APPLICABILITY OF THE BODY IMAGE
BOUNDARY CONSTRUCT TO
THE PSYCHOPATHOLOGY OF
CHRONIC SVCHIZOPHRENICS.

Thesis for the Degree of Ph. D. .
MICHIGAN STATE UNIVERSITY
FRANCIS J. ELONG
1972

This is to certify that the
thesis entitled
APPLICABILITY OF THE BODY IMAGE BOUNDARY

CONSTRUCT TO THE PSYCHOPATHOLOGY OF
CHRONIC SCHIZOPHRENICS

presented by

Francis J. Long

has been accepted towards fulfillment
of the requirements for

Ph . D . degree in My

 

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Date August 9, 1972

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ABSTRACT

APPLICABILITY OF THE BODY IMAGE BOUNDARY
CONSTRUCT TO THE PSYCHOPATHOLOGY OF
CHRONIC SCHIZOPHRENICS
By

Francis J. Long

The utility of the body image boundary dimensions of
articulation, instability, and security as forecasters of relative
ego adjustment and differential effects of therapy in chronic schizo—
phrenia was investigated.

The 33 severely impaired schizophrenic _S_s were primarily
poor, innercity, and Black, who, according to medical examination,
were apparently free from mental retardation, organically based
psychopathology, and prior exposure to ECT. A pre ~posttest design
was used with the boundary indices being derived from regression
equations to control for varying productivity on the Rorschach, to
avoid the phenomenon of regression to the mean, and to free the
measures of change from, their initial value. The criterion measure

of changed relative ego functioning was also derived by this

 

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statistics
Z-SCOI‘G I
tailed .0

with the .

associati
relative e
6 and 20 I

increased

sion throw;
anoiher (1
bounda FF
bounda r1"
20 9&0me
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Francis J. Long

statistical procedure and all distributions were transformed onto

z -score distributions for purposes of comparability. The one-
tailed . 01 significance level was adopted for directional predictions
with the . 05 level being used in the absence of specificity.

The corrected boundary indices demonstrated only random
association with the validational criterion of clinical judgments of
relative ego functioning at the time of initial. hospitalization and at
6 and 20 months later. Only boundary articulation empirically
increased over time and all the measures of change in the state of
thebody image boundary failed to correlate with the degree of judged
change in relative ego functioning. The measures of boundary change
also did not evidence a differential therapeutic effect.

Using days of hospitalization from the initial date of admis-
sion through the subsequent periods of 6, 12, and 20 months as
another criterion of relative ego functioning, the initial corrected
boundary indices failed to reflect relative adjustment except for
boundary instability, which reached significance at the .05 level at
20 months, but in the direction opposite to that predicted by the
theory. This observation was not replicated using the 6 month
boundary indices and days hospitalized during the following 6 and

1 4 month periods.

 

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that the the;

Francis J. Long

A number of methodological problems are discussed with
serious questions being raised relating to the logical validity and
evident lack of clinical sensitivity of the operations currently
defining the dimensions of the body image boundary construct,
making it impossible to draw definite conclusions regarding the
ultimate utility of the construct for the study of chronic schizo-
phrenia.

It was concluded that the state of the body image boundary
as presently operationalized does not differentially reflect existing
or changed relative ego adjustment in chronic schizophrenia and
that the theoretical conceptualization of the schizophrenic process
as a progressive breakdown of the ego' s boundaries can neither be
supported nor refuted.

The current boundary dimensions are speculatively inter-
preted as anartifactual manifestation of cognitive interactions of
the affectual self and the outside world. The accuracy, maturity,
and defensiveness with which object representations, including that

of the body, ultimately reappear are questioned.

Approved:

 

Date:

 

 

 

AP

 

APPLICABILITY OF THE BODY IMAGE BOUNDARY
CONSTRUCT TO THE PSYCHOPATHOLOGY OF

CHRONIC SCHIZOPHRENICS

By

Francis J. Long

A THESIS

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

DOC TOR OF PHILOSOPHY

Department of Psychology

1972

 

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L ‘. ACKNOWLEDGMENTS

The longest journey begins with the first step, and of
great importance are those who help along the way. When and
where the journey. ends is not known, but while it continues those
who have helped will not be forgotten. I wish to thank the members
of my committee, Drs. B. Karon, A. Rabin, N. Abels, and
S. Jennings. My special appreciation goes to Bert Karon for not
only serving as my committee chairman but for his guidance and
support throughout my graduate career.

My thanks also goes to an untold number of readers who

have extended a hand along the way.

ii

 

 

USIOF'I
INTRODCI

Bodyl
I:
1

Body
E
h

PURPOSE

Probl
Rese:

METHOD
San”:
Evalg

Trea-

1 -‘\ .A f" A >— <

 

TABLE OF CONTENTS

LIST OF TAB LES
INTRODUC TION

Body Image Theory.
Psychoanalytic Theory
The Schizophrenic Process

Body Image Research .
Research: General .
Research: Schizophrenia

PURPOSE

Problem Statement .
Research Summary .

METHOD

Sample Description .
Evaluation Procedures
The Rorschach.
The Clinical Status Interview
Treatment of Data
Design .
Corrected Boundary IndiCes .
Changed Boundary Indices
Control Variables
Criteria of Validity
Therapeutic Effect

iii

Page

11
14
15
20

27

32
34

38

38
39
39
42
43
43
43
45
46
46
47

 

  

DISC L'SSII;

Methc‘
V

 

RESULTS

Pretreatment Analysis
Comparison Note . .
Subject Characteristics .
Group Differences

Validity Analysis . .
Predictive Validity .
Concurrent Validity

Posttreatment Analysis .
Boundary Change .
Group Differences

DISCUSSION .

Methodological Problems
Validity . .
Rorschach Examiners
Sample.......
Measuring , Procedure

Implications for Theory

Implications for Therapy

Implications for Research

SUMMARY
APPENDIX A: SCORING DIRECTIONS

BIB LIOGRAPHY

iv

Page
48

48
48
50
50
51
51
52
55
55
56

59

59
59
60
60
61
64
68
70

72
78

86

 

Table

‘1

Su

Co

 

Table

LIST OF TABLES

Subject Characteristics .
Coefficients of Interrater Reliability
Correlation of Observed Body Image
Boundary Indices with Rorschach
Protocol Length

Descriptive Statistics .

Analysis of Subject Characteristics
Predictive Validity Analysis

Concurrent Validity Analysis

Boundary Change Analysis

Page
39

41

44
49
51
53
54

55

 

that agreerr.
etiology, pa
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IN TRODUC TION

A brief review of the literature on schizophrenia reveals
that agreement among psychiatrists and psychologists as to its
etiology, pathology, clinical limits, and therapeutic treatment is
lacking (Wolman,. 1965). However, Freud' s (1927) structural con-
cepts, designated the id, ego and super ego and defined according
to function, provide a comprehensive theoretical framework within
which the progression, arrest, and regression of psychological
development and functioning can be assessed. The severity of ego
impairment in schizophreniais recognized by Freudians and non-
Freudians alike as evidenced by their common. theoretical emphasis
on loss of contact withreality, regression, and unconscious processes
in the disorder (Wolman, 1965).

Recently, with the quantification of certain dimensions of
the body image construct (Fisher & Cleveland, 1958; Secord, 1953;
Tait 8: Archer, 1955) interest in and emphasis on the body' 3 impor-
tance to the development and functioning of our psychic structure
, has been increasing. Reestablishment of the body image "boundaries"

(Des Lauriers, 1962; Federn, 1952; Freytag, 1961; May, Wexler,

 

Salkin, & 5
Paige, MCI
of this incr

TI
boundary c
L'pon findir
and clinica
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The degrei
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relative st

 

Salkin, & Schoop, 1963; Goertzel,. May, Salkin, & Schoop, 1965;
Paige, McNamara, 8: Fisch, 1964) in schizophrenics is one aspect
of this increasing concern.

This study is a longitudinal investigation of body image
boundary change as an index of ego functioning in schizophrenia.
Upon finding a significant correspondence between boundary change
and clinically judged ego -functioning, the differential effects of
three forms of therapy on the body image boundary will be explored.
The degree of body image structure as an indicator of the severity
of the schizophrenic reaction will also be investigated by relating

relative structure to length of hospitalization.

Body Image Theory

 

Historically, psychologists have shown little direct interest
in the bodyimage concept, although for more than half a century it
has been recognized as a potentially useful frame of reference for
the study of personality (Freud, 1927; Head, 1926; Schilder, 1935).

Prior to the 1950' s, the major emphasis came from the
field of neurology. During the first quarter of the century, such
men as Bonnier (1905), Head (1920), and Pick (Oldfield & Zangwill,
1942) described body image distortions in their patients caused by

intracranial pathology and amputation of body extremities. Henry

Head (1926) developed one of the first theories related to this concept.
He observed that each individual gradually develops a "schema” of
himself against which all body movements are judged. Head (192 6)
not only emphasized this model' 3 guiding influence on body posture
and orientation, but implicitly indicated that the mental schema was
an unconscious frame of reference for evaluating a wide range of
experiences.

Between the 1920' s and the 1950' s, the interest in the body
image concept cOntinued to stem from neurology, but the emphasis
gradually shifted to include psychological as well as neurological
considerations (Andre-Thomas, 1946; Bychowski, 1943; Curran
B: Frosch, 1942; Curran 8L Levine, 1942; Heymann, 1947; Langhi,
1940; Pirisi, 1950; Reitman, 1947; Sandifer, 1946; Scott, 1948;
Teitelbaum, 1941). During this period of time, the literature was
dominated by the work and theoretical writings of Paul Schilder
(1934,1935, 1938, 1942a, 1942b, 1950). These writings (Schilder,
1934,. 1935) not only relate to physiologically based body image
distortions, but to those reported by individuals suffering from
functional psychotic reactions. For Schilder (1950), who attempted
to theoretically integrate the physiological, psychological and socio-
logical factors contributing to the formation of the body image, the

body image plays an important role in the development of the self

 

system whic
relates to h:-
awareness
obiects.

A1:
(Bender, Gil
1949; Benet
1940' s and
into clinical
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system which, in turn, significantly influences how the individual
relates to his environment. He also emphasized that body boundary
awareness was maintained through contact with reality and its
objects.

Although purely neurological studies continued to appear
(Bender, Green, & Fink, 1954; Bender, Shapiro, & Schappell,

1949; Benedek & Angyal, 1940; Freed & Pastor, 1951) in the late
1940' s and early 1950' s, the body image concept was being integrated
into clinical practice through use of newly developed projective tech-
niques (Buck, 1948; Machover, 1949) into diagnostic test batteries.
By the late 1950' s, emphasis on the body image concept was primar-
ily psychological.

Body image studies using word associations, drawings,
distorting mirrors, aniseikonic lenses, tachistoscopically presented
pictures of distorted bodies, estimation tasks and responses to ink
blots to measure such variables as body anxiety (Secord, 1953),
body dissatisfaction (Jourard & Secord, 1955), body size (Nash,
1951), plasticity of the body scheme (Schneiderman, 1956), position
of the'body in space (Witken, Lewis, Hertzman, Machover, Meiss-
ner, &Wagner,. 1954), preferred body proportions (Jourard &
Secord, 1955), and gender designations assigned to various body

regions (Nash, 1958). However, the main impetus came from the

 

theoretical :
who have f0'
body image.

Li};
Cleveland (1
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theoretical and empirical work of Fisher and Cleveland (1958, 1968)
who have focused their attention on the ”boundary" dimension of the
body image.

Like the psychoanalysts to be discussed later, Fisher and
Cleveland (1958, 1968) believe that the process of separating self
from non -self is crucial to the formation of personality. They
theorized that during maturation and development, the body image
boundary gradually develops from an internal location within the body
to the body' 3 surface as the bodily regions of pleasurable contact
with the environment change from location to location. The body
boundary becomes more definite through contact with the environ-
ment, resulting in a body image boundary that corresponds fairly
well with the actual body wall of the normal adult. Postulating a
continuum of vagueness—definiteness upon which an individual' 3 con-
ceptualization of his boundary falls, Fisher and Cleveland (1958,
1968) assume that one projects this conceptualization into relatively
unstructured stimuli such as ink blots.

The theoretical writing most directly applicable to the body
image construct are those of Schilder (1935,. 1950) and Fisher and
Cleveland (1958, 1968), but many existing theories of perception and

personality contain body image considerations.

 

 

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adopted the
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From the field of perception, for example, Myers (1911)
adopted the concept of ”schema" to explain certain aspects of space
perception in the autokinetic phenomena. Koffka (1935) also used
this concept in developing his theoretical consideration of "spatial
frameworks. " More recently, Wapner and Werner (1965) have based
their theory and investigations on the assumption that there is no
perception of external objects without a bodily frame of reference.
Witkin (Werner & Wapner, 1965) has urged the investigation of body
image. development in relationship to all aspects of psychological
growth. Lending credence to this urging is the emphasis placed upon
the importance of the body to ego ~fo'rmation by Gesell (1948) and
Piaget (1963) and their theories of child development.

Body image implications and personality theOry are illus-
trated by Adler' s (1930) dynamic formulations which center around
the body and attitudes developed towards it. Reich (1949) speaks of
psychic conflicts expressed in patterns of muscle toneness which
influence how the individual experiences himself and others. Sullivan
(1947) postulates that "insecurity" disrupts the integration of body
parts into the self system and forces the individual to adopt action
and thought designed to protect the poorly integrated self system
from threat. . However, the psychoanalytic school of thought has
continuously emphasized the importance of the body' 8 contribution

to psychic structure development, organization, and adjustment.

 

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Psychoanalytic Theory

 

According to Freud (1927), the fundamental function of the
ego is the testing of reality, but at birth the components of the mental
apparatus are not differentiated from each other. This is the stage
of primary narcissism and objects in the outside world do not exist.
Differentiation of the ego coincides with the discovery of external
objects and the ego becomes more differentiated as reality becomes
more differentiated. Thus, the ego exists insofar as it is differen-
tiated from objects that are not ego.

Freud's (1927) statement that "The ego is first and foremost
a body-ego [p. 31], " suggests that the body image is the nucleus of
the ego. Through increment and decrement of bodily tensions, the
infant gradually recognizes these sensations and that there is "some-
thing" out there which assists him in the reduction of tension.

Bodily sensations are developmentally integrated into the psychic
structure and used as a basis for discriminating between the outer
world and the body. Knowledge of spatial and temporal boundaries
is gradually gained as the individual differentiates self from non-
self.

With the beginning awareness of outer objects, the indi-
vidual begins to recognize himself as an object and according to

Fenichel (1945) "The sum of the mental representations of the body

and its organs, the so-called body image, constitutes the idea of I
and is of basic importance for the further formation of the ego
[ p. 36 ] . "

Psychosexually, the temporal and successive increment of
erogenous sensations arising from the oral, anal, and genital areas
of the body must be integrated into the psychic structure and
ultimately permitted discharge in accordance with the demands of
this structure. Thus, the body image is influenced by and reflects
the individual' 3 successes and failures at integrating these erogenous
sensations into his being. Disturbed personality integration sug-
gests disturbed body image integration (Freud, 1927; Federn,, 1952;
Klein, 1932; Jung, 1931, 1944; Reich, 1949; Rose, 1966; Woodbury,

1966).

_Eigo boundary and body ego. —-Considering ego functioning

 

from a phenomenological point of view, Paul Federn (1952) contrib -
uted significantly to the theory of ego development by introducing the
constructs of "ego boundary" and "body ego. "

Federn (1952) views the ego as an "experienced" psycho-
somatic unit and used the concept of boundary .to designate the outer
extent of the felt unity of the ego' 8 contents, beyond .which ego
feelings do not exist. He postulated two major boundaries, one

between the ego and the outsideworld and one between the ego and

the id. Sensations arising within and crossing a boundary are sensed
as mental, and belonging to the ego, while stimuli impinging on a
boundary and passing through it are sensed as real, as belonging to
the external world. According to Federn (1952), the sensing of
reality. is one. of the main functions of the ego' s boundaries.

Federn' s concept of the bodily ego, the somatic component
of the ego, represents the continuous awareness of the body' 3
sensory and motor apparatus, its proprioceptions and perceptions
of the body and of objects in the outside world. These felt contents
are bounded and stimuli from the outside world passing through the
bodily ego boundary "charged with a particular quality of sensation
and bodily ego feeling [p. 43 ] " create the sense of reality (Federn,
_ 1952).

Initially, all the infant' s perceptions are egotized because
the existing ego, both mental and bodily, has no boundaries (Federn,
1952). Throughdiscovery of the body, the existing ego is progres-
sively organized, differentiated and bounded. The individual' 8
contact with the external world creates ego states composed of
various perceptions--tactile, visual, auditory, olfactory, etc. --
which appear and disappear primarily through physical movements.
The ego cannot withdraw from its bod-ily sensations, but it gradually

, learns to control physical movement which provides control over

10

the perceptual field. Gradually the sense of self as subject and as
object comes into being as the individual differentiates bounds and
detaches himself from what is not himself.

As the bodily ego becomes more consolidated, the ego
feeling becomes more and more complete. Bodily ego feeling is
the psychical representation of the body ego boundary which reflects
the sensed limits of one' 3 body and its parts. The normal individual
with a healthy ego possesses full ego feeling for his actual body
boundaries which delineates him from the external world.

The bodily ego contains more than just the united evidential
aspects of the body; it contains mental representation of objects
located in the outside world. A growing awareness of external
objects means an enlarging bodily ego boundary. It is the repre-
sentationof these objects in relation to the body, the core of the
bodily ego, which orients the individual to his- surroundings.

Federn's formulations (1952) equate development of the
body image withdevelopment in the bodily ego, but he does not
consider them as identical. The body image is seen as the changing
presentation of the total configuration of the body while the bodily
ego represents the continued awareness of the body. Federn states
that an investment of bodily ego feeling in the body image results in

a correspondence between the entire body image and the bodily ego

11

boundary. Thus, the bounded bodily ego feeling at any given moment
is the evidential component of the body image.

Developmentally, an extension of bodily ego feeling means
a change in both bodily ego boundary and the configuration of the
body image. As the neonate progresses through the various ego
stages, corresponding states of the body image are developed.
Maintenance of achieved level of ego differentiation and functioning
are dependent. upon the maintenance of coherent, united body ego
feelings. Disturbances of the ego, such as repression, regression
and fixation are equally imposed on the body image. Thus, when
ego feeling‘is denied access to,. or withdrawn from an area of the
body, the bodily ego boundary is incomplete and the body image
boundary. is likewise deficient. When withdrawal of invested bodily
ego feeling from a part of the body occurs, the person loses the
sensation that the bodily part belongs to himself. Such withdrawal
of bodily ego feeling disrupts the body image as reflected by the
disturbed bodily ego boundary. These disturbances are strikingly

evident in schizophrenia.

The Schizophrenic Process

 

According to Freud (1920), ego impairment in schizophrenia

begins with the withdrawal of cathexis from external objects and the

12

world in general. Reality controls diminish and the individual
cathects his own ego. Contact with reality is resigned and the ego
gives way to the unconscious wishes and impulses of the id.

This break with reality and the symptoms of ego dis-
integration are interpreted by Freud as a regression to the pre -ego
pre ~object stage of psychological development. At this stage, the
boundary between the individual and the outside world is unclear and
the schizophrenic, through the mechanism of projection (Freud,
1950), perceivesmany of his own sensations as coming from the
environment. These hallucinations and delusions are judged by
. Freud (1920) as attempts to restore emotional contact with external
objects.

Federn (1952), in opposition to Freud, theorizes that the
basic mechanism underlying the schizophrenic process is withdrawal.
of ego cathexis. The ego' s boundaries, both mental and bodily,
weaken and break down because of this withdrawal, resulting in the
manifest pathology of schizophrenia.

When the ego' s boundaries are weakened by the withdrawal
of cathexis, the coherent unity of feeling is disrupted. Mental
phenomena, such as remembrances and unconscious impulses,
along with bodily sensations, which were previously recognized as

belonging to the egotized self, penetrate the ego' s boundary as

13

"real. " Fusion of these falsifications with actual. reality is
manifested as hallucination and delusion. Regression to former
ego boundary states precede or accompany these symptoms as a
defensive measure against further disruption of ego feelings.
Correct perception of reality is impossible because of the weakened,
regressed ego boundary.

Federn (1952) views the disruption of the ego' s boundaries,
both mental and bodily, as being accompanied by an influx of anxiety
andterror. Although boundaries are initially strengthened by this
influx, when the anxiety and terror are unchecked and prolonged,
ego cathexis is drained away, resulting in the further disruption of
boundaries. It is suggested that during the phase of inner ego
boundary breakdown, when falsifications of reality are being con-
structed, the schizophrenic may hypercathect these delusional
conceptions and withdraw from reality to avoidthe. confusion and
"mutilation". of ego feeling contingent upon repeated collisions
between these falsifications and "actual" reality. The process of
boundary breakdown is interrupted by "sealing" off one' 3 self from
reality, the hypercathexis of one' s thoughts as "real" precludes the
necessity of testing reality. This avoidance of anxiety, terror,
and boundary. breakdown is at the expense of ego boundary flexi-

bility.

14

Federn (1952), unlike Freud, does not see schizophrenia
as untreatable. Theorizing that the separate distinctiveness of an
individual' s identity and his ability to relate to the outside world
as such is dependent upon maintenance of the bodily ego boundary,
Federn views the schizophrenic as having, lost the ability to expe-
rience his bodily ego boundary as a coherent, continuous unity
because of the-withdrawal of ego cathexis. Thus, the halting and
reversal of the schizophrenic process can be characterized as the
conservation and re -establishment of ego cathexis in the bodily-ego
boundary, the evidential component of the body image boundary.
This research is concerned with there -establishment of the body' s
, image boundary differentiated definiteness as an index of ego

functioning - in schiz ophrenia.

Body Image Research

 

The use and understanding of the body image, body schema,
body concept, etc. , has been gaining in prominence since the 1950's.
, More controlled, better designed studies of the body image have
been conducted in adiversity of context making the literature diffi-
cult to systematically review and consolidate into a coherent picture.
This survey will be restricted to those studies having a more direct

bearing on the current investigation.

15

Research: General

 

Much of the literature is composed of descriptive clinical
observations, such as those by Bonnier (1905), Head (1920), Pick
(Oldfield 8: Zangwill,. 1942), and Schilder (1935), concerning body
image distortions associated with brain damage and limb amputation.
Serving well to establish the phenomenological existence of the body
image as a psychological variable, these descriptions include
accounts of drug effects (Savage, 1955) and reports of the distor-
tions accompanying altered states of consciousness, toxic conditions
and fatigue (Schilder, 1950).

One of the earliest studies involving normal subjects was
that by Klein and Schilder (1929) who analyzed the performance and
subjective‘reports' of their subjects while working with the Japanese
illusion on entangled arrangement of the upper extremities which
reverses the position of the left and right hands. They concluded
that the differentiation and maintenance of the body image is depen-
dent upon one' s being in contact with reality through moving, touch-
ing, and seeing.

Experimental results with normal subjects tend to support
this conclusion. Reduction of the total amount of sensory stimu—
lation, especially when diffused non -pattern visual stimulation is

involved, causes a wide variety of cognitive, motor, sensory, and

16

perceptual effects to occur, the most dramatic of which are
hallucinatory experiences, including the presence of other people
(Bexton, Heron, &.Scott, 1954; Heron, Doan, & Scott, 1956; Lilly,
1956; Goldberger & Holt, 1958).

The work of Strauss and Weiner (1938) and Strauss (1939)
associated the body image disturbance of finger agnosia with an
inability to do certain mathematical problems and to grasp-certain
spatial relationships. Similarly, Teitelbaum (1941) found a psycho-
logical connection between the individual' 5 knowledge of his body
and his performance of certain tasks while using hypnosis to study
disturbances of the left and right sides of the body. These investi-
gations suggest that the body. image is associated with and may serve
as a frame of reference for modes of perception and performance of
various tasks.

Curran and Frosch (1942), using a semistructured inter-
view with adolescents concerning active feelings about the body,
foundlittle personality disturbance accompanying experiences of
the body as a'whole, but they reported that social adjustment was
poor among adolescents with excessive body preoccupation. Mach-
over (1964) compared the figure drawings of college students with
their performance *on'some of Witkin' s (1954) perceptual tasks.

The field dependent subjects indicated low evaluation of the body

17

while themore independent students showed narcissistic investment
in the body, mature sexual features, and well integrated body
imagery in their drawings. These studies suggest that mature,
integrated body attitudes are associated with social adjustment and
with the way an individual views himself in relation to unstructured
spatial tasks.

Cleveland and Fisher' 3 (1954) initial observation that
rheumatoid arthritis patients produced Rorschach percepts with hard,
protective, containing peripheries suggested to them that boundary
qualities of ink blot percepts may be related to the feelings one has
about the body' 3 periphery. This assumption resulted in the intro-
duction of the "body image boundary dimension" (Fisher 8: Cleveland,
1958) indexed by two Rorschach content scores, "barrier” and
"penetration. " However, Fisher and Cleveland (1958) devoted less
attention to the penetration score than to the barrier score and
significant relationships between the penetration score and the
variables studied were not demonstrated (Mednick, 1959).

Since the introduction of the quantified boundary definiteness-
vagueness continuum, there have been repeated demonstrations that
psychosomatic symptom formation of an internal (heart and stomach)
and external (skin and muscle) nature correspond with boundary

indefiniteness and definiteness, respectively (Fisher 8: Cleveland,

18

.1958; Cleveland & Fisher, 1960; Williams 8: Krasnoff, 1964;
Cassel, 1965). Penetration scores have only tended to be higher
for individuals affected by internal symptoms as opposed to those
suffering from external psychosomatic symptoms.

Psychosomatic patients with exterior and interior/symptoms
have been shown to differentially channel physiological reactions to
the exterior «and interior of the body. in correspondence with the site
of their symptoms (Fisher, 1963; Armstrong,. 1963).

The‘relationship between boundary definiteness and the way
the individual reacts to stress has also been investigated. Davis
(1960) found that individuals with differentiated boundaries reacted
in the external measures of physiological stress and individuals
with indefinite boundary reacted in certain interior measures of
stress. Using inducedlaboratory stress, a negative relationship
was found between boundary definiteness as indicated by the barrier
score and emotiOnal expressiveness by Brodie (19.59). McConnell -
and Daston (1961) obtained a positive relationship between favorable-
ness of attitudes towards pregnancy and boundary definiteness of
females. After-delivery, the barrier index of definiteness did not
change. The stress of existing or impending bodily disablement
was more adequately coped with by individuals indicating boundary

definiteness on the Rorschach than those indicating indefiniteness of

19

boundary (Ware, Fisher, 8: Cleveland, 1957; Fisher 8: Cleveland,
1958; Landau, 1960; Sieracki, 1963).

Studies comparing normal subjects with high and low boundary
differentiation as indexed by the barrier score have shown that the
more definite the individual' 3 boundary, the more likely he will
behave autonomously, manifest high achievement motivation, be
invested in task completion, be spontaneously expressive and
interested in communicating with others, face hostility, and serve
an active, integrative role in small group situations (Fisher 8:
Cleveland, 1958; Cleveland 8: Morton, 1962; Ramer, 1963; Fisher,
1963, 1964a).

Changesin the boundary indices, primarily in the barrier
score, have been affected by induced somatic awareness (Fisher
8: Renik, 1966; Renik 8: Fisher, 1968; VanDeMark 8: Neuringer,
1969; Darby, 1970) and by sensory isolation (Reitman, 1962; Reit-
man 8: Cleveland, 1964). Although the changes associated with
induced somatic awareness were not consistent, Reitman and
Cleveland (1964) differentially effected three different measures of
the body image boundary with schizophrenics.

Not all of the research is conclusive, but there is support
for the general conclusion that the body image, especially its
boundary definiteness, plays an important role in any individual' 3

psychological makeup and functioning.

20

Research: Schizophrenia

 

Schilder (193 5), observing the body image distortions
experienced by schizophrenics, concluded that these distortions
cannot be clearly distinguished from those experienced by people
suffering from organic pathology and Bychowski (1943), writing from
clinical observations, supported this claim. Many compiled lists
of body image distortions experienced by the schizophrenic have
since appeared (Fenichel, 1945; Fisher 8: Cleveland, 1968;
Lukianowicz, 1967). These lists not only demonstrate the functional
importance of the body in schizophrenia, but when compared with
organically based distortions (Bychowski, 1943) suggest that in time
of stress, either from physical disruption of the body or severe
psychological disorganization, the body image is likewise disrupted
and disorganized.

The clinical literature also contains many descriptive
accounts of body image disturbances in schizophrenic patients,
strikingly underscored by Bleuler' s (1950) vivid observations of
bizarre transformation in body form and body sensation. Laing
(1960) describes in detail the phenomenological existential view of
the schizophrenic body image disturbance which he characterizes

as a feeling of being "disembodied. "

21

Observations made during the psychotherapy of schizophrenic
patients have suggested that their improvement was often accompanied
by areorganization of the body image (Bleuler, 1950; Hafner, 1959).
Such clinical observations have in turn led to speculation like that of
Burton (1959) that successful treatment of chronic schizophrenia
cannot occur without a reorganization of the body image.

As a consequence of these clinically based considerations,
many approaches to the treatment of schizophrenia have been based
on techniques designed toincrease body awareness through relearning
the pattern of bodily sensations that accompany various postures,
sets, and emotional states (Des Lauriers, 1962; May, Wexler,
Salkin, 8: Schoop, 1963; Goertzel, May, Salkin, 8: Schoop, 1965;
Paige, McNamara, 8: Fisch, 1964). Best illustrating these
approaches is Des Lauriers' (1962) position, which states that
"making a schizophrenic aware of his body, particularly his bound-
aries, is one of the prime methods for restoring his individuality
and reality testing [p. 120] ."

Several studies have dealt with loss of body image boundary
such as that by Bender and Keeler (1952), whose work with schizo-
phrenic children receiving electric shock treatment resulted in the
conclusion that the children had. difficulty determining the boundaries

of their body after shock. The body image disturbances observed

22

were similar‘to those found in dreams and in altered states of
consciousness. Phillips and Rabinovitch (1958) analyzed the
symptoms of 604 schizophrenic patients and judged those with
hallucinatorysymptoms as failing to adequately separate the self
from external objects. These patients were judged the most
disturbed of the sample. Victor (1964) found, comparing psychotic
males with normal male hospital employees, that boundary fluidity
was positively correlated with the tendency to judge perceptions

of real objects as possibly ”unreal. " However, he found a chance
relationship between body boundary fluidity and the judgment that
misperceptions were correct.

Zucker (1962) compared sixty paranoid schizophrenics,
half of whichwere ambulatory and half were hospitalized. Assess-
ingego boundaries and body image characteristics, the ambulatory
group manifested significantly less body. image disturbance than
the hospitalized group. The hospitalized group gave more indica -
tions of boundary disturbance than the ambulatory group.

Jortner (1966) compared schizophrenics with alcoholics
and neurotics'using his "inside -outside" score, a measure of body
_ image boundary transparency. He found the schizophrenic giving
significantly more of these responses to the Rorschach than the non-
schizophrenic group. It was concluded that schizophrenia seems to

involve a breakdown in the body boundary.

23

Fisher and Cleveland (1958, 1968) have extended their body
image boundary dimension to the area of psychotic behavior. Their
findings of significantly lower barrier and significantly higher pene -
tration scores for schizophrenics as compared with neurotics and
normals supports the theoretical considerations of schizophrenia as
a condition in which the individual lacks body image boundary definite-
ness. However, the boundary indices (Fisher 8: Cleveland, 1958) did
not distinguish the neurotic from normal subjects. Similar findings
were reported by Cleveland (1960) and by Reitman and Cleveland
(1964). Holtzman, Thorpe, Swartz, and Herron (1961) found the
penetration score significantly higher for schizophrenics than for
normals. The barrier score tended to be higher for‘normals but
the difference when compared with schizophrenics did not reach sig -
nificance.

Two studies by Fisher (1964b, 1966) found no significant
differences for the penetration-score among schizophrenic, neurotic,
and normal subjects of both sexes. The barrier score was signifi-
cantly higher for (the normal male than the male psychiatric groups.
For'the females, the barrier score initially failed to distinguish
among the groups (Fisher, 1964). In the second study (Fisher,
1966), the female schizophrenics indexed greater boundary definite-

ness than the female neurotics. Jaskar and Reed (1963) reported

24

that the barrier score did not discriminate normal females from a
mixed group of hospitalized neurotic and schizophrenic women. In
a personal communication to Fisher (1963), McPartland and Hornstra
reported significantly greater boundary definiteness in their normal
male and female controls than in their neurotic and schizophrenic
subjects.

Fisher and Cleveland (1958) found no significant difference
in boundary definiteness between forty paranoid and forty undif-
ferentiated schizophrenics. Paranoid schizophrenics were found to
possess significantly greater boundary definiteness than non-
paranoids by Conquest (1963) after he subtracted the penetration
score from the barrier score. Using this procedure, Fisher (1964)
replicated these findings. Similar findings were obtained by him
(Fisher, 1966) using the Chi-square statistic without subtracting the
penetration score from the barrier score.

Fisher and Cleveland (1958) noted that schizophrenic
patients who were the most regressed were the ones with Rorschach
percepts of bizarre, concrete body image boundary breakdown and
the ones most prone to experience sensory distortions. Further-
more, a positive relationship between total number of reported
body image distortions and nurses' rating of ego disintegration in.

both male and female schizophrenics was reported by Fisher (1966).

25

Hornstra and McPartland (1961) found that schizophrenics
with high barrier scores were the patients with ward behavior rated
by the hospital staff as restless, acting out, and initiatory of contact
with others, both patients and personnel. Low barrier schizophrenics
were rated as retarded and withdrawn, not initiating contact with
others.

Cleveland (1960), in a two phase study, investigated changes
in boundary indices for schizophrenics as they recovered from the
acute stages of psychosis. A significant positive relationship was
found between decrease rated morbidity and decrease in penetration
scores during the first five weeks of drug therapy. This relation-
ship was still evidenced after thirteen weeks of treatment, but the
barrier score changes showed no significant correspondence with
the morbidity ratings. Patients rated as unimproved, tended to in-
crease their penetration scores.

In the second phase, Cleveland (1960) had patients rated
at admission and at discharge by two psychiatrists for amount of
improvement. Improved patients showed a significant decrease in
their penetration scores as compared with scores at admission.
Those rated as "markedly improved" not only significantly
decreased their penetration scores but significantly increased

their barrier scores on the Rorschach.

26

Reitman and Cleveland (1964) investigated changes in the
boundary indices using sensory isolation with hospitalized neurotics
and schizophrenics. Test ~retest difference for the controlled group
of schizophrenics was not significantly different, and the initial test
scores forthe controls did not significantly differ from the experi-
mental group of schizophrenics. After four hours of sensory isola -
tion, consistent changes were effected in the boundary indices for
the experimental groups. The schizophrenics significantly decreased
their penetration scores while the neurotics significantly increased
their penetration scores. Barrier significantly increased for'the
schizophrenics while it decreased for the neurotics. Tactile sensi-
tivity increased and. decreased for the schizophrenic and neurotic,
respectively. Estimation of body size became more accurate for
the schizophrenic and less accurate for the neurotics after the

isolation.

PURPOSE

The idea that the body plays a central role in man' 3 total
psychological organization and functioning has a long, varied and
complex history. It is through the body and its sense organs in
interaction with the environment that the individual separates, dif-
ferentiates, and bounds himself from the outside world. The body
is not only experienced in relation to the outer world as it exists
for-the individual, but in relation to all aspects of the self.
Representing the differentiated self from the non -self, the individ-
ual' 3 knowledge of his body and the outside world is embodied in
the body image, the individual' 3 mental conceptualization of his
bounded physical being and interactions with the outside world and
the self.

Observations of body image distortions experienced by
brain damaged and post operative patients (Bonnier, 1905; Head,
1920; Schilder, 1935), by schizophrenics (Bleuler, 1950; Laing,
1960) and normals in altered states of consciousness (Schilder,
1950), and the effects of drugs (Savage, 1955) suggest that an inte-

grated, coherent body image is the basic frame of reference for

27

28

sensing the self and the outer world as meaningful. This research
assumes that psychic and somatic factors are intimately related and
that the body image, especially its boundary, is an enduring part of
the personality, not merely a reflection of a disturbance in some
part of the physical being.

Since the introduction of the body image boundary dimension
by Fisher and Cleveland (1958), several investigations have made
the assumption that the definiteness -indefiniteness of the body image
boundary is reflected in the attributes ascribed to the periphery of
ink blot images more tenable. Fisher and Fisher (1964), using
introspective reports, coupled high and low barrier scores as
measured by the Rorschach with exterior and interior sites of
perceived bodily sensations, respectively. This linkage of barrier
score with bodily experiences was more directly demonstrated by
Fisher and Renik (1966), Renik and Fisher (1968), VanDeMark and
Neuringer (1969), and Darby (1970). Through experimental manipu-
lation of bodily awareness, significant changes in the attributes
projected on the periphery of ink blot images were demonstrated
by these investigations. Such changes in the boundaries of pro-
jected imagery strongly support the contention that the character
of one' s bodily. image boundary as indexed by the barrier score

influences one' s perception of what is ”out there. "

29

Holtzman' s et al. (1961) factor analytic investigation of
sixteen samples, including such groups as college students, average
adults, seventh graders, elementary school children, five -year-olds,
depressed patients, and schizophrenics, found the barrier score,
across all samples, correlated with Rorschach indices of ego
integration. Thus, the barrier score appears to be a measure of
ego integrationand body image boundary articulation.

The significance of the penetration score (Fisher & Cleve-
land, 1958) has not been as well established. Its relationship to
the barrier score has been recorded as insignificantly low, some-
times negative andinsignificant (Fisher 8; Cleveland, 1958), and at
times significantly positive (Darby, 1970). Theintra —individual
stability of the penetration score varies greatly (Holtzman et a1. ,
1961), but empirical findings show the penetration score as trend—
ing towards a significantly higher level of occurrence for low as
compared with high barrier groups.

Factor analytic study of the penetration score (Holtzman
et a1. , 1961) showed this score significantly associated with Ror-
schach indices, suggesting emotional immaturity, bodily preoccupa-
tion, emotionally disturbinggfantasy life, and psychOpathology.
Interpretation of the varied findings regarding the pene-

tration‘score in relation to the significance of the barrier score

30

suggests that the relative prominence of the penetration score
appears when there is a weak and ill defined body image boundary,
and there is sensitivity to rather immediate situational conditions,
boundary vulnerability and threatened disruption. Thus, the pene-
tration score appears to represent body image boundary stability-
instability.

Research has repeatedly shown distinct and consistent
individual differences in body image boundary articulation (Cleve-
land & Sikes, 1966; Daston & McConnell, 1962; Fisher, 1963;
Reitman & Cleveland, 1964).

The theoretical characterization of the schizophrenic as
an individual who can no longer cathect his mental and bodily ego
boundaries to their normal extent because the withdrawal of
cathexis has created a weakness and regression of the ego system,
which may continue through a break with reality (Federn, 1952)
has been supported by several investigations. Schizophrenics, when
compared with normals and neurotics, have been found to possess
significantly less boundary articularion (barrier) and significantly
greater boundary. instability (penetration) than the comparison
groups (Fisher & Cleveland, 1958; Cleveland, 1960; Reitman &

Cleveland, 1 96 4).

31

Federn (1952) also asserts that when contact with reality is
given upaduring the early stages of the schizophrenic process, when
the individual is faced with the breakdown of the inner-ego boundary
because of cathexis withdrawal, the body image boundary articulation
is relatively more preserved and protected from the emotional impact
of cathexis withdrawal than when extreme regression occurs before
the break with reality. The research findings suggest that the schizo-
phrenic does avoid boundary instability to a degree and preserves its
articulation through giving up ”actual reality" and hyper-cathecting
his falsified thoughts as "real" (Conquest, 1963; Fisher, 1964b,
1966; Fisher & Cleveland, 1958; Zucker, 1962.).

Federn' s (1962) hypothesized break with reality as a con-
sequence of the schizophrenic mechanism of total ego cathexis
withdrawal as a defense against further disruption does not pre-
clude the continued withdrawal of cathexis. Phillips and Rabinovitch
(1958) analyzed the sumptoms of 604 schizophrenics and concluded
that those patients with hallucinatory symptoms failed to separate
the self from external objects and were judged the most disturbed
of their sample. Bender and Keeler (1952) reported that electro-
shock therapy left schizophrenic children unable to determine
the boundaries of their bodies, and Fisher and Cleveland (1958)

noted that the schizophrenics who were the most regressed were the

32

ones with Rorschach percepts of bizarre, concrete, body image
boundary breakdown as well as the ones most prone to experience
sensory distortions.

Federn (1952) suggests that reinvestment of cathexis in the
ego system reverses the schizophrenic process. Research findings
indicate that boundary change canwbe induced by a variety of methods

(Cleveland, 1960; Darby, 1970; Reitman & Cleveland, 1964).

Problem Statement

 

The theorists in schizophrenia have generally viewed the
behavioral manifestations of the disorder as a reflection of decreased
ego. integration and functioning. In light of Federn' s (1952) theo-
retical consideration of the schizophrenic process and the existing
empirical data, it appears that body image boundary articulation and
stability are ascertainable symptoms of ego regression and progres-
sion during the schizophrenic process. Demonstrations of boundary
change (Cleveland, 1960; Darby, 1970; Fisher & Renik, 1966;
McConnell & Daston, 1961; Reitman & Cleveland, 1964; Renik &
Fisher, 1968) clearly. illustrate the possible utility of the indices as
measures of adjustment.

Body image boundary articulation appears to be positively

related to ego functioning. This resea rchassumes that the barrier

 

 

C0

trg

F8

a:

33

score (_B_) is a mental projection of the body image boundary
organization and, as such, represents the degree of separateness
from. the outside world.

Body image boundary instability appears to be negatively
related to ego functioning. This study assumes that the penetration
(_B_) score is a mental projection of the body image boundary break—
down and, as such, represents the degree of fusion with the outside
world.

Adjustment of boundary articulation by removal of boundary
instability appears to better discriminate ego functioning among the
traditional psychiatric classifications of schizophrenia. This

investigation assumes that the 2 minus theP (B-P) indexes the

 

consistency of the body image boundary and, as such, represents

the degree of security of separateness from the outside world.
Clinical use of these indices in research requires that

their degree of predictive and concurrent validity be established.

By assuming that length of hospitalization reflects severity of the

schizophrenic process, the relationship between the boundary indices

and days of hospitalization (DH) will provide an indication of their

utility. as indicators of the severity of the schizophrenic reaction.

The correspondence between these indices and clinical ratings of

relative ego functioning from clinical status interviews (CS) will

indicate their concurrent utility as indices of ego functioning.

34

Upon finding an acceptable level of correspondence between
the boundary indices and relative ego functioning, the change in
boundary indices will be used to assess the differential effects of
the three forms of therapy employed in the Michigan State Psycho-
therapy Research Project. This phase of the investigation is based
on the assumption that change in the schiZOphrenic' s boundary is

due to the effects of the intervening therapy.

Research Summary

 

The major hypothesis advanced in this research is that
the state of the body image boundary, its articulation and its sta-
bility, is associated with relative ego functioning in schizophrenia.
A combination of the two factors into one index is expected to be a
better indicator of relative ego functioning then either factor alone.

Using Fisher and Cleveland (1968) _B_ and 3 scores after
correction for varying response productivity on the Rorschach to
measure body image boundary articulation and instability, respec-
tively, the following hypotheses are designed to assess the boundary
indices' degree of utility as predictors of the severity of the

schizophrenic process.

HYPOTHESIS I

 

Body image boundary articulation, reflected by the _B_

score, will be negatively related to DH.

35

HYPOTHE SIS II

 

Body image boundary instability, reflected by the 3

score, will be positively related to DH.

HYPOTHESIS III

 

A combination of the body image boundary indices, formed
by subtracting the corrected penetration score (£11) from the cor-
rected barrier score (_C_B), will be negatively related to DH to a
significantly greater degree than either of the separate boundary

indices.

The following hypotheses are designed to assess the boundary
indices' degree of utility as concurrent predictors of relative ego

functioning.

HYPOTHESIS IV

 

Body image boundary articulation reflected by the _B
score will be positively related to clinical ratings of relative ego

functioning from CS.

HYPOTHESIS V

 

Body image boundary instability, reflected by the 3
score, will be negatively related to clinical ratings of relative

ego functioning made from CS.

36

HYPOTHESIS VI

 

A combination of the body image boundary indices, formed
by subtracting the CP score from the CB score, will be positively
related to clinical ratings of relative ego functioning to a signifi-

cantly greater degree than either of the separate boundary indices.

HYPOTHESIS VII

 

Changed body image boundary articulation, reflected by
the changed _B score (CCB), will be positively related to changed

clinical ratings of relative ego functioning made from CS (CCS).

HYPOTHE SIS V III

 

Changed body image boundary instability, reflected by the

changed 3 score (CCP), will be negatively related to CCS.

HYPOTHESIS IX

 

A combination of the changed body image boundary indices,
formed by subtracting the CCP score from the CCB score, will

be positively related to CCS to a significantly greater degree than

either of the separate boundary indices.

37

A demonstration that body image boundary articulation and/
or boundary instability are significant indicators of relative ego

functioning will enable the exploration of the following hypotheses.

HYPOTHESIS X

 

Body image boundary articulation will be differentially
affected by the three forms of therapy employed in the Michigan
State Psychotherapy Research. (Which types of treatment will pro-

duce the most change is not clear.)

HYPOTHE SIS XI

 

Body image boundary instability will be differentially
affected by the three forms of therapy employed in the Michigan

State Psychotherapy Research Project.

HYPOTHE SIS XII

 

The combined body image boundary index will be differ-
entially affected by the three forms of therapy employed in the

Michigan State Psychotherapy Research Project.

METHOD

Sample Description

 

Thirty -three of the 36 clearly schizophrenic patients,
originally selected in sets of three from admissions to the Detroit
Psychiatric Institute for random assignment to treatment in the
Michigan State Psychotherapy Research Project, were used in this
study. These subjects (Es) were severely impaired, most, if not
all, of a chronic nature. According to medical examination, these
_Ss were apparently free from mental retardation, organically-
based psychopathology, and prior exposure to ECT. Two of the
original SS were omitted from this study because complete sets of
data were not available for them, and one _S_, who died during the
project, was not replaced because of randomization problems. A
comprehensive description of the sample and factors influencing its
ultimate structure has been published by Karon and O' Grady (1969).

The distributions by age, education, race, and sex for the
Es used in this research are given in Table 1. The sample is pri-

marily poor, innercity, and Black.

38

39

Table 1

Subject Characteristics

 

 

 

Characteristic N Characteristic N
Sex Education
Male 1 6 None
Female 1 7 1 -5 1
5 -9 7
Race High School
Negro 2 5 Incomplete 12
White 8 High School
Complete 10
Age University
- 16 -1 7 3 Incomplete 2
18 -22 9 University
2 3 -2 8 9 Complete 1
2 9 -35 6
36 -44 5
45 -49 1

 

 

 

 

Evaluation Procedures

 

The Rorschach

 

The Rorschach was individually administered to all the
_S_s at the time of selection and after 6, 12, and 20 months from
each _S_' 3 date of selection for the project. Two examiners were
used, one doing all. testing through the first 12 months, and the
second testing at 20 months. Both examiners were advanced
graduate students in clinical psychology who had completed course

work on the Rorschach. Neither examiner knew to which treatment

40

group the _S_s belonged. Beck' 3 (1961) recommended procedures
were followed and responses were recorded by hand.

Two raters, one undergraduate honors college student and
one graduate student in clinical psychology, scored the Rorschach
protocols for}; and _l: according to the system devised by Fisher
and Cleveland (1958; 1968). The instructions given the raters are
found in Appendix A.

After familiarizing the judges with the Rorschach, the
scoring system, and providing them with scored protocols as guides
(Fisher & Cleveland, 1968), each rater independently scored two
practice sets of schizophrenic Rorschach protocols taken from the
literature (Weiner, 1966). Practice set one contained six protocols
and practice set two contained seven. Each set of protocols was
scored by both raters. Upon completion of each practice set by the
judges, product moment correlation coefficients of interrater
reliability‘were computed and further discussions with the raters
were conducted to clarify scoring discrepancies. Similar discus-
sions occurred after completion of the first and third sets ofS
protocols.

The initial (R1), 6 - (R2), and 20-month (R3) protocols
used in this study were uniformly duplicated and coded to obscure

their identity. Eleven sets of nine protocols each were randomly

41

selected without replacement from the total group of 99 protocols.
Pearson product moment correlations were computed for each set
of actual data to assess interrater reliability. These coefficients

are shown in Table 2.

Table 2

Coefficients of Interrater Reliability

 

 

 

Data Sets N E _B_
Practice 1 6 .586 . 512
Practice 2 7 . 704 .713
Actual 1 9 .989 .987
Actual 2 9 .904 . 964
Actual 3 9 . 885 . 797
Actual 4 9 . 852 . 975
Actual 5 9 . 813 . 898
Actual 6 9 . 942 . 968
Actual 7 9 . 936 . 950
Actual 8 9 . 989 .981
Actual 9 9 .806 .914
Actual 10 9 . 993 . 922
Actual 11 9 .622 .955
Actual Total 99 . 922 . 947

 

 

 

 

The obtained interrater reliabilities for the 99 protocols were
. 922 for the_B_ score and . 947 for the}: score. Both coefficients

are within the range reported by Fisher and Cleveland (1958; 1968).

I
-i'
a!

I: flrwv-n-r '

42

.The Clinical Status Interview

 

Eaché participated in a 30 minute semi-structured
interview conducted by an experienced psychiatrist. Each interview
was tape recorded. All patients were interviewed four times
paralleling the testing schedule used with the Rorschach. However,
only the initial (CSI)’ 6- (C82), and 20—month (CS3) interviews
were used in this study.

The areas of inquiry relative to manifest ego functioning
were: ability to care for self, ability to work, sexual adjustment,
social adjustment, absence of hallucinations and delusions, degree
of freedom from anxiety, amount of affect, variety and spontaneity
of affect, satisfaction with self and life, achievement of capabilities,
and benign versus malignant effect on others.

Two Ph. D. candidates in clinical and personality psychology
rated relative ego functioning from the recorded interviews. The
aforementioned criteria of ego functioning were clinically integrated
into a unidimensional judgment for each _S_ which was quantified
relative to all Es according to a scaling technique developed by
Estavan and modified by Karon and O' Grady (1970). Paired inter-
views were presented to the two raters, who were allowed to clarify
the verbal content when the quality of the recordings was poor before
making theirindependent judgments. Two judgments were involved

with each pair offis. After each rater independently decided which

 

43

individual of a given pair was healthier, each rater then independently
decided what proportion of mental health the sicker_S_ of the pair
possessed in relation to the mental health of the healthier_S_ of the
pair. Discussion of completed ratings was permitted. A detailed
report of the scaling technique, the method used in pairing and the
determination'of the reliability and validity of the ratings has been
published by Karon and O' Grady (1970). The split -half 3 coefficients
for CS1 intrarater consistency were .83 and . 79 with the interrater
reliability coefficients being .87 and .82. Equally high coefficients

of internal consistency and interrater reliability were obtained for

the CS2 and CS3 ratings.

Treatment of Data

 

Design

A pre -posttest design with the corrected barrier and pene —
tration scores along with their combination into a single index of the
state of the body image boundary serving as the dependent variables

was employed in the research.

Corrected Boundary Indices

 

The relationships between the observed _B_ and _I: scores

and the uncontrolled Rorschach ptotocol length for R1, R2, and R3

 

44

 

 

 

 

 

 

 

are shown in Table 3. All of these correlations exceptE for R2 were
significant beyond the .05 level.
Table 3
Correlation of Observed Body Image Boundary Indices
with Rorschach Protocol Length
Body Image r Significance
Rorschach Boundary Indices — Level
R1 I_3_ . 7699 - . 01
3 . 3731 . 05
R2 3 . 5671 . 05
_f: . 0938 _n_s_
R3 2 . 4824 . 01
_I: . 5520 . 01
Note: f. = 31, N = 33

The significant effect of varying protocol length was
removed by McNemar' s (1962) recommended procedure of trans-
forming the various distributions into _z_ score distributions, deter-
mining the regression of theBandE 3 score distributions on their
respectivefi distributions, and then subtracting the predicted_B_

andfii score values for each_S_ from his observedl_3_ and £_z_

15.]: ._.

45

scores. These corrected_z_ score values for each_S_ from each
testing were used as the best indicators of his "true" _B_ and "true"
_P_ scores.

Since the coefficient of nondetermination (1 -_r_2), indicating
the proportion of :12 that is independent of the regression of _¥_ and
_X_, resulted in a coefficient of . 9912 for the R Edistribution, this
distribution was directly transformed into a _z_ score distribution
without correcting for _B_.

The combined boundary index of security was obtained by
subtracting the £35. score from the 22.3.. score for each individual,
except for R2, where_(_3_B_-_1:was used for this index because less

than 1 percent of the variance in P was accounted for by variation

in 3.

Changed Boundary Indices

 

The predicted 1 score B and z score 3 distributions,

obtained by the regression of the R corrected boundary indices on

3

the R1 CB and CP E score distributions, were subtracted from the

R3 z score CB and CP distributions to determine the distributions
of changed corrected boundary indices (McNemar, 1962). This
statistical procedure not only freed the changed scores from the

effects of regression to the mean but also made them independent

of their initial value.

46

Control Variables

 

The degree of association between the R corrected boundary

1
indices and the_§_ variables of race, age, sex, and education were
assessed (Pitman, 1937).

Measures of intelligence in this sample reflect relative
impairment resulting from the psychotic process. An analysis of
even vocabulary I. Q. and the corrected boundary indices may have
resulted in a significant, but spurious correlation. Since studies
with non -psychotic subjects by Appleby (1956), Fisher and Cleveland
(1968), and Ware, Fisher, and Cleveland (1957) have shown only a
chance relationship between intelligence and the body image boundary
scores, the I. Q. was not used as a control variable.

Potential difference in the state of the body image boundary

between treatment groups at the start of the project was investigated

by a one -way analysis of variance.

Criteria of Validity

 

Each _S_' 3 DH between his initial selection as a S and the
subsequent 6, 12, and 20 months of the project were assumed to
reflect relative impairment of ego functioning by the psychotic
process. These distributions of DH were used as the criterion

measure for assessing the predictive validity of the ”true" body

47

image boundary indices. Because of the longitudinal nature of the

study, only the R data were used for intragroup replication purposes.

2

The ratings of relative ego functioning made from the CS
interviews served as the criterion measure of concurrent validity.
Changed relative ego functioning after 20 months, also used as a
criterion measure, was determined by. the same statistical pro-
cedure (McNemar,. 1962) used to calculate the change in the cor—
rected boundary indices after 20 months.

A significant relationship between these criterion of validity
was demonstrated. The initial and 6 months ratings of relative ego

functioning correlated -. 71 and -. 64 with the number of DH during

the six month period subsequent to each set of ratings.

Therapeutic Effect

 

The significance of the change in the body image boundary
dimension over time was assessed (McNemar, 1962) by computing

the mean difference for related samples between the R1 corrected

boundary indices and the R corrected boundary indices. A one -way

3

analysis of variance‘was used to evaluate fora differential thera-

peutic effect.

RESULTS

This section-systematically reviews the sequential
analysis of the body image boundary scores in relation to the
control variables, to the criteria of predictive and concurrent
validity, and to observed change in these indices over time. As
can be seen by the following results, the boundary scores were not
affected by the factors of race, age, sex, and education once
correction for _R was made. The hypotheses concerning the
predictive and concurrent validity of the corrected boundary
measures were not confirmed. Replication using the R2 data also
failed to support these hypotheses. The _C_B_ score was the only
boundary index significantly changing over time, but analysis of its

significant increase between groups indicated no differential effect

of therapy.

Pretreatment Analysis

 

Comparison Note

 

The descriptive statistics for the raw score distributions

, R , and R Rorschach evaluation are

of _I_3_, 3, and _R_ for the R1 2 3

48

49

given in Table 4. One or two extreme scores accounted for each of
the skewed distributions, but analysis of the raw data indicated a
linear relationship between the boundary measures and R. The
nonsignificant t of . 986 obtained between response productivity for
R1 and R3, the largest empirical discrepancy for the two examiners,

suggested comparable Rorschach performance under different

 

 

 

examiners.
Table 4
Descriptive Statistics
Rorschach Mean S. D. Median Range
R1
_R_ 15.373 9.766 15 2-55
B 2.773 3.329 1.5 0-14
E 2.621 3.018 1 0-12.5
R2
3 17.454 7.211 16 4-32
B 2. 97.0 2. 506 3 0-12
'5 2.606 2.920 1.5 0-10.5
R3
_R_ 17.000 5.545 18 3-27
B 2.818 2.400 3 0-10.5
E 1.818 1.841 1 0- 6. 5

 

 

 

 

 

50

Fisher and Cleveland (1958; 1968) failed to report means
and standard deviations for the _B_ and 3 scores obtained from 40
chronic undifferentiated schizophrenics responding freely to the
Rorschach. Reporting only a mean _P_t of 18. 5 for this group along
with'ranges 0 through 6 and 0 through 9 with medians of 2 and 4
for the _B_ and _I: distributions respectively precludes any direct
statistical comparison of these findings with those of this investiga-
tion. However, greater variability appears initially evident in this
sample, gradually decreasing over time and resulting in more

comparable ranges of performance.

Subject Characteristics

 

The product moment and point biserial correlation coef-
ficients obtained as non -parametric tests of association (Pitman,
1937) between the initial corrected boundary indices and the _S_
characteristics of race, age, sex, and education are shown in
Table 5. Only chance relationships were found, indicating that the

corrected boundary indices are independent of these variables.

Group Differences

 

A one -way analysis of variance of the R1 corrected

boundary indices between the pretreatment groups indicated no

significant differences in the state of the body image boundary

51

Table 5

Analysis of Subject Characteristics

 

 

 

 

Sex Race Age Education
Item
2 _P_ .13. .13. E. 3 _B_ 3
Correlation . 248 -. 029 . 178 . 178 . 027 -. 309 -. 022 . 047
Significance ns n ns n
Level —— _S_ _ .3 2?. 2?. 23’. PE.

 

 

 

 

 

 

 

 

 

Note: d.f. = 31, N = 33

between the therapy groups. The E E (2, 30) = 2. 311, _p> . 05 and
the_P_ 3(2, 30) = 3.2386, _p_> .05.

Since the control analysis of each correlated distribution
demonstrated non ~significant relationships and differences for the
pretreatment analysis, it was assumed that the combined boundary

CB and CP score distributions, was inde-

1—

index, based on the R

pendent of the _S_ variables and did not significantly differ between

the pretreatment groups .

Validity Analysis

 

Predictive Validity

The product moment correlation coefficients for the cor-

rected boundary indices for R1 and R2 and the periods of

52

hospitalization are given in Table 6. None of these correlations
reached the one -tailed . 01 level of significance. In opposition to the
theoretical prediction of a positive relationship between boundary
instability and DH, a negative relationship betweengfi for R1 and
DH trended toward and reached significance at the .051evel at

20 months.

Replication of this analysis using the R CB and _13,

2
uncorrected because of its random association with _13._

(3.: . 093), resulted in random relationships. Hypothesis III,
stating the significantly greater predictive efficiency of the com-

bined boundary index over that of the separate indices, is clearly

not confirmed .

Concurrent Validity

 

Non -significant relationships were found between the
CS1 ratings of relative ego functioning and the R1 corrected
boundary indices, using a one -tailed .01 level of significance.
Similar findings were obtained for the R2 and C82 data.

Change in the corrected boundary indices after 20 months

failed to correlate with the change in relative ego functioning after

20 months. These correlations are reported in Table 7 and suggest

53

Table 6

Predictive Validity Analysis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Periods
. . Corrected . . .
Hospitalized . Significance
. Boundary Correlation
Given Indices Level
in Months
R1
_Ii . 043 is:
0-6 _I: -. 202 £13
CB-CP . 048 _n_s_
E . 016 I13
0 - 12 _B_ -. 266 33
CB-CP . 110 _r_i_s_
_Ii -. 008 _n_s
0-20 _P_ -.299 .05>p>.01
CB-CP —. 017 n_s
R2
CB . 064 _r_1_s_
6 - 12 _P_ . 236 _ns
B-_I: -. 103 25".
CB . 035 113
6 -20 E . 107 _n_s_
CB -_F_’ -. 125 _ns

 

 

 

 

54

that the boundary dimensions are not reflective of relative ego

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

functioning.
Table 7
Concurrent Validity Analysis
Corrected . Significance
Rorschach Boundary Correlations
. Level
Indices
CS1
CB -. 073 _n_s
R1 CP .075 E
CB — CP -. 088 gs;
C82
CB . 191 _n_s_
R2 _I: -. 073 £13
CB -__P_ . 175 _n_s
CCS3
CCB .085 _n_s
R3 CCP -. 016 _n_s
CCB - CCP . 070 _n_s
Note: d.f. = = 33

55

Demonstration of random associations between the ratings
of relative ego functioning and the combined boundary index, as
well as with the corrected separate boundary indices, does not

confirm Hypotheses VI and IX.

Posttreatment Analysis

 

Boundary Chang:

 

The mean differences between the _C_I: and _C__B-_C_P_ scores
for R3 and the R1 El: and ESE-g scores were not significant at
the two -tailed . 05 level. However, a significant mean difference was
obtained between the R _C_B_ and R _C_B_. These findings, reported

in Table 8, indicate no change in the corrected boundary indices

except for a significant increase in the CB score after 20 months.

Table 8

Boundary Change Analysis

 

 

 

Boundary S Significance
Indices MD SD MD t Level
CB. .4662 1.0964 . 1909 2.4421
CP .0382 .9899 .1723 .2217 _n_s
CB - CP .40924 1.41819 .25659 1.59488 :13

 

 

 

 

 

 

Note: d.f. = 32, N: 33

56

Group Differences

 

Group differences were analyzed for change in each
boundary index from R1 to R3. A one —way analysis of variance
of change for each boundary index between groups from R1 to R3
revealed no significant group differences attributable to a differ-
ential therapeutic effect, _C_BE (2, 30) = .2906, p > .05;

_C_P__E (2,30) =1. 1783, p> .05; and -C_B -££ (2,30) = .0620,
p > .05. These results indicate that boundary instability and
boundary security remained essentially the same over time while

the significant increase in boundary articulation occurred equally

among all groups.

 

DISCUSSION

A variety of studies (Fisher, 1959b, 1960; Fisher &
Cleveland, 1955, 1956, 1957, 1958, 1960) have been conducted to
validate the _B and 3 boundary dimensions. These supportive
findings. however, have been primarily based on the results from
normal and neurotic individuals. Investigations of schizophrenia
have failed to clarify the relationship between the boundary concepts
and psychopathology.

The theoretical formulations advancedin this research
were derived from psychoanalytic and ego psychology, especially
that of P3111 Federn (1952). It was hoped that a longitudinal investi-
gation of the body image boundary of chronic schizophrenics as they
functionally improved or deteriorated would provide information
that would verify and help define more adequately the dynamic role
of the body image boundary in psychosis. However, the current
findings did not demonstrate significant associations between the
state of the body image boundary, mirrored by the _B_ and E quali-
ties of Rorschach percepts, and relative ego functioning, reflected

by global clinical ratings and days of hospitalization. Boundary

57

58

instability increasingly trended toward predictive significance over
time, but this trend was opposite to that predicted by the theory,
and was not reproduced by the replication phase of the study. The
long term prognostic value of a high degree of boundary instability
at the onset of a schizophrenic episode is highly speculative at best.

Although boundary articulation significantly increased over
time, it did not forecast change in relative ego functioning and
manifested no indication of a differential therapeutic effect at the
end of 20 months. Thus, the corrected boundary indices do not
appear to differentially assess existing or changed ego adaptability
in chronic schizophrenia. Support is not provided for the theoreti-
cal conceptualization of schizophrenia as a progressive breakdown
of the ego' s boundaries. The boundary construct, as currently
assessed, is interpreted as an artifactual manifestation of the cog—
nitive interaction of the affectual self and the outside world.

A number of possible reasons, centering around the
methodology, may have accounted for these nonconfirmatory
results. Methodological questions can be raised concerning the
criteria of validity, the use of two Rorschach examiners, the
nature of the sample, and the measuring procedure. These will be
turned to in their judged order of importance for the outcome of

this investigation.

59

Methodological Problems

 

Validity

A controversy exists regarding the assumptions underlying
the choice of criteria of validity (Malamud, 1946; Rapaport, 1948),
but Guilford (1956) and Karon (1968) have emphasized that the
ability of any measure to forecast an aspect of life constitutes its
validity. Thus, agreement between the generally accepted criteria
of days hospitalized and clinical ratings of relative ego functioning
was sought based on the assumption that congruence between these
measures could be interpreted as evidence for their own validity
against which the validity of the corrected boundary indices could
be determined. The two methods of evaluating ego functioning, with
only the guidelines governing discharge from the hospital lacking
explicit statement, were conducted independently of each other by
different individuals.

Under these conditions the observed interconsistencies of

-. 71 and -. 64 between CS and CS

1 respectively, with each sub-

2
sequent six month period of hospitalization, indicate that these
criteria are highly dependable measures of relative ego adjustment.

Thus, the present nonsignificant results do not appear to be a con-

sequence of the unreliability of the criterion measures.

60

Rorschach Examiners

 

The criticism of employing more than one examiner
(Mednick, 1959) is less meaningful when the_R_ distributions in
Table 4 are compared. Productivity, the measure upon which the
boundary indices depend, varied between R1 and R2 under the same

examiner as much as it varied between R1 and R3 with different

examiners. A t test of the differences ing for R1 and R3 was not
significant. Thus, a differential examiner effect on productivity

does not appear evident.

Sample

Population differences and sample size may have a decisive
effect on the precision of correlational studies. A number of factors
influenced the ultimate composition of the group (currently studied
(Karon & O' Grady, 1969) andeas not exceedingly large. These
factors may have altered the values of the correlation and regres—
sion coefficients, although the direction of possible influence from
their true values is not known.

More immediately important is the question of homogeneity
or heterogeneity of the sample. Although factorsoperated influenc-

ing sample composition, inspection of thefidistributions in Table 4

suggest that a wide range of pathology (Phillips 8: Smith, 1953) or

61

relative ego functioning existed within the sample. Thus, derivation
of the corrected boundary indices from regression coefficients
based on heterogeneity of impaired ego functioning is expected to
have better approximated the "true” boundary indices than had these
derivations been based on the Rorschach performance of a more

homogeneous group.

Measuring Procedure

 

The high coefficients of interrater reliability, obtained
for inexperienced judges following standard instructions and pre—
scored examples, suggest that confidence can be placed in the
ratings. Focus thus turns to the method used to control for_R_and
the scores themselves.

The use of scores derived from regression equations
markedly deviated from the usual methods of controlling produc-
tivity. It did not necessitate the exclusion of short records or the
arbitrary reduction of long protocols to a fixed number. Removal
of the effect of_f_t_ in this manner may have removed other effects
associated withfiwhich are not strictly controlled when_R_ is a fixed
number.

The original scoring system (Fisher & Cleveland, 1958)

was criticized because of a lack of standardization (Eigenbrode 8:

62

Shipman, 1960; Mednick, 1959; Wylie, 1961) and because of an
overlap between the two major categories of scoring (Cassell,
1964). A post-mortem analysis of the revised scores (Fisher 8:
Cleveland, 1968) raises serious questions about the system' s
logical validity.

Close examination reveals an arbitrariness concerning not
only which responses are scored, but which score they receive.
As examples, the new system now scores all articles of clothing,
but excludes the popular bow tie of Card 111 and the boots on Card IV
because of their frequency. The bearskin on Card IV is also
excluded, yet percepts emphasizing the characteristics of an animal
skin are scored. Masks are generally excludedfrom theB category
without explanation as to when they are scored or why such a "cover-
ing" is excluded when a wig is specifically l_3_. Mouth, scored}:
when opened for intake or expulsion, is not scored when speaking
or singing. Confusion is also evident in the B scoring of inlet
and the _B_ scoring of harbor entrance. Percepts of the body wall
being damaged or broken' are _B_, while such specific examples as
"bloated cat" and "a person caught between two stones" are_B
percepts. Thus, the criticisms of inconsistency and ambiguity

still apply to the scoring system.

63

Quantification of verbal elaborations, especially those of
the psychotic, along such narrow lines ignores the dynamic range
of such behavior. For example, a high animal percent equals
boundary articulation while clinically it is associated with constric-
tion, stereotypy, and inflexible ego functioning. Such test behavior
coupled with a tendency to perseverate (Klopfer 8: Spiegleman, 1956),
creates a clinical picture of an ego differing greatly from one with
well articulated boundaries. On the other hand, "vagina" given to
Card III, D3 scored F+ (Beck, 1961), is not clinically suspect in
itself but absolutely seen as _B_. Equally undifferentiated is the
clinical distinction of the bizarre and concrete from the symbolic,
i. e. , insides of the body as opposed to a broken vase. Thus, the
system also lacks clinical sensitivity.

Even though the B and 3 dimensions were loaded on the
factors of ego integration and disintegration respectively (Holtzman
et al. , 1961), the preceding considerations suggest inherent weak-
nesses in the scoring system. Such clouding within and between the
scoring categories as well as the lack of clinical sensitivity may
well have masked the discovery of existing relationships between
boundary qualities and relative ego functioning. However, use of

the boundary construct as currently measured with schizophrenics

l
_

 

64

appears to be a misapplication in the investigation of relative ego

differentiation.

Implications for Theory

 

Because the evidenced lack of correspondence between the
state of the body image boundary and relative ego adjustment is
based on a scoring system that is highly suspect, it is impossible
to draw firm conclusions regarding the theoretical characterization
of the psychotic process as a progressive breakdown of the ego' s
boundaries. However, it is more clear that the boundary dimensions
as currently measured lack utility as forecasters of relative ego
functioning in chronic schizophrenia.

To the degree that boundary differentiation was assessed
at the onset of the manifest schizophrenic episode, the random
association of this measure with existing ego functioning indicates
that varying degrees of boundary "cathexis" exist regardless of the
degree of ego impairment. This suggests that contact with reality
is abandoned at varying levels of boundary differentiation, but that
ego functioning and boundary articulation do not necessarily regress
simultaneously.

The failure of the significant increase in boundary differ-

entiation ovér time to agree with change in relative ego functioning

65

further indicates that boundary change does not covary with improved
or'deteriorated ego adjustment. Boundary articulation does appear
to come from the differentiation and delineation of object representa-
tions, including that of the body, rather than from the reduction of
boundary instability evidenced by the nonsignificant change in
boundary instability over time.

This differentiating and bounding of object representations,
with boundary articulation and ego adjustment repeatedly demonstrat-
ing no agreement, raises a serious question regarding the accuracy
and maturity with which conceptual as well as object representations
ultimately reappear. Such reorganizing and bounding of object
representations, including the body, may in the face of the psychotic
disruption constitute a restitutive effort to gain the security, realis-
tic or not, of a more stable frame of reference from which the
ego' s reciprocal dealings with the self as object and the outside
world are made possible. Thus, differential cognitive accuracy of
the ego determines for-both the degree of realism.

Varying degrees of boundary differentiation accompany the
clinical manifestations of schiZOphrenia, but manifest change in
boundary differentiation of the psychotic is not necessarily accom-

panied by equally evident change in ego adjustment.

.1!

‘4‘“ :A‘

 

2’-

66

Like boundary articulation, boundary instability varied
freely in relation to existing relative ego —adjustment. Change in
stability over time did not differ significantly from the initial degree
of instability and was also randomly associated with change in ego-
functioning.

Statistically, insignficant as a predictor of relative ego-
impairment, initial boundary instability did empirically reach
through R

significance from R This trend suggests that the

1 3'
greater the instability in relation to the degree of existing boundary
articulation at the time of hospitalization, the less relative ego-
irnpairment and better the prognosis for remission. Although the
precise meaning of this trend is not known, it does contradict the
theoretical prediction that the greater the boundary articulation

and the less the boundary instability at the time of hospitalization,
the less the relative ego -impairment.

Previous studies have reported a decrease of boundary
instability when the threat of penetration and disruption of the
integrity of the body image boundary was removed (Cleveland, 1960;
McConnell 8: Daston, 1961; Reitman 8: Cleveland, 1964). These
reports have suggested that the current measure of instability

mirrors varying degrees of affect related to boundary disruption.

Speculating on this basis, this trend may well reflect differential

67

affect arousal stimulated by the psychotic loss of control. It is not
known how much boundary loss occurred prior to the appearance of
manifest symptomatology, but this interpretation suggests that the

greater the anxiety, if not terror, in relation to the existing degree

of boundary differentiation at the time of the psychotic break, the

1

less the relative ego -impairment. Thus, the relatively low insta-

‘Q_fl

 

bility and high articulation pattern as compared with the relatively
high instability and low articulation pattern may reflect the differ-
ence between a gradual, defended loss of reality as Opposed to a
sudden, undefended loss of reality. This interpretation assumes
that boundary differentiation is a manifestation of cognitive inter-
action with the affectual self and the outside world, the degree and
quality of contact with reality dependent on cognitive elaboration.
Thus, boundary articulation may be an artifact of cognition.
Interpretation of boundary instability as an. index of affect
arousal makes the failure of instability to significantly decrease
over time difficult to explain. This failure may imply a relatively
persistent fear of breakdown regardless of ego -adjustment, which
may or may not be the resultant effect of having previously expe-
rienced the helplessness and vulnerability of loss of control. It also
must be recalled that the samplewas primarily poor, innercity,

and Black, and instability may be a general factor of their style of

68

life. Support for the affect arousal interpretation through replication
of the predictive trend also was not provided using the R2 data.

In summary, the pattern of overall boundary change, which
indicated that differentiation significantly increased while instability
remained essentially the same, suggests the possible restitution of
previouSly existing boundaries. However, complete lack of asso-
ciation with existing and changed ego —adjustment equally suggests
cognitive reorganization, delineation, and segregation of object
representations, including that of the body, which may correspond
in varying degrees with "reality. " Body image boundary differen-
tiation is interpreted as a manifestation of cognitive interaction
with the psychosomatic affectual self and the outside world. Its

degree of correspondence with reality is seen as dependent on cog-

nitive elaboration of these interactions.

Implications for Therapy

 

Keeping in mind the previously noted reservations,
especially those regarding the scoring system, the following impli-
cations are also offered in a tentative vein.

The significant increase in boundary articulation across
groups over time in the absence of correlational association with

existing or changing relative ego functioning, without therapeutic

69

emphasis on this aspect of change, supports Burton' 3 (1959) claim
that the body image is reorganized during the course of psycho-
therapy with schiz0phrenics. This unsolicited variability in the
restitution of the body image boundary accompanying various thera-
peutic approaches, including routine hospital care, does not negate
the development and execution of programs designed to extend the
differential limits of the body image but questions their relevance
in the absence of vis -a -vis therapy and the theoretical foundation
upon which such programs are based.

Boundary articulation increase in relation to the lack of
significantdecrease in boundary instability suggests that chronic
schizophrenics gain security of the body as a frame of reference
through reorganization of a body image totalityrather than through
reduction of threatening disruption. If boundary articulation nor—
mally bears a relationship to ego functioning, then boundary
reorganization after a psychotic break appears to represent a
defensive rather than developmental reorganization of the body
image.

The affect arousal interpretation of the instability measure
trending toward predictive significance of remission also suggests
defensive organization of the body image boundary. These consid-

erations along with interpretation of the body image boundary as a

III}
'1

 

7O

manifestation of cognitive elaboration points to the need for
consistent support, guidance and interpretation as a monitoring
influence on the rebounding of object representations including that

of the body.

Implications for Research

 

Several areas of further investigation are suggested by the
present research. Most obvious is the analysis of the complexity
of theB and 3 dimensions to determine the underlying factors of
covariation. A closer examination of these factors in relation to
the formal aspects of the Rorschach may not only clarify the lack
of consistency foundin the literature concerning these relationships,
but permit a more adequate investigation of possible associations
between ego adjustment and the state of the body image boundary.

Although background body signals influence perception,
this relationship is not direct and the mediating process of cognitive
elaboration of somatic stimulation needs investigation. More spe-
cifically, how can cognitive elaboration of somatic sensations
eliminate or create emotional situations?

Through relating the factors which more precisely define
the boundary dimensions to wide range variables of psychopathology,

the meaning of the body image boundary construct to pathological

71

functioning will become more evident as well as aid the possible
discovery of other relationships relevant to abnormal adjustment.
Such questions as the-role of boundary differentiation in relation to

the reactive—process continuum, the-remission and nonremission

of psychotics, and the manner in which a relatively well -differentiated
body image is developed while outside object representations are
unrealistically distorted illustrate points of beginning, once the

psychological meaning of the boundary dimensions is realized.

SUMMARY

The theoretical importance placed on the body image,
primarily by psychoanalytic and ego psychology, along with recent
empirical findings using psychotic subjects, led to a general
- expectation of significant relationships between the state of the body
image boundary and relative ego functioning in chronic schizophrenia.
More specifically, it was predicted that the greater the degree of
boundary articulation, the better the relative ego functioning, with
improvement or deterioration of relative ego adjustment over time
beingassociated with similar change in boundary articulation.
Conversely, the greater the boundary instability, the poorer the
relative ego functioning, with improved or deteriorated functioning
being accompaniedby a decrease or increasein boundary insta-
bility, respectively. Boundary security, a measure empirically
obtained by removing the degree of instability from the degree of
boundary articulation, was not only expected to evidence the same
relationships as articulation, but to reflect relative ego adjustment

significantly better than either of the separate boundary dimensions.

72

73

The original 36 severely impaired schizophrenics,
selected in sets of 3 from admissions to the Detroit Psychiatric
Institute for random assignment to therapy in the Michigan State
Psychotherapy Research Project, were reduced to 33 because of
. incomplete data and served as Es in this research. The sample
was primarily poor, innercity, and Black, which, according to
medical examination, was apparently free from mental retardation,
organically. based psychopathology, and prior exposure to ECT.

Two independent measures of relative ego functioning
were obtained: days of hospitalization from date. of first admission
through-the subsequent periods of 6, 12, and 20 months; and
clinical judgments of relative ego adjustment at the time of initial
hospitalization and later at 6 and 20 months. Hospital discharge
was governed by the psychiatric staff and the clinical guidelines
used were not explicitly stated, but the ratings, independently
completed by 2 graduate students in psychology, were made
according to the _S' 3 relative ability to care for self, ability to work,
sexual adjustment, social adjustment, absence of hallucinations
and delusions, degree of freedom from anxiety, amount of affect,
variety and spontaneity of affect, satisfaction with self andlife,
achievement of capabilities, and benign versus malignant effect on
others. Ratings were made‘from tape recorded interviews conducted

along these lines by an experienced psychiatrist.

 

74

Initially, an interrater reliability of . 87 and intrarater
consistencies of .83 and .79 were obtained for the 6- and 20-month
ratings. The initial and 6—month ratings of relative ego functioning
also correlated -. 71 and -. 64, respectively, with DH during each
subsequent 6 month period supporting the utility of the criterion
measures.

The Rorschach was individually administered and scored
according to Beck' 3 (1961) system by 2 graduate students in
clinical psychology, the second examiner being responsible for only
the 20-month data. A t test analysis of response productivity, the
factor on which the boundary measures are dependent, revealed no
differential examiner effect. The observed ranges of productivity
also indicated a wide range of relative ego functioning among the _Ss.

Two student judges were trained and given practice scoring
protocols for}? and _P according to Fisher and Cleveland' 3 (1968)
system prior to independently scoring the randomly presented
protocols of this study. The overall interrater coefficients of . 922
for_B_ and . 947 for 3 indicated that confidence could be placed in
these judgments.

The repeated measurements of the state of the body image
boundary necessitated by the pre -posttest design were derived from

regression equations to control for varying productivity on the

75

Rorschach, to avoid the phenomenon of regression to the mean and
to free the measures of change from their initial value. Change in
relative ego functioning was obtained by this statistical procedure
and all distributions were made comparable by transformation into
E-score distributions.

Analysis of the associations between the initial corrected
boundary indices and theSvariables of race, age, sex, and educa-
tion revealed no significant covariation between the boundary
measures and these variables. Significant treatment group differ-
ences also were not evidenced by the initial corrected measures.

The correlational analysis indicated no concurrent relation-
ship between the corrected boundary indices and relative ego
functioning at any time. The measured changes in the state of the
body image boundary also failed to correlate with the degree of
change in relative ego adjustment.

Random associations were observed between the boundary
indices and days of hospitalization (DH) for the various time inter-
vals except for initial boundary instability, which trended toward
and reached predictive significance at the . 05 level of confidence
for the total period of 20 months. However, the direction of this

observation was in opposition to that predicted by the theory.

76

Use of the 6 month boundary indices also failed to support
both the expected concurrent and predictive relationships between
the boundary dimensions and the criteria of relative ego adjustment.

Although boundary articulation significantly increased over
time, it, like the nonsignificant measures of changed instability and
security, manifested no differential therapeutic effect.

Methodological issues centering around the chosen criterion
measures of relative ego functioning, the use of 2 Rorschach
examiners, the composition of the sample, and the measuring pro-
cedure are considered. Primarily because of ambiguity and incon-
sistency within and between the _B_ and E dimensions, along with an
apparent lack of clinical sensitivity on the part of the measuring
procedure, the ultimate utility of the body image boundary construct
as an index of relative ego functioning in chronic schizophrenia
remains questionable.

Concluding that the current dimensions of the body image
boundary do not differentially reflect existing or changed relative
ego adjustment in chronic schizophrenics, these dimensions are
speculatively interpreted as a manifestation of cognitive elaboration
of interactions of the affectual self and the outside world. Although
boundary articulation reappears as chronic schizophrenics improve,

the accuracy, maturity, and defensiveness with which not only the

77

body image but other object representations are differentiated and

rebounded is questioned.

APPENDIX A

SCORING DIRECTIONS

APPENDIX A

SCORING DIREC TIONS

Directions for Scoring Barrier*

 

The scoring of Barrier adheres 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, mem-
brane, 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 0 is given when
Barrier is absent. With minor editorial revision, detailed instruc-
tions 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.

 

*Reproduced in full from S. Fisher and S. E. Cleveland,
Body Image and Personality, Dover Publications, Inc. , 1968.

 

78

79

woman in a high -necked dress imp with a cap that has a
person in a fancy costume tassel on it

woman in a long nightdress person with mittens or gloves
man with a crown people with hoods

man in coat with a lace collar feet with fancy red socks
man in a robe man with a cook' 3 hat

man with a high collar man with chaps

The popular boots on card IV and the bow tie on III are not
scored as clothing because of the frequency with which they are
given.

(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 Siamese cat
badger goat mink rabbit skunk
beaver hippo mole rhinoceros tiger
bobcat hyena mountain scorpion walrus
chameleon leopard goat sea lion weasel
coyote lion peacock seal wildcat
crocodile lizard penguin sheep or wolverine
porcupine lamb zebra

An ordinary cat is scored 0.

Any animal skin (except bearskin on card IV) may be con-
sidered 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

80

Included are all shelled creatures except crabs and
lobsters. Lobsters and crabs are scored only in the unusual

instances in which the shell alone is seen.

mussel snail shrimp clam turtle

(c) Score references to enclosed openings in the earth.

valley ravine mine - well canal
shaft

(d) Score references to unusual animal containers.

bloated cat . pregnant kangaroo - udder
woman

(e) Score references to overhanging or protective sur-

faces.

umbrella awning dome shield

(f) Score references to things that are armored or much

dependent on their own containing walls for protection.

tank battleship armored man in rocket ship
car armor in space

 

81

(g) Score references to things being covered, surrounded,

or concealed.

bowl overgrown. by a plant man covered with a blanket

house surrounded or covered person hidden by something
by smoke someone peeking out from

log covered by moss behind a stone

person behind a tree donkey with a load covering

person caught between two stones his back

(h) Score references to things with unusual container -like

shapes or properties.
bagpipes throne ferris wheel chair

(i) Masks are generally scored 0. All references to
buildings and vehicles with containing attributes (e. g. , automobile,
airplane, rocket, tents, quonset hut, igloo, fort, arch) are scored
Barrier.

Do not score instruments which grasp or hold. Examples:
pliers tweezers tongs

(j) Additional general examples of Barrier responses

scored 1.

basket
bay

bell

book
book ends
bottle
bubble
cage
candlehold er
cave
cocoon

82

cove

curtain

dancer with veil

frosting on cake

fuzzy poodle

globe

harbor

headdress

hedge along a
walk

helmet

inlet

lake surrounded
by land

Directions for Scoring Penetration*

 

mountain covered
with snow

net

pot

river

screen

spoon

urn

wall

wallpaper

wig

land surrounded
by water

As in the case of Barrier, the scoring of Penetration is

taken directly from Fisher and Cleveland. An individual' s feeling

that his body exterior is of little protective value and could be

easily penetrated is considered to be expressed in his Rorschach

responses in three different ways: (1) images that involve the

penetration, disruption, or wearing away of the outer surface of

things ("bullet penetrating flesh, " "squashed bug, " ”shell of a

turtle that has been broken open, " "badly worn away animal skin");

(2) images that emphasize modes or channels for getting into the

interior of things or for passing from the interior outward to the

exterior (”open mouth, " "vagina, " "anus, " "an entrance, "

 

*Reproduced in full from S. Fisher and S. E. Cleveland,
Body Image and Personality, Dover Publications, Inc. , 1968.

 

 

 

83

”doorway"); and (3) images that involve the surface of things as
being easily permeable or fragile ("soft ball of cotton candy, "
"fleecy cloud, " "mud that you can step through”). The following
is an enumeration of the specific subcategories of Penetration of
Boundary response.

(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

boy spitting

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.

X-ray picture body cut open

body as seen through a inside of the body
flouroscope autopsy

cross section of an organ

(c) Score 1 for references to the body wall being broken,

fractured, injured or damaged.

84

mashed bug wound
wounded man man stabbed
person bleeding man's skin stripped off

All references to loss of a body member are scored Pene-
tration (e.g. , ”amputation, " "head cut off").

(d) Score 1 for responses involving some kind of degenera-
tion 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 geyserspurting out of ground
fountain shooting up oil gusher coming in

(f) Score 1 for all openings.

anus doorway looking into rectum
birth canal entrance the throat vagina
window nostril

(g) Score 1 for references to things which are insubstantial

and without palpable boundaries.

cotton candy ghost shadow soft mud

85

(h) Score 1 for all references to transparency.

can see through the dress
transparent window

(i) 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

3‘.

F .. lfid‘ W 'in
l

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