Antidepressive behaviour: A preliminary report

Behav Res & Therap). ,976.Vol 14.pp 2X9-29')Pergamon Press.Prmted II,Great Br,,a,n

ANTIDEPRESSIVE BEHAVIOUR: A PRELIMINARY REPORT VICKY Department

of Psychology.

Institute (Rrcriwtl

RIPPERE* of Psychiatry.

London

S.E. 5, U.K

22 Ju(I. 1975)

Summary-Outside the psychological literature it is common knowledge that when people feel depressed they ordinarily try to do something about it. In the clinical literature, this commonplace fact is in danger of being forgotten. Using an empirically-derived checklist of activities consensually identified as being ‘the thing to do when feeling depressed’. the present study examines (1) the distribution of reported antidepressive behaviour (ADB) in a _eroup consisting of depressed and non-depressed psychiatric patients and normals and (2) the relatlonship between an individual’s sex. personality (locus of control). and patient status and (a) the amount of ADB he reports and (b) how much of it he regards as helpful. All Ss reported some ADB but not all reported any that was helpful. In an analysis of variance, no main effects of sex. personality or patient status were found, but sex interacting with personality was significantly related both to the overall amount of ADB reported and to the amount found helpful. The findings have implications for the sorts of concepts that a theoretical formulation of ADB will require as well as for the ways in which clinicians conceptualize depressed patients.

It is only within the last decade that behaviourally-minded psychologists have discovered depression. Before Ferster’s pioneering essay, ‘Classification of Behavioural Pathology’ (Ferster, 1965), the leading psychological formulations of depression were psychodynamic, and experimental work was restricted to seeking deficits in the performance of depressed patients on various tests and laboratory tasks. The virtual absence of the affective disorders from Maher’s widely used textbook, Principles of Psychopathology (Maher, 1966), reflects the longstanding disinterest of psychologists in the subject. The only reference to depression in the index of this 525-page book is to a passing mention in the context of a discussion of ECT. However, all that has now changed, and for the past five years or so depression has been a major growth industry. A survey of the Psychological Abstracts index at lo-yearly intervals starting with 1953 showed 16 (1953), 33 (1963) and 139 (1973) references listed under the heading of ‘Depression’, respectively. In a more qualitative vein, the recent NIMH-sponsored symposium on The Psychology of Depression (Friedman and Katz, 1974) attests the rise of an impressive lot of formal research paradigms within which much of contemporary work is being conducted. Although this rapidly growing body of research promises to make significant contributions to the understanding and treatment of depression, there may be some cause for concern in the fact that in this work the phenomena of depression are largely treated as if they occurred in a socio-cultural vacuum. The a-social, biological emphasis is understandable in view of the derivation of much of this work from research on animals, where there is no question of culturally-transmitted rules of conduct in adversity. But understandable though it may be, this emphasis on the ways in which humans are similar to lower animals will need to be supplemented by attention to precisely those ways in which. by virtue of language and culture, humans differ from rats, dogs, and the higher primates, if a truly adequate psychology of humun depression is to emerge from contemporary research efforts. In particular, unless the animal analogue and reinforcement-theory based studies are supplemented, at least one interesting, complex, arguably important, and characteristically human aspect of depression is likely to be left out of psychology. Let us examine the situation. * Present address:Departmentof Psychology,University 289

College

London,

Gower

Street, WClE

6BT

390

VICKY RIPPERE

Practically everyone seems to know that when people feel depressed they ordinarily try to do something about it. That is. people commonly engage in. and are commonly known to engage in. what we may call antidepressive behaviour (ADB). In the contemporary literatures of clinical psychology and psychiatry, on the other hand. this otherwise commonplace aspect of behaviour seems either to have escaped notice altogether or to have undergone peculiar distortions. The phenomenon is perhaps most conspicuous by its absence from Lewinsohn’s recent work on pleasant activities and depression (Lewinsohn and Libet, 1972: Lewinsohn and Graf, 1973). despite their finding that subjects tended to engage in certain activities when in low moods. And in what appears to be the only extensive discussion of the subject in the literature prior to the present study -0stow’s chapter on ‘The Struggle Against Depression’ in his book The Psychology of Melancholy (Ostow, 1970~the individual is represented as being largely unconscious of the fact that he behaves in certain ways in an attempt to ward off depression. In Ostow’s view, such ‘antidepressant activity’ is also considered pathological. In neither case does there appear to be adequate appreciation of the commonplace, traditional. culturally-transmitted, rule-following, and adaptive character of ADB. The present. predominantly descriptive, study was undertaken in an attempt to correct this curious scotoma in the vision of contemporary clinical researchers. The study encompassed two separate though related issues: antidepressive behaviour and the common knowledge that exists about it. As the latter will be dealt with extensively in a separate article, it will be considered only briefly here. The common knowledge that exists about ADB in Western. English-speaking culture is a phenomenon of the order which Berger and Luckman (1967), in their theoretical treatise on the sociology of knowledge, have designated as ‘the social stock of knowledge’. The term refers to the fund of objectified and accumulated experienece in a society that is transmitted, often in lapidary formulations, from one generation to the next so that it is available to the individual in defining and attempting to solve the problems he encounters in everyday life. It is to the social stock of knowledge that, for example, Cohen and Taylor (1972) refer when they note that ‘our socialization.. . prepares us for encountering’ a range of ‘familiar problems [with] culturally approved modes of solution.. . and specialized agencies of help and support’. Such typical problems and solutions are familiar to psychologists. A well-known example is the item on the WISC Comprehension subtest, ‘What is the thing to do when you cut your finger? The-probably apocryphal-child who is reputed to have answered ‘Bleed’, would not earn points towards his IQ for this naturalistic account of the probable result of the contingency, for what the question is aiming to elicit is riot whether the child knows what happens next but whether he knows the culturally-prescribed rule to fohow in this typical situation. Similar sorts of rules are involved in ADB. and it was the aim of the pilot study to demonstrate their existence and to establish which sorts of behaviour are commonly supposed to be antidepressive. The main study, using a behaviouralitem checklist derived from the pilot investigation, examined reported engagement in, and efficacy of, these antidepressive activities. METHOD

Merld. Fifty available English-speaking subjects. 2.5 of either sex, in the age range 9-68 (mean 29 years) were asked in an open-ended interview, ‘What is the thing to do when you’re feeling depressed ? If clarification were requested, Ss were told that the question could refer to what common sense would tell one to do, to what one oneself did, or to what others were known to do. Duta anctl~*.si.s. A ‘response’ was operationally defined as an item of behaviour capable of being performed independently of other items of behaviour. Thus ‘go out and see friends’ counted as two responses, because one can go out without seeing friends and see friends without going out. Ss produced some 731 responses, which were subjected

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report

to content

analysis using inductively-derived categories. After a correction for withinsubject redundancy (e.g. an item mentioned more than once by the same S was only counted the first time), the remaining 655 coded responses were subjected to frequency counts. Results. In the initial frequency counts an inverse relationship was found between the frequency of mention and the number of items mentioned at that frequency. Thus 18 Ss (36”,, of the sample) concurred in mentioning one particular item (‘see a friend’). whilst at the opposite extreme there were some 84 items mentioned by only one S. On average. items were mentioned by 3 Ss or more. When the proportion of items mentioned by more than one S (‘consensual items’) and of those mentioned by only one S (‘non-consensual items’) were computed. some 87.20,, of all items mentioned were consensual and only 12.89, non-consensual. The vast predominance of consensual items over non-consensual items and the high degree of consensus on some items were taken to reflect the existence of a social stock of knowledge regarding ‘the thing to do when feeling depressed’. The pool of consensual items was then condensed (by combining related items together) to a list of 100 which formed the basis for the Antidepressive Activity Questionnaire (AAQ) used in the main part of the study. The main stutl~~

The main study looked at how much ADB people report and how much of their antidepressive activity they find helpful. Subjects. Eighty English-speaking adults, 40 of either sex, in the age range 16-68 (mean 34 years) subdivided into 5 groups of 16 (8m, 8f), participated in the study as unpaid volunteers. The groups were: Psj&iatric pntients-1. Depressed outpatients (OPD) attending a psychiatric teaching hospital for treatment of their depression. 2. Depressed inpatients (IPD) receiving treatment for their depression in the same teaching hospital group. Mean length of current hospitalization was 6 weeks (m) and 9 weeks (f). 3. Non-depressed control outpatients (OPC) attending the same hospital for treatment of other conditions than depression. With the exception of one male schizophrenic patient, members of this group had phobias or anxiety states. Non-py~chiatric

controls

(‘nornrals’~.

Clinical

ps_whology

postgruduate

students

(CPN) at the Institute of Psychiatry. 5. General practice medical pafients (GPN) attending a nearby general practice for treatment of non-psychiatric conditions. It should be noted that administrative rather than psychometric criteria were used to allocate subjects to groups. As the depressed patients were at widely differeing stages of their depressions and treatments, with some responding well and others not appreciably to drugs. ECT, and/or psychological treatments. it was considered neither feasible nor particularly meaningful to reshuffle subjects according to scores on some n priori depression measure. Marcriuls. Each S completed two paper and pencil questionnaires: I. the ‘Social Reaction Inventory’, a version of Rotter’s (1966) Internal-External Locus of Control scale. modified by Shepherd (1972) for use with British subjects. 2. the ‘Antidepressive Activity Questionnaire’ (AAQ), the derivation of which has been described. In addition to checking any of the 100 items on this checklist that corresponded to what he did when feeling depressed, S was asked to indicate how frequently he engaged in the activity (by ticking one of three columns, marked ‘rarely’, ‘sometimes’, and ‘quite often’) and how helpful he found it (by ticking one of three columns, marked ‘not very’. ‘moderately’, and ‘very’). Behaviours not included on the list could be added on the last page of the questionnaire. Procetllrre. The majority (72 of 80) Ss completed the questionnaires on their own and returned them to the investigator, either by post or in person. The remainder completed them with the investigator’s help, in an interview. The main reasons for requiring help were defective vision, mislaid spectacles, and poor concentration. These

292

VICKY RIPPERE

Ss’ protocols did not appear to differ in any systematic way from those of the other S,s. The GPN group returned their questionnaires to their doctor, without ever seeing the investigator. Depressed inpatients were asked to differentiate on their AAQ forms between activities they engaged in whilst in hospital. whilst out of hospital, and both in and out of hospital, by using the letters H, 0, or B instead of X. Design. The study was designed to examine a number of questions. only two of which can be considered in this preliminary report: 1. How is antidepressive behaviour, expressed in terms of the three variables (a) number of AAQ items checked (n items) (b) number of items rated (either ‘moderately’ or ‘very’) helpful (nH) (c) percentage of checked items rated helpful (q
Although the relationship between the popularity and efficacy of individual antidepressive activities will not be considered in detail until a later paper, it may help put some flesh on the bare, quantitative bones reported here to note briefly that the most popular

A preliminary

29?

report

items were: watch television (53 people); keep busy (49); talk to someone about how I’m feeling, and read a newspaper or magazine (47); do something I enjoy, and smoke (44). The items most often rated helpful were: keep busy (39 times); have coffee or tea, and talk to someone about how I’m feeling (37); do something I enjoy, and watch television (36); do something to take my mind off it (35); and see a friend (34). Those most often rated not very helpful were: try to find out what is making me depressed (22); wallow in feeling depressed (19); have something to eat, watch television. and read a newspaper or magazine (17); get angry about something, try to get my situation into perspective. and try to act as if I weren’t feeling depressed (16); stick to my normal routine (15). 1. Distribution of ADB variables: n items, nH and “/,H in total group. Ranges, means and standard deviations for the 3 ADB variables in the group of 80 Ss as a whole are given in Table 1. Table I. viations number centage

Ranges, means and standard defor “number of items checked.” of items rated helpful,” and “perof items rated helpful by all subjects” Variable

Range Mean S.D.

n items

nH

682 31.86 18.33

O-17 22.38 14.35

%H O-100 71.99 22.30

It will be seen that although all 3 variables span a large part of the range. n items, unlike the other two, does not extend all the way to zero. Thus all Ss checked at least 6 items of ADB, regardless of whether any of it was rated helpful. It appears that we are dealing with two rather differently distributed variables, n items being continuously distributed or characteristic of everyone in some degree, whilst nH (and by extension T;H) is distributed discontinuously, characteristic of some but not others. 2. ADB cariables

n items, nH and %H as a function control and depressed patient status group

of subject

variables.

sex. locus of

The 5 patient status groups, already subdivided by sex, were further subdivided within each sex according to low or high external (E) locus of control score. The allocation of subjects to low or high E groups was made by dividing each subgroup of men or women at the mean E score for that group, Ss above the mean being operationally defined as ‘high E’ and those below the mean as ‘low E’. In some groups this convention led to having cells of 3 and 5 instead of 4 and 4 subjects. Means and standard deviations for the resulting Sex x Locus x Group subgroups are given in Table 2. A 3-factor analysis of variance was carried out for each of the 3 ADB variables, using a multivariate ANOVA programme adapted for the London University CDC 6600 computer by B. S. Carter. No significant main effect of Sex, Personality, or Group on any of the 3 ADB variables was found, although Sex came near to having an independent effect on nH (p < 0.07) and Group on n items (p < 0.08). However, on both n items and nH there were significant interactions between Sex and Personality (n items: F = 3.933,dr l,l, p < 0.05; nH: F = 6.325, df l,l, p < 0.01). A similar S x P interaction was found on “,
VICKY RIPPERE

294

high external women have fewer, and fewer helpful, antidepressive activities than high external men and low external women. Ex~ination of the results in the more qualitative form of graphs reveals several features that are not immediately discernible from the numerical summaries. Graphs of subgroup means for the 3 ADB variables are given in-Figures -1% Table 2 Means and standard deviations for “number of items checked. **“number of items rated helpfur and “percentage of items rated helpful by all sex x locus of control x patient status subgroups Group Sex

nH

Mean

23.17 IO.80

16.67 IO.50

‘70.83

S.D. High E

&an S.D.

49.00 Il.31

38.50 3.54

80,OG 9.90

Low E

lean

45.50

S.D.

35.57

37.25 34.59

70.00 28.74

High E

Heart S.D.

36.00 24.75

18.25 6.45

65.00 29.60

Low E

Mean S.D.

44.25 26.89

la.50

55.50

12.01

36.14

High E

Mean S.D.

35.00 30.93

17.50 12.23

51.50 44.35

LC%?E

Eean S.D.

33.00 21.70

28.67 17.90

90.33 8.74

Bigh

Mean S.D.

37.60 18.19

31.20 16.53

79.60 12.14

Mean S.D.

33.60 6.07

22.60 10.39

69.60

High E

bean S.D.

51.33 16.92

25.67 f3.65

41 59.33 .o5

Low E

&?an S.D.

27.33 19.14

21.67 13.65

85.33 14.05

High E

Mean S.D.

28.40 t8.54

20.60 21.42

55.80 37.31

Low E

Hean S.D.

19.00 15.59

14.67 10.69

80.67 9.02

High E

Mean S.D.

27.60 6.69

19.40 5.23

69.80 7.92

Low E

Rean S.D,

46.75 16.56

38.50 16.38

80.00 13.83

Bigh

Eean S.D,

29.00 IO.89

17.75 11.87

55.25 26.83

Low E

Mean S.D.

13.40 2.88

11.60 3.21

87.20

High E

MeEUl

28.67

S.R.

86.33 12.10

LwE

&an S.D.

7.51 24.75

24.33 3.5t

7.63

21 loo 7.53

84.00 9.90

21.50 5.20

16.75 6.50

79.00 25.86

Low E

F

0

M

g F

E

Low E M

* 2 ’

F

M

tzs fzz F

E

M

6

*F High E

L

$ H

n items

H

2

Variable

Locus of Control

Mean S.D.

* Depressed Inpatients* reportedADB when --out in the analysis of variance.

of

hospital

24.41

31.63

was

la.20

not included

295

A preliminary report

o-o-LOWE

High E

LOW E

High E

LOCUSOf Control Fig. 1. The relationship

of locus on control, mean number of items and sex of subjects in all groups.

Fig. 2. The relationship of Locus of Control, mean number of helpful items and sex of subjects in all groups.

296

VICKY RIPPERE

LOWE

Hlgn E

LOCUS of Fig. 3. The relationship

of Locus

LOWE

HlghE

control

of Control. mean percentage subjects in all groups.

of helpful

items and

sex of

In all 3 figures, the similarity between the patterns in the two non-patient groups and the depressed outpatient group is striking. Since the two non-psychiatric control groups effectively comprise a replication of each other, these patterns may probably be taken to represent norms for the relationship of the 2 subject and the 2 ADB variables. If this is so, the fact that the OPD data assume similar patterns suggests that being depressed per se need not affect an individual’s antidepressive behaviour, at least not when considered at this level of analysis. What varies in the graphs of these groups of subjects is the slope of the lines and their elevation on the ordinate. That is, the differences in these aspects of the antidepressive activity of normals and depressed outpatients are quantitative rather than qualitative. The depressed inpatient group, on the other hand, and the outpatient control group, generated patterns that differ not only from those of the three ‘normative’ groups but also, with the exception of n items, from each others’, to such an extent that in some cases (OPC nH, 0,,H) there is no S x P interaction but a large sex difference, and in other cases (IPD, OPC n items) the direction of the S x P interaction observed in the normative groups is actually reversed. The fact that the data patterns for the IPD group differ from those of the OPD group, which themselves do not differ appreciably from those of the 2 normal control groups, provides support for the choice of site of treatment for depression, but not presence/absence of clinical depression, as a variable relevant to ADB. At least one of the depressed inpatients clearly indicated that he regarded going into hospital as itself an act of antidepressive behaviour. writing it in as an item on the space provided on the questionnaire. Finally, the fact that the neurotic control outpatient group’s patterns differ from those of the depressed outpatients and the two non-psychiatric groups suggests that the similarity in these three latter groups’ patterns does not simply reflect the fact that they are not in hospital. It also suggests that phobias and anxiety states may be associated with qualitative differences. relative to normals, in the relationship between a person’s

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sex, personality, and ADB, such that phobic high E women and low E men have relatively less. and less helpful, ADB and low E women and high E men relatively more, and more helpful, ADB than their counterparts in the non-psychiatric groups. Thus the effect of psychological symptoms on a person’s antidepressive activity may depend not only on the type of symptoms but also on the type of person. In at least one type of person, high external women, some kinds of psychological difficulties may be associated with enhanced effectiveness, rather than with impairment, of reported ADB, in comparison with ‘normals’. DISCUSSION

What do these findings mean? What are their implications for the sorts of concepts that an eventual theoretical formulation of ADB is likely to require? And have they any relevance to clinical practice? Full answers to these questions must await a more comprehensive presentation of the rest of the findings, but some tentative points are raised on the basis of the few results presented here. First, the finding that all subjects reported some antidepressive activities confirms, reassuringly, what most people already knew anyway, namely that ADB is a very common practice. The ‘finding’ is significant only in that it establishes empirically what was previously a matter only of common sense, suggests that the method of measurement has, at least, face validity, and helps in interpreting the findings about the distribution of helpful ADB. The finding that not all subjects reported some helpful ADB or, the other way round, that some subjects rated all of their antidepressive activities ‘not very helpful’, suggests that in addition to being widespread, ADB is also robust, persisting in the face of failure to produce the desired result. This finding poses a problem for explanation: if their antidepressive activities don’t work, why do people report that they continue to perform them? Is the finding just an artefact of a negative response set? The uniformly positive response to the item selection part of the questionnaire suggests not. Moreover, analysis of the Sex x Personality relationship in subjects scoring highest and lowest on the 3 ADB variables found the same sort of interaction at the extremes as throughout the distribution as a whole, which suggests that the finding is unlikely to be merely artefactual. If it cannot be explained away, how is the finding to be explained? Is it adequate to say that people’s self-help behaviour resists extinction because it has been built up on an intermittent reinforcement schedule? Or would we do better to comb the social stock of knowledge for prescriptive rules for people to follow in the event of their first antidepressive activity falling flat? Such rules might be of the order of the general adage. ‘If at first you don’t succeed, try, try again’, or they might be more specific to the case of still feeling depressed after executing an antidepressive activity. In either case, following such rules would help an individual keep going and thus override the ‘extinction’ of his ADB. If the persistence of ADB is a matter of rules. then the sort of conceptualization that it will require is one which explicitly allows for such sociobehavioural rules and meta-rules for the following of them. At present, the most likely framework for such a formulation is probably the general theory of planned behaviour proposed by Miller, Galanter and Pribram (1960) in their surprisingly unappreciated book. Plans and the Structure of Behaviour. Such a formulation would, of course, be unrepentantly cognitive, requiring the individual to possess a concept of ‘feeling depressed’, the ability and inclination to monitor his affective state, to discriminate states of ‘feeling depressed’ from other states, to decide, on the basis of comparing his present state with some standard that it was bad enough for action to be taken to correct it, and, taking account of available resources and other relevant information, to select a particular rule to follow from the repertoire, initiate and execute the behaviour, and again monitor his state for changes induced by the activity. If successful, he would then exit from that particular TOTE unit and

79x

VICKY RIPPERE

do something else: if unsuccessful, he would then follow the appropriate rule. choose another antidepressive activity, and repeat the process of testing. It seems highly unlikely that animal analogues and straight reinforcement-theory type formulations would be up to this task. Similarly, the finding that both the number of items of ADB an individual reports and the number he rates helpful are a function of sex interacting with personality also points to the inadequacy of simple learning formulations that fail to take sex differences and individual differences into account. It is not immediately obvious why the effect of a person’s relative externality of locus of control on the amount of ADB and helpful ADB should be different in men and women, But it is obvious that if such organismic variables systematically affect people’s antidepressive activity they will have to be taken seriously in any comprehensive formulation of the phenomenon. At first glance. the lack of a main effect of depressed patient status on the 3 ADB variables may seem rather startling. Surely the stereotype of the depressed as passive and helpless would not lead one to expect that depressed patients would report, on average, as much, and as much helpful, ADB as non-depressed non-patients. But the finding loses its surprising character if instead of a learned helplessness model (Seligman, 1974) the ‘apperceptive mass’ that one brings to it is that branch of the social stock of knowledge that may be called the Western cultural tradition of antidepressive advice. If one accepts the notion that depressed people have given up trying to cope, on the other hand, the existence of this 2000-year-old tradition of behaviourat prescriptions for the low in spirits, transmitted to the modern age in such works as Burton’s Anatomy of Melancholy, and which lives on in countless popular articles, pamphlets and books advising the depressed how better to help themseives, becomes incomprehensible. Is it more plausible to assume that the tradition is without foundation than that the stereotype is oversimpli~e~? This is not just a rhetorical question. It would, of course, not arise within the frames of reference of the majority of contemporary clinicians, whether of a learning theory. eclectic psychiatric, or psychodynamic orientation, all of which, despite their many differences, concur in ignoring the patient’s participation in the long cultural tradition of self-help in depression. The question thus has a large and direct clinical implication for the way we conceptualize our depressed patient and whether we regard him as having an important contribution to make to his own recovery. Consider, for example, the implication of sharing Ostow’s view that the depressed patient’s ‘desire for help and the readiness to accept it’ are ‘symptoms of the illness’ (Ostow, 1970). If such a patient isn’t helpless and passive to begin with, is he not likely to get that way once therapy has given him insight into the error of his ways? Malleson (1973) has recently noted ‘the extent to which helpers actually perpetuate the conditions for which they give help’ (p. 141). This point brings us to the main clinical implication of the present findings, The first is simply that it is high time we renewed our acquaintance with our patients’ efforts to help themselves, to take these efforts seriously, and not to invalidate them by *knowing better’. If nothing else, we might be able to communicate more satisfactorily if we again shared their awareness of what-fortunately-remains to many of them an important aspect of clinical reality. A lack of consensus about the existence, let alone the importance, of ADB between patients and professionals became painfully evident to the investigator in the course of collecting data for the study. Some professional colleagues, hearing about the study. seemed genuinely surprised at the idea that there was anything there to investigate at all. Patients, on the other hand, often seemed surprised that a professional should wish to study it, and quite a few expressed satisfaction at finally getting some acknowledgement for their efforts. The second clinical implication of the findings is that it seems feasible to assess systematically, objectively, and economically an individual’s habitual and characteristic coping activity, not in terms of such woolly hypothetical constructs as ‘ego strength’ but in terms of specifiable behaviour. Further work will. of course, be needed to find out

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whether ‘treatment’ outcome is related to having a repertoire of helpful antidepressive activities and, if so, whether coping behaviour provides a predictor that is superior to measures of ‘coping pathology’, as Jacobs er al. (1973) have somewhat quixotically renamed their measure of ego strength. If so, assessment of a person’s behavioural coping resources might well eventually contribute as much to his prognosis as do history and the symptoms with which he presents. Several authors (e.g. Zubin and Fleiss, 1971; Kiloh et al., 1972; Brown, 1972) have recently expressed similar views. noting that in future attendon will need to be given to a person’s psychological assets as well as his liabilities. AckrloM,led~enlrrlrs-This work was carried out as part of the author’s M.Phil dissertation in Clinical Ps!cholog> at the Institute of Psychiatry. London. 1 am especially grateful to Fraser Watts. mq suprr\isor. and to Dr. W. R. Gray of Beckenham for help with collectmg the general practice data.

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