masts “MWwillLlllllflllllllljflnjljflll ‘ .W V" ;’_-~.\( wip' " A ., - Pa». m.»{n““-e-=‘¢=«‘""’ ' ’ 'inw This is to certify that the thesis entitled Repeated, Superficial, Self—cutting: Study of a Behavioral Treatment Program presented by Margaret Ann Thomas has been accepted towards fulfillment of the requirements for Ph.D. degrepin Counseling, Personnel Services and Educational Psychology 0-7639 RETURNING MATERIALS: )V1ESI_J Place in book drop to LIBRARIES remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. Might $540923 REPEATED, SUPERFICIAL, SELF-CUTTING: STUDY OF A BEHAVIORAL TREATMENT PROGRAM BY Margaret Ann Thomas A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Counseling, Personnel Services and Educational Psychology 1981 ABSTRACT REPEATED, SUPERFICIAL, SELF-CUTTING: STUDY OF A BEHAVIORAL TREATMENT PROGRAM 6 H 7 /00 BY Margaret Ann Thomas The purpose of this research was to evaluate the effectiveness of a specific, behaviorally oriented treat- ment program used with patients who repeatedly inflicted superficial skin cuts on themselves. The treatment program consisted of strenuous physical exercises and self-induced, exercise-related non-injurious pain. A second purpose of this investigation was to determine if self-induced, non- injurious pain was a necessary component of the treatment program. The sample for the study consisted of five subjects who met criteria established for identifying repeated, superficial "cutters" who cut themselves without suicidal intent. A modified single case AB design (A/B/B+C/B) was used to compare the effectiveness of two variations of the treatment program (exercise and exercise with pain). Measures of frequency of self-cutting and frequency of urges to cut were obtained from self-report data maintained Margaret Ann Thomas by each subject and, where applicable, from hospital staff members. The Friedman Two—way Analysis of Variance on Ranks was used to test hypotheses of differential treatment effects on cutting behavior and urges to cut. The Spearman Rank Correlation Coefficient was used to test hypotheses of a relationship between frequency of cutting and frequency of urges to cut during each phase. Finally, observational analyses of data and clinical descriptions of each subject were presented. The results indicated the treatment procedures did not have statistically significant different effects on the frequency of self—cutting or on the frequency of urges to cut. Also, no statistically significant relationships were found between frequency of self-cutting incidents and fre- quency of urges to cut during any of the experimental phases. There was evidence of practical significance however. Of the three subjects who participated in all treatment phases, one stopped cutting herself and the other two substituted another less destructive symptom, scratching. Finally, suggestions for future research were presented. ©COPYRI Margar 1981 COPYRIGHT BY Margaret Ann Thomas 1981 T 1‘ a... a..- D-€ "l ACKNOWLEDGMENTS This project was possible with the assistance of Dr. Lionel W. Rosen and Dr. Norm Kagan, co—directors of the dissertation. A special thanks to Dr. Rosen for being a patient teacher and friend. I am grateful to Dr. Kagan for his continuous assistance throughout my doctoral program. I also wish to express my appreciation to the other members of my committee: Dr. William C. Hinds, Dr. Alton R. Kirk, and Dr. Cecil L. Williams. I want to thank Geetha for her advice concerning the analysis of the data and Dr. Sam Plyler for his wise counsel. I am grateful to the patients who so willingly and Openly participated in this project. I have learned much from them. Thanks also to Dr. Harry Mahannah and Dr. Louis Nemser for referring potential subjects to me. A special thanks is extended to the staff of the Psychiatric Inpatient Unit at St. Lawrence Hospital, Jaye Hamilton, and Carrie Fergueson O'Neil for their assistance. To my family, Anne, Christopher, David, and Edith, thanks for their support and understanding as well as their insistance that I be "human." Finally, I extend my deepest affection to James Blake Thomas for expecting my separateness as well as sharing in Our intimacy. iii II. TABLE OF CONTENTS Page LIST OF TABLES . . . . . . . . . . . . . . Vii LIST OF FIGURES. . . . . . . . . . . . . . ix Chapter I. INTRODUCTION . . . . . . . . . . . . 1 Statement of the Problem. . . . . . . . 1 Need for the Study. . . . . . . . . . 1 Theoretical Framework. . . . . . . . . 4 Delimitations of the Study . . . . . . . 8 Definition of Terms . . . . . . . . . 9 Assumptions . . . . . . . . . . . . lO Hypotheses . . . . . . . . . . . . 10 Overview . . . . . . . . . . . . . 11 II. REVIEW OF THE LITERATURE AND RELEVANT THEORIES . 12 Descriptive and Epidemiological Studies. . . 13 Treatment Studies . . . . . . . . . . 14 Pain . . . . . . . . . . . . . . 17 Definition. . . . . . . . . . . . l8 Theories of Pain. . . . . . . . . . 19 Pain Threshold . . . . . . . . . . 28 Pain Tolerance . . . . . . . . . . 32 Attention and Anxiety . . . . . . . . 34 Exercise as a Form of Self-induced Non- injurious Pain. . . . . . . . . . 36 Learning Theory. . . . . . . . . . . 37 Drive-reduction Theory. . . . . . . . 37 Negative or Forced Practice . . . . . . 42 Paradoxical Intention . . . . . . . . 46 Satiation . . . . . . . . . . . . 48 Generalization . . . . . . . . . . 49 Summary . . . . . . . . . . . . iv IV. Chapter Page III. DESIGN AND METHODOLOGY . . . . . . . . 55 Description of the Sample . . . . . . 55 Procedures for Selection of Subjects. . . . 55 Operational Measures . . . . . . . . . 58 self—reports o o o o o o o o o o o 58 Staff Reports. . . . . . . . . . . 58 Clinical Interview . . . . . . . . 62 Minnesota Multiphasic Personality Inventory (MMPI) . . . . . . 62 Multiple Affect Adjective Checklist (MAACL). 64 Psychiatric Records. . . . . . . . . 68 Treatment Procedures . . . . . . . . . 69 Baseline Phase . . . . . . . . . . 69 B1 Phase . . . . . . . . . B+C Phase . . . . . . . . . B Phase . . . . . . . . . . . 71 . . . . 72 2 Selection and Training of Trainers . . . . 73 Statistical Hypotheses . . . . . . . . 75 Experimental Design . . . . . . . . . 77 Methods of Analysis . . . . . . . . . 78 Statistical Analysis . . . . . . . . 78 Observational Analysis. . . . . . . . 80 Summary . . . . . . . . . . . . . 82 IV. ANALYSIS OF RESULTS 0 O O O O O O O O O 84 Restatement of the Problem . . . . . . . 84 Subjects . . . . . . . . . . . . . 85 Hypothesis 1 . . . . . . . . . . . 86 Hypothesis 2. . . . . . . . . . . . 87 Hypothesis 3. . . . . . . . . . . . 90 Hypothesis 4. . . . . . . . . . . . 91 Hypothesis 5. . . . . . . . . . . . 92 Hypothesis 6. . . . . . . . . . . . 95 Clinical Descriptions. . . . . . . . . 96 Subject M.C. . . . . . . . . . . . 96 Subject T.O. . . . . . . . . . . . lg: Subject W.S. . . . . . . . . . . . 154 Subject F.B. . . . . . . . . . . . 177 Subject D.N. . . . . . . . . . . . ‘.‘."\‘OC‘- _Jvr . u.- . u-‘a- .— ”yuu c v-py‘m fly. a 5—. Chapter Summary 0 C O O O V. SUMMARY, CONCLUSIONS, DISCUSSION AND IMPLICATIONS FOR FUTURE RESEARCH Summary Conclusions . . . . Discussion . . . . Implications for Future APPENDICES Appendix A. Definitions . . . B. Informed Consent. . . C. Medications . . . . D. Trainers' and Patients' (Inpatient Format) . E. Trainers' and Patients' (Outpatient Format) .' Research 0 0 Tape Typescripts F. Clinical Interview Outline . G. MMPI Instructions . . H. MAACL Instructions . I. Body Diagrams. . . . J. Sample Self—injurious Behaviors Observation Form BIBLIOGRAPHY. vi 0 Tape Typescripts Page 192 195 195 198 198 207 209 211 216 220 245 267 273 275 277 284 286 10. 11. 12. 13. 14 (I) rn _'_ ”—71 Table 10. 11. 12. 13. 14. Hypothesis 1: Variance on Hypothesis 2: Variance on Hypothesis 3: Coefficient Hypothesis 4: Coefficient Hypothesis 5: Coefficient Hypothesis 6: Coefficient Subject M.C.: for Figures Subject T.O.: for Figures Subject T.O.: Exercises. Subject W.S.- for Figures Subject W.S.: Sessions Subject W.S.: Sessions . Subject F.B. for Figure Subject F.B.: Sessions . LIST OF TABLES Friedman Two—way Analysis of Ranks . . . . . . . . . Friedman Two—way Analysis of Ranks . . . . . . . . . Spearman Rank Correlation Spearman Rank Correlation Spearman Rank Correlation Spearman Rank Correlation . o 0 ~ a u o o o 0 Self— —cutting Incidents, Legend 9 and 10 . . . . Self— cutting Incidents, Legend 14 and 15. . . . . . Exercise Data-—Scheduled . o o o Self— ~cutting Incidents, Legend 19, 20, and 21 . . . Exercise Data—-Schedu1ed - o o o u a a o o 0 Exercise Data—-"As Needed" 6 o o a o a o v o ' Self-cutting Incidents, Legend 27 . . . . . . . . . . Exercise Data--Scheduled Page 88 89 9O 92 94 95 100 113 126 133 148 149 156 172 Table 15. 16. 17. Subject F.B.: Sessions . Subject D.N.: for Figure 33 Exercise Data--"As Needed" Self—cutting Incidents, Legend Summary of Hypotheses and Results . . . . viii Page 173 180 193 ' “Wm-.2333“ ‘ 10. ll. 12. 14. 15. 16. (l) 10. 11. 12. 13. 14. 15. 16. LIST OF FIGURES Pain Threshold Curve, Stimulus Intensity—— Threshold Time . . . . O O O O 0 Primary Molar Behavior Principle. . . . Law of Reinforcement. Questions Listed in the Subject's Notebook for the Baseline Questions Listed in the Subject's Notebook for Phases. . . . . the B 1' B+C, Phase. . and B2 0 0 O O O Self—injurious Behaviors Observation Form. Frequency of Self—cutting and Urges to Cut Hypothesis 4: Frequency of Cutting and Frequency of Urges to Cut. . . Subject M.C.: Subject M.C.: Extremities, Subject M.C.: Subject M.C.: Subject M.C.: Urges to Cut. Subject T.O.: Relationship Between Ranks of Self—cutting Incidents, Left Upper Extremity. . . . . Self-cutting Anterior. . MMPI Profile 0 O O O Incidents, Lower MAACL Raw Scores . . . Frequency of Self—cutting Upper Extremity. . . . Subject T.O.: Subject T.O.: Self—cutting and Incidents, Left Self-cutting Incidents, Right Upper Extremity. . . . . . . MMPI Profile ix Page 29 38 40 59 6O 61 81 93 98 99 105 107 109 111 112 119 ' “W.“ ?icure . .a \i 0 2E. 28. 29. 30. 31. 32. 33. 34. 35. 36. Figure Page 17. Subject T.O.: MAACL Raw Scores . . . . . . 121 18. Subject T.O.: Frequency of Self—cutting and Urges to Cut. . . . . . . . . . . . 128 19. Subject W.S.: Self-cutting Incidents, Left Upper Extremity. . . . . . . . . . . 130 20. Subject W.S.: Self-cutting Incidents, Right Upper Extremity. . . . . . . . . . . 131 21. Subject W.S.: Self—cutting Incidents, Trunk. . 132 22. Subject W.S.: MMPI Profile . . . . . . . 141 23. Subject W.S.: MAACL Raw Scores . . . . . . 143 24. Subject W.S.: Medication Data (thioridazine and flurazepam hypochloride) . . . . . . 146 25. Subject W.S.: Medication Data (acetaminophen, magnesium and aluminum hydroxide, and orphenadrine) . . . . . . . . . . . 147 26. Subject W.S.: Frequency of Self-cutting and Urges to Cut. . . . . . . . . . . . 151 27. Subject F.B.: Self-cutting Incidents, Left Upper Extremity. . . . . . . . . . . 155 28. Subject F.B.: MMPI Profile . . . . . . . 164 29. Subject F.B.: MAACL Raw Scores . . . . . . 166 30. Subject F.B.: Medication Data (thioridazine, flurazepam hypochloride). . . . . . . . 169 31. Subject F.B.: Medication Data (acetaminophen) . 170 32. Subject F.B.: Frequency of Self-cutting and Urges to Cut. . . . . . . . . . . . 175 33. Subject D.N.: Self—cutting Incidents, Left Upper Extremity. . . . . . . . . . . 179 34. Subject D.N.: MMPI Profile . . . . . . . 187 35. Subject D.N.: MAACL Raw Scores . . . . . . 189 36. Subject D.N.: Frequency of Self—cutting and Urges to Cut. . . . . . . . . . . . 191 X Psychi. 0’ “I C? *3. .- SUbSeq1 have C( Wrist 1 hospite CHAPTER I INTRODUCTION Statement of the Problem The purpose of this study was to analyze the effective- ness of a specific behaviorally oriented treatment regime used with patients who repeatedly inflicted superficial skin cuts on themselves. The treatment program consisted of two key elements: strenuous exercise and self-induced, exercise-related,non-injurious pain. A second purpose of this study was to determine if self-induced, non-injurious pain was a necessary component of the treatment program. Need for the Study In his 1964 Presidential Address to the American Psychiatric Association, Dr. Jack R. Ewalt observed that Our long, difficult cases increasingly consist of the character and personality disorders--the wrist Slashers, the promiscuous, and the improvident and lazy, and the aggressive reactions. We must learn to care for them. (Ewalt, 1964, p. 7) Subsequent to Ewalt's address, clinicians and researchers have consistently agreed that a problem exists. Some view wrist Slashers as the new chronic patients in mental hospitals, replacing schizophrenics (Graff & Mallin, 1967, p. 36). patterr that cc Shapirc 5 Dr” apPIOp] throng} ficial StudieE behaVic p. 36). Others cite self-cutting as an increasingly common pattern (Grunebaum & Klerman, 1967) as well as phenomenon that constitutes part of a new clinical syndrome (Rinzler & Shapiro, 1968). A more recent study (Whitehead, Johnson, & Ferrence. 1973) reports evidence that the incidence of self—injurious behavior has assumed major proportions. These authors suggest that in the general population, rates of self-injury may be has high as 1,400 cases per 100,000 population per annum. They also contend that there are no reasons to believe that the increase in self—injurious behavior will not continue to rise in the future. With respect to wrist cutters, both Clendenin and Murphy (1971) and Weisman (1975) report that of persons making suicidal attempts, more than 11% cut their wrists. These reports do not differentiate between repeated wrist cutters and those who cut themselves for the first time. Therefore these figures may be too high an estimate of the incidence of repeated cutting. In order to learn to care for wrist Slashers as Ewalt challenged, it would seem necessary for therapists to be able to diagnose the syndrome and recommend and institute appropriate treatment programs. A review of the literature through 1980 revealed that the syndrome of repeated super- ficial wrist cutting had been described. A majority of the studies reviewed about wrist cutters and wrist cutting behaviors were descriptive and epidemiological in nature (Graff & Mallin, 1967; Clendenin & Murphy, 1971; Asch, 1971; Rinzle Klaus: F! by aut Physic sugges althou Kafka treatm and dy a foil in the feelin emetic thr0ug modifi Rinzler & Shapiro, 1968; Rosenthal, Rinzler, Walsh, & Klausner, 1972; Pao, 1969; and Dunten, 1977). The need for this study arose from the awareness that repeated, superficial cutting behavior is extremely diffi— cult to modify. In addition, little research was reported regarding the treatment of repeated, superficial cutting behavior. Only one study of those reviewed specifically and primarily addressed the treatment of patients with this syndrome who were not psychotic, schizophrenic, retarded, or children. Grunebaum and Klerman (1967) delineated a treat- ment approach based on ego psychology although the effective- ness of the program was not discussed. A variety of other treatment approaches were suggested by authors of the descriptive and epidemiological studies. Physical contact or substitute stimulation of the skin was suggested by Graff and Mallin (1967) and by Novotny (1972) although they cautioned that sexual stimulation be avoided. Kafka (1969), Pao (1969), and Crabtree (1967) discussed the treatment of repeated superficial wrist cutters from analytic and dynamic points of View. Nelson and Grunebaum (1971) in a follow-up study of wrist cutters attributed improvement in these patients to an increased ability to verbalize feelings, the use of constructive action during times of emotional crisis, and the control of psychotic delusions through psychiatric follow—up and medication. Gardner and Gardner (1975) initially suggested that modification might be achieved through the use of tensio: behav. the r! Stimu Pao Rinzl 1975; "dead indiv also Parti tension-relieving rewards or through coupling the self- mutilating act with an aversive stimulus. They also con- ceptualized the Graff and Mallin (1967) technique of holding the patient as a comforting and tension-relieving reward, superior in effect to self-mutilation (Gardner & Gardner, 1975, p. 131). They conclude that if this explanation was accurate, it would be logical to teach patients a way to control distressing tension. The present study was an attempt to examine a treat- ment approach that might be effective in modifying repeated, superficial cutting behavior. Patients identified as repeated, superficial cutters frequently respond to dis- tressing stimuli by cutting. The treatment program studied provided an alternative response. Theoretical Framework Research in the area of repeated, superficial cutting behavior suggested that a myriad of stimuli may result in the response of self-cutting. Examples of these varied stimuli include: unbearable tension or anxiety (Graff, 1967; Pao, 1969); object loss (Grunebaum & Klerman, 1967; Rosenthal, Rinzler, Walsh, & Klausner, 1972); anger (Gardner & Gardner, 1975; Grunebaum & Klerman, 1967); and feeling "empty" or "dead" (Asch, 1971; Rinzler & Shapiro, 1968). Intensive individual case studies have found a variety of stimuli may also be connected to the response of self~cutting for a particular patient (Burnham & Giovacchini, 1969; Pao, 1969). L. "J Thus, a multitude of feelings, thoughts, and situations may prompt a patient into self—cutting behavior. Pain may also be an integral aspect of the subjective experience of repeated, superficial self-cutting. Such cutting may be a form of self-induced pain in response to stress (e.g., unbearable anxiety and/or intense anger) or the need for stimulation. However, self~cutting is injurious; tissue damage occurs. Thus, the behavior of self-cutting may be considered a form of self—induced, injurious pain. From a behavioral standpoint, altering conditions antecedent to self—cutting behavior would be difficult, if not impossible. Another approach to change is to focus on the behavior or response. Repeated, superficial self-cutting may be conceptualized as the way an individual has learned to respond to a variety of stimuli. If such behavior is learned, it would appear likely that it could be changed through the application of learning theory. Thus, repeated, superficial self-cutting may be considered a learned habit, a drive-reducing, conditioned, avoidance response. The intractability of repeated, superficial self-cutting be— havior suggest it is a learned habit which has attained its maximum habit strength. Following Hullian theory (Hull, 1943, 1951) one could predict that if superficial self—cutting was evoked volun— tarily and under conditions of massed practice, a negative habit of "not cutting" could be built up, resulting ulti— mately in the cessation of cutting. Further, cessation of cutting would be expected to generalize beyond the practice situation (Yates, 1958). However, instructing an individual to voluntarily and repeatedly self-cut would be unjusti— fiably damaging. An alternative behavior must be used. Superficial self-cutting was described above as possibly being a form of anxiety release and/or a painful form of stimulation. An acceptable alternative behavior would per- mit anxiety release and reproduce painful stimulation. In discussing maladaptive responses to anxiety, Wolpe and Lazarus (1968) suggested that one way to reduce such behaviors was by the increased use of motor activity. Specifically, Lazarus instructed patients to perform some forceful muscular activity in immediate association with an anxietyeprovoking, or otherwise disturbing, thought or image (Lazarus, 1965, p. 301). Four patients treated by Lazarus with this technique reported considerable improve- ment. Vigorous motor activity seemed to temporarily block anxiety—arousing thoughts and images and to result in a lower level of anxiety. Subsequent research has supported Wolpe and Lazarus' suggestion. Sustained muscle contraction and vigorous physical activity have been shown to be associated with reduced anxiety in clinically anxious and non-anxious patients (Bahrke, 1979; Grim, 1971; Harper, 1978; Morgan & Horstman, 1976; Sime, 1977; WOod, 1977). In contrast, light physical exercise is not related to a change in anxiety (Morgan, Roberts, & Feinerman, 1971; Sime, 1977). L. Rather (D :4 (I) ' 1 O .. “Av--~,. uo' Rather, light exercising is more likely to be experienced as stimulating. Another phenomenon is associated with vigorous physical exercising. Muscular pain frequently occurs during vigorous exercising; soreness and stiffness usually appear some hours later (Morehouse & Miller, 1976, p. 32). According to Marshall "the pain of excessive muscular action is so well known as to be typical of pain" (Marshall, 1894, p. 287). Thus, vigorous physical exercising may be conceptualized as a form of tension relief and as a form of self-induced, l . non—injurious pain. As such, vigorous, painful physical exercising may be an alternative to self—cutting. In summary, following Hullian theory, one could in- struct a repeated, superficial self-cutter to exercise vigorously, repeatedly, painfully and in association with urges to cut. Under such conditions the urge to cut would be paired with vigorous, painful physical exercising. A negative habit of "no urges to cut--vigorous, painful phy— sical exercising“ should be built up, resulting ultimately in the cessation of the cutting behavior. Cessation of cutting would be expected to generalize beyond the practice situation. In order to determine if self-induced, non-injurious pain is a necessary component, the above instructions could be modified. A repeated, superficial self-cutter could be instructed to exercise vigorously, repeatedly, and in association with urges to cut. While following the modified inStri to pr: to £0 instructions the individual would be told to stop exercising just as soon as exercising became uncomfortable or painful for them. Under the modified conditions the urge to cut would be paired with vigorous physical exercising. Theoreti- cally a negative habit of "no urges to cut-~vigorous physi- cal exercising" should be built up, resulting ultimately in the cessation of cutting behavior. Again, cessation of i cutting would be expected to generalize beyond the practice situation. Delimitations of the Study The patients included in the study were referred for treatment by Lansing, Michigan, mental health professionals. All patients referred from March 1980 through March 1981 who met the subject characteristics (Chapter III) were included -in the study. Patients involved in the study were not randomly selected nor were they randomly assigned to treatment pro— grams. No delayed measures were used to evaluate post treatment long term changes. 1 One postulate of this study was that the treatment programs were not dependent on any particular trainer. In an attempt to reduce trainer inconsistency, standardized instructions and directions for trainers were developed (Appendices D and E). The experimenter used these materials to provide training for the trainers. The trainers agreed to follow the treatment programs as outlined. However, VP) ‘1 hOCLG I .- $- . 8 LI! Oil there was no formal assessment of trainer behavior during their sessions with subjects. The basis of this study was that the treatment programs would provide alternative responses to cutting behaviors. The treatments were not intended to modify any other be- haviors or to affect intrapsychic or interpersonal conflicts. The experimenter served as a treatment program coordina— tor for each subject. The treatment programs for use with repeated, super- ficial self-cutters were intended for use in a variety of settings. However, all findings in this study must be interpreted within the confines of the above delimitations. Definition of Terms In this study special terms were defined as follows: Repeated cutting--cutting two or more times during the past month. Superficial cutting--delicate incisions, the lethality is considered to be low. Self-cutting--a self-inflicted wound of the wrist, trunk, legs, or arms which penetrates the skin. Urge to cut-—a thought, image, or fantasy of cutting one's own body. Without conscious suicidal intent-~the individual denies suicidal intent; the lethality of the cutting is considered low. Oil-S: ML 10 This investigation was based on the following assump- tions: 1. Repeated, superficial cutting is a learned behavior. 2. Exercising and exercising with pain are behaviors that can be learned. 3. The treatment programs are replicable. Hypotheses The following general hypotheses were tested in this study. These hypotheses are stated in testable form in Chapter III; Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis At least one of the treatment procedures (baseline, exercise, exercise with pain, and exercise) reduces cutting behavior. At least one of the treatment procedures (baseline, exercise, exercise with pain, and exercise) reduces urges to cut. The frequency of urges to cut and the frequency of cutting episodes are posi- tively related under baseline conditions. The frequency of urges to cut and the frequency of cutting episodes are posi— tively related under B (exercise) treatment conditions. The frequency of urges to cut and the frequency cutting episodes are negatively related under B+C (exercise with pain) treatment conditions. The frequency of urges to cut and the frequency of cutting episodes are posi- tively related under B2 (exercise) treatment conditions. “f 11* i. L nut. I vubv 31' 08 q ~A - hin' Anvil a ’f" .aév vet-arc. .ab‘wu- v €888! Y. ‘- 11 Overview Literature on the treatment of repeated, superficial cutting is reviewed in Chapter II. Topical areas covered include: descriptive and epidemiological studies; treat- ment studies; pain theory and concepts; and learning theory. The design of the study is described in Chapter III. The nature of the sample, measures used, and the experimental design are discussed in detail. Research hypotheses are stated in statistical form and the analyses are delineated. The data are presented and analyzed in Chapter IV. A dis- cussion and conclusions based on the results of the investi- gation are stated in Chapter V. Implications for future research are also suggested. CHAPTER II REVIEW OF THE LITERATURE AND RELEVANT THEORIES This chapter is divided into two major sections. First, literature related to the treatment of repeated, superficial self—cutting behavior is reviewed. TOpical areas are descriptive and epidemiological studies and specific treat— ment studies. The second section of this chapter includes a review of theories relevant to the treatment paradigm investigated. Self-induced, non-injurious pain was a component of the treatment program studied. Therefore, a review of pain theories as well as concepts related to the induction and measurement of pain is included. In addition, exercise as a form of self-induced, non—injurious pain is discussed. Also, because the treatment program was a behavioral approach, a review of related learning theories and techni- ques is included. Specifically, drive reduction theory, negative or forced practice, paradoxical intention, satia- tion, and generalization are discussed. 12 D J; Singl i - -1 l3 Descriptive and Epidemiological Studies Research findings suggest that typically . . . the cutter is an attractive, intelligent, un- married young woman, who is either promiscuous or overly afraid of sex, easily addicted, and unable to relate successfully to others. She is an older one in a group of siblings with a cold, domineering mother and a withdrawn, passive, hypercritical father. She slashes her wrists indiscriminately and repeatedly at the slightest provation, but she does not commit suicide. She feels relief with the commission of her act. (Graff & Mallin, 1967, p. 38) A more recent and more broadly based study suggested a somewhat different portrait of the typical wrist cutter. Clendenin and Murphy (1971) compared wrist cutters to a larger population of people who attempted suicide. Forty percent of the wrist cutters in this study were male. When compared to the female wrist cutters in this study, the male wrist cutters were younger and less often married. It must be noted, however, that the Clendenin and Murphy study did not differentiate between first-time and repeated wrist cutters. Descriptions of repeated wrist cutters by other authors include characteristics such as anhedonia . (Asch, 1971; Rinzler & Shapiro, 1968), depression and complaints of emptiness (Asch, 1971), and recurrent episodes of depersonalization that may be related to an inability to deal with specific feelings (Asch, 1971; Rosenthal, et al., 1972). Pao's (1969) descriptions of wrist cutters were based on cutting patterns. Coarse cutters typically made a single, deep incision close to a vital point such as the and p; as ch: SChiz< (1967 Cholo psych: 14 jugular vein or radial artery. This type of cutting was rarely repeated. Superficial cutters made only delicate, superficial, carefully designed incisions. These patients tended to repeat the cutting behavior again and again. Dunten (1977) summarized and integrated the descrip- tions of other investigators by suggesting that there may be five different types of wrist cutters. 1. Adolescent, hysterical "suicide attempts" in the face of minor crises. 2. More seriously disturbed individuals injure them- selves without awareness during spells of deper- sonalization brought on by acute inner conflict. This type of cutting serves as "psychic acupunc- ture," which relieves mental anguish, but is not experienced physically. 3. Psychotic cutters mutilate their bodies in response to voices or to satisfy delusions that certain parts are evil and must be destroyed or punished. 4. The retarded, brain damaged, and those given to periodic imbalances such as diabetes or epilepsy, injure themselves as a result of their physical problem, due to either a loss of control over their actions or over self-destructive impulses. 5. Certain individuals cut themselves in the hope of dying. (Dunten, 1977, pp. v—vi) Treatment Studies As stated in Chapter I, only one study specifically and primarily addressed the treatment of patients identified as chronic, superficial wrist cutters who were not psychotic, schizophrenic, retarded, or children. Grunebaum and Klerman (1967) delineated a treatment approach based on ego psy- chology. The program attempted to integrate an individual psychotherapeutic approach within the context of understanding Utili: £1 :12 SiZed peUti. recotm needs Wider aPPro 15 the interpersonal dynamics of a ward social structure. Psychotherapy in this program was aimed at providing patients with a corrective emotional experience, enabling patients to "abandon pathological defensive techniques, particularly projection and acting out," and helping them to learn to control impulses. These authors concluded that unless the patient's psychodynamics were understood and the interpersonal impasse involved in the wrist cutting episode resolved, the patients would most likely repeat their superficial wrist cutting behavior. However, while the treatment program was described in great detail, the effec- tiveness of the program was not discussed. A variety of other treatment approaches were suggested by authors of the descriptive and epidemiological studies. Physical contact or substitute stimulation of the skin suggested by Graff and Mallin (1976) and by Novotny (1972) although they cautioned that sexual stimulation be avoided. The aim of therapy according to Graff and Mallin (1976) was to assist patients to mature to the point where they could utilize words rather than more primitive gestures as a sign Of a relationship with an important person. It was hypothe- sized that with this advance more conventional psychothera- peutic techniques might then be relied upon. Novotny's recommendations involved the interpretation of dependency needs and wishes for attention and the interpretation of underlying anger and hostility. According to Novotny, the apprOpriate approach was dependent upon which factors counte (1969] intens pr0b1e cular. defen: made 1 Wrist an in Const the c f0llo trEat ,_ -1 1_.. 16 seemed to be in the foreground of the patient's psychic life at a particular time. Kafka (1969) and Pao (1969) discussed the treatment of repeated superficial wrist cutters from both analytic and dynamic points of View. In his presentation of a psycho- analytic study of a self-mutilating patient, Kafka emphasized the importance of the patient's problems with limits of their bodies, of their power and of their capacity to feel, 3 as well as the development of object relationships including 1 the notion of the patients treating their bodies as transi- tional objects and the develOpment of transference and countertransference in the therapeutic relationship. Pao (1969) described problems he encountered in his individual intensive psychotherapy with three female patients. These problems included staff countertransference issues, parti- cularly feelings of aloneness after patients out themselves; defensive use by patients of "brittleness" (e.g., "You've made me so upset I feel like cutting myself (Pao, 1969, P. 203)]; and the inability of these patients to use their observing ego. Nelson and Grunebaum (1971) in a follow-up study of wrist cutters attributed improvement in these patients to an increased ability to verbalize feelings, the use of constructive action during times of emotional crisis, and the control of psychotic delusions through psychiatric follow-up and medication. They concluded that Optimal treatment included both the development of a IEWEIC an ave reliez induC. beCau; the t; gener theor 17 patient—therapist alliance and the reinforcement of patients' controls over their symptoms through a treatment approach that combined education, identification with the therapist, and an appropriate mix of limit-setting and permissiveness. Finally, according to Gardner and Gardner (1975) all authors who discussed repeated superficial self wrist cutting acknowledged that this behavior was extremely difficult to modify. These authors initially suggested that modification might be achieved through the use of tension-relieving rewards or through coupling the self-mutilating act with an aversive stimulus. While finding a superior tension— relieving reward might be difficult, Gardner and Gardner conceptualized the Graff and Mallin (1967) technique of holding the patient as a comforting, tension-relieving reward which was superior in effect to self-mutilation. They went on to state that if this explanation was accurate, it would be logical to teach patients a way to control distressing tension, perhaps auto-relaxation which patients could use whenever they felt themselves becoming tense. 2212 A review of pain theories and concepts related to the induction and measurement of pain is included in this chapter because self-induced, non-injurious pain was a component of the treatment paradigm under investigation. First, a general definition of pain is presented. Then several theoretical models of pain perception are reviewed. An overvie ment 0: tensio: discus C) (D I h fl ._a *0 rEactl are Ill unPle 18 overview of concepts related to the induction and measure- ment of pain is presented next. Finally, exercise/muscle tension as a form of self-induced, non-injurious pain is discussed. Definition Pain is generally considered to be a subjective eXperi- ence of a noxious stimulus. Most authors agree that pain is not a single experience but rather that it is a complex perceptual experience. An individual's perception of pain includes a sensory experience and a reaction to that sensory experience. The intensity of pain perceived by an indi- vidual is influenced by that person's unique past experi— ences, by the meaning that person gives to the pain-producing l stimulus, and by that person's state of mind at the moment (Melzack, 1961; Vander, Sherman, & Luciano, 1975). A per- son's reaction to the sensory experience of pain involves an emotional response, such as anxiety or fear, and a behavioral response, such as withdrawal. The sensation of pain can be dissociated from the emotional and behavioral components by drugs (e.g., morphine), surgery (8-9.. lobotomy), or by selective brain processes. When the reactive (emotional and behavioral) and sensory components are not associated, pain is felt but it is not necessarily unpleasant (Vander, Sherman, & Luciano, 1975, p. 510). 1—___ ’ (J {U ’._-1 . 5 (W '1‘! psych: Psych. betWe Ghee 19 Theories of Pain Specificity Theory. According to the Specificity Theory free nerve endings are pain receptors and generate pain impulses. These impulses are carried by specific nerve or pain fibers, A-delta and C fibers in peripheral nerves. The pain fibers carry the pain impulse primarily to the lateral spino-thalamic tract in the spinal cord. Then the spino-thalamic tract carries the impulses to a pain center in the brain. Physiological evidence supports the existence of specialization within the somesthetic system. In addition there is some research evidence that a small number of specialized fibers may exist that reSpond only to intense stimulation. However, this does not mean that these special— ized fibers must always and only produce pain when stimulated. The Specificity Theory contains an implicit assumption that stimulation of pain receptors necessarily elicits only the sensation of pain. This assumption has been called the psychological assumption. Research does not support the psychological assumption of a one-to-one relationship between the intensity of stimuli and the subjective experi— ence of pain. Evidence (Beecher, 1965; Pavlov, 1927, 1928) suggests that central nervous system activities may affect the per— ception of pain. Beecher (1965) studied a group of wounded American soldiers. These soldiers denied any pain related to extensive injuries. "In the early hours the wound seemed L—___ direcl is re Clini: EVer, PrOpO Speci inter minar with 20 to be construed as a good thing . . the wound meant . . a ticket to the safety of the hospital and then home . . " (Beecher, 1965, p. 125). Pavlov (1927, 1928) subjected dogs to electrical shocks, burns, or cuts. Food was con— sistently presented to the dogs after the noxious stimulus. Eventually the dogs responded to the noxious stimulus as signals for food, no longer showing even the slightest sign of pain. These observations suggest that, at least under , the conditions described, intense noxious stimulation can 1 be prevented from producing pain and that noxious stimula- 1 tion can be a conditioned stimulus for eating behavior. In summary, the Specificity Theory is based on the idea of physiological specificity. The theory also assumes a direct connection from the receptor to the brain where pain is recognized. The first assumption is substantiated by clinical evidence; the second assumption is refuted. How— ever, as noted by Melzack and Wall Physiological specialization is a fact that can be retained without acceptance of the psychological assumption that pain is determined entirely by impulses in a straight—through transmission system from the skin to a pain center in the brain. (Melzack & Wall, 1965, p. 972) Pattern Theory. The Pattern Theory of pain was proposed in response to the psychological assumption of the Specificity Theory. Goldsheider suggested "that stimulus intensity and central summation are the critical deter- minants of pain" (Melzack & Wall, 1965, p. 973). Consistent with Goldsheider's postulations Livingston (1943) proposed that i verber ‘ o 2.118;“. E 21 that intense noxious stimulation of the body sets up re- verberating circuits in spinal internuncial pools that can then be activated by usually non-noxious stimuli to generate unusual volleys of stimulation that are consciously inter- preted as pain. A specialized input-controlling system is theororized to prevent stimulus summation from occurring under normal conditions. This theory purports the existence of a rapidly conducting fiber system which inhibits synaptic transmission in a more slowly conducting system that carries the signal for pain. Researchers have identified these systems as epicritic and protopathic (Head, 1920), fast and slow (Lewis, 1942), phylogenetically new and old (Bishop, 1959), and myelinated and unmyelinated (Noordenbos, 1959) fiber systems. The slow system establishes dominance over the fast in pathological conditions, resulting in a diffuse, burning pain. The Pattern Theory of pain suggests that a nerve impulse pattern for pain is produced by intense stimulation of nonspecific fibers. Many aSpects of pain can be explained by the Pattern Theory concepts of central summation and input control. However, the various specific theoretical mechanisms that have been proposed . . . fail to comprise a satis- factory general theory of pain. They lack unity, and no single theory so far proposed is capable of integrating the diverse theoretical mechanisms. (Melzack & Wall, 1965, p. 974) Open ‘ In CO' or in Hilhn fiber that Prodt quent of a1 22 Gate-Control Theory. The Gate-Control Theory is based on five propositions and their related explanatory mechanisms. First, a spinal gating mechanism in the dorsal horns is believed to modulate the transmission of nerve impulses from afferent fibers to spinal cord transmission (T) cells. Researchers (Wall, 1964; Melzack & Wall, 1965) suggest that the substantia gelatinosa (SG) appears to be the site of the gating mechanism. The SG acts as a gating system by modulating the conduction of nerve impulses from peripheral fibers to T cells. According to Hillman and Wall (1969) the cells in lamina 5 are the T cells most likely to have a critical role in pain perception and response. The second proposition of the Gate-Control Theory is that the gating mechanism is influenced by the relative amount of activity in small-diameter and large-diameter fibers. Specifically, activity in small fibers tends to open the gate or facilitate transmission of nerve impulses. In contrast, large fiber activity tends to close the gate or inhibit transmission of nerve impulses. Research by Hillman and Wall (1969) has shown that activity in large fibers produces a burst of activity in the T cells followed by a period of inhibition. These studies have also shown that activity in small fibers activates the cells and then produces a prolonged activity and a facilitation of subse— quent inputs. Melzack and Wall (1965) suggested that three aspects of afferent input are important for pain. First, the ( t)‘ of ti there becal gate Steel this incr, the . .————_—~—_ 23 ongoing activity which precedes a stimulus is significant. The Spinal cord is continually stimulated by incoming nerve impulses. Small fibers are primarily responsible for handling this continual barrage. These small fibers tend to be active and to adapt slowly. The result is that the gate is held in a relatively Open position. Second, the nature of the stimulus-evoked activity is important. For example, the number of active receptor-fiber units is increased when a gentle pressure stimulus is applied suddenly to the skin. This stimulation produces a disproportionate relative increase in large-fiber over small-fiber increase because many large fibers impulses fire the T—cells but also partially close the presynaptic gate thus shortening the barrage generated by the T cells. In contrast, increased stimulus intensity results in the involvement of more receptor-fiber units and an increase in the firing frequency of active units. Under this con— dition the effects of the large- and small-fiber inputs tend to counteract each other, although over time the output of the T cells slowly rises. When stimulation is prolonged there is a relative increase in small-fiber activity because large fibers begin to adapt. Consequently, the gate is opened further and the output of T cells rises more steeply. The output of the T cells can be decreased at this point by increasing the larger-fiber activity. An increase in large—fiber activity overcomes the tendency of the large fibers to adapt. Vibration and scratching are ways t the st active more tract tr01. the( acti‘ all nerv acti 24 ways to produce this effect. In summary, the effects of the stimulus barrage are determined by the total number of active fibers and the frequencies of nerve impulses that they transmit and by the balance of activity in large and small fibers (Melzack & Wall, 1965, p. 975). This relative balance of activity in large versus small fibers is the third aspect of afferent input important to pain. The third prOposition of the Gate-Control Theory is that the gating mechanism is influenced by nerve impulses that descend from the brain. Cognitive processes such as attention, anxiety, and past experiences have been shown to influence pain perception (Melzack, 1973). The amount of influence that cognitive processes can have is deter— mined in part by the temporal~spatial properties of the input patterns. Specifically, some of the most unbearable pains, such as cardiac pain, rise so rapidly in intensity that the individual is unable to achieve any control over them (Melzack & Wall, 1967, p. 978). On the other hand, more slowly rising temporal patterns, such as birth con- tractions, are amenable to some central nervous system con- trol. A central control trigger is the fourth prOposition of the Gate-Control Theory. Some central nervous system activities, such as fear, may Open or close the gate for all inputs at any position on the body. Other central nervous system activities involve selective, localized gate activity. For example, Beecher (1959) described men wounded L__— EXCes Pain 1€Ve§ on tj Subs' Vent l 2 5 in battle who felt little pain from war wounds but who com- plained about clumsy insertion of intraveneous needles. Thus, signals from the body must be identified, evaluated in terms of prior experiences, localized, and inhibited before the action system responsible for pain perception and response is activated. Therefore, a central control trigger that activates the particular, selective brain processes that exert control over the sensory input was proposed (Melzack, 1973, p. 161). Melzack and Wall (1965) suggested that either the dorsal column-medial leminsus system or the dorso-lateral path could fulfill the functions Of the central control trigger. The fifth propostion of the Gate-Control Theory is the action system. Melzack and Wall suggested that prolonged monitoring of afferent input by central cells results in pain. Specifically, there is spatial and temporal summation or integration of the arriving barrage of nerve impulses by the T cells. When the output of the T cells reaches or exceeds a critical level, the action system responsible for pain experience and response is triggered. This critical level is determined by the afferent barrage that impinges on the T cells and has already undergone modulation by substantia gelatinosa (SG) activity (Melzack & Wall, 1965, p. 975). Melzack and Cosey (1968) stated that the output of the T cells is projected into two major brain systems: the ventrobasal thalamus and somatosensory cortex via . neos medi medi siol aspe modt syst 58315 evaj com tie] and the 1101: Whi has“-.- 26 neospinothalamic fibers, and the reticular formation and medial intralaminar thalamus and the limbic system via medially coursing fibers. Based on behavioral and phy- siological studies, Melzack and Cosey have proposed three aspects of the action system. First, the selection and modulation of the sensory input through the neospinothalamic system in part provides the neurological basis of the sensory—discriminative dimension of pain. Second, the activation of reticular and limbic structures through the paramedial ascending system, comprised of medially coursing fibers, underlies the very strong motivational drive and unpleasant affect that propel an individual into action. And third, higher central nervous system processes, such as evaluation of input in terms of prior experiences, exert control over activity in both the discriminative and motiva— tional systems (Melzack & Cosey, 1968). It is assumed that these three categories of activity interact with one another to provide perceptual infor- mation regarding the location, magnitude, and spatio— temporal properties of the noxious stimulus, motiva— tional tendency toward escape or attacks, and“ cognitive information based on analysis of multi-model informa— tion, past experience, and probability of out-come of different response strategies. All three forms of activity could then influence motor mechanisms respon— sible for the complex pattern of overt responses that characterize pain. (Melzack, 1973, p. 163) In summary, the Gate—Control Theory proposed by Melzack and Wall (1965) was an attempt to develop a comprehensive theory of pain. According to this theory, in the dorsal horns of the spinal cord a neural mechanism acts as a gate which increases or decreases the flow of nerve impulses ._l < I) <1 (I) Theo: mode the ther invo Theo can Sior Conc ence alt, tior inpl 197. 27 from peripheral fibers to the central nervous system. Thus, somatic input is influenced by the mediating effect of the gate before it evokes pain perception and response. Further- more, the extent to which the gate increases or decreases sensory transmission is determined by the relative activity in large and small fibers and by descending influences from the brain. Finally, neural areas reSponsible for pain experience and response are activated when the amount of information that passes through the gate exceeds a critical level (Melzack, 1973). Sensory Decision Theory of Pain. The Sensory Decision Theory, proposed by Lloyd and Appel (1976), is a theoretical model for studying the perceptual process associated with the pain experiences of humans. According to this theory there is a difference between sensory and cognitive factors involved in the perception of pain. The Sensory Decision Theory also assumes that these sensory and coqnitive factors can be measured and can be analyzed individually. The Sensory Decision Theory purports that three dimen— sions (social-cultural, emotional—motivational, and conceptual-judgmental) contribute to and modify the experi- ence of pain, a noxious sensory input. Each dimension alters the other two. For example, a reduction in motiva— tion or emotional arousal can influence noxious sensory input, thus leading to a lower perception of pain (Chapman, 1974). im (M< st.‘ e1. th. 19 Pd in- ar 28 Criticisms of the Sensory Decision Theory of pain include the necessity of careful training Of observers, long periods of data collection for each person, and elabo- rate computational procedures. The assumptions that sensory and cognitive factors can be measured and can be analyzed independently have also been questioned. Nonetheless, the theory has been popular in recent years. The importance Of sensory, affective, and evaluative responses to noxious stimuli are emphasized as well as the importance of under— standing and measuring psychological variables. Finally, the theory implies an interaction of physical and psychologi- cal variables (autonomic reSponses, muscular responses, psychological and social/environmental reactions) involved in the complex experience of pain (Chapman, 1974). Pain Threshold Pain threshold is generally defined as the lowest intensity of stimulus at which a person reports feeling pain (Melzack, 1973). The pain threshold of a particular (con- stant intensity) stimulus is measured by the total time elapsing between the beginning of stimulation and the time the subjects first report "it hurts" (Brown, Fader, & Barber, 1973, p. 3). In order to determine an individual's threshold for the pain of a particular pain-provoking stimulus, both the intensity of the stimulus and the duration of stimulation are measured. The intensity of the stimulus is increased mu .1. the tic CHI Cu .1. Fig (P1 is pa: tin em fex Wi. 29 in progressive steps. Simultaneously, a record is kept of the length of time until the person reports a pain sensa- tion. These data are then plotted as a strength-duration curve which graphically shows the pain threshold. Figure l is a pain threshold curve where the pain—provoking stimulus is radiant heat. g’? .38 6 #‘\ 00-- «3'6 3'5 500-— 58 D m 400-~ U)\ m 23 o... 300-- M 3,9. 200.- -:—1 rd (303,51 1001- 4Jr-l L. G-u-l T HE t t t i Time (seconds) Figure 1. Pain Threshold Curve, Stimulus Intensity—- Threshold Time. (Procacci, ZOppi, Maresca, & Romano, 1974, p. 108). In this figure intensity of the stimulus (radiation) is reported on the ordinate; the time needed to reach the pain threshold is reported on the abscissa. This pain threshold curve shows that a sensation of pain is experi— enced when a very intense stimulus is applied for only a few seconds. Likewise, "a stimulus of much less intensity will eventually become painful if it continues for more than a few seconds" (Jerome, 1978, p. 36). in ver bri phy muc cie The inc‘ may per des Se\ We] (re 0f The di: Sul 30 Cutting of the skin is generally acknowledged to result in the sensation Of pain. Cutting may also be considered a very intense or acute stimulus that needs only to be applied briefly to elicit a sensation of pain. In contrast, vigorous physical exercising may be conceptualized as a stimulus of much less intensity but which will become painful if it con- tinues for more than a few seconds. Research has shown no significant differences in pain thresholds across sexes, age groups, and cultural or ethnic backgrounds (Sternbach, 1974). A point will come, if the intensity and/or duration of a stimulus are increased suffi- ciently, when an individual reports the sensation Of pain. That point is relatively constant. What varies is the individual's reaction. Specifically, an individual's report of the experience and the behavior that individual exhibits may vary greatly from person to person or within the same person over time (Jerome, 1978, p. 38; Chapman & Jones, 1944). Two studies by Wolff and Jarvik (1963, 1964) were designed to assess the generality of pain tolerance by using several pain-evoking methods on the same subject. Subjects were tested for their pain tolerance using cutaneous pain (radiant heat and ice water) and deep muscle pain (injections of hypertonic and hypotonic saline into the gluteus medius). The results suggested that pain thresholds elicited by different stimuli seem to be related to (a) if the resulting subjective pain sensations were similar in quality regardless :1 str1 IES' rel sal Ack res des Six anC Shc We: 31 of the body structure stimulated or (b) if the same body structure was stimulated, regardless of the quality of the resulting pain sensations. In the second study, Wolff and Jarvik found consistent differences in the correlations of the thresholds for the right and left hands. Because only 3 of the 53 subjects were left-handed, the authors discussed their findings with respect to the right-handed subjects. Specifically, except for the radiant heat method, ice water pain thresholds for the left or non-dominant hand were almost completely un- related to the thresholds of the other techniques (hypertonic saline and hypotonic saline) (Wolff & Jarvik, 1964, p. 597). Acknowledging that additional studies are necessary, the researchers speculated: . that it is the dominant hand which is responsible for the greater degree of relation between thresholds of pain, which in turn suggests that the dominant side is either more sensitive or more closely integrated with an individual's affective behavior than the non- dominant side. (Wolff & Jarvik, 1964, p. 598) Davidson and McDougall (1969) also reported a study designed to assess the generalizability of pain tolerance by using several pain-evoking methods on the same subject. Sixty-five female subjects were tested for their pain toler— ance using cold pressor, radiant heat, pressure, and electric shock methods of experimental pain induction. The subjects were also administered three personality tests measuring introversion, neuroticism, and manifest anxiety. These test scores were correlated with pain tolerance scores in ane son; in pai exe mur am PM hdl (De im Illa: th. 32 1 an effort to examine the relationship between these per— sonality variables and pain tolerance. 1 The results showed a significant correlation (p<0.05) l in pain tolerance levels between pressure and shock and between pressure and cold. None of the other pain induction methods were significantly correlated. This finding suggests there is no significant generalization of pain tolerance. With regard to personality variables, shock tolerance was found to be significantly (p<0.05) related to extraversion. Pressure and shock tolerance were also both significantly (p<0.05) negatively related to manifest anxiety. In dis- cussing the correlation between the pressure method and manifest anxiety the authors noted it was the only method in which the experimenter was required to actively apply a painful stimulus. Possibly any anxiety on the part of the examiner at having to apply the pressure stimulus was com— municated tO the subject. If this was so, then perhaps anxiety on the part of the examiner at having to apply the pressure stimulus may have interacted in some way with the anxiety of the subject and this uncontrolled variable could have complicated interpretation of results for this method (Davidson & McDougall, 1969, p. 88). The above consideration may have implications for this investigation. Specifically, the attitude and approach of a trainer working with a subject doing exercises with pain may have an effect on the subject. Further discussion of this issue is included in Chapter III and V. Pai to to ha\ (1? mal de; do; st: re} Si< Wi‘. of 1‘8! 98] 33 Pain Tolerance How much of a painful stimulus an individual is willing to experience is called pain tolerance. Pain tolerance can be measured by the total time elapsing between the beginning of stimulation and the time the subject withdraws from stimulation (Brown, Fader, & Barber, 1973, p. 3). Sternbach and Tursky (1965) reported that the levels at which subjects refused to tolerate a painful stimulus depended, in part, on their ethnic origin. These differ- ences in pain tolerance reflect different ethnic attitudes towards pain (Melzack, 1961, 1973). Several other variables have also been shown to influence the experience of pain. These factors include: past experiences, the meaning of the situation, attention, anxiety, and suggestion. The influences of early experience on the perception of pain was demonstrated experimentally by Melzack and Scott (1957). They raised Scottish terriers from infancy to maturity in isolation cages. As a result the dogs were deprived of normal environmental stimuli. At maturity the dogs failed to respond normally to a number of noxious stimuli. Some dogs put their noses into flaming matches repeatedly; others tolerated pin pricks with little or no sign of pain (e.g., no strong emotional response and no withdrawal from the pin or experimenter). A control group of dogs, litter-mates reared in normal environments, responded predictably; that is, the experimenters were generally not able to touch these dogs with the pin or flame mo: huh I85 rel prc am 196 ti< of Be su: of Pd. re re St 34 more than once. If these findings can be generalized to humans, one could wonder whether isolation as a child might result in failure to recognize painful stimuli and thus be related to repeated, superficial self-cutting. The meaning that an individual associates with a pain- 1 producing situation has been shown to influence the degree and quality of pain the person feels. Beecher (1959, 1961, 1965) observed the behavior of soldiers severely wounded in battle during World War II. Most of the soldiers denied having pain or had so little they did not want any medica- tion to relieve the pain. "Only one out of three complained of enough pain to require morphine" (Melzack, 1973, p. 29). Beecher repeated the study with a group of civilians who had surgical wounds similar to those of the soldiers. Four out of five civilian surgical patients complained of severe pain and asked for morphine. Beecher concluded that . . . there is no simple direct relationship between the wound peg s3 and the pain experienced. The pain is in very large part determined by other factors, and of great importance here is the significance of the wound. . . . In the wounded soldier it was relief, thankfulness at his escape alive from the battlefield, even euphoria; to the civilian, his major surgery was a depressing, calamitous event. (Beecher, 1959, p. 165) Attention and Anxiety Attention seems to involve the active orientation and reception of stimulus energy as well as the focusing of a restricted supply Of peripheral energy on a particular stimulus. Thus in the perception process, attention may hav att wel he to to 35 have both selective and amplifying functions. That is, attention seems to restrict the range of sensory input as well as increase the clarity of perception (Jerome, 1978, p. 41). With regard to pain perception, attention to stimula- tion contributes to the intensity of the pain experience (Melzack, 1973). Hall and Stride (1954) reported that when the word "pain" was included in a set of instructions, anxious subjects reported as painful a stimulus they had not regarded as painful when the word was not included in the instructions. The authors suggested that the anticipa— tion of pain may have increased anxiety and thereby the intensity of the pain perceived. In contrast, distraction from a painful stimulus in— creases pain tolerance. Athletes for example have been known to sustain severe injuries during the excitement of a game without being aware that they have been injured (Melzack, 1973). In addition, meditation and muscular relaxation are psychophysiological methods of pain relief (used in mild to moderate pain) that involve the concept of distraction. As described above, Davidson and McDougall (1969), using the Taylor Manifest Anxiety Scale, found a significant negative correlation between patients' anxiety scores and pain thresholds. That is, high anxiety scores were related to low pain tolerance and low anxiety scores were related to high pain tolerance. Anxiety may activate attention behe Anxi eval acc Thi nor cha the blc blc st: acc the (Gt Vic 36 behaviors such as orienting and focusing on painful stimuli. Anxiety may also amplify an individual's affective and evaluative responses to pain and increase general autonomic arousal. Thus, a pain-anxiety-attention-arousal-increased pain cycle may develop (Jerome, 1978, p. 45). Exercise as a Form Of Self—Induced, Non—Injurious Pain During and following strenuous muscular exercise, individuals may experience muscular pain, soreness, and stiffness. Muscular pain usually occurs during exercise, while soreness and stiffness occur later. During exercise, blood vessels in the active muscles are strongly vasodialated although blood vessels in the peripheral areas are contracted. Continued strenuous physical exercising results in an accumulation of acid waste products, primarily lactic acid. This excess of lactic acid is due in part to the absence of normal blood circulation. Specifically, because of the change in blood flow there is not enough oxygen to oxidize the lactic acid. In addition there is insufficient over-all blood flow to diffuse the lactic acid into the circulating blood. Thus, as a result of anerobic metabolism during strenuous physical exercising large amounts of lactic acid accumulate in the muscle fibers. Researchers postulate that the lactic acid irritates pain receptors in the muscles (Guyton, 1977; Jerome, 1978; and Morehouse & Miller, 1976). Vigorous physical exercising may thus be conceptualized as a form of self-induced, non-injurious pain. __L—¥ Q) (n and int prc mer St: to be- in Ac. 37 Learning Theory The treatment regime outlined in this study was based on behavior modification principles. Abnormal behavior, such as repeated, superficial self—cutting, was conceptualized as the way an individual had learned to respond to stress. Since such behavior was learned, it could be changed through the application of learning theOry (O'Leary & Wilson, 1975, p. 16). A theoretical understanding of the proposed treatment presupposes a knowledge of learning theory, particularly principles of behaviorism initially formulated by Hull (1943, 1951). In this section several behavioral concepts will be reviewed including: drive—reduction theory, satiation, negative or forced practice, paradoxial intention, and generalization. ' Drive-Reduction Theory The theoretical model of learning developed by Hull (1943, 1951) includes several basic constructs and their interrelationships. Drive, (D), is primary motivation; it prompts the individual to action. (S) represents environ- mental Or external stimuli. Drive stimuli, (SD), are stimuli associated with a given drive; (SD) is also referred to as a drive state. (SUR) symbolizes innate reactions or unlearned impulses. Hull described the inter-relationship between stimulus (S), drive (D) and innate reactions (SUR) in his Primary Molar Behavioral Principle (see Figure 2). According to this principle: L; 38 Ase .a .mams .Hssmc mcoepccebaoo o>euc can mSHDEHpm Hocpo Eoum mcfluaomms chHBQOpom cofluommu one Eonm coepooamm Eocene c pesos once too: or“ oumcHEHop on waoxfla muoe one coeposflbsoo OH Ho mafiasae>eeae Hopped porn “m; noncommms mo momcomwou m .OHQHOQHHm H0H>mnom HMHOZ wucfiflum .m onsmflm ocflxo>o mo snesmnnamnoa may m>mn ] Awq)fiw. _ . V M ademe N O ~eHHU UHHM coflumHseflpm OocHQSoo Moons . ;;IJL rei whi rei the a r con PIE 39 Organisms at birth possess receptor effector con- nections ( U ) which, under combined stimulation (S) and drive IDI, have the potentiality of evoking a hierarchy of reSponses that either individually or in combination are more likely to terminate the need than would be a random selection from the reaction potentials resulting from other stimulus and drive combinations. (Hull, 1943, p. 66) In other words, responses activated under a particular set Of circumstances are those responses most likely to satisfy or reduce the need. This postulate is basic to Hull's drive-reduction theory. Hull formally proposed the role of drive reduction in reinforcement as his Law of Reinforcement (see Figure 3) which states: Whenever a reaction (R) takes place in temporal con- tiguity with an afferent receptor impulse (5) resulting from the impact upon a receptor of a stimulus energy (S), and this conjunction is followed closely by the diminution in a need (and the associated diminution in the drive, D, and in the drive receptor discharge, SD), there will result an increment, A(-—-+R), in the tendency for that stimulus on subsequent occasions to evoke that reaction. (Hull, 1943, p. 71) Stated more succinctly, drive reduction produces reinforcing consequences and, conversely, reinforcement is the reduction of drive by need satisfaction. Furthermore, a response which reduces a drive becomes associated or connected to that drive. When the drive occurs again the previously associated response will tend to be made. Habit strength (SHR) in Hull's model refers to the unobservable theoretical strength of association, mentioned above, between neural representations Of stimulus and response. It is present whether the organism is actually 40 . 'I 111111 c Tim. AV «Homfl 9:0. Aom .ms .dd .HmmH mmsoomou swap mxo>o 0p msasaepm page How monoccmp m ou AHH© SH zofluocflfiflp means can sues poecHUOmmm mammoHo we Acm+mv coeuoconsoo map can .pcoEcoHomchm mo Seq .m n cmcommcu c cosmeoommc Acmflslmaflpv hammoHo mH mamas he use W r- J 4 .xjw mwmasmfifl mmMo>m Occummacs mo hoonumHQ on“ mo OEOm mmsoflm mpcpm m>HH© Ef ac re 11' it CC 41 responding or not (Yates, 1970, p. 26). Increase or growth of habit strength is learning. Two additional theoretical constructs add clarity to this Hullian learning paradigm. Reaction-evocation potential (SER) is defined as the product of a function Of habit strength (SHR) multiplied by a function Of the relevant drive (D) (Hull, 1943, p. 239). SER = (SHR X D) It is the excitatory strength of the capacity for responding (Yates, 1970, p. 25). However, reaction potential does not take into account inhibitory forces. In order to do so, Hull defined effective reaction potential (SER) as reactive potential less inhibitory forces. SER = (SER) ‘ (IR + SIR) Effective reaction potential is the reaction potential actually available to an individual to perform a given response at a particular point in time. The term (IR) symbolizes reactive inhibition, a fatigue— like condition or need for rest after a response. As such, it is a drive state. Hull assumed that reactive inhibition counteracted the power of a particular stimulus to elicit the associated response (Hull, 1943, p. 391). Thus, after the sequence in di ’4 . r?‘ ‘I 00 th on to tc Ir. ti. me 12 Si ’ ’7‘”‘l 42 its ’ SD :> sup,“ ' :2 Rn _'___ «5111;, the response Rn will tend to not be repeated until the inhibition produced by the initial performance of Rn has dissipated. Reactive inhibition was believed by Hull to dissipate over time. This dissipation is reinforcing as it reduces a drive state. Consequently, any responses made during the period of dissipation are reinforced, including the response of "not responding." Hull labeled this incom— patible active state of not responding (SIR), conditioned inhibition. Negative or Forced Practice Negative or forced practice is a behavioral technique first specifically described by Dunlap (1928, 1930, and 1932). He suggested a general treatment procedure based on a postulate regarding the role of repetition in habit formation. Using this method, the patient was instructed to voluntarily and repeatedly perform the undesired behavior. In his writings, Dunlap also provided case illustrations of the successful application of negative practice to the treat— ment of tics, Obsessions, nailbiting, and stammering (Dunlap, 1928, 1930, and 1932). It is interesting to note that simultaneously Pavlov was observing similar phenomena in in in‘i ti 1). 43 in his animal experiments. As described by Pavlov, in internal inhibition the positively conditioned stimulus I . . . becomes, under definite conditions, negative or inhibitory; it now evokes in the cells of the cortex a process of inhibition instead of the usual excita- tion. Conditions favouring the development of con- ditioned reflexes of the negative or inhibitory type are frequent occurrence, and these reflexes are met with not less frequently than reflexes of the positive or excitatory type. (Pavlov, 1927, p. 48) Yates (1958) refined and expanded Dunlap's ideas and procedures, specifically as they applied to the treatment of tics. PrOpOsing a theoretical model of the tic as a learned habit, Yates suggested that some tics are drive- reducing conditioned avoidance responses, originally evoked in a highly traumatic situation (Yates, 1958, p. 175). In Hullian terms, Yates described the reaction potential (SER) of such tics as a multiplicative function of the habit strength (SHR) Of the tic and the momentary drive strength of anxiety (D). Following Hullian theory, Yates . . . predicted that if the tics were evoked volun- tarily under conditions of massed practice, a negative habit of "not doing the tic" should be built up, resulting ultimately in the extinction of the tics and that this extinction should gener— alize beyond the test situation. (Yates, 1958, p. 181) Yates then derived a treatment method from this theo— retical model of the tic as a learned habit which has attained its maximum habit strength (Yates, 1958, p. 176). Using negative or forced practice the subject was instructed to voluntarily and repeatedly perform the maladaptive behavior. Such repetition has come to be called massed pra OI beh beh ave of per 51:1 to exc C86 1118] the Si. til SU' re de th 44 practice. The consequence of massed practice is fatigue, or in Hullian terms, large amounts of reactive inhibition (IR) are generated. At this point, emitting the undesired behavior becomes painful while the act of "not doing“ the behavior is positively reinforced by the avoidance of the aversive condition of fatigue. As described above, the act of not emitting the undesired behavior becomes a conditioned inhibition (SI R). Referring back to Hull's definition of effect1ve reaction potential (SER) = (SHR x D) — (IR + SIR), it is apparent that as reactive and conditioned inhibition increase, the potential for the individual to perform the specific undesired behavior decreases. If the strength of inhibitory factors (I + ) can be increased R SIR to the point where they equal or exceed the strength of excitatory factors (SHR x D), the undesired behavior will cease. Results reported by Yates (1958) on a series of experi— ments with one patient support the validity of his proposed theoretical model. Massed practice Of tics did lead to a significant (p<.001) decrease in the number of voluntary tics performed per minute. Evidence was also presented supporting a hypothesis that decline in tic frequency was a function of increase in conditioned inhibition (SIR), "not doing" the tic, rather than merely the accumulation of reactive inhibition (IR), fatigue. There was also a reported decline in the patient's involuntary tics. Self-reports by the patient indicated improvement outside of the experimental setl had OCC' pot as net cor hac‘ To 1e: Th: ma: re: 45 setting. Specifically, the patient reported her nasal tic had almost stopped completely and eyeblink and throat tics occurred much less frequently. She felt there was very little change in the stomach tic she experienced. The patient also reported feeling generally improved, able to relax, and that her friends also noticed these changes in her. Finally, Yates demonstrated that for the nasal, throat, and stomach tics of this patient, very prolonged periods of massed practice followed by a prolonged rest lead to a significant decrease in the frequency of volun- tarily produced tics. Osgood (1953) and Gleitman, Nachmias, and Neisser (1954) criticized Hull's formulation of effective reaction potential. Hull conceptualized reactive inhibition (IR) as negative drive and conditioned inhibition (SIR) as negative habit. As previously stated, Hull related these concepts by addition, rather than by multiplication as he had related positive drive (D) and positive habit (SHR). To correct for this inconsistency, Jones prOposed a new learning equation: I )l SER = 6 [(D ' IR) X (SHR _ s R (Jones, 1958, p. 180) This revision suggests that effective reaction potential may be determined by the multiplicative interaction of a resultant drive state (D — IR), and a resultant habit state (SHR - SIR) (Jones, 1958, p. 180). Also, according to the rev: tre.‘ sug' (Wa the SEI cli Fre thi in ids do: he be. 1381‘ 46 revised formula, positive and negative drive—states are treated similarily as are positive and negative habits, suggesting that.they are both subject to the same laws (Walton, 1961, p. 150). When Jones' formula is multiplied out the result is SER = 6 [(D x SHR) — (IR x SHR) — (D x SIR) + (IR x SIR” From this it can be seen that the same drive (D) can activate both positive habits (SHR) and negative habits (SIR) (Walton, 1961, p. 151). Thus, once a habit has been extinguished by the method of negative practice, any increase in drive serves only to increase the potentialities of both habits proportionally so that no recovery takes place (Kendrick, 1960, p. 225). Paradoxical Intention Another behavioral change technique used by some clinicians is paradoxical intention. First described by Frankl (1955, 1960), this method involved having a person think about doing or actually performing the feared behavior in exaggerated fashion to the point of absurdity. Frankl identified two components involved in neurotic behavior: anticipatory anxiety and a compulsion to self—observe. By doing or wishing exactly what the patient fears, the patient necessarily confronts the anticipatory anxiety. Frankl believed that paradoxical intention would also enable patients to develop a sense of detachment toward their 1181 obs the pa mo 19 th SY F0 b1 to at th so Si 47 neuroses, thus taking advantage of their tendency to self- observe. In this context, he shared Allport's views about the role of humor in the integration of personality. Humor may throw an otherwise intolerable situation into a new and manageable perSpective. The neurotic Who learns to laugh at himself may be on the way to self-management, perhaps to cure. (Allport, 1950, p. 92) Gerz (1962) applied paradoxical intention to the treat— ment of the phobic and obessive—compulsive patient. He too believed that anticipatory anxiety, or fear of the occurrence of particular symptoms, was characteristic in phobic neuroses. Anticipatory anxiety will frequently cause the symptoms to occur. The pattern becomes cyclical; the more the patient fears the appearance of the symptoms and the more the patient tries to avoid the occurrence of the symptoms, the more likely it is that the feared symptoms will occur (Gerz, 1962, pp. 375-76). Gerz applied paradoxical intention to the treatment Of phobias involving the autonomic nervous system, over which he said peOple had no voluntary control. For example, a person cannot blush as soon as they try to blush. Theoretically, when paradoxical intention is applied to such phobias two things happen. First, the person is unable to do that which they fear. Second, the person's attitude changes; instead of trying to avoid the behavior, the person is trying to perform the behavior. As the per— son's attitude changes the person will begin to see the situation as humorous thus putting distance between oneself and 196 int in He was hax as sic‘ pre stL we: Rat sin Sat Mir in puk 48 and the affect associated with the neurotic fear (Gerz, 1962, p. 376). Gerz did not describe the application of paradoxical intention to the treatment of obsessive-compulsive behavior in as much detail as he described the treatment of phobias. He did indicate that in his experience paradoxical intention was not as effective in changing obsessive-compulsive be- haviors as in changing phobic behaviors. Obsessive-compulsive behaviors might be conceptualized as approach behaviors while phobic behaviors could be con— sidered avoidance behaviors. Using paradoxical intention the individual performs (approaches) the behavior that has previously been avoided. The treatment program in this study was not a form of paradoxical intention. The patients were not requested to perform behaviors they had avoided. Rather, they were told to repeat a behavior qualitatively similar to their cutting behavior. Satiation Richard Burton, writing under the pseudonym Democritus Minor, described the elements of the condition of satiation in his three part volume Anatomy of Melancholy (originally published in 1628). Thus much I dare boldly fay, He or fhe that is idle, be they of what condition they will, never fo rich, fo well allied, fortunate, happy, let them have all things in abundance, and felicity, that heart can wifh and defire, all contentment, fo long as he or fhe, or they are idel they fhall never be pleafed, never well in body and minde, but weary ftill, fickly ftill, vexed ftill, loathing ftill, weeping, fighting, Sir des the the thj be} amc by the WOI 911C dat Sal tac and 49 grieving, fufpecting, offended with the world, with every object, withing themfelves gone or dead, or elfe carried away ffrom fome foolifh phantafie or other. (Democritus Junior, 1651, p. 86) Since that time, authors have used the term satiation to describe the seemingly paradoxical situation where although ". . . external reinforcers seem plentiful and strong enough for most people, they are inadequate for others" (Ullman & Krasner, 1975, p. 574). Ullman and Krasner (1975, p. 574) defined satiation as the existence of a surplus of a reinforcing stimulus such that the reinforcer is no longer reinforcing. According to this definition, if an individual repeatedly performs a behavior (e.g., massed practice) a surplus of reinforcing stimulus will be produced. When a surplus exists, the rein— forcer is no longer reinforcing. As discussed above, in Hullian terms repeated or massed practice generates large amounts of reactive inhibition (IR). Thus, the mechanism by which satiation works is reactive inhibition. This is the same mechanism by which negative or forced practice works. Generalization Pavlov first demonstrated the existence of the phenom— enon of generalization in 1927. At that time he reported data from animal experiments showing that a conditioned salivary response established (e.g., conditioned) to a tactile stimulus could be elicited by a thermal stimulus and by a tonal stimulus (Pavlov, 1927, p. 114). In die the mat rar the Acc In as of and 5111: Sti or i exa to ass inc the 50 discussing the basis for such a mechanism, Pavlov suggested that stimulus generalization ". . . can be interpreted from a biological point of View by reference to the fact that natural stimuli are in most cases not rigidly constant but range around a particular strength and quality of stimulus in a common group" (Pavlov, 1927, p. 113). Concurrently and independently, Thorndike described the phenomenon of generalization as response by analogy. According to his Law of Assimilation or Analogy: . . . to any situations which have no special original or acquired responses of their own, the response made will be that which by original or acquired nature is connected with some situation which they resemble. For $2 to resemble 51 means for it to arouse more or less of the sensory neurones which 81 would arouse, and in more or less the same fashion. (Thorndike, 1923, p. 138) In other words, a person will respond to any new situation as they would to some situation like it or like some aspect of it (Thorndike, 1932, p. 401). Studies by Hovland (1937a and 1937b) demonstrated stimulus generalization in human subjects. Response generalization is said to occur when a stimulus (81) will elicit a reSponse (Ri) similar to the originally conditioned response (R1). Bekhterev cited an example of response generalization in animals. According to him, ". . . if a dog is prevented from realising an association reflex in that extremity in which it has been inculcated, it is replaced by a reflex in the extremity on the other side" (Bekhterev, 1932, p. 216). pr ha be ti th in ph di re: ti' fl: San 51 Research in the area of repeated, superficial cutting behavior suggests that there are a myriad of stimuli which may result in the response of cutting. Examples of these varied stimuli include: unbearable tension or anxiety (Graff, 1967; Pao, 1969); object loss (Grunebaum & Klerman, 1967; Rosenthal, et al., 1972); anger (Gardner & Gardner, 1975; Grunebaum & Klerman, 1967); and feeling "empty" or "dead" (Asch, 1971; Rinzler & Shapiro, 1968). Intensive individual case studies have found a variety of stimuli may also be connected to the response of wrist cutting for a particular patient (Burnham & Giovacchini, 1969; Pao, 1969). Thus, a multitude of feelings, thoughts, and situations may prompt a patient into wrist cutting behavior. From a be- havioral standpoint altering conditions antecedent to cutting behavior would be difficult, if not impossible. An alterna- tive approach to behavior change is to focus on the response (e.g., cutting) to the various cues. In other words, teach the patient a different and non-injurious response. In introducing a new response, one takes advantage of the phenomenon of stimulus generalization; a variety of con- ditions will result in the new, non-injurious response. Summary Descriptive and epidemiological studies have described repeated, superficial self-cutters as usually being attrac— tive, intelligent, single young women who have sexual con— flicts, are easily addicted, and have difficulties forming satisfying relationships. These individuals often have mot ChE The USE was re; set by ind pro and tiv ies Phy Kaf tre. Gru: Sel: the: OVe: (19' S61: 52 mothers who are described as cold and domineering and fathers characterized as passive, withdrawn, and hypercritical. These patients tend to repeat the cutting behavior again and again but without intending to commit suicide. They also usually felt relief after cutting (Graff & Mallin, 1967). In reviewing the literature on treatment, only one study was found that specifically addressed the treatment of repeated, superficial wrist cutters who were not psychotic, schiZOphrenic, retarded, or children. The program outlined by Grunebaum and Klerman (1967) attempted to integrate an individual psychotherpeutic approach with the interpersonal dynamics of a ward social structure. Therapy was focused on providing the patient with a corrective emotional experience and at helping them learn to control impulses. The effec— tiveness of the program was not discussed however. A variety of other treatment approaches were suggested by the authors of the descriptive and epidemiological stud- ies. Novotny (1972) and Graff and Mallin (1976) suggested physical contact or substitute stimulation of the skin. Kafka (1969) and Pao (1969) discussed the psychoanalytic treatment of repeated, superficial self—cutters. Nelson and Grunebaum (1971) concluded that the optimal treatment of self-cutters would include both development of a patient— therapist alliance and reinforcement oftflmapatient's controls over their impulses to cut themselves. Gardner and Gardner (1975) suggested three different approaches to modifying self-cutting behaviors: use of tension-relieving rewards; cou tea ha; rep dif tiv ret stu beh ual unj des a P beh sti as non ins Wit amo: gen. (ex. Wouj no: Cia1 53 coupling the self-cutting act with an aversive stimulus; and teaching patients a way to control distressing tension, per— haps relaxation training. All authors acknowledged that repeated, superficial self—cutting behavior is extremely difficult to modify (GardnereeGardner, 1972). The learning theory concepts of drive reduction, nega- tive or forced practice, and generalization were the theo— retical basis of the treatment paradigm investigated in this study. First, however, a modification in the undesired behavior to be treated was necessary. Instructing individ— uals to voluntarily and repeatedly cut themselves would be unjustifiably damaging. Superficial self-cutting was described as possibly being a form of anxiety release and/or a painful form of stimulation. An acceptable alternate behavior would permit both release of anxiety and painful stimulation. Strenuous physical exercise was conceptualized as a form of tension relief and as a form of self-induced, non-injurious pain. According to the treatment paradigm, subjects would be instructed to voluntarily and repeatedly perform exercises with pain in association with urges to cut themselves. Large amounts of reactive inhibition (IR) were expected to be generated. At this point emitting the undesired behavior (exercising with pain in association with urges to cut) would become very uncomfortable. Simultaneously, the act of "not doing" the behavior (not exercising with pain in asso- ciation with urges to cut) would be positively reinforced by lea] and sub; The S R exc< the act; urge cia- as a 0an ery iza' ass< tiC¢ beh; 54 avoiding the aversive condition of fatigue. Thus, the act of not emitting the undesired behavior would become a con— ditioned inhibition (SIR). Referring back to Jones' (1958) revision of Hull's learning equation, = 6 [(D-IR) X (SHR-SIR)], as reactive SER and conditioned inhibition increased, the potential for the subject to perform the undesired behavior would decrease. Theoretically, if the strength of inhibitory factors (IR and SIR) could be increased to the point where they equalled or exceeded the strength of the excitatory factors (SH and D), R the undesired behavior would cease. Also, the same drive (D) activates both H (exercising with pain in association with S R urges to cut) and sIR (not exercising with pain in asso- ciation with urges to cut). Therefore, once SHR had ceased as a result of negative practice, any increase in drive would only increase the potentialities of both habits so no recov- ery of sHR would be expected. Finally, stimulus general— ization suggests that cessation of "exercising with pain in association with urges to cut" would generalize beyond prac- tice situations. Specifically, repeated, superficial cutting behaviors could be expected to stop. 00‘ ca: tre Sta ana ‘ e u CHAPTER III DESIGN AND METHODOLOGY This chapter is subdivided into eight sections which cover the following topics: description of the sample, pro— cedures for selection of subjects, operational measure, treatment procedures, selection and training of trainers, statistical hypotheses, experimental design, and methods of analysis. Description of the Sample The sample for the study consisted of five subjects. All five subjects were referred by Lansing, Michigan, mental health professionals for treatment of repeated, superficial cutting behavior. Subjects had to have a history of super- ficial cutting without conscious suicidal intent. Procedures for Selection of Subjects The medical directors of two Lansing psychiatric inpa- tient units (St. Lawrence Hospital and Ingham Medical Hos— pital) and the coordinator of research at the Michigan State University Counseling Center were contacted about this pro— ject. Staff members at these agencies agreed to refer potential subjects to the experimenter for possible 55 56 participation in the study. In order to be considered for inclusion in the study a patient had to meet a set of sub— ject characteristics. The subject characteristics were based on criteria suggested intheliterature as defining chronic, superficial wrist cutting behavior. These defi— nitions were broadened, for the purposes of this study, to include people who repeatedly and superficially cut them— selves, not just chronic, superficial wrist cutters. Repeated cutting behavior was defined as cutting behav- ior that had occurred two or more times (Gardner & Gardner, 1975; Roy, 1978) during the previous month. Such patients were said to have a history of self-cutting (Rosenthal, Rinzler, Walsh, & Klausner, 1972). Superficial cutting was described by Pao (1969) as delicate incisions. The lethality of cutting is considered low in superficial cutting (Kaplan & Fik, 1977). Cutting was defined as any self—inflicted wound (Rinzler & Shapiro, 1968) which penetrated the skin (e.g., drew blood). Repeated, superficial cutters who injured themselves without conscious suicidal intent denied suicidal intent and the lethality of their cutting was low (Kaplan & Fik, 1977; Novotny, 1972). Subjects who met the criteria of being repeated, super- ficial cutters without suicidal intent were excluded from further consideration if any of the following conditions were present. Patients whose current psychiatric diagnosis included schizophrenia or psychosis as defined in DSM—III (American Psychiatric Association, 1980) were excluded. Also participation inclusion in ject characte based on crit chronic, supe nitions were include peopl selves, not ' R8 eate ior that had 1975; Roy, 1 were said to Rinzler, Wal described by of cutting i eFik, 1977) wound (Rinzl (e.g., drew injured then suicidal in1 (Kaplan & Ff Subject ficial cutti further con present. P included so (Aherican P 56 participation in the study. In order to be considered for inclusion in the study a patient had to meet a set of sub— ject characteristics. The subject characteristics were based on criteria suggested intimaliterature as defining chronic, superficial wrist cutting behavior. These defi- nitions were broadened, for the purposes of this study, to include people who repeatedly and superficially cut them— selves, not just chronic, superficial wrist cutters. Repeated cutting behavior was defined as cutting behav— ior that had occurred two or more times (Gardner & Gardner, 1975; Roy, 1978) during the previous month. Such patients were said to have a history of self—cutting (Rosenthal, Rinzler, Walsh, & Klausner, 1972). Superficial cutting was described by Pao (1969) as delicate incisions. The lethality of cutting is considered low in superficial cutting (Kaplan & Fik, 1977). Cutting was defined as any self—inflicted ) wound (Rinzler & Shapiro, 1968) which penetrated the skin (e.g., drew blood). Repeated, superficial cutters who injured themselves without conscious suicidal intent denied suicidal intent and the lethality of their cutting was low (Kaplan & Fik, 1977; Novotny, 1972). Subjects who met the criteria of being repeated, super- ficial cutters without suicidal intent were excluded from further consideration if any of the following conditions were present. Patients whose current psychiatric diagnosis included schizophrenia or psychosis as defined in DSM—III (American Psychiatric Association, 1980) were excluded. Also L—l— . precluded frc self-mutilat. an organic to physical ill impairment 0 subjects con Psychiatric schizophreni retardation identified have preven cises as de and Appendi Any sul voluntarily admitted" we to participz position. The st‘ who met the participate consent for clinical in logical tee Form F; and were also 1 self-cuttix 57 precluded from further consideration were patients whose self-mutilaton occurred when the patient was suffering from an organic mental disorder associated with substance abuse, physical illness, or trauma, such that there was a major impairment of the patient's state of awareness. Potential subjects considered retarded according to DSM-III (American Psychiatric Association, 1980) were exluded. (The terms schizophrenia, psychosis, organic mental disorder, and retardation are defined in Appendix A.) Finally, patients identified as having physical or muscular defects which might have prevented them from safely performing physical exer— cises as described (see Chapter III, Treatment Procedures; and Appendices D and B) were excluded. Any subjects who were psychiatric inpatients had to be voluntarily admitted inpatients. The criterion "voluntarily admitted" was selected to ensure that any subject who chose to participate in this study did so from a totally voluntary position. The study was explained by the experimenter to patients who met the criteria described above. Patients who agreed to ) participate in the study were requested to complete subject consent forms (Appendix B), participate in a structured clinical interview (Appendix F), and complete two psycho— logical tests (Minnesota Multiphasic Personality Inventory, Form F; and Multiple Affect Adjective Check List). Subjects were also requested to maintain daily records related to self—cutting. L¥ Subjects frequency of ysis of the ' study. In a subject were descriptions generating Self-reErts Each su book contain plasticized to answer th urge to cut, session. Th Figures 4 an Staff Report If a St requested tc behaviors b: injurious B« Diagrams (A; behaviors. instruction were intend cutting beh 58 Operational Measures Subjects were requested to maintain records of the frequency of their urges to cut and cutting episodes. Anal- ysis of the data was designed to test the hypotheses of the study. In addition, assessment procedures involving each subject were designed to provide a basis for clinical descriptions of each subject and to provide information for generating post hoc hypotheses. Self—reports Each subject was given a small (2-3/4" X 4-1/2") note— book containing a pad of lined paper, a golf pencil, and a plasticized card of questions. The subjects were instructed to answer the questions in Unenotebook each time they had an urge to cut, each time they cut, and after each exercise session. The questions for each treatment phase are found in Figures 4 and 5. Staff Reports If a subject was hospitalized, staff members were requested to record their observations of any self—injurious behaviors by the patient. A notebook containing Self- injurious Behavior Observation Forms (Figure 6) and Body Diagrams (Appendix I) was provided for the recording of these behaviors. Sample entries were included to supplement the instructions on the forms (Appendix J). The staff reports were intended as a cross—check for subject self—reports of cutting behaviors and scheduled exercise sessions. 59 Please answer these questions each time you have an urge to cut yourself and each time you out yourself. Start each entry on a new page. 1. Date and time 2. What were you thinking/feeling/ doing just before you became aware of an urge to cut yourself? 3. What did you do in response to the urge to out yourself? 4. Then how did you feel and what did you think? Figure 4. Questions Listed in the Subject's Notebook for the Baseline Phase. Figure. 5. Ple yox til on Figure 60 Please answer these questions each time you have an urge to out yourself and each time you out yourself. Start each entry on a new page. 1. 2. Date and time What were you thinking/feeling/ doing just before you became aware of an urge to cut yourself? What did you do in response to the urge to out yourself? Then how did you feel and what did you think? If you exercised: a. Was this a scheduled or "as needed" session? b. What exercises did you do? c. How many of each? d. For how many minutes total? e. How vigorously? 7-6-5-4—3-2-1-0 very not at all f. How much pain? 0 ----- 100 none most imaginable 5. Questions Listed in the Subject's Notebook for the 2B , B+C,-and B Phases” 1 2 21:; _..:._._.<>Z...UJ:~ u..~_:_><:n:_ nu.SC~::—.Zh ILQEU. 212.132 2.7 .L .rLI T: _ I». 6]. .Euom coauo>uombo mn0H>mcom wsoflnoncfiuwaom .w ousoflm .0: ucmoflUCfi mbfiuomwp on: umEmummwp cowmwwm mo numcma upmuflsvou >©on co mcauuso ouoofipcfl “muweanmoa :oflucouum mo ucouxo nofl>wsob .mmsicmsm .mmsnuem Hmufiome oumofipcfi can po>uomno mo Hones: oumowocw mm: obflnomop coflumooH xumE mo mZOHmmmw mZOHmmmm mmOH>wm$o meommxm mmHommxm zmfimwwwa msoeesnzTnsmm €23,258 as? mean symmmAszopmzH omBmmDOWm owqaommom mwzfio LO muzmoH>m .mwon :30 m.ucofiumm 059 cu >u=ncw Hmowmxnm cospoud scans muofl>mnob nocuo mam opsaocfl ou conduct who muofi>mnon msOwuswCMIMHmm Hwnuo .30H pouconcoo ma msfluuso mzu m0 >veao£uma on» ouon3 van :fixm on» mononuocod nuflcs :oflmwucfl pwuofiamcfiuuawm xcm mm pmchwp ma mcwuusonmaom Hmwoflmuomsm .cowmmom no ucopflocfl comm now zuvcw wumummwm m mxmz ZfiOh ZOHH<>mmme mmOH>0 Baseline Hypoth Hypotl F, H otl Hypothesis 4: Null Hypothesi Ho S: 4: Alternative Hypothesi Ha Hypothesis 5: Null Hypothesi Ho Alternativ Hypothesi Ha Hypothesis 6: Null Hypothesi Ho S: S: e S: S: 6° Alternative Hypothesi Ha S: 76 Frequency of urges to cut and frequency of cutting episodes are related under B1 treatment con— ditions. Frequency of urges to cut and frequency of cutting episodes are positively related under B1 treatment conditions. Frequency of urges to cut and frequency of cutting episodes are not related under B+C treatment conditions. Frequency of urges to cut and frequency of cutting episodes are negatively related under B+C treatment conditions. Frequency of urges to cut and frequency of cutting episodes are not related under B2 treatment conditions. Frequency of urges to cut and frequency of cutting episodes are positively related under B2 treatment conditions. A modi mampbell & design can baseline, E self-induce series of t the first I and change: cutting in: addition 0: induced, e; phase, B2! injurious 1 ment effec- the treatm, sPecifical non‘injUri. A ser design, we three Of t by HerSen LT LO 77 Experimental Design A modified single case A-B time series design was used (Campbell & Stanley, 1966; Hersen & Barlow, 1978). The design can be represented as A/B/B+C/B where A represents baseline, B represents physical exercises, and C represents self—induced, non—injurious pain. The A phase involved a series of baseline observations as described previously. In the first B phase, Bl’ the treatment program was introduced and changes in the dependent variables, urges to cut and cutting incidents, were measured. The B+C Phase involved addition of one component of the treatment package, self— induced, exercise—related, non—injurious pain. The final phase, B2, involved withdrawal of self—induced, non— injurious pain. This design was intended to measure treat- ment effects and to evaluatetjkaeffect of one component of the treatment program, self—induced, non-injurious pain. Specifically, did addition and withdrawal of self-induced, non-injurious pain alter treatment effects. A series of five N—of—l studies, using the A/B/B+C/B design, were conducted. This series of studies followed three of the four guidelines for direct replication suggested by Hersen and Barlow (1978): l. Therapists and settings should remain constant across replications. 2. The behavior disorder in question should be topo— graphically similar across subjects. 3. Sub mat 4. Tre fai The fir viously, it produced ChE ers) and set Two aha observatione The Fr was used to matched or form, the F EtChieved in treatment p Obtdined fr measurement Scaling (He was aPPrOpx The us metric tesi be met, 8 l the Parame. 78 3. Subject background variables should be as clearly matched as possible. 4. Treatment should be uniform across subjects until failures ensue (Hersen & Barlow, 1978, p. 334). The first guideline was not followed. As stated pre— viously, it was believed that if the treatment procedures produced changes they would do so across therapists (train- ers) and settings. Methods of Analysis Two analyses are performed on the data: statistical and observational. Statistical Analysis The Friedman Two—way Analysis of Variance on Ranks (x2) was used to test Hypotheses l and 2. Where data from k matched or dependent samples are at least in ordinal scale form, the Friedman test is appropriate. Matching was achieved in this study by comparing each subject under all treatment procedures. Frequency counts, such as those obtained from subjects in this study, are interval scale measurements. Interval scaling is higher than ordinal scaling (Hays, 1973, p. 85). Thus the Friedman statistic was appropriate for use with these data. The use of parametric tests was precluded because para— metric tests require a number of assumptions which could not be met. Specifically, analysis of variance or the F test is the parametric technique used for testing whether k samples have come f : associated 1 are as £011: 1. Oh di 2. Th. 3. Th. ar. co 19 The ab. data collec‘ independent dePendent. suggest the Of the unde 0f Cutting ' Parametric the Paramet drawn. Thu With the da The Fr s12. 0f the cedures 11nd or not ther PIOCedUreS. Of a null h 79 have come from identical populations. The assumptions associated with the statistical model underlying the F test are as follows: 1. Observations are independently drawn from normally distributed pOpulations. 2. The populations all have the same variance. 3. The means in the normally distributed population are linear combinations<1feffects due to rows and columns (e.g., the effects are additive) (Siegel, 1956, p. 160). The above assumptions could not be made regarding the data collected in this study. The observations were not independent; repeated measures on the same individual are dependent. Also, there was no evidence in the literature to suggest the nature of the parameters (means, variance, etc.) of the underlying distributions of the populations (frequency of cutting behaviors and frequency of urges to cut). Non- parametric statistical tests do not make assumptions about the parameters of the population from which the sample is drawn. Thus, the most appropriate statistical test for use with the data in this study was a non-parametric test. The Friedman x2 test is an over—all test of whether the size of the frequency counts depended on the treatment pro- cedures under which they were obtained. It indicates Whether or not there is an over-all difference among the treatment procedures. Only if the Friedman x2 test permits rejection of a null hypothesis can procedures be justified for testing significant (Siegel, l9 Ranks Test differences The Sp to test Hy; parametric applied to relation C< ciation be- cutting in- each of th Phase, and gation did 0f repeate teSt wheth between fr inCidents 913m The t dents and (Figure 7: Obtained : The 3 COmpare b haVe bEEn 80 significant differences between any two of the treatments (Siegel, 1956, p. 160). The Wilcoxon Matched-Pairs Signed— Ranks Test would be appropriate for testing significant differences between any two related samples. The Spearman Rank Correlation Coefficient (rs) was used to test Hypotheses 3, 4, 5, and 6. This statistic is a non- parametric test appropriate for use with-ordinal data. As applied to the data in this study, the Spearman Rank Cor- relation Coefficient is a measure oftfimastrength of asso— ciation between frequency of urges to cut and frequency of cutting incidents. Spearman coefficients were computed for each of the four treatment phases (Baseline, B Phase, B+C 1 Phase, and B2 Phase). Since the subjects in this investi— gation did not constitute a random sample from a population of repeated, superficial cutters, it was not appropriate to test whether the observed rS values indicated an association between frequency of urges to cut and frequency of cutting incidents in the population. Observational Analysis The graphs presented are frequency<1fself—cutting inci- dents and frequency of urges to cut plotted across time (Figure 7). These graphs are presented showing the data obtained from each subject. The purpose of observational analysis of data was to compare behavior during any given phase with what it would have been if an intervention had not been made. Two types 1113 01 set .pou Op momHD 6cm mcflpHSOImaom mo monosvosm .5 ousmflm p50 0p momma o mpcooflosw mcflppso x mmmonm tam mom pcofipmwsh. mm mm vm mm om mm mm wm mm om ma wH vH NH OH m o v N O H O N ing on sebinpnuabquqno—gjes go Aouenbaxg O m 0 <1“ of comparis Phase A (b5 (exercise). able if the of the slop efiects are gent slope: p. 268; Ka: tional com] Five . being repe. out suicid used to co: behavioral Subje Per day an selves, B exercise S Stop each fortahie C SubleCts t, Painful tc COLlld des; 82 of comparisons were made. First, did performance during Phase A (baseline) overlap with performance during Phase B1 (exercise). Treatment effects are usually regarded as reli~ able if there is no overlap. Second, what were the directions of the slopes of the data in Phases A and 31‘ Treatment- effects are usually regarded as reliable if there are diver— gent slopes in Phases A and B (Hersen & Barlow, 1976, 1 p. 268; Kazdin, 1978, p. 637). These two types of observa- tional comparisons are made for all adjacent phases. Summary Five subjects were selected who met the criteria of being repeated, superficial cutters who cut themselves with— out suicidal intent. A modified single case AB design was used to compare the effectiveness of two variations of a behavioral treatment program. Subjects were told to perform specified exercises twice per day and also each time they had an urge to cut them— selves. Before beginning a scheduled exercise session, sub- jects were to imagine how they feltvdunithey had an urge to cut. Trainers assisted the subjects with the scheduled exercise sessions. During two phases subjects were told to stop each type of exercise just as soon as it became uncom- fortable or painful for them. In the intervening phase, subjects were told to repeat each exercise until it became painful to them and then to keep exercising as long as they could despite the pain. Measur to out were subject and The Friedma to test by; ting behavf lation Coei ship betwee cut during data and Ci 83 Measures of frequency of cutting and frequency of urges to cut were obtained from self-report data maintained by each subject and, where applicable, from hospital staff members. The Friedman Two-way Analysis of Variance on Ranks was used to test hypotheses of differential treatment effects on cut- ting behavior and urges to cut. The Spearman Rank Corre- lation Coefficient was used to test hypotheses of a relation— ship between frequency of cutting and frequency of urges to cut during each phase. Finally, observational analyses of data and clinical descriptions of each subject were presented. The re restatement sample are data and ar and discuss subject pe] urges to CI tions Of e,“ tions inch The s' ‘3 treatmen. and Superf modified 8 MeaSUres o quency Cou gathered w ranks, a n deperldent CHAPTER IV ANALYSIS OF RESULTS The research data are analyzed in this chapter. A restatement of the research problem and a description of the sample are included. Each hypothesis is restated and the data and analyses relevant to each hypothesis are presented and discussed. Observational analyses of data for each subject pertaining to frequency of cutting and frequency of urges to out are also presented. Finally, clinical descrip— tions of each subject are included. The clinical descrip— tions include psychological and behavioral data. Restatement of the Problem The study was designed to examine the effectiveness of a treatment program to be used with patients who repeatedly and superficially cut themselves without suicidal intent. A modified single case AB time series design was used. Measures of treatment effectiveness were obtained from fre— quency count records maintained by each subject. The data gathered were analyzed by a two-way analysis of variance by ranks, a non-parametric statistic appropriate for use with dependent data. One dimension of the statistical analysis 84 was the tre jects. The relation c< ation betwe urges to CI descriptiOJ Subjei by Lansing ment of re subjects i was 22.8 y Four enrolled a Pleted hig fOur-year Other pati was employ At th jects were 3 m0Nths 5 described ships wit} part to he Old 85 was the treatment phase and the second dimension was sub— jects. The data were also analyzed by a non-parametric cor~ relation coefficient to determine the strength of associ- ation between frequency of self-cutting and frequency of urges to cut. Observational analyses of data and clinical descriptions were included for each subject. Subjects Subjects for this investigation were patients referred by Lansing, Michigan mental health professionals for treat— ment of repeated, superficial cutting behavior. All five subjects in the study were Caucasian women. The average age was 22.8 years with a range of 16 to 28 years. Four of the five had completed high school; one was enrolled as a high school junior. Of the four who had com- pleted high school, three were enrolled in college (two at four-year universities, one at a community college); the other patient had previously completed a masters' degree and was employed full—time. At the time of their involvement in the study, all sub- jects were single. Two subjects had been married (one for 3 months and one for 3 years) but were divorced. One subject described herself as "gay"; she had also had sexual relation— ships with men. This subject attributed her "gayness" in part to having been raped by three men when she was 18 years old. As a behaviors 1 month t intervent subjects hospitali ing major (tricycl: diazepine Four or psych< hol depei rheumato. jects we: inpatien' was a ps- Pleting began th H W Hol Ha The 86 As a group, the patients reported histories of cutting behaviors averaging 67.8 months (5.65 years) with a range of In terms of previous 1 month to 144 months (12 years). four of the five interventions for self-cutting behavior: subjects had been involved in psychotherapy; two had previous hospitalizations; and three had received medications includ— ing major tranquilizers (phenothiazines), antidepressants (tricyclic derivatives), and minor tranquilizers (benzo- diazepines). Four of the five subjects reported notable physical and/ or psycholoqical problems: irriatable bowel syndrom; alco— hol dependence; anorexia nervosa; pelvic inflamitory disease; and dissociative neurosis. Two sub— rheumatoid arthritis; jects were treated on an outpatient basis and one as an inpatient (psychiatric unit). A fourth subject initially was a psychiatric inpatient but was discharged before com— pleting her participation in the study. A fifth subject began the treatment program as an outpatient and completed the program as an inpatient. Hypothesis 1 The different treatment procedures (baseline, Ho : l . n U 0 I Q exerCise, exercrse Wlth pain, exerCise) have no differential effect on cutting behavior. Hal: At least one of the treatment procedures (base- line exercise, exercise with pain, exercise) reduces cutting behavior. These hypotheses were formulated to compare the effec— tiveness of different treatment procedures (baseline, exercise, ting beha Data A Pr = 3 and that xi = >1§= .80 Since p_= significa H01. The dures ha' H02 Ha The that dii eXercise on Urges Da* A 1 N = 3 a' that xi >< a; II 1. 87 exercise, exercise with pain, and exercise) on reducing cut- ting behavior. Data are presented in Table l. A Friedman Two-way Analysis of Variance on Ranks for N = 3 and k (number of treatment procedures) = 4, indicated that X; = .80 which is highly insignificant. Specifically, xi = .80 is significant at between the .958 and .910 levels. Since p = .958 is greater than the previously established significance level of a = .05, the decision is to not reject Hol. The conclusion is that the different treatment proce- dures have no differential effect on cutting behavior. Hypothesis 2 H02: The different treatment procedures (baseline, exercise, exercise with pain, exercise) have no differential effect on urges to cut. Ha2: At least one of the treatment procedures (base- line, exercise, exercise with pain, exercise) reduces urges to cut. These hypotheses were developed to test the prediction that different treatment procedures (baseline, exercise, exercise with pain, exercise) would have different effects on urges to cut. Data are presented in Table 2. A Friedman Two—way Analysis of Variance on Ranks for 3 and k (number of treatment procedures) = 4, indicated N: that Xi = 1.30 which is not significant. Specifically, X3 = 1.30 is significant between the .910 and .727 levels. GmHUHGXE N Emma £+w3 CUTLLC>k U+m <0Mf’\n\!(\l. '(II Ill 1 L c .1 fr Hm Q CO UUCGHHQ> M0 mfim>HTC< %G3I03B CMEUTflHh «H WHWTQUOQN II.H oHQmH 88 #50 commouc away omwmown mHmMHmsw HmoHpmHUMbm can :H towsHosH no: mums .z.o voonQSm .ommnm oCHHommm map Houmc mtsum map mo Ucm .O.E vuwwndms mm.o FH.N m.m-m m.N H N o m o mprUHUEH xscm msflupso «0 “09552 Illllllllllllllllu meoHoxm mm wusopHocH scam asauuso mo honfidz lllllllllllllllll: :Hmm SpHB owHonwxm U+m vo.H mm.o cOHHMH>wo pnwucmum mm.m eH.~ sacs sac: vim m.NIN mmcmm I i x o s.z.a uccflnsm m.N H m.N H .m.m Howflnsw m o N o .m.s nccmnsm s H m o .o.e nocnnsm - I I o *.U.2 Howflnsm mucmpHocH m pcwcHoc scam asaubso sacs msauusoH mo Honsdz mo wobssz Islulallnllxlxlll : i-.- wwflohwx Hm m ocHchmm fl wxfimm "H nhncsnoasmnl.a canes CU WL$C>.¢_ . WVHCQNH Hm < i (If) ,I t I‘I I, , | v“ I ”hill... HINT | CO OUCQHHQ> M0 WflM%HflC< %Q3IO3B CTEUTflHh "N WHTTHUOQNEII.N @HQMH 89 .ommnm ocHHommm can Hopmm wosum msu mo #50 comment Mona omsmoon mHmemcm HMUHumempm one GH topsHocH no: mums .z.m boomnsm Ugo .U.2 pommnsms wb.o ©N.H H mb.H cOHpMH>mQ wumwamum cH.m mm.m m m scam secs mIm.H sIm.H mIH sIH cases I I I I I I I o s.z.o pocnnsm m mm s as m mH H c .m.a pccnncm m OH m 8H H m s as .m.chcchnsm m.H o m.H o m H a m .o.e nocmnsm u I I I I I I o a.o.z uccmnsm mucmpHocH mpcprodH mucopHonH mucoUHocH xcom mGHpuso Mcmm manuDU xcmm mchpsu xcmm maHuysu mo ncnssz mo Hcessz mo nonssz mo chssz mmHouoxm GHom ##Hz omHoHoxm omHOwam oQHHommm mm o+m Hm a .mxcmm co mocoHHm> mo mHm>Hmcd wasnosa cmfimeHm "N mHmosuommmll.m oHQMB Since 2 = significa H02. The dures hat Hypothesi H03: Ha The. there wa and freq- Dat Table 3. ‘\ SubjeCt Subject SubjeCt Subject Subject 90 Since p_= .910 is greater than the previously established significance level of a = .05, the decision is not to reject H02. The conclusion is that the different treatment proce- dures have no differential effect on cutting behavior. Hypothesis 3 H03: Frequency of urges to cutanuifrequency of cutting episodes are not related under baseline con— ditions. Ha ° Frequency of urges to cut and frequency of cutting conditions. episodes are positively related under baseline These hypothesesvmnxaformulated to determine whether there was a relationship between frequency of self—cutting and frequency of urges to cut under baseline conditions. Data are presented in Table 3. Table 3.—-Hypothesis 3: Spearman Rank Correlation Coefficient. Number of Urges to Rank Number of Cutting Rank Cut Incidents Subject M.C. 0 1.5 0 2.5 Subject T.O. 3 3 O 2.5 Subject W.S. 44 5 0 2.5 Subject F.B. 6 4 l 5 Subject D.N. 0 1.5 0 2.5 For indicated the freqt cut under The (Siegel, rS (.3631 observed Thus, Ho: The cutting < line COh< W Ho4 Ha The there Wa and freq Dat For was Cale indicate the PIES 91 For N = 5, the Spearman Rank Correlation Coefficient indicated a small positive relationship (rS = +.363) between the frequency of self-cutting and the frequency of urges to cut under baseline conditions. The critical value of rS is .900 for N = 5 and m = .05 (Siegel, 1956, p. 284). Because the observed value of rS (.363) is less than the critical value of rS (.900), the observed value is not significant at the s = .05 level. Thus, Ho cannot be rejected at the m = .05 level. 3 The frequency of urges to cut and the frequency of self- cutting episodes are not significantly related under base- line conditions. Hypothesis 4 Ho4: Frequency of urges to cut and frequency of cut- ting episodes are not related under Bl treat— ment conditions. Ha Frequency of urges to cut and frequency of cut- ting episodes are positively related under B1 treatment conditions. These hypotheses were developed to determine whether there was a relationship between frequency of self-cutting and frequency of urges to cut under Bl treatment conditions. Data are presented in Table 4. For N = 3, the Spearman Rank Correlation Coefficient was calculated to be zero. The finding of rS = 0 may indicate no linear relationship between the variables or the presence of a curvilinear relationship. Visual inspection of Figure 8 suggests that a curvilinear Table 4. Subject Subject Subject Subject Subject —5— *81 statist; after t] relatio: frequenI Th. level w‘ Viously is to n Th and the related % Ho Ha 92 Table 4.--Hypothesis 4: Spearman Rank Correlation Coefficient. Number of Number of Urges to IRank Cutting' Rank Cut. Incidents Subject M.C. * - - - Subject T.O. 0 l 1 2.5 Subject W.S. 5 2 0 1 Subject F.B. 19 3 l 2.5 Subject D.N. * - - - *Subject M.C. and Subject D.N. were not included in the statistical analysis because they dropped out of the study after the Baseline Phase. relationship may exist under Bl treatment conditions between frequency of self-cutting and frequency of urges to cut. The calculation that rs = 0 is significant at the .1667 level when N = 3. Since 2 = .1667 is greater than the pre- viously established significance level of a .05, the decision is to not reject H04. The conclusion is that the frequency of urges to cut and the frequency of cutting episodes are not significantly related under B1 treatment conditions. Hypothesis 5 . Frequency of urges to cut and frequency of cut- 5 ting episodes are not related under B+C treatment conditions. HO Ha : Frequency of urges to cut and frequency of cut- 5 ting episodes are negatively related under B+C treatment conditions. Figure 2 93 Rank of Self—Cutting Frequency Illh I Till I .5 1.0 1.5 2.0 2.5 3.0 3.5 Rank of Frequency of Urges to Cut Figure 8. Hypothesis 4: Relationship Between Ranks of Frequency of Cutting and Frequency of Urges to Cut. The there we and fret Da Table 5 Subject Subject Subject Subject Subject -——____ *s Statist after t Ft indicat freQUer underr T1 -500 16 Previol not re- 94 These hypotheses were formulated to determine whether there was a relationship between frequency of self-cutting and frequency of urges to out under B+C treatment conditions. Data are presented in Table. 5 Table 5.-—Hypothesis 5: Spearman Rank Correlation Coefficient Number of Number of Urges to Rank Cutting Rank Cut Incidents Subject M.C. * - - - Subject T.O. l l O 1 Subject W.S. l6 2 3 3 Subject F.B. 68 3 l 2 Subject D.N. * - - - *Subject M.C. and Subject D.N. were not included in the statistical analysis because they dropped out of the study after the Baseline Phase. For N = 3, the Spearman Rank Correlation Coefficient indicated a positive relationship (rS = +.50) between the frequency of self-cutting and the frequency of urges to cut under.B+C conditions. The calculation that rS = +.50 is significant at the .500 level when N = 3. Since 2 = .500 is greater than the previously established level of a = .05, the decision is to not reject H05. The and the BC treat Hygothes HOE Ha The there we and free Dat Table 6. SUbject Subject SubjeCt Subject SubjeCt *SI statiSt: after t1 95 The conclusion is that the frequency of urges to cut and the frequency of cutting episodes are not related under BC treatment conditions. gypothesis 6 Ho - Frequency of urges to cut and frequency of cut— 6 ting episodes are not related under 82 treatment conditions. Ha6: Frequency of urges to cut and frequency of cut- ting episodes are positively related under B treatment conditions. 2 These hypotheses were developed to determine whether there was a relationship between frequency of self—cutting and frequency of urges to out under B2 treatment conditions. Data are presented in Table 6. Table 6.--Hypothesis 6: Spearman Rank Correlation Coefficient. Number of Number of Urges to Rank Cutting Rank Cut Incidents Subject M.C. * - - - Subject T.O. 0 l O 1.5 Subject W.S. lO 2 O 1.5 Subject F.B. 38 3 l 3 Subject D.N. * - - — *Subject M.C. and Subject D.N. were not included in the statistical analysis because they dropped out of the study after the Baseline Phase. The strong pc of self-c high freq frequenci frequenci The the .500 greater t decision The the frequ related c For CUtters, fiVe SUbj below. T Cific inf StUdY and regarding Sub' w M She Was a Pation in 96 The Spearman Rank Correlation Coefficient indicated a strong positive (rS = +.866) relationship between frequency of self-cutting and frequency of urges to cut. Specifically, high frequencies of self-cutting were associated with high frequencies of urges to cut; low frequencies with low frequencies. The calculation that rS = +.866 is significant between the .500 and .1667 levels when N = 3. Since 2 = .500 is greater than the previously established level of a = .05, the decision is to not reject H06. The conclusion is that the frequency of urges to cut and the frequency of cutting episodes are not significantly related under B-2 treatment conditions. Clinical Descriptions For a more detailed understanding of individual self— cutters, case histories and psychological assessments of the five subjects who participated in this study are presented below. The presentation on each subject also includes spe- cific information about the subject's participation in the study and an observational analysis of frequency data regarding cutting incidents and urges to cut. Subject M.C. M.C. was a 16 year old, single Caucasian young woman. She was a high school junior at the time of her partici- pation in the study. flied 3 weeks 1 cut herse She used the othel not know popped i1 M.C. very angJ hurt myse but it dc but it's said that ter it f. herself : thing, I M.C. Self. SI While wa: herSelf ( night. ] their mo. M'C' Sai< m0ther. Fin: be Sometj was not a 97 History of self—cutting. M.C. first cut herself about 3 weeks before she began participating in this study. She cut herself on two separate occasions within an 8 day period. She used a razor one time to cut herself and an exacto blade the other time (see Figures 9 and 10, and Table 7). She did not know why she decided to cut herself, "It just kind of popped into my head." M.C. said when she cut herself the first time she was very angry. The second time she said "I kind of wanted to hurt myself." When she cuts herself she "can feel the pain, but it doesn't really register. And I don't know, I feel it but it's kind of like I don't really feel it." She also said that "it seemed like the more blood there was, the bet- ter it felt. That's why I went over them." After she cut herself she felt "calm inside." "It doesn't really do any— thing. Makes me feel better at the time." M.C. did not tell anyone immediately after she cut her- self. She said she told her sister about the first cutting while walking to school about a week later. After cutting herself on the second occasion she went to sleep for the night. Her sister saw the cuts the next morning and told their mother. When M.C.‘s mother asked what had happened M.C. said she walked away and "just kind of ignored her" mother. Finally, M.C. was asked if cutting herself would still be something she might do to feel better. She said no but was not able to articulate why she might have changed her Figure 9' Figure 9. Ventral Subject M.C. Extremity 98 Dorsal Self—cutting Incidents, Left Upper FiQUre . MM..-M.L_ . ._ 99 “WW H1... Figure 10. Subject M.C.: Self-cutting Incidents, Lower Extremities, Anterior. 100 Table 7.—-Subject M.C.: Self—cutting Incidents, Legend for Figures 9 and 10. Incident Date Implement Medical Used Treatment 1 October 5, Tool with None 1980 a razor blade 2 October 12, Exacto None 1980 knife mind. Asked what advice she might give to someone thinking about cutting themselves she replied, "I'd tell them not to do it because it doesn't help anything." Perhaps this was also her own advice to herself. Family history. M.C. was the third of four children born to her parents. Her parents,both40 years old, have been married 22 years. M.C. said her father works in a shop; her mother has an office job. She said her parents "get along pretty good" and so does the family. M.C. said she "gets along pretty good" with her mother. She does not feel very close to her mother but said "we talk, but nothing really personal or anything." She said she gets along with her dad "OK; we don't talk much." M.C. has a sister 22 years old, a brother 20, and a sister 15 years old. She said her older sister was married for 2 years, divorced, and remarried. The sister has a 2 year old daughter from her first marriage. M.C. said she and her older sister “get along pretty good now; we used to, 101 we never liked each other too much before, but now we get along pretty good." M.C. said her older sister saw a ther- apist at a community mental health center sometime after she first got married because "she was having a lot of problems, she just needed some help." M.C.‘s older brother is 20 years old. He is in service and has been stationed abroad for about a year. According to M.C., while she was growing up her older brother and sister did not want M.C. and her younger sister around: "they didn't want the little kids, they didn't want nothing to do with the little kids." However, M.C. was also clear in stating that shortly before her brother left for overseas they (she and her brother) started getting closer and they were talking together more. She said she misses him quite a bit now. M.C. and her "little" sister get along well part of the time, "then about half of the time we're fighting over some— thing, mostly clothes or who's gonna clean what." According to M.C., she and her younger sister wear the same size cloth— ing and "have to share clothes because ma ain't got enough money to buy separate clothes for both of us. So we just kind of buy clothes together and share." M.C. does not believe she and her sister should have to share clothes but she also acknowledged that "it works out a lot better that way" (e.g., she has more variety than if they did not share). M.C. reported no particular ethnic or religious influ- ence while she was growing up. - —— fl-.-.o- _.__ 102 Social history. M.C. reported that she has never liked school. She recalled that as about a first grader she hid in the bushes so she would not have togo to school; her mother found her and took her. During the middle of M.C.'s second grade year her family moved from the city to the country, and consequently to a rural school district. She did not like living in the countryanuishe did not like the schools there either. Between 7th and 8th grades her family moved back to the city. She did not mind moving; her best friend in the country had moved away and she did not feel like she had any friends. The move back was hard for her though. She felt the country school had been "behind every- one" academically but the city school she moved to was "kind of ahead of everybody." She still feels behind. She does not like school and usually receives C's and D's in academic classes (e.g., math, history, English). Art is her favorite subject; she receives A's and B's in that and in home economics. Peer relationships seem difficult for M.C. At the time of her participation in the study M.C. said she did not have any special girlfriend. She had recently been good friends with a girl but that girl had suddenly stOpped talking to her. M.C. did not know why; they had been friends for about a year and a half. M.C. did report having a boyfriend, some- one she had met about 10 days before she was hospitalized. She said he had "kind of changed my mind about a lot of 103 things; I'm happier, and I don't want to kill myself no more." Medical history. M.C. was diagnosed as having irritable bowel syndrome about 2 years ago. She described the symptoms as dating back to seventh grade, 4 years ago, but said she went to quite a few doctors before anyone figured out the problem. Psychological history. M.C. took an overdose of pills (she did not know what) about a year ago, coincidentally about 10 days before her brother left to go overseas. She denied any connection between overdosing and her feelings about her brother leaving. She said she overdosed because she broke up with her boyfriend and he "started saying some stuff." She went luxme, took about 30 pills, went to sleep and woke up about 5 hours later sick to her stomach. Her mother took her to the hospital where M.C. had her stomach pumped out. Afterwards M.C. was taken to see a psychologist whom she saw briefly ("I talked to her for like about 5 min- utes") and then the whole family was seen for several sessions. M.C. said she would not talk during the family sessions so the family stopped going. According to M.C. she did not talk because she was angry and because she did not like the therapist and did not want help from her. M.C. also recalled that family members were very upset, they cried, because she had overdosed. M.C. was admitted to a psychiatric inpatient unit about 1 week before she began participating in this study. She 104 was admitted because she had Cut herself twice during the previous 8 day period. Psychological Assessment. M.C.'s MMPI profile (Figure ll) can be considered valid. The results suggest she may have a defensive structure that enables her to function despite seVere problems. In general her profile suggests that she may repeatedly act out and then feel guilty or sorry about what she has done. However, the remorse she feels may not be sufficient to preventluflrfrom acting out again. To others M.C. may appear moody, unpredictable, out— going but also shy, anxious and perhaps fidgety. She tends to be concerned about what others think of her. At the same time she seems to feelalienated from others. Her relation- ships are likely to be shallow and aimed at satisfying her own needs. She may also have poor family relationships. Her feelings of depression seem to be characterized by a sense of sadness. She tends to be self-deprecating and she may have significant concerns about herself and who she is. She also seems to be angry in a sullen, brooding way. She may be in conflict with authority figures (parents or school representatives). Also, M.C. has numerous somatic com- plaints. While some somatizing is age appropriate (e.g., common among adolescents), M.C. may be somatizing anxiety. She may also be getting her dependency needs met by getting others to take care of her. Elevations on scales 2, 4, and 9 are consistent with tendencies to act out anger in self-destructive ways. Such 105 120 110 100 90 7O /\ v a «-— L'rO »- 3o 20 10 F' . igure 11. Subject M.C.: MMPI Profile behaviors may, in part, be manipulative. Finally, M.C.‘s defenses seem to be acting out, somatization, denial, ration- alization, and intellectualization. M.C.'s score on the Taylor Manifest Anxiety Scale of the MMPI was in the highly anxious range (she scored 28; scores of 20 or more are considered high anxiety) (Dahlstrom & Welsh, 1960). Extremely high scores, such as M.C's, often reflect characteristics that interfere with learning and may also indicate depressive or other psychopathological pro— cesses which distract individuals from concentrating (Dahlstrom & Welsh, 1960). These observations seem con- sistent with M.C.‘s overall MMPI profile. Oniflmafirst MAACL--In General and Modified Today forms administered to M.C., she described herself as anxious (words such as: fearful, nervous, tense, upset), and depressed (words such as: blue, lonely, rejected, sad, unhappy). Just prior to cutting herself, she tends to feel more hostile than usual and somewhat more anxious and depressed than usual (Figure 12). At the conclusion of her participation in this study, M.C.‘s depression score was markedly lower than initially. Her anxiety and hostility scores were also lower. In summary, M.C. appears to be an angry, depressed, and anxious adolescent girl. She tends to somatize anxiety. In addition she tends to act out her angry feelings (perhaps related to unmet dependency needs) in ways that may be manip— ulative. Her mother was not outwardly affectionate and her father seemed passive and withdrawn. While M.C. characterized Raw Scores Figure 12. ~107 8 10 12 l4 l6 18 20 Baseline Treatment Days and Phases MAACL In General x anxiety A depression 0 hostility Subject M.C.: MAACL Modified Today xx anxiety AA depression 00 hostility MAACL Raw Scores. 2 108 her home life and family relationships as "pretty good" one gets the sense of there being little there for her. M.C.‘s choice of self—cutting seems similar to her overdosing: anger turned inward that is also an indirect, manipulative expression of anger toward others. Participation in this study. When M.C. was first referred for possible inclusion in this study she was a psychiatric inpatient. She was discharged after the sixth day of involvement in the study. During those 6 days she was involved in the Baseline Phase. That phase was continued after her discharge from the hospital. During her 3 week involvement in this study, M.C. reported no urges to cut and no self-cutting (Figure 13). At the end of 3 weeks the experimenter decided not to pro— ceed any further with the treatment program. M.C. agreed to contact the experimenter if in the future she had urges to cut herself or if she cut herself. At the time of this writing (April 1981) she had not done so. Subject T.O. T.O. was a 20 year old, single Caucasian woman. She was a third term college freshman at the time of her partici- pation in this study. She was majoring in the social sci— ences and thought she might enjoy working with people on a one-to-one basis. History of self-cutting. T.O. first cut herself in late September of 1980. She cut herself on about four separate 109 30 20 Frequency 8 10 12 l4 16 Baseline Treatment Days and Phases x cutting incidents o urges to cut Figure 13. Subject M.C.: Frequency of Self—cutting and Urges to Cut. llO occasions between late September and the end of October 1980. She cut herself again twice in early December 1980, just prior to her participation in this study (see Figures 14 and 15; also Table 8). She used a razor blade to cut herself. T.O. said she decided to cut herself because "I just, I needed to feel pain right away, immediately. It was the quickest way to do it. I guess I just wanted to see myself physically hurt, to be able to sit and look at myself and see myself being hurt. And so I chose to out myself, I guess." In describing what it felt like when she cut herself T.O. said, "Well, there was physical pain, but ontfluaemotional or intellectual level, I was beginning to feel more relieved. The more I cut, the better I felt, despite the fact that it hurt . . .I got to the point where I felt much more calm." She said she cut herself when she felt very angry and second— arily because she wanted attention. However, she did not tell anyone right after she cut herself; her desire for attention seemed to be related to not receiving attention that she wanted but that she was unable to ask for it directly. Her boyfriend knew about her cutting eventually. She said he usually became upset (secondary gain?) and wanted to understand why she had cut herself. T.O. was aware that she tended to "take things in and twist them around and internalize them as if I was at faultJ' She understood this tendency to turn her angry feelings back on herself as a pattern she had learned while growing up. This was also a focus of her current therapy. \ \\ 18 (“in 1A . Ventral Dorsal Figure 14. Subject T.O.: Self—cutting Incidents, Left Upper Extremity. lB lA Figure 15. s “‘— —~ ,' ">77 E // Ventral Subject T.O: Extremity. Dorsal Self—cutting Incidents, Right Upper 113 Table 8.--Subject T.O.: Legend to Figures 14 and 15. Incident Date Implement Medical Used Treatment la December' 4, Razor None 1980 (a.m.) lb December'14, Razor None 1980 (p.m.) 2 December 10, Razor None 1980 T.O. did not know anyone else who cut themselves. She did report other ways she currently used on occasion to hurt herself: pulling some hairs outcflfher head and banging her head on the shower wall. She said she did these things some- times (e.g., about once per week) rather than cutting herself. T.O. recalled that while growing up she "used to tug on my hair, and again, I tried to hit my head on the shower walls, stuff like that. Never anything as drastic as cutting myself up, but just little things. I would purposely fall off my bike." She said falling off her bike "somewhat relieved the anger, but then again, when I was younger the physical pain meant more. I mean, after I fell off of course I felt phys— ical pain, so my attentions were more focused on that. But it helped a little again, like what I do now." T.O. could not specify the frequency of self-injurious behaviors while she was growing up except to say "it didn't happen that often, 'cause usually I'd just, I did my best to repress this anger that I felt." 114 When asked if she cut herself because she wanted to or because she felt a need to, T.O. responded "both, I want to and I feel I have to, I need to. Just, I feel like it's something that has to be done." Asked how her life would be if she stopped cutting herself T.O. said "with alternative ways of venting my anger, it would probably be much better, be much more helpful. If I did keep cutting it would still be a release. So either way, with or without, I don't think it makes that much difference." Finally, T.O. was clearly ambivalent about whether or not she wanted to stop cutting herself: "intellectually, yes; emotionally, when I get very angry, no." Family history. T.O. was the third of six children born to her parents. She reported no particular ethnic influences while growing up. However, religion, Catholocism, was stressed and T.O. went to a parochial school through the eighth grade. T.O.‘s parents have been married about 27 years. Her father, 50 years old, is an engineer with a large automobile company. Her mother, 47 years old, did not work outside the home until about 2 years ago. She is now employed as a clerk in a small gift shop. T.O. described her parents‘ relation— ship as "beautiful" as far as she knows except for problems with T.O.‘s younger sister who has "caused quite a bit of stress between them, but never to the point that they'd split up or anything like that." (A further description of the younger sister's problems is included below.) 115 T.O. said her relationships with the people in her family was "generally good, but recently, like over the past couple of years since I've been dealing with this anger, it hasn't been quite as good." She described her family as extremely tight knit; she feels closest to her older sister and closer to her mother than to her father. T.O.‘s brothers and sisters are as follows. Her oldest sister is 25 years old, a nurse, single, and she calls T.O. frequently to see how she is. Next is an older brother 24 years old who does public relations work. He is engaged. The next sibling after T.O. is an 18 year old brother, he is a high school senior. The two youngest siblings are a girl 16 years old and a boy 14 years old. The 16 year old sister is the sister who has caused a lot of stress in the family and between the parents. Accord- ing to T.O., her younger sister has seen a series of psycho— logists and psychiatrists for about 12 years, since about age 5 (since she started kindergarten). T.O. described her sister as very rebellious and manipulative, "she knowingly disrupts any family goings-on and she's constantly got my parents coming and going." The sister has never hurt her— self although she "threatens constantly." Also, this sister and the father apparently have an adversary relationship. T.O. believes this may be because the sister is resentful of how much time the father has Spent with the youngest brother. This brother almost died of double pneumonia when he was 6 months old. 116 Social history. T.O. reported that her family moved about seven times, her father was transferred "back and forth quite a bit." She enjoyed school and did well academically. However, even as a young child of 5 or 6 she recalled being terribly angry inside. I was happy at school, very happy. I was happy with the family. I would go through these same stages I'm going through now, where I'll go for a few days and I'll be perfectly fine, happy, content, and then I start in with these, I get extremely negative and then very angry. And I can remember doing that when I was very young. And I'd run around and break toys and hit my brothers and sis- ters. My parents would yell at me. I think they thought I was doing it to be just downright obnoxious. But it was something I couldn't control . . . I guess from what I've learned now, I took it to mean that there was something wrong with me. That that wasn't normal to be that angry, though I continued being angry and going through these phases. I just figured I was different, I was young. Peer relationships have at times been a source of some problems for T.O. She described herself as getting along very well with classmates in elementary school, even being "the leader of the pack, the instigator." In eighth grade T.O. had a relationship with a girlfriend in which she ended up feeling "very used." T.O. said this girlfriend criticized her and that she, T.O., often took the blame for things that her friend was upset about. T.O. ended the relationship at her mother's suggestion. However, she referred to that experience as "a very bad soar, to this day I find it hard to differentiate between when someone tells me something critical and when someone gives me a compliment. I immedi- ately question them." m—w 117 T.O. enjoyed high school and did well academically, all A's and B's. She started dating the young man who was cur— rently her boyfriend when they were in high school. And during high school she grew away from most of her girlfriends because she spent so much time with her boyfriend. Her first year at college, 1979—80, was difficult. She said she "was terribly homesick and wanted mother's cooking" for about the first 2 months. She also had roommate prob- lems; her first roommate was very similar to her eighth grade girlfriend. T.O. said she did "pretty well, average" in her classes. In the fall of 1980 T.O. got a new roommate. She said they have not had any problems. Medical history. When T.O. was in sixth grade she was diagnosed as having rheumatoid arthritis which she said "started out as being water on the knee from about third grade on." She was not able to participate in sports and could not go "on quite a few of the family outings." In dis— cussing her arthritis T.O. said "I think it played a bigger part in my life than I had ever acknowledged, and I realize much more of it now." T.O. said she takes-6-12 aspirin a day for her arthritis. T.O. reported that she recently started taking lorazepam once in a while (one pill every 2—3 days) to clam herself down. Psychological history. In late October 1980 T.O. said she tried to commit suicide by cutting herself. While she was cutting herself she called her boyfriend. "I talked to him for a few minutes and I guess he could tell I was kind 118 of irrational and so he came over right away. And then he walked in and saw I was doing it." T.O. had started seeing a psychiatrist about 2 weeks before she tried to kill her- self. She sought help because of her cutting behavior and suicidal ideation. After she tried to kill herself the psychiatrist recommended hospitalization but T.O. was "against it at that particular time." T.O. continued seeing the psych— iatrist on an outpatient basis. Psychological Assessment. T.O.‘s MMPI profile (Figure 16) can be considered valid. The results suggest she has a defensive structure which enables her to function in day-to— day life despite severe problems. In general, she may be confused and under tremendous pressure. Her problems may revolve around lack of achievement and identity issues. These conflicts may be the impetus behind her seemingly active withdrawal from people. To others T.O. may appear moody, unpredictable, full of energy but shy, anxious, and perhaps fidgety. She tends to be concerned about what others think of her. At the same time she seems to feel alienated from others. Her relation- ships are likely to be shallow and aimed at her own need satisfaction. She may feel she is lacking some quality which is fundamental to relating successfully to others. Her feelings of depression seem to be characterized by a sense of gloom. She tends to be self—deprecating and she may have significant concerns about herself and who she is. She also seems to be angry in a sullen, brooding way. She 120 110 100 90 80 119 70 5o 140 p. / \ 3o 20 10 Figure 16. Subject T.O.: MMPI Profile. 120 may be in conflict with authority figures (parents or school representatives). Also, her many unstable moods and easy excitability suggest she may have poor impulse control. Elevations on scales 2, 4, and 9 are consistent with tendencies to impulsively act out in self-destructive ways. Although she may feel guilty for acting out, the guilt may not be enough to keep her from acting out again. Finally, her primary defenses seem to be acting out, intellectuali- zation, and rationalization. T.O.‘s score on the Taylor Manifest Anxiety scale of the MMPI was in the highly anxious range (T.O. scored 31; scores of 20 or more are considered high anxiety). Extremely high scores, such as T.O.‘s, often reflect characteristics that interfere with learning and may also indicate depressive or other psychopathological processes which distract indi- viduals from concentrating (Dahlstrom & Welsh, 1960). These observations seem consistent with T.O.‘s over-all MMPI profile. On the first MAACL--In General and Modified Today forms administered to T.O., she described herself as anxious (words such as: afraid, desperate, nervous, tense), depressed (words such as: alone, blue, destroyed, gloomy, lonely, lost, unhappy), and hostile (words such as: angry, bitter, disagreeable, mad, offended, stormy). Just prior to cutting herself she tends to feel less anxious, depressed and hos- tile than usual (Figure 17)- .mmnoom 3mm sodas H.o..H. pomnnsm .eH museum spflaenmon oo coflwmoumwo << hyoflxcm xx speaepmoe o coammmummo < >poflxcm x amUOB UmHmHUOS Q04¢2 Honcww CH QU¢¢2 Bowmw m5: wowmcm can mwco #coEpmoHBr see aw massed . m o+m .pi eeeeemem Ill ;. mc.ma, m mm em mm om @H ma ea I] I] 121 l l 1 OH om SBIOOS ME’H om l I l J l J l l I I I ow l I I l 122 Throughout her participation in this study T.O.'s anxiety scores remained relatively constant except for a low point on treatment day #20. Her depression and hostility scores also remained relatively constant although these scores showed more variability than the anxiety scores. At two follow-up testings (12 and 68 days) T.O.'s depression and hostility scores dropped to their lowest levels. Her anxiety score stayed within its previous range (moderate to severe anxi— ety), but it was lower than on pre-treatment testing. In summary, T.O. appears to be an angry, depressed, and anxious young woman. She seems to have significant concerns about who she is and her relationships seem shallow. She tends to act out her angry feelings, perhaps related to unmet dependency needs, in ways that may be self-injurious (e.g., self-cutting). While T.O. described her family as "extremely tight knit," her statement may reflect her position among the sibling (third of six children) rather than the inter— personal relationships. T.O. also apparently learned as a young child of 5 or 6 that her angry feelings were a sign of something wrong with her. In addition, she learned to feel responsible for other people's feelings. Her choice of self- cutting seems to be anger turned on herself, and at times an indirect expression of anger toward someone else because she did not get the attention she wanted from that person. Participation in this study. T.O. was first referred for possible inclusion in this study during the final week of classes of the fall term. She was planning to leave the 123 Lansing area for the holiday season. Baseline data was col— lected for 4 days and then the firsttreatment phase was initiated. After 2 days of following the B treatment.pro— 1 gram T.O. said she had cut herself again and that she would be leaving Lansing the following day for her holiday break. Consequently the experimenter made the decision to implement the B+C treatment phase on treatment day #6. T.O. participated in one exercise with pain session with a trainer. She was given an audiocassette of exercise with pain instructions to take home with her. T.O. also agreed to have the experimenter call her at home every 2 days. These telephone contacts were made as arranged. On treatment day #11 T.O. was told to change exercise instruction. By telephone the experimenter explained to T.O. to continue exercising twice per day and when she had an urge to cut her— self, only she was again to stop exercising as soon as it became uncomfortable for her (B2 exercise instructions), She agreed to do as instructed. The experimenter continued to call T.O. every 2 to 3 days. During the telephone con— versation T.O. said "everything was going fine" and she was doing the exercises twice per day. When T.O. returned to Lansing she met briefly with the experimenter. At that time T.O. said she had actually stopped exercising after treatment day #10. She said she had experienced a lot of stress at home during the holidays.’ On treatment day #10 she had had an urge to cut herself, had 124 picked up a razor blade, but decided she no longer needed to injure herself in that way. T.O. agreed to participate in two follow-up sessions, one about a week after she returned to Lansing and one at the end of winter term. At the first post-treatment inter— view T.O. reported she had had no urges to cut herself and she had not cut herself. When asked what about the treat— ment program might have been helpful she replied "something about the pain of doing the pain exercises killed or destroyed the urge to cut myself; I could still in a way feel it, the pain, the pulling [muscles]". IT.O. was con— tinuing to feel stress at home and school. She also said she does "some exercises even now when I become upset, some- times to the point of pain." The second post-treatment interview was held the last week of classes of winter term. (This was an attempt by the experimenter to ascertain whether end-of—the—term stresses might affect urges to cut or self-cutting.) T.O. reported she was experiencing stress again, similar to the end of the previous term. Now when she felt stressed she was more apt than before to share her problems with others andsfluacalled home more. She said she recognized she is independent and yet still somewhat dependent on her parents/family. About 2 weeks before the interview T.O. started to cut herself. She said she had been upset about problems with her boy- friend, got drunk, and then started to cut herself. But she stopped herself because she thought "Why am I doing this? I — —A' —..4¢L_L 125 don't want to do this. I don't want to hurt myself." T.O. said she did not hurt herself in any other ways. Finally, T.O. said she had terminated therapy (by mutual agreement) with her therapist about 1 week before the second post- treatment interview. Data regarding T.O.'s scheduled sessions are presented in Table 9. This table shows information about scheduled exercise sessions across three treatment phases. (T.O. did not report an "as needed" exercise session.) The exercise information in Table 9 was obtained from the subject's note— book. The following statements are based on the information in Table 9: l. T.O. averaged about two scheduled exercise sessions during the B1 and B+C Phases. Thus, she apparently complied with the instructions to do two scheduled exercise sessions per day during those phases. 2. T.O. averaged more sit-ups and leg—lifts during the B1 Phase than during the B+C Phase. 3. She averaged more leg—lifts during the B+C Phase however. 4. Her average subjective vigor rating was higher dur— ing the B+C Phase than during the B1 Phase. 5. T.O.'s average subjective pain rating was higher during the B+C Phase. Thus, she seemed to be com— plying with instructions to exercise with pain dur— ing the B+C Phase. 126 Table 9.—-Subject T.O.: Exercise Data--Schedu1ed Sessions B B+C B Number of days in treatment phase 2 5 17 Number of scheduled exercise sessions 4 11 - Average minutes per scheduled exercise session 15 14.64 — Sit—ups :U 22.25 18.91 - (SU) SU 2.63 2.12 - range 20—25 15-22 - P76 10 4.18 — Push—ups s _ (PU) PU 0 2.32 range 10 3-11 - II 3.25 5.36 - Leg-lifts s . (LL) LL 0.50 0.92 range 3-4 3-6 - Subjective V' 4.75 4.91 — vigor s _ rating V 0.96 0.54 (V) range 4—6 4-6 - Subjective P 30.63 54.55 — pal? Sp 7.18 10.83 — rating (P) range 25—40 25-65 — 127 ‘ Observational analysis. Figure 18 presents frequency of self-cutting incidents and frequency of urges to out both plotted across time (treatment days) for Subject T.O. Obser-~ vational comparisons of overlap and trend are made for all adjacent phases considering first self-cutting incidents and then urges to cut. Self-cutting. The frequency of self-cutting incidents during the Baseline Phase overlaps with the frequency of cut- ting during the B Phase. The trends in both of these 1 phases might also be considered similar, no trend. Similar statements can be made regarding frequency of self-cutting between all subsequent adjacent phases. These observations suggest there was no reliable difference in treatment effects between any two adjacent treatment phases for T.O. Urges to cut. The frequency of urges to cut during the Baseline Phase overlaps with the frequency of urges to cut during the B Phase. The slopes in these two phases may be 1 different. The slope in the Baseline Phase may be decreasing; there is no slope or zero trend in the frequency of urges to CUt during the B Phase. Thus there may be a difference in 1 treatment effects between Baseline and B1 Phases regarding urges to cut. However, any difference between phases could not be considered reliable and may be a factor of chance. The frequencies of urges to cut during the 111 and B+C Phases overlap. The trends or slopes in both of these phases might also be considered similar, no slope. These Frequency .128 2 4 6 8 10 ' 2 14 16 ‘ 2 2 6 30 Baseline Bl B+C B2 Treatment Days and Phases x cutting incidents o urges to cut Figure 18. Subject T.O.: Frequency of Self-cutting and Urges to Cut. 129 observations suggest there areIK>reliable differences in treatment effects between the B1 and B+C Phases for T.O. In summary, observational analyses suggest no reliable difference in treatment effects between phases for either frequency of self-cutting or frequency of urges to cut for Subject T.O. Subject W.S. Subject W.S. was a 25 year old single Caucasian woman. She was a junior at a state university at the time of her participation in this study. She was employed part-time as an aide in a nursing home. After graduation W.S. hopes to work withtflmaelderly, perhaps setting up programs and services. She expressed particular interest in helping aged alcoholics. History_of self—cutting. W.S. first cut herself when she was a freshman in college. She cut herself 10 to 25 times in the 2 years she was in college in Florida. She believes she was probably "loaded" (under the influence of alcohol) when she cut herself those times "because [She] was loaded every day." During the following four year period she only cut herself two times. Before W.S. began partici— pating in this study she had cut herself twice within a 3 week period. She cut herself on four separate occasions during March 1981 (see Figures 19, 20, and 21; also Table 10). She was not under the influence of alcohol or drugs on either of these occasions. In discussing her recent 130 5A Figure 19. I Ventral Subject W.S.: Extremity. Dorsal Self—cutting Incidents, Left Upper 131 5B \W \\ 18 11 I / b/l Ventral Dorsal Figure 20. Subject W.S.: Self-cutting Incidents, Right Upper Extremity. 133 Table 10.--Subject W.S.: Self~cutting Incidents, Legend for Figures 19, 20, and 21. Incident Date Implement Medical Used Treatment la February .3, Razor None 1981 lb February' 3, Razor None 1981 2 February 21 , Razor None 1981 3 March 13, Bottle cap Wiped with alcohol 1981 pads 4 March 16, Bottle cap Areas painted with 1981 povidone-iodine 5a March 20, Piece of Areas painted with 1981 glass povidone-iodine 5b March 20, Piece of Areas painted with 1981 glass povidone-iodine cutting W.S. said "that's what scared me so much when I was doing it lately, because I wasn't on anything." W.S. described cutting as a way to punish herself as well as a way to relive "the tension and pressure that's built up, and I feel better afterwards. And I enjoy doing it." In describing the pain when she cuts herself W.S. stated "it doesn't hurt like if I accidently out myself doing dishes or something, that hurts. But when I do it intentionally, it's like I don't feel it as much." In addition, W.S. said she feels "very satisfied" when she cuts herself. She also enjoys "watching the razor cut into my flesh." 134 When asked why she might have decided to cut herself the first time W.S. said, "I never thought of szefore, I just, this idea one night, I just did it. I don't know where I got the or anything." She was upset because two friends were upset with each other over her. So she went to another friend's house, smashed an ashtray outside and cut herself. "I felt better, because I felt I've punished myself for what I'd done, but I really hadn't done anything, except that was the way I was thinking." W.S. said before she cut herself the first time she did not know anyone else who cut them— selves and had never heard of such behavior. After cutting herselftflmafirst time a man living at the house where she had gone gave her something to wash up with but he did not say anything about what she had done to her- self. In general, she does not tell people after she cuts herself. When asked if cutting herself was something she did because she wanted to do it, or something she felt she needed to do, or maybe something else, W.S. responded as follows: I feel it as a real need. Definitely a need. But then, because I know it helps and I enjoy doing it, I enjoy the act itself, then I want it too. But it starts as just feeling a need mostly, like when you feel you need to eat or . . . Family history. Subject W.S. was the youngest of four children born to her parents. She has two brothers (32 and 30 years old) and a sister 27 years old. W.S. reported no particular ethnic or religious influences while she was grow— ing up. 135 Until W.S. was 13 years old, her family lived on a military base in northern Michigan. Her father was a jet pilot in the military, a "career man." W.S. did not recount any particularly notable experiences during those years. She had a group of friends she enjoyed and she did well in school. When W.S. was 13 or 14 years old her father retired from the service. He had always wanted to live in Florida so W.S., her sister, and her parents moved to Florida. W.S.‘s brothers did not move with the family; they were enrolled at state universities in Michigan. The move from northern rural Michigan to urban Florida proved difficult in many ways for W.S. She was acutely aware of differences in life styles, "it was like two different cultures." Soon after the move her mother became quite sick but it was 6 months before the problem was diagnosed and treated. During this time W.S. felt a lack of support. She had not yet established close peer relationships, her older sister "was older enough so she could understand a little what was going onfl'her brothers were back in Michigan, her father was working and trying to deal with the mother, and her mother seemed very changed and was not emotionally available. As a consequence of all these factors W.S. "got into doing drugs at 14." W.S. described her brothers and sister as very warm, sensitive, and affectionate. She described her relation— ships with them as "fine." Her sister was diagnosed 5 years ago as having a congenital spinal problem; she has had 136 several spinal fusions, is in chronic pain, and may eventu— ally be paralyzed. W.S.'s relationship with her father seems to be charac— terized by much distance. He was frequentlygone while she was growing up. One gets the sense of him as a background figure in W.S.‘s life except at the point where her life was clearly disrupted. The family move to Florida was based on her father's desire to live there. Her relationships with her mother was different. There is a sense of her mother having been emotionally available at least until she became ill shortly after the move to Florida. At the same time W.S. feels that no matter what she does it "doesn't quite measure up" to what her mother expects. W.S. traces many of her guilt feelings to feeling she hascknuasomething wrong (e.g., not measured up to mother's expectations). Social history. W.S. attended college in Florida for 2 years after high school. She had achieved a 3.9 GPA in high school but her first year in college was very difficult: Soon as I got there, man, I just went crazy. Like, its well . . . I don't put all the blame on my parents, but they did have some influence on it because, all my life I'd never had to make any decisions for myself or had any responsibility, of any nature. And, I still don't know really why I started doing so much dope and drink— ing so much, but I think it's basically because I wasn't real happy, and especially as time went on and I was doing terrible in school, and all these ideals that I set for myself, I was not reaching. I was feel— ing a lot of anxiety." W.S. went on to describe how both of her brothers and her sister had experienced similar difficulties when they first 137 went to college although they had all done very well academ— ically in high school. (Such a repeated pattern of sepa— ration difficulties suggests the possiblity of a family-- originated separation--individuation conflict.) Since high school W.S. has felt that most of what men wanted from her was sex. She described her sexual relations as "always too painful, never enjoyable." When she was 20 years old W.S. was raped by three men in Florida. Again she found herself without a support system. "All my friends just took off, they didn't give me any help whatsoever, I think it was a little too close to home for comfort or some— thing." W.S. chose not to tell her mother "because I knew it would hurt her." W.S. felt she had to handle the situ- ation all by herself and yet all she wanted "was someone to hold" her. Five months later W.S. moved back to Michigan because she "couldn't handle living" in Florida any more. In terms of sexual identity W.S. now calls herself "gay." Her views about relationships, however, suggest that for her sexual identityas "gay" may be a way to avoid intimate relationships with men and to get some nurturing from women (mother). "I really don't like shutting out an entire half of the race, and I know there are some good men out there, but I don't know if I could ever trust one again." 'W.S. also described that after being raped, she felt as if her "inner self or whatever had to take care of" her. Given her wish to be held at that time, one could speculate that her 138 unconscious wish was to be held and taken care of by her mother. Medical history. W.S. reported a long history of sub- stance abuse since high school. Her drug use has included marijuana, speed, "downers," "acid," "coke," and PCP. She has also abused alcohol for the past 7 years. Recently she was drinking 4 to 12 beers a day, beginning before noon. Since admitting herself to the alcohol unit she has identi- fied herself as an alcoholic. She had not had a drink from early February throughluflrparticipation in this study. In October 1976 W.S. had a grad mal seizure. She saw a neurologist who performed a CAT scan and other tests. According to W.S., he found no neurological basis for the seizure and suggested it mightlunnabeen caused by the drugs she was using. W.S. took phenytoin sodium for 2 years and has not had any recurrence of seizures. (It is curious that her seizure occurred almost exactly one year after she was raped. Perhaps the seizure was an anniversary reaction.) Psychological history. W.S. believes her involvement with drugs when she was in ninth grade was a way to cope with her problems at the time. This is one theory I have that when I was in ninth grade and all this shit was going on, and Igot real heavy into drugs and "I hurt my family a hell of a lot, and I was never punished for that. It was like, it was like they understood why I was doing it, you know. I mean everybody, my teachers and everything, they were just so nice about it, and I guess it" 'cause they saw that I was a nice person, it was just that I was having troubles, that's why I was doing 139 it. Then I think I felt that I should have been pun— ished for that and then since then, it's like, I've always felt like I disappointed my parents and that I'm a big failure to them and to myself, and to, I don't know . . . When W.S. was 19 she attempted suicide. She took an overdose of codeine and drank a couple of pitchers of beer. After lying down however, she decided "to give it one more shot," called an acquaintance, and went out with that person and drank coffee all night. She said she has thought about killing herself a lot but she has only acted on the thought one time. W.S. was in therapy for a couple of months when she was 22 years old. She went to a mental health clinic for help because she started having recurring nightmares about the rape. She felt that therapy was helpful in terms of "desen- sitizing" her to the experience, making it "into a memory instead of so real in my mind." (Although the experience may be more of a memory, as she talked about it W.S. still seemed to experience very strong feelings about it.) Since September 1980 W.S. has been seeing a woman thera- pist at a university counseling center. She sought help at that time because she was feeling depressed and tense most of the time and she was blaming herself for many things that were happening around her. For the first 4 months of therapy W.S. felt the more she worked on in therapy, the more she needed to drink. Finally her therapist suggested she go to the substance abuse clinic. For several weeks W.S. continued to see her therapist and a counselor at the substance abuse 140 clinic weekly. Then in February 1981 W.S. admitted herself to an inpatient alcohol program. W.S. reported that her brothers and sister have been aware oflmn:problems (drugs, alcohol, and emotional). She said their response was to tell her they loved her and that "it hurt them to think that I'd been doing that (drugs)." She has not told her parents about her problems. Until recently she said she thought it was expected that she deal with her problems by herself. She also believed that people would be glad that she cut herself because they probably thought she should be punished. Psychological assessment. W.S.‘s MMPI profile (Figure 22) can be considered valid although she may have been con- sciously presenting herself favorably. The results suggest she may have a rigid, tight defensive structure that enables her to function despite severe problems. In general her profile is one of an individual who is depressed, fearful, irritable and who may be described by others as passive- aggressive (Duckworth & Duckworth, 1976). To others W.S. may appear moody, unpredictable, outgoing but also shy, anxious, and perhaps fidgety. Her relation- ships tend to be superficial and aimed at satisfying her own needs. Her feelings of depression seem to be characterized by a sense of sadness. She tends to be self-deprecating and she may have significant concerns about herself. She also 141 120 100 9C 80 70 a A “.11... _~- V LLC‘ r-- - ___.,-__. 30 20 10 Figure 22. Subject W.S.: MMPI Profile 142 seems to be angry in a sullen, brooding way. She may be in conflict with authority figures (parents or school repre- sentatives). Marked elevations on scales 2 and 4 and a moderate elevation on scale 9 are consistent with tendencies to act out anger in self-destructive ways. Although she may feel guilty for acting out, the guilt may notlflaenough to keep her from acting out again. Finally, her primary defenses seem to be acting out, rationalization, and intellectual- ization. W.S.‘s score on the Taylor Manifest Anxiety Scale of the MMPI was in the highly anxious range (she scored 24; scores of 20 or more are considered high anxiety) (Dahlstrom & Welsh, 1960). This observation seems consistent with W.S.‘s over-all MMPI profile. On the first MAACL-~In General and Modified Today forms administered to W.S., she described herself as anxious (words such as: alone, blue, sad, unhappy), and hostile (angry, disgusted, stormy). She did not feel particularly different just before cutting herself. Throughout her participation in this study W.S.‘s anxi— ety, depression, and hostility scores fluctuated markedly but within the same relative position to each other. Her scores on these scales reached their lowest levels on the final administration of the test (Figure 23). In summary, W.S. seems to have much in common with chronic, superficial cutters as described in the literature. 143 .me00m 36m @0454 zbaaapmoc o spefiepmos oo . . coammmummo << coflmwmumoc < .mpmflxcm xx hpwflxcm x autos cmemeeos sodas Hmnocoo 2H doses momccm cum mxmo bcmEpmmHB m o+m H mm om mm em emm em 33 3 NH O N mCHwaom OH ON om ow sexoos meg o MN OHUWHM 144 She is an attractive, intelligent, unmarried young woman. She appears to be angry, depressed, and anxious. She seems to have significant concerns about who she is including sex— ual identity issues. She also has an acknowledged addiction, alcohol. W.S. experienced her mother as emotionally supportive until W.S. was 13 years old. At that point W.S. felt the stresses of moving and of her mother being sick for 6 months. The lack of support W.S. felt during that time seems to have had considerable impact. She also characterized her mother as being very demanding of her and her father as being very distant. Participation in this study. W.S. was referred for pos— sible participation in this study the day after she was admitted to a psychiatric inpatient unit. She was admitted because of "depression; suicidal ideation; inability to con— trol self-destructive impulses with intensification of long- term pattern of cutting wrists and arms with razor blade exacerbated by alcohol withdrawal;anmifeelings of failure from dropping out of being expelled because of cutting her~ self one time an alcohol treatment program." When W.S. was first admitted to the psychiatric unit she was placed in the intensive care area or "closed side" because of her suicidal ideation. She was transferred to the open side on treatment day #3. 145 W.S. completed all treatment phases as an inpatient. While in the hospital she was given several medications: flurazepan hypochloride, magnesium and aluminum hydroxides, thioridazine, orphenadrine citrate, and acetaminophen. Total daily dosages of these medication are charted in Figures 24 and 25. These medications are described in Appendix C. Thioridazine was prescribed for treatment of the patient's depression and anxiety. Her total daily dosage (see Figure 24) was within the 20—200 mg/day range suggested (see Appendix C) for the treatment of these symptoms in adults by this drug. Data regarding W.S.‘s exercising are presented in Tables 11 and 12. These tables show information about sched— uled and "as needed" exercise sessions across the three exer- cise treatment phases. The information was obtained from the subject's notebook and from hospital staff records (Self— injurious Behaviors Observation Form). The following state— ments are based on the information in Tables 11 and 12: l. W.S. averaged about two scheduled exercise sessions during each of the phases. Thus, she apparently complied with the instructions to do two scheduled exercise sessions per day. 2. W.S. averaged fewer than one "as needed" exercise session per day. .146 .Aoofluoanoommc Endowmncam can mcflmmpfluoflcpv when coflmeHpoS opwsoacoommn Edmmumucam x ocflumcflu0H£c o mommzm pco when #coEccmHB m U+m m N om mN 0N wN N 0N ma mfl ea NH OH m m ".m.s nomflnsm mcflfiommm a N OON % om 1 E T.— W T... TI— I rm. ooa 1 E m S .d e I oma G P. rA .wN muzmflm 147 .chfiupmcocmuo can .mcflxoupmc ESfiHHgHm. UQM EUHmQfiUME ~C®£QO§HEM¥®OMV Muhmm COH¥MOHU®E "om-3 #UOWQSW Asee sea manages as occupflo ocflupmcmnmuo x Amen “mm mpoabmp no moo #V ocflxostwc EScHEDHm can Esflmmcmme < ANMU Hum may cosmocHEMpmom o mommnm can mmmo pcchmoHB mm o+m Hm oceaommm N om mN mN vNN ON ma ma 3” NH.o.m m m v N OOH CON oom cow oom cow oow com Rea 18d smPIEIIIIW 1210; .mm ousmflm 148‘ Table ll.--Subject W.S.: Exercise Data--Schedu1ed Sessions. Bl B+C B2 Number of days in treatment phase 4 13 10 Number of scheduled exercise sessions 8 25 17 Average minutes per sched- uled exercise session 7.25 9.92 5.88 SE 5.25 31.00 23.76 Sit-ups 5 (SU) SU 4.13 18.60 5.14 range 3-15 3—65 15-34 PU 12.88 24.40 21.23 Push-ups s (PU) PU 3.94 8.87 3.38 range 10—22 15-50 15-28 if 2.13 12.28 5.47 Leg-lifts 5 (LL) LL 1.73 6.47 1.74 range 1-6 1-28 2-8 Subjective V 4.00 4.80 2.94 vigor 8 rating V l-77 1.22 1.29 (V) range 2-7 3-7 2-6 Subjective F 38.75 85.20 21.68 pain 5 rating P 19:04 5.86 10.47 (P) range 10-60 75-95 10-50 Table 12.--Subject W.S.: Exercise Data——"As Needed"Sessions. B+C B 2 Number of days in treatment phase 13 10 Number of "as needed" exer- cise sessions 10 5 Average minutes per "as needed" exercise session 9.50 7.6 SU 18.20 24.40 Sit—ups 8 (SU) SU 15.95 4.83 range 0-41 20-32 PU 26.60 24.00 Push—ups s (PU) PU 9.85 6.12 range 10-45 18-31 PP 10.40 6.20 Leg—lifts 8 (LL) LL 8.82 1.10 range 0-28 5-8 Subjective V 6.67 5.80 vigor 3 rating V 0.50 0.45 (V) range 6-7 5-6 Subjective P 84.22 32.00 pain 5 rating P 12.81 4.47 (P) range 60-98 25-35 150 3. She averaged more time per exercise session (sched- uled or "as needed") during the B+C Phase than dur- ing either other phase. 4. W.S. averaged more of each type of exercise during the B+C Phase than during the B and B phases; 1 2 except she averaged more sit-ups during "as needed" B2 sessions than during "as needed“ B+C sessions. 5. Her average subjective vigor rating was highest dur- ing B+C sessions (scheduled or "as needed"). 6. Her average subjective pain rating was highest dur— ing B+C sessions (scheduled or "as needed"). Thus, she seemed to be complying with instructions to exercise with pain during the B+C Phase. 7. On the average, W.S. performed more scheduled exer- cises, with less subjective vigor and pain, and in less time during the B Phase than during the B 2 Phase. The exercise instructions during these 1 phases were identical (stop exercising just as soon as it becomes uncomfortable). This finding may be the result of increased physical endurance. Observational analysis. Figure 26 presents frequency of self-cutting incidents and frequency of urges to out both plotted across time (treatment days). Observational compar- isons of overlap and trend are made for all adjacent phases considering first self-cutting incidents and then urges to cut. wafiJ-r' as .q 94- ' 151 .p50 0p wmeD can mchpSOImacm mo wococvoum ”.m.3 comnnnm “:0 Op moms: o mpcmpfiocfl mCHUpSo x mm mommcm cum mwmo ccoEpmoHB U+m N om wN mN «N NN ON ma ma ea NH. OH. m w v .em enemas m mcflaommm N Aouenbexg 152 Self—cutting. The frequency of self-cutting incidents during the Baseline Phase overlaps with the frequency of cutting during the B Phase. There was no reported self— 1 curring during either phase. Additionally, there is no trend or lepe in either phase. These observations suggest no reliable difference in treatment effects between the Baseline and B Phases for Subject W.S. l The frequency of self-cutting incidents during the B1 Phase overlaps with the frequency of cutting during the B+C Phase. The slope or trend in these two phases may be dif— ferent. The slope during the B+C Phase may be slightly posi— tive. Thus, there may be a difference in treatment effects between the B1 and B+C Phases with regard to self—cutting incidents. However, any difference between phases could not be considered reliable and may be a factor of chance. The frequencies of cutting incidents between the B+C and B2 Phases also overlap. The lepes may be different in these two phases. As stated above, the slope during the B+C Phase may be slightly positive; there is zero slope during the B2 Phase. However, any difference between phases could not be considered reliable and may be a factor of chance. In summary, these visual analyses suggest there was no reliable difference in treatment effects between any two adjacent treatment phases for Subject W.S. with regard to frequency of self-cutting. 153 Urges to cut. The frequency of urges to cut during the Baseline Phase overlaps with the frequency of urges to cut during the B Phase. The lepes during these phases seem 1 different. The slope during the Baseline Phase seems very high or positive; the slope during the B1 Phase seems slightly negative. Thus there may be a difference in treat— ment effects between the Baseline and B1 Phases. However, any difference between phases could not be considered reli— able and may be a factor of chance. The frequency of urges to cut during the B1 and B+C Phases overlap. The slopes in these two phases also seem similar, slightly negative. Thus, there does not appear to be a reliable difference in treatment effects between the B1 and B+C Phases for Subject W.S. with respect to frequency of urges to cut. The frequencies of urges to cut during the B+C and B2 Phases overlap. The lepes in these two phases seem dif— ferent. The SIOpe during the B+C Phase seems slightly nega— tive while the lepe during the B Phase seems slightly 2 positive. Thus, there may be a difference in treatment effects between the B+C and B2 Phases with regard to urges to out. However, any difference between phases could not be considered reliable and may be a factor of chance. Summary. In summary, observational analyses suggest no reliable differences in treatment effects between phases for either frequency of self-cutting or frequency of urges to cut for Subject W.S. 154 Subject F.B. F.B. was a 28 year old, divorced Caucasian woman. She had been married briefly when she was 23 years old. F.B. had a master's degree and at the time of her participation in the study she was employed as a case-worker. History of self-cutting. F.B. first cut herself about 9 years ago as a college sophomore. She cut herself about four times over the period of a year and did not cut herself again until February 1981. She cut herself on six separate occasions during February and March 1981 (see Figure 27 and Table 13). F.B. described the time period just before she cuts her— self as either a struggle and then calm or a period of very intense tension where the only release is to act, to cut herself. After she cuts herself she generally feels relieved and more able to cope. When asked why she might have decided to cut herself the first time F.B. said, Mostly because of, I wanted and needed to see the blood, I didn't believe I was alive. So I needed to see some— thing that there, there was proof of that, also that the visual proof, and also the feeling, the pain that went with it, to know that there was something there and I could connect the two togetheranuihave it make sense. Interestingly F.B. knew one other person who cut her— self, a high schoolgirlfriend. She knew about the girl- friend's cutting during high school but "couldn't do anything about it." F.B. cut herselftfluafirst time after receiving 155 v l I > t o Ventral Dorsal Figure 27. Subject F.B.: Self—cutting Incidents, Left Upper Extremity. 156 la l3.--Subject F.B.: Self-cutting Incidents, Legend to Figure 27. . ~. Implement Medical ,1dent Date Used Treatment 1 Early February, Swiss army None 1981 knife 2 Late February, Swiss army None 1981 knife 3 March 5, 1981 Piece of None glass 4 March 8, 1981 Piece of None glass 5 March 13, 1981 Barrette Lacerations painted with povidone— iodine 6 March 26, 1981 Barrette None a letter from this same friend in which the friend described several serious problems but told F.B. not to call or write. F.B. said she felt helpless and that sense of helplessness had compounded other concerns. "There was a lot of, I was starting to feel confused about what I was doing, not having any real sense of structure or support and that was some, I think that was affecting what went on at that time, too." F.B. used a razor the first time she cut herself. After cutting the first time she told an upperclass student who had previously expressed concern and support for her. "I wanted somebody else to do something about it, because I couldn't. I didn't know what to do." Now she tends not to tell anyone she has cut herself although she may call and 157 .sk a friend to "talk to me and just distract my attention from the intensity of what was going on." When F.B. has an urge to cut herself she finds dis- tractions such as "very general non-threatening conversation" helpful in preventing her from cutting herself; hot baths also have been helpful because they help her calm down. Situations where she has to make a "really critical decision" about herself (e.g., to admit herselftx>the hospital or not) are apt to increase the likelihood of F.B. cutting herself. When asked what her life would be like if she stopped cutting herself F.B. responded: I would be dead. I mean, I think that's really how I resolve that conflict at this point. It's some kind of——it appeases the part that wants to be self— destructive at the same time it's not so self— destructive that I commit suicide. And if I didn't have that, I don't know what I would do. Family history. F.B. was the only child born to her parents, each of whom had been married previously. F.B. was raised with her half—sister. The half-sister, 6 years older than the subject, was the child of the mother's pre~ vious marriage. F.B. reported no particular ethnic or religious influences while she was growing up. However, the maternal grandmother lived withtflmafamily and did much of the care-taking for the two girls. When F.B. was a child her mother worked as a registered nurse, frequently working the night shift. According to F.B.‘s perceptions her mother was probably "an active sub— stance abuser" (amphetamines, depressants, and alcohol). 158 a subject felt her mother was not reliable, "I couldn't unt on her being there." At the same time F.B. said "she kes it real difficult to be independent from her . . . she :ts up, I think, and I know I'm part of that, a lot of Lther/or situations . . . where it seems like I have to hoose between her and a friend of mine." F.B. also .escribed her mother as using a lot of denial. For example, :he mother repeatedly said the father was "perfect, there's nothing wrong with him” until after the divorce when she acknowledged some of the problems. F.B.‘s father was an engineer with an aeronautics firm. She said he “would have preferred that I had not been born." F.B. said he was scary to her and that she and her sister "weren't allowed near him." Her father left the family when F.B. was 15 years old; she did not seem him again until she was about 20 years old. At that time he made several con- tacts with her and seemed to want to establish a relation- ship. However, F.B. experienced her father's behavior as frequently unusual and she was uncomfortable with him. The subject‘s father died about 3 years ago at the age of 60. She believes he died of diabetic complications. She also described him before his death as "very, very paranoid." According to F.B., he said repeatedly "no one's gonna steal my ideas, I'm not going to give them my ideas." F.B. also understood that her father's diabetes was diet controlled. However, he apparently was angry with his doctors and 159 1imed "that they had prescribed the wrong medication for n and it was their fault he was in this situation." The subject characterized her parent's relationship as pnflictual; there were numerous verbal fights and a number 3 physically violent incidents (e.g., father threw mother gainst a wall and then hit her in the face). The subject aid she has very few recollections of childhood experiences. That she does recall she describes as usually "very terrify- ing." One of her memories was as a young child, 2 to 5 years old, being put under a cold shower by her father when she cried. F.B.‘s sister is now 34 years old; she has been married for about 12 years and has 2 children. Her sister apparently was somewhat responsible for F.B. as a young child (e.g., being told to take F.B. and go away and play when the par— ents had an argument). Also, when F.B. was an infant the sister had to sleep with the grandmother so that F.B. could have a bed. The sister's seeming role of "the responsible one continued when their father left. At that point the mother and sister developed a closer relationship but with the sister in the role of care-taker. F.B.‘s relationship with her maternal grandmother was warm and supportive; "she was a lot more emotionally avail- able most of the time." The grandmother took care of F.B. and her sister particularly when their mother worked. She was also the refuge when their parents argued. F.B. said 160 she misses her grandmother; she died a month or 2 after F.B.‘s father. As F.B. described her family and their various relation— ships there was a sense of a family secret and much denial to protect that secret. According to F.B., . . . what happened was there was a conspiracy, there had to be in order to keep the secret, and the prob- lem with it was that the price of the conspiracy was that someone would have to die. There was a lot that went into keeping that secret and what I figured out was that if I told, if I said "wait a minute, you know what I see here doesn't fit with what you're saying," then somebody would die, either my mother would die or my grandmother or my sister, or I would die, because I would either lose their protection, they wouldn't be able to protect me from my father, or else if I didn't say anything, then, you know, I'm left having to deal with all this, trying to fit reality in, and what everybody else is telling me is reality, and to make some kind of sense out of it. Social history. The subject reported that she did very well in school. In fifth grade she was selected to partic- ipate in a special class for gifted students. She and 28—30 other students remained together in that program for 3 years; she described the group of students as becoming quite close, "they were sort of, in lots of way, my family." Through eighth grade F.B. had a number of satisfactory peer relation- ships and she felt she was well-liked at school. When F.B. was 15 years old she experienced several losses; her father left the family and F.B. went to a dif- ferent high school than her close friends from elementary school. She described that period as very difficult and felt it was a long time before she developed a new group 161 of friends. In fact, from high school on F.B.'s relation- ships seem to have been primarily a series of one-to-one relationships. She dated very little during high school. F.B.'s college experience was marked by a series of roommates and academic majors. Where grade school and high school had been stable, structured environments in which she had done well, college was different. Eventually she met an upperclass student, who like a high school student teacher, said to her "You're capable of something, you can do something." After graduating from college F.B. drifted. First she started taking typing classes so that maybe she could be a secretary, then she traveled by herself for several months, and she finally settled in Michigan. In the 6 years F.B. has lived in the mid-Michigan area she has held several jobs and completed her master's degree. Shedecided to pursue a master's degree in social work because others told her she worked well with people. F.B. met the Jmfll she married at her first job in Michigan. They were married briefly (3 months). F.B. sug— gestedgetting a divorce when her husband began staying away from home soon after their marriage. Since her divorce F.B. has been involved in a number of relationships some of which she described as emotionally destructive to her. F.B. lives alone now. She has several close friends including a woman friend she has known since college. 162 Medical history. The subject‘s medical history was not notable except that about 2 years ago she was diagnosed as having pelvic inflamitory disease (P.I.D.). She was told that because of the P.I.D. within several years she would probably be sterile. Knowledge of this condition has prompted F.B. to re-evaluate her goals. She had considered having children an "open option." When having children sud- dently became "not such as open option," F.B. realized it was more important to her than she had thought. Psychological history. F.B. was in therapy for 2—2 1/2 years during the time she was completing her master's degree. She sought help because she felt anxious. She was hospital— ized then briefly for anxiety and "mental upset." F.B. left that therapy relationship not trusting the therapist. She has been in therapy in the Lansing area for about 6 months. One week after she became involved in this study she admitted herself to a local psychiatric inpatient unit. (The issue of her being hospitalized had been raised before she started in the study. Hospitalization had been sug— gested by her psychiatrist because of increased self—injury ideation.) F.B. has been diagnosed by psychiatrists as having a borderline personality disorder and/or a dis— sociative neurosis. Current therapy, including hypno— therapy, has revealed "several different ego states that usually interact on a coexistent level. The most active ego state recently (February and March 1981) has been a 163 hostile, destructive ego state which has been 'punishing' the others through wrist cutting." Psychological assessment. F.B.'s MMPI profile (Figure 28) can be considered valid. The results suggest she may have a defensive structure that enables her to function despite severe problems. In general her profile suggests that she is anxious, depressed, and that she may be having trouble thinking or concentrating. People with such pro- files tend to have numerous somatic complaints, keep others at a distance because they are afraid of emotional involve- ment, and to be afraid of a loss of control (Duckworth & Duckworth, 1976). To others F.B. may appear moody, unpredictable, friendly, gregarious, Inuzalso shy, anxious, amd fidgety. Others may also experience her as seductive or manipulative and sometimes helpless appearing. She tends to be concerned about what others think of her. At the same time F.B. seems to feel alienated from others. Her relationships tend to be poor, shallow and aimed at satisfying her own needs. Her feelings of depression seem to be characterized by a sense of gloom and pessimism. Eflmadoes not believe there is much for her to feel good about particularly with regard to herself. She tends to be self-deprecating and she may have significant concerns about herself and who she is. She seems angry in a sullen, brooding way. Strong, unmet dependency needs may be conflictual for her. Also, she '164 120 110 100 90 80 7O _ \ 60 —«~ « 50 Z/ “5 ho l-- 30 2O 10 Fi ' _gure 28. Subject F.B.: MMPI Profile 165 expressed concern about social problems, typical of people in the helping professions. However, she may also feel resentment for rules and regulations. Elevations on scales 2, 4, and 9 are consistent with tendencies to act out anger in self—destructive ways. In addition, the extreme elevation on scale 3 would support the presence of dissociative experiences. Finally, F.B.'s defenses seem to be somatization, denial, acting out, ration— alization, and intellectualization. F.B.'s score on the Taylor Manifest Anxiety Scale of the MMPI is in the highly anxious range (F.B. scored 30; scores of 20 or more are considered high anxiety) (Dahlstrom & Welsh, 1960). Extremely high scores, such as F.B.'s, often reflect characteristics that interfere with learning and may also indicate depressive or other psychopathological processes which distract individuals from concentrating (Dahlstrom & Welsh, 1960). These observations seem con— sistent with F.B.'s overall MMPI profile. On the first MAACL—In General and Modified Today forms administered to F.B. she described herself as anxious and depressed. Just prior to cutting herself she tends to feel more depressed and hostile than usual (Figure 29). Through- out most of her participation in this study F.B.'s anxiety scores remained relatively constant. Her anxiety score was lowest on the last administration. F.B.'s depression scores fluctuated considerably, increasing to a high point during the middle of the B treatment phase. Her hostility scores 2 166 J .mosoom sex does: ".m.m poomnsm .mm ensues suesenmoe oo seesenmoe o scammonoo << coflmmoumop < Npmflxcm xx Npmflxcm x xeeos ememeeoz sodas flamenco 2H noses mommnm can whoa pcprmoue mm o+m Hm enaomem m cm em mm omfl we, we. ea (NH. OH. m OH. ON sexoDS MPH Om ow 167 followed a similar pattern. Both her depression and hostil- ity scores were dropped off again on the last administration of the MAACL-In General although not to their originallevels. In summary, Subject F.B. seems to have much in common with wrist cutters described in the literature. She is an attractive, intelligent, and unmarried young woman. Her mother was not outwardly affectionate towards her and her father was withdrawn and hypercritical. F.B. frequently feels depressed and describes her dissociative experiences as a way to deal with uncomfortable (painful) experiences. Her home life as a young girl was characterized by parental arguing, fear of her father, lack of communication with her parents, and episodes of physical violence. Such a setting fosters insecurity and self—deprication as seen in F.B. Her choice of self—cutting may be both a learned tension relieving behavior and a way to control her child- hood fear that someone (she) will die (be killed) if the family secret becomes know. Participation in this study. When F.B. was first referred for possible inclusion in this study she was an outpatient. At that time she was also considering hospital— ization. Her psychiatrist had recommended hospitalization because of her increased self-injury ideation. Baseline and B1 treatment phases were concluded while she was an outpatient. The B+C Phase was initiated and later that night F.B. decided to admit herself to the hOSpital. She completed 168 the B+C and B Phases as an inpatient. While in the hospital 2 she was given several medications: flurazepam hypochloride, thioridazine, and acetaminophen. Total daily dosages of these medications are charted in Figures 30 and 31. These medications are described iJIAppendix(3. Thioridazine was prescribed for treatment of the patient's depression and anxiety. Her total daily dosage (see Figure 30) was within the 20—200 mg/day range suggested (see Appendix C) for treat— ment of these symptoms in an adult by this drug. Several modifications of the treatment procedures (as outlined in Chapter III) were made for F.B. First, F.B. and a number of trainers who worked with her doing exercise plus pain observed that F.B. seemed to dissociate during these exercise periods. F.B. said she dissociated as a way to avoid feeling any discomfort or pain. She also seemed to be using the imagery as a way to avoid feeling, that is she would stay focused on the imagery while exercising and not feel any discomfort. Consequently her exercise plus pain, and subsequently exercise until pain, instructions were changed. F.B. and the trainers working with her were told that she was not to do the imagery during the scheduled exercise sessions. In addition F.B. was to focus on what she felt in her body as she exercised, in particular she was to focus on feeling pain during the exercise with pain sessions. These instruc— tion changes were instituted on treatment day #11. '169 .AopHHoHcoommc Emmommucflm .ocflmopflsoflcpv memo coflumoflomz mpflHoHnoommn Emmoumnsaw x mcflNmUHuOflcw o mommcm can memo ccofipcose Nm U+m Hm vN NN ON O OH. ea NH OH. O w v one ON ON .memm N ON ".mom #UTWQSW Keg :ed'smexbrIItw Iego; .Om THUDflm V170 .HconmosHEMHOUOO memo COHcmoHOoz ".m.m pommbum coamocHficpmom o mommcm pcm mhmo pcofipwoua N H m + m one ommm om ON ON 0 m .H ON NN ON O OH OH NH. OH. O O O N OOH OON OOO OOO com OOO OOb Keg 18d smexbrttrw Iago; .HO unseen 171 During the first 3 days of the B+C Phase, which were her first 3 days hospitalized, F.B. did many, many sit-ups (168, 132, and 156). As a result she developed an open blister on her coccyx. This sore was painfultx>her when she did sit- ups. Also, staff members serving as trainers were spending long periods of time working with her in scheduled exercise sessions (1 1/2 hours, 45 minutes, 45 minutes). Neither con- tinued irritation of an open wound nor disproportionate use of staff time could be justified. Thus, beginning the eleventh treatment day F.B. was also told to discontinue doing sit-ups. Data regarding F.B.'s exercising are presented in Tables 14 and 15. These tables show information about sched- uled and "as needed" exercise sessions across the three treatment phases. The information was obtained from the subject's notebook and hospital staff records (Self—injurious Behaviors Observation Form). The following statements are based on the information in Tables 14 and 15: 1. F.B. averaged about two scheduled exercise sessions during the B+C and B2 Phases. Thus, she apparently complied with the instructions to do two scheduled exercise sessions per day during those phases. 2. F.B. averaged about two "as needed" exercise sessions per day during the B1 and B2 Phases; she averaged three "as needed" exercise sessions per day during the B+C Phase. 172 Table l4.-—Subject F.B.: Exercise Data——Schedu1ed Sessions. Number of days in treatment phase 4 Number of scheduled exercise sessions 6 Average minutes per scheduled exercise session 13.17 SP 18.17 Sit-ups 5 (SU) SU 5.31 range 10-25 PE 7.17 Push-ups s (PU) PU 2.48 range 4-10 11‘ 4.67 Leg-lifts 5 (LL) LL 1.51 range 3—10 Subjective V 2.17 “9‘.” 8v 0.75 rating (V) range 1—3 Subjective P 7.33 pa“? SP 6.50 rating (P) range 2-20 B+C 10 19 22.85 *64.50 *76.58 *4—168 39.56 19.31 4—63 12.44 15.17 3-70 2.74 0.87 1-4 30.11 19.90 3—60 *Sit—ups stopped after treatment day #11. B2 10 33.00 7.56 22-53 8.84 3.80 1—16 3.03 1.11 1-6 8.74 10.46 2—50 173 Table 15.-—Subject F.B.: Exercise Data--"As Needed" Sessions. B1 B+C B2 Number of days in treatment phase 4 10 10 Number of "as needed" exercise sessions 9 30 21 Average minutes per "as needed" exercise session 10.11 12.17 8.67 80 19.33 *29.71 * - Sit'uPS 5 13.14 *48.27 * — (SU) SU range 10-25 *0—132 * - FE 11.56 21.77 20.71 Puig‘Hps SPU 7.47 10.56 8.43 U range 5-25 4-46 8—43 if 3.11 5.73 3.71 Le3’ljfts SLL 1.36 5.88 3.69 LL range 0-4 1-33 0—10 Subjective V 2.89 2.88 3.79 vigor SV 0.78 1.01 1.47 rating (V) range 2—4 1—4 1—6 Subjective P 6.56 24.46 7.67 Pain Sp 6.44 16.59 3.37 ratin (P)g range 1-20 1-60 , 3—15 *Sit—ups stopped after treatment day #11. 174 3. F.B. averaged more of each type of exercise during the B+C Phases and spent on the average more time per scheduled exercise session during the B+C Phase than for the B1 and B2 Phases. 4. Her subjective vigor rating increased across time. 5. Her subjective pain rating was highest during the B+C Phase. Thus, she seemed to be complying with instructions to exercise with pain as long as she could during the B+C Phase. 6. F.B. did more exercises, more vigorously, and at a higher subjective pain level during the B2 Phase than during the B1 Phase. She also took, on the average, less time per scheduled exercise session in the B Phase. The exercise instructions during 2 these phases were identical with regard to pain (stop exercising just as soon as it becomes uncom— fortable). The higher average number of exercises performed and the higher average vigor rating may be the result of increased physical endurance. The higher average subjective pain rating may similarily be an increase in pain tolerance. 7. F.B. spent more time exercising during scheduled sessions than during "as needed" sessions. Observational analysis. Figure 32 presents frequency of self-cutting incidents and frequency of urges to out both plotted across time (treatment days). Comparisons of overlap >1 0 $21 o s U o y .14 2 Baseline Figure 32. 46810 B1 Subject F.B.: Urges to Cut. '175 12 14 16 18 20 22 24 26 28 B+C B2 Treatment Days and Phases x cutting incidents o urges to cut Frequency of Self—cutting and 176 and trend are made for all adjacent phases considering first self—cutting incidents and then urges to cut. Self—cutting. The frequency of self-cutting incidents during the Baseline Phase overlaps with the frequency of cut— ting during the B Phase. The trends in both of these 1 phases might also be considered similar, no trend. Similar statements can be made regarding frequency of self—cutting between all subsequent adjacent phases. These observations suggest there was no reliable difference in treatment effects between any two adjacent treatment phases for Subject F.B. Urges to cut. The frequency of urges to cut during the Baseline Phase overlaps with the frequency of urges to cut during the B Phase. The slopes in these two phases are dif— l ferent. There is no slope or zero trend in frequency of urges during the Baseline Phase. The slope during the B1 Phase is clearly decreasing. Thus, there may be a difference in treatment effects between the Baseline and B1 Phases with regard to urges to cut. However, any difference between phases could not be considered reliable and may be a factor of chance. The frequencies of urges to cut during the B1 and B+C Phases overlap. The slopes in these two phases are also different. There is a negative or decreasing slope during the B1 Phase. The slope in the B+C Phase is not as apparent. The line of best fit would seemingly be one with zero or a slightly positive slope. Thus, there may be a difference in treatment effects between the B1 and B+C phases with regard L'. _1".J_' 177 to urges to cut. However, any difference could not be con- sidered reliable. The frequencies of urges to cut during the B+C and B2 Phases overlap. The slopes in these phases are not clear. As stated above, the slope in the B+C Phase may be zero or slightly positive. The slope of the line of best fit in the B2 Phase would seem to be positive. Thus there do not seem to be any reliable differences in treatment effects between the B+C and B Phases for Subject F.B. 2 Summary. In summary, observational analyses suggest no reliable difference in treatment effects between phases for either frequency of self—cutting or frequency of urges to cut for Subject F.B. Subject D.N. D.N. was a 28 year old, divorced Caucasian woman. She was 21 years old when she married. D.N. said she had a "really decent husband" but that she was having so many prob— lems of her own (self-cutting and anorexia nervosa) that she "couldn't handle a relationship with him. I guess I felt guilty for all the things I was doing and I felt like he really deserved someone better, and so I asked for a divorce." She also felt the relationship was "too good and I better get out before something happens" (abandonment fear?). She was divorced at age 24. At the time of her participation in this study D.N. was enrolled as a sophomore at a community college. She had 178 switched majors several times and was currently majoring in human services. D.N. said she thought she might like to work in a home for mentally retarded or emotionally disturbed peo— ple, or perhaps a half—way house. D.N. was also doing volun— teer secretarial work part—time. History of cutting. D.N. first cut herself when she was 13 years old. Her father wanted her to play the piano for a church song service. D.N. told him she could not do it because she got very nervous playing in front of people. He got really, really mad at me, saying well, here we put all this money into you taking piano lessons. Now I ask you to do one thing for the church and you won't do it. You know, he really laid it on me and I remem— ber I just ran upstairs and I cut myself like one or two times and then I went out for a long walk, but it [cutting] seemed like it relieved so much feelings and stuff or emotions, that after that it seemed like I keep going back to it. When asked how many different times she had cut herself D.N. said, "I don't even know, at least a hundred times.“ Before D.N. began participating in this study she had cut herself on two different occasions within the previous 2 week period (see Figure 33 and Table 16). D.N. described cutting as something she felt she deserved. "Sometimes I would feel like I hurt other people or I did something to hurt someone else and then I felt like then I deserved to be hurt. And, but then sometimes it seems like it could have been just that I was angry at someone else, and rather than saying I was angry at them, just say you know, I was hurt by them, and then just feel like I had 179 Ventral Dorsal Figure 33. Subject D.N.: Self-cutting Incidents. 180 1 Table l6.-—Subject D.N.: Self—cutting Incidents, Legend for Figure 33. . Implement Medical Inc1dent Date Used Treatment 1 March 13, Razor None 1981 2 March 15, Razor None 1981 to hurt myself Or something."- When she cuts herself DiN. usually does not feel it. After she has cut herself she feels "almost physically relieved, not as much tension" although she also feels "really disgusted" with herself. When asked why she might have decided to cut herself the first time D.N. said she did not know why, she had "never thought of doing something like that, and she had never heard of anyone else doing it. Asked if she cut herself because she wanted to or because she needed to D.N. responded I think it's just feeling the need to do it. Just like, I dissociate so much when I do it, you know, like it's, that's all I can think of, I have to do it and you know it's just like it's really essential that I cut myself. In general D.N. has not told people after she cut her- self. However, on several occasions she cut herself while hospitalized and needed bandages so she told a staff member. At these times D.N. said she did not want other people to know, "I use to dread going to tell them I did it. I thought people were going to be really angry at me for doing it." 181 D.N. said she wanted to stop cutting herself. She thought her life would probably be better if she stopped cut- ting because "I think I'd feel somewhat better about myself and also, I think that if I was getting it out in different ways, you know, what I was feeling, like doing it different ways, I think that alone would make me feel better about myself. Because when I'm not cutting, I feel more normal or something, more like other people." Family history. D.N. was the youngest of two children born to her parents. She has a sister 3 years older than herself. D.N. reported no particular ethnic influences while she was growing up. She did experience a strong religious orientation. Her family went to a Protestant reform church. D.N. described the church as "pretty strict." She said she was "forced to go" to church once a week and she resented that pressure. She no longer attends church regularly, "just once in a while." D.N.‘s father, 51 years old, was a car sales manager. She described him as "not giving but he doesn't really know how to give. He's real businesslike." D.N. said she and her dad have a hard time communicating but they are doing better. Her mom, also 51 years old, has not worked outside the home since D.N. was born. She said her mom "use to be real hard, but now she's mellowed out a lot, and she's really giving." D.N. described her relationship with her mother as "real close." As a very young child D.N. said she was a "momma's 182 baby, I guess I just cried if anyone else picked me up." Apparently,1un:mom did not like D.N.‘s strong attachment, "she couldn't stand it, it drove her nuts.“ In telling about her family in general D.N. said she was still very dependent on them for reactions to what she does, too dependent on them. While she was growing up D.N. said her parents fought a lot, "all the time." Then D.N. dropped out of college after 1 year, moved out of the house and got a job. At about the same time her parents separated, saw a marriage counselor, and got back together. D.N.‘s response was "here I left and they got back together, maybe I should have left earlier." She traced the change in her mother totflmapoint where the parent's relationship improved. At that point her mother "just kind of mellowed out more towards everybody.“ D.N. described her sister as very giving, sensitive, and affectionate. She said she and her sister have always been very close. "It's kind of like we paired up together just to survive and have someone understand." D.N. recalled that she felt very lonely when her sister went away to college. Her sister married soon after graduating from college but is now getting a divorce. Social history. D.N. described herself as quiet, trying to please everybody, and a good student through fourth grade. From fifth through ninth grades she said she was "mouthy" (talked a lot in class) and uninhibited. She understood that Change as being related to having a man teacher who kidded 183 around with her and a girlfriend, "we were kind of like his favorites. I guess the security of being with someone else and having him always joke around with us kind of brought that out." Generally D.N. had a small group of friends and one really close friend. In eighth grade she started dating a boy and they went together for the next 5 1/2 years. In about ninth grade D.N. started using drugs (marijuana, THC, mescaline, and hash). She was aware of becoming more with— drawn again about that time. By this point she had also started binging and vomiting (see Psychological history for details) and cutting herself. After high school graduation D.N. went away to college for a year. She did not like college so she moved back home. She did not like living at home after having been away at school, so she found a job and an apartment of her own. Medical history. D.N. used drugs frequently during high school. At the time of her participation in this study she said she only smoked pot once in a while. She also acknowledged taking diet pills or "stuff to keep awake or get a buzz on, but nothing real important." D.N. also has about one alcoholic drink per day but she did not feel she abused alcohol. D.N. has had her appendix and gall bladder removed. She had the gall bladder operation when she was 24 years old. 184 Both her mother and maternal grandmother had their gall bladders removed when they were young women. Psychological history. When D.N. was in eighth grade she started a pattern of vomiting after eating. She tried to be secretive but her parents caught on to what she was doing. She has continued this pattern as well as binging and vomiting since eighth grade. Although D.N. has seen a num— ber of mental health professionals her vomiting and related weight loss problem was not diagnosed as anorexia nervosa until about a year ago. When she was in tenth grade D.N. was seen as an out- patient at a psychiatric hospital for about a year. (The hospital was also knOWn for its religious orientation.) D.N. did not think therapy was helpful, in fact she felt her therapist thought she was guilty for having a sexual relation- ship with her boyfriend. D.N. did not see another therapist until she was 22 years old. At that time her father confronted her although indi— rectly, "he would say it's obvious you have a problem, people normally don't do what you do." Her father finally set up an appointment for her with a woman psychiatrist. D.N. saw that therapist for 4 or 5 months but felt resentful about having to go. The therapist told D.N. to start doing things She wanted to do. According to D.N., "I think I took what she said to too much of an extreme, it was almost like it kind of shocked my husband, it just didn't work out. 185 It wasn't very helpful, in fact it almost ruined our. marriage.“ About a year later D.N.‘s father set up an appointment for her with another therapist. She saw that woman once, walked out, and never returned. Two years later D.N.‘s family doctor referred her to a counselor. She saw that therapist on an outpatient basis but "iizwasnLtworking out and I ended up in the hospital for a while." She was hospitalized by her family doctor because she was cutting herself. He had also prescribed an anti- depressant for her. She tooktjxepills to the hospital and reportedly overdosed three different times. She did not remembaroverdosing. Later that year, 1979, D.N. was hospitalized two dif— ferent times because of her weight; she weighed 85 pounds and her potassium level was very low. Also in 1979 D.N. went to Mayo Clinic for another evaluation. According to D.N., the staff at Mayo Clinic recommended hospitalization for 1 to 5 years. D.N. became very upset when she returned home and overdosed again. She was hospitalized by her family doctor who then referred her to a Lansing psychiatrist for treat- ment. She transferred to a Lansing hospital for several months at which time anorexia nervosa was diagnosed. D.N. decided to stay in the Lansing area after she was discharged so she could continue working with the psychiatrist; she has now seen him on a regular basis for a year. 186 D.N. described binging and vomiting and sometimes starving herself in terms similar to those she used to describe her self-cutting. When she binge—vomits “it's kind of a release of a lot of tension and it's almost easier to do than cutting sometimes, almost more accessible." She dif- ferentiated the function of binge—vomiting from that of cut- ting: "the binge—vomiting is like a reaction of a lot more emotions and feelings than the cutting. I think the cutting is mostly from what I can figure out, I think it's mostly when I'm angry. Where the binge—vomiting is, I think, I could be angry or really tense or a bunchexercise for two (2) 15 minute periods each day, preferably scheduled several hours apart and at least one (1) hour after you have had a full meal. Wear comfortable, loose-fitting clothing. Also, exercise in a room where there is carpeting on the floor. Exercise instructions: Three exercises will be described for you. Do each exercise while it is being described. STOP exercising just AS SOON AS any one type of exercise becomes uncomfortable or painful. Each exercise will be described one time. Repeat the exercise until it becomes uncomfortable for you. Remember to STOP just AS SOON AS a particular exercise becomes uncomfortable or painful for you. Continue your work-out until you have done all three types of exercises. To begin this and all scheduled exercise sessions, you are to imagine how you feel when you get an urge to cut your— self. You might try closing your eyes. Really try to remem— ber what your thoughts and feelings are when you have an urge to out yourself. When you have a clear image of those thoughts and feelings about cutting yourself continue with this tape. (Pause on tape.) Sit—ups: Lie on your back on the floor with your hands behind your neck and your knees bent. Place your feet flat on the floor and under a heavy piece of furniture. Keeping your hands behind your neck, roll up to a sitting position. Touch your elbows to your knees and lie back down. Continue doing sit—ups but STOP just AS SOON AS they become uncomfort- able or painful for you. Count the number of sit~ups you do. Stop this tape while you do them. (Pause on tape.) Push-ups: Lie on the floor on your front. Place your hands on the floor at about shoulder level. Keeping your hands, knees, and feet on the floor, raise your upper body. Now, keeping your back straight, bend your elbows and lower your body ALMOST to the floor, but do NOT lie on the floor. Raise up by straightening your arms. Again, keep your back straight. Continue doing push-ups but STOP just AS SOON AS they become uncomfortable or painful for you. Count the number of push-ups you do. Stop this tape while you do them. (Pause on tape.) 266 You have now completed one scheduled exercise session. Remember, you are to exercise for two (2) 15 minute periods each day. In addition to those sessions, exercise "as needed." In other words, do the exercises, as instructed, WHENEVER you become aware of a thought, feeling, or urge to out yourself. Notes: After each exercise session, whether scheduled or "as needed,‘ please answer the questions in the small exercise notebook with which you have been provided. Take time now to familiarize yourself with the questions in the notebook, then answer the questions for the exercise session you have just completed. That concludes this tape. APPENDIX F CLINICAL INTERVIEW OUTLINE II. APPENDIX F CLINICAL INTERVIEW OUTLINE Identifying information A. Name B. Address C. Birthdate D. Sex E. Marital status F. Ethnicity G. Religious orientation H. Current employment I. Education (years completed) History of self—cutting behavior A. When did you last out yourself? 1. What were the circumstances (why, when, where, how)? 2. What was the result? a. How did you feel; what did you think; what did you do? b. How did others react? c. How did you want other people to respond to you (before you out yourself and afterwardsfl’ B. How many times (different occasions) have your out yourself? 267 -M‘G‘. ._ #-—' _____ —.~—___A---—q.—- 268 C. When did you first think about cutting yourself? 1. Do you have any ideas regarding why you picked (wrist) cutting? 2. Does anyone else in your family out themselves? 3. Do you know anyone else who cuts themself? D. When did you first out yourself? 1. What were the circumstances (why, when, where, how)? 2. What was the result? a. How did you feel; what did you think; what did you do? b. How did others react? c. How did you want other peOple to respond to you (before you out yourself and afterwards)? E. When was the next time you cut yourself? F. Do you fantasize hurting yourselfiraother ways? 1. What ways? 2. How frequentenuihow vivid are your fantasies? G. Do you hurt yourself in other ways? 1. What ways? 2. How frequently? 3. Do you alternate the ways you hurt yourself? 4. Do you know why you might choose one way to hurt yourself one time and a different way to hurt yourself another time? H. When you cut yourself, is that something you do because you want to do it or because you feel a need to do it or something else? I. Do you ever think about stopping (wrist) cutting? 1. Have you ever tried to stop cutting yourself before? "‘IIIIIIIIIIIIIIIlll---r—— III. 269 a. How? b. When? c. What were the results? What was the longest period you ever stopped yourself from cutting? What is helpful in preventing you from cutting yourself? a. Do other forms of pain (e.g., stomach aches, head aches, other physical illnesses) pre- vent you from cutting yourself? b. What tends to make you cut yourself more? 4. What would you/your life be like if you stopped? 5. Do you want to stop now? Do you have any advice or suggestions for someone who might be thinking about cutting themselves for the first time? Family and social history A. Family history of psychiatric disorders (history of hospitalizations, psychiatric treatment, suicides in extended family) Age, attitudes, personality characteristics of fam- ily members Relationships with family members Health or cause of death of parents, grandparents, siblings; give ages, dates, and patient‘s reactions Incidence of diseases known to be genetically influenced Quality and nature of relationships with non—family members Quality and nature of sexual relationships Developmental history 270 1. Prenatal and birth:. planned or unplanned preg- nancy; mother's age, health and attitudes during pregnancy; father's age, health and attitudes; labor and delivery data; parents' feelings regarding health and sex of child; ages, atti- tudes of other sibs; social and emotional cli— mate of home 2. Infancy (0-2): growth and development, mental, physical, motor; sleeping patterns; feeding and weaning; toilet training; walking; talking 3. Childhood (2-12): play, peer relations; mastery—achievement; relations with adults; school, separation from parents, attitudes toward school; relationship with teachers, peers; significant births and deaths; family relations and climate; parent surrogates; major family crises. 4. Adolescence (13—21): physical development; sex- ual development, relationships; interests, hob- bies; leaving high school; leaving home; efforts to achieve independence, work; relations with others; goals, values. 5. Early adulthood (22—35): end of formal school— ing; military service; employment; courtship; marriage; children; lifestyle—-setting, home; sexual adjustment; changes of health in family members. Current psychosocial functioning: how do you spend your time (describe a typical day including living circumstances, employment, school, relationships, recreational activities) J. Psychological history 1. History of mental health contacts (why, when, by whom, how long, type of treatment, helpful?) 2. History of psychiatric hospitalizations (why, when, how long, where, results) 3' Have you ever tried to kill yourself? If yes, obtain details regarding each attempt (why, when, how, reaction of self, reaction ofothers, etc.) K. Medical history 271 1. Determine if any of the following conditions are present: neurological disorders such as epi- lepsy or brain tumors; medical diseases such as endocrinological disorders 2. Obtain a history of alcohol and drug use includ- ing type and amount 3. Review patient's significant medical illnesses 4. Present general physical health (including cur- rent eating and sleeping patterns) 5. Medications (past and current) IV. Mental status examination A. Appearance and behavior 1. Appearance (size, dress, features, etc.) 2. Behaviors (general level of activity and move— ment, posture, gestures, interaction with interviewer) 3. Speech (coherence, rate, pressure, volume, dis- orders in pronunciation and articulation, dia— lects, slang, etc.) B. Affects 1. Quality of emotions (e.g., flatness, intensity, and duration) 2. Range of feelings expressed by the patient 3. Appropriateness of affect in relation to con— tent of thought and social context 4. Specify any prevailing affect C. Cognitive functions 1. Is the patient oriented to time, place, person 2. Memory a. Recent: check patient's accuracy in report- ing recent events b. Remote: check accuracy of historical infor- mation obtained from patient (e.g., where she/he was born, parents'-first names, etc.) 1‘TIIIIIIIIIIIIIIIIIll---:——_ 272 Attention and concentration (ask patient to say the months of the year backwards) 4. Intellectual functioning a. Problem solving: estimation of patient's ability to cope with environment and solve problems in daily living b. Awareness of current events c. Simple mental calculations: assess patient's ability to do practical calculations (e.g., calculate how much change she/he would receive for purchases totaling $4.31 if give the cashier $5.00;howlong would it take to reach a city 120 miles away if drive 60 miles per hour) D. Thought processes and c0ntent 1. Evaluate the tempo, relevance and coherence of associations between ideas Assess the patient's ability to think abstractly 3. Note looseness of associations; concreteness Presence of delusions, obsessions, phobias Presence of altered sensory perceptions (illusions, hallucinations, disorders of body image) E. Insight: is the patient aware of the nature and causes of her/his problems F. Judgment Is there anything I have not asked about that you think I should know? Sections II, III, and IV were adapted from the OPME Manual (Rosen, Schneider, Singleton, & Stein, 1977). APPENDIX G MMPI INSTRUCTIONS APPENDIX G MMPI INSTRUCTIONS Testing Instructions — Minnesota Multiphasic Personality Inventory After the break the following instructions are given to the patient: The next form you fill out will be the Minnesota Multiphasic Personality Inventory. Just as the word inventory implies, there are no right or wrong answers. This booklet contains 566 true and false questions. What you are to do is to mark the answers true as applied to you or false as applied to you. Answer the questions with your first impression. Answer according to how things are now-a—days, not how it was some time in the past or how you would like things to be. If you are unable to answer a question, or if the question does not seem to apply to you, you may leave it blank. Try to answer as many questions as you can. At this point, the test booklet, an.answer sheet and a pencil are given to the patient. The answer sheet is pre- marked with the patient's subject code number and the date of testing. The patient is requested to app put their name on the answer sheet. Then the instructions are read aloud. This inventory consists of numbered statements. Read each statement and decide whether it is true as applied pp ypp or false aa applied :9 yp_. _— You are to mark your answers on the answer sheet you have. Look at the example of the answer sheet shown at the right. If a statement is TRUE or MOSTLY TRUE, as applied to you, blacken between the lines in the column headed T. (See A at the right.) If a statement is FALSE or NOT USUALLY TRUE, as applied to you, blacken between the lines in the column headed 273 ; 274 F. (See B at the right.) If a statement does not apply to you or if it is something that you don't know about, make no mark on the answer sheet. Remember to give YOUR OWN opinion of yourself. Do not leave blank spaces if you can avoid it. In marking your answers on the answer sheet, pa sure that the number of the statement agrees with the number on the answer sheet. Make your marks heavy and black. Erase completely any answer you wish to change. Do not make any marks on this booklet. Remember, try to mark some answer to every statement. NOW OPEN THE BOOKLET AND GO AHEAD. After the patient has completed the MMPI all testing materials (test booklet, answer sheet, and pencil) are col— lected from the patient. L i ' '——‘r;:~‘“_-:;;-r——.—=.Wm___ . APPENDIX H MAACL INSTRUCTIONS APPENDIX H MAACL INSTRUCTIONS Testipg Instructions - Multiple Affect Adjective Check List In General Form For all patients who participate in this study we do some psychological testing to see what relationship, if any, there is between their cutting behavior and their personality. To do this, we use two forms of the Multiple Affect Adjective Check List and the Minnesota Multiphasic Personality Inventory. There are no right or wrong answers; just how you see things compared to others. The first form you will be given is the Mul— tiple Affect Adjective Check List — In General Form. At this point the MAACL — In General Form and a pencil are given to the patient. The form is pre—marked with the patient's subject code number and the date of testing. The patient is requested to p23 put their name on the form. Then the instructions are read aloud. DIRECTIONS: On this sheet you will find words which describe different kinds of moods and feelings. Mark an X in the boxes beside Unawords which describe how ypp generally feel. Some of the words may sound alike, but we want you to check all EDS words that describe your feelings. Work rapidly. (Zuckerman & Lubin, 1965.) When the patient has completed the MAACL — In General Form all testing materials (test form and pencil) are col— lected and the patient is given a 5 minute break. 275 276 Testing Instructions — Multiple Affect Adjective Check List Modified Today Form The MAACL - Modified Today Form and a pencil are given to the patient. Again, the form is pre—marked with the patient's subject code number and the date of testing. The patient is requested to not put their name on the form. Then the instructions are read aloud. DIRECTIONS: On this sheet you will find words which describe different kinds of moods and feelings. Mark an X in the boxes beside the words which describe how you feel just before you out yourself. Some of the words may sound alike, but we want you to check all the words that describe your feelings. Work rapidly. (Adapted from Zuckerman & Lubin, 1965.) When the patient has completed the MAACL — Modified Today Form all testing materials (test form and pencil) are collected. 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