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1972 Cognitive Distortion and Locus-Of-Control in Depressive Psychiatric Patients. Terrence James Laughlin Louisiana State University and Agricultural & Mechanical College

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LAUGHLIN, Terrence James, 1 9 H H - COGNITIVE DISTORTION AND LOCUS OF CONTROL IN DEPRESSIVE PSYCHIATRIC PATIENTS.

The Louisiana State University and Agricultural and Mechanical College, Ph.D., 1972 Psychology, clinical

University Microfilms, A XEROX Company , Ann Arbor, Michigan c o g n i t i v e d i s t o r t i o n a n d lccits o f c o n t r o l IN DEPRESSIVE PSYCHIATRIC PATIENTS

A Dissertation

Submitted to the Graduate Faculty of the Louisiana State University and Arricultural and Mechanical Collere in partial fulfillment of the requirements for the decree of Doctor of Fhilosophy

in

The Department of Psychology

hy Terrence .lames Lauahlin 3.A., Carle ton Nniversity, Ottawa, Canada. 1995. M.A., Carle ton I’niversity, Ottawa, Canada. 1998. Auaust, 197?. PLEASE NOTE:

Some pages may have

i nd i st i net print.

Filmed as received.

University Microfilms, A Xerox Education Company ACKNOWLEDGMENTS

To the many people who have gone out of their way to make this investigation possible, I wish to extend my sincere thanks.

Throughout my doctoral candidacy, Dr. Joseph G.

Dawson has provided helpful direction, supportive inter­ est and valued friendship for which I am particularly grateful.

Apart from serving on my doctoral committee, Dr.

Edwin 0. Timmons has had a strong positive influence on my working relationships with others and, by example, has stimulated an ever-deepening appreciation of my fellow man. The other members of my committee, Dr. Perry H.

Prestholdt, Dr. Felicia A. Pryor and Dr. Herbert G. Hicks have offered constructive criticism and suggestions through which this investigation has benefited immensely. Dr.

Kenneth L, Koonce of the Department of Experimental Stat­ istics gave generously of his time in reviewing, formul­ ating and modifying methods of statistical analysis.

Dr, Ronald S. Pryer, Dr. M.K. Distefano, Jr., and

Mrs. Margaret W, Pryer of Central Louisiana State Hospital provided stimulating encouragement in the developmental phases of this investigation. To James R. Bartsch, also of Central Louisiana

State Hospital, a special note of thanks. Without his total commitment, keen interest and many extra efforts, this investigation could not have been conducted. Mr.

Lewis De Cuir also contributed invaluably to the testing program. In addition, I am grateful for the complete cooperation extended by Dr. Julian C, Kennedy and all

Admissions Unit personnel who were involved in one way or another with this investigation,

I am indebted to Barbara S, Boyle for permission to reproduce the vocabulary section from the Shipley-

Institute of Living Scale. Partial funding of this investigation was provided by a Louisiana State University

Dissertation-Year Fellowship and by a research grant from the LSU Student Government Association.

Finally, and most of all, I would like to thank my parents, Mr. and Mrs. J. 0. Laughlin, for their unquest­ ioned support, my wife Karen for her complete devotion, help and infinite understanding, and my baby son Sean for sharing his first months of life with the preparation of this dissertation. TADLE of c c f t e f t s

FAGE TIr’ LE P A G E ...... i

ACK FCV/LEDGLEFTS...... ii

LIS T OF '"A FEES ...... vi

IJS f OF FIG1'R E S ...... vii

A 3S TRACT ...... viii

I . IFvRCD"CI’IO F ...... 1 Testinr for Cornitive Distortion ...... 22

Criterion Feasures of Depression and Locus

of C o n t r o l ...... 28

Problem ...... 30

hy p o t h e s e s ...... 33

II. •LET i: 0 D ...... 33

Subject:;...... 35

Subject Selection Faterials ...... 39

Test Vaterials ...... hi

P r o c e d u r e ...... 83

Ill RES FI T S ...... 8 s

.Responses to Semantic Differential Concepts

as a Functj ori oi’ Patient Type and Concept . . 58

iv TABLE OF CONTENTS (CONTINUED)

Highest, Lowest and Actual Performance

Estimates as a Function of Patient Type and

Trial ...... 5 6

Performance Evaluations and Patient Type. . 67

Locus of Control as a Function of Patient

yp>G 69

IV. d j s c ’s s i o n ...... 71

Semantic Differential Findings . , 71

Nehavioral ^cst Findings ...... 7/1

Locus of Control ...... 77

Few Directions for Treatment . . . 80

Su-mcstions for Further Research . 82

-IDLICCDAPNY

APPENDICES 103

VITA 1L6

v LIST OF TABLES

TABLE PAGE

1. Ranked Frequencies of Selection of Scales Considered Lost Relevant In Thinking About The Three C o n c e n t s ...... 2?

2. Summary of Feans, Standard Deviations and Ranges for Demographic Variables on which Patient Groups './ere Latched ...... J o

? • Summary of Ranges, Feans and. Standard Deviat­ ions of Concept Scores as a Function o 1 Patient, Type and Concept ...... 1-9

d . Summary of Analysis of Variance of Coneop EO'V-- • • 's' . '>f Patio t • s' Concent , ......

Cochr.ar.-Cox 'riest Applied to Differences Retwoon Patient Type Feans for each Concept r,°

r- • ’evaan-i'eu] s Procedure Applied to Differences, .-ctween Concept loans V/ithin Patient Tyne. . . ft

v. Summary of Ranmes, Feans and Standard Deviat­ ions of Performance Estimates as a Function of Patient Type and T r i a l ...... t'?

Summary of Analysis of Variance of iiiyhest Estimated Performance Scores as a Function of Patient Type ansi T r i a l ...... 60

M . Cochran-Cox Test Applied to .'differences between Patient Type Feans for each trial Fr.der ''i^hest, Lowest and Actual Estimate Coriditions...... 6.1

10. Fewman-Kouls Procedure Applied to Differences detv/eon Trial I ears for Hiyhest, Lowest and Actual Estimate Conditions ...... 02

11. Summary of Analysis of Variance of Lowest Estimated Performance Scores as a Function of Patient Type and T r i a l ...... 0 \

12. Summary of Analysis of Variance of Actual Estimated Performance Score:; as a Function of Patient Typo and Trial . on

v i. LIST OF FIGURES

FIGURE PAGE

1. Mean concept scores as a function of patient type and concept. 5 k

2. Mean estimates under highest, actual and low est estimate conditions as a function of patient type and trial. 58 ABSTRACT

The primary purpose of the present investigation was to test for existence of negatively distorted thought processes which Aaron Beck has described as characteristic of depression. A secondary objective was to investigate a relationship between patient type and locus of control.

Twenty-five depressive patients and 2^ nondepress-

ive patients, matched for age, sex, education and monthly earned income voluntarily served as subjects. No patients showed evidence of alcohol abuse, drug abuse, brain damage or schizophrenic process. All were first admissions who achieved a vocabulary score of 18 or more on the vocabul­ ary section from the Shipley-Institute of Living Scale.

Patient type assignment was based on clinical diagnosis and cutoff scores on the Beck Depression Inventory.

All patients were individually tested within 48 hours after admission. In part one, each completed the

Internal-External (I-E) Control scale and a specially- designed semantic differential consisting of three main concepts representing components from Beck's cognitive triad theory ("My life so far", "Myself", "My life as it will be"), one control concept ("Cat") and 24 bipolar, evaluative, adjective scales. Part two consisted of a specially-designed 3-trial, SO-block, letter-digit coding test for which performance scores were fixed at

37/^0, 41/50 and 47/50, Patients were asked to estimate

their highest possible, lowest possible and actual expect

ed scores for each trial, to rate their performance on

each trial under four conditions, and to explain why they

assigned the ratings they did.

As hypothesized, depressive patients scored

significantly lower (more negatively) than nondepressive

patients on each of the three main concepts of the seman­

tic differential. However, depressive patients' mean

score for "My life as it will be" was significantly highe

than their mean score for "My life so far" or "Myself",

There were no significant differences between groups

regarding the control concept. Also, as hypothesized,

depressive patients gave significantly lower mean estim­

ates of highest, lowest and actual performance scores on

all three trials of the coding test. Nevertheless, mean

estimates on trial 3 were significantly higher than on

trials 1 or 2 for patient types combined. Contrary to prediction, there was no evidence of a significant assoc­

iation between patient type and positive/negative per­

formance rating on any trial, under any of the four con­

ditions. Also, contrary to prediction, depressive pat­

ients scored significantly higher (more externally) on the I-E scale than did nondepressive patients.

Although the overall strength of Beck's triad theory was questioned, it was concluded that negative thought distortion is an important pathognomic feature of depression and that an external orientation may be more important in the dynamics of depression than an internal orientation. New directions for treatment were discussed and suggestions for further research presented.

x c;{AFTER r

TLTR0D7CTI0L

Heprocnion, a lonm-s tandinp;, monumental mental health problem, currently reigns as the second most freq­ uently diarnosed mental disorder (Lewinsohn e_t a_l. , 1969)#

From a medical standpoint, depression has been described as the number one cause of human suffering (Kline, 1966) - a status supported by its association with suicide

(Pokorny, 1966; Temoche et. a_l. , 1966). Despite recognit­ ion and description from the time of the ancient Greeks

(durton, 16-2 1 ; Jelliffe, 1931; Dilboorp, 196.1), milestone coritri l-'xior::; of Abraham (1911 , 1916, 1926) and Freud

(1917 ), and recent year:: of active research on depression, unresolved empirical and theoretical problems abound

(Grinker e_t al. , 1961; seek, 196?; Silverman, i960;

Klerman, 1971).

Lewinsohn ej- _al. (1969) have pointed out that the term "depression" is ubiquitous and often ill-defined.

Dependin/t on the writer, it may be used to designate a mood state, symntom, syndrome, disease process, or discrete nosological entity (Lehman, 19 59; deck, 1967), Dichotomous distinctions continue to be made on the basis of etiolopy

(e,p.,reac li ve vs. endogenous depression) and symptomatology 2

(e.a,, neurotic vs. psychotic depression; agitated vs. retarded depression). The arguments offered on behalf of these subdivisions (Gillespie, 1929; Partridge, 19^-9;

Githeil, 19^9; Hamilton and White, 1959; Hose, 1963; Kil- oh and Garside, 1963; Carney ejt al., 1965) have been reject­ ed by those who consider such practice an impediment to the understanding and treatment of depression (ilapother,

1926; Lewis, 1 9 3 ‘9 1936; Curran, 193?; Ascher, 1952; Gar- many, 1 9 r9'■; Kenninyer, 1963; Heron, 1965; Kendell, 1968;

Kcndcll and Gourlay, 1970). Other distinctions between post-partum depressions, involutional melancholia and manic-deprcssive psychoses, emergence of more pluralistic approaches (hill, 19605 Eysenck, 1 9 r;0; Klerman, 1971) » and so-called "depressive equivalents" (Kennedy and

Wiesel, 19H6) leave no doubt that the topic is complex and "multifaceted" (slumenthal, 1971).

As one miaht expect, lack of precise definition and characterization of depression, combined with contemporary preference for differential diagnosis of subclasses according to standard nomenclature (A.P.A.,

196?), has impeded investigations of ctioloyic factors in depression (Huston, 1971). Although innumerable studies of possible biochemical, hereditary and phy­ siological causes have generated testable hypotheses worthy of future research, results, generally have been 3 contradictory and inconclusive (Beck, 1967),

Psychoanalytic writers, focusing mainly on uncon­ scious factors, have offered a variety of psychodynamic formulations and conceptualizations of depression.

Freud (1917) compared melancholic depression with grief reaction. The former is characterized by vague or imag­ inary emotional loss of love object which results in a fall of self-esteem and a tendency to self-reproachment on the part of the ego. Inhibition of functions results from investment of ego energy into the strong anti- cathexis necessitated by the "narcissistic wound".

In grief reaction, there is actual loss of a love object but no accompanying fall in self-esteem and no self- criticism by the ego. Loss of interest in the outside world is due to absorption of libidinal energy by the

"work of mourning".

Abraham (1911, 1916) stressed the importance of hostility and orality in depression. In a later paper

(1924), he introduced the concept of primal depression, describing it as "a severe injury of infantile narcis­ sism through a combination of disappointments in love".

A child's reaction to this early oral frustration est­ ablishes the pattern which subsequent depressions follow. Klein (19^8) and Fairbaim (1952) held that depression is a combination of sadness associated with 4

loss of love object and guilt over sadistic fantasies

which are reactive to the frustrating lack of gratific­

ation. Gero (1936) concurred with Abraham on the sign­

ificance of the orality concept in depression.

Both Rado (1928) and Fenichel (1945) described

severe depression as a result of a lowering of self­

esteem following frustration of narcissistic supplies

and attempt to force restoration of these vital supplies

from the introjected love object. Weiss (1944) also

referred to loss of self-esteem which results from in­

jured narcissism. According to Weiss, a buildup of

self-hatred due to feelings of guilt and inferiority

over this loss leads to melancholic depression. The

latter is distinguished from simple depression which is due to exhaustion of the libido in an unsolvable conflict.

Although their actual conception of the process by which self-esteem is lost differs somewhat from that

of Rado and Fenichel, Bibring (1953) and Jacobson (1953) also viewed it as the central element in depression. In addition to loss of love object, Bibring referred to frustration of other individual aspirations which are

"narcissistically significant" for self-esteem (e.g., to be worthy, strong, good, secure, etc.). He oonceived of depression as primarily stemming from "inner-systemic conflict" (i.e., within the ego itself). In Jacobson's 5

equally ego-psychological conceptualization, pathology

in any of the determinants of the self-esteem (e.g.,

superego, ego ideal, self-representations, etc.) could

contribute significantly to depression.

In summary, the psychoanalytic literature has

emphasized early frustrating loss of one kind or another,

breakdown of self-esteem, and activation of predominantly

oral-aggressive, recovery mechanisms in the etiology of

depression. By way of criticism, Mendelsohn (1959.

I960) evaluated these formulations as dogmatic, unduly

universally applied and theoretically unsophisticated.

He questioned whether psychoanalytically-oriented stud­

ies have yet established a correlation between infantile

experience and adult depression or paid sufficient heed

to the complex nature of depression. Such criticism has

also come from within psychoanalytic ranks (Salzman, 1968).

In contrast to psychoanalysts' preoccupation with

unobservable, intrapsychic constructs, those with a

behavioral orientation emphasize quantifiable, inter­ personal aspects of depression. Skinner (1953) Has

argued against postulation of inner states because alone,

they are irrelevant to a functional analysis of behavior.

According to behavioral principles, verbal and nonverbal

indicators of depression can be reliably observed and 6 measured if specifically defined. The resulting, object­ ive data then allow for establishment of the empirical relation between depressive behaviors and environmental events which precipitate and maintain depression

(Liberman and Raskin, 1971).

Ferster (1966) hypothesized that frequency of adaptive behavior can be reduced by one or more environ­ mental events which act to produce a decrease in rate of positive reinforcement (e.g., aversive stimuli or punish­ ment, loss of a close friend or relative, excessive behav­ ioral requirements prior to reinforcement, etc.). Accord­ ing to Ferster, such reduced adaptive behavior is the primary indicator of depression. Depressed individuals who are restricted in their range of social interaction are particularly vulnerable to interpersonal loss

(Ferster, 1965). In Lazarus' (1968) view, depression is a response to "inadequate or insufficient reinforcers". He was one of the first behavior therapists to successfully employ behavior modification techniques in the treatment of depression. Burgess (1969)» working with individuals, and Liberman (1970), working with families, have also reported clinical successes in the modification of depressive behaviors.

Lewinsohn jtal. (1969) have been engaged in a 7 commendable research effort with the expressed objective of developing and testing out a behaviorally oriented theory of depression. Within their theoretical frame­ work, these authors have assumed that s (1) some depress­ ive behaviors are elicited by a low rate of positive reinforcementi (2) different environmental events, as well as an individual's personal characteristics (e.g., social skill) are causally related to a state of low positive reinforcementj (3) where low rate of activity and verbal behavior are concerned, the depressed individ­ ual is on a prolonged extinction schedule* (*0 social environment, particularly the immediate family, streng­ thens and maintains depressive behaviors by reinforcing them with sympathy and concern, etc. Hostility and aggression are considered secondary to, and elicited by, low positive reinforcement. Lewinsohn and his colleagues code interpersonal "actions" and "reactions" of depressed persons at home and in psychotherapy group situations.

Data are used to formulate a "behavioral diagnosis" of a client's difficulties as well as the treatment goals and procedures necessary to restore an adequate schedule of positive reinforcement.

By way of review and comparison, both psychoanal­ ytic and behavioral views stress the significance of

"loss" in the etiology of depression. Psychoanalysts 8 are concerned with intrapsychic consequences of loss, hehaviorists with its observable and quantifiable ante­ cedents and consequences. Liberman and Raskin (1971) pointed out that not all losses lead to depression and perhaps psychoanalytic theory may provide cues as to which losses are most significant for a given individual.

The same authors also noted that considerably more research is necessary to empirically validate the behaviorists* social reinforcement model.

Somewhere between psychoanalytic and behavioral positions, and apart from mainstream of theory on the topic, Beck (1967) advocated a cognitive theory of dep­ ression. He viewed disturbances in depression in terms of the activation of a primary triad consisting of a very negative view of self, of personal experiences and of future. Other phenomena associated with depression,e.g., lack of motivation, affective state, physical symptoms, etc., were regarded as consequences of dominance of this triad and idiosyncratic misinterpretations of experiences forced on the individual. Beck (1967* p. 255) described the three components of his triad1

(first) . . • construing experiences in a negative way. The patient consistently interprets his interactions with his environment as representing defeat, deprivation, or disparagement. He sees his life as filled with a succession of burdens, obstacles or traumatic situations, all of which detract from 9

him in a significant way. (second) . • . viewing himself in a negative way. He regards himself as deficient, inadequate or unworthy, and tends to attribute his unpleasant experiences to a physical, mental or moral defect in himself. Furthermore, he regards himself as undesirable and worthless because of his presumed defect, and tends to reject himself because of it. (third) . . . viewing the future in a negative way. He anticipates that his current difficulties or suffering will continue indef­ initely. As he looks ahead, he sees a life of unremitting hardship, frustration and deprivation.

Beck went on to formulate a circular feedback model in which the depressive patient's negative conceptualiz­ ations lead to feelings of sadness and hopelessness,etc•, which in turn contribute to a deepening of depression, and so on. Seitz (1970, p.4) proposed a similar cycle for the neurotic depressive patienti “The more negatively a person thinks, the worse he feelst the worse he feels, the more negatively he thinks.“

Beyond Beck's work, which Ullmam(1970) considered superior in the area of cognition, there has been little emphasis on the role of thought processes in depression.

In many ways this neglect or oversight is surprising given the number of contemporary theorists who recognize the importance of cognitive processes in mental disorders.

Ellis (1962) assigned primary importance to distorted thinking in depression, anxiety reactions and other neur­ oses. Schachter and Singer (1962) theorized that cognit­ 10

ive factors may exert a "steering function" in determin­

ing emotional states, by providing the "framework within

which one labels his feelings". They indicated that

cognitions available to subjects dictated the label appli­

ed to a state of physiological arousal when no appropriate

explanation was given regarding effects of epinephrine

injection. Arieti (1963) maintained that human emotion

and motivation are "intimately related to cognitive proc-

esses"and that the latter, themselves, create emotional

situations. Harvey (1965) described a critical, inter­ dependent relationship between cognition and affect in

which the former "functions as the baseline for affective

arousal and motive instigation". Denford (1967) described depressive reaction as a mobilization of "mental energies"

and focusing of thought on an unsolved emotional problem

to attempt its solution. Kraines (1957) noted that think­

ing disturbances in depression often tend to be overlooked but clearly placed them second to mood and somatic changes.

Standard psychiatric texts (Redlich and Freedman, 19661

Gregory, 1968j Kolb, 1968) have also contributed to de­

emphasis of cognitive distortions by asserting primacy of mood disorder. Beck (1971 . p. ^9 5) summarized what he considered a paradox1

For normal subjects, the conceptualization of a situation determines the affective state, but in psychopathology, the affective state determines the cognition. 11

Beck (1967) reported his own study of fifty

depressed patients whom he saw in psychotherapy or formal

psychoanalysis. Comparing interview data from these

patients with those from a group of nondepressed patients

similar in age, sex and social position, Beck found

evidence of distorted thought processes across all levels

of depression. Formal characteristics of idiosyncratic

ideation which typified verbalizations of his depressed

patients included low self-evaluation, ideas of depriv­

ation, self-criticism self-blame and self-commands,

exaggeration of problems and difficulties and escapist

and suicidal wishes. In addition, Beck identified certain

processes of distortion which he classified as paralogical

("arbitrary inference", "selective abstraction" and "over­

generalization"), stylistic ("magnification" and "mini­ mization"), and semantic ("inexact labelling"). To the

depressed patients themselves, their distorted cognitions

seemed to arise automatically, to have an involuntary quality, to be plausible, and to perseverate across a variety of life experiences. Moreover, these patients

frequently recalled that an unpleasant thought (often

the idea of being deficient)preceded unpleasant affect.

In another study involving 10-category ratings of the dreams of 218 patients, Beck and Ward (I96I) found

that patients who scored in the moderately depressed and 12

severely depressed ranges of the Beck Depression Inventory

reported significantly more masochistic dreams (scored

for deprivation, thwarting, physical attack, etc.) than

a nondepressed group. These findings supported earlier

studies (Beck and Hurvich, 1959).

Against the argument for emphasizing the import­

ance of distorted thought processes in depression has been

the recognized failure of a few psychological test

batteries and experimental studies (e.g., Friedman, 196^1

Kendrick and Post, 1967) to show consistent evidence of

their existence (Beck, 1967). Single studies employing

a small number of subjects, such as that conducted by

Payne and Hirst (1957) have yielded isolated results

difficult to incorporate into general theory of thinking

in depression (e.g., "Depressives overincluded a highly,

significantly greater amount than normal controls").

Nevertheless, Beck (1967) has offered an impressive and persuasive argument in support of his innovative hypoth­ esis that there is a primary thinking disorder in dep­ ression and that typical distortions originate from a set of three major cognitive patterns. Certainly, before

Beck's hypothesis can be validated, it will be necessary to gather stronger empirical data which demonstrate that thought processes of depressed individuals are in fact different from those of comparable, nondepressed individ- 13

uals. Before such data are collected, the strength

of the triad hypothesis per se must be evaluated.

Beck has emphasized the depressive*s tendency

to view himself in a negative way. A number of studies

on attitude towards self seem relevant to this position.

Bills (195*0 found that subjects with low self-acceptance

(Index of Adjustment and Values) showed significantly

more signs of depression on the Rorschach (#W, WiM, Sum

C, F + % , T/R) than subjects with high self-acceptance

scores. Berger (1955) found significant (pc.Ol) negative

correlations of -.**5 and -.5*+ between Self Acceptance scale scores and MMPI D scale scores for male and female subjects respectively. Block and Thomas (1955) instructed fifty-six college students to complete an 80-adjective, self-administered Q sort as they saw themselves at the time, and a week later, as they ideally wanted to be.

Those students who expressed self-dissatisfaction tended to score significantly higher on the MMPI D scale.

Zuckerman and Monashkin (1957) found a similar relation­ ship between self-dissatisfaction scores and MMPI D scale scores among psychiatric patients. In contrast,

Mullen (1958) concluded that there was no relationship between self-hatred and depression within a non-psychiat­ ric population administered the MMPI, Rorschach and Q-sort.

However, her complex, operational definition of self-hate 14 and nonpathological levels of conscious and unconscious depression exhibited by a small group of college frat­ ernity members (N»36) appeared to mediate against sign­ ificant results. Engel (1959) evaluated self-concepts of public school children on several measures over a two year test-retest period. She found that those whose negative self-concept persisted over that time tended to be significantly more maladjusted (i.e., they had higher MMPI D and Pd scale scores that those who persist­ ed in a positive self-concept. Beck and Stein (i960) found a significant correlation of -.66 between self- concept scores and Beck Depression Inventory scores, as well as a significant correlation of -.42 between self­ acceptance scores and BDI scores. Laxer (1964) found neurotic depression associated with low "Real Self" raing and with perception of self as bad, weak and pass­ ive. Seitz (1969) found that neurotic depressives tend­ ed to over-emphasize negative aspects of past and present interpersonal experiences and to describe themselves more negatively than would others. Miskimins (1967) also found such a tendency toward self-devaluation in neurotic depressive patients. Kaplan and Pokomy (1969) collected personal interview data from a random sample of five hundred adult respondents. Their data included responses to a measure of self-derogation and a measure 15 of depressive affect. Very rarely did a subject with high self-derogation scores score low on their depressive affect scale or vice versa. Statistical analysis support­ ed the investigators' hypothesis of a significant positive relationship between self-derogation scores and reported depressive affect. Finally, Harrow and Amdur (1971)* employing a modified Q-sort, found that both neurotic and psychotic depressive patients had significantly more negative self-concepts than a group of nondepressive patients of mixed diagnoses (including forty-eight schizophrenics, thirty personality disorders, six manic disorders, seven OBD and three other). There was a slight but nonsignificant tendency for psychotic depress­ ive patients to have more negative self-concepts than neurotic depressive patients. In general, research findings from the above studies appear to offer consid­ erable supporx for Beck's hypothesized relationship between depression and negative view of self.

Beck (1967) also described the depressive patient as one who pessimistically expects his situation to remain unchanged in the future. Although research and theory on temporal orientation have generally neglected the broader area of outlook on the future (Gunn and

Pearman, 1970), some of the relevant literature lend at least indirect support to Beck's position. Over three 16

decades ago, Israeli (1936) demonstrated markedly limited

future time orientation for several nosological groups,

Strauss (19^7) described depressed patients as unable

to let go of past for future, Cassidy £t al. (1957)

found that medical patients with chronic or terminal

illnesses were more optimistic about their future than

were depressed patients. Despite good prognoses, the

latter group generally expected not to improve. Accord­

ing to Frank (196ba), the medical profession has long

recognized that absence of positive expectations can

retard recovery from illness, and in extreme cases, bring death more rapidly. Results from Stuart's (1962) research

led her to describe the individual with a depressive tendency as one who has a constricted future outlook• does not expect success and sees his situation as hope­ less. Melges and Fougerousse (1966) found that, compared to other diagnostic groups, patients in the acute stages of both neurotic and psychotic depression tended to view their future life as purposeless. In contrast, many of

Harrow et als. (1966) depressive subjects reported a lack of despair about the future, Wessman and Ricks

(1966) found a significant relationship between positive mood and greater future time orientation, Dilling and

Rabin (1967) found that depressive patients showed more curtailed future perspective than schizophrenic patients 17

on various time measures (perspective, perception,

orientation). Both groups were less future oriented

than normals. Goldrich (1967) found that doctoral

candidates who were judged as making efficient progress

toward their degree had less tendency to describe un­

pleasant events and introduced more future referents

on the Thematic Apperception Test than students judged

as inefficient. Efficient subjects also scored higher on

a scale of conscious optimism about the future. Shybut

(1968) found that hospitalized, severely disturbed

subjects had a significantly shorter time perspective

than non-hospitalized or moderately disturbed subjects.

Proctor (1968), working with V.A. patients, sixty-eight

percent of whom had scores in the depressed range of

the MMPI (i.e., a T score of 70 or over), confirmed a

predicted relationship between unpleasant emotional state

and restricted future orientations. Foulks and Webb

(1970) administered the Time Reference Inventory to

a group of alcoholic patients, a group of chronic schiz­

ophrenic patients, a group of acute schizophrenic pat­

ients, and a group of "primary" depressive patients.

Depressive patients marked significantly more pleasant

items as being in the past than did the other three

groups but there were no differences among groups in number of unpleasant items assigned to the future. 18

Braley and Freed (1971) assessed temporal orientation via Q-sort items. For their small sample of psychiatric outpatients of mixed diagnoses (N=18), results indicated more present-pastness than future-focusing, compared to a nonpsychiatric control group. Other writers have described "sense of futurity" as the most deficient temporal mode for several categories of psychiatric patients (Dubois, 195**J Arieti, 1955* Minkowski, 1958) and have recognized or implied the importance of its degree and quality for effective personality organiz­ ation (Adler, 1925* Rank, 19**5* Allport, 1950* Rapaport,

1951* Fedem, 1952* Kelly, 19551 May, 1958* Erikson,

1959). Beck's emphasis on the depressive patient's view of future also has obvious implications for therapy wherein it is important to know what depressed patients, as well as others, think of their chances for recovery.

Freud (1953» p.289) wrote that "expectation . . • coloured by hope and faith, is an effective force with which we have to reckon . . . in all our attempts at treatment and cure". From an existential point of view,

Heidegger (1962) wrote that projection toward the future is primary for the psychological health of man. "The openness of the future and the expectation of change" are basic to contemporary existentialist therapies (Mendel, 19

19190. Take away a focus on future and such concepts as beeominr .and self-actualization are rather meaningless

(Taslow, lf>66). Frank (1969b) considered elicitation of hope essential to all psychotherapies.

It would seem, then,that Beck's attempt to relate depression to nerative future orientation is a sound one; in combination with negative view of self, discussed above, it adds considerable strength to his triad hypothesis. Both cognitive patterns, certainly, have had their share of association with psychopathology in rcncral» denress ion in particular; the task remains

to demonstrate thoi conjoint, .active exis.ter.ee with nerative view of life exneriences in depression.

To this investigator, it appears that the locus of control cons tract 1:: intimately related to Beck's

theory of throe, major, nerative, corn ilive patterns in depression, particularly nerative view of the future.

Expectation of indefinite sufferinr implies a sense of hopelessness or inability to effect an alteration in behavioral outcomes.. In extensive reviews, Hotter

(1966), Lefcourt (1966) and Joe (19?1 ) have all pointed to rescareh-suryested relationships between perceived internal-external control and adjustment/maladjustment.

'Vith. the exception of alcoholic patients (Goss and

Toros,ko, 1970; Distefano, c_t al. , 1972) * subjects 20

described as pathological or maladjusted have tended

to score significantly higher on external control than normal subjects (e.g., Shybut, 1968; Distefano et al.,

1971). Few studies have dealt directly with the rel­ ationship between locus of control and depression.

Abramowitz (1969)* using Rotter's Internal-External

(I-E) Control scale (1966) found that external control varied positively with depression (Guilford Depression

Scale). Contrary to his expectation, Aarons (1968) found similar results. As the respective authors dis­ cussed, their results suggested that proneness to hope­ lessness may be stronger than self-blame in the dynamics of depressives, disconfirming psychodynamic theories of assumed responsibility for the individual's hopeless­ ness. This issue is important but weakened by failure to use subjects other than college students. However,

Harrow and Ferrante (1969) found that depressive patients were more internally-oriented (I-E scale) than schizo­ phrenics and became more so after six weeks. Forrest

(1970) investigated self-punitive behaviors of psycho- metrically depressed and nondepressed subjects in a two- person interaction situation. Subjects could avoid higher intensity shock from a confederate by rewarding the confederate, shocking him, or shocking themselves. 21

Depressed subjects selected the self-shock alternative more often than their non-depressed counterparts. During

the data collection phase of a research project, Steinke

(1971) has also found a tendency for patients diagnosed as depressive to score more internally on the I-E scale that patients with other diagnostic classifications.

Data related to the above came from a classic factor analytic study by Friedman e t al. (1963). One of four distinct clinical syndrome pictures which emerged for one hundred and seventy psychotic depressive patients included affective depression with guilt, loss of self­ esteem, doubting and internalizing tendencies. Rosenthal and Gudeman (1967) on the other hand, reported that one characteristic of a self-pitying constellation was "blam­ ing the environment rather than self". Although Hersch and Scheibe (1967) found that external scorers (I-E scale) checked fewer favorable and more unfavorable, self descriptive adjectives than internal scorers, the self­ acceptance studies in general have offered evidence in favor of internalization. Bills et al. (1951)» Bills

(1953)» and Zuckerman and Monashkin (1957) all described the low self-acceptor as one who tends to internalize blame for his problems. Harvey et al. (1961) also mentioned internal control and self-blame as being char­ acteristic of depressives and Schiffman (i960), using the 22

Picture Arrangement Test, found depressive patients more self-confident than normals that their efforts would win over a hostile or indifferent group. In short, whether depressives internalize or externalize remains a clouded theoretical issue. Beck's triad theory provides for both possibilities. However, more research data appear to favor the possibility of there being a positive relationship between depress­ ion and intemality. This possibility is in line with traditional psychoanalytic theory reviewed earlier, but contrary to what one would probably predict for other forms of maladjustment (Joe, 1971)•

Testing for Cognitive Distortion

This investigator shares Beck's (1967) opinion that psychological tests have failed to detect thinking disorder in depression because they have not been spec­ ifically designed for that purpose. The semantic diff­ erential technique (Osgood et al.• 1957) is vital to research described herein as one part of a twofold attempt to overcome that deficiency. Hovland and Rosenberg

(I960) wrote that this technique "may be interpreted rs illuminating some of the major cognitive dimensions of attitudes". A second, and equally important behavioral test will be described later. 23

With the semantic differential technique, subjects

rate selected concepts along several bi-polar adjective

scales. Responses are presumed to reflect connotative

meaning to subjects of concepts rated. Several factor

analytic investigations involving a variety of different

concepts and scales have repeatedly shown the existence

of evaluative, potency and activity dimensions of connot­

ative meaning. However, it has also been shown that

there is a real danger in assuming that because a scale

was heavily loaded on a particular dimension in previous

research, it will represent the same dimension with diff­

erent concepts in new research (Osgood, et al,, 19571

Gulliksen, 1958? Ware, 19591 Komorita and Bass, 19671

Heise, 19691 Presly, 1969). General reliability and

validity data regarding the semantic differential are presented in Osgood et al. (1957 pp. 126-166), The

validity data has satisfactorily demonstrated that

semantic differential scores parallel clinical events

(Osgood et al., 1957; Marks et al., 1965).

Evaluation scales have tended to be the most

stable (Norman, 1959; Osgood, 1962) and consistently,

the evaluative dimension has accounted for the largest proportion of explained variance. Kubiniec and Farr

(1971) found no evidence of concept-scale interaction with regard to evaluative scales when freshman university 2^ students assessed dimensions of their self-concept

(e.g., HMy Past” , "My Future", etc. . . .). Also, scales which represented activity or potency dimensions, when used to rate miscellaneous concepts, clustered with evaluative scales when personally meaningful concepts were involved (i.e., became evaluative in nature).

Kubiniec and Farr (1971) suggested that the scale comprising a particular semantic differential should be selected on the basis of the specified pur­ pose for using the instrument. The same authors also suggested that where one is primarily interested in individual differences in attitude, it might be more efficient to employ only evaluative scales. Marks

(1965) pointed out that it is usually the evaluative component which is of most interest in such research with psychiatric patients and later wrote "it is clear that an evaluative component generally predominates in psych­ iatric patients when they rate emotional concepts"

(Marks, 1966, p.9^9). Luria (1959) found the evaluative component most reliable in differentiating therapy and nontherapy groups. However, a review of current liter­ ature in the area indicated that most investigators have continued to employ a wide variety of scales sampling the evaluative, activity and potency dimensions regard­ less of instrument purpose. 25

Supporting the use of the semantic differential

in the manner intended by this investigator, Marks

(1966, p.948) concludedi

• . • the semantic differential technique can be used successfully to detect distinctive patterns of meaning for carefully selected psychiatric syn­ dromes, These patterns can throw light on the nature of the psychiatric disturbance, provided that one is clear beforehand how one's hypotheses relate to scores on particular concepts and scales.

In addition, Davol and Reimanis (1969) found the sem­ antic differential useful in studying the cognitive components of anomie. And, although he did not invest­ igate the specific hypothesis, the results of Allison's

(1963) research with a two-dimensional semantic differ­ ential led him to predict that depressed persons would tend to give a "preponderance of responses on the bad side of the good-bad continuum".

To develop a semantic differential tailored to the proposed research, the investigator selected a list of thirty-eight bipolar evaluative adjective scales from overlapping semantic differential and depression liter­ ature (particularlyi Osgood, et al., 1957» Jenkins and

Russell, 1958? Heise, 19651 Beck, 1967). Selection was on the basis of perceived relevance to the following concepts, each representing a separate component from

Beck's cognitive triad (adequacy of representation was agreed upon by the investigator and three colleagues)! 26

"My life so far", "Myself", and "My life as it will

be". Sixteen members of the psychology and social ser­

vice staffs of a state psychiatric hospital were then

asked individually to select the twenty-five scales

that each considered most meaningful and relevant in

thinking about all three of these concepts (an idea

modified from Mitsos, 1961, who found a direct relation­

ship between personal meaningfulness of scales and degree

to which concepts rated were saturated with meaning).

The "Scale Selection Questionnaire" is presented in Appen­

dix A. The ranked frequencies of selection for the thirty-

eight scales are presented in Table 1. It was decided

that the final differential would be made up of twenty-

four scales, all of which were chosen by better than

sixty-two percent of the staff members (i.e., a cutoff

was made at "positive - negative"). This version is described later.

Since normal psychological functioning cannot

be assumed for depressed individuals, there is no

assurance that attitude, particularly if negatively dis­

torted, will be consistent with behavior. In other words,

a negative outlook may be more subjective than objective

(Friedman, 1964), To avoid dependency on a subjective,

albeit sophisticated attitudinal measure alone, the second part of this research into thinking disorder in depression TABLE 1

RANKED FREQUENCIES OF SELECTION OF SCALES CONSIDERED

N'OST RELEVANT IN THINKING ABOUT THE THREE CONCEPTS

Scales Frequency of Selection (N=l6)

Happy -- Sad 16 Successful — Unsuccessful 16 Secure -- Insecure 16 Useful -- Useless 16 Important — Unimportant 16 Good -- Bad 16 Pleasant — Unpleasant lc Interesting -- Boring 16 Hopeful — Hopeless 16 Valuable -- Worthless 1U Adequate -- Inadequate 13 Full -- Empty 13 Likeable -- Unlikeable 13 Easy — Hard 13 Satisfactory — Unsatisfactory 13 Tolerable -- Intolerable 12 Free — Restricted 12 Acceptable -- Unacceptable 12 Healthy — Sick 12 Lucky — Unlucky 11 Wise -- Foolish 11 Great -- Terrible 10 Worthy -- Unworthy 10 Positive -- Negative 10 Favorable -- Unfavorable 9 Nice -- Awful 9 Superior -- Inferior 8 Winning -- Losing 8 Beautiful -- Ugly 8 Possible -- Impossible 7 Fair -- Unfair 7 Safe — Dangerous 6 Right — Wrong 6 Beneficial — Harmful 5 Perfect -- Imperfect 3 Fresh -- Stale 3 True — False 2 Clean -- Dirty 2 28

involves a specially-designed behavioral test. Certain

crieria were considered essential! a) the test had to be

simple enough not to provoke extraneous frustration on

the part of subjects, yet challenging enough to allow

them to believe they were responsible for their own

performancei b) it had to be sufficiently ambiguous to

necessitate a subject's cognitive judgment regarding the

success/failure quality of his performance; c) it had to

be of such design that the investigator could easily

control subject performance according to preset achieve­ ment levels.

A simple letter-digit coding test was developed

to comply with the above requirements; its specifications

and use will be described later. Observations from a

trial administration of the coding test to a sample of patients comparable to those participating in the main research proper indicated that developmental criteria had been satisfied.

Criterion Measures of Depression and Locus of Control

In line with emphasis on a specific measure for a specific purpose, the Beck Depression Inventory (Beck et al., 1961) and the Internal-External (I-E) Control scale (Rotter, 1966) have been selected as criterion measures of depression and locus of control respectively. 29

After a thorough review of depression-type

inventories, e.g., MMPI-D scale (Hathaway and McKinley,

19^2) and its shorter versions (McCall, 19581 Canter,

I9601 Dempsey, 196*01 Hamilton Ratir^Scale (Hamilton,

1960)i Clyde Mood Scale (Clyde, 1961)» Depression Rating

Scale (Wechsler et al., 1963)1 Multiple Affect Adjective

Check List (Zuckerman and Lubin, 1965)1 Self-rating

Depression Scale (Zung, 1965)1 Self-rating questionnaire

for Depression (Rockliffe, 1969), this investigator is

convinced of the comparative superiority of the BDI.

The BDI is independent of administrator bias,

can be easily administered and answered in a few min­ utes, and shows no statistically significant association

with age, intelligence or sex (Metcalfe and Goldman,

1965). Factor analytic studies of the BDI have revealed

a noticeable "general factor" of depression (Cropley and

Weckowicz, 19661 Beck, 1967) and other studies have found

that BDI scores correspond well with clinical pictures presented by depressed patients (Nussbaum et al., 1963i

Beck, 1967i Blaser et jgd., 1968). Substantial additional

data on reliability and concurrent and construct validity

are presented in Beck (1967).

The I-E scale is a measure of the degree to which an individual believes that reinforcements are con­

tingent upon his own behavior (intemal-control) or 30

independent of his own behavior and due to luck, chance, fate, etc, (extemal-control). Reported test-retest reliability for the I-E scale (one to two month intervals) has ranged from ,48 to .84 but consistently above .60

(Rotter, 19661 Hersch and Scheibe, 1967* Harrow and

Ferrante, 1969). Internal consistency estimates of reliability have been relatively stable and moderately high, ranging between ,65 and .76 with nearly all cor­ relations in the ,70s (Rotter, 1966). Good discriminant validity is indicated by low correlations between I-E scale scores and variables such as intelligence, social desirability and political affiliation (Rotter, 19661

Hersch and Scheibe, 1967). As mentioned above, excellent, extensive reviews of the use of the I-E scale in previous research are reported in Rotter (1966), Lefcourt (1966), and Joe (1971).

Problem

The empirical and theoretical literature on depression is vast but marked by inconclusion. Depending on viewpoints of various authors and researchers, depress­ ion has been assigned a seemingly infinite number of characteristics, most of which suffer from a paucity of substantiating evidence. Moreover, for a variety of 31 reasons, there has been a particular, investigative under-emphasis of the relation between thought processes and depression. This investigator concurs with Ullmanh's opinion (1970, p. 201) that "Activities called cognitions should be formulated and dealt with in the same manner as all other human behavior".

Beck (1967) formulated a cognitive triad hypoth­ esis in which he viewed idiosyncratic thought content of depressives in terms of a negative view of self, a neg­ ative view of life'8 experiences, and a negative view of future. Although much of the relevant literature testifies to the strength of individual components within Beck's proposed triad, no objective research with psychological tests has validated their actual, joint dominance of the depressive's thought processes. Dem­ onstration of a thinking disorder as Beck has postulated would (a) support development and implementation of psychotherapeutic strategies specifically directed to­ ward the disorder, (b) imply a need to revise contemporary nosological classification systems to include more emphasis on thinking disorder as a major pathognomic feature of depression and, (c) suggest the possibility that, besides depression and schizophrenia, some form of thinking disorder may be characteristic of other psychiatric disorders. In addition, exploration of a 32

relationship between thought disorder in depression and locus of control appears to have merit as a logical extension of Beck's position.

The primary purpose of the present investigation is to employ both a semantic differential and a behavioral test to investigate existence of those idiosyncratic thought processes which Beck has described as character­ istic of depression, and to determine whether those thought processes differentiate psychiatric patients whose primary diagnosis is depression from nondepressed psychiatric patients. Specifically, the semantic differential will be used to study relationships between patient type (i.e., depressive versus nondepressive) and patterns of response disposition to three main concepts. The latter were each selected to represent a separate compon­ ent from Beck's (1967) cognitive triad and included1

1. MMy life so far"

2. "Myself" 3. "My life as it will be"

The behavioral test, with identical, predetermined achievement levels for all subjects, will be used to study relationships between patient type and objective estimates of 1

1. Highest expected performance score

2. Lowest expected performance score 33

3. Actual expected performance score over

three trials. The behavioral test will also be used to

study association between patient type and subjective

evaluation ofj

1. Immediate, pre-trial performance

2. Immediate, post-trial performance

3. Short-term future performance ("tomorrow")

, Longer term future performance ("one year")

over three trials,

A second purpose of the present investigation

is to employ the I-E scale to inves ti.-'a te a relationship

between patient type and locus of control.

hypo theses

Trie following hypotheses correspond to expressed purpose:: so i forth above i

1. Responses to semantic differential concepts as a function of patient type and concept,

a. Patient types, will differ in their responses to the concepts: "by life so far", "Myself" and "My life as it will be". Depressive patients- will score significantly lower (i.e., more ncratively) than nondepressive patients on each concept.

2, hiyhest, lowest and actual performance estimates as a function of patient type and trial.

b. Patient types will differ in their estimates of highest expected performance scores. Depressive patients will yive a significantly lower estimate than nondepressive patients on each of three trials. c. Patient types will differ in their estimates of lowest expected performance scores. Depressive patients will give a significantly lower estimate than nondepressive patients on each of three trials, d. Patient types will differ in their estimates of actual expected performance scores. Depressive patients will give a significantly lower estimate than nondepressive patients on each of three trials.

Performance evaluations and patient type. e. There will be a significant association between patient type and performance rating. Depressive patients will tend to assign lower (i.e., more negative) pre-trial, immediate post-trial, short-term future, and longer-term future ratings than non­ depressive patients on each of three trials•

Locus of control as a function of patient type. f. Patient types will differ in their per­ ceived locus of control. Depressive pat­ ients will demonstrate significantly great­ er belief in internal control (i.e., score lower on the I-E scale) than nondepressive patients. CHAPTER II

m e t h o d

Sub.iec ts

General Population

Psychiatric patients between the ages of 16 and 51 years who were first admissions, to a state hospital during the four-month period of data collection, and who showed no evidence of alcohol abase, drug; abuse, brain damage or schizophrenic process, made up the general population from which two specific sub--roups wore selected.

S p e d f i c G roan::

Cut of I'd; total admissions there were new admissions (1°1 females and Ibl males). Cf these, 169 patients met the above criteria. Through unavoidable cir­ cumstances (e.g., scheduling conflicts,, unusually high ad­ missions on a given day) 21 suitable patients were "missed" by the testing program. The remaining 1 U H patients were d v e n the vocabulary test from the Shipley-Institute of

Living Scale (Shipley, 19^0a; 19^-Ob) either at the time of their clinical interview or shortly before or after it.

To ensure that all potential subjects could read and adeq- 36 uately comprehend the test materials and accompanying directions, only those who achieved the arbitrary but judgmentally selected minimum score of eighteen (vocab­ ulary age equivalent i 12.3 years) were tested further.

Twenty-five patients either failed to achieve the necess­ ary vocabulary cut-off score or elected not to participate in the research. An additional eight patients were ex­ cluded because of excessive omissions, somatic complaints or gross disorientation during formal testing. For admin­ istrative reasons, the remaining 115 patients completed all testing at the same time each completed the Beck

Depression Inventory. As BDI results became available, and before other materials were scored, patients were selected for the following matched groups of 25 members eachi

1. Depressive patients. All patients included in this group were diagnosed as having a depress­ ive disorder according to standard nomenclature and achieved a minimum of 20 on the BDI. Diagnoses were as followsi 17 depressive neuroses, 4 psychotic depressive reactions, 3 manic- depressive illnesses, depressed type, and, 1 involutional melancholia.

2. Nondepressive patients. All patients included in this group were diagnosed as having other than a depressive disorder according to standard nomenclature and achieved a maximum score of 14 on the BDI. Diagnoses were as followsi 8 anxiety neuroses, 1 hysterical neurosis, 2 schizoid personality disorders, 2 obsessive- compuleive personality disorders, 3 paranoid personality disorders, 1 passive aggressive personality disorder, 1 hysterical personality disorder, 1 manic-depressive illness, manic type, 1 sexual deviation, 2 adjustment reactions 37

of adult life, 2 adjustment reactions of adol­ escence and 1 marital maladjustment.

Patients were individually matched on the basis of age

(within six years), sex, number of years completed in

school (within three years) and monthly earned income

(within $100). Because of the patients* relatively high

demographic homogeneity, matching was well within set

limits in most cases. Depressive psychiatric patients

were matched with nondepressive psychiatric patients to

satisfy the research need for comparisons between such

groups (Mahrer and Bornstein, 1969) and to ensure that

any observed differences would be characteristic of

depressive patients alone, rather than psychiatric pat­

ients in general. There were seventeen females and

eight males in each group. Means, standard deviations

and ranges for other matching variables are presented

in Table 2. A summary of additional demographic variables

is presented in Appendix B. Mean vocabulary test score

for nondepressive patients was 25*72 (S.D. 4.73# Range

18-36). Mean vocabulary test score for depressive pat­

ients was 26.44 (S.D. 4.45, Range 21-39)* Mean BDI score for depressive patients was 26.24 (S.D. 6 .36,

Range 20-42). Mean BDI score for nondepressive patients was 6,88 (S.D. 4.33* Range 0-14), 38

TABLE 2

SUMMARY OF MEANS, STANDARD DEVIATIONS AND RANGES

FOR DEMOGRAPHIC VARIABLES ON WHICH PATIENT

GROUPS WERE MATCHED

Variable Denressives (N=25) Nondenressives1 (N«25) Mean S.D. Range Mean S.D. Range

Age 32.68 11.33 16-53 32.28 9.08 17-50

Education 11,20 1.66 8-16 11.64 1.92 8-16 (Yrs.)

* Monthly 246.64 291.64 0-900 245.40 298.74 0-1000 earned in­ come

* Includes 13 subjects from each group who reported no earned income. 39

Subject Selection Materials

Vocabulary Test

The vocabulary test from the Shipley-Institute of

Living Scale (Shipley, 1940aj 1940b) presents 40 words of increasing difficulty printed in capital letters, each accompanied by four other words printed in small letters,

A subject simply underlines one of the four words which he thinks means the same thing as the capitalized word.

An example is provided. There is a 10-minute time limit, including time taken to read instructions. One point is earned for each vocabulary item correct plus an additional point for every four items not attempted, A scoring key is provided on the back of the manual. Ordinarily, lack of available validity data for this test would preclude its being used. However, its ease of admin­ istration, brief time limit and lack of comparable altern­ atives favor its employment in the limited capacity of a preliminary screening device, A few studies have found correlations between total Shipley score (vocabulary plus abstraction scores) and Full-scale Wechsler Adult Intell­ igence Scale I.Q.'s to be consistently above ,?0 (Sines and Simmons, 1959» Wiens and Banaka, 1960» Stone and

Ramer, 19651 Bartz, 1968), 40

Personal Information Sheet

A brief, one-page sheet of questions (see Appendix

C) was included to provide basic demographic information

on all patients, A completed personal information sheet

also reflected a patient's voluntary consent to participate

in the research*

Beck Depression Inventory

The Beck Depression Inventory (Beck et al., 1961|

Appendix D) is composed of 21 categories of symptoms and

attitudes of depression, primarily clinically derived.

Eighty-nine sentences make up the categories from which a

subject selects the one from each category most closely

describing himself. Numerical values from 0-3, assigned

to each statement, indicate its degree of severity. Items

were not chosen with any theoretical position regarding

the etiology and underlying processes of depression in mind. Beck and Hurvich (.1959) used the following break­

down of scoresi severely depressed, 26+j moderately depressed, 15-25i nondepressed, 0-14. This investigation employed a more distinct breakdown without eliminating

the entire "moderate" rangei depressed, 20+j nondepressed,

0-14. Had a normal rather than patient nondepressed group been used, both cut-off scores might have been

lowered slightly. 41

Tent Materials

I-E Scale

The I-E scale (Rotter, 1966j Appendix E) is a

forced-choice questionnaire with 23 relevant items and

six fillers. Subjects must select one of two statements

making up each item. The higher a subject's raw score

(maximum ** 23), the greater his personal belief that rein­

forcements are controlled by luck, chance, fate, etc.

Low scores reflect a subject's belief that reinforcements

are contingent upon his own abilities, etc.

Semantic Differential

The final version of the semantic differential

(Osgood et al., 1957) employed appears m Appendix F.

Seven-point scales (Miller, 1956) were set up in graphic

Form II which has the advantages of being easy to reprod­ uce, being easy to score, allowing constancy of meaning

in the concept being thought about, and being more satis­

fying to the subjects using it (Osgood et al., 1957)*

To facilitate the subjects' task, positions on the scales were specified by a set of adverbs as recommended by Wells

and Smith (I960). This specification is somewhat of a departure from usual presentation form. Each concept appears at the top of a separate page with the twenty- four adjective scales below. Scale order and adjective polarity direction (e.g., good-bad or bad-good) were U2

determined randomly with the stipulation that no more

than three scales of the same polarity direction could

appear together (to prevent position preferences).

Presentation order of concepts within the semantic

differential varied randomly.

To examine the possibility that depressive pat­

ients generalize their negative outlook, regardless of

concept being responded to, a fourth, affectively neutral,

control concept — "Cat" (Snider and Osgood, 1969)

was also included.

Preliminary administration of the devised sem­

antic differential to a sample of patients comparable to

those participating in the main research proper indicated

they were able to follow instructions and complete the

scales without a great deal of difficulty.

Behavioral Test

The behavioral test (Appendix G) is essentially a three-trial paper and pencil coding test based on a code of five capitalized letters (A,K,H,T,E) each with an accompanying arabic numeral (3»1»5»2,7). Fifty answer blocks per trial are arranged in a step-like format with

1*4-, 12, 10, 8 and 6 blocks per row (bottom to top). The step-like format was chosen to emphasize subjects' prog­ ression through the test. The letters are placed in the 43

top two-fifths of the answer blocks in a semi-random

fashion so that the same letters neither appear side by side nor directly above or below each other. Answer blocks for all three trials appear on the same sheet, with the code directly to the left of the top row. Thus,

as a subject proceeds, he has ready reference to his performance level on the previous trial(s). Instructions are presented verbally.

Procedure

Most patients were individually tested within

24 hours of admission, all were tested within 4fci hours.

Testing was conducted by the investigator and two exper­ ienced, Master's level, hospital staff members.

Part One Excluding initial screening with the vocabulary test from the Shipley-Institute of Living described above, testing consisted of two parts. For the first part patients were asked to complete a 14-page, d f x 11" booklet (entitledi Questions for Patients) containing the Personal Information Sheet, BDI, I-E scale and semantic differential. An explanation of the voluntary nature of the research and general instructions were given verbally as well as printed on the front cover of the booklet (see Appendix H). The Personal Information

Sheet appeared first in every booklet. The remaining three measures appeared in counterbalanced order follow­ ing a Latin Square arrangement. Most patients completed the booklet within a 30-60 minute period. They were free to ask any procedural questions of the attending examiner and these were answered directly. Rest breaks were permitt­ ed at the end of a given section when necessary.

Part Two

Upon completion of his booklet a patient proceeded with part-two, the 3-trial letter-digit coding test(always given last to avoid possible contamination of preceding measures). Standard general instructions (Appendix I) were presented verbally after the examiner placed an answer sheet in front of the patient and thanked him for his participation to that point. Before beginning trial one of the coding test patients were asked 1) to rate their expected performance on a seven-point scale ranging from "very poorly" to "very well" (see Appendix J),

2) to explain why they assigned the rating they did, and

3) to estimate their highest possible, lowest possible and actual expected scores (out of 50) for the test (Appendix

I). All responses, including verbatim ones were recorded on a special data sheet (Appendix J). Patients then proceeded with the first trial proper and were stopped 45 at 74# completion (block 37)♦ regardless of individual differences in working speed. They were then asked for more ratings including how they thought they did and why, how they would do tomorrow and why, and how they would do in one year and why (Appendix I).

For the second trial, the question procedure was identical except for the deletion of "why" questions. All patients were stopped at 3 2 % completion (block 41).

Questions for the third and final trial replicated all those of the first trial. All patients were stopped at 9 ^ % completion (block 47).

As a patient worked on the three trials of the coding test, the attending examiner occasionally glanced at his wristwatch to strengthen face validity of the proc­ edure. Percentage increments from trial to trial were small, yet consistently in the direction of increased success from an already, intentionally high, preset base­ line of 74^, Thus the test situation was sufficiently structured for patients' estimates and evaluations to tap their cognitive judgment (Sutcliffe, 1955J Feather,

1967). Most patients completed all phases of the coding test procedure within a 15-25 minute period.

Method of Analysis

Semantic differential data were set up for anal­ ysis of variance as in a two-factor experiment with repeat­ 46

ed measures on one factor (each patient in both groups

responding to all four conceptsi MMy life so far” , "Myself",

"My life as it will be" and "Cat"). This analysis was a modification of the procedure described by both Winer

(1962, pp.296-318) and Lindquist (1953» pp.267-273)* care being taken to account for pair effect as a between- subjects source of variation. Raw data per se consisted of scale scores. A scale score was the score assigned by a patient*s (x) on one of the seven positions of a bipolar scale. There were 24 scale scores per subject for each concept which combined to yield a total concept score. Scale scores of 1 and 7 represented the negative and positive bipolar extremes respectively. Maximum concept score was 16ti.

Coding test estimate data were set up for three separate analyses of variancei highest estimate, lowest estimate, and actual estimate. These analyses were similar to the above, with patient type still forming a between factor with two levels, but with trials forming a within factor with three levels (instead of four, as for semantic differential concepts), A given estimate could range between zero and 50*

I-E scale score data were set up for statistical analysis by means of a t-test for a two-matched-group design (McGuigan, I 9 6 0 , pp. 1 6 2 - 1 6 3 ) . Chi square analysis was employed to determine which individual

I-E scale items differentiated between depressive and nondepressive patients.

Chi square analysis was also used to evaluate the association between patient type and subjective, coding test performance ratings. CHAPTER III

RESULTS

Responses to Semantic Differential Concepts as a Function of Patient Type and Concept

A summary of ranges, means and standard deviat­ ions of concept scores as a function of patient type and concept is presented in Table 3.

Table ^ contains a summary of the analysis of variance of concept scores as a function of patient type and concept.

The F-ratio for differences between patient types was significant beyond the ,001 level. Whether patients belonged to the depressive or nondepressive group did seem to affect concept scores in general.

The F-ratio for differences within concepts was also significant beyond the ,001 level. The concept responded to did appear to affect concept scores when considered over the two patient types,

A third F-ratio, that for Concept x Patient

Type interaction was also significant beyond the ,001 level. Apparently, magnitude and direction of effects of concepts differed for depressive and nondepressive patients• 49

TABLE 3

SUMMARY OF RANGES, MEANS AND STANDARD DEVIATIONS

OF CONCEPT SCORES AS A FUNCTION OF

PATIENT TYPE AND CONCEPT

Concept Patient Range Mean S.D. Type*

C-l D 36-119 77.64 22.54 ND 72-162 132.52 20.44

C-2 D 51-102 77.52 14.54 ND 113-164 141.32 13.55

C-3 D 34-162 113.20 31.50 ND 120-168 151.64 12.36

C-4 D 90-168 121.32 19.47 ND 60-159 123.68 23.66

* N = 25 Key

C-l "My life so far" D Depressive Patients

C-2 "Myself” ND Nondepressive Patients

C-3 "My life as it will be”

C-4 "Cat" 50

TABLE 4

SUMMARY OF ANALYSIS OF VARIANCE OF CONCEPT

SCORES AS A FUNCTION OF PATIENT

TYPE AND CONCEPT

Source SS df MS F

Pairs (P) 13973.60 24 582.22 .86

Patient Types (T) 79480.85 1 79480.85 117.42*

Error (TxP) 16246.03 24 676.92

Concepts (C) 23353.26 3 7784.42 21.20*

C x T 27587.38 3 9195.79 25.04* Residual 52878.62 144 367.21

* p<.001 51

Hypothesis a

Patient types will differ in their responses to the concepts* "My life so far", "Myself” and "My life as it will be". Depressive patients will score significantly lower than nondepressive patients on each concept.

In the overall analysis of variance employed, sums of squares for the various concept levels were not independent because the same patients responded to all concepts. Following Lindquist's recommendation (1953* p. 273) the Cochran-Cox approximate t-test (Cochran and

Cox, 1950* PP« 92-93) was used for testing the signifi­ cance of the difference between patient type means at each concept level. Results of this analysis are pres­ ented in Table 5» The three mean concept scores for depressive patients were significantly lower than corresponding mean concept scores for nondepressive pat­ ients beyond the .01 level. Obtained results supported

Hypothesis a.

Additional Findings a

As noted earlier, a fourth, control concept —

"Cat" was added to test for generalization of negative outlook to affectively neutral concepts. This concept was included in analysis of variance and Cochran-Cox procedures. Results of the latter (Table 5) indicated that the mean concept score for depressive patients did 52

TABLE 5

COCHRAN-COX TEST APPLIED TO DIFFERENCES BETWEEN

PATIENT TYPE MEANS FOR EACH CONCEPT

Concept N?) - D t

C-l 54.88 9.56*

C-2 63.8O 11.11*

C-3 38.44 6 .70* C-4 2.36 .41

* for p<.01, V = 2.66

MX C-l "My life so far"

C-2 "Myself"

C-3 "My life as it will be"

C-4 "Cat" 53

not differ significantly from that of nondepressive

patients. As is graphically apparent from inspection

of Figure 1, a similar response tendency for both

patient types to the control concept contributed to the

significant interaction effect between concept and patient type.

Several a posteriori comparisons of differences

between pairs of concept means were also carried out to

assess the nature of those differences. Because of

the significant concept x patient type interaction, the

Newman-Keuls procedure (Winer, 1962, pp.80-85) was applied

to comparisons within patient type levels (see Table 6).

Results indicated that depressive patientsi

1) scored significantly higher on "Cat" and on "My life as it will be" than on "Myself" (p<.01) 2) scored significantly higher on "Cat" and on "My life as it will be" than on "My life so far" (p<.01) 3) did not demonstrate significant mean score differences between "My life so far" and "Myself" or between "My life as it will be" and "Cat".

Scores for nondepressive patients indicated that they*

U) scored significantly lower on "Cat" than on "My life as it will be" or on "Myself" (p<.01) 5) scored significantly lower on "My life so far" than on "My life as it will be" (pc.Ol) 6) did not demonstrate significant mean score differences between "Myself" and "My life as it will be", or between "My life so far" and "Myself", or between "Cat" and "My life so far". Figure 1. Mean concept scores as a function a as scores concept Mean 1. Figure MEAN CONCEPT SCORE *

CONCEPTS ------fptet ye n concept. and type patient of ------DPESV PATIENTS DEPRESSIVE * - ODPESV PATIENTS NONDEPRESSIVE

54 55

TABLE 6

NEWMAN-KEUIS PROCEDURE APPLIED TO DIFFERENCES

BETWEEN CONCEPT MEANS WITHIN PATIENT TYPE

Means (D) C-4 C-3 C-l C-2

121.32 113.20 77.64 77.5?

C-4 121.32 8.12 43.68* 43.80* c -3 113.20 35.56* 35.68* C-l 77.64 .12

Means (ND) C-3 C-2 C-l C-4

151.64 141.32 132.52 123.68 c -3 151.64 10.32 19.12* 27.96* C-2 141,32 8.80 17.64*

C-l 132.52 8.84

* p<.01 (df :* 144) Ke^r

C-l “My life so far"

C-2 "Myself”

C-3 "My life as it will be" C-4 "Cat" 56

In brief, three contradictory trends for patient types

also contributed to the significant concept x patient

type interaction effect. First, where depressive pat­

ients scored significantly lower on "Myself" than on

"Cat", the opposite was true for nondepressive patients.

Secondly, where depressive patients scored significantly

lower on "My life so far" than on "Cat", no significant

mean difference existed for nondepressive patients

(although the direction was opposite). Finally, where

nondepressive patients scored significantly higher on

"My life as it will be" than on "Cat", no significant

mean difference existed for depressive patients (al­

though the direction was opposite).

A complete graphical and numerical summary of

mean scale scores as a function of patient type and

concept may be found in Appendix K. For response pat­

tern illustration purposes, scales are arranged in the

same polarity direction.

Highest, Lowest and Actual Performance Estimates as a Function of Patient Type and Trial

A summary of ranges, means and standard deviations

of highest, lowest and actual performance estimates as a function of patient type and trial is presented in

Table 7. Means are also graphically compared in Figure 2. TABLE ?

SUMMARY OF RANGES, MEANS AND STANDARD DEVIATIONS OF PERFORMANCE

ESTIMATES AS A FUNCTION OF PATIENT TYPE AND TRIAL

Estimate Patient Trial 1 Trial 2 Trial 3 Type* Range Mean S.D. Range Mean S.D. Range Mean S.D.

Highest D 10-50 32.12 8.74 15-50 32.48 8.72 15-50 35.60 9.33

ND 20-50 42.56 8.69 30-50 40.68 5.90 35-50 43.56 4.44

Lowest D 4-25 15.44 7.36 5-38 19.88 8.77 5-40 21.72 10.26

ND 15-46 28.56 10.06 15-40 30.02 7.47 20-45 32.68 7.01

Actual D 8-45 28.00 8.06 12-40 29.92 7.13 13-45 31.48 7.33

ND 15-50 38.48 8.52 30-50 38.00 4.75 30-50 40.12 5.43

* N ■ 25 -0 iue . enetmtsudrhget ata n lws siae odtos as conditions estimate lowest and actual highest, under estimates Kean 2. Figure MEAN ESTIMATE - 0 4 30- 50- 20 - RASTRIALS TRIALS a function of patient type and trial. and type of patient function a HIGHEST 2 3 -» DEPRESSIVE PATIENTS NONDEPRESSIVE PATIENTS - - 0 4 0 2 - 0 3 - 0 5 10- - ACTUAL 2

3 40- 20 30- 50-| 10- - T 2 3 2 I ------TRIALS LOWEST 1 ------

T 59

Hypothesis b

Patient types will differ in their estimates of highest expected performance score. Depressive patients will give a significantly lower estimate than nondepress­ ive patients on each of three trials.

Table 8 contains a summary of the analysis of variance of highest estimated performance scores as a function of patient type and trial.

The F-ratio for differences between patient types was significant beyond the .001 level. Cochran-Cox test results for differences between patient type means at each trial level are presented in Table 9. On each of the three trials, highest estimate of performance for depress­ ive patients was significantly lower than that of non­ depressive patients beyond the .01 level. Obtained results fully supported Hypothesis b.

Additional Findings b

The F-ratio for differences between trials was significant beyond the .025 level (Table 8). A posteriori comparisons between pairs of trial means were carried out to assess the nature of those differences (Newman-

Keuls procedure, Table 10). Results indicated that the mean highest estimate for patient types was significantly higher on the third trial than on the first or second trials (p<.01). No significant difference was found 60

TABLE 8

SUMMARY OF ANALYSIS OF VARIANCE OF HIGHEST ESTIMATED

PERFORMANCE SCORES AS A FUNCTION OF

PATIENT TYPE AND TRIAL

Source SS df MS F

Pairs (P) 2670.33 24 111.26 .80 Patient Types (T) 2948.17 1 2948.17 21.08** Error (T x P) 3356.3^ 24 139.8$

Trials (C) 243.25 2 121.63 4.10*

C x T 46.77 2 23.39 .79

Residual 2845.97 96 29.65

* p <•025 ** p <.001 61

TABLE 9

COCHRAN-COX TEST APPLIED TO DIFFERENCES

BETWEEN PATIENT TYPE MEANS FOR EACH

TRIAL UNDER HIGHEST, LOWEST AND

ACTUAL ESTIMATE CONDITIONS

Estimate Trial ND - D t

1 10.44 5.14*

Highest 2 8.20 4.04*

3 7.96 3.92*

1 13.12 6.25*

Lowest 2 10.44 4.97*

3 10.96 5.22*

1 10.48 5.62*

Actual 2 8.08 4.48*

3 8.64 4.79*

* for pc.Ol, t/ = 2.74 (all estimates) 62

TABLE 10

NEWMAN-KEULS PROCEDURE APPLIED TO DIFFERENCES

BETWEEN TRIAL MEANS FOR HIGHEST, LOWEST

AND ACTUAL ESTIMATE CONDITIONS

Highest Means Trial 3 Trial 1 Trial 2

79.16 74,68 73.16

Trial 3 79.16 4.48* 6.00*

Trial 1 74.68 1.52

Lowest Means Trial 3 Trial 2 Trial 1

54.40 50,20. 44.00

Trial 3 54.40 4.20* 10.40*

Trial 2 50.20 6.20*

Actual Means Trial 3 Trial 2 Trial 1

71.60 67.92 66.48

Trial 3 71.60 3.68* 5.12*

Trial 2 67.92 1.44

* p<.01 (df * 96) 63

between trial 1 and trial 2.

Hypothesis c

Patient types will differ in their estimates of

lowest expected performance scores. Depressive patients

will give a significantly lower estimate than nondepressive

patients on each of three trials.

Table 11 contains a summary of the analysis of

variance of lowest estimated performance scores as a

function of patient type and trial.

The F-ratio for differences between patient types

was significant beyond the .001 level, Cochran-Cox test

results for differences between patient type means at

each trial level (Table 9) indicated that depressive

patients consistently gave a significantly lower, mean

lowest estimate than nondepressive patients (p<,01).

Obtained results fully supported Hypothesis c.

Additional Findings c

The F-ratio for differences between trials was

also significant beyond the .001 level for the lowest

estimate condition (Table 11). A posteriori comparisons

between pairs of trial means (Newman-Keuls procedure, Table

10) indicated that, similar to the highest estimate

condition, mean lowest estimate for patient types was

significantly higher on trial 3 than on trials 1 or 2 64

TABLE 11

SUMMARY OF ANALYSIS OF VARIANCE OF LOWEST ESTIMATED

PERFORMANCE SCORES AS A FUNCTION OF PATIENT

TYPE AND TRIAL

Source SS df MS F

Pairs (P) 4005.00 24 166.88 .90

Patient Types (T) 4965.13 1 4965.13 26.85*

Error (T x P) 4438.71 24 184.95

Trials (C) 684.33 2 342.17 15.10*

C x T 50.49 2 25.25 1.11

Residual 2175.17 96 22.66

* p<.001 65

(p<.01). In addition, however, mean lowest estimate

on trial 2 was significantly higher than that on trial

1 (p <.01).

Hypothesis d

Patient types will differ in their estimates of

actual expected performance scores. Depressive patients

will give a significantly lower estimate than nondepress­

ive patients on each of three trials.

Table 12 contains a summary of the analysis of

variance of actual estimated performance scores as a

function of patient type and trial.

As for the preceding two estimate conditions,

the F-ratio for differences between patient types was

significant beyond the ,001 level. Cochran-Cox test

results for differences between patient type means at

each trial level (Table 9) again indicated that depress­

ive patients consistently gave a significantly lower,

mean actual estimate than nondepressive patients (p<,01).

Obtained results fully supported Hypothesis d.

Additional Findings d

The F-ratio for differences between trials was

significant beyond the .025 level for the actual est­

imate condition (Table 12). The Newman-Keuls procedure

applied to comparisons between pairs of trial means 66

TABLE 12

SUMMARY OF ANALYSIS OF VARIANCE OF ACTUAL ESTIMATED

PERFORMANCE SCORES AS A FUNCTION OF

PATIENT TYPE AND TRIAL

Source SS df MS F

Pairs (P) 2186.00 24 91.08 .75

Patient Types (T) 3082.67 1 3082.67 25.40**

Error (T x F) 2913.33 24 121.39

Trials (C) 17^.29 2 87.15 4.27*

C x T 39.41 2 19.71 .97

Residual 1959.63 96 20.41

* p<.025 ** p<.001 67 yielded results (Table 10) similar to those found for the highest and lowest estimate conditions. Once again, mean actual estimate for patient types was significantly higher on trial 3 than on trials 1 or 2 (pc.01). As was the case for the highest estimate condition, mean actual estimate on trial 2 was not significantly differ­ ent from that on trial 1.

Performance Evaluations and Patient Type

Hypothesis e

There will be a significant association between patient type and performance rating. Depressive patients will tend to assign lower (i.e., more negative) pre­ trial, immediate post-trial, short-term future, and longer- term future ratings than nondepressive patients on each of three trials.

A summary of chi square tests of association between patient type and performance rating is presented in Appendix L. On an a priori basis, the neutral category

4 ("about average") was eliminated from analysis. The remaining six categories were reduced to twoi 0-3 (below average or negative) and 5-7 (above average or positive).

Data were then analysed within 2 (patient types) x 2

(categories) contingency tables with Yates's correction for continuity applied in all cases. Of twelve chi 68 squares computed, none achieved significance beyond the

.20 level. Hypothesis e was rejected in its entirety.

The data failed to provide evidence of a significant association between patient type and performance rating on any trial of the four rating conditions.

As noted above, patients were asked why they assigned the ratings they did for the first and third coding test trials. Verbatim responses were recorded with the intention of three independent judges scoring them for negative content (e.g., exaggeration of test difficulty, denial of ability, self-depreciation, etc.) and positive content (e.g., expressed confidence, view­ ing the test as relatively easy, etc.), the latter scores to be subjected to chi square analysis to determine if patient types differed in the number of "positives'*and

"negatives". Results from the two trials were to be compared to examine the effects of experience with the test. However, results of the analysis associated with

Hypothesis e and inspection of verbatim recordings negated the utility of analysis as planned. On a subjective basis, patients' responses were almost homo­ geneously positive with significant differentiation on the basis of type obviously nonexistent. 69

Locus of Control as a Function of Patient Type

Hypothesis f

Patient types will differ in their perceived locus of control. Depressive patients will demonstrate significantly greater belief in internal control (i.e., score lower on the I-E scale) than nondepressive pat­ ients.

For depressive patients, mean I-E score was

9.04 with range 2-16 and S.D. 3.81. For nondepressive patients, mean I-E score was 6.88 with range 0-20 and S.D, 4.05. Comparison of I-E scores for patient types by means of a matched t-test revealed that they did differ significantly in perceived locus of control (t = -2.29» df = 24) at the .05 level of confidence. However, direct­ ion of the difference was opposite to that specified by

Hypothesis f. Depressive patients scored significantly higher (more external) on the I-E scale than nondepressive patients. Directional effects were consistent for females

(t = -1.34, df « 16) and males (t = -2.15. df = 7) but at unacceptable levels of confidence (.20 and .10 respect­ ively) .

A summary of chi square tests of association between patient type and response tendency on the I-E 70

scale appears in Appendix M. Yates's correction for

continuity was applied whenever cell frequencies dropped below 5» While externally-scored alternatives were

chosen more often by depressive patients for 16 of 23

relevant items, only items 4,7 and 13 (see Appendix F)

significantly differentiated between patient types beyond the ,05 confidence level. Depressive patients endorsed the following statementsi

(Item 4) Unfortunately, an individuals worth often passes unrecognized no matter how hard he tries.

(Item 7) No matter how hard you try some people just don't like you.

(Item 13) It is not always wise to plan too far ahead because many things turn out to be a matter of good or bad fortune anyhow. CHAPTER IV

DISCUSSION

Thought processes of depressive psychiatric patients appear to be different from those of compar­ able, nondepressive psychiatric patients. For first admission patients who are both diagnostically and psycho- metricall.v depressed, results of the present investigation suggest that cognitive distortion is an important path­ ognomic feature of their depression. However, although providing; partial support, obtained results question the overall strength of the cognitive triad postulated by

Beck (1967)i negative view of self, life's experiences and future,

Semantic Differential Findings

Over 2^ different, evaluative semantic differ­ ential scales, depressive patients achieved a significantly lower (more negative) total score on each of the concepts

"My life so far", "Myself" and "My life as it will be", than nondepressive patients. To the extent that this consistent response pattern reflects thoughts about the concepts rated, depressive patients may be described as predisposed to thinking more negatively about the triad components those concepts were selected to represent. 72

It is conceded that a negative view of past experiences and even of self may be justified (i.e., realistic) by actual events to some extent, but it is unlikely that the frequency of such events would vary significantly for two closely matched groups of patients, regardless of members' diagnoses. In any event, extension of this negative view to future events cannot be based on objective evid­ ence and reflects only distorted thought process.

Although depressive patients scored significantly lower on "My life as it will be" than nondepressive pat­ ients, as hypothesized, their mean score for that concept was significantly higher than for "My life so far" or

"Myself". Despite considerable concept score variabil­ ity within the group, this inconsistency challenges the validity of Beck's third triad component, suggesting that first admission depressive patients may be less pessimistic about their future than readmissions, returns from conval­ escent leave, inpatients who have shown little improvement or outpatients. Smith e_t al (1972) found that first admiss­ ion psychiatric patients were more optimistic about their chances for adjustment after release from the hospital than were patients with prior admission histories. For many first admissions, coming to a psychiatric hospital represents a "last stand" effort to gain relief from their depression. The initial flurry of professional attention 73

which typifies most admission routines may contribute

to temporary optimism regarding therapeutic outcome.

If such is the case, maximum therapeutic benefit could

be derived from intensive treatment programs which stress

immediate involvement of the depressed patient, that is,

before his negative outlook extends to such intervention

efforts.

Depressive and nondepressive patients did not

score significantly different on the control concept

"Cat". Both groups were positive in their orientation.

Apparently, depressive patients' negative outlook does

not generalize via response set to affectively neutral

concepts and thought disorder in depression may be con­

sidered more specific than that generally considered

characteristic of schizophrenia. The same finding

also reflects patients' capacity to make discriminate

use of scale positions rather than just the extremes as

other investigators have reported (Bopp, 1955» Beitner,

196li Neuringer, 1963* Zax et al., 196^* Arthur, 1965*

Fransella, 1965) and supports the use of adverbial modifiers (Wells and Smith, I960). An additional point

is worth noting. Depressive patients thought more posit­

ively about the animal cat than about themselves or their

lives to date. Nondepressive patients were more realistic

in thinking less of an animal than themselves and, although 74

results were not significant, showed a directional tend­ ency to think less of "Cat" than "ily life so far".

Finally, the information presented in Appendix

K testifies to the merits of employing only evaluative scales within a semantic differential tailored to test specific hypotheses (Kubiniec and Farr, 1971). Inspection alone suryests that the majority of the individual scales were hirhly discriminant for patient types across the three main concepts. It is clear , as Harks (1966) has contended, that: the semantic differential technique can be offee lively employed to further undorstandinr of

■particular psychiatric disorders.

behavioral Test Findings

The le ttcr-d i ^ it codiny tost allowed for tin all- important and necessary behavioral demons,tration of cog­ nitive distortion. It is one thiny to test for ncyatively distorted thouyht processes by means of the semantic diff­ erential technique, another to demonstrate their effect on actual behavior in the face of contradictory evidence.

The codiny test procedure provided depressive and nondepressive patients with identical feedback reyardiny their predetermined performances on each trial. A base­ line success of 74^ increased consistently over trials.

For the first trial, patients were confronted with a relatively ambiguous situation in which requested est­

imates depended upon previously formed expectations.

By the second and third trials, the test situation was

more structured. Patients were familiar wit hi the code

and in a position to rely upon cognitive interpretations

of current experience for their estimates. Given the

same information as nondepressive patients on which to

base those interpretations, depressive patients gave

significantly lower mean estimates of highest, lowest

and actual performance scores on all three trials. In

fact, their actual and highest estimates for the third

trial were still below the pre-set success level exper­

ienced or. the first trial. The lower estimates given

by depressive patients are considered evidence for the effects of negatively distorted thought processes.

Another important qualification weakens Beck's

theory. For all estimate conditions there were signific­ ant trial and patient type effects but no significant

interaction between the two. Depressive and nondepressive patients combined gave significantly higher mean estimates on trial 3 than on trials 1 or 2. This finding may be taken as an indication that depressive patients did not complet­ ely distort feedback available to them and did alter their expectations, however slightly, in the same direction as 76

nondepressive patients. Perhaps a more difficult behav­ ioral test with a greater number of trials and smaller but consistent, fixed performance estimates would permit more thorough analysis of the thought distortion process.

Such a test might serve as a test of limits, providing an indication of just how obvious and repetitious success feedback must be before differences between the two groups of patients are no longer significant.

For the lowest estimate condition only, mean estimate on trial 2 for patient types combined was sign­ ificantly higher than that for trial 1. Apparently, trial one's 7 ^ success level was sufficient for patients to raise their estimates of lowest possible scores sign­ ificantly higher for trial 2 but not their estimates of actual or highest possible scores.

There was no evidence of a significant association between patient type and performance rating, under four conditions, on any of the three trials. While depressive patients rated their immediate and future performances on the coding test as highly as did nondepressive patients, their objective estimates of highest, lowest and actual scores did not reflect the same positive outlook. Pos­ itive performance ratings for "tomorrow" and "a year from now" were in accord with depressive patients' thinking about "My life as it will be", discussed above. It is possible that, when asked how they would do and how

they did do on a given trial, depressive patients ack­ nowledged their successes via the subjective ratings but clung unrealistically to previously acquired negative expectations when pressed for concrete estimates.

Locus of Control

Contrary to prediction, depressive patients scored significantly higher (more external) on the I-E scale than did nondepressive patients. However mean scores for both groups (9.04 and 6 .88) were within the range of mean scores which Rotter (1966) reported for his normative sample (N=1180, mean 8.29) and several other non­ psychiatric samples(lowest mean 5*94). No doubt non­ depressive patients' low mean score is partially a res­ ult of excluding schizophrenics from that group. For example, Distefano e_t al. (1972) reported a mean I-E score of 9.5 for 50 male patients, 36 of whom were diag­ nosed as schizophrenic. For another group of 167 patients

(71 males, 96 females) at the same hospital, 84 of whom were diagnosed as psychotic, Smith et al. (1972) reported a mean I-E score of 8.?. Shybut (1968), employing a modified I-E scale, found that "severely disturbed" patients (N=45» predominant diagnosis of schizophrenic reaction) had a stronger belief in external control than 78

"moderately disturbed" patients (n=^5» predominant diag­

nosis of character disorder or psychoneurosis) or a non­

hospitalized group of staff members (N=30). It should

also be noted that 17 of the 25 depressive patients in

the present study were diagnosed as depressive neurotic.

The group's mean I-E score may be somewhat low because

of this concentration (68%),

While it may be possible to differentiate var­

iously defined psychiatric groups by means of I-E scale

scores, and thereby understand such groups a little bett­

er (behavioral prediction, treatment planning, etc.),

the significance of such differences should be kept in

perspective and interpreted with a good deal of caution.

The same caution would appear applicable to employment of

I-E scale scores as indices of adjustment/maladjustment.

Depressive patients' mean I-E score may also

have been lower than that which would have been achieved by other than first admissions. The majority (80%) of depressive patients were voluntary admissions. Coming

to the hospital may represent a final display of confid­ ence by such patients in the efficacy of their own efforts before surrendering to burgeoning thoughts of hopelessness.

I-E scale items (Appendix E) may emphasize social and political concerns at the expense of adequate analysis

of an individual's intrapersonal concerns. The latter 79

are more significant in the dynamics of depression.

Although item analysis revealed that only three items

differentiated depressive patients from nondepressive

patients, those three were distinctly personal in rel­

evance. A heavier concentration of such items would

likely result in higher scores for depressive patients

in particular. Gurin et al. (1969) and Mirels (1970)

have argued that the amount of control over rewards an

individual believes he personally possesses may be quite

different from what he believes the average citizen has

over social and political affairs, etc.

Although it may be somewhat simplistic to draw

parallels between externality and negative outlook

(hopelessness) and between intemality and self-blame,

the data do suggest a more important role for ideas of

hopelessness than self-blame in the dynamics of depression.

This conclusion supports those of Aarons (196b) and Abram-

owitz (1969) which were based on results from college

samples, but seriously questions Laxer's (1964b) contention

supporting psychoanalytic theory that high self-blame is

a necessary factor in(neurotic) depression. The guilt and

self-reproach tendencies which depressive patients often manifest in therapeutic and other interpersonal situations may be less important dynamic factors than manipulating

attempts to exploit the sympathies of concerned others 80

(Cohen et al., 1954j Bonime, 1966).

Finally, Odell (1959) and Crowne and Liverant

(1963) found a significant positive relationship between externality and tendency to conform. Becker (1958),

Gibson et al. (1959) and Spielberger et al. (1963) des­ cribed manic-depressive patients as having a propensity for conforming behavior. Results of the present investig­ ation suggest that conforming behavior may be a personality trait of depressive patients in general.

New Directions for Treatment

Psychotherapy for the depressed patient has been poorly developed at best, marked by vagaries and diffuse applications which have been criticized by London (1964) and Strupp (1970). Costello and Belton (1970) summarily dismissed extant approaches as "based on clinical lore" and proceeded to discuss only electroconvulsive shock and antidepressant drugs in a chapter on treatment.

Holding back the development of psychotherapeutic techniques for dealing with depression has been the wide­ spread failure of mental health professionals to isolate and concentrate upon specific problems, and to create unique, empirically-tested strategies suitable for appli­ cation to those problems. The depressive patient's mal­ adaptive, negative views regarding life's experiences, 81

self and future, as isolated in the present investigation,

are appropriate problems on which to focus therapy tech­ nique development efforts,

A review of the relevant literature suggests that potentially significant contributions toward techniques aimed at modifying these cognitive distortions are likely to come from the work of cognitive therapists (e.g., Ellis,

1962i Beck, 1963, 1967) and, surprisingly enough, that of the behavior therapists. In recent years, many of the latter have recognized the importance of cognitive factors in treatment (e.g., Valins and Ray, 1967» Davison, 1968;

Bandura, 1969» Davison and Valins, 1969f Marcia et al.,

1969). Beck (1970) compared cognitive therapy to behav­ ior therapy and described several techniques by which the former modifies distorted cognitions, including train­ ing patients to recognize, objectify and label those distortions. According to Beck (p. 196)»

In cognitive psychotherapy, the patient examines his distorted ideas and is trained to discriminate between rational and irrational ideas, between objective reality and internal embroidery. He is able to bring his reality testing to bear and to employ judgment. He is thus able to realize with conviction that his idiosyncratic ideas are irrat­ ional.

In the same,article, Beck suggested a simple dichotomous classification for therapeutic techniques 1 cognition- 82

oriented and behavior-oriented.

Bergin (1970) found Beck's scheme "limited and un-

supportable", criticized the empirical basis of cognitive

therapy, noted overlap in the cognitive and behavioral

approaches, and questioned the utility of other than a

multidimensional approach to treatment. According to

Bergin (p. 20b)i

There may be highly specific interventions which have a behavioral or cognitive focus but these are always either embedded in a multidimensional context or have multiple consequences.

This investigator agrees with Bergin's (1970) advoc­

acy of a multidimensional approach as the only realistic

approach to modifying cognitive distortion in depressive patients. Both thought processes and overt behavior will

have to be effectively integrated into such an approach.

Despite outstanding criticism of both, the cognitive

and behavioral approaches are considered to have the most

to offer in that direction.

Suggestions for Further Research

Several directions for further research are suggested by results of the present investigation or appear logical extensions of it.

1. There is a need to demonstrate whether cognitive

distortion is primary in depression and to 83

delineate the nature of its relationship to

affective disturbance. One approach might in­

volve the study of verbal behavior along the

action-thought dimension (suggested by Grisso,

1970). Similarly there is a need to determine

which comes first, belief in external control

or psychopathology (Joe, 1971).

2. There is a need to compare depressive patients

with schizophrenic patients who are traditionally

thought of as having a qualitatively different

type of thought disorder (Kasanin, 19^1 Lewis

and Piotrowski, 195^? Arieti, 19551 Beliak, 195b).

Since depressive symptoms are often an important

part of the presenting symptoms of some schiz­

ophrenic patients (Shanfield et al., 1970),

depressive patients should be compared to schiz­

ophrenic patients with and without depressive

symptoms.

3. There is a need to extend the study of thought

disorder to psychiatric disorders other than

depression and schizophrenia.

4. There is a need to extend the present investigation

to include geriatric, illiterate, and non-white

group8 . There is a need to compare depressive patients of different admissions statuses. For instance,

Paykel (1971) included a group of depressive out­ patients in a classification study using cluster analysis. He discovered the clear emergence of a group of young depressive patients with person­ ality disorder along with three other groups in a hierarchical structure.

There is a need for follow-up testing of depressive patients at time of discharge to determine whether overt signs of clinical improvement are accompanied by modified thought distortion and decreased belief in external control. Kramer e_t al. (1965) found no significant decrease in percentage of depressive themes in dreams of depressive patients who were considered clinically improved. BIBLIOGRAPHY

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k l k c t 'Io :; qi\e s 7Io ::;.a i r e 10 4

SCALE SELECTION QUESTIONNAIRE

In forthcoming research patients will be asked to rate the concepts MY LIFE SO FAR, THYSELF, and MY LIFE AS IT WILL 3E on several bipolar adjective scales. Below is a carefully selected list of such scales. Please examine this list, think about the scales within and select (x) the 25 you consider most relevant in thinking about all three concepts mentioned above,

THANK YOU.

1. Good -- Bad

2. Possible -- Impossible

3. Adequate — Inadequate

4. Full — Empty

5. Favorable -- Unfavorable

6 . Fresh -- Stale

7. Fair — Unfair

8 . Tolerable — Intolerable

9. Great -- Terrible

10.Free -- Restricted

11.Lucky — Unlucky

12.Worthy -- Unworthy

13»True -- False

14.Acceptable — Unacceptable

15.Wise — Foolish

16.Harpy -- Sad

17.Likeable — Unlikeable 105

SCALE SELECTION QUESTIONNAIRE (CONT'D)

___ 18. Right -- Wrong

___ 19. Superior -- Inferior

20 . Pleasant — Unpleasant

21. Nice -- Awful

___ 22 . Easy -- Hard

23. Successful -- Unsuccessful

___ 2 k . Safe — Dangerous

___ 25. Secure — Insecure

___ 2 6 . Clean -- Dirty

27. Winning -- Losing

28. Useful — Useless

29. Positive -- Negative o c~\ •

1 Interesting -- Soring

___ 31. Beneficial -- Harmful

32. Hopeful -- Hopeless

33. Perfect -- Imperfect

___ 3 L*. Valuable -- Worthless

35. Satisfactory -- Unsatisfac

36. Beautiful -- Ugly

37. Healthy -- Sick cc 0^

• Important -- Unimportant APPEKD1X 13

S'T'lv'ARY OF T)ETOORAF?;iC VARIABLES 0:. WHICH

PAT IE'.’"’ TYPES WERE H O 1''' FA TO E D 10?

SUMMARY OF DEMOGRAPHIC VARIABLES ON WHICH

PATIENT TYPES WERE NOT MATCHED

Variable Number, D Number, ND

Race i White 25 24 Negro 0 1

Marital Statusi Single, never married 4 3 Married, living with spouse 15 16 Separated 3 4 Divorced 2 2 Widowed 1 0

Job Statusi Working full time 12 11 Housewife 8 8 Not Working 5 6

Occupational Grouping* Professional 2 2 Managerial 1 2 Clerical 1 3 Saleswork 1 2 Skilled 6 2 Semi-skilled 1 1 Housework 8 8 J.5I3HS ::o i j ,T;uth o ^:;i iv.Monyad

3 XIG! IMddV 109

PERSONAL INFORMATION SHEET

Please give the following important facts about yourself»

NAME i AGE i

RACE i White SEX« Male Negro Female Other

WHAT IS THE LAST YEAR OF SCHOOL YOU FINISHED?

Grammar 1 3 High 9 College 13 School 2 6 School 10 I k 3 7 11 15 k 8 12 16

More than college

WHAT IS YOUR PRESENT MARITAL STATUS?

Single, never married Divorced Married, living with spouse Widowed Separated

WHAT IS YOUR PRESENT .JOB STATUS?

Working full-time Housewife Working part-time Not working

WHAT TYPE OF WORK DO YOU DO?

ABOUT HOW MUCH DO YOU EARN A MONTH?

DO NOT WRITE BELOW THIS LINE

Working Dx

Date Signed AFPErrjix o

HECK DEPRESSION I:VEKTORY Ill

Below are several groups of statements. Pick out ONE statement from each group which best describes the way you feel today, that is RIGHT NOW} Mark your answer (x) to the left of that one statement. READ ALL STATEMENTS in each group BEFORE making your choice.

A. ( ) I do not feel sad ( ) I feel blue or sad ( ) I am blue or sad all the time and I can't snap out of it ( ) I am so sad or unhappy that it is quite painful ( ) I am so sad or unhappy that I can't stand it

B. ( ) I am not particularly pessimistic or discouraged about the future ( ) I feel discouraged about the future ( ) I feel I have nothing to look forward to ( ) I feel that I won't ever get over my troubles ( ) I feel that the future is hopeless and that things cannot improve

C. ( ) I do not feel like a failure ( ) I feel I have failed more than the average person ( ) I feel I have accomplished very little that is worthwhile or that means anything ( ) As I look back on my life all I can see is a lot of failures ( ) I feel I am a complete failure as a person (Parent, husband, wife)

D. ( ) I am not particularly dissatisfied ( ) I feel bored most of the time ( ) I don't enjoy things the way I used to ( ) I don't get satisfaction out of anything any more ( ) I am dissatisfied with everything

E. ( ) Idon't feel particularly guilty ( ) I feel bad or unworthy a good part ofthe time ( ) I feel quite guilty ( ) I feel bad or unworthy practically all the time now ( ) I feel as though I am very bad or worthless

GO ON TO THE NEXT PAGE 112

F. I don't feel I am being punished I have a feeling that something bad may happen to me I feel I am being punished or will bepunished I feel I deserve to be punished I want to be punished

G. I don't feel disappointed in myself I am disappointed in myself I don't like myself I am disgusted with myself I hate myself

H. I don't feel I am any worse than anybody else I am critical of myself for my weaknesses or mistakes I blame myself for my faults I blame myself for everything bad that happens

I. I don't have any thoughts of harming myself I have thoughts of harming myself but I would not carry them out I feel I would be better off dead I feel my family would be better off if I were dead I have definite plans about committing suicide I would kill myself if I could

J. I don't cry any more than usual I cry more now than I used to I cry all the time now. I can't stop it. I used to be able to cry but now I can't cry at all even though I want to

K. I am no more irritated now than I ever am I get annoyed or irritated more easily than I used to I feel irritated all the time I don't get irritated at all at the things that used to irritate me

GO ON TO THE NEXT PAGE 113

L. ( ) I have not lost interest in other people ( ) I am less interested in other people now than I used to be () I have lost most of my interest in other people and have little feeling for them () I have lost all my interest in other people and don't care about them at all

K, () I make decisions about as well as ever () I try to put off making decisions () I have great difficulty in making decisions ( ) I can't make any decisions at all any more

N . ( ) I don't feel I look any worse than I used to ( ) I am worried that I am looking old or unattractive ( ) I feel that there are permanent changes in my appearance and they make me look unattractive ( ) I feel that I am ugly or repulsive looking

0. () I can work about as well as before ( ) It takes extra effort to get started at doing some thing ( ) I don't work as well as I used to () I have to push myself very hard to do anything ( ) I can't do any work at all

P. ( ) I can sleep as well as usual () I wake up more tired in the morning than I used to ( ) I wake up 1-2 hours earlier than usual and find it hard to get back to sleep ( ) I wake up early every day and can't get more than < hours sleep

Q. () I don't get any more tired than usual ( ) I get tired more easily that I used to ( ) I get tired from doing anything ( ) I get too tired to do anything

GO ON TO THE NEXT PAGE 114

R. () My appetite is no worse than usual () My appetite is not as good as it used to be ( ) My appetite is much worse now ( ) I have no appetite at all any more

S. ( ) I haven't lost much weight, if any, lately ( ) I have lost more than 5 pounds ( ) I have lost more than 10 pounds () I have lost more than 15 pounds

T. ( ) I am no more concerned about my health than usual () I am concerned about aches and pains or ups et 5 tomach or constipation ( ) i am so concerned with how I feel or what I feel that it's hard to think of much else () I am completely absorbed in what I feel

U. ( ) I have not noticed any recent change in my interest in sex () I am less interested in sex than I used to be ( ) I am much less interested in sex now () I have lost interest in sex completely APPENDIX E

INTERNAL-EXTERNAL (I-E) CONTROL SCALE Below are several pairs of statements. Please select the ONE statement of each pair which you more strongly believe to be the case as far as you are concern­ ed. Mark (x) to the left of that statement. Be sure to select the ONE you actually believe to be more true rather than the one you would like to be true. This is a measure of personal belief t there are no right or wrong answers. In some cases you may believe both state­ ments or neither one. If so, select the ONE you more strongly believe to be the case as far as you are concern­ ed. Consider each statement by itself and do not be influenced by your previous choices.

Children get into trouble because their parents punish them too much. The trouble with most children nowadays is that their parents are too easy with them.

Many of the unhappy things in people's lives are partly due to bad luck. People's misfortunes result from the mistakes they make.

One of the major reasons why we have wars is because people don't take enough interest in politics. There will always be wars, no matter how hard people try to prevent them.

In the long run people get the respect they deserve in this world. Unfortunately, an individual's worth often passes unrecognized no matter how hard he tries.

The idea that teachers are unfair to students is nonsense. Most students don't realize the extent to which their grades are influenced by accidental happenings.

Without the right breaks one cannot be an effect­ ive leader. Capable people who fail to become leaders have not taken advantage of their opportunities.

No matter how hard you try some people just don't like you. People who can't get others to like them don't understand how to get along with others. Heredity plays the major role in determining one's personality. It is one's experiences in life which determine what they're like.

I have often found that what is going to happen will happen. Trusting to fate has never turned out as well for me as making a decision to take a definite course of action. in the case of the well prepared student there is rarely if ever such a thing as an unfair test. Many times exam questions tend to be so unrelated tc course work that studying is really useless.

Becoming a success is a matter of hard work, luck has little or nothing to do with it. Getting a job depends mainly on being in the right place at the right time.

The average citizen can have an influence in government decisions. This world is run by the few people in power, and there is not much the little guy can do about it.

When I make plans, I am almost certain that I can make them work. It is not always wise to plan too far ahead because many things turn out to be a matter of good or bad fortune anyhow.

There are certain people who are just no good. There is some good in everybody.

In my case getting what I want has little or nothing to do with luck. Many times we might just as well decide what to do by flipping a coin.

Who gets to be the boss often depends on who was lucky enough to be in the right place first. Getting people to do the right thing depends upon ability, luck has little or nothing to do with it.

As far as world affairs are concerned, most of us are the victims of forces we can neither understand nor control. By taking an active part in political and social affairs the people can control world events.

Most people don't realize the extent to which their lives are controlled by accidental happenings. There is really no such thing as "luck". 19. One should always be willing to admit mistakes. It is usually best to cover up one's mistakes.

20. It is hard to know whether or not a person really likes you. How many friends you have depends upon how nice a person you are.

21. In the long run the bad things that happento us are balanced by the good ones. Most misfortunes are the result of lack of ability, ignorance, laziness, or all three.

22. With enough effort we can wipe out political corruption. It is difficult for people to have much control over the things politicians do in office.

23- Sometimes I can't understand how teachers arrive at the grades they give. There is a direct connection between how hard I study and the grades I get.

2^. A good leader expects people to decide for themselves what they should do. A good leader makes it clear to everybody what their jobs are.

25. Many times I feel that I have little influence over the things that happen to me. It is impossible for me to believe that chance or luck plays an important role in my life.

26. People are lonely because they don't try to be friendly. There's not much use in trying too hard toplease people, if they like you, they like you.

27. There is too much emphasis on athletics in high school. Team sports are an excellent way to build character.

28. What happens to me is my own doing. Sometimes I feel that I don't have enough control over the direction my life is taking.

29. Most of the time I can't understand why politicians behave the way they do. In the long run the people are responsible for bad government on a national as well as on a local leve1. APPENDIX F

5 E FAI: TIC DIF FE RE I\ TIA L Printed at the top of each of the following four pages is a different concept for you to think about. Below each concept is a set of scales made up of different pairs of words. By marking an (x) along a scale, you are to express your thoughts about what these concepts mean to you.

If you feel that the concept at the top of the page is VERY closely related to one end of the scale, you should place your (x) as followsi

Beautiful x i » i i j i Ugly or Beautiful i___i____»_____i___«_ i x Ugly

If you feel that the concept is QUITE closely related to one or the other end of the scale you should place your (x) as followsj

Beautiful ____» x t___i_____i___i_ i Ugly or Beautiful i___i____i_____i___i x >____ Ugly

If you feel that the concept is only SLIGHTLY related to one side as opposed to the other, you should place your (x) as followsj

Beautiful ___ »___i x i_____i___i_____t___ Ugly or Beautiful i___i____i_> x i_ i Ugly

If you feel that the concept is EQUALLY related to both sides of the scale ... to one as much as to the other ... you should place your (x) in the middle space.

Beautiful i___i____t x i____i_ i Ugly

IMPORTANTi (I) Place your (x) between the dotsi THIS NOT THIS i t i x 1 I x I

(2) Do not omit any scales

(3) Mark only one (x) on any scale.

NOW GO AHEAD, WORK AS FAST AS YOU CAN, AND MARK YOUR FIRST FEELINGS ABOUT THE CONCEPTS. .121

KY LIFE SO FAR

Negative Positive Good Bad Adequate Inadequate Sick Healthy Useful Useless Unimportant Important Restricted Free Tolerable Intolerable Lucky Unlucky Boring Interesting Likeable Unlikeable Valuable Worthless Terrible Great Hard Easy Unacceptable Acceptable Satisfactory Unsatisfactory Secure Insecure Wise Foolish Unsuccessful Successful Unpleasant Pleasant Full Empty Unworthy Worthy Happy Sad Hopeless Hopeful

// quite / /equally/ / 7 / quite / / / very slightly slightly very 122

MYSELF

Negative Positive Good Bad Adequate Inadequate Sick Healthy Useless Useful Important Unimportant Free Restricted Intolerable Tolerable Lucky Unlucky Interesting Boring Likeable Unlikeable Worthless Valuable Terrible Great Hard Easy Acceptable Unacceptable Unsatisfactory Satisfactory Insecure Secure 'Wise Foolish Successful Unsuccessful Pleasant Unpleasant Full Empty 'Worthy Unworthy Sad Happy Hopeful Hopeless / T / / / ./ / / quite /equally/ quite / very slightly slightly very 123

KY LIFE AS IT WILL BE

Negative Positive Good Bad Adequate Inadequate Sick Healthy Useful Useless Unimportant Important Restricted Free Tolerable Intolerable Lucky Unlucky Boring Interesting Likeable Unlikeable Valuable Worthless Terrible Great Hard Easy Unacceptable Acceptable Satisfactory Unsatisfactory S e c u re Insecure Wise Foolish Unsuccessful Successful Unpleasant Pleasant Full Empty Unworthy Worthy Happy Sad Hopeless Hopeful /////// / quite /equally/ quite / very slightly slightly very 124

CAT

Relative Positive Good Bad Adequate Inadequate Sick Healthy Useful Useless Unimportant Important Restricted Free Tolerable Intolerable Lucky Unlucky Borina Interesting Li keable Unlikeable Valuable Worthless Terrible Great Hard Easy Unacceptable Acceptable Satisfactory Unsatisfactory Secure Insecure W i s e Foolish Unsuccessful Successful Unpleasant Pleasant Full Empty Unworthy Worthy Happy Sad Boneless Hopeful

// quite 7 /eq/ lally/7 / quite/I / very slightly slightly very APPENDIX G

BEHAVIORAL TEST A K H T e 3 1 S' 2 7

H R S J TRIAL

H

START

AK H TE 3 / 5 2 7

SECOND TRIAL

H

start

A K H T E 3 1 5 2 7

THIRD TRIAL

H

START APFE

OCKLE 128

QUESTIONS FOR PATIENTS

You, the patient, are the most valuable source of information about yourself that we have* As part of a research project designed to gather such important information, we would appreciate your cooperation in answering the questions within this booklet and com­ pleting a brief task which follows. You may rest assured that all information obtained in this way will be kept in strictest confidence. Your participation is totally voluntary, but again, very much appreciated. If you would like to help out, just read the paragraph below, turn the page and begin. Thank you.

This little booklet contains several different, but not difficult questions. Your answers to these questions will help us t< know you better. All the instructions you need to follow are printed inside the booklet. Please read them carefully as you work along at your own speed. Answer every question on every page. You do not have to worry about how well you are doing because there are no such things as right or wrong answers. V/hen you finish, please check your booklet over and be sure you have answered all the questions. appe::.’)ix i

■iELAYICRAL TEST IUSTRl’CTIO:^

A: E) RATING SCALE 130

General Instructions

LOOK AT THESE BOXES TO YOUR LEFT. (E points). EACH TOP BOX PiAS A LETTER IN IT, WHILE EACH BOTTOM BOX HAS A NUMBER IN IT. AS YOU CAN SEE, EVERY LETTER HAS A DIFFERENT NUMBER. YOUR TASK IS TO START HERE (E points to first box, bottom row, first trial) WHEN I SAY AND PUT IN AS MANY OF THESE EMPTY BOXES AS YOU CAP: THE NUMBER THAT SHOULD GO THERE. DO THE BOTTOM ROW FIRST (E points, moving finger left to right), THEN MOVE UP TO THE NEXT ROW AND SO ON. THERE ARE 50 (E accentuates) EMPTY BOXES ALTOGETHER. FOR INSTANCE, WHAT NUMBER GOES UNDER THE "H"? (E pauses for answer; corrects if necessary; repeats for "A"; proceeds when it is obvious the patient understands).

BEFORE YOU BEGIN, I HAVE A FEW BRIEF QUESTIONS.

Questions t First Trial la WHICH OF THESE (E displays and points to rating scale) BEST DESCRIBES HOW YOU THINK YOU WILL DO ON THIS TASK? (£ records) lb 'WHY DO YOU THINK THAT? (E records verbatim response; encourages beyond "Just do" and "I don't know", etc.)

2a WHAT IS THE HIGHEST SCORE YOU THINK YOU MIGHT POSSIBLY GET THIS TIME? (E records)

2b WHAT IS THE LOWEST SCORE YOU THINK YOU MIGHT POSSIBLY GET THIS TIME? (E records)

2c WHAT IS THE ACTUAL SCORE YOU THINK YOU WILL GET THIS TIME? (E records)

THANK YOU. NOW START HERE (E points to first box, bottom row, first trial) AND SEE HOW MANY BOXES YOU CAN FILL IN BEFORE I TELL YOU TO STOP.

(Fatient completes First trial to "T", 4th row) ---

3a WHICH OF THESE (E displays and points to rating scale) BEST DESCRIBES HOW YOU THINK YOU DID ON THE TASK THIS TIME? (E records)

3b WHY DO YOU THINK THAT? (E records) 131

General Instructions (Cont'd)

4a WHICH OF THESE (E points to rating scale) BEST DESCRIBES HOW YOU THINK YOU WOULD DO ON THIS TASK IF YOU TRIED IT AGAIN TOMORROW? (E records)

4b WHY DO YOU THINK THAT? (E records)

5a WHICH OF THESE (E points to rating scale) BEST DESCRIBES HOW YOU THINK YOU WOULD DO ON THIS TASK IF YOU TRIED IT AGAIN A YEAR FROM NOW? (E records)

6b WHY DO YOU THINK THAT? (E records)

Questions i Second Trial

BEFORE WE PROCEED I HAVE A FEW MORE 3RIEF QUESTIONS. (E repeats questions la,2a, 2b, 2c; lb is excluded)

THANK YOU. NOW ONCE AGAIN START HERE (E points to first box, bottom row, second trial) AND SEE HOW MANY BOXES YOU CAN FILL IN BEFORE I TELL YOU TO STOP.

(Patient completes second trial to "A", 4th row ) ---

E repeats questions 3a, 4a, 5a; 3bt 4b, 5b are excluded.

Questions i Third Trial

BEFORE 'WE PROCEED TO THIS FINAL TRIAL I HAVE SOME BRIEF QUESTIONS AS BEFORE. (E repeats questions la, lb, 2a, 2b, 2c).

THANK YOU. NOW ONE LAST TIME START HERE (E points to first box, bottom row, third trial) AND SEE HOW MANY BOXES YOU CAN FILL IN BEFORE I TELL YOU TO STOP.

(Patient completes third trial to "E", 5th row) ---

E repeats 3a through 5b. 132

PERFORMANCE RATING SCALE

very quite fairly about fairly quite very well well well average poorly poorly poorly

7 2 AFI-'Ef.'DIX 13^

NAME

Ratings Will Do Did Do Tomorrow 1 year

1st Trial ______2nd Trial ______3rd Trial ______

Estimates Highest Lowest Actual

1st Trial ______2nd Trial ______3rd Trial ______

Verbatim Answers — 1st Trial

Why/Will

Why/Did

Why/T

Why/1 Yr

Verbatim Answers -- 3rd Trial

Why/Will

Why/Did

Why/T

Why/1 Yr APPENDIX K

GRAPHICAL AND NUKERICAL S U G A R Y

OF DEAD SEMANTIC DIFFERENTIAL

SCALE SCORES AS A FUKCTIO:.’ CF

PATIENT TYPE AND CONCEPT DEPRESSIVE PATIENTS MY LIFE SO FAR NONDEPRESSIVE PATIENTS

4 ND D

Positive I'.egative 5.32 2.88 Good Bad 5.65 3.16 Adequate Inadequate 5.52 2.92 Healthy Sick 5.60 3.96 Useful Useless 5.96 3.28 Important Unimportant 5.88 3-32 Free Restricted 5.60 4.04 Tolerable i Intolerable 5.24 3.24 Lucky / Unlucky 5.36 2.84 Interesting / Boring 5.44 3.52 Likeable Unlikeable 5.72 3.48 Valuable Worthless 5.80 3.76 Great Terrible 5.08 3.72 Easy Hard 4.16 3.20 Acceptable Unacceptable 5.84 3.16 Satisfactory Unsatisfactory 5.92 2.84 Secure Insecure 4.96 2.48 Wise Foolish 5.32 3.00 Successful Unsuccessful 5.64 2.88 Pleasant Unpleasant 5.08 3.28 Full Empty 5.60 3.20 Worthy Unworthy 6.04 3.24 Happy Sad 5.20 2.88 Hopeful Hopeless 6.32 3.72

7 6 5 4 3 2 DEPRESSIVE PATIENTS

KYSELF NONDEPRESSIVE PATIENTS

ND D

Positive Heeative 5.88 3.12 Good 3 ad 6.12 3.56 Adequate Inadequate 5.60 3.00 Healthy Sick 5.64 4.32 Useful Useless 6.44 3.00 Important Unimportant 6.16 2.76 Free Restricted 5.28 2.88 Tolerable Intolerable 5.92 3.08 Lucky Unlucky 5.20 3.16 Interesting 3oring 5.68 3.44 r Unlikeable 6.48 4.12 Likeable i Valuable Worthless 6.44 3.48 Great Terrible 5.36 3.64 Easy Hard 5.36 3.60 Unacceptable 6.36 3.32 Acceptable ri Satisfactory Unsatisfactory 6.28 2.72 Secure Insecure 5.20 2.04 Wise Foolish 5.92 3.24 Successful Unsuccessful 5.44 2.92 Pleasant Unpleasant 6.36 4.04 Full Empty 5.56 2.68 Worthy Unworthy 6.24 2.96 Happy Sad 5.52 2.44 Honeful Hopeless 6.64 3.64

ni T DEPRESSIVE PATIENTS KY LIFE AS IT WILL BE NONDEPRESSIVE PATIENTS

6 4_____ 3 2 ND

Positive 1 Negative 6.56 4.28 Good { \ Bad 6.60 4 ,56 Adequate Inadequate 6.32 4.60 s > Healthy o Sick 6.06 5.28 o' Useful <\ Useless 6.76 5.08 Important Unimportant 6.52 4.92 Free Restricted 5.72 4.32 Tolerable <: Intolerable 6.36 4 ,48 Lucky Unlucky- 5.52 4. 52 Interesting r"" \ Boring 6.44 5.00 Likeable /V Unlikeable 6.40 4.96 Valuable Worthless 6.52 4.80 V Great V. Terrible 6.12 4.64 Easy Hard 5.36 3.76 Acceptable Unacceptable 6.60 4.68 Satisfactory v N Unsatisfactory 6,48 4.80 X Secure > Insecure 6.12 4.44 '.Vise ( 1 Foolish 6.38 4.96 Successful J Unsuccessful 6.38 4.88 t Pleasant 1 Unpleasant 6 .36 5.08 >l Full / Empty 6.33 4.84 '.V or thy <\ Unworthy 6.56 5.00 Happy > / Sad 6.32 4.32 Hopeful / Hopeless 6.64 5.12

2 DEPRESSIVE PATIENTS

NONDEPRESSIVE PATIENTS

ND D

Positive Negative 4.52 5.08 Good Bad 4.96 5.60 Adequate Inadequate 4.85 4.72 Healthy Sick 5.24 5.24 Useful Useless 5.00 4.92 Important Unimportant 4.72 4.84 Free Restricted 5.32 6.28 Tolerable Intolerable 5.44 5.12 Lucky Unlucky 5.08 5.68 Interesting Boring 5.48 4.76 Likeable Unlikeable 6.12 5.04 Valuable Worthless 4.72 4.60 Great Terrible 4.92 4,64 Easy Hard 4.64 4.76 Acceptable Unacceptable 5.76 5.08 Satisfactory Unsatisfactory 5.56 4.80 Secure Insecure 5.00 5.04 Wise Foolish 5.04 5.24 Successful Unsuccessful 4.52 5.00 Pleasant Unpleasant 5.24 5.64 Full Empty 5.08 4.64 Worthy Unworthy 5.72 4.48 Happy Sad 5.36 5.00 Hopeful hopeless 5.40 5.20 APPEITDIX L

SIir.T.ARY OF CHI SQEARE TESTS OF ASSOCIATION

HET’.TEEK PATIENT TYPE A ED performance

PATITO l'+l

SUMMARY OF CHI SQUARE TESTS OF ASSOCIATION

BETWEEN PATIENT TYPE AND PERFORMANCE

RATING

2 Condi tion Trial Patient Rating Category* i—1 0^ X ** P< Type I 5-7

1 D 3 13 ND 1 22 .87 .50

How patients 2 D 2 13 thought they ND 0 20 1.87 .20 would do 3 D 2 17 ND 0 22 .69 . 50

1 D 3 18 ND 2 21 .01 .95

How patients 2 D 2 20 thought they ND 0 22 .52 .50 did do 3 D 2 21 ND 0 22 AS . 50

1 D 2 19 ND 1 21 .00 1.00

How patients 2 D 2 20 thought they ND 0 22 . 52 . 50 would do tomorrow 3 D 2 21 ND 0 23 .52 .50 1*42

SUKKARY OF CHI SQUARE TESTS OF ASSOCIATION

BETWEEN PATIENT TYPE AND PERFORMANCE

RATING (CONT'D)

Condition Trial Patient Rating Category* y p < Type 1-3 5-7

1 D 3 19 ND 1 23 .33 .70

Row patients 2 D 1 22 thought they ND 0 21 .00 1.00 would do in one year T D 1 22 ND 0 ?M .00 1.00

* Category *4 ("about average") was excluded from analysis. Categories 1-3 include "very poorly", "quite poorly", and "fairly poorly". Categories 5-7 include "fairly well", "quite well", and "very well".

Yates's correction for continuity applied. APPENDIX P

SUFFARY CF CHI SQUARE TESTS OF ASSOCIATION

■3ETV/KEN PATIENT TYPE A N ’!) RESPONSE

TENDENCY ON TPiE I-E SCALE SUMMARY OF CHI SQUARE TESTS OF ASSOCIATION

BETWEEN PATIENT TYPE AND RESPONSE

TENDENCY ON THE I-E SCALE

2 It' Patient Response Tendency x ** Type Internal External

2 D 19 6 ND 21 4 .13

3 D 4 21 ND 6 19 .13

4 D 9 16 oc ND 19 6 •

< D 13 12 ND 13 12 .00

6 D 23 2 ND 23 2 .00

7 D 12 13 ND 19 6 4.16

D 14 11

9 CO o ND 13 12 •

10 D 22 3 ND 22 3 .00

11 D 20 5 ND 21 4 .13

12 D 16 9 ND 20 5 1.60

13 D 7 18 ND 13 10 5.19

15 D 20 5 ND 22 3 .15 14-5

SUMMARY OF CHI SQUARE TESTS OF ASSOCIATION

BETWEEN PATIENT TYPE AND RESPONSE

TENDENCY ON THE I-E SCALE (CONT'D)

2 I tem* Patient Response Tendency X ** P< Type Internal External

16 D 22 3 ND 2k 1 .01 .95

17 D 11 lk r:D 16 9 2.01 .20

18 D 6 19 ND 12 13 3.12 .10

20 D 17 8 ND 15 10 .35 .70

21 D 12 13 ND 15 10 .46 .50

22 D lk 11 ND lk n .00 1.00

23 D 2k l ND 23 2 .00 1.00

25 D 11 lk ND 16 9 2.01 .20

26 D 15 10 ND 17 8 .35 .70

28 D lk 11 ND 16 9 .33 .70

29 D 17 8 ND 21 k .99 . 50

* See Appendix F for actual content

** Yates's correction applied where f cell<5 VITA

Terrence James Lauphlin was born in Ottawa,

Canada on September 2 7, 19^19. lie prew up in Ottawa, receiving bin Grade XIII iionours Matriculation from

Fisher Park Hiph School in 1962, his Bachelor of Arts depree from Carleton University in 196 2 and his Master of Arts derree in Psychology from Carleton I'niversity in 1969.

Terrence Lauphiin berran his training for the

Ph.D. decree in clinical psychology at Louisiana State

I’niversity in September, 1967. lie completed his clinical internship at Central Louisiana State hospital in

Pineville between Aupust 1970 and Aupust 1971.

Terrence Lauphlin is a Candida to for the Ph.D. derrec at the Summer 1972 commencement. EXAMINATION AND THESIS REPORT

Candidate: T errence James Laughlin

Major Field: Psychology

Title of Thesis: Co g n it iv e D isto r t io n and Locus of Control in De pr e s sive

P sych i atr i c Pa tien t s

Approved:

^ / j U II Vy)dh Professor and Chairman

Dean of the (Graduate Schl

EXAMINING COMMITTEE:

O

Date of Examination:

June 22, 197^