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The relationship among perceived social support, self-critical cognition and neurotic symptoms in rehabilitation… McGinity, Alix M. 1992

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THE RELATIONSHIP AMONG PERCEIVED SOCIAL SUPPORT, SELF-CRITICAL COGNITION AND NEUROTIC SYMPTOMS IN REHABILITATION MEDICINE STUDENTS: A CORRELATIONAL STUDY by ALIX M. MCGINITY B.Sc.R., University of British Columbia, 1982 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES The Department of Counselling Psychology We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1992 © Alix M. McGinity, 1992 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. (Signature) Department of Counselling Psychology The University of British Columbia Vancouver, Canada Date. Oct. 14th 1992 DE-6 (2/88) ii Abstract A review of the literature indicates that a significant number of students are psychologically distressed during their professional education. Most of the research in this area focuses on sources of stress for students, usually confined to factors within the scope of the educational experience. Researchers generally agree, however, that stress experienced in a given situation is largely a function of an individual's perception of the circumstances and that characteristics of the situation, characteristics of the individual and mediating factors external to the situation are all determinants. The purpose of this descriptive, exploratory study was to examine the relationship among the following psychological variables among second, third and fourth year students in a rehabilitation medicine program: (a) the perception of available social support and satisfaction with this social support, (b) the tendency to process self-relevant information in self-critical and self-defeating ways, and (c) the manifestation of psychological distress in the form of neurotic symptoms. A sample of 83 students (73 females and 10 males) in an occupational therapy and a physical therapy program completed the Social Support Questionnaire, the Self-Critical Cognition Scale, and the Hopkins Symptom Checklist. The Social Support Questionnaire included two dimensions; (a) the availability of perceived social support; and (b) satisfaction with perceived social support. The Hopkins Symptom Checklist included five dimensions; (a) somatization; (b) obsession-compulsion; (c) interpersonal sensitivity; (d) depression; and (e) anxiety. A Pearson Product-moment correlational analysis was conducted on the two Social Support Questionnaire dimension scores, the five Hopkins Symptom Checklist dimension scores and the Self-Critical Cognition scores. A series of t tests were done to examine differences on the variables between occupational and physical therapy students as well as a one-way ANOVA among three groups according to the year in the program. The results showed that both perceived availability of social support and satisfaction with social support correlated significantly, in a negative direction, with self-critical cognition (p < .001). The two measures of the social support variable also correlated significantly, in a negative direction, with all dimensions of the Hopkins Symptom Checklist (p < .001) except somatization. There was no statistically significant difference between occupational therapy students and physical therapy students. The ANOVA revealed that third year students were statistically significantly more obsessive-compulsive than second and fourth year students (p < .05). Table of Contents Page Abstract i Table of Contents iV List of Tables v List of Figures vi Acknowledgements vii CHAPTER I: Introduction 1 Background 1 Problem Statement 5 Purpose 5 Definitions 6 Limitations 6 Summary 7 CHAPTER II: Literature Review 8 Social Support 8 Conceptualization of Social Support 12 Social Support and Mental Health Indices 14 Clinical Psychiatric Symptoms 16 The Relationship Between Social Support and Self-critical Cognition 18 Conclusions and Research Hypotheses 21 CHAPTER III: Methods 23 Subjects 23 Measures 24 Procedures 30 Design 31 CHAPTER IV: Results 32 CHAPTER V: Discussion 40 Conclusion 46 Recommendations 47 APPENDICES: A Table A-1 49 B. Table B-2 50 C Social Support Questionnaire 51 D. Self-critical Cognition Scale 61 E. Hopkins Symptom Checklist 63 REFERENCES 65 List of Tables Page Table A-1. A Summary Table of Rehabilitation Medicine Students Mean Scores on the Research Instruments 49 Table B-2. A Summary Table of Clinical and Non-clinical Samples' Mean Scores on the Hopkins Symptom Checklist Factors 50 Table 3. Pearson Correlation Coefficients among the Social Support Variables, Self-critical Cognition and the Neurotic Symptom Dimensions 37 Table 4. Summary Data and Analysis of Variance on Variable Obsession-compulsion by Variables Year 2, Year 3, and Year 4. 39 vi List of Figures Page Figure 1. Aspects of Social Support 12 Figure 2. Pearson Product-moment Correlationships 36 vii Acknowledgements According to Cobb (1976) social support is information leading the subject to believe: 1) that he/she is cared for and loved. 2) that he/she is esteemed and valued. 3) that he/she belongs to a network of communication and mutual obligation. To truly understand this conceptualization of social support is to know it in relationship. I express my sincere gratitude to Dr. Ishiyama for his unfailing support throughout this endeavour. I also express my deep appreciation to my friend, Gwen Palmer. She, too, knows this conceptualization of social support. 1 CHAPTER I: Introduction Background My involvement as a teaching assistant with students in the School of Rehabilitation Medicine at the University of British Columbia has promoted a subjective awareness of the psychological distress a number of students seem to experience during the four year program. Ostensibly this distress appears to be related to the demands of the academic program. For the most part these demands are the same for each student. However, the degree of the distress experienced and how it is manifested appears to differ for individual students. This suggests that there are more variables to be considered than just those determined by the education program. A review of the literature on stress experienced by students reveals that most studies focus primarily on sources of stress on students, and on allied health students generally. Only two studies attempted to look at stress in rehabilitation medicine students as a specific target population. Burnout, a psychological distress condition brought about by unrelieved stress, tension and anxiety, which are believed to impair a person's physical and mental health and work performance (Yuen, 1990), has been researched extensively. However, relatively few studies have examined this condition in students. Examination of the literature reveals that most studies examining sources of stress for students are confined to factors within the scope of the educational experience. Zujewskyj and Davis (1985), in one of two studies attempting to look 2 at sources of stress in nursing students, noted that stress for this group could be classified under the categories of "academic" and "clinical". Beck and Srivastava (1991), in the other study, acknowledged the importance of characteristics of the individual as well as mediating factors that are external to the specific stressful situation but focused their research primarily on characteristics of the situation, that was, the nursing program. Amount of material, examination grades, lack of timely feedback and difficulty with patient responsibilities have been identified as sources of stress in both medical and dental students (Lloyd & Gartrell, 1983; Garbee, Zucker & Selby (1980). Francis and Naftel (1983) in their study of stress among physical therapy students included the following non-academic and non-clinical sources of stress such as financial, personal, and drug related but still focused primarily on the students experience specific to the academic program. For the most part, these studies revealed a general agreement that the professional education process itself, for this group, can be a psychologically stressful experience. Academic pressures related to studying difficult material, long hours of classroom instruction and independent study, and clinical practice often seem to become a combined source of intensified stress among students (Beck & Srivastava, 1991; Bush, Thompson & Van Tubergen, 1985; Francis & Naftel, 1983). Looking at a much larger population of college students from a variety of academic programs, Bush, Thompson and Van Tubergen (1985) developed a personal assessment of stress factors instrument which included the following four 3 subcategories; (a) academic factors; (b) personal factors; (c) relationship factors; and (d) home and community factors. This instrument identified multiple sources of stress as well as stress intensity. Academic factors were perceived as the greatest source of stress, followed by personal factors, relationship factors, and home and community factors respectively. Relationships and home and community factors ranked highest in stress intensity, however there was no descriptive measure of the manifestation of this stress intensity. Studies on how psychological distress is manifested in students are few and appear to assume an underlying condition of burnout. Haack (1987, 1988), in two related studies, reported a high level of burnout in student nurses and identified that the level of burnout increased with each additional year they spent in school. Using a burnout measurement inventory and measures of depression, alcohol consumption, social support, and attributional style, she explored stress related disorders among undergraduate nursing students over a period of two academic years. High depressive symptoms, an increase in the frequency of alcohol use and an increase in burnout symptoms were reported by the majority of the subjects. There is no research in the literature on how psychological distress is manifested in rehabilitation medicine students, as of yet. Researchers generally agree that the stress experienced in a given situation is largely a function of the individual's perception of the circumstances (Lazarus & Folkman, 1984). There appear to be three major determinants of perceived stress; (a) characteristics of the situation; (b) characteristics of the individual; and 4 (c) mediating factors that are external to the specific situation (Murphy, Nadelson & Notman, 1984). For rehabilitation medicine students at the University of British Columbia, Vancouver, B.C., Canada, the characteristics of the academic program appear to be no different than those identified for other allied health students. The demands of learning difficult material, long hours of classroom instruction, independent study and clinical practice over a four year period appear to be the same for these students. Information about the characteristics of rehabilitation medicine students and information about mediating factors external to the academic program is lacking. The only research available that is related to characteristics of rehabilitation medicine students, focuses on personality factors primarily in occupational therapy students, and is inconsistent (Brown, 1989). The present study focused primarily on characteristics of the individual. Specifically it examined three characteristics of the individual; (a) perception of social support and degree of satisfaction with it; (b) tendency to process self-relevant information in self-critical and self-defeating ways; and (c) amount and type of neurotic symptoms experienced. Social support is more commonly regarded as a mediating factor and external to the specific situation. In this study it is the subject's perception of social support available rather than the subject's report of instrumental social support received that is being measured. This makes this variable an intrinsic capacity rather than an extrinsic outcome. 5 Pearson product-moment correlations were performed to determine the strength of the relationships among perceived available social support and satisfaction with available support, a self-critical cognitive tendency, and the type of and the amount of neurotic symptoms experienced. T tests and ANOVAs were conducted to explore differences between the variables as well as among the sub-samples, based on grouping subjects according to their year in the program and also according to occupational and physical therapy specialization. Problem Statement It is documented that allied health students experience significant psychological distress during their professional training. While this has been readily observed in rehabilitation medicine students at the University of British Columbia, Vancouver, B.C., no study to date has been conducted to explore this in this specific student population. Furthermore, the research done in the area of psychological distress experienced by allied health students during their professional training has focused primarily on sources of stress within the educational programs. There is very little research on the characteristics of the individual and the relationship between these characteristics and his/her experience of stress. This is despite general agreement among researchers that the stress experience in a given situation is largely a function of the individual's perception of the circumstances. Purpose The primary purpose of this study was to examine the amount of available 6 satisfactory social support perceived by rehabilitation medicine students and its relationship with two other variables; (a) self-critical cognition and (b) the amount and kind of psychological distress experienced. A secondary purpose of this study was to investigate any differences among variables between occupational therapy and physical therapy students, and among second, third and fourth year students. Definitions Social Support: Information belonging to one or more of the following three classes (Cobb, 1976): 1) information leading the subject to believe that he is cared for and loved 2) information leading the subject to believe that he is esteemed and valued 3) information leading the subject to believe that he belongs to a network of communication and mutual obligation. Self-Critical Cognition: One's tendency to process self-relevant information in self-critical and self-defeating ways (Ishiyama & Munson, in press). Neurotic symptoms: Self-reported clinical psychiatric symptoms as measured by the Hopkins Symptom Checklist, with subscales on somatization, obsession-compulsion, interpersonal sensitivity, depression and anxiety (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). Limitations Because the sample size is relatively small, especially that of male rehabilitation medicine students, the generalizability of the results will be limited. As well, the sample consists of students only, and students in one specialty 7 program. Also, this study looked at only selected characteristics of the individual and only one time. Summary This chapter has introduced the study, provided the background, identified the problem and articulated the purpose of the study. As well, the limitations of the study were discussed. 8 CHAPTER II: Literature Review Mental health represents the psychological and emotional status of a person. The promotion and maintenance of mental health involves many variables, including genetic, biological, psychological and social factors. A preliminary review of the literature in mental health reveals an abundance of research in all of these areas, describing positive and negative contributing factors. Their manifestation is of a psychological, emotional and behavioral nature. The frame of this study is biopsychosocial, and special attention is given to the relationships among social support, self-critical cognition and clinical psychiatric symptoms. It was anticipated that perceived social support mitigated self-critical thinking and clinical psychiatric symptoms and the relationships among those three constructs in a normal rehabilitation student population were explored. This section reviews the research to give a perspective to the meaning of social support, self-critical cognition and clinical psychiatric symptoms. It also addresses problems in the conceptualization of these constructs and describes the relationship between them. Social Support The subject of social support has been given much attention in the last twenty years and researchers have generated a substantial body of literature. A great number of studies on the nature and consequences of social support result in a general conclusion that it somehow promotes mental and physical health, but what it is, how it is provided and by whom, and how and under what conditions it 9 affects health, are ongoing open questions (Veiel, 1985). A preliminary review of the literature reveals a fundamental problem for researching these questions in that there appears little agreement as to how social support ought to be conceptualized (Lin & Dean, 1984; Sarason, Levine, Basham & Sarason, 1981; Tardy, 1985; Turner, Frankel & Levine, 1983; Veiel, 1985), and when operationalized, the measures of social support are as varied as the number of investigators (Broadbent, Kaplan, James, Wagner, Schoenbach, Grimson, Heyden, Tibblin, & Gehlbach, 1983). The vast number of definitions of social support illuminates this problem. House (1981) defines social support as an interpersonal transaction involving concern, aid and information about oneself and the environment while Kaplan, Cassel and Gore (1977) refer to an internal state of met needs or to the availability of psychosocial resources. Lin, Simeone, Ensel, and Kuo (1979) define social support as support accessible to an individual through social ties to other individuals, groups, and the larger community. Cobb (1976) defines it as information that one belongs to a socially coherent community and is loved and esteemed. Confusion and variance in the definition of social support are reflected in the many different measures used in empirical investigations. Throughout the literature, social support has been variously addressed in terms of social bonds (Henderson, 1977; Henderson, Byrne, & Duncan-Jones, 1981), social networks (Mueller, 1980), meaningful social contact (Cassel, 1976), and available confidantes (Brown, Bhrolchain, & Harris, 1975). While there is discussion on the active ingredients of social support, for example, availability and adequacy of attachment and social integration (Henderson, Duncan-Jones, Byrne, & Scott, 1980), network structure, the supportiveness of network relationships, and changes in the network (Mueller, 1980), as well as evidence of a number of validated and reliable measurements of the same, there have been relatively few attempts to organize research data within a comprehensive conceptual framework. Without a conceptual framework, analytical research tends to be speculative and the process of synthesis and integration of the data lacks direction. Veiel (1985) presents a conceptual schema identifying three principal dimensions with nine different categories, for the conceptualization, operationalization and measurement of social support. These are: 1. Support type: psychological, instrumental, crisis, or everyday 2. Relational context: sources 3. Assessment focus: transactions, relationships, subject, or object The focus here is on social relationships and transactions of individuals. Lin and Dean (1984), from a review of discussions in the literature, identify four elements of social interactions and several measures in each of the elements, as central to the concept of social support. They are: 1. the relationships between the ego and the source transmitting the help 2. the channel or network in which such help is transmitted 11 3. the message or content of the transmission which is conveyed or is perceived as help. 4. the social context within which the transmission takes place. Tardy (1985) identifies five issues and sixteen aspects of social support involved in the conceptualization and operationalization of social support (Figure 1). They are: 1. Direction: received/provided 2. Disposition: available/enacted 3. Description/Evaluation: described/evaluated 4. Content: emotional/instrumental/informational/appraisal 5. Network: family/close friends/neighbours/co-workers/community/ professionals This appears to be the most comprehensive, and encompasses the many dimensions and elements involved in defining the concept at an operational level. Figure 1. Aspects of social support (Tardy, 1985) SOCIAL SUPPORT Direction received provided Disposition Description/evaluation Content Network family close friends neighbours co-workers community professionals Conceptualization of Social Support Given the domain of concern in this study, that is, perceived social support, Cobb's (1976) conceptualization of social support is the most meaningful. Since the amount of support is not always related to perceptions of being supported, it is the cognitive appraisal of social support that is regarded as the central target of measure (Barrera, 1981). Specifically, Cobb conceives social support to be information belonging to one or more of the following three classes: (1) information leading the subject to believe that he/she is cared for and loved; (2) information leading the subject to believe that he/she is esteemed and valued; (3) information leading the subject to believe that he/she belongs to a network of communication and mutual obligation. Social support thus refers to the clarity or certainty with which the individual experiences being loved, valued, and able to count on others should the need arise. This cognitive-psychosocial conceptual frame for social support may underpin research on social bonds (Henderson, 1977; Henderson et al., 1981), meaningful contact (Cassel, 1976), confidants (Brown et el. 1975), and social support generally (Dean & Lin, 1977). It is also congruent with key concepts in a number of psychotherapies. Adlerian therapy contends human behaviour is motivated by goals that are aimed at bringing security and overcoming feelings of insecurity. The goal of belonging is fundamental to human behaviour (Adler, 1964). Reality therapy (Glasser, 1981) is based on the notion that human behaviour is based on the need to fulfil basic human needs such as belonging, attaining a sense of self-worth and being in control of one's own destiny. When one meets these needs one develops an identity characterized by success and self-esteem. Therapy is designed to help people meet their needs for loving, being loved and feeling worthwhile to themselves and others. Person-centered therapy (Rogers, 1959) is based on a deep faith in the tendency for humans to develop in a positive and constructive way if a climate of 14 respect and trust is established. All of these approaches have a phenomenological perspective, that is, a "subjective reality" view, as do existential therapy and Gestalt therapy. Sarason and Sarason (1990) assert that social support research has suffered from poorly developed theory and that a more theory-driven approach would be conceptually valuable and provide impetus for the methodological improvements needed for empirical advances. They ascertain that a diversity of approaches that can be integrated to reflect the complex phenomena being explored is needed. Social Support and Mental Health Indices Despite variations in the concept and methods of studying social support, there is consistent evidence that social support does play an important role in maintaining and promoting psychological health. The view that social support is related to mental health is discussed by many researchers, and much attention has been given to the hypothesis that social support may contribute to mental health (Brown, Bhrolchain, & Harris, 1975; Dean & Lin, 1977; Henderson, 1984; Mueller, 1980; Pearlin, Lieberman, Menaghan, & Mullan, 1981; Turner, 1981; Williams, Ware, & Donald, 1981). Dean and Lin and their colleagues have examined the relationship between social support and psychological well-being in a number of studies (Dean, Ensel, & Lin, 1981; Dean & Lin, 1977; Lin & Dean, 1984; Lin, Dean & Ensel, 1979). As already described, they conceptualized five elements of social support and measured components of these elements in relation to life events. Their results 15 revealed that social support is an indication of the integration of the individual in the social environment, and in this way exerts a direct and positive influence on mental health. They also posit that social support has a buffering effect against the effects of life stress and protects against depression. In their view social support is a significant factor in the etiology of mental health. Brown, Bhrolchain and Harris (1975) have shown that a confiding relationship, in which people can talk intimately about themselves and their problems, reduces the risk of depression following a major life event or a long-term difficulty. Similarly, Miller and Ingham (1976) have reported results supporting those of Brown et al. (1975). In their study, women reporting the lack of an intimate confidante had psychological symptoms of significantly greater severity than those reported by their more adequately supported counterparts. Further examination of the literature on the relationship between social support and psychological health reveals a series of studies by Henderson and his associates (Henderson, Byrne, Duncan-Jones, Scott & Addock, 1980b; Henderson, Duncan-Jones, Addock, Scott, & Steel, 1978a; Henderson, Duncan-Jones, Byrne, & Scott, 1980a; Henderson, Duncan-Jones, McAuley, & Ritchie, 1978b). They developed the Interview Schedule for Social Interaction, an instrument designed to measure the availability and perceived adequacy of a number of facets of social relationships. Their results revealed that availability and adequacy of both attachment and social integration were significantly related to both neurosis and depression (Henderson et al., 1980b). 16 Sarason, Levine, Basham and Sarason (1983) demonstrated significant negative correlations between the amount of available satisfactory social support and measures of emotional discomfort. As a group, women with low social support appeared to be significantly less happy and more introverted than those women with high social support. The results for men tended to be in the same direction but the correlations were not as strong. Clinical Symptoms Most clinical research on the manifestation of clinical psychiatric symptoms has been reductionistic in process and outcome, and relied on symptom and behaviour measures focused on specific symptom clusters. In this broad area of research, attention has been paid to cognitive disturbances, interpersonal issues, somatic physiologic responses, and affective states and responses. Numerous tests and measures have been developed and validated to assess each of these dimensions independently, such as the Beck Depression Inventory (Beck & Beamesderfer, 1974); the Hamilton Rating Scale for Depression (Hamilton, 1960); the Zung Self-Rating Depression Scale (Zung, 1965); the Social Avoidance and Distress Scale (Watson & Friend, 1969); the Shyness Scale (Cheek & Buss, 1981); the Mood Scale (Wessman, Ricks, & Tyl, 1960); and the State Trait Anxiety Inventory (Spielberger, Gorusch, & Lusherne, 1970). While specificity pre-empts generalization in research, the research relying on these measures, however, has generally minimized the importance of the interrelationships among the primary dimensions underlying distress. Self-report description of psychiatric symptoms is a necessary component of adequate evaluation and diagnosis. Objective measures of behaviours, which appear to be reflective of psychological distress, are open to a variety of confounding variables and an individual's perception and report of his/her own psychological experience would be more reliable for capturing the person's unique perspective on problems (McNeil, Greenfield, Attkisson & Binder, 1989). Self-report provides exclusive information that is simply unavailable through other assessment channels. The Minnesota Multiphasic Personality Inventory (MMPI) (Hathaway & McKinley, 1967) and the Psychological Screening Inventory (PSI) (Lanyon, 1970) have proved useful for description and classification of psychopathology, however they appear to measure personality traits rather than psychological states (Hoffmann & Overall, 1978). This poses difficulty when assessing for symptoms subject to change in relation to external factors, such as losses of people in social networks and life events. Within the broad area of research on classification of psychopathology, one of the challenges has been to delineate basic dimensions underlying clinical symptoms, a necessary first step to produce research on such problems as diagnosis, patient typing, and prediction of treatment response (Derogatis, Lipman, Covi, Rickels, & Uhlenhuth, 1970). It also is necessary for determining interventions that can target specific symptoms, e.g. relaxation training for anxiety states. Factor analysis has assumed a pivotal role in the development of multi-dimensional psychiatric symptom measures. It has been used in studies covering most of the traditional diagnostic classes, resulting in instruments for research in psychoses, neurotic behaviours and the basic syndromes of the depressive disorders (Derogatis et al., 1970). The Relationship Between Social Support and Self-Critical Cognition Self-critical cognition, the tendency to process self-relevant information in self-critical and self-defeating ways, has been linked to various forms of negative affect. Whether it is the product of an individual's negative affect or whether it is inherent to an individual's intrinsic way of processing information from his/her world, thus making him/her vulnerable to negative affect, seems yet to be determined. Much of the literature on self-criticism has examined it as an independent factor in depression (Beck, Rush, Shaw, & Emery, 1979; Blatt, D'Afflitti & Quinlin, 1979; Brown & Silberschaltz, 1989; HoUon & Kendall, 1980), and one study reported positive correlations between self-criticism and anxiety (Meichenbaum & Butler, 1980). Ishiyama and Munson (in press) propose that self-esteem and self-criticism should be treated as a product of a self-evaluational process. They regard a self-esteem or self-criticism index as part of the process of self-evaluation and have developed an instrument to measure the self-critical cognitive process specifically. In the development of this measure, they considered the following eight features of self-critical information processing: (a) selective focus on negative information; (b) preoccupation with negative information and prolonged focus; (c) spontaneous rumination on negative information without external input; (d) failure to handle negative information constructively; (e) exaggeration or over-generalization of negative information; (f) loss of objective perspective and neglect of positive information; (g) quickness to draw premature self-critical conclusions; and (h) social comparison of self to others leading to negative self-assessment or affect. Of particular interest to this study is the relationship between self-criticism and perceived social support. Correlations between means on the Self-Critical Cognition (SCC) scale (Ishiyama & Munson, in press) and means on the Social Avoidance and Distress Scale (Watson & Friend, 1969), the Fear of Negative Evaluation Scale (Watson & Friend, 1969) and the Public Self-consciousness Scale (Fenigstein, Scheier, & Buss, 1975) are all moderate to high and positive, suggesting that self-critical cognition has a strong social or interpersonal component. There appears to be very little empirical research on the relationship between social support and self-critical cognition. As already stated, the research in this area examines primarily the extent to which one's intimate relations with others has an effect on one's mental health generally. How social support relates to cognitive coping specifically, is less discussed. Pearlin, lieberman, Menaghan and Mullan (1981) examined social support and coping in an attempt to understand how life events, chronic life strains and self-concept influence depression. The results of this study indicate that both social support and coping are mediators in the stress-distress process. They reduce chronic strains that may occur following a negative life event, and prevent the loss of self-esteem and the sense of mastery that chronic strains and negative life events may produce. In the researchers' view, it is through an effect on self-concept that social support and coping influence the risk of depression. According to Meichenbaum (1977), self-statements affect a person's behaviour in much the same way as statements made by another person. Bandura (1986) asserts that self-relevant phenomena lie at the heart of many causal processes. Beck (1976) reported that a central characteristic of most depressive people is self-critical behaviour. Selective abstraction, magnification and minimization result in an increasing negative interpretation of environmental information by the depressed person. Lazarus' (1984) research on the coping process has revealed that the cognitive system is the first to be engaged when an individual is exposed to a stressor. Here, the individual attempts to discern the significance of the stressor for his/her well-being, interpreting it in one of four ways: as a threat, as a source of harm, as a loss, or more benignly, as a challenge. This primary appraisal process precedes the process of secondary appraisal in which the individual assesses the coping resources, both personal and environmental, at his/her disposal. Here, social support has a major role to play since the availability of peer consultants and advocates will add to the individual's confidence in his/her ability to master the demands of the stressor. Influence of social support on the primary appraisal process can be more subtle, entailing not only direct responses such as the provision of information about the nature of stress and active efforts to remove or soften it, but also indirect responses involving social comparisons. When the person compares his/her own emotional reactions to others, the individual's confidence in his/her ability to overcome the threat will be either augmented or diminished depending on how the reference group reacts. In sum, at a psychological level, feedback from supportive companions that communicates reassurance and affirmation may prevent damage to a person's self-concept by conditioning a steadfast sense of self-esteem and personal efficacy. It can also counteract a person's propensity to blame themselves for causing their own adversity or for not being able to control its course or outcome, thus preventing active coping efforts from being hampered by self-recrimination. Conclusions and Research Hypotheses There is a lack of research testing models predicting psychological distress as a function of the main effects of self-critical cognition and low social support. This study provides data to test the hypothesis that perceived social support is correlated to self-critical cognition and that there is a relationship between them and neurotic symptomology. 1. Perceived social support will be negatively correlated to a self-critical tendency in processing self-relevant information. 22 2. Perceived social support will be negatively correlated to neurotic symptoms. 3. A self-critical tendency in processing self-relevant information will be positively correlated to neurotic symptoms. A series of t tests will be conducted to examine any differences between occupational therapy and physiotherapy students. An exploratory analysis of data based on year in the program will be conducted using percentage comparisons and one-way ANOVAs. 23 CHAPTER III: Methodology This chapter outlines the subjects, the measures, the procedures, and the design of the study. Subjects The population from which this sample was drawn was the students in the Rehabilitation Medicine program at the University of British Columbia, Vancouver, British Columbia, Canada. The sample was comprised of 10 males and 73 females (total 83), 43% of the total number of students in the program at the time of the study. The female respondents made up 88% of the subject sample. The number of male respondents (12%) was small, but the percentage of male students in the population was also small (18%). Ages ranged from 19 to 49 years. The mean age was 25.8 and the standard deviation was 5.7 years. The data for this study were provided by three successive classes of rehabilitation medicine students who started the program in 1988 (fourth year students), 1989 (third year students), and 1990 (second year students). Before applying for this program, all students had successfully completed one year of pre-requisite courses. The majority of the respondents (58%) in the rehabilitation medicine sample were occupational therapy students, while 42% were physical therapy students. Thirty-eight of the respondents (45.8%) were fourth year students. Thirty-two (38.5%) were third year students, and thirteen (15.7%) were second year students. Measures All of the measures used in this study were in the form of a written questionnaire. Social Support Questionnaire (SSQ). This is a self-report questionnaire designed to measure availability of and satisfaction with social support (Sarason, Levine, Basham, & Sarason, 1981). Respondents identify people, by name or initials, and relationship, to whom they are able to go for support for each of 27 problems. They then indicate the level of their satisfaction with the total support for each specific issue along a six-point continuum from "very satisfied" to "very dissatisfied" (Appendix C). The distinction between amount of and satisfaction with social support is a strength of this questionnaire. Regardless of how social support is conceptualized, the subjective experience of social support would seem to have three basic dimensions: (a) quantity; (b) type; and (c) quality. Firstly, there is no doubt that support has a quantitative element. Having no friends or relatives or acquaintances available to turn to in times of need obviates the necessity for assessing other factors of support in one's network. The relationships that make up the social support network are the basic building blocks of social structure and their formation, maintenance and severance are universal and fundamental social processes (Hammer, Makiesky-Barrow, & Gutwirth, 1978). The available number of people alone, however, does not address the integrity of the concept of support. As already discussed, social support is multi-faceted and a multitude of types of support has been identified in the literature. Veiel (1985) distinguished between crisis support, psychological support, instrumental support, and everyday support. Tardy (1985) distinguishes between emotional, instructional, informational and appraisal support and Lin and Dean (1984) distinguish between instrumental and expressive support. The amount of perceived social support is likely to vary according to the specific type needed in relation to life events encountered (Lin & Dean, 1984; Brown & Harris, 1978). Finally, available social support, regardless of type, does not presuppose adequacy or satisfaction with social support. Lowenthal (1968) demonstrated in studies on social support in the elderly population that social support can be experienced as toxic for some people who show a long-standing preference to having only limited social interests. A large interconnected network, such as a family, can be mobilized for support but also disapproval, ostracism and rejection (Leavy, 1983). The quality of the relationships is integral to social support. The social support questionnaire (SSQ) measure of availability, the social support number (SSN), is calculated by dividing the number of people providing support by the total number of items in the questionnaire (27). The measure of satisfaction with available social support (SSS) is calculated by dividing the summed satisfaction ratings by the total number of items (27). The availability (SSN) score yielded a test-retest correlation of .90 over a period of 4 weeks with a sample of 107 college students while the satisfaction (SSS) score was slightly less reliable with a correlation of .83 (Sarason, Levine, Basham, & Sarason, 1981). The Social Support Questionnaire (SSQ) was selected because most of the questions deal with emotional or affective support (Tardy, 1985) which is congruent with the conceptualization and definition of social support chosen for this study. Although four items representing instrumental support are included e.g. whom could you really count on to help you out in a crisis situation, even though they would have to go out of their way to do so, and some others could be ambiguous e.g. whom could you really count on to help you out if you had just been fired from your job or expelled from school, the majority of items clearly assess emotional support e.g. who accepts you totally, including both your worst and best points. Self-critical Cognition Scale (SCC). This is a self-report scale developed by Ishiyama and Munson (in press) to measure a self-critical cognitive tendency in processing self-relevant information. Items, such as, "When things go wrong, I tend to criticize myself quite readily before assessing the situation objectively", are rated on a 1 to 6 scale according to a disagree/agree continuum. Subjects in their validation of this study filled out the original 25-item version of the Self-critical Cognition (SCC) scale. Thirteen items were used to calculate the total score as an index of self-critical cognition. According to Ishiyama & Munson (in press), the 13-item version correlated highly with the former 25-item version (r=.96; n=561). Based on their item reduction procedure, 8 of these 13 items were positively cued and 5 items were reverse scored for calculating the total self-critical cognition score (SCC) (Appendix D). According to Ishiyama and Munson (in press), a self-esteem or self-critical index is part of the psychological phenomenon of self-appraisal, and needs to be understood in terms of process (cognitive operations), structure, content and outcome. One self-focuses, activates a habitual pattern of processing and framing information in relation to an existing self-schema, and selectively attends to certain self-related information both externally provided and internally generated. This results in certain emotions and self-evaluative thoughts. This scale is designed to assess more directly the underlying dispositional tendency to focus on certain aspects of self and the tendency to process self-related information in self-critical and self-defeating ways. A criticism of the Social Support Questionnaire (SSQ) (Sarason, Levine, Basham, & Sarason, 1981) is that while the reliability of the instrument is satisfactory, there are considerable problems in validation of the adequacy of satisfaction index because of openness to confounding by contextual factors and personality traits (Henderson et al., 1981). The specificity of the SCC instrument might contain that. The scale has evidenced high internal consistency (Cronbach's alpha=.89, n=561 combining males and females) and test-retest reliability of r(138)=.81 with a 6.5 week interval. A two-factor solution in an exploratory factor analysis provided the most interpretable scale structure (Factor 1: negative self processing; Factor 2: failure in positive self-processing). The scale s construct validity was supported by meaningful correlations with measures of self-esteem, social anxiety and distress, shyness, fear of negative evaluation and depression. The Self-Critical Cognition scale was correlated negatively with the Rosenberg's (1965) Self-Esteem Inventory (SEI), and positively correlated with the Beck Depression Inventory (BDI: Beck & Beamesderfer, 1974) as well as the following four social anxiety scales: the Social Avoidance and Distress Scale (SAD) (Watson & Friend, 1969), the Fear of Negative Evaluation Scale (FNE) (Watson & Friend, 1969), and the Shyness Scale (Cheek & Buss, 1981). In addition it was positively correlated with Fenigstein, Scheier and Buss's (1975) Public Self-Consciousness Scale, a measure of tendency to see oneself as an object of others evaluative attention. The Hopkins Symptom Checklist (HSCL-58). The Hopkins Symptom Checklist (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974) is a 58-item, self-report symptom rating scale. It was chosen because of the range of symptomology examined and its sensitivity to symptom change. Attention has been paid to physiological, cognitive, interpersonal and affective states and responses, which results in a multi-system measure of clinical symptoms manifested in psychological distress. The Hopkins Symptom Checklist (HSCL-58) is the precursor to the SCL-90, a clinical rating scale comprised of 90 items reflecting nine primary symptom dimensions believed to underlie the majority of symptoms and behaviours observed in psychiatric outpatients. Five of these nine dimensions are included in the 58 item version reprinted in 1974 (Appendix E). The HSCL-58 tends to focus on conventional neurotic symptoms and the items are rated on a 4-point-scale of distress. A series of factor-analytic studies of both psychiatrists ratings (Lipman, Rickels, Covi, Derogatis, & Uhlenhuth, 1969) and patient self-ratings (Derogatis, Lipman, Covi, & Rickels, 1971) have identified 45 of the 58 items used for subscoring and isolated the following five primary symptom dimensions underlying the scale: (a) somatization (r = .87); (b) obsessive-compulsive (r = .87); (c) interpersonal sensitivity (r = .85); (d) depression (r = .86); and (e) anxiety (r = .84). A brief description of the constructs defined by these dimensions is provided by Derogatis, Lipman, and Covi (1973). The somatization dimension is comprised of 12 items which reflect distress arising from perceptions of bodily dysfunction. Some examples are cardiovascular, gastrointestinal and respiratory complaints. Headaches, pain and discomfort localized in gross muscular groups are also represented, as well as somatic equivalents of anxiety. The obsessive-compulsive dimension is comprised of 8 items which focus on thoughts, impulses, and actions that are experienced as unremitting and irresistible by the person but are of an undesired nature. The interpersonal sensitivity dimension is comprised of 7 items focused on feelings of personal inadequacy and inferiority, particularly in comparison with other individuals. Self-deprecation, feelings of uneasiness, and marked discomfort during interpersonal interactions are reflected in this factor. The sub-scale for depression reflects a broad range of the concomitant symptoms of the clinical depression. Eleven items in this dimension reflects feelings of hopelessness and futility as well as other cognitive and somatic correlates of depression. The anxiety dimension is comprised of 7 items reflecting symptoms and behaviours usually associated with a clinical anxiety disorder. Restlessness, nervousness and tension are included in this factor. Items touching on free-floating anxiety and panic attacks are also represented. The Hopkins Symptom Checklist (HSCL-58) has been empirically established and validated in a series of clinical investigations involving over 2,500 individual patients. It has shown adequate reliability, good construct validity, reasonable factorial in variance and differential sensitivity to change in controlled studies of psychotropic drugs and psychotherapy (Lipman, Covi, & Shapiro, 1977). Procedures Permission to approach the students in the program and actively recruit volunteer participants was obtained from the Director of the School of Rehabilitation Medicine at the University of British Columbia. A time was arranged with individual professors for the researcher to meet with students at the beginning of class, and explain the study to the students and invite them to participate. Students were told that the researcher was completing her graduate degree in counselling psychology and for her thesis, was conducting a study on the relationships between self-critical cognition, social support and psychological distress in rehabilitation medicine students. They were told there were three questionnaires and that the expected length of time to complete this package was approximately 45 minutes. It was clearly stated, both verbally and in writing on 31 the questionnaire, that their participation was completely voluntary and there was no remuneration. They were assured of anonymity and confidentiality. Some of the questionnaires were completed in the school at times arranged with the investigator, and others were taken home, completed and returned. Informed consent was obtained. The average length of time to complete the instrument package was 45 minutes. Data were collected throughout the second month of the winter semester. Design Descriptive statistical analysis (i.e., percentage comparisons) was done to provide information on demographic data such as age, gender, specialty area, and year in the program, as well as correlational analyses of the social support, self-critical cognition and neurotic symptomology variables. Exploratory analyses were performed on demographic data and the variables studied, using Pearson product-moment correlation coefficients to determine the direction of the relationships among these variables, as well as the strength. Comparisons between sample group means and variable means were performed, using t-tests and ANOVAs. All statistical tests were two-tailed. A significance level of .05 was used. CHAPTER IV: Results This chapter presents a summary of the descriptive statistics, and the correlations among the variables, in terms of Pearson r coefficients. Following this, the results of t test and the ANOVA are presented. A summary of the rehabilitation medicine students mean scores on the research instruments are shown in Table A-l (Appendix A). The social support number (SSN) scores for the 27 items in the Social Support Questionnaire ranged from 0.93 to 9.00 and the SSN mean score was 4.70 (SD = 1.9). The range of the social support satisfaction (SSS) scores for the 27 items was from 2.5 to 6.0, and the SSS mean score was 5.11 (SD = .7). These results indicate that there was very little difference between perceived social support mean scores reported by rehabilitation medicine students and the mean scores reported by Sarason, Levine, Basham and Sarason (1981): 4.25 (n = 602) for social support number (SSN), and 5.38 (n = 602) for social support satisfaction (SSS). This means that rehabilitation students are not an unusual sample. Differences in the range of mean scores, however, was very distinct. The score for the rehabilitation medicine student with the lowest social support number mean (SSN m = .93), was two people less than the lowest (SSN m = 2.92) social support number mean reported by Sarason et al. (1981). The highest social support number mean score (SSN m = 9) was 3.24 more than the highest social support number mean (SSN m = 5.46) reported by Sarason et al. (1981). The range of social support satisfaction (SSS) mean scores for the 27 items compared to the social support satisfaction mean scores reported by Sarason et al. (1981) was also very different. The rehabilitation medicine students who were least satisfied with their social support (SSS m = 2.5) scored 2.62 points less than the social support satisfaction mean score (SSS m = 5.12) reported by Sarason, et al (1981). The highest social support satisfaction (SSS) score for rehabilitation medicine students (SSS m = 6.0) was .43 points more than the highest social support satisfaction (SSS m = 5.57) reported by Sarason, et al. (1981). The 13-item Self-critical Cognition (SCC) scale yields a score ranging from 13 to 78 after reverse scoring the five positively-cued items. The higher the score, the greater the tendency to process self-relevant information negatively. The range for rehabilitation medicine students was from 14 to 72. The mean score was 40.99 with a standard deviation of 12.5. This is comparable to the mean score of 40.30 (SD = 11.20) reported by Ishiyama and Munson (in press). This indicates again that the rehabilitation medicine students are not an unusual sample. The rehabilitation medicine students' Hopkins Symptom Checklist factor mean scores on each of the dimensions were as follows: (a) 1.83 (SD = .56) for somatization; (b) 2.22 (SD = .66) for obsession-compulsion; (c) 2.32 (SD = .67) for interpersonal sensitivity; (d) 2.07 (SD = .60) for depression; and (e) 2.04 (SD = .60) for anxiety. These means are higher than the factor mean scores on all dimensions except anxiety, reported for an anxious neurotic sample (fl = 1435) by Derogatis et al., (1974): (a) 1.91 (SD = .59) for somatization; (b) 1.95 (SD = .67) 34 for obsession-compulsion; (c) 2.00 (SD = .68) for interpersonal sensitivity; (d) 2.04 (SD = .63) for depression; and (e) 2.22 (SD = .67) for anxiety. The students' scores were all considerably higher than the factor mean scores reported by Derogatis et al. (1974) for a non-clinical sample (n = 735). The mean scores were reported as follows: (a) m = 1.14 for somatization; (b) m = 1.6 for obsession-compulsion; (c) m = 1.2 for interpersonal sensitivity; (d) ni = 1.3 for depression; and (e) m = 1.11 for anxiety. No standard deviations were reported. These scores on the HSCL are half of those scores reported for rehabilitation medicine students. A summary of the anxious neurotic and non-clinical samples' mean scores are shown in Table B-2 (Appendix B). The results for the variables measured by the Hopkins Symptom Checklist (HSCL) show that the highest HSCL factor mean score for rehabilitation medicine students was in the interpersonal sensitivity dimension (m = 2.32, SD - .67). The lowest factor mean score was 1.83 (SD = .56) for somatization. Pearson product-moment correlation coefficients for the three variables, self-critical cognition, social support and clinical psychiatric symptoms, are shown in Figure 1. The first hypothesis indicating that available satisfactory social support would be negatively related to self-critical cognition was supported. The Pearson correlation coefficients among the social support dimensions, social support number (SSN) and satisfaction with social support (SSS), and self-critical cognition (SCC), are both strong in a negative direction. The Pearson correlation coefficient for social support number (SSN) and self-critical cognition (SCC) is r = -.38 (p_ < .000) and it is r = -.34 (p. < .001) for satisfaction with social support (SSS) and self-critical cognition (SCC). The second hypothesis that perceived social support would be negatively related to neurotic symptoms was supported using the social support scores (SSN and SSS) and the Hopkins Symptom Checklist (HSCL) score (the sum of the five dimensions: somatization, obsession-compulsion, interpersonal sensitivity, depression and anxiety). Examination of the Pearson correlation coefficients between both Social Support Questionnaire dimensions, SSN and SSS, and each of the five Hopkins Symptom Checklist dimensions revealed that three symptom dimensions were most closely related. The relationships between social support satisfaction and the interpersonal sensitivity and depression dimensions were r = -.28 (g=.006) and r = -.30 (g=.004) respectively. The Pearson correlation coefficient between interpersonal sensitivity and social support number was r = -.25 (g=.012) and the correlation between social support number and obsession-compulsion was r = -.29 (p=.004). When the relationship between the two dimensions of social support and neurotic symptoms are studied, it becomes apparent that the amount of perceived social support, as measured by the social support number (SSN) score, has a somewhat higher negative correlation with total neurotic symptoms (HSCL) score (r = -.28) than satisfaction with perceived social support (SSS) score (r = -.24). 36 Figure 2. Pearson product-moment correlationship among social support number, social support satisfaction, self-critical cognition, and Hopkins Symptom Checklist scores. -critical / jnition \ Social Suppc -.38*** -.34*** An*** >rt Number -.28* .43*** / - . 2 4 * Hopkins Symptom Checklist Social Support Satisfaction *** p < .001 ** p < .01 p < .05 37 TABLE 3 Pearson Correlation Coefficients among the Social Support Variables. Self-critical Cognition and the Neurotic Symptom Dimensions SSN SSS SCC SSN SSS SCC HSCL Total Somatization Obsession -compulsion Interpersonal sensitivity Depression Anxiety .43 (81) p=.000 -.38 (82) p=.000 -.28 (81) p=.006 -.20 (81) p=.034 -.29 (81) p=.004 -.25 (81) p=.012 -.23 (81) p=.021 -.22 (81) p=.023 .43 (81) p=.000 -.34 (81) p=.001 -.24 (80) p=.016 -.06 (80) p=.309 -.19 (80) p=.049 -.28 (80) p=.006 -.30 (80) p=.004 -.23 (80) p=.021 -.38 (82) p=.000 -.34 (81) p=.001 .47 (82) p=.000 .24 (82) p=.014 .57 (82) p=.000 .46 (82) p=.000 .42 (82) p=.000 .30 (82) p=.003 + Sum of somatization, obsessive-compulsive, interpersonal sensitivity, depression and anxiety scale. HSCL Hopkins Symptom Checklist (Derogatis et al, 1974). SCC Self-Critical Cognition (Ishiyama & Munson, in press). SSN Social Support Number (Sarason et al., 1981). SSS Social Support Satisfaction (Sarason et al., 1981). 38 The third hypothesis that self-critical cognition would be positively related to neurotic symptoms was supported using the self-critical cognition scores (SCC) and the total Hopkins Symptom Checklist score (HSCL), and the five dimensions of the Hopkins Symptom Checklist. The Pearson correlation coefficient between total neurotic symptom score (HSCL) and self-critical cognition (SCC) was r = .47 (p_ < .000), indicating a positive, strong relationship. Pearson product-moment correlation coefficients for each of the HSCL dimensions and self-critical cognition and social support are presented in Table 3. Examination revealed that the relationship between obsessive-compulsive symptoms and self-critical cognition (SCC) was the strongest with a correlation coefficient of r = .57 (g < .000). The Pearson correlation coefficients for interpersonal sensitivity and self-critical cognition (SCC) and depressive symptoms and self-critical cognition (SCC) also indicated positive, strong relationships at r = .47 (p. < .000) and r = .42 (p_ < .000), respectively. All of the HSCL dimensions and the total HSCL score were positively related to self-critical cognition, thus supporting the third hypothesis. T tests for the occupational therapy and the physical therapy students revealed no significant differences between them on any of the variables. ANOVAs were conducted on all variable scores to see if there were any significant differences between students according to year in the program. Table 4 presents the only significant difference (g < .05) found among second, third and fourth year students scores was in the obsessive/compulsive dimension of the HSCL. Third year students were more obsessive-compulsive than second and fourth year students. 39 Table 4. Summary Data and Analysis of Variance on Variable Obsession-compulsion by Variables Year 2. Year 3. and Year 4. Year 2 Year 3 Year 4 n: 13 30 38 m 14.58 19.07 17.89 Source d.f. S.S. MS. F. F Prob Between Groups 2 172.53 86.26 3.26 .04 Within Groups 77 2038.36 26.47 Total 79 2210.89 40 CHAPTER V: Discussion This chapter discusses the results of this study and makes recommendations for further research. This study investigated the nature of the relationship among the following three variables: (a) perception of available satisfactory social support, (b) the tendency to process self-relevant information in self-critical and self-defeating ways, and (c) neurotic symptoms, in a rehabilitation medicine student sample. The following hypotheses were tested: 1. Perceived social support would be negatively correlated with a self-critical tendency in processing self-relevant information. 2. Perceived social support would be negatively correlated with neurotic symptoms. 3. A self-critical tendency in processing self-relevant information would be positively correlated with neurotic symptoms. It appears from the results of this correlational study that rehabilitation medicine students higher in perceived social support have a less self-critical tendency in processing self-relevant information and experience fewer neurotic symptoms. This is consistent with the findings of Sarason, Shearin, Pierce, and Sarason, (1987) who found that college students higher in social support endorsed more positive and fewer negative qualities as self-descriptive than did students lower in social support. Statistically significant, moderately strong, negative relationships were found between the social support dimensions and self-critical cognition scores. These results were expected and supported the first hypothesis. 41 These results might also be understandable with reference to the results found by Ishiyama and Munson (in press). The correlations between the Self-critical Cognition scale and the other theoretically related variables they chose for construct validity purposes suggest that self-critical cognition has a strong social component. It appears that the more self-critical one is, the more socially avoidant and distressed one feels, and the greater the fear of negative evaluation. Likewise, the more self-critical one is, the more shy, the more socially anxious, and the more publicly self-conscious one is. All of these sociability characteristics may influence one's perception of both the availability and the satisfaction with social support. The social support mean scores were similar to the published norms for the Social Support Questionnaire (Sarason, Levine, Basham, & Sarason, 1981). However, the range of social support number and social support satisfaction mean scores was very different. This difference in the range scores for social support for rehabilitation medicine students and those reported by Sarason et al. (1981) lends itself to further research. One factor to explore might be the differences in network development for students in a specialty program compared to students with a general studies focus. One might contend that the rehabilitation medicine students, by virtue of the specialty program structure, that is, in school all day, with the same class members, five days a week, have less opportunity to meet a large and varied population from which to establish supportive relationships. There was a statistically significant relationship between social support and neurotic symptoms. This was a moderately strong, negative relationship, indicating the less available, satisfactory social support perceived, the more neurotic 42 symptoms reported. These findings supported the second hypothesis. They also supported the findings by Sarason, Levine, Basham, and Sarason (1981). They found significant negative correlations among the social support number (SSN) and the social support satisfaction (SSS) measures of Social Support Questionnaire and emotional discomfort, specifically anxiety, depression and hostility. Brown et al. (1975) and Miller & Ingham's (1976) studies on friends and confidantes found that people with few friends were more at risk of serious psychological distress when encountering life crises. In the correlational analyses between the social support variables and the dimensions of the neurotic symptom measure the correlation between social support number (SSN) and interpersonal sensitivity deserves commenting on. This was a moderately strong, negative relationship, indicating the more interpersonal sensitivity the less social support perceived. This may not be surprising when one considers the literature on self-concept theory which proposes that one's perception of others is a reflection of one's own self-identity. If an individual feels inadequate and inferior, and markedly uncomfortable during interpersonal interactions, and projects the same onto others, then the outcome might be a lack of perceivable social support (Swann & Read, 1981). Statistically significant, moderately strong, negative correlations were also found between the social support number and the obsessive-compulsive symptoms, and social support satisfaction and depressive symptoms. This is supported by much evidence in the literature showing a direct association between social support measures and other psychological and psychiatric conditions. Broadbent, Kaplan, James, Wagner, Schoenbach, Grimson, Heyden, Tibblin, and 43 Gehlbach (1983), did a very comprehensive review of the epidemiologic evidence for a relationship between social support and health. They describe eleven studies which found direct relationships among social support and depression, anxiety, and physical or somatic symptoms. The results of the descriptive analyses of the sample and the variables indicated that the rehabilitation medicine students did experience high psychological distress as manifested in neurotic symptoms measured by the Hopkins Symptoms Checklist (Derogatis et al., 1974). The rehabilitation medicine students' profile was very similar to that of the anxious neurotic patient samples, and these students' scores are approximately twice as high as the scores of a normal (non-clinical) population on all dimensions. This finding is consistent with the results of the research conducted on psychological distress in nursing students (Haack, 1987, 1988), general college students (Albuquerque & Rao, 1990), and medical students (Kumaraswamy, 1989). What is prominent and relevant to this study, are the students' scores on each of the dimensions in the Hopkins Symptom Checklist measure. The most neurotic symptoms reported were in the interpersonal sensitivity dimension. These symptoms focus on feelings of inadequacy and inferiority, particularly in comparison with other individuals. The high score on this symptom dimension may be related to feelings of competitiveness, perhaps a discreet characteristic in individuals in a group of high achievers. The least neurotic symptoms were reported in the somatization dimension. Somatization symptoms reflect distress arising from perceptions of bodily dysfunction, such as cardiovascular, gastrointestinal and respiratory complaints. Headaches, pain and discomfort localized m gross muscular groups are also represented. Rehabilitation medicine students appear to be very physically active in a variety of sports and it may be that high levels of physical activity mitigate somatic symptoms. Self-deprecation, or self-condemnation and self-disparagement are also characteristic of people with high levels of interpersonal sensitivity, along with feelings of self-consciousness and negative expectancies in relation to interpersonal communications (Derogatis, Lipman, & Covi, 1973). As one might expect, therefore, a statistically significant, strong and positive correlation was found between the self-critical cognition variable and the interpersonal sensitivity variable. This supports the findings of Ishiyama and Munson (in press) in their Self-Critical Cognition (SSC) scale validation study. The correlation between the self-critical cognition score and the score on the obsessive-compulsive dimension of the Hopkins Symptom Checklist was the highest in the Pearson product-moment correlation analysis. The obsessive-compulsive dimension represents cognitive disturbances. Obsessive-compulsive symptoms are thoughts, impulses, and actions that are experienced as unremitting and irresistible by the person but are of an ego-alien or unwanted nature (Derogatis, Lipman, & Covi, 1973). When one considers self-criticism in terms of process, or cognitive operations, as is postulated by Ishiyama and Munson (in press) and Ingram (1990), it is possible to conceive of a strong relationship between self-critical cognition and obsessive-compulsive symptoms. When one self-focuses, activates a habitual pattern of processing and framing information in relation to existing self-schema, and selectively attends to self-related information both externally provided and internally generated, the result is certain emotions and self-evaluative thoughts (Ishiyama & Munson, in press). The experience of obsessive-compulsive symptoms as unremitting and irresistible thoughts could exacerbate this self-critical cognitive tendency. Likewise when one considers the self-regulatory perseveration theory developed by Pyszcznski and Greenberg (1987). This proposes that depression and other negative affect may be maintained due to a failure to exit a self-defeating pattern of information processing. Obsessive-compulsive cognitive behaviours could influence the ability to control or cease these patterns of processing self-relevant information, thus influencing an individual's ability to exit a self-defeating pattern of information processing. It is not surprising then that the scores obtained in the correlational analysis indicate a moderately strong positive relationship between the tendency to interpret self-relevant information negatively and the experience of neurotic symptoms, interpersonal sensitivity and obsessive-compulsivity in particular. These findings support the third hypothesis. And finally, the ANOVA revealed that third year students had significantly more obsessive-compulsive symptoms than the second and fourth year students. One might speculate that students in third year might be more influenced by a culture which embodies achievement and competition, as well as the sources of stress in the academic program itself. The second year students are new to these factors and fourth years are over the hill and preparing to leave. The present study suggests several implications for further research. As already mentioned, correlational studies between high and low scoring subjects on 46 all variables should be conducted, with a view to further research as to comparative differences in various areas of performance. For example, do these two groups differ academically and socially? It is necessary in future research to administer the Hopkins Symptom Checklist measure to a sample of non-rehabilitation medicine university students and compare their scores with the scores provided by this sample. It might be that the level determined in the rehabilitation medicine student sample is not significantly higher than other college student scores, using the same measure. The Hopkins Symptom Checklist does not offer norms for college students. The results of the HSCL dimensions lend themselves to future research. It would be interesting to investigate elements of the symptom clusters experienced by rehabilitation medicine students more comprehensively, and to examine relationships between them and other intrinsic characteristics of the individual such as competitiveness and high achievement. The present study is correlational in nature. According to Bordens and Abbott (1988), correlational research is exploratory and offers no causal or etiological explanation regarding the variables being studied. It may identify variables that may be causally related, however, in this way providing a rich source of hypothesis that may be later experimentally tested. Conclusion The conclusion to this study is that rehabilitation medicine students who perceive a high amount of satisfactory social support experience less self-criticism and psychological distress than those students who perceive a low amount of social support. Rehabilitation medicine students as a group, however, experience very high levels of psychological stress as manifested in neurotic climcal symptoms. Their perception of available satisfactory social support and their tendency to process self-relevant information in self-critical ways is similar to other students, whereas their amount of clinical symptomology is much higher than the general population. Recommendations 1. The School of Rehabilitation Medicine faculty and students are informed of the results of this research study. 2. The School of Rehabilitation Medicine ensures the students have ready access to counselling and that students be encouraged to utilize such services. 3. The students entering the program have opportunity to develop stress management skills. 4. The School of Rehabilitation Medicine examines the academic program for intrinsic stress-producing variables and reduces them when and where possible. Appendices A. TABLE 1: A Summary Table of Rehabilitation Medicine Students' Mean Scores on the Research Instruments B. TABLE 2: A Summary Table of Clinical and Non-clinical Samples' Mean Scores on the Hopkins Symptom Checklist Factors C SOCIAL SUPPORT QUESTIONNAIRE D. SELF-CRITICAL COGNITION SCALE E. HOPKINS SYMPTOM CHECKLIST 49 Appendix A TABLE 1 A Summary Table of Rehabilitation Medicine Students' Mean Scores on the Research Instruments Mean SD n Social Support Number (SSN) 4.70 1.9 83 Social Support Satisfaction (SSS) 5.11 .7 83 Self-critical Cognition (SCC) 40.99 12.50 83 Hopkins Symptom Checklist (HSCL) imens ions: somatization obsession-compulsion interpersonal sensitivity depression anxiety 22.00 17.79 16.21 22.79 14.28 6.69 5.27 4.71 6.60 4.21 82* 82 82 82 82 Hopkins Symptom Checklist Total 93.07 23.33 82 Hopkins Symptom Checklist (HSCL) Factors: somatization obsession-compulsion interpersonal sensitivity depression anxiety 1.83 2.22 2.32 2.07 2.04 .56 .66 .67 .60 .60 82 82 82 82 82 * missing data - 1 female respondent did not complete this questionnaire. Appendix B TABLE 2 A Summary Table of Clinical and Non-clinical Samples' Mean Scores on the Hopkins Symptom Checklist Factors 50 Hopkins Symptom Checklist (HSCL) Factors: somatization obsession-compulsion interpersonal sensitivity depression anxiety Anxious Neurotics (D = m 1.91 1.95 2.00 2.04 2.22  1435) SD .59 .67 .68 .63 .67 Non-Clinical (n = 735) m SD* 1.14 1.16 1.12 1.13 1.11 * SDs were not presented for non-clinical sample. Appendix C Survey on Social Support The following questions ask about people in your environment who provide you with help or support. Each question has TWO parts. PART 1: List all the people you know, excluding yourself, whom you can count on for help or support in the manner described. Give the person's initials and their relationship to you. DO NOT LIST MORE THAN ONE PERSON NEXT TO EACH OF THE NUMBERS BENEATH THE QUESTION. DO NOT LIST MORE THAN NINE. PART 2: Circle HOW SATISFIED you are with the overall support you have in the manner described. If you have no support for a question, check the word "No one", but still rate your level of satisfaction. 1. Whom can you really count on to listen to you when you need to talk? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied Whom could you really count on to help you if a person whom you thought was a good friend insulted you and told you that he/she didn't want to see you again? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 3. Whose lives do you feel that you are an important part of? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 4. Whom do you feel would help you if you were married or had just separated from your spouse? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied Whom could you really count on to help you out in a crisis situation, even though they would have to go out of their way to do so? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied Whom can you talk with frankly, without having to watch what you say? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 7. Who helps you feel that you truly have something positive to contribute to others? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 8. Whom can you really count on to distract you from your worries when you feel under stress? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 9. Whom can you really count on to be dependable when you need help? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 10. Whom could you really count on to help you out if you had just been fired from your job or expelled from school? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 11. With whom can you totally be yourself? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial Relationship 4) 5) 6) 4 A little satisfied 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 Fairly dissatisfied 1 Very dissatisfied 12. Whom do you feel really appreciates you as a person? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial Relationship 4) 5) 6) 4 A little satisfied 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 Fairly dissatisfied 1 Very dissatisfied 13. Whom can you really count on to give you useful suggestions that help you to avoid making mistakes? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 14. Whom can you count on to listen openly and uncritically to your innermost feelings? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 15. Who will comfort you when you need it, by holding you in their arms? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 16. Whom do you feel would help if a good friend of yours had been in a car accident and was hospitalized in serious condition? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial Relationship 4) 5) 6) 4 A little satisfied 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 Fairly dissatisfied 1 Very dissatisfied 17. Whom can you really count on to help you feel more relaxed when you are under pressure or tense? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 18. Whom do you feel would help if a family member very close to you dies? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 19. Who accepts you totally, including both your best and worst points? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 20. Whom can you really count on to care about you, regardless of what is happening to you? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 21. Whom can you really count on to listen to you when you are very angry at someone else? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial Relationship 4) 5) 6) 4 A little satisfied 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 Fairly dissatisfied 1 Very dissatisfied 22. Whom can you really count on to tell you, on a thoughtful manner, when you need to improve in some way? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial Relationship 4) 5) 6) 4 A little satisfied 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 Fairly dissatisfied 1 Very dissatisfied 23. Whom can you really count on to help you feel better when you are feeling generally down-in-the-dumps? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 24. Whom do you feel truly loves you deeply? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 25. Whom can you count on to console you when you are very upset? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial Relationship 4) 5) 6) 4 A little satisfied 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 Fairly dissatisfied 1 Very dissatisfied 26. Whom can you really count on to support you in major decisions you make? 0) No one Initial Relationship 1) 2) 3) 6 Very satisfied 5 Fairly satisfied Initial 4) 5) 6) 4 A little satisfied Relationship 3 A little dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 27. Whom can you really count on to help you feel better when you are irritable, ready to get angry at almost anything? 0) No one Initial Relationship 1) 2) 3) 6 5 Very Fairly satisfied satisfied Initial Relationship 4) 5) 6) 4 3 A little A little satisfied dissatisfied Initial Relationship 7) 8) 9) 2 1 Fairly Very dissatisfied dissatisfied 61 Appendix D Self-critical Cognition Scale (SCC) When you think about yourself, how does your mind work? Please indicate how much you agree or disagree with the following statements by circling the appropriate numbers. 1 2 3 4 5 6 Strongly Moderately Slightly Slightly Moderately Strongly Disagree Disagree Disagree Agree Agree Agree 1. I'm good at looking at myself critically while still remaining positive toward myself.* 2. I tend to blow my weaknesses, limitations, and mistakes out of proportion in my thinking. 3. When I see someone else doing something well, I become critical of my own activities and accomplishments. 4. I tend to spoil my good feelings about myself by thinking of or looking for, something negative within me. 5. I often turn negative feedback from others into constructive courses of action without getting too hard on myself.* 6. Somehow I have a tendency to come to a critical conclusion about myself too easily. 7. When things go wrong, I tend to criticize myself quite readily before assessing the situation objectively. 8. I sometimes find myself thinking of negative things about myself for no reason. 62 9. Once I detect a weakness in me, or notice a mistake I have made, It is hard to stop thinking negative things about myself. 10. When I experience a failure or a criticism, I can generally keep from being carried away with critical thoughts about myself.* 11. I tend to appreciate my weaknesses and inabilities without becoming overly critical of myself.* 12. I tend to focus on the positive aspects of myself more readily than on the negative aspects.* 13. I tend to get carried away with my weaknesses and forget to appreciate my strengths when I think seriously about myself. Asterisks (*) indicate reverse scoring items. Appendix E Hopkins Symptom Checklist How serious are the following symptoms if you experience any of them? Please circle an appropriate number for each item to indicate the level of distress you tend to experience. S( 1 1 1 1 1 1 1 1 1 1 • 1 1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-:ALE: - 2 - 3 - 2 - 3 - 2 - 3 - 2 - 3 - 2 - 3 - 2 - 3 - 2 - 3 - 2 - 3 . - 2 - 3 - 2 - 3 -• 2 - 3 -- 2 - 3 -- 2 - 3 -- 2 - 3 -- 2 - 3 -• 2 - 3 -• 2 - 3 -• 2 - 3 -• 2 - 3 -• 2 - 3 -• 2 - 3 -• 2 - 3 -2 - 3 -• 2 - 3 -• 2 - 3 -2 - 3 -2 - 3 -- 4 -4 - 4 -4 -4 -4 -4 -4 -4 -4 -4 -4 -4 •4 •4 -4 •4 •4 •4 •4 •4 •4 •4 •4 4 4 4 1 Not at all (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) - 2 - 3 4 Extremely distressful headaches nervousness or shakiness inside being unable to get rid of bad thoughts or ideas faintness or dizziness loss of sexual interest or pleasure feeling critical of others bad dreams difficulty in speaking when you are excited trouble remembering things worried about sloppiness or carelessness feeling easily annoyed or irritated pains in the heart of chest itching feeling low in energy or slowed down thoughts of ending your life sweating trembling feeling confused poor appetite crying easily feeling shy or uneasy with the opposite sex a feeling of being trapped or caught suddenly scared for no reason temper outbursts you could not control constipation blaming yourself for things pains in the lower part of your back feeling blocked or stymied in getting things done feeling lonely feeling blue worrying or stewing about things feeling no interest in things feeling fearful your feelings being easily hurt having to ask others what you should do feeling others do not understand you or are unsympathetic feeling that people are unfriendly or dislike you having to do things very slowly in order to sure you are doing them right heart pounding or racing nausea or upset stomach feeling inferior to others soreness of your muscles loose bowel movements difficulty in falling asleep or staying asleep having to check and double-check what you do difficulty making decisions wanting to be alone trouble getting your breath hot or cold spells having to avoid certain places of activities because they frighten you your mind going blank numbness or tingling in parts of your body a lump in your throat feeling hopeless about the future trouble concentrating weakness in parts of your body feeling tense or keyed up heavy feelings in your arms or legs Somatization 1 - 4 - 1 2 - 1 4 - 2 7 - 4 2 - 4 8 - 4 9 - 5 2 - 5 3 - 5 6 - 5 8 Obsession-compulsion 9 - 1 0 - 2 8 - 3 8 - 4 5 - 4 6 - 5 1 - 5 5 Interpersonal sensitivity 6 - 1 1 - 2 4 - 3 4 - 3 6 - 3 7 - 4 1 Depression 5 - 1 5 - 1 9 - 2 0 - 2 2 - 2 6 - 2 9 - 3 0 - 3 1 - 3 2 - 5 4 Anxiety 2 - 1 7 - 2 3 - 3 3 - 3 9 - 5 0 - 5 9 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 1 - 2 - 3 - 4 Subscore Items: (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) REFERENCES Adler, A (1964). 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