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The Psycho-Social World Of The Leprosy (Hansen'S Disease) Patient: Assessment Of Community Reaction To The Disease And Patient Psychologicalfunctioning
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The Psycho-Social World Of The Leprosy (Hansen'S Disease) Patient: Assessment Of Community Reaction To The Disease And Patient Psychologicalfunctioning
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THE PSYCHO-SOCIAL WORLD OF THE LEPROSY
(HANSEN’S DISEASE) PATIENT:
ASSESSxMENT OF COMMUNITY REACTION TO THE DISEASE
AND PA TIENT PSYCHOLOGICAL FUNCTIONING
by
P a tric ia E lizab eth F lynn
A D isse rta tio n P re s e n te d to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In P a r tia l F u lfillm en t of the
R eq u irem en ts fo r the D egree
DOCTOR OF PHILOSOPHY
(Psychology)
June 1971
INFORMATION TO USERS
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University Microfilms
300 North Zeeb Road
Ann Arbor, Michigan 48106
A Xerox Education Company
72-23,142
FLYNN, Patricia Elizabeth, 1929-
THE PSYCHO-SOCIAL WORLD OF THE LEPROSY
(HANSEN'S DISEASE) PATIENT: ASSESSMENT OF
COMMUNITY REACTION TO THE DISEASE AND
PATIENT PSYCHOLOGICAL FUNCTIONING.
University of Southern California, Ph.D., 1971
Psychology, general
University Microfilms, A XERQ\ Company, Ann Arbor, Michigan
© 1972
PATRICIA ELIZABETH FLYNN
ALL RIGHTS RESERVED
U N IV E R S IT Y O F S O U T H E R N C A L IF O R N IA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 0 0 0 0 7
This dissertation, written by
m m ..P a tric ia .Elizjabeth^Flynn________ _ _ ______
under the direction of hex. Dissertation Com
mittee, and approved by all its members, has
been presented to and accepted by The Gradu
ate School, in partial fulfillment of require
ments of the degree of
D O C TO R OF P H IL O S O P H Y
| J Dean
Date...
DISSERTATION COMMITTEE
Chairman
PLEASE NOTE:
Some pages may have
indistinct print.
Filmed as received.
University Microfilms, A Xerox Education Company
DEDICATION
To m y p a re n ts , John and C atherine F lynn, who have given of
th e m se lv e s in so m any w ays, to facilitate m y a r r iv a l a t th is place
and m om ent in tim e , th is w ork is dedicated with affection.
ACKNOW LEDGEM ENTS
i
T his is the place w here the h e a rt speaks.
When one begins to recount the n u m b er of people who have
played a p a rt, la rg e o r sm a ll, in the attain m en t of th is goal, one feels
th at a t le a s t a tenth of the population in the w orld m u st be involved!
So it would seem . But th e re a re c e rta in ones, individuals and groups,
who will light the h a lls of m e m o ry when re m in is c e n c e s of G raduate
School Days o ccu r. To th ese I owe p a rtic u la r thanks fo r th e ir unique
and p e rso n a liz e d contrib utions. I would re c a ll the follow ing:
D octor H e rm a n H arv ey , who m ight be d e sc rib e d , borrow ing
fro m a n o th er d iscip lin e, a s the im m e d ia te , efficient, and final cause.
He h as been a t once in sp irin g and e x a sp e ra tin g , thought-provoking,
and plain provoking, dem anding and supporting, a so u rc e of c reativ ity
I
and d e s p a ir, of co m fo rt and irrita tio n . He h as been a ll th in g s, a m ain
sp u r to achievem ent which, a fte r a ll, rig h tly d e s c rib e s a p ro p e r
C h a irm an of C o m m itte e !
My C om m ittee m e m b e rs , the D octors N orm an L evan, N orm an •
i
T ib e r, and C onstance L ovell, who have been g en ero u s with th e ir tim e
and help, p arsim o n io u s and gentle in th e ir c ritic is m .
D r. G eorge R hodes, consultant, sch o lar, te a c h e r, and frien d
who w as resp o n sib le for the p ro ce ssin g and handling of the e n tire
»
sta tis tic a l p ro c e d u re . He h a s guided m e, with such infinite patience,
throug h the p re c isio n and rig o r of sta tistic a l thinking, a t which
discip lin e the c lin ica l m ind so frequently b a lk s !
D r. M a rg a re t Storkan, whose acquaintance I m ad e in h e r role
as C onsultant to the L ep ro sy Clinic and who has b eco m e, o v e r the
y e a r s , a d e a r frien d . In such a capacity, through all the r e s e a r c h
ph ase, she h a s functioned as consultant, e d ito r, a d v is o r, p ro m o te r,
and fello w -q u affer on o ccasion . She has indeed, M . . . m ad e the
crooked w ays straig h t. "
D o cto rs Ann E lconin and Leona M iller at U S C -M edical C enter;
D octors Stanley Tobias and R o n ald R eisn er at H arb o r G e n e ra l H ospital;
D o cto rs John T h erio t, N orm an O 'F a r r e ll, and C a rl K orn a t the
p riv a te clin ics; attending and staff ph y sician s, n u r s e s , a tte n d a n ts, and
p e rso n n e l in a ll th e se fa c ilitie s , whose attitude can only be d e sc rib e d
a s e x tre m e ly accom m odating. T heir g ra c io u sn e ss w as m ad e m o re
p re c io u s by the fac t that I w as acutely aw are that our p re s e n c e f r e
quently m ade a busy, crow ded, and at tim e s chaotic c lin ic , even m ore
so.
My re la tiv e s , a lm o st a ll the twigs on all the b ra n c h e s of the
fam ily t r e e , u n cles, a u n ts, cousins, who functioned in a d iv e rs ity of
c a p a c itie s a s s c o re -c h e c k e rs , p r o o f -r e a d e rs , X e ro x e rs , and g e n eral j
e x p e d ite rs.
My frie n d s, who during this tim e allow ed m e the ro le of Social [
I
B a rb a ria n , and m y b u sin e ss acquaintances who p e rm itte d m e the ro le 1
of Struggling Student. j
i !
I
j My ty p ist, B illie R iley, who has m ade a thing of beauty out of ;
a c re a tiv e ly c arv ed up m a n u sc rip t. i
! i
The anonym ous good people co m p risin g the a b stra c tio n known J .
a s C om m unity Sam ple, whose v e ry re a l hum anity w as rev e ale d in giv- t
i ' I
I i
ing fre e ly of th e ir tim e for the b e tte rm e n t of th e ir fellow m en. ■
I ;
I |
| And la stly , and m o st ten d e rly , m y p atien ts. I say "m y" j
! !
i i
b e c a u se how ever b rie f the m eeting, so often som ething "click e d " i
I s
I
betw een us when they p e rm itte d m e a c c e s s to th e ir own p riv ate psychic'
.w orld, in this m o st a ltru is tic g e stu re . Though freq u en tly poor in
m a te ria l'w a y s , they w ere ric h in a generous s p irit, and w ithout them
!we would be now here in th is w ork.
The B ard has said it w ell, in P o lo n iu s' advice to L a e rte s ,
The frie n d s thou h a st, and th e ir adoption trie d ,
G rapple th em to thy soul with hoops of ste e l . . .
T hese a re m y frie n d s. This I have done.
T A B L E O F CO N TEN TS
L ist of T ables ................................................................................................. viii
C hapter Page
I. IN T R O D U C T IO N ............................................. .......................... 1
H isto ry of L ep ro sy
M edical A sp ec ts
II. PSYCHOLOGICAL PHENOMENA . . . . ........................ 18
Review of the L ite ra tu re
The P ilo t Study
C onclusions R egarding T h re a t P o ten tial of
H an sen 's D isease
III. THE STRESS PARADIGM AND EX PE R IM E N T A L
D E S IG N .......................................................................................... 40
The S tre ss P a ra d ig m of L a z a ru s
A nalysis of P ilo t Study in S tre s s P a ra d ig m
E x p e rim e n ta l Strategy
IV. M E T H O D ......................................................... . 79
P h ase I. Com m unity A ttitudes A s s e s s m e n t
P h ase II. M e asu rem en t of P atien t P sycho log ical
Functioning
V. R E S U L T S ........................................................................................ 105
A s se ssm e n t of Com m unity A ttitudes T ow ard
D isease
A s se ssm e n t of P a tie n t Functioning
C h ap ter P age
VI. DISCUSSION 146
P h ase I. A s s e s s m e n t of C om m unity A ttitudes
T ow ard D isease
P h ase II. A s s e s s m e n t of P a tie n t F unctioning
Im plications fo r P a tie n t M anagem ent and R e s e a rc h
Sum m ary
A. Bogardus Social D istance Scale (R evised)
fo r Illn ess
B. State-A nxiety Scale
C. T rait-A n x iety Scale
D. B ody-C athexis Scale
E . Self-C athexis Scale
F . L ette r to P s o r ia s is P a tie n ts
G. Explanation of Study to E x p e rim e n ta l G roup
H. E xplanation of Study to C ontrol G roups
R E FE R EN C ES 171
APPENDIXES 180
vii
/ •
LIST O F TABLES
T able Page
1. Two-W ay A nalysis of V ariance: Sem antic
D ifferential, P e rs o n a l Involvem ent F a c t o r ........................... 110
2. C ritic a l D ifferences Betw een M eans: Sem antic
D ifferential, P e rs o n a l Involvem ent F a c to r,
D ise ase Group E ffect (N = 90) ........................................... 112
3. C ritic a l D ifferences Betw een M eans: Sem antic
D ifferential, P e rs o n a l Involvem ent F a c to r,
Social C lass E ffect (N = 9 0 ) ................................................... . 113
4. Two-W ay A nalysis of V ariance: Sem antic D ifferential,
T h rea t F a c t o r ........................................................................................ 115
5. C ritic a l D ifferences Betw een M eans: Sem antic
D ifferential, T h re a t F a c to r , D ise ase Group E ffect
(N = 9 0 ) ..................................................................................................... 116
6. C ritic a l D ifferences Betw een M eans: Sem antic
D ifferential, T h re a t F a c to r, Social C lass
E ffect (N = 9 0 )........................................................................................ 117
7. Two-W ay A nalysis of V ariance: Sem antic D ifferential,
Social A cceptability F a c t o r ........................................................... 118
8. C ritic a l D ifferences B etw een M eans: Sem antic
D ifferential, Social A cceptability F a c to r, D ise ase
Group E ffect (N = 9 0 ) ............................................................... 120
9. C ritic a l D ifferences Betw een M eans: Sem antic
D ifferential, Social A cceptability F a c to r, Social
C lass E ffect (N = 9 0 ) ........................................................................ 121
v iii
T able Page
10. Tw o-W ay A n aly sis of V arian ce: B ogardus Social
D istance Scale (Score No. 1 A ffiliation S c o r e )........ 123
11. D iffere n ce s B etw een M eans: B ogardus Social
D istan ce Scale (1), D ise ase G roup E ffect (N = 90) . . . 124
12. D iffere n ce s B etw een M eans: B ogardus Social
D istance Scale (1), Social C lass E ffect (N = 9 0 )..... 126
13. Tw o-W ay A n aly sis of V arian ce: B ogardus Social
D istance Scale (Score No. 2 D isaffiliatio n Score). . . . 127
14. D ifferen ces B etw een M eans: B ogardus Social
D istance Scale (2), D ise ase G roup E ffect (N = 90) . . . 128
15. D iffere n ce s B etw een M eans: B ogardus Social
D istance Scale (2), Social C lass E ffect (N = 9 0 ) ..... 130
16. P e a rs o n P ro d u c t-M o m en t C o rrela tio n : Sem antic
D ifferen tial F a c to r s and B ogardus Social D istance
Scale No. 1 (A ffiliation S c o r e ) ........................................ 132
17. P e a rs o n P ro d u c t-M o m en t C o rrela tio n : Sem antic
D iffere n tia l F a c to r s and B ogardus Social D istance
Scale No. 2 (D isaffiliation S c o r e ) .................................. 132
18. O ne-W ay A nalysis of V ariance: D o g m atism Scale
(N = 8 8 ) ....................................................................... 134
19. O ne-W ay A n aly sis of V arian ce: B o dy-C athexis
Scale (N = 8 8 ) ............................................................................ 136
20. O ne-W ay A n aly sis of V ariance: S elf-C ath ex is
Scale (N = 8 8 ) ................................ 137
21. P e a rs o n P ro d u c t-M o m en t C o rrela tio n : B ody-C athexis
and S e lf-C a th e x is ...................................................................... 138
22. O ne-W ay A nalysis of V ariance: S tate-A nxiety Scale
(N = 8 8 ) ......................................................................................... 140
T able Page
23. O ne-W ay A naly sis of V ariance: T rait-A n x iety
Scale (N = 8 8 ) .................................................................................... 141
24. P e a rs o n P ro d u ct-M o m en t C o rrelatio n s: 1) Body-
and S elf-C athexis Scales; 2) State- and T r a it-
A nxiety S c a le s ......................................... 143
25. P e a rs o n P ro d u c t-M o m en t C o rrelatio n s: 1) D og m atism
and B ody-C athexis; 2) D ogm atism and S elf-C athex is . 145
x
CHAPTER I
INTRODUCTION
In the m o rn in g of re c o rd e d tim e , one finds re fe re n c e to
"le p ro sy " in m ed ica l w ritin g s. S crutiny of e a rly m a n u s c rip ts , how
e v e r, would su g g est the t e r m im plied m o re a fra m e of m ind than an
a ctu al d ise a s e entity. Its m ean ing v aried a c ro s s geographical d iv i
sions and throug h tim e , but the one com m on fa c to r which gave it fo rm .
was a u n iv e rs a l, p e rv a siv e , negative attitude evoked when the te r m
was applied to a given c lin ica l phenom enon. One can v irtu a lly d if
fe re n tia te five d ifferen t phenom ena connected with the te r m . The
f ir s t is the d ise a s e , le p ro sy , a s recognized by m o d ern diagnostic
c rite r ia . ' The second is any condition to which the n a m e , " le p ro s y ,"
is applied. A th ird is the condition itse lf, under w h atev er nam e. A
fo u rth is any clin ical p ic tu re w hich m a sq u e ra d e s o r re s e m b le s
lep ro sy , and which consequently c a r r ie s with it notions of d isfig u re
m en t, p ro g re s s iv e m u tilatio n , and th re a t of tr a n s f e r by som e fo rm of
contact w ith a patient. The fifth denotes som e type of p rim itiv e
thought p ro c e s s , som ething of an a lm o st m y stic n a tu re , which is
evidenced by a fe a r tra n s m itte d by the m e re m ention of the d ise ase.
1 •
2
This la tte r is seen on o ccasio n in the m ed ica lly in itiate, individuals
sophisticated and tech n ically know ledgeable about the d ise a s e itse lf,
but who resp o n d in an em otionally p rim itiv e fashion in the handling of
th e ir patients known to have lep ro sy . In su m m a ry , one m ight say that
the f e a r a ttac h es to the nam e, to the concept, to the d is e a s e p e r se , all
of which a re conceptually som ew hat se p a ra b le .
On the b a sis of the above th e s e s , a tw o-fold p ro je c t suggested
itse lf a s the c o re of the p re s e n t investigation. The f i r s t would be the
investigation of g e n eralize d com m unity attitu d es to d e te rm in e what
beliefs and re a c tio n s ex isted re g a rd in g le p ro sy in a m o d ern , u rb a n
ized, and re la tiv e ly educated population. The second ph ase would be
to a s c e rta in w hether o r not the com m unity beliefs and re a c tio n s had
a d em o n strab le effect on the psychological functioning of the le p ro s y
patien ts, as com p ared with patients having o th er d ise a se e n titie s, but
tow ard whom a le s s negative re a c tio n is d irec te d .
H isto ry of L e p ro sy
M iddle and F a r E a s t
A ncient m ed ical w ritin g s as e a r ly as 1400 B. C. r e f e r to
"lep ro sy . " E gyptians defined a "tum our of the god X ensu, " and
coined the p h ra s e , "the death b efo re death. " Chinese w ritin g s
d e scrib e d a clinical p ictu re only re m o te ly resem b lin g le p ro sy ,
a sc rib in g its etiology to good o r evil fo rc e s known as "F e n g -sh u i"
(Feeny, 1964). S im ila r vague d escrip tio n s occur in o th er F a r and
Middle E a s t m ed ica l re c o rd s . One v e rsio n of etiology is th at it was a
c alam ity im posed by the divinities to punish an ind ividual's life o£
im m o rality . T ra n s m is s io n o c c u rre d by cohabitation with a healthy
p a rtn e r, the p u rp o se of which was to "se ll" the d isease so th at the
afflicted one would have le s s (Skinsnes, 1964). D espite th ese n u m e r
ous re f e r e n c e s , the clin ical d e scrip tio n is not p re c ise enough to w a r
ra n t identification with le p ro sy a s it is diagnostically known today.
This would suggest th at in these e a rly w riting s, the te r m had been
applied to a v a rie ty of conditions o th er than lep ro sy , and th a t the fe a r
a sso c ia te d w ith d isfig u re m e n t, m utilation, and contagion had attached
itse lf to se v e ra l e n titie s which m ight have antedated the ap p earan ce of
le p ro sy p e r se. H isto ria n s validate such a conclusion, indicating that
". . . it is v e ry difficult to sub stantiate the existence of le p ro sy in
e a rly tim e s in the N ear and Middle E a s t" (Cochrane and Davey,
1964, p. 2).
M ore a c c u ra te accou nts, h ow ever, a re found in Indian, E a s t
A sian, and C hinese w ritin g s, suggesting that lep ro sy m ight have
indeed ex isted under such a nam e, o r un der other n a m e s. Though it
m ight have ex isted b efo re 600 B. C. , the f ir s t authoritative re fe re n c e s
a p p eared in China a t th at tim e, e a r lie r re fe re n c e s being inconclusive
(C ochrane and Davey, 1964, p. 4).
Ju d a e o -C h ristia n C ulture
The p ictu re in this p a rt of the w orld in ancient tim e s a p p e a rs
to be that of the a sc rib in g of a g e n eric te r m to a nu m b er of sc a ly skin
conditions. Any skin d isfig u rem en t would have re su lte d in autom atic
b anishm ent fro m the cam p of I s ra e l. Consequently, the Old T esta m e n t
re fe re n c e s , including the continuously quoted le p ro sy ritu a ls re c o rd e d
in L eviticus, a re in a c c u ra te and probably do not r e f e r to le p ro s y , the
specific c lin ica l entity. The t e r m m o re p ro p e rly should have been
tra n s la te d "defiled" o r " c u rs e d , " r a th e r than its having been re fe ra b le
to a given d ise a se (C ochrane and Davey, 1964, p. 2). It would ap p ear
th at in th is section of the w o rld , the fe a r of a disfiguring , m u tilatin g , .
and contagious d ise a se p rec ed e d the actu al advent of le p ro s y itself.
H ippocrates m ade re fe re n c e , in 467 B. C. , to " le p ro sy . " His
d e scrip tio n , how ever, was sufficiently vague and im p re c is e a s to m ake
it highly questionable a s to the au th en ticity of the d ise a se to which he
re f e rr e d . A ccu rate clin ical d e sc rip tio n s of nodular le p ro s y did ap p ea r
in the w ritings of A ra etu s and G alen around 150 A. D. (C ochrane and
Davey, 1964, p. 4). It m ay be a ssu m e d th at som ew here betw een the
e r a of H ip pocrates and the la tte r p h y sician s, le p ro sy did m ak e its
ap p earan ce in the w e ste rn w orld. It purp o rted ly ap p ea re d aro u n d
300 B. C. in the M e d ite rra n e a n a r e a , probably having been brought
back by A lexander the G re at fro m India. While the Old T e sta m e n t
re fe re n c e s m o st likely a re spu rio us, those of the New T estam en t
m ight v ery w ell have r e fe rr e d to the tru e entity, since it w as known
to e x ist in the a re a at the tim e (Browne, 1970).
M iddle A ges and M odern T im es
M ost c ertain ly , lep ro sy was d iagn ostically identifiable in the
M iddle A ges. It reach ed its highest incidence betw een 1000 and 1400
A. D. L a z a r houses dotted E urope, though not a ll patients inhabiting
th em had lep ro sy . Again one se es the broad extension of the term ;
m any who b o re sym ptom s resem b lin g le p ro sy w e re m ista k e n fo r
p atien ts having the d ise a se . The illn e ss continued in c o n sid era b le
n u m b e rs in w e ste rn E urope until the la tte r p a rt of the nineteenth
cen tu ry , p a rtic u la rly in Norway.
D uring the la s t century, a sh a rp in c re a s e o c c u rre d in the
P a c ific isla n d s, supposedly the re s u lt of Chines m ig ra tio n . In 1865,
the H aw aiian governm ent began to seg reg ate the p atien ts by law, and
the follow ing y e a r the le p e r settlem en t on M olokai was e stab lish ed .
W ithin the United S tates, by 1800 the incidence was of sufficient
im p o rt to w a rra n t attention of the m ed ical p ro fessio n . The source
w as g e n erally attrib u ted to the A frican slav es; but F re n c h , P o rtu
g u ese, and Spanish im m ig ran ts w ere probably significant c a r r i e r s .
Scandinavian im m ig ra n ts who settled in the U pper M iss issip p i Valley,
and G erm an im m ig ran ts to T exas, brought with them fro m E urope
individuals who had the d ise a se ; this o c c u rre d in the m iddle and la tte r
p a rt of the nineteenth cen tu ry . The d ise a se was tra n s m itte d to f ir s t
and second g e n eratio n s, and died out in the th ird g en eratio n sp o n
tan eo u sly before effective m ed icatio n had been d isc o v ere d . T h ere was
no tra n s m is s io n to m e m b e rs of the com m unity except in a few q u e s
tionably defined c a se s. The n u m b er of indigenous c a s e s in the state of
L o uisian a was of sufficient m agnitude to prom pt providing a se ttlem e n t
a t C a rv ille in 1894. This ho sp ital becam e a fe d e ra l fac ility un d er the
su p e rv isio n of the United S tates Public H ealth S ervice in 1921 and
s e rv e s a ll U. S. re s id e n ts having the d ise a se .
H isto ric a lly , the tre a tm e n t acco rd ed those afflicted with
le p ro s y m ight be d e sc rib e d as c a p ric io u s, th e re being no d istin ct
p attern in g in so fa r a s the e m e rg e n c e of an h u m an itarian app roach. At
the w o rst it has been cru el,, as exem plified by the p ro sc rib in g of
specific c o stu m e s, the c a rry in g of w arning bells and c la p p e rs , the
painting of a p a tien t's hom e a designated c o lo r, the attendance a t M ass
through slits in the w all called " le p e r 's peeps. " The e m p h asis in a ll
of th is w as the p rotection of the g e n e ra l population fro m contact with
the patient. F re q u en tly , th is am ounted to isolatio n w ithout any type of
cu stodial c a re , with re su lta n t little attendance to the needs of the
patient. C ustodial c a re when provided in the la z a re ts w as not m an d a
to ry , n or w ere the p atients confined; a s a m a tte r of fa c t, punishm ent
fo r in frac tio n of the ru le s was expulsion fro m the fa c ility , this being
seen a s the m o st se v e re c h a stise m e n t (Feeny, 1964, pp. 27-32). Until
v e ry re c e n tly , in stan t banishm ent was p ro sc rib e d by c e rta in A frican
jungle tr ib e s . O ccasionally, the picture is punctuated by an ab ru p t
change of a ttitu d e , such a s had to o ccu r when the C ru s a d e rs th e m
se lv es re tu rn e d with the d ise a se . The h e ro ic stru g g le of F a th e r
D am ien a t M olokai to institute hum ane tre a tm e n t fo r the islan d out-
c a s ts is a n o th er b rig h t spot in the usual, g rim h is to ry of re je c tio n ,
iso latio n , and o utright p ersecu tio n . Only w ithin the p r e s e n t c en tu ry
can one d is c e rn the vague and still in co n sisten t outline of what m ight
be c o n sid e re d an enlightened p a ttern of hum ane c a re .
M edical A sp ects
M orphology, E tiology, Incidence, and P re v a le n c e *
M y co b acteriu m le p ra e was f ir s t o b se rv ed in 1874 by the
N orw egian phy sician H ansen, who concluded th at the b a c te riu m w as the
specific cau se of the d ise a se (Cochrane and Davey, 1964, p. 13).
H is to ric a lly , th is w as the f ir s t tim e a b a c te ria l cau se of a d ise a s e w as
* Source m a te ria l fo r this section was obtained fro m M edical
B ulletin M B -10, V eterans A d m in istratio n , Dept, of M edicine and
S u rg e ry , M ay 25, 1965. The author also w ishes to thank D r. N orm an
L evan, C h airm an , Dept, of D erm atology, U SC -M edical C e n te r, Los
A n g eles, fo r h is co m m en ts and suggestions in the p re p a ra tio n of this
section.
e sta b lish e d . T his led to an enorm ous burgeoning of know ledge c o n
c ern in g b a c te rio lo g ic a lly caused d is e a s e s , eventuating in the d is c o v e ry
of the m o s t im p o rta n t M ycobacterium tu b ercu lo sis.
The only known source of infection is hum an, but the route of
\
tra n s m is s io n is e n tire ly speculative a t this tim e. At the m o m en t,
though sk in -to -s k in con tact is co n sid ered a likely m ode, m an y doubt
th is , o fferin g a s an a lte rn a tiv e the route of inhalation. Supporting th is
la tte r th e o riz in g is the a p p earan ce of n a sal stuffiness a s a freq u e n t
f i r s t sym pto m . Unlike the M ycobacterium tu b e rc u lo s is , it h a s not
been tra n s m itte d su c ce ssfu lly to hum an beings by innoculation.
R e s e a rc h h a s been lim ite d b ecau se it h as not been cu ltu red in vitro;
and only re c e n tly has a su c ce ssfu l attem p t been m ade to m u ltip ly a c id -
fa s t b a c illi in the footpads of m ice innoculated with hum an lep ro m ato u s
m a te r ia l (Shepherd, I960). T hese ex p erim en ts have been su c c e ssfu l
un d er v e ry lim itin g conditions, and th e re are no o th er a n im a l m odels
av ailable fo r study.
The incubation p erio d , according to p re se n t thinking, is co n
s id e re d to range fro m th re e to th irty y e a rs .
B a c te rio lo g ic a lly and clinically, th e re a re two definitive types
of le p ro s y , plus two designated in te rm e d iate groupings. T h ese w ill
be c o n sid ere d in the sectio n on C linical Phenom ena.
9
E ndem ic a r e a s g e n e ra lly follow the eq u ato r, but th is does not
d elim it o c c u rre n c e e lse w h e re . H ighest incidence is in India and tr o p i
cal A frican c o u n tries. Rate of contagion is low ; only about five p e rc en t
of those exposed in an a re a of high incidence will becom e infected.
T his d e c re a s e s to about o n e-ten th of one p e rc en t under f a irly favorable
c irc u m s ta n c e s such a s im proved hygiene, le s s overcrow din g with co n
sequent reduced close contact with infected p e rso n s (C ochrane and
D avey, 1964, p. 10; F ite , I960). In endem ic a r e a s , le p ro s y is usually
contacted in childhood, although exposure in adulthood is effective.
A dult exp o su re is m o re freq u en tly seen in individuals fro m n o n
endem ic a re a s who tra v e l to endem ic a re a s .
Within the United S tates, indigenous c a se s o ccu r in so u th e a ste rn
T e x a s, southern F lo rid a , L ouisiana, and Hawaii. T hese a r e c o n
s id e re d endem ic a r e a s . Although la rg e n u m b ers of c a s e s o c c u r in
sou th ern C alifornia and in New York, these a re a s a re not en dem ic
becau se tra n s m is s io n of the d ise ase to fam ily o r co n tacts is not found.
With the exception of H aw aii, and to a le s s e r extent so u th e a s te rn T exas
and F lo rid a , the d ise a s e is g en erally an "im p o rted " one, being found
in im m ig ra n ts fro m the C aribbean a re a , M exico, Sam oa, and the
P hilippine Islan d s.
10
C linical Phenom ena
Two m a jo r types of le p ro sy a re identified, T uberculoid and
L ep ro m ato u s, and two su bgroups, the Indeterm inate and D im orphous.
The distinction betw een the two m ajo r types is based p rim a rily on the
am ount of im m u nity the patient p o s s e s s e s against the d ise a s e . This
im m unity influences both the type and extent of the le sio n s.
C ecil and Loeb (1967) d e sc rib e the two m ajo r c la s s e s a s
follow s:
[The L ep ro m ato u s v a rie ty is] . . . m alignant, sta b le , positive
on b a c te ria l exam ination, in filtrated skin lesion s. P e rip h e ra l
n e rv e tru n k s becom e involved as it p ro g re s s e s , u su a lly in s y m
m e tric a l fashion, and with n e u ra l sequelae in advanced sta te s.
[The T uberculoid type is] . . . usually benign, sta b le , negative
on b a c te ria l exam ination. M ost c a se s have e ry th e m a to u s skin
lesio n s which a re elevated m arg in ally . Sequelae to p e rip h e ra l
n e rv e involvem ent m ay develop in som e c a se s, re su ltin g in
se rio u s and disablin g d e fo rm ity (pp. 296-297).
The In d ete rm in ate type can evolve tow ard e ith e r type o r can
re m a in unchanged indefinitely. The e a rly lesio n is u su a lly a no nde
s c rip t hypopigm ented m a c u la r a r e a frequently evidencing d e c re a se d
sen satio n to hot and cold stim u li. A n aesth esia m ay be p re s e n t, but
• u su ally it is a la te r developm ent. Some feel that the p rim a ry lesio n
m ay o c cu r at the site of innoculation contact, frequently on the face;
2
The au th o r acknow ledges with thanks the a s s is ta n c e in the
fo rm of co m m en ts and suggestions given in the p re p a ra tio n of th is
sectio n by Dr. M a rg a re t A. Storkan, D erm atology C onsultant, .H an
s e n 's D isease C linic, U .S. P. H. S. , San P e d ro , Calif. . .
th is , ho w ev er, h as not been conclusively established.
The D im orphous type has fe a tu re s, clinically and m ic r o r
sco p ically , of both L ep ro m ato u s and T uberculoid types. It involves
sk in lesions of the plaque, band, o r nodular type. The e a rlo b e s p r e
sen t the a p p e a ra n c e of lep ro m ato u s infiltration (C ecil and Loeb, 1967,
p. 298). C linical p ro g re s s m ay follow e ith er the L ep ro m ato u s o r
T uberculoid c o u rs e .
D ia g n o sis.- -In the L ep ro m ato u s type, two c r ite r ia a re
re q u ire d : d e m o n stra tio n of the a c id -fa st bacillus in conjunction with
the typical histologic changes of a fat-fille d cell collection (Virchow o r
fo am c e lls), w ith o r w ithout neurologic dam age. In T uberculoid le p
ro s y , sin ce,th e o rg a n is m s a re scanty and m ay not be detectable a t a
given tim e , diagnosis hinges on d em o n stratio n of the h isto lo g ical
re s p o n s e , n am ely , the tu b ercu lo id granulom a, with a clin ical picture
th a t includes evidence of p e rip h e ra l n e rv e dam age.
C linical S igns.
1) L e p ro m ato u s type. In the e a rly state, the patient dem on
s tr a te s thickening of the skin which m ay be diffuse o r which m ay
a cc u m u late into lum ps o r nodules. T hese lesions m ay be accom panied
by p ig m en tary changes o r se n so ry changes. Site m ay be v irtu a lly any
a r e a of the skin. A "full-blow n" case which has gone undiagnosed and .
u n tre a te d fo r som e tim e m ay have a g re a t num ber of o rg an ism s
num berin g in the m illio n s which accum ulate in nodules and papules
called le p ro m a s . T hese have p red ilectio n fo r fac e, elbow s, k n e e s,
and e a rlo b e s. E n la rg e m e n t, due to the fo rm atio n of m a s s e s of the
lip id -filled fo am c e lls with th e ir b acilli, fu rth e r d isto rts the n a tu ra l
line and configuration of the a re a . The c o rru g a te d , fu rro w e d line of
the fo reh e ad , w hich led to the d e scrip tio n of the leonine fa c e , is a
re s u lt of the b a c te ria l invasion and re a c tio n in the skin. N erv es of the
c e rv ic a l chain and the u ln a r n e rv e s m ay be palpably en larg ed . Hands
and fee t m ight be ed em ato u s. If a n a e sth e sia is p re s e n t in e x tre m itie s ,
s c a r s a re u su ally p re s e n t a s re s u lt of tra u m a to the a re a . The
d e stru c tio n of e x tre m itie s in lep ro sy a re due to the n e rv e dam age,
r a th e r than involvem ent by the le p ro sy b a cilli (F ite, I960, p. 2).
Lym ph nodes m a y be palpable. Involvem ent m ay include vital o rg an s
such a s liv e r and kidney. E ry th e m a nodosum le p ro su m (ENL), a n
a lle rg ic re a c tio n to infection, is a freq u en t accom panim ent to this
type of lep ro sy . It is thought rela te d to the G eneral A daptation Syn
drom e becau se it a p p e a rs a s a resp o n se to a la rg e n um ber of differing
agen ts, and a p p e a rs in p atien ts with low g e n eral re s is ta n c e (M uir,
1962). T his re a c tio n is su p erim p o sed on the p rim a ry infection, and
clin ically the patient m ay becom e studded with nodules of varying
s iz e s , te n d e r to touch.
13
In p resen tin g h is co m p lain ts, the patient m ay believe he h a s
a r th r itis , due to the foot and hand sw elling. He often com plains of
g e n e ra l m a la is e , fe v e r, o r lo ss of sensation.
The leonine fe a tu re s and eyebrow lo ss can occur re la tiv e ly
e a rly follow ing infection due to the p re se n c e of a la rg e n u m b er of
b a cilli. If p e rip h e ra l n e rv e s have profound b a c illa ry invasion, m o to r
activ ity lo ss can o ccu r. Thus "claw hand, " "drop foot, " and fa c ia l
n e rv e p a ra ly s is m ay o c c u r at e ith e r e a r ly o r late stag es. V isual lo ss
is a freq u e n t sequela of c a s e s which have gone u n tre a te d with effective
m edication. B acilli have an affinity fo r o cu lar s tru c tu re s of the eye
o th er than the optic n e rv e . Bone d e stru c tio n of the n o se, and a b s o r p
tion of digits due to tra u m a and se p sis u sually o ccu r a t advanced
sta g e s, p a rtic u la rly if u n tre a te d o r if ineffective m ed icatio n w as u sed.
2) T ub erculoid type. B ecause of the b e tte r im m u n ity of th ese
p a tie n ts, the infection lo c a liz e s in a few skin lesio n s, and in one o r
two n erv e p a tte rn involvem ents. The b a cilli tend to lo calize m o re in
the n e rv e s , resu ltin g in a c le arin g of skin m an ifestations but not th at
of the n e rv e , following tre a tm e n t. T his c ateg o ry re q u ire s m o re tim e
to d e m o n stra te a c le a r clin ical p ictu re; because of th is, the infection
h a s a g r e a te r p ro b ab ility of settling in the n erv e. Although the b a c illi
m ay d isa p p e a r und er tre a tm e n t, the question of re sid u a l n e rv e dam age
and re p a ir is a p rim a ry p ro b lem with the T uberculoid type.
14
P re se n tin g com plaints m ight include lo ss of sen satio n to a
c irc u m s c rib e d a re a of the skin, " a r th r itis " due to the nerve involve
m en t in the e x tre m itie s , o r m o to r o r m u sc le w eakness in hands, feet,
o r a r m s due to the n e rv e pathology.
A re le v a n t asid e a t this point is the im p re ss io n a laym an m ight
fo rm should he o b se rv e a H a n se n 's D isease patient but be unaw are of
h is diagnosis. Such w ill p e rm it m o re valid in ference regarding
p re se n c e o r ab sen ce of su rp lu s th re a t content attached to the d ise a se ,
a c ritic a l point in the d esig n of this study.
In the T uberculoid type, it is possible that a laym an m ight
o b se rv e ab so lu tely nothin g, if extensive n e rv e dam age had not
o c c u rre d . If such had o c c u rre d , the sw elling of jo in ts m ight be in te r
p re te d a s a rth ritis ; foot d ro p m ight be thought to be a sso c ia te d with
polio, o r a re s id u a l bone tra u m a .
In the L ep ro m ato u s type, the flushed face m ight be m ista k en
fo r sunburn, the sw elling and re d n e ss of hands as tra u m a tic bu rn,
the face and a r m nodules a s "hives. "
Although not an exhaustive lis t of the possible in te rp retatio n s
which m ight be given to clin ical signs, they a re re p re se n ta tiv e of the
e rro n e o u s conclusions which m ight be reach ed . M ore im portantly,
they d e m o n stra te that the signs a re not unique to H an sen 's D ise ase,
but sh a re a com m unality with o ther m ed ica l sy ndrom es.
15
P ro g n o s is .- -P a tie n t's life expectancy in L ep ro m ato u s le p ro sy
is sh o rte n ed , not p rim a rily b ecause of the extension of the d is e a s e ,
p a rtic u la rly w ith m o d e rn th erap y , but because of com p licatio n s such
as am y lo id o sis o r E N L (Hopkins and F a g e t, 1944). P a tie n ts have died
of re p e a te d s e v e re re a c tio n s which have re su lte d in g e n e ra l inanition,
but th is is r a r e today b ecau se of the effectiveness of the m ed ica tio n s.
Steroid m e d ic a tio n is the m o st freq u e n t cause of death today. It is
given to c o n tro l acute n e u ritic re a c tio n s and E N L , and the side effects
on vital o rg a n function is the d ire c t cause of death.
T h ere is no evidence to date th at T uberculoid p a tie n ts have
d e c re a se d life expectancy.
T re a tm e n t. - -M edications of choice a re s e v e ra l com pounds of
the sulfone fam ily . T hese w ere introduced in 1941 on a t r ia l b a s is a t
the L e p ro s a riu m at C a rv ille. S ev eral d eriv ativ es of the p a re n t s u l-
phone diam inodiphenylsulphone (DDS) have been em ployed, but DDS
re m a in s the m o s t g e n e ra lly used , since it is inexpensive and a s e ffe c
tive a s any o th e r drug u sed (Bushby, 1964, pp. 344-346). A d m in is tra
tion is by m outh, and m edication is quite fre e fro m side effects fo r
m o st p a tie n ts, though fo r som e it m ay in c re a se the tendency to EN L.
One of the m o st strik in g advances in the la s t few y e a rs h as b een the
seren d ip ito u s finding that E N L resp o n d s to T halidom ide. The d i s
co v ery w as m ade at the le p ro s y h o sp ital in J e ru s a le m , w here patients
16
w ere being given T halidom ide a s a sedative, before it had been d is
co v ered as a cau sativ e agent of phocom elia.
An o ccasio n al patient is r e s is ta n t to the su lfones, and other
ag ents a re c u rre n tly un der study.
C o n tro l.--T h e E x p e rt C om m ittee on L ep ro sy of the W orld
H ealth O rg an izatio n h as taken a firm stand that le p ro s y belongs in the
m a in s tre a m of m ed ical c a re . P a tie n ts should be tr e a te d in g e n eral
h o sp itals and c lin ics. If h o sp italizatio n is n e c e s s a ry , it should be
only fo r the purpose of tre a tin g an acute condition in a m o re efficient
m a n n e r, a s w ith any o th er d ise a se . E ven during such a tim e , the
question of isolation is highly debatable, m any questioning its n e c e s
sity. L e p ro s a ria can only be ju stified on the b a sis of socio -econom ic
g rounds, providing d o m ic iliary c a re fo r those unable to support th e m
se lv e s, but not on the b a sis of isolation.
W ithin the United S tates, req u ire m e n ts v a ry fro m sta te to state
and a re m utab le. The abandonm ent of isolation p ro c e d u re s is advanc
ing a s rap id ly a s the o vercom ing of the p reju d ices of P ublic H ealth
officials w ill p e rm it. The le p ro s a riu m at C arville is s tr ic tly a volun- .
ta r y type of h o sp italizatio n , though som etim es both p h y sician s and
p atien ts a re not m ade aw are of th is.
If a patient is h o spitalized for an acute L ep ro m ato u s reactio n ,
he is kept until such tim e a s the b acilli a re a r r e s te d o r dead under
17
m ic ro sc o p ic exam ination. He then re tu rn s to h is fam ily , w here no
iso latio n is em ployed, even in re s p e c t to children. F a m ily and con
tac ts a re on a prophylactic re g im e n of sulfones fo r a tw o -y ear peripd;
the patient m ay have to take m edication fo r the r e s t of his life. Even
should he in cu r additional re a c tio n s, he is not re q u ire d to be r e
hospitalized .
T uberculoid p atien ts re q u ire no h o sp italizatio n o r isolation
p ro ce d u re at any tim e. They a re on drug th era p y for a t le a st th ree
y e a rs . In som e fa c ilitie s they a re tre a te d for a lo n g er period. No
prophylactic p ro g ra m is in stitu ted fo r e ith er fa m ily o r contacts of the
patient.
CHA PTER II
PSYCHOLOGICAL PHENOMENA
Review of the L ite ra tu re
A ttention to the psychic phenom ena of the le p ro sy patient h as
in no way kept pace with the investigatio n and p ro g re s s in m ed ical
a re a s . One m ight hypothesize that lack of attention on the p a rt of the
social sc ien tist is due to the iso latin g p ro c e d u re s u su ally em ployed
following diagnosis. And until re c e n t y e a r s , little data w ere available
concerning ra te of contagion. T h is, coupled with the observable
d estru ctiv e pathology, would re in fo rc e any stereo ty p ic b eliefs con
cerning the loathe so m en ess and contagion of the d ise a s e , m aking the
H an sen's D isease patient a not v e ry d e sira b le subject fo r close o r
prolonged scru tin y ! The data which have been available com e m ainly
fro m individuals actively involved in patient serv ice. Beyond the
obvious question of o b s e rv e r b ia s , m o st of the studies lack c r ite r ia
expected in scientific study. . Some ar.e th eo re tic al, with no re fe re n c e
to w hether or not fo rm u latio n s re s te d on sam ple observation. O th ers
a re studies done on v ery sm a ll sa m p le s, with no attem p t to co n tro l
fo r w ithin-group v arian ce o r to em ploy a co ntrol group. In studies
18
19
involving c o m p a riso n g roups, no evidence is p re se n te d of p ro ced u re
to co ntrol fo r e x tra n eo u s v a ria n ce by even m inim al m atching p ro c e
d u re s. In m o s t stu d ies, su b jects a p p e a r to be se lec te d solely on the
b a s is of av ailab ility .
T h e o re tic a l-O b se rv a tio n a l Studies
M uir (1939)» basing his fo rm u latio n on field o b se rv atio n and
in terview , th e o riz e d th at the concealm ent of the d ise a s e on the p a rt of
the patient lead s to a chron ic state of d rea d and ev en tu ates in the
re p re s s io n of feelin g s. He en u m e rated q ualities which enhanced the
p a tie n ts' chance of "re c o v e ry , " o r being fre e fro m activ e signs, as
". . . c h a ra c te r , in tellig en ce, com m on sen se, p e rs e v e ra n c e , d e te r- '
m ination to get b e tte r, and obedience to a ll in stru c tio n s" (p. 116).
R y rie (1951), not re p o rtin g the n u m b er of patients on whom he based
his o b serv atio n s and co nclu sion s, offered a psychodynam ic fo rm u la
tion: lep ro sy patients had an irra tio n a l f e a r produced by the visible
bodily b lem ish es and based on a sen se of guilt which he attrib u ted to
an in cest com plex. The guilt re su lte d in m aso ch istic behavior, d e m
o n stra te d by the p a tie n t's neglect of his m ed ical reg im en . D ream s
w ere infantile and e le m e n ta ry , content extending back to p re -m o rb id
days. H enderson (1964) investigated eleven patients in a la z a re t in
New South W ales by field o b serv atio n and p sy c h iatric interview . Sub
je c ts had had the d ise a s e fro m one m onth to tw enty y e a rs . He felt
20
th at they tended to have p arano id ten d en cies, w ere re lu c ta n t to show
th em se lv e s to o ther p atients and v is ito rs , and m a n ife ste d " in stitu
tional n e u ro s is. " The la tte r w as defined as lack of planning, in te re s t
and initiative. D e p re ssio n w as the m o st significant clin ica l finding.
W ithin the United S ta te s, a ll studies to date re p o rte d involved
subjects at the C arv ille L e p ro sa riu m . Low inger (1959) review ed the
diagnostic re c o rd s of the p sy c h ia tric consultation s e rv ic e a t C arville.
He found a ten p e rc e n t p rev alen ce of psychosis; the breakdow n showed
the m a jo r cause w as fro m sen ile degeneration, with ch ro n ic sch izo
phrenic p a ttern s and one p aran o id state constituting the re m a in d e r of
the c a se s. He stated th at a d m issio n is usually follow ed by a d e p re s
sion of se v e ra l m o n th s' duration; denial o c cu rs upon a d m issio n o r
la te r. W ithdraw al, guilt, and lo ss of s e lf-e s te e m so m e tim es led to
dep erso n alizatio n . T hose who w ere adjudged " b e tte r adju sted" had
developed a p assiv e-d ep en d en t resig n atio n with p aran o id overtones.
Cannon (1964), in case w o rk in terv iew , found patients to be d e p re ssed ,
anxiou s,’ and prone to denial a s the m a jo r defense. G ussow (1964),
rep o rtin g his o b serv atio n s fro m casew o rk , indicated th a t patients
re p o rte d little affective re a c tio n to the new s of d iagnosis; a ll but two
denied suicidal ideation a t tim e of diagnosis d isc lo su re .
C ontrol G roup Studies
C hatti and C houra (1954) com pared a le p ro sy group with a
tu b ercu lo u s group fro m anoth er institution. No evidence w as given to
indicate th at an a ttem p t had been m ade to equate the two. They con
cluded th a t the le p ro sy patients w ere cyclothym ic in n a tu re , irrita b le ,
e g o tistic a l and undisciplined, excited, sen sitiv e, hateful of society,
and prone to be su icid al. The b a se s on which th ese conclusions w ere
rea ch e d w ere not given. Suggested tre a tm e n t fo r r e f r a c to r y patients
w as that they be sent hom e; since they tru ly p re fe r re d to be isolated,
such actio n would be ex p erien ced a s punishm ent, and they would re tu rn
to the in stitu tio n docile! Sim m el (1956) investigated the phantom lim b
phenom enon a t C arv ille. She em ployed patients who had had the i ll
n e s s fo r m o re than tw enty y e a r s , and had undergone a b so rp tio n of
fin g e rs o r to es a s sequela of the illn e ss. T h irty -o n e digital am putees
a t a V eteran s H ospital se rv ed a s co n tro ls. The c ritic a l v a ria b le found
was tim e: if the ab so rp tio n had o c c u rre d sh o rtly b efo re su rg e ry , the
phantom o c c u rre d with in tact digits. A s im ila r finding was p re s e n t in
the co n tro l group, the o c c u rre n c e of phantom follow ing e ith e r a tr a u
m a tic o r su rg ic a l am putation. An in te re stin g but unexplained finding
w as th at if a leg am putation w ere done on a patient with ab so rb ed
d ig its, the phantom w as an in tact lim b with whole digits.
22
O bjective A s s e s s m e n ts
M oulun (1950) in M exico used the R orschach to co m p are a n in
p atient and o u t-p atien t group. Although the two groups did not differ
in in tellig en ce, affectivity, o r in tro v e rsiv e -e x tro v e rsiv e ten d en cies,
the o u t-p atie n t group gave significantly m o re R o rsc h ac h signs a s s o c i
ated with d e p re ssio n and a g g re ssio n tow ard the environm en t. L o rd
(1954) also u sed the R o rsc h ac h in group a d m in istratio n on 35 patients
a t M olokai, but no co m p arativ e group was involved. She found d im in
ish ed c re a tiv ity with possible re g re s s io n to m ore p rim itiv e in tellectu al
o rien tatio n . She noted reduced capacity fo r thinking, freq u en tly found
in com m u nity-type o r institution al living a s exem plified by this s e ttle
m ent. A llard ice and Dole (1966) investigated 26 m ale p atien ts who had
had the illn e ss and w ere h o sp italized at. the Honolulu fa c ility fro m one
m onth to 23 y e a rs . C ontrols w ere volunteer subjects who had had no
m a jo r illn e ss. Subjects w e re m atched on age, ra c e , education, and
so cio -eco n o m ic level. They em ployed Cleveland and F i s h e r ’s (1958)
th e o re tic a l fo rm u latio n reg a rd in g an ind ividual's conceptualization of
h is body boundary as being c o rre la te d with fundam ental p e rso n a lity
v a ria b le s. They u sed the B a r r ie r , P e n e tra tio n , and A natom y sc o re s
outlined by the th e o ris ts and obtained on the H oltzm an Inkblot T est.
T h e ir findings validated C leveland and F i s h e r 's (1958) conclusions
re g a rd in g body boundaries of n o rm a ls and ill subjects: the two groups
23
did not differ significantly in body p e rc ep t, nor did the length of illness
sig nificantly affect the s c o re s .
W eigand and Dawson (1967) investigated 85 p atien ts a t C arv ille,
em ploying as th e ir m e a s u re the P e rce p tu al R eaction T e s t, a s e r ie s of
a b s tra c t designs to which the subject responds on a fo u r step sc ale to
the d e g re e he lik e s the design. Ten sc ale s had been d esig n ed e m p ir i
cally and validated a s d iscrim in atin g ten psychopathological c rite rio n
groups fro m n o rm a ls. The b a sis of te s t selection w as th at it w as a
p e rso n a lity te s t suitable fo r ad m in istratio n to p atien ts who did not
re a d o r w rite E nglish. Subjects in the study w ere m o stly of Spanish
background. No co n tro l group was em ployed, but c o m p a riso n of
r e s u lts with a tu b e rc u lo sis sam ple fro m another study w as done. No
data, how ever, w ere given a s to the equivalence of th e grou ps c o m
p a re d . F indings indicate that H an sen 's D isease g ro u p s respond ed
s im ila rly to the N eurotic and D ep ressed c rite rio n g ro u p s, and signifi
can tly d ifferen t fro m the m en tal re ta rd a te s , S chizophrenic, and C h a r
a c te r D iso rd e r groups. In terestin g ly , both m ale and fe m a le s sco red
s im ila rly to the P sychotic c rite rio n group, a finding id en tica l w ith the
tu b e rc u lo s is group. One would question both the e m p iric a l'd e riv a tio n
of th is sc a le , a s w ell a s the in feren ces that m ight be draw n, since two
group s m an ifestly not psychotic happen to respond s im ila r ly to a
P sychotic c rite rio n group.
24
O bjective A s s e s s m e n t D esigns Using
C o n tro l/C o m p a riso n G roups
In the w r ite r 's opinion, the m o st extensive study fro m the
standpoint of a s s e s s m e n t m ethods em ployed, is th at of K am iya (1959).
Two g ro u p s, an in -p atien t and o u t-p atien t, w ere co m p ared . No data
w ere given reg a rd in g the equivalence of groups, how ever. P sy ch ia tric
and bedside in terv iew s and q u e stio n n a ire s, objective and projective
te s ts c o m p rise d the b a ttery . In co m p ariso n with o th er m ed ical groups,
th e re w as no h ig h er incidence of e ith e r p sy ch o sis o r suicide. Both
groups ad m itted to feelings of c atastro p h ic sham e and alienation, and
the author concluded that the ap p aren t "contentm ent" the su bjects p o r
tra y e d w as r a th e r apathy. R o rsch ach findings w e re s im ila r to those
re p o rte d fro m o th er studies previously cited: im m a tu rity a n d 'r e s tr ic
tion of in te re s t. On the in -p a tie n t/o u t-p a tie n t dim en sio n , the o ut
patien ts exhibited g re a te r inhibition, dependence, w eak er se lf-
a s s e r tio n and se lf-d e fen se, and strong feelin g s of f e a r and guilt
re g a rd in g the d ise ase and its discovery. The in v estig ato r concluded
th at in stitu tio n alizatio n tended to reduce inhibition, resig n a tio n , and
in tro v e rsio n . K am iya found that two groups e m e rg e d , in te r m s of
psychodynam ic functioning, which tran scen d ed the h o sp italize d /n o t
ho sp italized dichotom y. The "R esigned" group w ere apath etic,
r e p re s s iv e of a g g re ssiv e feeling, and w ere u sually found am ong the
m o st se v e re c a se s. The "A g g re ssiv e s" showed striv in g tow ard
25
autonom y and achievem ent; a g g re ssio n was d ire c te d not at the
environm ent, but at th e m se lv e s because of th e ir fate a s lep ro sy
patien ts.
M aisel (1964) c o m p a red a group of slow r e c o v e r e r s with fa st
r e c o v e r e r s , using a s a con tro l group tuberculous p atien ts. R ecovery
ra te w as a s c e rta in e d by two independent p h y sic ia n s' ra tin g s. He
hypothesized fa s t r e c o v e r e r s would be found to be m o re "psychologi
cally healthy" a c r o s s g ro u p s, and that no d is e a s e -s p e c ific p erso n ality
c h a ra c te ris tic s would be found. In stru m en ts included the R o rsch ach ,
E d w ard s P e rs o n a l P re fe re n c e Scale (E PPS), and R osenzw eig P ic tu re
F ru s tr a tio n T est (R P F T ). Subjects in the slow and fa s t groups w ere
co m p arab le on age, sex, m a r ita l sta tu s, education, and intelligence.
A second con trol group of n o rm a l subjects provided c rite rio n m e a
s u r e s fo r psychological h ealth no rm ativ e values. T hey w ere equated
to the e x p e rim e n ta l groups on the aforem entioned v a ria b le s. Since the
slow r e c o v e re r s in both groups w ere found to be o ld er and hospitalized
fo r a longer tim e , a n a ly se s of cov ariance, adjusting fo r age and length
of h o sp italizatio n w ere u se d to control fo r the effect of th ese v ariab les.
R o rsc h a c h signs w ere em ployed which w ere a sso c ia te d with m atu rity ,
in n er ten sio n and conflict, preoccupation w ith eg o cen tric n eed s,
ability to delay im p u lsiv e n e ss, sensitivity to so cial a m e n itie s,
em pathy, re sp o n siv e n e ss to environm ent, ability to contro l em otions,
and ego stre n g th . D eterm in atio n of the m an n er in which a subject
handles a g g re s s io n was m e a su re d by the R P F T ; and fo u r sc ale s of the
E P P S w e re u se d to a s s e s s independence, dependency, affiliation, and
in te rp e rs o n a l u nderstanding. The two m ain hy potheses w ere confirm ed
slow r e c o v e r e r s do differ significantly fro m fa st r e c o v e r e r s on m o st
of the p e rso n a lity phenom ena, and the slow r e c o v e r e r /f a s t re c o v e re r
dichotom y tra n s c e n d s d ise a se group, th e re being no specific p e rso n a l
ity c h a r a c te r is tic s significantly re la te d to e ith er d is e a s e in re s p e c t to
re c o v e ry tre n d . The fa st r e c o v e re rs did not differ significantly fro m
the n o rm a l group on any of the in d ices. F a s t r e c o v e r e r s w ere found to
be m o re m a tu re , able to e sta b lish w a rm and em pathic p e rso n al r e l a
tio n sh ip s, controlling of both im pulsive tendencies and resp o n siv en e ss
to the enviro nm en t. They had g re a te r ego stren g th , le s s in n er te n
sion and conflict, w ere m o re independent, and had le s s dependency
n eed s. In the handling of a g g re ssio n , the slow r e c o v e r e r s w ere found
to evade confronting th e ir a g g re ssiv e feelin g s, u su ally "glo ssing over"
f ru s tra tin g e x p erien c es. While the N in this study w as sm a ll (N = 10)
fo r each group, and m any of the R o rsc h ac h in d ic ato rs a re continuously
open to qu estion and fu rth e r r e s e a r c h v erificatio n , th is study m ay be'
singled out a s the b e st controlled and designed to d ate, w ithin the
U nited S tates, and gives in te re stin g data c o rre la te d w ith the co n tro l of
the d ise a s e . No c a u se -e ffe c t rela tio n sh ip is posited, m e re ly a s s o c ia
tion. The finding of no significant differen ces betw een d ise a s e s in
27
t
te r m s of p e rso n a lity functioning o ffers an in te re s tin g finding to be J
co m p ared with those to e m e rg e fro m the p re se n t inv estig atio n . j
T
P ilo t Study
The w rite r com pleted a study (Flynn, 1967) on an o u t-p atien t
I
population at the Special D erm atology Clinic (H a n se n 's D ise ase Clinic) ;
of the United States P ublic H ealth S ervice in San P e d ro , C alifornia. :
T h irty -fo u r subjects p a rticip a te d . T h ere w ere two p h a s e s , a taped j
s e m i-s tr u c tu r e d in terv iew and an objective a s s e s s m e n t by m eans of the
M innesota M ultiphasic P e rso n a lity Inventory (MMPI). j
Subjects w ere predom inantly M ex ican -A m erican ; those who
w ere not w e re 'fro m an a s s o rtm e n t of different n a tio n a litie s. The
nationality d istrib u tio n roughly appro xim ated the g e n e ra l clinic popu- i
|
lation. T w en ty -th ree m a le s and eleven fem a le s p a rtic ip a te d , the d is- j
!
trib u tio n on th is v a ria b le again p a ra lle lin g the clinic population. j
: i
I
The s e m i-s tru c tu re d n a tu re of the interview im p lied that while j
i
J
questions and o rd e r of p re se n ta tio n of questions w e re id en tical, the j
i
in v estig ato r was fre e to p u rsu e any lead that su g g ested its e lf fro m the j
|
su b je c t's resp o n se . No attem p t was m ade to in te r p re t, re fle c t, o r j
i
i
probe at any level d e ep e r than the su b je c t's conscious p resen tatio n . }
j
5
Since the intent was to see how the su bjects saw th e m se lv e s and p r e
sented th em se lv e s to the w orld on a conscious lev e l, the design was
e x p lo rato ry . No fo rm a l hypotheses w ere e n te rta in ed , nor w ere
28
co ntrol groups included. The qu estio n n aire contained th irty -fo u r
questio ns covering the follow ing a re a s : 1) childhood, w ith e m p h a sis
on c h ild -re a rin g p ra c tic e s and p ercep tio n of p a re n ta l fig u re s; 2) p s y
chological life -sp a c e a t tim e of diagnosis d isc lo su re; 3) im m ed iate
re a c tio n and coping p ro c e s s e s ; 4) changes in coping and p ercep tio n s a s
a function of tim e; and 5) evaluation of tre a tm e n t in re fe re n c e to both
m ed icatio n and handling by m ed ical p erso n n el. The M M PI was alw ays
a d m in iste re d following in terview . In addition to sta n d ard clin ical
s c a le s , additional ones w ere em ployed to m e a su re re sp o n se s e ts ,
specific d efen ses, ego stre n g th s and w eak n esses, lev el of anxiety,
so cial beh av io r, and so cial needs. T hese included A nxiety and
R e p re ssio n scales; H y s te ric a l D enial and R evised Ego S trength
Scales; subtle and obvious Psychopathic Deviate and P a ra n o id Scales;
Dependency Scale; Social R esp onsibility, Social Status, and D om inance
Scales; Social D e sira b ility and A cquiescence S cales.
M edical and dem ographic v a ria b le s felt c ru c ia l to fo rm a tio n of
a ttitu d e s, p ercep tio n s, and coping w ere included in the data a n a ly se s.
The m ed ica l v a ria b le s included such fa c to rs as age of onset and d u r a
tion of illn e ss, type of le p ro sy , am ount of o bservable pathology, and
the extent of the pathological p ro c e ss on function and m obility.
Data an aly sis was both quantitative and qualitative in the in te r
view. The qualitative a sp e c t included d escrip tio n of the p a tie n t's
\
ap p ro ach to the in te rv ie w , nam ely his cooperative o r withholding
tend encies; how v e rb a lly fre e he ap p eared , the am ount of affect he
displayed and in re la tio n to which topics. A ll interview re s p o n se s
which allow ed of th e ir being co n sid ered in a quantitative fashion w ere
subjected to p a ra m e tr ic o r n o n -p a ra m e tric sta tistic a l a n a ly sis. The
M M PI data w e re quantitatively sco red . In addition to the i n t r a
in stru m e n t a n a ly se s, a c o rre la tio n an aly sis was set up to d e te rm in e
the re la tio n sh ip betw een p e rc e p tio n s, attitu d es, and coping a s rev e ale d
in the in te rv ie w , and the su b je c t's objective psychological functioning,
a s d e te rm in e d by the M M PI data. .
Only th o se findings w hich b e a r on the c u rre n t in v estig atio n will
be h e re c o n sid ere d . T hese include not only data which attain e d a high
lev el of s ta tis tic a l sig n ifican ce, but phenom ena which w ere e ith e r so
unexpected o r pro vocative a s to w a rra n t th e ir fu rth e r in v estig atio n in
the p re s e n t study.
The pilot study w as conceptualized within the bro ad o utlines of
a psychological s tr e s s p arad ig m . The findings w ere th e re fo re i n t e r
p rete d w ithin th is context.
P sy ch o lo g ical L ife-S pace at Sym ptom O nset
F o r the co n sid era tio n of the possible existence of psychological
s t r e s s , not re fe ra b le to the d is e a s e , being p re se n t at sym ptom a p p e a r
ance, the w rite r chose C ap lan 's (1961) definition of s tr e s s : " . . . a
30
th re a t involving the d an g er of the lo ss of an object o r a so u rce of
sa tisfac tio n of n eed s, o r a th re a t that you m ight lose som ething o r
som eone you love . . . o r the lo ss its e lf" (pp. 18-19). Two types of
s tr e s s w ere then d elin eated , a p rec ip ita te o r acute s t r e s s o r , and a
p ro tra c te d o r chronic and n o n -u su al s tr e s s o r . C r ite r ia fo r identifi
cation of such s t r e s s o r s w e re defined, against which the data in the
in terv iew w ere evaluated.
P re c e d e n t fo r in v estig atio n of the psychological life -sp a c e at
tim e of sym ptom a p p ea ra n c e had been established by an im p re ssiv e
body of re c e n t lite ra tu r e w hich suggests this psychic dim ension to
illn e ss; that is , the p re s e n c e of a psychological s t r e s s , u n related to
the illn e ss p e r se and p rec ed in g its appearance (LeShan, 1955, 1956;
Schm ale, 1958; G reene and Young, 1956). G raham and h is a sso c ia te s
(G race and G raham , 1952; G rah am and Wolf, 1953; G rah am , Stern,
and W inokur, I960) have posited specific attitudes to w ard c e rta in life
s tr e s s o r c irc u m s ta n c e s a s being a sso c ia te d with specific illn e sse s.
R ahe, M ey er, Sm ith, K ja e r, and H olm es (1964) in v estig ated two
tu b e rc u lo sis sa m p le s, u sin g a s a control group a n o rm a l population
m atched on se v e ra l v a ria b le s . E x p erim e n tal groups differed signifi
cantly fro m co n tro ls in having e x p erien ced a se v ere psychological
s tr e s s w ithin a two y e a r p re -m o rb id period, usually in the n atu re of
the a lte ra tio n of a close p e rso n a l a sso c ia tio n by death o r illn e ss.
31
Follow ing this line of thought, and within the p a ra m e te rs of
s tr e s s as outlined above, the patients in the pilot sam ple to a sig n ifi
cant level w ere undergoing psychological s tr e s s not re la te d to le p ro sy
2
at the tim e when the lep ro sy sym ptom s f ir s t ap p eared (X = 16.83,
1 df, p < 0. 001). A psychic dim ensio n to H an sen 's D isease w as thu s
d e m o n stra te d . Given the p resen c e of a p re -m o rb id vulnerab ility to
this p a rtic u la r o rg an ism , the o c c u rre n c e of a sufficient level of u n r e
lated psychological s tr e s s will be c o rre la te d with sym ptom a p p earan ce
in H a n se n 's D isease. Since this is an illn e ss of fluctuating c o u rs e , one
cannot help but co nsider the im p licatio n of future psychic s tr e s s and its
b e arin g on rep eated rea ctio n s.
P sych olo gical C risis
A phenomenon c irc u m s c rib e d in the a re a of psychological s tr e s s
/
by its te m p o ra l and qualitative a s p e c ts , is te rm e d c r is is .
[C ris is is] . . . a concept of what happens when a p e rso n fa c e s
a difficulty, e ith e r a th re a t [italics m ine] of lo ss o r a lo s s , in
which his existing coping re p e rto ir e is insufficient, and he
th e re fo re has no im m ediate way of handling the s tr e s s . (Caplan,
1961, p. 41)
The em p h asis is on a period of tim e of b rie f duration, and upon the
individual's total lack of a re p e rto ire of coping sufficient to handle the
situation a p p ro p ria te ly . The lack of re p e rto ire te m p o ra rily re s u lts in
ap p aren tly random ized, ineffectual, in ap p ro p riate beh av io r, and is
freq u en tly accom panied by significant negative em otional o v erlay and ,
32
e x p re ssio n . By the definition and d escrip tio n , the su b jects in the study
a t a highly significant level had undergone a psychological c r is is .
D ata fo r th is in feren ce w ere tak en fro m th e ir own v e rb a liz atio n s
reg a rd in g the p ercep tio n of th e ir m en tal sta te , the ineffective behavior
they d escrib e d as having engaged in, and the profound level of negative
effect and fantasy they a d m itte d a s having experienced.
A ttitu d es, P e rc e p tio n s, and Coping
The su b je cts' in itial p e rc ep tio n and attitude to w ard le p ro sy
co n sisted of two m a jo r com ponents w hich one m ight in fer w e re r e s
ponsible fo r the c ris is : the fan ta sy of physical d e stru c tio n that they
felt the d ise ase im plied, and the fe a r of sep aratio n fro m fam ily and
frie n d s b ecau se of enforced isolation . The initial im p act of the
d is e a s e , beyond the fan ta sy expectations w as, for m a le s , p rin cipally .
a vocational disruption . F o r the fe m a le s, the so c ia l-fa m ilia l w ith
d raw al w as param ount. Initial coping s tra ta gem was in fe rre d fro m an
O penness Score. T his sc o re w as a percentage s c o re , b a sed on the
nu m b er of potential c a te g o rie s available to the patient fo r d isc lo su re
of his diagnosis v e rs u s the n u m b er he actually used. P o te n tia l c a te
g o rie s included such designations a s spouse, c h ild ren , p a re n ts,
extended fam ily, close frie n d s. The potential c ateg o ries v aried fro m
patient to patient, and w ere calcu lated individually fo r each one. The
O penness Score thus re p re s e n te d the su b je ct's p ro cliv ity to be open
with his fam ily , frie n d s, and extended social c irc le following diagnosis.
The tre n d w as to be se c re tiv e within the fam ily, and m o re so beyond
its lim its . T his is an in te re stin g finding, when c o n tra ste d with su b
je c ts ' v e rb a liz atio n s reg a rd in g the im pact of the d ise a s e upon him self
and his fam ily . While they perceiv ed ra d ic a l changes w ithin th e ir own
liv e s, they saw it as having little effect on that of th e ir fam ily . Nor
did they ad m it to any change in feeling tow ard th e m se lv e s on the p a rt
of the fam ily . All of th ese findings reach ed highly significan t levels.
The v ariab le of tim e produced no change in the p e rc e p tio n s,
a ttitu d e s, o r coping, with one exception. A ttitude tow ard the d ise ase
changed, in th at the fa n ta sie s of d estru ctio n and s e v e re physical
im p a irm e n t no longer held, leaving only the so cial iso latio n and w ith
d raw al com ponent. D isc lo su re proclivity also re m a in e d , on the whole,
unchanged. M ost anticipated som e negative re a c tio n on the p a rt of the
en v iro n m en t should they be m o re open in rev ealin g the n a tu re of th e ir
illn e ss.
Two phenom ena in th ese data a re salient. One is the im p e r
viousness of p e rc ep tio n s, and attitu d es to those dem ographic and
m e d ic a l v a ria b le s n o rm ally thought to influence the fo rm atio n of the
f o rm e r by th e ir d isc rim in ativ e function. To all intents and p u rp o se s,
w ith a few sc a tte re d exceptions, these v a ria b le s w ere in o p era tiv e ,
both in the in itial p h ases and even in th e ir providing of a "feedback"
34
function o v e r tim e. Initial and subsequent coping, in te r m s of degree
and kind of openness shown, w ere a lso unaffected by th e ir function.
W ithin su b je c ts, no p a tte rn e m e rg e d suggestive of e ith e r the function
ing of a ’’ feed back" m ec h a n ism o r a p e rso n a lity -c o n siste n t tra it. The
second datum of note is the e x iste n c e , o r coexistence of perceptions
w hich a p p e a r ratio n ally o r logically incom patible, fro m the standpoint
of an o b s e rv e r. Such would be the p ercep tio n of the illn e s s ' having a
profound effect on the p a tie n t's life, but no effect on h is fam ily; o r the
p ercep tio n th at, while the subject expected reje ctio n fro m the g en eral
e n v iro n m en t, none was evident in h is fa m ily 's attitude tow ard him .
T hese phenom ena will be com m ented upon in the next section.
C linical and M M PI F indings
O v er the c o u rse of the m o re than one y ear spent in data c o lle c
tion, the in v estig ato r fo rm e d a g e n e ra l picture of the s a m p le 's psychic
m akeup and functioning which w as validated by the M M PI findings.
Subjects as a group ap p ea re d to be in no acute psychological s tr e s s .
T hey ap p ea re d stable and p o ss e s se d of a reaso n ab ly good level of ego
stren g th . M anifest anxiety w as ab sen t, except in a few. T h ere w ere
no g ro s s parano id n o r actin g -o u t tend encies. None was on w elfare, .
a ll ap p ea re d to be p e rfo rm in g w ork suitable to th e ir so cial ro le. They
w ere stra ig h tfo rw a rd in th e ir p re se n ta tio n , beyond an in itial m inim al
sh y n ess. They did not se e m d e siro u s of responding in e ith e r a socially-
35
d e sira b le o r a cq u iesce n t fashion. T hey ap p eared to want to convey to
the in v estig ato r the fac t that they w e re functioning rea so n a b ly a d e
quately in th e ir som ew hat r e s tric te d w orld, and th at they had a good
feeling about th e m se lv e s a s p e rso n s.
The M M PI data, g ath ered on about one-half of the sam ple only,'
can only be re g a rd e d a s p ro v isio n al. A selectiv e fa c to r m ight have
been op eratin g , in that those of h ig h er educational lev el w ere m o re j
g e n e ra lly included in th is phase of a s s e s s m e n t b e ca u se of th e ir own :
w illingness to p a rticip a te at the tim e of th e ir subsequent v isit. •
Two m a jo r findings e m e rg e . All sc o re s w e re found to lie j
w ithin n o rm a l range (T s c o re s 50 to 69). While som e of the clin ical !
i
sc a le s would be c o n sid ered in b o rd e rlin e range, th e re w as no indica- !
i
i
tion of d istin ct clinical psychopathology. Nor w as th e re a com m on j'
i
c lin ical profile suggesting a p e rso n a lity configuration a sso c ia te d with j
!
the d ise a s e . T his la tte r finding is c o n sisten t with r e s e a r c h in chronicj
I
illn e ss (Stew art and V ineberg, 1955; Hovey and Kooi, 1959; Smith, j
1962). i
{
V alidity sc ale s and sc a le s desig ned to c o r r e c t fo r resp o n se ;.
j
b ia s w ere w ithin n o rm a l ran g e , indicating no g ro ss d isto rtio n o r ]
resp o n se se ts op erativ e due to e x tra n eo u s fac to rs such a s need to j
;
a p p e a r good o r bad, o v e rd e fen siv e n e ss, d e sire to be acq u iescen t o r to*
i
i
I
resp o n d in a socially d e sira b le m a n n e r.
36
C linical sc a le s showed the highest sc o re s on the Hypochon
d r ia s is , D e p re ssio n , and H y ste ric a l sc a le s, a tria d co n sisten tly e le
vated in illn e ss of chronic n a tu re . T hese a re in te rp re te d a s investing
em otional affect in the p ro b lem s of illn e ss while denying em otional or
n e u ro tic type sym ptom s; a d m issio n of som e anxiety and d e p re ssiv e
ten d en cies did o c c u r. H ow ever, the A (Anxiety) fa c to r, which
W elsh (I960) c o n sid e rs the b e st indicator of g en eralize d em otional
u p se t, w as not elev ated (T sc o re 46. 5).
M e a s u re s fo r defense m ech an ism s such a s re p re s s io n , h y s
te r ic a l denial, and fo r ego deficits such a s dependency, found the
group v e ry fav o rab ly aligned with n orm ativ e sam p les which had been
draw n fro m n o n -clin ic a l o r n o n -p sy ch iatric populations. S im ila rly ,
m e a s u r e s of ego stren g th , social tendencies and b eh av io r, yielded
fav o ra b le c o m p a riso n s with n o n -clin ical no rm ative sa m p le s.
The profile suggested a group of people, not in tro v e rte d by
n a tu re but fo rce d to a recog nitio n of social w ithdraw al and alienation.
They have invested th e ir affect in the problem s of illn e s s , and do not
engage in undue paranoid feelings o r in acting out in e ith e r a so cially
deviant o r exhibitionistic m an n e r. They have good ego stren g th ,
exhibit n o rm a l so cial ten d en cies and behavior. W ithin th e ir e n v iro n
m en t they function w ell psychically and without g re a t anxiety. I n te r
view d ata, how ever, would suggest this functioning m ight have been
37
p u rch a se d a t the co st of a self-im p o sed social r e s tric tio n and
w ithdraw al.
I n te r - c o r r e la tio n of M M PI data with interview data w as c o n
spicuous by its lack of significant c o rre la tio n s beyond what would be
expected on a chance level. Such would indicate the in te re s tin g p o s
sibility th a t the su b je c ts' a ttitu d es, p ercep tio n s and coping re g a rd in g
the d ise a s e a re functioning rela tiv e ly independently of o v e ra ll psychic
functioning; a t the le a s t, they have not m ade decisive in ro ad s in te r m s
of psychopathology.
C onclusions R egarding T h rea t P o ten tial of
H an sen 's D isease
The above rev iew would suggest that, at the p re s e n t tim e ,
fro m a c lin ica l standpoint, th e re is little b a sis fo r le p ro sy being co n
sid e re d a m e d ic a l th re a t of significant p rop ortion by the patient,
exceeding th at of o th er chronic illn e sse s. The effectiv en ess of the
c u rr e n t m ed ica tio n s in the a rre s tin g and d estru ctio n of the b a cilli and
in the elim in atio n of clinical signs would indicate, fo r m o st p a tien ts,
a m o re s a lu ta ry pro g n o sis than that which attach es to o th er d is e a s e s .
T h is, of c o u rs e , would re fe r to patients who have been diagnosed not
too long a fte r sym ptom appearance and who have had a c c e s s , during
the c o u rse of the d ise a s e , to the new m ed icatio n s. Such a g e n e ra liz a
tion would be applicable to the m a jo rity of patients in any a re a in which .
38
e a rly diagnosis is possible and in which the effective m edication is
obtainable.
The th re a t potential v is - a -v is individuals com ing in contact
with a H a n se n 's D isease patient is a lso m in im al, in re g a rd to p o s s i
b ility of contacting the d ise a se . Such is obviously a tte ste d to by the
few iso latio n p ro c e d u re s c u rre n tly re q u ire d , and the fa c t that in c e r
tain types of the d ise a se none is n e c e s s a ry . This again re fle c ts the
efficacy of the m edication fro m the standpoint of the patient a s well as
its prophylactic function fo r those in contact with a patient.
The data on psychological functioning of le p ro s y patients also
in d ic ate s m in im al th r e a t potential re a lis tic a lly e x ists w ithin the group,
p a rtic u la rly in re fe re n c e to th e ir behavior tow ard o th e rs. T here is no
g re a te r incidence of psychosis w ithin th is population a s com pared with
o th er ill groups o r with the n o rm a l population. H ostile affect is m ostly
in te rn a liz e d . If a g g re ssiv e feeling is e x p re ss e d , it is m o re likely to
be d ire c te d at self than the environm ent. T here is no evidence of a
g r e a te r tendency to act out, in e ith e r a m an ic, ex h ib itio n istic, o r
so cially deviant m a n n e r. On the c o n tra ry , th e re a re m o re data to sug
g e st inhibition of such behavior. The only th re a t potential in the a re a
of psychic functioning a p p e a rs to be in the patient in re la tio n to h im
self, in te r m s of se v e re d e p re ssio n and possible suicide. Such would
have seco n d ary ra m ific atio n on his close a s s o c ia te s and fam ily. But
39
th e re a re no available studies indicating any higher suicide ra te among
this population. One m ight conclude, fro m the standpoint of both the
patient and his in tim a te s, re a lity -b a se d th rea t potential is m in im al.
F in a lly , fro m the m o st c u rs o ry level of th re a t a s s e s s m e n t,
th at of c lin ica l o r psychological phenom ena available to a c asu a l
o b s e rv e r , to the naive individual th re a t potential is m in im a l. C lini- .
cally , the m ed icatio n co n tro ls sufficient signs as to m ak e the
re m a in d e r of o b se rv ab le signs attrib u tab le to other d is e a s e . The
exception would be those whose h isto ry long predated the sulfone e ra .
The p a tien ts d e m o n stra te , as a group, no signficiant psychopathology,
e ith e r in b eh av io r o r affect ex p re ssio n , that would re p r e s e n t th re a t
to c a su a l o b s e rv e rs .
One m ay safely conclude in re g a rd to the g e n e ra l population
th a t the p o ssib ility of encountering a lep ro sy patient is m in im al, and
should such an encounter o c c u r, the re a lis tic th re a t, in any a r e a of
functioning, is at a m in im al to nonexistent level.
CHA PTER HI
THE STRESS PARADIGM AND EX PERIM EN TA L DESIGN
The S tre ss P a ra d ig m of L azaru s
The specific findings of the pilot study and the m ode of th e ir
in te r- re la tin g , seem ed m o st efficiently explained within the context of
a s tr e s s p a ra d ig m outlined by L a z a ru s in Psychological S tre ss and the
Coping P r o c e s s (1966). Since im p etu s and directio n fo r the c u rre n t
study g rew out of the pilot investigation, th is s tr e s s fo rm u latio n was
em ployed a s the th e o re tic a l s tru c tu re fo r derivation of the hypotheses
in the p re s e n t study.
L a z a ru s preface,s his s tr e s s a n aly sis by d em o n stratin g the
p leth o ra of m eaning attached to the te r m , depending upon its use in a
given a r e a of scien ce. W ithin the field of psychology, he notes its
im p re c is e u se , a t tim e s re fe rrin g to a stim ulus v a ria b le , a t tim e s to
a re s p o n s e , and a t still o th e rs to an intervening v ariab le function. He
su g g ests th at definition p reced e a n a ly sis, and defines s t r e s s a s
. . . a g en eric te r m fo r the whole a re a of p ro b lem s th at •
includes the stim u li producing s t r e s s rea ctio n s, the rea ctio n s
th e m se lv e s, and the v ario u s intervening p ro c e ss e s . . . . S tre ss
is not . . . stim u lu s, re sp o n se , o r intervening v a ria b le , but
r a th e r a collective te r m fo r an a r e a of study (p. 27).
40
41
He w a rn s so cial sc ie n tis ts ag ain st a tendency to a r r iv e p re m a tu re ly a t j
i
a g e n e ra l th e o ry of s tr e s s : j
! i
In o rd e r to have a g en eral th e o ry of psychological s t r e s s fo r > *
a ll a n im a ls, one ten ds to elim inate c a te g o rie s w hich a r e p rim e j
th e o re tic a l too ls fo r understanding the p e rso n . . . . In the effo rt j
to be phylogenetically in clu siv e, one is likely to ig n o re o r a t le a s t j
u n d erp lay p ro b lem s of social approval and d isa p p ro v a l, conflicts j
o v er so cial ro le s and expectations, and in te rn a liz e d n o rm s o r j
sta n d ard s. . . . The arg u m en t is not ag ain st g e n e ra l th e o ry , but j
r a th e r a g ain st ru lin g out the v e ry distinction s th at a re u sefu l in j
one sp e c ie s, the hum an, when developing such a th e o ry . . . . The j
g e n eral p rin c ip le s m u st encom pass the hum an phenom ena a s j
d etails w ithin a la r g e r sy stem . . . a s specific v a ria b le s th a t func- j
tion in specific w ays w ithin this sy ste m , (p. 15) I
1 - i and again, j
!
. . . s tr e s s cannot be defined exclusiv ely by situ a tio n s, i
because the cap acity of any situation to produce s t r e s s re a c tio n s i
depends on c h a r a c te r is tic s of the individual. . . . The im p o rtan t
ro le of p e rso n a lity fa c to rs in producing s tr e s s re a c tio n s re q u ire s j
th at we define s tr e s s in te r m s of tra n sa c tio n s betw een individuals j
and situations [ita lic s m ine] ra th e r than of e ith e r one in isolation.
(P- 5)
The conceptual m a trix out of which L a z a ru s d e riv e s h is sp ecific fo rm u
latio n s is that of cognitive activity. The c e n tra l c o n stru c t is t h r e a t ,
which functions a s an intervening v a ria b le . T h re a t im p lie s a sta te in
which "the individual an ticip a te s a confrontation with a h a rm fu l c o n
dition" (p. 25). Its p ro p e rtie s include an a n ticip a to ry function, a
dependency upon cognition, and drive. "H arm " is defined a s a th w a rt
ing of an individual's m o tiv es. The cognitive a sp e c t im p lie s th at
i
th re a t a p p ra is a l is not a sim ple p ercep tio n of the e le m e n ts of a situ a
tion, but a judgm ent, an inference in which the data a r e a s s im ila te d to
4 2
a c o n stellatio n of ideas and ex p ectan cies (p. 44). The a p p ra isa l is a
tra n s a c tio n betw een the individual and the situation. The anticipatory
quality a r i s e s fro m the a p p ra is a l of fu tu re h a rm . The drive com po
nent ste m s fro m the cap acity of cognitions involved in th re a t a p p ra isa l
to function as m o tiv a to rs in the individual to engage in som e type of
copying activ ity to rem o v e h im se lf fro m the anticipated danger.
T h re a t A p p ra isa l
Two p h a ses a re involved in th re a t a p p ra isa l. P rim a ry
a p p ra is a l involves a s s e s s m e n t of the th re a t; seco n d ary a p p ra isa l con
c e rn s evaluation of the co n seq u en ces of a given stra te g y altern ativ e
th at m ight be cho sen to red u ce th re a t. The p ro c e ss does not im ply a
p ro tra c te d thought p ro c e ss ; it m ay be instantaneous. The a p p ra isa ls
m ay o v e rla p o r o c cu r spontaneously, as when c e rta in fa c to rs in the
stim u lu s a r e re le v a n t to both th re a t and coping. L a z a ru s distinguishes
two se ts of fa c to rs in h e re n t in both a p p ra is a ls which d e te rm in e degree
of th r e a t a s s e s s e d and choice of coping stra ta g e m : fa c to rs in the
stim u lu s configuration and fa c to rs in the p e rso n a lity s tru c tu re . These
have slightly d ifferen t r e fe re n ts , depending on the phase involved.
In p rim a ry a p p ra is a l, fa c to rs w ithin the stim u lu s configuration
d eterm in in g th re a t a p p ra is a l and its se v e rity include: 1) balance of
pow er betw een h a rm and c o u n te r-h a rm re s o u rc e s ; 2) im m inence of the
h a rm fu l confrontation; 3) am biguity of stim ulus cues concerning the
43
h a rm . P e rso n a lity v a ria b le s determ in in g d e g re e of th re a t ap p raised
include: 1) the stren g th and p atterning of the p e rs o n 's m otivational
sy ste m v is - a -v is th e 's itu a tio n 's capacity to challenge them ; 2) his
b elief sy ste m s reg a rd in g the frie n d lin e ss o r safety of the e n v iro n
m en t, and h is cap acity to m a s te r it; and 3) his in te lle ctu al re s o u rc e s.
Secondary a p p ra is a l is an interv en in g p ro c e s s o c c u rrin g
betw een th re a t a p p ra is a l and coping p e r se. It involves an evaluation
of the consequences of any action tendency:
. . . the issu e co n cern s how m uch am I in d an g er fro m
anything I do about the th re a t or to what extent w ill any p a rtic u
la r action re lie v e the danger (p. 161).
The evaluation, as with p rim a ry a p p ra is a l, need not be in full
a w a re n e ss no r re p re s e n t an a c c u ra te judgm ent of the re a lity of the
situation. F a c to rs w ithin the stim ulus configuration and the p e rso n a l
ity stru c tu re d eterm in e the a p p ra isa l. L ocation of th e actu al agent of
h a rm , viability of a lte rn a tiv e actions in te r m s of an a c tio n 's not '
inviting fu rth e r jeo p ard y fro m the h a rm stim u lu s, and situational con
s tra in ts which m ight m ilita te against c e rta in fo rm s of action: a ll a re
com ponents of the stim ulus influencing a p p ra is a l.
W ithin the p e rso n ality s tru c tu re , m otivation, a s enco m passed
by o n e 's in te rn alize d values and n o rm s, m ight inhibit e x p re ss io n of
c e rta in action tend encies. Ego re s o u rc e s such a s im p u lse control,
and coping tendencies such a s stable p e rso n a lity d isp o sitio n s to
44
e n co u n ter o r avoid, would again influence e ith e r e x p re s s io n o r
inhibition of c e rta in ty pes of action ten d en cies.
Coping and A ffect
W ithin the se co n d a ry a p p ra isa l fo rm u la tio n , L a z a ru s speaks of
"ac tio n te n d e n c ie s. " The im plication is th at while a d ire c t action of
a g g re s s io n o r avoidance is the m o st spontaneous re s p o n se to th re a t,
fa c to r s w ithin stim u lu s configuration, o r p e rso n a lity , o r both, m ay
m ilita te a g a in st such e x p re ss io n . Should d ire c t a ctio n not be viable,
"cognitive m a n e u v e r" o r "cognitive r e a p p ra is a l" o r d efen se m e c h a
n is m s a s tra d itio n a lly u n d ersto o d , a r e brought into play. This
s tra ta g e m p e rm its the r e a p p ra is a l of the so u rc e of h a r m in such a
m a n n e r th a t its th re a t p otential is red u ced , without any d ire c t action
being tak e n to change the objective situation. P re d isp o sitio n to such
coping would be the p re s e n c e of a s e v e re o r prolonged th re a t, a s well
a s the la c k of any viable actio n tendency.
L a z a ru s a ssig n s to each action o r action tendency a unique
a ffe c t w hich o c c u rs only in the p re se n c e of a specific fo rm of coping.
A n g e r a cc o m p a n ie s a g g re s s iv e action, fe a r is the concom itant of
a v o id an ce, h o p e le ss n e ss o r apathy a ttac h to a n o -e s c a p e n o -v iab le-
a c tio n situ atio n . If th e re is an a ttem p t to e x p re ss an actio n tendency
in the p re s e n c e of conflict over in te rn alize d o r so c ie ta l n o rm s, guilt
o r sham e o c c u r. To an x iety he a ssig n s the function of being a
45
re sp o n se v a ria b le . It a r is e s in only one context: the th re a t h as been
a p p ra ise d , but the h a rm -p ro d u c in g stim u lu s is am biguous and not
.located, th e re fo re not p e rm ittin g an action tendency w ith its attendant
affect to be g en erated . It is an in te rm e d ia te re sp o n se , the p rim a ry
re sp o n se to th re a t when no coping s tra ta g e m is im m e d ia te ly p o ssib le.
Since defense m e c h a n ism s by definition involve a re -e v a lu a tio n
of the situ atio n so that th re a t no longer e x ists o r is red u c ed to a m in i
m u m , no actio n tendency is g en erate d . T h ere fo re , negative affect is
not p re s e n t, if the defense is su c ce ssfu l. Should the cognitive m a n e u
v e r d e te rio ra te , anxiety m ay a r is e , but only in the unique psychologi
c a l-te m p o ra l ju n ctu re d e scrib e d .
The m o st significant im plication reg ard in g an x iety in this
th e o re tic a l fo rm u la tio n is th at its ab sen ce indicates the th r e a t h as been
som ehow m a s te re d . No b rie f is m ade fo r the efficiency o r re a lity -
o rien ted fe a tu re s of the stra ta g e m . G enerally, the m o re s e v e re the
th re a t, the m o re p rim itiv e the cognitive p ro c e ss e s which o p e ra te .
Such would n a tu ra lly effect the m ode of coping chosen.
A nalysis of P ilot Study in Context of
S tre ss P a ra d ig m
The C ris is
C a p la n 's (1961) definition of c r is is em p h asizes a te m p o ra l
perio d in which coping r e p e rto ire s a r e not available. L a z a ru s (1966),
while not co n sid erin g it sp ecifically within his fo rm u latio n , does note
. . c r is is is a m o re g e n eral m o la r event than th re a t, containing the
elem en ts of th re a t, but not n e c e s s a rily being defined as synonym ous
with any single th r e a t 1 ’ (p. 410). F u r th e r , " C ris is su g g ests the idea
of a period . . . in which m a jo r th re a ts and fru s tra tio n s that tax
adaptation a re p ro m in e n t" (p. 408). T hat c r is is had been su stain ed
by a significant n um ber of patients was a sc e rta in e d by th e ir v e rb a liz a
tion d e scrib in g the m en tal state and b eh av io ral m an ifesta tio n s which
follow ed. W ithin the s tr e s s m odel, one m ay a ssu m e in p r im a ry
a p p ra is a l that an e x tre m e th re a t had been a sse ss e d : "T he m o re se v e re
and b a sic is the h a rm conveyed by the stim u lu s, the m o re u n iv e rsa l
is likely to be the s tr e s s re a c tio n " (p. 57). A gain, the su b je c ts'
v erb alizatio n s suggest the so u rce and scope of th re a t: physical
d e stru c tio n and social w ithdraw al and isolation. One m ight in fer fro m
th is not only th re a t to o n e 's lite ra l su rv iv a l, but th re a t to life goals
and values, em otional and affiliative n eed s, vocational and econom ic
life; o r sim ply, a th re a t to e v e ry fac et of survival. Since the th re a t
ste m s fro m w ithin self (p resen ce of d ise a se s) and fro m the e n v iro n
m ent (im position of so cial isolation expectancy), the th re a t is fu rth e r
enhanced by w ithdraw al of environm ental support at the v e ry tim e
such is needed: " . . . any lo ss of support fro m th ese e x te rn a l r e
so u rc es in the face of th re a t in c re a s e s the th re a t by w eakening the
cap a city of the individual to m a s te r the d a n g er" (L a z a ru s, 1966, p.
101). The balance of pow er notion im p lie s that th re a t a s s e s s m e n t is
dependent upon the in te n sity of the h a rm -p ro d u c in g stim u lu s v is -a -v is
the in d iv id u al's cap a city to cope with it. How does one cope with a
p r o g r e s s iv e , d e g en e ra tiv e d ise a s e ; how does one cope with, and
red u ce the th r e a t poten tial, of v irtu a lly the e n tire e n v iro n m en t? The
h e lp le s s n e s s of the individual in coping (seco n d ary a p p ra isa l) m u st
c e rta in ly have re s u lte d in an en o rm o u s th re a t a p p ra isa l: "The m o re
potent is the a n ticip a te d stim u lu s event to produce h a rm in re la tio n to
the in d iv id u al's r e s o u r c e s , the g r e a te r is the likelihood of th r e a t
a p p ra is a l" (p. 111). C ris is would be inevitable fo r m o st.
Coping, A ttitu d e s, and P e rc e p tio n s
The c r i s i s , by definition, p a s s e s when som e fo rm of coping
is evolved. It need not n e c e s s a r ily be the m o st re a lity -o rie n te d m ode
of handling the situ atio n , but fro m the standpoint of the individual; it
rre d u c e s the th r e a t potential of the h a rm -p ro d u c in g stim u lu s. The
c lin ica l im p re s s io n of the subjects during in terv iew , and supported by
the M M PI data, indicated th at su c c e ssfu l coping had been d isco v ered
and the th re a t som ehow m a s te re d . The concept of " m a s te ry " does not
n e c e s s a r ily im ply that the th re a t no lo n g er e x ists. It sim p ly m eans
th at th e re a re no d e m o n stra b le phenom enological o r psychological
co n co m itan ts a sso c ia te d w ith it in evidence. The p rim e in d icato r,
w ithin the s t r e s s p a ra d ig m , is lack of anxiety. N eith er clinically nor
on the M M PI g e n e ra liz e d anxiety in d ic ato r w ere th e r e significant signs
of anxiety. T hat a re s id u a l th re a t re m a in s , and the n a tu re of it, m ay
be in fe rre d fro m th re e so u rc e s: the su b je c ts' v e rb a liz a tio n s, the'
im p e rv io u sn e ss of m o st of th e ir attitu d es to change, and th e ir d is
c lo su re p ro c liv itie s. T hose who m entioned change in attitude ov er
tim e in dicated th at it c e n te re d on the physical ram ific a tio n s of the
d ise a se : they no lo nger fe a re d the d e stru c tio n they o rig in a lly fan-
ta s ie d , nor did they fe a r the e x tre m e fo rm of iso latio n such as would
be re p re s e n te d by a le p ro s a riu m . O th er attitud es had not changed:
they still saw the illn e ss a s having profound effect on th e ir liv e s, m e n
tioning m ainly the vocation p ro b lem s and so c ia l-fa m ilia l w ithdraw al it
en tailed . A ndnone of the v a ria b le s included in the study, which t r a
ditionally a r e thought to influence attitude fo rm atio n , p e rc e p tio n s, and
coping, ap p ea re d to re s u lt in v a ria b ility in perceiving o r responding.
N or did th ese affect d is c lo s u re ten d en cies o r d isc lo su re patterning.
The v a ria b le of tim e p rovided, ap p aren tly , no type of "feedback" fu n c
tion to a lte r attitu d es o r coping. T his all suggests a re s id u a l th re a t;
since the p atien ts th e m se lv e s indicated that m o st of the fe a r connected
with the d ise a se p e r se had d issip a te d a s a re s u lt of tre a tm e n t, one
can in fer that the re s id u a l th re a t is posed by the g e n e ra l environm ent.
The n a tu re of coping evolved m ay be su rm ise d by the fact that.
49
no significant negative affect w as seen clinically o r in the M M PI data,
which im p lie s, in the s tr e s s p a ra d ig m , that no specific action te n
dency was co n sid ere d viable coping, and th at a defensive re a p p ra is a l
had o c c u rre d . The conditions for such exactly m atch ed the situation
with which the subjects w e re faced:
1) T h rea t is a p p ra ise d ; 2) the th re a t is v e ry g re a t; 3) no
fo rm of coping is viable; 4) an agent of h a rm cannot be sp e c ifi
cally lo cated , resu ltin g in no possible d ire c t action tendency
being feasib le; 5) so cial n o rm s favor o r produce p r e s s u r e
tow ard defensive re a p p ra is a l (action tendencies would e n c o u r
age fu rth e r negative re a c tio n on the p a rt of the environm ent);
6) stim u lu s inform ation that su pports a defensive r e a p p ra is a l
m ak es it m o re likely (th rea t situation is sufficiently am biguous
to p e rm it som e evidence in support of a defense). (L a z a ru s,
1966, p. 309) '
The phenom ena of the c lin ical m a te ria l and M M PI data sug
g ested th at no single defense w as em ployed to a significant degree.
C linically, no specific defense m e c h a n ism s, on a group level, w ere
d isc e rn ib le . The M M PI data showed n e ith e r re p re s s io n , denial, p ro
je c tio n , n o r in d ic a to rs of m o re in tellectu alized d e fen ses to be beyond .
n o rm a l range o r into the c lin ica l psychopathological ran g e . The stru c
tu r a l and phenom enological a sp e c ts of the in terv iew p ro c e d u re su g
g ested that som e type of cognitive defense p ro c e ss w as going on, but
one which was b ro a d e r than, and subsum ing of, a n u m b er of defenses.
50
E x p e rim e n ta l Strategy
The th ru s t and v ecto r of the p re s e n t investigation a ro s e
p rim a rily out of the pilot study findings which w ere then fitted to the
s tr e s s p a ra d ig m outlined by L a z a ru s . Individually, the findings w ere
a t tim e s unexpected and thus provocative; collectively they ap p eared
puzzling. The s tr e s s p a ra d ig m seem ed m o st suited to explain the is o
lated and collective phenom ena. The paradigm itse lf, how ever, rested
on specific a ssu m p tio n s reg a rd in g th re a t which the data of the pilot
study had not yet s a tis fa c to rily satisfied . It was to the validation of
th e se a ssu m p tio n s that the p re s e n t study a d d re sse d itself.
The f ir s t assu m p tio n co n cern ed the p resen c e of th re a t within
the stim u lu s configuration, the la tte r being defined a s the g e n eral
com m unity in its attitu d es tow ard H an sen 's D isease. D em onstration
of such g e n eralize d th re a t would have to be m ade on the b a sis of se v
e ra l sa m p le s of com m unity a ttitu d e s. These attitudes would en co m
p a ss both cognitive and em otion al a sp e c ts of d ise a se . The fo rm e r
im plied "m eaning, " o r "know ledge, " o r "objective fa c ts" which people •
held re g a rd in g the illn e ss. E m otional facets included le s s ratio n al o r
objective a ttitu d e s, feelin g s, and b eh av io ral p ro cliv ities. It would be
re q u ire d that it be d e m o n stra te d th at th ese w ere q ualitatively o r q u a n -‘
tita tiv ely m o re negative than th ose held in relation to other d is e a s e s .
T his would involve co m p ariso n of o th er disease en tities along the
51
sam e d im ensions of a s s e s s m e n t. Illn e sse s chosen fo r such c o m p a ri
son ideally would be those which w ere also functioning as control
groups in the patient phase of the investigation. The rationale fo r this
would be that d ifferen c e s in patient functioning d e m o n stra te d a c ro s s
d ise a s e s m ight then be validly c o rre la te d with specific attitudes known
to be held about the d ise a s e .
The second and th ird a ssu m p tio n s a risin g fro m the pilot study
and the s tr e s s p a ra d ig m r e f e r d ire c tly to the patient population. Con
clusions reg ard in g d iffe re n tia l functioning in H an sen 's D isease patients
m ig ht be leg itim ate ly draw n only if a com parison w e re m ade with other
d ise a se g rou ps. T hese would sh a re , cum ulatively, a ll the salien t
fe a tu re s of H a n se n 's D ise a se with the exception of the hypothesized
level of social stigm a attach ed to the d ise ase. Any d ifferen ces in
functioning on the p a rt of the le p ro s y group m ight then be m o re validly
a ttrib u te d to the hypothesized th re a t value of the d ise a se in co rp o rated
in the v ariab le of so cial stigm a.
The second a ssu m p tio n of the pilot study was th a t the p e rv a
siv e n e ss, se v e rity , and n a tu re of the th re a t existing in the stim ulus
configuration as p e rc eiv e d by the lep ro sy patient dem anded a p a rtic u la r
type of coping. It was th e o riz e d that in secondary a p p ra is a l a "defen-*
sive re a p p ra is a l" was judged to be the m o st a p p ro p ria te , becom ing the
p rim a ry coping m e a s u re . D em o n stratio n would have to be m ade of
52
the ex istence of such a cognitive defense m ech an ism , and its function
ing in e ith e r a qualitativ ely o r quantitatively significantly different way
in the H a n se n ’s D ise ase patient as co m p ared with o th er patient groups.
The th ird a ssu m p tio n in an aly sis of the pilot study data w as
th a t the th re a t, as a p p ra ise d by the p a tien ts, had been m a ste re d . The
conclusion w as b ased on the inability to d e m o n stra te , a t eith er a
clin ical o r objective a s s e s s m e n t lev el, a significant o r pathological
level of anxiety. H ow ever, th is finding was con sid ered inconclusive
b e ca u se of the selectiv e fa c to r p re su m a b ly operating in the M M PI
su b -sam p le a s s e s s e d , and b e cau se of the anxiety in d icato r em ployed.
T his a ssu m p tio n dem anded fu rth e r validation by em ploym ent of m o re
refin ed in d ic a to rs a c r o s s both E x perim ental-and C ontrol groups.
T hese would a n sw e r the follow ing questions: 1) had the th re a t been
rea so n a b ly w ell m a s te re d , a s defined by the s tr e s s p a ra d ig m 's c r i
te rio n of ab sen ce of significant lev e ls of anxiety; 2) had the coping
m ec h an ism s been significantly su c ce ssfu l o r little d ifferent fro m the
coping of patien ts with o th er illn e s s e s , a s m e a su re d by the anxiety
level d ifferen ces betw een E x p e rim e n ta l and Control G roups?
All c o n stru c ts sp e cifica lly chosen fo r exam ination, besides
th e ir relev an ce to pilot study and the s tr e s s form ulation, had to con
fo rm to a th ird c rite rio n : a d e m o n stra te d c ritic a l role in th eo re tic al
fo rm u latio n s of m a jo r schools of p e rso n ality functioning.
53
The te s t in stru m e n ts w ere ch osen on the b a sis of co n stru ct and
d isc rim in a n t validity in re g a rd to the concept under sc ru tin y , and on
th e ir d e m o n stra te d re lia b ility in re p o rte d studies.
Choice of C o n stru cts
A s s e s s m e n t of the M eaning of D isease: the Sem antic D iffer
ential fo r H ealth.-- T h e re q u ire m e n t fo r in stru m e n tatio n h e re dem anded
a te s t that would e licit the m o re id eatio n al, a b s tra c t, o r objective con
notations and laten t m eanings a ttac h ed to illn e sse s. F u r th e r , it had to
be of wide enough scope to tap s e v e ra l dim ensions of illn e ss, and
p o ss e s s sufficient d isc rim in a n t validity to m e a su re significant q u a li
tativ e d ifferen ces a c r o s s illn e s s e s on th e se dim ensions.
The Sem antic D ifferen tial, developed by O sgood, Suci, and
Tannenbaum (1957), has been em ployed a c r o s s d isc ip lin es, languages,
and c u ltu re s a s a valid in stru m e n t in the m e a su re m e n t of connotation
and laten t m eaning of w ords and concepts. The technique c o n sists in
the evaluation of a concept along the p rim a ry axes of evaluation-
poten cy-activ ity. T his is done on a s e r ie s of sc ale s which a re
anch ored by a d jectiv es of b ip o lar m eaning. Jakobovits (1966) initiated
a r e s e a r c h p ro g ra m to validate the in stru m e n t in 24 languages. Of
th e se , fifteen an aly se s have been com pleted. The p rim a ry evaluative-
potency -activity d im en sio n s, using 50 sc a le s rating 100 concepts,
54
e m e rg e d in a ll c u ltu re s. The au th o r concluded: "T he fact that each
p a n -c u ltu ra l fa c to r is defined by sc ale loadings of co m p arab le size
a c r o s s all languages p ro v es the tru e p a n -c u ltu ra l n a tu re of the
sem an tic space as m e a su re d by th e se p ro c e d u re s" (Jacobovits, 1966,
p. 26). M aclay and W are (1961) u sed a m odified sem an tic differential
w ith th re e n o n lite ra te A m e ric a n Indian trib e s , and found that it validly
d isc rim in a te d betw een co n stellatio n s of m eaning found in the th re e
d ifferen t tr ib a l languages.
Jenkins (1966) re p o rte d the developm ent of a s e t of sc a le s
d ire c tly concerned with h e a lth -re la te d behavior. T h ese m e a su re d
beliefs about su scep tib ility , se v e rity , salien ce, and prom inence in
thought and d iscu ssio n . The sc a le s w e re m odified to include v erb al
lab els a t v ario u s points along the sc ale , in addition to the bipolar nouns
and a d je ctiv es. H is f i r s t study em ployed a sam ple of 436 subjects in
a la rg e u rb an F lo rid a county. F o u r d ise a s e s w ere studied: c a n c e r,
poliom yelitis, tu b e rc u lo sis, and m en tal health. N in ety -six c o m p a ri
sons of cum ulative freq uen cy yielded 61 d ifferences betw een d ise a se s
at the 0. 01 lev el of confidence. A second study by the sa m e author (1966)
on tu b e rc u lo sis initially yielded a "m uddy" fa c to ria l p ic tu re . T hree
an aly ses on the b a sis of the th re e ethnic groups involved in the study
yielded significant d ifferen ces on the n u m b er of f a c to r s , the n a tu re of
the fa c to rs , and the sc ale s loading on the fa c to rs. Je n k in s' la te s t study
55
(1968) on c a n c e r, polio, and m ental illn e ss involved a fa c to r a n a ly sis
which yielded th re e fa c to rs com m on to all d ise a se s; ho w ev er, the
com ponents of the fa c to rs , such as pain, sev erity , th re a t, v a rie d as
a function of the d ise a se , a s did the sc a le s which c o m p rise d the
com ponents.
C om m unity A ttitudes and B ehavioral T en d en cies.- - T h e a s s e s s
m ent of m eaning, connotation, "knowledge" about an illn e ss y ield s data
on one a sp e c t of th rea t: how th reaten in g is the d ise a se to the c o m m u
n ity ? One m ight then hypothesize reg a rd in g the c o u n te r-th re a t p o ten
tia l of the com m unity tow ard the patient, since such knowledge is a
potential m o b iliz e r of attitu d es and behav iors. One m ight a ls o a rg u e ,
th at such a b stra c tio n s could re m a in in the cognitive re a lm and not be
tra n s la te d into behavior; if such o c c u rre d , th re a t potential would be
lim ited o r m inim ized . It is im p e ra tiv e , then, to e sta b lis h w h eth er o r
not a re la tio n sh ip e x ists betw een what one "knows" about a d is e a s e and
how one fe e ls about a d ise a s e , the la tte r being the p r e c u r s o r.o f
b eh av io ral tendencies.
B ogardus (1939) m ade such a distinction: ", . . opinion is
e ith e r what a p e rso n thinks he knows o r a judgm ent of values . . . "
(p. 69). "An attitude m ay be defined . . . as an acq u ired e sta b lish e d
tendency of a p e rso n to act [italics m ine] with re fe re n c e to any o b je c
tive phase of his social environm ent" (p. 72). He h y p o th esized th at
56
a ttitu d es a r e re fle c te d in te r m s of social d istan c e, defined a s " . . .
the d e g re e of cooperative behavior that m ight be expected in a p a rtic u
la r situ atio n " (p. 72). T hese attitudes a re re la tiv e ly sta b le .o v er
groups and o v er tim e , re su ltin g in a h ie ra rc h ic a l o rd e rin g of groups
along a d im en sio n of so cial intim acy. The stim u lu s is the stereotype
which the individual holds of the group, and w hich is re fle c te d when he
is called upon to give his f i r s t feeling reactio n .
B ogardus has devised a scale which h a s been u sed to ra te all
types of g roup s. A ttitudes tow ard national, ethnic, and ra c ia l groups
have been found to differ on the b a sis of sex (B ogardus, 1959), p arty
m e m b e rs h ip (B est and Sohner, 1956), and cu ltu re (L am b ert, 1952).
E vidence fo r c o n stru c t validity and in te rn al c o n sisten c y was cited by .
B ogardus h im s e lf (1947 and 1958). Follow ing a d m in istra tio n of one
te s t, su b jects com plained to h im how in co n sisten t they w e re in th e ir
•
a ttitu d e s to w ard different g ro u p s, and felt guilty about feelings which
they felt th ey "should not" have tow ard o th e rs. In the second study,
B ogardus su rv ey ed studies of national and ethnic groups in ap p ro x i
m ately s im ila r sam p les o v er a th irty -y e a r perio d te rm in a tin g a fte r
W orld W ar II. The ratin g s given the groups c lo sely p a ra lle le d both
the p o litical thinking, the w artim e a llia n c e s, and the shifts in both
which took place o ver this tim e span. M urphy and L ik e rt (1938) and
H a rtle y (1946) re p o rt c o rre c te d sp lit-h alf re lia b ilitie s in the range of
0. 94 to 0. 97, but these a r e possibly som ew hat inflated values due to
57
re sp o n se set. C am pbell (1952) in a rev iew for M ental M e a su re m e n ts,
com m ented th at the Social D istance Scale ". . . is so good, and so
n a tu ra lly suited to its purpose, that if B ogardus had not invented it,
som eone e ls e would h a v e 1 ' (p. 324).
Cognitive Functioning: the Open and Closed B elief S y stem . - -
Choice of this a r e a of study was d ete rm in e d by the o b serv atio n , in the
pilot study, of what m ight be d e sc rib e d a s a p ro c e ss phenom enon, and
the fo rtu ito u s d isc o v e ry of a th e o re tic a l fo rm u latio n th at d e scrib e d ,
and accounted fo r, ju s t such a p ro c e ss . The p ro c e ss ap p eared to go
beyond a p a rtic u la r m ode of defense. It appeared to be a cognitive
o p e ra tio n in which data w ere se lectiv ely "filtere d , " allow ing the
a d m issio n of som e, excluding o th e rs , and a t tim e s p e rm ittin g the
sim u ltan eo u s co ex isten ce of a p p aren tly incom patible id e a s, with no .
a p p a re n t d isc o m fo rt being exp erienced by the subject. R okeach (I960)
d e s c rib e s th is o c c u rre n c e in h is fo rm u latio n of a cognitive s tru c tu ra l
netw ork w hich c o n tro ls and affects a ll a re a s of ideological, p ercep tu al,
a e sth e tic , and b eh av io ral functioning. The c en tral c o n stru c t is th at of
a b e lie f-d isb e lie f sy ste m in which the sy ste m s re la te to one another in
an open o r clo sed m a n n e r, with no re fe re n c e to specific content. The
functions of the sy ste m a re two: to know and u n d erstan d , and to w ard
off th re a te n in g a sp e c ts of re a lity . When the need to know p re d o m i
n a te s, and the need to w ard off th re a t is absent, the tendency is fo r the
58
sy ste m to be open. At such tim e s , inform ation will be rec eiv e d , p ro
c e ss e d , d isc rim in a te d , a s s e s s e d , and acted upon in a c c o rd with
objective situ atio n al re q u ire m e n ts . If the need to w ard off th re a t p r e
v ails, the sy ste m b eco m es m o re closed. Data a re then evaluated
a rb itr a r ily to co n fo rm with an ticip ated re w a rd s and punishm ents. The
sy ste m is dynam ic, fluctuating in resp o n se to the predom inating need. .
H ow ever, chronic situ atio n al dem ands can re s u lt in a tendency fo r the
sy ste m to re m a in re la tiv e ly clo sed, in pro p o rtio n to the degree to
which the individual is m ade to feel alone, iso lated, and h e lp less in
the w orld. As the sy ste m tends tow ard clo sed n ess, R okeach se es it:
. . . to r e p re s e n t, in its totality, a tightly woven netw ork
of cognitive defense a g a in st anxiety. Such psychoanalytic
defense m e c h a n ism s as re p re s s io n , ratio n alizatio n , denial,
p ro jectio n , re a c tio n fo rm atio n , and overiden tification m ay all
be seen to have th e ir re p re se n ta tio n in the fo rm of som e belief
o r in the fo rm of som e s tr u c tu r a l rela tio n am ong beliefs [ ita lic s
m ine]. Indeed, we su g g est th at, in the e x tre m e , the closed s y s
te m is nothing m o re than the total netw ork of psychoanalytic
defense m e c h a n ism s o rg an ized to g eth er to fo rm a cognitive s y s
te m and designed to shield a vulnerable m ind. (Rokeach, I960,
p. 70)
He d ifferen tiate s the fo rm u la tio n fro m that of F e s tin g e r 's (1957) co g
nitive disso n an ce. The la tte r is pred icated p rin cip ally on dissonance
betw een two d isp a ra te b e liefs, which dissonance pro d u ces affective
d isc o m fo rt that c a u se s the individual to engage in a behavioral o r
psychic m an eu v er to red u ce the dissonance. In c o n tra st, R okeach's
re fe re n t is an o rg an izatio n of belief and disbelief sy s te m s.
59
Incongruence is handled by reo rg a n iz in g the data into a su b sy stem
along lines of s im ila rity to congruent belief sy ste m s.
S tru c tu ra lly , the n etw ork co n sists of belief and disbelief s y s
te m s a rra n g e d along a continuum of th ese dim ensions: belief -
disb elief, c e n tr a l- p e rip h e ra l, and tim e . In re g a rd to the belief -
d isb elief a x is, open sy ste m s a r e c h a ra c te riz e d by low reje ctio n of
disbelief sy s te m s , com m u nication within and betw een belief and d i s
belief sy s te m s, and a high d e g re e of differentiation w ithin disbelief
sy s te m s. Along the c e n tra l-p e r ip h e ra l dim ension, the c e n tra l region
c o n sists of p rim itiv e b eliefs. In an open system , the w orld one liv e s :
in is seen a s frien d ly , a u th o rity is not absolute, and the c e n tra l and
p e rip h e ra l b eliefs a re in com m unicatio n with one an o th er. In re g a rd
to tim e , open sy ste m s a re c h a ra c te riz e d .b y broad tim e p e rsp ec tiv e ,
with no undue e m p h a sis on p a st, p re se n t, o r fu tu re. C losed sy ste m s •
m a n ife st opposite c h a ra c te ris tic s .
H isto ric a l an teced en ts fo r the th eo ry a re found in the work of
M aslow '( 1943) and A dorno, F re n k e l-B ru n sw ik , L evenson, and Sanford
(I960) on the a u th o rita ria n p e rso n ality . Building on M aslow ’s psych o
dynam ic a n aly sis and d e sc rip tio n of the perso n ality , the la tte r auth ors
c a r r ie d out an ela b o rate e x p e rim e n ta l study which included hypotheti
cal fo rm u latio n s te ste d by in terv iew and objective a s s e s s m e n ts . The
F scale w as designed to m e a s u re the a u th o rita rian sy n d ro m e, which
60
was felt to be right-w ing fa s c istic in political outlook. The study
becam e the s to rm -c e n te r fo r c o n tro v e rsy , being c ritic iz e d for m ethod
ological in su fficien cies and g ratu ito u s in te rp re ta tio n of data, to fit the
psychoanalytic m odel (C h ristie and Jahoda, 1954). But it had a
phoenix-like quality, g e rm in atin g a g re a t body of r e s e a r c h on the
a u th o rita ria n syndrom e. R okeach, in critiqu eing the F scale i n te r
p re ta tio n , felt that the a u th o rs took an unw arranted lea p fro m the
fa s c is tic , right-w ing p o litical view (content phenomenon) to the g e n
e ra liz a tio n of an a u th o rita ria n p e rso n a lity stru c tu re . He holds th at
a u th o rita ria n is m is a s tru c tu ra l phenom enon, in which individuals
holding p o lar opposite view s on a subject m ay exhibit the identical
m ode of cognitive functioning.
R okeach designated th is cognitive phenomenon of the open-
clo sed sy ste m "dogm atic, " to m ake it conceptually d istin c t fro m the
w ork of the e a r lie r th e o r is ts , fro m both a sem antic standpoint and fo r
r e s e a r c h pu rp o ses. He designed a scale to m e a su re the phenom enon
fro m both a s tru c tu ra l and content a sp ec t. He com pleted two stu d ies
(Rokeach and F r u c h te r , 1956; F r u c h te r , Rokeach, and Novak, 1958)
of a fa c to r analytic n a tu re , in w hich the sc ale s w ere e n te red into the
a n a ly sis with the F sc a le , an opinionation scale, an e th n o c en trism
sc a le , and anxiety, p a ra n o ia , and se lf-re je c tio n sc a le s. Findings
indicated; 1) d ogm atism is fa c to ria lly d isc rim in ab le fro m a u th o ri
ta ria n is m , e th n o c en trism , and rigidity; and 2) although it m e a s u re s
som ething s im ila r to a u th o rita ria n is m , it is independent of the left-
rig h t political dim ension. R okeach, McGovney, and Denny (1955)
w ere able to d e m o n stra te the c o n stru c t validity of the concept as d is
tinguished fro m rig id ity in an e x p e rim e n ta l task in which two phases of
a p ro b lem w ere involved. D ifferen tial predictions re g a rd in g the speed
of p e rfo rm an c e of each group, designated dogm atic and rigid by p rio r
a s s e s s m e n t, w ere hypothesized and confirm ed at significant levels.
The p red ictiv e validity of th e c o n stru c t was d e m o n stra te d in two
stu d ies. B urke (1966), investigating so cial p e rc e p tiv e n e ss, predicted
h ig h er social acuity on su b je cts sc o rin g low on the d o g m atism scale,
b ecau se on the b a sis of the th e o re tic a l im plications, such subjects a re
le s s stereo ty p ed in thinking and m ake g re a te r use of a wide range of
inform ation in d ecisio n -m ak in g . His prediction was confirm ed.
Zagona and Z u rch er (1965) o b se rv ed a c la s s of students over an en tire
s e m e s te r in both c la s s ro o m p e rfo rm a n c e and group pro blem -solving
situations. All had been a s s e s s e d at the beginning of the se m e s te r a s
high o r low in dogm atism . T hey m ade differential p red ictio n s re g a rd
ing c la ss ro o m beh avior, re la tio n to in s tru c to r, types of exam inations
p re fe rre d , and behavior and affect in c la ss ro o m d isc u ssio n . In the
p ro b lem -so lv in g g rou ps, th ey w ere able to have the groups divided on
the b a sis of high d o g m atism -lo w d o g m atism groups. A gain, p red ic
tions of differential p e rfo rm a n c e w ere m ade in re g a rd to the type of
62
group s tru c tu re each would re q u ire , re la tio n to the group lea d er,
m ethod of p ro b le m -so lv in g p r e f e r r e d , affect under s t r e s s . All
hypotheses w e re sig n ifican tly co n firm ed . Rokeach d e m o n stra te d , in a
s e r ie s of e x p e rim e n ts (R okeach, I960) the pred ictiv e validity of the
th e o ry o v er a wide ra n g e of b eh av io r, such as solving nonsense p ro b
le m s , e sth etic ta s te s , and evaluation of p e e rs.
The S e lf-C o n ce p t.--Im p e tu s to explore the self-co n cep t was
prom pted in itially by an unexpected finding in the pilot study. In
clin ical interview , the subjects p re se n te d the p ictu re of individuals
who thought w ell of th e m s e lv e s , o r at le a s t had a need to so p re se n t
th e m se lv e s to the e x a m in e r. In view of the g en eralize d com m unity
negative rea ctio n to w a rd the d is e a s e , one m ight have anticipated
re p e rc u s s iv e effects on se lf-im a g e , resu ltin g in a deflated se lf
perception. S econdary co n sid era tio n fo r use of se lf-c o n ce p t in the
p re s e n t study re la te d to its c e n tra lity in the s tr e s s p a ra d ig m a s an
organizing p rin cip le , subsum ing m o tiv e s, values, and goals, all of
which a re c ritic a l in th e p ro c e s s of th re a t a p p ra isa l and choice of
coping stra ta g em .
F o rm a l atten tio n to self a s phenom enological object in an indi
vid u al's p erceptu al field w as f i r s t e la b o rated by Snygg and Combs
(1949). "By the phenom enal self is m ean t the individual's own
unique o rg a n iz a tio n of ways of reg ard in g self; it is the g e sta lt of his
concepts of self" (p. 126). A s the fundam ental fra m e of re fe re n c e , it
is re la tiv e ly c o n siste n t, sta b le , and re s is ta n t to change. P r im a r y
m otivation is th a t of self-enhancem ent;, any in co n siste n t s e lf-p e rc e p
tions a r e ex p erien c ed a s th re a t, which the individual a tte m p ts to
red u ce by 1) reo rg a n iz in g his phenom enal se lf to include the percep-.
tions; 2) denying th em acceptance into the phenom enal field , o r 3)
selectin g only c o n sisten t p ercep tio n s.
R a im y (1949) was the f ir s t to em ploy se lf-c o n c e p t a s an o p e ra
tional c o n s tru c t in psychotherapy. He c o n sid ere d it a h ig h e r o rd e r
c o n stru c t, an exp lan ato ry principle needed to a c c o u n t'fo r functional
in te r-re la tio n s h ip of attitu d es within the p e rso n a lity o rg an izatio n .
S elf-ap p ro v al and se lf-d isa p p ro v a l w ere seen as two en d s of a con
tinuum ; the balance betw een them dictated ad ju stm en t. S elf-approval
was the dependent v a ria b le in the th erap eu tic p ro c e s s , to which he
a d d re s s e d his r e s e a r c h e ffo rts. . .
R o g e r s 1 account of the p ro c e ss phenom ena a s s o c ia te d with
c lie n t-c e n te re d th e ra p y was based on the afo rem en tio n ed t h e o r is ts 1
w orks. H is distin ctio n betw een adjustm ent and n e u ro s is pivots on the ‘
o rg an iz atio n of se lf-p e rce p tio n s: an individual functions adequately so
long as a ll p ercep tio n s in a w a re n e ss a re congruent w ith the s e lf-
im age. In tru sio n of d isco rd an t perceptions in itia te s d istu rb a n c e .
64
S e lf-id e al co ngruence b ecam e the c e n tra l dependent v a ria b le in the
th e ra p e u tic p ro c e s s . P sy ch o th erap y was seen as the providing of a
I
p e rm is s iv e , accep tin g a tm o sp h e re in which the client can d a re to
e x p erien c e feelin g s and percep tio n s which he fo rm e rly denied because
of th e ir inco ngruence with se lf-im ag e . A m o re flexible, accep tin g
se lf-im a g e ev o lv es, reducing the d isc rep a n cy betw een self and id e a l.
R o g e rs and Dym ond (1954) instituted an extensive r e s e a r c h p ro g ra m ,
explo rin g the n a tu re of the th erap eu tic p ro c e ss and its re la tio n to
changes in se lf-c o n ce p t. S elf-ideal congruence b e ca m e the sine qua
non of a d ju stm e n t, stim u latin g a p leth o ra of r e s e a r c h beyond the
c lie n t-c e n te re d school. While the o b v erse proposition seem ed i r r e
futable, the equating of se lf-id e a l congruence with a d ju stm en t began to
be s e rio u s ly questioned a s a re s u lt of e x p erim e n tal findings. '
C o n stru c t validity of " s e lfi" as m ea su re d by p a p e r-a n d -p e n c il
te s ts , w as challenged. M ohanty (1965) suggested a so cial d e sira b ility
fa c to r w as being m e a s u re d , Z uckerm an and M onashkin (1957) fe lt it
w as a g e n e ra liz e d defensive in d icato r, a s suggested by high c o rre la tio n
w ith the K sc a le on the M M PI. A ltro cch i, P a rso n , and Dickoff (I960)
found high c o rre la tio n with s e lf-re p o rt and re p re s s iv e defensive p a t
te rn in g m e a s u re d by the M M PI. The ’'ad justm ent” side of the equation
was a lso v u ln erab le. B lock and T hom as (1965), using the re p r e s s io n -
se n sitiz a tio n M M PI continuum as.indicativ e of ego o v e r- c o n tro lle r s
65
and u n d e r-c o n tro lle r s , suggested th at a c u rv ilin e a r function in self-
re p o rt in d ic e s 'm o re aptly defined ad ju stm en t. B yrne, Golightly, and
Sheffield (1965), com paring th e ir s e lf -r e p o rt index with C alifornia
P sychological Inventory findings, indicated that the b e st "adjusted"
individuals w ere r e p r e s s o r s . In the a re a of d em o n strab le psycho
pathology, the c o n stru c t validity of "ad ju stm en t" as an inference d e
rived fro m s e lf - r e p o r t m e a s u r e s rec eiv e d its m o s t se rio u s challenge.
Subjects p rev io u sly a s s e s s e d , by p sy c h ia tric diagnosis, interview ,
objective a s s e s s m e n ts o th er than s e lf -r e p o r ts , a s e ith e r m aladjusted
(Chase, 1957) o r sc h izo p h ren ic (H illson and W orchel, 1957), produced
s e lf -re p o r ts indistingu ishable fro m findings on n o rm al groups 1
The problem a p p eared to ste m fro m s e v e ra l so u rc es: 1) co n
stru c t validity of s e lf -r e p o r t in v en to rie s, 2) r e s e a r c h p aradigm s,
3) dem and c h a r a c te r is tic s of the e x p erim e n tal setting, and 4) definition
of the te r m " a d ju s tm e n t."
In re g a rd to the f i r s t , m o st indices of s e lf-re p o r t contain ite m s
of a high' level of fac e -v a lid ity ; freq u en tly s e lf-r e p o r ts a re based on a
d isc rep a n cy sc o re . Both so u rc e s of e r r o r can be tra c e d to the m anip-
ulability fa c to r. W ylie (1961), in an exhaustive study of self-concept,
w arns:
One m u st u n d ertak e a slow accum ulation of info rm ation in re g a rd
to re lia b ility and c o n stru ct validity at the ite m level, if any c le a r
m eaning can be attach ed to o n e's m e a s u re s , (p. 322)
66
The p ro life ra tio n of s e lf-ra tin g in v en to ries, without r e g a r d for the
above, m ak e s m eaningful co m p ariso n a c ro s s studies u s e le s s .
C oncerning the r e s e a r c h p aradigm , two p ro b le m s ex ist. One i3 *
the wide u se of R -R d e sig n s, in which two resp o n ses a r e c o rre la te d .
C o rre la tio n a l stu d ies can n e v e r yield data on c au se -effe ct re la tio n - .
sh ip s. Secondly, r e s e a r c h designs re q u ire the u se of m o re so p h isti
cated s ta tis tic a l p ro c e d u re , such as an aly sis of v a ria n ce . Wylie
o b se rv e s: "Som e of the a p p a re n t contradictions m ay be due to the
in te ra c tio n of v a ria b le s which a re a s yet unexplored in a sy ste m atic
w ay" (I960, p. 322).
The dem and c h a ra c te ris tic s of the situation in which the p r o
c e d u re s a r e c a r r ie d out dem and a cognitive a p p ra isa l of the situ ation
w hich, d espite a su b je c t's h onest effort to be objective, stim u late
m o tiv atio n al te n d e n cies to produce a p a rtic u la r type of se lf-im a g e .
A h o sp italize d sch izo p h ren ic would c erta in ly ap p raise the situation, in
re g a rd to what is being dem anded of him , som ewhat d ifferen t than a
psy ch o th erap y candidate, o r a college sophom ore being paid to take
p a rt in a la b o ra to ry e x p e rim e n t!
R eg ard in g the definition of ad ju stm en t, Wylie o b s e rv e s .
The m o s t im p o rtan t fa c t that em erges, (in the study of non-
c lin ica l [ita lic s m ine] populations) is the general lack of c o r r e
latio n am ong d ifferen t indices of adjustm ent, even am ong those
which a re re lia b ly m e a su ra b le and which should expect to c o r r e
late w ith one a n o th e r . . . o ur data yield no evidence justifying
67
the a ssu m p tio n that ad ju stm en t, in its p resen t state of definition,
should be c o n sid e re d a u n ita ry tr a it [italics m ine] in c lin ically
u n se lec te d populations. (I960, p. 234)
The d e c isio n to u se the c o n stru c t of self, despite its m uddy
conceptual sta tu s , w as prom pted not so m uch by the naive hope of
obtaining a valid re p o r t of self, but ra th e r to see how the subject needs
to see h im s e lf and p ro je c t h im se lf to o th e rs . Within the hypothesized
fo rm u la tio n s to be te s te d in the study, the self m u st be seen in a p o si
tive fash io n in o r d e r th at the individual m ay function effectiv ely in what
he h as a p p ra is e d a s a th rea te n in g w orld, albeit at the p ric e of a d efen
sive m a n e u v e r. We would a g re e with L a z a ru s in stre s s in g the positive
a sp e c ts of defense:
. . . d efense is . . . adaptive when it allows the individual
to be m o re c o m fo rtab le and not be se rio u sly d isru p ted in o th e r
on-going a c tiv itie s. If th e re is nothing that can be done to a v e rt
the h a rm , the individual m ay be as well off defending as he would
be to view the situ atio n re a lis tic a lly . (L azaru s, 1966, p. 289)
Body C oncept.- - T h is concept ap p eared a fruitful one fo r in v e s- '
tigation b e c a u se w ithin the E x p erim e n tal group, the body is the h a r
bin g er of a d is e a s e a g ain st which so m uch negative re a c tio n h y p o th et
ica lly is d ire c te d . It functions a s a continuous, perh aps sym bolic
re m in d e r of the th re a t and reje ctio n the patient m ay be ex p erien cin g .
Such a function would suggest a possible rejectio n on the p a rt of the
individual to w ard th is body sy stem . Q uestions posed fo r th is in v e s ti
gation would include w hether o r not such a reaction o c c u rre d , whether.
68
or not such a re a c tio n would be significantly g re a te r than in individuals
who had illn e s s e s in which the body did not play such an annunciating
function, o r would it be significantly g re a te r than in illn e ss in which
body a p p e a ra n c e did play a ro le , but without the hypothesized so cial
stigm a th at a tta c h e s to lep ro sy . O r would the opposite phenom enon
take p la c e --w o u ld the p rim a ry defensive op eration dictate a positive
perception of the body a s p a rt of a need to see oneself in a positive
m a n n e r, to c o u n te ra c t the g eneralized rejectio n stem m in g fro m the
e n v iro n m en t?
The m u ltid im e n sio n al statu s of the self-co ncept usually su b
sum es the b o d y -sy s te m a s a su b sy stem of self. F re u d a ssu m e d a
c a u se -e ffe c t re la tio n sh ip in h is view of anatom ical sex d ifferen ces a s
productive of d ifferen tial feelings in s e lf-re g a rd of m en and women.
A d le r's co n stitu tio n al in fe rio rity idea as influencing c h a ra c te r d e v e l
opm ent p osited a s im ila r relatio n sh ip betw een body and self. C leveland
and F i s h e r 's (1958) m o re re c e n t form ulation s suggest an opposite
re la tio n s h ip --p e rs o n a lity configurations p red isp o se an individual
v
tow ard p e rc e iv in g his body in specific w ays.
S eco rd and J o u ra rd , without specifically explicating the d i r e c
tion of the re la tio n sh ip , have investigated the relatio n sh ip of feelings
about body and se lf and th e ir m utual interdependence, a s well a s the
effect of th e se feelin g s on o ther a re a s of psychic functioning. S ecord
69
(1953) d e m o n stra te d th at undue body concern, a s indicated by
re s p o n se s to a hom onym te s t, was a sso c iated with anxiety and d is
turbed feeling s about the body im age as seen on the R o rsc h a c h p ro to
col, and with feelin gs of body d issa tisfac tio n , a s in dicated b y a body-
acceptance sc a le . Secord and Jo u ra rd (1953), defining b o d y -cath ex is
as "the d e g re e of feeling of satisfactio n o r d issa tisfa c tio n w ith the
vario u s p a rts o r p ro c e s s e s of the body" (p. 343) hypothesized a s ig
nificant re la tio n sh ip to e x ist betw een th ese feelings and feelin g s
tow ard self. They devised a scale of identical fo rm a t to m e a s u re
both. They a lso hypothesized negative feelings would be a s s o c ia te d
with anxiety and feelings of in se c u rity reg ard in g self, a s m e a s u re d by
the aforem entioned hom onym te s t and M aslow 's (1945) s e c u rity -
in se c u rity sc a le . A ll hypo theses w ere confirm ed. Johnson (1956)
investigated the rela tio n sh ip betw een sym ptom s of illn e s s re p o rte d
and feelin g s tow ard body and self, using the scales devised by Secord
and J o u ra rd , the C ornell M edical Index, and the T aylor M anifest
A nxiety Scale a s anxiety in d icato r. The findings re g a rd in g the r e l a
tionship betw een self and body feelings w ere c ro s s -v a lid a te d , a s w ere
th e ir re la tio n sh ip to anxiety. The relatio n sh ip with so m atic c o m
plaints indicated a m o d e ra te in v e rse c o rre la tio n , rea ch in g significance
only fo r fe m a le s (p < 0. 05). R osen and R oss (1968) em ployed the
body-cathexis and se lf-c a th e x is s c a le s, controlling fo r the v a ria b le of
70
im p o rtan c e of the body p a rt to the subject. They w ere able to dem on
s tra te c o rre la tio n a l d ifferences as a function of this v ariab le: o v e ra ll
c o rre la tio n was 0. 52 fo r all ite m s, 0. 62 for ite m s above m ean im p o r- .
tan c e, and 0 .2 8 fo r ite m s below m ean im po rtance.
The questio n ra is e d by Johnson's (1956) study reg a rd in g a p o s
sible re la tio n sh ip existing betw een illn ess and sym ptom atology and
o n e 's feelin g s tow ard the body, invited speculation in the p re s e n t study.
Would such a tre n d be validated by the c u rre n t re s e a r c h , involving
d e m o n stra b ly ill su b jects, as opposed to sam ples of n o n -clin ic a lly
defined g ro u p s such a s w ere in the re fe re n t study? O r would the
n o rm a l c o rre la tio n expected to ex ist be vitiated by a defensive need to
p e rc e iv e the body p o sitiv ely ?
A nxiety. - - The n e c e ssity to explore the c o n stru c t of anxiety
a r is e s d ire c tly out of its c ritic a l and pecu liarly unique position in the
s t r e s s p a ra d ig m in re la tio n to th re a t m a s te ry . . Beyond th is, no th eo
r e tic a l fo rm u la tio n w orth its salt can be con sidered adequate without
its having dealt with and found a functional place fo r anxiety in the
a rtic u la tio n of the theory.
F r e u d defined anxiety as an unpleasant affective sta te , which
state included psychological phenom ena such a s a p p reh en sio n and
feelings of d re a d , as w ell as physiological phenom ena concom itant
with autonom ic a ro u s a l. It se rv ed both cue and m otivating function in
h is th e o re tic a l s tru c tu re , w arning of potential danger and m obilizing
the individual to cope. He distinguished n eurotic fro m objective ;
anxiety. O bjective anxiety w as based on apprehen sion of an objective
e x te rn a l d a n g er. N eurotic anxiety was b ased on an in te rn alize d d an
g e r, the so u rc e of which w as u sually an in stin ctu al im pulse which had :
been r e p r e s s e d but which w as th rea te n in g to e m e rg e . His whole elab- j
o ra tio n of defen se m e c h a n ism s w as an effort to delineate the m ethods j
by which the individual a ttem p ts to rid h im se lf of conscious a w are n ess ! ■
of p rim itiv e im p u lse s, thus avoiding anxiety. :
i
S u lliv an 's (1953) fo rm u latio n defines anxiety as a state of a p p re
hension a ris in g fro m the experien cing of fa ilu re in in te rp e rs o n a l re la - !
|
tions. M ay (1950), in an e x iste n tia l fra m e w o rk , c o n sid e rs it the re s u lt
of a p p re h en sio n of som e th re a t to a value held in trin sic to o n e 's e x is t
en ce. E ven theologians have taken cognizance of its p e rv a siv e n e ss as
a phenom enon of the age. In T illic h 's (1952) ontological form ulation,
anxiety is a re sp o n se v a ria b le , but not a n eu rotic m an ifestatio n , the
■ i
• \
u n iv e rs a l re a c tio n to th re a t of non-being. M o w re r's (1950) form ulatio n
j
h as an e x iste n tia l-o n to lo g ic al f la v o r- -in h is la tte r-d a y g u ilt-a n d - •
re stitu tio n fo rm u latio n , anxiety is an affect resu ltin g fro m guilt fe e l
ings about som ething one h as done and w ishes he had not. R estitution
is the m e a n s by which it is elim inated. T his fo rm u latio n is an alm o st
p o lar opposite of F r e u d 's explanation of n eu ro tic anxiety;
i ’
i _ _ _ _ _ _ _ _ ' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
72.
L earn in g th e o ris ts , exem plified by the Hull (1943) and Spence
(1958) m o d els, a c c o rd anxiety the position of an hypothetical em otional
re s p o n se , one of the com ponents of effective drive s ta te . In a m u lti
plicative re la tio n sh ip with habit stren g th , it produces e x c ita to ry poten
tia l, d e te rm in in g the stre n g th of a given resp o n se . The value of the
learn in g th e o r is ts ' ap p ro ach lay in the lo w -o rd e r hy p o th eses generated
in w hich d ifferen tial lev els of anxiety com bined with o th er com ponents
of the basic equation w ere exam ined. Low er o rd e r law s of lea rn in g
and m otivation w e re capable of sc ru tin y and explication.
H is to ric a l rev ie w su g g ests, how ever, that the concept of
anxiety p e r se is vague; alw ays the focus h as been on its a n te ce d en ts,
its p ro p e rtie s , its function a s stim u lu s, cue, in tervening, o r resp o n se
v a ria b le . F a c to r a n a ly sis p e rm itte d attention to the su b stan tiv e p ro p
e r tie s of the c o n stru c t, and findings indicate a m u ltid im e n sio n al p h e
nom enon. C attell and Scheier (1958, 1961) a rriv e d a t two se co n d -
o rd e r fa c to rs , d e sc rib in g two types of anxiety which e n c o m p a sse d dif
f e re n t typ es of v a ria b le s in the fac to r loadings. One m e a s u re d r e l a
tiv ely stable c h a r a c te r is tic s of the p erso n ality , and w ere co m posed of
m o re psychological-type v a ria b le s such as "ego w e a k n e s s ," " e rg ic
te n s io n ," "guilt p ro n e n e ss, " "su sp ic io u sn e ss, " and "tend ency to
e m b a rra s s m e n t. " The o th er type of anxiety showed a p a tte rn of v a r i
a b le s , m o stly autonom ic in d ic a to rs, which covaried o v e r m e a su re m e n ts
73
and defined a fluctuating condition of the o rg an ism .
S p ie lb e rg e r e m p iric a lly d em o n strated the validity of th ese as
s e p a ra te c o n stru c ts in two e x p erim e n tal investig ation s. In the f ir s t
one (Johnson and S p ie lb e rg e r, 1966), indices of state anxiety (" . . .
an o rg a n ism ic sta te , c h a ra c te riz e d by subjective, co n scio u sly p e r
ceived feelin g s of a p p re h en sio n and tension, together with activ atio n
of the autonom ic s y s te m 1 1 [p. 20]) included systolic blood p r e s s u r e ,
h e a r t r a te , and an ad jectiv e check lis t on which su b ject ra te d h is a t -
th e -m o m e n t fee lin g s. T ra it indices (". . . anxiety p ro n e n e ss . . .
d ifferen c e s betw een individuals in the probability th at anxiety sta te s
w ill be m an ifeste d u n d er c irc u m s ta n c e s involving varying d e g re e s of
s t r e s s " [p. 15]) included the T aylor M anifest A nxiety Scale, and an
adjective check lis t on which subject ra te d his feelin g s a s th ey g e n
e ra lly w e re . Two e x p e rim e n ta l se ssio n s w ere held. In each, m e a
s u re m e n ts w e re tak en b efore and a fte r the tre a tm e n ts w e re applied.
T hese w e re a m u sc le rela x a n t train in g pro ced u re (within sessio n ) and
the p a ssa g e of tim e (betw een session). Findings indicated th a t while
tra in in g produ ced significant d e c re a se in anxiety state m e a s u r e s ,
t r a i t m e a s u r e s showed no such change. C o rrelatio n s betw een t r a i t
m e a s u re s w ere high and stable ov er tim e; c o rre la tio n s betw een state
m e a s u re s w ere m o d e ra te o r negligible. The la tte r finding is c o n s is
ten t in s t r e s s r e s e a r c h which em ploys physiological in d ices as
74
dependent v a ria b le s (L a z a ru s, 1966, p. 225). The second study
(Hodges and S p ie lb e rg e r, 1966) involved an a sse ss m e n t of anxiety two
m onths p rio r to the e x p e rim e n ta l se ss io n , in which se ss io n the t r e a t
m en t c o n sisted of e le c tric shock, u n d er warning o r n o-w arning condi
tions. Subjects w e re designated High A nxious/Low Anxious on the
b a sis of T ay lo r MAS; th ey w ere a lso asked in the p r e -s e s s io n how they
thought they m ight resp o n d to e le c tric shock, on the b a s is of f e a r , in a
psychological e x p e rim e n t. H A 's and L A 's w ere assig n ed on a random
b a sis to the two conditions of the ex p erim en t. The ex p erim en tal
re s u lts .indicated m a rk e d in c re a s e in h e a rt ra te , the dependent v ariab le
a sso c ia te d with sta te anxiety, in su b jects exposed to the th re a t condi
tion, but no d ifferen c e s in High and Low Anxious subjects. H ow ever,
those who indicated e x tre m e fe a r of e le c tric shock two m onths e a r lie r
showed g r e a te r in c re a s e in h e a rt ra te in respo nse to th re a t of shock
than th o se who had re p o rte d a t th at tim e little o r no fe a r. The conclu
sion w as th at the d ifferen tial am ounts of ANS a ro u sa l produced by the
s t r e s s o r situation w as a function of the su b jects' "cognitive a p p ra isa l"
of the situation. T hose who differ in tra it-a n x ie ty w ill respond with
differing am ounts of sta te -a n x ie ty to "ego s tr e s s " situatio ns.
The d istin ctio n betw een the two types of anxiety seem ed a u s e
ful one in .the p re s e n t study. The g en eralized anxiety indicato r used in
the pilot study em ployed no such conceptual distinction. P o ssib ly
75
d ifferen tial v a ria n c e s contributed by each type of anxiety w ere being
o b scu red in the final g e n e ra l sc o re. S pielberger developed two scales
designed to m e a s u re the two c o n stru c ts. These a re d e sc rib e d , and
re lia b ility data given, in the M ethodology Section. B aseline lev e ls of
t r a i t and state anxiety, co m p ared a c r o s s groups, m ight yield su b sta n
tive data reg a rd in g the in h e re n t th re a t value of the d ise ase a s m e a
s u re d by a n x ie ty -p ro n e n e s s, the re sid u a l th re a t a s m e a su re d by s ta te -
anxiety, and in fe re n c e s re g a rd in g the degree of m a s te ry achieved.
E x p e rim e n ta l P ro p o s a ls and H ypotheses
The follow ing co n sid era tio n s reg ard in g the c o n stru c ts to be
in v estig ated , and th e ir in te r-re la tin g within the s t r e s s p arad ig m , sug
g ested th em se lv e s a s w orthy of exploration in the study:
1. The v erb al la b e l, le p ro sy , e lic its in the g e n e ra l population
a ste reo ty p e of b eliefs and "fa c ts" re le v a n t to the d ise a s e w hich is
negative in n a tu re and w idely sh ared . This stereotype influences both
attitu d es and b e h av io ral p ro c liv itie s of the population vis-& -vis indi
viduals having H a n se n 's D ise ase. T h erefo re:
H ypothesis I: L e p ro sy will be evaluated by the com m unity in a
significantly m o re negative m an n er than w ill any o th er m ed ica l group.
H ypothesis II: L e p ro sy patients will significantly differ fro m
o th e r patient groups in being that group which the g e n eral public would
d e s ire to m ain tain a t the g re a te s t so cial distance. ,
76
H ypothesis IH: T h ere will be a sign ificant re la tio n sh ip betw een
the adjudged neg ativ ity of a d ise a se group and the d e s ir e to m aintain
so c ia l d ista n c e , in the two d ise a se group s judged m o s t negatively and ■
le a s t negatively.
2. Such a negative re a c tio n to w ard the d is e a s e co n stitu tes a
s e rio u s th re a t to the patient, a s th re a t is a p p ra ise d by h im . Since the
th r e a t is ubiquitous, continuous, but not of a n a tu re to p e rm it a specific
ag en t of h a r m to be lo cated , a g ain st which an actio n tendency m ight be
g e n e ra te d , a defensive re a p p ra is a l would be the m o st viable coping
s tra ta g e m . Such a s tra ta g e m would have to be of su fficien t b read th to
e n c o m p a ss, and have a p rim a ry reg u latin g effect, on a ll a r e a s of
psychic and b e h av io ral functioning. The n a tu re of the m ec h a n ism
would be an o p e ra tio n w hereby data in im ica l to su b sy ste m s e sse n tia l
to p sy ch ic functioning a re sc re e n e d out; data suppo rtive of the su b
s y s te m s is adm itted to a w a re n e s s, thus p e rm ittin g the sy s te m s to
function a t a level of optim um su rv iv al consonant w ith the continuing
i
p re s e n c e of the th re a t.
H ypothesis IV; L e p ro sy patients w ill evidence a m o re sig n ifi
can tly clo sed b elief sy ste m than w ill patients of o th er m ed ical groups.
H ypothesis V: T h ere will be a significant d ifferen ce in the
s c o re s on the D og m atism Scale of that group which h a s been m o st
p o sitiv e ly evaluated, as co m p ared with th at m o st n eg ativ ely evaluated,
the la tte r being le p ro sy group.
77
s
3. Since the cognitive defense reg u lates su b sy stem s in the
psychic s tru c tu re , and since self and body m ay be c o n sid e re d su b sy s
te m s , one would expect the following to o ccu r. In the face of the gen
e ra liz e d negative rea ctio n tow ard the H a n se n 's D ise ase p atien t, it
would a p p ea r e sse n tia l that c e rta in key sy ste m s be p e rc e iv e d by the
patien t in a positive fashion in o rd e r to c o u n te rac t the effect of the
g e n eralize d negative reactio n and p e rm it h im to function adequately.
F o r th is rea so n , the cognitive m e c h a n ism will p e rm it a d m issio n of
a g re a te r n u m ber of enhancing self and body p e rc e p ts, re s u ltin g in
positive body and self im ag es. T h erefo re:
H ypothesis VI: L ep ro sy patients w ill show a sig n ifican tly
h ig h er b o dy-cathexis and se lf-c a th e x is than will patients in o th e r .
m ed ica l groups.
H ypothesis VII: In each m edical group th e re w ill be a sig n i
ficant rela tio n sh ip betw een feelings to w ard body and feelin g s tow ard
self.
4. Since all anxiety is indicative of u n su ccessfu l m a s te r y of
th re a t, and since a ll su ccessfu l d efenses should elim in ate anx iety, and
since the cognitive defense stra ta g e m and the body and self concepts
m a y be co n sid ered the m ajor and m in o r d efenses a g ain st th re a t r e
spectiv ely, we m ay expect the follow ing rela tio n sh ip s to obtain:
78
H ypothesis VIII: Low body and low self-cath ex is will be a s s o
ciated with feelings of anxiety in a ll g ro u p s, with le p ro sy patients being
significantly le s s anxious than o th er g roups.
H ypothesis IX: T h ere will be a significant positive re la tio n
ship betw een the openness of o n e 's belief sy stem and feelings tow ard
self and b o d y --th o se having the m o st clo sed sy stem w ill d em o n strate
m o re positive feelings tow ard self and body.
C H A PT ER IV
METHOD
P h a se I: Com m unity A ttitudes A s s e s s m e n t
In the a ttem p t to d e te rm in e the attitu d es of a c o n te m p o ra ry ,
u rb an iz ed so ciety to w ard lep ro sy , c e rta in c o n sid era tio n s se e m e d
m a n d a to ry in o r d e r to a s s u r e that a re p re se n ta tiv e sam pling, re f le c t
ing the e n tire g e n eralize d com m unity was obtained. Age ran g e and
sex d istrib u tio n had to be adequately re p re s e n te d , a s both v a ria b le s
a r e known to influence attitude fo rm atio n and b e h a v io ra l tendency.
The sam ple had to be h etero g en eo u s, re p re se n tin g s e v e r a l s tr a ta of
society . O n e's socioeconom ic lev el, enco m p assin g v a ria b le s of g en
e r a l education, ex p o su re to g re a te r o r le s s b re a d th of life e x p erien c e,
and so p h isticatio n , a r e known to affect to le ra n c e of gro u p s unlike o n e's
own. F in a lly , hypothetically it would be anticipated th at individuals
who have specific tra in in g in the m ed ical scien c es would p o s s e s s ob
je c tiv e data th at would co u n teract in a c c u ra te , extant ste re o ty p e s o r
p e rs o n a l p reju d ice.
The sa m p le s, th e re fo re , th at w ere chosen d iffered sufficiently'
as to p e rm it a b ro ad rang e of age d istribution . The n o n -m e d ic a l
79
80
groups w ere so d isp a ra te socioeconom ically that no o v e rla p was
possible econom ically, so cially, o r educationally. The u p p er socio
econom ic sam p le, while s im ila r to the m ed ical grou p on the socio
econom ic lev e l, contained no subject who had m e d ic a l o r p a ra m ed ica l
tra in in g , thus a s s u rin g a non-contam inating effect of th is v a ria b le in
the f o rm e r group. The th re e sam p les contained fifteen m a le s and
fifteen fe m a le s , draw n fro m a pool of twenty su b jects in each group.
E lim in atio n of a subject w as on the b a sis of e ith e r p re s e n ta tio n of an
invalid re c o rd o r seco n d arily on a random b a sis.
Subjects
U pper Socioeconom ic L ev el.--M a le subjects w e re draw n fro m
the R o ta ria n Club, fe m a le s fro m th e A ssista n c e L eague, both of which
a re lo cated in San P e d ro , C alifornia. T hese a re p h ilan th ro p ic-ty p e
o rg an iz atio n s, and roughly com parable in b read th of a c tiv itie s and the
socioeconom ic lev el of m em b ersh ip , a t le a st in th is p a rtic u la r c o m
m unity. • Subjects ranged in age fro m late tw enties to six ty -p lu s. Men
w ere u su ally engaged in p ro fessio n al, executive, o r m a n a g e ria l type
w ork. W omen w ere non-em ployed m a tro n s. An a p p ro x im atio n of
socioeconom ic lev el, using H ollingshead and R e d lich 's (1958) c r ite r ia
would be C lass U.
81
L ow er Socioeconom ic L ev el.--S u b je c ts in th is group w ere
draw n fro m two so u rc es: a co m m u n ity -sp o n so red p ro g ra m called
P ro je c t WIN (W ork Incentive P ro g ra m ), located in E a s t Los A ngeles,
and the T o b erm an Settlem ent House in San P e d ro . Since the prepon
d era n ce of the WIN group w ere of M e x ica n -A m erica n background, the
second so u rce was used to a s s u r e a m o re v a rie d r a c ia l d istrib u tio n
th a t would appi-oximate the ethnic d istrib u tio n in the g re a te r Los
A ngeles a re a .
P ro je c t WIN re c e iv e s county fund s, and w as designed to help
low er c la ss adults w ith educational o r job n e ed s. C la sse s a re given
in E n g lish language fo r those who speak o r re a d poorly. Simple
m a th e m a tic s , spelling, h isto ry , read in g , and civics co m p rise the
sch o lastic p ro g ram . T rain in g is given fo r se m i-s k ille d w ork such as
cle rk in g o r typing. In addition to the M e x ic a n -A m e ric a n sub jects,
th e re w e re a few blacks and w hites. Age range was fro m 25 to 50.
C andidates w ere selected for the p ro g ra m by the school sy stem , not on
a ran d o m b a sis. M ales w ere e ith e r not w orking at a ll o r held night
jo b s. F e m a le s w ere predom inantly housew ives.
The T o b erm an Settlem ent H ouse, funded by com m unity and
p riv ate donation, has a s its population both w orking and unem ployed
c itize n s of the com m unity. This fa c ility provides a v a rie ty of s e r v
ic e s, ranging fro m e m e rg en c y food and clothing ratio n s, to d a y -c a re
82
cen ter and ad u lt c la s s e s . E thnic re p re se n ta tio n is m o re evenly
divided than a t the f o rm e r re s o u rc e am ong b lacks, w h ites, and
M e x ica n -A m erica n s. In addition to the m o re d iv ersified ethnic
re p re se n ta tio n , T o b erm an w as included to counterbalance any s e le c -
«
tive fac to r th at m ight have been operating in the WIN sam p le due to
the n o n -ran d o m selectio n of su bjects for the p ro g ram . Subjects
included in the sam ple w e re black and white, ranging in age fro m 25
to 45. A ccording to H ollingshead and R edlich (1958) c r i t e r i a fo r
socioeconom ic lev el, su bjects w ere judged to be in C lass IV and V.
M e d ic a l-P a ra m e d ic a l G roup. - -Subjects w ere draw n fro m the
V eteran s H o sp ital, Long B each, C alifornia. M ales w ere physicians on
the G en eral M edicine and S u rg ery S ervice. They ranged in age fro m
25 to 60, w ith skew ing of the d istrib u tio n tow ard the 25 to 35 range.
F e m a le s w e re n u rs e s w orking on the following se rv ic e s: G en eral
M edicine and S u rg ery , Spinal C ord Injury, and P sy c h ia try . Age range,
with a fa irly equal d istrib u tio n , was fro m 23 to 60'.
In stru m en ts
M e a su re m e n t of A ttitudes and B eliefs about D isease: The
Sem antic D ifferential fo r H ealth (Jenkins, 1966).--T h is is a 1 6 -scale
protocol which m e a s u re s dim ensions of belief about a given illn e ss.
Concepts a r e evaluated by p o lar a d jectiv es and nouns, with in te r-
83
m ed iate v e rb a l labels along m o st sc a le s. Each line is subdivided into
20 sp a ce s by " h a s h m a rk s" ; each space having an additive value of two,
the h a s h m a rk s having in te rm e d iate odd values. Subject was in stru cted
to place h is c h e c k m a rk anyw here along the line. Scoring w as by a
p lastic r u le r on which the s c o re s had been placed re la tiv e to the p o si
tion of the ch eck m ark .
It w as o rig in a lly planned to evaluate the "negativity" of a
d ise a s e by a d e te rm in a tio n m ade by th re e judges, w hose re lia b ility
had p re v io u sly been e stab lish ed , as to which scales connoted a th r e a t
ening, an x iety -p ro v o k in g , o r socially unacceptable m ean ing. F o r
tu ito u sly , Jen kin s (1968), in a study on m ental illn e s s , c a n c e r, and
p o lio m y elitis, had fa c to r analyzed h is re s u lts and found th at th re e
fa c to rs e m e rg e d a c ro s s the th re e d is e a s e s , with the sa m e sc a le s con
trib u tin g the significant loadings in a ll d ise a se s, with m in o r additions.
The P e rs o n a l Involvem ent fa c to r c a rrie d the connotation of th re a t,
su scep tib ility , sa lie n ce , risk . This fa c to r, in the c a se of c a n c e r,
had sig n ifican t loadings fro m two additional sc a le s, design ated by the
au th o r a s " th re a t. " A Social A cceptibility facto r was defined by two
sc a le s. It was decided that this e m p iric a lly derived definition of
negativity was a m o re valid m ethod by which to proceed. In th e p r e s
ent study, th e re fo re , th re e cum ulative s c o re s , re p re se n tin g the
dim ensions of p e rso n a l involvem ent, th re a t, and social accep tab ility
84
w e re u sed to designate negativity. They w ere tre a te d se p ara tely in
s ta tis tic a l a n a ly sis to d e te rm in e the am ount of v a ria n ce contributed
fro m each so u rc e .
M e a su re m e n t of B ehavioral T endencies in R esponse to D isease:
B ogardus Social D istance Scale (Appendix A ).--T h is scale was m odified
to use a s the stim u lu s fa c to r the seven d ise a s e s evaluated in the
Sem antic D ifferen tial fo r H ealth. It is a one-page ite m , with printed
in stru c tio n s fo r se lf-a d m in istra tio n . Subjects a re a sk ed to w ork a s
quickly as p o ssib le and re c o rd th e ir f ir s t feeling re a c tio n s , with as
m any ch ec k m a rk s fo r each d isease a s th ey feel b e st re p re s e n ts th e ir
feelin g s. A se v e n -ste p in te rv a l scale, designating p ro g re s s iv e levels
of so cial in tim acy , is used. S everal m ethods of sc o rin g have been
u se d , fro m u se of e ith e r e x tre m e sc o re (B ogardus, 1933) to an a r ith
m e tic m ea n of a ll e n trie s checked (M urphy and L ik e rt, 1938). Since a
m ea n sc o re m ight o b scu re intensity of re a c tio n to a given d ise a se , two
sc o re s w e re u sed and en te red in the an aly sis se p a ra te ly --th e extrem e
sc o re of both affiliation and d isaffiliation that the individual checked in
re g a rd to the d ise a se . It w as reaso n ed th a t the u se of the two sc o re s
m ight provide qualitative data reg ard in g b eh av io ral p ro cliv ities in
re sp o n se to d ise a se .
Seven d ise a s e s w ere evaluated on both in stru m e n ts b ecause at
the tim e th a t this f ir s t phase was c a r r ie d out, the C ontrol groups had
85
not been definitively d e te rm in e d . Beyond H ansen 's D ise ase, the six
m e d ic a l e n titie s re p re s e n te d p o ssib le c o n tro l groups fro m which three
would u ltim a te ly be chosen.
P ro c e d u re
The obtaining of sa m p le s, and the solicitatio n of th e ir help,
w as id en tical fo r a ll g ro ups, with m in o r m odification a s indicated. An
individual who functioned as a s u p e rv is o r, o fficer, o r consultant to the
group w as contacted. T his p e rso n functioned as lia iso n with the group
to e lic it th e ir co o p eratio n . He was told th at the investigation was a
study about a ttitu d e s to w ard illn e ss and the subject of a d octoral d is
se rta tio n . It w as then explained that it w as felt that knowledge about
how people fee l to w ard illn e ss would be a valuable tool in the p h y si
c ia n 's a rm a m e n ta riu m when he had to tr e a t an individual having a
given d ise a s e . Two of the lia iso n s knew of the in v e s tig a to r’s re s e a rc h
in the a re a of lep ro sy ; th e re fo re , w hile the p resen ta tio n was su b sta n
tiv e ly the sam e to th em , it w as explained th at o ur p rim a ry in te re s t was
to see if H a n se n 's D ise a se would be respo nded to in a m o re negative
fash ion . It was a sk ed that they p re s e n t the req u e st fo r cooperation in
a vague and sketchy m an n e r such as it had been p re se n te d to them ,
attem p tin g to a ro u s e m otivation by em phasizing the value that such a
study would have to the m ed ial p ro fessio n , and the seco n d ary benefit
th a t m ight a c c ru e to th e m se lv e s o r o th e rs should physicians have this
info rm atio n av ailab le to them . The lia iso n s designated a s non-naive
w ere sp ecifically w arn ed to m ake no allusions to H an sen 's D isease.
T hey w ere told th a t follow ing collection of the data, they would be
given a m o re e la b o ra te explanation of the study, but that at p re s e n t too
m u ch in fo rm atio n m ight affect th e ir p resen ta tio n to the group and
u ltim ately b ias the su b je c ts' re s p o n se s. The lia iso n s w ere not given a
p re p a re d speech to give to th e ir re sp e c tiv e groups, a s it was felt that
th e ir own p re s e n ta tio n would be m o re effective in the p a rtic u la r co n
tex t of the group. It was ask ed that cooperation of subjects be sought
at a re g u la r m ee tin g of the group.
When group co o p eratio n had been secu red , the in v estig ato r m et
the group a t one of th e ir re g u la rly scheduled m eetings. In the c ase of
the subgroup d esig n ated P r o je c t WIN, a special m eeting was called at
lunch h o u r. B a sic a lly the sa m e d e scrip tio n of the pu rpose was
rep e ate d in the in tro d u c to ry r e m a rk s by the E x p e rim e n te r. Follow ing
th e s e , the te s t p ro to co ls w e re d istrib u te d in a counterbalanced o rd e r,
the second in stru m e n t being given out on an individual b a sis following
the su b je c t's com pletion of the f ir s t.
The S em antic D ifferen tial fo r H ealth has no printed in stru ctio n ,
so the follow ing w as given:
You w ill see th at you have seven tw o-page booklets. On
each of th ese tw o-page booklets, you will be asked to give your
feelings about one d is e a s e , the nam e of which is given at the top
of the f ir s t page. You m ay m a rk your answ er with e ith e r a check
87
o r c ro s s , anyw here along the line, that best d e s c rib e s your
feelin g s. You do not have to re c o rd your an sw er d ire c tly
below any of the w ords w ritte n above the line; anywhere along
the line is sa tis fa c to ry . It does not have to be in a space; it
m ay be on top of one of the slanted lin es. You w ill notice that
som e of the q u estio n s se e m to re q u ire m o re than one a n sw e r,
according to w hat you know about the d isease. If you run into
th is situatio n, place your a n sw e r w here you think m o st of the
c a s e s would fall. F o r exam ple, if you think a c e rta in d ise a s e
o c c u rs ch iefly am ong babies and young people, decide in which
group m o st c a se s fall, and place your m a rk th e re . If you f e e l
it's so m ew h ere in betw een, place the m a rk som ew here in betw een
the two g ro u p s. If you feel, in the case w here only two ch o ices
a re given, th a t n e ith e r ap p lies, place your c h ec k m a rk in the
m iddle.
Subjects w ere th en en co u rag ed to a sk any questions th ey m ight need to
have c la rified . A lthough the above instruction on the Sem antic D if
fe re n tia l w as given b e fo re the testin g period began, it was re p e a te d a
second tim e la te r in the te stin g se ssio n fo r those who did not o rig in a lly
have the p ro to co l b e fo re th em when the in stru ctio n w as f i r s t d e liv ere d .
It w as a n ticip a te d that m any subjects would fin ish both f i r s t and
second p ro to co ls a t roughly the sam e tim e at different points in th e
se ssio n . Since the in v e stig a to r was the sole a d m in is tra to r, th e re
would not be tim e fo r even a c u rs o r y inspection to d etect the p o ssib ility
of an invalid re c o r d due to lack of com prehension of in stru ctio n . The
m a te r ia l had been identified by code num ber only, and su b jects had
been in stru c te d a t the beginning of the se ssio n not to place th e ir n a m e s
on the p ro to co ls. T h e re fo re , tow ard the end of the se ssio n , su b je cts
w ere ask ed to sign th e ir n a m e s and a d d re s s e s on a sheet beside th e ir .
88
code n u m b ers b efo re d ep artin g fro m the room . The p u rp o se of this
d e p a rtu re w as explained to the subjects as above, but in m o re diplo
m a tic te r m s .
While we reco g n ized the p o ssib ility of the b ias in re sp o n se
th a t m ight have ensued on the re m a in d e r of the p ro to co ls follow ing the
announcem ent, it was fe lt that the r is k was less than the p o ssib le bene
fit th a t m ight a c c ru e . We w ere unable to demand th at the e n tire group
re m a in until a ll had finished, b ecau se subjects in a ll gro u p s had other
co m m itm en ts th at n e c e s s ita te d th e ir leaving as soon a s p o ssib le. The
expectation re g a rd in g u n sc o rab le pro to co ls did m a te ria liz e in a ll
g roups. When such o c c u rre d , the subject was co ntacted e ith e r in
p e rso n o r by m a il. The n a tu re and location of the iso la te d e r r o r was
pinpointed by the In v estig a to r, and th at sheet only w as re tu rn e d to him .
A ll data sh e ets had been X eroxed b efo re re tu rn to the su b je c ts, so that
the re c o rd was av ailab le to be su re th a t no other changes beyond the
design ated one had been m ade. C om parison of a ll su ch sh eets in d i
cated that no g ratu ito u s changes had been made.
The e n tire p ro ce d u re took fro m one-half h o u r to one h o u r, with
su b jects m o re so p h isticated in te st-ta k in g generally takin g a s h o rte r
tim e .
89
S tatistical T re a tm e n t
H ypothesis I.- - T h is hypothesis concerned the adjudged n eg a
tivity of a d ise a s e as d eterm in ed by the Sem antic D ifferential. T hree
cum ulative s c o re s , based on the th re e fa c to rs of P e rs o n a l Involvem ent,
T h rea t, and Social A cceptability, and consisting of the scales c o m
p risin g the fo rm atio n of the fa c to rs , w ere en tered into th re e two-way
A nalyses of Varianfce (C lass x D isease design). D ise a se Main E ffect,
C lass M ain E ffect, and C lass by D isease In teractio n w e re exam ined in
each.
H ypothesis II.- -T h is hypothesis concerned the d eg ree of social
distance d e sire d a s a function of the d ise a se . Two s e ts of sc o re s w ere
em ployed, re p re se n tin g the two e x tre m e s of distance and affiliation.
T hese w ere e n te re d into two, tw o-w ay A nalyses of V arian ce. D isease
M ain E ffect, C lass Main E ffect, and D ise ase by C lass In teractio n were
explored.
H ypothesis III.- - T h is hypothesis concerned the re la tio n sh ip that
ex ists betw een perceiv ed negativity of a d ise ase and th e d e sire to
m ain tain social distance. P e a rs o n r c o rre la tio n s w e re com puted
betw een the Sem antic D ifferential and B ogardus Social D istance Score
1, and the Sem antic D ifferential and B ogardus Social D istance Score 2,
fo r the two d ise a se groups ra te d le a s t and m ost negatively on the
Sem antic D ifferential.
P h ase - II: M e a su re m e n t of P a tie n t
P sy ch o lo g ical Functioning
E x p e rim e n ta l D esign fo r P a tie n t P opulation
The e x p erim e n tal p ro c e d u re , to be detailed in a la te r section,
w as p e rfo rm e d on four g ro u p s, the E x p erim e n tal Group and th re e Con
tr o l G roups. The E x p e rim e n ta l G roup w as the le p ro s y sam ple. The
C ontrol G roups w ere p s o ria s is sam p le to control for the v a ria b le of
skin lesion, diabetic sam ple to co n tro l fo r the v a ria b le of chronic
d ise a s e , and flu sam ple to c o n tro l fo r the v a ria b le of illn e ss p e r se,
though not of a chronic n a tu re .
In selectio n of co n tro l p a tie n ts, no subjects w e re included who
had an o th er m a jo r illn e s s , a p sy c h ia tric h isto ry , o r an alcoholic h is
to ry . One exception to the f ir s t c r ite r io n was m a d e -- if e ld e rly sub
je c ts had h y p erten siv e o r c a rd io v a s c u la r involvem ent of not m a jo r
p ro p o rtio n , they w ere included in the sam ple. "M ajor prop ortion "
w as defined as h o sp italizatio n fo r the condition on one o r m o re o c c a
sio n s, o r control of. the pathology by continuous u se of m edication.
T his exception was p e rm itte d b e ca u se the H an sen 's D isease subjects
of advancing age freq u en tly had th e se conditions in addition to the
le p ro sy . •
The four groups w e re m atched on four additional v a ria b le s
becau se of e ith e r th e o re tic a l o r e m p iric a lly derived relev an ce to
attitude fo rm atio n and coping p a tte rn s . These w e re age, sex, m a r i
ta l sta tu s, and ethnic background.
A g e .--P sy c h o lo g ic a l stu d ies a r e innum erable which re p o rt the
effect of age on p ercep tio n s and attitude form ation. W ithin the s tre s s
p a ra d ig m it would be c o n sid e re d a c ritic a l com ponent in p rim a ry
th re a t a p p ra is a l, sp e cifica lly in the individual's a s s e s s m e n t of the
"balance of pow er " e x is tin g betw een the anticipated th re a t and his
re s o u r c e s to cope with it.
Sex. - - P sy ch o lo g ical lite ra tu re in e v ery a re a continually con
fir m s the d ifferen tial effect of th is v a ria b le on p erc ep tio n and a tti
tude. E m p iric validation of its d isc rim in ativ e function o c c u rre d in the
pilot study in which m en and w om en differed in th e ir p ercep tio n s sig
nificantly in re g a rd to the m o st c ritic a l im m ediate changes the illness
w rought in th e ir liv es, and the b ig g est problem the illn e ss had r e p r e
sented to th em over tim e .
M a rita l S tatu s.- - S t r e s s and c r is is form ulations c o n sid er the
p re s e n c e o r absence of sig nificant em otional support, p a rtic u la rly that
re n d e re d by fam ily, as a c ritic a l v a ria b le in the w ithstanding and
reso lu tio n of c r is is . L a z a ru s notes:
92
. . . any lo ss of support fro m th ese e x te rn a l re s o u rc e s in
the face of th re a t in c re a s e s the th re a t by w eakening the cap acity
of the individual to m a s te r the danger. C o nversely , any evidence
th at such su p p o rt e x ists and w ill function to w eaken the h arm fu l
im p a ct of the an ticip ated stim ulus condition will se rv e to reduce
the d eg ree of th re a t. (1966, p. 101)
In C ap lan 's (1964) fo rm u la tio n on c r is is and its reso lu tio n , he
in d icates:
. . . it is n e c e s s a r y to take into account not only the p e rso n
h im se lf, but a lso the r e a litie s of h is m ilieu and h is in te rp la y
w ith o th er people, so th at in d isc u ssin g c r is is re so lu tio n we
m u st place g re a t e m p h a sis on th is play of fo rc e s . A m an does •
not u su ally face a c r i s is alone, but is helped o r h in d ere d by
those aro und h im . T hese o p e ra te . . . to provide h im with the
knowledge and confidence to solve p ro b lem s in c e rta in acceptab le
w ays, . . . through taking co m p lem en tary ro le s which e n
co u rag e o r suppo rt h im in c e rta in lines of actio n which have been
found by h is c u ltu re . . . to be su ccessfu l m ethods of p ro b le m
solving. (p. 43)
E m p iric a lly , the pilot study rev e ale d the d ifferen tial effects produced
by th is v a ria b le on both the handling of the c ris is situation brought
about by d iag n o sis d isc lo su re and in the subsequent coping initiated.
S ev eral su b je cts who had,, a t the tim e of diagnosis d is c lo s u re , no
fam ilia l su p p o rt in the p re se n c e of spouse o r c h ild ren ad m itted to
suicidal ideation and h a lf-h e a rte d attem p t. In the evolution of coping
p a tte rn s , a tre n d which fell sh o rt of significance suggested itse lf in
the data of the M M PI. It m ight be conceptualized a s the adoption of
coping p a tte rn s a p p ro p ria te to social role: m a r r ie d su b je cts appeared
to in v est th e ir subjective com plaints m o re heavily in the contingencies
of illn e s s , to inhibit acting out and a n tiso c ia l ten d en cies to a g re a te r
d e g re e , and to be m o re se c re tiv e in d isc lo su re of d iagn osis to o th e rs .
The opposite w as found in single su bjects with no im m e d ia te fam ily to
whom they w e re re sp o n sib le . This suggested the p ossible e x iste n ce of '
th e p e rc ep tio n of the m a r r ie d ro le as one dem anding m o re resp o n sib le
and so cially a ccep tab le b eh av io r, as w ell a s one req u irin g m o re se lf-
re lia n c e and ego stre n g th . The la tte r c h a ra c te ris tic s m ig h t be in fe rre d
fro m the d iffe re n c e s in d isc lo su re p ro cliv ities on.the p a rt of m a r r ie d
a s c o m p a red w ith single subjects.
N ational B ackground.--T h e dichotom y of M exican/no n-M exican
*
w as em ployed fo r th is v a ria b le . This was req u ired b e ca u se of the
p rep o n d e ran c e of M e x ica n -A m erica n subjects in the clinic population,
and the wide ethnic d istrib u tio n of o th er clinic su b jects w hich would not
p e rm it any o th er n atio nal group sufficient in num ber fo r study. T his
v a ria b le had prov ed its d isc rim in atin g function in the pilot study. Sig
n ifican t d ifferen c e s had e m e rg e d reg a rd in g the following: p e rc ep tio n s
of childhood, p e rc e p tip n of p aren tal fig u re s, m odes of d iscip lin e, and
the consequent effect of th ese on d isc lo su re p ro cliv ities re g a rd in g the
illn e s s .
S ubjects
E x p e rim e n ta l G roup.- -T h is group (leprosy patien ts) was
obtained fro m a potential pool of approxim ately 90 p atien ts who attend
the Special D erm atolo gy Clinic (H ansen's D isease Clinic) at the United
S tates P ublic H ealth S ervice fac ility in San P e d ro , C alifornia. Selec
tio n w as r e s tr ic te d by the c rite r io n that the patient speak and rea d
E n g lish . Since the m a jo rity of the p atien ts who attend the clinic a re
fo re ig n -b o rn , m any w ere im m e d ia te ly excluded b ecau se of inability to
m e e t th is re q u ire m e n t. P a tie n ts w ere chosen s tric tly on the b a sis of
a v aila b ility , but since the d a ta -g a th e rin g covered a tw o -y e a r period
fro m 1968 to 1970, th e re w as an adequate d istrib u tio n of those seen
r a r e l y and freq u en tly at the clinic.
The clinic population c o n sisted of a p p ro x im ately 60 p ercen t or
m o re patients of M e x ica n -A m erica n background. O th er nationalities
re p re s e n te d included F ilip in o s, Ja p a n e se , Sam oans, Indians, Cubans,
and H aw aiians. T h ere w ere only five n a tiv e-b o rn , non-M exican -
A m e ric a n U. S. c itiz e n s. D ata w ere g ath ered on 34 su b je cts, but
b e ca u se of the p ro b lem s of m atching in th re e C ontrol G roups, the final
sa m p le co n sisted of 22 su b jects. Of th e s e , 12 w ere m a le and 10
fe m a le . ’ M ean age of the m a le s was 38. 9 y e a r s , of the fem a le s 41. 6
y e a r s . Of the m a le s , 10 w ere m a rr ie d , 2 w ere not m a r r ie d (single);
6 w e re of M e x ica n -A m erica n background, 6 w ere of o th e r national
b ackgrou nds. The fem ale sam ple included 7 m a r r ie d and 3 not m a r
rie d . Of the la tte r , 2 w ere widowed and 1 single. Seven w ere of
M e x ic a n -A m e ric a n background and the rem ain in g of o th er nationalities.
95
C ontrol G rou ps.--S u b je c ts in the th re e groups w ere obtained
p rin cip ally fro m the two county h o sp ita ls of Los A ngeles: USC-M edicai
C en ter and H arb o r G eneral H ospital. It had been planned to use only
subjects fro m th ese fa c ilitie s b e cau se patients attending these h o sp i
ta ls m o st clo sely ap p ro x im ated , in ethnic d istrib u tio n and socioeco
nom ic level, subjects in the E x p e rim e n ta l Group. The e n tire diabetic
group, and all but th re e su b je cts in the flu group, w e re obtained at the
county h o sp itals. The p s o ria s is group p re se n te d a prob lem , in that
the n u m b er of patients of M e x ic a n -A m e ric a n background who satisfied
a ll c rite rio n v a ria b le s was lim ite d . T h e re fo re , the Investigator con
tac te d m ed ical clinics in e a s t L os A n geles which p rim a rily served
M e x ica n -A m erica n p atien ts. P a tie n ts attending th ese clinics rougly
app ro x im ated the county h o sp ita l population's socioeconom ic level.
One m ight hypothesize a se le c tiv e fa c to r o p eratin g in the p atients'
choice of such clinics over county fa c ilitie s , since m any would be
eligible financially for the la tte r . T his would r e f e r to those in p a r
tic u la r who spoke both languages. P h y sician s who op erated these
c lin ics w ere unable to specify any p a rtic u la r m otivational c h a ra c te r is
tic s th at m ight be influencing such choice, so one m u st leave it in the
r e a lm of speculation.
96
In stru m en tatio n
M e a su re m e n t of O penness o r C losedness of B elief System s:
R okeach (i960) D o g m atism Scale (F o rm E ).-- T h is is a 4 0 -ite m scale,
the fifth rev isio n of the o rig in a l 6 6-item scale. Data on re lia b ility and
validity w ere obtained on a c ro s s -c u ltu r a l b a sis, a reg io n a l b a sis
w ithin the United S tates, v ary in g socioeconom ic and educational levels
in the c ro s s -c u ltu re sa m p le s, h o spitalized groups, re lig io u s, and
p o litical ideological sa m p le s. R eliab ilities for sam p les m o st closely
approxim ating the sa m p le s in the p re s e n t study a re re p o rte d in the
range of 0. 78 to 0 .9 3 .
Item s in the te s t p u rp o rted ly tap the following stru c tu re and
content of belief sy ste m s: 1) iso latio n within and betw een belief and
disbelief s y s te m s, and the re la tiv e d e g re e s of d ifferentiatio n of the
belief and d isb elief sy ste m s; 2) content of prim itiv e b e lie fs, such as
the n atu re of the w orld we live in, what the future h as in sto re fo r us,
the adequacy of self, what m u st be done to reliev e feelings of in ad e
quacy, identification with a c a u se , c o n c e rn for pow er and statu s;
3) the n a tu re of po sitive and negative authority; 4) the in te rre la tio n s
am ong the p rim itiv e , in te rm e d ia te , and p e rip h e ra l beliefs; 5) the tim e
p e rsp ec tiv e dim ensio n in te r m s of the individual’s se lf-o rie n ta tio n .
Subject is asked to c o n sid er a statem ent and indicate the extent
to which he a g re e s o r d is a g re e s . The choices a re a rra n g e d on a
97
six-po int L ik e rt-ty p e scale. Level of a g re e m e n t ra n g e s fro m +1 to
+3, d isa g re e m e n t fro m -1 to -3. To e ac h resp o n se a constant of +4
is added. Score is the alg eb raic sum .
M e a su re m e n t of State and T ra it Anxiety: S ta te -T ra it A nxiety
Inventory (S p e ilb e rg er, G ursuch, and Lushene*) (Appendixes B and
C ).--T h e in v e n to ry .c o n sists of two s c a le s , both labeled "Self-
A nalysis Q u e stio n n aire. " The State sc a le ask s the individual how he
fee ls a t this given m o m en t, the T ra it sc ale a sk s how he fee ls on the
ite m g en erally . R espondent ra te s h im s e lf for each q u estio n on a fo u r-
point sc ale . C a te g o rie s fo r the T ra it sc a le range fro m " a lm o st n e v e r"
to "a lm o st always".; State scale c a te g o rie s extend fro m "not at a ll" to
" v e ry m uch so. " E ach category is additive by one point, but som e of
the ite m s a re r e v e r s e d . Scoring is done by key, w hich r e v e r s e s
w eights for indicated ite m s. To the a rith m e tic sum of s c o re s , a con
stant of +50 is added fo r the State sc ale and a +10 fo r the T ra it scale.
In tern a l co n sisten c y (alpha) re lia b ilitie s a re re p o rte d fro m
0. 80 to 0. 85 fo r n o n - s tr e s s conditions and 0. 90 to 0. 95 fo r s tre s s ,
conditions. S p lit-h alf re liab ilities fo r A -S tate sc a le a re as follow s;
*C. D. S p ie lb e rg er, R. G orsuch, and R E . L ushene, "S tate-
T ra it A nxiety Inventory" (P re lim in a ry T e st M anual), unpublished,
undated m a n u s c rip t rec eiv e d in p e rso n al com m unication w ith the
se n io r auth or.
98
0. 87 m a le s , 0. 88 fem a le s; fo r A - T r a it Scale 0. 83 for m a le s and
0. 84 fo r fe m a le s.
M e a su re m e n t of F eelin g s T ow ard O n e 's Body and O n e’s Self:
Body C athexis Scale and Self C athexis Scale (Secord and Jo u ra rd ,
1953, A ppendixes D and E ).--T h e Body C athexis Scale is an inventory
of 46 body p a rts , and the Self C athexis Scale an in v en to ry of 36 p e r
so n ality tr a its o r c h ra c te ris tic s . P rin te d in stru c tio n s, identical in
f o rm a t, ap p ea r at the head of both p ro to c o ls. Subject is ask ed to
in d icate, on a fiv e-p o in t scale, how he feels about the body a r e a o r
p e rso n a lity c h a ra c te ris tic in question. Choice ra n g e s fro m a v e ry
negative feeling, through a n e u tra l position, to a m o st positive feeling.
E a c h categ o ry re p re s e n ts an additive sc o re fro m +1 to +5. F in a l
s c o re is a m ean sc o re value.
The au th o rs re p o rt sp lit-h a lf re lia b ilitie s (c o rre c te d by
S p earm an -B ro w n form ula) of 0.81 fo r B ody-C athexis and 0 .9 0 fo r Self-
C athexis. Johnson (1956) indicated t e s t - r e t e s t re lia b ility of 0. 72 for
B ody-C athexis and 0. 74 for S elf-C athexis.
P ro c e d u re
P ro c e d u re fo r E x p erim en tal and C ontrol groups w as the sam e,
. except fo r m odifications as noted h e re in . The in vestig atio n w as c a r
rie d out in a room u sually used as an exam ining ro o m of the clinic.
99
The com pletion of the te s t proto cols took one to one and one-half h o u rs,
and the tim e fa c to r was u su ally a function of the su b je c t's te st-ta k in g
sophistication . No p e rso n al in terv iew preced ed the se ssio n .
Solicitation of the subjects d iffered slightly according to group.
F o r the E x p erim en tal g roup, the E x p e rim e n te r knew m o st of the su b
je c ts fro m the e a rlie r pilot study. C h a rts w ere available fo r p r e
selectio n of subjects who would m e e t su b ject c rite r ia fo r inclusion in.
the investigation. In the Control g ro u p s, c h a rts w ere not available.
A ccordingly, the E x p e rim e n te r stationed h e rs e lf in the waiting ro o m
of the clin ic, at the tim e the clinic m e t. If an individual looked like
a likely p ro sp e c t fro m the standpoint of a potential m atch with a su b
je c t in the E x p erim en tal group, the E x p e rim e n te r m ade p re lim in a ry
contact in the waiting ro o m . Follow ing a b rie f explanation of the study
a s being an investigation of attitud es connected w ith illn e ss, the
E x p e rim e n te r questioned the subject in r e g a rd to h is eligibility on
c rite rio n v a ria b le s. F o r the p s o ria s is group, so licitatio n of subjects
w as attem p ted by le tte r, a fte r the in itial sam ple pool proved so sm all.
The E x p e rim e n te r review ed all the c h a rts a t the h o sp itals with known
p s o ria s is diagnosis. To potential su b je cts a le tte r went out under the
sig n atu re of the E x p e rim e n te r and the d ire c to r of the D erm atology
S ervice, inform ing the patient of the n a tu re of the study, setting up-a
p a rtic u la r appointm ent tim e on a re g u la r clinic day, and inviting the
100
su b je c t's cooperation (Appendix F). P o stc a rd s w ere enclosed for
acceptan ce o r reje ctio n . T his p ro ce d u re was used until all known /
possib le subjects had been contacted; following exhaustion of this pool
of su b je c ts, the contact at the p riv ate clin ics, as e a r lie r noted, was
m ade. The p ro ce d u re at th e se clinics for solicitation of sub jects p a ra
lleled th at which obtained a t the county hospital clinics;
If an individual e x p re s s e d in te re s t, following p re lim in a ry con
tac t, in taking p a rt in the p ro je c t, he w as taken to the exam ining
ro o m , w here a detailed explanation of the p ro ject w as given. This
explanation was v a rie d slightly fo r the E x p erim en tal group because
of the sophistication of the su b jects (Appendixes G and H). If the sub
je c ts a g re e d to take p a rt, te stin g began im m ediately. P ro to c o ls w ere
given in one se ssio n to c o n tro l fo r effect of situational v a ria b le s; only
the E x p e rim e n te r a d m in iste re d th em to control for effect of the ex p e
rim e n te r v ariab le. O rd e r of the te s ts was random ized, to c o n tro l for
o rd e r effects.
All in stru m e n ts had w ritte n in stru ctio n s prin ted a t the top.
Subject w as asked to re a d the in stru c tio n and if he had any question or
w as not c e rta in of the ta s k , he was encouraged to a sk the E x p erim e n ter
fo r clarificatio n . F u r th e r , he was told that if, as he went along, he
did not u n d erstan d a question, o r w as u n c ertain as to a w o rd 's m e a n
ing, he m ight a sk fo r help. While we recognized the se rio u s incursion
this m ade on valid p ro ce d u re in re g a rd to c o m p arab ility of data with
n o rm ativ e s a m p le s, we felt it a n e c e s s a ry evil. O ur p rim a ry aim was
to obtain data on psychic functioning. In stru m en ts that a re c o m p re
h en sib le to people of lim ited education and capable" of yielding the kind
of in fo rm atio n re q u ire d a re difficult to find. A ccordingly, this c o m
p ro m ise was decided upon. To m itig ate its effect, stan d ard ized sy no
nym s o r explanations w e re dev ised , and w ere uniform ly re n d e re d to
subject upon re q u e st. If the explanation of one w ord w as re q u ire d ,
s e v e ra l synonym s w ere given. If a concept needed to be explained,
only a c o n crete exam ple w as given, b ecau se it w as felt that the level
of a b stra c tio n , r a th e r than the w ords th e m se lv e s, w ere giving the d if
ficulty. Follow ing the a d m in istra tio n of each te s t, the E x p e rim e n te r
went o v e r with the sub ject those questions on the proto col which she
felt m ight be beyond the su b je c t's educational level, o r which had, with
p revious su b je c ts, freq u en tly given tro u b le. At this tim e the subject
was again encouraged to in q u ire about any o ther questions which m ight
have p re se n te d a p ro b lem . T his w as done to a s c e rta in th at a ll q u e s
tions had been sufficiently com prehended.
The subject was p e rm itte d a "b rea k " in the te s t a d m in istratio n .
T his o c c u rre d e ith e r by v irtu e of his appointm ent with the physician,
which in te rru p te d the p ro c e d u re , o r at any tim e he so requested.
It w as evident, in the solicitation of all subjects in a ll grou ps,
th at a v e ry low ra te of a ttritio n p rev ailed am ong those contacted. It
102 .
w as felt that this w as due to the context in which the study was p r e
sented . It w as p re se n te d as an a ttem p t to obtain inform ation which
would be of benefit to the phy sician in the future handling of c a s e s of
the p a rtic u la r d ise a s e . Such help to the physician would re fle c t in his
dealing with the patient. R e m a rk s lik e, "If it will help o th ers with this
d i s e a s e ,1 1 o r "If they can find out m o re about m y d ise a se . . . " w ere
h e a rd freq u en tly , su g gesting o p e ra tio n of both a ltru is tic and s e lf-
in te re s t m o tiv a to rs as influencing the notable level of cooperation
rec eiv e d .
S ta tistica l T re a tm e n t of H ypotheses
H ypotheses IV and V .- - T h e s e hypotheses re la te to the c lo s e d
n e s s of belief sy s te m s of le p ro s y su b jects and a ll o th e r patient groups
(H ypothesis IV), and th at group w hich had been evaluated le a st n e g a
tively by the g e n e ra l population (H ypothesis V). Sim ple A nalysis of
V arian ce w as p e rfo rm e d , follow ed, if indicated, by a t te s t to ev alu
ate significance of d ifferen ce betw een m ean s betw een H an sen 's D isease
groups as c o m p a red w ith a ll o th e r d ise a s e groups (H ypothesis IV) and
as co m p ared with the group le a s t negatively perceived (H ypothesis V).
H ypothesis VI.- - T h is hy p o th esis concerned the hig h er sc o re s of
H a n se n 's D ise ase g ro u p a s c o m p a red with other groups on Body-
C athexis and S elf-C athexis S cales. A Simple A nalysis of V ariance
103
was done on both Body- and S elf-C ath ex is S cales, followed by a t test
if n e c e ssa ry , to d e te rm in e if th e re w ere any significant differences
between m ea n s.
H ypothesis V II.- - T h is concerned the posited significant r e l a
tionship existing in each m e d ic a l group betw een feelings tow ard body
and feelings tow ard self. P e a rs o n p ro d u ct-m o m en t c o rre la tio n s were
computed betw een B ody-C athexis and Self-C athexis Scales in both E x
perim en tal and Control gro u p s and d eterm in atio n was m ade of signifi
cance of the obtained c o rre la tio n .
H ypothesis VIII.- -T h is hypothesis w as concern ed with: anxiety
level in H a n se n 's D isease gfroup as opposed to C ontrol groups; and
relatio nship betw een anxiety level and feelings tow ard body and self.
1) A Simple A naly sis of V a ria n ce , followed by a t te s t, if indicated,
was p erfo rm ed to te s t fo r significance of difference betw een m eans of
leprosy group and each of the o th er d ise a se groups; 2) P e a rs o n
product-m om ent c o rre la tio n s fo r both E x p erim en tal and Control groups
w ere com puted to d eterm in e rela tio n sh ip betw een a) b ody-cathexis and
state-an x iety , b) b o dy-cathexis and tra it-a n x ie ty , c) se lf-c a th e x is and
state-anxiety, and d) se lf-c a th e x is and tra it-a n x ie ty .
H ypothesis IX.--H y p o th esis IX concerned the rela tio n sh ip
existing betw een openness of o n e 's belief sy stem and feelings tow ard
o n e 's body and o n e 's self. P e a rs o n p ro d u ct-m o m en t c o rre la tio n s
w e re obtained betw een 1) sc o re on dog m atism scale and sco re on ;
I
b o d y -cath ex is sc a le , and 2) sc o re on d ogm atism scale and sc o re on
se lf-c a th e x is sc ale . D eterm in atio n of level of significance of obtained'
c o rre la tio n s w as m ade.
i
1
!
E quipm ent U s e d .--A ll A n alyses of V ariance w e re c a rr ie d out :
i
on the G en eral E le c tric T im e-S h arin g C om puter System #265. The |
specific p ro g ra m used w as the M ultiple A nalysis of V ariance P ro g ra m s
M. A. N. V. 3$***. ' P e a rs o n p ro d u ct-m o m en t c o rre la tio n s and t te s ts i
w e re done on the O livetti P ro g ra m m a M odel #101.
C H A PT E R V
RESU LTS
A s s e s s m e n t of C om m unity A ttitudes T ow ard D isease
A nalysis of V ariance w as se le c te d as the a p p ro p ria te sta tistic a l
te s t of the significance of the d ifferen ce in social c la s s attitudes and
the need for so cial d istan ce, in re fe re n c e to the v ario u s disease e n ti
tie s. Individual a n a ly sis of the th re e chosen fa c to rs on the Sem antic
D ifferential fo r H ealth w as p e rfo rm e d b ecau se in Je n k in s' (1968) study
in w hich the fa c to rs had been d e riv e d , they had e m e rg ed as th ree of
the fo u r p rin cip al axes accounting f o r the com m on fa c to r v ariance in
the c o rre la tio n m a trix and had re m a in e d rela tiv e ly unchanged in the
orthogonally ro ta te d solutions, thus supporting the notion of th eir
re la tiv e independence.
L indquist (1953, p. 72) points out that the assum ptions u n d e r
lying the F te s t re q u ire th at groups be draw n fro m the sam e p aren t
population, the v a ria n ce fo r c rite r io n m e a s u re s be the sam e fo r each
group, the d istrib u tio n of the c rite rio n m e a s u re s be n o rm al, and (the
null hypothesis) the m ean of the c rite rio n m e a s u re s be the sam e fo r
each group. In the a n aly sis of v a ria n c e fo r the th re e fac to rs derived
105
fro m the Sem antic D ifferential, the f i r s t th ree a ssu m p tio n s a r e m et,
a s illu stra te d by the c o m p a rab ility of the stan dard deviations fo r group
m ea n s liste d in the resp e c tiv e ta b le s. On the B ogardus Social D istance "
m e a s u r e s , the v a ria n ce fo r the diabetic group d iffers significantly
fro m the o th er d ise ase group s. Inspection of the d istrib u tio n s'o f
Social D istance s c o re s re v e a ls th a t the attitudes e x p re ss e d by the
so cial c la s s e s a re co n sisten t and n o n -v ary in g ,th at they a re n o n -n o rm al
in d istrib u tio n , resu ltin g in m in im a l v arian ce fo r the attitude tow ard
d iab etes. B ecause the e x p re ss e d attitud e of the r a t e r s is so c o n s is
tent, one can only conclude that this re p re s e n ts th e ir opinion tow ard
the d ise a se as fa r a s need for so c ia l distance is concerned. H ence,
any difference in m ea n s betw een d iab etes and o th e r d ise a se groups
r e p re s e n ts a tru e difference in a ttitu d e s, despite lack of v a ria n ce . In
L in q u ist's (1953, pp. 78-90) rev iew of the N orton stu d ies, he c o n
cludes th at "even with violent d e p a rtu re fro m the th e o re tic a l r e q u ir e
m en ts re p re se n te d in this fo u rth p hase of the study, the F d istributions
still re p re s e n t a fa irly good fit to the n o rm a l-th e o ry d istrib u tio n . "
Since in the two a n a ly se s (B ogardus Social D istance Scale, Score 1 and
Score 2) the attitude is so c o n sisten t th at no value would a c c ru e fro m
an effo rt to tra n s fo rm the data to a n o rm aliz e d d istrib u tio n , and since
the m ean d ifferen ces a re so g re a t betw een H ansen's D ise ase and d ia
b e te s, the fo rm e r being the m ain focus of the study, the findings m ay
be accepted as tru e differen ces in attitu d e.
L indquist (1953, p. 93) fu rth e r suggests that when significant
F ra tio s a r e obtained, if the tre a tm e n t groups a re of the sam e size for
each m ain effect (D isease G roup and Social C lass), and the v a ria n ce s
a re hom ogeneous, r a th e r than com pute t fo r significant d ifferen ces
one m ay com pute a " c ritic a l d ifferen ce" according to the following
form u la:
w here
t = value of t sig nificant a t the selected lev el fo r
the given d e g re e s of free d o m
m s = m ean sq u a re w ithin groups (residu al v a ria n ce )
n = n u m b er of su b jects in each group
He in d icates that when the conditions fo r u se of a d a s specified a re
m e t, it is u n n e c e ssa ry to com pute t, since the additional lab o r offers
no im p ro v em en t in p red ictio n o r in reductio n in e r r o r . Follow ing
com putation of d at c ritic a l lev e ls (0.05 and 0.01 p e rc en t), one m ay
then re p o rt any values exceeding the d value as significant a t the
stated lev el. *
L indquist sug gests in the c ase of heterogeneous v a ria n c e s , the
t te s t fo rm u la be used a s given below:
d = t I 2m s
108
t =
M1 - M2
2 2
Sum d, Sum d~
1 + *
a l < nl - l) n 2
In a ll c a s e s , the c ritic a l difference fo rm u la was u sed . In the specific
B ogardus Social D istance Scale c a s e s cited , a t was com puted. Since
th is did not re s u lt in differences in significance fro m those com puted
by the d, they w ere not em ployed in the study.
T e st of H ypothesis I
H ypothesis I stated that in re g a rd to g e n e ra l b eliefs about
d ise a s e , H an sen 's D isease would be evaluated in a significantly m o re
negative m a n n e r than any o th e r d ise a se group s. The negativity w as
d ete rm in e d by selected sc a le s on the Sem antic D ifferen tial fo r H ealth
th at had e m e rg ed as th re e fa c to rs in Je n k in s' (1968) study. T hese
w ere:
P e rso n a l Involvem ent
Scale A: A lm ost nobody gets it . . . to . . . m any people
get it.
Scale E: Chance you have of getting it:
No chance . . . to . . . big chance.
Scale O: Often talked about . . . to . . . n e v er talked about.
Scale L: I think about it often . . . to . . . I n ev er think
about it.
109
T h re a t
Scale D: C auses v e ry little d isco m fo rt . . . to . . . is
e x tre m e ly painful.
Scale F : R a re ly c au se s death . . . to . . . u su a lly cau se s
death.
Scale J:- A m ild d ise a se . . . to . . . a pow erful d ise a se .
Social A ccep tability
Scale G: C lean . . . to . . . d irty .
Scale P: P ro u d . . . to . . . d isg ra ce d .
The fa c to rs of P e rs o n a l Involvem ent and Social A ccep tab ility had
a p p eared a c r o s s d ise a s e s. In the c ase of c a n c e r, P e rs o n a l Involve
m ent had linked as a doublet with the T h re a t Scales a s defined in the
p re s e n t study, and gave a c le a r- c u t T h re a t fa c to r on th a t d ise a s e .
Since an unam biguous T h re a t fa c to r did not e m e rg e in the o th er two
d is e a s e s , the P e rs o n a l Involvem ent fa c to r ap p eared to be the only one
capable of c a rry in g any sem an tic evaluation of r is k o r danger, and
hen ce negativity in th e se d ise a s e s. F o r th is re a so n , and b ecau se of
its c o n sisten t ap p earan ce a c ro s s d ise a s e s in the o rig in a l study, it was
included in the p re s e n t study, a s potentially being capable of connoting
negativity.
The A nalysis of V ariance of the P e rs o n a l Involvem ent fa c to r
(Table 1) indicated highly significant d ifferen ces in both m ain effects.
The F R atio fo r D isease G roups was 95.223, significant beyond the
TA BLE 1
TWO-WAY ANALYSIS O F VARIANCE: SEM ANTIC D IF F E R E N T IA L ,
PERSO N A L INVOLVEM ENT FA C TO R
Source Sum of Squares
D egrees of
F re e d o m M ean Square F Ratio Significance
M ain E ffect
(D isease)
8130.29
3 2710.10 95.22 0.001
M ain E ffect
(Social C lass)
264.96 2 132.48 4. 66 0.01
Interaction
(D isease by Social C lass)
278.71 6 46. 45 1.63 NS
R esidual 9904.27 348 28.46
Total 18578.22
359 359
HI
0.001 level; th at of Social C lass 4.655, significant beyond the 0.01
lev el of confidence. Interaction effects w ere not significant.
E xam ination of c ritic a l differences betw een the m e a n s fo r
D ise ase G roups (Table 2) showed that e v ery d ise ase significantly d if
fe re d fro m e v ery other d isease in te r m s of resp o n d e n ts' feelin g s of
p o ssib le p e rso n al involvem ent with the p a rtic u la r d ise a s e ; a ll d iffe r
e n ce s w e re beyond the 0. 01 level. In terestin g ly , the o rd e rin g of the
d is e a s e s along the dim ensions of involvem ent w as a s follow s: flu,
d ia b e te s, p s o r ia s is , and H an sen's D isease. One would conclude th at
H a n se n 's D isease w as the le a st negatively p erceiv ed if the fa c to r in
the p re s e n t study actually c a r r ie s a tru ly negative valence. The q u e s
tion w ill be co n sid ered fu rth e r in the section in w hich H ypothesis HI is
d isc u sse d .
The c ritic a l differences betw een m eans of the Social C lass
M ain E ffect (Table 3) rev ealed a significant difference only betw een
the U pper Socioeconom ic and Lower Socioeconom ic g ro u p s, th is a t the
0. 01 level. D ifferences betw een Upper Socioeconom ic and M ed ical-
P a ra m e d ic a l groups fell ju st short of significance (d = 1. 13; the d
re q u ire d fo r an 0. 05 p ercen t level is 1. 36). The o rd e rin g of the-
groups in th e ir perception of becom ing involved with a given d is e a s e ,
ranging fro m low to high involvem ent, was: U pper C la s s, M ed ical-
P a ra m e d ic a l, L ow er C lass.
112
TA BLE 2
CRITICAL DIFFEREN CES BETW EEN MEANS:
SEMANTIC D IFFER EN TIA L, PERSONAL INVOLVEMENT FACTOR
DISEASE GROUP E F F E C T
(N = 90)
H a n se n 's D isease D iabetes P s o ria s is
D iabetes
a
9.83
P s o r ia s is
a
5. 78 4 .0 5 a
F lu 12. 64a 2. 8 l a 6 .8 6 a
M eans and Standard D eviations
H an sen 's D isease D iabetes P s o r ia s is F lu
M ean 13. 66 23.49 19.4 4 26. 30
S tandard ±5. 44 ±5. 63 ±5. 29 ±5. 56
D eviation
a d = 2. 056 fo r 0. 01 percen t.
113
TABLE 3
CRITICAL D IFFEREN CES BETW EEN MEANS:
SEMANTIC D IFFE R EN TIA L, PERSONAL INVOLVEM ENT FACTOR
SOCIAL CLASS E F F E C T
(N = 90)
M edical-
P a ra m e d ic a l
U pper
Socioeconom ic
L ow er
Socioeconom ic
U pper Socioeconom ic 1. 12
L ow er Socioeconom ic 0.98 2. 10a
M eans and Standard D eviations
1
M ean 20. 77 19. 65 21.7 5
Standard D eviation ±5.05 ±5. 87 ± 5.47
ad = 1. 781 at 0. 01 percent.
114
A n aly sis of V ariance of the T h re a t F a c to r (T able 4) yielded
highly significant re s u lts for both M ain E ffe cts, but not fo r Interaction.
The F Ratio for D isease G roups was 81. 742 and fo r Social C lass
16.845, both significant beyond the 0.001 level.
E x am ination of the c ritic a l d ifferen ces betw een m e a n s of
D isease G roups (Table 5) showed th at each d ise a se d iffered fro m e v ery
o ther d ise a se a t the 0. 01 level. This m eant that th r e a t potential
in c re a s e d in significant in crem en ts fro m the low on p s o r ia s is through
flu and d iab e te s, to lep rosy.
The c ritic a l d ifferen ces betw een m eans on the M ain E ffect of
Social C lass (Table 6) gave two out of th re e significant d ifferen c e s
betw een c la s s e s at the* 0. 01 level of confidence. T hese o c c u rre d when
the L ow er Socioeconom ic groups differed fro m both U pper Socio
econom ic and M e d ic a l-P a ra m e d ic a l groups in p erceiv in g the d ise a se s
as being m o re threatening. The la tte r two did not differ significantly
fro m one another.
A n aly sis of V ariance of the Social A ccep tability F a c to r (Table
7) yielded highly significant M ain E ffects but n o n -sig n ific an t I n te r
action. The F Ratio for D isease G roups w as 50. 799, sig nificant at the
0.001 lev el, as was the F Ratio for Social C la ss, w ith a value of
12.379-
TA B LE 4
TWO-WAY ANALYSIS O F VARIANCE: SEM ANTIC D IF F E R E N T IA L , TH REA T FA C TO R
Source Sum of Squares
D eg rees of
F re e d o m M ean Square F Ratio Significance
M ain E ffect
(D isease)
7330.02 3 2443.34 81.74 0. 001
M ain E ffect
(Social C lass)
1007.04 2 503. 52 16.85 0. 001
Interaction
(D isease by Social C lass)
136.89 6 22. 82 0. 76 NS
R esidual 10402.00 348
29.89
Total 18875.96 359
116
TABLE 5
CRITICAL D IFFER EN C ES BETW EEN MEANS:
SEMANTIC D IFFE R EN TIA L, THREAT FA CTO R,
DISEASE GROUP E F F E C T
(N = 90)
H a n se n 's D isease D iabetes P s o r ia s is
D iabetes 6. 39a
P s o ria s is 1 2 .39a
r-
5. 99
F lu 8. 79a
_ . _ 3 .
2. 40
_ _ 2t
3. 59
i
M eans and Standard D eviations
H a n se n 's D isease D iabetes P s o r ia s is F lu
M eans 24. 68 18.29 12.30 15. 89
Standard ±5. 92 ±5.01 ±4.73 ±6. 13
ad = 2. 108 for 0. 01 percent
117
TABLE 6
CRITICAL D IFFEREN CES BETW EEN MEANS:
SEMANTIC D IFFER EN TIA L, THREAT FA CTO R.
SOCIAL CLASS E F F E C T
(N = 90)
M edical-
P a ra m e d ic a l
U pper
Socioeconom ic
L ow er
Socioeconom ic
U pper Socioeconom ic 0 .6 4
• .
L ow er Socioeconom ic 3 .8 3 a 3. 19a
M eans and Standard D eviations
M ean
16. 30 16. 94 20. 13
Standard D eviation ±5. 53
±4.89 ± 5.95
ad = 1. 825 for 0.01 percent.
TA BLE 7
TWO-WAY ANALYSIS O F VARIANCE: SEM ANTIC D IF F E R E N T IA L ,
SOCIAL A C C E PT A B IL IT Y FA C TO R
Source Sum of Squares
D egrees of
F re e d o m M ean Square F Ratio Significance
M ain E ffect
(D isease)
6402.72 3 2134. 24 50.80 0.001
M ain E ffect
(Social C lass)
1040.16 2 520.08 12.38 0. 001
Interaction
(D isease by Social C lass)
235.69 6 39.28 0 .9 4 NS
R esidual 14620.77 348 42.01
Total 22299.33
359
0 0
119
T his fa c to r w as highly d iscrim in atin g on both Main E ffects, as
indicated by c ritic a l d ifferen ces betw een m eans for both D isease
G roups and Social C lass. C ritic a l d ifferences for D isease groups
(Table 8) d ifferen tiated e v e ry d ise ase fro m e v ery o th er at the 0.01
level. The so cial accep tab ility a sp ect of a d ise a se , ranging fro m m ost
to le a s t a cc ep tab le , w as: d iab etes, flu, p s o ria s is , H an sen 's D isease.
The d ifferen c e s betw een Social C lasses on this fac to r a re given
in T able 9. Both U pper Socioeconom ic and M e d ic a l-P a ra m e d ic a l
groups d iffered fro m the L ow er Socioeconomic group a t the 0. 01 level
of sign ificance, and fro m each o th er a t the 0.05 level. A ssignm ent of
a Social A cceptability designation to the resp ec tiv e illn e s s e s , fro m
le a st accep table to m o st acceptable was as follows: L ow er Socio
econom ic, M e d ic a l-P a ra m e d ic a l, Upper Socioeconom ic.
S u m m arizin g , the hypothesis stating that in te r m s of g e n eral
b eliefs, le p ro sy would be the m o st negatively evaluated d ise a se was
con firm ed. The one exception w as the P e rso n a l Involvem ent fa c to r,
in which su b jects saw th e m se lv e s a s being possibly le a s t involved with
H a n se n 's D ise a se in te r m s of e ith e r contagion o r salien ce in thought
and discu ssio n . The L ow er Socioeconom ic group c o n sisten tly ra te d
d ise ase en tities in a m o re negative fashion. Lack of significant in te r
action in any of the a n aly se s of variance c le a rly indicated that no unique
p ercep tio n s of p e rso n a l involvem ent, th re a t, o r so cial acceptability
V
120
TABLE 8
CRITICAL D IFFEREN CES BETW EEN MEANS:
SEMANTIC D IFFER EN TIA L, SOCIAL A C C E PTA B IL IT Y
FA CTO R, DISEASE GROUP E F F E C T (N = 90)
H a n se n 's D isease D iabetes P s o r ia s is
D iabetes 11. 41a
P s o r ia s is 5. 36a 6. 05a
F lu C O
•
o
3. 00a 3. 05a
M eans and Standard D eviations
H a n se n 's D isease D iabetes P s o r ia s i s - . F lu
M eans 25.93 14. 52 • 20. 57 17. 52
Standard
D eviation
± 7.37 ±6. 26 ±7. 20 ±5.86
a d = 2. 473 fo r 0. 01 p e rc en t.
121
TABLE 9
CRITICAL D IFFEREN CES BETW EEN MEANS:
SEMANTIC D IFFER EN TIA L, SOCIAL A C C E PT A B IL IT Y
FA CTO R, SOCIAL CLASS E F F E C T (N = 90)
M edical
P a ra m e d ic a l
U pper
Socioeconom ic
L ow er
Socioeconom ic
U pper Socioeconom ic 1.78a
L ow er Socioeconom ic 2 .3 7 b 4. 15b
•
M eans and Standard D eviations: Social C la s s
M ean 19 . 44 17.66 21.81
S tan dard D eviation ±7. 58 ±6.95 ± 8.54
St
d a t 0. 05 p ercen t = = 1. 648
b
d at 0. 01 p e rc en t = : 2. 142
•
122
a r e re la te d to so cial c la s s , o r train in g and education, as should be
m o s t n o tic ea b le, if e x iste n t, p rim a rily in the M e d ic a l-P a ra m e d ic a l,
and se c o n d a rily in the U pper Socioeconom ic Group.
T e s t of H ypothesis II
H e re in was prop osed th at le p ro sy would be the d is e a s e fro m
w hich people would d e s ire to m aintain the g re a te s t s o c ia l d ista n c e .
Tw o-w ay A n aly sis of V ariance of the B ogardus Social D istance
Scale w as p e rfo rm e d on each of the two sc o re s: the f i r s t s c o re in d i
c ated the d e g re e of c lo s e n e ss o r affiliation p e rm itte d to an individual
who had a given d ise a s e (B ogardus Social D istance Scale S core No. 1);
th e second re p re s e n te d the opposite end of the sc o rin g continuum , and
w as in te rp re te d as the d eg ree of disaffiliation the su b ject d e s ire d to
have in re g a rd to a p atien t who had a p a rtic u la r d is e a s e (B ogardus
S ocial D istance Scale Score No. 2).
A n a ly sis of V arian ce of Scale No. 1 showed highly sig n ifican t
M ain E ffe cts of both v a ria b le s (Table 10). The F R atio fo r D ise a se
G roups w as 69. 849» significant beyond the 0.001 le v e l, and th a t of
Social C lass was 6. 170, significant a t the 0. 005 lev el. In te ra c tio n
proved n o n -sig n ifican t.
C ritic a l d ifferen ce findings fo r the M ain E ffect of D ise a se
G roup (T able 11) d e m o n stra te d that p ercep tio n of le p ro s y d iffered fro m
the p e rc e p tio n of e v e ry o th er d ise ase at the 0.01 lev e l, the ra tin g
TABLE 10
TWO-WAY ANALYSIS OF VARIANCE: BOGARDUS SOCIAL DISTANCE SCALE
(SCORE NO. 1 AFFILIATION SCORE)
Source Sum of Squares
D eg rees of
F re e d o m M ean Square F Ratio Significance
M ain E ffect
(D isease)
388.96 3 129.66 69.85 0. 001
M ain E ffect
(Social C lass)
22.91
2 11.45 6. 17 0.005
Interaction
(D isease by Social C lass)
15.83 6 2. 64 • 1.42 NS
R esidual 645.97 348 1.86
Total 1073.66 359
124
TA BLE 11
D IFFE R EN C ES BETW EEN MEANS:
BOGARDUS SOCIAL DISTANCE SCALE (1),
DISEASE GROUP E F F E C T (N = 90)
H a n se n 's D ise a se D iabetes P s o ria s is
D iabetes
> »
2 .4 5 a
P s o r ia s is 2 .0 6 a 0. 39
F lu 2. 58a 0. 13 0.52b
M eans and Standard D eviations
H a n se n 's D isease D iabetes P s o r ia s is F lu
M ean 3. 99 1. 54 1.93 1.41
Standard
D eviation
± 1 .9 9 . ±0. 64 ± 1.26 ±1. 14
a d = 0.534 for 0. 01 p e rc en t,
d = 0. 404 for 0. 05 p e rc en t.
125
su b jects d e sirin g le a s t affiliation with H ansen's D ise ase p a tie n ts. In
c o n tra st, only one o th e r in te r-d is e a s e co m p ariso n yielded a d ifference
significant at the 0. 05 level; th is o c c u rre d betw een p s o r ia s is and flu.
R espondents d e s ire d a g re a te r affiliation with flu p atien ts a s co m p ared
to p s o r ia s is .
The Social C la ss v ariab le yielded two out of th re e c r itic a l dif
fe re n c e c o m p a riso n s (Table 12), both a t the 0.01 lev el. Both U pper
Socioeconom ic and M e d ic a l-P a ra m e d ic a l would p e rm it a significantly
g r e a te r d e g re e of affiliation than would the Low er Socioeconom ic
group a c r o s s d is e a s e s .
The A nalysis of the Score 2 (D isaffiliation Score) showed s ig
nificant M ain E ffects but non-significant Interaction. (Table 13). The
F R atio fo r D ise ase groups reach ed 20. 859, significant a t 0. 001 level;
fo r th at of Social C lass the finding was 3.900, significant a t the 0.025
level of confidence.
C ritic a l differences betw een m eans showed th at the only s ig
nificant d ifferen ces o c c u rre d , and all a t the 0. 01 lev e l, when le p ro sy
w as co m p ared with each of the o th e rs (Table 14). R espondents thus
adm itted to w ishing a g re a te r degree of disaffiliation when H a n se n 's
D isease was c o n tra ste d with o th er d is e a s e s , but not n e c e s s a r ily
req u irin g significantly different disaffiliation when the o th e r d ise a s e s
w ere co m p ared with each oth er. P s o r ia s is was ra te d a fte r H a n se n 's
D isease on both affiliation and disaffiliation dim ensions.
126
TABLE 12
D IFFE R EN C ES BETW EEN MEANS:
BOGARDUS SOCIAL DISTANCE SCALE (1),
SOCIAL CLASS E F F E C T (N = 90)
»
M edical-
P a ra m e d ic a l
U pper Low er
Socioeconom ic Socioeconomic
U pper Socioeconom ic 0 .0 5
L ow er Socioeconom ic 0. 56a 0. 51a
M eans and S tandard Deviations: Social C la s s
M ean 2. 02 2 .0 7 2 .5 8
Standard Deviation ±1.23 ± 1.07 ±1.67
a d a t 0. 01 p e rc e n t = 0. 460.
TABLE 13
TWO-WAY ANALYSIS OF VARIANCE: BOGARDUS SOCIAL DISTANCE SCALE
(SCORE NO. 2 DISAFFILIATION SCORE)
Source Sum of Squares
D egrees of
F re e d o m M ean Square F Ratio Significance
M ain E ffect
(D isease)
68.23 3 22. 74 20.86 0.001
M ain E ffect
(Social C lass)
8. 51 2 4.25 3.90 0. 025
Interaction
(D isease by Social C lass)
13.36 6 2.23 2. 04 NS
R esidual 379.43 348
1.09
•
Total 469.53 359
tv
128
TA BLE 14
D IFFE R E N C E S BETW EEN MEANS:
BOGARDUS SOCIAL DISTANCE SCALE (2),
DISEASE GROUP E F F E C T (N = 90)
H a n se n 's D ise ase D iabetes P s o r ia s is
D iabetes i. ioa
P s o r ia s is 0.8 8a 0.22
F lu
0.99a
0.11 0.11
M eans and Standard D eviations
H a n se n 's D ise ase D iabetes P s o r ia s is F lu
M ean 5. 28 4. 18 4. 40 4. 29
S tandard
D eviation
±1.45 ±0. 69 ±0. 84 ±0. 98
a d = 0. 409 fo r 0. 01 p e rc e n t.
129
• The Social C lass E ffect on D isaffiliation (T able 15) p re se n te d
only one significant co m p a riso n . Low er and U pper Socioeconom ic
groups re q u ire d a significantly different (0. 01 level) d e g re e of
disaffiliation.
S um m arizing , H ypothesis II was confirm ed. L e p ro sy was
singled out as the only d ise a s e fro m which r a te r s would d e s ire s ig
nifican tly g r e a te r so cial d istan c e, as m e a su re d by c r ite r io n sc o re s
of both affiliation and disaffiliation. The Lower Socioeconom ic group
dem anded the g re a te s t am ount of so cial distance, a s shown by th re e
out of fo u r significant c o m p ariso n s with the other two c la s s e s . Upper
Socioeconom ic and M e d ic a l-P a ra m e d ic a l groups did not d iffer fro m
each o th e r to a significant d eg ree on the degree of so c ial d istan ce
w hich they d e sire d .
T est of H ypothesis III
T his hypothesis proposed a significant re la tio n sh ip betw een
adjudged negativity of a d ise a se and the d e sire to m ain tain so cial d is
tan ce in those two groups evaluated le a st and m ost negatively. In the
fo rm u la tio n of th is hy p o th esis, it was anticipated th at by a m ethod of
e ith e r ra n k -o rd e rin g o r the obtaining of an av erag e m ean d ifferen c e ,
one d ise a s e would e m e rg e as m o st negatively, and a n o th er a s le a st
n egatively p erceived. L ep ro sy was m o st negatively p e rc e iv e d , but
n e ith e r m ethod produced a le a st negatively rated d ise a s e . T h e re fo re ,
130
TABLE 15
D IFFE R EN C ES BETW EEN MEANS:
BOGARDUS SOCIAL DISTANCE SCALE (2)
SOCIAL CLASS E F F E C T (N = 90)
M ed ical-
P a ra m e d ic a l
U pper
Socioeconom ic
L o w er
Socioeconom ic
U pper Socioeconom ic 0 .1 6
•
L ow er Socioeconom ic 0.21 0. 37a
M eans and Standard D eviations
M ean 4. 52 4. 36 4. 73
S tandard D eviation ±1. 16 ±0. 85 ± 1 .0 6
a d = 0.352 for 0.01 p e rc en t.
131
a cum ulative s c o re , re p re se n tin g the sum of the d ifferen ce betw een
the sc o re of each d ise a s e v is - a -v is H an sen 's D isease on the T h re a t
and Social A cceptability F a c to r s , w as obtained. By th is m ethod, the
flu group was le a s t n egatively perceived. The P e rs o n a l Involvem ent
F a c to r was not included. A s noted in H ypothesis I, the ra n k -o rd e r
r e v e r s a ls that had e m e rg e d on this fa c to r, as opposed to the d ir e c
tio n al tren d evident on the o ther two, suggested that in the p re se n t
study this fa c to r did not b e a r the anticipated negative connotation, as
did the o th er two fa c to rs.
F u r th e r support fo r th is p re m ise was d em o n strated in Hypoth
e s is III. The P e a rs o n p ro d u c t-m o m e n t c o rre latio n s betw een the
Sem antic D ifferential F a c to r s and the B ogardus Social D istance
S co res No. 1 (Affiliation) and No. 2 (Disaffiliation) a re given in Tables
16 and 17. On the A ffiliative dim ension, the proposed relatio n sh ip
o c c u rre d with both the T h re a t and Social A cceptability F a c to r s - - f o r
the H a n se n 's D isease group, the c o rre la tio n reached a significant level
of 0 .0 1 p e rc e n t, and the flu group, 0 .0 5 percent. No, o r an in sig n ifi
cant rela tio n sh ip , ho w ev er, o c c u rre d on the P e rso n a l Involvem ent
F a c to r. On the D isaffiliative S core, the c o rre latio n s reach ed a p ro b
ably significant level (0.05 percent) with the H ansen's D isease group,
w hile not d e m o n stra tin g a significant rela tio n in the flu group. The
lack of v a ria b ility exhibited on th is disaffiliative dim ension probably
132
TABLE 16
PEARSON PRODUCT-M OM ENT CORRELATION:
SEMANTIC D IFFE R EN TIA L FACTORS AND
BOGARDUS SOCIAL DISTANCE SCALE NO. 1
(AFFILIATION SCORE)
P e rs o n a l
Involvem ent T hreat
Social
A cceptability
H an sen 's D isease 0 .00 0 0 . 302b 0 .2 7 b
F lu 0.042 0. 206a 0. 2 i a
a r fo r 0. 05 p e rc e n t = 0. 205 fo r 89 df
b _
b r fo r 0. 01 p e rc e n t = 0. 270 fo r 89 df
TABLE 17
PEARSON PRODUCT-M OM ENT CORRELATION:
SEMANTIC D IFFE R E N T IA L FACTORS AND
BOGARDUS SOCIAL DISTANCE SCALE NO. 2
(DISAFFILIATION SCORE)
P e rs o n a l
Involvem ent - T hreat
Social
A cceptability
H an sen 's D isease 0. 133 0 . 265a 0. 210a
F lu 0 .0 2 6 0.060 0. 130
a r for 0. 05 p e rc en t = 0. 205 for 89 df
133
did n o t'p e rm it the covariation re q u ire d fo r the e sta b lis h m e n t of the
significant c o rre la tio n . One would conclude fro m the re s u lts that the
hypothesis rec eiv e d strong support. People tend to o rd e r th e ir
behavior tow ard a given d ise a s e m o re strongly in te r m s of an
e x tre m e ly negative evaluation and som ew hat le s s stro n g ly when an
illn e ss is perceiv ed in a c o m p a rativ ely benign fash io n . The v a r ia
bility is m o re evidenced on a dim ension of affiliation p e rm itte d , as c o m
p a re d with the disaffiliation re q u ire d .
A s se ssm e n t of P atien t Functioning
T e st of H ypotheses IV and V
The f ir s t of these hypotheses p redicted th a t le p ro s y subjects
would d e m o n stra te a significantly m o re clo sed b elief sy ste m than
patien ts of o th er m ed ical groups. The second p ro p o se d th a t those two
patient groups which had been evaluated by the com m unity in the le a st
and m o st negative fashion would d em o n strate a significant d ifference
betw een the openness and clo sed n ess of th e ir re s p e c tiv e belief sy s-
• terns v is - a -v is each o th er. It was fu rth e r proposed th a t H a n se n 's
D isease would be th at group m o st negatively evaluated. To te s t both
of th ese hypotheses a one-w ay A nalysis of V arian ce w as p erfo rm ed
on the D ogm atism Scale S co res (Table 18). The B etw een G roups
effect yielded an insignificant F Ratio of 1.038. T h e re fo re , no
TABLE 18
ONE-WAY ANALYSIS OF VARIANCE: DOGMATISM SCALE (N = 88)
Source Sum of Squares
D eg rees of
F re e d o m M ean Square ■ F Ratio Significance
Betw een G roups
(D isease) •
3571.12 3 1190.38 1. 04 NS
R esidual
(Within Groups)
96371.86 84 1147.28
T otal 99942.99 87
■
M eans and Standard D eviations
- H an sen 's D isease D iabetes P s o ria s is F lu
M eans
Standard Deviation
, 186.00
± 29. 79 •
118. 50
±32. 62
173. 64
±34. 15
175. 82
±39. 61
135
significant d ifferen ces betw een groups obtained, and H ypotheses IV
and V w ere not supported.
T est of H ypothesis VI
It was proposed that le p ro sy subjects would d e m o n stra te a
significantly m o re positive body cathexis and se lf-c a th e x is than sub
je c ts in o th er m ed ical groups. S cores on the Body-C athexis Scale and
S elf-C athexis Scale w ere e n te re d into two one-w ay A n aly sis of V a ri
ance (T ables 19 and 20). The F Ratio fo r the Body C athexis Scale was
1. 081 and that fo r S elf-C athexis w as 0. 167, both indicating th at no •
significan t d ifferen ces betw een groups ex isted , as m e a s u re d by th ese
sc a le s. H ypothesis VI was not con firm ed.
T est of H ypothesis VII
T his p ro p o sal stated th at a significant re la tio n sh ip would obtain
betw een the way a p e rso n fe e ls about his body and the way he feels
about him self. P e a rs o n p ro d u ct-m o m e n t c o rre la tio n s of the sc o re s of
Body and S elf-C athexis Scales d em o n stra te d the p ro posed positive
rela tio n sh ip at significant lev e ls (Table 21). The H a n se n 's D isease
group showed a c o rre la tio n of 0. 758; the diabetes group yielded one of
0. 531; the flu group c o rre la tio n w as 0. 652. All w e re significant beyond
the 0. 01 level of confidence. The stre n g th of the c o rre la tio n lie s in a
range considered m o d e ra te , indicating a substantial rela tio n sh ip
TABLE 19
ONE-WAY ANALYSIS OF VARIANCE: BODY-CATHEXIS SCALE (N = 88)
Source Sum of Squares
D egrees of
F re e d o m M ean Square F Ratio Significance
Betw een Groups
(D isease)
0.86 3
0.29 1.08 NS
R esidual
(Within Groups)
22.20 84 0.26
i
: Total
i
23.06 87
J
I
M eans and Standard D eviations
-
-
H a n se n 's D isease D iabetes P s o ria s is F lu
M eans 3.29 3.02 . 3 .1 4 3.09
:Standard D eviation ± 0 .6 0 ±0. 53 ± 0 .4 4 ±0. 42
TABLE 20
ONE-WAY ANALYSIS OF VARIANCE: SELF - CATHEXIS SCALE (N = 88)
Source Sum of Squares
D eg rees of
F re e d o m M ean Square F Ratio Significance
Betw een G roups
(D isease)
0 .184 3 • 0. 06 0.1 7 NS
R esidual
(Within Groups)
30.790 84 0.37
•Total 30. 97 87
M eans and Standard D eviations
H an sen 's D isease D iabetes P s o ria s is F lu
M eans 3.31
3.19
3.21 3.27
Standard D eviation ±0. 54 ±0. 63 ± 0 . 54 ±0. 65
138
TA BLE 21
PEARSON PRODUCT-M OM ENT CORRELATION:
BODY-CATHEXIS AND SELF-C A TH EX IS
H an sen 's D isease D iabetes P s o r ia s is Flu
0 .7 5 8 a 0 . 531a 0.2 8 6 0. 652a
& r at 0.01 p e rc e n t = 0. 526 fo r 21 df.
139
the two v a ria b le s. The p s o ria s is g ro u p 's c o rre la tio n of 0 .2 8 6 did not
re a c h a significant level. The hypothesis was c o n sid ered a s p a rtially
supported.
T est of H ypothesis VIII
The following w ere posited within this hypothesis: 1) low body
and self-feelin g s would be a sso c ia te d with feelings of anxiety; and 2)
H a n se n 'sD is e a se subjects would d em o n strate significantly le s s anxiety
than o th er groups. To te s t the second p a rt of the h yp oth esis two one
way A nalysis of V arian ces w ere p erfo rm ed on T rait-A n x ie ty and S tate-
A nxiety S cales. The a n aly sis of State A nxiety (Table 22) yielded an
insignificant F Ratio of 0. 768; that of T ra it A nxiety produced an F
R atio of 0.411 (Table 23). The re s u lts d e m o n stra te d that subjects of
d ifferen t d ise a se groups did not differ fro m one ano th er in adm itting to
sym ptom s a sso c ia te d with e ith er State (situational) o r T ra it (chronic)
A nxiety. This p a rt of the hypothesis p ertain in g to significant d iffe r
e n ces betw een lep ro sy and the control groups on anxiety w as not
supported.
The f ir s t p a rt of the hy p o th esis, dealing with a significant
in v e rs e relatio n sh ip which was to obtain betw een both body and s e lf
feelings and anxiety, w as investigated by m ean s of four P e a rs o n
p ro d u ct-m o m en t c o rre la tio n s on the following sc o re s : 1) Body C athexis
and State-A nxiety; 2) Body C athexis and T rait-A nxiety; 3) Self-
TABLE 22
ONE-WAY ANALYSIS OF VARIANCE: STATE ANXIETY SCALE
(N = 88)___________ ________
Source Sum of Squares ! ■
D egrees of
F re e d o m M ean Square F Ratio Significance
Betw een G roups
(D isease)
264. 13 3 8 8.04 0. 77 NS
R esidual
(Within Groups)
9611.86 84 114.43
; Total
i
9875.99 87
i
i
»
M eans and Standard D eviations
H an sen 's D isease D iabetes P s o r ia s is F lu
M eans 37. 18 36.68 36.45 40. 73
Standard Deviation ± 1 1 .8 3 ±11.41 ± 9.20 ±8. 75
; TABLE 23
i
I
ONE-WAY ANALYSIS OF VARIANCE: TRAIT ANXIETY SCALE
_________________________ (N = 88)______________________________
Source Sum of Squares
D eg rees of
F re e d o m M ean Square F Ratio Significance
Betw een G roups
(D isease)
113.85 3 37. 95 0.41 NS
R esidual
(Within Groups)
7755.86 84 92.33
T otal
!
7869.72 87
i M eans and Standard D eviations
i
H an sen 's D isease D iabetes P s o ria s is F lu
M eans 42. 00 40.82 40. 59 38. 82
Standard D eviations ±9.12 ± 9 .7 4 ±10.14 ±8. 47
142
C athexis and S tate-A nxiety; 4) Seif-C athexis and T ra it-A n x ie ty . The
pro p o sed re la tio n sh ip w as d e m o n stra te d at significant lev e ls fo r th re e
out of fo ur m e a s u r e s in both le p ro sy and diabetic g ro u p s, but on no
m e a s u re s fo r e ith e r of the o th er two d ise a se s (T able 24).
The H an se n ’s D ise ase group showed a c o rre la tio n betw een body
fee lin g s and sta te of anxiety of -0. 480, and se lf-fe elin g s and tr a it
an x iety of -0. 423; both a re significant at the 0.05 le v e l of confidence.
The c o rre la tio n which obtained betw een se lf-fe elin g s and sta te anxiety,
-0. 682, exceeded the 0.01 level.
In the diabetic group, c o rre la tio n s reach in g the 0. 05 lev e l of
significance w e re obtained betw een body feelings and sta te anxiety
(-0. 450) and body feelin g s and tr a it anxiety (-0. 512). T hese c o r r e l a
tio n s w e re in the m o d e ra te ran g e , indicating a su b sta n tia l rela tio n sh ip
ex istin g betw een the two v a ria b le s. The c o rre la tio n betw een s e lf
fe e lin g s and t r a it anxiety was -0. 738, significant a t the 0. 01 lev el and
in te rp re te d as illu stra tiv e of a high c o rre la tio n that show s a m a rk e d
re la tio n sh ip . A fo u rth c o rre la tio n fo r the diabetic group fell sh o rt of
sig n ifican ce, that betw een self-feelin g s and state an x iety ( - 0 .3 9 4 - -an
0 .0 5 lev e l re q u ire s -0 .4 1 3 c o rre latio n ).
E xam ination of the o th er two groups indicated that the c o r r e l a
tio n s w e re all in the p red icted in v e rse direction, d esp ite th e ir not
rea ch in g significant lev e ls.
143
TABLE 24
PEARSON PRODUCT-M OM ENT CORRELATIONS:
1) BODY-AND SELF-CATHEXIS SCALES;
2) STATE-AND TRAIT-ANXIETY SCALES
•
H a n se n 's D isease Diabetes P s o r ia s is F lu
Body C athexis -
State A nxiety
-0. 480a -0. 450a -0. 104 -0.271
Body C athexis -
T ra it A nxiety
-0.3 28 -0 .5 1 2 a -0 .0 7 6 -0.28 5
Self C a th e x is-
State A nxiety
- 0 . 682b -0. 394 -0. 238 -0. 400
Self - C athexis -
T ra it A nxiety
-0. 423a -0 .7 3 8 b -0. 374 -0 .2 6 4
a r a t 0. 05 p e rc e n t = 0. 413 for 21df
b r a t 0. 01 p e rc e n t = 0. 526 fo r 21df
r
144
It w as concluded th at the portion of the h yp oth esis dealing with
the c o v a ria tio n of fe e lin g s tow ard self and body was p a rtia lly
sup p o rted .
T e st of H y pothesis IX
T his p ro p o sitio n stated th at su b jects with m o re open b e lief
s y s te m s would d e m o n s tra te le s s positive feelings to w a rd self and body.
Two P e a rs o n p ro d u c t-m o m e n t c o rre la tio n s fo r each g ro u p w ere c o m
puted betw een the s c o re on the D ogm atism scale v e rs u s the s c o r e s on
B o d y -C ath ex is and S elf-C ath ex is sc a le s. Out of eight c o rre la tio n s ,
only one re a c h e d a sign ificant lev el (T able 25). T his o c c u rre d in the
H a n se n 's D ise ase grou p on the D ogm atism -B ody C athexis rela tio n sh ip ;
the c o rre la tio n of 0 .4 1 4 was significant a t the 0.05 le v e l, co n sid ere d to
be a m o d e ra te c o rre la tio n which d e m o n stra te d su b sta n tia l re la tio n sh ip .
In the diabetic g roup, the c o rre la tio n of -0. 400 betw een D o g m atism
and B o d y -C ath ex is fell sh o rt of the 0 .0 5 level; with 21 d e g re e s of f r e e
dom , an r of 0. 413 is n e c e s s a ry . In th is group, the re la tio n sh ip was
an in v e rs e one. T h ere was no d isc e rn ib le p attern , e ith e r w ithin
g ro u p s o r betw een g ro u p s, in re g a rd to the stre n g th and d ire c tio n of
the re la tio n sh ip , on e ith e r D o g m a tism /B o d y -C ath ex is o r D o g m a tism /
S e lf-C ath ex is c o rre la tio n s . It was concluded that the hyp o th esis was
not su pported.
145
TABLE 25
PEARSON PRODUCT-M OM ENT CORRELATIONS:
1) DOGMATISM AND BODY-CATHEXIS
2) DOGMATISM AND SELF-CA TH EX IS
H a n se n 's D isease D iabetes P s o r ia s is F lu
D o g m atism -
Body C athexis
0. 414a -0.400 -0 . 198 0. 105
D og m atism -
Self-C athexis
-0 .1 9 5 -0 .207 0. 250 -0 .0 0 6
a r at 0. 05 p e rc e n t = 0. 413 for 21df
CHAPTER VI
DISCUSSION
P h a se I. A s s e s s m e n t of Com m unity A ttitudes
Tow ard D isease
This p a rt of the study yielded inform ation in four m a jo r a re a s :
1) the n a tu re of p e rc ep tio n s reg a rd in g illn ess; 2) the fa c to rs c ru c ially
re la te d to the shaping of behavior in re fe re n c e to a given d ise a se ; 3)
the sin g u lar po sition of le p ro sy in the p e rc e p tu a l-b e h a v io ra l economy;
and 4) the effect of so cial c la ss upon p ercep tio n s and behavior.
The re s u lts indicated that illn e ss is not perceiv ed as a n o n
sp e cific, g e n e ra liz e d condition. E ach illn e ss is p erceiv ed in a unique
fashion, sh a rin g com m on p ro p e rtie s but n e v e rth e le s s distinct fro m
one another by v irtu e of th ese p ro p e rtie s having id io sy n cratic function
ing a c r o s s d is e a s e s . Nor do the qu alities a p p e a r to covary, but
r a th e r function quite autonom ously. The deg ree to which a d ise a se is
p e rc e iv e d a s p o sse ssin g c e rta in c h a ra c te ris tic s d e te rm in e s the
a ssig n m e n t of e ith e r a benign o r negative evaluation. A cum ulative
ev alu atio n of e ith e r a v e ry negative o r co m p arativ ely benign n a tu re
r e s u lts in c o m m e n su ra te behav ior m odification.
146
147
.P e rs o n a l involvem ent, in te rm s of e ith e r contagion o r salience
in thought and d isc u ssio n , although a fa c to r in the evaluation of i l l
n e s s , does not n e c e s s a rily b e a r a negative connotation. Unlike the
e a r lie r r e s e a r c h re p o rte d on c a n c e r, th is fa c to r functioned indepen
dently in the d ise a s e s in th is p re se n t study, and did not link with a
th re a t fac to r. B ecause it did not b e a r a negative valence, it did not
affect b ehavioral p ro p e n sitie s.
The assig n m en t of e ith e r a significant th re a t o r so cial u n a cc ep t
ability value to a d ise a se c o rre la te d with avoidant-type b eh av io ral
tendencies. The th re a t connotation subsum ed q u alities of pain, death,
and power. Social a ccep tab ility , with its p a ra m e te rs of " c le a n - d ir ty ,"
" p ro u d -d is g ra c e d ," though conceptually inexplicit and probably in c o r-
porative of a g re a t deal of unspecified v a ria n ce within th ese d im e n
sio ns, n e v e rth e le s s proved highly d isc rim in a tiv e in its production of
differen tial perceptio ns a c r o s s d ise a s e s and social c la s s e s . The p o s
sibility th at th is fac to r is c ru c ia lly linked to o b serv ab le d isfig u rem en t
is suggested by the finding th at, while p s o ria s is was ra te d the le a s t
th reaten in g d ise a s e , it w as ra te d next to le p ro sy in its being u n accep t
able. In c o n tra st, d iab e te s, though actually a m o re th rea te n in g
d ise ase fro m its pathological con sequents, w as judged the m o st
acceptable d ise a se . C onceptualizing an in te rn a l-e x te rn a l continuum ,
one m ight c o n sid er so cial accep tab ility linked with the am ount of dis-.
figuring pathology o b serv ab le: p s o ria s is is a m o st evident d isease;
d iab e te s, sh o rt of g ro ss pathology, p re s e n ts a m o re in te rn a liz e d ,
n o n -o b se rv ab le p ro c e ss.
Though an ex tre m e ratin g of e ith e r benign o r negative valence
attached to a d ise a se w ill re s u lt in b eh av io ral m odification, in re s p e c t
to both affiliative and disaffiliative ten d e n cies, an in te rm e d iate ra tin g
does not ap p reciab ly affect b eh av io ral ten d en cies. F u r th e r , b eh av
io ra l ten d en cies a re m o re c le a r, and exhibit g r e a te r v a ria b ility , when
resp o n d en ts ra te th em se lv e s on the d e g re e of affiliatio n they w ill p e r
m it in re fe re n c e to a given d ise a se . A pparently affiliation is a m o re
differen tiatin g b eh av io ral m o tiv a to r th an the need to d isa ffilia te, o r
m a in ta in a given am ount of social d istance fro m an individual w ith a
p a rtic u la r d ise a se .
.Leprosy, on both p erc ep tu a l-e v alu a tiv e and b eh av io ral d im e n
sio n s, w as singled out a s the d ise a se b e arin g the m o st negative
valence. T h is, despite the a d m issio n that it was the d ise ase w ith
which resp o n d en ts w ere le a s t involved. C onsidering the contents of
the th re a t dim ension, the judgm ent th a t it re p re s e n te d the s e v e r e s t
th re a t is plainly in a c c u ra te , w ith qualification. In a re a s in which
effective m edication is av ailab le, and in which the d isease is diagnosed
and tre a te d soon a fte r sym p tom a p p ea ra n c e, it is a co n tro llab le p a th
ology* not lethal, and u su ally not productive of a g re a t am ount of pain.
T his would be p a rtic u la rly tru e in a r e a s of potential encounter,' such
as the United States would r e p re s e n t to our com m unity sam p les.
H an sen 's D ise ase was a lso se en a s the m ost "d irty " and "d isg ra c e fu l."
One su sp ects the d irtin e s s a sp e c t to be a sso c iated with such s te r e o
types as the le p e r 's running s o r e s , dropping off of d ig its, p a rts of the
face m issin g . A gain, effective drug reg im en has e ra s e d a stereo ty p e
which, even i n f o r m e r day s, w as p a rtly in accu rate. The "d isg ra c e d "
connotation re c a lls the synonym of "o u tcast" to be le p e r, bringing to
m ind the tra d itio n a l en fo rced iso latio n o r banishm ent. To a g re a t
extent, " d isg ra c e d " is highly suggestive of an in ac c u ra te ste reo ty p e,
p a rtic u la rly in a p p ro p ria te in a tech n ically advanced and sophisticated
civilization. The p o la ritie s of th ese two scales which en co m p ass
"so cial accep tab ility " contain so m uch surplus m eaning as to defy p r e
cise definition; n e v e rth e le s s , they ap p aren tly a re pow erful b eh av io ral
m o tiv a to rs. D espite the in a c c u ra c y of the th re a t judgm ent and the
conceptual fu z z in e ss of the so c ial acceptability evaluation, both w ere
significantly linked to re s p o n d e n ts' d e sirin g of the g re a te s t social d is
tance in re fe re n c e to lep ro sy . W ithin the s tr e s s p aradigm , th ese find
ings d e m o n stra te d th at the g r e a te s t s tr e s s that d ise ase poses to the
com m unity re s id e s in H a n se n 's D ise a se . The avoidant behavior fol
lowing such evaluation, in tu rn , re p re s e n ts the significantly g re a te r
s tr e s s potential to the H a n se n 's D isease patient, who evaluates the
attitudes and behavior as a continuous source of th re a t.
.The re la tio n sh ip of so cial c la s s to p ercep tio n s, b e liefs, and
b eh av io ral ten d en cies yielded substantive trends. Social accep tability
produced the g r e a te s t significant c la s s d ifferen ces, the th re a t facto r
differentiated low er c la s s fro m both o th e rs, and the p e rso n a l involve
m ent facto r was re sp o n sib le fo r the le a st am ount of c la ss difference.
On a ll th re e f a c to r s , the lo w er socioeconom ic resp o n d en ts differed
fro m the o th er g ro u p s, and c o n sisten tly ren d e red the m o st negative
ra tin g s on a ll fa c to rs . On b eh av io ral indices of both affiliation and
disaffiliatio n , th e re w e re le s s d ifferen ces between upper and m ed ical
g ro u p s, but the low er c la s s m o re frequently differed fro m the o ther
two, and alw ay s in the d ire c tio n of significantly w ishing g re a te r social
d istan ce.
Two tre n d s a re notew orthy: the resp o n siv en e ss of behavior to
e x tre m e ju d g m en ts, and the c o n sisten t tren d of the lo w er c la ss to m ake
e x tre m e jud gm ents. In te rp re ta tio n within a s tr e s s fo rm u latio n would
suggest that a c e rta in lev el of s t r e s s m u st be p re se n t to incite b eh av
io ra l changes, the o b v e rse a lso being tru e . Secondly, the low er socio
econom ic c la s s m u st im pute to all illn e ss a g re a te r s tr e s s potential
than o th er groups. T his a s s u m e s p a rtic u la r im p o rt for the le p ro sy
patient. W ithin the study sa m p le , the g re a te s t d isp e rsio n of H ansen's
D isease subjects would be c la ssified as m e m b e rs of th is socioeconom ic
group, and th is finding m o st likely is generalizable to the H a n se n 's
151
D isease population throughout the w orld. C onsidering that the g re a te s t
am ount of the p a tie n t's social and occupational co n tact w ill be with
m e m b e rs of his own socioeconom ic stra tu m , the th re a t a p p ra is a l can
be of the g re a te s t m agnitude becau se of the p roxim ity of th o se who
judge him m o st h a rsh ly .
The second m a jo r finding reg ard in g the effect of so cial c la s s
on p erceptions and b eh av io r is that v a ria b le s such a s m e d ic a l train in g ,
g e n e ra l educational lev el, o r socioeconom ic advantage had no s y s te m
a tic effect a c r o s s the h ie ra rc h y of d ise a s e s. One would an ticip ate that
a m ed ical p e rs o n 's su p e rio r train in g and knowledge, o f the so p h istic a - ‘
tion bo rn of m o re education o r so cial p resen ce would in te r a c t with p a r
tic u la r d ise a se e n titie s, producing differential effects a s a function of
th is v ariab le. Such did not o c c u r, attestin g to the m o re em otionally
r a th e r than objectively toned b a sis of reactio n to d is e a s e , both-on
ideational and b eh av io ral lev e ls.
P h a se II. A s s e s s m e n t of P atient F unctioning
Two m a jo r findings, subsum ing all h y p o th eses, overshadow ed
all o th ers in th is p o rtio n of the study. F i r s t , H a n se n 's D ise a se su b
je c ts d e m o n stra te d no significant difference in functioning fro m Con
tr o l groups in the psychological a re a s under study. Secondly, the
m a jo r g e n e ra l p re m is e s p red icted by a s tr e s s p a ra d ig m re c e iv e d
152
re sp e c ta b le validation a c ro s s d ise ase groups, although c e rta in
specific rela tio n sh ip s did not obtain.
The b asic dynam ic form ulation, within the s tr e s s m odel, called •
fo r cognitive re a p p ra is a l to be the m a jo r coping m ec h an ism . Such
re a p p ra is a l would a tte s t to the p resen c e of a continuous, u n iv e rsa liz e d
type th re a t, and would be m an ifest in a closed belief sy ste m . The
s u c c e ss of the coping would be m e a su re d by the p resen c e o r absence
of significant am ounts of anxiety. A lso proposed was a po sitive r e l a
tionship betw een the c lo sed n e ss of the belief sy stem and significantly
m o re positive feelin g s tow ard self and body, these la tte r being con
ceptualized by the in v estig ato r as p a rt of a belief su b sy stem .
N orm ative data available on m o re than 40 sa m p le s (A lter and
W hite, 1966) showed th at the study’s sam ple m eans a p p ro x im ated m o st
c lo sely that of the two groups with the highest re p o rte d s c o r e s , that of
VA D o m icilia ry and E n g lish fac to ry sam p les. D isp ersio n of m eans
a c r o s s groups v a rie d w idely, and w ere significantly low er in groups
who w ere physically w ell, of b e tte r education, o r of h ig h er so c io
econom ic lev el. Since the study sam ples have in com m on with the
aforem entio ned n o rm ativ e h ig h -m ean sam p les both socioeconom ic
lev el and illn e ss, it would be difficult to determ ine the am ount of
v a ria n ce a ttrib u ta b le to e ith e r source in the obtaining of the high m ean
s c o re s seen in the p re s e n t study. A conclusion m ay be drawn,- how
e v e r, fro m the fact that the d ise ase groups d em o n strated a m uch m o re
153
closed belief sy ste m than a lm o st a ll the norm ative sa m p le s. Since
closed belief sy ste m has been conceptualized as a defensive netw ork
against an a p p ra ise d th re a t, it is reasonable to infer that all d isease
groups a re exp erien cin g som e type of continuing th re a t again st which
they cope in p a rt by adhering to a closed belief sy ste m .
Although th re e of the fo u r groups d em o n strated the significant
cov ariatio n u su ally found betw een feelings tow ard body and self, th ese
feelings w e re not found to re la te to how open o r clo sed the cognitive
netw ork w as, as had been h ypothesized. It would thus ap p ear that body
and self feelings do not o p e ra te d ire c tly as su b sy stem s of the m ajo r
cognitive belief sy ste m s. T his finding lends som e support to R okeach's
th e o re tic a l position that the b e lief sy ste m s subsum e a v a rie ty of
defen ses. In c o n tra st, body and self feelings, if questionably
enhanced, m ight b e tte r be seen a s the product of one defense, such as
denial o r re p re s s io n . T hat th e re m ight have been defensive perception
of these sy s te m s is suggested by the relatio n sh ip betw een se lf-e ste e m
and dogm atism given in fa c to ria l stu d ies, and the rela tio n sh ip of phy
sical sym ptom atology to d e c re a se d body-cathexis. B riefly, dogm atism
has been found to be a sso c ia te d w ith low se lf-e ste e m and s e lf
rejectio n ; poor feeling tow ard the body has been significantly related to
physical illn e ss o r p resen tin g so m atic com plaints. The d ise ase groups
re p o rte d self and body feelings a lm o st identical with sam p les who a re
154
physically w ell and b e tte r socioeconom ically advantaged. T hese
a lm o st identical findings in subjects defined a s dogm atic and known to
have e ith e r chronic m ed ical pathology o r acute m ed ical sy m p to m a
tology stro ngly suggest a defensive p o stu re in body and s e lf
perception . If such is the c a se , it would be e n tire ly explicable within
a s tr e s s co ntext--coping with th re a t is p red ic ated upon s e v e ra l
a p p ra is a ls , am ong which is the p ercep tio n of o n e 's self a s capable and
adequate to m eet the th re a t.
The findings in re g a rd to anxiety lev el lend additional support
to the possibility of defensive body and se lf-fe elin g s. A vailable n o r
m ative data show a c o n sisten t rela tio n sh ip betw een poor body and se lf
feelings and significant levels of anxiety. Significantly h ig h er anxiety
lev els w ere found in a ll groups when c o m p a riso n s w ere m ade with
n o rm ativ e sam p les. The type of anxiety found in the v a rio u s groups
lends cred en ce to illn e ss as the m o re significant s tr e s s in the sub
je c ts ' liv e s, in co m p ariso n with the socioeconom ic fa c to r. In the .
chronic m ed ical g roups, tr a it anxiety o r chronic anxiety w as present;
in the flu group, th e re w as no evidence of t r a i t anxiety, but r a th e r of
the state (situational) anxiety. C hronic anxiety in the s t r e s s p aradig m
is a sso c ia te d with the a p p ra isa l of th re a t of a continuing n a tu re . That
the flu subjects did not d em o n strate this type of anxiety would indicate
th at the th re a t is a sso c ia te d with the chronic illn ess; situational anxiety
shown in the flu group probably can be accounted for by the te m p o ra ry
psychic d ise q u ilib riu m a sso c ia te d with the d isco m fo rt of the acute
m ed ica l p ro c e s s in which flu subjects found th em selv es. The m o st
im p o rtan t im plication of the p re se n c e of significant lev els of anxiety
within the s t r e s s fra m e w o rk is th at m a s te ry of the a p p ra ise d th re a t
h a s not been e n tire ly su c c e ssfu l, despite the coping e ffo rts. Illn ess
obviously re p re s e n ts a continuous th re a t which the su b jects have not
been able to handle com pletely, an im p o rtan t piece of datum to be
taken into account in the patient m an agem ent a re a .
E xam ination of proposed in tra -p sy c h ic re la tio n sh ip s u sually
found to e x ist in re p o rte d stu d ies, such a s the b o d y -self relatio n sh ip ,
the re la tio n sh ip betw een b o d y -se lf feeling s and anxiety, showed that
le p ro sy and diabetes m o st freq u e n tly validated th ese u su a lly found
phenom ena. In c o n tra st, the flu group d em o n strated only one and
the p s o r ia s is group none. T his invites speculation. D espite its d e sig
nation a s a chronic d is e a s e , one m ight hypothesize th at on a subjective,
e x p erien tial level, p s o ria s is is m o re s im ila r to flu in the c o u rs e of its
acute fla re u p s and re m is s io n s and in its gen erally m o re topical, a s
opposed to total sy ste m , involvem ent. P e rh ap s a to ta l-o rg a n pathology,
such a s H a n se n 's D isease and diabetes re p re se n t, call fo rth a life -sty le
consonant with "to tal chronic illn e s s " p aralleling th at of "total w ell
n e ss. " In such chronic p a tte rn s , basic relatio n sh ip s m ig h t have a
g r e a te r p ro p en sity to consolidate and e m e rg e . In c o n tra st, the-
156
co m p arativ ely m o re acute e x acerb atio n and re m is s io n e p iso d es
c h a ra c te riz in g flu and p s o ria s is m ight d isru p t and m ak e le s s stable
the u su ally found psychic in te r-re la tio n s h ip s .
The m a jo r questions posed by the findings on p atien t functioning
a re two. Why did not significant d ifferen ces betw een d is e a s e groups
e m e rg e in any a re a of psychic functioning? In view of the m an ifestly
significant m o re negative rea ctio n tow ard H a n se n 's D is e a s e , concep
tualized a s the s tr e s s potential av ailab le to le p ro s y p a tie n ts, why did
th ese not d e m o n stra te significant d ifferen ces in p sy ch ic functioning
ap p ro p ria te to the attitudes acco rd ed th e m ?
The conclusion posed by the f i r s t question is th a t a ll m u st be
exp erien cin g a sim ila r d eg ree and kind of s tr e s s a s s o c ia te d with
illn e ss. The n atu re of the s tr e s s se e m s m o st efficien tly explicated by
social ro le th eory. Within this fra m e w o rk fo u r phenom ena a re e m p h a
sized: ro le , expectations of role d e riv a tiv e s, c o n fo rm itie s, and ro le ’
conflict. P a rso n s (1964) conceives of illn e ss a s "deviant b e h a v io r,"
inasm u ch as the individual fails to fulfill in stitu tio n ally defined e x p ec
tatio n s of one o r m o re of his societal ro le s. As a re s u lt, som ething
"goes w rong" in his social rela tio n sh ip s. This im p o se s s tr a in because
of lo ss of support fro m the surrounding group due to the fa ilu re to
uphold the n o rm ativ e value p a ttern s. The s tra in and conflict a ris e
when he is unable to conform with expectation s, o r w hen still-v ia b le
ro le ex p ectan cies becom e incom patible with the sick ro le , o r when
c e rta in expectations connected with illn e ss a re not elucidated. W ell-
defined sick ro le expectancies include: 1) exem ption fro m perfo rm an ce
of n o rm a l so cial obligations; 2) a fre e in g fro m re sp o n sib ility fo r one's
sic k state; 3) recogn itio n that illn e ss is an u n d e sirab le so cial state to
be gotten out of a s expeditiously as possible; 4) reco g n itio n of the need
fo r help, which in c u rs the obligation to cooperate with the physican to
becom e well. Beyond th e se , we would hypothesize th a t the sick role
e n c o m p a sse s m o re subtle ex p ectan cies, le s s well explicated. These
would flow fro m the id io sy n cra tic p erceptio ns of each illn e ss with
th e ir co rre sp o n d in g b eh av io ral c o rre la te s . W ithin a s t r e s s fo rm u la
tion, th ese ta c it expectations would constitute a so u rce of th re a t to the
individual b ecau se of th e ir am biguity and ill-d efin itio n w hich lim its
adequate coping. One does not posit a hom ogeneous s t r e s s re la te d to
e v e ry illn e s s , but r a th e r one shaped by the in dividual's expectancies
in re g a rd to h is p a rtic u la r d ise a se . Support fo r th is po sition appeared
in a study by K asseb au m and B aum ann (1965) in which the n a tu re of the
s t r e s s differed a c r o s s d ise a s e s: it w as a com posite of the d ise a se p er
se , and its im plicatio n to its victim a s a function of sex , ag e, ethnic
o rig in , and occupational catego ry.
S um m arizing , the u n iv e rs a l s tr e s s produced by illn e ss is a
com bination of 1) the pathological im plication of the d ise a s e p ro c e ss
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itse lf; 2) the conflict eng endered by sick role ex p ectan cies gen erated by
the c o m m u n ity 's p e rc ep tio n s and b eh av io ral re a c tio n s tow ard that
d is e a s e , which m ay be functioning a s tacit m e d ia to rs of so cial in te r- *
a ctio n . T his u n iv e rs a l s tr e s s o r a sso c ia te d with illn e ss and a p p ra ise d
a s a continuing th re a t would explain why no d ifferen ces a c r o s s groups
e m e rg e d in th e ir psychic functioning.
Although H a n se n 's D isease s h a re s the sam e type of s tr e s s with
C o n tro l g ro u p s, the d e m o n stra te d negative re a c tio n to the d ise a se
would a p p aren tly indicate a g re a te r degree of s t r e s s , which hyp o
th e tic a lly should have produced v a ria tio n in psychic functioning. No
d iffe re n c e s found by m ean s of the m e a s u re s'em ployed suggests th re e
p o ss ib ilitie s .
The f ir s t is that th e re is available in the coping r e p e r to ir e of
the H a n se n 's D ise ase patient an additional stra te g y which h a s the
e ffe ct, dynam ically, of reducing the level of a p p ra ise d th re a t to that
e x p e rie n c e d in o th er illn e s s e s , re su ltin g in sim ila rity of functioning.
T his is the iso latio n and w ithdraw al tendency. The pilot study had
p ro d u ced two re le v a n t p iec es of data: an openness sc o re had indicated
th a t not only w ere su b jects s e c re tiv e of diagnosis at the tim e it was
m a d e , but that the tendency p e rs is te d to re m a in so, tim e o r e x p e ri
ence producing little m odification. The resp o n d en ts, by spontaneous
v e rb a liz a tio n , singled out the w ithdraw al and social iso latio n a s the
1 5 9
g r e a te s t p ro b lem connected with the illn e ss. R em em b ering that such
is not a m an d a to ry p ro c e d u re , one m u st assum e it had been self-
im p o sed . Such a m ec h an ism , shielding lep ro sy p atien ts fro m the full
im p a ct of com plete exposure to com m unity perceptions and behavioral
re a c tio n s to the d is e a s e , would function to reduce the th re a t a p p ra isa l,
re s u ltin g in s im ila rity of coping to th at of o th er d is e a s e s .
T h e re is the p o ssib ility that a t conscious lev e l of a s s e s s m e n t,
no tr u e d iffe re n c e s do e x ist between H an sen 's D isease and o th er
d is e a s e s . D ifferen ces m ight only e m e rg e when le s s conscious p ro
c e s s e s a re tapped. O r p erhaps the only differences a r e w ithin-group,
r a th e r th an b e tw een -g ro u p d ifferen ces, that is.no d is e a s e -s p e c ific
p e rs o n a lity c o rr e la te s o r psychological syndrom es do se p a ra te the
d is e a s e s fro m each o th er. The an sw er m ight be found in a dichotom y
such a s the slo w -fa st re c o v e ry ra te , as had been d e m o n stra te d in one
of the cited stu d ies, which tra n sc e n d s d isease e n titie s.
Im plication s fo r P atient M anagem ent and R e se a rc h
If one a cc ep ts the p re m ise that illn ess e licits a u n iv e rs a l s tre s s
re a c tio n , one com ponent of which is the com m unity's attitude tow ard
the d is e a s e , c e rta in c o ro lla rie s follow. Those resp o n sib le fo r both
m e d ic a l m an ag em en t and patient c are would do w ell to be a w are of this
m o re subtle a sp e c t of illn e ss, in addition to the obvious s tr e s s created
by the pathological p ro c e s s and the fe a r of lethal consequents.
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Sensitivity to the rela tiv e th r e a t and social accep tab ility fac ets of the
d isease would enhance a p p re c ia tio n of the n a tu re of psychic conflict the
patient m ight be ex p erien cin g a s a backw ash of these sh a red g e n e ra l
ized attitud es and p ro c liv itie s .
To such an end, r e s e a r c h activ ity m ight be d ire c te d tow ard
c la rifica tio n of the following:
1. A s s e s s m e n t of the c u rre n t th re a t and so cial acceptability
p otentials of m a jo r d is e a s e s .
2. D eterm in atio n of w h ether o r not the th re a t value is based
on a c c u ra te inform atio n. .
3. Identification of the v a ria b le s that c o m p rise and delim it
the so cial a c c e p ta b le n e ss of a d ise a s e , and d e te rm in a
tion of w hether o r not th ese v a ria b le s differ a c ro s s
d ise a s e s.
4. Isolatio n of o th er fa c to rs , e ith er g en eraliza b le a c ro s s •
d is e a s e s o r p e c u lia r to a given d ise a s e , which c o r r e
late with av o id an t-ty p e behavior.
E d ucation of the public on all the fa c to rs re la te d to illn ess
which encourag e negative re a c tio n tow ard the patient with a given
d isease entity is e sse n tia l. T his is p a rtic u la rly tru e if such reactions
a re based on in a c c u ra te ste re o ty p e s. T h ere is no re a so n to suspect
that the phenom enon which o c c u rre d in re la tio n to H an sen 's D isease is
not op erativ e to a l e s s e r extent a c r o s s o th er illn e s s e s .
L ep ro sy p re s e n ts an ex cellen t exam ple of the victim ization of a
group on the b a sis of in a c c u ra te ste reo ty p es. The th re a t potential
e sse n tia lly c ru m b le s un d er scru tin y . Is the so cial unacceptability
a sso c ia te d with the d ise ase linked to d isfig u rem en t, the equating of it
with isolation o r banishm ent, o r with som e o th er a n ac h ro n istic id eas?
T h ere m ight be o th er, not yet m e a su re d o r iso la te d , fa c to rs which
contribute to a cum ulative avoidance effect. Such data m u st be expli
cated to d e se n sitiz e the negative potential elicited by the sem antic
lab el. It is the w r i t e r ’s opinion that to change the n am e accom plishes
nothing to red u ce s tr e s s potential; d e sen sitizatio n effected by the p ro
viding of objective info rm atio n a p p e a rs a m o re efficient way to change
attitu d es and b eh av io ral ten d en cies. Nor does it s e e m w ise to en co u r
age the patient to d is a rm h im self of the iso latio n and w ithdraw al
d e fe n se s, if such defenses a re not being em ployed a t a pathogenic
lev el. His feelings reg a rd in g the affect d ire c te d a t h im a re not p a ra
noid; they a r e factu ally b ased , and until vigorous ed ucative m ea su re s
have been able to reduce o r a lte r the feelings tow ard the d ise a se , it
would be unw ise to in sist that he abandon a coping m ec h a n ism that
in su lates h im against the full im pact of com m unity rea ctio n . Such
exp o su re would only in c re a s e additional th re a t a p p ra is a l, perm itting
h im to function le s s efficiently than he p re se n tly does. At the m om ent,
he a p p ea rs to o p erate adequately in the re s tric te d w orld in which he
liv e s.
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V isual education would ap p ear to be a n e c e s s a ry p a rt of the
educative p ro c e ss for H an sen 's D isease p a tien ts. "One look is w orth
a thousand w o rds. " E x posure to patients re p re se n tin g both the clinical
types of le p ro sy and the v a rio u s phases of the pathological p ro c e ss
could wipe out m any ste reo ty p es. The w rite r can p e rso n a lly a tte st to
the efficacy of this p ro ced u re. T actile contact would a lso be a pow er
ful e ra d ic a to r of fantasy. O bservation th a t the patient can enjoy close
physical contact with o th ers without d an g er of contagion to the non
infected p a rty is a potent d isa b u se r of th is p a rtic u la r ste reo ty p e. A
m u lti-m o d a lity approach a p p e a rs a m o st p ro m isin g m ethod to reduce
the s tr e s s potential of the d ise a se to the com m unity. Such reduction
would eventuate in the d e sire d attitudinal and b eh av io ral changes within
the com m unity; this in tu rn would attenuate the c o m m u n ity 's level of
th re a t to the patient.
The dem o n stratio n of no b etw een -g ro u p d iffe re n c e s in the a re a s •
of psychic functioning explored would su g g est th at, in the a re a of
handling of the le p ro sy patient on the p a rt of both h is m e d ic a l and
so cial c o n ta cts, he not be handled a p p re cia b ly d ifferen tly than patients
w ith o ther illn e s s e s . W hether due to the additional d e fe n se s he
em p loy s, o r o th er p erso n ality c o rre la te s ex istin g but not ex plored in
th is study, he a p p e a rs no m o re p sy ch ically vulnerable than any other
d ise a se group, and thus not in need of any q u alitativ ely different
ap proach.
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R e s e a rc h efforts into the psychic econom y would now seem
m o st p ro m isin g along two a p p ro ach es. The d e m o n stra tio n of no dif
fe re n c e s betw een groups would indicate that a s s e s s m e n t m ight be
m odified in two ways. In stru m e n ts, the intent of which is le s s obvious,
m ig ht be u sed to prev ent the social d e sira b ility set o r defensive
m anipulation which in stru m e n ts whose questions p o s s e s s a d eg ree of
fa c e -v a lid ity encourage. P ro je ctiv e protocols a lso m ig h t be em ployed
to m e a s u r e le s s conscious lev e ls of functioning.
The second m a jo r r e s e a rc h approach would sw itch focus fro m
b etw een -g ro u p to w ithin-group differences. As a cited study had
shown, the fa s t-s lo w dichotom y yielded significant d iffe re n c e s within
g ro u p s. T his m ight be the only a re a of tru e d ifference. Although that
study had been done on an in-p atient population, the fa s t-s lo w phe
nom enon a p p e a rs in o u t-p atien t groups, a sso c ia te d with both ra te of
re c o v e ry and contro l of re a c tio n s. Data on this dim ension would be
advantageous to both m ed ica l and psychological m an ag em en t of the
patient. ' A w are n ess of the conflicts the patient m ight be ex periencing
re la te d to the re c o v e ry phenomenon could be em ployed to the end of
in stitu tin g a m e lio ra tiv e psychic intervention.
The findings in th is study, th eir im p licatio n s, and suggestions
fo r r e s e a r c h a re based on, and applicable to, an o u t-p atie n t sam ple
existing in an urb an ized , technically advanced society. While the data
164
can probably be g e n e ra liz e d to sim ila r sa m p le s, its applicability is
highly q uestionable if significant dim ensions of the so c ial context
ch an g es. One of the m o st im p re ssiv e facts one le a rn s about H ansen's
D ise a se is the tre m e n d o u s d isp a rity of p ro b lem s encoun tered by the
le p ro s y patient a s a function of his geographical and socioeconom ic
environm en t.
Sum m ary
T his study w as an investigation into the p sy c h o -so c ia l w orld of
the H a n se n 's D ise ase patient. Its focus was on two a re a s : 1) com m u
n ity a ttitu d e s re le v a n t to the d ise ase; 2) the psychological functioning
of the p atien t, to d e te rm in e w hether o r not significant d ifferen ces
e x iste d in c o m p a riso n with individuals having o th er illn e s s e s , which
d iffe re n c e s m ight be in fe rre d to re la te to com m unity attitu d es towa.rd
H a n se n 's D ise a se .
The in v estig atio n was stru c tu re d in the context of a s tr e s s p a ra
digm . N egative attitu d es on the p a rt of the com m unity tow ard the
d is e a s e w e re conceptualized as a stim ulus which activ ated the a p p ra isa l
of th re a t by the patient. This a p p ra isa l, functioning a s an intervening
v a ria b le , m obilized coping m ec h an ism s a p p ro p ria te to the perceiv ed
th re a t. The m agnitude and ubiquitous n atu re of the th r e a t would
dem and, r a th e r than a d ire c t action tendency, a cognitive defensive
re a p p ra is a l to red u ce the th re a t potential potential of the stim ulus.
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Success of the stra te g y would be deduced from the p re se n c e o r absence
of significan t am ounts of anxiety.
T hat phase of the study con cern ed with com m unity attitudes
hypothesized the following:
1. H a n se n 's D ise a se , a s co n trasted with o th er d is e a s e s ,
would be m o re negatively judged along both p e rc ep tu a l -
b elief and b eh av io ral dim ensions.
2. A significant re la tio n would obtain betw een th e s e two
v a ria b le s in the d ise a se groups evaluated le a s t and
m o st negatively.
P re d ic tio n s reg a rd in g patient psychic functioning included the
following:
1. In the th re e dim ensions of psychic phenom ena a s s e s s e d ,
th at of cognitive defense, anxiety lev el, and body and
se lf-im a g e , significant differences would a p p e a r betw een
le p ro s y and the C ontrol groups.
2. A significant re la tio n sh ip would ex ist betw een s e lf- and
body-feelings a c ro s s groups, and positive feelin g s would .
be re la te d to the e x p erien cin g of le s s anxiety. 1
3. Body- and self-feelin g s w e re conceptualized a s su b sy stem s
w ithin the cognitive netw ork, and since H a n se n 's D isease
was posited to have the m o st closed netw ork, th is closed
sy ste m would be re la te d to defensive body- and s e lf
p e rc ep tio n s. The re s u lt would be the finding of the m o st
positive body- and se lf-im ag e in the le p ro sy group, with
concom itantly significantly le s s anxiety.
Subjects for the f ir s t phase consisted of th re e sa m p le s of th irty
su b je cts each, equally divided betw een m ales and fe m a le s, and r e p r e
senting th re e s tra ta of society. The upper socioeconom ic level was
166
re p re se n te d by m e m b e rs of a R o tarian Club and A ssista n c e League;
low er socioeconom ic su b jects w ere draw n fro m a settlem ent house and
a c o m m u n ity -sp o n so red education-job train in g p ro g ra m ; and the m e d i
c a l-p a ra m e d ic a l c la ss w as solicited fro m a V eterans H ospital and
co n sisted of staff physicians and n u rs e s . Two in stru m e n ts w ere
em ployed, on which the su b jects rated seven d ise a se s which included
the E x p e rim e n ta l and C ontrol d ise a s e s. These w ere the Sem antic Dif
fe re n tia l fo r H ealth, which m e a s u re d the p e rcep tu al-ev alu ativ e-b elief
content of d ise a se . The second was the B ogardus Social D istance
Scale, which a s s e s s e d b e h av io ral tendencies as d e m o n stra te d by a
social d istan ce continuum , rev e ale d in polar affiliative and d isaffili-
ative s c o re s .
P a tie n t groups co n sisted of the E x p erim en tal sam p le, a group
of 22 le p ro s y subjects draw n fro m an o ut-patien t clinic fo r the disease,,
and 3 m atched Control groups re c ru ite d fro m o u t-p atien t county and
priv ate clin ics. The diabetic sam ple controlled fo r the v ariab le of
chronic d ise a s e , the p s o ria s is group controlled fo r skin lesion, and
a flu sam ple fo r illn e ss p e r se, not of a chronic n a tu re .
Dependent v a ria b le s w ere the sc o re s on the following indices:
the D ogm atism Scale, , w hich m e a su re d openness of clo sed n ess of
belief sy ste m , o r the defensive netw ork; S p ie lb e rg e r's State and T ra it
A nxiety S cales, which a s s e s s e d chronic and situational anxiety levels;
167
and Secord and J o u r a r d 's B o dy-an d Self-C athexis S cales, designed to
evaluate body- and se lf-im a g e .
All the hypotheses in the f ir s t phase of the study rec eiv e d sub
stan tial validation. L e p ro sy , along both behavioral and cognitive
dim ensio ns, was rated significantly m o re negatively than C ontrol
groups. The proposed significant relatio n sh ip betw een p e rc e p tu a l-
belief and behavioral functioning was also d em o n strated in the two
e x tre m e ly rate d gro ups, H a n se n 's D isease and flu..
The su p ra -o rd in a te findings of the patient phase w e re two. No
significant differen ces betw een H an sen 's D isease and C ontrol groups
w ere d em o n stra te d on the five c rite rio n m e a su re s. Secondly, the
s tr e s s fo rm u latio n rec e iv e d su b stan tial validation a c ro s s d ise a s e
groups; but its specific app licability to H ansen's D ise a se , and som e of
the subordinate h y potheses it would ap p ea r to g e n erate , did not.
Secondary findings included the d em onstration of a re la tiv e ly
closed belief sy ste m a c r o s s all d ise a se groups, fro m which w as
in fe rre d 'th e p re se n c e of som e type of s tr e s s and th re a t a p p ra is a l co m
m on to all. The significant rela tio n sh ip hypothesized to e x ist betw een
body- and self-feelin g s rec e iv e d substantive support in th re e out of
four g roups, but the equivalence of s c o re s with those of n o rm ativ e
sam p les suggested som e d eg ree of defensive perception o p e ra tiv e .
Bodyr- and se lf-im ag e p e rc e p tio n s, how ever, w ere not re la te d to the
168
op en n ess of c lo sed n e ss of the cognitive netw ork; such would validate
the position of the cognitive s y s te m 's th e o ris t that the netw ork sub
su m es a v a rie ty of d efen ses; it would indicate that if defensive p e r
ception is involved, it is m o re d ire c tly a function of a single defense,
such as denial or re p re s s io n . The d e m o n stra tio n of significantly
h ig h e r le v e ls of anxiety than those of n o rm ativ e sa m p le s led to two
conclusions: 1) the postulation of a com m on s tr e s s potential acting
on all d ise a se groups w as fu rth e r supported; and 2) the th re a t
a p p ra ise d by all groups had not been com p letely m a s te re d .
P rin c ip a l conclusions and suggestions re g a rd in g r e s e a rc h w ere
s tru c tu re d around the s t r e s s context. Illn e ss was conceptualized as
re p re se n tin g an a p p ra ise d th r e a t to th e com m unity, which a p p ra isa l
w as refle cted in the T h re a t and Social A ccep tability com ponents of the
d ise a s e . T hese fa c to rs a p p e a re d to be im p o rtan t b eh av io ral m odifiers
in tlie c ase of an e x tre m e ra tin g of a d ise a s e . Suggestions for patient
m an ag em en t w ere g e a re d aro und in c re a s in g a w a re n e ss of the strength
of th e se fa c to rs w ithin each d is e a s e , identification of o th er negatively-
valenced fa c to rs a sso c ia te d w ith d ise a s e , m o re p re c is e definition of
the so c ial accep tab ility p a ra m e te rs w ithin and a c r o s s d is e a s e s .
F in a lly , through education of the g e n e ra l public, attem p t should be
m ade to d e stro y in a c c u ra te s te re o ty p e s , which m ight be providing the
negative content of th e se fa c to rs . A m u lti-m o d a l ap p ro ach w as
169
suggested in the case of le p ro sy , since it had been d em o n strated that
m uch of the negativity g en erated tow ard this d ise a s e is based on out
m oded and in ac cu ra te extant ste re o ty p e s .
The p rim a ry conclusion re g a rd in g patient functioning was that
a ll groups sh a red a com m on source of s tr e s s . T his w as the ap p raisal
of a th re a t fa c to r resid in g in illn e s s , which extended beyond the physi
cal im p licatio n s and e n co m p assed the negative com m unity attitudes
tow ard d ise a s e . The explication of the n a tu re of th is p a rtic u la r th reat
seem ed b e st explained in a social ro le th e o ry context. G eneralized
ex p ectan cies accom pany the sick ro le , producing conflict or s tre s s .
T h ese a r is e fro m expected co n fo rm ities which com pete with norm al
extant so cial ro le s. Social ro le su g g ests another so u rc e of s tre s s .
T his evolves fro m ta c it expectancies which m ight be deduced fro m the
p e rc e p tu a l-e v a lu a tiv e and b eh av io ral dim ensio ns g e n e ra te d tow ard
e ach d ise a se Such in ex p licitn ess g e n e ra te s th r e a t b ecau se it inhibits
c le a rly defined coping and invites co n jectu re on the p a rt of the patient
as to w hat m ight be expected of him . A dditionally, such expectancies
m ight com pete with n o rm a l ro le s .
The finding of no significant d ifferen ce betw een E x perim ental
and C ontrol groups in the m a jo r a r e a s of psychic functioning was given
s e v e ra l in te rp re ta tio n s. One w as th at an effective reduction of the
th re a t potential posed by the com m unity tow ard the le p ro s y patient
170 |
had been achieved by an isolation and w ithdraw al tendency. These
I
had the dynam ic effect of equating the p e rc eiv e d th r e a t to that of other ;
: i
; I
d is e a s e s . T h ere was a lso the p o ssib ility th at the in stru m e n tatio n
i j
m ig h t have been unsuitable fo r rev ealin g tru e d ifferen c e s should they
i •
!
e x ist. It was suggested that le s s task -o b v io u s p ro to co ls m ight be
S »
I • :
em ployed to d isco u rag e resp o n se se ts and defensive m anipulation of ;
{ i
I i
the te s t m a te ria l. P ro je c tiv e te s ts m ight a lso prove useful to tap le s s;
i i
! i
co n scio u s, o r le s s c o n scio u sly -c o n tro lled , s p h e re s of psychic func- j
i !
tioning. F in a lly , the p o ssib ility th at no tru e d ifferen ce does e x ist j
J
I !
betw een groups m u st be co n sid ered . T h e re fo re , the m o st productive j
! ‘
r e s e a r c h m ight o ccu r in the w ithin-groups p a ra d ig m , focusing on such'
| . j
' d im en sio n s as a fa s t-s lo w re c o v e ry phenom enon, and explicating the i
i
I
p e rs o n a lity dynam ics o r c o rre la te s a sso c ia te d w ith the dichotom y.
Caution re g a rd in g the g en eralizin g of re s u lts w as m ade because
|
! of the e x tre m e d isp a rity of p ro b lem s the le p ro s y patient fa c e s as a j
i
function of both his geographic and socioeconom ic m ilieu .
R E FE R E N C E S
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174
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175
Jenkins, C. D. , and Z yzanski, S. J. D im ensions of belief and feeling
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j
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|
I
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J
*
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i
f
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|
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A P P E N D I X E S
A PPEN D IX A
BOGARDUS SOCIAL DISTANCE SCALE
(REVISED) FOR ILLNESS
181
A PPEN D IX A
BOGARDUS SOCIAL DISTANCE SCALE (REVISED) FO R ILLNESS
IKSTRUCTION’S
1 . In o rd e r to keop your s c a le anonymous, do n o t sig n name, b u t g ir o y o u r s e lf .
a s much freedom as p o s s ib le i u se only check m arks,
2 . P lea se g iv e your f i r s t f a - l l n y r e a c tio n s In ev ery c a s e ,
3 . Give your f e l i n e r e a c tio n s to each m ed ical d ise a se In term s o f th e p ic tu r e
o r s te re o ty p e you have of th e e n t ir e g ro u p . Mark each group even I f you
do n o t know I t .
U. Check a s many o f seven columns In each c a se a s your f e e lin g s d i c t a t e .
5 . Work a s ra p id ly a s p o s s ib le . ~
P lea se remember to g iv e your f i r s t f e e lin g r e a c tio n s f o r ev ery group and to
g iv e f e e lin g r e a c tio n s to y o u r c h ie f p ic tu r e o f each groups a s a w hole.
Would
marry
In to
group
Would
have a s
c lo se
frie n d s
Would
have a s
n ex t door
n eig h b o rs
Would
work 1:
same
o f f ic e
Pave as
i speaking
a c q u a in t
ance only
Have as
v i s i t o r s
o n ly to
my n a tio n
Would debar
from my
n a tio n
H ypertension
(xugn oiooc
p re s s u re )
I x l t l s
(Eye In fe c
tio n )
o r
C o n ju n c tiv i
t i s
(Eye In fe c
tio n )
.......
' • • .
D iab e te s
H ansen's
D isease
(L eprosy)
•
P s o r ia s is
(S k in
d is e a s e )
D ysentery
.
F lu
182
A PPE N D IX B
STA TE-A N X IETY SCALE
183
SELF-ANALYSIS QCESTIONNAIRB
Form B -l
Nam e • Date ..... ■ — - —
DIRECTIONS! A number of statements which people have used to describe themselves are given
below. Read each statement and then check the appropriate column to the right
of the statement to Indicate how you fe e l -right now, that i s , at th is moment..
There are no right or wrong answers.
Do not spend too much time on any
one statement, but give the answer
which seems to describe your present
feelings best, .
Not at All Somewhat Moderately So Very Hu<
1. Right now 1 feel c a l m . . . •••••• 1 2
3
k
2. I feel secure at the moment,...... . 1 2
3
k
3.
I am presently worrying over some
possible misfortunes........................
1 2
3
4.* At this time I feel that I am a steady perscn. 1 2
3
5.
I feel regretful at the moment.........••••.. 1 2
3
$.
1 2
3
J *
7.
I am worrying about something right now..••••. 1 2
3
8. At the present time I feel rested...•••••••».. 1
•
2
. 3
4
9.
I feel tense and anxious.....••••..•••••••»».. 1 2
’ ‘ 3
10. At the moment I feel free of guilt...........
1 ' 2
3
J *
11.
1 2
.3
>
12. Bight now I feel that I as no good at all..... ' I'. '
2
3
13. X feel X am about to go to pieces............
1 2 *
3
4
B-l-
-2 -
14. lip resen tly f e e l s e lf - c o n f i d e n t .......* ...
15. At th is moment I f e e l happy.• • • • • • • • • • • • • •
16. I f e e l content.. . . . . . . . . . . . .
17. I am worried righ t n o w ................ ..
18. I presently f e e l over-excited and "rattled"
19. I f e e l joyful a t the moment.• • .• • • • • • • • • • • »
20. I f e e l p leasan t.. . .
W ot At A ll Somewhat
2
2
2
2
2
2
2
Moderately So
3
3
3
3
3
3
3
Very M uch So
4
4
It
4
4
185
A PPE N D IX C
T R A IT-A N X IETY SCALE
186
SRU-AWALYSTS O'JSSTIONNAIRB •
Fora B-2
Nam e • Date
D IR EC TIO N S* A number of statements which people have used to desoribe themselves are given
below. Read each statement and then check the appropriate column to the right
of the statement to Indicate how you generally feel.
There are no right or wrong answers.
Do not spend too much time on any
one statement, but give the answer
which seems to describe how you
generally f e e l.
Almost Never Sometimes Often Almost Alvayi
1. I tir e q u ick ly........................................ • • • • • • • • • • •
2 3
4
2. I f e e l lik e c r y in g ...............................• •« • •• •• •• •
1 2
3
It
3.
I wish I could be as happy as others seem
to be.............
2 3
4
I am losin g out on things because I can't
make up m y mind soon enough...• • • • « • • * • • • • .« ..
2
3
4
5.
I f I had m y l i f e to liv e over again, I
2 3
1 * •
6. I am "calm, cool, and collected " .......................... 1 2
3
k
7.
I f e e i that d iff ic u ltie s are p ilin g up so that
I cannot overcome them,••••••••..............•••».••
2
3
k
8. I worry beyond reason over something that
r e a lly doesn't matter. 1 2
3
k
9.
I f e e l u s e l e s s . . . . . . . . . . . . ........... • • • • • • ............ 1 2
3
U
10, I am inclined to take things h a r d . . . . . . .......... * 1 2
3
k
•
H
H
L ife i s a strain for m e . . . . . . « « , . , . i , . a. , (‘ . ( , #
1 • 2
3
B-2
12. I lack s e lf - c o n f id e n c e .......• • • • • • • * • • • • • • • • • •
13. I shrink from facing a crisis or difficulty....
14. I f e e l b l u e . . . . . . .........
15. I do (have done) many things which I r e g r e t ....
16. I brood.
17. Some unimportant thought runs through m y
mind and bothers me. ...........• • • • • • • • • •
18. I take disappointments so keenly that I
can’t put them out of my mind...
19. 1 feel tired.. .
20. I get in a state of tension or turmoil as I
. . think over m y recent concerns and Interests. •• •
Almost Never Sometimes Often Almost A T w ftV S .
2 / 3
It
2
3
It
2
3
It
1 . 2 3
It
2
3
It
0
1 2 3
It
1 2
3
It
1 2
3
It
1 2
3
It
•
A PPE N D IX D
BO D Y -CA TH EX IS SCALE
189
INSTRUCTION!
O n the follow ing pages are lis te d a number of things ch aracteristic of you or related
to you. You are asked to Indicate which things you worry about and would lik e to
change i f It were p ossib le, and which things you liave no feelin g s about one way or the
other.
Consider each Item lis te d below and check the column which b est represents your feelin g s
about yourself now according to the follow ing sca lei
1 - strongly d islik e and wish change could somehow be made
2 - don’t lik e , but can put up with
3 - have no particular feelin g s one way or the other
4 - d e fin ite ly lik e , am pleased with
5 - consider myself particularly and unusually fortunate
Strongly d islik e
and wish change
could somehow be
made
Don't lik e ,
but can
put up with
Have no particular
feelin g s one way
or the other
r
D efin itely lik e ,
am pleased with
Consider
myself
particularly
and unusu
a lly
fortunate
H A IR
I
i
FACIAL C O M P L E X IO N
►
APPETITE. •
H A N D S
DISTRIBUTIO N O F.
H A IR O V E R B O D Y
■
N O S E
FIN G ER S
E LIM IN A TIO N
Strongly d islik e
and wish change
could somehow be
made'
Don*t lik e , but
can put up with
Have no particular
feelin g s one way
or the other
D efinitely lik e ,
a m pleased with
Consider
myself
particularly
and unusually
fortunate
W R IST S
B R E A T H IN G
•
W A IST
E N E R G Y L E V E L
•
•
B A C K
E A R S
C H IN
E X E R C ISE
A N K L E S
•
•
N E C K
SH A P E O F H E A D
B O D Y BUILD
PR O FIL E
H E IG H T
W ID T H O F S H O U L D E R S
A R K S
•
C H E S T
E Y E S
HIPS
SKIN T E X T U R E
•
Strongly d islik e
and wish change
could somehow be
made
Don*t lik e , but
can put up with
Have no particular
feelin g s one way
or the other
D efin itely lik e ,
am pleased with
Consider
myself
particularly
and unusually
forturnte
LIPS
L E G S
T E E T H
F O R E H E A D
FE E T
SL EE P
V O IC E
•
H E A L T H
SE X ACTIVITIES
K N E E S
P O S T U R E
1
-
F A C E
•
W E IG H T
•
S E X (H A L E O R F E M A L E )
B A C K V IE W O F H E A D
• :
T R U N K I
•
A PPE N D IX E
SE L F-C A T H E X IS SCALE
193
194
INSTRUCTIONi
O n the follow ing pages are lis te d a number of things ch aracteristic of you or related to you.
You are asked to Indicate which things you worry about and would lik e to change I f i t were
p ossib le, and which things you have no feelin g s about one way or the other.
Consider each item lis te d below and check the column which best represents your fee lin g s about
yourself now according to the follow ing sca lei
1 - strongly d islik e and wish change could somewhow be made
2 - don’t lik e , but can put up with
3 - have no particular feelin g s one way or the other
5 - d efin itely lik e , am pleased with
5 - consider myself particularly and unusually fortunate
Strongly d islik e
and wish change
could somehow be
made
Gon’t lik e ,
but can
.put up with
Have no particular
Feelings one way
or the other
D efin itely lik e ,
am pleased with
Consider
myself
particularly
and-unusually
fortunate
FIRST W A N E
K O H A L S
ABILITY T O E X P R E SS
SE LF
T A ST E IN C L O T H E S
SEN SE 0? L U T Y
SO i-HIS i'IC ’A T T O 'J
S i t I P-U1 STAfilllNG
L I r it G O A L S .
ARTISTIC T A L itH T o
l
T O L E R A N C E ;
f\O 0! v S
G H N :\i- A L K N O W L lil.G E
I K A .G T :;avj O .i
j
P O P U L A R IT Y
i
f
S SL F -O G :! El i'SuC 5 i
AblLITY T O E X P R E SS
S Y M P A T H Y
|
E M O T IO N A L C O N T R O L
SELF-C O N SC IO U SN ESS
G E N E R O SIT Y
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Strongly dislike
and wish change
could somehow be
cade
Don’t like,
but can
put up with
Have no particular
feelings one way
or the other
Definitely like,
am pleased with
Consider
myself
particularly
and unusually
fortunate
ABILITY T O A C C E P T
CRITICISM
XtTISTIC A N D
L IT E R A R Y T A S T E
.
T H E IF ttNHSS
*
p e r s o n a l it y
SK IF-I-.
ABILITY T O C U " C ivvT H A T ii
ABILITY T O T A K E O R D E R S
T hiAIJR TS
s e n s i t i v i t y t o o p i n i o n
O F O T H E R S
ABILf IT T O L E A D
L A ST N A M E
3 K P U L S E S
K A N -L '.iiS
H A N L-vhirifJO
i n i 'klltgench i .kvel
A T H L E i’fO SKILIjS
c k -:ai'LV .-;;:.-:.s s
L O V E LIFE
S T R E N G T H O F C O T /IC T IO .'J
HAfl-'l N KUS
C oV JvJlE '-iC E
SKILL N IT H H A N D S
F E A R S
C A rA ” IT V K O |{ W O R K
c o n s c i e n t i o u s n e s s
A B IL T T Y T O K E L T P E O P L E
SEi.F-i:iSClPI,r.NE
SU.iO'iSn ?1 f.ITY
N E A T N E S S
•
VO-SAT. 0 1 ARY
f n i. :n M I iini'iOri
W IL L rO.-l.'.k
111 j. v I ' . i i i
ABILITY T O K A K K D ECISIO NS
D R E A M S
6
A PPEN D IX F
L E T T E R TO PSORIASIS PA TIENTS
196
A PPEN D IX F
L E T T E R TO PSORIASIS PATIENTS
Los A ngelos County G eneral H o s p ita l
U n iv e rs ity o f S outhern C a lif o r n ia
School of M edicine
S e c tio n o f Derm atology
2025 Zonal Avenue
Los A ngeles 90033
June 16, 1969
D ear
At th e p re s e n t tim e th e Departm ent o f Dermatology I s a tte m p tin g to
f in d out more about th e s k in d is e a s e which you h ave, p s o r i a s i s . The
o n ly way we can do t h i s i s by se e in g and ta lk in g w ith as many p a t ie n t s
as p o s s ib le . T here a re n o t too many p a t ie n t s , how ever, who have
p s o r i a s i s . For th is re a s o n , we v ery much need your c o o p e ra tio n to
make the stu d y a su c c e ss. U nless we o b ta in the help o f the few p e o p le
who have th is s k in d is e a s e , we w ill n o t be ab le to com plete our i n v e s t l -
g a tio n and w ill f a i l in o u r e f f o r t s to le a r n ttore ab o u t your i l l n e s s .
In s h o r t, we need you!
The p ro ce d u re i s v e ry sim p le . I t w i l l ta k e on ly about one and
o n e -h a lf hours o f your tim e .
You w ill have to come to the h o s p it a l only o n ce.
You Will lipi have Lu wu ir.c d .
You w ill n o t have to ta k e any new m e d ic a tio n .
You w ill o n ly have to b e seen b y , and ta lk w ith , one member o f
our s t a f f , p r iv a t e ly .
You w ill n o t have to pay fo r a v i s i t . . . . i t is f r e e .
I f your money i s lim ite d , and th e c o s t o f c a r f a r e Is a problem ,
we w i l l g iv e you c a r f a r e money bo th ways when you come to
th e C l i n i c . .
Even i f y o u r sk in i s n o t b o th e rin g you now, we s t i l l w ant to see
you.
W e have made an appointm ent f o r you a t the Derm atology C l in ic ,
O u t-P a tie n t B u ild in g . C lin ic SP61. f i f t h f l o o r , on
a t A.M. I f you ca n n o t come ‘ a t th is tim e, p le a se c a l l th e
Derm atology C lin ic d i r e c t l v (CA. 5 -3 1 3 1 , ex cen sio n 3175). They w i l l
g iv e you a n o th e r appointm ent on a Monday o r Thursday m orning, w hichever
I s more co n v en ien t fo r you. I f you c a l l th e C lin ic to change your
appointm ent tim e , p le a se be s u re to c e l l them th e appointm ent is f o r
th e PSORIASIS (o r DERM A TO LO G Y ) RESEARCH STUDY. T h is i s v ery im p o rta n t!
Thank you f o r your h e lp in t h i s w orthw hile stu d y .
Very t r u l y y o u rs,
N O R M A N LEVAN, M.D.
P ro fe s s o r o f M edicine
Chairm an, Derm atology
p e f ..
PLEASE BRIKG THIS LETTER WITH YOU, and SH O W IT AT THE DESK, when you come
f o r your ap p o in tm en t.
197
APPEND IX G
EXPLANATION OF STUDY GIVEN TO
EX PER IM EN TA L GROUP
198
APPEN D IX G
EXPLANATION OF STUDY TO EX PER IM EN TA L GROUP
A s you know, we have been attem pting to le a r n m o re about
your d ise a s e and how it affects you as a whole p e rso n . We fee l that
the d o c to rs w ill be able to u nderstand your p ro b lem s b e tte r and be
able to tr e a t you m o re effectively if they know how the d ise ase affects
your whole life. We a r e now try in g to find out if the kind of d isease
a p e rso n h a s influences h is g en eral outlook on life. In o th er w ords,
does your illn e ss cau se you to see things differen tly fro m a p erso n
who h as som e o th e r d ise a s e . To find th is out, we a re going to a sk you
to fill out som e q u e stio n n a ire s. They a re anonym ous, that is , you
don't have to put your nam e on them . So you don't have to w o rry that
som eone w ill a s s o c ia te your a n sw e rs with your n am e. We have found
that people a r e so m e tim e s m o re fra n k and open if they don't have to
a ttac h th e ir n a m e s to th e ir a n sw e rs. The only.people who will have
a c c e s s to your a n sw e rs a re the people d ire c tly involved with your ill
n e ss. A lso, we a re not so m uch in te re s te d in how one p erso n answ ers
as we a r e in finding out how th irty people with your d is e a s e do. We
a re try in g to se e how a whole group re a c ts , to see if it is different .
199
200
fro m a whole group of patients who have a n o th er d ise a s e .
This is a voluntary study. Nobody can fo rc e you to take part.
But we would a p p re c ia te your help so m uch, b e cau se it is only through
cooperating people like y o u rse lf th a t we can find out the a n sw e rs to
th ese im p o rtan t questions. R e m e m b e r, in the long run, you m ay be
helping yourself. But m o st c e rta in ly you w ill be helping o th e rs who
happen to get the sam e illn e ss a s you have in the fu tu re.
A PPE N D IX H
E X PLA N A TIO N O F STUDY TO CONTROL G RO U P
201
A P PE N D IX H
EX PLA N A TIO N O F STUDY TO CONTROL G RO UP
At the p re s e n t tim e , we at th is h o sp ital (or clinic) a r e a tte m p t
ing to find out m o re about your p a rtic u la r illn e ss. D oes having the
d ise a se you have affect your outlook on life in g e n e ra l? In o th e r w ords,
does your illn ess cause you to see things differently fro m a p e rso n who
h as some other d is e a s e ? We don't know a t the p re s e n t tim e. We s u s
pect it m ight, But we a r e n 't su re . We fee l that if we can find out the
an sw e r to this question, it w ill be a g re a t help to the d o c to rs trea tin g
your disease. They w ill then be able to tr e a t you m o re effectively, and
a s a whole p e rso n , when they know how the d ise ase affects your whole
life. We will a s k you to fill out som e q u e stio n n a ire s. They a re anony
m o u s, that is, you don’t have to put your nam e on them . So you don't .
have to w orry th at som eone w ill a sso c ia te your a n sw e rs with your
nam e. We have found th at people a re so m etim es m o re fra n k and open
if they don't have to a ttac h th e ir n am es to th e ir a n sw e rs. A lso, we a re
not so m uch in te re ste d in how one p e rso n an sw e rs as we a re in finding
out how thirty people w ith your d ise ase do. We a re try in g to see how a
202
203
whole group r e a c ts , to see if it is d ifferen t fro m a whole group of
patients who have ano th er d isease.
T his is a voluntary study. Nobody can fo rce you to take part.
But we would a p p re cia te your help so m uch, b ecause it is only through
cooperating people like y o u rse lf that we can find out the a n sw e rs to
th ese im p o rtan t qu estion s. R e m e m b e r, in the long run, you m ay be
helping yourself. But m o st c e rta in ly you will be helping o th e rs who
happen to get the sam e illn e ss a s you have in the fu tu re.
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Asset Metadata
Creator
Flynn, Patricia Elizabeth
(author)
Core Title
The Psycho-Social World Of The Leprosy (Hansen'S Disease) Patient: Assessment Of Community Reaction To The Disease And Patient Psychologicalfunctioning
Degree
Doctor of Philosophy
Degree Program
Psychology
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
OAI-PMH Harvest,psychology, general
Language
English
Contributor
Digitized by ProQuest
(provenance)
Advisor
Harvey, Herman (
committee chair
), Levan, Norman (
committee member
), Lovell, Constance (
committee member
), Tiber, Norman (
committee member
)
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c18-495486
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UC11363568
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7223142
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495486
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Flynn, Patricia Elizabeth
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University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
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The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
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psychology, general