Journal of Personality Assessment - Marianne Nygren [Articol (de Tradus)]

7/27/2019 Journal of Personality Assessment - Marianne Nygren [Articol (de Tradus)]

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Rorschach Comprehensive System Variables

in Relation to Assessing Dynamic Capacityand Ego Strength for Psychodynamic PsychotherapyNYGRENCSANDPSYCHOTHERAPY

Marianne Nygren

Department of Psychology

Stockholm University

Few studies have concerned the relation between Comprehensive System (CS; Exner, 1991,

1993, 2003) Rorschach variables, and suitability for psychodynamic psychotherapy. In this

study, I predicted correlations between 17 rationally selected CS variables and suitability forpsychotherapy as represented by ratings of Dynamic Capacity and Ego Strength. The partici-

pants were 52 psychotherapy applicants between 20 and 57 years old. The ratings were per-

formed after clinical interviews anddecisionsconcerningselectionof theapplicants. EA,FC,

Blends, Zf, and MQo correlated positively and YFY negatively with Dynamic Capacity rat-

ings, whereas EA, FC, and Blends correlated positively and YFY and F% negatively with

Ego Strength ratings. EA, FC, YFY, Zf, MQo, and F% also differed between the applicants

selected and those not selected for psychotherapy. Considering earlier research, the results

for Blends, Zf, and F% were interpreted as replications and for MQo and EA as showing sat-

isfactory consistency.

There are few studies of the Rorschach Comprehensive Sys-

tem (CS; Exner, 1991, 1993, 2003) that have focused on as-

pects of ego functioning related to suitability forpsychodynamic psychotherapy. However, this area has been

researched over the past 20 years with other methods yield-

ing positive findings. Researchers have shown considerable

interest in psychological mindedness, quality of relations,

and motivation as possible predictors of completion and out-

come of psychodynamic psychotherapy and of the pa-

tienttherapist relationship.

Conte et al. (1990) developed a self-report instrument

with good internal consistency, the Psychological Minded-

ness Scale (PMS), and carried out a study to determine if this

instrument can predict outcome of psychodynamically ori-

ented psychotherapy. PMSwaspositively correlated with the

number of psychotherapy sessions attended by the patients

and with outcome. In a study of construct validity, Conte,

Buckley, Picard, and Karasu (1995) showed that PMS was

related to being sociable, assertive, not submissive, and ac-

cepting of othersandthat it wasalso related to egostrength.

Hglend, Engelstad, Srbye, Heyerdahl, andAmlo (1994)

used clinical ratings to measure the pretreatment level of in-

sight, a variable that is related to psychological mindedness.

In accordance with their predictions, Hglend et al. (1994)

found that pretreatment insight was inversely related to drop-

ping out from individual psychodynamic psychotherapy.

Hglend et al. (1994) also found that in interaction with treat-

ment length, insight was significantly related to outcome 2and 4 years after treatment.

The Psychological Mindedness Assessment Procedure

(PMAP) described by McCallum and Piper (1990b) is an-

other measure of psychological mindedness that has dem-

onstrated good reliability and validity. It is constructed on

the basis of psychodynamic theory and employs a standard-

ized videotape-interview procedure. In two studies of

short-term psychoanalytically oriented group psychother-

apy, PMAP emerged as highly predictive of attrition but

not of outcome (McCallum & Piper, 1990a) and as a stron-

ger predictor of dropping out than psychiatric symptoms

and severity of target objectives (McCallum, Piper, &

Joyce, 1992). In a day treatment program for patients with

severe psychological problems (Piper, Joyce, Rosie, &

Azim, 1994), univariate analyses showed significant posi-

tive association both between PMAP and patients capacity

to work in group therapy and between PMAP and outcome.

In multivariate analyses, both PMAP and patients work in

group therapy were independently related with outcome.

Tasca et al. (1999) studied patients with serious emotional,

coping, and interpersonal problems treated in a mainly

group therapy based hospital program and found that

JOURNAL OF PERSONALITY ASSESSMENT, 83(3), 277292

Copyright 2004, Lawrence Erlbaum Associates, Inc.


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chronicity of psychiatric problems and PMAP emerged as

significant single predictors of completion.

Pretreatment quality of patients interpersonal relations is

another variable that has interested researchers and that has

been studied in combination with psychological mindedness.

In a review of research on quality of object relations and

short-term psychodynamic psychotherapy, Piper andDuncan (1999) discussedpossible clinical implications of as-

sessments of quality of object relations with focus on actual

(observed or reported) behavior. One such implication is that

assessment of quality of object relations can give informa-

tion that is valuable and relevant for interpretations of trans-

ference in psychodynamic psychotherapy. Baumann et al.

(2001) studied the reliability and validity of the Capacity for

Dynamic Process Scale (CDPS), developed by Thackrey,

Butler, and Strupp (1993). According to Baumann et al., the

nine basic areas of CDPS cover three aspects of therapeutic

collaboration: modulation of affect, interpersonal relations,

and insight or introspection. Baumann et al. showed that

CDPS can be reliably scored, that it is internally consistent,and that it has discriminant validity in relation to two Diag-

nostic and Statistical Manual of Mental Disorders (4th ed.

[DSMIV]; American Psychiatric Association, 1994) Axis V

rating scales (Global Assessment of Functioning and Global

Assessment of Relational Functioning) and to self-report

measures of psychopathology and interpersonal functioning.

For theDSMIVAxis V ratingscale SocialandOccupational

Functioning Assessment, there was no significant relation

with external rater scoring of the CDPS, but the correlation

with therapist ratings was significant. Moreover, CDPS was

shown to differentiate between patients terminating psycho-

therapy prematurely and remainers, and there was also some

evidence that the CDPS is related to therapeutic alliance.Piper, Joyce, McCallum, and Azim (1998) addressed the

question if quality of interpersonal relations and psychologi-

cal mindedness can predict whether interpretive or support-

ive therapy will be most suitable for the patient. Quality of

relations turned out to be significantly related to improve-

ment in individual interpretive but not in supportive therapy,

whereas psychological mindedness had a significant rela-

tionship with outcome for the interpretive and supportive

groups taken together. There was no significant relationship

between dropping out and quality of object relations or be-

tween dropping out and psychological mindedness. At fol-

low-up after 6 and 12 months, the relation between quality of

object relations and outcome was maintained, whereas there

were no follow-up effects for psychological mindedness

(Piper, Azim, McCallum, Joyce, & Ogrodniczuk, 1999).

When the data were analyzed with hierarchical linear model-

ing, somewhat contradictory results were obtained; quality

of object relations was related to outcome in supportive but

not in interpretive therapy (Ogrodniczuk, Piper, Joyce, &

McCallum, 2001).

Moras and Strupp (1982) studied short-term

psychodynamic psychotherapy and as predicted, they found

positive and significant correlations between quality of

pretherapy interpersonal relations, therapeutic alliance, and

positive collaboration in therapy. The results also suggested

a positive relation between quality of interpersonal relations

and outcome of psychotherapy. In a study of short-term indi-

vidual psychodynamic psychotherapy by Piper et al. (1991),

quality of object relations was significantly related to bothpatient-rated and therapist-rated therapeutic alliance and to

improvement both of general symptoms and specific target

problems. Both quality of interpersonal relations and psy-

chological mindedness were directly related to outcome in a

psychodynamic group-oriented day treatment program for

patients with severe psychological problems (Piper, Joyce,

Azim, & Rosie, 1994); quality of object relations was related

to two of three outcome factors, and psychological minded-

ness was directly related to favorable outcome for three out-

come factors. Hglend (1993) studied quality of

interpersonal relations and DSMdiagnoses in relation to out-

come of dynamic individual psychotherapy of brief to mod-

erate length. Hglend (1993) found that the collectivecontribution of quality of interpersonal relations, the Global

Assessment Scale (Axis V; DSM[3rd ed.; American Psychi-

atric Association, 1980), and presence versus absence of per-

sonality disorders significantly predicted dynamic change

(i.e., better interpersonal relations and self-esteem, new

self-understanding or insight, and increasedproblem-solving

capacity) but not symptomatic change.

Clinicians and researchers have long emphasized motiva-

tion as a crucial variable for predicting how an individual

will benefit from psychotherapy (Garfield, 1994; Orlinsky,

Grawe, & Parks, 1994; Roth & Fonagy, 1996). Sifneos

(1978), who found that motivation related to successful out-

come of psychotherapy (short-term and long-term), usedseven criteria to assess motivation for change: ability to rec-

ognize the psychological nature of symptoms; tendency to

give honest and truthful accounts of emotional difficulties

coupled with introspection; willingness to participate ac-

tively in the treatment; willingness to change, to explore, and

to experiment; curiosity and willingness to understand one-

self; realistic expectations of therapeutic outcome; and will-

ingness to make reasonable sacrifices. These criteria have

later constituted a base in other studies of motivation and

psychodynamic psychotherapy. Keithly, Samples, and

Strupp (1980) studied motivation, measured with a scale that

was mainly based on Sifneoss criteria, in relation to out-

come and process in short-term dynamic psychotherapy.

Keithly et al.s results suggested that pretherapy patient mo-

tivation is related to patienttherapist interaction (inversely

related to negative therapist attitude and patient hostility and

positively related to patient active participation in therapy),

especially early in psychotherapy. Hglend (1996) used

seven motivation items modified after Sifneos andfound that

two of these criteria, motivation for change and realistic ex-

pectations, predicted outcome measured 4 years after termi-

nation of brief dynamic psychotherapy. A factor analysis of

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10 reliably rated selection criteria, modified after Sifneoss

selection criteria for brief dynamic psychotherapy, yielded

four dimensions of psychotherapy suitability: motivation,

circumscribed focus, flexible interaction with the evaluating

interviewer, and quality of object relations (Hglend,

Srbye, Srlie, Fossum, & Engelstad, 1992). A combination

of these factors predicted dynamic but not symptomatic out-come of psychodynamic psychotherapy of brief to moderate

length.

RESEARCH ADDRESSING THE CS

AND PSYCHODYNAMIC PSYCHOTHERAPY

Thus, there is a wealth of studies demonstrating that espe-

cially psychological mindedness, quality of object relations,

and motivation are related to psychotherapy outcome, favor-

able patienttherapist relationship, or completion of therapy.

The assessment methods have mostly been ratings by inter-

viewers or observers, the PMAP (McCallum & Piper,1990b), and patients self-ratings. In contrast, CS studies of

the problem area are few. However, there is a limited evi-

dence of the validity of some CS variables in assessment for

dynamic psychotherapy (Alpher, Perfetto, Henry, & Strupp,

1990; Bihlar & Carlsson, 2000, 2001; Exner &

Andronikof-Sanglade, 1992; Garfield, 1994; LaBarbera &

Cornsweet, 1985; Meyer & Handler, 1997, 2000; Nygren,

2004; Weiner & Exner, 1991).

Alpher et al. (1990) studied 15 rationally chosen variables

from the CS structural summary in relation to the CDPS,

which focuses on the patients capacity to collaborate thera-

peutically during a semistructured interview. As mentioned

earlier, Baumann et al. (2001) studied the reliability and va-lidity of the CDPS with positive results. The clinician con-

ducting the interview in theAlpher et al. (1990) study carried

out the CDPS ratings of the patient immediately after per-

forming the interview. Moreover, independent judges rated

the CDPS after viewing videotapes of the interviews.

The CS scores selected by Alpher et al. (1990) were Hu-

man Movement responses (M), Blends, Pure Form propor-

tion (Lambda), Organizational Activity (Zf), percent poor

Form responses (X %), number of Responses (R), Experi-

ence Potential (ep; now called Experienced Stimulation

[es]), Deviant Responses (DR), Form-dominated Chromatic

Color (FC/CF+C), Pure Form responses (F), Egocentricity

Index, unadjusted D, InanimateMovement (m), White Space

responses (S), and Texture responses (T).

To calculate the degree of association between the CS

variables and the ratings of CDPS, a five variable, stepwise

regression model was used. For the clinician ratings, the re-

gression containing the CS variables Zf, DR, es, Sum T, and

Lambda was significant, F(5, 36) = 5.45, p < .001, and R was

.66, n = 41. The regression was also significant for theratings

by the independent judges, F(5, 28) = 6.01, p < .001, R being

.71, n = 34. The CS scores in this regression were Zf, DR, es,

Blends, and m. Thus, for the clinicians ratings and the rat-

ings by the independent judges taken together, Zf, DR, es,

Sum T, Blends, and m turned out to be positively and

Lambda negatively related to the ratings of patients poten-

tial for engaging in the process of a dynamic psychotherapy.

However, es turned out to be a suppressor variable, that is, a

variable sharing variance with the predictor variables but notpredictive of the criterion, and DR was interpreted to be a

possible positive predictor of a patients potential for engag-

ing in the process of a dynamic psychotherapy but only

given an otherwise intact personality (Alpher et al., 1990, p.

227).

Two exploratory studies concerning the CS and ther-

apy-goal formulations in psychodynamic psychotherapies

have been reported by Bihlar andCarlsson (2000, 2001).The

firststudy(Bihlar&Carlsson,2000)concernedagreementbe-

tween psychodynamically oriented therapists therapy-goal

formulations and patients problems as indicated by the CS.

For thepatient group inwhich thelevelof agreementbetween

therapists goals and patients problems was low, Bihlar andCarlsson (2000) argued that the Rorschach might provide in-

formation that can be difficult to obtain in pretherapy inter-

views. In the second study, Bihlar and Carlsson (2001)

compared CS scores for two groups of patients. In the first

group, there was a high level of agreement between the thera-

pistsplannedgoalsandthe actualgoalsreportedby thethera-

pists after therapy. In the second group, the agreement

betweenplannedandactualgoalswaslow.SelectedCSscores

differentiated these two groups. The results were interpreted

as indicating thatfor somepatients, thestandardclinicalinter-

view wasnotan adequate instrument to make assessments for

dynamic therapy and that additional instruments might yield

valuable information about the patient.LaBarbera and Cornsweet (1985) carried out a study in

which they predicted relations between psychological flexi-

bility, as represented by the constructs of instability and per-

ceptual sensitivity, and the outcome of dynamically oriented

treatment of child psychiatric inpatients. Rationally selected

CS scores measured instability and perceptual sensitivity.

LaBarberaandCornsweet found that children whobenefitted

from treatment demonstrated perceptual sensitivity as indi-

cated by lower Lambda scores, more Blend responses, and

more organizational effort (Zf and ZSum). The children who

benefitted from treatment also showed higher instability as

indicated by a greater difference between irritating stimuli

(es) and organizing resources (EA) than thechildren who did

not benefit from treatment.

There are also a few studies that give indirect support for

CS scores as indicators of patients suitability for psycho-

therapy. Two studies reported by Weiner and Exner (1991)

and by Exner and Andronikof-Sanglade (1992) in which

changes in CS variables were predicted as psychotherapy

outcome are relevant to psychotherapy outcome and give in-

direct support to the validity of some structural variables in

the Rorschach. Moreover, an index of Ego Strength derived

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from six components of the Rorschach test, the Rorschach

Prognostic Rating Scale (RPRS; Klopfer, Ainsworth,

Klopfer, & Holt, 1954), has been used with some positive re-

sults concerning psychotherapy outcome (Garfield, 1994;

Meyer, 2000; Meyer & Handler, 1997, 2000). However, the

RPRS is based on administration and scoring according to

theKlopfer et al.Rorschach tradition, so theresults cannotberegarded as direct support for the CS, even though the RPRS

was derived from scores similar to those in the CS.

Nygren (2004) studied psychotherapy patients from

three different units using the same set of rationally se-

lected CS scores as in this study. In that study, two groups

of patients who were sufficiently well functioning to bene-

fit from treatment limited to individual psychodynamic

psychotherapy on a once or twice weekly basis were com-

pared with a third group comprised of psychotherapy pa-

tients with personality disorders and serious psychological

problems for which an individually designed outpatient

program was deemed necessary.

The first group in Nygren (2004), a subsample from theparticipants in this study, consisted of 25 applicants person-

ally seeking and being selected for psychodynamic psycho-

therapy in an advanced psychotherapy training program. In

the training program, psychotherapy patients with rather well

developed ego functions were preferred. The second group

was a sample of psychotherapy outpatients from the Stock-

holm Comparative Psychotherapy Study (Carlsson, Nygren,

Clinton, & Bihlar, 1996). This group comprised patients that

received individual dynamic psychotherapy from authorized

private practicing psychologists paid by the County Council.

These patients either had been referred or had sought

psychotherapeutic help by themselves. In the third group, the

contrasted group, all patients had been referred from otherpsychiatric units to a special psychotherapy unit established

to treat patients with personality disorders using

psychodynamically oriented individually designed outpa-

tient programs. Patients were referred to the special unit if

they were deemed possible to help with psychodynamic psy-

chotherapy, even though there was a serious lack of motiva-

tion for treatment and low quality of object relations. As

shown earlier, lack of motivation and low quality of object

relations are patient characteristics that are related to unsatis-

factory outcome of psychodynamic psychotherapy.

Considering these differences in recruitment, Nygren

(2004)hypothesizedthatpatientsinthefirsttwogroupswould

have higher levels of variables related to suitability for

psychodynamic psychotherapy than the patients in the third

group. However, unlike this study, no systematic data on ego

functioning related tocapacities toengagein andbenefit from

psychotherapy were available for all groups. Consequently,

thepredictions aboutCS scoredifferencesbetweenthegroups

in the Nygren (2004) study had to be based on assumptions

about differences in therapy suitability between the groups.

For 8 of the selected CS variables, the results were in accor-

dancewiththepredictions.EA,Blends,Zf,MQo,FD,AG,and

COPwerehigher and F% lower among patients from the first

two groups than among patients from the third, contrasted

group. When just patients with personality disorders in the

second group were compared with the patients in the third

group,thepatternofsignificantdifferencesremainedthesame

except that the COP difference was no longer significant.

Like the studies by Alpher et al. (1990) and LaBarbera andCornsweet (1985), in this study and theNygren(2004) study,

I have focused on a selection of CS summary scores. How-

ever, the Rorschach can be coded and analyzed in different

ways. Jansonand Stattin (2003) elucidated this in a recent ar-

ticle and pointed out that Rorschach research has shifted be-

tween theobjectivecodingof discrete response elements and

global-holistic ratings. Although both approaches are valu-

able, since the advent of the Comprehensive System (Exner,

1991, 1993, 2003), research has focused mostly on discrete

codes, whereas research using a global-holistic approach has

become rare. However, research on global-holistic ratings

has been conducted on human drawings, and predictions

from intuitive ratings have been validated (Burley & Han-dler, 1997; Tharinger & Stark, 1990). Janson and Stattin

(2003) called attention to the fact that clinicians regularly

combine discrete codes into meaningful categories and that

the dichotomy between single-coded data and a

global-holistic approach, often forthcoming in research, may

seem artificial to clinicians. However, as Acklin (1992) and

Weiner (2000) pointed out, the importance of an integrative

approach in the interpretation of Rorschach data is central.

For such an approach, both the coding and the qualitative as-

pects of the Rorschach are important, and research concern-

ing the validity of the scores in the Rorschach in different

kinds of assessments is thus desirable.

Thepurposeof this studywasto investigate therelationbe-tweenthe interpretations of rationallyselectedstructural vari-

ables in the CS and clinical ratings of suitability for dynamic

psychotherapy. The broad concept of therapy suitability was

represented byDynamicCapacity(relatedto thepatientsper-

formance in the therapeutic situation) and Ego Strength. The

terms Dynamic Capacity andEgo Strength aredefined by the

ratingvariables presentedin Table1. Thevariables tobe rated

were formulated to represent limiting-potentiating continua

of Dynamic Capacity and Ego Strength.

This study differs from most of the earlier studies of the

CS and psychotherapy in the way that the CS scores were se-

lected and predictions formulated. The rational ground for

the selection of CS scores was that according to the interpre-

tations commonly assigned to them, it should be reasonable

to expect them to measure aspects related to Dynamic Capac-

ity and Ego Strength. The study most similar to this one is the

Alpher et al. (1990) study. However, in that investigation, al-

though the CS scores were rationally selected and related to

ratings of CDPS, the conceptual ground for the selection of

CS scores was not described.

As mentioned, Nygren (2004) used the same set of CS

variables as in this study. However, that study compared

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groups that were supposed to differ in aspects that are central

for therapy suitability, although no individual data other than

the Rorschach were available for comparison between the

groups. In this study, I assessed all individuals, and motiva-tion (a variable supposed to be especially low in the con-

trasted group in the Nygren, 2004, study) was but one of

several patient variables rated.

In summary, the central issue addressed by this study was

the following:Are interpretations commonly associated with

the CS supported by their relation to clinical ratings to which

they should, on conceptual grounds, be related? I tested hy-

potheses concerning correlations between 17 rationally se-

lected CS variables and clinical ratings performed for this

study. Moreover, I also carried out analyses of the differ-

ences in CS variables between those applicants that were se-

lected for psychotherapy and those that were not accepted.

METHOD

Selection of CS Variables and the Rationale

of the Predictions

In this study and Nygren (2004), I have used the same set

of CS variables and formulated predictions from the same

conceptual foundation. Both studies are part of a broader

project that is conducted with the purpose to focus on the

same selection of CS scores in studies with different de-

signs. On conceptual grounds, the results of the studies in

the project are expected to be similar. Therefore, the resultsfrom one study do not influence the predictions of the

other. However, a consequence of this is that the predic-

tions that follow sometimes contradict what would have

been predicted if they had been based on the actual results

observed in the Nygren (2004) study.

Many of the CS scores selected are the same as those se-

lected by Alpher et al. (1990). Among the scores that re-

ceived positive results in that study, all except DR and es

were selected. DR, one of the Special Scores in the CS, was

not included because as mentionedearlier, Alpheret al. inter-

preted DR as a possible positive indicator for dynamic psy-

chotherapy only for patients with intact personalities. The es

score was not included because it operated as a suppressor

variable in Alpher et al.s study. Moreover, five CS variables

from theself and interpersonal perception cluster and twoCS

variables from the control and stress tolerance cluster were

included in this study but had not been used by Alpher et al.

The CS scores selected, the predictions formulated, and the

rationale for the predictions are presented following.

The control and stress tolerance cluster. EA (Ex-perience Actual) is the sum of M (Human Movement an-


TABLE 1

Rating Variables Concerning Dynamic Capacity and Ego Strength

Endpoint Categories

Variable Low High

Dynamic CapacityPsychological mindedness

A good psychological mindedness means capacity and inclination for self reflection and

introspection, capacity to both experience, feel, and think (1) Very insufficient (7) Very goodMotivation

Expected motivation to co-operate in psychotherapy (1) Very insufficient (7) Very goodCooperation

Expected capacity to establish therapeutic cooperation (1) Very insufficient (7) Very good

Ego StrengthReality testing capacity

Means the capacity to differentiate ones own inner world from outer surrounding realities, ones

own ideas and thoughts from the thoughts of others, fantasy from reality. (1) Very insufficient (7) Very goodCapacity for genuine relations

Means to be able to have enduring mutual relations with a real interest for the other person. (1) Very insufficient (7) Very goodSelf and object constancy

To be able to recognise good and bad aspects of one and the same person, also of oneself; to have an

integrated whole image of persons and to have a clear adequate border between oneself and others (1) Very insufficient (7) Very good

Impulse control

Capacity to control, in a reasonable way, ones own impulses, let thoughts direct actions, to workthrough conflicts within oneself instead of acting them out (1) Very insufficient (7) Very good

Access to a well-functioning defense structure

Means that one has not a small number of rigid defences but is able to use a variety of defence

mechanisms; is not dependent on primitive defenses, for example projection and denial sometimes

in combination with acting out (1) Very insufficient (7) Very good

Degree of realistic self-evaluationThe self-evaluation can be reasonable and realistic; it can also seem unreasonable and not rooted in

reality, but more built on the subjects private ideas and fantasies (1) Very unreasonable (7) Very reasonableGlobal rating of Ego Strength (1) Very low (7) Very good


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swers) and WSumC (Weighted Sum Color answers). In the

CS, EA is interpreted as indicating available resources and

capacity to implement deliberate coping strategies. It is con-

ceptualized as related to but not identical with Ego Strength

(Exner, 1991, 1993). EA was not selected in the Alpher et al.

(1990) study, but in the study by Nygren (2004), the predic-

tion that the values of EA should be higher in the groups ofpatients assumed to have greater therapy suitability received

support. In this study, I predicted EA to be positively related

to Dynamic Capacity and to Ego Strength.

The Form Dominant Color response, FC, is interpreted to

be related to affective experiences that are cognitively di-

rectedandbettercontrolled (Exner, 1993). Although a strong

dominance of FC responses can be a sign of very strong con-

trol of emotions, FC was regarded as indicating mainly posi-

tive capacities and was predicted to be positively correlated

with both Dynamic Capacity and Ego Strength. However, in

the Alpher et al. (1990) study, FC/CFC was not related to

CDPS, and in the study by Nygren (2004), the prediction that

thenumber of FCs shouldbe greater among patients assumedto be more suitable for dynamic psychotherapy did not re-

ceive support.

Diffuse Shading responses (FY, YF, and Y) are inter-

preted as indicating an experience of stress-related psycho-

logical helplessness and inability to influence ones situation

(Exner, 1991, 1993). In this study as well as in Nygren

(2004), I assumed that feeling unable to influence ones situ-

ation could make it difficult to be motivated for

psychotherapeutic cooperation. Meyer (1992), in a review of

earlier factor analytic studies of the Rorschach, found that

Form Dominant scores are qualitatively different from

non-Form Dominant scores. Moreover, it seems probable

that Form Dominance in Diffuse Shading answers is relatedto better ego functioning than non-Form Dominance

(Kleiger, 1992, 1997). However, in the study by Nygren

(2004), the number of YF + Y scores was not greater in the

group of patients assumed to be less suitable for

psychodynamic psychotherapy. The prediction I formulated

in this study was that thenumber of non-Form Dominant Dif-

fuse Shading answers, YF + Y, should be negatively corre-

lated with both Dynamic Capacity and Ego Strength.

InanimateMovement responses,m, another scorefrom the

es,are interpreted as indicating inner tensions anda feeling of

forces being outside the control of the participant. Often the

tension is interpreted to be of situational character (Exner,

1991, 1993). According to Weiner (1998), lack of m often in-

dicatesindifferenceandlackofconcern,whereaselevationsin

m indicate concern about being exposed to forces outside

ones control. Lerner (1991)discussedthe implications of the

m response from a psychoanalytical standpoint andviewed it

as indicating repressedmaterial coming into awareness in the

form of subjectively experienced tensions. Lerner suggested

that this gives an opportunity to establish contact around the

patientsfeelingsof distressandmakesthe individualaccessi-

ble to therapeutic intervention.Klopfer et al. (1954) discussed

Inanimate Movement as an indicator of inner tensions and of

an awareness of forces out of control indicating strength be-

cause the individual does not use dissociationand disintegra-

tion. Alpher et al. (1990) found that m related positively to

ratings onCDPS,but inthe study byNygren (2004), the num-

ber of m was not greater among the patients assumed to be

more suitable fortherapy.In this study,I predictedm tocorre-late positively with Dynamic Capacity.

Sum T, number of Texture responses, was positively re-

lated to CDPS as rated by the clinicians in the Alpher et al.

(1990) study. Most nonpatients give at least one T response,

usually an FT answer to Card VI, whereas patients give Tex-

ture responses less frequently (Exner, 1993). Sum T is inter-

pretedto be related to a capacity for close relations with other

persons. In the CS, an absence of T answers is interpreted as

indicating a tendency to be guarded and/or distant in inter-

personal contacts, whereas an elevation of T (T > 1) can indi-

cate stronger than usual needs to be dependent on others and

a feeling of emotional deprivation and interpersonal

neediness (Exner, 1993; Weiner, 1998). Exner (1993) foundthat therapists tended to rate T-less patients as less motivated

during the first 3 months of psychotherapy than they rated

patients with T answers. In the study by Nygren (2004), the

prediction concerning T responses was not verified. As both

T = 0 and T > 1 are interpreted as being related to problems

with closeness in relations, it is difficult to formulate predic-

tions for linear correlations. However, in this study, the pre-

diction that Sum T should be positively related to Dynamic

Capacity was motivated by the result received by Alpher et

al. (1990).

Blends, which consist of two or more determinants com-

bined in a single response, are mostly interpreted as involv-

ing some affective experience (Exner, 1991, 1993). Blendswere positively related to CDPS as rated by independent rat-

ers in the Alpher et al. (1990) study and in the study by

Nygren (2004); Blends were more frequent in the groups of

patients assumed to have higher levels of therapy suitability.

In the study by LaBarberaandCornsweet (1985), thenumber

of Blends of washigheramong children classified as improv-

ing. Few Blends might indicate difficulties in situations that

are emotionally complex. Although the psychological com-

plexity indicated by high proportions of Blends can be re-

lated to difficulties in dealing with affect for persons with

limited control resources, Blends often indicate an asset

(Exner, 1993). In this study, number of Blends was predicted

to be positively correlated to both Dynamic Capacity and

Ego Strength.

Cognitive triad: Information processing, ideation,and mediation. Frequency of Organizational Activity, Zf,

was positively related to CDPS in the Alpher et al. (1990)

study, and in the study by Nygren (2004), the prediction was

supported. In the LaBarbera and Cornsweet (1985) study,

children classified as improvers had more Zf responses than

children classified as decliners. In the CS, Zf is conceptual-

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ized as an indicator of willingness to attempt to synthesize

the world in a meaningful way. It is also regarded as being re-

lated to a persons ambitiousness and motivation (Exner,

1991, 1993). In this study, I predicted Zf to be positively re-

lated to Dynamic Capacity.

The relative amount of Pure Form responses is inter-

preted as being related to openness to experience, high val-ues indicating detachment and lack of flexibility (Exner

1991, 1993; Weiner, 1998). In this study, number of Pure

Form responses in relation to total number of responses,

F%, was used instead of the CS structural summary vari-

able Lambda (L). F% is conceptually and mathematically

comparable to L but has better properties for research

(Meyer, Viglione, & Exner, 2001). In the Alpher et al.

(1990) study, L was inversely related to CDPS. In the study

by Nygren (2004), the prediction that F% should be higher

among the patients supposed to be less suitable for psycho-

therapy was supported, and in the LaBarbera and

Cornsweet (1985) study, L was lower among the children

classified as improvers. In this study, I regarded lack offlexibility as related to rigid defenses, whereas I regarded

flexibility and willingness to become involved as indicating

a therapeutic asset. I predicted F% to be negatively corre-

lated to both Dynamic Capacity and Ego Strength.

Number of Human Movement responses, M, is generally

interpreted as being related to an inner-directed orientation

and a capacity for imagination and fantasy (Blatt & Ford,

1994; Exner, 1993; Lerner, 1991). Weiner (1998) contended

that accurately seen M responses(M+, MQo, andMQu) indi-

cate empathic capacity, whereas distorted M (M) responses

indicate lack of empathic capacity.M is an important score in

the RPRS in which M answers of good fit with the blot are

seen as indicating an asset and as a good prognostic sign(Klopfer et al., 1954). In the CS, as in the Klopfer et al. sys-

tem, M is scored according to Rorschachs criterion (Exner,

1993). Alpher et al. (1990), who did not find M related to

CDPS, didnotdifferentiate between M responsesof different

Form Quality. In the CS, there are four levels of Form Qual-

ity: superioroverelaborated, ordinary, unusual, and minus.

The Ordinary Form level includes answers that use form to

define an object that is easy to see, that is, frequently seen by

others and that does not have the overelaboration of the form

features characterizing the superior Form level. More than

one response with this overelaboration can be related to a

perfectionist or obsessive style (Exner, 1991). As patients

with obsessiveproblems aredifficult to treat with therapeutic

methods that do not include exposure and response preven-

tion (Roth & Fonagy, 1996), and as answers coded as un-

usual Form can be quite idiosyncratic or even regarded as

distorted by some, I predicted only the number of Human

Movement responsesof Ordinary Form level,MQo, to corre-

late positively with Dynamic Capacity. In the study by

Nygren (2004), the results supported the predictions that

MQo should be more frequent in groups of patients suppos-

edly more suitable for psychodynamic psychotherapy.

Weighted Sum Special Scores, WSUM6, are interpreted

as indicating bizarre anddisturbed thinking. Highervalues of

WSUM6 are regarded as a sign of pathological psychologi-

cal functioning (Exner, 1991, 1993). X % is interpreted as

indicating distorted perceptual mediation, an important as-

pect of reality testing capacity. In the study by Nygren

(2004), the predictions that the values of X % and WSUM6should be higher among patients that were supposed to be

less suitable for psychodynamic psychotherapy were notver-

ified. In thisstudy, I predicted WSUM6 and X % to be neg-

atively related to EgoStrength.As mentioned, DR, oneof the

scores in the WSUM6, was positively related to CDPS in the

Alpher et al. (1990) study but was not included as a separate

score in this study.

Affective features. Klopfer et al. (1954) argued that

White Space responses, S, could indicate an asset, a con-

structive self-assertiveness, and according to the CS, lower

values of S can be a sign of sound self-assertiveness (Exner,

1991, 1993). Higher values (> 2) are interpreted as indicatinga negativistic and oppositional set toward the environment

(Weiner, 1998). In this study, such negativism was assumed

to be related to patients resistance, which is associated with

negative therapeutic outcome (Orlinsky et al., 1994), and I

predicted S to be negatively correlated to Dynamic Capacity.

However, in thestudy by Nygren (2004), theprediction about

higher number of S responses among the patients assumed to

be less suitable for psychodynamic psychotherapy was not

verified.

Self and interpersonal perception clusters. Reflec-tion responses, FrrF > 0, are interpreted in the CS as indicat-

ing narcissistic defensive needs. These needs are seen as adominating element in the self-concept of the person and as a

narcissistic-like feature (Exner, 1991, 1993; Weiner, 1998;

Weiner & Exner, 1991). Exner (1991) wrote, This charac-

teristic forms a basic personality orientation or style that is

highly influential in decisions and behaviors because of the

need for frequent reaffirmation or reinforcement of the exag-

gerated sense of personal pride (p. 173). This elaboration of

the interpretation of FrrF and the elaboration by Weiner

(1998) sound more like a description of a narcissisticperson-

ality than of a person just showing narcissistic defenses. As

patients with narcissistic personalities are often regarded as

difficult to treat with psychotherapy, especially time-limited

therapy (Kernberg, 1975; McWilliams, 1994), I predicted

FrrF to correlate negatively with Dynamic Capacity. How-

ever, the prediction by Nygren (2004) about more reflection

responses among patients supposed to be less suitable for

psychodynamic psychotherapy was not verified.

Form Dimension, FD, was identified during the develop-

ment of the CS. It is interpreted as being related to

self-inspecting behaviors (Exner, 1991, 1993). One or two

FD responses are interpreted as indicating sound

self-inspection, whereas more than two FD responses can in-



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dicate exaggerated involvement with self-examination, even

rumination about the self. However, as self-inspecting capac-

ity is generally preferable in insight psychotherapy, my pre-

diction was that FD should be positively correlated to

Dynamic Capacity. In the study by Nygren (2004), the pre-

diction was verified that FD should be less frequent in the

group of personality-disturbed patients assumed to be lesssuitable for therapy.

Aggressive Movement responses, AG, and Cooperative

Movement responses, COP, are interpreted to provide infor-

mation about the cognitive sets that persons have concerning

interactions with others (Exner, 1991, 1993). AG indicates

an aggressive/forceful set. Weiner (1998) contended that a

high score on AG is not always an indication of

maladaptation, and he recommended that AG should be in-

terpreted more as indicating assertiveness than anger.

Hilsenroth, Handler, Toman, and Padawer (1995) found that

patients terminating psychodynamic psychotherapy prema-

turely had fewer AG and more COP than those remaining in

treatment. The prediction that both AG and COP should bemore frequent among patients assumed to be more suitable

for psychotherapy was verified for AG and partly supported

for COP in the study by Nygren (2004). Although research

concerningthe relationbetween patientsaffectiveresponses

and therapy outcome is not unequivocal, it seems that the pa-

tients total affective reactions to therapy (negative and posi-

tive reactions) are related to positive therapy outcome

(Orlinsky et al., 1994). Although AG thus can indicate a lia-

bility, my overall prediction was that both AG and COP

should be positively correlated to Dynamic Capacity.

I predicted PER, Personalized Answers, which are inter-

preted to indicate defensiveness characterized by intellectual

authoritarianism (Exner, 1991, 1993), to correlatenegativelywith Dynamic Capacity. Research indicates that patients

openness in contrast to defensiveness during the therapeutic

process is associated with positive outcome (Orlinsky et al.,

1994). However, the prediction that PER responses should

be more frequent among thepatients regarded as less suitable

for psychotherapy was not verified in the study by Nygren

(2004).

Participants

This study was carried out in a unit for advanced psychother-

apy training to which patients applied for psychotherapy on

their own initiative. All applicants first met a senior psychia-

trist/psychoanalyst who was responsible for the medical/psy-

chiatric aspects of the program. Applicants who were psy-

chotic, alarmingly depressed, or in acute crisis were

recommended to seek help elsewhere and did not return for

further assessment. They were not invited to take part in this

study, an arrangement that may have reduced the range and

severity of problems in thepatient group. The psychiatrist in-

formed the applicants that were accepted for further assess-

ment about this study, invited them to take part, and handed

them a written description of the study with an attached reg-

istration form. Fifty-two consecutive psychotherapy

applicants, 36 women and 16 men, agreed to take part in the

research project. The average agewas 35 years, ranging from

20 to 57 years, and length of education was on average 14

years, ranging from 9 to 20 years.

The training unit was a psychoanalytic psychotherapy unitwhere all patients were treated with psychodynamic psycho-

therapy. The protection of the integrity of both the therapy

applicants and the candidates was very strong. This circum-

stance led to restraints for this study. The only data available

were the Rorschach and the clinical ratings. No information

regardingthenumberof applicants that refused to take part in

the study was given, and no information concerning diagno-

ses, therapy process and outcome, or any information from

the patients files was at my disposal.

Interviewers

The interviewers in this study were 15 experienced clinicalinterviewers, 4 men and 11 women, who were candidates in

an advanced 3-year training program of individual

psychodynamic psychotherapy. The interviewers did not

treat any patients they interviewed; instead the applicants ac-

cepted for psychotherapy were entered on a waiting list. All

interviewers, 10 psychologists (MA), 2 social workers, and 3

psychiatrists, had basic training in psychodynamic psycho-

therapy and at least 3 years of experience from psychother-

apy under supervision before entering the advanced training

program. The interviewers in this study were in the third and

fourth terms of the advanced psychotherapy-training pro-

gram, a period during which they received special training

and supervision in psychotherapy assessment.

Procedures

Three assessment interviews were performed, andeach inter-

view was discussed in supervisory team conferences. The in-

terviewer carried out the ratings for this study after the team

had made the decision to accept/not accept the applicant.

Finally, the Rorschach was administered and scored inde-

pendent of all clinician interviews, treatment team discus-

sions, and ratings. The Rorschach data was used only for this

study, and this data was not available to any of the clinical in-

terviewers or treatment team discussions and thus could not

influence the selection of patients for psychotherapy or sub-

sequent ratings of Dynamic Capacity and Ego Strength.

Assessment interviews and selection of patients forpsychotherapy. The applicants participating in this study

were given three unstructured clinical interviews with a

45-min duration. This was the regular assessment procedure

of the unit preceding the decision to accept or not accept ap-

plicants intopsychotherapy. The interviews were thus carried

out in natural clinical situations.

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The candidates psychotherapy assessments were super-

vised in teams (four students and two supervisors) that met

oncea weekfor 2 hr during the period that data were gathered

for this study. Between the interviews, the candidates were

guided by the teams about how to proceed. When the assess-

ment interviews were finished, the task of the supervisory

teams was to assess the patients capacity to benefit frompsychodynamic psychotherapy and to decide collectively if

the clients should be accepted and put on a waiting list for

psychotherapy. No DSMdiagnoses were made in connection

with the assessments for psychotherapy. The therapies that

were to be conductedby candidates in training were intended

to last for 2 years with a frequency of two times per week.

Personality aspects related to the patientsDynamic Capacity

and Ego Strength were considered important, but the selec-

tion method was not formalized, and no scales or other selec-

tion instruments were used.

Of the applicants willing to take part in the research, 29

were selected, and 23 were referred to or recommended to

seek other treatments according to the decisions arrived at bythe teams. Of the 29 selected applicants, 20 started and ful-

filled 2-year therapies.

Formulation of rating variables and carrying out of

ratings. The applicants participating in the research pro-

ject were rated on special scales. I formulated three 7-point

rating variables relating to aspects of Dynamic Capacity and

seven variables relating to Ego Strength in cooperation with

teachers and supervisors in the program (see Table 1). The

variables were selected and formulated to be in agreement

with what was regarded as central by the supervisors in the

program and therefore natural for the candidates to rate. Be-

fore starting to collect data, I distributed the scales to thecan-didates to study, and I subsequently discussed the variables

with each of the supervisory teams. Moreover, for all rating

variables except for motivation and capacity to cooperate,

written definitions were formulated in cooperation with the

teachers and supervisors in the program. Directly below the

name of the variable in the rating form, a short definition was

given, and more comprehensive descriptions of the variables

were formulated in an appendix. The Rating Scale of Ego

Balance (Sandell, 1994) functioned as a model for the con-

struction of the descriptions. An overview of the variables in

the rating form with the definitions given below the variable

names is presented in Table 1.

The candidate that had interviewed the applicant carried

out the ratings after the completion of the team discussions

and after the team decision to select or not select the appli-

cant for psychotherapy. These ratings were an addition to the

regular selection procedure of the unit, and the ratings were

more specific than thediscussions and thedecision processes

in the supervisory teams, which were free to take any aspect

of the case into consideration. The instructions to the candi-

dates making the ratings were the following: After the as-

sessment interviews and after you and the team have come to

a decision about what you are going to recommend the pa-

tient, you rate the patient yourself. Make the ratings on your

own, in peace and quiet.

Internal consistency and validity of ratings. Descrip-tive data for Dynamic Capacity and Ego Strength are pre-

sented in Table 3. The patients total scores on Dynamic Ca-pacity and Ego Strength were calculated as the sum of the

ratings achieved on the subscale items. It was not possible to

assess interrater reliability. The internal consistency of the

ratings was good; Cronbachs alpha for Dynamic Capacity

was 0.93, and it was 0.91 for EgoStrength.Thepoint-biserial

correlations between the selection decisions of the supervi-

sory teams and the individual ratings performed by the inter-

viewers were .68 (n = 52, p = .000) for Dynamic Capacity

and .55 (n = 52, p = .000) for Ego Strength. Thus, although

the ratings apparently had been influenced by thediscussions

and by the decision in the supervisory team, this dependence

was not complete.

Rorschach administration and scoring. I, as an ex-perienced user and an instructor of the CS, carried out the

administration and scored the Rorschach according to the

CS guidelines. The Rorschach was conducted only for this

study and independent of the assessment interviews, treat-

ment team discussions, the selection decisions, and the rat-

ings of Dynamic Capacity and Ego Strength. Moreover, the

psychologist that independently performed the reliability

scoring also had no knowledge of the assessment inter-

views, treatment team discussions, the selection decisions,

and the clinical ratings of Dynamic Capacity and Ego

Strength. After I gave the feedback about the Rorschach re-

sults to the patients only, I made the Rorschach protocolsanonymous, and then I rescored when all the Rorschach

data had been collected.

Reliability of Rorschach scoring. To assess the reli-

ability of the scoring, 20 of the rescored protocols (38%)

were independently scored by an experienced psychologist

and senior teacher of the CS regularly working with the

method. This psychologist was only involved in the reliabil-

ity scoring of the CS protocols; she had not taken part in the

administration of the Rorschach in the study, andshe was un-

aware of the original scoring of the CS protocols, of the clini-

cal ratings, of the assessment interviews, of the treatment

team discussion, and of the selection of applicants for psy-

chotherapy. Scoring disagreements were not resolved,and all

scores used in the analyses were those I assigned. For the 20

rescored protocols, two-way random, absolute agreement,

intraclass correlations (ICC; 2,1) were calculated with the

statistical software Rorschach Research Utilities (Version

0.9.3), developed by Janson (2002; Janson & Olsson, 2001).

The data presented here consist of ICC values for the proto-

col-level reliability of summary scores. The ICC values are

presented in Table 2.



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ICC values less than .40 were regarded as poor, between

.40 and .59 as fair, between .60 and .74 as good, and over .75

as excellent (Cicchetti, 1994). The lowest ICC, .57, obtained

for YF, was a fair value, and the ICC values for the remaining

CS variables were within the range good to excellent (M=

.80).

Statistical Analyses

Correlations between CS variables and clinical rat-ings. Descriptive data and correlations with the number ofRorschach responses (R) for the CS scores are presented in

Table 3. Correlations were calculated to examine the relation

between the selected CS scores and the ratings of Dynamic

Capacity and Ego Strength. Because the expected direction

of thecorrelations was formulated a priori, one-tailed signifi-

cance tests were used for all hypothesized associations. Age

of the participants correlated significantly with both Dy-

namic Capacity (.43, n = 52, p = .001) and Ego Strength

(.38, n = 52, p = .003), so partial correlations controlling for

age were used in all analyses. Moreover, R correlated signifi-

cantly with EA, m, F%, Zf, and S, and in the analyses for

these CS variables, partial correlations controlling for both

age and R were used.

However, the recommendations by Viglione (1995) and

Curran, West, and Finch (1996) have been that partial corre-

lation, a parametric method, should only be used when the

skewness of the Rorschach variables and the kurtosis are

Documents

Journal of Personality Assessment - Marianne Nygren [Articol (de Tradus)]