This article was downloaded by: [University of Toronto Libraries] On: 02 October 2014, At: 05:56 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
Predicting Suicide Using The Rorschach Inkblot Test John M. Kendra Published online: 10 Jun 2010.
To cite this article: John M. Kendra (1979) Predicting Suicide Using The Rorschach Inkblot Test, Journal of Personality Assessment, 43:5, 452-456, DOI: 10.1207/s15327752jpa4305_1 To link to this article: http://dx.doi.org/10.1207/s15327752jpa4305_1
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Journal of Personality Assessment, 1979,43,5
Predicting Suicide Using The Rorschach Inkblot Test J O H N M. KENDRA Temple University
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
Abstract: Three hundred and seventy-five Rorschach protocols were scored blind and then divided into three groups: psychiatric controls, suicide attempts, and suiclde effectors. Using the stepwise procedure of multiple discriminant analysis a trio of formulas, composed of six weighted variables each, and a constant, were constructed to apply to each of the three groups based on a test sample of 100 subjects in each group. Cross validation results on a new sample of 25 subjects In each group predicted classification wlth 52% overall accuracy at step six (chance .33). Internal reliability tests showed all values significant beyond .001. Discussion integrates the test data into the literature o n suicide, and attends to the problem of overlap of predictability which occurs with most prediction scales.
Research into suicide prediction can be divided into three kinds of studies. Most frequently used is the pure survey kind of study, exclusively demographic in nature, which merely counts characteristics. The second is done via the case history approach, wherein an individual case of suicide is discussed solely from the psychoanalytic (or some social, usually Durkheim) framework. Rarely in this type of approach is there hypothesis testing or experimental technique of any sort. The third and least frequently used method involves a combination of the two above. In these instances, some effort is taken to gather records on attempted or effected suicides where some battery of psychological tests were given, and the results compared, among or between groups. Reviews of the literature indicate that the Rorschach has the best potential as a predictor of suicide. This position is supported by Lester (1970) and Neuringer (1965). More specifically, it is the use of multiple signs grouped in scales, which had proven so fruitful (Hertz 1948, 1949; Martin 1951; Piotrowski 1970), rather than single signs, determinants and ratios, or content approaches. This art~cleis based on a d~ssertationwritten in partla1 fulfillment of the requrrements for the Ph D, degree In Clinrcal Psychology a t Temple Univers~ty. The author acknowledges the support and guidance of Russell Eisenman, Leona Aiken, and Herbert Hamsher who formed the core of the dissertation committee, and ta Ronald Th~stedof the Stanford University Dept. of Statistics for his invaluable aid Reprint requests may besenttotheauthorat theaddress given at the end of the art~cle
It was the purpose of this study to create such a scale for suicide prediction, using the Rorschach, which avoids prescribed personality theory for data collection, and avoids demographic indices, to test the hypothesis that: formulas composed of empirically derived signs, using the multiple discriminant analysis method, would differentiate the three groups (effectors, attempters, controls) significantly better than chance. Method Subjects The Rorschach protocols used in this project were gathered from four sources: 17 from the Irving Schwartz Institute, Philadelphia, Pa.; 43 from the Univ. of Rochester (N. Y.) School of Medicine & Dentistry; 160 from the Menninger Foundation Clinic files, and 159 from the files of the Los Angeles Suicide Prevention Center. All protocols were copies of original records taken verbatim. The sampleconsisted of 375 subjects and was divided into three groups of 125 subjects each, the groups being suicide effectors, suicide attemptors, and psychiatric controls. All subjects in the effector and attempter groups were individuals who sought psychiatric help for problems specifically related to suicide. Controls consisted of individuals seeking psychiatric treatment for problems other than suicide, and who denied any history of such attempts. In addition, control subjects were selected by matching demographic characteristics to the other two groups.
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
JOHN M. KENDRA In the effector group, the age range was from 16to61 withameanageof30.5; in the attemptor group the age range was 10 to 57 with a mean age of 28.3; and in the control group the age range was 8 to 62 with a mean age of 29.2. Tests of significance (ANOVA) for differences among groups showed non-significance 0, > .05). All subjects used in the study were white. There were 102 males and 23 females in the effector group; 30 males and 95 females in the attempter group; and 76 males and 49 females in the control group. The test for differences in sex among groups using a three sample ~ 2test was significant, ~ 2 (2) , = 86.107, p -= .001. Scoring The specific variables used are the 44 scored variates of the Piotrowski Rorschach scoring system. These are the Area components W, D W, D, Dd, and S; Determinants M; FM, m, c', Fc', Fc, c, FC, CF, and C; Content Categories animal, animal detail, human, human detail, anatomy, nature, map, object, fire, smoke; clouds, blood, artlarchitecture, clothing, botany, and food; F+%, N R (VIII-X), R (VIII-XI%, %, A%, H%, at%; the ratios of W:M, M:CC, and Cc:C C; sex shock, shading shock, and color shock. In each of the area components, determinants, and content categories each variable was treated as an independent variable, the total for any variable/ protocol achieved by frequency count. For example, "a bat in flight" to plate V was counted once for the W, once for the FMand once for the animal content. In addition to this basic rule, any adscript S, to any other determinant ( W, D W, D, Dd) was added to the total S to achieve Sum S. Any adscript c'or c, to any determinant other than m or C, was added to the Fc'or Fc to achieveatotal Fc'ortotal Fc. If the c' or c was an adscript to m or C, when they were without Form, the shading was added to the c' or c column to achieve total c' or total c. Two changes were made when coding the data for computer programming. Ratios were reduced to one number by
dividing the first variable by the second. The second change involved the coding of shocks, which were coded as binary values. Data Alna/ysis Methods The statistical procedure used in the study utilized a step-wise search for the minimum number of variables which would successfully predict suicide. The entire sample of 375 subjects werescored blind by the author according to both Piotrowski (1957) and Beck(1945). They were then identified and placed in the appropriate grloups, 125 in each group. Using the randorn numbers table, 25 subjects in each group were selected to represent the cross-validation sample. Tests of significance among groups in the cross-validistion sample for age and sex differences conformed to the pattern established in the test sample. After the predictor variables were identified, the cross-validation study was carried out in which the prediction of group identification was malde, based on thediscriminant equations derived from the test sample of 300 subjects. The table of random number.J was again used to select 29 subjects from the entire pool of ,375 for an internal reliability check. A11 29 participants' tocols were re-scored according to lotrowski and the: six most important variables, defined as those selected through the stepwise muiltiple discriminarit analysis for use in the discriminant equation, were tested for reliability of scoring. Time interval between scoring each subject's protocol was three months.
y-
Resubs Empirical Identi'ficatim of the Sign Battery All 44 variables in the Piotrowski Rorschach scoring system were used in the identification of the sign battery. Means and sigrnas for each of the variables were comp,ared at the .0l level for 18 variables ( D , k t FM, Fc: Fc, CF, C, A, Ad, Hd, food, N,N(VII1-X), %(VIJI-X), y o , H%, W:M'and M:CC). Computation of Eta2 however showed that in the best case (EM), only 14%ofthevariation
Predicting Suicide with the Rorschach Table 1 Total Percent Correctly Classified in Both Test and Cross-Validation Groups at Each Step Step
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
1
2 3 4 5 6 7 8 9 10 11
12 13 14
Test Group (n= 300)
Cross-Vahdat~on Group (n = 75)
45.0 48.3 51.7 55.0 57.3 59.0 65.0 67.6 66.9 68.3 68.8 69.3 67.0 67.6
37.3 37.3 42.6 49.3 50.6 52.0 52.0 54.6 53.9 53.3 55.4 56.0 57.8 58.6
suggested by the ANOVA results could be accounted for by group differences. This supports the contention that even though statistical significance levels as measured by ANOVA are high, the amount of "explaining" (the amount of predictive value) as measured by Eta* is control: attempter: effector:
.74(FM) 1.07(FM) .65(FM)
+ +
+
+ + +
All tests were significant,F(2,292)p< .01. To make the predictions regarding the cross-validation group, the three discriminant equations were constructed based on thedataat step6. That equation which yields the highest score ofthe three indicates the correct group membership of the subject. In a classification matrix constructed at step 6 indicating in which group each subject was placed according to the above formula, 48.1% of the controls, 51.8% oftheattempters,and57.1%ofthe effectors were correctly classified. A difference of proportions test was used to determine whetherthe total number of subjects correctly classified by the procedures at step 6 (52%) was above chance levels, resulting in a z score of 6.98, p < .Oaf. Since the ultimate goal of this classificatory scheme is clinical intervention, it matters little what thedifferences are if the classification is into a potential attempter or potential effector group. Therapeutic intervention would be synonymous with either group. While misclassifying a control as an attempter
.71(Fcf) .85(C) + .24(P%) .I7(H%) + .20(W:M) -5.72 .60(Fc1) 1.22(C) .26(P%) 4-.20(H%lo) + .21(W:M) -8.38 1.41(Fc') 1.28(C) f .31(P%) -i.lS(H%) -t .27(W;.M)-8.26
very low for any single sign. At this point multiple discriminant analysis, using the step-wise procedure was introduced. Since the pilot study showed a leveling off of prediction at step 14, the procedure was stopped at this step. Table 1 shows the percent correctly classified on the test group (n = 300) and the cross validation sample (n = 75) at each of the 14 steps. As can be seen from the Table, the point of decreasing returns for prediction of the crass-validation sample was passed at step6. It was therefore decided to use step 6 as the cutoff point, and these values were used in the prediction equations. To determine if the groups were significantly different,all pairs ofgroups were contrasted by multivariate tests of significance of difference between groups.
+
or effector is a considerable error, it is less significant than misclassifying an attempter or especially an effector as a control. Combining attempters and Table 2 Percentage of Subjects in the Cross-Validation Sample Correctly Classjfied as Either Suicidal or Nonsuicidalat Each Step (Overall Percentage Also Shown) Step
1 2 3 4 5 6 7-13 14
Suicidal
Nonsuicidal
Overall
80 68 72 84 72 72
16 32 36 32
58.6 56. 60. 66.6 62. 65.3
44
52
-
-
-
76
68
73.3
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
JOHN M. KENDRA effectors into a single group called "suicidal" at each step, the results are shown in Table 2. "Overall correctly classified" is the percentage correctly classified with respect to the suicidal-nonsuicidal dichotomy. Discussion A major criticism regarding previous attempts at using an established test like the Rorschach inkblots to make predictions about psychiatric populations, lies in retaining long outmoded, unscientifically supported, hypotheses from mainly psychoanalytic theory. These hypotheses are then applied to samples and ifthey areunsupported, anew search through the same theoretical framework is begun to "explain" the results. This hypothesis is then tested, etc. ad infinitum. In the last ten years or so, more and more research projects have begun appearing in the literature, like Martin's (1951) and Piotrowski's (1970) studies, which accumulated and tested data, without staying locked into any prescribed theory. In most previous studies of the demographic variables of suicide, consistent age, race and sex differences appear. Previous studies have shown that whites commit 9 out of every 10 suicides (cf. Henry & Short, 1951; Schmid & Van Arsdol, 1955). Nonwhites were not deliberately excluded from this study which was restricted to available data. It is, however, apparent that since all the subjects were white, the effected suicide group may represent but one-third the national sample. By this it is meant that while nonwhites actually commit only 1 in every 10 suicides, nonwhites are more frequently represented in the effector column as first-time attempters. Whites more frequently make multiple attempts before they actually kill themselves. The reason for this is because nonwhites are more apt to use lethal methods of attempting suicide, specifically shooting, jumping, hanging, or drowning; whites more frequently use pills. The reasons for these racial differences are not well understood, beyond the obvious socioeconomic and environmental explanations.
With regard to sex differences, it is again known that males effect suicide three times as frequently as do females. Females on the other hand attempt suicide three times as frequently as do males (cf. Farberow 8i Shneidman, 1961; Henry & Short, 1951) Note that in our sample, both populations and cross-validation samples approximate these figures. While the specific sex subsamples are representative of national statistics, the specific break{downswithin each group are too small to interpret meaningfully. Similarly, numerous studies have investigated the specifics of age-related suicide (cf. Schneidman & Farberow, 1961). It is noted that the majority of such studies concern nationally reported statistics generally on file with the Bureau of Census. Our sample was composed of sub-jects from 4 institutions, an already bialsed sample, and one which has not been c:linically investigated with regard to age. In addition, it is admitted that this study deals with an unusual if not biased samlple in that it only involves subjects (a) who have been seen at an institution, (b) have been given psychological tests, and (c) have specifically responded to the Rorschach inkblots. To attempt to equate them with the majority of sui~cidalpersons in this country is at best naive. Breakdown by age then, while perhaps interesting, accpmplishes none of the interests of this study and was therefore not done. Table 2 groiups suicide attempters and suicide effectors into the category "suicidal" and t r ~ a t scontrols as "nonsuicidal." This was done because the point in fact is that clinically we have rarely treated differently people who voice suicidal ideation, threaten suicide, attempt suicide, or will effect suicide. The only significant chsinrpe in terms of therapeutic intervention, will depend more on whether than (clinicianis in private practice, clinic practice or employed in an inpatient setting. 'Suicidal precautions" in an inpatient setting is a practically universal proc:erdure whether someone is voicing fears of lack of impulse control or is threatening to make an attempt. Rarely are "iscolation techniques,"usually meaning seclusion, used anymore to
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
Predicting Suicide with the Rorschach deal with threats of suicide in hospitals, and the only recourse the outpatient clinician has, is to hospitalize the seriously suicidal patient. It isapparent then, that at this point of development of classificatory schemes, combining attempted and effected suicides is more pragmatic for treatment purposes. The results shown in Tables 1 and 2 raise the question as to why the accuracy of classification leveled off so early and did not continue at the same rate right up to step 44. One might expect that each variable contributes something to prediction and that as each was added, accuracy would continue. The results here show that only a few variables really help in "explaining" the final composition of groups into which individuals were classified. By this it is meant that as more variables areentered (after step 6), the discriminant functions more and more reflect the peculiarities and individual characteristics of the subjects, and less and less a structure common to the group. In additim, there is the problem of overlap in thy:predictability of the various variables. An example is when variable A and B both give significant wnivariate Fratios, but bothalso account for precisely the same differences among the groups. They would therefore essentially classify the same subjects correctly. If now, variable A enters the equation first, then variable B will not enter at all because it overlaps completely with A. If variableB overlaps mostly with A but not entirely, and A enters first, the increase in predictability from B will be hardly noticeable. Thus, as more variables are entered into the process, the less accurate the process becdines, due to the increased influence of peculiar pattern8 in the data upon whiq11.the disprimingtors are based. I In summary, by using the stepwise procedure of multiplct discriminate analysis, a trio of equations have besn canstructed, cansisting of six waighted variables and a constant, which suol~essfully classified a g r a y of individuals into three grayps defined as psychiatric controls, suicide attempters, and suicide effectors. This was done at above chance levels. The specific variables were empir-
ically defined and therefore are not subject at this point to clinicalinterpretation. References Beck, S. J . Rorschach test, Vol. II, A variety of personality pictures. New York: Grune and Stratton, 1945. Farberow, N. L., & Shneidman, E. S. (Eds.) 7he crv for help. New York: McGraw-Hill, 1961. Henry, A. F., & Short, J . F. Surcideandhornicide: Some economic, sociological and psychological aspects of aggression. Glencoe Illinois: Free Press, 1951. Hertz, M. R. Suicidalconfigurationsin Rorschach records. Rorschach Research Exchange and Journalof Projective Techniques, 1948,12,3-$8. Hertz, M. R. Further study o f "sicidal"configurations in Rorschach records. Rorschach Research Exchange and Journal of Projective Techniques, 1949.13.44-73. Lester, D. Attempts to predict suicide risk using psychological tests. Psychological Bulletin, 1970, 74, 1-17. Martin, H. A. A Rorschachstudvofsuicide. Unpublished Doctoral Dissertation, University of Kentucky, 1951. Neuringer, C. The Rorschach test as a research device for the identification, prediction and understanding of suicidalideation and behavior. Journal of Projective Techniques, 1965, 29, 71-82. Neuringer, C., & Kostoe, R. R. Suicide research and non-rejection of the null hypothesis. Perceptual and Motor Skills, 1964,22, 115-1 18. Piotrowski, Z. A. Perceptanalysis: A fundamentaNv reworked. exoanded. and svstematized ~ o k c h a c hmethod,'2nd printing. Philadelphia: Ex Libris, 1965. Piotrowski, 2. A. Test differentiation between effected and attempted suicides. In E. Wolff (Ed.), Pntrerns of selfdestruction: Depression and suicide. Springfield: C. C. Thomas, 1970. Schmid, C. F.,&VanArsdol, Jr., M. D. Completed and attempted suicides. American Sociologzcal Review, 1955,20,273-282. Tuckman, J. Suicide and the suiclde prevention center. In E. Wolff (Ed.), Patternsofself-destruction, Springfield: C. C. Thomas, 1970. U. S. Bureau of the Census. Statistical abstract of the U. S. I966 (87th ed.). Washington D.C.. author, 1966. U. S . Department of Health, Education and Welfare, Public Health Service. Vital Sfatistics of the U. S. Month!v Supplement. Washington, D. C.: U. S. Government Printing Office, 1968. Weisman, A. D. On dyinganddenyng, New York: Behavioral Publications, 1972. Dr. John Kendra Santa Clara County Health Dept. Blossom Hlll M. H. Center 841 Blossom Hill, San Jose, California 95123 Received: September 8, 1978 Revised: February 12,1979
Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
Predicting Suicide Using The Rorschach Inkblot Test John M. Kendra Published online: 10 Jun 2010.
To cite this article: John M. Kendra (1979) Predicting Suicide Using The Rorschach Inkblot Test, Journal of Personality Assessment, 43:5, 452-456, DOI: 10.1207/s15327752jpa4305_1 To link to this article: http://dx.doi.org/10.1207/s15327752jpa4305_1
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Journal of Personality Assessment, 1979,43,5
Predicting Suicide Using The Rorschach Inkblot Test J O H N M. KENDRA Temple University
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
Abstract: Three hundred and seventy-five Rorschach protocols were scored blind and then divided into three groups: psychiatric controls, suicide attempts, and suiclde effectors. Using the stepwise procedure of multiple discriminant analysis a trio of formulas, composed of six weighted variables each, and a constant, were constructed to apply to each of the three groups based on a test sample of 100 subjects in each group. Cross validation results on a new sample of 25 subjects In each group predicted classification wlth 52% overall accuracy at step six (chance .33). Internal reliability tests showed all values significant beyond .001. Discussion integrates the test data into the literature o n suicide, and attends to the problem of overlap of predictability which occurs with most prediction scales.
Research into suicide prediction can be divided into three kinds of studies. Most frequently used is the pure survey kind of study, exclusively demographic in nature, which merely counts characteristics. The second is done via the case history approach, wherein an individual case of suicide is discussed solely from the psychoanalytic (or some social, usually Durkheim) framework. Rarely in this type of approach is there hypothesis testing or experimental technique of any sort. The third and least frequently used method involves a combination of the two above. In these instances, some effort is taken to gather records on attempted or effected suicides where some battery of psychological tests were given, and the results compared, among or between groups. Reviews of the literature indicate that the Rorschach has the best potential as a predictor of suicide. This position is supported by Lester (1970) and Neuringer (1965). More specifically, it is the use of multiple signs grouped in scales, which had proven so fruitful (Hertz 1948, 1949; Martin 1951; Piotrowski 1970), rather than single signs, determinants and ratios, or content approaches. This art~cleis based on a d~ssertationwritten in partla1 fulfillment of the requrrements for the Ph D, degree In Clinrcal Psychology a t Temple Univers~ty. The author acknowledges the support and guidance of Russell Eisenman, Leona Aiken, and Herbert Hamsher who formed the core of the dissertation committee, and ta Ronald Th~stedof the Stanford University Dept. of Statistics for his invaluable aid Reprint requests may besenttotheauthorat theaddress given at the end of the art~cle
It was the purpose of this study to create such a scale for suicide prediction, using the Rorschach, which avoids prescribed personality theory for data collection, and avoids demographic indices, to test the hypothesis that: formulas composed of empirically derived signs, using the multiple discriminant analysis method, would differentiate the three groups (effectors, attempters, controls) significantly better than chance. Method Subjects The Rorschach protocols used in this project were gathered from four sources: 17 from the Irving Schwartz Institute, Philadelphia, Pa.; 43 from the Univ. of Rochester (N. Y.) School of Medicine & Dentistry; 160 from the Menninger Foundation Clinic files, and 159 from the files of the Los Angeles Suicide Prevention Center. All protocols were copies of original records taken verbatim. The sampleconsisted of 375 subjects and was divided into three groups of 125 subjects each, the groups being suicide effectors, suicide attemptors, and psychiatric controls. All subjects in the effector and attempter groups were individuals who sought psychiatric help for problems specifically related to suicide. Controls consisted of individuals seeking psychiatric treatment for problems other than suicide, and who denied any history of such attempts. In addition, control subjects were selected by matching demographic characteristics to the other two groups.
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
JOHN M. KENDRA In the effector group, the age range was from 16to61 withameanageof30.5; in the attemptor group the age range was 10 to 57 with a mean age of 28.3; and in the control group the age range was 8 to 62 with a mean age of 29.2. Tests of significance (ANOVA) for differences among groups showed non-significance 0, > .05). All subjects used in the study were white. There were 102 males and 23 females in the effector group; 30 males and 95 females in the attempter group; and 76 males and 49 females in the control group. The test for differences in sex among groups using a three sample ~ 2test was significant, ~ 2 (2) , = 86.107, p -= .001. Scoring The specific variables used are the 44 scored variates of the Piotrowski Rorschach scoring system. These are the Area components W, D W, D, Dd, and S; Determinants M; FM, m, c', Fc', Fc, c, FC, CF, and C; Content Categories animal, animal detail, human, human detail, anatomy, nature, map, object, fire, smoke; clouds, blood, artlarchitecture, clothing, botany, and food; F+%, N R (VIII-X), R (VIII-XI%, %, A%, H%, at%; the ratios of W:M, M:CC, and Cc:C C; sex shock, shading shock, and color shock. In each of the area components, determinants, and content categories each variable was treated as an independent variable, the total for any variable/ protocol achieved by frequency count. For example, "a bat in flight" to plate V was counted once for the W, once for the FMand once for the animal content. In addition to this basic rule, any adscript S, to any other determinant ( W, D W, D, Dd) was added to the total S to achieve Sum S. Any adscript c'or c, to any determinant other than m or C, was added to the Fc'or Fc to achieveatotal Fc'ortotal Fc. If the c' or c was an adscript to m or C, when they were without Form, the shading was added to the c' or c column to achieve total c' or total c. Two changes were made when coding the data for computer programming. Ratios were reduced to one number by
dividing the first variable by the second. The second change involved the coding of shocks, which were coded as binary values. Data Alna/ysis Methods The statistical procedure used in the study utilized a step-wise search for the minimum number of variables which would successfully predict suicide. The entire sample of 375 subjects werescored blind by the author according to both Piotrowski (1957) and Beck(1945). They were then identified and placed in the appropriate grloups, 125 in each group. Using the randorn numbers table, 25 subjects in each group were selected to represent the cross-validation sample. Tests of significance among groups in the cross-validistion sample for age and sex differences conformed to the pattern established in the test sample. After the predictor variables were identified, the cross-validation study was carried out in which the prediction of group identification was malde, based on thediscriminant equations derived from the test sample of 300 subjects. The table of random number.J was again used to select 29 subjects from the entire pool of ,375 for an internal reliability check. A11 29 participants' tocols were re-scored according to lotrowski and the: six most important variables, defined as those selected through the stepwise muiltiple discriminarit analysis for use in the discriminant equation, were tested for reliability of scoring. Time interval between scoring each subject's protocol was three months.
y-
Resubs Empirical Identi'ficatim of the Sign Battery All 44 variables in the Piotrowski Rorschach scoring system were used in the identification of the sign battery. Means and sigrnas for each of the variables were comp,ared at the .0l level for 18 variables ( D , k t FM, Fc: Fc, CF, C, A, Ad, Hd, food, N,N(VII1-X), %(VIJI-X), y o , H%, W:M'and M:CC). Computation of Eta2 however showed that in the best case (EM), only 14%ofthevariation
Predicting Suicide with the Rorschach Table 1 Total Percent Correctly Classified in Both Test and Cross-Validation Groups at Each Step Step
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
1
2 3 4 5 6 7 8 9 10 11
12 13 14
Test Group (n= 300)
Cross-Vahdat~on Group (n = 75)
45.0 48.3 51.7 55.0 57.3 59.0 65.0 67.6 66.9 68.3 68.8 69.3 67.0 67.6
37.3 37.3 42.6 49.3 50.6 52.0 52.0 54.6 53.9 53.3 55.4 56.0 57.8 58.6
suggested by the ANOVA results could be accounted for by group differences. This supports the contention that even though statistical significance levels as measured by ANOVA are high, the amount of "explaining" (the amount of predictive value) as measured by Eta* is control: attempter: effector:
.74(FM) 1.07(FM) .65(FM)
+ +
+
+ + +
All tests were significant,F(2,292)p< .01. To make the predictions regarding the cross-validation group, the three discriminant equations were constructed based on thedataat step6. That equation which yields the highest score ofthe three indicates the correct group membership of the subject. In a classification matrix constructed at step 6 indicating in which group each subject was placed according to the above formula, 48.1% of the controls, 51.8% oftheattempters,and57.1%ofthe effectors were correctly classified. A difference of proportions test was used to determine whetherthe total number of subjects correctly classified by the procedures at step 6 (52%) was above chance levels, resulting in a z score of 6.98, p < .Oaf. Since the ultimate goal of this classificatory scheme is clinical intervention, it matters little what thedifferences are if the classification is into a potential attempter or potential effector group. Therapeutic intervention would be synonymous with either group. While misclassifying a control as an attempter
.71(Fcf) .85(C) + .24(P%) .I7(H%) + .20(W:M) -5.72 .60(Fc1) 1.22(C) .26(P%) 4-.20(H%lo) + .21(W:M) -8.38 1.41(Fc') 1.28(C) f .31(P%) -i.lS(H%) -t .27(W;.M)-8.26
very low for any single sign. At this point multiple discriminant analysis, using the step-wise procedure was introduced. Since the pilot study showed a leveling off of prediction at step 14, the procedure was stopped at this step. Table 1 shows the percent correctly classified on the test group (n = 300) and the cross validation sample (n = 75) at each of the 14 steps. As can be seen from the Table, the point of decreasing returns for prediction of the crass-validation sample was passed at step6. It was therefore decided to use step 6 as the cutoff point, and these values were used in the prediction equations. To determine if the groups were significantly different,all pairs ofgroups were contrasted by multivariate tests of significance of difference between groups.
+
or effector is a considerable error, it is less significant than misclassifying an attempter or especially an effector as a control. Combining attempters and Table 2 Percentage of Subjects in the Cross-Validation Sample Correctly Classjfied as Either Suicidal or Nonsuicidalat Each Step (Overall Percentage Also Shown) Step
1 2 3 4 5 6 7-13 14
Suicidal
Nonsuicidal
Overall
80 68 72 84 72 72
16 32 36 32
58.6 56. 60. 66.6 62. 65.3
44
52
-
-
-
76
68
73.3
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
JOHN M. KENDRA effectors into a single group called "suicidal" at each step, the results are shown in Table 2. "Overall correctly classified" is the percentage correctly classified with respect to the suicidal-nonsuicidal dichotomy. Discussion A major criticism regarding previous attempts at using an established test like the Rorschach inkblots to make predictions about psychiatric populations, lies in retaining long outmoded, unscientifically supported, hypotheses from mainly psychoanalytic theory. These hypotheses are then applied to samples and ifthey areunsupported, anew search through the same theoretical framework is begun to "explain" the results. This hypothesis is then tested, etc. ad infinitum. In the last ten years or so, more and more research projects have begun appearing in the literature, like Martin's (1951) and Piotrowski's (1970) studies, which accumulated and tested data, without staying locked into any prescribed theory. In most previous studies of the demographic variables of suicide, consistent age, race and sex differences appear. Previous studies have shown that whites commit 9 out of every 10 suicides (cf. Henry & Short, 1951; Schmid & Van Arsdol, 1955). Nonwhites were not deliberately excluded from this study which was restricted to available data. It is, however, apparent that since all the subjects were white, the effected suicide group may represent but one-third the national sample. By this it is meant that while nonwhites actually commit only 1 in every 10 suicides, nonwhites are more frequently represented in the effector column as first-time attempters. Whites more frequently make multiple attempts before they actually kill themselves. The reason for this is because nonwhites are more apt to use lethal methods of attempting suicide, specifically shooting, jumping, hanging, or drowning; whites more frequently use pills. The reasons for these racial differences are not well understood, beyond the obvious socioeconomic and environmental explanations.
With regard to sex differences, it is again known that males effect suicide three times as frequently as do females. Females on the other hand attempt suicide three times as frequently as do males (cf. Farberow 8i Shneidman, 1961; Henry & Short, 1951) Note that in our sample, both populations and cross-validation samples approximate these figures. While the specific sex subsamples are representative of national statistics, the specific break{downswithin each group are too small to interpret meaningfully. Similarly, numerous studies have investigated the specifics of age-related suicide (cf. Schneidman & Farberow, 1961). It is noted that the majority of such studies concern nationally reported statistics generally on file with the Bureau of Census. Our sample was composed of sub-jects from 4 institutions, an already bialsed sample, and one which has not been c:linically investigated with regard to age. In addition, it is admitted that this study deals with an unusual if not biased samlple in that it only involves subjects (a) who have been seen at an institution, (b) have been given psychological tests, and (c) have specifically responded to the Rorschach inkblots. To attempt to equate them with the majority of sui~cidalpersons in this country is at best naive. Breakdown by age then, while perhaps interesting, accpmplishes none of the interests of this study and was therefore not done. Table 2 groiups suicide attempters and suicide effectors into the category "suicidal" and t r ~ a t scontrols as "nonsuicidal." This was done because the point in fact is that clinically we have rarely treated differently people who voice suicidal ideation, threaten suicide, attempt suicide, or will effect suicide. The only significant chsinrpe in terms of therapeutic intervention, will depend more on whether than (clinicianis in private practice, clinic practice or employed in an inpatient setting. 'Suicidal precautions" in an inpatient setting is a practically universal proc:erdure whether someone is voicing fears of lack of impulse control or is threatening to make an attempt. Rarely are "iscolation techniques,"usually meaning seclusion, used anymore to
Downloaded by [University of Toronto Libraries] at 05:56 02 October 2014
Predicting Suicide with the Rorschach deal with threats of suicide in hospitals, and the only recourse the outpatient clinician has, is to hospitalize the seriously suicidal patient. It isapparent then, that at this point of development of classificatory schemes, combining attempted and effected suicides is more pragmatic for treatment purposes. The results shown in Tables 1 and 2 raise the question as to why the accuracy of classification leveled off so early and did not continue at the same rate right up to step 44. One might expect that each variable contributes something to prediction and that as each was added, accuracy would continue. The results here show that only a few variables really help in "explaining" the final composition of groups into which individuals were classified. By this it is meant that as more variables areentered (after step 6), the discriminant functions more and more reflect the peculiarities and individual characteristics of the subjects, and less and less a structure common to the group. In additim, there is the problem of overlap in thy:predictability of the various variables. An example is when variable A and B both give significant wnivariate Fratios, but bothalso account for precisely the same differences among the groups. They would therefore essentially classify the same subjects correctly. If now, variable A enters the equation first, then variable B will not enter at all because it overlaps completely with A. If variableB overlaps mostly with A but not entirely, and A enters first, the increase in predictability from B will be hardly noticeable. Thus, as more variables are entered into the process, the less accurate the process becdines, due to the increased influence of peculiar pattern8 in the data upon whiq11.the disprimingtors are based. I In summary, by using the stepwise procedure of multiplct discriminate analysis, a trio of equations have besn canstructed, cansisting of six waighted variables and a constant, which suol~essfully classified a g r a y of individuals into three grayps defined as psychiatric controls, suicide attempters, and suicide effectors. This was done at above chance levels. The specific variables were empir-
ically defined and therefore are not subject at this point to clinicalinterpretation. References Beck, S. J . Rorschach test, Vol. II, A variety of personality pictures. New York: Grune and Stratton, 1945. Farberow, N. L., & Shneidman, E. S. (Eds.) 7he crv for help. New York: McGraw-Hill, 1961. Henry, A. F., & Short, J . F. Surcideandhornicide: Some economic, sociological and psychological aspects of aggression. Glencoe Illinois: Free Press, 1951. Hertz, M. R. Suicidalconfigurationsin Rorschach records. Rorschach Research Exchange and Journalof Projective Techniques, 1948,12,3-$8. Hertz, M. R. Further study o f "sicidal"configurations in Rorschach records. Rorschach Research Exchange and Journal of Projective Techniques, 1949.13.44-73. Lester, D. Attempts to predict suicide risk using psychological tests. Psychological Bulletin, 1970, 74, 1-17. Martin, H. A. A Rorschachstudvofsuicide. Unpublished Doctoral Dissertation, University of Kentucky, 1951. Neuringer, C. The Rorschach test as a research device for the identification, prediction and understanding of suicidalideation and behavior. Journal of Projective Techniques, 1965, 29, 71-82. Neuringer, C., & Kostoe, R. R. Suicide research and non-rejection of the null hypothesis. Perceptual and Motor Skills, 1964,22, 115-1 18. Piotrowski, Z. A. Perceptanalysis: A fundamentaNv reworked. exoanded. and svstematized ~ o k c h a c hmethod,'2nd printing. Philadelphia: Ex Libris, 1965. Piotrowski, 2. A. Test differentiation between effected and attempted suicides. In E. Wolff (Ed.), Pntrerns of selfdestruction: Depression and suicide. Springfield: C. C. Thomas, 1970. Schmid, C. F.,&VanArsdol, Jr., M. D. Completed and attempted suicides. American Sociologzcal Review, 1955,20,273-282. Tuckman, J. Suicide and the suiclde prevention center. In E. Wolff (Ed.), Patternsofself-destruction, Springfield: C. C. Thomas, 1970. U. S. Bureau of the Census. Statistical abstract of the U. S. I966 (87th ed.). Washington D.C.. author, 1966. U. S . Department of Health, Education and Welfare, Public Health Service. Vital Sfatistics of the U. S. Month!v Supplement. Washington, D. C.: U. S. Government Printing Office, 1968. Weisman, A. D. On dyinganddenyng, New York: Behavioral Publications, 1972. Dr. John Kendra Santa Clara County Health Dept. Blossom Hlll M. H. Center 841 Blossom Hill, San Jose, California 95123 Received: September 8, 1978 Revised: February 12,1979
