relation of aggression in the personality to outcome with electro-convulsive shock therapy

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Relation of Aggression in thePersonality to Outcome withElectro-Convulsive ShockTherapyLewis G. Carpenter Jr. aa Napa State Hospital , Imola, California, USAPublished online: 06 Jul 2010.

To cite this article: Lewis G. Carpenter Jr. (1957) Relation of Aggression in thePersonality to Outcome with Electro-Convulsive Shock Therapy, The Journal ofGeneral Psychology, 57:1, 3-22, DOI: 10.1080/00221309.1957.9920345

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The Journal of General Psychology, 1957, 67, 3-22.

RELATION OF AGGRESSION I N THE P E R S O N A L I T Y TO

SHOCK THERAPY* OUTCOME WITH ELECTRO-CONVULSIVE

NaPa State Hospital, Imola, California

LEWIS G. CARPENTER, JR.

A. INTRODUCTION This article is an account of an experimental test of the major hypothesis

that outcome with EST (electro-convulsive shock therapy) is dependent on direction of aggression in the personality. Direction of aggression is refined and elaborated to include the dimension of ego alienation and ego belong- ingness of hostility.

B. THEORETICAL CONSIDERATIONS T h e dynamic specification of psychopathology which is therapeutically

amenable to EST is unknown at the present time. Many explanatory theories have been proposed. Gordon ( 6 ) has listed 50 of these, and certainly there are several in addition.

EST is usually prescribed for psychotics who show such signs as retarda- tion, depression, periodicity, and mania. T h a t is, excluding its application for management purposes, the commonest criterion for the therapeutic use of EST is the predominance of affectivity. This probably has its origin in two sources.

O n the one hand, practical experience seems to justify such a basis. Throughout the world and seemingly independent of culture, race, and lo- cality, there is remarkable consistency in the reported rate of remission in affective states with the application of EST ( 7 ) .

O n the other hand, there is psychoanalytic theory ( 1 , 5 ) . So standard and basically conservative a text as that of Kalinowski concerns itself with these hypotheses. Thus : “Related to this theory are those concepts which hold that the patient has an ambivalent attitude toward life and death, the treatment representing a punishment for his sins. After expiation of these sins, the patient returns to life, which he was unprepared to accept before” ( 7 ) .

*Received in the Editorial Office on October 22, 1954, but destroyed in the fire of May 1, 1956. T h e author did not see the news item concerning the fire, hence the regrettable delay in publication.

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4 JOURNAL OF GENERAL PSYCHOLOGY

Since the theory of affectivity involves the intrapsychic use of punishment ( I ) , both the empirical findings about recovery from affective states with E S T and the a priori psychoanalytic explanation of the effect of E S T point to the possible importance of punitiveness in the therapeutic outcome with E S T .

A n understanding of the theory of the determination of direction of hostility in the personality is crucial for the specification of the hypothesis.

According to the British school of psychoanalysis, the child is threatened by psychic annihilation which is the danger of having no relief from its instinctual and particularly its aggressive tensions ( 3 ) . T h e child responds to this danger which, it should be noted, is indigenous to the child, having no external origin, by incorporating the aggressive impulses which previously had been displaced onto external objects, e.g., the mother. In Ernest. Jones’ view, this is the origin of the superego.

Th i s abandonment and loss of the hostile external objects, which then results in the incorporation of the hostility, would seem to be close to the dynamics described by Freud in Mourning and Melancholia ( 5 ) . Here the loss of the ambivalently regarded love object was seen to have the consequence of incorporation. Furthermore, as renunciation is self-imposed loss, i t becomes possible to comprehend within this framework the dynamics of superego formation and its hypertrophy, which is generally found to follow instinctional renunciation. Thus, as Freud has described in Ciailization and its Discontents (4), it is the most saintly and ascetic person who feels he has cause for the greatest self-reproach. Alexander, Jones, Klein, Isaacs, and Reik all have considered that feelings of guilt are increased by the thwarting of instinctual gratification. W h a t is of great importance to our present investigation is Freud’s belief that the fundamental renunciation is specifically the renunciation of aggression. There is some experimental sup- port for these theories (9).

I t follows that there are a t least two possible aims of introjection. O n the one hand, the aim of introjection may be to ward off the danger of attack by the feared outer objects, originally created by projection of the child’s own hostitle impulses, by the device of identification with the aggressor. T h a t is to say, the aggressor’s power is taken in to provide strength adequate to fight the aggressor. This aim is extrapunitive.

On the other hand, the aim of introjection may be to guard against attack, but this time by the device of constructing an inner replica which will operate to make the child conform to the demands of the fearsome (parental) figures and make expiation for real or fantasied transgressions. T h u s

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LEWIS G. CARPENTER, JR. 5

the child has what Isaacs calls the good, strict parent within him. This aim is intropunitive. Achievement of this aim results in superego tonicity.

This observation leads to a more comprehensive and probably more fundamental distinction which is the central distinction governing the selection of dependent variables in this investigation. If the changes in intrapsychic hostile forms which we have described are defensive in nature, then the grand, formal maneuver of whether the hostile impulse is made alien or syntonic to the ego is of paramount importance.

By syntonic is here meant the opposite of alien, namely that the impulse is within the ego and is experienced as part of the self. Within this dichotomy all modes and forms of hostility may be conceived to operate. W e may therefore make it the central differentiation in the specification of hostility. T h e expectation would be that, since ego-syntonic aggression appears to have as its aim the provision of a mechanism of expiation for actual or fantasied transgressions, the experiencing of EST by such personalities would function as atonement.

C. SPECIFICATION OF EGO-SYNTONIC INTROPUNITIVENESS AND

EGO-ALIEN EXTRAPUNITIVISM What are the general characteristics of an individual whose hostile im-

pulses are alienated from the ego? In such a person the superego is externalized and is not in the ego. Other people, social customs, and laws act as controls. In this person, the parents or fearsome projections were never introjected, but are kept outside as feared figures. As an example, there might be an initial and persisting absence of self-criticism in the ego with indiscriminate hostility toward others. On frustraton, the individual might suddenly commit suicide in an ultimate hostile expression. Or again, such a person, having little awareness of his motives, being essentially anti-intraceptive, and having rigidly contained them, might suddenly murder, actually or in fantasy, without realization of why he did it. Such a person could feel no responsibility and therefore no real guilt for his action. H e would be expected to have emotions and behavior consistent with the expectation of reprisals from an external superego. H e would now be a person saving himself. H e is the person who would claim temporary insanity or of whom others might say that he was not himself. H e is the person, too, who would be expected to manifest immorality of a hostile character when external moral authority undergoes dissolution, or when external authority itself becomes immoral as it did, for example, in Nazi Germany. On the other hand, when external authority embraces the mores of kindliness, and when

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6 J O U R N A L OF GENERAL PSYCHOLOGY

the ego defensive structure of such a person is strong, he may behave in an exemplary fashion. I t can be seen that the structure of this personality is such that its ego defenses are neither broad nor deep, and as a result are characteristically intolerant of tension.

W h a t are the general characteristics of an individual whose hostile impulses are intropunitive and ego-syntonic? In such a person the superego is partly within the ego. Parental authorities or autogenous feared projections have been introjected. Primary ambivalences are therefore appreciated to some extent ; the negative aspects are particularly relevant to our discussion. There is some experimental evidence for this penetration (9, 11) . One would expect especially the expression of a large amount of aggressive content in fantasy material (2) . There is awareness of aggressive aims. In consequence, the ego, aware of what are perceived by it as transgressions, although these are seldom actual, constantly tries to placate the superego by suffering and contrition and in this way gain absolution and its love. T h e individual behaves toward his superego as he would i f he expected mitigation of anger of moral authorities following the administration of punishment. In an inferential way, this is evidence that fear is the matrix for guilt. There is no question here of fooling or flaunting the superego because distinction of the ego from it is imperfect. This is a formal statement to express the responsibility which the individual feels for his hostility. Such a person laments his hostility; is tortured by guilt; feels worthless; looks for atonement, is apologetic, self-critical, self-abasing, and self-denying of gratification. Since, psychodynamically, transformation is never so perfect that there is no residue of what was prior, it is not surprising that in cases where aggression is directed against the self there is also subverting aggression against the environment. This in no way invalidates the over-all distinction. T h e presence of such a process in self-punishment has been noted by Flugel ( 3 ) , who describes it in saying, “In nearly all cases of aggression turned against the self, a channel is left open along which the original object of aggression can be made to suffer.”

Having derived and described the psychological maneuver of alienation or coherence of hostility to the ego, we must now particularize the manner in which hostility is thus handled. This will yield the operational definition which we shall use to make the general dichotomy with subjects’ protocols.

D. SPECIFICATION OF EGO-SYNTONIC AGGRESSION 1. Statements about feeling humiliation, worthlessness, sinfulness, self-

immolation, guilt as a consequence of aggressive feelings. There should

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be evidence that these feelings are felt as related to the subject who takes total responsibility for them. There may or may not have been violation of canons: in most cases there probably will not have been. T h e uneasy feeling which accompanies a prolonged run of good luck is a homely example where there is little intensity. Actually, non-violation and feelings of guilt probably go together. Freud (Ciwilizution and its Discontents) pointed out that a person’s conscience is strict in proportion to his righteousness since he is exag- geratedly aware of his unacceptable impulses. Through renunciation these instincts become the more insistent resulting in intensified feelings of guilt (Alexander, Reik, Jones, Isaacs, Klein) . Conscience is thus the consequence of instinctual renunciation ( Ciwilizution and its Discontents-Freud) . Freud felt further that the fundamental renunciation was the renunciation of aggression which then joins the superego in its attack on the ego.

Statements which imply the subject aggresses against himself by re- inforcing the opposition or frustration due to moral authorities. There is collaboration between aggression from outside and the recoil of the subject’s own aggressiveness. The gain from this kind of introjection may be that the subject defends against a dreaded external attack by creating an internal replica of the attacker which can be counted on to please the attacker as in the erection of an internal parental authority. This is distinguished by being qualitatively identical to authority requirements but quantitatively exaggerated. There is over-obedience rather than straightforward compliance which differ- entiates it from the conduct that would result from simple copying or introjection of the authorities’ attitude. This caricatured obedience results in im- pediment, harm, or humiliation of the self.

3. Statements which indicate asceticism. Much of contemporary civilization results from the postponement of gratification for a future greater gain. When the goal is distant, general, indefinite, when approach to it seems asymptotic, when gratification is only partial on reaching the goal because the goal then is made a subgoal; when the self-abnegation seems un- duly vigorous or prolonged in respect to the value of the goal; when renunciation itself is valued, often as a discipline rather than as an undesired but necessary means to the goal of gratification-then asceticism may be said to be internally aggressive. It is possible that in such cases gratification has become intimately related to tension and internal and/or external inhibition without which it is felt as either meaningless or wrong.

Statements which indicate pleasure in self-denial of gratification. This is moral masochism. In such cases gratification has become intimately related to the experiences of tension which is itself relished as a pleasure.

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Genetically the need for punishment has condensed with sexual wishes, there being a regression to the Oedipal situation where conscience was emergent from sexuality; thus upon regression, morality is again sexualized. Such an act is self-punishing because the tension represents the non-fulfillment of a primary and/or secondary need. Fasting and prolongation of fatigue are relevant instances.

Statements which indicate pleasure must be compensated by suffering, submission to punishment. T h e subject should not perform this punishment with the motive of making the world feel guilty and thus aggressing against it in retaliation for its having provided and permitted the pleasure. T h e basis of this guilt is fear. I t is differentiated from No. 1 above in that pleasure is here antecedent while in the former case gratification is actually renounced. This is the simple case of placating the introjected moral authorities (superego) after breaking a proscription.

Statements which imply making reparation. T h e return in kind is a straightforward case of (a) giving up the relevant gratification which was the fruit of the real or phantasied aggression. This is close to undoing. Such self-determined forsaking of gratification is intropunitive. ( b ) implicit apology to the transgressed, apology being a basic renunciation, an avowed denial and renunciation of aggression. Symbolic sacrifice as for example offering food to the gods is an appropriate paradigm.

7. Statements which indicate confession. Confession carries with it a t the same time implicit self-reproach, a denial of further aggression and a tentative willingness, in assuming responsibility for the transgression, also to accept punishment.

Statements which indicate that the experience of punishment brings with it the demand for an even greater and progressively greater degree of punishment. T h e lack of instinctual gratification through the imposition of frustration and punishment may result in regression. But there is greater aggression (in particular) and other instinctual demands extant a t these earlier levels together with the resurgence of early threats (internal and/or external in origin) of castration and mutilation, thus intensifying the need for punishment. T h e following two categories are included here not so much because of the penetration of the ego by hostility but becawe at an organis- mic level the individual is self-punishing. I n this limited sense there is a measure of discontinuity with preceding categories.

Statements which indicate the repression of guilt. Thus the affective component of shame and guilt is suddenly and unreasonably dropped, although the content of the act or phantasy may survive. O r such an affect

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emerges suddenly, from where the subject does not know. Presumably derivative affective expressions would in any event be manifested.

10. Circumscription of gratification. ( a ) Occupational inhibition, e.g., writer’s cramp. There is fear of some forbidden action or condition or an aesthesia or paralysis of a part which might be used for forbidden purposes. ( b ) Compulsions which prevent the subject from infringing upon a taboo. These are intropunitive not only in the sense that to employ them is to inhibit or distort the subject’s aims but also in the sense that they some- times involve an organic dysfunction.

E. SPECIFICATION OF EGO-ALIEN AGGRESSION 1. Statements about feeling humiliation, worthlessness, sinfulness, self-

immolation, guilt with responsibility externalized. There should be evidence that these feelings are felt as related to the subject but that he has incomplete responsibility for them. Thus, the subject feels guilt for hating his spouse but cites provocation.

2. Identification with the aggressor. The dynamics of this introjection may be that the subject protects against the attack of his projected infantile destructive aims (sucking the life out, biting, rending, tearing-M. Klein) as well as actual external threats by identifying with the aggressor, exchang- ing the passive for the active part and thus being fortified by having the powerful aggressiveness within him.

Statements of projected aggression. T h e world is represented as per- secuting or victimizing the subject.

Statements implying reaction formation to aggression attributable to self and/or others. Thus, kindliness, sweetness, goodness are attributed in a degree which is unrealistic. This is glorification. Ultimately, this is the substitution of suicide for murder.

5. Statements indicating displaced hostility. For example, phobic involve- ments. Thus, hate for the father is displaced onto the bad horse; or displacement to social movements, etc.

6. Statements implying repression of aggression. Thus, the aggressive component is suddenly and unreasonably dropped and evidently lost to the subject. Or, an aggressive impulse emerges Suddenly, from where the subject does not know. Presumably derivative affective expressions, would, in any event, be manifested.

7. Statements of ingratiation, seduction. Feeling hostile because the world has not given enough, there are attempts to force the world to give.

8. Statements implying inhibition of aggression. Greater paucity of content and expression for aggressive themes.

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9. Statements implying suppression of aggression. An evident, conscious effort to minimize revelation of aggression.

10. Statements implying sublimation of aggression. Content might deal with embalming or slaughtering. This must be differentiated from sublimation which is restitution for an aggressive, destructive act or phantasy.

11. Rationalization of aggression. Feelings of guilt are usually absent. Rationalization is not merely for the sake of social conformity e.g. suppression but is used as an ego defense, e.g., inhibition. T h e aggressive content is excused or explained.

12. Statements indicating denial of aggression. “I do not know what is happening here-certainly nobody is being killed.”

13. Statements implying destructive introjection. T h e object which becomes part of the subject is misused and/or annihilated in accordance with a hostile aim. T o incorporate is to destroy as well as to achieve closeness. T h e mode can be oral or anal but orality usually predominates.

Statements implying undoing of aggressive acts. There is evidence of the use of the magic of expiation to annul antecedent acts. T h e magical nullification of an act by another act.

Statements that indicate the use of isolation as a defense against aggression, penetrating the ego. This is used in the narrow sense of flaunting the superego, devaluing it, though homage is paid to the extent that the superego is recognized as a barrier to be overcome.

Statements indicating the presence of sado-masochism. A view is taken consistent with Freud in Instincts and their Vicissitudes (1915) in regard to the genetic primacy of sadism. T h e masochistic drives are generally co- existent and represent a simple inversion. In accordance with Ernest Jones and Reike ( A u s Leiden Freuden, 1940) the genetic core of sado-masochism is taken to be the aggressive character of infantile love. As a consequence of the projection of early aggressive phantasies (M. Klein) there is the de- velopment of a chronic expectation of punishment. T h e intent of the masochistic destruction is to anticipate this punishment from the world and so to control the amount of it, together with eliminating anxiety from the uncer- tainty of what and when punishment will impinge ( T h e Problem of Anxiety -Freud). Thus, it becomes a technique for reality control for saving oneself, having as the area of its reference conditions which are perceived as external to the self, although in origin they are so in minimal extent. I n addition to the above origin, it must inevitably be that a person who is in such psychological straights that he must so ward off punishment is a very hostile person. Expectation of punishment leads to putting others in the wrong and to

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general aggression as defense. Thus, there is a perpetuation and augmenta- tion of the original sadism and a connection with overt hostility. It is for these reasons that sadistic and masochistic drives and behavior coexist clini- cally. Freud noted (Mourning and Melancholia) that in melancholia extro- punitiveness interpenetrates intropunitiveness. There is not an expected humility and submission consistent with the self-vilification. Such subjects take offense readily, complain of objectionable treatment and manifest a general nuisance value.

Statements which indicate that the subject is using his own discom- fort for externally hostile aims. Ultimately this is the suicide “now they will be sorry,” or the lesser tyranny of tears. Those who commit aggressions on themselves can be sure to irritate, embarrass, discommode, or shame the individual to whom the aggression was originally directed, although the mode and intensity may be changed. I t enables the aggressor to (4) avoid guilt, ( b ) direct counter-aggression. In addition to the above, the aggressor may subtly make the adversary feel guilt plus depriving the adversary of himself satisfying aggression-“cheating the gallows” by suicide. T h e suicide is perhaps the ultimate case in point, for if the fundamental, primitive sin is to kill (probably prior to incest) there can be no act more hostile than to make someone else into a killer.

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F. EXPERIMENTAL DESIGN Following are the basic elements of the design and the instruments which

were employed: ( u ) Pre-shock evaluation of mental status (clinical evaluation, Minnesota Multiphasic Personality Inventory). ( b ) Determination of direction of aggression (Sentence Completion, Thematic Apperception Test, Picture Frustration, E Scale of the California Ethnocentrism Scale) (8). ( c ) Course of EST. ( d ) Determination of patient’s attitude toward EST made after two to four treatments (interview). ( e ) Post-shock evaluation of mental status (clinical evaluation, Minnesota Multiphasic Personality Inventory).

T h e difference between ( u ) and ( e ) constitute the criteria for the predictors, ( b ) and ( d ) . In order to determine what are the maximum relationships between the several predictors and the two criteria, multiple correlation was employed.

G. THE CRITERIA Working with the pre- and post-EST protocols as pairs, two raters were

instructed to rate each profile on a 10-point scale according to the degree of over-all mental health, from one (incapacitation) to 10 (good normal

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adjustment). They were further instructed that there might be from all to no cases a t any point on the scale. T h e MMPZ raters did not know the clinical evaluations (second criterion-to be described), nor the ratings on the predictors.

T h e estimate of over-all mental health was defined by the patient’s capaci- ties in respect to the following areas, which were further specified in some detail: ( u ) Amount of responsibility for his own welfare that the patient can assume. ( b ) Amount of physical care which must be provided for the patient. ( c ) Capacity for productive work. ( d ) Character of the patient’s interpersonal relations. ( e ) Capacity for adequately handling his impulses and emotions. ( f ) Capacity for evaluation and dealing with reality.

T h e algebraic difference between the ratings of pre- and post-EST MMPZ protocols constituted the criterion derived from the MMPZ. T h e criterion is thus a difference score.

T h e second measure which was employed as a criterion of change between pre- and post-EST was a clinical rating scale for over-all mental health, as defined above. So that the measures could be compared, the same 10-point scale was used as was employed with the MMPI.

T h e rating was accomplished before and after the course of E S T by the chief psychiatrist of the shock wards from which the subjects were drawn. Ratings were made without knowledge of the determination of direction of aggression or of the evaluation of the MMPZ protocols.

As was the case with the MMPZ as a criterion, an algebraic difference was computed between the pre- and post-treatment ratings. T h e criterion score was a difference score representing amount of change rather than final status. T h u s two patients with the same difference score might be a t very different levels of health, while two patients having different difference scores might be a t the same level of health.

H. THE PREDICTORS T h e Thematic Apperception Tes t cards employed were 18 GF, 6 BM,

12 F, 15, 13 MF, 3 BM, 17 GF, and 3 GF. These cards were selected for their potentially punitive content.

A Sentence Completion Tes t was designed for this study. Items were developed which were brief and which referred to a variety of critical areas of frequent traumatic experience, such as loss of control, victimization, failure, loss of sustenance, humiliation, seduction, physical threat, etc.

All items of the Picture Frustration Tes t were used. T h e E Scale of the California Ethnocentrism Scale is scored objectively. A

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high score implies an ethnocentric and perhaps authoritarian character which theoretically should be related to ego-alien extrapunitivism. High scorers externalize and project unacceptable impulses, ideas, and affects. There is a tendency toward repression and characteristically the superego is externalized.

T h e interview, typically an hour long, covered the following aspects from the point of view of the patient and was taken down verbatim.

1, How severe a procedure is E S T ? These data helped indicate especially the intensity of feeling.

2. How pleasant or unpleasant an experience is i t? These data helped indicate especially the quality of affect and also provided an opportuniw to observe how the ego handled it. T h e assumption was that the experience was basically unpleasant.

3. Wha t were the feelings experienced while waiting for treatment? These data tended to validate those above in (1) and (2) by placing the question in a concrete and immediate situation.

“What do you think about treatment for you?” These data provided an initial indication of whether the ego accepted or rejected the experience. When considered together with the preceding three areas, this helped to establish the intensity and quality of the relation of the aggression, instigated by E S T , to the ego.

How does the patient imagine E S T works within him? Wha t model does he use for explanation? These data helped to indicate the quality of destructiveness or sustenance in the frame of which the patient regarded the experience. T h e inquiry also provided an opportunity for the expression of hostility against or, contrariwise, identification with the aggressor.

Are neutral or unpleasant therapies preferred for the aleviation of minor illnesses? Are unpleasant remedies more confidence-inspiring ? Does the patient seek to experience or to escape pain and unpleasantness? These data helped confirm the consistency of the perception of the E S T experience with the patient’s more general behavior and attitudes.

Does the patient believe that unpleasant remedies work by punishing the body?

Is E S T perceived as a magic procedure which, as a consequence of faith, fills the patient with a feeling of power (introjecting electricity) and well-being? These data helped to differentiate the handling of the aggression by the ego. Thus the patient whose hostility was ego-syntonic and directed against his ego would perhaps regain the love of the superego through suffering, all of which would be expressed in an intraceptive way. T h e ego-

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alien extrapunitive person, on the other hand, would be expected to treat the experience as an act unconnected with himself, a magical laying on of hands.

W h a t are the patient’s attitudes toward punishment of others? Did the patient think he ever punished himself? 9.

10. Does E S T ever feel like punishment?

I. RATING THE PREDICTOR PROTOCOLS Each of the protocols from the Thematic Apperception Test, Sentence

Completion, Picture Frustration, and interview was analyzed as a whole and rated on a six-point scale for both ego-alien extrapunitiveness and ego-syntonic intropunitiveness. These estimations of hostility in the personality and its relation to the ego form a summary of the entire extensive and intensive impression. T h e raters used the specifications which were elaborated earlier as a basis for the categorizations.

For each protocol the algebraic difference between the rating for ego-alien extrapunitiveness and that for ego-syntonic intropunitivism was computed. T h e difference between the two ratings was intended to represent the domi- nance in regard to extensity and intensity, the direction of hostility and its relation to the ego. T h e scores obtained were thus difference scores and as such do not indicate the absolute magnitude of the rated hostility.

Three raters rated the predictor protocols. Raters 1 and 2 rated the TAT protocols, raters 1 and 3 rated the Sentence Completion and Picture Frustration Study, and rater 1 rated the interviews. Ratings were accomplished without knowledge of the ratings of others or of the criteria determinations.

J. SUBJECTS T h e experimental population was drawn from two hospitals, the Langley

Porter Clinic, San Francisco, and the Veterans Administration Hospital, Palo Alto. In each case, both men and women were used. There were fifty-one patients in all.

K. RESULTS 1. Reliability of the Criteria

Table 1 presents the intercorrelations among the criteria. T h e product moment correlation between the ratings on the MMPI for the two raters was 0.92. T h e correlations between clinical ratings and the ratings of the MMPI protocols by the two raters were 0.48 and 0.51. When the ratings for the two raters using the MMPI were pooled by summing and were correlated with the clinical ratings, the resulting r was 0.50. All of these relationships were significant a t the 0.01 level.

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TABLE 1 PRODUCT MOMENT CORRELATIONS AMONG CRITERIA*

MMPI rated MMPI rated independently by pairs

Rater Rater Pooled Pooled 4 5 4 and 5 4 and 5

MMPZ rated Rater 5 6.92

Clinical

independently Pooled 4 and 5 6.96

ratings 6.48 6.51 6.51 6.50

*Criteria scores are difference scores.

On the whole, we may be satisfied with the criteria. T h e above determinations gave convincing evidence that estimates of mental health as defined were reliably made. Furthermore, we can say with confidence that there was considerable communality between the clinical and the test criteria.

2. The Predictors and Their Eficiency a. Thematic Afifierception Test. Table 2 presents data from the T A T .

T h e correlation between the pooled (for the two raters) ratings on the

TABLE 2 PRODUCT MOMENT CORRELATIONS BETWEEN TAT* AND CRITERIA*

T A T Rater 1 Rater 2 Pooled 1 and 2

Rater 4 6.35* 6.42? 6.45t 6.4lt 6 . W $.Mi

MMPI rated independently t:$:ds4 and

6.38* e.45t 6 . W

MMPI rated by pairs Pooled 4 and 5 6.34t 13.34* 645t

Clinical rating

*TAT and Criteria scores are difference scores. $Significant at the 0.05 level. ?Significant a t the 0.01 level.

T A T and the pooled MMPI ratings was 0.45. T h e correlation between the same data from the T A T and the other criterion, the change in mental health measured by clinical ratings, was 0.32.

Both of these correlations indicate that improved mental status goes with ego-syntonic intropunitiveness, while regression or little improvement goes with ego-alien extrapunitiveness. T h e r of 0.45 has a significance level con-

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siderably better than the 0.01 level, while the r of 0.32 has a significance level nearer 0.01 than 0.05.

T h a t the two TAT raters were able to make their determinations reliably was evidenced by an r of 0.72. Similarly, the reliability coefficients for the two TAT raters’ ratings for ego-alien extrapunitiveness was 0.82 and for ego-syntonic intropunitiveness was 0.73. T h e last two were, of course, not based on difference scores but on the absolute magnitudes.

Picture Frustration Study. Table 3 presents data from the Picture Frustration Study. W i t h the pooled MMPZ ratings as the criterion, ratings on the Picture Frustration Study correlated 0.24. T h e corresponding figure

b.

TABLE 3 PRODUCT MOMENT CORRELATIONS BETWEEN PICTURE FRUSTRATION STUDY* A N D CRITERIA*

Picture Frustration Study

Rater 1 Rater 2 Pooled 1 and 2 Rater 4 .24 -$.23 Rater 5 .18 .19 MMPZ rated

independently Pooled 4 and 5 .24 .20

.02

.02

.04 MMPZ rated

by pairs Pooled 4 and 5 .24 +.15 .08 Clinical

rating .09 -6.28 4 . 0 5

*Picture Frustration Study and Criteria scores are difference scores.

for the clinical ratings was 0.09. Neither of these coefficients was significant a t the 0.05 level.

It was the subjective impression of the raters that the responses were in many cases insufficient to warrant a judgment as to the direction of aggression and its relation to the ego. T h e patient very often put on his social clothes, so to speak, for the social situations depicted. I n addition, the responses were frequently so laconic that, while the relevant affect was doubt- lessly expressed, i t was impossible to make the necessary inferences.

Sentence Completion Tes t . Table 4 presents data from the Sentence Completion Test. W i t h the pooled MMPZ ratings as the criterion, ratings on the Sentence Completion Tes t correlated 0.3 1. T h e corresponding figure for the clinical ratings as the criterion was 0.46. T h e former is significant a t the 0.05 level and the latter at the 0.01 level.

In the instances of both Sentence Completion and Picture Frustration, one of the pairs of raters was different from that with the TAT. In spite of the fact that the two raters had undergone together a preliminary training period of five hours, it was evident from the correlation matrix (Table 7 )

c.

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LEWIS G. CARPENTER, JR. 1.7

TABLE 4 PRODUCT MOMENT CORRELATIONS BETWEEN SENTENCE COMPLETION TEST* AND CRITERIA.

Sentence Completion Test

Rater 4 MMPI rated independently t:2:d54 and

Rater 1 Rater 2 Pooled 1 and 2 0.29 -0.05 0.18 0.324 -0.05 0.19 0.314 -0.04 0.19

MMPI rated

Clinical by pairs Pooled 4 and 5 0.31 0.05 0.21

ratings 0.46" -0.25 0.03

*Sentence Completion and Criteria scores a re difference scores. *Significant at the 0.05 level. ?Significant a t the 0.01 level.

that this third rater was evaluating different variables than were the other two raters.

T h e relationships achieved by the deviant rater ware consistently opposite in sign and degree from the relationships found by the other members of the rating pair, the latter having agreed markedly (see reliability coefficients on the TAT, Table 7 ) with the second rater on the TAT (see Tables 3 , 4, and 5 ) . Furthermore, the deviant rater was consistent in his ratings on the Picture Frustration and on Sentence Completion. T h e r was 0.68.

I t is clear, th&efore, that the deviant rater's evaluations could not be used in the forthcoming multiple correlations. I t would have been inadvisable to discard these data had the relationships been simply low or in disagree- ment here and there with the other raters. Positive relationships always can be found by suppressing nonsupporting data or by capitalizing on chance. T h e present case, however, is very different. From the consistency of the deviant rater's relationships, the conclusion can be drawn that he rated different variables than did the other two raters.

TABLE 5 PRODUCT MOMENT CORRELATIONS BETWEEN INTERVIEW* AND CRITERIA*

Interview

MMPI rated independently

Rater 4 Rater 5 Pooled 4 and 5

0.41$ 0.36t 0.414

MMPI rated

Clinical by pairs Pooled 4 and 5 0.474

rating Pooled 4 and 5 0.404

*Interview and Criteria scores are difference scores. *Significant at the 0.05 level. t Significant at the 0.01 level.

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d . The Interview. Table 5 presents the data from the interview. T h e interview protocols were based on two variables: ( a ) the extent to which EST was seen as desirable suffering, and ( b ) the extent to whichEST was seen as undesirable imposition. According to the same reasoning as employed with the other predictors, a difference figure was then computed between the two variables.

Wi th the pooled MMPI ratings as the criterion, ratings on the interview correlated 0.47. T h e corresponding figure for the clinical ratings as the criterion was 0.40. Both of these correlations were significant at the 0.01 level.

e. E . Scale. Data from the E Scale are presented in Table 6. T h e E Scale yielded no significant correlation. It can contribute nothing, therefore, to the multiple correlation.

TABLE 6 PRODUCT MOMENT CORRELATION BETWEEN E SCALE AND CRITERIA*

E Scale

MMPI rated independently

Rater 4 Rater 5 Pooled 4 and 5

0.05 -0.16 4.05

M M P I rated

Clinical

by pairs Pooled 4 and 5 4 . 0 4

ratings Pooled 4 and 5 0.17

*Criteria scores are difference scores.

There is good reason for believing that, for patients as disturbed as were the subjects of this study, the sentences of the E Scale are too long and elaborate.

3. Combining the Correlations

Using the scores for Picture Frustration, Sentence Completion, interview, and pooled T A T , and the pooled MMPI scores as criteria, a multiple r of 0.56 was obtained. T h e standard error was 0.10 and the confidence level was superior to the 0.01 level.

T h e corresponding multiple correlation coefficient using the clinical criterion was 0.60. T h e standard error was 0.09. T h e confidence level was superior to the 0.01 level.

These coefficients show a positive relation between ego-syntonic intropunitiveness and favorable outcome and between ego-alien extrapunitiveness and unfavorable outcome with EST.

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4. Characteristics of the Exceptional Cases

It is a most interesting fact that of the 15 patients who demonstrated the poorest outcome according to the criteria, there was no case in which the patient was markedly ego-syntonic intropunitive according to the predictors.

There were, however, a number of exceptions found a t the other extremes. Examination of the test protocols of patients in whom a marked improvement had been demonstrated according to the criteria but who had been judged predominantly ego-alien extrapunitive revealed what appeared to be some systematic differences between their psychodynamics and those of the group who accorded to the prevailing trend. These cases operated to lower the correlations.

Perhaps the most striking feature was that the psychological problems were felt to be close to the surface. There were frequent verbalizations about refusal to go on with the test procedure because of the intolerable pain of doing so, the pain being associated with a threatened revelation of inadmis- sible inner processes which the patient felt he no longer could deny if pressed with the trenchant psychological instruments. T h e dynamic emphasis a t the ego defensive level was thus alienation. However, the quality of the alienation was neither rigid nor in depth. Its success was tentative and perhaps transitory. There was ample evidence that the acute anxiety and depression which were present had their source immediately from the lowered strength ratio between ego defensive alienation and id impulses. T h e impression was that the grand battle being fought by these patients was the struggle for repression. Typically these patients have been stripped of their more elaborate ego defenses.

T h e second systematic difference which appeared to characterize the deviant group was the frequency of direct aggression in their projections, the aggressive motive being recognized by the patient. T h e differentiating feature here was that the aggressive impulses were not turned against the self. I n the cases conforming to the dominant trend, the aggression was turned inward and appeared to function usefully as both an inner and an outer control. T h e deviant cases lacked this advantage and seemed weaker for it. I n the deviant cases there was a notable absence of any gratification or other secondary gain eventuating as a consequence of suffering. These seemed to be people who were more completely divested of inner resources than either of the dominant extremes.

T h e third difference between the deviant group and the group representing the dominant trend is that, while the conventional ego-alien extrapunitive

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LEWIS C. CARPENTER, JR. 21

subjects generally rejected the desirability of treatment or other intercession in any and all forms, the deviant group was prompted to participate un- willingly in the therapeutic regime. I t was as i f these latter persons, par- tially aware of the imminent break-through of their problems, were rendered so miserable in their plight that they were glad to accept any intervention. Evidently the hoped for consequence of submitting to intervention was not the involution of the afflicting personal problems in a psychotherapeutic sense, but a repression of them. Seemingly such an individual did not desire that he should be changed in any fundamental sense, but that he be no longer troubled.

L. SUMMARY AND CONCLUSIONS T h e selection of neuropsychiatric patients to whom electro convulsive shock

therapy is to be administered is based for the most part on empirical grounds. Accumulated evidence has shown that the probability of favorable outcome increases with the presence of affectivity in the symptomatology. T h e psychoanalytic theoretical explanation for this fact is that the provision of treatment functions as a substitute for the superego in its punishment of the ego. According to this theory, patients whose personality organization is intropunitive will have favorable outcome with E S T more frequently than is the case with extrapunitive personalities.

Elaboration of the psychoanalytic theory pointed to the possible importance of the admissibility of hostile motives to the ego. For theoretical reasons it seemed likely that aggressive motives toward others which were ego-alien comprised a psychopathology less susceptible to amelioration by E S T than does ego-syntonic intropunitivism. The hypothesis was developed that a relationship obtains between outcome with E S T and direction of aggression in the personality conditioned by its acceptability by the ego. I t is recognized that there are doubtless other variables, physiological and psychological, associated with the determination of outcome of EST and that probably all of the variables are interrelated. T h e positive demonstration of the hypothesis would establish an association only and could not be considered to limit the possible operation of other variables excepting as they were related to it.

This major hypothesis was tested by administering a number of psychological instruments to psychotic patients prior to their submission to E S T . From the results of this administration, judgments were made as to the pre- ponderance of ego-alien extrapunitiveness or ego syntonic intropunitivism. T w o different estimates of mental health were made before and after the course of treatment. Finally, determinations were made as to the relationship between the personality variables and the amount and direction of change in mental health following E S T .

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22 J O U R N A L O F GENERAL PSYCHOLOGY

'The results afforded a positive demonstration of the hypothesis. T h e findings suggested that further research in this area oriented around the problems of repression and ego syntonic extrapunitivisrn would be fruitful.

REFERENCES 1. ABRAHAM, K. Selected Papers on Psychoanalysis. London: Hogarth, 1948. 2. ADORNO, T. W., FRENKEL-BRUNSWIK, E., LEVINSON, D. J., & SANFORD, R. N. T h e

3. FLUGEL, J. C. Man, Morals, and Society. New York: International Univ. Press, Authoritarian Personality. New York: Harper, 1950.

1947. 4. 5 .- 6 .

7.

8.

9. 10.

11.

Freud, S. Civilization and Its Discontents. London: Hogarth, 1930. . Mourning and Melancholia. In CoNected Papers. London : Hogarth,

GORDON, H. L. Fifty shock therapy theories. Military Surgeon, 1948, 103,

KALINOWSKI, L. B., & HOCK, P. H. Shock Treatments and other Somatic Pro-

LEVINSON, D. J. An approach to the theory of measurement of ethnocentric

MURRAY, H. A. Explorations in Personality. Oxford: Oxford Univ. Press, 1938. ROSENZWEIG, S. The picture association and its application in a study of re-

SEARS, R. R. Survey of Objective Studies of Psychoanalytic Concepts. New

1948. (VOI. IV, pp. 152-72.)

397-401.

cedures in Psychiatry. New York: Grune & Stratton, 1946.

ideology. 3. of Prychol., 1949, 28, 19-39.

action of frustration. J. Personal., 1945, 14, 3-23.

York: Social Science Research Council Bulletin, No. 51, 1943.

Napa State Hospital Imola, California

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relation of aggression in the personality to outcome with electro-convulsive shock therapy

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