A study of the relationship between clinical manifestations of neurotic anxiety and Rorschach test performance

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A STUDY OF THE RELATIONSHIP BETWEEN CLINICAL MANIFESTATIONS OF NEUROTIC ANXIETY AND RORSCHACH TEST PERFORMANCE

A Dissertation Presented to the Faculty of the Department of Psychology The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

by Barbara MacMichael Stewart June 1950

UMI Number: DP30397

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T7t« disserta tio n ,

w r it t e n by

BARBARA..MAC MIC HAE L..M E WAR T.... u n d e r the g u id a n c e o f h..i er. F a c u lt y C o m m itte e on S tudies, a n d a p p r o v e d by a l l its m em bers, has been presen ted to a n d accepted by the C o u n c i l

'TN

t

on G ra d u a te S tu d y a n d R esearch, in p a r t i a l f u l f i l l m e n t o f re q u ire m e n ts f o r the degree o f DOCTOR

OF

P H IL O S O P H Y

%

CR$ FM$

Rj

k%

It is thus shown that, for this group, the most impor­ tant signs were K+k, d^, m, FK and C+, and it might therefore be concluded that these are the Rorschach signs most closely associated with anxiety as measured in this study.

However,

the limited number of cases would make generalizations u n ­ warranted .

29

Another recent study is that of Garrison ^ who adminis­ tered a group of thirty-eight tests, including the Rorschach, to thirty-two mental patients.

The Rorschachs were scored

for each of the following signs: 1. W 2. D+Dd+Dr 3. Form (sum of responses determined primarily by form)

^ Garrison, MThe Problems of Quantification and Objectification in Personality Measurement: A Symposium. II. Relationships Between Rorschach Scores and Clinical Changes in Mental Patients,M Journal of Personality, 17:146-152, December, 1948.

4. Movement (sura of movement responses) 5. Color (sum of color responses) 6. Average reaction time of first response to each card 7. Average reaction time of first response to colored cards 8* Average reaction time of first response to non-colored cards 9. Total number of responses. Each of the above items was compared to scores obtained from other tests, including an anxiety inventory.

The correlations

between Rorschach items and the inventory significant at the 5 per cent level or above were the following: W vs. Anxiety Inventory

+ .40

M vs. Anxiety Inventory

-.44

It thus appears that a preponderance of whole responses is shown to be related to anxiety, and that M is inversely related, while other Rorschach signs show no significant correlation.

It should be noted, in this connection, that

a study of shading responses was not included. A most important study isthat of in that it is the only large-scale

Elizur,3°

significant

study in which Rorschach

^0 Elizur, "Content Analysis of the Rorschach with Regard to Anxiety and Hostility," Journal of Projective Tech­ niques, 13:24-7-284, September, 1949.

34 content has been related to an outside criterion of anxiety. Although Rorschach believed that interpretation of his test should be based largely on the determinants used in arriving at a response, the Elizur study suggests that interpretation based only on the response content may provide a better under­ standing of an individual1s way of perceiving his world. The subjects were thirty student volunteers from Columbia University, ranging in age from nineteen to fortythree.

Rorschach tests were administered with instructions

to give several responses to every card, and each record used in the study contained between twenty and forty responses. After any response for which a score for anxiety or hostility seemed uncertain, the subject was asked to tell more about his concept.

Only the procedure and findings related to

anxiety will be reported here. Three outside criteria were used, a questionnaire, a self rating sheet, and an interview.

The questionnaire con­

sisted of fifty-five statements, including five related to fears and phobias, and five related to lack of self confidence, for which the subject indicated on a scale ranging from one to nine whether he considered the statement to be more or less true for him than for the average college person. The self rating sheet consisted of eleven items, five of which were related to fear, worry, general and sexual

shyness and feelings of inferiority.

The students were asked

to rate on a scale from one to nine the degree of intensity and the frequency with which they experienced a need to con­ trol these feelings. A forty-five minute interview was conducted during which the subject was encouraged to give information on four variables one of which was anxiety.

Independent ratings of

notes taken during the interview were made on a nine-point scale by three judges, and these ratings were combined to form an over-all rating.

The reliability of anxiety ratings

was .8 7 . The Rorschach scoring was confined entirely to con­ tent.

A capital letter (A) was used whenever anxiety was

expressed openly, while a small letter (a) was used for responses which revealed anxiety to a lesser degree.

An

A received a score of two and an a^was counted as one. Responses which implied both anxiety and hostility were given the combined score ah which was counted as an a^ for anxiety.

The final scores were made up of the weighted sum

of all A 1s and a/s and were referred to as Rorschach Content Test scores (RCT).

The following, in abbreviated form, is a

description of the scoring for anxiety as described in the Instructions for scoring:

1 • -Smofrions and Attitudes Expressed or Implied. Responses which reveal feelings or attitudes of fear, u n ­ pleasantness, sorrow, pity and the like are scored A. Responses which manifest such feelings or attitudes to a smaller degree are scored ju a weeping child, scored A.

Examples:

A frightening giant

An unpleasing animal, scored P . lib.

(New Yorks

Long­

CHAPTER IV EXPERIMENTAL TECHNIQUE In this chapter will be described the method of treating the therapy ratings and the Rorschach data, and the method of interrelating the two.

I.

TREATMENT OF THE THERAPY RATINGS

Distribution of the over-all therapy ratings for 112 cases, obtained from section I) of the questionnaire, was found to be skewed in the direction of minimal anxiety. The number of cases assigned to each category is shown below: Anxiety is the chief symptom

27

Anxiety is one of the chief symptoms

49

There is some manifest anxiety

23

There is little or no manifest anxiety

13

Since this distribution could not be divided for statistical purposes into relatively equal parts, it was decided to redistribute the cases after including additional data available under section A.

These data, combined with

the ratings in section D, could thus be used to form new over-all ratings on the basis of which the eases could then be divided into two equal groups.

57 The s.'three ratings in section A will hereafter be referred to as item 1 (verbalized anxiety), item 2 (anxious behavior), and item 3 (anxiety symptoms); section 1} will be referred to as item 4 (over-all rating). It was first necessary to obtain a quantitative score for each item, and for this purpose the following procedures were used.

For item 1 (verbalized anxiety) and

item 2 (anxious behavior), weights were assigned as follows: Frequent

Occasional

Rare or' Absent

Vague uneasiness

4

2

0

Tension

6

3

0

Panic

8

4

0

The assignment ofweights from zero to eight was an arbi­ trary one, designed to give a wider range than would have resulted with simple weights ranging from zero to four. Regardless of the size of weights, however, it was deter­ mined that the final distribution of cases would remain essentially the same. The individual total score for an item was obtained by totaling the weights for each of the three ratings made by the therapist.

Thus, for a patient rated "Vague uneasi­

ness, Frequent,M "Tension, Occasional,” and "Panic, Occa­ sional, ” the total score for the item would be eleven.

58 Item 3 (anxiety symptoms) was scored by assigning a weight of zero to "Rare or Absent," a weight of one to "Occasional” and a weight of two to "Frequent.”

The total

score for this item consisted of the total of all weights assigned to the thirty-one separate ratings.^ As a matter of interest, an analysis of each symptom under item 3 was made to determine the degree to which it differentiated between the seventy-six anxious and the* thirty-six relatively non-anxious cases divided on the basis of the first two and the last two conditions in Item 4 (over­ all rating), respectively.

The proportion of times that a

symptom was checked either as frequent or occasional was de­ termined for each group, and weights were assigned by use of o an "abac" designed for this purpose. These weights were not used, however, in determining the total score for item 3 since, according to Guilford, differential weighting of many items does not generally result in sufficiently higher validity to make the procedure worth while.

Symptoms written in by the rater in the blank spaces provided were not included in the study. ^ J.P. Guilford, Fundamental Statistics in Psychology and Education (New York! McGraw-Hill Book Company, In c ., 1942), p7 3i.

59 Item 4 (over-all rating) was scored on a scale from one to four, where four represented anxiety as the chief symptom and decreasing values indicated correspondingly less anxiety. Before combining the four separate item scores to form a total score for every individual, intercorrelations between each pair of items were computed in order to de­ termine whether they should all be used.

Had any of the

correlations between the first three items and item 4 been low, one or more of the items might have been eliminated. A biserial i? was computed for correlations involving item 3 , a continuous distribution, while a tetrachoric ;r was used to determine the relationships between all other items. Standard errors for biserial r were computed by the formula,

y ■/¥ The standard errors for a tetrachoric i? of zero were com­ puted to correspond to the obtained tetrachoric r/s on the basis of the following formulas

yy *

Vn

60 The ranges of scores for items 1, 2 and 3 were divided at their respective quartiles, and new scores ranging from one for the least anxious to four for the most anxious were assigned to each quarter.

Thus, for every individual, a

score lying between one and four was obtained for each of these items.

A corresponding four-point scale was already

available for the over-all rating, item 4..

The final therapy

rating consisted of the sum of these four scores, which would necessarily lie somewhere along a scale ranging from four to sixteen.

These cases were then divided into two groups of

fifty-six each so that each group contained an approximately equal number of cases in each of the thirteen scoring cate­ gories.

A further consideration in dividing the cases was

that each therapist who made more than one rating should be represented an equal number of times in each group.

Cases

were arranged on a continuum from most to least anxious, and the upper and lower twenty-eight in each group then became the anxious and non-anxious cases as derived from the original therapy ratings made in response to the questionnaire.

II.

TREATMENT OF THE OBJECTIVE RORSCHACH DATA

Quantitative signs.

As previously indicated, it was

decided to include in the exploratory part of this study approximately all of the Rorschach scoring symbols which can

61 be quantified with a minimum of subjective judgment, whether previously reported as indicative of anxiety or not*

In

order to define a sign, it was necessary to establish sub­ divisions within each scoring category*

These definitions

were arrived at empirically by determining at which point the distinction between anxious and non-anxious cases became most apparent*

For example, in treating the number of

responses to a record, a sign was considered to be present for any number equal to or greater than twenty-five, since this point was found to differentiate best between the two groups * Certain procedures were adopted in determining the numerical value of any scoring symbol*

Determinants for

additional responses were not included; however, additional determinants for main responses were included but were counted as one-half and added to the main determinants which received a weight of one.

The absolute number of each de­

terminant was used, since it is generally agreed that the converting of an absolute number of determinants into a proportion of total number of responses is necessary only when there is an over-all difference in R between the two groups.3

in this study the median number of responses for

3 L.J. Cronbach, ‘’Statistical Methods Applied to Rorschach Scores: A Review,“ Psychological Bulletin, 46: 409-411, September, 1949.

62 all cases was 24,5, and there was no significant difference between anxious and non-anxious cases in either Group I or Group II.

Therefore, conversion of scores into a proportion

of total responses would not have altered the results. As shown in the review of previous studies, Rorschach shading responses have generally been considered primary indicators of anxiety.

According to Klopfer and Kelley,^

Every single k response ‘and every K response other than the one just mentioned may be con­ sidered as an expression of some anxiety. (The exception referred to is the response "clouds” to card VII if given as the only K in a record.) It was therefore considered particularly important to include a study of Rorschach responses to shading.

Since

mere counting of shading responses may be an oversimplified approach to the problem, suggestions as to a more refined interpretation of shading were obtained in personal communi­ cation with Dr. Klopfer. It was Klopfer1s belief that anxious and relatively non-anxious cases could be differentiated in terms of the following relationships: 1. The ratio of number of responses to shaded cards

^ B. Klopfer and D.M. Kelley, The Rorschach Technique (Yonkers-on-Hudson, New York: World Book Company, 194£), p. 242.

63 c (IV, VI, VTI)

to number of responses to non-shaded cards.

2. The ratio of average reaction time on shaded cards (IV, VI, VII) to average reaction time on non-shaded cards. 3. The ratio of number of form responses (F) to num­ ber of differentiated shading responses (FK+Fc). 4. The ratio of total differentiated shading responses (EK+Fc) to total non-differentiated shading responses (k+K). 5. The ratio of total achromatic responses (Fc+c+C1) to total bright color responses (FC+CF+C). The foregoing ratios were computed for each of the fifty-six cases in Group I and divided at the median in order to determine whether they discriminated between anxious and non-anxious cases.

In case of numbers 3> 4 and 5 a prob­

lem was raised in terms of the quantity to be assigned to zero values.

Therefore, three methods were used to determine

whether any one proved to be more differentiating than the others.

In the first method, zero was rated l.Oj in the

second, zero was assigned a value of .1.

As a third approach,

the ratio concept was dropped in favor of computing the dif­ ference between the two numerical values, thus eliminating the problem created by a divisor of zero.

The method which

best differentiated the groups was retained, in each case,

5 Those cards which most frequently appear to give rise to shading shock.

64 and used in further application of these ratios to the test data. In addition to shading, quantitative signs were derived from other scoring categories as described by f

Klopfer and Kelley,0 and the final list includes most of the data found on the back page of the Individual Record

7

Blank.1

However, some anxiety indicators suggested by them

were not included.

General comments, aside from the core

response, were excluded for the reason that the Rorschachs in this study were administered by different people and re­ cording of responses may not have been complete or uniform. Other possible indications of anxiety, such as evasiveness, compulsiveness and color shock, were not treated directly because of the subjective evaluation required in judging the degree to which they are present or absent.

Excluded

for the same reason were such scoring categories as original responses, form level and succession. Additional signs were added as suggested by Buhler, Buhler and Lefever

8

and, in general, the final arrangement

^ Klopfer and Kelley, o p . cit., pp. 243-249. T B. Klopfer and H.H. Davidson, The Rorschach Method of Personality Diagnosis Individual Record Blank [Yonkerson-Hudson, New York: World Book Company, 1942).

® C. Buhler, K. Buhler,,and D.W. Lefever, "Development of the Basic Rorschach Score with Manual of Directions,11 Rorschach Standardization Studies, Number I. (Los Angeles: C. Buhler, 19^8), p. ll.

65 of signs, as shown in Table I, follows that presented by them.

In many eases the exact definition of a sign within

a given scoring category differs from that appearing in the Buhler list, since the sign defined in this way was found to be more differentiating than the one used by them.

This

is to be expected, .in part at least, because of differences in method of test administration.

Approximately all pos­

sible subdivisions of a category were considered, either by inspection of the distribution or by actually computing a correlation, before final definition of the signs pre­ sented in Table I was made. Abbreviations appearing in Table I in general follow those appearing on the Individual Record Blank.

Additional

abbreviations are to be interpreted as follows: Signs 1, 2, 45: VI, and VTI.

nS-cards” refers to shaded cards IV,

”NS-cards” refers to the remaining seven cards.

Signs 2, 43, 44, 45:

”R T ” refers to average reaction

time. Sign 36:

"Total shades

indicates the sum of

k+K+PK+Fc+c+C1 as a percentage of total responses. Signs 43, 44:

"C-cards" refers to colored cards,

"B-cards" refers to black cards. Signs 46,47,48: to the last three cards.

"CR” refers to the response percentage

66 TAELE I QUANTITATIVE RORSCHACH SIGNS

1. 2. 3. 4. 5.

(R S-cards) *'(R NS-cards) = .34+ (RT S-cards) ♦ (RT NS-cards) = 1,14+ F t (FK+Fc ) = 5+ (Zero=l.0) (FK+Fc)+ (k+K) = 5+ (Zero=.l) (Fc+c+C »)> (FC+CF+C)

6. 7. 8. 9.

R = 24R = 25+ Rejection ■= 1+ T = 30"+

10. 11. 12. 13.

M M M M

= = = =

0 to1 1 1/2 to2 2 1/2 to3 1/2 4+

14. 15. 16. 17.

FH FM < FM FM

- 0 to 1 M £ M/ less twice M twice ormore M

18. 19. 20.

m m m

= = —

21. 22. 23.

(k+K) absent (k+K) = 1/2 to 1 1/2 (k+K) » 2+

24. 25. 26.

FK FK FK

27. 28.

F#

29. 30. 31. 32. 33.

Fc = 0 to 1 Fc = 1 1/2 to Fc = 3+ C ^ Fc e = 3+

0 to1/2 1 to2 1/2 3+

absent = 2+ = 3+ = 40» 41+ 21/2

67 TABLE I (Continued) QUANTITATIVE RORSCHACH SIGNS

34

C 1 absent C 1 present Total shades^ = 20-

31 38 39

40

41

44 45

46

47

48 49

PC absent PC * 1 , FC i (CF+C) FC > (CF+C) (CF+C) = 2+ Stun C = 2Sum C = 2 RT C-cards) RT C-cards) RT S-cards)

10"+ > (RT B-cards) 10"+ < (RT B-cards) 10"+ > (RT NS-cards)

CR$ = 25-

51

CR$ = 26 to 40 CR# = 41+ Sum C ^ M Change in direction of Erlebnistyp

53 54 55

= 20 = 21 to 30 W$ = 31+ W:M "= 1:1 or more M

56

W:M = 2:1

57

W:M = 3:1 or more W

58 60

45D# = 46 to 55 T)% — 56+

61

d$ = 4+

63 64

Dd present S = 1/2 to 3 S = 3 1/2+

50

59

65 66 67

\S%

D% =

k%

=

k% k%

- 21-35 = 36+

20 —

68

TABUS I (Continued) QUANTITATIVE RORSCHACH SIGNS

6 8 . TorDe = 1:1+ 6 9 . To:De « 2:1 70. To:De « 3+:l 71. 72.

P * 5P = 6+

69 Sign 50.

"Change in direction of Erlebnistyp"

indicates a change in the introversial-extroversial ratio from M:sum C to (FM+m):(Fc-fc+C1) Signs 67, 68, 6 9 : totals to details,

"To:De" indicates the ratio of

(H+A):(Hd+Ad).

In order to determine which of the signs selected for study differentiated between the twenty-eight anxious and twenty-eight non-anxious cases in Group I, for each sign the number of cases in each sub-group in which it appeared was first computed.

These frequencies were then

converted into a proportion of twenty-eight.

A phi coef­

ficient of correlation, based on these proportions, was then determined for each sign by use of an ‘ abac for graphic estimates of phi.9

The lowest phi significant at the 10

per cent level of confidence for an N of fifty-six was 2 2 established through the use of chi square. Since X = N and a chi square of 2 .J06 is significant at this level, a significant phi would therefore be equal to

In order to add to the list of significant signs any which might be significant only when applied to extreme groups, phi coefficients were also computed on the fourteen most anxious and the fourteen least anxious cases representing the

9 Guilford, o p . cit., p. 297

upper and lower quarters of the group.

The lowest signifi­

cant phi at the 10 per cent level was determined for an N_ of twenty-eight, by use of the formula presented above. Because it was considered possible that a curvilinear relationship might exist, the cases were also divided into upper one quarter and lower three quarters, and into lower one quarter and upper three quarters. relations were then computed.

Two new sets of cor­

Since, in both of these cases,

the two groups were unequal in number, it was necessary to use a formula for the computation of phi, as follows:

0

= & _ £ __ z-B.J!' ■ •*/pqpT q'

Reference is made to Guilford-*-® for explanation of the symbols used.

Since the total number of cases remained

the same as that used in comparing upper and lower halves, the lowest significant phi at the 10 per cent level also remained the same. There was thus obtained a list of quantitative signs, significant at the 10 per cent level in discriminating be­ tween anxious and non-anxious cases in Group I when those cases were divided in any one of four ways.

10 Ibid., p. 246.

71 Content signs.

In addition to the quantitative

Rorschach scoring categories, it was considered important that an investigation of content categories he included as a part of this study.

Certain content categories have been

traditionally considered to be anxiety indicators.

According

to Klopfer and Kelley,11 "noncommittal contents, especially of an anatomical or geographical nature" are indications of insecurity. For this study, rather than adopting some

priori

list of content signs believed to be related to anxiety, an exploratory approach was again used, and all responses were considered before a final selection of content signs was made.

Accordingly, a chart was first compiled on which

every response for each of the ten cards was entered for all of the cases in Group I.

From this chart all responses

considered in any way deviant were entered on a new chart containing some forty or more roughly defined content cate­ gories.

Particularly helpful in selecting deviant responses

were the suggestions obtained from Klopfer and Kelley,1^

11 Klopfer and Kelley, o p . cit., p. 241. 12

Ibid., pp. 171-176; 240-245.

72

Buhler, Buhler and

Lefever,^3

wheeler1^ and E l i z u r . ^

These content groups were reworked in various ways in order to determine the optimum form for purposes of statistical study.

For example, "both the anatomy and sex

categories were first broken down into sub-groups.

How­

ever, it was found that the all-inclusive category in each case appeared to be at least as differentiating as any sub­ category might be.

A rather thorough study of color responses

was made, both as to determinant and content (whether explosive or submissive, and whether to cards II and III, or to VIII, IX and X ) .

However, due largely to difficulties of exact classi­

fication, it was decided to retain only two signs, indicating the response to color on cards II and III. A list of thirty-seven categories was finally selected as set forth in Table II.

In order to determine which of

these content groups differentiated between anxious and nonanxious cases, the fifty-six records were again divided into four equal groups ranging from most to least anxious as

13 Buhler, Buhler and Lefever, o p . cit., p. 11. ^ W.M. Wheeler, "An Analysis of Rorschach Indices of Male Homosexuality," Journal of Projective Techniques, 13:92-126, June, 19^9.

15 A. Elizur, "Content Analysis of the Rorschach with Regard to Anxiety and Hostility," Journal of Projective Techniques, 13s2^7-284, September, 19^9.

73 TABLE II CONTENT RORSCHACH SIGNS

1. 2. 3. 4. 5.

Anatomy, anatomical charts Sex X-ray Clouds Smoke

6. 7. 8. 9. 10.

Ice, snow, frost, icicles Water, fountain, pool Cliff Cave Plant (colored)

11. 12. 13. 14. 15.

Emblem Statue Rock, stone Caricatures, Disney, or mythological figures Faces, profiles

16. 17. 18. 19. 20.

Eyes Mask Bat Object Religious concept

21. 22. 23. 24.

Abstract Geography, map Blood, bomb, volcano, explosion, fire Threatening animals (snakes, dinosaurs, monsters, dragons, stingrays, etc.) Animals fighting or about to attack

25. 26. 27. 28. 29. 3?.

Threatening human figures (ghosts, police­ men, pirates, cannibals, witches, devils, etc.) Humans fighting or about to attack Dead human or animal, skeleton, or skull Threatening object (gun, arrow, spear, etc.) Expressions denoting fear or concern (terrifying, sinister, apprehensive, scared)

74

TABLE II (Continued) CONTENT RORSCHACH SIGNS

31*

32. 33. 34. 33. 36. 37.

Conditions resulting from injury or misfortune (disease, distortion, mutilation, amputation, dementia, decay, rot) Restraint or threat from without (being attacked, held, tied, burned) Fearful withdrawal (escaping, retreating, running away) FC response to cards II or III Any color response to cards II or III Animals (top D, card X), fighting or about to fight Any other response to top D, card X

75 indicated by the total therapy ratings.

The frequencies of

any single appearance of a sign in a given record for each of the four sub-groups were then determined. °

Phi coeffi­

cients of correlation were used, as previously described, to make a final selection of signs significant at the 10 per cent level in separating anxious from non-anxious cases in Group I, Elizur signs,

The study of Abraham Elizur, previously

described in the review of the literature, was published after the present investigation was partially completed.

Because

his findings were particularly pertinent to the problem con­ sidered here, it was decided that a separate scoring of each record according to his method might yield important infor­ mation as to the validity of this approach when applied to a new group.

Accordingly, each of the 112 records was scored

by this method, and the records were then divided at the median into two anxious and non-anxious groups on the basis of total scores received.

1

A question arose as to whether some frequency greater than one should be required to constitute a sign for any one record. A study of each category, however, showed in every case that a single appearance of a sign differentiated the groups about as well as any number greater than one.

76

III.

CORRELATIONS BETWEEN THERAPY AND OBJECTIVE RORSCHACH RATINGS

Each of the fifty-six records in Group II was scored by both the quantitative and content scoring signs derived from the data In Group I.

For each record negative signs

were subtracted from positive ones, and a distribution of resulting scores was made.

The cases were then divided*

approximately at the median into two groups, anxious and non-anxious, on the basis of these scores.

The records

divided in this way, were then compared to a division of the same records based on therapy ratings by use of the phi coefficient of correlation.

An abac table was used,

as previously described, where the proportion of cases showing agreement and the proportion failing to show agree­ ment became the ordinate and abscissa values.

The corres­

ponding Pearson r was estimated by the equation

637 The test for significance was made, as before, by use of the chi square corresponding to 0 . The above procedure was followed for (l) quantitative signs alone,

(2 ) for content signs alone,

bined, and (4) for Elizur signs alone.

(3 ) for both com­

For each of these

77 four procedures, results were broken down into those cases rated by the different professional groups, and phi corre­ lations were computed for each of the three groups. thus resulted sixteen correlations in all.

There

Pearson r 1s

were not estimated for these sub-groups, however, because this method of estimating

is valid only when the sub-groups

are equal in size, and there were some differences between the number of anxious and non-anxious cases rated by any one professional group. In order to determine the validity of any one sign when applied to this new group, the frequencies of appearance In anxious and in non-anxious records were tallied.

The phi

coefficient of correlation was used, where necessary, to de­ termine significance of the difference found.

IV.

TREATMENT OF THE SUBJECTIVE RORSCHACH DATA

For the purpose of obtaining subjective Rorschach ratings, from the entire 112 cases comprising Groups I and II, ten records were selected from those rated most anxious by the therapist and ten from those rated least anxious. These twenty records were then presented to seven judges who were asked to divide them Independently, on any basis

78 they wished* Into two equal groups considered to be most and least anxious.

Three of the seven judges, however,

requested a substitution of longer records for two short records which they preferred not to

rate, and such a substi­

tution was accordingly made.

were thus eighteen

There

identical records rated by all seven judges, two rated by only four judges, and two rated by only three judges. The judges were informed of the basis upon which the therapy ratings had been made, and were told that the original over-all rating (item 4) correlated highest with verbalized anxiety (item 1).

Further, they were told that ratings for

all cases in the anxious group indicated that the patient verbally expressed frequent uneasiness, frequent tension and frequent or at least occasional feelings of panic.

The judges

were also informed that some of thenon-anxious records rated were those of patients considered to be the therapist making the rating.17

to be

psychotic by

They were further told

that, in general, results based on the study of objective Rorschach signs did not appear to be significant. The judges who made these ratings ranged, in experience

17 Information obtained from Section E of the ques­ tionnaire showed that two of the ten patients rated anxious and none of those rated non-anxious were considered to be psychotic. For the total group of 112 cases, five anxious and five non-anxious patients were considered to be psychotic.

79 with the Rorschach, from experts in the field to graduate students in clinical psychology whose training in Rorschach interpretation is comparable to that of other graduate stu­ dents.

These Judges and the numbers by which they will

later be identified are as follows:

(1) Dr. Bruno Klopfer,

well known as a foremost authority in the field, and co-j o

author of a text

which has been widely used as a guide to

Rorschach interpretation;

(2) Dr. Charlotte Buhler, co-author

of the Rorschach Standardization S t u d i e s (3 ) pr< s.M. Wesley, professor of clinical psychology and consultant to the Veterans Administration;

(4) Dr. William M. Wheeler,

clinical psychologist on the staff of the Veterans Adminis­ tration;

(5 ) Mr. Robert Cartwright, clinical psychology

trainee with the Veterans Administration;

(6 ) Mr. James

Craine, graduate student in clinical psychology; and (7 ) Mrs. Julie Craine, graduate student in clinical psychology. A study of the reliability of these ratings was made in two ways.

First, the ratings of each judge were compared

in turn to those of every other judge who had rated the same twenty cases, and the average number of agreements between pairs of judges was computed.

The average number of agree­

ments on' twenty cases necessary to be significant at the

Klopfer and Kelley, op. cit. 3*9 Buhler, Buhler and Lefever, o p . cit.

8o 5 per cent level of confidence or above was determined as follows: Anxious and non-anxious cases were designated A and NA, respectively* The total number of ways in whicTT ten A records'can be selected from a group of twenty was first determined through use of the formula for the number of combinations (C_) of n objects taken r at a time: n! r! (n-r)! In this case, n = 20 and r = 10, resulting in 184,756 possible combinations. The probability of each number of agreements was next determined.20 The probability of agree­ ment on twenty cases is 1/184,756, since there is only one way of obtaining agreement on twenty cases. For disagreement on any one of the ten A*s, a compensating disagreement would occur in one of the ten NA's, resulting in agreement on eighteen cases. The number of such possible combinations is 10 x 10 = 100. The probability of agreement on eighteen cases is therefore 100/184,756. For disagreement on two of the ten A*s, compensat­ ing disagreements would oecur in two oT the ten N A fs, resulting in agreement on only sixteen cases. Dis­ agreements on two out of ten A*s could occur in as many combinations as we can take two things out of ten, or

20 These scores are all even numbers, ranging from zero to twenty, because for every error in designating an A there is necessarily a corresponding error in designating an NA. Although two of the elected not to take ad ­ vantage of the knowledge that the records were evenly di­ vided into A and NA and divided their cases into groups of nine and eleven, tKeir ratings will be treated as though they had done so, since to some extent this information was probably used by them.

81

10 ! ----------

=

45

8! 2! For each such combination of A fs there could be as many combinations of N A fs. The total number of possible combinations of pairs of A*s with pairs of NA*s is 45 x 45 = 2025, and Ifhere are therefor©1*025 ways of obtaining agreement on sixteen cases. The probability of obtaining sixteen agreements is 2025/184,756. Probabilities of obtaining other scores were determined in the same manner, and are shown in Table III. Also shown are ..cumulative probabili­ ties, i.e., the probabilities of obtaining agree­ ment on a certain number of cases or higher. Since, by chance, there are as likely to be agreements on zero eases as on twenty, on two eases as on eighteen, etc., the usual two-tail teat of departure from hypothesis was made by doubling the cumulative probabilities, also shown in Table III. It may be seen that agreement on no less than sixteen cases is necessary to be significant at the 5 per cent level, and that sixteen agreements or better are therefore re­ quired to reject the null hypothesis. A second study of reliability was made by consideration of those cases in which there was unanimous agreement among the seven judges in rating a case either anxious or nonanxious.

The probability that a case will be rated alike

(either anxious or non-anxious) by all seven judges is 2 (1/2)7 = 1/64, or less than .0 2 .

82

tabu

: iii

PROBABILITIES OF CHANCE OCCURRENCES OF VARIOUS NUMBERS OF AGREEMENTS BETWEEN RORSCHACH AND THERAPY RATINGS OF TWENTY ANXIOUS AND NON-ANXIOUS CASES

Number of agree­ ments 20 18 16 14 12 10 8 6 4 2 0 TOTAL

Number of ways it could occur

Probability of its occurring

1 100 2025 14400 44100 63504 44ioo 14400 2025 100 1

.000005 .000541 .010960 .077940 .238691 .343715 .238691 .077940 .010960 .000541 .000005

184756

.999992

Probability of this score or a higher one .000005 .000547 . O U 507 .089447 .328138 .671854 .910545 .988486 .999445 .999986 .999992

Probability of a score as far from the mean, or f&Ether .00001 .00109 .02301 .17889 .65628

83 V.

AGREEMENT BETWEEN THERAPY AND SUBJECTIVE RORSCHACH RATINGS

The number of agreements between the twenty Rorschach ratings and the corresponding therapy ratings was determined for each of the seven judges.

The number of agreements neces­

sary to be considered significant was sixteen, or equal to that for any pair of twenty such ratings as computed in the manner described above for determining reliability. Since it is generally agreed that the validity of ratings increases with the number of judges, a pooled rating was determined for each of the twenty rec o r d s . ^

The pooled

rating was compared to the therapy rating and the number of agreements necessary to be significant was again equal to sixteen, computed in the manner previously described. Another measure of agreement was employed by consider­ ing the obtained number of cases showing unanimous agreement among judges where this rating was also in agreement with the therapy rating.

The probability of obtaining any one such

unanimous agreement between eight ratings (seven Rorschach o

and one therapy) is 2 (l/2 ) , or less than .0 1 .

21 For the two records not.rated by three of the judges (and for which, two other records were substituted), the pooled rating was based on four judgments only. In case of an even split, the record was considered not in agreement with the therapy rating.

CHAPTER V RESULTS In this chapter results of the statistical treat­ ment of the data will be presented.

I.

DISTRIBUTION OP THE THERAPY RATINGS

The distributions of anxiety scores for 112 cases, obtained from Items 1, 2 and 3 of the therapy question­ naire, are presented in Table IV.

As shown there, scores

on Item 1 (verbalized anxiety) ranged from zero to 18, with a median at 9.7 and a Q of 4.3.

Scores for Item 2

(anxious behavior) ranged from zero to 18, with a median at 9.8 and a Q of 2*8.

Scores obtained from Item 3 (anx­

iety symptoms) ranged from zero to 46, with a median at 15.7 and a a of 8.2. Weights assigned to each symptom under Item 3 are shown in Table V, indicating those most frequently asso­ ciated with anxiety in the minds of the therapists who made the ratings..

It will be seen that only four symptoms

received a weight of 4, indicating little or no correlation with anxiety ratings, while eight symptoms received a weight of‘ 6 indicating high correlation.

The remaining nineteen

85

TABLE IV DISTRIBUTIONS OP ANXIETY SCORES FOR 112 CASES ON ITEMS 1, 2 AND 3 OP THE THERAPY QUESTIONNAIRE

Item 1 Verbalized Anxiety

Item 2 Anxious Behavior

Item 3 Anxiety Symptoms

0-18

0-18

0-46

Median

9.7

9 .6

15.7

First Quartlie

5.1

4.8

8.9

Third Quartile

13.7

10.3

25.3

4.3

2.8

8.2

Range

Semi-interquartile range Q

86

TABLE V WEIGHTING OP ANXIETY SYMPTOMS UNDER ITEM 3 OF THE QUESTIONNAIRE BASED ON THEIR FREQUENCY OF APPEARANCE IN 112 ANXIOUS AND NON-ANXIOUS CASES

Weight of 6

Weight of 5

Excessive worry Pseudoangina Tremors Excessive sweating Marked startle reaction Depression Excitability Restlessness

Rapid heartbeat Flushing Loss of appetite Weight loss Nausea Flatulence Blackouts Dizziness Sighing Oppressed breathing Diarrhea Enuresis Impotence Premature ejaculation Sleeplessness Nightmares Hypersensitivity to light, sound Irritability Fatigue

Weight of 4 Constipation Impaired concentration Poor memory Excessive drinking

Weights of 6 and 5 indicate positive correlation with anxiety. Weight of 4 Indicates correlation of zero.

87 symptoms received a weight of 5, showing a positive correla­ tion with anxiety ratings. The distribution for Item 4 (over-all rating) was presented in Chapter IV. The intercorrelations between pairs of items and the corresponding standard errors are presented in Table VI. Since the correlations between Items 1, 2 and 3 and the over-all Item 4, ranged from .72 to .91* they were con­ sidered to be valid items which could safely be included as part of a total score. The relative magnitude of the correlations between Items 1, 2 and 3 and Item 4 suggests that the over-all rating (item 4) was based mostly on the patient*s verbal expression of anxiety (item 1), next on Its symptomatic expression (Item 3), and least on the therapist*s observa­ tion of the patient during the interview (Item 2). In the Appendix the final therapy ratings assigned to the 112 questionnaires are shown.

As previously indi­

cated, they have been divided into two groups so'^that each group contains an approximately equal number of cases in each of the scoring categories which range from four to six­ teen.

Each of these groups is further divided into anxious

and non-anxious cases.

The median, which was used as the

dividing point on the anxiety continuum, fell within the

88

TABLE VI INTERCORRELATIONS BETWEEN PAIRS OF ITEMS RATED FOR ANXIETY ON THE BASIS OF RESPONSES TO 112 QUESTIONNAIRES

Items

Method of Correlation

1 and 4

Tetraehoric

.91

.15 (when r = 0)

2 and 4

Tetraehoric

.72

.15 (when r « 0 )

3 and 4

Biserial

.81

.06

1 and 2

Tetraehoric

.85

.15 (when r = 0 )

1 and 3

Biserial

.76

.06

2 and 3

Biserial

.64

.08

Standard Error

group of cases receiving a score of 11.

Reference was

therefore made to the original data to determine which of these cases should he assigned to the anxious and to the non-anxious groups, using small differences in raw scores as a basis for separation.

Those falling in the anxious

group are scored 11+ and those in the non-anxious group are scored

11-. Consecutive numbers from 1 to 112,

fying each

case, have been substituted for the code numbers

used during actual work-up of the data.

identi­

Those cases used

for the subjective Rorschach ratings are indicated, in­ cluding numbers 8 and 106 which were substituted for num­ bers 1 and

112, respectively, in the case of three raters,

the former

being short records which they preferred not to

rate.

Also shown is the professional affiliation of each

therapist who made a therapy rating, with a number arbi­ trarily assigned for purposes of identification.

II.

THE SIGNIFICANT RORSCHACH SIGNS

In Table VII are presented the thirteen positive and the twelve negative quantitative Rorschach signs sig­ nificant at the 10 per cent level or above in discriminating anxious from non-anxious patients on the first half of the data.

Included are those signs found significant when the

90 TABLE VII PHI COEFFICIENTS OF CORRELATION FOR QUANTITATIVE RORSCHACH SIGNS SIGNIFICANT AT 10 PER CENT LEVEL OR ABOVE FOR GROUP I

Subgroups*

4. 5. 9. 11. 13. 21. 25. 27. 29. 46. 50. 59. 67.

(FK+Fc )-s-(k+K) = 5+ (Zero=.l) (Fc+c+C 1) > (FC+CF+C ) T = 30**+ M = 1 1/2 to 2 M = 4+ (k+K) absent FK = 2+ F$ = 40Fc = 0 to 1 (RT S-eards) 1 0 !l+ > (RT NS-cards) Sum C ~ M D% » 46 to 55 k% « 36+

A

B

C

D

.25 .22 .22 .25 .24 .34 .45

.25 .30

ro 00

Positive Signs

.28 .22 .25 .28

Negative Signs 2. 3. 10. 19. 22. 28. 30. 36. 41. 48. 51. 53.

(RT S-cards)*(RT NS-cards) = 1.14+ F*(FK+Fc) » 5+ (Zero=l.0) .37 M = 0 to 1 m = 1 to 2 1/2 (k+K) - 1/2 to 1 1/2 .44 F$ » 41+ Fc = 1 1/2 to 2 1/2 Total shades$ = 20(CF+C) « 2+ .44 CR$ - 26 to 40 Change in direction of Erlebnistyp = 21 to 30 Significant Phi (P = .10):

* Subgroups Subgroups .Subgroups Subgroups

A: upper B: upper C: upper D: upper

.37

.25 .32 .23 .25 .28 .35

.25

.30 .22 .25

.22 .34 .22 .25 .22

.22

and lower quarters; and lower halves; one quarter, lower three quarters; three quarters, lowerone quarter.

.22

91 fifty-six cases in Group I were divided in any one of four ways: upper and lower quarters,

(Subgroup A ), upper and

lower halves (Subgroup B ), upper one quarter and lower three quarters (Subgroup Cj, and upper three quarters and lower one quarter (Subgroup D ) .

As previously indicated,

the upper groups include the cases rated most anxious by the therapists, and the lower groups include those rated least anxious. In Table VIII are presented the six positive and the seven negative content signs significant at the 10 per cent level or above in discriminating anxious from nonanxious patients in Group I.

Again the data were grouped

in four ways, and all signs found to be significant for one or more pairs of subgroups were included.

III.

CORRELATIONS OBTAINED BETWEEN THERAPY AND OBJECTIVE RORSCHACH RATINGS

As previously stated, each Rorschach in Group II was scored separately, and positive and negative signs were combined to obtain total individual scores.

This procedure

was followed for objective signs alone, content signs alone, and for both combined.

The resulting range of scores and

the medians are shown in Table IX.

It will be seen that

92 TABLE VIII PHI COEFFICIENTS OF CORRELATION FOR CONTENT RORSCHACH SIGNS SIGNIFICANT AT 10 PER CENT LEVEL OR ABOVE FOR GROUP I

Subgroups* Positive Signs 13. 14. IB. 31. 32. 36.

Rock, stone Caricatures, Disney or mythological figures Bat Conditions resulting from injury or misfortune Restraint or threat from without Animals (top D, card X), fighting or about to fight

A

B

C

D

.22

.27

.30 .43

.22 .33

.41

.29 .39

.42

.32

.39

Negative Signs 4. 7. 20. 22. 29. 34. 37.

Clouds Water, fountain, pool Religious concept Geography, map Threatening object FC response to cards II or III Response to top D, card X, other than animals fighting Significant Phi (P = .10):

* Subgroups Subgroups Subgroups Subgroups

A: B: C: D:

upper upper upper upper

.25 .23 -

.33 .28

.42 .31 .25

.37

.39

.39

.22

.22

and lower quarters; and lower halves; one quarter, lower three quarters; three quarters, lower one quarter.

.22

93

TABLE IX DISTRIBUTIONS OF RORSCHACH SCORES FOR GROUP II BASED ON ANXIETY SIGNS DERIVED FROM GROUP I

Quantitative Signs

s

Therapy Rating

Range

Anxious

-6 to +6

Non-anxious Total

Content Signs

All i Signs

Range

Median

Range

Median

0

-3 to +5

-1

-6 to +8

-.5

-5 to +5

0

-3 to +4

0

-7 to +3

+1

-6 to -6

0

-3 to +5

-1

-7 to +8

0

Median

94

there is very little difference in range between groups designated anxious and non-anxious by therapy ratings, and that the medians were approximately zero. v

Rorschach ratings of anxious and non-anxious were assigned to each case on the basis of division at the median and these ratings were compared to therapy ratings. The resulting phi coefficients of correlations, and corres­ ponding estimates of Pearson r_, are presented in Table X. It will be seen that on all data combined the estimated Pearson correlation between therapy and Rorschach ratings is--.14.

Estimated correlations based on Rorschach

quantitative signs alone and on content signs alone are -.16 and -.14, respectively.

In each case the Social

Worker group correlates negatively, the Psychologist group shows a zero correlation, and the Psychiatrist group cor­ relates in the positive direction. The only significant positive correlation is the estimated phi of +.58 between Psychiatrist therapy ratings and quantitative Rorschach ratings.

A further study was

made to determine whether the degree of this relationship might be increased if only those cases in Group I for which psychiatrists had made ratings were used in determining the Rorschach signs.

Among the fifty-six cases in Group I

were nine rated anxious and nine rated non-anxious by

95

TABLE X COEFFICIENTS OF CORRELATION BETWEEN THERAPY AND OBJECTIVE RORSCHACH RATINGS OF ANXIOUS AND NON-ANXIOUS CASES IN GROUP II

Source of Rorschach and Therapy Ratings

Number of Cases

Number of Agreements Between two Ratings

Phi

Estimated Pearson r

QUANTITATIVE SIGNS: Social workers Psychologists Psychiatrists

28 14 14

7 7 11

-.50** 0 + .58*

All combined

56

25

-.10

Social workers Psychologists Psychiatrists

28 14 14

11 7 8

— •21 0 +. 12

All combined

56

26

-.09

Social workers Psychologists Psychiatrists

28 14 14

10 7 9

-.28 0 + .28

All combined

56

26

-.09

-.16

CONTENT SIGNS:

-.14

ALL SIGNS:

* **

Significant at 5 per cent level of confidence; Significant at 1 per cent level of confidence.

-.14

96

psychiatrists.

All of the original seventy-two signs were

again tested for significance on the basis of their dis­ crimination between these eighteen cases.

Fourteen signs

were found to be significant, in either a positive or negative direction, at the 10 per cent level of confidence, as shown in Table XI.

These signs were then applied to

the nine anxious and five non-anxious cases in Group II for which psychiatrists had made the therapy ratings. Negative signs were subtracted from positive ones for each patient and a distribution of resulting scores was made.

Dividing this distribution into nine most anxious

and five least anxious cases resulted in seven agreements out of fourteen when compared to therapy ratings, which is only equivalent to chance expectation. The frequencies with which signs, both quantitative and content, appeared in all anxious and all non-anxious records of Group II are shown in Tables XII and XIII. None of these differences are significant.

The frequencies

with which quantitative signs, based on psychiatrist cases in Group I, appeared in anxious and non-anxious cases in Group II are shown in Table XIV.

Sign 19 (m = 1 to 2 l/2)

shows a significant difference at the 1 per cent level of confidence, while sign 38 (PC = 1 1/2+) and sign 43 (Sum C = 2 1/2+) are significant at the 5 per cent level.

97

TABLE XI QUANTITATIVE RORSCHACH SIGNS SIGNIFICANT AT 10 PER CENT LEVEL OR ABOVE IN DIFFERENTIATING PSYCHIATRIST CASES IN GROUP I

Positive Signs 4. 11. 18. 21. 29. 32. 52.

(FK+Fc) f (K+K) = 5+ (Zero=.l) M = 1 1/2 to 2 in = 0 to 1/2 (k+K) absent Pc = 0 to 1 c = Fc Sum C = 2-

Negative Signs 19. 30. 38. iH. 43.

m = 1 to 2 1/2 Fc = 1 1/2 to 2 1/2 PC = 1 1/2+ (CP+C) = 2+ Sum C = 2 1/2+

61:

d# = 4+

72.

P = 6+

98 TABLE XII FREQUENCIES OF QUANTITATIVE RORSCHACH SIGNS WHEN APPLIED TO ANXIOUS AND NON-ANXIOUS CASES IN GROUP II

Frequency in Group II Positive Signs for Group I 4. - 5. 9. 11. 13. 21. 25. 27. 29. 46. 50. 59. 67.

(FK+Fc)*(k+K) = 5+ (Zero=.1) ’(Fc+c+C1)> (FC+CF+C) T = 30”+ M = 1 1/2 to 2 M = 4+ (k+K) absent FK = 2+ F$ = 40Pc = 0 to 1 (RT S-cards) 10"+^- (RT NS-eards) Sura C £ M D$ = 46 to 55 A$ = 36+ TOTAL

Anxious

Non-anxious

11 10 20 3 12 7 1 15 9 8 13 5 19

14 12 21 3 14 14 6 13 9 8 8 11 20

133

153

16 12 7 12 9 13 10 15 17 18 7 5

15 15 7 12 11 13 15 20 12 12 3 6

139

141

Negative Signs for Group I 2. 3. 10. 19. 22. 28. 30. 36. 41. 48. 51. 53.

(RT S-cards)*(RT NS-cards) = 1.14+ P t (PK+Fc) = 5+ (Zero=l.0) M = 0 to 1 m == 1 to 2 1/2 (k+K) - 1/2 to 1 1/2 F % = 41+ Fe = 1 1/2 to 2 1/2 Total shades^ = 20(GP+C) = 2+ CR$ « 26 to 40 Change in direction of Erlebnistyp = 21 to 30 TOTAL

99 TABLE XXXI FREQUENCIES OF CONTENT RORSCHACH SIGNS WHEN APPLIED TO ANXIOUS AND NON-ANXIOUS CASES IN GROUP II

Positive Signs for Group I

il: 18. 31. 32.

36.

Rock., stone Caricatures, Disney or mythological figures Bat Conditions resulting from injury or misfortune Restraint or threat from without Animals (top D, card X), fighting or about to fight TOTAL

Frequency in Group II Anxious Non-anxious

9

9

15 20

13 21

13 4

9

4

4

65

58

9 8

9 9 8

2

Negative Signs for Group I 4. 7. 20. 22. 29.

34. 37.

Clouds Water, fountain, pool Religious concept Geography, map Threatening object FC response to cards II or III Response to top D, card X other than animals fighting

12

5

14 7 12

15

15

TOTAL

68

74

6 13

100

TABLE XIV FREQUENCIES OF QUANTITATIVE RORSCHACH SIGNS DERIVED FROM PSYCHIATRIST CASES IN GROUP I WHEN APPLIED TO ANXIOUS AND NON-ANXIOUS CASES IN GROUP II

Positive Signs for Group I 4. 11. 18. 21. 29.

32. 42.

(FK+Fc)* (k+K) » 5+ (Zero=.1) M = 1 1/2 to 2 m = 0 to 1/2 (k+K) absent Fe = 0 to 1 c « Fc Sum C = 2TOTAL

Frequency in Group II Anxious Non- anxious (N = 9) (N = 5) 3 1 3 4 4 4 3

2 1 0 3 2 0 1

22

9

Negative Signs for Group I! 19. 30. 38. 41. 43. 61. 72.

i = 1 to 2 1/2 Fc = 1 1/2 to 2 1/2 FC = 1 1/2+ (CF+C) * 2+ Sum C ~ 2 1/2+ 6.% « 4+ p = 6+

3 2 5 6 5 5 4 TOTAL

* **

30

Significant at 5 per cent level of confidence; Significant at 1 per cent level of confidence.

5** 2 5* 45* 2 3 26

101 Since these signs appeared more frequently in the non-anxious group, the results suggest that the presence in a record of 1 or more m, 1 1/2 or more FC, or 2 1/2 or more Sum

may

be a valid contraindication of anxiety. The distribution of anxiety scores for the 112 cases scored by the Elizur method ranged from zero to thirtythree, with a median at 6 .5 . standard deviation was 3-7-

The mean was 7.8 and the When this group was divided

at the median into anxious and non-anxious cases, it was found that JO of the 112 Rorschach ratings were in agree­ ment with the corresponding therapy rating.

As shown in

Table XV, the phi coefficient of correlation between Ror­ schach and combined therapy ratings was +.25 which is significant at the 1 per cent level or confidence. estimated Pearson 3? was +.39.

The

When correlations were

computed for the three professional groups separately, the resulting phi coefficients were +.18 for cases rated by social workers, +.48 for psychologists, and +.01 for psychiatrists.

The only significant correlation (at the

5 per cent level of confidence) for these professional groups was that for cases rated by psychologists. In order to compare the Elizur scoring method with the subjective Rorschach ratings of extreme cases, the number of agreements between the Elizur ratings and the University of Southern Californi® LlbTBIJ?

102

TABLE XV COEFFICIENTS OF CORRELATION BETWEEN THERAPY RATINGS AND RORSCHACH RATINGS DERIVED FROM. THE ELIZUR METHOD OF SCORING CONTENT

Number of Cases

Number of Agree­ ments Between Two Ratings

Phi

Social workers

54

32

Psychologists

26

19

Psychiatrists

32

17

i —1 o•

112

70

.25**

All combined

Estimated Pearson _r

• 1 —1 00

Source of Therapy Ratings

A S *

* Significant at 5 cent level of confidence. ** Significant at 1 per cent level of confidence.

.39

103 therapy ratings was determined for the twenty cases rated subjectively by seven judges.

The number of agreements

was fifteen, which is significant at the 5 po** cent level of confidence ,-L The frequencies with which each of the Elizur con­ tent signs appeared in anxious and non-anxious groups, as rated by the therapists, was determined. cies are shown in Table XVT.

These frequen­

For Group I, Group II, and

both groups combined, the first two columns (1 ) indicate the total number of times a sign appeared in all anxious and non-anxious records. statistically.

These results were not treated

The second two columns (2) indicate the

number of records in which a sign appeared one or more times.

The significance of these differences was deter­

mined by use of the phi coefficient and chi square, as previously described.

For the total group, only one sign

was significant, the content item "snake1* which appeared more frequently in the anxious group, resulting in a phi of .37, significant at the 1 per cent level of confidence.

1 A minimum of 16, rather than 13, agreements was necessary for significance in the subjective ratings because the judges had knowledge that there were an equal number of cases in each group. Since the Elizur scores were not af­ fected by an equal division of cases between the two groups, the method of determining significance was simplified. The procedure used may be found in Guilford, o£. cit., pp. 160-

162.

101

TABU XVI M I I H C I E S H I ® WHICH ELIZUR C O W T SIGHS APEEARED IH GROUP I, GROUP II AM) , . . _TOTAL.GROUP.OF 112_ApiOUS- AHD NOH:AHXIplJS.RORSCHACH RECORDS „ .

Content Sign MOTIONS AHD ATTITUDES (A) Fear, unpleasantness Sorrow

Total N.* 112 (1) • ■ (2) A ... HA A ■ . HA

Group I H = 56 .

Group II

in .• (2L. A ■ „ HA A - , HA

in ■ (2! A , HA A , . HA

12 2

5. 1

8 2

4 1

13 2

9 0

9 2

8 0

10 0 8'

8 2 6

5 0 T

6 2 5

. 3 1 5

9 2 2

3 1 4

T 2 2

29 6. 6 1 3 2 5 8 10 0 0

26 l 2 1 3 T 4 10 14 l l

22 6 6 1 3 2 5 5 T 0 0

16 1 2 1 3 5 3 T 9 . 1 1

23 5 3 4 1 10 T 14 16 3 5

3T 3 2 0 3 3 2 6 8 l 2

19 5 3 4 l T 5 10 10 3 4

21 1 2 0 2 2 2 5 T 1 1

15 T

10 3

9 6

9 5 0

6 3 0

T8 43

83 34

54 33

199

200

141

.* =

14 1

IT 4

12 1

13 1 .13

IT 4 8

8 l 11

13

52 11 9 5

41 11 9 5

12 12 22 26 3 5

63 4 4 1 6 10 6 16 22 2 3

3T 2 4 1 5 T 5 12 16 2 2

25 15

24 IT

14 10

16 16

6 11

9 10

4 T

T 10

19 4

IT 10 1

13 T 0

16 9 1

12 6 0

T 4 l

T 3 0

T 4 l

6 3 0

10 6 0

TOTAL (A) TOTAL (a).

191. 94

156 86

150 69

110 TO

84 4T

T8 43

6T 35

56 3T

107

TOTALWeighted Frequencies ,... (A= 1 , a = 1/2)

I76

398

369

290

215

199

169

149

261

E M M S AHD ATTITUDES (a) EXPRESSIVE BEHAVIOR.(A). . SYMBOLIC R E S M S E S (a). CULTURAL STEREO'S® A Bat . . . . . . . . . .... Sanke Monster Witch Dragon, ghost Human skeleton, skull Dead human, animal Blood Bomb, volcano, fire Clouds Smoke CULTURAL STEREOTYPES (a) Religion, Spider DOPLE CONNOTATION (a) , Human , Animal Other

25

4

9 10 15 IT 3

4

.

T '

1

(1) Frequencies indicate total number of times sign appeared in all records, (2) Frequencies indicate number of records in which sign appeared one or more times,

4t

6 4 . 0

56 .

105 In Group I, the Item “bat” appeared more frequently in the anxious group (significant at the 5 per cent level); the items “snake11 and “monster“ also appeared more frequently in the anxious records (significant at the 1 per cent levelj. In Group II, the item “snake” differentiated the groups at the 10 per cent level,

“witch" was significant at the 5 Per

cent level, and “human skeleton or skull” was significant at the 10 per cent level. This analysis of the table of frequencies indicates how few of the separate scoring categories differentiated significantly between groups. were in the negative direction.

In some cases frequencies It also indicates that

there is very little difference in results for the Elizur method, where every appearance of a sign In a record Is scored, and for the method used in the empirical part of this study where a content sign was scored only once in a record, regardless of the number of times it appeared.

IV.

RELIABILITY OE THE SUBJECTIVE RORSCHACH RATINGS

Each of the ratings made on twenty cases may be seen by reference to Table XVII, where the cases are listed in the order of presentation to the judges.

When the twenty

106 TABLE XVII AGREEMENT BETWEEN THERAPY AND' SUBJECTIVE RORSCHACH RATINGS OF TWENTY.ANXIOUS AND.NON-ANXIOUS CASES

Case Number 112 ** 110- 60

56 5 111

53 57 '4

109 2 1** 54-'-

59

52

55 58

3 108 61

Therapy Rating*

Agreement with Therapy Rating for seven Rorschach Ratings 1 6 2 4 3 5 7

NA NA A NA ' A

X X X X

x

NA NA. A A NA

X X X X

A . A NA A NA

X X

NA A A NA A

Number of Agreements

(x)

x„ X X

X X

X X X

X X X

X

X

X X X

X X X X

X

X

X

X

X

X X

X X X

( ) X X

X

( )

X X X

X X X

X X X

X X X

X

X

X

X

X X

X

X

XX

( )

( }

X

X

X XX

X

X X

X

X

14

X

X X XX X x

X X X

XX X XX

( )

. x_ X

x

X X X

X

X

Pool***

X

13

X

X X

X X

X

X

X X

12

12

15

14

12

14

-

*

A = Anxious.

NA = Non-anxious.

**

Records 106 and 8 were substituted for records 112 and 1, respectively, for raters 2 , 6 and 7 .

*** Double x indicates unanimous agreement.

107 judgments of one rater were compared to those of every other rater who had rated the identical twenty cases, it was found that the average number of agreements between pairs of raters was 12.6 which is not significantly above that to be expected by chance alone. When consideration was given to the eighteen records rated by all seven judges, it was found that five out of eighteen received ratings which were in unanimous agreement. Since the probability of any one record being rated alike by seven judges is .0 2 , it would seem unlikely that the obtained number of unanimous ratings should have occurred by chance alone.

V.

AGREEMENT OBTAINED BETWEEN THERAPY AND SUBJECTIVE RORSCHACH RATINGS"'

The number of agreements between subjective Rorschach ratings by seven judges and therapy ratings on twenty cases ranged from twelve to fifteen, with a median at thirteen (Table XVII).

None of these frequencies alone is signifi­

cantly above chance expectation.

However, the probability

that all seven judges should obtain scores either above or below the mean of ten is indicated by 2 (1/ 2 )^, or a pro­ bability of less than .02, which is significant.

108 When

for

determined,

it

with

the

than

chance.

each was

therapy

All

five

of

agreement

with

of

obtaining

eight

on

any

that

the

have

occurred

one

obtained by

found

the the

pooled

is

unanimous therapy

is

five chance

out

of

alone.

not

rating.

than a

were

in

rating

ratings

Since

Rorschach .01,

possible

it

was

agreement

significantly

Rorschach

(seven

less

Rorschach

fourteen

which

ratings

case

a

that

ratings,

in

alike

record

the and

better

were

also

probability one

seems

eighteen

therapy)

unlikely should

CHAPTER VI DISCUSSION

In

the

literature* indicators criteria of

the It

a

the of

was

approach*

with

the

the

about

which It

is

study* as

it

“h a n d l e d “ b y record by

the

is

therefore

were

that*

test

whole*

next

be

to

very

a

to

made

below

of

the

Rorschach

in

outside

as

to

methods

connection

r a t h e n than

selected was be

for

that

various

kinds

decided

to

investigate and

defense

this

investigation*

category

but

system*

of

For

Kelley*

should

be

one

anxiety

purposes

a

clear

and

the

of

this

unsystematized or

that

because

directly

which

the

not

Rorschach

affected

anxiety.

The

therapy

questionnaire

provide

ratings

on

that

anxiety*

is

more

to

aspect

Accordingly*

be

designed

to

for

there

handled.

believed

particular

little.

is

some

attempting

study.

important

it

Klopfer

some

chosen an

suggested

between

which

as

anxiety

know

systematized

on

relationship

suggested

should

of

by

review

study.

first

we

was

described

will

considered

in

their

"be d i s c u s s e d

differentiation ways

and

the

research

which

of

was

further

Suggestions

Rorschach

it

followed

stressed.

was

since

which

for

anxiety

expression

many

need

present

validation

of

discussion

by

it

than

was

anxiety

which

110 is

consciously

directly may of

by

not

be

clinic

felt

of

then

Although

in

we

of

negative

have

this

deep

as

for

support

the

obtained

and

psy c h i a t r i s t s 1 ratings,

Group

II,

when

To

explore

design

a

anxiety

study are

In large

this

point in

the

was

previous of

by

them

further,

which

considered

sample

controls,

rated

both in

the

it

emphasized.

selected In

the

this

a

the

did

suggested

Group

be

show

for

Group

evidence by

I

the

and alone.

important

and

does

Rorschach

considered

would

which

ratings.

Some

certain

were

to

conscious

ratings. importance

cases, study

with it

.

negative

results

both

is

deep

indices,

is

which

Rorschach

therapy

the

would

against

finding.

therapy

majority

anxiety,

unconscious

discussion,

carefully

I,

for

or

is.

find

and

between

signs

cases

to

however,

may

measures

shading

Group

the

anxiety

rather

signs

observed

relationship

If

expected

such

in

surface

but

hypothesis,

correlations

inverse

is This

probably

of

Rorschach

not

him.

erected.

anxiety,

signs,

did

it

this

been

relationship

whole,

favor

have

which

although,

an

of

or

treats

amount

might

certain

a

that

the

between

inverse as

and

who

here,

amount

surface

correlation

II,

the

patient

origin

assume

defenses

measure

this

therapist

might

directly,

anxiety,

the

neurotic

between

neurotic not

the

by

p a t i e n t s -used

We exist

felt

was

of

a

adequate possible

Ill to;obtain most

a

greater

previous

served

as

a

of

had

entire

ferent

previous

The

as

been

use

which

valid.

studies

than

It

might

of

a

might is

on

otherwise

for

have

possible

have a

reported

cross-validation

quite

also

repeated

that

failed

comparable

been

that

to

hold

but

dif­

group.

this

geneous

study,

the

was

group

and

this

In

the

studies

reported

as

perimental

showing design,

differences

in

differentiated disturbed seeking

there

one,

results.

of

than

hospitalized anxiety

would

voluntary

basis.

As

patients

were

rated

normal

group

outpatient

regard

be

was

in as

this

by

study,

having

some

clinic,

than

likely

shown

group

might

since

adequate

in

have

this

on

It

a

be

to

or

be can

ex­ that be

Patients

regardless expected or who

of

to

be

more

so

experience

treatment

thirteen no

the

emotionally

original

only

may

anxiety.

those

seek

the

little

of

normals,

only

homo­

previously

used;

whom

diagnosis,

Elizur,

based

a

cases

evaluating

were

all an

of

relatively in

and

results

anxiety

patients,

ratings

R a ’p a p o r t

groups

of

a

considered

in

conscious

therapy

be

selection

was

than

at

in

whole

easily

psychotic

homogeneous

a

of

normal

more

more

as

arbitrary

positive

patients,

or

no

must

amount

treatment

neurotic

of

cases

findings

study

Although in

on

accepted

results the

of

investigations.

check

erroneously

number

on

a

distribution of

manifest

the

112

anxiety.

112 For

seventy-six

symptom. less

We

would

of

be

the

known other.

the

extent in

to

that

even

more

to

or

of

to

be

findings

because

studies

a

of

this

a

chief

would

the

the

of

be

homo­

kind,

design

distribution

and

of

ference

of

criterion

use

it

this

it

therapy

cases

important

subject.

the

against

the

was in

in

study, ratings to

either a

a

measure

one

but

primary

clinic

the

justifiable

con­

situation

evaluating

Considering seem

this

which

of

two

therapist

therapy.

in

con­

Although

Rorschach

validity

therefore

noted

used were

anxiety,

psychiatrist,

any

interpretations the

an

criterion nor

the

is

prog­

purpose to

use

of a

kind. be

been

results of

in

a

between

of

would

should

have

positive

Rorschach

on

criterion

not

agreement

the

as

ratings

valid

progress

study,

It

a

criterion

served

those

be

a

research

Therefore,

for

criterion

a

future

groups

of

ratings

that

made

nosis

therefore,

select

planning

neither

the

this

in

therapy

actually

are

that

considered

investigation

In

to

selection

sideration

cern

this

was

result. The

were

in

advisable so

anxiety

expect*

group.

questionnaire would

them

might

significant

geneity

the

of

with

in

that

ratings

previous

found.

In

interview the

a

group

investigations

where

the

based

Rapaport

material

assistance

of

was

two

on

study,

as

evaluated

con­

a by

psychologists,

113 and of

this the

group

rating.

that

ratings

more

evenly

are

used.

have

such

dividual, of

the

For a

since

ratings.

rate

have

a

the of

a

anxiety.

on

It

by

direct which

was

investigation of

the

sible

to

encourage

comments

study

Elizur, and

rating

and

not in a

the

same or

is

criteria and

a

we in

a

greater have

exclamations

an

in­

knowledge it

make

was

all

of

suggested

by

used

inter­

asked

were

course out

such of

the

In

about

expect

brings

to

all

his feelings

therapy,

more

It

valid

rating.

that

have

the

of

self-rating.

would

be

raters

reason,

group

in

to

possible

sufficient

person

three

mind.

to

had

For

questioning

could

needs

by

the

specifically

unfortunate

different

on

s e l f .r a t i n g s

base

tend

check

a

patient

to

many

rater

not

While

a

same

advantage

was

single

was

added

reliability

it

questionnaire

subject

expressed that

which

the

study,

him.

the

in

when

to

an

the

person

study

material

done

one

of

feelings

be

as

added

been

by

than

The- i m p o r t a n c e

these

may

to

material,

be

only

to

have

present

conference

the

to

may

have

throughout

the

patient

Elizur

may

distributed

possible

of

There

made

not

view

approach

the

been It

Rorschach

administered

might

number recorded

which

records

are

then

of

have

with

uniformly considered

the to

this

the

been

responses,

In

as

pos­ was

various be

important

114 anxiety

indicators.

nificant

results,

evaluations The rather was

the

used

here

have

tion

were into

been

should

The

Elizur

thoroughly revealed data.

clearly In

this

its

sig­

subjective

patterns, frequencies, In

of

this

signs

show

positive

results,

applied,

a

a

study

importance

the

or

that

they

failed

indices

a

meaning

source

usual

study

which

of

in

signs

could

rating.

the

the

for

except

that

as

and,

also

mean

that

of

were

may

significant

use

study,

exploration,

separate

Investigated

this

the

of

suggested

through

of

area

particular

give

more

of

of

content

informa­

quantitative

content

the

case

Rorschach

was of

made

the

interpretation

demonstrated.

the

investigation

of

primary

Accordingly,

part

method,

gestions

further

Rorschach

simplified,

those

be

integral

a

in

records.

discussion.

too

to

and

previous

were

combined

objective

statistical

signs

focus

resulted

separate

to

still

have

studying

failure

was

Rorschach

of

the

It

not

the

frequencies

Elizur

bring

for

considered

statistical

when

was

in

might

Rorschach

computing

were

included.

an

the

emphasized

but

both

importance

than

patterns

to

of

This

preceding

paragraphs

represented

an

it

attempt

resulting

from

earlier

discussion

will

be

was to

build

research.

devoted

to

a

shown

The

how

upon

this sug­

remainder

consideration

of

115 factors

in It

anxiety

the

present

was

study

expected

might

result

that

from

of

behavior

in

therapy

in

arriving

at

their

questionnaire.

From

particularly

reference

items,

certain

drawn. of

It

for

balized final

anxiety)

which

was

the

as

interview the

the

of

of

may

signs least

of

than

is

the

therapist,

behavior to

be

of

when

serves

as

expected

anxiety only the

in

his

of

between may

be

in

1

(ver­

for

Item

a

final

3.

most

Those im­

therapists*

during in

the

contributing

agreement

with

himself

is

better

experienced

by

him

observation

of

the

basis

that,

ratings,

therapists*

the

patient

the

important

basis

important

the

on

Item

the

anxiety

that

degree

since

is

kinds

verbalization most

Finally,

suggestion the

the

of

therapists

considered

finding

report

own

included be

the

indices

with

This

to

was

was

judgment.

able

the

therapy

important

anxiety.

the

on

anxiety

anxiety

rating,

symptoms

was

by

the

highest

6

based

of

patient*s

most

of

of

definition

intercorrelations

anxiety

next of

used

ratings

therapy

weight

2)

were

about

the

behavioral

(Item

previous

It

a

of

final

patient*s

that

The

indices

observation

to

above.

operational

analysis

correlated

list

received

portant

an

over-all

judgment.

rating

which

covered

findings,

over-all

feelings

the

an

the

conclusions

appears

conscious

basis

to

in

not

for the

a

rating.

many

Rorschach

116 signs

originally

between

anxious

considered, and

non-anxious

clusions

can

be

titative

and

content

they

were

not

fifty-six

When of

signs

tions

fessional

the

in

each

from

combined

signs

negative

direction

rated

this

by

rather a

Since

explanation,

the

positive

correlation

to

II,

Group

been

more

Further from

it

valid

was

psychiatrist

from

to

we

no

con­ quan­

know

between

shown

the

that

the

to

a

be

of

these

the

The

Group

pro­ ratings.

of

them.

in

attributed

the

Yet,

of

for

absence

to

chance.

signs

did

when might

professional

using not

in

the

ratings

other

these

signs show

the

cases

significantly

their

I,

the

explanation

but,

cases,

the

half

group

quantitative that

correla­

significantly

new

a

basis

o t h e r .groups,

first by

the

on

making the

rated

on that

depending

showed

the

in

was

clear

only

those

scored

group.

cases

cases

since

was

correlate

not

can

of

I,

outnumbered

thought

investigation

of

therapists

applied

for

than

it

with a standard deviation of 4.1.

The

mean obtained for 112 clinic patients in this study was 7.8 with a standard deviation of 3.7.

Another reason for this

difference is suggested by the possibility that the Elizur records were scored more liberally, whereas in this study only those responses were scored which very closely matched the examples given by Elizur.

More specific definitions of

scoring categories used by him would make scoring by his method more objective, and results more comparable. The be the

a

very

success important

Rorschach

selects

for

the

Elizur

method

consideration

test.

further

significantly

of

Apparently study

between

two

only

an

in

future

signs

fails

to

to

what

research

empirical

those

groups,

points

with

approach,

which make

may

which

differentiate use

of

signs

121 with very low but positive validity which, in combination, do lead to positive results.

The analysis of Elizur sign fre­

quencies for Group I shows that the differences are so small that all but three of the twenty-one signs would have been rejected, even at the 10 per cent level, in an empirical approach such as was used in the main part of this study. Yet, by Elizur*s "armchair” selection of signs, significant results were obtained.

Therefore, his approach might be

preferred in making a selection of signs, but significant findings should be followed by an item analysis in order to determine which ones show frequencies in the expected direc­ tion.

This method was successful in spite of the presence of-

signs with frequencies in.the negative direction.

Elizur did

not publish his own frequencies for separate signs, but future research should be directed toward a determination of those which occur in the positive direction in each successive study. Then, even more significant results may be expected. Prom these results, it appears that conscious anxiety is reflected in the Rorschach through the content of re ­ sponses, rather than through the determinants used in arriving at these responses.

Thus, it appears that neither

shading, nor any other determinant or quantitative score, is a measure of anxiety as defined and measured by the therapy ratings.

This points to a rather important area

122 for future research which may support the present indi­ cation that consideration of determinants has been seriously overemphasized* and that a study of content may lead to a new emphasis in Rorschach interpretation. The finding of the Elizur approach, that psycholo­ gists1 ratings of anxiety as manifested in therapy agree more closely with Rorschach content scores than do those of social workers and psychiatrists, is in contrast to the earlier indication that psychiatrists* ratings were in better agreement with Rorschach findings.^

It may be that

the psychologists* concept of anxiety is different from that of the psychiatrists and the social workers, and that these differences are reflected in corresponding differences in agreement with content and quantitative Rorschach scoring methods.

Perhaps content is a direct reflection of conscious

anxiety, while quantitative scoring reflects a deeper anxiety. It may have been this deeper anxiety which correlated with

p

It might be argued that, for those sixteen cases where t h e .psychologist had himself administered the Ror­ schach to the patient, some contamination of therapy ratings occurred. However, agreement between the Elizur score and the therapy rating was found for only eleven of these cases, in contrast to agreement for all of the ten cases where the Rorschach had been administered by a psy­ chologist other than the one who made the therapy rating.

123 the psychiatrists1 ratings of patients without conscious anxiety, in other words, patients whose anxiety is deep and not manifest.

However, such a conclusion is open

to question in that the psychiatrists also showed rela­ tively higher correlations on the content approach used in the cross-validation study and on the content approach used by Wheeler.

It can only be concluded, therefore,

that the best agreement on anxiety is found between b e ­ havior in therapy, considered by the psychologists to reflect conscious anxiety, and the system of scoring content devised by Elizur.

Since Elizur is a psycho­

logist, perhaps psychologists have in common some par­ ticular concept of anxiety, not shared by social workers or psychiatrists, which influenced both the therapy and Rorschach ratings. The findings of this study, as a whole, serve to emphasize the importance of selecting for discussion in Rorschach interpretation only those variables for which validity has been established; and, in so doing, the degree of validity must always be kept in mind.

Thus,

it must be remembered that, although the Elizur method is shown to be valid for groups, only seventy out of 112, or five out of eight Rorschach scores were in agree­ ment with therapy ratings.

For any single record, therefore,

124 the chance of agreement is less than two to one. As personality variables are gradually added about which we can speak with some confidence,, the usefulness of the test will increase and on a basis which is demon­ strably sound.

It would seem that only in this way can

Rorschach workers convince those critics who so far have justifiably expressed skepticism toward claims for validity of the test.

CHAPTER VII SUMMARY AND CONCLUSIONS In this chapter will be presented a summary of the procedures followed in the study, and the results and conclusions drawn.

I.

SUMMARY

It was the purpose of this investigation to de­ termine the amount of agreement between ratings of conscious anxiety based on Rorschach tests and on therapeutic inter­ views.

The 112 subjects consisted of all patients at a

mental hygiene clinic to whom Rorschachs had been adminis­ tered during one calendar year and who had received a minimum of eight one-hour therapeutic interviews. The therapy ratings were derived from answers to a questionnaire filled out by the therapist who treated the patient.

The questionnaire consisted of four parts

in which the therapist rated (1) the frequency and intensity of the patient's verbalized feelings of anxiety,

(2) the

frequency and intensity of anxious behavior during inter­ views as observed by the therapist, and (3) the frequency of thirty-one separate symptomatic expressions of anxiety.

126 The fourth rating consisted of an over-all judgment by the therapist in terms of anxiety as* a chief symptom, anxiety as one of the chief symptoms, the presence of some anxiety, or an absence of anxiety.

Quantitative weights were as ­

signed to each of the four parts of the questionnaire and a total therapy rating for anxiety was then obtained for each patient. The 112 cases were arranged in rank order according to the amount of anxiety present, as measured by the therapy ratings.

This total group was then divided on an odd-even

basis into two equal parts so that each part contained a comparable range of anxious and non-anxious cases.

One

group of fifty-six cases was then divided at the median into an anxious and a non-anxious group.

The Rorschach

tests of these patients were used in a preliminary search for signs to determine which differentiated anxious from non-anxious records divided on the basis of therapy ratings. The records were scored for a total of seventy-two quantitative and thirty-seven content signs, and phi coef­ ficients of correlation were used to select those signifi­ cant at the 10 per cent level of confidence in differentiat­ ing anxious from non-anxious cases.

There were thus obtained

a list of twenty-five quantitative signs and a list of thir­ teen content signs which were then applied to the remaining

127 fifty-six cases to determine their validity when used with a new group.

The second group of records, scored hy these

signs, was divided into anxious and non-anxious cases which were then compared to a similar division based on therapy ratings.

Again phi coefficients of correlation*.from which

corresponding Pearson r js were estimated, were used to de­ termine the extent of agreement. The entire group of 112 Rorschach records was also scored for content by a method recently reported, through use of which anxious cases had been successfully differen­ tiated from non-anxious cases.

The resulting separation

of Rorschach records into anxious and non-anxious groups was then compared, as described above, to the correspond­ ing therapy ratings in order to determine the validity of this method when applied to a new group. The foregoing objective analysis of the Rorschach tests was followed by a subjective approach to determine whether greater agreement with therapy ratings could be obtained in this way.

Rorschach records of the ten cases

rated most anxious and then ten rated least anxious by the therapy ratings were presented to seven judges who were asked to separate them independently into two equal groups of anxious and non-anxious cases.

The extent of

agreement with therapy ratings on twenty cases was determined

128 for each judge separately, as well as the extent of agreement between a pooled rating of all judgments on each case and the corresponding therapy rating.

II.

CONCLUSIONS

The conclusions drawn on the basis of the foregoing procedures were as follows: 1. The over-all rating of anxiety by the therapists, in response to the questionnaire, resulted in a distribution in which anxiety was considered to be the chief symptom in twenty-seven cases, and one of the chief symptoms in fortynine cases.

For twenty-three cases some anxiety was con­

sidered to be present, and for thirteen cases little or no manifest anxiety was found. 2. Over-all therapy ratings were correlated most with the patient!s own verbalization of feelings of anxiety, as shown by the correlation between these two items of .9 1 . Over-all ratings correlated .81 with symptomatic expressions of anxiety, and .72 with the therapist!s observation of anxious behavior during the therapeutic interview. 3. Application of twenty-five quantitative Rorschach signs, derived from the first group, to the second group of records, and a division of cases on this basis into anxious

and non-anxious groups, resulted in a phi correlation of -.10 (r = -.16) with corresponding therapy ratings.

When

psychiatrist cases alone were separated on the basis of these signs, the correlation between therapy and Rorschach ratings was,+ .58, significant at the 5 per cent level of confidence.

Cases of psychologists alone correlated zero,

and the social worker cases correlated -.50 with the therapy ratings.

The psychiatrist cases in the first

group were then studied separately to determine a new list of significant signs which separated anxious from non-anxious records.

The resulting fourteen signs were

then used to score the psychiatrist cases in the second group, and a comparison with therapy ratings resulted in agreement on seven out of fourteen cases, which is only equivalent to chance.

It was suggested that the failure

to obtain agreement for psychiatrist cases when scored by their own signs may have been due to the limited range of total scores because of the small number of signs used. 4.

Application of the thirteen content signs to

the second group of cases resulted in a phi correlation with therapy ratings of -.09 (r_ =* -.14).

Psychiatrist

cases alone correlated +.12, psychologist cases alone correlated zero, and social worker cases alone correlated -.21 with therapy ratings.

None of these results was

130 significant. 5. Although the results of the foregoing comparisons were essentially negative, it was noted that the psychia­ trists* ratings correlated more highly with both quanti­ tative and content Rorschach scores in the second group than did those of the psychologists, while those of the social workers correlated in a negative direction.

This

relative order in the amount of correlation from one pro­ fessional group to the next is the same as that obtained in a parallel study of homosexuality in which the same test data, and ratings by the same therapists, were used. It is therefore suggested that this difference may re­ present a difference in the concept of anxiety as under­ stood by these three professional groups. 6

. When the total frequencies of each separate

Rorschach sign in all anxious and non-anxious records of Group II was determined, it was found that no quantitative signs differentiated these cases significantly in the ex­ pected direction.

For psychiatrist cases alone, however,

three of the negative content signs did differentiate the cases significantly, suggesting that these signs may be valid contraindications of anxiety. 7 . When the entire 112 cases were rated by the content method of scoring anxiety suggested by a previous

131 study, and the results were compared to therapy ratings, the resulting correlation was +.25, which is very signifi­ cant.

It is therefore concluded that this method of

measuring anxiety as expressed in the Rorschach test is more valid than either the quantitative or content approach which formed the main part of this study. 8

. When agreements with Rorschach ratings, as

scored by the above method, were considered for the three professional groups separately, the resulting phi coef­ ficients were +.01 for psychiatrists, +.18 for social workers, neither of which was significant, and +.48 for psychologists which was significant at the 5 per cent level of confidence.

Contrary to the previous findings, it

appeared that Rorschach signs of anxiety, at least as measured by this scoring method, are more in agreement with the concept of anxiety held by psychologists than that of the other professional groups. 9

. As a measure of reliability, when the judgments

of each of seven judges who rated twenty Rorschach records were compared to those of every other judge, the average number of agreements between any one pair was found to be approximately 12.6, which is not significant. 10. As a further measure of reliability, when the five cases showing unanimous agreement among all seven

132 judges were considered, it was found that this frequency appeared to be significantly better than chance. 11. The number of agreements with therapy ratings for each of the seven judges ranged from twelve to fifteen in a total of twenty.

Although the fact that all were con­

sistently in the positive direction is significantly better than chance expectation, none of the results alone is sig­ nificant . 12. When a pooled rating, based on the combined judgment of seven judges, was compared to therapy ratings, the number of agreements was not significantly above that to be expected by chance. 13. When the five unanimous Rorschach ratings found to be in agreement with therapy ratings were considered, it was found that this frequency appeared to be significant­ ly greater than chance expectation. 14. It is concluded, therefore, that a subjective Rorschach rating of anxiety for any one record may be accepted with confidence only when that record represents an extreme case, and only when the rating is based on unanimous agreement between seven judges.

It is further

concluded that individual subjective ratings, or pooled subjective ratings, as used in this study, cannot be con­ sidered measures of anxiety in agreement with therapy

133 ratings. 15. Possible reasons for the failure to show more positive results in the cross-validation study were con­ sidered, as follows.

The quantitative Rorschach scoring

symbols may be more suited to the rating of unconscious anxiety than to a rating of conscious anxiety.

The- group

used was a homogeneous one consisting of patients in most of whom some anxiety was present.

The concept of anxiety,

as,understood by the therapists who made the ratings, may differ from the kind of .anxiety which is measured by the quantitative scoring variables.

The questionnaire consisted

of ratings by the therapist which may be a less accurate measure of anxiety than answers to questions obtained directly from the subject.

The Rorschach tests were'ad­

ministered by different individuals and included many short records, as well as variations in the amount of verbatim recording of responses.

The signs applied to the Rorschach

data may have been oversimplified or improperly combined. Selection of signs on an empirical, statistical basis fails to include those of low validity which do, in combination, produce significant results, as shown in the Elizur approach. 1 6 . Continued research along the line3 represented by this study, particularly in the area of content, is

13^

considered of prime importance in the further development of Rorschach technique.

B I B L I O G R A P H Y

BIBLIOGRAPHY Beck, S.J., "Some Recent Rorschach Problems," Rorschach Research Exchange, 2:15-22, September, 1937______ , "Introduction to the Rorschach Method: A Manual of Personality Study," American Qrthopsychiatric Association Monograph, I, 1937- 278 p p . , Rorschach’s Test. New York: Grune and Stratton, Inc., 1944, Vol. 1, 2 2 3 pp. Vol. 2, 402 pp. Bell, J.E., Projective Techniques. and Company, 1948, 533 PP.

New York:

Longmans, Green

Bijou, S.W., editor, "The Psychological Program in A.A.P. Convalescent Hospitals. Report No. 15* Army Air Forces Aviation Psychology Program Research Reports, Washington, D . C .: U.S. Government Printing Office, 1947. 256 pp. Binder, H., "The ’Light-Dark1 Interpretations in Rorschach1s Experiment," Rorschach Research Exchange, 2:37-42, December, 1937* Brunswick, B., "The Effects of Emotional Stimuli on the Gastro-Intestinal Tone," Journal of Comparative Psychology, 4:19-79* 225-287* February and June, 1924. Buhler, C., Buhler, K* and Lefever, D.W., "Development of the Basie Rorschach Score with Manual of Directions," Rorschach Standardization Studies, Number I. Los Angeles: C. Buhler, 1948. 196 pp. Cameron, D.E., "Observations on the Patterns of Anxiety," American Journal of Psychiatry, 101:36-41, July, 1944. Cannon, W.B., Bodily Changes in Pain, Hunger, Fear and Rag e . New York: D. Appleton ancT~Uompany, 19^9. 404 pp. Cattell, R.B., Description and Measurement of Personality. Yonkers-on-Hudson, New York: World Book Company, 1946. 602 pp. Cronbach, L.J., "Statistical Methods Applied to Rorschach Scores: A Review," Psychological Bulletin, 46:393-429* September, 1949.

136 Darwin, G ., Expression of the Emotions in Man and Animals. New York! D. Appleton and Company, 1896. 572 pp. Dunbar, Helen Flanders, ^notions and Bodily Changes. York: Columbia University Press, 1935. 595 PP.

New

Elizur, A., "Content Analysis of the Rorschach with Regard to Anxiety and Hostility,w Journal of Projective Techniques, 13:247-284, September, 1949. Futterman, S., Kirkner, F.J., and Meyer, M.M., “First Year Analysis of Veterans Treated in a Mental Hygiene Clinic of the Veterans Administration,11 American Journal of Psychiatry, 104:298-305, November, 1947. Garrison, M . , “The Problems of Quantification and Objectifi­ cation in Personality Measurement: A Symposium. II. Relationships Between Rorschach Scores and Clinical Changes in Mental Patients,” Journal of Personality, 17:146-152, December, 1948. Guilford, J.P., Fundamental Statistics in Psychology and Education. New York: McGraw-Hill Book Company, Inc., 19K 3T3 pp. Hertz, Marguerite R . , “The Shading Response in the Rorschach Inkblot Test: A Review of its Scoring and Interpretation,” Journal of General Psychology, 23:123-167., July, 1940. Klopfer, B., “The Shading Responses,” Rorschach Research Exchange, 2 :76-78, March, 1938. Klopfer, B., and Davidson, Helen H., The Rorschach Method of Personality Diagnosis Individual Record Blank. Yonkerson-Hudson, New York: World Book Company, 1942. Klopfer, B. and Kelley, D.M., The Rorschach Technique. Yonkerson-Hudson, New York: World Book Company, 1942. 436 pp. Klopfer, W.G., “The Efficacy of Group Therapy as Indicated by Group Rorschach Records,” Rorschach Research Exchange, 9:207-209, December, 1945. Klebanoff, S.G., "A Rorschach Study of Operational Fatigue in Army Air Forces Personnel,” Rorschach Research Exchange, 10:115-120, December, 1946.

137 Kubie, L.S., "A Physiological Approach to the Concept of Anxiety,” Psychosomatic Medicine, 3 *263-276, July, 1941. Miale, F.R. and Harrower-Erickson, M.R., Personality Structure in the Psychoneuroses,11 Rorschach Research Exchange, 4:7174, April, 1940. Murphy, G., Personality. 1947. 999 PP.

New York:

Harper and Brothers,

Raines, G.N., and Broomhead, E., "Rorschach Studies on Combat Fatigue," Diseases of the Nervous System, 6:250-256, August, 1945. Rapaport, D., Diagnostic Psychological Testing. Chicago: The Year Book Publishers, I n c ., I94F: VoT. 1, 573 PP. Vol. 2, 516 pp. Rapaport, D., and Schafer, R., ”The Rorschach Test: A Clinical Evaluation,” Bulletin of the Menninger Clinic, 9*73-77* May, 1945. Rorschach, H., Psychodiagnostics. 226 pp.

Bern:

Hans Huber, 1942.

Rorschach H., and Oberholzer, E., "The Application of the Interpretation of Form to Psychoanalysis," Journal of Nervous and Mental Disease, 60:225-248, 359-379* Sep­ tember and October, 1924. Ross, W.D., "The ‘Anxiety Neurosis* Rorsehaeh Record Compared with the Typical Basically Neurotic Record,” Rorschach Research Exchange, 4:134-137* July, 1940. Swift, Joan W., "Relation of Behavioral and Rorschach Measures of Insecurity in Preschool Children," Journal of Clinical Psychology, 1:196-205* A£ril, 1945. Symonds, P.M., The Dynamics of Human Adjustment. D. Apple ton-Century Company, 1946"! 665 pp.

New York:

Wheeler, W.M., "An Analysis of Rorschach Indices of Male Homosexuality,” Journal of Projective,Techniques, 13*97126, June, 1949.

138 Wickert, F., editor, ‘Psychological Research on Problems of Redistribution. Report No. 14," Army Air Forces Aviation Psychology Program Research Reports. Washington, D . C .: U.S. Government Printing Office, 1947. 298 pp. Young, R.A., and Higginbotham, S.A., "Behavior Checks on the Rorschach Method," American Journal of Orthopsychiatry, 12:87-94, January, 1942. Zulliger, H., “Die Angst in Formdeutversuch nach Dr. Rorschach,11 Zeitschrift f$r Psychoanalysische P&dagogik, 7:418-420,

195T.

A P P E N D I X

QUESTIONNAIRES ON ANXIETY AND HOMOSEXUALITY

In filling out the questionnaire, it is essential that the basis of judgment be the patient’s status about the time of administration of the Rorschach. Thus, information such as the presence of nausea may not have come to the attention of the therapist until a later date, but since it was present as part of the patient’s problem at the time of the Rorschach it would be included. On the other hand, symptoms or traits which developed later in treatment would not be included.

Patient R-No

Supervisor ________ _

Rorschach No.

Number of Therapeutic interviews

Date of Rorschach

m

C„LrESTl O'NNAIRE ON ANXIETY

Code No

A. EXPRESSIONS OF ANXIETY (Note: lease insert checkmark to indicate fregnency of svmntpml "Frequent" means weekly or daily, "Cccasional"^means*about once monthfly.) 1. Patient verbally expresses conscious feelings of: v ague uneasiness tension panic 2. Patient's general behavior during interviev/s (apart- from his verbalizations) reflects feelings of: vague uneasiness tension pani c if 3. Pati.ent- complains of the following symptoms: ^ _,cJy oe

H _2l' ^ jT

excessive worry

impotence

^

x>~' r-^ cPI r*

H

E

1i . i -4

____ !

i

r

i l

rapid heartbeat

i—

premature ejaculation -i

pseudoangina tremors

r

sieeplessness

s

nightmares

1 I

i !

| i

flushing

hypersensitivity to light, sound

1

f i

excessive sweating loss of appetite

marked startle reaction

2-4

i

I