‘ A PILOT INVESTIGATION INTO THE EFFECTS OF AN INTERFERSONAL THERAPY APPROACH UPON MENTAL PATIENTS IN A GENERAL HOSPITAL SHORT.TERM PSYCHIATRIC SETTING Thesis for five Degree of DH. D. MICHIGAN STATE UNIVERSITY John Richard Levee 19 63 This is to certify that the thesis entitled A PILOT INVESTIGATION INTO THE EFFECTS OF AN INTERPERSONAL THERAPY APPROACH UPON MENTAL PATIENTS IN A GENERAL HOSPITAL SHORT-TERM PSYCHIATRIC SETTING presented by JOHN R. LEVEE has been accepted towards fulfillment of the requirements for Ph I D I degree in EDUCATIONAL PSYCHOLOGY D Major professor Date M—W 0-169 LIBRARY Michigan State University A PILOT INVESTIGATION INTO THE EFFECTS OF AN INTERPERSONAL THERAPY APPROACH UPON MENTAL PATIENTS IN A GENERAL HOSPITAL SHORT-TERM PSYCHIATRIC SETTING BY John Richard Levee 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 1963 ABSTRACT A PILOT INVESTIGATION INTO THE EFFECTS OF AN INTERPERSONAL THERAPY APPROACH UPON MENTAL PATIENTS IN A GENERAL HOSPITAL SHORT-TERM PSYCHIATRIC SETTING by John Richard Levee This study was concerned with investigating whether positive gains could be made by patients in a short-term psychiatric setting, by adding interpersonal therapy sessions to the regular hospital regimen. Differences were assessed by: (a) contrasting experimental- and control-group scores of each of the MMPI sub-scales using mean scale and profile analysis. and (b) sorting experimental— and control-group individual profiles into normal and abnormal categories ac— cording to Meehl's criteria and computing chi—square.' The study sample was composed of sixty-four patients in a general hospital psychiatric setting. randomly divided into an experimental group of fifteen male and sixteen fe- male patients. and a control group of fifteen male and eighteen female patients. Experimental patients received two to three hours of interpersonal therapy a week adminis— tered by the investigator. Therapy was based on the triadic dimensions of Rhona Rapoport. Average period of hospital— ization for all groups was from 1722 to 25.5 days. One to two days before discharge individual MMPI'S were administered to each patient of the study. The t—test analysis of the MMPI sub—scales yielded no significant difference for experimental patients receiving John Richard Levee interpersonal therapy over control patients. Mean profiles of the experimental and control groups showed typical psychi— atric patterns with primary elevations on the D. Sc. Pt. and Pd scales. A post‘hoc analysis of variance of the anxiety index (Ai) showed significantly higher male than female means. but independent of experimental effects. . Brief periods of hospitalization most likely limited the effectiveness of the interpersonal approach. Therapy with significant intimates of patients might enhance the effectiveness of this design. A PILOT INVESTIGATION INTO THE EFFECTS OF AN INTERPERSONAL THERAPY APPROACH UPON MENTAL PATIENTS IN A GENERAL HOSPITAL SHORT-TERM PSYCHIATRIC SETTING By John Richard Levee A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY College of Education 1963 ACKNOWLEDGMENT The writer is indebted to many peOple for the success— ful completion of this study: To Dr. William W. Farquhar, his major advisor, for guidance, support, and continued interestin and perspective of the problem. To the members of his doctoral committee, Dr. Bernard R. Corman, Dr. Harry Grater, and Dr. Hans Tock for their cooperation and guidance. To the medical staff and personnel of St. Lawrence HOSpital, Lansing, Michigan, for their endless patience and assistance. To John A. Patterson for technical and statistical assistance. And eSpecially to his wife, Mary, who as Head Nurse of the Psychiatric Unit of St. Lawrence HOSpital, first expressed an interestin and enthusiasm for such a study. ii TABLE OF CONTENTS Chapter Page I. THE PROBLEM . . . . . . . . . . . . . . . . . 1 Statement of the Problem 1 Theory 1 Definitions 3 The Hypothesis 5 II. REVIEW OF THE LITERATURE . . . . . . . . . . . 6 Controversy on the Effects of Therapy . . . 6 Importance of Objectivity and Comparability . . . . . . . . 9 Need to Assess Systematic Change . . . . . . 10 Criteria of Improvement . . . . 11 Goals of Therapy and Patient Attitudes . . . 12 Varied Treatment and Measure of Change . . . 14 Social Context as a Function of Change . . . 19 Summary . . . . . . . . . . . . . . . . . . 21 III. DESIGN AND METHODOLOGY . . . . . . . . . . . . 22 Psychiatric Setting . . . . . . . . 22 Experimental and Control Groups . . . . . . 23 Research Procedures . . . . . . . . . . . . 23 Instrumentation . . . . . . . . . . . . . . 24 Samples . . . . . . . . . . . . . . . . . . 26 Hypothesis . . . . . . . . . . . . . . . 29 Design Limitations . . . . . . . . . . . . . 30 Summary . . . . . . . . . . . . . . . . . . 30 IV, ANALYSIS OF THE DATA . . . . . . . . . . . . . 31 Mean Scale Analysis . . . . . . . . . . . . 31 Profile Analysis . . . . . . . 34 Male and Female Anxiety Index (Ai) Mean Differences . . . . . . . . . . . . 38 Normal- Abnormal Analysis . . . . . . . . . . 38 Summary . . . . . . . . . . . . . . . . . . 39 V. INTERPRETATION AND DISCUSSION OF RESULTS . . . 41 Discussion of Sub-scales and Profile Analysis . . . . . . . . . . . . . . . . 41 Group Differences . . . . . . . . . . . . . 42 Contributing Factors . . . . . . . . . . . . 42 iii Chapter Results Summary VI. SUMMARY AND CONCLUSIONS The Problem . . . . . . . Methodology and Procedure The Findings . . . Conclusions . . . . . . . . . . Implications for Further Research BIBLIOGRAPHY APPENDIX A MMPI RAW SCORES FOR THE TOTAL SAMPLE GROUPS APPENDIX B THE INTERPERSONAL THERAPY METHOD: A CASE SUMMARY iv Page 44 45 46 46 4b 47 48 48 53 58 Table 3.1 LIST OF TABLES Psychiatric Diagnostic Category Fre— quencies for Experimental and Control Samples Average Number of Days of HOSpitalization for Experimental and Control Groups Age. Educationaland Marital Data for Experimental and Control Groups Student "T” Tests of Mean Differences of MMPI Sub—scales for the Male Experi— mental and Control Groups . . . Student ”T” Tests of Mean Differences of MMPI Sub—scales for the Female Ex— perimental and Control Groups Analysis of Variance of the Ai Scales for Male and Female Groups Sorts of MMPI Profiles Into Normal and Abnormal Categories Based on Meehl's Criteria Page 27 28 29 32 33 3Q 40 LIST OF FIGURES Figure 4.1 Mean Raw Score Profile Comparison of Male Experimental and Male Control Groups 4.2 Mean Raw Score Profile Comparison of Female Experimental and Female Control Groups vi Page 36 37 CHAPTER I THE PROBLEM In recent years there has been an increase in the number of theoretical approaches to psychotherapy. At the same time. little attempt has been made to measure patient "change” or modification empirically in relation to a particular therapeutic approach. Statement of the Problem It was the problem of this investigation to assess experimentally the influence of individual interperSOnal therapy given to patients in a general hOSpital short-term psychiatric setting. An attempt was made to determine whether gain could be brought about in experimental patients with the use of inter— personal therapy two to three hours a week during the period of hOSpitalization. The two to three interpersonal therapy sessions a week were added to the normal regimen of treat— ment by a psychiatrist several times a week. Theory A need exists for a theoretical approach to therapy which gives recognition of the patient as a personality in conflict with the social environment from which he comes, and to which, hopefully, therapy will return him as a more adequate individual. Conceivably the more quickly therapy can be used before maladjustment becomes strongly reinforced and generalized, the less the need for extensive or intensi- fied treatment. In like manner, if keeping the patient in close proximity to his community during early treatment can be of value, the anguish experienced by patient and family will be less. Perhaps wasted man-hours and private or community costs for treatment can be reduced also. For this study a basic assumption was that the approach of therapy given to the patient while in the hOSpital should be such that it best meets the needsof his interpersonal and community relationships. Throughout the study the theo- retical approaches of interpersonal therapy based upon Sullivan,l Ackerman,2 and Rapoport3 are used because it appears that their approaches are consistent and complemen- tary to the patient‘s needs in a social context. A basic assumption was made that Rapoport's interpersonal approach to therapy would be most consistent with the philosophy and context of the psychiatric setting, and would best meet the general needs of most patients admitted to a general hOSpital 1Harry S. Sullivan, The Interpersonal Theory of Psychiatry (New York: W. W. Norton & Co., 19533. 2Nathan W. Ackerman, "The DevelOpment of Family Psycho— therapy," International Mental Health Research Newsletter. Postgraduate Center for Psychotherapy, Vol. 3, June 1961. pp. 1-16. 3Rhona Rapoport, "The Family and Psychiatric Treat— ment,” Psychiatry, Vol. 23, 1960, pp. 53—62. psychiatric unit for short—term hOSpitalization. It was further assumed that the sub-scale scores of the Minnesota Multiphasic‘Personality Inyentory would serve as av measure of the influence of the interpersonal therapy on patient gain, Definitions Two important concepts need definition for purposes of clarifying and communicating the research procedures. Therapy The present study was built upon Rapoport‘s conceptual framework of analysis of family-patient conflicts and adjust— ment.1 Within this conceptual framework, Rapoport proposes that the total relationship between patient and significant intimates determines role performances and failures. Three major dimensions of role strength and strain are postulated by RapOport as important areas of study: 1. The degree of compatibility between the norms of the family and patient concerning the nature and importance of roles gives clues to disagreements that exist within a family System. 2. The degree of compatibility of interacting systems of each family member reflects the psychological and person- ality needs that exist for each person within that family. 3. The emotional tone which is established by the interaction of people living together suggeststhe type of llbid. interaction which gradually dominates the life of each member. The degree to which norms are compatible between patient and family, Rapoport prOposes, determines the amount of harmony or strain in’assuming roles. Personality systems, likewise, may be so structured that the way one family member seeks gratification or handles tensions and frustrations may affect adversely how another member attempts to do so. Emotional tones in any relationship may have many variations, and be complex. Thus compatibility of norms and structures of personality Systems are changed in reSponse to sustained interaction. Improvement and Recovery Improvement and recovery were predetermined in this study. Improvement may be considered to be on a continuum between the extremes of sickness and recovery. Psychiatric- ally, improvement is considered a sufficient base line to determine patient discharge. For the general purposes of this study then, improvement is best defined as the psychiatric judgment that a patient has attained sufficient reality orientation, emotional stability and insight to allow him a suitable degree of self-direction in adjusting outside the immediate hOSpital setting and relating ade- quately in interpersonal and community relationships. It was hoped that for the experimental patients used in the present study, improvement in part. would consist in the patient's gaining insight into major difficulties of role performance. The psychiatrist's judgment of the degree U: of recovery was. in the last analysis. the main criterion of dis— charge. The decision was based on: (1) the progress of the psychiatrist's own treatment and interviews with patient and family or friends. (2) perusal of progress notes and nurses’ reports. and (3) consultation with the interpersonal therapist. MMPI‘s were‘not used in making discharge decisions. The Hypothesis It was hypothesized that the experimental patients who re— ceived interpersonal therapy during hOSpitalization. as a group. would score closer to the ”normal" on the MMPI scales than would control patients who did not receive interpersonal therapy. In particular it was assumed that for this hQSpital population the F (response conformity). D (Depression). Pt (Psychasthenia). Sc (Schizophrenia). Si (Social Introversion). and A1 (Anxiety Index) scales of the MMPI would be the most sensitive to change influenced by interpersonal therapy. Statement of the Research Hypothesis Greater improvement and adjustment in mental patients in short-term psychiatric treatment is expected from those who receive individual therapy. based upon interperSonal theory. than in those patients who do not receive such therapy. as measured by scores on the MMPI scales. The overall plan of the dissertation is as follows: In Chapter II studies on assessment of the effects of therapy are reviewed; in Chapter III the methodology and sample selection procedure of the design are presented; in Chapter IV the analy- sis of the data was given. while in Chapter V. an interpretation and discussion of results are presented. In Chapter VI a sum— mary. conclusions. and implications for further research are found. CHAPTER II REVIEW OF THE LITERATURE Most schools of therapy have as a goal the bringing of some amount of insight to‘a client concerning his problems, and modifying his behavior directly or indirectly for more adequate social adjustment. Needless to say, it is the hope that any treatment procedure will assist patients to make dynamic gains in a positive direction. Difficulties in effectuating this positive gain are often made complex by a multiplicity of variables that handicap any assessment of progress in therapy. Perhaps influenced by these diffi— culties, there are those 'who have claimed that psychotherapy has no effects on patient gain or may even have negative re— sults. Controversy on the Effects of Therapy Eysenck, in an extensive study of psychotherapy ef- fects with psychoneurotics, reports on the ". . . results of nineteen studies reported in the literature. covering over seven thousand cases, and dealing with both psychoanalytic and eclectic types of treatment."1 Patients receiving therapy were compared with patients presumably recovered 1H. J. Eysenck, ”The Effects of Psychotherapy: An Evaluation,” Journal of Consulting Peychology. Vol. 16. 1052. p. 320. \J without benefit of such therapy. Eysenck's conclusion was that the figures fail to support the hypothesis that psychotherapy aids in the recovery of psychoneurotic patients to any significant degree. He states: Patients treated by means of psychoanalysis improve to the extent of 44 per cent; patients treated eclec- tically improve to the extent of 64 per cent; patients treated only custodially or by general practitioners improve on the extent of 72 per cent. There thus appears to be an inverse correlation between recovery and psychotherapy; the more psychotherapy the smaller the recovery rate.1 Eysenck built his research and findings upon previous studies done by Landis and Denker.2 Denker's earlier re— search was upon the outcome and related effect of therapy of several different disciplines. He studied 500 conse- cutive psychoneurotic disability cases treated by general practitioners and a comparable group of patients treated by psychiatrists or psychoanalysts: Denker's conclusions were that no significant differences of therapeutic success mmmefound among patients treated by general practitioner, psychiatrist, and psychoanalyst. Wheeler, White, et al., did a twenty-year follow—up study of 173 patients diagnosed as being neurocirculatory asthenics (anxiety neurosis, effort syndrome, and neur— asthenia).3 These patients were compared for like lIbid., p. 322. 2Ibid. 3N. S. Lehrman, "The Potency of Psychotherapy,” Journal of Clinical and Experimental Psychopathology, Vol. 22, June 1961, pp. 106-111. periods of time to groups of similarly diagnosed patients treated by psychotherapists and psychoanalysts. Wheeler's conclusion was that no significantly better re— sults were obtained by psychotherapy than were obtained by a practitioner's giving simple reassurance and allowing for the passage of time. Wheeler emphasizes that even if significant differences were found among the studied groups, an evaluation that one treatment is better than another is not warranted because treatment procedures were not identical. One might question also the differences in clientele which would lead them to choose psychotherapist, psychoanalyst, or practitioner. The use of chemotherapy in medical treatment of patients may also be considered an important variable influencing outcomes. Critics of studies that question the values of therapy have been many. Rosenzweig's criticism of Eysenck‘s research is probably among the most pointed.1 Among Rosenzweig's allegations are: (l) misuse of population figures and overgeneralization of statistical results, (2) insufficient comparability of clientele, and (3) lack of definitions of what constitutes psychoneurosis, psychotherapy, and recovery for patients treated in different professional settings. About the psycho— analytic or eclectic approach used in Eysenck's study, Rosenz— weig comments that 80 per cent of the experimental groups 1Saul Rosenzweig."A Transvaluation of Psychotherapy: A Reply to Hans Eysenck,” Journal of Abnormal Social Psycho- logy, Vol. 49, 1954, pp. 2q84304. (I were treated by methods which vary between the eclecfic psychiatrist and general practitioner only in degree of expertise. and not in kind. To undertake an evaluation of the effects of psychotherapy by tallying outcomes at second hand. without even introducing the problem of dynamic change in various forms of illness and in varying therapeutic procedures. and. in default of such considerations. to reassign diagnoses and prognoses is to invite . . . inconsistencies and non sequiturs.l Importance of Objectivity and Comparability Notwithstanding some of the inadequacies. Eysenck took a knowledgeable stand upon the necessity for actuarial studies by first initiating what Landis called a base line and common unit of study. Too often the base line has been the physician's subjective judgment of patient progress. led on quite unempirically by the patient's report of how he is "feeling." Patient introspection. used in the best tradition of general medical practice. is allowed to contaminate what otherwise might be a more objective personality assessment. Lehrman2 offers the suggestion that therapy may in fact accentuate the extremes of patient population. and while some patients may be helped by therapy. others may \ in fact be harmed by it. This line of reasoning is lIbid.. p. 303. 2'N. S. Lehrman, "The Potency of Psychotherapy.” Journal of Clinical and Experimental Psychopathology. Vol, 22. June. 1061. pp. 106-111. 10 consistent with Cartwright’s1 comment on the studies done by Barron2 at the Kaiser Foundation HOSpital, Oakland, California, with patients in both group and individual ther— apy using waiting-list patient control groups. Cartwright concludes that the S DEsof MMPI scales used to assess change suggest; that some of the therapy-group patients had more deterioration during therapy than waiting—list controls. If this be the case, therapeutic failure must be reckoned with as a potential hazard, and ways of predetermining this possi- bility are a professional reSponsibility not lightly to be dismissed. Need to Assess Systematic Change ‘Too often change in psychotherapy is estimated in an unsystematic or haphazard way. Barron comments upon the unempirical attitude often present in biased evaluations of change in psychotherapy: To say that a remission is Spontaneous, . . . is generally to make a confession of ignorance; what we mean is that a change occurred for reasons we do not understand. When a change in a psychic state of a patient has occurred concurrently with the applica- tion of psychotherapy, we usually feel that we do understand the causes of the change. Unless, hBW- ever, we are certain that there is a significant increment in the recovery rate when psychotherapy is applied, we may be deceived in attributing the changes we have observed to the psychotherapeutic forces we think we have applied. Hence the 1D. S. Cartwright, "Note on 'Changes in Psycho- neurotic Patients with and without Psychotherapy,'" Journal of Consulting Psyghology, Vol. 20, 1956, pp. 403-404. 2 Frank Barron and Timothy F. Leary, "Changes in Psychoneurotic Patients with and without Psychotherapy," Journal of Consulting Psychology, Vol. 19, 1955, pp. 239-245. ll importance of research into psychological change under systenatically varied conditions. Schofield and Briggs2 suggest that a large part of the inadequacies of therapy evaluation Lay be related to the circumstances that many studies are done on out~patients not available for consistent and frequent evaluation ob— servation. In contrast. one night hope that in—patient studies should supply the adequacy of observation that these out-patient group studies lack. but the literature reveals such a hope to be short—lived. again because of exployment of a loose—knit and inconsistent base line of improvement judgments, and the lack of vigorous conpar— ability between experi ental and control group patients (if control groups are used at all). Criteria of Improvement 3 investigated the problem of Schofield and Briggs patient inproverent resulting fror hospitalization. Three sets of data were used in assessing a patient's in ediate reSponse in a therapy situation. and one measure of long— tern reSponse. I: ediate reSponse was assessed by: (1) changes in the MMPI during hOSpitalization. (2) daily rat— ings by nurses during hOSpitalization period. and (3) lIbid., p. 339. 5) “William Schofield and Peter F. Briggs. ”Criteria of Therapeutic PeSponse in HOSpitalized Psychiatric Patients." Journal of Clinical Psychology. Vol. 14. l 58. pp. 227—232. 3161a. 12 psychiatrists‘ clinical evaluation of condition on dis~ charge. The long term criterion was rehOSpitalization with the follow—up median per patient 5.3 years. In a sample of 130 heterogeneous h05pitalized psychiatric patients treated at the University of Minnesota hQSpitals for a period of not less than 30. nor more than 75 days. 31 per cent of the total samplewere rehOSpitalized. With rehOSpitalization or non~reh05pitalization as a criterion, post-therapy clinical judgxents had an overall ”hit" rate of 72 per cent as against a judgment of 62 per cent on the basis of MMPI change. Psychiatrists' ratings were concluded to give better prediction than the MMPI. Goals of Therapy and Patient Attitudes Among the Variables that ray well influence compar- ability of results between different psychotherapy approaches are frequency of therapy and goals of therapists. Michaux and Lorrl attempted to study these two factors as they interrelate. They used a sample of 133 male outpatients who had completed four months of therapy at seven Veterans Administration Mental Hygiene Clinics. Sixty-nine therapists were involved: 20 psychiatrists, 27 clinical psychologists. and 22 social workers. After initial interviews with patients. each therapist was asked to state treatment goals for the next four xonths. Goals were fitted to a schema of Reconstructive. Supportive. and Relationship therapies. #4 L A “1 lWilliarr. W. Michaux and Maurice Lorr. ”Psychotherapists’ Treatment foals.” Journal of Counseling Psychology. Vol. 8. . _ - - 4 .. 4.4.1.. 1961. pp. 250~254. 13 Reconstructive therapy was defined as ”personality change or modification with insight”; Supportive therapy was defined as ”maintaining or strengthening current adjustment"; Relation— ship therapy was defined as "facilitating patient's adjustment within the therapeutic relationship by focusing on his in— volvement in treatment." A fourth category was formulated to which was assigned "mixed. deferred. or vaguely formulated goals."1 The results showed that reconstructive goals were not as frequent as might be expected for twice—weekly patients. but more frequent for bi-weekly patients. Thera— pists rated patients after their first interview on the basis of severity of illness with scales measuring symptom distress. suspiciousness. resentment of authority. with- drawal. reality distortion. lack of impulse control. and self-preoccupation. Conclusions were that the kind of treatment did not appear to have any significant or syste— matic effect in changes occurring in patients. Hecht and Kroeber2 attempted to assess patients” atti— tudes toward treatment in a short-term therapy situation and suggest that personality attributes established by patients over an extended time before therapy may well interfere with goals of therapy set up by therapists. so that evaluation of change as the result of therapy is quite difficult. llbid.. p. 350. 2Shirley Hecht and T. C. Kroeber. Y'A Study in Pre— diction of Attitudes of Patients Towards Brief Psychotherapy." American Psychologist. Vol. 102 1955. p. 3iU. \ 14 Varied Treatment and Measures of Change Simon et a1.1 did an ambitious and extensive study upon the short—term differential treatment of schizophrenics. They took schizophrenics admitted to the Minneapolis V. A. Hospital and matched the patients into four treatment groups. randomized. with 20 patients to each group. as follows: clinicial judgment group. chlorpromazine group. reserpine group. and hOSpital routine group. The clinical judgment group was made up of patients receiving any therapy approach that was judged appropriate for the individual case. and used EST. insulin coma therapy. psychotherapy. and a variety and combination of drugs. The hospital group was given no treatment other than hospitalization. Other groups were given only chlor- promazine and reserpine. All groups participated in all other daily routines and special servicing provided by the hospital. For all groups extended use was made of social history. occupational adjustment ratings. and psycho- metrics. which included the MMPI. Improvement scales were used for assessment of each patient. As indicated by the clinical improvement scale. be— havior ratings. and the MMPI. Simon et al. found that the clinical judgment group was the most improved after 30 days. On the MMPI change was indicated by a lowering in ele— vation on the F scale. Hs. D. Hy. Pa. Pt. Sc. and Si 1Werner Simon et al.. "A Controlled Study of the Short—Term Differential Treatment of Schizophrenia.” American Journal of Psychiatgy. Vol. 144. 1958. pp. 10/7~1033. 15 scales, while no significant difference was found on Pd. Mf. or Ma scales. The average elevations of profiles were not considered schizophrenic in type. The chlorpromazine groups showed some improvement on the MMPI, but not as much as did the clinical judgment group. The only major change was on the Pa scale, although the average profile was still schizophrenic. The reserpine group showed little change over admission profile. A decreased Si scale on the MMPI indicated improved social comfort, but with the aver- age profile still schizophrenic. The hOSpital routine group showed no significant change on behavior ratings of MMPI profiles. The authors feel that future extensions of their study will determine the longer range reSponses of patients to the treatment procedures used. Our findings suggest that regardless of the type of treatment given, some factors are more indicative of prognosis than others. These confirm earlier re— ports that rapid onset with short duration is prognostically favorable, as is a good former occu- pational adjustment, and that those patients with sufficient ego strength to act out in their environ- ment appear to have,a better treatment probability than those who react with withdrawal and conformity. Furthermore, in our study, those patients whose early life was beset by hostile and rejecting fathers are least likely to recover, while those with mothers who, though inconsistent in their training methods, were nonetheless sources of pro- tection and strength, have favorable prognoses. However, for this short period of time, many factors long believed to be prognostic do not have value. Finally, we find some consistency in our data. The patients who improve show the improvement in many aSpects; in psychometric tests, in ward be- havior, and in clinical interview; while those who remain most schizophrenic fail to ihow demonstrable improvement in any of these areas. 1Ibid., p. 1084. 16 Kaufmannl has done notable research in studying MMPI changes as a function of therapy. Fifty-one students in the neuropsychiatric service of the University of Wisconsin were studied; 34 of the students were diagnosed’as ”anxiety tension state.” with the remaining distributed among various diagnostic groupings. The students studied. all rated by their thera- pists as improved. were given pre— and post-therapy MMPI's. along with a comparable group of non—therapy students. The results show that the therapy students obtained higher mean scores on every scale except the K scale. For female stu- dents the Mf scale also was elevated. The D. Pt. and Sc scales were found to be the most sensitive to and discrimin- ative of change. The Pt scale correlated highl3 with the Sc scale as effective in differentiating psychiatric patients. The Hs scale. and the Mf scale with females. showed the same discriminating tendency. but to a lesser extent than D. Pt. and Sc. The F scale showed some modifi- cation as a function of therapy and was able to discriminate effectively between control and patient groups; whereas. the Hy and Pd scales showed differences of groups from pre— to post—test. Kaufmann concludes that both the Pa and Ma scales served no value in this study. There were no significant changes of pre- to post-test scores in the control group. with the exception of the K scale. 1Peter Kaufmann. "Changes in the Minnesota Multiphasic Personality Inventory as a Function of Psychiatric Therapy." Journal of Consulting Psychology. Vol. 14. 19§O. pp. 47%— 464. - l7 Taulbee and Sissonl employed a technique of con- figurational analysis similar to Sullivan and Welsh,2 ap- plying the technique to 210 MMPI profiles for the purpose of testing the usefulness of this method in differentiating, diagnostically and psychodynamically, schiZOphrenic and psychoneurotic patients. The profiles were obtained from 0 two groups of schizophrenics and three groups of neurotics. Interpreting in terms of psychodynamics the authors explain: The Sc and Pa scales reflect the greater disturb- ance in thought processes, more of a tendency to distort and, in general, the more precarious reality contact of the schiZOphrenic patients. These patients are attempting to alleviate their anxiety by such defenses as projection (Pa) and hyper- activity (Ma), as contrasted to the neurotics' greater use of vague somatic complaints, repression and obsessive-compulsive behavior (Hs, Hy, and Pt) is consistent with the generally accepted view that they tend to be more hostile, asocial, suSpicious, impulsive, and less bothered by feelings of anxiety, self-doubt, and less able to show guilt or regret than neurotics. Also, the schizophrenics have stronger feelings of family and social alienation and rejection. The neurotics conflict usually takes place with himself whereas the schizophrenic, be- cause of ego's weaker ties with the external world, is more rebellious against conventional practices and expresses many of the emotions, eSpecially hostility, more openly than does the neurotic. The significance of the Mf and Pd scales in the scale pairs may be the schiZOphrenic's relatively less adequate identification with the cultural norm of masculinity and greater disregard for conventional behavior in general. . . . It is often very diffi- cult to differentiate, on the basis of the MMPI, the acute paranoid schiZOphrenic from the hOSpitalized neurotic. This is true because a defensive patient may keep his Pa score well within normal limits and 1Earl S. Taulbee and Boyd D. Sisson, ”Configurational Analysis of MMPI Profiles of.Psychiatric Groups," Journal of Consulting Psychology, Vol. 21, 1957, pp. 413—417. , 2P. L. Sullivan and G. S. Welsh, "A Technique for Objective Configural Analysis of MMPI Profiles,” Journal of Consulting Psychology, Vol. 16, 1952, pp. 383-388. 18 also because undue sensitivity and feelings of persecut1on may be present_1n many neurotics. From the results Taulbee and Sisson conclude that the configurational analysis.method yields an effective means of differentiating schizophrenic from psychoneurotic patients, of evaluating behavior processes of patients, and assisting in detailing for differential diagnosis. Garfield and Sineps2 applied this same configur— ational approach of Taulbee and Sisson to 129 patients in different diagnostic categories. Their results yielded many false positives occurring particularly with those scales pointed out by Taulbee and Sisson as discrimi— native of schizophrenia. They suggest, therefore, that the configurational method would yield more incorrect and in— determinate diagnoses than accurate ones. They state that the comparability of groups for both studies was difficult to control and so express the need for great caution in the use of the method diagnostically. When applied to un- selected samples in a clinical situation Garfield and Sineps conclude that the configurational method holds little promise of discriminative power. lEarl L. Taulbee and Boyd D. Sisson, "Configurational Analysis of MMPI Profiles of Psychiatric Groups," Journal of Consulting Psychology, Vol. 21, 1957, pp. 413-417. 2s. L. Garfield and J. Sineps, "An Appraisal of Taulbee and Sisson's 'Configurational[Analysis of MMPI Profiles of Psychiatric Groups,'” Journal of Consulting Psychology, Vol. 23, 1959, pp. 333-335. 19 Social Context as a Function of Therapy If the type of therapy and treatment are important functions of patient improvement, so too is the social con- text from which the patient comes and to which he returns. Sullivan, and more recently Ackerman1 have stressed the importance of family constellations and interaction as they relate to patient stress and recovery. Ackerman further urges the need to extend principles of diagnosis into diagnosis of families ”analogous to the vocabulary standards 2 for the description of individuals.” Ackerman comments that need exists to understand better the sources of both illness and health in the family unit. Important too, is the need to study verbal and non-verbal communication as it relates to the emotional health of the family group. Expectations of the family, particularly parents, have been shown to have important bearings upon levels of aSpiration, and feelings of success or failure.3 Current social work approaches attempt to study family problems as related to mutual adjustments when a patient is released from the hOSpital.4’5 1Nathan W. Ackerman, ”The Development of Family Psychotherapy," International Mental Health Research News— letter, Postgraduate Center for Psychotherapy, V01. 3, June 1661, pp. 1‘16. 21bid., p. 16. 3D. McClelland, et al., The Achievement Motive (New York: Appleton-Century—Crofts, 1953): 4Howard B. Freeman and O. G. Simons, "Mental Patients in the Community: Family Settings and Performance Levels," American Sociological Review, Vol. 23, April, 1958, pp. 147—154. 5 , "The Social Interpretation of Former Mental Patients,” International Journal of Social Psychiatry, Vol. 6, Spring 1959, pp. 264-271. 20 Rapoport suggests that it may be increasingly appro— priate to treat the entire family from which a patient comes, as a unit.1 Disorders in a patient may be influenced by significant relationships which are continued in therapy by the.patient. Such a conceptual framework has been studied in detail at the Social Rehabilitation Unit of Bel- mont HOSpital, England. Therapy at Belmont HOSpital is ap- proached in terms of role failure difficulties which are examined in a contextcfi’familial position, personal and social norms, and personality resulting from an accumulation ' of life roles. Bach role relationship is further analyzed into: (1) "fit" between norms of patient and intimates, (2) "fit" between personality systems of each family member interacting with the other, and (3) the emotional tone which is developed over a period of time in close relation- ships and which comes to characterize the major way of re— action to this relationship. Kohn and Prestwood2 report the results of group therapy sessions conducted with families of schiZOphrenic patients prior to release from hOSpitalization. Family therapy sessions were found useful in increasing family acceptance of patients returning home, and easing the strain of adjustment for patient and family members alike. Freeman thona Rapoport, ”The Family and Psychiatric Treat- ment,” Psychiatry, Vol. 23, 1960, pp. 53-62. 2Shirley Kohn and A. R. Prestwood, "Group Therapy of Patients as an Adjunct to the Treatment of Schizophrenic Patients,” Psychiatry, Vol. 17, 1954, pp. 177—185. 21 . l . . . . . . and Simmons believe that a patient's p051t10n 1n the family and relatives’ commitments to dominant values in the society. determine in large measure the amount of acceptance and tolerance of atypical behavior. Summary It has been suggested in this chapter that any effec- tive therapy must contend with a multiplicity of variables if it is to make appropriate assessment of change.. Efforts to make controlled studies have become more complex because of such variables as patient dynamics, population selection, clinical settings, ancillary treatment procedures, criteria of improvement, goals of therapy, and different measures of change, to mention but a few. Then too, variability exists from patient to patient because of the constantly unique and shifting needs of an individual coming from highly conditioned social settings with complex roles and eXpectations. An increasing awareness of the shaping in- fluence upon a patient of societal ”role expectations” have given greater dimensions to therapy, and greater burdens for research. 1Howard B. Freeman and O. G. Simmons, ”Mental Patients in the Community: Family Settings and Performance Levels,” American Sociological Review, Vol. 23, April 1958, pp. 147-154. CHAPTER III 'DESIGN AND METHODOLOGY In this chapter will be described the setting in which the study was done. the type of patients used. and the means by which change is measured. Psychiatric Setting First admission patients to the psychiatric unit of St. Lawrence HOSpital. Lansing. Michigan, between November. 1961. and March. 1962. were used in this experimental design. The unit had a 35—bed capacity and normally administers to both adult male and adult female patients. Although a sectarian hOSpital. there is no discrimination on the basis of religious preference. Many patients are admitted to the psychiatric unit under crisis conditions. such as occur in metropolitan areas. e.g.. police apprehension. suicides. overt psychotic episodes. Unlike the public or private mental hospital. the goals and approach of this hospital unit differ. The goal is to re- store a degree of stability to the patient by means of "crisis— therapy." Essentially the philosophy of the unit is that patients have much to gain if hOSpitalization is given as Soon as stress is incapacitating. The approach is predomin- ately supportive. i.e.. relief of stress. temporary gratifi- cation of passive—dependent needs. setting time limits to acting out. specific physiological helps such as rest. diet. ,7) [Q I.» medication. and EST. and by environmental manipulation. Unlike traditional mental hospitals, the milieu is open-ward in make— up. Attempts are made to impart to the patient the attitude that he is still close to the community to which he is to re- turn as soon as medically feasible. An atmosphere of locked doors and barred windows is almost non-existent. There is a continual striving to convey to the patient the attitude that being a patient in this unit has no stigma attached to it, and that he is treated with the same reSpect and consideration as is given to patients on the medical wards of the hospital. In addition to ward activities, patients are encouraged to have visitors, take part in community activities, and have holiday and weekend leaves whenever such activity is judged to contribute to treatment and recovery. Experimental and Control Groups At the time of admission to the unit, intake patients of the study were assigned to experimentaL and control-group rosters made up on an odd-even number basis by use Of a table of random numbers. All patients were given psychiatric examination immediately after‘admission. In the course of hospitalization experimental group patients were then given individual therapy sessions of from two to three hours per week within the functional limits of the hOSpital schedule. Research PrOcedures An interpersonal therapy approach, based upon the tri- adic dimensions of Rapoport. was used because it was considered to be consistent and Complementary to the above phi1o5ophy 24 of treatment.1 Interpersonal therapy‘2 was done by the writer. who is a doctoral candidate in educational psychology at Michigan State University. with a master's degree in clinical psychology and approximately three years‘ super- vised therapy experience in general hOSpital psychiatric settings. All therapy was given under the supervision of three psychiatrists. A number of clinical judgment treatments were administered routinely and include the use of EST. drug therapy. and periodic interviews by treating psychiatrists. Other servicing of the hospital. such as psychiatric social service and occupational therapy. were available equally to all patients. Control—group patients received the treatment and had services available to them as above. with the ex- ception of the interpersonal therapy sessions of the design. At such time as the treating psychiatrist judged that each patient was sufficiently improved to be discharged (see defi— nition of improvement and recovery. page 4). the booklet- form of the MMPI was administered to each patient of both the experimental and the control groups. Instrumentation MMPI scores for all scales were obtained for each patient by use of Friden scoring methods.3 Profiles for each thona Rapoport. ”The Family and Psychiatric Treatment." Psychiatry. Vol. 23. 1960. pp. 53—62. 2 . . . . . “A summary of an 1nd1V1dua1 case used in the study 18 presented in Appendix B. p. 58. 3MMPI raw scores for total sample groups can be found in the Appendix A. pages 54—57. DO U] patient tested were obtained. Group profiles, male and female, for both the eXperimental and control groups were obtained by averaging the individual profiles of patients of each group. Welsh's anxiety index1 also was computed for all patients,using T—scores rather than raw scores. The formula from which the anxiety index was computed is: (Hs + D + Hy) 3 + (OD+'Pt)-(Hs +Ih0). This formula averages the dimensions of hypochondriasis (Hs), depression (D), psychasthenia (Pt), and hysteria (Hy), to yield a measure of anxiety. MMPI scales were sorted into normal and abnormal groups on the basis of Meehl‘s criteria for abnormality. Profiles were called abnormal under the following four conditions: 1. Any of the eight components showed T equal to or greater than 90. 2. Any of the eight components showed T equal to or greater than 80, unless K was less than 40. 3. Any of the eight components showed T equal to or greater than 70, unless K was less than 50 and L less than 60. 4. Any of the eight components showed T equal to or greater than 652 unless K was less than 65 and L less than 60. The above criteria were used for the ten clinical scales of the present study. In Table 4.3 can be found the number of normal and abnormal profiles for each sample group. 1George S. Welsh and W. G. Dahlstrom, Basic Readipgs on the MMPI in Psychology and Medicine (Minneapolis: University OfIMinnesota Press, 1956). 2Paul E. Meehl, ”Profile Analysis of the MMPI in Differential Diagnosis," Journal of Applied Psychology, 30:5 (October, 1946), p. 518. 26 Chi—squares were computed on the normal—abnormal groups to test whether a greater number of normal profiles could be found in the experimental groups than in the con- trol groups. Samples The sexes were analyzed separately for both experi— mental and control groups. Male Experimental Group The male experimental group was comprised of 15 male patients ranging in age from 17 to 60 years, with a mean age of 40.0 years, and an average educational level of 10.0 years. Of the male experimental group, three were single, nine married, and three divorced. Psychiatrists' diagnoses of the group were eight psychotics, five psychoneurotics, and two personality disorders (see Table 3.1, page 27, for diagnostic detailing). This group was hOSpitalized for an average of 23.0 days and seen in therapy two to three hours a week. Male Control Group The male control group was comprised of 15 male patients ranging in age from 18 to 60 years, with a mean age of 33.0 years, and an average educational level of 11.1 years. Of the male control group, five were single and ten were married. Psychiatrists‘ diagnoses of the group were five psychotics, five psychoneurotics, and five person— ality disorders (see Table 3.1. page 27. for diagnostic 27 ToBLE 3.1 PSYCHIATRIC DIAGNOSTIC CATEGORY FREQUENCIES FOR EXPERIMENTAL AND CONTROL SAMPLES W Male Female Experi- Experi- Categories mental Control mental Control Psychotic *Depressive reaction 1 l SchiZOphrenic reaction simple type 1 paranoid type 1 l schizo-affective type . 1 undifferentiated (acute) 4 4 6 7 with alcoholism l N5 8 5* '7 8 Psychoneurotic Anxiety reaction‘ 1 2 Dissociative reaction 1 Conversion reaction ' 1 Obsessive compulsive l Depressive reaction 2 2 3 1 With alcoholism l , 1 Other 1 3 2 3 N” 5’ 5 8 7 Personali:y Disorder Inadequate l Emotionally unstable 1 Passive-aggressive 1 Dissocial reaction 1 Transient situational 1 1 With alcoholism 1 Undifferentiated 1 3 N 2 5 l '3 Group N 15 15 16 18 detailing). The male control group was hOSpitalized for an average of 17.2 days and had no interpersonal therapy. I.) , 1 (4'; TABLE 3.2 AVERAGE NUMBER OF DAYS OF HOFPITALIZATIUN FOR EXPERIMENTAL AND CONTROL GROUPS Male Female Experimental Control Experimental Control 23.0 17.2 12.4 2'. (VI U1 Female Experimental Group The female experimental group was composed Of 16 female patients ranging in age from 16 to 57 years. with a mean age of 35.0 years. and an average educational level of 11.2 years. Of the female experimental groups. two were single. ten were married. two divorced. and two widowed. Psychia— trists' diagnoses of the group were seven psychotics. eight psychoneurotics. and one personality disorder (see Table 3.1. page 27. for diagnostic detailing). The group was hOSpitalized for an average of 1J.4 days and seen in inter~ personal therapy two to three hours a week. Female Control Group The female control group was composed of 18 female patients ranging in age from 21 to 51 years Of age with a mean age of 35.4 years and an average educational level of 11.5 years. Of the female control group. four were single. 11 were married. two divorced. and one widowed. Psychia— trists’ diagnoses of the group were eight psychotics. seven psychcneurotics. and three personality disorders (see Table 3.1. page 27. for diagnostic detailing). The female group 29 TABLE 3.3 AGE, EDUCATIONAL, AND MARITAL DATA FOR EXPERIMENTAL AND CONTROL GROUPS m ""‘— Male :Female Experi- Experi- mental Control mental Control Mean Age (years) 40.0 33.0 35.0 35.4 Mean Education Level (years) 10.0 11.1 11.2 11.5 Marital Status ‘Single 3 5 2 4 Married 9 10 10 ll Divorced 3 0 2 2 Widowed 0 0 2 1 was hOSpitalized for an average of 25.5 days and had no interpersonal therapy. Hypothesis It was hypothesized that experimental raw-score means on the F, D, Pt, Sc, Si, and Ai scales would be signi- ficantly lower (.05 level) than control group raw-score means on these same scales. It was also hypothesized that chi-square for the normal-abnormal sorts of MMPI profiles would yield a significantly higher (.05 level) number of normals for the experimental groups as compared to control groups. 30 Design Limitations Within the design of this study are incorporated randomization and control elements. However, because of functional limitations, replication was not included to complete the three basic elements of modern experimental design. For this reason, estimates of stability error could not be made and the study was designated as explor- atory. The major compounding error was the use of only one therapist. Summary The sample used in this study was first admission patients to the psychiatric unit of St. Lawrence HOSpital, Lansing, Michigan. Fifteen experimental male patients and 15 control male patients, 16 experimental female patients and 18 control female patients constituted the various sub— samples of the study. Interpersonal therapy, based upon Rapoport's approach, was used with experimental patients because it appeared to be consistent with the philosophy of the hOSpital psychiatric treatment. MMPI’S were given to all patients to assess whether differences in personality dimensions occurred in experimental patients influenced by the interpersonal therapy given them. CHAPTER IV ANALYSIS OF THE DATA The criterion of gain in the present study was based upon MMPI evaluations. The analysis was conducted by: (a) contrasting the experimental- and control—group means of each of the MMPI sub-scales. and (b) classifying individual MMPI profiles of experimental and control patients into normal and abnormal categories. Mean Scale Analysis The research hypothesis. as stated previously. is: Greater improvement and adjustment in mental. patients in short-term psychiatric treatment is expected from those who receive individual therapy. based upon interpersonal theory. than in those patients who do not receive such therapy. as measured by scores on the MMPI scales. In particular. it was hypothesized that the experimental— group raw score means on the F. D. Pt. Sc. Si. and Ai scales would be significantly lower (.05 level) than the control- group raw score means on these same sub-scales. This lower— ing of experimental sub-scale means to approach "normal" means would thus reflect positive gain in therapy. The means and standard deviations were computed for each scale of the MMPI for female control and experimental groups. and male control and experimental groups. Welsh's1 1George S. Welsh and W. G. Dahlstrom. Basic Readings on the MMPI in Psychology and Medicine (Minneapolis: University of Minnesota Press. 1956). 31 3 3 .Ammuoomuhv massuow m.nmam3 co Ummmm x «w.- hom.n No.5H 00.5» Hm.bm ou.ve ifi< Ho.- oov.v nm.oa mo.am mo.ma nm.am flm hm. qmc.a oo.m mo.oa wo.m bw.om a: om. mao.m em.o mm.om mm.o ma.am um an. cma.m em.m em.om nm.o oo.Hm Hm oa.- mom.a HH.m ma.ma os.m oo.ma am am. wmm.H oo.m mH.vm cm.¢ om.mm m2 em.fi omn.a m<.m ew.mm mw.m mm.cm um Ho.H nos.a ou.¢ nw.Hm mo.m so.mm s: NH. omm.w mq.m oo.vm «0.0 sw.¢m o qo.H HR@.H wo.m mm.ma ea.m oe.oa mm Hm. moo.H oa.o om.Ha mo.v oo.HH x -- -- om.v oo.w oo.m oo.w m Rn.m Rom. mm.m ms.m oo.m sv.¢ n » mucmummmfim .D.m cam: .Dhm, semi mamom mm .m.c may we .m.m ma 2 Houpcoo ma 2 HassoEauuaxm u in manomo nomezoo oz< q~_.-E-—m 3 m— ‘ 0— 0 _ f, : 15-. L _ 20_ 0 15“ '71“? :‘45 ‘ : ' — 50 3 3 . ' 40": _ 10.- 15 _ 15__ ‘1—2 :40 . T 0— 5- - - 15— _§ 1_ - 35E ' 5- m- ' w— ,0_ ;: b i w: mJ_———7m : 0‘ ’ 0" 10- : : 25 ‘- _ ' _— '25 : 10- : 20; 0.- _ -_20 TorTc ? 1. F K H59.SK D Hy Pd-‘AK Mf Pa PrlK $001K fo'iK :s- 70,11: Control X 3.73 11.20 24.60 23.86 13.13 30.53 31.93 . N = 15 8.00 13.33 21.86 24.13 30.33 19.93 77.60 Experimental X 8.00 16.40 23.66 25.20 31.06 20.86 74.76 N = 15 4.46 11.60 24.86 26.53 13.00 31.13 31.26 37 FIGURE 4.2 MEAN RAW SCORE PROFILE COMPARISON OF FEMALE EXPERIMENTAL AND FEMALE CONTROL GROUPS Po _.._—.— K Hs~.SK D Hy Pd+.4K M1 Pti-lK sc+n< Ma-.2K s- “re-Tc , 120-7 7120 ns —' - — ’- 115 female : 3‘” 65; § - 110—:- 0 0 - 50_ - - 40- :--no i : ’ ' ‘ 50': 60': - : i 105 -_ 40- 50- - _ :- 105 - - - _ 1 lm—_ _ 45-: - 40- 25- 55-: 55—. _ -100 I ‘ - 45- ' 70—. 95 -_' 35- _ 15“ _ _ 35 : " 95 ' - - ' 50— 65— 90—' 0* : 40- - - - 50.: _ _‘_ -90 - - i w: ”I I ' - i 0% 85 - 30- 20— — 85 _ 30— - 2°- , 45-3 ‘5 - 30— 55; 80—: ‘130— 15- “ _ 35': - 35; ~: - I -':}0 75 - ‘20— ‘ : - 3°- ‘ ‘ ‘0— - 50F: _ 75 25' ‘10-: - - : _ c 0 "BI-8213;70 Control'X N = 18 Experimental 7 16 7.25 16.50 25.06 34.31 32.31 4.63 13.50 23.50 26.62 12.31 33.93 29.25 65 7; 80- 20- 20- _ ’ ' 55 000—m‘ ‘ :0 0 w— o - 55 ‘2 SO- ' ’ " 55 - 15- - \ 25— ' ‘0— ' 20- 35 I - _ : - m- m- 1 : :- 50-7—30 _ - _ —?.s --25-;-_—so 4s -_ 0; 1°: ,0; _ 20: 15- m—: :- 4s - 15.. 15‘ '. 40" ‘ : : 40— - 15f 5‘ “-0- : 15-: 2—40 ' _ ' 15-. : : 35 - 0‘ 5’- - I ,0; ; lo—f :— 33 - : 53—- ,0_ ' _ 45- 15'- 10.- 10- ’ I _ -———_ .—11 3° - - — 10- - s: '3 - 0- - 5.. ' O— I 25 f - ‘ _ _ 10- - - 25 0— 5% - 5- ‘- 20; - D r-ZO 0‘ “A: TorTc ? L F K Hs+.5K D Hy PanK M1 7 Pa PP 1K Sc ‘ 1K Ma 22K EL TorTc 4.77 13.44 25.11 23 38 12.77 31.33 30.83 6.72 16.67 25.72 36.16 31.44 18.94 63.30 21.25 58.54 38 scales for the female control group are Pa and Sc, with approximately similar elevated scales being Hy, D, Pd and Pt. Male and Female Anxiety Index (Ai) Mean Differences In this study no hypothesis was made about differences between male and female Ai means. The A1 scale was con- sidered to have an important bearing upon patient reaction to the interpersonal therapy given. The A1 means of the fe- male groups (experimental 58.54, control 63.30) appear to be much lower than the A1 means of the male groups (experimental 74.76, control 77.o0). As a post hoc investigation, a two- way analysis of variance was made for the A1 scales by sex and treatment grouping. Three individual scores were randomly dropped out of the female control group, and one score from the female experimental group in order to equalize group cell N‘s to 15 each. The F ratio_for sex is 10.24 and is significant beyond the .05 level. Treatment and Interaction F's are .40 and .11, reSpectively, and not significant. Data for the analysis of variance for the A1 scales can be found in Table 4.3. Normal~Abnormal Analysis In Table 4.4 can be found the number of normal and abnormal profiles for all four groups of the study based on Meehl's criteria. The female experimental group (N = 1o) is comprised of seven normal profiles, seven abnormal, and two invalid profiles. In the female control group (N = 18) 3o TABLE 4.3 ANALYSIS OF VARIANCE OF THE Ai SCALES FOR MALE AND FEMALE GROUPS Source of Variation S.S. df Mean Square F Between , 4551.42 3 1517.14 3.62 Within 23482.88 50 419.34 Total 28034.30 59 Sex 4295.99 1 4205.99 10.23 Treatment 207.87 1 207.87 .49 Interaction 47.50 1 47.56 .11 there are six abnormal, ten normal, and two invalid profiles. The male experimental group (N = 15) contains ten abnormal, three normal profiles, one invalid, and one questionable profile. In the male control group (N = 15) are found five abnormal, nine normal profiles, and one invalid profile. Chi—square was computed for normality-abnormality of the male groups in a 2 x 2 contigency table, using Yates cor- rection factor. The X2 value of the male group with one de- gree of freedom is 3.12 and is not significant. Chi—square was not computed for the female group because the observed to expected frequencies are sufficiently near each other to reveal their non—Significance by inspection. Summary Gain was assessed in this study by the use of MMPI scales. The assessment of the MMPI scales for the 40 TABLE 4 . .1 SORTS OF MMPI PROFILES INTO NORMAL AND ABNORMAL CATEGORIES BASED ON MEEHL‘S CRITERIA Male Female Sorts Experimental Control Experimental Control 0 E 0 E 0 E 0 E .Normal. 3 5.8 C) (1.2 7' 7.9) 10 9.1 Abnormal 10 7.2 5 7.8 7 0.1 0 0.0 Invalid* 1 1 2 2 5"" 1 Total N 15 15 lo 18 df = 1 x3 = 3.12 5% level, X3 > 3.84 - ~Not used in calculating chi square experimental groups (male and female), and control groups (male and female) was made by mean score analysis using t- tests and normal—abnormal sorts of profiles, based on Meehl‘s criteria. The t-test results revealed that there was no significant difference between experimental and control group means in the direction of making greater gain toward normality. The normal-abnormal sorts yielded typically psychiatric profiles with elevations on the D, Pt, Pd, and Sc scales for all four groups. There were no significant differences on sorts between experimental and control groups. CHAPTER V INTERPRETATION AND DISCUSSION OF RESULTS In this chapter will be presented an interpretation and discussion of results as they relate to differences in- fluenced by the interpersonal therapy approach of this study. Discussion of Sub—scales and Profile Analysis A number of researchers have found, in general, significant depressions of the D, Sc, Pt, and Hs scales after various periods of therapy with psychiatric patients. For the present study it was hypothesized that any gain as a result of therapy would be most evident on F. D. Pt. Sc. Si. and Ai scales. with mean scores of the experimental groups being closer to T-scores of 50 than would be the mean scores of control groups. Other researchers have found differences to be significant on these dimensions as a result of psychotherapy. The t—tests of MMPI sub-scale mean scores for both male and female groups of the study support the null hypo- thesis that there is no difference between experimental and control groups in the direction of therapeutic gain. 1W. G. Dahlstrom and George S. Welsh. An MMPI Hand- book (Minneapolis: University of Minnesota Press. 1000). 41 '42 Group Differences The four groups of this study similarly exhibit typi— cal psychiatric profiles1 with the MMPI scales D. Pd. Pt. and Sc being elevated. 'No differences were found as hypo- thesized between the sub-scale means for experimental and control groups at the time of discharge. Normal~abnorma1 sorts yielded much pathology consistent with psychiatric pro— files. but no differences were found among or between the groups. The male experimental group had a mean age of 40.0 years compared to a mean age of 33.0 years for the male con- trol group. despite the randomized selection of patients. The experimental males were hOSpitalized an average of 23.0 0.. days compared to an average of 17.2 days for the control group. Personality difficulties found in the male experi— mental group may be of longer duration and may have pro- gressed further by reason of the greater age of this group as compared with the control group. Contributing Factors Independent of the hypotheses and research design of the study. several factors were noted which may have pro— duced the negative findings. Differences were found in the diagnostic category frequencies (Table 3.1. page 27). where there were approxi- mately 20 per cent more psychotics in the male experimental group than were found in the male control group. The llbid. 43 diagnostic judgments suggest the findings of Schofield and Briggsl in which psychiatric ratings were concluded to give different (better) predictions of patient improvement than MMPI results. A two—way analysis of variance of treatment by sex (Table 4.3, page 39) indicated that the male group means were significantly different from the female means on the Ai scale. The treatment and interaction effects were not significant. The male experimental and control groups had Ai scale means of 74.76 and 77.60, respectively. In con- trast, the females of the study appeared to be less anxious than the males. The female experimental and control groups had means of 58.54 and 63.30, reSpectively. It is possible that the concepts of male and female roles, and societal expectations according to sex, have much bearing upon differences of anxiety levels.. Similarly, male and female role concepts are sampled heterogeneously by the items of masculine-feminine conventions. For this reason, more thorough testing of the relationship of Ai to Mf scales would be a worthwhile area of research. It might be hypo- thesized that longer-termed interpersonal therapy involving role concepts would be more difficult with males than fe- males. Males in the present study seemed to have much more difficulty with acceptable patterns of conduct than did femaleS. L A‘ lWilliam Schofield and Peter F. Briggs, ”Criteria of Therapeutic ReSponse in Hospitalized Psychiatric Patients," Journal of Clinical Psychology, Vol. 14, 1058. 44 Results The results obtained from the comparison of experi- mental and control groups suggest several conclusions: 1. U: The addition of interpersonal therapy to the hOSpital setting of the study has no appreci- able influence on patient improvement, as mea- sured by MMPI scales within the limits of this design. The finding of a lack of significant difference between the means of the various MMPI scales may be influenced by the nature of the diagnostic instrument, i.e., measurement may be (a) too molecular, or (b) validity may not assess short- term gains. The theoretical approach may be too superficial in treating the essential conflicts of patients. The term of hospitalization and thus the period of treatment may be too short for use of the interpersonal approach. several contributing factors outside the research design may have had some effect on groupcompari- sons, e.g., a greater number of psychotics in the male experimental group, greater anxiety in males as shown in Ai scale differences. Such variables may have arisen from sample selection factors, or be influenced by treatment effects. The design of the study did not permit separating these variables. 0. The use of only one therapist employing the interpersonal approach may have limited the findings. Possibly the interpersonal approach could be used more effectively by a more experi- enced or different therapist. Summary In this chapter are presented an interpretation and discussion of the results of the previous chapter. No difference was found between experimental and control groups in the direction of therapeutic gain. The use of inter- personal therapy appears to have no benefit to patients when added to the regular hOSpital regimen. All four groups ap- pear to be typical of psychiatric populations on the MMPI, with elevations found on the D, Pt, Pd, and Sc scales. It was suggested that contributing factorsinot controlled in the research design may have influenced the findings, e.g., differences in group pathology. CHAPTER VI SUMMARY AND CONCLUSIONS In this chapter will be presented a summary of the problem, design, and interpretation of results and, in addition, conclusions and implications for further research. The,Problem The purpose of this study was to investigate what gain would take place in patients receiving interpersonal therapy in a short-term psychiatric setting. Gain was assessed by sub—scale scores of the MMPI. Methodology and Procedure The randomized samples for the study were composed of 15 male and 16 female experimental patients contrasted to 15 male and 18 female control patients. Experimental patients received two to three hours of interpersonal ther- apy a week added to the regular hOSpital regimen in which all patients were seen by their treating psychiatrists. All patients were tested by the booklet form of the O-u MMPI one to two days previous to discharge. The comparison of experimental and control groups was made by: (a) con- trasting the means of each of the MMPI sub-scales using mean scale and profile analysis, and (b) sorting individual 46 47 profiles into normal and abnormal categories according to Meehl’s criteria and computing chi—squares. It was hypothesized that experimental raw score means would be significantly closer (.05 level) to "normal” means on the F, D, Pt, Sc, Si, and A1 sub—scales than would be control group raw score means on these same sub-scales. It was hypothesized that chi-square for the normal-abnormal sorts would yield significantly more (.05 level) normal pro— files for experimental groups than it would for control groups. The Findings The analysis of MMPI data as criteria.cfi' gain re— vealed the following: 1. The t—tests of the sub—scale means for both male and female groups show no significant difference for the experimental groups. receiving inter personal therapy. compared to control groups. R) Normal-abnormal sorts of profiles, according to Meehl‘s criteria, yielded no significant differ- ences for experimental and control groups. 3. All four sample groups have typical psychiatric profiles with primary elevations on the D, Sc, Pt, and Pd scales._ 4. Contributing factors outside the design of the study may have influenced the above results, e.g., imbalance of age and pathology in the randomized selection of the groups. 48 Conclusions The results of this study appear to support the follow— ing conclusions within the limits of the design: 1. Adding interpersonal therapy to the present regimen of short-term treatmentyields no dif- ferences in patients as measured by MMPI sub-scale means and normal—abnormal Sorts of profiles. The use of MMPI sub—scales may have limitations in assessing gain in short-term treatment, e.g., too molecular, and validity misses small differences. Patients discharged from the hOSpital unit of the study show much pathology as revealed by MMPI profiles and Meehl's criteria of normal-abnormal profiles. Implications for Further Research While the interpersonal approach used in the study indicates no significantdifference in patients. it is likely that the brief period of therapy was a limiting factor. Longer—termed therapy might have given more significant results. Pre-therapy tests might be added to the design to measuredifferences.this adding a covariance model when analysis indicates lack of randomness in the sample division. LN . 0 . 40 A more adequate equalization and randomization of sample groups might be made according to size, age, and pathology to yield clearer results. Simultaneous interviews or therapy with signifi- cant intimates of experimental patients might enhance the effectiveness of the interpersonal approach used. Anxieties tapped in the interpersonal approach were probably in evidence on the anxiety index scale (Ai). Larger samples of patients and more extensive research of male and female Ai scale relationships might yield more detailed inform— ation of differences between male and female groups. Anxieties are believed to have an im— portant relationship with the norms, role con— cepts, and personality systems sampled in the theoretical approach of the study. The MMPI was the only measuring device used in the study. A multiple criterion of tests pertin- ent to the interpersonal problems explored might be used for greater sensitivity in assessing differences. e.g.. Taylor Anxiety Scale. Edwards Personal Preference Schedule. Shorter forms of the MMPI, selection of scales, or other more convenient tests might be used in future studies of this kind. Many patients expressed discomfort about the length of the MMPI form. .60 7. Possibly the interpersonal approach might yield more positive results when used by a more ex- perienced therapist, or by several therapists. BIBLIOGRAPHY Ackerman, Nathan W. "The DevelOpment of Family Psycho- therapy," International Mental Research Newsletter, Postgraduate Center fer Psychotherapy, V01..3, June 1961, pp. 1-16. Barron, Frank and Leary, Timothy F. "Changes in Psycho— neurotic Patients with and without Psychotherapy,” Journal of Consulting Psychology, Vol. 19, 1955, pp. 239-245. Cartwright, D. S. "Note on 'Changes in Psychoneurotic Patients with and without Psychotherapy,'” Journal of Consulting_Psychology, Vol. 20, 1956, pp. 403-404. Dahlstrom, W. G. and Welsh, George S. An MMPI Handbook. Minneapolis: University of Minnesota Piess, 1960. Eysenck, Hans. J. "The Effects of Psychotherapy: An Evaluation," Journal of Consultigg_Psychology, Vol. 16, 1952, pp. 319-324. Freeman, Howard E. and Simmons, 0. G. ”Mental Patients in the Community: Family Settings and Performance Levels,” American Sociological Review, Vol. 23, April 1958, pp. 1470154. . "The Social Interpretation of Former Mental Patients," International Journal of Social Psychiatry, v61. 6, Spring 1959, pp. 264-271. Garfield, S. L. and Sineps, J. "An Appraisal of Taulbee ' and Sisson's ’Configurmional Analysis of MMPI Profiles of Psychiatric Groups,'" Journal of Consulting Psychology, Vol. 23, 1959, pp. 333—334. Hecht, Shirley and Kroeber, T. C. "A Study irrPrediction of Attitudes of Patients Towards Brief Psychotherapy," American Psychologist, Vol. 10, 1955, p. 370. Kaufmann, Peter. "Changes in the Minnesota Multiphasic Personality Inventory as a Function of Psychiatric Therapy," Journal of Consulting Psychology, Vol. 14, 1950, PP. 458-464. Kohn, Shirley and Prestwood, A. R. ”Group Therapy of Patients as an Adjunct to the Treatment of Schizo- phrenic Patients," Psychiatry, Vol. 17, 1954, pp. 177—185. 51 U1 [‘0 Lehrman, N. S. ”The Potency of Psychotherapy," Journal of Clinical and Experimental Psychopathology, Vol. 22, June, 1961, pp. 106-111. McClelland, D., et al. The Achievement Motive. New York: Appleton-Century—Crofts, 1953. Meehl, Paul E. "Profile Analysis of the MMPI in Differential Diagnosis," Journal of Applied Psychology, Vol. 30, October, 1946, pp. 517-524. Michaux, William W. and Lorr, Maurice. "Psychotherapists' Treatment Goals," Journal of Counseling Psychology. Vol. 8, 1961, pp. 2500254. Rapoport, Rhona. "The Family and Psychiatric Treatment,” Psychiatry, Vol. 23, 1960, pp. 53-62. Rosemmmig. Saul. "A Transvaluation of Psychotherapy: A Reply to Hans Eysenck," Journal of Abnormal Social Psychology, Vol. 49, 1954, pp. 2980304. Schofield, William and Briggs,’Peter F. "Criteria of Thera- peutic Reaponse in HOSpitalized Psychiatric Patients," Journal of Clinical Psychology, Vol. 14, 1958, pp. 227—232. Simon, Werner, et al. "A Controlled Study of the Short— Term Differential Treatment of Schizophrenia,” American Journal of Psychiatry, Vol. 114, 1958, pp. 1077-1085. Spiegel, John P. "The Resolution of Role Conflict Within . the Family," Psychiatry, v61. 20, 1957, pp. 1-16. Sullivan, Harry S. The Interpersonal Theory of Psychiatry. New York: W. W} Norton & Co., 1953. Sullivan, P. L. and Welsh, G. S. ”A Technique for Objective Configural Analysis of MMPI Profiles," Journal of Consulting Psychology, Vol. 16, 1952, pp. 383-388. Taulbee, Earl S. and Sisson, Boyd D. ”Configurational Analysis of MMPI Profiles of Psychiatric Groups,” Journal of Consulting Psychology, Vol. 21, 1957, pp. 413—417. Welsh, George S. and Dahlstrom, W. G. Basic Readings on the MMPI in Psychology and Medicine. *Mihneapolis: University oerinnesota Press, 1956. APPENDIX A MMPI RAW SCORES FOR THE TOTAL SAMPLE GROUPS 54 MMPI RAW SCORES FOR THE TOTAL SAMPLE GROUPS _ .22...- Male Experimental N 15 L F k Hs I) 107 Pd Mf Pa Pt Sc Ma Si A1 3 17 4 27 34 25 11 23 18 36 40 24 38 96 5 2 15 10 14 20 27 25 11 23 24 23 7 43 2 3 17 18 27 25 31 26 13 31 24 15 32 57 2 2 13 14 18 20 18 20 8 27 22 21 22 54 2 10 0 16 23 27 30 34 15 3 46 2b 20 80 4 16 10 15 34 32 24 18 14 43 42 19 52 114 6 10 a 14 27 27 34 20 16 34 3a 25 7 8n 4 11, 6 21 31 32 2o 28 13 35 39 18 44 85 5 c 14 18 28 21 23 23 11 28 2* 20 24 7n 5 5 1; 19 24 25 26 21 10 30 27 11 40 78 2 11 7 14 29 24 26 2O 10 34 30 21 30 09 4 6 8 12 21 18 23 3 10 31 28 20 36 76 7 4 15 11 1- 18 25 23 14 20 19 16 21 33 7 9 4 28 37 29 26 2 12 38 33 12 55 102 7 3 15 9 13 16 23 24 8 22 20 28 13 57 ”Derived from T—score equivalents LA LA MMPI RAW SCORES (continued) XI Male Control N 15 I. F K H5 1) Phi Pd. Mf Pa 'Pt 5k: Ma 81 Ai 4 6 3 ll 28 18 30 22 9 25 24 18 40 8» 1 ll 5 13 18 22 25 lo 14 36 41 25 35 72 l 4 7 10 21 17 21 24 19 21 17 ll 40 5¢ 4 7 8 16 24 24 21 25 13 35 28 20 45 82 4 7 7 20 28 21 21 22 12 32 2C 12 35 85 1 5 17 11 20 21 22 29 14 24 25 22 lo 58 8 6 9 20 32 32 23 25 10 32 30 17 41 85 5 12 18 13 23 18 2 24 9 34 36 24 25 8- 2 2 8 10 21 12 l) 24 ll 28 30 23 29 81 5 19 8 22 2 21 28 24 21 32 47 29 36 To 2 10 8 13 24 22 25 24 15 33 28 20 36 8C 4 8 21 13 21 27 33 25 15 27 34 17 2 56 10 2 25 18 24 23 24 26 10 27 28 1% 13 63 3 14 ll 1- 34 25 31 26 lo 39 37 21 43 114 4 9 11 13 17 20 2; 27 12 2o 31 19 l. 51 *Derived from T~score equivalents MMPI RAW SCORES (continued) Female Experimental N 16 L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si A1 0 17 5 21 2 2 25 23 17 44 52 2 40 82 9 23 23 30 34 32 32 30 17 3? 53 16 38 72 8 8 17 12 14 24 35 40 8 27 27 26 15 35 6 5 12 16 2' 26 29 37 12 2: 21 15 26 51 5 7 13 10 20 17 23 37 11 22 23 20 30 52 o 4 16 5 17 24 18 37 13 23 25 13 34 35 3 10 6 13 22 25 22 25 12 30 28 2o 25 34 7 2 24 15 22 24 18 35 10 34 29 10 34 63 2 13 10 21 17 25 25 40 11 36 35 33 25 45 2 l3 8 14 30 30 34 33 8 43 45 25 37 $2 6 10 ll 29 26 30 44 17 27 27 25 33 72 3 4 12 17 32 24 31 34 8 31 27 15 2 72 2 7 10 11 lo 11 24 2o 9 27 2? 17 25 57 4 5 17 11 15 22 2t 43 15 32 40 31 20 50 6 11 9 30 37 34 30 34 20 46 54 28 35 SJ 5 5 24 19 20 2F 24 31 5 27 2 l) 19 3b ”Derived from Tescore equivalents MMPI RAW SC RES (continued) FemaleUControl N 18 L F K H5 0 Hy Pd Mf Pa Pt Sc Ma 5:1 41* 2 19 6 24 40 30 31 38 19 45 49 27 48 108 1 25 9 23 39 34 32 34 23 51 61 24 4b 112 2 b 10 14 19 28 30 40 13 31 30 25 29 4o 9 n 11 18 23 23 26 25 15 30 28 20 25 83 2 9 10 13 25 22 18 35 14 37 39 10 27 81 7 2 18 13 26 22 16 37 8 28 23 13 32 c7 4 2 13 11 17 17 19 34 13 29 33 22 34 50 2 7 11 14 1 21 20 42 10 25 2o 15 37 45 7 1 21 22 28 31 2) 41 24 24 1 24 43 - 7 12 1' 30 28 8 41 3 36 27 1o 41 77 7 2 10 17 20 26 18 32 11 23 22 15 29 33 6 2 10 15 20 28 2 36 12 27 25 16 25 41 4 5 L17 13 17 22 17 40 12 32 34 21 23 54 1 6 11 14 30 30 30 36 11 40 31 12 18 ‘1 8 7 lo 26 20 35 27 2: 11 32 2 23 30 25 7 2 16 8 2 21 1% 40 7 21 2) 19 24 52 3 a 8 19 33 24 31 36 22 30 31 21 37 7 8 5 24 17 1% 21 2‘ 35 12 25 26 18 2: 52 u ‘ .- — *Derived from T—score equivalents APPENDIX B THE INTERPERSONAL THERAPY METHOD: A CASE SUMMARY THE INTERPERSONAL THERAPY METHOD: A CASE SUMMARY The interpersonal therapy used in this study repre— sents an attempt to explore with the patient three important dimensions which reflect personal adjustment: 1. The norms by which the patient expects to function are examined within his predominate social setting. Patient norms are compared with the norms of significant individuals of the patient, and societal expectations in general. 2. An overview is made of the personality system of the patient as reflected in his interacting needs, demands, and means of gratification in relation to otherS. 3. Determination is made of the emotional tone which comes to characterize the patient’s behavior be- cause of his reaction to significant others over an extended period of time. The patient is encouraged to recount past and present relationships and future expectations. He is also encouraged to display affect connected with the above dimensions, and to contrast his viewpoints with those of peers and signifi- cant others. An attempt is made to lead the patient to in— sightful conclusions about difficulties that may arise from conflicts within the context of interacting norms, perSon— ality systems and characteristic emotional tones. 5o (50 A summary is presented in the following section of one individual who was in the male experimental group of the study. In brief, the case illustrates some of the diffi- culties which arise in interpersonal areas and how these difficulties can be focused upon in therapy to encourage in- sight and decision-making. Patient: Bob C Age: 18 Days Hospitalized: 84 Therapy Sessions: 21 Bob is an only child and lives with his parents in their Lansing home. The family is of middle social-economic background, the father having worked for the State of Michigan for a number of years. The patient was born to Mrs. C. when she was 35 years of age; Mr. C. was 45 at the time. The parents relate that because of the lateness of a child in their lives, they showered him with affection and gifts. He became the center of their lives. During his early years in public school, Bob had been an average student who brought home average marks. He took piano lessons methodically, learned to play the saxaphone and clarinet, but seldom took part in activities with peers. Bob‘s time was always well planned for him by his parents. eSpecially his mother. Bob‘s mother commented when he came into the hoSpital that she was always watchful lest he be- come involved with "worthless activities and the wrong crowd. . . . He has an IQ of 138, but doesn’t take an inter- est in things.” 61 In his later school years as a maturing teen—ager, Bob never held a job. His activities kept him at home or in supervised situations.l Bob's mother constantly kept a check on his friends and activities, about which he commented, ”She‘d never leave me alone to think for myself!" Often his mother would take him to a doctor because of a fall, a bruise, or complainttaf an ache. In high school Bob became more lax about his studies and his music. He became the ”class clown” in an attempt to amuse his schoolmates, andihe defied teachers if they at- tempted to correct or control him. In Bob‘s second year of high school he was referred to the school's Psychological Clinic, but the case was closed after several interviews be— cause the school psychologist found the parents to be “un— cooperative and unwilling to face their responsibilities.” Bob was expelled from school. About this his mother com- mented at the hoSpital that he was "expelled for a lot of little things, like talking in class . . . although he's a class clown, everyone likes him.” After being expelled from school, Bob was seen privately by a psychiatrist, but was terminated after several visits because the psychiatrist had ”little support from the family . . . little insight from Bob.” Out of school, Bob became restless and increasingly resentful of his parents. He attempted to find several jobs. Adother time he attempted to join the Air Force, but at the last minute on each occasion he would become extremely anxious and fail to follow through. He then refused to seek employment, ”grew a beard and became a beatnik . . . began to seek companionship with the 'wrong crowd‘ . . .” accord— ing to his mother. Activity with his new companions in— cluded ”drag-stripping” on the city's main thoroughfare. Bob was repeatedly ticketed for speeding. Bob's father, in turn, paid all his traffic tickets dutifully, but at home he reacted with tirades about hiSEMHISnever amounting to any- thing. Bob soon reacted to his father's tirades with physi- cal violence which became increasingly serious. On one occasion he assaulted his father and broke one of his ribs. The parents, quite fearful of Bob's increasing rages, called the psychiatrist he had once visited. Under pretext of having him seen for a physical ailment, the parents brought him to the psychiatric unit of the hospital. At the time Bob was admitted to the hospital his mother appeared to be quite anxious and depressed about hav- ing to bring him. Both parents were fearful of how Bob would react when he found himself in the psychiatric unit. Ad- mission to the hospital was a crucial turning point, as the parents, eSpecially Bob's mother, could finally admit that perhapstmfir son had some difficulties. As expected, Bob be— came enraged at being admitted to the unit, and was placed in isolation. Therapy The first hour of therapy was devoted mostly to allow— ing Bob to talk freely about his reactions to hospitalization and letting him expound on what a " dirty trick" his parents played on him in bringing him to the hoSpital. He was en- Couraged to explore why his parents would resort to such tactics and what events he thought might have led up to this move on their part. Bob mumbled something about a strong temper and then reluctantly admitted that he had been abusive physically to his parents. He attempted to persuade the therapist that he saw the errors of his ways and that he wouhjmake amends if only he were allowed to go home. The thera— pist commented that he felt that Bob must be very uncomfort— able with some of his difficulties and he would like to be of some help if Bob wanted to talk about them. It was pointed out to Bob that since he was to be hospitalized for an indefinite period it might be to his advantage to make use of these sessions: should he desire to continue these sessions, he should express how he felt and what he thought. and be as honest as possible about his difficulties. Bob was told that insincere attempts to‘Win over the therapist would not help in understanding himself. Bob reacted to the first interview with reluctant sarcasm. The second and following sessions were directed to a general understanding and then a detailed inquiry to explore more in detail the frictions that existed at home among family members in terms of the dimensions of norm conflicts, personality systems, and emotional toning. Bob was asked to express how he saw himself at home, and what he thought his parents expected of him, both in day-to-day activity and for the future. He was also asked to appraise what he expected of himself. Inquiry was made about his performance in (54 school, and how he felt about working. Bob saw his father as very passive and uninterested in anything, a parent who only complained about what things cost him and never shared any activities with Bob. He saw his mother as picayune and picking on him, ”highly nervous." When asked to 8xplore his own personality, he described him- self as likable by most people, talented, but picked on too much. Despite little self—direction and being out of school, his expectations for the future were quite high and unreal— istic. He saw himself going on to law school or becoming a pianist. The nature of parents demands and their controls, and possible reasons for anxiety were explored. Because the term ”picked-on” was used quite often by both Bob and his mother, this term was explored in more detail as it applied to controls at home and in school. Bob was asked to explore what he might consider to be reasonable roles for a teen- ager and maturing adult, as compared to what might be expected from him when he was much younger. Over a number of sessions some of Bob's defenses broke down gradually and he was able to talk more easily and with increasing insight. He described inadequacies that he felt with peers, early dependency on his mother and her controls, and becoming a class clown in order to gain some sense of importance. His definite fears of increasing uselessness and inadequacy were shown as Bob contrasted himself with friends who were finishing school and going to college, good jobs, or the service. His rebellion appeared a strong 65 reaction to his desire for accomplishment on a footing with peers. and his strong feelings of dependency upon parents. In later therapy sessions Bob's insights led him to a confidence that he might be able to work out some of his difficulties more easily if he had a chance to go back to school and also get a job in order to be more self-sufficient. Controls Controls were considered essential to effective therapy. It was explained to Bob from the first week of hOSpitaliz- ation that he was expected to conform to the demands of the ho5pital routine. In conjunction with therapy, Bob was restricted from having any visitors, including his parents. By the restriction of visitors, the therapist intended to modify the intense emotional tone which was apparently dominating the interaction of Bob with his parents, and allow Bob to adjust to the norms imposed by the hOSpital. Privileges were defined, such as participation in group activities, TV viewing in the evenings, visits to the hOSpital store to buy sundries. At the outset Bob attempted to test controls by frequent abuse of privileges and the privacy of other patients. His privileges were consistently withdrawn so he soon modified his abuse. When Bob appeared to be functioning well within the limits imposed, privileges were extended to include weekend visits home. Bob was asked to return to the hOSpital when- ever he felt his emotions getting beyond his control. The therapist asked that during these weekend visits, Bob's 66 parents not discuss what progress he was making in the hospital, nor bring up the topics of school or future jobs. Bob cut short two of his weekend visits, returning to the hOSpital to avoid heated arguments with his parents or physical abuse. Difficulties that had arisen were talked out at length in therapy. Later home visits became less charged, although they were not entirely free from friction. Follow—through It was considered important that Bob be allowed to test out some of his insights and decisions. After several weekend visits, Bob asked that hospital privileges be ex- tended to him so that he could go out several hours during the day to look for a job. He arranged for testing and interviewing with the Michigan Employment Security Commis- sion, and explored various jobs to which he was referred. The therapist held several conferences with Lansing school administrators and they agreed to allow Bob to attend school two nights a week. Bob left for school from the hOSpital and returned directly after classes. Several weeks later he obtained a job painting the inside walls of a local grocery during his non—school evenings. Bob maintained an A average in his classes and stayed on the painting job to conclusion. This limited success gave him an increasing sense of self- direction and usefulness. The next job was a full-time one at a local discount store, at which time Bob was discharged from the hOSpital, to be seen by his psychiatrist on an out- patient basis. Synopsis Among the norms of the family members there were strong conflicts which worsened as Bob became a young adult. Bob's mother believed that complete supervising of all his activi- ties was important if he was to achieve. The father felt it sufficient to provide only financial support, to leave management in the home to his wife. Because of the controls Bob failed to develop any ability to test social roles for himself, to make many of his own decisions. Although he later resented controls, he also expected that his parents should be a constant source of supplyfor his physical wants. In the personality systems that developed, Bob's mother learned to gratify herself by being the overseer of Bob‘s activities and thus the model mother of an achieving son. Bob learned early that his mother was pleased if he achieved. He learned to control Situations outside the home by com— plaining often that he was picked on, to which his mother re- acted with support. He learned to control at home by somatic complaints. The emotional tone of the relationship derived from the conflicts in norms between Bob, his mother and father. As Bob became a young adult, he found that the con— stant decision—making of his mother, and his failure to meet demands outside the home were stripping him of any ability, or worth in the eyes of peers. The control that his mother imposed on Bob became less effective as he became more aware of how poorly he was able to pompete with peers. He attempted to rebel against control, but was unable to surrender his (18 dependency on parents and, in turn, rebelled the more strongly. Therapy with Bob was directed to: (a) lessening the emotional tone.that existed with family members by iSOIation, (b) encouraging him to explore his conflicts and abilities in terms of his own and others expectations of him, (c) encourag— ing him to come to insightful conclusions and decision-making about work, school, and the future in the context of a con- sistently controlled but supportive hospital setting. H 4 Iii. . - 3 ll. -iI-|1 “1 iii-4 iiiils 1" “ VII-i N H 3 0314 EU -‘[ il l-xl I - 1!. . Him-11 1911'... .2 . . .- fifiég .‘Iull‘l-i