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The Arts in Psychotherapy 34 (2007) 388397

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 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 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 nd creative ways of dealing with the illness and its treatment. With this comes a need to understand thingstheir lives, their own identities, their illnesses, and their best treatment options. Differences between the groups were found in specic 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 ll 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 difcult to assess. Kellogg (1978) began using mandalas in 1969, and after 9 years of collecting and classifying thousands of mandalas, identied several designs that seemed to be universal or archetypal ways of lling in a circle with color. And upon further study, Kellogg identied 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 signicance. Thus, each archetypal mandala

Corresponding author. E-mail addresses: (K. Bruscia), (C. Shultis), (K. Dennery).

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

K. Bruscia et al. / The Arts in Psychotherapy 34 (2007) 388397


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

in the Great Round signies a particular developmental state or stage of consciousness occurring throughout the life process (Kellogg, 1978, 1992). The Great Round provides the theoretical basis for the Mandala Assessment Research Institute (or MARI ) Card Test. In the test, the individual or client selects mandala designs from the Great Round along with colors that are most preferred or appealing, and these choices serve as a projection of the individuals state or stage of consciousness. The Great Round provides a multidimensional, multifaceted template for interpreting the MARI Card Test in that it

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, such as the development of an idea, steps in the creative process, development of a particular part of the self, stages in a relationship, 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 several states or stages of the Great Round at one time, and may be functioning at different developmental levels, depending on the life issues or tasks of greatest concern at the time. Moreover, throughout the life span, an individual may traverse the Great Round several times, to accomplish different developmental milestones and tasks, from conception to birth to death. The MARI Card Test The rst step in taking the MARI Card Test is for the individual to freely draw a mandala. When nished, the individual is presented a set of clear 3 in. 5 in. plastic cards, each embossed with one of the mandala designs in the Great Round, and then asked to choose design cards that are most preferred or appealing. The individual is then given a set of opaque 3 in. 5 in. color cards, and asked to match the preferred design cards with the most preferred color cards. The color cards are then placed under the clear design cards, and the individual is asked to place the matched card sets in rank order of preference. Since its inception, the MARI Card Test has undergone several revisions, with each version varying in the number of different design and color cards presented, and the number of card pairs to be chosen as preferred. In Kelloggs 1993 version (see Fig. 1), the card test consisted of 39 design cards (three versions for each of the 13 design stages of the Great Round), and 40 color cards (including one silver and one gold foil), and the individual was asked to select and rank six most preferred designs and matching colors (Frame, 2002). An important, but optional modication was made to the test by Frame (2002), who in addition to asking for the most appealing designs and colors, also asked the individual to choose a design that he or she is least drawn to and a color that reects 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 clients areas of repression or denial, which might not show up as clearly when using only the preferred-card choices (p. 29), while the healing color points to potentially effective approaches to treatment or management of that problem area. Review of research Research on Kelloggs mandala theory falls into two categories: studies on mandala drawings, and studies using the MARI Card Test. The studies on drawings typically provide frequency data on the kinds of mandalas most frequently drawn by particular client populations. For example, Couch (1997) classied 471 mandala drawings of 71 elderly individuals with dementia according to stages in the Great Round, and found that the most frequently drawn mandalas were 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 Disorder and 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 various populations, the main purpose being to determine if different groups have characteristic or different choices of design/stages and colors. For example, Cox and Frame (1993) compared 70 artists (including art therapists) with 70 participants in the general population, and found that artists most frequently selected Stages 0, 6, and 7, whereas the general population most frequently selected Stage 9. Stage 12 was most popular for both groups combined. As for color 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, 810 years of age, and modied the test to include variously colored foil cards. She found that the Japanese children most often chose Stages 8, 9, and 2, and rejected Stage 11; the American children most often chose Stages 11, 3, and 12, and rejected Stage 0. As for colors, the Japanese children most often selected pink foil, blue foil, and purple foil, and rejected black; the American children 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 and 3, 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 rejected colors 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 ve psychics and found that they chose Stages 1, 2, and 12 most often, with red and yellow as the preferred colors. Douglass (1996) administered two versions of the MARI Card Test to 98 sex offenders. In both versions, participants were presented 39 designs (without the color cards), and asked to choose six of their most preferred designs. In the rst version, she administered the 3 5 plastic cards individually as usually done; in the second version, she presented reduced photographic copies of the designs on letter size paper. Douglass found that there were signicant correspondences between the adapted version and the original version of the test on 9 of the 13 stages. She also found that the design choices of sex offenders remained constant over a 4-week period. Finally, she found that sex offenders most 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 selected designs were: 12 (12%), 1 (11%), 9 (11%), 11 (10%), 8 (9%), and 3 (8%); the most frequently selected colors were blues (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 had not. She found that the adoptees most often chose Stages 12, 1, and 3; while the non-adoptees chose Stages 12, 4, and 8. Looking at the differences between the two groups, Betts also noted that adoptees chose Stage 1 (68%) much more often 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 a subsequent administration of the card test. She also found that some of the students used the healing color from the rst test as a preferred color on the subsequent test, a nding she also obtained in looking at the test results of 30 of her own clients. Frame (2006) also administered the test to 22 couples, and used the results to assess their relationship and compatibility. She concluded that this Couple Compatibility Assessment using the MARI illuminated current problems, early inuences, strengths, weaknesses, future direction, as well as unrecognized emotions that may have affected their relationship (p. 29). No research studies were found that used the MARI Card Test on persons with chronic illness such as cancer or cardiac disease. Yet, in Kelloggs seminal work (1978), she pointed to the need and signicance of studying the mandalas of people with chronic illness, and particularly those with cancer. She thought the test would be helpful in investigating patterns that might consistently appear among cancer patients, and in differentiating patients in remission from those who succumb. The purpose of the present study was to determine if cardiac and cancer inpatients in an urban hospital have characteristic design and color choices on the MARI Card Test, and to determine if there are any differences between the two groups on their choices. Specic questions were: (1) Which designs and colors are most frequently preferred and rejected by cardiac patients, and what do these choices indicate? (2) Which designs and colors are most frequently preferred and rejected by cancer patients, and what do these choices indicate? (3) Are there differences between cardiac and 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 needs of hospitalized patients, but would also provide valuable data on the usefulness of the MARI Card Test in a hospital setting. Method Participants Participants were inpatients at an urban university hospital in the northeast USA. Criteria for inclusion in the study were: (1) hospitalized with a diagnosis of cancer or cardiac disease; (2) sufcient physical and mental stamina to undergo testing; (3) English-speaking; and (4) willingness to participate in the research as demonstrated by signing a consent form, presented orally or in writing. Participants were not paid for their participation. The study was approved by 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%), myocardial infarction (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%). Participants ranged 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 years of school, 55% up to 12 years, 32% up to 17 years, and 4% over 18 years. Materials A modied 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 the Great 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 reect the most characteristic or typical of the three designs for each stage; the colors were selected to include the colors regarded as most basic or common. (All three researchers have been trained in the MARI Card Test, and have experience in using the mandala in their work.) A concomitant modication made in the test was that, instead of asking each participant to choose six preferred card sets, a rejected card set, and a healing color, participants in the present study were asked to choose one preferred design and color, one rejected design and color, and one healing color. The test was modied in these two ways not only to conserve time and energy of the participants, but also to help them identify the single most pressing concern or issue at hand, both in the preferred and rejected domains. It is important to note that in most of the previous studies on the test, the frequencies of card choices reported do not take into account the ranking and relative importance given to each design and color by the participant. Specically, when the largest frequencies are reported, the actual number often includes cards that were chosen in all six rankings of the 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 relatively high. Finally, the present modication also has some statistical advantage in that it reduces the number of possible choices 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 in the study. Those who met inclusion criteria were then individually tested immediately after screening and signing of the consent form. The MARI Card Test took about 5 min to administer. It was administered as follows: Each participant was presented all 13 design cards, and asked to select one design that was most preferred or appealing, and one that was least preferred or appealing. The participant was then presented all 13 color cards, and asked to match the most preferred design with the most preferred color, and the least preferred design with the least preferred color. Finally, the participant was asked to select a color that would help to make the least preferred design more acceptable. The card choices 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 their choices of each individual design (df = 1) and each individual color (df = 1). The following signicant 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).

K. Bruscia et al. / The Arts in Psychotherapy 34 (2007) 388397 Table 1 Most frequently chosen cards Elicited choice Patient groups Cardiac Preferred design Stage 9 (29%) Stage 1 (13%) Stage 5 (13%) Stage 11 (34%) Stage 10 (16%) Stage 0 (10%) Silver sparkle (18%) Red (17%) Yellow (14%) Black (35%) White (12%) Yellow (20%) Silver sparkle (12%) Red (12%) Cancer Stage 9 (32%) Stage 11 (22%) Stage 12 (13%) Stage 11 (20%) Stage 2 (20%) Stage 0 (19%)


Rejected design

Preferred color

Silver sparkle (22%) Red (17%) Yellow (17%) Black (34%) Silver sparkle (10%) Silver sparkle (22%) Yellow (20%) Red (12%)

Rejected color Healing color

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 ShapiroWilk showed that age, length of illness, and education did not have normal distributions. Attempts to transform the data into normal distributions were unsuccessful, thereby necessitating nonparametric statistics. The MannWhitney Test was used to determine whether the cardiac and cancer groups differed signicantly in age, length of illness, and education. Signicant (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; the cardiac 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 predominantly African-American and male. Discussion Stage choices Both cancer and cardiac patients selected Stage 9 (crystallization) most frequently as their preferred design. According to Kellogg (1978), Stage 9 can signify accomplishment of ones goals, the realization of ones mission, and even perfection itself. Given its regulated, symmetrical nature, individuals select Stage 9 when they want to enjoy and preserve 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 of our being we are faced again with our imminent destruction (Kellogg & Di Leo, 1982, p. 43). Stage 9 is encountered often in mature, successful persons being confronted with change and the need to adapt (Kellogg, 1978). As one goes through 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 hang onto what they have accomplished in life, as they are being continually threatened by illness, pervasive changes in all aspects 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 the souls descent into the physical world and the darkness of the womb; it is a state of unconsciousness, accompanied by experiences of compression and depression (Kellogg, 1978). The task during this stage is to wait patiently for things to 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 reect an ongoing struggle with depression, and their need to keep the faith that they will survive their ght for life. Cardiac patients chose Stage 5 (the target) as their third most preferred design. Stage 5 is the space of selfprotection and self-preservation, achieved by setting boundaries around oneself, and through ritualistic (or even obsessivecompulsive) activities (Frame, 1989; Kellogg, 1978). This may reect the cardiac patients need to take care of themselves rather than other people, as well as their need to maintain a healthy daily routine. Stage 11 (fragmentation) gured prominently in the choices of both cardiac and cancer patients. It was the second most frequently preferred stage among cancer patients, while also being their most frequently selected rejected stagean obvious conict. Do they want to be there or not? Interestingly, cancer patients chose stage 11 more frequently as their preferred design than cardiac patients; and cardiac patients rejected Stage 11 more frequently than cancer 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 of boundaries, and the letting go of ones identity. It is the painful stage of disintegration following death. Those patients that preferred Stage 11 are indicating that they are in the throes of the fragmentation processthey are experiencing a falling apart or letting go, and this pre-occupies them. Those patients that rejected Stage 11 are indicating a fear of or resistance to entering the fragmentation stage. It is not surprising to see how prominently Stage 11 gures into the psyche of cancer and cardiac patients, and especially when considered in light of their preference for Stage 9. The juxtaposition of these two stages speaks to the existential conict of chronic illness: Should I try to hang on to myself, and the good in my life (preference for Stage 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 whom preferred Stages 9 and 11, and some of whom rejected 11. Here there is an obvious conict over what to do. Cardiac patients seemed more certain: they clearly prefer Stage 9, and soundly reject Stage 11. Apparently, they want to preserve their 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 signicantly 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 the painful destruction or loss of what has been. This rejection of death may indicate that cardiac patients are avoiding the thought of death, while still being concerned about it at some level. And with this in mind, the comparison with cancer patients is interesting. Cardiac patients may be more fearful of death than cancer patients. Interestingly, however, both cardiac 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 death than 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 to be worried about unchecked cellular growth. According to Kellogg (1978, 1992), Stage 2 represents the intrauterine experience of boundless multiplicities, regeneration, and fertilization, as well as ecstasy and nonordinary states of consciousness. When considered in light of cancer, rejection of this stage symbolizes the fear of cancer cells growing or multiplying (Frame, 1989). While having this concern, some cancer patients expressed hope in their choice of Stage 12 (transcendent ecstasy). This is the stage of rebirth or re-integration of what has existed, died, and disintegrated; it is 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 chosen for the preferred and healing colors by both cardiac and cancer patients, and black was most frequently chosen as the rejected color by both groups. In addition, for secondary choices, white was rejected by cardiac patients, and silver sparkle was rejected by cancer patients. The following discussion of colors and their meanings is based on mandala color 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 dealing with and/or curing their illness. Once again, a conict is seen over this strategy in cancer patients not found in cardiac patients. Specically, 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 to ground 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 is associated with the birth experiencewhere there is the strong will to live and to survive all threats, accompanied by feelings of both dependence and anger. These motives and feelings seem particularly relevant to having cancer or cardiac disease, where there is a constant struggle to survive both the illness and the treatment, accompanied by continual 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 associated with heightened consciousness, awareness, and insight. Thus, cardiac and cancer patients seem to be expressing a need to understand thingstheir life, their own identity, their illness, their best treatment option, and so forth. It is also important to note that yellow is the color of the sun, and can signify radiation; thus it is often seen in the color choices 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 can signify the conscious or subconscious fear of dying, or it may reect the depression or lack of hope associated with the 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 signify their avoidance of a spiritual crisis or task related to existential issues: to live or not to live, to deny what is or to surrender 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 ndings: (1) the demographic differences between the cancer and cardiac groups, and (2) the psychometric nature of the MARI Card Test. Because the two groups differed in age and length of illness, these two variables may be responsible for the differences in design and color choices between cancer and cardiac patients. In addition, because both groups were mostly African-American, and mostly male, the design and card choices of both groups may reect the choices of these two demographic groups. Anastasi (1976) identied three main psychometric problems with most projective tests: scorer reliability (extent of agreement between interpreters), retest reliability (consistency of responses over time), and validity (whether the test measures what it purports to measure). No research has been conducted on scorer reliability for the MARI Card Test; 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) Kelloggs theory 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 to interpreter. Anastasi (1976) points out that this is a problem indigenous to projective testing. In the present study, the interpreter was the primary author, who was certied 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 rst and foremost an assessment of states or stages of development at a given time in the individuals life cycles (Kellogg, 1978). For this reason, the MARI is recommended for use in tracing developmental or therapeutic change (Cox, 2002). Though traits may be inferred from choice patterns in a single test, and repeated choices of the same designs and colors over an extended period of time, or they may be unearthed through research (i.e., Douglass, 1996; Frame, 2002), the immediate interpretation of the card test refers primarily to the individuals here-and-now. Thus, with regard to the MARI , retest reliability issues do not apply in the same manner. As for validity, all of the mandala and MARI research reviewed in the introduction are attempts to establish at least concurrent criterion-related validity. Like the present study, the aim of these studies has been to identify characteristics of particular diagnostic groups or populations, and to compare them with others, thereby increasing the scope and accuracy of interpretations. Anastasi (1976) points out that often the comparison groups in validity research differ along other relevant independent variables (e.g., age, education), which might also account for differences in test results, and therein contaminate the ndings. That issue was evident in the present study, where both age and length of 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 expense of lower delity, 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 wide array of data, leading to unique insights about each examinee that have never been unearthed previously. Both of these advantages certainly inhere in the MARI Card Test. What then are the implications of the present study, and particularly for creative arts therapists? First, the present ndings suggest that the mandala may have clinical value in identifying potential strengths, concerns, and needs of medical patients in a hospital setting. The researchers found that the card test was administered very easily and quickly in 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 patients were confronting while in the hospital, but perhaps unable to communicate or work through verbally, especially in short-term care. Second, the present ndings provide a starting place for clinical assessment and treatment. The card test 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 yielded clinical information that would be useful to both medical and nonmedical staff working with chronically ill patients. As such, the present ndings provide a common ground for creative arts therapists and other hospital personnel to work collaboratively with the same patients. Finally, the present ndings add information about cancer and cardiac patients to 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 cancer patients, the following conclusions may be drawn. Cardiac patients want to preserve what they have achieved in life despite the threats of the disease. They struggle with depression, and need to keep the faith that they will survive their ght for life. Cardiac patients also try to protect themselves and their health through interpersonal boundaries and daily routines. They are more fearful and concerned over death than cancer patients, and they clearly reject the idea of surrendering to the illness, yet both death and surrender are of great concern. Unlike cancer patients, they resist and fear joining the world of the Spirit. Cardiac patients want to develop creative ways of dealing with and/or curing their illness. Like cancer patients, they are in a constant struggle to survive, and they often experience feelings of dependence, depression, and anger. They also have a need to understand themselves, their life, their illness, and their treatment options. Cancer patients also want to preserve what they have achieved in life despite the illness, however, unlike cardiac patients, they are less fearful of or concerned with death, and they are conicted over whether to accept or reject the fragmentation process (falling apart or surrendering to the illness). Cancer patients are greatly concerned with the possibility that their cancer cells may be growing and multiplying unchecked. They combat this fear with hopes of transcending the disease process. At the same time, cancer patients are conicted over whether they should face or look beyond the everyday realities of their illness, and whether they should seek traditional or alternative, more creative approaches to treatment. Like cardiac patients, cancer patients are in a constant struggle to survive both the illness and the treatment, and they have continual bouts with feelings of dependence, depression, and anger. With this comes a need to understand their life, their own identity, their illness, and their best treatment option. These ndings may be limited by demographic differences in age and length of illness found between the cancer and cardiac patients in this study, and by the psychometric issues inherent in projective testing. Nevertheless, the present ndings point to the potential clinical value of the MARI Card Test for creative arts therapists working in a hospital setting. Acknowledgments This study was made possible by a grant from the Pennsylvania Department of Health, offered through the Commonwealth Universal Research Enhancement Program (CURE), authorized through the Tobacco Settlement Act (Act 77 of 2001).

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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 of the 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 Music Therapy, for her role in envisioning and applying for the grant; Dr. Kenneth Soprano Vice-President for Research, for his administrative support; and Dr. Roslyn Gorin for her statistical guidance. References
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