UBC Theses and Dissertations

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UBC Theses and Dissertations

Development and evaluation of an affective problem solving program for chronic psychiatric patients Malkin, Pamela Cramond 1984

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DEVELOPMENT AND EVALUATION OF AN A F F E C T I V E PROBLEM SOLVING PROGRAM FOR CHRONIC PSYCHIATRIC PATIENTS by PAMELA CRAMOND MALKIN M.A., UNIVERSITY OF B R I T I S H COLUMBIA, 1972 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE O F -DOCTOR OF EDUCATION i n THE FACULTY OF GRADUATE STUDIES ( D e p a r t m e n t o f C o u n s e l l i n g P s y c h o l o g y ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA J u l y , 1984 ©Pamela Cramond M a l k i n , 1984 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department or by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t copying o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . nt of £2cTiL^V^t-l LtvMj ~ ( " ^ | C IK.SLOC^ Departme The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date i i : S u p e r v i s o r : D r . L e s l i e G r e e n b e r g A b s t r a c t A p p a r e n t m a l a d j u s t m e n t i n t h e l o w e r p r o g n o s i s p a t i e n t who s u f f e r s g r a v e p s y c h i a t r i c d i f f i c u l t i e s a n d f r e q u e n t l y i s h o s p i t a l i z e d may be due t o a l a c k o f a v a i l a b i l i t y o f r e l e v a n t P r o b l e m - S o l v i n g s t r a t e g i e s . R e c e n t d e v e l o p m e n t s i n c o g n i t i v e -b e h a v i o u r a l p r o g r a m s d e s i g n e d t o e n h a n c e a c q u i s i t i o n s o f P r o b l e m -S o l v i n g s k i l l s s u c h a s I n t e r p e r s o n a l C o g n i t i v e P r o b l e m - S o l v i n g S k i l l s T r a i n i n g ( I C P S ) h a v e been d i r e c t e d w i t h some s u c c e s s t o w a r d s t h e c h r o n i c p s y c h i a t r i c p a t i e n t p o p u l a t i o n . ( S i e g e l a n d S p i v a c k , 1 9 7 6 ) . However, many o f t h e s e c o g n i t i v e l y - o r i e n t e d p r o g r a m s may n o t be r e c o g n i z i n g t h e f u l l r a n g e o f s k i l l d e f i c i t s t h a t a r e s o commonly a s s o c i a t e d w i t h t h e p o o r e r p r o g n o s i s p a t i e n t . F a c t o r s s u c h a s m i s c o n c e p t i o n s a b o u t t h e n a t u r e o f t r e a t m e n t , p a t i e n t e x t e r n a l i z a t i o n o f p r o b l e m s , i n a b i l i t y t o r e c o g n i z e a n d d e f i n e p r o b l e m s o f an i n t r a p s y c h i c n a t u r e a n d l a c k o f r e f l e c t i o n i n d e c i s i o n - m a k i n g a r e common c h a r a c t e r i s t i c s o f t h e l ow p r o g n o s i s , l o w e r s o c i o - e c o n o m i c p a t i e n t who e n t e r s t r e a t m e n t . F u r t h e r , c u r r e n t ICPS t r a i n i n g m o d e l s p r o m o t e a l o c k -s t e p , s e q u e n c e d P r o b l e m - S o l v i n g p r o c e s s t h a t may n o t be f a m i l i a r o r m e a n i n g f u l t o t h i s p a t i e n t g r o u p . I C P S t r a i n i n g p r o g r a m s d i r e c t e d a t c h r o n i c p s y c h i a t r i c p a t i e n t s may a l s o l a c k t h e e m p h a s i s o n - p r o b l e m r e c o g n i t i o n a n d a c c u r a t e p r o b l e m d e f i n i t i o n , may f a i l t o t e a c h s p e c i f i c i t y a n d c o n c r e t e n e s s i n p r o b l e m e x p r e s s i o n , may i g n o r e t h e m i n i m a l l e v e l s o f a f f e c t i v e v o c a b u l a r y o f t h e l o w e r p r o g n o s i s p a t i e n t and i g n o r e t h e i m p o r t a n c e o f " d i s c o v e r y m e t h o d s " a n d s e a r c h s t r a t e g i e s i n e m o t i o n a l P r o b l e m -S o l v i n g . I n t h i s r e s e a r c h , an e m o t i o n a l P r o b l e m - S o l v i n g t r a i n i n g p r o g r a m b a s e d on c l i e n t - c e n t e r e d t h e o r y , t h e P r o c e s s O r i e n t a t i o n P r o c e d u r e ( P O P ) , was d e v e l o p e d a n d c o m p a r e d t o a t r a d i t i o n a l ICPS (PS) t r a i n i n g p r o g r a m . The POP f o c u s e s p r i m a r i l y upon a f f e c t , a t t e n t i o n t o p r o c e s s and a more g e n e r a l P r o b l e m - S o l v i n g o r i e n t a t i o n w h e r e a s t h e PS p r o g r a m t o w h i c h i t was c o m p a r e d f o c u s e s on c o g n i t i o n s and s e q u e n t i a l s t e p s i n P r o b l e m - S o l v i n g . T h e s e two p r o g r a m s were f i e l d t e s t e d w i t h a s a m p l e o f 73 c h r o n i c m a l e and f e m a l e h o s p i t a l i z e d p s y c h i a t r i c p a t i e n t s , a p o p u l a t i o n t h a t h a s been t r a d i t i o n a l l y v i e w e d a s h a v i n g a h i g h p r o b a b i l i t y o f r e l a p s e a n d a s r e s i s t a n t t o c h a n g e . F i v e w a r d s o f c h r o n i c p s y c h i a t r i c c a r e f a c i l i t y ( C r e a s e U n i t , R i v e r v i e w P r o v i n c i a l M e n t a l H o s p i t a l , C o q u i t l a m , B.C., C a n a d a ) , were u t i l i z e d i n a t w o - b y - f i v e ( t r e a t m e n t - b y - w a r d / t h e r a p i s t ) f u l l y c r o s s e d f a c t o r i a l d e s i g n . M e a s u r e s o f f o c u s i n g a b i l i t y ( t h e P o s t - F o c u s i n g Q u e s t i o n a i r e a n d t h e P o s t - F o c u s i n g C h e c k l i s t ) , means-ends p r o b l e m - s o l v i n g a b i l i t y ( t h e M e a n s-Ends P r o b l e m - S o l v i n g P r o c e d u r e ) , a n x i e t y ( t h e STATE a n d T r a i t A n x i e t y I n v e n t o r i e s ) , a n d s e v e r i t y o f symptoms ( G l o b a l S e v e r i t y o f Symptom I n d e x , SCL-90) were e x a m i n e d a s d e p e n d e n t v a r i a b l e s . I n d i c a t i o n s o f one n o n -v a l i d t r e a t m e n t c o n d i t i o n l e d t o t h e d i s c a r d i n g o f one w a r d . A 4 x 2 f i x e d e f f e c t s a n a l y s i s o f c o v a r i a n c e , u s i n g t h e SCL-90 G l o b a l S e v e r i t y I n d e x ( G S I ) a s c o v a r i a t e , was p e r f o r m e d on e a c h o f t h e p o s t m e a s u r e s o f t h e s e v e n d e p e n d e n t v a r i a b l e s . O n l y one s i g n i f i c a n t r e s u l t was o b t a i n e d : t h e G l o b a l S e v e r i t y I n d e x o f t h e SCL-90 was f o u n d t o be s i g n i f i c a n t l y d i f f e r e n t i n f a v o u r o f t h e POP t r e a t m e n t c o n d i t i o n s . B e c a u s e o f l a c k o f c o n t r o l s i n a f i e l d s e t t i n g , t h e r e s u l t c a n be j u d g e d a s a p r o m i s i n g b u t t e n t a t i v e f i n d i n g . C e r t a i n l y , t h i s r e s e a r c h i n d i c a t e s d e v e l o p m e n t o f an a f f e c t i v e l y - o r i e n t e d p r o g r a m t h a t s t r e s s e s s k i l l - b u i l d i n g i n t h e u t i l i z a t i o n o f t h e i n d i v i d u a l ' s i n t e r n a l e x p e r i e n c e o f an e m o t i o n a l l y - b a s e d p r o b l e m may h a v e a s much v a l u e f o r t h i s d i f f i c u l t c l i n i c a l p o p u l a t i o n a s t h e more c o n v e n t i o n a l s t e p - b y -s t e p P r o b l e m - S o l v i n g p r o c e s s u s e d i n c o g n i t i v e l y - o r i e n t e d ICPS p r o g r a m s . V TABLE OF CONTENTS Page AUTHORIZATION i i ABSTRACT . . . . i i i TABLE OF CONTENTS v i L I S T OF TABLES v i i i L I S T OF FIGURES • i x ACKNOWLEDGEMENTS x CHAPTER I . INTRODUCTION ' 1 P r o b l e m - S o l v i n g P r o g r a m s 1 P r o b l e m - S o l v i n g o f C h r o n i c P a t i e n t s 4 I m p o r t a n c e o f R e s e a r c h 5 D e f i n i t i o n o f Terms 7 I I . REVIEW OF THE LITERATURE 1 1 The R e c i d i v i s t i c P s y c h i a t r i c P a t i e n t 1 5 B i a s i n D i a g n o s i s a n d T r e a t m e n t 1 9 Lower P r o g n o s i s P a t i e n t V a r i a b l e s 2 2 S o c i a l C l a s s a n d P r o b l e m - S o l v i n g A b i l i t y 2 7 P r o c e s s F e a t u r e s o f t h e Lower S o c i o - E c o n o m i c P a t i e n t 3 2 P r o b l e m - S o l v i n g A p p r o a c h e s 4 7 C o g n i t i v e P r o b l e m S o l v i n g S k i l l s T r a i n i n g 5 5 I I I . THE DEVELOPMENT OF THE PROCESS ORIENTATION PROCEDURE 6 4 I n t r o d u c t i o n 6 4 Key T h e o r i t i c a l C o n c e p t s : W a r r e n , P e a r s o n , M e i c h e n b a u m , E x p e r i e n c i n g 6 8 R e f l e c t i o n a n d F o c u s i n g 8 9 ICPS T r a i n i n g a n d Means E nd T h i n k i n g I n t h e D e v e l o p m e n t o f t h e POP P r o g r a m 1 0 5 I V . METHODOLOGY 1 2 4 D e s c r i p t i o n o f t h e T r e a t m e n t s 1 2 4 C o n t e x t o f t h e S t u d y 1 2 6 S t a f f 1 2 8 D e s c r i p t i o n o f Wards a n d Ward P r o g r a m s 1 3 2 I n s t r u m e n t a t i o n 1 3 5 D e s i g n 1 4 9 D a t a C o l l e c t i o n P h a s e I - I V 1 5 0 v i . TABLE OF CONTENTS ( c o n t i n u e d ) Page V. DATA ANALYSIS AND RESULTS . 161 New T h e r a p i s t 161 S c o r i n g a n d D a t a E n t r y 162 I d e n t i f i c a t i o n o f N o n - V a l i d T r e a t m e n t s 163 D e m o g r a p h i c C h a r a c t e r i s t i c s o f t h e Sample 165 S t a t i s t i c a l A n a l y s i s a n d R e s u l t s 167 V I . DISCUSSION 180 L i m i t a t i o n s a n d Q u a l i f i c a t i o n s 180 T h e o r e t i c a l I m p l i c a t i o n s 183 P r a c t i c a l I m p l i c a t i o n s 190 F u t u r e D i r e c t i o n s 192 Summary 196 REFERENCES 199 APPENDIXES A. A u t h o r i z a t i o n t o C o n d u c t R e s e a r c h P r o j e c t R i v e r v i e w , December, 1982 248 R i v e r v i e w , December, 1983 249 B. P r o c e d u r e s T r a i n i n g i n Use o f POP a n d PS m a n u a l s T r a i n i n g P r o g r a m 251 T e s t i n g S c h e d u l e 254 I n f o r m e d C o n s e n t Form 255 G u i d e l i n e s f o r S e l e c t i o n o f P a t i e n t s 256 D e s c r i p t i o n o f P r o c e s s O r i e n t a t i o n P r o g r a m 257 D e s c r i p t i o n o f PS p r o g r a m 258 P a t i e n t A t t e n d a n c e R e c o r d 259 Summary o f F o c u s i n g T r a i n i n g I n s t r u c t i o n s 260 C. T r a i n i n g M a n u a l s POP M a n u a l 263 PS M a n u a l 415 D. A d d i t i o n a l T a b l e s , A n a l y s e s o f P r e m e a s u r e s ; Means and S t a n d a r d D e v i a t i o n s , a l l p r e m e a s u r e s T a b l e 1 491 T a b l e s 2 492 v i i L I S T OF TABLES T a b l e Page 1. Number o f P a t i e n t s B e g i n n i n g a n d C o m p l e t i n g T r e a t m e n t . 164 2. D e m o g r a p h i c I n f o r m a t i o n , 56 S u b j e c t s T h e r a p i s t s / W a r d s 1,2,3 a n d 5 166 3. GSI - P o s t T e s t Means A d j u s t e d f o r GSI - P r e t e s t 170 4. A n a l y s i s o f C o v a r i a n c e o f G S I , GSI p r e t e s t a s c o v a r i a t e 171 5. S t a t e A n x i e t y ( a ) p o s t t e s t means a n d a d j u s t e d f o r GSI p r e t e s t 172 6. T r a i t A n x i e t y (b) p o s t t e s t means a nd a d j u s t e d f o r GSI p r e t e s t 172 7. A n a l y s i s o f C o v a r i a n c e , S t a t e A n x i e t y 173 8. A n a l y s i s o f C o v a r i a n c e , T r a i t A n x i e t y 174 9 ( a ) . A n a l y s i s o f C o v a r i a n c e , Number o f R e l e v a n t Means (MEPMEAN), GSI p r e t e s t a s c o v a r i a t e 175 9 ( b ) . A n a l y s i s o f C o v a r i a n c e , I r r e l e v a n t Means a nd No Means (IMNM), GSI p r e t e s t a s c o v a r i a t e 175 1 0 ( a ) . MEPMEAN p o s t t e s t means, a d j u s t e d f o r GSI p r e t e s t . 176 1 0 ( b ) . IMNM p o s t t e s t means, a d j u s t e d f o r GSI p r e t e s t .... 176 11. A n a l y s i s o f C o v a r i a n c e , P o s t - F o c u s i n g Q u e s t i o n n a i r e .. 177 12. P o s t - F o c u s i n g Q u e s t i o n n a i r e means, a d j u s t e d f o r GSI p r e t e s t 178 13. A n a l y s i s o f C o v a r i a n c e , P o s t - F o c u s i n g C h e c k l i s t 179 14. P o s t - F o c u s i n g C h e c k l i s t means, a d j u s t e d f o r GSI p r e t e s t 179 TABLE OF FIGURES F i g u r e Page 1. P r o b l e m - S o l v i n g P r o g r a m - POP A f f e c t i v e ; P r o b l e m S o l v i n g P r o g r a m PS - C o g n i t i o n s : P r o g r a m D e s c r i p t i o n 108 2. Ward S c h e d u l e 128 3. I n s t r u m e n t a t i o n : V a r i a b l e s a n d I n s t r u m e n t s 135 4. E x p e r i m e n t a l D e s i g n 150 5. P h a s e s o f D a t a C o l l e c t i o n 151 i x A c k n o w l e d g e m e n t s I n any l a r g e p r o j e c t , a s t h i s p r o g r a m d e v e l o p m e n t and p r o g r a m e v a l u a t i o n h a s b e e n , t h e r e a r e c o u n t l e s s p e o p l e who a i d e a n d e n c o u r a g e a l o n g t h e way. T h e r e a r e some p e o p l e e s p e c i a l l y who d e s e r v e enormous c r e d i t b e c a u s e t h e i r c o n t r i b u t i o n l i t e r a l l y h a s made t h e d i f f e r e n c e a s t o w h e t h e r t h i s r e s e a r c h w o u l d e v e r come t o f r u i t i o n a n d be c o m p l e t e d w i t h a happy e n d i n g . My c o m m i t t e e members w h i c h i n c l u d e d L a r r y C o c h r a n ; my C h a i r m a n , L e s G r e e n b e r g ; J o h n H i g e n b o t t a m , Todd R o g e r s ; a n d R i c h a r d Y o u n g , h a v e a l l made v e r y u n i q u e and v e r y s p e c i a l c o n t r i b u t i o n s . I t i s v e r y d i f f i c u l t t o s i n g l e o u t one o v e r a n o t h e r b u t I w i l l t r y a n d h o p e f u l l y n o t f a i l . To L a r r y , I want t o s a y a v e r y h e a r t y t h a n k y o u f o r y o u r t r e m e n d o u s s u p p o r t and g e n u i n e c o n c e r n i n s e e i n g t h a t t h i s p r o j e c t h ad a happy c o n c l u s i o n . I w i l l n o t f o r g e t L a r r y ' s i n c i s i v e c r i t i c i s m s t h a t h e l p e d b r i n g r e a l c l a r i t y t o some o f t e n f u z z y i d e a s . To L e s G r e e n b e r g , my C h a i m a n , I want t o s a y , t h a n k y o u f o r y o u r e n t h u s i a s m a b o u t t h e c o n c e p t s t h a t b r i n g l i f e and m e a n i n g t o t h i s r e s e a r c h a nd whose c l i n i c a l p r o w e s s h a s s e r v e d a s a r e a l e x a m p l e t o me a s t o what t h e "good t h e r a p e u t i c h o u r " r e a l l y means. To J o h n H i g e n b o t t a m , words a l m o s t f a i l me, J o h n , y o u r f a i t h a n d s u p p o r t and g e n u i n e u n d e r s t a n d i n g o f t h e s t r e s s e s a n d s t r a i n s o f f i e l d r e s e a r c h k e p t me s a n e a n d g a v e me hope and f a i t h i n m y s e l f . Y o u r c o n t r i b u t i o n i s huge b e c a u s e o f t h e r i s k s y o u p e r s o n a l l y t o o k a s an a d m i n i s t r a t o r t o a l l o w a c o m p r e h e n s i v e p i e c e o f r e s e a r c h t o u n f o l d i n a c o m p l e x c l i n i c a l s e t t i n g . Y o u r c o n t r i b u t i o n i n my e s t i m a t i o n i s a r e s u l t o f a t r u e u n d e r s t a n d i n g o f t h e d i f f i c u l t i e s o f f i e l d r e s e a r c h a nd an a c t o f r e a l l o y a l t y a n d f r i e n d s h i p . To Todd R o g e r s , I want t o s a y , y o u r d e d i c a t i o n t o X t h e p u r i t y o f r e s e a r c h , I a d m i r e e n o r m o u s l y . You have i n s t i l l e d i n me a r e a l d e s i r e " t o do i t r i g h t o r n o t do i t a t a l l " . Thank y o u f o r t h e h o u r s y o u so w i l l i n g l y s p e n t a n d w h i c h a t t i m e s must h a v e f r u s t r a t e d y o u . I a l s o t h a n k y o u f r o m t h e b o t t o m o f my h e a r t f o r y o u r o b j e c t i v i t y a n d f a i t h i n my a b i l i t y t o g e t i t d o n e . To R i c h a r d Y oung, t h o u g h y o u were away on s a b a t i c a l , t h a n k y o u f o r y o u r i n i t i a l v e r y c o n s i d e r e d , c r i t i q u e s a nd y o u r s u p p o r t on y o u r r e t u r n a t t h e e n d o f t h e r e s e a r c h . B eyond t h e p e o p l e d i r e c t l y i n v o l v e d a s c o m m i t t e e members t h e r e a r e c o u n t l e s s c o n t r i b u t i o n s , w i t h o u t whose e n d e a r v o r s and a c t i v i t y on my b e h a l f , none o f t h i s c o u l d e v e r h a v e f o u n d way t o t h e c o m m i t t e e . I w o u l d l i k e t o e x p r e s s my g r a t i t u d e t o S u s a n A s a o k a , J a n H u g e s , D i a n a P r i s s i c k a n d my m o t h e r f o r " p l o w i n g t h r o u g h " so c o n s c i e n t i o u s l y p i l e s o f i n d e c i p h e r a b l e n o t e s w i t h humour and p e r s p e c t i v e a n d an a m a z i n g a b i l i t y t o make s e n s e o u t o f them. I w o u l d be r e m i s s n o t t o m e n t i o n one v e r y i m p o r t a n t p e r s o n whose i n d i r e c t c o n t r i b u t i o n h a s a l s o been e n o r m o u s , n o t j u s t a s an a c a d e m i c b u t a s an e x c e p t i o n a l human b e i n g , Bob P r o s s e r , who f i g u r a t i v e l y " h e l d my h a n d " t h r o u g h e v e r y l a s t a n a l y s e s and k e p t my s p i r i t s up when t h e y were s o o f t e n f l a g g i n g . Bob, y o u a r e a major, c o n t r i b u t o r t o t h e c o m p l e t i o n o f t h i s r e s e a r c h and y o u may have a c t u a l l y made me i n t e r e s t e d i n s t a t i s t i c s , w h i c h i s no s m a l l f e a t . The s t a f f a n d p a t i e n t s o f R i v e r v i e w must a l s o be g i v e n c o n s i d e r a b l e c r e d i t f o r t h e i r w i l l i n g n e s s t o u n d e r t a k e , t h e u n t r i e d . The r e s e a r c h f o r them I know was o f t e n d i f f i c u l t a n d t e r r i b l y t i m e - c o n s u m i n g and I t h a n k them d e e p l y f o r t h e i r xi c o m m i t t m e n t . I w o u l d l i k e t o e s p e c i a l l y t h a n k B e r n i e , G a r t h , Bob, G r e g , B a r b a r a , and B i l l f o r t h e i r p a r t a s t h e r a p i s t s . I w o u l d l i k e t o f u r t h e r e x t e n d my a p p r e c i a t i o n t o t h e n u r s i n g s t a f f a n d t h e p s y c h i a t r i s t s who so w i l l i n g l y a l l o w e d a r e s e a r c h p r o j e c t t h a t d i s r u p t e d n o r m a l w a r d a c t i v i t i e s t o go f o r w a r d . A s p e c i a l t h a n k s a l s o g o e s t o e a c h a nd e v e r y p a t i e n t who gave t h e i r t i m e and c o m m i t t m e n t t o t e s t i n g a n d t r e a t m e n t . I hope i t b r o u g h t e a c h o f t h e s e i n d i v i d u a l s s o m e t h i n g i n r e t u r n . F i n a l l y I want t o t h a n k some v e r y s p e c i a l f r i e n d s whose s u p p o r t , l o v e a n d warmth k e p t me g o i n g . To C o l e e n and B r u c e H a n s e n , y o u r many a c t s o f t r u e f r i e n d s h i p a n d y o u r r e l e n t l e s s p e r s p e c t i v e k e p t me g o i n g a n d I w i l l n e v e r be a b l e t o e x p r e s s j u s t how much y o u gave me. To H e l g a S t a s s m a n , y o u b r o u g h t l a u g h t e r a n d j o y t o my c h i l d r e n so o f t e n when I c o u l d n o t g i v e my e n e r g i e s t o them. I am so v e r y a w a r e , y o u o f t e n g a v e them t h e hugs a n d k i s s e s a n d s p e c i a l warmth, when I was a s " a b s e n t e e m o t h e r " . I want t o t h a n k my f a m i l y , Dad a n d Mom, t h a n k y o u f o r y o u r e n d u r i n g f a i t h i n my a b i l i t y a n d y o u r g r e a t e f f o r t s t o do what e v e r I r e q u e s t e d t o h e l p a l o n g t h e way. F i n a l l y a n d so v e r y i m p o r t a n t l y , I want t o e x p r e s s my deep l o v e a nd g r a t i t u d e t o my h u s b a n d , H a m i s h , who n e v e r c e a s e d t o be s u p p o r t i v e a n d who n e v e r l e t me g i v e up s o m e t h i n g he knew was so i m p o r t a n t t o me t o f i n i s h . As w e l l I must e x p r e s s my l o v e f o r my c h i l d r e n , N i g e l and J e s s i c a , who s u f f e r e d t h e l a c k o f a t t e n t i o n t h a t t h e y so much n e e d e d . I hope I c a n make up f o r t h a t a b s e n c e a s t i m e g o e s o n . F i n a l l y , I want t o t h a n k J o h n F l e m i n g whose t i m e and e f f o r t s on my b e h a l f a r e w i t h o u t m e a s u r e . You have s e r v e d a s a c o n f i d a n t e , a f r i e n d t o H a m i s h and m y s e l f , a n d a v o i c e o f r e a s o n . We t h a n k y o u f o r y o u r d e e p c a r i n g f o r o u r w e l f a r e . T h i s x i i . . . r e s e a r c h n e v e r w o u l d h a v e been c o m p l e t e d w i t h o u t y o u r c o n t r i b u t i o n . 1 CHAPTER I I n t r o d u c t i o n C o m p e t e n t i n d i v i d u