No More Learning

When the cases of stomach ulcer are not included, there are fewer men
? THE AUTHORITARIAN PERSONALITY
with the diagnosis "mixed neurosis. " But the trend is similar to that in the women, with z5 per cent and 33 per cent in the two lower groups, only 15 per cent and 9 per cent in the two higher quartiles. There were three cases of "mixed neurosis" in the low quartile, one in the high. Two of the three low scorers were reported as suffering from neurotic depression. All three seemed to be soft, openly dependent characters whose difficulties had been precipitated by rejection by a love object. This was recognized by the sub- jects and brought out in the first interview. The one high scorer in this category was depressed but also showed obsessive-compulsive and anxiety symptoms. The anxiety centered on the idea that he might harm himself and his baby. It had appeared suddenly and left him subject to recurrent attacks.
b. ANXIETY STATE
Women: Of all single categories, this one contains the largest percentage
of high scorers (zS per cent)-no low scorers, with few cases in the middle quartiles. (C. R. between percentage falling in the high and in the low halves of the E distribution is significant at the 5 per cent level). Five high scorers were classed as "anxiety state," and two very similar ones were classed as "anxiety hysteria. " Five of these seven suffered from "spells" of tension, ir- ritability, or hyperventilation symptoms often including dizziness and faint- ing. There was characteristic hypochondriacal concern, fear of death, of heart attack, and so on. Two women were afraid they would harm their children during the spells; one actually had choked her children on such occasions. In the picture of the two cases which did not have "spells," the hypochondriacal preoccupations with physical symptoms stood out and were combined with some depressed affect, in one case with schizo-affective reaction. There were no low scorers in this category.
Men: The numerical trend was less clear here, with a slightly greater pro- portion of cases in the low and low middle quartiles. There were four low scorers, three high scorers. One of the low scorers suffered from hyper- ventilation symptoms and fainting spells in certain situations of friction with
a brutally aggressive father. The other three were similar to the low-quartile cases classed as "mixed neurosis," except for clinically more marked anxiety, , with signs of much self-dissatisfaction, depression, social and sexual malad- justment, work disturbances, and some schizoid withdrawal.
The three high scorers showed physical anxiety symptoms with little conscious content. In one case this was coupled with much hypochon- driacal concern, and in another, with some paranoid trends involving anxiety dreams and fear of attack by a certain person. Two of the three attributed the onset of symptoms to accidents.
c. ScHIZOPHRENIA 1 Women: There were high- and low-scoring schizophrenics. None of the J high-quartile women fell into this group. The "high middles" that were j
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 909
classed as "schizophrenia" did not fall into any of the schizophrenic "types" (e. g. , hebephrenia, paranoia). They showed paranoid, catatonic, obsessive- compulsive, and other features. The difference between the high and low scorers seems to be similar for men and for women. The high scorers appear to be very infantile, constricted, narrow personalities, often classed as "schizophrenia, simple type. " Among the "high middle" women, several sudden post-partum psychoses of withdrawal in previously schizoid or com- pulsive+ schizoid personalities, were found. The low-scoring schizophrenics were more of the hypersensitive, introspective sort, with relatively much interest in their own and others' psychological lives, and with relatively much insight into their own illness.
With regard to paranoia, the following observations have been made. Our group did not include any cases diagnosed as "true paranoia," but it included several schizophrenics (and others) with paranoid ideas. Among these were high, low, and middle scorers. However, the paranoid symptoms of the low scorers appeared to be qualitatively different from those of the high scorers, in that the low scorers more often combined ideas of being persecuted with severe inferiority feelings-"others are threatening, rejecting, or ridiculing me because of my symptoms, because I am inferior. " The "devil" is not only threatening from outside, but is largely perceived as inside the person. The high scorers, on the other hand, tended towards more highly projective types of fantasies, sometimes accompanied by bragging, self-aggrandisement, and self-righteousness. Consciously, at least, the "devil" or evil forces were seen as only outside.
d. OBSESSIVE-COMPULSIVE NEuRosis. T h e r e w e r e o n l y I m a n a n d 4
women in this group. The man fell into the high-middle quartile on E. Of ' the 4 women, 2 were low, I was high middle, and I was high. One of the two obsessive-compulsive cases appearing in the low group was just on the borderline between the low and low-middle group and had an F score slightly above the mean. The other case, an all-round low scorer, showed no typical obsessive-compulsive pattern, but had a phobic tendency and much conscious anxiety and feeling of inadequacy. The 2 high-scoring women (I high middle, I high) were both classed as "obsessive-compulsive ruminative state" because of particularly rigid preoccupations, and constant ruminative thinking of schizoid quality. Extensive data are available only on the high-scoring case, a fifteen-year-old girl with preoccupations of a sexual character. She was worried because of fantasies about intercourse and pregnancy. During her stay at the hospital most of her conscious anxiety and ruminative thinking were centered about her physiological functions, particularly constipation,
and imagined somatic changes (enlargement of abdomen).
From the above description it can be seen that a number of psychological trends differentiate the ethnocentric from the non-ethnocentric patients,
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regardless of formal classification. These and other trends will be studied more directly, and interpreted in relation to our general theory, below.
E. ETHNOCENTRISM IN RELATION TO THE MINNESOTA MULTIPHASIC PERSONALITY INVENTORY
The question of possible relationships between ethnocentrism and psychi- atric diagnoses was approached in a preliminary way also by means of a test procedure known as the Minnesota Multiphasic Personality Inventory (from now on referred to as MMPI). This is an improved inventory of the Bern- renter type which has been validated against psychiatrists' diagnoses of care- fully studied cases. It contains several scales, each made up of items which differentiate statistically between patients showing a given clinical syndrome -such as conversion hysteria, paranoid conditions, or schizophrenia-and the general population. It was thought that the test scores might provide more valid and more reliable criteria than the diagnoses that had been made of our subjects by many different physicians with varying orientations, training, and experience.
Test results were available for 34 men and 48 women, that is, for 68 per cent of our total group. Because of the fact that men and women had to be treated separately, the number of subjects is far too small to lead to conclusive results.
Comparison of average scores on the various MMPI scales for the four E quartiles, and preliminary inspection of individual and group test profiles, failed to show large or consistent relationships between E and psychiatric syndromes as measured by this inventory. The results show a few trends suggesting that further research along the same lines might be well worth while.
The following are the names of the scales and brief descriptions of the principal psychological or psychiatric dimensions they are supposed to measure. The descriptions are condensations of those given in the far more detailed test manual. For a description of the test and its interpretations see Hathaway and McKinley (so).
r. Hypochondriasis-Scales I (HCh) and II (Hs). Both scales purport to measure the degree of abnormal concern about bodily functions; many of the symptoms mentioned are vague or belong among the list of common physical expressions of anxiety. Scale I is more valid be- cause it is less highly correlated with Sc and also contains an age correction.
z. Hysteria (Hy). A preliminary scale, measuring the degree of similarity between the subject (S) and patients who have developed conversion- type hysteria symptoms.
3? Depression (D). "Measures depth of clinically recognized symptom
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM
9I I
complex, depression. "? "A high score indicates poor morale (of the emotional type) with a feeling of uselessness and inability to assume the normal degree of optimism regarding the future. "
4? Hypomania (Ma). "Measures the personality factor characteristic of persons with marked overproductivity of thought and action. "
5? Psychasthenia (Pt). "Measures the similarity of subject to psychiatric patients who are troubled by phobias or compulsive behavior. " Mild degrees of this tendency may "be manifested merely in a mild de- pression, excessive worry, lack of confidence or inability to concen- trate. "
6. Paranoia (Pa). The preliminary scale, differentiating normals from a group of clinic patients characterized by suspiciousness, oversensitiv- ity and delusions of persecution with or without expansive egotism. Their diagnoses were usually paranoia, paranoid state or paranoid schizophrenia.
7? Schizophrenia (Sc ). Preliminary scale measuring similarity of subject's responses to those of patients who are characterized by bizarre and unusual thoughts or behavior.
8. Psychopathic Deviate-Scale I (Pd). Measures "absence of deep emo- tional response, inability to profit from experience and disregard of social mores. " (Revised) Scale II (Pd,) contains in addition a rather large group of items expressing a feeling of estrangement from the self and others, and is more highly correlated with Sc than is Scale I (Pd).
9? Mfr? Measures masculinity or femininity of interest pattern.
The scales are arranged in such a way that the means are so with Standard Deviations of 10. Deviations from soin the direction of o are usually disre- garded. Scores around 70 (i. e. , 2 S. D. above the mean), are usually consid- ered of borderline significance, scores above So as high. Elevations to 6o can be regarded as clinically significant when occurring in individual profiles in which most scores are close to so (or below).
Individuals with sufficient degrees of maladjustment to seek psychiatric help usually score high (2 S. D. above the average) on more than one of these scales. Recent clinical experience with the inventory seems to indicate that profiles or patterns of scores have more diagnostic significance than the single scores taken by themselves. In general, cases falling into the psychoneurotic group have their maximal scores on the HCh, Hs, Hy, D, and Pt scales (with secondary elevations on any of these), whereas psychotics on the whole have profiles with peaks on D, Sc, Ma, Pa, Pd, and Pdr.
Slight borderline elevations on the "psychotic" scales occur frequently in a great variety of conditions without clinical evidence of psychotic manifes- tations. At present, their significance is not quite clear. Harris and Christian- sen (48), in a study on the effect of short psychotherapy, have found that patients showing elevations on the psychotic scales and Pd, but without
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clinical evidence of psychotic tendencies, responded less well to psycho- therapy than others who did not have such scores.
Means for each of the MMPI scales were computed for each E quartile, with men and women being treated separately. These means are shown in Tables 7 and S(XXII). The number of cases in each of these subgroups was so small that no measure of variability was computed. However, profiles for individual cases were drawn for high and low quartile. They showed great variability with regard to magnitude of score as well as to type of profile. This means (I) that differences between means would have to be very large to be statistically significant, and (2) that even significant differ- ences between means for single scales would be hard to interpret, if one takes the view that only profiles, and not single scale values, have much psy- chological meaning. (a) On the whole, the low scorers made somewhat less abnormal scores. (b) This was especially true for the men on the scales Hypochondriasis I, II and Depression, and for men and women on Psychas- thenia, Paranoia, and Schizophrenia. The low-scoring women were some- what higher on Hysteria; the low-scoring men on Femininity of Interests. Because of the nature of the differences mentioned under (b), it was thought necessary to determine whether some of these trends were caused by pres- ence of psychotic cases in the group, especially since there were somewhat more psychotics among the high half (especially "high middles"). When the means for nonpsychotic subjects were computed separately, the average pat- terns and differences remained much the same. Because the number of cases was again reduced by this procedure, . and also because the patterns for high and high-middle scorers and those of low and low-middle scorers were similar in most respects, the figures for the two low quartiles and the two high quartiles, respectively, were combined (Figure I (XXII)).
The average profiles for the high scorers-especially for the men-re- semble most closely the "severe neurotic" pattern described by Harris and Christiansen in their study of the effects of brief psychotherapy; whereas the means for the low scorers resemble a more mildly neurotic pattern. The "severe neurosis" pattern, in which HCh and/or Hs, Hy, and D stand out as a pattern, with definite secondary elevation in Pd and with Pa, Sc approach- ing significance, but below the means for the first four scales, was found to be correlated with relatively poor prognosis for brief psychotherapy (of the sort administered at Langley Porter Clinic).
One difference between our high's average pattern and Harris and Christian- sen's poor prognosis pattern lies in the prominence in their group of second- ary elevated scores on Pd I, II. In our group there is little difference on these scales between our high- and low-scoring women and, for the men, the high scorers exceed the low scorers only on Pd II.
In the Harris and Christiansen study a question was raised concerning the
? WOMEN
N=34
"'
FIGURE 1 (XXII)
AVERAGE MMPI PROFILE FOR NON- PSYCHOTIC PSYCHIATRIC PATIENTS FALLING INTO EACH HALF OF THE E- SCALE DISTRIBUTION 1'0
~
5
8
C"l
~
1:"'
~ ~
ti
:I: z>
"
80
60
:;50 . . .
0
(. )
(/) 80
60
50
MEN
N=26
/
H1ghs (N=16)
gor-------------------------------------------------------~
'---Lows (N=16)
40. _------~----~--_. _ _ _ _. _ _ _~----~--------~------~--~
HCh Hs Hy D Ma Pt Pa Sc Pd Scales
~ ~. . . .
> 1:"'
? Quartile
Low(N=3) Lowmiddle (N=7) Highmiddle(N=7) High (N=9)
Half
Lowhalf(N=10) Highhalf(N=16)
HCh
Hs HY
Pa Sc Pd Pdr Mfr
58 67 59 63 72 566062 61 66 697563 70 63 616760 66 59
576261 61 68 657061 68 61
Mean (HCh, Hs,
HY, D)
63 64 72 74
63 73
Mean (Ma, Total Pa, Sc) Mean
63 64 57 61 68 70 61 67
59 62 64 68
TABLE 7 (XXII)
MEAN SCORES ON THE SEVERAL SCALES OF THE MMPI FOR SUBJECTS FALLING INTO EACH QUARTILE AND INTO EACH HALF OF THE E-SCALE DISTRIBUTION
Nonpsychotic Male Patients
Scales
D Ma Pt
54
56 60 66 73 55 60 59 71 69 90 61 76 68 74 71 84 54 73
55 62 66 71 58 63 64 73 70 86 57 74
66 65
67 65 70
? Quartile
Low(N=10) Lowmiddle(N=6) High middle (N =7) High(N=11)
Half
LOWhalf(N=16) Highhalf(N=18)
Pdr Mfr
Mean (HCh, Hs, Hy, D)
64 68 62
68
65 66
Mean (Ma, Total Pa, Sc) Mean
56 59 59 63 63 61 65 65
57 61 64 64
TABLE 8 (XXII)
MEAN SCORES ON THE SEVERAL SCALES OF THE MMPI FOR SUBJECTS FALLING INTO EACH QUARTILE AND INTO EACH HALF OF THE E-SCALE DISTRIBUTION
Nonpsychotic Female Patients
Scales
HCh Hs Hy D Ma Pt Pa Sc Pd
? 53 59 72 71 52 58 59 58 60
64 67 74 66 58 60 58 62 70
54 55 67 71 62 65 62 65 61
59 70 69 75 56 68 67 71 63 67 54
57 62 73 69 54 59 58 60 64 67 46 57 64 68 73 58 67 65 69 62 65 52
65 47 71 46 62 49
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psychological meaning of elevations on such scales as Ma, Pa, and Sc in the absence of clinically discernible psychotic trends. Therefore the items on each scale were (arbitrarily) grouped into subscales, each of which was de- signed to measure some common general attitude. None of the subscales for the so-called neurotic scales (HCh, Hs, D, Hy) differentiated between the poor and good prognostic groups. The subscales that did differentiate came from Pd and Ma, Sc, Pa. Their content revealed a common "feeling of being victimized," a "tendency towards perceiving one's problems as imposed from outside and resulting in a feeling of lack of control of senses and motorium. "
The difference between the neurotic and psychotic scales-apart from items referring to specific symptoms (e. g. , delusions)-seems to lie in the relationship of the ego to the world, and to the body.
Perhaps the finding that our high scorers are somewhat higher on the psychotic scales may be interpreted in the same way. It would certainly fit in with trends described earlier in this book, e. g. , the tendency to externalize and project unacceptable impulses, ideas, and affects. However, in order to test such an interpretation, an analysis of our data in terms of the Barris- Christiansen subscales would have to be made. This was not thought worth while mainly because of the small number of cases in our sample. Further study along these lines should prove rewarding.
One very unexpected result was that the high-scoring men obtained ex- tremely high scores on the depression scale, whereas clinically the low scorers, and especially the low-scoring women, showed the greatest tendency towards neurotic depressive symptoms. On the MMPI, the low-scoring women did not make particularly high D scores. (See also the discussion of the clinical material in Section G of the present chapter. )
These apparently contradictory results suggest that the D scale does not measure the same psychological tendencies as were observed clinically in our low scorers, who characteristically suffer from subjective depressions, feel- ings of inferiority and failure. Therefore, the items of the D scale were ex- amined and put in groups according to content. Out of the 6o items, only 2 3 clearly referred to the kind of feelings reported by our low subjects, these were:
r. Signs of inferiority feelings, easily hurt, unhappy, self-criticisms.
z. Opposition to cruelty and aggressiveness, lack of extrapunitiveness. 3? Submissive reactions in social situations.
4? Admission of uneasiness in social situations.
5? Lack of energy, and work inhibition.
6. Rejection of religious ideas (possibly).
The other 37 items referred to: impairment of mental functioning and of body functions; brooding and "worrying"; perception of the environmental forces as threatening or mistreating the subject; and general expressions of
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 917
"not feeling well," "don't care about anything. " Many of these items, per- taining as they do to very vague and nonspecific ideas, are clinically more consistent with anxiety or with anxious rumination of the more obsessive- compulsive variety than with neurotic depression. This leads to the supposi- tion that "depression" as measured by this scale is not a unitary process; that there may be qualitatively different types of depression which occur in indi- viduals with different personality structures.
F. PERSONALITY TRENDS AS REVEALED BY P A TIENTS' "ST A TEMENT OF PROBLEM" IN THE FIRST PSYCHIA TRIC INTERVIEW
The attempt to relate ethnocentrism to type of psychological disturbance, using only the conventional psychiatric classifications, produced some sta- tistical trends, but it did not in itself allow inferences about personality dynamics in high and low scorers. The particular problem posed at the be- ginning of the present chapter seemed to call for extensive clinical material.
Therefore, a greater proportion of subjects from the total Clinic group, than from other groups in the study as a whole, were studied by means of inter- views and T. A. T. 's.
However, due mainly to limitations of time, it was not possible to study intensively a large proportion of subjects from the high and low quartiles. This proportion was further decreased by the inclusion of some "middles" in the group to be interviewed. This was done for reasons of availability and out of special interest in certain individual cases. The total number of fairly complete case studies, including T. A. T. and interviews covering ideology as well as personal data and history, was 2 1 - 1 1 men and 10 women. These subjects represented a great variety of clinical pictures. Some types of cases, particularly needed for purposes of comparison, such as high-scoring obsessive-compulsives, high-scoring paranoids or low-scoring men with stomach ulcers, were not represented. Due to the limited number of cases interviewed and to the manner of their selection, no quantitative statements as to the relationships of ethnocentrism to personality structure, type of disturbance, and genetic factors can be made from our case material by itself. Most of the interviews gathered at the Clinic were, however, in- cluded in the larger sample of interviews employed in the quantitative anal- ysis reported in Chapters IX through XIII.
In the absence of a sufficient number of case histories on psychiatric patients for quantitative comparisons, the material gathered by the Clinic staff and recorded in the patients' charts was exainined for its usefulness for the present purpose. This material turned out to be very variable in amount and quality. Only in rare instances was sufficient material recorded in the charts to permit relatively complete dynamic formulation of the case.
Each physician's notes varied with regard to length, completeness, amount,
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and type of interpretation included in the recorded material. Also, the ma- terial from later contacts between patient and physician was obviously colored in uncontrollable amounts and directions by the patient's relationship to the therapist, the latter's personality and approach (number and kind of ques- tions asked), and by the therapeutic process (e. g. , increasing insight).
One part of the case records appeared relatively less variable in most of these respects. This was the first psychiatric interview in which the patient stated his reasons for seeking help at the Clinic. Here, the patient, confronted with an unknown but friendly clinic worker, was invited by a very general question to state his problem. The response was often recorded in the pa- tient's own words and often included the worker's observations regarding emotional concomitants. Here, then, was a sample of rather spontaneous
behavior in response to a more or less constant situation and relating directly to the patients' problems. This material was thought particularly suitable for a comparison of high and low scorers with regard to their views of and atti- tudes toward their psychological disturbance and its possible causes.
I. SELECTION OF MA TERIAL
A patient first entering the Clinic is usually interviewed by a psychiatric social worker, and later by a physician. The social worker's "intake inter- view" is recorded in an approximately standard order of topics, starting with social status, then "patient's story," followed by a few inquiries about "past history" and ending with an appraisal of the patient's understanding of and attitude toward the clinic service. In some cases of referral from other hospi- tals and agencies, a referral letter giving a similar but less standardized account takes the place of this interview. After a patient is admitted for clinic care, he sees a physician who usually begins by asking the patient to tell about the condition for which he seeks help. Often, the physician also asks how long the condition has existed and whether there are any other problems. After this there is usually an attempt at taking a case history.
The section preceding the questions as to past history is headed "chief complaint" and varies from a verbatim account of the patient's story, with behavioral description, to a list of the main symptoms.
In selecting our material, the part of the intake interview (or referral letter) headed "patient's story" and the physician's first notes of "chief com- plaints" were read. Whenever the two duplicated each other, the one that was more complete or that contained more of the patient's own words was used. Whenever one record contained a statement missing in the other, that statement was included along with the other material. Material relating to past history or other topics was included only when the record seemed to indicate that the patient brought it up spontaneously when asked about his symptoms, without a preceding question from the interviewer. These sec- tions of the case records, usually only a paragraph in all, were transcribed
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 919
verbatim along with the patient's sex, questionnaire scores, and official diagnosis. 5
These interview samples were obtained for all subjects falling into the high and low E quartiles.
Analysis of the data showed certain striking differences between the state- ments of the high and low scorers regarding type of complaint and general attitudes. To describe these differences a number of categories-very similar to some of those described in Chapter IX-were defined. All cases were then rated on these categories (variables) by independent raters who knew only the subject's sex and interview samples, but not the diagnoses or the ques- tionnaire scores.
The variables thought to be differentiating between high and low scorers in their intake interviews are described below. These descriptions were in- cluded in a manual that was employed by the raters. For each category we here note the variants which were presumed to be associated with high and with low scores on the E scale, but this information was, of course, withheld from the raters' manual itself.
2. THE SCORING MANUAL: DESCRIPTION OF VARIABLES
There were seven categories, some broader and more interpretable than others. They are defined in terms of behavior cues and should be regarded as various expressions of more general underlying dynamic trends. Thus, the variables overlap (in content) to a certain extent.
I. Emphasis on Somatic Symptoms. As was to be expected from earlier findings (Chapter XII) it appeared that in the story of their complaints more high than low scorers tended to put the main emphasis on somatic symptoms. The majority of persons neurotic enough to seek psychiatric help have some psychogenic somatic complaints. Patients vary both in amount and severity of these somatic symptoms and in the subjective importance these symptoms have for the patient. There was a considerable number of low scorers who had somatic problems, but these tended, for the most part, to state their problems in terms of faulty adjustment or emotional difficulties. Some of the high scorers, on the other hand, showed a particularly strong preoccupation with body processes, and anxiety about the integrity of bodily and nervous functioning. In some cases this focus on the physical aspect seemed related to fear of admitting the existence of psychological problems, which carried the connotation of "being crazy. " Attributing the symptoms to something physical could, in some cases, be due less to anxiety about the body itself than to the need for a device for removing a deficiency from the threatened
5 The material from the research on stomach ulcers did not include regular intake interviews; instead there were very condensed research interviews in which the patient was questioned regarding certain precipitating factors. We took from the records of these interviews those statements which seemed relevant to our scoring categories.
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ego. (Probably, however, the two motives usually occur in the same persons, mainly in those with obsessive-compulsive character traits, or in certain men with particularly strong castration fears. )
The raters were instructed to use the following criteria in deciding on presence or absence of the trait.
Presence: Patient may state numerous problems, including physical and psychological ones. Main emphasis is put on physical symptoms when these are: (I) mentioned as the main trouble; (2) mentioned first; (3) emphasized in some other way, as, for example, when other problems are stated only after the interviewer had brought them out.
Absence: Patient puts main emphasis on a psychological disturbance: (I) disturbance of mood; (2) in interpersonal relations; (3) impairment of work adjustment; (4) specific conflicts (about drinking, homosexuality, enure- sis, . . ); (5) more specific fears; (6) compulsions.
II. Intraception. This trait has been discussed in earlier chapters (VII, XII, XIV, XV), where it was seen to be a common correlate of low scores on E. It may be recalled that it expresses the tendency to think in terms of psychological experience. This involves a certain familiarity with one's inner life (especially in its content aspect) and a corresponding readiness to per- ceive others in the same terms (psychological insight, understanding).
Presence: The patient is aware of the fact that he has problems of a psy- chological nature (not purely physical problems). In addition, he states these problems with some appreciation of their psychological content.
Patient complains of specific difficulties: specific fears, conflicts, or envir- onmental problems; conflicts about sexual or aggressive impulses, problems in interpersonal relations. Sometimes the statements include the description of certain situations which seem connected with the symptoms. In this case the emphasis is not so much on the situation as the cause, but there is some insight into the psychological significance of the situation for the patient. (Not merely: "I feel this way when I do heavy work; when something or somebody bothers me. " Statement has to have more specific psychological content. )
Absence: (a) denial of any psychological difficulty; (b) emphasis is not on the content of the problem (conflict with family member; struggle with certain impulses, etc. ) but rather on the "malfunctioning" itself (the lack of mental energy, inability to concentrate, to think, to do this or that). The complaints are made in general vague terms: "I don't get along with people," "I don't feel well," "I am nervous. " Statement often seems to imply the idea of "a machine part" having broken down. Often the "machine" is the body, sometimes "the mind," "the head," "nerves. " Often it includes the idea of "going crazy. "
Sometimes the statement of the problem appears more specific (e. g. , "can't do such and such work") but the main thing about it is the idea that "one
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 92 I
cannot do one's duty" (for instance, as a good wife or mother) due to this unwelcome illness. The concern is not so much with the task itself or the feeling of failure involved in the present inability to carry it out, but rather with the violation of conventions and morals. But there is little awareness of specific conflicts, fears, frustrated desires, or life failures.
III. "Ego-alienness"
Presence (goes with high score); The symptoms and the patients' atti- tudes toward them give evidence of particularly strong repressions. The repressed problems and also some of the symptoms have a strong ego-alien quality. Certain impulses, problems, and even some symptoms are experienced as completely "foreign" to the self. They cannot be accepted or admitted. They "belong to the body," or they are the "breaking through" of a com- pletely unacceptable part of the personality. The person "cannot understand what makes me do that. " There is fear of something "devilish inside" that overwhelms the normal accepted self. Fear of "losing control. " Examples: "Fear I'll kill someone during one of my spells; fear I'll lose my mind. "
When certain impulses have broken through and have been expressed in behavior, this ego-alienness is expressed sometimes in moralistic statements and self-accusations ("Can't understand how I could do this"). Another criterion might be the blandness of the interview, stemming from the patient's inability to admit socially unacceptable impulses, either because of repression or because of fear of disapproval from the interviewer.
Absence: The symptoms are experienced as belonging to one's personality and life history. There may be severe conflict over some impulses, but the latter are admitted to consciousness and understood as part of one's self and life experiences. There is relative frankness and freedom from "moralism. "
In the case of obsessions, compulsions, delusions, and other psychotic manifestations, which usually have some ego-alien quality, the rating will have to be based on the relative emphasis on the ego-alienness itself ("Some- thing makes me do it; someone influences me; can't control it," etc. ), or on the degree to which the content of the symptom is consciously divorced from or related to the patient's past or present inner life.
IV. Externalized Theory of Onset and Causation of the Illness
Presence (goes with high E scores): Attempts at externalization of the symptoms by: (a) denying any and all precipitating factors. Tensions, de- pressions, etc. , appear "without any reason at all. " "It just appeared. " (b) dating the illness back to a very definite event or moment: an operation, a "spell," a death, a particular day-sometime during the last few weeks or years. "Before that I was well . . . happy . . . . " (c) making no attempt to relate the illness to one's past, especially not to childhood. No spontaneous references to childhood unless specifically questioned, during this first inter- vrew.
Absence: Spontaneously, or when asked about onset, states that the prob-
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lems have been present "for a long time"-for years, always or since child- hood, but perhaps in milder form.
V. Spontaneous Mention of Unhappy Childhood or Family Relationships
Presence (goes with low E scores): Patient spontaneously refers to his unhappy childhood. Often elaborates in great detail on_a history of frustra- tions (often with a clearly masochistic attitude). Complains of parents' pres- ent or past attitudes and is critical of them.
Absence: No spontaneous reference to childhood. Childhood, if discussed at all, is pictured as "happy and normal. " No criticism or other sign of hos- tility towards family members is expressed (except in "spells" and psychotic episodes), in spite of admission of friction. Sometimes there is clearly com- pensatory great concern for family members and their welfare.
VI. Cues Referring to the Patient's Character Structure
Obviously the interview fragments cannot be used to construct complete pictures of the subject's personality structure. It was found, however, that they often contained some important hints as to the nature of this structure. Formulation of categories listed below was, of course, guided by the con- cepts found most useful for distinguishing high and low scorers in the rest of the study. But only those categories were included which would be applied to the particular interview material at hand. The raters were asked to state for each case whether cues from List A or List B predominated in a record, or whether the record was "neutral" (meaning he could discern equally as many cues from "A" as from "B" or none at all).
List A (goes with high degree of ethnocentrism):
1. "Countercathectic" defenses. Men: counteraction against passivity.
Women: Anal reaction-formations. No mention of a love object or re-
lationship (other than spouse).
2. Extrapunitive or impunitive. 6 If self-criticism occurs, it is couched in
moralistic terms, "I am bad, have done wrong. " "God is punishing me. " Tendency either hysterically to dramatize certain physical symptoms, spells, etc. , or to minimize all complaints of a psychological nature.
3? Externalized superego. Religion: God is seen as an external judge of one's action. Illness is a punishment from God. Or religious standards are part of the conventional ideology. Religious reasons are given for refraining from divorce or suicide.
List B ("low" characteristics):
4? Absence of "countercathectic" defenses:
Direct expressions of orality: dependent character traits; eating, drink- ing, drugs. Dependency problems, nurturance. Open admission of weak-
6 Further research onirnpunitiveness is indicated. Here it seemed preferable to classify it "high;" it was "low" in Chapter XI (p. 406).
? PSYCHOLOGICAL ILL HEALTH AND POTENTIAL FASCISM 92 3
ness, passivity, femininitY in men. Love-seeking attitude. References to rejections by specific love-objects.
Sublimations: form an important part of the ego; references to achieve- ment. When symptoms interfere particularly with patient's work, this is stated in such a way as to suggest concern with the particular work he is doing. Emphasis on ideals. Concern with helping others, society; artistic activity and interest.
5? Intrapunitiveness, masochism: "I was mistreated as a child. " Identifica- tion with suffering; self-criticism ("I am a failure").
6. Internalized superego: guilt feelings, true depressions, religious ideas as part of the inner life of the person.
VII. Predominant Types of Symptoms
List A ("high"):
1. Physical anxiety symptoms and other emotional equivalents: "hyper-
ventilation syndrome"; dizziness, sweating, tingling sensations, numb- ness, tachycardia, breathlessness, fainting, tremors. Anxiety has no con- scious content.
2. Emotional outbursts, tantrums and "spells," in women.
3? Hypochondriacal fears: fear of death, heart attack, etc.
4? Hysterical conversions. 7
5? "Rigid compulsive rumination": repetitious complaints, self-accusa-
tions, self-reassurances, "thinking around and around in a circle. "
? 6. Depersonalization (sense of estrangement from self and world) in a person who emphasizes that heretofore he had had no tendency toward
timidity and withdrawal.
7. Suspiciousness, fear of people or aversion to people is stated in some-
what externalized terms: "They irritate me," "I can't stand them. They make me nervous. " (To be distinguished from hypersensitiveness and withdrawal when described in a more intraceptive way. )
8. Psychopathic tendencies, not in the sense merely of unconventional behavior (as the term is sometimes used) but rather in the sense of a really defective and not sufficiently internalized superego. Antisocial and destructive behavior, callousness, emotional shallowness.
9? Stomach ulcers in men, especially in subjects who emphasize their masculinity.