http://exhibits.library.stonybrook.edu/mfp/files/original/2e0c07f8713070c07cedfceccd13935e.pdf f963256ba3adedd04d38ff5d4403fc1f PDF Text Text Social Factors in the Selection of Therapy in a Voluntary Mantel Hospital Robert L. Kahn, Ph.D. Max Pollack, Ph.D. Max From Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Aided by Grant Me927 of the National Health Service. 10-8-57 N.Y. Institute of Mantel Health, U.S. Public j M M 3:) �Social Factors in the Selection of Therapy in a Voluntary Mental Hospital Recent investigations have indicated a relationship between social class and illness (3, 5, 6, and and incidence of mental psychiatric disorder with respect to type therapeutic selection 13, 1h), outcome (10). The and maintenance of treatment (2, 6, 15), present study is concerned with social factors in the selection of therapy in a voluntary mental hospital. In the studies reported by Bollingshead, Redlich and their co—workers (3, 5, 6, 13, 15), the population of classes New Haven was divided into five social basis of weighted criteria of education, occupation on the of residence. Of the residents who were under and place psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care Of was more common among the psychotherapies, psychoanalysis groups. was entirely restricted to the two upper Social class was the predominant determinant of the type of treatment selected even as follows: when the diagnosis "..... it is found was held constant. They summarize their results that treatment does not and medical determinants alone, but on the well. the lower classes. depend on psychological status position of the patient as degree Psychotherapeutic methods are applied in disproportionately high to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's financial resources or the �- 2 - extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting therapeutic techniques and services are available to where the same This requirement is met all patients. at Hillside Hospital. It is a non-profit, sectarian institution for the treatment of voluntary patients with "early curable mental symptoms" (h), pay. are admitted regardless of their and ability to criteria for accepting patients is their "ability to of the main One who non- participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy available is regarded as the when needed. primary method of treatment with organic therapies The average length of hospital stay is six months, al- though some patients remain for as long as a year. The present investigation is of electroshock therapy. an outgrowth of In previous work several years of study it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose patients differ of the present study from those was to determine whether electroshock receiving other forms of treatment in regard to cultural background, including such factors as education and personality as measured by the California F and place of birth, scale (1); secondly, whether these factors were also related to referral for adjunctive hoSpital services. �m: Population: as of March 7, The 1957 was entire in-patient adult population of Hillside Hbspital studied. This constituted a total of ranging in age from 16 to 68 with a mean 172 of 3h.6, and including patients, 58 men and 11h women. 1) The population was subdivided Procedure: into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only. * 2) The groups were compared for age, education and place of birth. I 3) of the California naire (see F All patients were tested scale suggested by Levinson (9). Appendix) which has been The F scale The patient reads ten statements indicates whether he agrees or disagrees with each statement tent. The and score given for each item ranges from one to seven and the score range is tained. is a question- related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). and ** with a ten-item.modification The 10 to 70. The to what ex- total greater the agreement the higher the score ob— statements themselves are extreme, uncritical or stereotyped expressions. patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data was included in both groups. In the results this makes a total of 179 subJects. * All patients were tested with the F scale prior to treatment. In the case of those patients who were actually on EST on march 7th their pre-treatment scores were used in the statistical compar- ** As part of ison since treatment. an ongoing study all the EST it had been found that EST significantly affects the score during �-uh) The population was subdivided in regard of certain adjunctive services in the hospital. Among to utilization such services available are group activities, occupational therapy, psychological testing therapy. The latter is a diagnostic and and creative therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psychological testing and creative therapy were selected for this study because both require a specific referral from the therapist. �RESULTS: data The 1) comparison of the treatment was analyzed as follows: scores and place of groups for age, education, F scale where diagnosis is held constant, prior to treatment, birth, 2) comparison significance of length of hospitalization 3) and h) comparison between groups referred for adjunctive hospital services. I. Comparison of Treatment Groups: For each of the three treatment groups the means and standard devia- -tions for the Table I. F scale scores, The EST group had age and years of schooling are presented in higher P scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These differences reach were statistically significant for statistical significance for education. cation to differentiate the groups electroshock group contained many was due, F score and age but failed to The failure of years of edu- in part, to the fact that the foreign born patients whose education was treatment groups were subdivided into difficult to evaluate accurately. 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Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe reneived psychotherapy alone. II. Comparison of Treatment Groups in Relation The to Diagnosis: diagnostic categories of the patients in this study are comparable to those reported in previous studies of the hospital population (12). Of the fl72 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and two with other diagnoses. portion of the depressed patients with other diagnoses. To (52%) As expected, a larger pro- received electroshock than did those control for the factor of diagnosis in choice or treatment, the psychotic depression patients were subdivided into those received electroshock and those are shown who were given psychotherapy alone. .02 The results in Table II. 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Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment: While the electroshock from those receiving insulin or psychotherapy, there intra-group differences. postulated that the To account While most of the less than three months for some were who EST scores and were older were treated Place of birth h0% months were born earlier than the is also a significant factor. cance, although 28% in the U.S. The were also compared according Patients who had on higher younger and lower F scale While hh% of those all patients referred after data was referred after a period were III the patients are within three months were foreign born, six it were placed on treatment to the period of hospitalization prior to electroshock. groups. considerable of these differences received after admission, about In Table to differ patient was referred for electro- which a given patients of three to twelve months. F still shown factors involved in selection of treatment same related to the readiness with shock. patients, as a group, have been education Just treated a period of fails of signifi- of those treated earlier had less than eight years of edu— cation. IV. Use of Adignctive Hospital Services: Comparison of the logical testing is shown patients referred for creative therapy in Table IV. It is clear that of these procedures had significantly lower more education and more were for these services. 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Ho. pa 96 AHHV Ammv angdwha Hm>oH Aoﬂv .mos : u .moa .woa .noa .moa n m mo nvmumq m m .moa on nova gang swap mama w m 0p m mama can» pnaowwﬂnmﬁm pqaoﬁmﬁnmﬁm nun» can» m on mama m m .moa on mnoz mama mm .moa whoa «nos m * ** �nmnpo hmmnmna $8 Away m m Asmav m Aamv m npuwm a3 Amwmv Aﬁmv cnmpmdm # muonsm m>wpwmuo A mo mm Aﬁmav ma *mm.m *mm.® $3 mqwam cam hﬁmwv Agapv Aﬁmpv u u m>w¢dz upon mwﬁpmme 3 a» ﬂame Amway Aapmv “*pmv 8 mm my mm MN am H» «x whoa no Haowwoaonommm m mo *mm.: mowpmosum *mm.m mndow m mo soamm :5 Awmav Aﬁmv a A$MHV n H ma mtm H.: Nx m «x ma >H p mwuw>hmm am IHHI mgm¢H m.m mm.m mo ***>.m m».H aowpwuscm mama; can; 3; aw v.0“ «.mH m.HH m>ﬁponmmd¢ m.mw**om.: mm no“ O.H h%ﬁ add m.ma 5mm m.mm m.HH p :.ma mm.m om¢ o.> cams. p.0m p.»m mam: .men H.oa***mm.m a dmunmwmm am 3: m.m~ cum: 9mm p.m: w.:~ m.ma r*wm.m choom mgqmwpwm m H.mm $.H: can: .umﬁn m.w m.:a rm>¢r amped Ho>oa mo mo. Ho. :8 pa pa pa amoavhmanona Appv newwnwmabo 3239 mumua «CC. Ammv .a.o pnmUHuHamHm pacuHMwumHm * ** HQNUﬁMHanm oz mmsouo .Hoaohmm m>wpmmuo mummy :.Honommm 8385 .Honoamm oz oz .a.o oz *** �DISCUSSlON: results indicate that the factors of education, age, place of birth The and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients better educated, native born and had lower F scores. Such who were younger, patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated were most likely to be and foreign born, referred for EST. particularly in Eastern Europe, These patients infrequently were referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hbllingshead, Redlich and their co-workers (3, 5, 6, 13, 15) who demonstrated related to the type of therapy received in a community. that social factors are The present study demonstrates that such factors are also significant in a hospital setting where ability to pay is not a criteria of therapeutic selection and of therapy are equally available to the With financial aspects and the where all forms entire population. availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations factors may of therapy. may be considered. The social relate directly to the empirically established criteria for choice On this basis a patient is referred for electroshock because older, poorly educated or foreign born, clinical experience having shown he that is �such persons respond best to adequate since 13 - this type of treatment. This explanation is in- half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to ‘choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communi- cation. Thus, a patient is not referred for electroshock because he is foreign born or poorly educated, but rather, these factors provide the difference in cultural background between patient and therapist which makes successful communi» cation less likely in the psychotherapeutic relationship. Robinson 33 EE' (15) in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic rela- tionship. In the present study, similarly, the patients who received psycho- therapy alone were more like the therapists with regard to the factors studied.* Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have score of 21.8 and a mean age of 33.9. Sixteen percent were born in Eastern Europe. Their mean years of education was over 20. * The 18 therapists had a mean F �-1ushown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are patterns appear to be likely to receive electroshock (7, 8). more frequent Such language in persons with poorer socio-cultural back- grounds. Social and cultural factors, in addition to their effect on cation patterns, that, has noted may communi~ also determine the manifest symptomatology. Opler (11) patients diagnosed as schizophrenic, differences in among symptoms are related to differences in cultural background. Frank gg'gl. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those mained had ideational shock patients (8) we In a study of personality factors in electro- have noted that certain patterns of symbolic value The F scale and likely to be associated with the development of a The indicates that symptoms re- symptoms. communication were more depressive psychosis. who relationship between communication pattern symptoms themselves are a mode and of communication. furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. study the F scale was In the present the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. �- 15 - Preliminary observations from a study in progress indicate that lowbscorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing closely for age and place of necessity for developing new their social differences, by matching them more birth. 0f possible greater importance is the modes of communication when treating patients who are refractory to conventional psychotherapeutic approaches.* While epidemiological studies have clearly structured some of the problems involved in selection of treatment, and have indicated the direction of further study, it still remains for more process~oriented definitive answers. * See Esecover's presentation of this topic in this issue. research to provide �- 16 - SUMMARY: 1. In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth and score on the California F scale were significantly related to the type of therapy received and to the utilization of adJunctive hospital services. 2. Patients and were be who were older, poorly educated, had higher foreign born, particularly in Eastern Europe, referred for electroshock. those patients who most were most F scores likely to Psychotherapy was the treatment of choice for closely resembled the therapist in these aspects. were present even when diagnosis was held 3. These relationships h. Among the electroshock patients the constant. significant in choice of therapy which a patient 5. was It is were same factors found to be also related to the readiness with referred for electroshock. postulated that treatment selection is the result of the communicative interaction between patient and be important insofar as they are therapist. Social factors may related to different modes of communication. �- 17 - REFERENCES Adorno, T.W., FrankeloBrunswik, (1950): & The E., Levinson, D.J. and Sanford, Authoritarian Personality, New R.N. York: Harper Brothers. Frank, J.D., Gliedman, L.H., Imber, S.D., Nash, E.H. and Stone, A.R. (1957): Why Neurol. Am. Leave Psychotherapy, A.M.A. Arch. Psychiat., 11; 283-299. & Freedman, L.Z. and Patients Hollingsheadﬁj. (1957): Neurosis J. Psychiat., Hillside Hospital, 29th 113: 769-775. Annual Report, 1956. Schizophrenia and Social Hollingshead,A.B. and Redlich, F.C. (l95h): Structure, Am. and Social Class, J. Psychiat., 110: 695-701. Social Class and Psychiatric Ecllingshead,A.B. and Redlich, F.C. (l95h): Disorders, in Interrelations Between the Social Environment and Psychiatric Disorders, New York: Milbank MEmorial Fund, pp. 195-208. -3 Kahn, R.L. and Fink, Therapy. Zubin, M. (1957): Changes in Language During Electroshock In Psychopathology of Communication (Roch, P. and J. Eds.), Kahn, R.L. and Fink, M.: New York: Grune & Stratton. Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol., in press. Levinson, D.J.: 10. Personal Communication. Morgan, N.C. and Johnson, N.A. (1957): Chronic Hospital Patient, Am. Failures in Psychiatry: J. Psychiat., The 113: 82h-830. �-18. REIFEEENCES ll. Opler, Schizophrenia and Culture, Scientific American, M.K. (1957): .. 191: 103-110. 12. Rachlin, H.L., Goldman, 6.8., Gurvitz, (1956): ll}. Redlich, F.C., Hollingshead, A.B., Roberts, 33., Robinson, H.A., KJ. (1953): Social Structure and Psychiatric Disorders, Am. J. Psychiat., ﬂ: 729-73h. Rennie, T.A.C., Srole, L., Opler, M.K. and Langner, T.S. (1957): Am. Titus, Psychiatric Treatment, Am. H.E. and Hollander, E.P. (1957): Tougas, R.R. (19511): Urban J. Psxghia‘b” 3.3;: 831-837. Robinson, H.A., Redlich, F.C. and Myers, J .K. (195M: Psychological Research: 17. Rachlin, L. Freedman, L.Z. and Meyers, and 16. A. and J. Hillside Hospital, 2: 17-40. 1950, Life and Mental Health, 15. Lurie, Follow-up Study of 317 Patients Discharged from Hillside Hospital in 13. 14., Social Structure J. Orthopsychiat., g5: 307-316. The California F Scale 1950—1955, P331301. Bu11., Ethnocentrism as 8. it: in 147-64. Limiting Factor in Verbal Therapy, In Psychotheragy and Personality Change, C.R. Rogers and R.F. Dymond, 18. Zierer, E. and eds., Chicago: University of Chicago Press, pp. l96-21h. Zierer, E. (1956): of Creative Activity, Am. Structure and Therapeutic J. Psychotherapy, i3: Utilization 11833519. �- 19 - APPENDIX F SCALE FORM Below are a number of statements. For each statement we want you to give us your personal opinion of whether you agree or disagree. Answer each statement according to one of the following: I DISAGREE A LITTLE AGREE PRETTY MUCH I DISAGREE PRETTY AGREE VERY MUCH I DISAGREE VERY I AGREE A I I LITTLE 1. No MUCH MUCH sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. h. think about 5. ation, When it, 6. the youth needs most is will to wOrk and is best for strict discipline, fight for family Nowadays when so many much, a person has an it him not to but to keep busy with more cheerful things. What and the a person has a problem or worry, rugged determin- and country. different kinds of people mix together so to protect himself especially carefully against catching infection or disease from them. 7. Sex crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. �-20.. 8. is to The best teacher or boss is the be done and how 9. the strong. go about to get over them and tells us exactly what it. Young people sometimes up they ought 10. to one who get rebellious ideas, but as they settle grow down. People can be divided into two distinct classes: the weak and �Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital Duration of Hospitalization. Discharge Ratings. and Diagnosis ROBERT L. KAHN. Ph.D.; MAX POLLACK. Ph.D.. AND MAX FINK. M.D. GLEN OAKS. N. Y. �Reprinted from the A. M. A. Archives of General Psychiatry December 1959, Vol. I, pp. 565—574 Copyright 1959, by American Medical Association Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital Duration of Hospitalization, Discharge Ratings, and Diagnosis ROBERT L. KAHN, Ph.D.; MAX POLLACK, Ph.D., and MAX FINK, M.D., Glen Oaks, N.Y. The increasing studies of the sociopsy— chological aspects of psychiatric treatment in recent years have primarily been concerned with treatment patterns in the community,12 private practice,29 and outpatient clinics.24'2” In the studies reported by Hollingshead, Redlich, and their co—work— ers ”'27 it was found that social class was a major determinant of the type of psy— chiatric treatment in the New Haven com— munity. Patients from the upper classes were more frequently treated with psycho— therapy, while somatic or custodial care was commoner among the lower classes. They summarized their results by noting: “It was found that treatment does not depend on psychological and medical determinants alone, but on the status position of the pa27 well.” tient as Weinstock,29 reporting the results of a poll of the American Psycho— analytic Association, observed that the pa— tients being treated by their members in private practice came disproportionately from the better—educated, high-income pop— ulation. Similar ﬁndings have been noted in studies of outpatient facilities. Myers and Schaffer 2" showed that the higher a per— son’s social class the more likely he was to be accepted for psychotherapy, treated by more highly trained personnel, and treated intensively over a long period of time. In another study Rosenthal and Frank 28 Submitted for publication April 16, 1959. From the Department of Experimental Psychia— try, Hillside Hospital. Aided, in part, by Grants M-927 and MY-2092, National Institute of Mental Health, National In~ stitutes of Health, US. Public Health Service. found almost a linear relationship between educational level and frequency of referral for psychotherapy. A more critical test of the importance of sociopsychologic factors in relation to psychiatric treatment would be in a setting where the same therapeutic techniques and services were equally available to all patients. This requirement is met at Hillside Hospital, which is a nonproﬁt institution for the treatment of voluntary patients with “early and curable symptoms,” 11 who are admitted regardless of their ability to pay. One of the main criteria for accepting pa— tients is their “ability to participate proﬁt— ably in psychotherapy.” 11 Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment, with physiodynamic therapies available when needed. The average length of hospital stay is seven months, although some patients stay for more than a year. In a previous study of the Hillside Hos— pital population,“ it was shown that the factors of age, education, place of birth, and degree of stereotypy, as measured by the California F Scale,1 were related to the selection of therapy. Those patients who were older, had less education, were foreign-born, and had high scores on the F Scale were more likely to receive convulsive therapy. In contrast, patients who were younger, better—educated, and native—born and obtained low scores on the F Scale re— ceived psychotherapy as their sole form of treatment. The purpose of the present study was to determine the relation of sociopsychological 27/565 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY factors to (1) the duration of hospitaliza— tion, (2) the clinical evaluations at time of discharge, and (3) the ﬁnal diagnosis. Population Method Population—The entire inpatient adult population of Hillside Hospital on March 7, 1957, was studied. This consisted of 171 patients, 57 male and 114 female, ranging in age from 16 to 68 years, with a mean of 35 years. Procedura—The patients were divided according to the duration of hospitalization, clinical response to treatment, and diagnosis. The duration was de— termined by the number of complete months in the hospital. The clinical response and the diagnosis were determined by the medical director at a staff evaluation conference, usually held just prior to the patient’s discharge. Each patient was rated as recovered, much improved, improved, or unim— proved on the basis of the reports of the therapist, supervising psychiatrist, and milieu staff. The discharge diagnoses were divided into four major groups: involutional psychosis, manic—depressive psychosis, schizophrenia, and psychoneurosis. These diagnostic categories included all but three patients in the population. Each patient was tested with a lO—item modiﬁcation of the California F Scale.20 The F Scale is a questionnaire which has been related to such factors as authoritarianism, acquiescence, ethnocentrism, and rigidity.1 The subject reads 10 statements and indicates to what extent he agrees or disagrees with each, i.e., “a little,” “pretty much,” or “very much.” The score for each item ranges from 1 to 7, and the total score range is 10 to 70. High scores indicate greater agreement with the statements. These are extreme, uncritical, or stereotyped expressions. For example, one state— ment is this: “If people would talk less and work more, everybody would be better off.” 1. Results Length of Hospitalization—In this population the duration of hospitalization ranged from 1 to 16 months, With a median of 7 months. For the purpose of analysis, the population was divided into three groups: 49 patients who were hospitalized for 1 to 5 months; 64, for 6 to 9 months, and 58 for 10 or more months. The relation of sociopsychological factors to the length of hospitalization is shown in Table l. The group of patients who were hospitalized for the shortest period had 28/566 1.—Dnration of Hospitalization: Total TABLE Months in Hospital No. to 5 to 9 or more 49 04 58 1 6 10 F Score. Mean 43.9 Age, Mean Yr. 45.5 32.5 27.9 40.1 31.0 Education. Mean Yr. ForeignBorn 10.0 11.9 12.8 41% 19% 10% x’=l5.0 I Moan Mean Diﬁ'i r- Diﬁ‘eiences Differences 13.0 § 1.9 T § ences to 1‘s. l to 5 vs. more 6 to 9 vs. more 1 0 lo 10 10 9 3.4 Mean or 12.9 § 17.6 § 2.8 9.5 § 4.6 * 0.9 or P<0.05. t P<0.02. I P<0.01. § P<0.001. * the highest mean F scores, were oldest, and had the least education and the largest per— centage of foreign—born. Conversely, the group in the hospital for 10 months or more had the lowest F scores, were youngest, and had the most education and the smallest percentage of foreign births. Patients who were hospitalized for an intermediate period fell in beLween these two groups for each of the factors. When the data for those patients who re— ceived convulsive therapy (Table 2) and those who received psychotherapy (Table .3) as their only form of treatment were analyzed separately, similar relationships between sociopsychological factors and length of hospitalization were found within each group. In the psychotherapy group there was an increase in mean years of education with greater months of hospitalization, but the differences fail of signiﬁcance. It may be noted, however, that many of the patients who were in the hospital for 10 months or more were under 19 years of age and were thus unable to achieve more than a limited number of years of schooling. These same relationships of sociopsychological factors to length of hospitalization were found when the patients were classiVol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 2.—Dnration of Hospitalization: Patients Receiving Convnlswe Therapy Months in Hospital F Score, No. Mean to 5 6 to 9 10 or more 15 1 to 5 vs. 1 to 5 vs. more 6 to 9 vs. more 1 “ T 1 § 17 25 to 9 10 or 6 58.2 45.6 34.9 . Mean Yr. 51.7 42.2 32.1 Yr. Born 6.5 12.3 13.2 67% 24% 16% x2=12.0 I Mean Diﬁer- ences ences ences 12.61 9.5 ‘ 5.81 1 of Hospitalization: Patients Receiving Psychotherapy Only Education, Mean Foreign- Mean Diﬁer- Months in _ 1 6 10 or § 19.6 § * 10.1 t NO- t0 5 to 9 or more 33 43 6.7 to 5 (is. to 5 vs. more to 9123. more 1 * 11-4 11.7 12.4 30% 16% 8% Mean to 9 10 or 6 1.6 12,4 10 * Diﬂ‘er- Differ— ences ences 14.1 * 0.3 18.4 * 1.0 or 10.8 Mean 4.3 0.7 . . almost deﬁnlte, a hnear, relat1onsh1p be— tween the ratings of improvement and these factors. Patients in the recovered group had the highest F scores, were oldest, least educated, and showed the highest incidence of foreign birth. In contrast, patients in the unimproved group had the lowest F scores, were younger, better educated, and were mostly native—born. Because of the wide variability within each group, however, only the factor of age reached a level of statistical signiﬁcance. Education also sig— niﬁcantly differentiated the groups when dichotomized according to those who had less than eight years of education and those who had eight years or more. Of the re— covered patients, 29% had less than eight IS TABLE 43-2 29.1 24-8 ForeignBorn P=0.001. . ﬁed according to four major diagnostic groups (Table 4). For each diagnostic class, the lowest F scores, youngest mean ages, most years of education, and least percentages of foreign—born were characteristic of patients hospitalized for the longest periods. As a group, patients diagnosed as schizophrenic were the most homoge— neous in relation to time in the hospital, showing major differences only in the F score, without a consistent trend for the factors of education or place of birth. 2. Results of Treatment—The relation of sociopsychological factors to evaluation on discharge is shown in Table 5. There 40-2 38-6 27-8 Differences 0.9 p<omL Mean Yr. Mean § P<0.05. P<0.02. P<0.01. F Score, Mean Education, Mean Yr. 26 Mean Diﬂer- 6 10.7 HOSDltal Age, x’=5.4 1 23.3 10 Age, TABLE 3.——Dui*a_tion _ _ 4.—Duration of Hospitalization in Patients Classiﬁed According to Diagnosis Diagnosis Months in Hospital F Score, Mean Mean Yr. Involutional psychosis ___________________ 1-5 58.2 50.9 35.0 58.8 54.5 52.3 9.6 16.0 40.0 46.1 33.1 46.8 39.1 35.5 11.0 11.7 12.3 39% 23% 40.1 36.6 36.1 41.0 27.1 27.1 8.7 12.5 12.5 50% 19% 13% 36.3 38.5 27.6 27.8 27.8 24.1 13.3 12.3 12.9 10% ‘ 6—9 10+ Manic-depressive psychosis .............. 1-5 6-9 10+ Psychoneurosis ........................... 1-5 6—9 10+ Schizophrenia ............................ 1-5 6—9 10+ Kahn et al. Age, Education, Mean Yr. 7.1 Foreign-Born 57% 43% 0 0 8% 12% 39/ 567 �M a? A. M. A. ARCHIVES OF GENERAL PSYCHIATRY TABLE Evaluation ............................... .......................... ................................ ............................. Recovered Much improved Improved Unimproved 5.—Discharge Evaluation No. 17 82 63 9 F Score, Mean 42.9 39.0 36.1 31.1 Age, Mean Yr. Education, Mean Yr. Foreign-Born 44.5 35.6 31.2 31.1 10.7 11.2 11.2 13.2 41% 22% 16% 11 % x 2=6.1 Mean Differences Recovered vs. Much Improved Recovered vs. Improved Recovered vs. Unimproved ............................. .................................... ................................. Much Improved 08. Improved ............................. Much Improved vs. Unimproved ........................... Improved vs. Unimproved ................................. 3.9 6.8 11.8 2.9 7.9 5.0 Mean Differences 8.9 * 13.3 I 13.4 4.4 4.5 0.1 * T Mean Diﬂ'erences 0.5 0.5 2.5 0.0 2.0 2.0 ' P<0.05. P<0.02. t P<0.01. 1‘ years’ education, while all of the unimproved patients had more than eight years’ educa— tion; the much improved and improved pa— tients were in between. By X2—analysis these results were signiﬁcant at the 5% level of conﬁdence. When the data were analyzed for the patients treated with convulsive therapy, the trends noted for the population as a whole were intensiﬁed (Table 6). Analysis of the patients who received psychotherapy as their only form of treatment (Table 7), however, failed to show any statistically signiﬁcant pattern. The recovered patients were oldest and had the highest percentage of foreign births, but education and F score did not show any clear trend. TABLE 3. Diagnosis.~—The relation of sociopsy- chological factors to diagnosis is shown in Table 8. Those patients classiﬁed as show— ing involutional reactions had the highest F scores, the oldest mean age, the least years of education, and the highest inci— dence of foreign birth. In contrast, pa— tients classiﬁed as schizophrenic had the lowest F scores, the youngest mean age, the most years of education, and the least num— ber of foreign—born. Patients classed in manic—depressive psychosis and psycho— neurosis categories were in between with regard to these social factors. Comment The present study has demonstrated that sociopsychological factors, in addition to 6.—Discharge Evaluation in Patients Receiving Convnlsive Therapy Evaluation N 0. F Score, Mean Recovered _______________________________ Much improved __________________________ Improved and unimproved _______________ 8 26 23 53.1 41.8 39.7 Mean Differences Recovered vs. much improved ______________________________ Recovered vs. improved and unimproved___________________ Much improved vs. improved and unimproved _____________ 11.3 13.4 ‘ 2.1 Age, Mean Yr. Education, Mean Yr. 51.6 43.8 32.3 9.4 10.6 12.3 Mean Foreign-Born 50% 35% 17% x *=3.5 Differences Mean Diﬁerences 7.8 19.3 I 11.5 t 1.2 2.9 1.7 * ’ P<0.05. P<0.02. I P<0.001. ’r 30/568 Vol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 7.——Discharge Evaluation in Patients Receiving Psychotherapy Only F Score, Mean N 0. Evaluation ............................... .......................... Recovered Much improved Improved and unimproved ............... 54 32-6 38.1 39 33.5 9 Age, Mean Yr. Education, Mean Yr. Foreign-Born 38.2 32.2 31.9 12.3 12.0 12.2 33% 15% 18% x '= 1.8 Mean Differences .............................. ................... ............. Recovered us. much improved Recovered vs. improved and unimproved Much improved vs. improved and unimproved 5.5 0.9 4.6 their previously determined importance in the selection of treatment, are also signiﬁcantly related to the duration of treatment, the evaluation of the results of treatment, and the psychiatric diagnosis. If such results were obtained in a survey of private practitioners, as in the Weinstock report,29 it could be concluded that the limitation of the number of practitioners and the expense of treatment served to select preferred persons from the upper social classes who could afford the treatment in terms of time and money. The present results, however, were obtained in an institution where the various kinds of'treatment were equally available to all patients and where the ability to pay was not a factor in the management of the patient. We postulate, therefore, that TABLE Mean Differences Mean Differences 6.0 6.3 0.3 0.3 0.1 0.2 the observed relationships are not due merely to mechanically selective aspects, such as income or the prestige status of the patient. Social factors are important because they are also related to psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. We shall attempt to evaluate these processes and their effect on the psychiatric relationships studied in terms of the inﬂuence of sociopsychological factors on the attitude and behavior of the therapist, the patient, and the therapist-patient interaction. Current data both from this laboratory 14 and from others 12'24’27'28 have demon— strated that psychotherapy is most likely to be sustained with those persons who most 8,—Diagnosis Diagnosis N 0. F Score, Mean Involutional psychosis ___________________ Manic-Depressive psychosis ______________ Psychoneurosis ___________________________ Schizophrenia ____________________________ 24 39 37 68 52.3 40.8 36.9 32.8 Age, Mean Yr. 56.7 41.9 29.4 26.1 Education, Mean Yr. 8.9 , 11.5 11.9 12.7 Foreign~Born 46% 26% 22% 10% x’=14.2 I Mean Involutional vs. Manic-depressive psychosis ................ Involutional psychosis vs. psychoneurosis __________________ Involutional as. schizophrenia ______________________________ Manic-depressive psychosis vs. psychoneurosis _____________ Manic-depressive psychosis vs. schizophrenia_______________ Psychoneurosis vs. schizophrenia ___________________________ Mean Mean Differences Differences Differences 11.5 I 15.4 I 19.5 § 14.8 27.3 § 30.6 § 3.9 8.0 4.1 12.5 15.8 3.1 § 2.0 ‘ 3.0 I 4.5 § 0.4 1.6 0.8 T § § P<0.05. T P<0.02. 1 P<0.01. § P<0.001. * Kahn et al 31/569 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY closely resemble the therapists with regard to cultural' background, systems of value, and communication patterns. With stress at Hillside Hospital on psychoanalytically oriented psychotherapy, it is consistent that those patients who are most like the therapists with regard to these factors would be kept in the hospital for the longest period. This was true for patients receiving convulsive therapy or psychotherapy and for all diagnostic groups. The length of time a patient remains in a psychiatric facility is related to the par— ticular function and philosophy of the insti— tution. In studies of outpatient clinics which have a psychoanalytic orientation 24,28 it has been observed that persons from the higher social classes, determined by educa— tion or income, are treated for a longer period. In contrast, in state mental hospitals, patients with the least education are kept longer and form a higher proportion of the chronically hospitalized groupfi'l'ﬁ23 The state—hospital therapist, viewing the in— stitution primarily as a custodial facility,12 is evidently oriented toward the more rapid discharge of those patients who come from a background most like his own. The observation of the relation between sociopsychological factors and improvement rating, particularly in those patients receiving convulsive therapy, may also be related to differences in communication patterns between therapist and patient that result in referral for convulsive therapy. The therapist may set different criteria for im— provement for theolder, less educated pa— tients than he does for the younger, more sophisticated ones. In the patient with littl/ education and with modes of expression different from his own, he may regard, for example, the manifestation of denial or minimization of symptoms as improvement.15 But in patients culturally like him— self, the expression of denial is regarded as a defensive operation, and the patient is considered unimproved. Ratings of improvement are also related to the base line of premorbid functioning. 32/570 . Thus, the rating of recovered is deﬁned at Hillside Hospital as “the reasonable ex— pectation that the patient will be able to return to his community and function as well, or better, than he did before he became ill.” 11 The therapist’s perception of the patient’s premorbid functioning may be inﬂuenced by the distance between his value system and that of the patient’s. The greater the social distance between therapist and patient the less rigorous the requirements for behavioral change may be. For ex— ample, for older, lower—class patients the ability to resume work may be the major criterion of improvement. For bettereducated patients work adjustment may be one of many criteria, including such intangible aspects of behavior as insight, work gratiﬁcation, and ease of sociability. The patient’s expectancy not only of the type of psychiatric treatment but of improvement is also dependent upon social back— ground.12 While the same trends were shown in the psychotherapy patients, the results did not reach the level of statistical signiﬁcance. This may have been due to the greater homogeneity of these patients for the factors studied, in contrast to the convul— sive group. The outpatient study by Rosenthal and Frank 28 also failed to ﬁnd a relation between social factors and improve— ment rating in the patients who received psychotherapy. This observation, also, was obtained in a population that was more homogeneous after the initial admission selection process and after the spontaneous screening effected by the patient’s willing— ness to attend treatment after he had been accepted. The marked relationship between socio— psychological factors and diagnosis is not surprising. Certainly, the relationship of age and diagnosis is an established concept in clinical psychiatry. In the involutional disorders and in dementia precox the names themselves have a chronological connota— tion. Landis and Page,19 in 1938, stated that age was the “most important single deter— Vol. 1, Dec., 1959 . �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT mining factor that we can know about men— tal disease.” They asserted that, given the age distribution of a group of patients, they could accurately predict the number in each diagnostic group, as well as the probable outcome with respect to recovery and the length of hospital residence. More recently, Frumkin,8 reporting the median ages of ﬁrst admissions to a mental hospital in Ohio, observed data similar to our own with re— gard to the ages for the various diagnostic groups. In the .present study, however, we have also shown that education, place of birth, and F score signiﬁcantly differentiate the major diagnostic groups in the hospital. In View of these ﬁndings, we have postulated that a psychiatric diagnosis is not just a one—to—one reﬂection of a speciﬁc type of behavior pattern but is also a value judgment in terms of social interaction. Thus, both in our own studies and in the work of 12 it has been noted that patients others with similar symptoms will receive different diagnoses, depending on their social background. An additional hypothesis relating socio~ psychologic factors to diagnosis may be based on the concept that persons from dif— ferent social backgrounds acquire different habitual modes of adaptation, communica— tion, and expression. Accordingly, under conditions of stress, altered brain function, or states associated with the onset of mental illness, a person will show those behavior patterns or symptoms which are similar to his habitual patterns. Thus, persons from a lower-class social background are more apt to communicate in nonverbal, physical terms, while upper—class people are more likely to do so in ideational and verbal modes. Thus, anger may be expressed by lower—class people by physical violence, while persons from the upper classes are more likely to resort to exhortation or argu— ment. Opler and Singer,25 studying schizo— phrenic Irish and Italian patients in a Veteran’s facility, found signiﬁcant difKahn et al. ferences in the types of symptoms related to cultural differences in the family backgrounds. Patients from Irish families in which the active expression of emotions were frowned upon and who had dominant, overprotective mothers, were passive, compliant, and withdrawn, and were fearful of anything which might separate them from the protection of the hospital. Patients with Italian family backgrounds that encouraged free expression of emotion and who were ruled by a dominant father, showed as— saultive and destructive behavior, were difﬁ— cult to manage, and were rebellious against authority. In a comparable study, Miller and Swan22 noted that hospitalized schizophrenic son patients exhibited signiﬁcant social—class difference in symptomatology. Lower-class patients showed a predominance of “motoric themes,” while middle—class patients exhibited “conceptual or r u m i n a t i v e themes.” Hollingshead and Redlich12 found a marked difference in the type of neuroses shown by persons from different social classes. While hysterical reactions were found predominantly at the lowest social levels, obsessive—compulsive patterns were characteristic of the upper classes. They felt thatthe lower—class patient expresses his neurosis by acting out, whereas the upper—class neurotic shows his symptoms in ideational dissatisfaction with himself. According to our hypothesis, then, we should expect that persons from lower social levels would show symptoms that are nonverbal, and are expressed predominantly in sensory or motor patterns. Among such types of symptoms Would be psychomotor retardation, anorexia, catatonic stupor, muteness, hysterical blindness, and paral— ysis. In this connection it is noteworthy that both hysteria and manic—depressive psychosis have been reported on the wane in the general populatio-n.2v4'8'10 This de— crease, in our view, is related to the general increase in educational level of the country as a whole. One cannot, of course, ascribe 33/571 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY the decrease in hysteria to a greater freedom in sexual matters; hysteria is commonest in more poorly educated people, who are least 26 has Rees inhibited sexually.”6 reported that those British soldiers who had hysterical symptoms in World War II were mainly the mental defectives. He noted that hysterical symptoms were related to intelli— 7 indi— has education. and Freyhan gence cated not only that the present clinical patterns of hysteria are different from those shown at the turn of the century but that such schizophrenic manifestations as “cataleptic stupors, stereotypical motor peculiar— ities, grandiose excitement, and violent behavior” are difﬁcult to ﬁnd today. These observations suggest that a sociopsycho— logical framework can lead to the prediction of future patterns of mental illness. In our investigations of persons with de— pressive psychoses, we have frequently noted a pattern of premorbid behavior characterized by lack of imagination, creativity, and introspective capacity, and by conven— tionality and general rigidity.13 Similar patterns have been reported by other authors.3'5""21 We believe that a deprived cultural background, such as that involving little or no education, with the early years spent in an illiterate environment with meager cultural resources, is conducive to the development of such a personality pat— tern. When mentally disordered, such per— sons react with the repertoire of behavior patterns that we term “depression.” It is important to keep in mind that while the relationship between social factors and the psychiatric aspects described is probably applicable as a general principle, the speciﬁc ﬁndings may vary in different settings or institutions. For example, Hollingshead and Redlich12 found that schizophrenia was a diagnosis proportionately commoner among the lower than among the upper classes, while at Hillside Hospital the schizophrenic patients had the highest education. This discrepancy may be related to differences in composition of the two populations, the Hillside patients being drawn largely from 34/572 the middle-class groups, with relatively few from the upper or lower social classes. In Hillside Hospital the diagnosis of schizo— phrenia may indicate an “interesting” pa— tient, while in a state hospital population the same diagnosis may represent a patient who is “hopeless.” From the perspectives developed in this report, observations which are commonly explained in motivational and “dynamic” terms may also be understood in other ways. Thus, some situations where a pa— tient is said to be “hostile” or “resisting psychotherapy” may reﬂect a problem in communication between patient and ther— apist, related to their differences in social background. It also is apparent that the social back— ground of the majority of the mentally ill paients is such as to make the current prac— tice of universally employing a verbal, in— sightful-oriented therapeutic approach a difﬁcult, if not inappropriate, procedure. The answer to the problem of how to treat the vast number of mentally ill may be not to train more and more psychother— apists, but, rather, to develop therapeutic techniques more suitable to the patient’s own systems of value and communication. Summary and Conclusions Signiﬁcant relationships were found be— tween sociopsychological factors and dura— tion of hospitalization, discharge evaluation, and diagnosis in a voluntary mental hos— pital. Patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign—born, and had the highest scores on the California F Scale. Younger, native—born, more edu— cated, and lower F—score patients were hos— pitalized the longest. The same relationship of these factors to length of hospitalization was found when analyses were made according to type of treatment (convulsive therapy or psycho— therapy) and diagnosis. Discharge evaluations of improvement were signiﬁcantly related to age, the older ' . Vol. 1, Dec., 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT patients having the more favorable ratings. Analysis of the data by type of treatment demonstrated that patients rated as recovered or much improved after convulsive therapy had the highest F scores, the least education, and were most likely to be foreign-born. Diagnoses of schizophrenia or psychoneurosis were associated with lower F scores, younger ages, more education, and native birth. The older, less educated, foreign—born, high-F-score patients were most frequently classiﬁed under involutional or manic—depressive psychosis. It is postulated that these relationships reﬂect the inﬂuence of social background on psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. These not only contribute to the pattern of mental ill— ness but affect all aspects of the patient— therapist interaction. Hillside Hospital, 75-59 263d St. (Dr. Fink). REFERENCES Adorno, T. W.; Frenkel-Brunswik, E.; Levinson, D. J., and Sanford, R. N.: The Authoritarian Personality, New York, Harper & Brothers, 1950. 2. Arieti, S.: The Decline of Manic—Depressive Psychosis: Its Signiﬁcance in the Light of Dynamic and Social Psychiatry, paper read at 113th Annual Meeting of American Psychiatric Association, Chicago, 1957. 3. Arnot, R.: The Predepressed Personality, A.M.A. Arch. Neurol. & Psychiat. 76 :617-618, 1. 1956. 4. Chodoff, P.: A Re-examination of Some Aspects of Conversion Hysteria, Psychiatry 17: 75—81, 1954. Cohen, M. B.; Baker, R; Cohen, R. A.; Fromm—Reichmann, F., and Weigert, E.: An Intensive Study of 12 Cases of Manic—Depressive Psychosis, Psychiatry 17:103-137, 1954. S. H. W., and Meltzer, B. N.: Predicting Length of Hospitalization of Mental Patients, Am. J. Sociol. 52:123—131, 1946. 7. Freyhan, F. A.: The Impact of Somatic Therapies on Course and Clinical Proﬁle of the Schizophrenias, J. Clin. & Exper. Psychopath. 19: 6. Dunham, 195-201, 1958. Frumkin, R. M.: Occupation and Major Mental Disorders, in Mental Health and Mental 8. Kahn et al. Disorder, prepared by a committee of the Society for Study of Social Problems, edited by A. M. Rose, New York, W. W. Norton & Company, Inc., 1955, pp. 136—160. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Depression, Proceeding 42d Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1952, pp. 199—209. 10. Harvey, W. A.: Changing Syndrome and Culture: Recent Studies in Comparative Psychiatry, Internat. J. Soc. Psychiat. 2:165—171, 1956. 11. Hillside Hospital: Twenty-Ninth Annual Report, 1956. 12. Hollingshead, A. B., and Redlich, F. C.: Social Class and Mental Illness: A Community Study, New York, John Wiley & Sons, Inc., 1958. 13. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. Neuropsychiatry, to be published. 14. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside Hosp. 6: 9. 216-228, 1957. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Proceedings of 46th Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958. 16. Kinsey, A. C.; Pomeroy, W. B., and Martin, C. 13.: Sexual Behavior in the Human Male, Philadelphia, W. B. Saunders Company, 1948. 17. Kramer, M.; Goldstein, 11.; Israel, R. H., and Johnson, N. A.: A Historical Study of the Disposition of First Admissions to a State Mental Hospital, Public Health Monograph No. 32, Government Printing Ofﬁce, 1955. 18. Kramer, K.; Pollack, E. S., and Redick, R. W.; Studies of Incidence and Prevalence of Hospitalized Mental Disorders in the United States: Current Status and Future Goals, paper read at the 49th Annual Meeting of the American Psychopathological Association, New York, 1959. 19. Landis, C., and Page, J. D.: Modern Society and Mental Disease, New York, Farrar & Rinehart, Inc., 1938. 20. Gallagher, E. B.; Levinson, D. J., and Erlich, I.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hospital, edited by M. Greenblatt, D. J. Levinson, and R. H. Williams, Chicago, Free Press, 1957. 21. Malamud, W.; Sands, S. L., and Malamud, I.: The Involutional Psychoses: A Socio—Psychiatric Study, Psychosom. Med. 3:410—426, 1941. 22. Miller, D. R., and Swanson, G.: Defense Against Conﬂict and Social Background, paper 15. 35/573 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY read as part of a symposium at the meeting of the American Psychological Association, September, Disorder, New York, Milbank Memorial Fund, 1953. 23. A.; Redlich, F. C., and Myers, J. K.: Social Structure and Psychiatric Morgan, N. C., and Johnson, N. A.: Failures in Psychiatry: The Chronic Hospital Patient. Am. J. Psychiat. 113 :824-830, 1957. 24. Myers, J. K., and Schaffer, L.: Social Stratiﬁcation and Psychiatric Practice: A Study of an Out-Patient Clinic, Am. Sociol. Rev. 19: 307-310, 1954. 25. Opler, M. K., and Singer, J. L.: Ethnic in Behavior and Psychopathology, Internat. J. Soc. Psychiat 2:11-22, 1956. 26. Rees, J. R.: in discussion on paper by Gruenberg, E. M., in Epidemiology of Mental Differences 36/574 1950, pp. 51—52. 27. Robinson, H. Treatment, Am. J. Orthopsychiat. 24:307—316, 1954. 28. Rosenthal, D., and Frank, J. D.: The Fate of Psychiatric Clinic Outpatients Assigned to Psychotherapy, J. Nerv. & Ment. Dis. 127 :330343, 1958. 29. Weinstock, H. 1.: Report of the Central Fact—Gathering Committee of the American Psychoanalytic Association, paper read at the 48th Annual Meeting of the American Psychopathological Association, New York, 1958. Prénted and Published in the United States of America ��J. Hillside Hospital, 6: 216-228, 1957. SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL1 ROBERT L. KAHN, PH.D.,2 MAX POLLACK, PH.D.,3 and MAX FINK, M.D.4 Recent investigations have indicated a relationship between social class and psychiatric disorder with respect to type and incidence of mental illness (3, 5, 6, l3, l4), selection and maintenance of treatment (2, 6, 15), and therapeutic outcome (10). The present study is concerned with social factors in the selection of therapy in voluntary mental hospital. In the studies reported by Hollingshead, Redlich, and their coworkers (3, 5, 6, 13, 15), the population of New Haven was divided into ﬁve social classes on the basis of weighted criteria of education, occupation and place of residence. Of the residents who were under psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care was more common among the lower classes. Of the psychotherapies, psychoanalysis was entirely restricted to the two upper groups. Social class was the predominant determinant of the type of treatment selected even when the diagnosis was held constant. They summarize their results as follows: ". . . it is found that treatment does not depend on psychological and medical determinants alone, but on the status position of the patient as well. Psychotherapeutic methods are applied in disproportionately high a 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, U. 8. Public Health Service. 2Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3Scnior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 4 Director, Department of Experimental Psychiatry, Hillside Hospital. ‘ 216 �SOCIAL FACTORS IN SELECTING THERAPY 217 ‘ degree to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient’s ﬁnancial resources or the extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques and services are available to all patients. This requirement is met at Hillside Hospital. It is a nonproﬁt, k, h . ....-_.._...-.,...v..... nonsectarian institution for the treatment of voluntary patients with “early and curable mental symptoms" (4), who are admitted regardless of their ability to pay. One of the main criteria for accepting patients is their “ability to participate proﬁtably in psychotherapy." Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment with organic therapies available when needed. The average length of hospital stay is six months, although some patients remain for as long as a year. The present investigation is an outgrowth of several years of study of electroshock therapy. In previous work it has been shown that certain aspects of personality were signiﬁcantly related to patient selection and therapeutic efﬁcacy of electroshock (8). The purpose of the present study was to determine whether electroshock patients differ from those receiving other forms of treatment in, regard to cultural background, including such factors as education and place of birth, and personality as measured by the California F scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. mum METHOD Population: The entire inpatient adult population of Hillside Hospital as of March 7, 1957 was studied. This constituted a total of 172 patients, ranging in age from 16 to 68 with a mean of 34.6, and including 58 men and 114 women. Procedure: (1) The population was subdivided into three groups, according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only.‘5 5All patients are seen in psychotherapeutic sessions during ’hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data were included in both groups. In the results this makes a total of 179 subjects. .... “.4. na. ._‘....-..—._4.,_....—««... . gbnyw. C) �KAHN—POLLACK—FINK 218 (2) birth. The groups were compared for age, education and place of (3) All patients were tested6 with a ten-item modiﬁcation of the California F scale suggested by Levinson (9). The F scale is a questionnaire (see Appendix) which has been related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). The patient reads ten statements and indicates whether he agrees or disagrees with each statement and to what extent. The score given for each item ranges from one to seven and the total score range is 10 to 70. The greater the agreement the higher the score obtained. The statements themselves are extreme, uncritical or stereotyped expressions. (4) The population was subdivided in regard to utilization of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing and creative therapy. The latter is a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psychological testing and creative therapy were selected for this study because both require a speciﬁc referral from the therapist. RESULTS The data were analyzed as follows: (1) comparison of the treatment groups for age, education, F scale scores, and place of birth; (2) comparison where diagnosis is held constant; (3) signiﬁcance of length of hospitalization prior to treatment; and (4) comparison between groups referred for adjunctive hospital services. Comparison of Treatment Groups For each of the three treatment groups the means and standard deviations for the F scale scores, age and years of schooling are presented in Table l. The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These differences were statistically signiﬁcant for F score and age but failed to reach statistical signiﬁcance for education. The failure of years of education to differentiate the groups was due, in part, to the fact that the electroshock 1. 6As part of an ongoing study all the EST patients were tested with the F In the case of those patients who were actually on EST on March 7 their pretreatment scores were used in the statistical comparison since it had been found that EST signiﬁcantly affects the score during treatment. scale prior to treatment. �SOCIAL FACTORS IN SELECTING THERAPY .850 :wmuuom Eon $5“ 82m 39.7114? $.32 o ammokoh we 219 55 ..ﬁ.:namo cwMuSh .ummmﬁuom omen”.— ﬁamr: $.85“ $83 :25 .PEaZ x0 3:: 3:: Eom $.8va $532 ﬁvawm 55m mo .minamo 82m -ﬁmuuoh Eon @EE $3“ ﬁmmIv $.32 Agar: :otugﬁm 985 .me .3— $.8va now .«o 0 .Ssnamo .Eeum 988w ﬂ ”55H. K $5; ax? 3?: Gm 3. ea mm 532 2: 2: qﬁ wzoﬁom ‘8.“ $336 6m mow—mo? “2253‘; a 532 .59 ...23 3 2, N.— o o . ~23»me «I m5.— Gm q: 3 2;. n: gm 3” a :32. .8.” mi ed 3 ow< x0 532 :82 a5 n: a a tantamwﬁcc Gm 92 ”.2 a: mi. 3» 3m . :2.» tmhd £5 E2 BE 3:: 38mm 532 :82 .En 3: 3 hm any .3. 8. So. a an 3 38%?2.85:»; Esscma .o&u>m&.::=n=— aozéemﬁ 335-5“ 585-98— -OH—U smvhmm $5.19 r7305 .53.: uh .382: . .. 2.. �220 KAHN—POLLACK—FINK group contained many foreign-born patients whose education was difﬁcult to evaluate accurately. When treatment groups were subdivided into number of patients above and below eight years of education, the difference was signiﬁcant at the .01 level. The insulin and psychotherapy groups did not differ statistically for any of these factors. Both somatic groups had a higher percentage of foreign-born patients than the psychotherapy group, with the electroshock group being highest of all. Among the foreign-born patients, those who came from Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe received psychotherapy alone. Comparison of Treatment Groups in Relation to Diagnosis The diagnostic categories of the patients in this study are comparable to those reported in previous studies of the hospital popution (12). Of the 172 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and 2 with other diagnoses. As expected, a larger proportion of the depressed patients (52%) received electroshock than did those with other diagnoses. To control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those who received electroshock and those who were given psychotherapy alone. The results are shown in Table 2. While the two groups were comparable for age and education, the electroshock patients had a much higher mean F score, a difference signiﬁcant at the .02 level of conﬁdence. It is also demonstrated that a signiﬁcantly higher proportion of the electroshock patients were born in Eastern Europe. 2. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment While the electroshock patients, as a group, have been shown to differ from those receiving insulin or psychotherapy, there were still considerable intragroup differences. To account for some of these differences it was postulated that the same factors involved in selection of treatment were also related to the readiness with which a given patient was referred for electroshock. While most of the patients who received EST were placed on treatment less than three months after admission, about 40 per cent were referred after a period of three to twelve months. In Table 3 the patients are compared according to the period of hospitalization prior to electro3. �SOCIAL FACTORS IN SELECTING THERAPY .550 $.23. ax”: 5.3m 538mm jigli‘l EuEEEh we “Egan $53” «Rana— .Sauamu REE Kc .0332 50m §$§ $53“ EOENN §£Vmw awash 208 39$me a; How no con—8.6m 938» name Bwamwunﬁ exam; 15.3. Gm 3. 3 532 3: 3: Gm wﬁ n2 :32 3:. 9:. Ga 3: «.2 h :32 new q: wzogum 0:3 N .vm 38C. somnuﬁﬁum we mama? :32 . 86 £5 85 utoﬁbﬁ 5.3» a mud ow< 582 a3 and 3:»..qu kc . é.“ 38m :ontﬁwEoU :32 ea BE 3m 8. «liq. a $6 . ‘ . :3 Hammama .oﬁrmémm -onuwnm ha. , . 2!!!!) .. , ‘ W 7 832: . ,1" w 322: , 221 �KAHN—POLLACK—FIN K 222 ., .550 @va c o sin uo .£6 . 33mg 583m uncuzm $53 m o $53 ﬁgs: a : Mano cum—m 2.25355 -0322 50m 3 @932 3.2% 308 $.83 $5me : mm new “o :otuggxwmom QUE :oumusvm wweﬂamo “26> w Aﬁwua 32:: c 3015 kc m Ewnud 45 55H. S a 85 :2 85 £5 a: 8.... a; 9 :4 :3.” 3» :82 .En E...“ 2.2 N: ms: a 8; :3.“ 5* 3... Gm 5.. am 3.. 38> 582 am hi 3.; Gm 3: mﬁ 2: 532 93 mg Gm q: 582 2:. mo can: mEEouuV Szuzcm 8.. uw< :3 Sam \0 . m3 38m zowtuiEeU h mo as 3 .88 him -mNSSEmo: 52: Susannah. sum—SA €3.88... no: 4 w. $04 ,w ‘ 8 e5 $6 kwoa :2: o m 532 c: m Gan—u .85 0.82 c 33 o2 2.2 e 2 » .22 me. 8. aa -608 .88 ~22 m Ema—u 30..— 288 :2: 308 .85. 3 n 285:? 385:”; 52: o 308 88¢ . 2. . �SOCIAL FACTORS IN SELECTING THERAPY 223 Shock. Patients who had higher F scores and were older were treated earlier than the younger and lower F scale groups. Place of birth is also a signiﬁcant factor. \Vhile 44 per cent of those treated within three months were foreign-born, all patients referred after a period of six months were born in the U. S. The data on education just fails of signiﬁcance, although 28 per cent of those treated earlier had less than eight years of education. .,,. ,, . mug-r; Adjunctive Hospital Services Comparison of the patients referred for creative therapy and psychological testing is shown in Table 4. It is clear that those referred for either of these procedures had Signiﬁcantly lower F scores, were younger in age, had more education and more were nativeborn than patients who were not referred for these services. 4. Use of DISCUSSION .. "155' . , The results indicate that the factors of education, age, place of birth, and F scale score were signiﬁcantly related to the type of therapy received and to the utilization of adjunctive services‘ in this hospital. Psychotherapy was the treatment of choice for those patients who were younger, better educated, native-born and had lower F scores. Such patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated and foreign-born, particularly in Eastern Europe, were most likely to be referred for EST. These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still signiﬁcant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich, and their co-workers (3, 5, 6, 13, 15) who demonstrated that social factors are related to the type of therapy received in a community. The present study demonstrates that such factors are also signiﬁcant in a hospital setting where ability to pay is not a criterion of therapeutic selection and where all forms of therapy are equally available to the entire population. With ﬁnancial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations maybe considered. The social factors may relate directly to the empirically established criteria for choice of therapy. On this basis a patient is ' �KAHN—POLLACK—FINK 224 .850 ﬁn“; $me Amwutch 35:30 533mm «@055 A03: Aﬁmwvmw H 1%: 35:2 @33 @3: @8va §§8 .mwmuamo «50 853 .25“ «:8 $63 .23 2:5 go ARE; 50m aways $95: $.38 138% Z MFGSK. 805 1%» 3w .uo H ~838va PﬁmSaﬁbﬁ .Nmenamu mud“; «Eu 3?: $.27: 33“ $.32 Gm ﬂ. 3 a.» 38> 582 3: 2: 3“ N: mic—om kc v 8.938% .Um 35? we 8.“ :82 a octhd £5 QN m5 3 , uptuzzbuv. . .Sx 2: we a: E: 532 SN 3». 5.8 5.3 Gm 2: ”.2 a: 2: 3w 5.3 3» ASV 32v Gm .tnowJ. ....ewm "A: S. vw< Vutﬁwm :8: . 2:».zum Kc a5 tooomd :8.” ~22 3,2 no. 8. 38m h 582 532 £5 Nﬁu «.3. 2 :32 so. a3a :oﬂuEwEoU st 333.5 3380 u>tmuu0 332:. REEF oz 285:?“ 285:»; ..H..U .._oau>mm .355 38.“. Saucmcmmm .355 Amaze... oz uhu OZ 0z . .3 2. �,amr»: . “ ‘ .. SOCIAL FACTORS IN SELECTING THERAPY 225 , .. new... 4.. ,wu referred for electroshock because he is older, poorly educated or foreign-born, clinical experience having shown that such persons respond best to this type of treatment. This explanation is inadequate since half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communication. Thus, a patient is not referred for electroshock because he is foreign-born or poorly educated, but rather these factors provide the difference in cultural background between patient and therapist which makes successful communication less likely in the psychotherapeutic relationship. Robinson et al. (15), in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic relationship. In the present study, similarly, the patients who received psychotherapy alone were more like the therapists with regard to the factors studied.7 . Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have shown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are likely to receive electroshock (7, 8). Such language patterns appear to be more frequent in persons with poorer sociocultural backgrounds. Social and cultural factors, in addition to their effect on communication patterns, may also determine the manifest symptomatology. Opler (11) has noted that, among patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank et a1. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those, who remained had ideational symptoms. In a study of personality 7 The 18 therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen per cent were born in Eastern Europe. Their mean years of education was over 20. , .vr" �KAHN—POLLACK—FINK 226 factors‘in electroshock patients (8) we have noted that certain patterns of symbolic value and communication were more likely to be associated with the development of a depressive psychosis. The relationship between communication pattern and symptoms indicates that symptoms themselves are a mode of communication. The F scale furnishes a quantiﬁable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an etlmocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. In the present study the F scale was the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical signiﬁcance. Preliminary observations from a study in progress indicate that lowscorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing their social differences, by matching them more closely for age and place of birth. Of possible greater importance is the necessity for developing new modes of communication when treating patients who are refractory to conventional psychotherapeutic ap1 proaches. While epidemiological studies have clearly structured some of the problems involved in selection of treatment,‘and have indicated the direction of further. study, it still remains for more processoriented research to provide deﬁnitive answers. SUMMARY In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth, and score on the California F scale were signiﬁcantly related to the type of therapy received and to the utilization of adjunctive hospital 1. servrces. ’ Patients who were older, poorly educated, had higher F scores and were foreign-born, particularly in Eastern Europe, were most likely to be referred for electroshock. Psychotherapy was the treat2. �. . p *Wﬂg g “A 4““ .. )WA-W.~»‘,.I_~HWW‘W« "r .t. SOCIAL FACTORS IN SELECTING THERAPY 227 ment of choice for those patients who most closely resembled the therapist in these aspects. 3. These relationships were present even when diagnosis 'was held constant. 4. Among the electroshock patients the same factors found to be signiﬁcant in choice of therapy were also related to the readiness With which a patient was referred for electroshock. 5. It is postulated that treatment selection is the result of the communicative interaction between patient and therapist. Social factors may be important in so far as they are related to different modes of communication. APPENDIX “Wadwﬂ a F SCALE FORM . Below are a number of statements. For each statement we want you to give us your personal opinion of whether you agree or disagree. Answer each statement according to one of the following: I AGREE A LITTLE I AGREE PRETTY MUCH I AGREE VERY MUCH 3),." glue»: ‘. 1. No sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. 4. When a person has a problem or worry, it is best for him not think about it, but to keep busy with more cheerful things. to 5. What the youth needs most is strict discipline, rugged determination, and the will to work and ﬁght for family and country. 6. Nowadays when so many different kinds of people mix together so much, a person has to protect himself especially carefully against catching an infection or disease from them. 7. Sex crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. 8. The best teacher or boss is the one who tells us exactly what is to be done and how to go about it. 9. Young people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down.‘ . \4 I DISAGREE A LITTLE I DISAGREE PRETTY MUCH I DISAGREE VERY MUCH �\‘ KAHN—POLLACK—FINK 228 People can be divided into two distinct classes: the weak the and strong. 10. REFERENCES (1) (2) (3) (4) (5) (5) (7) Adorno, T. W.; Frenkcl-Brunswik, E.; Levinson, D. J. 8c Sanford, R. N.: The Authoritarian Personality. New York: Harper 8.: Brothers, 1950. Frank, J. D.; Gliedman, L. H.; Imber, S. D.; Nash, E. H. 8: Stone, A. R.: Why Patients Leave Psychotherapy. A.M.A. Arch. Neurol. (9' Psychiat., 77: 283-299, 1957. Freedman, L. Z. 8: Hollingshead, A. B.; Neurosis and Social Class. Am. J. Psychiat., 113:769-775, 1957. Hillside Hospital: 29th Annual Report, 1956. Hollingshead, A. B. 8: Redlich, F. C.; Schizophrenia and Social Structure. Am. ]. Psychiat., 1102695-701, 1954. Hollingshead, A. B. Fe Redlich, F. C.: Social Class and Psychiatric Disorders. In: Interrelations Between the Social Environment and Psychiatric Disorders. New York: Milbank Memorial Fund, pp. 195-208, 1954. Kalm, R. L. 8: Fink, M.: Changes in Language During Electroshock Therapy. In: Psychopathology of Communication, ed. P. Hoch 8: J. Zubin. New York: Grune 8: Stratton, 1957. Kahn, R. L. 8: Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy. Conf. Neural. (in press). (9) Levinson, D. J.: Personal Communication. (10) Morgan, N. C. 8.: Johnson, N. A.: Failures in Psychiatry: The Chronic Hospital Patient. Am. J. Psychiat., 113:824-830, 1957. (11) Opler, M. R.: Schizophrenia and Culture. Scientiﬁc American, 197:103-110, - (8) 1957. Rachlin, H. L.; Goldman, G. S.; Gurvitz, M.; Lurie, A. 8: Rachlin, L.: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950. This Journal, 5:17-40, 1956. (13) Rcdlich, F. C.; Hollingshcad, A. B.; Roberts, B. H.; Robinson, H. A.: Freedman, L. Z. 8c Meyers, J. K.: Social Structure and Psychiatric Disorders. Am. ]. Psychiat., [09:729-734, 1953. (14) Rennie, T. A. C.; Srolc, L.; Opler, M. K. 8: Langner, T. 8.: Urban Life and Mental Health. Am. J. Psychiat., 113:831-837, 1957. (15) Robinson, H. A.: Redlich, F. C. 8: Myers, J. K.: Social Structure and Psychiatric Treatment. Am. ]. Orthopsychiat., 24:307-316, 1954. (15) Titus, H. E. 8c Hollander, E. P.: The California F Scale in Psychological Research: 1950-1955. Psychol. Bull., 54:47-64, 1957. (17) Tougas, R. R.: Ethnocentrism as a Limiting Factor in Verbal Therapy. In: Psychotherapy and Personality Change, ed. C. R. Rogers 8: R. F. Dymond. Chicago: University of Chicago Press, pp. 196-214, 1954. (13) Zierer, E. 8: Zierer, E.: Structure and Therapeutic Utilization of Creative Activity. Am. ]. Psychother., 10:481-519. 1956. (12) . �Social Factors in the Selection of Therapy in a Voluntary Mantal Hospital Robert L. Kahn, Ph.D. Max Pollack, Ph.D. Max Fink, M.D. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Aided by Grant M-927 of the National Health Service. 10-8-57 Institute of mental Health, U.S. Public N.Y¢ �Social Factors in the Selection of Therapy in a Voluntary Mental Hospital Recent investigations have indicated a relationship between social class and psychiatric disorder with respect to type illness (3, 5, 6, and therapeutic and incidence of mental selection and.maintenance of treatment (2, 6, 15), 13, 1h), outcome (10). The present study is concerned with social factors in the selection of therapy in.a voluntary mental hospital. In the studies reported by Hollingshead, Redlich and (3, 5, 6, 13, 15), the population of classes on the of residence. New Haven was their co-workers divided into five social basis of weighted criteria of education, occupation Of the residents who were under and place psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care Of was more common among the psychotherapies, psychoanalysis groups. Social class selected even as follows: when " was was held constant. They summarize is found that treatment does not and medical determinants alone, but on the well. entirely restricted to the two upper the predominant determinant of the type of treatment the diagnosis ..... it was the lower classes. their results depend on psychological status position of the patient as Psychotherapeutic methods are applied in disproportionately high degree to the upper social levels. The data of this study would most psychotherapy takes place in a setting seem to indicate that where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's financial resources or the �extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques This requirement is met and services are available to all patients. at Hillside HoSpital. It is a non-profit, sectarian institution for the treatment of voluntary patients with "early curable mental symptoms" (h), pay. of the main One who non— and are admitted regardless of their ability to criteria for accepting patients is their "ability to participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy available is regarded as the primary when needed. The average method of treatment with organic therapies length of hospital stay is six months, al- though some patients remain for as long as a year. The present investigation is of electroshock therapy. an outgrowth of several years of study In previous work it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose patients differ of the present study was to determine whether electroshock from those receiving other forms of treatment in regard cultural background, including_such factors as education and personality as measured by the California F and place of to birth, scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. �Mame: Population: as of March 7, 16 entire in-patient adult population of Hillside Hospital studied. 1957 was ranging in age from llh The This constituted a to 68 with a mean total of 172 of 3h.6, and including patients, 58 men and women. Procedure: 1) The population was subdivided into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only. * 2) The groups were compared for age, education and place of birth. 3) of the California naire (see F All patients were tested scale suggested by Levinson (9). Appendix) which has been indicates whether tent. The scale is a question- The patient reads ten statements he agrees or disagrees with each statement and to what ex- score given for each item ranges from one to seven and the total score range is tained. The F related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). and ** with a ten-item modification The 10 to 70. The greater the agreement the higher the score obs statements themselves are extreme, uncritical or stereotyped expressions. patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data was included in both groups. In the results this makes a total of 179 subjects. * All part of an ongoing study all the EST patients were tested with the F scale prior to treatment. In the case of those patients who were actually on EST on march 7th their pre-treatment scores were used in the statistical comparison since it had been found that EST significantly affects the score during ** As treatment. �- h h) The population was subdivided in regard to of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing therapy. The latter is and be analogies life experience (18). Psychological testing and creative therapy selected for this study because both require a specific referral therapist. creative a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to of utilization were from the �RESULTS: data The was analyzed as follows: 1) comparison of the treatment groups for age, education, F scale scores and place of where diagnosis is held constant, prior to treatment, birth, 2) comparison significance of length of hospitalization 3) and h) comparison between groups referred for adjunctive hospital services. I. Comparison of Treatment Groups: For each of the three treatment groups the means and standard devia— tions for the Table I. F scale scores, age and years of schooling are presented in The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. differences reach were statistically significant for statistical significance for education. cation to differentiate the groups electroshock group contained many was due, F These score and age but failed to The failure of years of edu- in part, to the fact that the foreign born patients whose education was difficult to evaluate accurately. When number of eight years of education, the difference was patients above and below significant at the .01 level. not differ statistically for The treatment groups were subdivided into insulin any of these and psychotherapy groups did factors. �*** ** ﬁg * $3qu dumumww 33mg. menwmwowOa mmwnwOu macaw mmeanmcpwn Humcﬁuamov Hamcwwuawmwoan mnmunHnmUd md .oow mumbwwwomsw 309 mwmuwwwomud ma ma .OH .ow 38 w.w ma Hw.o 83.. Emma wrm ﬂaw ES. 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Comparison of Treatment Groups in Relation to Diagnosis: The diagnostic categories of the patients in this study are comparable to those reported in previous studies of the heapital population (12). 172 32 patients, as psychoneurosis and two with other diagnoses. with other diagnoses. To (52%) As expected, a larger pro- received electroshock than did those control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those received electroshock and those shown who were given psychotherapy alone. .02 The who results in Table II. While the two groups were comparable shock the 78 were classed as schizophrenic, 60 as psychotic depression, portion of the depressed patients are Of patients for age and education, the electro- had a much higher mean F score, a difference significant at the It is also that a significantly higher level of confidence. demonstrated proportion of the electroshock patients were born in Eastern Europe. �* mug $0.33 mmHImeoUOI wﬁduogmumg $5 mHmUManmﬁw $8 ma .Om ooswmuwmom Hm<mw 9mm waw. Emma 5.0 8Q Emma w ow mnoum m}? 9mm a maﬁa. 5.: 2mmb ab 5.m 55 Sh ”5.: mu mmdwmmdm Emma audr mmm 0.8 0.8 9% a cwmw. ma wmwaUOdwo Emma a 8.0 Hob 9m fr Emma MmmHm ow unmammmwos prﬁm mu Waco. xm u : w 2:3 3&3 HH :30 waves «mmum m H.mu mmomu<ma 0% m mm 0H 8253 @050. 25% Uumwmnmua Beam vamm xm u mm pm Smé 383 wowu wwmom #.0w * 0% zmaw<m w pm Hammaamsa mcwovm mmmdmun 30,3 ow 3me wwudw p H 3&3 GE oawmw �- 9 - III. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment: While the electroshock from those receiving insulin or psychotherapy, there intra-group differences. postulated that the same To account While most of the less than three months for some have been shown were patients who received after admission, about EST h0% was to differ considerable of these differences patient which a given of three to twelve months. In Table it was were also referred for electro— were placed on treatment were referred after a period III the patients are to the period of hospitalization prior to electroshock. F still factors involved in selection of treatment related to the readiness with shock. patients, as a group, compared according Patients who had higher scores and were older were treated earlier than the younger and lower groups. Place of birth is also a significant factor. within three months were foreign born, six months were born cance, although 28% in the U.S. The While hh% of those all patients referred after data education just on F fails scale treated a period of of signifi- of those treated earlier had less than eight years of edu— cation. IV. Use of Adjunctive Hospital Services: Comparison of the logical testing is shown patients referred for creative therapy in Table IV. It is of these procedures had significantly lower clear that those referred for either F more education and more were native born than for these services. and psycho- scores, were younger in age, had patients who were not referred �** * w Beam Bowm bmmm ﬁo m Em: «was dams mumuwwwomba m 3 w Hmmm 308m m ma mw w 0 gem. Bow. Bow. 80m. o n ma Hm<mw mHMou bmmmaw do 38. ow w $8 38. awwmdamua momvwdmwwumawon 32 “Hwy .OH 5% arms wsmu u Bow. 3 m dumb 38. 80m. mwmbHWHomUd w .Om Hm<mw ooswmwwmos m.4m 3.5 95 Emma UH%H. ww.m 5.4 SL Ewan w ow macaw Ema H.Mm H4.w d Fm tro ww.m Sam mme mu m.mm**.wm.5 mu} $.4H Tme UMWﬁ. wo.H .zmmu mmwwmbam bmm v.5 H.mw d Ho.w Hm.“ 53 mu >ooowawum wamxwmbu v.8 H.mw UHHH. Kama Hm.m ﬂ; mb Emma Mmmwm ao mocnmawou o.wm PS 0.3 ebwﬁw om d m.o Pm “.4 mb u Ho Hammaw HHH N m H H 0 m ow waves 323 333 m :.mm ammwm manomdwoa HP AHOO$V m mw 60ch SR3 momvwdmwwnmawou m ow on Baum wHHow xm PH n AHOO$V a Hm 393 3&3 wows do zmdw<m wwmom m.wm* Hammdams¢ w o 383 0 0 pm ow mcuowm mmmdmus 395 wwuwu m R§ oawmu u �zo *** ** * ac n.e. zo 593. wanWOH.u - oummdw<m ammﬂm wmwauou. mammaw<m zo mwmuwwwnmbﬁ mHmuwanmbd owocwm mumswwwombd Awmv o.e. Sea gamumww mw 2.: m» ma oosvaumOb ewmuquawomv Amqv .ow .Om ow .OOH‘Hmamu wm<mw wm<mw m.w up.» uwww. Emma :H.: w: :w.4 mm.“ Saws w wmdeUdm mooam Hm.w a w.wm*4 arm Hm.w po.m mu wmwmwuma m.wm***po.w cwww. Emma w&.4 we; Wm.m mm.a Emma 4.0 bmm % m.mm**.w.o Hw.: a 5.» Hm.m 5.» Ho.a wow Ho.p mu :.mo**wm.w >aucundwdo ﬁuww smmu Hp.m rw.m Emma wmmwm wacnmdwou H.4w m.<*** & m.wm ow E p.» w.“ Bbmbm mu mmH<Hnmm H< N» u Hm prwv m 33 mm ww p mmwot ow u Awmﬁv Am$v m «mmdm m.mw* macomduon r.mm* mw d mm Am4$v 3.33 Ammﬁv mm m ow mmRnwowomwoww 0% Amway Beam ammﬁwmm xm 4H mp u N» Q: my moan zmdu<m u Aqmav 8% A4H$V “mpgv mum wwmnm m.wm* m.mm* Hm v mw H ow mcuowm owmmaw<m mmmdmwu prﬁv Q: “MN$V Amﬁv wwudw m m m m Amﬁv :3: Amﬁv Ammv akumnm OdWmH �-12.. DISCUSSION: results indicate that the factors of education, age, place of birth The and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients better educated, native born and had lower F scores. Such were younger, who patients were also referred more frequently for the auxiliary hospital services of psychological testing creative therapy. Conversely, those patients were older, poorly educated likely to were most be and foreign born, referred for EST. who and had higher F scale scores, particularly in Eastern Europe, These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich and their co—workers (3, 5, 6, 13, 15) who demonstrated related to the type of therapy received in a community. The present study that such factors are also significant in a hospital setting demonstrates ability to that social factors are is not a criteria of therapeutic selection pay and where all where forms of therapy are equally available to the entire population. With financial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, factors may of therapy. two alternative interpretations may be considered. The social relate directly to the empirically established criteria for choice On this basis a patient is referred for electroshock because older, poorly educated or foreign born, clinical experience having shown he that is �- 13 such persons respond best to adequate since this type of treatment. This explanation is in- half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional cation. Thus, a modes of therapy, such as mode of communi- patient is not referred for electroshock because he is foreign born or poorly educated, but rather, these factors provide the difference in cultural background between patient and therapist which makes successful communi» cation less likely in the psychotherapeutic relationship. Robinson 33 Ei' (15) in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic tionship. In the present study, similarly, the patients who rela— received psycho- therapy alone were more like the therapists with regard to the factors studied.* Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations haVe therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen percent were born in Eastern Europe. Their mean years of education * The 18 was over 20. �-11).shown that verbally and use of uncommunicative persons, prone to denial, evasion, stereotypy cliches are likely to receive electroshock (7, 8). patterns appear to be more frequent in persons with poorer Such language socio-cultural back- grounds. Social and cultural factors, in addition to their effect cation patterns, that, has noted may among on communi- also determine the manifest symptomatology. Opler (11) patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank 33 a}. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those mained had shock ideational patients (8) we symptoms. symptoms likely to The indicates that The F In a study of personality factors in electro~ hare noted that certain patterns of symbolic value and communication were more depressive psychosis. re~ who be associated with the development of a relationship between communication pattern symptoms themselves are a mode and of communication. scale furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital lation, Levinson (9) found that high—scorers were popuu less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. study the F scale was In the present the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. �Preliminary observations from a study in progress indicate that low—scorers the scale have a poor response to electroshock, and that those with high F on F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing closely for age and place of necessity for developing their social differences, by matching birth. new modes Of them more possible greater importance is the of communication when treating patients who are refractory to conventional psychotherapeutic approaches.* While epidemiological studies have clearly structured some of the problems involved in selection of treatment, and have indicated the direction of further study, it still remains for more process-oriented research to provide definitive answers. * See Esecover's presentation of this topic in this issue. �_ 16 - SUMMARY: 1. In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth and score F on the California scale were significantly related to the type of therapy received and to the utilization of adjunctive hospital services. 2. who were older, poorly educated, had higher F scores foreign born, particularly in Eastern Europe, were most likely to and were be Patients referred for electroshock. those patients who most Psychotherapy was the treatment of choice for closely resembled the therapist in these aspects. were present even when diagnosis was held 3. These relationships h. Among the electroshock patients the constant. significant in choice of therapy which a patient S. was were factors found to be also related to the readiness with referred for electroshock. It is postulated that treatment selection is the result of the communicative interaction between patient and be important same therapist. Social factors may insofar as they are related to different modes of communication. �m 17 - REFERENCES Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, R.N. (1950): & The Authoritarian Personality, New York: Harper Brothers. Frank, J.D., Gliedman, L.H., Imber, S.D., Nash, E.H. and Stone, A.R. (1957): Why Neurol. & Patients Leave Psychotherapy, A.M.A. Arch. Psychiat., 11: 283—299. Neurosis and Social Class, Freedman, L.Z. and Rollin gsheadﬁﬁ. (1957): Am. J. Psychiat., Hillside Hospital, 29th 113: 769-775. Annual Report, 1956. Schizophrenia and Social Hollingshead,A.B. and Redlich, F.C. (l95h): Structure, Am. J. Psychiat., 110: 695-701. Social Class and Psychiatric Hollingshead,A.B. and Redlich, F.C. (l95h): Disorders, in Interrelations Between the Social Environment and Psychiatric Disorders, New York: Milbank Memorial Fund, pp. 195-208. Kahn, R.L. and Fink, Therapy. Zubin, M. (1957): Changes in Language During Electroshock In Psychopathology of Communication (Hoch, P. and J. Eds.), Kahn, R.L. and Fink, M.: New York: Grune & Stratton. Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol., in press. Levinson, D.J.: 10. Personal Communication. Morgan, N.C. and Johnson, N.A. (1957): Chronic Hospital Patient, Am. Failures in Psychiatry: J. Psychiat., The 113: Sen-830. �_ 18 _ REFERENCES 11. Schizophrenia and Culture, Scientific American, Opler, M.K. (1957): £91: 103» 110. 12. Rachlin, H.L., Goldman, G.S., Gurvitz, M., Lurie, (1956): J. Hillside Hospital, 2: 1950, and Psychiatric Disorders, Am. Social Structure J. Psychiat., Am. J. Psychiat., 109: 729-73h. Titus, Psychiatric Treatment, Am. H.E. and Hollander, E.P. (1957): Urban 113: 831—837. Robinson, H.A., Redlich, F.C. and Myers, J.K. (l95h): and 16. l7—h0. Rennie, T.A.C., Srole, L., Opler, M.K. and Langner, T.S. (1957): Life and Mental Health, 15. L. Redlich, F.C., Hollingshead, A.B., Roberts, B.H., Robinson, H.A., Freedman, L.Z. and Meyers, K.J. (1953): 1h. Rachlin, Follow-up Study of 317 Patients Discharged from Hillside Hospital in 13. A. and Social Structure J. Orthopsychiat., g3: 307-316. The California F Scale in Psychological Research: 1950-1955, Psychol. Bull., 53: h7-6h. 17. Tougas, R.R. (195%): Ethnocentrism as a Limiting Factor in Verbal Therapy, In Psychotherapy and Personality Change, 0.3. Rogers and R.F. Dymond, 16, Zierer, E. and eds., Chicago: University of Chicago Press, pp. l96-21h. Zierer, E. (l956): of Creative Activity, Am. Structure and Therapeutic Utilization J. Psychotherapy, lg: h81-519. �- 19 - APPENDIX F SCALE FORM Below are a number of statements. For each statement we give us your personal opinion of whether you agree or disagree. want you to Answer each statement according to one of the following: I AGREE A I I I DISAGREE A LITTLE AGREE PRETTY MUCH I DISAGREE PRETTY AGREE VERY MUCH I DISAGREE VERY LITTLE 1. No MUCH MUCH sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. h. think about 5. ation, an it, a person has a problem or worry, it is best for him not to but to keep busy with more cheerful things. What and the 6. much, a When the youth needs most is will to work and strict discipline, fight for family Nowadays when so many rugged determin- and country. different kinds of people mix together so person has to protect himself especially carefully against catching infection or disease 7. from them. Sex crimes, such as rape and mere imprisonment; such criminals ought to attack be on children, deserve more than publicly whipped, or worse. �”"1 ‘ -20.. 8. is to The best teacher or boss is the be done and how 9. to go about 10. the strong. tells us exactly what it. Young people sometimes up they ought to get over them and one who get rebellious ideas, but as they settle grow down. People can be divided into two distinct classes: the weak and � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Social factors in selection of therapy in a voluntary mental hospital. J Hillside Hosp., 6: 216-228, 1957. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-25-030 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Kahn, Robert L.; Pollack, Max; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 4 items. 1: [Preprint]. 2: Reprint from the A. M. A. Archives of General Psychiatry December 1959, Vol. I, pp. 565—574; title: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital. 3: Xerox of J. Hillside Hospital publication. 4: Another [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published