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Dependency factors in suicidal behavior Pollett, Janet M. 1977

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C- 1 DEPENDENCY FACTORS IN SUICIDAL BEHAVIOR by Janet- M. Pollett B .A . , Dalhousie University, 1973. A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in the School of Nursing We accept this thesis as conforming to the required standard The University of British Columbia May, 1977 Q Janet H. Po l le t t , 1977 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 rep-resentatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Nursing The University of British Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 ABSTRACT DEPENDENCY FACTORS IN SUICIDAL BEHAVIOR This study was undertaken to answer the following question: Is excessive dependence related to suicidal behavior? In addition, as depression may be an integral part of suicidal behavior, the following question was ex-plored: Is depth of depression related to suicidal behavior? These questions were explored by the administration of three questionnaires - the Navran Dy, the Frequency of Dependency Expression Questionnaire, and the Beck Depres-sion Inventory. The questionnaires were administered to two groups: Group 1 comprised those who had attempted suicide and Group 2, those who had not attempted suicide. In addition, the Navran Dy was administered to the mater of each client in both groups. There were ten clients and ten mates in each group. A t-test was done to determine whether the means of each group differed significantly on four measures: (1) the Navran Dy (administered to clients); (2) the Navran Dy (administered to mates); (3) the Frequency of Dependency Expression Ques-tionnaire; and (4) the Beck Depression Inventory. The findings partially supported the notion that those who attempted suicide are excessively more dependent than those who did not. That is, their i mean scores on the Navran Dy were significantly different; however, the mean scores on the Frequency of Dependency Expression Questionnaire did not differ. Dependency of mates in both groups was identical. Finally, there was a borderline significance between both groups in depth of depres-sion with the suicidal group being more depressed than the non-suicidal group. ii TABLE OF CONTENTS Page ABSTRACT i I INTRODUCTION 1 The Problem 3 Specific Objectives of the Study 3 Hypotheses Tested in the Study 3 Definition of Terms Used 4 Assumptions of the Study 5 Limitations 6 SIGNIFICANCE OF THE STUDY 6 Methodology 8 SUMMARY AND OVERVIEW OF THE REMAINDER OF THE STUDY 9 II REVIEW OF THE LITERATURE 10 INTRODUCTION 10 SUICIDE 11 The Sociological Theory of Suicidal Behavior 11 The Psychoanalytic Theory of Suicide 13 The Interpersonal Theory of Suicide 14 DEPENDENCY 17 Psychoanalytic Theory of Dependency 17 Social Learning Theory of Dependency 19 Parental Loss in Childhood and Suicidal Behavior in Adulthood 21 Adult Dependency 22 Farber's Theory of Suicide 25 Dependency and Suicide - Research Studies 27 Interpersonal Dependence and Suicide -Research Studies 29 Depression and Suicidal Behavior 33 Research Studies 33 SUMMARYary 36 III METHODOLOGY 38 Setting 38 Sample 38 Criteria for Selection of Sample 39 TABLE OF CONTENTS - continued Page DATA COLLECTION TOOLS 40 The Navran Dy:. 40 Measurement of Frequency of Dependency Questionnaire 41 Reliability of the FDEQ 45 Validity of the FDEQ 45 The Beck Depression Inventory 46 IMPLEMENTATION OF THE STUDY 47 Data Collection 47 Hypothesis..... , 48 Data Analysis 48 IV DATA ANALYSIS AND RESULTS 50 Data in Relation to Hypothesis 50 V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 63 summary 63 Discussion of Findings 64 Conclusions 66 Implications and Recommendations 66 BIBLIOGRAPHY 69 Books 69 Journals 70 APPENDICES 74 iv LIST OF TABLES Page TABLE I 5 1 TABLE II 5 4 TABLE III 5 7 TABLE IV 6 0 v LIST OF FIGURES Page Figure 1 Comparison of Groups 1 and 2 on a measure of trait dependence as measured by the Navran Dy 52 Figure 2 Comparison of groups 1 and 2 on a measure of interpersonal dependence as measured by the Frequency of Dependency Expression Questionnaire (FDEQ) • 55 Figure 3 Comparison of groups 1 and 2 on a measure of trait dependence as measured by the Navran Dy 58 Figure 4 Comparison of groups 1 and 2 on a measure of degree of depression as measured by the Beck Depression Inventory (BDI) 61 vi 1 Chapter I INTRODUCTION This study will examine the role of dependency as a determinant in suicidal behavior. In Canada, 2,413 people took their own lives in 1970; this was a rate of 11.3 per 100,000 of the population.^ In recent years in Canada suicide rates have been on the increase, however, the increase in the preva-lence of suicide attempts has been even more dramatic. Relative to the magnitude of the problem there has been a scarcity of studies, particularly Canadian studies, which can assist in the evaluation of, and intervention in, the problem of attempted suicide. In recent years increasing attention has been given to defining the role of a nurse. More nurses are accepting responsibility for broadening their knowledge to include skills in understanding the psychological and sociological aspects of human behavior. How can we enhance our understanding of suicidal behavior to ensure effective prevention and treatment? The wish to die has been historically associated with a depressed state. Consequently, a major therapeutic approach has been the treatment of the 1 J . H. Brown, "Suicide - The Deserted Field," Canadian Psychiatric Association Journal, Vol . 18, 1973, p. 93. 2 Ibid. 3 Ibid. 4 Eugene Levitt, et al , Depression (New York : Springer Publishing Company, 1975) p. 47. 2 symptoms of depression. Some theoreticians claim that the only difference between those who attempt suicide and those who do not is their depth of . ' 5 depression. In other words, depression is a significant determinant of sui-cidal behavior.^ It is the researcher's contention that problems arising from dependency difficulties cannot be overlooked as a major contributing factor to suicidal behavior and, furthermore, that suicidal behavior can be a product of conflicts resulting from excessive trait and interpersonal dependence with-out a significant degree of depression. Lester (1972) did a comprehensive review and summary of all research findings on suicidal behavior. In relation to dependency and suicidal behavior he stated: "Dependency has frequently been noted in the suicidal individual. However, there have been few intensive investigations of the degree of dependency of the suicidal person. "7 Are suicidal persons generally more dependent? Are suicidal persons excessively dependent in their interpersonal relationships? Ane1 isuicidal persons more apt to select a dependent spouse? This present study is an attempt to answer these questions by investigating the degree of dependency of the suicidal person and his/her mate. Norman Farberow et al , "Suicide Among Patients With a Diagnosis of Anxiety Reaction or Depressive Reaction in General Medical and Surgical Hospitals," Journal of Abnormal Psychology, 71 : 4, 1966, p. 287. ^ Eugene Paykel et al , "Suicide Attempts Following Acute Depression,11  The Journal of Nervous and Mental Disease, 153 : 4, 1971, p. 234. ^ David Lester, Why People Kill Themselves (Springfield, Illinois : Charles C . Thomas, 1972) p. 185. 3 The Problem The problem with which the present study is concerned is this: Is dependency a significant contributing factor in suicidal behavior? The problem will be explored by administration of two dependency scales, the Navran Dy and the Frequency of Dependency Expression Question-naire (FDEQ) to two groups of adults: one group seen following a suicide attempt, and one group seen following a psychiatric admission not precipit-ated by a suicide attempt. In addition, the Navran Dy was administered to the mate;;of each individual in both groups. Specific Objectives of the Study The specific objectives of this study were: 1 . To determine whether individuals who attempted suicide were more dependent, both in trait and interpersonal dependence, than those who did not attempt suicide. 2. To determine whether those who attempt suicide select a more highly dependent mate than those who do not, attempts suicide. 3. To monitor the extraneous variable of depression which will demon-strate whether those who attempted suicide were more depressed than those who did not attempt suicide. Hypotheses Tested in the Study The null hypotheses tested in this study are: 1. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of trait dependence. 4 2. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of interpersonal dependence. 3. There is no significant difference between those who attempt suicide and those who do not attempt suicide in the trait dependency of their selected mates. The depth of depression of all subjects is to be monitored. Consequently, it was also possible to test the following null hypothesis: 4. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of depression. Definition of Terms Used Adult - for the purpose of this study refers to persons between the ages of eighteen and fifty-five. Suicide Attempter - for the purpose of this study refers to any individual seen following non-fatal self inflicted injury. Dependent Adult - for the purpose of this study is defined as the person possessing the following characteristics: 1. Likes to be in close physical proximity to other people. 2. Likes to have physical contact with other people. 3. Desires to be the centre of attention. 4. Seeks pcdise and approval from others. o 5. Resists separation from other people. as measured by the Navran Dy and the Frequency of Dependency Expression Questionnaire. 8 Eleanor Maccoby and John Masters. "Attachment and Dependency", Carmichael's Manual of Child Psychology, ed. P. H. Mussen (New York : Wiley, 1970). p. 74. 5 Depressed Adult - for the purpose of this study is defined as the person possessing the following characteristics: 1. A specific alteration in mood, e . g . , sadness, loneliness, apathy. 2. A negative self concept characterized by self reproaches and self blame. 3. Regressive and self punitive wishes accompanied by desires to escape, hide, or die. 4. Vegetative changes such as insomnia, anorexia, loss of libido. 5. Change in activity level such as retardation of agitation.^ as measured by the Beck Depression Inventory (BDI). Assumptions of the Study The study was based on the following assumptions: 1. the client will look to the mate for gratification of dependency needs; 2. there are multiple factors involved in the determination of suixidal behavi or; 3. that suicidal behavior is an outcome of personality and situational factors; 4. that situational factors were random or non-operative; 5. that an act of self inflicted injury is motivated by a wish to die. Aaron Beck, The Diagnosis and Management of Depression, (Philadelphia The University of Pennsylvania Press, 1973) p. 5. 6 Limitations 1. A greater percentage of suicide attempts occur among single, separated, widowed, and divorced persons. The design of this study limits the population to those individuals who are married or living common-law. 2. Suicide attempts occuring in psychotic clients, persons younger than eighteen, and older than fifty-five, were excluded from this study. 3. Suicide attempts occurring in clients who did not speak English fluently were excluded from this study. SIGNIFICANCE OF THE STUDY As previously stated, the incidence of suicide in Canada is increasing dramatically. ^ It is well recognized that if an individual attempts suicide the probability of subsequent suicidal behavior increases. Dorpat and Ripley (1967) did a follow-up study of attempted suicides.^ From the results of this study it was estimated that 10 to 20 percent of those subjects subsequently killed themselves. The rate of suicide in Vancouver is twice the national 12 average. One of the primary goals of nursing is pneventiofrin» The nurse who becomes therapeutically involved with the suicidal client is faced with the prob-lem of future prevention. The nursing plan must involve interventions in which ^ Brown, Loc. Cit. ^ T. Dorpat et a l , "The Relationship Between Attempted Suicide and Completed Suicide," Comprehensive Psychiatry, Vol . 8, 1976. pp. 74-89. 12 C . Cocking. "If B .C. is Paradise, Why is the Suicide Rate the Highest in Canada," Saturday Night, Sept. 1973, p. 23. 7 the prevention of future suicide attempts is a goal. This study was designed to demonstrate that nursing interventions designed to prevent future suicidal behavior must include a plan for intervening into the dependency problems of the client. Excessive dependence in patients is? a recurring problem to psychiatric nursing. Peplau feels that when dependency is a problem it is best approached through patient teaching.' 4 By this she meant that patients showing such de-pendence should be given information about their interactive relations with those whom they are dependent upon. The nurse aids the client in becoming more aware of his dependency needs and in improving his/her way of expressing those needs. In addition, the client must be aware that the provider for his needs, e . g . , a spouse, also has dependency needs which must be met. This study will provide the nurse with a means of evaluating dependency needs of suicidal persons and their spouses. With this knowledge the nurse can be better equip-ped to anticipate some of the dependency problems which may be existing. Recog-nition of a dependency problem and appropriate anticipatory guidance should be an integral part of the therapy given those who attempt suicide. "The reduction of emotional dependency poses complex problems for the practitioner in the field of rehabilitation because this dependency is conditioned by powerful relationships over which the professional has little direct control, namely, family relationships."^ H. Peplau, Interpersonal Relations in Nursing, (New York : G . P . Putnam's Sons, 1952), p. 185. 1 4 Ibid., p. 187. 15 George Goldin, Dependency and Its Implications for Rehabilitation, (Toronto : D. C . Heath & Company, 1972) p. 28. 8 Clearly the professional can have more control by working directly with the client and significant family members to resolve overdependent relationships. This study is particularly significant in that it is providing some information about the dependency needs of both the client and significant family member. The more empirical data which is gathered concerning dependency in a relation-ship, the better equipped will be the professional to have more direct control of the problem. Methodology This study employed a quasi-experimental design. Data was collected from two groups of psychiatric patients and their mates. Group 1 consisted of clients who had attempted suicide, and their mates. Group 2 consisted of clients who sought psychiatric help without an attempted suicide, and their mates. Four psychiatric wards in two agencies were used to obtain subjects. The re-searcher was notified when clients who had attempted suicide were admitted. All such clients who met the criteria and agreed to participate were included, with their mates, in Group 1. The subjects in Group 2 were selected by a matching process. They were matched with the suicidal subjects as to age, length of hospitalization, and occupation. Only one researcher was used throughout this study, and the experimental approach in both groups was identical. All clients received three questionnaires: The Beck Depression Inventory, the Navran Dy dependency scale, and the Frequency of Dependency Expression Questionnaire. All mates received one questionnaire, The Navran Dy dependency scale. 9 A comparative analysis was done on the degree of dependence of the client who attempted suicide, and his/her mate, and of the client who had not attempted suicide, and his/her mate. SUMMARY AND OVERVIEW OF THE REMAINDER OF THE STUDY The purpose of this study, then, was to determine whether trait de-pendence of client and spouse and interpersonal dependence are major contri-buting factors to suicidal behavior. If dependency is shown to be a significant factor in suicidal behavior, then professionals caring for those who attempt suicide must consider using dependency interventions as a treatment modality in the prevention of suicide. Chapter II is a review of the literature. The major theoretical com-ponents of suicidal behavior and dependency are discussed. Pertinent research studies of both concepts are presented. In addition, due to the significance of depression to suicidal behavior, a section was used to present current research in this area. Chapter III is a description of the methodology employed in this study. In Chapter IV an analysis of the data is presented. Finally, in Chapter V , the research findings are discussed, conclusions are drawn, and recommenda-tions for further study are presented. Chapter II REVIEW OF THE LITERATURE INTRODUCTION What causes a person to attempt or commit suicide? Suicidal behavior is a complex phenomenon, consequently there is no singular answer to this question. Research has provided a number of major indicators to predict sui-cide. Tuckman and Young (1963) have done several studies to identify charac-teristics of a high risk suicidal g r o u p . T h e characteristics are: age 45 or older, male, white, separated/widowed or divorced, living alone, unemployed, poor physical health, abnormal mental condition, medical care within previous six months, and previous attempt or threat of suicide. Murphy (1972) added two more components to identify high risk - primary affective disorder and alcoholism. This study has focused on only one factor, a factor which the author believes to pervade all suicide attempts. That factor is dependency. This chapter elucidates a theoretical understanding of dependency and suicide, and reports research in the area to support the theory presented. The chapter begins with a description of the major theories of suicide: the sociological theory, the psychoanalytic theory, and the interpersonal theory. The pervasiveness of 16 Jacob Tuckman and William Young, "A Scale for Predicting Suicidal Risk in Attempted Suicide". J . of Clinical Psychology, Vol . 24, 1968, pp. 17-19. 17 George Murphy, "Clinical Identification of Suicide Risk", Archives of  General Psychiatry. Vol . 27, Sept. 1972. 11 dependency throughout these theories is then discussed. Following this, the theoretical background of dependency is discussed beginning with dependency in childhood accompanied by research studies supporting the childhood depend-ency theory. Next, dependency in adulthood is discussed. Next, Farber's theory of suicide is presented. The author feels this theory encompasses all other theories and one of its major components is dependency. To lend support to this study, research on dependency in suicidal behavior is discussed. Finally, the pervasiveness of depression in suicidal behavior is explored by the presenta-tion of research studies in the area of depression and suicide. SUICIDE THE SOCIOLOGICAL THEORY OF SUICIDAL BEHAVIOR The sociological approach to the understanding of suicide has its origins in the work of Durkheim who believed that certain characteristics of the societal group determined the suicidal behavior of its members. The characteristic which he emphasized was the degree of integration. "Integration of the society means that its members possess shared beliefs and sentiments, interest in one another, and a sense of devotion to common goals ."^ Durkheim described three categories of suicide: egoistic, altruistic, and anomic. Egoist suicide results from lack of integration of the individual into society. Durkheim described this happening when the individual does not ^ John Beebe, "Evaluation of the Suicidal Patient", Psychotic Treatment Crisis/Clinic/Consultation, ed. , C . Rosenbaum and John Beebe (New York : McGraw-Hill Book Company, 1975). p. 20. 12 have enough of himself involved in political ties, religious ties, and/or family ties. Under such circumstances the individual has to rely upon his own resources, he has no social group upon which to depend. The individual asserts himself to excess and only individual needs are recognized. Durkheim believed that ex-cessive individualism takes away man's raison d'etre: "Man cannot live without attachment to some object which transcends and survives him, and that the reason for this necessity is a need we must have not to perish. The individual alone is not a sufficient end for his act iv i ty ."^ Altruistic suicide results from over-integration. In this circumstance the ego is over-controlled by social regulation. Too little importance is given to the self and all consideration is given to a cause. 2^ Anomic suicide results when there is a change in social regulation. 2' A belief or devotion, which has provided the individual with fulfillment of his needs and satisfactions has come into question. This can happen, for example, when society broadens its know-ledge beyond that which the individual can endure. Suicide as the result of a divorce is an example of anomic suicide. The institution of marriage no longer exercises its control over the individual. Emile Durkheim, Suicide, translated by John Spaulding and George Simpson. Glencoe, Illinois : The Free Press, 1951), p. 210. 2 0 Ibid., p. 221. ^ Ibid., p. 15. 13 THE PSYCHOANALYTIC THEORY OF SUICIDE The psychoanalytic theory of suicide emphasizes the concept of aggres-sion. This particular approach to suicide has its origins in the works of Freud. He assumed the existence of two drives, the life- instinct, or sexual drive, Eros; and the death instinct, or aggressive drive, Thanatos. 2 2 These drives operate interdependent!y. With maturation and the development of the superego the drives become fused and;ineutralized by a loved object. If there is incomplete or inefficient functioning of the loved object the aggressive activity may emerge, "...hostile impulses arise when the organism is frustrated in satisfying its other oq needs." These hostile impulses directed towards a loved one may be un-acceptable and consequently turned inward against the self. This process may result in depression and suicidal tendencies. Psychoanalysts have paid the most attention to suicides springing out of severe depressions. Rado recognized the importance of dependency adapta-tion involved in depression and subsequent suicidal behavior. 2 4 Dependency adaptation refers to self-directed rage which is used by the individual in an attempt to be reconciled with the object of his frustrations. The object of frustrations refers to a significant other who does not provide for the dependency 22 Samuel Futterman, "Suicide : Psychoanalytic Point of View", Cry For Help, ed . , Norman Farberow and Edwin Schneidman. (New York : McGraw-Hill Book Company, Inc., 1961), p. 168. 2 3 Ibid., p. 170. 2 4 Herbert Hendin, "Suicide : Psychoanalytic Point of View", Cry For Help, ed. Norman Farberow and Edwin Schneidman (New York : McGraw-Hill Book Company, Inc., 1961), p. 183. 14 needs. Retroflexed anger is behavior that the individual views as adaptive in restoring or acquiring dependency gratification. In the event of a loss of a loved one these individuals blame themselves. They feel that they do not deserve better. This conflict of frustrated dependency is evident for a period prior to the suicide attempt. In response to Rado's theory Hendin has stated, "A factor worth noting is that, when a depression is in reaction to the loss of a person, the relation-ship often has been a markedly dependent and symbiotic one, and one in which the patient's self-esteem was dependent upon the relationship.1125 THE INTERPERSONAL THEORY OF SUICIDE The interpersonal approach focuses upon man in relation to others, an approach illustrated by Sullivan and Adler. The core of Sullivan's work was an interest in communication. Sullivan's theory rests on two propositions:20 (1) emotional disturbances result from and are perpetuated by inadequate com-munication, and (2) each individual involved in a dyadic relationship is involved as a portion of an interpersonal field as opposed to a separate entity. In other words, the client exhibiting abnormal behavior cannot be singled out and studied in isolation. In addition, Sullivan identified anxiety as the chief disruptive force in interpersonal relations. The anxiety which Sullivan described has its origins in the total dependency of infancy. "The need for the relief of anxiety 97 is called the need for interpersonal security." Sullivan believed that a 2 5 Ibid., p.. 184. 2 6 Harry Stack Sullivan, The Interpersonal Theory of Psychiatry, (New York W. W. Norton & Company, Inc., 1953), p. x i i . 2 7 Ibid., p. xxi. person's consciousness of himself, or his identity, resulted from the "organized experience of reflected appraisals by the significant other persons in the course 28 of one's life." A person's psychological development is determined by the quality of his interpersonal experiences throughout life. Quality is demonstrated by the degree to which you understand how you are perceived by significant others such as close friends, parents, lover. Sullivan felt that suicidal behavior was the result of unresolved conflicts and failures of personal relations. Adler primarily viewed suicide as an attempt to manipulate others to meet one's own needs. The AcJIerian theory sees the individual's behavior as motivated by an inner striving which is ^useful" and therefore governed by social interest. "Social interest is the capacity to understand and accept the social interrelatedness of the human life, to empathize with one's fellow man, and thus to be in harmony with the social world. The poorly adapted individual is motivated by an inner striving which is "useless". Adler felt that suicidal behavior and depression were closely related. Both occur in individuals incapable of social interest. Such an individual has interest only in the self and is unable to be an equal partner in interrelations. They are persons dependent upon the achievement and support of others, they are demanding in their dependency wishes they lack feelings of competence, and envy others who appear better adapted. 2 ^ Maurice Green, "Suicide, The Sullivanian Point of View", Cry For Help, ed . , Norman Farberow and Edwin Schneidman (New York : McGraw-Hill Book Company, Inc., 1961), p. 221. 2 ^ Heinz Ansbacher, "Suicide, The Adlerian Point of View", Cry For Help, ed . , Norman Farberow and Edwin Schneidman (New York : McGraw-Hill Book Company, Inc., 1961), p. ;205. 16 Adlerian theory sees the suicide attempt as a demand for fulfillment of depend-ency wishes, a chance for the individual to exercise competence, an act of revenge against "healthier" others, and finally a means of getting sympathy. These three theories are presented in the literature as the major theories of suicide. Although each was derived from very different schools of thought, they all imply that dependency is significant to suicidal behavior. The needs of the suicidal person for dependence and feelings of security were evident in all three approaches. The sociological approach stressed that man cannot rely upon his own personal resources but, at the same time, he must not ignore those resources. The implication is that man must recognize his need to be depend-ent upon society which will provide him with a sense of security. Ties in societal groups provide the individual with a security base which is essential for personal growth. From the psychological theory one of the dynamics des-cribed was frustration of dependency needs. Despite the fact that this approach stresses intrapsychic phenomenon its stimulus object is originally an external object which becomes incorporated into the self. The individual suffers a loss, of threat of loss, of a loved one - the external object. A person with an in-adequate security base will suffer excessive frustration under the threat of impend-ing loss of a loved one. Finally, the interpersonal approach stresses the import-ance of the need for dependence. Sullivan describes a need for interpersonal security which he felt occurred when dependency needs were met. Adler implies that dependency craving is the major motivating force in suicidal behavior and depression. 17 DEPENDENCY PSYCHOANALYTIC THEORY OF DEPENDENCY A central concept in the psychoanalytic approach to the understanding of dependency is object relations, which usually means the relations of an indi-30 vidual to other persons. According to this theory, the origins of dependent attitudes can be traced to the oral stage of development (0-1 years). One of the baby's first object relations is the breast or bottle which is associated with experiences with the mother. Experiences with the mother during feeding are of great significance and are instrumental determinants of dependency manifesta-tions in later life. It is through the process of feeding that strong emotional bonds 31 32 33 develop between baby and mother. ' ' At this oral stage a majority of the infant's psychic energy is directed toward the gratification of oral needs. According to psychoanalytic theory healthy dependence will develop if, during the oral stage, the mother gives warm indulgent affectionate c a r e . 3 4 If a mother, in an attempt to control behavior, feeds her child when he is good and withholds food when he is bad, the child establishes an association between love and food 30 Willard W. Hartup, "Dependence and Independence", Developmental  Psychology, ed. , Robert Liebert et al . (Englewood Cliffs, New Jersey : Prentice-Hall, Inc., 1974), p. 350. 31 Ibid. 32 Jerry Wiggins, et al . The Psychology of Personality, (Don Mills, Ontario : Addison-Wesley Publishing Company, 1971), p. 489. 33 George J . Goldin, et a l , Dependency and Its Implications for Rehabilitation, (Lexington, Massachusetts : D. C . Heath and Company, 1972), p. 2. 34 Hartup, op. ci t . , p. 150. 18 on the one hand, and rejection and withholding of food on the other. As a con-sequence, oral deprivation is extremely anxiety provoking because it is associated 35 with parental rejection. 36 Erickson described the oral stage as a stage of basic "trust vs. mistrust". If oral deprivation occurs the infant will fail to develop trust in the parent, or parent figure. The infant may express dependency demands as a result of feel-37 ings of insecurity and a need to reaffirm the emotional bond. On the other hand, oral deprivation may result in passive behavior. The infant becomes passively 38 dependent, which is expressed in good behavior. Developmentally, the infant moves from the oral stage to the anal stage. Erickson describes the anal stage as the stage which is characterized by "autonomy qp vs. shame and doubt". Independence is the theme of this stage. Autonomy develops through the child's mastery of his sphincter and other muscles. If the infant moves from the oral stage feeling insecure and inadequate he will be reluc-tant to undertake new independent behavior. Erickson associates independence, mastery, and competence with a strong and intact identity. Orally fixated indi-viduals do not have the ego strength to enforce independent behavior. 4^ Frustra-tions later in childhood do contribute to dependency conflict and may increase dependency; however, they are not considered as crucial asi the events of the first year of l i fe .^ 35 Ibid. 36 Goldiirivjr op. ci t . , p. 3. 37 Ibid. 38 Wiggins, op. ci t . , p. 490. 39 Goldin, op. ci t . , p. 3 40 Ibid. 41 Harrup, op. c i t . , p. 350. 19 Dependency from a psychoanalytic orientation develops in the first year of life in response to anxiety produced by oral deprivation which is associated by the infant with the loss, or threat of loss, of a loved one. Meeting depend-ency needs during this stage of life facilitates the development of feelings of competence. Frustration of dependency needs in other stages of childhood may impede the development of competence; however, no stage of life is as important as infancy. SOCIAL LEARNING THEORY OF DEPENDENCY Most social learning theorists also stress the significance of early child-hood in the development of dependency. The early social learning theorists con-ceptualized dependency as a drive or need which is learned during the process of socialization. 4 2 Learning takes place as a result of reinforcement.4^ Prior to reinforcement, behavior occurs randomly. Through reinforcement, random behavior becomes a conditioned response; for example, crying becomes a conditioned res-ponse for the acquisition of food. While acquiring food the infant receives physical contact, attention and affection. These behaviors become associated with the primary drive of hunger and are consequently described as secondary reinforcers. 44 45 46 These secondary reinforcers create dependency as a learned response. ' ' 42 Wiggins, op. ci t . , p. 511. 43 Goldin, op. ci t . , p. 5. 44 Ibid. 45 Hartup, op. ci t . , p. 351. 46 Wiggins, op. ci t . , p. 511. 20 Prior ro the development of dependency, the mother, or mother figure, is a means to an end; as dependency develops the mother becomes an end in herself. She acquires the properties of secondary reward simply because she has been associated with the reduction of primaryc'drives. In this theory dependency has its origins in an essentially distinctive response such as hunger, and moves from this to a socially conditioned response. Sears (1953), a social learning theorist, presented the concept of depend-ency somewhat differently. According to Sears the dependency drive develops following deprivation of social rewards. The mothering which occurs during the reduction of primary drives becomes a social reward which the infant expects to receive. If the infant is deprived of this social reward, conflict develops between expectation of reward and non-reward.^ From both theories, we learn that emotional dependence originates with the physical dependence of infancy and, further, that the concept of mothering is instrumental in the development of dependency. In addition, Sears, like psycho-analysts, associates dependency with frustration caused by parental rejection or deprivation. Research has been done which gives some support to the above gen-eralizations derived from the major theories. The following research studies indicate that interruption in 'mothering' during childhood impedes the normal adjustment in adulthood. 47 Ibid. 21 PARENTAL LOSS IN CHILDHOOD AND SUICIDAL BEHAVIOR IN ADULTHOOD AO Crook and Raskin (1975) studied parental loss in childhood in two groups. They looked at 115 depressed inpatients who had attempted suicide, 115 depressed patients who had not attempted suicide, and 285 "normal" subjects. ParentaJ loss in childhood through separation, divorce, or desertion significantly differentiated the suicidal group from the other two groups. Loss of a parent through natural causes did not appear related to later suicidal behavior. Greer (1966) studied two groups of adult patients, those who had, and those who had not attempted suicide. 4^ The variable which he tested was ^parental loss. His findings indicated that a significant, p «=* .001, number of patients in the attempted suicide group had experienced the loss in childhood of both parents. He also noted that the attempted suicide patients lost their parents more commonly before the age of five than those patients in the control group. Lukianowicz (1972) studied one hundred female patients who had attempted suic ide .^ One of his findings revealed that 47% of the patients had lost either one or both parents during childhood. Adams et al (1973) explored the relationship between parental loss in child-51 hood and later suicidal phenomenon. They studied three groups of patients at a 48 Thomas Cook and Allen Raskin, "Association of Parental Loss with Attempted Suicide and Depression", Journal of Consulting and Clinical Psychology, Vol . 43, No. 2, 1975. p. 277. 49 S. Greer, "Parental Loss and Attempted Suicide : A Further Report", British Journal of Psychiatry, Vol . 112, 1966, pp. 465-470. 50. N . Lukianowicz, "Suicidal Behavior : An Attempt to Modify the Environment", British Journal of Psychiatry, Vol . 121, 1972, pp. 387-390. 51. Kenneth Adam et al , "Suicidal Ideation and Parental Loss", Canadian Psychiatric Association Journal, Vol . 18, 1973, pp. 95-99. mental health clinic: those who had lost a parent or parents through death, those who had lost a parent through divorce, and those whose parents were alive and still living together. The results showed a significant correlation between early parental loss and the presence of significant suicidal ideation. Dorpat et al (1965) reported that the severity of the suicidal behavior was related to the type of loss experienced. Their results indicated that the death of a parent during childhood favoured completed suicides in adulthood, whereas loss through separation or divorce favoured unsuccessful attempts. ADULT DEPENDENCY The literature contributes very little to the understanding of normal depend ency in adulthood. However, dependency is " . . .one of the most significant, enduring and pervasive qualities of human behavior. From birth to old age it influences the form of all dyadic relationships."^3 It is a natural adaptive behavior that is not limited to childhood. Hartup has said that "whenever an individual gives evidence that people, as people, are satisfying 54 and rewarding, it may be said that the individual is behaving dependently." These approaches imply that dependency is a motivating factor contributing to be-havior in interpersonal relationships, and that the concepts used to describe depend ency in childhood can be applied in adulthood. The frequency and intensity of r c dependency declines as the individual matures; however, the basic dynamics are 52 Dorpat et a l . Loc. C i t . , pp. 74-89. 53 Goldin, op. c i t . , p. 2. 54 Hartup, op. c i t . , p. 349. 23 unchanged. Gewirtz (1956) has said that the major problems raised in relation to dependency in children may be considered a subclass of general behavior prob-lems characteristic of all humans.^ A cluster of behaviors, considered to represent dependency, is described in the literature. They are seeking physical contact, seeking to be near, seeking attention, seeking praise and approval, and resisting separation. 56 The author feels that it has been estabilils'hed that dependency is a signifi-cant motivator of human behavior. How does dependency function as a motivator? From a review of the literature the writer believes that the satisfaction of depend-ency needs provides a secure base for the maturation and growth of personality. Dependency needs are greatest in the first year of life. If dependency needs are met during that time a secure social base is established. The baby begins to feel safe and secure and less threatened by parental rejection. The classical studies done with monkeys (Harlow, 1966) demonstrated that monkeys raised in isolation from other monkeys or people were incapable of developing any social attachments, 57 or displaying social behaviors. The hypothesis generated from this study is that if dependency needs in early childhood are not met the child will be inearjqble of adapting as a social human being. The meeting of dependency needs, thus provid-ing safety and security, is a necessary condition for the development of an independ-ent, competent adaptation to the environment. Bowlby stated that "a well found 55 Jacob L. Gewirtz, "A Program of Research on the Dimensions and Antecedents of Emotional Dependence", Child Development, 27 : 2, June, 1956,. p. 205. 56 Maccoby and Masters, op. ci t . , p. 76. 57. Wiggins, op. ci t . , p. 170. 24 self reliance develops in parallel with reliance on a parent who provides the child with a secure base from which to explore."^ This relationship between dependence and independence operates through-out one's life. Many theorists view dependence and independence as though they were opposites on the same continuum, and that an individual moves in one direc-tion from dependence to independence. The author believes that they are separate but interrelated concepts. This belief is supported try the literature by Bel Iers (1955), Heathers (1955), and Bowlby (1973). Beller stated, "We shall expect therefore to find a moderate, but not high negative relationship between depend-ence and independence."^0 Heathers expressed the view that meeting dependency needs can facilitate independence.0^ Bowlby has said that "Human beings of all ages are happiest and able to deploy their talents to the best advantage when they are confident that, standing behind them, there are one or more trusted persons who will come to their aid should difficulties arise. That is, a secure base will facilitate independent behavior. A person who has dependency needs met feels secure to explore his environment and take risks which results in a positive personality growth. If dependency needs are not met the individual is not free for personality growth as he/she is preoccupied with anxiety associated with feelings of insecurity and inadequacy. Bowlby suggests that there are two 58 John Bowlby, "Self Reliance and Some Conditions That Promote It", Support, Innovation and Autonomy, ed . , Robert Gosling (London : Tavistock Publications Limited, 1973), p. 35. 59 Emmanuel Beller, "Dependence and Independence in Young Children", The Journal of Genetic Psychology, Vol . 87, 1965, p. 27. 60 Glen Heathers, "Acquiring Dependence and Independence : A Theoretical Orientation", The Journal of Genetic Psychology, Vol . 87, 1955, p. 280. 61 Bowlby, op. c i t . , p. 23. variables for the healthy development of dependency in adults. One is that there is someone who is a trustworthy figure and willing to provide the kind of security base required. The second concerns the ability of the individual to recog-nize when another person is trustworthy and can provide a secure base. In addi-tion, the individual must himself be capable of providing a security base in such a way that the interpersonal relationship which develops is mutually rewarding, a The view of Bel Iers, Heather, and Bowlby support the opinion that adults 'grow' when they are operating from a secure base, that is, when depend-ency needs have been met. Adult 'growth' has often been referred to as maturity. A centrally important theme of maturation is the development of competence. White (1952) suggests that exposure to life events determines the individual's ability jto cope with problems, increases the effectiveness of strategies, deepens their appreciation of their surroundings, and expands their resources for happiness.0 As an individual enters adulthood he has to master a number of skills so that he can function to capacity in a wide variety of situations. If an individual has mastery over his environment then he is competent. FARBER'S THEORY OF SUICIDE It was necessary to present the concept of dependency prior to introducing Farber's theory of suicide. Farber(1968) postulated that suicidal behavior is based 62 Ibid. 63 Robert White, Lives in Progress, (New York : Holt, Rinehart and Winston, Inc., 1952), p. 332. 26 on an impaired feeling of competence.0^ He believed that lack of competence contributes to an individual's inability to sustain hope. The suicidal person gives up hope, he does not feel that he has the mastery to cope with the demands of his life. Farber states that frequently this recognition of an inability to cope is r:associated with the loss, or threat of loss, of a loved one whom an individual has depended upon for his own feelings of competence. "The subject feels com-petent only when succored, protected, led, by a person perceived as strong - a parent, a spouse, a lover - in a relationship that is markedly symbiotic. A healthy mutual dependence in a relationship makes reflection and self-realization possible and is a quite normal part of any marriage. 0 0 However, it becomes too high a price to pay when it imposes too heavy a limitation on the mate's independent action and autonomy. As a result, frustration and hostility develop in the relationship. According to Farber, this frustration and hostility results in rejection of the excessive ly dependent partner.»7The rejection is followed by feelings of helplessness and incompetence in the rejected person, which generates an insatiable hunger for love and succor. This antagonizes the partner and enhances rejection. This situation eventually leaves the dependent individual with a sense of worthlessness and hopelessness which may eventuate an act of suicide. 0 ' 7 The underlying theme of Farber's theory is that suicidal individuals do not have a secure base. They are handicapped by an impaired feeling of competence 64n :^ Md"uriJce ,Fdi~ber>y Theory of Suicide, (New York, Funk and Wagnalls, 1968), p. 28. 65 Ibid., p. 29. 66 Robert Gosling, Support Innovation and Autonomy, (New York : Harper & Row Publishers, Inc., 1973), p. 171. 67 Farber, op. c i t . , p. 30. 27 which is further threatened by the loss of that which provides some security. It may be a job, a religious belief, a lover, a husband, money, and so forth. DEPENDENCY AND SUICIDE - RESEARCH STUDIES Research studies investigating dependency in those who attempt suicide give some support to the theory delineated. That is, dependency is a significant factor in the understanding of suicidal behavior. Tabdchnick (1961) theorized that suicide attempters are individuals "more than usually dependent." He further hypothesized that this type of individual often becomes involved in a symbiotic relationship with another dependent person. He felt that such a pair would be masochistic, leading to both individuals feeling angry toward one another, rejecting one another, and finally suicidal behavior exhibited by one of the pair. In an attempt to verify this theory Tabachnick studied, in depth, several cases of attempted suicide. He focused on the individual in the immediate environment of the suicide attempter, an individual with whom the sui-cidal person was deeply emotionally involved. Tabachnick reported that his clinical findings supported his theory. Hattem (1964) studied Tabachnick's hypothesis.°° He was unable to lend support to the hypothesis; in fact, he found the reverse to be true. He did find that suicidal persons were excessively dependent, however the spouse tended to be 68 Norman Tabachnick, "Interpersonal Relations in Suicide Attempts," Archives of General Psychiatry, Vol . , 1961, p. 16421. 69 J . V . Hattem, "Precipitating Role of Discordant Interpersonal Relationships in Suicidal Behavior," Dissertation Abstracts, Vol . 25, 1964, p. 1335-1336. excessively independent. He did not use a control group. Braaten and Darling (1962) studied college students who had attempted, or thought seriously of suicide, and compared them with a group of nonsuicidal subjects.^ One of their findings was that students who had attempted or thought of suicide were characterized by excessive dependence. Lester (1969) studied students who had reported attempting or threatening suicide in the past with those who reported never having considered suicide.^' His results demonstrated that suicidal individuals scored higher on the Navran Dy Dependency Scale. Pal lis and Birtchnell (1976) examined the relationship between personality 79 characteristics and suicidal behavior. Their population consisted of psychiatric patients who were divided into three groups: (1) patients who had attempted suicide, (2) patients with suicidal ideation, and (3) patients without any suicidal history. These patients were given thirteen personality scales, two of which were dependency and depression. There was a significant difference between suicide attempters and non-suicidals in their degree of depression and dependency (p<^.01), as well as other scales. "The results are in agreement with previous reports that suicide attempters, compared with non-suicidal patients, are more hostile, depend-ent, sociopathic, and prone to depression." 70 L. J . Braaten and C . D. Darling, "Suicidal Tendencies Among College Students", Psychiatric Quarterly, Vol . 36, 1962, pp. 665-692. 71 David Lester, "Resentment and Dependency in the Suicidal Individual", Journal of General Psychology, Vol . 81, 1969, pp. 137-145. 72 D. Pal lis and J . Birtchnell, "Personality and Suicidal History in Psychiatric Patients", Journal of Clinical Psychology, 32 : 2, Arpil, 1976, pp. 246-253. Paykel (1974) did a survey of the general population for the prevalence 73 of suicidal ideation. Their samples consisted of 720 subjects and their data collection method was interviewing. They collected information about the presence and intensity of suicidal ideation and feelings in the last five years. They also collected demographic data and data which they termed psychiatric symptoms. Among the psychiatric data there were three symptoms classified as representing dependency: (1) feel no one understands you, (2) feel weak all over, and (3) can't take care of things because can't get going. The subjects who had experienced suicidal feelings in the last five years were compared with those who had not had such feelings. The two groups differed significantly on the three items which represented dependency (p. «=£-.001). The other symptoms in which the groups significantly differed were those symptoms representative of depression. INTERPERSONAL DEPENDENCE AND SUICIDE - RESEARCH STUDIES Fellner (1961) hypothesized that suicide attempts result when a significant other, such as parent or spouse, provokes i t . 7 4 He felt that people attempted suicide when their verbal threats of suicide were met with counter aggression. That is, when the significant other responds with an "I dare you" attitude. Fellner studied ten cases of psychotic and nonpsychotic attempters. His results indicated that the nonpsychotic was involved in an intense relationship with a spouse, parent, or friend, which was in conflict. The patient dealt with this conflict in a clinging 73 E. S. Paykel, et a l , "Suicidal Feelings in the General Population : A Prevalence Study", British Journal of Psychiatry, Vol . 124, 1974, pp. 460-469. 74 Carl Fellner, "Provocation of Suicide Attempts", Journal of Nervous and  Mental Disease, Vol . 133, 1961, pp. 55-58. 30 demanding manner which eventually provoked negative feedback from the partner. It was this feedback which seemed to result in the suicide attempt. Kumler (1964) studied the communication between suicide attempters and 75 significant others. One of her findings was that a suicide attempt follows a series of mutual rejections which intensifies the isolation and anxiety of the suicide attempter. Unfortunately there was no control group, the sample was small (n=10) and no statistics were presented. Farberow and McEvoy (1966) studied the medical records of patients who had been on a medical-surgical ward with a diagnosis of anxiety reaction or depressive reaction. 7 0 They selected the medical records of individuals who had committed suicide and matched them with the medical records of patients on the same ward who had not committed suicide. Subjects were matched on many vari-ables including psychiatric diagnosis. Examination of the records suggested that the suicidal patients experienced more severe psychiatric symptoms of anxiety and depression. An object loss pattern was more evident in the records of those who had committed suicide. This pattern was interpersonally based, with each person feeling the impending loss of a loved one. In all the suicide cases there was a sign of marital discord. The social and marital adjustment of the suicide patient was characterized by a marked dependence on the spouse or significant other. Harris (2966) studied what effect the "continuance or severance" of the relationship of the suicidal individual and the significant other had on continued 75 F. Kumler, "Communication Between Suicide Attempters and Significant Others : An Exploratory Approach", Nursing Research, Vol . 13, 1964, pp. 268-270. 76 Norman Farberow and Theodore McEvoy, "Suicide Amont Patients with Diagnosis of Anxiety Reaction or Depressive Reaction in General Medical and Surgical Hospitals", Journal of Abnormal Psychology, Vol . 71, No. 4, 1966, pp. 287-299. 31 77 suicidal behavior. Her results indicated that those suicidally inclined individuals who remained in the dyadic relationship had more suicidal threats or attempts than those who severed the relationship. 78 Fawcett (1969) studied completed, attempted, and threatened suicides. Those subjects judged as high suicidal risks had demonstrated a long-standing in-ability to maintain warm and mutually interdependent relationships. Despite overtly conventional marriages, the partners tended to be interpersonal Iy isolated. Simon and Lumry (1970) studied cases in which the spouse of the patient 79 committed suicide. This study was designed to "demonstrate that loss of love object, as well as acute interpersonal reaction, while frequently leading to divorce threats and actions, can also become the principal determinant in completed suicides. " They studied nine cases. It was a retrospective study for which they used the medical records of the patient whose spouse had committed suicide. The results indicated severe dependency situations in seven of the nine cases. The suicides seemed to be a response to threat by the spouse of separation or divorce. Again, this study has the methodological problem of no well-defined parameters of that which they are studying. Farberow and Reynolds (1971) designed a study for the purpose of looking 80 at the variability of dyadic crisis and to examine the dependency aspects.' 7l£ Rosalie Harris, "Factors Related to Continued Suicidal Behavior in Dyadic Relationships", Nursing Research, Vol . 15, 1966, pp. 72-75. 78 Jan Fawcett et a l , "Clues from Interpersonal Communication", Archives of General Psychiatry, Vol . 21, 1969, pp. 129-137. 79 Werner Simon and Gayle Lumry, "Suicide of the Spouse as a Divorce Substitute", Diseases of the Nervous System, September, 1970, pp. 608-612. 80. Norman Farberow and David Reynolds, "Dyadic Crisis Suicides in Mental Hospital Patients", Journal of Abnormal Psychology, Vol . 78, No. 1, 1971, pp. 77-85. 32 It was a retrospective study using the records of male suicides. They studied two groups: dyadic, those experiencing difficulties from a dyadic relationship, and non-dyadic, those with no evidence of difficulties from the dyadic relationship. The charts were examined for the presence of discord/conflict with the significant other love object, loss of love object, and none of the above. Fifty subjects were subdivided into three groups: strained (n=22) - still physically living together, broken (n=20) - physical separation, and terminated (n=8) - separation as a result of death. Dependency patterns torbe identified by the researcher were clearly out-lined. The significance between the two groups on an assigned measure of depend-e ent personality was significant at the .05 level, with the dyadic group being higher on dependency. The dyadic group was significantly higher on dependence on spouse for child rearing, ( p . < .01), and outfight requests to be taken care of, (p. .01). . Maxmen^ and'iTucket; (1973) studied the case histories of twelve persons who 81 had a history of multiple suicide attempts. Their results indicated that a suicide attempt was always preceded by some interpersonal difficulty. The subjects had very low self esteem and indicated that their good feelings about themselves came from an introjection of positive qualities of a significant other. The authors con-cluded that the major characteristics of these subjects were their dependence and persistent depression. This study, however, had striking limitations. Their sample was small and the results were determined from clinical impressions of case histories 81 Jerrold Maxmen and Gary Tucker, "No Exist : The Persistently Suicidal Patient", Comprehensive Psychiatry,Vol. 14, No. 1, January/February, 1973, pp. 71-78. 33 without an outline of criteria for such characteristics as self esteem and dependency. DEPRESSION AND SUICIDAL BEHAVIOR Many theorists believe that depression is a pervasive factor in suicide. Research in this area is inconclusive, some studies to be reported support the theory, while others do not. RESEARCH STUDIES no Pokomy (1964) did a retrospective study using medical records. He looked at the diagnosis of sixty-five patients or expatients of a veteran's psychia-tric hospital who had committed suicide. His results indicated that the patients with a diagnosis of depression were significantly more prone to suicide. Guze and Robins (1970) studied seventeen individuals suffering from primary affective disorder, and compared them with statistics from the general population.^3 The risk of suicide amont individuals suffering from primary effective disorder is approximately thirty times that which is seen in the general population. Silver et al (1971), in a similar study, found a significant direct relation-84 ship between depression and seriousness of intent. Paykel et al (1971) collected data from 220 depressed subjects, 189 of whom were followed up ten months later to determine the number of suicide 82 Alex Pokorny, "Suicide Rates in Various Psychiatric Disorders", The Journal of Nervous and Mental Disease, Vol . 139, No. 6, December 1964, p. 83 Samuel Guze and Eli Robins, "Suicide and Primary Affective Disorders", British Journal of Psychiatry, Vol . 117, 1970, pp. 437-438. 84 Michael Silver et a l , "Relation of Depression of Attempted Suicide and Serious-ness of Intent", Archives of General Psychiatry, Vol . 25, December 1971, pp. 573-576. attempts.^ In 189 subjects there were fifteen unsuccessful attempts and one success-ful. Results indicated that the suicidal persons had not recovered from their index level of depression as compared with the nonsuicidal persons. Woodruff et al (1971) attempted to correlate different psychiatric diagnoses with suicide attempts. Two diagnoses, homosexuality and hysteria, were sig-nificantly associated with suicide. Primary affective disorder was not significantly associated with suicide. Poeblinger et al (1973) administered the Minnesota Multiphasic Personality 87 Inventory to thirty-seven depressed patients, nine of whom had attempted suicide. From the results it was apparent that depression and anxiety were significantly related to suicidal behavior. Minkoff (1973) studied the relationship between hopelessness and depression, 88 and the seriousness of suicidal intent. The results indicated a significant differ-ence between depression and intent; however, there was a greater significant difference between hopelessness and intent. Barraclough et al (1974) did a retrospective study of one hundred completed suicides, using hospital records.^0 They matched their subjects with living depressives. 85 Eugene Paykel et al , "Suicide Attempts Following Acute Depression", The..Journal  of Nervous and Mental Disease, Vol . 153, No. 4, 1971, pp. 234-243. 86 Robert Woodruff et al, "Suicide Attempts and Psychiatric Diagnosis", Diseases of the Nervous System, September, 1972, pp. 617-621. 87 W. J . Poeblinger et al, "Suicide Risk and MMPI Scores, Especially as Related to Anxiety and Depression", Life-Threatening Behavior, Vol . 3, No. 2, Summer, 1973, pp. 147-153. 88 Kenneth Minkoff et al , "Hoplessness, Depression and Attempted Suicide", American Journal of Psychiatry, Vol . 30, No. 4, April , 1973, pp. 455-459. 89 B. M. Barraclough et a l , "A Hundred Cases of Suicide : Clinical Aspects", British Journal of Psychiatry, Vol . 125, pp. 355-373. The results indicated that those who had committed suicide appeared to be more depressed than the living depressives. Buglass and Horton (1974) designed a study for the purposes of developing a predictive scale for repeat suicide attempts.0^ They studied two groups, repeaters and non-repeaters. The diagnosis of depression was not a significant difference between the two groups. In other words, their results indicated that depression was not a predictor for future suicidal behavior. El-Gaaly (1974) compared depressed patients who did not attempt suicide with depressed patients who did attempt suicide in relation to social dysfunction 91 and depression. There was a significant difference in the degree of social dys-function between the two groups; those who had attempted suicide experienced a greater degree of social dysfunction. There was no significant difference between the two groups in the depth of depression. Leonard (1974) correlated suicidality ratings of ninety psychiatric patients with five possible indices of depression including self rating of depression, dep-ression as measured by the Minnesota Multiphasic Personality Inventory, and a 92 separate depression scale. The results indicated that only some aspects of dep-ression can be correlated with suicidal behavior. The self ratings of depth of depression seemed to correlate highest with suicidal behavior. The authors noted 90 Dorothy Buglass and John Horton, "A Scale for Predicting Subsequent Suicidal Behavior", British "Journal of Psychiatry, Vol . 124, 1974, pp. 573-578. 91 A . El-Gaaly, "Social Dysfunction in Depressives and Attempted Suicides", Acta Psychiatrica Scand., Vol . 50, 1974, pp. 341-347. 92 C . V . Leonard, "Depression and Suicidality", Journal of Consulting and  Clinical Psychology, Vol . 42, No. 1, 1974, pp. 98-104. The authors noted that depression was not an overall consistent factor in suicidal behavior. They noted that long hospitalizations resulting in dependency diffi-culties seemed to be a more consistent factor correlating with suicidal behavior. The author concluded that "the study of dependency and control problems may prove more useful than the study of overt depression. " go Pokorny et al (1975) repeated Minkoff's study. Subjects were inter-viewed within seventy-two hours of the attempt. They found a significant direct correlation (p. <C .05); however, they found no significant correlation between hopelessness and seriousness of intent. SUMMARY In summary, although the theory of suicide has been approached from different disciplines, one of the commonalities of these theories is the concept of dependency. Mutual dependency is normal in relationships and provides indi-viduals with a sense of security. This secure base facilitates personal growth and adaptation which enhances competence. If dependency in-an interpersonal relationship interferes with the development of competence in either member, then it is not healthy and creates frustration and rage. Sucidal behavior is one possible outcome of unhealthy relationships. Studies reported provided 93 Alex Pokorny et al, "Hopelessness and Attempted Suicide : A Reconsideration American Journal of Psychiatry, Vol . 132, No. 9, September, 1975, pp. 954-956 37 support to the concept that dependency is higher in individuals displaying suicidal behavior. In addition, they provide evidence that suicidal behavior is usually preceded by a disturbance in the interpersonal relationship with a significant other. Finally, research to date does not support the notion that depression is a pervasive component of suicidal behavior. Chapter III METHODOLOGY The approach used was a quasi experimental matched groups design. The dependent variable was suicidal behavior, and the independent variables were trait dependency of client, trait dependency of spouse, and interpersonal depend-ency of client. Depression was monitored as a relevant variable, that is, a variable known or believed to influence the effect being measured.0^ SETTING Two large general hospitals were used in conducting the study. Clients were obtained from inpatient psychiatric wards at both hospitals in addition to the psychiatric assessment unit at one of the two hospitals. All questionnaires were completed by the clients and mates in the privacy of either the client's room or a ward office. The study was conducted over a nine-month period from July, 1976, to March, 1977. SAMPLE The total sample consists of 40 S(s). These were divided into two groups: group one comprised ten clients and mates, making a total of twenty, group two also 94 Robert Plutchik, Foundations of Experimental Research. (New York : Harper & Row, Publishers, 1968). p. 149. comprised ten clients and mates, making a total of twenty. The two groups were differentiated by suicidal behavior. Those clients in group one were included be-cause they had recently attempted suicide which resulted in hospitalization. When the researcher was made aware of such an admission the client and mate were ap-proached for consent to participate in the study. If both agreed, and the sample criteria were met, they were requested to sign the consent forms. Following this the questionnaires were administered. When a client was obtained for group 1 the researcher then studied clients in all settings to find a suitable match for the client in group 1. The clients in group 2 were matched on age, employment, and length of hospitalization, with clients in group 1. No attempt was made to match the mate in group 2 with the mate in group 1. The ages of the clients in both groups ranged from 23-53 with 10% in their twenties, 40% in their thirties, 40% in their forties, and 10% in their fifties. 80% of the clients were female, that is, eight females in each group. Six of these females in each group were housewives. Two in each group were employed. Among the six non-working housewives, 50% had professional degrees or diplomas -i .e . , B .A . , or R .N . There were two male clients in each group. One male client in Group 1 and a match in group 2 were unemployed. The other male client in group 1 and a match in group 2 were tradesmen. Criteria for Selection of Sample The criteria for selection of all subjects were as follows: (1) Male and female between the ages of eighteen and fifty-five. 40 (2) Married or living common law, with mate not younger than eighteen and not older than fifty. (3) Non-psychotic. (4) Non-toxic, that is, rational and coherent. (5) Has not been recently discharged from hospital, that is, within three months. Ethical Considerations: Written consent was obtained from all clients partici-pating in this research project (see Appendix A). The clients were in no way made to feel obliged to participate in the study. All information collected is strictly confidential. A code number, not the client's name, was used to identify data collection forms. DATA COLLECTION TOOLS  The Navran Dy This scale measures trait dependence and contains fifty-seven items ext-racted from the Minnesota Multiphasic Personality Inventory (MMPI). It was de-vised in 1954 by L. Navran. Content validity was determined by a panel of sixteen judges. The reliability coefficient using one hundred patients was deter-mined by the Kuder-Richardson Formula to be . 9 1 . ° ^ This tool was administered to all subjects (see Appendix B). 95 Leslie Navran, "A Rationally Derived MMPI Scale to Measure Dependency", Journal of Consulting Psychiatry, Vol . 18, No. 3, 1954, p. 192. 41 Measurement of Frequency of Dependency Questionnaire (F .D .E .Q . ) This tool was developed by the researcher. It was designed using the five behaviors which Beller (1955) showed to be components of a dependency dr ive .°° The components are: Physical contact, proximity, attention, help, and recognition. One of the hypotheses of Beller's study stated that the five components listed above would correlate highly within individuals and could con-sequently be considered components of a dependency drive. The study was con-ducted with children who were rated on specific behaviors which the author felt represented each of the five components in question. He used only one example to illustrate the behaviors which he selected to represent one particular component. The example component illustrated was recognition. Recognition was operationally defined by Beller as behavior which seeks any form of praise or approval. Some of the items selected to represent recognition were as follows: (T) the child runs to the teacher to show, or tell the teacher what he/she has done, e . g . , "I washed my hands", or "I drank all my juice"; and (2) calling to the teacher to watch what he/she is doing, e . g . , a child swinging shouts, "watch me". These items represent the behavior of a child seeking recognition. Beller defined the remaining four components in his article; however, he did not discuss any of the behaviors which he used to represent the components. Physical contact refers to body contact in which the contact is an end in itself, rather than a means to 96 Emmanuel K. Beller, "Dependency and Independence in Young Children", The Journal of Genetic Psychology, Vol . 87, 1955. pp. 25-35. on end. Proximity is similar to physical contact. It is an act of seeking physi-cal closeness. Attention refers to behavior specifically aimed at capturing an-other person's attention. Help refers to behavior by which the child seeks help or assistance for a task which he/she is capable of completing alone. The results of Beller's study supported the hypothesis stated earlier, in that subjects who scored high on one of the components consistently scored high on the other components. The five components discussed are the foundation for the FDE question-naire. The next step in developing the questionnaire was to select items which could represent these components. A review of the literature on dependency revealed that researchers who had previously attempted to measure this construct had used similar components. Berg (1974) developed a questionnaire to be filled 97 out by mothers which would measure dependency in children. His components were: affection, communication, assistance, and travel (how often the child travels without the mother). These components closely resemble physical contact, proximity and help seeking behavior. Some of the items which Berg felt represented his components were: (1) Did you wash or bath him/her? (2) Did he/she kiss you on going out, or coming into the house? (3) Did he/she gooon a bus without you? (4) Did he/she talk over his troubles with you and ask your help about what was going on in the family? 97 Ian Berg, "A Self-Administered Dependency Questionnaire ( S . A . D . Q . ) For Use With Mothers of School Children". British Journal of Psychiatry, Vol . 124, 1974. pp. 1-9. All of the items were followed by a five-point scale which ranged from less than once a week to not at all , to more than once a day. Berg listed the components and the twenty-one items representing the components; however, he did not discuss his selection of particular items. Golightly et al (1970) attempted to develop a 98 dependency scale for children. They developed a questionnaire with sixty-five items which they administered to 258 children. The authors used no external criteria for dependency. They used their judgment as to the items which they felt measured dependency. The items were true/false statements and the following are some examples: (1) I often telephone my friends; (2) I like to have my mother hug me; (3) sometimes I stay home alone; (4) I ask my teachers a lot of questions; (5) I go swimming with my friends; and (6) my mother brings me to school. These items appear to measure proximity, physical contact, attention, help-seeking and recognition. However, the authors did not identify major components of de-pendence. In developing a tool to measure dependence the trend in the literature has been to select the components which represent dependency, then select behaviors most representative of the components. Most of the attempts to develop a tool to measure dependence have been done with children. Derdiarian (1974) 98 Carol Golightly, Don Nelson, James Johnson, "Children's Dependency Scale", Developmental Psychology, Vol. 3, No. 1, 1970. pp. 114-118. 44 developed a behavioral checklist to measure dependence in hospitalized adults using Beller's five components as the base.°° This checklist provided good guidelines for selecting items when using Beller's components. The behaviors which Derdiarian used were numerous, and only a few will be quoted here as examples: 1. Seeks physical contact: (a) asks to hold nurse's hand when conversing; (b) asks to hold nurse's hand during activities; (c) touches nurse's hand when conversing. 2. Seeks proximity: (a) asks nurse to sit on bed or pull up a chair; (b) tells jokes or stories to keep nurse in the room; (c) calls friends, family, on the telephone to pass the time of day. 3. Seeks attention: (a) requests "extra" services; (b) says or does things that shock or surprise nurse; (c) speaks loudly in halls. 4. Seekshelp: (a) asks for help to start or complete self care; (b) asks for help (suggestions) although he/she has the knowledge to make the decision alone; (c) sends family member to get information from the nurse. 6. Seeks recognition: (a) makes such statements as "how do you like my new robe?" (b) seeks personal recognition through the recog-nition of other, e . g . , "my daughter is a nurse"; (c) conforms to hospital rules without complaining. The items on the FDEQ were derived from scanning all items listed in the three articles discussed, and modifying those items to be appropriate to interpersonal 99 Anays K. Derdiarian. "An Analysis of Dependence, Independence Behavior Variables in Surgical Patients with Emphasis Directed to Trait and State Dependence", University of California, Los Angeles, Unpublished MSN Thesis Abstract, 1974. 45 dependency in adults. RELIABILITY OF FDEQ A pilot study was conducted to determine reliability using the test-retest method. Nineteen university nursing students were administered the test on two occasions separated by a 3-week period. The two sets of scores were then correlated using the Spearman rank-correlation coefficient (r.):^^ n ( N 2 - l ) The correlation coefficient was .9. VALIDITY OF THE FDEQ Validity was determined by a panel of ten judges. The questionnaire contained thirty-five items and each item was marked with the component it was representing. That is, proximity, seeks help, seeks recognition, seeks attention, or seeks physical contact. The judges were asked to rate each item on a five-point scale as to how well the item measured the component indicated, ©ne on the scale represented a poor indicator, 5 represented a good indicator. Percentage agreement was determined for a score of 4 or 5. A rating of 3 or less was not included in percentage tabulations. The items with less than 70% 100 Gene Glass and Julian Stanley, Statistical Methods in Education and Psychology, (New Jersey : Prentice-Hall, Inc., 1970). p. 174. agreement were removed from the questionnaire, leaving thirty items. Of the remaining thirty items, four were 70% agreed upon, one was 80% agreed upon, and the remaining twenty-five items were agreed upon by 90 or 100% of the judges. For example, ten judges independently rated question 22 with 5 which was the upper end of the scale. Therefore, item 22 was accepted as a good indicator by 100% of the judges. The judges were selected from members of the health care team and comprised a director of psychiatric nursing, two psychiatric nurse clinicians, two medical-surgical staff nurses, four psychiatric nurses, and one psychologist (see Appendix C). THE BECK DEPRESSION INVENTORY This depression inventory is extensively used at the Health Sciences Centre Hospital, U . B . C . , and was recommended by the psychologist who has been using the tool. This tool contains twenty-one items and its reliability using two hundred subjects and the split half technique was .86 using Pearson r and .93 with the Spearman-Brown correlation. Extensive studies have been done for construct, predictive and concurrent validity and have been shown to be valid. 101 Arron Beck, Depression, (Philadelphia : University of Pennsylvania Press, 1970) , p. 70. 47 IMPLEMENTATION OF THE STUDY In May, 1976, the Director of the Research Committee of a large general hospital was approached by the researcher in relation to conducting the study. A research proposal was submitted to the Research Committee, and to the medical directors of the psychiatric units of this institution. In July, 1976, permission was granted, by telephone, to begin the study at that hospital. In July, 1976, the researcher telephoned the Director of Nursing at a second hospital, who requested two copies of the research proposal, one for herself and one for the medical director of psychiatry. In two weeks, permission was granted to conduct the study at that institution. The researcher visited all units involved at both institutions familiarizing herself with the staff, and explaining the study to interested staff. The head nurses on all units were provided with the sample criteria list. Arrangements were made so that the researcher telephoned or visited the units daily when possible. Three months into the study the units were being contacted twice a week for potential subjects. DATA COLLECTION All subjects were seen on one occasion only by the same experimenter. The clients in each group received three questionnaires. The mates in each group received the Navran Dy questionnaire only. Three tests were used to collect data: the Navran Dy Scale, the Frequency of Dependency Expression Question-naire, and the Beck Depression Inventory. The subjects were initially asked to read and sign the consent form. All subjects (clients and mates) received the Navran Dy. Only the psychiatric clients in each group received the FDEQ and the Beck Depression Inventory. The subjects were instructed to answer all questions as quickly as possible. The researcher was always present but did not assist the subjects in any way. HYPOTHESIS The study was designed to test the following null hypothesis: 1. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of trait depend-ence, as measured by the Navran Dy. 2. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of interpersonal dependence, as measured by the FDEQ. 2. There is no significant difference between those who attempt suicide and those who do not attempt suicide in the trait dependency of their selected mates as measured by the Navran Dy. 4. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of depression as measured by the Beck Depression Inventory. DATA ANALYSIS The hypothesis stated that there is no difference between the means of the two populations studied on four variables, that is, trait dependency of clients, impersonal dependency of clients, trait dependency of mates and depression of clients. The statistic used to test all hypotheses was a one-tailed t-test for independent samples with the assumption that the underlying populations sampled 49 are normally distributed. The formula used was as follows: s J?, - "x The hypotheses were rested at the .05 level of significance. Chapter three has presented methodology and type of data analysis done. Chapter four is a presentation of data analysis computation and results. 102 Glasser and Stanley, op. c i t . , p. 269. 50 Chapter IV DATA ANALYSIS AND RESULTS Data will be presented in relation to each hypothesis. The Olivetti computer was used for all data analysis. Two programmed magnetic tapes were used. The first was a program to compute means and standard errors. The second tape was a program to compute Students' t for independent samples when the mean and standard error are known and when the N's are equal (see Appendix E for presentation of all raw data). DATA IN RELATION TO HYPOTHESIS Hypothesis 1. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of trait dependence as measured by the Navran Dy. The Navran Dy contains 57 items which are answered by a True/False response. A total score can range from 0-57 with 57 indicating a high level of trait dependence. This questionnaire was administered to twenty clients, ten clients who had attempted suicide (group 1) and ten clients who had not attempted suicide.(group 2). The score obtained was a summation of each dependent response. Table I and Figure 1 following present the raw data from which the X , SEand t-test were computed. 51 TABLE I Group 1 Group 2 Clients Navran Dy Navran Dy 1 (female) 24 46 2 (female) 42 32 3 (female) 33 24 4 (male) 38 9 5 (male) 34 14 6 (female) 40 39 7 (female) 40 36 8 (female) 52 24 9 (female) 44 32 10 (female) 43 11 X" 39.0 26.7 S .E . + 2.38 + 3.95 52 40 H Q c o > D z c o 30 J o u oo c D 20 H 10 Group 1 Group 2 Figure 1. Comparison of Groups 1 and 2 on a measure of trait dependence as measured by the Navran Dy. * p « c ; .01 The t-test of Group 1 vs Group 2 as computed with the Olivetti prog-ram was 2.667. Using the percentile points of t-distribution table at 18 df (Nj+N2~2) this was shown to be significant at the .01 level. The data analysis indicates that those who attempted suicide scored sig-nificantly higher on the Navran Dy than those who did not attempt suicide. Consequently, hypothesis 1 was rejected. The alternate hypothesis was accepted. That is, there is a significant difference between those who attempt suicide and those who do not attempt suicide in their degree of trait dependence as measured by the Navran Dy. Hypothesis 2. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of interpersonal dependence as mea-sured by the FDE questionnaire. The FDE Questionnaire contains thirty items, each based on a 6-point scale of frequency. The lower end of the scale (1) indicated the highest frequency. The possible total score ranges from 30-180 with 30 indicating a high degree of personal dependence. The score obtained was a sum of the responses to each question. Table II and Figure 2 follow. 54 TABLE II Group 1 Group 2 Clients FIBDIQ FDEQ 1 111 95 2 150 110 3 104 73 4 82 115 5 120 129 6 85 92 7 92 98 8 109 121 9 71 109 10 101 80 x " 102.5 102.2 S.E . + 7.08 + 5.64 ioo H o LU Q c o o o c D 90 80 H 70 H Group 1 Group 2 Figure 2. Comparison of groups 1 and 2 on a measure of interpersonal dependence as measured by the Frequency of Dependency Expression Questionnaire (FDEQ). 56 It is obvious from Table II and Figure 2 that both groups are the same. The computed rarest was .0331 which is not significant. Consequently hypothesis 2 was accepted. Hypothesis 3. There is no significant difference between those who attempt suicide and those who do not attempt suicide in the trait depend-ency of their selected mates as measured by the Navran Dy. As stated under Hypothesis 1, the score for the Navran Dy can range from 0-57 with 57 being a high level of trait dependence. Table III and Figure 3 follow. 57 TABLE III Group 1 Group 2 Mates Navran Dy Navran Dy 1 18 23 2 16 18 3 27 10 4 35 29 5 17 35 6 21 10 7 21 35 8 37 19 9 30 11 10 16 18 X 23.8 20.8 S .E . + 2.51 + 3.03 58 40 H Q c D > D z c o 30 o o co c D (1) 20 i o A Group 1 (mates) Group 2 (mates) Figure 3. Comparison of groups 1 and 2 on a measure of trait dependence as measured by the Navran Dy. Using the Olivetti program t was computed to be .7624 (df 18). This is not significant. Consequently hypothesis 3 was accepted. Hypothesis 4. There is no significant difference between those who attempt suicide and those who do not attempt suicide in their degree of depression as measured by the Beck Depression Inventory. The Beck Depression Inventory contains twenty-one items. Each item contains 4-6 statements and each statement is given a weight from 0-3. The total score can range from 0-63 with 63 indicating a high degree of depression. When completing the questionnaire the individual selects the statement in each item which best describes him/her. The total score obtained is a summation of each weighted response. Table IV and Figure 4 follow: 60 TABLE IV Group 1 Group 2 Client Beck Dep. Inv. Beck Dep 1 3 20 2 40 21 3 28 15 4 14 12 5 16 1 6 30 17 7 28 14 8 33 19 9 3 23 10 29 0 S .E . 22.4 + 4.01 14.2 + 2.52 61 40 H CO c o 30 H o o c o c D 20 10 Group 1 Group 2 Figure 4. Comparison of groups 1 and 2 on a measure of degree of depression as measured by the Beck Depression Inventory (BDI). *p-=L .1 Using the Olivetti program t= 1.7314 (df=18). This was very close to being significant at the .05 level. The percentile point t distribution at a8 df required a t = 1.734 to be significant at the .05 level. As the require-ment for significance at the .05 level was not met, hypothesis 4 was accepted. Data analysis revealed that only one of the independent variables, trait dependency of client, differentiated those who attempted suicide from those who did not. Interpersonal dependency and trait dependency of spouse do not appear to contribute to suicidal behavior. The analysis of the dep-ression data suggests that depression may be significantly associated with rsuicidal behavior; however, it was borderline in this study, with a significance e at the .1 level. Chapter V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS SUMMARY This research study was undertaken to examine dependency factors in suicidal behavior. Dependency was proposed by the researcher to be an independent variable affecting the dependent variable suicidal behavior. The dependency factors studied were trait dependency of client, interpersonal de-pendency of client, and trait dependency of mate. Two groups of Psychiatric clients were studied: Group 1 consisted of clients who had attempted suicide resulting in hospitalization, and their mates. Group 2 consisted of clients who had not attempted suicide, but who had been hospitalized due to emotional problems, and their mates. Each group consisted of ten clients and ten mates. Al l clients in each group were ad-ministered the Navran Dy questionnaire and the Frequency of Dependency Expression questionnaire. All mates in each group were administered the Navran Dy. In addition, depression was monitored by administering the Beck Depression Inventory to all clients in each group. The data collected were subjected to the t-test with .05 as the accept-able significance level. Findings showed that the clients in each group differed significantly in their measure of trait dependence. Interpersonal dependency of client and trait dependence of mate did not differ between groups. Depression of clients differed significantly between groups at the .1 level. DISCUSSION OF FINDINGS Those individuals who attempted suicide were significantly more trait dependent than those who did not attempt suicide. However, they were identi-cal in their interpersonal dependence. A trait has several characteristics: (a) a trait is an attribute of behavior, not the behavior itself - certain behaviors prompt us to categorize the performer as dependent; (b) a trait is relatively enduring - an individual who has been and still is dependent can be predicted to be dependent in the future; and (c) traits can be influenced by situational determinants. Derdiarian, in a study of patients hospitalized for surgery, showed that admission to hospitalization does not significantly change trait depend-ency; however, trait dependency was significantly increased following surgery. As Derdiarian stated, it is quite likely that when the client needs material assistance from others he becomes psychologically dependent. | n this present study the clients in the suicidal group were more likely than clients in group 2 to have received physical care immediately upon admission. Such care entailed gastric lavage, intravenous therapy, catheterization and/or assistance with mobili-zation. When evaluating the finding that trait dependency is higher in individuals 103 Wiggins, op. c i t . , pp. 120-124. 104 Derdiarian, op. c i t . , p. 11. attempting suicide, the intervening variable of physical dependence of the suicide attempter in the initial hospitalization phase must be kept in mind. What are the implications of trait dependency being significantly dif-ferent between groups and interpersonal dependence being idential between groups? The Frequency of Dependency Expression Questionnaire measured the frequency of expression of behaviors believed to be germane to the fulfilling of dependency needs. Peplau has stated that individuals develop excessive dependency needs from either frequent rejection of dependency expression in childhood, resulting in fear of expressing dependency needs. Or, from over-protection, where the mother anticipates and provides for dependency needs before they are expressed, resulting in lack of acquisition of behaviors to meet dependency needs. The individual who has been overprotected passively expect j gratification of dependency! needs. 7 n e implication is that it is not incon-gruent for the clients attempting suicide to be higher on trait dependency and not differ on behavioral expressions of dependency when compared with clients who did not attempt suicide. The findings suggest that dependency of the chosen mate is not a facto affecting suicidal behavior. Finally, there is some suggestion from the data that depression may well be significantly higher in those who attempt suicide. If the sample had been slightly larger it is likely that the difference would have been significant. 105 Peplau, op. ci t . , pp. 175-177. The implications are that trait dependency is an integral part of depression. This is a view shared by psychoanalysts and independent theorists such as Farber and B e c k . ' ^ ' CONCLUSIONS On the basis of the findings of this study the following conclusions were made: 1. Suicide attempters do have a significantly higher level of trait dependence than non-suicide attempters. 2. Suicide attempters do not display a higher level of interpersonal dependence than non-suicide attempters. 3. Suicide attempters do not select mates higher in trait dependency than the mates of non-suicide attempters. 4. Suicide attempters do have a higher degree of depression than non-suicide attempters, however this was not significant. IMPLICATIONS AND RECOMMENDATIONS The results of this study have implications both for further research, and for practice. It has been shown in this study that trait dependency more clearly differentiated between those who attempted suicide and those who did not attempt suicides, than did depression. Clearly, dependency cannot be 106 Futterman, loc. cit. 107 Farber, op. c i t . , p. 30 108 Beck, 1970, p. 35. ignored as a significant contributing factor to suicidal behavior. The implications for further research bring several questions to mind. Was the trait dependency of the suicide attempter a true indication, or was it falsified by the enforced physical dependence in the initial stage of hospi-talization? Did the clients in both groups differ from non-psychiatric "normals" in their levels of trait dependence? Are the selected mates of both groups more trait dependent than the mates of non-psychiatric "normals"? And, finally, what are the appropriate interventions to reduce trait dependence? © r , cean trait dependence be altered? The researcher feels that much is to be gained by gathering further information to understand dependency factors affecting depression and suicidal behavior. If research is designed to include the mate, it is wise to prepare for a long period of time for data collection. This researcher has found many problems associated with studying suicidal behavior in individuals who are married or living common-law. First, you have to acquire the permission of two people rather than one. Often the client agreed to participate in the study and the spouse refused. Secondly, it seems that a greater percentage of indi-viduals who attempt suicide in the Vancouver region are widowed, separated, divorced or single. The researcher collected data of all attempted suicides seen at a large general hospital from October 14, 1976 to October 31, 1976. During that time forty-four persons were seen at that institution following a suicide attempt: 23 - single, 3 - divorced, 2 - widowed, 2 - separated, 11 - married, and 3 were prisoners. For Practice This research study has implications for practice in that it substantiated the notion that excessive trait dependence is a problem in the management of individuals who have attempted suicide. Individuals with excessive dependency needs are incapable of meeting the dependency needs of others, consequently close relationships are less than mutually rewarding. From the results of this study we would expect excessive dependency needs among those who attempt suicide. Consequently, intervention planning should include treatment of their dependency problems. 109 Gosling, op. ci t . , p. 25. BIBLIOGRAPHY BOOKS Beck, Aaron. Depression. Philadelphia : University of Pennsylvania Press, 1970. . The Diagnosis and Management of Depression. Philadelphia : University of-Pennsylvania Press, 1973. Campbell, W. G . Form and Style in Thesis Writing. Boston : Houghton Mifflin Company, 1969. Farber, M. Theory of Suicide. New York : Funk & Wagnalls, 1968. Farberow, N . L. , and Schneidman, E. (eds.). Cry for Help. New York : McGraw-Hill Book Company, 1961. Glass, G . V . , and Stanley, J . C . Statistical Methods in Education. Englewood Cliffs, New Jersey : Prentice-Hall, 1970. Goldin, George. Dependency and its Implications for Rehabilitation. Toronto : D. C . Heath and Company, 1972. Gosling, Robert. Support, Innovation and Autonomy. London : Tavistock Publications, 1973. Lester, David. Why People Kill Themselves. Springfield, Illinois : Charles C . Thomas, 1972. Levitt, Eugene, et a l , Depression. (New York : Springer Publishing Company, 1975. p. 47. Leibert, Robert, (ed.) Developmental Psychology. Englewood Cliffs, New Jersey : Prentice-Hall, 1974. Mussens, P. H. (ed.). Carmichael's Manual of Child Psychology. New York : Wiley, 1970. Peplau, H. Interpersonal Relations in Nursing. New York : G . P. Rjtnam's Sons, 1952. Plutchik, Robert. Foundations of Experimental Research. New York : Harper & Row Publishers, 1968. 70 Rosenbaum, C , and Beebe, J . (eds.). Psychiatric Treatment Crisis/Clinic/  Consultation. New York : McGraw-Hill Book Company, 1975. Spaulding, J . , and Simpson, G . (trans.). Suicide, by Emile Durkheim. Glencoe, Illinois : The Free Press, 1951. Sullivan, H. S. The Interpersonal Theory of Psychiatry. New York : W. W. Norton & Company, 1953. White, Robert. Lives in Progress. New York : Holt, Rinehart and Winston, Inc. 1952. Wiggins, Jerry et al . The Psychology of Personality. Don Mills, Ontario: Addison-Wesley Publishing Company, 1971. JOURNALS Adam, Kenneth and others. "Suicidal Ideation and Parental Loss". Canadian Psychiatric Association Journal. 8 (1967), 95-99. Barraclough, B. M . , and others. "A Hundred Cases of Suicide : Clinical Aspects". British Journal of Psychiatry. 125 (1974). 355-373. Beller, Emmanuel. "Dependence and Independence in Young Children", The Journal of Genetic Psychology. 87 (1955). 25-35. Berg, l.'an. "A Self-Administered Dependency Questionnaire ( S . A . D . Q . ) for use with Mothers of School Children", British Journal of  Psychiatry. 124 (1974). 1-9. Braaten, L. J . , and Darling, C . D. "Suicidal Tendencies Among College Students", Psychiatric Quarterly. 36(1962). 665-692. Brown, J . H. "Suicide - The Deserted Field", Canadian Psychiatric Association Journal. 18 (1973). 93. Buglass, D., and Horton, J . "A Scale for Predicting Subsequent Suicidal Behavior". British Journal of Psychiatry, 124(1974). 573-578. Cocking, C . "If B.C. is Paradise, Why is the Suicide Rate the Highest in Canada", Saturday Night. 1973. Crook, T . , and Raskin, A . "Association of Parental Loss with Attempted Suicide and Depression". Journal of Consulting and Clinical Psychology. 43 : 2 {\975)7l7T. Dorpat, T. L . , and others. "The Relationship Between Attempted Suicide and Completed Suicide". Comprehensive Psychiatry. 8 (1967) 74-89. Farberow, N . L. , and others. "Suicide Among Patients with a Diagnosis of Anxiety Reaction or Depressive Reaction in General Medicine and Surgical Hospitals." Journal of Abnormal Psychology. 71 : 4 (1966). 287-299. Farberow, N . L. , and Reynolds, D. "Dyadic Crisis Suicides in Mental Hospital Patients". Journal of Abnormal Psychiatry. 78 : 1 (1971). 77-85. Fawcett, Jan, and others. "Clues from Interpersonal Communication", Archives of General Psychiatry. 21 (1969). 129-137. Fellner, Carl. "Provocation of Suicide Attempts". Journal of Nervous and Mental Disease. 133 (1961). 55-58. Gewirtz, J . L. "A Program of Research on the Dimensions and Antecedents of Emotional Dependence". Child Development. 27 : 2 (1956) Golightly, C , and others. "Children's Dependency Scale". Developmental Psychology. 3 : 1 (1970). 114-118. Greer, S. "Parental Loss and Attempted Suicide : A Further Report". British Journal of Psychiatry. 112 (1966) 465-470. Guze, S . , and Robins, E. "Suicide and Primary Affective Disorders". British Journal of Psychiatry. 117 (1970). 437-438. Harris, Rosalie. "Factors Related to Continued Suicidal Behavior in Dyadic Relationships". Nursing Research. 15 (1966) 72-75. Hattem, J . V. "Precipitating Role of Discordant Interpersonal Relationships in Suicidal Behavior". Dissertation Abstracts. 25 (1964). 1335-1336. Heathers, Glen. "Acquiring Dependence and Independence : A Theoretical Orientation". The Journal of Genetic Psychology. 87 (1955) 280. Kumler, F. R. "Communication Between Suicide Attempters and Significant Others : An Exploratory Approach." Nursing Research. 13 (1964) 268. Leonard, C . V . "Depression and Suicidally". Journal of Consulting and Clinical Psychology. 42 : 1 (1974) 98^T0~£ Lester, David. "Resentment and Dependency in the Suicidal Individual". Journal of General Psychology. 81 (1969). 137-145. Lukianowicz, N . "Suicidal Behavior : An Attempt to Modify the Environment". British Journal of Psychiatry. 121 (1972) 387-390. Maxmen, J . , and Tucker, G . "No Exist : The Persistently Suicidal Patient". Comprehensive Psychiatry. 14 : 1 (1973). 71-78. Minkoff, Kenneth, and others. "Hopelessness, Depression and Attempted Suicide". American Journal of Psychiatry. 30 : 4 (1973). 455-459. Murphy, George. "Clinical Identification of Suicidal Risk". Archives of General Psychiatry. 27 (1972). 356-359. Navran, Leslie. "A Rationally Derived MMPI Scale to Measure Dependency". Journal of Consulting Psychology. 18 : 3 (1954). 192. Pallis, D., and Birtchnell, J . "Personality and Suicidal History in Psychiatric Patients". Journal of Clinical Psychology. 32 : 2 (1976). 246-253. Paykel, Eugene, and others. "Suicide Attempts Following Acute Depression". The Journal of Nervous and Mental Disease. 153-: 4 (1971). 234-243. Paykel, Eugene and others. "Suicidal Feelings in the General Population : A Prevalence Study". British Journal of Psychiatry. 124 (1974). 460-469. Poeblinger, W. J . , and others. "Suicide Risk and MMPI Scores, Especially as Related to Anxiety and Depression". Life-Threatening Behavior. 3 : 2 (1973). 147-153. Pokorny, Alex. "Suicide Rates in Various Psychiatric Disorders". The Journal of Nervous and Mental Disease. 139 : 6 (1964). 499=-506. Pokorny, Alex. "Hopelessness and Attempted Suicide : A Reconsideration" American Journal of Psychiatry. 132 : 9. (1975). 954-956. Silver, Michael, and others. "Relation of Depression of Attempted Suicide and Seriousness of Intent". Archives of General Psychiatry. 25 (1971) 573-576. Simon, W. , and Lumry, Gayle. "Suicide of the Spouse as a Divorce Substitute". Diseases of the Nervous System. September (1970). 608-672:: Tabachnick, Norman. "Interpersonal Relations in Suicide Attempts". Journal of Clinical Psychology. 24 (1968) 17-19. Tuckman, J . , and Young, Wm. "A Scale for Predicting Suicidal Risk in Attempted Suicide". Journal of Clinical Psychology. 24(1968) 17-19. Woodruff, Robert and Others. "Suicide Attempts and Psychiatric Diagnosis Diseases cof Ithe Nervous System. September (1972). 617-621. APPENDIX A Consent Form 75 APPENDIX A CONSENT FORM I, the undersigned, do agree to participate in this study conducted at the Hospital. It has been explained to me that the purpose of this study is to acquire knowledge about people experiencing acute emotional discomfort and their subsequent method of seek-ing relief from this discomfort. I understand that participation in this study involves answering three questionnaires consecutively which will require ap-proximately forty-five minutes of my time. I understand that confidentiality will be maintained and that my name will not be used. I understand that I am free to withdraw from the study at any time. I have been told that, on request, I will be informed of the results of the study when completed. SIGNATURE WITNESS DATE 1 APPENDIX B Navran Dy APPENDIX B Navran Dy Please mark a "T" beside each statement that is true, or mostly true as applied  to you, and an "F" beside each statement that is false or not usually true as applied to you. Remember to give your own opinion of yourself. Do not leave any space blank if you can avoid., it. Try to make some answer to every statement. I am about as able to work as I ever was When I take a new job, I like to be tipped off on who should be gotten next to. At times I have very much wanted to leave home. Noione seems to understand me. I have had periods of days, weeks, or months when 1 couldn't take care of things because I couldn't "get going". I loved my father. I wish I could be happy as others seem to be. I used to like drop-the-handkerchief. My feelings are easily hurt. I am easily downed in an argument. I am certainly lacking in self-confidence. I believe in the second coming of Christ. I have met problems so full of possibilities that I have been unable to make up my mind about them. I am happy most of the time. Criticism or scolding hurts me. Appendix B - continued My conduct is largely controlled by the customs of those about me. I cry easily. I do not tire quickly. I like to know some important people because it makes me feel important. What others think of me does not bother me. I find it hard to make talk-.when I meet new people. I feel weak all over much of the time. I do not have spells of hay fever or asthma. I wish I were not so shy. My people treat me more like a child than a grown-up. I brood a great deal. I have been disappointed in love. I have difficulty in starting to do things. I am entirely self-conficent. When in a group of people I have trouble thinking of the right things to talk about. In school I found it very hard to talk before the class. Even when I am with people I feel lonely much of the time. I am easily embarrassed. I feel great anxiety about something or someone almost all the time. I have certainly had more than my share of things to worry about. I usually have to stop and think before I act even in trifling matters. I have several times given up doing a thing because I thought too little of my ability. Appendix B. - continued. 1 am inclined to take things hard. I am more sensitive than most other people. Religion gives me no worry. When I am feeling very happy and active, someone who is blue or low will spoil it al l . I wish I could get over worrying about things I have said that may have injured other peoples' feelings. People often disappoint me. I have often felt badly over being misunderstood when trying to keep some-one from making a mistake. I frequently ask people for advice. 1 have sometimes felt that difficulties were piling up so high that I could not overcome them. I often think, "I wish I were a child again." I am apt to hide my feelings in some things, !to the point that people may hurt me without their knowing about it. I am apt to pass up something 1 want to do because others feel that I am not going about it in the right way. I feel like giving up quickly when things go wrong. I pray several times every week. I feel sympathetic towards people who tend to hang on to their grief and troubles. I sometimes find it hard to stick up for my rights because I am so reserved. People can pretty easily change me even though I thought that my mind was already made up on a subject. I shrink from facing a crisis or difficulty. If I were an artist I would like to draw children. I am apt to pass up something 1 want to do when others feel that it isn't worth doing. APPENDIX C Frequency of Dependency Expression Questionnaire 81 APPENDIX C Frequency of Dependency Expression Questionnaire The following questionnaire has been designed for the purpose of research. It is very important that all questions are answered carefully. However, do not spend a great deal of time on any one question. Do not change your answers. Please answer all questions. Many items contain the term spouse. Spouse refers to your husband or wife. See Answer Code - left  Answer Code You answer each item by placing one of those numbers Very frequently 1 in the space provided. Moderately frequently 2 Select the number beside the set of words which is true Frequently 3 or mostly true as applied to you. Infrequently 4 There is no correct answer Moderately infrequently 5 Example: 1. I do gardening. (6) Very Infrequently 6 In the above example the answer given was -very infrequently. My spouse and I share common leisure activities, tell my spouse I love him/her. cry. dress to please my spouse, buy gifts for my spouse. sit beside my spouse when watching T .V . or reading, accompany my spouse on outings, hug my spouse tell my spouse he/she dresses well, touch my spouse when talking to him/her. hold hands with my spouse when walking, have sexual intercourse with my spouse shout at my spouse tell my spouse his/her cooking is good even when it is not. When I buy food I select what my spouse would like even if I do not like it. Appendix C - continued. During my day's work, I telephone my spouse at least once. In social gatherings, I ask my spouse to assume responsibility for introductions. I ask my spouse if he loves me. I hyrry home. When my spouse is late I pace the floors. I kiss my spouse. I spend hours improving my personal appearance. When my spouse is late I place telephone calls attempting to locate him/her. I talk about the accomplishments of my spouse. If I plan to go to a movie, I ask my spouse to help me choose the movie. When I feel tired I ask my spouse to help me with the household chores that I normally am supposed to do. If my spouse is busy with an activity I offer my helpf.o I pout. When I am not feeling well I pretend to my spouse that I feel worse than I really do. I ask my spouse if the way I dress pleases him/her. APPENDIX G ,i ( c o n t i n u e d ) R e l i a b i l i t y T a b u l a t i o n s " —• - —'• V " >-Score on i n i t i a l t e s t i n g . R a nking f o r f i r s t t e s t S c o r e on second t e s t i n g R anking f o r f i r s t t e s t d i f f e r e n c e between r a n k i n g s f o r each p e r s o n d i f f e r e n c e squared s l fh. S 2 R 2 d d2 118 9 125 11 -2. 4. 147 18 151 18 0. 0. 171 19 166 19 0. 0. 138 17 138 16.5 0.25 .25 124 10.5 126 13 -2.5 6.25 128 13 128 14 -1.0 1 93 2 94 2 0. 0. 127 12 125 11 + 1. 1. 77 1 90 1 0. 0. 124 10. 5 105 3.5 7.0 49. 133 16 137 15 1. 1. 109 6.5 116 6 .5 .25 129 14 138 16.5 -2.5 6.25 132 15 123 9 6. 36. 101 3 106 5 -2. 4. 107 5 105 3.5 1.5 2.25 104 4 125 11. -7. 49. 109 6.5 120 8 -1.5 2.25 14 8. 117 7 1. 1. d 2 - 163.5 R + + 6 d2 - = 1 6 (163.5) = 1 -981 n ( N 2 - l ) 19 (360) . 6 840 = 1 - .1434 = .8566 = .9 APPENDIX C - c o n t i n u e d V a l i d i t y T a b u l a t i o n s % Agreement Q u e s t i o n s JUDGES' RESPONSES f o r 4 o r 5 A B C D E F G H I J g. "5 1 3 5 4 5 4 4 5 5 4 5 90 3 5 5 5 5 2 3 3 5 3 4 70 4 4 5 5 5 5 3 5 5 4 4 90 5 5 5 4 5 5 5 5 3 5 5 90 6 5 5 5 5 4 4 4 5 4 5 100 7 5 5 5 5 5 5 5 3 4 5 90 3 5 5 4 5 4 5 5 4 3 4 90 9 5 5 5 5 5 5 5 5 5 4 90 10 3 5 5 5 4 4 3 4 5 5 90 11 5 5 5 5 5 5 5 5 4 5 90 14 5 5 5 5 5 5 5 5 5 5 100 15: 5 5 5 5 5 5 5 5 5 5 100 16 5 5 5 5 5 5 5 5 4 5 100 17 4 5 5 5 4 4 3 4 4 3 70 18 5 5 5 5 5 4 5 4 4 3 90 19 5 5 4 5 4 5 3 5 4 5 90 21 5 3 3 5 5 5 5 4 5 5 80 22 5 5 5 5 5 5 5 5 5 5 100 23 5 5 4 5 4 4 3 5 3 3 70 25 5 5 4 5 5 4 4 4 3 5 90 26 5 5 5 5 5 5 5 5 4 4 100 APPENDIX G - c o n t i n u e d # % Agreement Q u e s t i o n s JUDGES' RESPONSES f o r 4 o r 5 A B C D E F G H I J % 27 4 5 5 5 5 4 5 5 5 5 100 28 5 5 4 5 4 5 4 4 2 5 90 29 5 5 3 5 4 4 4 5 4 5 90 30 5 5 4 5 5 5 5 3 4 5 90 31 5 5 5 5 5 3 3 3 4 4 70 32 5 5 4 5 4 3 3 3 4 4 70 33 5 5 5 5 5 5 5 5 4 5 100 34 5 5 5 5 3 5 5 5 4 5 90 35 5 5 5 5 5 5 5 4 4 5 100 Note: The f o l l o w i n g q u e s t i o n s were o m i t t e d from the q u e s t i o n n a i r e as p e r c e n t a g e a g r e e -ment amongst judges was l e s s than 70%: 2 5 5 5 5 2 3 3 5 3 3 50 12 5 5 5 5 5 4 3 2 2 2 60 13 5 5 5 5 3 3 1 4 2 3 50 20 3 5 5 5 3 4 3 3 4 4 60 24 5 3 5 1 5 2 1 2 3 3 30 CO APPENDIX D Beck Depression Inventory 87 APPENDIX D Beck Depression Inventory 0 I do not feel sad 1 I feel blue or sad 2a I am blue or sad all the time and I can't snap out of it. 2b I am so sad or unhappy that it is quite painful 3 I am so sad or unhappy that I can't stand it. 0 I am not particularly pessimistic or discouraged about the future la I feel discouraged about the future 2a I feel I have nothing to look forward to 2b I feel that I won't ever get over my troubles 3 I feel that the future is hopeless and that things cannot improve. 0 I do not feel like a failure 1 I feel that I have failed more than the average person 2a I feel I have accomplished very little that is worthwhile or that means anything. 2b As I look back on my life all I can see is a lot of failure 3 I feel I am a complete failure as a person (parent, husband, wife) 0 I am not particularly dissatisfied la I feel bored most of the time lb I don't enjoy things the way I used to 2 I don't get satisfaction out of anything anymore. 0 I don't feel particularly guilty 1 I feel bad or unworthy a good part of the time 2a I feel quite guilty 2b I feel bad or unworthy practically all the time now 3 I feel as though I am very bad or worthless 0 I don't feel that I am being punished 1 I have a feeling that something bad may happen to me 2 I feel" liam being punished or will be punished 3a I feel I deserve to be punished 3b I want to be punished 7 88 Appendix D - continued 0 la lb 2 3 0 2 2 3 0 1 2a 2b 3a 3b 0 1 2 3 0 1 2 3 0 1 2 0 1 2 3 don't feel disappointed in myself am disappointed in myself don't like myself am disgusted with myself hate myself don't feel I am any worse than anybody else am critical of myself for my weaknesses or mistakes blame myself for my faults blame myself for everything bad that happens don't have any thoughts of harming myself have thoughts of harming myself but I would not carry them out feel I would be better off dead feel my family would be better off if I were dead have definite plans about committing suicide would kill myself if I could don't cry any more than usual cry more now than I used to cry all the time now. I can't stop it used to be able to cry but now I can't cry at all even though I want to. am no more irritated now than I ever was feel annoyed or irritated more easily than I used to feel irritated all the time don't get irritated at all at the things that used to rritate me have not lost interest in other people am less interested in other people now than I used to be have lost most of my interest in other people and have ittle feeling for them have lost all my interest in other people and don't care about them at all make decisions about as well as ever try to put off making decisions have great difficulty in making decisions can't make any decisions at all any more 89 Appendix D - continued 0 I don't feel I look any worse than I used to 1 I am worried that I am looking older or unattractive 2 I feel that there are permanent changes in my appearance and they make me look unattractive 3 I feel that I am ugly or repulsive looking 0 I can work about as well as before la It takes extra effort to get started at doing something lb I don't work as well as I used to 2 I have to push myself very hard to do anything 3 I can't do any work at all 0 I can sleep as well as usual 1 I wake up more tired than I used to in the morning 2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep 3 I wake up early every day and can't get more than 5 hours sleep 0 I don't get any more tired than usual 1 I get tired more easily than I used to 2 I get tired from doing anything 3 I get too tired to do anything 0 My appetite is no worse than usual 1 My appetite is not as good as it used to be 2 My appetite is much worse now 3 I have no appetite at all now 0 I haven't lost much weight, if any, lately 1 I have lost more than 5 pounds 2 I have lost more than 10 pounds 3 I have lost more than 15 pounds 0 I am no more concerned about my health than usual 1 I am concerned about aches and pains or upset stomach or constipation 2 I am so concerned with how I feel or what I feel that It's hard to think of much else 3 I am completely absorbed in what I feel 0 I have not noticed any recent change in my interest in sex 1 I am less interested in sex than I used to be 2 I am much less interested in sex now 3 I have lost interest in sex completely 9 APPENDIX E Summative Table of All Raw Data APPENDIX E SUMMATIVE TABLE OF ALL RAW DATA GROUP A GROUP B Client Mate Client Mate S(s) FDEQ N.DY BDI N.DY FDEQ N.DY BDI N.DY 1 111 24 3 18 955 46 20 23 22 150 42 40 16 110 32 21 18 3 104 33 28 27 73 24 15 10 4* 82 38 14 35 115 9 12 29 55* 120 34 16 17 129 14 1 35 6 85 40 30 21 92 39 17 10 7 92 40 28 21 98 36 14 35 8 109 52 33 37 121 24 19 19 9 71 44 3 30 109 32 23 11 10 101 43 29 16 80 11 0 18 X +102.5 39.0i 22.4 23.8 102.2 26.7 14.2 20.8 S . E . + 7.08 + 2.38 + 4.01 + 2.51 + 5.64 + 3.97 + 2.52 + 3.03 *Clients 4 and 5 in each group were males. 

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