Participants
Participants in Stage 4 included 25 play therapists and play therapist-supervisors who each had more than 10 years of clinical experience. To verify the criterion-related validity of this scale, 25 participants were each asked to select two children aged 7 to 9 years from their clinical cases, one should be judged to have strong ego strength, the other should be judged to have weak ego strength. These two children were either currently receiving counseling or had received counseling within the past 6 months. Of the 89 sessions with children that were analyzed, there were 24 game play therapy sessions of children evaluated to have strong ego strength and 63 game play therapy sessions of children evaluated to have weak ego strength.
In addition, 55 children aged between 7 and 9 years who received play therapy at two child counseling centers in Seoul area had their game playing attitudes analyzed to verify the scale’s concurrent validity. Children aged 7, 8, and 9 years were 30.9% (N = 17), 41.8% (N = 23), and 27.3% (N = 15), respectively, while 72.7% (N = 40) were boys and 27.3% (N = 15) were girls.
Measurements
The Rorschach test [
88] measures the respondent’s cognitive style and psychodynamic construct based on the respondent’s response to ten inkblot cards. The evaluator directly assesses the child’s personality characteristics on the types of variables of the comprehensive system of this test, including resistance to stress, affect control, interpersonal skills, egocentricity, cognitive organization skills, copying deficit skill, presence of depression and perception disorder, excessive vigilance, and degree of compulsion [
89]. The Rorschach test provides an optimal opportunity to measure ego impairment because it induces the respondent to use cognitive, affective, and human or representational resources to organize an ambiguous and complex task [
90]. Thus, a number of researchers have verified the diagnostic efficacy and validity of the special indexes of the Rorschach CS [
91,
92], and contributed to measuring ego strength by using certain variables of the Rorschach test or developing Rorschach Prognostic Scale (RPRS) and Ego Impairment Index (EII) [
93,
94].
In our study, the reasons for using the Rorschach test as a criterion-related validity test are as follows. First, it was difficult to ensure the reliability of self-report test due to the age of child participants, thus a type of test conducted by the experimenter was needed. Unlike other self-report tests, the Rorschach test’s responses cannot be consciously manipulated by the test subjects. Second, the validity and reliability of the Rorschach test were scientifically assured with the introduction of Exner’s Comprehensive System (CS) [
91,
92]. In addition, the Structural Summary in CS allows the evaluation of the overall domain of individual thinking, emotions, interpersonal relationships, frustration tolerance and coping resources, and cognitive processing and intervention [
88], and it was most consistent with the construct of ego-strength that we attempted to evaluate. Past studies have created scales with some Rorschach variables [
95], in the current study, however, we excluded random selection of variables and used all seven core sections and six special indexes to evaluate a broader and more comprehensive domain related to ego-strength.
Procedure and data analysis
The CESS was designed in a way such that higher scores are associated with weaker ego strength in order to improve clinical efficacy in detecting problematic behaviors. Thus, two positive items from F2: Cognitive Strategy, F4: Interpersonal Functioning, and F5: Frustration Tolerance were reverse scored. First, the participating children undergoing therapy were divided into strong ego strength and weak ego strength groups, and a t-test was performed to analyze differences in scores of the five factors of the CESS between the two groups in order to determine criterion-related validity of the CESS.
Next, concurrent validity of the CESS was determined by analyzing the correlations between the scores of the 5 factors of the CESS and scores of all variables of six special indexes of Rorschach CS (Perceptual Thinking Index; PTI, Depression Index; DEPI, Copying Deficit Index; CDI, Suicide Constellation; S-CON, Hypervigilance Index; HVI, Obsessive Style Index; OBS) and the seven sections of structural summary (Core Section, Ideation Section, Affect Section, Mediation Section, Processing Section, Interpersonal Section, and Self-Perception Section). Two clinical psychologists interpreted the Rorschach test of 55 children, and the inter-rater reliability was good, with 0.89.
Results
Group differences. As shown in Table
4, a significant difference between the two groups emerged through the analysis of the game play therapy sessions of children who were reported to have strong and weak ego strength to verify the criterion-related validity. As the CESS is designed in a way that higher scores represent weaker ego strength, a higher score on the CESS indicates weak ego strength. The children reported to have weak ego strength had significantly higher mean scores on the overall scale and in the sub-variables of Coping Strategy, Cognitive Strategy, Ego Restriction, Interpersonal Functioning, and Frustration Tolerance. This suggests that this scale can distinguish between groups with strong and with weak ego strength.
Table 4
Verification of differences in scores between strong and weak ego strength groups (N = 89)
Coping strategy | 8.50 (3.62) | 16.58 (16.59) | − 6.41*** |
Cognitive strategy | 13.29 (3.86) | 18.62 (5.32) | − 4.47*** |
Ego restriction | 5.63 (2.60) | 11.70 (5.15) | − 5.51*** |
Interpersonal functioning | 8.00 (2.48) | 10.67 (2.49) | − 4.47*** |
Frustration tolerance | 8.04 (3.47) | 12.24 (3.14) | − 7.64*** |
Total Score | 43.46 (12.05) | 71.81 (14.90) | − 9.16*** |
Concurrent validity: correlations between CESS and Rorschach. In order to determine concurrent validity of the CESS, we analyzed the correlations between the scores of the five factors of the CESS and scores of all variables in the seven sections of the comprehensive system of the Rorschach test (Core Section, Ideation Section, Affect Section, Mediation Section, Processing Section, Interpersonal Section, and Self Perception Section) and six special indexes (Perceptual Thinking Index, PTI; Depression Index, DEPI; Copying Deficit Index, CDI; Suicide Constellation, S-CON; Hypervigilance Index, HVI, and Obsessive Style Index, OBS).
The results are shown in Table
5. Mild to moderate correlations were obtained between the CESS factors and Rorschach variables. With regard to Rorschach index, the correlations between F5 (Frustration Tolerance) and F2 (Cognitive Strategy) factors and the CDI were significantly positive,
r = 0.33 (
p = 0.013) and
r = 0.29 (
p = 0.033), respectively. Rorschach CDI was calculated based on the individual’s stress tolerance and cognitive resources, mental activity (EA < 6, Passive > Active + 1) and coping resources (AdjustD < 0), interpersonal skills (COP < 2, AG < 2), emotional expression (WSumC < 2.5, Afr < 0.46), and intimacy formation (SumT > 1, Isolate/R > 0.24). An increase in CDI suggests that individuals have low stress tolerance, low coping skills, and passive cognitive performance in social settings [
96]. Therefore, the positive correlation between F5 (Frustration Tolerance) and F2 (Cognitive Strategy) of the CESS and CDI indicates the validity of the CESS.
Table 5
Pearson correlations between CESS and Rorschach indices (N = 55)
CDI | .02 | .29* | .15 | .24 | .33* | 3.40 | 1.04 |
DEP1 | .05 | .08 | .27* | .21 | .14 | 3.24 | 1.15 |
PTI | .00 | − .19 | − .07 | − .06 | − .07 | 2.11 | 1.50 |
S-CON | .23 | .03 | .11 | .16 | .12 | 5.35 | 1.58 |
HVI | .17 | .20 | − .01 | − .07 | − .13 | 2.27 | 1.37 |
OBS | − .02 | .08 | − .14 | − .11 | − .08 | 0.73 | 0.71 |
Number of response | .05 | − .03 | − .30* | − 14 | − .09 | 19.24 | 8.60 |
Lambda | − .03 | − .20 | .14 | − .04 | .29* | 2.30 | 3.00 |
Pure C | .21 | .23 | .35** | .26 | .09 | .45 | .88 |
COP | − .15 | − .17 | − .18 | − .27* | − .27* | .33 | .70 |
Afr | .48*** | .03 | .04 | .09 | − .03 | .44 | .15 |
S | .41** | − .07 | − .07 | − .05 | − .05 | 1.27 | 1.68 |
A | .04 | − .18 | − .34* | − .10 | − .24 | 4.05 | 8.10 |
Dd | − .12 | − .12 | − .30* | − .28* | − .06 | 2.64 | 3.66 |
DQ + | − .10 | − .27* | − .23 | − .20 | − .14 | 3.45 | 3.34 |
S-% | .31* | .06 | .12 | .08 | .07 | 0.06 | 0.11 |
In addition, F3 (Ego Restriction) factor was significantly positively correlated to Depression index (DEPI),
r = . 27 (
p = 0.049). In four of the seven criteria of the Rorschach DEPI, specific criteria overlap with withdrawal from social domains along with energy decline, such as domain of egocentricity (3r + (2)/R > 0.44 and Fr + rF = 0), restriction of emotional expression (Afr < 0.46, Blends < 4), increase of isolation index ([Bt + 2 × Cl + Ge + Ls + 2 × Na]/R > 0.24), or restriction of cooperative interaction (COP < 2) [
88]. In other words, an increase in the DEPI reflects social contraction and withdrawal along with energy decline. Thus, the positive correlation between DEPI and F3 (Ego Restriction) of the CESS seems to ensure the validity of social avoidance and withdrawal tendency for the CESS F3. These results indicate that weaker ego strength is associated with lower social skills and increased avoidance.
The F1 (Coping Strategy) factor and the other CS variables, Afr (degree of interest in affective stimuli), S (white space response), and S-% (proportion of distorted form that involve use of white space), were also significantly positively correlated, r = 0.48 (p = 0.000), r = 0.41 (p = 0.002), and r = 0.31 (p = 0.023), respectively. These results indicate that children who display greater number of inappropriate coping strategies are more likely to show emotional response, passively express frustration, and lose judgement ability so that they have a distorted perception of a situation when frustrated.
F2 (Cognitive Strategy) factor was significantly negatively correlated with DQ + (Developmental quality; assessment of a person’s ability to analyze and synthesize information) r = -−0.27 (p = 0.048), showing more use of inappropriate cognitive strategies is indicative of lower organizing skills using cognitive resources.
F3 (Ego Restriction) factor was significantly correlated with number of response r = − .30 (p = 0.029), Pure C (number of pure color response) r = 0.35 (p = 0.009), a (number of flexibility responses) r = − .34, (p = 0.012), and Dd (unusual detail response) r = − .30, (p = 0.026). These results show children with high degree of ego restriction are unable to actively express the characteristics of their experience and are likely to have impulsive emotional response.
F4 (Interpersonal functioning) factor was significantly correlated with COP (cooperative movement)
r = − .27, (
p ≤ 0.043) and Dd (unusual detail response)
r = − .28 (
p = .042). This demonstrates that children who show behaviors that are more inappropriate in interpersonal functioning are less able to positively interpret interactions with others and have poor sensitivity, such as difficulty detecting small details. F5 (Frustration Tolerance) factor was significantly correlated with Lambda (crude index of responsiveness)
r = .27 (
p = .036) and COP (cooperative movement)
r = − .27 (
p = .044). This shows that children with lower frustration tolerance are less able to utilize various resources in the environment and experience positive interaction with others [
88].