Ror 2015 36 issue 1

Rorschachiana 36, 1 Š 2015 Hogrefe Publishing

DOI: 10.1027/1192-5604/a000067

Editorial

Compendiarius Sadegh Nashat Tavistock Clinic, London, UK

The present issue is an unusual one as it includes two special sections as well as the traditional general one. The highly successful 2014 special issue on the Thematic Apperception Test and other storytelling techniques had to be spread over two issues given the number of its articles and quality of its content.

This editorial will therefore be short to give enough space for our 2015 special section on Neuroscience and the Rorschach. Emiliano Muzio, our Guest Editor, has gathered a series of highly relevant and original articles for the second issue of the journal.

The general section this year includes two articles. Peterson discusses the frequency of White Space responses at card II and X and proposes an interesting theory linking perceptual, cognitive and developmental theory on face perception and recognition, and face content at the Rorschach. Yasuda’s study aims to understand the relationship between eye movements and location recognition failures of clients at the enquiry phase. The results indicate that a complex process is at play between eye movement and queried location.

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Rorschachiana 36, 2–18 © 2015 Hogrefe Publishing

DOI: 10.1027/1192-5604/a000063

Original Article

Faces in the Clouds Charles A. Peterson Independent Practice of Clinical Psychology, St. Paul, MN, USA

Abstract. White-Space Face responses on (primarily) Rorschach Cards II (WS or DS5) and X (WS or DdS30) have traditionally been scored Form Minus and regarded as pathological indicators of impaired reality testing, poor cognitive focusing, even psychosis/brain damage. These responses may now surpass the frequency cut-off for unusual/minus form level scoring. Puzzlingly, recent research moves these “faces in the clouds” from “abnormal” toward statistical “normality.” Attachment theory/research is combined with an object relations perspective and infant face perception research to suggest that these responses are the face of cradle-to-grave object-seeking needs, something urgent, vital, but not always rational, ultimately contributing to identity formation. It is more important to try and understand these responses, rather than simply rescore them.

Keywords: white space, form level, attachment, object relations

“There are no rules of architecture for a castle in the clouds.”

G.K. Chesterton

Although such airy wool-gathering need follow no rules, the scientific and responsible use of the Rorschach must follow rules. The Rorschach was once a Tower of Babel, in which the tribes of Beck, Hertz, Klopfer, Piotrowski, and Rapaport-Schafer wagged their tongues but did not converse (Exner, 1969). Even those who followed one of the great systems often “customized” and “personalized” the scoring rules as they saw fit (Exner and Exner, 1972). Confusion was upon the land. For example, a major review of shading scoring (Campo & De Santos, 1971, p. 6ff) noted that none of the major systems define or score these responses with any consistency, going so far as to note that Binder’s (1959) “scoring is 2

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not always consistent with his theoretical definitions,” lamenting the internal and external confusion created by his work. Differences among the five Great Systems have effectively prevented parametric research, often gutting substantive conclusions.

Exner’s (2003) Comprehensive System, first published in 1974, quieted the troubled waters, and rules replaced chaos. Theory was set aside in favor of empiricism. This was consistent with Rorschach’s wish to “avoid subjective evaluation” and to use “statistical methods” (Rorschach, 1921/1942, p. 23). The Comprehensive System is now the most widely used system for Rorschach administration and interpretation, remains one of the most frequently used personality tests in the world, and carries enough scientific rigor to be accepted in court (Gacono, Evans, Kaser-Boyd, & Gacono, 2008).

Statement of the Problem The Comprehensive System (CS; Exner, 2003) cannot rest on its many laurels. There are a number of problems with the CS (Mihura, Meyer, Dumitrascu, & Bombel, 2012), and this note will focus on one of them, in this instance, the surprisingly high incidence of White-Space-FaceMinus responses (WSFMR) delivered to Cards II and X, where poor form and the potential figure-ground-blurring furrow the tester’s brow. The following WSFMRs – traditionally scored “poor form” (Beck, Beck, Levitt, & Molish, 1961, pp. 141, 197; Exner, 2003, pp. 595, 633) – are prototypal, exemplary: Card II: Response: “The whole thing looks like an old man’s face.”

Inquiry: “Eyes, mouth, whiskers, neck, all of it. Just the shape, and the black beard.” Score: WSo FC’- Hd 4.5 PHR WSFMRII. Card X: Response: “The face of some kind of Sgt. Pepper’s hippie, eyes, moustache, flowers in his hair.” Inquiry: “The whole thing. The face in there. Hair, flowers, ‘stache, the mess of colors. Looks like it, don’t ya think?” Score: WS+ CF- Hd, Bt 5.5 PHR WSFMRX. Exner (2003) says these responses, while minus, “are not necessarily low frequency … a curious phenomenon that is not well understood, but which apparently occurs because those subjects tend to perceptually close the broken contour. Nevertheless, it is properly coded as minus because the person must create contours that do not exist in the stimulus” (p. 124).

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So how frequent are these problematic responses? How big a problem is this? Eblin, Meyer, Mihura, Viglione, and Horn (2010) report that the incidence of these WSFMRs across diverse samples/norms has surpassed the 2% cutoff for coding minus responses, reaching 15+% in a college sample! Incredibly, their samples find a higher percentage of WSFMRs in nonpsychotic than psychotic patients. In other words, these responses are occurring more often than the cut-off for minus responses and are not pathognomonic of psychosis. By definition, Rorschach responses are scored “minus,” (Exner, 2003, p. 123) when they occur in less than 2% of the records/responses and prove difficult for the examiner to apprehend. At one point, because of these high numbers, Eblin (Eblin et al., 2010) suggests these WSFMRs might better be scored u instead of −. However, their numbers may be inflated, due to their uncritical inclusion of all faces, when we know that the human face is significantly different from, say, the face of a praying mantis. Animal faces other than primate will not be considered in this account.

Weinberger and Andronikof (2012) puzzlingly include “heads” and “masks” when scoring/discussing “face” responses, when we know that infants do not process “heads” in the same way they process “faces” (cf., Goren, Sarty, & Wu, 1975). Further, mask responses typically involve deception, falseness, suspicion, “secrecy and self-concealment” (Bohm, 1977, p. 136).

Eblin et al. (2010) go on to suggest that scoring these responses as poor form will result in higher X-% and, necessarily, inflated predictions of psychosis, for example, an elevated PTI. Exner (2003) is not so certain: Some examiners are loathe to code a response minus, apparently influenced by the faulty impression that a minus answer will have great interpretive significance. That is not true. The majority of people, from all groups, give one or more minus responses. (p. 124)

Norms and Theory What to do about this problem? One answer is to adjust the scoring, ultimately adjusting the relevant ratios and norms, etc. The ex cathedra solution is: All WSFMRs are now White Space Face Unusual Responses.

Problem fixed! Another, very different answer, an about-face in fact, 4

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might be found in a theory-(and research)-driven understanding of these responses. In harmony with Meehl’s (1978) preference for good theory over a feeble t test or two, I hope to cast a plausible theoretical/ conceptual net around these troublesome responses.

All of the Great Systems presume that the subject’s experience of Self and Other will be projected onto the receptive inkblots. Responses to the unfamiliar stimuli will involve an “attribution of qualities, feelings, attitudes, experiences and strivings of one’s own to objects (people or things) of the environment” (Schachtel, 1966, p. 10; emphasis removed).

The depressed person will produce deflated, spare, dysphoric, dark, morbid responses; the angry person will produce edgy, sadistic, pointed, aggressive, perhaps constricted, perhaps fulminating, responses. The psychotic person will produce distorted, disorganized, peculiar, odd, tangential, illogical responses. The great issues, including an accounting of available psychological resources, the regulation of self-esteem, connection to others, management of separation and loneliness, expression of love and hate, navigation between dominance and submission, protection of psychological integrity, all may be present in the Rorschach protocol.

After all, “one of the main purposes of Rorschach’s test is to throw light on the way in which people experience the world, their life, themselves” (Schachtel, 1966, p. 318), their “hopes, fears, assumptions, demands and expectations” (Schafer, 1954, p. 6).

Attachment and Face Perception Attachment, peppered with loss, is the red thread that runs through all of life’s joys and travails (Bowlby, 1958, 1969; Stern, 1985). Without attachment, the child may not survive (Spitz & Wolf, 1946a). If the child survives without a healthy, secure attachment, developmental arrest is almost inevitable (Blatt & Levy, 2003; Spitz & Wolf, 1946b).

How might an attachment perspective inform the question of what to do about these increasingly frequent WSFMRs on Cards II and X? We know that the infant arrives hard-wired to orient, root, grasp, and suck. “Evolution has provided the baby a running start at face recognition” (Carey, 1992, p. 93). These behaviors are initially expressed/ activated in relation to mother’s face. Mother’s face is where the infant’s progressive internalization and structuralization begins, marked by, in order: the ability to differentiate mother’s face and smell, the special 5

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smile reserved for mother, stranger anxiety, separation anxiety, symbiosis anxiety, object constancy, and eventual identity formation. Stern and Sander (1980) have shown that “visual pursuit and auditory pursuit” are present “from the first day of life … There are strong preferences, from the beginning for certain stimuli … [specifically] … facial configurations” (p. 184). Spitz (1955) observed that “the first visual percept is the human face” (p. 216). Bowlby (1969) concluded that “there is a marked bias to respond in a special way to … the visual stimuli arising from a human face” (p. 265). The newborn shows special interest (free gazing time) in stimuli that “resemble a human face” (Bowlby, 1969, p. 271). Wright (2006) sums it up nicely: “Just as the infant has an in-built propensity to relate to the human face, so will it have an in-built expectation of response (facial mirroring) that will lead to a search for it” (p. 183).

Sutherland (1963) notes that, later in life, inner objects function like a “scanning apparatus” which “seek a potential object in the outer world” (p. 117). In sum, the loving face attached to a loving mother helps the child attach in order to provide stability and security throughout the life cycle. Faces, and our relations with them, are the building blocks of identity formation.

Beginning with the research of Fantz (1958, 1961), cognitive and experimental psychologists have clearly established that the newborn infant is sensitive to pattern recognition, and pattern detection, especially when the stimuli resemble a face. “Infants with a mean age of just nine minutes” differentially attend to a schematic as opposed to a scrambled face (Goren et al., 1975, p. 548). Maurer and Barrera (1981) show that 2-month-old infants can discriminate among schematic figures where the facial features were arranged naturally, symmetrically but scrambled, or scrambled and present asymmetrically. Even more amazing, Easterbrook, Kisilevsky, Muir, and Laplante (1999) showed that 1- to 3-day-old infants can discriminate between face-like patterns from scrambled face patterns. Mondloch et al., (1999) have concluded that there is a “mechanism, likely sub-cortical, predisposing newborns to look toward [find?] faces” (p. 419). Emphasizing the importance of contrast in visual stimuli, Tomalski, Csibra, and Johnson (2009) have experimentally demonstrated that infants – and adults! – show preference for face patterns.

Surveying cognitive development, Johnson and Morton (1991) conclude that “our ability [at any age] to process information about faces is greater than for any other class of stimuli” (p. 23). Whether infant or adult, whether man or beast, “primates appear to have sophisticated face processing abilities” (Johnson & Morton, 1991, p. 43). More recently 6

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Kanwisher (2000) offers the broad conclusion that faces are a special class of stimuli with special salience for our perceptual systems, turning the heads of young and old.

The Rorschach and Face Perception Let us now return to the “diagnostic experiment based on perception” (Rorschach, 1921/1942, p. 184) known as the Rorschach Inkblot Test.

The patient produces a WSFMR on either Card II or Card X. What to make of it? The Rorschach literature offers little help. For example, Exner (2003), Kleiger (1999), Rapaport, Gill, and Schafer (1946), Schachtel (1966), and Weiner (2003) offer neither data nor opinion on these WSFMRs. The little that is said about these WSFMRs is malignant and dated. Phillips and Smith (1953) are the most insistent that these kinds of responses are a very bad sign: “The development of any head-on face [response] is a paranoid schizophrenic sign. To the extent that faces are given to space areas (as a reversal of figure and ground) … the more aberrant are the thought process and the greater the likelihood of paranoid schizophrenia” (p. 144). Weiner (1966) follows suit: These responses are “so rare, [so] great an impairment of cognitive focusing that in the absence of brain damage even a single occurrence of such a percept suggests a schizophrenic thought disorder” (p. 34). I.B. Weiner (personal communication, May 29, 2011) has subsequently reconsidered this conclusion, no longer considering the response pathognomonic for schizophrenia, even if the arbitrariness of the contour might raise the question of poor cognitive focusing, not to mention the distorted human representation.

Even if we conclude that the study of white space on the Rorschach has – to date – focused on figure–ground reversal and oppositionality (Fonda, 1977), there are signs of change. Beck (1960), discussing Melville (and the white-whale, Moby Dick), refers to a “ghastly whiteness,” “the lure of the [burial] shroud,” and the “snowy mantle” of phantoms and ghosts (p. 145). Emptiness, nothingness, absence, and aloneness prevail.

Zulliger (1954, pp. 58, 269) argues that responses involving white (as a determinant) appear in the records of “oversensitive and easily hurt subjects who endeavor to hide their sensitivity.” It may be reasonable to conclude that he is speaking of subjects with an anxious, insecure 7

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attachment. When Bohm (1977) also notes that the white is “an expression of aggression” (p. 46), I might suggest, plausibly, the anger serves differentiation, regulating a certain safe distance for attachment. Beizmann (in Smith, 1997) sees a connection between space and separation anxiety.

Smith (1997) regards some white spaces as “voids,” triggering issues of emptiness and aloneness, potential space that must be filled, just like the infant fills the space between Self and mother. There is “something anxiety arousing about space” (p. 204). For example, the space/gulf between the figures (D9) on Card III, or the felt distance between tester and subject, may trigger “the pain of separation” (Smith, 1997, p. 204).

Bohm (1958) prefers the “somewhat obscene designation,” “hole shock” (p. 103), and suggests that both male and female subjects are struggling against femininity, which could be understood as a struggle in service of differentiation and individuation. Discussing the use of white space on Card VII (“only”), Bohm references “abandonment,” yet another call for the subject to “find” faces (an object). Although Card VII is often (too casually) called “the mother card,” it is not immediately clear why we would not find similar derivatives in other white voids! Smith (1997) reminds us that Cards III, VII, and IX have open spaces that are somewhat receptive, even if they are less frequently misused. Conclusion: An empty or lonely world will be repopulated.

Not restricting his observations to Cards II and X, Schachtel’s rarified assessment (1966) takes the analysis in a different direction: The perception of faces, especially when movement is involved, “probably comes about by man’s tendency to perceive that which he expects (hopes or fears) to see” (p. 242). Hopes or fears? Relatedness and self-definition (Blatt & Levy, 2003)? Alternative names for attachment and loss? We have already concluded that humans are hard-wired to find the human face, which is life-giving to the infant, and which may be comforting to the adult (Adler & Buie, 1979; Peterson, 1992).

Given the hard-wiring to find a face, where might we find one on the Rorschach? We must remember the fact that a Rorschach response is always the product or function of the subject/patient’s personality factors plus the stimulus (card) to which it is given (cf., Zubin, Eron, & Schumer, 1965; Peterson, 2011; Peterson & Maitland-Schilling, 1983;). Working from a Winnicottian perspective, Knafo’s apt phrase nicely summarizes the process: the test subject “part discovers and part creates” the response (2010). So, perceptually, which cards lend themselves to the subject/ patient hard-wired to discover a face? Since response frequency suggests “card pull,” apparently Cards II and X do (Eblin et al., 2010). A turn to 8

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the cognitive/perceptual literature will inform the answer to this question.

Johnson and Morton (1991, p. 135), in their book Biology and Cognition: The Development of Face Recognition, provide a stepwise account of what stimuli lend themselves to the perception of a face, their findings almost suggesting a checklist of requirements for face perception in the world or on the Rorschach. To what degree do their research-driven conclusions approximate Cards II and X? (a) Infants have a preference for symmetrical stimuli – the Rorschach?, check; (b) infants prefer stimuli with a pattern at some distance from the edge, check; (c) infants prefer patterns on the upper half of a display, check; (d) infants prefer stimuli with a strong vertical component, check; (e) infants prefer stimuli with rounded contours, check (Card II more so than Card X). Both cards apparently look somewhat like a face, indicated by the (growing?) percentage of responses to the cards, and match Johnson and Morton’s (1991) perceptual requirements for a stimulus to promote face perception. The Rorschach stimuli are fertile, fecund, awaiting the subjects seeking a face/object.

The Interpretation of These Faces in the Clouds Of course WSFMRs, like any other Rorschach variable, must be interpreted in relation to the on-board determinants and the larger universe of variables This account in no way suggests that the increased incidence of these WSFMRs may not require some statistical/normative tinkering.

It does suggest that it is not so puzzling (card pull/response frequency plus face-/object-finding needs) that faces are seen in the spaces on Cards II and X. This tentative conclusion might open the window to look at these responses in a new light, perhaps as dimensional, rather than healthy versus pathological, since so very little of mental life is categorical.

The following “examples” of WSFMRs illustrate how these responses might be positioned along a continuum: Bad: Card II: Response – “A clown’s face. Oooo, not good.” Inquiry – “The red, white and black circus colors. It’s bloody, maybe his head was stepped on by 2 black elephants right there on his cheeks.”

WSo CF.FC’- 2 Hd, Bld, A MOR CONTAM 4.5 AgPast PHR FMRII. Better: Card II: Response – “Ernest Hemingway’s face, eyes, mouth, manly beard; he’s angry.” Inquiry – “The Whole thing. Beard is black.

He’s glaring mad.” WSo M(a). FC’- Hd, Hx 4.5 PHR FMRII. 9

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Good-Enough: Card X: Response – “A sweet grandmother’s smiling face, with brightly colored bows and ribbons in her hair; she has soft hair (touches the card). She wants to help someone.” Inquiry – “The whole thing. Face in the middle. The colors made me think of ribbons and bows.” WS+ M(a).CF.FT- Hd, Cg COP 6.0 PHR FMRX. The first response is consistent with Weiner’s (1966) signs of impaired cognitive focusing and affective deregulation and might be congruent with a psychotic level of personality organization. The second response might be suggestive of someone with a history of angry, conflicted attachment and prickly masculinity, uncomfortable with closeness. The third response might be consistent with a foundation built upon – if still longing for – happy and fulfilling attachment. Obviously the entire record, other test and interview data would provide the corrective for such airy hypotheses. The fact that these face responses are found along the central axis of the cards highlights their centrality to the Self (Schachtel, 1966).

One more factor should be considered: In addition to the stimulus itself, WSFMRs on Card X may reflect attachment issues (and generate facefinding needs) because Card X is the last card in the deck, often the “goodbye” to the test(er), another mini-separation and loss (Appelbaum, 1961).

This short piece is a call to arms. Some of the dated citations in this article argue for fresh theory. Dedicated research must address the central questions surrounding these responses: Are these responses associated with a subject’s object hunger (Texture)? Presence or absence of H content? Good or Poor Human representation? How about comparisons with measures of attachment (e.g., George & West, 2012)? Differences when faces are delivered to white versus other areas of the blot (e.g., D3 on Card IV)? Correlated with any particular symptom presentation/ diagnosis? Risking a sermon to the choir, the importance of studying the object has long been championed by psychoanalytically minded Rorschachers (e.g., Blatt & Lerner, 1983; Lerner & St. Peter, 1984).

Weinberger and Andronikof (2012) insist that the face is so involved in the development of the self that “these responses might be especially rich [with] projective material” (pp. 28–29). J.H. Klieger (personal communication, May 24, 2011) scans face responses for information about an “individual’s experience reading affect from facial cues [in] close interpersonal contact.”

Are these responses indicative of impaired cognitive focusing, failed reality testing, and thought disorder? Not necessarily. Eblin et al.

(2010), after considering whether to score these responses as u, conclude 10

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that these responses should be scored as −. Eblin and colleagues refer to the presence of these responses as a “perceptual lapses,” and not a direct marker for psychosis. But, reality testing is never the categorical split of “failed” or “intact” reality testing: Their findings, and this author’s argument, are consistent with Freud’s (1924) take on “healthy” or “normal” reality testing, namely, one that “disavows the reality as little as does a neurosis, but … exerts itself, as does a psychosis, to effect an alteration of that reality” (p. 185). In other words, people will alter reality, in this case, the Rorschach stimulus, to find an object. “Knowing that people have a tendency to ‘look for faces’ might help us understand some of these responses, especially, when they seem not to coincide with the objective features of the blot” (Weinberger & Andronikof, 2012, p. 28). Facefinding needs, in effect, overwhelm the reality regulation of the stimulus.

If Palermo and Rhodes (2007) ask, “Are you always on my mind,” the answer appears to be a qualified yes. We should not expect that this is a conflict-free sphere of the human personality. Weinberger and Andronikof’s data (2012) show that high-face responders have more diffuse shading responses, more passive responses, more MORbid responses, more AGgressive responses, the sum suggesting helplessness, sadness, and frustration, that is, depression, the very stuff of the human condition.

Following Darwin, we know that the infant’s distressed face hopes to evoke care-giving in the mother. Dysphoric/poorly formed faces on the Rorschach may serve – per Darwin – to evoke caregiving in the tester who must turn diatrophically toward the person in distress.

Conclusion and Suggestions There is much more to learn about these WSFMRs. We will not solve the problem with a simple normative fix. Norms without theory are just numbers, but theory without norms might just be fantasy. In any case, we can “not let […] the numbers make decisions for us” (Weiner, 2011). In other words, frequency alone should not necessarily alter policy. After all, our mothers reminded us: “Just because everyone else jumps off a bridge, should you?” I think not. Creating contours where there are none may – if not necessarily – reflect problems with focusing and figure– ground reversal, whether more (u) or less (-) common. Because we now know that face-finding is hard-wired in our nature, and because 11

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we know that need persists throughout the life cycle, object-finding needs may be the better hunch in understanding these responses.

There is, however, no good answer, thus far, as to why these responses are seen with greater frequency. Does this reflect some ominous trend in the population at large? Was Eblin’s sample somehow inadvertently saturated with psychopathology? Since the Eblin et al. sample is based on college students (adolescents), we should expect to find them in a second individuation, a work in progress, dealing with “isolation and loneliness,” and identity, propelling an intensified search for objects (Blos, 1962, p. 12). Even if we concede that we are predisposed to find and favor facial stimuli (Palermo & Rhodes, 2007), we wonder if the issues vary greatly according to the age of subjects? The latter question may be very relevant since face recognition/processing skills do not follow a linear developmental course (Carey, 1992; Ellis, 1990; Scott & Nelson, 2006; Wasserstein, Barr, Zappulla, & Rock, 2004). Carey (1992) says: “Locating the source of developmental change [in the individual] is not easy” (p. 101). Is the population at large more disturbed? To posit why these responses may have become more frequent across time would require even more speculation. Consistent with this attachment-theory-driven account, Millon (2010) advances reasons why there may be more borderlines in the population today. Borderlines, with attachment and object constancy issues (Adler & Buie, 1979) and consequential reality testing problems (especially in the interpersonal realm; Abend, 1982), would likely produce more of these responses, possibly infiltrating the samples.

We may discover that e-mail and a web of social media will ultimately influence object constancy. Our cell phones throw our object/face hunger wishes into space, and timely responses from the other side of the world convince us that the object/face is out there.

However, there is one fact we must accept: face-recognition receptors and face-seeking mechanisms are present at the dawn of life, necessarily finding faces in the nursery, followed when adolescence fuels a renewed search for objects on the way to identity integration. Faces must be found, whether in the clouds or in the inkblots, the search expressing something vital but not necessarily rational. The amalgam of faces, internalized, becomes our identity. Mindful of other losses, Winston Churchill said we must think about “the faces that are not there.” The Rorschach is one such opportunity.

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C. A. Peterson Wright, K. (2006). Preverbal experience and the intuition of the sacred. In D. M. Black (Ed.), Psychoanalysis and religion in the 21st century: Competitors or collaborators?

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Charles A. Peterson 1549 Albany Avenue St. Paul MN 5417 USA Tel. +1 651 645-2120 E-mail Charles.Peterson626@comcast.net

Summary The Comprehensive System (CS) is the most widely used system for Rorschach administration and interpretation, remains one of the most frequently used personality tests in the world, and carries enough scientific rigor to be accepted in court. However, the CS has a number of problems requiring attention, in this instance, the surprisingly high incidence of White-Space-Face-Minus responses delivered to Cards II and X. These responses create contours where none exist, often demonstrate figure–ground problems, and are traditionally scored poor form (i.e., minus). Recent normative studies document the growing incidence of these responses, their surprising frequency (i.e., greater than 2%) requiring a change from minus to unusual form level. Rather than simply change the scoring (problem fixed?), the author provides a (complementary) theory and research-driven understanding of these responses. In addition, these responses, depending upon other on-board determinants and the clinical interview, likely exist on a continuum from bad to good-enough, since so very little of mental life is categorical. Cognitive, perceptual, and developmental research converges to show that the infant is “wired” for face perception, searching for – and favoring – stimuli that could represent faces. Face-finding needs overwhelm/reshape the stimulus, whether “reality” (e.g., three dots and a curved line readily become a face) or a Rorschach card, expressing a need that is vital, if not always rational.

Résumé Le Système Intégré (SI) est l’un des systèmes les plus utilisé pour la passation et l’interprétation du Rorschach, qui est un des tests de personnalité le plus utilisé au

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Faces in the Clouds monde, et qui possède la rigueur scientifique nécessaire pour être admis comme outil d’expertise légal.

Néanmoins, le SI pose plusieurs problèmes qui méritent un attention particulière, notamment le nombre élevé de réponses intégrant le blanc et de mauvaise qualité formelle aux planches II et X. Ces réponses créent des contours, qui n’existeraient pas autrement, et sont traditionnellement d’une mauvaise qualité formelle. Les récentes études normatives ont trouvé une fréquence assez élevée (plus de 2%) de ce type de réponse dont la qualité formelle a été reclassée comme inhabituelle. Au lieu de simplement changer la cotation (problème résolu ?), l’auteur propose une théorie complémentaire pour interpréter ces réponses. De plus, celles-ci dépendent d’autres déterminants et de l’entretien clinique, probablement qu’il existe un continuum, puisque si peu de l’activité mentale peut être catégorisée. Les recherches sur la perception, la cognition et le développement montrent que le tout jeune enfant est ‘câblé’ pour percevoir, chercher et montrer une préférence pour les stimuli qui représentent des visages. Le besoin de chercher un visage va donc remodeler le stimulus (quelle que soit la réalité) exprimant un besoin vital, si non toujours rationnel.

Resumen El Sistema Comprehensivo (CS) es el más ampliamente utilizado para la administración e interpretación del Test Rorschach, que se mantiene como uno de los tests de personalidad más frecuentemente usados en todo el mundo y ha alcanzado suficiente rigor científico como para ser aceptado en el ámbito forense.

Sin embargo, el CS plantea algunos problemas que requieren atención, como por ejemplo, la alta incidencia de respuestas Menos de Caras-con-Espacio-Blanco que aparece, sobre todo, en las Láminas II y X. Estas respuestas crean contornos imaginarios, a menudo presentan dificultades en la integración de figura-fondo y han sido tradicionalmente codificadas como de Forma pobre (casi siempre FQ -).

Recientes estudios sobre datos normativos señalan la creciente incidencia de este tipo de respuestas y su sorprendente frecuencia (mayor del 2%), lo cual requeriría un cambio de codificación de menos a inusual (FQu, en lugar de FQ-). Ahora bien, en lugar de un simple cambio en su codificación, el autor ofrece una teoría complementaria con los datos de investigación correspondientes, que ayuda a comprender este tipo de respuestas. También señala que estas respuestas dependen de otras variables acompañantes como los Determinantes y los datos de la entrevista clínica, como si existiera un continuum, donde aún se sabe poco de su elaboración mental. La investigación cognitiva, perceptiva y evolutiva convergen e indican que el niño está predispuesto a percibir “caras”, buscando y favoreciendo la captación de los estímulos que podrían representar caras. Las necesidades de captación de “caras” parecen impregnar y reorganizar la percepción de los estimulos (si la “realidad”, por ejemplo, tres puntos y una línea curva pudieran convertirse fácilmente en una cara, en las Láminas de Rorschach), y este mecanismo podría estar expresando una necesidad vital, no siempre racional.

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要約 包括システム（CS）はロールシャッハ法の施行法、解釈法として最も広く使用されているシステ ムであり、依然として世界で最も多く用いられているパーソナリティ・テストのひとつであり、法 廷で採用されうる科学的な厳密さを十分に備えている。しかしながらその一方で CS は注目 を集める数多くの問題を有している。例えば、ⅡカードやⅩカードに産出される空白領域のマイ ナスの顔反応の驚くべき高さの出現率である。これらの反応はそこには存在しない輪郭をつく り出し、しばしば図と地の問題を表しており、伝統的に貧しい形態水準（すなわち、マイナス） であるとスコアされる。最近の規範的な調査では、これらの反応の発生率は上昇しており、 非常に高い頻度であり（すなわち、２％よりも高く）、形態水準をマイナス反応（－）から unusual（u）に変更する必要が生じている。（問題の解決は？）単純にスコアリングの変 更というよりは、筆者はこれらの反応を理解するために取り入れられた（現代）理論（と調 査）を提供している。加えて、それは精神生活の実にほんのわずかな部分しか断定することが 出来ないものなのであるが、これらの反応は他の幅広い要因と長期間にわたって行われる臨 床的な面接にもとづいている。認知的、知覚的、発達的な研究によれば、顔を表象する ——そして好きな——刺激を探して幼児は顔の知覚を“呼び起こされる”という結論に収斂して いる。顔を見つけたいという欲求は刺激（それが現実〔例えば、3 つの点と曲線はたやすく顔 に見える〕であろうがロールシャッハの図版であろうが）を圧倒し／刺激を異なった形にし、そ れは必ずしも合理的ではないが、極めて重要な欲求の表現となっている。

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Rorschachiana 36, 19–39 © 2015 Hogrefe Publishing

DOI: 10.1027/1192-5604/a000051

Original Article

Failure of Location Recognition in the Rorschach An Eye-Tracking Investigation Masaru Yasuda Department of Psychological Sciences, Kwansei Gakuin University, Japan

Abstract. Eye movements during the Rorschach Inkblot Method (RIM) were monitored to investigate the existence of location recognition failures that were accompanied by clients’ explanations in the inquiry phase.

We hypothesized that perceived locations may have differed from actual explained locations if fixations did not occur – and visual attention was diverted to other locations – just before the response in the free association phase. The eye movement data of 29 participants under a Rorschach administration were collected, and 688 responses were obtained. Of these, 195 responses that involved perception of small, specific locations were used to investigate the association between pre-response eye movements and queried locations. Six responses of three participants showed fixations within 3 s before the time of response at locations different from the locations provided in the explanation. Responses made to similar but different locations were indicative of potential failures of location recognition.

Keywords: eye tracking, location recognition, recognition failure, Rorschach Inkblot Method

The Rorschach Inkblot Method (RIM) requires clients to report the perceptual experiences that are triggered by the presented inkblots; these reports are then analyzed and interpreted. When clients’ statements are not clear and subsequent coding becomes difficult, examiners must ask nondirective questions during an inquiry phase and then code clients’ explanations of their perceptual experiences. Exner (2002) emphasized the importance of the inquiry phase in determining the quality of interpretation and provided an exhaustive set of rules for the questioning procedure, including how to ask questions and how to use keywords that are 19

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related to the questions. Even if the questions are formed with great care, in some cases examiners are unable to elicit responses that reflect clients’ perceptual experiences with the inkblots. Such inability may sometimes be attributable to memory problems of the client. For example, Lerner (1998) described a case in which recognition failed for a client in a dissociative episode, and he construed this failure as part of a defense mechanism. Exner (2002) and Rose, Kaser-Boyd, and Maloney (2001) suggested that some client behaviors (e.g., reacting as if they have forgotten their own responses, the inability to explain their perceptual experiences) reflect their resistance to the procedure. Takahashi (2009) introduced a protocol for use with hospitalized patients with schizophrenia who may have failed to recognize their responses for reasons such as lack of attention, decline in short-term memory, and activation of defense mechanisms. In addition, Kataguchi (1987) reported that precise coding was difficult during testing of older adults with declining memory retention.

Previous studies have thus shown that clients occasionally experience recognition failure and cannot explain their perceptual experiences.

However, humans are capable of inventing explanations of outcomes so that the outcomes will make sense (e.g., Johansson, Hall, Sikstr€om, & Olsson, 2005). It is therefore possible that the presence of recognition failure may be concealed by the construction of explanations of perceptual experiences to suit the response (Okabe & Kikuchi, 1993). Some researchers have tacitly assumed that recognition failure does not occur, because the RIM procedure has no conventional methods to detect it.

If recognition failure occurs, then the client’s description in the inquiry phase may not always accurately reflect the perceptual experience.

Further, recognition failure would cast doubt on the overall reliability and validity of the RIM, which relies on clients’ description and interpretation of their perceptual experience at the moment of response. Therefore, it is imperative to investigate whether or not recognition failure occurs, and if it does, to clarify the factors causing recognition failure and its consequences.

In order to examine this potential recognition failure, it is necessary to record clients’ perceptual experiences independently of their explanations and to investigate any differences between their explanations and the recorded perceptual experiences. Monitoring eye movements, or eye tracking, which has been used recently in numerous Rorschach studies, is well suited for collecting information about people’s perceptual 20

Eye Tracking and Location Recognition in the Rorschach

experiences (e.g., Dan, Kong, & Wang, 2009; Dauphin & Greene, 2012; Hori, Fukuzako, Sugimoto, & Takigawa, 2002; Lukasova, Zanin, Chucre, de Macedo, & de Macedo, 2010; Minassian, Granholm, Verney, & Perry, 2005). Eye movements are typically considered to reflect visual attention. Thus, if clients’ explanations in the inquiry phase are not associated with their eye movements in the free association phase, it is possible that the perceptual experience that they explain is different from their actual experience, and they are providing a postscript explanation.

Some researchers have argued that factors such as low introspection ability and low linguistic ability may contribute to dissociation of clients’ actual experience and their explanation in the inquiry phase (Kataguchi, 1987). Therefore, in the present study, we focused on the location category, which is not strongly influenced by introspection or linguistic abilities and has a direct relationship to eye movements. Location is an important factor when interpreting data-processing clusters; moreover, it affects other coding categories, such as developmental quality, form quality, pairs, and reflections. Thus, exploring the potential recognition failure of location has strong implications for the methodology and interpretation of the Rorschach.

For each response, we individually examined associations between eye movements at the response and the explained locations in order to identify occurrences of recognition failures. If recognition failure occurred, we examined factors causing the recognition failure, as well as its effects on the interpretation. Recognition failure was defined as a situation in which no visual attention was deployed to the explained location just before the response. In this situation, participants may have paid attention to a different location in formulating their response and may have failed to recognize the actual location to which they had responded; thus we hypothesized that such participants explained the wrong location.

For each response with possible recognition failure, participants’ eye movements during recognition in the inquiry phase were analyzed to examine the presence of broad exploratory eye movements, which are thought to occur with potential recognition failure. In this way, our hypothesized definition of recognition failure as a lack of fixation to the location before the response could be comprehensively examined.

Responses that were assumed to be recognition failures, and factors causing recognition failure, as well as its effects on the interpretation, were further analyzed using the procedure described.

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Method Participants Participants were 35 second-year psychology students from a Japanese private university (four men, 31 women) with no record of visits to psychiatric institutions. Participants received course credit for taking part in the study. All participants reported normal or corrected vision and no color vision deficiencies. Four participants were removed from data analysis because their eye opening and posture habits created difficulty in data collection, and two participants were removed because their inquiry phases were insufficient owing to time limitations. As a result, the data from 29 participants (three men and 26 women) were analyzed.

Materials The Rorschach inkblots were stored in electronic form using a colorcalibrated scanner (GT-X970, Seiko Epson Corporation, Nagano, Japan).

The electronic inkblots were shown on a monitor that was especially made for an eye tracker (Tobii T60, Tobii Technology, Stockholm, Sweden).

The eye tracker was adjusted for ambient light using a monitor calibrator (Spyder3 Elite, Datacolor, Lawrenceville, NJ, USA). This monitor differs from typical eye trackers with headgear, and thus participants were not likely to notice that their eye movements were being monitored.

In the present study, examiners used computers to display the inkblots.

In the typical Rorschach administration, examiners sit close to clients and show the inkblots to them; however, in the present study the presence of an examiner may have diverted the participant’s attention. Therefore the examiner stayed in the next room to operate the computers and communicated with the participant through a headset. Because of this use of materials, the present study differs from the classic RIM and may be considered more experimental in nature.

Procedure After participants provided informed consent, they were instructed to sit in front of the monitor and adjust their position to be 60 cm away 22

Eye Tracking and Location Recognition in the Rorschach

from the monitor. The eye tracker was calibrated, and participants received instruction on the Rorschach, based on the Rorschach Comprehensive System (RCS; Exner, 2002). The instructions were modified for eye-tracking purposes. The participants were told to gaze at a fixation point, a cross in the center of the monitor, prior to each inkblot presentation.

The fixation point appeared for 3 s, and then the first inkblot appeared for the free association phase. The procedure during inkblot presentation followed the RCS. A pilot study showed that, after producing two responses to the first inkblot presentation, participants tended to keep responding until stopped by the examiner. Therefore we modified the script for examiners to say after the second response, “You can respond as long as you wish,” in order to indicate that the response limit was up to the participants, and that they could actively decide when to stop.

When the participants verbally expressed the end of free association for the current inkblot, the examiner changed the monitor to blank, and then the participants looked at the fixation point for 3 s before proceeding to the next inkblot.

After 10 inkblots were shown in the free association phase, the inquiry phase was administered based on the RCS, using the same procedure of inkblot presentation. The instructions were modified so that participants used a pointer to indicate parts of the inkblot, in order to prevent blockage of the eye tracker’s built-in camera by their hand movements and loss of eye tracking as their heads moved along with their hands. The indicated parts of the inkblots were recorded by a camcorder and used to code the locations. If the participants failed to use the pointer to indicate each location during their explanation, the examiners reminded them to use the pointer to circle the location.

Following the inquiry phase for all the inkblots, the examiner asked three questions regarding the participant’s awareness of eye tracking: “Is there anything that you noticed during the test?”; “What kind of data do you think were collected in this test?”; and “In this test, I was recording where you were looking, your visual fixation points. Did you notice that?”

The responses to these questions revealed that no participants were aware that their eye movements had been monitored during the study. After all procedures were completed, the participants were debriefed about eye tracking.

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Table 1. Target Measurement Locations of Responses Card I

D4, D7, Dd28

Card II

D2, D3, DS5

Card III

D2, D3, D5, D9 (one side), DdS23, Dd31, Dd32, Dd34

Card IV

Dl, D2, D3, D4, D5, D6 (one side), Dd32

Card V

D6, D7, D9, D10

Card VI Card VII

D3, D8, Dd31 D1, D2 (one side), D3, D5, D9, Dd21

Card VIII

Dl, D2, D4, D5, Dd22, Dd27, Dd31, Dd33

Card IX

D1 (one side), D3, D4, D8, Dd22, DdS29, Dd34

Card X

Dl, D2, D4, D7, D8, D9, D10, D11, D12, D15, Dd28

Spatial and Temporal Range of the Eye Tracker In order to define the locations that received eye fixations during the explanations in the inquiry phase, the boundary of the fixated area was expanded by 1 cm, and this area was defined as the area of interest (AOI). The 1-cm space was intended to compensate for the radius of the visual field represented by the fovea when it is 60 cm from the visual stimulus. The time of the response was defined as the moment during the free association phase when participants began to utter words that were related to the content or the location. The temporal ratio of the fixation period within the AOI was recorded in 0.5-s intervals, from 9 s before the time of response through the 3 s following it, in order to analyze the preand postresponse attention patterns. However, application of the AOI criterion to define the fixation area could result in the inclusion of substantial areas of the inkblots, especially when the response was made to the whole area or to multiple locations. Therefore the fixation areas for target measurement were chosen to be locations with location numbers defined by the RCS (Exner, 2002) that did not exceed one third of the area of the entire inkblot. Table 1 shows the 60 areas that met this criterion for all responses observed in the present study.

Furthermore, eye movements of participants were recorded for 5 s, from 0.5 s after the starting time through to 5.5 s after the starting time.

This was done in order to investigate participants’ tendencies to make exploratory eye movements during the inquiry phase, by defining the starting time of the inquiry phase as the moment when the examiner uttered a word related to the content. Tobii Studio 3.21 was used to analyze fixation durations, and fixation standards were 24

Eye Tracking and Location Recognition in the Rorschach

defined based on the default number on the I-VT filter (Tobii Technology, 2012).

Results and Discussion Inter-rater Reliability A total of 688 responses were collected from the 29 participants, with an average of 23.7 responses (SD = 10.4, Max = 54, Min = 14) per participant.

Responses were eliminated when (1) participants used multiple locations that were apparently different from the location numbers, (2) they responded to the entire inkblot, (3) they could not explain the location during the inquiry phase, or (4) the eye tracker failed to record eye movements. The remaining 410 responses were analyzed by two raters with more than 10 years of experience with the RCS. Interrater reliability was 94.6%, with a kappa coefficient of .893. For 218 responses, at least one rater determined the response to be matched with the measured location; the two raters assigned 192 of these reactions (88.1%) to the same location number. The remaining 26 responses (11.9%) were discussed between the raters to determine the location number and to establish correspondence or noncorrespondence. Finally, 195 responses were determined to have met the criteria of the measured area and were used for the data analysis. Of the 688 responses, one response was made in the free association phase that revealed recognition failure during the inquiry phase. For this particular response, the examiner asked twice for an explanation of the location; however, no explanation was obtained, and this represented an apparent recognition failure.

The moment of response and the starting time of the inquiry were measured by two raters using 1/30-s intervals. The absolute values of the difference in time measurement between the two raters were an average of 0.012 s (SD = 0.020, Max = 0.10, Min = 0.00) for the moment of response, and an average of 0.019 s (SD = 0.027, Max = 0.10, Min = 0.00) for the starting time of the inquiry. In cases in which there was disagreement in time measurement between the raters, the average of the two raters’ measurements was calculated and defined as the time of the moment of response or the starting time of the inquiry.

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Figure 1. Percentages of fixation time to the response location relative to the momemt of response (N = 134–173). For each interval, responses for which recordings were missing for more than 0.1 s (22–61 responses) were treated as missing values. Error bars indicated standard errors.

Time Range of Eye Movements Related to Responses For each of the 195 responses analyzed, the time range from 9 s prior to the time of response to 3 s after the response was equally divided into 0.5-s intervals. For each of these 24 intervals, the percentage of the interval in which a fixation occurred within the AOI (denoted as the temporal ratio of the fixation) was calculated; these ratios are shown in Figure 1. As Figure 1 demonstrates, that average fixation times to the response area gradually increased through the 9 s before the moment of response and decreased sharply after the response. Figure 2 shows the distribution of time differences between the time of fixation before the response and the moment of response. For 189 responses (96.9%), this time difference was less than 3 s; for 90 responses, the fixation to the response location was made at the moment of response.

This analysis suggests that the response locations are typically attended to just before the responses, and fixations do indeed occur. Thus, this methodology may be used to identify discrepancies between the queried location and the response location, and lack of fixation just before the response may be diagnostic of potential recognition failure.

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Eye Tracking and Location Recognition in the Rorschach

Figure 2. Number of responses (total 195) within each 0.5-s intervals difference between the pre-response fixation to the response location and the time of response, for 0–9 s.

Discrepancies Between Fixation Locations Immediately Before the Response and Queried Locations Six (3.1%) of the 195 responses were produced more than 3 s after the final fixation to the queried location, in other words, delayed postfixation responses. The hypothesis that they represent potential recognition failure was supported: The more time that passed, the greater the possibility that participants were paying attention to areas different from the claimed response location. Three of the 29 participants (10.3%) showed delayed postfixation responses. Examples of these responses are shown in Figure 3. The participants made three delayed postfixation responses to the cards shown in panels (a), (b), and (c), two responses to (d) and (e), and one response to (f). The control response (g), provided for comparison purposes, was produced by the same participant who produced responses (a) through (c) and was observed between the (a) and (b) responses. The total numbers of responses for each of the three participants were 42, 44, and 44 responses.

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Figure 3. Eye movements observed from 9 seconds before the response moment for participants with delayed postfixation responses. (a)-(f): Delayed postfixation responses. (g): Control response for comparison. (a), (b), (c), And (d) are from the same participants; (d) and (e) are from the same participants.

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Eye Tracking and Location Recognition in the Rorschach

Eye Movements Related to Delayed Postfixation Responses at Inquiry Phase An additional analysis was conducted to examine if delayed postfixation responses shared characteristics with potential recognition failure.

Six delayed postfixation responses made before the explanation in the inquiry phase were compared to 189 responses in which fixation to the response location was observed during the 3 seconds prior to the response. Each inkblot was overlaid with an 8 × 6 grid, with one grid square corresponding to a 30 mm × 28 mm rectangle. For the two types of responses, the number of grids that were fixated more than once in the 5 second period, from 0.5 seconds after the starting point of the inquiry through 5.5 seconds after the starting time, were calculated and compared. The average number of fixated grids in the delayed postfixation responses was 8.17 (SD = 2.48, Max = 11, Min = 5), and the average number of fixated grids for the 189 responses was 5.30 (SD = 1.98, Max = 13, Min = 2). A t-test indicated a significant difference (t(193) = 3.47, p < .001, r = .24) between the two types of responses. Figure 4 shows the grids that were fixated during the 5 seconds for all responses (a) through (g).

Eye movements of the six delayed postfixation responses were observed in a relatively broad area; on the other hand, fixation of the control response was observed immediately after the examiner finished speaking.

The above results suggest that the locations of responses were not readily recognized in delayed postfixation responses, and exploratory eye movements were initiated as a reaction to the examiner’s query. These results support the original hypothesis that the delayed postfixation response is associated with a potential reaction to recognition failure.

Comparison Between Fixation Locations Prior to Delayed Postfixation Responses and Explained Locations Regarding the six delayed postfixation responses, the response location explained by the participants and fixation location during the 3 s prior to the response were compared qualitatively, and factors causing recognition failure were examined (see Figure 3). All of the following descriptions referring to form qualities are based on data developed for the Japanese population (Takahashi, Takahashi, & Nishio, 2009): 1. For the fourth inkblot, (a) Raccoon Dog (code: Dd32) and (b) Dog (code: D1) were derived from the same participant’s response; 29

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Figure 4. Eye movements and fixation grids are after examiner prompts about content during the inquiry phase. Gray shading indicates grid in which fixation were observed. (a)-(f): Delayed postfixation responses. (g): Control response for comparison. (a), (b), (c), And (d) are from the same participants; (d) and (e) are from the same participants.

however, in the 3 s before the response, numerous fixations were observed in Dd32 for (a) and in D1 for (b). The content of (a) Raccoon Dog and (b) Dog are similar. Further, for the response Animal Face the forms of two locations were similar, with D1 corresponding to FQo and Dd32 to FQu. Therefore, it can be assumed that there was confusion between the two responses, and the other areas were explained.

2. For (c) Snake (code: Dd21), a large number of fixations around D5 were observed from 3 s before the response. Therefore this response was originally perceived in the D5 area; however, the D5 and Dd21 areas both include protruding objects, and their forms are similar.

Thus, it is possible that the D5 area was mistakenly explained in the inquiry phase.

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Eye Tracking and Location Recognition in the Rorschach

3. For (d) Sweeper (code: D2), a large number of fixations around D5 were observed from 3 s before the response. Therefore, this response was originally perceived in the D5 area; however, the D2 and D5 areas are both narrow at the top and wide at the bottom and similar to the Sweeper shape. Thus, it is possible that the area was mistakenly explained in the inquiry phase.

4. For (e), Human (code: Dd31), a large number of fixations around D3 were observed from 3 s before the response. Therefore, this response was originally perceived at the D3 area; however, Human (D3) and Doll (Dd31) share the basic forms of FQu and are easily perceived as human shapes. Thus, it is possible that the area was mistakenly explained at the inquiry level.

5. For (f) Crawfish (code: Dd34), a large number of fixations centered around Dd35 were observed in the time range just before response production. Therefore, this response could correspond to the Dd35 or D6 area (including Dd35). In either area, FQu includes the Crab Skull response, and Crawfish, as an example of Crustacean, could be coded as FQu by extrapolation. D6 or Dd35 are also areas that can be perceived as Crawfish; however, Dd34 includes the content that corresponds to FQo, Shrimp Arm. The Crawfish response was produced without clarifying if it referred to the body or arm; thus it is possible that the area was mistakenly explained in the inquiry phase.

Observations 1 through 5 share the common characteristic that participants mistakenly explained their responses on the basis of form similarities in multiple areas. In an explanation based on signal detection theory, highly similar stimuli could have functioned as distractors and induced recognition failure (e.g., Ashby & Perrin, 1988; Banks, 1970); however, for the Rorschach, recognition failure could be attributed to multiple locations that are similar enough to be perceived as having the same content.

Total Responses of Participants Containing Delayed Postfixation Responses The total number of responses by all three participants that included delayed postfixation responses was large. Factors causing recognition failure were examined from this perspective. The three participants 31

M. Yasuda

produced an average of 43.3 responses (SD = 1.2), which was greater by three standard deviations than the average number of responses of the total Japanese sample (Takahashi, Takahashi, & Nishio, 2007), 23.5 (SD = 6.9). Furthermore, it was significantly greater than the average, 21.5 (SD = 8.3), of the participants who did not produce the delayed postfixation response (Mann–Whitney U test, Z = 2.59, p < .01, r = .48).

The production of a large number of responses may induce errors because it promotes interference between responses in recognition.

Moreover, it may reflect the ability to apply reconstructive processes based on keywords provided by examiners. This may explain participants’ tendency to respond to locations that have not been experienced.

Effects of Location Recognition Failure on Interpretations of the Rorschach In the present study, six of the 195 responses (3.1%) were suggestive of location recognition failure. However, the effects of these responses were subtle, because the quantitative (mean) range defining the analytical criterion of locations and form qualities was broad, and coding similarities were readily found. Furthermore, the study was performed on healthy college students who had no memory problems.

The finding that the same explanation was applicable to both perceptual experiences and delayed postfixation responses suggests that the explained experience did not merely reflect a perceptual experience but also reflected a postscript explanation. As Schachtel (1966) and Kataguchi (1987) have suggested, “what kind of a perceptual experience occurred” and “how the perceptual experience was explained” are both important factors that reflect individual characteristics.

Apparent Recognition Failure Of the 688 responses obtained in the present study, one response, shown as (h) in Figure 5, indicated recognition failure in the inquiry phase.

Moreover, because of this apparent recognition failure, the participant could not explain the response. This participant provided a total of 20 responses. Figure 5 shows changes in the participant’s eye movements from 9 s prior to the moment of response in the free association phase through 3 s after this moment, as well as eye movement for 5 s in the 32

Eye Tracking and Location Recognition in the Rorschach

Figure 5. Eye movement at pre- and post-response with apparent recognition failiure, and eye movements and fixation grids after examiner prompts in the inquiry phase. Gray shading indicates grids in which fixations were observed.

inquiry phase, from 0.5 s of the starting moment of the query to 5.5 s after this moment.

One apparent recognition failure was observed in which a participant forgot the response location in the inquiry phase. Eye movements during the 3-s period prior to the response suggest that the Bird response (FQu; Takahashi et al., 2009) was produced at the D5 area. The eye movement pattern of the apparent recognition failure was different from that of the delayed postfixation response: No broad exploratory eye movement was observed, but rather the eye movement pattern during the time before the response was reproduced. Nonetheless, recognition failure occurred, suggesting that close observation of the D5 area, the area that appears to be a bird, was induced in response to the examiner; however, the participant was unable to reproduce the perceptual experience confidently enough to use in the response.

In addition, the participant who showed the apparent recognition failure did not produce a delayed postfixation response, and the total number of responses produced by this participant was within Âą1 standard 33

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deviation of the average Japanese respondent. This fact suggests that the participant had average perceptual ability; however, reconstruction of the perceptual experience was not complete enough to develop an alternative explanation to compensate for the recognition failure. As a result, the recognition failure became salient, accounting for the difference from the delayed postfixation responses.

Limitations and Future Directions In this study, we applied experimental methodology, which differs from normal Rorschach administration, by using computers and placing examiners and participants in different rooms. It should be noted that these differences placed limitations on the normal Rorschach procedures: For example, participants could not rotate the inkblots, and all bidirectional communication between examiners and participants was only verbal. In addition, the targets of analysis were limited, in that we analyzed only response locations with location numbers that were relatively easy to perceive. Finally, participants were healthy university students, who are less prone to recognition failure than clinical populations. The present study is the first step in research on potential and apparent recognition failure, and future studies should explore the application of our findings on recognition failure to RIM administration in clinical populations.

The present study employed eye tracking and analyzed each response made by participants, using a methodology that is applicable to other research. One potential application is reliability and validity research on Rorschach variables other than response location, such as developmental qualities or determinants. For example, an investigation of shading responses could be conducted. Shading responses have a great influence on interpretation, even with only a single response. By examining if participants pay attention to clear shades inside inkblots, it should be possible to determine whether or not the light shade is actually involved in the response formation.

The methodology of this study may also be applicable to clinical settings, as eye trackers become more readily available with the development of scientific technologies. The present procedure could be used to reveal clientsâ&#x20AC;&#x2122; perceptual processes that are not verbally salient and to establish 34

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an interpretation method based on their eye movements. Therefore, the methodology used in the present study offers a novel method for data collection and interpretation of the Rorschach as well as for future clinical applications.

Acknowledgments This work was supported by JSPS KAKENHI Grant Number 24830116.

A part of this study was presented at the 77th Annual Convention of the Japanese Psychological Association (Sapporo, Japan, September 2013).

I would like to thank Hirokazu Ogawa and Kazuya Inoue for helpful comments, and Kazuko Kishimoto and Masami Kurayama for coding.

References Ashby, F. G., & Perrin, N. A. (1988). Toward a unified theory of similarity and recognition. Psychological Review, 95, 124–150.

Banks, W. P. (1970). Signal detection theory and human memory. Psychological Bulletin, 74, 81–99.

Dan, Z., Kong, K., & Wang, X. (2009). Exploring the objectivity of the Rorschach inkblot test – a research from an eye movement experiment. Psychological Science (China), 32, 820–823.

Dauphin, B., & Greene, H. H. (2012). Here’s looking at you: Eye movement exploration of Rorschach images. Rorschachiana, 33, 3–22.

Exner, J. E. (2002). The Rorschach, a comprehensive system, Vol. 1. Basic foundations and principles of interpretation (4th ed.). New York, NY: Wiley.

Hori, Y., Fukuzako, H., Sugimoto, Y., & Takigawa, M. (2002). Eye movements during the Rorschach test in schizophrenia. Psychiatry and Clinical Neurosciences, 56, 409–418.

Johansson, P., Hall, L., Sikström, S., & Olsson, A. (2005). Failure to detect mismatches between intention and outcome in a simple decision task. Science, 310 (5745), 116–119.

Kataguchi, Y. (1987). Kaitei shin shinrishinndannhou Rorschach test no kaisetsu to kenkyuu [Revised new psychological diagnosis, research, and explanation of the Rorschach]. Tokyo, Japan: Kaneko shobo.

Lerner, P. M. (1998). Psychoanalytic perspectives on the Rorschach. Hillsdale, NJ: Analytic Press.

Lukasova, K., Zanin, L. L., Chucre, M. V., de Macedo, G. C., & de Macedo, E. C. (2010). Analysis of exploratory eye movements in patients with schizophrenia during visual scanning of projective tests’ figures. Jornal Brasileiro de Psiquiatria, 59, 119–125.

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M. Yasuda Minassian, A., Granholm, E., Verney, S., & Perry, W. (2005). Visual scanning deficits in schizophrenia and their relationship to executive functioning impairment.

Schizophrenia Research, 74, 69–79.

Okabe, S., & Kikuchi, M. (1993). The Rorschach test Q&A. Tokyo, Japan: Seiwa shoten.

Rose, T., Kaser-Boyd, N., & Maloney, M. P. (2001). Essentials of Rorschach assessment.

New York, NY: Wiley.

Schachtel, E. G. (1966). Experiential foundations of Rorschach’s test. New York, NY: Basic Books.

Takahashi, M., Takahashi, Y., & Nishio, H. (2007). Rorschach kaishakuhou [The interpretation methods of the Rorschach]. Tokyo, Japan: Kongo shuppan.

Takahashi, M., Takahashi, Y., & Nishio, H. (2009). Rorschach test keitaisuizunnhyou [The atlas of form qualities of the Rorschach]. Tokyo, Japan: Kongo shuppan.

Takahashi, Y. (2009). Rorschach test ni yoru personality no rikai [Understanding of personality based on the Rorschach]. Tokyo, Japan: Kongo shuppan.

Tobii Technology (2012). Determining the Tobii I-VT fixation filter’s default values: Method description and results discussion. Retrieved from http:// www.tobii.com/Global/Analysis/Training/WhitePapers//Tobii_WhitePaper_ DeterminingtheTobiiI-VTFixationFilter’sDefaultValues.pdf Masaru Yasuda Department of Human and Social Sciences Osaka Ohtani University 3-11-1, Nishikiorikita Tondabayashi-shi Osaka Japan Tel. +81 721 24 4829 Fax +81 721 24 4829 E-mail yasuda.masaru@gmail.com

Summary In the inquiry phase of the Rorschach Method, clients are required to recognize responses and explain perceptual experiences they had when producing the responses. However, clients sometimes fail to recognize their responses, for example, some clients claim that they have forgotten the responses. This study investigated the possibility of potential failure to recognize responses, in which the failure to recognize is concealed by subsequently inventing explanations. In order to examine this, eye movements when implementing the Rorschach Method were monitored and analyzed. It was hypothesized that when the locations where fixations were observed prior to the responses and the locations of responses explained in the inquiry phase did not match, clients failed to recognize the

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Eye Tracking and Location Recognition in the Rorschach locations where they actually perceived the responses and, therefore, invented the explanation that the responses were made in other locations.

The Rorschach inkblots were shown to participants (N = 35) using an eye tracker, and the Rorschach Method was implemented following the Rorschach Comprehensive System. We analyzed the responses that were explained as having been made in a small specific area. The boundary of the small area was expanded by 1 cm, and this area was defined as the area of interest (AOI). The fixation period within the AOI prior to the response was examined.

A total of 688 responses were collected from 29 participants, in whom eye movements were correctly measured. Among them, 195 responses made in the specific small area were investigated and eye movements during 3 s prior to the response were analyzed. It was confirmed that fixation occurred in locations that were different from the explained location in the case of six responses.

Furthermore, in the inquiry phase of the six responses, exploratory eye movements were observed in a relatively broad area of the inkblots, which were initiated as a reaction to the examiner’s query. Furthermore, qualitative analysis of the six responses indicated that participants might have perceived responses in different locations that have form similarities to the locations they explained. These results suggest possibilities of potential failures in response recognition with regard to responses produced in the small area.

要約 ロールシャッハ法の質問段階において、クライエントは反応を再認し反応産出時の知覚体験 を説明するよう求められる。ただし、まれに反応の忘却を主張するクライエントが存在すること からも伺えるように、クライエントは時として反応再認に失敗する。本研究では、再認に失敗 しながらも後づけの説明を行うことで再認失敗が補完される、潜在的な反応再認の失敗が 存在する可能性を調査することを目的とした。この目的を達成するために、ロールシャッハ法実 施下における眼球運動が測定された。そして、反応産出直前に停留が行われた領域と、 質問段階で説明された反応領域とが一致しない場合、実際に反応を知覚した領域の再認 に失敗し別の領域を説明したとの仮説が立てられた。 35 名の調査対象者に対し、ロールシャッハ図版を眼球運動測定用モニターで提示し、 包括システムの手続きでロールシャッハ法を実施した。本研究では、特定の小領域を用い たと説明された反応を分析対象とした。この小領域の輪郭を 1cm 拡大した範囲を興味領域 とし、反応の何秒前まで興味領域に対する停留が見られたか調査した。 眼球運動測定が適切に行われた 29 名の調査対象者から 688 反応が産出され、この うち特定の小領域に産出された 195 反応が分析対象として扱われた。この 195 反応に対 して反応産出の直前 3 秒間の眼球運動を分析した結果、 6 反応において説明された反応 領域とは別の領域に対して停留が行われていたことが確認された。また、この 6 反応の質 問段階では、検査者が反応について質問を始めた直後に、図版の広範囲を走査する探 索的な眼球運動が見られた。そして、 6 反応に対する質的分析により、説明された領域と 形態的に類似した別領域に反応を知覚していた可能性が高いことが示された。以上の結果 から、小領域に産出された反応に関しては、少数ながら潜在的な反応再認の失敗が存在 する可能性が示唆された。

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Résumé Dans la phase enquête du Test de Rorschach, il est demandé aux clients de reconnaître leurs réponses et d’expliquer les expériences perceptives qu’ils ont eues pendant qu’ils donnaient ces réponses. Cependant, certains clients n’ont quelques fois pas pu reconnaître leurs réponses. C’est le cas de ceux qui disaient avoir oublié leurs réponses. Cette étude a exploré la possibilité d’incapacité potentielle à reconnaître les réponses, dans laquelle l’incapacité à reconnaître est dissimulée par l’invention d’explications. Pour ce faire, la mise en application du Test de Rorschach a consisté en la surveillance et l’examen des mouvements d’yeux.

On a émis l’hypothèse que lorsque les emplacements où des fixations ont été observées avant les réponses et les emplacements des réponses expliquées dans la phase enquête ne correspondaient pas, « les clients n’arrivaient pas à reconnaître les emplacements où ils avaient perçus les réponses et, par conséquent, inventaient l’explication selon laquelle les réponses avaient été données dans d’autres emplacements.

Les taches d’encre de Rorschach ont été montrées aux participants (N = 35) au moyen d’un suiveur oculaire, et le Test de Rorschach a été mis en œuvre suivant le Comprehensive System (CS) de Rorschach. Nous avons ensuite analysé les réponses que les clients ont expliqué avoir données dans une petite zone spécifique.

La dimension d’une petite zone a été agrandie de 1 cm, et cette zone a été définie comme zone d’intérêt (ZI). La période de fixation de la ZI avant la réponse a été examinée.

Un total de 688 réponses a été collecté chez 29 participants, chez qui les mouvements des yeux ont été correctement mesurés. 195 de ces réponses données dans la petite zone spécifique ont été analysées et les mouvements des yeux dans les trois secondes précédant la réponse ont été analysés. On a confirmé que les fixations se produisaient dans des emplacements différents des emplacements expliqués dans le cas de six personnes. En outre, dans la phase d’enquête des six réponses, des mouvements exploratoires d’yeux ont été observés dans une zone relativement large des taches d’encre; ces mouvements ont été initiés en réaction à la question de l’examinateur. En outre, l’analyse qualitative a indiqué que les participants peuvent avoir perçu les réponses dans différents emplacements qui ont des similarités de forme avec les emplacements qu’ils ont expliqués. Les résultats ci-dessus indiquent qu’il existe des possibilités d’incapacités potentielles à reconnaître les réponses par rapport aux réponses produites dans une petite zone.

Resumen En la fase de investigación del Método de Rorschach, se pide a los clientes que encuentren respuestas y expliquen las experiencias perceptivas que tuvieron durante la producción de las respuestas. Sin embargo, los clientes a veces no reconocen sus respuestas; por ejemplo, algunos clientes afirman que olvidaron las

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Eye Tracking and Location Recognition in the Rorschach respuestas. Este estudio investigó la posibilidad de la posible falla en el reconocimiento de las respuestas, en casos en los que la falla en el reconocimiento se oculta mediante el posterior invento de explicaciones. Con el fin de explorar esto, se monitorizaron y examinaron los movimientos oculares mientras se aplicaba el método de Rorschach. Se planteó la hipótesis de que cuando las ubicaciones donde se observaron fijaciones antes de las respuestas y las ubicaciones de las respuestas explicadas en la fase de investigación no coincidían, los clientes fallaron en el reconocimiento de las ubicaciones donde ellos realmente percibieron las respuestas y, por tanto, inventaron la explicación sobre que las respuestas se habían realizado en otras ubicaciones.

Se mostraron las manchas de tinta de Rorschach a los participantes (N = 35) utilizando un rastreador ocular, y se aplicó el Método de Rorschach de acuerdo con el Sistema Comprehensivo de Rorschach. Se analizaron las respuestas que se explicaron como hechas en un área pequeña específica. El límite del área pequeña se expandió en 1 cm, y esta área se definió como el área de interés (AOI).

Se examinó el período de fijación dentro de AOI antes de la respuesta.

Se recolectaron un total de 688 respuestas provenientes de 29 participantes, en quienes se midieron adecuadamente los movimientos oculares. Entre dichas respuestas, se investigaron 195 respuestas realizadas en el área pequeña específica y se analizaron los movimientos oculares durante los tres segundos previos a la respuesta. Se confirmó que la fijación ocurrió en ubicaciones que eran distintas a la ubicación explicada en el caso de seis respuestas. Además, en la fase de investigación de las seis respuestas, se observaron movimientos oculares exploratorios en un área relativamente amplia de las manchas de tinta, mismos que se iniciaron como reacción ante la petición del examinador. Asimismo, el análisis cualitativo de las seis respuestas indicó que los participantes podrían haber percibido las respuestas en diferentes ubicaciones que tienen similitudes de forma con las ubicaciones que explicaron. Los resultados anteriores sugieren que existen posibilidades de posibles fallas en el reconocimiento de las respuestas con respecto a respuestas que se producen en el área pequeña.

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Rorschachiana 36, 40–57 © 2015 Hogrefe Publishing

DOI: 10.1027/1192-5604/a000058

Special Section: The TAT and Other Storytelling Projective Methods Original Article

IQ and Defense Mechanisms Assessed with the TAT Phebe Cramer Department of Psychology, Williams College, Williamstown, MA, USA

Abstract. The concept of defense mechanism has a long history in psychoanalysis and clinical psychopathology. The function of defenses has been modified over the years, from a counter-force against instincts to the protection of self-esteem. To understand the role of defenses in pathological and normal development, a coding method to use with Thematic Apperception Test (TAT) stories – the Defense Mechanism Manual (Cramer, 1991a) – has been developed and validated. Three broad defenses – Denial, Projection, and Identification – may be coded with this method. The article presents examples of TAT stories that have been coded for defense use. These show how defense use changes after a period of psychotherapy, and how defenses change with age. Evidence for reliability and validity is provided, both from correlational and experimental studies. The remainder of the paper focuses on the relation between the use of defense mechanisms and intelligence.

Research has shown that the two ego functions of defense and IQ are not correlated in childhood and adolescence, but are correlated in adulthood defenses and IQ. Importantly, IQ serves as a moderator for the effect of defense use on variables such as psychiatric symptom change, level of Ego Development, and Big Five personality traits.

Keywords: defense mechanisms, developmental differences, intelligence, personality, storytelling

Defense mechanisms are “constructs that denote a way of functioning of the mind” (Wallerstein, 1985, p. 222). Defenses are manifest as “specific behaviors, affects or ideas that serve defensive purposes” (Wallerstein, 1985, p. 222). There is general agreement that the purpose of defenses is to prevent other ego functions from being disrupted or disorganized by excessive negative affect, such as anxiety or guilt.

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IQ, TAT, and Defenses

In his early studies of psychopathology, S. Freud (1894/1962)described an aspect of the mind, called a defense function, whereby painful thoughts and feelings could be concealed. With the publication of The Ego and the Id (Freud, 1923/1961) and Inhibition, Symptoms and Anxiety (Freud, 1926/1959), defense became one of the functions of the ego, the purpose of which was to protect the ego against the discharge of instinctual demands. The first systematic theory of defense mechanisms was provided by Anna Freud in her 1936 book, The Ego and the Mechanisms of Defense. In this book, she reconciled the two views of S. Freud regarding the function of defenses – that defense against painful thoughts and feelings and defense against the instinctual drives are based on the same motives and serve the same purpose, namely, to “ward off” anxiety and guilt feelings.

Fenichel (1945) expanded this concept of the function of defense mechanisms. Defenses were now understood to defend the ego not only from inner dangers – instinctual demands and the related anxiety – but also against dangers based on external prohibitions, the violation of which result in feelings of guilt and loss of security and of self-esteem.

Fenichel thus made an important addition to the assumption that defenses function to protect the ego from being overwhelmed by instinctual impulses: Defenses may also function to protect the self from loss of esteem. This latter idea was also introduced by Lampl de-Groot (1957).

Although the concept of the defense function was discovered through the study of psychopathology (Freud, 1894/1962), it was also noted that defense mechanisms are a necessary part of normal development (Freud, 1937/1964), a point of view echoed by A. Freud (1965). Early on, there were warnings in psychoanalytic writings not to equate defense mechanisms with pathology (e.g., Glover, 1937; Loewenstein, 1967). According to psychoanalytic theory, a defense may be considered part of normal development if it serves the purpose of maturation, growth, and mastery of the drives. In contrast, defense is an indication of pathology if it is used primarily to ward off anxiety, strong instinctual demands, and/or unconscious conflict, and is inappropriate with regard to the reality situation and the individual’s developmental level (c.f., Bibring, Dwyer, Huntington, & Valenstein, 1961; Lampl de-Groot, 1957; Loewenstein, 1967; Wallerstein, 1967).

With this broader conception of the nature and function of defense mechanisms, there are several interesting questions that might be investigated. For example, if defenses are part of normal development, which defenses do children use, and does this change with age? In nonclinical 41

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adults, are defenses related to personality differences, and to personality change? In clinical patients, how is pathology related to defense use, and does this change following therapeutic treatment? In order to explore these questions, the researcher must have a satisfactory method for assessing defense mechanisms.

This article presents a method to assess defense mechanisms and to study these questions, based on coding Thematic Apperception Test (TAT) stories with the Defense Mechanism Manual (DMM; Cramer, 1991a, 2006). The coding method has been described in a detailed manual, freely available online: (http://web.williams.edu/Psychology/ Faculty/Cramer/Cramer.html). Three broad defenses – Denial, Projection, and Identification – may be coded with this method.

Examples of Stories Coded With the DMM In the study of individual clinical patients, assessing defenses at different points in treatment will give an indication of how the patient may be changing. For example, the following stories come from a 41-year-old woman who was hospitalized due to disabling dependency and complaints of multiple physical and psychological symptoms. She appeared immature, helpless, and unable to care for herself. On admission to the hospital, she told the following story to TAT Card 1 (examples of defense use are in italics): Okay, the boy has been playing the violin and he’s supposed to practice more, but he doesn’t want to, and he’s just staring at it, wishing it would go away so he wouldn’t have to play it anymore and he can go outside and play. Like he wants to be good at it but he doesn’t want to spend all his time practicing it, he’s like ambivalent. Is that enough (?) Well, he’ll halfheartedly play for another half hour. And, it’ll be time to eat and he will have missed going outside to play.

In this story, the responsibility for action and change is placed outside of the self (“wishing it would go away”) rather than taking any personal responsibility or making any personal effort (“just staring at it”), and wanting gratification without work (“he wants to be good” but “doesn’t want to practice”). The focus on eating at the end suggests regressive tendencies.

In terms of defense use, this initial story provides evidence of Denial of

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reality (“wishing it would go away”), and the rejection of mature Identification (not wanting to work at it, not wanting to delay gratification).

After 2.5 years of treatment, she told the following story to the same TAT card: I don’t know. I think he’s grown up and he’s looking back to when he was little, and he has this wonderful guitar, uh, violin … He had violin lesson and he just didn’t want to play and he like gave it up but now a grownup, he like wishes he practiced so he would have been … uhm .. a violinist. He feels as a grownup … he feels regret ....

Several important changes in the patient’s thinking over the treatment period are shown in this story. After the treatment period, there is a greater capacity for self-refection and self-observation (“he’s looking back”). There is also a recognition of personal responsibility, without blaming another (“wishes he practiced”). There is also recognition that work could have led to a mature profession (“would have been a violinist”), and a demonstration of the capacity for self-observation and criticism (“he feels regret”). He now identifies himself as a grownup.

In terms of defense use, all of these new ideas are evidence of the mature defense of Identification.

Research with this method has also demonstrated that children and adolescents of different ages show differential use of the three defenses (e.g., Cramer, 1987; Porcerelli, Thomas, Hibbard, & Cogan, 1998). Young children until age 7 use predominantly Denial; older children and early adolescents use predominantly Projection; late adolescents and college students show strongest use of Identification. These developmental differences have also been demonstrated as longitudinal change (Cramer, 1997). These differences are exemplified in the following three stories, one from a 5-year-old, one from an 11-year-old, and one from a college student.

The story below was told by a 5-year-old child to a picture of a man and a woman swinging on trapezes at the top of a circus tent. The picture is part of a research series (examples of Denial are in italics): Acrobats: The lady jumped up. The man might hold her hand. He is! He might slip. But he won’t, because his legs are hooked on and he is a good acrobat.

The lady won’t either, but her hands, they look like they will but they won’t…. Their hair is flying up, so her hair won’t go down until the man lets her down. [What are they feeling?] The man is feeling her arms and the lady is feeling his arms.

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In this story, there is an ongoing concern about the acrobats falling. However, the storyteller continually denies that this will happen – he won’t, the lady won’t either, they won’t. The example of concrete thinking at the end of the 5-year-old’s story is striking.

The next story was told by an 11-year old boy, to TAT card 17BM, which depicts a single man clinging to a rope (examples of Projection are in italics): Once there was a story about a man and he was building a house and then some warriors came along and broke down the house and were trying to kill him. Luckily he escaped and went away on his horse. Trying to get into the government building, he climbed up a rope and got in and killed the emperor.

In this example, the storyteller adds, from his own thoughts, the presence of destructive and murderous warriors, an escape, and a murdered emperor. There is nothing in the picture to suggest these frightening additions; they are projected from the storyteller’s own hostile fantasies.

The story also interestingly illustrates two sides of projection. In the beginning, it is the warriors who wish to break down the man’s house and kill him. At the end, the man is carrying out the murderous intentions that had previously been attributed to someone else – namely, to kill someone.

Finally, we consider a story told by a male college student to a research picture showing a person standing near a large flask, one hand upraised (several examples of the defense of Identification are italicized): Mark Parker is a lab scientist at MIT doing independent research – He is currently hot on the trail of an amazing breakthrough sure to win him a Nobel Prize… As he progresses through the final stage of his work, he notices some odd readouts on his computer printout of data. Shocked by the revelation that his great discovery may, in fact, never materialize, he rushes over to this equipment and pulls out the one beaker of material which is producing the faulty data …. As Dr. Parker stares into the beaker, he thinks about his enormous time commitment to this work and the ridicule that will come from his peers… It would be very easy for Dr. Parker to remedy the situation and get rid of the evidence and present his other findings as proof of his theory, but that would break the ethical code of research science… Dr. Parker thinks of fame, glory, money, success, shame, guilt and responsibility. As the beaker is crushed in the heat of the incinerator … his only thought becomes “I wonder if anyone will ever find out ”.

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In this story, the main theme is the conflict between maintaining a personal image of an ethical, hard-working scientist and the temptation to engage in unethical behavior. There is evidence of self-reflection: The scientist realizes that he has put a great deal of work into this research, he realizes that societal rules should be followed, and at the same time, he is worried that his hard work will be for naught, that a transgression will be discovered, and that he will be blamed. The concern for morality is strong, but not quite strong enough. Nevertheless, the scientist continues to fear discovery of his immoral act.

Other Applications of the DMM In addition to studying defense use and change in individual patients, TAT stories coded with the DMM may be used in research studies comparing a group of patients before and after experiencing treatment.

A study of this type was carried out with a group of psychotic patients who were hospitalized and treated with intensive, psychoanalytically oriented therapy (Cramer & Blatt, 1990). A comparison of their defense use at entrance to the hospital and after 15 months of treatment showed that total defense use, and especially the use of the immature defense of Denial, had decreased, and that this decrease was associated with degree of clinical improvement.

The DMM is also useful for research studies in which we may wish to determine if defense use is related to changes in personality. Several published studies have demonstrated that changes in adult personality dimensions, such as the Big Five personality traits and Identity Status, can be predicted from knowledge of DMM defense use (e.g., Cramer, 2003, 2004). For example, the use of Identification at early adulthood predicted a decrease in Big Five Neuroticism and an increase in Big Five Conscientiousness between early adulthood and late middle age. A number of other significant relations between the use of all the defenses at early adulthood and subsequent Big Five change were found in this study.

With children, DMM scores have been found to be related to personality variables such as Social Anxiety, Ego Undercontrol, Externalizing and Internalizing Behavior Problems, and Perceived Competence (Cramer, 2009b; Sandstrom & Cramer, 2003b).

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Using the DMM: Scoring For each of the three defenses, there are seven subcategories that may be scored. These scores are then summed to provide a total score for each of the three defenses. The coding categories, with examples, are presented in Table 1.

The most efficient approach to scoring is to code one defense at a time, one picture at a time. This helps the coder keep a constant mindset while examining each story for the presence of examples of each defense.

For each of the seven subcategories for a defense, a tally is recorded on a scoring sheet; a subcategory may be coded for as many times as it occurs within a story. At the end of the story, the tallies for the seven subcategories are summed, yielding a total score for the defense for that story. After all stories have been coded for that defense, the story totals are added to provide the overall score for that defense, for that person.

These raw defense scores may be used to determine defense use, or a proportional score may be obtained, by dividing the individual defense score by the summed total of the three defenses. The latter type of score is useful when comparing two groups that differ in the length of the stories that they tell (e.g., young children and older adolescents).

To become proficient with the coding method for the DMM, the coder should have some background in defense mechanism theory. It is also helpful to have clinical sensitivity â&#x20AC;&#x201C; what has been called â&#x20AC;&#x153;listening with a third ear.â&#x20AC;? Considerable practice is required, including comparison of practice scoring with that done by an experienced coder for the same stories. Coded stories for such a reliability check are available from the author. Depending on the skill of the coder, between 20 and 30 hr of practice is generally required.

Once satisfactory proficiency has been attained, subsequent use of the DMM for research purposes should always include an examination of interrater reliability. A group of stories from the total sample of participants should be randomly selected and scored by two coders. A Pearson product moment correlation coefficient, or an intraclass correlation coefficient statistic should be used to determine the agreement between the two coders, for each defense, with a value of .65 being generally acceptable to indicate reliable coding. If this value is not obtained, coders may wish to discuss points of disagreement and modify coding scores accordingly.

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IQ, TAT, and Defenses

Table 1. Defense Mechanism Manual scoring categories: Denial, Projection, Identificationa Denial (1) Omission of major characters or objects Example: Failure to refer to the violin on TAT Card 1 (shows boy with violin).

(2) Misperception Example: Referring to the violin as a toy boat.

(3) Reversal Example: “He’s dead, and he’ll come back to life.”

(4) Statements of negation Example: “At first I thought he was dead, but he isn’t.”

(5) Denial of reality Example: “It was just a dream.”

(6) Overly maximizing the positive or minimizing the negative Example: “It is the biggest in the world.”

(7) Unexpected goodness, optimism, positiveness, or gentleness Example: “He has always failed, but he knows that he will be successful in the end.”

Projection (1) Attribution of hostile feelings or intentions, or other normatively unusual feelings or intentions, to a character Example: “He has a mean personality [unexplained].”

(2) Additions of ominous people, animals, objects, or qualities Example: “He got an axe and killed him [no axe-like object in picture].”

(3) Magical or autistic thinking Example: “He was putting spells all over the man.”

(4) Concern for protection from external threat Example: “There is a killer lying in wait for him.”

(5) Apprehensiveness of death, injury, or assault Example: “He is going to fall and break his leg.”

(6) Themes of pursuit, entrapment, and escape Example: “He’s escaping; he’s running, the robbers are chasing him.”

(7) Bizarre story or theme Example: “He ate a big piece of wood and got all bloated and blew up.”

Identification (1) Emulation of skills Example: “He wants to do it like his teacher does.”

(2) Emulation of characteristics, qualities, or attitudes Example: “He is trying to be Tarzan.”

(3) Regulation of motives or behavior Example: “He feels guilty for what he did.”

(4) Self-esteem through affiliation Example: “He realizes that he and his classmate are in exactly the same situation … they become very close and comfort themselves with the situation.”

(5) Work; delay of gratification Example: “He has to study really hard.”

(6) Role differentiation Examples: mention of specific adult roles, such as “teacher,” “sailor,” “farmer,” priest,” “soldier,” “scientist,” etc.

(7) Moralism Example: “He robbed a bank, but the cops caught him. Justice will out.”

Note. aA more complete version of the coding system appears in Cramer (1991a) and at http:// www.williams.edu/Psychology/Faculty/Cramer/cramer.html.

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Both experienced psychologists and graduate students have shown that good interrater reliability with the DMM is possible. In published research (cf. Cramer, 2006), interrater reliability for Denial has ranged from .71 to .95; for Projection from .71 to .88; and for Identification from .74 to .93.

The reliability findings are similar for graduate students who have used the DMM for their PhD dissertations: Denial (.66–.87); Projection (.81–.95); Identification (.67–.96).

Validity of the DMM Evidence for DMM validity comes from a series of research studies in which stress was intentionally introduced into the storytelling situation, with the intent of determining whether DMM defense use would increase under conditions of stress, as would be predicted by theory. In these experiments, the stress conditions for children included apparent failure in a game-playing task (Cramer & Gaul, 1988) and rejection by a playmate (Sandstrom & Cramer, 2003a). The stress conditions for adults included harsh criticism of storytelling ability (Cramer, 1991b) and challenge to their sex-role orientation (Cramer, 1998). In each of these studies, participants who were stressed increased their use of defenses coded by the DMM, as compared to their defense use prior to stress and/or to a group of nonstressed controls. These findings are consistent with clinical theory – that under conditions of negative affect arousal, defense use will increase. The findings thus provide evidence for the validity of the DMM method.

Defense Mechanisms, Intelligence, and IQ In the remainder of this paper, the relation between intelligence and the use of defense mechanisms, as assessed with the DMM, is discussed. Both of these factors involve cognitive operations, and both show developmental change with age. We then ask whether DMM scores are related to the intelligence, or IQ, of the individual.

The answer is: The relation between defense use and IQ appears to differ at different ages. Studies have shown that among children, 48

IQ, TAT, and Defenses

adolescents, and emerging adults DMM defense use and IQ are unrelated. In a study of children aged 6–11 years, neither the use of Denial nor the use of Projection was related to Peabody Picture Vocabulary Test IQ (rs = −.03 and .01; Cramer & Brilliant, 2001). In a sample of 12-yearolds, Stanford–Binet IQ was not significantly related to Denial (r = .00), Projection (r = .10), or Identification (r = −.10; Cramer, 2009a). In a sample of 18-year- olds, Wechsler–Bellevue IQ was not significantly related to Denial (r = .03), Projection (r = .19), or Identification (r = .07; Cramer, 2008). Likewise, in a sample of 23-year-olds, DMM defense use was unrelated to WAIS IQ (Cramer, 1999).

However, for older adults, DMM defenses have been found to be related to IQ level (Cramer, 2003, 2004). In a community sample of 155 adults, the use of Denial and Projection at ages 30 and 37 were positively correlated with WAIS IQ measured at ages 40 and 47. In another community sample, the Vocabulary subtest of the WAIS-R was significantly related to DMM Identification; the relation of Projection with IQ was positive, but not significant. There was no relation with Denial (Blaess, 1998).

Why should we find DMM defense use to be related to IQ in adults, but not in children? One possibility is that defenses and intelligence develop on two separate unrelated pathways during childhood. An alternate explanation comes from the fact that IQ scores in childhood are adjusted for chronological age. An IQ score is calculated by dividing the child’s mental age by chronological age, where mental age is determined by the number of items answered correctly on an intelligence test, as compared to the average age at which normal children can pass the same number of test items.

Thus, if we looked at the relation between defenses and intelligence scores that are not adjusted for chronological age – i.e., mental age, rather than IQ scores – the obtained relation between intelligence and defenses might be different. At any one chronological age, lower mental age might be associated with using a less mature defense, such as Denial, and higher mental age might be associated with using a more mature defense, such as Projection or Identification. However, when children with the same mental age, but different chronological ages, are put into the same group, their IQs will differ. A given mental age for an 8-year-old will yield a different IQ than the same mental age for a 10-year-old, and thus the relation between intelligence and defense use may be obscured.

However, for adults, this problem does not occur because the IQ score does not depend on chronological age.

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Research with adults has also shown that the nature of the relation between IQ and personality variables is moderated by defenses. For example, in a study of young adults (Cramer, 1999) the findings showed that defense and IQ interacted in predicting Loevingerâ&#x20AC;&#x2122;s level of Ego development. High levels of Ego development were associated with high IQ and low use of Denial, or, with low IQ and high use of Denial. By contrast, low levels of Ego development were associated with high IQ and high use of Denial, or with low IQ and low use of Denial. Thus for persons with lower IQs, strong defense use appears to support their attainment of higher ego levels.

One way of understanding this interaction between Denial and IQ is to note that use of the defense of Denial is related to immaturity in an adult (e.g., Cramer, 2006). Immaturity in an adult may be the result of limited intellectual resources â&#x20AC;&#x201C; that is, a lower IQ. In this case the defense of Denial may be a developmental match for the IQ level and may facilitate adaptation appropriate to this personâ&#x20AC;&#x2122;s level of functioning. Put another way, if the IQ is insufficient to promote successful adaptation, defenses may play a needed compensatory role. By contrast, if IQ is high, then the use of an immature defense may interfere with adaptive functioning.

In these instances, defense use appears to compensate for low IQ. This compensatory role of defense has been found in other studies. For example, the interaction of DMM defense and IQ has been shown to predict Big Five personality traits (Cramer, 2003). For individuals with lower IQ, the use of Identification predicted higher Extraversion, greater Agreeableness (for women) and greater Conscientiousness (for men). Again, the defense appears to play a compensatory role for individuals with lower IQs, fostering more positive outcomes. The results were different for high-IQ adults. For high IQ, use of Identification was unrelated to Extraversion and negatively related to both Agreeableness (women) and Conscientiousness (men).

Within hospitalized adults, IQ was found to moderate the relation between DMM defense use and psychiatric symptom change following treatment (Cramer, 2005). Focusing on the most seriously disturbed patients in a psychiatric hospital, the interaction between DMM defenses and IQ for determining clinical change over a 15-month period was determined. The results showed that, for patients with a lower IQ, a decrease in the use of defenses over the 15-month period predicted a decrease in psychiatric symptom level and an increase in level of interpersonal functioning. However, for these lower-IQ patients, an increase in defense use predicted an increase in psychiatric symptoms.

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IQ, TAT, and Defenses

Table 2. Relation of IQ and defense mechanisms to pathology/healthy personality: patients and nonpatients Low IQ

High IQ

Patients

Defenses increase pathology

Defenses decrease pathology

Nonpatients

Defenses increase healthy personality

Defenses are unrelated/ negatively related to healthy personality

The interaction between IQ and defense use for predicting personality in these psychiatric patients was thus different from that found with nonpatients. For patients with lower IQs, defenses function to maintain or strengthen the existing, pathological personality organization. It appears that defenses support their pathological symptoms. However, for patients with higher IQs, an increase in defense use predicted decreased symptoms and better interpersonal functioning. For these higher-IQ patients, defenses appear to control or suppress manifestations of pathology.

By contrast, for healthy individuals with lower IQs, an increase in the use of defenses results in an increase in their existing positive personality traits.

Thus, the effect of the interaction between DMM defenses and IQ is different for nonpatients and psychiatrically disturbed patients. For nonpatient individuals with low IQs, defenses play a positive role. For patients with low IQ, defenses have a negative role. In either case, for low-IQ persons, defenses function to support the existing personality organization, be it pathological or healthy.

By contrast, for patients with a high IQ, defenses and IQ work in tandem to control pathology. For high-IQ nonpatients, the use of defenses appears to be unrelated or negatively related to healthy personality (Big Five traits, Ego level; see Table 2.)

These findings all suggest that, when assessing the relation between defense use and personality in adults, the possibility that IQ moderates the effect of defenses should be considered. If the effect of defenses at different levels of IQ is not considered, one might erroneously conclude that defense use is unrelated to pathology or to personality factors. That is, the main effect of defense use may not be statistically significant, because it is obscured by the interaction with IQ.

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Defense Mechanisms and Ethnic Samples There has been some interest for using the DMM with non-White samples, and in countries outside of the United States. A study with Hispanic and African American early adolescents (Hernandez, 1999), with a diagnosis of Conduct Disorder, found the same results as a similar study with White early adolescents (Cramer & Kelly, 2004): Conduct Disorder was associated with high use of Denial and low use of Identification.

One study has compared the DMM defense use of Asian and White women (Hibbard et al., 2000). In this study, the degree of acculturation of the Asian women was related to their DMM defense of Identification.

The findings showed that greater loss of Asian identity (greater acculturation) was associated with lower Identification scores. Importantly, the DMM scores were found to be equally valid for the two ethnic groups.

In fact, the predicted relations between DMM defense scores and criterion variables such as Narcissism, Attachment Style, and Interpersonal Behavior were actually stronger for the Asian than for the White women.

The DMM has also been discussed in publications from Argentina and the Czech Republic (Cramer, 2013; Soukupova, Goldmann, & Cramer, 2012).

References Bibring, G. L., Dwyer, T. F., Huntington, D. S., & Valenstein, A. F. (1961). A study of the psychological processes in pregnancy and of the earliest mother-child relationship. Psychoanalytic Study of the Child, 16, 9–72.

Blaess, D. R. (1998). The relationship among defense mechanisms, psychological and physical health symptoms, and electrodermal response to emotionally evocative stimuli (Unpublished doctoral dissertation). California School of Professional Psychology, San Diego, CA. Cramer, P. (1987). The development of defense mechanisms. Journal of Personality, 51, 78–94.

Cramer, P. (1991a). The development of defense mechanisms: Theory, research and assessment. New York, NY: Springer-Verlag.

Cramer, P. (1991b). Anger and the use of defense mechanism in college students.

Journal of Personality, 59, 39–55.

Cramer, P. (1997). Evidence for change in children’s use of defense mechanisms.

Journal of Personality, 65, 233–247.

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IQ, TAT, and Defenses Cramer, P. (1998). Threat to gender representation: Identity and identification.

Journal of Personality, 66, 335–357.

Cramer, P. (1999). Ego functions and ego development: Defense mechanisms and intelligence as predictors of ego level. Journal of Personality, 67, 735–760.

Cramer, P. (2003). Personality change in later adulthood is predicted by defense mechanism use in early adulthood. Journal of Research in Personality, 37, 76–104.

Cramer, P. (2004). Identity change in adulthood: The contribution of defense mechanisms and life experiences. Journal of Research in Personality, 38, 280–316.

Cramer, P. (2005). Another “lens” for understanding therapeutic change: The interaction of IQ with defense mechanisms. In J. S. Auerbach, K. N. Levy, & C.E. Schaffer (Eds.), Relatedness, self-definition and mental representation: Essays in honor of Sidney J. Blatt (pp. 120–133). New York, NY: Brunner-Routledge.

Cramer, P. (2006). Protecting the self: Defense mechanisms in action. New York. NY: Guilford Press.

Cramer, P. (2008). Identification and the development of competence: A 44-year longitudinal study from late adolescence to late middle age. Psychology and Aging, 23, 410–421.

Cramer, P. (2009a). The development of defense mechanisms from pre-adolescence to early adulthood: Do IQ and social class matter? A longitudinal study.

Journal of Research in Personality, 43, 464–471.

Cramer, P. (2009b). An increase in early adolescent undercontrol is associated with the use of Denial. Journal of Personality Assessment, 91, 331–339.

Cramer, P. (2013). Estudios empiricos sobre mechanismos de defensa [Empirical studies of defense mechanisms]. Subjetividad y Procesos Cognitivos, 17, 97–117.

Cramer, P., & Blatt, S. J. (1990). Use of the TAT to measure change in defense mechanisms following intensive psychotherapy. Journal of Personality Assessment, 54, 236–251.

Cramer, P., & Brilliant, M. (2001). Defense use and defense understanding in children. Journal of Personality, 69, 291–321.

Cramer, P., & Gaul, R. (1988). The effects of success and failure on children’s use of defense mechanisms. Journal of Personality, 56, 729–742.

Cramer, P., & Kelly, F. D. (2004). Defense mechanisms in adolescent conduct disorder and adjustment reaction. Journal of Nervous and Mental Disease, 192, 139–145.

Fenichel, O. (1945). The psychoanalytic theory of neurosis. New York, NY: Norton.

Freud, A. (1936). The ego and the mechanisms of defense. New York, NY: International Universities Press.

Freud, A. (1965). Normality and pathology in childhood. New York, NY: International Universities Press.

Freud, S. (1962). The neuro-psychoses of defence (Standard edition, 1, pp. 206–212).

London, UK: Hogarth Press (Original work published in 1894).

Freud, S. (1961). The ego and the id (Standard edition, 19, pp. 12–66). London, UK: Hogarth Press (Original work published in 1923).

Freud, S. (1959). Inhibitions, symptoms and anxiety (Standard edition, 20, pp. 77– 174). London. UK: Hogarth Press (Original work published in 1926).

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P. Cramer Freud, S. (1964). Analysis terminable and interminable (Standard edition, 23, pp. 216– 253). London, UK: Hogarth Press (Original work published in 1937).

Glover, E. (1937). Symposium on the theory of the therapeutic results of psychoanalysis. International Journal of Psychoanalysis, 18, 125–132.

Hernandez, W. (1999). The use of defense mechanisms among adolescent boys diagnosed as conduct disordered, depressed and normal (Unpublished doctoral dissertation). City University of New York, NY. Hibbard, S., Tang, P.C.-Y., Latko, R., Park, J.-H., Munn, S., Bolz, S., & Sommerville, A. (2000). Differential validity of the defense Mechanism Manual for the TAT between Asian American and whites. Journal of Personality Assessment, 75, 351–372.

Lampl de-Groot, J. (1957). On defense and development: Normal and pathological.

Psychoanalytic Study of the Child, 12, 114–126.

Loewenstein, R. M. (1967). Defensive organization and autonomous ego functions.

Journal of the American Psychoanalytic Association, 15, 75–809.

Porcerelli, J. H., Thomas, S., Hibbard, S., & Cogan, R. (1998). Defense mechanism development in children, adolescents, and late adolescents. Journal of Personality Assessment, 71, 411–420.

Sandstrom, M., & Cramer, P. (2003a). Girls’ use of defense mechanisms following peer rejection. Journal of Personality, 71, 605–627.

Sandstrom, M., & Cramer, P. (2003b). Defense mechanisms and psychological adjustment in childhood. Journal of Nervous and Mental Disease, 191, 487–495.

Soukupová, T., Goldmann, P., & Cramer, P. (2012). Systém hodnocení obranných mechanismu˚ v TAT podle Phebe Cramerové [Defense mechanisms assessment in ˇ ermák, T. Fikarová (Eds.), TematickoTAT according to Phebe Cramer]. In I. C apercepcˇní test: interpretacˇní perspektivy [Thematic Apperception Test: Interpretative Perspectives] (pp. 401–420). Nové Zámky. Slovakia: Psychoprof.

Wallerstein, R. S. (1967). Development and metapsychology of the defense organization of the ego. Journal of the American Psychoanalytic Association, 15, 130–149.

Wallerstein, R. S. (1985). Defenses, defense mechanisms, and the structure of the mind. In H. P. Blum (Ed.), Defense and resistance (pp. 201–225). New York, NY: International Universities Press.

Phebe Cramer Department of Psychology Williams College Williamstown, MA 01267 USA Tel. +1 413 597-2463 Fax +1 413 597-2085 E-mail phebe.cramer@williams.edu

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IQ, TAT, and Defenses

Summary Contemporary psychoanalytic theory recognizes that defense mechanisms may be used to control for anxiety and guilt associated with unacceptable impulses and thoughts, and also may be used to protect self-esteem. Defenses may be associated with psychopathology, but are also understood as part of normal development.

A method for coding the presence of three defense mechanisms, as revealed in TAT stories, is described. The defenses of Denial, of Projection, and of Identification are each represented by seven subcategories that represent different ways in which the defense may be manifest. Evidence for reliability and validity is provided. Several example stories are given, showing how defense use in psychiatric patients changes after treatment, and how defense use changes across childhood and adolescence.

The remainder of the paper focuses on the issue of the relation between defense mechanisms and IQ. Research has shown that IQ moderates the effect of defense mechanisms in predicting personality and personality change. For adults from the general population, for those with lower IQs, the use of defenses supports higher and more positive levels of adaptation, as seen in level of Ego development and Big 5 personality traits. This positive effect is not found for high IQ individuals.

It appears that defense use helps to compensate for lower intellectual ability.

However, in psychiatric patients, the relation between defense use and IQ for predicting personality change was reversed. For high IQ patients, defenses functioned to control pathology. For lower IQ patients, the use of defenses strengthened their pathological symptoms. After treatment, a decrease in defense use of lower IQ patients was associated with a decrease in symptoms. These disparate findings may be reconciled by the observation that, for lower IQ individuals, defenses serve to support the existing personality structure, either healthy or pathological.

Résumé Les théories psychanalytiques contemporaines postulent que les mécanismes de défenses servent à contrôler l’angoisse et la culpabilité associées à des pensées et pulsions indésirables, mais servent aussi à protéger l’estime de soi. Les défenses peuvent être associées à la psychopathologie mais elles font aussi partie du développement normal. Cet article présente une méthode de cotation de la présence de mécanismes de défenses dans des protocoles de TAT. Les mécanismes de déni, projection, et identification sont représentés grâce à sept sous-catégories qui permettent de rendre manifestes ces mécanismes. Les preuves de validité et de fidélité sont discutées. Plusieurs exemples de protocoles illustrent comment ces mécanismes changent chez des patients psychiatriques après traitement, et comment ils changent de l’enfance à l’adolescence.

La deuxième partie de cet article porte sur la relation entre mécanismes de défense et QI. Des études ont montré comment le QI modère l’effet des mécanismes de défense et peut prédire les changements au niveau de la

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P. Cramer personnalité. Chez les adultes de la population générale et les personnes au QI bas, les mécanismes de défenses soutiennent un niveau d’adaptation plus élevé et plus positif, comme observé par le niveau du développement du moi et au Big 5. Cet effet positif n’est pas observé chez des individus au QI élevé. Il semble que les défenses peuvent servir à compenser un niveau intellectuel plus bas. Cependant, la relation entre mécanismes de défense et QI est inversée chez les patients psychiatriques. Le QI est utilisé pour contrôler la pathologie chez les personnes à haut potentiel. Pour les personnes à QI moins élevé, les défenses renforcent les symptômes pathologiques. On observe une baisse des défenses après traitement, associée à une baisse des symptômes chez ces derniers. Les résultats pourraient indiquer que les mécanismes de défenses chez les personnes à QI bas servent à soutenir la structure de la personnalité normale ou pathologique.

Resumen La teoría psicoanalítica contemporánea reconoce que los mecanismos de defensa se utilizan para controlar la ansiedad y la culpa conectadas a ideas o impulsos inaceptables, y también se usan para proteger la autoestima. Es decir, las defensas pueden ir asociadas a psicopatología pero también se entienden como formando parte del desarrollo normal. Se describe aquí un método de codificación de la presencia de tres mecanismos, según se revelan a través de las historias que el sujeto elabora en el TAT. Las defensas de Negación, Proyección e Identificación, se representan en siete subcategorías que indican diferentes modos de manifestación de las mismas. Se ofrecen evidencias de fiabilidad y validez y varios ejemplos de historias, mostrando cómo se utilizan las defensas en pacientes psiquiátricos tras el tratamiento y cómo el uso de las defensas cambia a lo largo de la infancia y la adolescencia.

El resto del trabajo se centra en el tema de las relaciones entre los mecanismos defensivos y el CI. Los datos de investigación señalan que el CI modula el efecto de los mecanismos de defensa en la predicción de la personalidad y sus cambios. Entre adultos de la población general, en aquellos con CI más bajo, el uso de las defensas parece mantener rangos más elevados de adaptación, como se observa en el nivel de desarrollo del Ego y en los 5 Grandes Rasgos de personalidad. Este efecto positivo no aparece en los sujetos con CI alto. Estos datos indican que el uso de defensas ayuda a compensar la presencia de menores habilidades intelectuales. Sin embargo, en pacientes psiquiátricos, la relación entre uso de defensas y CI para predecir cambios de personalidad es la inversa. En pacientes con CI alto, las defensas parecen ayudar a controlar la patología. En pacientes con CI bajo, el uso de las defensas parece fortalecer los síntomas patológicos. En cambio, después del tratamiento, la disminución del uso de defensas en pacientes con CI bajo se asocia con la disminución de los síntomas. Estos hallazgos contradictorios deben integrarse con la observación de que, en individuos con CI bajo, las defensas pueden servir para mantener la estructura de personalidad existente, sea ésta saludable o patológica.

56

IQ, TAT, and Defenses

要約 現代精神分析理論では、防衛機制は受け入れることが困難な衝動や思考に関連している 不安や罪悪感をコントロールするのに用いられるものであり、同時に自己評価を保護するた めに用いられると認識している。防衛はおそらく精神病理と関連しているが、同時に正常な発 達の一部としても理解することが可能である。TAT 物語にあらわれる３つの防衛の存在を コードする方法が記述されている。否認、投影、同一化の防衛が、それぞれ防衛が明白 に存在している異なった方法で明らかである７つの下位カテゴリーによってあらわされる。確 かな信頼性と妥当性がそなわっていた。精神科の患者が治療後にどのような防衛をもちいるよ うになったか、児童期と思春期で防衛がどのように変わるかについて示す、いくつかの物語の 例が提示されている。 本論文の残りの部分は防衛機制と IQ の関連の問題に焦点が当てられている。防衛機制 がパーソナリティやパーソナリティの変化を予測する効果を IQ が抑制することが調査によって示さ れている。一般人口の成人にとって、 IQ の低い人々にとって、防衛の使用は自我発達のレ ベルや Big Five のパーソナリティ特性にあらわされるような、高度でポジティヴな適応のレベル を支えている。この正の関係性は IQ の高い人々には認められなかった。防衛の使用は、低 い知的能力を補う助けになるようである。しかしながら、精神科の患者においては、パーソナリ ティの変化を予想する防衛の使用と IQ の関係性は逆転する。 IQ の高い患者にとって防衛は 病理をコントロールする機能がある。 IQ の低い患者にとっては、防衛は彼らの病理症状を強 める。治療ののち、 IQ の低い患者にとって防衛の減少は症状の減少と関連していた。この異 なった発見は、 IQ の低い人々にとって防衛は、健康的であれ精神病的であれ、存在する パーソナリティ構造を支えることに貢献することの観察と一致しているであろう。

57

Rorschachiana 36, 58â&#x20AC;&#x201C;81 Š 2015 Hogrefe Publishing

DOI: 10.1027/1192-5604/a000057

Special Section: The TAT and Other Storytelling Projective Methods Original Article

External Validity of SCORS-G Ratings of Thematic Apperception Test Narratives in a Sample of Outpatients and Inpatients Michelle B. Stein1, Jenelle Slavin-Mulford2, Caleb J. Siefert3, Samuel Justin Sinclair1, Michaela Smith1, Wei-Jean Chung1, Rachel Liebman1, and Mark A. Blais1 1

Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA, 2 Georgia Regents University, Department of Psychology, Augusta, GA, USA, 3 University of Michigan-Dearborn, Dearborn, MI, USA

Abstract. The Social Cognition and Object Relations Scale-Global Ratings Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker-Aspen, 2011) is a reliable system for coding narrative data, such as Thematic Apperception Test (TAT) stories. This study employs a cross-sectional, correlational design to examine associations between SCORS-G dimensions and life events in two clinical samples. Samples were composed of 177 outpatients and 57 inpatients who completed TAT protocols as part of routine clinical care. Two experienced raters coded narratives with the SCORS-G. Data on the following clinically relevant life events were collected: history of psychiatric hospitalization, suicidality, self-harming behavior, drug/ alcohol abuse, conduct-disordered behavior, trauma, and education level.

As expected, the clinical life event variable associated with the largest number of SCORS-G dimensions was Suicidality. Identity and Coherence of Self was related to self-harm history across samples. Emotional Investment in Relationships and Complexity of Representations were also associated with several life events. Clinical applications, limitations of the study, and future directions are reviewed.

Keywords: Thematic Apperception Test, performance-based tasks, narrative data

58

SCORS-G,

clinical

history,

External Validity and TAT

Object relations (OR) theory focuses on how representations for self and others develop and influence functioning (Blatt, 2008; Kernberg, 1984).

An individual’s object-relational world begins in infancy, and internal representations forming the basis of OR develop (i.e., become more complex and integrated) as the result of both maturational processes and life experiences. In adulthood, internal OR impact relations with others, self-view, and how one makes sense of events in the world. As such, clinicians often seek to determine the overall quality of a patient’s OR and identify deficits and areas of strength.

A number of measures for assessing OR exist (see Huprich & Greenberg, 2003). Many are self-report inventories, although some involve rating narratives. Narratives (e.g., psychotherapy sessions; stories) often contain rich, nuanced data that can be particularly useful for conceptualizing OR. The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & PinskerAspen, 2011; Westen, 1995) is one such system useful for rating OR from patient narratives. Research to date suggests that the SCORS-G can be rated reliably and has promising clinical utility. Only a handful of studies link the SCORS-G to clinically relevant life event variables (e.g., history of suicide attempts, trauma).

Establishing associations between the SCORS-G and life events of clinical import would further demonstrate the construct validity of the tool by showing that it taps OR constructs in a theoretically consistent and clinically meaningful manner. OR theories postulate that maladaptive OR increase a person’s vulnerability to various challenges and difficulties.

Likewise, negative life experiences (e.g., trauma) can contribute to the development or maintenance of maladaptive OR. If this is the case, then OR measures, like the SCORS-G, should be associated with the experience of difficulties in life, regardless of whether maladaptive OR are the cause or the result of such challenges. The present study examines the relationship between the SCORS-G dimensions and clinically relevant life events variables. This is the first study that simultaneously examines relationships between SCORS-G dimensions and clinical correlates within both an inpatient and outpatient sample. Examining such a wide array of relationships prevents us from focusing on any single area (e.g., trauma; self-harm; substance abuse) in great detail. Rather, we simultaneously explore and identify relationships that can be examined in greater detail by future investigators.

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The Social Cognition and Object Relations Scale-Global Rating Method The SCORS-G is an expanded version of the Social Cognition and Object Relations Scale (SCORS; Westen, Barends, Leigh, Mendel, & Silbert, 1990; Westen, Silk, Lohr, & Kerber, 1985). As the name implies, the SCORS was developed to provide clinicians with a tool for rating cognitive and affective dimensions of OR (Stein, Slavin-Mulford, Sinclair, Siefert, & Blais, 2012; Westen, 1995). The SCORS was initially developed for use with borderline personality disorder populations. Over time, however, use of the SCORS expanded to other populations. The SCORS-G extended the SCORS, by including additional dimensions to capture a wider range of OR functions in an effort to increase the measure’s usefulness with a wider array of clinical populations.

Table 1. Example scoring of TAT narrative Sara Grace is sobbing in her bedroom. Her boyfriend just broke up with her. She really cared about him and thought she was a wonderful girlfriend, but apparently that wasn’t enough.

She just wasn’t good enough. She sulks and wonders if she can ever find anyone who can love her. She is embarrassed at how upset she is over this. She struggles between wanting him back and hating him. That’s all.

Variable Rating

Explanation

COM

4

Internal experience (i.e., thoughts) regarding the break-up is described in a detailed way and there was an oscillation between loving and hating him (i.e., identification of conflict). However, understanding of the break-up is not very sophisticated and there is no mention of the boyfriend’s internal states.

AFF

3

The break-up is a negative and painful experience and there is no mention or indication of abuse and/or malevolence.

EIR

2

Sara Grace cares about ex-boyfriend and is invested in him; however, given that his thoughts and feelings are not mentioned in combination with the break-up, her action and concern regarding limited relationships in the future, this is given a score of 2.

EIM

4

Morals or values are not mentioned in this narrative and given a default score of 4.

SC

4

The coherence and flow of this narrative is intact. There are few gaps.

AGG

3

Sara Grace describes “hating” her ex-boyfriend, which is a description of angry feelings.

SE

2

Sara Grace feels inadequate and is self-denigrating. On a deeper level, she feels unlovable.

ICS

3

Feelings about herself as well as what she wants from relationship vary widely and are unstable.

60

External Validity and TAT

The SCORS-G is composed of eight dimensions: Complexity of Representations of People (COM), Affective Quality of Representations (AFF), Emotional Investment in Relationships (EIR), Emotional Investment in Values and Moral Standards (EIM), Understanding of Social Causality (SC), Experience and Management of Aggressive Impulses (AGG), SelfEsteem (SE), and Identity and Coherence of Self (ICS; for a thorough description of SCORS-G dimensions, see Stein et al., 2011 and Westen, 1995). All dimensions are rated along 7-point scales; lower scores indicate more pathological and maladaptive functioning and higher scores indicating more mature and adaptive functioning (refer to Table 1 for scoring example).

Of the eight dimensions, five (COM, EIR, EIM, SC, and AGG) “measure developmental aspects of object relations and social cognition” (Westen et al., 1985, p. 9). OR theory holds that representations become more complex and integrated as individuals move through a series of developmental stages. Maturing representations give rise to more adaptive ways of functioning. Representations in infancy are simplistic and poorly integrated, resulting in more limited and immature functioning. In infancy, this is considered developmentally appropriate. With cognitive development, children’s representations become increasingly complex and integrated throughout the journey to adulthood, culminating in more adaptive functioning.

The five developmental dimensions of the SCORS-G are organized such that low ratings are given for functioning associated with less mature (i.e., earlier) stages, whereas higher scores are given when functioning is consistent with more mature (i.e., later) stages. We consider the EIR scale as an example. A score of 1 indicates functioning similar to an infant (e.g., highly dependent; one-directional relationships), while an EIR score of 3 would indicate more child-like capacities (e.g., room for some autonomy; but limited reciprocity). Higher scores (e.g., 6) indicate more mature functioning, such as greater capacity and desire for interdependent relationships with others that involve both give and take. If, in adulthood, one continues to operate from a need gratification, nonreciprocal stance, this would garner very low EIR ratings. For adults, this level of functioning would be considered developmentally inappropriate, problematic, and suggestive of a need for intervention. The three remaining dimensions (AFF, SE, and ICS) are also based on a continuum from maladaptive to adaptive aspects of object relational functioning; however, they do not necessarily follow a developmental trajectory.

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M. B. Stein et al.

Life Events and Object Relations Life event data refer to information related to major life outcomes, such as education level, marital status, employment, health status, psychiatric history, and legal history. This information can be obtained from an individualâ&#x20AC;&#x2122;s life history or from formal historical records (Block & Block, 1980; John & Soto, 2007). These life data are especially relevant to clinicians given their relation to treatment utilization and complexity of treatment. In our study, we chose two types of life event variables: (1) variables that have been used in SCORS-G literature to date (i.e., in an attempt to replicate previous findings), and (2) variables that have not been examined in relation to the SCORS-G (to better understand underlying processes), but are considered important in clinical settings and are common among high treatment utilizers. Also, we chose to examine two samples to assess the extent to which patterns were ubiquitous across functional severity and treatment setting. We review prior research and derive hypotheses from previous findings for the present study.

Psychiatric Severity and Problems in Adaptation Number of psychiatric hospitalizations and suicide attempts are two life event variables reflecting psychiatric severity. Given that psychopathology impacts oneâ&#x20AC;&#x2122;s ability to understand, regulate, and navigate self and relationships, we hypothesize that life events associated with psychiatric severity will be related to less adaptive overall OR. We expected number of hospitalizations would be negatively associated with SCORS-composite.

Multiple studies link suicidality to disruption across several SCORS-G dimensions, particularly AGG, SE, and ICS (Damsky & Ackerman, 2013; Lewis, 2013). Thus, we expected suicidality to be linked to lower composite scores and to AGG, SE, and ICS. Self-harming behaviors can be indicative of both psychiatric severity and problems adapting and coping. Previous OR research (Clemence, 2013; Damsky & Ackerman, 2013; Whipple & Fowler, 2011) suggests that self-harm is associated with a complex pattern of underlying dynamics (i.e., feelings about self, affect/anger modulation, personal meanings of self-harming behavior, interplay between self-harming and status of current relationships, etc.). Thus, we expected history of self-harm to be negatively related to a number of SCORS-G dimensions. Problems with substance abuse and aggression can also suggest difficulties in adapting 62

External Validity and TAT

and psychiatric severity. Given limited empirical literature (DeFife, Goldberg, & Westen, 2013), correlations between SCORS-G dimensions, alcohol/drug abuse, and conduct-disordered behavior are exploratory.

History of Childhood and Adult Trauma Trauma can impact personality functioning (Blatt, 2008; Kernberg, 1984).

The impact of trauma may vary as a function of the nature of the trauma (e.g., physical or sexual) and when in development the trauma occurred (e.g., childhood or adulthood). Trauma in childhood may have a more disruptive impact on underlying domains of personality functioning. Previous studies have examined OR within adult populations with trauma histories (Callahan, Price, & Hilsenroth, 2003; Ortigo, Westen, DeFife, & Bradley, 2013; Porcerelli & Cogan, 2014; Price, Hilsenroth, Callahan, PetreticJackson, & Bonge, 2004; Slavin, Stein, Pinsker-Aspen, & Hilsenroth, 2007). Therefore, consistent with the literature, we hypothesized that those reporting childhood trauma will exhibit lower ratings on feelings about (AFF) and understanding of others (SC), as well as poorer self-worth (SE).

Level of Education This is the only life event variable included in this study involving simple demographic information. This variable was included because higher levels of education are more cognitively demanding, and require greater cognitive flexibility and capacity for abstract reasoning. Thus, an individualâ&#x20AC;&#x2122;s level of educational achievement can serve as a rough index of certain cognitive capacities. For example, level of education has been related to IQ scores (e.g., Stein et al., 2012). Cognitive flexibility and capacity for abstract reasoning are tapped by SCORS-G dimensions associated with cognition, such as COM and SC (Stein et al., 2012). We hypothesized that level of education would be associated with more adaptive ratings of these two dimensions.

Method Participants Participants were 234 (177 outpatient and 57 inpatient) patients obtaining treatment from the psychiatry department at an academic medical 63

M. B. Stein et al.

center in the northeastern United States. We included both an outpatient and inpatient sample, in part, to examine associations across levels of severity. Further, studying the SCORS-G in naturalistic, clinical samples is important for demonstrating that the tool can tap clinically relevant constructs within the settings in which it is likely to be used.

Our outpatient and inpatient sampleâ&#x20AC;&#x2122;s average age of was 40 (SD = 15) and 36 (SD = 14.1) years for outpatients and inpatients, respectively.

Regarding education, on average, outpatients possessed 14.6 (SD = 2.8) years of education, while inpatients possessed and 13.7 (SD = 2.9). In both samples, there were slightly more males (54% male [outpatient]; 57% male [inpatient]). Patients were predominately single (60% [outpatient]; 61% [inpatient]). In both samples, patients were primarily Caucasian (87% [outpatient]; 81% [inpatient]) with 3.9% (outpatient) and 1.7% (inpatient) self-identifying as African American, 1.7% (outpatient) and 10.2% (inpatient) as Asian, and 4.4% (outpatient) and 8.2% (inpatient) as Hispanic. In our outpatient sample, the most common referral diagnoses were depressive disorder (43%), anxiety disorder (17%), and bipolar disorder (16%). In our inpatient sample the most common referral diagnoses were depressive disorder (47%), psychotic disorder (18%), and bipolar disorder (13%). Both outpatients and inpatients tended to possess multiple diagnoses, have a complex clinical picture, and were referred for a diagnostic clarification.

Materials and Measures Thematic Apperception Test (Murray, 1943) Outpatient participants completed a standard TAT protocol as part of their routine clinical assessment. This protocol includes Cards 1, 2, 3BM, 4, 13MF, 12M, and 14. Psychiatric inpatients were administered an abbreviated protocol involving Cards 1, 2, 3BM, and 14. After administration, narratives were transcribed and de-identified. However, to make our samples more comparable and less susceptible to differences in card pull (see Stein et al., 2014), we only used ratings for the cards that were consistent across samples (i.e., Cards 1, 2, 3BM, and 14). Two expert raters (see Stein et al., 2012, 2014) who previously completed manualized training on the SCORS-G (Stein et al., 2011) scored all TAT narratives.

64

External Validity and TAT

Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein et al., 2011; Westen, 1995) The SCORS-G contains eight dimensions underlying ORs. COM evaluates the presence, degree, and differentiation of internal states/peopleâ&#x20AC;&#x2122;s personalities and relational boundaries. AFF examines the emotional lens through which a person views his/her environment. This includes both the emotional tone as well as how significant relationships are described/perceived in narratives. EIR assesses the depicted level of intimacy and emotional sharing. EIM measures how a person views others and acts in relation to morality and compassion for others. SC evaluates the extent to which the person understands human behavior as well as the narrativeâ&#x20AC;&#x2122;s coherence, logic, and reasoning. AGG explores the personâ&#x20AC;&#x2122;s ability to tolerate and manage aggression. And, SE and ICS assess self-worth as well as the degree to which a person has an integrated sense of who he/she is.

Life Event Data This study gathered information for 14 life/clinical event variables. They included: number of psychiatric hospitalizations and suicide attempts as well as history of suicidal ideation, self-harm, alcohol and drug abuse, homicidal ideation, violence, arrest, childhood sexual abuse, childhood physical abuse, adult physical abuse and adult sexual abuse, and lastly level of education.

Procedure This study involved a retrospective, chart-review design. Our assessment clinic maintains a data repository approved by the institutional review board. This repository contains all assessment and demographic data for all evaluations conducted. All evaluations include a semi-structured clinical interview, as well as a standard battery composed of self-report measures of personality and psychopathology, a TAT protocol, and neuropsychological measures. Data from this repository were used to create a database containing the life event data and SCORS-G ratings for use in this study.

65

M. B. Stein et al.

Table 2. Interrater reliability of the Social Cognition and Object Relations ScaleGlobal Rating Method (SCORS-G) dimensions for outpatient (1,312 TAT narratives) and inpatient (344 TAT narratives) Outpatient sample Dimension

M

SD

ICC(1)

Inpatient sample

ICC(2, 2)

α

M

SD

ICC(1)

ICC(2, 2)

α

COM

3.25

.66

.67

.80

.80

3.06

.90

.73

.84

.84

AFF EIR

3.49 2.83

.55 .64

.79 .76

.89 .87

.89 .87

3.38 2.75

.68 .68

.85 .79

.92 .88

.92 .88

EIM

3.79

.34

.74

.85

.85

3.79

.44

.79

.89

.89

SC

3.02

.72

.68

.81

.81

2.80

.91

.69

.82

.82

AGG

3.68

.39

.79

.88

.88

3.55

.48

.71

.83

.83

SE

3.83

.35

.66

.80

.80

3.89

.32

.64

.78

.78

ICS

4.58

.51

.71

.83

.83

4.50

.47

.75

.86

.86

Composite

3.56

.36

.72

.84

.84

3.47

.41

.74

.85

.85

Note. ICC = intraclass correlation coefficient; (1) = Model 1, one-way random effect; (2, 2) = Model 2, 2 raters, Spearman−Brown correction for two-way random effect; COM = Complexity of Representations of People; AFF = Affective Quality of Representations; EIR = Emotional Investment in Relationships; EIM = Emotional Investment in Values and Moral Standards; SC = Understanding of Social Causality; AGG = Experience and Management of Aggressive Impulses; SE = Self-Esteem; ICS = Identity and Coherence of Self.

Results SCORS-G Reliability Reliability rates for SCORS-G dimensions are shown in Table 2. Intraclass correlation coefficients (ICCs) were used to calculate SCORS-G ratings of TAT narratives. We calculated ICC (1) and the Spearman–Brown corrected two-way random effects model (2, 2). Shrout and Fleiss (1979) reported the magnitude for interpreting ICC values in which poor = < .40, fair = .40–.59, good = .60–0.74, and excellent = > 0.74. ICC (1) fell in the good to excellent range and ICC (2, 2) fell in the excellent range across samples.

The SCORS-G ratings of TAT narratives were highly reliable.

Group Differences We employed independent t tests to examine differences across groups for SCORS-G dimensions, education, as well as number of hospitalizations and suicide attempts. Our inpatient group exhibited lower AGG scores, 66

External Validity and TAT

F(1, 220) = 4.19, p = .04. With regard to life history variables, inpatients reported significantly more suicide attempts, t(231) = 16.11, p < .00, and number of hospitalizations, t(231) = 40.97, p < .00, than did outpatients.

For the dichotomous variables, we used χ2 tests to examine group differences. Inpatients more frequently endorsed a history of self-harm than outpatients did (χ2 = 10.73, p < .00). Outpatients more frequently endorsed history of adult sexual abuse than inpatients did (χ2 = 4.82, p = .03).

Due to incomplete or missing data, sample sizes for comparisons vary from 96 to 163 in the inpatient sample and 42 to 55 for the inpatient sample. For most variables, there was a reasonable distribution of endorsement rates. However, in our inpatient sample, we excluded adult sexual abuse due to low endorsement rates.

SCORS-G and Life Event Data Bivariate correlations were used to examine relationships between the SCORS-G dimensions and clinically relevant life event variables. Given the nature of cross-method assessment and to protect against spurious findings, we set two critical values for reporting results. We only discuss statistically significant (i.e., p ≥ .05) correlations with effect sizes of ≥ .20. Such magnitudes reflect at least small to moderate effects.

As can be seen in Table 3, nearly all the life event variables evidenced a correlation in the expected direction with a SCORS-G dimension.

The EIR and COM dimensions were associated with the largest number of life event variables. We discuss correlates of each life event variable in the following sections.

Psychiatric Severity and Problems in Adaptation We expected number of psychiatric hospitalizations to be associated with maladaptive ORs (i.e., SCORS-G composite). In our outpatient sample only, number of hospitalizations was negatively associated with the SCORS-G composite (r = −.26, p < .01), as were the COM (r = −.20, p = .01) and EIR (r = −.21, p = .01) dimensions. No associations were significant for the inpatient sample.

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M. B. Stein et al.

Table 3. Findings and correlations by SCORS-G variable Life event

COM

AFF

Alc abuse#

EIR

EIM

SC

AGG

SE

ICS

Total

−0.22*

Arrest# −0.22*

−0.22*

Suicide attempts Self-harm#

−0.23*

−0.20*

−0.20*

−0.21*

−0.34! −0.30!

−0.20* −0.38!

Drug abuse#

−0.20* −0.20* −0.28!

Psychiatric hosp

−0.20*

−0.21*

−0.26*

Childhood sex abuse# −0.22*

−0.20*

Childhood Phy abuse#

−0.20* −0.33!

Adult Phy abuse# −0.27*

Suicidal ideation#

−0.28* −0.35* −0.26* −0.22*

−0.29!

Homicidal ideation#

0.29!

Education

0.24*

−0.30! −0.25* 0.22*

*

= Outpatient; ! = Inpatient; COM = Complexity of Representations of People; Note.

AFF = Affective Quality of Representations; EIR = Emotional Investment in Relationships; EIM = Emotional Investment in Values and Moral Standards; SC = Understanding of Social Causality; AGG = Experience and Management of Aggressive Impulses; SE = Self-Esteem; ICS = Identity and Coherence of Self; Total = SCORS-G Composite Score; Alc Abuse = Alcohol Abuse; Psych Hosp = Number of Psychiatric Hospitalizations; Childhood Phy Abuse = History of Childhood Physical Abuse; Adult Phy Abuse = History of Adult Physical Abuse; Education = Level of Education. #Point biserial (rpb) correlations.

We hypothesized that suicidality would be associated with more maladaptive ORs overall (SCORS-composite) and we expected suicidality to be associated with the largest number of SCORS-G dimensions. In addition, we anticipated obtaining specific associations with dimensions emerging in prior studies (AGG, SE, and ICS). In our outpatient sample, history of suicidal ideation was negatively correlated with the SCORS-G composite (r = −.22, p = .01). We also found associations between history of suicidal ideation and the following dimensions: AFF (r = −.27, p = .01), AGG (r = −.28, p = .01), SE (r = −.35, p = .01), and ICS (r = −.26, p = .01). Number of suicide attempts was also inversely associated with the SCORS-G composite (r = −.20, p = .01), and specifically linked to the SC (r = −.20, p = .01).

In our inpatient sample, relationships emerged between the SCORS-G, number of suicide attempts, and history of suicidal ideation. Although unrelated to overall ORs, history of suicidal ideation was negatively correlated with AFF (r = −.29, p = .04), and AGG (r = −.30, p = .02). Association with SE 68

External Validity and TAT

trended toward significance (r = −.24, p = .07). Number of suicide attempts was inversely related to AFF (r = −.34, p = .01), EIR (r = −.30, p = .03), and AGG (r = −.38, p < .01).

We hypothesized that history of self-harm would be negatively associated with a number of SCORS-G dimensions. This was not supported. ICS was negatively correlated with history of self-harm across outpatient (r = −.20, p = .01) and inpatient (r = −.28, p = .05) samples. There was a negative trend in terms of the relationship for self-harm and AFF in our inpatient sample (r = −.24, p = .08).

Our hypotheses regarding alcohol and drug abuse were exploratory.

In our outpatient sample, history of alcohol abuse was negatively related to the SCORS-G Composite (r = −.20, p = .01) and the following dimensions: COM (r = −.22, p < .01), EIR (r = −.22, p = .01), and SC (r = −.23, p = .01).

History of drug abuse was negatively associated with EIR (r = −.20, p = .01) and AGG (r = −.21, p = .01). No significant associations were obtained in the inpatient sample.

Our hypotheses regarding conduct disordered behavior were also exploratory. In our outpatient sample, history of arrest was negatively related to EIR (r = −.22, p = .01) and history of homicidal ideation was negatively correlated with EIM (r = −.25, p ≤ .01). In our inpatient sample, homicidal ideation was positively related to COM (r = .29, p = .04) and trended toward significance with SC (r = .27, p = .06). No significant correlations were found with history of violence in either sample.

History of Childhood and Adult Trauma We hypothesized that patients endorsing childhood trauma would have lower, more pathological SCORS-G ratings on AFF, SC, and SE. This was not supported. However, in the outpatient sample, childhood sexual abuse was negatively related to COM (r = −.22, p = .03) and EIM (r = −.20, p = .05). Childhood physical abuse was also negatively correlated with EIM (r = −.20, p = .05). There was also a trend toward significance between EIM and adult physical abuse (r = .20, p = .05). In the inpatient sample, adult physical abuse was negatively related to AGG (r = −.33, p = .03).

Level of Education We hypothesized that education level would be positively associated with COM and SC. This was supported in our outpatient sample: COM 69

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(r = .24, p = .01) and SC (r = .22, p = .01). In our inpatient sample, associations between education level with COM (r = .25, p = .08) and SC (r = .27, p = .06) only trended toward significance.

Discussion The present study assessed the relationship between patientsâ&#x20AC;&#x2122; OR and a range of life event variables of clinical import. SCORS-G dimensions were modestly connected to several real-world events in our clinical samples.

This suggests that SCORS-G dimensions tap into something that is also impacted by events that are clinically relevant. Our findings are also counter to the arguments suggesting that narratives produced in response to TAT cards say very little about the person producing the narrative. If this were true, then associations between narrative ratings and life events should be distinctly lacking. We did not find this to be the case.

We coded an array of life event variables related to psychiatric severity and treatment utilization (i.e., number of hospitalizations; suicide attempts) and problems in adaptation (i.e., alcohol and drug abuse, homicidal and suicidal ideation, history of arrest and self-harm). We also included life events that may arrest the maturational process and/or negatively impact internal representations resulting in more maladaptive ways to relating to self and others (i.e., history of childhood trauma). Finally, demographic information expected to be associated with cognitive dimensions of the SCORS-G (i.e., COM and SC) were also included (i.e., level of education).

With regard to psychiatric severity, number of hospitalizations and frequency of suicide attempts were both associated with more global pathology as evidenced by the SCORS-G composite score. This is consistent with OR theory, which holds that more maladaptive and immature internal representations should correspond to greater problems relating to the self and others. At times, such deficits may impair functioning to a point that requires notable external support (i.e., hospitalization). On other occasions, such deficits may manifest as rather extreme, maladaptive attempts to cope with distress (i.e., suicide attempts). Thus, when patients produce low SCORS-G composite, clinicians should be aware that the patient may be currently experiencing or have previously experienced significant difficulties functioning or coping with distress.

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The pattern of OR dimensions related to hospitalization suggests a nuanced relationship. As numbers of hospitalizations increase, patients describe characters in more simplistic, polarized, and need-driven ways.

One would imagine that as severity increases, it becomes exceedingly more challenging to think complexly about self and others (COM) and it is easier to feel more consumed by oneâ&#x20AC;&#x2122;s emotional experience (i.e., harder to take perspective). The ability to independently soothe oneself is lessened (EIR), hence the need for more acute care.

Among the life event variables, history of suicidal ideation and number of suicide attempts were related to the most SCORS-G dimensions. COM and EIM were the only dimensions unrelated to these variables. These findings suggest that suicidality is associated with more disruption across cognitive, emotional, and self/other functioning than other life history variable studied. When one considers specific dimensions, outpatients and inpatients endorsing a history of suicidal ideation produced TAT narratives that were more malevolent (AFF), described others in more hostile ways, exhibited less modulated aggression (AGG), and had lower selfworth (SE) than those patients who had no history of suicidal ideation.

In our inpatient sample, AFF and AGG were also significantly negatively related to number of suicide attempts. Patients who endorse ideation and/or have a history of attempts appear to view themselves and/or others in negative and painful ways, anticipate hostility, and struggle to control aggressive impulses. Patients who do not view others as a source of comfort and support, and who may even see them as a source of danger or distress, are unlikely to turn to others for aid in times of need. Further, difficulties regulating feelings of anger or aggression may contribute to hostile interpersonal interactions that may trigger or exacerbate distress.

When such qualities are paired with negative self-views and doubt regarding personal efficacy, the problems causing distress may be experienced as insurmountable and overwhelming. In such cases, suicide may seem a viable means for alleviating distress relative to other options (e.g., talking to others; trusting oneâ&#x20AC;&#x2122;s self).

Previous research on self-harm consistently links self-harm to more maladaptive OR; however, the specific dimensions implicated vary across studies (Clemence, 2013; Damsky & Ackerman, 2013; Whipple & Fowler, 2011). In our study, history of self-harm was negatively associated with identity diffusion (ICS). In inpatients, there was a trend toward greater painful affective tone and other people were described more harshly (AFF). This is consistent with theoretical understandings of self-injury 71

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as a way to regulate aspects of self (Kernberg, 1984) as well as emotional states (Linehan, 1993) through some external force.

To our knowledge, this is one of the first studies to examine aspects of self/other functioning (via SCORS-G ratings) in people with a history of alcohol and drug abuse. Outpatients with a history of alcohol abuse produced narratives lower in overall quality of OR. Their narratives tended to be concrete and simplistic (COM), with limited capacity to provide coherent accounts of social interactions and charactersâ&#x20AC;&#x2122; thought processes (SC). Characters within narratives showed limited capacity for investing in relationships with others; interactions tended to be more need-driven and less reciprocal (EIR). Clinically, people suffering from alcohol abuse have difficulties focusing on their emotional world (Thorberg, Young, Sullivan, & Lyvers, 2009) and this is perhaps captured in this study by their minimalistic responses to the TAT. As with self-harm, there is a known association between self-regulation and alcohol abuse (Graham & Glickauf-Hughes, 1992). Likewise, patients with a history of drug use described characters that used others or objects for regulatory functioning (EIR). There were no significant differences in aspects of cognition, but rather in response to feelings/management of aggression.

While this study serves to establish connections between SCORS-G dimensions and substance abuse, it is important that future studies examine these associations in greater detail.

With regard to conduct-disordered behavior, outpatients with a history of arrest were more need driven and felt less of an investment in others (EIR). One way to understand these findings with regard to history of arrest is that the underlying motivation that is evoked in individuals with an arrest history is as an imbalance in terms of external need for gratification and connection with others. The need to gratify needs appears to exceed the desires to invest and connect with others. In fact, others may be viewed more as avenues to need-gratification. Those endorsing history of homicidal ideation produced narratives where characters were less considerate, exhibited less empathy or remorse, and overall were less compassionate about others (EIM). Perhaps individuals with less developed internal standards for governing interpersonal behavior are more willing to consider violence toward others as an avenue for resolving conflicts.

Together, these findings would suggest that the motivation to harm others at times may be stronger than the concerns about the well-being of others, especially when internalized moral standards are limited. In our inpatient sample, homicidal ideation was positively correlated with COM. One possibility for this latter finding may be because of our unique 72

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sample. Patients who endorse homicidal ideation and are referred for diagnostic clarification may have more intact thought process than those being referred for clarification surrounding inefficiencies in thinking (psychosis). Another possibility is that patients endorsing homicidal ideations are more focused on others and as such describe internal states more readily. There is less fusion and more separateness (perhaps more externalization) of characters. More specifically, inpatients experiencing homicidal ideations are more aware of and can verbalize emotionally laden thoughts, feelings, and/or urges than those who do not endorse history of homicidal ideation. They are more likely to describe how they have been impacted by other people or how other people have impacted them (albeit likely negatively). In contrast to self-harm or suicidal ideation, experiencing homicidal ideations implies a focus on an “other.”

Being able to focus on these thoughts, feelings, and/or urges of both self and other are captured in COM. Group differences were more prominent with history of trauma. Outpatients endorsing a history of childhood sexual abuse produced narratives where internal states were more polarized (e.g., good/bad) and there was increased fusion between characters (COM). EIM was negatively related to childhood sexual and physical abuse and positively related (trend) to adult physical abuse. In the narratives of those reporting childhood trauma, characters tended to behave in more inconsiderate and selfish ways exhibiting less remorse, whereas with adult physical abuse more consideration was taken into account with regard to another person in the narrative or at least they exhibited some remorse. Adults with a history of physical abuse were more likely to produce narratives suggesting difficulties regulating feelings of anger and aggression. Characters were characterized as hostile and aggressive. A question emerging from these findings regards the extent to which these patients’ TAT narratives reflect their personal moral view (narratives depicting self) versus their understanding of perpetrators’ views (narratives depicting how trauma survivors view others and environment).

This is difficult to tease apart with narratives told in the TAT. Future investigators may wish to examine this issue using other forms of narrative data (e.g., psychotherapy, early memory narratives, and clinical interviews) where the demarcation of self and other are more obvious.

Limitations We did not have uniform results across samples. Our outpatient sample yielded more significant findings than our inpatient group. This is likely 73

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due to sample size. We attempted to strike a meaningful balance by setting two critical values for significance one of which is an effect size indicator (r â&#x2030;Ľ .20); however, some associations may have been missed in the inpatient group. This is evidenced by several notable trends with inpatients that were significant with outpatients. Another possibility focuses on the uniqueness of our clinical samples (e.g., select group of inpatients and outpatients are referred for psychological assessments and less comparable to general psychiatric inpatient unit or outpatient clinic).

We have a certain number of variables in our repository, not all variables are rated for each patient and some variables are endorsed more often than others. Given the preliminary nature of research on the external correlates of SCORS-G ratings, we chose to examine the life history variables as independent events or outcomes. This allowed us to explore for unique or differential patterns of relationships among life events and SCORS-G variables. However, it is possible that the life variables used in this study reflect a smaller number of underlying dimensions and that these underlying dimensions account for the observed correlations.

Therefore, future research in this area should consider the potential advantage of creating dimensional representations of external correlates as this approach might enhance or sharpen the interpretation of the findings.

Also, it is unclear the extent to which differences in psychiatric diagnoses between the two groups also impacted findings. It would be beneficial for future research to examine how the SCORS-G differs across diagnostic groups. Moreover, it is unclear the extent to which verbal productivity (e.g., word count and/or level of engagement) could be contributing to differences between two groups. Unfortunately, due to us controlling for card pull and limiting the card set to Cards 1, 2, 3BM, and 14, our overall word count variable could not be used to test this possible limitation. Finally, our sample is fairly well educated and mainly Caucasian, thus limiting the generalizability of our findings with different ethnicities, cultures, and socioeconomic status. Replicating this study across ethnicities and cultures is highly urged.

Our approach to coding specific life events as either absent or present may also be limited in some respects. For example, trauma severity may be related to the extent to which certain aspects of OR are disrupted more than others (Porcerelli & Cogan, 2014; Slavin et al., 2007). Similarly, we did not differentiate among severity of suicide attempts, intensity of suicidal ideation, intensity of substance abuse, or frequency of self-harm.

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Further, for some variables, there was no way to determine whether the life event was current or past. For example, we did not differentiate among those who were currently engaged in the process of self-harming from those with a history of self-harm.

Conclusion Despite the limitations, we were able to identify relationships between life events and SCORS-G dimensions in theoretically consistent ways at a more global level. Further, this is the first study to simultaneously examine a wide range of clinically relevant life event variables within a naturalistic clinical setting. A disadvantage of this approach is that it limited our ability to focus on any one set of variables in great detail. However, the advantage of this approach is that the present data can now be employed by future researchers in a way that might inform future research efforts and directions.

Finally, this relationship between clinical history and SCORS-G dimensions has implications for clinical and assessment research. Clinically, knowing which aspects of OR are associated with relevant life history variables can help identify deficit areas that may benefit from intervention (e.g., increasing complexity, differentiation, and social reasoning/perception vs. targeting shame, inadequacy, and identity diffusion vs. increasing emotional regulation). In addition, this can assist clinicians in gaining a better understanding of how certain life event data contribute to engagement in therapy (e.g., patients endorsing suicidality may see others in more malevolent and aggressive ways and as such it would be useful for clinicians to be mindful of how this impacts the therapeutic alliance and perceptions of therapist, particularly during periods of acute distress).

References Blatt, S. J. (2008). Polarities of experience: Relatedness and self-definition in personality development, psychopathology, and the therapeutic process. Washington, DC: American Psychological Association.

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Block, J. H., & Block, J. (1980). The role of ego-control and ego-resiliency in the organization of behavior. In W. A. Collins (Ed.), Development of cognition, affect, and social relations: The Minnesota symposia of child psychology (Vol. 13, pp. 40–101).

Hillsdale, NJ: Erlbaum.

Callahan, K., Price, J., & Hilsenroth, M. (2003). Psychological assessment of adult survivors of childhood sexual abuse within a naturalistic clinical sample. Journal of Personality Assessment, 80, 174–185.

Clemence, A. J. (2013). SCORS ratings among patients with NSSI: Response to treatment.

Paper presented at Society for Personality Assessment Annual Conference, San Diego, CA. Damsky, L., & Ackerman, S. J. (2013). Differentiating borderline patients with and without self-injury and suicide attempt using the SCORS. Paper presented at Society for Personality Assessment Annual Conference, San Diego, CA. DeFife, J. A., Goldberg, M., & Westen, D. (2013). Dimensional assessment of self and interpersonal functioning in adolescents: Implications for DSM-5’s general definition of personality disorder. Journal of Personality Disorders, 27, 1–13.

Graham, A., & Glickauf-Hughes, C. (1992). Object relations and addiction: The role of transmuting externalizations. Journal of Contemporary Psychotherapy, 22, 21–33.

Huprich, S. K., & Greenberg, R. P. (2003). Advances in the assessment of object relations in the 1990s. Clinical Psychology Review, 23, 665–698.

John, O. P., & Soto, C. J. (2007). The importance of being valid: Reliability and the process of construct validation. In R. W. Robins, R. C. Fraley, & R. F. Krueger (Eds.), Handbook of research methods in personality psychology (pp. 461–494). New York, NY: Cambridge University Press.

Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press.

Lewis, K. (2013). Social cognition and object relational functioning in suicidal individuals: Relationship with common risk and protective factors. Paper presented at Society for Personality Assessment Annual Conference, San Diego, CA. Linehan, M. (1993). Cognitive-Behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press.

Murray, H. A. (1943). Manual for the Thematic Apperception Test. Cambridge, MA: Harvard University Press.

Ortigo, K. M., Westen, D., DeFife, J. A., & Bradley, B. (2013). Attachment, social cognition, and posttraumatic stress symptoms in a traumatized, urban population: Evidence for the mediating role of object relations. Journal of Traumatic Stress, 26, 361–368.

Porcerelli, J. H., & Cogan, R. (2014). Total lifetime victimization, object relations, and defensive functioning. Paper presented at Society for Personality Assessment Annual Conference, Arlington, VA. Price, J., Hilsenroth, M., Callahan, K., Petretic-Jackson, P., & Bonge, D. (2004). A pilot study of psychodynamic psychotherapy for adult survivors of childhood sexual abuse. Clinical Psychology & Psychotherapy, 11, 379–391.

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Slavin, J., Stein, M., Pinsker-Aspen, J., & Hilsenroth, M. (2007). Early memories from outpatients with and without a history of childhood sexual abuse. Journal of Loss and Trauma, 12, 435–451.

Stein, M., Hilsenroth, M., Slavin-Mulford, J., & Pinsker-Aspen, J. (2011). Social Cognition and Object Relations Scale: Global Rating Method (SCORS-G), (4th ed.)

(Unpublished manuscript). Massachusetts General Hospital and Harvard Medical School, Boston, MA. Stein, M. B., Slavin-Mulford, J., Siefert, C. J., Sinclair, S. J., Renna, M., Malone, J., …, Blais, M. A. (2014). SCORS-G stimulus characteristics of select thematic apperception test cards. Journal of Personality Assessment, 96, 339–349.

Stein, M. B., Slavin-Mulford, J., Sinclair, S. J., Siefert, C. J., & Blais, M. A. (2012).

Exploring the construct validity of the Social Cognition and Object Relations Scale in a clinical sample. Journal of Personality Assessment, 94, 533–540.

Thorberg, F. A., Young, R. M., Sullivan, K. A., & Lyvers, M. (2009). Alexithymia and alcohol use disorders: A critical review. Addictive Behaviors, 34, 237–245.

Westen, D. (1995). Social Cognition and Object Relations Scale: Q-sort for Projective Stories (SCORS-Q) (Unpublished manuscript). Department of Psychiatry, The Cambridge Hospital and Harvard Medical School, Cambridge, MA. Westen, D., Barends, A., Leigh, M., Mendel, M., & Silbert, D. (1990). Social Cognition and Object Relations Scale (SCORS): Manual for coding interview data (Unpublished manuscript). University of Michigan, Ann Arbor, MI. Westen, D., Ludolph, P., Block, M. J., Wixom, J., & Wiss, C. (1990). Developmental history and object relations in psychiatrically disturbed adolescent girls. American Journal of Psychiatry, 147, 1061–1068.

Westen, D., Silk, K., Lohr, N., & Kerber. (1985). Object Relations and Social Cognition: TAT scoring Manual: TAT scoring manual (Unpublished manual). University of Michigan, Ann Arbor, MI. Whipple, R., & Fowler, J. C. (2011). Affect, relationship schemas, and social cognition: Self-injuring borderline personality disorder inpatients. Psychoanalytic Psychology, 28, 183–185.

Michelle Stein Massachusetts General Hospital & Harvard Medical School Psychological Evaluation and Research Laboratory (PEaRL) One Bowdoin Square, 7th floor Boston, MA 02114 USA Tel. +1-617 724-6300; ext. 111 134-0378 E-mail mstein3@partners.org

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Summary The Social Cognition and Object Relations Scale-Global Ratings Method (SCORSG; Stein, Hilsenroth, Slavin-Mulford, & Pinsker-Aspen, 2011) is a widely used and reliable measure for coding narrative data, particularly Thematic Apperception Test (TAT) narratives. This study contributes to the ongoing construct validation of the SCORS-G by examining its relationship to nontest life event correlates in a sample of psychiatric outpatients and inpatients undergoing psychological assessment at an academic medical center. Administering the TAT and obtaining SCORS-G ratings of narrative data was a standard part of the assessment process. We coded an array of life event variables related to psychiatric severity and treatment utilization (i.e., number of hospitalizations; suicide attempts) and problems in adaptation (i.e., alcohol and drug abuse, homicidal and suicidal ideation, history of arrest and selfharm). We also included life events which may arrest the maturational process and/ or negatively impact internal representations resulting in more maladaptive ways of relating to self and others (i.e., history of childhood trauma). Finally, demographic information expected to be associated with cognitive dimensions of the SCORS-G were also included (i.e., level of education). SCORS-G dimensions were modestly connected to several real-world events in our clinical samples. This suggests that SCORS-G dimensions tap into something that is also impacted by events that are clinically relevant. With regard to psychiatric severity, number of hospitalizations and frequency of suicide attempts were both associated with more global pathology as evidenced by the SCORS-G composite score. Among the life event variables, history of suicidal ideation and number of suicide attempts were related to the most SCORS-G dimensions. Across both samples, Identity and Coherence of Self was the only variable significantly related to history of self-harm and cognitive variables (Complexity of Representations of People and Understanding of Social Causality) were positively related to Level of Education. Meaningful relationships were also found between SCORS-G dimensions and history of trauma, alcohol/drug abuse, and conduct disordered behavior. Lastly, when examining the SCORS-G dimensions, Emotional Investment in Relationships and Complexity of Representations of People were associated with the most number of external correlates. This study expands on SCORS-G and TAT research with regard to exploring a broad range of life history variables across settings. It also highlights the extent to which narratives, particularly the TAT, can be applied to real world data in an empirically reliable, valid, and meaningful way.

Résumé Le Social Cognition and Object Relations Scale-Global Ratings Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker-Aspen, 2011) est une mesure utilisée pour coter des données discursives, en particulier des protocoles du Thematic Apperception Test (TAT). Cette étude est une contribution à la validation du SCORS-G en lien avec des événements de vie de patients psychiatriques hospitalisés

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External Validity and TAT ou ambulatoires, passant une évaluation psychologique dans un centre médicouniversitaire.

Nous avons coté une série d’événements liés à la sévérité des troubles psychiatriques et du besoin de traitement (par exemple le nombre d’hospitalisations, les tentatives de suicide), et des problèmes d’adaptation (problèmes d’addictions, idées suicidaires, comportements d’automutilations). Nous avons aussi pris en compte des événements de vie qui ont eu un impact sur le processus de maturation ou/et ont eu un impact négatif sur les représentations internes qui ont pour conséquence des comportements intra et interpersonnels mal adaptatifs.

Enfin, des informations démographiques (comme le niveau d’éducation) ont été associées aux dimensions cognitives du SCORS-G. Ces dimensions étaient modestement liées à certains événements de vie dans notre population clinique. Ceci suggère que le SCORS-G met le doigt sur quelque chose qui est aussi influencé par des événements qui ont une importance clinique. La sévérité des troubles psychiatriques, le nombre d’hospitalisations et la fréquence des tentatives de suicide sont associés à un niveau plus élevé de pathologie comme le démontre le score composite au SCORS-G. Les antécédents d’idées suicidaires et le nombre de tentatives étaient les variables les plus en lien aux dimensions du SCORS-G. Dans les deux échantillons, les variables identité et cohérence du moi étaient fortement en lien avec les antécédents d’automutilations et les variables cognitives du SCORS-G. Cette étude explore les liens entre des événements de vie et les données au TAT cotées à l’aide du SCORS-G. Elle permet aussi de voir comment les données discursives au TAT peuvent être mise en lien de manière significative à l’histoire du sujet.

Resumen La Escala Global de Cognición Social y Relaciones de Objeto (Social Cognition and Object Relations Scale-Global Ratings Method: SCORS-G) de Stein, Hilsenroth, SlavinMulford y Pinsker-Aspen (2011) es una medida fiable y ampliamente utilizada para codificar datos narrativos, especialmente las historias del Test de Apercepción Temática (TAT). Este estudio contribuye al logro de la validez de constructo de la SCORS-G, a través del examen de los relatos con eventos vitales conectados, en una muestra de pacientes psiquiátricos internos y externos durante su evaluación en un centro médico académico. La administración del TAT y la obtención de las puntuaciones de SCORS-G sobre los datos narrativos constituyó una parte protocolizada del proceso evaluativo. Se codificó una colección de variables sobre eventos vitales, relacionadas con la severidad del trastorno y el tratamiento (p.e. número de ingresos hospitalarios; intentos de suicidio) y con problemas adaptativos (p.e., abuso de drogas o alcohol, ideación homicida o suicida, historial de arrestos y autoagresiones). También se incluyeron eventos vitales que pudieran afectar al proceso madurativo y/o tener un impacto negativo en las representaciones internas, con el resultado de modalidades disfuncionales de relación consigo

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M. B. Stein et al. mismo o con los demás (p.e., historia de traumas infantiles). Finalmente, se incorporó también información demográfica que pudiera asociarse con las dimensiones cognitivas de SCORS-G (p.e., nivel de educación). Las dimensiones de SCORS-G aparecieron en nuestras muestras clínicas modestamente conectadas con varios eventos reales. Esto sugiere que las dimensiones de SCORS-G acceden a un campo que también sufre el impacto de acontecimientos con relevancia clínica.

En relación con la gravedad psiquiátrica, el número de hospitalizaciones y la frecuencia de intentos de suicidio aparecieron asociados ambos con mayor patología global, como señalan las puntuaciones compuestas de SCORS-G. Entre las variables de los eventos vitales, la historia de ideación suicida y el número de intentos de suicidio se relacionaban con la mayoría de las dimensiones de SCORSG. En ambas muestras, Identidad y Coherencia de Sí Mismo fue la única variable significativamente relacionada con antecedentes de autolesiones y las variables cognitivas (Complejidad de las Representaciones de las Personas y Comprensión de la Causalidad Social) aparecieron positivamente relacionadas con el Nivel de Educación. También se encontraron relaciones significativas entre dimensiones de SCORS-G e historia de traumas, abuso de alcohol/drogas y conducta desordenada.

Por último, cuando se examinaron las dimensiones de SCORS-G: Investidura Emocional de Relaciones y Complejidad de Representaciones de Personas se asociaron con el mayor número de correlatos externos. Este estudio se extiende en el análisis de la investigación sobre SCORS-G y TAT en relación a la exploración de un amplio rango de variables de la historia vital en contextos. También arroja luz sobre la utilidad de las narraciones, especialmente en el TAT, que pueden ser aplicadas al estudio de datos del mundo real de una manera empírica, fiable, válida y significativa.

要約 社会的認知と対象関係の広範的な評定法（SCORS-G, Slavin-Mulford, & Pinsker-Aspen, 2011）は広く用いられており、物語のデータ、特に主題統覚検査（TAT）の物語をコーディ ングするための信頼性のおける尺度である。この研究は、アカデミック医学センターにおける心 理学アセスメントを受ける精神科の外来および入院患者の標本において相関が認められる、 検討されていないライフイベントとの関係性を吟味することで、進行中の SCOR-S の構成概念妥 当性に貢献する。 TAT を施行され、物語データの SCORS-G の評定を得ることがこのアセスメ ント過程の標準的な部分である。われわれは精神病の重症度と治療の利用（換言すれば、 入院回数や自殺企図）、適応の問題（換言すれば、アルコールや薬物依存、殺人あるい は自殺の念慮、逮捕や自傷の経歴）と関連している一連のライフイベント変数をコード化した。 われわれはまた、成熟過程を阻害するかもしれず、内的表象にネガティブな衝撃を与え、自己 や他者とより不適切な方法で関係するという結果に終わるかもしれない（換言すれば、子ども時 代のトラウマの歴史）ライフイベントも含めた。最終的には、 SCORS-G の認知の次元と関係し ていると期待される人口統計学的情報（換言すれば、教育レベル）もまた含まれた。 SCORS-G の次元はわれわれの臨床群の標本におけるいくつかの現実の世界のイベントとある程 度の関連性があった。このことは、 SCORS-G の次元が、臨床的に関連のあるイベントによって また衝撃を与えられる何かを活用していることを示唆している。精神科の重症度に関して言えば、

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External Validity and TAT 入院回数や自殺企図の頻度は SCORS-G の集成値が証拠となる全般的な精神病理と関連 がある。ライフ・イベント変数の中で、自殺念慮の臨床歴、自殺企図の回数はたいていの SCORS-G の次元と関連があった。どちらのサンプルにおいても、アイデンティティと自己の一貫 性が、自傷行為の臨床歴と唯一関連性があった変数であり、（他者の表象の複雑性や社 会的因果性の理解などの）認知的変数は教育レベルと正の相関の関係にあった。 SCORS-G の次元と、トラウマの歴史、アルコールや／または薬物依存、行為障害行動の意味のある関 係性が見出された。最後に、 SCORS-G の次元を吟味すると、関係性への情緒的投資、他 者の表象の複雑性は多くの外的な関係性と関連があった。本研究は SCORS-G と TAT の研 究を横断的な領域で広い範囲のライフ・ヒストリーの変数に関連させて、適用範囲を広げてい る。物語、特に TAT は経験的に信頼でき、妥当性を有し、意味がある方法で、現実の世 界のデータに応用することができる程度を、この研究は強調している。

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Rorschachiana 36, 82–103 © 2015 Hogrefe Publishing

DOI: 10.1027/1192-5604/a000053

Special Section: The TAT and Other Storytelling Projective Methods Original Article

Personal Problem Solving of Partners in Divorce Proceedings Tereza Soukupova and Petr Goldmann Charles University in Prague, Mental Hospital Bohnice, Prague, Czech Republic

Abstract. The Thematic Apperception Test is one of the most frequently administered apperceptive techniques. Formal scoring systems are helpful in evaluating story responses. TAT stories, made by 20 males and 20 females in the situation of legal divorce proceedings, were coded for detection and comparison of their personal problem solving ability. The evaluating instrument utilized was the Personal Problem Solving System-Revised (PPSS-R) as developed by G. F. Ronan. The results indicate that in relation to card 1, men more often than women saw the cause of the problem as removable. With card 6GF, women were more motivated to resolve the given problem than were men, women had a higher personal control and their stories contained more optimism compared to men’s stories. In relation to card 6BM women, more often than men, used emotions generated from the problem to orient themselves within the problem. With card 13MF, the men’s level of stress was less compared to that of the women, and men were more able to plan within the context of problem-solving. Significant differences in the examined groups were found in those cards which depicted significant gender and parental potentials. The TAT can be used to help identify personality characteristics and gender differences.

Keywords: George F. Ronan, personal problem solving, partners in the divorce proceedings, Personal Problem Solving System-Revised

Introduction In all cultures, the telling of stories is an important narrative method for social education and the handing over of myths from one generation to another. It is also the way of sharing experiences and providing instructions on how to solve problems that arise both in the personal arena 82

Personal Problem Solving of Partners

and within social groups. Analysis of narrative material is one of the means of determining what kinds of experiences are handed over by storytellers to their listeners.

Any narrative material could potentially be used for such an analysis, such as the interpretation of dreams and fantasy (Freud, 1955; Henry, 1973; Morgan & Murray, 1935), the interpretation of images from the WAIS-R Picture Arrangement subtest (Westen, 2002), or stories obtained through the Thematic Apperception Test (TAT; Cramer, 2004; Teglasi, 2001). The TAT came into existence as an instrument for the investigation of personality, based on picture interpretation (Morgan & Murray, 1935); however, Schwartz came up with the same idea even earlier (Schwartz, 1932). He was also the first who emphasized personal problem solving in his apperception method.

Many researchers point out the great importance of surveying personal problem solving, as it is closely related to emotional perception, the theory of mind, and attributional style (Penn, Sanna, & Roberts, 2008). Penn declares that social cognition involves the interface of emotional and cognitive processing, whereas neurocognitive processing is relatively affectneutral. Research workers involved in schizophrenia treatment point out the importance of the recognition and development of personal problem-solving skills in their patients (Penn et al., 2008). Also, Rath (2003) found the relationship between social problem-solving selfappraisal and performance in a variety of subjects with brain injury.

Personal problem-solving issues have been studied from various points of view. The dynamically oriented approach was applied by Garner (1970).

The ability for personal problem solving to be exploited by cognitive behavioral therapy (CBT) in depressed patients was investigated by Chen, Jordan, and Thompson (2006), who concluded that problem-solving appraisal might play an important part in CBT for reducing depression.

Different tools have been created for the investigation of personal problem-solving approaches. The Problem-Solving Inventory (PSI; Heppner & Petersen, 1982) is a questionnaire widely used as a self-report measure of applied problem solving in the US (Sahin, 1993).

D’Zurilla and Nezu’s (1982) problem-solving model of depression hypothesizes that depressed mood can be caused by deficiencies in any of the five problem-solving components: problem orientation, problem definition and formulation, generation of alternatives, decision making, and solution implementation and verification. On the grounds of their own research, D’Zurilla and Nezu (1990) developed the Social ProblemSolving Inventory (SPSI) – a multidimensional self-report measure of social 83

T. Soukupova and P. Goldmann

problem-solving abilities. The SPSI consists of two major scales and seven subscales. The two major scales are the Problem Orientation Scale (POS) and the Problem-Solving Skills Scale (PSSS). Subsumed under the POS are three subscales: the Cognition subscale, the Emotion subscale, and the Behavior subscale. The PSSS is divided into four subscales: the Problem Definition and Formulation subscale, the Generation of Alternative Solutions subscale, the Decision Making subscale, and the Solution Implementation and Verification subscale.

Ronan, Colavito, and Hammontree (1993) created a specific assessment tool utilizing findings from D’Zurilla’s investigation on personal problem solving. In order to avoid the possible dangers of bias in questionnaire tools (Groth-Marnat, 2009), they applied projection methods and used the advantages of the TAT. Although the TAT was one of most frequently used apperceptive techniques in the world, in clinical practice story responses were often evaluated impressionably and formal scoring systems were often not used. Therefore, a sensitivity training procedure used to assess personal problem-solving skills was developed (Ronan, Date, & Weisbrod, 1995).

The Personal Problem-Solving System-Revised (PPSS-R) came into existence after the review of the first version called the Personal ProblemSolving System (Ronan et al., 1996). The theoretical grounds for the PPSS-R arose from the work of D’Zurilla and Nezu (1982, cited in Ronan, Gibbs, Dreer, & Lombardo, 2008). Ronan’s scoring system itself follows the outline of the Social Problem-Solving Inventory (D’Zurilla & Nezu, 1982, cited in Ronan et al., 2008).

The PPSS-R assesses how people identify, conceptualize, and resolve personal problems. The relationship between personal problem-solving skills is inversely proportional to the experience of stress. This means that in the situation of major stress, an individual’s personal problem-solving capacity decreases (D’Zurilla, 1988, cited in Ronan et al., 2008).

Ronan and coworkers monitored four fundamental components, that is: Story Design, Story Orientation, Story Solution, and Story Resolution; three of these components are composed of four elements that partially describe the qualities of that component.

The component Story Design (SD) contains four elements pertaining to the process of problem formulation (D’Zurilla & Nezu, 1982, cited in Ronan et al., 2008). Time span is the first element, the cause of the problem is the second, the realistic assessment of the problem is the third, and the fourth is the manner in which the story is detailed and integrated (Ronan et al., 2008).

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The component Story Orientation (SO) also contains four elements that assess the degrees of positive motivation, personal control, confidence, and emotional distress (Ronan et al., 2008).

The component Story Solutions (SS) determines the quantity of solutions that are generated; all solutions are taken in account â&#x20AC;&#x201C; both those that are proper as well as those that are inadequate in the story. The SS component is based on brainstorming and achievement concepts that do not have only one possible interpretation. Individuals who provide a small number of solutions could be persons who either do not have any more ideas, or those who select only the most suitable solutions from the many possibilities. The SS records the number of overt and covert possible story solutions (Ronan et al., 2008).

The component Story Resolution (SR) likewise contains four elements that determine: the effectiveness of decision making, the degree to which positive aspects of the story resolution outweigh the negative, the likelihood of maximizing both short- and long-term goals, and the time and energy required to bring about problem resolution (Ronan et al., 2008).

Ronan et al. (2008) reported the PPSS-R means and standard deviations for the following adult samples: college students, community residents, jail inmates, clients from affiliated clinics of psychology departments, seriously impaired community mental health center clients, and psychiatric day treatment clients. Their analyses reveal no gender differences.

In our previous research we investigated the personal problem-solving skills of priesthood candidates in the TAT stories using the PPSS-R (Goldmann & SoukupovĂĄ, 2014). The results give evidence supporting the usefulness of the PPSS-R in ascertaining the abilities of coping with stress in the personal and social fields. The results obtained for individual priesthood candidates corresponded to their age and education in such a way that the older candidates showed a higher maturity in this field.

The Present Study We decided to undertake an exploratory study utilizing the TAT and the PPSS-R, because in the course of our forensic practice we often encounter differences in the personal problem-solving abilities of couples involved in partnership break-up, where such couples are not able to come to an agreement on the custody of their children without the assistance of 85

T. Soukupova and P. Goldmann

a third party. Our hypothesis was that there are differences in the personal problem-solving abilities of men and women in situations where disputes over child custody exist. We expected that with the help of the TAT we would find differences between men and women in certain dimensions of the PPSS-R scoring system.

For our research we used the TAT, because this apperceptive technique allows for the subject under investigation to be closely monitored in difficult social situations. The TAT cards are quite suitable for these purposes, as they provide stressful themes that the subject must come to terms with.

We chose the PPSS-R because it identifies certain mental functions that are useful in the problem solving of social situations – reality testing, emotions, motivations, and resolution skills in situations of personal problems.

Method Participants In our research, we used 40 TAT protocols from 20 couples (20 men and 20 women), which were obtained during expert witness psychological examinations (in court proceedings determining child custody). Expert witness psychological examinations (undertaken by the authors of this article) proceeded between 2007 and 2014. All of the persons examined were of Czech nationality and examinations were ordered by the court.

Couples were either already divorced or had applied for divorce, or in the case of unmarried couples, they were in partnerships that had already broken up and where the participants were as parents undergoing court proceedings to determine either full or alternating custody for at least one child. The 40 protocols for research were randomly selected from the authors’ portfolio, totaling 41 couples (i.e., 82 protocols). The average age of the male participants in this study was 43.3 years (range = 35–62 years). The average age of the female participants was 35.8 years (range = 30–43 years).

The average length of education was 13.3 years for men, and 13.1 years for women. In both groups the minimum length of education was 11 years and the maximum was 17 years. Comparing the male and female groups according to age (t(19) = .17, p = ns) and according to the length of their 86

Personal Problem Solving of Partners

education (t(19) = .24, p = ns) did not yield any statistically significant difference. Therefore, the sample was determined to be homogeneous in terms of its age and length of education.

Procedure In his studies, Ronan usually presents the following TAT cards: 1, 2, and 4, or 7BM, 10, and 13MF. In our studies we proceed with the set of TAT cards used at the Bohnice Psychiatric Hospital in Prague by many of the psychologists in the Czech Republic: 1, 2, 3BM, 4, 6GF, 6BM, 18BM, 8BM, 10, 13MF, 18GF, and 5. This set emerged as a derivation of Bellak’s set (Bellak & Abrams, 1996). These TAT cards tend to draw certain patterns of responses that constitute their card pull. In our clinical practice we use Cards 10 and 5, despite the fact that patients often do not create a story that could be scored with the PPSS-R. These cards are included in our set merely to play the role of “cards for relaxation,” which allow patients to unwind in the middle of TAT sessions so that they do not face stressful situations with TAT cards at the end of the assessment session. This strategy of card sequence has proved to be very useful, helping patients to deal with the task effectively and creating a quality working partnership. This could be paralleled with Rorschach’s card order, where the fifth card is usually the easiest and provides the patient some space for relaxation.

For our survey we selected cards that frequently feature a personal or social problem (Weiner, Greene, & Roger, 2008) in such a way that, by applying the usual instructions, it would become quite probable that participants would generate a story from which individual components involved in the mastering of the problem could be tracked: 1, 2, 6GF, 6BM, 10, 13MF, and 18GF. From this set we eventually discarded results from Card 10, because in this instance the study subjects only rarely created a story that contained a personal problem. In our work we used neither Ronan’s instructions nor the classic ones (Murray, 1943), but rather the version that is widely used in clinical practice: This is a storytelling test. I have some pictures here that I am going to show you, and for each picture I want you to make up a story. Tell what has happened before and what is happening now. Say what the people are feeling and thinking and how it will come out (Weiner et al., 2008, p. 433).

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Ronan and coworkers suggested these specific PPSS-R instructions for the subjects: This is a problem-solving task. I have some pictures I am going to show you.

For each picture identify the main character and describe what his or her problem might be. Develop a story around this problem. Be sure to note how the problem developed, what is happening now, how the problem will be resolved, and what the outcome might be. Say what the main character and the other people in the story are thinking and feeling. The type of problem you develop is up to you (Ronan et al., 2008, pp. 209-210).

Applying Ronan’s modified instructions usually results in the provision of answers that contain an identifiable problem, which lends itself to be evaluated using the PPSS-R. Also, our method of test administration is different from the original method. The clients tell their story and the psychologist records verbatim the clients’ answer. In this way the possibility of client censorship is reduced, which would otherwise be greater if the client were to write down his/her own stories. We decided to administer the TAT as usual, because we use the PPSS-R in standard clinical practice and we did not want to change our accustomed procedure of assessment utilizing the TAT. Measures The protocols were selected randomly and were scored by the authors of this study using the PPSS-R. Questionable cases were mutually consulted.

For the scoring of stories, we created a recording sheet comprising all the components and their respective elements. In each story we searched for the desired category, which we then quantified according to the instructions of the PPSS-R. The scoring criteria were applied using the main character and the main problem situation. Although whole numbers are used to designate response options (−1, 0, 1, 2, 3), the use of a midpoint (e.g., 1.5) is acceptable. A value of 3 is considered as the optimal result, with a normal functioning client generally moving in the range of 1 to 2. A value of −1 is given for each subscale to a poor, ineffective, or deficient response. A value of 0 is given to responses that cannot be scored on the subscale. The interrater reliability was calculated for each card, and the κ values ranged from .42 to .64.

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The component Story Design contains: 1. SD1 – Does the story problem contain a past, present, and future?

2. SD2 – Is there indication of the cause of the story problem or trouble?

3. SD3 – Rate the level of distorted beliefs, appraisals, and assumptions about the story problem.

4. SD4 – Rate how well the story problem is integrated and detailed.

The component Story Orientation contains: 1. SO1 – How positively motivating is the situation?

2. SO2 – How likely is it that there will be an attempt to exert personal control over the problem?

3. SO3 – How much confidence is demonstrated for dealing with the problem?

4. SO4 – Rate the level of emotional distress.

The component Story Solutions contains: 1. Record the number of overt and covert story solutions.

The component Story Resolution contains: 1. SR1 – Rate the degree to which the story solutions minimize personal distress.

2. SR2 – Rate the degree to which the positive consequences for the main character outweigh the negative consequences.

3. SR3 – Rate the degree to which story solutions address both shortand long-term goals.

4. SR4 – Rate the degree to which the concerns are ameliorated.

Four component scores and a total per-card score are obtained for each TAT card. Three of the component scores – Story Orientation, Story Design, and Story Resolution – are derived by summing up the scores for each of the elements associated with that particular component and dividing the total by 4. The Story Solutions score is derived by adding the total number of story solutions generated. The per-card scores are obtained by adding the four component scores. The per-card component scores are added to obtain aggregate component scores. Aggregate component scores are added to obtain a total PPSS-R score (Ronan et al., 2008; see Appendix).

In our clinical practice we use the individual components SD, SO, SS, SR, and their elements, not the total scores as Ronan and colleagues 89

T. Soukupova and P. Goldmann

do. Moreover, we do not divide the components SD, SO, and SR by 4.

We apply this method also in our research for purposes of clarity and for the possibility of comparing results easily.

We do not calculate total scores, as they are created through the sum of incompatible scores – one type of score is generated through scaling (i.e., SD, SO and SR), while the second type is generated through the simple addition of proposed solutions (i.e., SS). The latter type of score is comparable to the former with difficulty. In clinical practice it seems more appropriate to work with the individual component scores.

Results We compared the scores of every pair of cards, for each component and element. The scores obtained were compared using the paired t test.

Statistically significant differences are presented in Table 1.

Table 1. Statistically significant differences Men

Women SD

M

SD

Paired t

1.85

0.96

1.35

0.73

.014*

SO1: Positive motivation

0.20

1.25

0.88

1.08

.027*

Card 6GF SO2: Personal control

0.60

1.39

1.41

1.37

.022*

3.27

4.04

4.88

1.55

.002**

0.50

0.50

0.94

0.54

.003**

SO4: Emotional distress

0.95

1.36

1.82

1.10

.043*

Card 13MF SD1: Time span

0.70

1,00

0.00

1.21

.019*

−0.35

0.91

–0.89

0.31

.010*

M Card 1 SD2: Cause of problem Card 6GF

Card 6GF SO: Story orientation Card 6GF SS: Story solution Card 6BM

Card 13MF SR1: Effectiveness of decision making Note. *p < .05. **p < .01.

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Between the men and women, we found statistically significant differences only for Cards 1, 6GF, 6BM, and 13 MF. Statistically significant differences were not found for the other cards (Cards 2 and 18GF).

The differences observed between men and women in our study of personal problem-solving strategies are in some cases statistically significant.

When investigating the results of particular individuals it becomes apparent that useful information can be gleaned from the comparison of results of specific couples. With most of the couples, we find lower personal problem-solving skills in one of the individuals â&#x20AC;&#x201C; and with some of the couples we observe lower skills in both of the partners.

This can be illustrated in the following case study: Couple M19 and F19 married after 3 years of knowing each other, and subsequently divorced after 7 years of marriage. They share a daughter together, over whom a legal dispute is underway, as both are seeking custody. Both parents are university educated and hold successful jobs. The former spouses have difficulty communicating together; M19 expresses concerns that his daughter is being corrupted by her mother against him, so that his daughter would not be interested in maintaining contact with him. F19 indicates that her former husband exerted force against her, a claim that he categorically denies.

Both parents were psychologically examined using Rorschach CS, MMPI-2, and the TAT. With Card 1, similar results were observed for both spouses for the Story Design, Story Orientation, and Story Solution components. For the card depicting the boy with the violin, M19 held a more realistic stance and displayed a greater sense of achievement â&#x20AC;&#x201C; the possible explanation being that even during their family time the father both proposed and realized solutions, in relation to general affairs and the spending of free time with their daughter.

For card 6GF, we again see the fatherâ&#x20AC;&#x2122;s better results in the areas of Story Design, Story Orientation, and Story Solution. This is indicated by his good ability to respond to the image where a woman is addressed by a dominant man; the wife, however, finds it difficult to respond in an ideal way.

With card 6BM, the ability to find adequate solutions to the problem is displayed by the mother. Her better results in the Story Resolution component may be attributed to fact that on this card the male is depicted in the submissive role.

With card 13MF, both partners have trouble in cognitively understanding the problem (SD) and in generating enough effort for its resolution.

Scores are presented in Table 2.

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Table 2. Scores of individual components and their elements Card 1

SD1 SD2 SD3 SD4 SD SO1 SO2 SO3 SO4 SO SS SR1 SR2 SR3 SR4 SR M19

1

2

1

1

5

2

3

3

2

10 1

3

3

0

3

9

F19

1

1

1

1

4

2

3

1

2

8

2

0

2

0

2

4

6GF

M19

1

2

1

1

5

2

3

3

2

10 1

3

3

0

3

9

6BM

F19 −1 M19 0

0 3

1 1

1 1

1 5

1 1

0 1

1 0

2 2

4 4

1 1

−1 −1

0 0

3 0

F19

1

2

1

1

5

2

1

0

2

5

1

2

2

0

13MF M19

1

−1

1

1

2

−1

3

0

3

5

1

1

0

−1

−1

2

1

1

3

1

3

0

0

4

2

0

0

0

F19

0 2 −1 −2 1

5

−1 −1 0

0

Note. M19 = male, F19 = female.

Across all the cards, we find that the most developed skills in both of the spouses are those within the field of Story Orientation. We can therefore assume that the focal point of their endeavors with problems is within the fields of emotion and motivation. The partners also have an equivalent low score in Story Solutions, which signifies that both generate only a minimum number of possible solutions or individual steps. Generally it can be concluded that both spouses, regardless of their favorable education and good professional standing, display poor results particularly in the area of grasping of problems and in the determination and effort aimed at the solving of problems. In both partners, vacillation can be witnessed, which is dependent on what role the presented figures on the TAT cards have currently adopted. In specific situations this means that both the certainty and effectiveness of proposed solutions to problems vary according to what role the male or female character has been given. This may well explain why couple M19 and F19 are unable to jointly come to an agreement and why they have taken their matter to court.

Discussion The results indicate that with Card 1, men more often view the cause of the problem as removable.

With Card 6GF, women were found to have a higher personal control and their stories contained more optimism compared with the men’s stories. In women this card usually provoked a greater emotional reaction, 92

Personal Problem Solving of Partners

which was often unpleasant. While for men this card generally received either a neutral or positive emotional response, women often expressed feelings of threat. The higher personal control and optimism from the womenâ&#x20AC;&#x2122;s side could be an expression of their defense and the eventual necessity of taking the solution actively into their own hands.

With Card 6BM, women more often used emotions generated from the problem to orient themselves within that problem. It may be the case that in stressful situations, women have a greater ability to use their emotions more adaptively than men are capable of.

With Card 13MF, the menâ&#x20AC;&#x2122;s level of stress was smaller than that of the women, and men were more capable of planning in the context of problem solving. For men, Card 13MF more easily elicited strategies that helped them to solve the problem. It is obvious here that the TAT does not really have equivalent cards for both sexes, which logically leads to the different reactions seen in men and women. Some of the cards are more emotionally demanding for women.

The possible differences between men and womenâ&#x20AC;&#x2122;s problem-solving strategies have been examined in gender psychology. Social learning theory emphasizes the significant influence of the formation of gender roles.

In the course of their development, men and women adopt genderrelated behavior through modeling and reinforcement (Helgeson, 2012). The sex-role stereotypes usually expect the greater use of cognitive strategies and aggressive behavior in men, whereas for women the employment of emotional strategies and a greater degree of empathy is expected.

The degree of aggression used in partnership disputes was investigated

by Bettencourt and Miller (1996, cited in Helgeson, 2012). Their metaanalysis showed that provocation led to the greater use of aggression than did nonprovocation, and that provocation altered the size of the sex difference in aggression. Our research involved couples who were involved in protracted disputes, in which mutually provocative behavior is often present, with the aim of drawing out from the other partner such behavior that would be deemed by the court as disqualifying for parental custody.

With regard to gender research, some authors have confirmed that differences exist in problem-solving skills. A marital interaction study showed that couples who had cohabited prior to their engagement displayed more negative interactions, less supportive behavior, and poorer problem-solving skills than those who had cohabited only after their engagement (Kline et al., 2004, cited in Helgeson, 2012). In our study, 93

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however, we did not inquire into the research groupâ&#x20AC;&#x2122;s formal relationship aspects.

The case illustration of pair M19 and F19 shows that in clinical practice it is appropriate, for specific couples, to determine whether as expected the woman adopts more of an emotional strategy and the man more of a cognitive strategy in problem resolution. In some cases this expectation does not present itself, and rather in these specific couples the expected gender roles have been reversed. In both of these situations, it is possible and necessary to carry out further advisory consultations and formulation of recommendations for the court.

Apperceptive techniques are suitable for assessing the quality of social relations and personal coping strategies primarily because they contain in themselves an explicit social pull. While in the Rorschach test the social pull is present implicitly and the client can easily pass, in apperceptive techniques it is not possible to omit this explicit social pull, and the client is forced to use and demonstrate his/her own inner resources to create a solution. The point is to activate social executive functions.

In our exploratory study we approached the obtained data with the belief that we would find significant differences in the personal problem-solving skills between male and female groups in the situation of legal divorce proceedings. The results show that groups differ only in a few parameters. Results are dependent on the cards used, which elicit different types of reactions from identical stimuli. In our research we found differences between the examined groups for those cards where a significant gender and parental potential exists. The fact that the results obtained through the assistance of the TAT are dependent on the cards used has repeatedly been demonstrated in other studies utilizing the TAT (compare, e.g., Lilienfeld, Wood, & Garb, 2000).

In our previous research work the presence of intercultural differences was also shown through the TAT stories, which are reflected in the results obtained through the scoring system. When comparing results obtained

by Ronan and colleagues on two triads of cards presented, it is obvious that they obtained different results than we did (Goldmann & SoukupovĂĄ, 2014; Ronan et al., 2008). In contrast to the study of Ronan et al., there is a significant lower scoring of the Story Orientation component by Czech nationals (Goldmann & SoukupovĂĄ, 2014). We suppose that in this field there is a significant cross-cultural difference between the Czech and American populations. The Czech population may have lower personal confidence as shown in the mastering of problems compared with the results obtained from American subjects.

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The differences between our results and those of Ronan can also be due to the different instructions we use.

Study Limitations The results obtained do not reflect in absolute numbers the ability or inability for adaptive conduct in social situations, but only statistical differences between the two groups. In practice this means that where one group responds in an immature way, the second group is immature only to a lesser extent than the first.

This study is limited by the use of standard instructions compared with Ronanâ&#x20AC;&#x2122;s more sophisticated instructions, which lead patients to more explicitly create stories containing problematic situations. Our standard instructions correspond with clinical practice, as we wanted to use data acquired during regular assessments. In such cases only certain cards are suitable for evaluating answers using the PPSS-R method.

We are also aware that only a small number of sample subjects were investigated in this exploratory study. Our findings, however, may serve as an inspiration for future research in this field.

Implications for Practice and Future Studies For the application of PPSS-R in clinical practice, we suggest that the percard component and aggregate component scores SD, SO, SS, SR, be focused upon. This is useful for a detailed survey of strengths and weaknesses in the field of social and personal problem-solving skills.

In this work and in our clinical practice, for clarity we only use aggregate component scores without dividing by 4, as recommended in the PPSS-R manual.

Ronan suggests the calculation of scores and their conversion to total PPSS-R scores as more useful for clarity in the presentation of research data. But in clinical practice, psychologists using this simplification lose valuable data, which could be used in personality assessments and in psychotherapy. It is also important to point out the complication caused by the conversion of data to the total PPSS-R score. Summation of aggregate component scores SD, SO, and SR with the SS component score is

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performed to obtain a total score. However, the SS score is created in a different way, as it is a simple addition of all of the generated solutions.

This SS score is therefore not proportional to the aggregate component scores SD, SO, and SR. It could happen that an individual who is very productive will obtain a positive PPSS-R score, without showing sufficient gain in the other components. Clinical psychologists should not forget to perform a qualitative analysis on the resultant score. First of all, this is important in order to ascertain the substantiality of the suggested solutions and also their ethical value. In practice we encounter individuals that show social skills at a very good level, but their approach to the solution of problems is unethical or antisocial.

In practice it is useful for the psychologist to work with a permanent set of cards that creates its own local norms. In this way, results can be compared and particular individuals can be investigated for their abilities of personal problem solving.

We are sure that the PPSS-R protocol could be applied advantageously to other apperceptive techniques. We currently apply Ronanâ&#x20AC;&#x2122;s paradigm in clinical conditions in the assessment of childrenâ&#x20AC;&#x2122;s and adolescentâ&#x20AC;&#x2122;s stories obtained by the Roberts-2 apperceptive technique (Roberts & Gruber, 2005).

In further investigations it would be useful to compare the personal problem-solving skills of couples who undergo court proceedings over child custody, with those couples who are able to approach their divorce utilizing more mature strategies and who are able to come to a consensus without the involvement of courts. It would also be useful to test the statistical significance of associations between both age and education with the different PPSS-R scores.

Conclusion The application of the PPSS-R in the evaluation of TAT stories yields promising results. Differences between men and women in some components are statistically significant. Results indicate that in personal problem solving men utilize more cognitive strategies and women more emotional ones. For clinical assessment, it is important to compare personal problem-solving skills in each particular couple. The differences and similarities serve as important guidelines for forensic assessment, counseling, or psychotherapy.

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References Bellak, L., & Abrams, D. M. (1996). The T.A.T the C.A.T., and the S.A.T. in clinical use.

Boston, MA: Allyn & Bacon.

Chen, S.-Y., Jordan, C., & Thompson, S. (2006). The effect of cognitive behavioral therapy on depression: The role of problem-solving appraisal. Research on Social Work Practice, 16, 500–510.

Cramer, P. (2004). Storytelling, narrative, and the Thematic Apperception Test. New York, NY: Guilford Press.

D’Zurilla, T. J. (1988). Problem-solving therapies. In K. S. Dobson.(Ed.), Handbook of cognitive-behavioral therapies (pp. 85–135). New York, NY: Guilford Press.

D’Zurilla, T. J., & Nezu, A. M. (1982). Social problem solving adults. In P. C. Kendall (Ed.), Advances in cognitive-behavioral research and therapy (pp. 202–275).

New York, NY: Academic Press.

D’Zurilla, T. J., & Nezu, A. M. (1990). Development and preliminary evaluation of the Social Problem-Solving Inventory. Psychological Assessment, 2, 156–163.

Freud, S. (1955). The interpretation of dreams. New York, NY: Basic Books.

Garner, H (1970). Psychotherapy, Confrontational problem solving technique. St. Louis MO: W. H. Green.

Goldmann, P., & Soukupová, T. (2014). Coping strategies of priesthood candidates in TAT stories. Sborník XXVI. Bohnické sexuologické dny. Brno, Czech Republic: Akademické nakladatelstvi CERM. Groth-Marnat, G (2009). Handbook of psychological assessment. Hoboken, NJ: John Wiley & Sons.

Helgeson, V. S. (2012). The psychology of gender, (4th ed). Upper Saddle River, NY: Pearson Education.

Henry, W. E. (1973). The analysis of fantasy. Huntington, NY: Robert E. Krieger.

Heppner, P. P., & Petersen, C. H. (1982). The development and implications of a personal problem-solving inventory. Journal of Counseling Psychology, 29, 66–75.

Lilienfeld, O., Wood, J. M., & Garb, H. N. (2000). The scientific status of projective techniques. Psychological Science in the Public Interest, 1, 27–66.

Murray, H. (1943). Thematic Apperception Test manual. Cambridge, MA: Harvard University Press.

Morgan, C. D., & Murray, H. (1935). A method for investigating fantasies – the Thematic Apperception Test. Archives of Neurology & Psychiatry, 34, 289–306.

Penn, D. L., Sanna, L. J., & Roberts, D. L. (2008). Social cognition in schizophrenia. Schizophrenia Bulletin, 34, 408–411.

Rath, J. F. (2003). Social problem solving and community integration in postacute rehabilitation outpatients with traumatic brain injury. Rehabilitation Psychology, 48, 137–144.

Roberts, G. E., & Gruber, C. (2005). Roberts-2. Los Angeles, CA: WPS. Ronan, G. F., Colavito, V., & Hammontree, S. (1993). Personal problem-solving scoring of TAT responses: Preliminary reliability and validity data. Journal of Personality Assessment, 64, 118–127.

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Ronan, G. F., & Gibbs, M. S. (2008). Scoring manual for Personal Problem-Solving System-Revised. In S. R. Jenkins (Ed.), A handbook of clinical scoring systems for thematic apperceptive techniques (pp. 209–227). New York, NY: LEA. Ronan, G. F., Gibbs, M. S., Dreer, L. E., & Lombardo, J. A. (2008). Personal Problem-Solving System-Revised. In S. R. Jenkins (Ed.), A handbook of clinical scoring systems for thematic apperceptive techniques (pp. 181–207). New York NY: LEA. Ronan, G. F., Senn, J., Date, A., Maurer, L., House, K., Carroll, J., & VanHorn, R. (1996). Personal problem-solving scoring of TAT responses: Known groups validation. Journal of Personality Assessment, 67, 641–653.

Sahin, N. (1993). Psychometric properties of PSI in a group of Turkish university students. Cognitive Therapy and Research, 17, 379–396.

Schwartz, C. A. (1932). Social-situations pictures in the psychiatric interview.

American Journal of Orthopsychiatry, 2, 124–133.

Teglasi, H. (2001). TAT and other storytelling techniques assessment. Hoboken, NJ: John Wiley & Sons.

Weiner, I. B., Greene, R. L., & Roger, L. (2008). Handbook of personality assessment.

Hoboken, NJ: John Wiley & Sons.

Westen, D (2002). Social Cognition and Object Relations Scale (SCORS): Manual for coding TAT data. Retrieved from http://www.psychology.emory.edu/clinical/ westen/index.html Tereza Soukupova Charles University in Prague Psychiatricka nemocnice Bohnice Ustavni 91 181 02 Prague 8 Czech Republic E-mail tsoukupova@gmail.com

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Appendix PPSS-R Scoring Sheet1 The scoring criteria are applied using the main character and the main problem situation. Although whole numbers are used to designate response options (–1, 0, 1, 2, 3), the use of a midpoint (e.g., 1.5) is acceptable.

Calculating Scores Four component scores and a total per-card score are obtained for each TAT card. Three of the component scores – Story Orientation, Story Design, and Story Resolution – are derived by summing up the scores for each of the elements associated with that particular component and dividing the total by 4. The Story Solutions score is derived from adding the number of story solutions generated. The per-card scores are obtained by adding the four component scores. The per-card component scores are added to obtain aggregate component scores. Aggregate component scores are added to obtain a total PPSS-R score.

• Card Number • Main Character • Problem • Story Solutions • Story Resolution

PPSS-R Score

• • • • •

1

Story Design: SD (SD1 + SD2 + SD3 + SD4)/4 = Story Orientation: SO (SO1 + SO2 + SO3 + SO4)/4 = Story Solution: number of overt and covert story solutions = Story Resolution: SR (SR 1 + SR2 + SR3 + SR4)/4 = Total: (SD + SO + SS + SR) =

From Scoring Manual for PPSS-R (Ronan & Gibbs, 2008).

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Summary This study examined personal problem solving skills in the situation of legal divorce proceedings. For this purpose, we decided to use the Thematic Apperception Test (TAT) for it’s suitability to assess quality of social relations and personal coping strategies. TAT is a valid instrument in this field because it contains explicit social pull. We evaluated collected stories through Personal Problem-Solving SystemRevised (PPSS-R) by G. F Ronan. PPSS-R consists of four fundamental components: Story Design, Story Orientation, Story Solution and Story Resolution. Three of these components are composed of 4 elements which describe partial qualities of each component.

40 TAT protocols from 20 couples (20 male and 20 female) were coded for detection and comparison to capability of their personal problem solving. We used cards 1, 2, 6GF, 6BM, 10, 13MF, 18GF, and we compared the values reached in PPSS-R by men and women for each component and each element for every card.

Statistically significant results indicated that with Card 1 men more often see the cause of the problem as being removable. In relation to Card 6BM, women, more often than men, used emotions generated from the problem to orient themselves within the problem. With Card 6GF women had higher personal control; they more often used emotions generated from the problem to orient themselves in the problem and their stories contained more optimism compared to men’s stories.

With Card 13MF, the level of stress of men was more reduced compared to women, and men were more able to plan in the context of problem solving. Card 13MF showed that men found it easier to elicit strategies to help solve a problem.

Significant differences in the examined groups were found in those cards which depicted significant gender and parental potentials. Results indicated that for personal problem-solving men utilize more cognitive strategies and women more emotional ones. Within clinical assessment it is important to compare the personal problem-solving skills used within each particular couple. Differences and similarities are important guidelines for forensic assessment, counseling, or psychotherapy.

Souhrn Studie se veˇnuje schopnostem ˇresˇit osobní problémy v rozvodové situaci. Rozhodli jsme se pro tento úcˇel pouzˇít Tématický apercepcˇní test (TAT), který se ukazuje jako vhodný nástroj pro meˇˇrení kvality sociálních vztahu˚ a osobních zvládacích strategií. TAT je pro tuto oblast validním nástrojem, protozˇe obsahuje explicitní sociální výzvu. Vyhodnotili jsme získané prˇíbeˇhy skórovacím systémem G.F.Ronana Personal Problem- Solving System-Revised (PPSS-R). PPSS-R je tvorˇen cˇtyrˇmi základními dimenzemi: Story Design – Provedení prˇíbeˇhu, Story Orientation – Orientace prˇíbeˇhu, Story Solution – Navrzˇená ˇresˇení prˇíbeˇhu a Story Resolution – Vyrˇesˇení prˇíbeˇhu. Trˇi z teˇchto dimenzí jsou tvorˇeny dalsˇími cˇtyrˇmi subdimenzemi, které popisují kvality, jimizˇ jsou dimenze tvorˇeny.

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Personal Problem Solving of Partners Protokoly TAT 20 páru˚ v rozvodovém ˇrízení (20 protokolu˚ muzˇu˚ a 20 protokolu˚ zˇen) byly hodnoceny z hlediska posouzení schopnosti ˇresˇit osobní problémy a s cílem porovnat tuto schopnost u muzˇu˚ a u ˇzen.

Pouzˇili jsme TAT tabule 1, 2, 6GF, 6BM, 10, 13MF, 18GF abychom porovnali hodnoty dosazˇené pomocí PPSS-R mezi muzˇi a zˇenami pro kazˇdou dimenzi a subdimenzi vsˇech pouzˇitých tabulí.

Výsledky na hladineˇ statistické významnosti ukazují, zˇe na tabuli 1 muzˇi cˇasteˇji povazˇují prˇícˇinu problému za odstranitelnou. Na tabuli 6GF uvádeˇjí zˇeny vysˇˇsí osobní kontrolu, cˇasteˇji vyuzˇívají své emoce ke zvládnutí problému a jejich prˇíbeˇhy jsou optimisticˇteˇjsˇí, nezˇ prˇíbeˇhy muzˇu˚. Na tabuli 6BM zˇeny cˇasteˇji pouzˇívají emoce pomáhající k vyrˇesˇení problému. Muzˇi uvádeˇjí významneˇjsˇí redukci osobního stresu na tabuli 13MF a na této tabuli jsou schopni cˇinit rozhodnutí v kontextu ˇresˇení problému. Na této tabuli snáze vytvárˇejí zvládací strategie vedoucí k ˇresˇení problému.

Výsledky sveˇdcˇí o tom, zˇe muzˇi k ˇresˇení mezilidských problému˚ vyuzˇívají více strategie kognitivní a zˇeny více vyuzˇívají strategie emocˇní. Pro klinické posouzení je nejdu˚lezˇiteˇjsˇí porovnat schopnosti ˇresˇit mezilidské problémy v rámci kazˇdého páru.

Zjisˇteˇné podobnosti a rozdíly jsou du˚lezˇité v situaci forenzního posuzovaní a pro eventuální psychoterapii nebo poradenskou intervenci.

Résumé Le test projectif TAT (Thematic Apperception Test, Murray, 1943) est l’une des techniques projectives les plus fréquemment employées. Les systèmes formels de notation sont utiles pour évaluer les histoires inventées sur la base de ce test. Cellesci, conçues par 20 hommes et 20 femmes en instance de divorce, ont été codées afin de détecter et comparer les modes de résolution de leurs problèmes personnels.

Le système de notation retenu est celui mis au point par George F. Ronan, le PPSS-R (Personal Problem Solving System-Revised). Les résultats indiquent que, pour la planche 1, les hommes estiment plus fréquemment que l’origine du problème peut être éliminée. Pour la planche 6GF, les femmes font preuve d’une plus grande maîtrise de soi, utilisent plus souvent leurs émotions afin de surmonter leurs problèmes et se montrent plus optimistes dans leurs récits que les hommes. Pour la planche 6BM, les femmes ont eu davantage recours que les hommes aux émotions suscitées par leur problème pour s’y orienter. Les hommes font preuve d’un niveau de stress moindre pour la planche 13MF et sont capables de prendre des décisions dans le cadre de la résolution de leurs problèmes. Nous relevons des différences au sein des groupes observés pour les planches particulièrement liées à la thématique du genre ou à celle de la parentalité. Dans le cadre de la pratique clinique, le PPSS-R se révèle être un instrument utile pour évaler les compétences mises en oeuvre au sein d’un couple pour résoudre leurs problèmes personnels. Le test TAT nous permet de mettre en évidence les caractéristiques personnelles et les différences liées au genre.

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Resumen Este estudio examina habilidades de resolución de problemas personales en el proceso del divorcio. Hemos decidido emplear el Test de Apercepción Temática (TAT) lo que parece ser un instrumento adecuado para medir la calidad de las relaciones sociales y las estrategias de afrontamiento personal. TAT es un instrumento válido en este ámbito, ya que contiene un reto social explícito. Las historias obtenidas se evaluaron a través de Personal Problem- Solving SystemRevised (PPSS-R) de G.F.Ronan. SSPP -R consiste de cuatro componentes fundamentales: Story Design - Diseño de la historia, Story Orientation – Orientación de la historia, Story Solution – Solución de la historia y Story Resolution – Resolución de la historia. Tres de estos dimensiones se componen de 4 subdimensiones que describen las cualidades parciales de cada dimensión.

40 protócolos de TAT de 20 parejas (20 varones y 20 mujeres) fueron evaluados en términos de evaluar la capacidad de resolucionar las problemas personales y comparar esta capacidad entre los hombres y las mujeres.

Se utilizaron las láminas 1,2, 6GF, 6 BM, 10, 13MF, 18GF para comparar los valores obtenidos con el SSPP -R entre los hombres y las mujeres para cada dimensión y subdimensión en todas las láminas.

Los resultados al nivel de significancia indican que los hombres en la lámina 1 consideran a menudo la causa del problema como eliminable. En la lámina 6GF las mujeres reportaron un mayor control personal y sus historias son más optimistas que las historias de los hombres. En la lámina 6GF las mujeres están motivadas por el problema para solucionarlo más que los hombres. Los hombres informaron una mayor reducción en el estrés personal en la lámina 13MF y son capaces de tomar decisiones en el contexto de la resolución de problemas en esta lámina. En esta misma lámina forman más fácilmente unas estrategias de afrontamiento para enfrentar al problema.

Los resultados indican que para la solución de problemas personales los hombres utilizan más las estrategias cognitivas y las mujeres las emocionales. Para la evaluación clínica, es importante comparar la capacidad de resolver los problemas interpersonales dentro de cada pareja. Diferencias y similitudes son importantes para la evaluación forense, la intervención de asesoramiento o la psicoterapia.

要約 本研究は法的に離婚が進行している状況における個人の問題解決スキルを吟味している。こ の研究目的のためにわれわれは主題統覚検査（TAT）を使用することに決定した。というの はこの検査が社会関係や個人の対処戦略の質をアセスメントするのに適しているからであ る。 TAT は、明確な社会関係性を含んでいるので、この領域で妥当な方法である。 私たちは収集された物語を、 G.F. Ronan による個人の問題解決システム改訂版（PPSSR）によって評価した。PPSS-R は ４ つの基本的な構成要素から構成されている：物語の デザイン、物語の方向性、物語の解決、物語の硬さ。これらの構成要素のうち ３ つ は、それぞれの構成要素の部分的な質を記述する ４ つの要素から構成されている。

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Personal Problem Solving of Partners ２０ のカップル（２０ 名の男性と２０ 名の女性）からえられた４０ の TAT プロコト ルが彼らの個人の問題解決の能力を調べ、比較するためにコード化された。われわれは １、２、６GF、６BM、１０、１３MF、１８GF の図版をもちい、われわれはそれぞ れの図版のそれぞれの構成要素のそれぞれの要素の、男性と女性による PPSS-R で到 達した値を比較した。 統計的に有意な結果は、図版１で男性は問題の原因はより除去可能であると見て いることを示した。図版 ６BM に関して言えば、女性は男性よりも、問題の中で彼らに向け られた問題から発生してくる情緒を使用することが多かった。図版 ６GF については、女性は より高い個人の統制を有しており、問題の中で彼らに向けられた問題から発生してくる情緒を 使用することが多く、彼らの物語には男性の物語に比較して楽観性がより含まれていた。図 版１３MF については、男性のストレスレベルは女性に比較してより低減されており、男性は 問題解決の文脈を説明することがより可能であった。 分析された群において有意差は、重要なジェンダーや親としての可能性が描かれている 図版において見出された。本研究の結果によれば、個人の問題解決に関して言えば、男 性はより認知的な方略を用い、女性は情緒的なものをより用いることを示していた。臨床アセス メントにおいて、すべての特定のカップルにおける個人の問題解決スキルを比較することはもっと も重要なことである。差異や類似性は法医学の領域におけるアセスメントやカウンセリン グ、心理療法の重要なガイドラインである。

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Rorschachiana 36, 104–106 © 2015 Hogrefe Publishing

DOI: 10.1027/1192-5604/a000061

Book Review Brainwashed Nicolae Dumitrascu1 and Joni L. Mihura2 1

2

Danielsen Institute at Boston University, Boston, MA, USA, Department of Psychology, University of Toledo, Toledo, OH, USA

Sally Satel & Scott O. Lilienfeld. (2013). Brainwashed: The Seductive Appeal of Mindless Neuroscience. New York, NY: Basic Books. ISBN (softcover) 978-0-465-01877-2, US $26.99.

“Brains are hot,” state the authors of this interesting and easy-to-read book on neurocentrism (i.e., the view that our all our behaviors and experiences can be explained from the perspective of the brain), which became a mythology now enthusiastically embraced by media and the public.

Dr. Satel (a psychiatrist) and Dr. Lilienfeld (a psychologist) attempt to cool down this “hotness” of the brain in their book by deconstructing the inflated assumptions of neurocentrism.

Modern brain imaging (functional magnetic resonance imaging [fMRI]) is the authors’ main target, as fMRI became arguably the icon of science making visible the esoteric complexity of the brain and thus offering the illusion of the ultimate understanding of the mind: As Satel and Lilienfeld state, “With its implied promise of decoding the brain, it is easy to see why brain imaging would beguile almost anyone interested in pulling back the curtain of the mental lives of others: politicians hoping to manipulate voter attitudes, marketers tapping the brain to learn what consumers really want to buy, agents of the law seeking an infallible lie detector, addiction researchers trying to gauge the pull of temptations, psychologists and psychiatrists seeking the causes of mental illness, and defense attorneys fighting to prove that their clients lack malign intent or even free will.”

The book begins with a basic overview of brain imaging (fMRI) that intends to give the reader an understanding of brain organization, how brain scans are constructed, and the limits of drawing conclusions about specific emotions or thoughts simply from examining fMRI results.

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The authors argue that, far from being a mirror of our mind, fMRI is subject to limitations – deriving from the nature of the brain (e.g., there is no one-to-one correspondence between a particular brain area and a particular psychological experience) and fMRI methodology – that are often overlooked. While their presentation is instructive and accessible to nonspecialists, the reader may find some scarcity of technical details about how fMRI works. Also, one of the limitations of fMRI – the issue of false-positive findings due to statistical error – is a common issue in research that is not specific to fMRI. After an overview of brain imaging, the authors turn their attention to some of the misapplications of neuroscience in the areas of marketing, psychology of addiction, and law. For instance, the authors challenge the statement made by “neuromarketers” that fMRI offers an accurate reflection of buyers’ intentions and desires by measuring their brain reactions to products or their advertising. Satel and Lilienfeld argue that, while neuromarketing is not necessarily “junk science,” there is no compelling evidence that it is a more effective method to measure or influence people’s buying decisions compared with the traditional marketing methods. In part, the role of fMRI in marketing is hard to assess due to the lack of transparence of neuromarketing companies concerning their research methodology and related findings.

From the desire to buy, the authors turn to the issue of pathological desire – addiction. While Satel and Lilienfeld acknowledge the advances in neuroscience showing that addiction “entails both biological alterations in the brain and in deficit of personal agency,” they also assert that “the fact that addiction is associated with neurobiological changes is not, in itself, proof that the addict is unable to choose.” Thus, they challenge the medical model of addiction as a chronic and incurable disease and argue that this model (supported by fMRI “evidence”) distracts the attention from finding valuable treatments of addiction based on environmental and psychological factors rather than solely on medication: “The most effective interventions aim not at the brain but at the person. It’s the minds of addicts that contain the stories of how addiction happens, why people continue to use drugs, and, if they decide to stop, how they manage to do so. This deeply personal history can’t be understood exclusively by inspecting neural circuitry.”

No less interesting is the chapter dedicated to the utility of neuroimaging in the area of law. Can fMRI be used as accurate evidence for lying?

Are scans showing differences in psychopaths’ brains indicative of their inability to resist their murderous impulses? Can we remove the idea of 105

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personal responsibility in criminal court cases based on brain imaging?

Or, more generally, “Will our knowledge about the brain necessitate a radically new way of thinking about human beings as moral agents worthy of blame and praise?” The authors conclude that science will never be able to address the issue of free will and responsibility, because this is not an empirical issue.

Brainwashed is not necessarily a book for readers avid for more technical information (e.g., about how brain scan works). There are many historical details, quotes from authority figures in the field, and anecdotal evidence mixed with research findings supporting the authors’ ideas. The authors intend to convey a balanced message, as they do not deny the merits of neuroscience in understanding behavior, but call for healthy skepticism and humility in treating the new scientific discoveries as the absolute Truth. However, sometimes the reader has the impression of a too “black-and-white” view. Also, the reader may be left with the impression that there are too few ideas discussed in too many pages.

On the more positive side, Brainwashed is written in an alert and captivating style, and one of its important merits is that it is accessible to nonspecialists. The overarching goal of the book is to increase people’s awareness about how easily science can turn to pseudoscience that can be used to fool or mislead us. As Satel and Lilienfeld state, “Naı¨ve media, slick neuroentrepreneurs, and even an occasional overzealous neuroscientist exaggerate the capacity of scans to reveal the contents of our minds, exalt brain physiology as inherently the most valuable level of explanation for understanding behavior, and rush to apply underdeveloped, if dazzling, science for commercial and forensic use.” To a large extent, one can say that the authors attained this goal.

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Rorschachiana 36, 107–109 © 2015 Hogrefe Publishing

DOI: 10.1027/1192-5604/a000066

Book Review Multimethod Clinical Assessment Marianne Nygren Private Practice, Stockholm, Sweden

Hopwood, C. J., & Bornstein, R. F. (2014). Multimethod Clinical Assessment .

New York, NY: The Guilford Press. ISBN (hardcover) 978-1-4625-1601-8, US $60.00. ISBN 978-1-4625-1614-8 (e-pub), US $60.00.

This is an important book of high quality. The goal formulated by the editors is: “To strengthen the links between evidence-based multimethod assessment and clinical practice by providing systematic reviews of how to incorporate diverse assessment techniques in the laboratory, clinic, and consulting room.”

This ambition makes the book valuable for different groups of readers: students, clinicians, and researchers. For the clinician looking for an up-to-date presentation of assessment methods that can be used in combination, the book is a rich source of information. The reader wanting to learn more about the pros and cons of different clinical assessment methods will find insightful and informative discussions in several chapters. For researchers in clinical assessment the book is also informative: different authors describe the status concerning research in their fields. Moreover, the integrative ambition also makes the book suitable for readers with different theoretical backgrounds.

The three parts of the book cover the major domains of clinical assessment. The section “Personality and Individual Differences” throws light on the fundamental value of personality science in clinical assessment.

The section “Psychopathology and Resilience” is not organized around discrete diagnostic categories, but instead around evidence-based dimensions of personality. Finally, in the “Clinical Management” section, aspects not covered in initial assessments are in focus.

The invited authors were instructed to discuss assessment methods for key constructs in their field, review empirical evidence supporting 107

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integration of the methods discussed, and to present a case where the described assessment methods had been clinically useful. As a result the chapters have a similar structure and this facilitates their reading.

In a short review, it is not possible to comment meaningfully on the separate contributions. However, there are important aspects that are focused on by many of the authors. Commenting on some of these aspects may give the reader an idea of the value of the book.

Assessment Methods The main kinds of assessment methods elucidated in the book are selfreports, performance-based measures, and informant reports. Some authors also describe behavioral measures, use of archival data, and observer reports. Traditional and novel, explicit and implicit, and sometimes even pioneering assessment methods from basic science are presented.

For most psychological assessments the constructs measured are nomothetic and assumed to be relatively stable over time. However, in clinical work, idiographic variables often have a central value and the same is true for variables fluctuating over time. This is elucidated in a fascinating way in the chapters on process assessment, risk assessment, and assessment of affective processes.

Incremental Validity In the introduction chapter, Hopwood and Bornstein point out that it is only by insight into the processes engaged in different tests that we can understand the convergences and the divergences between them.

Traditionally, psychologists have assessed the validity of one instrument by its correlation with other similar instruments. Thus the value of incremental validity, already formulated by Campbell and Fiske in 1959, has been overlooked. Modest correlations between two methods that each validly predicts different aspects of behavior tell us that the methods provide incremental clinical validity. This is elucidated throughout the book when different authors stress the importance of incremental validity.

The discussion of incremental validity is especially informative in the chapter on multimethod assessment and treatment planning.

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Book Review

Diagnostic Models In almost every chapter it is stressed that the assessment methods described give valuable information beyond that supplied by categorical psychiatric diagnoses or unimodal assessments. The book elucidates how a more frequent use of personality assessment instruments has a positive impact on the assessment and understanding of psychopathology. In the final chapter, the editors emphasize this; as distinguished from the descriptive symptom-focused categorical diagnostic system used in contemporary psychiatry, factor models from quantitative psychology yield structures common across normality and different kinds of pathology.

This opens up possible explanations of symptoms and behaviors that seem conflicting in a categorical system. Moreover, the combination of moderately correlated valid assessment methods gives incremental clinical utility compared with the information achieved by psychiatric diagnosis or assessment with only one instrument or strongly correlated instruments.

Despite all the clear advances of multimethod clinical assessment, many psychologists use unimodal assessment. The reason, according to most of the authors, is related to habit, economic aspects, time aspects, and lack of insight into the importance of incremental clinical utility. This may lead to less-than-optimal treatments and unnecessary suffering for the patients, and in the long run to unnecessarily high costs. However, more knowledge and research concerning how to integrate instruments with only modest correlations are needed. Hopefully, this valuable book will inspire both clinicians and researchers to intensify their efforts in the field. This is a book that I warmly recommend to clinical assessors of different theoretical orientations.

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