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Rational hypnotherapy : a therapeutic intervention for anxiety neurosis and panic attacks 1987

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RATIONAL HYPNOTHERAPY: A THERAPEUTIC INTERVENTION FOR ANXIETY NEUROSIS AND PANIC ATTACKS by PHILIPPA J. LEWINGTON B.A. (Honors), The University of Alberta, 1980 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA Apr i l , 1987 © Philippa J. Lewington, 1987 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. Department of Counselling Psychology The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date A p r i l 20, 1987 Abstract The efficacy of a rational hypnotherapeutic intervention for anxiety states and panic attacks i s the focus of this research. Based on a single subject research design, the co-researcher was asked to complete pre-therapy, during and post-therapy assessments of personality, self-concept, mood states, stress and physiological symptoms. The baseline period was two weeks and therapy lasted 13 weeks. There were two weeks of post-therapy measures and f i n a l l y a six-month follow-up study. The intervention was comprised of progressive relaxation, guided imagery, a cognitive restructuring and behaviour rehearsal based on an A-B-C-D-E paradigm. The subject examined her self-defeating or ir r a t i o n a l thoughts in c r i t i c a l incidents and her subjective emotional behavioural and physiological reactions. She was then asked to substitute her own new more rational thoughts in the same situation. Post-therapy results from the objective tests and self-reports demonstrated significant improvement in almost a l l areas. Following the rational hypnotherapeutic intervention the co-researcher showed a normal personality p r o f i l e , increased self-concept, improvement in mood states and a significant reduction in stress and physiological symptoms. This improvement was maintained in the six-month follow-up. Rational hypnotherapy is effective, re l a t i v e l y short-term and encourages the client to play an active role in finding new ways to deal effectively with problems and accept control over his/her own l i f e . i i i TABLE OF CONTENTS Page Abstract i i Table of Contents i i i L i s t of Tables v i L i s t of Figures v i i CHAPTER I INTRODUCTION TO THE STUDY 1 Nature of the Study 2 Purpose of the Study 3 Hypotheses Tested 4 Rationale f o r Hypotheses 4 Si g n i f i c a n c e of the Study 6 Limitations of the Study 7 CHAPTER II REVIEW OF THE LITERATURE 9 Anxiety 9 What i s Anxiety? 9 C l a s s i f i c a t i o n s 12 Research Issues 13 C l i n i c a l Issues 15 Hypnosis and Hypnotherapy 16 What i s Hypnosis? 17 Di s s o c i a t i o n 19 Hypnosis and Psychotherapy 2 0 Hypnosis and Anxiety 21 Hypnosis and Rational Therapy 2 4 i v Page CHAPTER I I I METHODOLOGY 27 Subject . 27 Pre-, During and Post-Treatment Procedures 28 Procedure 29 Instruments: 32 Barber S u g g e s t i b i l i t y Scale . . . . 32 Minnesota Multiphasic P e r s o n a l i t y Inventory 34 Tennessee Self-Concept Scale . . . . 35 P r o f i l e of Mood States 37 Subjective Stress Inventory . . . . 39 Phy s i o l o g i c a l Symptoms Scale . . . .40 Single Subject Research Design 41 Analysis 45 CHAPTER IV RESULTS . 47 Barber S u g g e s t i b i l i t y Scale 47 Minnesota Multiphasic P e r s o n a l i t y Inventory 47 Tennessee Self-Concept Scale 49 P r o f i l e of Mood States 52 Subjective Stress Inventory 56 Phy s i o l o g i c a l Symptoms Scale . . . . . . 74 V CHAPTER V DISCUSSION AND CONCLUSIONS 78 Comparisons & Evaluations 78 Response to Hypotheses 81 Internal and External Validity 82 Jus t i f i c a t i o n of the Study 84 Summary and Conclusions 86 REFERENCES 89 APPENDIX A Cr i t e r i a for Panic Disorders 98 APPENDIX B Trance Induction and Intervention . . . 100 APPENDIX C Barber Suggestibility Scale. 105 APPENDIX D Minnesota Multiphasic Personality Inventory 114 APPENDIX E Tennessee Self-Concept Scale 129 APPENDIX F Profile of Mood States 13 6 APPENDIX G Subjective Stress Inventory 138 APPENDIX H Physiological Symptoms Scale 140 APPENDIX I MMPI Profiles 142 v i L I S T OF T A B L E S Page T a b l e 3 - 1 30 LIST OF FIGURES Page F igure 4-1 48 F igure 4-2 50 F igure 4-3 51 F igure 4-4 53 F igure 4-5 54 F igure 4-6 55 F igure 4-7 57 F igure 4-8 58 F igure 4-9 59 F igure 4-10 60 F igure 4-11 61 F igure 4-12 62 F igure 4-13 64 Figure 4-14 67 F igure 4-15 68 Figure 4-16 69 F igure 4-17 70 Figure 4-18 7 2 F igure 4-19 73 F igure 4-20 7 5 F igure 4-21 7 6 Figure 4-22 77 1 CHAPTER I INTRODUCTION TO THE STUDY Anxiety and panic attacks are becoming i nc rea s ing l y preva lent i n our North American soc i e t y . Estimates range from two m i l l i o n (Gorman, Liebowitz & K l e i n , 1984) to as many as 10 m i l l i o n Americans (Fishman & Sheehan, 1985) who experience acute, unprovoked anxiety a t tacks . These spontaneous attacks are u sua l l y assoc iated with fee l i ng s of dread and doom. D izz iness , choking sensat ions and r ap id heart ra te lead the v i c t i m to be l i eve s/he i s s u f f e r i n g a heart a t tack or l o s i n g c o n t r o l . Increased frequency of attacks leads to phobic avoidance i n which the v i c t i m assoc iates the attacks with s p e c i f i c se t t ings or act ions such as eat ing i n res taurants or d r i v i n g a ca r . Fear of attacks and avoidance behaviours may come to dominate the v i c t i m s ' d a i l y l i f e , r e s t r i c t i n g or even e l im ina t ing normal, s o c i a l a c t i v i t i e s i n severe cases. A growing awareness and knowledge of anxiety and panic at tacks has l ed to the establ ishment of a wide v a r i e t y of treatment plans f o r t h i s d i so rder . For severa l decades psychoanalys is and behaviour therapy reigned as the premiere treatments i n the f i e l d . More recent l y however, cogn i t i ve therap ie s , drug treatments and hypnotherapy have become recognized as v i a b l e and in some cases, p re fe rab le a l t e r n a t i v e approaches. In recent years there has been an emphasis p laced on succe s s fu l l y combining these therap ies 2 ra ther than employing only one set of techniques. Pharmacotherapy, used to suppress at tacks , can stand alone or be employed i n conjunct ion with behaviour or cogn i t i ve therap ie s . Hypnotherapy can be combined as a u s e f u l component with other in tervent ions such as cogn i t i ve therapy. Psychoanalys is , because of i t s temporal commitment and i t s f i n a n c i a l l y tax ing nature i s no longer a p re fe r red approach to anxiety d i so rder s . C l i n i c i a n s from most schools seem to agree that anxiety d i sorders can be t rea ted succe s s fu l l y and i n most cases, concluded a f t e r short - term therapy. Lengthy psychotherapy may not be appropr iate except i n cases where more severe psycho log ica l problems under l i e the anxiety. Nature of the Study Since many d i f f e r e n t t h e o r e t i c a l approaches c la im c l i n i c a l success i n the treatment of anxiety d i so rder s , the c l i e n t and/or the the rap i s t have choices i n the methods which may be most e f f e c t i v e . The c l i e n t can 'shop around' or seek a p a r t i c u l a r type of therapy. A f l e x i b l e the rap i s t can assess the c l i e n t and h i s / he r i n d i v i d u a l concerns and devise a unique program to meet the c l i e n t ' s s p e c i a l needs. Some c l i e n t s may respond we l l to drugs, others to behaviour or cogn i t i ve therapy without medications and others w i l l do best with both. Hypnotherapy may represent the standard psychotherapeutic approach of a c l i n i c i a n or i t may act as an 3 e f f e c t i v e adjunct to another approach. I t has been used with behaviour therapy (Clarke & Jackson, 1984), with cogn i t i ve therapy such as E l l i s ' Rat iona l Emotive Therapy (Tos i , 1974) and as an autonomous therapy (Er ickson & Ross i , 1979). Purpose of the Study Th i s study was developed to evaluate the e f fec t i venes s of r a t i o n a l hypnotherapy i n reducing or e l im ina t i ng anxiety s ta te s . The s ing le case experimental design w i l l l i m i t the scope of our f ind ings and w i l l not permit genera l i za t i ons to be drawn from the r e s u l t s . However, and perhaps more important ly, t h i s approach a f fo rd s , as a second ob jec t i ve , the opportunity to propose and design a therapeut ic s trategy which enables the r a t i o n a l , cogn i t i ve c apac i t i e s of the c l i e n t to be combined with conscious and unconscious learn ings v i a hypnotherapy i n a manner which al lows the c l i e n t to explore and make changes i n h i s / h e r own i n d i v i d u a l way and i n a v a r i e t y of d i f f e r e n t ways. This approach i s not r i g i d l y s t ruc tured but ra ther provides gu ide l ines which f a c i l i t a t e the c l i e n t ' s ac t i ve p a r t i c i p a t i o n and with f l e x i b i l i t y which encourages and values the c l i e n t ' s unique pe r sona l i t y and current s i t u a t i o n . 4 Hypotheses Tested Hypothesis 1: There w i l l be s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n scores from ob jec t i ve assessment (Minnesota Mu l t iphas i c Per sona l i t y Inventory, Tennessee Se l f Concept Sca les , P r o f i l e of Mood States) p r i o r to therapy and the change scores fo l lowing the treatment program. S p e c i f i c a l l y , the change scores w i l l r e f l e c t improved se l f -es teem and se l f - concep t , reduced s e l f - c r i t i c i s m , a pe r sona l i t y p r o f i l e more c l o s e l y approximating the normal or mean scores, and improvement i n mood s tates ( i . e . reduced scores i n the subscales tens ion/anx iety , depres s ion/de jec t ion , a n g e r / h o s t i l i t y , and increased scores i n the subscale v i g o r ) . Hypothesis 2; There w i l l be a s i g n i f i c a n t d i f f e r e n c e i n sub jec t i ve assessment of symptoms (Subject ive Stress Inventory, Phy s i o l o g i c a l Symptoms Scale) preceding and fo l l ow ing therapy completion. S p e c i f i c a l l y , the change scores w i l l i nd i c a te a reduct ion i n percept ion of s t re s s as we l l as fewer and l e s s severe p h y s i o l o g i c a l reac t i ons . Rat iona le f o r Hypotheses C l i n i c a l research implementing r a t i o n a l therapy and hypnosis have reported success i n reducing emotional, p h y s i o l o g i c a l and behavioural problems (Reardon, To s i & Gwynne, 1977; Boutin, 1978; Gwynne, Tos i & Howard, 1978; 5 Howard, Reardon & T o s i , 1982; T o s i , Howard, Gwynne, 1982; Blumenthal, 1984). Anxiety d i sorders have been demonstrated to be h i gh ly t r e a t a b l e u t i l i z i n g approaches ranging from r e l a x a t i o n techniques to behaviour therapy to psychopharmacology (Frankel , 1976; Sp iegel & Sp iege l , 1978; Er ickson & Ross i , 1979; Smai l , 1984; Gorman, Liebowitz & K l e i n , 1984; Ba l lenger , 1984; Garret t & Waldmeyer, 1985; Beck & Emery, 1985). Hypnotherapy, employed as an autonomous therapy or i n c o l l a b o r a t i o n with other therapeut ic methods has been demonstrated to make use of a na tura l phenomenon to enhance, quicken, i n t e n s i f y and conso l idate learn ings i n therapy (Cheek & LeCron, 1968; Haley, 1973; F ranke l , 1976; Kroger, 1977; Er i ckson & Ross i , 1979; Bandler & Gr inder, 1981; Araoz, 1985). The present research w i l l take advantage of the progress made i n the use of r a t i o n a l - and hypno- therapy whi le o f f e r i n g a sa fe, t r u s t i n g and t r a d i t i o n a l l y l e s s - d i r e c t i v e means f o r the c l i e n t to d i scover learn ings i n her own unique way and at a pace appropr iate to her needs and goals . The c l i e n t w i l l be d i r e c t e d through re l axa t i on exerc i ses and guided imagery but dur ing ac tua l therapy she w i l l be allowed to l e t her subconscious mind choose the events and s i tua t i on s which need to be brought to new l e v e l s of awareness. The 6 the rap i s t w i l l not always be aware of these events and s i t u a t i o n s and the c l i e n t w i l l not be ob l i ged to d ivu lge them unless she vo lunteers to do so. This approach fo l lows the phi losophy that " e f f e c t i v e therapy does not depend on the c l i n i c i a n ' s understanding of the process lead ing to such b e n e f i c i a l change as Watzlawick (1978), Ross i (Er ickson & Ross i , 1979), and others have reminded us , " (Araoz, 1985, p.42). S i gn i f i c ance of the Study The aim of t h i s research i s two- fo ld . I t i s intended to t e s t the e f fec t i venes s of a cogn i t i ve hypnotherapeutic i n te rven t i on as a treatment fo r anxiety d i so rder s . The widespread nature of anxiety d i sorders (Gorman, Leibowitz & K l e i n , 1984; Fishman & Sheehan, 1985; Garret t & Waldmeyer, 1986) requ i res therap i s t s to be prepared to t r e a t numerous such cases. The i n ten t i on of t h i s study i s not to i s o l a t e the •per fec t ' therapy. Rather, i t promotes a th ree -pa r t phi losophy. Every the rap i s t must have an approach f o r dea l ing with c l i e n t s present ing anxiety symptoms. Secondly, that approach should be te s ted and proven e f f e c t i v e . F i n a l l y , and equa l l y important ly, the the rap i s t must be f l e x i b l e i n choosing an approach which i s cons i s tent with each i n d i v i d u a l c l i e n t s ' needs and personal s t y l e . In other words, one formula can not be used i n every s ing le case. The t r u l y 7 t a l en ted the rap i s t has an a b i l i t y to determine which of the proven approaches and techniques or which combination of them, w i l l best serve the c l i e n t ' s s p e c i a l needs as e f f e c t i v e l y and as qu i ck ly as po s s i b l e . Therefore, a new cogn i t i ve hypnotherapeutic approach i s being t e s ted as a po s s i b l e opt ion on the t h e r a p i s t ' s menu f o r t r e a t i n g anxiety d i so rder s . A second goal of t h i s study i s to experiment with a s i ng le case research design. This represents an attempt to overcome the p i t f a l l s and l i m i t a t i o n s of the t r a d i t i o n a l case study. The present researcher w i l l attempt to r e c t i f y common e r ro r s ou t l i ned by Nugent (1985) and respond to the c a l l f o r sound, s i ng le case methodology (Hersen & Barlow, 1976; Kazdin, 1982; Nugent, 1985; Mott, 1986). By fo l lowing s t r i c t gu ide l ines f o r s i ng le case research and thereby enhancing i t s i n t e r n a l and externa l v a l i d i t y , s i ng le case research designs may take a p lace as a recognized and valued methodology a longs ide the t r a d i t i o n a l con t ro l group designs. The p r a c t i c a l i t y of s i ng l e case research i s obvious and i t would al low p r a c t i t i o n e r s a medium fo r present ing unique c l i n i c a l cases based not on anecdotal desc r ip t i ons but on a sound methodological framework. L im i ta t i ons of the Study The primary l i m i t a t i o n of t h i s research i s tha t , as a s i n g l e case design, genera l i za t ions to be drawn from the 8 r e s u l t s must be l i m i t e d . I f the chosen therapy i s success fu l i n t h i s p a r t i c u l a r case, we cannot assume that i t w i l l be succes s fu l i n a l l cases. However, s t r i c t adherence to methodology gu ide l ines should help e l iminate unexplained or unpredicted f a c t o r s ' e f f e c t on the outcome. P r a c t i c a l and e t h i c a l cons iderat ions prevented the researcher from choosing an A-B-A-B design which would have strengthened the research f ind ing s . S i m i l a r l y , these same cons iderat ions requ i red that the base l ine cond i t i on be shor ter than des i red . Tawney & Gast (1984) c i t e e t h i c a l cons iderat ions as an acceptable motive f o r bypassing the usual 1 s t a b i l i t y i s c l e a r ' r u l e , s t a t i n g that under these cond i t ions " shor te r base l ine cond i t ions are understandable and t o l e r a t e d , though the demonstration of experimental con t ro l may be weakened." (p. 160). 9 CHAPTER II REVIEW OF THE LITERATURE Anxiety Anxiety i s the human beings ' b u i l t - i n mechanism fo r coping. I t i s a d i s tu rb ing and unpleasant sensat ion which serves as a warning s i gna l to some impending r i s k or danger. I t ' s e f f e c t s may be biochemical (as i n the form of adrenal ine r e l ea se ) , p h y s i o l o g i c a l ( increased heart r a te , sweating, d i z z i n e s s ) , cogn i t i ve (messages to s e l f such as "I may embarrass myse l f " ) , emotional (such as f ee l i ng s of t e r r o r ) , mot iva t iona l (des ire to f l e e a threaten ing s i tua t ion ) and/or behavioura l (such as being unable to speak). M i ld l e v e l s of anxiety can p ro tec t us and even prompt increases i n i n d i v i d u a l performance l e v e l s . Thus, anxiety can be seen as an i n e v i t a b l e experience f o r any human being and not an i n d i c a t i o n of i l l n e s s or abnormality (Smail, 1984). What i s anxiety? What p r e c i s e l y i s anxiety and where does i t cross the boundary between being func t i ona l and hea l thy, and being patho log ica l ? Hamilton (1982) descr ibes anxiety as a p a r t i c u l a r mood, a modif ied and continuous s ta te of fear which can be normal ( in response to obvious threats) or pa tho log i ca l i n which there i s no externa l threat or there i s a g ros s l y exaggerated reac t i on , d i spropor t ionate to the cause. He def ines an anxiety s ta te or anxiety neurosis as 10 represent ing a pat tern of symptoms which are dominated by a p a t h o l o g i c a l l y anxious mood. According to Kroger (1977), "anx iety i s a un i ve r sa l human response due to hidden tens ion. I t becomes patho log ic when, without provocat ion or awareness, fears are experienced" (p. 349). Spe ige l and Speigel (1978) descr ibe developing anxiety as having a snowball ing e f f e c t . Pe r i od i c attacks develop into a cyc l e i n which the i n d i v i d u a l recognizes a s i t u a t i o n which makes him/her anxious and the phy s i c a l symptoms which accompany i t . "He then begins to respond to the phy s i ca l s i gna l s with worry, which then provokes even more phy s i c a l d i scomfort . Th i s sets up a feedback c y c l e , which esca la tes i n to a major and immobi l iz ing s ta te of anx iety" (p. 23 0). Lader (1982) suggests that an " i n e f f a b l e f e e l i n g of foreboding i s the core of anx iety" (p. 11). Beck (1985) po s i t s that anxiety " i s genera l l y considered a normal reac t i on i f i t i s aroused by a ' r e a l i s t i c ' danger and i f i t d i s s i pa te s when the danger i s no longer present. I f the degree of anxiety i s g rea t l y d i spropor t ionate to the r i s k and the seve r i t y of pos s ib le danger, and i f i t continues even though no ob jec t i ve danger e x i s t s , then the reac t i on i s cons idered abnormal" (p.30). Researchers i n the f i e l d of anxiety and anxiety d i sorders o f ten complain about the casua l , f l e x i b l e and 11 ambiguous use of the terminology and of the term ' anx ie ty ' i n p a r t i c u l a r (Paul, 1969; Beck & Emery, 1985). May, i n h i s 1950 p u b l i c a t i o n , The Meaning of Anxiety dec lared that he and many other t h e o r i s t s on anxiety (Freud, Go ld s te in , and Horney were c i ted) d i f f e r e n t i a t e fea r , "a r eac t i on to a s p e c i f i c danger" versus anxiety which i s " u n s p e c i f i e d , vague, ob jec t l e s s " (p. 190). S p e c i f i c a l l y , May def ined anxiety as " the apprehension cued o f f by a threat to some value which the i n d i v i d u a l holds e s s e n t i a l to h i s ex i s tence as a pe r sona l i t y " (p. 191). C larke & Jackson (1983) u t i l i z e three response systems ( s e l f - r e p o r t , behavioura l and phys io log i ca l ) f o r measurements of fear and anxiety. The d i f f e r e n c e between the two, they c la im, i s that anxiety covers " the many e f f e c t s which flow from adverse and threatening experiences" whereas fear represents " the e f f e c t s generated by unlearned (" innate") threat s as we l l as i n connection with phobias" (p. 169). Chapl in (1975), not ing that the two terms are l oo se l y used synonymously, descr ibes fears as a " s t rong emotional r eac t i on i nvo l v ing sub jec t i ve f ee l i ng s of unpleasantness, a g i t a t i o n and des i re to f l e e or hide . . . fear i s a reac t ion to a s p e c i f i c present danger; anxiety to an an t i c i pa ted danger"(p. 196). Beck & Emery (1985) suggest that "anx iety may be d i s t i ngu i shed from fear i n that the former i s an emotional 12 process whi le fear i s a cogn i t i ve one. Fear invo lves the i n t e l l e c t u a l appra i sa l of a threatening s t imulus; anxiety invo lves the emotional response to that appra i s a l . . . Fear then, i s the appra i sa l of danger; anxiety i s the unpleasant f e e l i n g s ta te evoked when fear i s s t imulated" (p.9). E l abora t ing on t h i s po in t , the authors p o s i t that one can l a b e l fear as r a t i o n a l or i r r a t i o n a l , l o g i c a l or i l l o g i c a l s ince i t i s based on l o g i c , reasoning and sens ib le assumption or the oppos i te, f a u l t y reasoning and assumptions. Anxiety, however, cannot be l a b e l l e d as r e a l i s t i c or u n r e a l i s t i c s ince " i t r e f e r s to an a f f e c t i v e response not to a process of eva luat ing r e a l i t y " (p. 10). F i n a l l y , panic d i sorder has been recognized as a d i s t i n c t e n t i t y under anxiety d i sorders i n the DSM-III (1980). Panic d i sorder invo lves r e p e t i t i v e , spontaneous panic attacks c rea t ing an overwhelming, subject i ve f e e l i n g of t e r r o r . In the DSM-III (1980) the c r i t e r i a f o r diagnosing panic d i so rder are out l i ned (Appendix A ) . Beck & Emery (1985) descr ibe panic as "an intense, acute s ta te of anxiety assoc ia ted with other dramatic p h y s i o l o g i c a l , motor and cogn i t i ve symptoms. The p h y s i o l o g i c a l c o r r e l a t e s of panic are an i n t e n s i f i e d ver s i on of those of anx iety" (p.10). C l a s s i f i c a t i o n s The American P s y c h i a t r i c A s s o c i a t i o n ' s D iagnost ic and 13 S t a t i s t i c a l Manual (DSM-III, 1980) c l a s s i f i e s anxiety d i sorders under three categor ies : 1) Phobic d i sorders (or phobic neuroses) inc lude agoraphobia with and without panic a t tacks , s o c i a l phobia and simple phobia. 2) Anxiety s tates (or anxiety neuroses) incorporate panic d i so rder , genera l i zed anxiety d i so rder and obsessive compulsive d i sorder (or obsessive compulsive neuroses). 3) Post - traumat ic s t res s d i so rder may be acute, chron ic or delayed or a t y p i c a l anxiety d i so rder . I t i s i n t e r e s t i n g to note that panic d i so rder d i d not become c l a s s i f i e d as a d i s t i n c t and separate e n t i t y under the anxiety s tates sub-heading u n t i l the 1980 r e v i s i o n of DSM-III. For years t h i s common mental hea l th problem has been c l a s s i f i e d under the general term of ' a n x i e t y ' . I t i s not s u r p r i s i n g then that " the t r a d i t i o n of lumping a l l d i sorders i n to l a rge categor ies , with l i t t l e phenomenologic d i s t i n c t i o n , b lu r red research f i nd ing regarding the nature of patho log ic anx iety" (Gorman, Leibowitz & K l e i n , 1984, p.3). Research Issues Results of inves t i ga t i ons in to the e t i o l ogy of anxiety and panic d i sorders appear to be cha l leng ing psychotherapy as 14 the fundamental treatment and p s y c h i a t r i c use of b i o l o g i c a l treatments i s prompting a reassessment of anxiety s tates (Hamilton, 1982). P i t t s St McClure 's (1967) c o n t r o v e r s i a l s tud ies us ing sodium l a c t a t e i n j e c t i o n s may increase our understanding of the biochemical mechanisms operat ing i n panic d i so rder . In a 1969 study, P i t t s a t t r i b u t e d anxiety to excess ive l a c t i c ac id or d e f i c i e n t ca lc ium. Pharmacotherapy i s becoming i nc reas ing l y popular with mental hea l th p ro fe s s i ona l s t r e a t i n g anxiety and panic a t tacks . T r i c y c l i c ant idepressants such as imipramine and monoamine oxidase i n h i b i t o r s such as phenelzine b lock spontaneous panic attacks but can be assoc iated with high blood pressure and/or drowsiness. A new drug on the market, a benzodiazepine c a l l e d alprazolam repor ted ly provides f a s t e r r e l i e f and has fewer s ide e f f e c t s . Bal lenger (1984) reported succes s fu l treatment of phobia us ing these drugs but other experts are l e s s c e r t a i n about how alprazolam works (Fishman & Sheehan, 1985). Beck & Emery (1985) caut ion that " i n view of the strong evidence of cogn i t i ve and other psycho log ica l f ac to r s i n t h i s d i so rder as we l l as behavioural methods f o r r e l i e v i n g i t , i t seems premature to make a commitment to an exc lus i ve organic e t i o l o g y " (p.85). C l i n i c a l research s tudies i n to the o r i g i n s , development and treatment of anxiety d i sorders by behav iour i s t s (Clarke & 15 Jackson, 1983; Turner, 1984) and cogn i t i ve the rap i s t s (Tos i , Howard & Gwynne, 1982; Beck & Emery, 1985) continue to help r e f i n e our knowledge of t h i s d i sorder and t e s t the e f f i c a c y of the treatments. Continued studies should lead to fu r ther refinement of the i n d i v i d u a l d i sorder c l a s s i f i c a t i o n s as we l l as to an accurate p r e d i c t i o n of which c l i e n t s w i l l respond to pharmacological therapy, which w i l l bene f i t from short-term therapy and which ones requ i re longer term psychotherapy. The r o l e of hypnosis as a f a c i l i t a t o r of the techniques should a l so become c l e a r e r (Mott, 1986). C l i n i c a l Issues The d iver se t h e o r e t i c a l approaches to anxiety d i sorder manifest equa l ly v a r i e d c l i n i c a l approaches to i t s treatment. While the d i so rder i s considered to be h i gh ly t r ea t ab l e i n p r a c t i c a l l y a l l cases, the c l i e n t may rece ive short or long term therapy, with or without medicat ion, may l i e motionless on a couch, or a c t i v e l y change h i s / h e r personal s i t u a t i o n . Each method claims to be v a l i d , r e l i a b l e and succe s s fu l . Theor i s t s concerned with the b i o l o g i c a l and genet ic components of anxiety d i sorder may c a l l f o r a r e v i s i o n i n the c l i n i c a l approach to incorporate newer, more e f f e c t i v e medicat ions. There seems to be a general consensus among psychotherapis ts that the the rap i s t should intervene to help the c l i e n t f i n d more' a l t e rna t i ve s i n l i f e , to produce changes 16 which al low the c l i e n t to grow and develop (Haley, 1973). Drugs which ease anxiety may i n f a c t , b lock the recovery process by permi t t ing the s u f f e r e r to avoid confront ing and overcoming t h e i r f ea r s . The c l i e n t can l ea rn to experience and c o n t r o l the anxiety us ing re l axa t i on techniques, deep breath ing, se l f -hypnos i s and biofeedback (Fishman & Sheehan, 1985) . In the 1950's and 1960's, psychoanalyt ic and behavioural approaches dominated i n the f i e l d of anxiety d i s turbances. Since that time there has been a move towards e f f e c t i v e short term therapy and away from lengthy and expensive ana ly s i s sess ions . Cogni t ive and behavioural t he rap i s t s continue to design and r e f i n e programs which help c l i e n t s dea l with anxiety and panic attacks i n a r e l a t i v e l y short per iod of t ime. The fo l lowing sec t ion explores and inves t i ga tes hypnotherapy as i t i s app l ied alone and i n conjunct ion with some of the prominent c l i n i c a l approaches to anxiety d i so rder . Hypnosis and Hypnotherapy "At the most general l e v e l , the goal of the hypnot i s t i s to change the behaviour, sensory response, and consciousness of another person. A subs id ia ry goal i s to extend that person ' s range of experience; to provide him with new ways of th ink ing , f ee l i ng s and behaving. Obviously, these are a l so 17 the goals of therapy. Both hypnot i s t and the rap i s t seek through the r e l a t i o n s h i p with a person to introduce v a r i e t y and extend the range of h i s a b i l i t i e s " (Haley, p. 21). What i s Hypnosis? From Mesmer, de Puysegur, Durand de Gros, Charcot and Janet through to modern day hypnot i s t s and hypnotherapists, events i n the development of hypnosis have been c o l o u r f u l and c o n t r o v e r s i a l , (Cheek & LeCron, 1968; F ranke l , 1976; H i l ga rd , 1977; Sp iege l & Sp iege l , 1978). However, one step taken by an Eng l i sh phys i c i an i n the 1840's has played a s i g n i f i c a n t r o l e i n the f i e l d ' s cont inuing s t rugg le f o r recogn i t i on and p ro fe s s i ona l acceptance. James Bra id (Kroger, 1977) borrowed from the Greek word f o r s leep 'hypnos' and coined the term •hypnotism'. By the time Bra id r e a l i z e d that a hypnotic s tate represented a near opposite to s leep ra ther than a p a r a l l e l to i t , i t was too l a t e . This term leads to misunderstandings even today. What Bra id , and others s ince have r e a l i z e d i s that the hypnotic s ta te or trance a c t u a l l y invo lves almost complete absorpt ion or focus ing of one 's a t t e n t i o n by an idea, image or sensat ion. This degree of absorpt ion creates an unawareness or masking of events normally monitored by the conscious mind so that d i s t r a c t i o n s to l ea rn ing become minimized. At the same time, awareness may heighten on processes normally outs ide of conscious i n f l uence . For 18 ins tance, one 's a t ten t i on may be d i r e c t e d to p h y s i o l o g i c a l changes, such as sensations i n the hands or ra te of breathing which are constant events but normally outs ide our conscious awareness. Research has a l so demonstrated d i f f e rence s between s leep and hypnot ic t rance inc lude loss of r e f l e x and lo s s of consciousness i n s leep but not i n trance s t a te , (Cheek & LeCron, 1968). Some researchers (Posner, 1973; Sternberg, 1975) be l i eve that cogn i t i ve a c t i v i t y , outs ide awareness precedes and in f luences conscious p sycho log i ca l processes. In other words, the unconscious mind acts as a f i l t e r or even as a censor, r e s t r i c t i n g and c o n t r o l l i n g what enters conscious awareness. M i l ton E r i ck son ' s c l i n i c a l work demonstrates a r e l i a n c e on the unconscious mind's a b i l i t y to choose the appropr iate time to al low an idea or p iece of informat ion to become acces s ib le to the conscious awareness of h i s pa t ien t and i s descr ibed i n E r i ck son ' s (1980) well-known phrase, ' t r u s t i n g the unconsc ious. ' I t i s important to recognize that t rance i s not a f o re i gn s ta te imposed on the c l i e n t by a t h e r a p i s t but i s i n f a c t a very na tura l phenomenon which occurs spontaneously and which r e p l i c a t e s natura l mental processes whi le respect ing and promoting i n d i v i d u a l i t y . For that reason, Araoz (1985) sees hypnosis as " i d e a l to f a c i l i a t e the process by which people l ea rn to ac t i va te t h e i r own unique resources and p o t e n t i a l s to reso lve t h e i r own problems i n t h e i r own ways." ( p . x - x i ) . 19 D i s soc i a t i on Janet (1907) introduced the concept of d i s s o c i a t i o n which r e f e r s to the human a b i l i t y to operate mental ly on more than one l e v e l at a t ime. In f a c t , Janet a c t u a l l y es tab l i shed d i s s o c i a t i o n as a s i g n i f i e r of pathology (Sanders, 1986). H i l ga rd (1973) has explored the d i s s o c i a t i v e process, r e v i v i n g and r e v i s i n g J a n e t ' s ideas i n an attempt to understand how a l t e r e d s tates of consciousness occur and how they can be maintained. In 1977, H i l ga rd proposed a " neo -d i s soc i a t i on theory of hypnosis i n which d i s s o c i a t i o n could be viewed on a continuum of behaviour from normal to p a t h o l o g i c a l " (p. 84-85). He a l so descr ibed hypnosis as a focus ing and d i s s o c i a t i v e process (Hi lgard, 1977). Gruenewald (1986) recogn iz ing d i s s o c i a t i o n as a d e s c r i p t i o n of processes which can not be observed d i r e c t l y , s ta tes that " d i s s o c i a t i o n phenomena manifest themselves i n what appears to be memory loss and behavioural change on a broad spectrum from normal to pa tho l og i c a l , with d i s s o c i a t i o n proper being considered a d i s t i n c t form of psychopathology of g reater or l e s s s e v e r i t y " (p.116). D i s soc i a t i on then can be seen as a continuum. For example, at one end of t h i s continuum i t can be u t i l i z e d v i a hypnotherapy to a i d i n personal growth and development (Araoz, 1985) by prov id ing temporary mental journeys or escapes and i t can be used as a technique fo r i n t e r r u p t i n g 20 hab i tua l mental processes. I t i s a s ta te , l i k e r e v e r i e , whereby one can detach onesel f from the immediate environment but s t i l l funct ion adequately and appropr ia te ly opening up new awareness to change. At the other end of the continuum, d i s s o c i a t i o n can be demonstrated by mu l t i p l e p e r s o n a l i t i e s in which one part operates completely independently and of ten without the knowledge of the other par t s . Th is could be descr ibed as pa tho log i ca l d i s s o c i a t i o n as opposed to the h e a l t h i e r example of adaptive d i f f e r e n t i a t i o n (Watkins, 1986). Hypnosis and Psychotherapy In 1980, researchers Shevrin and Dickman used the r e s u l t s of t h e i r s tud ies to assert that "no psycho log ica l model that seeks to exp la in how human beings know, l ea rn , or behave can ignore the concept of unconscious psycho log ica l processes" (Tosi & Baisden, 1984, p. 160). By us ing hypnosis and l ea rn ing more about the p o t e n t i a l of the unconscious mind, the combination of hypnosis and psychotherapy may increase the chances of reaching a success fu l therapeut ic goa l . "By i t s e l f , i t (hypnosis) i s not a treatment. I t i s the counse l l i n g and therapy that i s important" (Barber, 1986, p. 28). F ranke l , i n h i s foreword to Clarke and Jackson (1983) a l so agrees that " the therapeut ic outcome matters more than the consequences of an induct ion procedure or one 1 s 21 commitment to a t h e o r e t i c a l p o s i t i o n ( p . i x ) . Diamond (1986) caut ions that "hypnosis i s not a therapy i n i t s e l f and the subsequent dimensions may be f a c i l i t a t i v e or i n h i b i t o r y among var ious t h e o r e t i c a l and t e c h n i c a l o r i en ta t i on s to treatment" (p. 239). In other words, hypnosis i s simply another means to an end, but i s not therapy i n and of i t s e l f . Hypnotherapy, or hypnosis used i n conjunct ion with psychotherapy can lead to very succes s fu l therapeut ic r e s u l t s . According to Diamond (1986), " the advantages of hypnotic t r a i n i n g occur regardless of whether the c l i n i c i a n continues to employ d i r e c t or i n d i r e c t hypnot ic procedures with c l i e n t s " (p. 238). M i l ton E r i c k s o n ' s techniques exempl i f ied succes s fu l hypnotherapy us ing i n d i r e c t hypnotic communication i n which there was no formal t rance induct ion r i t u a l . The p r a c t i c e of hypnotherapy has changed s i g n i f i c a n t l y over the past t h i r t y years . A renewed i n t e r e s t has l ed to a more na tura l and le s s d i r e c t i v e a p p l i c a t i o n of hypnotherapy. People o f ten be l i eve that the ' hypnot i s t ' w i l l c on t ro l them and they must surrender to h i s w i l l . Although t h i s b e l i e f p e r s i s t s , hypnotherapy today represents a more c o l l a b o r a t i v e e f f o r t i n which the the rap i s t uses h i s / he r s k i l l s to f a c i l i t a t e the c l i e n t ' s greater l ea rn ing and understanding of h im/herse l f . Hypnosis and Anxiety S ince anxiety d i sorders are r e l a t i v e l y widespread i n our 22 western cu l t u re , many c l i n i c i a n s who p r a c t i c e hypnotherapy have app l ied i t to the treatment of anxiety s ta tes , panic attacks and phobias (Frankel, 1976; Er ickson & Ross i , 1979; T o s i , Howard & Gwynne, 1982; Clarke & Jackson, 1983). In each case, these researchers were able to u t i l i z e hypnot ic techniques t h e r a p e u t i c a l l y and i n conjunct ion with each one's d i f f e r i n g t h e o r e t i c a l p o s i t i o n . Many the rap i s t s who do not p r a c t i c e formal hypnotherapy, do employ r e l axa t i on and guided imagery techniques as a component of t h e i r treatment p lan for t h e i r anxious or d i s t raught c l i e n t s . Kroger (1977) recognizes anxiety as a human un i ve r sa l i n which we reac t to increas ing s t resses and demands which may be combined with fee l i ng s of i n s e c u r i t y and inadequacy. However, he be l ieves that repressed anxiety i s much more d i f f i c u l t to t r e a t due to the b u i l d up of defens ive symptoms which b lock the o r i g i n a l c o n f l i c t or emotion from awareness. Kroger (1977) categor izes these i n d i r e c t l y expressed anxiety reac t ions i n to three types. Phys io log ic conversions lead to psychophys io log ic or psychosomatic i l l n e s s , f a t i gue s tates and d e b i l i t a t e d cond i t ions . These may be cor rec ted by psychotherapy with or without hypnosis. In the case of h y s t e r i c a l react ions r e s u l t i n g from a traumatic experience, hypnosis can be used i n s p e c i f i c ways to r e l i e v e expectat ions of anxiety i n s i m i l a r s i t u a t i o n s . Psycho log ica l conversions o r i g i n a t i n g with anxiety, become psycho log i ca l symptoms and react ions such as phobias, depress ion and hypochondrias is . Hypnotherapy may be used to help reevaluate the c l i e n t ' s needs under ly ing these symptoms. In F r anke l ' s (1976) ana lys i s of case h i s t o r i e s repor t ing treatment of phobic behaviour, he used hypnosis with imaginal d e s e n s i t i z a t i o n and claims that i n each case the c l i e n t s learned more qu ick ly than with h i s rout ine decond i t ion ing procedure. C l i e n t s a l so reported s i m i l a r i t i e s between t h e i r exposure to hypnosis and t h e i r experience of t h e i r symptoms but found that i n hypnosis the experiences were c o n t r o l l a b l e and reassur ing as opposed to the p rev ious l y fearsome experiences without hypnosis. Cheek and LeCron (1968) descr ibe t h e i r employment of hypnotherapy to t r e a t anxiety and fear assoc iated with death and dying, c h i l d b i r t h , insomnia, traumatic experiences, denta l work and even hypnosis i t s e l f . Meer (1985) wr i tes about the importance of se l f -hypnos i s as a technique f o r phobic su f fe re r s to deal with anxiety so that fears may be experienced and c o n t r o l l e d ra ther than avoided. M i l l e r (1986) presents three case reports i n which he s u c c e s s f u l l y u t i l i z e s b r i e f recons t ruc t i ve hypnotherapy fo r anxiety s ta tes by increas ing the c l i e n t s coping a b i l i t i e s or by recons t ruc t ing the traumatic s i t ua t i on s which l e d to the anxiety s ta te . In the f i r s t case, increas ing the c l i e n t s coping mechanism i s p a r t i a l l y success fu l but her anxiety 24 d i s s i pa ted a f t e r she regressed to a p a r t i c u l a r l y upset t ing experience i n chi ldhood and was able to transform her d i s t r e s s as a v i c t i m in to ac t i ve express ion of her outrage. Th i s approach claims to a l l e v i a t e anxiety symptoms "without having to work through e laborate he i r a r ch i e s of anxiety provoking events" (M i l l e r , p. 145). Hypnosis and Rat iona l therapy Hypnosis has been used i n c o l l a b o r a t i o n with E l l i s ' Ra t iona l Emotive Therapy (RET) and v a r i a t i o n s of RET i n severa l d i f f e r e n t ways. In essence, RET attempts to d i scover i n e f f e c t i v e , s e l f - d e f e a t i n g , i r r a t i o n a l thoughts, help the c l i e n t recognize these i r r a t i o n a l b e l i e f s and t h e i r r e s u l t i n g emotional, cogn i t i ve and behavioura l consequences and to s e l e c t and subs t i tu te more r a t i o n a l thoughts. "The main subgoals of RET cons i s t of he lp ing people to th ink more r a t i o n a l l y ( s c i e n t i f i c a l l y , c l e a r l y , f l e x i b l y ) ; to f e e l more appropr i a te l y ; and to act more f u n c t i o n a l l y ( e f f i c i e n t l y , undefeat ing ly) i n order to achieve t h e i r goals of l i v i n g longer and more happ i l y " ( E l l i s & Bernard, 1985, p. 5). Hypnosis can be used to rehearse scenes i n which r a t i o n a l thoughts rep lace prev ious ly i r r a t i o n a l ones, to f i n d and make use of hidden resources w i th in the s e l f , and to r e i n f o r c e p o s i t i v e se l f - s ta tements . Examples of therap ies combining hypnosis and RET inc lude 25 Rat iona l Suggestion Therapy (Blumenthal, 1984) and Rat iona l Stage D i rected Hypnotherapy (RSDH) (Tos i , 1974). In accordance with E l l i s ' phi losophy, these two appraoches agree that "thought i s the genesis of emotional and behavioura l express ion" (Araoz, 1985, p. 11) so that changes must be aimed at the b e l i e f s and value system, not behaviour or emotion. Having once i d e n t i f i e d i r r a t i o n a l thoughts and b e l i e f s , Blumenthal (1984) introduces se l f -hypnos i s so that the c l i e n t may rehearse new approaches us ing h i s imagination and suggestions i n a re laxed s t a te . "The cogn i t i ve e x p e r i e n t i a l model (RSDH) views hypnosis as a n a t u r a l l y occurr ing phenomenon that may be se l f - i nduced or other- induced, depending on the degree to which a person i s r ecep t i ve , suggest ib le , or w i l l i n g to explore the p o s s i b i l i t i e s of the funct ions of the mind i n e i t h e r a systematic or a nonsystematic fash ion. Hypnosis i s l a r g e l y charac te r i zed by concentrat ion, focused awareness, r e f l e c t i v e thought, r e l a x a t i o n , and s e l e c t i v e a t ten t i on or i n a t t e n t i o n . Any of these processes can be d i r ec ted toward or away from informat ion or f ac t s e x i s t i n g i n the person and environment" (Tosi & Baisden, 1984, p. 164). In RSDH there are s i x developmental stages (awareness, exp lo ra t ion , commitment, implementation, i n t e r n a l i z a t i o n and behavioura l s t a b i l i z a t i o n ) and w i th in these stages there are e x p e r i e n t i a l themes. An ABCDE paradigm "def ines the s e l f as a complex set of cogn i t i ve , a f f e c t i v e , p h y s i o l o g i c a l and behavioura l funct ions occurr ing w i th in a s o c i a l environment" (Tosi & Baisden, 1984, p. 155). These researchers employ a hypnotic- imagery modal ity to amplify the cogn i t i ve r e s t r u c t u r i n g process. In both of these therap ies , hypnosis i s teamed with r a t i o n a l / c o g n i t i v e approaches and serves to heighten and i n t e n s i f y the psychotherapeutic experience. 27 CHAPTER III METHODOLOGY Subj ect Th i s research was conducted i n the form of a s i ng le case research des ign. The subject was a woman, i n her ea r l y f o r t i e s , married with three c h i l d r e n of ages 15, 19 and 22. She had high school equivalency and was cons ider ing apply ing f o r a co l l ege program. Her husband was away o f ten on business which would l a s t up to e ight weeks. She was p lanning to re turn to her regu lar seasonal job which was beginning two months l a t e r . She was seeking therapy f o r r e l i e f from "panic a t tacks " (her words), s leep ing problems, los s of weight and lack of appet i te . She descr ibed her panic attacks as a t i ghtness i n the throat and chest and upset stomach and d i zz ine s s experienced at shopping centres , when v i s i t i n g her s i s t e r ' s home and when d r i v i n g alone. She was having d i f f i c u l t y f a l l i n g as leep at n ight and would awaken o f ten and remain awake f o r hours. She had dropped i n weight from 138 pounds to 124 pounds and was very concerned about t h i s weight l o s s . She had been to see a medical doctor i n hope of f i nd ing treatment f o r her stomach problems as we l l as d i s rupt ions i n her menstrual c yc l e and vag ina l i n f e c t i o n s . A l l of these problems had a r i sen w i th in the two to three 28 month per iod p r i o r to her seeking psychotherapy. She had no previous p s y c h i a t r i c h i s t o r y and had never su f fe red panic a t tacks , anxiety s tates or phobias i n the past. She descr ibed h e r s e l f as "hea l thy, energet ic , and a c t i v e " before the panic attacks began. She had not experienced any phy s i c a l problems i n the past and had only seen her doctor f o r standard medical checkups. P re - , During and Post-Treatment Procedures P r i o r to ac t i ve involvement i n treatment, the subject (hereafter known as Ann) was asked to complete two sets of p re te s t i ng procedures. Two weeks before treatment began, and again one week before treatment began, she f i l l e d out the P r o f i l e of Mood States (POMS), a Subject ive Stress Inventory (designed by the researcher and subject and a l so r e f e r r e d to as the Personal Stress Experience Inventory) s p e c i f i c a l l y to monitor the s u b j e c t ' s unique symptoms and permit assessment of Ann's s leep ing pat terns , anxiety episodes and appet i te loss or increase. The Phy s i o l o g i c a l Symptoms sca le was a l so f i l l e d out to provide informat ion on her p h y s i c a l hea l th and p h y s i o l o g i c a l react ions such as heart p a l p i t a t i o n s , f a i n t i n g and v e r t i g o . Ann continued completing these forms on a weekly bas i s fo r the durat ion of the treatment and f o r two weeks fo l lowing treatment terminat ion. One week before treatment, Ann was asked to do the 29 Minnesota Mu l t iphas ic Per sona l i t y Inventory (MMPI) and the Tennessee Sel f -Concept Scales (TSCS). These procedures were repeated fo l lowing the treatment program and f i n a l l y f o r a fo l low-up assessment s i x months l a t e r . The f i r s t one-hour sess ion with Ann dea l t with an i n t roduc t i on to hypnosis, explanat ion and c l a r i f i c a t i o n of any misconceptions or doubts and a pre l iminary induct ion . During t h i s hour she a l so completed the Barber S u g g e s t i b i l i t y Sca le . Procedure This study fol lowed recent gu ide l ines f o r s i n g l e case experimental design (Kazdin, 1982; Barlow & Hersen, 1984; Nugent, 1985; Mott, 1986) inc lud ing continuous assessment, base l ine assessment and s t a b i l i t y of performance (Kazdin, 1982) . Assessment was performed under an A-B-A t imes - se r ie s design (Jones, Vaught & Weinrott, 1977, Hartmann et a l . , 1980). The subject came i n f o r weekly sess ions l a s t i n g one to one and a h a l f hours. Therapy l a s ted 13 weeks. The hypnot ic induct ion which was employed invo lves progress ive r e l axa t i on with background music (the music i s op t i ona l and depended upon the sub jec t ' s p re ference ) . The next stage i s the 'p leasant s cene ' i n which Ann envis ioned h e r s e l f at a p lace ( rea l or imaginary) i n which she 30 experienced fee l i ng s of comfort, r e l axa t i on and contentment. (Normally the subject has se lec ted a p lace p r i o r to induct ion and has descr ibed i t so the t he rap i s t can help the c l i e n t more f u l l y v i s u a l i z e and experience the scene.) Ann was d i r e c t e d to be aware of the p o s i t i v e a s soc ia t ions with t h i s p lace and reminded that she may re turn to i t at anytime. She was then d i r e c t e d to leave the pleasant scene and v i s u a l i z e a red ba l loon (Walch, 1976). Next to the ba l loon was a pad of paper and a pen. Ann was i n v i t e d to wr i te any problems, people, experiences of g u i l t she wanted to f ree h e r s e l f from and put the p iece(s ) of paper i n the basket under the ba l l oon . When she was ready she l e t the ba l loon go and watched i t c l imb higher and h igher, f u r ther and fu r ther away ca r ry ing the burdens she wished to cast as ide. During the f i r s t sess ion there was a l so an explanat ion of the A-B-C-D-E theory (Tos i , Howard & Gwynne, 1982) and i t s a p p l i c a t i o n to the therapy. Table 3-1: T o s i ' s A-B-C-D-E Paradigm A B C D E S i t ua t i on Cognit ion Emotional response Phy s i o l og i ca l concomitant Behaviora l response 31 Once the in te rvent ion had begun, the e x p e r i e n t i a l a p p l i c a t i o n of t h i s method fol lowed the red ba l loon technique. While i n t rance, Ann was asked t o v i z u a l i z e a t e l e v i s i o n screen. When she was ready she could turn on the TV screen and v i s u a l i z e or r e c a l l an i nc iden t , any inc ident of her choosing i n which she experienced negative f e e l i n g s . By watching the screen, ra ther than r e - l i v i n g an unpleasant experience, Ann was able to watch h e r s e l f i n a sa fer , more detached and l e s s emotional way. The A-B-C-D-E components were i d e n t i f i e d and gave her the opportunity to i d e n t i f y some of her i r r a t i o n a l thoughts and s e l f - d e f e a t i n g tendencies . Having done so, Ann would then re turn to her p leasant scene when she f e l t comfortable and conf ident . She was then asked to v i s u a l i z e the same inc ident but t h i s time s u b s t i t u t i n g more r a t i o n a l thoughts and el imminating s e l f - d e f e a t i n g a t t i t u d e s . Throughout t h i s sequence, Ann responded to questions by the t he rap i s t and descr ibed the events and her implementation of r a t i o n a l self-management s k i l l s . Occas iona l ly the the rap i s t prompted her f o r ideas and thoughts which would lead to d i f f e r e n t behav ioura l , p h y s i o l o g i c a l and emotional responses but most of the time Ann guided the cogn i t i ve r e s t ruc tu r i n g and behavioura l rehearsa l h e r s e l f . Having recreated the inc ident and r e a l i z e d new options and pos s ib le outcomes, Ann would be asked i f she had another inc ident she wanted to explore. I f so, the 32 hypnotherapy continued, i f not she was d i r e c t e d to come out of the trance s ta te , f e e l i n g re f reshed. Usua l l y a d i scuss ion of her r eac t i on to the sess ion fo l lowed. (Appendix B). An audiotape was prepared so that the subject could l i s t e n to i t each day between" appointments. I t contained a tape - record ing of the re l axa t i on and guided imagery exerc i ses presented i n the second interv iew. Ann was i n s t ruc ted to l i s t e n to the tape at night as i t was to serve a second purpose of he lp ing her f a l l as leep and re s t more peace fu l l y . I t was an t i c i pa ted that fo l lowing the i n i t i a l sess ions and a f t e r l i s t e n i n g r e g u l a r l y to the audiotape, the trance induct ion would take l e s s t ime. Instruments The measurements of treatment e f f i c a c y were based on data c o l l e c t e d from the Barber S u g g e s t i b i l i t y Sca le, MMPI, TSCS, POMS, Subject ive Stress Inventory and the Phy s i o l og i ca l Symptoms Sca le . The Barber S u g g e s t i b i l i t y Scale The Barber S u g g e s t i b i l i t y Scale (BSS) was administered to the subject p r i o r to treatment (Appendix C). The BSS (Barber, 1969) invo lves e ight standardized te s t suggestions with corresponding ob jec t i ve score c r i t e r i o n i nc lud ing post-experimental ob jec t i ve scor ing of t e s t 33 suggestions. Subject ive scores are a l so t a l l i e d from the s u b j e c t ' s response to a quest ionnaire of t h e i r sub jec t i ve experience of each of the e ight t e s t suggestions. The subject was assessed on the ob jec t i ve and sub jec t i ve responses. The ob jec t i ve scores had a maximum t o t a l of e ight (one f o r each t e s t suggestion) and the sub jec t i ve t o t a l maximum was 24 po ints (up to three po ints f o r each suggest ion). The e ight items are: arm lowering ( r i ght arm); arm l e v i t a t i o n ( l e f t arm); hand lock ; t h i r s t h a l l u c i n a t i o n ; ve rba l i n h i b i t i o n ; body immobi l i ty; post -hypnot ic response; and s e l e c t i v e amnesia. The subject rece ived a po in t i n each of the items i f ; the r i g h t arm dropped four inches or more; the l e f t arm rose four inches or more; the subject was unable to unclasp her hands; swallowed, moistened l i p s i n response to t h i r s t suggest ion; was unable to speak her name; was unable to stand f u l l y e rec t . The four th , seventh and e ighth suggestions were scored po s t -hypno t i c a l l y r e c e i v i n g one po int i f the subject commented on having been t h i r s t y dur ing the t e s t ; c leared her throat or coughed when the designated cue was presented; and f a i l e d to r e c a l l one s p e c i f i e d item whi le remembering at l e a s t four others. The subject i ve quest ionnaire measured the degree to which the subject experienced each suggestion ( i . e . the r i gh t 34 arm f e l t ; not heavy, s l i g h t l y heavy, heavy, very heavy) and confirmed i n the interv iew fo l lowing that her response was not simply to fo l low the i n s t ruc t i on s or to p lease the t h e r a p i s t . The Barber Sugges t i b i l t y Scale i s s i g n i f i c a n t l y c o r r e l a t e d with the Stanford Hypnotic S u s c e p t i b i l i t y Sca le, Form A at .62 f o r the ob jec t i ve por t i on and .78 f o r the sub jec t i ve po r t i on (Ruch, Morgan, H i l ga rd , 1974). The Minnesota Mul t iphas ic Per sona l i t y Inventory The MMPI was administered to the subject p r i o r to treatment, immediately fo l lowing terminat ion of treatment and once again f o r a six-month fo l low-up (Appendix D). The MMPI, the most widely used pe r sona l i t y inventory (Anastas i , 1982), cons i s t s of 566 statements to which the subject responds with ' t r u e 1 , ' f a l s e ' , or 'cannot s ay ' . O v e r a l l , the MMPI y i e l d s 13 scores. I t provides scores on ten c l i n i c a l s ca le s . They are: Hypochondrias is; Depression; H y s t e r i a ; Psychopathic dev ia te ; Mascu l i n i t y -Femin in i t y ; Paranoia; Psychasthenia; Schizophrenia; Hypomania; and Soc i a l I n t rover s ion . Three v a l i d i t y s ca le s : the l i e score; v a l i d i t y score; and c o r r e c t i o n score; check f o r care lessness , t e s t - t a k i n g a t t i t u d e , mal ingering and misunderstanding on the par t of the examinee. 35 I t should be noted that as the MMPI manual caut ioned, the scores from the c l i n i c a l sca les were not i n te rp re ted l i t e r a l l y or used to at tach p s y c h i a t r i c l abe l s but rather were used i n co l l abo ra t i on with other t e s t s descr ibed i n t h i s chapter to help create an o v e r a l l p i c t u r e of the s u b j e c t ' s current mental, emotional and phys i ca l s t a te . A l so , the mul t id imens iona l i t y and overlap of the MMPI sca les meant that pa t tern ana ly s i s o f f e r s a v i a b l e opt ion to s ing le sca le i n t e r p r e t a t i o n . The quest ionable r e l i a b i l i t y of some of the MMPI sca les , the l i m i t a t i o n s of the normative sample the t e s t was based on and i t s i n s e n s i t i v i t y to sub- and c r o s s - c u l t u r a l d i f f e rences (Dahlstrom et a l , 1972; Butcher & Pancher i , 1976; Dalhstrom & Dalstrom, 1979) makes caut ious and knowledgeable i n t e r p r e t a t i o n of the MMPI scores imperat ive. The Tennessee Sel f -Concept Scales A second pe r sona l i t y t e s t , the Tennessee Sel f -Concept Scale (TSCS) was administered to the subject p r i o r to and immediately fo l lowing treatment as we l l as once more i n a six-month fo l low-up study (Appendix E ) . The TSCS i s made up of 100 items, 90 items form the main body of the t e s t f o r assess ing se l f -es teem. Ten more items, borrowed from the MMPI l i e sca le ( F i t t s , 1965) monitor 36 s e l f - c r i t i c i s m . The subject responds to each t e s t statement with a score of 1 to 5 represent ing a range from 'completely- f a l s e 1 to 'completely t r u e ' . The sub jec t ' s o v e r a l l s e l f - concep t i s r e f l e c t e d i n a t o t a l p o s i t i v e score der ived from a two-dimensional frame of re ference. The s u b j e c t ' s i n t e r n a l frame of reference i s scored by i d e n t i t y , se l f - acceptance and behaviour. H i s /her externa l frame of re ference i s composed of phy s i ca l s e l f , mora l / e th i ca l s e l f , personal s e l f , fami ly s e l f and s o c i a l s e l f . The v a r i a b i l i t y score i nd i ca te s the amount of incons i s tency from one area of s e l f - p e r c e p t i o n to another and the d i s t r i b u t i o n score .measures the s u b j e c t ' s degree of c e r t a i n t y i n what s/he says about h im/herse l f . The manual claims the r e l i a b i l i t y c o e f f i c i e n t s range from .67 to .92 with high .80's being the norm. The manual a l so claims good v a l i d i t y i n group d i s c r im ina t i on and p r e d i c t i v e v a l i d i t y i s a l so reported to be h igh. Some sca les show c o r r e l a t i o n s with the MMPI, The Edwards Personal Preference Schedule, I za rd ' s Se l f Rating P o s i t i v e A f f e c t Scale and Tay lor Anxiety Sca le. Despite c r i t i c i s m s of the t e s t (Gable, LaSa l le & Cook, 1973; Stanwyck & Garr i son, 1982) , Suinn (1972) claims " the Tennessee S e l f Concept Scale ranks among the be t te r measures combining group d i s c r i m i n a t i o n with s e l f concept in format ion " , (p. 151). P r o f i l e of Mood States 37 The POMS was administered two weeks p r i o r to therapy and then each week subsequently u n t i l two weeks a f t e r completion of therapy. I t was a l so given s i x months l a t e r f o r the fo l low-up study (Appendix F ) . The POMS i s a s e l f - r a t e d 65-item inventory composed of ad jec t i ve s or phrases which the subject ra tes on a f i v e po int s ca le (from 'not at a l l ' to 'extremely ' ) de sc r i b ing h i s /he r f ee l i n g s dur ing the past week. Redundancy i s b u i l t i n to the quest ionna i re i n an e f f o r t to compensate f o r the attempt to make measurements on mood as an undefined continuous sca le ( i . e . a c l i e n t may f e e l somewhere between 'two' and ' t h r e e ' and a r b i t r a r i l y choose 'two' one time and ' t h r e e ' another). The POMS i s a standardized mood sca le with s i x independent sub-sca les : tens ion -anx ie ty ; depres s ion -de jec t ion ; a n g e r - h o s t i l i t y ; v i g o r ; f a t i gue ; confusion-bewilderment. Many items on the POMS are s i m i l a r and are grouped in to c l u s t e r s to represent the s i x independent subscales. A f ac to r ana ly s i s of i t can be used, f o r instance, to reduce large numbers of measurements to a smal ler , more manageable s i z e ( S t i t t , Frane & Frane, 1977). The POMS was used i n a more c l i n i c a l format i n t h i s case. The use of a s i ng le case research design means that a reduct ion of the measurements f o r ana ly s i s i s not requ i red . The r e s u l t s of each subscale 38 allowed the researcher to monitor f l u c t u a t i n g mood changes of the subject and use t h i s data i n an ongoing way dur ing therapy. The r e s u l t s were a l so assessed r e t r o s p e c t i v e l y to study the pos s i b le e f f e c t s of the therapy on the s u b j e c t ' s mood s ta tes dur ing treatment and a f t e r the s i x month fo l low-up. The r e l i a b i l i t y of the POMS fac tor s i s represented by the i n t e r n a l cons i s tenc ies and the t e s t - r e t e s t r e l i a b i l i t y . Based on a normative sample of 1,000 p s y c h i a t r i c outpat ients , the i n t e r n a l cons istency i s reported (McNair, Lor r , Doppleman, 1981) as ranging from .84 to .95 with an average r e l i a b i l i t y of .91. The t e s t - r e t e s t r e l i a b i l i t y estimates ranged from .65 to .74. Based on c o r r e l a t i o n s between POMS scores at intake and pretreatment, the authors po in t out that "seeking and f i nd ing a source of p s y c h i a t r i c treatment i s i n i t s e l f probably assoc iated with change i n emotional s t a te s " (p. 10), and there fore these estimates of r e l i a b i l i t y may be lower f o r that reason. They a l so argue that mood i s a f l u c t u a t i n g s ta te and cannot be expected to a t t a i n the same l e v e l s as more s tab le per sona l i t y c h a r a c t e r i s t i c s . Using s tudies i n short-term psychotherapy, c o n t r o l l e d pa t i en t drug t r i a l s , response to emotion inducing condi t ions and concurrent v a l i d i t y c o e f f i c i e n t s and other POMS c o r r e l a t e s , the authors provide evidence f o r the p r e d i c t i v e and construct v a l i d i t y of the POMS. The b r i e f psychotherapy 39 s tud ies (Lorr, McNair, Weinskin, Michaux & Raskin, 1961; Lo r r , McNair, Weinstein, 1964) showed outpat ients experienced s i g n i f i c a n t (p < .001) improvement i n tens ion -anx ie ty , depres s ion -de jec t ion , a n g e r - h o s t i l i t y and fa t i gue and improvement i n v i go r . A comparison study (Haskel l , Pugatch & McNair, 1969; Ho l s te in , 1970) suggests that "POMS does not change simply as a funct ion of repeated t e s t i n g dur ing treatment and that the degree of change i s meaningful ly c o r r e l a t e d to e i t h e r durat ion of treatment, the ending of treatment, or both" (p.110). Subject ive Stress Inventory The Subject ive Stress Inventory was administered to the subject beginning two weeks p r i o r to therapy and subsequently each week u n t i l two weeks a f t e r completion of therapy. I t was a l so g iven s i x months l a t e r f o r a fo l low-up study (Appendix G). The Subject ive Stress Inventory was developed by the researcher and subject as a means of assess ing f l u c tua t i on s i n s t ress l e v e l s and monitoring areas of continuous, extreme s t re s s . I t was used to provide base l ine data of the subj e c t ' s cond i t ion p r i o r to therapy and was used as a gu ide l i ne f o r he lp ing assess the e f fec t i venes s of the treatment program. T o s i , Howard & Gwynne (1982) measured 40 improvement with ob jec t i ve t e s t r e s u l t s from tbe MMPI and TSCS and from base l ine and during therapy s e l f report data. The item content was based upon areas which the subject s p e c i f i e d as being p a r t i c u l a r l y s t r e s s f u l (such as going out i n p u b l i c or t r y i n g to f a l l a s leep) . The inventory a l so took in to account p h y s i o l o g i c a l problems such as l o s s / i nc rea se i n weight or changes i n the menstrual c y c l e . In t o t a l , 23 words or phrases ( i . e . r e l a t i o n s h i p with spouse, going to the doctor, housework) were presented and f o r each one the subject rated the degree of s t re s s /anx ie ty (from 1 ' low' to 5 ' h i gh ' ) experienced as a r e s u l t of that s i t u a t i o n . Base l ine, dur ing and post therapy data served to monitor emotional and p h y s i o l o g i c a l response changes. Phy s i o l og i ca l Symptoms Scale The Phy s i o l og i ca l Symptoms Scale (PSS) was completed two weeks p r i o r to therapy and each week subsequently u n t i l two weeks a f t e r the completion of therapy. I t was administered again f o r the s i x month fo l low-up study (Appendix H). The content of the PSS was borrowed from the DSM-III (1980) c r i t e r i a f o r panic d i so rder . Twelve symptoms are l i s t e d and the manual s tates that at l e a s t four must occur dur ing the attack to warrant the panic d i so rder d iagnos i s . In c o l l a b o r a t i o n with the subject , e ight commonly experienced 41 symptoms were chosen f o r the PSS. Each week she rated the s e v e r i t y and frequency of the symptom by a r a t i n g of 1 ' low' to 5 ' h i g h 1 . The e ight symptoms are: dyspnea; p a l p i t a t i o n s ; v e r t i g o ; parethes ia s ; sweating; f a in tnes s ; t rembl ing and shaking; fear of dying/going crazy. Once again the base l ine data, frequency and s e v e r i t y of at tacks before therapy were compared to t h e i r frequency and s e v e r i t y dur ing and fo l lowing therapy. S ing le Subject Research Design S ing le case experimental designs must be recognized as d i s t i n c t from case s tud ies . The l a t t e r , anecdotal i n nature, tend to have poor i n t e r n a l v a l i d i t y and are o f ten impossible to r e p l i c a t e . Many researchers have c r i t i c i z e d the case s tudy ' s r e l i a n c e on inferences drawn from uncont ro l led reports (Kazdin, 1982; Nugent, 1985; Mott, 1986) and advocate ins tead the use of the s i n g l e case des ign. In contras t to case s tud ies , s i ng le case experimental design uses repeated ob jec t i ve measures i nc lud ing continuous assessment of performance over time and a demand f o r s tab le l e v e l s of performance before and a f t e r treatment. According to Bloom & F i s cher (1982), " s i n g l e system designs invo lve planned use of a research design, c l e a r measurement r u l e s , e x p l i c i t eva luat ion procedures, and a c l e a r i d e n t i f i c a t i o n of an i n te rven t i on program, i nc lud ing when i n te rven t i on s t a r t s 42 and when i t i s completed" (p. 294). Th is al lows the researcher greater conf idence i n suggesting causa l in ference, i nc reas ing the i n t e r n a l v a l i d i t y of the s i ng le case design over that of the case study (Hersen & Barlow, 1976). In t h i s s i ng le case experimental des ign, the present researcher fol lowed general gu ide l ines presented by Kazdin, (1982), d i r e c t l y addressed issues and c r i t i c i s m s ou t l i ned by Nugent (1985) and borrowed from the example set by Gwynne, Tos i & Howard (1978) . Continuous assessment i s Kazd in ' s (1982) f i r s t requirement of s i ng l e case designs. Th i s al lows the i nve s t i g a to r the opportunity to examine the pa t tern and s t a b i l i t y of performance before treatment i s i n i t i a t e d , ( i . e . performance without treatment) and the e f f e c t s of the in tervent ions ( i . e . performance with treatment). In t h i s study, the continuous assessment was based on both ob jec t i ve and sub jec t i ve measures. The ob jec t i ve data came from the standardized POMS (described e a r l i e r i n t h i s chapter) and from s e l f - r e p o r t s from the Subjec t i ve Stress Inventory and the Phy s i o l og i ca l Symptoms Scale (both descr ibed e a r l i e r i n t h i s chapter ) . These t e s t s were administered weekly throughout the durat ion of therapy. The second requirement of s i ng le case research i s ba se l ine assessment. This r e f e r s to the data de sc r i b ing l e v e l and s t a b i l i t y of performance before the in tervent ions which 43 helps assess the seve r i t y of the c l i e n t ' s problems as we l l as serv ing a p r e d i c t i v e func t ion . As long as the l e v e l of performance i s s tab le or s tab le d e t e r i o r a t i o n , future p ro jec t i on s would l i k e l y p r e d i c t a cont inuat ion of the base l ine performance. So, once a recognized t rend has been e s tab l i shed , " i f an i n te rvent ion i s app l ied and the s tab le pa t te rn changes, t h i s suggests that the i n te rven t i on ra ther than other f ac to r s i s respons ib le " (Nugent, p. 195). The base l ine assessment f o r t h i s research was conducted us ing ob jec t i ve and subject i ve t e s t scores beginning two weeks p r i o r to therapy. The data came from the same te s t s used f o r continuous assessment (POMS, SSI, PSS). In the study by Gwynne, Tos i and Howard (1978), and i n a l a t e r study, (Tos i , Howard, & Gwynne, 1982), a two week base l ine per iod was implemented. Kazdin (1982), Nugent (1985) and Mott (1986) are vague i n t h e i r de sc r ip t i ons of the durat ion that cons t i tu te s the base l ine except to say that the data should demonstrate s t a b i l i t y informat ion. The present author chose to fo l low the example set by Gwynne, To s i and Howard (1978), and designed a two week base l ine per i od . As we l l as ob ject i ve t e s t s p r i o r to therapy, a h i s t o r y of the cond i t i on was taken i n c l ud ing i t s frequency, seve r i t y and durat ion as we l l as record ing any per iods of improvement or remiss ion of the symptoms. Nugent (1985) descr ibes h i s framework f o r eva luat ion i n 44 four components. F i r s t , the use of ob jec t i ve data i s e s s e n t i a l so that i t i s not necessary to r e l y on the t h e r a p i s t ' s op in ion of anecdotal in format ion. By c l e a r l y d e f i n i n g the problem, ob jec t i ve measurement procedures can be e s tab l i shed . Secondly, Nugent (1985) c a l l s f o r a p r e - and post-treatment measurement design, ob jec t i ve measures of the problem taken once before and once a f t e r treatment. In the present research, the p r e - and post treatment are the MMPI and the TSCS administered two weeks before therapy and two weeks fo l lowing completion of therapy. Nugent's (1985) t h i r d and fourth dimensions of h i s eva luat ion framework, use of repeated measures and s t a b i l i t y in format ion, correspond with Kazd in ' s (1982) continuous assessment and base l ine assessment r e s p e c t i v e l y . They have been covered e a r l i e r i n t h i s sec t i on . Kazdin (1982) advocates the use of an A-B-A-B design i n which there i s a) the base l ine cond i t i on ; b) i n t e r ven t i on ; c) withdrawal of treatment; and d) reinstatement of the i n t e r v e n t i o n . Perhaps i n a laboratory s e t t i n g or i n l a rger c o n t r o l l e d s tud ies us ing vo lunteers , t h i s design would be acceptable. In the present research, c l i n i c a l p r i o r i t i e s outweigh research i n te re s t s and the A-B-A-B design had to be r e j e c t e d . I t becomes an e t h i c a l quest ion when the withdrawal of treatment (poss ib ly prematurely) serves to answer 45 researchers ' questions but i s not i n the best i n t e r e s t s of t h e i r c l i e n t s . The A-B-A design seemed f a r more adaptable to s i ng le case research s ince these cases u sua l l y a r i s e i n the course of everyday c l i n i c a l work ra ther than i n t r a d i t i o n a l group comparison research. Nugent (1985) agrees with Kazdin (1982) and Bloom and F i s cher (1982) that "use of repeated measures before and dur ing treatment, e s s e n t i a l l y an A-B s i ng le case des ign, appears a minimum requirement f o r making data-based causa l i n fe rence s " , (p. 196). He a l so po int s out that " the A-B des ign, with s t a b i l i t y informat ion and the mu l t i p l e base l ine s i ng le case designs seem p a r t i c u l a r l y w e l l - s u i t e d f o r use with hypnotic i n te rvent ions " (p. 196). Nugent (1985) c a l l s on researchers , and hypnotherapists i n p a r t i c u l a r , to adhere to gu ide l ines f o r s i ng le case designs so that e f f e c t i v e therapeut ic technology may develop. Ana ly s i s The ana ly s i s of the data was based on an in ter rupted t ime - se r i e s A-B-A withdrawal des ign. (Borg & G a l l , 1979; Kazdin, 1982; Tawney & Gast, 1984). As mentioned i n the previous sec t i on , the A-B-A design was chosen over the more powerful A-B-A-B design s ince , i n t h i s p a r t i c u l a r case, the c l i n i c a l outcome took precedence over research i n t e r e s t s . Therefore, treatment was not withdrawn u n t i l such time as the t h e r a p i s t was conf ident the subject would not re turn to ba se l i ne . For the v i s u a l ana lys i s of graphic data, Tawney & Gast (1984) attend t o : (1) the number of data po ints p l o t t e d w i th in a cond i t i on , (2) the number of v a r i ab l e s changed between adjacent cond i t ions , (3) l e v e l s t a b i l i t y and changes i n l e v e l w i th in and between cond i t ions , and (4) t rend d i r e c t i o n , t rend s t a b i l i t y , and changes i n t rend wi th in and between cond i t ions , (p. 159). We examined the amount of v a r i a b i l i t y i nd i ca ted on the ord inate sca le and i d e n t i f i e d the l e v e l change by comparing the f i r s t and l a s t data po int s w i th in a cond i t i on . The l e v e l change between adjacent condi t ions was a l so s tud ied. The t rend d i r e c t i o n or s lope showed whether there i s improvement or decay of the ordinate va lue, and i t s steepness over t ime. The t rend was estimated us ing the s p l i t - m i d d l e l e v e l of progress method (White & Haring, 1980) which i s cons idered to be a more accurate and r e l i a b l e estimate than the freehand method. As we l l as i s o l a t i n g and ana lyz ing the data pat terns , a therapy l og h i g h l i g h t i n g s i g n i f i c a n t events or circumstances was employed to help exp la in sudden changes, an unexpected v a r i a b i l i t y and p o t e n t i a l l y compounding v a r i a b l e s which might threaten the i n t e r n a l v a l i d i t y of the study. 47 CHAPTER IV RESULTS Barber S u g g e s t i b i l i t y Scale The subject scored e ight out of e ight on the ob jec t i ve sec t i on of the t e s t and 23 out of 24 on the sub jec t i ve responses. In other words, she responded p o s i t i v e l y to a l l e ight t e s t suggestions. On the subject i ve quest ionna i re , which determines the degree to which she experienced each suggestion she scored f u l l marks except fo r one item. When she was i n s t ruc ted that her arm would become very heavy, she descr ibed her arm as f e e l i n g heavy, not very heavy. Such high scores tend to be i n d i c a t i v e of h i gh ly suggest ib le c l i e n t s who make good hypnot ic subjects . Minnesota Mu l t iphas ic Per sona l i t y Inventory The p r o f i l e s from the pre-therapy, post - therapy and fo l low-up admin is t rat ions are provided i n Appendix I and i l l u s t r a t e d i n F igure 4-1. The i d e n t i f i c a t i o n of pa tho log i ca l dev i a t i on i s genera l l y accepted as any score of 70 or higher ( i . e . two standard dev ia t ions above the mean), (Anastas i , 1982) . The pre-therapy p r o f i l e shows e ight scores exceeding t h i s mark. They are: V a l i d i t y (F) = 76; Hypochondriasis (Hs) =82; Depression (D)=94; Hys ter ia (H)=96; Psychopathic deviate (Pd)=80; Paranoia (Pa)=76; Psychasthenia (Pt)=77; Schizophrenia (Sc)=87. The post-therapy shows only one sca le which remains above the normal range, Pd=73. By the s i x month MMPI P r o f i l e MMPI Scales Figure 4-1. Ann's uncorrected (non-K corrected) p r o f i l e for pre-therapy ( s o l i d l i n e ) , post-therapy (broken l i n e ) and follow-up (dotted l i n e ) . fo l low-up, a l l scores are wi th in the normal range. The MMPI r e s u l t s suggest that the seve r i t y of the symptoms were s i g n i f i c a n t l y reduced by the time of the post - therapy assessment. The fol low-up shows fu r ther improvement and maintenance of a l l areas of improvement over the s i x month per iod . Tennessee Sel f -Concept Scale The pre-therapy p r o f i l e ( f i gure 4-2) shows a moderately e levated s e l f - c r i t i c i s m score (T=57), low t o t a l c o n f l i c t score (T=38) and her t o t a l score (overa l l self -esteem) i s T=41, almost one standard dev ia t i on below the mean. A l l p o s i t i v e scores ( l = ident i t y ; 2= s e l f - s a t i s f a c t i o n ; 3=behaviour; A=physical s e l f ; B=moral-ethical s e l f ; C=personal s e l f ; D=family s e l f ; E=socia l s e l f ) are at or below the mean (Tl=38; T2=45; T3=40; TA=33; TB=38; TC=50; TD=46; TE=47). The empi r i ca l sca les show high scores f o r general maladjustment (TGM=63), pe r sona l i t y d i so rder (TPD=61) and neurot i c (TN=63). The post- therapy p r o f i l e ( f i gure 4-3) s e l f - c r i t i c i s m score i s T=46, t o t a l c o n f l i c t T=58, and the t o t a l p o s t i i v e score increased one and a h a l f standard dev ia t ions to T=56. A l l p o s i t i v e scores but one ( f a m i l y - s e l f TD=48) are above the mean, (Tl=52; T2=58; T3=56; TA=55; TB=56; TC=63; TE=59). Four of the s i x emp i r i ca l sca les are below the mean (GM, PSY, PD and N). Defensive p o s i t i v e i s now TPD=54 and pe r sona l i t y Figure 4 - 2 . Ann's pre-therapy p r o f i l e of the Tennessee Self-Concept Scale Post-therapy Tennessee Self-Concept Scale Profile Sheet Clinical and Research Form NO a Piollle Lir.l.» .33 1.2_ m /*> Iii axBk IS 34 fei 3515 i5_ la Ji? Jo ^ Jtt J8.<2x fee Ifia 4a _i3 51 IfL J _ . i'-.vn *-•' i -' til i:' i/ ii' :M , .i •'  i> ;t. in i m IL. : / i.- M •„ :.t::; i.i| • .".(ili_.il St.,:;.-; .I tiU I'l 1 ;.f.,l fi .it; t'iri."! il luvutbt; trilwi JU I1i.l .Ort'cf SirOlui, ait: .iS-.tWili .H(|[htl / i:..lt.:i, Figure 4-3. Ann's post-therapy profile of the Tennessee Self-Concept Scale. 52 i n teg ra t i on improved s i g n i f i c a n t l y to TP1=63. By the s i x month fo l low-up study ( f i gure 4-4), the s e l f - c r i t i c i s m score had maintained the post - therapy improvement, TSC=48, t o t a l c o n f l i c t was the same at T=58 and o v e r a l l se l f -es teem had increased again to T=65. The p o s i t i v e scores are a l l i n the normal range, (Tl=56; T2=63; T3=65; TA=59; TB=59; TC=64; TD=58; TE=63). The pat tern f o r the emp i r i ca l sca les i s s i m i l a r to the post - therapy repor t , only two scores above the mean, TDP=57 and TPI=61. The change score f o r s e l f - c r i t i c i s m , before and a f t e r the i n te rven t i on i s s i g n i f i c a n t , T = l l . The change score fo r the t o t a l p o s i t i v e pre-and post - therapy i s T=15 and between pre-therapy and fo l low-up, T=24. These r e s u l t s suggest o v e r a l l improvement of the components of se l f - concep t a f t e r the therapeut ic i n te rven t i on . The fo l low-up p r o f i l e shows t h i s p o s i t i v e se l f - concept remained s tab le or strengthened s i x months a f t e r treatment completion. (Figure 4-5 i l l u s t r a t e s the comparison of the three sets of s cores ) . P r o f i l e of Mood States Ann's average t o t a l mood disturbance score (TMD) p r e - therapy was 124.5 ( f i gure 4-6). On the f i r s t week of pre- therapy t e s t i n g her tens ion/anx iety score was 33 out of po s s i b l e 36 (=64); depress ion/deject ion was 42 out of 60 (T=59); a n g e r / h o s t i l i t y was 11 out of 48 (T=47); v i go r was 2 Follow-up Tennessee Self-Concept Scale Profile Sheet Clinical and Research Form 3 NDS Prolltt i'i Limits in Haw scoiu* $± 4^ - * 3t_ i^a m a3 at a_ is as & ifi ai.. i«v 1. «z e » 3o ia j/a. i i _ 8L f3_ _i_ . • >(••:• tl'i Hi.; i-ri.jiu .il -. .ir;„ ul < ,f,i I'D ,ii;l H .11.; HH'n;(lt<-t il  i;:Vlsls(: \itiitll, SO lkil Imvtl Cl/y bljurua ijU; .IStM JUlUil Wil I.JHOI / I.t'lt;:, Figure 4-4. Ann's follow-up p r o f i l e of the Tennessee Self-Concept Scale. NDS Profile Limits Figure 4 - 5 . Comparison of Ann's pre-therapy, post-therapy and follow-up TSCS p r o f i l e s . (Pre-therapy - broken l i n e ; post-therapy - s o l i d l i n e ; -CIT . . _ J_.. 1 -i- x 55 POMS TMD Figure 4-6. Ann's total mood disturbance scores from baseline to follow-up. 56 out of 32 (T=38); fa t i gue was 28 out of 28 (T=68) and confusion/bewilderment was 15 out of 28 (T=52). 1 By post - therapy, tens ion/anx iety was down to 6/3 6 (T=33), depress ion/object ive 1/60 (T=33); a n g e r / h o s t i l i t y 5/48 (T=41); v i go r 16/32 (T=61); f a t i gue 6/28 (T=42); confusion/bewilderment 2/28 (T=33). To ta l mood disturbance had dropped dramat ica l l y to 4. Fol low-up scores were: tens ion/anx iety =0 (T=3 0) ; depress ion/deject ion = 1 (T=3 3) ; a n g e r / h o s t i l i t y = 5 (T=41); v i go r = 29 (T=80+); fa t i gue = 0 (T=34); and confusion/bewilderment = 2 (T=33); TMD = 21. F igures 4-7 to 4-12 i l l u s t r a t e the s i g n i f i c a n t change scores from base l ine assessment to the s i x month fo l low-up. The change score from the base l ine to fo l low-up scores were s i g n i f i c a n t f o r tens ion/anx ie ty , T=34; depress ion/deject ion change score, T=26; v i go r , T=42+; fa t i gue , T=34; T=19 was the change score f o r confusion/bewilderment. The raw change score f o r the TMD was 148. These r e s u l t s compliment the TSCS and MMPI r e s u l t s which a l so documented s i g n i f i c a n t improvement through the i n te rven t i on and improvement s t a b i l i t y from post- therapy to the fo l low-up. Subject ive Stress Inventory The Stress Experience Quest ionnaire (Appendix V) o r i g i n a l l y contained 23 items. F ive of the o r i g i n a l items 57 POMS Figure 4-7. Ann's t-scores at baseline, intervention, post-therapy and follow-up for the POMS tension-anxiety scale. 58 POMS F i g u r e 4-8. A n n ' s t - s c o r e s a t b a s e l i n e , i n t e r v e n t i o n , pos t - the rapy and f o l l o w - u p f o r the POMS d e p r e s s i o n s c a l e . 59 POMS ostt- Follow- up 30-• 1 1 1 1 1 1 r- 9 10 11 12 13 14 15 16 45 Weeks Figure 4-9. Ann's t-scores at baseline, intervention, post-therapy and follow-up for the POMS ange r - h o s t i l i t y scale. 60 POMS Base-l i n e Intervention Post- Follow-therapy up 6 7 8 9 10 11 12 13 14 15 16 45 Weeks Figure 4-10. Ann's t-scores at baseline, intervention, post-therapy and follow-up for the POMS vigor scale. 61 POMS Figure 4-11. Ann's t-scores at baseline, intervention, post-therapy and follow-up for the POMS fatigue scale. 62 POMS Base-line Intervention Post- Follow-therapy up i i i r 9 10 11 12 13 14 15 16 Weeks Figure 4-12. Ann's t-scores at baseline, intervention, post-therapy and follow-up for the POMS confusion-bewilderment scale. 63 were dropped (a mutual decision between the researcher and the subject) because they were, or became, irrelevant or extraneous. For that reason, items #3, 6, 9, 10, 11 w i l l not be documented in the analysis. Also as i t occurs as a general theme throughout the graphs, i t i s worth noting two incidents which account for increased stress scores. In week 5, Ann and her family moved to a new house and in week 14, Ann's husband became unemployed. As we w i l l see, many of the graphs, even those demonstrating improvement trends, have a marked increase of stress experience during weeks 5 and 14. Item 1, relationship with spouse (figure 4-13), shows i n i t i a l improvement following a deteriorating baseline (score dropped from 5 to 3). However, the s p l i t middle line of progress (White & Haring, 1980) covering 13 weeks of therapy i l l u s t r a t e s an accelerating trend (increasing in ordinate value over time). Post therapy scores suggest improvement (scores=2 and 1), follow-up score=2. Item 2, relationship with her children, (figure 4-13) moderate reduction in stress i s indicated although the follow-up score shows a deteriorating change of trend. Change score from baseline to follow-up i s 2. Interaction with friends, item 4 (figure 4-13) demonstrates a baseline stable at the high stress level (5), gradual reduction in stress and a stable low stress level (1) #1 relation- ship with spouse 5- 4- OJ S3- u CO 8 2 - 0) CO 1- Base-line Intervention 3ost-therapy - • 1 1 r- 64 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks #2 relation- ship with children #4 inter- action with friends Base-line 5- 4- M 3-u co co o to <u u in 1- Intervention 5ost- Follow- tlerapy 1 I 1 r t r up 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks 4- S3- u co co 2- CO 1- Base-line Intervention 3ost- Follow-lerapy up 1 1 : 1 1 1 1 1 i i 1 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks Figure 4-13, Ann's stress scores (SSI) at baseline, intervention, post-therapy and follow-up, for relationship with spouse, relationship with children and interaction with friends. 65 for post-therapy and follow-up reports. Change score =4. Figure 4-17 represents item 5, going out in public. A stable high stress baseline (5) drops immediately once therapy begins (3) and by the fourth week the v a r i a b i l i t y i s considerably reduced leading to a stable low stress level (1) for the four f i n a l weeks of therapy as well as the post-therapy and follow-up scores. Change score = 4. Item 7, going to the therapist, (figure 4-17) began and remained as a non-stress inducing event for Ann. The only changes to the regular low stress scores (1) were on the aforementioned weeks (5, stress score=2 & 14, stress score=3) which caused overall increases in perception of stress. Eating, item 8, was Ann's f i r s t and most consistant complaint. As we see in figure 4-15, an i n i t i a l improvement (3) after the stable high stress baseline (5), was only temporary as an accelerating slope shows this problem remained significant throughout therapy. There are signs of improvement post-therapy (post-therapy=3,4, follow-up=2) but not enough to confirm a reversing trend. Item 12, going to sleep (figure 4-18) has a stable high stress baseline (5) reporting a serious problem at the outset of treatment but a drastic and relatively stable improvement (1) occurred immediately and persisted right through to the follow-up (1). 66 Amount of sleep, item 13 (figure 4-18) was also a concern fo r Ann i n the months p r i o r to seeking therapy. She would have trouble f a l l i n g asleep then would awaken often and remain awake f o r hours at a time. Baseline i s stable at high s t r e s s (5), post-therapy and follow-up stable at low stres s (1) • Item 14, a n t i c i p a t i n g commencement of job (figure 4-17) was another primary consideration f o r Ann (baseline=5). The s p l i t middle l i n e of progress suggests a downward trend i n s t r e s s l e v e l , the scores remained r e l a t i v e l y high (X=3.5). Ultimately, Ann was recommended by her physician not to return to work due to her p o t e n t i a l a l l e r g y to chemical used i n the plant where she worked. This explains the sudden drop i n s t r e s s l e v e l following completion of therapy. An unusual baseline i s presented f o r item 15, housework, (figure 4-19). Jumping from high stres s (5) to low s t r e s s (1) i n one week, the during therapy scores are scattered amongst • the mid-range scores (2 to 4) and from week 12 onward, the l e v e l i s stable at low stres s (1). The s p l i t middle l i n e of progress shows a decelerating slope. Changes i n weight (item 16) (figure 4-15) p a r t i c u l a r l y weight l o s s were very upsetting to Ann, (baseline=5). The post-therapy scores (3 and 2) and follow-up score (1) suggest improvement occurred during the intervention phase. Taking medication (item 17) (figure 4-16) showed baseline Subjective Stress Inventory 67 #19 marriage Base-line Intervention Post- Follow- therapy u p 1 2 3 8 9 10 11 12 13 14 15 16 17 45 Weeks #23 social gatherings Base-line Intervention Post- Follow- therapy up 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks Figure 4-14. Ann's stress scores (SSI) at baseline, intervention, post-therapy and follow-up for marriage and social gatherings. #8 eating 0) u o u cn cn cn cu u u CO Subjective Stress Inventory Baselinle Intervention 5- 4- 3- 2- 1- Post- tiherapyj i i i i i i i i i i i i i i i i 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks #16 change in weight CU U O O cn cn cn cu >-i 4J CO Baseli 5- 4- 3- 2- 1- ne Intervention i i i i 1 2 3 4 i 5 Post- Follow- therapy up i i i i i i i i i i i i i 6 7 8 9 10 11 12 13 14 15 16 17 45 #21 change in eating habits Baseline cu ^ u o a 3-1 cn cn cu u 4-1 2- 1- Weeks Intervention Post- Follow-ttherapyi up 1 i 2 3 4 5 6 7 i 8 i i i i i i i i i i 9 10 11 12 13 14 15 16 17 45 Weeks Figure 4-15. Ann's stress scores (SSI) at baseline, intervention, post-therapy and follow-up, for eating, change in weight and change in eating habits. Subjective Stress Inventory 69 #17 taking medication 5. oj . u k-o o co co 3-co cu u 1 i ' I • i i i i i i i I i i i r~l i i 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks #20 minor il l n e s s I I I I I i i i i P~i i f 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks Figure 4-16. Ann's stress scores (SSI) at baseline, intervention, post-therapy and follow-up, for taking medication and minor i l l n e s s . #5 going out in public Subjective Stress Inventory Baseline Intervention 4- 3- 2- 1- Post- i 7 Q therapjy 1 1 i 1 1—i 1 1 1—i—i 1—i 1 i — — I 1 r 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks #7 going to the therapist Baselii 5- 4- 3 2- 1- Intervention Post- Follow-therapjr up A I I I I I I I I I I I I I I I I I I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks #14 anticipa- ting commence- ment of job Baseline 4- 3- 2- 1- '. I li i 2 3 Intervention I I i i I I I I 3ost- Follow-ierapy i up i—r T 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks Figure 4-17. Ann's stress scores (SSI) at baseline, intervention, post-therapy and follow-up, for going out in public, going to the therapist and anticipation of commencement of job. 71 scores of 5, 4, post-therapy scores of 4, 3 and a fo l low-up of 4. Item 18, money matters ( f i gure 4-19) shows a base l ine of 1 and fo l low-up of 1 but cons iderable f l u c t u a t i o n dur ing therapy. Stress l e v e l r e l a t i n g to her marriage, item 19 ( f igure 4-14) form the same conf i gura t ion as item 1, r e l a t i o n s h i p with spouse, change score from base l ine to post-therapy=4. Item 20, minor i l l n e s s ( f i gure 4-16) has a base l ine of 5, post - therapy score of 4 and fol low-up score of 1. A high s t res s base l ine of 5 i n item 21, eat ing hab i t s , ( f i gure 4-15) (week 4 score=2) responded i n i t i a l l y to the i n te rven t i on but gradua l ly re t rea ted back towards the ba se l i ne (5) u n t i l the post-therapy (1) and fo l low-up (1) repor t s . As with f a l l i n g as leep, item 22, s leep hab i t s ( f i gure 4-18) improved dramat ica l l y upon commencement of therapy from base l ine of 5 to scores of 1 i n the f i r s t two weeks of the i n te rven t i on and maintained t h i s improvement throughout the durat ion and the fo l low-up except f o r weeks 5 and 14. The s o c i a l gatherings, item 23, ( f i gure 4-14), shows a s t re s s reduct ion s lope (baseline=5) l e v e l l i n g o f f towards the end of therapy and maintaining low s t res s (1) through the post - therapy and fo l low-up. F igure 4-20 shows Ann's t o t a l s t res s scores at the ;H2 going to s leep Base l i np 5- 4- 3- 2- 1- 1 r- Subjec t ive S t r e s s Inventory In t e rven t i on P o s t - herafjy y 2 I—i 1 1 1 1 1 1—i 1 1 1 1- + -t—t-1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks #13 amount of s leep Base l ine In t e rven t ion 5- 4- 3- 2- 1- P o s t - Fo l low- tiherapx up T 1 1 1 1 1 1 1 1 1 1 1 1—l_i—i r— 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks ,'22 change i n s l eep ing hab i t s Base l ine In t e rven t ion 5- 4- 3- 2- 1- ' o s t - Fo l low- ;herapv up T 1—-} 1 1 1 1—i 1 1 1 1 1 1—i 1 1—i—t- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks F igure 4-18 Ann 's s t r e s s scores (SSI) at b a s e l i n e , i n t e r v e n t i o n , post- therapy and f o l l o w - u p , for going to s l eep , amount of s leep and change i n s l eep ing h a b i t s . Subjective Stress Inventory 73 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks #18 money matters cu u o o CO co co 0) l - l J - l co Baseline Intervention Post- 5- 4- 3- 2- 1- ;herapy 1 1— .1 1 1 1 1 1 1—1 1 1—J—i. —1_. i J — i —11 Follow-up 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 45 Weeks Figure 4-19. Ann's stress scores (SSI) at baseline, intervention, post-therapy and follow-up, for housework and money matters. 74 basel ine, during therapeutic intervent ion, post-therapy and s ix months l a te r . The change score between condit ions (baseline to intervention phase) i s 51. The change score from basel ine to follow-up i s 53. Figure 4-21 shows the pre - , post - and follow-up score across the 18 SSI items. Phys io log ica l Symptoms Scale Figure 4-22 i l l u s t r a t e s the sever i ty of symptoms in a p re - , post-therapy and follow-up assessment. A l l but one pre-therapy scores were ' 3 ' or above with an overa l l sever i ty t o t a l of 32. By the post-therapy reports, the highest score was 12• for a sever i ty t o t a l of 10 and the follow-up showed one symptom at ' 2 ' , the rest at 1 1 ' for a t o t a l score of 9. As with the other object ive and subject ive tes t s , s i gn i f i can t improvement has been shown to have taken p lace by the post-therapy assessment. Follow-up scores have confirmed success i n maintaining th i s improvement. 75 Subjective Stress Inventory Figure 4-20. Ann's total stress score for baseline, intervention, post-therapy and follow-up. 76 Figure 4-21. Ann's stress scores for each of the Subjective Stress Inventory items taken pre-therapy (solid l ine) , post-therapy (broken line) and at six-month follow-up (dotted l ine) . Items from Subjective Stress Inventory 77 Figure 4-22. Ann's severity of symptoms scores for each of the items on the Physiological Symptoms Scale taken pre-therapy (solid l ine) , post-therapy (broken line) and at six-month follow-up (dotted l ine . 78 CHAPTER V DISCUSSION AND CONCLUSIONS Comparisons and Evaluations Any assessment t oo l , including standardized tes t s , may provide incomplete and misleading information i f interpreted l i t e r a l l y and in i s o l a t i on . The scales and inventories used in th i s study were intended to h igh l ight problem areas, provide a c learer , more complete p ic ture of the subject and to confirm or contradict reports from other tes t s . From the comparison and evaluation of tes t resu l t s we can generate an accurate and e f f i c i e n t c l i n i c a l and research descr ipt ion of Ann, her problems and her progress. In studying the tes t re su l t s , the therap i s t ' s expertise and c l i n i c a l experience with the subject i s valuable for assessment of the accuracy of the analyses. For instance, in the case of the analys is and interpretat ion of the MMPI c l i n i c a l and research scales, caution i s recommended in determining the p r o f i l e v a l i d i t y . I f the therap i s t ' s experience of the c l i e n t i s not consistent with some of the tes t re su l t s , the therapist must use d i s c re t ion and not attach labels casual ly. The pre-therapy p r o f i l e s of the MMPI and TSCS present quite consistent p ictures of the subject. The MMPI c l i n i c a l scale analys is and interpretat ion describe the subject as tense, unduly worried and prone to phys ica l ailments such as 79 headaches, stomach problems and insomnia. She scored more than two standard deviations above the mean on eight scales: V a l i d i t y Scale F; Scale 1 (Hypochondriasis); Scale 2 (Depression); Scale 3 (Hysteria); Scale 4 (Psychopathic dev iate) ; Scale 6 (Paranoia); Scale 7 (Psychasthenia): and Scale 8 (Schizophrenia). This f i t s with an elevated s e l f - c r i t i c i s m score on the TSCS and below average scores in overa l l self-esteem (she i s anxious, depressed, unhappy, has low confidence) and ident i t y , s e l f - s a t i s f a c t i o n , behaviour, phys ica l s e l f , mora l -eth ica l s e l f , family s e l f and soc i a l s e l f . High scores for general maladjustment, personal i ty disorder and neurosis also seem to be in agreement with the MMPI re su l t s . From a c l i n i c a l perspective, the f i r s t task was to i dent i f y the sources which were i n te r fe r ing with her emotional and phys ica l wel l -being. Ann bel ieved she had very l i t t l e contro l over her circumstances which l e f t her fee l ing powerless and worthless. This notion i s confirmed by the basel ine scores from the POMS. Her t o t a l mood disturbance (TMD) score i s very high as a resu l t of elevated leve l s of tension, depression, fat igue and confusion and a sense of depleted v igor. The phys io log ica l symptoms (PSS) complaints at the basel ine far exceeded l a te r scores. Eleven of the 18 subjective stress categories (SSI) were 80 stable at level '5* during baseline assessment with health and social issues being particularly stressful. For example, the social gatherings (item 23) score shows the high stress levels typically created by the cycle of the panic attack victim. She had a panic attack in a social situation, associated the unpleasant experience and physical reactions with that setting and eventually became panicky even at the thought of re-entering that situation so she would avoid i t . Post-therapy reports from the MMPI, TSCS, and PSS aligned to form a picture of significant overall improvement. Only one scale over 70 (Scale 4, Pd) remained on the MMPI. On the TSCS, Ann's self-criticism score had dropped, her total positive score (overall self-esteem) was much higher and a l l other positive scores (except 'family') were above the mean (T=50). Most of the empirical scales had dropped with exception of 'personality integration' and 'defensive postive'. The PSS also showed a reduction of symptoms in almost every category. Significant improvement on the POMS and much of the SSI as well, a l l point to the succcess of the intervention. The assessment indicate that Ann's self-esteem grew and developed as she accepted more control of her l i f e . The explanation of the A-B-C-D-E theory gave her a better understanding of her situation and a belief in her own 81 a b i l i t y to make pos i t i ve and construct ive changes. As the panic attacks reduced, going out in pub l ic and v i s i t i n g fr iends became far less traumatic for her. Regular re laxat ion exercises and sustained improvement of her s leeping habits were bene f i c i a l for her attempts to cope with her problems. In general, the follow-up study showed an extension of the progress seen in post-therapy. A l l the MMPI scales were within the normal range. The TSCS showed a healthy p r o f i l e and the PSS, POMS and SSI scores were stable or showed continued improvement. In summary, a l l of the tests indicated s i gn i f i c an t po s i t i ve changes a f te r the therapeutic intervent ion and the follow-up scores showed th i s improvement has been sustained s ix months l a te r . Response to Hypotheses In almost a l l cases, the change scores between the basel ine and follow-up reports were s i gn i f i c an t and indicated that therapy was successful . The object ive assessments (MMPI, TSCS, POMS) showed increased self-esteem, improved se l f -concept, normal ( i .e . not pathological) persona l i ty p r o f i l e and a reduction in unpleasant and s t a t i c mood states. S im i l a r l y , the subjective assessments (SSI, PSS) demonstrated reduced stress leve l s and fewer and less severe 82 phys io log ica l symptoms fol lowing the therapeutic intervent ion. It was also suggested that the use of an audiotape of re laxat ion exercises might reduce time spent on trance induct ion. This var iab le was not measured but i t was a valuable adjunct to the therapy and did seem to resu l t in fas ter and eas ier trance induction. It also served to re in force learnings from previous sessions and a id in helping Ann relax and sleep more r e s t f u l l y . Internal and External V a l i d i t y Was th i s r a t i ona l hypnotherapeutic intervent ion responsible for the changes and improvements in Ann's condition? Mott (1986) warns that therapies using hypnosis represent mult ip le interventions which threaten in terna l v a l i d i t y . But i s hypnotherapy a mult ip le intervention? I t i s a therapeutic approach which encompasses the hypnotherapist 's own personal i ty and imagination and involves learning and growth in and out of trance states. While th i s approach does employ a s p e c i f i c trance induction r i t u a l , that i s not to say that the 'non-hypnotic' supportive psychotherapy which may fol low does not also include the subject spontaneously s l i pp ing in and out of trance. Therefore, th i s intervent ion i s presented not as a potpourri of R.E.T., hypnosis and supportive psychotherapy. Rather i t i s a un i f i ed whole in 83 which the subject uses ra t iona l se l f -eva luat ion in and out of trance and the therapist f a c i l i t a t e s th i s with d i rec t supportive learning, in and out of trance. Kazdin (1982) l i s t s f i ve threats to in terna l v a l i d i t y : h i s tory , maturation, tes t ing , s t a t i s t i c a l regression to the mean and mult ip le interventions. The therapy log was intended to guard against these hazards. By keeping track of s i gn i f i c an t events, such as resu l t s from medical tes t s , her husband's unemployment and the f i nanc i a l s t ra ins of moving to a new house, we could account for each one's impact on her current condit ion. Mott (1986) points out that when symptoms are severe even an i ne f fec t i ve intervent ion w i l l show some regression toward the mean. The resu l t s presented e a r l i e r c l e a r l y show that there was not simply a mild improvement but p r o f i l e s which went from patho log ica l ly deviant to healthy, well-balanced p r o f i l e s . The researcher has attempted to present the theore t i ca l framework of th i s intervention in such a way that others may rep l i ca te the study with c l i en t s with s imi la r diagnoses. The underlying psychodynamics, c l i e n t ' s degree of motivation and external support systems w i l l not be the same. Nor w i l l the in terac t ion between the therapis t and c l i e n t . The gene ra l i z ab i l i t y of any s ing le subject design i s r e s t r i c t e d since we cannot assume that an intervent ion which 84 was successful in a s o l i t a r y case w i l l be successful i n a l l cases. However, by fol lowing Nugent's (1985) guidel ines, the researcher has made th i s study as v a l i d and r e l i a b l e as poss ib le. The intervent ion has been out l ined so that i t may be dupl icated and tested. J u s t i f i c a t i o n of the Study New ins ights are a prerequis i te for s ing le case reports which are worthy of pub l icat ion (Fromm, 1981). This study proposes to contribute to the l i t e r a t u r e a new approach to r a t i ona l s e l f - d i r e c t i o n within a hypnotherapeutic framework. . This study approaches a r ep l i c a t i on of s im i l a r case report (Tosi, Howard & Gwynne, 1982) but re jec t s the need for the c l i e n t to re-experience negative a f fec t in an e f f o r t to i dent i f y se l f -de feat ing cognitions and behaviours in a s i tua t ion chosen by the therapis t . The present research appl ies a less d i rec t i ve approach, t rus t ing the subject ' s subconscious mind to se lect an appropriate event (Haley, 1973) . "You don't t e l l yoursel f what you are going to do in a trance state. Your unconscious mind knows an awful l o t more than you do," (Erickson, 1980). The subject views the event on a video screen, permitting her to object ive ly evaluate her thoughts, actions and behaviours without having to r e l i v e an unpleasant experience. As a resu l t the therapy may be less traumatic for the c l i e n t and may answer more d i r e c t l y her conscious and subconscious needs. 85 This study also responds to a c a l l by Nugent (1985) for hypnotherapists to upgrade s ing le methodology in the continuing e f f o r t to develop r e l i a b l e therapeutic technology. In the opinion of the present researcher, the primary area of contention i s the basel ine phase. The c l i n i c a l inappropriateness of an extended basel ine period has been discussed e a r l i e r in the study as was the therap i s t ' s i n a b i l i t y to await indisputable signs of condit ion s t a b i l i t y . This i s the point at which sound methodology and c l i n i c a l d i s c re t i on are at odds. The compromise in th i s study was to l i n k a two week basel ine period with the case h i s tory which described, in anecdotal fashion, the subject ' s condit ion deter iora t ion over several months p r i o r to her seeking therapy. This approach was favoured over extending the basel ine and withholding therapy. Unl ike a case study, t h i s s ing le case research design using p re - and post-therapy measures, repeated measures over time, standardized assessments and se l f - repor t s considerably reduces any threats to in terna l v a l i d i t y and allows the researcher to pos i t that i t was the intervent ion and not other factors which were responsible for the change which took place. 86 SUMMARY AND CONCLUSIONS In th i s study, the present researcher has proposed and tested a form of ra t iona l hypnotherapy which emphasizes cognit ive restructur ing to overcome anxiety neurosis and panic attacks. These disorders are widespread, frequent and often d e b i l i t a t i n g but the prognosis for t h e i r treatment i s promising. I t i s therefore the re spons ib i l i t y of the researcher to invest igate and ve r i f y or re jec t tentat ive hypotheses so that c l in i cans encountering anxiety states and panic attacks may be sure of se lect ing an e f f ec t i ve intervent ion program. The therapeutic approach taken in th i s study involved hypnotherapy comprised of re laxat ion exercises, guided imagery, and subconscious d i rec t i on of c r i t i c a l inc idents, r a t i ona l se l f -eva luat ion in cognit ive restructur ing and behavioural rehearsal on the part of the subject. A s ing le subject research design was employed to tes t both the theory in pract ice and the f e a s i b i l i t y and e f f i cacy of t h i s design for c l i n i c a l reports. In th i s research we have attempted to take another small step toward creat ing a design which i s compatible with c l i n i c a l p r i o r i t i e s while maintaining a sound methodology. The subject was a woman in her ear ly f o r t i e s who was su f fer ing panic attacks, associated phys io log ica l problems and general ized anxiety states. She came in seeking 87 therapy and was very motivated to change. She agreed to complete the tests described e a r l i e r in the study, and did so without exception. Baseline assessment of her condit ion indicated i t to be severe and deter iorat ing . Improvement in her condit ion within the f i r s t two weeks of therapy was a resu l t of r e l i e f from her s leeping problems, the calming e f fec t s of the re laxat ion exercises and her own expectations that therapy would be successfu l . A f ter two weeks, many of her symptoms deter iorated back towards the basel ine phase. The gradual overa l l trend accelerat ion from th i s point i s more expressive and ind i ca t i ve of the treatment success than the e a r l i e r phase as i t includes the peaks and setbacks which occurred as therapy progressed. By the end of the therapeutic intervent ion per iod, most of her symptoms had regressed, she no longer suffered panic attacks and her phys ica l condit ion had improved. Ann's own perception of herse l f was that she f e l t better , had a greater understanding of herse l f and her resources, she was no longer f e a r f u l , and reported that she had suffered no more panic attacks. Her increased soc i a l in teract ion and involvement in a c t i v i t i e s outside her home confirm th i s . This study confirms the report by Tos i , Howard & Gwynne (1982) who implemented a successful cogn i t i ve -exper ient ia l intervent ion for anxiety neurosis. 88 Rational hypnotherapy i s e f fec t i ve , as demonstrated by the continuous assessment resu l t s and the c l i e n t ' s s e l f - r epo r t . 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In Clarke, J .C . & Jackson, J .A. Hypnosis and behavior therapy: The treatment of anxiety and phobias. NY: Springer Publishing Co. P i t t s , F.N. J r . & McClure, J.N. J r . (1967). Lactate metabolism in anxiety neurosis. New England Journal of Medicine, 277: 1329-1336. Posner, M. (1973). Coordination of in terna l codes, i n W. Chase (Ed.) V i sua l information processing. NY: Academic Press. Reardon, J . P . , Tos i , D.J., & Gwynne, P.H. (1977). The treatment of depression through ra t i ona l stage d i rected hypnotherapy (RSDH): A case study. Psychotherapy: Theory, Research & Pract ice, 14(1), 95-103. Ruch, J . C , Morgan, A.H., & Hi lgard, E.R. (1974). Measuring hypnotic responsiveness: A comparison of the Barber sugges t i b i l i t y scale and the Stanford hypnotic s u s c e p t i b i l i t y sca le, Form A. Internat ional Journal of C l i n i c a l and Experimental hypnosis, 22, 365-376. Sanders, S. (1986). A b r i e f h i s tory of d i s soc i a t i on . American Journal of C l i n i c a l Hypnosis, 2_9 (2) , 83-85. Sheehan, D.V. (1986). The anxiety disease. Bantam Books. Smail, D. (1984). I l l u s i on and r e a l i t y : The meaning of anxiety. London: J.M. Dent & Sons Ltd. 96 So lof f , P.H. & Bar te l , W.G. (1979). E f fects of denia l on mood and performance in cardio-vascular r e h a b i l i t a t i o n . Journal of Chron. P i s . , 32, 307-313. Spiegel, H. & Spiegel, D. (1978). Trance and treatment. NY: Basic Books. Stanwyck, D.J. & Garrison, W.M. (1982). Detection of faking on the Tennessee Self-Concept Scale. Journal of Personal ity Assessment, 46, 426-431. Sternberg, S. (1975). Memory scanning; New f indings and current controvers ies. Quarterly Journal of Experimental Psychology, 27(1). S t i t t , F.W., Frane, M. & Frane, J.W. (1977). Mood change in rheumatoid a r t h r i t i s : Factor analys is as a t oo l in c l i n i c a l research. Journal of Chron. P i s . , 30, 135-146. Suinn, R.M. In O.K. Buros (Ed.) The mental measurements yearbook, NJ: Gryphon Press. Tawney, J.W. & Gast, P.L. (1984). Single subject research in spec ia l education. Ohio: Charles E. M e r r i l l Publishing Co. Tos i , P.J. (1974). Youth toward personal growth: A ra t iona l emotive approach. Columbus, Ohio: M e r r i l l . Tos i , P.J. & Baisden, B.S. (1984). Cogn i t ive-exper ient ia l therapy and hypnosis, in W.C. Wester & A.H. Smith, J r . (Eds.) C l i n i c a l hypnosis: A mu l t i d i s c ip l i na ry approach, 155-178. Phi ladelphia: J .B. L ippincott Co. 97 Tos i , D., Howard, L. & Gwynne, P.H. (1982). The treatment of anxiety neurosis through ra t iona l state d i rected hypnotherapy: A cogn i t i ve -exper ient ia l perspective. Psychotherapy: Theory, Research & Pract ice, 191, 95-101. Walch, S.L. (1976). The red bal loon technique of hypnotherapy: A c l i n i c a l note. Internat ional Journal of C l i n i c a l and Experimental Hypnosis, Vo l . XXIV(1), 10-12. Watkins, J .G. (1986). Hypnoanalytic egostate therapy. Workshop presented in Vancouver, B.C. Watzlawick, P. (1978). The language of change: Elements of therapeutic communication. New York: Basic Books. White, O.R. & .Haring, N.G. (1980). Exceptional Teaching. Columbus, Ohio: Charles E. M e r r i l l . 98 APPENDIX A C r i t e r i a for Panic Disorder American Psychiatric Association Diagnostic and S t a t i s t i c a l Manual of Mental Disorders, Third Edition Washington, D.C., APA, 1980 C r i t e r i a for Panic Disorder At least three panic attacks within a three-week period in circumstances other than during marked physical exertion or i n a life-threatening situation. The attacks are not precipitated only by exposure to a circumscribed phobic stimulus. Panic attacks are manifested by discrete periods of apprehension or fear, and at least four of the following symptoms appear during each attack: 1. Dyspnea 2. Palpitations 3. Chest pain and discomfort 4. Choking and smothering sensations 5. Dizziness, vertigo, or unsteady feelings 6. Feelings of unreality 7. Paresthesias 8. Hot and cold flashes 9. Sweating 10. Faintness 11. Trembling and shaking 12. Fear of dying, going crazy, or doing something uncontrolled during an attack APPENDIX B Trance Induction and Intervention Trance Induction "Make yourself as comfortable as you can...allow your muscles to relax, close your eyes...feel the sensations, warm and relaxing...allow them t d r i f t down and down...allow the music and my voice and any surrounding sounds to become part of your comfort and relaxation... take a deep breath and gruadually release a l l the tension and stress from your body system...take in the oxygen so that every body c e l l w i l l be re v i t a l i z e d , energized.. .each time you exhale l e t a l l the tension and stress leave your body...and l e t the music make you feel more and more relaxed...drifting...drifting...you make feel certain sensations... allow them to become more comfortable, more relaxed...as a l l parts of your body can become more r e s t f u l , more limp...with each breath you may notice your body i s just beginning to feel more and more relaxed, more and more calm...allow yourself to feel the sensations of relax- ation i n your muscles, i n your chest, i n your arms, i n any part of your body...consciously you don't need to pay attention to a l l the things I'm saying to you because consciously you may be thinking about other things or fantasizing about something else...your unconscious mind w i l l understand and remember the things I'm going to talk about and your unconscious mind w i l l u t i l i z e the things I'm going to be talking about, for your own benefit. . . I ' 11 count from five backwards to one and you can d r i f t deeper and deeper, more and more relaxed..5... inhaling...exhaling...4...drifting down...3...2...allow yourself to d r i f t a l i t t l e deeper... breathing very regularly...heart rate i s normal...all the internr 1 functions are normalized... 1...and relax. (This induction, and variations of i t , can take from 10 to 15 minutes). 102 Pleasant Scene (The c l i e n t i s asked to think of a pleasant scene before the trance induction. The therapist should use the words and adjectives supplied by the cl i e n t to describe the scene to help her visualize and experience i t more f u l l y ) . "Imagine you're at a beautiful place... fresh air...nice breeze... birds in the distance...enjoy the sensations of comfort... breathe i n the fresh air and l e t i t r e v i t a l i z e and energize your whole body system...let your body absorb a l l the energy...enjoy your quiet, peaceful surroundings... feel the warm sun on your face and your shoulders... l e t those feelings within you of peace and confidence and calmness f i l l your body...allow them to reenergize those positive feelings within you...you may not hear a l l the things I'm saying...you may be list e n i n g to the waves r o l l i n g onto the beach...or you may be thinking of something else...your unconscious mind w i l l remember...now spend a few moments enjoying your beautiful surroundings...I w i l l be quiet for a few moments so you can completely enjoy your safe, peaceful,relaxing place...(therapist remains s i l e n t for 2-4 minutes). Red Balloon "Now I want you to s i t down there i n that comfortable place...that relaxing place...see a basket with a pencil and paper beside you... you may write on that paper anything thats bothering you...anything that causes you discomfort or problems... i t may be an incident or a person...anything at all...there may be one or there may be more than one...write each one down on a separate piece of paper...when you've done that, breathe i n and out three times...now, throw the pieces of paper and the pencil into the basket...get r i d of a l l your tension and stress...look up from the basket and you can see i t s attached to a big helium balloon, a red helium balloon...let i t go...picture i t floating away... d r i f t i n g up end up into the sky...away and away and awav...so beautiful, so relaxed and calm...drifting up and up into the blue sky so that a l l you can see i s a red dot...enjoy the soft music and the quiet sounds and allow a l l t h e sounds and feelings to become pare of your relaxation... Cognitive Restructuring "Isow i t s time to leave this pleasant scene but remember as you go that this i s your place and you can return here any time you wish...so l e t s return to the o f f i c e . . . s t i l l enjoying the sense of relaxation and peacefulness...comfortable, confident feelings...look around the o f f i c e u n t i l you see the TV screen...tell me when you see the TV... I want you to visualize on that screen a situation which caused you discomfort or anxiety...picture yourself i n that situation...as you see i t , t e l l me about it...what are you thinking in that situation...and how are you feeling...how does your body feel at that moment...what are you doing i n that situation...now, can you t e l l me about any of your thoughts or beliefs i n that situation that you might now see as s e l f - defeating or irrational...(allow c l i e n t to make suggestions)...any others...alright, now I want you to return to your pleasant scene, and a l l the feelings of comfort and relaxation and calmness you feel there...feel the sun and the l i g h t breeze...allow the fresh a i r to refresh and r e v i t a l i z e you...allow yourself a few moments to feel a l l the positive sensations there... Behaviour Rehearsal "Now I want to you to return to the o f f i c e and the TV screen...you can visualize the same situation again but this time see yourself with your new ideas, your more rational thoughts... t e l l me what you see this time, inserting those new thoughts...how are you feeling now.. how does your body feel...what are you doing i n that situation... (Therapist works through situation i n which c l i e n t has subsituted more rational thoughts and beliefs resulting i n new behaviours, emotions and physiological reactions). (The therapist works through one or more situations with the c l i e n t . As therapy progresses the c l i e n t may volunteer more information, requiring fewer questions from the therapist). Termination of Formalized Trance "Now I'm going to count from one to five and as I do so you w i l l begin to slowly wake up and as I'm counting you don't have to l i s t e n to me consciously because your unconscious w i l l remember to forget what i t wants to fet and remember as much as your conscious mind wants you to. 1...you '11 feel comfortable and relaxed...2...as I count you can begin to open your e y e s . . . 3 . . . s t i l l feeling relaxed and p o s i t i v e . . . 4 . . . 5 . . . when you're ready you can open your eyes feeling refreshed and relaxed (Following trance, the c l i e n t may wish to review the events which took place and discuss the situation or situations and their ABCDE components). APPENDIX C Barber Suggestibility Scale Barber, T.X. Hypnosis: A S c i e n t i f i c Approach New York: Van Nostrand Reinhold, 1969. 106 The Barber Suggestibility Scale The BSS can be administered under a variety of experimental conditions: with and without Hypnotic Induction, with and without Task Motivational Instructions, by means of a tape-recording or by oral presentation. Generally the scale has been administered to subjects with their eyes closed. Eight Test Suggestions 1. Arm Lowering. "Hold your right arm striaght out in front of you like this ." (Guide the subject to extend the right arm direct ly in front of body at shoulder height and paral le l to the f loor.) "Con- centrate on your arm and l isten to me." (Begin timing) "Imagine that your right arm is feeling heavier and heavier, and that i t ' s moving down and down. It's becoming heavier and heavier and moving down and down. It weighs a ton! It's getting heavier and heavier. It's moving down and down, more and more, coming down and down, more and more; i t ' s heavier and heavier, coming down and down, more and more, more and more." (End 30 seconds) "You can relax your arm now." (If necessary, ask the subject to lower the right arm.) Objective score cr i ter ion: 1 point for response of 4 inches or more. (Response is measured by placing a ruler near the subject's hand at the beginning of the suggestions and noting degree of displacement at the end of the 30-second suggestion period.) 2. Arm Leviation. "Keep your eyes closed and put your left arm straight out in front of you in the same way. Concentrate on your 107 arm and l.isten to me." (Begin timing) "Imagine that the arm is becoming lighter and l ighter, that i t ' s moving up and up. It feels as i f it doesn't have any weight at a l l , and i t ' s moving up and up, more and more. It's as light as a feather, i t ' s weightless and ris ing in the a i r . It's lighter and l ighter, r is ing and l i f t ing more and more. It's lighter and lighter and moving up and up. It doesn't have any weight at a l l and i t ' s moving up and up, more and more. It's lighter and l ighter, moving up and up, more and more, higher and higher." (End 30 seconds) "You can relax your arm now." (If necessary, ask the subject to lower the arm.) 3. Hand Lock. "Keep your eyes closed. Clasp your hands together t ight ly , and interlace the fingers." (If necessary, the experimenter states, "Press your hands together, with palms touching," and assists the subject to interlock the fingers and to bring the palms together.) "Put them in your lap. Concentrate on your hands and hold them together as t ightly as you can." (Begin timing) "Imagine that your hands are two pieces of steel that are welded together so that i t ' s impossible to get them apart. They're stuck, they're welded, they're clamped. When I ask you to pull your hands apart, they' l l be stuck and they won't come apart no matter how hard you try. They're stuck together; they're two pieces of steel welded together. You feel as i f your fingers are clamped in a vise. Your hands are hard, so l id , r ig id ! The harder you try to pull them apart the more they wi l l stick together! It's impossible to pull your hands apart! The more you try the more d i f f i cu l t i t w i l l become. Try, you can't." (End 45 seconds) 108 (5 second pause) "Try harder, you can't." (10 second pause) "You can unclasp your hands now." Objective score c r i t e r i a : \ point f o r incomplete separation of the hands a f t e r 5 second e f f o r t ; L point for incomplete separation a f t e r 15 second e f f o r t . 4. T h i r s t H a l l u c i n a t i o n . "Keep your eyes c l o s e d . " (Begin timing) "Imagine that you've j u s t f i n i s h e d a long, long walk i n the hot sun. You've been i n the hot sun for hours, and for a l l that time you haven't had a d r i n k of water. You've never been so t h i r s t y i n your l i f e . You f e e l t h i r s t i e r and t h i r s t i e r . Your mouth i s parched, your l i p s are dry, your throat i s dry. You have to keep swallowing and swallowing. You need to moisten your l i p s . (3 second pause) You f e e l t h i r s t i e r and t h i r s t i e r , d r i e r and d r i e r . T h i r s t i e r and t h i r s t i e r , dry and t h i r s t y . You're very very t h i r s t y ! Dry and t h i r s t y ! Dry and t h i r s t y ! " (End 45 seconds) "Now, imagine d r i n k i n g a c o o l , r e f r e s h i n g g l ass of water." (5 second pause) Obj e c t i v e score c r i t e r i a : \ point i f the subject shows swal- lowing, moistening of l i p s , or marked mouth movements: a d d i t i o n a l \ point i f the subject i n d i c a t e s during the "post-experimental" questioning that he or she became t h i r s t y during t h i s t e s t (e.g., " I f e l t dry." " I was parched." " I f e l t somewhat t h i r s t y . " ) . (See "postexperimental" questions f o r f i n a l s c o r i n g c r i t e r i a on t h i s t e s t . ) 5. Verbal I n h i b i t i o n . "Keep your eyes c l o s e d . " (Begin timing) "Imagine that the muscles i n your throat and jaw are s o l i d and r i g i d , as i f they're made of s t e e l . They're so s o l i d and so r i g i d , that you can't speak. Every muscle i n your throat and mouth i s so t i g h t and so r i g i d that you can't say your name. The harder you t r y to say your 109 name che harder it becomes. You can't talk! Your larynx has tightened up; your throat and jaw feel as i f they are in a vise. Your throat is clamped so t ightly that you can't talk; you can't say your name. The harder you try the harder i t w i l l be. "It's useless, the words won't come out; you can't speak your name; i t ' s impossible to talk! The harder you try to say your name the harder i t wi l l become. Try, you can't!" (End 45 seconds) (5 second pause) "Try harder; you can't." (10 second pause) "You can say your name now." Objective score c r i t e r i a : ^ point i f the subject does not say name after 5 second effort; 1 point i f subject does not say name after 15 second effort . 6. Body immobility: "Keep your eyes closed." (Begin timing) "Imagine that for years and years you've been s i t t ing in that chair just as you are now. Imagine that you've been s i t t ing in that chair so long that you're stuck to i t ! It's as i f you're part of the chair. Your whole body is heavy, r i g i d , solid and you weigh a ton. You're so heavy that you can't budge yourself. It's impossible for you to stand up, you're stuck right there! Your body has become part of the chair. When I ask you to stand up you won't be able to do i t ! You're stuck tight. The harder you try the tighter you' l l be stuck and you won't be able to get up. You're heavy in the chair! Stuck in the chair you can't stand up. You're so heavy and stuck so tight. You can't stand up and you're stuck. Try you can't." (End 45 seconds) (5 second pause) "Try harder, you can't." (10 second pause) "You can relax (or s i t down) now." (The subject is considered not standing i f he or she rises 110 s l i g h t l y from the c h a i r without s t r a i g h t e n i n g i n t o an erect posture. In t h i s event, the experimenter says, "Try to stand f u l l y e r e c t . You can't", instead of "Try harder, you can't.") Objective score c r i t e r i a : k point i f the subject i s not standing f u l l y erect a f t e r 5 second e f f o r t . 1 point i f not standing f u l l y erect a f t e r 15 second e f f o r t . 7. " P o s t h y p n o t i c - l i k e Response" (The au d i t o r y stimulus con- s i s t s of tapping once on the metal back of a stop watch with a fou n t a i n pen). (Begin timing) "When t h i s experiment i s over i n a few minutes and your eyes are open, I ' l l c l i c k l i k e t h i s (experimenter presents a u d i t o r y stimulus) and y o u ' l l cough a u t o m a t i c a l l y . At the moment I c l i c k ex- perimenter presents s t i m u l u s . Y o u ' l l cough. I t w i l l happen a u t o m a t i c a l l y . When I c l i c k l i k e t h i s (stimulus i s presented) y o u ' l l cough immediately. I ' l l c l i c k and y o u ' l l cough. When your eyes are open, I ' l l c l i c k ( stimulus i s presented and y o u ' l l cough. When I c l i c k y o u ' l l cough." (End 30 seconds) Obj e c t i v e score c r i t e r i o n : 1 point i f the subject coughs or c l e a r s throat " p o s t e x p e r i m e n t a l l y " when presented w i t h the aud i t o r y stimulus. 8. S e l e c t i v e Amnesia. "Your eyes are s t i l l c l o s e d but I'm going to ask you to open them i n a minute. When they're open I'm going to ask you to t e l l me about these t e s t s . " (Begin timing) " Y o u ' l l r e - member a l l the t e s t s and be able to t e l l me about them, a l l except f o r one. There's one that y o u ' l l completely forget about as i f i t never happened! That's the one where I s a i d your arm was becoming l i g h t e r and moving up and up. Y o u ' l l forget a l l about that and when you t r y to think about i t , i t w i l l s l i p even f u r t h e r away from your mind. You w i l l forget I l l completely that I told you that your arm was becoming l ighter. This is the one test that you cannot remember! You wi l l remember that I said your arm was heavy and a l l the other tests wi l l be perfectly clear but the harder you try to remember that I told you your arm was ris ing the more d i f f i c u l t i t w i l l become. You wi l l not remember unti l I give you permission by saying. Now you can remember, and then, and only then, you w i l l remember that I said your arm was r is ing!" (End 45 seconds) Objective score cr i ter ion: i point i f the subject does not refer to the Arm Levitation item (Test-suggestion 2) but recalls at least four other items and then recalls Test-suggestion 2 in response to the cue words. "Postexperimental" Objective Scoring of Test-suggestions 4, 7 and 8 "Open your eyes, the experiment is over." Scoring of Test-suggestion 7. The "Posthypnotic-like" Response item (item 7) is scored at this point. The experimenter presents the auditory stimulus after the subject has opened his or her eyes and before conversation commences. Scoring of Test-suggestion 8. The experimenter next asks: "How many of the tests can you remember?" The experimenter prompts the "subject by asking, "Were there any others?" "Can you think of any more?" and "Is that a l l ? , " unti l the subject mentions at least four of the test-suggestions. If the subject verbalizes the Arm Levitation item during the r e c i t a l , he or she receives a score of zero on Test-suggestion 8 (Selective Amnesia). If the subject does not include the Arm Levitation item in the enumeration, the experimenter f inal ly states, "Now you can remember," and, i f the 112 subject s t i l l does not verbalize the Arm Levitation item, "You can re- member perfectly well now!" The subject receives a score of 1 point on Test-suggestion 8 (Selective Amnesia) i f he or she mentions at least four of the test- suggestions, but does not mention the Arm Levitation item before given the cue words, and verbalizes the Arm Levitation item when given the cue words. "Now you can remember," or "You can remember perfectly well now!" Final scoring of Test-suggestion 4. The objective scoring of Test-suggestion 4 is completed when the subject refers to this item during the r e c i t a l . At this point the experimenter asks: "Did you become thirsty during this test?" If the subject answers, "Yes" to this question he or she receives the additional *j point on Item 4. If the subject answers, "Yes" but adds a qualifying statement, e .g. , "I had been thirsty to begin with," he or she is asked: "Did the imaginary glass of water help quench your thirst?" If the subject now answers, "Yes" he or she receives the additional ^ point. The maximum Objective score obtainable on the BSS is 8 points. "Revised" Subjective Scores After Objective scores have been assigned, the subject is given a mimeographed questionnaire which assess subjective responses to the BSS and is worded thus: Please answer the following questions truthful ly . Place a check mark above the most accurate answer. 1. When i t was suggested that your right arm was heavy and was moving down, the arm felt: not heavy; s l ightly heavy; heavy; very heavy. 113 2. When i t was suggested that your left arm was light and was moving up, the arm fel t : not l ight; s l ightly l ight; l ight; very l ight. 3. When i t was suggested that your hands were stuck together and you wouldn't take them apart, the hands felt: not stuck; s l ightly stuck; stuck; very stuck. 4. When it was suggested that you felt thirsty, you fe l t : not thirsty; s l ight ly thirsty; very thirsty. 5. When i t was suggested that your throat was stuck and you couldn't speak, your throat felt: not stuck; s l ight ly stuck; stuck; very stuck. 6. When it was suggested that you were stuck to the chair, you fe l t : not stuck; s l ightly stuck; stuck; very stuck. 7. When the experiment was over the experimenter clicked his fingers (presented the posthypnotic cue), you fe l t : not l ike coughing; s l ight ly like coughing; like coughing; very much like coughing. 8. When the experiment was over and you were recall ing the tests, you felt that you remembered the test about the arm ris ing (the test S was told to forget): with no d i f f i cu l ty ; with slight d i f f i cu l ty ; with d i f f i cu l ty ; with great d i f f i cu l ty (or did not remember at a l l ) . Each of the above eight items receives a score of 0 to 3; 0 for the f i r s t answer ("not"), I for the second ("slightly"), and so on. The total Subjective scores on the eight items thus range from 0 to 24. APPENDIX D Minnesota Multiphasic Personality Inventory S.R. Hathaway & J.C. McKinley The Psychological Corporation, N.Y., 1943. 115 DO NOT MAKE ANY MARKS ON THIS BOOKLET 1. I like mechanics magazines. 2. I have a good appetite. 3. I wake, up fresh and rested most mornings. 4. I think I would like the work of a librarian. 5. I am easily awakened by noise. 6. I like to read newspaper articles on crime. 7. My hands and feet are usually warm enough. 8. My daily life is full of things that keep me in- terested. 9. I am about as able to work as I ever was. 10. There seems to be a lump in my throat much of the time. 11. A person should try to understand his dreams and be guided by or take warning from them. 12. I enjoy detective or mystery stories. 13. I work under a great deal of tension. 14. I have diarrhea once a month or more. 15. Once in a while I think of things too bad to talk about. 16. I am sure I get a* raw deal from life. 17. My father was a good man. 18. I am very seldom troubled by constipation. 19. When I take a new job, I like to be tipped off on who should be gotten next to. 20. My sex life is satisfactory. 21. At times I have very much wanted to leave home. 22. At times I have fits of laughing and crying that I cannot control. 23. I am troubled by attacks of nausea and vomiting. 24. No one seems to understand me. 25. I would like to be a singer. 26. I feel that it is certainly best to keep my mouth shut when I'm in trouble. 27. Evil spirits possess me at times. 28. When someone does me a wrong I feel I should pay him back if I can, just for the principle of the thing. 29. I am bothered by acid stomach several times a week. 30. At times I feel like swearing. 31. I have nightmares every few nights. 32. I find it hard to keep my mind on a task or job. 33. I have had very peculiar and strange experi- ences. 34. I have a cough most of the time. 35. If people had not had it in for me I would have been much more successful 36. I seldom worry about my health. 37. I have never been in trouble because of my sex behavior. 38. During one period when I was a youngster I engaged in petty thievery. 39. At times I feel like smashing things. 40. Most any time I would rather sit and daydream than to do anything else. 41. I have had periods of days, weeks, or months when I couldn't take care of things because I couldn't "get going." 42. My family does not like the work I have chosen (or the work I intend to choose for my life work). 43. My sleep is fitful and disturbed. 44. Much of the time my head seems to hurt all over. 45. I do not always tell the truth. GO ON TO THE NEXT PAGE 46. My judgment is better than it ever was. 47. Once a week or oftener I feel suddenly hot all over, without apparent cause. 48. When I am with people I am bothered by hear- ing very queer things. 49. It would be better if almost all laws were thrown away. 50. My soul sometimes leaves my body. 51. I am in just as good physical health as most of my friends. 52. I prefer to pass by school friends, or people I know but have not seen for a long time, unless they speak to me first. 53. A minister can cure disease by praying and putting his hand on your head. 54. I am liked by most people who know me. 55. I am almost never bothered by pains over the heart or in my chest. 56. As a youngster I was suspended from school one or more times for cutting up. 57. I am a good mixer. 58. Everything is turning out just like the prophets of the Bible said it would. 59. I have often had to take orders from someone who did not know as much as I did. 60. I do not read every editorial in the newspaper every day. 61. I have not lived the right kind of life. 62. Parts of my body often have feelings like burn- ing, tingling, crawling, or like "going to sleep." 63. I have had no difficulty in starting or holding my bowel movement. 64. I sometimes keep on at a thing until others lose their patience with me. 65. I loved my father. 66. I see things or animals or people around me that others do not see. 116 67. I wish I could be as happy as others seem to be. 68. I hardly ever feel pain in the back of the neck. 69. I am very strongly attracted by members of my own sex. 70. I used to like drop-the-handkerchief. 71. I thinlr a great many people exaggerate their misfortunes in order to gain the sympathy and help of others. 72. I am troubled by discomfort in the pit of my stomach every few days or oftener. 73. I am an important person. 74. I have often wished I were a girl. (Or ii you are a girl) I have never been sorry that I am a girl. 75. I get angry sometimes. 76. Most of the time I feel blue. 77. I enjoy reading love stories. 78. I like poetry. 79. My feelings are not easily hurt. 80. I sometimes tease animals. 81. I think I would like the kind of work a forest ranger does. 82. I am easily downed in an argument. 83. Any man who is able and willing to work hard has a good chance of succeeding. 84. These days I find it hard not to give up hope of amounting to something. 85. Sometimes I am strongly attracted by the per- sonal articles of others such as shoes, gloves, etc., so that I want to handle or steal them though I have no use for them. 86. I am certainly lacking in self-confidence. 87. I would like to be a florist. 88. I usually feel that life is worth while. 89. It takes a lot of argument to convince most people of the truth. GO ON TO THE NEXT PAGE 90. Once in a while I put off until tomorrow what I ought to do today. 91. I do not mind being made fun of. 92. I would like to be a nurse. 93. I think most people would lie to get ahead. 94. I do many things which I regret afterwards (I regret things more or more often than others seem to). 95. I go to church almost every week. 96. I have very few quarrels with members of my family. 97. At times I have a strong urge to do something harmful or shocking. 98. I believe in the second coming of Christ. 99. I like to go to parties and other affairs where there is lots of loud fun. 100. I have met problems so full of possibilities that I have been unable to make up my mind about them. 101. I believe women ought to have as much sexual freedom as men. 102. My hardest battles are with myself. 103. I have little or no trouble with my muscles twitching or jumping. 104. I don't seem to care what happens to me. 105. Sometimes when I am not feeling well I am cross. 106. Much of the time I feel as if I have done some- thing wrong or evil. 107. I am happy most of the time. 108. There seems to be a fullness in my head or nose most of the time. 109. Some people are so bossy that I feel like doing the opposite of what they request, even though I know they are right. 110. Someone has it in for me. 117 111. I have never done anything dangerous for the thrill of it. 112. I frequently find it necessary to stand up for what I think is right. 113. I believe in law enforcement. 114. Often I feel as if there were a tight band about my head. 115. I believe in a life hereafter. 116. I enjoy a race or game better when I bet on it. 117. Most people are honest chiefly through fear of being caught. 118. In school I was sometimes sent to the principal for cutting up. 119. My speech is the same as always (not faster or slower, or slurring; no hoarseness). 120. My table manners are not quite as good at home as when I am out in company. 121. I believe I am being plotted against. 122. I seem to be about as capable and smart as most others around me. 123. I believe I am being followed. 124. Most people will use somewhat unfair means to gain profit or an advantage rather than to lose it. 125. I have a great deal of stomach trouble. 126. I like dramatics. 127. I know who is responsible for most of my troubles. 128. The sight of blood neither frightens me nor makes me sick. 129. Often I can't understand why I have been so cross and grouchy. 130. I have never vomited blood or coughed up blood. 131. I do not worry about catching diseases. GO ON TO THE NEXT PAGE 132. I like collecting flowers or growing house plants. 133. I have never indulged in any unusual sex practices. 134. At times my thoughts have raced ahead faster than I could speak them. 135. Ii I could get into a movie without paying and be sure I was not seen I would probably do it. 136. I commonly wonder what hidden reason another person may have for doing something nice for me. 137. I believe that my home life is as pleasant as that of most people I know. 138. Criticism or scolding hurts me terribly. 139. Sometimes I feel as ii I must injure either my- self or someone else. 140. I like to cook. 141. My conduct is largely controlled by the customs of those about me. 142. I certainly feel useless at times. 143. When I was a child, I belonged to a crowd or gang that tried to stick together through thick and >hin. 144. I would like to be a soldier. 145. At times I feel like picking a fist fight with someone. 146. I have the wanderlust and am never happy un- less I am roaming or traveling about. 147. I have often lost out on things because I couldn't make up my mind soon enough. 148. It makes me impatient to have people ask my advice or otherwise interrupt me when I am working on something important. 149. I used to keep a diary. 150. I would rather win than lose in a game. 151. Someone has been trying to poison me. 118 152. Most nights I go to sleep without thoughts or ideas bothering me. 153. During the past few years I have been well most of the time. 154. I have never had a fit or convulsion. 155. I am neither gaining nor losing weight. 156. I have had periods in which I carried on ac- tivities without knowing later what I had been doing. 157. I feel that I have often been punished without cause. 158. I cry easily. 159. I cannot understand what I read as well as I used to. 160. I have never felt better in my life than I do now. 161. The top of my head sometimes feels tender. 162. I resent having anyone take me in so cleverly that I have had to admit that it was one on me. 163. I do not tire quickly. 164. I like to study and read about things that I am working at. 165. I like to know some important people because it makes me feel important. 166. I am afraid when I look down from a high place. 167. It wouldn't make me nervous ii any members of my family got into trouble with the law. 168. There is something wrong with my mind. 169. I am not afraid to handle money. 170. What others think of me does not bother me. 171. It makes me uncomfortable to put on a stunt at a party even when others are doing the same sort of things. 172. I frequently have to fight against showing that I am bashful. 173. I liked school. GO ON TO THE NEXT PAGE 174. I have never had a fainting spell. 175. I seldom or never have dizzy spells. 176. I do not have a great fear of snakes. 177. My mother was a good woman. 178. My memory seems to be all right. 179. I am worried about sex matters. 180. I find it hard to make talk when I meet new people. 181. When I get bored I like to stir up some excite- ment. 182. I am afraid of losing my mind. 183. I am against giving money to beggars. 184. I commonly hear voices without knowing where they come from. 185. My hearing is apparently as good as that of moat people. 186. I frequently notice my hand shakes when I try to do something. 187. My hands have not become clumsy or awk- ward. 188. I can read a long while without tiring my eyes. 189. I feel weak all over much of the time. 190. I have very few headaches. 191. Sometimes, when embarrassed, I break out in a sweat which annoys me greatly. 192. I have had no difficulty in keeping my balance in walking. 193. I do not have spells of hay fever or asthma. 194. I have had attacks in which I could not control my movements or speech but in which I knew what was going on around me. 195. I do not like everyone I know. 196. I like to visit places where I have never been before. 119 197. Someone has been trying to rob me. 198. I daydream very little. 199. Children should be taught all the main facts of sex. 200. There are persons who are trying to steal my thoughts and ideas. 201. I wish I were not so shy. 202. I believe I am a condemned person. 203. If I were a reporter I would very much like to report news of the theater. 204. I would like to be a journalist. 205. At times it has been impossible for me to keep from stealing or shoplifting something. 206. I am very religious (more than most people). 207. I enjoy many different kinds of play and recreation. 208. I like to flirt 209. I believe my sins are unpardonable. 210. Everything tastes the same. 211. I can sleep during the day but not at night. 212. My people treat me moreilike a child than a grown-up. 213. In walking I am very careful to step over side- walk cracks. 214. I have never.had any breaking out on my skin that has worried me. 215. I have used alcohol excessively. 216. There is very little love and companionship in my family as compared to other homes. 217. I frequently find myself worrying about some- thing. 218. It does not bother me particularly to see animnln suffer. 219. I think I would like the work of a building contractor. GO ON TO THE NEXT PAGE 220. I loved my mother. 221. I like science. 222. It is not hard for me to ask help from my friends even though I cannot return the favor. 223. I very much like hunting. 224. My parents have often objected to the kind of people I went around with. 225. I gossip a little at times. 226. Some of my family have habits that bother and annoy me very much. 227. I have been told that I walk during sleep. 228. At times I feel that I can make up my mind with unusually great ease. 229. I should like to belong to several clubs or lodges. 230. I hardly ever notice my heart pounding and I am seldom short of breath. 231. I like to talk about sex. 232. I have been inspired to a program of life based on duty which I have since carefully followed. 233. I have at times stood in the way of people who were trying to do something, not because it amounted to much but because of the principle of the thing. 234. I get mad easily and then get over it soon. 235. I have been quite independent and free from family rule. 236. I brood a great deal. 237. My relatives are nearly all in sympathy with me. 238. I have periods of such great restlessness that I cannot Bit long in a chair. 239. I have been disappointed in love. 240. I never worry about my looks. 241. I dream frequently about things that are best kept to myself. 120 242. I believe I am no more nervous than most others. 243. I have few or no pains. 244. My way of doing things is apt to be misunder- stood by others. 245. My parents and family find more fault with me than they should. 246. My neck spots with red often. 247. I have reason for feeling jealous of one or more members of my family. 248. Sometimes without any reason or even when things are going wrong I feel excitedly happy, "on top of the world." 249. I believe there is a Devil and a Hell in afterlife. 250. I don't blame anyone for trying to grab every- thing he can get in this world. 251. I have had blank spells in which my activities were interrupted and I did not know what was going on around me. 252. No one cares much what happens to you. 253. I can be friendly with people who do things which I consider wrong. 254. I like to be with a crowd who play jokes on one another. 255. Sometimes at elections I vote for men about whom I know very little. 256. The only interesting part of newspapers is the "funnies." 257. I usually expect to succeed in things I do. 258. I believe there is a God. 259. I have difficulty in starting to do things. 260. I was a slow learner in school. 261. If I were an artist I would like to draw flowers. 262. It does not bother me that I am not better look- ing. 263. I sweat very easily even on cool days. GO ON TO THE NEXT PAGE 264. I am entirely self-confident. 265. It is safer to trust nobody. 266. Once a week or oftener I become very excited. 267. When in a group of people I have trouble thinking of the right things to talk about. 268. Something exciting will almost always pull me out of it when I am feeling low. 269. I can easily make other people afraid of me, and sometimes do for the fun of it. 270. When I leave home I do not worry about whether the door is locked and the windows closed. 271. I do not blame a person for taking advantage of someone who lays himself open to it. 272. At times I am all full of energy. 273. I have numbness in one or more regions of my skin. 274. My eyesight is as good as it has been for years. 275. Someone has control over my mind. 276. I enjoy children. 277. At times I have been so entertained by the cleverness of a crook that I have hoped he would get by with it. 278. I have often felt that strangers were looking at me critically. 279. I drink an unusually large amount of water every day. 280. Most people make friends because friends are likely to be useful to them. 281. I do not often notice my ears ringing or buzzing. 282. Once in a while I feel hate toward members of my family whom I usually love. 283. If I were a reporter I would very much like to report sporting news. 284. I am sure I am being talked about. 285. Once in a while I laugh at a dirty joke. 121 286. I am never happier than when alone. 287. I have very few fears compared to my friends. 288. I am troubled by attacks of nausea and vomit- ing. 289. I am always disgusted with the law when a criminal is freed through the arguments of a smart lawyer. 290. I work under a great deal of tension. 291. At one or more times in my life I felt that some- one was making me do things by hypnotizing me. 292. I am likely not to speak to people until they speak to me. 293. Someone has been trying to influence my mind. 294. I have never been in trouble with the law. 295. I liked "Alice in Wonderland" by Lewis Carroll 296. I have periods in which I feel unusually cheer- ful without any special reason. 297. I wish I were not bothered by thoughts about sex. 298. If several people find themselves in trouble, the best thing for them to do is to agree upon a story and stick to it. 299. I think that I feel more intensely than most people do. 300. There never was a time in my life when I liked to play with dolls. 301. Life is a strain for me much of the time. 302. I have never been in trouble because of my sex behavior. 303. I am so touchy on some subjects that I can't talk about them. 304. In school I found it very hard to talk before the class. 305. Even when I am with people I feel lonely much of the time. 306. I get all the sympathy I should. GO ON TO T H E NEXT PAGE 307. I refuse to play some games because I am not good at them. 308. At times I have very much wanted to leave home. 309. I seem to make friends about as quickly as others do. 310. My sex life is satisfactory. 311. During one period when I was a youngster I engaged in petty thievery. 312. I dislike having people about me. 313. The man who provides temptation by leaving valuable property unprotected is about as much to blame for its theft as the one who steals it. 314. Once in a while I think of things too bad to talk about. 315. I am sure I get a raw deal from life. 316. I think nearly anyone would tell a lie to keep out of trouble. 317. I am more sensitive than most other people. 318. My daily life is full of things that keep me interested. 319. Most people inwardly dislike putting them- selves out to help other people. 320. Many of my dreams are about sex matters. 321. I am easily embarrassed. 322. I worry over money and business. 323. I have had very peculiar and strange experi- ences. 324. I have never been in love with anyone. 325. The things that some of my family have done have frightened me. 326. At times I have fits of laughing and crying that I cannot control. 327. My mother or father often m< ,>e me obey even when I thought that it was unreasonable. 328. I find it hard to keep my mind on a task or job. 122 329. I almost never dream. 330. I have never been paralyzed or had any un- usual weakness of any of my muscles. 331. If people had not had it in for me I would have been much more successful. 332. Sometimes my voice leaves me or changes even though I have no cold. 333. No one seems to understand me. 334. Peculiar odors come to me at times. 335. I cannot keep my mind on one thing. 336. I easily become impatient with people. 337. I feel anxiety about something or someone almost all the time. 338. I have certainly had more than my share of things to worry about. 339. Most of the time I wish I were dead. 340. Sometimes I become so excited that I find it hard to get to sleep. 341. At times I hear so well it bothers me. 342. I forget right away what people say to me. 343. I usually have to stop and think before I act even in trifling matters. 344. Often I cross the street in order not to meet someone I see. 345. I often feel as if things were not real. 346. I have a habit of counting things that are not important such as bulbs on electric signs, and so forth. 347. I have no enemies who really wish to harm me. 348. I tend to be on my guard with people who are somewhat more friendly than I had expected. 349. I have strange and peculiar thoughts. 350. I hear strange things when I am alone. 351. I get anxious and upset when I have to make a short trip away from home. GO ON TO T H E NEXT PAGE 352. I have been air aid of things or people that I knew could not hurt me. 353. I have no dread of going into a room by myself where other people have already gathered and are talking. 354. I am afraid of using a knife or anything very sharp or pointed. 355. Sometimes I enjoy hurting persons I love. 356. I have more trouble concentrating than others seem to have. 357. I have several times given up doing a thing because I thought too little of my ability. 358. Bad words, often terrible words, come into my mind and I cannot get rid of them. 359. Sometimes some unimportant thought will run through my mind and bother me for days. 360. Almost every day something happens to frighten me. 361. I am inclined to take things hard. 362. I am more sensitive than most other people. 363. At times I have enjoyed being hurt by someone I loved. 364. People say insulting and vulgar things about me. 365. I feel uneasy indoors. 366. Even when I am with people I feel lonely much of the time. 367. I am not afraid of fire. 368. I have sometimes stayed away from another person because I feared doing or saying some- thing that I might regret afterwards. 369. Religion gives me no worry. 370. I hate to have to rush when working. 371. I am not unusually self-conscious. 372. I tend to be interested in several different hob- bies rather than to stick to one of them for a long time. 123 • 373. I feel sure that there is only one true religion. 374. At periods my mind seems to work more slowly than usual. 375. When I am feeling very happy and active, someone who is blue or low will spoil it all. 376. Policemen are usually honest. 377. At parties I am more likely to sit by myself or with just one other person than to join in with the crowd. 378. I do not like to see women smoke. 379. I very seldom have spells oi the blues. 380. When someone says silly or ignorant things about something I know about, I try to set him right. 381. I am often said to be hotheaded. 382. I wish I could get over worrying about things I have said that may have injured other peo- ple's feelings. 383. People often disappoint me. 384. I feel unable to tell anyone all about myself. 385. lightning is one of my fears. 386. I like to keep people guessing what I'm going to do next. 387. The only miracles I know of are simply tricks that people play on one another. 388. I am afraid to be alone in the dark. 389. My plans have frequently seemed so full oi difficulties that I have had to give them up. 390. I have often felt badly over being misunder- stood when trying to keep someone from mak- ing a mistake. 391. I love to go to dances. 392. A windstorm terrifies me. 393. Horses that don't pull should be beaten or kicked. 394. I frequently ask people for advice. GO ON TO THE NEXT PAGE 395. The future is too uncertain for a person to make serious plans. 396. Often, even though everything is going fine for me, I feel that I don't care about anything. 397. I have sometimes felt that difficulties were pil- ing up so high that I could not overcome them. 398. I often think. "I wish I were a child again." 399. I am not easily angered. 400. If given the chance I could do some things that would be of great benefit to the world. 401. I have no fear of water. 402. I often must sleep over a matter before I decide what to do. 403. It is great to be living in these times when so much is going on. 404. People have often misunderstood my intentions when I was trying to put them right and be helpful 405. I have no trouble swallowing. 406. I have often met people who were supposed to be experts who were no better than I. 407. I am usually calm and not easily upset. 408. I am apt to hide my feelings in some things, to the point that people may hurt me without their knowing about it. 409. At times I have worn myself out by undertak- ing too much. 410. I would certainly enjoy beating a crook at his own game. 411. It makes me feel like a failure when I hear of the success of someone I know well. 412. I do not dread seeing a doctor about a sickness or injury. 413. I deserve severe punishment for my sins. 414. I am apt to take disappointments so keenly that I can't put them out of my mind. 124 415. If given the chance I would make a good lead- er of people. 416. It bothers me to have someone watch me at work even though I know I can do it well. 417. I am often so annoyed when someone tries to get ahead of me in a line of people that I speak to him about it. 418. At times I think I am no good at all 419. I played hooky from school quite often as a youngster. 420. I have had some very unusual religious ex- periences. 421. One or more members of my family is very nervous. 422. I have felt embarrassed over the type of work that one or more members of my family have done. 423. I like or have liked fishing very much. 424. I feel hungry almost all the time. 425. I dream frequently. 426. I have at times had to be rough with people who were rude or annoying. 427. I am embarrassed by dirty stories. 428. I like to read newspaper editorials. 429. I like to attend lectures on serious subjects. 430. I am attracted by members of the opposite sex. 431. I worry quite a bit over possible misfortunes. 432. I have strong political opinions. 433. I used to have imaginary companions. " 434. I would like to be an auto racer. 435. Usually I would prefer to work with women. 436. People generally demand more respect for their own rights than they are willing to allow for others. GO ON TO THE NEXT PAGE 437. It ia all right to get around the law ii you don't actually break it. 438. There are certain people whom I dislike so much that I am inwardly pleased when they are catching it for something they have done. 439. It makes me nervous to have to wait. 440. I try to remember good stories to pass them on to other people. 441. I like tall women. 442. I have had periods in which I lost sleep over worry. 443. I am apt to pass up something I want to do because others feel that I am not going about it in the right way. 444. I do not try to correct people who express an ignorant belief. 445. I was fond oi excitement when I was young (or in childhood). 446. I enjoy gambling for small stakes. 447. I am often inclined to go out of my way to win a point with someone who has opposed me. 448. I am bothered by people outside, on streetcars, in stores, etc., watching me. 449. I enjoy social gatherings just to be with people. 450. I enjoy the excitement of a crowd. 451. My worries seem to disappear when I get into a crowd oi lively friends. 452. I like to poke fun at people. 453. When I was a child I didn't care to be a mem- ber of a crowd or gang. 454. I could be happy living all alone in a cabin in the woods or mountains. 455. I am quite often not in on the gossip and talk of the group I belong to. 456. A person shouldn't be punished for breaking a law that he thinks is unreasonable. 125 457. I believe that a person should never taste an alcoholic drink. 458. The man who had most to do with me when I was a child (such as my father, stepfather, etc.) was very strict with me. 459. I have one or more bad habits which are so strong that it is no use in fighting against them. 460. I have used alcohol moderately (or not at all). 461. I find it hard to set aside a task that I hare undertaken, even for a short time. 462. I have had no difficulty starting or holding my urine. 463. I used to like hopscotch. 464. I have never seen a vision. 465. I have several times had a change oi heart about my life work. 466. Except by a doctor's orders I never take drugs or sleeping powders. 467. I often memorize numbers that are not im- portant (such as automobile licenses, etc.). 468. I am often sorry because I am so cross and grouchy. 469. I have often found people jealous oi my good ideas, just because they had not thought oi them first. 470. Sexual things disgust me. 471. In school my marks in deportment were quite regularly bad. 472. I am fascinated by fire. 473. Whenever possible I avoid being in a crowd. 474. I have to urinate no more often than others. 475. When I am cornered I tell that portion oi the truth which is not likely to hurt me. 476. I am a special agent oi God. 477. Ii I were in trouble with several friends who were equally to blame. I would rather take the whole blame than to give them away. GO ON TO T H E NEXT PAGE 478. I have never been made especially nervous over trouble that any members oi my family have gotten into. 479. I do not mind meeting strangers. 480. I am often afraid of the dark. 481. I can remember "playing sick" to get out of something. 482. While in trains, busses, etc., I often talk to strangers. 483. Christ performed miracles such as changing water into wine. 484. I have one or more faults which are so big that it seems better to accept them and try to control them rather than to try to get rid of them. 485. When a man is with a woman he is usually thinking about things related to her sex. 486. I have never noticed any blood in my urine. 487. I feel like giving up quickly when things go wrong. 488. I pray several times every week. 489. I feel sympathetic towards people who tend to hang on to their griefs and troubles. 490. I read in the Bible several times a week. 491. I have no patience with people who believe there is only one true religion. 492. I dread the thought of an earthquake. 493. I prefer work which requires close attention, to work which allows me to be careless. 494. I am afraid of finding myself in a closet or small closed place. 495. I usually "lay my cards on the table" with peo- ple that I am trying to correct or improve. 496. I have never seen things doubled (that is, an object never looks like two objects to me with- out my being able to make it look like one object). 126 497. I enjoy stories of adventure. 498. It is always a good thing to be frank. 499. I must admit that I have at times been worried beyond reason over something that really did not matter. 500. I readily become one hundred per cent sold on a good idea. 501. I usually work things out for myself rather than get someone to show me how. 502. I like to let people know where I stand on things. 503. It is unusual for me to express strong approval or disapproval of the actions of others. 504. I do not try to cover up my poor opinion or pity of a person so that he won't know how I feel. 505. I have had periods when I felt so full of pep that sleep did not seem necessary for days at a time. 506. I am a high-strung person. 507. I have frequently worked under people who seem to have things arranged so that they get credit for good work but are able to pass off mistakes onto those under them. 508. I believe my sense of smell is as good as other people's. 509. I sometimes find it hard to stick up for my rights because I am so reserved. 510. Dirt frightens or disgusts me. 511. I have a daydream life about which I do not tell other people. 512. I dislike to take a bath. 513. I think Lincoln was greater than Washington. 514. I like mannish women. 515. In my home we have always had the ordinary necessities (such as enough food, clothing, etc.). 516. Some of my family have quick tempers. GO ON TO T H E NEXT PAGE 517. I cannot do anything well. 518. I have often felt guilty because I have pre- tended to feel more sorry about something than I really was. 519. There is something wrong with my sex organs. 520. I strongly defend my own opinions as a rule. 521. In a group of people I would not be embar- rassed to be called upon to start a discussion or give an opinion about something I know well. 522. I have no fear of spiders. 523. I practically never blush. 524. I am not afraid of picking up a disease or germs from door knobs. 525. I am made nervous by certain animals. 526. The future seems hopeless to me. 527. The members of my family and my close rela- tives get along quite well. 528. I blush no more often than others. 529. I would like to wear expensive clothes. 530. I am often afraid that I am going to blush. 531. People can pretty easily change me even though I thought that my mind was already made up on a subject. 532. I can stand as much pain as others can. 533. I am not bothered by a great deal of belching of gas from my stomach. 534. Several times I have been the last to give up trying to do a thing. 535. My mouth feels dry almost all the time. 127 536. It makes me angry to have people hurry me. 537. I would like to hunt lions in Africa. 538. I think I would like the work of a dressmaker. 539. I am not afraid of mice. 540. My face has never been paralyzed. 541. My skin seems to be.unusually sensitive to touch. 542. I have never had any black, tarry-looking bowel movements. 543. Several times a week I feel as if something dreadful is about to happen. 544. I feel tired a good deal of the time. 545. Sometimes I have the same dream over and over. 546. I like to read about history. 547. I like parties and socials. 548. I never attend a sexy show ii I can avoid it. 549. I shrink from facing a crisis or difficulty. 550. I like repairing a door latch. 551. Sometimes I am sure that other people can tell what I am thinking. 552. I like to read about science. 553. I am afraid of being alone in a wide-open place. 554. If I were an artist I would like to draw children. 555. I sometimes feel that I am about to go to pieces. GO ON TO T H E NEXT PAGE 556. I can very careful about my manner of dress. 557. I would like to be a private secretary. 558. A large number of people are guilty of bad sexual conduct. 559. I have often been frightened in the middle of the night. 560. I am greatly bothered by forgetting where I put things. 561. I very much like horseback riding. "' 128 562. The one to whom I was most attached and whom I most admired as a child was a woman. (Mother, sister, aunt, or other woman.) 563. I like adventure stories better than romantic stories. 564. I am apt to pass up something I want to d< when others feel that it isn't worth doing. 565. I feel like jumping off when I am on a big! place. 566. I like movie love scenes. 129 APPENDIX E Tennessee Self-Concept Scale W.H. F i t t s Western Psychological Services, C a l i f . , 1964. Completely False Mostly False Partly False and Partly True Mostly True Completely True 1 2 3 4 5 Item No. 1. I have a healthy body 1_ 3. I a m an attract ive person • 3 5. I cons ide r mysel f a s loppy person 5 19. I a m a decen t sort of person 19 2 1 . I a m an honest person 21 2 3 . I a m a bad person 23 37 . I a m a cheer fu l person 37 39 . I a m a c a l m and easygo ing person • 39 4 1 . I a m a nobody 4 1 55 . I have a fami ly that wou ld always he lp m e in any k ind of t rouble 55 57 . I a m a m e m b e r of a happy fami ly 57 59 . My f r iends have no con f i dence in me 59 73 . I a m a f r iendly person • 73 75 . I a m popu la r with m e n • 7 5 77 . I a m not interested in what other people do 77 9 1 . I do not always tell the truth 91 9 3 . I get angry s o m e t i m e s • 93 1 2. 4. 6. 20 . 22 . 24. 38 . 40 . 42 . 56 . 58 . 60 . 74 . 76 . Completely False Mostly False Partly False and Partly True Mostly True Completely True 1 2 3 4 5 131 Item No. l ike to look n ice and neat all the t ime a m ful l of aches and pa ins 4 ' -.: a m a s ick person ,* 6 - - ^ a m a rel ig ious person 2Q:£t a m a mora l fa i lure . . . 2 2 ' | & $ a m a moral ly weak person 24£;:yg have a lot of sel f -control 3 8 v a m a hateful person 4 0 a m los ing my m ind 4 2 " ^ a m an important person to my f r iends and fami ly . 5 6 a m not loved by my fami ly feel that my fami ly doesn ' t t rust me a m popu lar with w o m e n a m m a d at the whole world 78 . I a m hard to be fr iendly with 92 . O n c e in a whi le I th ink of th ings too bad to talk about 94 . Some t imes , when I a m not fee l ing wel l , I a m c ross 2 6 o i g i i & 7 6 § l S i I f 9 2 l i i l . 9 4 Completely False Mostly False Partly False and Partly True Mostly True Completely True 1 2 3 4 5 Item No. 7. I a m nei ther too fat nor too thin 7_ 9. I l ike my looks just the way they are 9_ 11. I wou ld l ike to change s o m e parts of my body 11 25 . I a m sat is f ied with my mora l behavior 2 5 27 . I a m sat is f ied with my re lat ionship to G o d 27 29 . I ought to go to c h u r c h more 29 4 3 . I a m sat is f ied to be just what I a m 4 3 4 5 . I a m just as n ice as I shou ld be 4 5 4 7 . I desp i se myse l f 47 6 1 . I a m sat is f ied with my fami ly re la t ionships 61 63 . I unders tand my fami ly as well as I shou ld 63 65 . I shou ld trust my fami ly more 6 5 79 . I a m as soc iab le as I want to be 79 8 1 . I try to p lease others, but don't overdo it 81 8 3 . I a m no good at al l f rom a soc ia l s tandpoin t 8 3 9 5 . I do not l ike everyone I know 95 97 . O n c e in a whi le, I laugh at a dirty joke 97 3 8. 10. 12. 26 . 28 . 3 0 . 44 . 46 . 48 . 62 . 64. 66 . 80 . 82 . 84 . Completely False Mostly False Partly False and Partly True Mostly True Completely True 1 2 3 4 5 133 Item No. a m neither too tall nor too short don' t feel as well as I shou ld . . . shou ld have more sex appea l . . a m as rel ig ious as I want to be . •:,v 10:. any, •.y:li^-\yfij^-.~p. . § i 2 S i i i ! wish I cou ld be more trustworthy ^ 2 8 v ; « - * shou ldn ' t tel l so many l ies a m as smar t as I want to be a m not the person I would l ike to b e . wish I d idn' t give up as easi ly as I do . i 3 0 £ ® f t § treat my parents as well as I shou ld (Use past tense if parents are not l i v i n g ) ^ 6 2 ^ § | j i | a m too sensi t ive to th ings my fami ly says shou ld love my fami ly more 266 •-' a m sat is f ied with the way I treat other people | 8 0 ; ^ ^ ^ shou ld be more poli te to others ought to get a long better with other people 84- :;- 96 . I goss ip a little at t imes ,96 y U ^ . 98 . At t imes I feel l ike swear ing 4 9 8 134 Completely False Mostly False Partly False and Partly True Mostly True Completely True 1 2 3 4 5 Item No. 13. I take good care of mysel f phys ica l ly 13 15. I try to be carefu l about my appea rance 15 17. I often act l ike I a m "al l t h u m b s " 17 3 1 . I a m true to my rel igion in my everyday life 31 33 . I try to change when I know I'm do ing th ings that are wrong 3 3 35 . I s o m e t i m e s do very bad th ings 3 5 4 9 . I can a lways take care of myse l f in any s i tuat ion 4 9 5 1 . I take the b lame for th ings without gett ing m a d 51 5 3 . I do th ings without th ink ing about t h e m first 53 67 . I try to play fair with my f r iends and fami ly 6 7 69 . I take a real interest in my fami ly 69 7 1 . I give in to my parents (Use past tense if parents are not l iving) 71 1 85 . I try to unders tand the other fel low's point of view 85 87 . I get a long wel l with other people 87 89 . I do not forgive others easi ly 89 99 . I wou ld rather win than lose in a g a m e 99 5 Completely False Mostly False Partly False and Partly True Mostly True Completely True 1 2 3 4 5 135 Item No. feel good most of the t ime *14 do poorly in sports and g a m e s g!6 a m a poor s leeper |̂l8 « do what is right most of the t ime |32 some t imes use unfai r m e a n s to get ahead J34 have t rouble do ing the th ings that are right solve my p rob lems qui te easi ly , change my m ind a lot try to run away f rom my p rob lems do my share of work at home quarre l with my fami ly do not act l ike my fami ly th inks I shou ld :'• ,68*' see good points in al l the people I meet *.86:/f-r.* do not feel at ease with other people 88 9 0 . I f ind it hard to talk with s t rangers 9 0 100. Once in a whi le I put off unti l tomorrow what I ought to do today . 1 0 0 6 136 APPENDIX F P r o f i l e of Mood States D.M. McNair, M. Lorr & L.F. Droppleman Educational and Industrial Testing Service, C a l i f . , 1971. 137 Below is a list of words that describe feelings people have. Please read each one carefully. Than fill in ONE circle under the answer to the right which best describes HOW YOU HAVE BEEN FEELING DURING THE PAST WEEK INCLUDING TODAY. The numbers refer to these phrases. 0 = Not at all 1 = A little 2 = Moderately 3 = Quite a bit 4 = Extremely Col -.C! O.P. (5) 3 i t s 5 H s I 2 2 fc o S £ ° J 2 2 « z < a o UJ 21. Hopeless ® © 0 ® : 0 ' 22. Relaxed ® 0 ® ® ® i .„ ; * 5 - 2 i < 5 Z < 2 O J J 45. Desperate 0 ' 5 3 4 46. Sluggish ° ' 2 '3. J > - J U H > < « < ; s *- -* * r. * b a Z £ o -> o a E z < a o iu 1. Friendly ® 0 ® 0 0 2. Tense 0 0 ® ® ' ® 23. Unworthy ® Q ® ® ® 24. Spiteful ® © ® ® ® 47. Rebellious S .'. 2 V 0 48. Helpless '? ?• ?• » 25. Sympathetic ® 0 ® ® 0 ; 26. Uneasy ® 0 ® @ ® 49. Weary ' 3 3 4 50. Bewildered ° ' - 1 4 3. Angry ® 0 S ® ® 4. Worn out ® ® ® 0 ® 27. Restless ® 0 ® @ ® 28. Unable to concentrate ® 0 @ ® ® 51. Alert 0 '. 2 I- f. 52. Deceived 0 I 2 .1= 5. Unhappy ® ® 0 ® ® 6. Clear-headed 0 0 0 0 0 29. Fatigued ® 0 ® @ ® 30. Helpful . ® 0 ® ® ® 53. Furious A »* 2 3 54. Efficient '. ' 2 ' 4 8. Confused 0 ' . . ! . ;®®® 31Annoyed @ 0 ® ® ® 32. Discouraged ® 0 ® ® 0 55. Trusting ° *. 56. Full of pep - 2 3 4 9. Sorry for things done . si' '.V 'A' 10. Shaky 5 0 0 ; ® ® 33. Resentful ® 0 ® S ® 34. Nervous ® 0 ® ' 0 ® 57. Bad-tempered J ' 1 3 4 58. Worthless 0 ' 2 3 » 11. Listless ° 0 ® ®-® 12. Peeved .•< '.L '.«.';»; 0 35. Lonely ® 0 ® ® ® 36. Miserable 0 0 0 0 ® 59. Forgetful 5 ' 2 3 4 60. Carefree • ' 2 3 4 13. Considerate t l ^ 0 0 ' 14. Sad 0 '1 0 0 ® ' 37. Muddled 0 0 0 0 ® 38. Cheerful ® 0 0 0 0 ; 61. Terrified 0 • 2 3 4 62. Guilty • ; 2 3 4 15. Active ?.• f '«.' -A' 16. On edge 0 A .1 'A 39. Bitter 0 0 0 0 0 40. Exhausted 0 0 0 0 0 63. Vigorous 2 3 4 64. Uncertain about things . . ? 1 5 3 ' 17. Grouchy £ ? 1 i 18. Slue 3 '.' 'V >' A' 41. Anxious ® 0 0 © 0 42. Ready to fight . . . . 0 0 0 0 ® 65. Bushed 0 ' 2 3 4 MAKE SURE YOU HAVE ANSWERED EVERY ITEM. ĵ̂ > POM 021 19. Energetic 0 '.. V'?. t 20 PanicKv 0 ' 2 3 4 43. Good natured 0 0 0 ® 0 44. Gloomy ® 0 0 3 ' POMS COPVRiGnT •" 197 EziTS Eci-cationai ana Inausina! Tesnng Service, San Diego, CA 92107. Reoroauciion o* this tojrr. any ^neâ s sinewy Drzr.-oKS'z. 138 APPENDIX G Subjective Stress Inventory Stress Experience 139 Dr. Du-Fay Der Dept. of C o u n s e l l i n g Psychology U . B . C . How much s t r e s s / a n x i e t y do you experience as a r e s u l t of the f o l l o w i n g : Low High 1. ro.l.uUionali 11> wlLh M pun HI.' 1 2 J 4 5 2. r e l a t i o n s h i p w i t h c h i l d r e n 1 2 3 4 5 3,. i n t e r a c t i o n w i t h co-workers 1 2 3 4 5 4. i n t e r a c t i o n w i t h f r i ends 1 2 3 4 5 5. going out on nub i l e (shopping, e tc) 1 2 3 4 5 6.. going to the Doctor 1 2 3 4 5 7. go in^ to the t he r ap i s t 1 2 3 4 5 8. consuming/eat ing 1 2 3 4 5 9. before menstrual pe r iod 1 2 3 4 5 10. du r ing menstrual pe r iod 1 2 3 4 5 11. du r ing o v u l a t i o n 1 2 3 4 5 12. going to s leep 1 2 3 4 5 13. amount of s leep 1 2 3 4 5 14. a n t i c i p a t i n g commencement of job 1 2 3 4 5 15. housework 1 2 3 4 5 16. change i n weight ( g a i n / l o s t ) 1 2 3 4 5 17. t a k i n g medica t ion 1 2 3 4 5 18. money matters 1 2 3 4 5 19. marriage 1 2 3 4 5 20. minor i l l n e s s 1 2 3 4 5 21. change i n e a t i ng hab i t s 1 2 3 4 5 22. change i n s l e e p i n g hab i t 1 2 3 4 5 23. s o c i a l gather ings 1 2 3 4 5 140 APPENDIX H Physiological Symptoms Scale Physiological Symptoms 141 Dr. Du-Fay Der Dept. of Counselling Psychology U.B.C. To what extent have the following symptoms been present: 1. Dyspnea ( d i f f i c u l t y breathing) 1 2 3 verv muc 4 5 2. Palpitations 4 5 3. Vertigo 4 5 4. Paresthesias (pins & needles) 4 5 5. Sweating 6. Faintness 4 5 4 5 7. Trembling/Shaking 4 5 8. Fear of Dying/Going Crazy 4 5 APPENDIX I Minnesota Multiphasic Personality Inventory Pro Pre-therapy, post-therapy and follow-up 1A3 MINNESOTA MULTIPHASIC PERSONALITY INVENTORY Compu te r G e n e r a t e d R e p o r t M. 0 . ANGUS & A s s o c i a t e s L i m i t e d . Pre-therapy Name: A g e : 40" S e x : FEMALE D A T E : G r a p h o f K - C o r r e c t e d T S c o r e s sssssssBnasaasasssaaasaaBsaaaBo: 10 20 Raw<+ K) 1 1 14 13 31 42 45 31 33 17 47 53 23 35 TK / S c a l e 41 ? 40 L 76 f 51 K 87 HS (1) 94 D (2) 36 HY 79 PD 45 MF <3) 76 PA (6) 86 PT (7) 97 SC (8) 65 MA (9) 62 S I <0> 30 40 + +- + -t— + <3) (4) + + + +- + (SCALES 1 , 4 , 7 , 3 & 9 WERE K CORRECTED) :ssss=:s3S03SSBSBa=sasensss==ss=ss=ssss=ss= 50 60 70 80 90 100 110 120 -+ 1 + 1 + + + + + XXXXX I + + + -+ 1 + 1 + 1- + + + XXXXXZ I + + + •I + 1- XXXXXXXXXXXXXX + -I + 1 + +- XX I + •I + 1- + + XXXXXXXXXXXXXXXXXXXX+ — I + 1 + +- + + ssasaaassasssmnaBnaBasfi WELSH CODE: G r a p h o f Non K - C o r r e c t e d T S c o r e s , • Raw S c o r e 1 1 14 13 ** 24 42 45 26 33 17 34 40 20 33 XXXXXXXXXXXXXXXXXXXXX-XX + + XXXXXXXXXXXXXXXXXXXXXXXX + + XXXXXXXXXXXXXXXX + + + XXX I _ _ + + + XXXXXXXXXXXXXX + + + XXXXXXXXXXXXXXXXXXX + + + XXXXXXXXXXXXXXXXXXXXXXXXX + + XXXXXXXXX I + + + +- 1 + 1 + + + + XXXXXXX I + + + iBsssssssssassesssesaaassssssasssxssssssssssscssssassssssssssssssaBasassss isss 8 3 2 * 1 7 " 4 6 ' 3 0 - / 5 : # F ' - K / ? L : # <*• DENOTES SCALE USUALLY K CORRECTED) '—S3 assess: 30 40 saassBSfioscss The a n a l y s i s and i n t e r p r e t a t g i v e n a b o v e . I t may no t a p p l y i f R e s e a r c h s c a l e s w h i c h f o l l o w 50 1 — XXXXX 60 •I- 70 —+ 1 — I I 80 90 100 110 120 XXXXXX XXXXXXXXXXXXXX XX I - t 1 + 1-XXXXXXXXXXXXXXXXX + + + XXXXXXXXXXXXXXXXXXXXXXX + + XXXXXXXXXXXXXXXXXXXXXXXX + + XXXXXXXXXXXXXXXX + + + + 1 + 1 + + + + + XXX I + + + + 1 + 1 + + + + + XXXXXXXXXXXXXX + + + + 1 + 1 + + + + + xxxxxxxxxxxxxxx + + + + 1 + 1 + + + -I- + XXXXXXXXXXXXXXXXXXXX+ + + + 1 + 1 + + + + + XXXXXXXX I + + + + 1 + 1 + + + + + XXXXXXX I + + + + 1 + 1 + + + + + :assssstBasaasaasaBaesa=sssaassjaass=B=s=S5=s3sss a s s e s s i n g c a u t i o n . on b e l o w i s based on t h e K-CORRECTED p r o f i l e an e l e v a t e d K s c o r e o b t a i n e d . he i n t e r p r e t a t i o n may o r may no t be u s e f u l f o r a p a r t i c u l a r c l i e n t ' s p r o f i l e . They s h o u l d be used w i t h e x t r e m e 144 MINNEBOTR_MULTIPHASIC PERSONALITY INVENTORY Compu te r G e n e r a t e d R e p o r t M . 0 . ANGUS & A s s o c i a t e s L i m i t e d . . Post-therapy Name: A g e : S e x : FEMALE DATE: Graph o f K - C o r r e c t e d T S c o r e s Raw< + KT TK 7 S c a l e ~ 1 0 ~ 2 0 30 (SCALES__1 1 ̂ 7 1 8 _ 4_3_WERE K CORRECTED^ 4 « i a l a 70 I 0 i a - Tea Tia 120 •1- 0 & 5 22 13 19 28 32 39 10 £ 6 28 20 19 41 ? 56 L 55 F 68 K 50 HS 49 D 66 HY 81 PD 45 MF 56 PA 51 PT 58 SC 58 MA 44 S I +- + XXXXX •I- (1) (2) (3) <4) (5) (6) (7) (8) (9) (0) + XXXX -1 + XXXX -1 + xxxxxxxxxx -1 + X -1 + X •I- + -+ + + + +- + xxxxxxxxx •I-xxxxxxxxxxxxxxxxx •I-+ +- + XXX — I XXXX — I X X + + + •I- XXX •I- XXXXX •I- + + -+ + -+ + WELSH CODE: Graph o f Non K - C o r r e c t e d T S c o r e s Raw S c o r e T / S c a l e 10 20 30 XXXX +----J_ +~1 4 " ' 3 - 9 8 6 7 1 / 2 5 0 : # K — L F / ? :# 40 1** 5 1 N ° I E S sS-h- ufy?4rY 50 60 70 80 ~90~ •I- XXXXX •I- K C O R R E C T E D 100 110 1 2 0 ** ** a 6 5 22 19 28 23 39 10 4 6 16 19 41 ? 56 L 55 F 68 K 41 HS (1) 49 D (2) 66 HY (3) 73 PD (4) 45 MF (5) 56 PA (6) 38 PT (7) 44 SC <S> 54 MA (9) 44 S I (0) +- + XXXX •I-XXXX •I- H— + XXXXX t- 1 - XXXXXXXXXX •I- -1 + XXXXXXXXX •I- xxxxxxxxxxxxx . I K " + + XXX •I-XXXX —+ 1 XXXXXXX •I- XXXX 1 — XXX •I- + + + + +- XXXX 1- The a n a l y s i s and i n t e r p r e t a t g i v e n a b o v e . I t may not a p p l y i f R e s e a r c h s c a l e s w h i c h f o l l o w a s s e s s i n g a p a r t i c u l a r c l i e n t ' s p r o f i l e c a u t i o n . on b e l o w i s based on t h e K-CORRECTED an e l e v a t e d K s c o r e o b t a i n e d . p r o f i l e he i n t e r p r e t a t i o n may o r may not be u s e f u l f o r They s h o u l d be used w i t h e x t r e m e 145 MINNESOTA MULTIPHASIC PERSONALITY_INVENTORY Compute r G e n e r a t e d R e p o r t M . D . ANGUS & A s s o c i a t e s L i m i t e d . Graph o f K - C o r r e c t e d T S c o r e s Follow-up Name: . A g e : 40 S e x : FEMALE D A T E : (SCALES 1 , 4 , 7 , 8 & 9 WERE K CORRECTED) Raw(+ K) 0 1 41 5 1 53 5 1 53 IS 1 62 14 1 52 18 1 47 23 1 61 27 1 69 41 1 .41 13 1 63 25 1 50 25 1 54 17 1 50 22 1 47 TK / S c a l e ? L F 5 (1) (2) 10 20 30 + + +- (7) (0) + + — + 40 50 XXXXX 60 70 80 90 100 110 120 XXX XXXX XXXXXXX -f.— XX + X X XXXXX XX XXXXXXX xxxxxxxxxxz xxxxxxxxx XXX WELSH CODE: ssaasBBaaanafisaansBSBBD: 4 6 3 - 8 1 9 7 / 0 2 5 : # K - F L / ? : # Graph o f Non K - C o r r e c t e d T S c o r e s ( •* DENOTES SCALE USUALLY K CORRECTED) Raw S c o r e T / S c a l e 10 20 30 *» ** 0 5 5 19 4 18 25 19 41 13 6 6 13 22 41 ? 53 L 55 F 62 K 45 HS (1) 47 D (2) 61 HY (3) 63 PD (4) 41 MF (5) 65 PA 41 PT 44 SC + +- +- + +- (6) (7) (8) 48 MA (9) 47 S I <0> The a n a l y s i s and i n t e r p r e t a t g i v e n a b o v e . I t may n o t a p p l y i f R e s e a r c h s c a l e s w h i c h f o l l o w a s s e s s i n g a p a r t i c u l a r c l i e n t ' s p r o f i l e , c a u t i o n . 40 50 60 70 80 XXXXX XXX •I- XXXX XXXXXXX XXX XX . I +— XXXXXXX •I-xxxxx •I- •I- xxxxxxxx XXXXX t- 1 - XXXX • 1 - XX f 1 - XX Y I - xxxxxxxxx •I- 90 100 110 + 120 + + + + + + on b e l o w i s based on t h e K-CORRECTED p r o f i l e an e l e v a t e d K s c o r e o b t a i n e d . he i n t e r p r e t a t i o n may o r may not be u s e f u l f o r They s h o u l d be used w i t h e x t r e m e

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