JOURNAL OF PERSONALITY ASSESSMENT, 83(3), 277292 Copyright 2004, Lawrence Erlbaum Associates, Inc.

Rorschach Comprehensive System Variables in Relation to Assessing Dynamic Capacity and Ego Strength for Psychodynamic Psychotherapy
CS AND PSYCHOTHERAPY NYGREN

Marianne Nygren
Department of Psychology Stockholm University

Few studies have concerned the relation between Comprehensive System (CS; Exner, 1991, 1993, 2003) Rorschach variables, and suitability for psychodynamic psychotherapy. In this study, I predicted correlations between 17 rationally selected CS variables and suitability for psychotherapy as represented by ratings of Dynamic Capacity and Ego Strength. The participants were 52 psychotherapy applicants between 20 and 57 years old. The ratings were performed after clinical interviews and decisions concerning selection of the applicants. EA, FC, Blends, Zf, and MQo correlated positively and YFY negatively with Dynamic Capacity ratings, whereas EA, FC, and Blends correlated positively and YFY and F% negatively with Ego Strength ratings. EA, FC, YFY, Zf, MQo, and F% also differed between the applicants selected and those not selected for psychotherapy. Considering earlier research, the results for Blends, Zf, and F% were interpreted as replications and for MQo and EA as showing satisfactory consistency.

There are few studies of the Rorschach Comprehensive System (CS; Exner, 1991, 1993, 2003) that have focused on aspects of ego functioning related to suitability for psychodynamic psychotherapy. However, this area has been researched over the past 20 years with other methods yielding positive findings. Researchers have shown considerable interest in psychological mindedness, quality of relations, and motivation as possible predictors of completion and outcome of psychodynamic psychotherapy and of the patienttherapist relationship. Conte et al. (1990) developed a self-report instrument with good internal consistency, the Psychological Mindedness Scale (PMS), and carried out a study to determine if this instrument can predict outcome of psychodynamically oriented psychotherapy. PMS was positively correlated with the number of psychotherapy sessions attended by the patients and with outcome. In a study of construct validity, Conte, Buckley, Picard, and Karasu (1995) showed that PMS was related to being sociable, assertive, not submissive, and accepting of others and that it was also related to ego strength. Hglend, Engelstad, Srbye, Heyerdahl, and Amlo (1994) used clinical ratings to measure the pretreatment level of insight, a variable that is related to psychological mindedness. In accordance with their predictions, Hglend et al. (1994) found that pretreatment insight was inversely related to drop-

ping out from individual psychodynamic psychotherapy. Hglend et al. (1994) also found that in interaction with treatment length, insight was significantly related to outcome 2 and 4 years after treatment. The Psychological Mindedness Assessment Procedure (PMAP) described by McCallum and Piper (1990b) is another measure of psychological mindedness that has demonstrated good reliability and validity. It is constructed on the basis of psychodynamic theory and employs a standardized videotape-interview procedure. In two studies of short-term psychoanalytically oriented group psychotherapy, PMAP emerged as highly predictive of attrition but not of outcome (McCallum & Piper, 1990a) and as a stronger predictor of dropping out than psychiatric symptoms and severity of target objectives (McCallum, Piper, & Joyce, 1992). In a day treatment program for patients with severe psychological problems (Piper, Joyce, Rosie, & Azim, 1994), univariate analyses showed significant positive association both between PMAP and patients capacity to work in group therapy and between PMAP and outcome. In multivariate analyses, both PMAP and patients work in group therapy were independently related with outcome. Tasca et al. (1999) studied patients with serious emotional, coping, and interpersonal problems treated in a mainly group therapy based hospital program and found that

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NYGREN positive and significant correlations between quality of pretherapy interpersonal relations, therapeutic alliance, and positive collaboration in therapy. The results also suggested a positive relation between quality of interpersonal relations and outcome of psychotherapy. In a study of short-term individual psychodynamic psychotherapy by Piper et al. (1991), quality of object relations was significantly related to both patient-rated and therapist-rated therapeutic alliance and to improvement both of general symptoms and specific target problems. Both quality of interpersonal relations and psychological mindedness were directly related to outcome in a psychodynamic group-oriented day treatment program for patients with severe psychological problems (Piper, Joyce, Azim, & Rosie, 1994); quality of object relations was related to two of three outcome factors, and psychological mindedness was directly related to favorable outcome for three outcome factors. Hglend (1993) studied quality of interpersonal relations and DSM diagnoses in relation to outcome of dynamic individual psychotherapy of brief to moderate length. Hglend (1993) found that the collective contribution of quality of interpersonal relations, the Global Assessment Scale (Axis V; DSM [3rd ed.; American Psychiatric Association, 1980), and presence versus absence of personality disorders significantly predicted dynamic change (i.e., better interpersonal relations and self-esteem, new self-understanding or insight, and increased problem-solving capacity) but not symptomatic change. Clinicians and researchers have long emphasized motivation as a crucial variable for predicting how an individual will benefit from psychotherapy (Garfield, 1994; Orlinsky, Grawe, & Parks, 1994; Roth & Fonagy, 1996). Sifneos (1978), who found that motivation related to successful outcome of psychotherapy (short-term and long-term), used seven criteria to assess motivation for change: ability to recognize the psychological nature of symptoms; tendency to give honest and truthful accounts of emotional difficulties coupled with introspection; willingness to participate actively in the treatment; willingness to change, to explore, and to experiment; curiosity and willingness to understand oneself; realistic expectations of therapeutic outcome; and willingness to make reasonable sacrifices. These criteria have later constituted a base in other studies of motivation and psychodynamic psychotherapy. Keithly, Samples, and Strupp (1980) studied motivation, measured with a scale that was mainly based on Sifneoss criteria, in relation to outcome and process in short-term dynamic psychotherapy. Keithly et al.s results suggested that pretherapy patient motivation is related to patienttherapist interaction (inversely related to negative therapist attitude and patient hostility and positively related to patient active participation in therapy), especially early in psychotherapy. Hglend (1996) used seven motivation items modified after Sifneos and found that two of these criteria, motivation for change and realistic expectations, predicted outcome measured 4 years after termination of brief dynamic psychotherapy. A factor analysis of

chronicity of psychiatric problems and PMAP emerged as significant single predictors of completion. Pretreatment quality of patients interpersonal relations is another variable that has interested researchers and that has been studied in combination with psychological mindedness. In a review of research on quality of object relations and short-term psychodynamic psychotherapy, Piper and Duncan (1999) discussed possible clinical implications of assessments of quality of object relations with focus on actual (observed or reported) behavior. One such implication is that assessment of quality of object relations can give information that is valuable and relevant for interpretations of transference in psychodynamic psychotherapy. Baumann et al. (2001) studied the reliability and validity of the Capacity for Dynamic Process Scale (CDPS), developed by Thackrey, Butler, and Strupp (1993). According to Baumann et al., the nine basic areas of CDPS cover three aspects of therapeutic collaboration: modulation of affect, interpersonal relations, and insight or introspection. Baumann et al. showed that CDPS can be reliably scored, that it is internally consistent, and that it has discriminant validity in relation to two Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSMIV]; American Psychiatric Association, 1994) Axis V rating scales (Global Assessment of Functioning and Global Assessment of Relational Functioning) and to self-report measures of psychopathology and interpersonal functioning. For the DSMIV Axis V rating scale Social and Occupational Functioning Assessment, there was no significant relation with external rater scoring of the CDPS, but the correlation with therapist ratings was significant. Moreover, CDPS was shown to differentiate between patients terminating psychotherapy prematurely and remainers, and there was also some evidence that the CDPS is related to therapeutic alliance. Piper, Joyce, McCallum, and Azim (1998) addressed the question if quality of interpersonal relations and psychological mindedness can predict whether interpretive or supportive therapy will be most suitable for the patient. Quality of relations turned out to be significantly related to improvement in individual interpretive but not in supportive therapy, whereas psychological mindedness had a significant relationship with outcome for the interpretive and supportive groups taken together. There was no significant relationship between dropping out and quality of object relations or between dropping out and psychological mindedness. At follow-up after 6 and 12 months, the relation between quality of object relations and outcome was maintained, whereas there were no follow-up effects for psychological mindedness (Piper, Azim, McCallum, Joyce, & Ogrodniczuk, 1999). When the data were analyzed with hierarchical linear modeling, somewhat contradictory results were obtained; quality of object relations was related to outcome in supportive but not in interpretive therapy (Ogrodniczuk, Piper, Joyce, & McCallum, 2001). Moras and Strupp (1982) studied short-term psychodynamic psychotherapy and as predicted, they found

CS AND PSYCHOTHERAPY 10 reliably rated selection criteria, modified after Sifneoss selection criteria for brief dynamic psychotherapy, yielded four dimensions of psychotherapy suitability: motivation, circumscribed focus, flexible interaction with the evaluating interviewer, and quality of object relations (Hglend, Srbye, Srlie, Fossum, & Engelstad, 1992). A combination of these factors predicted dynamic but not symptomatic outcome of psychodynamic psychotherapy of brief to moderate length.

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RESEARCH ADDRESSING THE CS AND PSYCHODYNAMIC PSYCHOTHERAPY Thus, there is a wealth of studies demonstrating that especially psychological mindedness, quality of object relations, and motivation are related to psychotherapy outcome, favorable patienttherapist relationship, or completion of therapy. The assessment methods have mostly been ratings by interviewers or observers, the PMAP (McCallum & Piper, 1990b), and patients self-ratings. In contrast, CS studies of the problem area are few. However, there is a limited evidence of the validity of some CS variables in assessment for dynamic psychotherapy (Alpher, Perfetto, Henry, & Strupp, 1990; Bihlar & Carlsson, 2000, 2001; Exner & Andronikof-Sanglade, 1992; Garfield, 1994; LaBarbera & Cornsweet, 1985; Meyer & Handler, 1997, 2000; Nygren, 2004; Weiner & Exner, 1991). Alpher et al. (1990) studied 15 rationally chosen variables from the CS structural summary in relation to the CDPS, which focuses on the patients capacity to collaborate therapeutically during a semistructured interview. As mentioned earlier, Baumann et al. (2001) studied the reliability and validity of the CDPS with positive results. The clinician conducting the interview in the Alpher et al. (1990) study carried out the CDPS ratings of the patient immediately after performing the interview. Moreover, independent judges rated the CDPS after viewing videotapes of the interviews. The CS scores selected by Alpher et al. (1990) were Human Movement responses (M), Blends, Pure Form proportion (Lambda), Organizational Activity (Zf), percent poor Form responses (X %), number of Responses (R), Experience Potential (ep; now called Experienced Stimulation [es]), Deviant Responses (DR), Form-dominated Chromatic Color (FC/CF+C), Pure Form responses (F), Egocentricity Index, unadjusted D, Inanimate Movement (m), White Space responses (S), and Texture responses (T). To calculate the degree of association between the CS variables and the ratings of CDPS, a five variable, stepwise regression model was used. For the clinician ratings, the regression containing the CS variables Zf, DR, es, Sum T, and Lambda was significant, F(5, 36) = 5.45, p < .001, and R was .66, n = 41. The regression was also significant for the ratings by the independent judges, F(5, 28) = 6.01, p < .001, R being .71, n = 34. The CS scores in this regression were Zf, DR, es,

Blends, and m. Thus, for the clinicians ratings and the ratings by the independent judges taken together, Zf, DR, es, Sum T, Blends, and m turned out to be positively and Lambda negatively related to the ratings of patients potential for engaging in the process of a dynamic psychotherapy. However, es turned out to be a suppressor variable, that is, a variable sharing variance with the predictor variables but not predictive of the criterion, and DR was interpreted to be a possible positive predictor of a patients potential for engaging in the process of a dynamic psychotherapy but only given an otherwise intact personality (Alpher et al., 1990, p. 227). Two exploratory studies concerning the CS and therapy-goal formulations in psychodynamic psychotherapies have been reported by Bihlar and Carlsson (2000, 2001). The first study (Bihlar & Carlsson, 2000) concerned agreement between psychodynamically oriented therapists therapy-goal formulations and patients problems as indicated by the CS. For the patient group in which the level of agreement between therapists goals and patients problems was low, Bihlar and Carlsson (2000) argued that the Rorschach might provide information that can be difficult to obtain in pretherapy interviews. In the second study, Bihlar and Carlsson (2001) compared CS scores for two groups of patients. In the first group, there was a high level of agreement between the therapists planned goals and the actual goals reported by the therapists after therapy. In the second group, the agreement between planned and actual goals was low. Selected CS scores differentiated these two groups. The results were interpreted as indicating that for some patients, the standard clinical interview was not an adequate instrument to make assessments for dynamic therapy and that additional instruments might yield valuable information about the patient. LaBarbera and Cornsweet (1985) carried out a study in which they predicted relations between psychological flexibility, as represented by the constructs of instability and perceptual sensitivity, and the outcome of dynamically oriented treatment of child psychiatric inpatients. Rationally selected CS scores measured instability and perceptual sensitivity. LaBarbera and Cornsweet found that children who benefitted from treatment demonstrated perceptual sensitivity as indicated by lower Lambda scores, more Blend responses, and more organizational effort (Zf and ZSum). The children who benefitted from treatment also showed higher instability as indicated by a greater difference between irritating stimuli (es) and organizing resources (EA) than the children who did not benefit from treatment. There are also a few studies that give indirect support for CS scores as indicators of patients suitability for psychotherapy. Two studies reported by Weiner and Exner (1991) and by Exner and Andronikof-Sanglade (1992) in which changes in CS variables were predicted as psychotherapy outcome are relevant to psychotherapy outcome and give indirect support to the validity of some structural variables in the Rorschach. Moreover, an index of Ego Strength derived

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NYGREN COP were higher and F% lower among patients from the first two groups than among patients from the third, contrasted group. When just patients with personality disorders in the second group were compared with the patients in the third group, the pattern of significant differences remained the same except that the COP difference was no longer significant. Like the studies by Alpher et al. (1990) and LaBarbera and Cornsweet (1985), in this study and the Nygren (2004) study, I have focused on a selection of CS summary scores. However, the Rorschach can be coded and analyzed in different ways. Janson and Stattin (2003) elucidated this in a recent article and pointed out that Rorschach research has shifted between the objective coding of discrete response elements and global-holistic ratings. Although both approaches are valuable, since the advent of the Comprehensive System (Exner, 1991, 1993, 2003), research has focused mostly on discrete codes, whereas research using a global-holistic approach has become rare. However, research on global-holistic ratings has been conducted on human drawings, and predictions from intuitive ratings have been validated (Burley & Handler, 1997; Tharinger & Stark, 1990). Janson and Stattin (2003) called attention to the fact that clinicians regularly combine discrete codes into meaningful categories and that the dichotomy between single-coded data and a global-holistic approach, often forthcoming in research, may seem artificial to clinicians. However, as Acklin (1992) and Weiner (2000) pointed out, the importance of an integrative approach in the interpretation of Rorschach data is central. For such an approach, both the coding and the qualitative aspects of the Rorschach are important, and research concerning the validity of the scores in the Rorschach in different kinds of assessments is thus desirable. The purpose of this study was to investigate the relation between the interpretations of rationally selected structural variables in the CS and clinical ratings of suitability for dynamic psychotherapy. The broad concept of therapy suitability was represented by Dynamic Capacity (related to the patients performance in the therapeutic situation) and Ego Strength. The terms Dynamic Capacity and Ego Strength are defined by the rating variables presented in Table 1. The variables to be rated were formulated to represent limiting-potentiating continua of Dynamic Capacity and Ego Strength. This study differs from most of the earlier studies of the CS and psychotherapy in the way that the CS scores were selected and predictions formulated. The rational ground for the selection of CS scores was that according to the interpretations commonly assigned to them, it should be reasonable to expect them to measure aspects related to Dynamic Capacity and Ego Strength. The study most similar to this one is the Alpher et al. (1990) study. However, in that investigation, although the CS scores were rationally selected and related to ratings of CDPS, the conceptual ground for the selection of CS scores was not described. As mentioned, Nygren (2004) used the same set of CS variables as in this study. However, that study compared

from six components of the Rorschach test, the Rorschach Prognostic Rating Scale (RPRS; Klopfer, Ainsworth, Klopfer, & Holt, 1954), has been used with some positive results concerning psychotherapy outcome (Garfield, 1994; Meyer, 2000; Meyer & Handler, 1997, 2000). However, the RPRS is based on administration and scoring according to the Klopfer et al. Rorschach tradition, so the results cannot be regarded as direct support for the CS, even though the RPRS was derived from scores similar to those in the CS. Nygren (2004) studied psychotherapy patients from three different units using the same set of rationally selected CS scores as in this study. In that study, two groups of patients who were sufficiently well functioning to benefit from treatment limited to individual psychodynamic psychotherapy on a once or twice weekly basis were compared with a third group comprised of psychotherapy patients with personality disorders and serious psychological problems for which an individually designed outpatient program was deemed necessary. The first group in Nygren (2004), a subsample from the participants in this study, consisted of 25 applicants personally seeking and being selected for psychodynamic psychotherapy in an advanced psychotherapy training program. In the training program, psychotherapy patients with rather well developed ego functions were preferred. The second group was a sample of psychotherapy outpatients from the Stockholm Comparative Psychotherapy Study (Carlsson, Nygren, Clinton, & Bihlar, 1996). This group comprised patients that received individual dynamic psychotherapy from authorized private practicing psychologists paid by the County Council. These patients either had been referred or had sought psychotherapeutic help by themselves. In the third group, the contrasted group, all patients had been referred from other psychiatric units to a special psychotherapy unit established to treat patients with personality disorders using psychodynamically oriented individually designed outpatient programs. Patients were referred to the special unit if they were deemed possible to help with psychodynamic psychotherapy, even though there was a serious lack of motivation for treatment and low quality of object relations. As shown earlier, lack of motivation and low quality of object relations are patient characteristics that are related to unsatisfactory outcome of psychodynamic psychotherapy. Considering these differences in recruitment, Nygren (2004) hypothesized that patients in the first two groups would have higher levels of variables related to suitability for psychodynamic psychotherapy than the patients in the third group. However, unlike this study, no systematic data on ego functioning related to capacities to engage in and benefit from psychotherapy were available for all groups. Consequently, the predictions about CS score differences between the groups in the Nygren (2004) study had to be based on assumptions about differences in therapy suitability between the groups. For 8 of the selected CS variables, the results were in accordance with the predictions. EA, Blends, Zf, MQo, FD, AG, and

CS AND PSYCHOTHERAPY
TABLE 1 Rating Variables Concerning Dynamic Capacity and Ego Strength
Endpoint Categories Variable Dynamic Capacity Psychological mindedness A good psychological mindedness means capacity and inclination for self reflection and introspection, capacity to both experience, feel, and think Motivation Expected motivation to co-operate in psychotherapy Cooperation Expected capacity to establish therapeutic cooperation Ego Strength Reality testing capacity Means the capacity to differentiate ones own inner world from outer surrounding realities, ones own ideas and thoughts from the thoughts of others, fantasy from reality. Capacity for genuine relations Means to be able to have enduring mutual relations with a real interest for the other person. Self and object constancy To be able to recognise good and bad aspects of one and the same person, also of oneself; to have an integrated whole image of persons and to have a clear adequate border between oneself and others Impulse control Capacity to control, in a reasonable way, ones own impulses, let thoughts direct actions, to work through conflicts within oneself instead of acting them out Access to a well-functioning defense structure Means that one has not a small number of rigid defences but is able to use a variety of defence mechanisms; is not dependent on primitive defenses, for example projection and denial sometimes in combination with acting out Degree of realistic self-evaluation The self-evaluation can be reasonable and realistic; it can also seem unreasonable and not rooted in reality, but more built on the subjects private ideas and fantasies Global rating of Ego Strength Low High

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(1) Very insufficient (1) Very insufficient (1) Very insufficient

(7) Very good (7) Very good (7) Very good

(1) Very insufficient (1) Very insufficient

(7) Very good (7) Very good

(1) Very insufficient

(7) Very good

(1) Very insufficient

(7) Very good

(1) Very insufficient

(7) Very good

(1) Very unreasonable (1) Very low

(7) Very reasonable (7) Very good

groups that were supposed to differ in aspects that are central for therapy suitability, although no individual data other than the Rorschach were available for comparison between the groups. In this study, I assessed all individuals, and motivation (a variable supposed to be especially low in the contrasted group in the Nygren, 2004, study) was but one of several patient variables rated. In summary, the central issue addressed by this study was the following: Are interpretations commonly associated with the CS supported by their relation to clinical ratings to which they should, on conceptual grounds, be related? I tested hypotheses concerning correlations between 17 rationally selected CS variables and clinical ratings performed for this study. Moreover, I also carried out analyses of the differences in CS variables between those applicants that were selected for psychotherapy and those that were not accepted.

METHOD Selection of CS Variables and the Rationale of the Predictions In this study and Nygren (2004), I have used the same set of CS variables and formulated predictions from the same conceptual foundation. Both studies are part of a broader

project that is conducted with the purpose to focus on the same selection of CS scores in studies with different designs. On conceptual grounds, the results of the studies in the project are expected to be similar. Therefore, the results from one study do not influence the predictions of the other. However, a consequence of this is that the predictions that follow sometimes contradict what would have been predicted if they had been based on the actual results observed in the Nygren (2004) study. Many of the CS scores selected are the same as those selected by Alpher et al. (1990). Among the scores that received positive results in that study, all except DR and es were selected. DR, one of the Special Scores in the CS, was not included because as mentioned earlier, Alpher et al. interpreted DR as a possible positive indicator for dynamic psychotherapy only for patients with intact personalities. The es score was not included because it operated as a suppressor variable in Alpher et al.s study. Moreover, five CS variables from the self and interpersonal perception cluster and two CS variables from the control and stress tolerance cluster were included in this study but had not been used by Alpher et al. The CS scores selected, the predictions formulated, and the rationale for the predictions are presented following.

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

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NYGREN Inanimate Movement as an indicator of inner tensions and of an awareness of forces out of control indicating strength because the individual does not use dissociation and disintegration. Alpher et al. (1990) found that m related positively to ratings on CDPS, but in the study by Nygren (2004), the number of m was not greater among the patients assumed to be more suitable for therapy. In this study, I predicted m to correlate positively with Dynamic Capacity. Sum T, number of Texture responses, was positively related to CDPS as rated by the clinicians in the Alpher et al. (1990) study. Most nonpatients give at least one T response, usually an FT answer to Card VI, whereas patients give Texture responses less frequently (Exner, 1993). Sum T is interpreted to be related to a capacity for close relations with other persons. In the CS, an absence of T answers is interpreted as indicating a tendency to be guarded and/or distant in interpersonal contacts, whereas an elevation of T (T > 1) can indicate stronger than usual needs to be dependent on others and a feeling of emotional deprivation and interpersonal neediness (Exner, 1993; Weiner, 1998). Exner (1993) found that therapists tended to rate T-less patients as less motivated during the first 3 months of psychotherapy than they rated patients with T answers. In the study by Nygren (2004), the prediction concerning T responses was not verified. As both T = 0 and T > 1 are interpreted as being related to problems with closeness in relations, it is difficult to formulate predictions for linear correlations. However, in this study, the prediction that Sum T should be positively related to Dynamic Capacity was motivated by the result received by Alpher et al. (1990). Blends, which consist of two or more determinants combined in a single response, are mostly interpreted as involving some affective experience (Exner, 1991, 1993). Blends were positively related to CDPS as rated by independent raters in the Alpher et al. (1990) study and in the study by Nygren (2004); Blends were more frequent in the groups of patients assumed to have higher levels of therapy suitability. In the study by LaBarbera and Cornsweet (1985), the number of Blends of was higher among children classified as improving. Few Blends might indicate difficulties in situations that are emotionally complex. Although the psychological complexity indicated by high proportions of Blends can be related to difficulties in dealing with affect for persons with limited control resources, Blends often indicate an asset (Exner, 1993). In this study, number of Blends was predicted to be positively correlated to both Dynamic Capacity and Ego Strength.

swers) and WSumC (Weighted Sum Color answers). In the CS, EA is interpreted as indicating available resources and capacity to implement deliberate coping strategies. It is conceptualized as related to but not identical with Ego Strength (Exner, 1991, 1993). EA was not selected in the Alpher et al. (1990) study, but in the study by Nygren (2004), the prediction that the values of EA should be higher in the groups of patients assumed to have greater therapy suitability received support. In this study, I predicted EA to be positively related to Dynamic Capacity and to Ego Strength. The Form Dominant Color response, FC, is interpreted to be related to affective experiences that are cognitively directed and better controlled (Exner, 1993). Although a strong dominance of FC responses can be a sign of very strong control of emotions, FC was regarded as indicating mainly positive capacities and was predicted to be positively correlated with both Dynamic Capacity and Ego Strength. However, in the Alpher et al. (1990) study, FC/CFC was not related to CDPS, and in the study by Nygren (2004), the prediction that the number of FCs should be greater among patients assumed to be more suitable for dynamic psychotherapy did not receive support. Diffuse Shading responses (FY, YF, and Y) are interpreted as indicating an experience of stress-related psychological helplessness and inability to influence ones situation (Exner, 1991, 1993). In this study as well as in Nygren (2004), I assumed that feeling unable to influence ones situation could make it difficult to be motivated for psychotherapeutic cooperation. Meyer (1992), in a review of earlier factor analytic studies of the Rorschach, found that Form Dominant scores are qualitatively different from non-Form Dominant scores. Moreover, it seems probable that Form Dominance in Diffuse Shading answers is related to better ego functioning than non-Form Dominance (Kleiger, 1992, 1997). However, in the study by Nygren (2004), the number of YF + Y scores was not greater in the group of patients assumed to be less suitable for psychodynamic psychotherapy. The prediction I formulated in this study was that the number of non-Form Dominant Diffuse Shading answers, YF + Y, should be negatively correlated with both Dynamic Capacity and Ego Strength. Inanimate Movement responses, m, another score from the es, are interpreted as indicating inner tensions and a feeling of forces being outside the control of the participant. Often the tension is interpreted to be of situational character (Exner, 1991, 1993). According to Weiner (1998), lack of m often indicates indifference and lack of concern, whereas elevations in m indicate concern about being exposed to forces outside ones control. Lerner (1991) discussed the implications of the m response from a psychoanalytical standpoint and viewed it as indicating repressed material coming into awareness in the form of subjectively experienced tensions. Lerner suggested that this gives an opportunity to establish contact around the patients feelings of distress and makes the individual accessible to therapeutic intervention. Klopfer et al. (1954) discussed

Cognitive triad: Information processing, ideation, and mediation. Frequency of Organizational Activity, Zf, was positively related to CDPS in the Alpher et al. (1990) study, and in the study by Nygren (2004), the prediction was supported. In the LaBarbera and Cornsweet (1985) study, children classified as improvers had more Zf responses than children classified as decliners. In the CS, Zf is conceptual-

CS AND PSYCHOTHERAPY ized as an indicator of willingness to attempt to synthesize the world in a meaningful way. It is also regarded as being related to a persons ambitiousness and motivation (Exner, 1991, 1993). In this study, I predicted Zf to be positively related to Dynamic Capacity. The relative amount of Pure Form responses is interpreted as being related to openness to experience, high values indicating detachment and lack of flexibility (Exner 1991, 1993; Weiner, 1998). In this study, number of Pure Form responses in relation to total number of responses, F%, was used instead of the CS structural summary variable Lambda (L). F% is conceptually and mathematically comparable to L but has better properties for research (Meyer, Viglione, & Exner, 2001). In the Alpher et al. (1990) study, L was inversely related to CDPS. In the study by Nygren (2004), the prediction that F% should be higher among the patients supposed to be less suitable for psychotherapy was supported, and in the LaBarbera and Cornsweet (1985) study, L was lower among the children classified as improvers. In this study, I regarded lack of flexibility as related to rigid defenses, whereas I regarded flexibility and willingness to become involved as indicating a therapeutic asset. I predicted F% to be negatively correlated to both Dynamic Capacity and Ego Strength. Number of Human Movement responses, M, is generally interpreted as being related to an inner-directed orientation and a capacity for imagination and fantasy (Blatt & Ford, 1994; Exner, 1993; Lerner, 1991). Weiner (1998) contended that accurately seen M responses (M+, MQo, and MQu) indicate empathic capacity, whereas distorted M (M) responses indicate lack of empathic capacity. M is an important score in the RPRS in which M answers of good fit with the blot are seen as indicating an asset and as a good prognostic sign (Klopfer et al., 1954). In the CS, as in the Klopfer et al. system, M is scored according to Rorschachs criterion (Exner, 1993). Alpher et al. (1990), who did not find M related to CDPS, did not differentiate between M responses of different Form Quality. In the CS, there are four levels of Form Quality: superioroverelaborated, ordinary, unusual, and minus. The Ordinary Form level includes answers that use form to define an object that is easy to see, that is, frequently seen by others and that does not have the overelaboration of the form features characterizing the superior Form level. More than one response with this overelaboration can be related to a perfectionist or obsessive style (Exner, 1991). As patients with obsessive problems are difficult to treat with therapeutic methods that do not include exposure and response prevention (Roth & Fonagy, 1996), and as answers coded as unusual Form can be quite idiosyncratic or even regarded as distorted by some, I predicted only the number of Human Movement responses of Ordinary Form level, MQo, to correlate positively with Dynamic Capacity. In the study by Nygren (2004), the results supported the predictions that MQo should be more frequent in groups of patients supposedly more suitable for psychodynamic psychotherapy.

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Weighted Sum Special Scores, WSUM6, are interpreted as indicating bizarre and disturbed thinking. Higher values of WSUM6 are regarded as a sign of pathological psychological functioning (Exner, 1991, 1993). X % is interpreted as indicating distorted perceptual mediation, an important aspect of reality testing capacity. In the study by Nygren (2004), the predictions that the values of X % and WSUM6 should be higher among patients that were supposed to be less suitable for psychodynamic psychotherapy were not verified. In this study, I predicted WSUM6 and X % to be negatively related to Ego Strength. As mentioned, DR, one of the scores in the WSUM6, was positively related to CDPS in the Alpher et al. (1990) study but was not included as a separate score in this study.

Affective features. Klopfer et al. (1954) argued that White Space responses, S, could indicate an asset, a constructive self-assertiveness, and according to the CS, lower values of S can be a sign of sound self-assertiveness (Exner, 1991, 1993). Higher values (> 2) are interpreted as indicating a negativistic and oppositional set toward the environment (Weiner, 1998). In this study, such negativism was assumed to be related to patients resistance, which is associated with negative therapeutic outcome (Orlinsky et al., 1994), and I predicted S to be negatively correlated to Dynamic Capacity. However, in the study by Nygren (2004), the prediction about higher number of S responses among the patients assumed to be less suitable for psychodynamic psychotherapy was not verified. Self and interpersonal perception clusters. Reflection responses, FrrF > 0, are interpreted in the CS as indicating narcissistic defensive needs. These needs are seen as a dominating element in the self-concept of the person and as a narcissistic-like feature (Exner, 1991, 1993; Weiner, 1998; Weiner & Exner, 1991). Exner (1991) wrote, This characteristic forms a basic personality orientation or style that is highly influential in decisions and behaviors because of the need for frequent reaffirmation or reinforcement of the exaggerated sense of personal pride (p. 173). This elaboration of the interpretation of FrrF and the elaboration by Weiner (1998) sound more like a description of a narcissistic personality than of a person just showing narcissistic defenses. As patients with narcissistic personalities are often regarded as difficult to treat with psychotherapy, especially time-limited therapy (Kernberg, 1975; McWilliams, 1994), I predicted FrrF to correlate negatively with Dynamic Capacity. However, the prediction by Nygren (2004) about more reflection responses among patients supposed to be less suitable for psychodynamic psychotherapy was not verified. Form Dimension, FD, was identified during the development of the CS. It is interpreted as being related to self-inspecting behaviors (Exner, 1991, 1993). One or two FD responses are interpreted as indicating sound self-inspection, whereas more than two FD responses can in-

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NYGREN them a written description of the study with an attached registration form. Fifty-two consecutive psychotherapy applicants, 36 women and 16 men, agreed to take part in the research project. The average age was 35 years, ranging from 20 to 57 years, and length of education was on average 14 years, ranging from 9 to 20 years. The training unit was a psychoanalytic psychotherapy unit where all patients were treated with psychodynamic psychotherapy. The protection of the integrity of both the therapy applicants and the candidates was very strong. This circumstance led to restraints for this study. The only data available were the Rorschach and the clinical ratings. No information regarding the number of applicants that refused to take part in the study was given, and no information concerning diagnoses, therapy process and outcome, or any information from the patients files was at my disposal. Interviewers The interviewers in this study were 15 experienced clinical interviewers, 4 men and 11 women, who were candidates in an advanced 3-year training program of individual psychodynamic psychotherapy. The interviewers did not treat any patients they interviewed; instead the applicants accepted for psychotherapy were entered on a waiting list. All interviewers, 10 psychologists (MA), 2 social workers, and 3 psychiatrists, had basic training in psychodynamic psychotherapy and at least 3 years of experience from psychotherapy under supervision before entering the advanced training program. The interviewers in this study were in the third and fourth terms of the advanced psychotherapy-training program, a period during which they received special training and supervision in psychotherapy assessment. Procedures Three assessment interviews were performed, and each interview was discussed in supervisory team conferences. The interviewer carried out the ratings for this study after the team had made the decision to accept/not accept the applicant. Finally, the Rorschach was administered and scored independent of all clinician interviews, treatment team discussions, and ratings. The Rorschach data was used only for this study, and this data was not available to any of the clinical interviewers or treatment team discussions and thus could not influence the selection of patients for psychotherapy or subsequent ratings of Dynamic Capacity and Ego Strength.

dicate exaggerated involvement with self-examination, even rumination about the self. However, as self-inspecting capacity is generally preferable in insight psychotherapy, my prediction was that FD should be positively correlated to Dynamic Capacity. In the study by Nygren (2004), the prediction was verified that FD should be less frequent in the group of personality-disturbed patients assumed to be less suitable for therapy. Aggressive Movement responses, AG, and Cooperative Movement responses, COP, are interpreted to provide information about the cognitive sets that persons have concerning interactions with others (Exner, 1991, 1993). AG indicates an aggressive/forceful set. Weiner (1998) contended that a high score on AG is not always an indication of maladaptation, and he recommended that AG should be interpreted more as indicating assertiveness than anger. Hilsenroth, Handler, Toman, and Padawer (1995) found that patients terminating psychodynamic psychotherapy prematurely had fewer AG and more COP than those remaining in treatment. The prediction that both AG and COP should be more frequent among patients assumed to be more suitable for psychotherapy was verified for AG and partly supported for COP in the study by Nygren (2004). Although research concerning the relation between patients affective responses and therapy outcome is not unequivocal, it seems that the patients total affective reactions to therapy (negative and positive reactions) are related to positive therapy outcome (Orlinsky et al., 1994). Although AG thus can indicate a liability, my overall prediction was that both AG and COP should be positively correlated to Dynamic Capacity. I predicted PER, Personalized Answers, which are interpreted to indicate defensiveness characterized by intellectual authoritarianism (Exner, 1991, 1993), to correlate negatively with Dynamic Capacity. Research indicates that patients openness in contrast to defensiveness during the therapeutic process is associated with positive outcome (Orlinsky et al., 1994). However, the prediction that PER responses should be more frequent among the patients regarded as less suitable for psychotherapy was not verified in the study by Nygren (2004). Participants This study was carried out in a unit for advanced psychotherapy training to which patients applied for psychotherapy on their own initiative. All applicants first met a senior psychiatrist/psychoanalyst who was responsible for the medical/psychiatric aspects of the program. Applicants who were psychotic, alarmingly depressed, or in acute crisis were recommended to seek help elsewhere and did not return for further assessment. They were not invited to take part in this study, an arrangement that may have reduced the range and severity of problems in the patient group. The psychiatrist informed the applicants that were accepted for further assessment about this study, invited them to take part, and handed

Assessment interviews and selection of patients for psychotherapy. The applicants participating in this study were given three unstructured clinical interviews with a 45-min duration. This was the regular assessment procedure of the unit preceding the decision to accept or not accept applicants into psychotherapy. The interviews were thus carried out in natural clinical situations.

CS AND PSYCHOTHERAPY The candidates psychotherapy assessments were supervised in teams (four students and two supervisors) that met once a week for 2 hr during the period that data were gathered for this study. Between the interviews, the candidates were guided by the teams about how to proceed. When the assessment interviews were finished, the task of the supervisory teams was to assess the patients capacity to benefit from psychodynamic psychotherapy and to decide collectively if the clients should be accepted and put on a waiting list for psychotherapy. No DSM diagnoses were made in connection with the assessments for psychotherapy. The therapies that were to be conducted by candidates in training were intended to last for 2 years with a frequency of two times per week. Personality aspects related to the patients Dynamic Capacity and Ego Strength were considered important, but the selection method was not formalized, and no scales or other selection instruments were used. Of the applicants willing to take part in the research, 29 were selected, and 23 were referred to or recommended to seek other treatments according to the decisions arrived at by the teams. Of the 29 selected applicants, 20 started and fulfilled 2-year therapies.

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a decision about what you are going to recommend the patient, you rate the patient yourself. Make the ratings on your own, in peace and quiet.

Internal consistency and validity of ratings. Descriptive data for Dynamic Capacity and Ego Strength are presented in Table 3. The patients total scores on Dynamic Capacity and Ego Strength were calculated as the sum of the ratings achieved on the subscale items. It was not possible to assess interrater reliability. The internal consistency of the ratings was good; Cronbachs alpha for Dynamic Capacity was 0.93, and it was 0.91 for Ego Strength. The point-biserial correlations between the selection decisions of the supervisory teams and the individual ratings performed by the interviewers were .68 (n = 52, p = .000) for Dynamic Capacity and .55 (n = 52, p = .000) for Ego Strength. Thus, although the ratings apparently had been influenced by the discussions and by the decision in the supervisory team, this dependence was not complete. Rorschach administration and scoring. I, as an experienced user and an instructor of the CS, carried out the administration and scored the Rorschach according to the CS guidelines. The Rorschach was conducted only for this study and independent of the assessment interviews, treatment team discussions, the selection decisions, and the ratings of Dynamic Capacity and Ego Strength. Moreover, the psychologist that independently performed the reliability scoring also had no knowledge of the assessment interviews, treatment team discussions, the selection decisions, and the clinical ratings of Dynamic Capacity and Ego Strength. After I gave the feedback about the Rorschach results to the patients only, I made the Rorschach protocols anonymous, and then I rescored when all the Rorschach data had been collected. Reliability of Rorschach scoring. To assess the reliability of the scoring, 20 of the rescored protocols (38%) were independently scored by an experienced psychologist and senior teacher of the CS regularly working with the method. This psychologist was only involved in the reliability scoring of the CS protocols; she had not taken part in the administration of the Rorschach in the study, and she was unaware of the original scoring of the CS protocols, of the clinical ratings, of the assessment interviews, of the treatment team discussion, and of the selection of applicants for psychotherapy. Scoring disagreements were not resolved, and all scores used in the analyses were those I assigned. For the 20 rescored protocols, two-way random, absolute agreement, intraclass correlations (ICC; 2,1) were calculated with the statistical software Rorschach Research Utilities (Version 0.9.3), developed by Janson (2002; Janson & Olsson, 2001). The data presented here consist of ICC values for the protocol-level reliability of summary scores. The ICC values are presented in Table 2.

Formulation of rating variables and carrying out of ratings. The applicants participating in the research project were rated on special scales. I formulated three 7-point rating variables relating to aspects of Dynamic Capacity and seven variables relating to Ego Strength in cooperation with teachers and supervisors in the program (see Table 1). The variables were selected and formulated to be in agreement with what was regarded as central by the supervisors in the program and therefore natural for the candidates to rate. Before starting to collect data, I distributed the scales to the candidates to study, and I subsequently discussed the variables with each of the supervisory teams. Moreover, for all rating variables except for motivation and capacity to cooperate, written definitions were formulated in cooperation with the teachers and supervisors in the program. Directly below the name of the variable in the rating form, a short definition was given, and more comprehensive descriptions of the variables were formulated in an appendix. The Rating Scale of Ego Balance (Sandell, 1994) functioned as a model for the construction of the descriptions. An overview of the variables in the rating form with the definitions given below the variable names is presented in Table 1. The candidate that had interviewed the applicant carried out the ratings after the completion of the team discussions and after the team decision to select or not select the applicant for psychotherapy. These ratings were an addition to the regular selection procedure of the unit, and the ratings were more specific than the discussions and the decision processes in the supervisory teams, which were free to take any aspect of the case into consideration. The instructions to the candidates making the ratings were the following: After the assessment interviews and after you and the team have come to

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TABLE 2 ICC for Responses Summed Over Whole Rorschach Protocols
CS Score EA FC YF Y m Sum T Blends Zf F% MQo WSUM6 X% S FrrF FD AG COP PER

NYGREN kurtosis were within acceptable limits and partial correlations carried out.

ICC (2,1)a 0.89 0.79 0.57 0.79 0.68 0.83 0.86 0.96 0.82 0.72 0.84 0.80 0.92 1.00 0.72 0.74 0.71 0.78

Comparisons between applicants selected and not selected for psychotherapy. The comparisons between the applicants that were selected for psychotherapy and those that were not accepted were carried out using independent samples t tests. It was reasonable to assume that CS score differences between applicants accepted and applicants not accepted for psychotherapy should be in the same direction as was predicted for the correlations. This assumption motivated the use of one-tailed significance tests. Effect sizes were calculated with Cohens d using pooled variance and adjusted for unequal sample sizes.

RESULTS The results of the partial correlations between the CS scores and the ratings of Dynamic Capacity and Ego Strength are presented in Table 4, and the t tests of the differences between the applicants selected and those that were not selected are presented in Table 5. To give the reader comprehensive information, all correlations of the CS scores with Dynamic Capacity and Ego Strength are included in Table 4. For clarity, the predicted correlations and their p values are underlined. Dynamic Capacity did not correlate significantly with R. For the correlations with the selected CS scores, there were 6 hits of 15 possible. Significant results were received for EA, FC, YFY, Blends, Zf, and MQo, and for AG, there was an almost significant result in the predicted direction. The results were negative for Sum T, m, F%, S, FD, FrrF, COP, and PER. For S, the correlation with Dynamic Capacity was significant (two-tailed) in the direction opposite to that predicted. As the expected direction of the correlations was formulated in the predictions, one-tailed tests were used. However, EA, FC, and Blends also reached a two-tailed significance level. The predictions for the control and stress tolerance cluster and for the cognitive triad were the most frequently verified. The predictions for self-perception and interpersonal perception were not successful, although the prediction for AG received some support. Ego Strength did not correlate significantly with R. Predictions were confirmed for five of the seven CS scores: EA, FC, YFY, Blends, and F%. Four of the five significant findings belong to the control and stress tolerance cluster. The results for these five CS scores also reached a two-tailed significance level. The results for WSUM6 and X % were negative. As mentioned, partial correlations were used in all analyses to control for age that correlated significantly with both Dynamic Capacity and Ego Strength. If age was not controlled for, the results remained mainly the same. However,

Note. Total number of responses scored = 521. n = 20. ICC = intraclass coefficients; CS = Comprehensive System. aICC (2,1) = two-way, random, absolute agreement ICC.

ICC values less than .40 were regarded as poor, between .40 and .59 as fair, between .60 and .74 as good, and over .75 as excellent (Cicchetti, 1994). The lowest ICC, .57, obtained for YF, was a fair value, and the ICC values for the remaining CS variables were within the range good to excellent (M = .80). Statistical Analyses

Correlations between CS variables and clinical ratings. Descriptive data and correlations with the number of Rorschach responses (R) for the CS scores are presented in Table 3. Correlations were calculated to examine the relation between the selected CS scores and the ratings of Dynamic Capacity and Ego Strength. Because the expected direction of the correlations was formulated a priori, one-tailed significance tests were used for all hypothesized associations. Age of the participants correlated significantly with both Dynamic Capacity (.43, n = 52, p = .001) and Ego Strength (.38, n = 52, p = .003), so partial correlations controlling for age were used in all analyses. Moreover, R correlated significantly with EA, m, F%, Zf, and S, and in the analyses for these CS variables, partial correlations controlling for both age and R were used. However, the recommendations by Viglione (1995) and Curran, West, and Finch (1996) have been that partial correlation, a parametric method, should only be used when the skewness of the Rorschach variables and the kurtosis are < 2.0 and < 7.0, respectively. In this study, FC and S were too skewed, and FC also had too high values of kurtosis to permit the use of parametric methods. However, both FC and S had one outlier, and when this was removed, skewness and

CS AND PSYCHOTHERAPY
TABLE 3 Means, Standard Deviations, Median, Minimum, Maximum, Skewness, and Kurtosis for DC, ES, and the CS Variables

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Score DCb ESb R EA FC FCe YFY SumT Blends m F% Zf MQo WSum6 X% S Sc FrrF FD AG COP PER

M 4.55 3.91 26.87 11.10 2.38 2.18 1.00 1.00 6.50 2.94 0.32 14.83 3.13 20.87 0.18 2.98 2.76 0.46 1.29 1.81 1.44 0.98

SD 1.28 0.97 10.47 4.49 2.10 1.48 0.97 1.10 2.55 2.04 0.13 4.91 1.79 13.54 2.54 2.54 2.03 0.83 1.23 1.53 1.20 1.16

Mdn 4.67 3.78 24.50 10.75 2.00 2.00 1.00 1.00 6.50 3.00 0.30 14.00 3.00 18.00 0.17 2.00 2.00 0.00 1.00 2.00 1.50 0.50

Minimum 2.00 2.00 13.00 3.00 0.00 0.00 0.00 0.00 1.00 0.00 0.03 5.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Maximum 7.00 6.00 64.00 23.00 13.00 6.00 3.00 5.00 13.00 11.00 0.74 28.00 9.00 59.00 0.64 14.00 8.00 3.00 4.00 7.00 5.00 4.00

Skewness 0.28 0.29 1.30 0.68 2.70 0.61 0.54 1.55 0.10 1.72 0.66 0.74 0.94 0.86 1.97 2.02 1.04 1.75 0.61 0.88 0.64 0.82

Kurtosis 0.81 0.43 2.03 0.26 12.00 0.026 0.79 2.93 0.19 4.22 1.58 0.60 1.89 0.13 6.61 5.98 0.62 2.15 0.59 1.20 0.41 0.56

Correlation With Ra .43** .22 .11 .12 .16 .21 .50** .31* .45** .27 .03 .08 .44** .39** .15 .18 .10 .09 .02

Note. N = 52. DC = Dynamic Capacity; ES = Ego Strength; CS = Comprehensive System; R = number of Rorschach responses. aFor the CS variables also correlations with number of responses. bSum of scores divided by number of items. cn = 51, one outlier removed. *p .05, two-tailed. **p .01, two-tailed.

TABLE 4 Partial Correlations Between CS Scores and the Ratings of Dynamic Capacity and Ego Strength
Dynamic Capacity CS Score R Control and stress tolerance EA FC YFY m Sum T Blends Information processing, ideation, and mediation Zf F% MQo WSUM6 X% Affective features S Self- and interpersonal perception FrrF FD AG COP PER Correlation .07a .37**b,c .30*a,c,d .25*a .03b .09a .28*a,c .26*b .12b .23*a .15a .07a .32b,d,e .25a .06a .23a .18a .14a p .319 .004 .016 .041 .409 .262 .023 .032 .192 .049 .286a .582 .011 .040 .331 .051 .098 .159 Ego Strength Correlation .15b .47***b,c .42***a,c,d .30*a,d .09b .13a .35**a,c .22b .29*b,c .11a .14a .03a .27b .03a .04a .08a .10a .04a p .154 .000 .001 .018 .514 .336 .006 .122 .021 .418 .169 .417 .062 .882 .774 .574 .488 .778

Note. N = 52. The results for the predicted correlations are underlined, and these associations are presented with one-tailed p values (even if the finding was in the direction opposite of prediction, as was the case for S and FrrF and Dynamic Capacity). CS = Comprehensive System; R = number of Rorschach responses. aAge partialed out. bR and age partialed out. cThe variable also reached two-tailed significance. dn = 51, one outlier removed. eThe result was significant (p = .022, two-tailed) in the direction opposite to that predicted. *p .05, one-tailed. **p .01, one-tailed.

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NYGREN
TABLE 5 Comparison of Dynamic Capacity, Ego Strength, and the CS variables Between Applicants Selected and Applicants Not Selected for Psychotherapy
Selecteda M SD 0.83 0.90 9.73 5.02 2.48 0.98 1.67 1.32 2.84 4.86 0.10 1.93 12.96 0.09 2.87 0.99 1.27 1.64 0.98 0.97 M 3.58 3.31 26.65 9.59 1.83 1.30 3.09 0.96 6.13 13.04 0.36 2.52 24.08 0.17 2.35 0.13 1.13 1.48 1.26 1.39 Not selectedb SD 1.07 0.70 11.56 3.22 1.34 0.87 2.46 0.76 2.14 4.46 0.14 1.41 13.85 0.12 1.92 0.34 1.18 1.34 1.42 1.27 t 6.59 4.71 0.13 2.35 1.74 2.07 0.45 0.26 0.98 2.44 2.22 2.28 1.54 0.18 1.62 2.99 0.82 1.39 0.97 2.29 p .000***e .000***e .898 .014*e .044* .021*e .327 .396 .179 .009**e .016*e .014*e .064 .427 .055 .003 .206 .085 .167 .011*e Effect Sizec 1.85 1.30 0.04 0.63 0.49 0.58 0.12 0.06 0.26 0.68 0.58 0.64 0.43 0.09 0.45 0.77 0.23 0.39 0.27 0.68

DCd ESd R EA FC YFY m Sum T Blends Zf F% MQo WSUM6 X% S FrrF FD AG COP PER

5.32 4.39 27.03 12.29 2.83 0.76 2.83 1.03 6.79 16.24 0.29 3.62 18.31 0.18 3.48 0.72 1.41 2.07 1.59 0.66

Note. All significance tests, except for R, are one-tailed. CS = Comprehensive System; DC = Dynamic Capacity; ES = Ego Strength. an = 29. bn = 23. cCohens d, calculated using pooled variance and adjusted for unequal sample size. dSum of scores divided by number of items. eThe variable also reached two-tailed significance. *p .05. **p .01. ***p .001.

for three CS variables, the significance of the results was different; the correlation between MQo and Dynamic Capacity did not reach significance (r = .18, p = .100), whereas the correlation between AG and Dynamic Capacity became significant (r = .28, p = .021). For FC and Dynamic Capacity, there was a tendency, not a significant correlation, in the predicted direction (r = .20, p = .081). Table 5 presents the results of the one-tailed t tests that were performed to compare Dynamic Capacity, Ego Strength, R, and the CS variables between the group of applicants selected for psychotherapy and those not selected. The differences were significant (both one-tailed and two-tailed) for both Dynamic Capacity and Ego Strength, with effect sizes, d, being 1.85 and 1.30, respectively. For EA, FC, YFY, Zf, F%, and MQo, the results were significant (one-tailed) as could be expected from the correlations between these CS scores and the clinical ratings of Dynamic Capacity and Ego Strength; the effect sizes, d, ranged between 0.49 for FC to 0.68 for Zf. The results for EA, FC, YFY, Zf, and MQo even reached two-tailed significance. However, even though the number of Blends correlated significantly with both Dynamic Capacity and Ego Strength, it did not differ between applicants selected or not selected for psychotherapy. Even though PER did not show the hypothesized significant negative correlation with Dynamic Capacity, it had a significantly higher mean (even fulfilling two-tailed requirements) in the group not selected for psychotherapy.

DISCUSSION In this study, I examined relations between rationally selected CS scores and suitability for psychodynamic psychotherapy as represented by clinical ratings of Dynamic Capacity and Ego Strength. The participants were psychotherapy applicants interviewed by candidates in an advanced training program of psychodynamic psychotherapy. No predictions were formulated concerning psychotherapy outcome. Results in the predicted direction were received for EA, FC, YFY, Blends, Zf, MQo, and F%. As mentioned earlier, only a few prior studies have focused on rationally selected CS scores and therapy suitability. Alpher et al. (1990) investigated rationally chosen variables from the CS structural summary in relation to the CDPS. In a study of dynamically oriented treatment of child psychiatric patients, LaBarbera and Cornsweet (1985) predicted the relation between outcome and psychological flexibility as measured by rationally selected CS scores. Nygren (2004) compared groups of psychotherapy patients assumed to differ in psychotherapy suitability. However, unlike in this study, no individual data other than the Rorschach were available in the Nygren (2004) study. As mentioned earlier, this study and the study by Nygren (2004) are linked and part of a project that examines the same selection of CS scores in studies with different designs. The studies by Alpher et al. (1990) and LaBarbera and Cornsweet (1985) used many of the CS scores used in this study.

CS AND PSYCHOTHERAPY Six of the selected CS scoresEA, FC, YFY, Blends, Zf, and MQocorrelated significantly and in the predicted direction with the ratings of Dynamic Capacity, and for AG, there was a tendency in the predicted direction. For the ratings of Ego Strength, the correlations were significant in the predicted direction for EA, FC, YFY, Blends, and F%. The positive results for Blends, Zf, and F% as indicators for psychodynamic psychotherapy were regarded as replications; these scores have received consistent support in earlier research concerning CS scores and psychodynamic psychotherapy (Alpher et al., 1990; LaBarbera & Cornsweet, 1985; Nygren, 2004). Unlike in the Alpher et al. (1990) study, correlations were only predicted for M responses of Ordinary Form, MQo, in this investigation. However, in the RPRS (Klopfer et al., 1954), which has shown a positive relation to psychotherapy outcome (Garfield, 1994; Meyer, 2000; Meyer & Handler, 1997, 2000), Human Movement responses of good Form is an important score, and in the study by Nygren (2004), MQo received support. As the significant result for MQo in this study is consistent with these earlier results, it is interpreted as replicated support for MQo as a positive indicator for psychodynamic psychotherapy. EA and YFY that were supported in this study were not included in the studies by Alpher et al. (1990) or LaBarbera and Cornsweet (1985). Moreover, in the Alpher et al. study, Form Dominated Color was represented by the CS variable FC/CF+C, whereas FC was selected in this study. However, because predictions for EA were verified both in this study and by Nygren (2004), EA has replicated support as a valid indicator when the Rorschach is used in decisions concerning psychodynamic psychotherapy. For YFY and FC, no conclusions can yet be drawn because the predictions for these CS variables were verified in this study but not by Nygren (2004). It should also be pointed out that the results for MQo and FC only shed light on parts of the result for EA, as no predictions were formulated for MQu, MQ, CF, and C. Moreover, the predictions concerning Diffuse Shading responses were only formulated for YFY; the results in this study do not relate to the assumptions about differences between Non-Form Dominant and Form Dominant diffuse shading (Kleiger, 1992, 1997; Meyer, 1992). AG, another score that was not included in the studies by Alpher et al. (1990) or by LaBarbera and Cornsweet (1985), showed a tendency in the predicted direction in this study and was supported in the study by Nygren (2004). This is in accordance with the result received by Hilsenroth et al. (1995) in which patients terminating psychotherapy prematurely had fewer AG and more COP than those remaining in treatment. Although more research is needed about AG and COP in psychotherapy assessment, the result for AG is regarded as promising. Sum T and m were positively related to CDPS in the Alpher et al. (1990) study but did not receive support in this

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study nor in the study by Nygren (2004). Moreover, the predictions for X % and S were not supported in Alpher et al., this study, or in Nygren (2004). Finally, predictions for Wsum6, FrrF, FD, COP, and PER were not supported in this study, although FD and COP received support in the study by Nygren (2004). The mean values for EA, FC, YFY, Zf, and MQo were higher and the mean for F% lower in the group of applicants accepted into psychotherapy than in the group not selected for treatment. As emphasised earlier, the Rorschach was methodologically independent of the ratings of Dynamic Capacity and also of the selection of applicants for psychotherapy. Thus, the significant CS differences between the applicants selected and those not selected for psychotherapy demonstrated that these CS variables also independently predicted the decisions about selection of applicants for psychodynamic psychotherapy. The means of Dynamic Capacity and Ego Strength differed significantly between the group of applicants accepted into psychotherapy and those not selected. Although agreement between the ratings and the selection decisions was strong, it was not complete; the point-biserial correlation between Dynamic Capacity and selection was .68 (n = 52, p = .000) and between Ego Strength and selection, .55 (n = 52, p = .000). The mean values for Blends did not differ between the group of applicants selected and the group not selected for psychotherapy. This finding is remarkable because this CS variable received strong support against the rating criteria in this study as well as in earlier research. However, a possible explanation is that the affective qualities, interpreted in the CS to be indicated by Blends, were more salient to the interviewers who had interacted with applicants and provided ratings than to the members of teams who made the final decision regarding selection. Predictions for PER were not supported in this study or in the study by Nygren (2004), but the mean values for PER differed significantly between the applicants selected for psychotherapy and those not accepted. It is only possible to formulate the tentative explanation that the kind of defensiveness intellectual authoritarian thought to be associated with PER answers was somehow easier to grasp for members of the supervisory teams than for the interviewers. The interviewers rated Dynamic Capacity and Ego Strength after the completion of the team discussions and after the team decision to select or not select the applicant for psychotherapy. Thus, there was a risk that the ratings were influenced by implicit processes not consciously perceived by the interviewer such that the ratings could be biased by impressions not reflecting ego functions related to capacity to engage in psychodynamic psychotherapy. The risk for such bias should be greater in the individual ratings than in the selection decisions in the supervisory teams. These were collective decisions grounded on indirect information and also on thorough discussions, and moreover, the teams were free to take into consideration other aspects of

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NYGREN and MQo, each of which received support and replicated the results of earlier research (Alpher et al., 1990; LaBarbera & Cornsweet, 1985; Nygren, 2004), are interpreted in ways relating closely to psychological mindedness, quality of object relations, and motivation. As elucidated in the beginning of the article, these are qualities that researchers have found to be related to the outcome of psychodynamic psychotherapy and to completion of psychotherapy (e.g., Conte et al., 1990; Garfield, 1994; Hglend, 1993, 1996; Hglend et al., 1994, 1992; Keithly et al., 1980; McCallum & Piper, 1990a, 1990b; McCallum et al., 1992; Moras & Strupp, 1982; Ogrodniczuk et al., 2001; Orlinsky et al., 1994; Piper et al., 1991, 1999; Piper & Duncan, 1999; Piper, Joyce, Azim, et al., 1994; Piper et al., 1998; Piper, Joyce, Rosie, et al., 1994; Roth & Fonagy, 1996; Tasca et al.,1999). As mentioned earlier, Janson and Stattin (2003) pointed out that clinicians might find the dichotomy between single codeable data and a global-holistic approach to be artificial, even though this distinction is evident in research. Karon (2000) emphasised the importance of interpretations of qualitative clinical data in the Rorschach and warned that formal scoring systems lack that information, whereas Acklin (1992) and Weiner (2000) stressed the importance of an integrative approach in the interpretation of Rorschach data. Although the focus of this study was on the coding aspects of the CS, the conceptual ground for the formulation of the predictions will hopefully make the results meaningful to clinicians working with assessment for psychodynamic psychotherapy. The usefulness of combining different sources of Rorschach information in psychotherapy assessment remains to be challenged by research. At present, studies of the value of the structural aspects of the CS in psychotherapy assessment seem to be the most important work to be carried out with regard to the CS and psychotherapy. The main purpose of using the Rorschach as a supplement to the interview in psychotherapy assessment should be to foresee possible complications during the therapy process and so facilitate the planning and shaping of the psychotherapy. A basis for this task should be selected CS indicators that have consistently proved to be valid in psychotherapy assessments. The Rorschach could then help to plan psychotherapeutic treatment in accordance with the patients capacities (see Bihlar & Carlsson, 2000, 2001).

the applicant beyond the Dynamic Capacity and Ego Strength ratings. However, depending on what was considered important by the teachers and supervisors in the advanced psychotherapy training program, the decisions of the teams should be related to ego functions that are important for the capacity to engage in and benefit from psychodynamic psychotherapy. The Rorschach was methodologically independent of the selection decisions (as it was of the rating criteria), and these team-based selection decisions should be related to ego functions that are central for the capacity to engage in and benefit from psychotherapy. Although it is possible that the ratings of Dynamic Capacity and Ego Strength may have been implicitly biased by the treatment team discussions and subsequent decision to accept the patient for treatment, such bias did not extend to the analyses involving the CS variables. Because this Rorschach data was collected and scored completely independent (i.e., no criterion contamination) of the interview information, treatment team discussions, treatment selection, and clinician ratings, Rorschach CS data was an independent predictor of this clinical data. The results of these analyses indicate that the CS variables were independently related to treatment team decisions to accept a patient into treatment as well as to clinician ratings of Dynamic Capacity and Ego Strength. These findings provide strong clinically applied criterion validity for the CS scores. One possible limitation in this study is that the range of problems in the group of participants may have been narrowed because psychotic patients, alarmingly depressed patients, and patients in acute crises were referred or recommended to seek help elsewhere before the psychotherapy assessments started. Moreover, the circumstance that the patients of the unit were not referred but applied for psychotherapy on their own initiative may have narrowed the range of problems among the participants. However, the main weakness is that it was not possible to assess the interrater reliability of the rating scales. Although the internal consistency of the ratings was quite satisfactory (Cronbachs was 0.93 for Dynamic Capacity and 0.91 for Ego Strength), the lack of interrater reliability data also makes it impossible to estimate the attenuation in the correlations between the CS scores and the clinical ratings. However, because the ratings were similar to clinical evaluations generally performed in assessment for psychodynamic psychotherapy, and as the participants were psychiatric patients assessed for psychotherapy in naturalistic conditions, the results can be considered ecologically valid and possible to generalize to real world clinical assessments of Dynamic Capacity and Ego Strength. Thus, although recognizing the limitations of this study, the results are interpreted as unequivocally positive for some of the CS variables selected, mainly from the control cluster and the cognitive triad, as useful in assessment for dynamic psychotherapy. Moreover, it is worth noticing that Zf, F%,

ACKNOWLEDGMENTS Marianne Nygren is now with the Stockholm County Council, North Psychiatry. I thank Karin Gyllenskld and Per Stenfelt for their commitment and support during both planning and realization of this study. I specially thank Rolf Sandell for his commitment and invaluable discussions. I am grateful to Kristina Nordstrm for help with the reliability scoring of Rorschach records. Thanks also to Steve Wicks for checking the English.

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Marianne Nygren Stockholm County Council,North Psychiatry Hsselby-Vllingby Psychiatric Department Jmtlandsgatan 161 S16260 Vllingby, Sweden E-mail: marianne.nygren@minmail.net Received March 10, 2003 Revised March 2, 2004