• TABLE OF CONTENTS
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 Title Page
 Acknowledgement
 Table of Contents
 List of Tables
 Abstract
 Introduction
 Review of the literature
 Methodology
 Findings
 Discussion
 Appendices
 References
 Profile






Title: Guided imagery training as treatment for alcoholism /
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 Material Information
Title: Guided imagery training as treatment for alcoholism /
Physical Description: ix, 112 leaves : ; 28 cm.
Language: English
Creator: Hughes, William Gordon, 1947-
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 1982
Copyright Date: 1982
 Subjects
Subject: Imagery (Psychology)   ( lcsh )
Alcoholism -- Treatment   ( lcsh )
Alcoholism counseling   ( lcsh )
Counselor Education thesis Ph. D
Dissertations, Academic -- Counselor Education -- UF
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Thesis: Thesis (Ph. D.)--University of Florida, 1982.
Bibliography: Bibliography: leaves 92-111.
General Note: Typescript.
General Note: Vita.
Statement of Responsibility: by William Gordon Hughes.
 Record Information
Bibliographic ID: UF00099083
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000334834
oclc - 09537619
notis - ABW4477

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Table of Contents
    Title Page
        Page i
        Page ii
    Acknowledgement
        Page iii
    Table of Contents
        Page iv
        Page v
    List of Tables
        Page vi
    Abstract
        Page vii
        Page viii
        Page ix
    Introduction
        Page 1
        Page 2
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
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        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
    Review of the literature
        Page 23
        Page 24
        Page 25
        Page 26
        Page 27
        Page 28
        Page 29
        Page 30
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        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
        Page 38
        Page 39
    Methodology
        Page 40
        Page 41
        Page 42
        Page 43
        Page 44
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        Page 58
        Page 59
        Page 60
        Page 61
        Page 62
        Page 63
        Page 64
    Findings
        Page 65
        Page 66
        Page 67
        Page 68
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        Page 70
        Page 71
        Page 72
        Page 73
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        Page 75
        Page 76
    Discussion
        Page 77
        Page 78
        Page 79
        Page 80
        Page 81
    Appendices
        Page 82
        Page 83
        Page 84
        Page 85
        Page 86
        Page 87
        Page 88
        Page 89
        Page 90
        Page 91
    References
        Page 92
        Page 93
        Page 94
        Page 95
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        Page 97
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        Page 106
        Page 107
        Page 108
        Page 109
        Page 110
        Page 111
    Profile
        Page 112
        Page 113
        Page 114
        Page 115
Full Text











GUIDED IMAGERY TRAINING AS TREATMENT FOR ALCOHOLISM


BY

WILLIAM GORDON HUGHES



















A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF DOCTOR OF PHILOSOPHY




UNIVERSITY OF FLORIDA


1982

































Copyright 1982


by


William Gordon Hughes




















ACKNOWLEDGEMENTS


The author would like to express his sincere

appreciation to Dr. Gary Seller for his assistance

and direction throughout the development and completion

of this dissertation. The author also thanks the

other members of his committee, Dr. Ben Barger and

Paul W. Fitzgerald, for their assistance.
















TABLE OF CONTENTS


ACKNOWLEDGEMENTS ......................................

LIST OF TABLES ........................................

ABSTRACT ..............................................



CHAPTER I INTRODUCTION...............................


CHAPTER II


CHAPTER III


Background information...................
Need for Study...........................
Rationale................................
Research Hypotheese......................
Definition of Terms......................
Organization of the Study ...............

REVIEW OF THE LITERATURE .................

Anxiety in the Alcoholic.................
Stress and Drinking......................
State and Trait Anxiety..................
Low Self-Esteem..........................
Overview of Imagery......................
Concept of Successful Treatment..........
Rationale for Imagery as Treatment......

METHODOLOGY...............................


Research Design.........
Research Hypotheses.....
Selection of Subjects...
Instrumentation ........
Procedure...............
Statistical Analysis....
Limitation of the Study.


FINDINGS ................................


................
................
................
.... ............
................
................
................


CHAPTER IV









CHAPTER V DISCUSSION. .............................. 77

Implications ............................ 78
Recommendations ......................... 80

APPENDIX A DRINKING QUESTIONNAIRE.... ................ 82

APPENDIX B OUTLINE: IMAGERY TRAINING SESSION
FOR THERAPISTS ........................... 83

APPENDIX C DIAGRAM OF TREATMENT GROUPS............... 85

APPENDIX D RELAXATION TECHNIQUES.. .................... 87

APPENDIX E INTERVIEW OUTLINE: IDENTIFYING
CHARACTERISTICS FOR IMAGERY SESSION....... 91


REFERENCES ............................................ 92

PROFILE .............................................. 112
















LIST OF TABLES


Table Page


1. ATTRITION OF SUBJECTS . . . . .. .66

2. ANOVA SUMMARY TABLE FOR TREATMENT AND
STATE ANXIETY DIFFERENCES . . . .. .69

3. ANOVA SUMMARY TABLE FOR TREATMENT AND
STATE ANXIETY DIFFERENCES LIMITED TO
CONTINUOUS EPISODIC ALCOHOLICS. ... .71

4. ANOVA SUMMARY TABLE FOR TREATMENT AND
TRAIT ANXIETY DIFFERENCES . . . .. .72

5. ANOVA SUMMARY TABLE FOR TREATMENT AND
TRAIT ANXIETY DIFFERENCES LIMITED TO
FIRST STAGE ALCOHOLICS. . . . .. .73

6. ANOVA SUMMARY TABLE FOR TREATMENT AND
TRAIT ANXIETY DIFFERENCES LIMITED TO
CONTINUOUS/EPISODIC ALCOHOLICS. ... . 74

7. ANOVA SUMMARY TABLE FOR TREATMENT AND
STATE ANXIETY DIFFERENCES LIMITED TO
FIRST STAGE ALCOHOLICS. . . . .. .75











Abstract of Dissertation Presented to the Graduate
Council of the University of Florida in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy





GUIDED IMAGERY TRAINING AS TREATMENT FOR ALCOHOLISM



By



William Gordon Hughes



August, 1982


Chairman: Dr. Gary Seller
Major Department: Department of Counselor Education


This study was designed to test the efficacy of

Guided Imagery Training and specifically Progressive

Relaxation/Guided Imagery Training as a treatment for

alcoholics. The study is a quasi-experimental research

study using a randomized control group pretest-posttest

factorial design. A 2 x 4 factorial design of two

classifications of alcoholics and four treatment groups

was used. Using the Diagnostic and Statistical

Manual III, alcoholics were classified either First

Stage or Continuous/Episodic alcoholics. The four









treatment groups were control, Progressive/Relaxation

Training, Guided Imagery Training, and Progressive

Relaxation/Guided Imagery Training. Pretests and

posttests were administered to 120 outpatient clients

in three treatment centers in Florida. Criterion

measures were the Tennessee Self-Concept Scale, Speil-

berger's State-Trait Anxiety Inventory, and a Drinking

Questionnaire, developed by the investigator. Treat-

ment period was five one hour sessions. Control Group

was actually five sessions based on the Reality Therapy

approach. The three experimental groups were divided

evenly, one half session Reality Therapy, one-half

experimental session. Guided Imagery Training emphasized

subject participation. Subject selected situations

he wanted to cope with more effectively; situations

were the focus of imagery session; subject verbalized

as he visualized the situation; and subject reinforced

visualized coping behavior by describing positive

emotions regarding coping behavior. Emphasis was on

coping. Treatments produced no change in self-esteem

or actual drinking behavior. Progressive Relaxation/

Guided Imagery Training significantly reduced state and

trait anxiety more than Control Group and Progressive

Relaxation Training. Guided Imagery Training significantly


viii









reduced state and trait anxiety more than the Control

Group. Guided Imagery was determined to be a signifi-

cant part of Progressive Relaxation/Guided Imagery

Training. A comparison was made of Guided Imagery

Training, in this study, to that in past research.

Recommendations were made that treatment be extended to

have impact on self-esteem and drinking behavior.














CHAPTER I
INTRODUCTION


This study addresses the problem of successful

alcoholism treatment. In addressing this problem it

becomes necessary to understand the basic tenets of

alcoholism. Chapter I presents background research

regarding social influence on alcoholism, along with

research on the disease concept, psychological theories,

and addictive cycle of alcoholism.

Chapter II presents a literature review regarding

two personality characteristics of alcoholics, anx-

iety and low self-esteem. This prospectus suggests

guided imagery can be a successful treatment for al-

coholism. An overview of imagery and a rationale for

imagery as treatment are presented. In treating

alcoholics, a fundamental problem has been identified,

the inability to cope (Blane, 1968; Chafetz, 1959;

Chafetz, Blane, and Hill, 1970; Silber, 1959, 1967,

1970, 1974). Two factors influencing this inability

are low self-esteem and hiqh anxiety level (Berg, 1971:

Gary and Guthrie, 1972; Gross and Carpenter. 1971;

Masserman, 1976; McLachlon, 1976; Browne, 1976).

Chapter III outlines the research design, instru-

mentation, research procedure, and statistical analysis.








Specifically, this prospectus suggests that guided imagery

can increase self-esteem, reduce the anxiety level and

consequently reduce drinking in the alcoholic.


Background Information

Disease Concept

In 1971, the American Medical Association adopted

a statement identifying alcoholism as a complexy disease

with biological, psycholngical- and sociological com-

ponents" (Todd, 1975, p. 396). Like other conditions

it follows a more or less specific sequence. The sus-

ceptible individual is exposed to the causative agent and

the early states of the process begin. When the process

contains self-perpetuating mechanisms which develop as a

"consequence" of the condition, the syndrome is furthered.

At this point the characteristics of the alcoholic

have changed from their original status of "susceptibility

to alcoholism" to those of alcoholism itself. This

duality in which the factors perpetuating alcoholism

may not only be "predisposing factors," but also its

"consequences," has led to much confusion surrounding the

pathogenesis of alcoholism. A clear description of the

interaction of these two different types of causative fac-

tors is essential to the understanding of the pathogenesis

of alcoholism.








The concept of the development of alcoholism follows

largely the theoretical formulations of Seevers (1968) in

the psychopharmacologic area and Jellinek (1960) in his

work on the disease concept of alcoholism. Essentially

this concept postulates the origins of alcoholism may be

biological, psychological or social. The biological

origins may be genetic or they may be prenatal and acquired

as in those infants born to alcoholic mothers. The

psychological elements contributing to the development

of alcoholism cover a broad spectrum of psychopathology,

which may be biological, experiential, or both. The

social factors contributing to the development of alcoholism

add their distinctive influence to the process. The

total interaction of all these influences presents widely

varying patterns in different people and represents a

model of predisposition toward development of alcoholism

for any individual.

The question as to which of these elements is most

significant must be answered on an individual case basis.

The thrust toward the development of alcoholism presumably

is a combination of biological, psychological, and social

influences so that when one or two are very strong, the

third may be moderate or negligible.








Genetic Theory of Alcoholism

There is evidence that alcoholics may have as their

predisposing etiological factors different elements in one

of the areas of biology, psychology, and sociology. The

example of the familial pattern in alcoholism is well es-

tablished. That is, alcoholics tend to come from families

where parents and siblings have a high incidence of alco-

holism. A recent study by Goodwin, Schulsinger, Heransen,

Guze, and Winokur, (1973) demonstrates significant relation-

ships between biological parent alcoholism and biological

child alcoholism. This study involved children of alcoho-

lic parents adopted into families containing no alcoholics.

The study found that 18% of the biological children of al-

coholics would be diagnosed as alcoholic whereas only 5%

of the non-alcoholic control group were diagnosed in this

manner. Goodwin et al. (1973) further estimates that approx-

imately 25% of the siblings of alcoholics will become alco-

holic whereas the incidence in the general population is 5%.

Psychological Theories of Alcoholism

An instance of alcoholism which derives mainly from

psychological disorder may be the so-called situational

alcoholic. Because of an immediate stressful situation an

individual may turn to alcohol as a sedative for his extreme

anxiety and depression. When the precipitating situation

has been resolved, drinking may cease.









In addressing the psychological factors, a look at

the schools of psychology and their view of alcoholism is

necessary. McCord, McCord and Gudeman (1960) have listed

three Neo-Freudian explanations for the cause of alcoholism:

1. The classical Freudian view states that alcohol

abuse is the result of unconscious tendencies,

particularly self-destruction, oral fixation or

latent homosexuality;

2. The Adlerian view is that alcohol abuse repre-

sents a struggle for power;

3. A more general psychoanalytic view is that

alcohol abuse is the result of inner conflict

between dependency drives and aggressive drives.

The Cestalt Therapy theory view may be considered a

merger of psychoanalytic thought and Gestalt theory.

According to Perls, Hefferline, and Goodman (1951), the

alcoholic is seen as an "adult suckling" suffering from oral

underdevelopment. He is considered to be a person who wants

his "solutions" to life generally to be in liquid form,

prepared, so that he can avoid the "excitement" which

accompanies the difficult task of grappling with them.

Learning and Reinforcement Theory (Dollard and Miller, 1950)

also explains the process of alcohol addiction and is pri-

marily based on two aspects of alcohol ingestion. First,









there is the proposal that alcohol itself has primary

reinforcing properties. That is, the chemical effect of

alcohol is tension or drive reducing (relaxing). Second,

the ingestion of alcohol may be followed by other reinforcing

events or stimuli, which serve in turn to reinforce the act

of alcohol ingestion. If the effects have reward properties,

the future use of alcohol becomes more likely. The reward

properties may be ease of interaction with others or a

pleasurable shift of emotion. The Humanistic-Phenomeno-

logical view appears to be relatively less concerned with

formal models of personality than other schools. Its focus

is more on the experiencing human being and his drive toward

self-fulfillment (May, 1961). Alcoholism in this context

may be seen as a manifestation of blocked awareness or

thwarted growth.

Social Influence on Alcoholism

The idea has recently gained credence that social

forces may be among the most important in predisposing to

alcoholism. The socially isolated, unemployed person in the

ghetto area has come to be seen as almost entirely the pro-

duct of social rather than biological or psychological forces.

The attitude has been fostered by the experience in heroin

addiction where susceptibility to addiction is often more a

function of social milieu in a given place at a given time than

it is the biology or psychology of any specific individual









(Chein, Gerard and Rosenfeld, 1964). Supporting this is the

statement by the Commission of Inquiry into the Non-Medical

Use of Drugs:

Availability . that is, the opportunity
for use and access to a supply of a
drug . remains a primary matter of social
concern. Without availability the vulnera-
bility which is created by certain factors
of a psychological and social nature would
never be tested. Thus, availability remains
one of the most important causal factors.
(Le Dain, 1973, p. 33)

Addictive Cycle

The second causative factor, after predisposing factors,

is the addictive cycle. The addictive cycle begins with

the frequent ingestion of alcohol. The frequent ingestion

of alcohol results, as it does with all depressant psycho-

active drugs, in the development of tolerance, both metabolic

and psychologic. Gradually, the individual finds that he

needs ever increasing doses to obtain the same psychologi-

cal reward that he could previously obtain with smaller

doses. The ingestion of continually larger doses results

in bathing of the tissues of the central nervous system in

high concentrations of the drug. This in turn results in

the gradual onset of physical dependence. With physical

dependence comes withdrawal symptoms and these act, both

directly and indirectly, to perpetuate and to increase the

rate of drug-seeking behavior.









The specific role that physical dependence plays in

perpetuating the addictive cycle has long been disputed.

However, it is interesting to note that the early defini-

tions of "addiction" (Seevers and W'oods, 1953) involved the

necessary presence of physical dependence. In the field

of heroin addiction, Dole and Nyswander (1965) believe phy-

sical dependence is the major driving force in heroin seek-

ing behavior. They describe "craving" as a psychological

equivalent of physical dependence manifested as persistent

withdrawal symptomatology.

The significance of physical dependence in the develop-

ment of heroin addiction may be more apparent than it is

in the development of alcoholism but it is by no means more

important. Tolerance and physical dependence develop more

slowly with alcohol than they do with morphine or its de-

rivatives. Therefore, their import is less obvious in al-

coholism than in heroin addiction. On the other hand, once

physical dependence does develop in alcoholism, withdrawal

symptomatology is far more severe and more persistent than

with heroin (Kissin, Schenker, and Schenker, 1959; Schenker,

Schenker, and Kissin, 1962; Tripp, Fluckiger, and Weinberg,

1959). Accordingly, craving for the causative agent to

relieve withdrawal symptomatology is probably as great in

alcohol as it is in heroin addiction.









"Craving" for Alcohol

It is important to distinguish between craving during

an ongoing drinking bout and craving when the individual

is abstinent. In the first instance, withdrawal symptoma-

tology occurs throughout intoxication with particular

exacerbations in the morning after brief periods of absti-

nence (Kissin, 1974). The presence of tremulousness, anx-

iety, depression, and insomnia constitutes the conditioned

stimulus for which drinking has become the conditioned response.

Craving during drinking is the subjective equivalent of

withdrawal symptoms associated with learned recognition

that alcohol will relieve those symptoms. These reinforc-

ing mechanisms make the craving for alcohol during a drinking

binge irresistible so that the alcoholic loses his ability

to control his drinking. Loss of control becomes the larger

descriptive term of the phenomenon occurring during the

compulsive drinking bout. Stein, Niles, and Ludwig (1968,

p. 601) found that uncontrolled drinkers reported "longer

and more frequent blackouts, more frequent delirium tremens,

'shakes', vague fears and phobias associated with prolonged

drinking than did controlled drinkers."

Recent research suggests that craving during abstinence

may have greater psychological elements than those involved

in loss of control. Ludwig, Wikler and Stark (1974) have

developed an experimental model which supports both









physiological and psychological mechanisms. They postu-

late that "craving for alcohol (during periods of no

physical dependence) represents the cognitive symbolic cor-

relate of a withdrawal syndrome which can be produced by

internal or external stimuli. This stimulus could be among

other things, emotional stress or a favorite bottle of

liquor. Hore (1974) reported on a questionnaire survey of

750 alcoholics in AA as to whether they had experienced

moderate to severe craving for alcohol in the previous week.

One third responded positively. There was a high correlation

of craving with levels of anxiety and depression. "Cravers"

had a significantly higher incidence of drinking during the

past month and a significantly lower incidence of three-

month abstinence periods than did "noncravers."

Thus, it is clear that some form of craving which leads

to renewal of alcohol-seeking behavior does occur when the

fully developed physical dependency has been achieved. At

that point the alcoholic wants to drink to relieve symptoms

of alcohol withdrawal tremulousnesss, depression, insomnia)

or to relieve either real (stress) or conditioned (bottle

of liquor) symptoms of withdrawal as in craving.

Alcoholism as Symptom or Disease

The foregoing conceptualization helps illuminate the

dispute as to whether alcoholism is a symptom or a dis-

ease. It is apparent that in the early stages of alcoholism









when the susceptible individual develops primary psycholo-

gical dependence, alcoholism is a symptom. Here the alco-

holic drinks to relieve some underlying discomfort or to

satisfy some need to get "high." At that state alcohol is

merely the instrument through which the individual achieves

relief or satisfaction; the underlying pathology whatever

it may be, is the cause of the drinking. In this phase

alcoholism is a symptom of a variety of underlying patholo-

gies, each one of which might be considered a different ill-

ness. At the end of the process however, when the cyclic

phenomena of tolerance, physical dependence, loss of control,

and craving have ensued, alcoholism becomes a disease. At

this point, regardless of what may have driven the individual

to drink in the first place, it is now alcohol and his physi-

cal and psychological dependence on it which are the driving

motivations. With progression, the syndrome becomes more

unitary both in its etiology and in its clinical manifesta-

tions. Whereas the dynamics and clinical signs of early

alcoholism vary considerably, the pattern in late chronic

alcoholism of physical, psychological, and social deteriora-

tion becomes unmistakable. Symptoms of chronic alcoholism

include physical and psychological deterioration, loss of

employment, family and/or marital problems, and legal pro-

blems.









Breaking the Addictive Cycle

In order to treat the alcoholic, the addictive cycle

must be broken. The addictive cycle is effectively broken

with abstinence, usually through detoxification at an inpa-

tient unit. Once the cycle is broken, the therapist is con-

fronted with the set of circumstances which underlie the

psychological dependence on alcoholism. Different thera-

pists emphasize different aspects of the problem, some

stressing biological predisposition, some the psychological,

and others the social. To a large extent, these different

emphases determine the form of therapy offered. Despite

the widely divergent approaches, proponents of all models

tend to agree that the dynamic of most alcoholics can be

described as an aberration in "coping" (Kissin and Begleiter.

1977).

Alcoholics cannot deal with the normal frustrations

and irritations of the external world nor can they deal with

the anxiety, depression and sense of inadequacy which exists

within them (Blane, 1968; Chafetz, 1959; Silber, 1959, 1967,

1970, 1974; Chefetz, Blanc and Hill, 1970).


Need for Study

It is currently recognized that in spite of the number

of physicians, psychiatrists, psychologists and mental

health professionals treating alcoholics, many forms of

treatment continue to be minimally effective (Blane, 1977;










Chafetz, Blane and Hill, 1970). Due to questionable

treatment effectiveness many professionals appear to have

lost interest in the treatment of alcoholics (Zimberg, Wal-

lace and Blume, 1978).

Many principles which govern the treatment of alco-

holics have never been clarified. Smart, Schmidt, and Mass

(1977) state that there is no established treatment which

guarantees more than approximately 35% abstinence rates.

Primarily because of this low rate. Plant (1967) and Blum

and Blum (1967) recommend the multiple treatment approach

in an effort to find the most appropriate treatment for

the client. The multiple treatment approach has justly

been criticized because in many instances it becomes

synonymous with the "shotgun" approach. That is. the

alcoholic is brought into contact with many modes of therapy

in hopes one will be successful. This is not necessarily

wrong but it would be more efficient if the specific ele-

ments of successful treatment were utilized, and those not

influencing positive outcome were discarded. Thus, there

is a need to identify specific treatment modalities that

produce positive outcomes.

Rationale

The identification of a successful treatment modality

becomes important with the proposed cutback in the budget









for substance abuse program (Budget, 1980). The proposed

Federal Budget of Fiscal Year 1981 would mean cutbacks of

$50.9 million by the National Institute of Alcohol Abuse

and Alcoholism, the major funding source for public alcohol

treatment centers in the nation.

Greater emphasis is being placed on programs to docu-

ment successful outcomes in the treatment of alcoholics.

Evaluation of treatment is becoming necessary to perpetuate

state and federal funding of alcohol treatment programs in

the state of Florida (Draft for Florida State Plan for Al-

coholism for Fiscal 1980-81, 1980).

This study investigates a treatment modality successful

in treating the alcoholic. Benefits have been previously

documented. The study describes the alcoholic along the

dimensions of self-esteem, state and trait anxiety, and

measures the effects of three forms of treatment on these

dimensions as well as on drinking behavior and the urge

to drink.


Research Hypotheses

This study will address the following null research

hypotheses:

1. Guided Imagery Training will produce no

change in self-esteem.










2. Guided Imagery Training will produce no change

in state anxiety.

3. Guided Imagery Training will produce no change

in trait anxiety.

4. Guided Imagery Training will produce no change

in frequency of actual drinking behavior.

5. Progressive Relaxation Training will produce no

change in self-esteem.

6. Progressive Relaxation Training will produce no

change in state anxiety.

7. Progressive Relaxation Training will produce no

change in trait anxiety.

8. Progressive Relaxation Training will produce no

change in frequency of actual drinking behavior.

9. Progressive Relaxation/Guided Imagery Training

will produce no change in self-esteem.

10. Progressive Relaxation/Guided Imagery Training

will produce no change in state anxiety.

11. Progressive Relaxation/Guided Imagery Training

will produce no change in trait anxiety.

12. Progressive Relaxation/Guided Imagery Training

will produce no change in frequency of actual

drinking behavior.









Definition of Terms

The following list refers to terms to which frequent

reference will be made throughout the study:

Alcoholic: a person meeting the diagnostic criteria

of the DSM-III for Alcohol Dependence 303.92. The essential

features of Alcohol Dependence are either a pattern of

pathological alcohol use or impairment in social or occu-

pational functioning due to alcohol, and either tolerance

or withdrawal (DSM-III, 1980).

Alcoholism: a term used synonymously with Alcohol

Dependence 303.9x (DSM-III, 1980).

Alcohol Abuse: a pattern of pathological use for

at least one month that causes impairment in social or

occupational functioning (DSM-III, 1980).

Anxiety: "an affect distinguished by its specific

unpleasurable characteristics. Anxiety consists of a somatic,

physiological side (disturbed breathing, increased heart

activity, vasomotor changes, musculoskeletal disturbances

such as trembling, paralysis and increased sweating) and a

psychological side (a feeling state characterized by the

following: awareness of powerlessness, presentment of im-

pending and almost inevitable danger, a tense and physically

exhausting alertness, an apprehensive self-absorption which

interferes with effective solution of reality-problems, and

an irresolvable doubt concerning the probability of the










actual appearance of the threat)" (Hinsie and Campbell,

1977, p. 49).

Coping: "adjusting, adapting, successfully meeting

a challenge. Coping mechanisms are all the ways, both con-

scious and unconscious, which a person uses in adjusting to

environmental demands without altering his goals or pur-

poses" (Hinsie and Campbell, 1977, p. 163).

Covert: "that which cannot be observed" (Wolman,

1973, p. 83). In this study thoughts are described as

covert.

Craving: the desire for alcohol after withdrawal

from alcohol has terminated (DSM-III, 1980).

Detoxification Center (Detox): an inpatient setting

that provides approximately five day counseling and medical

services to prevent withdrawal complications in persons who

have been abusing alcohol.

Diagnostic and Statistical Manual of Mental Disorders-

Third Edition (DSM-III): the official manual of the

American Psychiatric Association containing diagnostic

criteria, a multiaxial approach to evaluation, and de-

scriptions of mental disorders.

Imagery: "the formation of images, figures, or

likenesses by the mind" (Wolman, 1973, p. 188).

Imagination: "the faculty of forming mental images

or concepts of what is not actually present to the senses"

(Wolman, 1973, p. 188).









Imagine: "to form a mental image or concept not

actually present to the senses" (Wolman, 1973, p. 188).

Impairment in Social or Occupational Functioning Due

to Alcohol Use: violence while intoxicated, absence from

work, loss of job, legal difficulties (e.g., arrest for in-

toxicated behavior, traffic accidents while intoxicated),

arguments or difficulties with family or friends because of

excessive alcohol use.

Manipulate: to alter or change. In this study,

thoughts are manipulated. This means the individual alters

or changes his thoughts.

Overt: "that which can be observed" (Wolman, 1973,

p. 42). An example is behavior that can be observed.

Pathological Pattern of Alcohol Use: this phrase de-

scribes a need for daily use of alcohol for adequate func-

tioning; inability to cut down or stop drinking; repeated

efforts to control or reduce excess drinking by "going on

the wagon" (periods of temporary abstinence); or restricting

drinking to certain times of the day; binges (remaining

intoxicated throughout the day for at least two days); oc-

casional consumption of a fifth of spirits (or its equiva-

lent in beer or wine); amnesic periods for events occurring

while intoxicated (blackouts); continuation of drinking

despite a serious physical disorder that the individual knows

is exacerbated by alcohol use; drinking of non-beverage alco-

hol (DSM-III, 1980).










Self-Concept: a multidimensional construct describing

how an individual views himself. This construct includes

the following dimensions based on the Tennessee Self-Concept

Scale: defensiveness, self-esteem, identify, self-satisfac-

tion, how the person perceives his behavior, how the person

views his body, moral/ethical view, sense of personal worth,

worth as a family member, self as perceived in relation to

others.

Self-Esteem: an element of self-concept describing how

an individual values himself. Individuals with high self-

esteem tend to like themselves, feel that they are persons

of worth, have confidence in themselves, and act accordingly.

Individuals with low self-esteem are doubtful about their

own worth, see themselves as undesirable, often feel anxious,

depressed and unhappy, and have little faith or confidence

in themselves.

Self- Image: an element of self-concept describing how

an individual views his body, his state of health, his phy-

sical appearance, skills, and sexuality.

State Anxiety: "a transitory emotional state of the

human organism that is characterized by subjective, conscious-

ly perceived feelings of tension and apprehension, and

heightened autonomic nervous activity" (Spielberger, 1966,

p. 18). These anxiety states may vary in intensity and fluc-

tuate over time.










State-Trait Anxiety Inventory (STAI): a forty

statement self-report scale for measuring two distinct

anxiety concepts, state anxiety and trait anxiety (Fitts,

1965).

Stress: "any interference which disturbs the func-

tioning of the organism at any level, and which produces a

situation which is natural for the organism to avoid"

(Hinsie and Campbell, 1977, p. 720). External and internal

conditions that affect the regulators of physical and psycho-

logical homeostasis in an individual (Gregory and Smeltzer,

1977).

Stressor: any condition or situation which can cause

stress. According to Hans Seyle (1974), stresses include

infection, trauma, nervous strain, heat, cold and muscle

fatigue.

Subclassification of Course of Alcoholism: the

DSM-III (1980) provides the following guidelines to be used

in indicating the course of illness in the fifth digit (303.9x)

Code Course Definition

0 Unspecified Course unknown or
First Signs of ill-
ness with course
uncertain

1 Continuous More or less regular
maladaptive use for
over six months









Course

Episodic






In Remission


Code

2






3


Tennessee Self-Concept Scale (TSCS): a scale of

100 self descriptive statements which the subject uses to

portray a multidimensional picture of himself (Spielberger,

Gorsuch and Lushene, 1970).

Tolerance: a need for markedly increased amounts

of alcohol to achieve the desired effect, or markedly di-

minished effect with regular use of the same amount (DSM-III,

1980).

Trait Anxiety: "the relatively stable individual

differences in anxiety proneness, that is, differences be-

tween people in the tendency to respond to situations per-

ceived as threatening with elevations in anxiety state in-

tensity" (Spielberger, 1966, p. 32).


Definition

A fairly circum-
scribed period of
maladaptive use, with
one or more simi-
lar periods in the
past

Previous maladaptive
use but not using sub-
stance at present.
The differentiation
of this from no long-
er ill and from tne
other course categories
requires consideration
of the period of time
since the last period
of disturbance, the
total disturbance,
and the need for con-
tinued evaluation or
prophylactic treat-
ment









Visualize: "to form mental images or pictures"

(Wolman, 1973, p. 403).

Visualization: "the act of forming mental images

or pictures" (Wolman, 1973, p. 403).

Withdrawal: the development of Alcohol Withdrawal

291.80 whose characteristic symptoms are coarse tremor

of the hands, tongue and eyelids, nausea and vomiting,

malaise or weakness, autonomic hyperactivity (such as

tachycardia, sweating, and elevated blood pressure),

anxiety. depressed mood or irritability that follow

within several hours cessation of or reduction in alcohol

ingestion by an individual who has been drinking alcohol

for several days or longer (DSM-III, 1980).


Organization of the Study

The remainder of this study is organized into four

additional chapters plus appendices. Chapter II reviews

anxiety and self-esteem in the alcoholic, presents a his-

torical view of imagery as treatment, and proposes a rationale

for imagery as treatment of the alcoholic. Chapter III covers

research design, hypotheses, instrumentation, procedure and

evaluative measures. Results are presented in Chapter IV.

Chapter V presents the conclusion for the study and allows

the researcher to suggest recommendations.













CHAPTER II
REVIEW OF THE LITERATURE


This review addresses three areas. The initial

section delineates two personality characteristics of

alcoholics: high anxiety and low self-esteem. The

second provides an overview of imagery as treatment.

The third evaluates the concept of successful treatment

with special emphasis on the rationale of imagery as

treatment.


Anxiety in the Alcoholic

Researchers have observed anxiety symptoms in alcoho-

lics and consider anxiety to be a basic characteristic of

the alcoholic (Milt, 1977; Chafetz, Blane and Hill, 1970).

Silber (1959; 1967; 1974) identifies the alcoholic's coping

with anxiety as a major problem.

Silber (1974), specifically identifies alcoholic

personality characteristics as low tolerance of frustration

and anxiety. Recommended treatment is that the alcoholic

learn to reduce anxiety and improve coping skills. Addi-

tional evidence for the identification of anxiety as a

basic personality characteristic is the finding of Masser-

man (1976). He observed that alcoholics display high anx-

iety. McLachlon (1979), Scorzelli, and Reinke-Scorzelli

(1976) and Dunn and Hedberg (1974) also identify high

anxiety levels in the alcoholic.
23










Stress and Drinking

In reviewing anxiety in the alcoholic it becomes

essential to examine the influence of stress. Eaton, Peter-

son and Davis (1976, p. 238) in Psychiatry: Medical Out-

line Series determined "a stress situation exists when

something in the environment causes a threat to life; a

risk of injury; an actual or potential loss of security,

self-esteem, or important sources of satisfaction." Thus

the result of stress takes the form of anxiety manifested

by tremor, tension, sweating, restlessness, irritability

and difficulty in concentration (Eaton, Peterson, and Davis,

1976). By definition, the result of stress on individuals

is anxiety and since the present environment is charged

with stresses (Seyle, 1974), the alcoholic cannot avoid

dealing with anxiety. Stress is not synonymous with

anxiety but because of their interrelationship, anxiety

is exhibited in the presence of stress.

The reaction of the alcoholic to stress is predicta-

ble. Researchers have found direct correlation between

stress and drinking by the alcoholic (Higgins and Marlatt,

1975; Miller, Hersen, Eisler, and Hilsman, 1974; Sadana,

Thistle, and Forsyth, 1978; Strickler, Tomaszewski, Maxwell

and Suib, 1979). The greater stress an alcoholic perceive;,

the greater the tendency to drink. As might be expected,






25



levels of anxiety are positively correlated with an

alcoholic's drinking (Bundle, Whitlock, and Franks, 1974;

Cahalan and Cisin, 1968 (a); Cahalan and Cisin, 1968 (b);

Kraft and Al-Issa, 1968; Morrissey, 1979).

Maloof (1975, p. 116) found that drinking suppressed

the stress reactions of alcoholics. He also concluded that

"drinking helps alcoholics cope with stress by affecting

their cognitive appraisal of stimuli." Alcohol's analgesic

effect lessens the impact of affective stressors, particu-

larly those due to undesirable life events.


State and Trait Anxiety

An additional investigator, Spielberger (1966),

has identified high anxiety in alcoholics. Due to his ex-

tensive research in anxiety, he has identified two distinct

types: state and trait.

Parker, Gilbert and Thoreson (1978), Eno (1975),

Browne (1976), and Strickler, Bigelow, Wells and Liebson

(1977) have all found both high state and trait anxiety

in the alcoholic. Additionally, Cautela and Rosenstiel

(1975) have identified high state anxiety in drug addicts.

Low Self-Esteem

There is substantial research to support that male

alcoholics have poor, inadequate or distorted self-image,

low self-esteem or poor self-concept (Kinsey, 1966, 1968).









Cahn (1970) reported that 150 professional therapists, treat-

ing alcoholics, identified the following core personality

characteristics of alcoholics: anxiety, depression, self-

depreciation, compulsiveness, dependence and immaturity.

Similarly, Blum and Blum (1967) in their investigative work

summarized the traits most commonly referred to: restless,

angry, depressed, insecure, conflicted, anxious, deeply

guilty, lacking self-esteem and assertion, emotionally un-

stable, low frustration tolerance and hiah but unfulfilled

aspirations.

Of these personality characteristics, researchers

have consistently identified one they consider significant--low

self-esteem (Cautela and Rosenstiel, 1975; Charalompous,

Ford and Skinner, 1976; Chafetz, Hill, and Blane, 1970).

Other investigators have specifically identified low self-

esteem in the alcoholic: Gross and Adler, 1970; Tomsovic,

1976; Felde, 1973. They have found upon entering treatment,

most alcoholics display this characteristic.

The question of whether low self-esteem produces alco-

holism or alcoholism produces low self-esteem may be a moot

point, but the fact that low self-esteem is a characteristic

of alcoholism is significant. Support that low self-esteee

precedes alcoholism is presented by Jones (1968) in a

longitudinal study of sixty-seven children to adulthood.

Of the ones developing into problem drinkers and alcoholics,

low self-esteem was a common thread. McCord (1972) in a









follow-up study produced similar results and Cahalan and

Room (1974) found low self-concept was a factor predictive

of problem drinking in adult life. Although researchers

may not agree if low self-esteem necessarily precedes or

occurs during the development of alcoholism, it is conceded

that low self-esteem is a significant characteristic of the

alcoholic.


Overview of Imagery

The effect of imagery on behavior has been noted by

many researchers. Assagioli (1977) states every image

has in itself a "motor drive," meaning that our images

initiate behavior and that if behavior can be viewed as a

process. then imagery becomes a part of that process.

Jacobson (1968), in developing the procedure he called Pro-

gressive Relaxation, found that imagery does not just affect

the mind but also parts of the body. He gives the following

examples: think of reading and our eyes move toward the

imagined paper; think of brushing hair and there is muscle

action in the arm that brushes hair.

In addressing imagery and behavior, Kreitler and KreLtler

(1976, p. 148) in their investigation of cognitive orien-

tation substantiate the hypothesis "that cognitive system

and in particular the orientative aspect of cognitive con-

tents as well as their various forms of interplay determine

the direction of human behavior." Through this hypothesis








and through other investigation, they assert that our images

shape our action. Supporting this assertion, that images

shape action, are Weiss (1952), Taub and Berman (1968),

Milner (1970) and Pribram (1971). Also Prince (1975) states

imaging is one of the basic tools of problem solving.

Specifically, imagery has been successful in improving

self-concept (Krop, Calhoon, and Verrier, 1971). Additionally

Beck (1970) and Susskind (1970) believe a person can visu-

alize what he wants to be. According to these researchers,

visualization builds self-confidence, provides a means

of self-identification, and provides techniques for coping

with anxiety provoking situations.

Modeling

One researcher who has been successful in using imagery

as a treatment modality is Bandura. Bandura's use of imagery

has been in modeling (1969, 1970). Modeling, according to

Bandura, means that the subject views a live person or video

tape of a person performing a specific behavior he wants to

learn. He then visualizes the subject performing the be-

havior. The subject models the behavior in his mind. Also,

the subject may simply be asked to visualize someone (rarely

himself) performing the targeted behavior. Bandura's

premise for modeling is that "virtually all learning phe-

nomena resulting from direct experiences can occur on a

vicarious basis through observation of other people's beha-









vior and its consequences for the observer" (1970, p. 350).

He also supports that most behavioral changes are cogni-

tively mediated and that persons can acquire intricate re-

sponse patterns and emotional responses through visualiza-

tions.

Covert Modeling

Kazdin also has been successful in using imagery as a

treatment modality. He has designated his imagery procedure

as Covert Modeling. For Kazdin, covert refers to the use

of the mind to visualize scenes. Primarily, Kazdin has been

successful in modifying non-assertive and avoidance behavior

(1973, 1974 (a), 1974 (b), 1975, 1976, 1979).

Initially, Kazdin used live or filmed performances for

the subject to view. Later he discovered that models were

unnecessary as subjects could visualize the desired behavior

without prompting. Kazdin (1974) (a) also added positive

reinforcement to his modeling paradigm. After the subject

visualizes the desired behavior, he visualizes something

that would be positively reinforcing. This positive rein-

forcement could range from an ice cream cone to a pleasant

experience. The results of these Kazdin studies indicate

that subjects can be taught assertive behavior and can reduce

avoidance behavior through Covert Modeling.

Covert Conditioning

Another investigator using imagery to modify behavior

is Cautela. He titles his work in this area Covert Con-

ditioning: covert sensitization, covert positive reinforce-









ment, covert negative reinforcement, covert extinction

(1966, 1967, 1970, 1971, 1972, 1973; Cautela and Rosenstiel,

1975).

Covert Sensitization

Covert sensitization is used to treat maladaptive

approach behavior. It is based on the punishment paradigm

in which an aversive stimulus is presented simultaneously

with the response to be decreased. The subject imagines

that he is performing the behavior to be decreased. Then

he imagines some aversive reaction. Next the subject imagines

a self-control scene, a pleasant scene that is safe. secure

and not associated with either the primary situations or

the aversive scene.

The following is an example of a covert sensitization

session: The subject wants to eliminate the habit of smoking.

The counselor directs him through the imagery. As the sub-

ject imagines he is holding a cigarette, lighting it, and

bringing it to his lips, he is told to imagine that he be-

gins to feel sick to his stomach. In his imagination, he

begins to vomit. The vomit goes all over the floor, his

cigarettes, his friends, and himself. He is then asked

to visualize the complete scene and signal the therapist

by raising his index finger, when he actually feels nauseated.

When he raises his finger, he is told to imagine that as he

rushes outside into the fresh clean air, the nausea goes away

and he no longer feels ill.









Covert Positive Reinforcement

Covert positive reinforcement is used to treat mala-

daptive avoidance behavior. The basic assumption of covert

reinforcement procedures is that a reinforcing stimulus

presented in imagination Functions in a manner similar to

an externally applied reinforced. In covert positive rein-

forcement, the subject imagines the behavior he wished to

increase. Then he imagines a reinforcing stimulus.

The following is an example of a covert positive rein-

forcement session: The subject wants to become more con-

fident when he is talking to girls. First the subject selects

a "reinforcement" scene, a situation he can visualize and

experience pleasure. Then the subject imagines he is going

to call a girl for a date. As he picks up the phone to

dial, the counselor says "reinforcement." The subject im-

mediately visualizes the reinforcement scene. When the sub-

ject indicates that the image is clear, the therapist con-

tinues. The girl answers and he responds. Then he asks her

if she is free Saturday night and tells her that he would

like to take her out. The counselor says "reinforcement"

and the subject visualizes the reinforcement scene. As

the subject visualizes the conversation scene, the "rein-

forcement" is used selectively to promote the continuation

of the conversation scene.

Covert Negative Reinforcement

Covert negative reinforcement is used to treat maladap-

tive avoidance behavior. The basic assumption is the escape









conditioning paradigm in which a noxious stimulus is presented

and is terminated when the response to be increased is per-

formed. The subject imagines he is in a very aversive si-

tuation. When the scene is clear, the subject upon hearing

a cue word erases the scene with the noxious stimulus and

then imagines the response to be increased.

The following is an example of a covert negative rein-

forcement session: The subject wants to be able to walk

into a room full of people and feel comfortable. The sub-

ject is told the following: You can feel yourself tied

down in a chair in your living room; you don't see yourself

there, but you try to imagine you are actually there; now

look around you; you can see all the furniture; you can

feel the chair underneath you; suddenly, you see a snake

coming toward you; you try to struggle to get away, but

you can't. Now when this scene is very clear, the subject

immediately erases the noxious stimulus scene and imagines

the response to be increased--walking into a room full

of people and feeling comfortable.

Covert Extinction

Covert extinction is used to treat maladaptive approach

behavior. The basic assumption is that if a subject is in-

structed to imagine that the reinforcing stimulus maintain-

ing his covert or overt behavior does not occur, then that

behavior will decrease in probability. The subject ima-










gines the behavior he wishes to decrease. Then, he

imagines the normally occurring reinforcing stimulus does

not occur.

The following is an example of a covert extinction

session: The subject wants to quit stuttering. In this case,

stuttering is maintained and reinforced by the environment.

The counselor asks the subject to imagine the following

scene; you are sitting in the school cafeteria; you choose

the place you usually sit; you can hear and see students

walking around, eating and talking; there is an empty

chair near you; a pretty blond comes over and asks if

she can sit down; you stammer "ya ya. .ya. .ya. .

yes." She absolutely does not react to your stuttering.


Concept of Successful Treatment

Successful treatment for alcoholics requires that

specific treatment goals are met. The primary goal of

treatment for the alcoholic has been and is currently

abstinence (Chafetz, Blane and Hill, 1970; Guze, Tuason,

Stewart, and Picken, 1963; Kissin and Begleiter, 1977;

Milt, 1977).

As mentioned previously, two important personality

characteristics of the alcoholic must be dealt with: low

self-esteem and high anxiety. The Veterans Administration

Alcohol Rehabilitation Program in Sheridan, Wyoming, used

self-concept as measured by the Tennessee Self Concept

Scale as a measure of successful treatment (Tomsovic, 1976).










It has been determined by the program that an elevation

in self-concept is necessary to increase the individual's

effectiveness in coping with his addiction. Others recom-

mending self-concept as a measure of successful treatment

are Gross and Adler (1970), Gross, (1971), Felde (1973),

and Lowe and Thomas (1976).

Because an alcoholic's anxiety level is positively

related to his alcohol consumption, a treatment recommenda-

tion is improved coping of or a reduction in anxiety (Higgins

and Marlatt, 1975; Strickler, Tomaszewski, Maxwell and Suib,

1979; Miller, Hersen, Eisler and Hilsman, 1974). Foy, Miller,

Eisler, and O'Toole (1976) recommend anxiety coping training

for alcoholics. They indicate an improvement in anxiety re-

duction results in improved social coping. Dollard and

Miller (1950) concur that a reduction in anxiety increases

a client's problem solving capacities. O'Leary, Rohsenow,

Shau and Donovan (1977) recommend reduction of anxiety as

a measure of successful treatment.

In addition to research supporting the individual

reduction of anxiety and increase of self-esteem for the al-

coholic, there is support for a correlation between anxiety

and self-esteem. There is evidence that with an increase

in self-esteem, there is a reduction in anxiety (McCandless,

Castaneda, and Palermo, 1956; Castaneda, Palermo and McCand-

less, 1956). Mitchell (1959) in a study of one hundred










college students found the higher the self-concept, the lower

the anxiety level. Supporting the inverse relationship be-

tween self-esteem and anxiety are Lipsett (1958), Foy et al.

(1976) and Coopersmith (1959, 1960). Hamacheck (1971) sum-

marized the relationship by stating that the anxiety a person

experiences in a situation depends partially on his overall

concept of personal adequacy and self-esteem. High self-

esteem persons faced with anxiety producing situations de-

liberate carefully and make high quality decisions.


Rationale for Imagery as Treatment

Crucial to the belief that imagery can be an effective

treatment modality is the acknowledgement of three basic

concepts:

(1) Covert processes affect overt behavior (Cautela,

1973; Wolpe, 1973; Homme, 1965; Lazarus and Abramovitz, 1962;

Schwartz and Higgins, 1971). An example of this concept

is that a reinforcing stimulus presented in the imagina-

tion can result in an increase in the frequency of a beha-

vior.

(2) Manipulation of imagery can effectively modify

maladaptive behavior (Cautela, 1966, 1967, 1970; Wolpe,

1958; Williams, 1941; Arnold, 1945). An example is covert

sensitization in which a subject imagines aversive condi-

tions occurring concurrently with the behavior he wishes









to terminate. The repetition of imagining this scene

results in a decrease of the unwanted behavior.

(3) Manipulation of covert processes can influence

overt processes in a predictable manner (Cautela, 1970,

1972; Lang, 1964; Kazdin, 1974 (b); Wolpe, 1958; Antonitis,

1951; Paul, 1966. An example is imagining a pleasant

situation after performing a behavior tends to increase

the frequency of that behavior. Another example is imagining

an unpleasant situation after performing a behavior tends to

decrease the frequency of that behavior.

Not only can imagery modify behavior, it has other

characteristics that enhance it as a treatment modality:

(1) there is no reliance on equipment, (2) procedures can be

applied in almost any situation, (3) procedures are not

limited to practical reality, as anything may occur in the

imagination, (4) neither imagery nor learning is observable,

but results of both can be measured by behavioral change.

(Cautela, 1973).

Treatment using imagery has been determined successful

in treating alcoholism by Coperman (1977), Flannery (1976),

Cautela (1972, 1966), and Ashem and Donner (1968). Addi-

tionally, imagery has been successful in treating related

drug addiction (Cautela and Rosenstiel, 1975; Droppa, 1973;

Wisocki, 1973; and Cahoon and Crosby, 1972).










By identifying the specific aspects of these success-

ful studies, a comparison can be made that will demonstrate

the uniqueness of this study. Coperman (1977) identified

covert sensitization aversivee imagery) plus hypnosis.

In Cautela and Rosenstiel (1975), Cautela (1966, 1972),

and Lesser (1967), the significant aspects were identified

as relaxation and modification of consequences of drink-

ing through aversive imagery. Flannery (1976) used covert

aversive imagery and covert modeling. Wisocki (1973)

identified homework (imagery trials at home), emphasis on

self-control and aversive imagery. Droppa (1973) in a

review of behavioral treatment for drug addiction con-

cludes that there is a lack of research which systematical-

ly controls for relevant variables. Cahoon and Crosby

(1972) in their review of literature found success with

a learning based approach in which the therapist selects

imagery situations and consequences. Ashem and Donner

(1968) identified aversion imagery which produced a

phobic response to alcohol and generality of session

to subject's environment.

The characteristics which make this imagery study

unique follow. (1) This study uses subject directed

positive reinforcement whereas identified studies rely on

aversive imagery. One study did use covert positive









reinforcement but that study and this one differ signi-

ficantly in the origin of the reinforcement. In this

study, the reinforcement comes from the subject when

the therapist asks him to verbalize his positive emotions

about himself regarding his imagined coping with the

problem situation. The reinforcement originates with

the subject whereas in covert positive reinforcement the

reinforcing image is a therapist designed scene that will

be continually used in therapy with the subject. In this

study the therapist provides the direction for the rein-

forcement but the subject determines how it will be exper-

ienced. (2) This study places more responsibility on the

subject than described covert methods. In this study the

subject selects the problem that will become the imagery

situation in the session. (3) This study used a coping

model whereas covert positive reinforcement uses a mastery

model. In the coping model, the subject performs the

desired behavior in spite of his experienced anxiety. In

the mastery model, attempts by the therapist are made to

alleviate as much anxiety as possible. When the subject be-

gins to feel anxious while imagining the scene, the therapist

will have him stop and visualize the reinforcing scene. Then

when the subject is not anxious, he will continue visualizing

the original scene. (4) This study evaluates treatment

outcomes of imagery, relaxation, and the interaction of






39


imagery and relaxation, whereas past studies evaluated

one variable. (5) The imagery in this study is holistic

in that there is no limitation as to the focus of the

imagery sessions. Imagery sessions deal with any aspect

of the subject's life (marital, drinking, vocational,

inter-personal), whereas past studies focus only on modifying

the consequences of drinking (changing the outcome from

pleasurable to unpleasurable). (6) This study is com-

prehensive in regard to number of subjects. One hundred

twenty subjects participated. In the nine studies

cited above, the maximum subject number is seven, while

four studies have only one subject.














CHAPTER III
METHODOLOGY


The review of literature indicates low self-esteem

and high anxiety levels are important personality

characteristics of the alcoholic. These personality

characteristics are significant in that they perpetuate

the addictive cycle of alcoholism (Kissin and Begleiter,

1977; Milt, 1977). They become part of the process of

alcoholism that distinguishes between alcoholism as a

symptom and as a disease. Initially low self-esteem and

high anxiety influence drinking, then drinking influences

self-esteem and anxiety. When they become interrelated,

to the extent they are both cause and effect, the addic-

tive cycle is complete.

Self-esteem is positively correlated with a person's

coping skills (Herbert, 1968). The lower a person's self-

esteem, the more difficult it is for him to cope. Addi-

tionally, the lower a person's self-esteem, the lower his

expectations (Williams & Cole, 1968). Lowered expecta-

tion of success increases anxiety and reduces successful

coping (Hughes, 1969).

As low self-esteem and high anxiety levels are inherent

in alcoholism, a treatment procedure that increases self-










esteem and reduces anxiety has been recommended (Cahn,

1970; Tomsovic, 1976). Research investigating this

treatment procedure may be useful to those treating al-

coholics. This study additionally describes alcoholics

along the dimensions of self-esteem and state and trait

anxiety. The design of the study, hypotheses, population

selection of the sample, instrumentation, research

procedures, statistical analysis, and limitation of the

study are discussed in this chapter.


Research Design

This study in quasi-experimental research uses a

randomized control-group pretest--posttest factioral de-

sign. A 2 x 4 factioral design of two classifications of

alcoholics and four treatment groups is used. Assignment

of subject to treatment group is randomized. The four treat-

ment approaches consist of Control, Progressive Relaxation

Training, Guided Imagery Training and Progressive Relaxation/

Guided Imagery Training. In this study, the Control group

has not been assigned "no treatment" as in many studies,

but receives treatment based on Reality Therapy principles.

All three experimental treatment groups and the control

group receive five treatment sessions. Therefore, oLtcome

measures for the three experimental treatments are compared

to outcome measures of subjects involved in therapy. The










two classifications of alcoholism are First Stage Alcoholics

and Episodic/Continuous Alcoholics. These classifications

are derived from the subclassifications of alcoholism in the

DSM-III.

Because personality characteristics of alcoholics

cross all boundaries of sex, age, education, and race, this

study addresses two classifications of alcoholics that

affect outcome of treatment (Kissin and Begleiter, 1977;

O'Leary, Rohsenow, Shau and Donovan, 1977; Tomsovic, 1976).

There is significant research to support the belief that the

fewer the significant problems an alcoholic has experienced,

due to his drinking (marital, employment, financial, legal

problems), the greater the potential for successful treat-

ment. Mindlin (1960) found marital status, present econo-

mic resources, occupation status and arrest record to be

predictors of treatment outcome. The more positive each

of these predictors, the greater the chance for success.

Zimberg, Wallace and Blume (1978) found that the farther

the alcoholism had progressed, the less the chance for re-

covery. There are additional researchers who support that

first stage alcoholics, having minimal losses of their

support systems, are better candidates for treatment than

those with significant losses (Blum and Blum, 1967; Blane,

1968; Baekeland, 1977; Kissin and Begleiter, 1977).









In the present design in regard to internal validity,

between session variations are controlled since they affect

both groups equally (Isaac and Michael, 1978). Within-session

variations are addressed by treating subjects (Isaac and

Michael, 1978). Differential selection is controlled by

random selection methods. Maturation and protesting effects

occur equally for all groups. Differential mortality is

assessed for nonrandom patterns, and statistical regression

is controlled when extreme scores from the same population

are randomly assigned to groups (Isaac and Michael, 1978).

In regard to external validity, interaction of selection

and treatment are controlled because the population from

which the subjects are drawn is the same population to

which the results will be generalized (Kerlinger, 1973).

To avoid reactive effects of experimental procedures, the

control group and the experimental groups receive equal

attention (Kerlinger, 1973; Isaac and Michael, 1978).

This study examines the effect of treatment using

guided imagery on self-esteem, state and trait anxiety, and

drinking by the alcoholic. In the treatment of alcoholism,

relaxation training, specifically Progressive Relaxation,

has been used successfully and has reduced anxiety (Eno, 1975).

Because of the interrelationship of relaxation and imagery,

imagery has at times been interpreted as a modified relax-










ation procedure. Therefore, the study employs a treatment

group using Progressive Relaxation and a treatment group

combining Progressive Relaxation and Guided Imagery. Thus

the efficacy of imagery as treatment is addressed, along

with the individual effect of relaxation and the combined

effect of relaxation and imagery.

The dependent variables are the Self-Esteem scale on

the Tennessee Self-Concept and the State Anxiety scale and

Trait Anxiety scale on the State-Trait Anxiety Inventor,.

Another dependent variable is the Drinking Questionnaire,

At the end of treatment, subjects are asked how many drinks

they have consumed and how many times they have wanted

(craved) a drink during the preceding two weeks. Two weeks

have been found to provide adequate base line data to

describe drinking behavior (Bergin and Lambert, 1978; Cahr,

1970; Lowe and Thomas, 1976). After five weeks of treat-

ment, the two week period is used to determine effectivenes-

of treatment in regard to drinking. Validity of these

measures depends on self report, but self report of drink-

ing behavior has been determined to be valid in similar

research situations (Sobell and Sobell, 1978). The Drink-

ing Questionnaire determines how many drinks the person h3a

had during the past fourteen days. It also determines how

many times the person has wanted to drink.










Research Hypotheses

This study will address the following hypotheses and

test for significance at the alpha equals .05 level:

1. Guided Imagery Training will produce no change

in self-esteem.

2. Guided Imagery Training will produce no change

in state anxiety.

3. Guided Imagery Training will produce no change

in trait anxiety

4. Guided Imagery Training will produce no change

in actual drinking behavior.

5. Progressive Relaxation Training will produce no

change in self-esteem.

6. Progressive Relaxation Training will produce no

change in state anxiety.

7. Progressive Relaxation Training will produce no

change in trait anxiety.

8. Progressive Relaxation Training will produce no

change in actual drinking behavior.

9. Progressive Relaxation/Guided Imagery Training

will produce no change in self-esteem.

10. Progressive Relaxation/Guided Imagery Training

will produce no change in state anxiety.









11. Progressive Relaxation/Guided Imagery Training

will produce no change in trait anxiety.

12. Progressive Relaxation/Guided Imagery Training

will produce no change in actual drinking be-

havior.


Selection of Subjects

The population addressed in this study consists of

Florida alcoholic clients with a primary diagnosis of

Alcohol Dependence 303.9x based on the Diagnostic and

Statistical Manual of Mental Disorders-Third Edition (1980).

Results from this study are expected to generalize to

treatment of alcoholics nationally because personality

characteristics of alcoholics cross all boundaries of sex,

age, education, and race (Blane, 1968; Kissin and Begleiter,

1977; O'Leary, Rohsenow, Shau and Donovan, 1977; Tomosovic,

1976; Vanderpool, 1969). This diagnosis is determined by

counselors charged with that responsibility by licensed

alcoholism facilities under the supervision of the Department

of Health and Rehabilitative Services of the State of Florida.

Range of education and experience for counselors in this

study are B.A. degree to Ph.D. candidate and four to eight

years experience in alcoholism treatment.

Subjects were drawn from those in outpatient treatment

facilities. No one under the influence of alcohol or the

effects of alcohol withdrawal was admitted to the study.










The sample includes both male and female, at least 18

years of age, with a minimum of six years formal education.

A sixth grade education is required to complete the

Tennessee Self-Concept Scale (Fitts, 1965) and the State-

Trait Anxiety Inventory (Spielberger, Gorsuch, and Lushene,

1968).

Three Florida alcoholism programs regulated by the

State Department of Health and Rehabilitative Services

agreed to participate in the study. Those participating

are: the Community Alcoholism Program, North Central

Florida Community Mental Health Center, Gainesville; the

Immokalee Treatment Center, a satellite of the David T.

Lawrence Mental Health Center, Naples; and Southwest

Florida Alcoholism Services, Inc. in Fort Myers.

Prospective subjects were asked by counselors to par-

ticipate in an experimental treatment program. In the pre-

sentation to the clients, it was fully explained that no ani-

mosity would be expressed if they declined and that their

decision would not adversely affect the quality of their

treatment. Each volunteering subject read and signed a

"Consent to Research" form prior to the experimental procedure.

Subjects were not financially reimbursed for their participa-

tion and were so informed.









Instrumentation

The instruments used in this study are the Tennessee

Self-Concept Scale published in 1965 by William H. Fitts and

the State-Trait Anxiety Inventory published in 1970 by

Spielberger, Gorsuch and Lushene.

The Tennessee Self-Concept Scale, hereafter called the

Scale, was developed because there was a need for a measure-

ment which is easy to read and understand, widely applicable,

well standardized and multi-dimensional in the description

of the self concept. The Scale consists of 100 statements

which the subject uses to describe himself. The Scale is

self administering so it can be completed in groups as well

as individually with subjects age 12 or older having at

least a sixth grade reading level. The range of time needed

to complete the Scale is 10-20 minutes. It is also appli-

cable to the whole range of psychological adjustment from

healthy, well adjusted people to psychotic patients (Fitts,

1965).

Two forms are available: a Counseling Form and a

Clinical and Research Form. The Counseling Form is more

appropriate for self interpretation and feedback to sub-

jects. The Clinical and Research Form provides a better

understanding of the personality dynamics of the subject,

but is also more complex in terms of scoring analysis and

interpretation. Since this researcher's primary use for

the Scale is a valid and reliable measure of self-esteem,










and both the Counseling Form and the Counseling and Research

Form provide the same P Score (self-esteem score), the

Counseling Form is used in this study. Additionally, the

Counseling Form is easier to score and provides eleven

Self Scores.

The Counseling Form of the Scale provides scores de-

scribing the following personality dynamics: a Self Crit-

icism Score measuring defensiveness; a P Score, reflecting

overall level of self-esteem; Identity (What I am); Self

Satisfaction Score; Behavior Score (What I do); Physical

Self (subject's view of body); Moral Ethical Self (feelings

of good or bad); Personal Self (personal worth); Family

Self (worth as a family member); Social Self (self in re-

lation to others); Variability (variability in perception

of self); and Distribution (certainty about way subject

sees self). Scores may be displayed on a profile sheet and

there they may be converted to percentile scores. The Scale

may be either hand or computer scored. For this study,

the Scale is hand scored.

The test-retest reliability coefficients for both forms

of the TSCS range from .60 to .92, with most coefficients

in the .70 to .80 range (Fitts, 1965). The classification

system used for Raw Scores and Column Scores has been de-

termined to be valid which assures content validity (Fitts,

1965).










Between groups validity has been substantiated by Col-

lins, Burger, and Doherty (1970), Herbert (1968), and Hughes

(1969). Bergin and Lambert (1978) found the TSCS to be both

valid and reliable. Also supporting the validity of the

TSCS scores are Duncan (1966) and Resnick, Rauble, and

Osipow (1970). Gross and Adler (1970) have also substan-

tiated content validity for the TSCS. Additionally a high

correlation was found to exist between the Minnesota Multi-

phasic Personality Inventory and the Scale on measurements

of self-esteem (Fitts, 1976).

Wylie (1961) in her review of personality measuring

instruments found the TSCS to have discriminant validity.

This finding was verified by Williams and Cole (1968), Van-

derpool (1969), and Lipsett (1958). Bergin and Garfield

(1978) in their review of self-concept measures recommend

the TSCS as a valid and reliable instrument.

The State-Trait Anxiety Inventory is comprised of

separate self-report scales for measuring two distinct anx-

iety concepts: State Anxiety (A-State) and Trait Anxiety

(A-Trait). The State-Trait Anxiety Inventory (STAI) A-

Trait scale consists of twenty statements that ask people

to describe how they "generally" feel. The A-State Scale

also consists of twenty statements, but the instructions re-

quire subjects to indicate how they "feel at a particular

moment in time." Most people with a fifth or sixth grade










reading ability have no trouble understanding and respond-

ing to all STAI items. The Inventory has no time limit

and range of time to complete the inventory is 6-8 minutes

for college educated to 20 minutes for less educated and/

or mentally disturbed. Scores can be converted to percen-

tile rank using norm tables. The STAI can be either hand

or computer scored.

Test-retest reliability correlations for the STAI

A-Trait are quite adequate ranging from .73 to .86 while

those for the A-State scale should reflect the influence of

unique situational factors existing at the time of test-

ing. Alpha reliability test-retest correlations for the

A-State scales were computed and found to be .83 to .92

(Spielberger, Gorsuch, and Lushene, 1970). Alpha relia-

bility coefficients are typically high under psychological

stress. On separate occasions, it was determined to be

.92 and .94. Evidence of internal consistency was pro-

vided by item-remainder correlations. Item-remainder

correlations for both A-State and A-Trait were all above

.50 (Spielberger, Gorsuch, and Lushene, 1970).

Validity and reliability of the STAI have been sup-

ported by Hodges and Felling (1970) and O'Neal, Spielberger

and Hansen (1969). Concurrent validity of the STAI A-Trait

scale and the IPAT Anxiety Scale was found to be .75 (Cat-

tell and Scheiner, 1963); with the Taylor Manifest Anxiety










(1953) it was .80; and with the Zuckerman Affect Adjective

Checklist (1960), it was .58. High construct validity

was supported with the pre- and posttest of nine hundred

seventy-seven undergraduate students at Florida State

(Spielberger, Gorsuch and Lushene, 1968).

The Drinking Questionnaire (Appendix A) is a ques-

tionnaire developed by the researcher to obtain two pieces

of information: number of drinks consumed and number of

times the respondent wanted to drink during the past two

weeks (14 days). The quality of the information obtained

in the Drinking Questionnaire depends on the validity

of self report. Self report has been determined to be an

accurate means of obtaining data regarding the drinking

behavior of an alcoholic both while in treatment and prior

to treatment (Guze, Tuason, Stewart, and Picken, 1963;

Sobell, Sobell, and Samuels, 1974; Sobell and Sobell, 1975;

Sobell and Sobell, 1978; Sobell, Maisto, Sobell and Cooper,

1979). Sobell, Maisto, Sobell and Cooper (1979) established

the accuracy of self reports to be in the .79 to .98 range.

One of the reasons for this accuracy is attributed to the

importance of drinking to the alcoholic. Any period of

drinking or abstinence becomes significant and is remembered

by the alcoholic. In the six studies supporting the

validity of self report of drinking behavior, they all










directly asked the subject how many drinks (or how much)

he had been drinking. The Drinking Questionnaire follows

this example and asks the subject directly how many drinks

he has had and how many times he has wanted to drink.


Procedure

Five therapists participated in the study, three at

Southwest Florida Alcoholism Services, Inc., one at the

Community Alcoholism Program, and one at the Immokalee

Treatment Center. To eliminate any experimenter bias, the

researcher is not a therapist in this study. The therapists

participated in a two hour training session. An outline

identifying the topics covered in this training session is

provided in Appendix B. During the training session, the

principles of imagery as treatment, the four basic treat-

ment procedures, and a rationale for each were explained.

Therapists also role played an imagery treatment session

and received a cassette of the relaxation procedure to be

used in treatment sessions.

Four treatment groups are utilized: Control, Progres-

sive Relaxation Training, Guided Imagery Training and Progres-

sive Relaxation/Guided Imagery Training. A diagram of treat-

ment groups including content and time frame is provided in

Appendix C. The Control group received sixty minutes

(100% of the session) of verbal therapy based on Reality

Therapy principles. Each of the other three groups received










30 minutes (50% of the session) based on Reality Therapy

principles and the remaining time based on the group

designation: Progressive Relaxation (30 minutes or 50%),

Guided Imagery (30 minutes or 50%), and Progressive

Relaxation/Guided Imagery (30 minutes or 50%). Each treat-

ment group had five sessions. Cautela (1966, 1967, 1972)

has found covert sensitization to be successful in two to

three one hour sessions. Ashem and Donner (1968) found

covert sensitization to be successful with alcoholics

in five thirty minute treatments. The amount of time spent

in treatment sessions in this study is equal to that in

Cautela's and Ashem and Donner's successful studies. By

using four groups, the specific effects of Progressive

Relaxation, Guided Imagery, and the interaction of Pro-

gressive Relaxation and Guided Imagery was determined.

All subjects in this study have a diagnosis of 303.9x,

Alcohol Dependence or Alcoholism. The purpose of the fifth

digit is to identify course of illness. Four categories

are provided by the DSM-III (1980). 0 indicated Unspecified

or First State; 1 indicates Continuous; 2 indicates Episodic;

and 3 indicates In Remission. Actually these subclassifica-

tions describe type of drinking. Episodic refers to cir-

cumscribed maladaptive periods of use while Continuous

refers to regular maladaptive use. In this study, subjects

are divided according to two classifications. One group has










a diagnosis of 303.90 or first Stage Alcoholism. The

other classification consists of subjects whose course of

illness is more extensive than the first stage, requiring a

diagnosis of 303.92 or 303.93. The two classifications

are First Stage and Continuous/Episodic. Criteria for

the classification of First Stage are: no criminal charges,

not more than one driving offense, no loss of employment,

and no divorce due to drinking. If the subject does not

meet these criteria, then the subject is classified Con-

tinuous/Episodic.

Each subject volunteering for the study was assigned

to a treatment group on a random basis. For each therapist,

the first client agreeing to participate in the study joined

the Control group. The second joined the Progressive Relax-

ation Training group; the third, the Guided Imagery Training

group; the fourth, the Progressive Relaxation/Guided Imagery

group. Then the schedule is repeated. When a subject drops

out, the next subject fills that vacancy, joining the vacated

treatment group. The normal attrition rate (those dropping

out before completing four sessions) at Southwest Florida

Alcoholism Services is 43%. Had there been an abnormal attri-

tion rate in any one treatment groups, attempts would have

been made to obtain the necessary number of subjects to equal

the number in the other groups. If that could not be










accomplished, then the drop outs from that group would have

been contacted to determine the reason for their early

termination.

If a subject became intoxicated and his intoxication

interfered with participation in the study, then he was

dropped from the study. At the termination of the study,

the treatment groups are compared in regard to number of

drop outs. Treatment procedures are presented on an indi-

vidual basis. Each Progressive Relaxation, Guided Imagery

and Progressive Relaxation/Guided Imagery session involves

only the subject and therapist.

Subjects in the study were asked to complete the

Tennessee Self-Concept Scale (TSCS), the State-Trait Anxiety

Inventory (STAI), and the Drinking Questionnaire (Appendix

A). The Tennessee Self-Concept Scale requires a sixth

grade reading level and the Spielberger State-Trait Inventory

requires an eighth grade reading level. Based on the

highest grade completed, indicated by potential subjects

on the intake form and quality of their completing the form,

the therapists made a determination whether a reading

test was needed. If the therapist suspected a prospective

subject's reading level was not eighth grade, a reading test

was administered. The test selected was the Botel Reading

Inventory A Word Opposites Test (Botel, 1970). This test

is used by the Lee County School System and provides reading










levels one through twelve. Those completing the inventory

but not achieving an eighth grade reading level were not

counted in this study.

In most instances success of treatment is measured

only by abstinence, but alcoholism is a disease that affects

all facets of a person's existence; therefore the vehicle

for evaluating treatment must be multi-diminsional. The

need for a multi-dimensional evaluation has been expressed

for a number of years (Wallerstein, 1956; Mindlin, 1960;

Hill and Blane, 1970; Lowe and Thomas, 1976; Baekeland,

1977). In this study success is measured along the dimen-

sions of actual drinking behavior, self-esteem, state anxiety,

and trait anxiety. Following the fifth session, each

subject completes the Drinking Questionnaire, Tennessee Self-

Concept Scale, and State Trait Anxiety Inventory.

The focus of the Control group is Reality Therapy.

Following are important concepts to the treatment of

the Control group (Reality Therapy): the therapist becomes

involved with the client; the therapist demonstrates that

he cares for the client and that the client is important;

the client is helped to accept his alcoholism; he is helped

to understand he cannot control his drinking; he is helped

to realize that he is responsible for this behavior; focus

is on the client identifying his needs and outlining proce-










dures for meeting his needs. These concepts follow the

basic outline of Glasser's Reality Therapy (1965).

The Progressive Relaxation Training group received

five sessions of relaxation therapy. To assure that treat-

ment is standardized, the relaxation session included a

thirty minute cassette of Jacobson's Progressive Relaxation

exercise with soft music in the background. The exercise

was produced locally from a script (Appendix D). The

remainder of the session follows the Reality Therapy guide-

lines previously described. Jacobson's Progressive Relaxa-

tion exercise was chosen because of its history of effective-

ness in reducing anxiety (Wroblewski, 1977). Progressive

Relaxation has been successfully used to reduce both

State and Trait anxiety in alcoholics (Eno, 1975; Parker,

Gilbert, and Thoreson, 1978). Additionally, Progressive

Relaxation has improved coping in alcoholics (Maloof, 1975).

Reduction in drinking has also been achieved through relaxa-

tion training (Benson, Greenwood, and Klemchuk, 1975).

Strickler, Bigelow, Wells and Liebson (1977) have found

that one brief session of relaxation training is sufficient

to reduce alcoholic's anxiety levels and prior relaxation

instructions can protect alcoholics from anxiety produced

by drinking related stimuli.










Prior to the Guided Imagery Training sessions, an

intake evaluation was obtained. During this procedure,

specific problem areas were identified. These problem areas

were verified during treatment planning at the end of the

evaluation. When the client agreed to become a subject in

the study, he was asked to describe a situation that

typically represents that problem. From that situation,

specific descriptive characteristics were obtained. This

was done so the therapist could verbally present the charac-

teristics to assist the subject in visualizing the situation.

An interview outline has been developed to assist the

therapist in identifying these characteristics. This Inter-

view Outline is found in Appendix E.

In initiating the Guided Imagery session, the ther-

apist asks the subject to find a comfortable position and

take a few deep breaths to relax. After the subject is re-

laxed, the therapist directs the subject in visualizing one

of the scenes he has identified as problematic (Cautela,

1967, 1970). When the scene is clear, the subject raises

his right index finger. The therapist then asks the subject

to describe the scene. It has been found that having subjects

self-verbalize as they visualize enhances the effectiveness

of the visualization process (Meichenbaum, 1971, 1976, 1977).

This increases the vividness of the imagery.









The subject is instructed to view the scene as he

would through his own eyes, not as he would if he were

viewing a film in which he were an actor (Kazdin, 1976,

1979). The subject verbally describes the scene and de-

scribes the coping behavior he is performing. After the

subject visualizes his coping behavior, the therapist

assists him in processing his emotions. The subject

identifies his emotions from the time he began to clearly

visualize the scene until he has accomplished his coping

behavior. Emphasis is placed on how he feels about him-

self after accomplishing the coping behavior. A coping

model has been chosen over a mastery model because it has

been more efficient in producing behavioral change (Kazdin,

1973; Heichenbaum, 1971). In this situation, coping is

defined as being initially anxious but performing the

desired behavior in spite of the anxiety. Mastery is

defined as performing the desired behavior and exper-

iencing no undesirable emotion.

Emphasis is placed on the subject's emotions regarding

himself after he accomplishes the coping behavior. It

has been found that performing the desired behavior visual-

ly and having a favorable consequence afterward increases

the actual desired behavior (Ladouceur, 1974; Marshall,

Boutilier, and Minnes, 1974).










After successfully visualizing the coping behavior

and processing the associated emotion, the imagery proce-

dure is repeated. The subject visualized the same scene,

his coping behavior, and identified and discussed the emo-

tions he experienced in that situation. Repeating the

same scenes and the favorable emotional consequences tend

to increase the chances of performing the coping behavior

(Cautela, 1967, 1970; Hurley, 1976; Meichenbaum, 1976,

1977).

A new situation is introduced each imagery session.

But prior to introduction of the new situation, each subject

repeats the previous scenes in which he visualized success-

ful coping behavior. The Progressive Relaxation/Guided

Imagery Training combines Progressive Relaxation Training

and Guided Imagery Training in one-half of the sixty minute

session. The exact procedure for each has been previously

described.


Statistical Analysis

Outcome measures are the Tennessee Self-Concept Scale,

State-Trait Anxiety Inventory, and Drinking Questionnaire.

Data collected from these scales produce measures of self-

esteem, state anxiety, trait anxiety, number of drinks

consumed, and number of times wanted a drink. Data from

the outcome measures were collected prior to the treatment

sessions and after the treatment sessions were concluded.










After administration of the outcome measures, the data were

prepared for statistical analysis. Demographics collected

were age, sex, race, education, and length of alcoholic

drinking.

Independent variables are the four treatments, in-

cluding the control group. The other factor affecting

treatment outcome is classification of alcoholism. The

effect of First Stage and Continuous/Episodic Alcoholism

on outcome is evaluated.

A two-way analysis of variance (ANOVA) is used for

determining significant differences in the two by four

table of two alcoholic classifications and four treatments.

The two-way analysis of variance is appropriate when study-

ing the effects of two independent variables on a single

criterion. The underlying assumptions of analysis of

variance are randomly selected subjects from normally

distributed populations, homogeneity of variance, and pro-

portionality of cell frequencies (Roscoe, 1975; Isaac and

Michael, 1978). A Cochran C Test is used to test for homo-

geneity of variance. The Cochran C Test was chosen because

it is conservative and is more powerful than the Hartley F

max Test, if five samples or more are used (Roscoe, 1975).

The level of significance for all tests is set at the .05










level. When a significant F-ratio is obtained, the

differences between groups are analyzed. Also due to

pre- and posttesting, significant increases or decreases

in scores are explored. Significant increases in self-

esteem indicate that treatment improves the subject's self-

esteem. A significant decrease in state anxiety, trait

anxiety, number of drinks consumed, and number of times the

subject wanted to drink suggests treatment improves that

particular personality characteristic or behavior.


Limitations of the Study

A common concern of quasi-experimental research is

generalizability (Isaac and Michael, 1978). This is a con-

cern because research sites have been limited to three. How-

ever, the core personality characteristics have been so well

defined in previous chapters that outcome of treatment with

one group of alcoholics should generalize to others (Chafetz,

Blane and Hill, 1970; Kissin and Begleiter, 1977; Blane, 1968).

Another concern is the use of five therapists. Of

concern is the effect on treatment outcome due to individual

therapist characteristics. Recognizing this, each therapist

provides all four treatments.

Despite the possible limitation of generalizability,

the study has the potential for adding knowledge about










the effectiveness of imagery treatment, and the effect

of imagery on specific personality characteristics. There

is an identified need to substantiate the effectiveness of

treatment using imagery (Cautela and Rosenstiel, 1975).

Low self-esteem, high state and trait anxiety have been

identified as characteristics common to alcoholics (Bert,

1971; Masserman, 1976). Additionally, the increase of

self-esteem and decrease of state and trait anxiety in-

creases the probability of sobriety (Gross and Adler,

1970; Higgins and Marlatt, 1975). Lack of information

identifying the effects of imagery on self-esteem, state

and trait anxiety, and the successful treatment of

alcoholics indicate a need for that evaluation.










CHAPTER IV

FINDINGS



The sample for the study was composed of fifty-

nine males and sixty-one females. The mean age was 38.25

with a standard deviation of 10.2. The mean number of years

of education was 10.73 with a standard deviation of 1.56.

There were one hundred eleven white and nine non-white sub-

jects. The mean length of alcoholic drinking was 4.42

years for the total sample. For First Stage alcoholics,

it was 2.88 years with a standard deviation of 1.61. For

Continuous/Episodic, the mean length of alcoholic drinking

was 5.97 with a standard deviation of 3.23.

Forty-eight subjects dropped out of the study. The

normal attrition rate at Southwest Florida Alcoholism

Services is 43%. Attrition rate for this study is 28.5%.

See Table 1. A chi-square of independence was used to

determine if classification of alcoholism and treatment

groups were independent based on attrition. These variables

were found to be independent. Antabuse was used by 68% of

the subjects, but it was not considered an influence on

treatment, as antabuse has not been proven to be a treatment

outcome determinant (Mindlin, 1960).

For this study, the mean pre-test self-esteem

score is 304.04 and the standard deviation is 37.85.










This compares with the Fitts (1965) standardization group,

whose mean self-esteem score was 345.57 and standard de-

viation was 30.70.


TABLE 1
ATTRITION OF SUBJECTS


Control


First
Stage

5


Continuous/
Episodic

8


Total


13


Progressive
Relaxation 6 9 15



Guided Imagery 4 7 11



Progressive
Relaxation/
Guided Imagery 2 7 9


Total 17 31 48



The mean state anxiety score is 48.47 with a stan-

dard deviation of 16.67. The mean trait anxiety score is

50.88 with a standard deviation of 8.33. Anxiety scale

means were similar to the means for neuropsychiatric pa-

tients (Spielberger, Gorsuch, Lushene, 1970). The state

mean was 47.74 and the trait mean was 46.62. For compari-

son, the state means for male college freshmen, under-










graduates, and high school students were 38.07, 37.68 and

39.37, respectively. The trait means were 40.01, 36.35,

and 36.99, respectively.

Because some of the differences between pre- and

posttest scores were negative, and the computer does not

accept negative numbers, it was necessary to convert the

differences to positive numbers. To accomplish this,

a constant was added to each pre- and posttest score

difference. Adding a constant does not change the differ-

ence between the scores but does enable the computer to

make the desired calculations. Following are the constants

and the scales to which they were added: twenty-one to

the Tennessee Self-Concept Scale, fifteen to the State

Anxiety Scale, twelve to the Trait Anxiety Scale, and

thirty-six to the Drinking Questionnaire.

An analysis of variance (ANOVA) was chosen to

determine the significance of changes on the criterion

variables due to treatment. Underlying assumptions for

analysis of variance as a parametric technique are ran-

domly selected subjects from normally distributed popula-

tions, homogeneity of variance, and proportionality of

cell frequencies (Isaac and Michael, 1978). All subjects

were selected randomly from the out-patient population at

three treatment centers in Florida. All cells contain

fifteen subjects. A Cochran C Test was used to test for










homogeneity of variance. In all cases the hypothesis was

retained that there were no significant differences between

the variances. The tabled value is .638 where k=2, n=60.

The calculated Cochran C Test statistics for pre-tests on the

Tennessee Self-Concept Scale, State Anxiety Scale, and Trait

Anxiety Scale were .567, .543, and .520, respectively.

The research hypotheses for this study were written

in the null form. It was predicted that Progressive Relaxa-

tion Training would produce no change in self-esteem, state

anxiety, trait anxiety or actual drinking behavior and these

hypotheses were accepted. Additionally, the two classifi-

cations of alcoholics, First Stage and Continuous/Episodic,

produced no significant differences in treatment outcomes.

It was predicted that Guided Imagery Training would

produce no change in self-esteem, state anxiety, trait

anxiety or actual drinking behavior, and no change did

occur in self-esteem or actual drinking behavior. But,

Guided Imagery Training did significantly reduce state

anxiety more than the Control Group (Reality Therapy based

group). Treatments were compared using an analysis of

variance that yielded an F of 7.546, significant at the

.05 level. Differences between Guided Imagery Training

and the control group produced a t=2.745. This data is

presented in Table 2.









TABLE 2
ANOVA SUMMARY TABLE FOR TREATMENT
DIFFERENCES


Source of
Variation


Between Groups


Within Groups


Total
*p (.05


Sum of
Squares


192.49


986.30


1178.79


Group Statistics


Group N Mean


Control 30 12.93


Relaxation 30 11.87


Imagery 30 10.87


Relax/Imagery 30 9.50


test Between Group means (Values of p
tailed test).


AND STATE ANXIETY


Mean
Squares


64.16


8.50


F


7.546


SD


3.28


2.75


2.40


3.15


are for two-


Control
Imagery

Control
Relaxation/Imagery

Relaxation
Relaxation/Imagery


t = 2.745
p = .006

t = 4.56
p = .000

t = 3.143
p = .001


----










With Continuous/Episodic alcoholics, Guided

Imagery Training significantly reduced state anxiety

more than either the Control Group or Progressive

Relaxation Training. Analysis of variance yielded an

F of 4.53, significant at the .05 level. These data

are presented in Table 3.

Guided Imagery Training significantly reduced

trait anxiety more than the Control Group and the

Progressive Relaxation Group. Analysis of variance

yielded an F of 8.92, significant at the .05 level.

Differences between Guided Imagery Training and the

Control Group and the Progressive Relaxation Group

produced t=2.227 and t=3.199, respectively. These

data are presented in Table 4. With both First Stage

and Continuous/Episodic alcoholics, Guided Imagery

Training reduced trait anxiety significantly more than

Progressive Relaxation Training. With First Stage al-

coholics, a t=2.421 was found. With Continuous/Episo-

dic alcoholics, a t=2.017 was found. Both are signi-

ficant at the .05 level. These data are presented in

Tables 5 and 6.

The null hypotheses were accepted for Pro-

gressive Relaxation/Guided Imagery Training in that

no change was produced in self-esteem, or actual drink-










TABLE 3
ANOVA SUMMARY TABLE FOR TREATMENT AND STATE ANXIETY
DIFFERENCES LIMITED TO CONTINUOUS/EPISODIC ALCOHOLIC


Source of
Variation


Between Groups


Within Groups


Total
*p <.05


Sum of
Squares


113.60


458.13


581.73


Mean
Squares


37.87


8.36


F


4.53


Group


Control


Relaxation


Imagery


Relax/Imagery


test Between Group
tailed test).


t = 3.41
p = .000

t = 2.526
p = .016

t = 2.273
p = .039


Group Statistics


N Mean SD


15 13.60 3.74


15 12.40 2.75


15 10.00 2.42


15 10.93 2.46


means (Values of p are for two-


Control
Imagery

Control
Relaxation/Imagery

Imagery
Relaxation/Imagery


--


--


--~---


-----











ANOVA SUMMARY TABLE FOR
DIFFERENCES


Source of
Variation


Between Groups


Within Groups


Total
*p ~.05


TABLE 4
TREATMENT




Sum of
Squares


272.03


1179.27


1451.3


Group Statistics


Group N Mean


Control 30 9.87

Relaxation 30 10.67


Imagery 30 8.03


Relax/Imagery 30 6.83


test Between Group means (Values of p
tailed test)



t = 2.227 Con
p = .045 Ima

t = 3.685 Con
p = .000 Rel

t = 3.199 Rel
p = .000 Ima

t = 4.656 Rel
p = .000 Rel


AND TRAIT ANXIETY




Mean
Squares F


90.68 8.92


10.17


SD


4.21

2.35


2.20


3.54


are for a two-


trol
gery

trol
axation/Imagery

taxation
gery

taxation
axation/Imagery










TABLE 5
ANOVA SUMMARY TABLE FOR TREATMENT AND TRAIT ANXIETY
DIFFERENCES LIMITED TO FIRST STAGE ALCOHOLICS


Source of
Variation


Between Groups


Within Groups


Total
*p( .05


Sum of
Square


146.19


674.00


820.19


Mean
Squares


48.73


12.04


F


4.049


Group


Control

Relaxation


Imagery


Relax/Imagery


test Between Group
tailed (test)



t = 2.263
p = .040

t = 2.421
p = .023

t = 3.105
p = .011


Group Statistics


N Mean


15 9.67

15 10.73


15 7.67


15 6.80


Means (Values of p


SD


4.24

2.43


2.26


4.38


are for a two-


Control
Relaxation/Imagery

Relaxation
Imagery

Relaxation
Relaxation/Imagery


----- --


--





74


TABLE 6
ANOVA SUMMARY TABLE FOR TREATMENT AND TRAIT ANXIETY
DIFFERENCES LIMITED TO CONTINUOUS/EPISODIC ALCOHOLICS


Source of
Variation


Between Groups


Within Groups


Total
*p < .05


Sum of
Squares


129.12


499.87


628.98


Mean
Squares


43.04


8.93


F


4.822


Group


Control

Relaxation


Imagery


Relax/Imagery


test Between Group
tailed test)


t = 2.933
p = .002

t = 2.017
p = .078

t = 3.422
p = .000


Group Statistics


N Mean SD


15 10.07 4.32

15 10.60 2.35


15 8.40 2.16


15 6.87 2.61


means (Values of p are for a two-


Control
Relaxation/Imagery

Relaxation
Imagery

Relaxation
Relaxation/Imagery









TABLE 7
ANOVA SUMMARY TABLE FOR TREATMENT AND STATE ANXIETY
DIFFERENCES LIMITED TO FIRST STAGE ALCOHOLICS


Source of
Variation


Between Groups


Within Groups


Total
*p <.05


Sum of
Squares


161.52


986.3


1178.79


Mean
Squares


53.84


8.5


F


7.316


Group


Control

Relaxation


Imagery


Relax/Imagery


test Between Group
tailed test).


Group Statistics


N Mean


15 12.27

15 11.33


15 11.73


15 8.07


rean (Values of p


SD


2.71

2.74


2.12


3.17


are for a two-


Control
Relaxation/Imaqery

Relaxation
Relaxation/Imagery

Imagery
Relaxation/Imagery


t = 4.240
p = .000

t = 3.298
p = .000

t = 3.702
p = .000










ing behavior. However, Progressive Relaxation/Guided

Imagery Training significantly reduced state and trait

anxiety more than either the Control Group or Progressive

Relaxation Training. These data are presented in Tables

2 and 4. The difference between Progressive Relaxation/

Guided Imagery Training and the Control Group based on

state anxiety, was t=4.56, and between Progressive Relaxa-

tion/Guided Imagery Training and Progressive Relaxation

Training was t=3.143. Both are significant at the .05

level. The difference between Progressive Relaxation/

Guided Imagery Training and the Control Group based on

trait anxiety was t=3.685, and between Progressive Re-

laxation/Guided Imagery Training and Progressive Relaxa-

tion Training was t=4.656. Both are significant at the

.05 level.

With First Stage alcoholics, Progressive Relaxa-

tion/Guided Imagery Training significantly reduced state

anxiety more than Guided Imagery Training alone. Analy-

sis of variance yielded an F of 7.316 between these two

treatment approaches. Differences between Progressive

Relaxation/Guided Imagery Training and Guided Imagery

Training yielded t=3.702. This is significant at the

.05 level. Table 7 presents these data.













CHAPTER V
DISCUSSION


This study was designed to test the efficacy of

Guided Imagery Training as a treatment of alcoholics. To

test this and to evaluate the component parts of Progressive

Relaxation/Guided Imagery Training, four treatment groups

were employed: Control, Progressive Relaxation Training,

Guided Imagery Training, and Progressive Relaxation/Guided

Imagery Training. The Control group received treatment as

normally provided by three outpatient treatment programs

from which the subject were selected. Therefore, results

of the three experimental groups are compared to the out-

come of the three treatment program approaches. The

approaches of the three treatment programs follow the

Reality Therapy model. Therefore, results of the experi-

mental groups are compared to the results of the Reality

Therapy.

Treatment of addictive disorders with imagery seems

to originate with Cautela (1966, 1967, 1970, 1971, 1972,

1973; Cautela and Rosenstiel, 1975). Cautela has titled

his work Covert Conditioning. In this approach, aversive

imagery is paired with the behavior desired to be extin-

quished. Recently, positive reinforcing imagery has been









utilized, but the approach continues to focus only on the

addictive behavior. The therapist continues to describe

the scene, and to choose the reinforcing scene (i.e. ice

cream cone).

Implications

The demographics verify three previous research

findings about alcoholics. Self-esteem is low and state

and trait anxiety are high. The mean self-esteem score

is 304.042. For Fitts (1965), the mean self-esteem score

for the adult population is 345.57. The anxiety scores

for subjects closely resemble those of neuropsychiatric

patients (Spielberger, Gorsuch, and Lushene, 1970). The

state and trait anxiety scale means for this study are

48.47 and 50.88, respectively. The neuropsychiatric

patients' state and trait means are 47.74 and 46.62,

respectively.

Findings from this study support the following

positions. Progressive Relaxation/Guided Imagery Train-

ing significantly reduces state and trait anxiety more

than either Progressive Relaxation Training or Reality

Therapy. Guided Imagery Training significantly reduces

state and trait anxiety more the Reality Therapy. Pro-

gressive Relaxation Training did not significantly re-

duce state and trait anxiety more than Reality Therapy.

Two effective short term (five sessions) anxiety treatment









approaches (Guided Imagery and Progressive Relaxation/

Guided Imagery Training) have been identified.

Imagery is an integral part of Progressive Relaxa-

tion/Guided Imagery Training in that this combination

training is significantly more effective in reducing state

and trait anxiety than Progressive Relaxation Training.

However, this combination training is not significantly

more effective than Guided Imagery. This assertion is

further substantiated by the fact that Guided Imagery

Training significantly reduced state and trait anxiety

more than Reality Therapy, whereas Progressive Relaxa-

tion Training did not.

Guided Imagery Training in this study differs

substantially from imagery described in previous research.

In this study, the subject chooses situations he wants

to cope with more effectively. Subject chosen situations

are the focus of imagery sessions. Imagery sessions are

not limited to extinguishing the addictive behavior. Al-

though the therapist initiates the scene (situation), the

subject completes it and verbalizes the scene as he "sees"

it. The subject reinforces his coping behavior by verba-

lizing his positive emotions about his coping behavior.

The primary emphasis is on coping, not extinguishing ad-

dictive behavior.









One implication from the study is that a signifi-

cant change in drinking behavior should not be expected

in short term treatment. Significant changes in actual

drinking behavior during treatment did not occur. Those

who were drinking during the base period before treatment,

reduced their drinking but not significantly. Those who

were abstinent during the base period, remained abstinent

or did not significantly increase their drinking.

Both state and trait anxiety can be affected in a

short treatment time (five weeks/five sessions). Anxiety

was significantly reduced, but drinking behavior was not

significantly changed. This indicates that drinking be-

havior is only partially affected by anxiety and does not

yield to a reduction of anxiety.

Improved self-esteem was not found to be a realistic

short term treatment goal. One explanation is that self-

esteem is a result of lifestyle. Therefore, before self-

esteem substantially improves, the subject may need more

psychological distance between his past life and present

lifestyle. This psychological distance could only come

about with time, when the contrast between past life and

present lifestyle becomes more apparent.


Recommendations

This study verified that alcoholics have low self-

esteem and high state and trait anxiety. Low self-esteem

and high anxiety necessitate a treatment approach that

addresses these problems.









A multi-measure evaluation of treatment is recommended.

This study illustrates the problem, if only one criterion

measure is used. If either anxiety or drinking behavior

was used as the criterion measure, then the results would

be skewed either positively or negatively. Therefore, a

comprehensive criterion measure could contain psychological

and behavioral components. Psychological components could

include self-esteem, state and trait anxiety. Behavorial

components could include drinking, legal involvement, em-

ployment, and marital situation.

Based on the results of this study, both Guided Imagery

Training and Progressive Relaxation/Guided Imagery Training

are successful in reducing anxiety in alcoholics. These

treatments become notable because the two approaches are

effective; treatment period is brief; and required training

for both approaches is minimal. Although Guided Imagery

Training and Progressive Relaxation/Guided Imagery Training

were effective in five sessions in reducing state and trait

anxiety, it is recommended that the number of treatments be

extended as a maintenance measure. It is also recommended

that the treatment period be increased to positively modify

self-esteem and actual drinking behavior.

















APPENDIX A


Drinking Questionnaire


During the past two weeks (14 days) how many drinks
have you had?



(Drink = one beer; one glass of wine; one mixed drink;
if double = two drinks; if bottle, give size)





How many times have you wanted to drink?









APPENDIX B

Outline: Imagery Training Session for Therapists



I. Definition: Imagery

II. Effect of Imagery on Behavior
(Assagioli; Jacobson; Pribram; Krop, Calhoon,
Verrier; Rosenthal and Reese)

III. Imagery and Man's Potential

IV. Modeling
(Bandura)

V. Covert Modeling
(Kazdin)

VI. Covert Sensitization
(Cautela)

VII. Covert Positive Reinforcement
(Cautela)

VIII. Covert Negative Reinforcement
(Cautela)

IX. Covert Extinction
(Cautela)

X. Cognitive Behavior Modification
(Meichenbaum)

XI. Purpose of Study

XII. Experimental Design

XIII. Experimental Procedure

XIV. Imagery Procedure

XV. Relaxation Procedure





84



XVI. Guided Imagery/Relaxation Procedure

XVII. Conclusion



(Expected Training Time 120 minutes)









APPENDIX C

Diagram of Treatment Groups


Session Treatment Time

Control

1 Reality Therapy 60 mins.
2 Reality Therapy 60 mins.
3 Reality Therapy 60 mins.
4 Reality Therapy 60 mins.
5 Reality Therapy 60 mins.

Progressive Relaxation

1 Progressive Relaxation 30 mins.
Reality Therapy 30 mins.
2 Progressive Relaxation 30 mins.
Reality Therapy 30 mins.
3 Progressive Relaxation 30 mins.
Reality Therapy 30 mins.
4 Progressive Relaxation 30 mins.
Reality Therapy 30 mins.
5 Progressive Relaxation 30 mins.
Reality Therapy 30 mins.

Imagery

I Imagery 30 mins.
Reality Therapy 30 mins.
2 Imagery 30 mins.
Reality Therapy 30 mins.
3 Imagery 30 mins.
Reality Therapy 30 mins.
4 Imagery 30 mins.
Reality Therapy 30 mins.
5 Imagery 30 mins.
Reality Therapy 30 mins.

Progressive Relaxation/
Imagery

1 Progressive Relaxation 15 mins.
Imagery 15 mins.
Reality Therapy 15 mins.





86




2 Progressive Relaxation 15 mins.
Imagery 15 mins.
Reality Therapy 30 mins.
3 Progressive Relaxation 15 mins.
Imagery 15 mins.
Reality Therapy 30 mins.
4 Progressive Relaxation 15 mins.
Imagery 15 mins.
Reality Therapy 30 mins.
5 Progressive Relaxation 15 mins.
Imagery 15 mins.
Reality Therapy 30 mins.









APPENDIX D


Relaxation Techniques

Relaxation of Arms (time 4-5 minutes)

Settle back as comfortably as you can. Let yourself relax
to the best of your ability... Now, as you relax like that,
clench your right fist, just clench your fist tighter and
tighter and study the tension as you do so. Keep it clenched
and feel the tension in your right fist hand, forearm...
and now relax. Let the fingers of your right hand become
loose, and observe the contrast in your feelings... Now,
let yourself go and try to become more relaxed all over...
Once more, clench your right fist really tight...hold it;
and notice the tension again... Now let go, relax; your
fingers straighten out, and you notice the difference once
more... Now repeat that with your left fist while the rest
of your body relaxes; clench that fist tighter and feel
the tension... and now relax. Again enjoy the contrast...
Repeat that once more, clench the left fist, tight and
tense... Now do the opposite of tension...relax and feel
the difference. Continue relaxing like that for awhile...
Clench both fists tighter and tichter, both fists tense...
study the sensations...and relax; straighten out your fin-
gers and feel that relaxation. Continue relaxing your
hands and forearms more and more... Now bend your elbows
and tense your biceps, tense your biceps; tense them harder
and study the tension feelings...alright...straighten out
your arms, let them relax and feel that difference again.
Let the relaxation develop... Once more, tense your biceps;
hold the tension and observe it carefully...straighten the
arms and relax; relax to the best of your ability... Each
time, pay close attention to your.feelings when you tense
up and when you relax. Now straighten your arms, straighten
them so that you feel most tension in the triceps muscles
along the back of your arms; stretch your arms and feel
that tension... And now relax. Get your arms back into
a comfortable position. Let the relaxation proceed on
its own. The arms should feel comfortably heavy as you
allow them to relax... Straighten the arms once more so
that you feel the tension in the triceps muscles; straighten
them, feel the tension...and relax. Now lets's concentrate
on pure relaxation in the arms without any tension. Get
your arms comfortable and let them relax further and fur-
ther. Continue relaxing your arms ever further. Even
when your arms seem fully relaxed, try to go that extra
bit further; try to achieve deeper and deeper levels of
relaxation.









Relaxation of Facial Area with Neck, Shoulders,
and Upper Back (time 4-5 minutes)

Let all your muslces go loose and heavy. Just settle
back quietly and comfortably. Wrinkle up your forehead
now; wrinkle it tighter... And now stop wrinkling your
forehead, relax and smooth it out. Picture the entire
forehead and scalp becoming smoother as the relaxation
increases... Now frown and crease your brows and study
the tension... Let go of the tension again. Smooth out
the forehead once more... Now close your eyes tighter
and tighter...feel the tension...and relax your eyes.
Keep your eyes closed, gently, comfortably, and notice
the relaxation... Now clench your jaws, bite your teeth
together; study the tension throughout the jaws... Relax
your jaws now. Let your lips part slightly... Appreciate
the relaxation... Now press your tongue hard against the
roof of your mouth. Look for the tension... All right,
let your tongue return to a comfortable and relaxed posi-
tion... Now purse your lips, press your lips tighter and
tighter... Relax the lips. Note the contrast between
tension and relaxation. Feel the relaxation all over your
face, all over your forehead and scalp, eyes, jaws, lips,
tongue and throat. The relaxation progresses further and
further... Now attend to your neck muscles. Press your
head back as far as it can go and feel the tension in the
neck; roll it to the right and feel the tension shift;
now roll it to the left. Straighten your head and bring
it forward, press your chin against your check. Let your
head return to a comfortable position, and study the re-
laxation. Let the relaxation develop... Shrug your shoul-
ders, right up. Hold the tension... Drop your shoulders
and feel the relaxation. Neck and shoulders relaxed...
Shrug your shoulders again and move them around. Bring
your shoulders up and forward and back. Feel the tension
in your shoulders and in your upper back. Drop your
shoulders once more and relax. Let the relaxation spread
deep into the shoulders, right into your back muscles; re-
lax your neck and throat, and your jaws and other facial
areas as the pure relaxation takes over and grows deeper...
and deeper...ever deeper.

Relaxation of Chest, Stomach, and Lower Back
(time 4-5 minutes)

Relax your entire body to the best of your ability.
Feel that comfortable heaviness that accompanies relax-
ation. Breathe easily and freely in and out. Notice how









the relaxation increases as you exhale...as you breathe
out just feel that relaxation... Now breathe right in and
fill your lungs; inhale deeply and hold your breath. Study
the tension... Now exhale, let the walls of your chest
grow loose and push the air out automatically. Continue
relaxing and breathe freely and gently. Feel the relaxa-
tion and enjoy it... With the rest of your body as relaxed
as possible fill your lungs again. Breathe in deeply and
hold it again... That's fine, breathe out and appreciate
the relief.

Just breathe normally. Continue relaxing your chest and
let the relaxation spread to your back, shoulders, neck
and arms. Merely let go...and enjoy the relaxation. Now
let's pay attention to your abdominal muscles, your sto-
mach area. Tighten your stomach muscles, make your abdomen
hard. Notice the tension... And relax. Let the muscles
loosen and notice the contrast... Once more, press and
tighten your stomach muscles. Hold the tension and study
it... And relax. Notice the general well-being that comes
with relaxing your stomach. Now draw your stomach in,
pull the muscles right in and feel the tension this way.
Now relax again. Let your stomach out. Continue breathing
normally and easily and feel the gentle massaging action
all over your chest and stomach... Now pull your stomach
in again and hold the tension... Now push out and tense
like that; hold the tension and...once more pull in and
feel the tension...now relax your stomach fully. Let
the tension dissolve as the relaxation grows deeper. Each
time you breathe out, notice the rhythmic relaxation both
in your lungs and in your stomach. Notice thereby how
your chest and your stomach relax more and more... Try and
let go of all contractions anywhere in your body... Now
direct your attention to your lower back. Arch up your
back, make your lower back quite hollow, and feel the
tension along your spine...and settle down comfortably a-
gain relaxing the lower back... Just arch your back up and
feel the tensions as you do so. Try to keep the rest of
your body as relaxed as possible. Try to localize the
tension throughout your lower back area... Relaxing further
and further. Relax your lower back, relax your upper back,
spread relaxation to your stomach, chest, shoulders, arms
and facial area. These parts relaxing further and further
and ever deeper.

Relaxation of Hips, Thighs, and Calves, followed by
Complete Body Relaxation (time 4-5 minutes)

Let go of all tensions and relax... Now flex your buttocks
and thighs. Flex your thighs by pressing down your heels as









hard as you can... Relax and note the difference... Straight-
en your knees and flex your thigh muscles again. Hold the
tension... Relax your hips and thighs. Allow the relaxa-
tion to proceed on its own... Press your feet and toes down-
wards, so that your calf muscles become tense. Study that
tension... Relax your feet and calves.. This time bend your
feet towards your face so that you feel tension along your
shins. Bring your toes right up... Relax again. Keep re-
laxing for awhile... Now knees, thighs, buttocks, and hips.
Feel the heaviness of your lower body as you relax still
further... Now spread the relaxation to your stomach, waist,
lower back. Let go more and more. Feel the relaxation all
over.. Let it proceed to your upper back, chest, shoulders
and arms right to the tips of your fingers. Keep relaxing
more and more deeply. Make sure that no tension has crept
into your throat; relax your neck and your jaws and all your
facial muscles. Keep relaxing your whole body like that
for awhile. Let yourself relax.

Now you can become twice as relaxed as you are merely by
taking in a really deep breath and slowly exhaling. With
your eyes closed so that you become less aware of objects
and movements around you and thus prevent any surface ten-
sions from developing, breathe in deeply and feel yourself
becoming heavier. Take in a long deep breath and let it
out very slowly... Feel how heavy and relaxed you have
become.

In a state of perfect relaxation you should feel unwilling
to move a single muscle in your body. Think about the
effort that would be required to raise your right arm. As
you think about raising your right arm, see if you can no-
tice any tensions that might have crept into your shoulder
and your arm... Now you decide not to lift the arm but to
continue relaxing. Observe the relief and the disappear-
ance of the tension.

Just carry on relaxing like that. When you wish to open
your eyes, count backwards from five to one. You should
then feel fine and refreshed, wide awake and calm.









APPENDIX E

Interview Outline:
Identifying Characteristics for Imagery Session



I Situation Theme of situation

II Persons List of persons in situation

III Description of Persons How persons dress, phy-
sical description

IV Mood General Mood of persons involved

V Personality General personality of persons
involved

VI Appearance Reaction and first impression of
the persons

VII Time Time, if time of day is important to si-
tuation

VIII Place Detailed description of location si-
tuation occurs (colors, significant objects)

IX Personal Emotional State Subject's general
emotional state in the situation

X Outcome Desired outcome of situation




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