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A study of the role of relationships in the treatment of mildly mentally retarted, acting out adolescents

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A study of the role of relationships in the treatment of mildly mentally retarted, acting out adolescents

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Content A STUDY OF THE ROLE OF RELATIONSHIPS
IN THE TREATMENT OF
MILDLY MENTALLY RETARDED, ACTING OUT ADOLESCENTS
by
Elsa Pottala Pauley
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)
October 1983
UMI Number: DP24930
All rights reserved
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UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CAUFORNIA 90089
This dissertation, written by
ELSA POTTALA PAULEY
under the direction of h sz Dissertation
Committee, and approved by all its members,
has been presented to and accepted by The
Graduate School, in partial fulfillment of re
quirements for the degree of
DO CTO R OF PH ILO SO PHY
<2^||
T%1
Dean
Date ...f.LS.
DISSERTATION COMMITTEE
Chairperson
To
Matthew Van Petten Pauley
and
Alexandra Foust Pauley
for their
patience, enthusiasm, and encouragement
in this endeavor
ACKNOWLEDGEMENTS
My family has fully participated with me in my
pursuit of an advanced degree. From my earliest childhood
I remember my father, Arne Pottala, always encouraging me
to obtain the best education that I could. Unfortunately,
he is not alive to share this time with me. My mother,
Caroline Pottala, has always given me wonderful help and
guidance in making my educational and career decisions.
My sister, Mary Pottala, has been unshakingly supportive
to me. My children, Matthew and Alexandra Pauley, to whom
I dedicate this project, are constant sources of
inspiration and love. This has been a shared project and,
without all their participation, it would not have the
same meaning to me. For this, I gratefully acknowledge
them all.
I wish to thank my committee members, particularly
Dr. Don Schrader, my chairperson, who has provided me with
valuable guidance. Drs. Friend and Hocevar have also been
of invaluable assistance. Dr. Hocevar particularly helped
with the methodological and statistical portions of this
project.
I want to acknowledge one person who has been of
i i i
special significance in my graduate education, Dr. William
Ofman. His classes and writings in the field of
Humanistic Existential psychotherapy have formed the
underpinnings not only for my own personal philosophy, but
also for this research project itself.
My friends and colleagues have also been of help in
the refinement of the ideas which are embodied in this
dissertation. I wish particularly to thank Nancy Parks,
Sandra Zoe Brown, and Elaine Tobin for their insights, and
their willingness to discuss them.
I also wish to acknowledge the administration of
Gateways Hospital for permitting me to use their program
and their data for my research. Dr. Paul Yates and Kathy
Boyum, M.S., were especially helpful regarding data
administration and collection.
Finally, I wish to thank the residents who
participated in the program at Gateways. Their personal
suffering brought them to such a place. I hope that such
a program may alleviate not only their trauma, but that of
others as well.
w
Abstract
This study was designed to investigate the effects of
a treatment method emphasizing relationship building on
relationship behavior ‘ and acting out behavior in
adolescents who are mildly mentally retarded, act out, and
are being treated in a residential, in-patient setting.
The treatment method was called
relationship-building, or interpersonal psychotherapy, and
consisted of focusing upon educating and encouraging
changes in the ways individuals relate to one another.
Relationship treatment occurred through the various
interpersonal transactions between resident and staff
members and was thus not confined to traditional
psychotherapy.
This investigation was a single subject, ex post
facto research design, with six single subjects. The
research instrument was Yates' Resident Progress Scale,
which measured six dependent variables: verbal
aggressiveness, verbal and physical assaultiveness on
peers, verbal and physical assaultiveness on staff,
participation in program, cooperation with staff, and
overall relationship behavior. The first three variables
v
were associated with acting out behavior; the second three
with relationship behavior.
Using interpersonal, borderline personality, and
milieu theory with regard to the etiology and treatment of
adolescent psychopathology, particularly with regard to
acting out, the following results were predicted: 1)
acting out behavior would decrease and relationship
behavior would increase if baseline ratings and
end-of-treatment ratings were compared;2) in short-term
analysis, acting out behavior would not consistently
decrease; 3) on a short-term basis, there will be an
inverse relationship between acting out behavior and
relationship behavior.
Results were generally consistent with hypotheses
based upon interpersonal and borderline personality
theory. With regard to Hypothesis 1, three of the six
subjects demonstrated unequivocably that relationship
behavior increased and acting out behavior decreased, in
association with a treatment method emphasizing
relationship-building. Results strongly supported the
hypothesis that adolescents' acting out behavior manifests
short-term worsenings during treatment, on a
month-to-month basis. Results regarding the correlation
between acting out behavior and relationship behavior, on
a short-term basis, were more mixed, although generally
v i
supportive of the hypothesis.
These results have clinical and theoretical
implications. Further research is indicated to specify
types of relationship behavior, to more clearly link them
with acting out behavior, and to learn what type of
correlation exists between acting out and relationship
behavior, on a short-term basis.
TABLE OF CONTENTS
Page
DEDICATION ii
ACKNOWLEDGEMENTS iii
ABSTRACT v
LIST OF TABLES x
Chapter
I. INTRODUCTION 1
Background of the Problem
Statement of the Problem
Purpose of the Study
Research Questions
Theoretical Framework
Assumptions
Hypotheses
Delimitations
Definition of Terms
Organization of the Remainder of the Study
Etiology of Adolescent Psychopathology
Treatment of Acting Out Adolescents
In-Patient Treatment of Adolescents
Mild Mental Retardation as a Complicating
Factor
Patterns of Behavioral Change
Research Design
Sample Selection
Ethical Considerations
Instrumentation
Procedures
Chapter
II. REVIEW OF THE LITERATURE 27
Chapter
III. METHODOLOGY 110
V 1 1 1
Data Collection Procedures
Data Analysis
Summary
Chapter
IV. ANALYSIS AND DISCUSSION OF FINDINGS . . . .
Hypothesis Testing
Discussion
Summary
Chapter
V. SUMMARY, IMPLICATIONS, AND RECOMMENDATIONS.
Background of the Problem
Review of the Literature
Hypotheses
Me thodology
Results
Implications and Recommendations
REFERENCES ..........................................
REFERENCE NOTES ...................................
APPENDIX
A. YATES' RESIDENT PROGRESS SCALE ...........
127
154
167
178
179
LIST OF TABLES
Table Page
1. Duration of Phases in Study.................. 119
2. Mean Scores on Acting Out Behavior
Dimensions at Baseline and End of
Treatment...................................... 129
3. Mean Scores on Relationship Behavior Dimensions
at Baseline and End of Treatment ...... 130
4. Subject 1, Mean Scores on Acting Out and
Relationship Behavior Dimensions in Short-
Term Comparisons............................. 136
5. Subject 2, Mean Scores on Acting Out and
Relationship Behavior Dimensions in Short-
Term Comparisons............................. 137
6. Subject 3, Mean Scores on Acting Out and
Relationship Behavior Dimensions in Short-
Term Comparisons............................. 138
7. Subject 4, Mean Scores on Acting Out and
Relationship Behavior Dimensions in Short-
Term Comparisons............................. 139
8. Subject 5, Mean Scores on Acting Out and
Relationship Behavior Dimensions in Short-
Term Comparisons............................. 140
9. Subject 6, Mean Scores on Acting Out and
Relationship Behavior Dimensions in Short-
Term Comparisons............................. 141
x
CHAPTER I
INTRODUCTION
This study is concerned with the effects of a
treatment method emphasizing relationship-building upon a
certain population of adolescents, those who have been
diagnosed as mildly mentally retarded and conduct
disordered and who live in an in-patient setting. The
stated treatment goal for these adolescents is the
reduction of their acting out behavior to the point that
they can be discharged to a less restrictive setting.
This study will attempt to ascertain if relationships
are an important aspect in the outcome of treatment of
these adolescents by measuring the long- and short-term
trends in both their relationship behavior and their
acting out behavior over the course of treatment and
determining what kinds of correlations, if any, exist
between the two types of behavior.
The two trends are reflective of different aspects of
this study. The long-term trend relates to the overall
importance of relationships in enabling individuals to
live in society without necessarily exhibiting behavioral
1
symptoms. The short-term trends are indicative of the
pattern of behavioral change (short-term worsenings vs.
steady improvement) during treatment.
Background of the Problem
A preferred technique in the practice of
psychotherapy has long been a discussed question in the
literature. Most reviews (Bergin & Lambert, 1978?
Luborsky, Singer & Luborsky, 1975? Shapiro (1980)? Smith &
Glass, 1977) have concluded that there is no difference
between various methods, with the exception of certain
specific disorders (e.g., phobias). However, a common
factor which all forms of therapy share is the therapeutic
relationship. The importance of the therapy relationship
in achieving positive outcomes in therapy has been
insufficiently studied and rarely measured. This seems
primarily due to the research problems involved in
controls and adequate measures.
Another aspect to this problem has to do with the
relationship between acting out behavior and interpersonal
difficulties. Some theorists write that acting out
behavior is one form of response to difficult
interpersonal and environmental situations. They
recommend that treatment concentrate upon improving
patients' ability to form healthy relationships (Arsenian,
1970? Haslam, 1978? Ofman, Note 1). The theoretical
2
position implies that as personal relationships are
improved, people will have less reason to act out.
However, this conclusion has not been adequately
investigated.
Although there remains disagreement among scholars,
the literature today generally reflects that psychotherapy
is effective (Bergin & Lambert, 1978; Hynan, 1981;
Luborsky et al., 1975; Shapiro, 1980; Smith & Glass,
1977). However, the question remains regarding the
pattern of behavioral change. Do individuals improve
gradually and steadily, do they improve all at once, or do
they improve and then regress (over the short-term)?
Expectations of individuals in treatment differ according
to the theory one accepts. While scholars may accept that
behavioral changes do not come about easily, overnight, or
without regression, the popular literature remains less
convinced. Empirical validation of the more scholarly
position has not, however, been established in the
literature.
Adolescents today may be viewed as experiencing
significant emotional distress, as evidenced in the
dramatic statistical increases since the 1950's in their
acting out behavior. This behavior includes such
activities as successful and attempted suicides, alcohol
and substance abuse, running away, aggressive acts such as
3
fighting, and anti-social acts such as stealing, and
sexual promiscuity. One accepted form of treatment for
these disturbed individuals is psychotherapy and,
consequently, the issues discussed above become especially
relevant when considering treatment.
Mental retardation and acting out behavior have been
linked statistically. While the statistical findings are
somewhat contradictory, there is evidence that individuals
who are mentally retarded are more likely to develop
acting out behavioral problems than a normal population
(Hutt & Gibby, 1979; Koller, Richardson, Sc Katz, 1983).
The literature is divided over the questions of which
problem (the retardation or the behavior) should be
considered primary and what is an appropriate treatment
method (particularly for those who are mentally retarded).
Disturbed and/or mentally retarded adolescents are
generally treated on an out-patient basis. However, when
their behavior becomes threatening to society, they may be
removed from their homes and placed in an institutional
setting (Alt, 1960). In-patient treatment may comprise a
broad range of therapies, including milieu therapy,
occupational and recreational therapy, therapy in a school
setting, group therapy, and traditional, one-to-one
therapy. The role of relationships in therapy then also
4
widens to include many helping relationships. The
correlation between these various relationships and
behavior has been written about theoretically (cf.,
Beavers, 1968; Holmes, 1964; Rinsley, 1965, 1968, 1974;
Ofman, Note 1), but has not been adequately measured
empirically. This seems most probably due to the research
concerns involved in adequate control.
Statement of the Problem
The problem is to study the effects of a treatment
method emphasizing relationship-building in an in-patient
setting with mildly mentally retarded adolescents who act
out. This will be done by measuring the frequency of both
relationship behavior and acting out behavior over the
course of treatment and establishing the correlation
between the two. Secondarily, the problem is to determine
if the pattern of acting out behavior over the course of
treatment is subject to short-term fluctuations and if
these fluctuations, if any, are correlated with changes in
these adolescents' relationships.
Various theorists, representing diverse schools of
psychological thought from borderline personality to
maternal deprivation to interpersonal and existential
assert that psychopathology in general, and acting out
specifically, develop in response to problems or
difficulties in interpersonal relationships. Treatment
5
logically then focuses on these problemmatic
relationships, with different emphases placed by the
various schools of thought.
The research literature has theoretized about the
importance of the therapeutic relationship in bringing
about positive outcomes in psychotherapy (cf., Masterson,
1972; Miller, 1981; Ofman, 1976, Note 1). Borderline
personality theorists such as Masterson and Rinsley (1965,
1968, 1974, 1978) hold that the transference which occurs
in the therapy relationship permits patients to re-live
previous experiences and to experience previously denied
feelings, thus permitting them to establish healthier
relationships in the future. Interpersonal theorists such
as Arsenian (1970), Haslam (1978), and Ofman (Note 1)
write that psychotherapy helps individuals by enabling
them to form better relationships, first with their
therapists and then with other significant people in their
lives. If such theories are correct, then one should
expect that better relationships are associated with less
destructive, acting out behavior. This association should
be studied and verified empirically.
The literature has also been concerned with the
pattern of change during treatment. The theory that
progress is followed by regression or, more prosaically,
that "people get worse before they get better" is widely
6
accepted by professionals in the mental health field, but
is less accepted by the general populace.
If the two theoretical positions described above are
correct, then acting out behavior and relationship
behavior should be correlated on a short-term basis. In
other words, patients' short-term acting out regressions
should be associated with changes in relationships.
However, statistical evidence of the correlation is
insufficient to draw a conclusion.
While the above concerns deal with psychotherapy in
general, they are applicable to treatment of a specific
population. This group consists of mildly mentally
retarded, acting out adolescents. There is some question
in the literature if treatment emphasizing relationships
is appropriate with this population.
Additionally, these adolescents' behavior is
considered sufficiently disturbed that they are confined
in an in-patient setting. This setting widens the scope
of the relationship issue to encompass the various
modalities offered in this setting.
Thus the primary concern of this study is to examine
the effects of multi-modal treatment emphasizing
relationship-building on the behavior of this adolescent
population.
7
Purpose of the Study
The proposed study is designed to:
1. Examine the correlation between relationship
behavior and acting out behavior over the course of
treatment in an in-patient setting with a population of
mildly mentally retarded, acting out adolescents.
2. Determine the pattern of acting out behavioral
change in this population over the length of treatment.
3. Examine the correlation, if any, between the
pattern of acting out change and the pattern of
relationship change over this same time frame.
Data from this investigation may be particularly
helpful in establishing priorities in treatment with this
population. First, it may support the theoretical
position that psychotherapy (as manifested through various
modalities) is an appropriate method of treatment. This
has particular significance for those classified as mildly
mentally retarded, for whom such treatment has been
questioned. Second, positive findings would lend credence
to theories emphasizing relationship-building in
treatment. Third, positive findings would be an
indication that individuals' ability to form relationships
can change over time. If such is the case, then a focus
upon relationships becomes even more important in
8
psychotherapy for this population. Fourth, positive
findings would support the position that acting out
behavior is not insensible, but is associated with
difficulties in interpersonal relationships. Fifth,
findings which reflect that adolescents' acting out does
not decrease in an overnight or consistent fashion could
change unrealistic expectations of these individuals by
themselves, their families and society.
While positive findings will have particular
significance for this specific population, they will also
add empirical support to a general theoretical position
which holds that relationships are highly significant in
both the causation of psychological distress and in the
treatment of those who suffer from such pathology.
Research Questions
This investigation seeks answers to the following
questions:
1. Do adolescents who act out, are mildly mentally
retarded and live in an in-patient setting respond to
treatment emphasizing relationship-building by increasing
their relationship behavior and decreasing their acting
out behavior? In other words, will increased personal
relationships, provided by relationship-enhancing
treatment, lead to decreases in acting out behavior?
2. Does the acting out behavior of this same
9
population show short-term worsenings over the course of
treatment, or is there steady improvement (or decline)?
3. Is the acting out behavior associated with
changes in relationship behavior, on a short-term basis?
Theoretical Framework
There are several theories which attempt to explain
the etiology of psychopathology, its treatment, and the
course of treatment by defining the central issue as one
of difficulties in or deprivation from interpersonal
relationships. These theories may be broadly subsumed
under either borderline personality theory or
interpersonal theory. Together they provide comprehensive
understanding of the processes which lead to emotional
disturbance and of the forces which bring about growth
during treatment, both in the general population and in
the specific group studied herein. These theories are
applicable in the in-patient setting described in this
study. In addition, the theory regarding the role,
function, and structure of a therapeutic milieu
supplements that of borderline and interpersonal theory in
this particular environment. Last, the theory that the
mildly mentally retarded can be treated with psychotherapy
best explains how a treatment method emphasizing
relationship-building is appropriate with this specific
10
population. These concepts are briefly introduced here
and will be presented in greater detail in Chapter II,
Review of the Literature.
Borderline Personality Theory
Masterson (1972, 1974) presented a good summary of
borderline personality theory and treatment methodology.
Borderline personalities develop because of problems in
the mother (or primary child-rearing adult) -child
relationship which occur during the child's very young
life, particularly during the separation-individuation
stage (18 - 36 months). The child is unsuccessful in
achieving normal independence from the mother at this time
because the mother, herself a borderline personality,
cannot give the child the emotional support which the
child needs to accomplish separation. Instead, she
fosters a symbiotic union with the child in which
continuing dependence is encouraged, thus providing her
with the emotional support she needs. The child remains
fixated on the mother and suffers from developmental
arrest.
The fixation may go undetected until adolescence,
when normal physical maturation occurs and independence
issues again surface between parents and child. The
stress which accompanies adolescence may cause clinical
symptons to appear.
11
The two diagnostic hallmarks of borderline
personalities are abandonment depression brought about by
the constant threat that the mother will take away her
emotional support and narcissistic-oral fixation
(emotional immaturity). Additionally, these adolescents
feels constant guilt because of their wish to leave
parents who are continually needy.
Clinical manifestations of the borderline personality
syndrome are many and vary with the individual. However,
such adolescents characteristically seek immediate
satisfaction and relief from anxiety, possess a low
frustration tolerance, and are unable to control their own
feelings. They defend against their feelings by denial
and, most commonly, aggressive acting out.
Masterson (1956, 1972, 1974), Masterson, Tucker and
Berk (1963) and Rinsley (1965, 1968, 1974, 1978) all
concerned themselves with treatment for adolescents with
borderline personality disorders. The first therapeutic
priority is to control the acting out behavior(s).
Masterson viewed these behaviors as both a non-verbal plea
for help and a defense against experiencing painful,
underlying feelings. Controlling the behavior not only
responds correctly to the plea, but also erodes the
defense which prevents underlying feelings from surfacing.
During this time the therapeutic relationship is
12
____
established. This phase of treatment is called
"resistance" or testing.
The second phase of treatment, "working through",
begins when the therapeutic alliance is established and
acting out behavior greatly diminished through external
controls. In this phase, the original experiences between
mother and child are relived by the child, primarily
through transference operations, and the adolescent begins
to experience the depression, rage and guilt which have
been denied. While acting out has been curtailed, it
frequently reoccurs when particularly painful memories are
exposed.
The third phase of treatment is resolution or
termination. Internalization of control over behavior was
begun during phase two, and is further solidified during
the resolution phase. During this time adolescents begin
to integrate formerly denied feelings into their
personalities. Patients experience people as "whole"
entities, rather than split into either totally good or
bad individuals. Ongoing relationships between family
members are explored as the adolescents assume their
normal developmental role, that of pursuing an independent
life.
The therapeutic relationship is vital to successful
13
treatment, according to borderline personality theory
(Masterson; Miller, 1981? Rinsley). Through this
relationship patients relive those important early
childhood experiences and feelings which had been
previously denied. Without the transference between
patient and therapist, psychological health could not be
restored and destructive patterns changed. Thus,
theorists look upon the relationship as one of
transference, not one which has meaning as a relationship
in and of itself.
Interpersonal Theory
In interpersonal theory, psychological problems arise
because of difficulties in interpersonal relationships and
individuals' subsequent isolation (Ofman, 1976? Rogers,
1939, 1942, 1951? Sullivan, 1953? van den Berg, 1972?
Ofman, Note 1). Psychopathology is manifested in both
verbal and non-verbal communication, including acting out
behavior (Sullivan). Acting out behavior thus is one kind
of response to problems which result from interpersonal
relationships (Ofman, 1982).
Although acting out behavior is responsive to
situations, it is also an inherently "unrelated" or
"omnipotent" act (Symonds, 1974? Ofman, Note 1). That is,
when an event (particularly an unpleasant one) occurs,
people do not respond directly to or confront this
14
situation. Rather, they incorporate the negative feelings
and deal with them in isolation (e.g., running away).
The long-term Menninger Foundation Psychotherapy
Research Project (Kernberg, 1973) convincingly established
that the individuals who had sufficient ego strength to
establish and maintain good interpersonal relationships
were those whose prognoses were best in psychotherapy.
Interpersonal theory does not dispute this research, but
points out instead that those people with poor prognoses,
and poor relationships, are precisely those who are most
needy of psychological assistance. Thus, Arsenian (1970),
Haslam (1978), and Symonds (1974) asserted that one goal
in psychotherapy was to enable individuals to improve
their relationships with others. This is particularly
important with the unrelated adolescents who act out
(Symonds, 1974).
Because of the interpersonal nature of psychological
problems, the therapeutic relationship is critical in
establishing psychological well-being. Ofman wrote that
the relationship is the "healing event" (1976). However,
this relationship is not established easily or quickly
(Holmes, 1964). Within the therapy relationship(s), these
adolescents are more receptive to adult influence, to
understanding the reasons for and consequences to their
15
behavior, and to learning more constructive types of
responses (Ofman, Note 1). Ofman wrote, "It is in the
interpersonal context within which behavior must change"
(Note 1, p. 4). As these individuals become more involved
with others, their acting out behavior decreases.
Even with increasing relatedness, the pattern of
change in acting out behavior is not an unbroken line.
Kell and Mueller (1966) and Ofman (Note 1) wrote of the
deep-seated ambivalence which individuals have toward
psychological change. Although acting out may not be
considered a constructive way of dealing with distress, it
has nonetheless served as a defense against the feelings
of interpersonal isolation. Adolescents may be tempted to
"undo" healthy interactions because these events remind
them of past abandonments. They undo by acting out
(Ofman, Note 1).
Thus, in interpersonal theory interpersonal events
are both the cause of psychopathology and the context in
which health is restored. Acting out is a particular
response to distressing relationships. The therapeutic
relationship permits patients to learn the reasons and
consequences to their behavior, as well as exploring
alternative behavior. It is the necessary condition for
psychological change (Ofman, Note 1).
16
Therapeutic Milieu Theory
A therapeutic milieu refers to a treatment setting in
which the environment is recognized and utilized as a
therapeutic agent through which psychological change can
occur (Cumming & Cumming, 1962). This milieu can consist
of a number of treatment modalities, including group
therapy, recreational therapy, and art therapy, for
example.
Gunderson (1978) wrote that there were five functions
which a milieu could perform. These functions are not
mutually exclusive, are not all necessarily present, and
may be present at different times. These functions are
containment, support, structure, involvement and
validation. Containment refers to maintaining the
physical well-being of patients. Support deals with
helping patients feel better and enhancing self-esteem.
Structure refers to those aspects of the milieu which
provide predictable organization and is most closely
aligned with milieu therapy. Involvement concerns itself
with involving patients actively with their environment.
Validation refers to ward processes which establish
patients' individuality.
In an in-patient setting, other relationships besides
the traditional therapeutic one may become important and
therapeutic in their own right, either by design or simply
17
by the nature of the milieu. There is a substantial body
of literature (Cowen, Zax, & Laird, 1966; Hilgard & Moore,
1969; Joubrel, 1971; Mitchell, 1966; Schaefer, 1981;
Ofman, Note 1) which specifically advocates using the wide
range of relationships available in this setting, as well
as volunteers, as therapeutic instruments.
Treatment of Mildly Mentally Retarded Adolescents
Mental retardation occurs in individuals in varying
degrees of severity. The Diagnostic and Statistical
Manual of Mental Disorders (DSM-III) (1980) specified that
mild retardation referred to those with IQ's between 50
and 70. Much of the research with regard to appropriate
treatment for these people does not differentiate between
levels of retardation.
There is disagreement in the literature regarding
treatment of the mentally retarded (without consideration
of the level of retardation). Rogers (1942), Fenichel
(1945), Sarason (1949) and Abel (1953) wrote that verbal
psychotherapy was inappropriate for the retarded.
However, there is clinical evidence which supports the
theory that the retarded can benefit from traditional
psychotherapy (Campbell & Browning, 1975; Heiser, 1954;
Hutt & Gibby, 1979; Menolascino, 1977; Thorne, 1948).
Hutt and Gibby wrote that interactions, the key element in
18
psychotherapy, occur at many levels, only one of which is
verbal. They concluded that, while the mentally
retarded's lack of verbal skills may be a limiting factor,
it does not preclude the effectiveness of traditional
psychotherapy.
Assumptions
1. Relationship-enhancing psychotherapy is an
appropriate treatment method with a mildly mentally
retarded population.
2. Relationship-enhancing treatment in a milieu
setting may be widened to include all relationships
between staff and patients.
3. An series of single case studies is an
appropriate research design in which to study the
hypothesized effectiveness of relationship-enhancing
treatment.
4. A series of single case studies which replicate
findings diminishes threats of internal and external
validity.
5. Changes in measured behavior are assumed to
result from the treatment, as shown by the research
literature.
Hypotheses
The following hypotheses will be examined:
19
1. Adolescents receiving treatment emphasizing
relationship-building will demonstrate overall increased
relationship behavior and decreased acting out behavior
over at least a six-month period, as demonstrated by
comparison of baseline and end-of-treatment measurements
of staff ratings on the Yates' Resident Progress Scale.
2. Adolescents receiving treatment emphasizing
relationship-building will exhibit a pattern of acting out
behavioral change which includes short-term worsenings and
improvements, as demonstrated by a month-to-month
comparison of baseline and treatment measurements of staff
ratings on the Yates' Resident Progress Scale.
3. Adolescents receiving treatment emphasizing
relationship-building will demonstrate an inverse
correlation between relationship behavior and acting out
behavior, as demonstrated by a month-to-month comparison
of baseline and treatment measurements of staff ratings on
the Yates' Resident Progress Scale.
Delimitations
The following delimitations are in effect in this
study:
1. The sample in this study is restricted to six
mildly mentally retarded, conduct disordered adolescents
between the ages of 13 and 17.
20
2. The population sample is limited to approximately
25 mentally retarded, acting out adolescents living in one
residential, in-patient setting between the years of 1982
and 1983.
3. Due to the theory linking poor interpersonal
relationships and acting out behavior, findings of this
study may not be generalizable to populations other than
those who act out.
Definition of Terms
Acting out behavior. This term is generally defined
in the psychological literature as acting without insight.
From a sociological viewpoint, the term generally refers
to anti-social or delinquent behavior. Acting out
behavior may take many forms, some of which are running
away, drug and alcohol abuse, sexual promiscuity, and
self-destructive acts.
Behavior. This term is best defined for this study as
encompassing all activities of an individual which can be
observed by another. Thus behavior includes not only
acting out activities, such as running away, but
activities which indicate relatedness with another, such
as conversation.
Behavioral problems. This term is best defined as
21
referring to behavior which involves acting out.
Borderline personality. This term is best defined as
describing a syndrome characterized at an underlying level
by abandonment depression and narcissistic-oral fixation.
Clinical manifestations take many forms. In adolescents
these forms commonly include aggressive acting out.
Conduct disorder. This term is best defined for this
study by a definition set forth in the DSM-III. It
stated, "The essential feature is a repetitive and
persistent pattern of conduct in which either the basic
rights of others or major age-appropriate societal norms
or rules are violated" (1980, p. 45). Conduct disorders
include four specific sub-types:
1. Undersocialized, Aggressive. A repetitive and
persistent pattern of aggressive conduct and
failure to establish a normal degree of affection
or empathy with others (DSM-III, pp. 47-48).
2. Undersocialized, Nonaggressive. A persistent and
repetitive pattern of nonaggressive conduct and
failure to establish a normal degree of affection
or empathy with others (DSM-III, p. 48).
3. Socialized, Aggressive. A repetitive and
persistent pattern of aggressive conduct and
evidence of social attachment to others (DSM-III,
22
p. 49).
4. Socialized/ Nonaggressive. A repetitive and
persistent pattern of nonaggressive conduct and
evidence of social attachment to others (DSM-III,
pp. 49-50).
Developmental Disability. This term refers to
problems which result from disruptions in normal
development. Developmental disabilities include
retardation and seizure disorders. In this study, the
particular developmental disability considered is mild
mental retardation.
Dual Diagnosis. This term refers generally to
individuals who have been diagnosed as developmentally
disabled and with some form of psychological illness. In
this study, the developmental disability refers to mild
mental retardation.
In-patient Treatment. This term refers to a treatment
setting in which people live on a 24-hour basis.
In-patient treatment may take two forms:
1. Hospital Setting. A hospital setting is
considered to be a closed or locked environment in
which patients are prohibited from moving freely
by the physical setting itself (e.g., locked
doors, bars on windows).
23
2. Residential Setting. A residential setting is one
in which patients are not prevented by the
physical setting from moving freely.
Mental Retardation. The DSM-III stated that the
essential features of this term are significantly
subaverage intellectual function resulting in or
associated with impairments in adaptive behavior with
onset before the age of 18 (1980, p. 36). There are four
levels of retardation:
1. Mild. This level is roughly equivalent to the
educational category "educable". IQ level is from
50 to 70. This level contains approximately 80%
of the mentally retarded (p. 39).
Moderate. This . category is approximate to the
educational category of "trainable". IQ level is
from 35 to 49. This group makes up 12% of the
retarded population (p. 39).
3. Severe. This group is unable to profit from
vocational training and may be able to perform
simle work tasks under close supervision as
adults. IQ level is from 20 to 34. This group
makes up 7% of individuals who are mentally
retarded (p. 39).
4. Profound. A highly structured environment, with
24
constant aid and supervision, is required at this
level. Very limited self-care may be possible
during adult years in a highly structured
environment with constant aid. IQ level is below
20. This group constitutes less than 1% of the
mentally retarded population (pp. 39-40).
Milieu Therapy. This term, or the synonym,
therapeutic milieu, may be best defined as treatments in
which the environment is recognized and utilized as a
therapeutic agent through which psychological change can
occur (Cumming & Cumming, 1962).
Relationship Behavior. This term refers to acts by
people which signify their intent to be involved with the
other person. Some examples of relationship behavior
include conversations, playing with other people, and
behaving in a way that is not physically harmful to
another person.
Relationship Therapy. This term is best defined for
this study as therapy which encourages the establishment
of healthy interpersonal behavior, both with the therapist
and with other individuals. Therapeutic tools include
focusing upon the interpersonal process, making the
process explicit, educating patients as to more
appropriate behavior, and modeling alternative behaviors.
This therapy may occur in various forums including
25
individual psychotherapy, group psychotherapy, school, and
recreational therapy. It may be provided by all staff
members associated with the treatment program.
Organization of the Remainder of the Study
Chapter II presents a review of the literature and
relevant research for this study. Five principal areas
are discussed: 1) etiology of psychopathology, 2) the
treatment of adolescent psychopathology, 3) in-patient
treatment of adolescents who act out, 4) mild mental
retardation as a complicating factor, and 5) the pattern
of behavioral change.
The methodology of this study is presented in Chapter
III. Topics in Chapter III include design, sample
selection, ethical considerations, data collection,
procedures, and data analysis.
Chapter IV presents the findings of the study and a
discussion of the results.
Chapter V presents the summary, conclusions, and
recommendations for future study.
26
CHAPTER II
REVIEW OF THE LITERATURE
The review of the literature will discuss the role of
relationships in the treatment of adolescents who act out
and are mildly mentally retarded in five sections. First,
the general area of the etiology of adolescent
psychopathology will be discussed, with attention paid to
interpersonal theory, theory regarding disruptions in
childhood relationships, borderline personality theory,
the developmental origin of psychopathology, and the
relationship between psychopathology and acting out.
Second, the treatment of adolescents who act out will
be reviewed. Four areas will be discussed, including
goals and methods for treatment, the therapy relationship
in general, the therapy relationship with adolescents, and
empirical evidence regarding the relationship between
ability to get along with other people and
psychopathology. The therapy relationship with
adolescents is of particular importance and will be
examined in three sub-sections: characteristics of the
relationship, initial difficulties in establishing the
27
relationship, and therapeutic responses to acting out.
Third, in-patient treatment of adolescents will be
reviewed. This section considers the treatment of
adolescents in a larger setting than the traditional
therapeutic one. While the previous sections regarding
treatment are applicable in an in-patient setting,
additional factors which affect treatment and
relationships with adolescents will be discussed here.
These include: rationale, purpose and goals for
in-patient treatment? the functions of the milieu?
adolescents in an in-patient setting? the role of the
therapist? and the role of the staff.
Fourth, the issue of mild mental retardation as a
complicating factor will be reviewed. This section will
consider three areas: statistics regarding any
correlation between mild mental retardation and behavioral
and psychological problems, explanations regarding such
correlations, and treatment of the mildly mentally
retarded as a particular group.
Fifth, the issue of patterns of behavioral change
(especially acting out behavioral change) will be
reviewed. Four theorists, Levy, Rinsley, Kell and
Mueller, and Ofman, who support a position that the
pattern of behavioral change is uneven will be discussed.
28
Finally, the empirical work of Shapiro and his colleagues
will be reviewed.
Etiology of Adolescent Psychopathology
The etiology of adolescent emotional disturbance will
be discussed in five areas: interpersonal theory,
theories regarding disruptions in childhood and their
relationship with emotional/behavioral difficulties,
borderline personality theory, theories regarding the
developmental origin of psychopathology, and theories
regarding the relationship between acting out and
psychopathology.
Interpersonal Theory
Interpersonal theory makes no particular distinction
between the development of adolescent psychopathology and
the development of psychopathology in general.
Interpersonal theorists consider interpersonal events to
be at the heart of psychopathology. In this sense,
diverse humanistic and existential theoreticians such as
Rogers (1939, 1942, 1951) and Ofman (1976, Note 1) may be
considered to be interpersonal theorists.
The first systematic formulation of interpersonal
theory was presented by Sullivan (1953). The major
interpersonal themes which he developed were:
1. Human personality is "the relatively enduring pattern
29
of recurrent interpersonal situations which
characterize a human life" (pp. 110-111).
2. An individual's self-esteem is interpersonal in both
its development and its current content.
3. Psychopathology is the result of disordered
interpersonal relations and is manifested in
disordered interpersonal communication.
4. Disordered communication includes both verbal and
nonverbal arenas.
5. Disordered communication reflects a person's
"parataxic distortions", in that the patient
generalizes to the therapist or other involved person
earlier experiences in interpersonal relatedness.
Van den Berg (1972) expressed the basic interpersonal
concept succinctly. He stated, "Loneliness is the central
core of his the patient's illness, no matter what his
illness may be. Thus, loneliness is the nucleus of
psychiatry" (p. 105). Loneliness or isolation results
because individuals experience deep interpersonal pain,
and subsequently turn away from this pain or conceal these
feelings by withdrawal from the interpersonal context
(Ofman, Note 1).
Levy (1938) pointed out that interpersonal
difficulties are part of the normal human condition. He
stated,
30
As soon as close human impacts begin to be felt
between two people, anxieties, guilt feelings,
feelings of frustration, insecurities and
resentments are liberated. In varying degrees the
two people in contact have a hell of a time. (p.
64)
Psychopathology develops when these normal difficulties
become extreme. The pathology takes the form of
estrangement from the context in which normal
relationships occur and replacement of this context with
intra-psychic motivation and stimulation (Laing &
Esterson, 1970; Ofman, 1976).
Interpersonal theory asserts that interpersonal
relationships throughout childhood and adolescence play a
critical role in psychological well-being (Nitzberg,
1980). It rests upon the developmental work of Piaget
(1932), who defined the nature of interpersonal relations
as basic to perceptions of the "self". Thus, while these
theorists do not locate the source of distress necessarily
in childhood relationships, they do maintain that human
personality develops in an interpersonal setting from
infancy onward.
The significance of relationships is emphasized in
the writing of Arsenian (1970), who said that there is a
close relationship between mental health and the ability
to form friendships. Conversely, those people who are
psychologically "unhealthy" suffer from unhappiness,
31
self-involvement, and the inability to form friendships.
Disruptions in Childhood Relationships
There are many theorists who look to early childhood
relationships as the source of psychopathology,
particularly in the adolescent disorders. The first
scholars who cited these disruptions in childhood
relationships as the cause of long-term disturbance
focused upon the issue of "maternal deprivation".
Bowlby's (1946, 1951) studies regarding infants'
separation from their mothers as the result of long-term
hospitalization described psychological symptoms resulting
from these separations. In a comprehensive review,
Horrocks (1976) summarized the supporting evidence that,
of all the early childhood identifications, the mothering
one is the most significant in ego formation.
However, other writers challenged the Bowlby
assertion that the loss of mothering per se is responsible
for emotional disturbance. Rutter (1971, 1972, 1980)
wrote that admission to a hospital, with the subsequent
disruption in mothering bonds, was not a particularly
important factor in the development of serious long-term
disturbance, especially of an antisocial or delinquent
nature. (He added that it was also not of significant
import in the development of mental retardation.) Rutter
(1972) instead associated causation with children's
32
failure to develop relationship bonds with either parent.
He wrote in 1971 that fewer children who had a
satisfactory relationship with one parent were antisocial,
compared with those who had poor relationships with both
parents. He concluded that a variety of disruptions in
childhood, from deprivation (hospitalization) to
separation (divorce), could cause emotional and behavioral
disturbances in children if the children failed to develop
satisfactory bonds and were consequently "affectionless"
(1972, p. 102).
Rogers (1939) anticipated Rutter's broader
hypothesis. He wrote that in homes where marital
satisfaction was greater and the home was free of strife,
the parents demonstrated a normal degree of affection for
their children. In these homes, childhood difficulties
were overcome in a majority of cases. Conversely, in
homes where parents consistently displayed a lack of
affection toward their children, there was no improvement
in the children's behavior in 64% of the cases. He
concluded that the parent-child relationship was of
"fundamental importance" in determining personality
development (p. 180).
Schneider (1972) supported Rutter and Rogers in his
research which cited the area of lack of interpersonal
skills resulting from poor familial relationships as an
33
important manifestation in adolescents with behavioral
problems. Conger (1975) also suggested that parents were
the single most important factor in adolescent
development. Ross & Glaser (1973) wrote in a sociological
study that individuals who were successful in leaving
ghetto environments had at least one strong parent or
parent surrogate who had high expectations for the child
and gave the child sustained love.
Goldfarb (1943) did not write specifically of this
debate concerning the cause of disruption during
childhood. Rather, he concentrated on the differential
effects of children who had been institutionalized as
opposed to those who were raised with consistent foster
care. He concluded that the early experience of
institutional children was psychologically a "highly
isolated one. The emotional and intellectual deprivation
resulting from the absence of adults produced a series of
distinctive personality traits" (p. 129). These traits
included less social adjustment, simpler mental
organization, less complex practical adjustment, and less
capability in establishing normal human relationships than
other individuals.
Thus, while there is disagreement over the exact
source of disruption during childhood, particularly
between those who assert that the loss of mothering is
34
critical and those who believe that it is the more general
parental role that is crucial, there is overwhelming
agreement that these childhood disruptions can cause
emotional and behavioral disturbance in later years.
Borderline Personality Theory
Borderline personality theory is a vast topic and for
more detailed analyses in this subject the reader is
referred to the work of Spitz (1965), Bowlby (1946, 1951,
1960, 1969), Rinsley (1965, 1968, 1972, 1978), Mahler
(1965, 1968), and Miller (1981). Borderline personality
theory focuses upon the significant acts of the mother
because of the traditional child-rearing role which women
have played in Western civilization. Consistent with
writings in the field, this review will also use the word
"mother" and the pronoun "she". The use of these words
should not be misconstrued to mean that only women play a
"mothering" role with their children.
Masterson (1972, 1974) summarized borderline
personality theory as it applies to adolescents. In
normal development, the first stage is symbiosis (3 mo. -
18 mo.). Symbiosis may be defined as an interdependent
relationship in which both parties (mother and child) are
necessary for the existence of each other. The mother is
very critical during this stage because she supplies the
35
"fertile soil", the nurturing, in which the child's ego
development takes place; she mediates between the child
and his or her environment; and she performs many of the
ego functions which the child later assumes.
The symbiotic stage is followed by the separation-
individuation stage (18 mo. - 36 mo.), one which is
equally crucial to development. This stage parallels and
is partially brought on by children's capability to walk.
As walking progresses, children undergo an intrapsychic
separation (in addition to the environmental reality) and
begin to perceive their own identities as separate from
their mothers. Three forces push children along the
normal developmental pathways: children's unfolding
individuation, the mother's encouragement and support, and
children's mastery of new ego functions. Children's
success in separating-individuating from their mothers is
a key part of the foundation upon which the rest of ego
structure is built.
In adolescents with borderline personalities the
natural developmental events do not take place. Masterson
(1972, 1974) and Miller (1981) wrote extensively about
such adolescents. The mother herself is a borderline
personality and consequently is unable to give her
children the emotional "supplies" (encouragement and
support) which they need to successfully
36
separate-individuate. Instead, she fosters a symbiotic
union with her child, encouraging the child's dependency
to maintain her own emotional equilibrium. She uses the
child to defend against her own feelings of abandonment.
She consequently clings to the child and does not support
the child's necessary growth toward
separation-individuation.
As a result, such children are threatened with the
withdrawal of emotional support from their mothers when
they attempt to separate. Unable to tolerate this
abandonment, the children learn to disregard certain of
their potentials in order to preserve the source of their
emotional supplies. They defend against feeling abandoned
by utilizing mechanisms such as ego splitting (viewing
oneself as totally good or totally bad) (Stewart, 1970)
and denial (Jacobsen, 1957). However, these defenses
"effectively block the patient's developmental movement
through the stages of separation-individuation to
autonomy" (Masterson, 1972, p. 23).
Thus, the cause of pathology in later years is a
developmental arrest at the stage of separation-
individuation, which produces severe deficits in ego
functioning. Three consequences of this fixation make
later interpersonal relationships difficult and often
unsatisfactory. First, the defenses of ego and object
37
splitting persist. Second, the patient fails to achieve
object constancy? that is, the person is unable to
maintain an interpersonal relationship when frustrated or
dissatisfied. Thus, relationships may fluctuate widely
depending upon the patient's need state. Third, the child
associates the negative attitudes of the mother with his
or her own self-image.
To summarize and give an overview: the two
diagnostic hallmarks of the borderline personality are
abandonment depression and narcissistic-oral fixation (the
phase at which development is arrested). The former is
obscured by the utilization of defense mechanisms such as
denial and ego and object splitting. The latter is masked
by the chronological age of the patient, which obfuscates
the true emotional, age of the patient. In addition, at
every instance that the child attempts to separate from
the parent, as in normal development, the child feels
guilt because of the wish to leave the parent.
The clinical manifestations of a person's borderline
syndrome are many and vary with the individual. However,
such adolescents characteristically are motivated by the
pleasure principle, seek immediate satisfaction and relief
from tension, possess a low frustration tolerance, and are
unable to control their own feelings.
Masterson (1972) stated that the most common defense
38
in these adolescents is aggressive acting out. Acting
out may take the form of simple boredom and restlessness,
but may also progress from this point to anti-social
behavior, stealing, alcohol abuse, drug abuse, sexual
promiscuity or running away. These adolescents act out
for the same reason that a drug addict uses narcotics:
"to fill the emptiness caused by the abandonment
depression" (Masterson, p. 61).
The Developmental Origin of Adolescent Psychopathology
There is general agreement in the scholarly
literature that adolescent psychopathology does not
develop overnight with the onset of puberty (cf.,
Disruptions during Childhood section). The clinical
manifestations may, however, appear suddenly, immediately
before or during adolescence (Masterson, 1972). Perhaps
as a result of the sudden onset of symptomatology, the
popular belief during the 1950's was that adolescent
emotional distress was indeed the result of the
maturational changes which accompany puberty. The
argument then continued that in these cases, psychotherapy
was not warranted because the adolescent would eventually
mature and the emotional distress would disappear
(Masterson, 1972).
Masterson (1972), Masterson, Tucker, and Berk (1963)
and Weiner (1970) wrote that psychological problems may
39
have been in "remission" during the quiescent years of
childhood. This distress then becomes evident during
adolescence because of the problems associated with ego
formation and identity that occur normally during this
time. That is, during normal development adolescents grow
toward independence and mastery of their environment.
Those who are unable to make this transition because of
earlier, unresolved issues may show symptoms of
psychological distress which reflect these earlier
traumas, as opposed to reflecting the normal stress of
adolescence.
Masterson (1972) conducted a study to ascertain which
of the above theories was correct. He followed 78
adolescent out-patients for 5 years and measured the
presence or absence of clinical symptoms over this time
period to ascertain if such symptoms did indeed disappear
with the termination of adolescence. He found that these
patients did not outgrow their problems, but that these
problems had, if anything, worsened. If the theory that
emotional problems were a natural side-effect of
adolescent development was correct, then one would expect
emotional problems to decline with increasing age. Since
the problems did not, in fact, disappear, Masterson
concluded that adolescent psychopathology derives from
events which occur earlier in life than the onset of
40
physical maturation.
Psychopathology and Acting Out
The literature establishes quite clearly the linkage
between problems in interpersonal relationships and the
development of psychopathology. Acting out is one
particular manifestation of psychopathology and is
characterized by a lack of insight and antisocial or
delinquent behavior (Symonds, 1974). Various forms of
acting out include persistent and serious lying, stealing,
repeated running away, physical violence against persons
or property, and chronic violation of age-appropriate
rules (DSM-III, pp. 48-50).
Symonds wrote that acting out behavior may be broadly
divided into two categories. In the first, the behavior
is seemingly disconnected from other people. In the
second, the the person who acts out is aware of other
people and acts out through them (e.g., fighting,
manipulating, or blaming). Symonds emphasized, however,
that "all acting-out behavior is essentially an unrelated
act" (p. 363).
Adolescents who act out generally share certain
common characteristics. Both Symonds (1974) and Ofman
(Note 1) pointed out that these individuals live only in
the immediate present. Additionally, they find it
41
difficult to delay gratification and possess a low
frustration tolerance (Masterson, 1972). The inability to
plan for the future not only is a characteristic of those
who act out, but also serves to continue the process,
because there is no point in withstanding immediate
frustration without some forseeable positive results
sometime in the future (Ofman, Note 1).
Acting out may be considered to be a form of
non-verbal communication (Hendrickson, Holmes, & Waggoner,
1959; Masterson, 1972). If this is the case, then the
issue arises of precisely what this behavior communicates,
or what is intended by those who act out. The literature
suggests that at least five non-exclusive meanings may be
gathered from acting out behavior.
First, acting out is considered to be a plea for help
(Masterson, 1972). He wrote that adolescents who act out
are unable to communicate their emotional distress
verbally and thus resort to non-verbal expressions. The
acting out behavior will continue until the plea is heard
and responded to (p. 45).
Second, acting out serves as a defense against
underlying painful feelings which have been denied
(Hendrickson & Holmes, 1959; Holmes, 1964; Masterson,
1972, 1974; Rinsley, 1968, 1974; Symonds, 1974; Ofman,
Note 1). Masterson regarded these acting out behaviors as
42
discharging feelings which more correctly should be
associated with painful childhood issues. Ofman wrote
that while acting out behavior is associated with negative
feelings, these feelings are nonetheless a substitute for
a deeper, interpersonal pain.
Third, acting out is one kind of response to
interpersonal events. Interpersonal theorists such as
Ofman (1976) and Sullivan (1953) considered all actions as
intentional responses to events in the world. While these
responses may be reflective of past experiences (parataxic
distortions), or may be societally inappropriate (Ofman,
Note 1) they are still related to the immediate events
which preceded them.
Fourth, acting out behavior is unrelated (Symonds) or
omnipotent (Ofman, Note 1) behavior. Omnipotence and
unrelatedness are interconnected in that unrelated acts
appear to have been originated without any interpersonal
context, so they appear to be self-motivated. That is,
these individuals respond in such a way as to remove or
negate the interpersonal context. For instance, if
someone speaks hurtfully to such adolescents, they might
respond by hitting the person or becoming verbally
abusive. Such responses are not only inappropriate, but
are designed to stop the interpersonal conversation from
continuing (Ofman, Note 1).
43
____ i
Fifth, acting out during treatment may serve as
resistance to treatment. Masterson (1972, 1974) and
Rinsley (1968, 1974) expected that acting out would erupt
frequently during treatment as painful childhood material
was uncovered because the patients would resist the
exploration. Kell and Mueller (1966) wrote of patients'
deep-seated ambivalence to change and of regression (or
continuing acting out) as expressive of that ambivalence.
Ofman (Note 1) wrote of the resistance as "undoing", in
service of maintaining the self as it was and of
maintaining a childish, irresponsible position in the
world.
Thus, acting out is one expression of
psychopathology. It should be understood as non-verbal
communication with at least five inter-related meanings
including a plea for help, a defense, a response, an
unrelated act, and a resistance.
Summary
In this section various theories regarding the
etiology of adolescent psychopathology have been
discussed. Interpersonal theorists located the source of
psychopathology in continuing distressful interpersonal
relationships, to which individuals respond by withdrawal
and dependence upon intrapsychic motivation. Both
44
alternatives lead to isolation and subsequent development
of clinical symptomatology.
Some authors attempted to locate both the precise
time of these interpersonal traumas and their common
source. There is considerable research evidence linking
early childhood deprivations and disruptions with the
development of particularly anti-social behavior. There
is disagreement in the literature, however, between those
who associated such behavior with deprivations in the
mother-child relationship and those who cited problems
with either parent or both parents.
Borderline personality theorists maintained that
mothers' inability to provide adequate nurturance and
support at the time of separation-individuation from their
children locked these children into a symbiotic
relationship with them. The children consequently suffer
from developmental arrest and abandonment depression and
are characterized generally by aggressive acting out
behavior.
There was substantial scholarly agreement supporting
the position that even sudden manifestations of clinical
symptoms during adolescence should be linked with earlier
distress and not with the normal stresses accompanying
adolescence.
Acting out was considered to be one form of
45
psychopathology, characterized by unrelatedness and
anti-social behavior. It was regarded as communication
with at least five inter-related meanings, including a
plea for help, a defense, a response to interpersonal
events, an omnipotent or unrelated act, and a resistance
maneuver.
There is substantial agreement that interpersonal
relationships, whether in early childhood or present-day
events, are related to the development of psychopathology
in general, and to acting out in particular. The
implications of these findings to treatment will be
discussed in the next section.
Treatment of Adolescent Psychopathology
The section above established theoretical
associations between poor interpersonal relationships, the
development of psychopathology, and acting out behavior.
The theories which explain these associations also are
pertinent in the treatment of such behavior. They will be
discussed in the following format: goals and method for
treatment, the therapy relationship, the therapy
relationship with adolescents, and empirical evidence.
Goals and Method for Treatment
With most acting out adolescents, the clearly stated
goal is a behavioral one: a decrease in acting out
behavior to a socially acceptable level (Program
__________________________ 46—
Literature, Note 2). The issue then becomes one of
method: how does a therapist or other involved individual
go about discouraging undesirable behavior? Ofman (Note
1) pointed out, for instance, that simple punishment has
almost always been tried in the past with these
adolescents and has failed. What.other alternatives are
there?
Many of the scholars cited in the previous section
characterized these adolescents as unrelated to other
people. Arsenian (1970) wrote that the inability to form
friendships was one aspect of poor mental health. At the
same time, this description, one of inability to establish
relationships, places such adolescents in the category
which the Menninger Foundation study (Kernberg, 1973)
found associated with the least favorable prognosis from
psychotherapy. Should the conclusion then be that these
individuals should not be treated with psychotherapy?
Interpersonal theorists do not agree with the above
conclusion. Instead, they state that the appropriate
treatment method lies precisely in helping these people
develop a capacity to tolerate such relationships.
Arsenian wrote that therapy is the "development of the
capacity for friendship" (p. 37). Strupp (1980a) wrote
that people come into therapy purposefully seeking a "good
human relationship and satisfying relatedness" (p. 595).
47
Symonds (1974) stated, "One of the basic goals in
treatment is to develop a sense of relatedness to others"
(p. 366) through a socializing process in which dependency
relationships are allowed to develop. Ofman (Note 1)
wrote that only through relationships could the
adolescents be influenced. Rinsley (1968) concluded that
the treatment process comes to develop the "basic
attributes of a healthy child-rearing experience" (p.
628) .
Thus, those theorists who found that the underlying
reason for the development of acting out behavior rested
in poor or difficult interpersonal relationships also
maintained that these individuals would become
psychologically healthier through re-learning or
developing the abiity to sustain such relationships.
The therapy relationship
This sub-section will consider the importance of the
therapy relationship in producing the desired goals
discussed above. It will be divided into two parts:
research regarding the therapy relationship, and the
nature of the therapy relationship.
Research. There, have been several reviews which have
discussed if there are any differences in client outcomes
associated with specific therapeutic techniques.
Luborsky, Singer, and Luborsky (1975), Smith and Glass
48
(1977), Bergin and Lambert (1978), and Shapiro (1980) all
concluded after reviewing various outcome studies that
there were no significant differences in outcome relating
to alternative treatment techniques, with the exception of
certain circumscribed disorders (e.g., phobias). Smith
and Glass stated, "Unconditional judgments of superiority
of one type or another of psychotherapy, and all that
these claims imply about treatment and training policy,
are unjustified" (p. 760).
Shapiro (1980) wrote that two different
interpretations may be given to researchers' failure to
establish significant differences between therapeutic
methods. First, the negative findings might be attributed
to the imprecision in outcome research. The argument
continues, if the instruments or measures were more
accurate, the specific factors might be identified. The
second interpretation asserts that various therapies have
common factors which enable all forms of therapy to
produce positive outcomes.
These common factors have been explored by other
scholars, with primary attention being paid to the therapy
relationship itself. Luborsky et al. (1975) wrote about
these common or "non-specific" factors, "The most potent
explanatory factor is that the different forms of
psychotherapy have major common elements — a helping
49
relationship with a therapist is present in all of
them...." (p. 1006).
Frank (1965), Wolberg (1954), Rosenzweig (1936), and
Strupp (cited in Luborksky et al., 1975, 1980a, 1980b) all
wrote of the therapeutic relationship as the "common
denominator" in therapy, regardless of the technique used
by the therapist. It was Strupp's contention that a
helping relationship itself is the agent of change (cf.,
the staff in an in-patient setting sub-section). Hynan
(1981) concluded, "The relationships are the effective
ingredients, not the techniques" (p.15).
The term "relationship therapy" was first used by
Levy (1938) in his attempt to establish a therapeutic
methodology which focused upon improving and enhancing
feelings human beings have for each other. He wrote that
the strongest instrument at the therapist's disposal is
the development of "strong affection and respect" for the
therapist by patients (p. 67). Patterson (1974) stated,
The therapy relationship... is the specific
treatment for persons whose problems inhere in or
relate to the lack of or inadequacy of good, or
facilitative, interpersonal relationships in their
past and/or current life experience. (p. 11)
He concluded that the therapeutic relationship was the
necessary and sufficient condition in which psychological
50
change or growth can occur (p. 11).
The nature of the therapeutic relationship. There is
some disagreement in the literature between those scholars
who regard the relationship as one which has meaning in
its own right and those who believe the relationship is
significant because it permits the reliving of past
experiences.
Theorists in the existential or humanistic schools
generally ascribe a value to the therapy relationship as
an immediate event. For instance, Levy (1938) emphasized
that individuals' relationships with others were more
important than the intrapsychic struggle which they
manifested. He wrote that verbalizations should be
accepted as responses to other people rather than as
expressions of "mental mechanisms" (p. 68).
Ofman (Note 1) supported this position. He stated
that adolescents come into treatment to learn new, more
acceptable behaviors (as opposed to their dealing
primarily with past, childhood events). They learn these
responses within an involved and involving relationship
(p. 4) in which the therapist responds to the adolescents
as they act out.
Allen (1934) summarized this position when he wrote
that the relationship is important as
51
a clarifying milieu, not as a representation of
another person, past or present, but because of
what he is experiencing with me at the moment.
This does not deny that the patient will behave
toward me as he has to others. I accept that the
feelings he will come to experience with me and
toward me probably are the same feelings that he
has had toward others.... But I am providing an
opportunity for this child to experience himself
in a new and present relation, and in terms of the
present and not in the past. (p. 197)
The psychoanalytic school, including the school of
object relations and borderline personality, represents
another theoretical position regarding the nature of
relationships. It views the therapeutic relationship
largely as one of transference. That is, patients
transfer onto the therapist feelings associated with
someone from their past, typically a parent. Within the
therapeutic relation, patients re-experience the past,
release anxiety and gain insight about events in their
lives and their responses to these events. As wounds
carried from the past are healed, patients improve
(Masterson, 1972, 1974; Miller, 1981). Thus, the value of
the relationship lies in the re-living of past trauma
through the transference between patients and therapist.
While these two interpretations differ as to the
nature of the therapeutic relationship, they agree as to
the importance of the relationship itself. It is through
this relationship between therapist and patient that the
52
patient becomes healthier.
Psychotherapeutic Relationships with Acting Out
Adolescents
In the treatment of adolescents the therapy
relationship written about previously is of particular
importance. It is the means through which these
individuals may first experience themselves as independent
from another and thus capable of initiating their own
actions and feelings (Allen, 1942; Rogers, 1951; Taft,
1933). The relationship may allow adolescents,
particularly those with a history of disruptive
interpersonal exchanges, a healthier expression of
themselves (Allen, 1934). This sub-section will explore
the relationship between troubled adolescents and
therapists, considering the issues of the characteristics
of a good therapeutic relationship, initial difficulties,
and responses to acting out behavior.
Characteristics of a therapeutic relationship. While
therapeutic relationships are individual and unique,
without defined specific steps (Josselyn, 1957), several
authors have written of the components present in an
established relationship. Weiner (1970) wrote that the
impact of the treatment relationship which the therapist
builds with patients usually depends on the ability of the
53
therapist (1) to maintain the flow of communication, (2)
to foster patients' positive identification with the
therapist, and (3) to regulate patients' concern regarding
the implications of the treatment relationship for their
independence (p. 362).
Holmes (1964) described the following features of a
helpful and progressive treatment relationship with
adolescents:
1. The relationship develops spontaneously rather than by
design.
2. It is subjectively satisfying to both parties, but
only intermittently.
3. It survives transiently negative feelings, such as
anger, frustration, resentment, disappointment, and
distrust.
4. It permits both patient and therapist to tolerate the
falling short of original aims and to refocus upon new
problems.
5. It can accommodate patients' improvement in therapy,
with the accompanying double-edged threat and promise
of increased independence, the threat to both of
impending separation, and the threat of the decrease
in some neurotic symptoms.
6. The therapeutic relationship does not develop
overnight and does not come about easily. (pp» 8-9)
54
Initial difficulties. As stated by Holmes in point 6
above, the therapeutic relationship may be a difficult one
to establish, particularly with adolescents. Feinstein
(1980) wrote that this problem may be related to the
disparate values of therapist and adolescents. Weiner
(1970) attributed this problem to patients' age and normal
associated immaturity, which makes it difficult for them
to recognize the need for help. Lorand (1961) commented
that adolescents' characteristic impatience, lack of
insight, non-verbalization and refusal to cooperate make
therapy with teenagers difficult and frustrating for the
therapist. Kell and Mueller (1966) wrote in general of
the ambivalence which all patients feel toward therapy
because of their desire both to change and to avoid
feeling unpleasant emotions. This ambivalence may then
show itself as resistiveness to treatment.
The problem of establishing a relationship with
adolescents, particularly those who act out, may be
compounded by their unwillingness or inability to
communicate verbally (Hendrickson, Holmes, & Waggoner,
1959; Masterson, 1972). Hendrickson et al. stated,
So, although we meet with the patient for the
nominal purpose of exchanging ideas through words,
it is seldom that we hear a direct verbal
expression from an adolescent in which the
important feelings involved correspond to the
literal content of his statement. (p. 529)
55
Instead the adolescents "talk" most directly via
behavioral clues. Thus an important therapuetic function
is to learn to understand and respond to these non-verbal
communications (Hendrickson et al.).
Holmes (1964) explained that most adolescents are
brought into therapy unwillingly, as opposed to adult
clients, and that this unwillingness and refusal to admit
the need for therapy make the establishment of a
therapeutic alliance problemmatic. Thus, he concluded,
"The first order of business in the treatment of the
adolescent is to get him into treatment, and the next is
to keep him there" (p. 123). Weiner (1970) wrote that the
therapist may establish the relationship more quickly
through permitting patients to be comfortable, by engaging
them at a level beyond the superficial and obvious, and by
encouraging them to acknowledge and respect their own
roles in determining the course of treatment (p. 355).
Hendrickson, Holmes, and Waggoner (1959) wrote, "It
appears that the best way to 'build a relationship' with
an adolescent is to avoid scrupulously ariy self-conscious
effort to do so" (p. 528).
Therapeutic responses to acting out. Masterson
(1972) wrote that disturbed adolescents are actually
desperate for help, but are unable to verbalize their
distress. Consequently, acting out behavior is in reality
56
a plea for help on a non-verbal level and will continue
until their plea is heard and responded to (p. 45). Many
parents and occasionally the therapist "handle the
behavior permissively, thereby missing its true meaning
and rejecting his the patient's mute plea for control.
This throws him back on his own meager capacities and
plunges him into lonely despair" (Masterson, p. 50).
The appropriate therapeutic response is to control
patients' behavior for them, assuming responsibility for
that which they cannot themselves control. Masterson
wrote that the response of the therapist to the acting out
behavior of adolescents is "as much a true rescue
operation as the lifeguard who dashes into the water with
a life preserver" (p. 46).
To continue this approach to treatment of disturbed
adolescents, the control of acting out by the therapist
(or staff in an in-patient setting) serves three
functions. First, as mentioned above, it is the correct
response to the adolescents' plea for help. Second, it
decreases or eliminates the use of acting out as a defense
against or resistance to treatment (Hendrickson & Holmes,
1959; Holmes, 1964; Masterson, 1972, 1974; Rinsley, 1968,
1974). So long as the defense mechanism is allowed to
persist, the underlying significance of such actions will
remain hidden and the patient will remain unengaged from
57
t h e t h e r a p e u t i c a g e n t ( R i n s l e y , 1968). M a s t e r s o n (1972)
s i m i l a r l y s t a t e d t h a t t h e m a n a g e m e n t o f a c t i n g o u t
b e h a v i o r i s p a r t i c u l a r l y i m p o r t a n t b e c a u s e a c t i n g o u t
d i s c h a r g e s f e e l i n g s w h i c h m i g h t o t h e r w i s e a r i s e t o
c o n s c i o u s n e s s a n d b e c o m e a v a i l a b l e f o r t h e r a p e u t i c u s e ( p .
109). T h i r d , t h e c o n t r o l o f a c t i n g o u t b e h a v i o r i s t h e
a g e n t t h r o u g h w h i c h t h e t h e r a p y r e l a t i o n s h i p i s
e s t a b l i s h e d , b e c a u s e t h e r a p i s t s p r o v e t h e m s e l v e s w o r t h y o f
p a t i e n t s ' t r u s t ( M a s t e r s o n , 1972, 1974; R i n s l e y , 1968,
1974). T h i s p h a s e o f t r e a t m e n t i s g e n e r a l l y c a l l e d
r e s i s t a n c e .
As the process described above occurs and a
therapeutic relationship established, the most important
phase of treatment, "working through", can begin. During
this time, the therapeutic relationship is the vehicle
through which past relationships can be remembered,
discussed, and resolved. The patients' underlying
feelings of depression, rage (including homicidal
fantasies and impulses), fear, and guilt are addressed
(Masterson, 1972). As has been discussed above, a
transference develops in which patients' feelings toward
significant others in their past are directed toward the
therapist. When such feelings are aroused, they can then
be directed toward the appropriate historical recipient
and then explored. The absence of proper mothering, which
58
would have encouraged separation at an early age, and
consequent abandonment, which the patients experience,
must be felt directly by the adolescent patients.
Masterson (1972) and Miller (1982) emphasized that it is
only through first awareness and then actual mourning of
the loss that patients will become healthier.
Psychological well-being develops from an admission
of negative feelings toward people who previously were
given only positive feelings, and from the knowledge of
these individuals' negative as well as positive responses
to the adolescents. In this way, object splitting is
resolved and patients can begin to perceive themselves and
others as comprising both negative and positive aspects.
As awareness grows and mourning is acknowledged, the need
to defend against feeling these emotions diminishes.
Acting out, which is one defense, is no longer necessary
and therefore ceases. This psychological growth is
accomplished through the therapeutic relationship.
As discussed in the section concerning the nature of
the therapeutic relationship, another theoretical position
considers the therapy relationship not as a vehicle
through which to experience and resolve the past, but as
the actual event through which change occurs. Ofman (Note
1) wrote, "The adolescent....has been abandoned,
betrayed, lied to and isolated by significant others in
59
his life....He has learned to be what he or she is now"
(p. 1). The current relationship(s) is the situation or
context in which new behavior may be learned. Ofman
stated,
The adolescent...will have to be placed in a
situation where involvement with other
persons...is central.... It is within the human
context that influence occurs....It is the human
dimension which must become tacit and
internalized.... It is the therapeutic agents who
are the intermediaries between the miasma of the
resident's former life (its disorganization,
leading to the resident's disorganization), and a
gathering awareness that life can be
different...as an antecedent to a congealing of
some awareness or formulation of what that person
wants...and the steps which facilitate or impede
the attainment of that person's (growing)
awareness of his goals. (pp» 4-5)
T h i s v i e w i s c o n s i s t e n t w i t h t h e o n e d e s c r i b e d
p r e v i o u s l y i n t h a t a c t i n g o u t b e h a v i o r m u s t n o t b e
t o l e r a t e d . I t c o n s i d e r s t h e b e h a v i o r , h o w e v e r , a s m o r e o f
a l e a r n e d r e s p o n s e t o a n i n t e r p e r s o n a l s i t u a t i o n t h a n a s a
d e f e n s e o r a p l e a f o r h e l p ( a l t h o u g h t h e s e e l e m e n t s a r e
n o t d e n i e d ) ( H o l m e s , 1964? O f m a n , N o t e 1). T h e e m p h a s i s ,
h o w e v e r , i s n o t u p o n c o n t r o l l i n g t h e b e h a v i o r a t a l l c o s t s
b u t i n s t e a d u p o n c o n t r o l l i n g t h e b e h a v i o r w i t h a c e r t a i n
a t t i t u d e . O f m a n a n d H o l m e s a n d h i s c o l l e a g u e s
( H e n d r i c k s o n & H o l m e s , 1959, 1960; H e n d r i c k s o n e t a l .,
1959; H o l m e s , 1964) w r o t e t h a t t h e t h e r a p e u t i c a g e n t ( s )
m u s t h a v e a n a t t i t u d e w h i c h d o e s n o t a l l o w a c t i n g o u t
b e h a v i o r t o e x i s t . A c t i n g o u t b e h a v i o r m u s t b e t r e a t e d a s
60
unthinkable. Such an approach succeeds only if the
therapists are involved sufficiently in the relationship
to render their belief meaningful to the patients (Ofman,
Note 1).
The enforcement of limits and administration of
consequences to acting out must be given within the
context of the therapuetic relationship. The impact of
limits and consequences on the behavior of the adolescents
increases if they are connected to another person's
responses (Ofman, Note 1). The source of change "is the
influence growing out of the interpersonal relationship
where people are human, hurt, disappointed, glad for,
non-caring, soft, caring, hard, close, distant, paired,
proud, etc! Human" (Ofman, Note 1, p. 21).
Instead of regarding and treating acting out behavior
as an impulsive act determined by unconscious feelings,
this view considers the behavior to be an intentional,
although learned response. It is a response
characteristic of an unrelated person (Symonds, 1974).
Alternative behaviors can be offered by the therapist and
adopted by the adolescents as they learn that the old
behavior was intentional, as opposed to determined (Ofman,
Note 1). Thus the treatment objective becomes bringing
the adolescents into greater relationship with other
61
people so that acting out behavior is increasingly
anachronistic in that setting.
Empirical Evidence
Clinicians and scholars have written extensively
about the importance of therapeutic relationships in
treatment and the ability of individuals to have
relationships as an indication of psychological health.
There are in the literature a few studies in which authors
have provided clinical support for these theories.
Pitt (1964) studied the association between length of
hospitalization for adolescents and the quality of the
interactions between them and their peer group. He found
that length of hospitaliztion was correlated with the
quality of the interaction. The implication is that poor
relationships may be associated with psychological
symptoms requiring hospitalization and vice versa.
Working with delinquents, Massimo and Shore (1963;
Shore & Massimo, 1966) wrote of a vocationally-oriented
program in which therapists were involved in every aspect
of the delinquents' lives. The therapists focused on
practical and psychological assistance with problems. The
treated subjects had ' better records over two years than
the controls (fewer as well as less severe offences),
although the numbers were too small for statistical
62
evaluation.
Persons (1966) conducted group therapy which
attempted to establish relationships in which the
therapist acquired influence over the patients and then
exercised this influence systematically through modeling,
shaping, and persuasion techniques. Records indicated
that the treated group demonstrated less infractions
during treatment than a control group and a lower
recidivism rate over a one-year follow-up period.
Truax, Wargo, and Silber (1966) demonstrated a
correlation between therapist who offered high levels of
facilitative conditions to female juvenile delinquents in
a group therapy setting and their later
institutionalization rates. Those delinquents who
received high levels of facilitative conditions from
therapists later showed lower institutionalization rates
than a control group. Such a correlation implies that if
juvenile delinquents are treated interpersonally with
warmth and empathy, their anti-social behavior may
decrease.
Guerney, Coufal, and Vogelsong (1981) used a specific
method of Relationship Enhancement in which skills in
certain specific modes of interpersonal behaviors were
taught in a group setting utilizing psychologically
disturbed mother-daughter pairs. They compared these
63
results with a traditional therapy group and a control
group. Before treatment the three groups did not differ
from one another in the general quality of their
relationships. After treatment, the traditional therapy
group showed improvement on three of five measures of
general relationships; the Relationship Enhancement group
showed improvement on all five measures. Both treatment
groups showed greater improvement than the control group,
supporting a theoretical position that both traditional
therapy, which emphasizes the therapeutic relationship,
and Relationship-Enchancing treatment, will lead to
improvement in the quality of general relationships.
Girona (1972) studied the effects of a significant
volunteer adult in the environment of a child, under
experimental control, and assessed independently of other
factors. The treatment consisted of bulding a relationshp
between volunteer and patient over time. Results
supported hypotheses that there would be a significant
increase in the children's scores on general adjustment
and IQ and a significant decrement in the scores on need
nurturance afte child spend time with the adult. There
were no significant results with regard to scores on views
of self, views of adults, creativity, independence, and
aggression.
Haslam (1978) studied adolescent in-patients in a
64
psychiatric hospital and hypothesized that they would have
significantly fewer satisfactory human relationships than
a control group of non-psychiatric hospitalized patients,
and that the more difficulty the patients had in
developing these relationships, the worse would be the
prognosis (p. 305). (Haslam added, "A corollary of this
should be that a psychotherapeutic technique designed to
give the patient this kind of relationship should improve
the prognosis in proportion to its degree of success".)
(p. 305). Subjects were also divided into sub-groups by
psychiatric diagnosis. After the patient group was
selected, a two-year follow-up period occurred during
which this group received treatment of various kinds,
including "relationship therapy" (i.e., empathy).
Individuals were asked about the number of relationships
they had, and to rate the depth of these relationships
again at the end of the follow-up period.
A measure of the success of the relationship therapy
would be indicated by high scores in this measure.
Results supported the hypothesis that the patient group
had less adequate relationships than did the control
group. One psychiatric sub-group, that of personality
disorders, showed that the use of relationship therapy
appeared to have improved the adolescents' ability to
65
relate to others. In other diagnostic groups, its use
appeared irrelevant in this respect (p. 308). Results
also showed a positive correlation between final T.A.R.
score and a lack of residual symptons.
In a review of the literature regarding research and
traditional psychotherapy theory, Shapiro (1975)
concluded:
This review suggests that the literature does not
justify, and may indeed make untenable, the view
that social relationships have no place in the
modification of psychological disturbances. It
implies that, with greater specification of goals,
techniques and client and therapist
characteristics, the nature and extent of the
contribution of social relationships to treatment
outcomes will become increasingly clear.
Similarly, the operation of interpersonal
processes between the clinical psychologist and
his patients in other contexts is a valuable
object of concern. (p. 205)
Summary
In this section the treatment of adolescents who act
out was reviewed in four sub-sections. The first
considered goals and methods for treatment. The general
goal was considered to be a decrease in acting out
behavior to the point that the adolescents could live
appropriately in society. A theoretical position for
treatment in which acting out behavior is decreased by
increasing individuals' ability to get along with other
people was discussed.
66
Second, the therapy relationship itself was
discussed. Research indicated that there are no
differences between specific techniques in psychotherapy
with regard to outcome (with certain specific exceptions).
Various authors wrote that this lack of difference might
be attributed to the common factors which all therapies
share, particularly to the therapy relationship itself.
The nature of the therapy relationship was then reviewed.
Certain scholars, particularly in the object relations
school, considered the relationship to be largely one of
transference. Interpersonal theorists wrote that the
therapy relationship has a value in and of itself.
Third, the therapy relationship with adolescents was
reviewed. Characteristics of the therapy relationship
were considered. Initial difficulties in establishing the
relationship were the focus of some authors, who wrote of
particular problems with adolescents because of their
unwillingness to be treated, their immaturity, their
ambivalence, and their non-verbalization. Therapeutic
responses to acting out were then discussed. Some authors
considered the control of acting out behavior to be of
paramount importance, maintaining that this control serves
three functions: it responds appropriately to
adolescents' plea for help; it helps to eliminate acting
out as a defense; and it serves as the agent by which the
67
therapy relationship is established. Once the
relationship is established, these authors contended that
it functions as the vehicle through which patients mourn
their childhood abandonment. Interpersonal theorists
wrote that the therapy relationship, having immediate
value, offered a context in which genuine involvement
could bring about psychological change. They considered
the attitude of the therapist(s) to be of most importance
in the control of acting out behavior.
Fourth, empirical evidence was reviewed. These
studies indicate that there is a correlation between
relationships with other people and acting out behavior.
Studies by Massimo and Shore (1963), Shore and Massimo
(1966), Persons (1966), and Truax et al. (1966)
demonstrated in work with juvenile delinquents that lower
rates of anti-social behavior were associated with various
treatments emphasizing the importance and quality of
interpersonal relationshps.
Guerney et al. (1981) worked with mother-daughter
pairs and concluded that both Relationship-Enhancing
treatment and traditional therapy lead to increased
quality in the interpersonal relationshps, as compared to
a control group.
Girona (1972) concluded that interactions with a
significant adult could be associated with increases in
68
s u b j e c t c h i l d r e n ' s s c o r e s o n g e n e r a l a d j u s t m e n t a n d I Q .
Haslam (1978) compared adolescent psychiatric
patients and adolescent hospitalized non-psychiatric
patients. Psychiatric patients showed initailly fewer
adequate relationships. There was a two-year period
during which various treatments, including relationship
therapy, were given to the subject psychiatric group. In
a diagnostic group of personality disorder, the
relationshp therapy was associated with an increase in the
patient's ability to relate to others. In other
diagnostic groups, there was no correlation.
In-Patient Treatment of Adolescents
While the etiology and treatment methods discussed in
the previous sections are applicable to the treatment of
adolescents on an in-patient basis, there are several
factors which relate specifically to in-patient treatment.
These will be reviewed here in five sub-sections:
rationale, purpose and goals for placement; the functions
of the milieu; the client in an in-patient setting; the
role of the therapist; and the role of the staff.
Rationale, purpose, and goals for placement. There
are different means of assessing or diagnosing the need
for placement of adolescents in an in-patient treatment
setting, away from their families. Rinsley (1968) wrote
69
that such individuals are generally found to suffer from
"a variety of difficulties which together comprise the
protean syndrome of ego weakness" (p. 612) and are
typically diagnosed as "borderline" or given labels such
as "schizophrenic, psychotic, character
neurotic...immature, impulse-neurotic,
polymorphous-perverse, or infantile-narcissistic" (p.
612) .
Such diagnoses, in and of themselves, are not
sufficient cause for placement in an in-patient setting.
The actual reasons for the placement lie rather in
disturbed adolescents' tendency to act out or become
otherwise unmanageable in society at large. Rinsley
(1968) emphasized the environmental nature of placement
when he wrote that individuals are generally referred for
placement by other people (e.g., family, friends, or
representatives of various public agencies) because there
has been a disruption in interpersonal communication (p.
613) .
Rutter (1980) described specifically some of these
sociological reasons for placement:
when the young person's behavior was too disturbed
to be managed elsewhere...? when psychiatric
problems were associated with severe medical
conditions...; when there was a life-threatening
condition...? when intensive intervention was
required in conditions not manageable at home...?
when the problem required a controlled separation
70
of the adolescent from his family...; and when the
main therapeutic action required manipulation of
the total environment. (p. 286)
Alt (1960) stated these environmental reasons even more
succinctly: "The primary reason for removal from
community and family has been behavior which spells
hostility to the adult world" (p. 141).
While there is a fairly substantial body of
literature regarding the method of treatment for
adolescents in an in-patient setting, little has been
written regarding the purpose for such treatment, as
opposed to out-patient treatment, other than the removal
of acting out individuals from society. Rinsley is one of
the few authors who addressed this issue. He wrote that
there were three purposes in residential treatment: (1)
to provide a setting in which acting out, as a form of
resistance or as a defense, would not be abetted; (2) to
separate the adolescents from their skewed, pathological
familial constellations (since Rinsley assumed that the
cause of severe emotional problems rested within the
family structure); and (3) to provide an environment in
which patients' anxiety could be kept at an optimum level
(assuming anxiety has a curvilinear relationshp with
psychological change) for therapeutic work (1968, pp.
619-620).
In another article, Rinsley (1974) addressed other
71
r e a s o n s f o r t r e a t m e n t i n t h i s p a r t i c u l a r s e t t i n g . H e
w r o t e t h a t s u c h t r e a t m e n t m u s t p r o v i d e t w o b a s i c
i n g r e d i e n t s :
(1) It must provide accurate diagnosis, sensitive
understanding, and adequate psychiatric treatment
of the adolescent's illness. (2) It must provide
cognitive-intellectual and emotional growth
experiences, including education, and
occupational, recreational, and vocational
modalities appropriate for the patient's age and
cognitive development and for the nature, degree,
and chronicity of his illness. (p. 353)
Ofman (Note 1) added that the residents must learn to
assume responsibility for their own behavior during
in-patient treatment.
L i t t l e h a s b e e n w r i t t e n a b o u t t h e g o a l s f o r
i n - p a t i e n t t r e a t m e n t . A l t h o u g h i t m u s t b e a s s u m e d t h a t
o n e g o a l i s t o r e t u r n i n d i v i d u a l s t o a m o r e o p e n s e t t i n g
i n s o c i e t y w i t h o u t r e c i d i v i s m , t h i s i s r a r e l y e x p l i c i t l y
s t a t e d i n t h e l i t e r a t u r e .
Hendrickson, Holmes, and Waggoner (1959), Holmes
(1964), and Rinsley (1974) wrote concerning how the goal
stated above might be realized. They stated that basic
goals for residential treatment were for the adolescents
to develop greater internal strength (ego strength) in an
environment which was less threatening to them than normal
society, for them to develop healthier relationships with
adults and peers than they had had in the past, and for
72
these patients to be increasingly socialized so that they
might progress when they returned to a more open setting.
Functions of the milieu. A milieu is any environment
in which people live. Therapeutic milieu, or milieu
therapy, refers to treatment in which the environment is
recognized and utilized as a therapeutic agent through
which psychological change can occur (Cumming & Cumming,
1962? Gunderson, 1978). A therapeutic milieu can consist
of any number of treatment modalities, including, for
example, group therapy, a school program, occupational
therapy and recreational therapy (Holmes, 1964? Rinsley,
1974).
Various personnel may also be considered to be part
of the therapeutic milieu, including the care-taking
staff, teachers, nurses, administrators, and social
workers, in addition to psychotherapists, and may
establish therapeutic relationships with the residents
(cf., role of the staff sub-section).
In addition to the many components of the therapeutic
milieu, such a milieu may perform different specific
functions. Gunderson (1978) attempted to outline
underlying functions which may pertain to all milieus,
irrespective of psychological theory. He discussed five
functions which milieus could ideally perform, including
containment, support, structure, involvement, and
73
validation. These functions will be examined in greater
detail below.
1. Containment. Gunderson stated, "The function of
containment is to sustain the physical well being of
patients and to remove the unaccepted burdens of
self-control or feelings of omnipotence" (p. 329) . Every
author surveyed for this review who addressed him or
herself to this question stated unequivocally that
adolescents' acting out behavior must be controlled and
eliminated as soon as possible. Hendrickson and Holmes
(1959) gave an example of various scholars' reasoning:
In our opinion, no program can be therapeutic
which sanctions grossly delinquent behavior on the
false assumption that necessary prohibition of
such activities is not compatible with a
sympathetic and accepting attitude. (p. 970)
While various authors unanimously agreed upon the
above point, there was some disagreement upon the best
method through which control over behavior should be
obtained, particularly regarding the question of a closed
vs. an open setting. In-patient units may either be
locked, so that patients cannot elope (closed); or they
may be unlocked, so that patients are allowed greater
physical movement of their own volition. (In current
parlance, the closed setting is more commonly referred to
as a hospital setting and the open setting as a
74
residential one.)
Rinsley (1968) strongly advocated a closed setting.
He wrote,
The residential milieu must provide controls for
the patient's behavior, in some cases stringent
ones....To this end, the closed ward is essential,
for it alone provides the security of carefully
titrated behavioral restrictions which must
operate to force the patient back upon and within
himself, so to speak. (p. 619)
Conversely, Hendrickson and Holmes (1959) recommended
operation of a "semi-open unit with furnishings and
equipment planned more in the interests of pleasantness
than physical security" (p. 969), while concurrently
placing strict moral standards of behavior upon residents.
They reasoned that this type of setting was actually less
permissive than a closed one, because the expectations for
residents' behavior were so high.
However, in a discussion following the Hendrickson
and Holmes (1959) paper, Krush commented upon another
statement by Hendrickson and Holmes. They had written:
To profit by treatment in an all-adolescent ward,
patients — however sick — must have some little
potential for impulse-control. They must also
have enough relationship capacity to feel concern
about adult expectations of them. (p. 970)
Krush wondered if, by so limiting their population, the
authors might be "avoiding the problem of treating the
75
more seriously mentally ill adolescents" (p. 973).
2. Support. "Support refers to conscious efforts by
the social network to make patients feel better and to
enhance their self-esteem" (Gunderson, 1978, p. 329). The
purpose is to help patients feel less anxious and
distressed. It may be given as actual behavioral
provisions, as verbalizations emphasizing self-esteem, or
as verbalizations primarily dealing with the development
of ego strength. Milieus which emphasize support provide
nurturance and encourage patients to enter other, specific
therapies such as psychotherapy.
3. Structure. "Structure is all aspects of a milieu
which provide a predictable organization of time, place,
and person — i.e., it acts to make the environment less
amorphous" (Gunderson, p. 330). This function of a
milieu is the one most closely aligned with milieu therapy
because its intent is to promote more socially adaptive
behavior in patients. To be effective in treatment, the
milieu must be predictable and consistent (Treffert,
1969) .
A predictable and consistent structure may be
achieved in at least two non-exclusive ways. Beavers
(1968), Gunderson (1978), Hendrickson and Holmes (1959),
and Rinsley (1968) recommended establishment of privilege,
76
responsibility, or level systems wherein patients are
permitted increasing increments of privilege when they
display greater personal responsibiity for their actions.
Additionally, Alt (1960), Beavers (1968), Hendrickson and
Holmes (1959), Rinsley (1974), and Treffert (1969) wrote
that the daily schedule is an important aspect to
structure. A schedule largely filled with planned
activities promotes consistency and predictability. In
addition, these activities serve several therapeutic
purposes including reducing unstructured time in which
acting out behavior might occur, introducing opportunities
to interact and establish relationships with the staff and
peers, providing real conflicts which then reflect
important therapeutic issues, and increasing the skills of
the adolescents (Holmes, 1964).
4. Involvement. "Involvement refers to those
processes which cause patients to attend actively to their
social environment and interact with it" (Gunderson, p.
330). Activities which facilitate involvement include
patient- and staff-led groups, community meetings, open
and closed rounds, meetings regarding goals involving both
staff and patients, and patient-inspired activities.
T h e t e n d e n c y o f a d o l e s c e n t s t o f o r m g r o u p s , a n d t o b e
v u l n e r a b l e t o t h e o p i n i o n o f t h e s e g r o u p s , c a n b e a n
i m p o r t a n t a s p e c t i n h e l p i n g a d o l e s c e n t s t o w a r d
77
involvement. Group identification with adult societal
values can be promoted by the staff (Hendrickson & Holmes,
1959) and supported by other adolescents (van den Bergh,
1968; Holmes, 1964). Rinsley (1974) and Alt pointed out,
however, that adolescents may tend to form oppositional
sub-groups, particularly during the initial testing phase
of treatment, which may have to be dissolved before these
groups may function in a pro-societal manner.
5. Validation. "Validation refers to the ward
processes which affirm a patient's individuality"
(Gunderson, p. 331). Such processes include individual
program planning, a patient's right to privacy, and
one-to-one relationships between various staff and
patients.
Gunderson emphasized that while these functions could
all be achieved by a particular milieu, and while such a
milieu might indeed be the ideal, they do not all
necessarily exist within a therapeutic milieu. Nor are
they all necessarily present at the same time. For
instance, while a containment function seems essential at
the beginning of treatment, it may become less critical as
patients' acting out behavior decreases. Or, as Gunderson
wrote, a particular function may not be appropriate with
certain types of patients. For instance, a milieu which
emphasizes support may confirm a depressed patient's sense
78
of inadequacy. Finally, the emphasis which a particular
milieu places upon certain functions reflects the
treatment philosophy which the program has adopted (e.g.,
a behavioral program might emphasize structure).
Adolescents in an in-patient setting. This
sub-section will consider whether adolescents who are
treated in an in-patient setting act differently, by
virtue of their confinement itself.
Rinsley (1968, 1974) wrote that the defensive,
resistive maneuvers of adolescent in-patients may be
intensified, because of their persistent efforts to
sabotage the treatment and return to their disruptive, but
familiar family setting. He cited 13 resistance maneuvers
which confined adolescents typically perform. These
various forms of acting out are identification with the
aggressor (attempts to imitate the behavior of adults),
leveling (attempts to make friends of the staff),
flirtatiousness and seductiveness, oversubmissiveness,
persistent avoidance (frank negativism, disruptive efforts
to provoke isolation, absorption in daydreaming fantasy),
scapegoatism (denigration of peer group), outright
rebelliousness, transference diffusion (attempts to keep
knowledge of themselves spread thinly), somatization,
peer-age caricaturing (attempts to be viewed as a
"typical" adolescent), clique formation, "craziness" and
79
"pseudo-stupidity", and elopement.
Another way in which adolescents become different,
because of their confinement, is in the availability of
all their interactions for therapeutic scrutiny. Because
the residents live in the treatment setting, go to school
and play in this environment, and form alliances (neurotic
or otherwise) there, there are a multitude of real-life
events which can be used to advantage in exposing or
working with their psychological problems (Alt, 1960;
Hendrickson et al., 1959; Holmes, 1964). Thus, the
patients provide even greater exposure of their
psychological processes in an in-patient setting.
Therefore, while the psychological problems of these
adolescents remain unchanged when they are initially
confined, both their resistance and their availability for
therapeutic interactions may intensify, simply because of
the confinement.
The role of the therapist. The traditional role of
the psychotherapist will probably become less well-defined
in an in-patient setting because the therapist may
function in other arenas than the traditional therapy
hour.
For example, Alt (1960), Beavers (1968), Hendrickson
and Holmes (1959), Hendrickson et al. (1959), Holmes
(1964) and Masterson (1972) indicated that the therapist
80
may be one of the staff personnel who are responsible for
granting or curtailing privileges to residents. While
this expansion in the duties of the therapist may seem at
first to be disruptive to the therapeutic relationship,
Hendrickson and Holmes stated that such activities may be
of benefit in the establishment of such a relationship.
They reasoned that these adolescents are seeking "adult"
figures and that the non-verbal, but authoritative role of
the therapist in determining privilege levels would
establish the therapist as that adult. They wrote that
this form of non-verbal communication might serve to
establish the relationship more quickly than an overt
communication from a therapist wanting to establish a
relationship.
Alt (1960) concerned himself particularly with the
impossibility of classical therapeutic neutrality in an
in-patient setting. He stated that therapists will
inevitably be involved in decisions regarding patients'
privileges, whether they want to be or not, because they
can add necessary clinical input to a decision-making
process. If they were to pretend to be neutral, patients
would recognize the artificiality of the therapists'
position and would become less trustful and accessible to
treatment.
81
Alt (1960), Holmes (1964), and Masterson (1972) also
indicated that this involved position on the part of
therapists may provoke important feelings, particularly of
a negative nature, from their patients. These feelings
directly involving the therapists may then be utilized in
treatment, interpreted either as negative transferences or
as feelings related to real-life events.
Thus, therapists typically assume a more directly
involved and powerful role in the treatment of their
patients in an in-patient setting. While the role
represents a diffusion of the traditional, neutral
psychotherapeutic one, various authorities concluded that
a more involved stance may actually promote establishment
of a relationship and may bring important feelings into
the therapy setting.
Role of the staff. The staff in an in-patient
setting functions as a source of additional therapeutic
relationships, as an important structural unit, and as an
important attitudinal resource in the treatment of
disturbed adolescents.
The staff, in a general sense, may be said to
comprise all the personnel employed in the in-patient
setting, including, for example, the child care staff,
teachers, nurses, administrators, and social workers, in
addition to the more traditional psychotherapists. These
82
various agents may also develop therapeutic relationships
with the residents. In fact, Levy (1938) commented that
it might be easier for personnel other than trained
physicians to maintain a positive interpersonal
relationship with their patients. He stated,
It is a great temptation... for psychiatrists,
especially those psychoanalytically minded, to
forget the patient and his actual relationships
and interest oneself in the way his mind works and
the beauty of its various forms. For this reason
less sophisticated workers in this field make
good relationship therapists. (p. 68) (emphasis
added)
Additionally, the Vanderbilt Study (Strupp, cited in
Luborsky et al., 1975; Strupp & Hadley, 1978; Strupp, Note
3) compared the effectiveness of a group of five
experienced psychotherapists and seven college professors,
carefully chosen for their untrained helpfulness, in
working therapeutically with fifteen neurotic college
students. Both these groups were then contrasted with a
control group of students on a waiting list. Both
treatment groups were significantly more improved than the
control group on four of the six variables (MMPI,
self-rated overall change, experts' ratings on clinical
scales of disturbance, and patients', therapists', and
clinicians' ratings of changes in initial complaints).
H o w e v e r , r a t i n g s b y p a t i e n t s , t h e r a p i s t s a n d c l i n i c i a n s
\
showed no significant differences between the two
83
treatment methods.
Bergin . and Lambert theoretized that patients who
appear to undergo a kind of "spontaneous remission" might
have discovered powerful change agents that exist
naturally in society, people who are naturally gifted in
forming therapeutic relationships and consequently perform
a sort of "lay" therapy. They cited a growing body of
literature which supports the view that minimally trained
individuals can have significant effects upon the
psychologically disturbed (Bergin & Lambert, 1978, p.
150) .
Various studies have been conducted in which
minimally trained personnel interacted with disturbed
children or adolescents (Cowen, Zax, & Laird, 1966;
Hilgard & Moore, 1969; Mitchell, 1966; Schaefer, 1981).
In all cases, the patients were found to improve in such
categories as self-image, verbal skills, and ability to
interact after their involvement with such personnel.
In France, an "educateur" is utilized in the
treatment of disturbed children and, to some extent, this
person replaces the therapist (Joubrel, 1971; Linton,
1969). Joubrel quoted Lucien Bovel in explaining the
rationale for the educateur program: "'The only real
chance of "cure" for a socially maladjusted youngster is
to be able to form a warm and stable relationship, with an
84
adult worthy, in his eyes, of being loved'" (p. 295). In
France, educateurs are trained in an independent program
from social work or psychology to be concerned with the
"total life process" of the involved children (Linton, p.
6). The educateur is the closest person to the child, is
trained to act as a role model, and organizes the
patient's daily schedule. The educateur is the central
person in the reeducation and resocialization of the
disturbed child. This educateur acts as a member of a
medico-social-psycho-pedagogical team, but it is the
educateur who implements the team treatment program.
The educateur also acts as a mediator between the
youth and society, with the goal of completing a
reconciliation between the adult world and the world of
the child. He does this by developing a relationship with
the child which is not based on the traditional verbal
exchange. The relationship is rather understood as a
process based on children's modeling of behavior on the
educateur and gaining insight into behavior through what
the educateur does, as opposed to any planned verbal
exchanges (Joubrel, 1971? Linton, 1969).
Thus, the therapeutic milieu may contain various
personnel who form relationships with the adolescents,
kll of these relationships may be considered to be
"therapeutic", albeit not in the traditional sense.
85
With regard to structure, the staff may be organized
in a traditional, medical hierarchial fashion (Rinsley,
1974) or may be organized in a more horizontal, less
fixed-role fashion (Beavers, 1968; Treffert, 1969). The
more important issue appears to be that the staff
understand their various roles, as defined in that
particular treatment orientation, and that they perform
these duties consistently and with good communication
between them (Beavers; Holmes, 1964; Rinsley, 1974;
Treffert). In this way the staff helps provide a
therapeutic environment, an environment different from the
patients' disturbed homelife, and one which can promote
psychological growth.-
As an attitudinal resource, the staff functions in
two separate areas. First, the attitude of the staff
toward discipline is critical. The danger is that the
staff may react to acting out behavior either with too
much harshness or with too much permissiveness (Alt, 1960;
Beavers, 1968; Rinsley, 1968). Beavers wrote:
B o t h e r r o r s a r e m a d e f o r t h e s a m e r e a s o n — t o o
m u c h d i s t a n c e f r o m t h e p a t i e n t . T h e s t a f f m e m b e r
w h o i s t o o a u t h o r i t a r i a n t o a d o p t t h e
p r o b l e m - s o l v i n g a p p r o a c h h a s l e a r n e d o u t o f h i s
o w n l i f e e x p e r i e n c e t o h a n d l e p r o b l e m s d i s t a n t l y
a n d r i g i d l y . T h e o n e w h o i s t o o p e r m i s s i v e a l s o
i s d i s t a n t f r o m t h e p a t i e n t : h e i s n o t s e e i n g t h e
p a t i e n t ' s e g o d e f i c i e n c y a n d h i s p a t h e t i c w i s h f o r
c o n t r o l , f o r s o m e o n e t o s e t l i m i t s a n d t h u s t o
86
ease the anxiety in a situation that has become
too complex for the patient to handle. (p. 36)
Second, Holmes and his colleagues (Hendrickson &
Holmes, 1959, 1960; Hendrickson et al., 1959, Holmes,
1964) particularly emphasized the staff's role in
communicating and advocating expectations of the
residents. In the treatment program which they developed,
they maintained very definite, almost Victorian, standards
of social behavior for the patients. These codes included
compulsory attendance at meetings, dress codes, and strict
taboos against profane language, fighting, and physical
sex play (Hendrickson & Holmes, 1959, p. 970). The staff
attitude, reflecting these standards, was both that these
norms were an unavoidable reality and it was unacceptable,
even "unthinkable", for residents to behave in prohibited
ways (pp- 970-971). This staff attitude helped to create
the atmosphere into which residents were introduced upon
entering the program.
Thus, the staff functions as a source of additional
therapeutic relationships and to support the structure of
the in-patient setting. As such, they become an important
element in the therapeutic milieu. They demonstrate
alternative, less pathological means of relating to other
people through their consistency, their communication,
their attitude toward discipline, and their attitude
87
toward behavioral expectations.
Summary. In this section aspects of psychotherapy
which are pertinent to the in-patient treatment of
adolescents were reviewed. First, the rationale, purpose
and goals for placement were discussed. While the most
fundamental reason for the confinement of these
adolescents may be their, threat to adult society, the
purpose and goals for such treatment were stated to be the
development of greater ego strength, learning of more
appropriate social skills, and development of healthier
relationships in a less threatening environment, so that
the adolescents might return and live in a less structured
society.
Second, five general functions of a milieu were
reviewed. These functions are containment, support,
structure, involvement, and validation. While all these
functions may be present in a milieu, they may appear at
different times or be given different emphases. The
containment function is the most critical, initial
function which a milieu must provide. Structure is that
function most closely aligned with milieu therapy and
utilizes the environment itself to help promote
psychological change.
Third, the effect of confinement itself upon patients
88
w a s a d d r e s s e d , p a r t i c u l a r l y w i t h r e g a r d t o i n c r e a s e d
r e s i s t a n c e t o t r e a t m e n t a n d i n c r e a s e d a c c e s s t o a l l
p a t i e n t r e l a t i o n s h i p s .
F o u r t h , t h e r o l e o f t h e t h e r a p i s t w a s r e v i e w e d . I n
a n i n - p a t i e n t s e t t i n g , t h e t h e r a p i s t a l m o s t i n e v i t a b l y
b e c o m e s m o r e i n v o l v e d i n t h e l i f e o f p a t i e n t s . T h i s m a y
f a c i l i t a t e t h e d e v e l o p m e n t o f a t h e r a p e u t i c r e l a t i o n s h i p
a n d m a y a l s o c r e a t e a r e l a t i o n s h i p w h i c h i s a p a r t o f
r e a l - l i f e e v e n t s .
F i f t h , t h e r o l e o f t h e s t a f f w a s d i s c u s s e d . T h e
s t a f f s e r v e s a s a n i m p o r t a n t e l e m e n t i n t h e t h e r a p e u t i c
m i l i e u , b y w o r k i n g a s c o n s i s t e n t , c o m m u n i c a t i n g a d u l t s w h o
a r e a b l e t o p a r t i c i p a t e i n h e a l t h i e r r e l a t i o n s h i p s w i t h
t h e a d o l e s c e n t s t h a n t h o s e w h i c h t h e p a t i e n t s h a d
p r e v i o u s l y . T h e s e r e l a t i o n s h i p s m a y b e c o n s i d e r e d t o b e
o t h e r t h e r a p e u t i c r e l a t i o n s h i p s .
M i l d M e n t a l R e t a r d a t i o n a s a C o m p l i c a t i n g F a c t o r
I n t h i s s e c t i o n , t h e i s s u e o f m i l d m e n t a l r e t a r d a t i o n
w i l l b e a d d r e s s e d i n t h r e e a r e a s . F i r s t , s t a t i s t i c s
r e g a r d i n g t h e c o r r e l a t i o n b e t w e e n m i l d m e n t a l r e t a r d a t i o n
a n d b e h a v i o r a l o r p s y c h o l o g i c a l p r o b l e m s w i l l b e r e v i e w e d .
S e c o n d , p o s s i b l e e x p l a n a t i o n s f o r s u c h s t a t i s t i c s w i l l b e
d i s c u s s e d . T h i r d , t r e a t m e n t m e t h o d s i n w o r k i n g w i t h t h e
m i l d l y m e n t a l l y r e t a r d e d w i l l b e p r e s e n t e d .
89
Statistics
A major difficulty in examining the literature with
regard to mild mental retardation and behavior or
psychological problems in adolescents is that few scholars
differentiate between the different levels of mental
retardation. The DSM-III (1980) listed four levels of
mental retardation: profound (IQ below 20), severe (IQ
between 20 and 34), moderate (IQ between 35 and 49), and
mild (IQ between 50 and 70) (p. 39). The capabilities of
someone who is profoundly retarded are significantly
different than those of someone who is mildly retarded.
For instance, in the DSM-III the profoundly retarded are
described as quoted below:
During the preschool period these children display
minimal capacity for sensorimotor functioning. A
highly structured environment, with constant aid
and supervision, is required. During the
school-age period, some further motor development
may occur and the children may respond to minimal
or limited training in self-care. (pp. 39-40)
(emphasis added)
The mildly mentally retarded are described in the same
manual thusly:
Mild Mental Retardation is roughly equivalent to
the educational category "educable"....By their
late teens they can learn academic skills up to
approximately the sixth-grade level; and during
the adult years, they can usually achieve social
and vocational skills adequate for minimum
90
self-support, but may need guidance and assistance
when under unusual social or economic stress. (p.
39)
Thus, the validity and relevance of many of the
statistics cited below, statistics which do not
discriminate between levels of retardation, must be
questioned.
Roller, Richardson, and Katz (1983) conducted an
excellent study which did consider group statistics
according to levels of retardation. They examined
hospital and community records, and conducted personal
interviews with young adult subjects from a cohort, living
in a British city, who had been identified during
childhood as suffering from some degree of retardation.
By utilizing records and interviews, they attempted to
ascertain the percent of young people with retardation who
had experienced some degree of behavioral disturbance
during childhood and during the postschool (15-16 years of
age) years, as well as the type of disturbance.
They determined that 55% of the mildly mentally
retarded group experienced some form of behavioral
problem. During the childhood and postschool years, males
were most frequently classified as exhibiting the
characteristics of aggressive conduct disorder (during
childhood, 32%; during postschool years, 26%) or
antisocial behavior (during childhood, 35%; during
91
postschool years, 32%). Females during the childhood
years were most frequently characterized as exhibiting
emotional disturbance (35%) or antisocial behavior (20%).
During the postschool years, females were associated most
frequently with emotional disturbance (38%) or with
aggressive conduct disorder (30%).
A l t h o u g h K o l l e r e t a l . d i d n o t c o m p a r e t h e s e r e s u l t s
w i t h t h o s e o f a n o r m a l p o p u l a t i o n , t h e y c i t e d l i t e r a t u r e
w h i c h s t a t e d t h a t t h e i n c i d e n c e o f b e h a v i o r a l d i s t u r b a n c e
i s g r e a t e r i n t h e m e n t a l l y r e t a r d e d p o p u l a t i o n ( a s a
w h o l e ) t h a n t h e n o r m a l p o p u l a t i o n . F o a l e (1956)
c o r r o b o r a t e d t h e s e f i n d i n g s . H e w r o t e n o n - s p e c i f i c a l l y
t h a t r e t a r d e d a d o l e s c e n t s d i s p l a y m o r e b e h a v i o r
d i f f i c u l t i e s d u r i n g p u b e r t y t h a n t h e n o n - r e t a r d e d . H e
s t a t e d t h a t o n l y 6 % o f n o r m a l a d o l e s c e n t s d e v e l o p
p s y c h o n e u r o t i c r e a c t i o n s d u r i n g a d o l e s c e n c e , b u t t h a t 1 2 %
o f t h e m e n t a l l y r e t a r d e d d i s p l a y e d p e r s o n a l i t y i n v o l v e m e n t
d u r i n g t h e s a m e t i m e f r a m e . I n t h e i r r e v i e w , H u t t a n d
G i b b y (1979) c o n c u r r e d t h a t t h e m e n t a l l y r e t a r d e d d i s p l a y
a h i g h e r i n c i d e n c e o f p e r s o n a l i t y a b e r r a t i o n s t h a n d o e s a
n o r m a l p o p u l a t i o n .
T h e r e i s a d i s t i n c t i o n i n t h e l i t e r a t u r e b e t w e e n
a g g r e s s i v e b e h a v i o r a n d d e l i n q u e n t ( i . e . , c o n f i n a b l e )
b e h a v i o r , a l t h o u g h t h i s d i s t i n c t i o n i s n o t c l e a r - c u t a n d
i t i s u n c e r t a i n i n t o w h i c h c a t e g o r y " a n t i s o c i a l " b e h a v i o r
92
should be placed. Forbes (1958) wrote that the mentally
retarded may manifest more aggressive behavior,
particularly as adolescence approaches. Koller et al.
(1983) cited literature which stated that mentally
retarded people exhibited higher rates of antisocial
behavior.
H o w e v e r , s t a t i s t i c s a p p e a r t o b e m u c h d i f f e r e n t w h e n
d e l i n q u e n c y b e h a v i o r p e r s e i s e x a m i n e d . O f t h e r e p o r t s
r e v i e w e d , o n l y o n e s t a t e d c a t e g o r i c a l l y t h a t " p a t i e n t s "
w i t h l o w e r I Q ' s m a y b e a s s o c i a t e d w i t h d e l i n q u e n c y
( O ' C o n n e l l e t a l ., 1972). B e i e r (1964) s t u d i e d v a r i o u s
r e p o r t s a n d c o n c l u d e d t h a t c u r r e n t e s t i m a t e s o f t h e
d e l i n q u e n t p o p u l a t i o n w h i c h i s m e n t a l l y r e t a r d e d r a n g e d
f r o m .5% t o 55%. L i n k e n h o k e r (1978) c i t e d l i t e r a t u r e
w h i c h s t a t e d t h a t t h e m e a n I Q s c o r e s i n t h e d e l i n q u e n t
p o p u l a t i o n h a v e r i s e n o v e r t i m e f r o m a n I Q o f 71 i n 1931
t o 95 i n 1973. D y b w a d (1964) w r o t e t h a t t h e s e v e r i t y o f
m e n t a l r e t a r d a t i o n a c t s a s a r o a d b l o c k t o d e l i n q u e n t
a c t i v i t y a n d t h a t j u v e n i l e d e l i n q u e n c y w a s m o r e p r e v a l e n t
i n t h e u p p e r r a n g e s o f m e n t a l r e t a r d a t i o n ( a f i n d i n g w h i c h
t h e K o l l e r e t a l . s t u d y p a r t i a l l y c o r r o b o r a t e d ) . F i n a l l y ,
L e v y a n d M c L e o d (1977) s t u d i e d i n c a r c e r a t e d p e r s o n s a n d
c o n c l u d e d t h a t t h e r e w e r e a p p r o x i m a t e l y t h e s a m e
p e r c e n t a g e o f m e n t a l l y r e t a r d e d p e r s o n s i n p e n i t e n t a r i e s
a s t h e r e w e r e r e t a r d e d i n t h e g e n e r a l p o p u l a t i o n o f t h e
93
U n i t e d S t a t e s .
Thus, while there appears to be a greater incidence
of psychological and behavioral disturbance in the
mentally retarded, these findings must be qualified by the
lack of consistent replication in the statistics regarding
juvenile delinquency and by the lack of differentiation
between levels of retardation.
Explanations
Most authors concede that there is a relationship
between mental retardation and emotional disturbance and
maladaptive behavior. Hirsch (1959) explained this
relationship through the less mature ego structure of
retarded adolescents. He wrote that the retarded may have
simultaneously greater needs from people and less ability
to have these needs met than non retarded people. These
concurrent emotional problems may then lend themselves to
the development of maladaptive behavior. Tappan (1949)
and Giagiari (1971) maintained that mental retardation was
a complicating or compounding factor in adolescent
emotional problems.
Hutt and Gibby (1979) agreed, stating that the
incidence of mental retardation with maladaptive behavior
was not an indigenous condition, but rather a reflection
of the social and other difficulties which confront the
mentally retarded (p. 235). They noted that the
94
developmental distance between normal children and
mentally retarded children widens during adolescence, with
consequences to the mentally retarded of increased
negative self esteem and rejection by social institutions,
family, neighbors, and the peer group. Thus, deviant
behavior may result from the mentally retarded's failure
to meet the typical adolescent goals of success, status,
and prestige (p. 259). They concluded that the
maladaptive behavor of mentally retarded adolescents must
be viewed "from the same perspective as that of the more
normal child, seeing it as the result of disturbances in
the same developmental processes that are reacted to in
the same manner by all children" (p. 238).
These authors all basically agreed that mental
retardation is a compounding factor, not a causative
factor, in the development of maladaptive behavior in
adolescents. However, the minority opinion is explained
by Dybwad (1964), who wrote, "The handicap of inferior
intellectual endowment does constitute a specific
causative factor in delinquent behavior, particularly in
the upper ranges of mental defect" (p. 144).
Treatment
The issue of mental retardation as a complicating
factor vs. retardation as a causative factor leads into
the issue of appropriate treatment for mentally retarded
95
adolescents with behavioral problems. Those authors
(e.g., Dybwad, 1964) who maintained that mental
retardation is a causative factor in acting out problems
generally asserted that the mental retardation should be
treated, not the emotional problems. Mental retardation
may be treated by minimal vocational and self-help
training, sometimes in a protected setting.
T h o s e a u t h o r s w h o w r o t e t h a t t h e e m o t i o n a l o r
b e h a v i o r a l p r o b l e m s w e r e t h e c e n t r a l i s s u e g e n e r a l l y
m a i n t a i n e d t h a t t h e s e p r o b l e m s s h o u l d b e t r e a t e d , n o t t h e
r e t a r d a t i o n p e r s e . H o w e v e r , a m o n g t h e s e a u t h o r s t h e r e i s
d i s a g r e e m e n t r e g a r d i n g t h e p r o p e r f o r m o f t h e r a p y ,
p a r t i c u l a r l y t h e a p p r o p r i a t e n e s s o f v e r b a l t r e a t m e n t .
Rogers (1942) wrote that individuals should have at
least intelligence in the "dull-normal" range to be
amenable to verbal psychotherapy. Fenichel (1945)
believed that the ego, in mentally retarded people, did
not have the capacity to deal with its conflicts. Sarason
(1949) wrote that the retarded were unable to communicate
verbally and thus could not participate in traditional
therapy. Abel (1953) maintained that retarded individuals
did not have the necessary degree of verbal understanding.
Thus, all these authors held that verbal psychotherapy was
inappropriate with the mentally retarded.
T h e r e p o r t s c i t e d a b o v e a r e b a s e d u p o n t h e o r y . T h e r e
96
is some clinical evidence, however, that the retarded can
benefit from psychotherapy. Thorne (1948) studied the
effects of psychotherapy upon institutionalized, retarded
children and concluded that psychotherapy could be
effective. Heiser (1954) compared the effects of
psychotherapy upon 14 retarded children and reported that
psychotherapy was of benefit. Campbell and Browning
(1975) wrote that psychotherapy was not necessarily ruled
out for the retarded. Menolascino (1977) reviewed
psychiatric studies of the retarded and found that
psychotherapy was effective throughout all levels of
mental retardation.
Hutt and Gibby (1979) concluded that retarded
adolescents can benefit from psychotherapy. They wrote,
The 'currency' of the psychotherapeutic situation
is the interaction that occurs between the subject
and the therapist, and interactions occur in many
ways other than at the verbal level....Inability
to verbalize may be a limiting factor in some
phases of therapy, but it is not necessarily a
complete block to all psychotherapeutic work. (p.
494)
Summary. In this section three aspects to the issue
of mental retardation and behavior problems were reviewed.
First, statistics regarding the incidence of mental
retardation with maladaptive behavior were cited. These
statistics generally demonstrated a correlation between
97
the two. However, the lack of consistent findings
regarding mental retardation and juvenile delinquency and
the failure of many studies to cite statistics according
to level of retardation must render the findings somewhat
ambiguous. Second, explanations for the correlation were
explored. The most prevalent conclusion was that mental
retardation is a complicating factor in emotional
disturbance, not a causative factor. Third, treatment
methods were reviewed. While there were theoretical
statements regarding the inappropriateness of verbal
psychotherapy with retarded adolescents, there was
clinical evidence that such psychotherapy could be
conducted effectively.
Pattern of Behavioral Change
The issue of concern in this section is the pattern
of behavioral change. Does (positive) change occur in an
unbroken line, or does it progress and then retreat,
bearing out the oft-repeated phrases, "People get worse
before they get better" or "Two steps forward and one step
back." This pattern of change issue is not discussed
frequently in the literature in the literature, but it
does have important implications in the treatment of the
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emotionally disturbed, particularly those who act out.
Acting out teenagers are frequently disruptive and
dangerous in society. The society at large wants such
behavior controlled, so that it is not threatened. The
youths are occasionally incarcerated to protect society
(Alt, I960? Rutter, 1980).
There is urgency in such a situation and a demand
that the behavior be stopped immediately. But what if a
treatment method includes regression as part of the
treatment, and if successful treatment is impossible
without regression? In this eventuality, society should
be informed so that its expectations of these adolescents
might become more realistic. Parents and the adolescents
themselves should also integrate such knowledge, again so
that false or unrealistic expectations might be
diminished.
This section will explore the theoretical positions
of four authors, Levy (1938), Rinsley (1968, 1974), Kell
and Mueller (1966), and Ofman (Note 1), all of whom
support the view that regression does indeed occur during
treatment. The empirical work of Shapiro (Shapiro &
Shapiro, 1974? Shapiro & Hobson, 1972) will also be
considered as supporting evidence of this position.
Levy. Levy (1938) considered acting out during the
course of treatment to be the result of the two different
99
phases of treatment. He wrote that there was initially a
positive stage in treatment, during which the therapist
reassures the patient, calls attention to the existence of
the patient's strong positive feelings toward the
therapist, and reassures the patient of the value of
therapy and the necessity of not being afraid of these
feelings. He stated:
If the therapist keeps in close touch with the
patient's feelings for him and the role the
therapist is playing as the recipient of these
feelings ... the relationship between therapist and
patient becomes a workable and therapeutic one.
(p. 67)
The negative or antagonistic stage follows the
positive stage and during it patients express their
negative feelings, their resentments, hostilities,
aggression and hatred. Levy wrote:
All patients in the course of treatment must
express their negative feelings....All human
beings have such negative feelings; therefore no
treatment is complete without the patient using
the therapist for the free expression of these
hostile impulses. The open expression of hostile
feelings toward the psychiatrist is as essential
to treatment as the expression earlier in
treatment of affection and love. (p. 67)
In his discussion of how these negative feelings are
manifested, Levy wrote that different patients express
them in different ways, including acting out. Levy
concluded, "The patient moves along at a regular pace with
100
alternating periods of activity and recuperation" (p. 69).
Rinsley. Rinsley (1968# 1974) also viewed therapy as
consisting of stages: resistance, working through, and
termination. Acting out was considered to be an integral
component, particularly during the first two stages. He
wrote, "Fluctuating proneness to regression is a hallmark
of the adolescent's struggle toward an eventually stable
identity" (1968, p. 627). Consistent with this goal, he
considered the entire treatment process as a "healthy
child-rearing" experience in compressed time (1968, p.
628) .
During the first stage, he considered resistance (in
the form of acting out) as serving to preserve the ongoing
fusion or symbiotic ties between the patient and the
pathological family (1968). That is, during this stage
both patient and family want to preserve the links between
them, and thus the patient acts out. Control is imposed
externally, by the therapist and treatment setting. As
the patient begins to internalilze the external control,
the resistance phase ends and working through begins.
As stated above, the transition from the resistance
stage to the working through stage does not bring about an
end to acting out. In the working through phase, the
patients part with previous conceptions of themselves
101
(e.g., the idea of themselves as totally good or bad), and
consequently depression and mourning begin. Accompanying
the depression is sweeping regression in all areas of
psychological function (1968, 1974). Rinsley stated that
adolescents literally become more immature and that,
consequently, they frequently act out.
As mourning proceeds and regression begins to recede,
the termination phase of treatment begins. The patients
become ready for increased association with family members
whose limitations they may comprehend without becoming
enmeshed in them. The patients at this time also have
greater internal controls over their own behavior,
controls acquired through identification with the
therapist (1968, 1974). In Rinsley's view, acting out is
thus an integral part of the patients' progression from a
symbiotic relationship with their parents to a more
healthy, integrated and independent one.
Kell and Mueller. Kell and Mueller (1966) did not
regard therapy as divided into phases. Instead, they
looked at patients' ambivalence toward therapy. That is,
the adolescents want to change, but at the same time have
received some "gain" with their previous behavior and do
not wish to give up this aspect of their behavior. Kell
and Mueller considered this paradox to be a process, not a
"once and for all event" (p. 72). They suggested that the
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adolescents' struggle revolves around their ambivalent
feelings regarding independence. They want the security
of home and yet need an independent life. They wrote that
acting out is the externalization of this internal
struggle, as well as an impulsive act which permits them
to conceal their true feelings from themselves.
The vehicle for change in this situation is the
counseling relationship in which adolescents may learn to
understand their own motives. However, as the
relationship develops, it increases in intensity, leaving
patients more vulnerable to the experience of hurt and
pain, which Kell and Mueller believed to be a necessary
component of therapy. Patients, however, are in dread of
pain and avoid and defend against experiencing it.
Consequently, at these times of fear, they resist
therapeutic closeness through acting out.
Kell and Mueller wrote that the therapuetic
relationship was the fullest possible embodiment of
patients' struggle between the need for closeness (which
might lead to the experience of pain) and the need for
distance (which might lead to isolation) (p. 48). The
regressive or distancing events in therapy, when properly
addressed by the therapist, have the potential of
producing psychological change in patients. Thus Kell and
Mueller wrote that regression may often be the antecedent
103
to change (p. 79). They stated that regression is a
frequent and perhaps neccesary experience in the
counseling relationship (p. 83).
Ofman. Ofman (Note 1) wrote that there were several
aspects to "undoing" (p. 7). He, like Kell and Mueller,
thought that the adolescents experienced "secondary gain"
from this behavior. The gain is one of dulling or numbing
the senses to a deep interpersonal pain through
substituting another kind of pain, that of failure or
loneliness. They do this because they are afraid to
experience interpersonal contact, a consequence of having
been abandoned by people in the past. Thus, the patients
tend to undo the personal links, particularly after a
pleasing interaction, because of their fear that any
contact at all might lead to experiencing loss again (p.
7) .
Ofman also considered another reason for undoing. He
wrote that the adolescents have a deep-seated wish to
remain children, hoping that eventually a parent will take
care of them or redo the bad past into a better one.
Growing up implies the assumption of responsibility, with
the concomitant expectation that people can control their
own behavior. Thus, a continuation of acting out
reasserts the refusal to grow up and forsake that hope,
"the hope to have the parent(s) one never really had" (p.
104
7) .
The empirical work of Shapiro. All of the authors
discussed above considered acting out an integral and
continuing part of the therapeutic process, irrespective
of the reasons for it. However, there is limited
empirical literature supporting this theory.
Shapiro and Hobson (1972) and Shapiro and Shapiro
(1974) considered the idea of short-term setbacks in
treatment in their studies on depression, utilizing a
series of single-case experiments. In 1972 they conducted
17 psychotherapeutic interviews with one patient in an
attempt to measure specific changes in patients and relate
them to significant events occurring during therapy
sessions. They utilized a Personal Questionnaire (PQ) as
a means of obtaining repeated verbal reports by patients
of their mental state. This questionnaire recorded
fluctuations along a 4-point scale of severity. The PQ
scores were used to evaluate immediate changes in
patients' mental conditions following a therapy session,
particularly feelings associated with depression.
In previous studies (Hobson & Shapiro, 1970? Caplan,
Rohde, Shapiro & Watson, cited in Shapiro & Hobson, 1972)
the team attempted to replicate findings of an "immediate
improvement effect" in patients receiving individual
psychoterapy, as opposed to behaviorally-oriented
105
treatment. They were unable to do so.
Shapiro and Hobson's 1972 study was again an attempt
to replicate these findings, using an experienced
therapist. The PQ items reflected a predominance of
worsening over improvement, in measures taken immediately
after therapy sessions, with the largest indices of
variation in depression and tension. At the same time
that the short-term PQ scores were worsening, long-term
scores gave evidence of improvement. Thus this study
showed that long-term and short-term PQ scores were not
always in the same direction.
They considered two possible explanations for these
findings. First, the improvement scores might have been
caused by some form of spontaneous remission. Second, the
scores might reflect the success of a therapeutic strategy
in which worsenings are related to some "ultimately
therapeutic process" (p. 316). Shapiro and Hobson wrote
that interpretive psychotherapy is based on the assumption
that the patients' pre-established coping processes need
to be modified, not supported and maintained, if patients
are to gain lasting improvement. Since this process is
painful to the patients, they concluded that patients
might worsen over the short term.
Shapiro and Shapiro (1974) conducted a series of six
106
single-case studies in an attempt to achieve replicated
experimental control over short-term changes in the
intensity of the feeling of depression, as well as
concomitant changes in other feelings. Experiments were
carried out in two different clinical settings. In one
setting, interpretative psychotherapy principles were
applied. In the second setting, patients were
administered behavior therapy and a very few were given a
form of non-directive psychotherapy on an individual
basis. Results replicated previous findings in that there
was relatively frequent within-session worsening
associated with the interpretative sessions and relatively
frequent within-session improvements associated with the
modification sessions. Such findings give additional
support to the theory that individuals worsen before they
improve.
Summary. In this section, the position that patients
worsen in the short term, even if they improve over the
long term, was reviewed. The theories of four scholars
were discussed. Levy (1938) wrote that treatment may be
divided into two phases, a positive and negative, and that
during the negative phase acting out might occur. Rinsley
(1968, 1974) wrote of three phases of treatment,
resistance, working through, and termination. During the
first two phases, acting out is an integral component of
107
patients' behavior. In the first phase, they act out to
resist breaking symbiotic ties with their families. In
the second, they act out as part of the overall regression
associated with depression and mourning, as they slowly
deal with their childhood abandonment issues. Kell and
Mueller (1966) considered acting out to be reflections of
the ambivalence that all patients feel toward
psychological change. They thought that acting out or
resistance could be the precursor to change, if handled
successfully by the therapist. Ofman (Note 1) wrote that
adolescents act out because they experience a secondary
gain in that they are able to avoid experiencing the
deeper interpersonal pain associated with their histories
of failed relationships. Additionally, he considered
acting out to be an expression of.adolescents' refusal to
assume responsibility for their own actions. This
"refusal to grow up" was associated with their wish to
have someone (particularly a parent) take care of them and
to redo the past.
The empirical work of Shapiro and his colleagues
(Caplan et al., 1970; Hobson & Shapiro, 1972; Shapiro &
Hobson, 1972; Shapiro & Shapiro, 1974) provided some
empirical support for the above theoretical position.
Although their work dealt with the measurement of the
short-term experience of depression, it nonetheless
108
replicated clinically the view that individuals experience
short-term worsenings in feelings, even if they improve
over the long term.
This review of the literature has explored five areas
of concern: 1) etiology of adolescent psychopathology, 2)
treatment of adolescent psychopathology, 3) in-patient
treatment of adolescents, 4) mild mental retardation as a
complicating factor, and 5) the pattern of behavioral
change. It is the general purpose of this study to
explore the correlation between acting out behavior and
relationship behavior in a treatment setting emphasizing
relationships, over both the long and short term course of
treatment, with a population of adolescents who act out
and are mildly mentally retarded.
109
CHAPTER III
METHODOLOGY
This chapter provides a discussion of the procedures
followed in the implementation of this study. Described
in this section are: 1) design, 2) sample selection, 3)
ethical considerations, 4) instrumentation, 5) procedures,
6) data collection procedures, 7) data analysis, and 8)
limitations of study.
Research Design
A single subject, ex post facto research design of AB
form was used in this investigation. Discussion of this
design will be divided into four sections: single subject
research in general, single subject research of an AB
form, ex post facto research, and methodology of this
investigation.
Single Subject Research
The methodology of single subject design has been
well-documented by Hersen and Barlow (1976), Kazdin
(1978), Kiesler (1971), and Sidman (1960), among others.
The need for single case research was aptly expressed by
Goldman (1978):
110
The laboratory may permit exploration of variables
and may suggest things about people and methods,
but only real-life studies can provide the bases
for conclusions and generalizations about people
and about helping activities. (p. 8)
Group comparison designs pose several difficulties in
applied research, including particularly the averaging of
results over groups, the generality of findings, and
inter-subject variability (Bergin & Strupp, 1972).
Chassan (1967) and Sidman (1960) especially objected to
the averaging of results, which obscures individual
clinical outcomes in the group averages. Hersen and
Barlow (1867) wrote that, even in cases when specific
questions concerning effects of therapy are approached
from the group comparison point of view, "the problem of
obscuring important findings remains because of the
enormous complexities of any individual patient included
in a given treatment group" (p. 15). With regard to
generality of findings, Chassan (1967) concluded that
group study results do not consider changes in individual
patients and consequently may not be readily applicable to
the practicing clinician.
In response to these objections, there has been a
shift in research toward more single subject designs.
Gelso (1979) noted that single subject research has gained
momentum in both psychology and counseling since 1970.
Ill
Also in 1970, Bergin and Strupp proposed the experimental
single case approach for the purpose of isolating
mechanisms of change in the therapeutic process.
The foremost criticism of single subject research
designs is the lack of generalizability from sample to
population. Hersen and Barlow (1976) argued, however,
that such designs adequately deal with variability and
generalizability, particularly through the use of direct
replication. Additionally, Birnbrauer (1981) wrote that
external validity is established by placing the results
into a systematic context, i.e., determining the
principles which are expressed by the results.
Research Designs of AB Form
In the present investigation, a single subject
research design of AB form was employed. The major
characteristics of such a research design involve
obtaining a baseline, followed by a treatment phase.
Repeated measurements of dependent variables over time are
conducted throughout the investigation. Gottman (1973)
wrote, "The time-series designs provide a methodology
appropriate to the complexity of the effects of
interventions into human systems" (p. 95). Such designs
are also called associational and are correlational in
nature (Hersen & Barlow, 1976; Tracey, 1983).
These studies in the applied field of counseling fill
112
a needed gap, especially between studies which measure
only outcome and those which measure factors in the
counseling process itself (Gottman, 1973; Hersen & Barlow,
1976). The work of Shapiro (Hobson & Shapiro, 1970;
Shapiro, 1966; Shapiro & Hobson, 1972; Shapiro & Shapiro,
1974) was particularly cited by Hersen and Barlow as
demonstrating the utility of such a design. In his work,
Shapiro utilized the AB form to measure short-term changes
in individuals receiving psychotherapy, as well as
long-term outcome of treatment.
The primary criticism of research designs utilizing
the AB format is that of internal validity, the difficulty
of determining if measured changes are the result of the
treatment (independent variable). Shapiro (1966)
responded:
This conception does not take into account the
possibility that confounded effects could
themselves be lawful. Daily life involves the
experience of successive conditions, many of which
are repeated over and over again. Such processes
need to be investigated. (p. 4)
Tracey (1983) argued that replication of the design with
other subjects leads to greater confidence in conclusions
being related to treatment variables.
Another criticism of the AB design is again that of
external validity, the lack of generalizability to a
larger population because of the size and lack of
113
randomness in the sample. As in the case with single case
research in general, Hersen and Barlow (1967) and Shapiro
(1966) contended that direct replication of studies gives
considerable confidence in the generalizability of
findings. Shapiro stated that the scientific investigator
is "more interested in the relationships of changing
events" than in the unique patterns of events (p. 4).
Kazdin (1981) argued, with specific reference to more
naturalistic types of designs such as the AB form, that
such settings lend themselves to greater external validity
because they more nearly replicate the natural environment
than studies of an experimental, controlled nature.
Ex Post Facto Research
This study is ex post facto in nature because the six
subjects were chosen from a population of twenty-five
subjects after the treatment was completed. Kerlinger
(1973) defined ex post facto research as "systematic
empirical inquiry in which the scientist does not have
direct control of independent variables because their
manifestations have already occurred..." (p. 379). He
stated that there are three major weaknesses to such
research: 1) inability to manipulate independent
variables; 2) lack of randomization; and 3) difficulties
in interpretation, particularly with regard to causality
or conditionality (p. 390). He suggested that alternative
114
hypotheses be tested, as a means of controlling the
independent variables of such rsearch (p. 390).
Kerlinger emphasized, however, that ex post facto
research is valuable because "many research problems in
the social sciences and education do not lend themselves
to experimental inquiry.... Controlled inquiry is possible,
of course, but true experimentation is not" (pp. 391-392).
Methodology of This Investigation
As stated above, in the present investigation a
single subject design of AB form with six subjects was
employed. In this design, a number of behaviors were
identified and measured over three phases. These
included: 1) baseline, 2) treatment procedure, and 3) end
of treatment. The treatment variable used in this study
was relationship-enhancement. The dependent variables
used were three ratings of acting out behavior and three
ratings of relationship behavior as measured by the Yates'
Resident Progress Scale.
Selection of the Sample
The subject population of interest in this study
consisted of approximately 25 adolescents residing in the
Adolescent Residential Treatment Program (ARTP),
administered by Gateways Hospital. All residents received
the relationship-enhancing treatment. All residents who
participated in the ARTP program between July 1982 and
115
February 1983 were evaluated using the Yates' Resident
Progress Scale. Six residents were selected from the
entire population based on the following criteria: 1) an
equal number of male and female subjects were selected? 2)
subjects must have completed a minimum placement of six
months; and 3) completeness of available raw data for each
subject. Only six subjects met the criteria.
In addition to the methodological considerations of
the above criteria, other criteria applied to all
residents in the treatment program. These included: 1)
age between 13 and 17; 2) IQ scores between 50 and 70, as
measured by the WISC-R (mild mental retardation); 3) a
DSM-III (1980) diagnosis of some form of conduct disorder
(cf., Chapter I, Definition of Terms); and 4) removal from
the custodial home by some social agency (either the
Probation Department or the Department of Public Social
Services).
Ethical Considerations
The Human Subjects Committees of Gateways Hospital
and the University of Southern California consented to
this research investigation with the provision that in
addition to the subject's sex and age, only the raw data
and information extrapolated from this data be used and
discussed in the study. Written parental consent was
obtained for placement and treatment in the Adolescent
116
Residential Treatment Program.
Instrumentation
One rating scale was employed in this study: the
Yates' Resident Progress Scale (RPS). The RPS was
designed specifically for use in the Gateways ARTP
program. The scale is unusual in that it attempts to
measure behaviors associated with relationship-building,
in addition to the pure acting out types of behaviors more
commonly measured. It consists of a 30-item scale, each
item rated by an observer on a scale from 1 ("totally
disagree" or "never"), 2 ("somewhat disagree" or "almost
never"), 3 ("mixed" or "sometimes"), 4 ("somewhat agree"
or "often"), to 5 ("totally agree" or "always"). Total
scale scores range from 30 to 150.
The scale is divided in six sub-scales, three of
which are reflective of an acting out behavior dimension
and three of which reflect a relationship behavior
dimension. These categories include: 1) verbal
aggressiveness (3 items); 2) verbal and physical assaults
on peers (3 items); 3) verbal and physical assaults on
staff (3 items); 4) participation in program (3 items); 5)
cooperativeness with staff (2 items); and 6) overall
relationship behavior (3 items).
Sub-scale correlations are given below. Category 1
includes items 10, 11, and 12. These items correlate at
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.81, .40, and .61. Category 2 includes items 10, 18, and
29. These items correlate at .61, .38, and .61.
Category 3 includes items 15, 16, and 17. These items
correlate at .87, .81, and .80. Category 4 includes items
5, 6, and 7. These correlate at .73, .56, and .67.
Category 5 includes items 13 and 14. These correlate at
.74. Category 6 includes items 19, 20, and 21. These
three correlate at .50, .47, and .47.
Procedures
Residents did not enter the program concurrently.
Baseline, followed by treatment procedures, began on an
individual basis for each resident. Each subject
underwent two phases in this study. In addition, all were
evaluated at the termination of treatment. The phases
included: A) baseline, B) relationship-enhancing
treatment. Table 1 uses A and B to represent the phases
and shows the duration of the phases for each subject in
this study.
118
Table 1
Duration of Phases in Study
Subject A B
1
2
3
4
5
6
Baseline
Baseline measurements of the dependent variables,
particularly the acting out behaviors, were taken for all
subjects until stability was shown. At this time, the
Resident Progress Scale was administered. In this phase,
no active treatment intervention occurred. Residents
participated at a minimal level in program activities.
They attended regularly scheduled group activities, but
were not permitted to attend off-grounds outings, to
receive visitors, or to have home passes. They did not
participate in individual psychotherapy.
Relationship-enhancing therapy with other staff members
was kept to a minimum.
Treatment Emphasizing Relationships
Following the baseline period, each subject began
receiving intensive treatment emphasizing the importance
119
1 month
2 weeks
1 month
2 weeks
2 weeks
1 month
6 months
6 months
5 months
6 months
5 months
6 months
of relationships in all aspects of life. Since this
program was a residential one, treatment occurred on a
24-hour, 7-day per week basis. Treatment activities
included: individual psychotherapy, at least two times
per week; daily group therapy, including traditional
verbal psychotherapy, social skills, self-government, and
pre-vocational workshops; daily recreational therapy
emphasizing skill acquisition, improvement in self-esteem,
and group participation and cooperation; daily school at
which both skill acquisition and behavioral control were
emphasized; weekly resident and staff social activities,
emphasizing peer relationships; and bi-weekly outings,
focusing upon community relationships.
The staff provided relationship counseling by
continually discussing individual behavior (appropriate or
inappropriate) with each resident, the consequences of
such behavior, the reasons for such behavior, and the
staff person's reaction to such behavior. Residents were
encouraged to comment upon their own and others' behavior
and consequences for it. Personal responsibility for
one's own actions was intensively stressed.
The staff functioned therapeutically at several
levels. In the largest sense, the staff and residents
formed a milieu which provided all five functions
specified by Gunderson (1978): containment, support,
120
structure, involvement, and validation. These functions
were most clearly revealed in the use of a responsibiity
level system. Residents were placed at an appropriate
level of responsibility and privilege as demonstrated by
their behavior during the previous week. This behavior
was assessed by both staff and other residents. In this
way, residents perceived the consequences (positive or
negative) of their behavior. For specific incidents of
acting out behavior, consequences were made relevant to
the behavior whenever possible (e.g., the consequence for
damaging a chair included repairing it).
On a more individualized basis, staff members
provided relationship therapy according to their specific
work functions. Psychotherapists provided individual
psychotherapy and co-led all group therapy with a member
of the child care staff. Social workers were responsible
for community and parental liaison. Recreational
therapists and teachers worked in their respective areas
of expertise. Each resident was assigned to a child care
staff worker on both day and evening shifts. This person
was responsible for providing daily instruction, modeling,
and involvement in human interactions. Staff attitude, as
emphasized by Holmes (1964) and Ofman (Note l) was
considered of utmost importance.
121
Subjects
Subject 1. Subject 1 was a 15-year old female. She
was diagnosed as mildly mentally retarded, with a conduct
disorder, socialized, aggressive. The baseline period
lasted one month. The treatment phase lasted six months.
Subject 2. Subject 2 was a 16-year old female. She
was diagnosed as mildly mentally retarded, with a conduct
disorder, socialized, non-aggressive. The baseline period
comprised two weeks. She was treated for six months.
Subject 3. Subject 3 was a 16-year old female. She
was diagnosed as mildly mentally retarded, with a conduct
disorder, socialized, aggressive. The baseline period
lasted one month. She was subsequently treated for five
months.
Subject 4. Subject 4 was a 16-year old male. He was
diagnosed as mildly mentally retarded, with a conduct
disorder, socialized, aggressive. The baseline period
lasted two weeks. He was treated for six months.
Subject 5. Subject 5 was a 17-year old male. He was
diagnosed as mildly mentally retarded, with a conduct
disorder, undersocialized, . non-aggressive. The baseline
period lasted for two weeks. He was treated for five
months.
Subject 6. Subject 6 was a 13-year old male. He was
122
diagnosed as mildly mentally retarded, with a conduct
disorder, undersocialized, aggressive. The baseline
period lasted for one month. He was treated for six
months.
Data Collection
The Yates' Resident Progress Scale was completed for
each resident at the end of the baseline period and at
30-day intervals from this point, until the end of
treatment. This scale was completed by three staff
members assigned to each individual resident. These staff
include: individual psychotherapist, day-shift child care
staff person, and evening-shift child care staff person.
Staff members with different functions and thus different
perceptions of residents were utilized to mitigate
possible halo effects in rating dependent variables.
Data Analysis
The three hypotheses outlined in Chapter I are
restated here along with data analysis procedures.
Hypothesis 1. Adolescents receiving treatment
emphasizing relationship-building will demonstrate
overall increased relationship behavior and decreased
acting out behavior over at least a six-month period,
as demonstrated by comparison of baseline and
end-of-treatment measurements of staff ratings on the
123
Yates' Resident Proress Scale.
Hypothesis 1 was tested by noting the difference
between baseline and end-of-treatment ratings on all
dependent variables for all subjects. Visual inspection
of the baseline and end-of-treatment mean scores for each
subject was made to assess the impact of the
implementation of the relationship-building treatment.
Hypothesis 2. Adolescents receiving treatment
emphasizing relationship-building will exhibit a
pattern of acting out behavioral change which
includes short-term worsenings and improvements, as
demonstrated by a month-to-month comparison of
baseline and treatment measurements of staff ratings
on the Yates' Resident Progress Scale.
Hypothesis 2 was tested by noting the trends between
baseline and end-of-treatment ratings, on a month-to-month
basis, on all three dependent variables for all subjects.
Visual inspection of the baseline and treatment graphs was
made to assess the impact of the implementation of the
relationship-building treatment procedure.
Hypothesis 3. Adolescents receiving treatment
emphasizing relationship-building will exhibit an
inverse correlation between relationship behavior and
acting out behavior, as demonstrated by a
month-to-month comparison of baseline and treatment
124
measurements of staff ratings on the Yates' Resident
Progress Scale.
Hypothesis 3 was tested by noting the trends of the
data in all six areas for all subjects. Visual inspection
of the graphs for these subjects was made to assess the
relationship between acting out behavior and relationship
behavior on a short-term basis.
Summary
A single subject, ex post facto research design of AB
form was used to determine the correlation between acting
out behavior and relationship behavior, over the
short-term and long-term in acting out, mildly mentally
retarded adolescents in a residential treatment program.
Additionally, the pattern of acting out behavioral change
was determined. The independent variable was a treatment
method emphasizing relationship-building. Six subjects
were used and six dependent variables were measured under
baseline, treatment, and end of treatment periods.
The six dependent variables were measured by the
Yates' Resident Progress Scale. These variables include:
1) verbal aggressiveness, 2) verbal and physical
assaultiveness on peers, 3) verbal and physical
assaultiveness on staff, 4) participation in program, 5)
cooperation with staff, and 6) overall relationship
behavior. The first three of these variables were
125
associated with acting out behavior; the second three,
with relationship behavior.
126
CHAPTER IV
ANALYSIS AND DISCUSSION OF FINDINGS
This chapter will present and analyze the findings of
the study. Each hypothesis set forth in Chapter I will be
examined, first with respect to the individual results of
the six single subjects and then with respect to the group
results. The chapter will conclude with a discussion of
the findings.
The presentation of results in single-subject
research differs from that in traditional group designs.
Of particular concern is the definition of what is a
"difference" as the result of the treatment method or
independent variable and how this "difference" is
determined. Hersen and Barlow (1976) pointed out the
difference between statistical and clinical significance,
stating that the purpose of applied research is to "effect
meaningful clinical or socially relevant behavioral
changes" (p. 37). Statistical significance can both
overestimate and underestimate clinical significance.
Single subject research designs are concerned with
clinical significance. In this study, clinical
127
significance was determined by close visual inspection of
each subject's data, particularly with regard to the slope
and directionality of the data over the short- term
(month-to-month) and long-term (beginning and end of
project). In addition, the mean of the data for each
period was determined, and changes in the mean scores for
each period were also a factor in determining clinical
significance.
Hypothesis Testing
The three hypotheses outlined in Chapter I have been
restated here along with data analyses.
Hypothesis 1. Adolescents receiving treatment
emphasizing relationship-building will demonstrate
overall increased relationship behavior and decreased
acting out behavior over at least a six-month period,
as demonstrated by comparison of baseline and
end-of-treatment measurements of staff ratings on the
Yates' Resident Progress Scale.
Table 2 shows the mean score for each subject on all
three dimensions of acting out behavior of the Yates'
Resident Progress Scale in the baseline and end of
treatment phases. Table 3 shows the mean score for each
subject on all three dimensions of relationship behavior
in the baseline and end of treatment phases.
Subject 1 showed an increase in acting out behavior
128
Table 2
Mean Scores on Acting Out Behavior Dimensions
at Baseline and End of Treatment
Verbal Assaults Assaults
Aggressiveness on Peers on Staff
Subject 1
Baseline
End of Treatment
2.60 3.00
2.33 3.67
4.00
4.00
Subject 2
Baseline
End of Treatment
2.78 3.78
1.22 3.00
1 .89
1.22
Subject 3
Baseline
End of Treatment
4.33 4.33
3.22 3.44
2.56
3 .22
Subject 4
Baseline
End of Treatment
2.33 3.00
1.78 2.78
1 . 33
1.22
a
Subject 5
Baseline
End of Treatment
2.22 3.00
1.00 2.11
2 .11
1. 22
Subject 6
Baseline
End of Treatment
2.11 3.22
3.11 3.00
1 .89
3 .78
a
Raw data for
End of treatment
treatment.
months 4 and 5 of treatment
data reported here are for
were lost,
month 3 of
129
Table 3
Mean Scores on Relationship
at Baseline and End
Behavior Dimen
of Treatment
sions
Overall
Participation Cooperation Relationship
in Program with Staff Behavior
Subject 1
Baseline 3.33 3 .60 3.00
End of Treatment 2.67 2.50 2.67
Subject 2
Baseline 2.67 2.50 2 .56
End of Treatment 4.33 4.67 3.22
Subject 3
Baseline 4.00 3.50 3.00
End of Treatment 3 .56 3.16 3.89
Subject 4
Baseline 2.33 3.00 2.33
End of Treatment 3.73 3.67 3.78
a
Subject 5
Baseline 3 .67 3.67 3.00
End of Treatment 3 .88 4.33 3.67
Subject 6
Baseline 3.44 3.50 3.00
End of Treatment 3.56 3.16 3.67
a
Raw data for months 4 and 5 of treatment were lost.
End of treatment data reported here are for month 3 of
treatment.
130
on one dimension, a decrease on another, and no change in
behavior on the third. The relationship behavior of
Subject 1 decreased in all three areas. The hypothesized
result of an increase in relationship behavior was not
demonstrated by this subject. A decrease in acting out
behavior was manifested on only one of those three scales.
Thus, the postulated inverse correlation between the two
types of behavior was partially substantiated, but not in
the postulated direction.
Subjects 2, 4, and 5 all showed a decrease in acting
out behavior on all three scales between baseline and end
of treatment, as well as an increase in relationship
behavior on all three scales over the long-term. These
results bear out the hypothesized relationship between
acting out and relationship behavior and the
directionality of change in these behaviors after
treatment.
Subject 3 demonstrated a decrease in two measures of
acting out behavior, and an increase in the third. In
relationship behavior, Subject 3 showed an increase on one
measure and a decrease in relationship behavior with
regard to the other two. In this case then, the
postulated inverse correlation between acting out behavior
and relationship behavior was demonstrated on 2 of the 6
131
dimensions.
Subject 6 showed an overall increase in acting out
behavior, as demonstrated by increases in two of the three
scales measuring this behavior. This subject also
manifested an increase in relationship behavior on two of
three dimensions. The correlation does not corroborate
the postulated inverse relationship between acting out and
relationship behavior.
With regard to group results, Subjects 2, 4, and 5
provided direct replication of the postulated inverse
correlation between acting out behavior and relationship
behavior and the directionality of the change in these
behaviors after relationship-building treatment.
Additionally, four of the subjects showed an overall
decrease in acting out behavior. Four subjects also
showed an overall increase in relationship behavior. Two
of these subjects (3 and 6) were not included in both
categories. These results support Hypothesis 1 in that
relationship-enhancing treatment is associated with
decreases in acting out behavior and increases in
relatinship behavior.
The acting out sub-scale of verbal and physical
assaults on staff and the relationship sub-scale of
cooperation with staff both consider the same object of
behavior, the staff. If behavior reflects the theoretical
132
position that acting out is associated with lack of
relationships, then these two sub-scales in particular
should be inversely correlated (as postulated in
Hypothesis 1). Results on these two sub-scales were
compared for each subject. The changes in mean scores for
five of the six subjects support the hypothesis. The
score for the sixth subject was unchanged with regard to
the acting out sub-scale, and decreased with regard to the
relationship sub-scale, and therefore does not disprove
the hypothesis. Additionally, three' of the six subjects
showed an increase in the relationship behavior sub-scale
and a decrease in the acting out behavior sub-scale,
supportive of the postulated directionality of change
following treatment.
Positive and negative changes in behavior were summed
across all subjects for acting out and relationship
behavior from baseline to end of treatment. 72% of the
mean scores for all acting out behavior scales reflected a
decrease in such behavior from baseline to end of
treatment. 66.67% of the mean scores for relationship
behavior showed an increase in this behavior from baseline
to end of treatment. These two percentages lend support
to both the hypothesized inverse correlation between
acting out and relationship behavior and the postulated
133
directionality of the change in these behaviors when
undergoing treatment emphasizing relationship-building.
The percentages of positive and negative changes in
mean scores for all subjects on each dimension of acting
out were also computed. Four of six (83.3%) of the
subjects demonstrated a decrease in verbal aggressiveness.
Four of six (83.3%) of the subjects demonstrated a
decrease in verbal and physical assaultiveness on peers.
50% demonstrated a decrease in verbal and physical
assaultiveness on staff (one subject remained unchanged).
With regard to relationship behavior, the increases
and decreases from baseline to end of treatment were also
computed. 66.67% of the subjects demonstrated an increase
in participation in program activities. 50% of the
subjects showed an increase in their cooperativeness with
staff. 83.3% demonstrated an increase in overall
relationship behavior.
In summary, Subjects 2, 4, and 5 demonstrated across
all measures an increase in relationship behavior and a
decrease in acting out behavior. Results with Subjects 1,
3, and 6 were mixed. Group results supported the
postulated position of an increase in relationship
behavior and decrease in acting out behavior, after
relationship-building treatment. These findings indicate
that a treatment method emphasizing relationship-building
134
can be associated with an increase in relationship
behavior and a decrease in acting out behavior.
Hypothesis 2. Adolescents receiving treatment
emphasizing relationship-building will exhibit a
pattern of acting out behavioral change which
manifests short-term worsenings and improvements, as
demonstrated by a month-to-month comparison of
baseline and treatment measurements of staff ratings
on the Yates' Resident Progress Scale.
Tables 4, 5, 6, 7, 8, and 9 show the mean scores for
acting out behavior on three sub-scales of the Yates'
Resident Progress Scale for each subject. Every subject
showed short-term worsenings and improvements at some
point during treatment on all three sub-scales, with one
exception.
Subject 5 (Table 8) demonstrated a short-term
worsening on two sub-scales during month three, but on the
third sub-scale (verbal aggressiveness) acting out
behavior decreased and then remained stationary.
(However, the final two months of raw data were lost for
this subject.)
Subject 5 (Table 8) also manifested the smallest
absolute acting out behavioral change of any subject.
Scores on verbal aggressiveness decreased 1.22 during
treatment; scores on verbal and physical assaultiveness on
135
Table 4
Subject 1
Mean Scores on Acting Out and Relationship
Behavior Dimensions in Short-Term Comparisons
Month
Baseline 1 2 3 4 5 6
Acting Out
Behavior
Verbal
Aggressiveness 2.60 3.00 2.60 2.00 3.00 4.00 2.33
Assaults
on
Peers 3.00 3.60 3.60 2.60 3.11 4.67 3.67
Assaults
on
Staff 4.00 2.00 1.33 1.00 2.11 4.00 4.00
Relationship
Behavior
Participation
in Program 3.33 3.44 4.00 4.00 4.00 2.67 2.67
Cooperation
with
Staff 3.60 3.80 3.50 4.00 4.00 2.00 2.50
Overall
Relationship
Behavior 3.00 2.89 4.00 3.67 3.67 3.33 2.67
136
Table 5
Subject 2
Mean Scores on Acting Out and Relationship
Behavior Dimensions in Short-Term Comparisons
Month
Baseline 1 2 3 4 5 6
Acting Out
Behavior
Verbal
Aggressiveness 2.78 2.67 2 .00 1.00 2.00 1 .22 1.22
Assaults
on
Peers 3.78 3 .67 2 .89 1.67 3.67 2 .22 3.00
Assaults
on
Staff 1.89 2.78 2 .16 1.00 1.00 1 .00 1. 22
Relationship
Behavior
Participation
in Program 2.67 3.33 3.67 4.33 3.00 4.22 4.33
Cooperation
with
Staff 2.50 3 .16 4.33 4.00 3.00 4.67 4.67
Overall
Relationship
Behavior 2 . 56 2.11 3.22 2.33 2.33 3 .11 3.22
137
Table 6
Subject 3
Mean Scores on Acting Out and Relationship
Behavior Dimensions in Short-Term Comparisons
Month
Baseline 1 2 3 4 5
Acting Out
Behavior
Verbal
Aggressiveness 4.33 3 .00 2.67 3.00 3.33 3.22
Assaults
on Peers 4.33 3.44 3.11 3.67 3.33 3 .44
Assaults
on Staff 2.56 3 .00 1.78 2.33 2.67 3 . 22
Relationship
Behavior
Participation
in Program 4.00 3 .11 4.00 3.00 2.33 3.56
Cooperation
with Staff 3.50 3 .33 3.83 3.00 3 .00 3.16
Overall
Relationship
Behavior 3 .00 3.11 3.44 4.00 4.00 3 .89
138
Table 7
Subject 4
Mean Scores on Acting Out and Relationship
Behavior Dimensions in Short-Term Comparisons
Month
Baseline 1 2 3 4 5 6
Acting Out
Behavior
Verbal
Aggressiveness 2.33 3.00 2 .44 2.11 3.33 2.00 1.78
Assaults
on
Peers 3 .00 3.67 3.56 3.22 4.33 3.33 2.78
Assaults
on
Staff 1.33 1.67 2.11 1.00 4.00 1.33 1. 22
Relationship
Behavior
Participation
in Program 2.33 3.00 3 .89 3.56 2.66 3 .67 3.78
Cooperation
with
Staff 3.00 2 .50 3.16 3.83 3.50 4.50 3 .67
Overall
Relationship
Behavior 2.33 3.00 3 .22 3.33 3.00 4.00 3.78
139
Table 8
a
Subject 5
Mean Scores on Acting Out and Relationship
Behavior Dimensions in Short-Term Comparisons
Month
Baseline 1 2 3 4 5
Acting Out
Behavior
Verbal
Aggressiveness 2.22 1.11 1.00 1.00
Assaults
on Peers 3.00 2.00 2.00 2.11
Assaults
on Staff 2.11 1.00 1.00 1.22
Relationship
Behavior
Participation
in Program 3.67 4.11 4.67 3.88
Cooperation
with Staff 3.67 4.67 5.00 4.33
Overall
Relationship
Behavior 3.00 4.00 4.33 3.67
a
Raw data for months 4 and 5 were lost.
JL.4Q_
Table 9
Subject 6
Mean Scores on Acting Out and Relationship
Behavior Dimensions in Short-Term Comparisons
Month
Baseline 1 2 3 4 5 6
Acting Out
Behavior
Verbal
Aggressiveness 2.11 2.89 3.78 3.00 2.00 2.89 3.11
Assaults
on
Peers 3.22 3.89 3.56 3.22 3.33 3.56 3.00
Assaults
on
Staff 1.89 1.67 2.56 2.00 3.00 2.56 3.78
Relationship
Behavior
Participation
in Program 3.44 3.33 4.00 3.56 3.67 3.56 3.56
Cooperation
with
Staff 3.50 3.67 2.11 3.67 3.50 3.67 3.16
Overall
Relationship
Behavior 3.00 2.89 3.11 3.67 4.00 3.67 3.67
141
peers decreased 1.00 during treatment; and mean scores on
verbal and physical assaultiveness on staff decreased 1.11
during treatment.
Subject 4 (Table 7) demonstrated the most short-term
fluctuations as well as the most consistent pattern from
sub-scale to sub-scale. In this case, there were two
peaks and one valley during treatment, with acting out
behavior also decreasing at end of treatment (over
baseline).
In summary, all of the sub-scales pertaining to
acting out behavior on the RPS reflected short-term
worsenings (i.e., increases in acting out behavior) at
some point during treatment, with one exception. These
findings strongly support the hypothesis stated above.
Hypothesis 3. Adolescents receiving treatment
emphasizing relationship-building will exhibit an
inverse correlation between relationship behavior and
acting out behavior, as demonstrated by a
month-to-month comparison of baseline and treatment
measurements of staff ratings on the Yates' Resident
Progress Scale.
All subjects reflected short-term worsenings and
improvements in relationship behavior on all sub-scales
pertaining to that behavior, in addition to the short-term
142
worsenings in acting out behavior discussed with regard to
Hypothesis 2.
Subject 1 (Table 4) showed short-term changes in both
types of behavior. The change in behavior from month one
to month two reflected the inverse relationship between
acting out and relationships stated in Hypothesis 3. In
this case, acting out behavior decreased and relationship
behavior increased on two of the sub-scales which measure
each behavior. From month four to month five the same
inverse relationship was again demonstrated. All acting
out behavior increased, and all relationship behavior
decreased. The change in behavior manifested in the
ratings from baseline to month one, and from month three
to month four were not supportive of the postulated
correlation. The change manifested in the ratings from
months two to three, and from months five to six, were
inconclusive.
Subject 2 (Table 5) demonstrated changes in acting
out and relationship behavior from month-to-month which
supported the postulated inverse correlation in four of
the six possible time frames (baseline to month one, month
one to month two, month three to month four, and month
four to month five). The other two time frames (month two
to month three, and month five to month six) did not
143
demonstrate the inverse correlation.
Subject 3 (Table 6) showed changes in acting out and
relationship behavior from month-to-month which supported
Hypothesis 3 in three of five possible time frames. From
month one to month two the hypothesis was supported on all
sub-scales. From month two to month three, all three
acting out behavior scales increased, while two of the
relationship behavior indices decreased. From month three
to month four, acting out behavior increased on two
sub-scales and decreased on the other, while relationship
behavior decreased on one scale and remained the same on
the other two. The time frames from baseline to month
one, and from month four to month five, were not
supportive of the postulated inverse correlation.
The results of mean ratings with regard to Subject 4
(Table 7) indicated support of the hypothesized
correlation in three of six possible time frames (month
two to month three, month three to month four, and month
four to month five). The other three possible time frames
were not supportive of this hypothesis.
Case 5 (Table 8) showed the results of only the
baseline and first three months of treatment. In this
case, all observed changes in acting out and relationship
behavior from month-to-month demonstrated the postulated
144
relationship. From baseline to month one, all acting out
scales decreased and all relationship scales increased.
From month one to month two, all relationship scales
increased, while one acting out scale decreased and the
other two remained the same. From month two to month
three, two acting out scales increased and the three
relationship scales decreased.
The results from Case 6 (Table 9) indicate support
for Hypothesis 3 in three of the six possible time frames
(although the inverse correlation was manifested on only
two of the three possible sub-scales in each time frame).
These time frames were baseline to month one, month two to
month three, and month four to month five. The results
from month one to month two, and from month three to month
four, were non supportive. The time frame from month five
to month six was inconclusive.
To sum the data across all subjects, there were 32
possible time frames in which the postulated inverse
correlation between acting out and relationship behavior
might have been demonstrated. In 56.25% of these cases,
subjects manifested this inverse correlation on at least
two of the three sub-scales used to measure acting out
behavior and on at least two of the three sub-scales used
to measure relationship behavior. In 34.38% of these time
frames, the inverse correlation between these two types of
145
behavior was not demonstrated. In 9.38% of these
instances, the evidence was inconclusive.
In summary, each subject manifested short-term
worsenings in both relationship and acting out behavior on
a month-to-month comparison of ratings on the six
sub-scales. Each subject also demonstrated at least two
instances in which the particular month-to-month time
frame reflected an inverse correlation between the two
types of behavior. Only one subject (Subject 5), however,
demonstrated unequivocably the postulated inverse
correlation. The summed group data also demonstrated some
support of the hypothesis, in that 56.25% of all possible
time frames also showed this correlation. However, such
results are inconclusive and this hypothesis can only be
equivocably supported.
Discussion
This study was designed to investigate the effects of
treatment emphasizing relationship-building in the acting
out and relationship behaviors of adolescents who are
mildly mentally retarded, act out, and were confined in an
adolescent residential treatment program. The prediction
that such treated adolescents would manifest a decrease in
acting out behavior and an increase in relationship
behavior from the onset of treatment (baseline) to the end
146
of treatment was supported in three of six cases. The
hypothesis that acting out behavior would manifest
short-term worsenings and improvements was very strongly
supported. The prediction that short-term changes in
acting out and relationship behavior would corroborate the
inverse relationship predicted in Hypothesis 1 was
slightly supported.
The Yates' Resident Progress Scale was used to
measure acting out and relationship behavior. This scale
was developed for use in this particular ARTP program and
was consequently not available for modification or
addition. Unfortunately, the sub-scales consisted of, at
the most, three items. While the correlations within
these sub-scales were generally high, the scales may not
have been large and diverse enough to determine accurately
the variability in acting out and relationship behavior
from month to month.
Hypothesis 1 can be considered to be supported
because of the unequivocable direct replication of the
predicted findings in three of the six single cases. The
results on five of the six subjects comparing verbal and
physical assaults on staff and cooperation with staff
sub-scales also showed an inverse correlation between
acting out and relatinship behavior. Additionally, the
summing of group data recommended by Tracey (1983)
147
supported the predicted correlation.
The three cases which do not appear to support the
prediction should be examined more closely. The results
from Tables 2 and 3 which pertain to Subject 1 indicate
that relationship behavior decreased on all three
sub-scales. Additionally, acting out behavior increased
on one sub-scale, remained the same on another, and
decreased on the third. The only acting out scale which
decreased was verbal aggressiveness, potentially the least
destructive of the three types of behavior. The increased
acting out behavior and equal results on the other two
sub-scales should be weighted more strongly, because they
indicate greater potential harm to society. Thus, the
results in this case bear out the predicted inverse
correlation, but not the direction of predicted change.
One possible explanation of these results is that this
subject was a treatment failure in this particular setting
rather than a demonstration that the theoretical position
is invalid.
Subject 3 manifested a decrease in two types of
acting out behavior, and an increase in one (verbal and
physical assaultiveness on staff), as shown in Table 2.
Verbal and physical assaultiveness should be considered
one of the most serious types of behavior. On Table 3,
the only relationship behavior which increased was overall
148
relationship behavior. This sub-scale should again be
weighted more heavily than the other two, since it deals
most obviously with relationship issues. Thus, scores on
the most serious acting out sub-scale and the most
important relationship sub-scale both increased (i.e.,
acting out worsened and relationships improved), a result
not supportive of the hypothesis. However, if the
increased score on overall relationship behavior is
compared with the other two acting out sub-scales, on
which scores did decrease, the hypothesis may be
considered supported. Therefore, the results remain
inconclusive, neither supporting nor rejecting the
predicted correlation.
Results from baseline and end of treatment mean
scores with respect to Subject 6 also appeared
inconclusive. The subject's ratings increased on both
verbal aggressiveness and physical and verbal assaults on
staff sub-scales, while relationship behavior on two
dimensions (participation in program and overall
relatinship behavior) also increased. These results are
the most unsupportive of the predicted correlation of any
subjects. In this case, rater bias (the halo effect)
should be considered. Overall relationship behavior,
given more weight than the other two sub-scales, improved
at the same time that verbal aggressiveness and assaults
149
on staff worsened. Such findings might result from staff
members' reluctance to admit that a relationship was
worsening.
The support for Hypothesis 1 clinically corroborates
several theoretical positions. First, it gives weight to
theory that psychotherapy is appropriate with a mentally
retarded population. Second, these positive findings lend
credence to theories emphasizing relationship-building as
a treatment method, especially with this population.
Third, these findings support a position that the ability
of individuals to form and have relationships can change,
and thus poor relationships may not be an adequate
prognosticator of outcome in therapy. Fourth, these
findings support the position that acting out behavior may
be associated with difficulties in interpersonal
relationships.
Hypothesis 2 was clearly and strongly supported by
the results of this study. In all cases, there were
short-term worsenings during treatment, even in cases
where the subjects ultimately improved (particularly
Subjects 2, 4, and 5). This direct replication lends
credence to the generalizabiity of the hypothesis. (It is
also possible that such findings might have occurred
naturally.) Shapiro (Shapiro & Hobson, 1972; Shapiro &
Shapiro, 1974) also replicated short-term worsenings,
150
particularly in depression, during treatment and
theoretized that such findings were consistent with
treatment in which patients' pre-established coping
processes were addressed. The theoretical work of Levy
(1938), Rinsley (1968, 1974), Kell and Mueller (1966), and
Ofman (Note 1) also was clinically supported with these
results.
The results pertaining to Hypothesis 3 were
inclusive, although indicative of a relationship between
acting out and relationship behavior. The failure of this
research study to strongly support the hypothesis may have
three possible explanations. First, the measure itself
possesses only a small number of items within each
sub-scale, and thus may not accurately measure the changes
in various types of behavior. The acting out and
relationship scales are also not clearly related to each
other. Thus, if one acting out scale such as verbal
aggressiveness decreases, there is no method by which to
ascertain if a corresponding relationship-type of activity
has increased, even if other behaviors are unaffected.
There is also no readily apparent method utilizing this
scale to determine if ratings on one type of behavior may
be correlated with ratings on another in a subsequent time
frame.
Second, rater bias may again have been an influence.
151
In both Subject 1 (Table 4) and Subject 6 (Table 9), there
was a time frame in which acting out behavior increased,
but the relationship behavior sub-scales did not reflect a
decrease. Again in both cases, the following month also
indicated an increase in acting out behavior. In this
time frame, the relationship behaviors showed a decrease,
supportive of the hypothesized inverse relationship.
Raters may have had difficulty in giving lower scores on
relationship behaviors if they felt affection for the
subjects, even if the subjects were acting out. However,
when the acting out behavior continued for longer than one
month, the relationship behavior ratings also fell.
Third, this hypothesis stated simply that there was
an inverse correlation between acting out behavior and
relationship behavior, over the short-term, continuing the
same position as Hypothesis 1. However, Rinsley (1968,
1974), Kell and Mueller (1966), and Ofman (Note 1) all
wrote that acting out behavior may increase when a
relationship becomes too emotionally threatening. If this
theoretical position is correct, then relationship
behavior might increase and be followed by an increase in
acting out behavior, over the short-term. This
correlation might also be expressed over more than one
time frame.
152
Summary
The prediction in Hypothesis 1 that there would be an
increase in relationship behavior and a decrease in acting
out behavior in a population of acting out, mildly
mentally retarded adolescents in a residential setting was
supported by the findings of this research study. The
prediction that there would be short-term worsenings in
acting out behavior during treatment was strongly
supported by the results of this study. However, results
were inconclusive with regard to the hypothesized inverse
correlation between acting out and relationship behavior
in month-to-month comparisons of the two types of
behavior. Some support for this relationship was found,
but its exact nature remained unclear. Three possible
explanations for this lack of clear support were offered:
the measure itself did not provide the necessary
specificity with regard to how behaviors may be related in
various time frames, as opposed to one time frame, for
such in-depth examination? the halo effect might have
raised ratings on several of the relationship behavior
sub-scales, particularly in certain specific instances;
and the association between relationship and acting out
behavior may be of a short-term positive/positive nature.
153
CHAPTER V
SUMMARY, IMPLICATIONS, AND RECOMMENDATIONS
This chapter will briefly review the background of
the problem, the literature, the hypotheses, the
methodology, and results of the study. Implications of
these findings, as well as recommendations for further
research, will also be discussed.
Background of the Problem
Adolescents today may be viewed as experiencing
significant emotional distress and acting out behavior,
including such activities as successful and attempted
suicides, alcohol and substance abuse, running away, and
aggressive acts. Acting out behavior and mental
retardation have been linked statistically. There is
evidence that mentally retarded individuals may be more
likely to develop acting out behavioral problems than a
normal population (Hutt . & Gibby, 1979; Roller et al.,
1983). When the behavior of these adolescents becomes
threatening to society, they may be removed from their
homes and placed in an in-patient setting (Alt, 1960).
If these adolescents are placed in a residential
154
setting, the proper treatment to bring about a decrease in
acting out behavior becomes important. This is
particularly true with respect to the mentally retarded,
because there is disagreement regarding successful
outcomes for this population with traditional verbal
psychotherapy methods. When considering therapy in
general, scholars generally agree that there is no
difference between various treatment methods (with certain
specific exceptions). Common factors such as the therapy
relationship itself then may be considered for their
contribution to positive outcomes in psychotherapy.
Interpersonal and borderline personality theorists
ascribe the development of psychopathology to disturbances
or deprivations in interpersonal relationships. Acting
out may be one expression of these difficulties. Such
theorists advocate the therapy relationship as the vehicle
through which psychological growth may be achieved. In an
in-patient setting, therapy relationships may be expanded
to include more of the staff than only the
psychotherapist. If relationships and
relationship-building are important in treatment, they
should be specifically investigated.
Another issue is the short-term pattern of behavioral
change, particularly with respect to acting out. Do
155
individuals improve gradually and steadily, or do they
improve and then regress ("get worse before they get
better")? The popular literature generally expects that
patients should get better without regression. However,
this may not be in fact the actual case.
The present investigation was designed to intensively
study the effects of relationship-building treatment upon
acting out and relationship behavior from the beginning to
the end of treatment. It was also designed to ascertain
the pattern of acting out behavioral change during
treatment.
Review of the Literature
The literature shows that most scholars associated
the etiology of adolescent psychopathology with some form
of interpersonal disturbance. Interpersonal theorists
located the source of psychopathology in continuing
distressful interpersonal relationships, which force the
adolescents to withdraw and depend upon intrapsychic
motivation (Ofman, 1976; Sullivan, 1953). Other authors
looked more specifically at early childhood deprivations
and abandonments by one or both parents. Bowlby (1946,
1951) wrote that the issue of "maternal deprivation" was
of prime importance. Rutter (1971, 1972, 1980) believed
that disruptions in bonds with either or both parents
could cause the development of psychopathology.
156
Borderline personality theorists such as Masterson (1972,
1974) found the source of such pathology in the failure of
the mother and child to separate-individuate during the
child's early life. Masterson (1972) also wrote that the
emergence of psychological problems during adolescence
could usually be traced to earlier childhood problems, not
to normal maturational development.
Acting out is one particular manifestation of
psychopathology. It is a form of non-verbal communication
(Hendrickson et al., 1959; Masterson, 1972) with at least
five non-exclusive meanings. First, it may be considered
a plea for help (Masterson, 1972). Second, it serves as a
defense (Hendrickson & Holmes, 1959). Third, it is one
kind of response to interpersonal events (Sullivan, 1953).
Fourth, it is unrelated or omnipotent (Ofman, Note 1).
Fifth, it may serve as resistance to treatment (Rinsley,
1968, 1974).
The treatment of adolescents who act out is
associated with theories regarding the etiology of
psychopathology. A theoretical position which postulates
increasing the ability to form and have relationships as
the means by which to decrease acting out behavior is
consistent with interpersonal theory regarding the
etiology of adolescent psychopathology. Such theorists
consider the therapeutic relationship to be of primary
157
importance, even though they may differ in interpretation
of the nature of the relationship (Masterson, 1972, 1974;
Patterson, 1974; Ofman, Note 1). Such a relationship may
be particularly difficult to establish with adolescents
(Holmes, 1964). While there is considerable theoretical
evidence regarding the importance of the therapy
relationship in bringing about a decrease in adolescents'
acting out behavior, there is little empirical evidence to
support it.
If adolescents are placed in an in-patient setting
for treatment of their behavioral problems, the
traditional therapeutic relationship may be widened to
include other staff therapeutic relationships as well
(Levy, 1938; Strupp & Hadley, 1978). The milieu itself
may also be considered to be therapeutic (Cumming &
Cumming, 1962). The milieu performs the functions of
containment, support, structure, involvement, and
validation (Gunderson, 1978).
The literature generally agreed that mild mental
retardation is a compounding factor, not a causative one,
in the development of maladaptive behavior in adolescents
(Hutt & Gibby, 1979). However, most research supports a
statistical association between mental retardation and
behavioral problems (Koller et al., 1983). There is some
disagreement in the literature regarding appropriate
158
treatment for the mentally retarded. Some authors
theoretized that traditional verbal psychotherapy could
not be used with the mentally retarded. Others (e.g.,
Heiser, 1954; Menolascino, 1977; Thorne, 1948) provided
clinical evidence that such psychotherapy could be
conducted with retarded individuals.
There was support in the literature for a pattern of
behavioral change during treatment which included
short-term regression or worsenings. Kell and Mueller
(1966), Levy (1938), Rinsley (1968, 1974), and Ofman (Note
1) wrote in support of such a pattern. However, with the
exception of the work of Shapiro (Shapiro & Hobson, 1972;
Shapiro & Shapiro, 1974), there is little clinical
evidence to support such a pattern of behavioral change.
Further intensive clinical research is needed to
establish if relationship-building treatment may be
associated with improvements in acting out and
relationship behavior for mildly mentally retarded, acting
out adolescents in an in-patient setting. Clinical
research is also necessary to help establish the pattern
of behavioral change.
Hypotheses
Three hypotheses were postulated in this study. It
was predicted that acting out, mildly mentally retarded
adolescents treated with relationship-building would
159
demonstrate an increase in relationship behavior and a
decrease in acting out behavior from the beginning to the
end of treatment. It was predicted that these adolescents
would display short-term worsenings in their acting out
behavior during the course of treatment. Finally, it was
predicted that this population would demonstrate an
inverse correlation between acting out and relationship
behavior during treatment (short-term comparisons).
Methodology
A single subject, ex post facto research design of AB
form with six subjects was used in this investigation.
These subjects were followed through a baseline phase and
treatment phase until the end of treatment. The subjects
resided in an in-patient Adolescent Residential Treatment
Program (ARTP) administered by Gateways Hospital. The
selection of these subjects was based upon methodological
considerations, and upon demonstrated criteria of
intellectual functioning and behavioral problems.
During the treatment phase, subjects received
intensive treatment emphasizing the importance of
relationships in all aspects of life. Treatment
activities included: individual psychotherapy, daily
group therapy, daily recreational therapy, daily school,
weekly resident and staff social activities, and bi-weekly
outings. The staff provided therapeutic relationships in
160
a large sense, as a milieu, and upon a more individualized
basis, according to their specific work functions.
Each subject was closely monitored throughout the
study. Three staff members assigned to the individual
resident rated his or her behavior utilizing the Yates'
Resident Progress Scale. This scale provided three
measures of acting out behavior, including verbal
aggressiveness, verbal and physical assaults upon peers,
and verbal and physical assaults upon staff. It also
provided three measures of relationship behavior:
participation in program, cooperation with staff, and
overall relationship behavior. These sub-scales provided
the dependent variables for this study.
Results
Hypothesis 1 was supported by the results of the
study. Direct replication in three of the six single
subjects provided support for the postulated inverse
correlation. The results on five of six subjects also
showed an inverse correlation between acting out and
relationship behavior when comparing two specific
sub-scales (assaults on staff and cooperation with staff),
also supportive of the hypothesis. In addition, the
individual data were summed to provide group statistics.
72% of the ratings of acting out behavior from baseline to
161
end of treatment reflected a decrease in such behavior.
66.67% of the ratings of relationship behavior over the
same time period reflected an increase in this behavior.
Hypothesis 2 was strongly supported by the findings
of this research study. Direct replication with all
subjects showed that each subject's ratings showed
short-term worsenings with regard to acting out behavior,
with the exception of one sub-scale with one subject.
Hypothesis 3 was mildly supported by the results of
the study. All subjects' scores did exhibit short-term
worsenings in relationship behavior, in addition to acting
out behavior. Only 56.25% of the correlations between
acting out and relationship behavior, however, were in the
postulated inverse direction. The scores of Subject 1
demonstrated the inverse correlation in two of six
possible time frames. Subject 2's ratings exhibited the
hypothesized association in four of six possible time
frames. Subject 3's scpres showed the postulated
relationship in three of five possible time frames. The
ratings of Subject 4 demonstrated this relationship in
three of six possible time frames. Scores on Subject 5
exhibited the predicted relationship in all three possible
time frames. Subject 6's ratings demonstrated this
correlation in three of six possible time frames.
162
Implications and Recommendations
Based on the results of this study, the positions of
interpersonal and borderline personality theorists are
supported. These theorists (e.g., Levy, 1938; Patterson,
1974; Ofman, Note 1) advocated that adolescents (and
individuals in general) displaying psychopathology be
helped through the therapy relationship(s) to form better
personal relationships. In this eventuality, the
psychopathology (i.e., acting out behavior) should
diminish. Additionally, these results support a position
that the ability of an adolescent to form and have
relationships can change (Arsenian, 1970), and question
the results of such studies as the Menninger Foundation
Research Project (Kernberg, 1973), which use the ability
to form relationships as a prognosticator of poor outcome
in psychotherapy.
These results also support a theoretical position
which states that acting out behavior may be associated
with difficulties in interpersonal relationships
(Sullivan, 1953). Such support again emphasizes the
importance of relationships in psychotherapy.
This support also gives support to scholars who wrote
that the mildly mentally retarded could be treated
successfully with traditional psychotherapy (Hutt & Gibby
1979).
163
Similar studies utilizing relationship-building
treatment should be conducted. While the direct
replication of results in this study does give some
generalizability to the findings, they cannot be
considered inherently valid for other populations. These
populations should be investigated.
The findings of this study also strongly support the
theoretical position of Kell and Mueller (1966), Levy
(1938), Rinsley (1968, 1974), and Ofman (Note 1), as well
as the clinical studies of Shapiro (Hobson & Shapiro,
1972; Shapiro & Shapiro, 1974) with regard to the pattern
of behavioral change. The adage that "people get worse
before they get better" was upheld by these results. Such
results should be publicized as widely as possible, so
that society, parents, and adolescents themselves do not
continue to hold unrealistic expectations regarding the
ability of individuals to dramatically stop acting out.
However, further study should be made using a control
group, if possible, to better assess rater inconsistency
and improvements due to chance.
The results of this research study did not strongly
support the hypothesized inverse correlation between
acting out and relationship behavior during treatment,
over the short term. The lack of clinically significant
164
findings may have several possible explanations.
First, the Resident Progress Scale itself may lack
sufficient items to accurately measure behavior in a wide
range of areas. Using a rating scale for behavior is not
uncommon, but such scales generally concern themselves
with acting out types of behavior. The RPS attempts to
measure relationship types of behavior as well, and
consequently provides needed innovation in measurement.
Relationship types of behavior, however, need to be more
specified (e.g., items such as initiating conversation, or
eye contact). Acting out and relationship sub-scales
should also concern themselves with the same objects
(e.g., staff). These changes in the scale might make it
possible to follow behavioral change across time frames
(e.g., an increase in relationship behavior in time frame
one might be associated with an increase in acting out
behavior in time frame two).
Second, there may be rater bias toward subjects,
particularly with regard to rating them on relationship
behavior during the time that they act out. Raters may
want the patients to appear healtheir than they may in
fact be. Although an attempt was made in this study to
control for rater bias by using three independent raters
with different functions and relationships with the
subjects, an independent observer or self-rating scales
165
might diminish this effect.
A final explanation for the lack of clinically
significant findings may rest in theory regarding the
nature of the association between acting out and
relationship behavior. While it was theoretized that
acting out behavior should decrease as relationships
increased, some authors also stated that acting out might
increase during treatment as the result of emotional
difficulties associated with intense therapeutic
relationships (Kell & Mueller, 1966? Rinsley, 1968, 1974;
Ofman, Note 1). Thus, relationship and acting out
behavior both might increase over the short-term. This
theoretical position should be examined in greater depth.
166
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178
YATES'
APPENDIX A
RESIDENT PROGRESS SCALE
179
Name _________________
Date
GATEWAYS HOSPITAL ------------------------------
Adolescent Residential Treatment Program/DD
Resident Progress. Scale
State your level of agreement with the following statements by marking on the scale provided. Answer with
your first impression. Do not "overthink” your response.
A - Totally Disagree B - Somewhat Disagree
C - Mixed D - Somewhat Agree E - Totally Agree
The above-mentioned resident:
A B C D . E
1) Keeps his/her room clean. j j I I ^
2 ) Brushes teeth regularly. J 1 I j
3 ) Dresses neatly. J j
|
4 ) Bathes regularly. I
^ ........................................ ■ ...
5) Is on time to activities.
|
6) Is on time to school.
---- !
7) Gets out of bed on time.
...
1
- .. .
8) Demonstrates socially appropriate eating habits.
....
j
9) Demonstrates socially appropriate manners.
|
10) Is verbally hostile and aggressive to peers.
1
1.1) Is verbally aggressive to staff, in general.
12) Is verbally abusive to you in particular. I
13) Is cooperative with staff in general.
14) Is cooperative with you in particular.
15) Is physically threatening to staff (but does not carry
out threats).
j
16) Is physically abusive towards staff.
i .
I
i
A B C D E
17) Verbally threatens to harm staff. |
18) Attempts to instigate trouble for other peers. |
19) Forms positive relationships with staff. j
20) Forms positive relationships with peers.
21) Demonstrates overall improvement during tenure in program.
■ •
For the following statements, indicate the level of frequency appropriate for the above resident. Again,
answer with your first impression.
A - Never B - Almost Never C - Sometimes
D - Often E - Always
22) Threatens to harm individuals outside of Gateways
(family members, etc.).
D
i
H i
23) Has threatened to harm self, but does not carry out threat.
. . . .
24) Actually harms self, but not seriously.
25) Seriously harms self.
26) Destroys hospital property (windows, lights, etc.).
27) Steals.
28) Lies.
29) Engages in arguments with peers.
30) Demonstrates adequate self control.

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Creator Pauley, Elsa Pottala (author)

Core Title A study of the role of relationships in the treatment of mildly mentally retarted, acting out adolescents

Degree Doctor of Philosophy

Degree Program Education

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