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The effects of guided daydream experiences on level of self-esteem and depression in alcoholics

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The effects of guided daydream experiences on level of self-esteem and depression in alcoholics

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Content THE EFFECTS OF GUIDED DAYDREAM EXPERIENCES ON LEVEL OF SELF-ESTEEM AND DEPRESSION IN ALCOHOLICS by John William Hayden A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Education) August 19 82 UMI Number: DP24898 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Pu bl ish ing UMI DP24898 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 UNIVERSITY OF SOUTHERN CALIFORNIA TH E G RA DU ATE SC HO O L U N IV E R S IT Y PARK LOS A N G E LE S. C A L IF O R N IA 9 0 0 0 7 >83 This dissertation, written by John William Hayden under the direction of h.Diss er tat io n Com mittee, and approved by all its members, has been presented to and accepted by The Graduate School, in partial fulfillm ent of requirements of the degree of D O C T O R O F P H I L O S O P H Y Ms Dean TEE DISSE^ATION/CO Chairtnan ACKNOWLEDGEMENTS There are, of course, many people who have contributed help, encouragement, and challenge along the way to this long-sought accomplishment. I will try to recognize the principle ones. I am thankful to Professor Earl F. Carnes, my chair man, for his faith in me, his friendship, and his insist ence that I strive for the fullest measure of excellence within my reach. He has renewed my faith in the possibil ity of academic mentorship. Professors Donald Schrader and Milton Wolpin are to be thanked for their membership on my committee. Dr. Wolpin has contributed more than he knows to my desire to conduct sound and rigorous clinical research. I wish to thank Jim Conway of Pomona Valley Community Hospital and his staff, especially Percey Maynard and Marilyn Sachs, for their help and cooperation during the course of this study. Robert Kemp has contributed more than any other indi vidual to my phenomenological and personal understanding i i i of alcoholism. His courage, insight, loyalty, and friend ship have shown me that hope can be seized amidst even the greatest darkness. Paul Fairweather is my teacher, sponsor, therapist, and dearest friend. He has stood by me through the dark est times, and his belief in me has enabled me to believe in myself. Without him, this dissertation would probably never have been written. Darryl Freeland, my friend and associate, has also risked a great deal and has provided much encouragement along the arduous road to this accomplishment. Finally, I wish to thank my wife, Trudy, for her patience and endurance throughout the sometimes traumatic, always challenging process of completing my doctoral studies. ABSTRACT Alcoholism is discussed as an addictive process which has its roots and meaning in the imagination. Individuals who are embroiled in this and other addictive patterns are seen as having their inner symbolic structure organized around depriving, isolating and hopeless images which lead them to seek the fulfillment of their naturally interper sonal needs in a lonely, depersonalized way. Depression and low self-esteem commonly accompany the alcoholic pat tern, especially in individuals who present themselves for treatment. The purpose of this study was to investigate whether a series of positive imagery experiences would produce significant differences in levels of self-esteem and depression among a group of inpatient alcoholics, when compared with other patients who did not receive the visu alizations . Fifty patients in a hospital rehabilitation program were divided into two equal groups: (1) an experimental group which received a series of five Guided Daydreams, one per day, in addition to their regular regimen of group V therapy, educational lectures, and AA meetings; and (2) a control group which did not receive the Guided Daydreams but participated in the regular hospital program. All subjects were measured before and after five days of treat ment using the Rosenberg Self-Esteem Scale and the Zung Self-Rating Depression Scale. Two-month follow-up meas ures were also taken. The five Guided Daydreams were designed to provide subjects with an experience of good and positive images in a state of deep relaxation. The symbolic dimensions of ascent, descent, light, birth/ori gins, nurturance, and time were included in the daydreams. Results indicated that there were no significant dif ferences between groups on either of the posttreatment measures. It was suggested that a short, five-day period was not sufficient to indicate the effectiveness of what has been reported in the literature as a profound and far- reaching change in an individual's subjective experience of himself and the world. It may also be that the self esteem and depression measures utilized in this study were not sufficiently sensitive to measure the particular type of change produced by symbolic visualization. Suggestions for further research were offered which included a longer period of treatment and more subjective methods of measure ment . v i TABLE OF CONTENTS Page ACKNOWLEDGEMENTS .................... ii ABSTRACT............................................... iv Chapter I. INTRODUCTION................................. 1 Definitions ............... 2 Purpose of the S t u d y ........................ 10 II. REVIEW OF THE LITERATURE . . . 12 Personality Correlates of Alcoholism . . . 12 Alcoholism and Subjective Images ..... 20 The Importance of Imagery in Alcoholism Therapy . . .................. 24 A Note on Regression ...........33 Use of the Guided Daydream...............3 8 III. METHOD...................................... 49 Setting....................................... 49 Subjects ................................ 4 9 Research Design . 50 Procedure.....................................50 v i i Page Statistics......................... 54 Hypotheses ..... ............... 55 IV. RESULTS ....... 57 V. DISCUSSION AND RECOMMENDATIONS FOR FURTHER RESEARCH ............... 63 Recommendations for Further Research . . . 69 REFERENCES ........................................... 7 4 APPENDIXES ........................................... 83 A. IMAGERY RATING QUESTIONNAIRES . 84 B. GROUP THERAPY RESPONSE SHEET ........ 95 C. INSTRUCTIONS FOR RELAXATION AND GUIDED DAYDREAMS..........................9 8 D. ROSENBERG SELF-ESTEEM SCALE . . 108 E. ZUNG SELF-RATING DEPRESSION SCALE . 110 1 CHAPTER I INTRODUCTION Man's awareness of excessive drinking as a serious problem dates back to at least the dawn of history (Goodwin & Guze, 1979) . Alcoholism has been variously seen as a sign of a weak will, as a deep moral problem, evidence of poor character; and, increasingly in recent years, as a disease. With the advent of formal treat ment for alcoholism in the past few decades, there has been great interest in, and quite a proliferation of, various treatment modalities, and their relative effec tiveness is increasingly the subject of serious research. Since drinking problems are so common and widespread, and because the etiological inquiries concerning the disease are largely inferential, researchers in the field have been faced with the same kinds of limitations which face most early experimental enquiry into extremely com plex areas of human behavior. That is, many studies have focussed entirely on the definition of alcoholism it 2 self. There is also a large body of literature on the so- called alcoholic personality (Barnes, 1979). Each major school of psychotherapy has developed its particular approach to the treatment of alcoholism, and yet there are no definitive results which indicate that any one approach is superior to the others. Although there have been many studies concerning both self-esteem and depression in alcoholics, the rela tion of these personality variables to the internal image configurations in the individual's cognitive and affec tive structures has been largely ignored as a subject of inquiry. The purpose of this study was to approach these two areas of personality in an alcoholic population through a symbolic, imaginational experience designed to increase self-esteem and raise depression. It is self- evident that success in facilitating such emotional move ment would bring an individual into a position of far more strength and emotional health as he or she faces the rigors of achieving sobriety. Definitions The best definitions of alcoholism are those which limit themselves to rather strict behavioral and func tional considerations. The manifestations of alcoholism are so varied, and in many cases, so situation-specific, 3 that to venture beyond the most parsimonious definition is to risk loss of conceptual focus. McCord and McCord (1960) define an alcoholic as "...one whose repeated drinking of alcoholic beverages interfered with his in terpersonal relations or his social or economic func tioning" (p. 9). The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III, 1980), says: The essential feature of Alcohol Abuse (sic) is a pattern of pathological use for at least a month that causes impairment in social or occupational functioning due to alcohol. The essential features of Alcohol Dependence are either a pattern of path- ological alcohol use or impairment in social or occupational functioning due to alcohol, and either tolerance or withdrawal. Alcohol Dependence has also been called Alcoholism, (p. 169) One of the simplest definitions yet, was advanced by Goodwin and Guze (197 9): "Alcoholism is synonymous with problem drinking" (p. 118). The benefit of this last definition is that it en compasses any and all particular pathological drinking patterns. There is no one set of descriptions of drink ing patterns which can account for all forms of this illness. This diversity in drinking patterns explains ¥ the current emphasis on problems rather than a single set of symptoms, as the basis for diagnosing alcoholism. For the purposes of this study, a person was con sidered alcoholic if and when his or her drinking problem had reached such proportions that a hospitalization was necessary for detoxification and rehabilitation. All subjects in this study were inpatients in an alcoholic treatment facility, meaning at least that they were in serious difficulties socially (marriage, employment, etc.) and/or economically, and were alcohol-dependent. The dependent variables in this study were self esteem, as measured by the Rosenberg Self-Esteem Scale (196 5), and depression, as measured by the Zung Self- Rating Depression Scale. Rosenberg (1965) defines self-esteem as that condi tion in which the individual respects himself, considers himself worthy; he does not necessarily consider himself better than others, but he definitely does not con sider himself worse; he does not feel that he is the ultimate in perfection but, on the contrary, recognizes his limitations and expects to grow and improve. Low self-esteem, on the other hand, implies self rejection, self-dissatisfaction, self-contempt. The individual lacks respect for the self he ob serves. The self-picture is disagreeable, and he ' V.,* wishes it were otherwise. (p. 31) This scale was selected for its ease of administra tion, economy of time, and unidimensionality of the con- 5 struct. Robinson and Shaver (197 3) point out that since all the items revolve around liking and/or approving the self, the scale probably measures the self-acceptance aspect of self-esteem more than it does other factors. Kaplan and Pokorny (1969), in a factor analytic study using the Rosenberg Scale, found two uncorrelated factors: one they called "self-derogation", and the other appeared to them to reflect "a posture of conventional defense of individual worth..." (p. 425) Even if the Rosenberg Scale is not, as the author suggests, unidimensional, the items elicit responses from people regarding the kind of specific self-esteem and self-worth issues in which this study was interested. Wylie (1974) is complimentary toward this scale's straightforward and unitary approach to the measurement of self-esteem using a few items of seemingly homogeneous content, and she considers that "this scale deserves more research, development, and application." (p. 189) Depression can be regarded as an affect, which is a feeling tone of short duration; a mood, which is a state sustained over a longer period of time; an emotion, which is comprised of the feeling tones along with objective indications; or as a disorder, which has characteristic symptom clusters and complexes of signs and symptoms. The Zung Self-Rating Depression Scale (SDS) is intended to rate depression as a disorder. Its items seek infor mation along four basic parameters: pervasive affective disturbance; physiological disturbances (sleep disorder, weight loss, decreased sex drive, etc.); psychomotor dis turbances (agitation or retardation); and psychological disturbances such as confusion, emptiness, hopelessness, dissatisfaction, suicidial rumination. The instrument was developed for use in psychiatric research, but "readily lends itself to use in the general practice of medicine where most depressions-are first encountered" (Zung, 1974). It is an easily administered, short (20 items) , yet comprehensive measure of the chief symptoms of clinically-encountered depression. The independent variable in this study was a series of five Guided Daydreams. The Guided Daydream is an imagery technique which has been reported in European psychotherapy literature since Desoille in 1945 (Crampton, 1970) described his utilization of the technique in France. Since then the technique has been variously described by German (Leuner, 1969, 1978), Italian (Assa- gioli, 1965), Dutch (Van den Berg, 1962), and American (Crampton, 1965; Fairweather, 1981; Gerard, 1961; Schutz, 1965; Swartley, 1965) psychotherapists. While clinicians vary in their utilization and naming of the technique, they consistently agree that it is a "powerful means for 7 eliciting an intense experience of self." (Crampton, 1967, p. 22) The patient is asked to assume a comfortable position (sitting, which emphasizes that the will is important in the experience), and the Guide leads him through a muscle and breathing relaxation. The patient is then asked to imagine certain scenes and situations with as much vivid ness and clarity as possible. The patient's eyes are closed. The Guide emphasizes that no harm can come to the patient, and that the experience will be a helpful one. A single visualization takes about 20 to 30 minutes when administered in the manner used in this study.. The patient moves variously through such initial settings as the meadow, brook, mountain, house, ocean descent; more "advanced" images include encounter with relatives, the cave, a swamp motif, a volcano (Leuner, 1978). The Guide utilizes various "principles of management" (Leuner, 1966, p. 15) to aid the patient in overcoming barriers to on going fantasy events: confrontation, feeding, reconcil iation, magic fluids, exhausting, killing, and whatever other images the counselor considers helpful. After a single visualization session, patients commonly report a new, spontaneous awareness of the self as a living reality with previously unknown dimensions. WhiJe the content of the visualization lends itself to 8 symbolic interpretation and diagnosis, counselors observe at least three phenomena: 1. From within the person, the self is presented as an inner source of love, intelligence, wisdom, creativity, direction, and purpose. 2. The self becomes actualized and integrated as the counselor guides the person in experiencing expanded dimensions of presence, rising, de scending, and core depth. 3. The individual experiences deeply and symboli cally the inner capacity to overcome barriers to intrapsychic and personal mobility. Van den Berg (1962) beautifully described this process: Flying, swimming, and diving are made possible for us by a longing, never to be appeased, for the high and deep territories of our own exist ence. Where these territories become lost, swimming and flying become impossible... He who...in his reve evei1le overcomes his bar riers and learns to travel over and take posses sion of the territories beyond these barriers, so that to him all the regions of verticality are free and accessible again, will be able to move with equal freedom in his world of daily reality. (pp. 21-22) The present study drew largely, but with modifica tion, from imagery experiences suggested by Leuner (1978) and Assagioli (1965). Five Guided Daydream visualizations were administered to a group of patients hospitalized for alcoholic detoxification and rehabilitation. The series 9 consisted of the following scenes: (1) meadow, ascent of a mountain with the aid of a shepherd/good father figure, and light; (2). ocean descent with encounter with a sea monster, which was fought, subdued, and befriended; (3) birth regression; (4) ascent of mountain, and the exper ience of light entering the body and becoming concentrated at six major centers of energy; and (5) becoming a tree in the meadow and going through the time dimensions of a day, year, and lifetime, and concluding with the exper ience of death and rebirth. This particular sequence of GD1s was devised specifically with the goal of increasing self-esteem and reducing depression. Leuner (1978) reports several case histories wherein the GD was used successfully for the relief of chronic and acute depression. Singer (1974) stresses that the subjective experience of having control over one's own image production and the ability to produce and report on the images creates a "considerable positive affective situation in relation to ongoing fantasy" (pp. 219-220), and opens up the possibility for potent image transfor mation. It was expected that these two properties of guided imagery experiences would be useful interventions with an alcoholic population which is characterized, al most by definition, as having difficulty in the area of cognitive control and mood manipulation. 10 Purpose of the Study Although the use of imagery techniques has been wide spread in Europe for many years, it is only recently that imagery has begun to come back into its own in American psychology. The resurgence of the image which began, paradoxically, with the popularity of behavioral desensi tization methods (Holt, 1964), has sparked a very con siderable interest in the study and use of a broad variety of approaches to this basic element of human conscious ness. There are few reported studies of the use of imagery methods specifically with an alcoholic population. Frank (1979) used imagery techniques as a means of anxiety reduction in a group of chronic alcoholics and found that the experimental treatments significantly re duced the alcoholic's level of state-anxiety when compared to a no-treatment condition. Meshboum (197 8) found that image-focusing training was helpful to alcoholics by in creasing their ability to make good use of other thera peutic opportunities (group* therapy in particular) . To our knowledge, the use of a series of Guided Daydream visualizations with an alcoholic population has not been reported. This study represents the first known attempt' to assess the effectiveness of this particular method of imagery experience in alcoholics. Since the 11 imagination and stereotypical thought patterns are so important in any habitual, compulsive behavior pattern, intervention at the level of the imagination and the in troduction of an experience of image controllability carry with them great potential as a powerful means of interrupting and transforming what is a very deadly pat tern of thought and behavior. The questions addressed by this study were the following: 1. Will a series of five Guided Daydreams signifi cantly change the level of self-esteem as measured by the Rosenberg Self-Esteem Scale, in a group of inpatient alcoholics? 2. Will this change in self-esteem, if any, be found to be sustained two months after the ad ministration of the GD series? 3. Will a series of five Guided Daydreams signifi cantly change level of depression, as measured by the Zung Self-Rating Depression Scale, in a group of inpatient alcoholics? 4. Will this change in level of depression, if any, be found to be sustained two months after the administration of the GD series? 12 CHAPTER II REVIEW OF THE LITERATURE Personality Correlates of Alcoholism A major debate which has taken place over the years concerns whether an "alcoholic personality" does or does not exist. The extensive early study by McCord and Mc Cord (1960) utilized the mass of longitudinal data assem bled by the Cambridge-Somerville Project, and included analysis of information on 255 alcoholic and 255 matched control subjects. From family, educational, job, and marital history, McCord and McCord postulated an alcoholic personality characterized by low self-esteem, dependency, feelings of grandiosity, and aggressiveness. In ex ploring the background data on boys who later became alcoholics, they found the pre-alcoholics displayed fewer "abnormal fears" in childhood than did the normals. They also found no evidence of lack of self-confidence as a defining trait in pre-alcoholic boys. Why, then did 13 these traits appear when these boys reached adulthood? The authors postulated that, because most of these boys also suffered more from the lack of a clear masculine- identifying role model in their homes than did the nor mals, their pre-alcoholic personalities represented a possible over-reaction to suppressed inner feelings of intensified dependency. Perhaps, the authors reasoned, once the alcoholic disorder has set in, the individual's defenses collpase, and the traits of anxiety, dependency and fear of inferiority emerge. The aggressiveness of these men as pre—alcoholic boys might have been defensive posturing in denial of the fear and pain of their chaotic, conflict-ridden homes. This early study suffers from weaknesses inherent in the use of data previously gath ered for other purposes. The results actually amount to more of a psychologically-informed sociological descrip tion, than a true, controlled psychological inquiry. The logical connection between pre-alcoholic personality and alcoholic personality is, of necessity, inferential; and therefore, pretensions to established causality must be avoided. There are many others who have had similar backgrounds who do not become alcoholics. As a corre lational study, however, McCord and McCord's work points to a strong relationship between early family experience and alcoholism. 14 Every family study of alcoholism, regardless of country of origin, has shown much higher rates of alcohol ism among the relatives of alcholics than in the general population. According to a number of studies, about 25 percent of fathers and brothers of alcoholics are them selves alcoholics (Goodwin, 1971). Goodwin and Guze (1979) report a study by Dahlberg and Stenberg from Sweden in 1934 wherein it was found that in 25 percent of the alcoholics they studied, at least one of the parents was also an alcoholic. There has been extensive study of the question of hereditary transmission of a predis position toward alcoholism (Amark, 1951; Guze, Wolfgram, & McKinney, 1967; Winokur, Reich, Rimmer, & Pitts, 1970). There seems to be an excess of depression, criminality, sociopathy, and "abnormal personality" in the families of alcoholics. The literature is almost unanimous in its indications that alcoholism runs in families; but "...Whether the mode of familial transmission involves a genetic factor or is influenced by intrauterine or neo natal environmental factors remains after a century of studies and speculation, unknown." (Goodwin, 1971) The trait which united the various - types of alco holics described by Pollmer (1965) was that of an "enor mously high degree of free-floating anxiety about which they could do nothing for they did not know where it 15 came from." She found that alcoholics came from "happier" homes than the psychoneurotics in her study. She postu lated that they did not learn problem-solving behavior, or even problem recognition. Hence, the phenomenon of the alcoholic's legendary denial of his problem drinking was attributed to inadequate ability to assess and iden tify problems in general. In fact, many of her alcoholic subjects were not aware they had an emotional problem. Pollmer's study was largely conducted through structured interview with large numbers of subjects who had been classified as to IQ. Although the work lacked the rigor of controlled conditions, it offered many interesting questions which can be addressed- through more formal methods. In a very important review of 23 4 articles, Barnes (1979) concentrated his attention largely on empirical studies of alcoholism which employed psychometric instru ments as a means of assessing alcoholic personality traits. His purpose in conducting the review was to ascertain whether alcoholics as a group can be discrimi nated from non-alcoholics, other clinical groups, and other addicted groups on the basis of scores on person ality tests. Briefly, the survey indicates that elevated scores on several scales of the MMPI (Pd, D both were especially strong trends and Pt scales) discriminate _____ between alcoholics and other groups. The problem of intercorrelation of the MMPI scales was addressed by Spiegel, Hadley, and Hadley (1971) in a study which used multiple regression analysis. The results indicated that the Pd, Hs, and D scales of the MMPI were most discrim inating of alcoholics from normals. Our particular interest is in the prevalent indications of elevated D (depression) scale scores in an alcoholic population. Among the other tests surveyed by Barnes were the 16 PF, the Edwards Personal Preference Schedule, the Eysenck Personality Inventory, Rorschach studies, studies using the Thematic Apperception Test, figure-ground studies, and others. The author's conclusion points to the dis tinction between a pre-alcoholic personality and a clinical alcoholic personality. According to Barnes, alcoholics do present a fairly* common personality pattern when they present themselves for treatment. "This personality exists, no doubt, as a cumulative result of a prealcoholic personality and the effects of a person's drinking history in that per sonality pattern." (p. 622) Barnes' clinical alcoholic personality is characterized by neuroticism (chiefly anxiety and depression) and weak ego development, which is indicated by the following: lower ego strength, low frustration tolerance and impulsivity, hostility, shorter 17 future time extension, difficulty in establishing satis factory human relationships, sexual identity and role confusion, and a negative self-concept. This configura tion seems consistent with findings which link alcoholism with sociopathy (Goodwin & Guze, 1979)', in that many of the weak ego qualities which characterize the alcoholic population also describe sociopathic behavior. Williams (1974) presents the pre-alcoholic as one who is active, aggressive, impulsive, anti-social, thrill- seeking, restless; who has a seeming lack of concern for others combined with an extroverted, sociable nature. All of these qualities become less adaptive as the indi vidual moves into adulthood and are suggestive of even tual poor ego development in adulthood. Again, the similarities to the qualities of sociopathy are obvious. Williams (1974) points out that there are two major competing theories regarding the "alcoholic personality." The dependency theory asserts that the alcoholic has unmet dependency needs, and so becomes dependent on the use of a substance to assuage his anxiety (McCord & Mc Cord, 1960; Pollmer, 1965). Much of the data presented for substantiation of this theory is inferential in nature, because it represents a logical leap from seem ingly over-reactive aggressive behavior in pre-alcoholics and alcoholics, to an analysis of problem drinking as an 18 attempt to resolve dependency needs. Studies using the Rorschach Ink Blot test as a measure of oral-dependent imagery have provided only mixed results, and no strong conclusions may be drawn from them as regards alcoholic oral dependency or unresolved dependency needs (Barnes, 1979; Bertrand & Masling, 1969; Weiss & Masling, 1970). On the other hand, the "power theory", chiefly pro pounded by McClelland (1972), holds that the desire for power and the aggressive behavior of many alcoholics should be taken at face value. Although McClelland sees the concern for personal (as opposed to social) power as compensatory in nature, he believes that the consumption of alcohol is goal-oriented behavior. The problem drinker's self-report of the bolstering effect of alcohol should be seen in the context of his desire to feel personal power. That he feels the need to use alcohol in this manner and for this purpose is evidence of his own sense of poor ego strength. McClelland holds that the desire for personal power is an effect as well as a cause for problem drinking. In his investigations, he found that power fantasies tended to increase at high levels of consumption at cocktail parties. It might be that men with accentuated need for personalized power may receive direct gratification from thinking about triumph over others in fantasy. At any 19 rate, it seems that the burden of proof is on dependency theory to demonstrate why the aggression and activity found to characterize pre-alcoholic and alcoholic person alities should be interpreted as evidence for dependency, rather than be taken at face value as a need, albeit com pensatory in nature, for power. Opinion is still very much divided concerning the existence of an "alcoholic personality." Some say that there is enough evidence to venture a guarded assertion of such a personaltiy configuration (Barnes, 19 79; Wil liams, 1974). Others hold that we are no nearer a de finitive statement regarding the origins and causes of alcoholism than we are to a thorough understanding of any other psychiatric classification (Goodwin & Guze, 1979). What is clear is that an alcoholic individual who presents him- or herself for treatment is experiencing serious anxiety, depression, low self-esteem, poor future time extension, a degree of hopelessness, and many other of the aforementioned emotional and psychological disturb ances. Treatment, in order to be effective, must be in formed by an understanding of the alcoholic's personality configuration at the time of referral. One way of approaching this endeavor is to think of the patient's life condition in terms of the way it is experienced; i.e., his or her images of the self, of 20 possibilities, of the future, of problem resolution, and so on. Although the question of etiology cannot be de finitively answered, a clear understanding of the patient's presenting condition is of great help in de vising effective treatment modalities. .Whether or not depression, for instance, is a precursor to or a concom itant of alcoholism is not actually an issue which must be settled when one is considering the work of rehabili tation. Depression quite simply is present in most cases of serious alcohol abuse, and must be treated if the patient is to achieve a healthy sobriety. The presence of a poor self-concept and accompanying low self-esteem is a serious element in the alcoholic's experience of himself and must be dealt with and given therapeutic attention regardless of the sequential order of its ap pearance in the process of the development of the alco holic disorder. Both depression and self-esteem can be approached from an image point of view. Alcoholism and Subjective Images Alcoholism is an addictive process which has its roots and meaning in the imagination. Individuals who are embroiled in this pattern have their inner symbolic structure organized around depriving, isolating and hopeless images of themselves and of life which lead 21 them to seek the fulfillment of their naturally inter personal needs in a lonely, depersonalized and compulsive way. The experience of this complex emotional and moti vational problem, and the struggle to resolve and recover from this situation almost always involves periodic re mission and cyclical re-introduction of feelings under new and different circumstances (Brown, 197 7). That there are many serious emotional problems evidenced in the alcoholic presenting himself for treatment suggests that therapy is dealing with something more than a mere behavior problem. It is possible to conceive of problems in self esteem as having to do with self-perceptions; i.e., that the individual's images of himself are along certain self-defeating lines, and the interactions of images and behavior make for certain recurrent maladaptive patterns of living. If a model of a feed-back system between behavior and self-esteem is applied to this dimension, a person with low self-esteem can be expected to behave in ways consistent with such a self-concept and conse quently exhibit ineffective behavior (Charalampous, Ford, & Skinner, 1976). In a related manner, depression may be seen as the convergence of pessimistic images of the world and low self-esteem. Given such an image configuration in alco- 22 holies, it is not surprising to find them to be a popu lation which does not carry their thinking about their lives very far into the future (Imber, Miller, Faillace, & Liberman, 1971; Sattler, 1970). Roos and Albers (1965) found that alcoholics in their study took a short-range view of the future, saw the past as essentially gratifying, and the present as depressing. Smart (196 8) found that alcoholics displayed less coherence in their speculations about the future than even moderate social drinkers, even if their basic orientation was optimistic. It is quite possible that this lack of coherence concerning expectations about life, the presence of low self-image, and depression are behind the high levels of denial found in practically every alcoholicipopulation. Whitelock, Overall, and Patrick (1971) concluded that subjective discomfort and depression were more important factors in heavy drinking than was lack of impulse control in their group of state hospital inpatients. Gross and Alder (1970) also speak to the lack of coherence found.in alcoholics' images of their lives. Their test results suggest that the alcoholic's self perceptions are general and not specific to narrow phases of personaltiy and havior. They found that alcoholics rate themselves significantly lower on all scales of the Tennessee Self-Concept Scale than do nor- 23 mals, and framed a theory of alcoholic behavior deriving from low, poor, and derogatory self-concepts. Earlier, Vanderpool (1969) found his population of alcoholics scored substantially lower in self-concept on the Ten nessee Self-Concept Scale. Others who have reported similar findings on self-esteem/self-concept measures are: Connor (1962) , using the Gough Adjective Check List; Mindlin (1964), using a 137-item face validity- type questionnaire; Allen (1969), using the California Psychological inventory; and Clarke (1974) , using a Q- sort test. Possibly the best study to date is that of Berg (1974) in which, using the Chicago Q-Sort and the Gough Adjective List, he compared alcoholics with non alcoholics who were matched for neuroticism and extro version. Both measures indicated significantly lower self-image in the alcoholics. One of the confounding elements in these self esteem studies is that most of the alcoholics studied have referred themselves, or have been referred, for treatment. There is evidence that low self-esteem alco holics tend to’ submit to treatment far more readily than do alcoholics with higher self-esteem (Allen, 1969; Charalampous, et al., 1976; Mindlin, 1964). It may be that statements about low self-esteem should not be made about "alcoholics11, but should be restricted for the sake 24 of empirical accuracy to those seeking treatment. Chara- lampous, et al. (1976), in a study using the Rosenberg Self-Esteem Scale, noted that the low self-esteem levels of the "help seekers" was consistent with their premise that the behavior exhibited reflects not only self-esteem but also self-definition; i.<e., as a person who does or does not need help. An individual tends to behave in terms of his own image of himself. The Importance of Imagery in Alcoholism Therapy In any other case than a frank physical addiction to a substance, dependency is a psychological state, a set of learned behaviors as a response to a stressful situa tion. Recovery from the use of alcohol itself, in a medical sense, usually takes only a few days. After with drawal symptoms subside, treatment has two basic goals: (1) sobriety, and (2) amelioration of the psychiatric conditions associated with alcoholism (Goodwin & Guze, 1979) . Litman, Eiser, and Rawson (1977) hypothesize that relapse occurs as a result of interaction among (1) situ ations which are dangerous to the individual in that they may precipitate relapse, (2) the availability of "coping" strategies within the individual's repertoire to deal with these situations, and (3) the effectiveness and 25 appropriateness of these coping behaviors. The effective ness and approprateness of these behaviors may be atten uated or enhanced by the individual's self-perception and the degree of learned helplessness with which he views his situation. It is clear that the alcoholic pa tient would benefit from: (1) the enhancing of his aware ness of his own emotional states and the way in which they are related to the impulse toward drinking behavior; (2) increased focus on potentially "dangerous" situations, so that his vigilance could be increased; and (3) the poten tial increase in self-confidence and sense of control which often occurs as a result of increased self-defini tion.., All three of these goals may be effectively ap proached through the use of guided imagery experiences. The imaginational processes are at the forefront of recovery from alcoholism. If an individual cannot imagine what it would be to live soberly, the chances are that he will not achieve sobriety. Pollmer (1965) observed that many of her alcoholic subjects had been in their condition "for such a long time that their recol lection of living a normal life was almost non-existent" (p. 133). This was seen as one of the main causes for un successful treatment. It follows that depression and loss of hope would attend the image of an alcoholic con dition which was viewed as unchangeable. 26 Segal (1971) conducted a series of studies on per ception and imagery which suggest that these two processes share common brain pathways. Subjects were asked to imagine a certain object as if it were projected onto a blank screen in front of them. They were scarcely able to perceive when an actual picture of that object was being projected because the images produced by their imaginations were so vivid. This type of investigation suggests that, even at an organic level the perception/ encoding processes of the brain the old adage rings true: "It is all in how you see it." If perceptual and imaginal processes are this closely related, it is clear that a person's view of the world strongly influences his experience of it. The self-fulfilling nature of an indi vidual's expectations concerning the effects of his drink ing behavior is an especially strong element in alcoholic experience. Marlatt and Rohsenow (19 80) report a series of studies using a double-blind balanced placebo design in which subjects were observed for various behaviors under conditions where: (1) they thought they were drinking alcohol and actually were; (2) they thought they were drinking alcohol and were actually drinking tonic water; (3) they thought they were drinking tonic water and were actually drinking alcohol; and (4) they thought they were 27 drinking tonic water and actually were. Pilot testing re vealed that subjects could tell a mixture of one part vodka to five parts tonic water with no more than 50 per cent, or chance, accuracy. It was found that men who be lieve they have been drinking alcohol become less anxious in social situations even when it is tonic water that they have been drinking. Women, on the other hand, be come more anxious a finding attributed to the power of social convention regarding women who drink. Some of the effects on alcoholics were especially striking. Since all subjects were required to. abstain from alcohol eight hours prior to testing, alcoholic subjects sometimes arrived with the "shakes" and reported craving alcohol. After the drinking session, one man began acting in an intoxicated manner, stumbling around the room and making sexual advances toward a female experimenter and his drink had adtually been tonic water. Several other men in the expect-tonic/receive-vodka group still showed tremor and described a strong desire for alcohol, even after consuming the equivalent of double vodkas. The results of these studies throw the understanding of alco holism as a physical addiction into some question. But more importantly, for our discussion, they point out the power of images and expectations in the establishment of habitual or even occasional behavior patterns. 28 Ofman's (1976) discussion of the individual's "project" in the world may be seen in this light, as well. In the existentialist view, man freely creates his view of himself in the world and chooses, for his own good reasons, to see things the way he does. The alco holic's project clearly has severely negative conse quences, and it is a major object of rehabilitation to assist him or her in seeing the project and its various configurations and ramifications clearly. The therapeu tic intervention has to do with challenging the hereto fore self-evident nature of the individual1s images of his own reality, and inducing in him the awareness of his ability to change his perceptions by bringing his image structures into awareness. Singer (1976) reported that alcohol users in his study tended to be externalizers, rather than individuals who had a well-developed inner world of imagination. Alcohol users were more subject than nonusers to bore dom and mind-wandering, and their fantasies, though in frequent, tended to be fleeting and undeveloped. Those who said that they drank beer in hot weather, for in stance, or just to have fun, tended to have aggressive or sexual daydreams. Those who said they used alcohol to forget their problems, or because of sadness or loneli ness, also reported that their inner lives lacked con 29 trol and that their minds wandered. Their daydreams returned often to fantasies of fear and failure. It is reasonable to think that these kinds Of people would bene fit from a therapy oriented to the restructuring and strengthening of their inner image constellations. Segal, Huba, and Singer (1980) report a very ex tensive research project on the patterns of substance use in a large, national college population. They em ployed multivariate analysis techniques to analyze data gathered through interview, personality tests, and the use of the Imaginal Processes Inventory. Among their findings, they report four major correlational configu rations of motivational patterns found in those who use alcohol. (1) Alcohol serves as an essential part of social activities and is highly correlated with disin- hibitory sensation seeking this form of drinking is a means of "letting go" of reality and constraints. (2) Alcohol is used when feeling under pressure, when having problems and feeling lonely or sad, because one just feels like having a drink when there is nothing else to do, because of feelings of not getting ahead, and be cause it makes one feel better, relaxed, happier, and forget problems. "This constellation of correlations is indicative of a pattern of using alcohol to overcome frustration in a world that is not all that one fanta- 30 sizes it to be" (p. 157). (3) Alcohol is used when an individual is having problems and feeling mad, sad, or lonely. It is ingested because it makes one forget problems and feel better. Alcohol use along these di mensions is meant to reduce negative affect. "Reported inner experiences are generally dysphoric and alcohol use is perceived as a means of reducing such negative affec tive experiences and expectations in the ongoing thought processes" (p. 158) . (4) Alcohol is consumed due to a general personality style that is highly susceptible to group pressure tp conform. The significance of Segal, Huba, and Singer's studies is that they attempt to enter the "private per sonality" of the alcohol user. The processes of the imagination are explored, and new dimensions are added to the study of intrapsychic motivation as it is related to both the inner and outer world of the alcoholic person. "The relationships demonstrated in different analyses would appear to indicate that overall private personality or 'coping style' of the individual is intimately related to the individual's perceptions (sic) of her or his own substance use" (p. 167). This statement is in congruence with the studies of Marlatt and Rohsenow (1980). It is the imaginal and perceptual and subjective elements of personal experience that imagery techniques 31 address and with which they intersect. Indeed, the en tire monumental struggle involved in dealing with alcohol addiction is carried on primarily in the arena of inner motivation and attempts to cope with the exigencies of life. The use of visual image experiences has several advantages: (1) the preliminary relaxation exercises reduce the individual's defensiveness; (2) visual imag ination provides more direct access to the subject's affective processes than does rational/verbal input (Samuels & Samuels, 1975); (3) a visual experience may be more quickly and easily recalled, and may thus be more immediately effective in the face of impulsive temp tation to drink during recovery, than purely conceptual and verbal therapeutic interventions. "Visual imagery, when readily generated may be more effective than verbal mediation because the information in the image is spa tially organized permitting a rapid read-out of the relevant components..." (Paivio, 1971, p. 391) One particularly graphic and concrete use of imagery techniques with the alcoholic population was used by Cautela (1966, 1967). He developed a large number of scenes which link the images of alcohol consumption with nausea and other ghastly consequences. The individual is asked to imagine with as much affect and detail as possible a horrible, nauseating situation of which 32 drinking is the central component, with a view to the possibility that he will, through classical conditioning, link the image of alcohol with a graphic image of aver- sive consequences. Quite successful results have been reported (Anant, 1967; Donner, 1968), but the myriad other environmental influences which affect alcohol con sumption must also be taken into account when dealing with drinking behavior as a component of an individual's personality. In his di'scussion of some of the more symbolic modes of imagery technique, Singer (1974) stated that their effectiveness depends on the fact that the patient can discriminate more clearly his own ongoing fantasy pro cesses. Out of this, he becomes more aware of imagery situations he has avoided, is encouraged in a variety of fashions to engage in covert rehearsal of alternatives; and, hopefully, he becomes less afraid to make overt approaches to these situations. Singer went on to say that an increase in a generally positive affective state is associated with these imagery activities. "The nov elty of the fantasy activity, the sense of mastery of difficulty situations, the joy of recognition when sym bolic material can be translated into recognizable current interpersonal dilemmas all of these lead to increased positive affect and a sense of self-control." 33 A Note on Regression For years, theorists informed by psychoanalytic thought have regarded excessive drinking as a regressive behavior. It has been seen as evidence of a regression to the oral incorporative mode of libidinal gratifica tion. In a rather traditional statement of this position, Erikson (196 3) said: Addicts...depend, as the baby once did, on the in corporation by mouth or skin of substances which make them feel both physically satiated and emotion ally restored. But they are not aware that they yearn to be babies again. Only as they whine and boast and challenge are their disappointed and babyish souls revealed. (p. 212) This sort of literalistic statement of the basic Freud ian understanding of regression as a destructive desire to return to a more primitive means of coping with con flict has never been substantiated by research. Studies have been performed using Rorschach oral imagery re sponses which indicate "oral dependency," to demonstrate that this particular element of alcoholic experience is linked to unresolved dependency needs. As mentioned be fore, the results of these studies have proven inconclu sive (Ackerman, 1971; Barnes, 1979; Bertrand & Masling, 1969; Weiss & Masling, 1970; Wiener, 1956). The basis of Freud's understanding of regression was a sort of suspicion regarding its usefulness and respect ability as a coping mechanism. He tended to link it with 34 the death instinct, and saw it as a childish and neurotic retreat from facing life and its stresses in a mature and rational manner* Kris, one of the so-called "ego psychol ogists" in the psychoanalytic school, found in his clini-* cal experience that this denigration of regressive pro cesses did not explain enough^ about the behavior. He discussed a "regression in the service of the ego" (Kris, 1951). By this, Kris meant that a person may have to abandon his customary controls and regress temporarily to earlier stages of development in order to rebuild a new solution to an old problem. Although regression is still seen in Kris' position as a defensive and conservative reaction to suffering, he does not postulate that the individual wishes to remain in that position out of a basic desire not to face life; but that it is used as a sort of springboard for further development. Following Kris' lead, Erikson (1968) developed a position regarding regression in which he respected it as an attempt at existential integrity: I would call it the "rock-bottom attitude." This consists of the patient's quasideliberate surrender to the pull of regression and the only firm foun dation for a renewed progression. The assumption of such a deliberate search for the "base line" seems to carry Ernst Kris's "regression in the ser vice of the ego" to a dangerous extreme. But the fact that the recovery of our patients sometimes coincides with the discovery of previously hidden artistic gifts suggests further study of this very point. (pp. 212-213) 35 In Young Man Luther (1958), Erikson calls this rock-bot tom attitude "...an attempt to find that immutable bed rock on which the struggle for a new existence can safely begin and be assured of a future" (p. 103). The danger of regressive behavior for Erikson is, of course, that the individual may reach "rock-bottom" and stay there, forever lost to productive and happy life. Although Erikson eloquently admits and discusses the creative, pro gressive potential of regression, he clearly regards it as an undesirable and precarious necessity in a few cases. His vagueness about what is "rock-bottom" betrays his psychoanalytic distrust of what are regarded as the dark, dangerous instinctual forces of the id. Fairweather's (1981) understanding of regression rep resents a major departure from traditional theories. For him, "rock-bottom" is not a place of darkness, but light; not one of foreboding, but of hope and life. He inter prets regressive behavior as an "abortive attempt of the individual to relate self to the ground of Being" (p. 44). The process of dealing with trauma by a reversion to the safety and Security of an earlier mode of functioning is, in Fairweather's system, to be seen as "merely a small element of a much larger process, the process of symbolic regression" (p. 42). Symbolic regression is the process of bringing one's 36 personal and primordial history directly to bear upon his present experience. This is the process by which the individual relates himself to the promise of his birth by gaining access to the enduring cosmic and organic dimensions of his being. Symbolic regression, is not for the most part a conscious psychic func tion. However, it can work at the level of dream, myth, meditation, or certain imaginative states. It is the act of creating and investing symbols with psychic energy so that they mediate and express the full range of the relationship between self and Being. (pp. 42-43) In this light, regressive behavior is seen as an attempt at resolving inner and outer conflict and stress, as well as (at least, at times) a retreat from such reso lution. The telic dimensions of maladaptive, pathological behavior are seen in the light of a natural movement to ward a desired inward state of harmony, peacefulness, and wholeness. When drinking behavior is viewed in this way, Segal, Huba, and Singer's (19 80) findings can be inter preted in a more symbolic light. Drinking for the purpose of releasing interpersonal inhibition is also a guest for social and interpersonal spontaneity. Use of alcohol to "overcome frustration in a world that is not all that one fantasizes it to be" (p. 157) evidences a possible desire and wish for a world of harmony and where it is not so difficult to realize one's goals. Overcoming dysphoric and guilty fantasy and rumination through drinking alco hol is indication of the individual's natural desire to feel happy and legitimate in the world. Drinking as a conformity to group pressure may be perceived in terms of 37 the individual's desire for acceptance. Although exces sive drinking behavior is ultimately self-destructive, it should also be understood as an attempt to achieve certain states of being which are almost universally sought by human beings. It is the primary means used by an alco holic to reach these ends which proves ultimately abortive. Fairweather1s concept of symbolic regression describes a universal human activity in which individuals attempt to heal "the discrepancy between self and Being..." (p. 43) The loss of the capacity symbolically to regress results in regressive behavior. One of the major tools available to the therapist in facilitating the rediscovery of the capacity of symbolic regression, according to Fairweather, is the Guided Daydream. In the Guided Daydream, the individual is given the opportunity to experience states of inner harmony, free "fixated" energies, and regain a lost sense of the great powers of the human imagination. Through this kind of imaginal experience, the trapped energies of the inner child are freed, and the person is helped to begin learning to "relate to the self through experiencing a realm of images more congenial to the development of consciousness" (p. 55). 38 Use of the Guided Daydream The Guided Daydream is a technique which utilizes the type sof symbolic content which is more typical of the European style of psychotherapeutic imagery methods. The images utilized are much more symbolic and less concrete than those used in various forms of covert sensitization and desensitization techniques. Clinical descriptions of the GD emphasize that the technique can be effectively used by counselors of varying theoretical persuations. The counselor can, in describing the self, self-awareness, or self-actualization, use the term ."levels of awareness" as a common term in dialogue between such various schools as the psychoanalytically-oriented which describes "un conscious material", the learning theories which speak of deconditioning and retraining behavior, or the existen tialists who speak of responding and choosing with the whole self. Writers who describe work with the GD tend to use the terms "unconscious" and "conscious", but they do not see unconscious material as inaccessible; rather, they tend to view it as the inner core of which conscious ness is the perimeter. The use of the GD with alcoholics carries with it many advantages. Many such individuals have for years suppressed the use of their imaginations in the face of 39 stress, difficult emotions, social pressure and family pressure, through the use of alcohol as their chief means of coping. The compulsive, repetitious pattern of alco hol consumption has made the presence of other options less imaginable, damaged the individual's sense of hope and adequacy, and rendered his self-image and self-aware ness extremely vague and generalized at best. The clari fication of one's inner images, the discipline of explicit attention to the workings of the imagination, the experi ence of strong affect in response to the products of the mind's eye all of these should ostensibly give defini tion and a renewed sense of awareness of the personal condition of the alcoholic which will be helpful to him or her in the restructuring of life after alcohol. Gerard, a clinician within the psychosynthesis school, utilizes the GD for the realization of one's true self the discovery of the "unifying center" which is a "point of pure self-awareness" (Gerard, 1961). He uses the GD to help the client identify himself with his true self and to disassociate himself from his non-self. The use of the GD reveals, for Gerard, the self as a spiritual center that is sometimes revealed when imagining. Clinical experience with the GD has led Assagioli (1965) to utilize the term psychosynthesis as a way for the client to experience an "opening up" or "clearing 40 out", resulting in an integration of all aspects of the self. The physical manifestations of this are a variety of emotional responses including crying, tension, fear, laughter, elation, and relaxation (Schutz, 196 5). Gerard (1961) believes in using the GD as a means of transforming bound energies into productive and creative energies. "Inasmuch as symbols can express not only in fantile and primitive wishes but also unrealized potenti alities for growth, symbolic visualization may serve to evoke inner wisdom and inspiration as well as ethical, humanitarian and altruistic values" (p. 5). Desoille (1965) maintains that utilization of the GD is an educative process aimed at (1) identifying and ex periencing habit patterns and (2) exploring emotional po tentialities. He sees the GD process as a reconstruction involving two stages: (1) the client moves toward emo tional maturity, psychic growth and expansion of experi enced feelings? and (2) the client acknowledges life as it is with an integrated perspective. Desoille encourages the client to participate actively in the understanding and assimilation of his own images by attempting to recollect as much of the detail that occurs during the session as is possible. Leuner (1978) has developed by far the most system atic and rigorous and replicable approach to the use of 41 the GD. He emphasizes that the initial relaxation exer cises bring the individual to a regressive level of ex perience that can "give spontaneous rise to optical phe nomena of an imaginative nature" (p. 126). As the person becomes fully involved in the suggested fantasy experience, he or she becomes very strongly emotionally involved, and the feelings correspond to the content of the daydream. The major hypothesis upon which Leuner's work is based is this: "Certain dramatic activity or reactions during the fantasy that are characteristic of the primary process in dreams... can be used for direct intervention in the un conscious dynamics and thereby also for rapid changes in behavior, without having to address them verbally or even interpret them" (p. 143). Earlier, Leuner (1969, p. 6) presented six techniques for guiding and managing imagery in the GD: 1. Inner psychic pacemaker: ask the client to be guided by one of his own benign symbolic figures. 2. Confrontation: the client faces the feared or threatening object; the counselor tells the client to hold his ground, suppress his anxiety, stare the beast down, etc. 3. Feeding: as in confrontation, the client stays put, and controls the feared giant, etc., by feeding him into fullness and subsequent sleep. 4. Reconciliation: the client makes amends with the aversive figure by addressing and touching the figure in tenderness. The figure usually repre sents a part of the client himself, often the introjected parent, and therefore, reconciliation 42 with the figure means assimilating the introject that has split off and been projected. 5. Exhausting and killing: a discussion is initi ated around the nature of the threatening figure— ascertaining if the figure is a peripheral de rivative of an introject or the introject it self underscoring the need for caution in utilizing this technique, for it may be experi enced by the client as an attack against himself. 6. Magic fluids: a brook, spring, or ocean become the vehicle for experiencing the flow of psychic energy. While the management of imagery during a GD which is administered on an individual basis is more of a sponta neous process, this study utilized the GD administered to groups. Therefore, imagery management was built into the GD's as they were designed for presentation. The element of directional movement in the GD is of extreme importance. Desoille (1965) sees the GD as a symbolic mode of expression that provides the client with the greatest possible freedom of expression, because while describing his image in conventional language, he is un aware of its meaning, and he therefore has no need to control the expression of feelings that he is experiencing in the GD. A basic law of directional movement in the GD is that of symbolic ascent and descent (Desoille, 1965). Ascension, difficult for some, is often accompa nied by a luminous feeling that expresses a sense of calm, serenity, and joy. Descent, on the other hand, often c' __ evokes somber images that are unpleasant and distressing. Van den Berg (1962) defined the high as the symbol of un fettered realization, of future, of what may be possible, of choice,' of acceptance of what is new, etc. The low is the symbol of hampering restraint, of past, of being con fined or retained, of isolation of all contact and longing; but also of yielding to another longing, that of one's heart. Thus, Van den Berg (1962) added an additional dimension to depth that is positive—“ --that of yielding to one's deepest longings. Van den Berg (1962) points out that psychically sound persons can usually be invoked!; to ascend to the heights and descend to the depths quite easily. Neurot ics nearly always encounter barriers, and it is these barriers which are representative of the blocks to the free flow of emotional energies. He reports that after a barrier has been passed, the client experiences euphoric and energizing rest; purification has occurred, the body is rejuvenated, the spirits are improved, and the person in the dream has better clothes. Crampton (.1965) posits that movement inward as opposed to movement upward or downward in imaginary 0^0:3 space is symbolic of touching and experiencing one's own inner light. She also notes that the experiencing of one's deep fears and conflicts is in itself a sign of 44 progress. Hammer (1967) compiled a long list of GD symbolic directional movements: up, down, front, back, left, right, are of symbolic and therapeutic value in confronting intra- psychically hidden depths and highest capacities, ambitions and potentialities of intrapsychic functioning. Travel ing front or back will provide contact with the pa tient 1s hopes and expectations for the future... Going left or right also provides confrontation with images that symbolize acceptable and unacceptable aspects of the self. (p. 174) The function of the GD, then is to facilitate an ex pansion of retarded imaginative processes. As Gerard (196 4) states, "In many of us, imagination is either un developed or uncontrolled. If it is undevelopied, the per son when asked to visualize often cannot see anything, for everything has to be intellectualized and cannot be experienced directly in the world of images" (p. 9). Fairweather and Wright (196 7) add that "in dreams and visualizations the individual taps creative resources and integrative powers which he must resist and test on the conscious level before he can trust in that which he has always trained himself to doubt" (p. 84). Although the majority of the literature on the Guided Daydream has to do with visualizations administered on an individual basis, there are indications that it is also an effective technique when used in a group setting. 45 In his book, Joy, Schutz (1965) gives many examples of guided imagery used in groups. The application of the technique is somewhat haphazard in his examples, and is very much at the whim of the therapist or often of the group itself without a leader. But it is clear that the fantasy experiences shared by members are very facili- tative in the development of group cohesion, and they appear to evoke powerful emotional responses. Hershey and Kearns (1979) demonstrated that group- administered guided-daydreams significantly improved the scores of their intermediate-school-aged children on the Torrance Tests of Creative Thinking Ability. They did not report the content of the eight GD's, because they wished merely to demonstrate that the activity of facilitated fantasy was sufficient stimulation to improve the fluency, flexibility, and originality of their students' thinking ability. Scheidler (19 72) introduced guided imagery into a treatment program with mixed-sex groups of 10- and 12- year-olds. Children in both groups had unhappy family histories with considerable rejection or family breakup, and had exhibited to some extent a penchant for predelin quent behavior. The advantage offered by fantasy experi ence for the expression of conflict in symbolic terms, enabled the children to reveal and deal with their serious . 46 areas of difficulty within a short seven-session time per", riod. There were many reports from significant others in the children's lives of tangible and observable improve ments in their behavior and attitudes. Freeland (1982) developed a group therapy model using Guided Daydreams with boys from ages six to twelve. Fol lowing a theoretical rationale based on Fairweather's (1981) work, he postulated that the boys could become more related to the ground of their being through symbolic visualization; and therein could experience a more natural relation to authority and could experience themselves more fully in their organic, personal and cosmic dimensions. The age of the children made it possible for them to have easier access to their archetypal images than is commonly found in older clients. Out of a belief in the goodness and health of any person's deepest natural images, he hypothesized that visualization would bring about the identification of the self with good child images, in which the constellation of the Good Father/Good Mother/ Good Child would emerge. He developed a unique method in which image content was reported aloud by each boy during the visualization. By the second session, the boys began integrating one another's image content into their own GD's. They spon taneously introduced safety and nurturance content after 47 only a few visualizations. Soon, actual encounter among group members developed, including talk about family and peer relationships, daydreams, and fantasies. Behavioral observations, and favorable reports by parents and other significant others indicated that this method was success ful in altering and facilitating resolution of the con siderable authority conflicts with which the boys had been presented for therapy. Leuner himself has presided over studies using his technique in group settings. Singer (197 4) reports studies by Nerenz (1965, 1969), a student of Leuner, wherein Nerenz employed systematically varied classical music se lections as background for generating imagery in both individual and group-therapy sessions with heterogeneous neurotic patient samples. Also reported by Singer (19 74) was a study by another student of Leuner*s. Plaum (19 6 8) also utilized music to facilitate the generation of imagery in a group setting. Tests administered both before and after guided affective imagery provided psychometric indi cations of improvement on measures of rigidity, extrover sion, neuroticism, and anxiety. Although these studies lacked some important controls that could pin the positive response down specifically to the interaction of the music and guided imagery, they pointed to the possibilities for further evaluative research into the problem. They also 48 formally opened the investigation of the use of Leuner1s Guided Affective Imagery in groups. Although the inter active process between client and therapist is different when the GD is used in a group setting, the symbolic proc ess which is activated and addressed within the client is the same. Nerenz's studies indicate that whatever super ficial images may first be elicited by the combination of the music and the GD, there is consistent evidence that the images produced eventually move in the direction of profound "catathymic" imagery. "Personal, profound con flict situations emerged in various symbolic forms, and the unfolding sequences of imagery stimulated...were therapeutically significant" (Singer, 1974, p. 87). 49 CHAPTER III METHOD Setting The study was conducted at the Pomona Valley Commu nity Hospital's Alcohol Treatment Service, an inpatient rehabilitation program for the treatment of alcoholism. The program combines medical detoxification and treatment of ancillary medical problems attendant upon abuse of al cohol, with a rehabilitation program made up of the\fol lowing elements: educational lectures, films and tapes, attendance at Alcoholics Anonymous, structured group aware ness building exercises of various kinds, and group psycho therapy. Patients are normally required to stay 2 8 days to complete the full program. Subjects Subjects were all patients receiving treatment for alcoholism. With few exceptions, these people were self- ref erred and not present under duress (e.g., court-ordered diversion, etc.). Fifty (50) subjects were used, 25 in the experimental group and 25 in the control group. Pa tients in the study ranged in age from 18 to 68 years. They were drawn largely from the Pomona and San Gabriel Valleys. Research Design Since it was quite impossible to achieve randomiza tion of subjects in the setting where the study was per formed, a quasi-experimental, non-equivalent control group design was utilized (Campbell & Stanley, 1963). The groups were exactly similar in the method of recruitment, and with the exception of the experimental treatment it self, the regimen of treatment experiencedC:by both groups was as identical in format as possible. Procedure The experimental group consisted of all patients in the hospital at one time, and they were informed that the first week of every month is the regular week in which visualization group is held. They were not aware of the ; presence of a control group in the study. Each evening, Monday through Friday, members of the experimental group underwent a Guided Daydream experience. The series of five visualizations followed a sequence of themes or 51 scenes: meadow/mountain, descent into the ocean, birth regression, light, and tree. At other sessions during the week, subjects participated in the regular schedule of group exercises, educational lectures, films, and Alco holics Anonymous meetings. Rationale for the use of these particular visualiza tions follows. (1) The ascent of the mountain involves the experience of overcoming major obstacles, the utiliza tion of ascendant energies as opposed to the depressive strategies of many of these patients. The introduction of a Good Father figure, the shepherd, during this experience is meant to provide a sense of sponsoring and support of the struggle for ascendancy. Many of these patients have had a great deal of experience of father absence or of depriving father presence. The shepherd is provided as an encouraging and positive addition to what is usually a negative and depriving set of father images. The light is introduced as a symbol of intrapsychic energy and also of legitimacy. (2) The ocean descent visualization is a symbolic experience of intrapsychic depth, an aspect of inner life of which many of the patients are at least suspicious and many times, frightened. The confrontation of the sea mon ster is meant as a symbolic encounter with, transcendence of and acceptance of some aspect of the self which is 52 hated, avoided, or feared. (3); The birth regression visualization is meant to provide an experience of the nurturing Good Mother and the acceptability of being the needy child. It also helps to locate the individual in his or her own history,' as the child of a mother and a father. The experience amounts to a re-acquaintance of the individual with the primary fact of human existence, and underscores the legit imacy of human need. (4) The light visualization is designed to let the individual experience various levels of intrapsychic energy, and to open the possibility of releasing previous ly blocked energies. The patient may also gain a new or renewed sense of his own warmth. He is turned toward the good, positive energies of his existence, and turned away from negative, self-defeating, dark energies. (5) The tree visualization is aimed at the alcohol- ' ic1s disordered sense of time and continuity. Alcoholism is a disorder characterized by great impulsivity, and this visualization provides the experience of various types of time awareness. The symbolic representation of the com plete life-span expands the person's sense of his or her place in the stream of life, and can serve to reduce the kind of anxiety associated with an impulsive here-and-now orientation. And the element of death and rebirth in the 53 visualization is meant to imbue the participant with a sense of hope and renewal. After each visualization, subjects were asked to fill out a questionnaire rating each major image as to vivid ness, and giving a brief description of the image as seen and/or experienced (see Appendix A for questionnaire for mat) . The questionnaires operate on a five-point self- report of imagery vividness, ranging from "No imagery ex perience" to "Very intense image, bordering on a percept." (Brower, 1947) Of this particular means of measuring sub jective imagery experience, Singer and Tower (1980) said: "The simplicity of this method...makes one wonder why it has not turned up in any systematic use in the litera ture" (pp. 23-24). Control group subjects underwent the same basic regi men of therapeutic activity as the experimental group, with the exception of the Guided Daydream experiences. They engaged, instead, in group interaction sessions for the five days. To provide correspondence between the v::0> treatments, each subject in the control group was asked to fill out a questionnaire regarding the nature and quality of his or her experience in the group-therapy ses sion (see Appendix B). On Monday before the beginning of both experimental 54 and control treatments, and on Friday after their comple tion each subject was administered the Zung Self-Rating Depression Scale and the Rosenberg Self-Esteem Scale (Rosenberg, 1965). Two months following the posttest ad ministration of the instruments, they were administered a third time to all subjects in order to provide a follow- up measure. This third assessment was meant to ascertain whether there was any stability to short-term change measured over the week of intervention. It was also designed to offer additional evidence concerning the ef fectiveness of the intervention; i.e., whether the dif ferences between groups were due to the intervention, or due to an interaction between subject selection and spon taneous, remission of low self-esteem and depression (sta tistically speaking, a natural regression effect due to skewed population). Statistics This study utilized the t test to analyze and compare the mean scores of experimental and control groups. Al though no significant differences were found between ( ;/ groups in the pretest scores, an analysis of covariance was performed as a precaution against a Type II error. T tests were performed from measurements obtained immedi ately after completion of both treatments, and two months- 55 following both treatments. Hypotheses The following null hypotheses were examined: 1) The participation in a series of five Guided Daydream experiences by a group of alcoholic inpatients will not result in significantly greater difference in self-esteem ratings as measured by the Rosenberg Self-Esteem Scale before and after the Guided Daydream series, when compared with a control group, than would be predicted due to chance. 2) The participation in a series of five Guided Daydream experiences by a group of alcoholic inpatients will not result in significantly greater difference in depression ratings as measured by the Zung Self-Rating Depression Scale before and after the Guided Daydream series, when compared with a control group, than would be predicted due to chance. 3) The participation in a series of five Guided Daydream experiences by a group of alcoholic inpatients will not result in significantly greater difference in self-esteem ratings as measured by the Rosenberg Self-Esteem Scale 56 before and two months after the Guided Daydream series, when compared with a control group, than would be predicted due to chance. 4) The participation in a series of five Guided Daydream experiences by a group of alcoholic inpatients will not result in significantly greater difference in degression ratings as measured by the Zung Self-Rating Depression Scale before and two months after the Guided Daydream series, when compared with a control group, than would be predicted due to chance. 57 CHAPTER IV RESULTS f The purpose of this study was to ascertain whether participation in a series of five Guided Daydreams would have a significant effect on the level of depression and self-esteem in a population of inpatient alcoholics as com pared to,a control group of inpatients hospitalized in the same facility. The experimental and control groups were comprised of 2 5 patients each, and each patient underwent the same treatment program, with the sole variation being that those in the experimental group also participated in the Guided Daydream group. T test analyses of both groups' pretest scores on the Zung Self-Rating Depression Scale and the Rosenberg Self- Esteem Scale demonstrated no significant difference be tween the groups. Thus, it was assumed that both groups were drawn from essentially the same populations. 58 TABLE 1 COMPARISON OF MEAN SCORES ON ROSENBERG PRETEST GROUP # OF CASES X SD t df 2-tail probability Control 25 2.32 1.77 1.64 48 Experimental 25 3.08 1.498 0.108 N.S. TABLE 2 COMPARISON OF MEAN SCORES ON ZUNG PRETEST GROUP # OF CASES X SD t df 2-tail probability Control 25 50.20 11.67 0.67 48 Experimental 25 52.36 11.14 0.51 N.S. It was decided to proceed as planned with comparison of the groups using the t test since no significant pre test differences between groups were found. The first null hypothesis was upheld by the data, 59 which showed that there was no significant posttest dif ference between experimental and control groups on the Rosenberg Scale. TABLE 3 COMPARISON OF MEAN SCORES ON ROSENBERG POSTTEST GROUP # OF CASES X SD t df 2-tail probability Control 25 1.60 1.68 0.98 48 0.33 N.S. Experimental 25 2.04 1.49 The second null hypothesis was upheld by the data, which showed that there was no significant posttest dif ference between experimental and control groups on the Zung Scale. Thus, although both experimental and control groups evidenced a noticeable difference and improvement in both self-esteem and depression over the five days between measurements, no significant difference between groups emerged as a result of differential treatment. 60 TABLE 4 COMPARISON OF MEAN SCORES ON ZUNG POSTTEST GROUP # OF CASES X SD t df 2-tail probability Control 25 46.40 12.54 0.25 48 0.80 N.S. Experimental 25 45.56 11.12 The two^month follow-up measures cannot be regarded as a reliable and strong indication of lasting treatment effects, nor can they be regarded as an adequate comparison between the original groups. Follow-up measures were re turned by only 23 of the original 50 subjects. Although results cannot be regarded as conclusive, they are reported below. The third null hypothesis was also upheld by the data, which showed that there was no significant difference be tween groups on a two-months follow-up administration of the Rosenberg Self-Esteem Scale. 61 TABLE 5 COMPARISON OF MEAN SCORES ON ROSENBERG POST-POSTTEST GROUP # OF CASES X SD df 2-tail probability Control 11 Experimental 12 1.45 1.69 1.83 1.899 0.50 21 0.62 N.S. Finally, the fourth null hypothesis was upheld by the data, which showed that there was no significant difference between groups on a two-months follow-up administration of the Zung Self-Rating Depression Scale. TABLE 6 COMPARISON OF MEAN SCORES ON ZUNG POST-POSTTEST GROUP # OF CASES X SD t df 2-tail probability Control 11 Experimental 12 44.00 12.23 41.67 9.27 0.52 21 0.61 N.Si 62 Since subjects in this study were not randomly se lected, analysis of covariance was run on all data as a precaution against any pretreatment differences not indi cated or detected by the t tests. These analyses also produced no statistically demonstrable differences between groups. 63 CHAPTER V DISCUSSION AND RECOMMENDATIONS FOR FURTHER RESEARCH This study sought to investigate the possible effects on levels of depression and self-esteem produced in a group of inpatient alcoholics who participated in a five-session Guided Daydream group. The dependent measures were the Rosenberg Self-Esteem Scale (Rosenberg, 196 5) , and the Zung Self-Rating Depression Scale. Both measures were ad ministered to a 25-member experimental group and to a 2 5-member control group, which did not participate in the Guided Daydream series. The depression and self-esteem scales were given in a pretest, posttest, post-posttest sequence, with the posttest coming five days after the pre test, and the post-posttest coming two months after the pretest. Analysis of the data using the t test indicated that there were no significant differences between groups on any of the administrations of the dependent measures. Given the non-random nature of the subject pool, analysis 64 of covariance was run on all the data as a precaution against any pretreatment differences not indicated by the t tests. These analyses also produced no statistically demonstrable differences between groups. Any differences in the level of depression found in the experimental group after the five days of visualiza tion experience cannot, therefore, be attributed to their participation in the visualizations, because their post test scores on the Zung were directly comparable and not significantly different than the posttest scores of the control group. It is possible that improvements in the depression scores in both groups may be attributed to some combination of general treatment effects and spontaneous remission of depressive affect. Admission to a hospital for alcohol treatment is a critical and sometimes traumatic event for most patients. It is evidence of failure to cope with and successfully deal with one's life. That such an admission might be accompanied by depression is not surprising. As the course of treatment proceeds, how ever, and the patient becomes more familiar with surround ings and hospital routine, the initial depression may spontaneously ease up and be replaced with a sense of ac ceptance and even pride that one has chosen finally to do something substantial about a problem which has eluded solution for years. 65 By the same token, any differences in the level of self-esteem found in the experimental group after the five days of visualization cannot be attributed to their par ticipation in the visualizations. Their posttest scores on the Rosenberg were not found to be significantly dif ferent from those of the control group. The normal thera peutic regimen of the hospital includes group exercises and other experiences which are specifically designed to increase the patient’s flagging self-esteem. This is also one of the chief aims of Alcoholics Anonymous, whose meet ings all patients are required to attend. The addition of the Guided Daydream experience to the normal course of hospital treatment produced no significant difference in level of self-esteem as measured by the Rosenberg Scale. The data rendered by the two-months follow-up adminis tration of the Zung and Rosenberg scales are, unfortu nately, not as conclusive as those provided by the post- tests. They do,.however, follow the same trends, and also indicate no significant differences between groups. That only 46% of the original patients responded to the fol low-up testing is testimony both to the difficulty involved in securing such information in general, and in obtaining follow-information on alcoholics in particular. The general trends of remission of depressive symptoms and a raising of self-esteem level were found in the responses 66 of those who did participate in the follow-up measures. There were several weaknesses in the design of this study which were possible contributors to the absence of demonstrably significant differences between groups. First, the sequence of Guided Daydreams was probably too short for the effects of the imagery experiences to take hold. Even the "short-term" therapies reported by Leuner (1978) included a minimum of 15 GD sessions. It is pos sible that those involved in the GD sessions in this study were exposed to this modality for so short a time that they were able only to regard the experiences as an inter esting element in the course of their treatment, a sort of fascinating but inconsequential "mind trip." One of the essential features of effective imagery experiences is that the individual comes to believe in the significance of his own images as a reflection of an inner symbolic reality. Only five GD experiences could scarcely be ex pected to produce this kind of effect, especially in a population which is characterized by very little self- awareness and self-reflection. A second weakness of the design arose out of a sacri fice made for the sake of experimental control. The ad ministration of the Guided Daydreams purposely omitted any opportunity for the patients to interact with the Guide or with one another regarding the meaning or even the content 67 of their visualizations. Effective imagery experiences are almost by definition a learning process, in which the person familiarizes himself with the nuances of his own inner process of ongoing symbolic thought. Therapeutic change is brought about, at least in some measure, by the client's having the opportunity to relate the image se quence and the unique qualities of personal image produc tion to the particular way they reflect the major conflicts and obstacles and relationships in his or her; life. The design for this study did not provide any means or method for this process in the individual to be facilitated. Thus, there is no way of knowing to what extent the pa tients spontaneously engaged in this reflective process which stands at the center of the promised therapeutic effects of imagery experience. Although Leuner speaks extensively about the benefits of using Guided Affective Imagery as a means of conducting psychodynamically ori ented therapy with a minimum interference of the trans ference neurosis, the client is nevertheless engaged with the Guide as a teacher who helps in the facilitation arid understanding of the meaning of the imagery. This aspect of the GD process was omitted to control for the differ ential confounding effects of interpersonal interaction across situations and across groups. The third weakness of the design involves the par 68 ticular dependent measures used. Though the validity and reliability of both measures is quite well established, it is possible that they were not sufficiently sensitive to demonstrate adequately the qualitative differences in the therapeutic process in which patients in the two groups were involved. It is of extreme importance to take note of the limi tations on generalizability when a study demonstrates significant differences between groups. It is of equal importance to note such limitations, even when a study such as this present one reports non-significant findings. It would be irresponsible to suggest that the subjective quality of the therapeutic experience of those involved in the GD group was no different than that of the control group. The many personally expressed, but formally un reported and unassessed, feelings of joy, excitement, and surprise at the richness of the inner world of imagination were not included in the statistical data of this study. Individuals in the GD group consistently reported fascina tion, interest and a wish to know more about the process of initiated symbol projection and the meaning of their own inner experience. The parameters of this experimental study limit statements of effect strictly to the scores of the patients on the Zung Scale and the Rosenberg Scale. There were no significant differences between groups on 69 these measures. Recommendations for Further Research Future investigations of the use of imagery with alco holic populations would, first of all, be well advised to extend the imagery experiences over a longer period of time, and to use more actual Guided Daydreams. Especially when utilizing the more symbolic modes of imagery tech nique, the process of becoming familiar with the general direction and trends of one's own imagery process requires a certain amount of training and guidance. It is highly questionable whether this is possible within a mere five- day period. Second, dependent measures which address imagery and the imagination much more directly might prove more pro ductive and informative than psychometric measures of mood states and self-concept which are not directly related in their design and construction to the assessment of imagery configurations. Singer and Antrobus1 (197 0) Imaginal Processes Inventory could provide an informative pre- and posttest measure which could indicate any shift in an individual's general style of daydreaming which followed a series of GD experiences. Also, pretests measuring in dividual differences in imagery ability, such as the Betts Questionnaire Upon Mental Imagery (Sheehan, 1967) and TUI Gordon's (1949) test of image controllability could pro vide important information regarding the effectiveness of the GD with persons of varying imagery ability. Strosahl and Ascough (1981) point out that there are no extant measures for assessing imagery abilities that are specifi cally designed to assess the particular imagery abilities required during therapy. Construction of such a measure would greatly enhance the quality of inquiries into thera peutic effectiveness. A program of research along the following lines could be designed. A population of alcoholics could be followed beginning with their admission to an inpatient treatment program and continuing for six months following admission. Following detoxification, all patients could be asked to fill out the Imaginal Processess Inventory and one or more of the instruments designed to assess imagery ability. Also administered could be various psychometric measures of depression, self-concept, anxiety, etc. The Guided Daydream could be administered on a daily basis during the hospitalization, and after discharge, patients could be offered the option of attending weekly Alcoholics Anony mous meetings, or attending weekly Guided Daydream group sessions. The AA group would be regarded as a control group. The GD group could be conducted with an eye to assessing the ongoing process of imagery as it occurs, a 71 strategy strongly suggested by Strosahl and Ascough (1981). Using Freeland's (19 82) method, members of the GD group could be asked to report the imagery in their daydreams as it occurred. Tape recordings of the sessions could then be listened to by independent raters, who would assess the ongoing imagery process along certain yet-to-be-defined parameters. Members of the GD group could also be expected to write accounts of their daydream experience in the group, as well as any important night dreams or daydreams. Frank (197 8) found this method of keeping dream logs and sharing the contents with other members of a group to be extremely effective in the development of interpersonal empathy and appreciation of one's own and others' inner symbolic processes. At the end of the six month period, all of the pre test measures could be readministered and subjected to statistical analysis using multivariate statistical tech niques. Data from both the GD group and the AA groups could be compared to ascertain any differences that had developed regarding general daydream style, and some of the more clearly emotional states of the patients. The dream diaries of the GD group could be used as a very rich source of phenomenological case study material which would illustrate the process of gradual image transforma tion, and provide highly personal information about the 72 clinical impact of imagery. Meichenbaum (197 8) suggests that imagery-based thera pists produce change because they (1) "seduce," convince, teach the client to entertain the notion that his imagery contributes to his maladaptive behavior; (2) teach the client to become aware of and monitor his images and note their occurrence within the maladaptive behavioral chain, with the consequence of interrupting the maladaptive chain; and (3) alter what the client says to himself, and does, when he experiences images. The consequence of these processes is that they convey to the client a sense of control over his images and "inner life" and in turn overt interpersonal behavior. (p. 390) This "seduction," however powerful, amounts simply to another trick of the therapist in Meichenbaum's view. It is another effective tool in the "therapeutic armamentar ium." At a merely cognitive level, this description of what happens in imagery-based therapy is probably highly accurate. But the "seduction," in order to be effective, must appeal to some element in the client's consciousness which is responsive to the idea. One of the central attributes of a human being is the capacity to symbolize one's own life. Indeed, we have no choice but to do so. The mere possession of the language with which we communicate to one another and to ourselves establishes symbolic activity as a necessity. We are suggesting that Meichenbaum's "seduction" is more than one more novel approach to psychopathology and therapy. The use of imagery to address a person's inner symbolic 73 structure is an appeal to that element of his existence which most makes him human. Fairweather (1981) calls for a kind of theory and research which is abductive and dialectical rather than inductive and empirical or deductive and rational. Only from a phenomenological starting point based on clinical and practical experience is it possible to determine what issues evoked by consciousness are most important to deal with at inductive and deductive levels... Reasoning leading from conscious experience to the discovery of its hidden ground is now the kind of thinking man needs in order to determine what kinds of issues he must confront in his pursuit of psycho logical understanding. (p. 32) Further study of the Guided Daydream with alcoholics and other populations should combine rigorous observation and measurement with careful and extensive analysis of phenomenological reports of experience, imagery and sym bolic content. It is through this type of research that attention may be paid to alcoholic process which includes but is not limited to alcoholic behavior and its ramifica tions. Through addressing alcoholism at the symbolic level, which is to say, addressing the alcoholic human being and his symbolic representation of his situation; the therapeutic goal is carried beyond mere sobriety or controlled drinking, into the full possession of oneself and one *s being. 74 REFERENCES 75 REFERENCES Ackerman, M. J. Alcoholism and the Rorschach. Journal of Personality Assessment, 1971, 35, 224-228. Allen, L. R. Self-esteem of male alcoholics. Psychologi cal Record, 1969, 19, 381-389. Amark, D. Study in alcoholism: Clinical, social-psychi atric and genetic investigations. Acta Psychologica Scandinavia, Supp. 70, 19 51. American Psychiatric Association. Diagnostic and statis- tical manual of mental disorders (3rd ed.). Washing ton, D. C., APA, 1980. Anant, D. D. 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R., Overall, J. E., & Patrick, J. H. Per sonality patterns and alcohol abuse in a state hos pital population. Journal of Abnormal Psychology, 1971, 78, 9-16. Wiener, G. Neurotic depressives' and alcoholics' oral Rorschach percepts. Journal of Projective Techniques, 1956, 20, 453-455. 82 Williams, A. F. Causes of alcohol abuse. In J. G. Cull, & R. E. Hardy Eds.), Alcohol abuse and rehabilita tion approaches. Springfield, Illinois: Thomas Publishers, 1974. Winokur, G., Reich, T., Rimmer, J., & Pitts, F. N. Alco holism: III. Diagnosis and familial psychiatric illness in 259 alcoholic probands. Archives of General Psychiatry, 19 70, 2_3, 104-111. Wylie, R. C. The self-concept (Vol. 1). Lincoln: Uni versity of Nebraska Press, 1974. Zung, W. W. K. The measurement of depression. (copyright 1970). Available from Delta Systems, Inc., 2514 University Drive, Durham, NC 27 707. 83 APPENDIXES L 84 APPENDIX A IMAGERY RATING QUESTIONNAIRES 85 NAME___________ _________ V IS U A L IZ A T IO N #1 Please rate the images experienced during this visual ization according to the following criteria: 0 No imagery experience 1 Very faint image 2 Moderate intensity image 3 Intense image 4 Very intense image; bordering on a percept. I. Meadow (circle one number) 0 1 2 3 4 Briefly describe your meadow: II. Mountain (circle one number) 0 1 2 3 4 Briefly describe your mountain: 86 III. Shepherd (circle one number) 0 12 3 4 Describe the shepherd: IV. Ascent to the sun (circle one number) 0 12 3 4 Describe this experience briefly: What are your general feelings about this visualzation experience? 87 NAME_____________________ V IS U A L IZ A T IO N #2 . Please rate the images experienced during this visual ization according to the following criteria: 0 No imagery experience 1 Very faint image 2 Moderate intensity image 3 Intense image 4 Very intense image; bordering on a percept. I. Beach (circle one number) 0 1 2 3 4 Briefly describe your beach: II. Descent into ocean depths (circle one number) 0 1 2 3 4 Briefly describe your descent: 88 III. Sea monster (circle one number) 0 1 2 3 4 Describe your monster: The battle wi th the sea monster (circle one number) 0 1 2 3 4 Tell about your battle brieifly: What are your general feelings about this visualization experience? 89 NAME V IS U A L IZ A T IO N #3 Please rate the images experienced during this visual ization according to the following criteria: 0 No imagery experience 1 Very faint image 2 Moderate intensity image 3 Intense image 4 Very intense image; bordering on a percept. I. Mother or young woman (circle one number) 0 1 2 3 4 Briefly describe how your mother or the young woman looked to you: II. Intra-uterine environment (circle one number) 0 1 2 3 4 Describe how the intra-uterine environment felt 90 III. The experience of going backward and then forward in time and development (circle one number) 0 12 3 4 Briefly describe your experience: IV. The experience of birth (circle one number) 0 12 3 4 Describe this experience briefly: What are your general feelings about this visualization experience? 91 NAME_____________________ V IS U A L IZ A T IO N #4 Please rate the images experienced during this visual ization according to the following criteria: 0 No imagery experience 1 Very faint image 2 Moderate intensity image 3 Intense image 4 Very intense image; bordering on a percept. I. View from the top of the mountain (circle one number) 0 1 2 3 4 Describe the view: II. How vividly did you see the light? (circle one number) 0 1 2 3 4 Briefly describe: 92 III. Rate your feeling of the sensation of the light in your body, (circle one number) 0 12 3 4 Describe the sensation briefly: IV. Light radiating from your forehead (circle one num ber) 0 12 3 4 Describe the experience briefly: What are your general feelings about this visualization experience? 93 NAME_____________________ V IS U A L IZ A T IO N #5 Please rate the images experienced during this visual ization according to the following criteria: 0 No imagery experience 1 Very faint image 2 Moderate intensity image 3 Intense image 4 Very intense image; bordering on a percept. I. The tree as you saw it (circle one number) 0 1 2 3 4 Describe the tree you saw: II. The tree as you became it (circle one number) 0 1 2 3 4 Describe this feeling or experience: 94 III. The days, seasons, and years changing (circle one number) 0 12 3 4 Briefly describe: IV. The death of the tree (circle one number) 0 12 3 4 Describe this experience: V. The growth of the new tree (circle one number) 0 12 3 4 Describe briefly what you saw and how you felt: What are your general feelings about this visualization experience? 95 APPENDIX B GROUP THERAPY RESPONSE SHEET 96 NAME_____________________ GROUP THERAPY RESPONSE SHEET 1. The subjects discussed in group today were interesting _____ Strongly disagree _____ Mildly disagree _____ Mildly agree _____ Strongly agree 2. I understand myself better because of this group session. _____ Strongly disagree _____ Mildly disagree Mildly agree _____ Strongly agree 3. My drinking makes more sense to me as a result of to day's group. _____ Strongly disagree _____ Mildly disagree _____ Mildly agree _____ Strongly agree 4. It helped me to talk about my problems today in group. _____ Strongly disagree _____ Mildly disagree _____ Mildly agree _____ Strongly agree 97 5. I felt some support and encouragement from the other group members. _____ Strongly disagree _____ Mildly disagree _____ Mildly agree _____ Strongly agree 6. General comments: 98 APPENDIX C INSTRUCTIONS FOR RELAXATION AND GUIDED DAYDREAMS 99 APPENDIX C DIRECTIONS FOR THE GUIDED DAYDREAM SERIES Preliminary Relaxation 1) Utilize at least five minutes of muscle, warmth, and breathing relaxation: a. Have subjects close their eyes and assume a com fortable position. b. Instruct them or remind them that this experience will be helpful. c. Stress that no physical or emotional harm will come to them during this experience. d. Ask them to identify as completely as possible with the suggested images. e. Instruct patients to breathe in very slowly and deeply, and to exhale as fully as they can. f. For muscle relaxation, in a calm, relaxed voice, say: "My body is becoming more and more relaxed. I can feel the weight of my body against the chair...I feel the support of the chair beneath my legs and hips, behind my shoulders and back... My body is becoming heavier and more relaxed... 100 My arms are becoming heavier and more relaxed, and I am feeling at peace... No matter what I may think or feel, in the deepest part of myself, I am becoming more and more relaxed...All anxiety- provoking thoughts are being quietly lifted from my mind." These instructions are repeated sever al times for first the whole body, then the head, then the arms, then the back and spine, the left arm, the left leg, etc. g. For vascular relaxation, have the subjects imag ine a center of warmth, warm, and intense at the center of their bodies. The warmth is comforting and good. Then, instruct them to let the warmth flow downward into their hips, legs, and out to the tips of their toes. Then, let it flow up ward into the chest, out the arms to the tips of the fingers, then upwards to the top of their heads. Finally, the warmth flows down their faces until the whole of the body is united by the flow of the warmth. 2) After a few seconds of silence, a Guided Daydream scene will be suggested. Use such facilitative phrases as: "I am going to suggest that you imagine a mountain meadow...See it and experience the scene with all of your senses and in as much detail as you can." Stress detailed 101 experiencing of sensations and feelings: "How does this feel to you? Let yourself feel the feelings of..." 3) The five Guided Daydream experiences were designed to last from 20-30 minutes. The GD's were administered in the order in which they are listed here. Guided Daydream #1 The Meadow/Mountain Imagine you are in a mountain meadow. Uss all five senses in experiencing this meadow see, touch, smell, hear, taste. Let yourself enjoy the beauty. You can be any age you choose to be in this meadow...Look at the ani mals in the meadow...Find the stream, go over to it, and make contact with it (drink, put feet in it, bathe, etc.). Go upstream, ground rises, until you reach the first rock face of the mountain...You will now climb the mountain. You will not fall. As you climb the rock face of the cliff before you, you become trapped. You can go no fur ther, and you cannot go back down....Now a shepherd who is strong., but gentle and good finds you and helps you up to the top of the cliff. You climb the mountain with him. See his face. How do you feel with him? The climb is very difficult and exhausting, but you are able to reach the summit...At the summit, look around and see the panorama of all that is below. Especially take note of how far you 102 have come and let yourself feel the accomplishment of having climbed such a great mountain... Look up at the sun, and feel a particular ray of sunlight which is focussed on you. As you concentrate on this, you begin ascending up this ray and slowly approach the sun itself. You will not be burned, for the heat of the sun is warm and com forting, not consuming...You now enter the sun, and be come merged with it....Now, you begin your descent from the sun, and fall gently, as a leaf would slowly make its way to the earth. Slowly, you come down through the sky until you softly land on the soft grass Of.the meadow from which you originally came. Guided Daydream # 2 Ocean Descent Begin on a beach. Feel the sand beneath your feet. Smell the salt air, feel the ocean breeze... Go out onto a peninsula, then onto the pier at the end of the penin-1 sula, where there is a little boat tied up...You can take anything you want or need with you. Get into the boat, go out to sea, and take the boat to a calm place. Jump out of the boat, and dive deep. You will be able to stay underwater for unlimited lengths of time...Descend to the bottom of the ocean. There you will encounter a great sea monster. You must not turn away from this monster. 103 You engage the monster in a fight. No harm will come to you, but you must engage in this battle with the monster. After a while, you defeat and capture the monster. Bring the monster back up to the boat and there befriend the monster. Touch and stroke the monster tenderly...After this, throw the monster back into the sea, and bring the boat back to the pier, peninsula...Walk back to the beach, where you will lie on your back in the sun. Guided Daydream # 3 Birth Regression Imagine your mother as a young woman, standing in the meadow. If the image of your own mother is not comforting and relaxing, imagine a young woman who would represent good mother to you...Imagine mother nine months pregnant. ...Imagine the intra-uterine environment warm, guiet> protective, nurturing. A child can be completely relaxed and cared for in the womb, can have its deepest primal needs met...Get a very clear-image of the child in this woman's womb. What position is it in? etc... You are the child. Imagine yourself in the womb of mother. Feel yourself inside her body. You lack for nothing. You are completely safe... Imagine, now, that you are getting even younger, gradually smaller and younger in the womb...eight months old...seven months...six months. 104 There is more room for you to move around in the womb now.. You are happy and feeling wanted...five months.... three months. You are tiny now, only an inch or so long. One month...You have gone back now to being an ovum, an egg--- dependent on nothing, needing nothing, "a time in your history when you were not." Now you shall have a beginning a sperm from your father comes to fertilize the egg. The cell divides, over and over, and you pass into your mother*s uterus. The weeks pass and you gradually develop a spinal cord, a brain. It is four weeks and your heart has stafted to beat. Feel the beating of your heart. Your arms and legs are developing now. It is the fourth month after fertili zation, and your sex organs have come into being...Five months, your hands can now grasp and hold. You suck your thumb. Six months, you are moving.: around a great deal now. Seven months, eight months...there is less and less room, and you are nearing birth. You are being completely nourished; hear your mother's breathing, her muffled voice as she talks...You are now being born through the birth canal, helped by the hands of a man, your father or some other good man...You are being breast fed by your mother...You are now lying between your warm mother and your strong father, feeling safe and loved. — — ; __ 105 Guided Daydream # 4 Light Imagine that you are climbing a mountain. The ascent is not easy, but you will not fall. You are safe...Con tinue to climb until at last you reach the summit. Again, survey the complete panorama which can be seen from this mountain top...As you stand there, a narrow column of pure white light, about six inches in diameter descends on you and enters your body through the top of your head... The light travels directly through your body and set tles in your pelvis and sex organs. (About four minutes) Next, the light moves up and centers in your stomach and intestines and travels through all the convolutions of your digestive system, expanding and filling them with warmth, energy, and health. (About four minutes) Then the light moves up and centers in your heart, and radiates throughout your chest. (About four minutes) Then the light moves up and centers in your throat. After a bit, the light spreads from your throat to your mouth. (About four minutes) After this, the light moves up into your forehead. Now the light is in your forehead, and it radiates out from there. (About four minutes) Bring all the light back into your head...Finally, the light centers in the center of your brain...Now the 106 light leaves your body as it entered it, through the top of your head. Guided Daydream #5 The Tree You are again in a lush, verdant meadow. There is a young tree, vigorous and healthy in the meadow. Go over to it, touch it, smell it, lean against it...Now imagine that you yourself are the tree. You are this tree... It is morning. Feel the sunlight on your branches, the solar energy providing what is needed for the chemical processes in your body. Feel the way your roots go deep into the earth. Day is wearing on. It becomes cooler as afternoon proceeds to evening. Night has fallen and it is cold and still, but still you stand in the meadow, motionless and firm. Day follows upon day, night upon night, and the seasons begin to change. It is Summer, and you can feel the heat of the day, the relief of the evening and night. ...Autumn comes, and your leaves change color to brilliant yellows and reds. You look glorious. Now your leaves are falling, and the branches are becoming bare...It is Winter, and the ground is frozen, snow is falling, the flow of inner moisture is extremely slow. Now, with the first hint of Spring, your branches are putting forth 107 delicate new shoots, fresh and bright green new leaves. A year has passed. Feel your roots going ever deeper into the rich soil. You are ever more solidly established in the earth, your trunk is growing stronger. The spread of your branches extends further and further as year follows upon year. Feel the warmth and energy of the sun as it contributes to the growth of your foliage. The birds come and rest in your branches. Children come and play at your feet and climb on your trunk. Many, many years pass. You are looking older and larger; your bark is rougher, your branches more gnarled. You see many generations of children grow up and grow old and die. Slowly, the life ebbs out of you. Finally, you yourself die, you fall over and slowly decompose and become a part of the soil which originally helped you you to grow. You have returned to the earth. One day, in Spring, a seed which has been in your soil sends a small shoot above the surface and it begins to grow. In a few months, it has become a new sapling, occupying the same place you occupied for many years. Let yourself feel the revitalization of your life. 108 APPENDIX D ROSENBERG SELF-ESTEEM SCALE NAME 109 DATE______: ________ Please respond to the following items by indicating whether you strongly agree, agree, disagree, or strongly disagree. 1. On the whole, I am satisfied with myself. Strongly agree____Agree Disagree Strongly disagree__ 2. At times I think I am no good at all. Strongly agree Agree____Disagree_ Strongly disagree 3. I feel that I have a number of good qualities. Strongly agree Agree Disagree_ Strongly disagree__ 4. I am able to do things as well as most other people. Strongly agree Agree____Disagree Strongly disagree 5. I feel I do not have much to be proud of. Strongly agree Agree Disagree Strongly disagree 6. I certainly feel useless at times. Strongly agree Agree___ Disagree Strongly disagree 7. I feel that I am a person of worth, at least on an equal plane with others. Strongly agree Agree Disagree Strongly disagree 8. I wish I could have more respect for myself. Strongly agree Agree Disagree Strongly disagree 9. All in all, I am inclined to feel that I am a failure. Strongly agree Agree Disagree Strongly disagree 10. I take a positive attitude toward myself. Strongly agree Agree Disagree Strongly disagree__ 110 APPENDIX E ZUNG SELF-RATING DEPRESSION SCALE N am e A ge Sex Date N one OR a Little of the Time Some of the Time G ood Part of the Time Most OR All of the Time 1. 1 feel down-hearted, blue and sad 2. Morning is when 1 feel the best 3. Ihave crying spells or feel like it 4. 1 have trouble sleeping through the night 5. 1 eat as much as 1 used to 6. 1 enjoy looking at, talking to and being with attractive women/men 7. 1 notice that 1 am losing weight 8. 1 have trouble with constipation 9. My heart beats faster than usual 10. 1 get tired for no reason 11. My mind is as clear as it used to be 12. 1 find it easy to do the things 1 used to 13. 1 am restless and can't keep still 14. 1 feel hopeful about the future 15. 1 am more irritable than usual 16. 1 find it easy to make decisions 17. 1 feel that 1 am useful and needed 18. My life is pretty full 19. 1 feel that others would be better off if 1 were dead 20. 1 still enjoy the things 1 used to do C S 3 G Z G to M G i (- 3 H Z Q D G T) W H G G H O Z c n O > G W

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Creator Hayden, John William (author)

Core Title The effects of guided daydream experiences on level of self-esteem and depression in alcoholics

Degree Doctor of Philosophy

Degree Program Education

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

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Permanent Link (DOI) https://doi.org/10.25549/usctheses-c26-511026

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