; MSU RETURNING MATERIALS: Place in book drop to [JBRARJES remove this checkout from Jun—:— your record. FINES will be charged if book is returned after the date stamped be]ow. it??? -." 7‘ "17% 1% K144 WWj '1 A__ ‘ THE DEVELOPMENT AND EVALUATION OF A PSYCHOANALYTICALLY ORIENTED DAY TREATMENT PROGRAM BY Michael A. Teixeira A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1982 gram the r disoz This later fOr p demOg. theSe orient and me treatm analYt; MMPI Cc Visual. ABSTRACT THE DEVELOPMENT AND EVALUATION OF A PSYCHOANALYTICALLY ORIENTED DAY TREATMENT PROGRAM BY Michael A. Teixeira A psychoanalytically oriented day treatment pro- gram was evaluated over 18 months, based on census data, the MMPI and the Visual-Verbal Test measure of thought disorder, and a therapists' rating of client behavior. This program was compared with two other new and col- lateral day treatment programs; however, the only data for program comparison ultimately made available were demographic and census data on clients. Nevertheless, these data clearly showed that psychoanalytically oriented day treatment was more effective in motivating and maintaining chronic psychiatric clients in day treatment compared with the other two programs. Psychometric evaluation of clients in psycho- analytically oriented day treatment was based on the MMPI completed at pre-treatment, 6 and 12 months; the Visual-Verbal Test completed at 8 and 15 months; and Michael A. Teixeira the DTDB behavioral ratings completed at pre-treatment, 3, 6, 9, and 12 months. Continued planned assessments were not possible because of the abrupt disruption, and termination, of the program beginning at 15 months. The findings for the treatment sample of males and females in psychoanalytically oriented day treatment showed a significant improvement in thought disorder on the VVT direct measure of thought disorder apparent at 15 months. The DTDB ratings showed significant improve— ments in overall behavioral ratings at 3, 6, 9, but not 12 months. The MMPI findings were equivocal. At 6 months, the Lie and Hypochondriasis scales (males and females combined) showed the only near significant reductions. Males showed a significant increase on the Paranoia scale and the Psychotic Index, with a trend toward de- crease on the Lie scale. Females showed a significant decrease on the Manifest Anxiety and Psychasthenia scales, with a significant increase on the Ego Strength scale. The 12 month MMPI data suggest a regression; there were no significant findings. The absence of significant MMPI changes relative to the other outcome findings was considered in relation to psychotherapeutic process in these clients, disruptive environmental factors encountered in attempting to provide psychotherapeutic treatment to aftercare clients within the community Michael A. Teixeira mental health system and foster care homes, and lack of sensitivity of the MMPI to positive psychodynamic changes in psychotics. "It all began, I said, when I decided that some experts don't really know enough to make a pronouncement of doom on a human being. And I said I hoped they would be careful about what they said to others; they might be believed and that could be the beginning of the end." - Norman Cousins, Anatomy of an Illness ACKNOWLEDGEMENTS I would like to express my thanks to the members of the dissertation committee; Dr. A1 Aniskiewicz, Dr. Teresa Bernardez, Dr. Elaine Donelson, and Dr. Bertram Stoffelmayr, for their suggestions and support in the completion of this dissertation. And to the other Day Treatment staff therapists; Jane Bell, O.T.R., M.A., Marilyn Braman, S.W.T., and Keith Diedrich, M.A., and to Dr. Gail Harris, for their enthusiasm, skill, and collaboration in the development and operation of the experimental day treatment program. In particular, I would like to express gratitude to Dr. Bert Karon, dissertation chairman, for his steady guidance and patience through my training and supervision, and completion of the dissertation, and the impact he has had on my professional growth. And to the faculty and training supervisors in the Department of Psychology, Student Counseling Center and Olin Services, and the Psychological Clinic, at Michigan State University. Thanks to Mrs. Pat Bennett, typist, for her skillful presentation of the dissertation. ii TABLE OF CONTENTS Page LIST OF TABLES O O O O O O O O O O O O O O O 0 iv LIST OF APPENDICES O O O O O O O O O O O O O 0 Vi INTRODUCT ION O O O O O O O O O O 0 O O O O O O 1 THE PSYCHOTHERAPEUTIC TREATMENT OF SCHIZOPHRENIA C O O O O O O O O O O O O O O 5 Critical Issues; Equivocal Findings; and Ongoing Controversies . . . . . . . . 5 Controlled Research . . . . . . . . . . . . 5 Section Conclusions . . . . . . . . . . . 52 Broadening and Divergent Psychosocial Treatment Approaches . . . . . . . . . . . 53 Aftercare and Day Treatment/Partial Hospitalization . . . . . . . . . . . . 56 Group versus Individual Approaches . . . . 78 Section Conclusions. . . . . . . . . . . . 89 THE DEVELOPMENT AND EVALUATION OF A PSYCHO- ANALYTICALLY ORIENTED DAY TREATMENT PROGRAM 0 O O O O O O O O O O O O O O O O O 92 Day Treatment Program; Milieu; Day Center Facilities . . . . . . . . . . . . 92 Psychoanalytic Treatment of Psychotic Disorders; Theory and Practice . . . . . . 95 Therapists . . . . . . . . . . . . . . . . . 100 Clients 0 C O O O O O O O O O I O O O O O O 101 Psychotropic Medication . . . . . . . . . . 105 EVALUATION . . . . . . . . . . . . . . . . . . 107 Hypotheses . . . . . . . . . . . . . . . . . 108 METHODOLOGY . . . . . . . . . . . . . . . . . 110 Measures . . . . . . . . . . . . . . . . . . 114 Statistical Analysis . . . . . . . . . . . 119 RESULTS 0 O O O O O O O O C O O O O O O O O O 120 iii DISCUSSION 0 O O O O O O O I O O O O O Process-Outcome Evaluation of Psycho- analytically Oriented Day Treatment. Thought Disorder . . . . . . . . . Affect . . . . . . . . . . . . . . Object Relations/Interpersonal Behavior . . . . . . . . . . . . Some Comments on the MMPI . . . . Sex Differences . . . . . . . . . Client Motivation for Continuation (and Maintenance) in Treatment; Program Effectiveness. . . . . . Ability to Function out of the Hospital . . . . . . . . . . . . The Demise of the Experimental Day Treatment Program. . . . . . . . Obstacles of Psychotherapeutic Day Treatment . . . . . . . . . . . Flaws in this Study. . . . . . . . Conclusion . . . . . . . . . . . . S UMMARY O O O O O O O O O O O O O O 0 LIST OF REFERENCES . . . . . . . . . . APPENDICES O O O O O O O O O O O O O 0 iv Page 135 135 135 138 139 140 144 144 146 148 156 160 162 166 169 189 LIST OF TABLES Table Page 1. Diagnostic Categories of Total Sample of Day Treatment Group I (n=l7) over 18 months . . . . . . . . . . . . 103 2. Diagnostic Categories of Total Sample of Day Treatment Group II (n=19) over 18 months . . . . . . . . . . . . 104 3. Comparison of Three Day Treatment Pro- gram Client Populations on Demo- graphic Variables . . . . . . . . . . . 112 4. DAYS, MONTHS, and DAYS PER MONTH by Sex, Marital Status, and Group, with Age and Education 0 O 0 O O O O I O O O O O 121 5. Comparison of Three Day Treatment Program Populations: Total DAYS, MONTHS, and DAYS PER MONTH Attended over 18 months . . . . . . . . . . . . . . . . 122 6. Comparison of Pre-Treatment, 6 Months, and 12 Months MMPI Scores for Day Treatment Group I, n=8 (males=4; females=4) . . . . . . . . . . . . . . 125 7. Comparison of Pre-Treatment, 6 Months, and 12 Months MMPI Scores for Day Treatment Group I Males (n=4) . . . . . 126 8. Comparison of Pre-Treatment, 6 Months, and 12 Months MMPI Scores for Day Treatment Group I Females (n=4) . . . . 128 9. Comparisons between Male and Female Change Scores; T1-T2, T2-T3, and Tl-T3 O C O O O O O O O I O O O O O O 0 129 10. Comparison of VVT Scores at 8 months (T1) and 15 Months (T2) for Total Sample, and by sex 0 O O O O O O O O O O O I O O C 130 V Table Page 11. DTDB Analysis of Variance: Score 1 to Score 5 by Subject, Sex, Test (T1 to T5) over 12 Months . . . . . . . . 132 12. Comparisons of DTDB Ratings Pre-Treat- ment to 3, 6, 9, and 12 Months by Subtest Score, with Sex . . . . . . . 133 vi Appendix A. LIST OF APPENDICES Theoretical Integration: Psycho- dynamic and Neurophysiological Corollary Mechanisms in Schizophrenia . . . . . . . . . . Raw Cell Means for DAYS, MONTHS, and DAYS PER MONTH by Group and Demo- graphic Variables . . . . . . . . Day Treatment Program Descriptions. Day Therapy Data Base (DTDB) Rating Scale . . . . . . . . . . . . . . vii Page 189 225 231 235 INTRODUCTION More than 30 years ago, speaking at the Con- ference on Psychotherapy with Schizophrenic Patients sponsored by the Department of Psychiatry at Yale, Dr. Freida Fromm-Reichmann (Brody & Redlich, 1952) noted two factors which she held responsible for the reluctance and delay in providing directed, intensive psychoanalytically oriented psychotherapy for schizo- phrenic patients. The first factor she attributed to "the teachings of classical psychiatry, according to which the verbal communications of the disturbed schizophrenic could not be understood. His interpersonal manifestations, evi- denced by attitudes, gestures, and actions were con- sidered to be even less intelligible to the psychiatrist than his verbalized communications." The second factor Fromm-Reichmann attributed to ". . . the older teachings of classical psychoanalysis. According to these percepts, the infantile, 'narcis- sistic' self-engulfment of the schizophrenic made it impossible for the psychoanalyst to establish a workable doctor-patient relationship with him.1 Those who pro— moted this line of reasoning, thereby opposing attempts to treat schizophrenics psychoanalytically, were guilty of overlooking Freud's statement2 in which he expressed the hope for future modifications of psychoanalytic technique which would make it possible to do intensive psychoanalytically oriented psychotherapy with schizo- phrenics" (Brody & Redlich, p. 89). In addition to the above two factors pointed out by Fromm-Reichmann, a third factor that has further de- layed (Hill, 1974), and has even been used to repudiate the efficacy of psychotherapeutic treatments of schizo- phrenia, began with the introduction of chloropromazine in the middle 19503, and has continued with the subse- quent proliferation and endorsement of neuroleptic drugs as "Anti-Psychotics" and as "the most effective treat- ment of schizophrenia" (e.g., May 1968) despite growing 1Giovacchini (1979) admits that "because of Freud's powerful and authoritative influence, a young analyst had to possess considerable courage and con- viction or stubbornness and foolhardiness to accept psychotic patients for analysis . . . The occurrence of transference in psychotic patients is no longer a de- batable issue. It occurs and this is a simple empiri- cal fact, reported by many investigators" (p. 397). 2Freud, S. (1904) p. 71. evidence to the contrary in terms of: (1) significant subgroups of drug nonresponders; (2) clinical improve- ment and maintenance on placebos; (3) psychosocial treat- ment versus drug treatment outcome; and (4) neuroleptic drug risks and complications, (e.g., Anthony, Cohen, & Vitalo, 1978; Baldessarini & Lipinski, 1973; Berger & Rexroth, 1980; Bockoven & Solomon, 1975; Carpenter et a1., 1977; Crane, 1973; Davis, 1975; Davis, Gosenfeld, & Tsai, 1976; Gardos & Cole, 1976; Goldstein et a1., 1969, 1970; Grinspoon et a1., 1972; Gunderson, 1977; Hogarty, Goldberg, & Schooler, 1974; Karon & VandenBos, 1972; Leff, 1976; Leff & Wing, 1971; Magaro & Vojtisek, 1971; Mosher & Menn, 1978; Paul et a1., 1972, 1977; Rappaport et a1., 1978; Rosen et a1., 1971; and Young & Meltzer, 1980). The current status of the psychotherapeutic treatment of schizophrenia is commented on by King and Goldstein (1979): The research literature concerning the effectiveness of psychotherapy is replete with contradictory and equivocal results. Recent reviews of the literature show studies to be distributed between two categories: the minority, which find psy- chotherapy alone or in conjunction with pharmacotherapy to be effective in re- ducing symptomatology, hospital stay, or readmission; and the majority, which find psychotherapy to be no more effective than drug alone or 'no treatment,‘ milieu therapy, or 'regular hospital treatment.‘ There is no clear tendency toward either of these findings. Evidence that would permit a decisive judgment concerning the effectiveness of psychotherapy with schizophrenics is not yet available. Similarly, Mosher and Keith (1980), in an ex- tensive review of psychosocial treatments of schizo- phrenia, make the following critical observations on the issue of quality control in psychotherapy outcome research: A striking aspect of the treatment studies included in this review is what is being touted as 'therapy.’ Individual treatment, given on a 15- to 30-minute weekly or bi- weekly basis, would unquestionably be con- sidered inadequate by practitioners of individual psychotherapy. Yet, this is the principal form of 'individual therapy' given in the outpatient studies reviewed here. Likewise, group meetings focused on medica- tion and compliance would not be recognized by most clinicians as 'group therapy.’ In addition, the therapies are generally very vaguely described, with little information provided concerning their focus and formats. Finally, the treatment is frequently de- livered by therapists of uncited character- istics and qualifications. No wonder psy- chosocial treatment for schiZOphrenia is in disrepute! (p. 31). THE PSYCHOTHERAPEUTIC TREATMENT OF SCHIZOPHRENIA Critical Issues; Equivocal Findings; and Ongoing Controversies Despite the ongoing scientific controversies over the nature of schizophrenia, and the relative effectiveness of psychotherapy, medication, and combined psychotherapy and medication in the treatment of schizo- phrenic disorders (Bellak, 1979; Bellak & Loeb, 1969; Gunderson & Mosher, 1975; Gunderson, 1977; Shershow, 1978), clinical researchers have continued to study and advance psychotherapeutic treatment approaches for psy- chosis in general, and schizophrenia in particular, and to report on the progress that has been made during the past 75 years (e.g., Arieti; Benedetti; Boyer; Brody & Redlich; Burnham; Bychowski, Eissler; Ekstein; Federn; Ferenczi; Fromm-Reichmann; Gendlin; Giovacchini; Gunderson; Hill; Jacobson; Jung; Karon; Kernberg; Knight; Lidz & Lidz; Mosher; Rosberg; Rosen; Rosenfeld; Schwing; Searles; Sechehaye; Segal; Semrad; Sullivan; Wexler, Whitaker & Malone, and Will, among many others). Controlled Research The systematic evaluation of the effectiveness of psychotherapeutic treatments of schiZOphrenia compared 5 with somatic methods of treatment was begun in the early 19605 with controlled outcome studies. To date, five major treatment projects have been reported: Bookhammer et a1., Direct Analysis (1966); Rogers et a1., Client Centered (1967); Grinspoon et a1., Analytically Oriented (1967); May et a1., Ego Supportive (1968); and Karon & VandenBos, Active Psychoanalytic and Ego Analytic (1972). A new collaborative study of intensive psychotherapeutic treatment of acute schizophrenics is in progress at McLean Hospital and Boston University (Mosher & Keith, 1980). Bookhammer, Meyers, Schober, and Piotrowsky re- ported "A Five-Year Follow-Up Study of Schizophrenics Treated by Rosen's 'Direct Analysis' Compared with Controls" (1966). Patients for the study were selected from con— secutive admissions to the Psychiatric Reception Center of the Philadelphia General Hospital. The selection criteria were: 15-35 years of age, first attack of overt symptoms within a few months, no previous history of psychosis, no complicating physical illness, and no previous psychiatric treatment for the psychosis. Patients were clinically evaluated by two psy- chiatrists and referred for treatment to either the Institute for Direct Analysis or to one of the other cooperating hospitals for "usual treatment" at that hospital. Two and one-half years into the study a random control group was added. This group also met the selec- tion criteria and represented a random selection of patients who had been through the Psychiatric Reception Center at approximately the same time as the patients in the other two groups. The three patient groups studied were: a Direct Analysis group of 14 patients; a Designated Control group of 18 patients; and a Random Control group of 19 patients. Clinical psychiatric examinations were made on all patients "at regular intervals." The follow-up period was the same for all patients, 5.0-5.5 years. At the end of the follow-up period, the results of treat- ment and changes in the clinical status of the patients were evaluated based upon the criteria of the following six aspects of the patient's feelings, reasoning, and overt behavior: 1. Changes in objective signs and subjective symptoms were noted. 2. The patient's attitude toward himself was judged according to changes in anxiety and depression, in self-acceptance, and in expectations for the future. 3. The changes in attitude toward others were based on changes in the degree of emotional interest in others, changes in relations with the members of the immediate family, changes in constructive cooperation with others, and friendliness. 4. Thought processes were another important aspect of our evaluation. Changes were observed in the amount and quality of de- lusional thinking, in the preservation and diversity of thought content, and in the concern with reality problems. 5. Any changes in useful work output were noted. Amount and accuracy of work were the bases for evaluating the work record. 6. Finally, the amount of time spent outside of a hospital was considered in reaching the conclusion as to whether the patient had improved or failed to improve during the follow-up period. After evaluating all the data each patient was rated as either improved or unimproved. The follow-up was long enough to establish a reliable trend in personality changes: toward improvement, increased deterioration, or a stationary level with occasional devia- tions in either direction. Of the six aspects evaluated, thought processes and psychological relations with others were considered the most important in terms of improvement and unim- provement (p. 603). The results of the study are presented as a ‘percentage of rated improvement after the five-year follow-up: the Direct Analysis group 57%; the Designated Control group 67%; and the Random Control group 58%. The overall improvement rate for all patients was 61%. The investigators concluded that the results showed no significantly better outcome for the group of patients treated by the method of Rosen's "Direct Analysis" when compared with two other groups of patients; a designated control group and a random control group. In reviewing the Bookhammer et a1. study, Feinsilver and Gunderson (1975) criticize the defi- ciencies of the study, namely the lack of description of the specific types of treatment received by the con- trol patients, who the therapists were, and information about the frequency and duration of the "Direct Analytic" psychotherapy. What is perhaps the main limitation of this study, as Feinsilver and Gunderson note, is the lack of independent and standardized measures, and baseline assessments made prior to the follow-up evaluation ratings of improvement. It is important to consider the importance of the process-outcome variable of duration of treatment in the evaluation of these results. Both observers and critics of Rosen's method of "Direct Analysis" (Brody, 1959; Brody and Redlich, 1952; English et a1., 1961; Fromm-Reichmann, 1959; Scheflen, 1961; Searles, 1965; Spotnitz, 1961; and Whitaker and MalOne, 1953) have generally acknowledged the striking improvements pro- duced in Rosen's patients in a relatively short amount of time. Nevertheless, the intensive short-term focus of "Direct Analysis" has been criticized as being inade- quate for the lasting, long-term resolution of the lO psychosis, and fundamental structural changes in psy- chotic personalities. Moreover, as Karon (1963) points out, evaluation of "Direct Analysis" is further complicated by Rosen's subsequent deviation from his original psychotherapeutic technique: Rosen's technique (1953) took its name from the fact that he used 'direct' interpreta- tions to make the unconscious meaning of symptoms conscious. In his early views, he held that the psychosis was '1ike a dream' and that making the latent content conscious served to undo the psychosis. According to Brody's description (1959), to which Rosen (1959), surprisingly, does not seem to ob- ject, Rosen no longer aims primarily at bringing unconscious conflicts to life, but rather at simply making the patient feel ashamed and guilty about being psychotic. p. 36. Rogers, Gendlin, Kiesler, and Truax (1967) published a volume reporting the results of a five year study on the impact of psychotherapy with hospitalized schizophrenics, and with normals, in an effort to determine the elements in the therapeutic relationship which are significant to the process of personality and behavioral change during and consequent to psychotherapy. Rogers had previously formulated three atti- tudinal conditions which he considered "the necessary and sufficient conditions of therapy"-—emphatic under- standing, unconditional positive regard, and therapist 11 congruence or genuineness--independent of the method, technique, or theoretical orientation of the therapist. The design of the study called for three groups with 16 subjects each: (1) a more chronic group of schiz- ophrenic patients (defined in terms of hospitalization for over 8 months), (2) a more acute group of schizo- phrenic patients (hospitalized less than 8 months), and (3) a normal group of volunteers ostensibly recruited for a personality study. From the total sample of 48 subjects--schizophrenics and normals-—24 were to be randomly chosen for client centered psychotherapy. An attempt was made to obtain a stratified sample matched for age, sex, and socio-educational status. Schizophrenic patients were also matched in pairs for psycho-social disturbance using the Luborsky Health-Sick- ness Rating Scale. A coin toss determined which member of the matched schizophrenic patients would be offered therapy, the other pair member becoming a control. Therapy patients were seen twice weekly for 50-minute interviews until termination (several months — 2% years). The control group received normal hospital treatment in a progressive state hospital. The eight therapists who volunteered to partic— ipate in the study clustered toward a client-centered approach, with more experienced and less experienced therapists in the sample of therapists. The variables 12 under study, because of their generality, were consid- ered to remain operant "despite much variation in therapist behavior." Each therapist was randomly assigned a triad of subjects (one from each group; chronic, acute, and normal). All subjects were to be evaluated at beginning the project and at three and six month intervals (how- ever, the investigators encountered numerous diffi- culties with patient c00peration, and were forced by these realities to settle for less frequent evaluations and incomplete data). The psychological test battery consisted of the Minnesota Multiphasic Personality In- ventory (MMPI), the Rorschach, the Thematic Apperception Test (TAT), the Wechsler Adult Intelligence Scale (WAIS), the StrOOp Interference Test, the Truax Anxiety Scale, and a Q-sort of self-related items. Therapists and subjects completed Barrett-Lennard Relationship Inventories assessing the relationship be- tween them. Controls filled out the Relationship Inventory for a significant other. Rating scales for therapeutic conditions were specifically designed for the study (Accurate Empathy, Congruence, Unconditional Positive Regard) and four scales for assessing process level (Experiencing, Personal Constructs, Manner of Problem Expression, and Manner of Relating). Blind ratings were made on 13 excerpts of tape recorded interviews by trained under- graduate raters. Every subject in the project was also to be seen in a Sampling Interview at three months into the project and at three month intervals thereafter, with the same interviewer for all subjects. Therapy and control schizophrenic patients were additionally rated on their hospital behavior at three month intervals by ward staff using the Wittenborn Psychiatric Rating Scales. These extensive project data represented assess- ments of the therapeutic relationship made from three different vantage points: the perceptions of the sub- jects; the therapists; and the unbiased judges. The major results of the project were many promising and theoretically consistent, but statisti- cally insignificant trends, and fewer significant out- come findings. Schizophrenic patients in client-centered psy- chotherapy were generally found to perceive relatively low levels of therapist understanding, acceptance, and genuineness, but this perception tended to increase slowly over therapy. The schizophrenic patients tended to perceive primarily the level of warm acceptance and genuineness of the therapist, with empathic understanding only 14 gaining in importance later on in the therapy. The investigators comment on this finding, [which has important technical implications for the conduct of psychotherapy with schizophrenic patients] that for the schizophrenic patient, the focus in entering a thera- peutic relationship appears to be more upon the level of acceptance, warmth, caring, and trust offered by the therapist than on empathic understanding. These differential therapist attitudes of acceptance-positive regard, congruence-genuineness, and empathic understanding were found to stabilize early in therapy and to remain relatively constant throughout therapy. Therapist attitudes were also found to be positively related, but appeared to tap differing dimensions of the interaction. No significant relationship was found between the degree of therapist empathy, congruence, and accept- ance (conditions) and the degree of process movement (". . . the behaviors of the person who is in process, the degree to which he is not static, his involvement in the ongoing, change-effecting process, [and] . . . the state of changingness which the person has currently achieved."). The schiZOphrenic patients generally showed a very limited degree of process movement. The level of therapist understanding and genuine- ness showed a significant positive relationship to the 15 schizophrenic patients' level of self-experiencing and self-exploration. Moreover, the more the therapist was perceived as understanding and genuine, the more likely was the patient to show a greater degree of self-experi- encing and self-exploration. Furthermore, this positive relationship between the level of therapist congruence and empathy and the level of patient process involvement was found to generalize to the level of openness to experience in the patients' interviews with a third person, the sampling interviewer. It was found that the patients who showed a higher level of process in contact with the sampling interviewer (expressiveness of feelings, self-explora— tion, self-awareness) also showed a significant decrease in schizOphrenic pathology and symptoms and a better record of remaining out of the hospital. The same positive relationship between the level of experiencing in the sampling interviews and better hospital release rate and other evidence of favorable outcome was found for the control group. The outcome results from the psychological test battery were ultimately based on pretreatment and one battery of tests late in therapy or at the end of therapy3 3There was a wide range in final MMPI testing (between 324 days before termination and 105 days after termination). 16 due to the many problems encountered with securing patient c00peration or comprehension for testing. The test findings showed a significant reduction in schiZOphrenic behavior on three scales of the MMPI (F, K, Sc) for both therapy patients and control pa- tients. The therapy group in general did show a slightly better discharge rate 12 months after the termination of therapy, and follow-up data indicated that the therapy patients were more successful in maintaining themselves outside of the hospital. The group of patients receiving the highest level of accurate empathy showed a significant reduction in schizophrenic pathology on the schizophrenia scale (Sc) of the MMPI; conversely, patients in therapeutic relation- ships rated low on accurate empathy showed a trend toward increase in their schizophrenic pathology [a y§£y_im- portant research finding relevant to quality control of psychotherapy variables in psychotherapy outcome re- search, and underscoring the fact that "psychotherapy" is not a homogeneous variable in psychotherapy outcome research]. Findings for the control patients were intermediate between the high and low empathy receiving patients. Thematic Apperception Test (TAT) data showed evidence of greater constructive personality change in the therapy patients than in the control patients on 17 various indices of change on the TAT. The therapy patients' TAT's showed a significant decrease in emo- tional distance from the experiences described in the TAT's pre- to post-test. This finding was interpreted as an indication that the therapy patients showed a re- duced need to deny or to emotionally distance themselves from their experiences. The therapy patients also showed a significant improvement in the appropriateness of their emotional expression whereas the control patients showed a trend toward more extreme expression of emotion. Finally, Rogers et al. found significant positive relationships between evaluations of the therapeutic re- lationship made by the unbiased raters and the schizo- phrenic patients, but found that the therapist evalua- tions of the same relationship were often significantly negatively related to the perceptions of the raters and patients. They also found that, "In the more successful cases, the patient and therapist tended to see the re- lationship in similar fashion with scores positively correlated. In the less successful cases there was a sharply negative correlation between the perceptions of patients and therapists." The investigators concluded from these last findings that, "For the purposes of understanding and predicting the dynamics and outcomes of psychotherapy with schizophrenics, the assessment of the relationship 18 by the therapist is less satisfactory and presumably ) less valid than the assessment by the patient or by an unbiased judge." Heller (1969), reviewing the Rogers et a1. pro- ject, notes that the distinguished commentators who reviewed the clinical tapes and transcripts of the pro- ject were fairly unanimous in perceiving the project therapists as often "cool, aloof, and overintellectu- alized." However, since the therapeutic model was client-centered or non-directive therapy, perhaps, as Heller concludes, "a more active, giving style may be required for these conditions [empathy, congruence, and positive regard] to be properly communicated to the [psychotic] patient." Feinsilver and Gunderson (1975) comment in their review that: This study is particularly noteworthy because it was the first to state that psychotherapy for schizophrenic patients can produce measure- able differences from control patients and that its effectiveness seems to be related to the establishment of a therapeutic relation- ship characterized by empathy and congruence. No other study has attempted to sift out the critical determinants within a psychothera- peutic relationship which can effect outcome in schiZOphrenic patients. Rogers et al. have not treated the patient and the thera- pist as independent variables, but rather have focused upon their relationship--the interaction and process of therapyIYP. 408). These reviewers criticize as a major contaminat- ing factor the fact that the control patients received 19 drugs as a regular part of their usual hospital treat- ment while the psychotherapy patients apparently received medication "in a completely uncontrolled, irregular, and unknown fashion." Feinsilver and Gunderson conclude: This is unfortunate because it is difficult to be sure, in retrospect, how drugs affected the study's ultimate findings. One might speculate that, since the controls probably received more drugs than the experimental group, the effectiveness of psychotherapy reported might be more impressive than it at first appears (p. 409). Grinspoon, Ewalt, and Shader (1967, 1972) published the results of a project on the treatment of schiZOphrenia comparing phenothiazines in conjunction with individual psychotherapy and an active therapeutic milieu, and individual psychotherapy and active milieu without concomitant phenothiazines. Two groups of ten chronic schizophrenics were each successively transferred from the wards of the Boston State Hospital to a special research ward (the Clinical Research Center) of the Massachusetts Mental Health Center for the two years of treatment and study. The patients were randomly chosen from the larger ward pOpulation of males, unmarried, 18-35 years old, hospitalized for at least three years, and without brain damage or serious organic disease. The mean age of the patients in the two groups of ten patients (which 20 were combined for the research analysis) was 26.7 years; these patients had spent an average of 6.5 years in mental hospitals and an average of 7.5 years had elapsed since their initial hospitalization. The Phillips Premorbid History Scale for these 20 chronic schiZOphrenic males showed a very poor pre- morbid adjustment which was regarded as consistent with a process type of schizophrenia. The Hollingshed-Redlich Two-Factor Index of Social Position showed a similarity of social class origin for the patient sample (Lower, Class V). Diagnostic categories for the sample included Paranoid, Undifferentiated, Catatonic, Simple, and Hebephrenic classifications of schiZOphrenia. Upon transfer to the Special research ward, each group of ten patients was administered identical cap- sules "the contents of which were to remain unknown to the clinical staff." One difference in procedure be- tween the two successive experimental groups occurred at this point of transfer: Group I patients received an inert placebo at the point of transfer to the special research ward. Group II patients, several weeks prior to being transferred, had their medications converted to an equivalent dose of thioridazine (Mellaril), which was then gradually tapered off during a ten week "drying out" period. 21 Thus, at approximately 13 weeks after admission for the first group of patients to the ward, and at approximately 22 weeks after admission for the second group transferred to the ward two years later, five patients in each group were randomly chosen to receive thioridazine, while the remaining five in each group began to receive a placebo. Another difference in the treatment of the two groups occurred at this point; the first group was begun on an active placebo containing phenobarbital and atropine sulfate (to mimic the side effects of thior- idazine in an attempt to ensure double-blindness in the experimental design). Dosages of the thioridazine and phenobarbital were built up in graduated dosages over a four-week transitional period; the ward administrator was then informed only that he could adjust the drug dosage within certain prescribed limits of dosage. At approximately 32 weeks, Group I placebo patients were changed from the active to an inert placebo. Group II patients were begun on an inert placebo. After 66 weeks into the study, patients in each group who had been receiving thioridazine were instead given placebo for a three month drug withdrawal period following which thioridazine was resumed and maintained until the end of the study. 22 The investigators describe the psychotherapy, therapists, ward staff, and milieu program: All patients in both groups were treated equally with regard to the other two pri— mary treatment modalities, psychotherapy and milieu therapy. Each of the patients began intensive individual psychotherapy with senior staff psychiatrists, all of whom were either psychoanalysts or psy- choanalytically oriented and all of whom were considerably experienced in the psy- chotherapy of schiZOphrenia. All patients began psychotherapy about four months after beginning to receive project medica— tions, and all were seen at least twice a week over the remainder of each two-year period (1972, p. 148). A nursing staff of twenty-five pe0p1e, an occupational therapist and a social worker involved the patients in an intensive pro- gram for the entire two-year period. Among the various facets of this milieu program were diverse activities, ranging from thera- peutic community meetings and other group or individual ward functions to frequent beach outings, museum visits, and the like (1967, p. 117). The 18 therapists in the study were experienced psychoanalytically oriented psychiatrists on the senior staff of the Massachusetts Mental Health Center who were asked to undertake a commitment to treat one of the patients at least twice a week for two years. Grinspoon observes that: From the point of view of their qualifica- tions and experience, they were an excep- tional and impressive group. However, most of them did not match the first-year resi- dents for enthusiasm and eagerness. To a man they were already too busy with teaching and treatment responsibilities, and now they were being asked to spend at least two hours 23 a week for two years without any addi- tional compensation in someone else's research project. It is certainly not to be wondered at that some of them seemed less than enthusiastic. In fact, what seems remarkable is that there was not, under these circumstances, more am- bivalence than was apparent . . . How their differences in attitude and senti- ment about the project was reflected in their work with the patients is difficult to assess, but it must be noted that such differences did exist (1972, p. 20-21). The main focus of the study was on changes in manifest psychOpathology and adjustment to the ward environment based upon two rating scales: The Behavioral Disturbance Index (BDI) is a 54-item scale which assesses the degree to which patient behavior, thinking processes, and affect are disturbed. The Hospital Adjustment Scale (HAS) is a 90-item scale which measures the patient's capacity to adapt to the environment. A third source of data were the patient diaries ("Please write about your experiences today, particularly your thoughts and feelings"), and the daily ward nursing notes. Psychological evaluations were obtained for the patients toward the end of the "drying out" period and approximately two years later at the end of the special ward assignment. The psychological test battery in— cluded the Wechsler Adult Intelligence Scale (WAIS), Rorschach, Thematic Apperception Test (TAT), Sentence Completion, and free drawings. Unfortunately, results of 24 the analyses of the psychological test data have ap- parently never been published. Mental status examinations were also adminis- tered at the two testing periods. Additionally, for Group I patients, Quantified Mental Status scores (QMS) were obtained from two independent psychiatrists scoring the mental status write-up "blind" to treatment. Mental status examinations were obtained for Group II patients one year after discharge and quantified in the same manner. The findings reported for the BDI and HSI data were that on both scales the combination of phenothia— zines and psychotherapy was found to be significantly greater in reducing symptomatology and improving adapta- tion than placebo and psychotherapy. Patients receiving psychotherapy and phenothiazine showed some change as evidenced by quantitative changes on the BDI and HAS. The psychotherapy and placebo patients showed no change over the course of two years. The substitution of placebo for phenothiazine was found to lead to a worsening in psychOpathology. Therapists' absences were found to have no significant effect upon the patients on either pheno- thiazine, placebo, or the sample taken as a whole. The investigators concluded from this finding that 25 there was no evidence that a substantial working al- liance had been established.4 Grinspoon et a1. concluded from the findings that "psychotherapy alone (even with experienced therapists) does little or nothing for chronic schizo- phrenics in two years' time. Moreover: Phenothiazine therapy in conjunction with psychotherapy seems to work quite well at reducing florid symptomatology and also perhaps at making the patient more "reach- able', more receptive to communication with the therapist and others. Though some therapists have made the claim that pharma— cotherapy can only interfere with progress in psychotherapy. our findings do not bear this out (p. 153). However, the authors acknowledge that even with pharmacotherapy:S The observed changes did not suggest that the patients were any less schiZOphrenic but for the most part merely meant that the group exhibited less florid symptoma- tology . . . There was no evidence that any enduring and fundamental change had been achieved by medication (p. 154). There are, however, important findings reported in the Boston study which are supportive of the effec- tiveness of psychoanalytically oriented psychotherapy 4C.f., patient reactions to therapist absences in Fromm-Reichmann (1950); Giovacchini (1979); Searles (1965). 5C.f., May (1968). 26 with particular therapists, and consistent with psycho- analytic theoretical and technical conceptualizations of psychosis (viz, repression of intense affect, especially rage; regression as a defense). In the summary chapter of project findings for both chronic and acute schizophrenic patients, Grinspoon et al. report that: Regardless of drug or therapist type, patients who improved most had therapists who more often attempted to have their patients discuss anger, while those pa- tients who improved least were treated by therapists who were less likely to try to get patients directly to discuss anger (p < .05) p. 246. We continue to conclude that appropriate antipsychotic drug regimens are of pri- mary value in the treatment of acute and chronic schiZOphrenia. However, we would now add that the degree of improvement may vary as a function of therapist type (p. 247). Furthermore, as Karon (Magaro, 1976) points out: If one looks at the ability to stay out of the hospital in the long run or to function outside the hospital in the long run, as Opposed to criteria which reflect ward ad- justment, then even studies whose findings are supposedly negative report gains for patients receiving psychotherapy (e.g., Grinspoon et a1., 1972) p. 184. In reviewing the Grinspoon et a1. project, Cole criticizes the lack of drug and placebo controls on the chronic wards of the state hospital from which the study patients were transferred to the special research ward. He observes that: 27 Without these necessary controls, it is im- possible to say how the intensive non-drug therapy affected either the drug or the placebo groups (p. 129). It would be helpful to know whether the drug-treated patients achieved a level of adjustment only equal to that at which they had been before they left the state hospital or whether they were substantially improved over that level (p. 130). Feinsilver and Gunderson (1975) comment on the study that: . . . Conclusions specific to the value of psychotherapy itself cannot be drawn be- cause the study lacked a control group in the same setting which did not receive psy— chotherapy (p. 414). Regarding the finding that the placebo group was not appreciably improved with intensive psychotherapy and intensive milieu; and in fact may have been made worse, Cole questions whether the intensive milieu was not too intensive, driving these chronic schizophrenic patients into further psychotic withdrawal:6 In pharmacological terms, one can certainly conceive of a toxic dose of environmental stimulation. Perhaps a less intense pro- gram would have yielded more improvement. 6Social withdrawal in chronic schizophrenics has been found to be associated with increased physiological arousal (Venables & Wing, 1962). Leff (1976) suggests that schiZOphrenics may monitor their own sensitivity to emotional stimulation and employ social withdrawal as a defense against overstimulation. Venables & Wing suggest a relationship between the level of arousal and reduction of motivation as expressed in behavior or in affective responses. 28 It is certainly possible that both a barren custodial milieu and an overactive one could be deleterious to chronic schizophrenic pa- tients with limited psychic resources. Phenothiazines in animal studies appear to enable the organism to screen out irrele- vant stimuli while preserving the ability to respond to important stimuli. If, as recent work by Jones et al. suggests, schi- zOphrenics are overresponsive even to trivial stimuli, perhaps chronic schizo- phrenics really need a phenothiazine to be able to tolerate intensive interpersonal therapies (p. 130). Greenblatt (Grinspoon et a1., 1972) was an observer on the special research ward, and comments: My second observation is that several fac- tors may possibly have slowed the recovery of patients transferred and treated at the Clinical Research Center. The small ward, for example, with high ratio of staff-to- patient, the intensive social interaction, plus the high hopes and expectations of the staff for therapeutic progress, may have threatened patients to the point of exag- gerating or hardening their pathological defenses. To an outside observer the cli- mate in the Clinical Research Center was extraordinarily different from that at Boston State. In the latter instance 'Open Spaces' and less intense expectations of staff concerning patient progress seemed to prevail (p. xi). Zetzel (1967) concludes: "It does not, however, enable us to draw any definite conclusions as to the degree to which such patients might, under Optimal con- ditions, achieve significant intrapsychic maturation as a result of long-term, intensive psychotherapy." The uncontrolled variables of research and clinical expectations, physical environment, and 29 staff-to-patient ratio have been criticized as factors which interfered with optimal treatment in the Boston study. Other subtle factors could have been the para- noid fantasies aroused in these already suspicious and mistrustful schizOphrenic patients, by perceptable and persistent observation by staff for rating purposes ["the ever-present problem of patient and staff expect- ancy effects and increased vigilance" - Paul et a1., 1972]; the daily diary directive for "thoughts and feelings" which may have been perceived by these patients as "thought control," intrusiveness, criticism, and guilt-arousal (e.g., Leff, 1976; Tarrier, 1979); and possibly exacerbation of the homosexual paranoid anxi- eties, described in the case histories, on the small, all male special research ward. Patient Robert, one of the acute schizophrenic patients who had been a law student, was described as refusing to take his project capsules because he believed them to be poison. He also had the interesting delusion that he was "a participant in a hockey game." A relevant example may further illustrate some of the problems of uncontrolled countertherapeutic variables that can contaminate the results in psycho- social treatment outcome studies, often in undetected ways. 30 Spadoni and Smith (1969) also reported a nega- tive result for milieu therapy in the treatment of schiZOphrenic patients. Their milieu design excluded individual psychotherapy, drugs, and other somatic treatments. Psychotic behavior was seen as a disguised communication (message) to be understood (decoded) by staff and then fed back to the patient in the form of an interpretation or confrontation. Once the underlying meaning Of the symptom was uncovered and communi- cated tO the patient, he would feel 'under- stood,‘ leading to his feeling accepted by the group. Such acceptance would then motivate him to communicate and behave more apprOpriately. The staff spent a good part Of each day analyzing and interpreting patient communication, both in staff and patient meetings (p. 548). Given this humanistic and Optimistic treatment approach, the investigators were very distressed by the outcome Of the treatment: they encountered a high inci- dence of acting-out on the unit and a low improvement rate; in particular, they Observed that: The two year period of the project was marked by many incidences of assaultive, destructive, denudative, bizarre, and regressive behavior. There was an ex- tremely high elOpment rate. During one six month period, more elOpments occurred from this lS-bed unit than from all the remaining units Of 300 beds combined (p. 549). To account for this unexpected outcome, it is suggested that the extreme attention-seeking and ag- gressive acting—out behavior may have been an unpredicted 31 but understandable reaction to the milieu treatment approach itself. This is because rather than inducing the patient to "feel accepted by the group," with this therapeutic goal in turn leading to the goal Of more apprOpriate communication, the milieu as described may have inadvertently had the Opposite negative effect of making the patient feel neglected or rejected as an individual, with his identity and needs being sub- ordinated to "the group." Spadoni and Smith had stipulated that: Group involvement was all-important. The group was the method Of controlling and changing behavior. Individual patient needs were subordinate to the needs of the group. Staff members were discouraged from forming relationships with individual patients but instead were advised to relate to them as a group. Patient complaints, questions, and symptoms were constantly being referred back to the group for discussion and decision—mak- ing rather than handled on an individual basis (p. 548). Thus, the angry acting-out behavior in the Spadoni and Smith study can be understood dynamically since schizophrenics are generally regarded as being notoriously sensitive to perceived rejection, in the same way that the possible overstimulation in the Boston study Clinical Research Center may have adversely affected outcome in that project. Parenthetically, it is noteworthy that etio- logical research (Bellak, 1979; Goldstein & Rodnick, 32 1975; Karon & VandenBos, 1981; Leff, 1976) suggests that preschiZOphrenics are pathogenically raised in familial environments in which the child's individual feelings, needs, and ways of experiencing are not recognized, understood, or met Often enough; in which there is a characteristic "blurring" Of separate indi- vidual identities; and in which there are Often subtle but consistent deprivations and rejections, or more blatant and destructive developmental traumas and failures. The SchiZOphrenia Research Project (May,l968; 1976a; 1976b) compared the relative effectiveness Of five different treatment methods commonly practiced for the treatment of schizOphrenia in a good public hospital: (1) individual psychotherapy alone, (2) ataraxic drugs alone, (3) individual psychotherapy plus ataraxic drugs, (4) electroshock, and (5) milieu [defined as a control group receiving none of the other specific treatments]. Admissions to Camarillo State Hospital were screened for: diagnosis Of schiZOphrenia; first admis- sion or no significant prior hospitalization; age 16-45 inclusive; no history Of organic brain damage, epilepsy, or history Of alcohol or drug addiction; and no major physical illness or complicating factor that might interfere with any Of the five treatment methods. Pa- tients selected for the study were defined as middle 33 prognosis schiZOphrenics. The 228 male and female pa- tients were randomly assigned to one of the five treat- ment groups. Each one Of the five different forms of treat- ment was provided by each psychiatric resident, or psy- chiatrist having up tO three years Of post-residency experience. Six months of residency training were re- quired before a resident could begin psychotherapy with a patient. Each patient's treatment was supervised by a treatment supervisor experienced in the particular treatment that was being given and who believed in its efficacy. Care was taken to see that each form Of treatment was given a fair trial under good realistic con- ditions in suitable dosage for an adequate length of time-~unti1 the patient was either successfully released or treatment had been given for six to twelve months and both the treatment supervisor and the therapist agreed that it had been a failure. Those who were declared treatment failures, having failed to respond to one Of the five experimental treatments, were subsequently treated with GROUP PSYCHOTHERAPY PLUS ATARAXIC DRUGS. This was selected as a combination commonly used and advocated in public hospitals for the treatment of schizophrenic patients (1968, p. 57). Patients assigned to PSYCHOTHERAPY ALONE and to PSYCHOTHERAPY PLUS DRUG received from 7 to 87 hours Of psychotherapy (Mean 46 hours) until they were either released or declared treatment failures at the end of a year. Descriptively, May states that: From a more theoretical point of view, the therapy was in general ego-supportive and 34 reality defining. There was a minimum Of depth interpretation and use Of psycho- analytic terminology; a substantial focus on working through the patient's problems in his current life situation; some con- frontation with the reality Of the pa- tient's own behavior and Of the manner in which he was Operating; a considerable amount of clarification of perceptual dis- tortion; and emphasis on the therapist acting as a suitable model for introjec- tion (1968, p. 83). Evaluation was based upon comparison Of before and after treatment data. An independent rating team Of two psychoanalysts made initial and terminal ratings individually and consensually on the Menninger Health-Sickness Rating Scale (MHS) which provided a global rating Of clinical status and was used to make a prognostic rating for predicting the patient's level in two years; the Camarillo Dynamic Assessment Scales (CDAS) which rated psychodynamic factors (Affective Contact, Anxiety Level, Ego Strength, Extent to Which the En- vironment Suffers, Insight, Motivation, Object Rela- tions, Sense Of Personal Identity, and Sexual Adjust- ment), and ratings Of the severity and duration Of Precipitating Stress. The nursing staff rated patients consensually under the guidance Of the research nurse as senior rater on Patient Participation, Idiosyncratic Symptoms (ISR), the MACC Scale (Motility, Affect, Cooperation, and 35 Communication), the Menninger Health-Sickness Rating Scale (MHS), and a General Improvement Rating. The treating physician (therapist) completed the Jenkins Symptom Rating Scale (SRS), the Psychotic Con— fusion Scale (AA), a subscale Of the Ann Arbor Mental Status Scale (added in the second year Of intake begin- ning with patient #69), and the Clyde Mood Scale (CMS) (Friendly, Energetic, Clear Thinking, Aggressive, Jittery, and Depressed). Each Of the above ratings was made initially, at three month intervals, and after treatment. Psychological evaluation was made using a Self-sort Clyde Mood Scale (CMS) initially, at three month intervals, and at the end of treatment. Beginning with patient #10, the Similarities and Proverbs of the Wechsler Adult Intelligence Scale (WAIS) and the Shipley Scale were administered before, at three month invervals, and after treatment. The Minnesota Multi- phasic Personality Inventory (MMPI) was administered before and after treatment and at six months if the patient was still in the hospital. In addition to the standard MMPI scales, the Psychotic Triad index, Caudra Control Scale, Barron Ego Strength Scale, and the Taylor Manifest Anxiety Scale was scored. Finally, the Draw-a-Person test was Obtained before, every three months, and after treatment. 36 Comparison and evaluation of the five treat- ments were made based upon four general criterion categories: (1) Clinical--independent ratings of nurses, therapists, psychoanalysts. (2) Psychometric--MMPI, Similarities-Proverbs, Shipley Scales. (3) Movement--release rate and measures Of hospital stay. (4) Cost--various cost Of treatment indices. By clinical criteria, PSYCHOTHERAPY PLUS DRUG was generally found to be more advantageous than DRUG ALONE; however, the overall differences between the two treatments were small and not significant. The psychometric criteria showed DRUG ALONE to be superior to PSYCHOTHERAPY PLUS DRUG on almost all measures; however, these differences were small and not statistically significant except on one measure. Based upon the movement and cost criteria, DRUG ALONE was found to be superior to PSYCHOTHERAPY PLUS DRUG, with cost showing a significant difference between the two treatments; DRUG ALONE showed the highest re- lease rate and the shortest average length Of hospital stay. PSYCHOTHERAPY ALONE and MILIEU were found to be the least effective and most expensive forms of treat- ments, with ECT occupying an intermediate position. On 13 out of 19 clinical measures PSYCHOTHERAPY ALONE showed no significant effects. 37 Follow-up data on the outcome Of the five treat- ment methods were reported on stay from first admission and from first release (May et a1., 1976a, 1976b) for the total number of days hospitalized over cumulative periods Of one, two, three, four, and five years. The data showed that patients treated with PSY- CHOTHERAPY ALONE spent significantly more time in the hospital than patients treated with DRUG ALONE, PSYCHO- THERAPY PLUS DRUG, and ECT after one, two, and three years. The MILIEU group was not significantly dif— ferent from PSYCHOTHERAPY ALONE. This pattern Of dif- ferences held when only the initial treatment successes were considered; PSYCHOTHERAPY ALONE patients did significantly worse than ECT, DRUG ALONE, and DRUG PLUS PSYCHOTHERAPY groups at three years. Follow-up stay from first release data showed a significant difference at two years; the PSYCHOTHERAPY ALONE group was found to be significantly worse than the ECT group. At five years the PSYCHOTHERAPY ALONE group was significantly worse than DRUG ALONE, MILIEU, and ECT, but was not significantly different from the DRUG PLUS PSYCHOTHERAPY GROUP. In successfully treated ‘patients, PSYCHOTHERAPY ALONE was significantly worse than the other groups at two years, and than ECT at three 'years. There were no differences between the other groups . 38 The results Of May's influential Schizophrenia Research Project, with its large sample size and com- parison of five different treatments of schizophrenia, strongly support the conclusion that compared with ataractic drugs, psychotherapy alone is a relatively ineffective treatment for hospitalized schizophrenics. However, the generality Of this conclusion beyond the somewhat restricted conditions Of May's study may be more limited than would appear in many secondary sources. Feinsilver and Gunderson (1975) note that, "By most standards, May's study has only covered the initial phase of psychotherapy, and therefore cannot be used to assess the efficacy Of long-term psychotherapy." In fact, in the Camarillo study, patients received an average Of only 46 hours (over 6-12 months) of psycho— therapy compared with an average of 70 sessions (over 20 months) in the Karon et al. (1969; 1970; 1972; 1975a; 1975b) Michigan State Psychotherapy Project, which found psychoanalytic psychotherapy to be more effective than medication in producing long-term clinical improvement in schizOphrenics. Yet, Karon & VandenBos (1972) have noted that: If this study had confined itself to short term effects (six months) and included only the inexperienced therapists (even under supervision), it would have been necessary 39 to conclude that psychotherapy was Of no significant benefit to the patients as com- pared tO medication. However, if it had been confined to the experienced therapists, the benefit was discernable even at six months (p. 12). Greenblatt and Leavitt (May 1968), Rosen (1969), and Wexler (Gunderson & Mosher, 1975) comment that per- haps the relative ineffectiveness Of psychotherapy in the May project reflects the limited prior training and experience Of the project psychotherapists. Moreover, since the project therapists were supervised ". . . by a treatment supervisor experienced in the particular treat— ment that was being given and who believed in its ef- ficacy," Wexler (Gunderson & Mosher, 1975) and Hamilton (1968) raise the issues Of the variability in super- visor experience in, and attitude toward, the psycho- therapeutic treatment Of schizophrenia. Hamilton ex- presses the following concerns about the research methodology: 'Believed in the efficacy Of the particular treatment that he supervised.‘ The phrase in quotes is mentioned to point up some possible serious contradictions. Firstly, while a positive attitude is thought to be an im- portant aspect Of the supervisor, I could find no mention of what the therapists' in this regard were. Secondly, I was im- pressed that none Of the supervising psy- choanalysts commenting in the last chapter mentioned any conviction or bias in favor of intensive psychotherapy for acute schizo- phrenia, and Dr. May himself describes the therapy as 'ego-supportive and reality de- fining.‘ Regarding his own personal con- viction, Dr. Fine, one Of the supervising 40 analysts, is explicit: 'I am not generally in favor of psychoanalysis or formal psycho- thera in the treatment of acute schizo- phrenia. The supervision that I adminis- tered to the psychiatric residents was what I too would call psychotherapeutic manage- ment.‘ Another supervisor, Dr. Feldman, comments along a similar vein, urging 'proper 24-hour psychotherapeutic management' over psycho- therapy: ‘repeated brief contacts with the psychiatrist and ancillary personnel are much more beneficial with the acutely psychotic patient at this stage than any attempt to establish a psychotherapeutic relationship.‘ . . . Dr. Leavitt is quite clear: 'It has always (italics mine) been my impression that psychotherapy with such severely ill schizo- phrenic patients is Of restricted value, the principal indication being for research in- terest, and the principal beneficiaries being that limited number Of patients treated by a small group Of unusual therapists.‘ I cite these statements, sentiments that would probably be shared by the majority Of the psychoanalytic community, to point up the difficulty that plagues all research in psy- chotherapy, essentially the problem of standardization. The statements raise the possibility Of a con- tradiction between research design and meth— odology as carried out. I would gather, from the author's definition of psychotherapy as well as other statements throughout the book, that he would agree that the attitude Of the therapist is a significant factor influencing outcome (in my experience in psychotherapy with schizophrenics, it is crucial), and more data on that aspect of treatment would have been welcome. Other questions come to mind as the result of the supervisors' comments. It is possible that some Of the 'psychotherapy' patients received in actuality 'psychotherapeutic management'? (p. 731-732). 41 The Michigan State Psychotherapy Project (Karon et a1., 1969, 1970, 1972, 1975a, 1975b) was designed to evaluate the effectiveness of intensive individual psy- chotherapy for hospitalized schizophrenic patients, comparing two types of psychoanalytic psychotherapy--one without adjunctive medication and one using medication adjunctively--and usual hospital treatment with medica- tion. Patients for the study were selected from admissions to the Detroit Psychiatric Institute: The selection Of patients in our study was made by independent research personnel in sets of three for comparable severity and then random assigned to the three treatment groups. Assignment to individual thera- pists was on a rotation basis, determined by compatability with the therapists' schedules, and with the necessity of ade- quate training (without such training, our study would have been pointless). . . . Evaluation for selection was solely in terms of meeting the selection criteria. Selection was made by the same criteria and the same research personnel throughout. The selection criteria were: clearly schizo- phrenic symptomatology, no organic pathology, and acute onset. By the end Of the project the investigators realized that few if any of their patients were truly acute (at least one-third had been hospitalized pre- viously, which had not been divulged by the relatives in the screening interviews). 42 Thirty-six clearly schiZOphrenic patients, pri- marily poor, inner-city Black, chronic and severely im- paired, were randomly assigned to one of the three treatment groups: Group A--An "active" psychoanalytic psycho- therapy without adjunctive medication (Karon, 1963, 1976; Karon & Rosberg, 1958a, 1958b; Karon & VandenBos, 1977, 1981; Rosberg & Karon, 1958, 1959). Patients were seen for intensive individual psychotherapy sessions five times a week until discharge and usually once a week thereafter. The senior author (psychologist) treated four patients and supervised five trainees (three graduate students in clinical psychology and two psychiatric residents) who treated eight patients. Group B--An "ego-analytic" psychoanalytic psy- chotherapy using adjunctive medication (100-600 mgs. chloropromazine or equivalent daily, generally de- creased or eliminated at discharge). Patients were seen three times a week for at least 20 sessions and eventually reduced to one session per week. An ex- perienced therapist (psychiatrist) treated four patients and supervised five trainees (three residents and two graduate students) who treated eight patients. 43 Group C--The "hospital control" or comparison group7 of 12 patients receiving "usual hospital treat- ment" from psychiatric residents with medication (300-600 mgs. chlorOpromazine or equivalent daily). Patients who were not improved tO the point of discharge on medica— tion after a few weeks were transferred from this short-term municipal hospital to a state hospital for continued hospitalization. All patients were evaluated before treatment began and after 6, 12, and 20 months (end of treatment) by research personnel not connected with treatment who were "blind" to which treatment group the patient belonged to. The measures of the effectiveness Of psycho: therapy were divided into four categories: (1) length Of hospitalization, (2) clinical evaluation of function- ing (CSI), (3) direct measures of the thought disorder, and (4) projective tests. The psychological test battery included intel- lectual tests; the Thorndike-Gallup Vocabulary Test (TGV), the Porteus Mazes (PM), the Wechsler Adult Intelligence Scale (WAIS), and the Feldman-Drasgow 7Karon & VandenBos (1972) point out that "The control group was not a 'no-treatment' group. Addi- tional hours of individual psychotherapy can only be justified if they produce greater change than currently available mass treatment (i.e., medication)." 44 Visual-Verbal Test (VVT) measure Of the schizophrenic thought disorder, and projective tests; the Rorschach Inkblots and the Thematic Apperception Test (TAT). An intensive psychiatric interview, the Clini- cal Status Interview (CSI), was conducted by a psychi- atrist experienced with the kind Of patients being stud- ied, but unconnected with the treatment in any way. The CSI was recorded, edited only for reference to the spe- cific treatment received, and blind rated by research psychologists on the following 11 criteria Of mental health: ability to take care of self, ability to work, sexual adjustment, social adjustment, absence Of hal- 1ucinations and delusions, relative freedom from anx- iety and depression, amount Of affect, variety and spontaneity Of affect, satisfaction with life and self, achievement of capabilities, and benign rather than malevolent effect on others. The resulting quantitative measure was found em- pirically to be both reliable and valid, and represents the most carefully blind and yet relevant criteria to be used in any research on treatment with schizOphrenics (Karon & VandenBos, 1978, p. 481; see also Karon & O'Grady, 1970). Hospitalization data were recorded during the treatment phase (20 months) and a follow-up phase (20-44 months), with information collected from regional state, metropolitan, and private hospitals. The results Of the comparisons between patients receiving psychotherapy and patients receiving "usual 45 hospital treatment"--medication and usual hospital pro- grams, without psychotherapy--showed significantly less time spent in the hospital, improved overall functioning (CSI), and decreased thought disorder (VVT, WAIS, PM) in the patients who received intensive psychotherapy com- pared with patients who received routine hospital and post-hospitalization treatment. A more specific five group analysis Of the data separating out Group A and Group B patients, and pa- tients treated by experienced versus inexperienced therapists was also reported. Inexperienced therapists providing psycho- analytic psychotherapy with adjunctive medication were the most effective in getting their patients discharged. However, on the overall clinical status evaluation these same patients were not significantly different from the hospital comparisons. Patients of the inexperienced therapists using adjunctive medication spent about as much time hospitalized over the follow-up as the com- parison group. Patients Of the inexperienced therapists not using medication showed a comparable length Of hospi— talization to the hospital comparison patients during the treatment phase Of the project, but showed a marked long-term reduction in hospitalization over the two 46 year follow-up compared with patients who had received usual hospital treatment. Patients Of the supervisor and trainees in Group A (active psychoanalytic psychotherapy without medica- tion) showed the most striking improvement on the VVT, the most direct measure Of the schizophrenic thought disorder; significantly greater than Group B or the comparison patients. The patients Of the experienced therapists did significantly better in the long run than patients of the inexperienced therapists, showing a more balanced overall improvement, and much less time spent in the hospital than the comparison patients. Karon and VandenBos report that the two best predictors of outcome or long-term adjustment were the Clinical Status Interview (CSI) and the Visual-Verbal Test (VVT) measure of the schizophrenic thought dis- order; and improvement on these two measures best pre- dicted long-term adjustment. Moreover, "The long-term (follow-up) hospitalization data thus seems to reflect the change in the thought disorder during therapy (c.f., the 20 month VVT data), rather than the short-term hospitalization data." The findings of the Michigan State Psycho- therapy Project provide evidence for the effectiveness Of intensive psychoanalytic psychotherapy of 47 schizophrenia. Karon and VandenBos (1978) summarize the basic findings Of the project: Psychotherapy is more effective than medica- tion, particularly in the long run, in de- creasing thought disorder, improving overall clinical status, and decreasing hospitaliza- tion. Medication as an adjunct to psychotherapy makes behavioral control easier, but slows underlying change (i.e., improvement in thought disorder) and, hence, medication is preferable as a temporary rather than per- manent adjunct. Follow-up hospitalization data show a marked long-term advantage Of psychotherapy over medication in the patient's ability to stay out of the hospital. This long-term advantage is apparently medi- ated by the greater decrease in thought dis- order, i.e., the improved ability Of the patient to think realistically when he wants to do so. Treatment by psychotherapy costs less than treatment by medication in the long run (i.e., over four years: Karon & VandenBos, 1975a, b; 1976). May and Tuma (1975) are generally critical of the design and results of the Michigan State Psycho- therapy Project, pointing out criticisms of unrandomized patient assignment to therapists, small n, preferences for statistical procedures, and absence of thera- pist-centered analyses. They acknowledge that "The other reported differences between experienced and inexperienced therapists are not impressive, at best to be interpreted as weakly positive," but ignore the 48 major comparison between patients who received psycho— therapy and those who received medication without psy- chotherapy. Feinsilver and Gunderson (1975) comment that the Michigan State Psychotherapy Project findings are seri— ously weakened by the uncontrolled variables of drugs, hospital setting and transfer, and concluded that "It would seem that this study lends credibility to the idea Of 'gifted specialist' and casts doubt upon the positive interaction Of drugs and psychotherapy." Karon and VandenBos (1975a, b) have responded to the methodological criticisms Of May & Tuma (1975). Regarding the issue of how the hospital transfer Of the comparison group affected outcome findings, Karon and VandenBos report: That such a transfer did not work to the marked detriment Of the patients seems to be reflected in the fact that our compari- son group (medication only) did not spend any more time in the hospital during the first year of treatment than did the medi- cation only group in May's study; our worst group in terms of hospitalization spent no more time in the hospital than his best group, despite the fact that data from the two studies suggests that our patients were sicker (1975a, p. 144). Responding to the criticism raised about the "uncontrolled variable of drug use," Karon and VandenBos state: It was noted that three patients in the non-medication group received medication 49 upon the demand of the ward staff as an alternative tO mechanical restraints. How- ever, two of these cases do not appear in the final data (analysis including the two living patients which were excluded have been run; their inclusion does not materi- ally alter the findings). Medication for these patients was rare and typically for very brief periods of time (in no case more than two weeks during twenty months Of treat- ment) and in response to the distress of the ward staff (p. 13). A major strength of the Michigan State Psycho- therapy Project is that the investigators utilized sensitive measures Of thought disorder to directly evaluate the process and outcome of psychoanalytic treatment Of schizophrenia. The technical model for the modified parameters Of psychoanalytic psychotherapy, psychodynamics in schizOphrenia, emphasis upon the thought disorder and affect, and assessment procedures were all operationally and logically related to a uni- fying psychological understanding of schizophrenic dis- orders. The emphasis upon the direct evaluation of the thought disorder in schizophrenia is based upon Bleuler's classical Observation that the thought disorder is the primary psychological symptom of schizophrenia that accounts for the remaining fundamental and the acces- sory symptoms. The severity of the thought disorder, being the major symptom of the core pathology, should predict the severity of the psychosis. 50 Cancro (1969a, 1969b) studied 51 schizophrenics who were unmedicated throughout the period of testing and examination (to avoid the masking effect of drugs upon the severity of clinical signs). He found that the severity of the thought disorder was directly related to the severity of the schizophrenic illness, and that the formal signs of thought disorder were the best predictor of outcome. Furthermore, Cancro reported that: The significant intercorrelations between the measures of premorbid Object relations and the presenting signs of the illness support the hypothesis that there is a con- sistency of impairment across ego functions. Object relations, thought, and affect tend to show impairment in combination and not separately" (1969a, p. 546). Wynne & Singer (1963) and Lidz (1973) have also emphasized the significance of the thought disorder in the etiology and dynamics of schizophrenic disorders. The emphasis upon the prognostic importance of changes in the thought disorder is also supported by empirical research on the intellectual functioning of schizophrenics, summarized by Rabin and Wender (in Bellak, 1969), who conclude: The bulk of the evidence, reviewed here, and of earlier studies points to a reduction in intellectual functioning following the onset of schizophrenia. The loss, however, is re— versible. All in all, we have learned that schizophrenics manifest comparably lower intelligence long before the onset of the disorder, that further impairment of a re— versible nature tends to occur upon hos- pitalization and that the change in the course 51 of impairment is probably related to the overall clinical picture and, possible, to motivational factors in the testing situa— tion (p. 208). A significant feature of the Michigan State Psy- chotherapy Project, compared with other psychotherapy outcome research with schizophrenics, was the attempt to make the specified psychotherapies homogeneous experi— mental variables. The finding in the Rogers et a1. project of a significant relationship between decrease in schizo— phrenic pathology and accurate empathy; the finding in the Grinspoon et a1. project of a significant relation- ship between clinical improvement and therapist focus on anger; the therapist benign-pathogenesis variable (VandenBos & Karon, 1971) in the Michigan State Psycho- therapy Project; and the methodological criticism of "psychotherapeutic management" versus psychotherapy in the May et a1. project, evaluated together, underscore the conclusion that psychotherapy is not a homogeneous experimental variable in psychotherapy outcome research. As noted by King & Goldstein (1979): In most of these studies psychotherapy is regarded as a homogeneous process. The diversity in the psychotherapy process found both within and across studies may account for some of the variance in findings and renders even less equivocal findings diffi- cult to interpret. Heterogeneity in the nature of psychotherapy derives from varia- bility in (l) attributes Of the therapists; 52 (2) the formal model, theory, or techniques of theraPY; and (3) implementation of the therapeutic model in therapy interactions (p. 118). Section Conclusions The results from the Michigan State Psycho- therapy Project, along with supportive findings reported in the Boston and Wisconsin projects, have empirically demonstrated evidence for the feasibility and efficacy of the psychotherapeutic treatment of schizophrenia. However, both critics and proponents of the psy- chotherapeutic treatment of schizophrenic disorders have concluded that,at present, the availability of psycho- therapy for schiZOphrenics is so limited as to have only "heuristic value" for the treatment of only a very small number Of fortunate patients, and for theoretical and clinical research purposes. It remains, therefore, for the proponents of the psychotherapeutic treatment of schizophrenic dis- orders, to continue to develop brief and effective psychotherapeutic techniques (e.g., Davanloo, 1980; Karon & VandenBos, 1981), and to develop programmatic treatment approaches based upon these psychotherapeutic principles in order to maximize the availability and effectiveness of psychotherapeutic treatment for the 53 8 who sizeable population of schizophrenic individuals might benefit from such treatment. This treatment goal is one of the most challenging tasks in mental health for the decades ahead, but one which is feasible largely because of the increasing interest in the psychosocial treatment of schizophrenia and because of the increase in professional practitioners since World War II. Broadening and Divergent Psychosocial Treatment Approaches In 1970 the National Institute of Mental Health Center for Studies of Schizophrenia and the Behavioral Intervention Section of the Clinical Research Branch sponsored a national conference on schizophrenia which targeted evaluation of psychosocial treatment as an area of highest research priority. Gunderson (1977) and Mosher (Gunderson and Mosher, 1975) were two of the organizers of the con- ference. In an article reviewing the studies of drug 8Population studies report figures ranging from 1.0 per 1000 to 9.5 per 1000. (In Bellak, 1969, p. 104.) The Task Panel Reports submitted to The President's Com- mission on Mental Health (1978) estimate the incidence of schizophrenia at 0.5 to 3.0 percent; manic-depressive psychosis at 0.3 percent, and cite research findings which indicate that "two out of every five persons with psychoses and one out of every five with schizophrenia have never received treatment." (p. 16, v. II.) More- over, approximately two million peOple in the United States would be diagnosed as schiZOphrenic; about 100,000 new cases every year (p. 19). 54 and psychosocial treatment of schizophrenia since 1970, Gunderson summarized the following conclusions drawn from the research: 1. Use of drugs is not ethically necessary for care of all schizophrenic patients. It seems especially likely that good premorbid patients may recover without these measures. 2. The effectiveness and necessity for drugs will depend on the nature of the psycho- social context in which they are given. This includes in particular the attitudes and morale of the treatment staff within institutions and of the family after dis- charge. 3. Relatively inexpensive psychosocial after- care can assist patients in their social adjustment. 4. Milieu therapies can render relatively powerful effects on outcome (p. 13). A number of controlled outcome studies have evaluated the effectiveness of Aftercare and Day Treat- ment/Patient-Hospitalization programs. Effectiveness of these psychosocial treatment approaches has been evaluated in terms of the following (Test & Stein, 1978) outcome variables: (1) time spent out of the hospital, (2) relapse-readmission rates, (3) psychiatric symptoma- tology, (4) psychosocial adjustment and functioning, and (5) client satisfaction. Test and Stein (1978) cite the following six factors to account for the steady shift since 1955 from 55 maintaining patients in mental hospitals to maintaining "patients" in the community: (1) (2) (3) (4) (5) (6) The availability Of effective psycho- tropic drugs. The post-World War II explosion in the number of mental health professionals in all disciplines. Mental health principles intrinsic to the community psychiatry movement, specifi- cally the doctrine of treatment near home. Legal actions in the courts and through legislation to protect the civil rights of mental patients. Economic motives for reducing or shift- ing the cost of care for these patients. Research results that demonstrated quite conclusively that hospital treatment is relatively ineffective in helping patients establish a sustained community adjust- ment after discharge from the hospital (p. 350). However, the problem that has resulted from this shift away from institutionalization has become one Of how to effectively provide treatment for these individ- uals returning to the community, who are generally found to be leading impoverished and minimally coping exist- ences; with high recidivism, unemployment (Anthony, Cohen & Vitalo, 1978); and poor attendance and length of stay in aftercare and day treatment/partial hospitali- zation programs. Stein and Test make the critical Observation that: The presence of large numbers of patients in the community necessitated the development of treatment modalities for them; community treatment programs thus began to be imple- mented on a widespread basis. Unfortunately, 56 most such programs were neither well grounded in a theoretical framework nor based on evi- dence of demonstrated effectiveness (p. 350). [Underlining mine-M.A.T.] Aftercare and Day Treatment/ Partial Hospitalization Sheldon (1964) reported an early study undertaken to evaluate whether aftercare would significantly reduce hospital readmission. Eighty-three affective disordered and schizophrenic women with an age range of 20-59 years were randomly assigned to either aftercare or to their general practitioner (no aftercare) following discharge. Aftercare patients were randomly assigned to either a day center or to an out-patient clinic. Pa- tients were followed-up for a six-month evaluation period, based upon published statistics which showed that 50-70% of patients who relapsed do so within six months. Aftercare patients were found to have a signifi- cantly lower hospital readmission rate than patients who did not receive aftercare. Patients who attended after- care regularly showed a significantly lower readmission rate than patients with poor attendance. Aftercare was associated with a longer time spent under care during the six-month follow-up, but showed a shorter subsequent hospitalization time. 57 Unfortunately, Sheldon does not describe the aftercare treatment provided, although he does refer to "a primary therapeutic relationship" provided in treat- ment. Wilder, Levin, and Zwerling (1966) reported the results of a two-year (after admission) follow-up evalua- tion of acute psychotic patients treated in a day hospital. Acute patients admitted to the Bronx Municipal Hospital Center were randomly assigned to either a weekday day program, or to 24-hour inpatient service. There were no differences between the two patients' groups in age, sex, race, religion, marital status, or diagnosis. Approximately two-thirds of assigned pa- tients were "accepted" by the day hospital; one-half of the "rejected" patients were acute or chronic organic patients. Treatment staffs for both services were de- scribed as comparable in training and experience; both utilized medication and somatic treatment as necessary. The day hospital census was 25-30 patients; the in- patient service of four wards was 100 patients. Wilder et a1. describes each treatment service: Day hospital therapy is planned at three levels: individual, family and group. Psy- chiatric residents see their patients in- dividually a minimum of twice each week and see them together with the family at least 58 once each week. A social worker, usually with the treating doctor, makes an evening home visit during the first two weeks of hospitalization. Perhaps the most distinctive aspect of the therapeutic regimen of the day hospital is that it reflects the utilization of group processes for treatment. Patients are as- signed upon admission tO one of three ac- tivity groups of 8-10 patients. Each group has a group doctor, a nurse acting as ac- tivity leader and an aide-~all wearing ordinary street clothes. Small group co- hesiveness is further fostered by one—hour morning group discussions and a moderately structured daily group activity program. A 'therapeutic community' orientation is fostered by weekly community meetings and a patient government. Unlike the day hospital, the inpatient ser- vice is subjected to a tremendous pressure of admissions and the attendant disposi- tional problems. Many patients are quickly discharged back into the community and at least one-third are transferred to the state hospitals. Patients who are kept for longer treatment are usually seen in individual therapy; there is little family or group treatment. Although there are weekly ward meetings, scheduled activities are less fre- quent and tend to be along the more tradi- tional occupational therapy and recreational therapy models . . . (p. 1096). Evaluation was made by means of an interview schedule conducted by a trained research assistant with the patient and family member interviewed together and separately. Interviews were obtained for 92% of the patients; full ratings for about three-fifths of the study population. The results showed no significant differences in rehospitalization rates between the two treatment 59 services; however, the interval between discharge and first admission was significantly longer for the day hospital patients. The authors comment that the briefer period of inpatient treatment may account for this earlier readmission in the inpatient-treated groups, or the difference may reflect gains achieved by the day hospital patients who had continued to reside in the community during treatment. Interview ratings showed no significant dif- ferences on psychiatric status between patient and family or between treatment groups. Inpatient service patients rated their family adjustment significantly higher than did the day hospital patients. Both pa- tients and their families said that they preferred day hospital to 24-hour inpatient service. Both patient groups showed considerable social constriction and poor work performance, and frequent rehospitalizations. Guy, Gross, Hogarty and Dennis (1969) reported a controlled evaluation of day hospital effectiveness comparing a day hospital (drugs plus milieu) to an outpatient clinic (drugs alone). The sample of 137 patients were screened for age (18-65), patient motivation and family cooperation, antisocial behavior, overt suicidal behavior, severe mental retardation, severe brain damage, alcohol or 60 drug addiction, and medical conditions which would interfere with treatment. Following assessment, patients were randomly assigned to either the day center or outpatient clinic treatment groups. The day center treatment utilized chemotherapy, group psychotherapy, rehabilitation, and recreational therapies. Unforseen exigencies created a third group of patients accepted for day hospital treatment, but unrandomized and therefore not part of the experimental group. Assessment was carried out pre-treatment by an independent assessment team (psychiatrist, psychologist, social worker) to control for therapist bias. Evalua- tion was based upon the Brief Psychiatric Rating Scale (BPRS), Springfield Symptom Index, and three clinical global judgments Of psychiatric status and improvement. Reassessment was made at termination; the point of termination was a clinical decision made by the therapist. Results are based upon complete evaluations from 92 out Of 137 patients (67%). The authors report that nearly 20% of the patients dropped out/refused treatment, or were disruptive and unacceptable for day center; these patients were found to be significantly more severely disturbed on 23 out Of 29 psychiatric criterion measures . 61 The authors describe the patient sample as in- termediate between outpatients and inpatients in severity of illness: Characteristically, patients admitted to the BPDC were white, female, married, and living in a conjugal home. Their psychiatric his- tory was lengthy, including prior experience with psychotherapy and short hospitalization. Disruption of the family during the patient's developmental years was common as was their prior use of community psychiatric facilities (p. 330). The results of the data analyses showed signif- icant overall group differences on two global measures: the day center experimental group showed significantly greater symptom reduction than the other groups on the Global Severity of Illness measure, and significantly greater improvement on the Global Judgment of Degree of Improvement measure than the outpatient drug-alone group. Analysis of the data by diagnostic category showed significantly greater improvement for schizo- phrenic patients as compared to non-schiZOphrenic pa- tients; the day center experimental group schizophrenics showed significantly greater improvement on Suspicious- ness, Unusual Thought Content, and Hostility. Schizo- phrenics in both the day center experimental group and the outpatient group showed significant improvement on Emotional Withdrawal. Outpatient drug treatment showed a significantly shorter length of treatment; however, when therapeutic 62 outcome versus length of treatment were compared, pa- tients treated more than three months at the day center showed significantly greater improvement than day center patients treated less than three months. A Rehospitalization data showed no differences between the three groups in the number of patients re- hospitalized within one year Of termination of treat- ment; however, both day center groups showed signifi- cantly briefer rehospitalization than the outpatient treated group. The authors found that certain sociodemographic variables predicted significantly greater improvement on specific schizophrenic symptoms in both treatment groups: Married patients who live in conjugal homes exhibited overall greater symptom reduction than those from non-conjugal homes on the schiZOphrenic symptoms of Hallucinations, Conceptual Disorganization, Blunted Affect, and Unusual Thought Content. Similarly, those who were more than 20 years of age at the time of their first episode and had less than one month of previous hospitalization appear to gain greater benefit from either treatment. On the other hand, patients who were under 20 at the time of their first episode and have experienced longer periods of hospi- talization show significant worsening of symptoms such as Projection and Rage under day hospital treatment. The stimulation and intensity of interaction in milieu therapy may have a negative effect on these symptoms, an effect that is not apparent when drugs are used alone. 63 Of interest is the worsening of sexual prob- lems among day hospital patients without pre- vious psychotic episodes. It would seem that such patients become aware of their difficul- ties in this area only after an experience in the day hospital where group discussions bring this tOpic into focus. In the present study, marked schizo-affective features were observed among the schizophren- ic pOpulation. The symptom constellation which was significantly reduced among day hospital schizophrenics reflected improvement in communication and accessibility. These patients were less hostile, less withdrawn, less suspicious, and more cooperative. As this constellation of improvement was not Ob- served among the outpatient clinic schizo- phrenics, it seems reasonable to attribute the difference to the milieu component of the day hospital regime (p. 330). Herz, Endicott, Spitzer, and Mesnikoff (1971) reported a controlled study of day versus inpatient hospitalization. Patients were selected for the study by the senior author who screened all newly admitted patients (424) to the inpatient service; alone, and with their families. Screening criteria were that the patient not be "too ill" or "too healthy" for day care; family co- operativeness; and no physical illness. Ninety patients, representing 22% of all new admissions, met the criteria and were then randomly assigned to either day or in- patient hospitalization groups; by coincidence, each treatment group contained 45 patients. The average length of inpatient stay prior to assignment was approx— imately three days. 64 The authors describe the day center and in— patient treatment: Both day patients and inpatients were treated on the same 55-bed inpatient ward, which has an Open-door policy except for a closed ten-bed intensive care unit. Patients in both groups were treated by the same staff and participated together in the same activities during the day. The ward program is group oriented, with a strong emphasis on activities of patients. A full range of psychiatric treatments was utilized, including individual psychotherapy; group, family, milieu, and somatic therapy; and vocational rehabilitation. If it was deemed appropriate, patients were followed, after discharge from either day or inpatient hospitalization, as outpatients (p. 1372- 1373). Evaluation was made initially, at two weeks, four weeks, and five months after the last patient entered the study; the follow—up period varied from 21-143 weeks, with an average of slightly less than two years for patients in both groups. Psychopathology and role functioning were evaluated with the Psychiatric Status Schedule (PSS) and the Psychiatric Evaluation Form (PEF). The PSS utilizes a structured interview and an inventory of 321 items describing psychopathology and impaired role functioning which yield symptom scales and role-function— ing scales. The PSS was completed on admission and at four weeks by research interviewers not connected with treatment. The PEF consists of rating scales of psycho- pathology, role functioning, and overall severity of 65 illness. The PEF was completed by the treating psy- chiatric resident or psychology intern on admission and at two and four weeks. Research interviewers used the PEF in the long-term follow-up evaluation. Herz et a1. state that, "In terms of broad dimensions of psychopathology" the study group of pa- tients was comparable to the entire group Of patients including those excluded for being "too ill" and "too healthy;" however, they also report that, "The differ- ences between the study group and the two groups ex- cluded from the study were often statistically signif- icant (p < .05), but the magnitude of the differences was never large." Evaluation at two and four weeks was made on 75-82% Of the patients because of various diffi- culties. Significant differences appeared at four-week follow-up: the day patients showed significant improve- ment over the inpatients on the PEF scales Of Agita— tion-Excitement, Suicide-Self-Mutilation, Grandiosity, and Suspicion-Persecution. On the PSS, only one scale showed a difference between the two groups: the day patients showed significantly more improvement than the inpatients on the Inappropriate Affect, Appearance, or Behavior scale. At the long-term evaluation, the only differences found between the groups were that the day patients 66 showed significant improvement on Daily Routine-Lei- sure Time Impairment and House-Keeper-Role Impairment. The authors show by percentages that at every point in time compared, the inpatients showed a higher readmis- sion rate than the day patients; moreover, at every cross section evaluation more Of the day patients than inpatients were in the community--however, these dif- ferences in percentage rates are not reported with significance levels. Caffey, Galbrecht, and Klett (1971) in a study Of the effectiveness of brief hospitalization and after- care in the treatment Of schizophrenia compared 201 schizophrenic males randomly assigned to one of three treatment groups: (A) standard hospital care with dis- charge at physician's discretion and normal VA care (e.g., referral to social and psychiatric resources), (B) accelerated hospital care limited to 21 days and psychiatric and social work treatment by the same staff for one year on an outpatient basis, and (C) standard hospital treatment followed by the aftercare program given Group B. Consecutive admissions to 14 VA hospitals were screened for age (60 years or under), alcoholism, medi- cal conditions which could delay discharge, recent hospitalization, availability of a "home" following discharge, means of self-support, and potential for 67 destructiveness. Patients ranged in age from 19-55, with a mean profile of 37 years old, married, and living in a residential section Of a middle-class neighborhood with a pOpulation area of 25,000-100,000. Patients in all three groups were primarily treated with chlorpromazine (Thorazine), trifluoperazine (Stelazine), or thioridazine (Mellaril), alone or in combination. Groups were fairly comparable in medica- tion dosage; dosage was somewhat reduced during the out— patient phase. Inpatient psychotherapy for all patients con- sisted primarily of individual therapy, usually of a supportive nature, or individual therapy with conjunc- tive group therapy. The frequency of individual therapy varied from daily to once or twice monthly. Patients in Group A (standard hospital care) and Group C (standard hospital treatment followed by the aftercare program given Group B) who were readmitted were found to be patients who had been hospitalized for a significantly shorter time than nonreadmitted patients; and patients in Groups A and C combined who had been hospitalized for 30 days or less had significantly more readmissions than patients hospitalized for a longer time. Comparing Group B (shortened and more intensive discharge--directed treatment, with family involvement) 68 to usual hospital care: the IMPS ratings showed signif- icant improvement over the initial three week period for both brief and longer stay groups on the IMPS. Group B showed significantly less pathological disturbance on two variables (Retardation and Motor Disturbance). Ex- cluding Group B patients who required more than 21 days of hospitalization from the analysis, Caffey et al. reported that the remaining "successful" Group B pa- tients showed significantly less Paranoid Projection on the IMPS than patients in Groups A and C combined. Group B patients were found to manifest more pathological disturbance on the IMPS than the longer stay groups at the time Of discharge (Paranoid Projec- tion, Perceptual Distortion, Grandiose Expansiveness, and Conceptual Disorganization). Six month comparisons of the three treatment groups showed no significant dif- ferences. At 12 months, Group B showed significantly less Grandiose Expansiveness. On the KAS community adjustment evaluations there were only two significant findings: Group C was engaged in significantly more free-time activities at six months; and was significantly more negativistic than either Group A or Group B at 12 months. Group therapy varied from once to three times weekly. There were no differences between the experimental groups on frequency of therapy contacts. 69 Outpatient follow-up care with psychiatric and social work contacts were scheduled for one year for patients in Groups B and C. Approximately one-third Of the patients in Groups B and C were seen an average of once or twice weekly for the first three or four months following discharge, and then monthly thereafter. The average number Of home visits to these patients was around 18 (with a range of 1—45). Evaluation Of the effectiveness of the three treatment programs was based upon the Inpatient Multi- dimensional Psychiatric Scale (IMPS) and the Katz Ad- justment Scales (KAS). The IMPS is scored for ten syndromes defining psychosis. Psychologist-psychiatrist rating teams interviewed and rated all patients on the IMPS within three days after admission and at three weeks, six months, and 12 months after admission or at the time of discharge. The KAS evaluates community adjustment in terms of vocational and recreational activities and social interaction as reported by the patient and separately by a family member. The KAS was completed at six and 12 months after discharge. The results generally supported the effective- ness of aftercare services. NO differences were found between the groups on hospital readmission within one year after admission; and there was no difference in 70 the length of time spend out of the hospital prior to first readmission. Hogarty, Goldberg, and the Collaborative Study Group (1973); Hogarty, Goldberg, Schooler, Ulrich; the Collaborative Study Group (1974); and Goldberg, Schooler, Hogarty, and Roper (1977) have published the results of research on "Drug and Sociotherapy in the Aftercare of Schizophrenic Patients": one and two year relapse rates and prediction of relapse. The collaborative Outpatient Study in Schizo- phrenia was designed as ". . . a multiclinic attempt to provide evicence on how two modes of treatment (drug and sociotherapy) interact in the prevention Of relapse and enhancement of community adjustment over a considerable period Of time. With three clinic samples adhering to a common protocol of study, replication of results is made possible." Hospitalized schizophrenic patients were selected for the study utilizing the following criteria: (1) age 18-55; (2) a primary hospital diag- nosis of schizophrenia confirmed by the re- search psychiatrist; (3) currently hospital- ized for less than two years; (4) no evi- dence of organic brain syndrome; (5) intel- ligence quotient above 70; (6) no history of unmanageable drinking or drug abuse; (7) drug-free intervals; (8) have received phenothiazine as an inpatient and have no medical contraindications for chlorproma- zine therapy; (9) live within commuting distance Of the clinic; (10) provide a 'sig- nificant other' for rating purposes and 71 supervision of medication; (11) appear at the clinic within 21 days of discharge, and (12) receive no other ataractic other than study medication during the course of the investigation. Furthermore, to test the effects of MRT [Major Role Therapy] only wage earners and homemakers are included, with students ex- cluded by design. Patients meeting the selection criteria were consecutively discharged over an 18-month period to one of the three outpatient clinics: They were randomly assigned at intake to major role therapy (MRT): a sociotherapy consisting of intensive counseling. All patients were maintained with drug therapy during the first two months with medication gradually shifted to chlopromazine (Thora- zine) exclusively. At two months following intake, patients were again randomly as- signed on a doubleblind basis to identical looking 100-mg or 50-mg tablets of chlor- promazine or placebo. The study design initially specified that 15 male and 15 female patients at each clinic be randomly assigned to each of four treatments at the two month period: chlor- promazine alone, placebo alone, placebo and MRT, chlorpromazine and MRT. The desired 360 patients were then to be treated for a minimum of two years and for as long as three years (1973, p. 55). The study ultimately included 374 patients, with the specified number Of patients exceeded at two of the three clinics, and fewer than the desired 15 male pa- tients per treatment group retained because of exclu- sions for chronic alcoholism, transiency, or both. MRT 72 and non-MRT patients were seen an average of twice monthly. Evaluation of personal adjustment, social adjust- ment, and role performance was assessed at 6, 12, 18, and 24 months following hospital discharge, using ratings completed by the psychiatrist (Brief Psychiatric Rating Scale-BPRS, Inpatient Multidimensional Psychiatric Scale, and Springfield Symptom Index B-SSI), the social worker (the Major Role Adjustment Inventory and Casework Eval- uation Schedule specifically designed for this study), the patient (the symptom checklist), and the relative (Katz Adjustment Scales, Family Distress Scale). The results at 24 months showed that chlorpro- mazine is significantly more effective than placebo in forestalling relapse: on the average, chlorproma- zine-treated patients survived 17 months in the com- munity while placebo-treated patients survived 10 months, 80% of placebo—treated patients had relapsed compared to 48% of drug-treated patients. The authors defined re- lapse as ". . . clinical deterioration of such magnitude that rehospitalization is imminent; about 75% of relapse patients were actually rehospitalized." The size Of the drug/placebo difference is significantly greater for women than for men; by 24 months 63% Of male patients taking chlorpromazine have re- lapsed compared to 37% of female patients on the drug. 73 Major Role Therapy itself showed no significant effect on forestalling relapse over 24 months; however, MRT showed a significant effect after six months among patients who had survived in the community six months after hospital discharge. It was concluded that the drug/MRT effects were additive rather than interactive. Significant treatment effects began to show at 6 and 12 months, but were more pronounced at 18 months and sustained and further developed at 24 months. Anal- ysis of the various ratings of personal and social ad- justment showed no extensive main effect of chlorproma- zine or consistent main effect of MRT. The consistent interaction found between drug treatment and MRT was that: (1) among drug treated patients, those who do receive MRT adjust better; (2) among placebo-treated patients, those who do not receive MRT adjust better; (3) the inter- action between drug treatment and MRT ap- plies more to men than women and indicates that men receiving placebo and no MRT are the better adjusted survivors and; (4) drug treatment is more effective than the placebo for women, but placebo treatment is more ef- fective than the drug for men (p. 612, 1974). The investigators concluded that: The interactive effect of drug and socio- therapy takes at least 18 months to emerge, and two years before the influence of socio- therapy and drug treatment is uniformly dem- onstrated from the point of view of rela- tives, patients and therapists. If treatment objectives extend beyond the prevention of relapse, then our results suggest that schiz- Ophrenic patients must be continued in 74 treatment well beyond a single year follow- ing hospital discharge. Likewise, control- led evaluations Of either drug or psycho- therapeutic aftercare treatments of schizo- phrenic patients would be deficient in de— sign if limited to less than an 18-month period of treatment and observation. It is entirely possible, of course, that other drugs or routes of administration, or other forms of non-somatic treatment Offered by greater or lesser trained professionals could produce similar or more dramatic ef- fects earlier than 18 to 24 months (1974, p. 615). Washburn, Vannicelli, Longabaugh, and Scheff (1976) compared psychiatric day treatment and in— patient hospitalization. Ninety-three female patients between the ages of 16-72 (Mean 32.9), predominantly middle-class, newly admitted to McLean Hospital with a primary diagnosis of schizophrenia (50%), affective psychosis (12%), personality disorder (20%), or borderline personality (18%), were Obtained from a larger hospital sample of 165 patients who met the criteria for randomization. The 93 patients who agreed to participate in the study ‘were not found to be significantly different from the larger pOpulation in terms of age, chronicity, marital status, proximity of family residence from the hospital, education, socioeconomic status, and religious affilia- tion. Following two to six weeks of inpatient evalua- tion, 59 of the patients were randomly assigned to 75 inpatient service (30 patients) or to the day center (29 patients). The remaining 34 patients were included in a day center control group representing a group of "usual day hospital patients." There were no differ- ences between the randomized inpatient and day center groups on demographic or baseline pathology criteria. The specific study criteria were that patients not be so suicidal, homicidal, or incapable Of forming a treatment alliance as to preclude treatment in the day setting; and ability to finance treatment over the two years of the study. Treatment effectiveness was evaluated on dimen- sions of psychopathology and social adjustment and treatment costs. Baseline measures of mental status and family and community functioning were obtained prior to randomization. Psychopathology was evaluated using the Psy- chiatric Status Schedule (PSS), the Psychiatric Evalua- tion Form (PEF), and the Dynamic Assessment Scale (DAS). The P58 is a mental status interview which assesses symptomatology, role functioning, efficiency and conduct of leisure time activities and daily rou— tine, quality of interpersonal relationships, use of drugs and alcohol, and illegal or other antisocial activity. The PSS provides five summary scales: Subjective Distress, Behavioral Disturbance, Impulse 76 Control Disturbance, Reality Testing Disturbance, Sum- mary Role, and a Total score. Both a subject form and an informant form of the PSS were administered by trained interviewers at six month intervals. The PEF provides seven summary scales: Dis- organization, Subjective Distress, Anti-social Behavior, Withdrawal, Grandiosity, Role Performance, and Overall Summary. The PEF was administered every two months by trained interviewers. The DAS, adapted from the Camarillo Dynamic Assessment Scales, was designed to measure intrapsychic change in the patient as perceived by the therapist (e.g., ego capacity, tolerance for emotional contacts, attitude toward personal relationships, object rela- tions-Object choice, sense of personal identity role in life, insight, and motivation). The DAS was completed by the patient's therapist and/or case manager at six month intervals. Social adjustment was evaluated using the Family Adjustment Questionnaire, the Community Adjustment Questionnaire, the Burden Evaluation Line, and the num- ber of roles attempted by the patient. The Family Ad- justment Questionnaire rates the patient's involvement in family functions, ability to relate with family mem— bers, and ability to conform to family expectations. Parallel forms were administered to the patient and to 77 the informant by the clinical interviewer at six month intervals. The Community Adjustment Questionnaire rates the extent to which the patient participated in communi- ty activities and the quality of participation. Paral- lel forms were administered to the patient and informant every six months. The Burden Evaluation Line is a rating completed by the interviewer at six month intervals of the extent to which the patient's illness has imposed a burden on the family. The results of the data analysis showed that across treatment groups, Global Mental Status, Impulse Control, Family Adjustment Questionnaire, and Subjective Distress all showed significant improvement at all four comparison periods; community adjustment, role function- ing, global mental status (PEF), number of roles at- tempted, and burden showed significant differences base- line tO overall post-test. Comparing the day center experimental and in- patient groups on the measures of psychopathology, sub- jective distress was the only measure which showed a significant difference between the two groups. On the measures of social adjustment, the day center group showed significantly more improvement on community adjustment than did the inpatient group; however, by 18 months the inpatient group had caught up 'with the day center patients. 78 As expected, total direct charges were signif- icantly lower for the day group reflecting the lower cost of Operating and staffing an 8-hour versus a 24-hour facility. Day center patient families reported signifi- cantly less burden than did inpatient families at one year after admission to the study; and at termination of the study, day center families were significantly more satisfied with the treatment than were the in- patient families. Group Versus Individual Approaches In a review of controlled research on drug and psychosocial treatment of schizophrenia, Gunderson (1977) comments on the findings from studies of group therapy: These studies demonstrate uniform utility for nonintensive group therapy in the after- care of both acute and chronic schiZOphren- ics. This utility seems largely to be in the form of improving social, interpersonal behavior. Had outcome measures been lim- ited to assessments of symptoms, this area of effectiveness for group therapy would not have been apparent in several studies (p. 13). Levene, Patterson, Murphey, Overbeck, and Veach (1970) evaluated 31 diagnosed schizophrenic patients on the following criteria: living with a family member, on phenothiazines, no evidence of childhood autism or 79 schizophrenia, no evidence of organic brain syndrome, epilepsy, gross mental deficiency (IQ < 70), or alcohol or any addiction; and the presence on admission of two or more of the following symptoms: thinking or speech disturbance, catatonic motor behavior, paranoid idea- tion, hallucinations, delusional thinking other than paranoid, blunted or inappropriate affect, and dis- turbance Of behavior and interpersonal relationships. Each of two psychiatric residents saw patients in either monthly individual appointments (15-30 minutes duration) or monthly in an hour long group com- posed of five to seven patients. The investigators state that "the sessions were devoted to a review of current status and adjustment, and to renewal of medica- tions." Community adjustment and social behavior of patients not rehospitalized was assessed using the Katz-Lyerly social adjustment inventories, administered to the patients and to their relatives at the beginning Of the study and at the end of one year. Patients were also independently rated on the Brief Psychiatric Rating Scale (BPRS) by two psychia- trists in a joint inverview with the patient at the beginning of the study and at one year. The relatives, patients, and residents were also asked to rate the consistency Of medication taking during the year. 80 The results showed that 13 out of the 31 patients (41.9%) were rehospitalized within the year; three pa- tients drOpped out; and 15 (48.3%) remained in the treat— ment program for the entire year. Nine of the 13 pa- tients rehospitalized attended four or less follow-up appointments. No significant difference was found between individual and group-treated patients in rehospitaliza- tion rates. No differences were found between the individual and group treated patients on measures of adjustment and pathology; and initial measures did not predict rehospitalization. There were no differences between patients of the two residents. Levene et a1. concluded that neither method of aftercare treatment showed impressive results; and both were inadequate for about half the sample in community maintenance or further improvement. O'Brien, Hamm, Ray, Pierce, Luborsky and Mintz (1972) compared the relative effectiveness of group and individual therapy for schizophrenic aftercare patients. One hundred newly discharged and clearly schizo- phrenic patients from a state hospital referred to a mental health clinic were initially evaluated by two members of the research team who made independent observations and assigned a prognosis rating to each patient. The mean number of hospitalizations for the 81 sample was two; the mean length of the last hospitaliza- tion was 15.4 months. The initial evaluation was based upon the Overall-Gorham Brief Psychiatric Rating Scale (BPRS), a social effectiveness scale designed for this popula— tion, the Zung self-rating depression scale filled out by the patient, and a supplemental mental status scale used by the outpatient clinic. Prognosis was assigned on the basis of the prognostic factors described by Astrup and Vaillant: (l) absence of family history of hospitalization for schizophrenic-like illness, (2) non-schizoid develop- mental history, (3) confusion at the time of hospital admission, (4) absence of marked flattening of affect, (5) presence of depressive symptoms, (6) absence of low intelligence, (7) clear precipitating factors leading to psychosis, (8) acute onset of psychosis, and (9) presence of a stable marriage. Following the initial evaluation, patients were randomly assigned to group or to individual psycho- therapy; 50 patients being assigned to each treatment. Sixteen therapists (psychiatrists, supervised medical students, and social workers) provided group and indi- vidual psychotherapy which was described as supportive therapy. 82 Follow-up ratings with the scales used at ini- tial evaluation were made at 12 and 24 months after beginning outpatient treatment. The following criteria were used for the overall outcome evaluation at 24 months: 1. NO rehospitalization, and improvement of at least 20% in both the Brief Psychia- tric Rating Scale (BPRS) and the social effectiveness scale. 2. No rehospitalization and improvement (20%) in either social effectiveness or BPRS. 3. No rehospitalization and either worsening or no significant change ( < 20%) on both‘ scales. 4. Rehospitalization or a dropout with worsening or no change on the rating scales. An independent observer reviewed attendance and drug continuation at each follow-up. The decision to rehospitalize was generally made by a hospital psy- chiatrist who did not know about the study. The results showed that rehospitalization rates for individual and group therapy did not differ signif- icantly at 12 or at 24 months. The overall outcome rating at 24 months showed that group therapy patients had improved significantly more on both the BPRS and Social Effectiveness Scale; while the individual therapy patients showed significant improvement only on the Social Effectiveness scale. O'Brien et al. concluded: 83 "Thus the major effect of group over individual psycho- therapy as measured here was in clinically observed improvement." Herz, Spitzer, Gibbon, Greenspan, and Reibel (1974) studied the relative efficacy of minimal indi- vidual contact versus group therapy, with equal thera— pist time allocated to each treatment. One hundred forty-four aftercare patients were randomly assigned to either group (76) or individual (68) therapy; from this initial sample, 54 patients in each treatment were seen at least once in an individual screening appointment. Subsequently, 13 group and 9 individual patients dropped out. From the remaining treatment groups of 41 group and 45 individual patients; 7 group and 4 individual patients dropped out by the twelfth month end of treatment. Therapists were first-year psychiatric residents randomly assigned to individual or group treatment. Residents were supervised weekly by a senior attending psychiatrist. The therapy was described as "supportive, reality-oriented psychotherapy with little if any em- phasis on insight. In addition, there was an attempt to promote socialization and deal with interpersonal issues in the group." Evaluations were made by the therapist after the initial interview and at 4, 7, and 11 months using 84 the Problem Appraisal Scales (PAS) and the Menninger Health-Sickness Rating Scale (HSR). The PAS rates 38 areas of disturbance, including signs and symptoms Of manifest psychopathology, providing a scoring system of six broad dimensions of psychotherapy. The HSR pro- vides a single rating of overall mental health. Patients completed the Symptom Distress Check List (SCCL) at the same intervals as therapist evalua- tions were made. The SDCL is a self-rating of the intensity of a wide variety of subjective symptoms which are scored into five scales. The results of treatment showed an equivalent readmission rate Of 15% for both treatment groups, with a substantially higher rate for those who refused individual treatment initially. In general, the therapist and patient ratings showed only small amounts Of improvements, with no significant improvement in the level of psychOpathology and role functioning. At four months the PAS showed more improvement for the individual patients than the group patients on four out of six scales; however, at the seven month evaluation, this difference decreased to only two scales of the PAS showing a significant difference in favor of individual treatment. By the final evaluation at 11 months, there were no significant 85 differences between the treatment groups on therapist or patient ratings. The authors concluded that "although there were no differences in outcome measures between individual and group therapy, we nevertheless recommend that after- care programs shift to making much greater use Of group therapy of a supportive, reality-oriented type accom- panied by appropriate use of pharmacotherapy." However, more Objective conclusions can be made from the data reported. Herz et a1. apparently neglect the significance of the finding that 68% of group pa- tients remained in treatment for the 12 months compared to 76% of individual patients; furthermore, 32% of group patients dropped out of treatment by 12 months compared to 24% of individual patients, and if initial dropouts were included, the results would show that 49% of patients rejected group therapy treatment compared to 26% who dropped out of individual treatment. The results for individual therapy appear to be even stronger since "two-thirds of the group patients were seen either weekly or biweekly" as compared to less frequency of contact for the individual patients ("Seventy-five percent of individual patients were seen either biweekly or monthly for sessions ranging from 15 to 30 minutes"). 86 Finally, since most of the study patients were on psychotropic medication during the study, and no information was given as to whether a therapeutic goal was to decrease medication, it is interesting to specu- late whether given the initial reduction on the PAS in Depression-anxiety, Disorganization, Social Impairment, and Grandiosity-externalization for the individual pa— tients at four months, did pharmacotherapy not even- tually effect a ceiling or retarding effect upon further improvement with psychotherapy (c.f., Karon & VandenBos, 1972; Paul, 1972; Rappaport, 1977; Goldstein, 1969, 1970; Goldberg et a1., 1977). Claghorn, Johnstone, Cook, and Itschner (1974) evaluated the effectiveness of group therapy and main- tenance treatment of schizophrenics, reasoning that "psychotrOpic compounds alone cannot assist the out- patient in meeting the new and rigorous demands of daily living. Under such conditions, the schizophrenic might benefit from some form of psychotherapy, offered concurrently with pharmacotherapy." Forty-nine male and female outpatients diag- nosed as schizOphrenic and referred for outpatient treatment following their first admission to a state Jhospital, and without any serious intercurrent medical problems, were randomly assigned in a double-blind Inanner to one of four treatment regimens: 87 Each group received either thiothixene or chlorpromazine in conjunction with either weekly group therapy or no psychotherapy; duration of treatment was six months. Medication was prepared in identical-ap- pearing capsules, containing either 50 mg of chlorpromazine or 5 mg of thiothixene (dose levels were judged comparable), and dosages were adjusted individually to a schedule of one or two capsules taken three times daily. A single psychotherapy group was formed for patients receiving the two drugs. Group procedures tended to be of a structured nature, with emphasis on the problems and tasks of daily living. The two medication groups (thiothixene and chlorpromazine) contained 13 and 9 patients, respectively; the thiothixene-group therapy sample contained 14 persons, while the chlorpromazine-group therapy had 13 (p. 362). Patient evaluations were made pre-treatment and at monthly intervals thereafter. Evaluations were based on a global assessment of the degree of improvement rated by the psychiatrist, the Brief Psychiatric Rating Scale (BPRS), and the Interpersonal Test Battery--con- sisting of the Minnesota Multiphasic Personality Inven- tory (MMPI), the Interpersonal Check List (ICL), and the Thematic Apperception Test (TAT). The investigators give the following explanation of the conceptual framework of the Interpersonal system and the Interpersonal Test Battery: Responses on each test are scored in rela- tion to their position on a two-dimensional grid, with dominance-submission and affilia— tion-Opposition as the dimensions. Each test is conceptualized as reflecting a 88 'level' of behavior: the MMPI represents the level of public behavior, the self-reported ICL, the level of conscious behavior, and the TAT the level of preconscious behavior; in addition, an 'intentionality' or motivational measure is derived from the Pd and Mf scales of the MMPI (p. 362). The results showed significant improvement on the BPRS for all four groups; with no differences be- tween the four study groups. Because of problems with patient OOOperation, the sample of post-treatment Inter— personal Test Battery was reduced to 21 patients (43% of the total patient sample); the authors report that this subsample was not found to differ significantly from the remainder of the patient sample on pre-or post-treatment BPRS. The investigators conclude that the results show "subtle but meaningful changes in emotional funct- ioning due to concurrent group therapy." However, the results appear equivocal: for example, the drug-therapy group showed a significant shift on the ICL toward self-perceptions of themselves as lg§§_dominant and less affiliative following treatment. This group also showed a significant shift in TAT perceptions Of others as more dominant and more affiliative following treatment. Claghorn et a1. interpret these findings as indicating that these patients' "perception of the rest of the world as more healthy indicates a greater appreciation of their disability." 89 The findings in this study are limited by the six-month span of treatment, possible bias because the raters were the therapists, and 57% reduction in the post-treatment data sample. Section Conclusions The preceding review of controlled studies of aftercare and day treatment/partial hospitalization, and group versus individual therapy for psychotic patients generally, and schizophrenic patients in particular, supports a number of conclusions drawn from the research methodologies and outcome findings of the studies re- viewed: (1) Excluding a rather large and undefined group of patients who are judged "too ill" to be treated in aftercare and day treatment/partial hospitalization programs (Test & Stein, 1978), community based treatment approaches showed some advantages over hospital treat- ment in terms of fewer relapses, shorter hospital stay if rehospitalized, more improvement in psychosocial functioning and community adjustment, and slightly more improvement in symptomatology. (2) The aftercare and day treatment/partial hospitalization studies reviewed made routine use of drugs in treatment; reduction in medication dosage in relation to evidence of symptomatic improvement did 90 not appear to be valued as a treatment process and out- come goal. (3) Generally, supportive, therapeutic manage- ment, socialization-fostering therapies were preferred over psychoana1ytic-psychodynamic intensive psycho- therapies focused on dysfunctional intrapsychic anxiety conflicts, regression, transference distortions, and symbolic acting-out; utilizing "depth" interpretations Of content, structure, defenses, and transference, to reduce anxiety and confusion and to develop trust, relatedness, insight, awareness, and reality testing functions within the corrective, or reconstructive emo- tional, experience of the therapeutic "transference" relationship. (4) Almost all of the studies reviewed rely upon descriptive rating scales of symptomatology and social functioning by independent interviewers, staff, patients, and family members or significant other; psy- chometric and projective psychological testing are generally not utilized. In particular, direct measures Of thought disorder and intellectual functioning are usually not a part of the evaluation methodology de- spite the centrality of cognitive dysfunction in the diagnosis and nosology of psychotic disorders. (5) Generally, the treatment phase of these studies ranges from 12 months to 24 months; a number 91 of studies reported no significant findings at six months assessments. (6) Most of the studies reported some diffi- culties encountered with patient dropout from treatment, attendance and length of stay in treatment, as well as patient COOperation with completing evaluations, and resultant incomplete study data. These difficulties underscore the realities in attempting to provide treatment, much less testing, with this generally dis— turbed, unmotivated, uncooperative, uncommunicative, terrified, and resistent patient population, and sup- ports the conclusion that patient motivation is a primary process and outcome variable in psychosocial treatment with psychotic individuals. THE DEVELOPMENT AND EVALUATION OF A PSYCHOANALYTICALLY ORIENTED DAY TREATMENT PROGRAM Funding for the starting of three new day treat- ment programs for a tri-county community mental health system provided an opportunity for the development and evaluation of an experimental pilot study of psycho- analytically oriented day treatment at one of these centers, based upon a type of psychoanalytic psycho- therapy described and evaluated in the Michigan State Psychotherapy Project (NIMH grant MH 08790) reported by Karon and VandenBos (1981). Each of the three new day treatment programs was funded by the Michigan Department Of Mental Health to provide day treatment programming for ten full-time or 20 half-time clients per week. The programs were ini- tially funded for two day treatment therapists and one aide/van driver. Each of the three new day treatment programs became a unit of an existing small rural com- munity mental health center. Day Treatment nggram; Milieu; Day Center Facilities The experimental psychoanalytically oriented day treatment program was specifically designed to 92 93 provide severely dysfunctional chronic aftercare clients with meaningful and psychotherapeutically corrective or reconstructive, developmental experiences in three broad areas of functioning: (l) cognitive, (2) emotional, and (3) interpersonal, that are pathognomonic of psychotic ego regression and chronic high anxiety-arousal in functional psychoses. The experimental day treatment program inte— grated psychoanalytically oriented group psychotherapy, adjunctive individual psychoanalytic psychotherapy when indicated, movement therapy, dynamically oriented art therapy (Billig, 1970; Naumberg, 1950, 1953, 1966), activities of daily living (ADL) skill building, and periodic discussion groups on such relevant issues as communication skills, assertiveness training, human sexuality, and reality testing. The day treatment program was developed for two groups of ten half-time clients meeting on alternating weekdays. The day program typically began with clients arriving at the center on their own or transported by the agency van. The morning began with an unstructured arrival time during which clients could have coffee, read the newspaper, chat, or help staff set up for the day. The staff could form an initial impression of the mood of the clients during this time. Within a half hour of the clients arriving at the center, clients and 94 staff met for a morning meeting to jointly plan the day's schedule and shared responsibilities, and handle business and individual concerns-~which might be re— ferred for discussion in group therapy. Following the morning meeting, the group spent an hour in movement-music therapy responsive to the pervasive mood of the clients (e.g., passive/active, loud/soft, individual or interactive). This was followed by a break period, and group psychotherapy that contin- ued to lunch, which might be prepared jointly by clients and staff. Following lunch were large time periods in the afternoon for art therapy or projects, informal discus— sions, and scheduled individual psychotherapy appoint- ments. The day's schedule ended with an afternoon meeting intended to provide cohesiveness and closure for the group. Each Of the two client groups had edu- cational or recreational field trips scheduled on alternating Fridays. The important milieu characteristics associated with psychosocial treatment outcome have been discussed by Mosher and Gunderson (Bellak, 1979): they note that Bullard [1940] made the early suggestion of "an environ- :ment in which the patient may be sick and unpunished for it." 95 The facilities of the day center consisted of a large classroom-like day room with conference tables and chairs, bulletin boards on the walls, clients' plants at the windows, an adjacent kitchen, and a smaller group room furnished like a family living room. Psychoanalytic Treatment of Psychotic Disorders: Theory and Practice The psychoanalytically oriented treatment ap- proach developed for the experimental day treatment pro- gram was generally based upon clinical research on the etiology, psychodynamics, and treatment of psychotic disorders (e.g., Arieti, 1974, 1977; Bateson et a1., 1956; Bellak, 1969, 1979; Burton, 1961; Doucet and Laurin, 1969; Erikson, 1963, 1968; Fromm-Reichmann, 1950, 1959; Fairbairn, 1952; Freud, 1900; Gunderson and Mosher, 1975; Guntrip, 1968; Hill, 1974; Kernberg, 1975, 1976; Lidz, 1973; Rosen, 1953; Rosenfeld, 1965; Searles, 1965; Sullivan, 1953, 1962; and Wynne and Singer, 1963), and specifically upon an active intensive psychoanalytic psychotherapy of schizophrenia (Karon, 1958, 1960, 1963, 1964, 1976; Karon and Rosberg, 1958a, 1958b; Karon and vandenBos, 1977, 1981; and Rosberg and Karon, 1958, 1959) empflasizing object relations structural theory, oral dynamics and ego regression in psychosis, counter-transference analysis in understanding the delusional transference fantasy, and transference, 96 defense, and so-called "direct" interpretations of latent symbolic-symptom content in thought, affect, gesture, and behavior. As noted by Karon (1963, 1976): In fact, schizophrenics are a widely varied group of human beings. What they have in common is that they are using rather drastic techniques Of adjustment. Insofar as they have anything in common, they can be char- acterized by Bleuler's primary symptoms: autism, a withdrawal from people; the thought disorder, an inability to think logically when they want to; and, an ap- parent absence Of affect or inappropriate affect. They may also hallucinate, have delusions, and show a wide variety of other symptoms which Bleuler called secondary, but which call attention to themselves by the severity with which one's life is im- paired. All of these may be understood as attempts to deal with terror (anxiety seems too mild a term) of a chronic kind. Human beings do not tolerate chronic terror well. Unfortunately, so-called schizophrenic symp- toms, or defenses against terror, have a tendency to make the problem worse. Thus, for example, withdrawal from people reduces one's immediate fear of people, but it makes it harder to overcome the fear of peOple, or the thought disorder, or the apparent in- apprOpriateness of one's affect by decreas- ing corrective experience. Similarly, the thought disorder and/or inappropriate affect and/or delusions and hallucinations make it difficult to relate to peOple. Those peOple who have tended to use any of these in at- tenuated form as characteristic adjustive mechanisms are more likely to use them dra- matically in the so-called schizophrenic "break." In psychoanalytic terms, they are more likely to use regression as a defense. Nonetheless, it is clear that schizophrenia is a human potentiality. All of us, under enough stress of the right kind, would de- velop schiZOphrenic symptoms [e.g., "battle- field" psychoses]. 97 But most of the patients who break down under the stresses of normal life have been pre- pared for such a breakdown by their childhood. The patient has suffered from a series Of sub- tle and unsubtle rejections all his life which lead to the formation of a set of fantasies, conscious and unconscious, which then in— fluence how later experience is perceived and the development Of further fantasies, which eventually, of course, lead to a way of under- standing the world which is intolerable (Karon and Rosberg, 1958a, 1958b; Rosberg and Karon, 1958, 1959). The active psychoanalytic psychotherapy refer- enced above was specifically adapted for treatment in the group environment of the day treatment milieu. The day treatment staff worked together in male—female co-therapist dyads in the therapy groups to utilize the transference potentials of multiple therapy in an inten- tionally fostered environment designed to provide re- gressive and progressive developmentally corrective, or reconstructive in the structural sense, interpersonal learning experiences (c.f., Berke, 1979; Mosher and Menn, 1978). The therapeutic focus of the adapted group treatment approach was on individual psychoanalytic psychotherapy in a group context, over a more usual group process approach (therapeutic focus upon the individual rather than group process has been compared by Powdermaker and Frank, 1953; Yalom, 1970; and Rubinstein [Cancro et a1., 1974]). 98 The individual focus in group psychotherapy seems theoretically and clinically consistent with the withdrawal and autism in psychosis, and the psychotic's underlying prOpensity for intensive (symbiotic) dyadic transference relatedness, and identification and splitting processes (Kernberg, 1975; Mahler, 1971). Therefore, priority was given in the treatment approach to protection and nurturance (Karon, 1963; Karon and VandenBos, 1981; Rogers et a1., 1967), to resistance, transference, repression, undoing and acting-out, and the resolution of symbolic dissociation and intrapsychic conflict ("insight"), over the enhance- ment of social functioning per se. Fromm-Reichmann (1950), Karon (1963, 1976), Brody and Redlich (1952), and Sullivan (1962) have directly suggested that the therapeutic intervention with psychotics must be focused upon the reduction of anxiety-terror to allow for the re-establishment of interpersonal trust and contingent reality testing. The group context has been reported to lower resistance to intensive psychotherapy in schizophrenics (Brody and Redlich, 1952). The staff experience with the experimental day treatment groups suggested that intensive psychoanalytic psychotherapy in a group setting allowed for a "vicarious" Observational partic- .ipation, if not more direct individual verbal 99 participation in group, for all group clients, but especially for those clients in group who were initially or intermittently severely autistic, delusional and/or hallucinating, and uncommunicative; who might neverthe- less unwittingly evidence a nod, gesture, facial expres- sion, or other manifest reation to what another person was saying or feeling-~evident1y based upon a persisting capacity for identification, and therefore evidence of the potential for relatedness and internalization of therapeutic cognitive, emotional, and interpersonal learning experiences. Group psychotherapy was scheduled daily for each of the two separate day treatment groups scheduled on alternate weekdays. The duration of group therapy was approximately 1% hours daily. In addition, some 30% of day center clients received one-half to two hours of adjunctive individual psychotherapy per week; initially with only the writer, who had a 20-25 hour per week caseload of individual aftercare clients; after six months Of training, the other day center staff members began working individually with day center clients. The decision to provide some clients with regularly scheduled adjunctive individual psychotherapy (staff were generally available to clients for individ- ual time on an as-needed basis anyway), was based upon several well-considered imperatives: the client being 100 "at risk" of decompensation, suicide or assaultiveness; the client being overly withdrawn and terrified in the group setting and needing to develop a protective re- lationship fostered by the therapist; unyielding resis- tance or disruptiveness in group; and finally, if the client was processing in group therapy at a significantly faster pace than the other clients and was ready for transfer to aftercare for continuation in individual treatment. Therapists The experimental day treatment staff consisted of a female occupational therapist who was initially inexperienced in the psychotherapeutic treatment of psychotics, but had previous experience with a wide range Of patient pOpulations in close, supportive, and facilitating therapeutic relationship; a female social work technician with a psychodynamic orientation and previous experience in community mental health programs with aftercare clients; and the writer, a graduate stu- dent in clinical psychology working full-time as after- care therapist/day treatment therapist, with four years of training in the psychoanalytic psychotherapy of psy- choses supervised by Professor Bertram P. Karon, Depart— ment of Psychology, Michigan State University. Four months into the program, additional funds were 101 allocated to hire a male social worker with previous aftercare experience. The staff could be described as enthusiastic, Optimistic, cooperative, committed, energetic, tenacious, and nurturant. Three of the four staff members had com- pleted coursework with Dr. Karon. The staff developed therapeutic interventions with clients built upon accept- ance, concern, protection, nurturance, reassurance, understanding and insight, reparation and resolution, and reality testing. The staff met together daily after client hours for case review, ongoing training and pro- cessing, and development of all components of the ex- perimental day treatment program. Staff morale was generally strong although the nature Of the responsibil- ities were demanding and draining. Clients The experimental day treatment program and the two colateral comparison day treatment programs began services with chronic aftercare clients already residing within agency catchment areas in Adult Foster Care (AFC) boarding homes, or living with families or alone, and newly discharged patients from state hospitals and community psychiatric units referred for day treatment following discharge and community placement. 102 Clients referred for day treatment were inter— viewed by the day treatment staff, and on the basis of diagnosis, chronicity, and age, were assigned to one of the two treatment groups at each program (e.g., "high—functioning" and "low-functioning"). A total of 36 clients attended the experimental day treatment program over the program span of 18 months. An additional six clients were interviewed but did not follow through, dropped out after the first day or were referred to another agency (e.g., programs for the mentally retarded). A total of 17 clients were assigned to day treatment Group I, and 19 clients were assigned to Group II over 18 months. Group I averaged 12 clients over the 18 months Of the experimental day treatment program. Group I clients had a mean age of 28 years. Group I clients were primarily younger chronic psychiatric patients with histories of several psychiatric hospitalizations, psy- chotropic medications for several years or longer, and previous day treatment and dependent residential living (special training schools, half-way house, and AFC boarding homes). The following diagnostic composition of Group I clients shown in Table l is based upon a consensus of psychiatric hospital records, community mental health 103 records, psychiatric medication reviews, and day treat- ment staff assessment. TABLE l.--Diagnostic Categories of Total Sample of Day Treatment Group I (N=l7) over 18 Months. SchiZOphrenia acute type (1) male catatonic type (1) male disorganized type (1) female paranoid type (3) male (3) female undifferentiated/simple (2) female type with mild mental retardation Paranoia with explosive features (1) female Schizoaffective Psychosis (1) female Organic Brain Syndrome (1) female assocated with psychosis (3) males n=17 The severity Of impairment in these chronic aftercare clients is reflected in the fact that none were employed or attending school when they entered the program, and 13 (77%) were residing in AFC homes; two lived with their families, and two lived alone in close dependence upon their families. Stein and Test (1978) loosely define the characteristics of the "chronic psy- chiatric patient" as high vulnerability to stress, deficiencies in coping skills, extreme dependency, 104 difficulty with working in the competitive job market, and difficulty with interpersonal relationships. Group II averaged ten clients with a mean age Of 50 years. Group II included more chronic or debili- tated psychiatric patients with very lengthy hospitali- zation (up to 30 years in several cases) and psychiatric histories, ECT treatments, maintenance medication for many years, and generally poor prognosis. Eighteen of the 19 Group II clients resided in Adult Foster Care (AFC) boarding homes. Three clients in day treatment Group II were seen in adjunctive individual psycho- therapy. The diagnostic composition Of Group II clients is shown in Table 2. TABLE 2.-—Diagnostic Categories of Total Sample of Day Treatment Group II (n=l9) over 18 Months. SchiZOphrenia undifferentiated type (4) female (1) male paranoid type (2) female (2) male simple type with mental retardation (1) male Schizoaffective Psychosis (2) female (1) male Organic Brain Syndrome (1) female (1) male Psychosis with Epilepsy (1) male 105 TABLE 2.--Continued Alcoholic Deterioration Syndrome (1) male Adjustment Reaction of Adult Life (terminal illness)1 (1) female Hysterical Borderline Syndrome (1) female n=l9 lcerebral ne0plasm Psychotropic Medication Aftercare clients were typically referred for day treatment already maintained on conventional to high doses of neuroleptic drugs as routinely prescribed by state hospital and community mental health medication oriented psychiatrists. During the 18-month course of the experimental day treatment program, a consistent therapeutic goal was for client medication to be lowered in relation to evi— dence of symptomatic improvement, and more importantly, in response to client distress, side effects, and ex— pressed willingness to manage a reduction in dosage or complete termination of medication. The results of out- come research reviewed by Gunderson (1977) support the position that drugs may be unnecessary in an intensive psychosocial treatment milieu. 106 For lack of administrative authority, reduction in medication dosage was not strictly controlled, and therefore, could not be evaluated as an outcome variable. EVALUATION The formal hypotheses of this study Of psycho- analytically oriented day treatment are based upon the treatment goals stated before the inception of the pro- gram in a program proposal to Community Mental Health administration. Treatment goals were formulated from a review Of the theoretical and empirical research on treatment of psychosis generally, and schizophrenia in particular. The global treatment goal was to reduce psy- choticism. More specifically, the primary psycho- therapeutic treatment goals were to: (1) Reduce irrational—illogical thinking and delusional and hallucinatory distortions of reality testing. (2) Reduce the level of anxiety—arousal (terror). (3) Increase self-esteem and self-concept. (4) Develop insight and awareness of feelings, motivations, and conflicts. (5) Increase social functioning and related- ness; reduce autism, withdrawal, and isolation; reduce psychotic behavior via interpersonal corrective emotional learn- ing experiences. (6) Decrease or eliminate the need for drugs. 107 108 (7) Reduce the incidence of relapse-regres— sion and rehospitalization. Hypotheses The following process and outcome hypotheses are based upon the treatment goals stated above: Hypotheses I Thought Disorder--It is proposed that given the specific conditions of psychoanalytically oriented day treatment, clients will show a decrease in thought disorder, and an increase in reality testing and ego strength. Hypothesis I will be tested with the Visual-Verbal Test (VVT) measure of thought disorder, and with the following measures from the Minnesota Multiphasic Personality Inventory (MMPI); L, F, K, Paranoia, Schizo- phrenia, Psychotic Triad, Psychotic Index, Psychotic Score, and Ego Strength scale. Hypothesis II Affect--It is proposed that clients will evidence an increase in appropriate affect, awareness of affective reactions, and im- proved control of affect accompanied by a decrease in anxiety. Hypothesis II will be tested with the follow- ing measures from the MMPI: Hypochondriasis, Depression, Hysteria, PsychoPathic Deviate, Psychasthenia, Hypomania, Anxiety Factor, Internalization Ratio, and Manifest Anxiety scale. Hypothesis III Object Relations/Interpersonal Behavior--It is proposed that clients will show a reduc- tion in withdrawal, suspiciousness, and in- security-sensitivity, with an increase in self—acceptance, social functioning, and re- latedness. 109 Hypothesis III will be tested with the following measures from the MMPI: Psycho- pathic Deviate, Masculinity-Femininity, Paranoia, Schizophrenia, Hypomania, and Social Introversion; and the Day Therapy Data Base (DTDB) behavioral ratings of clients. Hypothesis IV Client-Motivation for Treatment; Program Effectiveness--Client motivation to remain in treatment and the effectiveness of psy— choanalytically oriented day treatment will be shown in client length of stay in treatment and frequency of attendance. Hypothesis V Ability to Function Out of the Hospital-- The treatment effects upon the ability to function outside of the hospital will be shown in rehospitalization rate and length of rehospitalization data. METHODOLOGY The psychological evaluation of psychoanalytic psychotherapy process-outcome variables proposed in Hypotheses I, II, and III (Thought, Affect, and Object Relations/Interpersonal Behavior) was based upon re- peated measures on the same clients. These measures are not only outcome measures, but are also process measures in the technical sense that changes in these psychological functions are hypothesized to be the fundamental elements of psychological change produced by psychoanalytic psychotherapy (Karon and VandenBos, 1981). Psychological testing was initiated with the clients in day treatment Group I; these younger and less chronic clients were expected to show change earlier than clients in day treatment Group II. The decision to limit the assessment of treatment outcome to the Group I clients was based upon realistic limitation on staff time and resources for a larger study. Comparative MMPI and VVT data were ultimately not made available from the two comparison day treatment programs because systematic client testing at regular intervals was not completed (eight MMPI's were Obtained 110 111 from one program for one time interval, but retest MMPI's were not available because, according to program staff, tests had gotten misplaced or had not been dated, or had not been completed for a particular client). Therefore, it proved to be impossible to obtain the hoped for psychological test data for an experimental design evaluating psychoanalytically oriented day treat- ment with two comparison day treatment programs. Thus, Group I clients serve as their own controls for a test-re- test evaluation of outcome, testing differences against the null hypothesis of no change. The absence of com- parison groups does not allow for the rigorous exclusion of alternative explanations for findings such as spontan- eous changes with time. It was finally possible to obtain demographic and length Of stay and frequency of program attendance data for comparison of the three concurrent day treat— ment programs. It was ultimately not possible tO obtain consent for access to rehospitalization data for the two comparison programs (these data were initially promised, but the information could only be retrieved by access to clients' names, which would require individual consent from each client; consequently, these data were not made available). The overall demographic data for all recorded clients attending the psychoanalytically oriented day 112 treatment program and the two comparison day treatment programs over an 18 months study period are presented in Table 3. TABLE 3.--Comparison Of Three Day Treatment Program Client Populations on Demographic Variables. Demographic Center 1 Center 2 Center 3 Statistical Variables No. % No. % NO. % Findings n= 36 51 69 Sex 2 Male 18 50 25 49 29 42 x =.86 Female 18 50 26 51 40 58 p <.65 NS Age Mean 37.4 36 40.8 F = 1.3949 SD 14.5 17.4 16.6 p <.25 NS Marital Status Single 29 81 30 59 38 55 Married 2 6 6 12 7 10 2 Widowed 4 8 6 9 =10.08 Separated 2 3 p <.26 NS Divorced 5 14 ll 22 16 23 Education a b Mean 10.8 9.8 ' 9.8 F = 1.733 SD 3.2 3.2 2.5 p <.27 NS aThree cases missing (1.9% total subjects). bIncludes 7 clients with academic years of special education. 113 As shown in Table 3, statistical comparisons (F, X2) of demographic variables (age, sex, education, and marital status) show no significant differences be- tween the three day treatment program client populations on these important demographic variables. However, it was noted that although Department of Mental Health data coding does not specify the number of years of special education versus mainstream educa- tion, a Community Mental Health "Evaluation Report" (February 8, 1979) at 15 months, recorded seven clients (14%) at one of the comparison centers (Center 2) coded for special education, but no clients at the other two centers coded for special education. In fact, four clients (11%) in the experimental day treatment program were known to have attended special education or insti- tutional training. The difference between the experi- mental program and the comparison program on the special education variable does not appear to be significant. Therefore, the homogeneity of demographic vari- able variance between the three day center client popula- tions suggests that the three day treatment programs can reasonably be compared for evaluation of length Of stay and frequency of program attendance as process-out- come measures Of the relative effectiveness of the three treatment programs. 114 Measures The psychological test battery combined an objective psychometric assessment of psychopathology, the Minnesota Multiphasic Personality Inventory (MMPI); a projective instrument, the Rorschach Inkblot Test;9 and a direct measure of thought disorder, the Visual-Ver- bal Test (VVT). The MMPI is the most carefully constructed and investigated inventory measure of various dimensions of psychopathology available, and is included in the "Core Battery" recommended in the "Report of the Clinical Research Branch Psychotherapy Measures Project (Waskow and Parloff, NIMH, 1975). In that report, Dahlstrom notes: Most therapy studies incorporate a simple pretreatment, posttreatment evaluation series. A number of studies employing the MMPI suggest that it may be profitable to administer the test more Often if an ex- tended treatment regime is planned. There is evidence that some treatment efforts induce greater disturbance in the course of producing ultimate remission and that risks of suicide or other acting-out be- havior deleterious to the patient or client shift from stage to stage in treat- ment. 9Unfortunately, the Rorschach testing had to be abandoned because approximately three months after the initial testing of all clients, the unscored Rorschach protocols disappeared from the agency front Office and were never recovered. 115 Periodic retesting indicates that the MMPI provides sets of scores that vary meaning- fully over a lengthy series of administra— tions and that are not merely random fluctua- tions in scale levels and patterns. Experi- mental studies employing periodic reexamina- tion by the MMPI also suggest that the vari- ations do directly covary with important behavioral features through periods of stress and that scores return to baseline with re- mission (p. 21). Form R of the MMPI (using only the first 400 critical items) was administered individually in order to facilitate these clients' ability to complete the lengthy inventory. Form R item numbers were appropri- ately converted for scoring of special research scales. Statistical analyses of MMPI data are based on uncor- rected raw scores. There was some unavoidable item attenuation on the Taylor Anxiety (TA) and Barron Ego Strength (ES) scales, which are composed of selected items from the full MMPI. The following special re- search scales, with computational formulas, were also utilized to assess the dependent variables of thought, affect, and interpersonal relations: Psychotic Triad (PT=Pa+Pt+Sc); Goldberg Psychotic Index (PI=[L+Pa+Sc]- [Hy+Pt]); Psychotic Score (PS=Pa+Sc+Ma); Welsh Anxiety Index (AI=[1.33D+1.00Pt1-[.66Hs+.66Hy]); and Welsh Internalization Ratio (IR=Hs+D+Pt/Hy+Pd+Ma). Group I pre-treatment MMPI's were obtained within the first month of the program as referrals were obtained (Time-l) for 11 clients. 116 Approximately six months later (T-2), eight MMPI's were obtained from the 11 clients who completed an MMPI at T-l. Two female clients who were struggling with highly ambivalent Object relations and related paranoid dynamics refused to retake the MMPI at T-2; and a catatonic male client completed an unscorable MMPI at T-2. Additionally, at T-2, a new male client com- pleted an initial MMPI. At approximately 12 months (T-3), eight clients completed a third MMPI. A male client with a diagnosis of psychosis associated with eplipsy (OBS) was rehospi- talized by his foster care homeowner for a relatively minor behavioral outburst at home and was subsequently transferred to a residential rehabilitation center with- out completing the MMPI at T-3. The two female clients who had refused to retake the MMPI at T—2 quit the day treatment program; one transferred to a sheltered work— shop for the mentally retarded, the other client con- tinued to be seen sporadically on an outpatient basis. The new male admission at T-2 (a paranoid schizophrenic) was rehospitalized by the same foster care Operator of the epileptic client already noted, supposedly for persistent homicidal threats and gestures; no further testing was obtained for this client. Additionally, four new referrals to the program at approximately T-3 117 completed an initial MMPI, but MMPI testing was sus— pended after Time-3. The Visual-Verbal Test (VVT) is a concept forma- tion task which was specifically designed to measure the thought disorder in schizophrenia (Bleuler's primary symptom of schizophrenia). The test authors (Feldman and Drasgow, 1951) found no overlap in scores between normals and hospitalized schizophrenics. The VVT was also found to be uncorrelated with I.Q. in normal sub- jects. The 42 items of the VVT were split into odd- and even-numbered forms to counter possible practice effects in retesting. Odd-even reliability has been established by the test authors (Spearman-Brown r=.86 for chronic schizophrenic sample). Karon and VandenBos (1972) found that the Odd-even items of the VVT provide good parallel forms of the test. The VVT was initially administered to all nine clients in Group I at eight months (T—l, and was read- ministered to the same nine clients at 15 months (T-2). Finally, clients in both experimental day treat- ment groups were rated consensually by the day treatment staff at three-month intervals using a Day Therapy Data Base (DTDB) behavioral rating scale. The DTDB was adapted by the agency from the Activity Therapy Data Base (Michigan Department of Mental Health T862, 8-74), and modified with item deletions and additions and an 118 expanded rating scale. The item deletions and additions were made by the day treatment staff on the basis of relevance to salient symptomatic features of psychoses, and meaningful criteria for behavioral assessments. The DTDB rates five main areas of observable behavior: (1) Social Skills (e.g., effectiveness of relating to peers; appropriateness of verbalizations). (2) Behavior (e.g., overly dependent; hostile; depressed). (3) Task-Oriented and/or Performance Skills (e.g., motivation; frustration toler- ance; work quality). (4) Sensory-Motor Performance (e.g., posture and ambulation; body image and awareness). (5) Activities of Daily Living (e.g., personal hygiene; eating habits; com- mitment to program). Each of the 37 items on the DTDB is rated on an 8-point scale: 1-No Problem--8-Extreme Problem. Group I DTDB ratings were made initially (n=ll), at three months (n=12), at six months (n=12), at nine months (n=ll), and at 12 months (n=10). As can be seen, most of the client assessment measures end at 12 months even though, as described, the experimental day treatment program continued for an 18 month period. Reserving more detailed explanation of what happened for the discussion section, it will only be noted here that at 15 months, the day treatment staff 119 received an abrupt administrative directive to change the focus of the program from psychoanalytic psycho- therapy to "rehabilitation," and to discontinue test assessment of clients. Statistical Analysis Hypotheses I, II and III: The dependent vari- ables (VVT, MMPI, DTDB) have been tested for significance by analysis of variance,and t-test. Hypothesis IV: The dependent variables (length of stay, frequency of attendance) have been tested for significance by analysis of covariance, correcting for the effects of age, sex, education, and marital status when appropriate, and t-tests. RESULTS The measures of the effectiveness of psycho— analytically oriented day treatment were: (1) length of stay in treatment and frequency of program attend- ance, (2) the MMPI, (3) the VVT, and (4) the DTDB. Comparisons, by analyses of covariance, Of the three concurrent day treatment programs on average length of stay and frequency of program attendance with demographic variables is shown in Table 4. Table 4 presents the relationships between demo- graphic variables sex, age, marital status, and educa- tion on outcome variables of DAYS, MONTHS, and DAYS PER MONTH for the three day treatment programs. Comparison of the three day treatment groups for DAYS shows a significant difference (p <.001), with a near significant effect of marital status (p <.07) on DAYS attended. Average MONTHS attended also shows a significant difference between the three treatment groups (p <.003), with a significant effect of marital status (p <.05), and age as a significant covariate (p <.03) on MONTHS attended. 120 121 TABLE 4.--DAYS, MONTHS, and DAYS PER MONTH by SEX, MARITAL STATUS, AND GROUP with AGE and EDUCATION. DAYS Source of Variation Covariates Age Educ Main Effects Sex M Stat Group Z—Way Interactions Sex M Stat Sex Group M Stat Group 3-Way Interactions Sex MStat Group Explained Residual TOTAL MONTHS Source of Variation Covariates Age Educ Main Effects Sex M Stat Group Z-Way Interactions Sex M Stat Sex Group H Stat Group 3-Way Interactions Sex MStat Group Explained Residual TOTAL DAYS PER MONTH Source of Variation Covariates Age Educ Main Effects Sex M Stat Group 2-Hay Interactions Sex M Stat Sex Group H Stat Group B-way Interactions Sex MStat Group Explained Residual TOTAL Sum of Squares 5620.286 3292.912 879.074 91686.531 285.366 18494.548 53533.699 16974.933 2411.521 2689.858 8503.961 1288.421 1288.421 115570.171 335961.136 451531.307 Sum of Squares 229.729 150.404 24.923 631.541 ‘O‘os 246.436 391.922 218.894 16.229 36.536 156.169 74.417 74.417 1354.581 4148.256 5502.837 Sum of Squares 9.561 2.937 3.882 243.648 19.223 53.591 146.768 50.997 6.530 3.345 29.821 9.661 9.661 313.867 809.150 1123.018 D an anuo MuHa HHN M F‘ r- m up a: a: to c U M um bNuO NUHO HHN N O 132 152 U M UN wa0 Nut-‘04 HHN pa UN NO 152 Mean Square 2810.143 3292.912 879.074 15281.088 285.366 6164.849 26768.849 1886.104 803.974 1344.929 2125.990 429.474 429.474 5776.509 2545.160 2970.601 Mean Square 114.864 150.404 24.923 138.590 4.405 82.145 195.961 24.322 5.410 18.268 39.042 24.806 24.806 67.729 31.426 36.203 Mean Square 4.760 2.937 3.882 40.608 19.223 17.864 73.084 5.666 2.177 1.672 7.455 3.220 3.220 15.693 6.130 7.388 P 1.104 1.294 .345 6.004 .112 2.422 10.517 .741 .316 .528 .835 .169 .169 2.270 3.655 4.786 .793 4.410 .140 2.614 6.236 .774 .172 .581 1.242 .789 .789 2.155 .780 .479 .633 6.625 3.136 2.914 11.922 .924 .355 .273 1.216 .525 .525 2.560 Signif. of F .335 .257 .558 .001 .738 .069 .001 .871 .814 .591 .505 .917 .917 .003 Signif. of F .029 .030 .375 .001 .709 .054 .003 .641 .915 .561 .296 .502 .502 .005 Signif. of F .461 .490 .428 O 001 .079 .037 .001 .506 .786 .762 .307 .666 .666 .001 156 cases were processed. 3 cases (1.9 PCT) were missing. 122 DAYS PER MONTH shows a significant group dif- ference (P <.001), with a significant effect of marital status (p <.04), and a near significant effect of sex (p <.08) on DAYS PER MONTH attended. Raw cell means for DAYS, MONTHS, AND DAYS PER MONTH by group and demographic variables are contained in Appendix B. More specific comparisons of length of stay and frequency of program attendance by treatment program are shown in Table 5 which shows the actual means for each group and the results of t-tests. TABLE 5.--Comparisons of Three Day Treatment Program Populations: Total DAYS, MONTHS, and DAYS PER MONTH Attended Over 18 Months. Center 1 Center 2 Center 3 n=36 n=51 n=69 Mean SD Mean SQ Mean S2 3 Days 94.19 63.11 45.12 47.52 p‘<.000 45.12 47.52 44.19 44.72 p‘<.914 94.19 63.11 44.19 44.72 p‘<.000 Months 11.22 6.15 6.29 5.16 p‘<.000 6.29 5.16 7.41 5.94 p‘<.277 11.22 6.15 7.41 5.94 p«<.003 Dayngonth 7.81 2.08 5.93 2.81 p‘<.001 5.93 2.81 4.96 2.45 p'<.045 7.81 2.08 4.96 2.45 p <.000 t-test As shown in Table 5, over the 18 months of day treatment evaluated by program, clients at the 123 psychoanalytically oriented program (Center 1) continued in day treatment significantly more DAYS (p<:.000), MONTHS (p < .000) , and DAYS PER MONTH (p < .001) than clients in the two comparison day treatment programs (Center 2 and Center 3). There were no significant dif- ferences in DAYS (p<<.91) or MONTHS (p<:.28) attended between the two comparison programs, but there appeared to be a significant difference in average DAYS PER MONTH (p <.05) between the two comparison programs. The differences evident in the total numbers of clients seen over 18 months at each of the programs (Center 1, n=36; Center 2, n=51; Center 3, n=69) shows more client attrition and turnover at the two comparison day treatment programs. Psychological process-outcome evaluations of treatment were made on Group I clients in psycho- analytically oriented day treatment. Comparable evalua- tions were not made at the two comparison day treatment programs. Therefore, psychological evaluations of Group I clients are based on clients serving as their own controls for test-retest evaluation of psychoanalytically oriented day treatment. MMPI testing was completed for the core group of clients in day treatment Group I at pre-treatment, six months and 12 months (continued evaluations planned for six month intervals were not made because of termination 124 of the program and evaluations at approximately 15 months). Table 6 presents pre-treatment (Time-l), six month (Time-2), and 12 month (Time-3) MMPI scores for the core sample of Group I male and female clients who completed retest MMPI's at six and 12 month assessments (subject attrition from pre-treatment sample was noted in the methodology and will be considered further in the discussion of findings). As shown in Table 6, the MMPI findings are not striking. For the core sample of Group I male and fe- male clients who completed MMPI retesting at six and 12 months, only two MMPI scales at six months showed a reduction from pre-treatment scores that even approached significance: the L (Lie) scale (p‘<.07) and the Hs (Hypochondriasis) scale (p‘<.07). The 12 month MMPI scores suggest a regression from the changes apparent at six months; the 12 month scores show no significant changes from pre-treatment scores on any scale. Pre-treatment (Time-l), six month (Time-2), and 12 month (Time-3) MMPI scores for the male subsample of Group I clients who completed at least two test-retest MMPI's are shown in Table 7. As shown in Table 7, for males at six months, two MMPI scores showed a significant increase; the Pa (Paranoia) scale (p‘<.02) and the PI (Psychotic Index) 125 TABLE 6.--Comparison of Pre—Treatment, 6-Months and 12- Months MMPI Scores for Day Treatment Group I n=8 (males=4, females=4). Pre-Treatment 6 Months 12 Months Scale Time-1 Time-2 Time-3 L 6.75/6.63# 4.75 p< .072 5.25 F 18/18.63 17.63 17.75 K 11/11.13 10.75 12.25 Hs 10.63/9.75 9.5 p<:.065 9.13 D 25/24.25 22.7 24.38 Hy 19.13/17.88 18.75 20.13 Pd 21.88/21.5 22.13 21.88 Mf 28.75/28.88 30.25 31.38 Pa 14.75/15 16.1 15.75 Pt 21.25/19.75 21.5 20.75 Sc 29.25/29 30.5 30.5 Ma 22.63/22.88 21.88 22.38 Si 32.88/32.l3 34.38 30.63 ES 23.13/23.5 23.88 23.25 TA 19/18.13 17.5 17.38 PT 66.63/66.88 68.5 68.63 PS 65.25/63.75 68.13 68.88 PI 10.38/13 11.13 11.13 IR .88/.86 .86 .86 AI 34.87/34.64 33.12 33.86 paired t statistics #The first figure consists of Time-1 clients who also took the MMPI at six months (Time-2); the second figure at Time-l is the mean for all clients who also took the MMPI at Time-3. 126 TABLE 7.--COMPARISON OF PRE-TREATMENT, SIX MONTHS AND 12 MONTHS MMPI SCORES FOR DAY TREATMENT GROUP I MALES, n=4. Pre-Treatment 6 Months 12 Months Scale Time-l Time-2 Time-3 L 5/4.75# 2.75 p< .10 5.5 F 18.5/19.75 18.25 16.5 K 9.5/9.75 7.5 11.25 Hs 9.5/7.75 8 8.5 D 22/20.5 20.75 23.25 Hy l7/14.5 14.75 18.75 Pd 20.25/19.5 20.5 19.5 Mf 27.5/27.75 28.75 29.75 Pa 12.25/12.75 15.75 p<<.02 14 Pt 20.5/17.5 22.75 20.5 Sc 26.75/26.25 32.75 29.5 Ma 21.5/22 24 24.5 Si 33/3l.5 32 27.75 ES 23.25/24 22.75 23 TA 18.75/16.75 17.75 16.75 PT 60.5/61 72.5 68 PS 59.5/56.5 71.25 64 PI 6.5/11.75 13.75 p‘<.002 9.75 IR .87/.82 .88 .86 AI 32.27/3l.82 35.34 33.44 paired t statistic #Clients at Time-l and Time-Z/Clients at Time-l and Time-3. score (p‘<.002). Along with these two significant score elevations, it can be noted that the L (Lie) scale 127 showed a decreasing trend (p<:.10). At 12 months, there were no significant changes from pre-treatment scores apparent for the male subsample. Pre-treatment (Time-l), six month (Time-2), and 12 month (Time-3) MMPI scores for the female subsample of Group I clients who completed at least two test—re- test MMPI's are shown in Table 8. As shown in Table 8 for females at six months, three MMPI scales showed significant changes from pre-treatment scores; the Pt (Psychasthenia) scale showed a significant decrease (p‘<.04), the ES (Ego Strength) scale showed a significant increase (p<<.02), and the TA (Taylor Anxiety) scale showed a significant decrease (p‘<.001). Comparison of difference (change) scores on the MMPI between males and females for pre-treatment to six months, six months to 12 months, and pre-treatment to 12 months is shown in Table 9. As shown in Table 9, females showed significantly more change (increase) on the K scale than males (p‘<.03) pre-treatment to six months, and a trend toward more change (decrease) than males on the Ma (Hypomanic) scale (p‘<.08) and TA (Taylor Anxiety) scale (p<=.07) at six months. 128 TABLE 8.--Comparison of Pre-Treatment, 6 Months and 12 Months MMPI Scores for Day Treatment Group I Females, n=4. Scale Pre-Treatment 6 Months 12 Months L 8.5 6.75 6 F 17.5 17 19 K 12.5 14 13.25 Hs 11.75 11 9.75 D 28 24.75 25.5 Hy 21.25 22.75 21.5 Pd 23.5 23.75 24.25 Mf 30 31.75 33 Pa 17.25 16.5 17.5 Pt 22 20.25 p<:.04 21 Sc 31.75 28.25 31.5 Ma 23.75 19.75 20.25 Si 32.75 36.75 p<:.07 33.5 ES 23 25.5 p<<.02 23.5 TA 19.5 16.25 p‘<.001 18 PT 72.75 64.5 69.25 PS 71 65 70 PI 14.25 8.5 12.5 IR .90 .85 .86 AI 37.46 30.90 34.29 paired t statistic 129 TABLE 9.--Comparisons Between Male and Female Change Scores T1-T2, T2-T3, and T1-T3. t value (male-female) Scale Tl-T2 T2-T3 Tl-T3 L .25 -2.09 -l.61 F -.04 .28 .59 K -3.13 p‘<.026 —1.41 -.25 Hs .70 -.66 -l.18 D -.68 .03 -l.63 Hy 1.14 -l.00 -.95 Pd 0.00 -.04 .19 Mf .18 .09 .35 Pa -l.32 .26 -.20 Pt -l.16 -.35 -.86 Sc -1.31 .58 -.39 Ma -2.24 p<<.065 -.80 -1.20 Si 1.41 -l.4l .92 ES 1.81 .46 .30 TA -2.09 p<<.081 .02 -.40 PT .32 -.02 .20 PS -1.49 .53 -.30 PI -1.53 1.00 .02 IR - .59 - -.14 AI - .66 -.24 -.24 pooled or separate variance estimate for significance level. Comparisons for six months to 12 months, and pre-treatment to 12 months showed no significant find- ings at these comparisons. 130 The Visual-Verbal Test (VVT), a direct measure of thought disorder, findings for males and females, and male and female subgroups, are shown in Table 10. TABLE 10.--Comparison of VVT Scores at 8 Months (T-l) and 15 Months (T—2) for Total Sample, and by Sex. Mean 4 Time 3 Errors .§2 St'd Error 3 g; 2-tai1 1 9 11.22 4.97 1.66 2.67 8 p< .03 2 9 7.56 4.83 1.61 1-2 3.67 4.12 1.37 r=.65 p .060 Mean # Time Sex 2 Errors s2 St’d Error 5 g; 2-tai1 1 M 10.50 6.61 3.30 2 M 4 8.50 6.14 3.07 F 5 6.80 4.09 1.83 .48 5.03 p<.65 NS 1—2 M 4 -2.00 3.16 1.58 F 5 -5.00 4.64 2.07 1.15 6.9 p<.29 NS qunEMe‘wndanoaestflmne finttdu§fis. Initial VVT testing was made during the eighth month of the treatment program with retesting scheduled for approximately six months later. The VVT findings show a significant reduction in thought disorder (p<=.03) within the evaluation interval during the latter half of the treatment program, at a time period when serious 131 external problems were already disrupting the operation of the program. The VVT data do not show a significant difference between males and females on the VVT at Time-l (p<<.74), Time-2 (p<=.65), or in difference (change) scores from Time-l to Time-2 (p<:.29). Table 11 presents analyses of variance for the DTDB behavioral ratings of Group I clients made at pre-treatment, and at three month intervals thereafter for a total of 12 months, by subtest score, sex, and test (Time-1 - Time 5). The subtests are: Score 1-— social skills, Score 2--prob1em behavior, Score 3--task oriented/performance skills, Score 4--sensory-motor, and Score 5--activities of daily living skills. The DTDB behavioral ratings show a significant change over testing on subtest scores 1, 2, and 3, but not on subtest scores 4 and 5 over 12 months. Sex shows a significant effect on subtests 3, 4, and 5, but not on subtests l and 2. More specific directionality of out- come findings on the DTDB ratings are presented in Table 12. Comparisons of DTDB ratings from pre-treatment to 3 months, 6 months, 9 months, and 12 months by sub- test score, and total sum score, and sex, are shown in Table 12. 132 mamoo. Ammam.m oomao. mammm.m «qawo. mmomm.¢ oeomm. memoo. mamvm. mevoo. a m0 a .mflcmem mvmam. ommom.e mmmam. mmmam.a mooqo. mvmme.m moooo. mmmmv.m emooo. menmm.m a mo a .mflcmem ohmvm.mv mmeo.mm mmmna.mma emvaw.vma mmmac.am .Mm coo: Hounm ehmvm.mv wmmflo.m¢ mmmna.mma wwvav.vma mmNHo.Hm .vm com: Hounm vaom.bmm HHMbv.mmm mommm.mrw awmov. mvwva. .vm com: mwmwnuommm voomm.mo hHmhm.mHH mmmho.maw mmmam.mmma mmmam.vom .Um cows mammnuommm mmvmm.mvom mmmmn.mmv¢ mmmmH.mmHh bmhm¢.hmhh HHomm.hmvH .Um mo Sow Houum .m .o Ase .Hv mmvmm.wvom mmmmh.mmv¢ mmmma.mmah hmhmv.hmhh HHomm.hmvH .am we saw HOHHM .m .Q Abe vaom.bmm HHth.mmm mmmmm.mnm mvmov. mvmwa. .wm mo Sow mammouomum hhHmv.NwN mmNHm.mmv Hhhom.mhma Hummw.m¢mm Naomv.wam .Um mo Sam mammnuomwm ouoow muoow muoom muoom muoom HNMQ‘ID mumwnm> nuflz mummelm conflum>floo xmm Bummmm whoom ouoom muoom muoom muoow I-INMQ'ID ouownm> .vv ouHB mummalm mumwum>flca Bmflfi Bummmm umme pom .xmm .uomnosm we m wuoom on a muoom .mSUCOZ NH Hw>O AmlB Ou HIBV "mocoflum> mo mwmwamcfi mDBQIn.HH mqmda 133 TABLE 12.--Comparisons of DTDB Ratings Pre-Treatment to 3, 6. 9. and 12 Months by Subtest Score, with Sex. ESTIMATES FOR SCORE 1 SEX Standard D. F. Coeff. Error 1 -.09073 .77206 TEST Standard D. F. Coeff. Error 1 7.15385 2.18430 2 10.05273 2.28643 3 9.92571 2.50313 4 4.05071 2.50313 ESTIMATES FOR SCORE 2 SEX Standard D. r. Coeff. Error 1 -.32097 1.77767 TEST Standard D. F. Coeff. Error 1 14.53846 5.02937 2 22.93697 5.26452 3 25.29262 5.76349 4 1.54262 5.76349 ESTIMATES FOR SCORE 3 SEX Standard D. P. Coeff. Error 1 3.43266 1.71583 TEST Standard D. P. Coeff. Error 1 11.92309 4.85440 2 12.95025 5.08137 3 14.46597 5.56298 4 5.34097 5.56298 ESTIMATES FOR SCORE 4 SEX Standard D. F. Coeff. Error 1 3.48293 1.35139 TEST Standard D. F. Coeff. Error 1 5.92308 3.82334 2 6.24810 4.00210 3 8.02753 4.38142 4 7.15253 4.38142 ESTIMATES FOR SCORE 5 SEX Standard D. r. Coeff. Error 1 2.61586 .91487 TEST Standard D. P. Coeff. Error 1 2.53846 2.58834 2 3.94235 2.70936 3 7.07622 2.96615 4 2.82622 2.96615 ESTIMATES FOR TOTAL SCORE SEX Standard D. P. Coeff. Error 1 9.74557 4.60324 TEST Standard D. F. Coeff. Error 1 42.07692 13.13420 2 56.00786 13.74780 3 68.90613 14.52126 4 20.96120 15.05128 T-Value T-Value 3.27512 4.39669 3.96532 1.61826 T-Value -.18056 T-Value 2.89071 4.35689 4.38842 .26765 T-Value 2.00059 T-Value 2.45614 2.54857 2.60040 .96009 T-Value 2.57729 T-Value 1.54919 1.56120 1.83218 1.63247 T-Value 2.85927 T-Value .98073 1.45509 2.38566 .95282 T-Value 2.11711 T-Value 3.20362 4.07395 4.74519 1.39265 Signif. of T .90696 Signif. of T .00199 .00006 .00025 .11230 Signif. of T .85749 Signif. of T .00580 .00007 .00006 .79014 Signif. of T .05123 Signif. of T .01779 .01414 .01241 .34192 Signif. of T .01316 Signif. of T .12804 .12518 .07327 .10926 Signif. of T .00631 Signif. of T .33175 .15229 .02113 .34555 Signif. of T .03946 Signif. of T .00241 .00017 .00002 .17014 Lower .95 Conf. -1.64391 Lower .95 Conf. 2.75960 5.45303 4.89006 -.98494 Lower .95 Conf. Lim. -3.89718 Lower .95 Conf. 4.42067 12.34611 13.69797 -10.05203 Lower .95 Conf. Lim. -.01914 Lower .95 Conf. Lim. 2.15729 2.72785 3.27471 -5.85029 Lower .95 Conf. Lim. .76428 Lower .95 Conf. Lim. -1.76848 -1.80309 - .78674 -1.66174 Lower .95 Conf. Lim. .77538 ' Lower .95 Conf. Lim. -2.66860 -1.50818 1.10910 -3.14090 Lower .95 Conf. Lim. .49014 Lower .95 Conf. Lim. 15.66884 28.36605 39.70919 -9.30144 Lim. Lim. Lim. Upper .95 Conf. Lim. 1.46248 Upper .95 Conf. Lim. 11.54809 14.65243 14.96137 9.08637 Upper .95 Conf. Lim. 3.25525 Upper .95 Conf. Lim. 24.65625 33.52783 36.88726 13.13726 Upper .95 Conf. Lim. 6.88446 Upper .95 Conf. Lim. 21.68887 23.17265 25.65724 16.53224 Upper .95 Conf. Lim. 6.20158 Upper .95 Conf. Lim. 13.61464 14.29929 16.84180 15.96680 Upper .95 Conf. Lim. 4.45634 Upper .95 Conf. Lim. 7.74553 9.39288 13.04334 8.79334 Upper .95 Conf. Lim. 19.00099 Upper .95 Conf. Lim. 68.48500 83.64967 98.10308 51.22383 134 As shown in Table 12, the DTDB ratings subtest scores 1 (social skills), 2 (problem behavior), 3 (task-oriented/performance skills) showed significant improvement at 3, 6, 9, and 12 month comparisons with pre-treatment ratings. Scores 4 (sensory motor per- formance) and 5 (activities of daily living skills) showed a significant improvement over pre-treatment ratings only at the 9 month comparison. Total sum scores on DTDB ratings showed significant improvement at 3, 6, and 9 months, but not at 12 month comparison with pre-treatment. Comparisons by sex found that females were rated significantly better overall than males on scores 3, 4, and 5; sex differences on total sum scores just missed significance. DISCUSSION Process-Outcome Evaluation of PsychoanalyticallyOriented Day Treatment Thought Disorder Hypothesis I proposed that given the specific conditions of psychoanlytic psychotherapy in day treat- ment, clients would show evidence of decrease in thought disorder, associated with improved reality testing and ego strength. The process-outcome measures of the effects of psychoanalytically oriented day treatment on reduction in thought disorder were based upon the Visual-Verbal Test (VVT), a direct measure of thought disorder, and the following MMPI scales: L, F, K, Pa, Sc, and special research scales; Barron Ego Strength (ES), Goldberg Psy- chotic Index (PI), Psychotic Score (PS), and Psychotic Triad (PT). The VVT, the direct measure of thought disorder, showed a significant reduction in thought disorder for males and females at an evaluation interval (8-15 months) late into the treatment program, even though the operation of the program was already seriously dis- rupted. The VVT was previously found to be very 135 136 sensitive to the effects of psychotherapeutic treatment upon the thought disorder in schiz0phrenia (Karon and VandenBos, 1981). The findings on the indirect measures of thought disorder based upon the MMPI (L, F, K, Pa, Sc, PT, PI, PS, and ES) were not striking; however, at six months, male and female clients did show a trend (p<<.07) toward reduction on the Lie (L) scale (i.e., denial of illness and need for help, repression, deception). At six months, females showed a significant in- crease on the Ego Strength scale, and significantly more change (increase) on the K scale (which has been associ- ated with improved ego strength) than males. Males showed a trend toward reduction on the Lie (L) scale accompanied by a significant increase on the Paranoia (Pa) scale, and the Psychotic Index (PI=[L+Pa+Sc]-[Hy+ Pt]). The other MMPI scores operationalized to evaluate changes in the thought disorder were not significant at six month comparison with pre-treatment. At 12 months, there were no significant changes from pre-treatment evident on the MMPI for males and females, or male and female subsamples. The increase on Pa and PI for males at six months suggest a transitory increase in psychoticism for males during this period of treatment. These findings for males could be explained by several 137 different possibilities: (1) reduction on the Lie scale, indicating less denial of illness and need for help, associated with increased (more truthful) endorsement of pathological items on the MMPI: (2) process char- acteristics of the psychotherapeutic treatment of psy— chotics (e.g., Kayton, 1975; Karon and VandenBos, 1981). For example, Karon and VandenBos have observed that: A careful systematic attempt to understand a paranoid system in detail will reveal that it changes from week to week and even from day to day, especially when it undergoes mutual scrutiny by a patient and an inter- ested psychotherapist. The paranoid system does not quite fit reality, and therefore enormous repair work is continuously being done by the patient to make it fit. The work gets frenetic when there is a thera- pist who continually brings the inconsis- tencies with reality to the patient's at— tention in a sympathetic way (p. 60); and (3) uncontrolled external factors reflecting the "intransigency of the environment" (Campbell and Stanley, 1963). The most critical uncontrolled external factors affecting the day treatment program were the internal problems at the board and care homes where the clients resided, and the tenuous and ambivalent re- lationship of these homes to the mental health system. These issues will be considered more fully in a later section of the discussion. Dahlstrom (Waskow and Parloff, 1975) notes that "experimental studies employing periodic reexamination 138 by the MMPI also suggest that the variations do directly covary with important behavioral features through per- iods of stress . . .." Affect Hypothesis II proposed that clients would show an increase in apprOpriate affect, awareness of affec— tive reactions, and improved control of affect accom- plished by a decrease in anxiety and confusion. The process—outcome measures of affective functioning (e.g., anxiety, anger-hostility, depres- sion) were based upon the following MMPI scales: Hs, D, Hy, Pd, Pt, and Ma; and special research scales, Taylor Anxiety (TA) scale, Welsch Anxiety Index (AI), and Welsh Internalization Ratio (IR). At six months, for males and females, only the Hypochondriasis scale (i.e., somatization, displace- ment) showed a reduction that even approached signif- icance (p<:.065). Females showed a significant reduc- tion on two measures of anxiety: the Psychasthenia (Pt) scale (e.g., obsessions, phobias, anxiety, doubt, guilt) and the Taylor Manifest Anxiety Scale. The remaining MMPI measures operationalized to evaluate changes in affective functioning were not significant (D, Hy, Pd, Ma, AI, and IR). 139 At 12 months, there were no significant changes from pre-treatment scores evident on the MMPI for males and females, and male and female subsamples. The improvement in affective functioning shown in the reduction in somatic complaints and preoccupa- tions for males and females, and the decrease in anxiety for females, apparent at six month evaluation but not at 12 months, suggests a transitory change in affect. However, it should be noted that the only measures of affective functioning are based on the MMPI. Object Relations/Inter- Personal Behavior Hypothesis III proposed that clients would show a reduction in withdrawal, suspiciousness-mistrust, and insecurity-sensitivity, with an increase in self-accept- ance, social functioning, and relatedness. The process-outcome measures of object rela- tions/interpersonal behavior were based on the following MMPI scales: Pd, Mf, Pa, Sc, Ma, and Si; and ratings of clients based upon the Day Therapy Data Base (DTDB) ratings of observable behavior: (1) social skills, (2) problem behavior, (3) task-oriented and/or perfor- mance skills, (4) sensory-motor performance, and (5) activities of daily living skills. The MMPI findings provide no evidence of im- provement in interpersonal functioning at either six 140 month or 12 month comparisons with pre-treatment. In fact, the six month findings for males suggested a transitory increase in paranoia. Females showed a trend toward increase on the Social Introversion (Si) scale (i.e., introversion-extroversion, and a trend toward more change (reduction) than males on the Hypomanic (Ma) scale at six month comparison). The DTDB therapist ratings of clients' observ- able behavior showed a significant improvement on ratings of social skills, problem behavior, and task-oriented/performance skills at 3, 6, 9, and 12 month comparisons with pre-treatment ratings. Ratings of sensory-motor performance and activities of daily living showed a significant improvement only at the nine month comparison. Total sum DTDB score showed significant client improvement at 3, 6, and 9 months, but not at 12 months. Again, the MMPI findings are not striking, although the DTDB findings show improvement in inter- personal functioning. Some Comments on the MMPI It is noteworthy that none of the study hypothe- ses are supported when tested by the MMPI, although the other process-outcome measures (VVT, DTDB behavioral ratings, length of stay in treatment and program 141 attendance) seem to be consistent with one another and supportive of the treatment hypotheses. Other investi- gators have also reported a lack of discernable findings when the MMPI is applied to the study of schizophrenia. For example, Rogers, Gendlin, Kiesler, and Truax (1967) also reported a lack of significant findings on MMPI measures in the Wisconsin psychotherapy with schizo- phrenics project, although the therapy group in general did show a slightly better discharge rate 12 months after/the termination of treatment, and follow-up data indicated that the therapy patients were more successful in maintaining themselves outside of the hospital. By contrast, measures based on the TAT showed evidence of greater constructive personality change in the therapy patients than in the control patients. Lest critics of the effectiveness of psychotherapy for schiZOphrenics endorse the lack of supportive findings based on the MMPI as authoritative, it should be noted that Haier, Rosenthal, and Wender (1978) reported that "on the basis of the MMPI data, there are no overall personality dif- ferences between the index and control groups" in a study of MMPI assessment of psychopathology in a sample of adopted away offspring of schizophrenics and matched controls. It is possible that the MMPI may not be sensi- tive enough to the process-outcome changes in psychotics 142 that can result from psychotherapeutic treatment or that these changes may become significant on the MMPI with more time. In any case, the phrasing of some MMPI items would appear to be biased against improvement or recovery since, to answer the item truthfully, a client must still endorse a pathological item that may no longer be valid. For example: 33. I have had very peculiar and strange experiences. 41. I have had periods of days, weeks, or months when I couldn't take care of things because I couldn't "get going." 156. I have had periods in which I carried on activities without knowing later what I had been doing. 194. I have had attacks in which I could not control my movements or speech but in which I knew what was going on around me. 251. I have had blank spells in which my activities were interrupted and I did not know what was going on around me. 278. I have often felt that strangers were looking at me critically. 291. At one or more times in my life I felt that someone was making me do things by hypnotizing me. 323. I have had very peculiar and strange experiences. 352. I have been afraid of things or people that I knew could not hurt me. Seven of the above items comprise nine percent (%%) of the Schizophrenia scale of the MMPI. The 12 month findings,or more appropriately, the lack of findings on the MMPI at 12 months, were dis- appointing and suggested a regression from the changes evident at six months comparison with pre-treatment. 143 In a report of clinical status change over 20 months of treatment in the Michigan State Psycho- therapy Project (Karon and VandenBos, 1970), these in- vestigators reported a similar regression in their out- come findings at the 12 month assessment: It is not known whether this up-down-up pattern of patient change is, in fact, the pattern typically made by patients over time, but a strong case could be made for such a pattern of change in patient func- tioning. Kiesler, Klein, and Mathieu (1965, 1967) found similar up-down pat- terns of functioning of schizophrenic patients, both within individual sessions and over the course of treatment. The patients make some gains and then feel safe enough to look into other areas of their functioning. The resulting un- covering results in a lowered level of functioning, but one that is higher than before treatment began, from which new gains can be made. Karon and VandenBos (1981) also noted that the Detroit Riots occurred just before their 12 month assessments were made, given that nearly all their study patients were Black, inner-city residents being treated by white therapists. It is interesting that similar disruptive countertherapeutic environmental variables ultimately led to the termination of the experimental day treat- ment program being evaluated, and the rehospitaliza- tion of six Group I clients from one particular boarding home within ten months. 144 Sex Differences In evaluating the apparent sex differences found on MMPI process-outcome measures, caution is advised by the small sample size. However, in a study of unmedi- cated schizophrenics in psychotherapeutic treatment, Zahn, Carpenter, and McGlashan (1981) also found "puz- zling sex differences" on measures of ANS functioning in improved schizophrenics. Improved male and female patients showed changes in opposite directions on some autonomic variables; males declined in reactivity and females increased in ANS reactivity from admission to discharge. Zahn et a1. concluded that "there is evi- dence that the psychosis may have affected male and female patients in different ways" rather than sex differences in stable "trait" phenomena. Client Motivation for Continua- tion (and Maintenance) in Treat- ment; Program Effectiveness Hypothesis IV proposed that client motivation to continue in treatment and the effectiveness of psy- choanalytically oriented day treatment would be shown in client length of stay and frequency of attendance statistics. Demographic and attendance summary data were obtained for the three concurrent day treatment programs. The three program models of day treatment compared were: 145 Center l--psychoanalytica11y oriented, Center 2--Educa- tional-Behavioral, and Center 3--Educational-Behaviora1- Counseling. Program treatment philosophies contained in a Community Mental Health "Evaluation Report" (February 8, 1979) are presented in Appendix C. Comparison of the three day treatment program statistics on total DAYS, MONTHS, and DAYS PER MONTH of continuation in treatment clearly showed that psycho- analytically oriented day treatment was superior to the two comparison day treatment programs in motivating and maintaining clients in day treatment over time. The critical importance of length of stay in treatment, and to a lesser extent, frequency of attend- ance, as process and outcome variables in psychosocial treatment of psychotic patients is supported by previous research suggesting that length of stay in treatment and frequency of attendance are positively related to out- come (Beard et a1., 1978; Click and Hargreaves, 1979: Goldberg et a1., 1977; Guy et a1., 1969; Hogarty et a1., 1973, 1974; Kirk, 1976; Karon and VandenBos, 1975; Levene et a1., 1970; McCranie and Mizell, 1978: Rubins, 1976; Shattan et a1., 1966; Sheldon, 1964; and Wilder et a1., 1966). Sue, McKinney, and Allen (1976) reported that of the 13,450 clients referred to aftercare services in 19 mental health facilities, 40% terminated treatment after one session. 146 The variables of length of stay and frequency of attendance in psychosocial treatment would seem to have central relevance to the symptomatology of psychosis in general, and schizophrenia in particular (e.g., autism, ambivalence, apathy, negativism, hostility, withdrawal, mistrust, suspiciousness, and disturbances of self-con- cept, volition, and motivation) and, therefore, to the primary process in the psychotherapeutic treatment of psychotic individuals; namely, the establishment of relatedness. As noted by Mosher and Keith (1980): "However, schiZOphrenia is defined, most persons who receive this diagnosis have extraordinary difficulty in establishing and maintaining human relationships" (p. 10). As in all intensive psychotherapies, the central difficulties in positive human relationships are manifested in the psy- chotherapeutic relationship, which provides a modality for understanding, experiencing, and resolving these difficulties through corrective psychotherapeutic com- munication between client and therapist(s).' Ability to Function Out of the HosPital Hypothesis V proposed that the effects of psy- choanalytically oriented day treatment on client ability to function outside of the hospital (community survival) 147 would be shown in rehospitalization rate and length of rehospitalization data. As discussed previously, rehospitalization data were ultimately not made available for the two compari- son day treatment programs; consequently, it is not pos- sible to draw any rigorous conclusions. Nonetheless, rehospitalization data were recorded for clients in psy- choanalytically oriented day treatment as one measure of client and program functioning. Of the total of 36 clients who attended experi- mental day treatment Group I and Group II over 18 months, the rehospitalization rate for Group I clients (n=l7) was eight rehospitalizations over 18 months: the re- hospitalization rate for Group II clients over 18 months was four rehospitalizations. This differential rehos- pitalization rate between younger and older chronic schizOphrenic patients would seem to be consistent with findings of long-term follow-up studies on the course of schiZOphrenia (e.g., Bleuler, 1976; Ciompi, 1980). The overall rehospitalization rate for the experimental day treatment program was 12 rehospitalizations (12/36=33%) over 18 months. It is noteworthy that of the eight rehospitalizations for Group I clients, six of the seven clients rehospitalized in Group I (n=l7 over 18 months) were all rehospitalized from the same boarding home 148 typically for behavioral altercations rather than psy- chotic decompensation requiring rehospitalization. These rehospitalization figures compare favorably with rehospitalization base rates reported by Anthony, Cohen, and Vitalo (1978) in their review of outcome studies. Their recidivism percentages were estimated to be 30 to 40% at one year, and 65 to 70% at three to five years. Length of rehospitalization proved not to be a reliable measure because: (1) clients were usually transported from the state hospital to the day center for continuation in day treatment at the client's re— quest; and (2) length of rehospitalization was typically due to the client not being allowed to return to the boarding home, and lengthy wait pending the availability of a new home for placement rather than psychotic de- compensation requiring a term of rehospitalization. The Demise of the Experimental Day Treatment Program Confidence in psychotherapeutic day treatment was built within the first six months of the experimental program by staff efforts to develop working alliances with clients, boarding home operators, families, and staff of collateral agencies such as emergency services, inpatient facilities, social services, social security, and physician practitioners. 149 Initially, skepticism and pessimism were ex- pressed within the mental health system when the psycho- analytically oriented day treatment program was first proposed and began treatment. Client satisfaction, the program operating over capacity, attendance and rehospitalization figures, and monthly meetings with boarding home operators, all pro- vided evidence of the effectiveness of the treatment approach. There was increasing interest and support coming from within the mental health system: site visits and staff consultations with other agencies, additional funding for the program, and a presentation by the staff at a regional partial hospitalization conference. Ironically, as such "good press" often encour— ages, for mixed reasons and often with paradoxical re- sults, the day treatment staff were informed that an effort was being made within the system to place the most difficult clients within the agency catchment area so that they could attend the program. The catalyst for the emergence of the real issues related to the treatment of psychotic patients within institutions--of a distinctly political character (i.e., power issues)--occurred after six months beginning with a series of recurrent confrontations between one of the boarding home operators and the clients residing in this home. 150 At four months into the program, a regressed female hebephrenic client had left this home late at night and hitch-hiked on the freeway back to the state hospital, approximately 80 miles away, from which she had been discharged to this home. Three months later, a rather immature and attention-seeking male was re- turned to the state hospital from this home for a be- havioral disturbance in the home, not a psychotic decom- pensation requiring rehospitalization. At ten months, a difficult paranoid client was also returned to the state hospital for persistent homicidal threats and gestures. Three more female clients and a retarded male (who was not a day center client) were also returned to the state hospital from this home. In total, over the 18 months of the program, six of the seven day center clients rehospitalized were all from this one particular boarding home (the seventh being a male with OBS following a car accident, who had a tendency to wander off at night). It seems worth mentioning that the clients re- turned to the state hospital from this particular boarding home were not so decompensated that they could not request to be, and were, transported from the local state hospital to the day center two to three days per week so that they could continue in the program (with the exception of the male who made homicidal threats; 151 he asked to continue in the program, but was deemed "too dangerous" by the hospital personnel). Half of the clients returned to the state hos- pital from this boarding home were not allowed to return to the home. This turnover in clients placed in this home and referred to the day treatment program accounted for most of the turnover in the day center census, apart from day center clients referred from day treatment to outpatient aftercare for continuation in biweekly indi- vidual psychotherapy. The state hospital admitting office finally in- formed this boarding home operator that legally, in- voluntary rehospitalization was determined on the basis of suicidal or homicidal threat to life, not behavioral difficulties or no longer wanting to put up with a particular client resident in the home. It was reported that in one incident, in order to circumvent this technicality, this AFC operator allegedly dropped off the offending client in the hospital parking lot and drove away. As would be expeCted from these clients, after the first two rehospitalizations, the other residents in the home expressed their fears that they would be the next to go, and would no longer be able to continue in the program. They were allegedly told by this operator that "Mental Health" had nothing to do with the way she 152 ran her home; they were told not to discuss what went on in the home with the mental health staff, although she persistently pressured clients about what was said at the day center. This particular home Operator had once commented to the writer that her fantasy was to run her own mental hospital. It was alleged that this home operator manip- ulated client medication in accordance with her decision that the clients needed more medication. There were several incidents on record in which she had argued with the CHM psychiatrist about increasing medication dosages even though he had insisted that the dosage was already at the upper limits of safety. Like other boarding home operators, she began taking some of the clients to a general practitioner for medication. There were other alleged incidents involving boarding home operators, such as persistent threats of rehospitalization for disciplinary purposes, physically threatening clients, religious pressures to accept the fundamentalist beliefs of the home operator, and in- structing clients in what they should and should not feel about their family members, as well as very idio- syncratic "interpretations" by homeowners to clients based on their prying into, and sometimes challenging, what was said ingroup or individual psychotherapy at the day center. These reported incidents involving 153 board and care homes would not surprise any therapist who has worked directly with such clients in the mental health system. In response to the repeated complaints of the difficulties in managing and transporting clients made by the one particular AFC homeowner, and threats by her to shut down her home, the agency pursued a constructive attempt with a liaison from the state hospital to secure a double payment contract for this home with the Depart- ment of Mental Health matching funds with Social Services and Social Security payments. However, when this AFC Operator persisted with covert threats to not encourage clients to attend day treatment or medication clinic, the agency director and larger administrative system decided to file a complaint with Social Services on behalf of the clients (this was not the first complaint filed against a boarding home by Mental Health on behalf of clients' welfare. It would be instructive if these complaints could be re- viewed by some legislative task force on the treatment of mental patients in the community). The ensuing battle between this homeowner and Community Mental Health involving the Department of Social Services had a very ironic resolution. By one of those familiar but always inexplicable twists of administrative politics, the day treatment staff were 154 first told that the administration would handle the problems with this homeowner, and to continue the opera- tion of the program as smoothly as possible; to being informed that the problems at that home were probably due to the clients becoming "too upset" by psychotherapy. It had been decided that the day treatment staff should discontinue intensive psychotherapy and redirect the program to "social work-rehabilitation" by the agency director. Apparently, in order to enforce the change in policy, non-day treatment staff entered group therapy and tape recorded sessions. All individual sessions with clients were to be tape recorded and reviewed by the agency director. One does not need extensive exper- ience in group psychotherapy or psychotherapy with psy- chotics to understand how these sudden and dramatic changes were probably perceived by the clients. In fact, it would be hard to imagine a more effective and covert way of sabotaging therapeutic trust and security with these clients. The shared stress and sense of obliquity for the clients and day treatment staff was managed in the best interests of the clients. It was hoped that the period of treatment would have some lasting benefits. The day center staff and other staff members gradually 155 resigned from the agency in relation to this administra- tive scapegoating. In retrospect, it is tempting to speculate about the role of politics and Kleinian dynamics (Klein, 1957) in these series of events resulting in the termina— tion of an experimental day treatment program. Again, this is another instance of "the tendency for adminis- trative decisions to be made on political rather than evidential bases" (Karon and VandenBos, 1981). Dommermuth and Bucher (1974) have discussed the problems of program develOpment within the Community Mental Health system: All too often trainees of other types [alter- native models of treatment] are later hired to administrate and plan these innovative attempts, a situation for which their chances of survival are slim. The positions often require responses of a political nature that are beyond the capabilities of these young professionals. Furthermore, they are often asked to act using conceptual armamentarium they do not fully understand, such as the sharp delineation of mental health care for a specific catchment area using public health concepts of primary, secondary, and tertiary treatment. The consequences of such involvement is often undesirable and Unanticipated for both the mental health staff members and the community needing their services. It can result in value shifts that restrict freedom in terms of treatment choices and the autonomy of the young professionals involved. It may even- tually lead to a stress on political skills to the relative neglect of service skills. Lastly, it is conceivable that such practices may perpetuate differential treatment patterns, 156 an evil most community mental health practitioners hope to eliminate (p. 156). Obstacles for Psychotherapeutic Day Treatment The most serious and persistent obstacles en- countered in attempting to provide psychotherapeutic day treatment for chronic aftercare clients were: (1) The strong resistance within Community Mental Health to providing psychotherapy for psychotic patients, based upon rigid institutional adherence to an exclusively organic-medication model of functional psychoses that excludes other models and methods of treatment. As noted by Mosher (Gunderson and Mosher, 1975), "Psychotherapy cannot Operate independently Of the institution's prevailing value system(s)." There appeared to be a rigidified institutional insistence upon chronic high "maintenance" levels Of medication for clients, and stubborn resistance to the evidence that psychotropic medication gag be reduced in relation tO symptomatic improvement (e.g., Karon and VandenBos, 1981) or may not even be necessary in an active psycho- social treatment program (e.g., Gunderson, 1977, 1979), in addition tO the more well-known evidence Of signif- icant subgroups of medication non-responders, and the serious long-term effects and symptomatic side effects Of chronic maintenance medication. 157 (2) The second most serious Obstacle to treat- ment process and outcome was the ambivalent and tenuous COOperation Of the boarding home operators. In general, the AFC Operators were supportive of clients spending day hours at the center. However, ambivalence and jealousy about the therapeutic relationship Of the clients to the day center appeared to have led some operators to place clients in the covert bind Of having to express preferences and gratitudes to the Operator. More overtly, AFC Operators might intrude into psycho- therapeutic process and question or contradict the inter- ventions of the therapists or, worse, attempt to make dynamic "interpretations" to clients themselves. There was also a general resistance, based upon previous experience with clients receiving only medica— tion and having medication increased for management, to the lowering Of medication in response to evidence Of symptomatic improvement. The impression Of medication seemingly conveyed by the AFC Operators was that medica— tion should be increased in response tO client "upset" (the "more the better" nOtion). Several incidents were seen in which day center clients were taken tO private general practitioners because the CHM psychiatrist re- fused tO comply with the wishes of the AFC operator; and Of situations in which the AFC Operators allegedly 158 increased medication dosages themselves in response to client "upset." (3) The third major problem encountered in attempting to provide psychotherapeutic day treatment had to dO with the handling and resolution Of client anger in any treatment Of psychosis, and the testing Of the credibility and durability Of the "holding environ- ment." In the Boston psychotherapy research project (Grinspoon, Ewalt, and Shader, 1972) positive outcome was found to be significantly related to therapist focus on anger. However, those unfamiliar with the psycho- therapeutic treatment and recovery Of psychotic patients may continue to regard the emergence of affect in a formerly blunted and withdrawn "good patient" who causes no problems, as a sign of symptomatic worsening or to unreasonably "form the erroneous impression that the psychological treatment damages the patient" (Benedetti [Laurin and Doucet, 1969]). Unfortunately, the average board and care home for psychiatric patients, like it or not, is, typically and unfortunately, not managed with the level Of skills, patience or goals exemplified by a Jackie Schiff (1970). The typical board and care home is, realisti- cally, a business enterprise, not a treatment facility. The average home Operator, in our experience, is a 159 divorced or widowed woman supporting herself. Properly cared for discharged psychiatric patients who are not living with their families is not an easy way to make a living. She need have no particular skill or experience in working with severely disturbed clients, but is paid to feed and house them. Since there is a severe short- age Of Openings and homes, client slots for placement are at a premium. If a resident in the home becomes a problem, the most expedient solution is to medicate, threaten or return the resident to the hospital with the intention Of Obtaining cooperation or replacement with a more compliant and less problematic resident (c.f., Van Patten and Spar, 1979). By contrast, the results that have been reported in studies of residential treatment facilities staffed by professional and trained paraprofessional staffs (e.g., Berke, 1979; Mosher and Menn, 1978) are very encouraging and could suggest that residential treatment facilities may be more effective and cost efficient than the present situation of subsidizing both Community Mental Health centers, programs and staffs, and resi- dential board and care homes. It may even be found, as our experience suggested, that the marked differences in orientation towards the clients and long-term goals in these two client settings (the board and care home versus a psychotherapeutic day treatment program) may 160 be damaging to the clients, based on contradictory mes- sages, expectations, and goals; which ultimately would be counter-therapeutic for the clients. Most therapists do not reward clients for being passive-dependent in- ternalizers Of real feelings or "good helpers," or regressed "babies" we can take care of; and if we did, we would not help them. What is needed is a living facility with similar therapeutic values. The aftercare and day treatment services Ob- served by the writer in five local CMH centers, if representative, raise serious questions about the quality Of "treatment" that is being provided to after- care clients who are typically being "treated" by bachelor level staff with minimal or irrelevant formal training or adequate supervision in any particular treatment modality or model of psychosis. The paradox that the most terrified and "sick" patients are typically being treated by the least trained and experienced ther- apists seems incomprehensible. Flaws in this Study The major weaknesses Of this study are small sample size of subjects in treatment, subject attrition, and lack of contrast group test data. The design Of the study was initially within the parameters of a quasi—experimental time-series control group design 161 (Campbell and Stanley, 1963). Client assignment to the three treatment groups, however, was not randomized, but was based on hospital discharge and community place- ment availability variables that were not controlled. Program comparison data were available for only demographic and length Of stay in treatment data. The study lacked treatment measures for the two comparison treatment groups. Therefore, although the changes seem significant, it cannot be concluded rigorously that any changes found in the experimental treatment group are better or worse than changes which may have been found had the same assessments been made for the two compari- son groups; Or that such changes are not due to extra— neous variables such as the passage Of time. As noted by Campbell and Stanley (1963): Where controls are lacking in a quasi-ex- periment, one must, in interpreting the results, consider in detail the likeli- hood Of uncontrolled factors accounting for the results. The more implausible this becomes, the more 'valid' the ex- periment. The more numerous and independent the ways in which the experimental effect is demon- strated, the less numerous and less plau- sible any singular rival invalidating hypothesis becomes (p. 36). Testings and ratings were made by the therapists, which contains a possible bias (c.f., Rogers et a1., 1967). On one measure (VVT), the initial test was at approximately Time—2 for the other measures. Also, 162 unfortunately, one Of the intended measures (Rorschach) had to be abandoned after baseline testing because the data disappeared. Complete planned evaluations at ap- proximately six month intervals for two years were not possible because Of external problems that caused sub- ject attrition, and finally, the abrupt termination Of the experimental day treatment program and evaluation, at 15 months. Conclusion The study presented was an attempt to evaluate the effectiveness Of an experimental trial of psycho- analytically oriented psychotherapeutic day treatment for chronic psychiatric patients. It provides evidence Of increased attendance and length Of stay in treat- ment, and Of a decrease in thought disorder and Of a behavioral improvement, although the latter two findings lack a comparison group. Evaluation of differential treatment outcomes in this study was made tenuous by the mixed diagnostic categories of the client sample, and by the small sample size. Nevertheless, the following clinical Observations are presented for consideration. (1) Psychoanalytically oriented psycho— therapeutic day treatment focused on the establishment of relatedness and the reduction Of anxiety seemed appro- priate for these chronic psychiatric (2) (3) (4) (5) (6) (7) 163 patients generally, across diagnostic categories, with the following more specific Observations; Generally, positive treatment effects seemed to be positively related to client intelligence and motivation for recovery, and negatively related to age and chron- icity. Clients with primary or secondary diag- noses Of Organic Brain Syndrome or Mini- mal Brain Dysfunction had the most diffi- culty with psychotherapeutic treatment; these clients tended to be emotionally labile, unreflective, impulsive, and to have fixed perseverative behavioral pat- terns and poor tolerance of stress and frustration. Half of the clients re- hospitalized for behavioral altercations had secondary diagnoses Of organic brain syndrome. Clients with treatment histories of ECT and/or lengthy hospitalization seemed to be least motivated for psychothera- peutic treatment; these clients were typically Obsequious and avoided or denied any negative affect in themselves or others. Emotionally reactive clients (e.g., schizoaffective, hebephrenic) seemed to be comparatively more involved in thera- peutic process, and showed more overt symptomatic improvement than affectively blunted, paranoid, and withdrawn clients. The autism Of these chronic clients was manifested in the relative lack Of group cohesiveness or process. There was - minimal interaction between the clients. Most Of the client's interaction was directed towards the staff. "Acting-out" in these clients typically took the form Of an infantile temper tantrum, attention seeking, or rebel- liousness-stubbornness. It is possible that this regressive "acting-out" versus 164 more malignant acting-out (assaultive— ness, self-destructive acts, sexual aggressiveness) was fostered by the therapeutic regression in a psycho- analytically oriented treatment milieu. While psychotherapeutic treatment Of psychotic individuals in the present study,and in the broader psychotherapeutic and psychosocial treatment outcome research literature, has shown evidence Of significant improvement in functioning within six months Of treat- ment on outcome measures, the effectiveness Of these treatments has previously been shown to be adversely affected by drugs, institutional Opposition, and counter—therapeutic resistance to treatment from the patient's environmental figures. Thus, the attempt to provide psychotherapeutic treatment for aftercare clients, as in this psycho- therapeutic model Of day treatment within the Community Mental Health system (an institutional system in which the prevailing model Of treatment for aftercare clients is an organic-medication model as opposed to psycho- therapy for non—psychotic and non-aftercare clients) is encumbered, and possibly not viable, because such at— tempts are in fundamental Opposition to the dominant attitudes toward the management Of these particular clients within the mental health system and community placement programs. 165 There continues to be an urgent need for re- search on treatment approaches for mental illness that can lead tO the development of theory and rational practice of mass treatment for the considerable pro- portion Of the population that requires such treatment (e.g., The President's Commission on Mental Health Task Panel Reports [1978]). Meanwhile, as noted by Stein and Test (1978) in their review Of community treatment Of chronic psychiatric patients, community treatment programs have been implemented on a widespread basis; but "unfortunately, most such programs were neither well grounded in a theoretical framework nor based on evidence Of demonstrated effectiveness." Even worse, as emphasized by Dommermuth and Bucher (1974), "People in the lower strata of our society have the greatest need for these services and receive the least and, at times, possible damaging. care." SUMMARY A psychoanalytically oriented day treatment pro- gram was developed and evaluated over 18 months. It was hypothesized that chronic psychiatric patients in psycho- therapeutic day treatment would show improvement on process-outcome measures Of psychological change: Thought (cognition), Affect, and Object Relations/Interpersonal Behavior, which were conceptualized as fundamental elements Of change produced by psychotherapeutic treat— ment. In addition, evaluation Of treatment was to be based upon length Of stay in psychotherapy, and frequency of attendance, which were related to program effective- ness and motivational variables in psychotherapeutic treatment of such clients. The experimental psychoanalytically oriented day treatment program was compared with two comparable and concurrent day treatment programs on demographic vari- ables, and length Of stay and frequency Of program at— tendance statistics. Comparison process-outcome test measures Of psychological change and rehospitalization data, although originally planned, were ultimately not made available from these two comparison day treatment programs. 166 167 Overall, clients in psychoanalytically oriented day treatment attended significantly more DAYS, MONTHS, and DAYS PER MONTH, than clients at the two comparison programs. The total rehospitalization rate for clients in psychoanalytically oriented day treatment was 12 rehos- pitalizations over 18 months (12/36=33%); the rehospi- talization rate for Group I clients, who were also evaluated on process-outcome measures, was eight re- hospitalizations (8/17=47%); the rehospitalization rate for Group II clients, who were Older, poorer prognosis and more chronic psychiatric patients not evaluated on process-outcome measures as part of the study, was four rehospitalizations (4/l9=21%) over the 18 months of the program. These rehospitalization figures compare favorably with available published base rate figures for comparable patients in treatment. Experimental Group I male and female clients showed a marked and statistically significant improve- ment in thought disorder at 15 months on the Feldman-Drasgow Visual-Verbal Test, the most direct measure of psychotic thought disorder. A near significant reduction on the Lie scale and the Hypochondriasis scale Of the MMPI was found for the total group at six months. Males showed a signif- icant increase on the Paranoia scale and the Goldberg 168 Psychotic Index at six months, accompanied by a trend toward reduction on the Lie scale. Females showed a significant reduction on two MMPI measures of anxiety; the Taylor Manifest Anxiety scale and the Psychasthenia scale; with a significant increase on the Barron Ego Strength scale, at six months. But the 12 month MMPI data suggested a regression in the MMPI scores; there were no significant changes from pre-treatment scores evident for the total sample, or male and female sub— groups, at the 12 month comparison. The equivocal MMPI findings for males compared with females, and the over- all lack of findings based on the MMPI were considered in relation to psychotherapeutic process variables, un- controlled disruptive environmental variables which may have interfered with the treatment, and the lack of sensitivity of the MMPI to process-outcome changes produced by psychotherapeituc treatment of chronic psychiatric patients. The Day Therapy Data Base staff ratings of observable client behavior showed significant improve- ment on ratings of social skills, problem behavior, and task-oriented/performance skills at 3, 6, 9, and 12 month ratings; ratings of sensory-motor performance and activ- ities of daily living skills showed a significant im- provement only on the nine month ratings. REFERENCES REFERENCES Alexander, F. Fundamentals of psychoanalysis. New York, 1963. Alexander, F. Psychosomatic medicine: Its principles and applications. New York: Norton, 1950. Alpert, M., and Friedhoff, A.J. An un-dopamine hypoth— esis of schizophrenia. SchizoPhrenia Bulletin, 1980, 6(3), 387-390. Anthony, W.A., Cohen, M.R., and Vitalo, R. The measure- ment of rehabilitation outcome. Schizophrenia Appenzeller, O. The autonomic nervous system. (2nd ed., rev.). Amsterdam: North-Holland, 1976. Arieti, S. Interpretation of schizophrenia. (2nd ed.) New York: Basic BoOks, 1974. Arieti, S. Psychotherapy of severe depression. American Journal of Psychiatry, 1977, 134(9), 864-867. Arnold, M.B. (ed.). The nature of emotion. Baltimore: Penguin Books,*1968. Bak, R.C. Masochism in paranoia. Psychoanalytic Baldessarini, R.J., and Lipinski, J.F. Risks versus benefits of antipsychotic drugs. New England Journal of Medicine, 1973, 289, 427-428. Bassuk, E., and Gerson, S. Deinstitutionalization and mental health services. Scientific American, 1978, 238(2), 46-53. Bateson, 6., Jackson, D., Haley, J., and Weakland, J. Toward a theory of schizOphrenia. Behavioral Science, 1956, 1, 251-264. 169 170 Beard, J.H., Malamud, T.J., and Rossman, E. Psychiatric rehabilitation and long-term rehospitalization rates: the findings of two research studies. Schizophrenia Bulletin, 1978, 4, 622-635. Bellak, L., and Loeb, L. (eds.). The schizophrenic syndrome. New York: Grune & Stratton, 1969. Bellak, L. (ed.). Disorders of the schizophrenic syn- drome. New York: Basic Books, 1979. Bemporad, J., and Pinsker, H. Schizophrenia: the mani- fest symptomatology. In S. Arieti (ed.) American handbook of psychiatry. New York: Basic Books, 1975. Benedetti, G. The handling of psychotic regression in individual psychotherapy. In P. Doucet and C. Laurin (eds.). Problems of psychosis: Inter- national colloquium ongpsychosis. Amsterdam: Excerpta Medica, 1971. Berger, P.A., and Rexroth, K. Tardive dyskinesia: clinical, biological, and pharmacological per— spectives. Schizophrenia Bulletin, 1980, 6(1), 102-116. Berke, J.H. I haven't had to go mad here. London: Penguin Books, 1979. Billig, 0. Structures of schizophrenic forms of ex- pression. Psychiatric Quarterly, 1970, 44(2), 187-221. Bion, W.R. Notes on the theory of schizophrenia. International Journal of Psychoanalysis, 1954, 35, 113-118. Birley, J.L.T., and Brown, G.W. Crises and life changes preceding the onset or relapse of acute schizo- phrenia: clinical aspects. British Journal of Psychiatry, 1970, 116, 327-333. Bleuler, M. The offspring of schizophrenics. In R. Cancro (ed.), Annual review of the schizophrenic syndrome 1974-5. New York: Brunner/Mazél, 1976. Bockoven, J.S., and Solomon, H.C. Comparison of two five-year follow-up studies: 1947-1952 and 1967-1972. American Journal of Psychiatry, 1975, 132, 796-801. 171 Bookhammer, R.S., Meyers, R.W., Schober, C.C., and Piotrowski, A.Z. A five-year follow—up study of schizophrenics treated by Rosen's "direct analy- sis": compared with controls. American Journal of Psychiatry, 1966, 123, 602-604. Bowers, M.B. Biochemical processes in schizophrenia. Schizophrenia Bulletin, 1980, 6(3), 393—403. Brandwin, M., Van Houten, W., and Ne, D. The continuing care clinic: outpatient treatment of the chronically ill. Psychiatry, 1976, 39, 102-117. Brody, E.B., and Redlich, F.C. (eds.). Psychotherapy with schizophrenics. New York: InternatiOnal Universities Press, 1952. Brody, M. Observations on direct analysis. New York: Vantage, 1959. Brown, G.W., and Birley, J.L.T. Crisis and life changes and the onset of schizophrenia. Journal of Health and Social Behavior, 1968, 9, 203-214. Bullard, D.M. (ed.). Psychganalysis of psychotherapy. Selected papers of Frieda Fromm-Reichmann. Chicago: University of Chicago Press, 1959. Burton, A. (ed.). Psychgtherapy of the psychoses. New York: Basic Books, 1961. Buss, A.H., and Lang, P.J. Psychological deficit in schizoPhrenia: I. Affect, reinforcement, and concept attainment. Journal of Abnormal Psy- chology, 1965, 70(1), 2-24. Caffey, E.M., Galbrecht, C.R., and Klett, C.J. Brief hospitalization and aftercare in the treatment of schizophrenia. Archives of General Psy- chiatry, 1971, 24, 81-86. Cameron, N. Personality development and psychopathology. Boston: Houghton Mifflin, 1963. Campbell, D.T., and Stanley, J.C. Experimental and quasi-experimental designs fOr research. Chicago: Rand McNally, 1963. Cancro, R. Thought disorder and schizophrenia. Diseases of the Nervous System, 1968, 29, 846-849. 172 Cancro, R. Clinical prediction of outcome in schizo- phrenia. Comprehensive Psychiatry, 1969, 10, 349-354. Cancro, R. Prospective prediction of hospital stay in schiZOphrenia. Archives of General Psychiatry, 1969, 20, 541-546. Cancro, R., Fox, N., and Shapiro, L.E. Strategic inter- vention in schizophrenia. New York: BehaviOral PublicatiOns, 1974. Cannon, W.B. Bodily changes in pain, hunger, fear and rage (2nd ed.). New York: Appleton, 1920. Carpenter, W.T., McGlashan, T.H., and Strauss, J.S. The treatment of acute schizophrenia without drugs: an investigation of some current assump- tions. American Journal of Psychiatry, 1977, 134(1), 14-20. Carrington, P. Dreams and schizophrenia. Archives Of General Psychiatry, 1972, 26, 343-350. Chapman, L.J. Recent advances in the study of schizo- phrenic cognition. Schizophrenia Bulletin, 1979, 5(4), 568-580. Chiland, C. (ed.). Long-term treatments of psychotic states. New York: Human Sciences Press, 1977. Ciompi, L. Catamnestic long-term study of the course of life and aging of schizophrenics. Schizophrenia Bulletin, 1980, 6(4), 606-618. Claghorn, J.L., Johnstone, E.E., Cook, T.H., and Itschner, L. Group therapy and maintenance treatment of schizophrenics. Archives of General Psychiatry, 1974, 31, 361-365. Cole, J.O. A lack of controls. International Journal Of PSYChiatry' 1967' 4(2), 129—131e Cousins, N. Anatomy of an illness. New York: Norton, 1979. Crane, G.E. Clinical psychopharmacology in its 20th year. Science, 1973, 181, 124-128. 173 Dahlstrom, W.G., Welsh, G.S., and Dahlstrom, L.E. An MMPI handbook. Minneapolis: University of Minnesota, 1972. Davanloo, H. (ed.). Short-term dynamic psychotherapy. New York: Jason Aronson, 1980. Davis, J.M. Overview: maintenance therapy in psychiatry. I. schizophrenics. American Journal of Psy- chiatry, 1975, 133, 1237—1245. Davis, J.M., Gosenfeld, L., and Tsai, C.C. Maintenance antipsychotic drugs do prevent relapse: a reply to Tobias and MacDonald. Psychological Bulletin, 1976, 83, 431-447. Docherty, J.P., Van Kammen, D.P., Siris, S.G., and Marder, S.R. Stages of onset of schizophrenic psychosis. American Journal of Psychiatry, 1978, 135(4), 420-426. Dommermuth, P.R., and Bucher, R. The psychotherapist in community mental health. In Roman, P.M., and Trice, H.M. (ed.s). The sociology of psy- chotherapy. New York: Jason Aronson, 1974. Duffy, E. Activation and behavior. New York: Wiley, 1962. Eissler, K.R. Notes upon defects of ego structure in schizophrenia. International Journal of Psycho- analysis, 1954, 35, 141-146. English, 0.8., Hampe, W.W., Bacon, C.L., and Settlage, C.F. Direct analysis of schizophrenia. Grune and Stratton, 1961T Erikson, E.H. Childhood and society (2nd ed.). New York: Norton, 1963. Erikson, E.H. Identity youth and crisis. New York: Norton, 1968. Fairbairn, W.R.D. Object-relatigns theory of the personality. New York: Basic Books, 1952. Farley, I.J., Price, K.S., McCullough, E., Deck, J.H.N., Hordynski, W., and Hornykiewicz, O. Norepine- phrine in chronic paranoid schizophrenia: above-normal levels in limbic forebrain. Science, 1978, 200(28), 456-458. 174 Fenichel, O. ‘Thepsychoanalytictheory'of neurosis. New York: Norton, 1945. Fenz, W.D., and Velner, J. Physiological concomitants of behavioral indices in schiZOphrenia. Journal of Abnormal Psychology, 1970, 76(1), 27—35. 1Frankenhaeuser, M. Experimental approaches to the study of catecholamines and emotion. In L. Levy (ed.). Emotions--theirparameters and measurement. New York: Raven Press, 1975. Freud, A. The ego and the mechanisms of defense (rev. ed.). New York: International Universities Press, 1966. :Freud, S. Some points for a comparative study of organic and hysterical motor paralyses. Standard Edition, Vol. I. London: Hogarth Press, 1968 (Originally published, 1893). ZFTeud, S. The neuro-psychoses of defense. Standard Edition, Vol. III. London: Hogarth Press, 1968 (Originally published, 1894). IEreud, S. The interpretation of dreams. New York: Avon Books, 1965 (originally published, 1900). lireud, S. On psychotherapy. In Therapy and technique. P. Rieff (ed.). New York: Collier Books, 1963 (originally published, 1904). Efireud, S. The unconscious. In Collected Papers, Vol. IV. London: Hogarth Press, 1946 (originally published, 1915). Freud, S. The problem of anxiety. New York: Norton, 1936. Fromm-Reichmann, F. Principles of intensive psycho- thera . Chicago: University of Chicago Press, 1950. Ganntt, L., and Schmal, M.S. Art therapy. Rockville: NIMH, 1974. Gardos, G., and Cole, J.O. Maintenance antipsychotic therapy: is the cure worse than the disease? American Journal of Psychiatry, 1976, 133(1), 32-36. 175 Garmezy, N. Children at risk: the search for the ante— cedents of schizophrenia. Part I. Conceptual models and research methods. SchizOphrenia Bulletin, 1974, 8, 14-90. Gellhorn, E., and Loofbourrow, G.N. Emotions and emotional disorders. New York: Hoeber Medical Division, 1963. Giovacchini, P.L. Treatment of primitive mental states. New York: Jason Aronson, 1979. Glatt, C.T., and Karon, B.P. A Rorschach validation study of the ego regression theory of psycho- pathology. Journal of Consulting and Clinical Psychology: 1974, 427'569-576. Goffman, E. Asylums: essays on the social situation of mental patients and other inmates. New York: Anchor BoOks, 1961. Goldberg, S.C., Schooler, N.R., Hogarty, G.E., and Roper, M. Prediction of relapse in schizo- phrenic outpatients treated by drug and socio- therapy. Archives Of General Psychiatry, 1977, 34, 171-184. Goldman, A.E. A comparative—developmental approach to schizophrenia. Psychological Bulletin, 1962, 59, 57-69. Goldstein, M.J., Judd, L.L., Rodnick, E.H., and LaPolla, A. Psychophysiological and behavioral effects of phenothiazine administration in acute schizophrenics as a function of premorbid status. Journal of Psychiatric Research, 1969, 6, 271-287. Goldstein, M.J. Premorbid, adjustment, paranoid status, and patterns of response to phenothiazine in acute schizophrenia. SchiZOphrenia Bulletin, 1970, 1(3), 24-37. Goldstein, M.J., and Rodnick, E.H. The family's con- tribution to the etiology of schizOphrenia: current status. SchiZOphrenia Bulletin, 1975, 14, 48-62. Greenwald, H. (ed.). Active Psychotherapy. New York: Atherton, 1967. 176 Grinspoon, L., Ewalt, J.R., and Shader, R.I. 'Schizo- phrenia, pharmacotherapy, and psychotherapy. Baltimore: Williams and Wilkins, 1972. Groen, J.J. The measurement of emotion and arousal in the clinical physiological laboratory and in medical practice. In L. Levy (ed.). Emotions—- their parameters and measurement. New York: Raven Press, 1975. Gruber, L. Group techniques for acutely psychotic in- patients. Group, 2(1), 31-39. Gruzelier, J.H. Bilateral asymmetry of skin conductance orienting activity and levels in schizophrenis. Biological Psycholong 1973, 1, 21-41. Gunderson, J.G. Drugs and psychosocial treatment of schizophrenia revisited. Journal of Continuing Education in Psychiatry, 1977, 12, 25-40. Gunderson, J.G. The current metaphychology of schizo- phrenia. In J.G. Gunderson and L.R. Mosher (eds.). Psychotherapy of schizophrenia. New York: Jason Aronson, i975. Guntrip, H. Schizoid phenomena, object relations and the self. London: Hogarth Press, 1968? Guy, W., Gross, M., Hogarty, G., and Dennis, H. A controlled evaluation of day hospital effective- ness. Archives of General Psychiatry, 1969, 20, 329-338. Haier, R.J., Rosenthal, D., and Wender, P.H. MMPI assessment of psychopathology in the adopted-away offspring of schizophrenics. Archives of General Psychiatry, 1978, 35, 171-175. Hamilton, L.A. May's conclusions are found to be generally confirmed by clinical experience. International Journal of Psychiatry, 1969, 8(4), 730-733. Heller, K. Review of Rogers et al.'s 'the therapeutic relationship and its impact: a study of psycho- therapy with schizophrenics.‘ Psychiatry, 1969, 32(3), 348-350. 177 Herz, M.I., Endicott, J., Spitzer, R.L., and Mesnikoff, A. Day versus inpatient hospitalization-~a controlled study. American Journal of Psy- chiatry, 1971, 127, 1371-1382. Herz, M.I., Spitzer, R.L., Gibbon, M., Greerspan, K., and Reibel, S. Individual vs. group aftercare treatment. American Journal of Psychiatry, 1974, 313, 808-812. Hill, L.B. Psychotherapeutic intervention in schizo- phrenia. Chicago: University of‘Chicago Press, 1974. Hogarty, G.E., Goldberg, S.C., and the Collaborative Study Group. Drug and sociotherapy in the after- care of schizophrenic patients: one year relapse rates. Archives of General Psychiatry, 1973, 28, 54-64. Hogarty, G.E., Goldberg, S.C., Schooler, N.R., and Ulrich, R.F. Drug and sociotherapy in the aftercare of schizophrenic patients.II. Two year relapse rates. Archives of General Psy- chiatry, 1974, 31, 606-618. Horowitz, M.J. Intrusive and repetitive thoughts after experimental stress: a summary. Archives of General Psychiatry, 1975, 32, 1457-1463. Huttunen, M.O., and Niskanen, P. Prenatal loss of father and psychiatric disorders. Archives of General ngchiatry, 1978, 35, 429-431. Jacob, T. Family interaction in disturbed and normal families: a methodological and substantive review. Psychological Bulletin, 1975, 82, 33-65 e Jacobs, 8., and Meyers, J. Recent life events and acute schizophrenic psychoses: a controlled study. Journal of Nervous and Mental Disease, 1976, 162, 75-87. Janis, I.L. Effects of fear arousal on attitude change: recent develOpments in theory and experimental research. In L. Berkowitz (ed.). Advances in experimental social psychology. New York: Academic Press, 1967. 178 Janowsky, D.S., El-Yousef, M.K., Davis, J.M., and Sekerke, H.J. Provocation of schiZOphrenic symptoms by intravenous administration of methylphenidate. Archives of General Psychiatry, 1973, 28, 185-191. Janowsky, D.S., and Davis, J.M. Methylphenidate, dextro- amphetamine, and levamfetamine. Effects on schizophrenic symptoms. Archives of General Psychiatry, 1976, 33, 304-308. Karon, B.P. The psychoanalytic treatment of schizo- phrenia. In P.A. Magaro (ed.). The construc- tion of madness. New York: Pergamon, 1976. Karon, B.P. The resolution of acute schizophrenic reactions: a contribution to the development of non-classical psychotherapeutic techniques. Psychotherapy: Theory, Research, and Practice, 1963, 1, 27-43. - Karon, B.P., and VandenBos, G.R. Clinical status change over 20 months of treatment. A paper presented at the Society of Psychotherapy Research conven- tion held in Chicago, Illinois, June 1970. Karon, B.P., and VandenBos, G.R. Issues in current research on psychotherapy vs. medication in treatment of schizophrenics. Ps chotherapy: Theory, Research, and Practice, 1975, 12(2), 143-148. Karon, B.P., and VandenBos, G.R. Psychotherapeutic technique and the economically poor patient. Psychotherapy: Theory, Research, and Practice, 1977, 14, 169-180. Karon, B.P., and VandenBos, G.R. Psychotherapyof gphizophrenia: treatment of choice. New York: Jason Aronson, 1981. Karon, B.P., and VandenBos, G.R. Psychotherapy with schizophrenics requires relevant training. Schizophrenia Bulletin, 1978 4(4), 480-483. Karon, B.P., and VandenBos, G.R. The consequences of psychotherapy for schiZOphrenic patients. Psychotherapy: Theory, Research, and Practice, 1972, 9, 111-120. 179 Karon, B.P., and VandenBos, G.R. Thought disorder in schizophrenia, length of hospitalization, and clinical status ratings. 'The Journal of Clinical Psychology, 1974, 30, 264-266. Kayton, L. Clinical features of improved schizophrenics. In J.G. Gunderson and L.R. Mosher (ed.). Psychotherapy of schizophrenia. New York: Jason Aronson, 1975. Keith, S.J., Gunderson, J.G., Reifman, A., Buchsbaum, S., and Mosher, L.R. Special report: schizo- phrenia 1976. Schizophrenia Bulletin, 1976, 2(4), 509-565. Kelly, D.H.W., and Walter, C.J.S. The relationship between clinical diagnosis and anxiety, assessed by forearm blood flow and other measurements. British Journal of Psychiatry, 1968, 114, 611-626. Kelly, D., Brown, C.C., and Shaffer, J.W. A comparison of physiological and psychological measurements on anxious patients and normal controls. Egy- chophysiology, 1970, 6(4), 429-441. Kernberg, O. Borderline conditions and pathological narcissism. New York: Jason Aronson, 1975. Kernberg, 0. Object relations theory and clinical psychoanalysis. New York: Jason Aronson,i1976. Kernberg, P.F. Childhood schizOphrenia and autism: a selective review. In L. Bellak (ed.). Eig- orders of the schizophrenic syndrome. New York: Basic Books, 1979. Kety, S. Heredity and environment. In J.C. Shershow (ed.). Schizophrenia: science and practice. Cambridge: Harvard University Press, 1978. Kielhoz, P. Psychopharmacology measurement of emotion in medical practice. In L. Levy (ed.). Emotions-:Eheirparameters and measurement. New York: Raven Press,*l975. King, G.E., and Goldstein, M.J. Therapist ratings of achievement of objectives in psychotherapy with acute schizophrenics. Schizophrenia Bulletin, 1979, 5(1), 118-129. 180 Kirk, S.A. Effectiveness of community services for discharged mental hospital patients. American Journal of Orthopsychiatry, 1976, 46, 646-659. Klein, M. Enyy and gratitude and other works 1946-1963. New York: Delta, 1975. Klein, N.S. Synopsis of Eugen Bleuler's dementia praecox or the group of schizophrenias. New York: International Universities Press, 1952. Knight, R.F. Introjection, projection, and identifica- tion. Psychoanalytic Quarterly, 1940, 9, 334-341. Lacey, J.I., and Smith, R.L. Conditioning and generaliza- tion of unconscious anxiety. Science, 1954, 120, 1045-1052. Lacey, J.I., Smith, R.L., and Green, A. Use of con- ditioned autonomic responses in the study of anxiety. In C.F. Reed, I.E. Alexander, and 5.5. Tomkins (eds.). Psychopathology: a source book. Cambridge: Harvard’University Press, 1963. Laing, R.D. The divided self. London: Tavistock, 1959. Lang, P.J., and Buss, A.H. Psychological deficit in schiZOphrenia: II. interference and activation. Journal of Abnormal Psychology, 1965, 70(2), 77-106. Langer, D.H., Brown, G.L., and Docherty, J.P. Dopamine receptor supersensitivity and schizophrenia: a review. Schizophrenia Bulletin, 1981, 7(2), 208-224. Lapidus, L.B., and Schmolling, P. Anxiety, arousal, and schizophrenia: a theoretical integration. Psychological Bulletin, 1975, 82(5), 689-710. LaTorre, R.A. The psychological assessment of gender identity and gender role in schizOphrenia. SchiZOphrenia Bulletin, 1976, 2(2), 266-285. Leff, J.P. SchiZOphrenia and sensitivity to the family environment. SchiZOphrenia Bulletin, 1976, 2(4), 566-574. 181 Leff, J.P., and Wing, J.K. Trial of maintenance therapy in schizophrenia. ‘British Medical Journal, 1971, 3, 559-604. Levene, H.I., Patterson, V., Murphey, B.G., Overbeck, A.L., and Veach, T.L. The aftercare of schizo- phrenics: an evaluation of group and individual approaches. Psychiatric Quarterly, 1970, 44, 296-304. Lidz, T. The origin and treatment of schizOphrenic dis- orders. New York: Basic Books, 1973. Lidz, T. Reply to Kety et a1. Schizophrenia Bulletin, 1977, 3(4), 522-526. Lipton, E.L., Steinschneider, A., and Richmond, J.B. The autonomic nervous system in early life. The New England Journal of Medicine, 1965, 273(3), 147-153. Livingston, G. The role of activity in the treatment of schizoid or schizophrenic patients. In H. Greenwald (ed.). Active psychotherapy. New York: Atherton Press, 1967. McCranie, E.W., and Mizell, T.A. Aftercare for psy- chiatric patients: does it prevent rehospitaliza- tion? Hospital and Community Psychiatry, 1978, 29(9), 584-587i McDonald, R.L. The role of emotional factors in obstretric complications: a review. Psycho- somatic Review, 1968, 30, 222-237. Magaro, P., and Vojtisek, J. Embedded figure per- formance of schiZOphrenics as a function of chronicity, premorbid adjustment, diagnosis and medication. Journal of Abnormal Psychology, 1971, 77, 184-191. Mahler, M.S. Perturbances of symbiosis and individua- tion in the development of the psychotic ego. In P. Doucet and C. Laurin (eds.). Problems of psychosis: International Colloquium on Psychosis. Amsterdam: Excerpta Medica, 1971. Malmo, R.B., and Shagass, C. Physiological studies of reaction to stress in anxiety states and early schizophrenia. Psychosomatic Medicine, 1949, 11’ 9-24. 182 May, P.R.A. Treatment of schizophrenia. New York: Science House, 1968. May, P.R.A., and Tuma, A.H. A follow-up study of the results of treatment. Archives of General Psy- chiatry, 1976a and b, 33, 474-478 and 481-486. Mednick, S.A. A learning theory approach to research in schizophrenia. Psychological Bulletin, 1958, 55, 316-327. Mednick, B.R. Breakdown in high-risk subjects: familial and early environmental factors. Journal of Abnormal Psycnology, 1973, 83(3), 469-475. Mednick, S.A., and Schulsinger, F. Studies of children at high risk for schizophrenia. In S.R. Dean (ed.). Schizophrenia: the first ten Dean award lectures. New York: MSS InfOrmation, 1973. Meyer, R.G., and Karon, B.P. The schizophrenogenic mother concept and the TAT. Psychiatry, 1967, 30, 173-179. Mintz, J., O'Brien, C.F., and Luborsky, L. Predicting the outcome of psychotherapy for schizophrenics. Archives of General Psychiatry, 1976, 33, 1183-1186. Mitchell, K.M. An analysis of the schizophrenogenic mother concept by means of the TAT. Journal of Abnormal Psychology, 1968, 73, 571-574. Mitchell, K.M. Social class and the schizophrenogenic mother concept. Psychological Reports, 1969, 24, 463-469. Mosher, L.R., and Keith, S.J. Psychosocial treatment: individual, group, family, and community support approaches. Schizophrenia Bulletin, 1980, 6(1), 10-41. Mosher, L.R., and Menn, A.Z. The surrogate "family," an alternative to hospitalization. In J.C. Shershow (ed.). Schizgphrenia: science and practice. Cambridge: Harvard University Press, 1978. Mueller, W.J. Avenues to understanding: the dynamics of pherapeutic interactions. New York: Appleton- Century-Crofts, 1973. 183 Munro, A. Some psychiatric non-sequelae of childhood bereavement. British Journal of Psychiatry, 1969, 115, 305—311. Naumberg, M. gynamically oriented art therapy: its ppinciples and practices. New York: Grune & Stratton,*1968. Naumberg, M. Psychoneurotic art: its function in psy- chotherapy. New York: Grune & Stratton, 1953. Naumberg, M. Schizophrenic art: its meaning in psycho- therapy. New York: Grune & Stratton, 1950. Nichols, N. The relationship between degree of maternal pathogenicity and severity of ego impairment—in schizophrenic offSpring. Unpublished dOctoral dissertation, University of Michigan, 1970. O'Brien, C.F., Hamm, K.P., Ray, B.A., Pierce, J.F., Luborsky, L., and Mintz, J. Group vs. individ- ual psychotherapy with schizophrenics: a con- trolled outcome study. Archives of General Psychiatry, 1972, 474-478. Offenkrantz, W. Multiple somatic complaints as a pre- cursor of schizophrenia. American Journal of Psychiatry, 1962, 119, 258-259. Paul, G.L., and Lentz, R.J. Psyghosocial treatment of chronic mental patients: milieu vs. social learning programs. Cambridge: Harvard Univer- sity Press, 1977. Paul, G.L., Tobias, L.L., and Holly, B.L. Maintenance psychotropic drugs in the presence of active treatment programs. Archives of General Psy- chiatry, 1972, 27, 106-115. Powdermaker, F., and Frank, J. Group psychotherap . Cambridge: Harvard UniverSiEy Press, I953. Rabin, A.I., and Winder, C.L. Psychological studies. In L. Bellak and L. Loeb (eds.). The schizo- phrenic syndrome. New York: Grune & Stratton, 1969. Rabin, A.I., Doneson, S.L., and Jentons, R.L. Studies of psychological functions in schizophrenia. In L. Bellak (ed.). Disorders of the schizophrenic syndrome. New York: Basic Books, 1979. 184 Rappaport, M., Hopkins, H.K., Hall, K., Belleza, T., and Silverman, J. Are there schizophrenics for whom drugs may be unnecessary or contraindicated? International pharmacopsychiatry, 1978, 13, 100-111. Raskin, D. Milieu therapy re-examined. Comprehensive Psychiatry, 1976, 17(6), 675-701. Rieder, R.O. Children at risk. In L. Bellak (ed.). Disorders of the schiZOphrenic syndrome. New York: Basic Books, 1979. Riskin, J., and Faunce, E.E. An evaluative review of family interaction research. Family Process, 1972, 11, 365-456. Rogers, C.R., Gendlin, E.T., Kiesler, D.J., and Truax, C.B. The therapeutic relationship and its im- pact: a study of psychotherapy with schizo- phrenics. Madison: University of WiSconsin Press, 1967. Rogler, L.H., and Hollingshead, A.B. Trapped: families and schiZOphrenia. New York: John Wiiey & Sons, 1965. Rosen, J.N. Direct analysis. New York: Grune & Stratton,*I953. Rosen, J.N. Psychotherapy and schizophrenia. Inter- national Journal of Psychiatpy, 1969, 8(4), 748-752. Rosenfeld, H.A. Psychotic states: a psychoanalytic approach. New York: International Universities Press, 1965. Rubins, J.L. Five-year results of psychoanalytic therapy and day care for acute schizophrenic patients. AmeriCan Journal of Psychoanalysis, 1976, 36, 3-26. Scheflen, A.E. A psychotherapy of schizophrenia. Illinois: Charles C. Thomas, 1961. Schiff, J. All my children. New York: Evans, 1970. Searles, H. Collected papers on schizophrenia and re- lated subjects. New York: International Univer- sities Press, 1965. 185 Selye, H. Stress and disease. In C.F. Reed, I.E. Alexander, and 8.8. Tomkins (eds.). ‘PSycho- pgthology: a source book. Cambridge: Harvard University Press, 1963. Selye, H. The stress of life (rev. ed.). New York: McGraw-Hill, 1976. Shattan, S.P., Dcamp, L., Fujii, E., Foss, G.G.,and Wolff, R.J. Group treatments of conditionally discharged patients in a mental health clinic. American Journal of Psychiatry, 1966, 122, 798-805. Sheldon, A. An evaluation of psychiatric aftercare. British Journal of Psychiatry, 1964, 110, 662-667. Shershow, J.C. Schizophrenia: science and practice. Cambridge: Harvard University Press, 1978. Shields, J. Summary of genetic evidence. In D. Rosenthal and S. Kety (eds.). The transmission of schiZOphrenia. Oxford: Pergamon Press, 1968. Shields, J., and Gottesman, I.I. Obstetric complica- tions and twin studies of schiZOphrenia: clari- fications and affirmations. Schizophrenia Bulletin, 1977, 3(3), 351-354. Snyder, S.H. Amphetamine psychosis: a "model" schizo- phrenia mediated by catecholamines. American Journal of Psychiatry, 1973, 130(1), 61-67. Snyder, S.H., Banerjee, S., Yamamura, H.I., and Greenberg, D. Drugs, neurotransmitters, and schizophrenia. Science, 1974, 184, 1243-1253. Sontag, L.W. War and the fetal-maternal relationship. Marriage and family living, 1944, 6, 3-4. Spadoni, A.J., and Smith, J.A. Milieu therapy in schizophrenia. Archives of General Psychiatry, 1969, 20, 547-551. Spitz, R.A. Hospitalism: an inquiry into the genesis of psychiatric conditions in childhood. Psycho- analytic Study of the Child, 1945, 1, 53-74. Spitz, R. The first year of life. New York: Interna- national Universities Press, 1965. 186 Spohn, H.E., Lacoursiere, R.B., Thompson, K., and Coyne, L. Phenothiazine effects on psychological and psychophysiological dysfunction in chronic schizophrenics. Archives of General Psychiatry, 1977, 34, 633-644. Spohn, H.E., and Patterson, T. Recent studies of psycho- physiology in schizophrenia. Schizophrenia BUlletin, 1979’ 5(4), 581-611e Steinberg, H.R., and Durell, J.A. A stressful social situation as a precipitant of schizophrenic symptoms: an epidemiologic study. British Journal of Psychiatry, 1968, 114, 1097-1105. Sue, S., McKinney, H., and Allen, D.B. Predictors of the duration of therapy for clients in the com- munity mental health system. Community Mental Health Journal, 1976, 12, 365-375. Sullivan, H.S. Schizophrenia as a human process. New York: Norton, 1962. Sullivan, H.S. The interpersonal theory of psychiatry. New York: Norton, 1953. Tarrier, N., Vaughn, C., Lader, M.H., and Leff, J.P. Bodily reactions to people and events in schizo- phrenics. Archives of General Psychiatry, 1979, 36, 311-315. Test, M.A., and Stein, L.I. Community treatment of the chronic patient: research review. Schizo- phrenia Bulletin, 1978, 4(3), 350-364. Tompkins, S.S. Affect, imagery, consciousness (2 vols.). New York: Springer, 1963, 1964. Trunell, T.L. The absent father's children's emotional disturbances. Archives of General Psychiatry, 1968, 19, 180-188. Tuma, A.H., and May, P.R.A. Psychotherapy, drugs and therapist experience in the treatment of schizo- phrenia: a critique of the Michigan State Pro- ject. Psychotherapy: Theory, Research and Practice, 1975, 12(2), 138-142. 187 Vaillant, G.E. Prognosis and the course of schizo- phrenia. SchiZOphrenia Bulletin, 1978, 4(1), 20-24. VandenBos, G.R., and Karon, B.P. A new therapist personality dimension related to therapeutic effectiveness. Journal of Personality Assess- ment, 1971, 35, 252-260. Van Dyke, J.L., Rosenthal, D., and Rasmussen, P.V. Electrodermal functioning in adopted-away off- spring of schizophrenics. Journal of Psychia- tric Research, 1974, 10, 199-215. Van Putten, T. Milieu therapy: contraindications? Archives of General Psychiatry, 1973, 29, 640-643. Van Putten, T., and Spar, J. The board-and-care home: does it deserve a bad press? Hospital and Com- munity Psychiatgy, 1979, 30(7), 461-464. Venables, P.H., and Wing, J.K. Level of arousal and the subclassification of schizophrenia. Archives of General Psychiatry, 1962, 7, 114- 119. Washburn, S., Vannicelli, M., Longabaugh, R., and Schoff, B.J. A controlled comparison evaluation of psychiatric day treatment and inpatient hospitalization. Journal of Clinical and Con- sulting PsycholOQY. 1976, 44, 665-675. Waskow, I.E., and Parloff, M.B. Psychotherapy change measures: report of the clinical research branch outcome measures project. Washington, D.C. U.S. Government Printing Office, 1975. Whitaker, C. (ed.). Psychotherapy Of chronic schizo- phrenic patients. Boston: Little, Brown & Co., 1958. ‘Wilder, J.F., Levin, G., and Zwerling, J. A two-year follow-up evaluation of acute psychotic patients treated in a day hospital. American Journal of Psychiatry, 1966, 112, 1095-1101. WOhlberg, L.R. The technique of psychotherapy (3rd ed., 2 vols.). New York: Grune & Stratton, 1977. 188 Wynne, L.C., Cromwell, R.L., and Matthysse, S. (eds.). The nature of schizophrenia: new approaches to research and treatment. New York: John Wiley & Sons, 1978. Wynne, L., and Singer, M. Thought disorder and family relations of schiZOphrenics. Archives of General Psychiatry, 1963, 191-206. Wynne, L.C., Singer, M.T., and Toohey, M.L. Communica- tion of the adoptive parents of schizophrenics. In J. Jorstad and E. Ugelstad (eds.). Schizo- phrenia 75: psychotherapy, family studies, re- search. Oslo: Universitetsforlaget, 1976. Yalom, I.D. The theory and practice of group psycho- therapy. New York: Basic Books, 1970. Zetzel, E.R. The usefulness--and limitations--Of the phenothiazines. International Journal of Psy- chiatry, 1967, 4(2), 138-139. APPENDIX A APPENDIX A THEORETICAL INTEGRATION: PSYCHODYNAMIC AND NEUROPHYSIOLOGICAL COROLLARY MECHANISMS IN SCHIZOPHRENIA Introduction Clinical experience and experimental evidence suggests that comparatively high levels of anxiety are a pathognomonic finding in schizophrenic disorders (Kelly and Walter, 1968). Studies have demonstrated high correlations between measures of anxiety and phy- siological concomitants of anxiety in anxious versus less-anxious psychiatric patients and controls (Kelly and Walter, 1968; Kelly, Brown, and Shaffer, 1970). Psychophysiological studies of high-risk off- spring, preschizophrenics, and schizophrenics, compared with controls have consistently demonstrated abnormal- ities in indices of psychophysiological autonomic "arousal" in these subjects (Fenz and Velner, 1970; Garmezy, 1974; Gruzelier, 1973; Lang and Buss, 1965; Spohn and PatterSon, 1979; Venables and Wing, 1962; and Zahn, Carpenter, and McGlashan, 1981). A corollary relationship has been suggested be- tween psychodynamic anxiety and psychophysiological 189 190 arousal (Groen, 1975; Kelly and Walter, 1968; Lapidus and Schmolling, 1975; and Mednick, 1958), which could support a psycho-somatic mechanism or process in schizo- phrenia. The theory for, and evidence of, a psycho-soma- tic model in schizophrenia is presently unsystematized, although there exists scattered and preliminary em- pirical evidence that could support such an etiological hypothesis. It is the purpose of this paper to review evidence that could support the hypothesis of a psycho-somatic model in the etiology and functional dynamics of at least some schizophrenic psychotic reactions. Psychodynamics: The Pathogenic Role of Anxiety in SchizOphrenia Clinical investigators (Arieti, 1974; A. Freud, 1966; Burton, 1961; Fairbairn, 1952; Fromm-Reichmann, 1950; Giovacchini, 1979; Gunderson and Mosher, 1975; Guntrip, 1968; Karon and VandenBos, 1981; the Kleinians [e.g., Rosenfeld, 1965]; Lidz, 1973; Mahler, 1971; Searles, 1965; and Sullivan, 1953, 1962; among many others) have long emphasized the dynamic relationship between maternal anxiety and infantile anxiety as a pathogenic or teratogenic developmental factor in the etiology of schizophrenic disorders. 191 Recently, it has been suggested that the patho- genic role of critical environmental variables may even include fetal develOpment in utero in exposure to maternal stress and anxiety physiology as it impinges upon the fetus (Huttunen and Niskanen, 1978; Lipton, Steinschneider, and Richmond, 1965; McDonald, 1968; Sameroff [Garmezy, 1974]; and Sontag, 1944). This is an area of study that unfortunately has not received serious enough consideration or adequate attention in etiological investigations. An ingenious retrospective epidemiological study using the Finnish pOpulation register (Huttunen and Niskanen, 1978) tested the role of maternal stress during pregnancy on offspring psychopathology. The study compared individuals whose fathers had died dur- ing their offspring's term in utero to a control group of individuals whose fathers had died during the first year of infancy. Death of husband was operationalized as one of the most intensive maternal stressors. Huttunen and Niskanen (1978) report that: The number of diagnosed schizophrenics treated in psychiatric hospitals and the number of persons committing crimes were significantly higher in the index than in the control group. The incidence of alcoholism and personality disorders was relatively high in both groups. The in- dex psychiatric cases had a low frequency of birth complications, whereas those of the control group were high. 192 The results suggest that especially during months 3 to 5 and 9 to 10 of pregnancy, maternal stress may increase the risk of the child for psychiatric disorders, per- haps mediated through the "inborn tempera- mgpp" of the child (p. 429). The findings of Huttunen and Niskanen (1978) support the hypothesis of a direct biological effect of maternal stress (which could also be conceptualized as maternal anxiety physiology) during pregnancy upon fetal development and "inborn temperatment," as well as sup- porting the pathogenic role of the early infantile en- vironment via the psychological transactional effects of maternal anxiety (review by Garmezy, 1974), depres- sion (review by Garmezy, 1974), and loss of father (Munro, 1969; Trunell, 1968), upon the child's per- sonality develOpment and increased risk of subsequent psychopathology and stress vulnerability. Huttunen and Niskanen conclude that, "the finer differentiation of the in utero environment, maternal stress, and subse- quent develOpment bears on the interpretation of cur- rent studies of the genetics of psychiatric disorders, as well as ultimate concerns with prophylaxis." In the well-known longitudinal high-risk pro- ject reported bvaednick and Schulsinger (1973), very similar uncontrolled, critical "pathogenic" environ- mental variables correlated with risk status, and 193 presumably unrelated to genetics, were found. B. Mednick (1973) reported that: (a) The mothers of the subjects in the breakdown group experienced more emo- tional stress during their pregnancies than did the mothers of the improved group. (b) The subjects in the breakdown group suffered loss of mother at an earlier age and tended significantly not to acquire a substitute mother [these children were raised in children's homes or by their fathers]. (c) The breakdown group tended to have mentally ill fathers as well as schizo- phrenic mothers. There were no fathers hospitalized for mental illness in the improved group (p. 469). In a review of Mednick and Schulsinger (1973) project data, Rieder (1979) points out that the mothers of the schizophrenic group were more frequently un- married, and that only two out of the 14 schizophrenics had been raised in an intact family. Such findings seem more supportive of the developmental etiological theory proposed by Lidz (1973, 1977, 1978), than supportive of a vague and unspecified genetic X-factor in the etiology of schizophrenia. Rieder (1979) notes that comparisons between the schizophrenic males and females suggest that differential factors may affect the etiology of schizo- phrenia in males and females, but that such predictors remain Obscure. 194 There is accumulating empirical evidence sug- gesting more specific pathogenic critical environmental variables in schizophrenogenic families (Goldstien and Rodnick, 1975; Karon and VandenBos, 1981; Jacob, 1975; Leff, 1976; Lidz, 1973, 1978; Nichols, 1970; Mitchell, 1968; Riskin and Faunce, 1972; and Wynne, Toohey, and Doane, 1979). These studies provide evidence of such pathogenic familial structural and transactional var- iables as amorphous and fragmented communication de- viance/transactional style deviance; parental marital skew, schism, and emotional divorce; and so-called "ex- pressed emotionality;" that is, criticism, hostility, overinvolvement, guilt induction, and intrusiveness. GoldsteinanuiRodnick (1975) also cite research on parameters of family structure that appear to differ- entiate the families of origin of good and poor pre- morbid schizOphrenics, and "corrective" factors which mitigate pathogenic variables and lessen the likelihood of psychotic developments. Karon and VandenBos (1981) have suggested that transactional "pathogenesis" can be understood as an unconscious defense against anxiety in the parent or parent's relationship to the preschizophrenic. This "pathogenesis," despite its often subtle manifestations, is pervasive and damaging psychologically to the emo- tional, cognitive, and social development of the child, 195 predisposing to anxiety, insecurity, confusion, aliena- tion, and characteristic developmental maladaptations and developments that increase vulnerability to en- vironmental stressors and risk of psychopathology. The evidence from these studies suggests that "schizophrenia spectrum" psychopathology is predicted by the degree of early infantile stress and trauma, pos- sibly including the fetal environment. High levels of childhood reactive anxiety (c.f., Garmezy, 1974) may lead to pathognomonic personality maladaptations such as the schizoid, psychOpathic, or stormy personalities (Arieti, 1974; Goldstein and Rodnick, 1975), or worse, to autism and childhood schizophrenia (Kernberg [Bellak, 1979]), and even to child mortality (Garmezy, 1974; Spitz, 1945). Thought Disorder: Cognitive Dys- FunctiOns Related to Anxiety Karon (1963, 1976), Lidz (1973), and wynne and Singer (l963),based upon empirical findings, have sug- gested a relationship between anxiety and thought dis- order in schizophrenia, as well as a relationship be- tween anxiety and communication/transactional disturb- ances demonstrated in families of schizophrenics. Harrow and Quinlan (Chapman, 1979) using several measures of thought disorder have also found that thought disorder is not unique to schizophrenics, but was found 196 in mild form in psychiatric patients with various diag- noses, although schizophrenics showed the most severe thought disorder. The findings of Harrow and Quinlan could provide support for the suggestion of a positive relationship between the level of anxiety and degree of thought disorder as an effect of anxiety, either psy- chologically, psychophysiologically, or determined by both. Holtzman et a1. (Spohn and Patterson, 1979) found smooth persuit eye movement anomalies (SPEM) or eye tracking deviance (ETD), which Holtzman et a1. interpret to be an involuntary attentional disorder, to be in- creased not only among schiZOphrenic, but also among nonschiZOphrenic functionally psychotic patients com— pared with controls. Holtzman, et al. found evidence of a positive relationship between the presence of thought disorder, as determined by psychological tests, and ETD in psychiatric patients. Like the trans- . actional/communication deviance variables related to anxiety (Wynne and Singer, 1963) repeatedly demonstrated in families of schizophrenics, ETD-suggesting an in- voluntary attentional disorder has been found in first degree relatives of schizophrenics compared with rela- tives of nonschizophrenic psychiatric patients and controls. 197 Experimental findings in studies of psycho- logical functioning in schizophrenics would generally appear to be consistent with the suggestion of the pathogenic role of anxiety in schizophrenia. In a re— view of psychological research, Rabin, Doneson, and Jentons (1979) note that: Experimental psychologists involved in schizophrenia research have for the most part shown that schizophrenics, as com- pared with normals, have a greater tendency toward stimulus avoidance, an inability to maintain set or attention, a deficit in generalizing and categorizing ability, and poor involvement in experimental tasks (especially those involving social stimuli) and, are socially withdrawn and subject to disturbed autonomic system functioning. This summary reported in a recent National Institute of Mental Health monograph is appropriately capped by the statement that "major questions remain about variability, reliability and etiological significance of the findings" (p. 181). It has been shown that the relationship between emotional arousal and perceptual and cognitive per- formance accuracy is curvilinear (inverted U curve of efficiency [Malmo and Shagass, 1949; Duffy, 1962]). Physiological studies of schizophrenics have demon- strated both overarousal and underarousal in schizo- phrenics (Fenz and Velner, 1970; Lang and Buss, 1965; Spohn and Patterson, 1979; and Venables and Wing, 1962). Janis (1967) found high arousal in short-term stress situations related to hypervigilance and temporary im- pairments in judgment, attention, and set in normals. 198 Specific Thoughts Stimulate Anxiety; Evidence of the Subconscious Activation of Anxiety Groen (1975) suggests the following Operational definition of anxiety: Purely psychologically anxiety can be de- fined as a peculiar, unpleasant feeling, characterized by the anticipation of a threatening or dangerous event that might happen in the future. When this future event is clear to both the subject and the investigator, the emotion is usually called fear; when the individual and the investigator are not quite conscious of the cause, the terms apprehension, anx- iety per se, or "free-floating anxiety" are used. The tendency of predisposition, which is present in some individuals more than in others, to react with anxiety to the per- ception of certain future events is called the anxiety trait; this is considered to be one of the characteristics of the indi- vidual personality. The emotion itself is designated as the anxiety state (Spielberger, 1966). . . . this anxiety trait depends largely on previous experience, conditioning, and learning of the individual. This may mean, for instance, that an event to which one individual reacts by anxiety may induce in another aggressivity, in others depression, and in others no more than curiosity; con- sequently it depends mainly on previous programming whether an individual will re- act by fight, flight, submission, or some other form of coping behavior (p. 732-733). Horowitz (1975) has summarized research findings supportive of a general model of cognitive response to stressful events: Clinical studies indicate that external stress events induce two seemingly 199 opposite deflections from conventional ways in which ideas and feelings are experienced. The stress event may be followed by intru- sive and repetitive thought, or by idea- tional denial and emotional numbing. A series of experiments examined one of the deflections, intrusive and repetitive thought and found it to be a general response ten- dency occurring across various populations and degrees of stress. This report summar- izes results from this series of replicated studies (p. 1457). After stressful events, even those of less impact than a "trauma," there is a tendency to repeated recollection of the event and related associations. This process will continue even if opposed by controlling maneuvers. The combination of automatic repetition and avoidance efforts leads to episodes of intrusive thought. With inte- gration, the automatic repetition ceases as a special memory effect. The stressful event becomes, like other memories, avail- able for recollection but is no longer preemptory in emergence (p. 1463). The model of cognitive response to stressful events demonstrated by Horowitz (1975) would appear to be consistent with the suggestion that chronic high levels of anxiety in schiZOphrenia can be reinforced by non-integrated or unresolved anxiety-stimulating intru- sive and repetitive thoughts. The suggestion that anxiety-stimulating intru- sive and repetitive thoughts are related to the rein- forcement of chronically high levels of anxiety would seem to have particular significance to schizophrenia, in which perseverative terrifying thoughts (Karon, 1963, 1976), misperceptions, delusions and hallucinations 200 would provide powerful stimuli for the reinforcement and exacerbation of anxiety reactions with autonomic con- comitants, the awareness of which could stimulate fur— ther disorganization and decompensation (negative feed- back mechanism) over time (c.f., Docherty, Van Kammen, Siris, and Marder, 1978). Lapidus and Schmolling (1975) cite empirical evidence [Fish, 1961: Harris, 1959; and Zuckerman, Albright, Marks, and Miller, 1962] that schizophrenic hallucinations may occur in the context of high arousal with reduced external stimuli [Lilly, 1956: Shurley, 1960]. I Research reported by Lacey and Smith (1954) and Lacey, Smith, and Green (1963) has demonstrated em- pirical evidence of the conditioning and generalization by unconscious anxiety response related to an experi- mentally induced "trauma" or stress. This conditioning and generalization of unconscious anxiety, and the stress effects on cognition research of Horowitz (1975) suggests likely avenues by which high chronic levels of anxiety are stimulated, reinforced, and exacerbated by environmental stressors (external) (Brown and Birley, 1968; Steinberg and Durell, 1968: Birley and Brown, 1970; Jacob and Meyers, 1976), as well as conscious and subconscious intrusive and repetitive thoughts (internal) related to previous traumatic experience, 201 conditioning, and learning (e.g., Goldstein and Rodnick, 1975; Karon and VandenBos, 1981). The research of Lacey et a1. (1954, 1963) demonstrated a discernable difference between uncon- scious and conscious anxiety response; unconscious anx- iety response was found to be related to less discrimi- nation and greater stimulus generalization in normal subjects. Chronic high anxiety level was also found to be related to less discrimination and greater generali- zation of anxiety response. However, Lang and Buss (1965) reviewed equivocal support for the relationship between anxiety and overgeneralization, and greater overgeneralization in schizophrenics compared with normals. Generalization of anxiety response would be consistent with psychodynamic psychological mechanisms in schizophrenia, such as anxiety-determined "trans- ference to the world at large" (Karon, 1963) and "parataxic distortion" (Sullivan, 1953, 1962). The Specific Role of Annihilation Anxieties in Schizophrenic Psy- chotic Reactions Human experience would suggest that the most terrifying thoughts have to do with death, being killed, attacked, and mutilated. Bettelheim, Karon (Karon, 1963), and Searles (Burton, 1961) have related the 202 precipitating or major chronic anxiety in schizophrenia to overgeneralization of the fear of dying or being killed. The psychodynamic hypothesis of overwhelming conscious and subconscious overgeneralized annihilation anxieties in the etiology and dynamics of schizophrenic psychotic reactions receives some support from a system- atic investigation of recalled dreams of schiZOphrenic women compared with dreams of nonschizophrenic female controls (Carrington, 1972). Carrington (1972) found that in general, dreams of schizophrenics suggested an acute state of emergency or stress. Dream variables correlated with degree of maladjustment, and appeared to be distributed along a continuum from normal to schizOphrenic. Carrington (1972) reported that: Supporting an interpretation of the dreams of the schizophrenic subjects as repre- senting an emergency stance is the fact that roughly one-half of the S group dreams of physical aggressions against the dreamer explicitly indicated the dreamer's life to be in danger. In some instances, the dream- er was actuallquilled in her dream. The remaining half of the 8 group dreams of physical assault on the dreamer involved sexual assaults, rapes, and other nonlethal attacks such as someone throwing a jar of spiders over the dreamer. In such dreams, while the dreamer's life wasrufi:explicitly described as being at stake, they often seemed to imply danger to life. In con- trast, danger to life was depicted in only one of the two NS [nonschizophrenic] dreams 203 of physical assault against the dreamer (p. 347). It is suggested that if such terror-arousing thoughts (often expressed symbolically in schizophrenic hallucinations, delusions, and gestures) as the fear of dying or being killed, the draining fantasy, abandon- ment, being swallowed or absorbed, or being ripped apart (Karon, 1963) are not resolved consciously, then such intrusive and repetitive terrifying thoughts may reinforce and exacerbate the chronic systemic terror syndrome of schizophrenic psychosis (Karon, 1963), mediated and exacerbated by conscious and subconscious stimulation of the autonomic nervous system corollaries of high anxiety. Namache and Ricks (Germezy, 1974) reported that one of the variables which was found to differentiate released schiZOphrenics from chronic schizophrenics in the Judge Baker research was the presence of expressed concern about dying during the acute phase of the psychosis. This finding suggests that conscious aware- ness of "annihilation anxiety" could be related to variables that affect outcome prognosis in schizo- phrenic psychoses. It is suggested that the frequently observed hypochondriacal or somatic symptoms ("delusions") that often precede or accompany schizophrenic psychotic 204 reactions (Docherty, Van Kammen, Siris, and Marder, 1978; Offenkrantz, 1962) could be related to the pro- dromal autonomic system responses of the psychotic's acute anxiety (terror) reactions. In a clinical study of improved schizophrenics (Kayton, 1975), Kayton noted the prominance of somatic complaints, phases of disorganization, feelings of re- jection, and "other psychotic behaviors including curling into fetal positions, huddling in corners, and being mute, blank, and out of contact with reality. These behaviors coincided with verbalized fears of annihilation, plunging into endless water, being suf- focated, fears of dying and destruction of the world." Psychophysiological Correlates of Anxiety: "Arousal“ Autonomic Nervous System Cannon's (1920) classical physiological studies first demonstrated that emotional states activate phy- siological functions. Kielholz (1975) discusses the psychological and the somatic concomitants of anxiety: Scientifically anxiety can be described in Jasper's terms as an elementary, unadapted emotional reaction which is inappropriate to the threatening danger and therefore cannot be countered by rational, purposive behavior. All anxiety is bound up with gestures and facial expression along with symptoms of autonomic stimulation of the ergotrOpic, adrenergic nervous system. Anxiety may sometimes be manifested only 205 at a physical level. These symptoms are then known as anxiety equivalents. It is apparent, then, that emotions may be mani- fested predominantly at a psychic, psycho- motor, or autonomic—endocrine level, or at all three at the same time (p. 748). It is suggested that in schiZOphrenia, and pos- sibly to some extent in all psychopathological states (Kelly and Walter, 1968), chronic high levels of anxiety related to intense emotions can effect functional as well as structural changes systemically, mediated by autonomic systems, and demonstrated by abnormalities in neurophysiological, neurochemical, hormonal, hematolo- gical, and histological findings reported in laboratory studies of schizophrenics (e.g., Bellak, 1979: Wynne, Cromwell, and Matthysse, 1978). It has been suggested in this paper that the autonomic disturbances that have been demonstrated in schizophrenics are functionally related to pathognomonic high chronic levels of anxiety. Findings reported in a study by Zahn (Keith, Gunderson, Reifman, Buchsbaum, and Mosher, 1976) could suggest that the autonomic dis- turbances in schizophrenics are not genetically determined. Keith et a1. (1976) note: Zahn (1975) studied a series of identical twins discordant for the diagnosis of schizophrenia. Schizophrenics and con- trols were not greatly different in elec- trodermal response when unimportant tone stimuli were presented. However, schizo- phrenics failed to show increased arousal 206 (more electrodermal responses) when the tone was important--a signal to respond in a reaction time task. Nonschizophrenic co-twins behaved as normals' controls did-- suggesting that autonomic variables indi— cate more about disease state than under- lying genetic vulnerability (p. 533). Van Dyke, Rosenthal, and Rasmussen (1974) com- pared adopted-away offspring of schiZOphrenics with matched adoptees with no history of parental psychiatric illness (subsample from Kety's Danish adOption sample). Van Dyke et a1. utilized Mednick and Schulsinger's procedures for measuring autonomic variables, and re- ported equivocal findings between adopted-away off- spring of schizophrenics and matched adoptees on autonomic variables: Summarizing the findings of this study, some evidence has been found that the index adoptees as a group exhibit significantly larger and more frequent responses to mild stimuli. No evidence was found that the index group, compared to controls, had faster response latencies, higher basal arousal, or slower response recovery rates. In addition, there was no evidence that index cases were more conditionable than the controls, or that they exhibit an in- ability to habituate to mild stimuli. In sum, the study shows evidence of only a weak relationship between the diathesis for schizophrenia and electrodermal activity (Van Dyke [Garmezy, 1974] p. 28). Garmezy (1974) comments in his review that: Van Dyke appropriately notes, however, that whereas Mednick and Schulsinger were com- paring control and well groups of adolescent risk samples with an already sick group of risk youngsters, his subjects were adults 207 and reasonably healthy as well, since only one of the index adoptee cases has been incapacited by illness (p. 28). However, it is exactly these findings, of a significant difference in ANS arousal between monozy- gotic co-twins discordant for the diagnosis of schizo- phrenia reported by Zahn (Keith et al. 1976) and the equivocal ANS differences found between index and con- trol adoptees reported by Van Dyke et al. (1974) which support a functional rather than a genetic or diathesis relationship between schizophrenia and ANS disturbances. Analyzed from a functional hypothesis, the autonomic variables have also been found to be related to prognosis and treatment outcome. Zahn, Carpenter, and McGlashan (1981) studied physiological data related to treatment outcome in a subsample of the NIH project (Carpenter, McGlashan, and Strauss, 1977). Zahn et al. (1981) found significant differences in autonomic vari- ables in drug-free acute schizophrenic improvers versus non-improvers over the four-month treatment period, although global ratings of psychopathology and a symptom rating scale on admission failed to differentiate the two groups. ANS activity was found to be predictive of short-term outcome: four months of treatment (psy- choanalytic psychotherapy, group therapy, family therapy [Carpenter, McGlashan, and Strauss, 1977] with marked improvement in ratings of severity of psychOpathology 208 was accompanied by decrease in heart rate in improved schiZOphrenics. Research has correlated heart rate with other psychological and physiological measurements of anxiety (Kelly and Walter, 1968; Kelly, Brown, and Shaffer, 1970). Sex differences were found in ANS variables (c.f., Mednick and Schulsinger [Rieder, 1979]). The group of patients who did not show improvement ini- tially were found to have a higher heart rate, slower habituation of orienting responses, and demonstrated less response to stimuli in a reaction time task. Commenting on the Zahn et al. findings, Keith et a1. (1976) observe: In general, the autonomic responses of the improved group closely resembled the auto- nomic responses expected from a normal pop- ulation, while the group that failed to improve responded more like a group of chronic schizophrenics, showing (1) higher autonomic arousal under basal conditions, (2) diminished autonomic response to stress, and (3) slow habituation of elec- trodermal orienting response to stimula- tion (p. 534). The evidence of a relationship between the severity of psychopathology, prognosis, and autonomic disturbances (Mednick and Schulsinger, 1973; Zahn et al. 1981) suggests that the autonomic nervous system may be functionally related to the mediation of the biological substrates of psychopathology, and that psychodynamic anxiety and psychophysiologic arousal function as (morollary psychopathological mechanisms in schizophrenic 209 psychotic reactions. It is suggested that environ- mental stressors and conscious and subconscious conflicts stimulate anxiety reactions. Physiological affective re- sponses in anxiety and rage may reinforce and exacerbate cognitive reactions in an intensifying and self-perpetuat- ing negative feedback circuit and anxiety overgeneraliza— tion that can lead to the severe acute and chronic anxiety-arousal (terror) syndromes of schizophrenic psy- chotic reactions. The findings reported in the NIH project (Carpenter, McGlashan, and Strauss, 1977; Zahn, Carpenter, and McGlashan, 1981) could suggest that relatively brief four months of psychotherapeutic treat- ment in unmedicated acute schizophrenics was related to reduced anxiety and psychophysiological arousal in im- proved schizophrenics, which has implications for both functional etiological theories of schiZOphrenia (and other psychoses) and psychotherapeutic process and out- come variables. Catecholamines in Schizophrenia Conscious and subconscious cognitive or idea- tional, anxiety responses appear to be mediated by com— plicated,and largely presumptive, feedback systems which activate neocortical, limbic, and reticular 210 systems, that in turn activate the ANS and its peri— pheral effector organs. Autonomic functions are integrated with other somatic processes; adrenergic response characteristi- cally produces generalized physiological effects rather than discrete localized effects. Adrenergic discharge leads to lowered thresholds in the reticular formation, thereby reinforcing an alert, aroused state. The ANS functions at a subconscious level, which is functionally consonant with the tripartite uncon- scious-preconscious-conscious psychodynamic model of psychological mentation, behavior, and psychopathology (Fenichel, 1945). Groen (1975) suggests that increased arousal is very closely associated with anxiety, and discusses an "anxiety-arousal feedback system." Activation of the anxiety-arousal mechanism can be simulated in some people by injection of epinephrine (Frankenhaeuser, 1975; Groen, 1975). Frankenhaeuser (1975) comments on these catecho- lamine infusion studies: The results are consistent with those from studies of the excretion of endogenous epinephrine in showing that an increase in circulating epinephrine is accompanied by a rise in nonspecific subjective arousal, and the affective tone is determined by the individual's cognitive appraisal of 211 the situation. Infusion of norepinephrine does not produce emotional reactions quali- tatively different from those produced by epinephrine infusions (p. 223). Frankenhaeuser (1975) summarizes findings from research on the influence of emotion-inducing stimuli, mediated by the CNS, upon the catecholamines: Catecholamine secretion varies widely under different psychosocial conditions. Under rest and inactivity, epinephrine secretion is generally low; under ordinary daily activities, secretion rises to about twice the resting level; and under moderately stressful conditions, secretion rates cor- responding to between three and five times the resting levels are often noted. Se- vere stressors may induce a further pro- nounced increase to levels indicative of pheochromocytoma (p. 213). The question of a direct action of the adrenalmedullary hormones on the central nervous system is of particular interest in the study of emotion. Although this still remains a somewhat controversial issue, the evidence now available suggests that epinephrine crosses the blood—brain barrier in the region of the hypothalamus and acts directly on the mesencephalic reticular formation and the posterior hypothalamus (c.f., reviews by Euler, 1967; Rothballer, 1959; Schildkraut and Kety, 1967). Little is known about the intra- cerebral concentration of epinephrine needed to achieve these effects, but it may well be that very small amounts are required (p. 211). It should be noted that repeated exposure to the same external situation [or pre- sumably to the same internal ideational stimulus, both conscious and subconscious, M.A.T.] is accompanied by decreased cate- cholamine secretion only insofar as the repetition is associated with a decrease in the state of subjective arousal. Under conditions where subjective arousal remains 212 at a high level, epinephrine output also stays high [such conditions would include neurotic anxiety, phobias, and acute and chronic schizophrenic psychotic reactions, M.A.T.] (p. 214) . In the course of repeated exposure epine- phrine excretion decreases successively provided that the subject gains better con— trol over the situation (p. 214). These findings suggest that stress and anxiety reactions stimulate adrenergic discharge which increases the levels of circulating catecholamines epinephrine and norepinephrine. These catecholamines may cross the blood-brain barrier and possibly hyperstimulate or dis- turb normal CNS receptor activity. Chronic high anx- iety activation of catecholamine action on CNS activity could account for the functional and structural aber- rations in psychophysiological arousal and neurochemi— cal activity that have been demonstrated in acute and chronic schizophrenic psychoses (e.g., Bellak, 1979; Wynne et a1., 1978). Brain catecholamines dopamine and norepine- phrine have been implicated in the physiopathology of schizophrenia (Bowers, 1980; Farley, Price, McCullough, Deck, Hordynski, and Hornykiewicz, 1978; and Langer, Brown, and Docherty, 1981). Bowers (1980) notes that: Most researchers doubt any simple, exclu- sive dopaminergic pathology in schizo- phrenia. Other catecholamine systems, as 213 well as other noncatecholamine neuro- transmitter systems which impact with dopaminergic neurons may play an im- portant role (p. 395). Langer et a1. (1981) suggest that psysiological or possibly psychological stimulation related to a kindling-like mechanism may lead to induction of dopamine receptor supersensitivity. Langer et a1. observe that: Acute schizophrenia has been associated with an increased number of recent life events and crises (Brown and Birley, 1968; Steinberg and Durell, 1968; Birley and Brown, 1970; Jacobs and Myers, 1976). The variations in number, severity, and pattern of life events in schizophrenics suggests a precipitant role for the disorder rather than a causative one (Jacobs and Myers, 1976). Receptor sensitivity in the meso- limbic and mesocortical DA systems might be progressively altered by repetitive stress- ful episodes--akin to DA agonist repetitive stimulation, possibly in the manner from which kindling results. This concept is supported by studies which demonstrate that effects of experimental stress on bio— genic amines in animals and man can be similar to those produced by psychomotor stimulants (Weil-Malherbe and Szara, 1971) (p. 216). It is relevant to note, in the context of the suggested role of the catecholamines in the psycho- physiology of schiZOphrenic psychotic reactions, that intensive and extensive administration of sympathomi- metic drugs like amphetamine and methylphenidate can produce a psychotic reaction in nonschizophrenics that is strikingly similar to paranoid schizophrenia (Alpert 214 and Friedhoff, 1980; Snyder, 1973; Snyder, Banerjee, Yamamura, and Greenberg, 1974). The sympathomimetic action of amphetamines and related agents evidently stimulates the release of the neurotransmitter catecholamines dopamine and norepine- phrine, potentiating catecholamine effects. Amphetamines, methylphenidate, as well as L-Dopa (a dOpamine precursor) produce exacerbation of pre-existing psychotic symptoms in schizophrenics. However, remitted schizophrenics, like normal, neurotic, and personality disordered subjects did not show acti— vation of psychotic symptoms following single dose administration of methylphenidate. Antipsychotic drugs were not found to be effective in blocking methyl- phenidate psychosis-activating effects in schizophrenics (Janowsky, El-Yousef, Davis, and Sekerke, 1973). Psy- chotic symptoms can also be activated by the tricyclic antidepressants, which block uptake of norepinephrine (Janowski and Davis, 1976). Janowski and Davis (1976) note that reserpine, which depletes catecholamines, and the "antipsychotic" drugs, decrease select schizo- phrenic symptoms via neurotransmitter effects. The R91e of Maternal Anxiety Physiology in Utero As noted previously, investigators have sug- gested that maternal anxiety physiology may be a 215 fetal teratogenic developmental factor in the etiology of schizophrenia. Lipton, Steinschneider, and Richmond (1965) reviewed research on the developmental biology of the autonomic nervous system and reported evidence of the vulnerability of the fetus to the effects of maternal anxiety physiology: Recent evidence suggests that nicotine during cigarette smoking can increase fetal heart rate. Sandler et al. reported that norepine- phrine may cross the placental barrier. In- jected into the mother at term, radioactive norepinephrine induced marked bradycardia and was recovered in the newborn infant's urine in small amounts. It is evident that much needs to be done to determine cardiac rate and electrocardiographic responses of the developing fetus to external stimulation, chemicals, neurohumoral agents and physio- logical and emotional changes in the mother. Hallman et al. described 1 case of striking fetal tachycardia associated with maternal fright induced in the laboratory. Recent animal studies by Shabanah, Toth, and Maughan documenting the role of the auto- nomic nervous system in controlling uterine blood flow suggest likely avenues by which maternal emotions may affect the developing fetus (PP. 149-150). As noted by Zahn (1977), subjects in the Mednick and Schulsinger project (1973), and subjects in two other high risk studies (Garmezy, 1974) were older children and adolescents. Perinatal infant studies would help clarify to what extent the ANS aberrations found in the pre-schizophrenic offspring of schizo- phrenic parents could be congenitally or environmentally 216 and psychogenically determined. Unfortunately, the perinatal study reported by Schacter, Kerr, Lachin, and Faer (Zahn, 1977), comparing the neonatal offspring of schiZOphrenic and normal parents, found only a significant interaction between maternal delivery medi- cation, diagnostic group, and tonic heart rate in the second but not the third postnatal day. Further infant research may demonstrate peri— natal ANS disturbances in the offspring of schizo- phrenic mothers, as well as offspring of nonschizo- phrenic mothers; however, these perinatal ANS dis- turbances in infants, if related to the effects of maternal anxiety physiology upon fetal develOpment, may prove to be only residual in nature, depending upon critical infantile environmental variables. The higher concordance rates found in dizygotic, as well as mono- zygotic twins, compared with other siblings (Shields, 1968) could well be explained by these intrauterine variables and/or combination with environmental vari- ables. Postnatal—perinatal ANS disturbances, if not related to or exacerbated by, intrauterine fetal ANS hyperstimulation or PBCs, might represent a develop— mentally global rather than discrete early phylogenetic and ontogenetic reactivity to abnormal levels and duration of infantile stress (c.f., Spitz, 1965): 217 stressors such as maternal separation and deprivation, prolOnged discomfort, frustration, trauma, lack of satisfying physical and emotional stimulation and care taking; noxious transactional effects of maternal tenseness, anxiety, irritability, and withdrawal; and parental conflict, for example. Infantile stress-anx- iety may be the develOpmental precursor, or patho- gnomonic factor, for what Fish (Rieder, 1979) described as "pandevelopmental retardation" associated with per- ceptual dysfunctions and psychological disturbances in children at high risk for subsequent severe psycho— pathology. Pregnancy and Birth Complications (PBCs) Garmezy (1974) has made an extensive review of the research on the antecedents of schizophrenia. Garmezy (1974) cites research that suggests that the PBC variables are not specific to schizophrenic mothers (see Shields and Gottesman, 1977 for a more recent dis- cussion). Sameroff and Zax (Garmezy, 1974) have found the incidence of pregnancy and birth complications to be equivalent among schizophrenic and neurotic-depressive women, and greater in these two groups than among personality—disordered and normal women. Sameroff and Zax also refer to studies that suggest that infant 218 growth retardation can result from atypical child rearing practices. Sameroff rejects the diathesis hypothesis for the increased incidence of pregnancy and birth complications in schizophrenic women, and instead suggests that anxiety is related to such obstetrical complications, and also to the [pathogenic] development of a deviant pattern of child-rearing practices. The primary role of anxiety suggested by Sameroff (Garmezy, 1974) is supported by the finding that both groups with the highest incidence of pregnancy difficulties, the schizophrenic and neurotic-depressive women, had higher anxiety levels than either the con- trol or personality-disordered women. Kelly and Walter (1968) also found that chronic anxiety, agitated de- pressive, and chronic schizophrenic subjects had higher anxiety levels than personality-disordered or normal subjects. Neuroleptic Drugs and Anxiety-Arousal Chronic maintenance neuroleptic drug treatment of schizophrenics may reduce some of the physiological effects of arousal in schizophrenics via selective catecholamine receptor actions, thereby producing limited symptomatic improvement rather than "cure." However, neuroleptic drugs do not resolve nor extinguish the 219 underlying anxiety conflicts that continue to reinforce and perpetuate the high anxiety-arousal reactions in schizophrenia (Grinspoon, Ewalt, and Shader, 1972). Spohn, Lacoursiere, Thompson, and Coyne (1977) found negligible effects of phenothiazines on all tests of cognitive dysfunction: abstract reasoning, autistic thinking, overinclusive thinking, random error tenden- cies, and excessive narrowing of concepts, in chronic schizophrenics. These investigators also reported that "for conventional indices of general arousal, drug-place- bo group differences were not demonstrable." Overall, phenothiazine effects on psychophysiological variables were equivocal. The serious long-term complications of mainte- nance neuroleptic drugs have been discussed by Berger and Rexroth, 1980; Gardos and Cole, 1976; Gunderson, 1977; Karon and VandenBos, 1981; and Rappaport, Hopkins, Hall, Belleza, and Silverman, 1978). Discussion Psychological and physiological research has been reviewed that could support the suggestion of a psychosomatic model in the etiology and functional dynamics of at least some schizophrenic disorders. A psycho-somatic mechanism or process in schizophrenia could provide an integrating explanation for the 220 psychological, physiological, biochemical, and his- tological dysfunctions and structural changes that have been demonstrated in studies of acute and chronic schizophrenics. Psychodynamic anxiety and psychophysiologic arousal in schizophrenic psychoses can be understood as corollary human reactive mechanisms to environmental stressors. Conscious and subconscious anxiety reactions with psychOphysiologic autonomic concomitants evidently interact in mediating the individual's characteristic responses to stress and threat. It is suggested that the autonomic system instability or disturbance found in high-risk children, preschizophrenics, and schizo- phrenics is the psychophysiologic corollary of the individual's level of chronic reactive anxiety since infancy, possibly even including fetal hyperarousal in utero in response to the effects of maternal anxiety physiology. Infantile neglect, rejection, and separation, as well as stable and unstable pathogenic familial environments produce excessive anxiety, insecurity, confusion, and alienation in the child that is not "contained" nor resolved. Pathognomonic chronic high anxiety and related stress vulnerability are in turn related to developmental disturbances in cognitive, 221 emotional, and social functioning which increase risk of "schiZOphrenia spectrum" psychopathology. In an influential review of psychological deficit in schizophrenia (Buss and Lang, 1965; Lang and Buss, 1965), Lang and Buss dismiss the primary role of high chronic anxiety in the etiology of schizophrenia as lacking strong empirical support. Lang and Buss conclude: What appears to be wrong with the theory is its specification of anxiety as the crucial drive that leads to schizophrenia. While it is true that many schizophrenics appear anxious, this could as readily be a relation to incapacity as a cause of it . . . The fact that chronic, withdrawn pa- tients frequently have high—somatic ac- tivity levels appears partially to save the theory . . .. The hypothesis that schizophrenics are overaroused receives some support. How- ever, the exact mechanism by which over- arousal can produce hyporesponsivity, high response variability, inattention, disturb- ances of set and association, and the other symptoms of chronic schizophrenia is yet to be explained (pp. 96-97). Research has been reviewed that could suggest that pathognomonic chronic high levels of reactive anxiety-arousal since early childhood, related to psychological, psychophysiological, and biochemical functional and structural changes, could well account for the dysfunctions in schiZOphrenia that Lang and Buss (1965) emphasize as requiring explanation. 222 Lang and Buss (1965) are also critical of an etiological theory based on anxiety because of the observation that more chronic and severe schizophrenics show less clinical anxiety. They also argue that obviously many individuals with extremely high anxiety levels never become schizophrenic. Kelly and Walter (1968) have noted that anxiety may not be overt in schizophrenics due to the well-known affective blunting or incongruity in the syndrome. They suggest that a physiological measure of anxiety may pro- vide more accurate evidence of the actual level of anxiety. Kelly and Walter (1968) found that chronic schizOphrenic patients had high basal forearm blood flow (which has been found to be a valid and reliable index of anxiety), high heart rates and anxiety self-ratings, and poor response to a stressful stimulus. The hyporesponsiveness to stress shown by forearm blood flow, heart rate, and self-rating, is consistent with other research findings of diminished autonomic respon- siveness in chronic schizophrenics, and could suggest a physiological "exhaustion" state (Selye, 1963) re- lated to chronic basal overarousal, and law of initial value effects. The argument that high anxiety individuals should become schizophrenic if the anxiety etiological theory is to be supported is obviously specious and 223 simplistic. Specific critical pathogenic environmental variables, presumably interacting with chronic high anxiety, have been shown to be related to schizophrenic versus nonschizophrenic outcomes (e.g., Goldstein and Rodnick, 1975). It is plausible that if schizophrenic psychotic symptoms are functionally related to the level and chronicity of anxiety-arousal, then a fungf tional definition of anxiety relating the severity of schizophrenic dysfunction to level of anxiety would sug- gest that schizophrenia represents the most extreme dysfunctional anxiety syndrome. The suggestion that schizophrenic symptoms are both symptoms of anxiety and conditioned defenses against anxiety (largely unadaptive) has been discussed in reference to schizophrenic thought disorder (Karon, 1963, 1976; Wynne and Singer, 1963), and withdrawal (Karon, 1963, 1976; Venables and Wing, 1962). Kelly and Walter (1968) provide a relevant example which illustrates the anxiety-related defensive reinforcement of symptoma- tology; in this case, "depersonalization," which was both a reaction to and defensive distortion of an anxiety-provoking situation: Lader and Wing (1966) describe an anxious patient who experienced an attack of de- personalization while measurements of skin resistance and heart rate were being made. The typical physiological pattern of an anxiety state changed to that of a normal 224 person. Later she said her feelings of panic suddenly subsided and she felt that the objects in the room no longer existed properly (p. 621). The implications for the treatment of schizo- phrenic syndrome disorders are apparent; anxiety must be "contained" and resolved, along with the development of more adequate internal resources and adaptive abil- ities for c0ping with life stresses. Psychotherapeutic and psychosocial treatment modalities have demonstrated such combined effectiveness (Karon and VandenBos, 1975, 1981; Mosher and Keith, 1980; Wolberg, 1977). More- over, as noted by Lidz (1977): The long-term follow—up studies of Ciompi and Muller (1976) and of M. Bleuler (1976) provide no evidence for differentiating acute and chronic schizophrenia on the basis of prognosis" (p. 522). APPENDIX B APPENDIX B Raw Cell Means for Demographic and Length of Stay and Frequency of Attendance Data, with Groups Cell Means Days By Sex MStat Group Total Population 56.32 (153) Sex 1 2 58.37 54.55 (71) (82) MStat 1 2 3 4 66.51 33.43 42.12 18.50 (96) (14) (41) (2) Group 1 2 3 94.19 45.35 44.19 (36) (48) (69) l 2 3 4 Sex 1 64.55 26.67 40.27 6.00 (56) ( 3) (11) ( 1) 2 69.25 35.27 42.80 31.00 (40) (11) (30) ( 1) 225 22 6 Days, Sex, MStat, Group Cell Means By Group 1 Sex 1 99.94 (18) 2 88.44 (18) Group 1 MStat 1 97.03 (29) 2 38.50 ( 2) 3 100.00 ( 5) 4 0 ( 0) Group = 1 MStat Sex 1 1 102.57 (14) 2 91.87 (15) Group = 2 MStat Sex 1 l 59.28 (18) 2 49.73 (11) Group = 3 MStat Sex 1 l 46.33 (24) 48.29 (24) 42.42 (24) 55.66 (29) 15.00 ( 5) 34.86 (14) ( 0) 64.00 ( l) 13.00 ( l) 8.00 ( 2) 219.67 ( 3) 40.90 (29) 46.57 (40) 51.50 (38) 45.14 ( 7) 33.59 (22) 18.50 ( 2) 3 99.67 ( 3) 100.50 ( 2) 19.00 ( 4) 41.20 (10) (0) (0) (0) (0) 227 Total Population 7.97 (153) Sex 8.06 (71) MStat 8.95 (96) Group 11.22 (36) MStat Sex 1 8.63 (56) 2 9.40 (40) Group Sex 1 11.89 (18) 2 10.56 (18) Group MStat 1 11.31 (29) 2 7.00 ( 2) 3 12.40 ( 5) ( 0) 7.89 (82) 6.43 (14) 6.33 (48) 5.67 ( 3) 6.64 (11) 6.29 (24) 6.38 (24) 6.93 '(29) 3.80 ( 5) 6.00 (14) ( 0) Cell Means by Months 6.41 (41) 7.41 (69) 6.36 (11) 6.43 (30) 7.14 (29) 7.60 (40) 8.68 (38) 8.14 ( 7) 5.32 (22) 3.50 ( 2) 2.00 ( 1) 5.00 ( 1) 228 Cell Means by Months (Continued) Group = l MStat l 2 3 4 Sex 1 11.50 12.00 13.67 0 (14) ( l) ( 3) (0) 2 11.13 2.00 10.50 0 (15) ( 1) ( 2) (0) Group = 2 MStat 1 2 3 4 Sex 1 7.33 2.50 3.50 0 (18) ( 2) ( 4) (0) 2 6.27 4.67 7.00 0 (ll) ( 3) (10) (0) Group = 3 MStat l 2 3 4 Sex 1 7.92 0 3.75 2.00 (24) (0) ( 4) (1) Cell Means by Days/Months Total Population 5.92 (153) Sex 1 2 5.80 6.03 (71) (82) 6.45 4.48 5.25 4.60 (56) (14) (41) (2) Group 1 2 3 7.80 5.90 4.96 (36) 48) (69) 229 Cell Means By Days/Months (Cont'd.) MStat 1 Sex 1 6.13 (56) 2 6.89 (40) Group 1 Sex 1 7.73 (18) 2 7.88 (18) Group 1 MStat l 7.85 (29) 2 5.92 ( 2) 3 8.32 ( 5) 4 0 Group = l MStat 1 Sex 1 7.92 (14) 2 7.78 (15) Group = 2 MStat 1 Sex 1 6.44 (18) 2 7.40 (11) 3.72 ( 3) 4.68 (11) 5.88 (24) 5.92 (24) 6.80 (29) 3.38 ( 5) 4.92 (14) ( 0) 5.33 ( 1) 6.50 ( 1) 2.92 ( 2) 3.68 ( 3) 4.90 (11) 5.38 (30) 4.53 (29) 5.27 (40) 5.11 (38) 4.85 ( 7) 4.76 (22) ( 2) 7.61 ( 3) 9.37 ( 2) 4.83 ( 4) 4.96 (10) 3.00 ( 1) 6.20 ( 1) (0) (0) (0) (0) 230 Cell Means By Days/Months (Cont'd.) Group = 3 » MStat Sex 1 4.86 0 2.94 3.00 (24) (0) ( 4) ( 1) APPENDIX C APPENDIX C Program Descriptions from CMH _“Eva1uation Report" (278779) Center 1: Treatment Philosophy and Process The description prepared by the staff states that the theoretical premise behind the program "is based on an understanding that the causes of mental illness are rooted in early childhood and in various life experiences that caused emotional damage." This premise leads the staff to a psychodynamic approach with an emphasis on group therapy and on the creation of a safe environment where clients have the opportunity for corrective emotional experiences. There is time scheduled for formal group therapy, but there is also informal therapy taking place on an ongoing basis. The focus is on treating each group as a family, allowing them to regress developmentally in a safe environment and then providing experiences by which they can re-learn more appropriate and healthy modes of being in the world. There is little focus on teaching skills to individual clients. The following is a description prepared by the staff of the kind of therapeutic milieu they hope to create for their clients: 1. Interested, optimistic helpers will be reliably present at the times promised. They will be there expressly to help the client. 2. The P.H. staff will, for given periods of time, center their attention on the client, on his or her needs, feelings, problems, and in a global sense, on the client as a struggling, alive and growing person. 3. The entire staff will demonstrate in their interactions with each other a wide range of healthy, family-like interactions marked by acceptance and honesty. 231 232 4. Acceptance of the client's total, emerging self will be demonstrated through a concern with the client's feelings, including confusion, fear, anger and rage, even when these feelings are communicated indi- rectly. When self-defeating behaviors become an issue, these will be dealt with as arising from a cause and, whether the cause is explored or not, it will always be communicated that the client is accepted regardless of behaviors. When limits have to be set to protect the client, other persons or property, this will be done with a gentle, reassuring firmness. 5. The physical setting of the Center will be cheerful and homey. There will be no locked doors or areas that are always Off Limits. There will, however, be areas where privacy is guaranteed both for clients in their individual sessions and for therapists in their conferences with each other. 6. Any rules and limits will be clear and reasonable, and their rationale always explained pa- tiently to the clients. 7. All staff will be a part of the treatment team regardless of their formal roles or titles. Staff will demonstrate that different roles and levels of authority can be present in a benevolent constellation of relationships. Center 2: Treatment Philosophy and Process The treatment philosophy ascribed to by the Staff is educational/behavioral. The emphasis is on teaching specific skills such as conversational skills and assertive behavior and on providing information to clients. Behavioral strategies are used to reinforce positive behaviors and to extinguish negative behav- iors. Some of the retarded clients are also taught to read and increase their vocabulary. Treatment Goals and Termination The overall treatment goals were defined by the staff as: 1. Increase positive behaviors 2. Decrease negative behaviors 233 3. Teach skills of living 4. Provide information to increase behavioral choices 5. Promote insight by clients into their own values, behaviors and needs. The original strategy was for the whole staff to develop a treatment plan once a client was opened at the center, and then go over this plan with the client. The plan is basically a list of positive behaviors to in- crease and a list of negative behaviors to decrease. The staff and client were then to review this plan every three months to assess progress. This review process is no longer Operating due to the time press felt by the staff. Since the clients are not kept informed of the staff's view of their progress, the termination process may be unclear. In general, the termination criterion is placement in a job training workshop (primarily from the high-functioning group). There is also turnover caused by some clients not returning to the center for reasons which are unclear. Center 3: Treatment Philosophy and Process The treatment philoSOphy of the staff can probably best be described as eclectic. One component is an educational/teaching approach as evidenced by the list of seminars and activities listed on page 11. The staff assumes that the client learnings which take place in these activities will in time be transferred to con— texts other than the Day Center. A behavioral philo- sophy is also in evidence. The staff uses verbal rein- forcement and aversive strategies to change specific behaviors of the clients. In addition, the staff at- tempts to structure the clients' environment to elicit desirable behaviors such as social interaction, and then uses tokens to reward such behavior. While the educational and behavioral approaches have predominated to date, the staff is also moving toward using a psychodynamic approach centered around verbal interpretations of client behavior, speech, and productions. The Counseling Center Director provides supervision to the staff in their efforts to implement this approach, which is primarily used in the group therapy situation. In addition, some of the activities, such as drawing exercise, seem designed to elicit 234 conflictual material for diagnostic and interpretive purposes, with the emphasis now on the diagnostic func- tion. Treatment Goals and Termination The primary treatment goals defined by the staff were twofold: increase social contact and decrease or eliminate bizarre behaviors. An increase in self-esteem was also stated as a goal. A "successful" client was therefore described as one who could get a job, establish and maintain a support group outside the program, no longer manifest bizarre behavior, and exhibit positive self-attitudes. In terms of the high- versus the low-functioning groups, the goals seemed to differ by degree rather than kind. The social goal for the high group is to increase the apprOpriateness of their interactions so that they can get jobs and make friends, while for the low group the goal is to establish any verbal interaction. In terms of bizarre behavior, the high group is expected to reduce such behavior to the point where they can "pass" in the outside world, while a goal for the low group is to become "less delusional." The high group graduates clients to the community, while the clients in the low group graduate to the high group. The staff's expecta- tions are communicated to the clients in terms of speci- fic behaviors that need changing. The turnover time was estimated to be six months to a year for the high group and three to five years for the low group. There has been little turnover in the low group in terms of graduating out of the program, or into the high group. APPENDIX D APPENDIX D DAY THERAPY DATA BASE CLIENT'S NAME EVALUATOR'S SIGNATURE DATE Ratinngcale: l 2 3 4 5 6 7 8 L l l J L l l I None Slight Minimal Mild Moderate Marked Severe Extreme A. SOCIAL SKILLS: 1. Effectiveness of relating to peers (spontaneity, etc.) 2. Appropriateness of verbalizations 3. Tendency to relate aggressively 4. Tendency to withdraw 5. Acceptance of limits B. BEHAVIOR: l. Overly dependent--i.e., seeks much help, asks many questions, requires support and reassurance. 2. Obsessive-compulsive--i.e., ritualistic, rigid behavior/thought. 3. Depressed--i.e., flattened affect, decreased motor activity, self-depreciating. 235 10. 11. 12. 13. 236 Demanding-~i.e., insists upon having own way, seeks special favors/help. Attention seeking--i.e., loud, silly and immature behavior, praise seeking, somatic complaints. Anxious--i.e., fidgety, perspiring, short attention span, worried affect. Hostile-~i.e., physically aggressive, verbally abusive, resistive to authority. Manipulative--i.e., uses others, plays people against each other, coyly seeks extra privileges/treatment. Overly compliant--i.e., obeys without question, very eager to please. Aggressive--i.e., usurps leadership role, attempts to control, verbally overwhelming. Disoriented--i.e., confused, out of contact with reality. Withdrawn--i.e., isolates self, no response when approached. Manic--i.e., hyperactive, loquacious, grandiose, aggressive. C. TASK-ORIENTED AND/OR PERFORMANCE SKILLS Level of motivation. Attention span (concentration). Frustration tolerance. Comprehends and responds to directions. Works independently. WOrks with others. Work quality. Organization. 237 D. SENSORY-MOTOR PERFORMANCE 1. Eye-hand and eye-foot coordination. Manipulative skills. Integration of two sides of the body. Spatial relationships with spatial awareness. Body image and awareness. Posture and ambulation. E. ACTIVITIES OF DAILY LIVING (ADL) SKILLS Personal hygiene. Clothing. Eating habits. Communication (telephone, transportation, written, etc.). Commitment to program.