CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
POSITIVE IMAGERY AND DEPRESSION
A thesis submitted in partial satisfaction of the
requirements for the degree of Master of Arts in
Psychology, Community/Clinical
by
Christina Lynn Cassel Olthof
May 1986
The Thesis of Christina Lynn Cassel Olthof is approved:
ger
oss, Ph.D.
California State University, Northridge
;;
Dedication
This thesis is dedicated as a celebration of the process of life for
my colleagues, friends, family, and my son.
iii
Acknowledgements
I take very special pleasure in acknowledging the encouragement
and assistance of Dr. Benjamin Mehlman, the chairperson of my thesis
committee, and of Dr. Barbara Tabachnick and Dr. Roger Moss, who
served as members of that committee.
I consider myself singularly
fortunate in having worked with a committee which combined science
with creativity and rigorous standards of performance with humanity.
I am deeply grateful to Dr. Marsha Fragner, Dr. Jeannie Wallace,
Dr. Joyce King and Dr. Sheila Zarrow of Community Psychological
Services for their encouraging words and inspirational support.
I thank my friends Donna Ferguson, Sharon Goodman, Karen Gunn,
Ted Hayden, Sue Meir, Steve Newby, David Neswald, Gloria Ryan,
Dan Sexton, and Sue Sampson because they have a way of making the
darkest days seem brighter.
I shou 1d also 1ike to express my appre-
ciation to Donna Ferguson for the endless hours she spent typing the
manuscript.
I especially want to thank my parents \'tlo have always been my
source of inspiration in the pursuit of my career achievements.
I am
also grateful to my aunt, Eloise; my brother, Greg; my niece Roussa;
and nephew, Nolan for their words of encouragement.
Special thanks
goes to my son, Dirk, for the courage and support he has shown me.
iv
Lastly, I thank the members of my graduating class:
David
Appleton, Adrienne Bradford, Sheryl Carlsen, Sydney Eaker, Donna Few,
David Neswald and Sue Sampson.
Special thanks to David and Sue for
their boundless energy and loving support.
Christina Cassel Olthof
April 9, 1986
v
Table of Contents
-DEDICATION •••••••••••••••••••••••••••••••••••••••••••••••••••••••• 111
ACKNOWLEDGEMENTS •••••••••••••••••••••••.•..••.••.•••••••••••••••.•• iv
LIST OF TABLES ••••••••••••••••••••••••••••••••••••••••••••••••••• viii
LIST OF FIGURES •••••••••••••••••••••••••••••••••••••••••••••••••• viii
ABSTRACT ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ix
INTRODUCTION •••••••••••••••••••••••••••••••••••••••••••••••••••• ~ ••• 1
Depression •••••••••••••••••••••••••••••••••••••••••••••••••••••!
Historical Review •••••••••••••••••••••••••••••••••••••••••••• 2
Theories/Treatment/Research ••••••••••••••••••••••••••••••••• lO
Psychoanalytic •••••••••••••••••••••••••••••••••••••••••••• lO
Theory •.•••.•.••.••..••..••.•.••••.•••••.•.••.•.••.•••.. 10
Treatment ••••••••••••••••••••••••••••••••••••••••••••••• l7
Behavioral •••••••••••••••••••••••••••••••••••••••••••••••• 22
Theories •••••••••••••••••••••••••••••••••••••••••••••••• 22
Research •••••••••••••••••••••••••••••••••••••••••••••••• 23
Treatment ••••••••••••••••••••••••••••••••••••••••••••••• 24
Research Limitations •••••••••••••••••••••••••••••••••••• 26
Cognitive ••••••••••••••••••••••••••••••••••••••••••••••••• 26
Theory •••••••••••••••••••••••••••••••••••••••••••••••••• 26
Research •••••••••••••••••••••••••••••••••••••••••••••••• 29
Imagery ••••••••••.••••••.••..••..••••.••.••.•..••.•••.•••••.•• 30
Historical Review ••••••••••••••••••••••••••••••••••••••••••• 31
Theories •••••••••••••••••••••••••••••••••••••••••••••••••••• 36
Research •••••••••••••••••••••••••••••••••••••••••••••••••••• 37
vi
The Present Study .•••••••.•••.•••••.•••.•••••.••••.•••••.•••.. 47
Hypotheses •••••••••••••••••••••••••••••••••••••••••••••••••• 49
METHOD ••••••••••••• ••••••••••••••••••••••••••••••••••••••••••••••• •50
Subjects ...................................................... 50
Test Instruments ••.•••••••••••••••••.••••.••••••.••••••••••••. 53
Procedure ••••••••••••••••••••••••••••••••••••••••••••••••••••• 53
RESULT$ •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 65
Univariate Analysis ••••••••••••••••••••••••••••••••••••••••••• 65
Profile Analysis •••••••••••••••••••••••••••••••••••••••••••••• 68
OISCUSSION ••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 72
Oepression •••••••••••••••••••••••••••••••••••••••••••••••••••• 76
Imagery •••••••••••••• •.•••••••••.••••••••••••••.••••••.•••••• •80
Depression and Imagery •••••••••••••••••••••••••••••••••••••••• Bl
Summary of Problems ••••••••••••..••••••••••••••.•••••••••••••. 82
SUMMARY AND CONCLUSION ••.•••••••••••••••••••••••••••..••••••••••.•• 84
REFERENCE$ ••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 89
APPEND I X•••••••••••••••••••••••••••••·•••••••••••••••••••••••••••••• 97
vii
List of Tables
Page
Table
1
List of Groups by Treatment and Level of Depression •••••••••• 52
2
Analysis of Covariance of Beck Depression Inventory Scores ••• 66
3
Adjusted and Unadjusted Mean Scores of the Beck Depression
Inventory (BDI 2) Associated with Treatment and Level of
Depression ••••••••••••••••••••••••••••••••••••••••••••••••••• 67
4
Profile Analysis of Time, Treatment, Depression, and their
Interaction •••••••••••••••••••••••••••••••••••••••••••••••••• 69
5
Mean Scores of the DMRS for Interaction of Treatment, Level
of Depression and Time Period •••••••••••••••••••••••••••••••• 70
List of Figures
1
Marginal Mean Scores of the DMRS Associated with the Main
Effect of Time Period •••••••••••••••••••••••••••••••••••••••• 71
viii
ABSTRACT
POSITIVE IMAGERY AND DEPRESSION
by
Christina Lynn Cassel Olthof
Master of Arts in Psychology, Community/Clinical
Sixty-five male and female undergraduate college students were
studied to determine the effect of positive imagery on depression.
These participants were pre-selected from a pool of 245 subjects W'lo
scored 12 or more on the Beck Depression Inventory.
Subjects were
randomly assigned to five ex peri mental groups, positive structured
imagery, positive unstructured imagery, relaxation, focus on the
problem and a no treatment control group.
bined for blocking purposes:
Beck's categories were com-
12-19 for mild-moderate depression, and
20-63 for moderate-severe depression to assure that all groups had a
proportunate number of persons in each category.
The Beck Depression
Inventory was used to determine the participants affect and level of
depression.
The Daily Mood Rating Scale was employed to assess the
daily mood of each participant.
A 5 x 2 between subject analysis of covariance was performed to
determine the affect of the respondents.
In addition a 5 x 2 profile
analysis was performed to detect any differences in mood change over
time.
ix
Univariate and multivariate statistical procedures yielded statistically nonsignificant results for the major comparisons between
treatment, level of depression and time period.
time period was statistically significant.
The main effect of
Since there were no sta-
tistically significant results due to treatment, the meaning of this
finding in this study is unclear, and only speculative interpretations
can be made.
Methodological problems and suggestions for future research are
discussed.
Possible explanations for the consistently nonsignificant
results of the statistical analyses of treatment and level of
depression, including interaction effects of treatment, depression and
time are explored.
X
Introduction
Depression is as old as mankind.
11
More human suffering has
resulted from depression than any other single disease affecting
mankind 11
11
(Kline, 1964, p.
732).
The term depression may refer to a
mild passing case of the blues, 11 to a symptom, to a syndrome, or to
an apparent disease.
depression.
There are no signs or symptoms unique to
Depression tends to affect mood, thought, social rela-
tions, and biological functions.
A depressive mood can vary between
being tense, sad or empty; thought within the suffers of this condition are a sense of hopelessness, and a feeling of self-deprecation;
activity is constrained; social activity is minimal; sleep may be
poor; there may be loss of weight and appetite; sexual drive is
lessened; and diurnal mood swings are common.
None of these symptoms
necessarily accompany depression and none are unique to depression.
We are living, perhaps as always, in a tumultous time, a time of
war, poverty, injustice, corruption, and decadence.
contra~d ict ions,
There are many
we are all ultimately alone and there are many reasons
to be depressed, yet most of us do not become clinically depressed
beings marked by futility, inadequacy, and immobilization.
1-bwever,
the depressed patient experiences just these feelings as well as,
often, feelings of unreality.
Mistaken judgement and unfounded fear
in trying to focus on the problems of daily living creates and reflects
within these patients these conflicts.
Paradoxically, the patient can
appear to be normal in al 1 respects during the intervals between
depression.
2
Historical Review
Among the ancients, "mania" was the label for all behavior
characterized by unusua 1 excitement and "mel ancho 1 i a" was used for
all individuals with abnormal depression.
The earliest record of
melancholia in Indo-Germanic cultures is that of the melancholia of
Bellerophon in the Homeric epics.
The first clinical descriptions of
melancholia was made by Hippocrates in the fourth century B.C.
Hippocrates, capable of systematic observation, was an original
thinker limited by the basic lack of knowledge of his time.
He
believed that man reflected the four principal elements of the universe -- earth, water, fire and air.
Fluids in the human body were
said to represent these elements with yellow bile being derived from
the earth, black bile from the water, blood from fire, and phlegm from
air.
Mental illness was a product of an imbalance of the bodily
fluids.
Melancholia was thought to be an excess of black bile.
Hippocrates considered manic and mel ancho 1 ic states to be chronic conditions, although he admitted the possibility of recovery in some
cases (Coleman, 1976).
Aretaeus, an outstanding historical contributor in the Roman
Empire in the first century A.D., believed mania and melancholia were
both representations of the same basic illness.
Aretaeus characterized
melancholia as "a lowness of the spirits without fever and •••
melancholy is the commencement and a part of mania," (Cameron, 1944,
p. 873).
He not only described the symtomatology of manias and
melancholias but also saw a connection between the two states.
He
observed that young people are more susceptible to mania and older
3
people to melancholia, and that, although the two states are related,
mania is not always an outcome of melancholia.
He seems to have anti-
cipated seventeen centuries earlier the contributions of Kraeplin.
In
some ways, he went even further than Kraeplin because he felt that the
spontaneous remissions were not reliable.
He also described very well
the religious, guilt-ridden, and self-sacrificing attitudes of the
melancholic and reported how a severe case of melancholia recovered
fully after the patient had fallen in love.
Plutarch, a Greek, in the second century A.D. described melancho1 i a as thus; "He looks on himself as a man the gods hate and pursue
with their anger.
1
Leave him, • says the wretched man, •Me, the
impious, the accursed, hatred of the Gods, to suffer my punishment.•
He sits out of doors, wrapped in sackcloth or in filthy rags.
He has
eaten or drunk something wrong, he has gone some way or other which
the Divine Being did not approve of.
The festival in honor of the
Gods give no pleasure to him but fill him rather with fear or a fright"
(Beck, 1967, p.5).
Homer, Plutarch, Hippocrates and Aretaeus described both mania
and melancholia as vividly as observers do today in our age.
They
characterize them as related disorders, noted the regularity of
remissons and recoveries, described the personality types of those \'klo
seemed most likely to develop the disorder and the circumstances that
appeared to precipitate the attacks.
They suggested treatments which
included environmental, psychological, physical, and medicinal
measures.
4
Although equally perceptive individual observations continued to
be made through the centuries, the knowledge and attitudes of the
ancients were suppressed during the Middle Ages.
As scientific medi-
cine emerged during the Renaissance, psychiatry was freed from demonology, and physicians rediscovered the phenomena described by
Hippocrates, Aristotle and Aretaeus.
The mentally ill were treated in
hospitals, which ultimately became humanistic in outlook and scientific in operation.
By the sixteenth century, mania and melancholia were generally
considered to be one disorder.
In 1684, a French physician named
Bonet first joined the two names together to form a single disorder
called manic-depressive insanity (Arieti, 1959).
The desire to syste-
matize and classify into orderly categories was characteristic of the
eighteenth century.
Stahl (1660-1734) was the first to divide mental
illness into those of organic origin and those of functional or
psychological origin.
Others contributed to these early, simple cate-
gories became more and more refined and took on a more refined delineation.
Nosologies such as:
melancholia hypochondrica (depression
with gastrointestinal complaints); melancholia thanatophobia
(depression with fear of death); and melancholia demonomania
(depression with fear of the devil) (Arieti, 1959).
At the very beginning of the nineteenth century, Pinel (1801)
wrote a vivid account of melancholia, using the Roman Emperor Tiberius
and the French King Louis XI as illustrations.
lia as follows:
He described melancho-
"The symptoms generally comprehended by the term
melancholia are taciturnity, a thoughtful pensive air, gloomy, suspi-
5
cious, and a love of so 1itude.
Those traits, indeed, appear to
distinguish the characters of some men otherwise in good health and
frequently in prosperous circumstances.
tt>thing, however, can be more
hideous than the figure of a melancholic brooding over his imaginary
misfortunes. If moreover possessed of power, and endowed with a
peverse disposition
and a sanguinary heart, the image is rendered
still more repulsive .. (Beck, 1967, p. 5).
Current conceptions and classifications of manic-depressive reactions derive from the work of Kraeplin, whose thinking in this area
had been influenced by Falret and Baillarger.
Falret studied patients
with depression and suicidal impulses for over thirty years; he noted
that some of them became elated and then depressed again.
published a description of the illness, called it
Circulaire ...
La Folie
Working independently, Baillarger published a report on
another series of patients, terming the illness
Forme. 11
11
In 1854, he
11
Folie a Double
He noted that some of the depressions proceeded to the deve-
lopment of a stupor from which patients did recover.
In 1882,
Kahlbaum described mania and melancholia not as two types of mental
disorder but as stages of the same disease.
that ended in recovery
chronic type
11
11
He named a milder form
cyc1othymia 11 and termed the more severe and
Vesania typica circu1aris
11
(Coleman, 1976).
Impressed by these studies, Kraeplin, in 1896, proposed the name
manic-depressive insanity for this entire group of disorders.
According to Kraep1in:
Q
6
11
Manic depressive insanity comprehends, on the one hand, the
entire domain of so-called periodic and circular insanity and on
the other, simple mania usually distinguished from the above.
In
the course of years I have become more and more convinced that
all the pictures mentioned are merely forms of one single disease
process •••
It is as far as I can see quite impossible to find
any definite boundaries between the single disease pictures \lklich
have been kept apart so far.
From 'simple' mania, the numerous
cases with two, three, four attacks in a lifetime lead over quite
gradually to periodic fonns and from these we reach circular
insanity, through those cases in which a more and more marked
initial or terminal stage of depression gradually complicates the
pure picture of mania, or in \lklich the long series of maniacal
attacks is unexpectedly interrupted by a state of depression •••
manic-depressive insanity, acts as its name indicates, takes its
course in single attacks, which either present the signs of socalled manic excitement (flight of ideas, exhaltation, and
over-activity) or those of a peculiar psychic depression with
psycho-motor inhibition, or a mixture of the two stateS 11
(Mendelson, 1974, p. 34).
Kraeplin is credited for making psychiatry a legitimate branch of
medicine by detailing a clear and concise classification system based
on the disease entity supposition that mental illness exists as a
separate and distinct disease and all the rules that apply to physical
diseases also apply to mental diseases.
Detailed descriptions of the
dementia praecox and manic depressive psychoses were presented by
'
7
Kraeplin as the two major psychoses.
Writing from the disease entity
position, he stressed the symptoms, the course of the disease and the
outcome.
Kraeplin felt that dementia praecox led to mental deteriora-
tion from which recovery was impossible.
Manic-depressive psychosis
was seen by Kraeplin as having no essential deterioration.
He was
uncertain about the etiology of manic-depressive insanity.
However,
he hypothesized that
11
defective heredity is the most prominent,
occuring in from seventy to eighty percent of the cases ••• physical
stigmata may also be present ••• of external causes, besides gestation,
alcoholic excesses are perhaps the most prominent, others are mental
shock, deprivation, and acute diseases .. (Mendelson, 1974, p.4).
Kraeplin accepted and recorded the classification of the psychoses into endogenous and exogenous diseases.
The endogenous were of
internal origin, caused by factors such as organic brain changes.
The
exogenous were of external origin, caused by factors unrelated to
heredity, metabolic differences or constitutional defects.
Kraeplin's
views on disease entities and his clinical descriptions of the major
psychoses can be felt presently in much of psychiatric thought.
However, Kraeplin's hypothesis of disease entities was the
center of controversy of German psychiatry for many years.
Another
major controversy was his exclusion of melancholia of the involutional
period from his concept of manic depressive insanity.
He considered
melancholia of the involutional period a separate entity with its own
variable prognosis.
It wasn't until 1907 that Drefus demonstrated
melancholia of the involutional period belonged in the general category of manic-depressive insanity (Mendelson, 1974).
Dreyfus studied
melancholies at the Heidelberg Clinic and by using Kraeplin's own
8
criterion of prognosis Dreyfus demonstrated the almost universal eventual recovery of melancholia except when dementia intervened.
Kraeplin conceded in 1920 that careful examination of the symptomatology of the patient would provide the basis for a valid prognosis of whether he would or would not deteriorate.
He originally felt
if a patient deteriorated he belonged in the dementia praecox category
and if there was no deterioration he belonged in the manic depressive
category.
Kraeplin decided
11
We are thus obliged to limit to the
utmost the assumption that this disorder is characteristic of a definite process 11 (Mendelson, 1974, p. 5).
Adolph Meyer in 1896 introduced Kraeplin•s scheme of diagnosis
into the Worcester Hospital.
Meyer emphasized that psychotic syndro-
mes were biological types of syndromes.
Meyer then went on to devise
a new Greek terminology based on the root word .. ergasia" which implies
activity of the individual as a person.
became known as the
11
The affective syndromes
thymergasias 11 which included the manic-depressive
group of Kraeplin•s together with the agitated depressions of the
involutional period (Mendelson, 1974).
Meyer was influenced by the Freudians and both were interested in
exploring the depths of human personality.
"Psychiatrists, under the
influence of Meyer and Freud, were no longer to stand at a distance
content to describe what they saw but were to inquire into \ttl at lay
beneath the surface manifestations of psychopathology, i.e., to
explore with increasing interest the depths of human personality.
Psychiatry ceased to be a psychology of surfaces and became a psychology of depths •••
Thus, from its long history as a classificatory and
9
descriptive science, was psychiatry humanized in these few decades"
(Mendelson, 1974, p. 7).
During the 1920 1 S, August Hoch, Kirby and MacCurdy did research
throughout the New York State Psychiatric Institute on several groups
that were considered to have good prognosis.
these groups stupors and states.
Hoch and Kirby called
In the manic-depressive group, they
were labeled "benign psychoses" because of their favorable prognosis.
Hoch tried to prove that apathy, agitation, and distressed perplexity
belonged within the group of depression and elation.
MacCurdy also
felt that "anxiety-apathy insanity" would be equally as appropriate as
manic-depressive insanity.
Dreyfus contented that melancholies were a sub-group of manicdepressive psychosis and they usually improved.
In 1922, 1-bch and
MacCurdy challenged Dreyfus by demonstrating from their research that
there were cases which did improve which they labeled "benign psychosis of manic-depressive variety" and cases W'lich did not improve
called "malignant psychoses clinically related to dementia praecox"
(Mendelson, 1974, p.8).
In 1911, Bleuler published a paper on schizophrenia in which he
suggested that the diagnosis of a disorder be made by clinical symptomology instead of the outcome.
was based on recoverability.
Up until this time, classification
Bleuler•s theory eventually brought an
end to the Kraepelinian theory.
Not until 1943, did Kleist try again to isolate mania and
depression as separate disorders and to understand the circular type
as an association of both.
From 1942 to 1944, Leonhard differentiated
10
between monopolar and bipolar psychoses.
Leonhard tenned periodic
manias and periodic depression as monopolar psychoses.
His research
found more affective psychoses in the relatives of patients with bipolar psychoses than among relatives of patients with mnopolar psychoses.
In 1966, Angst and Perris proposed that periodic mania and
manic-depressive disorders should be summarized as one illness but the
endogenous or periodic depressions are to be separated from the others
(Mendel son, 1974).
Throughout history it has been apparent that depression affects
all aspects of behavior.
Beck defines depression in tenns of five
points:
1.
-2.
3.
4.
5.
A specific alteration in mod: sadness, loneliness, apathy.
Negative self-concept associated with self reproaches and
self blame.
Regressive and self-punitive wishes: desires to escape, hide
or die.
Vegetative changes: anorexia, insomnia, loss of libido.
Change in activity level: retardation or agitation (Beck,
1967, p. 6).
Few syndromes have remained constant in clinical description
throughout history.
Depression has been classified under mel ancho 1i a,
manic depressive reaction, depressed type, manic depressive illness,
depressed type, and major depression.
The categories of depression
have been distinguished by severity, stress, outcome, and presently
depression is classified by current behavior and the patient •s
his tory.
Theories/Treatment/Research
Psychoanalytic Theory
Psychoanalytic insights into the problem of depression began with
11
Abraham in 1911.
Abraham hypothesized that behind every adult
depression there was a forgotten childhood depression.
He theorized
all depressives were basically oral individuals who need more love and
affection that they received.
Abraham felt that neurotic depression
happens when a person "has to give up his sexual aim without having
obtained gratification.
He feels himself unloved and incapable of
1 ov i ng and therefore he despairs of his 1ife and his future"
(Mendelson, 1974, p. 32).
In 1916, Abraham wrote an empirically based paper to support
Freud•s hypothesis of an oral pregenital stage.
In studying six cases
of manic depressive psychosis, he concluded that in all cases
depression resulted from an attitude of hatred which destroyed the
individual•s capacity to love.
The depressive then regresses to an
earlier stage of psychosocial development in Which gratification is
met by oral means.
According to Freud and Abraham, in the oral stage
the primitive child, bent on oral gratification, symbolically "eats
up" the love object, over-identifying with the object and mentally
incorporating it into himself in order to avoid losing it.
When in
later life the individual does, in fact, lose a love object, his rage
and reproach are turned inward and thus become se 1 f-reproach and se 1 floathing (Mendelson, 1974).
One aspect of the consequence of the oral fixation is a
heightened dependence on other people for support and emotional gratification.
According to Abraham, this dependence would contribute to
depression, since any minor rejection can lead to a total loss of
self-esteem in the highly dependent person.
12
In his paper in 1917 "Mourning and Melancholia," Freud drew a
distinction between grief and depression.
Grief is the conscious
reaction to the loss of a loved one real or fantasized while in
depression the true feelings of loss remain unconscious.
In
depress ion, the percept ion of loss is distorted and the ego is
weakened in its effort to repress the feelings of rage and sorrow.
Melancholia is defined by Freud as "the prfoundly painful dejection,
abrogration of interest in the outside world, loss of capacity to
love, inhibition of all activity and lowering of the self-regarding
feelings to a degree that finds utterance in self-reproaches and self
revil ings and culminates in a delusional expectation of punishment"
{Mendelson, 1974, p. 36).
1 ove object.
Freud saw the melancholic as losing his
Freud stressed that the love object need not have been
lost in reality but may have been lost intrapsychically.
In grief,
the person withdraws emotional attachment from the love object.
"To
the grieving person, the world becomes poorer, whereas the disturbance
of se 1 f regard is absent in mourning" (Mendel son, 1974, p. 36).
melancholia, Freud said it ws the ego that becomes poor.
In
Freud
stressed the fact that the depressive has a dominant and punitive
superego, for the source of his reproaches against the introjected
figure is his own superego.
The ego of the depressive, like that of
the neurotic, lacks the strength to cope with the pressures of his own
moral standards.
Freud analyzed the self-reproaches of depressed patients in 1917
and found, "If one listens patiently to the melancholic one cannot in
the end avoid the impression that often the most violent of them are
13
hardly at all
applicable to the patient himself but that with
insignificant modifications, they do fit someone else, some person \'klo
the patient loves, had loved or ought to love ••• so we get the key to
the clinical picture-- by perceiving that the self reproaches are
reproaches against a love object which have been shifted onto the
patient•s own ego-- (Mendelson, 1974, p. 37).
In other words, the
depressive introjects an ambivalently loved person who is the true
focus of the anger that he expresses against himself.
Abraham in 1924, in a paper, discussed the relationship between
obsessional neurosis and manic-depressive psychosis.
The manic-
depressive resembles the obsessive in his ambivalence to his love
object, attitude to cleanliness and order and his feelings about money
and possessions.
Abraham felt that the depressive resembled the
obsessional neurotic in his tendency to form delusional ideas of guilt
because of the patient•s unconscious hostility.
Abraham also saw the
hostile impulses as a result of the delusion of poverty which come
from a repressed perception by the individual of his own inability to
love.
The depressive finds hidden pleasure from his own suffering and
thinking about hirnsel f.
There are also differences in the disorders.
Abraham portrays the melancholic as having
broken off his object
relationship which he views the obsessional as clinging to, and with
any perceived threat to the object both react vio 1ent ly.
The
melancholic, however, regresses to the anal-expulsive destructive
phase and unconsciously destroys and rejects the object and becomes
depressed.
Reacting differently, the obsessional maintains contact
-with the love object due to his retentive tendencies.
The mel ancho-
14
lie, Abraham believed would regress to the oral phase and once recovered, he felt he would regress to the retentive controlling level of
the anal phase and like the obsessional may be able to function fairly
well •
Abraham theorized that the common defense mechanism of depressives,
as well as paranoids, is projection.
thought,
11
The patient repressed the
I cannot love people; I have to hate them" and then projects
"People hate me ••• because of my inborn defects.
Therefore, I am
unhappy and depressed" (Mendelson, 1974, p. 32).
Abraham suggested that depressed persons have ambivalent feelings
of love and hate toward the love object that they perceive as lost.
The ambivalence leads to anger toward the love object because the love
object has rejected the individual.
At the same time, the ambivalent
feelings give rise to guilt because of the individual•s belief that he
fa i 1ed to behave properly toward the now lost love object.
These
conflicting emotions combine to create a self-centered sense of loss,
suffering and despair.
According to Abraham, it is this self-centered
quality that differentiates depression from normal grief.
In other
words, depression is a narcissistic, inner-oriented state, while grief
is a realistic, outer-oriented state.
Both Abraham and Freud characterize the melancholic as "giving
everyone trouble, taking offense easily, and acting as if he has been
treated unjustly.
The melancholic•s so-called delusions of
inferiority besides being reproachfully directed against the introjected love object, may actually represent him to be a very powerful
and omnipotent monster of wickedness"
(Mendelson, 1974 p. 43).
15
Furthering Freud's investigation of The Ego and the Id, Rado in
1928 saw the depressive as having an "intensely strong craving for
narcissistic gratification" as well as "narcissistic intolerance"
(Mendelson, 1974, p. 46).
The depressive, according to Rado, is
childlike in his dependence of his love, approval, regard and recognition of others.
In contrast, the healthier person is able to derive
self-esteem from his own achievements.
Rado sees the depressive as
dependent on "external narcissistic supplies," a need for love and
approval from the outside world (Mendelson, 1974, p. 46).
Rado also
saw the depressive as having a high intolerance for narcissistic
deprivation.
It is more difficult for the depressive to let go of
petty offences and disappointments.
As a result of his or her depen-
dence on love and approval the depressive seeks reinforcement
friends and love objects.
~om
his
Rado states that the person prone to
depressive states is "most happy vtlen living in an atmosphere permeated with libido" (Mendelson, 1974, p. 46).
Rado believed that the depressive treats the love object as a
possession and if then a love object withdraws his love the depressive
becomes hostile and angry.
In an attempt to win back love, the ego
punishes itself, is full of remorse and begs for forgiveness.
"But
the stage on which this love scene is taking place is no longer the
real world.
courted.
It is no longer the lost love object that is being
The ego has moved from reality to the psychic plane and it
is this ,move from reality that constitutes the psychosis"
1974, p. 46).
(Mendelson,
The love object that was lost represents the parent
that never loved him.
When a child is punished and amends have been
16
made the parent restores love for the child.
internalize guilt without punishment.
Sometimes children
This concept is explained
psychodynamically when a child wins the love of his parents or his
superego by punishment (guilt) that was intrapsychically administered.
"His ego becomes the object of aggression or punishment by his
superego by the punishment that was intrapsychically administered
by his guilt.
His ego becomes the object of aggression or
punishment by his superego which is, at one and the same, the
internalization of both his judging and his loving parents.
After the punishment, the ego is again reconciled to the
superego.
The guilt serves the purpose of gradually decreasing
the tension between the ego and the superego.
sequence:
Thus, the
guilt, atonement, and forgiveness .. (Mendelson, 1974,
p. 47}.
Rado contended that despite his guilt the melancholic can't fully
forgive the love object and therefore blames the love object and this
part of his aggression is directed at the introjected object.
The
object is not all bad because the depressive had a love relationship
with it.
According to Rado,
11
The 'good object• whose love the ego
desires is introjected and incorporated in the superego.
There, in
accordance with the principle which ••• governs the formation of this
institution, it is endowed with the prescriptive right ••• to be angry
with the ego.
The • bad object • has been sp 1it off from the object as
a whole, to act, as it were, as whipping boy.
It is incorporated in
the ego and becomes the victim of the sadistic tendency now emanating
from the supe-rego"
(Mendelson, 1974, p. 47).
The cycle is completed:
17
hatreds guilt, self-reproach and punishments as well as splitting the
• bad object' from the good part of the object.
"The ego heaves a sigh
of relief and with every sign of blissful transport unites itself with
the 'good object' which has been raised to the position of the
superego.
Rado saw the melancholic process as a love dramas as a
grand attempt at reparations but enacted in the wrong spheres in the
psychic plane between the anthropomorphized institutions of the mental
apparatus rather than in relation to the object world.
1-bwevers the
restoration of self-esteem results from this psychological sequence"
(Mendelsons 1974s p. 48).
In summary, Rado conceptualized the melancholic as having considerable narcissistic needs.
Rado views the ego as playing both the
role of punisher as well as the giver of love and affection.
After
the loss of the love object, the mel ancho 1 ic becomes angry and tries
to get back his self esteem by punishing his ego and therefore the
cycle completes itself:
Treatment:
hatred, built, self-reproach and punishment.
Psychoanalysis
In the psychoanalytic treatment of depressions Abraham said that
psychoanalysis was "the only rational therapy to apply to the manicdepressive psychosis"
(Mendelson, 974, p. 271).
Abraham studied six
patients and believed that treatment needed to be done between attacks
of the manic depression because it was difficult to maintain treatment
with the severely depressed individual due to the difficulty
establishing a transference.
18
Successful treatment of transference issues were reported in two
cases of "periodic mental depression" by Clark in 1914.
rbwever, in
1919 Clark confirmed Abraham's belief that severe depressives were not
able to be reached and by 1923 contradicted himself again by claiming
to have had ten success fu 1 cases.
He recommended the most appropriate
treatment time was the periods when a patient was entering or just
coming out of a depression.
The focus of concern during the twenties and thirties was the id
and treatment consisted of making the unconscious conscious and
attaining an awareness of the repressed impulses.
Gero in 1936 conceptualized treatment for the depressive as consisting of acceptance and mastery of the genital anxieties because the
depressive adults want to be loved like children.
Gero•s treatment
consisted of character analysis; a process of historical development
in which repressed wishes are experienced from the unconscious and the
solution from the oral fixation becomes possible.
"The solution of the oral fixation is attained less by the adult
neurotic becoming conscious of his infantile wishes and being
thus able to resign these wishes \'klich he now recognizes as
infantile, than by his consciousness that he desires the breast
-- that is to say --the mother; and having become aware of this,
the infantile wish to nestle close to the mother, the longing for
the warm caressing body of the mother arouse also those dark and
ardent wishes of a later time of childhood when he fell passionately in love with his mother.
Consciousness of oral wishes
{l
19
turns into genital excitement.
That is why the actual
experiencing of oral wishes in analysis brings with it genital
sensations.
The solution of the oral fixations is therefore
attained if one succeeds in making the patient experience the
repressed oral impulses, for this experience does not stop at
the oral aims, but activates the genital object-relation of the
Oedipus-situation 11
(Mendelson, 1974, p. 273-274).
Gero then recommends bringing the aggression into consciousness.
11
It is finally necessary for this aggression to be worked out through
its many layers and fixation points until the aggressive impulses originating from the central conflict of the Oedipus situation are made
conscious and the genital anxieties and guilt mastered so that the
capacity of ex peri enci ng genital 1ife and obj ect-rel at ions to the
full, and without ambivalence, is re-established 11
(Mendelson, 1974,
p. 274) •
There are few studies which empirically investigate and report
systematic study of actual groups of depressive patients.
the work of Cohen et. al. (1954) is of particular interest.
Therefore,
These
researchers explored the psychodynamics and family backgrounds of
twelve cases of manic-depressive psychosis and reported that the families had been set apart from their environments by one or another factors such as minority status, economic difficulties or deviant
behavior in a member of the family.
The families counteracted the
social isolation by encouraging conformity and attempting to raise
their economic positions.
As a result of these pressures and stri-
'
20
vings, the family was given prime importance and individual family
members became merely instruments for achieving prestige.
Evidence
suggests that the adult manic depressive uses espressions of selfreproach as a defense against such demands.
prestige was usually impressed by the mother.
The need for winning
She tended to be the
dominant parent and was regarded as strong and reliable but cold and
unloveable.
The father was usually perceived as weak but loveable.
The mother blamed the father for the family's social failure and he
accepted the blame; the children found themselves in the dilemma of
b.elieving that they should strive for the goals set by the disliked
mother and avoid becoming like the loved father.
Usually the oldest
son or sibling who worked the hardest was envied by siblings but was
unaware of the envy and sacrificed his personal desires for the sake
of the family.
He became lonely, isolated and predisposed to
depression because he was not valued for his own sake.
Since the conclusions of Cohen et al. (1954) were based on only
twelve patients with no control group, Gibson (1958) used a technique
that differed from the previous study to investigate the twelve
patients a second time and also to study a group of manic depressives
with a control group of schizophrenics.
In general, his results were
congruent with those of Cohen et. al. (1954):
the two manic
depressive groups were very simil iar to each other in family background
and differed from the schizophrenics in having been subjected to
gr.eater family pressure toward prestige and to a greater degree of
sibling envy.
The mothers of manic depressives were more reliable
than the fathers, a family constellation not true for schizophrenics.
21
In one aspect, the second study (Gibson, 1958) did not bear out the
first (Cohen, et a. 1954):
the prestige strivings of the second manic
depressive group did not emerge from social isolation but from the
personality makeup of the parents.
However, Gibson•s study (1959)
suffered from a methodological weakness:
he obtained the additional
manic depressive group by taking one hundred and twenty consecutive
hospital admissions diagnosed manic depressive and then eliminated all
but twenty-seven of them on the grounds that for the rejected patients
the diagnosis was not certain enough or reliable information concerning family background was not available.
The methodological
weakness of self-selection could have resulted in experimental bias.
Parental deprivation in childhood is an important pre-disposing
variable for depressives.
Brown ( 1961) presented statistical evidence
that early loss by death of both father and mother was much more frequent for depressed patients thatn for non-psychiatric control groups.
Forty-one per cent of depressive patients had lost a parent before the
age of fifteen as compared with fewer than twenty per cent of the
controls.
Brown (1961) hypothesized that a child can be sensitized by
situations of loss of love and emotional deprivation so that s/he
breaks down in various ways in later life when faced with subsequent
situations of loss and rejection.
Clinical impressions indicate that the childhood interpersonal
relationships of manic depressives are almost invariably disturbed but
the disturbance is not consistent from patient to patient.
In many
cases, maternal deprivation and pressures to conformity are present as
stressed in Cohen•s study.
In others, a warm and satisfactory rela-
22
t ionship with both parents is interrupted by the loss of a parent,
usually the father.
In still others, the father is absent or is
psychologically cold.
The father may also have periods of depression
in which relationships with parents show marked fluctuations associated
with parental mood swings.
In psychodynamic treatment for depressives, there are some basic
goals to consider:
the analysis and fuller consciousness of early
childhood, specifically the lost love object; the exploration of the
self in an attempt to build self esteem; and the expression of anger.
These views for analysis must be considered in tenns of difficulties
which must be overcome in the treatment of these individuals.
In
1945, Fenichel summarized three difficulties that had to be overcome
in working with the depressive patient.
The first was oral fixation,
the second was ambivalence of transference, and lastly the inaccessibility of the patient.
Fenichel felt that
11
even if the analysis
fails, the patient is temporarily relieved through the opportunity of
unburdening himself by talkingn
(Mendelson, 1974, p. 174).
Mendelson (1974) in his detailed review of psychoanalytic
depression described the literature as a
11
great investigation. 11
11
great debate 11 instead of a
He felt that there was a tendency rather than
critically examining the individual dynamics to confirm if these dynamics supported or refuted the theo ret ica 1 concept.
Behavioral
Theories and Research
23
Learning theorists view depression in stimulus-response terms.
Depression is a severe loss of reinforcement.
Once positive reinfor-
cement is withdrawn and behaviors are no longer rewarded, the person
consequently will not longer emit these behaviors.
The person becomes
withdrawn, inactive and then depressed.
Behavioral theorists have proposed various factors that might predispose a person to depression.
Lewinsohn's theory is that depressed
individuals have a greater tendency to withdraw from adversive stimuli
than non-depressed people.
Lewinsohn (1972) suggests that the
depressed person's low rate of positive reinforcement may be due not
only to events in his/her life situation but to his own lack of social
skills.
Lewinsohn postulates that depressive behaviors alienate other
people.
In support of his hypothesis, Lewinsohn (1972) found that in
comparison to normal control groups, depressed people elicit and
engage in fewer human interactions, convey shorter messages and time
their messages less appropriately.
Research
Lewinsohn, Lobitz, and Wilson (1973) compared the autonomatic
responsiveness of depressed and non-depressed groups following aversive stimulation in the form of mild electric shocks.
The depressed
responded more (higher skin reactions) to the aversive stimuli than
did the non-depressed group.
This result might reasonably lead one to
expect the depressed individual to show a greater tendency to withdraw
from unpleasant situations.
24
Ferster {1965) points to the role of avoidance in depression.
He
suggests that when certain effective behaviors have been reduced by
the withdrawal of reinforcement, the anxiety produced by the tendency
to engage in these activities supresses them and encourages avoidance
behaviors such as withdrawing from social interaction.
The passive
quality of the depressed person•s behavior is linked to his tendency
to respond to the aversive control applied by other people rather than
to initiate behaviors on his own.
Another variable that may predispose some people to depressive
reactions is suggested by Seligman and others in the theory of learned
helplessness (Seligman et al, 1971; Seligman, 1974).
This theory was
based on a series of experimental studies with dogs.
After exposing a
number of dogs to inescapable electric shocks, the researchers found
that when the same dogs were later subjected to escapable shock, they
were either unable to initiate escape responses or were slow or inept
at escaping.
The researchers noted the similarities between the
behavior of the dogs and that of human depressives and hypothesized
that the depressives• inability to initiate adaptive responses may,
like that of the dogs, be due to a helplessness conditioned by earlier
inescapable trauma.
Treatment
The aim of Behavioral therapy is to teach the patient to be more
effective in obtaining positive rewards (Lewinsohn, 1972).
The
Behaviorist goes directly to the symptoms or the depressive behaviors
that need to be changed.
This can be accomplished by using a number
25
of techniques.
For example, the patient may be taught how to monitor
events using prepared schedules to increase pleasant events, and to
decrease unpleasant ones.
Relaxation training and social skills
training are also a part of the Behavioral therapy technique.
Patients are encouraged to diversify their behaviors, to interact with
more individuals, and to react more positively and more quickly to the
behaviors of others.
Coping responses are rewarded whi 1e depressive
behaviors are ignored.
According to Behaviorists, evidence exists that indicates the
behavioral treatments of depression may be more effective than either
antidepressant medication or traditional psychotherapy
(Rehm, 1981 ).
These claims of success, however, are classic arguments among all
theorists and researchers.
The most encouraging results were obtained
in a study by Mclean and Hakstian (1979).
One hundred and fifty-four
depressed subjects were randomly assigned to (1) short term
psychotherapy which attempted dynamic and personality insight, (2)
relaxation therapy, (3) Behavior therapy W'lich stressed goal setting,
communication, assertiveness and cognitive self-control, and (4) drug
therapy with 150 mgl. of amitriptyline maximum.
Participant require-
ments were that subjects had to have been depressed for at least two
months, be experiencing impaired functioning as well as elevated
scores on three depression tests.
weekly sessions.
Treatment consisted of 8 to 12
Behavior therapy was found to be most effective and
psychotherapy was least effective.
26
Research Limitations
There are some limitations in Behavioral research.
Most studies
reporting clear effects have been done by the originator of the technique and few replications have been done, especially by independent
researchers.
In most of the studies, the N•s are small, techniques
are not well specified and control groups haven•t been given an adequate chance to show an effect on their own terms.
In all research on depression, there is a problem of the definition of depression.
Behavioral studies have been particularly poor in
specifying the population studied.
Most of the behavioral studies lack
direct comparability, outcome measures are inconsistent, and there are
difficulties in comparing treatment parameters, time parameters, and
length of follow-up.
Research in the areas of biological, genetics,
sleep research, biochemical, sociological and epidemiological research
has not been incorporated in the behavioral literature.
Many studies in Behavior therapy research have used more than a
single technique and it is unclear which is really the effective technique when success is claimed.
and cognitive.
Many techniques are both behavioral
Generally, combinations of techniques appear to be
more effective than single techniques.
Cognitive Theory
Depression involves a number of changes:
emotional changes,
motivational changes, cognitive changes and changes in physical and
motor functioning.
Cognitive theorists believe the way the person
thinks about himself/herself is the critical variable in depression.
27
Beck (1967) suggests that with depressives there is a disturbance
in thinking that causes the development of the disturbed mood state.
Beck and Valin (1953) found that themes of self-punishment occur with
great frequency in the hallucinations and delusions of psychotically
depressed patients.
In a later study of patients in psychotherapy,
Beck and Hurvich (1959) found that the dreams of depressed patients
contain themes of low self-esteem, loss, deprivation, and frustration
in attempting to reach goals.
dreams as a "loser...
The depressive sees himself in his
Beck explains that the content of the
depressive•s dreams, fantasies, and delusions are detennined not by a
desire for suffering or self-punishment but by an idiosyncratic cognitive set or schema through which experiences are perceived in a negative 1i ght.
Beck postulates that if a person, because of early childhood
experience, develops a cognitive schema involving a negative bias
toward himself and a pessimistic view of the future, that person is
then predisposed to depression.
Stress can also easily activate the
negative schema and the resulting negative perceptions merely serve to
strengthen the schema.
For the depressive, the sad affect that
results from the depressive•s persistently negative interpretations of
experience is interpreted as further evidence of objective hopelessness.
Therefore, the negative cognitive set becomes progressively
more dominant as the depression deepens.
Beck (1967) characterizes the thinking patterns of depressed
patients as having minimal self regard, ideas of deprivation, selfcritizing, self-blaming, exaggerated ideas of responsibilities and
28
escapist and suicidal thoughts.
Beck sees the development of these
though process as being attributable to five major points.
The first
is arbitrary inference from a situation that is neutral or impersonal.
Secondly, self abstraction which is when a situation is taken out of
context and exaggerated while a person continues to concentrate on one
aspect of a situation.
Overgeneralization occurs when an overall
conclusion is based on a single incident.
Fourthly, magnification and
minimization occur when a person exaggerates his difficulties and
limitations and minimizes his achievements and capacities.
Inexact
labeling results from the magnification of an experience with a direct
association between the emotional response and the label instead of
the actual response and actual experience.
In all these various pro-
cess of thinking, usually the patient remains firm in his view of the
situation or thought.
The fixated thinking and the development of
these patterns usually parallels the course of the illness.
Lichtenberg (1957) hypothesized that depression stems from a
person's attributing to himself responsibility for not achieving his
goals.
Ellis (1962) suggests that the way a person thinks about him-
self may lead him to become self-accusatory and depressed.
Ellis
(1962) suggests that many people create for themselves a set of irrational values and unrealistic goals which they then require themselves
to live up to.
And when they fail, they become depressed despite the
fact that their goals were totally unreasonable.
Cognitive therapy treatment modalities are aimed at correcting
the depressed patient's negative view of the self.
Both positive
thinking and more realistic and logical thinking are encouraged to
29
promote behavior and mood changes.
As the therapist directs
discussions of specific problems, differences between therapist and
patient in their conceptualizations about these problems are resolved
logically.
Cognitive rehearsal and graded task assignment are used to
bring about behavioral change.
These methods lead to increased
mastery of situation that the depressed person considered to be
hopeless.
Research
Controlled studies indicate that cognitive/behavioral therapy is
superior to purely behaviora 1 or nand i rect ive approaches in bringing
about change in depressed patients
1977).
(Shaw, 1977; Taylor & Marshall,
Shaw (1977) showed some evidence for treatment efficacy.
Participants were assigned to cognitive therapy, behavior therapy, a
nondirective treatment control, or a waiting list at a university counseling center.
All therapy was conducted in small groups with the
investigator serving as the therapist for all subjects.
The effec-
tiveness of the treatment was assessed by the Beck Depression
Inventory and clinician ratings on the Hamilton Rating Scale for
depression.
Ratings on the Hamilton Rating Scale were made from
videotaped interviews by raters blind to treatment conditions.
Cognitive therapy was superior to behavior therapy and the nondirective group on both measures with each of those two groups superior to
the waiting list control.
The problem of a single therapist, with his
own biases, is not controlled in this study.
One roonth later in a
follow-up assessment, treatment gains were no longer statistically
significant.
30
Taylor and Marshall (1977) compared four treatment groups consisting of college student volunteers.
The groups consisted of:
1) cognitive-behavioral treatment, 2) cognitive therapy, 3) behavioral
therapy, and 4) no-treatment control.
Treatment consisted of six
sessions over six weeks by graduate student therapists.
Assessment
was determined by three measures; the Beck Depression Inventory,
MMPI-030 (a short version of the 60-item depression scale); and the
visual Analogue Scale.
Cognitive-behavioral treatment reduced the
symptoms more than the no-treatment control.
Mean differences that
were statistically significant were not maintained at five week
follow-up.
Cognitive/Behavioral therapy was found to be superior to imipramine treatment in chronically depressed and suicidal patients (Rush,
et. al, 1977).
Subjects had an unmixed depressive diagnosis W'lo were
applicants for treatment at an outpatient clinic.
Subjects were
assessed on both the Beck and Hamilton Rating Scale for depression.
Subjects were excluded who had a prior history of poor response to a
tricyclic antidepressant.
Cognitive therapy was administered for ele-
ven weeks in fifty minute sessions.
Treatment with the antidepressant
involved weekly supportive therapy for twenty minutes.
Both groups
showed improvement, but the cognitive therapy groups showed considerably more improvement.
At a three month follow-up, as well as at
six months, subjects continued to differ significantly (Rush, et. al.,
1977).
Imagery
31
Hi sto rica 1
Early psychological studies of imagery began during the
eighteenth century with Hume, the British philosopher, who compared
sensations and emotions (percepts) which he called impressions and the
more faint images which characterize thinking and reasoning.
His non-
experimental work was based on his personal experience with subjects
in his study.
He found that externally derived sensory material was
characterized by a greater degree of force and liveliness, or vividness, of the images when compared with thoughts.
It was not until the work of Schaub (1911) that experimental
scientific study determined that subjects \'ilo listened to actual
sounds in four different tasks reported that \'tlen both images and
sounds were presented the subjects could not differentiate an objectively presented stimulus from an imagined sound.
Perky (1910), a student of Titchner, demonstrated that if that
same image was projected on the screen the subject was unable to
discern whether the image was his own or if it was an internally
generated image.
During the first part of the twentieth century, there was controversy about the nature of imagery and whether all thinking required
some visual or auditory imagery in order to be carried on.
Titchner
supported this hypotheses, and Kulpe and Ach from the Wurzberg school
in Germany argued aginst Titchner•s position.
A series of studies
indicated that attitudinal sets did not require imagery in order to
influence thinking or perception, which settled the issue in favor of
the Wurzberg school.
32
The Wurzberg school marked the beginning of the behaviorist
school which led American psychologists away from the study of the
inner experience and the research of imagery was not investigated
again until the 1960's.
Segal (1971) replicated a study done by Perky
which indicated that individuals who had projected imagined scenes on
a blank screen could not detect whether an actual externally projected
image was simultaneously appearing on the screen.
The European studies of imagery were not as 1imited and
restrained experimentally as those of the American and British
researchers. Jung influenced the spirit of the times maintaining that
we carry within us a great range of metaphor and symbolism reflecting
the cultural experience of our past, and that this is related to the
major issues of masculinity, femininity, family, and the nature of man
within the universe.
Jung believed in analyzing a dream within its own structure,
whereas Freud believed in free association, separating out the elements and associating independently to them.
Freud's system led Jung
into his own method of active imagination in which a patient in
therapy attempts to re-dream the dream and re-experience it imaginally
and then report a kind of general overall reaction to the dream.
The
active imagination technique was encouraged for private use by the
patient to understand current problems since many tendencies in his
current life were likely to emerge in symolic form in his dreams.
It
seems obvious that Jung's method underlies the contemporary mental
imagery movement in psychotherapy.
Bachlard, a distinguished physicist at the Sorbonne, influenced
33
European psychology and psychotherapy through philosohpy.
the symbols of air, nature, and fire.
11
He examined
Bachelard argued that 'the
creative imagination' is the fundamental human experience and that
indeed it is as much a part of man's reality as the stored reproductions of external events and stimuli .. (Singer, 1974, p. 32).
Binet, a forerunner in the development of mental imagery, studied
his daughters and had them use the technique from generating images
with eyes closed which helped to structure the process involved in
imagery methods in psychotherapy (Singer, 1974).
Early in the twentieth century, Schultz, the originator of
biofeedback, began working on a technique for self-control and muscular relaxation which led to using imagery as a self control technique.
Schultz's main contribution to the field of mental imagery was the use
of a therapist's direction with controlled generation of imagery
(Schultz, 1959).
Oesoille, an engineer with no formal training in psychology or
psychiatry, is responsible for the majority of the mental imagery
techniques developed.
He had worked with a man named Caslant who had
attempted to develop a technique for generating psychic experiences.
Caslant used directed imagery scenes of climbing mountains, or
descending to the earth to dissipate actual memories so the individual
could generate a creative form of imagery that would be likely to
induce some extrasensory experiences.
Oesoille used Caslant's methods at first and then developed his
own technique called the "waking dream."
He formalized many of the
procedures still used by practitioners such as Leuner, Fretigny and
34
Virel and Assagioli who have had medical or psychological training.
Some of the mental imagery techniques developed out of Desoille's
work have been used in the United States.
Other applications of ima-
gery have appeared in Gestalt therapy techniques and behavior therapy.
Behaviorists insist that their techniques are scientifically more
objective.
However, the techniques rely on or include a combination
of relaxation and imagery.
Wolpe's method of systematic desensitization is designed primarily for patients with phobias.
In an interview, the details of the
irrational fears are noted, and the construction of a heirachy is
formed of the least frightening situation to the most frightening
situation.
These situations are used to generate images during treat-
ment, and usually the Jacobson method of relaxation is applied before
and after the phobic image.
Essentially, Wolpe's theory is based on
the principle that one cannot simultaneously be relaxed and anxious.
The idea is to teach patients to relax and then, while they are in the
relaxed state, to introduce a gradually increasing series of anxietyproducing stimuli.
Eventually, the patient becomes desensitized to
the fearful stimuli by virtue of having experienced them in a relaxed
state.
Chapman and Feather (1971) suggest that relaxed subjects are more
sensitive to the phobic properties of the controlled imagery, that
they experience the fearful emotion more vividly than the non-relaxed
subjects.
They seem to contradict Wolpe's position that one cannot be
simultaneously relaxed and anxious.
It may point up the fact that
35
relaxation may have the psychological effect of assisting the individual to generate more vivid imagery.
In a review by Mathews of the
psychophysiological measurements in desensitization treatment,
.. relaxation may augment both vividness and the autonomic effects of
imagery, while at the same time maximizing response decrement with
repeated present at ion 11 {Mathews, 1971, p. 88).
Wilkins (1972) sees imagery as the critical component in the
desensitization process; .. The instructed imagination of fear-relevant
scenes is the only necessary element .. (Wilkins, 1972, p. 34).
Wilkins
(1972) offers two models as an explanation as to why imagery is crucial to the procedure of desensitization.
The respondent model
believes the phobia is extinguished because the imagined conditioned
stimulus is not followed by the unconditioned stimulus.
The operant
mode 1 emphasizes that in i magi nation one becomes aware of the absence
of negative reinforcers and also, perhaps, experiences positive reinforcement by not avoiding behavior through fantasy.
Further research is needed in this area to determine the effects
of imagery in the process of desensitization.
1-bwever, it seems
possible that when the patient has gained an ability to control his or
her images, as a result, he has an added boost in self-esteem as well
as an improvement in his ability to confront a frightening situation.
The scientific study of the function of daydreaming, fantasizing,
and imagery is presently being investigated with renewed interest
(Paivio, 1971; Singer, 1966, 1971, 1974).
History and literature
substantiates the plausibility of the thesis that induced fantasy and
36
imagery techniques may play an important role in initiating behavioral
change.
Meichenbaum (1978) proposes that imagery-based therapists
produce change because the client is taught and comes to believe that
his/her imagery contributes to his/her maladaptive behavior.
Clients
are taught to become aware and monitor their images and note their
occurences within the maladaptive behavioral chain; the consequences
of interrupting the maladaptive chain alters vklat the clinet says to
h imse 1 f and does when s/he experiences the images.
The resu 1ts,
according to Meichenbaum, is that these processes convey to the client
a sense of control over his images, and in turn, over interpersonal
behavior.
Theories
One of the major recurring themes in all uses of imagery in
psychotherapy or behavior modification is that of the sense of selfcontrol the patient gains, since imagery is so private (Singer, 1974).
Bandura (1976) theorizes that social learning emphasizes cognitive
processes and the importance of producing ultimate behavior change.
Bandura suggests projecting thoughts into the future, which in turn
will elicit expectations of the outcomes and our images or selfverba 1 izat ions of vklether we can successfully carry out the necessary
actions to produce such outcomes.
Self-efficacy cognitions in the
form of imagery fantasies in some form determine \'klether we will initiate certain types of behavior as well as how long we will persist or
how much effort we will expend.
The positive image of coping may
reinforce the sense that one can handle situations and may ultimately
37
strengthen a sense of self-efficacy.
It is equally important to
stress that participation in frightening or unpleasant experiences
leave a memory of the negative affective experience.
It is also
possible that even without experiencing an actual unpleasant event, a
person's lack of belief in coping skills with such situations may lead
to negative affect in just imagining such situation.
One's self-efficacy orientation is strongly related to chronic
affective conditions such as depression.
Cundiff and Gold (1979) stu-
dies one hundred and thirteen males at the Veterans Administration
Hospital.
They found that depressed mental patients had fewer
daydreams of a pleasant, wishful nature than did other psychiatric
patients.
Starker and Singer suggested that it is possible to
establish a tentative link between depressed affect and daydreaming.
Findings indicate that psychiatric patients were observed to have less
positive reactions to daydreams and greater fear of failure in
daydreams.
Research
Schultz (1976) designed a study to investigate the immediate
changes in the affective state of sixty male depressed psychiatric
patients in response to speci fie imagery content.
One week after
admittance to the psychiatric hospital, each patient was seen individually and instructed to follow one of four imagery procedures of
either aggressive, socially gratifying, positive, or free imagery.
Patients were encouraged to regard the use of imagery as a ski 11 which
can be learned.
After getting comfortable, each individual was
instructed to close his eyes or to focus his gaze at a point and to
38
visualize the imagery scene in his "mind•s eye" in as much detail as
possible.
In the aggressive imagery procedure, the patient was
instructed to remember someone saying or doing something which angered
him.
The patient was requested to reca 11 someone saying or doing
something which made him feel very pleased in the socially gratifying
imagery procedure.
In the positive imagery procedure, the patient was
asked to remember a place in nature he went to relax.
The free ima-
gery procedure required the patient to report all thought, images,
fantasies and ideas without consciously trying to direct his stream of
consciousness.
This procedure lasted ten minutes and then further
data were gathered using cognitive, affective, and perceptual measures
which have been shown to be related to one•s level of depression.
Schultz•s study (1976) indicated that directed imagery
{aggressive, socially gratifying and positive) produced significantly
lower levels of depression than free imagery.
It was also found that
there were different responses to the various imagery procedures
depending upon the patient•s type of depression.
For the patients
whose depression was characterized by dependency issues, lower levels
of depression were achieved after aggressive and socially gratifying
imagery.
For the patients whos depression centered around self crit-
icism, lower levels of depression were attained after socially gratifying and positive imagery.
Those patients
\'~hose
imagery was
positively oriented, showed lower levels of depression after socially
gratifying and positive imagery.
The patients
\'~hose
imagery centered
around guilt themes showed more signs of depression after positive
imagery.
39
In another study, Burtle (1976) investigated eight depressed
patients with psychomotor retardation v.tlo experienced either positive
imagery training or relaxation training.
The positive imagery
training used a three-state procedure which involved perceptual
training using Thematic Aperception Test (TAT) cards, relaxation
training with practice in imaging TAT cards, and a period of making
self-generated positive changes in the TAT images.
Lower levels of
depression and an increase in imagery product ion were experienced by
those in the positive imagery training compared to those depressives
who experienced relaxation training only.
Jarvinen and Gold (1981) extended the work of Schultz and studied
the immediate changes and the long-term changes in the level of
depression in a six-month follow-up study.
Fifty-three mildly to
moderately depressed female undergraduates were assigned to neutral,
positive or self-generated positive imagery conditions as well as to a
no-treatment control group on the basis of their scores on the Beck
Depression Inventory.
Students in the neutral and positive imagery
group were given five neutral and five positive scenes to visualize
throughout the day and to picture each scene at least twice a day.
Students in the self-generated positive imagery group developed their
own five scenes according to the themes that matched the scenes of the
positive imagery group and were requested to visualize the scenes
throughout the day and to picture each scene at least twice a day.
Students in the no-treatment control condition were not given scenes
to image.
All students rated their moods on the Daily Mood Rating
Scale (DMRS) for the three-week period.
40
Lower levels of depression were reported for the students in the
three imagery groups as measured by the Beck Depression Inventory
(BDI).
The students also reported lower levels of depression on the
Zung Self-Rating Depression Scale and higher mood ratings, but these
findings did not reach statistical significance.
Thirty-one students
from the original fifty-three madera tel y depressed female undergraduates
responded to a follow-up questionnaire and shows no significant
differences in mean scores on the Beck Depression Inventory follow-up
between control and treatment groups.
1-bwever, fifty-seven per cent
of the students in the imagery conditions reported noticing a change
in mood as a result of the study compared to only thirteen per cent in
the no treatment control group.
Sixty-two per cent of the students
in the imagery conditions also reported that they were applying what
they had learned through the study and thirty-eight per cent of those
in the no-treatment control group reported doing so.
The results of
Jarvinen and Gold (1981) show that changes in the level of depression
through the use .of imagery can be attained and the degree of benefit
appears to diminish gradually over time.
Propst (1980) in a comparative study between immediate and a sixweek follow-up study in level of depression investigated the use of
religious imagery.
Propst's subjects scored rooderately high on a
religiosity scale. Propst assigned thirty-three female and eleven male
mildly depressed undergraduate students to one of four treatment
conditions:
non-religious imagery, religious imagery, self-monitoring
plus non-directive discussion, and a self-monitoring only.
A baseline
41
was established for two weeks showing a mildly depressed mood.
Each
student then experienced two one-hour group therapy sessions per week
for a four-week period for a total of eight group therapy sessions.
Students in the non-religious imagery group described their depressive
episodes and their images and then were asked to develop an awareness
of their depression-engendering images.
In an attempt to foster self-
awareness, the students were instructed to record their moods and
accompanying mental images five times daily between sessions.
In the
third group session, students were given a list of coping statements
that were directed toward modifying the three components of Beck's
cognitive triad of depression (1976):
future.
negative self, environment, and
The students then re-enacted their depressive images and used
their selected coping imagery and statements to modify their
depressive imagery.
In the religious imagery group, the procedures
were the same except a list of religious images and coping statements
were used to modify their depressive images (e.g.,
11
1 can visualize
Christ going with me into that difficult situation in the future as I
try to cope ... )
Students in the self-monitoring plus non-directive
discussion groups were free to discuss whatever they wanted, were
asked to record their daily mood and to record items for group
discussion on their mood record.
In the se 1 f-monito ring condition,
students were told that they were in a control group and were asked to
fi 11 out da i 1y mood records •
Students who were in the self-monitoring plus non-directive imagery and the religious imagery conditon reduced their level of
42
depression compared to the self-monitoring only condition.
Fourteen
per cent of the religious imagery condition students scored in the
depressed range whereas sixty per cent of the non-religious imagery
group and sixty per cent of the self-monitoring only condition still
scored in the depressed range.
Twenty-seven per cent of the students
in the self-monitoring plus non-directive discussion groups also still
scored in the depressed range.
A greater increase in group interac-
tion was shown by students who experienced religious imagery over the
students in other conditions.
In the six week follow-up study, there
was a trend (p L.lO) toward decreased global psychopathology and
decreased depression for the religious imagery condition as compared to
the other students.
1-bwever, there was no significant difference
among the four conditions in the students \\ho still scored in the
depressed range or in the group interact ion.
Propst findings are simil iar to Jarvinen and Gold (1981) in that
mildly depressed students are able to reduce their level of depression
immediately but the degree of benefit decreased over a six week
follow-up period.
However, Propst's findings minimize the likelihood
that demand characteristics produced the decrease in depression
because behavioral as well as self-report measures of depression in
the direct imagery therapy were used.
An even oore important
finding is demonstrated by the increased effectiveness of imagery when
it is coupled with the individual's value system.
Lipsy, Kassinove, and Miller (1980} investigated the immediate
changes in level of anxiety, depression, hostility and neuroticism
43
among Community Mental Health Center patients who were diagnosed as
neurotic or suffering from adjustment reaction of adulthood.
Thirty-
seven female and thirteen male patients were assigned to one of five
treatment groups which were then divided into high and low IQ groups.
Patients in the Rational Emotive Therapy (RET) were taught the principles of RET and given a minimum of twelve ABC statements to analyze,
as well as taught the eleven irrational ideas by Ellis.
Patients were
given bibliotherapy and behavioral assignments \'klen necessary.
Patients in the RT plus training in addition, beginning in the third
session, patients were given one RRR exercise per therapy session.
This exercise consisted of the patient and therapist reversing roles
for fifteen minutes so that by the end of the treatment each patient
had participated in ten RRR 1 s.
Patients in the RET plus Rational
Emotive Imagery (REI) condition were given the RET training and, in
addition, they were given one REI scene per therapy session so that by
the end of treatment each patient had participated in ten REI.
During
the fifteen minute REI session, the patient imagined a disturbing
event to which the patient typically responded with an irrational
thought and an excessive emotion.
The patient was then instructed to
imagine responding with rational thoughts \'klich led them to responding
to a new feeling which was less negative and excessive.
In the alter-
nate treatment (AT) control condition patients received a combination
of supportive therapy and deep muscles relaxation training.
Relaxation training exercises were introduced at the third session and
lasted for twenty minutes each therapy session.
At the end of the
44
twelve weeks, each patient had received two sessions of supportive
therapy and ten sessions of combined supportive therapy and relaxation
training.
Patients in the no contact (NC) control condition were
placed on a waiting list.
All patients in the three RET groups and
the AT condition met individually for a forty-five minute therapy
session once a week for a total of twelve weeks.
All patients were
administered the dependent measures immediately before and after the
twelve week period.
Both therapists had more than two years training
in RET and behavior therapy and were blind to the patients• scores.
The results indicated that the patients in the three RET conditions reported more RET content acquisition, less depression, less
neuroticism than those in the AT and NC conditions.
Patients in the
RET plus RRR and RET plus REI conditions reported lower state anxiety
than those in the AT and NC conditions.
There were also reported dif-
ferences for the high and low IQ patients to some of the treatment
conditions.
Regardless of the treatment, low IQ patients reported
lower depression that high IQ patients.
High IQ patients in the RET
plus REI condition reported less trait anxiety than low IQ patients in
the same condition.
Low IQ patients in the AT conditon reported less
trait anxiety than high IQ patients in the same condition.
Lipsky,
Kassinove, and Miller•s results (1980) seem to indicate that imagery
in therapy is effective in reducing depression as well as enhancing
the verbal psychotherapeutic methods.
IQ is not a major factor
affecting therapeutic benefit, but might possibly affect the length of
time and techniques to users.
It is also necessary to consider that
45
there are limitations to this study.
One limitation is that all
dependent measures were self-reported and there was no direct measure
of behavioral change as a result of the treatment.
Reardon and Tosi (1977) studied thirty-two adolescent delinquent
females to determine the changes in self-concept and level of
depression.
groups:
All adolescents were assigned to one of four treatment
Rational State Directed Imagery (RSDI) which is a combination
of imagery, deep relaxation or hypnosis and rational or cognitive
restructuring; a cognitive behavioral treatment approach which utilized vivid emotive imagery and relaxation; a cognitive treatment
approach using rational restructuring; a placebo treatment; and a notreatment control group.
weeks.
Each group met weekly for one hour for six
Self report measures of self-concept and level of depression
were obtained for all subjects.
Reardon and Tosi (1977) results indicate that adolescents in the
RSDI group reported a higher self-concept and a lower level of
depression than the other conditions.
A similiar improvement was
reported for the cognitive rational restructuring group.
The data
showed significant findings for six of nine Tennessee Self-Concept
scales and two of three Multiple Affect Adjective Check List scales.
In a follow-up study two months later, only those subjects in the RSDI
group reported higher self-concept and lower depression.
Therefore,
in considering these findings, it seems that directed imagery maybe
useful in reducing depression and in improving self-concept and selfesteem and those improvements can be maintained for at least two
months.
46
The effectiveness of imagery as a self-regulation procedure is
gaining increased recognition.
Singer (1978) reports therapeutic
effects with patients in a moderate depressive cycle with the inducement of positive nature scene imagery. Jarvinen and Gold (1981)
demonstrated that encouraging de pres sed subjects to attend to nondepressive daydreams reduced their level of depression.
Schultz•s
(1976) research demonstrates that severely depressed hospitalized male
patients who engaged in either self-esteem enhancing imagery of positive nature scenes, were able to reduce the amount of depression and
were more able to laugh and experience positive emotion.
Findings
from these studies suggest that the use of imagery in the two-fold
process: the generation of strong emotions that break through the
depressive cycle of negative thoughts and the maintenance of strong
emotions through the directedness of an imagery procedure that shifts
the subject from ruminating about current negative thoughts.
process lends further support to the
suggested by Lazarus (1968) and the
11
11
This
affective expression .. model
Circular feedback .. model
suggested by Beck ( 1967).
The circular feedback model suggests that there is an interaction
between cognition and affect that is mentally reinforcing, which
suggests that thoughts not only influence feelings but feelings can
influence thought content (Lazarus, 1968}.
Hammon and Glass (1975)
suggest that depressed subjects rate self-chosen pleasant activites
more negatively that non-depressed subjects.
Rychlak (1973) reported
that with increasing levels of depressive affect high school males
47
change their attitudes about thier fantasies and focus more on negative topics.
Similiar findings have been reported among general male
psychiatric patients (Starker and Singer, 1975) and a study with
depressed male psychiatric patients (Schultz, 1976) also lends support
to the circular feedback model of Beck (1967) that emotions can
influence thought content.
The Present Study
The purpose of the present study is to extend the research
dealing with imagery and depression.
Jarvinen and Gold (1981) studied
the immediate changes (3 weeks) and the long-term changes (6 months)
in the level of depression in a follow-up study.
In the Jarvinen and
Gold study, fifty-three mildly to moderately depressed female
undergraduates were chosen on the basis of their scores on the Beck
Depression Inventory and were assigned to neutral, positive or selfgenerated positive imagery conditons as well as to a no-treatment
control group.
Those subjects \'ilo scored 12 or more on the Beck
Depression Inventory and a pretest score of .30 to .81 on the Zung
Self-Rating Depression Scale were admitted to the study.
Students in
the neutral and positive imagery group were given five neutral and
five positive scenes to visualize throughout the day and to picture
each scene at least twice a day.
Students in the self-generated posi-
tive imagery group developed their own five scenes according to the
themes that matched the scenes of the positive imagery group and they
were requested to visualize the scenes throughout the day and to picture each scene at least twice a day.
Students in the no-treatment
48
control conditon were not given scenes to image.
The research was
analyzed using the Wilcoxen matched pairs signed ranks test.
The
instruments employed were the Beck Depression Inventory and the Zung
Self-Rating Depression Scale.
All students rated their moods on the
Daily r-t>od Rating Scale for the three weeks period.
The present study added new elements to Jarvinen and Gold (1981),
by expanding the experimental groups to include a group that focused
on their problems and negative thoughts to further test Jarvinen and
Gold's (1981) and Synder and White's (1982) supposition that depressed
individuals keep themselves depressed by turning positive experiences
into negative experiences.
Jarvinen and Gold (1981) suggested participants practice
imaging the scenes in the presence of the researcher to guarantee that
the scenes were positive.
In the present study, all positive imagery
treatment groups (structured and unstructured) were instructed in
visualization and practiced visualizing the scenes with the experimenter.
The positive structured imagery group had a tape of the ima-
gery which ensured that the scene was positive and the positive
unstructured imagery group wrote down their imagery scene in the initial meeting so that it could be confirmed that it was a positive
image.
Jarvinen and Gold (1981) also suggested the subjects introduce
their own elaborations into the scenes, in this study, the positive
unstructured imagery group generated their own positive scenes.
The
scenes included past, present, or future situations as long as they
had positive affect and outcome.
,, .
(1
49
Also, this study broadened the investigated population by
including male as well as female subjects.
The current study was an
expansion of the research of Jarvinen and Gold (1981 ).
The present
study employed the Beck Depression Inventory and the Daily Mood Rating
Scale.
The Zung Self-Rating Depression Scale was not employed due to
the lack of statistical significance attained in the Jarvenin and Gold
( 1981) research.
The focus was on the influence of imagery as an aid
in coping with depression.
The purpose of this study will be to further determine 'lklether
when the moderate or severly depressed student is deflected from
thinking about his/her present life concerns by having him/her focus
on positive imagery s/he may be helped to disrupt the cognitiveaffective circular feedback cycle.
The techniques to be used in this
study will not only consist of imagery feedback but also relaxation
therapy.
Specifically, the hypotheses are:
a)
Subjects in the positive imagery groups (structured and
unstructured) will experience a statistically greater reduction in depression than those subjects in the remaining
groups:
relaxation, focusing on the problem, and a no-
treatment control.
b)
Those subjects in the positive structured imagery group will
experience a statistically greater reduction in level of
depression than those subjects in the positive unstructured
imagery group.
'
c)
On the Daily r.t>od Rating Scale, the positive imagery
(structured and unstructured) and relaxation groups will
report a more positive state than those subjects instructed
to focus on the problem or who are exposed to no treatment.
Method
Subjects
The participants were male and female undergraduate volunteers
enrolled in introductory psychology courses at California State
University at Northridge.
Their participation partially fulfilled an
introductory psychology course requirement.
The Beck Depression
Inventory (BDI) was administered to 245 students.
From the pool of
245, 80 who scored more than 12 on the Beck Depression Inventory
agreed to participate.
stages of treatment.
Fifteen dropped out of the study at various
Of the 15 dropouts, four were in the positive
structured imagery group (of the four, one was in the low level of
depression and three were in the high level of depression), one was in
the positive unstructured imagery group (high level of depression),
four were in the relaxation group (of the four, one was in the low
level of depression, and three were in the high level of depression),
three were in the focus on the problem group (all in the high level of
depression}.
There was no significant difference in dropout rate due
to treatment, x2 (4)
= 2.2, P7 .05.
The 100re depressed subjects were
more 1i kely to drop out, however, x2 (1}
50
= 8.07,
p L .05.
51
The total number of participants was 65.
Subjects were randomly
assigned to five experimental groups, positive structured imagery,
positive unstructured imagery, relaxation, focus on the problem, and a
control group.
An unbiased assistant used a table of random numbers
to assign the participants to the groups.
In the positive imagery
group, there were 12 participants; in the positive unstructured imagery group, there were 15 participants; in the relaxation group, there
were 12 participants; in the focus on the problem group, there were 13
participants; and in the control, there were 13 participants.
52
Table I
Sample Size by Treatment and Level of Depression
Treatment
High
PSI
PUI
REL
FOP
CON
5
7
5
5
5
7
8
7
8
8
12
15
12
13
13
27
Depression
Low
38
PSI = Positive structured imagery
PUI = Positive unstructured imagery
REL = Relaxation
FOP = Focus on the problem
CON= Contro 1
High level of depression = 20-63 score on the Beck Depression Inventory
Low level of depression = 12-19 score on the Beck Depression Inventory
Test Instruments
The Beck Depression Inventory consists of twenty-one groups of
statements which describe symptoms that are integral to the depressive
sphere and that are graded according to the degree of their intensity
(Beck and Beamesderfer, 1974).
To evaluate internal consistency
split-half reliability was assessed.
The Pearson r between the odd and
even categories was computed and yielded a reliability coefficient of
0.86.
The correlation of BDI scores with the clinician's ratings of
depression and with other psychometric tests for depression constituted solid support for the concurrent validity of the BDI as well as
strong support for the construct validity of the BDI (Beck and
Beamesderfer, 1974).
The Daily Mbod Ratings Scale (DMRS) consists of a continuum scale
numbered one to ten with ten describing the best possible mood the
person has ever been in and one the worst (Appendix A).
This instru-
ment was used to assess the daily mood of each patient after the
treatment had been applied (Rehm, 1978; Jarvinen & Gold, 1981 ).
Procedure
All subjects were seen in groups.
The first session was iden-
tical for all subjects and subjects were told:
Thank you for participating in this study.
As you know, this
study concerns moods and I will tell you more about it later.
For
experimental purposes, I'm not able to tell you more about it
now.
There is the possibility that you will be asked to further
participate in this study for a three week period during which
54
time I will ask you to complete other questionnaires, keep some
records of your moods and have a short weekly meeting with me.
Only participants that are interested in making this committment
should fill out the questionnaire I am now going to hand out.
The instructions for the Beck Depression Inventory were read to the
group.
This is a questionnaire. On the questionnaire are groups of statements.
Please read each group of statements carefully.
Then
pick out the one statement which best describes the way you have
been feeling the past week, including today.
beside the statement you picked.
Circle the number
If several statements in the
group seem to apply equally well, circle each one.
Be sure to
read all the statements in each group before making your choice.
After the subjects completed the questionnaire, those students
who met the selection requirement were matched according to levels of
depression.
Beck's determined categories (10-15 for mild depression,
16-19 for mild-moderate, 20-29 for moderate-severe and 30-63 for
severe depression) were combined for blocking purposes:
12-19 for
mild-moderate depression and 20-63 for moderate-severe depression.
This procedure was used to assure that all treatment groups had a proportionate number of like-depressed persons, after blocking the subjects were randomly assigned to one of the five groups by means of a
table of random numbers.
Both the blocking and the assignment were
done by a nonparticipant who was unaware of the hypotheses and the
5S
treatment to which the groups were assigned.
The five treatment groups are:
positive structured imagery
(PSI), positive unstructured imagery (PUI), relaxation (REL), focusing
on the problem (FOP), and a control group (CON).
After the selection procedure and randomization to groups, the
subjects were instructed as follows:
Thank you for participating in this study.
This study concerns
moods and when it is completed I 1 11 explain it to you and answer
any questions.
As I explained before, you will be asked to par-
ticipate for three weeks in this study.
any kind at this time?
Are you in counseling of
Are you aware that there are counseling
services available on campus free-of-charge for any kind of
problem you may have?
If during the study you decide to par-
ticipate in counseling, I ask that you let me know for the purposes of the study.
Do you have any questions?
Thank you.
For
the next week I would like to make a daily record of your roood on
the sheet that is being passed around.
scale and rate just this day• s mood.
Starting tonight use this
Mood is defined as the
general or over-all state of mind you have been in for the entire
day.
On a scale of 1 to 10, 1 being the worst possible roood you
have ever been in and 10 being the best possible roood you have
ever been in, circle the number which best describes your mood
(Appendix).
go to bed.
At the end of each day fi 11 out this form before you
I wi 11 co 11 ect this from you next week.
any questions?
Thank you.
Do you have
,, .
At this point, the no-treatment control group was dismissed and
instructed to return weekly for the exchange of the Daily Mood Rating
Sea 1e form.
After the Daily Mood Rating Scale instructions, participants in
the individual treatment groups were given instructions.
The focus on
the problem group (FOP) was instructed to concentrate on things that
are going wrong in their lives for 15 minutes in the morning and again
for 15 minutes, once more, later in the day, in the afternoon, or
early evening for three consecutive weeks.
It was stressed that they
were only to think of the chief problems of their life at this time
during the day.
The instruct ions were as follows:
Every day for 15 minutes in the morning and once more later in
the afternoon or early evening, concentrate on the things that
are going wrong in your life.
Think of your chief problems in
this time period only and do not think of these problems again
until the next 15 minute period.
Are there any questions?
Next
week we will meet again to collect the Daily Mood Rating Scale.
Thank you.
The relaxation group (REL) was given the following instructions:
Every day for 15 minutes in the morning and 15 minutes once more
later in the afternoon or early evening you will be asked to do a
relaxation exercise.
Find a tranquil place and time where you
won•t be disturbed.
Lie down with your legs uncrossed and your
arms at your sides.
Close your eyes, inhale slowly and deeply.
57
Pause a moment, then exhale slowly and completely.
Allow your
abdomen to rise and fall as you breathe, do this several times.
You now feel calm, comfortable, and more relaxed.
your breathing will become slow and even.
self,
11
As you relax,
Mentally say to your-
My feet are relaxing; they are becoming more and more
relaxed.
My feet feel heavy •11
Rest for a moment.
same suggestions for your ankles.
Rest again.
Repeat the
In the same way,
relax your lower legs, then your thighs pausing to feel the sensations of relaxation in your muscles.
Relax your pelvis.
Relax your fingers.
Rest.
Relax your hands.
forearms, your upper arms, your shoulders.
neck.
Rest.
tongue.
whole body to relax.
Relax your
Relax your
Rest.
tt>w just rest.
Relax your
Allow your
You are now in a calm, relaxed state of
You can deepen this state by counting backwards.
in; as you exhale slowly, say to youself,
very relaxed ••• "
tally, "Nine.
11
Ten.
Breathe
I am feeling
Inhale again, and as you exhale repeat men-
I am feeling more relaxed ••• ~~
am feeling even more relaxed •• :•
Breathe.
Breathe.
11
Seven.
deeper and more relaxed. 11
more relaxed.
Six.
Four {pause).
Three {pause).
{pause).
Rest.
Relax your eyes.
forehead and the top of your head.
being.
Relax your
Relax your jaw, allowing it to drop.
Relax your cheeks.
Rest.
Two (pause).
11
Eight.
Deeper and
Five (pause).
One (pause).
Zero
You are now at a deeper and more relaxed level of
awareness, a level at which your body feels healthy, your mind
feels peaceful and open.
To return to your ordinary
I
58
consciousness, mentally say, .. I am going to move.
when I count
to three I wi 11 raise my left hand an stretch my fingers.
I wi 11
then feel relaxed, happy and strong, ready to continue my everyday activities .. (Samuels, 1983, p. 108).
relaxation exercise you just did.
Here is a copy of the
Please read over this every
time before you do the relaxation exercise.
The time you spend
actually doing the relaxation exercise is 15 minutes.
Next week
we will meet again to collect the Daily Mood Rating Scale (DMRS).
Are there any questions?
Thank you.
The subjects assigned to the Imagery conditions were encouraged
to regard the use of imagery as a ski 11 procedure that can be learned.
After a relaxation exercise was given, the subjects were asked to
close their eyes or focus on their gaze at a distant point.
Then the
subjects were instructed to follow one of the procedures by
visualizing the entire experience in his/her
11
mind 's eye .. in as great
detail as possible.
The positive structured imagery and the positive unstructured
imagery groups were instructed to do the imagery 15 minutes daily at
least twice a day for three consecutive weeks and to note on their
Daily Mood Rating Scale (DMRS) the number of times per day they did do
their imagery.
The positive structured imagery group were given a
standardized imagery to do twice a day.
The positive unstructured
imagery generated their own positive scenes.
The scenes could be
about past, present or future situations as long as they had positive
affect and outcome.
In the initial meeting, the positive unstructured
59
imagery group were asked to write down their imagery so that it could
be confirmed that it was a positive image.
The following instructions were given to the positive unstructured imagery groups:
Imagery is a skill procedure that can be learned.
Today you will
be creating your own private positive imagery by visualizing a
nature scene in your
possible.
11
mind •s eye 11 in as great a detail as
l'bw get as comfortable as possible.
place and time where you won•t be disturbed.
legs uncrossed and your arms at your sides.
inhale slowly and deeply.
completely.
Pause a moment, then exhale slowly and
As you relax, your breathing will become slow and even.
11
My feet are relaxing, they are
becoming more and more relaxed.
again.
Close your eyes,
You now feel calm, comfortable, and more
Mentally say to yourself,
moment.
Lie down with your
Allow your abdomen to rise and fall as you breathe,
do this several times.
relaxed.
Find a tranquil
MY feet feel heavy ...
Repeat the same suggestions for your ankles.
Rest for a
Rest
In the same way, relax your lower legs, then your thighs,
pausing to feel the sensations of relaxation in your muscles.
Relax your pelvis.
Rest.
Relax your fingers.
Relax your hands.
Rest.
Relax your forearms, your upper arms, your shoulders.
Rest.
Relax your neck.
drop.
Relax your tongue.
Rest.
Relax your forehead and the top of your head.
rest.
Allow your whole body to relax.
Rest.
Relax your jaw, allowing it to
Relax your cheeks.
Relax your eyes.
tt>w just
You are now in a calm,
6-0
relaxed state of being.
backwards.
11
Ten.
You can deepen this state by counting
Breathe in; as you exhale slowly say to yourself,
I am feeling very relaxed ••• ~~ Inhale again, and as you
exhale repeat mentally, Nine.
Breathe.
11
Seven.
"Eight.
I am feeling more relaxed •••11
I am feeling even more relaxed ••• 11
Deeper and more relaxed.
relaxed. 11
(pause).
Five {pause).
One (pause).
Six.
Deeper and more
Four (pause).
Zero (pause).
Breathe.
Three (pause).
Two
You are now at a deeper
and more relaxed level of awareness, a level at which your body
feels healthy, your mind feels peaceful and open (Samuels, 1983,
p. 108).
It is a level at which you can experience images in
your mind more clearly and vividly than ever before.
Think of a
peaceful place you have been or you have read about, or use your
imagination to create an environment.
and peaceful.
Breathe deeply •••
everything, hear everything.
environment?
You are feeling relaxed
See everything, feel
What colors do you see in your
Explore your place in nature.
Now before you
return, is there something you•d like to take with you?
are ready ••• you can say to yourself mentally,
move.
11
When you
I am now going to
When I count to three, I will raise my hand and stretch my
fingers.
I wi 11 then feel relaxed, happy and strong, ready to
continue my everyday activities:•
Now I would like you to
briefly write down your experience on paper and when you finish
please bring it to the front of the room.
Here is a copy
61
of the relaxation exercise you just completed, please
read over this every time before you do the relaxation and imagery.
The time you spend on imagery is 15 minutes.
Next week
we will meet again to collect the Daily Mood Rating Scale (DMRS).
Are there any questions?
Thank you.
The positive structured imagery group were given the same
instructions as the positive unstructured imagery group, but the
nature scene was different.
The following instructions were given to
the positive structured imagery group:
Imagery is a skill procedure that can be learned.
Today you will
be creating your own private positive imagery by visualizing a
nature scene in your own
possible.
11
mind •s eye 11 in as great detail as
First you will be guided through a relaxation exercise
and then you will have a tape of an imagery scene.
Now get as
comfortable as possible.
Find a tranquil place and time where
you won•t be disturbed.
Lie down with your legs uncrossed and
your arms at your sides.
Close your eyes, inhale slowly and
deeply.
Pause a moment, then exhale slowly and completely.
Allow your abdomen to rise and fall as you breathe, do this
several times.
You now feel calm, comfortable, and roore relaxed.
As you relax, your breathing will become slow and even.
Mentally say to yourself,
11
My feet are relaxing, they are
becoming more and more relaxed...
a moment.
again.
My feet feel heavy."
Repeat the same suggestions for your ankles.
Rest for
Rest
In the same way, relax your lower legs, then your thighs
62
pausing to feel the sensations of relaxation in your muscles.
Relax your pelvis.
Rest.
Relax your fingers.
Relax your hands.
Rest.
Relax your forearms, your upper arms, your shoulders.
Rest.
Relax your neck.
drop...
Rest.
Relax your tongue.
backwards.
Relax your eyes.
Seven.
11
Eight.
11
Nine.
Inhale again, and as you
I am feeling more relaxed •• :•
I am feeling even more relaxed •• .'•
Deeper and more relaxed.
Five (pause).
(pause).
You are now in a calm,
You can deepen this state by counting
I am feeling very relaxed •• .'•
Breathe.
l't)w just
Breathe in; as you exhale slowly say to yourself,
exhale repeat mentally.
11
Relax your cheeks.
Allow your whole body to relax.
relaxed state of being.
Ten.
Relax your jaw, allowing it to
Relax your forehead and the top of your head.
relax.
11
Rest.
Four (pause).
Zero (pause).
Breathe.
Six. Deeper and more relaxed.'•
Three (pause).
Two (pause).
One
You are now at a deeper and oore relaxed
level of awareness, a level at which your body feels healthy,
your mind feels peaceful and open.
(Samuels, 1983, p. 108).
It
is a level at which you can experience images in your mind oore
clearly and vividly than ever before.
you are walking through a forest.
many trees?
Is there a chill?
Is it a big forest?
Are there
As you walk through this forest
feel the earth beneath your feet.
walk through the forest? •••
In your mind •s eye imagine
Are there any sounds as you
any colors that you can see?
And as you walk through the forest, you•ll notice a trail that
begins to slowly wind its way up the mountain.
As you
"
'
63
walk, it becomes a little steeper, but you continue walking up
the trail.
And there, up ahead, you can see there's a place
where the trail levels off.
Walk up to that level part of the
t ra i 1, and there part of the way up the 100unta in, on the side of
the trail, cut deep into the mountain, there's a cave.
deep withing the cave, there's a light glowing •••
a safe cave so you walk inside.
camp fire.
It feels like
In the back there is a small
Sitting by the camp fire is a very wise person.
does this wise person look like?
of clothing?
And from
What kind of hair?
What
What kind
What kind of face does this wise person have?
Imagine it so clearly that you become this wise person looking
out of the 100uth of the cave.
Who just came up the trail?
Who do you see wa 1 king toward you?
Now become yourself again.
Approach
the camp fire and put a stick in the fire and sit down with this
wise person.
This wise individual turns to you and says,
have a question for me?
Ask this wise person a question.
to the answer and think about what it means...
11
Do you
Listen
Soon it •s going
to be time to leave this wise person but before you go, this
individual gives you a gift.
Imagine that gift.
gift does the wise person give you?
What kind of a
What does it mean to you?
Now it's time to leave the cave ••• the wise person says
goodbye •••
Remember at any time that you choose you can come
back to this cave.
Think of your question, think of the answer,
think of the gift, think of it's meaning •••
Slowly begin to walk
back down the trail, you created that mountain, that cave, that
wise person, you asked and answered your own quest ion and gave
64
yourself a gift in that cave, that wisdom, that gift is all
within you.
Remembering that walk through the forest and when
you•re ready come back to here.
say to yourself mentally,
11
When you are ready ••• you can
I am now going to move.
When I count
to three, I will raise my hand and stretch my fingers.
I will
then feel relaxed, happy and strong, ready to continue my everyday activities •
11
Here is a copy of the relaxation exercise and a
tape of the imagery you just completed.
Please read over this
each time before you do the relaxation exercise. The time you
spend on the imagery is 15 minutes listening to the tape in the
morning and 15 minutes once more later in the day in the afternoon or early evening.
Every day do the imagery at least twice a
day for the next week and note on the Daily Mood Rating Scale the
number of times per day you do the imagery.
The time you spend
on the imagery is 15 minutes listening to the tape.
Next week we
will meet again to collect the Daily Mood Rating Scale (DMRS).
Are there any questions?
Thank you.
The no treatment control group (CON) met weekly to exchange the
Daily Mood Rating Scale forms of the past week for new ones.
During the fourth meeting all subjects were administered the Beck
Depression Inventory.
The Daily Mood Rating Scale was also collected.
All subjects were told that after the study was completed they could
inquire in the research assistant•s office about the results of the
study and at that time they were also debriefed.
Results
Univariate Analysis
A 5 x 2 between subject Analysis of Covariance was perfonned on
one of the two dependent variables employed in this study.
This
dependent variable was associated with the affect of the respondents,
the posttest of the Beck Depression Inventory (BDI 2).
The pretest of
the Beck Depression Inventory (BDI 1) was used as a covariate.
The
independent variables consisted of treatment (positive structured imagery, positive unstructured imagery, relaxation, focus on the problem
and control) and level of depression (high and low).
Adjustment was
made for one covariate, the pretest of the Beck Depression Inventory
(BDI 1) to determine the level of depression prior to the administration of treatment.
Sat is factory results were obtained from eva 1uat ion of assumptions
of nonnality, homogeneity of covariance matrices, linearity, homogeneity of regression and multicolinearity.
The distribution of scores
on the Beck Depression Inventory was skewed and a logarithmic transfonnation was performed.
The raw scores are found in Appendix B.
The
transformed pretest and posttest Beck Depression Inventory scores were
employed in the analysis.
The results are presented in Table 2 and
the cell means are presented in Table 3.
65
66
Table 2
Analysis of Covariance of Beck Depression Inventory Scores
Sums of
Squares
DF
Mean
Square
F
p
1. 923
1
1.923
16.615
.001
Treatment
0.604
4
o. 151
1.305
.30
Depression
0.073
0.073
1.305
.40
0.528
.70
Source
Covariates
Log BDI 1
Main Effects
Interact ion
Treatment by
Depression
0.245
4
0.061
Residual
8.875
62
0.143
6.7
Table 3
Unadjusted Mean Scores of the Beck Depression Inventory (BDI 2)
Associated With Treatment and Level of Depression {No adjustment for
pretest).
Treatment Group
High Depression
Low Depression
PSI
10.00
5.71
PUI
18.29
6.38
REL
11 .oo
4.57
FOP
15.20
7.50
CON
18.80
8.50
Adjusted Mean Scores of the Beck Depression Inventory (BDI 2)
Associated With Treatment and Level of Depression.
Treatment Group
High Depression
Low Depression
PSI
.89
.72
PUI
1.20
.70
REL
1.04
.60
FOP
1.15
.89
CON
1 • 18
.91
68
The log transformed pretest (BDI 1) scores were significantly
related to the log transformed posttest (BDI 2), F (1,52)= 16.615,
pL.OOl.
There were no significant main or interaction effects for
treatment, level of depression, or treatment by depression interaction, p7.05.
Profile Analysis
A 5 x 2 profile analysis was performed on seven time periods
using SPSS Manova.
These seven periods were attained by combining the
twenty-one scores of the Daily Mood Rating Scale (DMRS) into seven
scores.
Time period 1 (PER 1) is the sum of the scores for each sub-
ject on the DMRS for day 1 to day 3; time period 2 (PER 2) is the sum
of scores for day 4 to day 6; time period 3 (PER 3) is the sum of day
7 to day 9; time period 4 (PER 4) is the sum of day 10 to day 12; time
period 5 (PER 5) is the sum of day 13 to 15; time period 6 (PER 6) is
the sum of day 16 to day 18; time period 7 (PER 7) is the sum of day
19 to day 21.
These seven periods were associated with the daily
self-reported affect of the respondents.
The five treatment groups
and high versus low level of depression served as the between subject
independent variables in this analysis.
Satisfactory results
were obtained from evaluation of assump-
tions of normality, homogeneity of variance-covariance matrices,
linearity, multi-collinearity and homogeneity of regression.
outliers were detected.
sented in Table 5.
No
The results of the profile analysis are pre-
9
69
Table 4
Profile Analysis of Time, Treatment, Depression and their Interaction.
Wilk's Lambda
OF
F
p
Depression
NA**
1 '53
1 .419
.239
Treatment
1'\1\ **
4, 53
.262
.901
Depression x Treatment
1'\1\ **
4,53
.491
.742
Treatment x Time
.582
24,168
1 .178
.268
Depression x Time
.868
6,48
1 • 212
.316
24, 168
.994
.476
6,48
3.386
.007*
Source
Levels
----
Parallelism
Depression x Treatment x
Time
.630
Flatness
Time
• 703
** Between-subjects effects are tested univariately
'
Table 5
Mean Scores of the DMRS for Interaction of Treatment, Level of Depression and Time Period
PSI
PUI
REL
DEP 1
DEP 2
17.200 19.125 15.200
16.000
16.600
16.615
18.000 17.875
18.000 18.714 18.400
15.714
17.000
17.538
18.125
17.429 20.428
16.600 18.125 16.400
18.286
20.400
18.354
19.857
19.500 18.875
17.143 19.000
16.600 17.500 16.000
21 .000
19.600
18.615
PER 5
18.857
17.500
22.750
16.714
20.285
17.400 19.375
20.000
20.143
18.000
19.338
PER 6
17.714
19.750
22.375
18.000 19.429
18.200 17.500
20.200
19.295
20.000
19.246
PER 7
20.857
18.750
22.000
18.857 19.800
17.750 15.800 16.714
18.400
18.892
18.892
DEP 1
DEP 2
PER 1
15.857
15.000 16.000
16.429 17.286
PER 2
18.000
18.5000 17.875
PER 3
17.571
20.250
PER 4
DEP 1
= Low
OEP 2
DEP 1
W\RGI ~L
MEANS
CON
DEP 1
DEP 1
DEP 2
FOP
DEP 2
Depression
DEP 2 = High Depression
'-I
0
71
Using Wilk 1 S criterion, there was no significant deviation from
parallelism over time associated with treatment, depression or the
treatment by depression interaction, p7 .05.
Similarly, when scores
were averaged over time, univariate analysis showed no significant
effects of level of treatment, level of depression, or their interaction p7 .05.
The main effects of time period was statistically significant,
F (6,48)= 3.38, pL .007, ~- 2=.297.
Since there was an overall trend
that seemed to indicate that the mood level increases over time, a
post hoc trend analysis was performed.
There was a significant linear
trend (improvement over time), F {6,58)= 2.31, pL.o5.
No significant
effect was found for the quadratic trend, p 7 .05.
21 .oo
20.50
20.00
19.50
19 .oo
18.50
18.00
17.50
17.00
16.50
16.00
15.50
] 5 .oo
2
3
4
5
6
7
Time Periods
Figure 1
Marginal Mean Scores of the DMRS Associated With the Main Effect of
Time Period.
Discussion
Although this study was designed as an expansion of other
research (Jarvinen and Gold, 1981; and Snyder and White, 1982) the
findings differed considerably.
Jarvinen and Gold (1981) hypothesized
that all imagery-based treatments would show a greater decrease in
depression, and that positive directed imagery would be the most
effective treatment strategy.
Snyder and White (1982) suggest that a
person in a depressed mood state is more likely to remember unpleasant
events and unhappy experiences and therefore, attempts to understand
and cope with the mood state may have the unintended effect of continuing the indivudual 's mood state.
hypotheses.
The present study had similiar
First, it predicted that subjects in the positive ima-
gery groups (structured and unstructured) would experience a greater
reduction in depression than those subjects in the other groups;
relaxation, focusing on the problem, and a no treatment control.
Second, it was expected that subjects in the positive structured imagery group would experience a greater reduction in level of depression
than subjects in the positive unstructured imagery.
Third, it was
predicted that when using the Daily Mood Rating Scale subjects in the
positive imagery (structured and unstructured) and relaxation group
would report a more positive state than subjects in the focus on the
problem and no treatment control group.
Jarvinen and Gold's research (1981) show a significant change in
level of depression from their pretest to posttest in the treatment
groups (neutral imagery, positive imagery and self-generated imagery)
72
73
but no such change in the control group scores.
There was no signifi-
cant difference between the scores of the treatment groups' scores.
They concluded that "the results support the idea that imagery can be
useful in interrupting the negative thought process of depression,"
(Jarvinen and Gold, 1981, p. 328).
The present research did not sup-
port any of these findings.
The present research found no statistically significant results
associated with level of depression or treatment.
The only signifi-
cant finding was a change over time, that is, mood levels improved
over time for all groups.
Through a trend analysis, it was determined
there was a significant linear trend but there was no significant
quadratic trend.
That is, mood improved steadily over time, with no
1evel ing off for the later time periods.
Of the 80 who agreed to participate in the study, fifteen dropped
out of the study at various stages of treatment.
Of the 15 dropouts,
four were in the positive imagery group (of the four, one was in the
1 ow level ·Of depression and three were in the high level of
depression), one was in the positive unstructured imagery group (high
level of depression), fou·r were in the relaxation group (of the four,
one was in the low level of depression and three were in the high
level of depression), three were in the focus on the problem group
(all in the high level of depression).
There was no significant dif-
ference in dropout rate due to treatment; however, the more depressed
subjects were more likely to drop out.
Among the high depression
level group, if the highest of the high dropped out of the study, then
the difference among the two groups (high and low depression) is not
74
as big a group separation or interaction.
Since there were no statistically significant results due to
treatment in this study, it may be that those subjects who did improve
in former research may have improved as a result of the Hawthorne
effect.
utable
The change in observed behavior may have been directly attri bto the fact that the subjects were aware that data were being
collected.
Awareness of being in a research study is typically con-
sidered to elicit socially desirable responses of greater satisfaction, such as an increase in mood level.
However, in this study, the
statistical data did not reveal subject rsponses to be socially
desirable in terms of treatment or level of depression, data did not
provide evidence that subjects were influenced by considerations of
social desirability.
Some have challenged the
11
Hawtho.rne effect .. in field experiments
(Cook, 1967) as well as in laboratory contexts (Weber and Cook, 1972).
There were differences between the Jarvinen and Gold 1 s study
(1981) and Schultz•s (1976).
Some of the differences in variables
that may have contributed to the lack of significance in the present
study found between level of depression and treatment were the subject
pool, demographics, operational definitions, and the level of
depression.
The subjects used by Jarvinen and Gold (1981) differed
from those employed in the present study.
In past research, there has not been a concensus as to whether
males or females have been more depressed.
Several studies suggest
that depression is more often reported by women (Friedman and Katz,
1974).
Jarvinen and Gold (1981) used only female college students
75
whereas the present study employed both males and females.
Schultz
(1976) employed male inpatients who were diagnosed as being depressed
or appearing dysphoric.
Schultz's (1976) results indicated that ima-
gery was a useful technique in treating the depressed population.
The
problem with comparing the current study to Schultz's research is the
difference in the population.
Both studies used males, but can one
compare inpatients with college students?
Burtle (1976) employed eight male subjects between the ages of
51-55 who were patients from a day treatment facility.
Two of the
four treatment groups were similiar to those employed in the present
study (Relaxation, and Positive Structured Imagery).
The hypothesis
that level of depression would decrease with Positive Structured
Imagery was supported in his study.
Again, due to the subjects popu-
lation, his study cannot be compared strictly to the present research.
Burtle's subject pool was small so statistical significance was harder
to achieve.
subjects.
Research has mixed results on the difference in age among
Friedman and Katz (1974) stated that depression is roost
often reported among the older population.
Also, although the present
researcher did not analyze age, it was apparent that the majority of
the students were in their early 20's \'ttlereas in hospital patients
(i .g., Burtle) subjects were much older.
We need to determine \'ttlether
there is a difference in reported depression for gender, and as roore
research needs to be done on both male and female college students.
Since no significant findings other than the difference between
76
the main effect of time were achieved, the rest of the chapter will
explore possible reasons for the lack of significance.
In addition,
suggestions for future research will be discussed.
'Depression
Problems with evaluating depression that may have influenced the
present results are operational definitions, conceptualization of
depression, and causality of depression.
broad.
The term depression is very
When one looks at the Diagnostic and Statistical Manual cate-
gorizations this concept becomes much clearer. According to the DSM
III, level of depression is significant in diagnosing disorders.
For
example, the most severe diagnosis is Major Depression in which the
individual experience a dysphoric mood or loss of interest in all
activities which is usually associated with other symptoms such as
insomnia and loss of appetite.
At the other end of the depressive
spectrum is Dysthymic Disorder.
III is that the depression is
11
The difference according to the DSM
not of sufficient severity and dura-
tion to meet the criteria for a Major Depressive Disorder
Psychiatric Association, 1980, p 221).
11
(American
In addition, length of the
depressive episode is relevant.
The dictionary defines deprssion as
11
an emotional condition,
either normal or pathological, characterized by discouragement, a
feeling of inadequacy, etc ... (Webster, 1983, p. 489).
can denote different levels of depression:
Therefore, one
normal or pathological.
According to Schultz (1976), the concept of depression can be:
1) a temporary mood state experienced by all individuals, 2) an acute
°.
77
psychological disorder, 3) a chronic character disorder.
In addition,
Schultz states that "these three phenomena vary along dimensions of
intensity, duration and degree of reality distortion" (Schultz, 1976,
p 130)
0
0
What all these descriptions point out and what has been summarized by Aitken (1969) is the limitation of our analog systems.
The results of the present study re-emphasize this point.
There
was a lack of significance attained on the Daily Mood Rating Scale
associated with treatment, depression, time, or their interaction.
A
possible explanation may be that depressed individuals don•t admit to
be labe 1ed
11
depressed ...
However, the Beck Depression Inventory con-
sists of statements which describe symptoms consistent with
depression, and it may be easier to agree with these behavioral observations taken one at a time.
Perhaps self-rating verbal scales are
limited in use for this population, or it may be that the Beck
Depression Inventory is not accurate.
Aitken states that "speech contains an assumption that the same
language is being spoken in order to communicate information, though
this assumption may be far from true 11 (Aitken, 1969, p. 989).
Thus,
using the word "depression 11 need not imply that people experience the
same feeling.
"The same amount of change may take place, but in only
some people will this alter a category term, and then only if the
change is from a certain initial value" (Aitken, 1969, p. 989).
Therefore, Aitken concludes that scales that have verbal context are
limited in use and possible
11
inadequate for examination of the exact
association to a related concept .. (Aitken, 1969, p. 989).
Zeally and
78
Aitken (1969) states that "since a person•s feelings are, by their
very nature, inaccessible to objective scrutiny, it follows that
measurement of mood depends to a large extent upon communication by
the subject to the observer."
(Zeally& Aitken, 1969, p. 993).
In
addition, when mood lies "beyond an arbitrary limit of •normality,•
illness is supposedly present and diagnosis becomes a matter of opinion.
To avoid indeciveness, these authors suggest that quantifying
the condition would allow observation of intrasubject changes, especially as a result of treatment.
Much of the literature does not employ specific operational definitions for depression, e.g., Burtle, 1975; Lipsky, Kassinove &
Miller, 1980; Rehm, 1978; Schultz, 1976; Starker & Singer, 1975, 1977.
Those studies using operational definitions are not necessarily consistent with other research.
In the Beck Depression Inventory manual
10-15 is defined as mild to moderate depression.
Propst (1982),
employing the Beck Depression Inventory, used greater than 15 to indicate mild or moderate level of depression.
Jarvinen and Gold (1981)
used the cut-off score as Jarvinen and Gold (1981 ).
If different
operational definitions are being used, the results can no longer be
compared.
Duration and intensity of depression are important considerations
in research.
Subjects who have just started experiencing depression
may be different in many regards from subjects who have a long history
of depression.
Recently depressed individuals might have a better
memory for how it feels not to be depressed and therefore can report
79
differences no longer available to those with a long continuous or even
chronic history of depression.
Clark and Teasdale (1982} found that depressed patients were
more likely to recall memories of unhappy experiences on occasions
when they were more depressed.
In addition, depressed patients rated
the current pleasantness of a recalled experience more negatively than
the original level of pleasantness, depending upon the current level of
depression (Clark & Teasdale, 1982}.
Schultz (1976) suggests that
depressed patients• experiences of depressive emotions persists and
grows so pervasively over time that their feeling state stands in
marked contrast to that of others around them who are experiencing
normal fluctuation in their emotional life.
Schultz (1976) suggested
that undesirable recent life experiences may contribute to initiating
the depressive cycle but play only a minor role in influencing present mood states.
Recent events may serve as cues to previous, more
traumatic life events which exacerbate and perpetuate the negative
self-image.
In the present study, the results of the level of
depression on the pretest of the Beck Depression Inventory may have
been influenced by recent life experiences that initiated the
depressive cycle, but may not have had an intense effect on the present mood state to create a more exacerbated negative self-image.
Another factor pertains to causality of depression.
It is often
assumed when dealing with college students that the majority
experiencing will have their mood reflect the immediate college
environment, this is situational, e.g., test taking, whereas other
populations might be more affected by personal undesirable life
events.
11__•_
--
80
In a study of depressed male psychiatric patients, Schultz (1976)
reported that undesirable recent 1i fe events (e.g., personal injury
or illness, marital problems, sexual problems, etc.) occurred more
frequently in this population than in normal population, and were more
likely to be continuous or chronic than were desirable events.
Once
an undesirable event occurs in the patient's life, the individual's
belief in his negative self-image and a negative world could lead in
turn to precipitate more undesirable events, and/or cause him/her to
interpret or attribute a greater degree of undesirability to his/her
recent life experiences.
Imagery
Problems with imagery techniques that might have influenced the
present results involve the specific type of imagery, the instrumentation, the clarity of the image, and the content.
The types of imagery employed have varied throughout the past
research (Burtle, 1975; Kaxdin, 1979; Lipsky, Kassinove & Miller,
1980; Propst, 1982; Reardon & Tosi, 1977; Schultz, 1976; Schwartz,
Brown & Ahern, 1980).
Propst (1982) employed imagery that had a reli-
gious theme and classified it as positive.
Whether this is positive
or not depends upon the subject, i.e., religious students versus subjects that do not have a belief in that particular religion.)
Several studies employed rational imagery such as Reardon & Tosi
(1977) who used rational stage directed imagery and Lipsky et. al.
(1980) who employed rational-emotive imagery.
Both the Jarvinen and Gold (1980) and the present research use
- -
a ,
81
11
positive imagery 11 (both structured and unstructured.)
But what is
considered positive for one can be totally negative for another individual or group, and may even vary for the same individual at different times.
Schultz (1976) suggested that content of imagery has a different
effect on different populations.
His patients whose depression was
characterized by themes of dependency achieved lower levels of
depression after aggressive and socially gratifying imagery, but
others, whose depression centered around self-criticism, attained
1ower levels of depression after socially gratifying and positive
imagery.
Finally, Dychman and Cowan ( 1978) state that for imagery to be a
successful therapeutic treatment, clarity or vividness of the imagery
is significant.
Kazden (1979) suggests that subjects who vary from
the scene or alter the scene in some way, make an interpretation of
group difference difficult.
1-bwever, there are huge problems in
making sure that all subjects experience the same imagery.
Depression and Imagery
The treatment for depression ranges from in-depth analysis to
pharmacology.
Depression is often a self-limiting illness so sta-
tistics on success rates for the various forms of treatment, where
controls are not present, are often unreliable.
Often, it is dif-
ficult to compare treatments.
The reported effect of imagery in the treatment of depression
varies.
Schultz (1976) suggested that some type of focused imagery
82
will distract an individual from his/her depressed mood state.
(1971) suggests that imagery acts as a distraction.
Singer
Jarvinen and Gold
(1981), on the other hand, proposed that positive imagery helps the
individual to contact and discharge suppressed affect, leading to a
reduction in conflict and a corresponding decrease in level of
depression.
Lazarus ( 1968) supports the affective expression model
(the deliberate stimulation of feelings of anger, amusement, affection, etc.) because it may disrupt the depressive cycle.
Beck (1967)
suggested that there are at least two types of depression.
If this is
the case, then, certain kinds of imagery might work better for one
type of depressive than for the other type.
Summary of Problems
To summarize the various problems that might have affected the
present study•s results:
First, it was difficult to establish an
operational definition of several key terms, such as level of
depression and positive imagery influenced as these are by the type or
nature and length of depression.
for different individuals.
11
Positive11 has a different meaning
For example, Jarvinen and Gold (1981)
used outdoor physical exercise as a positive imagery.
Exercise can be
a negative experience for one individual and a positive experience for
another.
Second, the type of population became a major problem in this
study.
The majority of published research has employed male
psychiatric inpatients.
Other studies used female college students.
Unfortunatley, the difference between the sexes was not examined
83
making comparisons with other groups difficult.
remedied by re-analysis.
However, this can be
It is suggested for future research to exam-
·ine possible differences between the sexes.
In addition, it appears that a more reliable method to determine
level of mood would be to employ both self-rating and observation.
Zeally and Aitken (1969) state that a quantified scale is more
reliable than a verbal scale.
Fourth, the time of the year that the study takes place might
pose a problem.
Subjects might appear less depressed at the
beginning or the end of the semester than when midterms or finals are
being taken.
Subjects were studied prior to and during midterms.
Exams might have had an impact upon level of depression for some participants in this study.
Although systematic bias was controlled by
random assignment, the problem may have increased error variance.
Jarvinen and Gold (1981) did not include information relevant to the
time of the school semester in their study.
A possible solution to this problem would be to use subjects at
various periods in the semester and compare the differences.
In addi-
tion, one should use a follow-up study to determine the length of
effectiveness of the treatment.
Finally, the 1iterature lacked relevant information as to the
details of prior studies.
It was difficult to determine how some
pub 1i shed researchers operationally defined their terms, and how
treatment was administered •
. .
~
Summary and Conclusion
This study is an examination of depression and imagery.
Many
unanswered questions have motivated a quest towards understanding the
phenomenon of depression, which has now produced voluminous literature and theories regarding a problem that dates to antiquity.
Depression has eluded concensus as to its etiology and definition.
Historical review of the terminology for depression reveals that
the designation or classifications have changed over the centuries as
well.
In the 4th century, the term melancholia was employed.
By the
16th century mania and melancholia were generally considered to be one
disorder.
In 1684, a French physician named Bonet first joined the
two names together to form a single disorder called manic-depressive
insanity.
From the 16th century to the present, there has been a lack
of concensus as to whether there were two distinct disorders,
and
11
11
mania 11
depression ," or one disorder combined.
The question often posed, given this definitional range, is \'ktat
is the etiology of depression?
Hippocrates attributed depression to
an excess of black bile, whereas others felt demons possessed the
individual.
The early scientists in many respects knew perhaps as
much as we do today.
They characterized the disorder, they described
personality types and suggested treatment that can be recognized in
some of our prescribed procedures today.
By the 18th century, the
origin of our contemporary diagnostic categorizations evolved.
The pertinent literature for this study was reviewed and the
major approaches on depression and imagery, as well as the empirical
84
85
literature, were examined.
Depression has traditionally been conceptualized by the
psychoanalytic school as the introjecton of anger.
Freud described
depressive reactions as resulting from a loss of a loved object, real
as in the case of mourning, and emotional as in the case of melancholia or clinical depression. Alternative views have focused on the role
of loss, anger and aggression in depression and whether the resulting
dynamic is turned against the self or outward.
The central role of
the loss of self-esteem, self-devaluation and self-reproach have been
postulated either as a trigger or a consequence of depression.
The classic behavioral explanation for depression states that
limited positive or negative reinforcements are the basis for
depression.
created.
When an individual avoids a situation, anxiety is
The individual withdraws from the aversive stimuli, creating
the response of depression.
The cognitive theorists suggest that depression involves emotion,
motivation, cognitive sets, physical and motor function changes.
The
way the person thinks about himself/herself may have devloped from
poor childhood experiences which helped to develop a negative cognitive set, in turn causing the development of a disturbed mood state.
Imagery as a procedure in treatment of depressives is basically a
new phenomenon.
The 18th century marks the beginning of the explora-
tion of imagery.
Hume compared sensations and emotions (referred to
as .. impressions .. by Hume) which characterized thinking and reasoning.
In the 1960 s, imagery as a treatment gained followers.
1
The
Zeitgeist was influenced by Jungian psychologists in Europe who
86
encouraged patients to understand current problems that emerged in
symbolic form in dreams.
Since the elaboration of imagery and its use is recent, there are
virtually no theories estabished specific to imagery.
Studies are now
being conducted to determine its use and whether its suited for
depressed subjects.
Presently, the empirical literature shows mixed
results.
The hypotheses for the study were:
a)
Subjects in the positive imagery groups (structured and
unstructured) will experience a statistically greater reduction of
depression than those subjects in the relaxation, focusing on the
problem, and a no treatment control group.
b). Those subjects in the positive structured imagery group will
experience a statistically greater reduction in level of depression
than those subjects in the positive unstructured imagery group.
c)
The Daily Mood Rating Scale will show that positive imagery
(structured and unstructured) and relaxation groups will report a more
positive state than those subjects in the focus on the problem and no
treatment control groups.
The procedure included sixty-five male and female undergraduate
college students to determine the effect of positive imagery on
depression.
These participants were pre-selected from a pool of 245
who scored 12 or more on the Beck Depression Inventory.
Subjects were
randomly assigned to five experimental groups, positive structured
imagery, positive unstructured imagery, relaxation, focus on the
problem, and a no treatment control.
Beck's categories were combined
87
for matching purposes:
12-19 for mild-moderate depression and 20-63
for moderate-severe depression.
Tests used were the Beck Depression
Inventory to determine the participant •s affect and level of
depression.
The Daily Mood Rating Scale was employed to assess the
daily mood of each participant.
A 5 x 2 between subject analysis of covariance was performed.
In
addition, a 5 x 2 profile analysis was performed to detect any differences in mood change over time.
Univariate and multivariate statistical procedures yielded statistically nonsignificant results in the major comparisons between
treatment, level of depression and time period.
effect of time was statistically significant.
However, the main
Since there was an
overall trend that seemed to indicate that the mood level improved
over time, a trend analysis was performed post hoc.
There was a
significant linear trend (improvement over time) but no significant
effect was found for the quadratic trend.
Jarvinen and Gold (1981) hypothesized that all imagery treatments
would show a greater decrease in depression, and that positive
directed imagery would be the most effective treatment strategy.
Snyder and White (1982) suggest that if a person is in a depressed
mood state, they are more likely to remember unpleasant events and
unhappy experiences and therefore attempts to understand and cope with
the mood state may have the unintended effect of continuing the individual mood state.
The subject pool, demographics, operational definitions and the
level of depression were some of the differences in variables that may
8B
have contributed to the lack of significance found between level of
depression and treatment.
Problems with imagery techniques that might
have influenced the specific type of imagery, the instrumentation, the
clarity of the image and the content.
It is recommended that future research employ a larger sample to
include mildly, moderate, and severe depressives to determine whether
type of treatment is affected by level of depression.
Factors that
have been discussed in this study or possible problems such as differing operational definitions, and the difference between the sexes,
as well as the element of time, should be examined further in order to
achieve an understanding of depression.
89
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APPEND I X
97
{.\
98
Appendix A
Daily Mood Rating Scale
Week #
ID#
Date
Note number of times per day you did imagery
Note times you did imagery:
a.m.
p.m.
---
1
2
Directions:
3
4
5
6
7
8
9
10
Please circle the number which best describes your mood.
1 being the worst possible mood you have ever been in and 10 being the
best pass i b 1e mood you have ever been in.
Mood is defined as the
general or overall state of mind you have been in for the entire day.
.
99
Appendix B
Raw Scores of Beck Depression Inventory
Positive Structured Imagery
Pretest
Posttest
13
26
13
24
26
14
12
18
38
18
15
24
17
15
02
11
12
04
03
01
11
09
04
01
Positive Unstructured Imagery
22
12
15
19
14
18
22
43
12
12
16
21
24
20
31
03
08
15
00
03
08
27
41
00
12
05
19
13
13
12
36
13
19
12
13
12
20
26
24
13
16
23
15
04
04
05
00
10
08
18
04
00
09
10
Relaxation
100
Debriefing
The purpose of this study was to extend the research dealing with
imagery and depression.
Those subjects who scored 12 or more on the
Beck Depression Inventory were admitted to the study.
The Beck
Depression Inventory determines the affect of the subjects.
Students
in the positive imagery treatment groups (structured and unstructured)
were instructed in visualization and practiced visualizing the scenes
with the experimenter.
The positive structured imagery group had a
tape of the imagery which ensured that the scene was positive and the
positive unstructured imagery group wrote down their imagery scene in
the initial meetings so that it could be confirmed that if was a positive image.
Students in the imagery groups, as well as the relaxation
group, did a relaxation exercise that they practiced with the experimenter.
There was also a group that focused on their problems and
negative thoughts.
Lastly, there was a no treatment control group.
All treatment groups participated in filling out the Daily Mood Rating
Scale, which was used to assess the daily mood of each subject.
The hypotheses are:
a)
Subjects in the positive imagery groups (structured and
unstructured) will experience a statistically greater reduction
in depression than those subjects in the remaining groups:
relaxation, focusing on the problem, and a not treatment control.
b)
Those subjects in the positive structured imagery group will
experience a statistically greater reduction in level of
depression than those subjects in the positive unstructured imagery group.
101
c)
On the Daily Mood Rating Scale, the positive imagery (structured
and unstructured) and relaxation groups will report a more positive state than those subjects instructed to focus on the problem
or who are exposed to no treatment.
Statistical procedures yielded statistically nonsignificant
results for treatment.
Thank you for participating in this study.