-- George von Hilsheimer and D.A. Quirk*

PREFACE
     My good friend, Douglas A. Quirk, was one of the pioneer psychologists in Canada. In the early 1960's when he went to work at Toronto's Queen Street Psychiatric Hospital he was the first psychologist in Canada to be given full charge of a psychiatric ward. He may have been the first psychologist in North America to have enjoyed this distinction.
      Doug began coming down to my residential treatment center in Florida in 1962. For about 12 years he came for at least two weeks every year. I moved to Virginia for several years and then back to Florida and in all of the years through 1997 Quirk would visit me at least once a year, often he visited three or four times in a year. I visited Toronto perhaps a dozen times to consult wherever it was that he was working - at Queen Street Hospital, the Clark Psychiatric Institute, and at the Ontario Correctional Institute.
      Doug was a gifted diagnostician and for more than 30 years I administered Rorschach's and sent him the records. He would send back detailed reports which always proved useful in helping my clients. He had trained on Breen and North's Diagnostic Differential Test which grew out of a method of scoring the Bender Gestalt. For 30 years I sent him the copies of DDT figures my clients had made for me. Doug, himself, had a curious reluctance to initiate telephone calls; but, I would telephone him at the drop of a symptom and chatter away with him about the needs of a client.      Doug served as my library, as well, "who did that study on pigeons and flashing lights?" Doug always knew.
      It is a curious reality to be finishing up the chapter of a book, and not have Doug to telephone about it. I even have to do my own library work. He died, suddenly, on the 3rd of December, 1997. I had called him two days before his death and discovered him to be sick, but "a touch of flu" thought I.
      Curiouser still, for Quirk wrote several first drafts of this work, and I have three different drafted aspects of his thoughts about what we did. He wrote this chapter from several perspectives, which was quite typical for us. Upside down, crosswise, diagonally through the materials. I can't yell at him now for his convolutions of thought and writing. I can only mutter at his ghost, which, perversely, is silent. He insisted that I co-author and receive co-worker credit for this work. I was reluctant to do this, for I was physically in the hospital and at the prison in which the work was done only about two weeks each year. Oddly enough, as I've steeped myself in reporting this work, I have lost my reluctance.
      Doug and I loved each other immediately we met. One of the reasons we worked well together was that we both believed that doctoral level psychologists were wasting a lot of time DOING therapy. We developed our conception of what it is that a psychologist should be doing yapping away deep into the nights; the techniques are mine as well as his, he just did the work. When I talked to his boss, Reg Reynolds, Reg reminded me, "you know Doug didn't do any of the hands on work, it was always scads of college students, volunteers, folk drafted out of the community service pool, a rag bag of individuals." So it turns out that both of us did a lot of thinking, then turned the work over to others. The way it should be for doctors of philosophy.
      Just like Quirk - volunteers everywhere. You never knew what kind of odd creature you'd find working with him. One of my Florida patients took her holiday to Ontario, just so she could spend two weeks working at the OCI. She came back marvelling a great deal about some of the other volunteers - spikey dyed hair, curious costumes, the works. I remember visiting with him once, and at the hospital the trousers of his suit burst apart at the seams. We drove to his apartment and got him into his OTHER suit. Not long after we were back at his office, this suit disintegrated, too. We had to go buy him a new suit. Quirk was never one to worry about appearance.
     The only human being I ever knew who loved to work as hard as me and did was Douglas A. Quirk. God rest him well. No psychologist ever loved his work more, or was better at it. I can vividly remember the first time he introduced me after I received my doctorate, "Dr. von Hilsheimer, he is a psychologist." It was better than being knighted!

INTRODUCTION
     It was an exciting time to be working as a psychologist in the 60's. The long Freudian nightmare was ending. The hallucinogenic fever of speculation was giving way to repeatable techniques and it was becoming respectable again to utter the name of Watson and Pavlov with respect and admiration. Von Hilsheimer was operating a residential treatment center for allegedly incorribible youth and demanded that 'psychotherapy' had to have demonstrably positive results. This requirement rather quickly cleared out the "lookie, touchie, healie, feelie, squealie crowd" who tended to be eaten up rather quickly by adolescent in-patients in any case.
     Green Valley was described by a number of visiting professionals as "the original behavioral sink", an accumulation of lost souls. Von Hilsheimer created a minor stir when his "IS THERE A SCIENCE OF BEHAVIOR?" concluded, "Yes, but not much of it is used in therapy."
     Quirk was recruited as one of scores of consultants who were invited to Green Valley to see if they had useful technology to share. It was love at first sight. Von Hilsheimer just qvelled looking at this visiting psychologist who would see 10 crazy kids in a row, and then talk about them all night. Doug found it magical that a useful idea would be transformed into a pilot project within a few hours of dreaming up the idea.
      Von Hilsheimer was interested in dry beds, and really didn't care if the kid who wet his beds was rebelling against his parents. Surely the boy could send mother a more straightforward message. Quirk agreed and introduced Von to a host of exciting ideas and to a working psychological technology.
WOLPE'S RECIPROCAL INHIBITION THERAPY (RIT)
     Wolpe came to Toronto and gave a week long course in Reciprocal Inhibition Therapy (RIT) which Doug attended. Doug's patients enjoyed some good results with this method; but Doug learned that many if not most of his schizophrenics could not visualize. If they did visualize it was in such a bizarre manner that they became hyperanxious. For example, when he asked one patient to visualize an elevator she saw herself hanging on by one hand to a razor across the bottom of the elevator and flying up as she dangled beneath the box.
      Schizophrenics also had probems relaxing. Doug would lift the patient's hand and drop it to see if the patient was relaxed. Often the patient's hand would just remain up in the air when he checked to see if they were relaxed. The responses of his schizophrenic patients often demonstrated catatonic 'posturing'.

METHOD
GALVANIC SKIN RESISTANCE (GSR)
      Schizophrenic patients also had difficulty reporting subjective units of distress (SUDS).
      I suggested to Quirk that he use the galvanic skin response (GSR) to monitor subjective distress and he began to do this. He bypassed the issue of the patient's capacity to form safe imagery by creating a library of slides he graded from innocuous to markedly distressing. He substituted immobility for the relaxation instructions in RIT and lantern slides for guided visual imagery.
      We made a light sensor for Doug which gave off an awful sound if the patient moved around. So an escape contingency was added to the routine; the patient could escape the obnoxious sound by being still. Doug projected a slide on the screen, the GSR would cause the skin resistance to drop and when the GSR recovered he would change the slide. This procedure was easily automated. Using this method he was able to obtain good results with schizophrenics.
      It should be remarked that schizophrenics do not respond well to positive reinforcement, tend to
ignore punishment conditioning, but do train rather well in escape conditioning models.
      Quirk thought that what the patient was doing was habituating; but von Hilsheimer suggested to him that Quirk was contingently reinforcing the increase in skin resistance. Quirk altered the basis for changing the slide from simple recovery of the basal level to require an increase of skin resistance to a value greater than the level at which the last slide was first projected onto the screen. Shaping the BSR higher resulted in faster improvement in the patients' perceptions and behavior.

GSR
      GSR is a bit difficult to talk about since the measure (GSR), is also the thing measured (GSR), and the values of the change and the basal values are often called by the identical name (GSR). What happens is that the value the patient has after resting some time is called the Basal Skin Resistance (BSR); then whatever movement occurs after a stimulus is called the Galvanic Skin Reflex (GSR), and both of these (GSR/BSR) are measured in ohms of resistance which are typically called the GSR.
     In this paper we will follow the convention of always refering to the basal skin resistance as the BSR; the change in the value of resistance we will simply refer to as "the reflex". It further complicates things that some authors change all of this language to Skin Conductance
Reflex (SCR). These are usually measured in microvolts of current. However, ohms of resistance are algebraically equivalent to ohms of
resistance. When we are doing desensitization or relaxation training
there is a great value to having a larger range of numbers on the relaxation side. Therefore we stick with the GSR.
      The research done on skin resistance by Mednick and others suggested that the GSR taps three domains related to anxiety: First, the basal skin resistance (BSR) provides an absolute curvilinear measure of arousal. The smaller the value of the ohms of resistance the more aroused the nervous system. When the patient is aroused and anxious her BSR is lower or smaller - she has fewer ohms of resistance.
      Second, the size of the response or reflex (the GSR) is a measure of the arousability of anxiety. The larger the value of the change in each GSR the more immediate anxiety.
      Third, the variation of the BSR and of the individual reflexes over time is a measure of the capacity for arousal in the autonomic nervous system (ANS).
      Skin resistance provides a measure of the patient's capacity for arousal in the ANS; a measure of the patient's immediate anxiety; and a measure of the absolute arousal of the ANS.
      When we train the patient to have higher values of BSR we are training against anxiety in all three domains.
      Schizophrenics tend to have BSR values about 10 to 30 times higher than others. A robust happy male might have a BSR of 300,000; but in contrast, a schizophrenic male of the same size might have a BSR of 1,000,000 to 3,000,000 Ohms of resistance. Quirk made an interesting observation. Even though he trained the patient to make higher values in each session the BSR tended to be lower in the next session. This lowering of the ceiling was particularly true in schizophrenics. At each session we have trained the patient to raise his BSR substantially, and
in the next session the trend of BSR was to be lowered.
      It is interesting to note that a similar observation has been made by clinicians who train using EEG. Although each session trains for higher amplitudes of the selected frequencies the trained and presumably normalized brain runs at a lower amplitude just like the brains of individuals without ADD/ADHD.
      In other words, ADHD children are seen to have significantly higher amplitude of EEG signals. They are trained to raise the amplitude of 13 Hz, or perhaps 10-16 Hz.
By the end of training, when they are no longer emitting the symptoms
of ADHD the amplitude of their EEG tends to be within the normal range. It has come down after having been trained up.
      Quirk named his method of automated slide change responding to an increase of Ohms of skin resistance Stimulus Conditioned Autonomic Response Suppression (SCARS).

RESULTS
      In a relatively brief time after initiating the SCARS treatment the supervisory panel of psychiatrists reviewed Quirk's decision to discharge 143 of 150 of the patients who were transferred to his ward. These patients had been hospitalized an average of 9 years. The patients had been in locked wards from 2 to 45 years. Two of these patients had been lobotomized.
      Treatment failed to help seven of these woman and one became worse after an event before treatment started on the ward and she never was treated by us. The psychiatrists concurred in the discharge of 143 patients. Of these 143 there were 15 who had some form of treatment in the three years after discharge while they were being followed. Social workers estimated that all of the women who remained free of treatment were enjoying a 'good' quality of independent life.
      As early as 1971 Quirk had given a substantial demonstration that GSR biofeedback provides a robust method of treatment for severely ill patients whose disorders have left them chronically hospitalized.
      THROUGH A LONG AND DISTINGUISHED career Douglas A. Quirk demonstrated the power of precise applications of biofeedback to populations in which common practice has no utility. Prisoners notoriously become worse in correctional institutions. It is a cliche that we are very good at making seriously criminal adults out of moderately delinquent juveniles. There is a general agreement in the field that we are unable to do anything positive with schizophrenics other than to put them into a chemical straightjacket or to allow them to age out of their disease.
      D.A. Quirk's insight that schizophrenics and criminals may be deficit in imagination, or oversupplied with frightening paranoid visions caused him to standardize a method of presenting graded trauma to patients, viz. the library of slide projected pictures he used in SCARS. Monitoring arousal through the venerable and well researched GSR permits a precise and useful control of a hierarchy of stress.

George von Hilsheimer, Maitland, Florida, April 2001

*The authors were associated from 1964 until D.A. Quirk died in 1997. Quirk interacted in the preparation of two drafts of this paper and read a third; the final form is the responsibility of von Hilsheimer. Some Canadian spellings, e.g. 'behaviour', 'centre', and some convoluted Quirkian paragraphs have been left intact in memory of D.A.Quirk. Readers and editors are asked to tolerate this excercise in fraternal piety.