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The Arts in Psychotherapy 34 (2007) 388–397 A comparison of cardiac and cancer inpatients on the MARI ® Card Test Kenneth Bruscia, Ph.D., MT-BC, FAMI , Carol Shultis, M.Ed., MT-BC, FAMI, LPC, Karen Dennery, MMT, MT-BC Temple University, 2001 North 13 th Street, Philadelphia, PA 19122, United States Abstract The MARI ® Card Test is a projective preference test developed by art therapist, Joan Kellogg, based on her extensive study of mandalas (circle drawings). As used in this study, the test involved selecting the most and least preferred mandalas from a set of archetypal designs, called the Great Round. The test was administered to 195 patients, 132 hospitalized for cardiac disease and 63 hospitalized for cancer. The purpose was to identify similarities and differences in the design and color choices of the two groups, and to interpret the choices. Based on mandala theory, the projective evidence indicated that both cardiac and cancer patients are trying to preserve what they have achieved in life, and both are fearful of falling apart. Along with a strong will to survive, there is a preoccupation with death, feelings of depression, dependence, and anger, and a general avoidance of deep existential or spiritual issues. The will to survive is accompanied by a strong tendency to find creative ways of dealing with the illness and its treatment. With this comes a need to understand things—their lives, their own identities, their illnesses, and their best treatment options. Differences between the groups were found in specific fears (death, falling apart, spread of cancer); however, these differences may be due to age and length of illness as well as diagnosis. The caveats of projective tests are examined, and implications are drawn for arts therapists. © 2007 Elsevier Inc. All rights reserved. Keywords: Mandala; Preferences; Cancer; Cardiac; Projective; MARI Introduction The MARI ® Card Test is a projective preference test developed by art therapist, Kellogg (1978), based on her clinical use and extensive study of mandalas (circle drawings). Kellogg elicited drawn mandalas by asking clients to use oil pastels to fill in a circle (10 × 1/2 in. in diameter) drawn in pencil on a piece of white (and sometimes black) 12 in. × 18 in. paper. Kellogg (1992) believed that using the circle on standard paper with standard media (oil pastels) eliminates many of the variables that make art so difficult to assess. Kellogg (1978) began using mandalas in 1969, and after 9 years of collecting and classifying thousands of mandalas, identified several designs that seemed to be universal or archetypal ways of filling in a circle with color. And upon further study, Kellogg identified a developmental sequence in which the designs and colors seemed to unfold cyclically throughout the life span. She called this developmental cycle “The Archetypal Great Round of the Mandala” (see Fig. 1). The Great Round, then, is a developmentally sequenced circle of mandalas that Kellogg believed were archetypal in nature, with regard to form, color, interpretive meaning, and developmental significance. Thus, each archetypal mandala Corresponding author. E-mail addresses: [email protected] (K. Bruscia), [email protected] (C. Shultis), [email protected] (K. Dennery). 0197-4556/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.aip.2007.07.005

A Comparison of Cardiac and Cancer In Patients

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Page 1: A Comparison of Cardiac and Cancer In Patients

The Arts in Psychotherapy 34 (2007) 388–397

A comparison of cardiac and cancer inpatientson the MARI® Card Test

Kenneth Bruscia, Ph.D., MT-BC, FAMI ∗, Carol Shultis, M.Ed., MT-BC, FAMI, LPC,Karen Dennery, MMT, MT-BC

Temple University, 2001 North 13th Street, Philadelphia, PA 19122, United States

Abstract

The MARI® Card Test is a projective preference test developed by art therapist, Joan Kellogg, based on her extensive study ofmandalas (circle drawings). As used in this study, the test involved selecting the most and least preferred mandalas from a set ofarchetypal designs, called the Great Round. The test was administered to 195 patients, 132 hospitalized for cardiac disease and 63hospitalized for cancer. The purpose was to identify similarities and differences in the design and color choices of the two groups,and to interpret the choices. Based on mandala theory, the projective evidence indicated that both cardiac and cancer patients aretrying to preserve what they have achieved in life, and both are fearful of falling apart. Along with a strong will to survive, there isa preoccupation with death, feelings of depression, dependence, and anger, and a general avoidance of deep existential or spiritualissues. The will to survive is accompanied by a strong tendency to find creative ways of dealing with the illness and its treatment.With this comes a need to understand things—their lives, their own identities, their illnesses, and their best treatment options.Differences between the groups were found in specific fears (death, falling apart, spread of cancer); however, these differences maybe due to age and length of illness as well as diagnosis. The caveats of projective tests are examined, and implications are drawnfor arts therapists.© 2007 Elsevier Inc. All rights reserved.

Keywords: Mandala; Preferences; Cancer; Cardiac; Projective; MARI

Introduction

The MARI® Card Test is a projective preference test developed by art therapist, Kellogg (1978), based on herclinical use and extensive study of mandalas (circle drawings). Kellogg elicited drawn mandalas by asking clients touse oil pastels to fill in a circle (10 × 1/2 in. in diameter) drawn in pencil on a piece of white (and sometimes black)12 in. × 18 in. paper. Kellogg (1992) believed that using the circle on standard paper with standard media (oil pastels)eliminates many of the variables that make art so difficult to assess.

Kellogg (1978) began using mandalas in 1969, and after 9 years of collecting and classifying thousands of mandalas,identified several designs that seemed to be universal or archetypal ways of filling in a circle with color. And uponfurther study, Kellogg identified a developmental sequence in which the designs and colors seemed to unfold cyclicallythroughout the life span. She called this developmental cycle “The Archetypal Great Round of the Mandala” (see Fig. 1).The Great Round, then, is a developmentally sequenced circle of mandalas that Kellogg believed were archetypal innature, with regard to form, color, interpretive meaning, and developmental significance. Thus, each archetypal mandala

∗ Corresponding author.E-mail addresses: [email protected] (K. Bruscia), [email protected] (C. Shultis), [email protected] (K. Dennery).

0197-4556/$ – see front matter © 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.aip.2007.07.005

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Fig. 1. The Archetypal Great Round of the Mandala1.

in the Great Round signifies a particular developmental state or stage of consciousness occurring throughout the lifeprocess (Kellogg, 1978, 1992).

The Great Round provides the theoretical basis for the Mandala Assessment Research Institute (or MARI®) CardTest. In the test, the individual or client selects mandala designs from the Great Round along with colors that aremost preferred or appealing, and these choices serve as a projection of the individual’s state or stage of consciousness.The Great Round provides a multidimensional, multifaceted template for interpreting the MARI® Card Test in that it

1 Reprinted by permission of MARI® Creative Resources.

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can be used to describe phases in myriad developmental or evolutionary processes that unfold throughout life, suchas the development of an idea, steps in the creative process, development of a particular part of the self, stages in arelationship, the process of therapeutic growth, life span development, and evolution itself (Cox, 2002; Kellogg, 1992).An individual, therefore, as evidenced by his or her design and color choices on the test, may be operating within severalstates or stages of the Great Round at one time, and may be functioning at different developmental levels, dependingon the life issues or tasks of greatest concern at the time. Moreover, throughout the life span, an individual may traversethe Great Round several times, to accomplish different developmental milestones and tasks, from conception to birthto death.

The MARI® Card Test

The first step in taking the MARI® Card Test is for the individual to freely draw a mandala. When finished, theindividual is presented a set of clear 3 in. × 5 in. plastic cards, each embossed with one of the mandala designs in theGreat Round, and then asked to choose design cards that are most preferred or appealing. The individual is then givena set of opaque 3 in. × 5 in. color cards, and asked to match the preferred design cards with the most preferred colorcards. The color cards are then placed under the clear design cards, and the individual is asked to place the matchedcard sets in rank order of preference.

Since its inception, the MARI® Card Test has undergone several revisions, with each version varying in the numberof different design and color cards presented, and the number of card pairs to be chosen as preferred. In Kellogg’s 1993version (see Fig. 1), the card test consisted of 39 design cards (three versions for each of the 13 design stages of theGreat Round), and 40 color cards (including one silver and one gold foil), and the individual was asked to select andrank six most preferred designs and matching colors (Frame, 2002).

An important, but optional modification was made to the test by Frame (2002), who in addition to asking for themost appealing designs and colors, also asked the individual to choose a design that he or she is least drawn to anda color that reflects his or her feelings about that design. The individual is also asked to select a second color that“seems to make the design more acceptable” (p. 29.). Thus, Frame added the notion of a “rejected” design and color,and a “healing” color. Frame has found that the rejected card set gives “important information about a client’s areas ofrepression or denial, which might not show up as clearly when using only the preferred-card choices” (p. 29), whilethe healing color points to potentially effective approaches to treatment or management of that problem area.

Review of research

Research on Kellogg’s mandala theory falls into two categories: studies on mandala drawings, and studies using theMARI® Card Test. The studies on drawings typically provide frequency data on the kinds of mandalas most frequentlydrawn by particular client populations. For example, Couch (1997) classified 471 mandala drawings of 71 elderlyindividuals with dementia according to stages in the Great Round, and found that the most frequently drawn mandalaswere Stages 5, 11, 6, and 1; the least frequently drawn were Stages 12, 4, 10, and 0. Similarly, Cox and Cohen (2000)reviewed hundreds of spontaneous and directed mandala drawings by individuals with Dissociative Identity Disorderand found that the most frequently drawn mandalas were Stages 2, 3, 4, 5, 9, and 11.

Research studies on the card test most often examine results obtained when the MARI® is administered to vari-ous populations, the main purpose being to determine if different groups have characteristic or different choices ofdesign/stages and colors. For example, Cox and Frame (1993) compared 70 artists (including art therapists) with 70participants in the general population, and found that artists most frequently selected Stages 0, 6, and 7, whereas thegeneral population most frequently selected Stage 9. Stage 12 was most popular for both groups combined. As forcolor choice, artists most often chose turquoise, while the general population most often chose azalea and chartreuse.

Marshall (1995) gave the card test to 49 Japanese and 83 American children, 8–10 years of age, and modified thetest to include variously colored foil cards. She found that the Japanese children most often chose Stages 8, 9, and2, and rejected Stage 11; the American children most often chose Stages 11, 3, and 12, and rejected Stage 0. As forcolors, the Japanese children most often selected pink foil, blue foil, and purple foil, and rejected black; the Americanchildren most often selected blue foil, silver foil, and red foil, and rejected black.

Bigelow (1995) administered the card test to 54 psychics and found that the most preferred stages were 12 and3, with almost no choice of Stage 5, and with Stage 11 as the most frequently rejected design; their most preferred

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colors were silver foil, purple, magenta, emerald green, royal blue, and turquoise, while their most frequently rejectedcolors were olive and avocado. Other researchers have also administered the card test to psychics. Rhinehart (1998)found that seven psychics tended to choose Stages 3 and 8, with red, green, purple, and silver as the preferred colors.Krippner and Rhinehart (1999) tested five psychics and found that they chose Stages 1, 2, and 12 most often, with redand yellow as the preferred colors.

Douglass (1996) administered two versions of the MARI® Card Test to 98 sex offenders. In both versions, participantswere presented 39 designs (without the color cards), and asked to choose six of their most preferred designs. Inthe first version, she administered the 3 × 5 plastic cards individually as usually done; in the second version, shepresented reduced photographic copies of the designs on letter size paper. Douglass found that there were significantcorrespondences between the adapted version and the original version of the test on 9 of the 13 stages. She also foundthat the design choices of sex offenders remained constant over a 4-week period. Finally, she found that sex offendersmost often selected Stages 2 (81%), 12 (74%), 9 (70%), 1 (69%), and 8 (68%).

Meadows (n.d.) gave the card test to 50 graduate students in business, and found that the most frequently selecteddesigns were: 12 (12%), 1 (11%), 9 (11%), 11 (10%), 8 (9%), and 3 (8%); the most frequently selected colors wereblues (21%), reds (17%), greens (17%), silver and gold foils (12%), and yellow (12%).

Betts (2000) compared the card choices on the MARI® of 16 adults who had been adopted with 16 adults who hadnot. She found that the adoptees most often chose Stages 12, 1, and 3; while the non-adoptees chose Stages 12, 4, and8. Looking at the differences between the two groups, Betts also noted that adoptees chose Stage 1 (68%) much moreoften than the non-adoptees (6%).

Frame (2002) tested 19 college students to better understand the rejected card choices and their stability over time.She found that the students most often rejected Stage 10, and that they did not choose the same rejected card on asubsequent administration of the card test. She also found that some of the students used the healing color from thefirst test as a preferred color on the subsequent test, a finding she also obtained in looking at the test results of 30 ofher own clients.

Frame (2006) also administered the test to 22 couples, and used the results to assess their relationship and compat-ibility. She concluded that this “Couple Compatibility Assessment” using the MARI® illuminated “current problems,early influences, strengths, weaknesses, future direction, as well as unrecognized emotions that may have affected theirrelationship” (p. 29).

No research studies were found that used the MARI® Card Test on persons with chronic illness such as canceror cardiac disease. Yet, in Kellogg’s seminal work (1978), she pointed to the need and significance of studying themandalas of people with chronic illness, and particularly those with cancer. She thought the test would be helpful ininvestigating patterns that might consistently appear among cancer patients, and in differentiating patients in remissionfrom those who succumb.

The purpose of the present study was to determine if cardiac and cancer inpatients in an urban hospital havecharacteristic design and color choices on the MARI® Card Test, and to determine if there are any differences betweenthe two groups on their choices. Specific questions were: (1) Which designs and colors are most frequently preferredand rejected by cardiac patients, and what do these choices indicate? (2) Which designs and colors are most frequentlypreferred and rejected by cancer patients, and what do these choices indicate? (3) Are there differences between cardiacand cancer patients in their choices of preferred and rejected designs and colors, and what do these differences indicate?Answers to these questions would be helpful, not only in increasing understanding of the strengths, concerns, and needsof hospitalized patients, but would also provide valuable data on the usefulness of the MARI® Card Test in a hospitalsetting.

Method

Participants

Participants were inpatients at an urban university hospital in the northeast USA. Criteria for inclusion in the studywere: (1) hospitalized with a diagnosis of cancer or cardiac disease; (2) sufficient physical and mental stamina toundergo testing; (3) English-speaking; and (4) willingness to participate in the research as demonstrated by signing aconsent form, presented orally or in writing. Participants were not paid for their participation. The study was approvedby the University Institutional Review Board for the protection of human subjects.

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A total of 195 participants participated in the study, 132 hospitalized for cardiac disease (75 male, 57 female),and 63 hospitalized for cancer (21 male, 42 female). Cardiac diagnoses included: congestive heart failure (38%),coronary artery disease (20%), post-transplant complications (15%), arrhythmia (10%), valve disorder (6%), myocardialinfarction (6%), and various others (14%). Seventeen forms of cancer were represented, including undifferentiated(22%), lymphoma (16%), lung (14%), uterine (14%), liver (12%), ovarian (12%), and 11 other forms (10%). Participantsranged in age from 26 to 87 years, with a mean of 60.3 years (S.D. = 13.9). With regard to race, 30% were Caucasian,61% were African-American, and 9% were other (Hispanic and Asian). As for education, 8% completed up to 8 yearsof school, 55% up to 12 years, 32% up to 17 years, and 4% over 18 years.

Materials

A modified version of the MARI® Card Test was used. Instead of presenting 39 design cards and 40 color cards,participants were presented with 13 each, that is, only one of the three designs representing each of the 13 stages in theGreat Round, and 13 colors (i.e., white, black, red, orange, yellow, emerald green, royal blue, indigo purple, brown,aqua, olive, and silver). The design cards were selected by the researchers to reflect the most characteristic or typical ofthe three designs for each stage; the colors were selected to include the colors regarded as most basic or common. (Allthree researchers have been trained in the MARI® Card Test, and have experience in using the mandala in their work.)

A concomitant modification made in the test was that, instead of asking each participant to choose six preferredcard sets, a rejected card set, and a healing color, participants in the present study were asked to choose one preferreddesign and color, one rejected design and color, and one healing color.

The test was modified in these two ways not only to conserve time and energy of the participants, but also tohelp them identify the single most pressing concern or issue at hand, both in the preferred and rejected domains. It isimportant to note that in most of the previous studies on the test, the frequencies of card choices reported do not takeinto account the ranking and relative importance given to each design and color by the participant. Specifically, whenthe “largest” frequencies are reported, the actual number often includes cards that were chosen in all six rankings ofthe preferred card sets, thereby obscuring which single design and color may be the most preferred (or rejected) of all,and thus the most important. This also explains why the percentages of participants choosing each stage are relativelyhigh. Finally, the present modification also has some statistical advantage in that it reduces the number of possiblechoices available to the participant, from 39 designs and 40 colors to 13 designs and 13 colors.

Procedures

Each participant was interviewed individually by one of the researchers to determine suitability for participation inthe study. Those who met inclusion criteria were then individually tested immediately after screening and signing of theconsent form. The MARI® Card Test took about 5 min to administer. It was administered as follows: Each participantwas presented all 13 design cards, and asked to select one design that was most preferred or appealing, and one thatwas least preferred or appealing. The participant was then presented all 13 color cards, and asked to match the mostpreferred design with the most preferred color, and the least preferred design with the least preferred color. Finally, theparticipant was asked to select a color that would help to make the least preferred design more acceptable. The cardchoices were then recorded.

Results

Percentages were computed for the frequency of design and color choices made by cancer and cardiac patients.Table 1 shows the designs and colors most frequently chosen as preferred, rejected, and healing.

Chi-square was used to determine whether there were differences between cardiac and cancer patients on theirchoices of each individual design (df = 1) and each individual color (df = 1). The following significant differences(two-sided) were found:

• Cancer patients chose Stage 11 as a preferred design more frequently than cardiac patients (p = .02).• Cardiac patients rejected Stage 10 more frequently than cancer patients (p = .04).

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Table 1Most frequently chosen cards

Elicited choice Patient groups

Cardiac Cancer

Preferred design Stage 9 (29%) Stage 9 (32%)Stage 1 (13%) Stage 11 (22%)Stage 5 (13%) Stage 12 (13%)

Rejected design Stage 11 (34%) Stage 11 (20%)Stage 10 (16%) Stage 2 (20%)Stage 0 (10%) Stage 0 (19%)

Preferred color Silver sparkle (18%) Silver sparkle (22%)Red (17%) Red (17%)Yellow (14%) Yellow (17%)

Rejected color Black (35%) Black (34%)White (12%) Silver sparkle (10%)

Healing color Yellow (20%) Silver sparkle (22%)Silver sparkle (12%) Yellow (20%)Red (12%) Red (12%)

• Cardiac patients rejected Stage 11 more frequently than cancer patients (p = .01).• Cancer patients chose silver sparkle as a healing color more frequently than cardiac patients (p = .05).

The Shapiro–Wilk showed that age, length of illness, and education did not have normal distributions. Attemptsto transform the data into normal distributions were unsuccessful, thereby necessitating nonparametric statistics. TheMann–Whitney Test was used to determine whether the cardiac and cancer groups differed significantly in age, lengthof illness, and education. Significant (two-sided) differences were found in both age (p = .01) and length of illness(p = .001). The cardiac group was older and had their illness for a longer time. The groups did not differ in education.As for race and gender, the cancer group consisted of 71% African-Americans and 29% non-African-Americans; thecardiac group had 59% African-Americans and 41% non-African-Americans. The cancer group consisted of 34%females and 66% males; the cardiac group had 45% females and 55% males. Thus, both groups were predominantlyAfrican-American and male.

Discussion

Stage choices

Both cancer and cardiac patients selected Stage 9 (crystallization) most frequently as their preferred design. Accord-ing to Kellogg (1978), Stage 9 can signify accomplishment of one’s goals, the realization of one’s mission, and evenperfection itself. Given its regulated, symmetrical nature, individuals select Stage 9 when they want to enjoy andpreserve what they have achieved in life; as a result, they may be reluctant to change, let go, or adapt to the inevitable.“We wish we could stop here forever, but just like the petals of a rose in full bloom, we sense that at the apogee ofour being we are faced again with our imminent destruction (Kellogg & Di Leo, 1982, p. 43). Stage 9 is encounteredoften in mature, successful persons being confronted with change and the need to adapt (Kellogg, 1978). “As one goesthrough many changes, it appears again and again as a stabilizing image throughout treatment” (Kellogg, 1978, p.123). Thus, in this context, through this design choice, cardiac and cancer patients may be revealing a need to hangonto what they have accomplished in life, as they are being continually threatened by illness, pervasive changes in allaspects of their being, and ultimately the possibility of their own demise.

Cardiac patients selected Stage 1 (the void) as their second most preferred design. This stage is associated with thesoul’s descent into the physical world and the darkness of the womb; it is a state of unconsciousness, accompanied byexperiences of compression and depression (Kellogg, 1978). The task during this stage is to wait patiently for thingsto evolve, and to trust the process (Frame, 1989). Within the context of heart disease, the preference for this design

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among cardiac patients may reflect an ongoing struggle with depression, and their need to keep the faith that they willsurvive their fight for life.

Cardiac patients chose Stage 5 (the target) as their third most preferred design. Stage 5 is the space of self-protection and self-preservation, achieved by setting boundaries around oneself, and through ritualistic (or evenobsessive–compulsive) activities (Frame, 1989; Kellogg, 1978). This may reflect the cardiac patient’s need to takecare of themselves rather than other people, as well as their need to maintain a healthy daily routine.

Stage 11 (fragmentation) figured prominently in the choices of both cardiac and cancer patients. It was the sec-ond most frequently preferred stage among cancer patients, while also being their most frequently selected rejectedstage—an obvious conflict. Do they want to be there or not? Interestingly, cancer patients chose stage 11 more fre-quently as their preferred design than cardiac patients; and cardiac patients rejected Stage 11 more frequently thancancer patients. In fact, Stage 11 was the most frequently rejected stage of cardiac patients.

According to Kellogg (1978), Stage 11 symbolizes fragmentation, mutilation, dismemberment, falling apart, loss ofboundaries, and the letting go of one’s identity. It is the painful stage of disintegration following death. Those patientsthat preferred Stage 11 are indicating that they are in the throes of the fragmentation process—they are experiencinga falling apart or letting go, and this pre-occupies them. Those patients that rejected Stage 11 are indicating a fear ofor resistance to entering the fragmentation stage.

It is not surprising to see how prominently Stage 11 figures into the psyche of cancer and cardiac patients, andespecially when considered in light of their preference for Stage 9. The juxtaposition of these two stages speaks tothe existential conflict of chronic illness: Should I try to hang on to myself, and the good in my life (preference forStage 9), and resist letting go (rejection of Stage 11), or should I let go and surrender to the illness and what it brings(preference Stage 11)?

The intensity of this dilemma – to hang on or let go – is particularly evident in cancer patients, some of whompreferred Stages 9 and 11, and some of whom rejected 11. Here there is an obvious conflict over what to do. Cardiacpatients seemed more certain: they clearly prefer Stage 9, and soundly reject Stage 11. Apparently, they want to preservetheir lives; moreover, they do not want to let go or surrender, and they are fearful of doing so.

Related to this avoidance of letting go, cardiac patients also rejected Stage 10 (gates of death) second in frequency,and significantly more often than cancer patients. According to Kellogg (1978, 1992), this stage symbolizes the end,termination, or death of any cycle; it signals the giving up of previous accomplishments, identities, and orders, and thepainful destruction or loss of what has been. This rejection of death may indicate that cardiac patients are avoiding thethought of death, while still being concerned about it at some level. And with this in mind, the comparison with cancerpatients is interesting. Cardiac patients may be more fearful of death than cancer patients. Interestingly, however, bothcardiac and cancer patients rejected Stage 0, “clear light,” which symbolizes oneness with the Creator or all of creation(Kellogg, 1978, 1992). One might conclude, then, that while cardiac patients seem to be more concerned with deaththan cancer patients, both groups reject the idea of joining (or re-joining) the world of Spirit.

Cancer patients have another concern. Based on their frequent rejection of Stage 2 (bliss), cancer patients appear tobe worried about unchecked cellular growth. According to Kellogg (1978, 1992), Stage 2 represents the intrauterineexperience of boundless multiplicities, regeneration, and fertilization, as well as ecstasy and nonordinary states ofconsciousness. When considered in light of cancer, rejection of this stage symbolizes the fear of cancer cells growingor multiplying (Frame, 1989). While having this concern, some cancer patients expressed hope in their choice of Stage12 (transcendent ecstasy). This is the stage of rebirth or re-integration of what has existed, died, and disintegrated; itis a metabolic ending and a new beginning (Kellogg & Di Leo, 1982).

Color choices

Color choices were quite consistent across both groups: silver sparkle, red, and yellow were most frequently chosenfor the preferred and healing colors by both cardiac and cancer patients, and black was most frequently chosen as therejected color by both groups. In addition, for secondary choices, white was rejected by cardiac patients, and silversparkle was rejected by cancer patients. The following discussion of colors and their meanings is based on mandalacolor theory as presented by Kellogg (1977, 1992), Kellogg, MacRae, Bonny, and Di Leo (1977), and Frame (1989).

Silver sparkle was the most preferred color of both cardiac and cancer patients. According to mandala color theory,silver sparkle is most often chosen when the person is using the imagination, dreams, altered states of consciousness,magical thinking, and/or out-of-body experiences to deal with a situation or problem. This seems to indicate that both

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cardiac and cancer patients are trying to go beyond reality or ordinary thinking to develop creative ways of dealingwith and/or curing their illness. Once again, a conflict is seen over this strategy in cancer patients not found in cardiacpatients. Specifically, cancer patients selected silver foil both as a preferred color and as a rejected color. For them,the questions seem to be whether to face reality about the illness or to transcend it, or going even further, perhaps toground oneself in traditional treatments or to seek alternative or complimentary approaches.

Red was the second most preferred color of cardiac and cancer patients. According to mandala theory, red isassociated with the birth experience—where there is the strong will to live and to survive all threats, accompaniedby feelings of both dependence and anger. These motives and feelings seem particularly relevant to having canceror cardiac disease, where there is a constant struggle to survive both the illness and the treatment, accompanied bycontinual bouts with feelings of dependence and anger.

Yellow was the third most preferred color of both groups of patients. According to mandala theory, yellow is asso-ciated with heightened consciousness, awareness, and insight. Thus, cardiac and cancer patients seem to be expressinga need to understand things—their life, their own identity, their illness, their best treatment option, and so forth. It isalso important to note that yellow is the color of the sun, and can signify radiation; thus it is often seen in the colorchoices of cancer patients (Frame, 1989).

Black was the most frequently rejected color of both cardiac and cancer patients. According to mandala theory,black can be equated to the loss of consciousness, darkness, death, and depression. As a rejected color, black cansignify the conscious or subconscious fear of dying, or it may reflect the depression or lack of hope associated withthe losses incurred as a result of the illness.

Finally, white was the second most rejected color of cardiac patients. According to mandala theory, this may signifytheir avoidance of a spiritual crisis or task related to existential issues: to live or not to live, to deny what is or tosurrender to it. This is consistent with their rejection of Stage 0, where the very meaning of life is confronted.

Two important caveats must be considered in interpreting and contextualizing all of the above findings: (1) thedemographic differences between the cancer and cardiac groups, and (2) the psychometric nature of the MARI® CardTest. Because the two groups differed in age and length of illness, these two variables may be responsible for thedifferences in design and color choices between cancer and cardiac patients. In addition, because both groups weremostly African-American, and mostly male, the design and card choices of both groups may reflect the choices ofthese two demographic groups.

Anastasi (1976) identified three main psychometric problems with most projective tests: scorer reliability (extentof agreement between interpreters), retest reliability (consistency of responses over time), and validity (whether thetest measures what it purports to measure). No research has been conducted on scorer reliability for the MARI® CardTest; however, certain aspects of the MARI® that insure greater scorer reliability than other projective tests are: (1)the number of response options are limited (13 designs, 13 colors), unlike many other projective tests; (2) Kellogg’stheory provides interpretive guidelines for each design and color choice. Nevertheless, interpretation of the MARI®

Card Test requires clinical skills and training in the test itself (Cox, 2002), both of which may vary from interpreter tointerpreter. Anastasi (1976) points out that this is a problem indigenous to projective testing. In the present study, theinterpreter was the primary author, who was certified as a teacher of the MARI®.

As for retest reliability, which is particularly important in the measurement of traits rather than states (Anastasi,1976), it is important to point out that the MARI® is first and foremost an assessment of states or stages of developmentat a given time in the individual’s life cycles (Kellogg, 1978). For this reason, the MARI is recommended for usein tracing developmental or therapeutic change (Cox, 2002). Though traits may be inferred from choice patterns ina single test, and repeated choices of the same designs and colors over an extended period of time, or they may beunearthed through research (i.e., Douglass, 1996; Frame, 2002), the immediate interpretation of the card test refersprimarily to the individual’s here-and-now. Thus, with regard to the MARI®, retest reliability issues do not apply inthe same manner.

As for validity, all of the mandala and MARI® research reviewed in the introduction are attempts to establish at leastconcurrent criterion-related validity. Like the present study, the aim of these studies has been to identify characteristicsof particular diagnostic groups or populations, and to compare them with others, thereby increasing the scope andaccuracy of interpretations. Anastasi (1976) points out that often the comparison groups in validity research differalong other relevant independent variables (e.g., age, education), which might also account for differences in testresults, and therein contaminate the findings. That issue was evident in the present study, where both age and lengthof illness differed between groups.

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Given these psychometric issues, Anastasi (1976) argues persuasively for the clinical value of projective techniques.She explains that: (1) projective techniques provide a broad band of information about the examinee at the expenseof lower fidelity, while objective tests provide a much narrower band of information at a high level of dependability;and (2) in projective techniques, constructs about the examinee accumulate inductively by consideration of a widearray of data, leading to unique insights about each examinee that have never been unearthed previously. Both of theseadvantages certainly inhere in the MARI® Card Test.

What then are the implications of the present study, and particularly for creative arts therapists? First, the presentfindings suggest that the mandala may have clinical value in identifying potential strengths, concerns, and needs ofmedical patients in a hospital setting. The researchers found that the card test was administered very easily and quicklyin the hospital room, and that patients enjoyed taking the test. It did not require any specialized or advanced cognitive,verbal, or artistic skills. Moreover, the interpretation of the present results illuminated many issues that the patientswere confronting while in the hospital, but perhaps unable to communicate or work through verbally, especially inshort-term care. Second, the present findings provide a starting place for clinical assessment and treatment. The cardtest was able to identify and narrow down the primary psychological concerns and needs of cancer and cardiac patients,while also pointing to possible subtle differences between the two groups. Third, the results of the card test yieldedclinical information that would be useful to both medical and nonmedical staff working with chronically ill patients.As such, the present findings provide a common ground for creative arts therapists and other hospital personnel to workcollaboratively with the same patients. Finally, the present findings add information about cancer and cardiac patientsto existing research on the MARI® Card Test.

Conclusions

In summarizing all of the projective evidence with regard to both design and color choices of cardiac and cancerpatients, the following conclusions may be drawn. Cardiac patients want to preserve what they have achieved in lifedespite the threats of the disease. They struggle with depression, and need to keep the faith that they will survive theirfight for life. Cardiac patients also try to protect themselves and their health through interpersonal boundaries anddaily routines. They are more fearful and concerned over death than cancer patients, and they clearly reject the ideaof surrendering to the illness, yet both death and surrender are of great concern. Unlike cancer patients, they resistand fear joining the world of the Spirit. Cardiac patients want to develop creative ways of dealing with and/or curingtheir illness. Like cancer patients, they are in a constant struggle to survive, and they often experience feelings ofdependence, depression, and anger. They also have a need to understand themselves, their life, their illness, and theirtreatment options.

Cancer patients also want to preserve what they have achieved in life despite the illness, however, unlike cardiacpatients, they are less fearful of or concerned with death, and they are conflicted over whether to accept or reject thefragmentation process (falling apart or surrendering to the illness). Cancer patients are greatly concerned with thepossibility that their cancer cells may be growing and multiplying unchecked. They combat this fear with hopes oftranscending the disease process. At the same time, cancer patients are conflicted over whether they should face or lookbeyond the everyday realities of their illness, and whether they should seek traditional or alternative, more creativeapproaches to treatment. Like cardiac patients, cancer patients are in a constant struggle to survive both the illness andthe treatment, and they have continual bouts with feelings of dependence, depression, and anger. With this comes aneed to understand their life, their own identity, their illness, and their best treatment option.

These findings may be limited by demographic differences in age and length of illness found between the cancer andcardiac patients in this study, and by the psychometric issues inherent in projective testing. Nevertheless, the presentfindings point to the potential clinical value of the MARI® Card Test for creative arts therapists working in a hospitalsetting.

Acknowledgments

This study was made possible by a grant from the Pennsylvania Department of Health, offered through the Com-monwealth Universal Research Enhancement Program (CURE), authorized through the Tobacco Settlement Act (Act77 of 2001).

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K. Bruscia et al. / The Arts in Psychotherapy 34 (2007) 388–397 397

Thanks to MARI® Creative Resources, 2532 Albemarle Avenue, Raleigh, NC 27610 for permission to reprint Fig. 1,the Great Round of the Mandala by Joan Kellogg. Archetypal to the title for Fig. 1. The Archetypal Great Round ofthe Mandala. All rights to use or reproduce MARI® images and the card test are reserved.

Thanks are also extended to the following faculty of Temple University: Dr. Cheryl Dileo, Professor of MusicTherapy, for her role in envisioning and applying for the grant; Dr. Kenneth Soprano Vice-President for Research, forhis administrative support; and Dr. Roslyn Gorin for her statistical guidance.

References

Anastasi, A. (1976). Psychological testing (4th ed.). New York: MacMillan Publishing Co..Betts, D. (2000). Application of the MARI® Card Test in an exploration of adoption issues: Pilot study. Unpublished paper, The National Children’s

Center, Washington, DC.Bigelow, V. (1995).The MARI® Card Test Profile of fifty-four psychics. In J. Douglass (Ed.), Proceedings of the first international conference on

the study of mandalas and the MARI® Card Test, sponsored by the Association of Teachers of Mandala Assessment. Unpublished manuscript,Baltimore, MD.

Couch, J. (1997). Behind the veil: Mandala drawings by dementia patients. Art Therapy: Journal of the American Art Therapy Association, 14(3),187–193.

Cox, C. (2002). In C. Malchiodi (Ed.), Handbook of art therapy (pp. 428–434). New York, NY: Guilford Press.Cox, C., & Cohen, B. (2000). Mandala artwork by clients with DID: Clinical observations based on two theoretical models. Art Therapy: Journal

of the American Art Therapy Association, 17(3), 195–201.Cox, C., & Frame, P. (1993). Profile of the artist: MARI® Card Test research results. Art Therapy: Journal of the American Art Therapy Association,

10(1), 23–29.Douglass, J. (1996). The MARI® Card Test ©: A reliability study of an adapted group version administered to sex offenders. Dissertation Abstracts

International, 62(1-B), 544. July 2001.Frame, P. (1989). Levels one and two training in mandala assessment and the MARI® Card Test. Unpublished materials. Charlottesville, VA: Round

Oaks Creative Center.Frame, P. (2002). The value of the rejected card choice in the MARI® Card Test. Art Therapy: Journal of the American Art Therapy Association,

19(1), 28–31.Frame, P. (2006). Assessing a couple’s relationship and compatibility using the MARI® Card Test and mandala drawings. Art Therapy: Journal of

the American Art Therapy Association, 23(1), 23–29.Kellogg, J. (1978). Mandala: Path of beauty. Lightfoot, VA: MARI.Kellogg, J. (1992, July). Color from the perspective of the great round of mandala. The Journal of Religion and Psychical Research, 15(23), 138–146.Kellogg, J., & Di Leo, F. (1982, January). Archetypal stages of the great round of the mandala. The Journal of Religion and Psychical Research,

5(1), 38–48.Kellogg, J., MacRae, M., Bonny, H., & Di Leo, F. (1977, July). The use of the mandala in psychological evaluation and treatment. American Journal

of Art Therapy, 16, 123–130.Krippner, S., & Rhinehart, L. (1999). Scores of psychic claimants on the MARI® Card Test. Subtle Energies and Energy Medicine, 8(2), 153–173.Marshall, F. (1995). Japanese and American children: Similarities and differences in the MARI® Card Test and mandala drawings. In J. Douglass

(Ed.), Proceedings of the first international conference on the study of mandalas and the MARI® Card Test, sponsored by the Association ofTeachers of Mandala Assessment. Unpublished manuscript. Baltimore, MD.

Meadows, S. (n.d.). A visual form of personality characteristics of MBA students using the MARI® Card Test. Unpublished master’s thesis, FloridaMetropolitan University.

Rhinehart, L (1998). The Great Round: Where psychics dwell. In R. Heinze (Ed.), Proceedings of the annual conference on shamanism andalternative forms of healing. Independent Scholars of Asia, Berkeley, CA, pp. 196–202.