THE USE OF INSTRUMENTAL MOTOR
AME VERBAL EARNING TECHNIQUES IN THE
TREATMENT OF CHRONIC SCHIZOPHRENICS

Thain hr the Deane 00 Ph. D.
MIO‘IIGAN STATE UNIVERSITY
John R. TiIIon
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thesis entitled

The use of instrumental motor and verbal learning techniques
in the treatment of chronic schizophrenics

presented by

John R. mm

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of the requirements for

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Date Jam 16. 1956.

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THE

THE USE OF INSTRUHLNTAL MOTOR AND VERBAL LEARNING
TE HIIQUES IN THE TREATEENT OF

CHRONIC SCHIZ OPHRL‘N IC S

BY
John R. Tilton

AN ABSTRACT

Submitted to the School of Graduate Studies of Michigan
State University of Agriculture and Applied
Science in partial fulfillment of the
requirements for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

Year 1956

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The present study has been an attempt to
apply some of the thinking and methodology of instru-
mental conditioning to the treatment of chronic and
withdrawn schiZOphrenics. The principle objective was
to condition verbal approach behavior in those patients
who had nearly ceased to use adequate verbalization in
ceping with the world around them.

Since nearly all patients of this catagory do
demonstrate some ability in carrying out simple motor
responses such as walking around the ward, handling eat-
ing utensils, smoking, etc., such motor responsiveness
seemed to be a good vehicle through which to begin cond—
itioning verbal approach behavior. The method employed
was the movement of a lever by the subjects in patterns
of increasing complexity until verbalization was a nec-
essary adjunct for arriving at the "correct" pattern of
movements. The subjects were instructed and guided both
manually and verbally and were rewarded by both candy
and praise for successful solutions. Toward the end of
the experimental period, simple word games were tried
with the subjects using the same rewards. This proced-
ure was compared with a direct "talk to" kind of therapy
and also with no treatment at all.

The results of two kinds of ratings (status
rating from interviews and improvement ratings by ward
personnel) indicated that there was some measureable

improvement in four of the five subjects of the experi-

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mental group, in two of the five subjects of the "talk to"
group, and in only one of the ten subjects of the group
which had no specific treatment. There was almost universal
agreement among the improvement raters that the language
facility of all the experimental subjects had shown some
improvement.

Observational results indicatei that the subjects
who were the most verbal to begin with gained more benefit
from the "talk to" therapy while they'benefitted very little
from the motor therapy. The converse was the case with the
mute or nearly mute subjects. The inability of the verbal
patient to use adequate verbalization on the motor tasks
was interpreted as the result of their responding with
behavior that was verbal, but that was antagonistic to
anything that might be useful in solving the motor tasks.
However in the "talk to" sessions, the examiner could make
apprOpriate responses to the verbal patients and achieve
communication. Furthermore, it appears that the more nearly
mute patients are more amenable to treatment via motor tasks
because the degree of their withdrawal reduces the number

of incompatible verbal reSponses.

THLz.

THE

THE USE OF INSTRUMENTAL MOTOR AND VERBAL LEARNING
TECHNIQUES IN THE TREATMENT OF
CHRONIC SCHIZOPHRENICS

by
John R. Tilton

A THESIS

Submitted to the School of Graduate Studies of Michigan
State University of Agriculture and Applied Science
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology
1956

ACKNOWLEDGMENT

The writer wishes to express his sincere gratitude
to Dr. M. Ray Denny for his valuable counsel and guidance
in the develOpment of procedure and theoretical aspects of
this paper and also his tolerant support and help in writ-
ing the final manuscript.

Gratitude is further expressed to the other members
of the Guidance Committee, Drs. Donald M. Johnson, Alfred
G. Dietz, and Donald L. Grummon,for their comments which
added to the clarity of the final c0py, and is also given
to the staff and trainees of the Psychology Department of
the Fort Custer VA HOSpital for their aid during the run-
ning of the experiment.

Lastly, perhaps the greatest gratitude is due to my
wife, Eileen, for her unknowing support and encouragement

throughout the entire project.

TABLE OF CONTENTS

CHAPTER
I. INTRODUCTION . . . . . . . . .
II. SOME THEORETICAL CONSIDERATIONS
III. THE PROBLEM . . . . .

IV. EXPERIMENTAL PROCEDURE . . .
Subjects . . . . . . . . . .
Apparatus . . . . . . . .
Procedure . . . . . . . . .

V. RESULTS . . . . . . . . . . .
General results . . . . . .
Experimental subjects . . .
Control I subjects . . . .
Control II subjects .
Continued subjects . . . . .

VI. DISCUSSION . . . . . . . . . .

VII. SUMMARY . . . . . . . .
BIBLIOGRAPHY . . . . . . . . .

APPENDIX . . . . . . . . . .

PAGE

18
26
29
29
31
54
41
41'
45
55
58
59
62
66
69
74

LIST OF TABLES AND FIGURES

TABLE PAGE
1. SUBJECTS . . . . . . . . . . . . . . . . . . . 32
2. RATINGS GIVEN SUBJECTS BEFORE AND AFTER EX-

PERIMENTAL PERIOD . . . . . . . . . . . . . 42
5. DIFFERENCES IN RATINGS BEFORE AND AFTER EX-
PERIMENTAL PERIOD . . . . . . . . . . . . . 45

FIGURE
1. APPARATUS . . . . . . . . . . . . . . . . . . 53

CHAPTER I
INTRODUCTION

Both clinical experience and an examination of the
published papers and books dealing with therapyimischizo-
phrenia indicate that our present level of knowledge in the
area is indeed limited. Theory and experimentation still
remain on an exploratory level. We have not yet achieved a
body of knowledge that permits us to have a connected pic-
ture of what occurs in the schizophrenic process.

Past and current treatments of the psychotic are not
based on a complete knowledge of the disorder, but they are
simply rationally directed attacks against the outstanding
symptoms. From what one can learn from published work in
the area, it appears as though varied attempts at treatment
have been made at one time or another from simple incanta-
tions to complex analytic propositions. There is often the
aura of magic around something about which we know very
little and this is regrettably the situation in the area of
psychotherapy.

Since the beginning of the concept of mental illness
as a disease, therapy in schizophrenia has had a varied in-
terpretation. Kraepelin (26) assumed that schizophrenia
was a well defined disease process. The behavioral mani-

festations of dementia praecox were assumed to be due to a

2
degenerative process in addition to possible metabolic dis-
orders. He took a very pessimistic view of the disease and
eXpressed very little interest in therapy.

E. Bleuler (5) agreed with Kraepelin about the or-
ganic etiology of the disorder but had a different Opinion
about the pathognomonic importance of early deterioration.
Unlike Kraepelin, Bleuler was a more optimistic therapist
and recommended patient and persistent empirical treatment,
using mainly psychological methods. Bleuler believed that
the essence of the disease was an intellectual and emotional
dissociation and a withdrawal from the outer world. He al-.
so made rigorous attempts to understand and describe the
essential features of the disease-~primary and secondary
symptoms--in the framework of the psychology of association
which was the prevalent psychological system of his time.

Adolf Meyer (35) stood in contrast to both Kraepelin
and Bleuler. He was not primarily interested in classifica-
tion but with the development of the disease and its manage-
ment, and he introduced a pragmatic viewpoint into the
treatment of schizoPhrenia. He did not consider it as a
disease entity but as a reaction type, holistically con-
ceived, between a psychobiological entity and a unique en—
vironment, and assumed multiple causes and processes which
were only loosely bound together by descriptive titles.

This contribution to the understanding and treatment of

3

schiZOphrenia stands today as the principal manner of view-
ing what might be called the schizophrenias. Such an ap-
proach, however, leaves the question of whether or not
there is any fundamental underlying process in the etiology
common to all schizophrenias. Assuming suchaamultiple
causation, treatment is bound to consist of a wide variety
of more or less unrelated physical and psychological meth-
ods.

There is presently no clear evidence for a single
underlying and fundamental disturbance. Most statements
made about behavioral facts in schiz0phrenia such as Krae-
pelin's deterioration (26), Bleuler's dereism (3), Jenkin's
inability to tolerate frustration (21), or Hoskin's lack of
empathy (19) are descriptive prepositions rather than etio-
logical assumptions. The only clear cut etiological as-
sumption made for schizophrenia lies in the psychoanalytic
theory where it is assumed that some definite childhood
trauma lies at the base of such a disease process. How-
ever, this assumption seems difficult to support. It would
be better if we could have clearly defined antecedent con-
ditions hypothesized that could be measured and tested ex-
perimentally.

Constitutional factors have been recognized as being
a possible determinant in the etiology of the disease

process and hereditary studies have been made to support

these claims (25). We know, for instance, that schizo-
phrenia is more prevalent in families with a schiZOphrenic
history, but there is no clear evidence for Mendelian rules
for such patterns. Studies such as Hartman's (17) for in-
stance, as reported by Brody (6), show a significantly
higher incidence of schiZOphrenia in both pairs of identi-
cal twins than in fraternal twins but no predictable ratio
or pattern seems to be followed. Also it is very difficult
to control for experience factors even when the subjects
are twins. Body build has been shown to correlate with
schizophrenia in studies by Kretschmer (28) and Wittmann,
Sheldon, and Katz (59), but exceptions to this rule are
frequent. These studies, while valuable, have not contrib-
uted much toward understanding the etiology and treatment
of the disease. The recognition that metabolic disorders
are common to many schiz0phrenics has attracted some inves-
tigators C18, 54, 35) but again with uncertain results. At
best such relationships are symptomatic of the disease and
still leave the question of underlying etiology unclear.
There has never been too great success in treating schizo-
phrenia with the use of hormones although this area does
hold some promise as an adjunct to psychotherapy.

In American psychology, the greatest interest seems
to lie in the psychological aspects of schizophrenia. To

arrive at psychological formulations at various levels of

abstraction by observing behavioral manifestations of the
disease would seem to be an easier approach than to try to
track down very slight and often obscure organic factors.
The well known exceptions to the behavioral approach are
Meyer's (55) psychobiological formulations and the broad
biological formulations of Hoskin's (l9).

Brody and Redlich (6) suggest that psychological
prOpositions about schiZOphrenia could be divided into two
groups: phenomenological descriptions, and etiological
(psychogenic) prepositions positing a cause and effect re-
lationship. Most of the propositions are said to belong to
the first category even though they may be poorly disguised
as belonging to the second. It is a fact, of course, that
we cannot always delineate between the two and in reality a
perfect description stating not only the sufficient but
necessary conditions of the disease would be an explanation
(l2). According to Brody and Redlich (6), most of the de-
scriptive prepositions in schizophrenia can be traced back
to Bleuler's (3) fundamental work and Freud's (l4) descrip-
tion of the Schreber case.

Most later attempts have remained quite close to the
descriptive accounts of what occurs in schizOphrenia. Har-
ry Stack Sullivan's (55) idea that there is a failure of
security Operations after panic with subsequent withdrawal

and regression is a clear exposition describing what hap-

pens in a schiZOphrenic attact. However, he does not de-
fine why the panic occurs nor exactly why his "security 0p-
erations" failed, nor why regression is the person's re-
sponse, i. e., what variables led to this occurrence.

Fenichel (13) reviews in detail most of the psycho-
analytic work and thinking in the area of mental disturb-
ance including schizOphrenia. The accounts given here are
both descriptive in nature and also attemptsto give causal
explanations for some of the disease processes, but as is
well accepted, most such propositions are extremely ab-
stract or from obscure origins and are very difficult to
test experimentally. Such expositions, however, have prob-
ably contributed much to modern thinking and are good ex-
amples of the contribution of psychoanalytic observation to
the science of behavior in general and schiZOphrenia in
particular. However, most such prepositions are based on
the reconstruction of the life history of the person with
the illness and as such are notably unreliable when trans-
ferred to predict schiZOphrenia in other instances. Our
knowledge of child rearing is still too scanty to state
knowingly which patterns will lead to schiz0phrenia in-
volvement.

Some make the general statement that the underlying
principle in schizophrenia is an inability to tolerate

frustration. Jenkins (21) discusses this thesis, and he

feels that the fundamental task of therapy is to increase
the threshold of frustration through an appropriate reha-
bilitation program. Jenkins' thesis is based on the work
of Lidz and Lidz (29), Tietze (55), and others who report
high frequencies of broken homes, paternal and maternal re-
jection in the patient's early life. Jenkins quotes the
work of Paris and Dunham (11) that most schiZOphrenics come
from ecologically underprivileged areas. The question as
to whether schiZOphrenia occurs in the so-called tough as
well.as tender societies has not been adequately clarified
andigguIdaIs‘jhieidCEIfc‘hn light on this general problem.

When one considers the organic therapies, they seem
to have the least rationale behind them. Shock treatment
and the various lobotomies apparently have their rationale
in the assumption that they reduce anxiety and tension and
guilt by the formation of rather unspecific brain lesions.
Redlich (6) quotes Meduna as saying that, "Shock treatment
is like the kicking of a Swiss watch" to make it work.
Janis (20) suggests that shock treatment reduces anxiety
and secondary effects by eliminating painful, guilt-
producing memories through the destruction of ganglion
cells and pathways.

A recent and as yet unpublished study at the VA Hos-
pital, Fort Custer, Michigan (15) indicates that some re—

sults are being achieved in the reduction of tension in pa-

patients through the use of the drug reserpine. If the
drug continues to show good effects toward this end, it
could readily replace the other more radical organic treat-
ments. The use of lobotomies has already been eliminated
in the treatment programs of many hospitals.

When there is such an unclear understanding of the
exact nature of schiZOphrenia and its etiology, it is under-
standable why its treatment is no more specific than it is.

The psychotherapeutic approaches are at least more
rationally directed attacks against the outstanding symp-
toms of schizophrenia, regression. All systems of psycho—
therapy aim at trying to establish some sort of contact be-
tween the patient and the therapist and/or eventually be-
tween the patient and reality. In attempting to achieve
suchtagoal many and varied methods have been tried with di-
verse results.

Brody (6) has reviewed the many successful attempts
of dynamic psychotherapy which have resulted in progress in
our technique and have contributed to our meager understand-
ing of schiz0phrenia. However, it would appear that no gen-
erally accepted theory accounts for the vast differences in
approach in psychotherapeutic techniques and their more or
less successful results with the schiZOphrenic. These tech-
niques vary all the way from simple ego-supporting ap-

proaches to the so-called id interpretations of Rosen (45);

9

from rigorous manipulation of the patient and his environ-
ment in the "total push" treatment to marked passivity on
the therapist's part in his treatment of the patient. And
last but not least, there is the major unanswered question
of why «the spontaneous remissions that- occuIs in all areas
of the disease without any definitive or specific handling
of the patient and his problems by anyone.

.One thing, however, seems agreed upon by all and
that is in all successful cases of treatment, there is a
reduction of tension and anxiety which may be expressed
directly or indirectly and which enables the patient to re-
establish contact with reality. This is true in both the
dynamic therapies which are aimed at the symptOms and the
more classical analytic therapies. These approaches are
not sharply divided in their techniques and assumptions,
but actually blend in many of their aspects.

Actually in the analysis of treatment procedures,
there has been very little research carried out which could
be considered at all definitive. Many studies suffer from
insufficient controls and careful observation Of individual
patients. Also the therapeutic enthusiasm or particular
bias of the investigators often leads to preconceived con-
clusions. The results of such studies cannot be pieced to-
gether with clarity into a good understanding of the essen-
tial variables involved in the treatment and improvement of

the schiZOphrenic.

n-

 

10

Much of the inability to piece this information to-
gether stems from the fact that we are lacking in good com-
parative data. Adequate reporting of therapeutic successes
adds much to our knowledge of personality dynamics but does
not really indicate what sort of treatment is beneficial.
Neither does the tendency in psychiatric literature to re-
port only the successes add particularly to the solution of
this dilemma.

It seems apparent that good evaluation of treatment
must contain both intensive and extensive observations of
patients treated in a controlled fashion. The application
of knowledge slowly gained through the understanding of
such controlled studies should result in the data we need
so badly at this level of our understanding.

Needless to say, such experimental designs present
almost insurmountable obstacles to the investigator and, as
a result, there are few good comparative evaluations of
psychotherapy. For that matter, there are only a few good
studies of the effect of shock treatment (42, 43, 46) or
such radical and relatively well defined treatment as the
various lobotomies (15, 58). Another complicating factor
is the schizOphrenic's unpredictable tendency to remit or
relapse. Bellak (2) reports figures for complete spontane-
ous remissions as being anywhere from 0% to 22%.

Still another problem consists of the rather free

and indiscriminant use of the diagnosis of schizophrenia

11
which has been applied to everything from acute and rela-
tively mild schizoid episodes to the progressively deteri-
orating, vegetative, back ward patient with organic compli-
cations.

It becomes obvious that a good evaluation of therapy
and well controlled studies of treatment techniques is an
immensely involved problem. To do the best job would re-
quire the cooperative endeavor of a team of investigators
who understand the thinking behind the design and who all
lend their efforts to the control of the procedures and
treatment of the patients. Such a procedure would have to
be undertaken if we are to understand what goes on and if
we wish to replace wishful thinking and conjecture with a
pragmatic science.

The pooling of material of intensive and consistent
treatment has not become a standard practice in most treat-
ment centers. There is a beginning recognition for such
efforts, however, and attempts are being made in this direc-
tionCS, 15, 16). Miller (36) has recently commented that:

It is to be expected that the first efforts at an ob-
jective, quantitative approach to any intricate matter
like the evaluation of process and outcome of various
forms of therapy would necessarily seem oversimplified
and naive. Relevant variables must be discovered and
isolated, methods for measuring them must be devised.
Recently there have been several attempts to apply

the concepts of learning theory to the problem of under-

standing the schizophrenic patient, and more specifically,

12
to utilize the thinking and methods of instrumental condi-
tioning in dealing with the problems of therapy with psy-
chotics. The impetus behind much of this work is the felt
need to put the possible variables influential in these
problems on a more observable and manipulable plane, and to
make a controlled attempt to find out just what the schizo-
phrenic is like and how he behaves.

In three recent mimeographed papers describing the
progress of team research headed by Skinner and associates
(16) at the MetrOpolitan State Hospital, Waltham, Mass., a
new program for studying schizophrenic behavior is present-
ed. The purpose of their research is to arrive at a readi-
ly measurable response pattern under as controlled condi-
tions as possible. The behavior concerned is a simple
lever-pulling task in an enclosed room in response to varied
incentives including candy, cigarettes, and the presenta-
tion of pictures projected on a screen for a short period.
They report that simple repetitive responses can be elicit-
ed in varying amounts in schizophrenics in all areas of ad-
justment or deterioration and dissociation. The interest-
ing phenomenon found in this work was that the rate of re-
sponding not only varied greatly among the subjects, all of
whom were treated the same, but that it also seemed to be
correlated with certain aspects of their disease and

changes in it. They report, for instance, that the over-

13
all rate of responding was related in a crude fashion to
psychiatric diagnosis, and that the pattern of rate changes
and ”distractions" within the testing period also varied
from patient to patient and differed from "normal" records.
They are at present examining the effect of different types
of reinforcement schedules, the effect of social rewards,
the effect of having another person in the room, etc.

Their conclusions at this time are summed up by their

statement:
The behavior of the psychotic patient can be success-
fully investigated with operant conditioning techniques.
The behavior generated is stable and predictable and
should provide a stable baseline for investigating
therapeutic, pharmacological, and physiological vari-
ables. Since psychotic behavior is controlled to some
extent by the reinforcing qualities of the immediate
physical environment, the extent of this control and
the effects of different schedules of reinforcement
should be further investigated.

At the VA Hospital, Fort Custer, Michigan, a simi-
larly designed experiment has been set up which has been
running for several weeks at the time of this writing (15).
The intent of this experiment is to determine the extent
and nature of response changes in schizophrenics resulting
from treatment by insulin shock therapy using a larger num-
ber of subjects than Skinner (16) reports in his study. To
date the response rates have varied among individual pa-
tients from 3 responses to several thousand in any one half

hour testing period using candy and cigarettes for reward.

The first group of subjects in this study (#30) has just

14
been completed. The results indicate that there is a cur-
vilinear relationship between rate of response and level of
the subject's adjustment. These subjects with a median
level of adjustment respond at the greatest speed. With
this group, however, the correlation between improvement
measures and change in lever-pulling behavior is not sig-
nificant.

The implications for further research in therapy
with such a technique are manifold. In addition to being a
well defined response pattern, lever manipulation allows a
measure of behavior changes with varying sorts of therapy;
it also suggests a certain therapeutic technique in itself.
Skinner 23 gl. report that there is a general increase in
Iresponse rates and a decrease in side dissociative behavior
and periods of distraction as the patients are continued in
the apparatus.

Another study by Peters and Jenkins (40) suggests
further implications for such a therapeutic approach. In a
study which was apparently entirely unrelated to those
above, Peters reports rather remarkable improvement in the
behavior of chronic and badly regressed schiZOphrenics as
the result of what has since been loosely referred to as
"fudge therapy." He required these patients to work prob-
lems of a simple motor type which were gradually increased

in their complexity. For a correct solution to these prob-

15
lems, the patients obtained a piece of fudge which they
were allowed to eat.

In order to explain the fact that theirpatients dis-
played more active and rational behavior after working his
more difficult motor tasks successfully, Peters and Jenkins
state that they have had a success experience for such out-
ward, problem-solving behavior which had heretofore been
frustrated. Using Maier's theory (40), Peters and Jenkins
suggest that this frustration resulted in dissociated, non-
goal-directed behavior. Such a success experience as pro-
vided by the problem solution was then thought to general-
ize therapeutically to other areas of living.

Possiblyiggst critical comment that can be made of
this study is that tit; attributaathe improvement chiefly,
if not entirely, to the problem-solving behavior and the
correct solution of the motor tasks for the fudge reward.
Perhaps the simple fact that some attention, regardless of
sort, was given the patients was the chief condition con-
tributing to the improvement. The fact that Peters and
Jenkins report such results using this technique with pa-
tients who were apparently real treatment problems is, how-
ever, a solid contribution.

Others have recently reported more or less specific
treatments for badly withdrawn schiZOphrenics. Roland (44)

for instance reports encouraging results by taking cataton-

TI

 

16
ice in stupors and training them individually using relaxa-
tional and social rewards for meager gains in verbal per-
formance. His technique is similar to that used by speech
therapists where larynx muscles are taught first to relax
and then respond in specific fashions to form vowel sounds
and eventually words.

N. R. F. Maier (31) tells of an approach of one of
his students which holds promise and which also utilizes a
verbal approach with supposed social rewards. Two patients
are carefully directed into social and verbal intercourse
'by two therapists, one for each patient. The therapists in-
form each of their patients how and what to say that would
be an apprOpriate reaponse to the other's comments in the
role that he was supposed to assume. Again, the accent is
on establishing more appropriate verbal responses and com-
munication with others.

It is interesting to note that verbal performance is
the main area for attack in treatment with these proce-
dures. Krasner (27) understandably points out in a recent
Ireport that there is always one element in the patient's
behavior which could serve as a dependent variable in
studying the effects of psychotherapy and that is the pa-
tient's verbalizations. There is general agreement among
the adherents of all schools of psychotherapy that one im-
portant aspect of the patient's behavior which the therapist

17

works with is that of verbalization. Shaffer and Lazarus
(47) go so far as to say:. "The techniques of getting pa-
tients to talk and to continue to talk must be the real
core of treatment." As both Shaw (48) and Shoben (50)
point out in their applications of learning theory to psy-
chotherapy, one means of extinguishing previously repressed
behavior, and all the anxiety it evokes, is to have it
verbalized (symbolically produced) and followed by no dis-
approval. But before the patient can find out that his
speech is not going to be punished or disapproved, he must
actually verbalize and see for himself that no negative re-

inforcement follows.

CHAPTER II
',

SOME THEORETICAL CONSIDERATIONS

If we consider the regressive phenomenon in schizo-
phrenia as similar to and concomitant with withdrawal be-
havior, we can make certain comparisons with theoretical
interpretations of approach-avoidance conditioning studies
with lower animals.

Mowrer (39) and Miller (37) have demonstrated the
strong acquired drive value of autonomic anxiety or fear
reaponses when they are attached to previously neutral
cues. Taken alone, such behavior seems to be maladaptive
since the nature of the anxiety arousing situation is not
known.

In discussing the theoretical implications of this
behavior much reference will be made to papers by Denny and
Adelman (9, 10) and Denny (8) in which they analysed the
typical shuttle box paradigm with rats, in order to de-
scribe what occurs in this behavioral phenomenon.

In the paradigm, the shuttle box is divided into two
parts by a barrier which is tOpped with a roller to prevent
the rat's perching on it. A rat is placed in one side of
the box which is painted black to add to the secondary cues
of that side. Mild shock is applied through the grid floor

which elicits in the rat a variety of vigorous responses.

19
There are emotional responses (autonomic) and escape re-
aponses (skeletal). All of these responses become condi-
tioned to the cues present in that side of the box. Even-
tually the rat successfully jumps the barrier and lands in
the other end of the box which is painted white or left un-
painted. They thus escape the shock and the escape re-
sponses cease to be elicited because of the cessation of
the aversive stimuli. In the white and relaxational re-
sponses are now elicited in the rat and in turn become con-
ditioned to the cues in that side of the box. Experimental
evidence for the conditioning of relaxational-approach re-
sponses of this type exists in studies by Barlow (l) and
Smith and Buchanan (51) which show that stimuli associated
with the cessation of shock acquire approach value.

If there is a latency period between the time when
the animal is placed in the black box and the administra-
tion of shock, the animal can avoid shock altogether by
hurdling the barrier before the shock is administered.

That is, the secondary cues of the black box have acquired
a conditioned aversive quality which elicits immediate fear
and escape responses. Learning to escape and avoid go on
concurrently even though the escape responses are the first
to appear (53, 54). The avoidant response is simply the
escape response with a short latency. Such avoidant re-

responses are extremely resistent to extinction and can

20
last a long time even with the lack of any shock being ad-
ministered (22, 49). This can be accounted for by the
strong approach-relaxational eliciting qualities of the
white side of the box which increases the strength of the
jumping respOnse even though the animal is no longer
shocked.

As the pattern of putting the animal in the black
side of the box is continued, the latencies for jumping be-
come longer and longer since that side of the box, in the
lack of the primary aversive stimulus (shock), becomes re-
laxation eliciting also. Occasionally the latency will be-
come so long that the animal is again shocked, which re-
establishes the jumping response stronger than ever.

The behavior of the chronic schiZOphrenic is remark-
ably similar to that of the rat under these conditions.
Although there are many manifestations of the disease and
many courses of its development, there does seem to be, in
nearly all cases where organic involvement cannot be demon-
strated, an early struggle for equilibrium or solution of
the conflict and the anxieties experienced by the ill fated
person. Maslow and Mittleman (32) speak of this as the
schiZOphrenic's early fear of a catastrOphe or some impend-
ing disaster which they struggle against but seem unable to
handle within the limits of "normal" behavior. This behav-

ior seems bizarre to the untroubled person and the patient

21
eventually shows the radical and aversive symptoms of men—
tal illness. If this early stage of the disease does not
remit under known treatment measures, a typical regressive
and deteriorating process occurs which is known to all
clinicians. To quote from an article by Boltz (4):

A degree of so-called regression and organismic stagna-
tion occurs that can be observed in thousands of con-
tinuous treatment schizOphrenics who never recover, who
remain in psychiatric hospitals for the remainder of
their lives, and who constitute 58% of the patients who

fill permanent treatment mental hospitals in the United
States.

To speculatifgggt occurs in such cases using the ter-
minology of instrumental conditioning, one could assume
that these persons have a strongly conditioned avoidant at-
titude or a response pattern that continues to be elicited
even in the absence of any apparent aversive stimuli on the
primary level. In addition, a strong relaxation pattern
elicits approach behavior to the "safety" of withdrawal,
and thus the tendency to continue to withdraw becomes
stronger and stronger as witnessed by the behavior of many
chronic patients who become more and more detached from the
world around them. These pe0ple seem not to have given up
in the pOpular sense of the word, but rather they seem to
be carrying out a response pattern which they are unable to
change because of the nature of the.environment in which

they find themselves. The continuous treatment wards of

most mental hospitals seem to resemble the white side of

22
the shuttle box in many respects. The emphasis is on paci—
fying the patient.

In the case of the rat who has been conditioned
strongly to avoid the cues attached to the originally aver-
sive stimulus (shock) and to approach those cues attached
to the relaxation responses, a strong set is established
which is virtually unchangeable until the primary aversive
stimuli are removed and he is forced over a period of time
not to make the avoidant responses in the presence of such
cues. This can be explained by the fact that the rat has
relaxational reaponses conditioned to the cues in the white
and of the box in a discriminative manner, that is, during
acquisition, each time the animal began to relax in the
black side of the box it received a shock and learned the
discrimination of first jumping over into the white side
before beginning to relax. If the shock employed is suffi-
ciently severe, the conditioned anxiety pattern will inva-
riably occur prior to any relaxation and will therefore not
extinguish at all. Failure to obtain extinction in dogs,
using a traumatic level of shock, has recently been report-
ed by Solomon, Kamin, and Wynn (52).

- One simple technique for facilitating extinction of
the avoidant responses is to force an antagonistic response

by preventing the animal from leaving the black shock cham-

ber. Whether or not the forced response would be relaxa-

23
tion or not would be determined in time by the presence or
absence of any aversive stimuli of the primary level. Sol-
omon, Kamin, and Wynn (52) and Brush, Brush, and Solomon
(7) found that this was the only way they could extinguish
the avoidant responses in certain ones of their dogs. For
others they had to punish them in the escape chamber.

Returning again to the behavior of the chronic
schiZOphrenic, the same concepts can be applied. Such a
person seems to have a definite resistance to movement of
any sort and appears to be completely amotivated. His be-
havior pattern,which was originally escape and avoidant in
Quality, now in the long term chronicity of the pathology
seems to be approach behavior directed toward all the vege-
tative and withdrawn aspects of the disease, even though
the original aversive stimuli may no longer be present.
Such behavior continues to be elicited simply because noth-
ing in the schizOphrenic's environment forces any other
mode of response in a consistent manner.

In successful therapy where the patient is manipu-
lated in some consistent manner or when he shows spontane-
ous remission after years of regressed behavior, the pa-
tient's behavior is somehow channeled into more normal pat-
terns which are antagonistic to the withdrawn behavior.
Slowly such behavior becomes conditioned to the external

cues in the absence of any aversive stimuli (anxiety). The

24
factors favoring the resulting improvement are too often
not defined in a way that would allow their repetition for
more treatment success.

In the failure of therapy, it could be that partial
remission of symptoms results in contact with a configura-
tion of events which acuaas a primary escape elicitor (is
anxiety-arousing), and which drives the patient into the
schizoPhrenic withdrawal again.

Peters' and Jenkins' (40) successes might be ex-
plained along these lines. The configuration of circum-
stances, including the rewards and the tasks set before
them to achieve the rewards, elicited responses heretofore
absent in the schiZOphrenic's response repertoire. The im-
portant thing was that Peters and Jenkins were successful
in forcing a problem—solving attitude or response pattern
on the patients who were previously withdrawing,rather than
attempting to solve their own problems.

In the lever-pulling experiment of Skinner 33 31.
(16), it was found that some patients learned to attend to
the task with less dissociative behavior with continued
lever-pulling. Such a finding is in line with the asser-
tion that the schiZOphrenic can learn responses which are
oriented toward the external situation. Circumstances
forced a response pattern which becomes more and more con-

ditioned to the cues of the situation in which they are

25
placed, thus resulting in better and more consistent behav-
ior of an outgoing sort toward manipulating the external
environment. Whether or not this behavior generalizes to
other circumstances is not known.

Presumably the essential features of all therapeutic
attempts that meet with some degree of success could be an
absence or diminution of the primary aversive stimuli, plus
a forcing of a more outgoing and problem-solving attitude
over a sufficiently long period of time so that such behav-
ior becomes conditioned to the stimuli of the environment.

That simple motor tasks may be an effective way to
start treatment with regressed schizOphrenics is supported
also by the fact that such regressed persons show a retarda-
tion in motor functions as part of their general symptoma-
tology. A recent study by King (25), where he used several
measures of motor response such as reaction time, finger
dexterity, etc., showed a significant loss of function in
the motor area that correlated roughly with degree of psy-
chotic withdrawal. He suggested that such measured losses
further demonstrated the totality of the withdrawal mecha-
nisms and the general loss of function resulting from psy-

chotic involvement.

CHAPTER III
THE PROBLEM

The most evident behavior that separates man from
the lower animals is his ability to verbalize and to think
and manipulate his environment symbolically. This also
seems to be the first ability that is affected in the
schizophrenic process, and as Shaffer and Lazarus (47),
Shaw (48), and Shoben (50) point out, the techniques that
get the patient to talk or symbolically produce previously
repressed or avoided behavior without its being followed by
punishment are the real core of treatment.

In all chronically regressed patients, this is ex-
actly the kind of behavior that is lost almost without ex-
ception. If some technique could be devised to force sym-
bolization and verbalization of repressed ideas and a prob-
lem-solving attitude which was followed by no punishment,
there are good indications that general improvement such as
Peters found should occur.

A possible way to approach such an end is suggested
by the work of Skinner £2 2;. (16) with the knob-pulling
tasks and the work of Peters and Jenkins (40) of increas-
ingly more complex motor tasks. It has been found that
many schiz0phrenics in all levels of withdrawal will re-

spond in some fashion to such simple motor tasks with the

27
possible exception of stuporous catatonics, and Roland (44)
reports some success with these when a lot of individual
attention is given.

What is needed is an attempt at a controlled longi-
tudinal study with a group of withdrawn schiZOphrenic sub—
jects using a device which enables one to move gradually
from a simple motor task to more complex ones requiring
verbalization to master them successfully. It should be a
task that lends itself to verbalization in easy steps be-
cause simple motor tasks are more available to the with-
drawn patient than those requiring verbalization. Thus a
simple motor response which gradually blends into verbali-
zation would seem to be a feasible way of beginning thera-
PY-

Since the work of the subjects should be as concen-
trated as possible and continued over a fairly long period
of time, the number of patients worked with by one investi-
gator is of necessity small. As a result, such an attempt
toward understanding what goes on in therapy with these
pe0ple can be little more than exploratory, and the present
study is so conceived. .

The hypothesis being tested is that chronically
withdrawn schizOphrenics can be conditioned to utilize ver-
bal symbols through the use of instrumental conditioning

techniques. Further, such techniques should condition a

28

problem-solving attitude that will be evident in more out-
going and "rational" activity in the patient. In other
words, the patient will be approach-conditioned to verbal
activity and problem-solving behavior; as a result there

should be a reduction in withdrawal symptoms.

CHAPTER IV
EXPERIMENTAL PROCEDURE

Subjects

The co-Operation of the personnel of one of the con-
tinuous treatment wards of the V.A. Hospital, Ft. Custer,
Michigan, and several clinical psychology trainees was en-
listed in the selection and rating of 20 chronic and marked-
ly withdrawn schiZOphrenics. An attempt was made to match
these patients as nearly as possible with respect to age,
length of hospitalization, intelligence, and length of
treatment by the pacifying drug reserpine. The twenty sub-
jects were then divided into three groups: Experimental-—
5 subjects, Control I--5 subjects, and Control II--lO sub—
jects. The only selective requirement was that the experi-
mental subjects show a definite liking for chocolate candy,
the assumption being that this might add to the reward and
incentive aspects of the task in the manner of Peters and
Jenkins' experiment (40). Their liking for this candy was
determined by having it in front of them during the initial
interview, offering it to them, and observing their re-
Sponse. If they took it and ate it, it was assumed that
they had a liking for it. About half of the subjects
showed a definite liking for the candy while the remainder

refused it even when it was offered.

30

Every subject was then rated as to the amount of his
dissociation and withdrawal on an eleven point scale devel-
oped by King and Merrell (24) to assess these factors in
schizophrenics. They report that with 40 subjects being
rated by three raters, an average inter-rater reliability
of .85 was achieved. With this scale one can make ratings
ranging from "normal" behavior with no demonstrable psy-
chotic symptoms to the most vegetative form of the disease
one is likely to find. An example of this status scale is
given in the Appendix.

The method used in the rating consisted of an indi-
vidual interview with each patient. The patient's behavior
was rated simultaneously, but independently, by three clin-
ical psychology trainees. There was remarkably close
agreement among each of the raters' judgments, which is
probably accounted for by the fact that all the subjects
ranged near the lower end of the scale. The patients were
all markedly withdrawn and uncommunicative and represented
nearly the lowest level of schiZOphrenic adjustment.

The age, length of hospitalization, and dosage of
reserpine were obtained directly from the hospital records.
The intelligence of each subject was estimated whenever
possible by the verbal portion of the Wechsler-Bellevue,
Form I. In all those subjects where no verbal contact
could be made at all, making administration of the test im-

possible, the WBIQ was estimated using the educational lev-

51
e1 as suggested by Wechsler's (S7) statistics and tabulated
by Wells and Ruesch (58). These measures along with their
means are given in Table l with the estimated IQ's from ed-

ucational level marked with asterisks.

Apparatus

A diagrammatic drawing of the apparatus used is
shown in Figure l. The apparatus was a portable box with a
3' by 3' face and 2'6" deep. A lever projected from the
face sufficiently far to allow freedom to grasp and move it
in two planes (vertical and horizontal) for a total of 8" in
any of the four directions from the center resting position.
The lever was supported at the back of the box by a compres-
sion spring which provides only enough tension to return
and hold it in the center position when not in use. Each
of the four slots (up, down, right, and left) were individ-
ually marked by Dialco gem lights of three different colors
that lighted up progressively (green, yellow, red) as the
lever traversed the slot. The red light did not light un-
til contact was made with the extreme position. The light-
ing arrangement was designed to further the attention value
of the apparatus, increase its exploratory value, and add
to the complexity of the movement patterns that could be
called for. In the lower left hand corner of the face of
the box was a small tray projecting 2" from the face, into

which small M&M chocolates could be individually dropped by

52

 

 

 

 

TABLE 1
SUBJECTS
Experimental Control I Control II
No. Age IQ igoggé. No. Age IQ igoggé. No. Age IQ ifioggé.
l. 29 73 26 6. 25 71 80 11. 35 98 6O
2. 4O 78 178 7. 36 94 48 12. 50 86 56
5. 55 101 66 8. 45 97 53 15. 25 110 50
4. 56 94 75 9. 50 7O 86 14. 27 115 12
5. 27 98 35 10. 45 111 115 15. 42 93 11
16. 25 90‘ 82
17. 36 90‘ 145
18. 25 66 6O
19. 41 90‘ 144
20. 36 90‘ 140
Aver. age: 33 Aver. age: 56 Aver. age: 34

Aver. IQ: 89
Length of hosp.: 76

Aver. IQ: 89

Length of hOSp: 72

Aver. IQ: 95

Length of hOSpu 74

 

 

‘Denotes ap roximated IQ from tOp school grade attained

per Wechsler's (57

norms as presented by Wells and Reusch (58).

These subjects were too dilapidated to be given IQ tests.

 

 

 

 

 

 

 

FIGURE 1

APPARATUS

 

 

 

 

 

 

33

34
a mechanical device manually Operated by the experimenter
from the side of the box. The entire apparatus was painted
black with the exception of the projecting part of the lev-

er and the candy tray,which were painted silver.

Procedure

The experimental subjects and the Control I subjects
were seen individually and privately for approximately
twenty minutes each, four days a week for ten weeks. The
Control II subjects were left entirely alone on the ward,
as far as this study was concerned, and led the same sort
of life as all the patients on the ward.

Each experimental subject was kept working with the
apparatus as much as possible during each contact with him.
There was no attempt made to discuss the subject's personal
problems or feelings except when he volunteered to do so,
which was a rare occurrence at first. The emphasis was
chiefly on working with the apparatus and later (for the
last four weeks) on word games such as word golf, anagrams,
and twenty questions. Every attempt was made to establish
a problem-solving attitude and to encourage the use of ver-
balizations to solve the tasks. A paper sack was provided
on each occasion in which they could place the candy reward.
They could take the candy with them when they returned to
the ward, or they could eat it as it was earned if they

wished.

35
The subjects were told initially that this was a

candy machine that required the correct movement of the
lever to get a piece of candy, and that they were to try to
find the quickest way and the easiest way of getting it.
They were informed that they could do with the candy what-
ever they wished.

At the beginning of the sessions with the experimen-
tal subjects, very simple response patterns were rewarded
with candy and verbal praise. Such patterns included a
simple and repeated downward movement of the lever or, as
was the simplest basic response with two subjects, one com-
plete turn around the board in either a clockwise or
counter-clockwise direction was rewarded. When it appeared
that a particular response pattern had been learned, i.e.,
no errors or inapprOpriate side behavior over a period of
several responses (usually ten responses in a row), the
problem was changed. With successive successes, the com-
plexity of the response pattern was increased in gradual
steps according to the patient's ability to deal with the
pattern without losing interest or demonstrating frustrated
behavior. Typically, the patterns employed roughly in or-
der of difficulty were as follows:

1. A simple downward movement or any single movement in
any one direction.

2. Inform subject that the first move is up, and he
must find the second move. (reward up, down)

56

5. Inform subject that the correct reSponse pattern in-
volves two moves that he must find for himself.
(reward right, down)

4. Again two moves are correct and subject must find
them both for himself. (suggest that he state his
planned approach)

5. Inform the subject that the correct pattern involves
three moves and thatthe first one is down. (reward
down, right, left, etc.)

6. Subject must find a pattern of three moves.

7. Inform subject that the lights are the important el-
ements to successful moves. he must find the cor-
rect light.

8. Subject must find a pattern of two lights to light
in correct order. (reward up red, right amber, etc.)

An attempt was made to have the subject verbalize
aloud his moves as he made them. Also they are instructed
to try to give the examiner a verbal plan of attack that
could be used to best arrive at a solution to the problems.
This was done later, after some progress was shown with the
simpler movements. Plenty of examples were given along
with manual guidance when called for.

The best way of increasing the complexity of the re-
Sponse patterns or exactly the best time to do so could not
be predetermined. However, the physical characteristics of
the box left many possibilities for varying the response
patterns freely at any time. The basis for suddenly chang-
ing the problem was the patient's behavior in terms of los-

ing interest or showing frustrated behavior.

37

It was assumed that most of these patterns, with the
exception of the simplest movements, could not be learned
readily as the result of simple motor conditioning, but
only if the responses were first verbalized. They could
then be quickly learned, eliminating all incorrect moves.
The inability of lower animals to learn multiple response
patterns that have any degree of complexity Li generally
attributed to the fact that the motor conditioning falls
far short of what can be accomplished by the human animal
who can employ verbalizations in a mediational role.

After it becomes apparent that the subjects verbal-
ized effectively and could learn new reSponse patterns
readily through the use of verbalizations, the apparatus
was drOpped in favor of purely verbal games with the thera-
pist. These games could be varied readily in complexity,
and this allowed for success experiences at many levels of
proficiency. Such games as anagrams, the unscrambling of
letters to produce good English words,were used. For the
more advanced subject twenty questions was excellent, be-
cause it allowed the subject to verbalize instrumentally at
various levels of abstraction. Because of our lack of
knowledge of the subjects' abilities, these games could not
be planned too far in advance. Therefore such information
will make up a part of the results of this study.

The Control I subjects were treated in a different

manner. The purpose of this group is to attempt to answer

58
those critics who would say that any improvement found in
the experimental subjects could not be attributed to the
conditioning methods used, but could be the result of the
fact that individual attention was given to the patients
regardless of the kind of treatment used. This is a neces-
sary control, of course. However, improvement found to be
present in the Control I group does not invalidate our
present hypothesis, since these subjects can be thought of
as being conditioned toward the use of language by the
simple attempt to communicate with them in an accepting at-
mosphere. It does throw more'light, however, on treatment
methodology and the most effective approach to it.

The Control I subjects were seen for an overall
period that closely approximated the total time spent with
the experimental group. The fifth working day out of each
Week was used to make up any time lost with the subjects
during the week. Such make-up times were necessary because
or delays and unforeseen circumstances that come with the
Scheduling of patients so closely. During the time that
they were seen, every attempt was made to try to establish
some sort of verbal communication with them. Questions
Were asked of them on any topic in which they might show
the remotest interest and then communication was carried on
fI‘om that point to topics surrounding their mental condi-

tZion, whenever they were able to do so. No motor tasks

39
were employed and the contact with them was purely on a
verbal or social level.

The Control II group was not seen after the original
interview and engaged in the same ward activities available
to all patients on the ward, including those in the other
two groups. No subject, regardless of his group, was de-
terred from engaging in these activities since they were
seen during their normally free periods. No one but the
investigator knew for sure which patients were being seen
or under what conditions, and therefore differential treat-
ment on the ward was not possible. The subjects were sim-
ply taken from the ward to the research room by the experi—
menter each day when they were available.

At the end of the ten weeks, each subject was again
rated by the same techniques that were used before, using
the same rating sheet and a new interview. Two of the
Original three raters rated the second time and a new rater
was added in place of the original one. This new rater had
never seen the patients before. None of the raters were
aware of which group the subjects were in.

In addition, two ward personnel (the charge aide and
his assistant) were asked to rate each of the twenty sub-
Jects on the basis of an improvement scale. This scale was
developed by King and Merrell (24) to use for this same

PUrpose in another study. It consists of two parts: the

no

first allows an over-all estimate of the general improve-
ment or worsening of the patient's condition on a six point
scale; the second part provides a check list to designate
in what areas the change was most evident in the estimation
of the rater. A c0py of this improvement scale is provided
in the Appendix. None of these raters on the improvement
scale knew which of the differential treatments had been
given to each of the patients.

As an added part of this study, two patients were
continued beyond the ten weeks period. One of these pa-
tients was in the original experimental group and one was
from the original Control I group. The experimental patient
(#1), seen as the most improved by the raters, was continued
on a less strict schedule. The Control I subject (#6) who
was seen as the least improved was transferred to the ex-
Perimental group and treated in the same fashion on the ap-

Paratus as the experimental group was originally.

CHAPTER V
RESULTS

General Results

One subject in the experimental group had to be
dropped about two weeks after the study began because of
.impulsive and aggressive behavior on the ward. He became
unmanageable to the extent that he had to be transferred to
a seclusion ward and could not be continued on the appara-
tus. At the time of this writing, the patient still re-
mains under close supervision, demonstrates impulsive beha-
vior, and is quite a management problem. 'The remainder of
the subjects were continued in the study throughout the ten
week period. The results of the status ratings before and
after the study are listed in Table 2, and the differences
between these ratings plus the results of the improvement
ratings are given in Table 3.

Thus it can be seen, in terms of the wide range of
improvement possible, that the changes which did occur were
fairly small. However, the direction of change seen in all
of the experimental group before and after the experimental
period is significant at the 5% level of confidence and just
short of the 1% level using a Fisher's "t" for small

samples. The difference in the ratings of the Control I

42
TABLE 2

RATINGS‘ GIVEN SUBJECTS BEFORE AND AFTER
EXPERIMENTAL PERIOD

 

 

 

 

 

Before Study After Study
Raters Raters
No. l 2 3 Mean 1 2 3 Mean
Experimental Subjects

1. 11 ll 12 11.3 9 7 8 8.0

2. 12 10 12 11.3 11 10 11 10.7

3. 10 10 10 10.0 8 9 9 8.8

4. ll 10 11 10.7 10 9 9 9.3

5. 7 7 8 7.3 - - - -

Control I Subjects

6. 10 10 10 10.0 11 10 10 10.3

7- ll 9 9 9.7 8 8 7 7.7

8. 9 9 9 9.0 9 10 10 9.7

9. 11 9 10 10.0 7 9 7 7.7
10. 9 9 8 8.7 9 9 11 9.7

Control II Subjects

11. ll 11 11 11.0 11 11 11 11.0
12. 9 7 7 7.7 9 9 7 , 8.5
13. 7 7 7 7.0 8 7 7 7.3
14. 9 8 7 8.0 9 8 8 8.3
15. 8 8 8 8.0 7 8 9 8.0
l6. 12 ll 12 11.7 12 11 12 11.7
17. 11 11 11 11.0 11 11 11 11.0
'18. 10 9 9 9.3 10 9 11 10.0
'19. 12 11 12 11.7 12 11 12 11.7
20. 12 11 12 11.7 12 ll 12 11.7

‘The higher the number the poorer the condition.

 

43
TABLE 5

DIFFERENCES IN RATINGS BEFORE AND AFTER
EXPERIMENTAL PERIOD

:— :.
—-‘—‘

Mean differences Improvement ratings

 

 

 

 

 

 

 

 

 

N°° in status ratings
Rater #l‘ Rater #2‘
Experimental Group

1. 3.3 4 3

2. .6 3 2

3. 1.2 4 4

4. 1.4 3 3

5. — - -

Control I Group

6. -0.3 1 2

7. 2.0 3 2

8. —0.7 2 2

9. 2.3 3 3
10. -l.0 2 2

Control II Group

114 0 2 2
12. -0.6 3 2
113. ' -0.3 3 l
14. -0.3 2 2
115. 0 2 2
115. 0 2 3
17. o 2 2
18. -0.7 2 2
19. o 2 2
2K). 0 2 2

‘Key to numbers:
1. Has become worse
2. Essentially no change
3. Shows minor improvement
4. Shows considerable improvement
(5. Shows very marked improvement)

1;?

 

44
ggroup before and after the experimental period is not sig-
ruiicant. Moreover, the difference in the two ratings for
‘the Control II group is not only not significant but what
little difference there is is in the Opposite direction.
Adl subjects of the experimental group, with the exception
of the subject dropped, were seen as having shown some de-
gree of improvement by the raters, while only two of the
(Sontrol I group were seen as having shown any improvement.

Considering the two types of ratings, the improve—
Inent scale is probably the most informative,since it is
laased on judgments of actual improvement instead of the pa-
‘bients' momentary status as seen in one fairly short inter-
‘riew. Also this scale provided a check list for denoting
‘bhe areas where any improvement was evident. The raters on
‘this scale had a day to day contact with the patients on
‘bhe ward while carrying out their work and therefore had a
Ilarge sampling of behavior from which to make their judg-
nnents.

A Fisher's "t" run on the measures of this scale
iahow a significant difference in amount of judged improve—
Dment between the experimental group and the control groups
Elt better than the 5% level of confidence. There was no
Eiignificance between the judged improvement between the
COntrol I and the Control II groups. In fact, the mean of

E111 the status ratings of the Control II group is lower,

_ 3.1-9;er

45
'though insignificantly, on the second rating than on the
.first, suggesting a more critical condition of the pa-
tients' adjustments or possibly a tendency to rate lower in
general when considering the patients' adjustments on the

second occasion.

Experimental Subjects

All of the experimental subjects showed a continued
interest in the candy and the apparatus throughout the ten
xweek period except one (subject #2) who lost interest in
‘the candy at the end of the first week. This subject was
'the most distractable and also the most verbal subject from
'the beginning. However, his verbal reproductions were
Ineaningless and illogical and can be described as a "word
salad" as is typical of the speech of many dilapidated
schiZOphrenics. Subject #2's attention could not be main-
tained on the apparatus for over a few seconds at a time.
When he did work with the lever, his movements were random
in nature and he never appeared to have a problem-solving
attitude. Many attempts were made to provide some incen-
‘tive for this subject to attend to the task, but with only
a minimum of success. The only sense that could be made
<Dut of his "word salad" was that he wished to be trans-
-ferred to another place, either another ward, hospital, or
‘town. The only incentive that worked at all was the verbal

Suggestion that no change could be made for the patient un-

46
'til he demonstrated some ability with the apparatus. This
:Btatement would occasionally result in nearly a minute of
leffort with the lever. However, throughout the ten week
iperiod, this patient never made over three consecutively
correct moves within any trial period, even with the sim-
jplest of the patterns. Also he was never able to verbalize
‘what he was doing with the lever successfully. ApprOpriate Irv“
‘verbalization seemed to represent an impossible task for ‘
liim and the experimenter's attempts to elicit this verbali-

.zation would result in his immediately losing interest in

 

‘the apparatus and beginning to use the word salad. Through- ;_?
<3ut the experimental period his performance suggested that ‘H
lie was never able to form a verbal picture of what he was

(doing. In the final ratings, this subject was seen as the

least improved of the experimental subjects. In fact, some

of the Control II subjects were seen as more improved.

‘What improvement was seen was judged to be present primari-

 

ly as the result of a diminution in the subject's use of g?
'the word salad on the ward. Otherwise he was not seen as I ”
sufficiently improved to warrant a change in his environ-
Inent either in terms of moving him to another ward or giv-
Iing him ground privileges. At this time, no one can hold a
(zontinued and meaningful conversation with this man.

The greatest successes were met with in patients #1

Etnd #3. There was a considerable behavioral difference in

 

47
these subjects before the experimental period. Subject #1
was hebephrenic in his reactions and simple in his thought
content. From the first, he appeared to relate verbally to
the experimenter, but it was soon evident that his talk and
thought content, as far as could be assessed from his beha-
vior, were shallow and stereotyped. It was stereotyped in

the sense that his repertoire of responses was extremely

limited and what was present was repeated even in situations

*where it was not apprOpriate. It was shallow in the sense
'that he never showed any real feeling for anything either
"by'expression or other physical response, i.e., he had a
‘typically flat effect.

Subject #3's behavior seemed to be more catatonic
inasmuch as he was slow in his movements and spent the
greatest part of each day lying on the floor apparently
asleep. When aroused, he would respond slowly and only
after making what appeared to be a great effort. he always
appeared sleepy and his talk, although usually apprOpriate,
'was limited to monosyllabic responses to direct questions.
lie never volunteered information or talked spontaneously in
zany situation, and his effect was also typically flat.

Both of these subjects (#1 and #3) responded about
‘the same with the apparatus at the beginning and both
:Showed continued interest in it and the candy. Interest-
Iingly enough, subject #3 continued to eat all his candy on

tflne ward, but subject #1 socialized enough to begin offer-

"at

48
ing his around to others toward the end of the ten week
period. Their earliest responses on the apparatus were
random in nature. Although they seemed to understand what
‘was wanted, they did not seem able to approach the tasks
systematically. However, of all the experimental subjects,
these two learned to use verbalization effectively the
soonest. They would state aloud what moves they were mak-
ing almost from the beginning and within a week, both were
able to suggest to the examiner what mode of approach might
‘be used to eliminate incorrect moves in arriving at a solu-

‘tion. They also learned to change set from one type of

jproblem to another which no subject was able to do at first.

iEWen though they were the best to learn, their interest in
‘the problems never failed to a point where they would not
continue with the apparatus.

Subject #4 was unique in that he was almost overly
‘willing to please as far as motor activity was concerned.
On the ward, he entered vigorously into all work details
and carried out simple tasks quickly. If, however, he was
Iiot directed toward any activity by a direct command, he
\vould spend most of his time either sleeping on the floor
<>r sitting slumped over in a chair for hours. On the appa-
IPatus, he would move the lever vigorously in all directions
Vflhen instructed to find the candy, but would continue to

Inove the lever without regard to the candy or without at-

it.

 

49
tempting to work out the correct moves and eliminate the
‘wrong ones. Every so often he would step long enough to
jpick up the candy he had happened to earn through his ran-
dom movements. He only seemed able to behave in a gross,
global, and undiscriminating manner once he had started.

He did this much in the fashion of an automaton that some—
one had forgotten to turn off. He never talked spontane—
ously to others even to making simple requests. When ques-
tioned directly, his responses were always in monosyllables
and so low in volume the words were barely discernible.
Iiis emotional responsiveness was nil and one could never
guess what his thoughts or his mood was or whether he even
experienced such things.

On the apparatus, this subject was vigorous in his
Inoves, but these moves bore little resemblance to that
inhich would indicate a problem-solving approach. When asked
‘to state aloud what he was doing, this slowed his response
Ineasurably, but he had difficulty keeping the moves and the
TStatements commensurate with one another. lt took many
(iays of both manual and verbal instruction before he could
Eihow some signs of improvement even with the simplest pat-
13erns. Also previous day's successes would not seem to car-
?Py'over to the next day and aid him in his performance.
ITVentually, however, by the end of the third week and the

lmeginning of the fourth, this subject began to show some

.;2. I“!
’ My

45

50
improvement and could plan his moves fairly well. He al-
ways seemed under pressure however to make a vigorous phys—
ical response rather than to verbalize or think out his ac-
tions prior to making them.

As mentioned earlier, subject #5 was lost to the ex-
periment early. However, this subject initially seemed to
show promise for the therapeutic procedure. He worked well
with the apparatus, eliminating incorrect moves systematic-
ally and maintaining a pattern of movements that would get
him candy. de expressed enjoyment in a childlike fashion
over the candy and the chance to work with the apparatus.
His verbalizations were meager and he often blocked when
speaking. After a week in the experiment, he was noticed
to be hallucinating vigorously and generally reacting to
stimuli that were not apparent to the examiner. It was
shortly after this that he became combative on the ward,
reacting to voices he hallucinated, and was subsequently
lost to this study.

It is interesting to note that, although the sub—
jects were matched as nearly as possible on several vari-
ables that were all a matter of record, their individual
personalities and modes of reacting to the experimental
Situation were all decidedly different. However, within a
‘wide range the earliest responses of all the subjects on

'the apparatus were exploratory in nature. The subjects

 

51
would move the lever around randomly, observe the movement
and watch the lights blink on and off. In general, the ap-
paratus and particularly the lights seemed to command at-
tention. The initial responses seemed to be without regard
for any planned or systematic manner of approaching the
problem. When the candy was first received, indicating a
correct move, they all seemed unable to repeat the movement
that immediately preceded the reward. As a result, it was
necessary to guide the movements through verbal instruction.
For instance, if the correct move was up-down or any such
dual movement, the subject was instructed that the trial was
incorrect whenever he made any two consecutive moves that
‘were incorrect, and that he should start over again after
returning the lever to the center.

Such simple moves as this dual movement were diffi-
cult at first for all the subjects to learn to carry out
consistently without error. For instance, two or three cor-
.rect moves would often be made, then an incorrect one fol-
‘lowed by as many random efforts to get the candy as had been
experienced in the first place. Or a single incorrect re-
:Sponse could be fixated; subject #4, after making a dozen
Or'so incorrect attempts to find the solution, persisted in
Inaking one incorrect move over and over again even when
'that move failed to produce candy and he was told that it

Vvas incorrect. 1t was also found in the earlier stages

 

 

52
that all the subjects would be able to work several patterns
correctly for ten or more consecutive successes only to
lose this ability on the following day and display random
movements again. Finally, however, after a good deal of
practice and attempting to verbalize what they were doing,
all the subjects except #2 were able to make consistently
correct moves of the simpler kind, and showed a day by day
advance in that each initial set of attempts seemed to be
the result of some plan based on the previous days' or the
previous trials' successes.

There were some differences in the speed with which
the various subjects were able to c0pe with the advancing
difficulty of the patterns. The greatest spread of capa-
bilities was seen when the subjects were requested to ver-
balize overtly what they were doing as they were carrying
out the movement. An amazing amount of difficulty was ex-
perienced with this apparently simple task. Also, when
first asked, no one was able to verbalize overtly a plan
of attack that could be used to arrive at a solution. The
patient that finally had the least difficulty with verbali-
zation of the solution was subject #3, and even he did not
organize a plan of attack until after a week and a half of
practice on the apparatus.

During the last four weeks of the experimental peri-
od, all of the experimental subjects were tried on the

simple word games. The first attempt was with anagrams,

53

using only common three letter words at first, then ad-

vancing to longer ones as they began to show proficiency in

the task.

The subjects were rewarded verbally by telling

them they were doing well when they met with success and

also by giving them one MEM chocolate for each letter of

the particular word they did correctly.

The order of their proficiency is listed below from

the most to
Subject

Subject

Subject

Subject

Subject

the least proficient:

#3

#1

#4

#2

#5

attained the level of fairly complex
twenty question games.

attained the level of 5 letter anagrams,
but could not work out the simplest
twenty question games.

could do three letter anagrams reasonably
well and occasionally four letter anagrams
but performance was always spotty.

always spotty even in the three letter
anagrams and always too distractable.

lost to experiment before this time.

The order in which these subjects fell in their word

game proficiency was approximately the same as their abil-

:ity to verbalize the movement patterns on the apparatus.

Jilso, a check with the ratings of improvement and final

EStatus of the subjects agrees very closely with this order.

The final disposition of the subjects in the experi-

Inental group was as follows:

Subject #3 was transferred from a closed ward to an

open ward and given ground privileges. He also has

54
agreed to join the patients' marching band which was a
major success, since all previous attempts in this di-
rection were unsuccessful. Whenever he meets the exam-
iner on the grounds, he seems to be pleased to speak to
him, although he remains very shy and schizoid in his
actions and has not yet been considered for a trial
visit home.

Subject #1 remains on a closed ward, because he is
considered an elOper. However, he carries on a much
better conversation with others, engages much more in
group activities Of the ward, and is considered less
delusioned by the raters.

Subject #4 has also been transferred from a closed
ward to an Open ward and given ground privileges. How—
ever, he is still very much preoccupied with his own
inner thoughts and walks about slowly as if in deep
thought. He will answer with a faint smile when spoken
to, but will otherwise pass directly by the examiner
without comment or sign of recognition. The raters see
this man as improved inasmuch as he has a more normal
activity level. However, he is not under consideration
for a trial visit at this time either.

Subject #2 remains on a closed ward and his over-all
behavior remains very much the same as before with the

possible exception Of the diminution in the use of the

 

;
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m.- .951

in

 

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4-
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55
word salad. He is seen as the least improved Of all
the experimental subjects. It is interesting to note
also that he has been hospitalized by far the longest
of anyone else in the experimental group.

Subject #5 remains on the seclusion ward and still
displays occasional impulsive and aggressive behavior
and is not being considered for transfer at this time.

Although there is still a remarkable difference in

each Of these patients' over-all condition and behavior
patterns, it is interesting to note that both raters on the
improvement check list see each Of the rated experimental
subjects as showing improvement in their verbal function.
{This is denoted by their checking one or both Of the fol-
lowing statements for each Of the subjects:

1. "The patient's speech is more logical or understand-

able to others."
2. "The patient speaks in a more normal tone of voice,

and at a more normal rate."

Control I Subjects
The subjects in this group can be divided rather
Saharply into two parts: those who were able to relate to
tihe examiner rather early in the contacts with them and to
C301:1tinue to do so for the ten weeks, and those who were

Eiither unable or unwilling to do so at any time.

 

- - =— 15.“ H2 ”unau—w

56

Those able to talk fairly effectively about more
than a very limited number Of tOpics were subjects #7 and
#9. Subject #7 was a very shy and soft spoken patient who
would originally rather keep quiet than run the chance of
becoming entangled in a situation which would upset him.
Through encouragement and an accepting attitude on the ex-
aminer's part, this patient began to discuss the events
that led up to his hospitalization and the fears he had for
the future. A dependent relationship was established with
the examiner in which the patient apparently looked forward
to the contacts and wanted to express his concerns. He al-
‘ways talked in a halting manner, but the feeling was that
lie did gain from the attention given to him. On the im-
Iprovement scale, one rater saw this patient as showing min-
:imal improvement with this change being most noted in the
:fact that the patient seemed better oriented and less con-
:fused. The other raters making their judgments as the re-
sult:of an interview, saw this patient as having a higher
rusting chiefly because he appeared less blocked and more
cOnfident. On the whole, however, this patient has not im-
pl?oved sufficiently to be considered for a ground pass.

Patient #9 is a rather simple person with apparently
bOrderline intelligence. He always seemed amiable and
W'illing to relate verbally but on a most childish level and

cC’ncerned himself only with the most simple tOpics such as

 

nu

'n

o.

57
the weather, his past days' activities, and the progress of
the baseball games. Over the period of the ten weeks, he
became more at home with the examiner; however, he was nev-
er able to seriously consider his pathology. The inter-
‘View raters were impressed with this man's greater verbal
proficiency in the second interview, and also his warmer
response to them. The improvement raters saw this man as
improved, because the staff considered him for a trial vis-
it home. He is presently on an Open ward and his behavior
is rational and non-impulsive, but very simple and uncom-
plicated.

Patients #6 and #8 were never able to relate verbal-
Ily to the examiner on a meaningful level during the entire
‘ten week period. They would either speak in a highly delu-
sional fashion about completely disconnected tOpics or re-
Inain impassive and silent. Patient #6 was the least able
‘to relate on any level and would forget who the examiner
iwas from one day to another. After having seen him for
Several weeks, he would still deny that he had ever seen
tlie examiner before. This patient was seen as having re-
nmained the same on the improvement scale by one rater and
518 having gotten worse by the other. Subject #8 can be de-
SCribed in about the same fashion except that he did remem-
finer the examiner from day to day. He would be reasonably

fI‘iendly one day and hostile the next, without apparent

AID-’1‘ y--

 

'rue rm fixfit “Emil—Add.“
s ' ' ' - _
v:

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24—4.:

11

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58
reason or willingness to talk about it. He continually re-
iterated in a rambling fashion his delusional ideas and
could never at any time express his thoughts in a consist-
ent and logical fashion. NO improvement was seen in this
Inan by any of the raters.

Subject #10 was an Older man who was concerned en-
tirely with the delusion that some organic malfunctioning
of the back of his brain was the complete and total cause
of his being hospitalized. This delusion could not be

shaken even in the least amount. He cannot support himself

 

(Nitside of the hospital and probably will remain in his
Ixresent hospitalized state, since no one outside is inter-
e sted in him.

Those subjects who were seen by the raters as the
Inost improved in the Control I group were those who were

sible to advance in their ability to communicate verbally

‘With.the examiner and to manipulate symbolically a growing rm
a
number of tOpics.
Control II Subjects L
é
Only one of these patients was seen as sufficiently j
3:

improved to warrant any radical change in his treatment
ipl?0gram, such as a change Of ward or trial visit home.
This apparent exception was subject #14, who at the insist-
erIlse of his parents, but against medical advice, was re-

1‘5ased in their care. No substantial change was seen in

59
his condition at the hospital except that one of the raters
did indicate minimal improvement. However, this judge ad-
mittedly based his rating on the fact that the patient went
home while the others did not. Since going home, as in
this case, can be influenced by many variables which are
irrelevant or only vaguely related to actual improvement,
this event cannot be accepted at face value as a criterion

of constructive change in a patient's condition.

The Continued Subjects

The result of the continued study with subjects #1
and #6 suggests that the nature of the patient's condition
may have more to do with the success of therapy than the
nature of the therapy itself. Subject #1 was seen on fif-
teen to twenty more occasions and little, if any, more im-
provement was noted. Personnel who are familiar with his
condition,other than the raters, take the position that he
is presently functioning as well as he ever has in his en-
tire life. He has been considered peculiar and schizoid
from his early childhood and has never been able to support
himself. He states that his life here in the hospital is
pleasant, and he appears tO have no aspirations for the fu-
ture beyond the present custodial care and routine activi-
ties. NO one outside the hospital is willing to accept him
and assume the responsibilities of his welfare. The chief

task would be to motivate him sufficiently to do something

60
with his life, since his intellectual faculties seem intact
and his emotional tone is balanced.

Subject #6, shortly after the 10 week experimental
period ended, was transferred to a seclusion ward because
he began disrobing on the ward and additional help was
needed in quieting him and keeping clothes on him. During
this time, he became very confused and active, with his be-
havior being completely irrational and uncontrolled. Since
this is a management problem, measures were taken to pacify
the patient, in the name Of treatment, as is done with all
such impulsive and unpredictable patients. He was given hy-
drotherapy (tubs), wet packs, and his medication was
changed. After a week or so Of such treatment, the patient
became more manageable, less active, but he also became
mute. He was cooperative in following directions but be-
yond this, little more can be said about his improvement.

At this time he was started on the apparatus in the
same manner as the experimental patients were originally.
His attention was very hard to maintain over anything but a
very short period of time. After a minute or two of some
effort with the lever, he would stop and just sit or look
about the room. During these periods, he would occasional-
ly giggle foolishly, play with his clothing, and often make
aborted attempts to rise from his chair. NO success was

achieved in getting the patient to verbalize his responses.

1 . 'LI. .- ‘1'.—

 

fi. "IE,

 

r"

[5 .-'KA~4.:-—

61

Requests made to him to state out loud what movements he
was making or might plan to make resulted only in half-
hearted mumbles that were rarely consistent with his moves.
These also would die out and persistent attempts to get him
to continue would result in a general depreciation in his
behavior.

After four weeks of trying to improve his problem-
solving attitude toward the task, the procedure was stopped
without its having resulted in any appreciable change in

the patient's condition. The main problem throughout was

 

in finding ways to elicit a continued effort on the pa-

tient's part toward any task.

 

‘- An

I

.4
"H“;

P r-."_—‘ _' *' "hf-ff (FWf—‘Wf't ~ -3.

CHAPTER VI
DISCUSSION

In this first effort to condition verbal behavior,
only meager results were Obtained. However, the use of the
motor tasks which increased progressively in complexity
does seem to Offer a sound approach to therapy with certain
types Of chronic mental patients. The most promise for
this procedure seems to be with those patients who have not
responded to traditional treatment methods (somatic, chem-
ical, and psychotherapeutic approaches) and receive only
custodial care. They have become more and more withdrawn,
anergic, and uncommunicative over the years, and this pat-
tern has become stabilized. Such individuals show very
little verbal activity but do walk around the dayroom,
smoke cigarettes, manipulate eating utensils, etc. In
short, motor responses are more available to these patients
than verbalization.

In contrast, the more verbal patients do not seem to
benefit from the motor learning approach as much, since
they are more interested in trying to express themselves on
an unrelated verbal level. It is as though the non—verbal
subjects needed to start from the beginning in using words
to OOpe with the world, while the verbal ones possess com-

peting responses of an inappropriate nature.

on

2.
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63
It is entirely conceivable that the chronic, non-
verbal, long-term patients have made an adequate adjustment

to the simple life of the hospital but that this adjustment

has not required anything other than simple motor responses.

Because they have already made an adequate adjustment to
their uncomplicated hospital life, there is little reason
to believe that these patients would display the bizarre
speech and confused behavior Of the early schizOphrenic if
they were to begin utilizing their language facilities
again. Their adjustment has simply left out the verbal re-
sponse along with an interest in more outgoing activities.

0n the other hand, the less withdrawn and more bi-
zarre appearing patient who displays a more vigorous and
misdirected symbolic activity is still struggling with pro-
found conflicts using his old mechanisms Of adjustment.
With this person, any attempt at treatment using a method
that tries to improve language facility, per se, probably
‘would not be as successful as a method devised to eliminate
specific conflicts using the typical face to face, verbal
jpsychotherapy. In this connection, it is relevant to note
that of the Control I subjects given purely "talk to" ther-
apy, the two most verbal patients at the beginning were
Seen as most improved at the end.

In addition to the above two, there seems to be

Eatill a third type of patient. This type seems to be exem-

 

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64
plified by subject #6 who seemed to be in the process of
withdrawing during the time he was seen in the continued
portion of the study, after having been shifted to the ex-
perimental condition. Often it appears as though the rou-
tine activities and the unvaried life of the hospitalized
patient at this particular period in his illness may actu-
ally facilitate the general process of withdrawal.

The chronology of the disease process which appears
to be most amenable to the present therapeutic approach
seems to be as follows. First the schiZOphrenic struggles
with deep-seated conflicts utilizing every mode of attack
at his disposal and generally appearing very bizarre in so
doing. Standard treatments are applied without appreciable
results until a general over-all withdrawal process is be-
gun. After a period of time away from the conflictual
world in which he lived and in the relative safety of the
routinized hospital existence, he reaches a level of with-
drawal which allows some degree of adjustment. At this
point, he suffers from no specific conflicts nor is there
any abnormal amount Of anxiety. The patients at this level
of existence make up a large percentage Of the custodial
ward patients and they continue at this level Of existence
for long periods of time without experiencing anything that
Inight alter this situation.

It is questionable whether the present technique

‘Nould be useful with patients at any other level of adjust-

65
ment without major modifications. However, if such stages
Of develOpment of the disease process as outlined above do
occur, it would be interesting to determine in further
studies which therapeutic techniques would be effective at
these various stages. it could be hypothesized that the
subjects at the most primitive level Of adjustment would
reSpond only through direct elicitation. Such subjects are
able to understand simple verbal commands but seem unable
to act on suggestions involving a planned approach tO any
tasks such as a systematic elimination of incorrect moves
in the lever-moving procedure. For instance, in subject
#1, manually guiding his moves in a systematic fashion at
first, while he verbalized these moves, seemed the only way
to improve his problem-solving approach to the task.

As this type of patient becomes more able to handle
the tasks, his interest seems to fail. At this point, so-
cial rewards might be more successful. Such rewards could
consist of praise from the therapist, pictures flashed on a
screen, sharing rewards with other patients, and, in the
more advanced subjects, a OOOperative effort or a competi-
tive effort between two patients or between the patient and
the therapist. Such a technique as the latter met with
success in the best adjusted patient of the experimental

group in this study.

. u ‘1‘”?

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CHAPTER VII
SUMMARY

The need for more controlled, comparative studies of
treatment procedures with schiZOphrenics was discussed. One
Of the areas where factual knowledge is most lacking is with
regard to the badly withdrawn and chronic schiZOphrenics
who make up the largest portion Of all patients institution-
alized in mental hospitals.

The present study has been an attempt to use some of
the thinking and methodology of instrumental conditioning.
The principal objective was to condition verbal approach
behavior in the badly withdrawn patients--those who had
ceased to verbalize almost entirely. Since nearly all pa-
tients do demonstrate some ability to carry out simple mo-
tor responses in adjusting to the demands of their environ-
ment, such motor responsiveness seemed to be a good vehicle
through which tO begin conditioning verbal approach beha-
vior. The method used was the movement of a lever in pat—
terns of increasing complexity until verbalization was a
necessary adjunct for arriving at the "correct" pattern of
movements. The subjects were instructed and guided both
'verbally and manually and were rewarded by both candy and
Ipraise for successful solutions. Toward the end of the ex-

19erimental period, simple word games such as anagrams and

 

 

 

 

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67
twenty questions were tried with the subjects, using the
same rewards. This procedure was compared with a direct
"talk to" kind of psychotherapy and also with no treatment
at all.

The results Of two kinds Of ratings (status rating
from interviews and improvement ratings by ward personnel)
indicated that there was some measurable improvement in
four of the five subjects of the experimental group, in two
of the five subjects of the "talk to" group, and in only
one of the ten subjects of the group which had no specific
sort of treatment. There was almost universal agreement
among the improvement raters that the language facility of
all the experimental subjects had shown some improvement.

Observational results indicated that the subjects
who were the most verbal to begin with gained more benefit
from the "talk to" therapy while they benefited very little
from the motor therapy. The converse was the case with the
mute or nearly mute subjects. The inability of the verbal
patientlto use adequate verbalization on the motor tasks
was interpreted as the result Of their responding with be-
havior that was verbal, but that was antagonistic to any-
thing that might be useful in solving the motor tasks,
‘whereas in the "talk to" sessions, the examiner can make
appropriate responses to the verbal subjects and achieve
communication. Furthermore, it appears that the more near-

ly mute patients are more amenable to treatment via motor

1‘-"

 

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68
tasks, because the degree of their withdrawal reduces the
number of incompatible verbal responses.

The greatest problem was in finding techniques which
would elicit continued attention to the apparatus and call
forth a continued effort toward the problems. The candy
rewards were believed to be primarily signals for success-
ful solution to the problems rather than being intrinsic
rewards. Verbal rewards, social praise and attention, suc—
cess in a competitive effort, and simply the solving of a
problem all seemed to contribute to the elicitation of con-
tinued effort.

The word games seemed effective in bringing about
additional verbal behavior that could be rewarded, espe-
cially in the less withdrawn patients. With badly with-
drawn subjects and with those whose speech is garbled and
meaningless, the games appeared to have very limited use—

fulness.

J

.1

l.

10.

ll.

12.

BIBLIOGRAPHY

Barlow, J. A., Secondary motivation through classical
conditioning. Amer. Psychologist, 7:273, 1952.
(Abstract)

 

Bellak, L., Dementia Praecox. New York, Grune and
Stratton, 1948.

 

Bleuler, E., Dementga Praecox or the Group Of Schizo-
or

phrenias. New k, International University

Press, 1950.

 

Boltz, H. B., A report of spontaneous recovery in two
cases of advanced schiZOphrenic organismic stagna-
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Brody, E. B., R. Newman, and F. C. Redlich. Sound re-
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Brody, E. B., and F. C. Redlich. Psychotherapy with
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Feigl, H., Logical Empiricism: Twentieth Century Phil-
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Janis, R. E., Psychological effects of electro convul—
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IO.

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74
APPENDIX

PERSONALITY ORGANIZATION-DISORGANIZATION

NO evidence of disorganization. Well composed. Ex-
cellent contact with the environment. Thinking is en-
tirely clear with no blocking or traces of bizarreness
in speech.

Minimal disorganization. Composed; anxiety (if pres-
ent) is controlIed. COntact with the environment is
unimpaired. Thinking shows absence of bizarreness.
Disturbances in this area are slight, momentary, and
confined to such phenomena as inability to concen-
trate, lapses in attention, and blocking.

Mild disorganization. Composure shows some disrup-

 

tion (e.g., anxiety). NO noticeable deficit in con-
tact with environment, but withdrawal trends may be

present. No bizarreness. Inability to concentrate,
lapses in attention, and blocking are apt to be fre-
quent. '

Considerable disorganization. Confused rather than

 

composed. Contact with environment is tenuous or
fluctuating. There may be traces Of bizarreness, with
possible transient hallucinations and delusions. Dif-
ficulty in concentrating, lapses of attention, and
blocking are characteristic. Speech may show circum—
stantiality, repetitions, and the like.

Pronounced disorganization. Marked confusion. Def-
inite impairment in contact with reality, but not dis-
oriented for time, place, or person. At least one Of
the following psychotic symptoms will be displayed to
an acute degree: bizarre thoughts, hallucinations,
delusions, mannerisms, depression, and the like. The
speech pattern is characteristically disturbed.

Almost complete disorganization. Overwhelming confu-
sion. Almost complete loss Of contact with reality.
Disoriented for at least one of the basic spheres
(time, place, person). Shows a variety Of psychotic
symptoms under #5. Communication may be all but im-
possible.

measure
ment 19‘
servatir

followil

A
\J
is

75
CLINICAL IMPROVEMENT SCALE

This scale represents an attempt to provide a crude
measure Of improvement in the patient's condition and adjust-
ment level over the last ten weeks. On the basis of your Ob-
servations of the patient, rate him in accordance with the
following categories:

1. Has become worse.

 

2. Essentially no change.
3. Shows minor improvement.
4. Shows considerable improvement.

5. Shows very marked improvement.

 

If you rated the patient as showing some degree of im-
provement, use the following check list to indicate the areas
in which this immprovement occurred. Check only the state-
ments which apply to the patient.

A. Thinking and reasoning:
( ) 1. Patient hallucinates less or is less delusional.

( ) 2. Patient is in better contact, is better oriented, or
in general shows less confusion.

( ) 3. The patient's speech is more logical or understand-
able to others. 7

( ) 4. The patient is not so concerned with ideas and words;
does not go over and over things in his mind or in
his speech so much.

( ) 5. Patient is less preoccupied with Somatic complaints
(e.g., aches, pains, fatigue, etc.).

B. Overt behavior:

( ) 6. The patient shows less unusual or manneristic beha-
vior, such as abnormal postures or unusual movements
of arms and legs.

( ) 7. The patient Speaks in a more normal tone of voice,
and at a more normal rate.

( ) 8. The patient's behavior is less impulsive, less unpre-
dictable.

‘f.

’11.\

()9.

(>10.

( ) ll.

76

The patient's behavior is more spontaneous; he is
able to respond more without keeping himself under
such tight control.

The patient shows less immature "attention-getting"
behavior.

The patient is more aware of personal appearance, is
less untidy, is more responsible in matters Of per-
sonal hygiene.

C. Emotion and mood:

 

(>12.

( ) 13.
( ) 14.
(>15.
(>16.

The patient has a more normal activity or energy
level.

The patient is better able to tolerate frustration.
The patient is less depressed.
The patient shows less anxiety or tension.

The patient is less hostile.

D. Interpersonal or social relationships:

(>17-

(>18.

( ) l9

( ) 20.

The patient is more approachable by other patients
and/or ward personnel.

The patient os more tolerant of the ideas and actions
Of others on the ward.

The patient more Often takes part in group activities
on the ward (cards, checkers, bull sessions, etc. ).

The patient shows a greater interest in the problems
and welfare of others on the ward.

E. Constructive motivation and behavior:

(>21.
( ) 22.

(>23-

( ) 24.

The patient has more insight into his condition.,

The patient is more cooperative; is better able or
more willing to follow instructions. 1

The patient has a more positive attitude toward T"\.‘
treatment. '

The patient's activities, on and Off the ward, are
more constructive.

NIH

93 03177 8453

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