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Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
The Rorschach With Hospice Cancer Patients and Surviving Cancer Patients Patricia B. Georgoff Published online: 10 Jun 2010.
To cite this article: Patricia B. Georgoff (1991) The Rorschach With Hospice Cancer Patients and Surviving Cancer Patients, Journal of Personality Assessment, 56:2, 218-226, DOI: 10.1207/ s15327752jpa5602_3 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5602_3
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, 1991, 56(2), 218-226 Copyright o 1991, Lawrence Erlbaurn Associates, Inc.
The Rorschach With Hospice Cancer Patients and Surviving Cancer Patients Patricia B. Georgoff
Downloaded by [University of Sussex Library] at 04:53 12 February 2015
Boca Raton, FL
Two groups, terminally ill hospice female lung and breast cancer patients and surviving female lung and breast cancer patients (mean age = 74.3 years), were given the Rorschach to discern the underlying personality structure. The hospice patients were found to be withdrawn, anxious, depressed, and unable to express their deep, fearful emotions. The surviving patients met life and death head-on and seemed richer for the experience. For 'tis the mind that makes the body rich. Shakespeare, ''Taming of the Shrew," Act IV, Scene 3, Line 198 (Rouse, 1978) T h e idea that the mind can influence the progression of disease has its roots in the writings of the ancient philosophers as well as the recent professionals' interest (Benson, 1984, 1989; Siegel, 1986) and the lay interest in psychosomatic medicine (Hay, 1984). Since World War 11, interest in the emotional antecedents in cancer has focused around either loss and depression (LeShan 1966; LeShan & Reznikoff, 1960; LeShan & Worthington, 1956) or personality characteristics, as revealed o n psychological tests. T h e utilization of the Rorschach has yielded some fascinating results. Tarlou and Smalheiser (1951) found cancer patients to be constricted and repressed. Klopfer (1957) concluded that fast-growing cancers correlated significantly with high investment in ego defenses (defensiveness) and slow-growing cancers with low investment in ego defenses. Csirszka and Hegedus (1964), working with leukemia patients, concluded they were unable to express hostile feelings. Bahnson and Bahnson (1964) concluded that cancer patients were not necessarily depressed, but overutilized the ego defenses of repression and denial, combined with a n unsatisfactory ego development. T h e conscious self was socially adequate but shallow, whereas the unconscious self was explosive and tragic, and the two selves remained strangers. Nemeth and Mezei (1964) hypothesized that somatic illness was the result of the internalization of broken
Downloaded by [University of Sussex Library] at 04:53 12 February 2015
HOSPICE AND SURVIVING CANCER PATENTS
219
interpersonal relations and was reflected on the Rorschach through a great number of anatomy responses. Their dependency was expressed by high oral needs; passive hostility was reflected by seeing wounds, broken and decayed objects, and smashed creatures. Booth (1965),in a study composed of lung aind other cancer and tuberculosis patients, concluded that cancer patients were anal, rigid, strove for independent self-expression, and avoided emotional involvements. Graves, Mead, and Pearson (1986)reported that medical students assessed by the Rorschach Interaction Scale, developed by Graves et al. (1906) for the precursors study (Thomas, 1988), showed that students who later developed cancer experienced a lack of closeness with their families, were less well-adjusted, and had a less well-balanced approach to ihterpersonal relationships. My study evolved from the concerns of the Hospice-By-The-Sea staffs desire to better meet the emotional needs of their patients. In order to be eligible for hospice services, the patient has to have a 6 months or less life expectancy as certified by their physician. They are admitted to the hospice proper only for pain control, acute symptom management, and respite.
METHOD Sample The Rorschach was administered to four terminally ill hospice patients: two with lung cancer and two with breast cancer. I compared their Rorschach responses with those of four cancer survivors: two with lung cancer and two with breast cancer. The subjects were all White females, ranging in age from 67 to 87 (mean age = 74.3 years). Among the survivors, the average period since initial diagnosis was 21 years, with a range between 6 and 35 years.
RESULTS The small sample size did not allow for broad sweeping generalizations and should be viewed as trends throughout this article. Table 1 reveals that the proportion of responses between hospice and surviving patients is substantially the same. There was, however, a reduced number of total responses among hospice patients relative to surviving patients. Within each category, breast cancer patients provided slightly more responses than did lung cancer patients. This agrees with the findings of Tarlou and Smalheiser (1951) and Csirszka and Hegedus (1964). Table 2 shows a summary of responses by the hospice and surviving patients.
220
GEORGOFF
TABLE 1 A Comparison Between the Number and Proportions of Hospice and Surviving Lung and Breast Cancer Patients Hospice Patients Responses Type
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Lunga Breasta Total
Surwiving Patients Responses
Number
Percentage
Number
Percentage
Difference in %
41 46 87
47.1 52.9
56 65 121
46.3 53.7
0.8 -0.8
TABLE 2 Hospice and Surviving Patient Mentions Hospice Patientsa Lung Responses
1
Surwiwing Patientsb
Breast
-
Lung Breast -
2
3
4
5
6
7
8
Total
Percentage Distribution
5 1 8
8 1 12
10 2 10
10
21
22
28
5 1 25 1 32
8 2 23
14
6 2 15 2 25
33
52 10 127 11 200
26.0 5.0 63.5 5.5 100.0
14
2 18
2 17 7 1 1 28
4 20
14
3 14 7 3 1 28
1 23
2 1 23
2 11 4 3 1 21
14 140 9 15 5 203
6.9 69.0 14.3 7.4 2.5 100.0
Location
W Wx
D d Total
1 16 8 25
18
Determinant
M F FC CF C Total
23 1 1 25
4
6
2
4
2
32
32
Note. W = whole; Wx = cut-offwhole; D = large detail; d = small detail; M = movement; F = form; FC = form color; CF = color form; C = color. "Patient Numbers 1-4. b~atientNumbers 5-8.
It also includes a summary of responses for the location and determinant scores as well as the responses between the lung and breast cancer patients. Within the location responses, whole, cut-off whole, and large detail accounted for almost 90% of the choices. This agrees with the findings of Tarlou and Smalheiser (1951) and followed the same trends found by Bahnson and Bahnson (1964). Similarly, form accounted for 69% of the responses. Bahnson and Bahnson (1964) reported the same results for their sample. There was a relatively small percentage of form and color responses (14.3%).This, too, agreed with Bahnson
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221
and Bahnson's (1964) findings. They suggested this was indicative of constriction and barrenness with the personality and that cancer patients live an emotionally bleak life. Table 3 reveals that within the location scoring category, hospice patients provided slightly over two thirds as many choices as the surviving patients. The proportion of whole responses was greater than the overall proportion, and the number of large detail responses was less. Although hospice patients had significantly more whole and part whole responses than suggested by the overall percentage, the numbers involved are relatively small. Bahnson and Bahnson (1964) found essentially the same trends for the whole responses, suggesting a superficial approach to the world. In both the hospice and surviving lung cancer patients provided only 85% as many responses as the breast patients. Within the response categories, lung cancer patients contributed substantially all of the small detail responses. Virtually all of these responses were from one lung cancer patient. Rappaport, Gill, and Schafer (1968) suggested that this is "an escape reaction to an anxiety-arousing situation" (p. 324). Within the determinant categories, the overall proportions between hospice and surviving lung and breast cancer responses were almost identical to those of the location responses. The hospice patients' proportion of form answers was significantly higher than the overall proportion (89% vs. 69%). This agrees with Bahnson and Bahnson's (1964) findings and again confirms the trend th~at cancer patients tend to be constricted, pay attention to only the obvious, and
TABLE 3
Summary Table of Breast and Lung and Hospice and Survivor Group Responses Hospice to Suwivor Responses
Hospice Total
Survivor Total
23 5 46 8 82
4 66 5 5 3 83
Lung to Breast
-
Percentage
Lung Total
Breast Total
29 5 81 3 118
79.3 100.0 56.8 266.7 69.5
21 4 57 10 92
31 6 70 1 108
67.7 66.'7 81.4 1000.0 85.2
10 74 24 10 2 120
40.0 89.2 20.8 50.0 150.0 69.2
5 68 15 4 3 95
9 72 14 11 2 108
55.6 94.4 107.1 36.4 150.0 88.0
Percentage -
Location
W Wx D d Total Determinant
M F FC CF C Total
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222
GEORGOFF
can deal with life only on a superficialbasis. The same applied to color responses, but the numbers involved again were too small to be meaningful. Largely due to the dominance of the form responses, the other hospice patient response categories were substantially less than the overall proportion. Between lung and breast patients, the form color responses were greater than expected among the lung patients. The movement and color form responses were considerably less. This, too, agreed with Bahnson and Bahnson's (1964) observations that cancer patients are unable to establish mature, emotional relationships. Table 4 reveals no significant difference between the content distribution of hospice and surviving patients, except for three notable exceptions. Objects were mentioned only 25% as frequently by hospice patients relative to the number of survivor responses. Among the survivors, three of the four mentioned objects, but eight of these percepts were from one individual. Rappaport et al. (1968) suggested that this could indicate the presence of anxiety. TABLE 4 Content Analysis of Hospice and Survivors Rorschach Scores Responses Content H,Hd A,Ad Anatomy Arch Art Birth Blood Color Clouds Coastline Fire Myth Objects Oxygen Plant Rocks Sex Skeleton Water Popular Original Total
Hospice Pattents
Surviving Patients
1
2
3
4
Total
5
6
7
8
Total
11 10
2 2
4 11 2
2 15
19 38 2 0 0 0 1 1 0 0 1 1 4 1 8 0 0 1 1 7 0 78
8 10
4 16
12 12
1 2
4 15 2 1
1
28 53 2 2 3 1 1
1 1
1 1 2 1
2
2 1 2
3
1 2
2
1 2
25
8
22
1 23
1 1
0
1
1 1
8
4
1 4
2 1 1 0 16 0
3
3
1
1 1
1
0
3
5
5
7
28
25
31
31
0 20 0 115
Hospice to Survivor Percentage 67.9 71.7 100.0 0.0 0.0 0.0 100.0 NM 0.0 0.0 100.0 NM 25.0 NM 266.7 0.0 0.0 NM NM 35.0 NM 67.8
Note. NM = not meaningful; H = human; Hd = human detail; A = animal; Ad = animal detail. "Patient Numbers 1-4. bPatient Numbers 5-8.
HOSPICE AND SURVIVING CANCER PATIENTS
223
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Relative to the number of survivor responses, plants were mentioned over two and one half times as often by hospice patients. All hospice patients offered at least one mention of plants, whereas among surviving patients, all of the responses were confined to one individual. The popularity of this percept within the hospice patients, combining both content -plant - and the determinant of form and color, would seem to suggest an inability to express affect (Rappaport et al., 1968). A11 of the patients in the study contributed at least one popular response, with surviving patients contributing almost three times as many of these responses as the hospice patients. This, of course, suggests some type of stereotypicalthinking (Rappaport et al., 1964).
DISCUSSION Since the expanded interest in death and dying (Kubler-Ross, 1969), the whole issue of the way our society deals with death (Becker, 1973) and the emergence of the hospice within our culture (Stoddard, 1978) has opened up the need to explore the feelings and emotions of the dying. The Rorschach was chosen for this study because I felt it would be less intrusive physically for the patients and would yield a richer understanding of the personality of the dying person. The difference between the total number of responses for each group (hospice = 87; survivors = 121), although not statistically significant, suggests the presence of depression within the hospice group. This would not be unexpected in view of the stage of death according to Kubler-Ross's theory. Within both groups, the breast cancer patients had slightly more total responses than the lung cancer patients. We can only speculate that the lung cancer patients would be more constricted, withdrawn, and less able to express themselves. The large percentage of whole, part whole, and large detail responses for both groups (89.5%) suggests these patients have a somewhat anxious approach to the world. This could be a function of their disease, their age (M = 74.3 years), or both. Virtually all of the small detail responses were found within the hospice group. Out of a total of 11 responses for both groups, 8 were accounted for by one hospice lung cancer patient. This has been interpreted as "an escape reaction from an anxiety arousing situationn (Rappaport et al., 1968, p. 324). This could suggest that the unconscious acknowledgment of death was too threatening for this patient. She verbally acknowledged that it was time to die, and without further physical deterioration, she did. She is the only patient to have died so far. Within the determinant category, there were four movement responses by the hospice group-two for each of the breast and none for the lung cancer
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224
GEORGOFF
patients-compared to the 10 movement responses for the survivor group. The interpretation for movement (Rappaport et al., 1968) is suggestive of a person's ideational capacity, feelings toward people, and sensitivity to maladjustment. This reduced number in the hospice group (again, the lung cancer patients produced none) is suggestive of withdrawal from relationships, depression, and an inability to express feelings. The survivor group had 10 movement responses, which suggests these women have better resources for ideation, are better able to express themselves, and interact with people and their environment. The small sample size precludes making emphatic conclusions, but the trend suggests the hospice patients are withdrawing emotionally and turning into themselves. An examination of the form responses, although not statistically significant, revealed a larger proportion in the hospice group, which is another indication of rigidity within this group. Traditionally, the color responses suggest a person's affective life and emotional responsiveness to people and the environment. The form color scores within the hospice group were 5.7% as compared to 19.8% found within the survivor group. This trend suggests that, within the hospice group, there is a reduced ability for affective expression. An examination of the color form responses, again, although not significant, is less (5.7%)in the hospice group as compared to 8.7% in the survivor group. However, the pure color responses were greater (3 responses to 2 responses) in the hospice group. Taken together, these scores seem to suggest that within the hospice group, there is a dampening of affect, but when feeling emerges, it is almost overwhelming. It also seems to suggest that they fear their impending death. In an examination of the content on these Rorschach protocols, one half of the objects designations (n = 8) resided within one surviving patient, who is obviously an anxious person. It is interesting to note that her survival rate is the lowest: 6 years. However, there was a ~reponderanceof ~ l a nresponses t in the hospice group (8 responses to 3). Although this could be open to wide speculation, a conservative explanation would be this is another indication of anxiety. Popular responses were found across all of the protocols. In reviewing these findings, it should be noted that there was a greater richness in the hospice breast cancer patients than in the lung cancer patients and even more so in the surviving breast cancer patients. The breast patients apparently have richer personalities. This issue needs further research. A special note should be made about the personalities of the surviving patients. In effect, all of these women, because of their ages, could be considered survivors. However, the women in the survivor group are larger-than-life personalities: That is, they are dynamic, "full charge" personalities. They were successful in whatever avenue they chose to expend their energy. It is almost as
HOSPICE AND SURVIVING CANCER PATIENTS
though they faced the ultimate challenge; they attacked, digested, conquered, and became what Dr. Karl Menninger (1959) called, 'Weller, than well." Recommendations in counseling the hospice patient would center around being aware these are very frightened people, for the most part, with no experience or knowledge of what lies ahead. They are withdrawing, but underneath there are many strong feelings that need to be addlressed; they need help in dealing with these feelings and any unfinished business.
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ACKNOWLEDGMENTS
A previous version of this article was presented at the Society for Personality Assessment Annual Meeting in San Diego, March 22-24, 1990. To the hospice patients, thank you for the heroic cooperation in wanting to contribute to this small advancement in science. This study could never have come about without the full and cheerful cooperation of Hospice-By-The-Sea, Boca Raton, FL. To the survivors, it was indeed life affirming to meet you for a short period of time. REFERENCES Bahnson, C. B., & Bahnson, W. E. (1964). Denial and repression of primitive impulses and of disturbing emotions in patients with malignant neoplasms. In D. M. Kesson & L. L. LeShan (Eds.), Psychosomatic aspects of neoplastic disease (pp. 42-62). London: Pitman. Becker, E. (1973). The denial of death. New York: Free Press, Division of Macmillan. Benson, H. (1984). Beyond the relaxation response. New York: Berkeley Books. Benson, H. (1989). Your maximum mind. New York: Avon Books. Booth, G. (1965). Irrational complications of the cancer problem. American Journal of Psychoanalysis, 25,41-60. Csi~szka,M. 0.J., & Hegedus, J. (1964). Psychological tests in leukemia patients. In D. M. Kessen & L. L. LeShan (Eds.), Psychosomatic aspects of neoplastic disease (pp. 18-29). Lonson: Pitman. Graves, I?. L., Mead, L. A., & Pearson, T. A. (1986). The Rorschach Interaction Scale as a potential predictor of cancer. Psychosomatic Medicine, 48, 549-563. Hay, L. &. (1984). You can heal ~. your life. Santa Monica, CA: Hav House, Inc. Klopfer, B. (1957). Psychological variables in huamn cancer. Journal of Projective Techniques, 21, 331-340. Kubler-Ross, H. (1969). On death and dying. New York: Macmillan. LeShan, L. (1966). An emotional life-history pattern associated with neoplastic disease. Annals of the New York Academy of Sciences, 125, 780-793. LeShan, L., & Reznikoff, M. (1960). A psychological factor apparently associated with neoplastic disease. Journal A b n d Social Psychology, 60, 439-440. LeShan, L., & Worthington, R. E. (1956). Some recurrent life-history patterns observed in patients with malignant disease. Journal Nervous Mental Disease, 124,460-465. Menninger, K. (1959). A psychiatrist's world. New York: Viking Press. Nemeth, G., & Mezei, A. (1964). Personality traits of cancer patients compared with benign tumor patients on the Rorschach Test. In D. M. Kesson & L. L. LeShan (Eds.), Psychosomaticaspects of
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GEORGOFF
Downloaded by [University of Sussex Library] at 04:53 12 February 2015
neoplastic disease (pp. 12-17). London: Pitman. Rappaport, D., Gill, M., & Schafer, R. (1968). Diagnostic psychological testing. New York: International Universities Press. Rouse, A. L. (1978). The annotated Shakespeare, Volume 1: The comedies. New York: Potter, Inc. Siegel, B. (1986). Love, medicine &miracles. New York: Harper & Row. Stoddard, S. (1978). The hospice movement-A better way of caringfor the dying. Briarcliff Manor, NY: Stein and Day. Tarlou, M., & Smalheiser, I. (1951). Personality patterns in patients with malignant tumors of the breast and cervix: A n exploratory study. Psychosomatic Medicine, 13, 117-121. Thomas, C. B. (1988). Cancer and the youthful mind. Adwances, 5, 42-58.
Patricia Georgoff 1599 NW 9th Avenue Boca Raron, FL 33432 Received March 5, 1990 Revised April 12, 1990
Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
The Rorschach With Hospice Cancer Patients and Surviving Cancer Patients Patricia B. Georgoff Published online: 10 Jun 2010.
To cite this article: Patricia B. Georgoff (1991) The Rorschach With Hospice Cancer Patients and Surviving Cancer Patients, Journal of Personality Assessment, 56:2, 218-226, DOI: 10.1207/ s15327752jpa5602_3 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5602_3
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, 1991, 56(2), 218-226 Copyright o 1991, Lawrence Erlbaurn Associates, Inc.
The Rorschach With Hospice Cancer Patients and Surviving Cancer Patients Patricia B. Georgoff
Downloaded by [University of Sussex Library] at 04:53 12 February 2015
Boca Raton, FL
Two groups, terminally ill hospice female lung and breast cancer patients and surviving female lung and breast cancer patients (mean age = 74.3 years), were given the Rorschach to discern the underlying personality structure. The hospice patients were found to be withdrawn, anxious, depressed, and unable to express their deep, fearful emotions. The surviving patients met life and death head-on and seemed richer for the experience. For 'tis the mind that makes the body rich. Shakespeare, ''Taming of the Shrew," Act IV, Scene 3, Line 198 (Rouse, 1978) T h e idea that the mind can influence the progression of disease has its roots in the writings of the ancient philosophers as well as the recent professionals' interest (Benson, 1984, 1989; Siegel, 1986) and the lay interest in psychosomatic medicine (Hay, 1984). Since World War 11, interest in the emotional antecedents in cancer has focused around either loss and depression (LeShan 1966; LeShan & Reznikoff, 1960; LeShan & Worthington, 1956) or personality characteristics, as revealed o n psychological tests. T h e utilization of the Rorschach has yielded some fascinating results. Tarlou and Smalheiser (1951) found cancer patients to be constricted and repressed. Klopfer (1957) concluded that fast-growing cancers correlated significantly with high investment in ego defenses (defensiveness) and slow-growing cancers with low investment in ego defenses. Csirszka and Hegedus (1964), working with leukemia patients, concluded they were unable to express hostile feelings. Bahnson and Bahnson (1964) concluded that cancer patients were not necessarily depressed, but overutilized the ego defenses of repression and denial, combined with a n unsatisfactory ego development. T h e conscious self was socially adequate but shallow, whereas the unconscious self was explosive and tragic, and the two selves remained strangers. Nemeth and Mezei (1964) hypothesized that somatic illness was the result of the internalization of broken
Downloaded by [University of Sussex Library] at 04:53 12 February 2015
HOSPICE AND SURVIVING CANCER PATENTS
219
interpersonal relations and was reflected on the Rorschach through a great number of anatomy responses. Their dependency was expressed by high oral needs; passive hostility was reflected by seeing wounds, broken and decayed objects, and smashed creatures. Booth (1965),in a study composed of lung aind other cancer and tuberculosis patients, concluded that cancer patients were anal, rigid, strove for independent self-expression, and avoided emotional involvements. Graves, Mead, and Pearson (1986)reported that medical students assessed by the Rorschach Interaction Scale, developed by Graves et al. (1906) for the precursors study (Thomas, 1988), showed that students who later developed cancer experienced a lack of closeness with their families, were less well-adjusted, and had a less well-balanced approach to ihterpersonal relationships. My study evolved from the concerns of the Hospice-By-The-Sea staffs desire to better meet the emotional needs of their patients. In order to be eligible for hospice services, the patient has to have a 6 months or less life expectancy as certified by their physician. They are admitted to the hospice proper only for pain control, acute symptom management, and respite.
METHOD Sample The Rorschach was administered to four terminally ill hospice patients: two with lung cancer and two with breast cancer. I compared their Rorschach responses with those of four cancer survivors: two with lung cancer and two with breast cancer. The subjects were all White females, ranging in age from 67 to 87 (mean age = 74.3 years). Among the survivors, the average period since initial diagnosis was 21 years, with a range between 6 and 35 years.
RESULTS The small sample size did not allow for broad sweeping generalizations and should be viewed as trends throughout this article. Table 1 reveals that the proportion of responses between hospice and surviving patients is substantially the same. There was, however, a reduced number of total responses among hospice patients relative to surviving patients. Within each category, breast cancer patients provided slightly more responses than did lung cancer patients. This agrees with the findings of Tarlou and Smalheiser (1951) and Csirszka and Hegedus (1964). Table 2 shows a summary of responses by the hospice and surviving patients.
220
GEORGOFF
TABLE 1 A Comparison Between the Number and Proportions of Hospice and Surviving Lung and Breast Cancer Patients Hospice Patients Responses Type
Downloaded by [University of Sussex Library] at 04:53 12 February 2015
Lunga Breasta Total
Surwiving Patients Responses
Number
Percentage
Number
Percentage
Difference in %
41 46 87
47.1 52.9
56 65 121
46.3 53.7
0.8 -0.8
TABLE 2 Hospice and Surviving Patient Mentions Hospice Patientsa Lung Responses
1
Surwiwing Patientsb
Breast
-
Lung Breast -
2
3
4
5
6
7
8
Total
Percentage Distribution
5 1 8
8 1 12
10 2 10
10
21
22
28
5 1 25 1 32
8 2 23
14
6 2 15 2 25
33
52 10 127 11 200
26.0 5.0 63.5 5.5 100.0
14
2 18
2 17 7 1 1 28
4 20
14
3 14 7 3 1 28
1 23
2 1 23
2 11 4 3 1 21
14 140 9 15 5 203
6.9 69.0 14.3 7.4 2.5 100.0
Location
W Wx
D d Total
1 16 8 25
18
Determinant
M F FC CF C Total
23 1 1 25
4
6
2
4
2
32
32
Note. W = whole; Wx = cut-offwhole; D = large detail; d = small detail; M = movement; F = form; FC = form color; CF = color form; C = color. "Patient Numbers 1-4. b~atientNumbers 5-8.
It also includes a summary of responses for the location and determinant scores as well as the responses between the lung and breast cancer patients. Within the location responses, whole, cut-off whole, and large detail accounted for almost 90% of the choices. This agrees with the findings of Tarlou and Smalheiser (1951) and followed the same trends found by Bahnson and Bahnson (1964). Similarly, form accounted for 69% of the responses. Bahnson and Bahnson (1964) reported the same results for their sample. There was a relatively small percentage of form and color responses (14.3%).This, too, agreed with Bahnson
Downloaded by [University of Sussex Library] at 04:53 12 February 2015
HOSPICE AND SURVNING CANCER PATIENTS
221
and Bahnson's (1964) findings. They suggested this was indicative of constriction and barrenness with the personality and that cancer patients live an emotionally bleak life. Table 3 reveals that within the location scoring category, hospice patients provided slightly over two thirds as many choices as the surviving patients. The proportion of whole responses was greater than the overall proportion, and the number of large detail responses was less. Although hospice patients had significantly more whole and part whole responses than suggested by the overall percentage, the numbers involved are relatively small. Bahnson and Bahnson (1964) found essentially the same trends for the whole responses, suggesting a superficial approach to the world. In both the hospice and surviving lung cancer patients provided only 85% as many responses as the breast patients. Within the response categories, lung cancer patients contributed substantially all of the small detail responses. Virtually all of these responses were from one lung cancer patient. Rappaport, Gill, and Schafer (1968) suggested that this is "an escape reaction to an anxiety-arousing situation" (p. 324). Within the determinant categories, the overall proportions between hospice and surviving lung and breast cancer responses were almost identical to those of the location responses. The hospice patients' proportion of form answers was significantly higher than the overall proportion (89% vs. 69%). This agrees with Bahnson and Bahnson's (1964) findings and again confirms the trend th~at cancer patients tend to be constricted, pay attention to only the obvious, and
TABLE 3
Summary Table of Breast and Lung and Hospice and Survivor Group Responses Hospice to Suwivor Responses
Hospice Total
Survivor Total
23 5 46 8 82
4 66 5 5 3 83
Lung to Breast
-
Percentage
Lung Total
Breast Total
29 5 81 3 118
79.3 100.0 56.8 266.7 69.5
21 4 57 10 92
31 6 70 1 108
67.7 66.'7 81.4 1000.0 85.2
10 74 24 10 2 120
40.0 89.2 20.8 50.0 150.0 69.2
5 68 15 4 3 95
9 72 14 11 2 108
55.6 94.4 107.1 36.4 150.0 88.0
Percentage -
Location
W Wx D d Total Determinant
M F FC CF C Total
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can deal with life only on a superficialbasis. The same applied to color responses, but the numbers involved again were too small to be meaningful. Largely due to the dominance of the form responses, the other hospice patient response categories were substantially less than the overall proportion. Between lung and breast patients, the form color responses were greater than expected among the lung patients. The movement and color form responses were considerably less. This, too, agreed with Bahnson and Bahnson's (1964) observations that cancer patients are unable to establish mature, emotional relationships. Table 4 reveals no significant difference between the content distribution of hospice and surviving patients, except for three notable exceptions. Objects were mentioned only 25% as frequently by hospice patients relative to the number of survivor responses. Among the survivors, three of the four mentioned objects, but eight of these percepts were from one individual. Rappaport et al. (1968) suggested that this could indicate the presence of anxiety. TABLE 4 Content Analysis of Hospice and Survivors Rorschach Scores Responses Content H,Hd A,Ad Anatomy Arch Art Birth Blood Color Clouds Coastline Fire Myth Objects Oxygen Plant Rocks Sex Skeleton Water Popular Original Total
Hospice Pattents
Surviving Patients
1
2
3
4
Total
5
6
7
8
Total
11 10
2 2
4 11 2
2 15
19 38 2 0 0 0 1 1 0 0 1 1 4 1 8 0 0 1 1 7 0 78
8 10
4 16
12 12
1 2
4 15 2 1
1
28 53 2 2 3 1 1
1 1
1 1 2 1
2
2 1 2
3
1 2
2
1 2
25
8
22
1 23
1 1
0
1
1 1
8
4
1 4
2 1 1 0 16 0
3
3
1
1 1
1
0
3
5
5
7
28
25
31
31
0 20 0 115
Hospice to Survivor Percentage 67.9 71.7 100.0 0.0 0.0 0.0 100.0 NM 0.0 0.0 100.0 NM 25.0 NM 266.7 0.0 0.0 NM NM 35.0 NM 67.8
Note. NM = not meaningful; H = human; Hd = human detail; A = animal; Ad = animal detail. "Patient Numbers 1-4. bPatient Numbers 5-8.
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Relative to the number of survivor responses, plants were mentioned over two and one half times as often by hospice patients. All hospice patients offered at least one mention of plants, whereas among surviving patients, all of the responses were confined to one individual. The popularity of this percept within the hospice patients, combining both content -plant - and the determinant of form and color, would seem to suggest an inability to express affect (Rappaport et al., 1968). A11 of the patients in the study contributed at least one popular response, with surviving patients contributing almost three times as many of these responses as the hospice patients. This, of course, suggests some type of stereotypicalthinking (Rappaport et al., 1964).
DISCUSSION Since the expanded interest in death and dying (Kubler-Ross, 1969), the whole issue of the way our society deals with death (Becker, 1973) and the emergence of the hospice within our culture (Stoddard, 1978) has opened up the need to explore the feelings and emotions of the dying. The Rorschach was chosen for this study because I felt it would be less intrusive physically for the patients and would yield a richer understanding of the personality of the dying person. The difference between the total number of responses for each group (hospice = 87; survivors = 121), although not statistically significant, suggests the presence of depression within the hospice group. This would not be unexpected in view of the stage of death according to Kubler-Ross's theory. Within both groups, the breast cancer patients had slightly more total responses than the lung cancer patients. We can only speculate that the lung cancer patients would be more constricted, withdrawn, and less able to express themselves. The large percentage of whole, part whole, and large detail responses for both groups (89.5%) suggests these patients have a somewhat anxious approach to the world. This could be a function of their disease, their age (M = 74.3 years), or both. Virtually all of the small detail responses were found within the hospice group. Out of a total of 11 responses for both groups, 8 were accounted for by one hospice lung cancer patient. This has been interpreted as "an escape reaction from an anxiety arousing situationn (Rappaport et al., 1968, p. 324). This could suggest that the unconscious acknowledgment of death was too threatening for this patient. She verbally acknowledged that it was time to die, and without further physical deterioration, she did. She is the only patient to have died so far. Within the determinant category, there were four movement responses by the hospice group-two for each of the breast and none for the lung cancer
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patients-compared to the 10 movement responses for the survivor group. The interpretation for movement (Rappaport et al., 1968) is suggestive of a person's ideational capacity, feelings toward people, and sensitivity to maladjustment. This reduced number in the hospice group (again, the lung cancer patients produced none) is suggestive of withdrawal from relationships, depression, and an inability to express feelings. The survivor group had 10 movement responses, which suggests these women have better resources for ideation, are better able to express themselves, and interact with people and their environment. The small sample size precludes making emphatic conclusions, but the trend suggests the hospice patients are withdrawing emotionally and turning into themselves. An examination of the form responses, although not statistically significant, revealed a larger proportion in the hospice group, which is another indication of rigidity within this group. Traditionally, the color responses suggest a person's affective life and emotional responsiveness to people and the environment. The form color scores within the hospice group were 5.7% as compared to 19.8% found within the survivor group. This trend suggests that, within the hospice group, there is a reduced ability for affective expression. An examination of the color form responses, again, although not significant, is less (5.7%)in the hospice group as compared to 8.7% in the survivor group. However, the pure color responses were greater (3 responses to 2 responses) in the hospice group. Taken together, these scores seem to suggest that within the hospice group, there is a dampening of affect, but when feeling emerges, it is almost overwhelming. It also seems to suggest that they fear their impending death. In an examination of the content on these Rorschach protocols, one half of the objects designations (n = 8) resided within one surviving patient, who is obviously an anxious person. It is interesting to note that her survival rate is the lowest: 6 years. However, there was a ~reponderanceof ~ l a nresponses t in the hospice group (8 responses to 3). Although this could be open to wide speculation, a conservative explanation would be this is another indication of anxiety. Popular responses were found across all of the protocols. In reviewing these findings, it should be noted that there was a greater richness in the hospice breast cancer patients than in the lung cancer patients and even more so in the surviving breast cancer patients. The breast patients apparently have richer personalities. This issue needs further research. A special note should be made about the personalities of the surviving patients. In effect, all of these women, because of their ages, could be considered survivors. However, the women in the survivor group are larger-than-life personalities: That is, they are dynamic, "full charge" personalities. They were successful in whatever avenue they chose to expend their energy. It is almost as
HOSPICE AND SURVIVING CANCER PATIENTS
though they faced the ultimate challenge; they attacked, digested, conquered, and became what Dr. Karl Menninger (1959) called, 'Weller, than well." Recommendations in counseling the hospice patient would center around being aware these are very frightened people, for the most part, with no experience or knowledge of what lies ahead. They are withdrawing, but underneath there are many strong feelings that need to be addlressed; they need help in dealing with these feelings and any unfinished business.
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ACKNOWLEDGMENTS
A previous version of this article was presented at the Society for Personality Assessment Annual Meeting in San Diego, March 22-24, 1990. To the hospice patients, thank you for the heroic cooperation in wanting to contribute to this small advancement in science. This study could never have come about without the full and cheerful cooperation of Hospice-By-The-Sea, Boca Raton, FL. To the survivors, it was indeed life affirming to meet you for a short period of time. REFERENCES Bahnson, C. B., & Bahnson, W. E. (1964). Denial and repression of primitive impulses and of disturbing emotions in patients with malignant neoplasms. In D. M. Kesson & L. L. LeShan (Eds.), Psychosomatic aspects of neoplastic disease (pp. 42-62). London: Pitman. Becker, E. (1973). The denial of death. New York: Free Press, Division of Macmillan. Benson, H. (1984). Beyond the relaxation response. New York: Berkeley Books. Benson, H. (1989). Your maximum mind. New York: Avon Books. Booth, G. (1965). Irrational complications of the cancer problem. American Journal of Psychoanalysis, 25,41-60. Csi~szka,M. 0.J., & Hegedus, J. (1964). Psychological tests in leukemia patients. In D. M. Kessen & L. L. LeShan (Eds.), Psychosomatic aspects of neoplastic disease (pp. 18-29). Lonson: Pitman. Graves, I?. L., Mead, L. A., & Pearson, T. A. (1986). The Rorschach Interaction Scale as a potential predictor of cancer. Psychosomatic Medicine, 48, 549-563. Hay, L. &. (1984). You can heal ~. your life. Santa Monica, CA: Hav House, Inc. Klopfer, B. (1957). Psychological variables in huamn cancer. Journal of Projective Techniques, 21, 331-340. Kubler-Ross, H. (1969). On death and dying. New York: Macmillan. LeShan, L. (1966). An emotional life-history pattern associated with neoplastic disease. Annals of the New York Academy of Sciences, 125, 780-793. LeShan, L., & Reznikoff, M. (1960). A psychological factor apparently associated with neoplastic disease. Journal A b n d Social Psychology, 60, 439-440. LeShan, L., & Worthington, R. E. (1956). Some recurrent life-history patterns observed in patients with malignant disease. Journal Nervous Mental Disease, 124,460-465. Menninger, K. (1959). A psychiatrist's world. New York: Viking Press. Nemeth, G., & Mezei, A. (1964). Personality traits of cancer patients compared with benign tumor patients on the Rorschach Test. In D. M. Kesson & L. L. LeShan (Eds.), Psychosomaticaspects of
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neoplastic disease (pp. 12-17). London: Pitman. Rappaport, D., Gill, M., & Schafer, R. (1968). Diagnostic psychological testing. New York: International Universities Press. Rouse, A. L. (1978). The annotated Shakespeare, Volume 1: The comedies. New York: Potter, Inc. Siegel, B. (1986). Love, medicine &miracles. New York: Harper & Row. Stoddard, S. (1978). The hospice movement-A better way of caringfor the dying. Briarcliff Manor, NY: Stein and Day. Tarlou, M., & Smalheiser, I. (1951). Personality patterns in patients with malignant tumors of the breast and cervix: A n exploratory study. Psychosomatic Medicine, 13, 117-121. Thomas, C. B. (1988). Cancer and the youthful mind. Adwances, 5, 42-58.
Patricia Georgoff 1599 NW 9th Avenue Boca Raron, FL 33432 Received March 5, 1990 Revised April 12, 1990
