relationships among sociometric status, prognosis, aid selected personality variables...
TRANSCRIPT
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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."
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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?
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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
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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.
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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
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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,
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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
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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.
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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.
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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
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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.
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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"""
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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
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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
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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
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^ 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