THE RATIONALITY/EMOTIONAL DEFENSIVENESS SCALE- I. INTERNAL STRUCTURE AND STABILITY

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1 Joouml of Psychosomaric Research, Vol. 35. No. 4/S, pp , $ Printed in Great Britain Pergamon Press plc THE RATIONALITY/EMOTIONAL DEFENSIVENESS SCALE- I. INTERNAL STRUCTURE AND STABILITY GARY E. SWAN,*+ DORIT CARMELLI,* ALISON DAME,* RAY H. ROSENMAN* and CHARLES D. SPIELBERGER~ (Received 30 October: accepted in revised form 8 January 1991) Abstract-In a lo-year prospective study, Grossarth-Maticek and colleagues reported that the tendency to repress and/or deny emotions was strongly predictive of cancer mortality. The method used to assess repression/denial was modified recently by Spielberger to form the Rationality/Emotional Defensiveness (R/ED) Scale. The present study investigates the psychometric properties of the R/ED Scale in 1236 male (mean age = 71.8 yr) and 863 female (mean age = 68.5 yr) participants in a 27.year follow-up of the Western Collaborative Group Study. Analyses revealed high interitem consistency (Cronbach s alpha = 0.77 and 0.78 for men and women, respectively) and two independent and stable factors that we labeled Anti-emotionality (27% of total variance) and Rationality (21% of total variance). Excluding cancer subjects, significant gender differences were observed for individual items, total R/ED score, and the two subscales. Comparisons of the 159 male cancer patients and the 175 female cancer patients with the corresponding noncancer subjects suggest possible gender x cancer status and age X cancer status interactions. These results challenge Grossarth-Maticek s assertion that rationality/antiemotionality is a unidimensional construct and indicate the need to take into account the effect of age and gender on the presence of these psychological constructs. INTRODUCTION GROSSARTH-MATICEK and colleagues [ll reported the results of a lo-yr prospective epidemiological study of 1353 subjects from Yugoslavia in which the tendency to repress and/or deny emotions was strongly predictive of cancer mortality. This tendency was measured by 11 items of an interview questionnaire in which subjects responded with either yes or no to each item. Cancer incidence was 40 times higher in individuals responding positively to at least 10 items on this rationalityiantiemotionality (R/A) interview scale. Stimulated by Grossarth-Maticek s results, Spielberger 121 developed the Rationality/ Emotional Defensiveness (R/ED) Scale, a psychometric scale based on the original R/A interview questionnaire. He found that cancer patients had higher R/ED Scale scores than a noncancer comparison group, but the cancer patients were also older and age was positively correlated with R/ED Scale scores [21. Since the R/ED Scale format conforms more closely to accepted standards of psychological tests than the Grossarth- Maticek questionnaire [31, it may be more readily applicable to epidemiological research, but more formal investigation of its psychometric properties is needed. To examine further the psychometric properties and correlates of the R/ED Scale, it was administered to 1393 surviving participants in an ongoing prospective cohort study of coronary heart disease and cancer incidence known as the Western Collaborative * Health Sciences Program, SRI International, Menlo Park, CA 94025, U.S.A. t Author to whom correspondence should be addressed at: Health Sciences Program, SRI International, 333 Ravenswood Avenue, Menlo Park, CA 94025, U.S.A. t Center for Research in Behavioral Medicine and Health Psychology, University of South Florida, Tampa, Florida, U.S.A. This research was supported through grants from the National Heart, Lung, and Blood Institute ROl HL32795 and RJR-Nabisco, Inc., Winston-Salem, North Carolina, U.S.A. 545

2 546 GARK E. SWAN et al. Group Study 141. In addition, the R/ED Scale was administered to 1027 female spouses of these male participants. The inclusion of women was considered important because the original Grossarth-Maticek er al. study 111 was biased toward males (950 males, 350 females). Moreover, expected gender differences in the use of psychological defense mechanisms would suggest different meanings for the construct measured by this scale for men and women. Grossarth-Maticek et al. 111 claimed that their R/A questionnaire measured a single entity that was highly predictive of cancer mortality. In support of this contention, they reported a factor analysis that revealed a large first factor accounting for 66% of the total variance, but no further data were presented regarding the internal structure of this questionnaire. In the present study, the availability of a large male and female sample provided a unique opportunity to examine the factor structure of the R/ED Scale and its stability, and to verify Spielberger s original findings from smaller samples of male and female subjects. The specific objectives of this investigation were to: (1) evaluate the internal consistency of the R/ED Scale items; (2) examine the factor structure of the R/ED Scale and its stability; and (3) explore the effect of gender, age and cancer status interactions on scores for the total R/ED Scale and its two subscales METHOD The subjects were participants in a 27.yr follow-up of the Western Collaborative Group Study [41 and their spouses. The recently concluded 27.yr follow-up examination updated morbidity and mortality for the original cohort of 3154 men who were evaluated initially in For the survivors, current status on a wide array of physiological, cardiovascular, psychological and behavioral variables. including the Type A behavior pattern and hostility, was determined. Questionnaires were mailed to all participants in the WCGS follow-up and their spouses. A total of 1393 men and 1027 women responded to the questionnaire and psychometric scales that were mailed after the follow-up examination. The mailing included a survey of cancer events, Spielberger s R/ED Scale, and several other scales known or suspected to have relevance to the psychosocial prediction of cancer. The response rates after one follow-up reminder were 80% for the WCGS subjects and 60% for their spouses. Of the WCGS subjects, 1% had died since the previous examination and 2% indicated they were not interested in participating. We obtained no response from the remaining 17%. Of the 1393 male respondents, 157 reported that they had previously been diagnosed as having cancer other than of the skin. Follow-up medical information and pathology reports confirmed 97% of the selfreports. The remaining 1236 male subjects included those reporting no cancer or only skin cancer. Of 1027 female respondents. 164 women reported some form of cancer other than of the skin. The final female noncancer sample for this analysis was 863. The mean age of the male noncancer sample used in this analysis was 71.8 yr (SD = 4.9 yr); they reported an average of at least 2 years of college and were mostly retired at the time of assessment (89.3%). A majority of the men (63%) were currently married, and 79.3% reported their primary occupation as either professional or managerial at the time of retirement. Males with cancer were, on average, older (M = 73.0 yr, SD = 5.0 yr), than their male noncancer counterparts, but were otherwise similar with respect to education, occupation at the time of retirement, retirement and marital status. Female noncancer respondents were, on average, younger (M = 68.5 yr, SD = 5.9 yr) and slightly less educated. Seventy-six per cent considered themselves retired. Female cancer respondents were, on average, older (M = 70.0 yr, SD = 5.6 yr) than their noncancer counterparts, but were otherwise similar with respect to education and retirement status. The R/ED Scale consists of 12 item statements (see Appendix) to which subjects respond by rating themselves on a 4-point scale, with I = almost never and 4 = almost always [21. Modification of Grossarth-Maticek s yes-no format was considered necessary because the original wording of the items was so extreme (e.g. Do you always try to do what is reasonable and logical? ) as to make positive responses seem implausible. The response alternatives for the R/ED Scale are the same as those used in the Trait Anxiety Subacale of the State-Trait Anxiety Inventory

3 Rationality/emotional defensiveness-i. 541 In constructing the scale, one of Grossarth-Maticek s original items ( Do you try to solve all interpersonal conflicts by using intelligence and reason, trying hard not to show any emotional response? ) was converted into the items I use intelligence and reason to overcome conflicts or disagreements with other people and When I am in a situation in which I strongly disagree with other people, I try not to show my emotions. The content of the other 10 R/A questions was largely unchanged. Spielberger [21 found that scores on his adaptation of the R/A scale correlated 0.84 with the original R/A questionnaire for both males and females in a sample of 428 university students. He also found the R/ED Scale to have high internal consistency, with alpha coefficients of 0.79 and 0.78 for males and females, respectively. Test-retest stability over a 7- to lo-week interval was good, with coefficients of 0.73 and 0.63 for males and females, respectively. Statistical methods Internal consistency of the R/ED Scale was evaluated separately for males and for females using Cronbach s alpha [71. Item-remainder correlations were also computed separately for males and females. The factor structure of the R/ED Scale was examined using the Principal Components Analysis (PCA) procedure [81. A carimax rotation was used to identify a parsimonious item-factor correlation pattern. The initial step in this phase of the analysis was to conduct a 12.component PCA to determine the number of factors with eigenvalues greater than 1, resulting in the retention of two factors. Given the large sample size employed in this study, it was possible to examine the stability of the resulting factor solution according to a split-half cross-validation procedure [91. The strategy entailed conducting a two-factor PCA with varimax rotation on each of two randomly determined split-half samples. The split samples consisted of 1042 and 1014 subjects. The rotated factor pattern resulted in standardized scoring coefficients from each of the two-factor solutions. Each set of scoring coefficients was then used to calculate two sets of factor scores for the entire study sample. Pearson correlations were computed between the two sets of scores to determine the stability of the factor structure. Using the results of the PCA as a guide, two subscale scores were created by summing individual item responses: Anti-emotionality (sum of items 5 through 12) and Rationality (sum of items 1 through 4). In separate analyses, the General Linear Model procedure [81 was then used to examine the main and interactive effects of gender, age and cancer status on the total R/ED score and the two subscales, Antiemotionality and Rationality. For the purpose of these analyses, age groupings were defined as: younger (<71 yr), middle (71-78 yr), and older (>78 yr) for men, and as younger (<68 yr), middle (68-75 yr), and older (> 75 yr) for women. Cell means and sample sizes are presented in Figs 1 and 2. Because 236 Antlemotlonallty I Rationality I NOlVXZflCNS Cancer status Cancers I Nmcan~ers Cancer status cancers E NOTE: Mean scmes are plotted. 51 _m Cell counts = Noncancer Cancer Males Females Noncancers cancers Cancer status FIG. 1. Gender x cancer interactions for R/ED Scale total score, Anti-emotionality and Rationality.

4 548 GARY E. SWAN et al Antiemotlonallty 148 I Mediim Age Group : Y& Medium Age Group o$ Total WED Scale - t&l63 cmmr - t.abjs noncancer - t - Femalescancer - dr - Femalesnoncancer NOTE: Mean scores are plaited Cell counts = Young Medium Old ywng Medium old Males CallCW NOllCtUlCW Females Cancer Noncancer Age Group FIG. 2. Age x cancer status interactions in males and females for R/ED Scale total score, Anti-emotionality and Rationality. this part of the analysis was intended to explore relationships rather than to confirm hypotheses about the constructs measured by the R/ED Scale, results are discussed at a significance level of p<o.lo. RESULTS Table I indicates that females scored significantly higher on the R/ED Scale than males, t (1774) = -2.12, p = 0.03, with significant male-female differences on 9 of the 12 individual items. Cronbach s alpha suggests high internal scale consistency in the total sample (0.77) and separately in men and women, with values of 0.77 and 0.78, respectively. Item-remainder correlations in the total male sample ranged from 0.22 (item 11) to 0.65 (item 9), with a median of In the total female sample, these values ranged from 0.16 (item 11) to 0.66 (item 9), with a median of Factor structure and stability Table II presents the results of factor analyses of the R/ED Scale items for the entire noncancer sample and for each of the two split-half samples. Emerging from this analysis were two highly replicable factors. The first factor, accounting for approximately 27 % of the total variance, correlated most highly with items 5 through 12 of the R/ED Scale. A review of these items suggests a dominant theme of antiemotionality in response to interpersonal conflict (e.g. When I am in a situation

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6 550 GARY E. SWAN et al. in which I strongly disagree with other people, I try not to show my emotions ). Consistency analysis revealed this factor to have very high stability, rab = Cronbach s alpha for this subscale was The second factor, accounting for approximately 21% of the total scale variance, was marked by high correlations with items l-4 of the R/ED Scale. These items appear to assess rationality as a general approach to life (e.g. I try to do what is sensible and logical ). This factor also had a very high stability, rab = Cronbach s alpha for this subscale was Gender x cancer interactions Figure 1 presents mean scores for the total R/ED Scale and its two subscales, plotted by cancer status and gender. Although the analysis of variance did not detect a significant gender X cancer interaction term for the total R/ED Scale score, F( 1, 2432) = 1.25, p = 0.26, we note that: (1) mean R/ED scores in male and female noncancer subjects are different (p = 0.03), with women scoring significantly higher than men; and (2) the trend in female cancer patients is to score lower than women without cancer, while the trend in male cancer patients is to score higher than males without cancer. A marginally significant gender x cancer interaction was observed for anti-emotionality, F(1, 2439) = 3.16, p = 0.08, with female noncancer subjects scoring marginally higher than male noncancer = 0.10). As for the total R/ED score, a crossover interaction was observed with the male-female difference being in the same direction. Although gender and cancer status did not interact significantly for the Rationality subscale, F( 1, 2439) = 0.86, p = 0.35, we observe that females free of cancer scored significantly higher on rationality than did males free of cancer (p = 0.01). Age X cancer status interactions Figure 2 shows mean scores in men for the total R/ED Scale and its two subscales by age and cancer status. Although the interaction between age and cancer was not significant for total R/ED scores, F(2, 1377) = 0.64, p = 0.53, we observe different relationships with age in male cancer patients than in their counterparts free of cancer. The middle-age group of cancer patients had the highest total R/ED score, while the relationship between age and total R/ED score approximates a positive trend among men without cancer, r = 0.08, p < The nature of the interaction is that of a crossover, with older male cancer patients scoring lower on total R/ED than the younger cancer patients, whereas older noncancer subjects scored marginally higher (p = 0.07) on total R/ED than the younger noncancer subjects. An analysis of variance on these data detected a marginally significant main effect for age, F(2, 1379) = 2.31, p = 0.10, for Anti-emotionality and a nonsignificant age x cancer status interaction, F(2, 1379) = 0.16, p = Multiple comparisons of the means revealed the effect to be due to the difference between young noncancer subjects and the noncancer middle-age < 0.01). A nonlinear relationship with age was also observed for Anti-emotionality with the middle-age group for both subjects with and without cancer scoring the highest. Anti-emotionality was significantly associated with age in male noncancer subjects, r = 0.07, p < 0.05, but not in male cancer patients, r = -0.02, NS. A nonsignificant crossover interaction effect was also observed on the Rationality

7 Rationality/emotional defensiveness-i. 551 subscale, F(2, 1379) = 1.89, p = Younger males with cancer scored the highest on Rationality, while the older males with cancer scored the lowest of all the six age x cancer subgroups. The correlation with age in subjects with cancer was negative and approached significance, r = -0.14, p < In contrast, there was a tendency (although not significant, r = 0.05) for Rationality scores to increase with age among men free of cancer. Figure 2 also summarizes the results of a parallel analysis done for women. The relationship between age and total R/ED score in women free of cancer is positive, r = 0.07, p < 0.05, and very similar to that seen in the male noncancer group. In women with cancer the relationship is nonlinear. In addition, the configuration is quite different from that in males: female cancer patients in the middle age group scored the lowest on total R/ED of all the groups. The overall interaction was, however, not significant, F(2, 1020) = 1.14, p = In females, the pattern of the age x cancer status interaction for Anti-emotionality, F(2, 1020) = 1.69, p = 0.19, was strikingly different from that for males. The trend between age and Anti-emotionality was negative among female cancer patients and positive among women free of cancer, the difference in means being the largest between the oldest age groups (p < 0.10). The age X cancer interaction for Rationality was very similar to that in males. In this analysis, the interaction term was significant, F(2, 1025) = 3.48, p = 0.03, with the largest difference emerging between the oldest cancer and noncancer groups (p = 0.04). Figure 2 shows that old females with cancer scored lower than the other female cancer subjects, and significantly lower than the young female cancer = 0.02). The correlation with age was negative and marginally significant, r = -0.13, p < Among noncancer subjects, no association with age was observed, r = 0.04, NS. DISCUSSION The analyses presented in this paper used a large sample of community-dwelling, relatively healthy, older men and women to examine the internal structure of the newly devised R/ED Scale [21 and thus should have sufficient generalizability to other populations of healthy, older persons. Mean scores for the total R/ED Scale are somewhat higher than those observed in the college-age sample reported by Spielberger (M = 33.8 and 32.2 for males and females, respectively), but similar to those observed in his sample of cancer patients. Internal consistency of the R/ED Scale in the present sample, as indexed by Cronbach s alpha, was high, with values of 0.77 and 0.78 for men and women, respectively. These values are identical to those reported by Spielberger [21 on much smaller and different samples. The relatively high alpha values suggest internal consistency for the total scale, an essential form of reliability [71. Review of the itemremainder correlations suggests that item 11 ( If someone deeply hurts my feelings, I may attack them or respond purely emotionally to him/her ), has, by far, the smallest association with the construct(s) measured by the rest of the scale. Significant differences on specific items and total scale scores were observed between males and females, with women scoring significantly higher on the total scale score. These findings suggest that women may use rationality and antiemotionality as global defenses against the experience and expression of negative

8 552 GARY E. SWAN et al. emotions to a greater degree than men. This finding is similar to what Spielberger 121 observed in his test sample of cancer patients, but opposite to what he found for college students, where males scored higher on the R/ED Scale than females. Spielberger 121 attributed this reversal in magnitude to the effects of age on responses to this scale. In his investigation, age correlated with R/ED scores 0.42 in women but only for men. In the present investigation, we consider the age effect a less probable explanation since the positive associations between age and total R/ED scores were found in both men (r = 0.08) and women (r = 0.07). Moreover, the lower mean age of women subjects would have resulted in women scoring lower than men on the total R/ED Scale. In their original writing, Grossarth-Maticek et al. [ 11 claimed that their rationality/ anti-emotionality interview was highly unidimensional, with factor analyses revealing a large first factor that accounted for 66 % of the total scale variance. However, from the present investigation it is apparent that Spielberger s adaptation of the interview consists of two distinct and highly replicable factors. The larger factor, accounting for 27% of the scale variance, was clearly related to anti-emotionality, i.e. the extent to which individuals use reason and logic to avoid interpersonally related emotions. The second factor, accounting for 21% of the scale variance, which we have associated with rationality, can best be described as indicating the extent to which an individual uses reason and logic as a general approach to life. Review of our results as shown in Fig. 1 indicates that men and women free of disease differ the most on 0.01) and only marginally on Antiemotionality. These results suggest that although women score significantly higher than men on the total R/ED score, the differences appear to result largely from differences in rationality. This finding suggests possible gender differences in the use of cancer-prone defense mechanisms. Our results also demonstrate the potential importance of taking the age x gender interaction into account in the study of rationality and anti-emotionality. Gender differences were clearly evident in the noncancer samples, with women scoring higher than men on the total R/ED Scale and its two subscales. The direction of gender differences, however, was reversed in the cancer samples, with males scoring higher than females for the total R/ED score and Anti-emotionality. Finally, potentially important associations between age and scores on the total R/ED Scale and its two subscales for both males and females were noted in subjects free of disease. However, after the diagnosis of cancer, these associations with age were reversed in direction. For women the effect of cancer diagnosis on the age-rationality association produced a significant difference between the oldest age groups, a pattern repeated at marginal levels of significance for Antiemotionality Further investigation of the characteristics with which Rationality/Anti-emotionality combine to exert a cancer-prone effect should be pursued. Given the acknowledged limitations of the current cross-sectional analysis, we believe that future longitudinal investigations of the R/ED-cancer hypothesis will profit from methodologies that account for age and gender differences. The decline in R/ED defense mechanisms with age in those with cancer could well be shown later to affect eventual survival, a possibility of great importance for efforts at prevention. Because of the relatively old age of this study cohort and its restricted age range, we would expect the

9 Rationality/emotional defensiveness-i. 553 interactions among age, gender and cancer status to be even more in evidence in future study cohorts with a wider age representation. Repression, suppression, control and denial of negative emotions have been related to the initiation and progression of cancer [ 1, These constructs can be viewed as defenses against intense emotion that have physiological and, ultimately, disease consequences. Our factor analysis has identified two constructs that may represent component defense mechanisms. Of the two factors, we hypothesize that Anti-emotionality, which may be defined as the specific avoidance of emotion in interpersonal situations, represents the most toxic element of the total construct. Further investigation of the similarities and differences in correlational patterns with other behavioral, demographic and physiological characteristics, as well as further prdspective studies, are needed to determine whether Anti-emotionality and Rationality each carries with it a differential risk for subsequent cancer, or, as Grossarth-Maticek et al. [ 1 I suggest, the constructs combine to form a global defense mechanism that represents the critical psychosocial risk factor. The study reported herein was conducted independently of a similar, recently published investigation of a Dutch adaptation of Grossarth-Maticek s original interview format [131. Although their analysis of an 1 l-item questionnaire resulted in somewhat lower estimates of internal consistency than those obtained in the present study, their factor analysis resulted in a similar two-factor structure that together accounted for 36% of the scale variance. A review of the items comprising these factors suggests similarity in content to those obtained in the present study. The similarities in dimensionality across cultures leads to increased confidence in the conclusion that the adaptation of Grossarth-Maticek s original questionnaire resulted in two separate components, each of which may be important in its own right as a psychologically meaningful entity and as a possible risk factor for disease. REFERENCES I GROSSARTH-MATICEK R, BASTIAANS J, KANAZIR DT. Psychosocial factors as strong predictors of mortality from cancer, ischemic heart disease and stroke: The Yugoslav prospective study. J Psychosom Res 1985; 29: SPIELBERCER CD. The Rationality/Emotional Defensiveness (R/ED) Scale: Preliminary Test Manual. University of South Florida, Tampa: Center for Research in Behavioral Medicine and Health Psychology, AMERICAN PSYCHOLOGICAL ASSOCIATION. Standards for Educational and Psychological Testing. Washington DC: American Psychological Association, ROSENMAN RH, BRAND RJ, SHOLTZ RI, FRIEDMAN M. Multivariate prediction of coronary heart disease during 8.5 year follow-up in the Western Collaborative Group Study. Am J Cardiol 1976; 37: SPIELBERGER CD. Manualfor the State-Trait Anxiety Inventory, Revised Edn. Palo Alto: Consulting Psychologists Press, SPIELBERGER CD, GORSUCH RL, LUSHENE RD. STAI Manual for the State-Trait Anxiety Inventory ( Self-Evaluation Questionnaire ). Palo Alto: Consulting Psychologists Press, ANASTASI A. Psychological Testing, Fourth Edn. New York: Macmillan, SAS INSTITUTE. SAWSTAT Guide Version, Sixth Edn Cary, NC: SAS Institute, EVERETT JE. Factor comparability as a means of determining the number of factors and their rotation. Multivariate Behav Res 1983; 18: KISSEN DM, EYSENCK HJ. Personality in male lung cancer patients. J Psychosom Res 1962; 6: GREER S, MORRIS T. Psychological attributes of women who develop breast cancer: a controlled study. J Psychosom Res 1975; 19:

10 554 GARY E. SWAN et al. 12. KNEIER AW, TEMOSHOK L. Repressive coping reactions in patients with malignant melanoma as compared to cardiovascular disease patients. J Psychosom Res 1984; 28: VAN DER PLOEG HM, KLEIJN WC, MOOK J, DONGE MV, PIETERS AMJ, LEER J-WH. Rationality and anti-emotionality as a risk factor for cancer: concept differentiation. J Psychosom Res 1989; 33: Interpersonal Behavior Scale (IBS-R/ED) APPENDIX Instructions. A number of statements are listed below which people have used to describe their interactions with others. Read each statement and then circle the appropriate number to indicate how ojien you generally react in the manner described. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe how you generally react. Almost Some Almost never times Often alwavs try to do what is sensible and logical I try to understand people and their behavior 1 try to behave reasonably in my relations with others I use intelligence and reason to overcome conflicts or disagreements with other people When I am in a situation in which I strongly disagree with other people, I try not to show my emotions If someone deeply hurts my feelings, I still try to treat them reasonably and to understand their behavior I try to understand other people even if I do not like them I succeed in avoiding arguments with others by using reason and logic (often contrary to my feelings) If someone acts against my needs and desires, I still try to understand him/her My behavior in most life situations is logical and reasonable, and not influenced by my emotions If someone deeply hurts my feelings, I may attack them or respond purely emotionally My use of reason and logic prevents me from attacking others, even if there are good reasons for doing so Copyright by C. D. Spielberger, E. P. Solomon, S. S. Krasner, and S. E. Oesterle

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