RELATIONSHIPS AMONG SOCIOMETRIC STATUS, PROGNOSIS,

AID SELECTED PERSONALITY VARIABLES OF

STATS HOSPITAL PATIENTS

APPROVED:

Graduate Committee:

Major rProfesso

Minor Professor

Committee Member

Committee Member

'^OO^OyTA.&/

Dean of tnp^chool of Sdua

Dean of t̂ ie Graduate School

ABSTRACT

Morris, Marvin Leo:.̂ Relationships gpoiome t rl c

Status^ Prog'uOBls, and Bjlooted Personality Variables of

State Hospital Pat5 ents. Doctor of Education (Counseling),

Augusts 1971 , 93pp., 14 tables, b5 bliography, 63 titles.

This study was conducted to investigate the possibility

of relationships among soci ome trie status, prognosis,, and

selected perso.aslity variables of state Hospital patients.

The specific objectives of this study v/::re to tiotormlno

(1) which patients have high sociometric choice status,

(2) it sociometrie choice status is related to prognosis, and

(3) if personality factors are associated with soeioinetric

choice status.

The first group cf subjects used in this study consisted

of 226 patients. These patients wore given a soeio.itetric

questionnaire, and were divided aaong high, raedium, and low

socioisetric choice status categories witn regard to the number

of socicKietric cnoices they received. They were tnon divided

E'.noag diagnostic categories A ( schisophrenic) r B (organic),

and C (other). Thirty months after the initial testing, a

follow-up study was conducted. These patients were divided

among success> pax-tial suc-osss* and failure categories, Tuose

vno were not presently hospitalised were called successes,

ana tnose who had been con litxaouuly hospitalized were called

2

failures. The patients who had boen. discharged arid readmitted

were called partial successes.

Conparisons wei-e warts among the aoeiometric high# ia odium,

and low categories on the variables of age, ehroiiicity, and

number of hospitalizations. Further comparisons yore made

among these categories to determine if differences existed

vrith regard to diagnostic categories and success rates. Hone

of these comparisons yielded significant differences.

The second group oS: subjects used in this study consisted

of 106 patients. These patients were given the soeiometrie

questionnaire and were divided ajeong socioraetric high, Eiediuei,

and low categories in the sair.e manner that the subjects in

the first group had been categorized. In addition, they

were given 5'ora 0 of the Sixteen Personality Factor QuGntiSJ-l"

BajLre. Comparisons of the sixteen subtest scores on this test

were made aioong the three sociouae trie s tat us categories, and

significant differences were found on subtests A and L. On

each of the two subtests, the socioraetric highs' scores more

closely approximated those of the general population than did

the scores of the socioraetric mediums and lows,

Tnirteen patients were in both groups of subjects used

in this study. Their sociometric status scores from both

tests were compared, and no significant changes in their

socioruetric status wer

3

1. Sociometrie status is not related to prognosis.

2. Socioaetric status 3S not related to age, chrcriielty,

number of hospitalizations,, or diagnosis.

3® Socicaetric status is related to temperament. High

socioaietric status Is associated with socially outgoing be-

havior and a wide range of emotional expression.

4. Sociometrie status is related to paranoid tendencies,

High sociometric status is associated with attitudes of trust,

5. So dome trie status does not change significantly

over a thirty-aonth period.

The results of this study indicate a need for further

related research with patients who have been recently hospi-

talized for the first tiros, as well as with patients from

private hospitals. Also, similar research over a longer

time period is needed,. *

This study was interpreted as providing limited support

for the use of sociometrie i;eahnitj.ues in a mental hospital.

Similarlyj, it was concluded that individual psychological

evaluations of mental patients should he acco.tipan5.sd by eval-

uations of their social-Interpersonal functioning and that

psychological strengths as well as weaknesses should be

evaluated.

RBLATIOUD HIPS AhONC- SOOIQHBIKIO STATUS, PROGNOSIS,

AMD SiiLJSOTBJ) PERSONALITY VARIABLES OF

STATE HOSPITAL PATIEITS

MS3ERTATION

Presented to the Graduate Council .of tb.e

North. Texas State University in. Partial

Fulfillment of' the Requirements

Eor t-He .Degree of

j)QOTO£ Ox'1 EDUCATION

By

KarvJii Leon :-:orr.is, M« H

Dsntorj Texas

August, 1271

3;ABLE OP CONT3N2S

Page

LIST or TABLES . . . „ . v

LIST OP ILLUSTRATIONS vii

Chapter

I. 11IT EO PU C T ION . . , 1 Statement of the Problem Hypotheses Theoretical BackgrouM Definition of Tories Limitations of the Study Ba s1c Abs UMp t i ona

II. SURVEY OF RELATED LITERATURE . . . . . . . . . 13

Mental Illness and Prognosis Social Aspects of Mental Illness and II o s p i t a I i % a t i o n

Sooiometrio Status and Prognosis Summary

III. PROCEDURES . . . . . . . . . 35

Research Catting Subjects Measuring Instrumentb Collection of Data Statist!cal Procedures

IV. PRjBS EST AT I ON All) AKALISIS OP DATA 55

Sociometrie Choice Status and Prognosis Socioroetric Choice Status and Demographic Variables

Socioaatric Choice Status and Personality Factors

Comparison cf Soeioftetrio Choice Status Scores of Patients Who Were in Both Groups One and Two

Comparison of Patients in Group One and Patients in Group Two among Demographic Variables

V. SUMMARY, CONCLUSIONS. AED R.EC OMME.K' PAT I OS S . . . 75

1 11

i v

TABLE 01' 0 O H ' T S S S — C o a t l n u a d

Pago

3' -P J'j N J) .1 yC A .o........* » « oo APPENDIX B . . . . . . . . . . . . . . . . 8 ?

BI£LIOGI!Ai;liY . , . . . 88

LIS'I: OP TABLBS

Tab ].o Page

I. Individual Diagnoses within Diagnostic Categories 38

II. Chi Square Test of Independence for Soclometrie Highs, Mediums, and Lows among Success, Partial Success, and Failure Categories 56

III. Analysis of Variance of Ages of Sociometric Highs, Mediums, and Levis . . . 57

IV. Analysis of Variance of Duration of Present Hospitalisations of Sooiowetric Ilighs, Mediums, and Lo'ns 58

V. Analysis of Variance of Bumbers of Hospitalinations of Sooiooetric Highs, Mediums, and Lows 59

VI. Obi Square Goodnoss of Fit Test for Sociometric Highw, Mediums, and LOTS among Diagnostic Categories A, 3, and C , 60

VII. Analysis of "Variance of Sixteen j^J^pnaliJ^ Factor QiwBtXonnai;re"*Scores~~amor>*g "High, Medium," ancFljol1'""Socioiaetric Status Categories . 62

VIII. Duncan's Few Multiple Range Test uf 16?F Subtest A Scores among High, Medium, and Low Sooionotric Status Categories . . 66

IX. Duncan's Multiple Range Test of 16PF Subtest I. Scores among High, Mediura, and Low Soeioraetrie Status Categories . . . . 6?

. X. Fisher's t Test for Related Samples Comparison of Sociometric Status Scores of Patients Who Here in Both Group One and Group Two . 63

XI. Fisher's t_ Test for Independent Samples Comparison of Ages of Patients in Group One and Group Two . 69

v3

Table Pax i;

XII Chi Square Goodness of Pit Test for Patients in Group Ona and Group Two among Diagnostic Categories A, Bs and 0 . . . . . . . . . . ,

XIII. Fisher's t Test for Independent ciple; Comparison of Chronioity of. Patients in Group One and Group Two e «& #

70

71

XIV., Fisher1 s _t Test for Indepaadent Samples Comparison of lumber of Hospitalizatj.oj.i8 of Patients in Group One and Group 'T.vo ... 72

I.-I S T 01? ILLU S T RA TI Oil ri

figure Page

1. Comparison of Mean 16PP Scores of Sociomstrlc Kighs, Mediums, and Lows . . . 65

vii

CiJAPT'JJR I

I NTHO.'UU G'XI OS

One of the most difficult px-obleas facing mental health

workers to da/ is that of the accumulation ox chronic mental

patients in state hospitals. Despite advances in treatment

techniques and subsequent decreases in state hospital popu-

lations, the number of hospital} zed chronic patients continues.'

to increase. A,t present this group of ''hard core" chronic

patients "constitutes approximately two-thirds of the resi-

dent hospital population, and will likely continue to increase,

even with higher initial discharge rates" (23» p. 8t ) *

Bay (1, p. ix) stated that "one-third of our patients get

well in spite of all we do, one-third go home with the help of

our attention and some adaptive gestures on the part of their

associates at lioiae, and the remaining third accumulates."

Hov-rever, as JC k b e_t al. (16) indicate, there is little agree-

ment among studies about which prognostic indicators are most

useful. SiariJarly, Paul (23) and Kichaux (15) concj.uded that

demographic and clinical data do not accurately predict the

course of hospital adjustment and postiiospital adjustment for

tae individua1 patient.

iSllsworth and Clayton (7) have stated that diagnosticians

have overewphasiz.ed psycho pathology in their evaluations of

patients and that they have not given sufficient attention to

1

2

the patient's psychologized, strengths. Similarly, C-ruenberg

(10) suggested that all personality studies should be aug-

mented by evaluations of social functioning. Some investi-

gators (25s 12) have concluded that the patients1 social-in-

terpersonal characteristics are the most significant prognostic

indicators. These studies suggest that psychopathology is

significant only to the extent that it produces social

isolation.

Since the measurement of psychological weaknesses has

failed to provide adequate Information upon which valid prog-

noses can be made, and research (7» 8, 12, 24, 25) indicates

that more accurate predictions can be made from measurements

of psychological strengths and social functioning, the need

for research in this area is becoming increasingly apparent.

However, at present, this area of inquiry is at a theoretical

sta.ge of developiasnt„

Yaillant (30, p. 617) stated that "by understanding prog-

nosis wo gain greater understanding of reversability, and by

understanding reversability we gain insight into the princi-

ples of treatment." Similarly, Marks (16, p. 118) concluded

that "the kinds of predictor variables which roost effectively

predict outcome are of theoretical interest since they may

\

shed light on toe nature of schizophrenia. . . . If social

adjustment is most predictive, then we wight compare the

•disturbance to a complex of bad habits."

3

Previous workers in the field of laeutal health, have

focused their attentions on the psychopatholgy of mental

illness. This approach has led to an, overeaph&sis upon psy-

chological weakxies&es v?ith a corresponding disregard for

psychological strengths. Patients therefore been viewed

in tarias of their disabilities. I'his philosophical orientation (

has led to a rather narrow, pessimistic set of expectations

for the prognosis of mental disorders. Hopefully, the study

of psychological strengths could provide a more optimistic,

yet realistic, philosophical orientation regarding the treat-

ment of mental disorders«.

Statement of the Problem

This study- was designed to investigate the possibility

of relationships among socioraetric §tatus, prognosis, and

selected personality variables of state hospital patients.

The purpose of this investigation was to answer the following

questions:

1. YJhich patients have high sociometric choice status?

2. Is socioaetric choice status related to prognosis?

3* What personality factors are associated with soc-io-

motric choice status?

%

Hypotheses

The following hypotheses ware tested;

1. Significant differences would exist among the dis-

charge rates of so dome trie highs, mediuras, and lows ever a

4

thirty-month period favoring patients with high soeioraetric

status.

2. Soclotaetric highs, xnediuas, and lows would not differ

significantly in terms o.f chronological age.

3. Sociometric highs, mediums, and lows would not dif-

fer significantly in terms of ohronicity, as defined RE the

duration of the 'present hospitalization.

4. Sociometric highs, mediums, and lows would not dif-

fer significantly with regard to their number of hospitali-

zations ,

3. Sociometric highs, mediums, and lows would not dif-

fer significantly in terms of diagnostic categories,

6. Sociometric highs, mediums, and lows would not dif-

fer significantly on their Sixfcean PerBonalit^ ffactor Quest! &*• "V

nalre scores.

7. Follow-up sociometric testing of a random group of

patients who were still hospitalised thirty months after tno

original sociometric testing would not reveal a significant

increase in their sociometric status,

8. Significant differences would not exist between each

of tne two groups of patients in this study with regard to

chronological age« •»

9« Significant differences would not exist between each

of t/ie tvvo groups of patients 5.n this study with regard to

dlagnostic cstagories.

*See page 9 fcr a description of the two groups used.

10. Significant differences would not exiut between

each of the two groups of patients in th.lt: study with regard

to chronicity, as defined as the duration of the present

hoapitalization.

11. Significant differences would not exist between

the two groups of patients in this study with regard to

their number of hospitalization;.-}.

Theoretj. cal Background .

Socially-oriented personality theorists, such as Harry

Stack Sullivan (26, 2'(t 28, 29) * have viewed mental illness

as being the result of impaired interpersonal ability, Sul-

livan proposed that the evaluation and treatment of Mental

patients be done within a social-psychological framework.

He further concluded,

The general science of psychiatry seems to rue to cover much the sarae field ao that which is studied by social psychology, because scientific, psychiatry has to be defined as the study of interpersonal re-lations, and this in the end calls for the use of the kind of conceptual framework that we now call field theory. From s.uch a standpoint, personality is* taken *to""be""hypothetical„ That which, can be studied is the pattern of processes which characterize the inter-action of personalities in particular recurrent situations or fields which "includeM the observer (29, p. 92).

However, while Sullivan was aware of the necessity of under-%

standing group structures; he offered no systematic approach

t o t .til s pro b 1 e a i,

Mental hospital treatment modalities are becoming in-

creasingly group orientedj and it ic becoming rare to see

5

such, an Institution. which does noi:. prof cos to have a "thera-

peutic community•11 Similarly, group counseling and group

psychotherapy are being u.5ed increasingly in most mental

hospitals. However, despite this trend, little research

has been done in the structure of Buck groups, and almost,

all psychological testing in mental hospitals is of an indi-

vidual nature.

Several waiters (11, 6,'5, and 14) have suggested that

socioiaetric techniques "be used in the study and treatment of

mental illness, but more clinical research, is needed to jus-

tify this approach since moat sociometric research has been

conducted in school settings (9, p. 2)-.

The s o c i o i a e t r i c technique was devised by J. I.. Moreno (19)

in 1934 and has been continually refined since that time.

This technique has been applied to ajaay different types of

groupsj and it has generated a large body of research.

Horthway defined a socioiaetric test as "a means for

determining the degree to which individuals are accepted in

a group, for discovering the relationships which exist among

individuals, and for disclosing the structure of the group

itself (21, p. 1). Sae further concluded this technique

"is most satisfactory for groups with well defined boundaries %

\

in wilier,! xae individuals knew each other at 3.east by name and

con cinuo vita soiao coaeoion ov>.r a reasonable ooriod of time*'1

(21 * p* 1)« Similarly5 jBonnoy stated,

The key Idea of kociomctry is that behind ever;/ formal organisation. . .there is an informal, spon-taneous organisation consisting of interpersonal at-tractions and repulsions, and that to is unstructured organization greatly affects the functioning of the formal organization as veil as playing a significant role in the personal, successes and failures of the group members. Trie primary purpose of sooiometry . . . Is to obtain quantitative data on these at-traction-repulsion patterns and to evaluate these data in terms of . . . objectives, from tne standpoint of individual agement ( 3s

. members 258).

and from that of group mars-

Moreno (19) postulated a positive relationship between

low sociometric status and a low level of psychological

adjustment. Several non-clinical studies (2* 4, 1 lj , and 22)

lend support to this position. However, Morthway (21) warns

that a direct correlation between cociometric status and

personality structure or mental health cannot be assumed.

Korthway and Yflgdor concluded that

the children who are high sociometrically on tne Ror-schach show a greater sensitivity to their environment— almost an active, conscious striving in using tne feeling tone of a situation to further their own ends. They also include a strong need for affection, They tend to view situations in a conventional lignt. There Is a conscious striving for approval. Those vrno have low so dome trie, scores are .less able to control their emotions and seem a more egocentric, moody, and im-pulsive group . . . . There are proportionately more seriously disturbed indivj duals in the high end low sociometric groups than in the-middle. In tiie high group the disturbances seem to be of psychoneurotic origin or general anxiety, while in the low group there are scniz-cphronie or schizoid types of "patterning

, (22, p. 197).

The previously cited stud3.es do not offer sufficient

justification for the use of sociometric techniques in

assessing and treating mental disorders in a mental hospit&l

8

since tney do not deal wita clinical populations. However,

a smo.ll but increasing bouy of knowledge is coming from

so'ciometric studies oi' mental hospital patients. Several

investigators (5* 1 5 1Y, and 20) have found relationships

between soeioaetrie status and mental health status or degree

of mental illness, suggesting a negative correlation between

level of social'functioning and degree of mental illness.

Furthermore, other investigators (7? 8, 24, and 25) have

found relationships between social functioning and poothospital

adjustment. These studies will be presented-in detail in the

following chapter since they suggest that the sociometric

teennique is applicable to the Mental hospital setting.

Definition of Terms

1 . Sooiometric High—The t e r a % sooiometric high refers

to patients who are placed in the upper third of their group

because of the number of choices they received on a socio-

metric questionnaire.

Sociometric Medium—The term socioraetric medium

refers to patients who are placed in the intermediate tnird

of their group because of the number of choices they received

on a sociometric questionnaire.

' Sociometric Low—The terra so close trie low refers

to patieats who are placed in the lower third of their group

because of the number of choices they received on a socio-

metrie que s tionnaire.

4-* Soclo;netrie Criolce Dtatus_—-S ociometric choice status

refers to the extent to which a patient was selected by other

patients as being some one witn whom they would like to be

in a therapy group. Sociomotric choice status is operation-

ally defined as the number of choices an individual receives

on the s oci ome trie questionnaire (Appendix 13).

Limitations of the Study

This study was limited to two groups of patients at the

Wichita Falls State Hospital in Wichita Palls, Texas. The

first group consisted of patients who were on four different

wards in June, 1968. The second group consisted of patients

who were on three different wards in December, 1970, The

fil'st and second groups overlap to some extent.

Basic Assumptions

1. Within any formal organization there is an informal

organization based upon patterns of interpersonal attractions

and repulsions.

2. Tne measuring instruments employed in this study

provide valid and reliable measurements of the variables they

are designed to measure.

CRA PTJill BIBLIOGRAPHY

1. Bay, Alfred P., ".trorsward,n Human Problems of a State Mental Jjoapifejl, by Ivan B s l ' J m a p , * B i ' a f c j ston MvxiXoKr'HoGraV-Kill Book Company, Inc., 1956.

2. Bla01x1,1011, S«, K. M. Goldstein, and ¥. Mandell, "Deviance and Position in the Small Group," Journal of Social. Psychol op::/, LXX (October-December ,~"T "96*"6y," 2B7-~293T**

5. Bonney, Kerl E., Mental Health in Education, Boston, Allyn and Bacon,~TrfcT," ? 9(56.**"

4. _ iiir, "Personality Traits of Socially Sue-""ci"csTuT^and '"Socially Unsuccessful Children," Journal of Educational Psychology, XXXIV (November, 19437*'"'*™ *i^9::4T2 7 ~

5. Brown» J. S., "Sooiometric Choices of Patients in a Therapeutic Community«" K u m h j i Relations, XVIII (February-November, 1965), 24l-25lT"""*^

6. Dolesa!, V., and 1-1. Hausner, '''Hear Soeioiaetrie Investi-gations in a Therapeutic Community with Special Reference to Treatment Results," Ifiterna11 ona3. Journal of Socl- ' ometry and Sociatry, IV""(Sep Cew ber~1)acernbcr7 1'96"¥) T"' 74179-'; — -

7. Ellsworth, R. B.j and W. H. Clayton, "Measurements of Improvement In Mental illness,tt Journal of Consulting Psychology, XXIII (1959), 15-20.- — "

8. Pairweather, George V7., ed., "The Situational Speci-ficity of Treatment Criteria," Social Psychology in Treating Mental Illness: An ExpfrRlhlm New York*, John~"WiTey & "Sonsi" T 9 " 6 " 4 T ™ — -

9. Gronlund, E. E., Sociometry in the Classroom, Hew York, Harper and Brotb¥rS7 1 9597 .

10.' Gruenberg, Ernest M., "The Social Breakdown Syndrome-— Soma Origins," The American Journal of Psychiatry, CXXIII (June, 196777*^8T"-f4l^~''^'"" ""** """*

11. Byde, R* ¥., and R. H. York, "A Technique for Investi-gating Interpersona.3. Relationships In a Mental Hospital/5

journal of Abnormal and Social Psycho] oj.;y, X..LII1 (July, T 9 W 7 " 2 B 7 - 2 9 9 T " " . •-

1 n

11

12, Jenkins, R. I.., a?xd L. Gurel, "Predictive Factors in Early Release, " Mental Hospital, I (1959)> 11-14.

13« Jennings, Helen, ,sil4. Isolation, New York, Longmans, Green and~'Ulb77T956T"" * " "

14. Koehn, Sharon, "interrelationships between Measures of Personal- Social Adjustment and Measures of Improvement in a Hospital Settingst: unpublished master1 s thesis, Department of Psychology, lTorth Texas State University, Dentonj I'exas, 1970,

15. JCuhlen, R. 6., and H. S. Bretseh, "Sociometrie Status and Personal Problems of Adolescents," Socionefcrg, X. (May, 194?), 122-132.

16. Marks, John, James C.« Stauff&cher, and Curtis Lyle, "Predicting Outcome in Schizophrenia,M Jojjrnsl of Ab-normal and Social I»XVJ (\9&5T7"'~i"W~T27~7'~"

17. McMillan, J. J., and J. Silverberg, "Soeiometrlc Choice Patterns in Hospital Ward Groups with Varying Degrees of Interpersonal Disturbances," Jojurnal of Abnortgal and Social Psychology, L (March, ^-TfaT ~*

18. Miehaux, William W., and others, ©be First Year Out? Mental patients after Hospjl̂ talisajt ion",' JBait irno r e', The Johns HopH"nn~ PrescT" 1*969". *

19« Moreno, J. 1., Who Shall, Survive?, Mew York, Beacon House, 1; - .

20. Murray, E. J., and l-l. Cohen, "Mental Illness, Milieu Therapy, and Social Organisation in Ward Groups," Journal of Abnormal and Social Psychology, LVIII TJiKSify7"l 959 JTTS-S'C

21. Northway, Mary L., A Primer of Sociometry, 2nd ed., Toronto, Canada, UnTversity of" T^fFnTo~Press, 1967.

22 . , and B. T. Wigdor, "Rorschach Patterns Related to the"*Socloraetric Status of School Children," Socioiaetry, X (May, 1947), 186-199.

%

23. Paul, Gordon l.« "Chronic Mental Patient; Current Status—< Future Directions," Psychological Bulletin. LX.X (1967), 81-94. -

24. Pishkin, V. „ and F. J. Bradshav-, Jr. , "Prediction of Response to ?r3 al Visit "in a Beuropsychiatrio Population/5

Journal of Clinical _Ps_,yohology, XVI (1970)? 85-88.

12

25. Shermans, Levis J., gnO others, "Prognosis in Schizo-phrenia : a Follow-Up Stud;/ of 538 Patients," Arctii vos of General Psychiatry* X (1964), 123-130.

26. Sullivan, Harry 3tack, Conceptions of Modorn Psychiatry, Washington, 1). 0., Wi111aVllaiinoij Wite" Psyoni'atrib Foundation, 1 94?.

27. _ T h e Interrsonal Theory of » * S c w Y o rk' IS0 r't'ori j 1 9 5 3*»"

28. ^ _ , The Psychiatric^ Interview, New fork̂ "l?orton7n̂ lyr.'"" """" ~

29. "Tensions Interpersonal and Intiri)i?ti*on&IT""*"a Psychiatrist' s View, n 5tojision_o That Cause War, edited by H. Oantril, Urban ia"7 111inois, UlB.v¥rsIty of Illinois Press, 1950.

30. Vaillant,, George 13., "The Prediction of Recovery 311 Schizophrenia,International Journal of Psychiatry, II (1966), 617-1277"""

CE-APm* n

SUBVJ3Y OP HfiLAXBi) LITJtSMl'UiLS

Tills survey of related literature is directed toward the

folio-,zing three 3 .l y cl t"> of research on mental illness;

1. Research concern:!ng mental illness and prognosis.

2.' Research concerning the social aspects of mental

illness and hospitalism,fcion.

3. Research concerning soeiometric status and prognosis.

Mental Illness and Prognosis

Early investigators of prognosis in schizophrenia (11,

16, 12, 29, 28, 30, 4, 25, 14, and 2} concluded that the

prognosis for remitting schizophrenia is 'much better than for

nonroi&i'tting schizophrenia. Furthermore, these investigators

all reached the following conclusions regarding prognosis in

schizophrenia;

1. The prognosis for patients whose prepsyehotic adjust-

ment was of a socially withdrawn nature is much poorer than

that for patients who were socially active and outgoing during

the prepsychotic period.

, 2. The prognosis for patients whose illness developed

in a slow insidious manner is much pooler than that for pa-

tients whose illness was of an acute onset.

13

'i 4

3. The prognosis for patients whoso illness evolved

with the relative absence of precipitating factors 1B much

poorer than that for patients whose il.1ness evolved in the

presence, of identifiable precipitating factors,

4. The prognosis for patients whose affective expression

is of a dullf rigid, or inappropriate' nature is much poorer

than for patients who express strong emotion or tension.

The consistency among: early studies of the prognosis of

schizophrenia led theorists to conclude that schizophrenia

resulted from two etiological patterns. They theorised that

one form of schizophrenia evolved as a chronic, deteriorative

process, while the other form occurred as a reaction to stress,

Therefore, the literature distinguished between "process

schizophrenia" and "reactive sch.1 zophreni&." (1 , p. 229).

Becker suggested that "an alternative assumption is that the

process-reaction syndromes are best thought of as end points

on a continuum of levels of personality organization" (1,

P. 229).

As a part of a larger study, Becker (1) administered

the Rorschach and the El&in Prognostic Scale to fifty-one

schizophrenic patients who had been recently admitted to a

state hospital for either the first or second time. The

Elgin Prognostic Scale ranked the subjects along a process-

reactive continuum, with niguer score indicating a process

schizophrenia and a poor prognosis. The patients' Rorschaca

responses were scored in terras of their levels of genetic

p

perceptual development, ranging froia Level One (diffuse,

global, imdi£ferenfciate d perceptions} to level fiix (highest

level perceptual dlffereivtiatiou and integration). The

Rorschach, mean genetie-lovei scores correlated -.641 (p. .001)

with the Biffin P^_^nostlo Scalc scores, indicating that

"there is evidence for a measurable dimension of regressive

and Immature thinking which is related to the process-reaction

dimension. In addition, the value of a levels-of personality-

organization interpretation of the process-reaction dimension

is supported'5 (1, p. 236).

Perets et. al. (13) conducted a comprehensive survey of

the literature on prognosis in schizophrenia. Prom a total

of five hundred and fifty studies they found one hundred and

twenty-five factors which were reported to be related to the

course of schizophrenia. These factors were then used as a

prognostic index for a study at Bollevue Hospital in 1958.

The subjects for this study were sixty-one patients who were

hospitalized with an initial diagnosis of schizophrenia. The

subjects were rated on the prognostic index to determine the

presence of absence of the specific characteristics being

studied, Each patient was interviewed between six and twelve

months after the initial contact, and was rated unimproved,

slightly improved, or improved. Fifty-five patients were seen

for the follow-up interview-?, and thirty were rated as unimproved,

six as slightly improved, and nineteen as improved. The sub-

jects rated as improved or unimproved were then compared by

1 6

statistical techniques to determine whiofc factory had been

prognostically significant. The following findings were

noted;

1. "Neither age, sex, diagnosis ror length of follow-up

was related to outcome, It is interesting that these are the

factors usually most carefully la&tchcd in experimental work"

(23, p. 147).

2. The following background factors were not significant

to outcomes

a. Sex

b. Religion

c. Heredity

d. level of social development

e. vrorlc history

f. Life situation

g. j$nvironujontal demands

h. .Alcoholism

i. Phys i cal h ea .1 th

3. Married patients fared significantly better than

single patients.

4. Patients whose prepsychotie personalities were of an

introverted nature did significantly poorer than their non-

introverted counterparts.

5. Patients with premorbid histories of successful so-

cial, vocational, and educational functioning fared much

better tnan pa tier* Is with poor premorbid histories.

17

6. "While age at edjcissioa bears no significant relation

to outcome, age at onsets if diciioto;si:

18

12, "Both first att,ue>: and previous remission have a

significantly wore favorable outcome wnen compared with a

chronic coarse. . . . There is DO significant difference be-

tween tnose yatic-ijto having a f3 ro t y.tt«ac>;: and those with a

history of previous remission" (23, p. 1 5^) .

13* "The presence of externally directed aggression,

hostility and irritability were all significantly related to

unfavorable outcome11 (23, p. 154).

14, "Good preserved affect way significantly related

to favorable outcorns with diminished or constricted affect

related to unfavorable outcomen (23, p. 154).

Perets el a K (23) stated that while their findings were

statistically significant- for the groups in their study, thoy

did not necessarily yield a valid prognosis for the indi-

vidual patient. In fact, one patient in tne improved group

demonstrated all of the prognostically negative signs.

Vaillant (27) reviewed the literature on prognosis in

schizophrenia and found that six prognostic factors were com-

mon among most of the studies, fliese factors were " (1) psy-

chotic depressive heredity; (2) symptoms suggesting a depres-

sive psychosis; (3) onset within six months before the fully

developed illness; (4) presence of precipitating factors;

(5) absence of a schizoid personality adjustment; and (6) con-

fusion or disorientation" (27, p. 627). "'ihe criteria were

applied retrospectively to sixty csr-afully studied and def-

initely diagnosed schisophrenics. Thirty were judged to have

19

1 recovered' and an equal number were consecutively admitted

controls" (27? p» 626). All six prognostic criteria proved

to s3 gui.1: i oant1 y aiftaren11ate the two groups of subjects ,

but vriien di f £erentiat i ons were wade on Multiple criteria, the

significances 'became extremely pronounced. All thirty sub-

jects in the "success" group possessed at least two prognos-

tics! ly favorable signs. Among the thirty subjects in the

"failure" group, six had BO prognostically favorable signs,

and only one had as many as three favorable signs;. However,

"none of the six prognostic criteria under scrutiny possess

great specificity in the individual case" (27, p. 624),

Paul (22), after reviewing hundreds of prognostic studies

stated that although the majority of these studies had ser-

ious weaknesses in their experimental designs, they did

agree to a large extent that variables suea as ago, sex, mar-

ital status, education, socioeconomic class, and social with-

drawal do predict the length of hospitalization to a degree.

However, he further stated that these variables do not provide

an adequate basis for predicting the pi ogress of the indi-

vidual patient. Similarly, Kichaux (20) found that age, sex,

raari tal status, and education are not related to post hospital

adjustment after a period of one year. Paul concluded that

individual patient traits do not constitute all of the pre-

dictive variables in terms of hospital adjustment ana post-

hospital adjustment; and that social•variables need to be

considered.

20

Social Aspects of Mental Illness

and Hospital!nation

A rapidly expanding body of research indicates that

social factors are related to both positive and negative

prognoses in mental illness, Writers in this field agree

(24, p. 892; 22t p. 82) that regardless of demographic or

clinical features, it is extremely unlikely that a mental

patient who has been hospitalised continuously for two years

or more can make a successful readjustment to the community,,

The probability of such an event is approximately 6 per cent.

There seems to be something about the social environment of

most mental hospital that renders a patient unfit for inde-

pendent community life. Lehrman (1?s p. 22?) concluded that

'"'the longer a patient is subjected to the rather authoritarian

atmosphere (of a mental hospital), , . . the smaller his

chances of recovery become." Similarly, Belknap (3, p. xi)

stated, "l believe, that nearly all of these hospitals have

become organised in such a way during their historical growth

that they are probably themselves obstacles in the development

of an effective program for treatment of the mentally ill."

Kantor and Gelineau (13. p. 66) concluded that

what malces such a vrard (a typical state hospital , ward) an improper place for schisophrenics (or anybody) is its staff members' selective insensi-tive, ty to the needs of its patients. It thwarts the rebel's desperate attempts at self-integration, it encourages the conformist's martyrdom, and it ritually mutilates the recluse's already mangled concept of self.

21

Gruenbc-rg (9) studied tcc social behavior of uiental

patients for wore than twelve years. He found tirnt patients'

patterns of social behavior develop independent o.f their

underlying symptomatology, Gruenberg' s investigation focused

primarily on the deterioration of social abilities among

chronic mental patients, and he formulated the Social Break-

down Syndrome (BBS) to explain this process. This theory

states that social deterioration begins when an individual

notices a discrepancy between what he can do and what is

expected of him. If he is unable to resolve -this conflict

through ego-defense rue chard eiac, he is likely to be seen by

others as being "different." The ne:ct step involves being

referred for diagnosis and treat went. .After being labeled

as "different,'* he is then hospitalized and meets a different

set of expectations. He is no longer expected to do things

he cannot do. He is expected only to follow orders, lie

soon learns to follow hospital orders even though he does

not identify himself as being like the other patients. How-

ever, as time passes, his ties with former associates are

severed, and he begins to regard himself as being 3.ike the

other patients. His social skills have become awkward from

disuse„ and the hospital becomes his world. Gruenberg con-

eluded tnat the human being is far too cduplicated to be

studied only in terras of psycho pathology, and he recommended

tnat all personality studies be augmented by studies of social

functi oning.

22

Several studies over the past sixteen years have explored

relationships between sodometrie status and mental health.

McMillan end Silverberg administered a socioaietric tost to

72 male patients from five different wards in a Veterans®

Administration nospit&l. These wards were selected to rep-

resent- '-a continuum, albeit gross, of the modal level of

interpersonal disturbances*' (1 9» p. 169)..

The five wards chosen to constitute the continuum of interpersonal disturbances were, in ascending order of degree of disturbance; (a) a neurological ward, (b) a medical ward with priwarily GI symptomatology, (c) an open psychiatric ward composed chiefly of neurotics as well as psychotics in remission, (d) s vrard of anxiety neurotics receivng insulin subshoc?! therapy, and (e) a closed ward composed chiefly of actively psychotic patients, the majority of which showed paranoid symptoms (1 9» p. 169)*

McMillan and Silverberg hypothesized that the degree of

interpersonal disturbances would correlate witn the severity

of the mental illness. Some support for this hypothesis was

found, but the degree of overlap of disturbances among the

wards resulted in equivocal findings.

Murray and Cohen (21), in a study patterned after that

of McMillan and Silverberg (19), adrainistered a sociometric

test to 132 male patients from six different types of wards

from a large army hospital. The following results were

obtained.

1. °A sociograa showed that the couple*ity of ward

social organization decreased as degree of mental illness

increased" (21, p. S3).

Ov.

2. ,?The percentage of social isolates Increased in the

more disturbed wards" (21, p. 54).

3® ,ffhe results suggest that ns mental illness increases

socioractric choices are influenced less by similarities in

social background variables auch as age, race, and popu-

lation area of origin" (21, p. 54)•

4. "jSzcopt for paranoid schisophrenics (who tend, to

choooe each other), similarities in diagnostic variables have

little effect on soeiorcetrie choices" (21 , p. 54).

Brown (5) administered. W o sociowetric tests to sixteen

female and thirteen male patients on a psychiatric ward in a

university teaching hospital,, Those patients varied widely

in terms of age, education, end diagnostic category. Each

socioaetric test required the patients to choose which other

patienta they wanted to associate with as well as which

other patients they did, not want to associate with. Also,

the remaining names were to be placed in a indifferent cate-

gory. The soeicraetric criteria vert leisure time associations

and therapy group memberships. Furthermore, each patient way

required to rate each of his peers as sicker than, healthier

than, or no different from himself. Also, the sixteen nurses

on the ward were ashed to rate each patient on a five point

scale from most sick to least sick. Socioaietrie scores and

sickness scores wore correlated, and the following results

were obtained:

9

24

1. The two soei owetri c cri leria correlated to an ex-

tremely high degree (r-~-i f 93)* Brown explained this finding

by stating that

possibly t

25

"'be in therapy group with," and the patients vrere instructed

to select the other patients that they would most snd least

like to associate with on these criteria. Nurses and psy-

chiatrists then rated the severity of each patient's symptoms

on a five point scale, and the psychiatrists also rated the?

patients' mental lies 1th status on a tivv point scale. Rank-

order correlations were conducted, between so d o m e trie scores

and the rating scores, and the following results were obtained<

1 . The two socioBietrie criteria correlated to a moderate

degree (r-+.68). This finding is consistent with that of a

previous study by Brown (5).

2. A significant relationship was found between psy-

chetele ("sit -with at meals") sociometric choice status and

men t a 1 h e a 11h s t a t u s (r-+ „ 41 ).

3» The relationship between sociotele ("be in therapy

group with") socioiaetric choice stratus and mental health sta-

tus was not significant (r-~-fr. >'f),

4. The relationship between psychetele soeiometrie

choice status and degree of symptom severity was not signifi-

cant (r«-.12).

5« The relationship between sociotele sociometric

choice status and degree of symptom severity was not signifi-

cant (r~-.04).

The previously cited studies (19, 21, 5* 13) provide

varying degrees of support for the hypothesis that personality

26

factors and. psychcpathciogy are related to socloraotrlc choico

status among psychiatric patients. However., it is obvious

that more research is needed in thl s area before unequivocal

conelusi or*a can oe reached.

Ellsworth and Clayton (7) state that social ability is

far more important than psychopathology in terms of pre-

dic11 ng discharge rates and oosthospita 1 ization adjustrnent

and that predictions arc better Hade from assets than from

liabilities. They found that nurse and aide ratings of pa-

tients' social behavior provided a ir.oro valid basis for

predicting discharge rates and posthoopital adjustment than

did psychiatrists' ratings of psychopathology.

Pishkin and Bradshaw (24) concluded that posthospital

adjustment is primarily related to social factors. They

found that patients who form group identifications while,

hospitalized are less likely to be reho spit all zed. than those

who form few or no such identj fications.

Marks (18) conducted a follow-up study of schiaophrenic

patients who had been discharged, from a Veterans1 Adminis-

tration hospital one year previously. He found that "social

assets predicted no better positively (and may have predicted

worse) than psychopathology predicted negatively" (18,

p. 123). He concluded that "return is not only unpredictable

froia our observation of the patients themselves but also frow

our observation of the stresses of the environment" (18,

p. 124). However, Sherman (25) conducted a tnree-year

27

follow-up study of 588 rjoligophrenic! men and found social with-

drawal to be the most valid predictor of re hospitalization}«

Soeiomstric Status and Prognosis

Fairweataer (8) conducted an intensive study of the ef-

fects of socialising techniques on a group of Ml malo mental

patients in a Veterans' AdmS nl strati on hospital,. Prow the i

hospital's total neuropsychiatries population, a ran&ora se-

lection of 193 patients was rcade; they were divided into two

groups? also in a random ra&zmer. Much variation existed among

these individuals v/ith regard to diagnostic categories and

chronicity, hut 90 per cent of them had psychotic diagnoses,

and A3 per cent had. bsexi hospitalised for two or wore years.

These two groups of patients were placcd on similar open wards

with similar daily activities. The control group received

tne hospital's standard treatment, but the patients in the

experimental group received treatment based upon resocial-

ization techniques and instrumental role perforaaanoe. fur-

thermore, the patients in the experimental group were placed

in problem-solving patient groups, and their ward behavior

determined the extent of their privileges, responsibilities,

and rewards. At the beginning and end of the twenty-seven

week treatment program, patients in both groups were evalu-

ated by psychological tests, ben^vior rating, and a 'socio-

metric technique. Follow-up data were gathered for the next

twenty-six weeks to determine the patients' progress.

28

As a part of tne Fairueather (8) study, Greasier (6)

administered the Soc_.l&X ?re/ereiKjq_ Photo Technique (SSPT)

to botli the experimental end control groups at the beginning

and end of the treatment period. The SPPT is a soci one trie

que s ti onnai re employlxig pao to graphs of the patients in each

group. Patients were required to enoosa the pictures* of

other patients with whoa they vrould want to associate in

various degrees of social intimacy. The questionnaire con-

sisted of the following aocioiaetrie criteria:

1 . Tallied with on ward 2. Hello in restaurant 3« Talk with in street •4, Go out with 5, Live on same street 0. Work at same pis ce 7. Go to for help

8. Close friends (6, p. 111).

Tne SPPT was initially administered after the first week of

treatment in order to allow the subjects to become acquainted

with eaco other before tbey made tne required interpersonal

choices„ A statistical analysis of the' SPfT data yielded

the .following conclusions:

1. Patients who give a large number of choices snow a

tendency to receive many choices. However, the correlations

on this criterion were low, reanging from .39 to .00 in in-

creasing degrees of social intimacy.

2. Correlations aruong socioraetric criteria ranged from

.80 to .97 in terms of choices received, indicating that

sociouietric status is relatively stable among the criteria.

29

3. Sodometrie status was not related to diagnostic

category,

4. Sociowetrie status was not related to chronieity.

5. The terminal 8?.PT evaluation indicated that the sub-

jects in the experimental group increased their rate of so-

ciometric choosing much more than did their counterparts in

l

the control group. However, the rates of eociomstrie caoosing

were not significantly different on the three most intimate

critei\la.

6. The terminal SPPT evaluation indicated that the sub-

jects in the experimental group increased in the rate of ao~

ciometrie choices they received much i»ore than did their

counterparts in tne control group® Significant differences

vere found between the two groups on ail of the sociometric •%

criteria,

Fairweather (8, Chapter 16) performed a factor analysis

of his data to determine which factors best predicted post-

hospital adjustment. The most significant factor among the

psychological measurements was called "social interaction"

and consisted of social behavior ratings and sociometric data.

Social preference (number of socioaetric choices given) was

not a significant variable, but selection by others (number

of sociometric choices received) was quite s3 gnlfleant. Cor-

relations between socloiaetrlc criteria and tne factor "social

interaction" ranged from .42 to ,53 progressively in terms of

the degree of interpersonal closeness of the criteria.

30

However, ratings of social, behavior correlated with trie .factor

"social interaction'5 fro*a .41 to .95. The most signifj cant

predictor of posthospital adjustment vras that of the duration

of previous hospitalization; the relationship was in a nega-

tive direction. None of the other historical data were of

significance,. In view of these findings, Jfeirweatner con-

cluded

that there :io only a small positive relationship between social activity within the hospital and making an adequate posthospital adjustment. It seems, therefore,, that treatment programs which are oriented toward a greater degree of social activity or verbalness are not necessarily preparing patients for more adaptive behavior in the co ram unity after release from the hospital (8, p. 280).

Summary

This chapter is divided into three sections. In the

firsts various authorities we re cited, concerning mental ill-

ness and prognosis5 and it was shown that certain demographic

and clinical variables do predict.hospital adjustment and

prognosis to a certain extent, but tnat such predictions for

individual patients are not particularly valid. Furthermore,

long-range prognoses based in these variables were shown to

be somewha t uvre1i ab1a„

In the second section, research was cited which emphasized

tne social aspects of mental illness and hospitalization.

Studies were presented vaich described the cl ©humanizing in-

fluence of most mental hospitals upon patients, and one paper

31

cited offered an explanation of this process. Studies were

also presented, shoring relationships between social function-

ing and degrees of psyohopatholo^y, as well as relationships

between social factors and tl'.-e post-hospital adjustment of

mental pat i e n t is ,

The third section citsd research- concerning relationships

between sociometrie factors and prognosis. Sociometric status

was shown to be unrelated to diagnostic category and chroni-

city, and. significantly related to post-hospital adjustment*

OBAP-i^a i)IPL10GHAPHY

1. Becker, W» C., nA Genetic Approach to the Interpretation and Evaluation of the Proeess~reacVi've Distinction in Schissox>hraaia, M Jouviial of Abnorisa) and Social Psychol-ogy* i/hl ( 1 9 5 6 ) — " —

2. Becker, ¥. 0., and R. L. KoFarland, "A Lobotoray Prognosis Scale,M Journal of Consult in..? Psychology, XIX (1955), 157-162.™"^'"""" — — -• ~ ~

3. Belknap, Ivan, H>i'.n?.n Prohlew^s of a State Mental Hospital, Hev; York, The Blakiuten l)i"viaion, McGrart-iiill Book Con*par.y $ Inc. } 1955.

4. Benjamin, J. D», "A Method for })ist:l nguiBhing and Evalu-ating Forisal Thinking Disorders In Schizophrenia,!!

and Tliougjit .In Sch.l% ophyci-ria., edited by J. S. ̂ . K.a¥an3Tni* Berke-feyV*TtVivorb'ity"'"of California Press, 1946*

5« Brovm, J. S., "Soelometric Choices of Patients i:o. a Ther-apeutic Community," Humn Relations, XYII1 (February-iloveaber, 1965), 241-1^517

6* Greasier, David L., "Amount and Intensity of Interpersonal Choice,15 Social P a t h o l ± r i freatjjj^ Mental IJJbipBs: J}Pz S^rbaohy ""e aft eel by George v/« Pair™ ifeather^ *He¥'~"Xork̂ *?oim""i[ilGy & Sons, Inc., 1964.

7. Ellsworth, H. B., and ¥. He Clayton, "Measurement of Improvement in Mental Illness«" Journal of Consulting Psychology., XXIII (1959), 15"20.~"""" ~

8. Fail-weather, George ed», "The Situational Specificity of Treatment Criteria," SocisJL Psychology in Treating Mental Illness: An Sxperfmfnt'al' A3?Jroabhf*'"i'e?f York, JoKn"lTiIey''"&' "Sono7"l 96"Vl ""

9. Gruenberg, Ernest H., "The Social Breakdown Syndrome— Some Originsj" The American Journal of Psychiatry,

, CXXIII (June, 1 W ) 7 T 4 ^ f 4B37 ~

10. Gui'el, Lee, "Release and GouuEO.nity Stay in Chronic Schizophrenia,H The American Journal of Psychiatry, CXXII (February ,~f9^7rW2~8997 ~ — '

33

11. Hunt, .R. 0.} and K. E„ ippel, "Prognosis In Psychoses Lying Midway between Schizophrenia and Manic-depressive Psychoses, American Journal of Psychiatry, XOIII (1936), 313-339.

12. Kant, 0., "Differential Diagnosis of Schizophrenia in the Light- of Concepts of Personality Stratification," American Journal of Pg/ohl^try, XOv'II (1940), 342-357»

13. Kantor, David, and Victor A. Gelirteau, "Making Chronic Schisophrenics,n Mwt&l Kypi erne* LIII (January, 1969), 54-66.

14. Kant or, R. E., J. Mo Ifa liner, and 0. I». Winder, "Process and Reactive Schiz ophrenia,Journal of Consulting Psy-chology, XVII (1953), 157-162.

15* Koehn, Sharon, "Intcrrela ti onchips Between Measures of Personal-Social Adjustment and Measures of Improvement in .a Hospital Setting," unpublished master's thesis, Department of Psychology, North Texas State University, Denton, Texas, 1970,

16. Langfeldt, G., "Prognosis in Schizophrenia and Pactoro Influencing Course of Disease? Cat-amnestic Study, In-cluding Individual Re-examination in 1936 with Some Considerations Regarding Diagnosis, Pathogenesis and Therapy, Acta Psychiatry and Neurology, Suppl. 13 (1937), 1 - 2 2 8 . '

17. Lehman, Nathaniel S,, "Polloir-Up of Brief and Prolonged Psychiatric Hospitalisation," Comprehensive Psychiatry, II (August, 1961), 227-240.

18. Marks„ John, James 0. Stauffaeher, and Curtis Lyle, "Predicting Outcome in Schizophrenia," Journal of Abnormal and Social Psychology, LIV'I (1963)* 117-T27'~

19. McMillan, J. J., and J. Silverberg, "Sociomstric Choice Patterns in Hospital YJsrd Groups with Varying Degrees of Interpersonal Disturbances," Jcmrna! of Abnormal and Social Psychology, L (March, T9B*51T"1 27""

20.. Michaux, William ¥», and others, The first rear Out: Mental Patients after Hoepit allaa¥lorx7 BO.'tiraoreV^The Johns Ho^Irj.ub^Pross",~"l969V - — -* —

21. Murray, E, J., and M» Cohen, "Mental Illness, Milieu Therapy, and Social Organization in Ward Groups," Journal of Abnormal and Social Psychology, LVIII fJaSi5.ry7""l 959)7'' 4H-.B4̂ ' " *""* *"*

34

22. Paul9 Gordon L.» "Chronic. Mental Patient; Current Status—Future Pirocticns." Peyeholop#caX Bulletin, 1XX. (196?) , 81 «-94„ ... ~

23. Peretji, 3). , M» .Albert, and A. Prieuhoff, ' "Prognostic factors in the Evaluation of Therapy," Evalua^jOii jof

^aatwent, edited by P. H. HocV"and"*J."Zubin, Kew*Tor £Graac"'& ' Stra11on, 1964,

24. Pishlrln, V,, and F. J, BradBho.;-;, Jr,, "Prediction of Response to Trial Visit in a. Heurop&ychiatric Population," Journal of Gllniual Psychology XVI (1960), 85-88.

25. Sherman, Lewis J., and others, "Prognosis in Schizo-phrenia j a Pollow-tJp Study of 588 Patients," Archives of General Psychiatry, X (1964), 123-130.

26. Stotsky, B. A., "A Ccaparison of Remitting and Hon-remitting Schizophrenia on Psychological Tests," Journal of Abnormal and Social Psychology, XLVII (1952), W'9~W(>» ~ — — - —

27. Vaillant, George E,» "The Prediction of Recovery in Schizophrenia," Î tGruajfcional̂ Jotirnal of P{̂ ĵ i?i'tr̂ » II (1966), 123-130:

28. Wittean, Phyllis, "Follow-up on Elgin Prognostic Scale Results," Illinois Psychiatric Journal, IV (1944), 56-59* — • —

29. , "Scale for Measuring Prognosis in SchiVoo^ Elgin State Hospital Papers, IV (1941 ), 20-33- — _ —

3°- and D. L. Steinberg, "Follow-up of ^3e"cttvenBvaTuatiori," JSlgin State Hospital Papers, V (1944), 216-227. « — — • *

CHAPTER III

PROOSBUHES

This chapter includes the descriptions of the research

setting, the subjects, the procedures for coil-acting the data,

and trie measuring instruments.

Research Se 11ing

The re&oarch. setting for this study was the Wichita Polls

Ktate Hospital in Wichita Palls, Texas. This Institution op-

erates under the direction of the Texas Department of Mental

Health and Mental Retardation, and administers treatment to

noui'opsychiatric patients. Psychiatric treatnumt in this ins-

titution is of an interdisciplinary^natures and treatment teams

are composed of psychologists, psychiatrists, physicians,

social, workers, and nursing personnel, as well as occupational,

re ex oa t.x onal, and xnciuo ti/xa.!. tber3.p.ists. The tx̂ eatifiw/i ti teaios

are augmented by other professionals, such as rehabilitation

counselors, chaplains, and teachers. During the time of this

study, the average census was approximately 1500 patients.

Most patients in the hospital were on some form of chemo-

therapy , but the primary treatment modality was milieu therapy.

Camming and Cuwmiiag (6) define milieu therapy as "a scientific

manipulation of the environment aliaed at oroducj n*? changes 1 r»

36

defines this technique as being "characterized by increased

social interaction, and group activities, expectancies and

group pressure directed toward 'normal' functioning, more in-

formal patient status, focus OK goal directed communications

freedom of moveiaent, and treatment of patients as responsible

human beings" (15, p. 85). The milieu therapy approach is

farther articulated by Jones (11, 10, 9)» Artiss (2), Edelson

(7), Kraft (12), and Wilroer (1?).

Subjects

Two groups of subjects were used in this study. The first

group consisted of 226 patients who were on four different

wards in June, 1968. These wards were selected as being repre-

sentative of the different types of typical wards in the hos-

pital. Two of these wards were open, two were closed, and

all four were sexually segregated- The closed wards were

"locked wards,i! where the more confused or assaultive patients

were kept under close supervision. The open wards were not

locked during the day, and patients on these wards had rela-

tively free access to the hospital grounds. The open and

closed female wards contained fifty-five patients each, while

seventy-five males were in a closed ward, and forty-one males

were on an open ward.

The second group of subjects used in this study consisted

of 106 patients cn three different wards in December, 1970,

These wards were also selected os being representative of the

basic types of wards in the hospital. One ward was for new

37

admissions; another ward was for patj ents receiving short-term

treatment; and another ward was for chronic patients* JSach of

these wards contained both male and feaale patients housed at

opposite ends of the ward, sharing the cafeteria and day rooias.

Fourteen male a and thirty female r» were on open wards, and

twenty-nine males and thirty-three females were on a closed

ward. Thirteen,of these subjects were individuals who bad

been included in the original research group.

The ages of subjects in the first group ranged from 16 to

67 ye arc of age, with a mean age of ."59.17 • The ages of sub-

jects in the second group ranged from 15 to 71 years of age,

with a mean age of 39.62.

Subjects in the first group had been hospitalized an aver-

age of 1.71 times, and the average number of months they had

been hospitalized since their last admission was 70.G5. Sub-

jects in the second group had been hospitalized an average of

2.14 times, and the average number of months they had been

hospitalized since their last admission was 69•67•

Subjects in each group were divided among three diagnostic

categories. Category A consisted of all schizophrenic diag-

noses. Because some of the previously cited studies were"

concerned only with schizophrenia, this diagnostic category

was-Isolated. Patients with organically-based disorders were

placed in Category B. This category included all diagnoses

of mental retardation and organic brain syndromes. Category

C included all subjects who did not fit into Categories A or B»

38

Category C consisted of diagnoses of rieuroaes, personality

disorders, and the major affective disorders.

In Group One;, 16B subjects were in Category A, 41 in Cate-

gory B, arid 17 in Category 0. In Group Two, 79 subjects were

in Category A, 21 in Category B, and 6 in Category C. A fur-

ther breakdown of these figures is shown in Table I,

TABLE I

INDIVIDUAL DIAGNOSES.WITHIN DIAGNOSTIC CATEGORIES

Diagnostic Category

A

Individual Diagnoses

S ehi zophrenia, Unspecified Type

Chronic, U n difforentia ted Schizophrenia

Acute II n d i f f e r e n t i a t e d Schizophrenia

Paranoid S chi zophrenia

Catatonic Schizophrenia

Hebephrenic Schi % o phreni a

Simple S c hizo phrenIa

Child aood Schizophrenia

Pe e vdone uTO11c Schizonarenia

Group One Sub jects

Group Two Subjects

Total! Subjects

"T

1 0 1

83 46 129

5 1 6

30 13 43

23 13 36

17 4 21

7 1 8

2 0 2

0 1 1

$9

TABU, -Cent j.nuod

Diagnostic Category

B

I ndi vi d up. J. Diagnoses

Organic Brain S yn d r o m a s v j. t h Psychosis

Organic Brain Syndrome, with Beh&vJoral Reaction

Organic Brain Syndrome

Me nta1 Re t ardati on, vith Organic Brain Syndrome

Mental Retardation, with Psychosis

1-icntal Retardati on, with Behavioral Reaction

ile-Ktal Kete rdati on

Group One Subjects

18

Psychosj b, U n s p e c i £ led 'J: y p e

Involutional Melancholia

Psychotic 1)3pre-s si on

Mani c-Depressive Psychosis

Schizoid Personality Disorder

Antisocial Personality Disorder

h

2

14

1

0

0

Group Tvo Subjects

10

3

0

3

0

1

Total subjects

0

1

0

0

Op £LiJ

7

6

17

1

2

1

1

2

•3

5

TA.BLK I — C o n t i n u e d

40

D i a g n o s t i c C a t e g o r y

( C o n t i n u e d )

T o t a l

I n d i v i d iJ ?.3. D i a g n o s e s

i n ad ecus, t o P e r s o n a l i t y .Disorder

i E m o t i o n a l l y Una t a b l e Pe r s e r i a l i t y D i s o r d e r

P a s s i v e A g g r e s s i v e P e r s o n a l i t y D i s o r d e r

Pa s ai ve 33 e p e n d e n t P e r s o n a l i t y D i s o r d e r

D e p r e s s i v e N e u r o s i s

Group One S u b j e c t s

226

Group Ti-ro S u b j e c t s

0

0

0

106

'j?otal S u b j e c t :

3

2

332

K e a s u r i n g I n 3 t r uu s e n t s

The p l x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e ( 1 6 P F ) ,

d e v e l o p e d by .Raymond B. C a t t k l l ( 4 ) , i s a t e s t of p e r s o n -

a l i t y wh ich was d e v e l o p e d through, f a c L o r a n a l y t i c t e c h n i q u e s .

A f t e r an e x t e n s i v e r e v i e w of t h e l i t e r a t u r e r e l a t e d t o t h i s

t e s t , L o r r (13» p . 363) c o n c l u d e d t h a t L p r e s e n t i t a p p e a r s

t o be t h e be.at x a c t o r - b a ^ e d p e r s o n a ]J t y i n v e n t o r y a v a i l a b l e . 4

Adcock ( 1 , p . 19?) s t a g e d thai', " t h e 16PF t e s t uidB f a i r t o

41

become the standard quobtionnairo-ty pe personality test of the

future. It provides a cosprehensiv?. range of traj t scores

which should be useful for occupational guidance and ay a

background to clinical examination." Similarly, Fischer

(8, p. 408) concluded that "Oattell's 16 P. 3*. Test is the

best test of personality tnus far developed to iseet the

stringent requirements of applied and clinical psychologists

for accuracy, usefulness, and brevity.'5

The Sixteen lector 0jliestioimalref as the

name implies, consists of sixteen basic subtests. "These

sixteen dimensions or scales are essentially independent.

That is to say, the correlation between one and anctner is

usually negligible, and having a certain position cn one does

not prevent the^person's having any position whatever on

another" (5r, p. 6). Sixteen ££~;3o^ flues11 ognrf \Ij'e

scores are expressed along a ten point continuum for eacii

factors ranging from one extreme to the other. These scores

are called sten (standard ten) scores, and are based upon a

normal distribution, with stens five and six containing the

middle 38-2 per cent of the general population. Stens four

and seven contain 30 per cent of the general population, and

stens three and eight contain 13.4 per cent. At the extremes

of the noriaal distribution, categories two and nine contain

8.8 per cent of the general population, end only h.6 per cent

is contained in categories one and ten. Sten scores are plot-

ted on the 1 6.!?P profile sheet' (Appendix A). The following

42 •

descriptions of the 16PF eca.les are sutthuarixed frcw OattelJ 1 s

Handbook for trie Sijxt&f « Persp^alitv Factor Questioanaj re

(4, Chapter 9)-

Factor A_—She A scale is essentially a measure of temp-

er am on t. Subjects who score lov.1 on this scale tend to be

reserved, detached individuals who are typically cautious in.

their emotional express!on and uueempromising in their approach

to solving problems, (the A- subject usually prefers to deal

with objects rather than with other people, and ho is likely

to be- overly cool and critical in his interpersonal relation-

ships. Conversely, subjects who score high, on this factor

tend to be very socially outgoing end display a greater range

of emotional expression than do low-scoring subjects, Sne

high-A individual usually prefers to deal with other people

rather than with objects and is typically rather flexible and

compromising in his approach to solving problems» Factor A

is affected to an appreciable degree by hereditary factors.

Factor B—-Tiie B scale is a measure of general intelli-

gence and abstract reasoning ability. Subjects who score low

on this scale tend to be of low mental capacity, and their

intellectual apprcaeo is essentially of a concrete nature.

Furthermore, they tend to be lov/ in judgment and perseverance.

Subjects who score high en this scale tend to be of high gen-

eral .-f.ental capacity, and tneir judgnent end perseverance are

above average. Factor B is also influenced to a large degree

b y h s r e d .11: i r y f a c t c r n.

43

Factor 0—The C scale is a measure of maturity arid per-

sonality integration, Subjocts who score low on this scale

tend to be easily frustrated and disorganized under stress,,

These ifldividuals are typically changeable in their attitudes

and interests, and they are quick to give up difficult tacks,

Subjects who score high on this scale are typically stable

and emotionally mature, and they tolerate stress well*

Factor E—The 38 scalo is essentially a measure of domi-

nance. Subjects who score low on this scale tend to be rather

submissive and dependent in their dealings with others, and

they are easily upset. Conversely, subjects who score high

on this scale are typically independent, assertive individuals

who are somewhat rebellious and headstiong in their dealings

with others.

Factor F—-The F scale is, to a degree, a measure of ex-

troversion. Subjects who score loir on this scale tend to be

taciturn, introspective individuals and are likely to be un-

communicative and melancholic, low F scores accompany most

mental disorders. Subjects "who score high on the F scale are

happy-go-lucky and enthusiastic in the pursuit of their goals.

Factor G—The G scale is a. Measure of self-control*.

Subjects who score low on this scale tend to be impulsive}

irresponsible individuals who are self-indulgent and undefend-

able. Conversely, subjects who score high on this scale are

typically conscientious, moralistic individuals who ere ex-

tremely responsible and emotionally disciplined.

Factor H-~-The H scale Is a measure of social boldnessa

Subjects who score lew on this scale ore typically timid,

sensitive individuals who are restrained and retiring in

their dealings "with others. Subjects who score high on thio

scale tend to be quite adventurous and uninhibited and are

outgoing and bold in social interactions.

Factor £ — T h e I scale is a measure of aesthetic interests

and fastidiousness. Subjects who score low on this factor

are typically tough-minded, self-reliant individuals who are

soiuewhat cynical and la eking in taste. Conversely, subjects

with high I score;; tend to be tender~raincled, dependent indi-

viduals who are artistically fastidious and imaginative.

factor L — T h e L scale is a pewsure of paranoid tendencies,

Subjects with, lew L scores are typically very trusting and

easy to get along with. They arc- rather free of jealousy

and understanding and permissive in interpersonal relation-

ships. Subjects with high L scores tend tc be very suspicious

of others and dogmatic and tyrannical in their dealings with

others.

Factor M — T h e M scale is a measure of practicality.

Subjects with low M scores are typically very conventional,

practical individuals who are not particularly creative, but

who.are extremely dependable. Subjects with high K scores

tend to disregard practical natters. Furthermore, they are

typically preoccupied with an intense, subjective inner life.

Factor K — T n e JBT seals is'a measure of sophist,icati on and

shrewdness. Subjects with low IT scores are typically rather

45

naive, gullible individuals wcio are low in social Intelli-

gence. However, they are emotionally genuine and spontaneous

in their dealings with other::.. Subjects with high H scores

tend to be very suave, polished individuals who are extremely

calculating and manipulative in interpersonal relationships.

Factor 0—Scale 0 is a measure of guilt pronencss. Sub-

jects with, loir 0 scores are typically rather tranquil and

self-assured, and they are not overly influenced by social

pressures. Subjects with high 0 scores tend to be worried

and anxious, and they are overly sensitive to other people's

a p p r o 'v a 1 a n d d i s a p pro re 1,

Factor Qj -—Scale Qi is a measure of conservatism of

temperament,, Subjects with low Qj scores are typically re-

spectful of established ideas and opposed to any change.

Low Qi subjects express more interest in religion than in

science, and they tend not to be interested in "intellectual"

thought. Conversely, subjects with high Q-j scores are typi-

cally well-informed individuals who are likely to experiment

with new approaches _to problems. They express more interest

in science than in religion, and they are frequently suc-

cessful as persuaders and leaders, •

Factor Qo—-Scale Qg is a measure of self-sufficiency.

Subjects with low Q2 scores are typically overly dependent

upon social approval5 and they generally "prefer to follow

rather than to lead others. Subjects with high Q2 scores

tena to be very resourceful and self-sufficient, and they are

rat.aer independent in. cheir s;roup behavior.

4* u

Pact or CJ^—Scalc Q3 is a Measure of sclf-senti Qient.

subjects with low scores tend GO lacfe will control and

character stability, and they show an insufficient consid-

eration of others. Subjects iiitn high Qj scores usually

have strong v?il.l power, and they typically exhibit louch con-

trol of their emotions and behavior. Those individuals are

inclined to b-s considerate of others, but they can s.l.so be

ob.31inate and compulsivo.

Pap tor O4—Scale Q/> is a mo a sure of tension. Subjects

witn low Q4 scores are typically calm and composed? and tney

generally express satisfaction with their situatj on. Con-

versely, subjects with hj gh Q4 scores are typically tense,

excitable, restless indivnduals who are frequently dissatis-

fied with their circuitstan.ee??.

Por:d 0 of the Sixteen yQrson&lity Factor Quest;lontj&lre

wss used for this study since .it is particularly applicable

to the population being studied. Form C of the 16PP re-

quire-:?; only a fifth-grs.de reading level and is '''intended for

tae average 'man. in the street'" (4, p. 25). This form of

the test consists of 105 items and typically requires thirty

to forty minutes to administer. Purther/aore, a parallel

f or& of the test is available for re testing (4, p. 3)• An-\

other reason for using For/.i 0 of trie 1 6.P.F is its inclusion

of a validity scale. The Motivational Hole Distortion Scale

(MD) is indicative of "(1) sabotage, a deliberate attempt

by an uncooperative subject to make the test useless, and

47

(2) BI.otiYation.al role d:'i, s tort ion, in which either- consciously

or unconsciously the subject gives a picture of fciiaself dis-

torted by the prisua of Lis OVA personality in the given test-

ing role" (4, p. 27). !:T1IP lib items are those which (a) them-

selves show max.ircu.ffi shift; from an anonymous to a Job-seeking

situation, a lid (b) correlate most with shifts in the person-

ality factors ih the sane situational change,, 1'he factors

found to change .most are A*, C*» F+, G-s-, H+, L~» M~, 0~, Qg'-'?

Q3+? and Q.4-(4, p. 55).

Cattell concluded that the validity of 3?ora« 0 of the

16PF ,fis decidedly high for so brief a test" (5t P* 7) • 1'he

individual test items were selected by factor analysis as

being representative of the primary personality factors,.

"i'lie mean correlation of all single items with the factors

they, re present is +. 37 > arid the wean correlation of each group

of six items with the factor it represents is about +.71"

(5, P. 7).

Cattell gave the following description of the reliability

of jporm 0 of the 16PF:

Reliability has been worked out as a test-re test correlation with a one-week interval, between. The values, obtained on a population of two hundred students were; Factor A, .54; B. .57> C, .47; i3> .42; F, • 50; G, .41; H, .61; I, .55; 1, .45; K, .39; H, .41; 0, .32;

, Ql t -71; Q2> .45; Q3, -52; Q4, .55- Some of these are not high, but their departure from unity it munt be remembered, covers "function-fluctuation,i. e», real changes in level of traits over time as well as test unreliability (5, p. 7)*

A sociometrie questionnaire (Appendix B) was used AM

this study, and trie soeioiaetrie data T-.'ere computed on tne

48

Boartey-ffessendcn Sooxpio^jjti (3). £ne oociometric question-

naire included the foil owing -j ntroduction;

We are i.n the prooe^w of forming several small therapy group:; on Ward^ ^ end would .11 ice to know which other people you would like to be in a group with; We are therefore asking that you. indicate your preference;:; on this form.

The subjects were instructed to vrite their names at

the top of the page and to "indicate yoitr choices by placing

an 'X' in the space by the person's name." The subjects were

limited to five choices, but they were free to give fewer or

no choices® Furthermore, the test, subjects were instructed

that "if there is anyone with whom you would definitely not

like to be grouped, please draw a line through that person's

name."

0o11ootion of Da ta

A sociometric questionnaire (.Appendix B) was adminis-

tered to the first group of patients in June, 1960,, Patients

on each selected ward were ranked along a continuum >/3 th re-

gard to tne number of socioifietric choices they received. In

cases where the numbers were equal< the final ranking was

made in terms of the number of mutual choices. Patients in

the third part of the continuum receiving the highest number

of choices were called Sociometric High£. Patients in the %

third part of the continuum receiving the lowest number of

choices were called Socl^etric Lows, and patients in the

intermediate group were celled Soc.lometi'lc Mediums.

49

Two months after too initial testing, the entire hos-

pital population was rcdi otrj bated* A geographical unit

system was initiated, and patients frosn sueoi.fic geographic

areas were placed together in separate areas of the hospital.

This change was made to simplify coHunu.riic.ation with the pa-

tients' home counties, thereby promoting earlier discharges.

Formerly, each social worker had to correspond with families

and social agencies within all sixty-five counties in the

hospital district. Under the ns>i geographic system, each

social worker dealt tfith only a few specific counties. The

unit system also facilitated vocational rehabilitation ser-

vices ana halfway house placements.

The effect of the hospital redistribution actually

enhanced the design of this study- The subjects in the orig-

inal group were distributed throughput the hospital in a

relatively random manner according to their geographic ori~

gins, and both males and females were placed on most wards.

In Decembers 1970, exactly thirty months after the ad-

mi iris treat ion of the original sodometrie questionnaire, a

follow-up study was conducted to determine how the patients

fared who had originally been tested. Hospital records in-

dicated which of these patients had been hospitalized contin-

uously for the thirty-month period, which patients had been

discharged, and which patients had been discharged and read-

mitted. Hospital records also indicated if any patients in.

the original group were discharged and rehospitalized in

50

another state hospital or it there "were any deaths during

hospitalization. The patients in. the original group were

divided among throe categories according to how they had

fared since the original testing, The Failure category

consisted of 111 patients xtho remained hospitalized Tor the

entire thirty-month periods as well as 8 patients who died

during this time without having been discharged. The Partial

Success category consisted of 20 patients who were discharged

at sorae time during the thirty-month period, bat who were

hospitalised in a state hospital at the time of the follow-

up study. The Success category consisted of 87 patients who

were not in a state hospital at the time of the follow-up

study.

The sociometric questionnaire (Appendix B) and Form 0

of the Sixteen Personality Factor Qussticomalre ware admin-

istered to the second group of patients in this study in

December, 1970, exactly thirty months after the original

study. Three patients, however, on the closed ward did not

take the Sixteen Personality Factor Questionnaire. Two of

these patients were too confused to take the test, and the

third was discharged before the test administration. Patients

in the second group were then divided among the Sociometric

High, Sociorastric Medium, and Soeiomntric Low categories in

the sainc manner that the subjects in Group One were categorized.

All testing in this study was conducted on the patients'

wards by ward attendant personnel. The hospital's chief

psychologist carefully instructed these attendants In tost

administration techniques. The teste were given, in the ward

cafeterias, and patients with poor vision and those with

reading difficulties wore given the tests verbally. The

Sixteen Pgrsopallty g&ctor OnestionnaIres were scoxed by psy-

chological technicians who had at least a baccalaureate

degree in psychology. 3!h.e socioaetric data were redorded and

scored by the chief psychologist,

Sta bistical Proeedures

Hypothesis Number One i»:as tested by a 3x3 chi square

test of Independence» This statlsti oal technicus is defined

by MoKemar (14, Chapter 13).

Hypotheses Two, Three, Pour, and Six were tested by

the statistical technique of simple, analysis of variance.

When olgnificant differences were noted among groups, the

Duncan new multiple range test "«as applied as a further test

of significance. These statistical techniques are defined

by Mel'Jeraar (14., Chapter 15)»

Hypotheses Five and Nine were tested by the chi square

goodness of fit statistical technique. This technique is

defined by McKemar (1h , Chapter 1 3) =•

? Hypotheses Eight, Ten, and Eleven were tested by

Pi sherds t_ tests for independent sai.aples (two-tailed test).

This statistical technique is defined by KeHestar (14,

Chapter 7)«

52

Hypothesis Seven vas tested by the t_ test for x'&lated

samples (two-tailed teat). This statistical technique is

defined, by Underwood (1 6S pp. 1 67-171

A significance; 'level of .05 was required to reject the

null hypothesis fore all computatiojas.

CifAPT.OH BIBLIOGRAPHY

1. Adcock, C. J., "16PF Review,u She fifth Merital Moaaiaro-ment« Yearbook, eci 11-sd by Oscar'^KT^Buros''Highland Park J" Hew* Jersey, The Gryphon Press, 1959.

2. Arties, K. I*, KLT,iou Th.e^SPX *]i Bohj^^pphroaia, Hew York, Grime & Stratton I' "Y§62 T . —

3o Borrney, Merl JS,, and Setb. A Feseenden, Manual.* l^ViQ&Xr Fessenden Soolograph, Lou Angeles, California Test Bureau,

4. Oattell, Raymond B., Herbert tf« Bber, and Kaurico M. Tatsuoka, Handbook for the Bixtesn Persoaalltv Factor Pn,estionnai rb_' f 970* e&« 9 C'iiaypoign, Illinois, Institute f or ~P'er» cmairty and Abi 1 i ty T e s i x tig. 1 970.

5' B Handbook Supplement for, Forci C, of ""the"* B1 xiieHî ijorsox̂ l3rty""Fa'cior' (Suc^J;^.nnaXre, 2Bd ed. s /̂Ta'tipaigb.p*"lI"Iiiiois» institute for Personality and A'bi 11 ty let;ting, 1962.

6. Gumming, Jo, and E. CuKcolng, Ego and K3.11e», Hew York, Atberton, 1962.

7 . Eda.lt:on, H., "The Sociot herepeutic Function in a Psy-chiatric Hospital, Jourzu*.! of the Fort Lncgan Kantal Ilealtii 0ep.ter, IV (T967 jr'V-^-SV' '

8. Fischer, Robert P., hThe Oattell 16 Personality Factor Ouesrbionnaire,11 Journal of Clinical Psychology, 12. (1956), 408-41 "" ~ ~ ™ "

9. Jonca, Ilaxwell, Beyond the. Therapeutic OoffT.unl ty, Kew Havenj ConaecticiTt^ieXe^uHivcfoi'ty Prose5 1 96B«

10. Social Psychiatry in the HospitaSV'and in '#Hscnf3i'"Spring!'\aid, Illinois, Charle's" "0. Thomas,""!9^2 „ ~

11. ,» Thê Therapeutic Ocqsiunity, Hew York, Ba b i c B o o ic s , 1 953»

12. Kraft, A. K., "The Therapeutic (Jejuni ty," JkmrH can Handbook of Psychietry, Vol, 3? ©silted by ,S» Arieti, ifew "York, Basic jdooIcj*, 1966,

53

^ 4

13. Lorr, Maurice, W16P.P. Review," The S5xtn Mental Mea-surements Ycf̂ rboo1.:, cdited "by 0scar KT^TrFfI7""Hig!irand Jhirk,. KeV J ersey, "I'ho Gryphon Pre so, 195 5 •

14. KcHeaar, Quirm, ̂ >̂-oĴ ol̂ ô ;Xoa.3v Dt«J;.ls11 cs, 4th ed., How York, Joh.n ¥ 1 le»y* &a&*"'&ou«'i*"Jv>c7T'"T̂ 9«"""

15. Pauls C-'Csrdoji !•, !iC:-irov...lc Mental Patient: Current Stsitus—Futare Bireu bion^, " P«y cholo^ical Bulletin, LXX (196?), 81-94. ~ —

16. Underwood, Benton J., and others-, Elementary Kew York, A pple ton-Century -Croft s 3"lnc ,,** 1'954."

17. yilmer, H. _A., "Tcwr-rd a Definition of the Therapeutic. Commu