Effects of length of hospitalization in a state hospital on concept of self and others

The aim of this explanatory study was to investigate the effect length of hospitalization had upon self acceptance (SA) and acceptance of others (AO) in 31 first admission patients between ages 21 and 60 in a state psychiatric hospital, as a predictive measure for planning psychiatric nursing intervention. Berger's (1950) SA and AO tool was used as a measuring device in a partially experimental design. The sample population was tested within 12 hours after admission and placed into two groups for retesting at either 2 or 3 months' hospitalization. For each group, Pearson Product-Moment correlations, r, were computed to determine relationships between scores on first and second testing and between scores on SA and AO. A correlation was determined for all subjects between age and improvement scores. A t ratio to test chance probabilities of differences in sex, marital status, religion, type of admission, medication and diagnosis was determined. All scores were obtained at 3-month retest significant at the .01 level. The 2-month retest scores failed to be significant. Correlations between SA and AO were significant at the .01 level. A linear relationship between age and SA reached < .05 level of significance; with married persons as compared to single, showing significantly greater improvement at the .05 level. The Berger tool appeared to be highly reliable, reaching correlations of .680 and .540 test-retest at 2 months, and .729 and .766 at 3-month retest. Findings indicate length of hospitalization might be used as a predictive measure to plan nursing care patients. The study was limited by the small sample and the partial experimental design. Areas for further nursing research were identified.

THE EFFECTS OF LENGTH OF HOSPITALIZATION IN A STATE HOSPITAL ON CONCEPT OF SELF AND OTHERS by rlildred Bradshaw A thesis submitted to the faculty of the University of Utah in partial fulfillment of the requirements for the degree of Master of Science Dep3rtment of Nursing University of Utah .June 1970 This 'l1wsis Haster of for the Science Degree by Mildred Bradshaw has been approved l'lay 1970 -����----.--.---.- UNIVERSITY Of UT AU U8RARJfJ ACKNOHLEDGHENT Sincere appreciation is expressed to those people whose many hours of encouragement, and assistance made possible completion of this study. Recognition and gratitude are extended to the patients and personnel of the Wyoming State Hospital for their cooperation and assistance. ili TABLE OF CONTENTS Page LIST OF TABLES AND FIGURES v Vi ABSTRACT Chapter I. INTRODUCTION 1 II. METHOD 12 III. RESULTS 19 DISCUSSION 31 IV. REFEREr:CES 37 APPENDIX A 40 APPENDIX B 44 VITA 45 tv LIST OF TABLES Page Table 1. Admission and Retest Mean, Standard Deviation, and t Score for Self-acccntance and Acceptance of Others • 26 LIST OF FIGURES Page Figure 1 2 3 Distribution by age and sex anwng the sHmple of 31 psychiatric patients 20 Distribution by sex, marital status, religion, horne community sIze, tyne of <.l.dmission, medication Hnd diagnoG.is of the 8.H;;ple of 31 psychiatric patients 21 Distribution by type of religion and type of diagnos L1 among 31 psych:ta tric pil tients . 23 v ABSTRACT The aim of this explanatory study was to investigate the effect length of hospitalization had upon self acceptance (SA) and acceptance of others (AO) in 31 first admission patients bet'\I]een ages 21 and 60 in a state psychiatric hospital, as a predictive measure for planning psychiatric nursing intervention. Berger's (1950) SA and AO tool was used as a measuring device in a partially experimental design. 111C sample population \·las tested within 12 hours after admission and placed into two groups for retesting at either 2 or 3 months' hospltali.?:fltion. For ench group, Pear~on Product-Noment correlations, E_, were computed to determine relationships between scores on first and second testing and between scores on SA and AO. A correlatIon 'vas and improvement scores. determinc~d for all subjects betHeen age A ,~. ratio to test chance probabLlities of differences in sex, marital status, religion, type of admission, medication and diagnosis was determined. All scores were increased from first to second testing with scores obtained at 3-month retest significant at the .01 level. 2-month retest scores failed to be significant. SA and AD were significant at the .01 level. between age and SA reached~.05 TIle Correlations between A linear relationship level of significance; with married persons as compared to single, showing significantly greater improvement at the .05 level. vi The Berger tool appeared to be hi~lly reliable, reaching correlations of .680 and .540 test-retest at 2 months, and .729 and .766 at 3-month retest. Findings indicate length of hospitalization might be used as a predictive measure to plan nursing care of patients. The study was limited by the small sample and the partial experimental design. for further nursing research were identified. vii Areas CHAPTER I INTRODUCTION There is a trend in present-day psychiatry to treat the patient \'lithin the community. A United States Dennrtment of Health, Education, and h1elfare report noted that the number of persons in state and county long-term care mental hospitals to I~O 1 thousand in 1968. ha~~ declined from 559 thousand in 1955 The repurt fur ther Gtated:. "These data pro- bably reflect mainly the impact of trs.nquilizers and other net·l drugs and the wider availability of community-based care which have reduced the need for prolon[!ed hospitalizr!tion of the r~;.:nt;llly ill (1969, p. 5)," Hhere hospi talJ.zation is p:~og:c.'(J.m) indicHtt~d unde::.~ the community centered it is provided on a short· .. te:C(:i basis, and the r>atient is returned to the community and home of days or ,,,eeks. ~·dth utmost expedience in a matter Psychiatr:ic uni ta in hospitals and community mental health centers are structured to provide such services. Large state mental hospitals are no longer be.lieved by many to be pn.!ferred or necessary treatment centers; however, for some states they continue to pr:ovide the major treatrnent facility H.ud supply of resource persons "'ilia arc p'cepared to tn~at the mnotionally disturbed. are still being admitted aud cared for in suell Numbers of people facilities~ particularly vlhere the hospital is the prtmdry source of care available or """here the inclividunl is financially unable to seek help This study was coner: n!cd vlith ODe els~rllere. aspect of patient ca.r~! in the 2 Wyoming State Hospital which meets the needs for hospitalization of a majority of the psychiatric patients in the state. The Veterans Administration Hospital and the State Training Schobl are total psychiatric facilities within the state limited to the care. of male veteran patients, and mentally retarded patients, respectively. Only 3 of the 31 community hospitals in the state provide separate small units for psychiatric inpatient services. the state, Of the 6 psychiatrists in 2 are at the Wyoming State Hospital. Clinical programs at the state hospital are directed toward meeting many of the needs of present-day psychiatric patients, including short-term, intensive, comprehensive care within the hospital, out tent corrmunity mental Ilealth services, and consultant and supportiv2 services to such caretaking professions as general practicioners of medicine, nurses, ImJycrs, clergymen, tec1chcrs, and \·wlfare 't'70rkers, ,·,here such services are not othen'lise l)rovided. The focus of the present study is upon one aspect of patients' response to hospitalization tn a state hospital. Th(~ purpose of the study was to determine what effect the length of hospitalization had upon the self-concept: and concept of others of a group of first acil:1ission patients to a state mental hospit.:ll. It ,"vas hypothesized that the concept of self and others could be measured and would offer information relevant to improvi.ng psychiatric nursing care of hospitalized patients. RedlIch and Freeman cited the following criteria for 3 hospitalization: (1) To remove the patient from unbearable pressures of his environment that make therapy difficult or impossible: (2) to carry out diagnostic and therapeutic procedures that are not feasible outside the hospital; (3) to protect and treat the patient who is danGerous to himself and others in the community (1966, p. 295). They noted the therapeutic utility of the hospital should be of more relevance in determining hospitalization and length of stay than severity of illness. Once a patient is ci.n] issue. hospitalized~ Hospitalization Is a cost prices have been risin~. length of stay becomes a cruexperience. Medical care The annual rate of increase from 1946 to 1967 was 3.9%, and from 1965 to 1967 accelerated to an annual rate of 6.5%. HOfipl tal ~cr.vicc care prices. charges h[i.\YC: been increasing faster than other medicul They rose 8.3% annually from 1946 to 1967 with the 2- year period 1965 to 1967 showing a sharp increase to about 16% per year (USDHEW, 1969, pp. 9-10). During 1967 and 1968 expenditures and appropriations for operating state mental hospitals increased by at least 10%~ with an increase of 20% for 7 states, and as great an increase as 40% for 2 states (Interstate Clearing House on Mental Health, 1969). Indirect cost of human waste and suffering, ,,,hile far more significant, cannot be measured directly. The current tendency toward the shortest possible hospitalization for psychiatric patients reflects a.wareness of such factors, however, patients continue to require hospitalization and sometimes for 4 long periods. The emphasis in all cases is to prevent the patient from becoming permanently regressed and asocial, and to keep the family and community engaged with the patient during the ti.rne the patient is becoming able to know hOt'l and ,.,hen to engage ,,,ith them (Redlich &. Freedman, 1966, p. 297). The tendency of p~ttcnts to regress and become asocial diminishes when interpersonal relationships are effeceiva. Providing and facilitating sud, relationships is a goal of psychiatric nursing, particularly in the hospital setting. It I::: assumed that one f s self-esteem is heightened through satisfying interpersonal situations. Self-8steem or a need to feel Numerous authorities have recogni;:ed that one respects othern only to the: extent that one respceu3 oneself (Fromm, 19 f t7, pp. 133--136: Fromm~ Reichman, 1959, pp. 7, 82; HUrers, 1951, pp. 520-522; Sulllvan, 1953, p. 308). The interpersonal situation is implicIt in developing and t:l-ai.'::ltaining au (,lPPl'opriute concc:pt of self and others. He~~d states, IIS e .l ves can only exist in definite relati.onship to other selveB (193t~, I f/) p.o . • rt Humans perceive and define themselves as they believe others perceive and define the.m. Such perception influ("!Uces behnvior mor~ than the actual happening (Brm·m & For,vler, 1966, p .. 23). It would seem to be reasonable to equate a low or diminished self--concept ':'lith mentn 1 disorder, and conversely to associate an increase in felf-esteem with condition. improvem~nt of the psychiatric patients' Self-concept and length of hospitalization as a psychiatric pntiant would appear to be interrelated. 5 The relationship between such factors as the patients' concept of self and others and the hospitalization process, including length of stay offer a field for study. Implications for psychiatric nursing would be great if critical time factors influenci.ng the patient's selfconcept could be identified. :;ursing intervention might then be planned more effectively to assist the patient in his return to mental health. In conducting this study, the investigator sought to determine if there were Foints in timD durIng the ea.rly period of hOGpitalization when changes in the patients' self-concept could be identified, thereby prcvidi0g som0 indic~tion for inU,:(vc!lltion. It \vas hypothesized that the experi-ence of being hospitalized "lould be accompanied by feelings of low self-esteem and that llospitalization would provide on opportunity for interpersonal experiences which would result in increased satlsfactlon and imnl'oved sclf-concept. The vic~lt- situdes of one's self-concept over a long period of hospitalization ~,-- ... '~ .'~--""" were beyond the scope of this study. Pertinent to the investigation are the following definitions: except length of time hospitalized over a contitlUed period, during which a brief ahsence of 2 or 3 days may occur. First E.\dmlssJon --.,--.-------.----.---.-~-------- 60 nev(~r are person~l be.tT;}(!en the ages of 21 and before admitted to a state mental hospital. S(~lf-conc';; is based on the scale developed by Berger (1950) which defined self-acceptance in terms of one's standards nnd values; 6 capacity to cope with life and assume responsibility for one's behavior; accept evaluation objectively; accept without denial or distortion one's feelings, abilities, and limitations; and to consider one's self of equal worth with others and not anticipate unjustified rejection by others. It is defined as the value one places upon one's self through self appraisal of all that one understands about one's self. Self-concept, self-esteem, sGlf-ucceptance, and self-respect are used interchangeably throughout the study. Con of others is aL"::o ba:3ed on the scale developed by Ber.ger (1950) which measures one's stated beliefs regarding attempts to the worth of others or their equal as parsons with oneself, and one's des:lre to serve others and show interest in others. def ini:~d C!:-.:j th(~ It is value one places Epon another. Th;;;n:e are conflicting opinions and many variables associated \v5.th the mC':ll1:ing of hospitali;(.iltion for patients. HOBpitalization can procl1ce detrimental effects upon a first admission patient "\-1ho f:lnds himself in a novel role without formal or informal learning in how to be a psyc:h:Latric patient (Par.sons, 1959, p. 153) .. procedures are carefully planned unfamili3r environment a role [0 ~lich Unless admission provide the new patient in this justifies his presence, such lack of role and ambiguity increases disorganization, confusion and stress (Cummings & CummIngs, 1963, Pl'. 206-207). Feelings of depersonalization, loss of control, and increased dependency may be most threatening to one's self-esteem. 7 Numford (1968) suggested the sick role excuses the patient from some obligations and imposes others, such as a wish to get well, seek help, and cooperate. Equal conformity to such roles need not be expected because social roles are learned, and mental illness is frightening and frequently becomes an area of denial. Denial and despair may cause the patient to withdraw support in his recovery and accept chronicity (King, 1966). Hospitalization may be viewed as convincing proof of illness with the burden of proof of one's sanity a frightening prospect. The hospital staff or the patient's family may subtly influence the patient to remain sick, or the patient m.ay use illness as a ~ethod of rrsistAnce to f~mily pressures and respon- sibilities (Bursten & D'Esopo, 1965). Contributing to stress and lowered self-esteem of the psychiatric patient may be the concept pre3ent~d by Stainbrook (1959) of "shameful" and "re.spectable" sick roles 1n our society, t>lith mental illness seen a~) a "shameful" role (p. 152). Separation anxiety Iuay contribute to one's lowered self-concept, particularly if hospitalization is Viet"ed as rej ection by loved ones; however, some patients may find living within the hospital more rewarding than life outside of the hospital. The anticipated outcome of recovery may have threatening impl:lcations, or one's life situation outside of the hospital may be intol(~rable. Strong dependency needs beine met u:tthin the hospital may { further weaken the motivatIon to recover. It appears, however, incom\. patible to remain a patient and also to maintaln the concept of self as a fully functioning person. Taylor (1965) noted the role of the patient 8 has been characterized as being temporary, submissive, relieved of responsibility, and socially undesirable. Such a role would not be expected to contribute to self-esteem. Many of these stated concerns appear to indicate a lowering of self-concept in rclntion to hospitali~ation. Conversely, however, hospitalization is viewed by many as supportive to self-esteem. ZUSlnan (1966) emphasized the moment when the mentally ill person first steps into the ward as the time starts to build. ~:lhen his old world crumbles and his new' one Hospitalization from this point of vie,,; carries an element of hope for an improved condition. toward health. A basic assumption of behavior is that the satisfaction of existing needs will allow for the emergence of more mature needs (Dro\;.vn & FOHlcc, 1966, p. 2 t.). In a hospital <1t:mosphere t'/here security, deoendency and biological needs are met, onels self-concept Tn3Y be enhanced. Freedom. to behave uithout fear of censure pe.rmits one's energy to be directed mvay from being guarded and toward developing n~re self-control. Sullivan (1964, pp. 169-171) noted that persons with mental disorders require removal f-rom home and community to a changed social order, such as a psychiatric hospital, before material alterations in their functional capo.city for living are possible. A study by Rosenberg (1970) noted a reciprocal relationship to exist between patients' unconscious defensive needs and institutional structure and culture. He stated that certain identifying 9 characteristics related to the patient's dependency-autonomy area, his perception of authority, and his sense of ego identity were significantly related to length of hospitalization. TIle higher propensity to dependent behavior, conflict Hith authority, and extreme doubts about self worth were predictive of increased length of hospitalization. A review of related literature failed to reveal a study directly concerned with the effect length of hospitalization in a state hospital had on the first admission patient's self-concept and concept of others. There were numerous studies that seemed to support the premise that self-concept changes during hospitalization. stud:i.e::; 8u[>port<!d th(-~ hY"pcth(:;~d.s that: self-esteem ':'JHG A number of louer-cd by pro- longed hospitalization. A study in a Veteran's Administration Hospital, defining longterm (IS more th;gn 90 days, noted that sw.:-:h lonr-term patients \Jere reluctant to leave the hospital because they lacked family and income, or the family rej l~ctcd them and exert!::J pressure to oppose release (Fineberg, Lange, & Cruser, 1967). Acceptance of the dependent patient role may be presumed to imply a shift from the pre-hospitalization selfconcept, while family disengagement appears related to long-term hospitaltzation. Length of hospitalization was observed to affect the personal orientation of long-stay psychiatric patients. Patients in the hospital a year continued to acquire knot·lledge of names of others, but ceased to do so after that time (Horgan, 1967). The results 't?Duld appear to indicate a change in self-concept particularly in relation to 10 others. A group of adolescents hospitalized on a short-term ward were found to have stages of adjustment reflecting evidence that a positive transference to staff could occur during short-term hospitalization (Abend, Kachalsky, &. Greenberg, 1968). Self-concept studies about persons with varying degrees of diagnosed pathology are of incidental interest, but not directly related to the question at hand. Friedman (1955) found persons classed as normal and those classed as paranoid schizophrenics had no significant difference in self-ideal. self--ideals. Neurotics vlere noted to have slightly lower Several studies indicated psychiatric patients had Im,;er self--concepts than nan--psychiatric persons (Tarokin, 1957: Tolar, 1957). Clinebell (1956, p. 51) attributed the expressed high self-esteem of the alcoholic patient to a defensive;n::lneu\Ter to liard off feelings of 10'>1 self-esteem. In the pre~)ent study diagnostic catagory ",;,:as con- sidered. The above studies indicate that numerous variables i.nfluence self-concept. No research studies "t·/ere noted which cited length of hospitalization as a variable affecting self-concept. Using the Berger (1950) "Acceptance of Self and Acceptance of Others" scale to measure the attitudes of first admission patients to a state psychiatric hospital, the follo"tJing hynotheses were made: (1) Patients will score lower on first testing, within the first 12 hours of hospitalIzation, than on a second testing given after a length of hospitalization of either 2 or 3 months. Such findings w0uld indicate a reactive lowering of the self-concept and concept of 11 others on admission, and an increased self-concept and concept of others after a short period of hospitalization. (2) Patients' scores on both first and second testing will indicate a positive correlation between acceptance of self and acceptanc~ of others. (3) Such variables as age, sex, marital status, religion, type of admission, diaRnosis, and medication will influence the self-concept and concept of others. In meeting the objectives of the study to determine if hospitalization affects the patient's self-concept, and to ascertain at what sDce.i fie periods this occurs ~ Cl time may be identifi.ed 't'lhen psychiatric nursing could be intensified in order to support the patient's selfesteem and enable him to achieve or maintain control. Such inter- vcntion and demonstrated respect at a particularly needed time when the patient is II ••• not at his best, is not most mature, most lovable (Holf£, 1963), II seems to be function of nur3ing, ~"hich pil'1."t of the need-fulfilling, nurturing includes helping the patient with problems of daily living, offering support and encouragement, helping him care for himself, develop his potential, and guide him toward more rewarding and useful patterns of behavior (Bueker, 1966). Such a helping rela- tionship furthers life goals extrinsic to the relationship, and fulfills sQcurity-<:1ependency needs intrinsic to the relationship (Polansky, 1965). CHAPTER II METHOD The aim of the study was explanatory, the design, partially experimE::ntal, and the content, nursing practice (Phillips & Thompson, 1967, pp. 2-6). The aim was to discover any relationship between the independent variable, length of ho~)pitali2atiol1, aud the depe,ndent variable, the patient's self-concept and concept of others, which could be predictive for planning psychiatric nursing care. Partial control over data collactin~ was effected by the rese;:rrcller determining at "'hat interval of time a questionnaire m(;~;lsuring self-acceptance and acc£~ptance. to a somnlc group of patients. of others \vould be admi.nistered Further control was established by limiting the sample of patients to be exami.ned to first admission patients to a state psychiatric Ih)spital, 'Hha vlcre bct~..;eel1 the ages of 21 and 60. Patients at the Hyoming State Hospital were selected for participation in the study. This institution was selected as it is the only state ment:'i.l hospital in the ll/hole State of \Jyamlng and one of the few places ~\ere psychiatric help is offered. It offers treatment for a great majority of HYOlning t s psyc.~hiatric population. The insti.tution is a progressive treatment-oriented Ilospital which has a relatively stable staff with qualified professionals of every discipline. Wyoming consists of small rural ~on~unities Much of and a few small cities. 13 Ranchers, oil population. ,~orkers, miners, and railroaders make up much of the In this state, patients are moved hundreds of miles away from familiar surroundings, in many instances to the state hospital to receive psychiatric care. The hospital is located in the southwest corner of the state in a small railroad-ranching community of Evanston (population 5000). The patients participating in the study were the first SO patients admitted ,\>,ho met the criteria of first admission patients to a state psychiatric hospital between the ages of 21 and 60. was collected from February 1, 1969 to May 9, 1969. comprined ~J% of the total ad~issions The sample l11c SO patients for that period. The rate of admission of those patients admissible to sampling, or the length of their hospitalization after admission were beyond the rc~)earcher 15 control. Adm.isoiol1 rates ~vel"e slo't'lcr and contained more previously admitted p . ~rticnts than anticipated. Of the 216 patients admitted) 79 were not first admission patients to a state hospital, 29 were under age 21, with 22 older than 60. Therefore, the original intent of the study was altered from one where all the sample group were tested with the first 12 hours after admission and retested at the end of 3 rnonthG, to a plan vlhere all of the sample ~o]ere tested \vithin the first 12 hours and retested at the time of discharge or the 3-month period, whichever occurred first, providing tile retest date was prior to July 9, 1969. of f date 0 Where a 3-month retest date would be beyond the cut- f July 9, 1 9, or \-,here a. discharge date had been determined which was leGS than 3 months, patients were retested at 2 months. This 14 resulted in two definite groups for purposes of retesting, with those patients tested at the time of discharge assigned to the group to which their retest date was closest within a 3-day overlap period. Those leaving earlier than 2 months \Vere not retested, but \-,ere dropped from the study. Thirty-one (62%) of the sample completed both tests with 19 (38%) failing to complete a retest. Some of the reasons for loss, aside from human error, were the refusal of the patient to comply, leaving against medical advise, transfer to a general hospital for special surgery, unexpected discharge without returning to the hospital following a short home visit, emergency leave due to death in a ratl(~ntt s f:mrU.y, and one lnc:ident uhere the patient was too confused to complete the second questionnaire. Data '-Jere collected through July 9, 1969. 'flH? sanlple vIas ro:cr'(d by <.1.cc.iden tal rather than random selee-- tion, as were the two groups. Such a method precludes assurance that the patients 1.n the sample or ei.ther proup were representative of first admission patient groups. It was not expected to establish any type of group matching to eliminate chance group differences. In order to carry out the study, aides who were in charge of patient units were approached to assist in the administering of the test. basis. These men and lvomen vlere asked to participate on a voluntary Each char.ge aide ~.;rho might be expected to administet" the evalua- tion tool was consulted by the researcher as to his or her feelings regarding assisting with such a project. To protect the patient from possible bias, each aide, if at all hesitant, was assured that other 15 arrangements would be made. assisted. All '-Jere most cooperative, and eight They fonned a relative homogeneous group as to age, educa- tion, and period of employment. They ranged in ages 41 to 55, had a high school diploma, and had been employed from 5 to 10 years. They were told the purpose of the survey was part of a thesis project to determine patients' attitudes as a possible way to evaluate and improve future hospital care. TIle exact nature of the study was not explained. The patients were given the same explanation and their participation was voluntary. They ,,,ere to be ass.isted in following directions, but none was to be encouraged if they expressed a disinclination to complete tlv~ form. They Here! ar.;sured thnt the test results or their refusal to complete a fOl~m 1;>lould not alter their present treatment. In addition to th!J questIonnaire, data "tvere taken from each patient's record as follows: age, sex, marital status, religion, occupation, home location, type of admission, medication, and diagnosis. The researcher, a graduate student in a psychiatric nursing program, collected these data. The Berger (1950) instrument used as the testing tool is a t,voscale instrument composed of 36 items to mCclsure attitude toward self and 28 items to measure attitude tOtvard others administered as a single test. The response mode requires the subject to respond on each item by marking a scale with scores ranginR from 1 to 5, with 5 assigned to a response of "true of myself" and the value decreasing to a score of 1 for "not at ;:111 true of myself. II For: items expressing a favorable attitude toward self or others, as in statement No. 34, "I feel that 16 I'm a person of worth, on an equal plane with others," the score is as marked. The direction of scoring is reversed for negatively worded items such as No. 17, HI am quite shy and self-conscious in social situations," so that a person marking 5 for a response of "true of myself" would receive an adjusted score of 1. A high score indicates high self-acceptance or high acceptance of others. The score range y]hen all items arc ansvlered is from a low of 64 to a possible high of 320. For purposc!s of scoring a key is provided 'tvhich indicates which items are self i.tems, ,vhtch other items, and which items are worded negatively. The questlonnD.ire is located in Appendix A, and the key is in(:luded. A sample of 200 st.1.tements by Berger (1950). \-laS used in development of the test On the basis of item analysis, the top 25% of the statements indicating high acceptance of self nnd others and the bottom 25% of the statem~nts others were selected. groups was USt~d The indIcating low acceptance of self and dlffen~.nce betlJeen mean scores of these as an index of discriminating power of the item. The standard error of the difference between means did not exceed .30 for any item, and all items in the final scales had critical rati6s of 3.0 or more, except three. The subjects used in selecting items for these scales "lere 200 students 'vho were in first-year psychology or sociology classes. They represented a tIlde range of socia-economic backgrounds and vocational interests, ranged in age from 17 to 45, and were drawn from day and evening college classes, adult YMCA classes, speech-problem classes, 17 and student counselees. Samples of prisoners and stutterers were used for reliability and validity studies. Further review of the instrument (Berger, 1950) included splithalf reliabilities obtained for five groups 'I;,'lhich ranged in size from 18 to 1133 vlith the self-acceptance scale for all but one group reported to be .894 or better, the one exception being .746. others scale ranged from .716 to .884. TIle acceptance of The Spearman-Bro~.m correction formula vIas used 1.n these estimates. Four estimates of validity ",'ere obtained by Berger (1950). First tllO groups of 20 member:3 each were asked to write freely about their a tti tudes. One group tl7<1S to t·rri tc regarding their at ti tudes tOlvard themselves, the other group about their attitude regarding others. The writings were graded by four Judges and the mean ratings correlated with corresponding scale scores. TIle correlation was .879 for self- acceptance and .727 for acceptance of others. Second, n group of 38 stutterers were matched as to age and sex with a group of 38 non-stutterers. TIle stutterers showed lower mean scores on the self-acceptance scale than non-stutterers with the p < .06. Third, a group of prisoners v7aS compared with a group of college students, matched for age, sex, and race. The prisoners scored lower than the students on both acceptance of others, with the p about .02, and acceptance of self vd.th the p<.O 1. Finally, a group of seven spe.~ch rehabilitation students rated for self--acccptancc by clinical ns::istants. ~.,ere The correlation score 18 between the clinical assistants' rating and speech students' selfacceptance score failed to reach a significant level (p<.59). The inconsistency of this test to demonstrate validity as sho"m by results of others might be explained on the basis of the smallness of the group and the questionable reliability of the clinical assistants. Further discussion and review of the Berger (1950) instrument can be found in Berger (1952), Shaw and Hright (1961, pp. 432-436), and Wylie, (1961, pp. 66-67). HhL1.e the Berger (1950) instrument was developed for use by persons not considered to be in need of psychiatric care, it has been used fJlth pnra!1oid schi.zop1n:r:.~ntcs to determIne unrealisti.c 3(;lf- enhancement (Havener & Izard, 1962). Dr. Berger, in response to a letter written by the investigator, confir.med that u.se of til(! ins1.:rvment to me.::u:;urc attitudes of pr.;ychiat-ric patients t.,Quld be appropriate if it ,\.,ere used as a measure of "expressed!! attitudes only. Mt:"!Hsure of internal vali.dity of such expressed attitudes could not be ascertained by use of the tool. A copy of Dr. Berger's letter is in Appendix B. The researcher made necessary adjustments of scores for negatively '<lorded questions, then results scored, and comparisons made bet~oJeen 011 all tests were i.ndividually first and second tes t scores, between self-acceptance scores and acceptance of other scores, and between the 2-month and 3-month groups. Data were statistically anal- yged along \lith information obtalned from the patients' records. test Has used for both the initial and rt.~test measurement. The CHAPTER III RESULTS From an original population of 50 patients, 62% (31) completed both questionnaires. The pntients ranged in age from 21 to 56 with the greatest number falling within the 25 to 29 age group, '"lith a median age of 31 and a mean age of 3 Lt.61. and 39% (12) were male. presented in Figure 1. In the sample, 61% (19) vlere female A distribution curve indicating age and sex is It shews n skewed frequency distribution toward the younger age range. The [!reater r:crcent,'1r~e of the 31 patien.ts from t.Jhom data \Olere collected Nerc sin01e (58Z), non··-Cathol.ic (61%), lower socio-economic clasHed persons (78Z), \'lho had be~;n living in communities bettveen 11,000 and 1-t3,OOO inoopulation prior to hot3p:ttali:~ation. Hith the exception of tilree teachers, one nraduate student, and one insurance adj uster in Group II (3-month retest), all others \V't1re house,,::ives or had. been t~rnployed b!~fort~ dishr/nlSh(~rs, hospttHl i.z<.ltion as unskilled laborers such as custodians, "mitresses, oil field tvorkers, and ranchers. Stxty-e:f.ght percent (21) T"lere voluntary admissions, and 1... 5% (14) rc.cei ved medicati.on \,;li-.l.lc in the hODpi. tal. The greater percentage, 68% (21), were diagnosed non-psychotic witll 32% (10) diagnosed psychotic. group Ftgure 2 1.8 a compIlation. of the above data, and :1.ncludes con~arisons. Tlh.~ . ."'.lously 31 patients 't.1ere placed in stated m;.~tho~1G: t"t'10 groups accordi.ng to pre- Croup I 'rJllth a retest date of 2 months (N=12) 20 10 ---. ~--4 9 0---0 Total N=31 Hale N=12 (39%) Female 1'::= 19 (61~O 8 CIl .j..J r:1 7 (!) '1"1 W (:j ~ 6 0 'ri H .j..J ('Ij ..,.... 5 ...t:: r.) ;;~. (f) j:l.; 4 1.+4 0 H ()) ~;.:l 3 Z 2 1 o 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 Age . 1. Distribution by age and sex among the sample of thirtyone psychiatric patients. 21 11 -.5 '5 ~ ~ I 74% ~.7,Z;~~~277U ::::hotiC 68% r" .1 Psycho tt c '.()'IV)L222/J'1'~O. ' '--------""".".... I '" CN M ;-J'-"- o )~ H UH H .-i til ./..J 6 .,....., ,',cd1cation :'ledication P. C... ;::1 ;::1 0 0 [~ ~ ~ ~------""'''7-r~~-r-~-l.:; 70 Z .........L-....:...-c...-'--t:_...c..........k-_......... _..t:_.--1:.._.J!.•. --L._...L._£~-i Va 1 un t a ry 63:'~ 68% L.. . Lc~.>_. ',~. Adlnission ... • Q e.oQ 01"'4 ~ -M (I) (I) or" r::1 ""d m I.H o 22 and Group II with a retest date of 3 months (N=19). The t'V10 groups were fairly closely matched on all noted variables with the exception of Catholic-non-Catholic and psychotic-nan-psychotic categories. Group II (3-month retest) had the larger percentage of both nonCatholic (68%) compared to (50%) in Group I (2-month retest), and nonpsychotics (74%) as compared to 58% in Group I. See Figure 3 for distribution of relirion and diagnostic types. As an estimate of reliability, a Product-moment correlation coefficient was obtained for each group to determine the relationship between scores on first and second testing using the Berger (1950) ins t".rument . For Group I, the correlation betr;leen the scores on self~ accl':ptance, ";'lhen first admitted to the hospital and tt·JO months later was .680. The test-retest correlation on acceptance of others was .540 . . .lith 11 Ei.' the for.ncr: correlation was significant at the .01 level; the latter did not reach the .05 level of significance. Hith Group II, the test-retest correlation for self-acceptance and acceptance of others was .729 and .766, respectively. The second test was given three months after admittance. both Hith 18 ~!, correlations y7Cre significant at less than the .01 level. The data provide an estimate of the reliability of Berger's (1950) scale. The reliab:i.l:Lty v:ras greater at 3 months than at 2 months which appears to suggest some stabilization of responses at 3 months, lvith responses at 2 rJonths seeming more erratic. A Pr.oduct-moment CotTE'~lntion coefficient ~"as determined for each 23 100 100% r- 90% 90 ~ 80 67% 70 r--- 32% 1- 30 21% 20 15% 10% - 10 9% 9% U) ~ Cd -.-I s::! U 'r-! m .-i Q 0 H (JJ (lj .;:~ H 0 4.1 tf.) Ct.l Q Ct::U R.C. H rC +J :J H ~ .w "r'I <U U) 'M ....-1 H l.J C.L co .c Ul 'M 0 U) t'J 0 ..c! +.J 0 'M p.... ~. >. ,.0 (I) H tI) 'r~ jl .j.J p, ft1 ~ C) 'rl o~ j:xJ OJ (l) 'tJ OJ .j.J Non-Roman Catholic Religion -------- C) 'ro{ (~ fj ~ "r'I ~, N fJ tf) {J) tI) C) ...c: U ru }~ 1'1) ~Cl c:: 'U ~ to ill {j) ~~ aJ ill 0 OJ (.J 0 .-i < .j.J C) 'M .-i -.-4 r--1 r! C- .,-l >-. ~·l r.:: ::J u. A~ Q ... n1 (!J '0 0 H Q) J.~ 0 tI) 'M Po4A H ;:l Q) c:: 0 ...c: u :>. til p... Psychotic Non-psychotic Diagnosis Fig. 3. Distribution by type of religion and type of diagnosis among 31 psychiatric patients. 24 group between the scores on self-acceptance and acceptance of others (Berger, 1950). For Group I, the correlation between self-acceptance and acceptance of others on the first testing was .835 (df~ll, p~.Ol). When tes ted again, tv:a months later, the correlation was .820 (d~=II, p<.Ol). In Croup II, the correlation between the self-acceptance and acceptance of others on the first testing Has .589 (~f=18, p<.Ol). When the group was again tested, three months later, the correlation was .656 (d~=18, p< Cori·c:lat.Lorw .01). bct~lec.n ;::c()re~:; on 1-;elf·-n.cci:.ptance and acceptnnce of others indicate a significant relationship a t , .01 level of probability between self-acceptance and the acceptance one has for othe.rs. (1947, Su(.::h findings support ci. ted thcoretlcal premises offromm pr. 133-136), Fromm-Reichm~n (1959, pp. 7, 82), Rogers (1951, pp. 520-522), & Sullivan (1953, p. 308), and lend thesis of the investi~ator cre~ence to the hypo- regarding correlations between self- acceptance and acceptance of others. For both Groups I and II there was an increase in scores on self-acceptance and of others from the first to the second The mean inerease for Group I, measured tf'!!=iting. vlaS of others. With 11 pectivaly. ~~re t~-lO months after 10.0 points on self-acceptance and 11.6 for acceptance adrnittanc.e, cance. acceptanc~ de~rees of freedom, ! scores of 1.55 and 1.81, res- obtained which failed to rC3ch the .10 level of signifi- The improvement for Group I was not statistically significant. 25 For Group II, the increase in scores on self-acceptance and acceptance of others was 7.3 and 1 /... 7, respectively, when measured three months after admit tanee. \-lith 18 degrees of freedom, ! scores of 3.29 and 2.90 'vere obtained \olhich were significant at less than the .01 level. The improvement for Group II 'tvas statistically significant. Increased scores on self-acceptance and acceptance of others following a period of hospitalization are indicative of imoroved change in self concept, which at 3 months was statistically significant at the .01 level. The hypothesis made by the investigator "las supported for the 3 month period. Refer to Table 1. In order to determine if there were a relationship between age a.nit improv{.~ment in scores on self-acceptance and acceptGnce of others, the data for both groups were combined (N:,:3l). A correlatj.on, !, 'vas then determ:i.ned for all subj ects bctv1een age and improvement scores. The correlation bet"leen age and self-acceptance \-7as .42 was significant at less than the .02 level. (~.:i=29) which Thus, the older patients shO't-'1ed gn'!ater i.mprovement in self-accentance during the. t"'0 or. three months of hospitaliz2tion. of self. Age was a significant factor in acceptance Acceptance of others and age were nor correlated at a signifi- cant level. Hith 29 df, the obtnined correlation of .21 did not reach the .05 level of Significance. :t<1arital status '\<1as a significant factor related to :i.mprovement in scores on se1f--acceptance. Married persons sholved a mean improvement score of self-acceptance of 15.2 compared to a mean improvement score of 3.4 for single patients. The t score of 2.20 with 29 df reached a TABLE 1 ADMISS ION !-u.~D RETEST HEA"-~, STANDARD DEVIATION, A::'JD t SCORE FOR SELF-ACCEPTANCE AND ACCEPTANCE OF OTHERS-- Group I Self-accep IT .,. I.. S.D .. X lIst I 93.0B Other -t b 25.20 i2nd 1103.08[16.40 11.55 a b c X G:..-oup II Acc~ptance self-acceptanceT Other Acceptance Is. D~ .~- .835 114.58 29.04 126.17 18.9711.81 1.8201 S .. D. 93.16 14.18 105.48 13.36 I t. c I X 1-118.05 3.291 r S.D. 1r.' ra r 26.44 .5 :9 132.74[ 28.71 2.90 .656 1 1 Product-~oment correlation coefficient between SA and OA significant at .01 level. Not Significant. Significant at .01 level. N 0\ 27 significant level of .05. Acceptance of others was also higher for married persons with a mean improvement score of 22.8 as compared to a mean improvement score of 9. for single persons. The t score of 1.81 ~'Iarried with 29 dE did ,not reach the .05 level of significance. per- sons, as compared to single persons, showed significantly greater improvement in their self-concept after two or three months of hospitalization; however, there were no significant differences between single and marrie.d persons 1.n amount of improvement on scores relating to acceptance of others. In order to deternline if religion were a factor relating to improvement, the P[I.tiE:mts -':'Jerc dLv:i.ded into Catholic and non-Catholic. Comparisons were then made between the amount of acceptance and acceptance of others. improv~ment in sclf- Thf.:! 12 Catholics showed a mean improvement of 1... 5 and 1/+.0 on self-aceeptancf! and acceptance of others, respectively. of 10.8 and 15.2. The 19 non-·Cathollcs shOvTed a menn improvement The difference bet'tvcen Catholic and on self-acceptance ,,,as 6.29 which, with 29 .<..l~. did not reach the .05 level of significance. the difference of 1.26 vIas not ai8nificant non~·Catholic and a !. score of 1.10, On acceptance of others, (!:.= .16, df;:::29 , p> .05) . Sex was not a significant variable ralhting to self-acceptance and acceptnncc of others. Females appeared to shOtV' greater improvement in self-acceptance than males. 10.4. The mean improvement for females was The mean imnrovement for males was 5.2. The t score was .904 for self-acceptance which, with 29 degrees of freedom was not significant. Hales appeared to uhml gre.ater improvement in acceptance of others with 28 a mean of 16.8 compared to 13.5 for females. 29 degrees of freedom was not significant. TIle t score of .1.15 with Both males and females showed higher acceptance of others than acceptance of self; however, a significant level of probability was not reached on any score regarding sex. In order to determine if type of admission were a factor relating to improvem2nt, comparisons were made betvleen voluntary and involuntary admissions. For the 21 voluntary patients, the mean improvement scores on self-acceptance and acceptance of others was 6.38 and 12.19, respectively. For the 10 non-voluntary patients the mean improvement scores l.\'f;l'e 12.5 (l.ud 20.~ for sel£·-accf~nt;:\nc2 and accentance of others. The difference between voluntary and non-voluntary patients on selfacceptance was 6.12, vlhich, tvith 29 df and a t score of 1.02) was not significant. On acceptance of others, the difference of 8.00 was not significant (!..==.96, ..?f~29). Thus, type of admission was not related to improvement in scores on self-aeceptance or acceptance of others. Hedication was not significant relating to improvement on either self-acceptance or acceptance of others scores. Comparisons were made between those receiving medication and those not receiving medication. For the ll. patients rece i vlng medication, the mean improvement score on self-acceptance and acceptance of others 'vas 6.53 and 7.86, respectively. For the 17 patients not on medication the mean improve- ment was 9.94 and 20.47 for self-acceptance and acceptance of others. The. difference betlleen those on medication and those not on medication on self-acceptance was 3.51 which, with 29 df and a t score of .619 was 29 On acceptance of others the difference of 12.61 was not significant. not significant (!=1.66, df=29). In order to determine if psychosis were a factor relating to improvement, the subjects were divided into psychotic and non-psychotic groups. Comparisons between the amount of improvement in self- acceptance and acceptance of others for the two groups were made. 10 diagnosed as psychotic ShOHCd a mean improvement of 6.1 and 9.4 on self-acceptance anci acceptance of others, respectively. psychotics sho~7ed The a mean improvemen t of 9 .09 and 17.20. The 21 non- The dif ference between psychotics and non-psychotics on self-acceptance was 2.99, uhich ~'lith 29 df significance. ~,p.d a _~ scor;~ of .I~9, dld not reach the .05 level of The difference between psychotic and non-psychotic patients on acceptance of others was 7.79, which with 29 degrees of freedom and a ! score of 1.94, did not reach .05 level of significance. Summary of statistical data presented in the current study indicates a high correlation at less thun the .01 level of significance between scores on first and second testing for acceptance of self in both Group I (2-month retest) and Group II (3-month retest). Acceptance of others scores tvere significant at less than the .01 level in Group II but failed to reach the .05 level of Significance in Group I. Correlations between scores on self-acceptance and acceptance of others on first and second testing of Groups I and II all reached significant levels greater than .01. In both groups there was an increase in scores on self-acceptance and acceptance of others from the first to the second testing. 30 Increases in Group II scores obtained at 3 months were significantly increased at the .01 level. Increases in scores for Group I were not statistically significant. The 1. inear relationship between age and self--acceptance (!:.= .42, p< . 02) ~'las significant. Narr:ied p.:'ltients, as compared to single patients, showed significantly greater improvement in their selfconcept after two or three months' hospitalization. All other comparisons and data failed to reach a significant level of probability of at least .05. No correlations were computed regarding size of home community O~ ~ocio-cco~cmic class as tIle economic, rural population. cntir~ samnle repreRented 3 lower socio- CHAPTER IV DISCUSSION The present study was directed tm<lard determining if a relationship existed bAtWQen length of hospitalization and the patients' acceptance of self and others, which might have implications for psychiatric nursing intervention. The 13(~rgcr (1950) testing tool was demonstrated to have high internal consistency as a reliable tool when used with a sample populat:i.on of first admission pati~~nts to a state hospital. Data support the hynothe::;is that score Hould be increased from the first to the second , indicating an increased self-acceptance and acceptance of others following the 3 mondls hospitalization. Increases in scores over: n level. 2-~month period £ailC'd to reach a 81 f1.e.3nt Thi.s may b.c; related to th;; small number in the sample retested, or it may be that 2 months is too brief a for dJ.sc(~rnible changes to OCt:ur. Test-retest correlations fo'( both Group I (2-month retest and Group II (3-month retest) bet\.,(;~en scores on self--acceptance and accep·;. lance of others indicated a r01ationship significant at greater than .01 level of probability, vlith Croup I shm<ling somevlhat higher correlat:l.ons. Data supported the hypothesis made by the investigator and the theory cited in the study \vhich stated there is a positive correlation between self-accentance and acceptance of others. Ihe results are in 32 accord with Berger's findings which noted the two factors as highly related, using the SA and AO measurement instrument. TIle higher cor- relations over the 2-month period may be related to the larger percentage of psychotic patients found in Group I (42% compared to 26% in Croup II) rather than evidence of greater imnroved self-concept. One would expect the psychotic to show a greater loss of identity, to experience more difficulty in delineating self from others. Havener and Izard (1962) using the Berger tool noted no correlation between self-acceptance scores and self-satisfaction of paranoid schizophrenics WilD were noted to appear lacking in self- related positive affect. In the present study diagnoses was not found to be a significant factor. The method of grouping for type of diagnosis resulted in extremely small numbers of patients ;15 representative of anyone diagnostic category and they were included under psychotic or nonpsychotic hend:lngs. Schizophrenics coml1osed 90% of the psychotic group, and alcoholics 67% of the non-psychotic group. Further studies would be of interest to determine what effect a sample population containing a hi~l percentage of alcoholic patients might have on a study measuring self-concept. In Group II 53% were alcoholics. Any inferences regarding improved self-concept at 3 months would need to take into consideration the composition of Group II. There t1ere no significant relationships bct~'leen religion, sex, type of admission, medication, and improvement in scores on selfacceptance. and acceptance of others. Further studies with larger 33 samples are indicated before discounting the influence of these variables. The method of grouping for type of religion resulted in small numbers of patients as representative of anyone denomination with the except.i.on of Roman Catholics: ther(:!fore, all religious denominations were included under Catholic or non-Catholic headings. The correlation (~::: .42, p< .05) betl;,ecn age and self-acceptance, while not high, was po!.;itively correlated J indicating the older pati.ent ~"as more self-accepting. Acceptanee. of others and age were not correlated at a significant level. The range in age from 21 to 56 p cccluci;;;d study by Zuckerman, Bacr, and Monnshkin (1956) noted variables of sex, age and education l<1ere no t carrel ated significantly with self- accept.:ltlce and acccp t:tncc of oth0r:-i, "lldch tends to refute the nrcs\,;. . nt study regarding age, but support the Tucker, and Bromet (1 findin~s regarding sex. Harrow, found that older patients and married patients were hospitalized for a si~nificantly shorter period of time than younger single patients. }furried persons, as compared to single persons, showed a greater improvement in self-concept; however, no significance in acceptance of others was demons trated. Th(~ importance of marriage in maintaining self--concept duri.ng hospitalization affords an area for further investigation. Longitudinal studies might provide information as to the persistence of this difference bcttveen married and non-married patients over a longer period of hospitalizntion. 34 The study Has generally li-mited by the small sample. As has been noted equal distribution of age, religion, and type of diagnosis was not accomplished. Future studies should consider the possibility of using matched groups and random sampling. Circumstances precluded desired control over persons administering the test and an unnecessary number of patients ",ere lost to sampling due to lack of follow-through by one individual administering the testinr, instrument. Further studi (~S ,\....,here one person or the investigator adminiBtered each test ,·;roul d offer more control of this variable. The influence of the testing. situation on results arc questioned. Gencl:alJzation of findings should be gU3rdcd bccnuse of the small fwmple, and should be restricted to similar populnt:i.olls ar.ising from a lO'\v0r socio-economic, rural populati.on" The geographical characteristi.cs of the location of the Hyoming State Hospital should be taken into account. Consideration of the effect of hospitalization in one's home comtmnity versus the situation Hhere long distances separated the pntient from his home are areas for further investigation. Limitations of the study, recognized at the onset, are those inherent j.n any st.uuy \·Jhcrc [11'1 "exprcsscd lf concept is jnvcsti[;atcd. Consideration must be given to such influences as social desirability of a particular response, amount of circumspection in self-disclosure, unconscious influences and extraneous environmental influences. Loevinger & Ossorio (1958) noted "expressed" high self-regard may indicate a good adjustment, or denial of problems and self-rejection 35 more serious than those who admit to lor~ this caution in use of the Berger tool. self-regard. Dr. Berger adds Reference is made to his letter in Appendix B. Implications for psychiatric nursing intervention indicate the time of admission and the first two months after admission as a period where the psychiatric nurse could offer increased efforts to stabilize concepts the patient has regarding himself and others, his hospitalization, and his illness. Such efforts could facilitate the patient's becoming more accepting of himself and others, and more effective in the interpersonal situation. By bCCfl!'ling aequ;;lin~~ed vdth the r>at"5.ent and nrovirl:ln;:; n care- giving nurturing relationship, a common ground for trust, mutual understanding, and communication may be e:';tablished, \\Thich could facilitate an improved concept of self and oth8rs measurable at less than the 3-month period determined in the study. The PQtient may then be expected to move spontancoHGly tmvard a more responsible less dependent role (BrOvi'll & Fowler, 19116, 107-111). A key role of the psychiatric nurse would seem to be to act as a social catalyst to influence the social atmospllere of the hospital to provide for this progreision from dependent to independent behavior (Olson & Lubeck, 1966, pp. 314-318). Steinfeld (1970, pp. 37-53) noted that too frequently the hospital setting provides a pathological environment similar to that of the family in "t-,hich symptoms fi.r~3t devf:~loped, in its effort to facilitate rehabilitation. and as such it fails If a period of hospitali- zation results in increased self-acceptance and acceptance of others 36 as the scores measured at 3 months in the present study indicated, the role of the psychiatric nurse must sustain and encourage this increased move toward health by guarding against authoritarian non-therapeutic intervention by her or other staff members. aware of her role as participant observer. She must constantly be REFERENCES Abend, S., Kachalsky, H., & Greenberg, ll. Reaction of adolescents to short-tenn hospitalization. ~.!'~ri..:;an Journal PSz.<?hiatry., 1968, 12 /+, 949-954. Berger~ R~lation of ~xnreGsed self-ac~eptnnce to the expressed o-{}i'en5-:--Url-pUb-D~sl;e-(r-m:mu.scr-ipt , -·Univer·s~ity- E. 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Self-perceptions of neuropsychiatric patients on the W-A-Y test. Journal of Clinical Psychology, 1957, 13, 403l't06. ---.--.--.--~----.---.-.--.~---- ..-------" U. S. Departm8nt of Health Educ.ation) and \.Jelfnrc. Tmvarc1 a soe:tal Hashington: U. S. Government PrJntin-g -b-f[fce~T~i69-. tvolff, I. S. The educated heart. 6:3 (l}) 58-60. Hylie, R. C. 1961. _'£~~~..!~_~~2~~ept. American Journal of tlnrs Lincoln: Zuckerman, N., Baer, H., & Honashkin, I. and normals. Journal of Clinical 1963, University of Nebraska, Acceptance of self, parents 1956,12,327- 332. Zusman, J. Our expectations influence our patients. 1966) 17 (4) L.O-l~ 3. ~~)_~.ltn~t~:!~_SY Psych i3::E-~Y, Hospital and APPENDIX A ACCEPTANCE OF SELF AND OTHERS QUESTIONNAIRE TIlis is a study of some of your attitudes. Of course, there is no right anSvlcr for any statem,~nt. The best: a.ns,.\'cr is whp.t you feel is true of yourself. Please read each statement and circle the answer that best applies to you. 1 Not at all true of myself 2 3 Slightly true of myself About ha1f't'lay true of mys(!lf 4 Hostly true of myself 5 True of myself *Items of the self scale are labelled S, and those of the otllers scale are labelled O. '~7'<Items marked Hith two ast:(:!risks are worded negatively; item scores are reversed b2fore the scnle is scored. *Scale ~'o'(S 1 S '1 0 3 0 4 *1·0 5 *1<S 6 **S 7 **S 8 **S 9 **0 10 £. I'd like it if I could find someonc\\1ho would tell me hm... to solve my personal problems. I don't que~tlon my worth as a person, even if I think others do. r can be comfo~table with all varieties of people--from the highest to the Imvcst. I can become so absorbed in the work I'm doing that it doesn't bothnr me not to have any i.ntImate friends. I don't approve of spending time and energy in doing things for other people. I beli(~v.~ ill loold.ng to my family and myself !!lore and letting others shift for themselves. Hhen T)eoplc s.ay nice things about me, I find it difficult to believe they really mean it. I think maybe they're kiddin~ me or just aren't being sincere. If there is any criticism or anyone says anything about me, I just can't take it. I don't say much at social affairs because I'm afraid that people ~\1ill criticize me or laugh if I say the ;;<jrong thing. I realize that I'm not living very effectively but I just don't believe that I've got it in me to use my energies in better ways. I don't approve of doing fHvors for people. If you're too agreeable they'll take advantage of you. .41 S 11 **S 12 };~':S 13 **S 14 *i,S 15 **8 16 **S **S 17 18 I look on most of the feelings and impulses I have toward people as being quite natural and acceptable. Something inside me just vlon t t let me be satisfied with any job I've done--if it turns out well, I get a very smug feeling that this is beneath me, I shouldn't be satisfied with this, this isn't a fair test. I f('~:;l diffe:rc:n t fror:1 othc-c pr:onle. J:' d like to have the feeling of security that com~s from knowing I'm not too different from others. I'm afraid for people that I like to find out what I'm really like, for tear they I d be disappoi.nted in me. I am frequently bothered by feelings of inferiority. Because of other people, I haven't been able to achieve as much as I should have. I am quite shy and self-conscious in social situations. In order to get along and be liked, I tend to be what people expect me to be rather than anything else. 19 I 1l,-;ua ip:noce t.h(~ lishing some important end. S 20 *>;',0 21 I se.e!~ to have. a rcal inner strength in handl:tnr:, things. Ifm on a pretty Golid foundation and it makes rne pretty sure of myself. 'I'llC'!\!'S no ne.n3e in co:~'.pro:ni ~Jh2n people have values I don't like, I just don't care to have much to do with them. 7'c*O 22 The pet"son you marry l1kly not be. perfect, but I believe in tryioR to get him (or har) to chan~e along desirable lines. **0 23 I see no objection to stepping on other people's toes a little if itill help me what I want in life. *·'·S 2!.j **0 25 I feel self-con:,ciotls lv-hen I'ro with people vTho have a superior position to mine in business or at school. I try to get people to do ,.,hat I want them to do, in one '.Jay or. another. **0 26 I often tell people what they should do \Alhen they're hnving trouble in making a decision. **0 27 I enjoy myself most 'tvhen I'm alone, **S 28 I think I'm neurotic or something. o 29 I feel neither nbove nor belotv the people I meet. o 30 a~lay from other people. Sometimes peopJe misunderstand me when I try to keep them from making miG ta~(es thn t could have an important ef feet on their lives. 42 **S 31 Very often I don't try to be friendly with people because I think they won't like me. **0 32 There are very few times when I compliment people for their talents or jobs they've done. o 33 S 34 **s 35 **0 36 I enjoy doing little favors for people even if I dontt knO'tv them \·lCll. I feel ttla t I I m a person of '<lorth, on an equal plane '>1ith others. I can't avoid feeling guilty about the way I feel toward certain peoole in my life. I prefer to be alone rather than have close friendships with any of the people around me. S 37 I'm not nfr3id of meeting new people. I feel that I'm a and there t s no reaSOn \>1hy they should dislike me .. I sort of only half-believe in myself. I seldom worry about other people. I'm really pretty self- ~..~ortlHvhile pf!rSOn **S o 38 ''(*s 40 1,,\-S 41 S 1~2 **0 43 o 44 **5 45 **0 46 **0 1.7 39 I'm very sensitive.. People say things and I have a tendency to think thc.y'n-:! criti.cizing me or insulting me in Some way and Inter when I think of it, they may not have meant anything like that at all. I think I hrJc eel"tain abi.litie::-:: •.tnd other people say so too, but I \,JOnde.r if I'm no t gi viur, them an importance way beyond uhat they deserve. I feel con f i<lent thnt I (.;<:.Hl do something about the problems that may arise in the future. I believe that people should get credi t for their accom·· plishment:3, but I very seldom come across 'Hark that deserves p1'£1.18e. When someone asks for advice about some personal problem, 11m most likely to say, "It's up to you to decide," ri1ther than tell hi m \vhat he should do. I guess I put on a show to impress people. I know I'm not the person I pretend to be. I feel thnt for the most part one has to fight his way through life. That means that people who stand in the way will be hurt. I can f t help feeling superior (or inferior) to most of the people I knm17. S 48 I do not '{-lorry or condemn myself if other people pass judgment against me. 43 **0 49 o 50 **s 51 52 **S **S **0 53 **0 55 0 56 'I'd; 54 I don't hesitate to urge people to live ~y the same high set of values vlhich I have for myself. I can be friendly with people ,~ho do things which I consj.der '''rang. I don't feel very normal, but I want to feel normal. vrhen I'm in a group I usually don't say much for fear of saying the wrong thing. I have a tendency to sidestep my problems. If people arc ,,;reak and inefficient I'm inclined to take advnntage of them. I believe you must be strong to achieve your goals. I'm easily irritated by people who argue with mc. Hhen I 'm deali.nE~ uith yvunger persons, I expect them to do what I tell them. **0 57 **S 58 S 59 I don't see nruch point to doing things for others unless they can do you some good later on. Even when peoDle do think well of me, I feel sort of guil ty beCatiS8 I know I l:iUSt be fooling them --tiU'lt if I were really to be myself, they ,.,oulcIn' t think '''ell of me. I feel that: lim on the same level as other peopl.e and that helps to establish good relations wirh them. in working things out for himself, I like to tell him ,\That to do. I feel that people are aot to react differently to me than they \-]ould normally reac t to other people. I live too much by other people's standards. **S 61 **S 62 **8 63 When I have to address a group, I get self-conscious and have difficulty saying things well. **8 64 If I didn't 3 have such hard luck, I'd accomplish much more than. I have. 44 APPENDIX B CORRESPONDENCE University of Minnesota Office of the Dean of Students Student Counselin~ Bureau Minneapolis, Minnesota 55455 Friday November 15, 1968 Dear Mrs. Bradshaw: I'm sorry about the delay in responding to your letter. There's been a lot of painting of offices, moving from one office to another, plus it slipping my mind. H'::tt/':~n(~r & I;l~rrd di.n n ~-';lrwr on IIUIT'(('nlistic ScI f~·En.hnncem(~nt in Paranoid ;:)(:llizopiLn21tics,~! puoli~;ht.::d in JO:.1rn.al of Ct)n~:Jluting Psychology, 1962, V. 26, No.1, 6S-63--usinr; my scales, "SA" & nAO." '111Cy tweJ the scale~j in a way I like to sec them used--as a measure of 'i·;hllt subjects about their aceeptancc of self and ot:h:'~r~) (Y)h(~nor:'.~no 1. --,~::) t:ht~t one: needs not [H! coneprned about the subject's "real ll self-acceptance or '\>!hether it is a healthy, realintic self-acceptance I'athc~r than a defense, disturbed picture the subject is presenting. Therl?, is no internal check on validity such as the L or K scales of the you miRht find it difficult to say whether a patient "improved I; 'vi thout some such check. For example, a patient might actually have improved even though his score on self-acceptance decreasef3--this reflocting a change from an extremely high but defensive or disturbed self-picture to a more moderate, but more realistic self-acceptance. ~NPI--so has If you are interested in the phenomenological picture for certain patients under certain conditions, that is, using the scale scores to describe this, that would be fine--using the scales to find e}{r~~~S~~ SA & AO. You 1 rc vlelcOIm~ to write furthe.r if you have any questions or would want me to send you the scales and related material. E. M. Berger Associate Professor