A Rorschach Trauma Content Index and PCL-R Understanding of Female  and Male Psychopaths 

Jason M. Smith & Carl B. Gacono 

        Trauma histories are ubiquitous within offender populations. Prevalence rates for trauma related diagnoses range from 12-54% for females and 4-21% for males (Adams et al., 2017). Much of the psychopathy/trauma literature from the past 20 years addresses methodological issues that obfuscate their findings (Cunliffe et al., 2021b). In this study, the relationship between trauma and psychopathy is explored by comparing the Rorschach Trauma Content Index between female psychopaths (n = 115) and male psychopaths (n = 44). Rather than being linear this relationship appears to be comorbid. Trauma-related disorders do not negate the presence of psychopathy. Offenders, both psychopathic and non-psychopathic, can exhibit histories of trauma. Total TCI scores do not differentiate among these offenders related to their histories of trauma. Our findings are used to explore what the TCI may be measuring in this offender population.  

Introduction: 

        Trauma and psychopathy are essential issues in the assessment and treatment of offenders (Gacono, 2016; Gacono & Meloy, 1994; Hare, 2003). Psychopathy has been described as a disorder characterized by profound emotional deficits, a lack of guilt and empathy, and antisocial behaviors (Hare, 2003). It provides a measure of discriminate ability for predicting outcomes, treatment response, and risk. Based on prior estimates, 10% of incarcerated women and 15-25% of men meet the threshold for psychopathy (PCL-R ≥ 30; Hare, 2003), while the relationship between reported trauma symptomology and gender is the inverse (incarcerated women, 12%-54%; men, 4-21%; Adams et al., 2017; Briere et al., 2016).  

        Hare‟s PCL-R (Psychopathy Checklist-Revised [PCL-R], 2003) is the gold standard for differentiating adult psychopathy groups (Gacono, 2016). PCL-R and/or Rorschach findings have highlighted the differences between male and female psychopaths (Cunliffe et al., 2016; Gacono & Meloy, 1994; Smith et al., 2021), suggesting that the male psychopath is an amalgam of a self-centered, grandiose, and narcissistic personality along with an antisocial/criminal lifestyle (Gacono, 2016; Gacono & Meloy, 1994), whereas the female psychopath demonstrates less arrogance and self-aggrandizement, more interest in others, and in some situations is less violent (Cunliffe et al., 2016; Smith et al., 2021). Female psychopaths can best be understood as having a malignant form of hysteria (Gacono & Meloy, 1994).  

        The women‟s affective and interpersonal style informs a type of pseudo-emotionality and pseudo-dependency which distinguish them from males (Kreis & Cooke, 2011; Smith et al., 2018, 2021). Both male and female psychopaths are organized at a borderline or psychotic level and share a similar cognitive style (Gacono & Meloy, 1994; Smith et al., 2021). Malignant narcissism masks the males underlying paranoid personality (Gacono & Meloy, 1994), while a malignant form of hysteria defends against the paranoid structure in the women (Cunliffe & Gacono, 2005; Gacono & Meloy, 1994; Smith et al., 2018, 2021). These empirical differences have informed suggested revisions for the PCL-R for women (see Cunliffe et al., 2021a), and suggest that gender would inform differential responses to trauma.  

Psychopathy & Trauma 

        Studies over the past 20 years have exhibited similar methodological errors, such as using an inappropriate measure for determining psychopathy. Correlations with PCL-R Factor 2 (antisocial lifestyle), rather than Factor 1, result in self-report measures such as the Personality Assessment Inventory (PAI; Edens et al., 2000) or the Psychopathic Personality Inventory (PPI; Lilienfeld, 1991; PPI-R; Lilienfeld & Widows, 2005) being of little use in forming psychopathy groups. Regarding the assessment of trauma, a reliance on inmate self-report without the support of third-party sources disallows certainty regarding the accuracy of these data (Craparo et al., 2013). These methodological flaws have contributed to counterintuitive and conflicting findings that lead to erroneous and nonsensical conclusions, such as complex trauma or PTSD mimics psychopathy (Herman, 1992), or trauma leads to psychopathic traits (Boduszek et al., 2019; Odgers et al., 2005). 

        Several studies have pointed to an association between trauma histories and the antisocial lifestyle component (Factor 2) of the PCL-R. Reported histories of childhood abuse in male offenders, were moderately related to the impulsive and irresponsible lifestyle facet, but not total PCL-R scores (Poythress et al., 2006). A history of suicide, physical, and/or sexual abuse in women offenders were found to be moderately correlated with PCL-R Factor 2 but negatively related to Factor 1 (Verona et al., 2005). Child abuse and neglect were found to be unrelated to PCL-R Factor 1 scores in male rapists (Graham et al., 2012). In a well-designed PCL: YV study (Psychopathy Checklist: Youth Version; Forth et al., 2003), with incarcerated German youth (N = 341; 170 male & 171 female adolescents), high levels of trauma correlated with Factor 2 (antisocial lifestyle) on the PCL: YV, but not with Factor 1 scores (affective & interpersonal facets; Sevecke et al., 2016). Cook et al. (2010) also found that correlations between PCL: YV Factor 2 and total scores predicted psychiatric hospitalization and adjustment difficulties, while Factor 1 scores did not.  

        In their study of 180 incarcerated women, Smith et al. (2020) found high rates of trauma-related disorders for both psychopathic (52.4%) and non-psychopathic (53.8%) offenders. It should be noted that the distribution of trauma disorders occurred equally between the psychopaths and non-psychopaths and high rates of psychopathy were noted in those without a trauma history. Around 50% of each group did not have trauma histories, suggesting a co-morbid rather than a causal relationship between trauma history and psychopathy (i.e., trauma causes psychopathy).  

        While trauma of all types can impact an individual‟s personality development, the idea that trauma causes psychopathy or is etiologically linked to psychopathy has not been demonstrated. This idea is a red herring fallacy diverting attention away from the erroneous argument some investigators (i.e., Motz, 2020) are trying to suggest, namely that the psychopathy construct cannot be applied to women (Cunliffe et al., 2021b).  

Rorschach Measures of Trauma 

        Comprehensive System (CS) Rorschach variables have been used extensively for studying trauma (Acklin, 2013; Armstrong, 2002; Armstrong & Loewenstein, 1990; Brand et al., 2006; Gacono & Meloy, 1994; Kaser-Boyd & Evans, 2008; Piotrowski, 2017; Smith et al., 2020, 2021; Viglione et al., 2012). While many indices provide support for the presence and nature of stress, vulnerability, a selfexperience of being damaged, and indices of primitive content (Gacono & Smith, 2022a; Perry & Viglione, 1991; Resnick, 1994), the Trauma Content Index (TCI; Armstrong & Loewenstein, 1990) has been used specifically for this purpose.  

The TCI is calculated by summing Rorschach responses that contain: 1) Blood (Bl), 2) Anatomy 

(An), 3) Sex (Sx), 4) Morbid (MOR; i.e., something is torn, broken, damaged) and 5) Aggressive 

        Movement (AG) divided by the total number of Rorschach responses ([Bl + An + Sx + MOR + AG]/R; CS, Exner, 2003; CS-R, Exner et al., 2022). A mean of 0.25 has shown specificity and sensitivity for trauma, while mean scores greater than 0.30 have been suggested to indicate traumatic intrusions and have been proven to differentiate traumatized and non-traumatized patients (Armstrong, 2002; Smith et al., 2020). A TCI score of ≥ 0.35 has shown to indicate dissociative symptoms (Brand et al., 2006). The fact that some combination of the TCI indices has been included in the Conceptual Ego Strength Index (primitive contents; CESI, Resnick, 1994; the Critical Contents score [R-PAS Crit Cont %; Meyer et al., 

2011]), the Ego Impairment Index (derepressed content; Perry & Viglione, 1991), and the Gacono Aggressivity Cluster (GAC, drive laden content, DLC; Gacono & Smith, 2022a), speak to the importance of what these scores measure as related to several dynamic issues.  

        Most research has supported the utility of the TCI (Armstrong & Loewenstein, 1990; KaserBoyd, 2021; Smith et al., 2020; Viglione et al., 2012; Zukerman et al., 2017). The TCI was correlated with personal traumatic history and intrusive traumatic imagery (Armstrong & Loewenstein, 1990; Zukerman et al., 2017). In a female offender population, the TCI was correlated with the total number of reported traumatic events and sexual abuse events but not total reported physical abuse events (Smith et al., 2020). High scores on the TCI have been related to sexual abuse, dissociation, physiological responses, higher levels of arousal, and those diagnosed with PTSD produce high scores (Armstrong & Loewenstein, 1990; Brand et al., 2006; Zukerman et al., 2017).  

        Interestingly, the TCI was significantly correlated with the PAI Borderline features scales (Smith et al., 2020). Both PTSD and Borderline Personality Disorder (BPD) were prominent within incarcerated women (Acklin, 2013; Smith et al., 2018, 2020). The TCI and Rorschach Oral Dependency (ROD) have also been found to be significantly correlated suggesting that traumatic intrusions may relate to higher levels of “dependency” (Smith et al., 2020). The association of the TCI with borderline features becomes particularly relevant, when considering the similarities of the TCI to components of the EII, CESI, and GAC and what it may be measuring. 

        TCI scores have been higher in debt collectors than those that have committed homicides or had low levels of violence (Nørbech et al., 2016). Female sexual offenders also tend to have had high TCI scores (M = 0.23; Smith et al., 2019). The relationship between AgPast (Gacono & Meloy, 1994) and the TCI (MOR) suggests the sense of damage relates to victimization or traumatic events (Kamphuis et al., 2008; Smith et al., 2020). For some antisocial offenders it provides a marker for their feelings of entitlement to harm others (Gacono & Meloy, 1994).   

        In this study, we examined the TCI in incarcerated female (n = 115; PCL-R ≥ 30) and male (n = 44; PCL-R ≥ 30) psychopaths. Our previous findings suggest that female psychopaths would produce a higher TCI score than male psychopaths due to their higher rates of somatic concerns (An) and damaged sense of self (MOR). We also explore how the unique styles of the male and female psychopath create different developmental pathways for responding to trauma. The hysterical style of the women, that includes somatic concerns (An + Xy; Kwawer [1980] Malignant Internal Processes) would lend itself to incorporating the impact of trauma (and a pseudo-dependency; Sum T, ROD) while the males‟ independent narcissistic style would function to deny, minimize, and defend against it (EGOI; Fr + rF; vulnerability).  

Method: 

Participants 

        The authors collected archival prisoner data at various USA prisons (N = 442; 105 males, 337 females). Participants provided informed consent, and the IRB and correctional institutions approved the research. The PCL-R (≥ 30) identified 120 females and 50 males. Two females (2%) were excluded as they had an IQ score < 80 (Shipley-2) and three had < 14 Rorschach responses (3%). The male group exclusions included two (4%) with IQs < 80 (SILS) and four (8%) with < 14 Rorschach responses.  

        After the IQ and total Rorschach responses exclusions there were 159 participants left to examine in the study (female psychopaths, n = 115; male psychopaths, n = 44). Inmate security status ranged from minimum to maximum. Males were 68% Caucasian, 18% African American, 11% Hispanic, and 2% Native American, with a mean age of 31.32 (SD = 6.48, range = 18-43). Females were 58% Caucasian, 32% African American, 8% Hispanic, 2% Asian, and 2% Native American with a mean age of 35.98 (SD = 9.85, range = 20-70). Males‟ offenses included 16% violent crimes, 18% drug offenses, 16% sexual offenses, and 50% other. Females‟ offenses were 46% drug-related, 16% fraud, 20% theft,  27% violent crimes, 12% sexual offenses, and 32% other. Reliable and verifiable data related to traumatic events for the males were not available. For the females, 59 (51%) did not have a reported/verified traumatic history and 56 (49%) did have reported and verified traumatic history. 

Measures 

         The Shipley Institute of Living Scale (SILS; Shipley & Zachary, 1986) or the Shipley-2 (Shipley et al., 2009), Psychopathy Checklist-Revised (PCL-R; Hare, 2003) and Comprehensive System Rorschach (CS; Exner, 2003; CS-R; Exner et al., 2022) were administered in accordance with test manual procedures. All measures were completed by doctoral-level Psychologists (Ph.D. or Psy.D.) with extensive training in the scoring, administration, and interpretation of these measures. 

The SILS/Shipley-2 were used to provide an estimate of intelligence. It is essential to utilize a cognitive measure in Rorschach studies as low IQ is one of several confounds that can contribute to a constricted Rorschach protocol (Gacono, 2019; Gacono & Gacono, 2008; Gacono & Smith, 2022b; Smith et al., 2018, 2020).  

        The Psychopathy Checklist-Revised (Hare, 2003) was used to determine the presence or absence of psychopathy. This measure contains 20 items and is administered via a file review prior to the semi-structured interview (CFIS; Gacono, 2005). During the interview, personality characteristics and antisocial behaviors are evaluated on a three-point ordinal scale with a total score range of 0 to 40. While optimal PCL-R cutoff scores may vary in clinical usage, a PCL-R total score ≥ 30 is recommended as a cut score when categorically comparing psychopaths and non-psychopaths (Gacono, 2016). This cut off ensures the presence of psychopaths in the study. Lowering the PCL-R total score for psychopathic women is not warranted for various reasons including its impact on the generalizability of findings (Cunliffe & Gacono, 2005; Smith et al., 2021). 

        The file review that was used for the PCL-R was also completed for the trauma history. Collateral records were reviewed to determine the presence of any trauma history. Self-report and the Stressful Life Events Screening Questionnaire (SLESQ; Goodman, Corcoran, Turner, Yuan, & Green, 1998) were used to identify women‟s trauma. To verify the trauma, there had to be collateral data to support if not it was classified as unverified.  

        All the Rorschach protocols were administered and scored per the Exner Comprehensive System Guidelines thereby ensuring the comparison of findings with other CS studies as well as the over 2500 patient and nonpatient CS data (Exner, 1991), and over 2000 other CS forensic protocols available (Gacono et al., 2008). Twenty protocols were scored blindly by two raters who have been trained extensively in the Rorschach and inter-rater reliability was calculated from these protocols.  

Data Analysis 

The Statistical Package for Social Sciences (SPSS) version 27 was used for all calculations and descriptive statistics. The data were analyzed for means, standard deviations, and ranges.  

Results: 

        The mean PCL-R score for women was 33.11 (SD = 2.27, range = 30-39), and very similar to the men (M = 33.14; SD = 2.32, range = 30-38). IQs for both groups (women M = 96.54, SD = 15.18, range = 80-155) and men (M = 101.30, SD = 9.58, range = 81-137) fell within average range. The women produced a valid number of Rorschach Responses (R; M = 21.88; SD = 8.83, range = 14-55) with a mean Lambda of 0.74 (SD = 0.69, range = 0.00-6.00). The women‟s total R were slightly higher than the men‟s R (M = 20.52, SD = 7.62, range = 14-52) while Lambda were slightly lower (Men M = 0.92, SD = 0.62, range = 0.13-2.50). Both R and Lambda differences represent a gender-based trend consistent with the psychopathic women producing significantly more CS determinants, indicative of their pseudoaffectivity and struggles with emotion (Gacono, 2019; Gacono & Smith, 2021; Smith et al., 2021). 

Table 1. Rorschach Responses and Lambda between Psychopaths 

Note: M = mean; SD = standard deviation; Freq = the number of individuals who produced at least one of the variables; statistic = t-test; R = responses; TCI = trauma content index; * = p < .05.  

For the TCI, the females produced significantly higher TCI scores than the males (women = M = 0.30, SD = 0.20; men = M = 0.22, SD = 0.20; t-test = 2.03, p = 0.022, es = 0.42). For replication and comparative reasons, the individual means, standard deviations, and frequencies were presented for AgPast and each of the TCI variables.  No statistical tests were completed on the individual scores.  

A supplemental TCI analysis the psychopathic women with and without a verified trauma history revealed virtually identical TCI scores (trauma [n = 59]; TCI = M = 0.30, SD = 0.20; no trauma [n = 56]; TCI = M = 0.31, SD = 0.22). Within the no trauma history group, 35 (60%) had a TCI ≥ 0.25.   

An additional comparison of non-psychopathic women (n = 54; TCI = M = 0.25, SD = 0.15) found a nonsignificant difference compared to the psychopathic females (n = 115; TCI = M = 0.30, SD = 0.20). Those non-psychopathic women with trauma histories (n = 24; M = 0.23, SD = 0.16) were not significantly different than those without trauma histories (n = 30, M = 0.26, SD = 0.15). Within the no trauma history group, 13 (43%) had a TCI ≥ 0.25.  

Discussion: 

        Although there are characteristics male and female psychopaths have in common (borderline or psychotic level of personality organization, similar cognitive style; Cunliffe et al., 2021b; Gacono, 2021; Smith et al., 2021), female psychopaths may be distinguished from their male counterparts by their negative self-image, dysphoric emotions, and heightened needs for approval and attention (as demonstrated by history, presentation, and Rorschach variables such as Lambda, Sum C‟, Sum Y, Sum T, Sum V, Sum C, INT, MOR, ROD). The aggressive, violent (in many cases physically imposing), narcissistic, grandiose, shallow, and detached presentation of male psychopath contrasts with the frequently affectively laden presentation of the female psychopath (Cunliffe et al., 2021b; Gacono, 2016; Gacono & Meloy, 1994; Hare, 2003). The male‟s grandiosity and shallowness affect circumvents any threats to their self-worth including experiences that would evoke feelings of vulnerability (such as trauma). Consequently, these indices are less prevalent on the Rorschach for non-sexually offending psychopaths.  

        The pseudo-dependency of female psychopaths is interpersonally evident through the way they incorporate the examiner as an aid for managing painful emotions and regulating self-esteem (Gacono & Smith, 2021). Unlike the males whose grandiosity and detachment ward off emotional disruptions to what is already shallow affectivity, the female uses others to stabilize an abundance of mostly dysphoric, poorly managed, and poorly tolerated affect (Smith et al., 2021). These women are also found to be sensitive to criticism or withdrawal of attention, needing others to mirror back to them that they are good (see Gacono & Smith, 2021; Smith et al. 2021 for gender related transference and counter transference issues). 

        Offender gender differences also present for patterns of aggression and violence (Smith et al., 2021). Women serving a sentence for a violent offense have been found to be twice as likely than men to have committed their offense against an acquaintance. Rorschach patterns support the heightened interpersonal dependency, poor understanding of others, and limited capacity for introspection which increase the female psychopath‟s risk of offending against her family, friends, and acquaintances. 

        Although male violence is frequently driven by narcissism, detachment, and a need to dominate (Gacono  & Meloy, 1994), much of female violence appears to be closely related to a lack of emotional control (affective violence; Cunliffe et al., 2021b; Smith et al., 2021) and concerns about disapproval and loss of group membership. These differences were reflected in the higher scores for women versus men on the TCI.  

        The TCI focuses on five variables: Bl, An, Sx, MOR, and AG. The first four were elevated for the female psychopaths (see Table 1). Somatic concerns (An) and a damaged sense of self (MOR, AgPast) are consistent with the hysterical style and borderline functioning of the women such that their low self-worth and somatic preoccupations create self-focus centered on dysphoria and self-critical attitudes (they tend to produce elevations for pair responses rather than reflections) and separate them from the men. When the female psychopath gazes into the mirror, she sees a devalued and damaged self (MOR; AgPast; somatic concerns; An), rather than an idealized one. She “needs” others to mirror back an ideal image that she cannot. As noted by Berg et al. (1994; in Gacono & Meloy, 1994): 

… object relations will be pre-oedipal in both groups [BPD women & ASPD women] … Both groups will be characterologically rigid, self-absorbed, and likely to express a narcissistic sense of entitlement: the borderline female‟s wish to be taken care of, the antisocial female‟s wish to take (Berg et al., 1994, pp. 18-19; in Gacono & Meloy, 1994, p. 108).   

        Hysterical mechanisms provide cover for a conflicted, inconsistent, broken caricature of feminine identity. Her tendency to accept a victim role (MOR correlates with AgPast; M = 2.25; victim of aggression; Smith et al., 2020) becomes a fallback position for her failure to accept responsibility for her behavior (victim stance; “If I had better parents then things would have been better”; PCL-R item 16).  

        For psychopathic women the prevalence of splitting and other immature defense mechanisms (Splitting; 78%; Projection, 85%; Boundary Disturbance; 83%; Pollyannish Denial; 61%; Hypomanic denial; 65%; Smith et al., 2021) would be consistent with borderline personality organization, dissociation, and traumatic intrusions suggested by the elevated TCI scores (TCI ≥ 0.30). The defenses are not effective, but rather, represent desperate strategies for coping with affect. Traumatic intrusions are linked to primitive paranoia found in female psychopaths (Smith et al., 2021). Dissociation is a common defense used in individuals with traumatic histories, and suggestive of the vulnerabilities inherent to borderline personality organization and borderline personality traits measured by the PAI (TCI; Smith et al., 2021; impaired abilities to manage and tolerate strong emotion (Acklin, 2013). Further, it has been suggested that “dissociation is an ideational defense employed to ward off overwhelming, intrusive, traumatic material” (Brand et al., 2006, p. 163). These women displayed dissociation but do not appear to be flooded (TCI ≥ 0.50) with traumatic content due to their fleeting and shallow emotional displays (Brand et al., 2006).  

        For psychopathic women, dissociation occurs in response to all types of stressors (Smith et al., 2021). The use of dissociation is supported by the higher rates of Impressionistic Reponses (IMP, Gacono & Meloy, 1994; Mp, Hx, AB [FQnone]) responses, Smith et al., 2021). The paranoia experienced within the borderline-hysterical personality (trauma in these individuals as well; Acklin, 2013; Gacono & Smith, 2021; Smith et al., 2021) is, in part, due to a felt awareness of their severe vulnerabilities (instability in several domains). The TCI seems to relate to difficulties managing strong emotion, an avoidance of unwanted internal experiences, and external experiences that could trigger a memory (Smith et al., 2020), traumatic symptoms (Smith et al., 2021), and a fragile sense of self.  

        The TCI score may also suggest how these women process their trauma and internalize (nonpatients) or act out (antisocial women) their emotions (also Fi + Ex scores; M = 0.50). For the female psychopaths it adds to the mix of emotions increasing frustration levels and making their inner world even more difficult to contain, avoid, and distance from. These difficulties managing affect contribute to their acting out/behavioral impulsivity.  

        In addition, 12% of the female psychopaths produced at least one Aggressive Vulnerability (AgV; Gacono & Meloy, 1994). AgV is coded when the person identifies a percept as vulnerable to attack, exploitation, or indicates that the object has taken steps to protect itself from predation (Gacono & Smith, 2022a). AgV implicates a sensitivity or preoccupation with vulnerability or being exploited, injured, or victimized and suggests an expenditure of psychic energy in protecting oneself (Gacono & Smith, 2022a). Joubert and Webster (2017) found AgV to be associated with sexual abuse, neglect, and physical abuse as well as with caregiver-rated conduct problems in a sample of foster care children. The AgV response does appear to indicate a sense of vulnerability and deviance/aggression based on a need for self-protection, an expected finding in female offenders. 

        At least 50% of female psychopaths did not have any reported histories of trauma. This supports a co-morbid relationship between psychopathy and trauma. From a treatment perspective, to assume that a trauma history negates the presence of an ingrained personality syndrome such as psychopathy (much like replacing a bonafide BPD diagnosis with a PTSD label; see Acklin, 2013), would be contrary to the data and lead to misguided interventions and, at times, disastrous results. As noted by Mason and Kreger, 

“... it is no more ethical to keep silent about a mental health diagnosis than a physical one.” (2020; p. 

196).  Correlations with the PCL-R Factor 2 scores rather than Factor 1 speak to this distinction.  

What does the TCI measure in Antisocial/Incarcerated Populations? 

        For our sample, the TCI mean score for men (M = 0.25) would suggest the presence of trauma despite its absence in their reported histories. Sixty percent of female psychopaths and 43% of nonpsychopathic women would be misclassified as having a trauma history based on a TCI score ≥ 0.25. It is not suggested to use the TCI score to determine the presence of trauma and in fact elevated TCI is like Dramatic Contents (Ganellen, 1994) that it is sometimes used to assess malingering on the Rorschach. As noted by Mason and Kreger, “It‟s a myth that BPD is a result of some form of childhood abuse. Yes, many people with BPD have been the victim of abuse, abandonment, neglect, or other mistreatment ... But we don‟t really know how many fit that pattern, because of flaws in the research” (2020, p. 238). The exact statement describes the relationship between trauma and psychopathy.    

        The frequency of AG in these forensic populations may underestimate the trait or process it purports to measure, when compared to non-patients (Gacono, 1988; Heaven, 1989). Gacono (1988) observed that antisocial personality disordered (ASPD) and psychopathic males, despite real world histories of violence, produced few AG movement responses (Exner, 2003) compared to Exner‟s (1991) presumably non-violent non-patients (Heaven, 1989). Perhaps, including one or more of the other Extended Aggressive scores might prove more fruitful (Gacono & Meloy, 1994; Gacono et al., 2008), or adding a half or full point for those MORs that are also AgPast. It should be noted that the total female psychopaths‟ group score was higher (M = 0.30) than not only our male psychopaths but also more than a group of nonviolent pedophiliac males with trauma histories (Gacono et al., 2008; N = 39; M = 0.14) and a group of sexual homicide male perpetrators which also had a history of trauma (Gacono et al., 2008; N = 38; M = 0.21).   

        Perhaps, TCI scores in higher functioning, neurotically oriented, non-patients relate to internal processes of trauma or ego-dystonic aggression (AG), resting on higher level defenses such as repression. While in the psychopathic women, it relates to self-critical attitudes and a tendency to accept a victim role and leads to an inability to regulate their own esteem relating to identity problems (PAI borderline traits).  

        So, does the TCI really measure “trauma”? The answer rests within an understanding of how the Rorschach works. The Rorschach does not measure diagnoses or a given behavioral historical marker, no more than a reflection response equals psychopathy (Fr + rF relates to self-focus-how one regulates one‟s self-worth). The Rorschach measures traits.  

        From this perspective the fact that there was no significant difference on the TCI for those with or without a history of trauma (regardless of psychopathy level) seems to negate its value for predicting a trauma in this population as well as the possibilities of creating false positives. The TCI seems to be assessing a type of personality vulnerability or weakness (note correlations with PAI borderline scales in our population; Smith et al., 2020).  

        With this as a premise, it is important to note the similarities of the TCI and the derepressed content items of the Ego Impairment Index, the primitive contents of the Conceptual Ego Strength Index (CESI; Resnick, 1994; now known in R-PAS as CritCont%, Meyer et al., 2011) and the drive laden material (DLC) in the Gacono Aggressivity Cluster (Gacono & Smith, 2022a). The authors of the EII (Perry & Viglione, 1991) and CESI (Resnick, 1994) suggest that the presence of those variables suggest a measure of ego lapse or failure to censor problematic imagery and/or the presence of dissociation. The drive laden content (DLC) of the GAC also suggests a vulnerability to acting on primitive aggressive/dysphoric impulses. The abundance of primitive content contributes to a weakness for acting out when stressed, while providing the fuel for the fire. Further research comparing primitive content between these four indices (TCI, EII, GAC, CESI/CritCont%) could lead to further clarity regarding what they measure (also see Holt, 1978; primary and secondary content).  

Conclusions: 

        Psychopathic men and women differ. The male‟s grandiosity functions effectively in warding off external and internal threats to self-image, while women‟s malignant hysteria does not. TCI differences support this pattern, whereby the women display more typical responses to the measurement of Rorschach trauma. 

        Trauma-based research purporting to study psychopathy must use an appropriate measure such as the PCL-R for creating psychopathy groups. Equally important, trauma histories, whenever possible, should be supported by third party information. As noted by one psychopathic male who had reported being raped and molested at age six, but later said that he had lied, “when you‟re going to be an actor, you need to set the stage right” (Meloy & Gacono, 1993, p. 359). It is not recommended using the TCI as a measure of “trauma” in this population. Considering it a direct predictor of trauma, rather than a measure of personality vulnerability, involves circular reasoning, hasty generalization, and confirmation bias. What it appears to identify here is a type of personality deficit frequently found in borderline personality functioning. As trauma is ubiquitous in borderline functioning (Acklin, 2013) the mistaken transposition from trait (personality vulnerability) to behavior (trauma) is easily understood.  

        Though it is not meant to make diagnoses, the Rorschach can provide information about personality characteristics, including the individual‟s response to trauma, above what is offered by selfreport measures. The current findings have both clinical and research implications, given that a recent analysis in the journal Traumatology found that „personality‟ issues are an under-studied area of scholarly investigation (Piotrowski, 2024). Finally, future trauma-related research with the Rorschach would benefit by investigating the relationship between the TCI, and other measures of primitive content, measures of PTSD, and perhaps, adjusting the Aggression score (AG) for the TCI when evaluating forensic offender populations (also see Piotrowski, 2020).  

References: 

Acklin, M. W. (2013). Psychodiagnosis of personality structure: Borderline personality organization. In J.R. Meloy, M.W. Acklin, C.B. Gacono, J.F. Murray, & C.A. Peterson (Eds.), Contemporary Rorschach Interpretation (pp. 109-121). Routledge. 

Adams, S., Houston-Kolnik, J., & Reichert, J. (2017). Trauma-informed and evidence-based practices and programs to address trauma in correctional settings. Illinois Criminal Justice Information Authority, 1, 1. https://icjia.illinois.gov/ researchhub/ articles/trauma-informed-and-evidence-based-practices-and-programs-to-address-trauma-in-correctionalsettings 

Armstrong, J. G. (2002). Deciphering the broken narrative of trauma: Signs of traumatic dissociation on the Rorschach. Rorschachiana, 25(1), 11-27. 

Armstrong, J.G., & Loewenstein, R.J. (1990). Characteristics of patients with multiple personality and dissociative disorders on psychological testing. The Journal of Nervous and Mental Disease, 178(7), 448-454. 

Berg, J., Gacono, C.B., Meloy, J.R., & Peaslee, D. (1994). A Rorschach comparison of borderline and antisocial females (Unpublished manuscript). 

Boduszek, D., Debowska, A., Willmott, D., Jones, A.D., DeLisi, M., & Kirkman, G. (2019). Is female psychopathy linked with child abuse? An empirical investigation using a person-centered approach. Jrna.l of Child Sexual Abuse, 28(6), 708-725. 

Brand, B. L., Armstrong, J. G., & Loewenstein, R. J. (2006). Psychological assessment of patients with dissociative identity disorder. Psychiatric Clinics, 29(1), 145-168. 

Briere, J., Agee, E., & Dietrich, A. (2016). Cumulative trauma and current posttraumatic stress disorder status in general population and inmate samples. Psychological Trauma: Theory, Research, Practice, and Policy, 8(4), 439-446. 

Cook, N. E., Barese, T. H., & Dicataldo, F. (2010). The confluence of mental health and psychopathic traits in adolescent female offenders. Criminal Justice and Behavior, 37(1), 119-135. 

Craparo, G., Schimmenti, A., & Caretti, V. (2013). Traumatic experiences in childhood and psychopathy: A study on a sample of violent offenders from Italy. European Journal of Psychotraumatology, 4(1), 214-271. 

Cunliffe, T., & Gacono, C. B. (2005). A Rorschach investigation of incarcerated female offenders with antisocial personality disorder. International Journal of Offender Therapy and Comparative Criminology, 49(5), 530-546. 

Cunliffe, T. B., Gacono, C. B., & Smith, J. M. (2021a). Descriptions of eight select psychopathic traits evident in women. In J.M. Smith, C.B. Gacono, & T.B. Cunliffe (Eds.), Understanding female offenders: Psychopathy, criminal behavior, assessment, and treatment (pp. 455-463). Elsevier Academic Press. 

Cunliffe, T. B., Gacono, C. B., & Smith, J. M. (2021b). Understanding bias in diagnosing, assessing, and treating female offenders. In J.M. Smith, C.B. Gacono, & T.B. Cunliffe (Eds.), Understanding female offenders: Psychopathy, criminal behavior, assessment, and treatment (pp. 33-112). Elsevier Academic Press. 

Edens, J. F., Hart, S. D., Johnson, D. W., Johnson, J. K., & Olver, M. E. (2000). Use of the Personality Assessment Inventory to assess psychopathy in offender populations. Psychological Assessment, 12(2), 132-139. 

Exner, J. E., Jr. (1991). The Rorschach: A comprehensive system: Interpretation, (Vol. 2). John Wiley & Sons. 

Exner, J. E. (2003). The Rorschach: A comprehensive system (4th ed.). Wiley. 

Exner, J. E., Fontan, P., & Andronikof, A. (2022). Rorschach: The Comprehensive System-Revised, Interpretation & Technical Manual: Rorschach Workshops.  

Forth, A. E., Kosson, D. S., & Hare, R. (2003). Hare Psychopathy Checklist: Youth version: Multi-Health Systems. 

Gacono, C. B. (1988). A Rorschach analysis of object relations and defensive structure and their relationship to narcissism and psychopathy in a group of antisocial offenders. United States International University. 

Gacono, C. B. (2005). A clinical and forensic interview schedule for the Hare psychopathy checklist-revised and screening version: Erlbaum. 

Gacono, C. B. (2016). The clinical and forensic assessment of psychopathy: A practitioner’s guide (2nd ed.). Routledge/Taylor & Francis Group. 

Gacono, C. B. (2019). The importance of Lambda to the generalizability of Rorschach findings reported in the literature. SIS Journal of Projective Psychology & Mental Health, 26(2),104-106. 

Gacono, C. B. (2021). Introduction. In J.M. Smith, C.B. Gacono, & T.B. Cunliffe (Eds.), Understanding female offenders: Psychopathy, criminal behavior, assessment, and treatment (pp. 1–32). Elsevier Academic Press.  

Gacono, C. B., & Meloy, J. R. (1994). The Rorschach assessment of aggressive and psychopathic personalities. Erlbaum. 

Gacono, C. B., Gacono, L. A., Meloy, J. R., & Baity, M. R. (2008). The Rorschach assessment of aggression: The Rorschach Extended Aggression scores. In C. B. Gacono, & F. B. Evans (Eds.), The handbook of forensic Rorschach assessment (pp. 543–559). Routledge/Taylor & Francis Group.  

Gacono, C. B., & Smith, J. M. (2021). The psychological assessment of female offenders. In J.M. Smith, C.B. Gacono, & T.B. Cunliffe (Eds.), Understanding female offenders: Psychopathy, criminal behavior, assessment, and treatment (pp. 241298). Elsevier Academic Press.  

Gacono, C. B., & Smith, J. M. (2022a). The extended aggression scores & Gacono aggressivity cluster: Assessing aggressivity with Comprehensive System-Revised. In J.M. Smith, Y. Weinberger-Katzav, & P. Fontan (Eds.), The Rorschach: A Comprehensive System–Revised: Supplementary scales handbook. Rorschach Workshops.  

Gacono, C. B., & Smith, J. M. (2022b). Some comments on the idiographic interpretation of Rorschach findings. SIS Journal of Projective Psychology & Mental Health, 29(1), 4-14. 

Gacono, L. A., & Gacono, C. B. (2008). Some considerations for the Rorschach assessment of forensic psychiatric outpatients. In C. B. Gacono, F. B. Evans (Eds.), The handbook of forensic Rorschach assessment (pp. 421–444). Routledge/Taylor & Francis Group.  

Ganellen, R. J. (1994). Attempting to conceal psychological disturbance: MMPI defensive response sets and the Rorschach. Journal of Personality Assessment, 63(3), 423-437. 

Goodman, L. A., Corcoran, C., Turner, K., Yuan, N., & Green, B. L. (1998). Assessing traumatic event exposure: General issues and preliminary findings for the Stressful Life Events Screening Questionnaire. Jrna.l of Traumatic Stress, 11, 521–542.  

Graham, N., Kimonis, E. R., Wasserman, A. L., & Kline, S. M. (2012). Associations among childhood abuse and psychopathy facets in male sexual offenders. Personality Disorders: Theory, Research, and Treatment, 3(1), 66-75. 

Hare, R. D. (2003). Hare Psychopathy Checklist-Revised (PCL-R) technical manual (2nd ed.): Multi-Health Systems, Inc. 

Heaven, T. R. (1989). The relationship between Hare's psychopathy checklist scores and selected Exner Rorschach variables in an inmate population. United States International University. 

Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377-391. 

Holt, R. R. (1978). Methods in clinical psychology (Vol. 1): Plenum Press. 

Joubert, D., & Webster, L. (2017). Aggressive drive derivatives in the Rorschachs of maltreated children and adolescents: Latent structure and clinical correlates. Journal of Personality Assessment, 99(6), 626-636. 

Kamphuis, J. H., Tuin, N., Timmermans, M., & Punamäki, R. L. (2008). Extending the Rorschach trauma content index and aggression indexes to dream narratives of children exposed to enduring violence: An exploratory study. Journal of Personality Assessment, 90(6), 578-584. 

Kaser-Boyd, N. (2021). The Rorschach and trauma–An update. Rorschachiana, 42(2), 118–138. 

Kaser-Boyd, N., & Evans, F. B. (2008). Rorschach assessment of psychological trauma. In C. B. Gacono, F. B. Evans (Eds.), The handbook of forensic Rorschach assessment (pp. 255–277). Routledge/Taylor & Francis Group.  

Kreis, M. K., & Cooke, D. J. (2011). Capturing the psychopathic female: A prototypicality analysis of the Comprehensive Assessment of Psychopathic Personality (CAPP) across gender. Behavioral Sciences & the Law, 29(5), 634-648. 

Kwawer, J. S. (1980). Primitive interpersonal modes, borderline phenomena, and Rorschach content. In J. S. Kwawer, H. D. Lerner, P. M. Lerner, & A. Sugarman (Eds.), Borderline phenomena and the Rorschach test (pp. 89-105): International Universities Press. 

Lilienfeld, S. O. (1991). Development and preliminary validation of a self-report measure of psychopathic personality: I and II. University of Minnesota at Minneapolis. 

Lilienfeld, S. O., & Widows, M. R. (2005). Psychopathic Personality Inventory-Revised. Personality Assessment Resources. 

Mason, P. T., & Kreger, R. (2020). Stop walking on eggshells. New Harbinger Publications. 

Meloy, J. R., & Gacono, C. B. (1993). A borderline psychopath:" I was basically maladjusted...". Journal of Personality Assessment, 61(2), 358-373. 

Meyer, G. J., Viglione, D. J., Mihura, J. L., Erard, R. E., & Erdberg, P. (2011). Rorschach Performance Assessment System: Administration, coding, interpretation, and technical manual. Rorschach Performance Assessment System. 

Motz, A. (2020). Taboo: Female psychopathy and sexual offending against children. In A. Motz (Ed.), Invisible Trauma (pp. 100116). Routledge. 

Nørbech, P. C. B., Fodstad, L., Kuisma, I., Lunde, K. B., & Hartmann, E. (2016). Incarcerated violent offenders' ability to avoid revealing their potential for violence on the Rorschach and the MMPI–2. Jr. of Personality Assessment, 98(4), 419-429. 

Odgers, C. L., Reppucci, N. D., & Moretti, M. M. (2005). Nipping psychopathy in the bud: An examination of the convergent, predictive, and theoretical utility of the PCL-YV among adolescent girls. Behavral Sciences & the Law, 23(6), 743-763. 

Perry, W., & Viglione Jr, D. J. (1991). The Ego Impairment Index as a predictor of outcome in melancholic depressed patients treated with tricyclic antidepressants. Journal of Personality Assessment, 56(3), 487-501. 

Piotrowski, C. (2017). Rorschach research through the lens of bibliometric analysis: Mapping investigatory domain. Journal of Projective Psychology & Mental Health, 24(1), 34-38. 

Piotrowski, C. (2020). Prominent assessment instruments in suicide and PTSD research on U.S. veterans. Journal of Projective Psychology & Mental Health, 27(1), 1-5. 

Piotrowski, C. (2024). Bibliometric analysis of the journal Traumatology: Prominent and under-studied areas of investigation. North American Journal of Psychology, 26(4), 823-830.  

Poythress, N. G., Skeem, J. L., & Lilienfeld, S. O. (2006). Associations among early abuse, dissociation, and psychopathy in an offender sample. Journal of Abnormal Psychology, 115(2), 288-297. 

Resnick, J. D. (1994). Rorschach assessment of ego functioning: A comparison of the EII and CESI. Loyola University Chicago.  

Sevecke, K., Franke, S., Kosson, D., & Krischer, M. (2016). Emotional dysregulation and trauma predicting psychopathy dimensions in female and male juvenile offenders. Child and Adolescent Psychiatry and Mental Health, 10, 1-13. 

Shipley, W. C., Gruber, C. P., Martin, T. A., & Klein, A. M. (2009). Shipley-2 manual. Western Psychological Services. 

Shipley, W. C., & Zachary, R. A. (1986). Shipley Institute of Living Scale. Western Psychological Services. 

Smith, J. M., Gacono, C. B., & Cunliffe, T. B. (2018). Comparison of male and female psychopaths on select CS Rorschach variables. SIS Journal of Projective Psychology and Mental Health, 25(2), 138-155. 

Smith, J. M., Gacono, C. B., & Cunliffe, T. B. (2020). Using the Rorschach Trauma Content Index (TCI) with incarcerated women. SIS Journal of Projective Psychology & Mental Health, 27(1), 12-20. 

Smith, J. M., Gacono, C. B., & Cunliffe, T. B. (2021). Understanding female offenders: Psychopathy, criminal behavior, assessment, and treatment. Elsevier Academic Press. 

Smith, J. M., Gacono, C. B., Kivisto, A. J., & Cunliffe, T. B. (2019). A PCL-R, Rorschach, and PAI investigation of females with sex offenses against minors and a Rorschach comparison with male pedophiles. Archives of Assessment Psychology, 9(1), 113-137. 

Verona, E., Hicks, B. M., & Patrick, C. J. (2005). Psychopathy and suicidality in female offenders: Mediating influences of personality and abuse. Journal of Consulting and Clinical Psychology, 73(6), 1065-1073. 

Viglione, D. J., Towns, B., & Lindshield, D. (2012). Understanding and using the Rorschach inkblot test to assess post-traumatic conditions. Psychological Injury and Law, 5, 135-144. 

Zukerman, G., Ben-Itzchak, E., Fostick, L., & Armony-Sivan, R. (2017). Information processing of the Rorschach's traumatic content Index in trauma-exposed adults: an event related potential (ERP) study. Biological Psychology, 127, 108-122.