary definiteness. Subjects in the Control group spent the time between tests viewing colored slides through an automatic desk—top viewer. The boundary indices developed by Fisher and Cleveland (1958), the Barrier and Penetration of Boundary scores, were used as measures of body boundary definiteness. Inducing somatic awareness in these schizophrenic patients increased their boundary definiteness as indicated by the significant increases in Barrier score achieved by the Somatic, Separateness, and Fusion groups. This was in— terpreted as direct support for Des Lauriers' theory. The attempt to increase boundary definiteness under conditions of minimal involvement, i.e., through cognitive means, 58 failed. This failure was interpreted as demonstrating not so much that a cognitive approach is not feasible but that stimulation which the patient can not avoid or ignore is necessary in dealing with schizophrenic patients. The Penetration of Boundary score was only slightly affected by the experimental manipulations. It was sug— gested that this score is a measure of an affective com— ponent of perceived boundary definiteness and is indicative of anxiety about body integrity and one's ability to control what happens to it. As such, it would not be much affected by isolated experiences, but would only be subject to stabilized, longer term gains in perceived definiteness. In addition, any effects the experimental manipulation had, or might have had, on this measure were no doubt depressed by the heavy tranquilization on which these patients were maintained. A highly significant correlation between the Barrier and Penetration scores was obtained for the pretest data. In addition, the pretest boundary scores as well as the boundary score changes from pretest to posttest were corre— lated with selected demographic characteristics of the sample. The Barrier score was found to be independent of these characteristics for the most part. The Penetration score, however, was found to be positively related to the patients' ages and their ages at first hospitalization. 59 Various ramifications of these results and their implications for the psychotherapeutic treatment of schizo- phrenic patients were discussed. In addition, areas of needed future research were delineated. REFERENCES Bellak, L. Schizophrenia: A review of the syndrome. New York: Grune and Stratton, 1966. Bender, Lauretta. Child psychiatric techniques. Spring- field, 111.: Charles C. Thomas, 1952. Bettelheim, B. Love is not enough. New York: Collier (paperback), 1965. Brodie, C. M. The prediction of qualitative characteristics of behavior in stress situations, using test— assessed personality constructs. Unpublished doctor— al dissertation, University of Illinois, 1959. Buytendjik, F. J. The body in existential psychiatry. Review of Existential Psychology and Psychiatry, 1961, 1, 149-168. Cameron, N. Schizophrenic thinking in a problem—solving situation. Journal of Mental Science, 1939, §§, 1012-1035. Cameron, N. Personality development and psychopathology. Boston: Houghton Mifflin, 1963. Cassell, w. A. A projective index of body interior aware— ness. Psychosomatic Medicine, 1964, 26, 172—177. Cassell, W. A. Body perception and symptom localization. Psychosomatic Medicine, 1965, 2], 171—176. Cleveland, S. E. Body image changes associated with person— ality reorganization. Journal of Consulting Psy— chology, 1960, 24, 256—261. Cleveland, 8- E., and Fisher, S. A comparison of psycho— logical characteristics and physiological reactivity in ulcer and rheumatoid arthritis groups: I. Psycho— logical measures. Psychosomatic Medicine, 1960, 22, 283—289. 60 61 Cleveland, S. E., and Morton, R. B. Group behavior and body image: A follow—up study. Human Relations, 1962, 15. 77-85. . *—— Daston, P. G., and McConnell, C. L. Stability of Rorschach penetration and barrier scores over time. Journal of Consulting Psychology, 1962, 2Q, 104. Davis, A. D. Some physiological correlates of Rorschach body image productions. Journal of Abnormal and Social Psychology, 1960, 69, 432—436. Des Lauriers, A. M. The experience of reality in childhood schizophrenia. New York: International Universities Press, 1962. Eigenbrode, C. R., and Shipman, W. G. The body image barrier concept. Journal of Abnormal and Social Psychology, 1950, pp, 450—452. Federn, P. Ego psychology and the psychoses. New York: Basic Books, 1952. Fenichel, 0. Early stages of ego development. In, Collected Papersz Vol. 2. New York: Norton, 1954. Ferenczi, s. The problem of the acceptance of unpleasant ideas: Advances in knowledge of the sense of reality. International Journal of Psychoanalysis, 1926, 1, 312-323. Fisher, S. The body boundary and judged behavioral patterns in an interview situation. Journal of Projective Techniques and Personality Assessment, 1964, 28, 181- 184. Fisher, S., and Cleveland, S. E. Body image and personality. Princeton: Van Norstrand, 1958. Fisher, S., and Renik, 0. Induction of body—image boundary changes. Journal of Projective Techniques and Personality Assessment, 1966, 29, 429-434. Freud, S. The ego and the id. New York: Norton (paper— back), 1962. Gesell, A. Studies in child development. New York: Harper, 62 Higgins, J. The concept of process—reactive schizophrenia: Criteria and related research. Journal of Ngrvous and Mental Diseases, 1964, 138, 9—25. Holtzman, H. W., Thorpe, J. S., Swartz, J. D., and Harron, E. W. Inkblot perception and personality. Austin: University of Texas Press, 1961. Landau, M. F. Body image in pgraplegia as a variable in ad— justment to physical handicap. Unpublished doctoral dissertation, Columbia University, 1960. McConnell, O. L., and Daston, P. G. Body image changes in pregnancy. Journal of Projective Techniques apgK Personality Assessment, 1961, 2;, 451-456. Maher, B. A. Principles of psychopathology. New York: McGraw—Hill, 1966. Mednick, s. The body's barriers go Rorschach. Contemporary Psychology, 1959, 4, 276-277. Piaget, J. The origins of intelligence in children. New York: W. W. Norton (paperback), 1963. Renik, O. D., and Fisher, S. Induction of body image boundary changes in male subjects. Journal of Pro— jective Techniques and Personality Assessment, 1968, 22, 45—49. Reitman, E. E., and Cleveland, S. E. Changes in body image following sensory deprivation in schizophrenic and control groups. Journal of Abnormal and Social Psychology, 1964, §§, 168—176. Schilder, P. The image and appearance of the human body. New York: International Universities Press, 1950. Strauss, E. W. The upright posture. Psychiatric Quarterly, 1952, 2p, 529—561. Van De Mark, S. N. Rorschach and body image: Induced somatic awareness and perception of ink blots. Un- published doctoral dissertation, University of Kansas, 1968. Wapner, S., and Werner, H. The bod percept. New York: Random House (paperback), 1965. 63 Williams, R. L., and Krasnoff, A. G. Body image and physio— Witkin, logical patterns in patients with peptic ulcers and rheumatoid arthritis. Psychosomatic Medicine, 1964, 2Q, 701-709. H. A. Development of the body concept and psycho— logical differentiation. In, Wapner, S., and Werner, H. (Eds.), The body percept. New York: Random House (paperback), 1965. APPENDIX A APPENDIX A Instructions to Subjects Well, Mr. , let me tell you why I asked you to come over to see me. I have a test of imagination here, an inkblot test. Have you ever taken an inkblot test before? Well, this is a fairly new one. It was just made in 1958 and we still don't know a whole lot about it. What I'm trying to do is to give it to as many people here in the hospital who are under 40 years of age as I can, just to see what kind of answers people give to the various cards. OK? Goodl Now what I do is give you the cards one at a time. You look at them and tell me whatever you think they might look like, represent, or be. You don't have to worry about right answers or wrong answers or what it's supposed to look like—-they're just inkblots and different people see different things. You'll probably see more than one thing on every card, but I only want one answer for each card. I'll be writing down what you say and I'll ask you a few questions about each one as we go along in order to try to see it the way you do. As you can see there are a lot of cards, and I do have a few other things I'd like you to do for me. So what I like to do is to go through half of the cards, take a 64 65 break and go do the other things, and then come back and finish this one up. Otherwise I think this one gets a little tedious. OK? OK, I guess that's all I need to tell you un— less you have some questions? Alright, then, let's get started, shall we? (Form A is administered) OK, let's take a break from this and if you'll come in the other room with me I have a few other things I'd like you to do for me. (Subject undergoes experimental conditions) OK, let's go back and finish up that first test, shall we. (Form B is administered) OK, Mr. , that's it unless you have any questions? Thank you very much for your time and cooper— ation. I appreciate it very much. 66 Instructions to Subjects during Experimental Conditions Control Group OK, Mr. . wa I'd just like you to watch these slides and relax for 15 minutes. Imagipation Group OK, Mr. . NOW I'd like to demonstrate some exercises for you. I'll do the exercise a couple of times and then I want you to imagine, just imagine, that you are doing that exercise. While you are imagining doing the exercise, I want you to focus your attention on how you think your body would feel. (Demonstration) OK, just imagine you are doing that exercise. Remember, focus your attention on how you think your body would feel at all times—- the feelings, physical sensations, and so on. Somatic Group OK, Mr. . Now I'd like you to do some exercises. I'll demonstrate the exercise a couple of times and then I want you to do that exercise. While you are do— ing the exercise, I want you to focus your attention on how your body feels. (Demonstration) OK, now I want you to do that exercise. Remember, focus your attention on how your body feels at all times——the feelings, physical sensations, and so on. 67 Separateness Group OK, Mr. . NOW I'd like you to lie on this table for a few minutes. That's a pretty hard table and while you're lying there I want you to focus your attention on how your body feels while you're lying on it. Think about the feelings, physical sensations, and so on. (after 4% minutes) OK, now would you describe to me as best you can how your body feels. Good: Now here I have a bucket of water. I would like you to put your hand in it and hold it there for a minute. While your hand is in the water, I want you to focus your attention on how it feels and describe all the sensations you experience. (this is done a second time with the other hand) Alrighti Now, if you will, I'd like you to take five minutes and write down all the ways you can think of in which you and I are different. For example, (E then points out a physical difference). Fusion Group OK, Mr. . New I'd like you to lie on this mattress for a few minutes. That's a nice soft mattress and while you're lying there I want you to focus your at- tention on how your body feels while you're lying on it. Think about the feelings, physical sensations, and so on. 68 (after 4% minutes) OK, now would you describe to me as best you can how your body feels. Good! Now here I have a bucket of water. I would like you to put your hand in it and hold it there for a minute. While your hand is in the water, I want you to focus your attention on how it feels and describe all the sensations you experience (this is done a second time with the other hand). Alrightl wa, if you will, I'd like you to take five minutes and write down all the ways you can think of in which you and I are alike. For example, (E then points out a physical similarity). APPENDIX B APPENDIX B Rules for Scoring Barrier* The scoring of Barrier adheres closely to the system outlined by Fisher and Cleveland in their studies of body image and personality. The concept of Barrier refers to any protective covering, membrane, shell, or skin that might be symbolically related to the perception of body-image boundaries. A score of 1 is given each response where Barrier is present; a score of O is given when Barrier is absent. With minor editorial revision, detailed instructions for scoring Barrier have been taken directly from Fisher and Cleveland. (a) All separate articles of clothing are scored Barrier. This is true also of all articles of clothing worn by animals and birds. Clothing worn by a person is scored only if it is unusual in its covering or decorative function. woman in a high-necked dress imp with a cap that has a person in a fancy costume tassel on it woman 1n a long nightdress person with mittens or man with a crown gloves man in coat with a lace collar people with hoods man in robe . feet with fancy red socks man With a high collar man with a cook's hat maniNith chaps *Reproduced in full from W. H. Holtzman, et al., Ink— blot perception and personality. Austin, Texas: University of Texas Press, 1961. 70 Examples of clothing being worn which are scored 0. woman in a dress man with a hat man with a coat on (b) Animals or creatures whose skins are distinctive or unusual are scored only if more than the head is given. alligator fox lynx prairie dog skunk badger goat mink rabbit tiger beaver hippo mole rhinoceros walrus bobcat hyena mountain scorpion weasel chameleon leopard goat sea lion wildcat coyote lion peacock sheep or lamb wolverine crocodile lizard penguin Siamese cat zebra porcupine An ordinary cat is Scored 0. Any animal skin may be considered Barrier if unusual emphasis is placed on the textured, fuzzy, mottled, or striped character of the surface. fuzzy skin skin with spots skin with stripes Included are all shelled creatures except crabs and lobsters. mussel snail shrimp clam turtle (c) Score reference to enclosed openings in the earth. valley ravine mine—shaft well canal (d) Score references to unusual animal containers. bloated cat pregnant woman kangaroo udder (e) Score references to overhanging or protective surfaces. umbrella awning dome shield 71 (f) Score references to things that are armored or much dependent on their own containing walls for protection. tank battleship armored car man in armor rocket ship in space (g) Score references to things being covered, surrounded, or concealed. bowl overgrown by a plant house covered by smoke log covered by moss person behind a tree person caught between two stones (h) man covered with a blanket person hidden by something someone peeking out from behind a stone donkey with a load covering his back Score references to things with unusual container— like shapes or properties. ferris wheel chair bagpipes throne (i) There are, however, unique structures are scored 1. tents arch quonset hut Masks or buildings are generally scored 0. a few exceptional instances in which igloo fort (j) Additional general examples of Barrier responses scored 1. basket cove mountain covered with snow bay curtain net bell dancer with veil pot book frosting on cake river book ends fuzzy poodle screen bottle globe spoon bubble harbor urn cage headdress wall candleholder hedge along a walk wallpaper cave helmet wig cocoon inlet land surrounded by water lake surrounded by land 72 Rules for Scoring Penstration* As in the case of Barrier, the scoring of Penetration is taken directly from Fisher and Cleveland. Any concept which might be symbolic of an individual's feeling that his body exterior is of little protective value and can be easily penetrated is likely to be scored 1 on Penetration. Fisher and Cleveland have suggested three types of images with which the subject may express such feelings of body pene— tration: (1) images that involve the penetration, dis- ruption, or wearing away of the outer surface of things ("bullet penetrating flesh," ”squashed bug”); (2) images that emphasize modes or channels for getting into the in- terior of things or for passing from the interior outward to the exterior ("open mouth,” "doorway"); and (3) images that involve the surface of things as being easily permeable or fragile ("soft ball of cotton candy,” "fluffy cloud“). De- tailed instructions are given below: (a) Score 1 for all references to the mouth being opened or being used for intake or expulsion. dog eating man vomiting dog yawning person with mouth open man sticking tongue out animal drinking man spitting *Reproduced in full from W. H. Holtzman, et al., Inkblot perception and personality. Austin, Texas: Uni- versity of Texas Press, 1961. 73 References to use of the mouth for singing or talking are scored 0. (b) Score 1 for all references to evading, bypassing, or penetrating through the exterior of an object and getting to the interior. Xeray picture body cut open body as seen through a flouroscope inside of the body cross section of an organ autopsy (c) Score 1 for references to the body wall being broken, fractured, injured or damaged. mashed bug wound wounded man man stabbed person bleeding man's skin stripped off (d) Score 1 for responses involving some kind of degener— ation of surface. withering skin withered leaf diseased skin deteriorating flesh (e) Score 1 for Openings in the earth that have no set boundaries, or from which things are being expelled. bottomless abyss geyser Spurting out of ground fountain shooting up oil gusher coming in (f) Score 1 for all openings. anus doorway looking into the throat rectum birth canal entrance nostril vagina window (9) Score 1 for references to things which are insub- stantial and without palpable boundaries. cotton candy ghost shadow soft mud .1 74 (h) Score 1 for all references to transparenCy. can see through the dress transparent window (1) Further general examples of Penetration responses that are scored 1: animal chewing on a tree torn fur coat broken—up butterfly frayed wings jigsaw not put together deteriorated wings doorway grasshopper pecking at something fish with meat taken off harbor entrance broken body man defecating bat with holes APPENDIX C 75 .mnpcoE CHs ON.ou so.m sm.m oo.o mm.m mo.m om.mm mm.H NH.eN oN.HH oo.oN m a- m NH HI 6 a mMH N HN Hosoan m NH mm mm m+ m m H- a m ONH a mN snooomm m NH mm mm mi N m H+ o m Hm H ON oooo m HH 6N mm o m m o a a as H oN HouOQMH 2 HH Nm om H- N m N. 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