PRIMARY PROCESS MANIFESTATIOIIS
IN THERAPISTS FOLLOWING A
PSYCHOTHERAPEUTIC SESSION

Thesis for the Degree of Ph. D.
MICHIGAN STATE UNIVERSITY
STANLEY S. SCHONBUCH
1968

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ABSTRACT

PRIMARY PROCESS MANIFESTATIONS IN THERAPISTS
FOLLOWING A PSYCHOTHERAPEUTIC SESSION

by Stanley S. Schonbuch

An attempt was made to objectively measure and experi-
mentally demonstrate clinically observed changes in therapist
thinking following a treatment session. Discussions of the
activity of therapists in dynamic or psychoanalytically
oriented psychotherapy have dealt with the intense involve-
ment of the therapist in the therapeutic process. Primary
process stimulation is experienced by the therapist due to
his need to regress in order to understand and communicate
with his patient. Observations of temporary and occasionally
inappropriate behavior by therapists following a therapy
session were interpreted as manifestations of increased pri-
mary process thinking due to a "carryover" of such thinking
from the therapy session itself.

Three groups, 11 therapists of schiZOphrenics, 11 thera-
pists of neurotics and 11 persons involved in a period of
“Social Interaction" (SI), and one group of five college
students, served as subjects in this study. The first three
groups were comprised of psychology graduate students,
psychiatric residents and social workers. They were matched

for age, sex, and discipline. Every subject was given the

3H“

Stanley S. Schonbuch

Holtzman Inkblots (Form A or Form B) and a mood scale ques-
tionnaire before and after an interpolated activity.

A Primary Process-Secondary Process questionnaire for amount
of primary process used during the therapy session or inter-
polated activity was administered and an informal interview
with the therapists took place, following this period. For
the two groups of therapists, the intervening activity con-
sisted of seeing a familiar patient, either neurotic or
schiZOphrenic, in a treatment session. The third group of
subjects were engaged in a "small talk" Social Interaction
situation with the experimenter. The five college students,
serving as another control group for changes in primary
process following cognitive activity, were required to in-
volve themselves in a task consisting of solving relatively
simple arithmetical problems.

The "pre" and "post" Holtzman protocols were scored for
three "pathology indicators," (Anxiety, Hostility, and Pathog-
nomic Verbalization) as well as by the Holt Manual For The
Scoring Of Primary Process Manifestations In Rorschach
ReSponses. These were scored for Level 1 and Level 2 pri-
mary process thinking, defense demand, defense effectiveness
and form level. The mood scale ratings were also scored
for possible changes in feelings following a treatment

session.

Stanley S. Schonbuch

In contrast to the therapists of neurotics, SI subjects
and cognitive activity subjects, therapists of schizoPhrenics
manifested significant increases in Level 2 primary process
thinking following a treatment session. No changes were
noted in any group, in terms of Defense Demand, Defense
Effectiveness, Form Level, Level 1 primary process responses,
or mood scale dimensions. A more detailed analysis of the
data yielded a significant increase in amount of libidinal
content in therapists of neurotics. In terms of the amount
of primary process thinking during the interpolated activity,
the following ascending order was reported: "cognitive"
subjects, then therapists of schizophrenics, therapists of
neurotics and last are the SI control subjects.

The above findings were related and discussed in terms
of the theory and observations of changes in thinking of
therapists following a treatment session and were seen as

supporting these propositions.

 

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Approved 6“ l_

Committee Chairman

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PRIMARY PROCESS MANIFESTATIONS IN THERAPISTS

FOLLOWING A PSYCHOTHERAPEUTIC SESSION

BY

Stanley S. Schonbuch

A THESIS

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

DOCTOR OF PHILOSOPHY

Department of Psychology

1968

.01

ACKNOWLEDGEMENTS

It is a difficult task to properly thank all those who
have contributed, in some way, to the completion of my
graduate studies and dissertation. Some have given by their
suggestions, encouragement and friendship, and others in all
these ways. These people are too numerous to name and thank
individually but they know who they are.

I would like to express my appreciation to members of
my thesis committee, Dr. Paul Bakan, Dr. Bertram Karon and
Dr. Bill Kell, who gave not only of their time but also valu-
able suggestions, recommendations and encouragement. To my
thesis director, Dr. A. I. Rabin, go my special thanks and
appreciation. He not only provided the necessary support,
but his knowledge of psychoanalytic theory and research
techniques gave life and substance to this thesis.

My parents also deserve thanks for their positive atti-
tudes towards education as well as their financial support
when there was need.

Finally, my gratitude and love go to my wife Helene,
for her patience and companionship throughout the course of
my graduate studies. She never failed to communicate faith

in me and in what I was doing. I will always be grateful.

ii

TABLE OF CONTENTS

CHAPTER Page
I. INTRODUCTION . . . . . . . . . . . . . . . . . 1
II. THEORETICAL BACKGROUND . . . . . . . . . . . . 5
Psychotherapy and the Unconscious. . . . . 3
The Therapist's Regression . . . . . . . . 5
Psychotherapy with SchiZOphrenics. . . . . 7
Current Observations . . . . . . . . . . . 10
III. METHODOLOGY. . . . . . . . . . . . . . . . . . 12
Subjects . . . . . . . . . . . . . . . . . 12
Procedure. . . . . . . . . . . . . . . . . 15
The Holtzman Inkblot Technique . . . . . . 14
Holt Scoring System. . . . . . . . . . . . 15
Operational Hypotheses . . . . . . . . . . 22
IV. RESULTS. . . . . . . . . . . . . . . . . . . . 24
Hypothesis I . . . . . . . . . . . . . . . 24
Hypothesis II. . . . . . . . . . . . . . . 25
Hypothesis III . . . . . . . . . . . . . . 25
Hypothesis IV. . . . . . . . . . . . . . . 26
Hypothesis V . . . . . . . . . . . . . . . 27
Therapists and Mood Changes. . . . . . . . 32
Additional Findings and Assumption of the
Study. . . . . . . . . . . . . . . . . 53
Color Scores . . . . . . . . . . . . . . . 54
Primary Process Thinking During the
Session. . . . . . . . . . . . . . . . 56
Primary Process in a Cognitive Activity
Control Group. . . . . . . . . . . . . 37
V. DISCUSSION . . . . . . . . . . . . . . . . . . 40
Changes in Primary Process . . . . . . . . 40
Defense Evaluation . . . . . . . . . . . . 41
Mood Evaluation. . . . . . . . . . . . . . 45

iii

TABLE OF CONTENTS - Continued

CHAPTER Page
Primary Process in Therapists of Neurotics 44
Implications and Suggestions for Future

ResearCh O O O O O O C O O O O O O O O 47

VI. SUMMARY AND CONCLUSIONS. . . . . . . . . . . . 50
REFERENCES 0 O 0 O O O O O O O O O O O O O O O O O O O 55
APPENDICES. . . . . . . . . . . . . . . . . . . . . . 56

iv

TABLE

1.

10.

11.

12.

15.
14.

LIST OF TABLES

Subject characteristics and composition of
experimental and control groups. . . . . . . . .

Changes in number of Level 1 and Level 2 primary
responses. . . . . . . . . . . . . . . . . . . .

Changes in Defense Demand and Defense Effective—

ness 0 O O O O O O O O O O O O O O O O O O O O 0
Changes in Form Level. . . . . . . . . . . . . .
Changes in Holtzman Factors. . . . . . . . . . .

Summary table of group comparisons on primary
process measures, defenses and Holtzman factors.

Changes in individual Holtzman Factors in thera—
pists of schiZOphrenics. . . . . . . . . . . . .

Changes in individual Holtzman Factors in SI
therapists . . . . . . . . . . . . . . . . . . .

Changes in individual Holtzman Factors in thera-
pists of neurotics . . . . . . . . . . . . . . .

Comparison of groups for changes in individual
Holtzman Factors . . . . . . . . . . . . . . . .

Summary table of group comparisons on mood scale
adjectives O O O O O O O 0 O O I O O O O O O O 0

Comparison of groups for libidinal and aggres-
sive content . . . . . . . . . . . . . . . . . .

Changes in Color Scores. . . . . . . . . . . . .

Amount of primary process thinking during the
therapy and control sessions . . . . . . . . . .

Page

15

25

26
27
28

28

5O

5O

51

51

52

54

56

57

LIST OF TABLES - Continued

TABLE Page

15. Changes in Level 1, Level 2 primary process,
Defense Demand, Defense Effectiveness, Form
Level and Holtzman factors in the Cognitive
Activity Control Group . . . . . . . . . . . . . 58

16. Summary table of mood changes in the Cognitive
Activity Control Group . . . . . . . . . . . . . 59

vi

LIST OF APPENDICES

APPENDIX

Therapist Questionnaire. . . . . . . . . . . .

Instructions for the Mood Scale and the Mood
Scale Adjectives to be Rated . . . . . . . . .

Instructions and Arithmetical Items Used for
the Cognitive Activity . . . . . . . . . . . .

Data Pertaining to Changes in Level 1, Level 2

rPrimary Process, Defense Demand and Amount of

Primary Process During the Session-bTherapists
of SchiZOphrenic Patients . . . . . . . . . .

Data Pertaining to Changes in Defense Effec—
tiveness, Form Level and Holtzman Factors--
Therapists of SchiZOphrenic Patients . . . . .

Data Pertaining to Changes in Level 1, Level 2
Primary Process, Defense Demand and Amount of
Primary Process During the Session--TherapiSts
of Neurotic Patients . . . . . . . . . . . . .

Data Pertaining to Changes in Defense Effec-
tiveness, Form Level and Holtzman Factors--
Therapists of Neurotic'Patients. . . . . . . .

Data Pertaining to Changes in Level 1, Level 2
Primary Process, Defense Demand and Amount of
Primary Process During the Session--Control

Therapists . . . . . . . . . . . . . . . . . .

Data Pertaining to Changes in Defense Effec-

tiveness, Form Level and Holtzman Factors--
Control Therapists . . . . . . . . . . . . . .

vii

Page

57

59

61

65

64

65

66

67

68

CHAPTER I

INTRODUCTION

DeSpite the commonly acknowledged role that the thera-
pist's unconscious plays in the process of understanding
and communication with the patient, no reported research has
attempted to deal with the possible effects or changes that
this process may have on the cognition and/or perception of
the therapist. Most research in the area of psychotherapy
has concerned itself with client variables and the effects
of therapy on the patient, and has almost completely ignored
any possible changes or effects on the therapist. In fact,
it has only been recently that researchers have concerned
themselves with the role of the therapist in the therapeutic
process.

This study is concerned with the effects of a brief
psychotherapeutic encounter on the thinking of therapists.
The use of the therapist's unconscious as a means of under-
standing his patient and the emotional stimulation afforded
the therapist because of the intense involvement necessary
for therapy, suggests that the therapist's cognitive and/or
perceptual functioning undergoes a temporary regressive

change or shift from the more mature and integrated secondary

process to the more infantile primary process. For purposes
of this study, primary process thinking is defined by the
presence of a) libidinal or aggressive content and b) formal
distortions of thought such as condensation, symbolization,
fragmentations, loose or fluid association, syncretic or
autistic logic, logical contradictions and impaired reality

testing as reflected in projective responses to inkblots.

CHAPTER II

THEORETICAL BACKGROUND

Psychotherapy and the Unconscious

Freud (1912), in an article addressing itself to the
psychoanalytic method of treatment, deals briefly with the
therapist's role in understanding his patient. A method,
suggested by Freud, for listening to the patient for under-
standing is "evenly hovering attention." That is, according
to Freud, "All conscious exertion is to be withheld from the
capacity for attention, and one's 'unconscious memory' to be
given full play; or to express it in terms of technique,
pure and simple: one has simply to listen and not to trouble
to keep in mind anything in particular" (pp. 118-119). This
technique was suggested not only for understanding the
patient but as a means for counteracting fatigue in the
therapist. In the same article, Freud suggests that the
therapist must use his own unconscious in order to understand
the patient's communication. This is recommended for recon-
structing and integrating the patient's communication in a
meaningful fashion. Freud states that ". . . he must bend
his own unconscious like a receptive organ towards the emerg-
ing unconscious of the patient, be as the receiver of tele-

phone to the disc." While the terms may differ somewhat,

the need for the analyst to use his own unconscious and to
permit his own free associations to arise in reSponse to
his patient's communications has been recognized by others
(Ferenczi, 1928; Knight, 1940; Loewald, 1957; Nacht, 1962;
Weigert, 1954).

Theodore Reik (1948), in a more literary and phenomeno-
logical presentation, deals rather extensively with this
problem of the therapist's understanding of the patient and
his communications. Initially, Reik appears content with
the use of a "third ear" to account for the therapist's
sensitivity and ability for dealing with the patient's com-
munications. He describes the treatment situation as one in
which there is almost a constant fluctuation between reality
and fantasy, on various levels, both for therapist as well
as the patient. Within this context, a therapist, through
the use of his "third ear," is able to understand the feel-
ings and non-verbal communications of the patient. Reik
also indicates that the optimum state of the therapist is
one in which he is able to "freely float" and range over all
statements by the patient and to neglect any particular and
Specifically strong focus on any one topic or statement.
Reik feels that this latter approach would hamper and limit
in scope the analyst's or therapist's ability to understand
the patient. He states that the therapist's use of his own
unconscious, in attempting to come to grips with the patient's

communications, is an emotional process with the role of

reasoning and logic being minimal. Reik also attempts to
become more Specific in terms of the processes by which his
"third ear" can operate. He indicates that in terms of the
patient, "The united or conflicting effect of the words,
gestures and unconscious signals that point to the existence
of certain hidden impulses and ideas will certainly not at
first stimulate the observing analyst to psychological com-
prehension. Their first effect will rather be to rouse in
him unconsciously impulses and ideas with a like tendency.
The unconscious reception of the signals will not, at first,
result in their interpretation, but in the induction of the
hidden impulses and emotions that underlie them. In popular
language, the unconscious and repressed impulses that betray
themselves by these signs act like stimuli or enticements
that release certain effects of a similar kind in the

analyst" (p. 557).

The Therapist's Regression

Rene Spitz (1956), in an article dealing with counter-
transference, defines it ". . . as one part of the analyst's
relation to his patient. . . ." He is cognizant of the need
of the analyst to regress briefly in order to enable him to
comprehend the infantile aSpects of the patient's behavior.
Spitz proceeds to warn against the dangers of this kind of
regression since it may become uncontrollable. He would

consider that this is acting out on the part of the therapist.

However, Spitz views the regression as necessary for attempt-
ing to understand the patient and for achieving insight.

In other words, the controlled regression is an occupational
hazard which must be ventured in order to achieve the greater
goal of understanding.

In an interesting job analysis or work description for
an analyst, Fleming (1960) explores the kinds of skills re-
quired of the therapist and the conditions under which the
analyst works. The emphasis of the paper is an exploration
of the ego functions of a successful analyst. Fleming begins
her thesis by stating that the main instrument of the analyst
is his own ego and that its use is the only means of reaching
the patient. The paper also involves a summary of other
works concerned with the role of the analyst in the thera-
peutic situation, and as such, integrates some papers already
presented above. Basically, it presents the therapeutic situ-
ation as one in which the therapist is very much involved
emotionally with the patient in order to understand the
patient‘s communications. Further, the therapist maintains
a "controlled or conditioned daydreaming," closely akin to
Freud's concept of "hovering attention," in order to gain as
much information as possible from the client's communications.
Fleming discusses an article by Kohut in which the latter
describes the manner in which the analyst "senses" the
primary process thinking in the patient by allowing himself

free play between his own fantasies and the patient's

fantasies, while simultaneously maintaining a secondary pro-
cess critical attitude toward his own regressive thinking.
What is required, therefore, is two levels of ego function-
ing, operating almost simultaneously. There is hypothesized,
then, a part of the ego observing externally and a part of
the ego which is turned inwardly, or in observing internally.
This conceptualization of a split, or shift, in the analyst's
ego functioning has been the subject of other papers (Ferenczi,
1928; Greenson, 1960). Fleming summarizes this dynamic yet
danger-fraught situation by indicating that "In other words,
the analyst's work requires living in two worlds--past and
present, real and unreal, of himself and someone else simul-
taneously."

Frijling-Schreuder (1966), in an article addressing it-
self to the adaptive use of regression as opposed to patho-
logical regression says that "The continuous confrontation
with regressive processes and with primary process function-
ing, makes psychoanalysis, however, an unhealthy job from
the point of view of integration and logical thining" (p.
567). That is, he too believes that the situation is fraught
with danger, because of the potential acting out on the

therapist's part.

Psychotherapy_with Schizophrenics
Kernberg (1965), dealing with countertransference and

its vicissitudes and dangers, in addition to presenting

various opposing definitions of the term, is mainly concerned
with both a description and explanation of the experiences

of the analyst occurring in the therapeutic situation. Most
germane to the present paper is Kernberg's interest in the
therapy of severely regressed individuals and how potentially
dangerous this treatment can be for the therapist. Kernberg
distinguishes between the analyst's regression because of

the "onslaught" on the analyst by the patient, and the ana-
lyst's regression in order to maintain emotional contact with
the patient. In contrast to Glover (1955), Kernberg believes
that the regression occurs because the analyst wishes to
maintain contact with the patient and that he "voluntarily"
engages in a regression in the service of the ego. In work—
ing with severely regressed patients, Kernberg says that

"At some point of regression, the therapist's own early
identifications may become reactivated, together with the
mechanism of projective identification. The therapist is now
faced by several dangers from within: (i) the reappearance
of anxiety connected with early impulses, esPecially those

of an aggressive nature which now are directed towards the
patient; (ii) a certain loss of his ego boundaries in the
interaction with that particular patient; (iii) the strong
temptation to control his patient in consonance with an
identification of him with an object of the analyst's own
past" (p. 45). DesPite Kernberg's statement that there are

compensatory mechanisms Operating within the analyst so that

some aspects of his ego remain intact, he does point out that
it is easy for the analyst to lose his objectivity temporar-
ily because of the quality of the communication between him—
self and the patient, and because of the severity and extent
of the regression required of the analyst. He states that
"Even with severely regressed patients, the therapist may
have lost his 'analytic objectivity' during the hour, but
after leaving the sessions or a few hours later slowly regains
his equilibrium. A process of working through occurs in the
therapist by which the stable, adaptive and cognitive struc-
tures formed around his later and more mature ego identity
act, one might say, in a supportive way to the part of his
ego in which primitive identifications, defense mechanisms
and impulses have been activated and where ego boundaries
have become fluid" (p. 46). FrommeReichmann (1952, 1955, 1958)
has often discussed the therapist's anxieties and the poten-
tial danger of loss of ego boundaries in dealing with
schizophrenics.

Savage (1961), dealing Specifically with countertrans-
ference in the treatment of schizophrenics defines counter-
transference in somewhat broader terms than those usually
encountered. In his definition, Savage includes the influ-
ence of the therapeutic process on the therapist's unconscious
reactions. He indicates that "Many problems, anxieties,
worries, and discomforts beset the analyst in the treatment

of schizophrenia, all of which may have unconscious--that is,

10

countertransference--imp1ications for the analyst" (p. 55).
He further indicates that the therapist's energies devoted
towards communicating with the very symbolic and defensive
nature of the psychotic's communications weigh more heavily
on the analyst because the regressions must be so severe
that the swing back from the experiencing ego to the observ-
ing ego is very difficult to achieve and ". . . is seldom
accomplished in toto."

In summary, then, what psychoanalytically oriented
clinicians and theoreticians have been describing is a treat-
ment situation in which both the patient and the analyst are
intensely involved with each other emotionally. That is, a
situation in which the analyst, in order to understand and
communicate with the patient, must be free to regress and to
use his own unconscious extensively. This necessary shift
and oscillation between the observing and the experiencing
ego of the analyst portend possible dangers for the therapist.
Particularly when dealing with psychotics, the analyst is
exposed to a situation in which he is apt to experience
archaic impulses and conflicts in his own unconscious func-
tioning. The "deep" regressions required with these patients

contributes significantly to the danger.

Current Observations
While involved in a research project dealing with the

effectiveness of various psychotherapeutic methods on

11

schiZOphrenics, it has been my own observation, as well as
that of other psychologists involved or acquainted with the
project, that some very distinct and observable changes occur
in therapists after seeing a patient for one session. While
the changes may differ somewhat, depending on the patient

seen for any one session, there appear to be some elements
common to all therapists. These changes may be conceptualized
as somewhat inappropriate affect and verbalizations, at times,
manifested in cursing, depression, anger, giggling and laugh-
ing when discussing particular aspects of their interactions
with their patients. These changes, although distinct and
substantial, appear to be of a temporary nature. These ob-
servations, closely parallelling the theoretical discussions
presented above, appear to be temporary manifestations of
primary process. The present paper is an attempt to objective-
ly demonstrate this phenomenon. The theoretic hypothesis of
this paper is that therapists exhibit a greater amount of
primary process thinking following a treatment session with

a schizophrenic patient. Operational hypotheses will follow.

CHAPTER III

METHODOLOGY

Subjects

The subjects employed in this study were 55 psycho-
therapists. This total group was comprised of psychiatric
residents, psychology graduate students and social workers.
Of the total number of subjects, 11 were therapists treating
schizophrenic patients while the remaining 22 subjects in-
cluded a group of 11 therapists engaged in psychotherapy
with neurotic patients (Control Group 1) and a third group
of 11 therapists served as a control for the fatigue factor
in therapy (Control Group 2). Control Group 1 was included
for the purposes of determining if the hypothesized changes
in therapists are related Specifically to the treatment of
schizophrenics or if they are general phenomena encountered
in the treatment of other psychopathologies. The therapists
were matched on variables such as age, field of discipline
and experience (Table 1). A fourth group of five college
students (Control Group 5) was also employed in order to
control and measure changes in hypothesized variables follow-

ing cognitive or secondary process activity.

‘12

15

Table 1. Subject characteristics and composition of experi-
mental and control groups.

 

 

 

Discipline Years of
Psychiat. Soc. Psych. Sex Av. Experi-
Res. Worker Grad. Male Fem. Age ence
Schiz. 2 2 7 9 2 28 2.5
Neur. 2 2 7 9 2 26.6 2.1
SI 2 2 7 9 2 26.1 2.6

 

Procedure

The 11 therapists, doing psychoanalyticallyeoriented
treatment with schizophrenic patients, comprised the experi-
mental group and were given Form A of the HgltzmanAInkblot
Technique (HIT) (1961) immediately preceding a therapy session
and Form B of the HIT immediately following a therapy seSsion
with one of their schiZOphrenic patients. This same pro;
cedure was followed with Control Group 1 subjects. Control
Group 2 therapists were individually engaged in "small talk"
or social interaction (SI) for one hour with the experimenter.
Form A of the HIT was administered to these subjects imme-
diately preceding the SI and Form B of the HIT immediately
following the SI hour. Control Group 5 subjects were required
to solve simple mathematical problems between administrations
of the Holtzman inkblots.

In addition to the Holtzman inkblots, a mood scale was

administered to all subjects, both before and after the

14

particular interpolated activity, as well as a questionnaire
designed to measure the amount of primary process thinking
used during the interval between test sessions. All sub-
jects were tested individually. The experimental group and
Control Group 1 were told that the experimenter is interested
in communication and its possible effects on the therapist
in the therapeutic process and that we wish to demonstrate
or observe these effects through testing. Control Group 2
subjects were informed of the experimenter's interest in
interpersonal communication and its effects on people and
that we are interested in measuring people's reactions to
social interaction.

Data were obtained from five sources: (1) HIT protocols
scored, using The Holt Manpal F0§_The Scoring Of Primary
Process Manifestations In Rorschach Responses (1965), (2) HIT
protocols using the Holtzman scoring schema, (5) an informal
appraisal of the therapy session by the therapist, (4) meas-
urement of mood changes, and (5) scores on the primary
process-secondary process questionnaire following the inter-

polated activity.

The Holtzmappgnkblot Technique

The Holtzman Inkblot Technique (1961), designed to over-
come both the clinical and experimental deficiencies and
shortcomings of the Rorschach, was the preferred projective

test for use, in part, because its norms are least familiar

 

'71

th
th
us
R0
an

th

15

to the subject population of the study and because it offers
two equivalent forms. The SOphistication of the subject
population as well as the relatively short test-retest inter-
val required that these criteria were of prime importance in
test selection. While maintaining a structure and format
similar to the Rorschach, Holtzman not only increased the
number of inkblots but, among other things, also increased
the variety of the blot characteristics, provided new scorable
dimensions, a means for keeping constant the number of re-
sponses each subject gives to the series and made parallel
forms available.

(1) The Holtzman protocols were administered and scored
using a combination of some of Holtzman's scoring schema and
the Holt Manual for scoring primary process. It was felt
that the use of parts of both scoring systems would provide
us with a greater range of data. Inasmuch as both the
Rorschach and the Holtzman appear to be structurally similar
and tend to elicit parallel material or responses, it was felt
that the use of the Holt scoring system, in its present form,
was justified. We followed Holt's method of administration
and type of inquiry with the exception that the inquiry was

undertaken after each response as suggested by Holtzman.

Holt Scoring System
In contrast to the empirically derived and nontheoretical

basis of Holtzman's system, the Holt scoring system for

16

primary process thinking is a systematic and formalized
method of scoring projective test material based on the
general psychoanalytic theory of thinking. Beginning with
Freud's (1900) discussions on the nature of primary process
and secondary process thought, supplemented by his descrip-
tion of unconscious processes and Rapaport's (1950, 1951,
1960) elaboration of the psychoanalytic theory of thinking,
a scoring system was devised which would serve as a more
formal and objective means of evaluating and interpreting
Rorschach responses within a psychoanalytic framework.
Guided by psychoanalytic assumptions about thought and per-
ception, the manual is composed of three parts: a) Content,
b) Formal ASpects and G) Control and Defense.

a) Scoring reSponses for Content entails both evaluat-
ing for the kind of drive that enters thinking as well as
its primitiveness. That is, responses are scored according
to whether they reflect drives with libidinal aims or ones
with aggressive aims. The distinction in primitiveness or
degree of closeness to the primary process pole of thinking
is one made by scoring either Level 1 or Level 2. Level 2
corresponds to the more socialized, civilized and mature
pole of the primary process continuum. For example, responses
such as "mouth" or "lips," classified as libidinal responses,
seen in isolation, would be given a Level 1 Oral Score
(L 10). If, however, the "mouth" or "lips" response was given,

but seen as part of a person or animal and unduly emphasized,

17

it would be considered a less primitive reSponse and would
receive a Lgvel 2 Oralp§core (L 20). Similarly, within the
aggressive categories, a response involving mutilation would
receive a Level 1 Results of Aggression Scp£§_(Ag 1R) while
a resPonse dealing with injury and deformity would receive a
Level 2 Results of Aggression Score (Ag 2R).

b) The Formal categories, for the most part, correspond
to Freud's description of the formal characteristics of
primary process thinking and unconscious ideation. That is,
responses in these categories deal with formal deviations
and distortions in thinking such as condensation, symboliza-
tion, fragmentations, displacement, loose associations,
autistic logic, logical contradictions and poor reality test-
ing. For example, one result of condensation occurs when
parts from two or more percepts are combined to make a new
creation that does not exist in a common cultural reality.
One such response could be "witches with tails" and this
would receive a Level 1 Composition Score (C—co 1). If the
composite image actually exists in mythology, art or folklore,
such as "Pegasus," it would be scored Level 2 Composition
(C-co 2).

c) The third and last category is intended to evaluate
the way in which an individual deals with his primary process
(pripro). That is, it is a means of objectively judging the
manner in which an individual reacts to or uses the expres-

sion or manifestation of his primary process material and

18

to what degree he is in control of it. ReSponses in this
category, among others, are ones such as 1) Criticism of
ReSponse or S's verbalization of his awareness that something
is wrong with the content or organization of his response;

2) Remoteness or the way in which the S puts distance between
himself and the response to make it more acceptable;

5) Context or the setting in which the S places his response
to make it more acceptable. For example, aggression may be
more acceptable if given within a cultural context such as
"soldier," "surgeon," or "butcher." 4) Projection of Responsi-
bility--S denies that he is responsible for giving the
response.

When all responses are scored, several total or summary
scores are then available for evaluation. For the present
study, the following summary measures were derived:

1) Sum Level 1--Consists of the total number of re3ponses
scored as having Level 1 primary-process manifestations.
Responses receiving one or more full primary-process scores
were counted as one, and responses with weak scores were
tallied as one-half.

2) SumpLevel 2--See procedure for Level 1 derivation

 

above.

5) Mean Defense Demand (DD), defined as the degree to
which a response requires that some defensive measures be
taken to make it socially acceptable for communication, is

rated on a 6 point scale with reSponses at the upper extreme

19

(4,5,6) indicating the greatest need for defense. Each re-
sponse given a primary process score is also rated on DD.
The mean Defense Demand consists of the sum of the ratings
for DD divided by the total number of reSponses given a
primary process score.

4) Mean Defense Effectiveness (DE), defined as the ex-
tent to which the Control or Defense was effective in reducing
anxiety and making an acceptable response to the blots, is
rated on a 12 point scale from +2 (Completely successful
Control and Defense, in a successful response) to -5a
(Disorganized responses, Undefended). Undefended responses
are designated by both a number (+2 to -5) and the letter 3.
Again, each response scored for primary-process also received
a score for DE. Mean Defense Effectiveness is the sum of
ratings for DE divided by the total number of responses giv-
en a primary process score.

5) Mean Form Leve1--Some measure of form accuracy or
the degree of similarity between the percept and the inkblot
characteristics. Every reSponse receives one of 8 Form
Level Scores. These scores range from an F+ with a rating of
+2 to an F— with a rating of -4. The mean Form Level is the
sum of the ratings for Form Level divided by total pro-
ductivity.

-While Holt reports a large number of correlations deal-
ing with scoring reliability, the most pertinent finding is
that a satisfactory level of scoring reliability can be at-

tained for major summary scores.

20

(2) Holtzman's scoring system is comprised of 22 scor-
ing variables, many similar or identical to those already
used on the Rorschach. The 22 variables include such cate-
gories as Location, Rejection, Penetration, Balance, Form
Definiteness, Color, Integration, and Barrier, among others.
In view of this author's observations concerning behavior
and affect change in the therapist following a therapy ses-
sion, attention was given to those scoring categories which
Holtzman empirically found to be correlated most highly with
emotional conflict and pathology of thought processes. These
factors are Pathognomic Verbalization, Anxiety and Hostility.
The variable of Anxiety (Ax) is scored on a 5 point scale
and is composed of 4 broad categories: Emotions and Attitudes
expressed or implied, Expressive behavior, Symbolic responses
and Cultural stereotypes of fear. The Hostility (Hs) vari-
able is scored on a 4 point scale and is based on symbolic,
implicit or explicit signs of hostility in the response.
Pathognomic Verbalization (V) is a variable scored on a 5
point scale and measures the degree of disordered thinking.
It is comprised of the following categories: Fabulation (FB),
Fabulized Combination (FC), Queer Responses (QR), Incoher-
ence (IC), Autistic Logic (AL), Contamination (CT), Self
Reference (SR), Deterioration Color (DC), and Absurd Response
(AB). Each response was scored for these three variables
and every subject received a total score for the three vari-
ables individually as well as a score based on the summation

of the 5 scoring categories.

21

(5) Because the course of psychotherapy can be so varia—
tflxa it was felt useful to obtain, following the second ad-
ministration of the HIT, some informal measure or indica-
tion of the status and functioning of the patient in the
particular session as well as the therapist's feelings and
comments about the session he has just had. Accordingly,
each therapist was interviewed briefly. This informal and
largely unstructured question and answer period was intended
to elicit Specific information concerning the therapist's
expectations and goals of the session, Specific topics that
were discussed and the therapist's reactions and feelings to
the patient during the session.

(4) In view of the previously reported observed increase
in the seemingly inappropriate feelings or moods of therapists
following a treatment session, a mood scale was introduced
to evaluate this variable objectively. The mood scale (see
Appendix B) employed was a modification of one suggested by
Nowlis and Green (1965). Mood factors used were Aggression,
Concentration, Anxiety, Fatigue, Sadness, Friendliness,
Surgency, and Relaxation. Each of the eight "factors" was
represented by three or four adjectives. The first seven
"factors" were derived by the authors from the administration
of over 100 mood adjectives to various groups of adults. The
data were factor analysed and have consistently yielded these
factors. As such, the ratings for all adjectives in a factor
were added and averaged. While "factor" 8 adjectives

(Relaxation) have not been found to cluster or correlate

22

reliably, they too appear to be relevant to the study.

(5) A questionnaire was given to all subjects in order
to gain some indication of the extent of use of primary
process thinking during the interpolated activity. On this
multiple choice test, each subject must choose, from one of
three alternatives, the word or phrase which best describes
his activity on nine dimensions. The three choices can be
ranked on a continuum from least to mpg; use of primary pro-
cess thinking. The scores can vary from a low of 9 (most
primary process) to a high of 27 (most secondary process).
This questionnaire was derived by the author and seems to
have face validity (see Appendix A).

Two psychologists familiar with both the HIT and with
Holt's scoring system served as scorers. Twelve pre-therapy
protocols, selected at random, were used for a reliability
check. Reliability coefficients obtained were .75, .74,

.71, .78 and .81 for Level 1 primary process, Level 2 primary
process, Defense Demand, Defense Effectiveness and Form Level

reSpectively.

Operational vaptheses:
It is hypothesized that, following a treatment session,
in contrast to control therapists, therapist of schizophrenics
1) will manifest an increase of both Level 1 and Level
2 primary process responses;
2) will manifest an increase in the Mean Defense Demand

characteristics of their reSponses;

3)

4)

5)

6)

25

will exhibit a lower Mean Defense Effectiveness
score;

will manifest a greater degree of pathology as
measured by Holtzman's 5 "pathology" indicators;
will manifest negative changes in Form Level;

will manifest changes in mood factors.

CHAPTER IV

RESULTS

Hypothesis I:

In contrast to the Control therapists (therapists en-
gaged in Social Interaction (SI) and the therapists of
neurotic patients), therapists of schizophrenics will mani-
fest an increase in both Level 1 and Level 2 primary process
responses following a treatment session.

AS seen in Table 2, despite a moderate increase in the
average number of Level 1 primary process reSponses in all
three groups of therapists, these changes are not statisti-
cally Significant. In terms of Level 2 reSponseS however,
both the therapists of neurotics and the SI therapists de-
creased somewhat while the therapists of the schizoPhrenic
patients increased in the mean number of Level 2 primary
process reSponses, receiving an average increase score of
+5.1. This increase is statistically significant (p<:.05).1.
An analysis of variance yielded a significant F of 5.66
(p4(.05) and indicates that the three group means differ
(Table 6). Duncan's Multiple Range Test (Edwards, 1962) fur-
ther denotes a significant difference between the therapists
of the schizophrenics and both the therapists of neurotics

and SI therapists.
24

25

Table 2. Changes in number of Level 1 and Level 2 primary
responses.

 

Therapists Therapists Control 2
of of Therapists
Schiz. Neurotics H
(N=11) (N=11) (N;=11)
L1 L2 L1 L2 L1 L2
Pre-therapy 5.0 15.7 1.4 14.6 1.0 10.5
Mean
Post-therapy 4.1 16.8 2.7 15.6 1.1 8.9
Mean
Difference +1.1 +5.1 +1.5 -1.4 +.1 -1.6
N.S. p< .05 N.S. N.S. N.S. N.S.

 

Hypothesis II:

In contrast to control therapists, therapists of schizo-
phrenics will manifest an increase in the mean defense demand
characteristics of their responses following a treatment
session.

Data in Table 5 clearly indicate that the average change
in the defense demand characteristics of the primary process
reSponses for all three groups of therapists is slight and
is not significantly different from what one might expect

entirely on the basis of chance variation.

Hypothesis III:
In contrast to control therapists, therapists of schizo-
phrenics will exhibit a lower mean defense effectiveness

score following a treatment session.

26

Table 5. Changes in Defense Demand and Defense Effective-

 

 

 

ness.
Therapists Therapists Control 2
of of Therapists
Schiz. Neurotics
(u=11) (N=11) (N=11)
DD DE DD DE DD DE
Pre-therapy 2.42 .90 2.19 .90 2.11 .95
Mean
Post-therapy 2.27 .98 2.19 .74 2.19 .78
Mean
Difference -.15 +.02 0.00 -.16 +.08 -.15
N.S. N.S. N.S. N.S. N.S. N.S.

 

The data in Table 5 reveal that the therapists in all
three groups manifested little change in defense effective-
ness and further that these changes were not statistically

significant.

Hypothesis IV:

In contrast to control therapists, therapists of schizo-
phrenics will manifest negative changes in the form level
of their responses following a treatment session.

Again, the data in Table 4 illustrate a small and in-
significant change in the form level scores for all thera—

pists.

27

Table 4. Changes in Form Level

 

 

 

Therapists Therapists Control 2
of of Therapists
Schiz. Neurotics
(N=11) (N=11) (N=11)
Pre-therapy .02 .17 .011
Mean
Post-therapy -.02 .16 .012
Mean
Difference -.O4 -.01 +.001
N.S. N.S. N.S.

 

Hypothesis V:

In contrast to control therapists, therapists of Schizo-
phrenics will manifest a greater degree of pathology follow-
ing a treatment session, as measured by Holtzman's three
"pathology" indicators.

The data in Table 5 indicate that the therapists of
schiZOphrenic patients increased in the average number of
"pathology indicators" while there was an average decrease
in Holtzman factors for both therapists of neurotics and the
SI therapists. The +9.4 average increase in "pathology in-
dicators" for the therapists of schizophrenic patients is
a significant change (p‘(.05). The decrease in both control
groups is relatively small and insignificant. .An analysis
of variance yielded an F of 5.89, significant at the p<:.05

level (Table 6), and indicates that the mean changes in

28

Table 5. Changes in Holtzman Factors

 

 

 

Therapists Therapists Control 2
of of Therapists
Schiz. Neurotics
(N=11) (N=11) (N=11)
Pre-therapy 27.6 50.5 19.4
Mean
Post-therapy 57.0 26.4 18.9
Mean
Difference +9.4 -5.9 -.5
p< .05 N.S. N.S.

 

Table 6. Summary table of group comparisons on primary pro-
cess measures, defenses and Holtzman factors.

 

 

 

Measure F d.f. Sig£:§:§ance
Level 1

primary process .68 50 N.S.
Level 2

primary process 5.66 50 p <.05
Defense Demand .19 50 N.S.
Defense Effectiveness .41 50 N.S.
Form Level .22 50 N.S.
Holtzman Factors 5.89 50 p<:.05

Libidinal ReSponses 5.52 50 gp4:.05

 

29

Holtzman factors in the three groups of therapists differ
from each other significantly. Duncan's Multiple Range Test
further suggests a Significant difference between the mean
score of the therapists of schizophrenic patients and both
groups of control therapists. The therapists of neurotics
with a mean decrease of -5.9 and the SI therapists with a
mean decrease of -.5 did not differ from each other signifi—
cantly.

A further analysis, treating each of the three Holtzman
variables separately, reveals a lack of significant change
in these variables for both the therapists of schizophrenics
and the SI therapists (Tables 7 and 8). However, while thera-
pists of neurotics do not change on Pathognomic Verbalization
or Hostility, they exhibit a significant depgease (-5.6) in
the Anxiety variable (Table 9). Nevertheless, an analysis
of variance of the difference scores for the comparison of
the three groups on this variable barely fails to reach

statistical Significance (Table 10).

50

Table 7.
of schiZOphrenics.

Changes in individual Holtzman Factors in therapists

 

 

 

 

Pre-Therapy Post-Therapy Diff t Sig. Level
Mean Mean (Post-Pre)
V 9.2 15.9 +4.6 2.19 N.S.
Ax 7.7 9.4 +1.7 1.54 N.S.
Hs 10.7 15.6 +2.9 1.81 N.S.
Table 8. Changes in individual Holtzman Factors in SI thera-

pists.

 

 

 

Pre-Therapy Post-Therapy Diff t Sig. Level
Mean Mean (Post-Pre)
V 4.6 5.5 +.91 .85 N.S.
Ax 6.9 6.2 -.72 .68 N.S.
Hs 8.0 7.0 —1.0 .55 N.S.

 

51

Table 9. Changes in individual Holtzman Factors in therapists
of neurotics.

 

 

 

Pre-Therapy Post—Therapy Diff t Sig. Level
Mean Mean (Post—Pre)
V 9.0 10.1 +1.1 .50 N.S.
Ax 9.1 5.5 —5.6 2.50 p<.05
HS 12.2 10.8 -1.4 .65 N.S.

 

Table 10. Comparison of groups for changes in individual
Holtzman Factors

 

 

Mean Change

 

Schiz. Neurotic Control F d.f. Sig. Level
V +4.6 +1.1 +.91 1.08 50 N.S.
Ax +1.7 -5.6 -.72 5.29 50 N.S.

HS +2.9 -1.4 -1.0 1.84 50 N.S.

 

52

Therapists and Mood Chapges:

As will be recalled, a mood scale was administered to
all therapists in order to measure changes in reported feel-
ings or moods following a therapy session. The data in
Table 11 are clearly indicative of a lack of significant
change in the subjective ratings of mood, in either direction,
for any of the thirteen mood dimensions.

Table 11. Summary table of group comparisons on mood scale

adjectives.
= =

Mean Change

 

 

Mood Schiz. Neurotic Control F d.f. Sig.
Aggression —.16 -.02 —.15 1.5 50 N.S.
Concentration +.08 +.18 -.45 2.5 50 N.S.
Anxiety —.56 —.05 —.54 .57 5O N.S.
Fatigue -.15 -.24 -.18 .05 50 N.S.
Sadness -.O9 +.14 —.07 .40 50 N.S.
Friendliness +.59 +.17 -.15 1.41 50 N.S.
Surgency +.06 +.05 +.15 .05 50 N.S.
Quiet -.09 .00 -.27 .17 50 N.S.
Nonchalant +.09 -.09 +.18 .27 50 N.S.
Restful +.O9 -.18 +.91 2.29 50 N.S.
Placid +.56 —.27 .00 .75 50 N.S.
Still -.54 -.56 +.09 2.10 50 N.S.
Leisurely -.27 -.27 +.45 .98 50 N.S.

 

55

Additional Findipgs and Assumption of the Study

While hypotheses concerning variables derived from a
more Specific analysis and evaluation of primary process
reSponses were not formulated, these reSponseS were divided
and classified according to their libidinal or aggressive
content. Evaluated in this way, a substantial and signifi-

cent increase in the mean number of libidinal responses is

 

noted in the group of therapists of neurotic patients. This
+1.86 increase (Table 12) in the number of responses of a
libidinal nature is a Significant change (p<(.05) and an F
of 5.52 (Table 6) suggests further that the three group means
differ significantly from each other. Duncan's Multiple
Range Test indicates that a significant difference exists
between the therapists of the neurotics and the SI therapists
on this variable. The mean increase evident for the thera-
pists of schizophrenics does not differ significantly from
either the therapists of neurotics or the SI therapists.
Although not regarded as a significant change, the therapists
of the neurotics decreased in number of reSponses with aggres-
sive content (§.= -1.7, Table 12).

These changes are also graphically illustrated in

Figure 1 (page 55).

54

 

 

 

Table 12. Comparison of groups for libidinal and aggressive
content.
Therapists Therapists Control 2
of of Therapists
Schiz. Neurotics
(N=11) (N=11) (N=11)
Agg Sex Agg Sex Agg Sex
Pre-therapy 9.8 4-86 10.5 4.40 6.7 5.18
Mean
Post-therapy 11.1 5.60 8.6 6.26 6.4 2.82
Mean
Difference +1.5 +.74 -1.7 +1.86 -.5O -.56
N.S. N.S. N.S. p5<.05 N.S. N.S.

 

Color Scores

In view of the generally accepted relationship between

color perception and affect,

color variable may be related
festations of primary process
Specifically, since FC scores

flect more adaptive affective

it was felt that perhaps the

to, and correlated with, mani—

thinking in therapists.

More

are generally thought to re-

reSponSiveness while C and CF

reSponses reflect greater immaturity and ego-centricity,

further evidence of regression in therapists following a

treatment session might be evident in the predominance of

color in responses given to the HIT.

According to the

Holtzman scoring schema, the use of color is rated on a 4

point scale ranging from 0 (no color) to 5 (purely color).

Mean Change in Aggressive and Libidinal Content

55

2.0» --- Aggression
--Libidinal
108'“

T

1.61
1.4«

T

1.2»
1.0»
0.9;-
0.6«-

0.4»

O.2~

0 A _ -
I \ I
-0.2» SChlZ. \ Neurotic SI Control

 

 

’
\
\>/
.

r
’

-O.4~

r
I
\

-O.6‘
-O.8;

I
\

“’100‘ \ [I
-1.2.

I
/
\

l
/
\

-1.4‘
-1.6'
-1.8w

r
I
\

 

Figure 1. Comparison of groups for changes in libidinal
and aggressive responses.

56

The mean color score was derived by a summation of all color

ratings divided by the highest color score obtainable.

Since only the chromatic or "mixed" cards were used for

scoring color, the highest color score possible was 99 for

Form A (55 cards) of the HIT and 95 for Form B (51 cards).
Contrary to expectations, inSpection of Table 15 sug-

gests a lack of significant change on this variable.

Table 15. Changes in Color Scores

 

 

Therapists Therapists
of of SI
Schiz. Neurotics Therapists
Pre-therapy .151 .165 .125
Mean
Post-therapy .144 .154 .105
Mean
Difference -.007 -.05 -.02
N.S. N.S. N.S.

 

Primary Process Thinking During the Session:

Inasmuch as evidence concerning the levels of therapist
thinking during the therapy sessions was based on theoretical
discussions and phenomenological, subjective reports, a
questionnaire was administered to all therapists in order to
obtain a more quantitative indication of this variable. Data

in Table 14 indicate that compared with the SI therapists,

57

both the therapistscflfschizophrenic patients and the thera-
« pists of neurotics report that they engage in more secondary
process thinking during the therapy session. The therapists
of schiZOphrenics received a score of 21.6, therapiSts of
neurotics a score of 20.8 and the SI control therapists a
score of 18.5 on the Primary Process-Secondary Process ques-

tionnaire.

Table 14. Amount of primary process thinking during the
therapy and control sessions.

 

 

Therapists of Therapists of Control 2
Schiz. Neurotics Therapists
(N=11) (N=11) (N=11)
Mean 21.6 20.8 18.5

 

An analysis of variance yielded a significant F of 15.5
(p41.01) and Duncan's Multiple Range Test further indicated
that both groups of therapists differ Significantly from the

SI therapists.

Primary Process in a Cognitive Activity Conpgpl Grppp:

In order to check further on the major assumption of
this research paper, a fourth group of subjects was included
and given a "cognitive" task to perform between the two test
sessions. This interpolated task involved solving Simple

arithmetic problems.

58

In summary, Tables 15 and 16 indicate that this group
did not change Significantly on any variable. In terms of
thinking during the "cognitive" activity, they manifested
much use of secondary process thinking as measured by the
primary process-secondary process sentence completion test
(§'= 24.2). This amount of secondary process thinking is
significantly greater than that used in any of the other

three groups.

Table 15. Changes in Level 1, Level 2 primary process,
Defense Demand, Defense Effectiveness, Form Level
and Holtzman factors in the Cognitive Activity
Control Group.

 

 

 

Pre-therapy Post-therapy ,Diff, t Sig.

Mean Mean (Post-Pre) ' Level
Level 1 1.2 1.8 +.6 .57 N.S.
P.P.
Level 2 12.2 12.4 +.2 .41 N.S.
P.P.
DD 2.4 2.58 +.02 .09 N.S.
DE .72 .88 +.16 1.2 N.S.
F. Level .22 .25 +.01 .06 N.S.
Holtzman 19.6 22.0 +2.4 .85 N.S.

Factors

 

Table 16. Summary table of mood changes in the Cognitive

Activity Control Group.

 

 

 

Mood Mean Change t Sig. Level
Aggression +.25 1.1 N.S.
Concentration -.20 1.5 N.S.
Anxiety +.15 .60 N.S.
Fatigue -.40 2.1 N.S.
Sadness -.20 2.5 N.S.
Friendliness -.40 2.1 N.S.
Surgency -.55 2.1 N.S.
Quiet 0 0 N.S.
Nonchalant 0 0 N.S.
Restful -.60 1.5 N.S.
Placid -.20 .54 N.S.
Still -.40 .50 N.S.
Leisurely 0 0 N.S.

 

CHAPTER V

DISCUSSION

Changes in Primary Process

While the data do not support the hypothesis of a Sig-
nificant increase in Level 1 primary process responses, they
are clearly indicative of a significant increase in the
number of Level 2 primary process responses. More Specifi-
cally, unlike the lack of significant change in blatantly
regressive thinking, therapists of schizophrenic patients do
increase in the relatively more socialized and socially
acceptable forms of regressive or primary process thought.
This divergence is not too surprising, however, in view of
the comparatively healthy and sophisticated subject popula-
tion. Further, one would expect that individuals who have
reached the educational level of that of our subjects would
be those who are creative and intelligent and who have suf-
ficient control over their impulses and thinking within a
broad range of stimulating situations and conditions. Their
clinical training and experience, though limited, might also
counterindicate Significant or extensive changes in the more
raw and blatant kinds of regressive thinking (see Table 1).

Parenthetically, therapists of schizophrenics and therapists

4O

41

of neurotics differ, to some extent, in their Level 1 pre-
therapy means (Table 2). Since most, if not all, therapists
select the kind of patient they wish to work with, this
initial difference in therapists suggests that perhaps
therapists with manifestations of more bizarre thinking
choose to work with patients exhibiting greater pathology.
AS one might expect, as with the increase in Level 2
primary process responses, the therapists of the schizo—
phrenic patients exhibited a Significant increase on the
Holtzman "pathology" indicators and that this increase is
significantly different from both the therapists of neurotics
and the SI subjects. This would appear to be corroborating
confirmation of a change to more regressive thinking in

therapists of schizophrenics following a treatment session.

Defense Evaluation

Contrary to expectations, there is a lack of any signifi-
cant change in either the "Shock value" or defense demand of
the primary responses recorded for the therapists or in their
ability to deal effectively with the increase in primary
process or regressive thinking. That is, even a more quali-
tative approach or analysis of the Level 1-Level 2 dimension
fails to reveal a significant increase in the extent to which
the primary process responses require more extensive defen-
siveness. Also, it appears that the therapists do not have
more difficulty in effectively managing the increased primary

process. The defensive structure seems to remain intact.

42

This latter result would counterindicate any suggestion

that the observed behavioral changes in therapists following
a treatment session with a schizophrenic patient are the
result or manifestations of any unmanageable breakdown in
defenses or the therapist's inability to deal capably with
the increased primary process. Rather, it appears that the
only change is in an increase in the amount of primary
process thinking and that the observed and reported changes
in behavior and thinking are manifestations of the therapist's
need to deal more freqppntly with primary process. More
specifically, if a therapist giggles once before a treatment
session, this may go unnoticed. If, however, a therapist
needs to giggle ten times, this will be noted and may be in-
correctly interpreted as the therapist's declining capacity
to control or effectively defend primary process material.
An additional independent indication of the therapist's con-
tinued capability to manage the increase in primary process
thinking appropriately, is the absence of significant changes
in the rated form level of the therapist's reSponseS. That
is, reality testing, ego strength and/or the therapist's
ability to deal logically, objectively and critically with
his environment appears unimpaired and parallels the lack of
significant change in defense effectiveness. Taken together,
these results may be interpreted as a demonstration of a
"regression in the service of the ego" by the therapist.

More particularly, this may be experimental evidence of a

45

"partial, temporary, controlled lowering of the level of
psychic functioning . . . without disruptive anxiety and
guilt" (Schafer, 1958). It is as though the therapist were
allowing himself to regress and so still maintains control

over his thinking.

Mood Evaluation

As will be recalled, a mood scale was administered to
all therapists and was introduced in order to arrive at a
more objective method of measuring changes in therapist's
feelings and thinking. Interestingly, no significant changes
on any of the thirteen mood scale factors were evident.
Superficially, this finding may appear inexplicable in view
of the obtained increase in Level 2 primary process responses
and "pathological" thinking. From the self report of thera—
pists, it would appear that they do not at least consciously
experience changes in their moods or feelings even on such
primary process related variables such as aggression, anxiety
and sadness. While this may suggest a lack of frank report-
ing of their real feelings both before and/or following a
therapy session, this interpretation would have to be mini-
mized because of the type of subjects they were, and because
they were, at times, painfully honest with their perceptions
and feelings on the Holtzman test. The apparent discrepancy
between the increase in Level 2 primary process reSponses

and the absence of reported change in feelings or moods may

44

better be explained as the difference between unconscious
changes as reflected in the responses to the Holtzman proto-
cols and the need to report conscious changes on the mood
scales. That is, changes may have been occurring without

awareness. More will be said about this later.

Primary Process in Therapists of Neurotics

As indicated previously, although not originally pre-
dicted, a more detailed analysis of the data in terms of type
of content reSponses produced by the therapists, suggests
that the therapists of the neurotic patients diSplay greater
variability in reacting to patients than either the therapists
of schizophrenic patients or the SI therapists. Specifically,
the therapists of neurotics increase significantly in the
number of libidinal responses while they decrease in number of
responses with aggressive content. This result is of inter-
est for two reasons. First it suggests that changes in
amount of primary process in therapists following a therapy
session is a more generalized phenomenon than originally con-
ceived, although the effects on therapists of neurotics are
relatively less extensive or generic. Unfortunately, the
information gained from informal questioning of the therapists
following the therapy session does not suggest any simple or
direct relationship between the content of the treatment
session and the type of primary process content produced in

the period following the therapy session.

45

Secondly, in conjunction with other data, this result
has implications concerning the unstated underlying assump-
tion of this study. There is an implication from subjective
reports of therapists, observations and theoretical discus-
sions concerning therapist activity during and following a
treatment session, that any changes in primary process think-
ing in therapists following a therapy session were due to a
"carryover" of increased primary process thinking during the
therapy session itself. For this reason, a questionnaire
was administered to all subject therapists. If this assump-
tion was correct, then the therapists of schizophrenic
patients, in contrast to both therapists of neurotics and SI
therapists, should report relatively greater use of primary
process during the therapy session. At first glance, the
data derived from this questionnaire appear to invalidate
this assumption. The therapists of both the schizophrenic
and neurotic patients, compared to the SI therapists, report
a significantly greater use of secondarypprocess thinking
during the therapy session. This greater use of secondary
process during the therapy session by both therapists of
schiZOphrenics and therapists of neurotics, concurrent with
the general increase in Level 2 primary process thinking in
therapists of schizophrenics and the increased amount of
libidinal content responses in therapists of neurotics,
favors an interpretation or assumption that the increased

amount of primary process following a treatment session is

46

the result of a "safety valve," "relaxation" or "homeostasis"
factor or principle. On the other hand, it is conceivable
that the greater use of secondary process thinking during

the session by both the therapists of schiz0phrenics and
neurotics reflects some anxiety and defensiveness of the
therapists and that despite this defensiveness, therapists
were exposed to, and experienced, primary process thinking at
some level. Hence, the increases in primary process thinking
following the therapy session can still be viewed as a func-
tion of "carryover" rather than "relaxation." This tentative
interpretation of unconscious experiencing of somewhat
anxiety-provoking primary process thinking despite defensive-
ness (increased secondary process thinking during the
session), can be seen in the light of the "subception" experi-
ments of McGinnies (1949) and McCleary and Lazarus (1950).

In these studies, subjects were unable to identify tachisto-
scopically presented anxiety-provoking stimulus words (either
socially tabooed words or nonsense words associated with
shock) while Simultaneously, GSR recordings indicated that
recognition was present. This result could, in part, also
explain the discrepancy between the measured increase in
Level 2 primary process reSponseS in the therapists of schizo-
phrenics and the absence of significant findings in the
reported moods or feelings of the therapists as measured by

the objective mood scale.

47

What remained then were two alternative, yet equally
plausible, assumptions. In order to check further in decid-
ing between the two interpretations, another group of sub-
jects were tested. In this group, an arithmetic task was
interpolated between the two testing sessions. It was felt
that if subjects were required to perform a task necessi—
tating increased secondary process in a relatively non-
threatening context, one in which defensiveness was unneces-
sary, that the subjects would manifest an increase in primary
process responses following the cognitive activity if the
"release" or "safety valve" assumption was correct and an
insignificant change in amount of primary process if the
assumption of "carryover" was more appropriate. Our results
with the cognitive activity control group clearly support
this latter assumption. Unlike the therapists of both
schiz0phrenics and neurotics, these subjects do not increase
Significantly on amount of primary process nor on any other
variable. This is particularly striking inasmuch as this
control group, during the interpolated task, employed a sig-
nificantly greater amount of secondary process thinking than

any other of the three groups of subjects.

Implications and Suggestions for_§uture Research
AS a whole, our results support the theoretical dis-
cussions and observations concerning the effects on level of

thinking in therapists of schizophrenics. As a group, we find

48

that following a treatment session, therapists of schizo-
phrenics exhibit a greater amount of primary process thinking
while maintaining adequate defense capability and that the
assumption of a "carryover" of primary process thinking from
the therapy session to the period subsequent to it, is a
reasonable one. .Although nothing explicit from theory or
observation clearly indicates a negative change in adequate-
ness of defense following a treatment session, the absence
of a significant change on this variable was contrary to
expectations and an important theoretical finding. While
not of principal interest, the finding of a change in level
of thinking in therapists of neurotics, though somewhat
more circumscribed, suggests that this phenomenon is of a
more general nature in the area of dynamic psychotherapy.
The finding of more primary process oriented thinkr
ing in therapists following a treatment session raises some
interesting practical questions concerning the scheduling
of patients. That is, what effect does this increased pri-
mary process thinking have on therapist's functioning and
effectiveness if he needs to see three, four or any number
of patients in a single day? Does the increase in primary
process diminish effectiveness or does the increase have
facilitating consequences? IS the increase correlated with
heightened or lowered "therapeutic creativity"? On an indi-
vidual basis, perhaps we should be concerned with the
therapist's "rate of recovery" if the primary process increase

has inhibiting results on treatment effectiveness.

49

The difference obtained between therapists of neurotics
and therapists of schiZOphrenics not only suggests the need
to observe and measure changes in therapists of other types
of patients but also indicates the necessity for a more de-
tailed and direct measuring of the content of the therapy
sessions. This may furnish evidence for some relationship
between the content of the session and the kind and extent
of the measured changes in thinking of therapists following
the session. More Specifically, does dealing with aggressive
and/or libidinal content during the therapy session produce
like or dissimilar changes in the thinking of therapists?
Possibly, stimulation by any primary process during the
session produces changes in primary process thinking in thera-
pists which are directly related to problem areas or concerns
of the particular therapist.

Quite possibly, the difference between therapists of
schizoPhrenics and therapists of neurotics is, in part, a
function of the difference in states of regression for these
two diagnostic entities. With this in mind, one wonders
what changes would result from treating children where, pre—
sumably, there is a greater need for the therapist to re-
gress and/or more extensive primary process stimulation for

the therapist.

CHAPTER VI

SUMMARY AND CONCLUSIONS

An attempt was made to objectively measure and experi-
mentally demonstrate clinically observed changes in therapist
thinking following a treatment session. Discussions of the
activity of therapists in dynamic or psychoanalytically
oriented psychotherapy have dealt with the intense involve-
ment of the therapist in the therapeutic process. Primary
process stimulation is experienced by the therapist due to
his need to regress in order to understand and communicate
with his patient. Observations of temporary and occasionally
inappropriate behavior by therapists following a therapy
session were interpreted as manifestations of increased
primary process thinking due to a "carryover" of such think-
ing from the therapy session itself.

Three groups, 11 therapists of schizophrenics, 11 thera-
pists of neurotics and 11 persons involved in a period of
"Social Interaction" (SI), and one group of five college
students, served as subjects in this study. The first three
groups were comprised of psychOlogy graduate studentsu
psychiatric residents and social workers. They were matched

for age, sex, and discipline. Every subject was given the

50

51

Holtzman Inkblots (Form A or Form B) and a mood scale ques-
tionnaire before and after an interpolated activity.

A Primary Process-Secondary Process questionnaire for amount
of primary process used during the therapy session or inter-
polated activity was administered and an informal interview
with the therapists took place, following this period. For
the two groups of therapists, the intervening activity con-
sisted of seeing a familiar patient, either neurotic or
SChiZOphrenic, in a treatment session. The third group of
subjects were engaged in a "small talk" Social Interaction
situation with the experimenter. The five college students,
serving as another control group for changes in primary
process following cognitive activity, were required to in-
volve themselves in a task consisting of solving relatively
Simple arithmetical problems.

The "pre" and "post" Holtzman protocols were scored for
three "pathology indicators,"(Anxiety, Hostility, and Pathog-
nomic Verbalization) as well as by the Holt Manual For The
Scoring Of Primary Process Manifestations In Rorschach
Responses. These were scored for Level 1 and Level 2 pri-
mary process thinking, defense demand, defense effectiveness
and form level. .The mood scale ratings were also scored
for possible changes in feelings following a treatment
session.

In contrast to the therapists of neurotics, SI subjects

and cognitive activity subjects, therapists of schizophrenics

52

manifested significant increases in Level 2 primary process
thinking following a treatment session. No changes were
noted in any group, in terms of Defense Demand, Defense
Effectiveness, Form Level, Level 1 primary process responses,
or mood scale dimensions. A more detailed analysis of the
data yielded a significant increase in amount of libidinal
content in therapists of neurotics. In terms of the amount
of primary process thinking during the interpolated activity,
the following ascending order was reported: "cognitive"
subjects, then therapists of schiZOphrenics, therapists of
neurotics and last are the SI control subjects.

The above findings were related and discussed in terms
of the theory and observations of changes in thinking of
therapists following a treatment session and were seen as

supporting these propositions.

REFERENCES

Edwards, A. L. Experimental design inypsychological research.
New York: Holt, Rinehart and Winston, 1962.

 

Ferenczi, S. The elasticity of psychoanalytic technique
(1928). In: Problems and Methods of Psychoanalysis,
pp. 7-102, New York: Basic Books, 1955.

Fleming, Joan. What analytic work requires of the analyst.
Journal of the American Psychoanalypic Association,
1961, 9, 719-729.

Freud, S. The interpretation of dreams. The Basic Writings
of Sigmund Freud. (Trans. A. A. Brill) New York:
Modern Library, 1958.

Freud, S. Recommendations for physicians on the psychoana-
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Freud, Collier Books, New York, N. Y., 1965.

Frijling-Schreuder, E. C. The adaptive use of regression.
International Journal of Psychoanalysis, 1966, 47 (2—5),
564-569.

 

Fromm-Reichmann, Frieda. Some aspects of psychoanalytic
psychotherapy with schiz0phrenics. In: Psychothegapy
with Schizgphrenics, ed. E. B. Brody & F. C. Redlich.
N. Y.: International Universities Press, 1952.

 

Fromm-Reichmann, Frieda. Clinical Significance of intuitive
processes of the psychoanalyst. Journal of the Ameri-
can Psychoanalytic Association, 1955, 5, 82-88.

Fromm-Reichmann, Frieda. Basic problems in the psychotherapy
of schiZOphrenia. Psychiatpy, 1958, 21, 1-6.

Glover, E. The techniqpe of_psycho-analysis. New York:
International Universities Press, Inc., 1955.

Greenson, R. Empathy and its vicissitudes. International
Journal of Psychoanalysis, 1960, 41, 418-24.

55

54

Holt, R. R. Manual for the scoring oflprimapy process
manifestations in Rorschach responses. Draft 9,
Research Center for Mental Health, New York University,
Fall, 1965.

Holtzman, W. H., Thorpe, J. S., Swartz, J. D., and Herron,
E. W. Inkblot perceppion and personality: Holtzman
Inkblot Technique. Austin, Texas: Univ. of Texas
Press, 1961.

Kernberg, 0. Notes on countertransference. Journal of the
American Psychoanalytic Association, 1965, 15, 58-56.

Knight, R. P. Introjection, projection and identification.
Psychoanalytic Quarterly, 1940, 554-541.

Loewald, H. W. On the therapeutic action of psychoanalysis.
International Journal of Psychoanalysis, 1960, 60,
16-25.

McCleary, R. A., and Lazarus, R. S. Autonomic discrimina-
tion without awareness. Journal of Personallpy, 1949,
18, 171—179.

McGinnies, E. Emotionality and perceptual defense.
Psychological Review, 1949, 56, 244-251.

Nacht, S. Curative factors in psychoanalysis. International
Journal of Psychoanalysis, 1962, 45, 206-211.

Nowlis, V. and Green, R. F. Factor analytic studies of the
mood adjective checklist. Technical Report No. 11,
Research Project No. NR 171-542, Contract Nonr-668 (12),
1965.

Rapaport, D. On the psychoanalytic theory of thinking
(1950). In R. P. Knight and C. R. Friedman (Eds.),
Psychoanalytic Psychiatry and Psychology. New York:
International Universities Press, 1954.

Rapaport, D. Organization and pathology of thought.
New York: Columbia University Press, 1951.

Rapaport, D. The structure of psychoanalytic theory:
A systematizing attempt. Psychological Issues, 1960,
2, No. 2 (Monogr. 6).

Reik, T. Listeninglwith the third ear. New York: Pyramid
Books. 1948.

55

Savage, C. Countertransference in the therapy of schizo-
phrenics, Psychiatry, 1961, 24: 55-60.

Schafer, R. Regression in the service of the ego: The
relevance of a psychoanalytic concept for personality
assessment. In: Assessment of Human Motives, ed.
Gardner Lindzey. Grove Press, Inc., New York, 1958.

 

Spitz, R. A. Countertransference: Comments on its varying
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analysis, 1954, 55, 242-246.

APPENDICES

56

57

APPENDIX A

THERAPIST QUESTIONNAIRE

These questions pertain to your activity during (the

therapy session, cognitive activity, our conversation).
Please select and circle the answer which best describes
your thinking during that part of the eXperiment.

1.

1a.

4.

4a.

During the interview I did a)little b)some c)a lot
of diagnostic formulating.

During the interview (cognitive activity), I did a)some
b)little c)a lot of rational and logical thinking.

The interview (cognitive activity) required a)some
b)a lot of c)a little effort.

During the interview (cognitive activity) I found myself
doing a)a lot of b)a little c)some daydreaming.

I would consider the session a)good b)average c)poor.

In terms of satisfaction, I found (the cognitive activity)
our conversation a)good b)average c)poor.

I felt a)distressed b)comfortable c)wonderful during
the interview (cognitive activity).

I found myself doing a)conStant b)some..¢)no.thinking
concerning the dynamics of the case.

I found myself doing 'a)constant b)some c)no thinking
concerning the real reasons behind (cognitive activity)
our conversation.

I found myself concentrating a)constantly b)to some
extent c)very little.

My interest during the interview (cognitive activity)
was a)intense b)fluctuating c)lacking.

During the session (COgnitive activity) I a)repeated1y
b)occasionally c)never experienced erotic or aggressive
feelings.

58

10. During the interview (cognitive activity) I experienced
a)much b)some c)no primary process ideation.

*-
Questions 1a, 4a, and 6a, are alternate or substitute
questions to be used for subjects in SI and cognitive
activity control groups.

59

APPENDIX B

INSTRUCTIONS FOR THE MOOD SCALE AND THE MOOD SCALE

ADJECTIVES TO BE RATED

Instructions for Mood Scale

Each of the following words describes feelings or mood.
Please use the list to describe your feelings at the moment
you read each word. If the word definitely describes how
you feel at the moment you read it, circle 4 to the right of
the word. For example, if the word is relaxed and you are
definitely feeling relaxed at the moment, circle the 4~as
follows:

relaxed<:>5 2 1 (This means you definitely feel relaxed
at the moment).

If the word only slightly applies to your feelings at
the moment, circle 5 as follows:

relaxed 4<:)2 1 (This means you feel slightly relaxed at
the moment).

If the word is not clear to you, or you cannot decide
whether it applies to your feelings at the moment, circle 2
as follows:

relaxed 4 5(::h (This means you cannot decide whether you
are relaxed or not).

If you definitely decide the word does not apply to your
feelings at the moment, circle 1 as follows:

relaxed 4 5 2 (This means you are definitely not relaxed
at the moment.(

Work rapidly. Your first reaction is best. Work down
the first column, then go to the next. Please mark all words.
This should take only a few minutes. Please begin.

60

defiant 4 5 2 1 engaged in thought 4 5 2 1
clutched up 4 5 2 1 fed up 4 5 2 1
introspective 4 5 2 1 at rest 4 5 2 1
affectionate 4 5 2 1 kindly 4 5 2 1
blue 4 5 2 1 unhappy 4 5 2 1
still 4 5 2 1 placid 4 5 2 1
tired 4 5 2 1 - restless 4 5 2 1
on edge 4 5 2 1 worn out 4 5 2 1
attentive 4 5 2 1 shakey 4 5 2 1
understanding 4 5 2 1 quiet 4 5 2 1
leisurely 4 5 2 1 sad 4 5 2 1

sorry 4 5 2 1 playful 4 5 2 1
angry 4 5 2 1 nonchalant 4 5 2 1
sleepy 4 5 2 1 lively 4 5 2 1

grouchy 4 5 2 1 lighthearted 4 5 2 1

61

APPENDIX C

INSTRUCTIONS AND ARITHMETICAL ITEMS USED FOR THE

COGNITIVE ACTIVITY

The following are some simple math problems I would like
you to solve. ‘Work carefully, for it is important that you
arrive at the correct answers.

 

 

5604252

Add
721 8250 10065 22018
565 655 5207 5689
225 9422 56722 78242
521 860 6528 8455
655 685 .560 6424
15 1045 7222 8945
28 422 861
67
Multiply
42546 565547 422558 655520
6420 62556 4202 89922
14525682 7825652 9654255
975255 854526

62

 

 

 

 

Divide
4220 / 65452206 421 / 62544587965
45222 / 5789255442 65525898 / 652572549121

 

 

452568 /58658989525 421 / 41256895466

65

 

 

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64

 

 

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65

 

 

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66

 

 

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67

 

 

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