THE DETERMINATION AND EVALUATION OF CHANGES IN PERSONALITY FUNCTIONING OFELECTRO-CONVULSIVE TREATED SCHIZOPHRENICS

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Sponsoring Committee: Professor Avrum Ben-Avi (vice Professor B r i a n E. Tomlinson, on leave), Professor Ernest R. Wood, Professor J. Darrell Barnard and Arnold Schillinger, M.D., Psychiatric Consultant

THE DETERMINATION AND EVALUATION OF CHANGES IN PERSONALITY FUNCTIONING OF ELECTROCGNVULSIVE-TREATED SCHIZOPHRENICS

STANLEY SAUL SCHWARTZ

Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of Education of New York University

3 ^ [Thaai* accepted

J350

April 28th, 1950

I, Stanley S. Schwartz, hereby guarantee that no part of the dissertation, "The Determination and Evaluation of Changes in Personality Functioning of ElectroconvulsiveTreated Schizophrenics," which I have submitted for publi­ cation has been heretofore published and/or copyrighted in the United States of America, except in the case of passages quoted from other published sources; that I am the sole author and proprietor of said dissertation; that the dissertation contains no matter which, if published, will be libelous or otherwise injurious, or infringe in any way the copyright of any other party; and that I will defend, indemnify and hold harmless New Y o r k U n i v e r s i t y against all suits and proceedings which may be brought and against all claims which may be made against New York University by reason of the publication of said dissertation.

TABLE OF CONTENTS PAGE THE PROBLEM Statement of the Problem Specific Problems Definition of Terms Delimitations Basic Assumption The Need for the Study Summary

1 1 2 2 4 5 5

9

RELATED LITERATURE Insulin and Metrazol Therapy Studies Electric Shock Therapy Studies Summary

11 12 18 22

PROCEDURE General Statement Description of the Treatment Process The Patient Group Diagnosis Age Educational Level Vocational Background Duration of Illness Previous Treatment Course of Therapy at Northport Patient Group Summarized The Test Battery The Bender-Gestalt Test The Rorschach Test The Word-Association Test The Draw-a-Person Test The Thematic Apperception Test The Color-Form Sorting Test Administration of the Test Battery Treatment of the Data Summary

24 24 25 27 3° 32

32 33

33 34

35 3°

37 39 42 46 49

52 55

$8 ol 63

PRESENTATION AND DISCUSSION OF TEST RESULTS 64 The Rorschach Test 64 Scoring Procedure 65 Comparison of Pre- and Post-Treatment Records in Terms of Group Data 76 Pre- and Post-Treatment Records Compared in Terms of Monroe Inspection Technique Scoring 82

TABLE OF CONTENTS (continued)

PAGE

CHAPTER IV

PRESENTATION AND DISCUSSION OF TEST

RESULTS (continued) The Rorschach Performance of Each Patient Pre- and PostTreatment and a Clinical Analysis of the Records The Thematic Apperception Test Scoring and Results Adequacy of Stories Responsiveness Personal Reference Interpersonal Interaction Male-Female Identification Dynamic Analysis Needs Effect of Environment Reaction of the Organism Adequacy of Principal Character Ending The Word-Assoeiation Test Reaction Time Frequency Count Zero Scores Association Disturbances Reproduction Failures The Color-Form Sorting Test Scoring Procedure Results The Draw-a-Person Test Size of Figures First Figure Drawn Position of Figures Rating Scale Comparison Goodenough Scores Judgments of the Figures The Bender-Gestalt Test Comparison of Pathological Indicators Rating Scale Comparison Ratings by Judges Summary V

ANALYSIS OF THE D A T A The Rorschach D a t a The Thematic Apperception Test Data The Word-As s o c i a t i o n Test Data The Color-Form Sorting Test Data The Dr aw-a-Person Test Data

88 137 137 137 141

141 143 146

147 150 152 158 lo2 167 169 170 170 172 173 174 175 17© 180 l8l 182 185 185 186 190 192 205 205 211 214 223 228 228 233 237 239 240

TABLE OF CONTENTS (continued) PAGE

CHAPTER ANALYSIS OF THE DATA (continued) The Bender-Gestalt Test Data Analysis of Individual Patient Data Changes in Personality Functioning with Respect to Age Duration of Illness Sub-diagnosis Previous E.C.T. Summary

V

SUMMARY, CONCLUSIONS AND DISCUSSION Summary Conclusions Discussion Future Research Possibilities The Test Battery Approach

VI

BIBLIOGRAPHY APPENDIX

A B

243 244 283 284 285 286 288 29I 291 294 295 297 297

299

LIST OF TABLES

TITLE 1

Background Data of the Patient Group

29

2

Distribution of Schizophrenic Diagnosis of Patient Group

32

3

Distribution of Patients by Age

32

4

Educational Level of Patient Group

32

5

Vocational Level of Patient Group

33

6

Estimated Duration of Illness of Patient Group

34

Previous Shock Therapy Received by Patient Group

35

Electroconvulsive Treatments Administered to Patient Group

36

Interval Between Pre-Test and First Treatment

59

Interval Between Final Treatment and PostTest

59

Tests Taken by Each Patient Before and After Therapy

61

7 8

9 10 11 12

Comparison of Composite Rorschach Scores, Pre- and Post-Treatment

7,71

13

Comparison of Monroe Inspection Scores

83

14

Areas of Disturbance on Monroe Inspection, Pre- and Post-Treatment

84

Comparison of Disturbance Indicators in Monroe Inspection Scoring of Rorschach Records

85

Direction of Change of Functioning in Monroe Areas

87

15

16

Rorschach Summaries, Pre- and PostTreatment of Patients #1-20

0-1

LIST OF TABLES (continued) TABLE NO.

TITLE

PAGE

Pre- and Post-Treatment Evaluation of Adequacy of T.A.T. Stories

139

37

Number of Words in T.A.T. Stories, Preand Post-Treatment, Compared

142

38

Comparison of Personal References, Interpersonal Interactions, and Unusual Male-Female Identification in the T.A.T. Stories

144

36

Dynamic Analysis of the T.A.T. Stories; 39

I.

40

II.

151

Needs A.Frustrating

153

41

B.Helpful

154

42

C.Neutral

155

43

Effect of Environment

Effect of the Environment on the Indi­ vidual Compared, Pre- and Post-Treatment

157

Dynamic Analysis of the T.A.T. Stories; 44

III.

Reaction of the Organism to the Environment A. Neurotic Symptoms B. Reactions of SelfSufficiency

45 46

Adequacy of the Principal Character Compared, Pre- and Post-Treatment

159 160

163

Dynamic Analysis of the T.A.T. Stories; 47

IV.

Adequacy of the Principal Character

48

49

V.

Ending

A. Not Adequate Maladjusted

164

B. Adequate Adjusted

166 168

LIST OP TABLES (continued) TITLE

PAGE

Comparison of Pre- and Post-Treatment Word-Association Test Scoring

171

Performance on Color-Form Sorting Test, Pre- and Post-Treatment

178

Comparison of Size of Drawings Pre- and Post-Treatment

I83

Comparison of Positions of Figures, Preand Post-Treatment

186

Rating Scale Values of Drawings, Preand Post-Treatment

189

Goodenough Scoring of Draw-a-Person Figures Compared

191

Pathological Indicators in Bender-Gestalt Records Compared

209

Comparison of Areas of Disturbance in Bender-Gestalt Records

210

Comparison of Bender-Gestalt Ratings, Pre- and Post-Treatment

213

Preferences of Judges on the Designby-Design Rating

215

Preferences of Judges on the Over-All Rating

216

Effect of Age on Over-All Change in Personality Functioning

284

Effect of Duration of Illness on OverAll Change in Personality Functioning

285

Effect of Sub-Diagnosis on Over-All Change in Personality Functioning

286

Effect of Previous Electroconvulsive Treatment on Over-All Change in Personality Functioning

287

LIST OF FIGURES FIGURE NO.

TITLE

PAGE

I - II

Male Drawings of Patient #1

195-196

III - IV

Male Drawings of Patient #5

197-198

V - VI

Female Drawings of Patient #5

199-200

VII - VIII

Male Drawings of Patient #15

201-202

IX - X

Female Drawings of Patient #15

203-204

XI - XII

Bender Designs of Patient #12

217-218

XIII - XIV

Bender Designs of Patient #14

219-220

X V - XVI

Bender Designs of Patient #15

221-222

CHAPTER I THE PROBLEM Statement of the Problem The purpose of this investigation is to determine and evaluate the changes in personality functioning of schizo­ phrenic patients who have undergone a course of electroconvulsive therapy

in a neuropsychiatric hospital.

The convulsive, and particularly the electroeonvulsive, therapies have become, since their modern introduction in 19331935 by Sakel, Von Meduna, and Cerletti and Bini'*', the thera­ peutic mainstay of those engaged in the treatment of the major mental disorders.

Continued application of these techniques has

resulted because empirical findings, on the whole, indicate ben­ eficial results.

What results in the personality functioning of

the psychotic individual who has received a course of such therapy is not particularly well-understood, however.

2

The present study is concerned with the application of psychological techniques in a clinical setting with the end in view of measuring and evaluating changes in personality function-

1. 2.

In this paper the terms "electroeonvulsive therapy11 (ECT) and "electro-shock therapy" (EST) will be used synonymously. L. B. Kalinowsky and P. H. Hoch, Shock Treatments and Other Somatic Procedures in Psychiatry, pp. 1-6. H. L. Gordon, "Fifty Shock Therapy Theories," The Military Surgeon, 103, (November, 1 9 4 8 ), pp. 397-401.

ing that follow the administration of electroconvulsive therapy to schizophrenic patients. Specific Problems It is proposed, in the course of this investigation, to determine and evaluate: 1.

The changes that occur in personality function­ ing as a constellation after a series of elec­ troconvulsive treatments.

2.

The changes that occur, and the degree and direction of change, of the following more important aspects of personality functioning: a.

the qualitative characteristics of the thinking process, including concreteness and abstraction.

b.

the control and effectiveness of emotional response.

c.

attitudes toward the environment and indi­ viduals in the environment.

d.

attitudes toward the self.

e.

the presence, expression and control of anxiety.

f.

the contact with reality and the indiffer­ ence or sensitivity to reality.

Definition of Terms Schizophrenia is defined here in the same terms as it

3 is in the clinical setting (the Veterans Administration) in which the investigation will take place; This term is synonymous with the formerly used term dementia praecox. It represents a group of psychotic disorders, characterized by funda­ mental disturbances in reality-relationships and concept formations, with consequent affec­ tive behavioral and intellectual disturbances in varying degrees and mixtures. The disorders are marked by strong tendency to retreat from reality, by emotional disharmony, unpredict­ able disturbances In stream of thought,-.and in some by a tendency to deterioration. Electroconvulsive therapy is the production of a grand mal seizure by means of the application of electric cur­ rent to the frontal and precentral regions of the brain.

The

apparatus used in all cases is the "Lectra", portable model. Voltage used ranges between 175 and 250, resistance is approximately l£0 ohms, amperage is 0 . 9 and duration of application is 0.2 seconds.

All of these factors are approximate and vary

from patient to patient depending on variable somatic resistance, number of previous shocks and atmospheric conditions.

The con­

stant factor in each case is that a grand mal seizure is pro­ duced.

A single electroconvulsive treatment is the production

of one grand mal seizure. Personality functioning in its present usage refers to the non-intellectual manifestation of the basic modes of be­ havior of the individual.

This term is not used to imply any

dichotomous structure of the individual but simply is intended

1.

Veterans Administration Technical Bulletin IOA-7 8 , October 1, 1947, Nomenclature of Psychiatric Disorders and Reactions. P. 9.

4 to delineate the area of concentration of this study. Delimitations The study is limited to male, schizophrenic, veteran patients of World War II who are between the ages of nineteen and thirty-five and who are receiving treatment at the Northport Veterans Administration Hospital, Northport, Long Island.

This

age group is, selected because it comprises a majority of those receiving electroconvulsive treatment at the Northport Hospital and because it represents more patients whose schizophrenic illness is uncomplicated (see below) by other disorders or dis­ eases • The study is limited to patients whose primary diag­ nosis of schizophrenia is uncomplicated by additional diagnoses (i.e., tuberculosis, epilepsy, alcoholism, etc.), to insure that unknown physiological interreactions do not influence the be­ havior of the individual and provide another variable in the investigation. The study is limited to patients who are at least minimally cooperative pre- and post-therapeutically to the ex­ tent that they make some attempt to perform adequately on a battery of psychological tests.

The judgment of oooperation

will be made by the investigator at the time of examination. While it is recognized that the degree of cooperation shown is to a large extent related to the illness of the patient, it is not believed that nil results on either pre- or post-therapeutic testing will assist in furnishing data for useful descriptive

5 and comparative analysis of personality functioning. The study is limited to patients who receive a mini­ mum of six electroconvulsive treatments.

This limitation is

necessitated by the fact that all patients at the hospital do not receive a uniform course of therapy.

Treatments are term­

inated when the patient’s reaction, in the opinion of the psychiatrist in charge of electroconvulsive therapy, shows either that further treatments will be of no value in his case or shows improvement to a sufficient extent that he becomes amenable to treatment by techniques other than shock therapy, such as psychotherapy or occupational therapy. Basic Assumption It is the basic assumption of the investigator that it is possible to determine, describe and evaluate changes in personality functioning through the use of a suitable battery of psychological tests.^ The Need for the Study As recently as 194-6, Gill and Brenman made the follow­ ing statement: Is it not astonishing that one of the most fre­ quently used therapeutic techniques in psychiatry should, be one that has practically no rationale, certainly no psychological rationale? But is it not more astonishing that the attempts to estab­ lish a rationale is so feeble? Our psychiatric researchers on shock therapy are for the most

1.

D. Rapaport, Diagnostic Psychological Testing. Volume I, pp. 5-7.

6 part content to report the numbers of cases given shock and the per cents of recovery in each category. How rarely is there any dis­ cussion or even description of the minutiae of the psychological status of the patient-, before, during, and after shock treatment. Bini2 in 1938 reported his experiments in inducing epileptic seizures in dogs by means of the passage of elec­ tricalcurrent through he would

their entire bodies and stated that

continue this line of research with a view toward

its

application to human therapy.

Within the period of a very

few

years the electroconvulsive technique for the production

of grand mal seizures as a physical therapeutic device in treat­ ment of the psychoses gained widespread use.

Kolb and Vogel^

surveyed more than three hundred hospitals in the United States in 1941 and reported, '•Electric shock therapy first came into appreciable use in 1939 and was adopted more rapidly than either insulin or metrazol.

It was being used by 42 per cent of mental

institutions during October, 1941, when its use was still in­ creasing with no evidence of diminishing interest...,*4' The hospitals which replied to the survey reported the administration of electric shock treatment to 7 , 7 &9 patients in 1940-1941

1.

L. S. Kubie, H. A. Murray, E. Kris, M. Gill, and M. Brenman, "Problems in Clinical Research j Round Table, 1 9 4 6 ," American Journal of Orthopsychiatry. 17, (April, 1 9 4 7 ), p. 2 1 8 . 2. L. Bini, "Experimental Researches on Epileptic Attacks Induced bv the Electric Current." American Journal of Psvchiatrv. 94, (May, 1938), pp. 172-1771 3 . L. Kolb and V. H. Vogel, "The Use of Shock Therapy in 3 0 5 Mental Hospitals," American Journal of Psychiatry. 9 9 , (July, 1942), pp. 90-100. 4. Ibid., p. §2. 5- Ibid.. p. 99.

7 As a reason for its widespread acceptance Kalinowsky and Hoch name the following advantages: 11(1) the method is technically simpler and cleaner than the intravenous injection of large amounts of fluid; (2 ) there is an immediate loss of consciousness which spares the patient any recollection of the application and makes refusal of treatment a rare occurrence. 11^ At the present time this form of therapy is in exten­ sive use in hospitals and offices of psychiatric practitioners for a wide range of mental disorders which range from the psyp choneuroses to schizophrenia. The great majority of research on its effects has been of the Mper cent improved or not im­ proved" type and has not shed sufficient light on the psycho­ logical consequences of the electroconvulsive technique.

In

this connection Kalinowsky and Hoch state, "Convulsive therapy has stimulated psychologic research less than might be expected. Those studies which have been made are mostly limited to the question of impairment of memory function during and after con­ vulsive t h e r a p y . J e s s n e r and Ryan state, "The mechanism by which electroshock produces improvement is unknown."4- They also make the following statement, with reference to the need for further research in electroshock therapy, "It is only after many more thousands of shocks have been given and a great deal

1.

L. B. Kalinowsky and P. H. Hoch,Shock Treatments and Other Somatic Procedures inPsychiatry, p. 106. 2. Ibid.. p p 169-191. 3. Ibi&-, p. 133. 4.' L. Jessner and V. G. Ryan, Shock Treatment in Psychiatry: 4 Manual, p. 122.

.

8 of research work done, that we can accurately evaluate the place of this apparently promising treatment in the therapy of mental disorders."'*' Eissler in 194-7 stated, "However, elaborate studies of the mental state of the patient after treatment are scarce and insignificant in number as compared with those studies in which gradations of so-called social adjustment

a|c

are taken as the

distinguishing factors of rough and superficial categories for statistical purposes." 2

With respect to the lack of clear-cut

evaluation of the results of shock therapy, Solomon has stated The place of this type of treatment (convul­ sive shock therapy) for the patient with schizophrenic psychosis is a subject which does not allow for any clear-cut evaluation. There can be no doubt that the behavior of many schizophrenics is greatly improved as the result of shock treatment. The general sense of well-being is quite often enhanced, and the appearance of many individuals is brought towards the normal. It is question­ able, however, whether the underlying schizo­ phrenic process and disturbance of^thinking mechanism is very greatly altered.^ The present study is designed to answer, in part, the need raised by the foregoing and other writers and practitioners

1. 2. 3. *.

Ibid.. p. 12^. K. R. Eissler, "Objective (Behavioristic) Criteria of Recov­ ery from Neuropsychiatric Disorders," Journal of Nervous and Mental Disease. 106, (November, 194-7), p. 5^3* H. C. Solomon, "Shock Therapy in the Military Services," in Manual of Ml] i tarv Neuropsychiatry (H. C. Solomon and P. I. Yakovlev, editors), p. 5 8 2 . That is, the "recovered, improved and failures" categoriza­ tions .

9 in the fields of psychiatry and clinical psychology for more knowledge of the psychological effects of electroconvulsive therapy in the personality functioning of the schizophrenic patient.

It is believed that insufficient attention has been

given to the psychological picture of the entire individual and that, to a large extent, a more adequate understanding of the effects of this form of therapy cannot be gained unless a global attack on the problem is made.

This study will be globally-

oriented, will be carried out in a natural clinical-therapeutic setting, and will utilize a batteiyof relatively standardized and objective psychological devices which are in wide use,*1, to to facilitate comparisons if similar studies are made in the future. It is believed that a before and after personality evaluation in psychologically meaningful terms, arrived at through the use of acceptable and adequate psychological instru­ ments, will contribute significantly to the understanding of the effects of electroconvulsive therapy on schizophrenic patients. Summary In Chapter I were presented the statement of the prob­ lem, the sub-problems, the definitions of terms, the delimita­ tions of the study, the basic assumption and the need for the study.

1.

C. M. Louttit and C. G. Browne, ’'The Use of Psychometric Instruments in Psychological Clinics,” Journal of Consult£££ Psychology. 11, (January, 194?), pp. 49-54.

10

The problem stated was the determination and evalu­ ation of changes in personality functioning of schizophrenic patients who have undergone a course of electroconsulsive therapy at the Northport Veterans Administration Hospital.

The

terms schizophrenia, electroconvulsive therapy and personality functioning, as used in this study, were defined. The study was delimited to male, schizophrenic, veteran patients of World War II who were between the ages of nineteen and thirty-five and who received a minimum of six electroconvulsive therapy treatments, and who were at least minimally cooperative pre- and post-therapeutically. As the basic assumption, the following was stated: That it is possible to determine, describe and evaluate changes in personality functioning through the use of a battery of suit­ able psychological tests. The need for the study was demonstrated through a statement of the widespread use of electroconvulsive therapy, and statements by authoritative psychiatrists and psychologists of the need for studies of this type.

CHAPTER II RELATED LITERATURE Malamud has stated, "A vast literature has accumu­ lated dealing with the application of psychological techniques to the psychiatric disorders.*1^

As one of the larger catego­

ries of these studies he named, "Studies concerned with pre­ dicting outcome of shock therapy and bearing on the problem of assessing capacity for spontaneous improvement." 2

The

need for such studies was obvious in psychiatric working sit­ uations in which it was of major importance to select patients with the maximal prognostic possibilities for the relatively limited treatment facilities available.

In addition to psy­

chological investigations bearing on the problem of prognosis, studies were performed to confirm or deny the thesis that shock therapy leads to impairment of the memory function, and to study the effects of shock therapy on intellectual and personality functioning.

1. 2.

D. I. Malamud, "Objective Measurement of Clinical Status in Psychopathological Research," Psychological Bulletin. 4-3, (May, 194-6), p. 246. Loc. cit.

12 Insulin and Metrazol Therapy Studies* Katz,"*- Piotrowski^ and Halpern3 used the Rorschach text to examine insulin-treated patients.

Halpern examined

seventeen schizophrenics before Insulin shock therapy.

Accord­

ing to the test results obtained, two generalized types of patients were found in the group.

One type was composed of

generally non-productive, rigid personalities who showed no capacity for emotional responsiveness and who had little ca­ pacity to identify with others.

These failed in therapy.

The

other type, those who were emotionally receptive and who dis­ played a capacity for empathy, did well with treatment.

Halpern

stated that the Rorschach signs differentiating these two groups would have permitted correct prediction of response to treat­ ment in fourteen out of seventeen cases. Kalinowsky and Hoch reported Katz* findings as follows: •••the Rorschach protocol usually corresponds with clinical findings during and after insulin therapy. However, there are exceptions to this general rule Insofar as patients completely cured clinically may still show some schizophrenic signs in the Rorschach records. In a series of

*. Research in insulin and metrazol therapy are included in this survey because of similarity to objectives, problems and approaches. oF 1. H. Katz, “Examination of Insulin-Treated Schizophrenics by the Rorschach Method, 11 cited by L. B. Kalinowsky and P. H. Hoch, Shock Treatments and Other Somatic Procedures in Psychiatry, pp. 71-72. 2. Z. Piotrowski, “The Rorschach Method as a Prognostic Aid in the Insulin Shock Treatment of Schizophrenia," Psychlatr-ie* Quarterly. 15, (October, 1941), pp. 807-822. 3- P. Halpern, "Rorschach Interpretation of the Personality Structure of Schizophrenics who Benefit from Insulin Therapy," Psychiatric Quarterly. 14, (October, 1940), pp. 826-8 3 3 .

13 1 5 fully recovered cases, only 5 were free of schizophrenic signs In the Rorschach protocol. Katz believes that the so-called full remissions following insulin treatment in schizophrenia are not real cures and do not differ basically from spontaneous re­ missions. The most common schizophrenic sign in the pretreatment protocols was poor form perception. Original answers and anatomic Interpretations were also poor. Less frequently seen were marked qualitative differences in interpretations, frequent color interpretations, and detail answers. Fairly often definite delusional content was present in the interpretations. Less frequent were inability to interpret some of the cards, abstract interpretations, and interpretations of the white spaces on the card instead of the figure shown. All the schizophrenic signs showed a gradual recession after insulin treat­ ment* The movement interpretations changed very little, but the color interpretations which were prevalent in the untreated cases were greatly reduced with treatment. On the basis of his "blind11 analysis of Rorschach records of insulin treated cases, Piotrowski

O

was able to predict

improvement correctly in fifty-three out of sixty cases and stated that with added experience (more precise definition of prognostic signs) could have correctly predicted improvement in ninety-three per cent of the cases (ninety-seven out of one hundred and four).

He found that the Rorschach distinguished

between emotional and intellectual regression and concluded that the greater the amount of intellectual regression the less the chances of improvement, while the greater the degree of emotion­ al regression the better the chances for improvement.

He main­

tained that the Rorschach technique was of considerable value

1. 2.

Kalinowsky and Hoch, oj). cit.. pp. 71-72. Piotrowski, 2E* cit.. pp. 8 0 7 -8 2 2 .

14 in precisely distinguishing between these two types of re­ gression.

Halpern'*’ also arrived at somewhat similar conclu­

sions . There have been several studies of the test-battery type to determine prognostic possibilities in insulin and metrazol therapy.

Wechsler, Halpern and Jaros

used a battery

of fifteen tests (some of which were short tests or sub-tests of larger scales) with twenty schizophrenics.

The battery in­

cluded a vocational interest blank, tests of counting by threes and naming words in three minutes, a similarities test, a direc­ tions test, and a word meaning test.

The authors concluded that

their results corresponded well with other estimates of the ef­ fects of treatment and also gave a high correlation (0 *7 3 ) with a clinical appraisal of the patients’ condition six to eighteen months after treatment.

In addition to the prognostic findings

the authors reported that some patients after therapy attained lower scores than before therapy and suggested the possibility that the therapy may have had a negative influence on their be­ havior and performance. Schnack, Shakow and Lively^ used the battery approach

n 2.

.

Halpern. o p cit.. pp. 826-633. D. Wechsler, F. Halpern, and E. Jaros, "Psychometric Study of Insulin-Treated Schizophrenics, ” Psychiatric Quarterly. 14, (July, 1940), pp. 466-4 7 6 . 3 . G. F. Schnack, D. Shakow, and M. L. Lively, ’’Studies in Insulin and Metrazol Therapy: I. The Differential Prog­ nostic Value of Some Psychological Tests," Journal of Personality. 14, (December, 1945), pp. 106-124.

15 with a mixed group of seventy schizophrenics who received pharma­ cological shock therapy (twenty-three insulin patients, twentyone metrazol patients, and twenty-six patients who received both insulin and metrazol).

They attempted to use a five-test battery

consisting of the 1916 Stanford-Binet Intelligence Test, the KentRosanoff Word Association Test, a level of aspiration test (the G. E. Tweezer Dexterity Board), the Rorschach Test, and the Thematic Apperception Test, but were forced to discard the Ror­ schach and the Thematic Apperception Tests because few of the patients had given usable records on both the pre- and post­ therapy tests.

It Is believed, because of the comparatively

small number of patients who received each type of therapy, be­ cause of the limited battery which was ultimately utilized, and because of the rather inapplicable nature of the Stanford-Binet to a group of adult psychotics, that their results are not of sig­ nificance prognostically nor do they furnish a unified picture of the changes Induced by the therapies investigated. Wittman and Russell^ used a battery consisting of tests of attention, rote memory, information, •orientation, substitution, and paired associates with thirty patients undergoing metrazol shock therapy but this study shed little light on the changes induced by treatment because the patients wpre post-tested at

1.

M. P. Wittman and J. T. Russell, "Mental Efficiency Levels Before and After Shock Therapy," Journal of General Psy­ chology. 26, (January, 1942), pp. 3-17*

16 Intervals from one-half hour to forty-eight hours after therapy and the resulting changes were of a transitory nature and were due to the immediate rather than to the longer-term effects of the treatment. Grhham^ used the abbreviated Stanford-Binet, the KentRosanoff Word Association, and the Rorschach Tests in a study of / the effects of insulin therapy on schizophrenics. Subjects in­ cluded sixty-one patients but these did not give results on all of the tests; complete Stanford-Binet results were obtained from fifteen, and Rorschach results from twenty-eight of the patients. Results of this study were inconclusive but showed positive correspondence with clinical improvement.

Jastak

found a similar

degree of correspondence with clinical improvement using intel­ ligence tests.

McNeel and co-workers^ found that results on a

battery of tests that included the Rorschach, tests of intelli­ gence, perseveration, orientation, concept formation, and word association showed a correspondence between the psychiatric and psychometric rating before, during, and after insulin shock therapy.

V. T. Graham, "Psychological Studies of Hypoglycemic Therapy, 11 Journal of Psychology. 10, (October, 1940), pp. 3 2 7 -3 5 8 . 2. J. Jastak, '‘Psychometric Changes Following Insulin Therapy," Delaware State Medical Journal. 11, (February, 1939)> PP* 114-119. 3 . B. H. McNeel, J. G. Dewan, J. G. Myers, L. D. Proctor, and J. E. Goodwin, "Parallel Psychological, Psychiatric and Physiological Findings in Schizophrenic Patients Under Insulin Shock Therapy," American Journal of Psychiatry. 9 8 , (November, 194-1), pp. 422-429*

IT

17 Bolles, Rosen and Landis1 used a battery of perform­ ance tests of the conceptualization-abstraction type (based on the investigations of Vigotsky, Hanfmann and Kasanin, and Gold­ stein) in an attempt to determine prognosis in schizophrenic patients undergoing insulin shock therapy.

Their group con­

sisted of nineteen patients who were pre-tested only.

Results

of the testing were compared with degree of clinical improve­ ment after therapy.

The study indicated that patients who did

well on the tests did well in therapy and vice-versa.

There

was no follow-up made nor were the test results compared with test results after the therapy was completed.

Zubin and Thompson,

also using a battery consisting of the Weigl, the BRL, and the Vigotsky tests, arrived at similar conclusions. Fingert, Kagan and Schilder^ used the Goodenough Draw­ ing Test with insulin and metrazol-treated patients and found that the test shed information on the psychological statiis

of

the patient which varied somewhat from the clinical findings; they stated, “Months after the completion of therapy, while the patient is in an excellent condition, we have noted that the schizophrenic tendencies seen in the drawings when the patient 4 is sick, are still present, although in a minor degree."

Tl

2. 3.

4.

M. M. Bolles, G. P. Rosen, and C. Landis, "Psychological Per­ formance Tests as Prognostic Agents for the Efficacy of Insulin Therapy in Schizophrenia," Psychiatric Quarterly. 12, (October, 1938), pp. 733-737. J. Zubin and J. Thompson, Sorting Tests in Relation to Drug Therapy in Schizophrenia. H. H. Fingert, J. R. Kagan, and P. Schilder, "The Goodenough Test in Insulin and Metrazol Treatment of Schizophrenia," Journal of General Psychology. 21 (October, 1939), PP* 3^9“ 3^* Ibid.. p. 364.

,

p

18

Electric Shock Therapy Studies Considerable work has been done to determine the ef­ fects of electric shock therapy on the memory function.

Zubin

and Barrera‘S found evidence for a slight loss in memory by teaching their patients a series of paired word associates composed of one familiar and one nonsense word.

They found

that when no shock intervened between learning and relearning the number of trials saved was significant; when shock was interpolated there was no saving, but rather a slight, though not significant, loss.

Zubin stated, "Learning, and retention

measured through recall and relearning, are adversely affected 2 by electric shock therapy."' These results were not confirmed in a study by Purcell-3 of six patients of mixed diagnoses. Brody,4, who studied five cases, concluded that there was a serious impairment of memory during or after electric shock therapy.

The memory defect seemed to be chiefly in connection

with familiar material, learned long before, particularly names of people or places, and habits of work.

Everyday trivialities

were affected most.

1.

J. Zubin and S. E. Barrera, "Effects of Electric Convulsive Therapy on Memory," New York Society of Experimental Biol­ ogy and Medicine Proceedings, 48, 1941, pp. 596-597* 2. J. Zubin, "The Effect of Electroshock Therapy on 'Inter­ ference1 in Memory," Psychological Bulletin. 39, (July, 1942), pp. 5H-512. (Abstract) 3 . P. Purcell, Psychometric Experiments Following Electrical Convulsive Therapy. Unpublished Master's Thesis, Columbia University, 1945, pp. 1-26. 4. M. B. Brody, "Prolonged Memory Defects Following Electro­ therapy," Journal of Mental Science. 90, (July, 1944), PP. 777-779.

19 Sherman, Mergener, and Levitan”*- administered before and after memory tests to ten patients, four of whom received electric shock and six chemoshock.

These tests included four

standard tests of immediate memory, one of recent memory, and one life situation test involving recent recall.

The induced

grand mal seizures were found to have no significant effect on recent memory as tested by these tests.

A slight improvement

of the average scores was found, which was attributed to the improvement in the patients’ general mental condition after treatment.

Stone, 2 however, who used two parallel forms of

the Wechsler Memory Test to obtain evidence of post-shock changes, found that electroconvulsive therapy produced a gen­ eral deterioration of cognitive functions, of which the memory losses were but one part.

Fifteen patients tested immediately

prior to and immediately after a period of therapy showed a fifteen per cent loss of memory.

Fourteen patients tested one

day after and two weeks after a period of therapy showed a rel­ ative gain of twenty-eight per cent.

Stone concluded that re­

covery of mental functions is slow and may not be complete, but admitted that the judgment of this is difficult because there is seldom accurate Information available of the patients' abil­ ities before the psychotic episode.

I"! 2.

I. Sherman, J. Mergener, and D. Levitan, ’’The Effect of Convulsive Treatment on Memory," American Journal of Psy­ chiatry.98. (November, 1941), pp. 401-403. C. P. Stone, "Losses and Gains in Cognitive Functions as Re­ lated to Electro-Convulsive Shocks," Journal of Abnormal and Social Psychology. 42, (April, 1947), pp. 206-214.

20

Other studies dealing with aspects of personality have been conducted, usually utilizing a single psychological tech­ nique or a small combination of techniques, but complete person­ ality studies using a battery of psychological tests to deter­ mine pre- and post-electroconvulsive therapy levels of function­ ing have not been found in the literature.

Lowenbach and Stain­

brook1 utilized Wertheimer*s Gestalt figures and were able to visualize the patient's recovery by means of the progressive im­ provement in the drawing of the figures at different periods following treatment.

Final results closely approximated the

performance obtained before treatment.

Stainbrook

had de­

scribed the stages through which the patient passes in his Ror­ schach performance Immediately after an electrically produced convulsion. Pacella, Piotrowski, and Lewis^ used the Minnesota Multiphasic Persohality Inventory and the Rorschach Test "to evaluate certain aspects of personality by relatively standard­ ized and objective methods."4' It was found that the Minnesota

1.

H. Lowenbach and E. J. Stainbrook, "Observations on Mental Patients After Electro-Shock," American Journal of Psy­ chiatry. 98, (May, 194-2), pp. 828 -6 3 3 . 2. E. J. Stainbrook, "The Rorschach Description of Immediate Post-Convulsive Mental Function," Character and Personality, 12, (June, 1944), pp. 302-322. 3 . B. L. Pacella, Z. Piotrowski, and N. D. C. Lewis, "The Effects of Electric Convulsive Therapy on Certain Person­ ality Traits in Psychiatric Patients," American Journal of Psychiatry. 104, (August, 1947), pp. ©3-91. 4. Ibid. p. 83

21 Multiphasic Test was of limited usefulness but, "In contrast to the Minnesota and other personality questionnaires which were not helpful as diagnostic or prognostic aids, the perceptanalytic test of Rorschach was a valuable prognostic and diag­ nostic aid.

The Rorschach findings paralleled the personality i changes observed clinically. 11 Improvement after therapy was found to be dependent on two different factors.

"One condition

for improvement was the presence of only mild or no intellectual regression."

2

This finding, it will be remembered, paral­

lels the findings made in Rorschach studies of insulin shock treatment.

"The other condition was that there he a marked

discrepancy between the potential and the actual level of the schizophrenic's mental or psychological functioning.

The great­

er this discrepancy, the greater the improvement seems to be, ii o other conditions being equal* 3 After a successful treat­ ment, the following personality changes were observed by means of the Rorschach: The patients became much more concise; they were less circumstantial; the logical co­ herence of their reasoning was improved* There was usually a definite improvement in the capacity for consciously directed and prolonged voluntary attention. They showed more control in thought and action. They were emotionally calmer and less sen­ sitive* At the same time they appeared emo­ tionally duller. 1. 2* 3* 4.

Ibid.. p. 90. Pacella, Piotrowski, and Lewis, oj>. cit., p. 90 L o g , cit. Loc. cit.

22 I

From the review of related literature and studies it is seen that the possibilities of psychological contributions to the field of psychiatric shock therapy have been exploited to a degree somewhat less than maximal.

While it is not pos­

sible to criticize the areas of investigation chosen by the workers cited, it is believed necessary to point out that most of the studies fall short, in one or several of the following respects: 1.

Study populations were generally not clearly

defined or delimited. 2.

Many of the studies utilized but one or a few

test techniques. 3*

The approaches were generally atomistic in

that only selected aspects of functioning were appraised; few efforts were made to view the entire post-therapeutic personality of the patient. 4.

Lack of either pre- or post-therapeutic

ing and dependence upon estimates of pre-psychotic levels or upon clinical observation of results of therapy. Summary In this chapter previous psychological research ac­ complished in the field of insulin and metrazol shock therapy, as well as electroconvulsive therapy, was surveyed, because of Similarity of objectives, problems, and approaches.

In addi­

tion to psychological investigations bearing on the problem of prognosis, studies were made to confirm or deny the thesis that

23 shock therapy leads to impairment of the memory function and to study the effects of shock therapy on intellectual and per­ sonality functioning. In the insulin and metrazol therapy field, conclu­ sions based on Rorschach evaluations by Katz, Piotrowsky, and Halpern were presented.

The Rorschach was found to be a good

prognostic indicator, and was found to correspond with clinical findings during and after therapy.

Several studies of the test-

battery type were performed in this field and the results of these, too, were reported as corresponding well with other estimates of the effects of treatment.

Investigations which

used concept formation, word association, and drawing tests were also mentioned in the literature. In the electric shock therapy field the bulk of pre­ vious psychological investigation was found to be in the area of memory function, the results of which were contradictory and inconclusive.

Dealing with other aspects of personality, the

Bender-Gestalt Test, the Rorschach Test, and the Minnesota Multiphasic Personality Inventory were utilized j the Rorschach was found to be the most useful of these instruments.

Pacella,

Piotrowski, and Lewis observed personality changes by means of the Rorschach after successful electric shock treatment. Shortcomings in the research to date were pointed out by the investigator.

CHAPTER III PROCEDURE In this chapter are described the treatment process, the selection and characteristics of the patient group studied, the test batteiy utilized, and the testing procedure followed. The statistical technique which was employed is also described; the evaluative methods which were used will be described in Chapter IV, ••Results." General Statement of Procedure A battery of psychological tests was administered to twenty successive^ schizophrenic patients, regardless of diag-

1.

These twenty patients were not a successive series, as ordi­ narily understood. As possible subjects, sixty-five patients were seen by the investigator in the course of this study. These sixty-five patients formed a continu­ ous series in that they were successively to begin their electroconvulsive treatments. The twenty patients who are the subjects of this investigation are those of the series of sixty-five who were sufficiently cooperative to have performed the entire test battery with only minor exceptions. Of the remaining forty-five patients seen, most were mute or insufficiently cooperative before be­ ginning therapy. Several patients were scheduled for therapy and tested, but were not begun in therapy for different reasons. Also excluded from the series under investigation were patients who were mute or uncoopera­ tive after the completion of therapy, as well as several who left the hospital too soon after therapy to be seen by the investigator.

25 nostic subclassifications (simple, hebephrenic, catatonic or paranoid), who satisfied the limitations previously imposed. The battery of tests was administered both before and after each patient completed a series of electroconvulsive therapy treatments. Description of the Treatment Process Each patient, after electroconvulsive therapy has been recommended for him by the psychiatric staff of the hospital, receives a thorough series of laboratory, x-ray, neurological, and medical examinations to rule out the pres­ ence of any contraindications to shock therapy.

He is then

transferred to Ward 11-A, the treatment ward. Two treatments per week are generally administered. Shock is given in the morning by a team consisting of the ward psychiatrist or a resident psychiatrist, one of the ward nurses, and two or three well-trained attendant-technicians.

In the

shock room the patient is placed on a table in a supine posi­ tion, after all dentures, chewing gum, and metal objects have been removed from him and after any tight clothing has been loosened.

The electrodes are placed on his head and the circuit

closing button is pressed by the physician present, passing the shock current through the electrodes. lost immediately.

Consciousness is usually

The resultant convulsion and aftermath are

described as follows by Barrera and Kalinowsky: The response usually resembles the typical grand mal attack of the epileptic. On closure of the shock circuit, there is an immediate loss

26 of consciousness with apnea and an initial strong flexion jerk of the trunk and extrem­ ities.. • This stage of apnea and unconscious­ ness may persist 1 - 2 sec or almost a minute, then passes into a stage not seen in the first type of response (minor type of response). Twitchings occur in the facial muscles or limbs, and the patient may emit a cry like true epi­ leptics in spontaneous seizures. A strong tonic contraction follows, affecting practically all muscle groups, gradually replaced by typical clonic movements in the same muscles. Marked peripheral vascular congestion develops, es­ pecially in the face, and there is usually some salivation. Incontinence of urine or feces is rare, but may be observed. The clonic movements finally cease and the patient, still unconscious, begins to relax. Respiratory move­ ments return after a variable period, usually with a few deep stertorous inspirations, and peripheral congestion rapidly disappears.•. After a quiet period of 1-3 min, when the patient is just about to regain consciousness, he may begin to struggle in rather wild and disorganized manner, persisting for several minutes, until consciousness is restored or quiet sleep ensues. In general, a patient is conscious within 10 min after the seizure. For 1 5 -3 0 min after regaining consciousness, the patient may remain confused, showing some dis­ orientation as to time, place and person.•• The entire seizure pattern may vary consider­ ably from patient to patient but generally seems to remain fairly constant for any one patient. 1 During the seizure the members of the shock team hold the patient firmly to the table at the shoulders and the knees to minimize the danger of fracture.

The physician and the nurse

are constantly alert to perceive any complications that arise, and administer immediate aid.

1.

Usually artificial respiration

Barrera, S. E., and L. B. Kalinowsky, "Electric Shock Therapy in Mental Disorders," in Medical Physics, pp. 337-338.

27 is administered (raising and lowering the patient*s arms to expand and contract the diaphragm), assisting the return of respiratory movements. After the convulsive seizure ensues in the shock room the patient is removed to a bed in the ward to regain r

consciousness and to sleep for about an hour.

This is the

end of the therapeutic process, and he then resumes normal ward routine until the next administration of therapy. The Patient Group The patients studied in this investigation were selected from all schizophrenic patients who were scheduled to receive a course of electroconvulsive therapy treatments at the Northport Veterans Administration Hospital, Northport, Long Island, New York, during the period February-October, 1948. The clerk on the shock ward notified the investigator at the time that a new patient was cleared for treatment.^

The

clinical record of the patient was then checked by the inves­ tigator to determine whether the patient satisfied all of the limitations of this study.

If so, the patient was seen in an

office in the shock ward and the test battery was administered. He was again examined two to four weeks after the final treat­

1.

That is, had received all of the necessary medical, surgical, x-ray and legal clearance. Permission of the guardian or next-of-kin was required before a patient was treated with shock therapy.

28 ment in his series*

Only those patients who were sufficiently

cooperative to perform most of the tests in the battery were included in this study. 1

Becuase every testable schizophrenic

who satisfied the limitations of this study was seen during the period in which testing was carried out, it is believed that the patient group investigated comprises a representative sample of the testable schizophrenic population of the hospital who undergoes electroconvulsive therapy* The subjects of this Investigation, as a result of the clinical procedure employed in selecting them as described above, were an unselected group for all factors except those described in the delimitations:

they were all male veterans

of World War II, schizophrenic, between the ages of nineteen and thirty-five, patients at the Northport Veterans Administra­ tion Hospital, had undergone a course of at least six electro­ convulsive therapy treatments, and were minimally cooperative to the extent of having taken a battery of psychological tests pre- and post-therapeutically.

They were not deliminted with

respect to schooling, duration of illness, previous hospital­ ization, previous treatment, vocational status, or sub-classi­ fication within the diagnosis of schizophrenia. Table 1 summarizes these salient characteristics for

IT

Three patients in this study have incomplete test batteries; two patients did not perform one test each and one patient did not perform three. See Table P. , for tests taken by each patient.

TABLE 1 Background Data of the Patient Group Date of Birth 12)

BirthPlace (ti

Age at i Years of Race Pre-Test School 14) (i)

pp. 199-217. 2.

G. B. Diminich, "An Application of the Rorschach Ink-Blot Test to Three Clinical Types of Dementia Praecox,"

3. 4.

S. J. Beck, Rorschach's Test. Volumes I and II. J. D. Benjamin and F. G. Ebaugh, "The Diagnostic Validity of the Rorschach Test," American Journal of Psychiatry. 94, (December, 193^), pp. 1163-1178.

5-

Klopfer and Kelley, oj>. cit.

6.

Beck, op. cit.

Journal of Psychology. 1, 1935* PP* 61-74.

44 reminds you of.

When you*re all finished with one card just

put it down here and 1 111 give you the next one."

After allow­

ing an opportunity for questions to be asked, the test was be­ gun with Card I.

The patient usually held the card in his

hand, but was not prevented from placing it on the desk if he desired. Encouragement by the examiner was offered throughout test performance, but stimulation only during response to Card I, to the extent of asking, 11Anything else?" if only one re­ sponse was offered.

Beyond this, no pressure was exerted to

produce additional responses to those offered spontaneously, nor was the patient’s flow of responses held to any maximum number per card.

Questions by the patient were referred back

to him with, "It's up to you," or "Any way you like." As the patient responded, the examiner recorded the responses verbatim.

Also recorded were the elapsed time be­

tween the presentation of the card and the initial response to the card (timing was accomplished by means of a stop-watch con­ cealed from the patient), the elapsed time between the presen­ tation of the card and the completion of all responses to the card, and the position in which the card was held by the pa­ tient.

Carefully noted were any behavioral manifestations by

the patient in the course of the test, such as unusual handling of the cards, flushing, staring, speech difficulty and the like. After the series of ten cards was responded to ini­ tially, an inquiry was conducted.

This is the usual procedure,

and has as its aim the location of areas of the cards responded

45

to (recorded by means of outlining the similar area on facsim­ ile ink-blots), the elaboration of responses and the elicita­ tion of sufficient information to enable accurate scoring^- of the determinants of the responses.

The technique of inquiry

utilized was that of Klopfer.2 His technique of testing the limits^ was not used because it was believed best to avoid any possibility of suggesting responses to the patient which might be given upon re-testing.

The responses to the inquiry ques­

tions were also recorded verbatim. Utilization of the Test Davidson^ has indicated that the Rorschach gives a description of the total personality which may be analyzed in terms of the following component categories: What use is being made of the subject's intellectual capacity; is he working above or below it; is he ambitious beyond his capacity; or is he lacking in ambition and falling short? What are the qualitative characteristics of his thinking process? Does he do better with abstract or con­ crete material? Is his thinking predominantly analytical or synthetic? Is he hypercritical, crude, or uncritical? Does his thinking show originality as well as the ability to think along the lines of other people? Does he lack common sense and show little contact with reality?

1.

The scoring and evaluative techniques are described in Chapter IV. 2. Klopfer and Kelley, 0£. ci£., pp. 40-51. 3. ________________ , 0£. cit., pp. 51-59* 4. H. H. Davidson, Personality and Economic Background.

46 Are his interests narrow or wide? What is his emotional responsiveness? How adequate is his control? Is he constricted? Impulsive? Does he tend to be introverted or extro­ verted? What is his attitude toward himself? Is he emotionally mature or repressed, at ease with himself or hostile toward himself? What is his attitude toward his surround­ ings? Does he feel secure or insecure in his social relations? Is he shut-in and indiffer­ ent or very sensitive to his surroundings? In addition, it is possible from Rorschach protocols to check on such emotional traits as aggressiveness, impulsiveness, tact, self- _ reliance, independence, anxiety, and so on. The Rorschach was utilized in this study to provide a picture of the global personality functioning of each pa­ tient, before and after electroconvulsive therapy.

In addition,

separate aspects of the test, such as movement, color, shading and form level, were analyzed for changes in terms of their clinical significance as related to shock therapy. The Word-Association Test The Word-Association Test came into clinical use with the work of Jung^ and has been included as part of psychological test batteries because it affords an opportunity for the indi­ vidual to manifest psychological disturbances, because it pro­ vides a clue to the troublesome areas of his personality, and

1. 2.

G. A. Muench, £xi Evaluation of Non-Directive Psychotherapy (citing Davidson), p. 15. C. G. Jung, Studies in Word-Association.

4-7 because it can also be used to investigate certain formal as­ pects of his thought processes. Description of the Test The Word-Association Test used in this investigation was one drawn up by S. Machover, of Kings County Hospital, New York City.

The test consists of fifty-six stimulus words, which

are varied to include both neutral and emotion-producing mate­ rial.

The list includes nine so-called double-barreled stim-

ulous words which are capable of interpretation in several ways, one of which is sexual or anti-social.

The first twenty-five

words of the list also appear on the Kent-Rosanoff list^ and afford an opportunity to compare the frequencies of the re­ sponses given with the frequency given by Kent and Rosanoff's thousand normals who responded to these words.

A list of the

words in the test appears as Appendix C. Administration of the Test The patient received the following instructions: am going to say some words, one at a time.

"I

As soon as you hear

my word I want you to answer with the first word that comes to your mind.

Answer with only one word and as fast as you can,

and don‘t repeat the word I say.

Remember, tell me the first

word that comes to your mind after you hear my word.

1. 2.

Any word

D. Raoaport. Diagnostic Psychological Testing. Volume II. pp. 13-84, contains an excellent discussion of the rationale of this test. A. J. Rosanoff, Manual of Psychiatry and Mental Hygiene. pp. 884-957.

48 will do.

Answer as fast as you can and with only one word.

Don't repeat my word." Following these instructions the practice or sample words "grass" and "table" were given.

If any failure to com­

prehend the instructions was evident, the instructions were repeated, and sometimes elaborated.

Then the sample words

were again administered, followed by the test proper. The words were given in the order listed on the test form, Appendix C. responses obtained.

The first twenty-five words were read and Then the patient was instructed:

"Now I

am going to repeat the same words I just gave you, and I want you to repeat the same answers. words you just gave.

Remember, give me the same

Don't think about them too hardj it's

easier than it sounds."

Following the re-administration of

the first twenty-five words the patient was told: going to give you some more words. did the others. repeated."

"Now I'm

Do these the same way you

We won't come back to these.

They won't be

Following this instruction, the remaining thirty-

one words were administered. Throughout the course of the test if the patient re­ peated the stimulus word or if he gave responses of more than one word he was told, "Remember, don't repeat my word," or "Remember, answer with only one word."

He was also frequently

reminded to respond as quickly as possible. All responses were recorded verbatim on the test form. A stop-watch was used and time, measured from the beginning of the statement of the stimulus-word to the beginning of the state-

49 ment of the response-word, was measured to the nearest second. The stop-watch was held conspicuously in the examiner1s hand and was visably consulted, to provide time pressure for the patient, in addition to that provided by the verbal instructions. Utilization of the Test The Word-Association Test was used in this investiga­ tion to measure conformity in thinking, the presence or absence of "association disturbances"-1-, the ability to handle emotionally-disturbing stimuli, the presence or absence of patholog­ ical indicators such as echolalia or clang associations, the change in speed of reaction, and to obtain a measure of re­ tention ability.

As an integral part of the test battery, it

was used to elicit specific areas of disturbance by means of individual meaningful responses. The specific techniques used in analyzing and util­ izing the Word-Association Test will be found in Chapter IV, "Results." The Draw-a-Person Test Drawing of a human figure is an activity which has been experienced by most individuals who have been reared and educated in this c u l t u r e . ^

1. 2.

Drawings have been used to evaluate

Rapaport, o£. cit.. pp. 40-42. Every patient investigated in this study stated that he had drawn a person, or had attempted such a drawing, at some time in his past experience.

50 intelligence in children,^* and have recently come into a vari­ ety of clinical uses, including catharsis, motor expression, therapy, and diagnostic investigation.

p

Description and Administration of the Test The test is simple In its administration.

The patient

was provided with a sheet of white, unlined paper, eight and a half by eleven inches in size, and a medium, number two pencil. He was instructed, "I want you to draw a person, a whole person. Draw it any way you want and take all ber, draw a whole

person."

the time you need.

Remem­

Questions asked by the patient re­

ferring to sex, size or placement on the page were referred to him with, "Do it any way you like; it's your drawing." After completion of a drawing, which was usually indicated by the patient1s pushing the paper away from him, or putting the pencil down on the desk, he was told, "That's fine. Very good.

Now I'd like you to make another drawing.

This time

draw a woman" (if the initial drawing was that of a man).

Or,

"This time draw a man" (if the Initial drawing was that of a woman) • If the patient drew a portrait, or part of a figure, he was instructed to complete it to form a whole person. was done several times if necessary.

1. 2.

This

If a drawing of something

F. L. Goodenough, Measurement of Intelligence b£ Drawings. M. Krim, Diagnostic Personality Testing With Figure Drawings.

other than a human figure was produced the patient was compli­ mented and given the preceding instructions once more. Questions were sometimes necessary to establish the sex of the first figure drawn, but no further inquiry was con­ ducted.

The drawings themselves form the record of this test.

In addition, careful notes were made of the investigator's observations of the performance; spontaneous responses and other clinical behavior were recorded. Utilization of the Test K. Machover has said, "The basic principle underlying the analysis of the drawings involves the projection of the self into the environment."1* In this study the Draw-a-Person Test was used as a supplement to the Rorschach in this respect and was utilized as an index of the patient's concept of the self and the body image.

In addition, It was possible to eval­

uate bizarreness in thinking and radical deviations from the usual drawings produced by normal individuals.

Thus, it af­

forded another opportunity to compare the pre- and post-therapy tests and evaluate the changes In light of the full clinical picture. A detailed account of the technique utilized in analyz ing the Draw-a-Person Test will be found in Chapter IV, "Results

Li

K. Machover, "A Case of Frontal Lobe Injury," Rorschach Re­ search Exchange and Journal of Projective Techniques. 11, (March, 1947), pp. 11.

52

The Thematic Apperception Test According to Murray and the staff of the Harvard Psychological Clinic who originated it, the Thematic Appercep­ tion Test (familiarly known as the TAT) "is a method of reveal­ ing to the trained interpreter some of the dominant drives, emotions, sentiments, complexes and conflicts of a personal­ ity."'1' The test is believed by clinicians to have special value because of ’’its power to expose the underlying inhibited tendencies which the subject, or patient, is not willing to admit, or can not admit because he is unconscious of them."

2

Beliak has stated, "The Thematic Apperception Test has become one of the two leading projective personality tests in the United States and its use is still increasing."3

The problems

of reliability and validity of the test are well-discussed by Tomkins.^ Description of the Test The test material consisted of five* pictures printed

1* 2* 34. *.

H. A. Murray, Thematic Apperception lest Manual, p. 1. Doc, cit. L. Beliak, 4 Guide to the Interpretation of the Thematic Apperception Test, p. 2. S. S. Tomkins, The Thematic Apperception Test, pp. 4-19. The test, as usually administered, consists of a series of ten or twenty pictures. Preliminary investigation with patients similar to those in the group investigated re­ vealed that reducing the series to five pictures would serve the purpose for which the test is used in this study and would not fatigue or bore the patients, or prolong the testing sessions unduly.

53 on white bristol board, nine and a half by eleven inches in size.

The pictures are of the 194-3 series and were reproduced

by the Harvard University Press.

The pictures used and a brief

objective description of each are: Picture 1 —

A young boy is contemplating a violin which rests on a table in front of him.

Picture 2 —

Country scene: in the foreground is a young woman with books in her hand; in the background a man is working in the fields and an older woman is looking on.

Picture 3BM-*0n the floor against a couch is the huddled form of a boy with his head bowed on his right arm. Picture 4 —

A woman is clutching the shoulders of a man whose face and body are averted as if he were trying to pull away from her.

Picture 5 —

A middle-aged woman is standing on the threshold of a half-opened door looking into a room.1

Administration of the Test The instructions suggested by Murray, with alterations where necessary, were given the patient: This is a story-telling test. I have some pictures here that I am going to show you and for each picture I want you to make up a story. Tell what has happened before and what is happening now. Say what the people are thinking and feeling and how it will come out. You can make up any kind of story you please. Do you understand? Well, then, here is the first picture.. .See how well you can do.

*. 1. 2.

BM refers to the use of this picture with boys or men. All descriptions taken from Murray, 0£. cit., pp. 18-19. Murray, 0£. cit.. p. 4.

54 Questions by the patient were generally referred back with, "Tell any story you please.

It’s your story."

After

finishing the first story the patient was complimented and short­ comings of the story, such as the omission of future outcome, or of under-description of the attitudes of the characters, were pointed out.

After this was done no further instructions were

given, nor was the patient further stimulated.

Liberal use was

made of praise and compliments for anything approaching a full and complete story. No time limit was enforced.

The stories obtained

were recorded verbatim by the investigator.

Also recorded were

lengthy pauses and other evidence of blocking as well as obser­ vations of any clinical behavior that occurred during the test. No inquiry was conducted, although in several instances ques­ tions were asked to clarify points made in the stories. Utilization of the Test As Murray has stated, "The TAT will be found useful in any comprehensive study of personality."1

In clinical prac­

tice the TAT and the Rorschach have been found to yield comple­ mentary information, the Rorschach in the area of personality structure and the TAT in the area of the functioning of that structure.

The TAT, moreover, has been found to yield infor­

mation more closely related to those superficial aspects (as well as to deeper aspects) which most immediately underlie be­ havior.

1.

Murray, o£. cit.. p. 1.

55

In this investigation the TAT was used mainly to provide a means of determining and evaluating the presence of psychological conflict or anxiety and the patient's tech­ nique of handling such conflict.

By means of analysis of the

pre- and post-therapy stories, a measurement of change and the type of change was made.

In addition, the TAT was util­

ized to evaluate the patient's attitude toward his environ­ ment and people in his environment, his attitudes toward him­ self, his adherence or departure from reality, the logic or a-logic of his thinking, and his pattern of needs.

Informa­

tion was also obtained relative to the energy level of the patient and his level of striving or aspiration. A complete account of the technique used in eval­ uating the TAT data will be found in Chapter IV, "Results." The Weiel-Goldstein-Sheerer Color-Form Sorting Test Goldstein and Sheerer, in discussing abstract and concrete behavior, have referred to them as dependant on two corresponding attitudes, and define attitude as "a capacity level of the total personality in a specific plane of activ­ ity."^

They have made the statement that "The normal person

is capable of assuming both, whereas the abnormal individual is confined to but one type of behavior —

the concrete."^

It

was believed by the investigator that an analysis of this type of behavior, from 1- the point of view of measuring change in

1. 2.

K. Goldstein and M. Sheerer, Abstract and Concrete Behavior. p. 2. Ibid.. p. 1.

56 abstract or concrete attitude, and 2- t h e point of v i e w of determining the prlaEry attitude of the patient as part of the total personality picture, would be of value in this study.

As a consequence, one of the tests used by Goldstein and Sheerer, the Weigl-Goldstein-Sheerer Color-Form Sorting Test was administered to the patient group as part of the test battery used in this study. Description of the Test

The test material consisted of twelve plastic geo­ metrical forms, four squares, one and a half by one and a half inches four circles, diameter one and a half inch; and four equilateral triangles, one and a half inches on each side.

In each set of

four equally shaped figures one figure was blue, one green, one red, and one yellow.

The reverse sides of all the figures were

white. Administration of the Test The purpose of this test is to determine whether the patient can sort the different figures according to the cate­ gories of form and color.

Thus, in the course of the test, it

is necessary for the patient to shift his point of view from one category to the other. The figures were arranged on the desk in random order before the patient, colored sides up.

He was told, "Sort the

figures you think belong together," or, "Put those together that go together."

Other wording was also employed until it was

apparent that the patient understood the task expected of him.

57 After he had completed a grouping he was asked, "Why do they belong this way?" or, "Why do those go together?" After the answer, as well as a diagram of the group­ ing, was recorded, the patient was asked, "Now put them to­ gether in another way," or, "Use a different method of putting them together."

The resultant grouping was recorded and the

patient was asked again, "Why do they belong this way?" or, "Why do those go together?"

This answer was recorded.

If the patient did not shift voluntarily from color to form, the figures were turned with the white sides up and the patient was asked to sort them.

If this was completed

successfully according to form, the figures were again turned color sides up and the entire procedure was repeated. Where necessary, the control experiments detailed by Goldstein and Sheerer'1' were performed to clarify the pattern­ ing or the verbalization of the patient. No time limit was Imposed.

All responses and spon­

taneous verbalization were recorded verbatim and all patterns and test results were recorded. Utilization of the Test The Color-Form Sorting Test was utilized in this study to determine the presence or absence of the abstract attitude, which Goldstein and Sheerer have stated to be

T~,

Goldstein and Sheerer,

op

. cit.. pp. 128-129.

58 ...the basis for the following conscious and volitional modes of behavior: 1. To detach our ego from the outerworld or from inner experiences. 2. To assume a mental set. 3» To account for acts to oneself; to verb­ alize the account. 4. To shift reflectively from one aspect of the situation to another. 5. To hold in mind simultaneously various aspects. 6. To grasp the essential of a given whole; to break up a given whole into parts, to isolate and synthesize them. 7. To abstract common properties reflective­ ly; to form hierarchic concepts. 8. To plan ahead ideationally; to assume an attitude towards the 'mere possible' and to think or perform symbolically.1 In addition to a determination of the presence or absence of the abstract attitude in each patient, a before and after-therapy evaluation of a degree of concreteness of each patient was made possible by means of this technique and af­ forded a basis for statistical comparison of the results of the treatment. An account of the technique utilized in analyzing this test will be found in Chapter IV, "Results.” Administration of the Test Battery An attempt was made to test each patient during the week in which treatment was to commence and again in two to four weeks after treatment was completed.^

H 2.

These time intervals

Goldstein and Sheerer, o p . cit.. p. 4. A ten to fourteen day period of varied degrees of confusion usually follows the treatment series.

59 could not be rigidly adhered to in all cases because of several unforeseen postponements of treatment or because patients were about to leave the hospital.

In no instance was a patient tested les;

than sixteen days after the last treatment was administered and in no instance was a patient tested while still overtly confused, as determined by the investigator in interview with the patient and with ward personnel.

A break-down of time intervals during

which the patients were tested before and after therapy is shown below in Tables 9 and 10® TABLE 9 Interval Between Pre-Test and First Treatment No. of Days

No. of Patients

1- 7

12

8-14-

5

15-21

2

22 or more

1 TABLE 10

Interval Between FinalTreatment No. of Days

and Post-Test

No. of Patients

16-18

7

19-21

9

22-2425-27

1 3

As noted previously, the patients were pre-tested in the ward in which they lived while undergoing therapy.

Testing

was carried on in a well-lighted office, adequately private and quiet to ensure good testing conditions.

Post-therapy testing

was accomplished either in the shock ward or, in the event that the patient was by that time in an open ward, in an office in

6o the Psychology Department. Before testing, every effort was made to gain rapport with the patient, to put him at ease, and to explain the reason for the testing.

This was particularly important in the post­

therapy testing, in order to dispel any ideas that the tests would be used to order more shock therapy or would be used to keep the patient in the hospital, or in a closed ward. Testing was usually accomplished in a single session or from two to two and a half hours, well-punctuated with rest periods for cigarettes, drinks of water, or walks around the building with the examiner.

In only a few cases was it nec­

essary to carry testing over from one day to another. The tests of the battery were administered in the order listed on pages 37 & 3 8 .This sequence provided a wellordered succession of, as one patient put it, "talking tests'* with "doing tests."

The Bender-Gestalt Test proved to be an

excellent introduction to the series by reason of its appar­ ent simplicity and because it provided a partial answer to whether the patient would cooperate sufficiently in taking the battery.

No patient who refused the Bender would agree

to take any other tests. Table 11 shows the tests taken by each patient.

61 TABLE 11 Tests Taken By Each Patient Before and After Therapy Patient Bender Word Draw-aColor-Form Number Rorschach Gestalt Association Person TAT Sorting 1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18 19 20

X X X X X X X X X X X X X X X X X X X X

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

X X X X X X X X X X X X X X X X X X X X

0

0 0 0 0 0 0 0 0 0

0 0 0

0 0

0 0 0 0 0

X X X X X X X X X X X X X X X X X X X

0 0 0 0 0 0 0 0

0 0 0 0 0 -

0 0 0 0 0 0

X X X X X X X X X X X X X X X X X X X -

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

X X X X X X X X X X X X X X X X X X X

0 0 0 0 0 0 0 0 0 0 0 0

X X X X X X X X X X X X X

0 0 0 0 0 0 0 0 0 0 0 0 0

-

-

-

0 0 0 0 0 0

X X X X X X

0 0 0 0 0 0

x test taken pre-therapy o test taken post-therapy - did not take test Treatment of the Data To obtain the level of significance of the difference between the pre- and post-therapy data which were quantified, such as the Rorschach composite protocols, the Word-Association times and pathological responses, the Bender pathological indi­ cators, and others, the standard error of the differences be­ tween means was obtained by using the formula^-:

Tl

C. C. Peters and W. R. Van Tfoorhis, Statistical Procedures and their Mathematical Bases, p. 165.

62 S -E -

ml - m2 ■

g A OrTT

, where S d ■ standard

deviation of the differences between paired scores.

This

formula takes into full account the correlation of the preand post-therapy group (since it is in the same group) with­ out making it necessary to compute the correlation. **■ The crit ical ratio was found by dividing the standard deviation of the differences (b d) by the standard error of the difference (S.E.

). ml - m2

The "Distribution of Students’ t"2 was used

to determine the level of significance of the differences obtained. Special scoring techniques were devised for the treatment of the Bender-Gestalt, Word-Association, Draw-aPerson, Thematic Apperception, and Color-Form Sorting Tests. These techniques are described in detail in Chapter IV, "Results," together with the results obtained. Individual clinical personality studies of each pa­ tient are presented in Chapter IV, as well as individual pro­ tocols of the Rorschach and pertinent extracts of other data obtained.

T.

2.

Ibid.. p p . 164-165. presents a derivation of this formula and shows how the correlation is included. Ibid., pp. 488-4-92.

63

Summary The patient group used in this study, the test battery, procedure in testing, and procedure in treating the data were presented in Chapter III. The patients were between the age of nineteen and thirty-four.

They were all male schizophrenics, classified

as simple - one, hebephrenic - eight, catatonic - five, and paranoid - six.

All had completed at least six years of

school, and had a mean educational level of 10.6 years.

Av­

erage estimated duration of illness was 3O.7 months, and all but four of the patients had been previously hospitalized. Seven patients had received no previous shock therapy.

The

number of electroconvulsive treatments administered in the course of therapy dealt with in this study varied from six to twenty-one, with a mean of 15.3 treatments.

All but one

were born in the United States and all but one were white. All of the patients required closed ward supervision at the time of pre-testing. The battery of tests selected to provide a global picture of personality functioning before and after therapy was:

The Bender Gestalt Test, the Rorschach Psychodiagnostic

Test, the Word-Association Test, the Draw-a-Person Test, the first five pictures of the Thematic Apperception Test, and the Weigl-Goldstein-Sheerer Color-Form Sorting Test.

Each

test and its method of administration was fully described. The statistical method used was outlined.

Data,

technique of scoring and evaluating the data, analyses and interpretations are presented in Chapter IV, '•Results."

CHAPTER IV PRESENTATION AND DISCUSSION OP TEST RESULTS In this chapter will be presented the procedure used in scoring and evaluating the data of the test battery5 the re­ sults of the tests will be presented on a group basis, and an individual pre- and post-treatment summary of personality functioning of each patient in the group will be discussed. The data will be presented on a test-by-test basis in order to determine and evaluate functioning, both quantitatively and qualitatively, within each test area.

Following this, the

data will be presented as a constellation, on a patient-bypatient basis, in order to make best use of the battery ap­ proach.

The results which will be presented in this chapter

are preliminary to an analysis of the data, which will be found in CHAPTER V,

“ANALYSIS OF THE DATA.“

The Rorschach Psychodiagnostic Test This section will concern itself with the procedure utilized in scoring the Rorschach Test, a presentation of the quantitative results obtained from the group, pre- and post­ treatment, an individual summary of the performance of each patient pre- and post-treatment, and a qualitative comparison of the performance of each patient on this test, pre- and post-treatment*

65 Scoring Procedure The initial scoring of the Rorschach was divided into three basic components.

The first, Location, deals with the

location of the responses, i*e#, whether the whole blot (W) is utilized in the percept, whether a large, usually perceived detail (D) is seen, whether a smaller but usually perceived de­ tail (d) is seen, or whether a minute portion or detail (Dd) is seen*

Some responses fall midway between the whole response

and the large detail response and these responses, generally interpreted as a tendency toward a whole response, are scored as a cut-off whole (W')«

Among the minute detail (Dd) re­

sponses are included the rare detail (dr) and the tiny edge detail (de),

The second component, Determinants Used, deals

with what aspect of the blot determines seeing the percept as it is seen, i.e., whether it involves form (F), primarily, or poor form (F-), any of the varieties of movement responses (M, FM, m), color (FC, CF, C), shading responses (Fc, K) or com­ binations of any of these#

The third component, Content.

Identifies what the percept is seen as, i.e*, human figures (H), animal figures (A), botanical percepts (Bt), etc* The interpretation of a Rorschach record involves an analysis of the various scoring factors obtained, the re­ lationships between these factors, and a qualitative analysis of the responses given*

The various factors will be discussed

below, together with a brief summary of their meanings and the relationships which are usually considered* The factors scored and their meanings are:

66 R

The total number of responses given during the performance proper* Additional re­ sponses are noted in the Individual Rorschach summaries after the plus (♦) sign* For ex­ ample , an individual who gives eighteen re­ sponses in the performance proper and three additional responses during the inquiry phase of the test has recorded as his number of re­ sponses 18*3« Approximately 30 to 35 R's are given in the normal record, with superior in­ dividuals sometimes giving more* The normal range is approximately between 20 and 75 re­ sponses*

W

A response to the entire blot* W, depending to a great extent on its quality, represents a healthy, Intelligent approach indicating an ability to synthesize and abstract* The ratio of W:M (human movement) responses is usually interpreted as an indication of the strivings or ambition of an individual as compared with his capacities; an excess of W:M beyond the ratio of 2:1 is an indication, if the over-emphasis is on W, that an indivi­ dual has strivings beyond his capacities to fulfill them or, if the over-emphasis is on II, that his capacities are not being utilized at an optimal level*

W*

A response to almost the entire blot. These responses are interpreted in somewhat the same manner as the W responses, but do not represent as high a degree of ability to synthesize and abstract*

D

A response to a large, usually perceived, de­ tail* Generally, approximately 60 per cent of the responses in normal records are D* These responses are an Indication of perceiving stimuli in the way that most people perceive them, and indicate a matter-of-fact perceptual approach, in which the obvious elements of a situation are recognized sufficiently so that the individual does not overlook the more matter-of-fact elements of his environment*

d

A response to a small, yet usually perceived, detail*

Dd dr de

A tiny and unusually perceived detail, or an unusually perceived detail, or a rare combination of details (dr) regardless of the size of the area* The de scoring is applied to a

67 response in a tiny area located at the peri­ phery of one of the blots* These unusual detail responses, when they exist beyond a small percentage of the total responses, may indicate a variety of personality attributes, ranging from anxiety and inability to free one's self of repression and conflicts, to a pedantic, detailistic approach to life situa­ tions. The interpretation of these responses, as with most other single areas of the Rorschach, must be made in combination with the total Rorschach configuration* S

F F# F»#

M

1.

The use of white space in formulating per• cepts to the blots* These responses are usually found in combination with the other location factors, (WS, DS, DDS)* The space responses may represent resistive or opposi­ tional tendencies in the personality insofar as they indicate that the individual utilizes in his perceptual approach a capacity for re­ versing the usually perceived ground-figure relationships* The use of form in determining the response. Form was scored as being of good or adequate quality (F), or poor quality (F-), based on the criteria given by Beck** The percentage of F responses (F$) in a record, if high (be­ yond 50$) may indicate a certain degree of per­ sonality constriction, in which the individual is "form-dominated’1 and is unable to utilize other aspects of the blot in formulating his percepts* Conversely, if a very low ¥ % is found, the indivi­ dual may be functioning in such a way as to neg­ lect the formal or structural aspects of a situa­ tion and may be influenced too highly by external or internal stimuli. F# may be either high or low among schizophrenics* An important relationship utilized in evaluating a total approach to real­ ity was the Ff$, which is the ratio of adequate or good form responses (F) to total form responses* The human movement response, a response in which human beings are perceived in motion or definite postures. These responses usually give some indication of the inner life, fantasy activity, or ideation of the individual* The M response is usually interpreted as a sign of inner ad­ justment where M responses are adequately balanced by the color responses*

S. J. Beck, Rorschach’s Test. I, Basic Processes, pp. 157-190

68 FH

Animal movement responses. These responses are generally Interpreted as movement re­ sponses on a more primitive or Instinctual level than the M responses. The presence of FM to a lesser degree than M is a sign of adjustment.

m

Inanimate movement responses, such as ob­ jects falling, explosions, etc. This re­ sponse is usually interpreted as an indica­ tor of tension within the individual.

FC F/C

This response is a combination of form and color utilized in the percept, with form dominant. This response is usually regarded as a sign of good emotional and social ad­ justment and indicates a capacity to react to the emotional elements of a situation with due regard for the realistic, formal qualities of the situation. Included with the FC responses, but of a somewhat different interpretative significance, are the F/C re­ sponses, which indicate a combination of form and color utilized in responding, with form dominant but with the color arbitrary.

CF C/F

A combination of form and color response with color dominant in the percept. This is a stronger reaction to the emotional elements of a situation, but still somewhat controlled by the formal and structural component. The C/F response indicates that the percept was determined by color and form with the color dominant and the form aspect arbitrary. This response is a less controlled type of response than is the CF. Where, in any record, CF ex­ ceeds FC or is present without FC, it is in­ dicative of some degree of emotional instability or immaturity.

C C indicates a pure color response in which the Cdes percept is determined by the color of the blot Csym and nothing else. Such a response may Indicate extreme instability unless controlled by a com­ bination of various other scoring components, such as M, high F % or FC responses. A pure color response Is rarely given by normal in­ dividuals and is most frequently seen in psychotic records. Cdes and Csym refer to responses which are determined by color used descriptively or by color used in a symbolic manner, respectively. These responses lie between the color form re­ sponse (CF) and the pure C response.

69 Cn

This scoring refers to a color naming re­ sponse, in which, the individual accepts as a percept the naming of colors on a blot* It is important in scoring these responses to ascertain definitely that the individual accepts the color naming as a response and is not merely describing the card, because this response is generally indicative of severe pathology and is frequently found among schizophrenic and organic patients*

Fc cF c

These scorings are affixed to texture responses and generally are interpreted as being indicative of sensitivity and toned-down emo­ tional responsiveness* Depending upon the total test configuration, these responses may suggest tact or caution* The form-dominated texture responses (Fc) are generally regarded as healthier signs than texture-dominated form responses (cF) or pure texture responses (c)*

Fk

This scoring refers to a two-dimensional shading response, such as "X-ray" or "relief map" re­ sponses* This type of response is often found in records of anxious or evasive individuals*

FK KF K

This scoring is used for the vista responses — the use of distance in formulating percepts* These responses frequently relate, when they exist in noticeable quantity, to introspective tendencies in the individual*

FC1 C ’F C*

This scoring is given where the blackness (most frequently) or whiteness is used as a color* Where the black areas are so used, the inter­ pretation is usually made of depressive trends or tendencies*

H (H)

Human responses* At least several H responses in a record would tend to indicate a normal, healthy amount of interest in other individuals in one’s environment* The scoring (H) is given where the human response is modified to the ex­ tent that a human percept is given but this per­ cept is seen as a mythological or hostile figure, (cyclops, devil). H responses should, in a nor­ mal record, be in excess of Hd (human detail) responses* .

A

Animal responses* These are common in all re­ cords and usually include up to approximately 50 per cent of the content categories. Markedly below 50 per cent of A responses is frequently

70 given by individuals whose perception of the blots is very deviant from normal per­ ception; markedly in excess of this figure is suggestive of stereotyped or banal per­ ception and thinking* Hd Ad

These scorings are given to responses which are seen as parts of human beings (Hd) or as parts of animals (Ad)» The ratio of H and A responses to Hd and Ad responses (H*A:Hd*Ad) is generally in favor of the H and A responses in the normal individual* An excess on the Hd and Ad side is usually interpreted as an indi­ cation of immaturity*

At

Anatomy responses* These differ from the human detail responses (Hd) in that Hd designates outer body parts (arms, legs, etc.) while At refers to inner parts or organs (lungs, kidneys, etc.). An emphasis on At responses may indicate hypochondriacal preoccupations or may point in the direction of somatic delusions, if bizarre and unusual*

Other The human, animal and anatomy responses usually comprise the largest content areas of a Rorschach record* The variety of other types of responses give us a key to the breadth of interest, or background, of the individual* A preoccupation with a single response category may indicate an area of conflict, or may indicate a role that an individual has adopted* Other content areas scored ares Abstract responses* These may include moods or emotions, or a connotation, such as brown recalls autumn.

Abs

AAt

—

Animal anatomy responses*

Aobj

—

Animal objects*

Furs, skins, etc*

Alpha —

Alphabet responses, “the letter V."

Arch

—

Architectural responses* Arches, towers, etc

Art

—

Artistic responses*

£1

—

Blood responses*

Bt

—

Botanical* All plant life, trees, etc., are included here*

71 Clo

—

Clothing responses.

Cld

—

Cloud responses.

Fi

—

Fire responses.

Fd

Mi mm

Food responses.

Geo

-- Geographic responses. of maps, place names.

Lds

—

Landscape responses. Usually as­ sociated with vista determinants.

MUS

—

Music responses. usually.

Instruments

Nature responses.

Na Obi

Maps, parts

—

Objects.

These are the most frequently described content areas. Where unusual contents are given as responses, they are spelled out in full* After the scoring was accomplished the ratios and per­ centages commonly utilized to portray the relationships among the various factors were computed,

A summary of these ratios

and percentages, with a brief summary of their meanings and the use to which they are put in interpretation, is discussed below* F%

A s discussed above, the F % is the ratio of

F responses, both good and poor, to the total number of responses in a record* This per cent indicates the extent to which the individual utilizes the formal or structural aspects of the stimulus material. High F % (greater than $ 0 % ) or low F % (less than 3°$) indicates “form domination" to the exclusion of other stimulus material, or insufficient consideration of the formal aspects of the material, respectively. F+%

The proportion of good responses to all re­ sponses containing a form element in a record,

72 excluding only the human movement (M) and color (FC, CF, C) responses* This is an ex­ tremely important measure, one which sheds much light on the Integrity of the individual's reality testing, the extent to which he is able to perceive as others do, and the extent to which he is capable of exercising self-critical ability* As with most other Rorschach measures, maximal is not necessarily optimal; i.e., the individual with an overly high ¥ * % (greater than 8 5 to 90 per cent) may be handicapped in his functioning in that he is unable to "take a chance" and perhaps emerge with new or original percepts* However, a low F«$ (60 per cent or below) usually indicates a very serious per­ sonality disturbance, in which the individual is unable to perceive well enough to test reality effectively. Low F*$ is generally found in cases of schizophrenia. k%

The proportion of all animal content responses to the content of the total number of responses. These animal responses include complete animals, animal details, animal objects and animal ana­ tomical responses* Because animal percepts are those most frequently seen by most people (to the extent of 3 0 to 50 Per cent), this percentage is another index to conformity in thinking and ability to form percepts as others in one's en­ vironment do. A high A % (greater than $0 to 60 per cent) may indicate a stereotyped or banal quality of thinking and perception.

P

A popular response. The popular responses were scored in accordance with the list given by Beck1 . The number of P responses are often in­ dicative of whether or not the individual sees things as other people do, and of conformity of thinking processes* A low number (fewer than five or six) of P responses is sometimes indica­ tive of a schizophrenic or organic condition*

WsM

The proportion of whole responses to human move­ ment responses* As indicated above, the accepted optimal ratio is usually 2 : 1 and marked deviations from this proportion, if the ratio is overweighted on the W side, may indicate that an individual has an amount of drive beyond his capacities to fulfill,

■^S* J. Beck, Rorschach's Test. I, Basic Processes, pp. 191-195.

73 or, If overweighted on the M side, may indi­ cate that the individual's capacities are not being utilized fully* Among pathological populations, this ratio frequently shows marked deviations in either direction* MiC

C bal.

msc

This is the ratio of human movement to the sum of all color responses* It represents the relationship between the functioning of the individual's inner life, ideation and fantasy activity, and the individual's mode of reacting to external stimulating emotion­ al situations. This proportion is commonly utilized to indicate the degree of introver­ sion (emphasis on M side) or extroversion (emphasis on C side)* A conspicuous dis­ proportion in this ratio may indicate that the individual reacts In a manner that inter­ feres with normal personality adjustment, in that he may be heavily over-reacting to in­ ternal stimuli and excluding emotional stimu­ li of the outside world, or vice-versa* Color balance or the ratio that exists in a record among form-color (FC), color-form (CF) and pure color (C) responses. The color bal­ ance of a well-adjusted individual is usually predominated by FC responses, with some CF responses and rare C responses* However, a normal adjusted individual who is somewhat emotionally volatile may show a number of CF responses similar to FC responses. In such a case, the CF responses should be balanced by a number of good M responses or buffer re­ sponses such as shading and good form. Where the weight of the C bal. ratio is heavily on the CF and C side, indications are present that the individual reacts in a somewhat un­ controlled emotional manner, and depending on the distribution of other factors in the re­ cord, may indicate impulsivity and uncontrolled behavior tendencies* This is a secondary MsC ratio, which gives the proportion of movement responses, other than human movement, to shading responses. It is commonly able to indicate a secondary, some­ what deeper, tendency to react in an internally or externally stimulated manner* A discrepancy in balance between the M:C ratio and the msc ratio may indicate that an individual is reacting in one way and yet basically, in terms of per­ sonality structure, has the potentiality for

74 reacting in the opposite way* For example, an individual may give an M:C ratio heavily weighted on the C side, Indicating a high degree of reactivity to emotional stimuli and yet his mjc ratio may indicate that he is an individual who, on a deeper level, may potentially be more prone to react on an in­ ternally-dominated basis* (H*-A:Hd»Ad) As previously described, this is the propor­ tion of complete human and animal responses to human! detail and animal detail responses* Generally, the H and A responses predominate in the normal individual and an excess on the Hd and Ad side is usually interpreted as an indication of immaturity* Some Hd and Ad should be present, however, to indicate that the individual perceives as others do, because there are, in the stimulus material, certain clear-cut, easily observed Hd and Ad responses* R 8-10#

This is the percentage of responses given in the original performance to the last three cards, which are colored cards* It represents, on a quantitative basis, the individual^ re­ activity in a general way to the color elements of the test series, even though he may not react with color responses* This percentage, among normals, is usually 30 to 40, and a figure above or below this may indicate a certain amount of over-stimulation by the color element or a lack of stimulation by this element.

R*T*chrom* This is the initial reaction time of the first response to each chromatic card of the series (II, III, VIII, IX, X), the time elapsing between the presentation of the card and the verbalization of the first response* R*T*achrom* This is the initial reaction time of the first response to each achromatic card of the series (I, IV, V, VI, VII). A percentage of the reaction times to the chroma­ tic and achromatic cards may indicate the presence of blocking or shock to the color or shading ele­ ments of the stimulus material* A delayed reac­ tion time (greater than 30 seconds) may indicate the presence of serious blocking or depression and very rapid reaction time (less than 5 seconds) may indicate a degree of impulsivity, a lack of critical judgment, or simply the fact that an individual is very alert in his perceptions* These

75 facts, of course, must be evaluated in the light of other factors in the test picture* For example, a different interpretation would be made of two individuals who both showed very rapid reaction times, one of whom had a high ¥ + % and the other a very low F*$* Suca:

Apps

Is the sequential use of the locations (W's, D's, d's, dd's and S's) within the responses to one card* Generally, succession relates to the individual's orderliness or degree of systematiza­ tion of thinking, or lack thereof; succession may range from rigid sequences of W , D, d, dd and S in every card, to a thoroughly disorganized and confused sequence in which not more than two cards are responded to in an orderly fashion* Succession is defined as rigid if all ten cards are responded to systematically and none unsys­ tematically; as orderly if between nine and seven cards are responded to systematically and only one to three cards are responded to unsystematical­ ly; as loose if six to three cards are responded to systematically and four to seven responded to unsystematically; and as confused if two to none are responded to systematically and if eight to ten are responded to unsystematically* Unless a sufficient number of responses are given in a record, it is not possible to determine succession for an individual, and his mode of succession is characterized as indeterminate * Succession re­ lates basically to logical thinking and perception in the individual, and pathology is usually sus­ pected if succession is loose or confused* This is the "apperceptive type," and indicates the manner of approach an individual takes to problems* The element of Rorschach reactions which indicates the manner of approach is the choice of locations* The usual individual utilizes the whole card in about one-quarter of the total responses, the usual detail areas (D, d) in about one-half to two-thirds of his responses, and usually not more than ten per cent of the re­ sponses will be located in unusual or tiny detail areas or in the white space* This apperceptive ratio is not of interpretative significance in itself and must be viewed in the light of the quality, for example, of its components* An ap­ perceptive proportion with an unusually high per­ centage of W signifies two vastly different things if, in one case the W is of good form quality and superior integration, and in another the W is com­ posed mainly of usual, popular responses, perhaps

vaguely seen, or W responses which have as their determinants F- qualities. Comparison of Pre- and Post-Treatment Records in Terms of Group Data A composite test summary was derived from the individual Rorschach records of eighteen patients of the study popula­ tion.

Patients #14 and #20 are excluded from this composite

summary because their records contained too few responses to be valid indicators of their personality functioning.

This

composite summary includes the major Rorschach scoring cate­ gories, which are grouped under Location. Determinants. Content and Other. Table

12

on the following page presents a group

comparison of the pre- and post-treatment records.

Most of

the scoring categories are included in the table, but responses which were given very infrequently are omitted. Comparison of the Location scores of the group indicates that only the W and WS score yields results which are signifi­ cantly different.

This difference is significant at greater

than the one per cent level of confidence.

No other Location

scores yield differences which are significant.

The Location

scores were also examined to determine whether significant dif­ ferences exist in the manner of approach to the blots.

The re­

sults show that no significant difference in this respect exists between the pre- and post-treatment results. In the Determinants category it is seen that the only sig­ nificant differences occur in the CF and C/F scores (between the two and five per cent level of confidence) and in the C

TABLE 12 Composite Rorschach Scores, Pre- and Post-Treatment Pre-Treatment Post-Treatment Mean

Determinants F FM FM FCfF/C CF*C/F C2 Fc FK KF*K F C '4-C1 Content H (H) Hd A Ad Obj

Bt At Wat Colors Art Geo Clo

Student's t

6.72 O.78 14.44 1.39 2.50 2.17

4.39 0.94 1 1 .2 8 1.28 1.44 1.39

7.83 5.58 2.33 2.83 0.9 4 2.28 1.22 1.78 0 .2 2 0.22 1.28

6.56 3.83 1.94 2 .2 2 0.94 1.22 0.44 I .67 0.17 0.17 0.61

1 . 2 8 1.55 1.72 1.26 0.39 0.58 0 . 6 1 0 .75 0 1 . 0 6 0.44 O .7 8 0 . 2 5 0 . 1 1 2 1 .8 2 0.05 ----- -0 . 0 5 -------0 . 6 7 O .3 8

1.61 1.06 1.44 7.5§ 1.56 4.56 1.00 0 .7 2 0.56 0.67 0 .6 1 0.50 0.33

1.44 0.50 1.61 5.g3 1.83 2.00 O .67 0.72 0.72 0.50 0.22 0.56 0.56

0.17 0.56 0.17 1.73 O .27 2.56 0.33 0 0.16 0.17 0.39 0.06 0.23

2-33 0.16 3.16 0.11 1.06 O.7 8

0.72

___ *

2.35 0.47 0.99 0.59

3.24 (4 .0 1 ) ___ * 1.34 --------

1.32 ( > . 1 0 ) ------ --

1.37 ( > . 1 0 ) -------- —

-

--------

2.41 (.0 5 -.0 2 ) 3 .1 2 (< .0 1 ) -------- —

-

1.76 (.1 0 )

0.46 0.41 0.57 1.04 0.46 1.21

_ —

- —

--------

-

O

Mean

V •

Location W+Ws W* D+Ds d+ds d .1 0 ) 1.65 ( > . 1 0 ) ------

-

2 . 1 2 (.0 5 )

--------

--------

--------

— ------

--------

--------

--------

— —

------ —

--------

—

inspection ^Figures were omitted where it was apparent upon : that no significant differences existed. Includes all S responses, primary and in combination. ^Includes C, Cdes, Csym and Cn responses.

(continued)

(continued) TABLE 12 Composite Rorschach Scores, Pre- and Post-Treatraent

Category

Pre-Treatment Post-Treatment M e a n S.E. Student's t Mean__________ Mean ____ Diff. D i f f . (& significance)

Other NoTR Rejections No. P R.T.chrom. R.T.achrom.

26.4 0.44 4.39 19.2" 12.3"

19.7 O .7 8 4.06 20.9" 18.4"

6 .7 0 3.6 6 O . 3 4 ---O .33 O .3 8 I.70 5.9 0 6.10 4.47

1 . 7 8 (.1 0 ) --1-37 (>.10)

79 category (at greater than the one per cent level of confidence). A difference in the FC* and C ’ scores was found, although only significant at the ten per cent level of confidence.

No other

significant differences were found among the Determinants category which were significant at the ten per cent level* A comparison of the Content category indicates that, for the most part, no significant differences obtain between the pre- and post-treatment testing.

The only Content category

which differs significantly after treatment is Objects, a difference which is significant at the five per cent level of confidence. In the Other category, the only difference which is seen to be of possible significance is the number of responses, which was found to be significant at the ten per cent level I

of confidence. Comparison of the composite Rorschach summaries, pre- and post-treatment, on a qualitative basis reveals that both es­ sentially represent pictures of personality malfunctioning. In each is seen underproductivity of total responses. average healthy adult produces approximately 30 R.

The

These

patients, somewhat underproductive before treatment, indicate decreased productivity after treatment (26.4 R to 19*7 R )« Reactivity to the stimulus material becomes somewhat more dif­ ficult, as measured by the initial reaction times to the cards. Reaction time to the colored cards increases from 19.2" to 20.9" and from 12.3" to 18.4-" to the uncolored cards. Approach in both composites is overweighted with whole (W)

80 responses at the expense of the usual detail responses (D and d).

After treatment this imbalance is maintained, but not to

the same degree.

The number of W responses decreases from

6.72 to 4*39# a significant difference at the one per cent level of confidence*

Too many tiny detail and white space (S)

responses are seen in both summaries, with a decrease in the post-treatment record. An important trend is seen in the decrease in the number of poor form (F-) responses from

to 3*8 3 . Both of these

figures are higher than they would be for the normal adult, but the post-treatment decrease points in the direction of greater respect for reality and improved reality testing ability. Fantasy and imaginative creativity, as indicated by the M responses, do not change appreciably after treatment (2*33 to I.94) and both are below the three or more M expected from the normal adult.

The average number of animal movement responses

(FM) also does not change markedly, 2.83 to 2.22, and both per­ formances in this area are lower than given by normal adults# Important and statistically significant differences are seen in the area of reaction to affectively stimulating mate­ rial (color reactions).

Comparison indicates no difference be­

tween well-modulated, effective color responses (FC) in either record (0*94 and 0.94) •

No difference in ability to respond ef­

fectively to emotional stimulation is seen.

At the same time,

significant differences exist between the number of egocentric, impulsive (CF) and pathological pure (C) color responses given

81 before and after treatment.

CF responses decrease from 2.28

to 1 .2 2 , a difference significant at between the two and five per cent level of confidence.

C responses decrease from 1.22

to 0.44, a difference significant at below the one per cent level of confidence.

The post-treatment results in this area

indicate that while no increased ability to deal effectively with emotion-producing stimulation is seen, a decline in more grossly pathological, impulsive and explosive responsivity occurs.

The normal adult is expected to give three or more

FC responses, with fewer CF and almost no C responses.

Both

pre- and post-treatment there are disproportionately too many CF and C responses, with too few FC responses, indicating, in addition to impulsiveness and emotional disturbance, emotional immaturity. The post-treatment summary indicates a decrease in anxiety indicators (c, KF, K), but this difference is slight.

There is

a tendency, however, toward a decrease in the C' responses, re­ flecting a decline in dysphoric mood and depression in responses to achromatic areas of the cards.

This difference is minimally

significant at the ten per cent level of confidence. Conformity (ability to see percepts that others do) as re­ flected in the number of popular responses (P) is below the six to eight expected from healthy adults and does not change after treatment to a noticeable extent. 4.06 post-treatment.

P is 4.39 pre-treatment and

82 Pre- and Post-Treatment Records Compared in Terms of Monroe Inspection Technique Scoring The next procedure utilized to determine differences between the performance on the Rorschach before and after treatment is the Monroe Inspection Technique.1

This tech­

nique, which is well-described in the reference given below, yields a total quantitative score based on degree of malad­ justment and a sub-score which indicates degree of adjustment or maladjustment In eight major areas of the Rorschach, time per response and refusals, location, content, form, shading, movement. color and color to movement. The pre- and post-treatment records of the patients in the study were scored and tabulated according to the criteria set forth by Monroe*

A total "adjustment score" (the lower

the score the higher the degree of adjustment) was obtained for each patient*

Monroe states, "A miscellaneous series of

about 100 serious pathological cases on whom we have tried the revised list showed a range in number of entries from 1 5 to 25. . . ”2 The total scores of the patient group, pre- and post­ treatment, are shown in Table

13 on the following page*

With

the exception of one patient (#2 , post-) no patient is signifi­ cantly below this range, although several are above.

The post­

treatment mean score is 18.4 compared to the pre-treatment mean

1. 2*

R. L. Monroe, Prediction of the Adjustment and Academic Performance of College Students by a Modification of the Rorschach Method* Ibid*, p. &6

TABLE 13

Monroe Inspection Scores

Case No. 1 2 3 4 _5 6

Score Pre-Shock 19

l8

7

8 9 10

_ .

11 12 13 If 16 17

_

18 19

Total N M

....

16 . 23 If 12 27 17 34 17 21 27 19 20 22 27 11 13 358

18

Score Post-Shock 17 4 14 18 25 13 ... 25 _ .... 13 27 20 11 If 22 23 26 2f 13..... 21 332 W

18.4 S. E. diff. ■ 1.49 t = 0.97 (P = .34)

Chanee - 2 -14 - 2 - f ♦10 ♦ 1 - 2 - 4 - 7 ♦ 3. _.... -10 -12 ♦ .3 ._ ♦ 3 ♦ 4 - 2 ♦ 2 ♦ 8 ♦21 1.44

84 score of 19*9*

This difference is not statistically signi­

ficant and indicates that, on an over-all level of total per­ formance, no basic change has occurred*

After treatment 8

patients received higher (more poorly adjusted) and 10 patients received lower (less poorly adjusted) scores, revealing incon­ clusive results insofar as the group is concerned. The Monroe Inspection Records were further broken down ac­ cording to areas of disturbance scored for the patient group, pre- and post-treatment. Table

These results are presented below in

14 . The average number of areas of disturbance pre­

treatment is 6*6 ; the average number of areas of disturbance post-treatment is 6 .2 * TABLE 14 Areas of Disturbance on Monroe Inspection, Pre- and Post-Treatment No* of Areas 1 2 3 4 ? 6 7 8 In Table

No. Patients Pre-Treatment 0 0 0 0 2 5 9 2

No. Patients Post-Treatment 0 1 0 0 3 o

5 3

15 is presented a detailed analysis of the

Monroe scoring for each patient, according to the maladjustment indicators in each area of scoring.

Of the eight areas, almost

all patients showed some disturbance in four, form ( 18 patients pre- and 17 patients post-treatment), shading ( 17 patients preand 16 post-), movement ( 18 pre- and 15 post-) and color ( 17 pre-

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99

Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #5 The post-treatment record of this patient gives us a picture of a person who has ncalmed down" considerably, per­ haps to an unhealthy degree*

Certainly, the pre-treatment

record was a chaotic one, disorderly and replete with patho­ logical responses (positional, contamination, personal refer­ ence)*

The post-treatment record is far more controlled (F$,

k % ) hut gives the impression of an individual who has lost

much, especially in the area of emotional living*

Color re­

sponses have disappeared completely, although responsiveness to the last three (colored) cards is almost doubled*

The

post-treatment record is far more dominated by pure form re­ sponses (F$), the majority of which are of poor quality*

While

the pre-treatment record was far more chaotic in a general sense, it also indicated a much wider range of sensitivity and interest, and along with this, a higher reality testing ability*

The post-treatment approach has deteriorated to the

extent that emphasis is completely on the usual detail re­ sponses and almost no integrated (W) responses are given.

The

post-treatment record is significantly different in the marked­ ly decreased number of C' responses, which existed to a con­ siderable extent in the pre-treatment record.

This would ap­

pear to indicate that a considerable amount of depressive (continued)

100

(continued) Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #5 trend which existed before treatment no longer exists to the same extent after treatment.

Inner activity and idea­

tion, which may have been of a somewhat delusional nature, has also declined markedly.

The post-treatment record, in

general, exhibits less chaos, less overtly depressive ten­ dencies, but considerable emotional flattening.

The amount

of control appears to be somewhat greater although there is no question that this patient, after treatment, is still functioning, personality-wise, on a markedly pathological level.

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104

Clinieal Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #7 Both records of this patient are grossly pathological* The greatest change which is seen after treatment is an al­ most complete emotional blunting as exhibited in a complete dropping out of all responses to the chromatic areas of the cards.

This may be due in some part to greater strivings

for control (F$) but it is immediately apparent that this striving is highly unsuccessful (F*$) •

In neither record

does he perceive as others do and in neither record, and to a somewhat lesser extent in the post-treatment one, is he able adequately to test reality in an effective fashion.

The post­

treatment record indicates a much more highly constricted pic­ ture of personality functioning, one in which the range of in­ terests is lessened to a great extent, and one in which his total reactivity in general is lessened.

It is much more of

an effort for him to respond after treatment, as indicated in the lowered number of total responses and in the greatly in­ creased reaction time to the cards, particularly to the color cards.

It is evident that while this individual, after treat­

ment, is seen to be flattened and relatively under-reactive it may be that some favorable change, so to speak, has taken place in that he is no longer responding in the random, grossly inadequate manner that he was before treatment to all sorts of (continued)

105

(continued) Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient # 7 ” emotionally disturbing external stimuli#

It is probable

that the nature of his psychotic illness has changed from one in which physical reactivity and turbulence predominated to one which now, on the whole, consists of a markedly de­ creased ability to perceive as others do, to test reality effectively, but one which no longer is as disturbing to this patient as before treatment#

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Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #10 The most noticeable impression gained from these two test records is the markedly increased responsiveness to the stimulus material in the post-treatment performance*

The

post-treatment record, however, is still a relatively con­ stricted one, dominated to a large extent by responses deter­ mined by pure form considerations.

There is no marked change

in emotional responsivity and color is still used but minimal­ ly in formulating his percepts*

The many indications of anx­

iety which were present in the pre-treatment record still are shown after treatment, (shading responses)#

Some evidence of

depressive trends are still Indicated and still exist in con­ nection with the human movement response, indicating perhaps that this individual still responds to his own ideation and fantasy activity in a dysphoric manner*

His reality testing

has improved to a considerable extent but he still perceives as others do (P) to the same minimal extent that he did before treatment*

Highly significant in the post-treatment record is

the dropping out of most of the marked pathological tendencies exhibited in the pre-treatment record, such as peculiar ver­ balizations, rejection, and the color-naming tendency*

In

his approach there still exists the same considerable over­ emphasis on minute details of the stimulus material, but in (continued)

114

(continued) qilnlcal Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #10 the post-treatment record the emphasis is not as great on poorly perceived whole responses as it was pre-treatment; most of the whole responses that he does give post-treatment, however, are still of poor quality.

In general, it may be

said that the post-treatment test record indicates that this individual’s personality functioning is on a somewhat less pathological level than it was before treatment, but that indications are still present that he conforms neither in his thinking nor in his perceptions to the activity in these areas of most other people.

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Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #15 Most conspicuous In a comparison of these two records is the fact that this individual's emotional responsiveness has become less impulsive and egocentric; his emotional responses (CF), despite a reduction in their absolute number, however, still are not adequately controlled*

His reality testing

ability is on as poor a level as it was before treatment, al­ though he is able to see more of the percepts ordinarily per­ ceived by other individuals*

The record after treatment is

still marked by peculiar behavior, bizarre responses, personal references and perseverative responses*

After treatment he re­

sponds more on an Ideation and fantasy level and indications are present that his ideation and fantasy may still be on a somewhat delusional level*

There are not as many indicators of

anxiety in the post-treatment record as there were before treat­ ment.

This individual still, after treatment, exhibits a con­

siderable amount of thinking disturbance.

He is still operat­

ing on a largely "blot dominated" level, although again not to the same extreme extent as he was before treatment* improvement in ability to relate to other people.

He shows no After treat­

ment he is more conscious of the form aspects of the stimulus material but is still, as was mentioned, unable to cope with them in a realistic way*

In general, this remains the test per­

formance of a highly schizophrenic individual and does not evi­ dence any marked change in basic personality functioning.

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of Patient #16 Pre- and Post-Treatment,

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131

Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #18 This patient's post-treatment record indicates a marked decline in productivity, and he appears to be more blocked and retarded in his functioning.

Reality testing ability,

as measured by the ¥ *%, has declined markedly, although he Is still able to see a limited number of popular percepts seen by most people.

His inner living remains fairly rich,

after treatment, although there is some evidence to indicate that associated with his ideation there comes into evidence some degree of depression.

There is also evidence that

some of his M responses may be highly self-motivated and per­ haps delusional, as is seen by personal reference to Card VII* After treatment there is seen less indication of anxiety and evasive tendency than were seen before treatment.

There are

indications after treatment that this individual is not as highly sensitive or as troubled by his own introspections and free-floating fears and anxieties.

He is not quite as reactive

to emotional stimuli, but when he does react it is in somewhat the same fashion as the pre-treatment record indicates; i.e., in a manner not too well modulated by the demands of the reality situation.

After treatment he becomes much more "blot-

dominated" and no longer responds to the more obvious details (continued)

132

(continued) Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #18 of the stimulus material responded to by most people*

His

range of interests has become somewhat more constricted, al­ though still comparatively rich, and he exhibits much less of an interest in other people in his environment*

The post­

treatment record is still that of an individual whose per­ sonality functioning is markedly disturbed and who is unable to test reality effectively or to react in an emotionally adequate manner to the demands of his environment*

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134

Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #19 The test picture presented by this patient after treat­ ment remains that of a highly over-ideational individual who is unable to perceive reality in an adequate manner*

After

treatment, his reactivity to the emotional aspects of situa­ tions is markedly decreased.

Even though it is decreased,

however, it still represents an individual functioning in this area in an immature, egocentric manner, and when he does react emotionally now this emotional reaction is coupled with a certain degree of tension and anxiety*

His responsivity is

greatly lowered, as is his range of interests*

He still is

able to see a great many of the percepts seen by most other people.

There are still Indications, in the post-treatment

record, of a thinking disturbance, as indicated by the posi­ tional responses both before and after treatment and in the relatively low number of integrated whole responses he is able to give compared with his capabilities.

While before

treatment there was some Indication that he possessed the ability to react, at times, in an adaptive manner in emotionproducing situations, after treatment this ability no longer is seen*

It can be said that after treatment this individual

is more involved and preoccupied with his own ideation and fantasy activity to the exclusion of being receptive to (continued)

135

(continued) Clinical Evaluation of Rorschach Performance. Pre- and PostTreatment. of Patient #19 environmental stimulation than he was before treatment.

At

the same time, there are indications in the record that the over-all functioning that he exhibits after treatment is more adaptive and less disturbing to him.

There is no evi­

dence after treatment of a deep change in his basic per­ sonality functioning.

I I

ft M M fc* •> ft • ft >•i >» o ft d © > •V •d • t=* . . fl d •*PS © 0 f t »*P • -p

d

EH

d • d m

ai • S

CQ

(Patient #14 rejected the TAT pre- and post-therapy.) (- indicates that patient refused this card.)

P

14-3

people taking this test.

An example of a story which was

tabulated as being of personal reference was given by Patient #4 to Card 4, pre-treatment, as follows: “The lust of a m a n whose past caught up with him after many struggles with his Inner self, his wife i s pleading for his sanity while his mother is In the background. Through many trials and. errors in life I will see my way and some d a y find the happiness we always wanted as God m a d e u s one and one alone." The personal references m a d e in the course of creating the stories are tabulated in T a b l e

38

*

It is seen that

12 patients made such references pre-treatment and 9 post­ treatment.

The total number of personal reference stories

decreased slightly after treatment, from 18 to 17* neither of these differences is

Clearly,

seen to be statistically

significant. Interpersonal Interaction The stories were next examined and scored on the basis of whether there occurred evidences of interaction or rela­ tionship between or among the individuals pictured in the stimulus material.

It has been observed in the investigator's

and others* experience that schizophrenic patients tend to iso­ late the pictures of individuals on the Thematic Apperception Test cards and in their stories to the cards to either des­ cribe the individuals represented or to have the individuals behave in a solitary or non-interacting manner.

For this rea­

son, evidences of interpersonal interaction in the stories

TABLE 38 Comparison of Personal References, Interpersonal Interactions, and Unusual Male-Female Identification in the T.A.T. Stories

Personal Reference

Interpersonal Interaction

Unusual Male-Female Identification

Case rie

1MU •

1 2 __3_ 4

rue 0 2

2-3-4 3 3 5

•p 6 7

2->3 1

8

1-2 3 1-2

9 10 11 12 13 1*5

.....

16

2-3-4 1 3

17

18 19 20 Total Cases Total Stories

4

2-3 1-2-3-4 2-3-4 3-4 1 2

12

9

18

17

JTJLrtS

ruoo

rrc

1-4 2 4 1-2-4-5 1-2-4-5 2-4 4 2-4-5

1-2-3-4-5 1-5 4-5_ 3-4-5 2-3-4-5 4

3 3

5 4 4 4-5 2-3-4-5 4 2-4 1 4

1-2-3-4-5

2 3 3 3

3-4-5 .. 3.... 1-3-4-5 4 2-4-5 ... 1-3-4___ 3 _ 3 1-4-5 4-

CM sO +

U> NO rH ♦

IN O < 0 rH O' tN •tt tN 30 CM cr tN cr O O 30 rH CM pH U CM pH nJ- cr *4- cr rH CM CM IN 30 O' IN 30 CM CM • • • • • • • • • • • • • • • CM cr p H to 1—1 pH CM 1—!1—1 rH rH 1—1 CM cr

to cr 1—1 • rH O "4- • • CM cr V 4*

a> a. 1

CM

HD '+ HD CM O HD 30 O '4' IN O HD IN CM 0 0 cr to ■ • • • • • • • • 9 * 9 • • • • • • O c r to 1 — 1 1—IO cr rH CM •4" CM O CM p H 1 —1 HD 1 —1 CM CM p H WH pH p W ft u oxi 0) as u a>HD• pH• 11 CM• N-• IN• O'• to• c r9 to• DO• CM• to• CM• (T9 • IN• IN• > CD o

04 c •P P a s i

O

172 to each stimulus-word which were given by Kent and Rosanoff's thousand normals who responded to these words.

These fre­

quencies were computed on the basis of how many of the thousand normals responded with a given response word; if, hypothetically, two hundred of the thousand responded "apple" to the stimulus-word "fruit" the frequency of "apple" is 200 on the list. The Kent-Rosanoff frequency was determined for each response-word given by each patient by referral to the KentRosanoff word list.

These frequencies were averaged for

each patient, pre- and post-treatment and are presented in Table 50

under "Average Kent-Rosanoff Count."

It is seen that the degree of conformity of responses, which is essentially what the word count measures, does not change significantly after treatment.

The range of average

frequencies inter-patient varies greatly both pre- and post­ treatment j pre-treatment the range is 14-203 and post-treatment it is 2-193.

It is seen on examination of the average fre­

quencies of each patient, that comparatively little change occurs after treatment. Kent-Rosanoff Zero Scores Zero scores were recorded for those response-words which received a frequency rating of zero; that is, were given as responses by none of Kent-Rosanoff1s sample of one thousand normals.

The zero scores, therefore, represent responses

which are most deviant from those given by normal individuals,

173

and practically all are highly individual responses* It is seen in Table

50

, under the heading "Number

Kent-Rosanoff Zero Scores," that all but 2 of the patients who gave scorable records pre-treatment and all but 2 of the patients who gave scorable records post-treatment gave at least one zero frequency score*

The range of such responses

pre-treatment is 0-l8 and post-treatment is 0-21.

No signi­

ficant change post-treatment for the group as a whole is seen to have occurred*

An increase is shown by 7 patients

post-treatment, a decrease by 10 and an equal number preand post-treatment by one* Association Disturbances The individual associations to the stimulus-words were next inspected and scored for evidence of "association dis­ turbances" as described by Rapaport.-*-

The following asso­

ciation disturbances were scored as such:

blocking (offer­

ing no reaction word), object naming, multi-word definitions of the stimulus-words, repetitions or partial repetitions of the .stimulus-word, clang associations where no sense re­ lationship is apparent, phrase completions, close reactions, adjectival associations (man - "good,"

table - "wood"),

self-refefences, perseveration, multi-word reactions excluding definitions, completely unrelated reactions, distant reactions, neologisms, effective reactions (value judgments), alternative

1*

D* Rapaport, Diagnostic Psychological Testing. Vol. II, pp* 40-42.

174 reactions, proper noun reactions, vulgar reactions, and mis-hearing the stimulus-word.

Rapaport states, "....the

greater the accumulation of symptoms of association dis­ turbance in a record, and the more they take the form of disturbances other than those of reaction time, reproduction time, or failure of reproduction, the more likely it is that maladjustment is profound and thought organization impaired.*The total number of association disturbances in the record of each patient, pre- and post-treatment, are shown in Table 50

under the heading, "Association Disturbances."

It is seen that the range of these disturbance scores is wide, both pre- and post-treatment.

The range pre-treatment

is 2 -4 8 5 post-treatment it is 4-54.

Comparing the group re­

sults pre- and post-treatment it is seen that no statistically significant change has occurred. More association disturbances were scored for 10 patients post-treatment, fewer for 6 , and an equal number for 2.

Only

8 patients of the group increased or decreased his number of association disturbances post-treatment by as many as 5*

It

is seen for the group as a whole, and for most of the indivi­ duals in the group, that comparatively little change in the production of association disturbances occurred after treat­ ment. Reproduction Failures After words 1-25 were presented and responded to by the IU

Ibid: p. 5 G

175

patient, he was instructed that the same words were going to be repeated by the examiner; he was to give the same re­ sponses that he did originally*

This aspect of the Word-

Association Test was scored in terms of reproduction failures. Under the heading, "Reproduction Failures Words 1-25," Table

50

, is presented the performance of each patient in

this area of the test*

It is seen that, similar to the re­

sults in association disturbances, an extremely wide range exists for the group, both pre- and post-treatment.

Pre­

treatment the range is 0-22; post-treatment it is 0 - 2 5 (per­ fect performance to complete failure to reproduce a single original response).

Statistically the difference for the

group after treatment is seen to be of no significance. In terms of changes by individual patients in the repro­ duction phase of the test, 9 patients show a decreased number of reproduction failures and 8 patients show an increased num­ ber post-treatment.

After treatment, 7 patients show a change

of 5 or more reproduction failures, 5 lo. the direction of decreased failures and 2 in the direction of increased failures• The Weigl-Goldstein-Sheerer Color-Form Sorting Test1 The description and administration of the Weigl-GoldsteinSheerer Color-Form Sorting Test were presented in CHAPTER III, "PROCEDURE."

Tl

The following sections deal with the scoring

K. Goldstein and M. Sheerer, Abstract and Concrete Be­ havior. pp. 1 1 0 -1 3 0 .

176 and evaluative procedures which were applied to the per­ formance and results of the test, pre- and post-treatmeht. Scoring Procedure and Results The results of the performance of patients on this test are initially qualitative and are dependent on the observa­ tions made by the examiner in the course of testing; no re­ cord of performance is accomplished by the patient in taking this test.

For this reason, and because there is as yet no

commonly accepted scoring procedure for the Color-Form Sorting Test, the investigator improvised a scoring pro­ cedure which is amenable to some degree of quantification. This scoring procedure is described below, Scoring Procedure As was described in CHAPTER III, the objective of this test is to determine whether the patient is capable of sort­ ing or grouping the test figures according to the categories of form or color; whether he is able to explain and verbalize his performance; and whether he can, after the initial group­ ing according to either form or color, shift in his perform­ ance and point of view to the other concept and perform a satisfactory sorting using the new concept*

The scoring pro­

cedure utilized closely follows these considerations*

The

shift from one sorting concept to another can occur spon­ taneously, in response to the examiner’s directions, or can be performed only after some assistance in the form of a demonstration is given by the examiner*

Another informative

177 aspect of the test is the question of whether or not pat­ terning is present in the solutions*

By patterning is

meant the arrangement of the geometrical test forms into patterns in the course of either a color or a form sort# Patterning indicates that there exists in the individual a lesser degree of ability to perform on a completely abstract level, i.e. that he includes, even in his correct solution and shift, some degree of concrete thinking.

The indivi­

dual who completes a color sort, for example, by casually grouping in a loose fashion the similarly colored pieces on different parts of the table, is operating on a higher ab­ stract level than the Individual who completes a color sort yet must arrange all of the pieces of a similar color into a pattern such as a line, a geometrical form or the shape of a thing that he identifies (a house, or tree, or machine part)• The scoring procedure describes the performance of each patient, pre- and post-treatment*

By referring to Table 51

an illustration of the test performance of a patient can be reconstructed*

Patient #1, for example, is seen to have

been able to make an adequate shift, pre-treatment, only after a demonstration trial.

In his performance, he showed

evidence of patterning, indicated by the asterisk. able adequately to explain his performance.

He was

Post-treatment

it can be seen that he was able to shift spontaneously, without the necessity of a demonstration, albeit still with patterning present, and was able to explain his performance

©1

w

d CMo O O

o I—I

cm

I

4

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tN 30 O' O rH CM

-P

as

O En

S spontaneous (initial trial) D demonstration trial (after demonstration) * Patterning present

and Post-Treatment Test, PreSorting on Color-Form Performance

cr
iirko

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30

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rH O' O • • • 0 0 CM V "T * * CM H tN O a • • cr cr V

cr

1 * * rH CM H rH . • • rH rH CM

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a) a p

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female larger. completed drawing

Pre- and Post-Treatment of Size of Drawings Comparison

TABLE

52

(in millimeters)

EH

© rH

X) Ir cr I

Ir

CM

cd

cr

rH

IfNfcO

So

©

P 1

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c r X) Ir

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p

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I

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IN CM

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rH CM rH

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* *■ indicates male larger; - indicates ** Computed only for those patients who both before and after treatment.

cdSo p ■M"

184 post treatment males, the pre- and post-treatment females and the combined size of both male and female pre- and post­ treatment figures, some significant differences emerge. Both the male and female figures, post-treatment, were drawn small­ er in size than they were pre-treatment.

The mean change in

the post-treatment male figures is seen to be -2 1 .1 ; this difference is strongly suggestive, although significant only at the 12 per cent level of confidence.

Of the 19 male fig­

ures drawn pre- and post-treatment, 14 decreased in size and 5 increased in size after treatment. The mean change in size of the female figures posttreatment was -33.7*

This difference is significant at

greater than the one per cent level of confidence (t of 3.42). Of the 19 patients who drew a female both pre- and posttreatment, 14 drew figures smaller in height and 5 drew fig­ ures larger.

The difference in the combined heights of male

and female of each patient after treatment was -58.4, a dif­ ference also significant at greater than the one per cent level of confidence (t of 2*94).

It can be seen that the

significance of this difference is due largely to the signi­ ficant change in height of the female figures drawn posttreatment,

Of the 20 patients whose drawings are included in

the "total change" column, 1 5 drew figures whose combined heights were smaller post-treatment and 5 drew figures whose combined heights were larger post-treatment.

185

First Figure Drawn In the administration of the Draw-a-Person Test, no instructions were given relative to the sex of the first figure drawn.

The instruction was simply, "Draw a person,

any person."

If a question was asked about the sex of the

figure to be drawn the answer given was always, "Any person you want.

It*s up to you."

The first figure drawn, both

pre- and post-treatment, was always noted by the examiner on the drawing. Before treatment 17 of the 19 patients who drew two figures drew the male first; only 2 drew the female first. After treatment 20 patients took the entire test; of these, 18 drew the male figure first and only 2 drew the female first.

No change in first figure drawn was shown by any

patient in the group; every patient who drew a male figure first pre-treatment drew a male figure first post-treatment, and vice versa. It is of interest to note that the only overt homo­ sexual patient in the group was one of the patients who drew the female figure first, pre- and post-treatment.

The other

patient who did this, however, was not a homosexual. Position of Figures Drawn It was noted for each drawing whether the figure was shown in profile or in full-face.

The positions of the

figures are shown on the following page in Table T i,

186 TABLE 53 Comparison of Positions of Figures, Pre- and Post-Treatment Male Pre Profile Full-Face

Female_____ Post 6 14

10 9

Pre

Post

9 9

10 10

It is seen that there is a greater tendency for the male figure to be drawn full-face rather than in profile after treatment than before treatment.

It Is obvious upon in­

spection, however, that no significant differences obtain between position of male figures compared pre- and post-treat­ ment, between position of female figures compared pre- and post-treatment, or between position of male figures compared to female figures both pre- and post-treatment. Hating Scale Comparison The drawing of each patient pre- and post-treatment was rated on a five point scale developed by Swartzlander.'1’ This scale was designed to permit reasonable objectification of evaluations of figure drawings with particular reference to a schizophrenic population.

It was not intended that the

distances between ratings be the same; changes from low to high ratings, however, indicate improvement in terms of an over-all evaluation of the drawings under comparison.

Ratings

were assigned to the figures drawn as follows:

1,

E. E. Swartzlander, The Psychological Effects of Prefrontal Leukotomy on Schizophrenics. (Ph.D, dissertation, New York University, 19457)

187 A rating of £ was assigned to any drawing that included good body propor­ tions (head approximately one-seventh as long as the entire figure, arms and legs well proportioned in relation to the body as a whole, and facial features such as the eyes, ears, nose and mouth propor­ tionate in size to each other and to the head), realistically arranged and clearly differentiated facial features and body parts, and without any bizarre features. A rating of 4 was assigned to any drawing that included good body propor­ tions with minor deviations, slight de­ viations in arrangement and differentia­ tion of facial features and body parts, slight evidences of bizarreness (i.e., skirted woman with naked chest) and some excessively emphasized facial fea­ tures (i.e., heavily shaded eyes, ears, lips, open mouths, et cetera). A rating of 3, was assigned to any drawing that included fair body propor­ tions with some distortion of features (i.e., small arms, pin-point eyes, et cetera), clothing present but inaccu­ rate or insufficient, and considerable over-emphasis on particular features (i.e., busts, trouser fly, et cetera). A rating of 2 was assigned to any drawing that included poor body propor­ tions with crude, poorly attached, or missing body and facial features, malproportioned head, crude or absent sex differentiation, clothing absent or sack­ like, some conspicuous bizarreness present, with an over-all impression of an immature child-like drawing. A rating of 1 was assigned to any drawing with extremely deviant body pro­ portions, grossly distorted, fragmentary, or missing appendages or facial features, transparent or no clothing, sex differ­ entiation absent, and conspicuous bizarre­ ness present to an extreme degree. Draw- . ings of microscopic size were rated as Is. 1*

Ibid., pp. B4 -8 5

188 The rating scale values of each drawing included in this study are presented in Table 54

on the following page.

It is seen, first, that there is a tendency for the male fig­ ure to be rated higher than the female figure, both before and after treatment. tive at between the 5

Pre-treatment the difference is sugges­ 10 per cent level of significance;

post-treatment the difference is suggestive at the 5 Per cent level of significance. Insofar as the changes in over-all rating after-treat­ ment are concerned, it is seen that they are not significant. There is a mean difference after treatment of only 0.15, with a p of .50.

It is seen that after treatment 8 patients

over-all drawing ratings increased, 6 decreased, and 6 re­ mained constant.

It Is also seen that the mean of both the

pre- and post-treatment male drawings remains constant at 2 .7 0 and that the mean of the post-treatment female drawings increases microscopically from 2.28 to 2 .3 2 .

Only 5 post-

treatment male drawings received higher ratings, 4 received lower ratings and 11 ratings were equal.

Of the post-treat­

ment female drawings, 5 received higher ratings, 3 received lower ratings and 10 ratings were equal. It is clearly seen that the semi-objective rating scale results indicate that little or no over-all change has oc­ curred in the drawings of human figures by the patient group after treatment.

Ir rr O rH CM O Xr • • « • O oO

O

•P O

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a a)

ITIS

0O'

HP

CM I r cr

HD

Xr o

CM

MD

CO OH

O EH

0

-p

05

o

O' • 'tf'

0

fh EH 1 ■p w

0 rH 0

o

i

CM

CM

CM CM CM

CM CM

CM

CM cr CM CM cr

CM

0

EH I •d HP a m 0

OJ

0

s

* * * * CM sO o Xr cr rH o O • • • • CM o CM

&

O IS •

o

a
rH IN cr O' O' IN IN to CO IN CM rH i—1 rH i —1 p Ph «H P d

cO 0)

Fh

Eh

I a>

Fh Oh

1 1

* to o to o to to to to o o O O to O o O to to to IN o CM o IN IN CM CM to to o to IN to to to CM IN CN 1 • . • • • • . . • • • . • . . * • • . 1 i— Io CN •sh to to O O' o O' IN rr N CO CO 'O CM rH rH rH rH iH rH rH rH

CO to . CO

O' * co P 01

P

d ©

•rH P

cO

Ph

P

rH CM rr "sh to

to •o CN CO CN O IN X) O' O H CM rr rH H iH rH rH 1— 1 rH i — 1 t— 1 rH CM

H H d / vi J) J xi © © d a

9s

*2 p

CO

* Extrapolated beyond Goodenough1s norms* ** Computed only for those patients who completed drawing both before and after treatment.

Scoring

of Draw-a-Person

x2j a a> O pH

Goodenough

TABLE

55

*H ft

192 of the differences obtained, however, is statistically significant. Comparing the pre- and post-treatment scores of the male figures drawn, it is seen that there is a mean increase of 0.34, a difference which is not significant.

The mean

score of the post-treatment female figures, however, shows an increase of 0.67*

This difference is significant at the

one per cent level of confidence.

After treatment, 10 male

figures receive increased scores, 7 receive a decreased score and 2 are equal.

Among the female figures, post­

treatment, 12 receive an increased score, 5 receive a de­ creased score, and 1 is the same as pre-treatment. The total change (male and female combined) in Goodenough scores post-treatment is seen to be an increase of O.9 7 .

The difference which obtains between the pre- and

post-treatment combined scores is significant at the 5 Per cent level of confidence.

This difference in the combined

score post-treatment is seen to be due largely to the sig­ nificant difference in the female drawings.

The combined

score, post-treatment, shows an increase in 12 cases and a decrease in 7 * Judgments of the Figures Drawn The figure drawings of each patient were presented to a committee of three psychologists-*- who were instructed to rate Tl

Appreciation is expressed to Dr. E. E. Swartzlander, Dr. M. Singer and Mr. Gerald Rosenbaum, who served as judges in this phase of the Draw-a-Person Test evaluation.

193

the drawings according to the following generalized criter­ ia:

reality of body proportions, realistic arrangement and

clarity of differentiation of facial features and body parts, absence of bizarre features, absence of emphasis or over­ emphasis on any body part and presence and appropriateness of clothing. The identification of the drawings, as to name of the patient and whether it was produced pre- or post-treatment, was concealed from the committee of raters.

The drawings

were presented simultaneously to the raters in an order de­ termined by using a table of random numbers*

The raters were

presented with the four drawings of each patient (male and female pre- and male and female post-treatment) at the same time and were asked

1 - to indicate their choice of the

'•better1' drawing (according to the criteria above) between the two male figures, 2 - to indicate their choice of "better" drawing between the two female figures, and 3 - to indicate their choice of the "best" drawing of the four produced by each patient* Among the male drawings, the judges indicated preference for the post-treatment figures of 14 patients and for the pre-treatment figures of 5 patients.

Of the 14 preferences

for the post-treatment males, 10 choices were unanimous and 4 a majority opinion.

Of the 5 preferences for the pre­

treatment male, 4 were unanimous and 1 was a majority opin­ ion. Among the female drawings, 11 of the post-treatment

194

-

figures were selected as "better," compared to 7 pre-treat­ ment figures so selected.

In contrast to the comparative

unanimity of choice among the male drawings, the female choices resulted in 5 unanimous and 6 majority opinions for the 11 post-treatment females preferred, and in 3 unanimous and 4 majority opinions for the 7 pre-treatment female fig­ ures preferred. In comparing the "best of four" evaluations, 13 of the post-treatment drawings were so judged and 4 of the pretreatment.

In the 2 cases there were split decisions, each

judge having selected a different drawing.

It is of interest

to note that of the "best of four" evaluations, 14 male fig­ ures were chosen compared to but 3 female figures. On the following pages, some illustrative reproductions of pre- and post-treatment drawings are presented.

I

C*M * 1 — I'M-TKMtMat Mai* (l) I

.jii

FIGURE I Pre-Treatment Male Drawing of Patient #1

1

/ I

■

Cm * I 1 — Post-Treetaent Male (1)

^

'i.

FIGURE II Post-Treatment Male Drawing of Patient #1

M - ':

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FIGURE III Pre-Treatment Male Drawing of Patient #5

FIGURE IV Post-Treatment Male Drawing of Patient #5

if'

5 —

Pr»-Tr»«t»»nt Fnala (2)1

FIGURE V Pre-Treatment Female Drawing of Patient #5

FIGURE VI Post-Treatment Female Drawing of Patient #5

CtH # lj —

FIGURE VII Pre-Treatment Male Drawing of Patient #15

Pr*-Tri*t»»nt Mala (1)

FIGURE VIII Post-Treatment Male Drawing of Patient #15

»Jr?

,1

I

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FIGURE IX Pre-Treatment Female Drawing of Patient #15

FIGURE X Post-Treatment Female Drawing of Patient #15

205 The Bender-Gestalt Test The Bender-Gestalt Test was administered to all 20 pa­ tients of the group, pre- and post-treatment.

The follow­

ing sections explain the scoring procedures which were uti­ lized and present the results which were obtained.

The des­

cription and administration of the test were described in Chapter III, "PROCEDURE•H Scoring Procedures and Results This test is difficult to evaluate objectively because of the nature of the productions obtained, i.e. the test re­ cords.

Three major scoring techniques were utilized, all of

which are clinical in approach; a comparison of pre- and post-treatment records in terms of pathological indicators, a comparison of ratings obtained on a scale devised by the Investigator and a comparison of the evaluations made by a committee of psychologist-judges.

These scorings and evalu­

ations and the results which were obtained through their use are described in the sections below. Comparison of Pathological Indicators, Pre- and Post-Treatment Bender^- and Hutt^, in their clinical use of the BenderGestalt Test with many varieties of psychopathological dis­ orders, found certain characteristics prevalent among

1* 2*

L. Bender. A Visual Motor Gestalt Test and its Clinical Use, pp. 98-106 M. L. Hutt, 4 Tentative Guide for the Admini st rat ion and Interpretation of the Bender Gestalt Test

206 schizophrenic patients.

As Hutt states, "Manifestations

will vary markedly In accordance with the type and severity of the disturbance." 1

Some of the manifestations of schizo­

phrenic disorder found by Hutt were utilized as a means of scoring the test and are referred to below as "pathological indicators." Scoring of Pathological Indicators The Bender-Gestalt record of each patient, pre- and post-treatment was examined and scored for the following pathological indicators: 1.

Rotation - Rotation is defined as any change in the

position of the axis of the figure.

The figure may be part­

ly or fully rotated as a whole or in piece-meal fashion.

It

connotes a distortion of reality and is evidence of bizarre perception.

It almost never occurs except in the case of

psychosis* Regression - Regression is the conversion of mature concepts into more primitive forms. are:

Examples of regression

transformation of dots into loops, loops into scribbles,

diamonds into squares or circles and, less definitely, dots and loops into dashes*

Regression is a manifestation of

deterioration. 3.

Dissociation - This refers to the splitting or sep­

aration of the figures.

1.

Ibid., p. 11

Bender states, "In the visual motor

20 7

gestalt function in schizophrenia, therefore, we find the fundamental disturbance of splitting expressing itself by a dissociation in the gestalt figures which often distorts them fundamentally so that the gestalt principles are split." 1 4.

Destruction of Gestalt - This is self-explanatory

and refers to a complete mis-perception or mis-reproduction of the basic relationship of the stimulus configuration. 5*

Confused Order - "A confused order Is one in which

the impression is definitely a chaotic one.

The drawings

are scrambled all over the page (or pages).

Often they over­

lap or collide.

It occurs most characteristically in psy­

chotic records, less frequently in the records of organic brain damage 6.

Gross Misuse of Space - This refers to great reduc­

tion of expansion of the size of figures or to the extensive use of white space (space left blank between drawings).

This

frequently relates to aggressive (large figures, over-use of space) or to withdrawing (small figures, under-use of space) characteristics of the patient. 7*

Condensation - Condensation refers to simplification

of the figures and*Ls the result of either immature emotional development or disturbed emotional functioning."3 Results in Terms of Presence of Pathological Indicators, Pre- and Post-Treatment

TZ

2. 3*

Bender, o p . cit.. p. 106 Hutt, oj)• cit.. p. 8 Ibid., p. 9

208 The results of scoring each record, pre- and posttreatment, in terms of presence of the pathological indica­ tors described, are presented in Table page*

$6

on the following

It is seen that the signs which occurred most frequent­

ly were regression, destruction of gestalt, gross misuse of space and condensation.

Relatively fewer patients displayed

the signs of rotation, dissociation or confused order.

The

only sign in which there occurred a change after treatment which is of statistical significance was destruction of ges­ talt, which was scored for the records of 11 patients pre­ treatment and 4 records post-treatment.

This difference is

significant at the 1 per cent level of confidence (mean difference 0 * 3 $ , S.E.diff. 0*11, t * 3*18).

All but two of

the other pathological indicator scores show a slight de­ crease post-treatment which is suggestive.

Regression de­

creases by 1 , dissociation by 3 , confused order by 3 and gross misuse of space by 1.

Rotation indicators show no change after

treatment and there is an increase by 2 in the number of pav

tients who produced records which were scored for condensation post-treatment. The total numbers of pathological indicators for each patient was obtained pre- and post-treatment and are pre­ sented in Table 57

•

*t

seen that only one patient com­

pleted a Bender-Gestalt record without at least one pathologi­ cal indicator pre-treatment and that 3

so post-treatment.

Comparing the pre- and post-treatment production of pathologi­ cal indicators, it is seen that the number decreases in the

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TABLE 57 Comparison of Areas of Disturbance in Bender-Gestalt Records Patient Number 1 2 _

3 _ 4 5

6

Pre-Treatment 2 1 2 4 0 5

.. .

2 1

7 8 _ 9 _ 10

15 16 17

3 1 5 * 4 5 4 4 3

ib 19

1 2

11 12 13 14

Difference

3..... 2

♦1 ♦1

1

-1

3

-1

1

*1

3 3

♦1

-2

2 1 1

♦1

-2 0 -3 -1

2 4 3

-1 ♦1 -1

0

3 4 2

0 -1 -1 -2

0 0

•

t = 2.17 (P = .05)

u>

S.E. diff. = 0.30

1

0 2 .2 0

0

DO • C\J

20 Mean

__

............... .

Post-Treatment

211 records of 12 patients post-treatment, and remains the same in the records of 2 patients.

The mean difference in the

production of these indicators for the group post-treatment is -0,65, a difference which is significant at the 5 Per cent level of confidence* Rating Scale Comparison, Pre- and Post-Treatment The over-all Bender-Gestalt performances were assigned ratings according to the following scale, drawn up by the in­ vestigator*

The ratings assigned were not intended to be

completely discrete nor is it assumed that the differences between ratings are of equal value.

The ratings in and of

themselves possess no known objective validity.

They were

used only to quantify in some manner the qualitative evalua­ tion of the records in order to be able to measure differences that resulted after treatment* The Rating Scale Criteria Ratings were assigned according to the following criteria: Score 5 - Size of reproductions approximately ap­ proximately those of test figures; no destruction of test configurations; ade­ quate auto-criticism; placement follows logical and systematic order; no patho­ logical indicators present; limited sketching and erasures; little varia­ bility in total test record; no pres­ sure difficulties* Score 4 - Size of reproductions varies from test "" figures by not greater than plus or minus one-fourth; no destruction of test configurations; adequate auto­ criticism; placement less logical and

212 systematic; no pathological in­ dicators; limited sketching and era­ sures; greater variability; some pressure difficulties. Score 3. - Size of reproductions varies from test figures by plus or minus onefourth to plus or minus one-half; no destruction of test configurations; lessened auto-criticism; placement follows loose, less systematic order; presence of one or two pathological indicators; greater amount of sketch­ ing and erasures; greater variability; greater pressure difficulties. Score 2 - Extreme deviations in size, greater than plus or minus one-half that of test figures; destruction of one or two test configurations; serious lack of auto-criticism; placement disorder­ ly, unsystematic — figures may run together; presence of more than two pathological indicators; marked sketching, overlining or erasures; marked variability; marked pressure difficulty — tremendous darkness or very faint reproductions. Score 1 - More extreme deviations in size; de­ struction of more than two test con­ figurations; complete lack of autocriticism; placement markedly con­ fused; presence of more than two pa­ thological indicators; great varia­ bility; difficult for observer to re­ concile reproductions with test figures. Results of Ratings of Bender Reproductions, Pre- and Post-Treatment Results of rating the Bender-Gestalt reproductions of each patient, pre- and post-treatment, are given in Table YS. It is seen that no patient in the group received the maximal rating of £ pre-treatment and that the record of only one pa tient (number 18) reached this level post-treatment.

The

TABLE 58 Comparison of Bender-Gestalt Ratings, Pre- and Post-Treatment Patient

Humber_______ Pre-Treatment 1 1 ________ 2 .A 2 4 4 i 1 6 2 7 8 V 2 9 10 1 2 li 12 _ 2 2 11 14 1 1 15. 16 2 2 1Z 18 19 20 2 Total Mean S.E.diff. t

46 2 .1 0

Post-Treatment_____Difference 0 1 0 0 0 2 -1 V 1 0 0 2 2 -1 ... >1 0 0 2 0 2 ♦1 1............ . 0 1 2 ♦1 0 2 ♦1 +2 5 0 ♦1 ..... .. _ ^ 2.55

♦5 0.25 0.14 1.79 .1 0

214 mean rating of the pre-treatment records is 2 .3 0 ; of the post-treatment records it is 2.55*

Both means are within

the pathological range, according to the criteria of the rating scale. The mean difference between the pre- and post-treatment ratings is ♦0.25*

This difference is suggestive only, al­

though statistically it is significant at the 10 per cent level of confidence, because of the 20 patients whose Bender records were rated, only 9 show change in either direction; 7 showing an increase post-treatment, and 2 showing a de­ crease.

For the greatest part, the Bender ratings remain

fairly constant post-treatment, only one record being rated by as much as 2 points higher; the other records which show a difference post-treatment differ by only one point each# Ratings by Judges The same judges* who assisted in the evaluation of the Draw-a-Person Test served as a committee of raters of the Bender-Gestalt Test. Rating Method The Bender-Gestalt records of each patient were altered temporarily to conceal the name of the patient and the identi­ fication of the record as either a pre- or post-treatment re­ cord.

The judges were given as a criterion the Bender-Gestalt

design cards and the Instruction to consider only the *Dr. E. £• Swartzlander, Dr. M. Singer and Mr. G. Rosenbaum, clinical psychologists.

215

similarity to or the difference from the Bender records of the design cards.

The pre- and post-treatment records were

presented in a random order for each patient, the order being derived from a table of random numbers. The Bender reproductions of each patient in the group were rated twice by each judge.

In the first series of judg­

ments, instructions were given to select the "better" design of each pair reproduced.

Thus, a series of judgments on a

design-by-design basis was obtained.

After an interval of

an hour, the Bender records were re-rated, this time in re­ sponse to instructions to rate the records (select the "bet­ ter" record) on a total-record basis, with emphasis on the over-all comparison of each pair of records. Results of Ratings by Judges The results of the ratings by judges on the design-bydesign comparisons indicate that there is a clear-cut pre­ ference for the post-treatment records, as shown in the fol­ lowing table. TABLE

59

Preferences of Judges on the Design-by-Design Rating Extent of Majority

Pre-Treatment Preferences 1 1 2 4

Post-Treatment Preferences 3 2 5 2

♦The record of one patient (#7) comprised only 6 reproductions. His post-treatment designs were preferred, 4-2.

216 It is seen that, on the design-by-design ratings by the judges, there was a tendency for more of the post-treatment records which were rated as •'better1' (1 6 ) to be so rated by a larger majority than were the pre-treatment records which were preferred (4). The ratings made by the judges on an over-all compari­ son of the Bender records show results which are essentially similar to those obtained in the design-by-design comparison, The over-all preferences of the judges are indicated in the following table* TABLE

60

Preferences of Judges on the Over-all Rating Record Preferred Pre-Treatment Post-Treatment

Unanimous Opinion

Majority (2-1) Opinion

1 13. 14

4 2

-

Total 5 15 20

Z

It is seen that by this method of judgment of* the Bender reproductions, 15 of the post-treatment performances were evaluated as "better" by the judges, while 5 pre-treatment records were so evaluated.

the

It is also seen

that there was comparatively more unanimity of opinion re­ garding the post-treatment records preferred than there was regarding the pre-treatment records preferred. Reproductions of the pre- and post-treatment BenderGestalt records of several „patients are presented on the /«

following pages for illustrative purposes*

FIGURE XI Pre-Treatment Bender Designs of Patient #12

FIGURE XII Post-Treatment Bender Designs of Patient #12

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FIGURE XIII Pre-Treatment Bender Designs of Patient #14

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FIGURE XIV Post-Treatment Bender Designs of Patient #14-

Case # 15

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o 0 o 0 0 0 oo 0 0 O O 0o o o 0 0 0 oo o o o o a o o c o o

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figure

XV

.Treatment Bender Designs of Patient #15

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FIGURE XVI Post-Treatment Bender Designs of Patient #15

223

Stinwia-ry In this chapter the results obtained through the use of the test battery were presented as measurements of the changes in personality functioning of electroconvulsivetreated schizophrenics.

Also presented were the various

techniques utilized in scoring and evaluating the components of the test battery. The Rorschach Psychodiagnostic Test was scored, first, according to the method of Klopfer and Kelly.

Comparison of

the group scores revealed the following differences post­ treatment.

In the location category only the W and WS score

showed a significant (at the one per cent level) decrease. Among the determinants, significant differences in CF (be­ tween the two and five per cent level) and C (greater than the one per cent level) were found. the direction of a decrease.

These changes were In

No significant differences of

importance were found to obtain in the content categories. The over-all decrease in the total number of responses de­ creased in a suggestive manner; this change was significant at the ten per cent level of confidence. On a qualitative basis it was found that both composite Rorschach protocols, pre- and post-treatment, essentially re­ presented pictures of personality malfunctioning.

Under­

productivity, difficulty in reactivity as measured by the Initial reaction time to the cards, approach overweighted with whole responses (generally poor or vague) at the ex­ pense of the usual detail responses, poor form, low

224 imaginative creativity and acceptable fantasy activity and overweight on more immature, emotionally disturbed responses to color stimulation were all seen pre- and post-treatment. Some changes in the direction of better adjustment were seen in the Rorschach records post-treatment (less impulsiveness, less poor reality testing, fewer anxiety and depression in­ dicators) but the impression of the group's Rorschach proto­ cols as a whole after treatment was that they reflected seri­ ous personality maladjustment. A "sign" approach (Monroe Inspection Technique) was also utilized in evaluating the Rorschach performances.

It was

seen that there were slight tendencies in the direction of improvement post-treatment but that none of these changes was statistically significant. Individual Rorschach summaries and interpretations were presented for each patient, pre- and post-treatment. The Thematic Apperception Test was scored and inter­ preted on the basis of the following categories:

adequacy

of the stories, responsiveness to the stimulus material, per­ sonal references, interpersonal interaction and unusual malefemale Identification.

In addition, the test was scored ac­

cording to a dynamic analysis of the content. It was seen that there was a slight increase (not signi­ ficant statistically) in terms of number of adequate stories recounted.

An Increased productivity, significant at the

one per cent level, was shown.

More of the stories told

post-treatment involved Interpersonal interaction themes. No

225 differences in unusual male-female identification occurred post-treatment. The dynamic scoring and analysis of the Thematic Apper­ ception Test indicated that in terms of need patterns, ef­ fect of the environment, reaction of the individual to the environment, adequacy of the principal character and endings of the stories, some tendencies toward better adjustment are seen after-treatment, although not in a statistically signi­ ficant manner.

The group, both pre- and post-treatment,

showed relatively larger need for belonging, tended to see the environment as generally frustrating and harmful to the individual, and tended to recount relatively more stories in which the individual was described as reacting in neurotic patterns showing insufficiency and frustration than stories in which the individual was self-sufficient and emotionally stable*

More of the principal characters were seen as gen­

erally inadequate than were seen as adequate, although there was a relatively greater Increase post-treatment in the stories in which the principal character was adequate.

More

of the patients gave stories which ended unsatisfactorily for the individual both pre- and post-treatment.

No signi­

ficant changes occurred in this area. The Word-Association Test was scored for reaction time, Kent-Rosanoff frequency count, Kent-Rosanoff zero scores, number of association disturbances and reproduction failures* Reaction time increased significantly (one per cent level of confidence) after treatment.

Conformity of responses, in

226

terms of the Kent-Rosanoff frequency count and number of zero scores did not change significantly after treatment; nor did the number of association disturbances, which was relatively high pre-treatment*

The number of reproduction failures,

which for the group as a whole was also relatively high pre­ treatment, showed no change post-treatment that was statis­ tically significant. The Weigl-Goldstein-Sheerer Color-Form Sorting Test was scored in terms of ability to shift concepts and to verbalize the rationale of performance*

Scoring was also carried out

for presence of patterning behavior*

A simple rating scale

was constructed to quantify the evaluation of performance* Results of these scoring procedures indicated that the group as a whole, pre- and post-treatment, demonstrated an impair­ ment of abstract ability, and that treatment resulted in no changes of behavior in this test which were statistically significant* The Draw-a-Person Test was scored for size of figures drawn, first (male or female) figure drawn, and position of figures drawn.

A rating scale comparison, Goodenough Test

score comparison, and a comparison of the preferences of a committee of judges were made on the pre- and post-treatment drawings obtained.

Differences in the heights of the post­

treatment drawings were obtained which were significant at the one per cent level.

The first figure drawn by all but

2 patients, both pre- and post-treatment, Was the male. There was no change after treatment in any patient of his

227 first figure drawn.

No significant change in the position

(profile or full-face) of the drawings was seen after treat­ ment.

Although rating scale evaluations of the drawings re­

vealed no significant differences after treatment, a com­ mittee of psychologist-judges who used more generalized cri­ teria for evaluating the drawings rated the post-treatment productions consistently higher than the pre-treatment re­ sults of the Draw-a-Person Test.

When scored according to

the criteria of the Goodenough Test the drawings showed im­ provement post-treatment in the drawings of the female fig­ ure which was significant at the one per cent level of confidence* The scoring and results of the Bender-Gestalt Test were presented.

It was seen that the presence of pathological

Indicators in the post-treatment records tended to diminish, although the change in the presence of only one, destruction of gestalt, changed significantly at the one per cent level. Results of a detailed rating scale evaluation of the records tended to indicate no change after treatment, but on a more inspectional, less detailed basis, a committee of judges who expressed preferences for each of an unidentified pair of re­ cords were consistent in their evaluation of the post-treat­ ment Bender reproductions as '•better** than the pre-treatment records.

j

CHAPTER V ANALYSIS OF THE DATA In this chapter the group data will be analyzed for changes in personality functioning.

Emphasis will be placed

upon the psychological significance and meaning of the test battery results obtained pre- and post-treatment.

In these

same terms the data obtained from each patient, on an indi­ vidual basis, will be analyzed.

There will also be presented

a comparison of the pre- and post-treatment test results with respect to age, duration of illness, diagnostic sub-category (hebephrenic, catatonic, paranoid), and with respect to whether the present series of electroconvulsive treatments was the first the patient had received or whether he had re­ ceived treatments prior to the present series. The Rorschach Data Analyzed The following analysis of the Rorschach data is depend­ ent upon the statistical comparison of the pre- and post­ treatment Rorschach protocols and scorings presented in Chapter IV, also upon the qualitative comparison of inter­ pretations of the records of the individual patients which were presented. The data, both from a comparison of the group scores and from a comparison of the ratings obtained through the

229 use of the Monroe Inspection Technique, indicate that pre­ treatment the group was extremely maladjusted in terms of personality functioning. tional response was poor.

Control and effectiveness of emo­ The amount of impulsivity, emo­

tional immaturity and emotional regression was high.

Poor

ability to form affective relationships with other individ­ uals in the environment predominated in the area of inter­ personal relationships.

A considerable amount of anxiety

was present and was expressed in a manner that indicated that its presence was poorly controlled and handled by patients in the group.

Reality-testing ability and contact with reality

were markedly impaired.

Conformity in thinking was minimal.

Evidences of adequate judgment and auto-critical ability were largely lacking.

There was seen little drive toward produc­

tivity and creativity and what originality of thinking was present was generally a bizarre, unrealistic type. From the statistical data, one highly important change post-treatment can be inferred.

It was seen that a decrease

in the CF responses occurred which was significant at the .05-.02 level and that a decrease in the pure color or C re­ sponses occurred which was significant at less than the .0 1 level.

These responses, as was discussed in the section on

Rorschach scoring, Chapter IV, relate to impulsivity, im­ maturity, egocentricity and emotional maturity.

Their de­

crease after treatment, coupled with no change in the more adaptive form of color response, the FC or form-dominated color response, indicates that, in the area of reactivity to

230 emotion-producing situations, these patients have toned-down and are no longer apt to be as explosive, regressed and un­ controlled as they were before treatment.

The lack of in­

crease in the more adaptive color responses indicates that no greater ability to cope with emotion- or affect-producing situations is present; after treatment this type of stimula­ tion is only less responded-to and less upsetting to the pa­ tients.

It is as though an individual who constantly was at

odds with his neighbors learned to adjust by ignoring them or dealing with them as little as possible, instead of learn­ ing to get along with them.

In this area of control and ef­

fectiveness of emotional response no positive changes in per­ sonality functioning have occurred, but the decrease of nega­ tive factors such as impulsiveness, explosiveness and regres­ sive indicators is of great significance. This decrease of negative factors, however, was seen to be insufficient to indicate that the group changed significant­ ly in the emotional imbalance which it showed pre-treatment. The disproportion changed from 0 .94-5 2.28:1.22 to 0.94:1.22:0.44 (FCsCFsC) but the post-treatment ratio was still seen to be overweighted with the less desirable CF and C responses, in­ dicating that the group’s personality functioning was still defective in the area of control and effectiveness of emotion­ al response. The decrease in the average number of W responses, signi­ ficant at the .0 1 level, which was the only significant change in the location factors, indicates that less ambition

231 and "push" were present post-treatment.

This decrease was

accompanied by a suggestive change in the approach of the patients to the stimulus material after treatment.

The

heavy emphasis on whole responses pre-treatment shifted clos­ er to a usual emphasis on more-readily perceived and commonsense elements of the stimulus situations.

This change in

approach,taken together with a suggestive decrease in poor form (F-) responses from a mean of 5*56 to a mean of 3 .8 3 , would appear to indicate that the group, after treatment, gained in reality testing ability and in improved contact with reality, although it is necessary to point out that the production of poor form responses after treatment is still typical of personality malfunctioning in terms of adequate contact with reality.

There was no statistically significant

change in conformity as measured by the popular (P) response; the mean numbers of P before and after treatment, 4.39 4.06, were below the minimum expected of a normal adult. Creative fantasy activity, as inferred from the human movement responses (M), was seen to decline slightly, al­ though not significantly, after treatment from 2 .3 3

1*94;

while the animal movement responses (FM), indicators of more immature and primitive fantasy activity, decrease from 2 .8 3 to 2 .2 2 , there is maintained, after treatment, the imbalance between the M and FM responses in favor of the FM, which in­ dicates that immaturity of personality functioning is still present for the group as a whole. Indications were found, more suggestive than

232 statistically significant, that anxiety was less in evidence and better controlled after treatment.

Indicators of de­

pressive tendencies, especially the dysphoric C 1 responses, were reduced after treatment from 1 .2 8 to 0.61, a change significant at the .10 level.

Both of these findings tend

to corroborate what Pacella, Piotrowski and Lewis have found. "If anxiety and depression are secondary results of the psy­ chosis, then shock therapy removes these secondary effects of schizophrenia.”-*- Less hostility and negativism, as meas­ ured by decrease in the space (S) and hostile human (H) re­ sponses, were shown after treatment.

S responses changed

from 2 . 1 7 to 1.39 post-treatment, a difference significant almost at the .10 level; (H) responses declined from 1.06 to 0.5 0 , a difference significant at the same level. Qualitatively and in terms of a decrease in the number of responses from 26.4 to 19»7> significant at the .10 level, the patients post-treatment tended to be more concise and less rambling. Summarizing the group results of the pre- and post­ treatment Rorschach comparison it may be said that after treatment the patients were better controlled, less impulsive and less explosive emotionally.

They were less anxious and

depressed, in better contact with reality, and showed fewer signs of negativism and hostility.

1^

Despite these changes,

B. L. Pacella, Z. Piotrowski, N. D. C. Lewis, ’’The Ef­ fects of Electric Convulsive Therapy on Certain Person­ ality Traits in Psychiatric Patients,” p. 90

233

the post-treatment Rorschach test records for the group as a whole indicate quite clearly that the basic personality pic­ ture remains that of schizophrenia. The Thematic Apperception Test Data Analyzed The stories to the first five cards of the Thematic Ap­ perception Test were utilized in this study in two ways:

in

terms of the formal aspects of the stories related, such as adequacy in terms of responding to the instructions and re­ sponsiveness to the stimulus material, in terms of number of words in each story; and in terms of the psychological signi­ ficance of the content of the stories as an indication of how the patient projected his concepts of himself in relation to other people and to his environment. The measure of adequacy of the stories told indicated that, on a group basis, there was little change after treat­ ment in ability to conform to the instructions given, or, when conformity was intended, to be able to perform adequate­ ly.

There was an indication in the increase of the number

of adequate stories told that individual patients who were able to conform to the instructions did so in more of the stories (number of adequate stories increased from 15 preto 36 post-treatment).

It is inferred that a qualitative

difference in terms of greater ability to conform occurred after treatment in those patients who possessed this ability to a more minimal degree pre-treatment. After treatment the group was seen to be more productive

234

in terms of number of words per story. nificant at the .01 level.

This change was sig­

In contrast to the lowering of

number of responses to the Rorschach stimuli, which are far less structured and therefore more threatening to these pa­ tients, the increased responsivity to the Thematic Appercep­ tion Test pictures, which are more objective and relate more to situations of every-day experience, indicates a somewhat better ability to deal more effectively with such situations, at least to the extent of responding more to them. Direct self-projection, measured by the number of self­ references in the stories, did not vary significantly after treatment.

As a group, these patients were as pathological

in this respect after treatment as they were before treatment. An important indication of change was observed in the increased number of stories which involved interpersonal in­ teraction.

The total number of Interaction stories given by

the entire group was 32 pre- and 4-9 post-treatment.

The dif­

ference was seen to be significant at between the .02 and .01 level.

This change, although not highly significant in

terms of number of patients who gave an increased number of personal interaction stories, is suggestive of a somewhat increased interest in desire for relationships with other people and is of some tentative importance in considering an over-all treatment for schizophrenics, a major factor of whose illness is believed to be a disinterest in, and an in­ ability to deal with, others in their environment. Unusual male-female identifications were unchanged after

235

treatment.

The number of unusual sexual identifications be­

fore and after treatment is suggestive of more confusion in sexual role than would be expected in a group whose person­ ality functioning was more mature and better adjusted in this area. In the analysis of the content and dynamic relation­ ships of the stories it was seen that no major changes of statistical significance occurred in the area of needs ex­ pressed by the group.

The low incidence of needs expressed

before treatment indicated the comparative lack of interest in normal drives shown in these stories by most people; the only need which was seen to be present in the stories before treatment of more than half the patient group was the need for belonging.

Despite the lack of major changes of statisti­

cal significance In the need area after treatment, the in­ crease both in the number of patients and in the number of stories which indicated needs after treatment is suggestive of an increased interest in the environment and an increased regard for the usual drives which impel most people. From the data presented which dealt with the effect of the environment on the individual, the reaction of the in­ dividual to the environment and the general adequacy of the principal characters, it was seen that before treatment the patient group regarded the environment as essentially punish­ ing, frustrating and harmful, reacted to this view of the en­ vironment with neurotic symptoms showing insufficiency and frustration and was

generally inadequate in

its

functioning

236 in the environment.

After treatment no changes of statisti­

cal significance were found in any of these areas of function­ ing.

There was a suggestion of minimal change in the ade­

quacy of the principal character in that there was a greater proportional change in the area of adequacy post-treatment than there was in the area of inadequacy.

Despite this

greater proportional change it was clear that more patients regarded their principal characters in the stories, who clin­ ically were inferred to be the projection of the patients themselves, as generally inadequate, both before and after treatment. These factors are generally related in clinical practice to deeper aspects of personality functioning which are more essentially part of the longitudinal developmental history of the individual than they are aspects of his immediate and more superficial functioning.

It is inferred from the lack

of significant change in these areas that no basic changes in personality structure, that is, of the individual's life­ long pattern of attitudes toward his environment, his pat­ tern of basic responsiveness to this environment and his con­ cept of his role of himself functioning in this environment, have occurred after treatment.

That these factors relate to

the life-histories of the patients in the group in an auto­ biographic manner is further borne out by the endings which the patient group comes to in its stories.

Before and after

treatment the endings of the stories are almost twice as fre­ quently unsatisfactory to the individual as they are

237 satisfactory to the individual.

It is seen in the results

in the previous chapter that more stories were told which ended satisfactorily after treatment, but by almost the same number of patients.

No change of statistical significance

occurred in the number of patients who tended to view himself and his environment in an optimistic manner. Summarizing the results of the analysis of the data ob­ tained from the Thematic Apperception Test it may be stated that, for the group as a whole, some changes in superficial aspects of personality functioning, such as productivity and desire for relationship with other individuals in the environ­ ment, occurred; changes in more deep-rooted, life-long pat­ terns of attitudes toward the environment and concept of self (for the most part unsatisfactory) were not shown.

Essential­

ly the results of the group analysis of the Thematic Appercep­ tion Test stories related by the patients indicate that the pattern of personality functioning exhibited before and after treatment was on a schizophrenic level; that no changes, aside from slight, symptomatic ones, can be said to have oc­ curred after electroconvulsive treatment.

Nevertheless, it

is pointed out that certain of the superficial changes, such as increased desire for relations with others, may have value in terms of amenability of these patients to further treat­ ment, such as psychotherapy. The Word-Association Test Data Analyzed The Word-Association Test was utilized in a manner

238 suggested by Rapaport, who stated, "In actual use, however, the test has turned out to be of limited significance in this (the assumption that disturbing areas of ideation can be in­ ferred from association disturbances on specific stimulus words) respect...The 'formal characteristics' of the associa­ tive reactions have been found to be in themselves diagnostically significant."1

The formal characteristics of the

associative reaction, such as reaction time, association disturbances and reproduction failures, were utilized in this investigation to yield further information relative to conformity of thinking process, presence of indicators of pathology, presence of adequate judgment and auto-criticism, and speed of reactions pre- and post-treatment. Analysis of the data obtained through the use of this test reveals that the only change of statistical significance that occurred post-treatment was the slowing of the speed of reaction.

The increase in reaction time to the words of the

entire word-list was significant at the .01 level.

This re­

sult is in accord with the suggestive Rorschach finding that the initial time of first response tended to increase after treatment. In none of the other areas of scoring was there shown significant change after treatment.

Conformity of thinking

process of the group as a whole was not improved, as shown by the Kent-Rosanoff frequency scores and zero scores.

1.

The

D. Rapaport, Diagnostic Psychological Testing. Vol.II, p. 13

239 presence of indicators of pathology, as shown by the number of association disturbances, was high before treatment and did not vary significantly after treatment*

Although it

might be inferred that a greater attempt was made after treat­ ment toward greater control, suggested by the significant in­ crease in reaction time, this attempt apparently did not suc­ ceed in increasing judgment and auto-criticism, because the indicators of association disturbances included such results of poor judgment and auto-criticism as completely unrelated reactions, clang associations, repetitions of the stimulus word and neologisms.

The number of reproduction failures af­

ter treatment did not change significantly; the immediate memory function, as measured by the ability to reproduce the previously-given associations to the stimulus words^was thus seen to be unchanged after treatment. The Color-Form Sorting Test Data Analyzed It was stated in Chapter IV that there were no signifi­ cant changes in the performance of the patient group on this test after treatment.

In terms of the purpose for which the

test was utilized, to determine the change in presence of con­ crete or abstract attitude,1 it is seen that no group change occurred.

It is seen that only 6 patients, pre- and post­

treatment, were able to perform what could be termed "com­ pletely satisfactory" solutions, solutions that could be

lT

K. Goldstein and M. Sheerer, Abstract and Concrete Be­ havior. p. 2

240 interpreted as being on a normally abstract level.

All of

the other patients, to a greater or lesser degree (mani­ fested by the amount of assistance and demonstration that was required before a solution was completed, or by the fact that a solution was not completed with maximal assistance), demonstrated some degree of impairment of the ability to func­ tion abstractly both pre- and post-treatment. Goldstein and Sheerer have made the statement, "The nor­ mal person is capable of assuming both (abstract and concrete attitude), whereas the abnormal individual is confined to but one type of behavior —

the concrete."-*-

If this experimental

conclusion is utilized as the frame of reference for an over­ all statement in terms of normality or abnormality, it would appear that the patient group, in terms of the Color-Form Sorting Test, was unchanged in basic concrete attitude des­ pite electroconvulsive-treatment, and continued to function abnormally in this respect. The Draw-a-Person Test Data Analyzed The results of the Draw-a-Person Test which were pre­ sented in Chapter IV were obtained to provide an additional index of bizarreness of thinking and a measure of radical de­ viations from the usual drawings produced by normal individu­ als.

Statistical treatment of the data on a group basis to

evaluate the patients' concept of the self and the body

1.

Ibid.. p. 2

241 image was not possible ; information relating to these as­ pects of personality functioning will be found in the individ ual analyses of the data which are presented later in this chapter.

In addition, it was possible to effect a compari­

son between the patients1 concepts of males and females, as indicated by their drawings, before and after treatment. Results of the comparison of size of figures drawn in­ dicated that the mean height of the female figure, before and after treatment, was greater than the mean height of the male figure, although not significantly so.

After treatment

there was seen a significant (at the .01 level) decrease in size of the female figures drawn and a decrease in size of the male figure, although not to a significant degree.

It

may be inferred that there was, for the group, a tendency to over evaluate the female and to view her in a dominant posi­ tion in relation to the male before treatment and that this over evaluation tends to decrease after treatment.

There may

be inferred from the decrease in the combined size of both drawings post-treatment a tendency toward a more realistic conception of the body image in terms of size and less tend­ ency toward grandiosity and unrealistic feelings of power related to size. No differences of significance emerged from the scoring of the performance of the test with respect to sex of first figure drawn, or with respect to the position (profile or full-face) of the figures drawn, although there is seen a suggestion of a great deal of immaturity in the fact that

242 half of the drawings pre- and post-treatment were in fullface, which is a performance on a lower genetic level than is a profile drawing* The difference in the combined (male and female) posttreatment Goodenough scores showed an increase of 0.97, which is significant at the .0 5 level, due largely to the signifi­ cant (at the .01 level) difference between the drawings of the pre- and post-treatment female figures.

These scores,

which did not take into account directly psychotic manifesta­ tions and bizarreties, indicate that on a group basis there was some improvement in the area of realistic concept of the body image, and particularly an improvement in the ability to deal with and draw the female figure in a more realistic manner. The ratings obtained through the use of the rating scale employed and those obtained through the judges1 evaluations appear to be at variance.

The rating scale evaluation in­

dicated that no significant change obtained after therapy. The preferences of the committee of three judges, in terms of "better" drawings, were clearly for the post-treatment pro­ ductions.

The rating scale placed higher value on the ab­

sence of pathological features and dealt with the drawings on an atomistic, detailed basis.

The judgments of the committee

were made on an over-all basis with less rigid criteria.

It

may be stated, therefore, that the absence of change which was shown through the use of the rating scale was due to the continued presence, post-treatment, of a similarly large

243

number of pathological features in the drawings as there were pre-treatment, but that on an over-all, inspectional basis the post-treatment drawings were rated as "better", for the most part, by the committee of judges.

The drawings were

comparatively better post-treatment, but were clearly still indicative of pathology in the individuals who produced them. The Bender-Gestalt Test Data Analyzed The Bender-Gestalt data, on a group basis, shows several changes of statistical significance after treatment.

The to­

tal number of pathological indicators shows a decrease which is significant at the . 0 5 level of confidence, but this change is dependent on only slight changes in all but one of the in­ dicators, destruction of gestalt, which alone changed post­ treatment to a degree which is significant at the .01 level. The rating scale scoring resulted in a change of mean rating from 2.30 to 2.55*

Both mean scores are within the pathologi­

cal range, according to the criteria of the rating scale, yet the change that occurred was suggestive (.10 level of confi­ dence) of improved performance on this test. The "blind" comparison of the pre- and post-treatment Bender records by a committee of judges resulted in a clear cut preference for the post-treatment reproductions. These changes after treatment indicate that a higher de­ gree of planning ability, foresight, and necessarily, control, were present.

Expression of pathological signs such as re­

gression, dissociation and gross impairment of visual-motor

244 functioning (indicated by destruction of the gestalt fig­ ures) tends to diminish.

It may be inferred that the im­

proved results on the test after treatment were accompanied by an improvement in the amount of auto-critical ability that the patients were able to exercise. The results, on the whole, tend to indicate that a greater adherence to the reality of the testing situation was present after treatment and that the patients exhibited better ability to test reality effectively in this situation. All of the indications of improvement found in the post­ treatment test records, however, must be qualified by the fact that in none of the areas evaluated did the test results for the group show movement out of the pathological range in which they were pre-treatment.

The post-treatment records for

the group as a whole are still identifiable as those of indi­ viduals showing personality malfunctioning on a schizophrenic level. Analysis of Individual Patient Data In the following section will be presented an analysis of the test data obtained from each patient, pre- and post­ treatment, with emphasis on the changes in personality func­ tioning, if any, that occurred after treatment.

This analy­

sis will be qualitative and clinical in approach. Analysis of Test Data of Patient #1 (27 year old catatonic schizophrenic; ill 3*5 months; no

245

previous physical treatment; 18 electroconvulsive treatments in present series.) On the Rorschach, better emotional control and less impulsivity after treatment are seen*

This control is at the

expense of this patient's total affect, which is completely blunted and flattened.

There is low responsiveness before

and after treatment, with a change toward fewer popular re­ sponses and an increased (4) number of rejections. The Thematic Apperception Test showed slightly increased productivity (45.4 mean words per story pre- and 6 9 . 8 posttreatment), a higher number of adequate stories and more stories showing interpersonal interaction.

The principal

characters in the stories were more adequate generally and the endings were slightly more satisfactory. need for belonging shown.

There was more

The environment was seen as more

undesirable and more frustrating,after treatment. In the Color-Form Sorting Test a slight improvement was seen.

The post-treatment solution was performed spontaneously,

while pre-treatment a demonstration trial was necessary.

Pat­

terning was present, both before and after treatment, indicat­ ing that a tendency toward concreteness and pathology was still present. Results are mixed on the Draw-a-Person and Bender-Gestalt Tests.

A higher rating was earned on the drawing rating

scale (total change of *2 ) on both the male and female draw­ ings although the formal quality of the drawings, as measured by the Goodenough scoring, decreased somewhat (-1.50)*

Th®

246 Bender post-treatment was poorer, with more indicators of pathology in evidence. On the Word-Association Test there were indicators of somewhat increased conformity (higher Kent-Rosanoff count, fewer zero scores) hut more evidence of disturbance was seen in the higher number of association disturbances. In summary, this patient shows superficial indications of improvement, specifically in the areas of better emotional control and slightly better reality testing.

It is seen, how­

ever, in the many evidences of pathology throughout the test material, that his personality functioning is still that of a basically schizophrenic individual after treatment. Analysis of Test Data of Patient #2 (3 1 year old paranoid schizophrenic; ill 1 2 .0 months; no pre­ vious physical treatment; 20 electroconvulsive treatments in present series.) The Rorschach indicates improved personality functioning in that there is better reality testing, a healthier pattern of emotional response and fewer indications of depression. Range of interests is still broad and production is high. There is seen, post-treatment, however, less orderly and looser thinking, excessive emphasis on minute details and in­ creased indications of anxiety.

Pathology is still evident

despite the over-all improvement in Rorschach performance as indicated by a change in Monroe Score from 18 negative in­ dicators pre-treatment to 4 post-treatment.

247 On the Thematic Apperception Test productivity is in­ creased (6 0.0 mean words per story pre-treatment to 1 25*8 post-treatment) and the formal characteristics of the stories are more adequate.

The environment is still seen as frustrat­

ing, however, and the individuals in the stories still react in neurotic patterns.

The principal characters are still

seen, post-treatment, as maladjusted and as failures who end the stories in ways which are unsatisfactory to themselves. The Color-Form Sorting Test, on which performance was good pre-treatment, reveals a trend toward increased con­ creteness and pathology with the presence f post-treatment, of patterning behavior.

Quantitatively the ratings pre- and

post-treatment remain constant at 5 * The Draw-a-Person and Bender-Gestalt Tests reveal few changes in post-treatment functioning, although slight nega­ tive changes occur.

The over-all drawing rating decreases

from 6 to 4 and there is a slight decrease (0.75) in the Goodenough score of the male figure, indicating slightly poor­ er concept of the self and body image.

The Bender is essenti­

ally unchanged from a mediocre performance with several patho­ logical indicators before treatment. The Word-Association Test indicates a greater extent of malfunctioning.

Conformity is lower (decrease in Kent-Rosanoff

count from 141 to 103, appearance of 5 zero scores) and more emotional conflict is seen in the increase in association disturbances from 10 to 15, also in the increase of reproduc­ tion failures from 3 to 4.

248 In summary, this patient has made gains after treat­ ment, particularly in the areas of somewhat increased reali­ ty testing ability and a healthier pattern of emotional re­ sponse, with a decrease in the pre-treatment indications of depression.

That these changes are superficial is seen by

the increased number of indications of disturbance and a more pessimistic and maladjusted view of the environment.

Indica­

tors of anxiety have increased and the thinking process has become more poorly organized.

Attention is misdirected at

minute details of the environment.

After treatment this pa­

tient is in better contact with his environment but is still an anxious, unhappy individual who shows many evidences of pathological personality functioning. Analysis of Test Data of Patient ( 2 7 year old catatonic schizophrenicj ill 19»0 months; no pre­ vious physical treatment; 8 electroconvulsive treatments in present series.) Indications are present in this patient’s Rorschach per­ formance that his reality testing ability has improved and that he is able to concentrate on more practical aspects of reality situations. treatment.

He is less blocked and repressed after

He has more energy available to him but his think­

ing and perception are on a more immature level.

He is dis­

interested in other people in his environment and possesses little ability to relate effectively to others.

Despite the

signs of improvement which are seen, his over-all Rorschach

24-9

performance is still in the pathological range (Monroe scores 16 pre- and 14 post-treatment)# The Thematic Apperception Test shows increased producti­ vity (mean words per story 2 1 . 8 pre- and 45.2 post-treatment). He was able to respond to Card 5> which was rejected pretreatment.

His stories, formally, are still inadequate after

treatment, indicating no change in ability to conform to in­ structions.

He shows greater need for recognition and sen­

sory gratification after treatment.

Few changes are seen in

the content of the stories, which tend largely to indicate un­ favorable effect of the environment coupled with neurotic and inadequate reaction to it. Improvement is seen in the Color-Form Sorting Test. Both the pre- and post-treatment performances were adequate, but post-treatment the pathological indication of patterning was no longer present.

The rating scores were unchanged (5

and 5)* On the Draw-a-Person Test slight improvement in the rat­ ing and Goodenough scores occurred, indicating a somewhat better concept of body image.

This improvement was more re­

lated to his better ability to portray the female figure. The Bender-Gestalt Test reveals little change from a mediocre pre-treatment level of performance; there was a slight decrease in pathological indicators. The Word-Association Test is essentially unchanged. relatively high conformity index is present both pre- and post-treatment (Kent-Rosanoff count of 203 and 193 9

A

250 respectively) and there are indications of emotional disturb­ ance in the presence of 6 association disturbances both be­ fore and after treatment. In summary, this patient shows improvement after treat­ ment in several areas.

His reality testing has improved and

he is seen to be less blocked and repressed.

He has more

energy available to him and is more productive. al ability has improved somewhat.

His conceptu­

Despite these indications

of improvement, however, he continues to exhibit signs of pathological personality functioning in that he continues to be unable to deal effectively with others in his environment, still is immature in his thinking and perception, and con­ tinues to exhibit a mediocre level of judgment and auto­ criticism.

Many of the indications of pathology present in

his pre-treatment test records continue to be present after treatment. Analysis of Test Data of Patient #4 (2 3 year old hebephrenic schizophrenic; ill 28 months; had previous course of 9 electroconvulsive treatments in 1947j 20 electroconvulsive treatments in present course.) A slight increase in reality testing ability is the only positive change post-treatment in the Rorschach scores of this patient.

The pre- and post-treatment records are other­

wise greatly similar in that he exhibits uncontrolled impulsivity, low conformity in thinking, lack of critical judgment and marked indications of serious pathological disturbance.

251

Post-treatment there is seen more disorder in the thinking process. On the Thematic Apperception Test there is little change in productivity and ability to conform to the formal require­ ments of the test increases slightly, 2 adequate stories being given post-treatment to 1 pre-treatment.

Pathological per­

sonal references are present both before and after treatment, decreased by 1 post-treatment.

There is a slight decrease

in stories involving interpersonal interaction, 4 pre- and 3 post-treatment.

The need pattern is changed from emphasis

on belonging to emphasis on affection and achievement.

The

environment is seen as more frustrating and harmful post­ treatment and more of the characters react with neurotic symptoms to the environment after treatment than they did before.

More of the principal characters are seen as general­

ly inadequate and maladjusted after treatment.

The trend of

the endings, with emphasis on unsatisfactory ones, is un­ changed post-treatment. Ability to shift readily and satisfactorily, as indicated by the Color-Form Sorting Test solutions, is unchanged. Max­ imal scores are obtained pre- and post-treatment. On the Draw-a-Person Test there is seen no change from a mediocre pre-treatment performance, insofar as the bizarre and pathological features of the drawings are concerned, but that more mature and acceptable formal characteristics are present is seen in the over-all improvement of the Goodenough scores (7.00 to 10.25 Tor the male and 8.00 to 8.75 for the

2?2

female, a total change of *4.00).

This indicates an improve­

ment in concept of self, although it is still on a pathologi­ cal level. The Bender performances, pre- and post-treatment were poor, both on over-all rating and number of pathological in­ dicators, indicating no change in visual-motor perceptual ability or ability to adapt in simple situations. On the Word-Association Test an improvement is seen in conformity indicators, although these continue to be at the pathological level post-treatment.

There is a continued ex­

tremely high number of association disturbances (21 and 2 2 ). Reproduction failures decline markedly from 10 to 5 but re­ main indicators of pathology in immediate memory function. In summary, there Is seen but slight changes in the per­ formance of this patient on the test battery, which both preand post-treatment were mixed and fluctuated from a high to a low level.

Basically, there are as many evidences of severe

personality malfunctioning present after treatment as there were before treatment.

His contact with reality is slightly

improved but the weight of the evidence indicates that post­ treatment personality functioning remains on a schizophrenic level. Analysis of Test Data of Patient #5 (19 year old hebephrenic schizophrenic; ill 4.0 months; no previous physical treatment; 20 electroconvulsive treatments in present series.)

253

The Rorschach, records of this patient indicate that post-treatment he is functioning on a more maladjusted over­ all level (Monroe maladjustment indicators increase from 15 to 25) post-treatment, despite the fact that there appears to be present better emotional control and less depressive ten­ dencies.

The degree of emotional upheaval present in the

pre-treatment record is replaced by considerable emotional flattening and almost complete blunting of affect post­ treatment.

Poorer reality testing ability is seen after

treatment.

The post-treatment record indicates less chaotic

functioning and at the same time loss in sensitivity and range of interest.

Post-treatment, chaos and emotional lability are

replaced by deadness and flattening, and by constriction of responsivity. On the Thematic Apperception Test he becomes less pro­ ductive and responsive (mean number of words per story de­ creases from 107*0 to 66.2).

His stories are generally ade­

quate in terms of conforming to test instructions, more so by 1 story post-treatment.

He displays interpersonal relation­

ships in 4 stories, both pre- and post-treatment, and a con­ fused sexual identification is no longer present after treat­ ment.

Need patterns are relatively unchanged, though more

need for achievement and affection is shown post-treatment. The effect of the environment post-treatment is slightly less frustrating and more helpful, and his characters are generally more adequate and tend to react to their environments with less aggression, hostility and withdrawing and with more

254

ambivalence and anxiety.

More of the stories have endings

which are satisfactory to the individual. There is seen some improvement in conceptual ability, as indicated by a better, although still inadequate, per­ formance on the Color-Form Sorting Test,

Pre-treatment, no

shift was possible and pathological patterning was present. Post-treatment, a solution was possible after a demonstration, and no patterning behavior was present.

The rating increased

from 1 to 3 , On the Draw-a-Person and Bender-Gestalt Tests, only slight changes occurred.

The drawing ratings were unchanged

after treatment but there was a decrease in Goodenough score for the male drawing (14.75 to 13«50) and &n increase for the female drawing (11.25 to 13.00).

All of his drawings were on

a relatively high level of maturity, but with pathological features present both before and after treatment.

The Bender

also was on a comparatively high level, but showed a slight decline in rating after treatment (4 to 3 ) due to the ap­ pearance of a pathological indicator (confused order). Word-Association Test results are mixed.

The major

trend is toward greater conformity (increase in Kent-Rosanoff count from 57 to 83, reduction of zero scores from 4 to 1) and less indication of maladjustment in that the number of association disturbances decreases from 19 to %

but reproduc­

tion failures increase from 4 to 8, indicating increased im­ mediate memory impairment.

Results of this test indicate

over-all improvement but the test factors discussed indicate

255

the continuing presence of pathological functioning. In summary, the major change which is seen in this pa­ tient's personality functioning is in the degree of emotion­ al "calming down" and flatness which has taken place. dence of depression is less in evidence.

Evi­

At the same time,

poorer reality testing ability, loss of sensitivity and di­ minished range of interests are seen.

Indications are present

in the Thematic Apperception Test that his superficial capa­ city to adjust to his environment and to others in his environ­ ment has improved somewhat.

Aggressive and hostile tendencies

have been replaced with ambivalence and anxiety.

No major

change is seen in self-concept but increased ease and ability to deal with the female figure is seen.

Conceptual ability

remains pathological. There is seen no basic change in the over-all picture of personality functioning, which remains on a pathological schizophrenic level^ although it can be stated that changes have occurred which make this patient somewhat more acceptable to his environment and slightly better adjusted in terms of his adjustment to his illness. Analysis of Test Data of Patient #6 (3 1 year old paranoid schizophrenic; ill 33*0 months; had previous course of 9 insulin coma treatments in 1947 J 20 electroconvulsive treatments in present series.) The Rorschach test data indicate that this patient ex­ hibits many indications of pathology, pre- and post-treatment.

256 After treatment his reality testing ability increases slight­ ly but he is still unable to see most percepts seen by others. His emotional reactivity is more egocentric but better controlled. There is more indication, post-treatment, of anxiety and inner turmoil.

He continues to show little interest in other peo­

ple in his environment and shows relatively little ability to deal with them effectively.

Both records are sparse and un­

productive and there are approximately the same number of mal­ adjustment indicators on Monroe scoring post-treatment (13) as there were pre-treatment (12). On the Thematic Apperception Test his production is minimal (mean words per story pre- and post-treatment 3 0 * 0 and 24.0 respectively).

All of his stories except one pre­

treatment, are inadequate in terms of complying with the full instructions.

He shows a pathological personal reference in

both a pre- and post-treatment story and the two instances of pre-treatment interpersonal interactions decreased to one post-treatment. few needs shown.

There was little change in need pattern, with The environment is portrayed as essentially

frustrating and harmful and the individuals portrayed general­ ly react to their environment with neurotic symptoms; the two stories in which the individuals reacted in a self-sufficient and stable manner pre-treatment are not repeated post-treatment.

Most of his T.A.T. characters are seen as not adequate

and in conflict situations and none of the endings of either the pre- or post-treatment stories is satisfactory to the characters in the stories.

2 57

The Color-Form Sorting Test indicates poor abstract ability, but a slight improvement is seen post-treatment. There is a change in performance from inadequate shift to adequate shift after demonstration. creased from 1 to 3 .

The rating score in­

Pathological patterning, however, is

present before and after treatment. The drawings remain pathological after treatment and on a low level, despite an increase of 1 point on the combined rating and a gain of 1.25 on the Goodenough score of the male.

Apparently a slight increase in self-concept has

occurred. The Bender-Gestalt performance is seen to be poor preand post-treatment, and shows no change in rating (1 and 1 ), although the number of pathological areas of disturbance de­ creases from 5 to 3 .

The post-treatment Bender remains highly

pathological and indicates a disturbance in perceptual-motor ability and adaptability in simple situations. On the Word-Association Test extreme disturbance in idea­ tion and emotional stability is seen.

Reaction time post­

treatment increases (1 .5" to 2 .5") and degree of conformity decreases.

Average Kent-Rosanoff count declines from an al­

ready low 23 to 11 and number of zero scores increases from 12 to 14.

Association disturbances show an increase from 47

to 54- and the number of reproduction failures is pathological­ ly high, 1 2 pre- and 11 post-treatment. In summary, this patient shows few changes toward improve ment after treatment.

He shows a slight increase in reality

258 testing ability and in degree of control of egocentric emo­ tional functioning, but in all other areas described con­ tinues to exhibit quite evident schizophrenic personality functioning. Analysis of Test Data of Patient #7 (26 year old hebephrenic schizophrenic; ill 29*0 months; no previous physical treatment; 20 electroconvulsive treatments in present series.) Both the pre- and post-treatment Rorschach records of this patient were grossly pathological.

An almost complete

emotional blunting is seen after treatment.

There is a great­

er striving for control but this Is unsuccessful.

Reality

testing ability declines slightly post-treatment.

Total re­

activity is lessened and it requires more effort for him to respond.

After treatment, however, he no longer reacts in

the grossly random, inadequate manner in which he did before treatment.

The post-treatment record Indicates that physi­

cal reactivity and turbulence less predominate his function­ ing than do poor reality testing and lack of contact with his environment.

The Monroe score decreases slightly from

27 to 25 and is still well wit h i n the range of serious patho­ logy. This patient rejected the Thematic Apperception Test post-treatment and no comparison w i t h the pre-treatment test is possible. Performance pre- and post-treatment on the Color-Form

259 Sorting Test is grossly Inadequate (ratings of 1 and 1).

Per­

formance was on a totally concrete level and pathological pat­ terning was present before and after treatment.

No change

occurred in this area. The Draw-a-Person and Bender-Gestalt tests are on a very low level pre- and post-treatment and indicate no change af­ ter treatment in poor self-concept, poor auto-critical abili­ ty, poor visual-motor ability and poor adaptability in simple situations.

There is seen an increased indication of regres­

sion in the post-treatment Bender performance. The Word-Association Test is characterized by abnormally high reaction time pre- and post-treatment, with an increase post-treatment from 5*2" to 6.4" in average time of reaction. Conformity is low and the number of association disturbances increases from 34 to 42 post-treatment.

Immediate memory is

still poor although reproduction failures decrease from 19 to 1 1 . In summary, this patient has changed but little after treatment.

All of the tests, pre- and post-treatment, indi­

cate the presence of severe personality pathology.

The only

major change was that post-treatment his emotional reactivity is less random and chaotic and becomes more flattened and dulled.

Basically, his schizophrenic personality functioning

before treatment remains present after treatment. Analysis of Test Data of Patient #8 (26 year old hebephrenic schizophrenic; ill 3^»0 months; had

2 6o previous course of 20 electroconvulsive treatments, 1946; 20 electroconvulsive treatments in present series.) Changes in the post-treatment Rorschach test indicate that this patient has improved in over-all personality func­ tioning (Monroe maladjustment indicators decrease from 17 to 13), particularly in the area of better emotional responsivity.

He becomes more controlled, less impulsive and less

egocentric.

He has a greater capacity for relating to other

people in his environment, but does not have much interest in doing so.

Evidence of thinking and perception disorder

is still present and reality testing is comparatively poor. There is seen less blocking and more socially adaptive re­ sponses. On the Thematic Apperception Test productivity increases (average words per story pre- and post-treatment 61.0 and IO3.6 respectively)•

There is a great change from all p r e ­

treatment stories formally inadequate to all post-treatment stories formally adequate.

More stories are told involving

interpersonal interaction.

More needs are shown post-treat­

ment and emphasis is changed from need for sensory gratifica­ tion to need for achievement.

More of the characters in the

post-treatment stories react in a self-sufficient and emo­ tionally stable manner to their environments.

Generally,

more of the T.A.T. characters are seen as adequate and ad­ justed and a more optimistic outlook is apparent post-treat­ ment in that all of the story endings are satisfactory to the individual and to society.

261 Abstract attitude, as shown by the Color-Form Sorting Test, is adequate pre- and post-treatment (ratings of 5 ami 5) and pathological patterning present before treatment is no longer present after treatment* In the Draw-a-Person and Bender-Gestalt Tests less change in performance is seen.

The over-all drawing rating

decreases slightly from 6 to 5> indicating no change in de­ gree of bizarrety of body image, although the formal charac­ teristics of the drawings, measured by the Goodenough score, changes for the male from 10.25 to 10.75 and for the female from 9.50 to 10.50.

The post-treatment Bender shows an ad­

ditional pathological feature, dissociation, and the rating decreases from 3 to 2 . The Word-Association Test becomes slightly more patho­ logical.

Average reaction time Increases from 1.7" to 2.6".

Conformity of response decreases

(Kent-Rosanoff count I33 to

7 1 ) and the number of association disturbances increases from 7 to 18*

Immediate memory function improves (reproduction

failures decline from 4 to none).

Indications are still

present of a thinking and association disorder. In summary, this patient demonstrates considerable im­ provement chiefly in the area of better emotional responsive­ ness, comprising more control, less impulsivity and less egocentricity.

Thinking and perception disorders are still

present and reality testing ability remains comparatively poor.

A better superficial picture of personality function­

ing is presented post-treatment, but evidence indicates that

262 he continues to function on a pathological, schizophrenic level* Analysis of Test Date of Patient #9 (25 year old hebephrenic schizophrenic; ill 25.0 months; had previous course of 23 Insulin coma treatments in 1947 j 21 electroconvulsive treatments in present series.) The Rorschach record after treatment indicates that little change has occurred in this patient.

Both before and

after treatment his reality testing is seen to be grossly inadequate to the extent that he is, in both, almost complete­ ly out of contact with reality.

If any change can be said to

have occurred, it is that the few good percepts present be­ fore treatment are no longer present after treatment.

There

Is indication of increased anxiety after treatment, although less concern with the outcome of the examination.

Both re­

cords contain many pathological indicators, such as contami­ nations, peculiar verbalizations and personal references. After treatment he responds in a more impulsive manner to the stimulus material and displays less auto-critical ability. He responds only minimally to the Thematic Apperception Test and all of his stories, pre- and post-treatment, are formally inadequate.

Two personal references which appeared

pre-treatment do not appear post-treatment.

His T.A.T. per­

formance was unchanged post-treatment in that all of his stories remained so inadequate as to be unscorable in the analytic procedure employed.

263 In the Color-Form Sorting Test no change in the concrete type of performance is seen (scores of 1 and 1) although pat­ terning, which was present before treatment, is no longer seen post-treatment• No change from pathologically poor pre-treatment per­ formance occurs on the Draw-a-Person Test.

The Bender rat­

ing increased from 2 to 3> reflecting a decline in pathologi­ cal indicators from 3 to 1*

Apparently, his visual-motor

perceptual ability in a relatively simple situation improved somewhat• The Word-Association Test remains grossly pathological post-treatment, the only change of note occurring in the in­ creased average reaction time from 3•4" to 8.3” .

Both per­

formances on this test were extremely deviant. In summary, it may be said that this patient's over-all personality functioning after treatment remains on an ex­ tremely pathological level, with pronounced estrangement from reality clearly evident.

If it can be said that any existed

before treatment, emotional control and auto-critical ability worsen after treatment, and an increased amount of anxiety is present. Analysis of Test Data of Patient #10 (29 year old hebephrenic schizophrenic; ill 41.0 months; had previous course of 20 electroconvulsive treatments in 1947; 10 electroconvulsive treatments in present series.) On the Korschach the most noticeable change post-treatment

264 is the increased responsiveness to the stimulus material. Evidences of anxiety and depression which were seen pretreatment continue to be present.

There is a considerable

improvement in reality testing ability and most of the pro­ nounced pathological tendencies which were present before treatment, such as peculiar verbalizations and color naming tendency, no longer are seen after treatment. change in emotional responsivity.

There is no

It is seen that the per­

sonality functioning of this individual is on a less patho­ logical level post-treatment, but is still deviant in the areas of thinking and perception. The Thematic Apperception Test also reveals increased productivity.

Average words per story increases post-treat-

ment from 33.8 to 58*8.

There is seen the relating of 2 for­

mally adequate stories post-treatment compared to none pre­ treatment.

A pathological personal reference, present pre­

treatment, is no longer present after treatment.

The number

of interpersonal interaction stories increases from 1 to 3 . He shows an increased number of needs, in the areas of achievement, belonging and sensory gratification.

The en­

vironment is generally seen as frustrating and there is a decrease in the number of stories in which it is seen as mo­ notonous post-treatment.

His principal characters are slight­

ly more adequate and the stories end more satisfactorily for them post-treatment. He shows a loss in the Color-Form Sorting Test.

Solutions

pre- and post-treatment were adequate in the spontaneous trial,

265 but pathological patterning was present with both solutions. After treatment he is no longer able to verbalize the ra­ tionale of his performance, and his rating decreases from 5 to 4, The Draw-a-Person Test indicates little change from a poor performance pre-treatment.

There is slight improvement

in his concept of the male, and the female figure improves only formally in Goodenough scoring, from 9*25 to 10.75* There is no change in a mediocre level of Bender-Gestalt performance • The Word-Association Test shows little change from a deviant, pathological pre-treatment performance.

The average

reaction times indicate impulsivity (1.6" and 1 .5”) and in­ dividual, atypical responses are frequent (zero scores of 17 pre- and 18 post-treatment).

The number of association dis­

turbances increases from 32 to 39*

These data indicate little

change from a disturbance in thinking and associative processes, with considerable bizarrety and pathological individuality. In summary, this patient's test battery indicates im­ provement in reality testing ability and in terms of decrease of certain pathological indications, but with many remaining after treatment.

No change in emotional response is seen.

Indications are present that personality functioning remains clearly on a pathological, schizophrenic level. Analysis of Test Data of Patient #11 (23 year old paranoid schizophrenic; ill 41.0 months; had

266 electroconvulsive treatments in 1945* number unknown; 15 electroconvulsive treatments in present series,) On the post-treatment Rorschach Test, considerable im­ provement is seen. from 21 to 11. seen.

The Monroe maladjustment score decreases

Increased ability to deal with reality is

Productivity is increased.

tivity have improved.

Ideational and fantasy ac­

Reaction to emotional situations is

more mature and less egocentric.

Peculiar behavior observed

pre-treatment is no longer present after treatment.

There

are Indications of more interest in, and increased ability to deal with, other people in his environment.

Handling of

the stimulus material becomes more orderly and typical.

How­

ever, breaks with reality are still seen and emotional re­ activity is overly labile. In the Thematic Apperception Test he becomes more pro­ ductive (mean number of words per story increased from 42.3 to 127.6 ) and all cards are responded to, whereas before treatment Card 5 was rejected.

There is an increase in the

number of formally adequate stories, indicating better abil­ ity to comply with the instructions.

Two personal reference

stories are still present but there is an increase in the number of interpersonal interaction stories from 1 to 4. While no needs were expressed before treatment, needs are expressed in all areas with emphasis on achievement, belong­ ing and sensory gratification after treatment.

There is a

slight tendency for the effect of the environment to be recog­ nized as more helpful.

Fewer of his characters react in

267 neurotic patterns and more show reactions of self-sufficiency; they are generally more adequate than they were pre-treatment and they more generally arrive at more satisfactory endings in the stories. On the Color-Form Sorting Test better abstract ability is seen post-treatment.

The rating score increased from 2 to

5"; although patterning is present before and after treatment, after treatment a spontaneous solution with adequate verbaliza­ tion of rationale is given, whereas before treatment solution was possible only after a demonstration and verbalization was inadequate, Improvement in the Draw-a-Person and Bender-Gestalt Tests is seen.

Over-all drawing rating increases from 5 to 6 and

there is an increase of 2,00 in the Good enough total score, indicating both less bizarreness and better formal character­ istics of the drawings.

The Bender rating is constant at 2,

but the number of pathological indicators decreases from 5 to 2 post-treatment; rotation, destruction of gestalt and con­ fused order are no longer present, indicating more orderly perceptual and visual-motor processes. The Word-Association Test shows increased conformity, fewer association disturbances (13 to 7 ) and markedly im­ proved immediate memory (17 reproduction failures pre-treat­ ment to 1 post-treatment)• In summary, this patient shows marked generalized im­ provement in personality functioning post-treatment, although indications continue to be present that this improvement does

268 not completely remove him from functioning within the schizo­ phrenic range. Analysis of Test Data of Patient #12 (29 year old catatonic schizophrenic; ill 47*0 months; had 16 electroconvulsive treatments in 1946; 20 electroconvulsive treatments in present series.) Most of the aspects of this patient’s post-treatment Rorschach record are similar to those of his pre-treatment record.

After treatment, however, he no longer is as produc­

tive and many of the indicators of anxiety and tension are no longer present.

Pathological color-naming reactions are still

present and reality testing ability remains impaired. sive tendencies are still In evidence.

No improvement in a-

bility to deal with others in his environment is seen. ergy level is somewhat reduced.

Depres­

En­

Several grossly pathological

responses, such as positional and confabulation responses, no longer appear.

Basic personality disturbance is still present

in the post-treatment Rorschach. The Thematic Apperception Test shows no change from the point of view of productivity.

That no improvement in com­

plying with the instructions on this test is present is seen in that all stories, before and after treatment, remain for­ mally inadequate.

Minimal (1 story) interpersonal interac­

tion is seen before and after treatment.

His T.A.T. stories

after treatment remain descriptive and plotless. His Color-Form Sorting Test indicates that he continues

269 to function on a concrete level; he is unable to perform a correct solution pre- or post-treatment (rating scores 1 and 1 ). The Draw-a-Person and Bender-Gestalt Tests are per­ formed pre- and post-treatment on a low, pathological level; there is little change.

Poor self-concept and visual-motor

and perceptual ability are seen.

There is little ability

present to adapt to a simple situation. Word-Association Test performance is relatively u n ­ changed from a fairly good one pre-treatment.

Conformity is

high (Kent-Rosanoff count pre- and post-treatment 158 and 160 respectively), but individual responses increase slightly from 2 to 4.

Association disturbances decrease from 7 to 5

and the number of reproduction failures is almost the same, 6 and

indicating some difficulty in immediate recall. In summary, this patient's test battery after treatment

indicates some improvement from a grossly pathological schizo­ phrenic picture before treatment.

Anxiety and tension no

longer are present to the same extent, but the continued d e ­ gree of impaired reality testing, poor conceptual ability, concreteness and abnormal reactivity clearly point out the fact that post-treatment his personality functioning remains of the pathological schizophrenic variety. Analysis of Test Data of Patient #13 (19 year old hebephrenic schizophrenic; ill 10.0 months; had previous electroconvulsive treatments in Jan. 1948, number

270 unknownj 14 electroconvulsive treatments in present series.) The post-treatment Rorschach record of this patient in­ dicates some superficial Improvement, but no alteration in the basic schizophrenic pattern of personality malfunctioning. Reaction to emotional stimulation remains unadaptive, though not to the same pathological extent as pre-treatment.

After

treatment, fewer controls on the tendencies toward impulsive­ ness and emotional outburst are present.

There is seen more

blocking and repression and less spontaneity post-treatment. Indicators of anxiety and depression are no longer present after treatment.

Less bizarreness is seen, but other patho­

logical indicators,

such as perseveration, are still present.

Some improvement in reality testing ability is seen, although this remains at the pathological level. There is somewhat increased responsiveness to the Thematic Apperception Test (mean number of words per story increases from 25*8 to 46.2), although this remains minimal, and there is a slight increase in the number of formally ade­ quate stories related.

Personal references are no longer pres­

ent and 3 stories involving interpersonal interaction emerge post-treatment, whereas none are present pre-treatment. Stories are generally sparse and tend to be descriptive. After treatment the environment is regarded as more frustrating and dominating and the characters tend to react in a more neurotic manner than before treatment.

There is a slight change after

treatment in that the characters are more hopeful and confi­ dent, and more of the story-endings are satisfactory to the

271 individual. The Color-Form Sorting Test shows slight change.

Un­

satisfactory solutions were given before and after treatment (ratings of 1 and 1 ) but pathological patterning appears post­ treatment.

The patient continues to function on a concrete

level. The Draw-a-Person performance increases in combined rat­ ing from 2 to 4 but remains very disturbed and pathological. Concept of body image remains poor and disordered. The Bender-Gestalt results indicate a slight improvement (rating of 2 pre- and 3 post-treatment) in visual-motor per­ formance, and though the number of pathological indicators decreases from 4 to 3, the after-treatment record is still clearly pathological. The Word-Association Test continues to indicate low con­ formity and highly individualized responses; although the number of association disturbances decreases from 43 to 15 and the number of reproduction failures decreases from 19 to 8 , the post-treatment results still indicate a high degree of emotional disturbance and immediate memory impairment. In summary, the post-treatment test battery of this pa­ tient indicates superficial improvement in personality func­ tioning, but the extent of improvement merely renders the ex­ tremely pathological condition less so, and does not alter it markedly away from the pathological schizophrenic personality picture that was seen pre-treatment.

272 Analysis of Test Data of Patient #14 (33 year old paranoid schizophrenic; ill 22.0 months; had 20 electroconvulsive treatments in 1946; 20 electroconvulsive treatments in present series.) This patient was the least productive of the group; he rejected the Rorschach, Thematic Apperception, Color-Form Sorting and Word-Association Tests before and after treatment. He was included in the study only because cooperative pre- and post-treatment and

1 - he was fully 2 - he gave full

performances on the two remaining tests of the battery, per­ mitting some evaluation of the results of his electroconvul­ sive treatment. The Draw-a-Person Test indicates slight positive change, but results are still bizarre and pathological.

Better formal

performance is seen in the increase in Goodenough scores; 7*50 pre- and 8.00 post-treatment for the male figure; 5»25 preand 7.00 post-treatment for the female figure.

Slightly more

mature concept of body image is thus seen. There is slight change in the Bender-Gestalt performance. Over-all rating remains abnormally low at 1 and the number of pathological indicators increases from 5 to 6 post-treatment. There is seen little ability to conform to the demands of reality in even a simple situation. In summary, although a full battery is lacking on this patient, the test results available, in addition to the in­ ferred significance of his refusal of most tests, pre- and post-treatment, indicate that his functioning continues at a

273 grossly pathological level of personality adjustment. Analysis of Test Data of Patient #1? (28 year old hebephrenic schizophrenic; ill 45.0 months; had previous course of 32 electroconvulsive treatments in 194-5; 20 electroconvulsive treatments in present series.) Few indications of change appear in the post-treatment Rorschach record, and for the most part it remains the per­ formance of a highly schizophrenic individual and does not 'evidence any marked change in basic personality functioning. Emotional response is impulsive and inadequately controlled; reality testing ability is as impaired after treatment as it was before.

The record is still marked by peculiar behavior,

bizarreties, personal references and perseverative responses. There is a slight decrease in anxiety indicators, thinking disturbance is still evident.

A gross

He remains unrealis­

tic and unable to deal with others in his environment. His Thematic Apperception Test shows an increase in pro­ ductivity (mean number of words per story increases from 32 *6 to 120.7 ), but a decline in number of stories, because post­ treatment Cards 4 and 5 become extremely disturbing to him and are rejected.

His stories, pre- and post-treatment, are

formally inadequate.

The number of pathological personal

reference stories increases markedly after treatment.

His

stories post-treatment indicate highly delusional tendencies. No changes of interpretive significance occur in the content of his stories.

274 On the Color-Form Sorting Test adequate solution is possible only after demonstration, pre- and post-treatment. There is no change in rating value (2 and 2) and performance is on a relatively concrete level. In the Draw-a-Person Test there is seen marked formal improvement

(Goodenough total change of «-5*00) and slight

improvement in terms of rating value (6 to 7)* The Bender-Gestalt is slightly improved in rating value (1 to 2), with a decrease in pathological indicators from 4 to 3>

remains highly pathological.

The Word-Association Test was not taken by this patient. In summary, despite some superficial indications of i m ­ provement, the test battery indicates that this patient con­ tinues to function in an unrealistic, emotionally disturbed manner and remains the performance of a highly schizophrenic individual whose basic personality malfunctioning remains unaltered. Analysis of Test Data of Patient #16 (34 year old simple schizophrenic; ill 24.0 months; had pre­ vious course of 36 insulin coma treatments in 1946; 6 electro­ convulsive treatments in present series.) On the Rorschach, this patient shows change after treat­ ment in that his emotional responsiveness, although still pathological, has toned down to a large extent; he no longer gives a tremendously large number of immature and impulsive color responses.

There are fewer indications of anxiety and

275 tension and there is a decrease in fantasy and ideational ac­ tivity.

Otherwise, functioning remains approximately the

same: a serious thinking disturbance, somewhat poorer reality testing ability and low conformity and pathological responses are present.

Range of interests is less broad and there is

less interest in other people seen. Productivity on the Thematic Apperception Test decreases markedly (mean number of words per story 222.2 pre- and 121.6 post-treatment).

There is a slight increase in the number of

formally adequate stories, but most remain inadequate.

There

is slightly decreased interpersonal interaction shown in the stories.

The pattern of needs remains constant, with empha­

sis on belonging.

The environment is seen as more frustrat­

ing post-treatmentj the principal characters react in a slightly more neurotic manner and generally are more inade­ quate, but less anxious and fearful; the endings of the stories remain unsatisfactory to the individuals in them. In the Color-Form Sorting Test he was able to function on an abstract level and completed adequate performance with good explanation, pre- and post-treatment, for ratings of 5 and 5 * His Draw-a-Person Test shows no changes after treatment and remains on a low level, with many indications of patholo­ gy still evident. concept.

There has been no change in his poor self-

The Bender-Gestalt Test also remains unchanged,

with a low rating and 4 pathological indicators before and after treatment.

27 6 On the Word-Association Test there is hut slight change. Reaction time increases (2.1 ” to 3.1"), conformity remains low, the number of association disturbances remains an index of emotional disturbance (10 to 7), and immediate memory function is slightly poorer, although still comparatively good. In summary, this patient shows change after treatment mainly in that his emotional response is less disturbed and anxiety and tension are no longer as evident.

There is no

doubt that serious personality pathology still exists, how­ ever, as manifested by poor reality testing, disturbed emo­ tionality, poor self-concept and inability to adapt success£-0 t'

fully to simple situations.

L x . -v ■.

v ..,

.

u.

Basically, he remains to function

as a pathological schizophrenic personality. Analysis of Test Data of Patient #17 (27 year old catatonic schizophrenic; ill 17*0 months; had 9 previous electroconvulsive treatments in 194-75 20 electro­ convulsive treatments in present series.) The Rorschach data indicate that this patient has be­ come unresponsive and emotionally "flattened," to an extreme. He is highly blocked and more repressed.

Reality testing a-

bility continues to be poor and the slight indication seen pre-treatment of ability to deal effectively with the emo­ tional aspects of the environment is no longer seen.

He be­

comes far less, and to a more pathological degree, reactive to his environment.

277 Reactivity to the Thematic Apperception Test stimulus material (possibly because it is more structured and less threatening) increases somewhat (mean number of words per story 6l.5 and 93.8, pre- and post-treatment). merly rejected is responded to.

A card for­

There is an increase in the

number of formally inadequate stories, 2 to 4, and an in­ crease in instances of pathological personal reference. Posttreatment the environment is regarded as more thwarting and punishing.

His characters react in neurotic patterns, al­

though slightly less inadequately* On the Color-Form Sorting Test his performance becomes poorer.

Rating decreases from 5 to 3; post-treatment solu­

tion requires a demonstration, while the pre-treatment solu­ tion was spontaneous.

\

His Draw-a-Person Test remains extremely pathological and formally immature.

There is a slight gain In Bender rat­

ing (2 to 3 )} the number of pathological indicators decreases from 3 to 2.

Performance still indicates poor perception and

inadaptability in a simple situation. The Word-Association Test performance worsens appreci­ ably: reaction time increases (1.5" to 3»5")> there is less conformity and more individualized responses (zero scores of 6 and 11), the number of association disturbances increases from a previous pathologically high number (30 to 33) and reproduction failures are more common (5 to 15), indicating great difficulty in immediate memory function. In

su m m a r y ,

it may be stated that this patient shows no

278 changes after treatment that indicate even minimally that his personality functioning is less pathological than previously. He appears to have lost ground in emotional adaptivity, ab­ stract ability and contact with reality. Analysis of Test Data of Patient #l8 (26 year old catatonic schizophrenic; ill 4-6.0 months; no previous physical treatment; 13 electroconvulsive treatments in present series.) The post-treatment Rorschaeh record of this patient shows increased blocking and retardation and decreased productivity. Reality testing ability has declined markedly.

Delusional

trends are seen in his self-referential movement responses. After treatment he becomes less sensitive, fearful and anxious, although some degree of depression comes into view.

He is

less reactive to emotional stimulation but his mode of reac­ tivity is unchanged from one which is unmodulated by demands of the reality situation.

His over-all degree of disturbance,

as measured by the Monroe technique, changes slightly from 11 1

to 13 indicators. His productivity to the Thematic Apperception Test is low and remains unchanged.

There is slight increase in the

number of formally adequate stories, 2 to 3*

a slight in­

crease in the number of pathological personal references. More needs, particularly for achievement, are shown; the en­ vironment is seen as less frustrating and more friendly and the characters are somewhat more adequate.

There is seen a

279 change toward more favorable story endings which are satis­ factory to the individual and to society. Improvement is seen in abstract ability, as measured by the Color-Form Sorting Test.

Post-treatment a spontaneous

solution is performed, while pre-treatment no solution was accomplished.

The rating increases from 1 to 5* although

pathological patterning is present both before and after treatment. Drawings remain on a comparatively high level, and im­ prove in terms of formal characteristics (Goodenough total increase'of 1.50).

On the Bender-Gestalt Test performance

improves markedly (rating change from 3 to 5) and no patholo­ gical indicators appear after treatment.

Improvement in self-

concept and visual-motor ability is seen, and adaptability in simple situations increases. The Word-Association Test results are essentially un­ changed, and continue to indicate evidence of association disturbances and impaired immediate memory function. In summary, this patient has made some superficial im­ provement in personality functioning, particularly in simple, more structured situations, but remains a basically disturbed, schizophrenic individual. Analysis of Test Data of Patient #19 (27 year old paranoid schizophrenicj ill 52.0 months; no pre­ vious physical treatment; 11 electroconvulsive treatments in present series.)

280 After treatment, this patient's Rorschach remains that of a highly over-ideational individual who is unable to per­ ceive reality in an adequate manner.

He is less reactive emo­

tionally^ but continues to function in this area in an imma­ ture, egocentric manner, coupled with increased tension and anxiety.

Range of interests and responsivity are lowered.

A thinking disturbance remains present.

He is more involved

and preoccupied with his own ideation and fantasy activity to the exclusion of being receptive to environmental stimulation. The Monroe score indicates a greater degree of maladjustment (13 maladjustment indicators pre-treatment, 21 post-treatment). His over-all productivity to the Thematic Apperception Test decreases, despite his refusal of 3 cards pre-treatment and only 2 post-treatment. adequate.

None of his stories is formally

Little interpersonal interaction is present and a

pathological personal reference appears post-treatment.

The

environment is seen as more frustrating and the characters tend to react in a more neurotic, inadequate manner after treatment.

The T.A.T. is very disturbing to him, before and

after treatment. On the Color-Form Sorting Test he indicates, before and after treatment, good abstract ability, and he is able to per­ form adequate solutions without patterning (ratings of 5

5) •

His drawings show a slight increase in bizarrety and poor self-concept, and formally are poorer and less mature after treatment• The Bender-Gestalt shows a change in that 2 pathological

281 indicators are no longer present after treatment. On the Word-Association Test average reaction time in­ creases (2 .0 " to 6 .1 "), there is a decrease in conformity (Kent-Rosanoff count 157 to 127, zero scores 2 to 6), no change in a high number of association disturbances (21 and 20), but a marked impairment in immediate memory (reproduc­ tion failures 1 pre- to 10 post-treatment). In summary, this patient shows little change in over-all personality functioning after treatment.

He remains over-

ideational, out of contact with reality, emotionally dis­ turbed and presents an increased amount of anxiety and tension. Analysis of Test Data of Patient #20 (33 year old paranoid schizophrenic; ill 29 «0 months; had previous series of 7 electroconvulsive treatments in 1947J 10 electroconvulsive treatments in present series.) This patient's Rorschach tests, pre- and post-treatment, were too sparse, evasive and over-controlled to be of inter­ pretative significance (8 and 4 total responses respectively). The only conclusion that can be drawn is that his functioning on this test remains extremely pathological and deviant. On the Thematic Apperception Test his responsiveness in­ creases (mean number of words per story is 3°»2 and 86.8 preand post-treatment) •

There is an increase of 2 in the number

of formally adequate stories, and more post-treatment stories involve interpersonal interaction.

A pathological personal

reference appears in one of the post-treatment stories.

The

282 environment is generally seen as helpful, more of his charac­ ters are viewed as adequate after treatment, and more of the story endings are satisfactory to the individual* His perfect performance, pre- and post-treatment, on the Color-Form Sorting Test (ratings of 5 and 5) indicates no change from a high degree of abstract ability* No change is seen in his drawings after treatment*

For­

mal quality of his productions is high, pre- and post-treatment* His Bender-Gestalt performance indicates improvement in visual-motor perceptual ability and adaptability in simple situations.

His rating increases from 2 to 3 and the patho­

logical indicators rotation, regression and destrustion of gestalt no longer appear.

Less pathology is evident here*

On the Word-Association Test his performance remains generally adequatej conformity is somewhat higher (decrease in zero scores from 2 to 0 ) and there is present a minimal number of association disturbances (2 and 4).

There is a

slight decrease in reproduction failures (5 to 4), indicating that immediate memory functioning is still disturbed. In summary, this patient shows signs of superficial im­ provement in his performance with more structured, objective material, but his suspiciousness and inability to function in a more amorphous situation (Rorschach) indicate that basically he continues to function on a pathological personality level. No basic change in the schizophrenic structure is seen after treatment.

283 Comparison of Changes in Personality Functioning With Respect to Certain Factors In the following section is presented an analysis of the data with respect to differential effects of electroconvulsive therapy on patients of different ages; with varying durations of illness; of different schizophrenic sub-diagnoses; and with respect to whether the patient had received electrocon­ vulsive therapy prior to the present series of treatments. The comparisons which follow are based primarily on the in­ dividual analyses of results of the test battery of the in­ dividual patients, which were presented in the preceding section* Comparison of Changes in Personality Functioning with Respect to Age of Patients Utilizing Table I, Chapter III, the patients were di­ vided into three age groups: age 19-25* comprising 6 patients

(#4, 5* 8 , 9 , 11, 13); age 26-29, comprising 9 patients (#1, 3 , 7 , 10 , 1 2 , 1 5 , 1 7, 1 8, 19); and age 30-34* comprising 5 patients

(#2, 6 , 14, 16, 20).

A comparison of over-all ef­

fect of electroconvulsive treatment on personality function­ ing was made among these three groups, utilizing the individ­ ual analyses presented in the preceding section, and is shown in Table

6l

on the following page.

284 TABLE

6l

Effect of Age on Over-all Change in Personality Functioning

Age Group

N 6 9

19-25 26-29 30-34

__ 1

Totals

20

Considerable Improvement 1 ---

1

Superficial or Slight Improvement

No Chanee Worse

4 6 __3

1 __2

1 2 __

13

3

3

It appears from the above table that, within the age range of patients in this study, age differences had little effect on the over-all personality changes that occurred af­ ter a series of electroconvulsive treatments* Comparison of Changes in Personality Functioning with Respect to Duration of Illness The patients were also divided into three groups on the basis of duration of psychiatric illness prior to commence­ ment of the present series of electroconvulsive treatments: patients ill less than 2 years, comprising 7 patients (#1 , 2 , 3 * 5 * 1 3* 14* 1 7 )j patients ill 2 to 3 years, comprising 6 patients (#4, 6 , 7, 8 , 9, 20)j and patients ill longer than 3 years, comprising 7 patients (#1 0 , 1 1 , 1 2 , 1 5 , 1 6 , 1 8 , 1 9 )• An analysis of the comparison of the over-all effect of electroconvulsive treatment on personality functioning of these three groups is presented in Table ing page.

62

on the follow­

285 TABLE 62

Effect of Duration of Illness on Over-all Change in Personality Functioning Superficial or Slight Improvement

Duration of Illness

N

0-24- months 25-36 » 37* "

7 6 JL

_1_

4

Totals

20

1

13

Considerable Improvement

5 4

No Change

Worse

1 1 1

1 1 1

It is apparent from the table above that duration of illness was not a factor in the over-all changes in personal­ ity functioning that occurred in the group under investigation. Comparison of Changes in Personality Functioning with Respect to Schizophrenic Sub-Diagnosis

Utilizing Table I, Chapter III, it is seen that the pa­ tient group comprises 8 hebephrenic schizophrenics (#4, 5 , 7 » 8 , 9 , 1 0 , 13, 15), 5 catatonic schizophrenics (#1 , 3 , 1 2 , 1 7 , 18) and 6 paranoid schizophrenics (#2, 6, 11, 14, 19, 20). An analysis of the comparison of the over-all effect of elec­ troconvulsive treatment on personality functioning of these three groups is shown in Table

63

on the following page.

(One patient (#16) was classified as a simple schizophrenic and is not included in this comparison.)

286 TABLE

63

Effect of Sub-Diagnosis on Over-all Change in Per­ sonality Functioning SubDiagnosis

N

Hebephrenic Catatonic Paranoid

8 5 6 19

Totals

Superficial Considerable or Slight Improvement Improvement

No Change

Worse

6

1

1

4 2

2

1 1 1

1

12

3

3

It is seen that the schizophrenic sub-classification had no effect on the over-all changes in personality func­ tioning which occurred in the group under study.

It is also

seen that the paranoid sub-group presented more variable re­ sults than did either the hebephrenic or catatonic. Comparison of Changes in Personality Functioning with Respect to Previous Electroconvulsive Treatment It is seen in Tables I and VII, Chapter III, that 7 pa­ tients in the group had never previously received any form of physical psychiatric treatment (insulin coma or electrocon­ vulsive) before the present series (#1 , 2 , 3 , 5> It 1 8 , 1 9 ). Ten of the patients received a course of electroconvulsive treatment prior to the present series (#4, 8, 10, 11, 12, 13, 14, 15, 17, 20).

A comparison of the over-all effects of the

present course of electroconvulsive treatments was made be­ tween these two groups and the results of this comparison are presented in Table 64

on the following page.

(Three pa­

tients (#6, 9, 1 6 ) received prior courses of insulin coma

287

therapy and were not included in this comparison.)

TABLE

64

Effect of Previous Electroconvulsive Treatment on Over-all Change in Personality Functioning Superficial Considerable or Slight No Improvement Improvement Change Worse

Status

N

Previous E.C.T. No prev.treatment

10 7

1

17

1

Totals

6 6

2

12

2

1 _

^

2

It is seen that, for the group under investigation, the consideration of whether a patient had or did not have pre­ vious electroconvulsive treatments did not appear to influence the over-all changes in personality functioning that occurred after the present series of treatments. It should be emphasized that the preceding four compari­ sons are suggestive, and are not presented as conclusive, be­ cause of the small number of patients in each group discussed. It should further be emphasized that these evaluations were made against the criterion of personality functioning prior to treatment, as measured by the test battery employed in this study, and not against the criterion of normal per­ sonality functioning.

It was clearly indicated in the in­

dividual analyses of the test battery of each patient that, despite the greatest amount of positive change In personality functioning indicated, every patient presented, post-treatment, a definite picture of basically pathological schizophrenic

1

288 functioning* Summary In this chapter the group data were analyzed for changes in personality functioning.

This analysis was performed on a

test-by-test basis. The result of major importance in the comparison of the Rorschach data was seen to be in the area of emotional reac­ tivity.

The patient group, post-treatment, was no longer apt

to be as emotionally uncontrolled, explosive and regressed as it was pre-treatment; this change in personality functioning was seen to occur not because positive adaptive behavior emerged, but because emotion-producing stimulation was more ignored and therefore less response-producing.

Despite this

change in the direction of more emotional control, the group as a whole still tended, after treatment, to remain emotion­ ally unbalanced. It was seen that less ambition and "push1’ were present post-treatment* A suggestive decline in poor form responses occurred post-treatment, indicating a slight gain in reality testing ability, although after treatment reality testing ability was still typical of personality malfunctioning. There was a decrease of indicators of anxiety and de­ pression, although not statistically significant. Post-treatment records tended to show fewer responses; they were more concise and less rambling.

289 Fewer signs of negativism and hostility were seen. Despite changes that occurred, it was stated that post­ treatment the Rorschach records for the group as a whole in­ dicated clearly that basic personality functioning remained on a schizophrenic level. On the Thematic Apperception Test the group was seen to be more productive and more successful in following instruc­ tions.

An increased desire for relationship with other in­

dividuals was seen in the increase in the number of stories which involved interpersonal relationships. sexual identification occurred.

No changes in

Changes in more deeply-

rooted, life-long patterns of attitudes toward the environ­ ment and concept of self in relation to the environment were not seen, after treatment.

These patterns remained unsatis­

factory for the group as a whole. The only difference of statistical significance that oc­ curred in the Word-Association Test results was seen to be a slowing of speed of reaction.

No change was obtained post­

treatment in conformity of associative process, judgment, auto< criticism or immediate memory function. The basically concrete attitude of the group, as mea­ sured by the Color-Form Sorting Test, was seen to be unchanged after treatment.

Impairment of ability to function on an ab­

stract level was seen pre- and post-treatment. The Draw-a-Person Test indicated a lessened tendency to view the female as dominating after treatment.

A more real­

istic conception of body image in terms of size and less

290 tendency toward grandiosity and feelings of power related to size were found to obtain.

On an over-all basis, improve­

ment in the drawings after treatment was seen by a committee of judges, but in terms of pathological indicators present in the post-treatment drawings it was stated that clear in­ dications of personality malfunctioning remained apparent. Post-treatment results of the Bender-Gestalt Test tended to indicate a decrease in the number of pathological indica­ tors present.

Suggestive changes toward slightly higher de­

gree of planning ability, foresight, auto-critical judgment and control were seen.

A greater adherence to the reality

of this testing situation tended to obtain.

The indications

of improved personality functioning found were qualified by the fact that the group did not show such improvement as to move the test results out of the range of pathological per­ sonality functioning.

The post-treatment records for the

group as a whole were still identifiable as those of basically schizophrenic individuals. The test battery of each patient was analyzed on an in­ dividual basis, with emphasis placed on the changes in per­ sonality functioning after electroconvulsive treatment. Comparisons were made to determine the effects, within the group studied, of age, duration of illness, schizophrenic sub-diagnosis and whether the patient had received a prior series of electroconvulsive treatments.

None of these com­

parisons revealed differences in changes in personality func­ tioning among any of the groups compared.

CHAPTER VI

SUMMARY, CONCLUSIONS AND DISCUSSION Summary This study was directed at determining and evaluating changes, through use of a battery of psychological tests, in personality functioning of a group of electroconvulsivetreated schizophrenics. The subjects were twenty schizophrenic patients hospi­ talized and treated at the Northport Veterans Administration Hospital.

These patients were all definitely diagnosed as

schizophrenics by the psychiatric staff of the hospital and their diagnoses were uncomplicated by additional diagnoses, such as tuberculosis, alcoholism, epilepsy, et cetera.

The

patients were between the ages of nineteen and thirty-four and were all male veterans of World War II. The group comprised one simple schizophrenic, eight hebephrenics, five catatonics and six paranoids.

All pa­

tients completed at least six years of school and had a mean educational level of 10.6 years.

Average duration of ill­

ness was 3 0 .7 months and all but four of the patients had been hospitalized previously.

Seven patients had received no

previous physical psychiatric treatment.

The number of elec­

troconvulsive treatments in the course of therapy dealt with in this study varied from six to twenty-one, with a mean of

292 15*3 treatments. The battery of tests selected to provide a picture of changes in personality functioning after electroconvulsive treatment was composed of the Bender Visual-Motor Gestalt Test, the Rorschach Psychodiagnostic Test, the Word-Association Test,

the Draw-a-Person Test, the first five pictures of the

Thematic Apperception Test and the Weigl-Goldstein-Sheerer Color-Form Sorting Test#

Each test and its method of ad­

ministration was fully described, as was the procedure uti­ lized in scoring and evaluating each test. The effect of electroconvulsive treatment on personality functioning was studied by means of the test battery, with particular reference to productivity, reality testing abili­ ty, conformity,

emotional reactivity, breadth of interests,

self-concept and body image,

attitudes toward the environ­

ment and other people in the environment, adaptivity, effec­ tiveness of thinking, abstract ability, association processes, judgment,

auto-critical ability, ambition and drive and patho­

logical indicators in personality functioning. It was found that total personality functioning was com­ paratively improved after electroconvulsive treatment in the areas of better control of emotional response and reality testing ability.

There was a decrease of indicators of anx­

iety and depression.

Fewer signs of negativism and hostility

were seen after treatment.

The patients tended to be more

concise and less rambling in their responsiveness. Somewhat increased productivity to stimulus material was

293 seen.

The patients showed increased desire for relation­

ship with other individuals in their environment.

Changes

in more deeply-rooted, life-long patterns of attitudes toward the environment and concept of self in relation to the environment were not seen.

These patterns remained un­

satisfactory for the group as a whole after treatment. Conformity of associative processes,

judgment and auto-

critical ability was shown by the results of the total test battery to be basically unchanged.

The group, after treat­

ment, continued to function on a concrete level with respect to basic attitude. A lessened tendency to view the female as dominating obtained after treatment.

A comparatively more realistic

concept of body image was shown. It was stated that despite indications of improvement from pre-treatment personality functioning, the test battery records of the group were still identifiable as being basi­ cally schizophrenic.

A pattern of personality malfunction­

ing obtained after treatment that included distorted view of reality and poor reality testing, lack of conformity in perception, imbalance in emotional-response pattern, im­ maturity, impaired thinking ability, abnormal association process, concretistic attitude, inadaptability in simple situations, generalized view of the environment as basically frustrating, threatening and dominating, and other indica­ tions of personality malfunctioning.

294

Conclusions On the basis of the findings given above and under the delimitations of the study noted, it is concluded that: 1.

The total pattern of personality functioning of

schizophrenics who have received electroconvulsive treat­ ments remains basically schizophrenic.

Patients who have

undergone such treatment become more cooperative, less hostile and negativistic and may be more amenable to other readjustment procedures, such as psychotherapy, but re­ main highly atypical and ill individuals. 2.

Superficial and symptomatic changes occur in the

areas of emotional control and responsivity, more adequate reality testing ability, greater interest in interpersonal relationships and less anxiety and depression. 3.

Electroconvulsive treatment does not result in

losses in personality functioning of schizophrenics. 4.

The changes in personality functioning of elec-

troconvulsive-treated schizophrenics vary considerably; the effects of such treatment on total personality function­ ing in a clinical situation, with respect to an individual patient, 5*

cannot validly be prognosticated. Changes in total personality functioning do not

v a r y because of the effect of factors such as age, duration of illness, previous electroconvulsive treatment or

295

schizophrenic sub-diagnoses* Discussion The conclusions of the present study, arrived at through the use of a battery of psychological tests, tend to agree with independent psychiatric findings obtained through the medium of observation and interview techniques. Thus, a group of psychiatric experts, pooling their ex­ perience in electroconvulsive therapy, has stated, "Any im­ provement which occurs appears to be due to modification of the affective c o m p o n e n t s . T h e

findings of the present in­

vestigator are in accord with this statement.

In discussing

the changes in emotional functioning of the schizophrenic group studied it was stated that the patients, after treat­ ment, were more emotionally controlled, less impulsive, less egocentric and less explosive.

Indeed, this was stated to be

one of the raa^or changes that occurred in the personality functioning of these patients.

In line with the conclusion

relating to the unchanged schizophrenic personality function­ ing of the patients after treatment, this same group of psy­ chiatrists stated,

"The schizophrenic personality is not al­

tered by electro-shock t h e r a p y . T h i s

finding, clinically

obtained, was also stated by Ozarin.3

1. 2. 3.

Group for the Advancement of Psychiatry, Committee on Therapy, Shock Therapy. Report Wo. 1, September 15, 1947, P. 1 Loc. cit. L. D. Ozarin, Electric Shock Therapy. Technical Bulletin V.A. 10-500, November 5, 1947, p. 12

296 The findings of this study were also in substantial a1 p greement with those of other psychological investigators, who utilized only single or a few tests. In this study it was seen that no changes in personality functioning which were sufficient to change the basic schizo­ phrenic pattern occurred.

Symptomatically, or in terms of

better hospital manageability, electroconvulsive treatments are probably of benefit to schizophrenic patients and to those who care for them.

In terms of therapy, or personality re­

adjustment, however, it is seen that electroconvulsive t r e a t ­ ment used alone is not fruitful or beneficial in the long run. The view that electroconvulsive treatments are therapy in and of themselves has not been demonstrated, and may lead to the abuse, deplored by the Committee on Therapy of the G.A.P.,

of

the use of electro-shock treatment as "the sole therapeutic agent, to the neglect of a complete psychiatric program."3 The present investigator also concurs in condemning the im­ mediate use of electroconvulsive treatment to the exclusion of adequate psychotherapeutic attempts. It is believed that the superficial positive personality changes that occur after electroconvulsive treatment, as indicated in this study, are potentially of value in a combined 1^

2. 3.

B. L. Pacella, Z. Piotrowski and N. D. C. Lewis, "The E f ­ fects of Electric Convulsive Therapy on Certain Person­ ality Traits in Psychiatric Patients," American Journal of Psychiatry. 104, (August 1947), p* 90 J. A. P. Millet and E. P. Mosse, "On Certain Psychological Aspects of Electroshock Therapy," Psychosomatic M e d i c i n e . 6, 1944, pp. 226-236 Group for the Advancement of Psychiatry, op. c i t ♦« p. 1

297 treatment program, in which individual and group psycho­ therapy and various rehabilitation procedures receive the degree of emphasis which shock therapy alone now receives in the usual current hospital practice. It may be true that "Man loves magic, be he patient or physician,

and an electrical current which shocks into un­

consciousness and convulsions, yet is capable of producing apparently miraculous benefits, comes close to that for which we all have some degree of longing,"! yet the problem of readjusting the personality functioning of as seriously pathological persons as schizophrenics is believed to involve more effort than the application of "magic." Future Research Possibilities Future research possibilities that are believed to be of potential contribution include studies of the changes in per­ sonality functioning of patients who are treated in a com­ bined program, as previously mentioned; studies designed to make possible specific prognoses for individual patients; and further standardization studies on the tests used in the battery employed in this study, particularly the Draw-a-Person and Bender-Gestalt Tests. A Note on the Test Battery Approach The tests of the battery employed in this study which were found to be of greatest value were the Rorschach and Thematic

1.

Millet and Mosse,

op.

cit.. p. 227

298 Apperception Tests. The other tests,

however, were of great

value in supplementing and rounding out the personality findings.

Use of a battery of tests, furthermore, minimizes

the danger of overlooking aspects of the functioning of some patients.

The author is reminded,

in this context, of a pa­

tient (not included in this study) who was extremely wellcontrolled and sufficiently evasive to cast doubt in the mind of the examiner that he was malfunctioning in any way. When he was tested with the Color-Form Sorting Test, however, he performed the correct solutions and then added, it another way."

Askedhow, he replied,

"I can do

"By odor." Inquiry

left little doubt regarding his pathological status. Use of a battery approach in psychological examination is by this time the only acceptable practice, but the im­ portance of this approach was re-emphasized for the investi­ gator in the course of this study.

Valuable information r e ­

garding the functioning

of many patients

would have been lost

if a single test of the

battery had been omitted.

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~

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5B3-596. Rorschach, H., Psychodiagnostics. Eerne, Switzerland: Hans Huber Verlag, 194-2. P. 2 3 8 . Rosanoff, A. J., Manual of Psychiatry and Mental Ihgiene. New York: John Hi ley, 193 8 . P- XVIII * 1091. Rosen, 3. R., Eecunda, L., and Finley, h. H., "Shock Therapy; Conservative Approach to Use, Including Study of Dlectroencephalographic Tracings Before, During and After Therapy, " Psychiatric Quarterly. 17; 194-3; PP* 6.17-641. Rosenzweig, 3., Psychodiagnosis: An Introduction to Tests in Clinical Psychology. New York: Grune and Stratton, 194-9. P. 350. Rotter, J. B., "Studies in the Use and Validity of the Thematic Apperception Test with Mentally Disordered Patients: I. Method of Analysis and Clinical Problems, 11 Character and Personality. 9, 1940, pp. 16-3 4 . _____________ , "Thematic ApperceptionTests: Suggestions for Administration and Interpretation," Journal of Personality. 15; 1946, pp. 70-92. Sakel, II., The PharmacologicalTreatmentof Schizophrenia. New York: Mental and Nervous Disease Monograph Series, Number 62, 1938 . P. XVIII * 136. Salzman, L. , "An Evaluation of Shock Therapy, / 1 American Journal of Psychiatry. 103 (March, 194-7), pp. 6 6 9~ 79• sands, D. E., "Electro-Convulsion Tii-.-rapy in 30I Patients in a General Hospital: "kith opecial Refer'. :Cc to Selection of Cases and Response to Treatment," British Medical Journal, 44-69, 194o, pp. r ' l ' . j ' j - ■ i ' ) j . Sargant, , and Slater, E., An Introduction to Somatic methods of Treatment in Psychiatry. Baltimore: Williams and WilkinS Company, 194o, P. XII * 171. Schafer, R., The Clinical Application of Psychological Tests. New York: International Universities Press, 194c. P. 346.

/

314 Sohilder, P., “Notes on Psychology of Metrazol Treatment of Schizophrenia,“ Journal of Nervous and rental Disease, 89 (February, 1 9 3 9 ), pp. 133-144. dchnack, G. F., Shakow, D., and Lively, M. L., “Studies in Insulin and Metrazol Therapy: I. The Differential Prognostic Value of Some Psychological Tests,''1 Journal of Personality. 14 (December, 1945), pp. 106-124. , "Studies in Insulin and Metrazol Therapy: II. Differential Effects on Some Psychological Functions," Journal of Personality, 14 (December, 1945), pp. 125-149. Shepley, N. H., and McGregor, J. S., “Clinical Application of Electrically Induced Convulsions, 11 Proceedings , Ro:va1 Society of Medicine, 33> 1940, pp. 267-274. Sherman, I., Mergener, J., and Levitan, D., "The Effect of Convulsive Treatment on Memory." American Journal of Psychiatry. 98 (November, 1941), pp. 401-403. Shipley, N. C., and Rant, F., "The Insulin Shock and Metrazol Treatments of Schizophrenia With Emphasis on the Psycho­ logical Aspects," Psychological Bulletin. 37 (May, 1940), pp. 259-284. Smith, H. G., "Shock Therapy at the Essex County Hospital," Journal of the Medical Society of New Jersey. 4 3 , 1946, pp. I3 O-I3 3 . Smith, L. if., Hughes, J., Hastings, D. J., and Alpers, B. J., “Electroshock Treatment in Psychoses," American Journal of Psychiatry. 98 (January, 1942), pp. 55$-561.' ____________________________________________ , “Immediate and Follow-up Results of Electro-Shock Therapy." American Journal of Psychiatry, 100 (November, I9 4 3 ), pp. 351-354. Solomon, H. C., "Shock Therapy in the Military Services," in Manual of Military Neuropsychiatry. P. XI * 764 TSolomon, IT. C., and Yakovlev, P. I., Editors). Philadelphia: Vr. B. Saunders, 1944. Stainbrook, E. J., “The Rorschach Description of Immediate PostConvulsive Mental Function,“ Character and Personality. 12 (June, 1944), pp. 302-322. _________________ , “Shock Therapy: Psychologic Theory and Re­ search," Psychological Bulletin. 43 (January, 1946) pp. 2 1 -6 0 .

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New York:

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316

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APPENDIX

APPENDIX

A

Bender-Gestalt Designs

APPENDIX

A

Bender-Gestalt Designs

A.

1.

o

o 0 o

5.

o o

o

O

o o

o

o

o

o

O

o

o o

o

o

o

o

o

o

o

o

o

APPENDIX

B

iiS?* \

Rorschach; P s y c h o d i a g n o s t i c s

IX

P rin te d in U. S. A.

APPENDIX

C

AOUVUAMllUiH X£jUl ASSOCIATION TEST

Name Examiner

Age Sex

Ward Diag.

Date School

No.

a. 1.53

Grass Dream

b. Table 19.^1 Memory

38.E Mother

2.21

Sweet

20.10 House

39.E Favorite

3,__7

Soft

21.45 Trouble

40.DB Dick

4.37

Sleep

22.73 Religion

41.? Master

5.2

Dark

23.48 Hard

42.E Breast

6.93

Quiet

24.6

43.DB Bear

7-67

Hungry

25.26 Wish

44.?

8.38

Anger

26 .DB Steel

45.DB Hot

9.29

Beautiful

27.E

46.E Woman

10.5

Man

28.DB Fairy

47-E Stink

11.83

Loud

29 •E

43.?

12.72

Long

30.DB Yellow

49.DB Beat

13.66

Blue

31.?

50.E Father

14.25

Slow

32.DB Pussy

51.E Money

15.42

Working

33*?

Country

52.E Strength

16.75

Child

34.E

Kill

53-DB Drink

17.88

Heavy

35. E

Sex

54.? Whiskers

18.31

Rough

36.E

Death

55-E Wife

37.E

Love

56.E Suicide

Deep

Kiss

Show

>

Home

Cow

Feet

Key: .Number after decimal corresponds to number in K-R list; DB is doublebarreled stimulus word; E additional emotionally weighted words; ? Replace as required. RT-KR: Av.

Md.

N. 3"+

Fr.Sc.-KR:

RT-DB7B: Av.

Md.

N. 3"+

N.Cont-KR:

Recall fail-KR:

av

.

% Subjective (Av.20?)

Complex Indicators: LT, P, B, M, E, R, S, C} Q, Total: Repeat 1st 25 words before proceeding with remainder.

Md.

N.Ind.

N.A-N:N-A-KR:

% Speech Habit (Av.5)