Some Comments on the Importance of Comparative Group Data for Interpreting Rorschach Findings

Carl B. Gacono & Jason M. Smith

        The Rorschach (RIM) provides information beyond what one gathers from self-report measures. In addition to CS data, psychoanalytic theory has led to several valid and reliable supplemental Rorschach scoring systems. When integrated, CS and supplemental RIM data increases the conceptual understanding of a patient or group, allowing for highly nuanced insights into personality functioning. In order to interpret Rorschach data one must understand that, for the most part 1) Rorschach variables measure traits (dimensions) not diagnosis (categories), that 2) the degree of pathology or health represented by a variable is determined in relationship to comparative group data, such as non-patients, and assessed within the context of the entire protocol or protocols (for group data), and, 3), confirming the presence or absence of a trait within a given sample necessitates a comparison to other relevant groups both those that contain threshold quantities of the identified trait, and those ―absence‖ the trait. Throughout this article we underscore the essential contribution of a nomothetic context (using comparative CS data) for anchoring Rorschach interpretation.

Introduction:

        The Rorschach is a perceptual-associative-judgmental task that partially bypasses volitional controls, yielding both structural and psychodynamic data, some of which is projected material (Bornstein &Masling, 2005; Exner, 2003). Rorschach data adds incrementally to, and provides data well beyond, what can be obtained with self-report measures (Bornstein &Masling, 2005; Gacono & Evans, 2008; Gacono & Meloy, 1994; Smith, Gacono, & Cunliffe, 2021). The Comprehensive System (CS) has an extensive research base, more than adequate normative, clinical, and forensic comparative datai (Exner, 2001, 2003, 2007; Gacono & Evans, 2008; Smith et al., 2021), and has been widely used in clinical and forensic practice, meeting the standards of admissibility and acceptance in court (Gacono et al., 2008; McCann  &  Evans,  2008;  Meloy,  2008; Piotrowski, 1996a, 1996b, 2007, 2017).

        Rorschach scoring begins with coding the Comprehensive System variables (CS, Exner, 2003) and generating a sequence of scores and structural summary. The experienced Rorschach user can complete most if not all the actual coding during the two phases (free association & inquiry) of administration. Interpretation begins in earnest by comparing the CS coding, indices, and constellations to relevant comparative group data. For example, how does this ―depressed‖ patient compare to inpatient depressives on relevant variables such as DEPI? To non-patients? This dual comparison (clinical group--non-patient group) anchors one’s hypothesis.

        In addition to CS generated data, psychoanalytic theory has provided a foundation for several other Rorschach supplemental reliable and valid scoring systems. These include systems for object relations (Blatt & Lerner, 1983; Kwawer, 1980), defenses (Cooper, Perry, &Arnow, 1988; Lerner & Lerner, 1980), developmental psychopathology (Urist, 1977), dependency (Bornstein &Masling, 2005; Masling et al., 1967), trauma (Armstrong & Loewenstein, 1990), aggressive drive derivatives (Gacono & Meloy, 1994; Gacono, Gacono, Meloy, &Baity, 2008), and thought organization (Athey, 1974; Meloy & Singer, 1991)ii. These additional systems provide a useful complement to CS scoring, allowing for the quantification of important Rorschach content, traits, and processes (Arnow&Reznikoff, 1976). Most of these systems, including their reliability and validity, have been summarized in five books (Bornstein &Masling, 2005; Kissen, 1986; Kwawer, Lerner, Lerner, & Sugarman, 1980; Lerner & Lerner, 1988; Lerner, 1991).

        Access to CS structural data, CS sequence data, and other supplemental scores increases one’s conceptual understanding of a patient or group and allows for nuanced insights into levels of personality functioning (unconscious, preconscious, conscious; Gacono & Evans, 2008; Gacono & Meloy, 1994; Gacono & Smith, 2021; Meloy, Acklin, Gacono, Murray, & Peterson, 1997; Stone &Dellis, 1960). While the Comprehensive System (Exner, 2003), alone, provides psychodynamic information concerning self-esteem regulation, affect management, defenses, object relations, and interpersonal functioning, these supplemental systems deepen our understanding of both individual and group personality (Gacono & Smith, in press).

A Nomothetic Context:

        When considering the context for forming Rorschach research hypothesis or interpreting individual or group data, three points emerge. Point #1--, each disorder is inherently dimensional, comprised of a cluster of specific traits. When present in sufficient quantities the traits reach a threshold whereby, they constitute a category (syndrome or disorder). Several disorders may share overlapping traits; however, no disorder (category) is mistaken for the other. In this manner the old Gestalt principle applies: The whole is truly greater than the sum of its parts. Paranoid and compulsive personality disorders share similarities in their cognitive style (focus on details, Dd). Narcissistic and paranoid people evidence grandiosity and self-reference, histrionic and narcissistic people share a need for attention, and so on. The combination of characteristics in sufficient quantities meets a threshold that determines group inclusion (diagnosis or category). For the most part, Rorschach variables measure traits not disorders per se. A specific disorder only begins to emerge when a composite of Rorschach variables appear that are linked to associated traits.

iii Gacono, Meloy, and Bridges (2000, 2008) study of Rorschach reflection responses among sexual homicide perpetrators (SHPs), psychopaths (Ps), and non-violent pedophiles (PEDs), provides an example. Similar frequencies of individuals from each group produced reflections. Reflection responses were not interpreted as a ―sign‖ of a diagnostic category, (psychopathy), rather the authors correctly identified their presence as being consistent with elevated self-focus (a trait- -self-focus or narcissism; also see Smith, Gacono, & Cunliffe, 2019). These findings were consistent with theory, as elevated self-focus is a trait associated with each of these syndromes.

        Point #2--inferences made related to the pathological nature of a Rorschach variable (associated trait) must be considered relative to frequencies and mean numbers found in non-patients or other groups that either contain the same trait or are hypothesized to lack the trait (i.e., non-patients; lacking or low levels of the trait). The nature of the trait must also be assessed within the context of the entire Rorschach protocol. For example, in comparing reflection responses among male psychopaths (Mean [M] = 0.72, Frequency = 44% produced at least one), sexual homicide perpetrators (M = 1.11, 45%) and male nonviolent pedophiles (M = 1.23, 44%), Gacono et al. (2000, 2008) noted that each group produced significantly more than non-patients (M = 0.20, 12%; Exner, 2007). Early on, Exner discovered that reflections relate to self-focus (Exner, 2003). Consequently, the Gacono et al. (2000, 2008) findings support high levels of self-focus in these clinical groups. Non-patients would not be expected to, and do not, exhibit the same type of self-focus as measured by reflections. Similar patterns for relevant variables would be expected between an avoidant personality and a narcissistic one or an avoidant personality and non-patients. It should be noted that even with a variable considered to be generally ―healthy‖ --FD (introspection)—its relative healthy (nature) can only be determined within the context of the entire protocol. An FD response produced with minus form and an accompanying ALOG special score in a protocol with reality testing and thinking problems, would not be interpreted as indicative of heathy introspection.

        Point #3 -- involves how the clinician assigns a trait to a group. For example, in the Gacono et al. (2000, 2008) study about 50% of each group member produced at least one reflection. Did those without reflections lack pathological self-focus? Why don’t 100% of the male psychopaths produce reflections? The answer to the first question is affirmatively NO. All the psychopaths (PCL-R ≥ 30) elevate on PCL-R Factor 1, which correlates with narcissism and reflections (in males). They are all not only self-focused but also pathologically narcissistic. The PCL-R assesses narcissism in a global and direct manner (observed attitude/behaviors), while the Rorschach scores and patterns do so indirectly, having the validity of variables been previously established through linking them to traits by demonstrating associated behavior(s). In the Gacono et al. study, other evidence in the history, PCL-R data, or other assessment information (i.e., MCMI-II) confirmed the self-focus demonstrated by the Rorschach for the three clinical groups. In the manner that the Rorschach can ferret out sub-groups within a given sample, the reflection response does not capture the pathological self-focus in all subjects, rather sub-groups will present their self-focus through the production of other indices and patterns (e.g., W:M, PER responses, etc.). So, while not all male psychopaths produce reflections, all male psychopaths are pathologically narcissistic. In a related manner none of the non-violent PEDs met the criteria for ASPD or psychopathy. Reflections represent a trait, and do not provide a one-to-one sign for a category (reflections = self-focus, not psychopathy). It is scientifically sound to attribute self-focus to each of Gacono et al. (2000, 2008) three groups based on a comparison of reflections with the CS non-patients (12% produce at least 1).

Rorschach Interpretation:

        Competent Rorschach interpretation requires examining scores and indices within a nomothetic context (comparative group data). In confirming the presence or absence of a trait within a given sample, it is the comparison to other relevant groups, both those that contain the same trait, and those absent the trait, that aids this determination. For example, in a recent article contrasting the differing personality styles of male (MP) and female (FP) psychopaths, Rorschach CS and supplemental coding related to malignant hysteria were found to discriminate between the groups (Gacono & Smith, in press). While the MPs had less indices of affect, both groups were found to be emotionally explosive (Pure C, MP, M = 0.70; FP, M = 1.07; NP, M = 0.17; CD, M = 0.47).

Three variables (AB, Hx, & IMP [Impressionistic response], Gacono, 1988), representing the core of the hysterical, impressionistic style (Shapiro, 1965), along with a constellation of hysterical defenses, differentiated between the groups. The FPs also produced AB and Hx in greater quantities than non-patients (Hx, FP = 39%, NP = 10%; AB, FP

= 44%; NP = 15%) supporting the ―malignant aspect‖ of the hysteria.

        The need for adequate nomothetic data is one of several reasons that the CS is considered the only validated primary system for Rorschach coding and interpretation. The development of newer alternate systems, such as the R-PAS (Meyer, Viglione, Mihura, Erard, &Erdberg, 2011) must have similar data acquired with their respective administration instructions prior to being considered appropriate for applied use. The supplemental systems offered in this article have also been found to be useful related to their validity findings but would benefit from additional comparative group data. Dr. Smith and I are attempting to create forensic comparative samples of these scores by coding them in the over 2000 forensic protocols from our archives (Gacono & Evans, 2008; Smith, Gacono, & Cunliffe, 2021). We welcome any collaborators.

References:

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

Athey, G. (1974). Schizophrenic thought organization, object relations, and the Rorschach test. Bulletin of the Menninger Clinic, 38(5), 406–429.

Arnow, E., &Reznikoff, M. (1976). Rorschach content interpretation. Grune and Stratton.

Blatt, S. J., & Lerner, H. D. (1983). The psychological  assessment  of  object

representation. Journal of Personality Assessment, 47(1), 7–28.

Bornstein, R. F., &Masling, J. M. (2005). Scoring the Rorschach: Seven validated systems. Mahwah, NJ: Lawrence Erlbaum Associates Publishers.

Cooper, S. H., Perry, J., &Arnow, D. (1988). An empirical approach to the study of defense mechanisms: I. Reliability and preliminary validity of the Rorschach Defense scales. Journal of Personality Assessment, 52(2), 187-203.

Exner, J. E. (1995). A Rorschach workbook for the Comprehensive System (4th ed.). Asheville, NC: Rorschach Workshops.

Exner, J. E. (2001). A Rorschach workbook for the Comprehensive System (5th ed.). Asheville, NC: Rorschach Workshops.

Exner, J.E. (2003). The Rorschach: A Comprehensive System (4th ed.). New York: Wiley.

Exner, J. E. (2007). A new US adult nonpatient sample. Journal of Personality Assessment, 89(Suppl. 1), S154–S158.

Gacono, C. B. (1988). A Rorschach interpretation of object relations and defensive structure and their relationship to narcissism and psychopathy in a group of antisocial offenders. Unpublished doctoral dissertation, United States International University, San Diego, CA.

Gacono, C. B., & Evans, F. B. (Eds.). (2008). The LEA series in personality and clinical psychology. The handbook of forensic Rorschach assessment (N. Kaser-Boyd & L. A. Gacono, Collaborators). New York, NY: Routledge/Taylor & Francis Group.

Gacono, C. B., Gacono, L. A., Meloy, J., &Baity, M. R. (2008). The Rorschach assessment of aggression: The Rorschach Extended  Aggression scores. In C. B.

Gacono, F. Evans, N. Kaser-Boyd, & L. Gacono (Eds.), The handbook of forensic Rorschach assessment (pp. 543-559). New York, NY US: Routledge/Taylor & Francis Group.

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

Gacono, C. B., Meloy, J. R., & Bridges, M. R. (2000). A Rorschach comparison of psychopaths, sexual homicide perpetrators, and nonviolent pedophiles: Where angels fear to tread. Journal of Clinical Psychology, 56(6), 757–777.

Gacono, C. B., Meloy, J. R., & Bridges, M. R. (2008). A Rorschach understanding of psychopaths, sexual homicide perpetrators, and nonviolent pedophiles. In C. Gacono,

1. Evans, N. Kaser-Boyd, & L. Gacono (Eds.), The handbook of forensic Rorschach assessment (pp. 379–402). Mahwah, NJ: Lawrence Erlbaum.

Gacono, C.B., & Smith, J.M. (2021). Essential issues to consider prior to using the R-PAS in a forensic context. SIS Journal of Projective Psychology & Mental Health, 28(1), 4-13.

Gacono, C.B., & Smith, J.M (in press). Understanding the psychopath from a psychodynamic perspective: A Rorschach study. Archives of Assessment Psychology.

Kissen, M. (1986). Assessing object relations phenomena. Madison, CT: International Universities Press.

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

Kwawer, J., Sugarman, A., Lerner, P., & Lerner,

1. (Eds.). (1980). Borderline phenomena and the Rorschach test. New York, NY: International Universities Press.

Lerner, H. D., & Lerner, P. M. (Eds.). (1988). Primitive mental states and the Rorschach. New York, NY: International Universities Press, Inc.

Lerner, P. M. (1991). Psychoanalytic theory and the Rorschach. Hillsdale, NJ: Analytic Press, Inc.

Lerner, P. M, & Lerner, H. (1980). Rorschach assessment of primitive defenses in borderline personality structure. In J. Kwawer, A. Sugarman, P. Lerner, & H. Lerner (Eds.), Borderline phenomena and the Rorschach test (pp. 257-274). New York, NY: International Universities Press.

Masling, J., Rabie, L., &Blondheim, S. H. (1967). Obesity, level of aspiration, and Rorschach and TAT measures of oral dependence. Journal of Consulting Psychology, 31(3), 233-239.

McCann, J. T., & Evans, F. B. (2008). Admissibility of the Rorschach. In C. B. Gacono, F. B. Evans (Eds.) & N. Kaser-Boyd, L. A. Gacono (Collaborators), The LEA series in personality and clinical psychology. The handbook of forensic Rorschach assessment (p. 55–78). New York: NY: Routledge/Taylor & Francis Group.

Meloy, J. R. (2008). The authority of the Rorschach: An update. In C. B. Gacono, F.

1. Evans (Eds.) & N. Kaser-Boyd, L. A. Gacono (Collaborators), The LEA series in personality and clinical psychology. The handbook of forensic Rorschach assessment (p.   79-88).   New   York: NY:

Routledge/Taylor & Francis Group.

Meloy, J. R., Acklin, M. W., Gacono, C. B.,

Murray, J. F., et al. (Eds.). (1997). The LEA

series in personality and clinical psychology. Contemporary Rorschach interpretation. Lawrence Erlbaum Associates Publishers.

Meloy, J.R., & Singer, J. (1991). A psychoanalytic view of the Rorschach Comprehensive System ―special scores‖. Journal of Psychological Assessment, 56(2), 202-217.

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. Toledo, OH: Rorschach Performance Assessment System, LLC.

Neumann, C. S., Vitacco, M. J., &Mokros, A. S. (2016). Using both variable-centered and person-centered approaches to understanding psychopathic personality. In

1. B. Gacono (Ed.), Personality and clinical psychology series. The clinical and forensic assessment of psychopathy: A practitioner's guide (p. 14–31). Routledge/Taylor & Francis Group.

Piotrowski, C. (1996a). The Rorschach in contemporary forensic psychology. Psychological Reports, 78(2), 458.

Piotrowski, C. (1996b). The status of Exner’s Comprehensive System in contemporary research. Perceptual and Motor Skills, 82(3_suppl), 1341–1342.

Piotrowski, C. (2007). Forensic psychological testing as a function of affiliation and organizational setting. Organization Development Journal, 25(1), 94-98

Piotrowski, C. (2015). On the decline of projective techniques in professional psychology training. North American Journal of Psychology, 17(2), 259–266.

Shapiro, D. (1965). Neurotic styles. New York: Basic Books.

Smith, J.M., Gacono, C.B., & Cunliffe, T.B. (2019). Understanding the Rorschach egocentricity index with incarcerated women. Archives of Assessment Psychology, 9(1), 139-155.

Smith, J.M., Gacono, C.B., & Cunliffe, T.B. (2021). Understanding female offenders: Psychopathy, criminal behavior, assessment, and Treatment. San Diego, CA: Elsevier.

Stone, H.K., &Dellis, N.P. (1960). An exploratory investigation into the levels hypothesis. Journal of Projective Techniques, 24, 333-340.

Urist, J. (1977). The Rorschach test and the assessment of object relations. Journal of Personality  Assessment,  41(19),  3-9

i Rorschach Workbooks for the CS (4th & 5th edition; Exner, 1995, 2001) included descriptive CS data for non-patient adults (N=600-700; also listed by high Lambda, introversive, extratensives, and ambitents), non-patient children and adolescents (N = 1390; also listed by age), adult outpatients (N=535), inpatient schizophrenics (N = 320), inpatient depressives (N = 315), and character disorders (N = 180). A new sample of 450 non-patients is also available (Exner, 2007). Descriptive group data is also available for over 2061 CS administered forensic protocols (Gacono & Evans, 2008; Gacono & Meloy, 1994; Gacono & Smith, 2021; Smith, Gacono, & Cunliffe, 2021).

ii See also Borstein and Masling’s (2005) Scoring the Rorschach: Seven Validated Systems. While validated these systems have relatively little comparative data as compared to the CS. Due to their extensive usage in forensic samples, the Gacono and Meloy (1994) Extended Aggression scores may be an exception.

iii Rorschach data are useful in sorting out sub-groups within any classification. As noted in psychopathy, every personality style and/or disorder also contains some amount of heterogeneity; with potentially identifiable subgroups (Neumann et al., 2016).