2011. Vol.2, No.9, 953-960
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.29144
Assessing Effects of National Trauma on Adaptive
Functioning of Mentally Healthy Adults:
An Exploratory Rorschach Study
Shira Tibon1,2, Lily Rothschild2,3, Liat Appel2, Ruth Zeligman1
1Department of Psychology, Academic College of Tel-Aviv Yaffo, Tel-Aviv, Israel;
2Department of Psychology, Bar Ilan University, Ramat Gan, Israel;
3Department of Psychology, University of Haifa, Haifa, Israel.
Received September 13th, 2011; revised October 15th, 2011; accepted November 18th, 2011.
The study evaluates deviations in Rorschach indices, usually related to effects of exposure to trauma, in three
samples of Israeli adult non-patients. Data collected from 41 Israeli undergraduates in 1996-1997, during a pe-
riod of increased rate of terror attacks in central cities of the country (Tibon, 2007), are compared to those of two
similar samples of 49 and 30 undergraduates collected in 2005-2007, before and after the Second Lebanon War
respectively. During this period, the rate and severity of terror attacks were lower. The results point out the
1996-1997 sample (High Terror Exposure) as showing prominent difficulties in the capacity to minimize felt
distress, in comparison to the other two samples, collected between January 2005 and January 2006 (Low Terror
Exposure) and between October 2006 and January 2007 (Lebanon War Exposure) respectively. Nonetheless, the
Lebanon War Exposure sample showed a tendency towards being alert and suspicious in interpersonal relation-
ships. The data are interpreted as demonstrating the utility of the Rorschach as an assessment tool that is more
responsive than previously thought to non-personality contextual factors such as national trauma.
Keywords: National Trauma, Terror, Mental Functioning, Distress Measures, Rorschach
Empirical research and clinical experience with people who
were exposed to national traumatic events such as war or terror
attacks have shown that both children and adults who were
present at the events would most frequently develop severe
stress reactions and psychopathological syndromes (Barenbaum,
Ruchkin, & Schwab-Stone, 2004; Fremont, 2004; Joshi &
O’Donnell, 2003; Sadeh, Hen-Gal, & Tikotzky, 2008; Shaw,
2003; Twemelow, 2004). Moreover, there is evidence that a
person needs not be present to have stress symptoms. Repli-
cated findings of studies conducted in the US following Sep-
tember 11, 2001, and in the UK following the terror attacks in
2005 describe substantial levels of stress in large numbers of
nonpatients who do not fit into the traditional definition of ex-
posure to trauma. These studies suggest that deliberate inflic-
tion of distress, as occurring in a collective traumatic event, is a
particularly potent psychological stressor. Furthermore, an on-
going threat of terrorism has been shown to affect both the
severity and duration of posttraumatic stress responses (Gidron,
2002; Rubin, Brewin, Greenberg, Simpson, & Wessely, 2005;
Schuster et al., 2001; Shalev, 2000; Silver, Holman, McIntosh,
Poulin, & Gil-Rivas, 2002; Torabi & Seo, 2004).
Apart from posttraumatic stress responses, effects of trau-
matic incidents have been shown in various psychopathological
syndromes commonly encountered in clinical settings, include-
ing dissociative reactions, depression, anxiety, substance abuse,
and even psychotic conditions (Galea et al., 2002; Gold, 2008;
Sautter et al., 1999; Shalev et al., 1998). Studies that examine
the inner experience of people who were under extreme threat-
ening situations such as persecution, arrest, deportation, and
imprisonment consistently show that these people are prone to
perceive reality in a constrained, dissociative, or paranoid-like
manner devoid of continuity and structure. These studies con-
clude that cognitive distortions, such as proneness to confuse
inner and outer worlds, would be one of the inevitable cones-
quences of persecution (Schreuder, 2001).
The systematic study of the impact of trauma on psychology-
cal functioning is relatively new and the standard assessment
protocol for evaluating traumatized people has typically been
restricted to a clinical interview and self-report psychometric
scales. However, there has been growing empirical evidence
that point out the Rorschach Inkblot Method (Rorschach, 1921)
as a valid tool that might be very useful for clarifying psycho-
logical experiences in both children and adult traumatized pa-
tients (Armstrong & Loewenstein, 1990; Brand, Armstrong, &
Loewenstein, 2006; Brand, Armstrong, Loewe nstein, & McNary ,
2009; Carlson & Armstrong, 1994; Clinton, & Jenkins-Monroe,
1994; Goldfinger, Amdur, & Liberzon, 1998; Hartman et al.,
1990; Holaday, 2000; Leavitt & Labott, 1998; Lerner, 1998;
Sloan, Arseault, Hilsenrot h, Harvill, & Handler, 1995; Steinberg,
1996; Swanson, Blount, & Bruno,1990; Viglione, 1990; Zelig-
man, Smith, & Tibon, 2011).
Unlike self-report measures, the nature of the Rorschach task
does not require awareness to internal experience of the trau-
matized person and is not vulnerable to over reporting. The
method can therefore be especially useful for unveiling dy-
namic processes (e.g., dissoci ative distancing from inner reality)
that often characterize people who were exposed to trauma.
Rorschach indices that have been usually explored in relation to
effects of trauma are based on the Comprehensive System (CS;
Exner, 1974, 2003), currently the most frequently used method
for applying the Rorschach in research and practice. These
indices include both markers that point out incapacity to mini-
mize subjective distress, and those demonstrating proneness to
S. TIBON ET AL.
psychopathological manifestations in the affective, interper-
sonal and cognitive realms.
Rorschach Markers of Trauma Effects
Rorschach Markers of Incapacity to Minimize
D and AdjD. The D and AdjD scores are CS indices that rep-
resent situationally-related and chronic failure to maintain a
sense of psychological equilibrium respectively (Exner, 2003;
Weiner, 2003; Weiner & Greene, 2008). These are the most
comprehensive CS constellation indices, composed of all the
major variables of available mental resources as compared to
the experienced demands of reality. Several studies showed that
a high percentage of traumatized people present D and AdjD
scores that are below the cutoff point of 0, presumed to indicate
incapacity to minimize situational and chronic distress respect-
tively. Lowered D and AdjD have consistently been found
among veterans from Vietnam or those who served at the Gulf
War, and were significantly different from those found in a
control group of soldiers who did not participate in war (Hart-
man et al., 1990; Levin, 1993; Sloan et al., 1995). These find-
ings demonstrate how coping is undetermined by the acute and
chronic management of intrusive thoughts and sense of help-
lessness that constitute substantial factors in traumatic experi-
ence (Wilson & Keane, 1997). Furthermore, Sloan, Arsenault,
Hilsenroth, Handler, and Harvill (1996) found that the signify-
cantly lowered D and AdjD scores of those exposed to war
stressors disappeared in a follow-up study conducted three
years after the initial collection of data.
Rorschach Markers of Pronessness to
S-CON. The S-CON is a CS constellation index that was
validated as a measure of self-destructiveness in adolescents
and adults. The index was found to be significant in samples of
adult patients indicating high level of distress (Exner, 2003;
Fowler, Piers, Hilsenroth, Holdwick, & Padawer, 2001). Al-
though usually not applicable for children, Clinton and Jen-
kins-Monroe (1994), found significant S-CON in children who
were sexually abused. Thus, within the clinical setting the
S-CON is suggested to be used in all cases of traumatized ado-
lescents and adults.
DEPI. The Depression Index (DEPI) is a CS measure of
general distress. Exner and Weiner (1995) pointed to a signify-
cant DEPI as being associated primarily with a persistent dis-
position towards recurring episodes of depression. Review of
Rorschach studies of patients in different age groups shows
mixed findings as to the predictive power of the DEPI in rela-
tion to DSM interview-based diagnoses (Jorgensen, Andersen,
& Dam, 2000). These studies show that a significant DEPI is
unrelated to observable behaviors that fit into DSM diagnoses
of mood disorders. Nonetheless, it can be used as a constella-
tion index for evaluating level of subjective distress. Elevated
DEPI was found among children and adolescents diagnosed
with Post Traumatic Stress Disorder (PTSD) as compared to
American reference data (Holaday, 2000), and in sexually
abused girls being compared to a matched clinical group with-
out history of abuse (Leifer, Shapiro, Martone, & Kassem,
1991), pointing out the depressive component of PTSD in chil-
dren and adolescents. Nonetheless, Rorschach depressive indi-
cators in protocols of traumatized adults seem to be less obvi-
ous (Frueh, Leverett, & Kinder, 1995).
HVI. The Hypevigilance Index (HVI) is a CS measure of
high alertness to potential sources of threat and is scored posi-
tive when the protocol does not include any Texture responses
(T) and four or more of seven other findings included in the
index are significant. A positive HVI is considered to be related
to projection of anger and hostility (Exner, 2003; Weiner, 2003;
Weiner & Greene, 2008). Exner (2003) found a positive HVI in
88% of patients diagnosed with paranoid schizophrenia and in
90% of a sample of patients with paranoid personality disorder.
Studies in traumatized people showed elevated HVI scores,
representing over-alertness and watchfulness associated with
traumatic experiences (Levin, 1993). HVI was used in the cur-
rent study as a dimensional variable (independent of T). As
such, it captures a cautious and detail oriented approach in
scanning the environment, underlying alertness, suspiciousness,
anger, and a need to protect and distance oneself in interper-
PTI. The Perceptual Thinking Index (PTI) is a CS constella-
tion index of impaired cognitive functioning. It was developed
as a revised version of the Schizophrenia Index (SCZI), both
evaluating ideational clarity and perceptual accuracy. These
indices were consistently found as valid measures in differenti-
ating schizophrenia-spectrum patients from non-patients and
patients diagnosed with other psychopathological conditions
including mood disorder with no psychotic features (Exner,
2003; Dao, & Prevatt, 2006). The PTI was empirically vali-
dated as a measure of thinking disturbances when used cate-
gorically with a cutoff score of 3 (Weiner & Greene, 2008).
Elevated SCZI or PTI were found in Rorschach protocols of
adults with traumatic background as compared to those without
history of trauma (Smith, Chang, Kochinski, Patz, & Nowinski,
2010), and in those of traumatized children and adolescents
(Holaday, 2000; Viglione, 1990) as compared to reference data.
These findings were interpreted as showing cognitive disrupt-
tion, when victims cannot comprehend or make sense of the
irrational, illogical, and confusing experiences.
TCI. The Trauma Content Index (TCI; Armstrong & Loewen-
stein, 1990) is a constellation index based on CS variables that
measures traumatic associations as being revealed in the Ror-
schach protocol. Elevated TCI scores are considered to be in-
dicative of intrusion of traumatic related material, bodily pre-
occupation, a sense of being impaired, and concerns about
physical integrity. Previous research found elevated TCI among
traumatized children, adolescents and adults with or without
diagnosis of dissociative disorders (Brand et al., 2006; Brand et
al., 2009; Kamphuis, Kugeares, & Finn, 2000; Scroppo, Drob,
Weinberger, & Eagle, 1998; Smith et al., 2010).
RFS. The Reality-Fantasy Scale (RFS; Tibon, Handelzalts, &
Weinberger, 2005) is a Rorschach index designed to operation-
alize Winnicott’s (1971) construct of potential or transitional
space between reality and fantasy, as explored by Ogden (1989)
in relation to different psychopathological states. Following
Smith (1990), the RFS applies Ogden’s model to Rorschach
work, defining a person’s proneness to show psychopathologi-
cal manifestations (e.g., psychotic thinking) in terms of differ-
ent forms of collapse of potential space. Previous research in
traumatized patients diagnosed with dissociative disorders
showed significantly lowered RFS scores, indicating psy-
chotic-like cognitive functioning as being revealed by collapse
of reality into fantasy (Zeligman, Smith, & Tibon 2010).
Normative D ata
The Rorschach CS has stimulated many empirical studies
addressed at measuring and improving the reliability, validity,
S. TIBON ET AL. 955
and normative data of the test (Exner & Erdberg, 2006; Vig-
lione & Meyer, 2008; Weiner, 1996, 2001; Weiner & Greene,
2008). Recently, Meyer, Erdberg, and Schaffer (2007) con-
ducted an international project that compared CS normative
data across 17 samples of adults and 31 samples of children and
adolescents from around the world. Overall, the data concern-
ing the adult samples in this project revealed a reasonable de-
gree of cross-national similarity, further confirming the Ror-
schach as a valid tool of personality assessment.
The Israeli sample of 41 students (Tibon, 2007), which was
included in the composite international sample, showed devia-
tions in CS markers of subjective distress. These deviations in
CS affective markers were not demonstrated in other realms of
mental functioning (e.g., cognitive, interpersonal) as compared
to the usually accepted CS cutoff scores of these measures.
Thus, although each of the participants in this sample fitted into
the definition of non-patients, the whole group showed substan-
tial signs of distress.
The deviations found in the Israeli sample were interpreted
as related to the traumatic events within the political context of
the Middle East. The Rorschach protocols were collected in two
periods during 1996-1997 (January 1996-February 1996; July
1997-September 1997) which followed the assassination of
Prime Minister Rabin in November 1995, and the collapse of
the Middle East peace process, resulting in prominent escala-
tion in the relationships between the State of Israel and the
Palestinian Authority. Data published by the Israeli Ministry of
Foreign Affairs (2008) show that during these months there
were 10 terror attacks with 52 people killed and hundreds in-
jured. These terror attacks were conducted mostly in major
cities in the center of the country and exposed the entire Israeli
population to constant unpredictable threat of terror.
When the published data are organized into quarterly sum-
maries for the years 1993 through 2008 it is clear that the 1996-
1997 sample was obtained during extreme stress. In fact, these
dates correspond to the two quarters that documented the
greatest number of attacks and the greatest number of people
who were killed or injured from 1994 to 2000. The national
trauma of Rabin’s assassination and the collapse of the peace
process was thus exacerbated by the terror attacks extremely
threatening the daily experience of the Israeli citizens. As re-
vealed by the data another spike in terror threat was in 2002.
However, since 2002 there was a gradual decrease in the num-
ber of people killed in terror attacks to15 in 2006 and 3 in 2007.
Furthermore, the Second Lebanon War in 2006 was felt as a
real threat mainly in northern Israel, while people in the center
of the country, who were not exposed to the direct threat of war,
did not change their daily routine. The focus of the present
study was to compare markers of distress in a sample of Israeli
non-patients collected during a period of increased rate of terror
attacks (High Terror Exposure) to samples collected during
periods of reduced rate of terror attacks before and after the
Second Lebanon War.
In line with the published data on terror attacks and empirical
Rorschach data that point out elevation in Rorschach distress
markers in traumatized patients, it was hypothesized that the
deviations in the CS markers of subjective distress, shown in
the Israeli sample, actually reflected the fact that the sample
was collected within the context of national trauma (Tibon,
2007; Meyer et al., 2007). The present study was aimed at fur-
ther exploring this hypothesis. Accordingly, the main hypothe-
sis was that similar samples of non-patients that were collected
in less traumatic periods, would differ from the High Terror
Exposure sample, collected in 1996-1997, as to Rorschach
markers of incapacity to minimize felt distress (D, AdjD). The
study further explored the differences between the samples as
to Rorschach markers of proneness to psychopathological
manifestations in the affective (S-CON, DEPI), interpersonal
(HVI), and cognitive (TCI, PTI, RFS-P) functioning.
Participants were drawn from three samples of Israeli under-
graduates studying in academic institutes in major cities at the
center of the country. Data collection for the first sample (High
Terror Exposure) took place in two distinct periods: January
1996-February 1996 (N = 24); and July 1997-September 1997
(N = 26). From the 50 participants originally included in this
sample, nine individuals were dropped by applying exclusion
criteria of severe psychopathological symptoms, past psy-
chiatric hospitalization or receiving mental health services
within the past two years including the time of testing (Tibon,
2007). The sample of 41 participants, within the age range of
19 - 35 years, was composed of 20 males and 21 females, all of
them Jewish who were born in Israel.
Data collection for the second sample (Low Terror Exposure)
took place in January 2005-January 2006. In this sample, 36
protocols were administered between January and July 2005,
and 23 between October 2005 and January 2006. From the 59
participants originally included in this sample, ten were dropped
by applying the same exclusion criteria as in the 1996-1997
sample. The sample of 49 participants, within the same age
range as the High Terror Exposure sample, was composed of 19
males and 30 females, all of them Jewish who were born in
Israel. Comparing the two samples as to the percentage of
males and fema les did not show significant difference (χ2 = .91,
p = ns, r = .10).
The third sample (Lebanon War Exposure) originally in-
cluded 36 participants who were administered the Rorschach in
October 2006-January 2007, following the war. From the 36
participants, two were excluded by applying the same psychiat-
ric criteria applied in the previous samples, two were excluded
because they served in the Israeli army during the war, and two
by applying an exclusion criterion of place of permanent resi-
dence in the northern part of country, which was exposed to the
missiles and rockets lunched by the Hizbollah during the war.
The sample of 30 participants, within the same age range of 19 -
35 years, was composed of 5 males and 25 females, al l of them
Jewish who were born in Israel. Because comparison with the
High Terror Exposure sample showed significant relation- ship
between gender and sample affiliation (χ2 = 7.83, p < .05, r
= .33), preliminary analyses were conducted to control for the
gender distribution in the three samples, using ANOVA for
gender × sample for all the dependent variables. These analyses
did not show any main effect for gender. Participants in all
three samples were in Israel for most of the time during which
the terrorist attacks and war took place. However, none of the
respondents was personally involved in any of the war or terror
occurrences that took place in the country at the time of the
Following Rorschach studies in traumatized people, we have
selected eight indices for comparing the samples. The decision
of selecting constellation indices rather than individual vari-
S. TIBON ET AL.
ables was based on the assumption that essentially scales with a
greater number of items from a conceptually related category
would be more reliable and more stable than a single item from
the same pool (Nunnally & Bernstein, 1994). Six of the con-
stellations, D and AdjD scores, S-CON, DEPI, HVI, and PTI,
are included in the CS (Exner, 2003). Although the two addi-
tional indices, the Traumatic Content Index (TCI; Armstrong &
Lowenstein, 1990) and the Reality-Fantasy Scale (RFS; Tibon,
Handelzalts, & Weinberger, 2005), are not included in the CS,
they are based on the system’s original variables and can there-
fore be applied by its users.
As noted, the D and AdjD are assumed to measure incapacity
to minimize situational and chronic distress respectively when
their value is below the cutoff point of 0. The S-CON is a statis-
tically generated constellation index designed to predict self-
destructive potential. The index consists of 12 variables and
ratios that together yield a single score in which 8 is used as a
cutoff point. The DEPI is a measure of general distress that
consists of 15 variables organized in seven conditions and is
considered to be clinically significant when it exceeds the cut-
off point of 5, indicating proneness to show mood disorders or
a chronic disposition to recurrent depressive episodes. The HVI
is a measure of high alertness to potential sources of threat. HVI
was used in the current study as a dimensional variable, captur-
ing a hyper vigilant approach in scanning the environment, and
a need to protect and distance oneself in interpersonal relation-
ships. The PTI is a global index of impaired cognitive func-
tioning, composed of eight Rorschach variables that are in-
cluded in five-criteria constellations based on combination of
The TCI is a measure of traumatic associations composed of
five CS variables of Anatomy (An), Blood (Bl), Sex (Sx), Ag-
gressive (AG), and Morbid (MOR) responses, divided by the
total number of responses in the protocol. Since there are no
published cutoff points for the TCI, the study used the average
TCI scores found in traumatized inpatients (M = .50; SD = .40)
and outpatients (M = .21; SD = .14) as a reference point against
which to assess whether the TCI should be considered clinically
significant (Brand et al., 2006; Kamphuis et al., 2000; Smith et
The RFS is an evidence-based psychoanalytically oriented
index that is composed of CS variables and an additional spe-
cial score of Reality Collapse (RC). The 11-point scale ranges
from –5 (reality collapse into fantasy) to +5 (fantasy collapse
into reality). A score of –5 represents the most extreme reliance
on fantasy with minimum contact with external reality and a
score of +5 represents a strong reliance on the real features of
the blot with minimal input of fantasy. A mean RFS score of a
given protocol (RFS-P) is expected to be within the range of
–.51 to +.65 in m entally health y adults.
Participants in all three samples were recruited through word
of mouth and were neither paid nor given extra credit in their
psychology classes for participation. However, they were of-
fered a meeting with a senior psychologist in which they would
be provided with feedback on testing results in exchange for
their participation. Half of the participants in each of the sam-
ples applied for a feedback meeting that was conducted by the
examiner a few weeks following the administration of the test.
The administration and scoring procedures of the three sam-
ples followed the CS guidelines available at the time of the
study. Accordingly, the administration and scoring procedures
for the High Terror Exposure sample followed the guidelines of
Exner (1995) and those for the two other samples followed the
guidelines as presented by Exner (2001). There are minor dif-
ferences between the two versions consisting mainly of addi-
tional prompts given to the subject in the 2001 edition. In line
with previous research (e.g. Meyer et al., 2007) the different
administration procedures did not produce significant differ-
ences as to the number of responses. Since seating next to the
testee, as recommended by Exner (1995, 2001), might raise
hurdles in some groups in Israel because of religious constrict-
tions regarding physical closeness, seating procedures were
diagonally opposite. These procedures are in line with the
guidelines provided by Allen and Dana (2004) stating that cul-
tural adaptations may dictate departures from CS procedures in
research studies. In all three studies test responses were pro-
vided by the participants in Hebrew. In the High Terror Expo-
sure sample the examiners coded their own protocols and then
an advanced student or an expert recoded each of the protocols.
Following this initial phase, a sample of the recoded responses
were examined by six groups of raters, each of them included
the two raters that originally scored the protocol. Interrater
reliability was computed for a sample of 35 protocols randomly
selected from the original sample. In the Low Terror Exposure
and Lebanon War Exposure samples, we used a similar scoring
procedure, in which all responses were first coded by the ex-
aminer and then by another coder, an advanced student super-
vised by a senior clinician. Following this initial phase, the
scoring of all the responses was reexamined by a senior clini-
cian. Interrater reliability for all the protocols in both samples
Results of interrater reliability, computed for the different CS
segments (Location & Space; Developmental Quality; Deter-
minants; Form Quality; Pairs; Contents; Popular Responses;
Special Scores), showed agreement percentages ranging fro m .90
to 1.00 in the High Terror Exposure Sample, from .80 to .96 in
the Low Terror Exposure Sample, and from .96 to 1.00 for the
Lebanon War Exposure Sample. The results of interrater reli-
ability in all the three samples meet the recommended criteria
for agreement statistics in Rorschach studies.
Results of oneway ANOVA which compared the three sam-
ples as to the number of responses (R) did not show significant
differences (High Terror Exposure: M = 22.12, SD = 8.02; Low
Terror Exposure: M = 23.08, SD = 8.53; Lebanon War Expo-
sure: M = 23.30, SD = 9.24). Furthermore, the mean number of
responses did not deviate from that of the composed interna-
tional sample (M = 22.31, SD = 7.90).
Table 1 presents the means and standard deviations for Ror-
schach markers of incapacity to minimize distress in the three
samples. Results of oneway ANOVA show that the D and AdjD
scores, indicating incapacity to minimize situational and chronic
distress respectively, significantly differed across the three
samples, with F(2, 117) = 9.61, p < .001, d = .38 for D, and F(2,
117) = 9.82, p < .001, d = .38 for AdjD respectively. Scheffe
post-hoc comparisons indicated that the High Terror Exposure
respondents showed significantly lowered D and AdjD as com-
pared to those of Low Terror Exposure sample. Furthermore,
these results were also shown when post-hoc Bonferroni cor-
rection (p < .05/8 = .006) was applied.
Table 2 presents the means and standard deviations for Ror-
schach markers of proneness to psychopathological manifesta-
tions in the affective (S-CON, DEPI), interpersonal (HVI), and
S. TIBON ET AL. 957
Means and standard deviations for Rorschach markers of Incapacity to minimize distress (D and AdjD) in the three samples.
High Terror (n = 41) Low Terror (n = 49) Lebanon Wa r ( n = 30)
CS Marker M SD M SD M SD
High Terro r -
Low Terror High Terro r -
Lebanon War Low Terror-
D Score –1.95 2.16 –0.10 1.64 –0.83 2.29 p < .001 ns ns
AdjD Score –1.00 1.70 0.47 1.42 –0.13 1.61 p < .001 ns ns
Note. High Terror = High Terro r Exposure Sample (1 996-1997); Low Terror = Low Terror Exposure Sample (January 2005-Jan uary 2006); Lebanon War = Lebanon War
Exposure Sample (Octob er 2006-Janua ry 2007); D Score = CS variable assumed to measure situational related incapacity to minimize felt distress; AdjD Score = CS vari-
able assumed to measure c hronic incapacity to minimize felt di stress. Post hoc analyses were computed by using Scheffe tes t.
Means and standard deviations for Rorschach markers of psychopathological manifestations (S-CON, DEPI, HVI, PTI, TCI and RFS-P) in the three
High Terror (n = 41) Low Terror (n = 49) Lebanon Wa r ( n = 30)
CS Marker M SD M SD M SD
High Terro r -
Low Terror High Terro r -
Lebanon War Low Terror-
S-CON 5.46 1.64 4.73 1.69 5.37 1.22 ns ns ns
DEPI 4.27 1.27 3.76 1.23 3.97 1.33 ns ns ns
HVI 2.71 2.01 3.82 1.79 3.90 2.00 p <.05 p <.05 ns
PTI 0.54 0.84 0.49 1.02 0.30 0.53 ns ns ns
TCI 0.19 0.15 0.16 0.12 0.16 0.12 ns ns ns
RFS-P –0.10 0.64 0.05 0.64 0.11 0.47 ns ns ns
Note: High Terror = High Terror Exposure Sample (1996-1997); Low Terror = Low Terror Exposure Sample (January 2005-January 2006); Lebanon War = Lebanon War
Exposure Sample (Octob er 2006 -January 2007); S-CON = Suicide Constellation Index; DEPI = Depression Index; HVI = Hypevigilance Index; PTI = Perceptual Thinking
Index; TCI = Trauma Conte nt Index; RFS-P = Reality-Fantasy Scale mean score of a given protocol. Between sample differences were computed by Scheffe test.
cognitive (PTI, TCI, RFS-P) functioning in the three samples.
Results of oneway ANOVA showed that the HVI, indicating
over alertness in interpersonal relationships, significantly dif-
fered among the three samples, with F(2, 117) = 4.77, p < .01, d
= .27. Scheffe post-hoc comparisons indicated that the High
Terror Exposure respondents showed significantly lower level
of alertness as compared to those of both the Low Terror Ex-
posure and the Lebanon War Exposure samples. However,
when a Bonferroni adjusted alpha level was used, none of the p
values met the standard (p < .05/8 = .006). Moreover, none of
the samples showed HVI that was higher than the normative
upper limit of the international reference data (4.43). Analyses
conducted as to other Rorschach markers of proneness to psy-
chopathological manifestations (S-CON; DEPI; PTI; TCI; RFS)
did not point to any significant difference across the samples.
The study evaluates deviations in Rorschach indices usually
related to effects of exposure to trauma in three Israeli samples
of non-patients. Data collected from 41 Israeli undergraduates
in 1996-1997 during a period of increased occurrences of terror
attacks in central cities of the country (High Terror Exposure
Sample) were compared to those of two similar samples of 49
and 30 undergraduates, collected in 2005-2007, before and after
the Second Lebanon War respectively. During this period, the
rate and severity of terror attacks were lower. The main hy-
pothesis was that the two samples collected during periods of
decreased terror threat in 2005-2007 (Low Terror Exposure;
Lebanon War Exposure) would differ from that collected in
1996-1997 (High Terror Exposure) as to Rorschach markers of
incapacity to minimize felt distress (D, AdjD). The study fur-
ther explored the differences between the samples as to Ror-
schach markers of proneness to psychopathological manifesta-
tions shown in traumatized people in the affective (S-CON,
DEPI), interpersonal (HVI), and cognitive (TCI, PTI, RFS-P)
The results confirmed the main hypothesis pointing out the
High Terror Exposure sample as exhibiting substantial incapac-
ity to minimize felt distress (lowered D and AdjD) as compared
to the Low Terror Exposure and the Lebanon War Exposure
samples. Nonetheless, respondents in these two samples sho wed
a tendency towards higher level of alertness (elevated HVI)
than those in the High Terror Exposure sample. Comparisons
between the samples as to Rorschach markers of proneness to
psychopathological manifestations of self destructtiveness (S-
CON), general distress (DEPI), and impaired cognitive func-
tioning (PTI, RFS) did not point to any significant difference
and were within the international normative range. Furthermore,
the samples did not differ on the Rorschach marker of traumatic
associations (TCI) that was in all three groups lower than the
average score found in traumatized inpatient and outpatient
The results as to the substantial subjective distress shown in
the High Terror Exposure sample seem to validate recent find-
ings that are at odds with traditional mental health models of
collective trauma, in which reactions to traumatic events are
strongly coupled with proximity to their occurrences in time
and place (Schuster et al., 2001). These results further draw
attention to the differences between the potential effects of war
and those of terrorist actions on public mental health. Although
the Lebanon War Exposure sample was collected during a pe-
riod of heightened threat to national security in which the Is-
raeli-Palestinian conflict was escalating (Kelman, 2007), this
sample did not show failure to minimize situational related
distress. The difference between the effects of the two types of
violent threat, i.e. terror attacks and war, on personal safety and
the resulting subjective distress might be related to the extent to
S. TIBON ET AL.
which civilians were able to be actively engaged in their own
defense. Research indicates that unlike the perils of war, threat
of terrorism offers no trusted safety signal such as siren nor safe
places (Shalev, 2006). On the other hand, factors decreasing
feelings of helplessness during war (e.g., anti-aircraft batteries)
might give people a sense of being in control. Furthermore,
mass terrorist attacks are highly visible disasters that are de-
signed to affect not only those in direct vicinity of the attacks
but the population at large. Consequently, the boundaries be-
tween direct and indirect exposure are blurred, resulting in sub-
stantial consequences among those who are directly as well as
indirectly affected by the attacks (Galea et al., 2002; Galea &
Resnick, 2005). Another factor that magnifies the traumatic
impact of terrorism is its impersonal and apparently random
nature. Terror attacks innocent civilians rather than professional
soldiers, and is promoted by violence detached from symbolic
meaning. A culture is often unable to cope and to come up with
useful solutions to something that is perceived as impersonal
and lacking symbolic meaning (Fonagy, 2003; Twemlow &
With respect to the inferences drawn from the results as to
public mental health, the nature of the conclusions touches on
the differences between absolute and relative perspectives on
normality. Ordinarily, normative Rorschach non-patient data
provide descriptive information about groups and offer refer-
ence points for comparing individual scores. Most important is
the basis they provide for developing some general interpretive
guidelines, using the deviation principle for evaluating whether
or not specific findings fit into the normative range (Exner &
Erdberg, 2005). The present results demonstrate that CS coun-
try-specific normative data, collected at different points of time,
might show deviations from the international norms because of
changing external conditions rather than because of personality
predispositions. Indeed, when a group of people is exposed to
collective traumatic events some may develop a stress disorder
while others may not. However, assessing what circumstances
may have led to a stress disorder may have implications for
treatment and prognosis. Showing acute, reactive disturbances
following national traumatic events requires different therapeu-
tic intervention than a chronic, persistent disorder. Nonetheless,
in Israel and other immigrant countries, in which the popula-
tions receive mental health services and assessment outside of
their country of origin, where certain collective traumatic
events would not be accounted for in the country’s norms, cli-
nicians should be aware of the patients’ historical context.
Nonetheless, the individuals who showed substantially ele-
vated distress in the High Terror Exposure sample were
unlikely to function as effectively as they would be able to with
less experienced stress. The mean D Score shown in this sam-
ple was deviant relative to what is expected even though it ap-
pears to be deviant because the Rorschach seems to be sensitive
to contextual factors. Thus, although a specific Rorschach
marker is found to be normative and adaptive in a certain coun-
try, it does not mean that one can ignore its implications for
clinical practice and/or mental health policy. The Rorschach,
when used for diagnostic purposes, shows a person’s status
with respect to deviations from normative standards. If a large
majority in a certain country shows signs of being distressed,
their stress is not deviant from a cultural perspective, but it is
certainly deviant from a clinical perspective. Being highly
stressed is not a normal state. It causes people psychological
difficulties, it detracts them from effective functioning, and it
should be regarded as a psychopathological condition that calls
for treatment, even if it is common. Indeed, there has recently
been a growing interest in studying the manner in which pro-
fessional communities of mental health clinicians, policy mak-
ers, and researchers should respond to the emerging needs fol-
lowing mass trauma (Miller, 2002).
In line with the implications of the deviated Rorschach mark-
ers of incapacity to minimize distress (D and AdjD) we can also
suggest possible implications of the tendency being revealed in
the Low Terror Exposure and Lebanon War Exposure samples
to exhibit paranoid-like positions (elevated HVI) in interper-
sonal relationships. Accordingly, when the real threat of terror
decreased, people might have been, as in paranoia, handling
their internal fear by projecting it outwards. If so, this could
make it easier for them to feel hurt and misunderstood, when
this was not intended, feelings that could have clinical and dip-
The results seem to have some important implications con-
cerning the validity of the Rorschach and its sensitivity to pick
up generalized environmental stressors affecting large groups
of people. Studies with other assessment tools have shown that
when evaluating the effects of war or terror threat on public
mental health, the timing of assessment is crucial and should
always be taken into consideration (Silver et al., 2002). In line
with these studies our data suggest that the Rorschach is more
responsive than previously thought to non-personality contex-
tual factors. This conclusion might be viewed as challenging
the belief that non-personality variance plays little part or can
be fully controlled in interpreting Rorschach data. To a degree,
this belief prompted the present study in which the validation
procedure is based on independent variables that are lodged in
documented facts of terror attacks rather than in inferences.
The present data further validate the D Score as the most
comprehensive CS marker of experienced distress (Weiner,
1996; Weiner & Greene, 2008), and are in line with previous
studies conducted among war veterans with PTSD. The inca-
pacity to minimize situation-related distress during a period of
increased terror threat, as shown in the present study, might
therefore be interpreted as demonstrating the validity of the D
Score in picking up more stress at a time when there is good
reason to expect there to be more stress. With respect to the
lowered AdjD in the High Terror Exposure sample, which al-
though not exceeding the normative range differed significantly
from to the other samples, a question might be raised as to
whether this index is more sensitive than presumed to contex-
One of the limitations of the present study relates to the in-
dependent variable (exposure to terror threat), not taking into
consideration other factors that could influence the reported
results. Thus, for example, direct exposure to trauma such as
childhood abuse might have been responsible for the elevated
subjective distress or for the over alertness, rather than the less
direct exposure to threat of terrorist attacks and living in a
country during a period of war. Nonetheless, there is no reason
to assume that these three non-patient samples differed in rela-
tion to direct exposure to trauma in the past and the reported
period of High Terror Exposure was indeed characterized by
severe terror attacks that extremely threatened the daily life of
the Israeli citizens (Israeli Ministry of Foreign Affairs, 2008).
This limitation is however related to the basic characteristics of
any convenient sample and the recruitment procedures, par-
ticularly in Rorschach studies that have implications for the
generalizability of the results.
Another limitation that bears upon generalizability of the re-
sults is the small size of the sample that might raise a question
as to the extent of which the findings can be generalized. How-
S. TIBON ET AL. 959
ever, a relatively small sample size seems to be the norm in
Rorschach research because the administering and scoring pro-
cedure can be extremely time consuming and requires special
skills of the examiner. The homogeneity of the sample as to age
and level of education might also limit the application of the
results to other groups of adult non-patients. Further research is
needed to substantiate and validate our findings suggesting
different dynamic processes in coping with effects of national
We would like to thank Roni Tibon and Roni Suchowski for
programming the Rorschach Reality-Fantasy Scale (RFS) that
served for processing the data in this study. We also thank Ba-
rak Rand and Ayala Ellis who coordinated and supervised the
work on Rorschach data.
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