http://exhibits.library.stonybrook.edu/mfp/files/original/10dd96ea03d444a3545ca7a104bdf5fe.pdf a67bc54ff65c228d90099b2591e160d9 PDF Text Text SOCIAL FACTORS AND COMMUNICATION IN PSYCHIATRIC PATIENTS I: 11: III: From Pollack Ph.D. Choice and Results of Therapy - Duration of Hospitalization and Diagnosis - Robert Observations in an Interview Setting - Joseph Jaffe Max L. Kahn Ph.D. . M.D. the Department or Murmantal Psychiatry, Hillside Hospital, Glen Oaks, L.I. , NJ. Presented October 19, 1958, at Hillside Hospital. �III: 9-29-58 Social Factors and Commmication in Psychiatric Patients 1: Choice and Results of Therapy Recent investigations by Hollingshead, Redlich, Frank, Levinson and others have indicated a relation between social class and psychiatric disorder with respect to type and incidence of mental illness, selection be present and maintenance of treatment and therapeutic outcome. report is concerned with the role of social factors in the . selection and efficacy of therapy in Hillside Hospital. me most intensive analysis of the relationship of social class to mental illness has been recently reported by Hollingshead, Redlich and their coworkers. In their studies the population of New Haven was divided into five social classes on the basis of weighted criteria or education, occupation and place of residence. or 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 comm among the lower classes. Of the psychotherapies, psychoanalysis was entirely restricted to the We upper groups. Social class was the predominant determinant of the type of treatment selected even when the diagnosis was held constant. They summarize their observations as follows: I'.... it is found that and does treatment not depend on psychological medical determinants alone, but on the status position of the patient as well. Psychotherapeufic in disproportionately high degree to the upper social data of this study would seem to indicate that most methods are, applied levels. The �in a setting where the background of the patient is similar to that of the therapist." It is possible, however, to relate the results obtained from these commity studies to such selective factors as the patient's financial psychotherapy takes place resources or the extent and type of treatment more critical test of the facilities available. A importance of social factors affecting choice of treatment would be in a setting where the same therapeutic tecrmiques and services are available to all patients, regardless of their ability to pay. is at Hillside Hospital. the 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. Thus a patient is seen in This requirement met regular therapeutic sessions throughout his hospital stay even when undergoing a course of caustic therapy. The average length of hospital stay is six months, with some The purpose patients remaining from of the present report is 12 to 16 months. to smnmarize the relation factors of age, education, place of birth, and social attitude (as measured by the California F scale) to the selection or between the treatment and the ratings of improvement at time of discharge in this environment. muons 1957 was The entire in-patient adult population of studied. This consisted of 171 patients, March 7, 57 men and 111; women , ranging in age from 16 to 68 years, with a mean of 35 years. �Procedure: The patients were tested with a ten-item modification of the California F scale suggested by Levinson. The F scale is a questionnaire which has been related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity. The patient reads ten statements and indicates whether he agrees or disagrees with each statement and to what extent. from one to seven and the The score given for each item ranges 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. For example, one of the statements would be is: "If people would talk less and work more, everybody better off." Choice of Therapy: will first take up the relation of these social and psychological factors to selection for treatment. During the period of this study, (Table I) approximately one-third of the patients received convulsive The small with and two-thirds treated psychotherapy were only. therapy group of patients who received insulin coma and drug therapies are not We represented on the slide. When compared to psychotherapy patients, the convulsive group were older, had fewer years of education not completed grade school also had a higher F - - many had and were frequently foreign born. They score, which indicates that these patients tended to agree with social stereotypes. At this time, the psychiatric residents and their supervisors were also tested. Their average F score was 21.8 with a mean age of thus more closely approximating the psychotherapy group than the 33 .9. �electroshock group. This figure has dealt with group averages for each of the factors mentioned. There was however marked at the patients is variability within each of the groups, with patients each end of a wide range. grouping shown group with reSpect to length of convulsive therapy. As One method in the analysis of the electroshock hospitalization prior to receiving illustrated in the next table electroshock patients were divided into three groups: were and (Table II), the 1) those who after admission, 2) between three after six months. There is a definite correlation treated within three six months, and 3) of sub- months prior to convulsive therapy and F score, age, education and birthplace. It is of interest that there is a gradient for each of the social factors. As a group the patients referred for between length of stay convulsive therapy after six months of hospitalization are most similar to the psychotherapy patients with respect to each of the factors. Che set of data not shown in the slide is the ratio of male to female patients referred for somatic therapy during each of these hospitalization periods. Although the ratio of females to males in the hospital population is two to one, hh per cent of the patients in the group treated within three months were male. In the group hospitalized for six months prior to convulsive therapy, however, only 7 per cent are males. Thus, male patients are referred for electroshock earlier in their hospital stay than As patients. expected, a larger proportion of depressed patients female ~ 52 cent - received electroshock than did those with other diagnoses. per To �-5. 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 the next slide (Table III). While the two groups are comparable age and education, the electroshock mean F shown in for patients had a significantly higher score and a higher percentage were foreign born. Thus, it may that persons classified as having a psychotic depression are not necessarily referred for electroshock because they are older or less educated, but rather that they come from cultural backgrounds that are be more commonly associated with psychologic processes that make successful in the psychoanalytically oriented psychotherapeutic relationship less likely. These findings are consistent with previous studies which have shown that patient-therapist differences in systems communication of values may hamper Redlich note: "We therapeutic relationship. As Hollingshead and are not sure what attributes a good patient must have, but they include sensitivity, intelligence, Social and intellectual standards similar to the psychiatrist‘s, a will to do desire to improve one's personality and status in life, attractiveness and charm. Rarely will such standards one's best, a youth, be admitted by psychiatrists. On the contrary, psychiatrists claim that the selection for treatment is based on purely psychiatric criteria....." Results of Therapy: Social factors are as significantly related to treatment result as they are to treatment selection. hospital treatment on To the 171 patients, analyze the effects of the we selected the discharge �evaluation as the criterion of improvement. At time of discharge a patient is classified in one of four categories: recovered, much improved, improved or unimproved. relation of social factors to the discharge evaluations is presented in the next slide (Table IV). There is a definite, almost The linear relationship, between the improvement rating and these four social factors. The recovered group of patients had the highest F scores, were oldest, least educated and of foreign birth. In contrast, showed the highest incidence the unimproved group had the lowest F scores, were younger and better educated - almost all having gone to college - and were primarily native~born. for patients treated with convulsive therapy the improvement ratings parallel those for the total population. Analyzing the data (Table V) Again, the recovered group had the highest mean F scores, was the oldest, most poorly educated with the highest incidence of foreign birth. The illustrates the relation of these observations next slide (Table VI) to time of referral for treatment. Within the electroshock group 67 per cent of those who were treated early in the course of hoSpitalization were rated as recovered or those treated after six these two groups. were more much improved, whereas months only 30 per cent were As was noted earlier, patients in this latter similar to the psychotherapy group It is classified in WEUh respect to these not surprising, therefore, that they were treated with somatotheragy only after an extensive course of social factors. psychotherapy. group �.7In summary, the observations that social factors are related to type of therapy received as well as therapeutic outcome are consistent with the studies of Hollingshead, Redlich and their coaworkers. their findings in demonstrating that these factors are also significant in a hospital setting where where and selection of not therapeutic criterion to a is pay ability all forms of therapy are equally available to the entire population. Furthermore, the present studies extenii While the relation between social factors and treatment selection are clear, and are consistent with previous findings, the relation of these factors to improvement ratings appears paradoxical. observations that those patients with high and less educated, more F scores, The who were older often received convulsive therapy and were discharged more frequently as recovered are consistent with the results reported in 1956 in a follow-up study of Hillside Hospital patients conducted by Rachlin, Goldman, Lurie, Gurvitz and Rachlin. It is possible that the differences in communication between therapist patient that result in referral for convulsive therapy may also influence the discharge rating. Thus, Kahn and and Fink have previously to denial, evasion, and benefit most receive to and of cliches use are likely stereotypy from electroshock. Such language patterns appear more frequent in shown that verbally uncommunicative persons, prone persons in the lower socioeconomic groups. Because of the differences therapist and patient, the therapist may set different criteria for improvement for the older less educated patients than he does for between the young, sophisticated ones, �class patient The lower may also set goals for himself that are The from class patient's the different patient. upper qualitatively aspirations for himself and the therapist's expectancy for the patient of time of hospital improvement at Ratings an interactive are process. discharge are relative in that they refer to a baseline of premorbid functioning. Thus the rating of recovered is defined as, "the reasonable expectation that the patient will be able to return to his community and function as well, or better, than he did before he became ill." therapist's perception of the patient's premorbid functioning may be influenced by the distance between his value system and that of the patient and both influenced by their social class. ‘The greater the social distance between therapist and patient the less rigorous the requirements for behavioral change. Fer example, for older, lower class patients, ability to resume work may loom as the major criterion The of improvement. For the upper class patient work adjustment only one of a may be host of criteria, including such intangibles as work gratification, ease of sociability, etc.. This presentation has dealt with a few of the relationships between social factors and psychiatric treatment in a voluntary, psychotherapeutically-oriented hospital. The other speakers will deal with many of the questions left unanswered in this report. �THERAPY SELECTION F Score Yrs. of Education Foreign gMeanz Age {Mean} Electroshock (Ii-57) 14306 ’40.3 11-2 26% Psychotherapy 36.1; 32.6 11.8 9% Groggs (Na102) SMean) % Born �.10TABLE II LENGTH OF HOSPITALIZATION PRIOR TO ADMINISTRATION OF ELEBTROSHOCK F Score gMeanz Groygs Less than 3 {N-Bh) 3 mos. to 6 mos. (N-IO) More than 6 mos. (N~13) Age (Mean! Yrs. of Education Ween! % ForeignBorn 148.3 M45 10.1 1:173 he. 7 39.8 11.7 30% 32.9 29.5 13.14 �-11TABLE III SELECTION OF THERAPY IN PATIENTS WITH PSYCHOTIC DEPRESSION Yrs. of Education Foreign— Born F Score SMean! Age SMean) Electroahock (N'Bl) 50.3 h8.6 10.6 1:253 Psychotherapy h1.0 h7.6 10.0 2h% GrouEs (n-29) SMean)___ % �-12TABLE :1 SOCIAL FACTORS AND DISCHARGE EVALUATION F Score SMean) Age gMean) Yrs. of Education gMeanz 1 ForeignBonn h2.9 Mus 10.7 Much Improved 39.0 35.6 11.2 22% Improved 36.1 31.2 11.2 16% 31.2 13.2 11% Recovered h1% (N-17 ) (n-82) (N'63) Uhimproved (n-9) 31.1 �-13TABLE V DISCHARGE EVKLUATION IN CONVULSIVE THERAPY Yrs.‘of F Score sMeanz Age SMeanz Education % Foreign- SMeanz Born 53.1 51.6 9.u 50% (N-26) h2.0 h3.8 10.6 35% Improved and unimproved (Ni23) 39.7 32.3 12.3 12% Recovered (N-B) Much Improved �-m- M TABLE VI LENGTH OF HOSPITALIZATION PRIOR TO ELECTROSHOCK AND DISCHARGE EVALUATION Recovered Much 8: Iflroved Improved U raved Groggs Less than 32% 6 mos. 70% 30% than 6 mos. 31% 59% (n-Bh) 3 to ms. 68% 3 (N-lO) More (N-13) & �III: 9-29-58 -15- Social Factors and Communication in Psychiatric Patients II: Duration of Hospitalization and Diagnosis Just heard a presentation of factors associated with the selection and results of treatments. I will next conéider the relation You have of these factors to length of hospitalization and to diagnosis. It is obvious that the length of time a patient stays in a mental hospital is related to the particular function and philosophy of the institution. In an institution such as Hillside Hospital which admits only voluntary patients and emphasizes psychoanalytically oriented psychothe In limited. particular of is the hospitalization length therapy, montthin 16 from complete to one was the studied the population range L months. of six over with an stay slightly average hospital, Several factors can.be postulated which might be related to the duration of hospitalization. Since it commonly takes less time to produce behavioral change with convulsive therapy than with psychotherapy, one would expect to find that the consulsive therapy patients are kept in the hospital for the shortest period while the psychotherapy patients are here longer. The data, as presented in Table VII, shows no significant difference between the two groups. If anything, there is a slight tendency for psychotherapy patients at Hillside to be institutionalized for the shorter period. A second possible factor is the severity of the patient's illness. be who will necessarily more intractable those are that patients It maintained in the hospital further to receive additional treatment. Examination demonstrates shown Table in VIII, the however, as data, of those that while patients hospitalized for the shortest period do have may be �Much and Improved, Recovered of of ratings incidence discharge a higher and chance are not significant. variation within a differences are the In the Hillside followhup study of Rachlin there was no relationship EELEE' it was also found that between discharge evaluation and length of time in the hospital. On the basis of the data and discussion presented by Dr. Pollack, be should a relationship there that hypothesis advance the further can we of and duration hospitalization. the background social patient's we oriented psychotherapy psychoanalytically With Hillside's stress on would expect that those patients who are most like the therapists with regard between a to these factors.would be kept The the period. for longest the in hospital data is presented in Table IX. Patients shortest who were period had the highest F scores, were hospitalized for the oldest, had the fewest Conversely, born. of native and smallest the percentage education of years F the lowest had the scores, the who longest the in hospital were those of and smallest the percentage education of most years youngest ages, the foreign born. These differences are statistically significant. In Table X a similar analysis is shown for only those patients receiving electroshock. Again, each of these factors is related to duration of hospitalization. The same results are obtained psychotherapy only is when the data of those patients receiving While XI. shown Table in as analyzed separately, F low have Pollack Dr. scores, are indicated, as these patients as a group, electroshock the than born and native more education have more younger, patients, there is still a significant difference within the group in the the time in hospital. of the to length according direction predicted �These same relationships of social factors to hospitalization are found even when the patients were subdivided according to diagnosis. In Table XII the data is shown for the in the hospital for each diagnostic group. F their final score and months The diagnoses were subdivided into four major groups and include all but three patients in the population studied. For each group there is a significant difference between those in the hospital for the shortest and the longest periods, with those in the longest having the lowest scores. Similar results are shown when the data is analyzed It is also shown for each diagnostic group with respect to age (Table XIII). for education (Table schizophrenic patients stay. It who were who XIV), with the exception of the had about the same education for each length of should be noted, though, that many of the schizophrenic patients here for ten months or more were quite young - around 16 or 17, and so did not have the opportunity to receive education beyond the middle of high school. Analysis of place of hospitalization is shown is associated with a birth for in Table each diagnostic group and length of XV. marked decrease Increase in length of hospitalization in the with the exception of the schizophrenics, number who of foreign born, again as a group, had very few such persons. The previous tables have indicated that not only is there a significant relation between each of the social factors studied and length of hospitalization, but that there are large differences between the diagnostic groups themselves, even when comparing patients with the same period of hospitalization. in Table XVI. The summary It is data comparing the diagnostic groups is shown clear that patients diagnosed as involutional psychosis �have the highest F scores, the oldest ages, the least years of education, highest incidence of foreign born. In contrast, the schizophrenics have the lowest F scores, were the youngest, had the most education and the and the of foreign born. The manic-depressive and psychoneurotic involutionals the to closer with the manic-depressive between, in patients fell least number like the schizophrenics. relationship between these social factors and the psychoneurotics most This marked and diagnosis is not surprising. Certainly the relationship of age and diagnosis is an established concept in clinical psychiatry. In the involutional disorders and What names themselves have a chronological conndstion. in dementia praecox the is unexpected, however, is that age should also be related to the and that the and disorders, psychoneurotic of manic-depressive diagnosis other social factors of education, place of birth and F score should in this hospital. the diagnostic major groups differentiate all significantly we have postulated two hypotheses to account for these relationships. The first is based on the fact that persons from different social backgrounds acquire different habitual and expression. modes of adaptation and patterns of communication Accordingly, under conditions of stress, damaged brain function, or other etiological conditions associated with the onset of mental illness, a person will show those behavior patterns or symptoms his habitual patterns. Thus, a person from background communicate in nonsverbal, to more lower apt social class is a do so in to more while class people likely are physical terms, upper which are of the same type as ideational and verbal terms. Thus, anger may be shown by lower class people by physical violence, while those from upper classes are more and Redlich Hollingshead exhortation argument. to to or resort likely �-19- have noted that these differences among people of different classes lead to different psychodynamic patterns in psychoanalytic terms. Thus, aggressive and sexual behavior behavior variation is is restricted among more acceptable among to lower class parents, while such the upper classes, lending to considerable the different social classes in superego development. Irish Italian patients who were diagnosed as schizophrenic in a V.A. Hospital, found significant differences in their types of symptoms related to cultural differences in their family backgrounds. Patients coming from Irish families in which active expression of emotions Marvin Opler, studying and were frowned upon and with dominant over-protective mothers, were passive, compliant and withdrawn, and fearful of anything which might separate them from the protection of the hospital. Patients with Italian family backgrounds that encouraged free expression of showed were assaultive and emotion and were ruled by a dominant destructive behavior, were difficult to father, manage and rebellious against authority. In a comparable study Miller and Swanson have also noted that hospitalized schizophrenics exhibit significant social class difference in symptomatology - lower class patients showing "motoric themes," while middle class patients exhibit "conceptual or ruminative themes." According to our hypothesis, then, we would expect lower social levels would show symptoms sensory or motor patterns. Among that persons from that are non-verbal, expressed in such types of symptoms would be psychomotor retardation, anorexia, catatonic stupor, muteness, hysterical blindness or paralysis. In this connection it is noteworthy that hysterical symptoms have been reported as the army far men more frequent among enlisted in than officers. In addition hysteria which was apparently so common in‘world.war I was not nearly so notable in wbrld'war II, and, in fact, has been reported �in the general population. This decrease, in our view, is related to the general increase in educational level of the country as a whole. If one finds a classical case of hysteria in New'York today, I on the wane Rican be immigrant Puerto the in likely it population who have the poorest socio-cultural background. (One cannot, of course, ascribe the decrease in hysteria to a greater freedom in sexual will understand that matters; has it is shown, most most common in more poorly educated people who, as Kinsey are least inhibited sexually). In the laboratories at Hillside Hospital the investigations of persons with depressive psychoses have been more intensive. we have noted a common of lack characterized hy these behavior of in people, premorbid pattern imagination, creativity and introspective capacity, and by conventionality and general rigidity. Similar patterns have been noted in a series of studies of such patients by other authors. background, such as that involving little we or believe that a poor cultural no education, spending early and cultural is environment, meager resources, in a illiterate largely years conducive to the development of such a personality pattern. When mentally disordered, such persons tend to react with a repertoire of behavior patterns consistent with their background which A we second hypothesis concerning the term depression. relation of social factors to and between do the with has interaction patient to diagnosis psychiatrist. this hypothesis a diagnosis may not be based on an actual how of the reflection extent a to but behavior great is a pattern, objective psychiatrist perceives or identifies the patient. It has been noted frequently that patients with similar symptoms will be differently diagnosed and treated depending on their social class. For example, we recently studied three According to patients who were admitted with similar symptoms of depression, anorexia and �insomnia. who was All three were referred for convulsive therapy. One woman, 62, born in Russia, of limited education with an F score of 70, was diagnosed as involutional melancholia. this country, with The second, aged hS, born in an F score of 53 and a high school education, was termed manic-depressive, depressed. The third, aged hh, also born in this country, with an F score of 33 and a college education, was diagnosed as psychoneurosis, reactive depression. In conclusion, in the Hillside Hospital population social factors of age, education, birthplace and F score are significantly related to the selection and results of treatment, length of hospitalization and diagnosis. These findings illustrate the importance of social factors in affecting language and communication patterns and the nature of the interaction patient and therapist. Current data, both from our own laboratory and as reported in the work of others, indicates that psychotherapy is most likely to take place with those persons who most closely resemble the therapists between in terms of cultural background and communication pattern. In Hillside, with its emphasis on psychotherapy, it is clear that patients who best meet this criteria are also keptthe longest. This is true for either patients receiving convulsive or psychotherapies alone, and for all diagnostic groups. In the evaluation of clinical improvement there may well be different expectancies towards patients in terms of these social factors. with may little In a person education and different modes of expression than ourselves, we regard, for example, the manifestation of denial as improvement. But in a patient much like ourselves in cultural background, the denial will be regarded as a defense and the patient is showing of considered unimproved. patient,himself, may have different expectancies not only in terms of the type of psychiatric treatment, but for what constitutes improvement as well. The �believe also that the attitude of the patient's family may be crucial in both the patient's and therapist's conception of what constitutes we improvement. relation between social factors and diagnosis was interpreted in affects background cultural one's that indicated was First ways. it The two the type and and accordingly and communication, of expression symbolic pattern the possible type of symptoms a diagnostic statement behavior pattern. patient and is not Rather, it that will be shown. Secondly, we believe that simply an objective evaluation of a given is a reflection of the interaction of the psychiatrist in relation to their respective cultural backgrounds and modes of communication. It is between mind the while relationship that in to keep important social factors and the psychiatric aspects described is probably applicable as a generalized principle, the specific findings may vary in different For example, in a study using the F score at the settings or institutions. Boston Psychopathic Hospital, the same relationship to type of treatment was noted as in our report, i.e., the electroshock patients had higher scores than those receiving psychotherapy. patients there, however, patients is was higher than Since the average score of the at Hillside, their psychotherapy had the same mean score as our electroshock cases. Another example the finding of Hollingshead and Redlich that schizophrenia common diagnosis proportionately among F was a more lower than upper classes, while at Hillside the schizophrenics had the highest education. This discrepancy two of the in composition the variation be accounted by for can probably middle from drawn the largely being the Hillside patients populations, lower classes. social few from the or with upper relatively groups �-23- In Hillside the diagnosis of schizophrenia may indicate an "interesting" same diagnosis the population while State Hospital in a patient, may represent a "hopeless" patient. It be tested to studies these by raised remains for the hypotheses In involved. the psychological of processes studies and for further interaction. communicative of studies on been working have particular we Some Dr. of the details Jaffe. and findings of this work will next be presented by �DURATION OF HOSPITALIZATION AND TYPE OF TREATMENT in Ho§ita1 Months Treatment Grog-pa 1 - 5 6 - 9 10 or more Electroshock (S?) 26% 30% M453 Psychotherapy (102) 32% he}! 25% " 5.73 df " 2 (3112 p - N.S. �-25TABLE VIII DURATION OF HOSPITALIZATION AND DISCHARGE EVALUATION Discharge Evaluation Months in Hoggital Recovered or Much Iggroved Improved or raved EM 1-5 (h9) 69% 31% 6-9 55% 15% 52% 148% (624) 10 or more (58) Chi2 df p - 3-83 2 N.S. �- 26.. TABLE IX DURATION OF HOSPITALIZATION AND F SCORE, AGE, EDUCATION AND PLACE OF BIRTH in Hogi‘bal Months 91-192 - 9 {bl-6h} 10 or more 133.9 10.5 31.0 Mean Age 145-5 32-5 27 .9 Years Education 10.0 11.9 12.8 W 19% 10% 1 ean F Score M Mean 5 Foreign Born - 5 6 ski-582 �-27TABLE X DURATION OF HDSPITALIZATION AND F SCORE, AGE, EDUCATION AND PLACE OF BIRTH IN PATIENTS RECEIVING ELECTROSHOCK Months in Hogaital -5 pm 52 6 Mean F Score 58.2 h5.6 3h.9 Mean Age 51.7 h2.2 32.1 6.5 12.3 13.2 67% 2h% 16% 1 Mean.Years Education % Foreign Born - 9 551-172 10 or more 531-25 2 �DURATION OF HOSPITALIZATION AND F SCORE, AGE, EDUCATION AND PLACE OF BIRTH IN PATIENTS RECEIVING PSYCHOTHERAPY ONLY in HogEital Months 1 - S 6 - 10 or more gN-262 SN‘BB} 9 SN-hB! Mean F Score h0.2 38.6 27.8 Mean Age [‘3 c 2 29 o 1 2,4 0 8 11.1; 11.7 12.1: Mean Years Education % Foreign Born 30% 16% 8% �W TABLE MEAN F XII OF DURATION TO ACCORDING GROUPS DIAGNOSTIC SCORES FOR HOSPITALIZATION Months Diagnostic in Hoggital 3;; L2; 58.2 50.9 35.0 Manic Depressive h0.02 h6.1 33.1 Psychoneuroses h0.05 36.6 36.1 Schizophrenia 36.3 38.5 27.6 Greg Involutional Depression 10 or more K �-30TABLE MEAN AGES FOR XIII DIAGNOSTIC GROUPS ACCORDING TO DURATION OF HOSPITALIZATION 10 or more Diggggstic Gregg 3L;§L £1;;2_ Involutional Depression 58. 8 5h. 5 52. 3 Manic Depressive h6.8 39.1 35.5 Psychoneuroses 141.0 27 .1 27.1 Schizophrenia 27.8 27.8 214. 1 �.31TABLE XIV W OF DURATION TO ACCORDING GROUPS DIAGNOSTIC FOR EDUCATION MEAN YEARS OF HOSPITALIZATION Months in Hogaital 10 or more 1;;;§ 51:113 7.1 9.6 16.0 11.0 11.7 12.3 Psychoneuroses 8.7 12.5 12.5 Schizophrenia 13.3 12.3 12.9 giggnostic Groggs Involutional Dapression Manic Depressive �-3 2.. TABLE Lv OF DURATION TO ACCORDING GROUPS DIAGNOSTIC BORN FOR FOREIGN PERCENTAGE HOSPITALIZATION in Hogital Months Digestic Grougs _1__-_§ 6 - 9 10 or more 0 Involutional Depression 57$ 113% Manic Depressive 39% 23% 0 Psychoneuroses 50% 19% 13% Schizophrenia 10% 8% 12% �TABLE XVI DIAGNOSIS AND F SCORE. AGE: EDUCATION AND PLACE OF BIRTH Dialysis Involutional Depression Mean F Score ' Mean Age Mean Years Education % Foreign Born {NI-21:2 Manic Depressive (NI-322 Psycho- ' neuroses Schizophrenia (Iv-372 $31-68) 52.3 140.8 36.9 32.8 56.7 1:1.9 29.1; 26.1 8.9 11. 5 11. 9 12. 7 146% 26% 22% 10% �-313- Relationship: Patient-Doctor the on Effects of Social.Factors Setting Interview Observations in an illustrate will I In this report how discussed factors the social hypothesis Our interview. clinical the in ommunication c affect morning this and mmunicate, can co that this is why treatment. results of psychiatric and choice the to relevant they are One way to test would hypothesis such a actual an in events, important psychodynamically that he to demonstrate such as age, factors to related significantly are setting, interview of a study the be might A step first and.F score. education, nativity communication of kind the of representative which is event, defined clearly psychotherapy. to relevant that is The phenomenon pattern. communication such one with deals This report e—recording tap the mentioned explicitly the patient no whether or studied is may bear upon transaction spontaneous This interview. during an experimental and interviews rimental in expe develops which transference situation t the well. as in psychotherapy METHOD: The clinical setting in which the observations we re made was an initial of patients edure proc screening the of interview. This was part interviews All hospital. this in therapies sive convul and referred for drug the during Psychiatry, imental Exper of Department the in were performed was It tests. psychological and physiological of battery week as a to asked was The patient and patient. doctor the of the first meeting was procedure unstructured generally and a about his difficulties, tell �.35followed. The purpose was to get an impression of the patient's communication patterns, and to secure a tape recording of the interaction. Several months ago, that the interview it was noted that some patients mentioned the fact was being tape—recorded, whereas nothing about the procedure. Since that time, recorded this data at the conclusion of I other patients said have each session. systematically In addition, the following experimental structure was purposely introduced. A Tanberg tape-recorder was prominently placed beside the desk which the interview took place. This instrument was turned on Just before the patient entered the room, and was clearly in his line of vision. was about at It the level of the desk, at a distance of about seven feet from the patient's chair. The red neon glow bulb, the revolving reels of tape, and the operating noise of the machine could all be observed. An unconcealed mire ran directly from the instrument, across the desk, to a microphone which - lay in clear view between doctor and patient. However, the interviewer no mention of by the made the recording set-up unless the subject was introduced verbally patient. OBSERV£IION33 Since this experimental structure have been recorded. 17 was introduced, 31 initial interviews The tape-recording was mentioned by 1h patients, while others made no such observation. They will henceforth be referred to as the "Mention" and No Mention" groups respectively. a) Qualitative: The patients variety of attitudes. who mentioned the recording expressed a The most common was curiosity, with inquiry as to the purpose of the interview, and the use to which the recordings might be put. �-36A minority expressed overt suspicion, either refusing to proceed with the interview for several minutes, or voicing their fears of humiliating or incriminating uses which might be did'nt know the room was bugged." made A of the recordings. One patient said, "I physician in this group of patients requested that the recorder be turned off for a moment so that he could ask a question as a colleague, "off the record." After a spontaneous mention of the to explore the attitude underlying the remark. recording, an attempt was made This varied from definite hostility and suspicion, through mild objection and uneasiness, to passive acceptance of the procedure. Only one patient expressed delight, saying, "I'm glad this is being recorded, In addition to these subjects who it's like a confession." explicitly mentioned the recording, patient is included in the "Mention" group. to the microphone, shook her head as if She one mute pointed to the recorder, then to say "no," and covered her mouth with her hand. In the "No Mention" group, non-verbal recognition of the recording was often apparent. Most of the patients looked repeatedly at the recorder and microphone , sometimes up furtively. Several of them actually touched or picked the microphone while speaking. I accompanied one patient back to the ward following the interview, and while chatting in a lighter vein she asked way, was that all recorded?" that the flNo-mention" group was aware of the recording. "By the Thus there was considerable non-verbal evidence Quantitative: Quantitative data for the "Mention" and Table-XVILIt is apparent that the group "No—mention" groups is seen in explicitly remarked about the reabout 20 years. They were also better who cording were younger, on the average, by educated, and with only a single exception were native born. They had a lower score on the F scale and I tended to spend more time with them. All the differences between the groups are statistically significant; �.37- TABLE MENTION XVII NO MENTION 53121:). N=17) 26.7 h5.2 1h.1 p< .002 10.9 P<: ~02 93 53 I><: .05 F SCORE 3h.1 11702 DURATION OF INTERVIEW (minutes) 39.6 2900 AGE (years) EDUCATION % (years) NATIVE BORN p‘<:’ .05 �DISCUSSION: Using a single objective index, 3:2. an overt statement about an unexpected experimental procedure, two patterns emerge from patients. The group of this group of subjects mentioning the recording have the same sociological characteristics as those patients from the total Hillside Hospital population are treated by psychotherapy alone. They are who less younger, have some college education, are native born, and are stereotyped in their attitudes. They mention the experimental procedure in a challenging way. Gill, Newman and Redlich have described the anxiety- producing effects of tape-recording psychiatric interviews. This group of patients meet the stress by verbalization of their subjective reactions. talk about it, ask questions, object, 222. The group who do not mention the recording have the same They sociological wharacteristics as those patients in the total Hillside Hospital population who are typically referred for electroshock (i;g. non-venaal therapy) or are hospitalized for the shortest period. They are older, have at most a high school education, are more likely to be foreign born, and are stereotyped in their attitudes as measured by the F scale. These patients the procedure overtly, although they notice the doctor, whatever you do is justified their compliance and what to say, but I'll be glad to it. Their attitude do not question is "You are and should not be questioned." In vauiescence they resemble surgical patients who submit themselves passively to treatment, neither resisting nor actively participating. When asked to tell about themselves their attitude often is, "I don't know The "Mention" group They do answer any questions you may ask." display a different attitude toward the therapist. not treat the physician's procedures as completely outside their �-39- verbalize their resistance, and express their negative feelings directly to the interviewer. The "mention" reaction indicates jurisdiction. They curiosity and the skepticism that Freud felt was required of the analytic patient. In discussing this point, Fenichel notes, that if the patient "is not skeptical at all, the suspicion is warranted that he is repressing negative transferences." It is not surprising that the interviewer, with a psychoanalytic orientation, spent about 10 minutes longer with the "mention" group. This study demonstrates, then, that these sociological factors may be related to actual differences in the quality of patient-doctor relationship. In this one limited aspect of the communication pattern, the sociological background allows us to predict whether the patient will verbalize his reactions or not. If this single stress situation is representative of the general behavior in psychotherapy, we can get some notion of why these related to choice or length of treatment. 'we factors are expect that patients who decline to mention such an obvious situation as a microphone and tape-recorder, will be equally loathe to express the variety of feelings about the therapist which are crucial for analysis of transference. Further studies of the data are in progress which may increase our understanding of the observations reported. For example, a detailed content analysis of the way in which the recording deviant cases. Two of these have already been described. patient, with high F score, who was mentioned sheds light upon the One was an older in contrast to the usual pattern of such persons, did mention the recording. Hewever, he differed from the other older patients in having a medical education. His way of mentioning the �-h0 - recording was to suggest a change in the interview from that of doctorpatient to that of colleagues speaking "off the record." One is tempted to predict the form of his therapeutic resistances from this event. Another patient mentioned the recording,but in an unusual way. She was delighted with the "confessional" aspects. In her sociological characteristics, she too did not fit a clear pattern, being in her 20's, but with a high F score. It is to be noted that she was an ex-Catholic. Other studies of the psychiatric interview, using experimental stresses more characteristic of psychotherapy, furnish additional evidence of the importance of sociological factors. For example, Saslow and Matarozzo research on psychotherapeutic communication. � 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 Research Files and Unpublished Works 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 Max Pollack, Robert Kahn, and Joseph Jaffe: Social Factors and Communication in Psychiatric Patients (research), 1958 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-11-012 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource Pollack, Max; Kahn, Robert L.; Jaffe, Joseph Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: research with Joseph Jaffe, Robert L. Kahn, and Max Pollack 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 Research