http://exhibits.library.stonybrook.edu/mfp/files/original/0f6719a23fdc7ec86b84e3ad0121dcb7.pdf 2c174223139f67b6ca449ef570bd2067 PDF Text Text SOCIOPSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WHO REFUSE CONVULSIVE THERAPY K MAX POLLACK, PH.D. Reprinted from THE Vol. 132, N0. L 2 Copyright © AND MAX FINK, M.D. JOURNAL OF NERVOUS AND MENTAL DISEASE by The Williams Printed in U.S.A. 1961 & February, Wilkins C0. 1961 �JOURNAL or NERVOUS AND MENTAL DIsEAsE Volume 132, No. 2, February 1961 Reprinted from THE Printed in U.S.A. SOCIOPSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WHO REFUSE CONVULSIVE THERAPY MAX POLLACK, PH.D.1 The growing recognition of the relation of social factors to referral for and response to somatotherapy in psychiatric treatment has stimulated increased study of “drop-outs”— patients who refuse to start or to continue treatment. Although the problem of “dropouts” is a major one in somatotherapy, it has received little attention. In convulsive therapy it is considered one of the most fre— quent “complications” of treatment (1) yet it is infrequently discussed (3, 7) and no systematic studies have been devoted to it. Systematic studies of “drop-outs” have been limited for the most part to patients in psychotherapy in out—patient facilities (4, 5, 9, 19, 20). These studies have consistently shown marked differences in social and psychological characteristics of patients who remain in psychotherapy and those who fail to continue. Those patients who remain in therapy have more years of education and who those class social than of higher are leave. In addition, their social attitudes, as measured by the California F Scale, show “less so—called conventionalism, stereotypy and less of an uncompromising insistence that ‘right’ and ‘wrong’ can be distinguished” (20). In sociopsychologic studies of the patient population of Hillside Hospital (12, 13) age, education, place of birth and degree of stereotypy, as measured by the F Scale, were related to selection for, and response to, convulsive therapy. Those patients who were older, had fewer years of education, were foreign-born and who manifested high scores on the F Scale were most likely to receive convulsive therapy, be hospitalized for Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., New York. 1 and MY—2715, National Institute of Mental Health, U. S. Public Health Service. Aided by grants MY—2092 AND MAX FINK, M.D. a shorter period, and be rated as improved at time of discharge. In contrast, patients who were younger, better educated, native-born and who obtained low scores on the F Scale, most often received psychotherapy as their sole form of treatment, were hospitalized for a longer time, and were more likely to be discharged with a rating of unimproved. Thus, the determination of psychiatric treatment was viewed as an interactive process, and related to the background, cultural values and communicative pattern of both therapist and patient. In view of this relation of psychosocial factors to selection for and response to treat— ment, it was postulated that in a psychotherapeutically—oriented hospital patients who refuse or fail to complete convulsive therapy would be significantly younger, better educated, and be less stereotyped and conventional than patients who completed a course of therapy. This study was undertaken to test this hypothesis. PROCEDURE The seventy-five consecutive iii-patients (27 males and 48 females) referred for con— vulsive therapy at Hillside Hospital during the one year period from October 1, 1957 to September 30, 1958 were included in this study. Hillside Hospital is a non-profit institution for the treatment of voluntary patients. Psychoanalytically-oriented psychotherapy is regarded as the primary method of treatment, with various somatotherapies available when necessary. All pa— tients are seen for individual psychotherapy three times a week, with psychotherapy continuing when other treatment, 6.9., convulsive therapy, is administered. Three social (age, education and nativity) and one psychological measure (the Cali153 �154 POLLACK A ND FINK fornia F Scale), were employed. A ten-item modification of the F Scale (6, 14) was administered to 53 referrals prior to treatment. In this task, the subject reads 10 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 range of total scores is ten to seventy. The greater the subject’s agreement, with the statement, the higher the score obtained. The statements themselves are extreme, conventional and stereotyped expressions. lr‘or example, one statement is, “If people would talk less and work more, everybody would be better off.” Patients were referred for convulsive therapy by the psychiatric resident with the ap— proval, frequently at the suggestion, of his supervisor. The referral form requesting treatment was sent to the psychiatrist in charge of the convulsive therapy unit for medical examination and the institution of treatment. Thus, it was possible to determine those patients who were referred for treatment but who refused to start. Convulsive therapy was generally administered three times a week, and grand mal convulsions were induced with the standard Medcraft alternating current instrument. RESULTS Of the 75 referrals for convulsive therapy, 13 refused treatment. Of these, seven failed to start and six refused to continue treatment. In the latter group, the number of treatments ranged from three to eight— short of the generally prescribed course of at least twelve treatments. TABLE 1 Mean Age, Education and F Score by Group N Group ' Acceptance Refusal Mean Difference (One—tailed t p< test) 62 13 (figs) Educa- 0:325) 40.3 11.6 29.7 13.7 — 10.6 +2.1 2.5 1.9 .01 .025 F Score 48.7 37.7 — 10.0 2.2 .025 Social and Psychologic Factors: The group of patients who accepted a full course of convulsive therapy was significantly older, less educated and manifested a higher mean F score than the group that refused treat— ment (Table 1). Furthermore, 37 per cent of the acceptance group were foreign-born as compared to eight per cent of the refusal group. While there was considerable overlap between groups with respect to these factors, the refusal group was more homogeneous than the acceptance group. Thus, there were no patients in the refusal group who had less than ten years of education (69 per cent of the group had attended college) and none were over fifty years of age. In contrast, 27 per cent of the acceptance group never went beyond grade school (eight years or less) and 31 per cent were fifty years or older. Differences in occupation between groups paralleled the differences in education. Thus, none of the patients in the refusal group were unskilled or manual workers. They were in clerical, professional and business vocations, Whereas ten subjects in the acceptance group were unskilled workers. Housewives were excluded from this tabulation. Relation to Diagnosis: The discharge diagnoses of seventy-three patients fell into four major categories: psychoneurosis, schizophrenia, manic-depressive, or involutional psychoses. Two patients were classified as “psychotic depression” without further specification. Although there was no statistically significant difference in diagnostic composition between the group accepting and those refusing treatment, the groups were dissimilar with respect to the incidence of the involutional psychoses (Table 2). No patient in the refusal group was discharged with a diagnosis of involutional psychosis, whereas 24 per cent of the acceptance group were so diagnosed. There was also a high positive correlation between this diagnosis and the sociopsychological factors studied. Thus, the mean age (56.7 years) and F score (61.4) were higher while the years of educa- �155 REFUSAL OF CONVULSIVE THERAPY tion (9.2 years) was lower than that for the total refusal group (Table 1). Relation to Improvement Ratings: At the discharge conference held by the Medical Director each patient is assigned one of four improvement ratings: recovered, much improved, improved or unimproved. The incidence of recovered and much improved ratings was significantly lower in the refusal group (Table 3). Six patients, all in the ac— ceptance group, were rated as recovered. The hospital discharges were more closely associated with refusal or discontinuation of treatment in the refusal group. DISCUSSION The present study confirms and extends previous findings in this laboratory (2, 12, 13) in demonstrating the importance of social factors and their psychological correlates in the selection for and response to psychiatric treatment. It supports the hypothesis that in a psychoanalytically-oriented hospital patients who refuse convulsive therapy would more closely resemble those who remain in psychotherapy and differ from those who are selected for and treated with convulsive therapy. The lower 1“ scores in the refusal group than in the acceptance group are correlated with a less compliant attitude toward authority and a more analytic approach in interpersonal activities. Review of the patients’ hospital records revealed that negativism, belligerence, uncooperativeness and attempts to manipulate the staff were more common in the refusal group. For example, 38 per cent of the refusal group as compared with only 17 per cent of the acceptance group formally petitioned the Medical Director for discharge from the hospital. (Almost all these patients withdrew their request for discharge shortly after the initial request). Referral for convulsive treatment was more often associated with problems of management, e.g., disturbing the ward or eloping from the hospital, than for depressive or confused thinking. In contrast, a higher TABLE 2 Discharge Diagnosis by Group Group Manic. Depressrve Psychosis Schizo. - Psychoneurosls phrenla Acceptance7 (11%)25 (40%) 2 (15%) 7 (54%) Refusal X2 13 4 Involu. tlonal Psychosis (21%) 15 (24%) (31%) 0 (0) = 2.28, p = n.s. TABLE 3 Discharge Improvement Ratings by Group Group Acceptance Refusal X2 Recoveredfi Much Improved 34 (55%) 3 (23%) Improved Unimproved (31%) 5 (38%) (15%) 5 (38%) 19 9 = 6.41, p = .05 percentage of the acceptance group were referred for convulsive therapy for alleviation of depressive symptoms. There is increasing evidence that accept— ance or rejection of psychiatric treatment is related to learned attitudes toward treatment by both patients and therapist (8, 9, 16, 17, 21). Most often these attitudes which correlate with socio-economic status are formed far in advance of treatment, and are most likely an intrinsic part of the person’s repertoire of behavior. Thus, patients from lower class backgrounds more frequently view psychiatric treatment as nonverbal and in physical terms whereas typically “the middle class patient is predisposed toward the acceptance of psychotherapy even before he arrives at the clinic” (9). In the sample studied there were many expressions of a negative attitude toward convulsive therapy long before the referral for convulsive therapy had been made. One patient, in treatment for several years prior to her current hospital admission, terminated treatment and transferred to another psy— chiatrist on each occasion when convulsive therapy was recommended. Another patient asked to sign the voluntary certification form on admission, appended the following note. “P.S., If I am given shock treatment �156 POLLACK AND FINK I’ll either kill myself or leave the hospital.” Other patients, particularly those who have been in individual psychotherapy prior to hospital admission, state that their previous therapists instructed them not to submit to convulsive therapy in that it would be harm- ful. Perhaps more important than either attitude of the patient or the psychiatrist is the factor of consistency of attitudes. Klerman et al., (17) have reported that young resident psychiatrists with psychoanalytic orientations frequently have unfavorable attitudes toward somatic therapy and are ambivalent about prescribing such treatment. In the present study there were many indications that referral for convulsive therapy was not the “free” choice of the resident physician but was made only after considerable pressure by administrative and nursing person- nel. A recent study by Kaplan and Lefkowits (15) of staff and environmental factors associated with referral for drug therapy in this hospital demonstrated that the psychiatrist’s tolerance for disturbed behavior was much higher than that of nurses and other personnel. Frequently the resident physician placed a premium on helping the patient modify his behavior without resort to somatotherapy. A similar observation was made by Sabshin and Ramot (21) and by Klerman (17) who found that “psychiatrists treating a patient with psychotherapy were unusually reluctant to add drug therapy.” Such attitudes may be conveyed to patients either overtly or covertly. Such observations reinforce the findings of Pasamanick, Dinitz and Lefton (18) that “despite protestations by clinicians that their reference is always the individual patient, clinicians, in fact may be so overly committed to a particular psychiatric school of thought, that the pa— tient’s diagnosis and treatment is largely predetermined.” The studies here would suggest that the psychiatrist’s ambivalent attitude toward treatment is not a general attitude but is related to the “social distance” of the patient to himself. The psychiatric resident frequently has less difficulty in recommending somatotherapy for a lower class patient but is indecisive when it comes to making a similar treatment referral for a patient who is culturally more like himself. The findings that objectors to convulsive therapy were more often discharged from the hospital as clinically unimproved is consistent with previous observations (7). Gordon (7) classified objectors into two categories—poorly oriented catatonic subjects who offered resistance to the treatment and responded with clinical improvement; and a better oriented group who objected to treatment on an attitudinal basis claiming they were “not in need of them.” This latter group were refractory to the clinical benefits of the treatment. Almost all of the patients in the refusal group of the present study could be classified in the latter group. It is of interest that most of the patients who refused convulsive treatment were prognostically poor selectees for convulsive treatment. In previous studies (2, 10, 11) we have shown that the incidence of ratings of improvement at discharge in young, welleducated, low F score patients was signifieantly lower than in the older, less educated, more stereotyped patients. The refusal group is part of that group of patients who are neither “ideal” patients for convulsive treatment nor are they very responsive to milieu treatment and psychotherapy. While referral for convulsive therapy in this and other hospitals has been markedly reduced within the past few years, the problems associated with attitude toward treatment, of which treatment refusal is but one aspect, are of persistent importance. In the absence of specific therapies for the majority of psychiatric disorders the further study of decision-making in psychiatric treatment may help delineate the forces associated with selection of therapy. �157 REFUSAL OF CONVULSIVE THERAPY SUMMARY 8. HAEFNER, D. 1’., SACKs, REFERENCES Treatment of Mental Disorder, p. 223. Saunders, Philadelphia, 1953. 2. FINK, M., KAHN, R. L. AND POLLACK, M. Psychological factors affecting individual differences in behavioral response to convulsive therapy. J. Nerv. Ment. Dis., 128: 243— 1. ALEXANDER, L. 248, 1959. 3. FLESCHER, J. The “discharging function” of electric shock and the anxiety problem. Psychoanal. Rev., 37: 277-280, 1960. 4. FRANK, J. D., GLIEDMAN, L. H., IMBER, S. 1)., NASH, E. H., JR. AND STONE, A. R. Why patients leave psychotherapy. A.M.A. Arch. Neurol. Psychiat., 77: 283—299, 1957. 5. FREEDMAN, N., ENGELHARDT, D. M., HAN— KOFF, L. B., GLICK, B. S., KAYE, H., BUCHWALD, J. AND STARK, P. Drop-out from outpatient psychiatric treatment. A.M.A. Arch. Neurol. Psychiat., 80: 657—666, 1958. 6. GALLAGER, E. B., LEVINSON, D. J. AND ERLICH, I. Some sociopsychological charac— teristics of patients and their relevance for psychiatric treatment. In Greenblatt, M., Levinson, D. J. and Williams, R. W., eds. The Patient and the Mental Hospital, pp. 263—285. Free Press, Glencoe, Ill., 1957. 7. GoRDON, H. L. ()bjectors to electric shock treatment are refractory to its therapy. New York J. Med., 46: 407—410, 1946. AND MAsoN, A. S. Physicians’ attitudes toward chemotherapy as a factor in psychiatric patients’ As part of a continuing investigation of the relation of sociopsychological factors to psychiatric treatment, the present study was concerned with the sociopsychological characteristics of patients who refused to start or to continue convulsive therapy. Thirteen of the 75 consecutive voluntary patients referred for convulsive therapy refused treatment during a one year period in a psychoanalytically-oriented institution. These patients were younger, better edu— cated and had lower scores on the CaliforniaF Scale than the group that accepted convulsive therapy. The diagnosis of involutional psychosis was absent in the refusal group, and patients in the refusal group were more often discharged as unimproved. The acceptance or rejection of psychiatric treatment is discussed in terms of learned attitudes toward psychiatric treatment by both patient and doctor. J. M. . responses to medication. J. Nerv. Ment. Dis., 131: 64—69, 1960. IMBER, S. D., FRANK, J. 1)., (,iLIEl)MAN, L. H NASH, E. H. AND SToNE, A. R. Suggesti— bility, social class and the acceptance of psychotherapy. J. Clin. Psychol., 12: 341— 344, 1956. 10. KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock 11. therapy. J. Neuropsychiat., 1: 45—49, 1959. KAHN, R. L. AND POLLACK, M. Prognostic application of psychological techniques in convulsive therapy. Dis. Nerv. Syst., supp. 20, pp. 180—184, 1959. 12. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in the selection of therapy in a voluntary mental hospital. J. Hillside Hosp, 6: 216—228, 1957. R. L., POLLACK, M. AND FINK, M. Sociopsychologic aspects of psychiatric treatment. A.M.A. Arch. Gen. Psychiat., 13. KAHN, 1: 565—574, 1959. L., POLLACK, M. AND FINK, M. Social attitude (California F Scale) and convulsive therapy. J. Nerv. Ment. Dis., 14. KAHN, R. 130: 187—192, 1960. 15. KAPLAN, A. AND LEFKOWITS, H. J. Influence of staff attitudes and environmental factors on treatment selection. J. Hillside Hosp. In press. Staff attitudes, decisionmaking and the use of drug therapy in the mental hospital. In Denber, H. C. B. Research Conference on the Therapeutic Community, pp. 191—214. Thomas, Springfield, 16. KLERMAN, G. L. 111., 1959. 17. KLERMAN, G. L., SHARAF, AND LEVINSON, D. J. M., HOLZMAN, M. Sociopsychological characteristics of resident psychiatrists and their use of drug therapy. Amer. J. Psy- chiat., 117: 111—117, 1960. B., DINITZ, S. AND LEFTON, M. Psychiatric orientation and its relation to diagnosis and treatment in a mental hospital. Amer. J. Psychiat., 116: 127—132, 1959. 19. ROSENTHAL, D. AND FRANK, J. D. The fate of psychiatric clinic out-patients assigned to psychotherapy. J. Nerv. Ment. Dis., 127: 18. PASAMANICK, 330—343, 1958. 20. RUBENSTEIN, E. A. AND LORR, M. A. A com- parison of terminators and remainers in outpatient psychotherapy. J. Clin. Psychol., 12: 345—348, 1956. J. Pharmacotherapeutic evaluation and the psychiatric setting. A.M.A. Arch. Neurol. Psychiat., 21. SABSHIN, M. AND RAMROT, 75: 362—370, 1956. ��We. lama-b.1031“! at tutu. cantata norm In: rum rum. and “no“. at. In rm IJ. no What a: mum»: manna-y ' mum mum ' In. v.1. at... at... a» 18-1715. ”-10,! of In“: an lulu-.1 mu it Intuit. put '0’. 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A raetut atndy hr 1.31:: and Lntuavtta (15) a: ufiatt‘ ‘36 fiuvironasnttl tna£ura I‘lfitiflficd with rut-tral for drug iburuyy 1: thin hmupltal doncmafirntnd 1ht$ ti. pnyuhtifirtlt's tolurnntc {at dilfiurhod buhavior nun filth htthflr tbs: thu‘ a: unrsau gal athor pornonnal. Iroquautzr $ho rasidont pirttutun placid : prontuu an htlpiu¢ tum patAnnt nadir: hit uninviur without rciart ta InimittIGrtyr. L ttnilcr ahltrvttton wt. and. by aubthaa and lanai (21) gun by xlawaau (17) ch. fauna an 'p-mmtruu was“; :- mums nu mummy.” tutu unusually rcluatnut to ada awn; shmrnpr'. Such ;tt1tuIOI :11 ha away-:Id ta F‘fiiifltl cashor ovurtly If sartrtly. aneh ahanrvlfitomn rntntnrat tbs tiadtnas w: Pnannnnlck. 91u1$: and Litiln (18) that ‘duaptso prostticisanu by clsnlaina; thtt that: maturtsco 1n tinny: til tndtvidunl pnfiitut. clanaatnnl, t; tact at; b. I. crawl: nannitfiad in a pnr‘taulnr psywhtntrio �«v11.» rental at $halnht, thu‘ tbs pl‘SOQt'o «instant: tad troutucnt an Itrguly prudotorntn¢d.‘ 2h. 'tnltut hat. would nuggnnt that tn. paychtntrstt'u 3:51thtat attitudo Qoward ‘rantnout 10 not . caunrul n‘titado but. :- "um to th- ‘uew. dunno" a: tu ”no“ u hinuult. 1h. pnyuhtn$tgc roatdant Iroquuutlr ha: 1:1: dittitulty .1: newt-gang Imumtwy tu- n In“ «In: M that. It“ in tudoalatvo than at sing: it fllkiil 3 51-31.: trustncnt roturral £0? a putiant who 1. cultnrtlxr unr- 1130 hxnuult. 1h. finding: taut ub3n¢£oru to cauvnlnlvt titrnpy sure gown otttn ditchnrgod tron in. h¢0p1¢I1 g. clintg‘lzy untupruvga 1n countltou‘ with privioul thnarvnfiloul (1). ccwdou (7) eluutttcc objector: int. tun untoxorioo . pcorly orxau‘cd c‘tatunte nubjoctu who uttarod raatatunao to it. tra:tn¢nt tud rucpaniud wi‘h elintanl ll,ffl?lfliu%3 lad a tottor ariastoi group vb. dbjcetnd $0 troutnont on ta uftt‘udtanl hula: e131u$u¢ §hu7 '1’. ‘not in lfibd it than“. Ibis lttinr group rutrtctnry to £30 Glitteal bnncltta at tho tr0&fiuont. Alntc‘ :11 at the patient: in thc rnrtlnl urcnp of tha prtuuut t‘udy ecnld ho alcnaittud tn :5. l‘tior crimp. n. in “mug fihfi wu$ .1 tin nation“ who to!!!“ ccnvulaivu traninult v.9. praguou‘fioally pour acluatsut It! eonvnlulvu tr::iu¢nt. In yrtvio‘l-utndaol (2.10.11) v. hnvo than: this tho incident. at ruttugs a! 1nprovuucu$ :t dilthnrg. in runn3, vulluoducutnd, luv 3 0:01. pattuats van wort l �smut-mu: 1.“ ma m In», u «and. mm tu-nmmumdmy aWnuu-u. of for 'mn‘ ”an” m WMSmmMmmpmsnuuun‘ Wu plant: m «0 mm at 9mm. mm «My «I In mu mm: m1” Mm u «u nu in 1m: max: round 1mm a. main ”u ma. a» "051m “mm It“ amt!“ W ”and.” at m... u m m mun. m mum: u but.” m: amomunumcmumxum w. muxmm «am» a! punt-m: mm. m mm an: a: In 3.70.1..th Win-It W his «1mm- ». 3m macaw an «man u .mm. ’ ' �m:u m at a mum immun- a :4»:me trauma W. m ‘ "nun u wanna train» “My “I nutnmhfiqlul it“ m mm um to at at m h "in“ “at ammu» “an” 75 at m mulls" 1mm“ mm "1W7 ”um mm a: ”mun" that” "(not wan-nu mm a m in: mm x: a pmmWth-r «mm mums“. Ma nun“, m mu. hm» mm m m 1 um um- ” u- «mm In“ m: flu m an 0: no lmhuml «mm mun"- Mm._ ”who“ m “m! u m m u ”nun m. n» mm alumni u nun-m. m. m ht «mum a mom... a: mantra mm 1: of attitudinI. “an!“ m 1m“ ”3mm. W and by “but m ”in“ law. at ‘ th- m mu m m um ‘ �um: Inn: 13:. lingafiaau Asttptanaa fictuaul t! to.) 13 19.1 II¢I filttlralu. (flunuinalnd 3 M) p ‘10.! :.s ' and «‘1 I’aonr: ¢ . Ur Irony 11.6 13.7 83.1 37.1 8.: «10.9 1.9 1.2 am .015 �fill-III 3mm» nag-nu h In“ 3m Wm Imam: tutu-not W 1 um a (151) (R6) 13 t (m) h 15 I: It“; , "‘ "' ‘1... (w) (an 15 o (M) (o) �1’ " ‘*‘13 P "‘ ~05 �1. “1-,. a. 3. ‘0 5. 6. nu, I" .“um. ‘fi’. mm. 3-1.. m0, M! m, M‘; ‘95,. W13 My .W. fl“.mg 3.: ”M, 1.3.“: m “on, 3:30; at um, la 1.3.1”; 1m; m. 3.1., mm, 1., hum“. W, ".1 11‘ £0.15, mm» Wu m. W. .infip 1’5“; m‘g 'o't,‘fog W mm, 1.3.. on... 3.3.. 2.: am. um 1950. 551.6“. 3; 3.3. m an», x... can mm, 3.3., cam-paramount). ¢Wmifiit a: ”an” m “on ”hum he ”nun”. ars-inn. 1:: Wk“. ’03.. N “am. ’0'. (“'o). m '.g . m, :- .. 0mm m... W;3;!” “‘13 6h. m, 1.8.: am. ’¢ m; 16. Mg 1”. wax: m; 30,-; '05.; up”: 1939. ’5'. C“ In“. ‘o'cl 3‘1! 1”: m. a: W” 8.9" M m, '0! '0’ M "1“.» "“ m; m. m 1,5,. M in. ma- ‘G'I. In“, ‘0'. I“ Shh)“. 1!“. 7 4 * * W4, g. m. �at. 11. m, 3.3... hawk. It. 10 816, 195?. nu. m m, 3.: m . Wm. w. M. an run, In ,1: “S. to”. mm... 2.2;... '11.: In... «a I. «mot, rug. 1!“. m: I”, 3.3.: Mm. at can mum» mm. a. «a 1.1... hunk. m mu,“can a train“ «W. ma m. mm. Km. and u.‘ 17. 1.. 1!. 3;. n 0.33.! "at: “um“, twain-nun and m must. mcmwummm hm. W” um, um. mm... 3.3.: 111, m: an.” 19“. a. 1.. 1.: m mm, mu. Wk, tam-u. 5.3.; m: I... 1".- 1,5,. woman, n. on mu. 3.»... w. W, m.. “W. IO. 1.1. was... m kn. Ian ”5‘38’j 1,5‘0 m”... a. mm mu» 3”. ' In. 1:! m, 1’s‘a I. and M... m: g: “WW � 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 Sociopsychological characteristics of patients who refuse convulsive therapy. J Nerv Ment Dis. 1961 Feb; 132:153-7. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-54-020 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource 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 Reprint and [preprint]. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Vol. 132, N0. 2 February, 1961 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